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development neuronal growth cones interpret balance attractive repulsive cues present extracellular environment find correct targets many phylogenetically conserved ligands receptors control axon guidance decisions discovered tessier lavigne goodman 1996 for example embryonic drosophila central nervous system cns midline glia cells secrete netrin slit netrin attracts axons across midline whereas slit repels axons preventing crossing harris et al 1996 ; netrin attraction mediated deleted colo rectal carcinoma dcc receptors slit repulsion mediated roundabout robo receptors keino masu et al 1996 kolodziej et al 1996 kidd et al chimeric receptors generated exchanging cytoplasmic domains attractive netrin receptor dcc repulsive slit receptor robo shown sign growth cone response encoded cytoplasmic domains receptors bashaw goodman 1999 to identify signaling molecules involved controlling axon guidance decisions used chimeric receptor overexpression phenotypes perform sensitized genetic screen overexpression robo dcc chimeric receptor robo extracellular domain fused dcc cytoplasmic domain leads dose dependent cns axon guidance defects axons abnormally cross cns midline also results reduced viability we screened ep collection collection p element inserts allow gal4-dependent misexpression flanking genes rorth et al 1998 genes overexpressed pan neurally combination robo dcc would enhance viability defects chimera such genes could play role dcc mediated attractive axon guidance alternatively could function parallel attractive signaling pathways here expression ep3035 dramatically enhances axon guidance defects robo dcc chimera leading significant increase ectopic midline crossing unpublished data molecular characterization genomic region adjacent ep3035 revealed large transcription unit encodes novel member dbl family guanine nucleotide exchange factors gefs cerione zheng 1996 specific rho family small gtpases fig in addition canonical dbl pleckstrin homology ph domains gef64c also contains several proline rich motifs including sequence similar enabled evh1 domain binding site lplpp niebuhr et al 1 rna situ analysis ep3035/elavgal4 embryos confirms ep3035 drives overexpression gef64c transcript in addition genetic enhancement robo dcc ep3035 phenocopied expressing uas gef64c transgene confirming enhancement due gef64c expression unpublished data protein expression analysis wild type embryos using mab gef64c reveals broad low level expression gef enrichment cns fig the specificity gef64c mab demonstrated comparing embryos expressing full length uasgef64c control elavgal4 expressing cooh terminal truncation uasgef64cc removes mab epitope fig robust cns expression seen animals wild type transgene low levels characteristic wild type expression seen animals truncated transgene fig 1 e f molecular characterization expression gef64c the location ep insert sequenced mutant alleles region used antibody generation indicated colored regions coding sequence indicated b. b schematic diagram gef64c gef64cc proteins the ph domain identified smart sequence analysis program low significance score 10 since known dbl domain proteins have ph domains flanking dbl included ph domain small question mark next sequences identified domains underlined color corresponding domain indicated b. f stage 1516 embryos stained anti gef64c antibody these sequence data available embl genbank ddbj accession ay064174 since gef64c identified gain function screen wanted assess consequence loss gef64c function midline axon guidance we generated point mutations gef sequenced three independent alleles see materials methods two alleles gef64c gef64c result premature stop codons third generates missense mutation cooh terminus protein fig embryos carrying mutations gef64c examined antibody labels cns axons mab bp102 no major defects discovered gef64c mutants longitudinal connectives commissural axon bundles comparable seen wild type animals fig rna interference using fragment gef64c double stranded rna also failed reveal strong axon guidance defects arguing maternal contribution explanation absence mutant phenotype unpublished data genetic redundancy could explain modest consequences removing gef64c indeed examination drosophila genome reveals 22 gefs specific rho family gtpases number appear expressed embryonic cns unpublished data this raises possibility multiple gefs function midline guidance disrupting one limited effect for example mutations drosophila trio another rho gef well established roles regulating axon outgrowth cause minor disruptions cns axon scaffold whereas profound effects combination mutations affect midline axon guidance awasaki et al 2000 bateman et al 2000 liebl et al 2000 newsome et al alternatively possible gef64c mutations cause defects subsets cns neurons defects readily apparent axons visualized simultaneously investigate potential requirement gef64c midline axon guidance looked effects removing gef64c function animals carried mutations frazzled fra gene encodes drosophila homologue dcc attractive netrin receptor kolodziej et al 1996 mutations fra cause range defects cns axon guidance consistent role attracting commissural axons midline fig fra gef64c double mutant embryos exhibit marked enhancement guidance defects typically observed fra mutants substantial reduction commissure thickness greater number segments commissures fail form fig thus fra mutant background normal axon attraction midline partially defective loss gef64c exacerbates defects suggesting endogenous role gef64c attractive guidance midline it noted double mutant analysis provide evidence gef64c involvement dcc signaling preclude role dose sensitive genetic biochemical interactions fra gef64c could suggest direct involvement dcc signaling thus far observed in contrast modest effects loss gef64c function pan neural overexpression gef64c using ep3035 uasgef64c results dramatic dose dependent gain function phenotype many axons abnormally project across midline the commissures thicker commensurate reduction longitudinal axon tracts fig the point mutations gef64c introduced ep3035 chromosome allowing gal4 overexpression mutant alleles none mutant alleles uasgef64cc transgene deletion dbl ph domains capable generating gain function phenotype indicating abnormal midline crossing due gef64c expression effect requires intact dbl ph domains examination gain function embryos antibodies wrapper noordermeer et al 1998 marker midline glia indicates guidance defects caused gef64c overexpression secondary consequence nonautonomous perturbations midline glial cell survival migration unpublished data gef64c gain function overcomes robo repulsion suppressed rhoa dominant negative note wild type appearance commissural longitudinal axon bundles embryo coexpressing gef64c rhoa dominant negative b relative gef64c alone the gef64c overexpression phenotype qualitatively similar phenotype mutations robo receptor raising possibility gef64c promotes attraction midline interfering robo repulsion first significant differences gef64c gain function robo loss function phenotypes robo mutations profound effects growth cones pioneer ipsilaterally projecting fasii positive posterior corner cell pcc pathway gef64c overexpression unpublished data second overexpression gef64c appear affect robo protein expression localization unpublished data the third observation relates genetic predictions based function commissureless comm comm downregulates robo receptors commissural axons tear et al 1996 kidd et al 1998b ) thus gef64c overexpression blocking robo function gef64c gain function least partially epistatic mutations comm case unpublished data reasons believe gef64c overexpression exerts effects stimulation attractive signaling pathway rather inhibition robo repulsion the gef64c gain function phenotype suggests increasing expression attractive signaling molecule possible overcome normal repulsive signals present midline determine whether gef64c expression would also allow axons cross midline genetic backgrounds axons biased toward repelled coexpressed gef64c hyperactive mutant form robo receptor roboy f bashaw et al 2000 pan neural expression uasroboy f results commissureless phenotype if roboy f background simultaneously drive gef64c expression many commissural axons able cross midline segments appear nearly wild type fig thus even artificially repulsive background gef64c allow significant axon growth across midline raising exciting possibility finding ways stimulate activity functionally homologous mammalian gefs could promote regrowth injured axons adult cns one likely scenario exerts effects specifically activating one rho family gtpases there six rhogtpases fly genome rac1 rac2 mtl rhoa rhol cdc42 dickson 2001 we made use gef64c gain function phenotype dominant negative gtpase transgenes rac1 rhoa cdc42 determine gtpases downstream target(s gef64c reasoning genetically limiting downstream target suppress gef64c gain function phenotype based largely differential effects rac rho neurite extension rac promotes extension rho promotes retraction proposed axon guidance rac could play role attractive responses whereas rho could stimulate repulsion dickson 2001 we therefore predicted gef64c gain function phenotype would depend rac activity rho surprisingly opposite appears true rhoa dominant negative strongly suppresses gef64c gain function whereas rac1 cdc42 dominant negatives little effect fig this observation argues simplest form model rac mediates attraction rho mediates repulsion test if specificity gef64c rhoa seen genetic experiments also observed independent assays gef64c function vitro binding guanine nucleotide exchange assays performed glutathione transferase gst pull experiments indicate gef64c bind equally well rac1 rhoa cdc42 unpublished data whereas gef64c acts vitro exchange factor rac rho exhibiting modest preference catalyzing exchange gdp gtp rho relative rac exchange activity cdc42 fig such promiscuity vitro association gefs small gtpases observed many rhogefs including vav trio van aelst d'souza schorey 1997 examine function gef64c effects actin cytoskeleton cultured fibroblasts determined fig microinjection gef64c expression vector quiescent serum starved swiss 3t3 cells resulted dramatic stimulation actin stress fiber formation relative control cells fig 4 b phenotype indicative rho activation hall 1998 coinjection gef64c c3 transferase protein inhibitor specific rho ridley hall 1992 completely blocked gef64c ability induce stress fibers arguing gef64c functions activating rho fig ( b cells injected gef64c expression construct show striking actin stress fiber formation ( b injection marker cells shown b. c cells coinjected gef64c expression construct c3 transferase protein ( c injection marker cells shown c. gef exchange assays rac rho cdc 42 the relatively weak significant exchange activity observe could attributable fact ph domain included assays fusion proteins containing dbl ph domains poorly expressed the reciprocal loss gain function genetic data presented support role gef64c promoting axon attraction cns midline overexpression gef64c overcome normal repulsive signals present midline even drive attraction midline background robo repulsion abnormally strong surprisingly genetic cell culture evidence suggest attractive effects meditated activation rhoa rac previous evidence number different experimental systems consistent general idea rac cdc42 positive regulators neurite outgrowth rho negative regulator reviewed luo 2000 these observations axon outgrowth extended axon guidance suggesting rac cdc42 would mediate attractive guidance responses rho would mediate repulsion led investigation role rho gtpases regulation axon guidance example ephexin gef rhoa implicated repulsive responses mediated eph receptors shamah et al 2001 repulsive effects drosophila plexin b member semaphorin receptor family also appear mediated rhoa driessens et al our findings suggest opposite also possible namely rhoa may also play role attraction argue single generalizable function rho gtpases axon guidance the simplest interpretation data gef64c promotes midline attraction stimulation attractive signaling pathway however noted gef64c function linked known receptor ligand system remains formal possibility gef64c expression could exert effects enhancing activity unknown repellant present lateral cns model would predict strong defects longitudinal extension fasii positive axons something observe nevertheless discovering rho gtpases elicit different even opposite axon guidance responses different contexts major challenge future promises enrich understanding molecular mechanisms axon guidance developing nervous system the ep insert gef64c ep3035 came screen 2300 line ep collection provided rubin lab flies ep line crossed flies constitutively express robo dcc chimera neurons uasrobo dcc elavgal4/tm3 a primary screen performed lines lethal coexpressed chimera lines lethal independent chimera eliminated remainder screened anatomically enhanced robo dcc axon guidance defects ems point mutations gef64c isolated f1 selection screen suppressors lethal interaction ep3035 uasrobo dcc ep3035/tm3 males mutagenized ems crossed uasrobo dcc elavgal4/tm3 non tm3 escapers isolated retested suppression lines established several lines failed give gef64c gain function phenotype selected sequencing the following fly stocks also used elavgal4 b df(3l)10h deficiency gef64c region c fra cyowggal comm ep3035/tm3gal e comm elavgal4/tm3gal f uasroboy f g uasracn17 h uasrhon19 uascdc42n17 j fra cyowggal gef64c tm6gal k fra cyowggal df(3l)10h tm6gal l ep3035,elavgal4/tm3gal genomic dna flanking ep3035 isolated used screen ld embryonic cdna library bdgp using standard procedures the full length gef64c cdna subcloned pcdna3.1 invitrogen puast expression mammalian cells transgenic flies respectively uasgef64cc derived full length uasgef64c transgenic lines construct established the pharmacia pgex system used gst fusions gef64c dbl dbl ph domains regions interest amplified pcr subcloned pgex gef exchange assays performed described previously self hall 1995 embryo staining monoclonal antibody production procedures gef64c amino acids 13161580 described previously kidd et al 1998a quiescent serum starved swiss 3t3 cells prepared described previously nobes hall 1995 cells microinjected expression vector pcdna3 encoding gef64c nucleus concentration 200 g ml injected cells marked coinjection biotin conjugated lysinated dextrans molecular probes 2 mg ml detected fixed cells using alexa 350 streptavidin molecular probes rho activity inhibited injection c3 transferase protein cdnas cell nucleus concentration 200 g ml after 2.5 h cells fixed without washing 4% paraformaldyhyde/0.2% gluteraldyhyde pbsa 10 min room temperature cells permeabilized 0.2% triton x-100/pbs 5 min blocked sodium borohydride 0.5 mg ml pbs 10 min room temperature cells stained filamentous actin structures incubating 20 min tritc conjugated phalloidin 0.1 g ml the ep insert gef64c ep3035 came screen 2300 line ep collection provided rubin lab flies ep line crossed flies constitutively express robo dcc chimera neurons uasrobo dcc elavgal4/tm3 a primary screen performed lines lethal coexpressed chimera lines lethal independent chimera eliminated remainder screened anatomically enhanced robo dcc axon guidance defects ems point mutations gef64c isolated f1 selection screen suppressors lethal interaction ep3035 uasrobo dcc ep3035/tm3 males mutagenized ems crossed uasrobo dcc elavgal4/tm3 non tm3 escapers isolated retested suppression lines established several lines failed give gef64c gain function phenotype selected sequencing the following fly stocks also used elavgal4 b df(3l)10h deficiency gef64c region c fra cyowggal comm ep3035/tm3gal e comm elavgal4/tm3gal f uasroboy f g uasracn17 h uasrhon19 uascdc42n17 j fra cyowggal gef64c tm6gal k fra cyowggal df(3l)10h tm6gal l ep3035,elavgal4/tm3gal genomic dna flanking ep3035 isolated used screen ld embryonic cdna library bdgp using standard procedures the full length gef64c cdna subcloned pcdna3.1 invitrogen puast expression mammalian cells transgenic flies respectively uasgef64cc derived full length uasgef64c transgenic lines construct established the pharmacia pgex system used gst fusions gef64c dbl dbl ph domains regions interest amplified pcr subcloned pgex gef exchange assays performed described previously self hall 1995 embryo staining monoclonal antibody production procedures gef64c amino acids 13161580 described previously kidd et al 1998a quiescent serum starved swiss 3t3 cells prepared described previously nobes hall 1995 cells microinjected expression vector pcdna3 encoding gef64c nucleus concentration 200 g ml injected cells marked coinjection biotin conjugated lysinated dextrans molecular probes 2 mg ml detected fixed cells using alexa 350 streptavidin molecular probes rho activity inhibited injection c3 transferase protein cdnas cell nucleus concentration 200 g ml after 2.5 h cells fixed without washing 4% paraformaldyhyde/0.2% gluteraldyhyde pbsa 10 min room temperature cells permeabilized 0.2% triton x-100/pbs 5 min blocked sodium borohydride 0.5 mg ml pbs 10 min room temperature cells stained filamentous actin structures incubating 20 min tritc conjugated phalloidin 0.1 g ml	the key role of the rho family gtpases rac , rho , and cdc42 in regulating the actin cytoskeleton is well established ( hall , a. 1998 . science . 279:509514 ) . increasing evidence suggests that the rho gtpases and their upstream positive regulators , guanine nucleotide exchange factors ( gefs ) , also play important roles in the control of growth cone guidance in the developing nervous system ( luo , l. 2000 . nat . rev . neurosci . 1:173180 ; dickson , b.j . 2001 . curr . opin . neurobiol . 11:103110 ) . here , we present the identification and molecular characterization of a novel dbl family rho gef , gef64c , that promotes axon attraction to the central nervous system midline in the embryonic drosophila nervous system . in sensitized genetic backgrounds , loss of gef64c function causes a phenotype where too few axons cross the midline . in contrast , ectopic expression of gef64c throughout the nervous system results in a phenotype in which far too many axons cross the midline , a phenotype reminiscent of loss of function mutations in the roundabout ( robo ) repulsive guidance receptor . genetic analysis indicates that gef64c expression can in fact overcome robo repulsion . surprisingly , evidence from genetic , biochemical , and cell culture experiments suggests that the promotion of axon attraction by gef64c is dependent on the activation of rho , but not rac or cdc42 .
first report atrial septal aneurysm asa published lang posselt 1934.1 since several asa cases studies published literature an asa congenital abnormality characterized localized bulging atrial septum either atria cardiac cycle asa formation secondary interatrial pressure differences may also primary malformation involving region fossa ovalis entire septum asa may isolated abnormality often found association structural cardiac abnormalities like mitral valve prolapse atrial septal defects initially asa considered rare congenital anomaly advancement two dimensional echocardiography recently broader use trans esophageal echocardiography tee detection abnormality become easier frequent best knowledge the previous report asa mimicking cor triatriatum sinister ramazan colleagues.2 studies using trans esophageal echocardiography tee shown prevalence 2% 10% asa.3,4 asas clinically silent found incidentally 1% general population.5 a 37-year old african female referred cardiology outpatient clinic complaints unresolved atypical recurrent chest pain one year duration she known hypertensive diabetic smoke cigarettes drink alcohol she denied usage medications aware presence heart disease among family members general examination normal young lady body mass index 24 kg the patient several investigations including electrocardiograms chest radiograph cardiac enzymes normal echocardiography revealed thickened myxomatous anterior mitral valve leaflet however definite mitral valve prolapse seen parasternal long axis view plav ) membrane seen across left atrium la extending anteroposteriorly base anterior mitral valve leaflet base posterior valve leaflet fig this membrane demonstrable within la apical four chamber apical two chamber views the apical four chamber view revealed hypermobile inter atrial septum least 12 mm excursion either direction figs 2 3 multiple parasternal long- short axis views apical four chamber view modified echocardiographic evaluations including sub costal views revealed membrane bisecting la plav described earlier cross section hypermobile inter atrial septum atrial septal aneurysm we categorized patient type 5 atrial septal aneurysm bi directional equidistant right well left cardio respiratory cycle see figs 2 3 our patient consent tee commenced prophylactic aspirin 300 mg daily later reduced maintenance dose 75 mg daily an asa usually involves area fossa ovalis.5,6 localized bulging inter atrial septum diagnostic criteria usually protrusion 6 mm right atrium ra la atriums.7 bulging entire atrial septum localized bulging protruding less 6 mm usually considered true aneurysm since bulging might seen absence true aneurysm.6 furthermore small pocket 36 mm long extending anteriorly left limbus fossae ovalis described anatomically normal subjects.8 aneurysm affecting entire interatrial septum never documented pathologically other authors used protrusion aneurysm 10 mm beyond plane atrial septum measured tee.3 patient bulging least 12 mm either atria different phases cardio respiratory cycle the pathogenesis atrial septal aneurysm might explained abnormal structure inter atrial septum change normal inter atrial pressure gradient both.9 atrial septal aneurysm may also result bulging septum primum tissue fossa ovalis.5 asa mostly benign entity it could swing la ra back la vice versa a variety patterns sac motion revealed literature.10,11 atrial septal aneurysm motion determined according classification introduced olivares reyes colleagues.4 aneurysm classified type 1 right r bulging ra type 2 left l bulging la type 3 rl major excursion bulges ra lesser excursion bulges toward la type 4 lr maximal excursion atrial septal aneurysm toward la lesser excursion toward ra type 5 atrial septal aneurysm movement bidirectional equidistant atria cardiorespiratory cycle the association asa mitral valve prolapse mvp suggests myxomatous degeneration might responsible abnormalities.12 patient myxomatous anterior mitral valve leaflet however definite prolapse detected inability obtain consent tee makes impossible us confidently exclude mvp other authors observed developmental abnormality affecting tissue interatrial septum mitral valve supposed.13,14 atrial septal aneurysm frequently associated atrial septal defects asds particular asd ostium secundum type patent foramen ovale pfo).15 occurs isolation usually result shunting these defects demonstrable study acknowledge limitations trans thoracic echocardiography tte detecting small pfo asd opposed tee could completed due lack consent tee shown sensitive tte detecting asas.3 associations asas atrial fibrillation documented,16 patient present palpitations document arrhythmia resting electrocardiography asa documented act arrhythmic focus generating focal atrial tachycardia it also tends aggravate stasis la blood flow predispose individuals minute la clots systemic thromboembolisms some authors observed asa aneurysm may mimic right atrial cyst tumor.17 patient commenced anti platelet therapy without anticoagulation this keeping findings homma colleagues,18 showed anticoagulation therapy warfarin compared aspirin patients asa pfo significant differences noted regard appearance thromboembolic events the appropriate treatment therapy asymptomatic patients significant associated cardiac lesions amenable surgery uncertain until known natural history lesion management decisions probably best made individual basis asa mimicking cor triatriatum remains rare clinical condition usually asymptomatic may occasionally present unresolved atypical chest pain investigation unresolved chest pain two dimensional echocardiographic scanning performed multiple windows multiple images acquired conventional modified views echocardiographic diagnosis made addition associated lesions mvp uncommon asa tee remains invaluable modality investigation accurate evaluation however limiting factor diagnosis especially consent given resource poor setting	an atrial septal aneurysm ( asa ) is a rare but well - recognized abnormality of uncertain clinical relevance . it is a localized bulging of the inter - atrial septum into either or both atria during the cardiac cycle . asa has been reported as an unexpected finding during autopsy but may also be diagnosed in living patients by echocardiographic techniques.we present a 37-year - old woman with a recurrent atypical chest pain of one - year duration . she was found to have a congenital atrial septal aneurysm on evaluation . the echocardiographic images mimicked a left sided cor triatriatum sinister . she had no other symptoms and had no co - morbidities . there was no audible murmur.asa can mimic cor - triatriatum and echocardiographic examination should be performed from multiple views before any echocardiographic diagnosis is made .
f-18 fluorodeoxyglucose fdg c-11 methionine pet ct studies done treated case glioblastoma multiforme sent evaluation recurrence apart recurrence primary site subependymal deposit noted trigone lateral ventricle well demonstrated c-11 methionine study compared f-18 fdg study this case therefore highlights important role c-11 methionine play evaluating recurrence also metastatic deposits possibility high grade tumors a 10-year boy post operative post radiotherapy case left temporal glioblastoma multiforme gbm referred f-18 flurodeoxyglucose fdg positron emission tomography computed tomography pet ct rule residual recurrent disease 6 months following completion therapy the fdg scan 3 months following therapy shown evidence viable residual metastatic disease 185 mbq f-18 fdg injected intravenously patient rested one hour followed pet ct acquisition discovery ste 16 camera ge low dose ct followed 3d pet emission scan brain 15 minutes images reconstructed 3d vue algoritm ge viewed xeleris workstation ge using volumetrix protocol tiny focus abnormal fdg accumulation was noted region trigone left lateral ventricle best appreciated plain pet image figure 1-arrow coronal saggital transaxial fused f-18 fdg pet ct images correlative c-11 methionine study done next day 20 minutes following intravenous injection 740 mbq tracer a well defined focus abnormal tracer accumulation region left trigone figure 2-arrow well appreciated mip plain pet fused pet ct methionine images f-18 fdg uptake vary greatly uptake high high grade tumors metastases however high rate physiologic glucose metabolism normal brain tissue detectability lesions restricted amino acid pet tracers like c-11 methionine contrast high uptake tumor tissue low uptake normal brain thus giving better lesion background ratios they transported cell via carrier mediated transport processes transport upregulated following malignant transformation case because subependymal deposit away grey matter could visualised f-18 fdg pet however deposit clearly delineated c-11 methionine study correlated well cect mri findings figure 3 gbm aggressive type brain tumor poor prognosis the tumor may extend meninges ventricular wall malignant cells carried csf may spread spinal cord cause meningeal gliomatosis though various studies literature compared f-18 fdg c-11 methionine evaluation gliomas recurrent brain tumors.[68 comparison metastases subependymal deposit reported the possibility subependymal metastases kept mind reporting f-18 fdg brain study gbm deposits well delineated amino acid tracer c-11 methionine study coronal saggital transaxial fused c-11 methionine pet ct images axial cect done subsequently showing mildly enhancing subependymal nodule b axial flair mr sequence showing hyperintense subependymal nodule trigone left lateral ventricle	a 10-year - boy post - operative , post - radiotherapy case of left temporal glioblastoma multiforme ( gbm ) was referred for f-18 flurodeoxyglucose ( fdg ) positron emission tomography / computed tomography ( pet / ct ) to rule out residual / recurrent disease 6 months following completion of therapy . the fdg scan 3 months following therapy had not shown evidence of viable residual or metastatic disease . the present scan showed a tiny focus of abnormal fdg accumulation in the region of the trigone of the left lateral ventricle which was best appreciated on the plain pet image . a correlative c-11 methionine study showed a well defined focus of abnormal tracer accumulation in the region of the left trigone . cect and mri done subsequently proved it to be a subependymal deposit . this case therefore demonstrates the possibility of subependymal deposits in gbm and the need for this possibility to be entertained during interpretation of the fdg study . it also highlights the advantage of labelled amino acids like c-11 methionine for clearly delineating subependymal deposits apart from the advantage for unequivocal interpretation of the pet study in recurrent brain tumors .
study protein aggregation burgeoning field research driven urgent need elucidate mechanism neurodegenerative diseases desire understand mimic natures ability create hierarchical complex nanostructures necessity understand minimise product loss processing formulation biopharmaceuticals aggregation particular importance therapeutic proteins lead loss product reduce efficacy alter biological activity pharmacokinetics even raise safety concerns increased immunogenicity 13 aggregation induced solution conditions protein concentration ph salinity temperature presence additives 4 5 stresses protein expression refolding freeze thaw cycles agitation exposure hydrophobic surfaces air including foaming also lead formation aggregates 2 46 each environmental factors typically encountered bioprocessing downstream processing storage also vivo delivery biopharmaceutical actives hence significant going work channelled exploring onset aggregation aggregation pathway understanding factors subsequently allows development informed strategy minimise aggregation biopharmaceutical production example inclusion surfactants influence protein monomer interactions the influence solution ph aggregation one studied important parameters controls onset aggregation final aggregate morphology this ph alters surface charge protein monomer also extent structural disruption prior aggregation hence influences propensity self assemble manner go onto aggregate for example ph values close isoelectric point repulsive interactions native monomers reduced making assembly favourable conditions phs far isoelectric point increased charge repulsion within protein destabilises folded conformation leading exposure hydrophobic groups turn drive self assembly unfolded states typically -sheet rich fibrillar structures 8 9 temperature another key factor critical factor commercial processes induces aggregation increasing temperature increases vibrational motion diffusion proteins necessary step aggregation moreover temperature nears denaturation temperature protein protein partially unfolds exposing hydrophobic regions induces aggregation the literature awash many studies postulate different models self assembly proteins generally divided two main categories empirical mechanistic mechanistic models based reaction scheme parameters relating kinetics thermodynamics process whereas empirical models utilise functions fit data physical meaning a large array different mechanistic models proposed broadly categorised monomer addition reversible association prion aggregation minimalistic 2-step quantitative structure activity relationships alternatively roberts proposed comprehensive generic mechanistic scheme protein aggregation associated generic equations went onto show could simplified certain conditions limiting cases overall models based idea aggregation mediated reactive intermediate equilibrium native state intermediate able aggregate initially via nucleation step followed growth phase native n intermediate aggregate many groups experimentally tested models techniques developed exploited study aggregation ex situ situ 13 14 ex situ state aggregation measured static samples long data acquisition times needed samples need separated dried fixed labelled example using electron microscopy mass spectrometry furthermore aggregation process reliably halted persevered series samples representing different stages situ measurements aggregation events monitored happen technique used needs sufficient time resolution process monitored data analysis complex since typically mixture component sizes aggregates monomers typical techniques currently used include circular dichroism fourier transform infra red dynamic light scattering 13 15 technique yield useful information aggregation process crucial able relate measured parameter back changes aggregation state aggregate size monomer depletion here thermal aggregation industrially relevant biopharmaceutical recombinant protective antigen rpa active component second generation anthrax vaccine examined visually via turbidity measurements information size shape aggregates formed obtained using combination optical environmental scanning electron microscopies two environmental conditions explored samples prepared without denaturant urea subsequently rate aggregate growth different isothermal temperatures compared using ultraviolet light scattering spectroscopy uv lss 1723 particle size extracted function time this done collecting spectra time without need remove material analysis hence demonstrating nondestructive situ time resolved method monitoring aggregation process results aggregation rpa discussed model describing kinetics thermodynamics aggregation presented rpa supplied avecia biologics uk 2 mg ml phosphate buffered saline solution adjusted ph 7.4 doubly distilled water obtained elga purelab ultra 18.2 all chemicals purchased either sigma aldrich uk acros organics uk reagent grade least 97% pure used recieved rpa samples supplied treated using following procedure provide consistent starting material analysis initially rpa precipitated solution heating 50c circa 5 min the resulting gel centrifuged 6000 rpm 1 minute supernatant discarded the gel resuspended adding doubly distilled water vortexing 2 min the gel resolubilized adding urea doubly distilled water form 8 urea solution rpa refolded dilution using 1 part rpa 8 urea 31 parts refold buffer this done two stages 1 7 dilution followed 1 4 dilution 2 minutes later refold buffer contained 25 mm tris 25 mm nacl 2 mm cacl2 adjusted ph 7.4 hydrochloric acid the final buffered samples contained circa 0.15 0.3 mg ml rpa 0.25 urea analysed immediately refolding this concentration chosen mimics conditions storage formulations protective antigen vaccines samples without urea prepared using refolding method followed dialysis using 3500 dalton molecular weight cutoff visking dialysis membrane medicell international ltd 10 times excess chilled refold buffer 18 hours refrigerator ~4c after external solution replaced twice fresh refold buffer allowed dialyse 24 hours the rpa sample recovered sealed membrane stored refrigerator circa 4c prior use the concentration refolded rpa solution determined uv absorbance 280 nm shimadzu uv 2501-pc spectrophotometer using molar absorption coefficient 72769 cm the isothermal aggregation rpa monitored visually time incubating samples range temperatures 4349c close denaturation temperature rpa 50.0c using recirculating water bath connected heating stage contained sample cell the temperature measured using calibrated k type thermocouple placed sample solution accurate 0.3c images rpa aggregates obtained using zeiss axioplan 2 transmission mode 10x magnification objective digital camera the aggregated samples pipetted onto microscope slide cover slip placed top aggregates mounted esem analysis simply lifting solution mica disc placing directly onto sample stage the samples examined using philips fei quanta 200 esem electron gun accelerating voltage set 30 kv sample stage 5c chamber pressure 6 torr light scattering spectra recorded using shimadzu uv 2501-pc spectrophotometer set record 250 390 nm every 2 nm medium scan rate the wavelength dependence absorbance arising light scattering particles solution follows relationship 1)a= absorbance wavelength constant scattering exponent the scattering exponent related particle size using mie theory mie equations solved range particle sizes nanometres micrometres wavelengths 320 390 nm using fortran programme adapted bohren huffman these calculations required refractive index particles surrounding solution relevant wavelengths the solution refractive index taken water particle refractive index calculated evaluating lorentz lorenz molar refraction using chemical formula rpa density 1.43 g cm the density based molecular weight rpa 82667 da volume 95.74 nm calculated vadar using crystal structure rpa stored protein data bank http://www.pdb.org/ pdb 1acc this value density considered reasonable compared density proteins similar molecular weight the values refractive index n calculated particles different wavelengths within visible region given table 1 these values subsequently extrapolated uv region using cauchy equation 2)n=1.642 79802 the results obtained using mie theory analysed give theoretical scattering exponent versus diameter providing means converting experimental scattering exponents particle size 3)d=0.686 6 6.869 521.397 4 23.795 323.682 2111.896 +642.207 particle diameter nm scattering exponent 320 390 nm solutions rpa 0.31 mg ml incubated range temperatures 2550c visual appearance monitored time this temperature range selected denaturation temperature rpa known ~50c a typical example changes recorded figure 1 shows visual appearance rpa solution time whilst held steady temperature 47.6c initially sample clear seen figure 1(a remained clear first minutes after 8 minutes sample started become cloudy evident figure 1(b the slightly cloudy homogeneous appearance sample indicates presence microscopic particles sufficient size concentration noticeably scatter visible light this seen comparing images figures 1(b 1(c latter appears cloudier after 32 minutes sample longer homogeneous since particles large enough observed visually started form see figure 1(e point forwards black background removed provide improved contrast observing macroscopic particles forming solution sample remained cloudy appeared brighter since light able enter behind the macroscopic particles easily observed appeared dark spots bright cloudy solution following emergence macroscopic particles observed initially increase size number seen images shown figures 1(e 1(f beyond point number individual particles appeared fall whilst continuing grow size figure 1(g the final image sample figure 1(h taken black background replaced enable comparison initial sample appearance it shows sample returned clear solution apart presence large white particles settled bottom sides cuvette such observations suggest small microscopic particles form initially causing sample appear turbid subsequently cluster form large macroscopic particles sediment due gravity critical size these visual results complemented turbidity measurements recorded identical conditions see figure 2 labels h figure 2 positioned relate photographs taken rpa aggregation shown figure 1 the turbidity assessed recording optical density using light wavelength 320 nm figure 2 shows sharp rise turbidity first 20 minutes incubation this consistent appearance growth particles solution indicated visual observations the subsequent fall turbidity suggests particles either decreasing size might occur aggregation reversible decreasing concentration could occur particles clustered form larger structures the latter consistent visual observation particles growing size reducing number time settling bottom sample cuvette similar visual turbidity observations noted samples incubated 43 49c appeared similar two step mechanism the time scales step varied widely however different temperatures time reach peak turbidity ranged circa 10 minutes 49c 10 hours 43c this dramatic increase aggregation rate versus temperature could driven either increasing translational kinetic energy protein monomers causing frequent collisions particles increasing internal kinetic energy protein monomers the latter drive monomers toward unfolded state associated exposure hydrophobic patches increasing likelihood collision results self association the morphology macroscopic particles formed incubation examined using optical electron microscopy figure 3(a shows typical optical micrograph rpa aggregates formed 16 hours 47c the micrograph reveals formation several aggregates different shapes sizes appear composed microscopic particles this consistent visual observation cloudy solution microscopic particles cluster form large aggregates the aggregates generally range length ~75 730 width ~5150 three aggregates fairly distinct structures labelled figure 3(a the smallest labelled 165 long 30 widest point this aggregate appears reasonably linear growth predominantly one direction limited side branching the two aggregates larger similar dimensions ~380 150 however dense structure whilst open structure the open structure consists branched system linear components similar aggregate suggesting precursor formation either one many components come together starting point growth combination the structure densely packed however still evidence branched structure similar structural features observed suggesting possibly precursor formation observations inferences also supported previous work fractal aggregates reviewed meakin such comparisons suggest rpa aggregates described fractal aggregates confirming formed clustering microscopic particles obtain information size shape microscopic particles the aggregates viewed esem typical micrograph given figure 3(b the microscopic particles appeared reasonably spherical uniform diameter approximately 500 nm this observation consistent previously reported results thermal aggregation proteins close isoelectric points showed formation monodisperse particulates here working ph 7.4 close isoelectric point rpa ph 5.6 therefore individual protein monomers reduced net charge in addition salt present buffered media screen remaining charge proteins thus long range charge charge repulsions could act barrier aggregation minimised the protein monomer likely partially unfolded temperature approaches denaturation temperature ~50c the exposed hydrophobic regions consequently drive nonspecific monomer aggregation conditions reduced net charge this turn leads formation three dimensional spherical aggregates observed figure 3(b the approximately uniform size particles sample suggests concentration remained reasonably constant growth consistent features protein aggregation summarised gosal ross murphy slight increase particle diameter 360 500 the rate aggregation different isothermal temperatures explored using uv light scattering spectroscopy uv lss spectra recorded every 20 seconds initially every 20 seconds 40 minutes depending aggregation rate such fast acquisition times provide speed advantage light scattering techniques analysing aggregation kinetics it clear absorbance initially chromophores protein absorb wavelength range absorbance intensity increases time difference successive spectra large initially reduces longer times this implies aggregates grew quickly initially rpa monomer concentration highest followed slowing growth rpa monomers consumed falling concentration as discussed previously rpa solutions became turbid incubation temperatures 43c therefore assumed multiple light scattering occurring it assumed however wavelength dependence light scattering obtained solving mie equations would hold scattering occurring uv spectra figure 4(a analysed see section 2.8 give aggregate diameter versus time see figure 4(b it clear particles grew quickly initial ~60 min gradually slowing reaching final particle size ~300 min temperature the equilibrium sizes particles formed increased slightly 390 500 nm increasing incubation temperature correlates well esem observations ~360500 nm this confirms assumption wavelength dependence light scattering turbid solution adequately approximated mie theory explore effect isothermal temperature particle growth rate and consequently gain insight aggregation kinetics particle size recorded function time range temperatures 4349c results given figure 5 the aggregate diameter versus time profile fitted 4)dmodel dfd0et/ dmodel model fit particle diameter nm df final particle diameter function converges nm d0 fitting parameter nm time constant particle growth process time the optimum fit found using newton method maximise correlation coefficient r whilst allowing value df vary the values d0 correlation coefficient calculated straight line fit using least squares regression plot ln(df dmodel versus time all profiles show increase diameter time however time taken reach maximum diameter markedly different temperature higher temperature shorter time scale reach maximum diameter this reflected results notable increase profile gradient temperature increased maximum gradient increases 2.7 times average every 1c increase temperature similar results obtained range samples containing additive 0.25 urea case similar trends observed time range incubation temperatures difference arising rate particle growth slightly faster sample presence 0.25 urea all samples contained homogeneous distribution particle size confirmed esem suggesting aggregate concentration remained constant time this means quantity rpa aggregates determined estimating aggregate concentration using ratio aggregate monomer volume difference quantity rpa incorporated within aggregates quantity monomer present initially gave monomer concentration time providing possible means assessing aggregation kinetics end data initial incubation times scattering increasing analysed using generalised scheme protein aggregation pathway this scheme outlined figure 6 n native state protein monomer intermediate unfolded denatured conformational state aj aggregate consisting j protein molecules am)n cluster particulate aggregates k1 k5 rate constants different processes this aggregation pathway simplified based aforementioned experimental observations considered reasonable exclude step since spherical nature aggregates inferred growth dominated single monomer addition rather clustering form irregular structures step b also considered played significant role since aggregates formed reasonably uniform size aggregate concentration would reasonably constant growth it reasonable expect new aggregates formed throughout aggregation process wide distribution aggregate sizes would observed the modelling aggregation kinetics simplified considering two limiting cases unfolding limited aggregation association limited aggregation tried association limited aggregation found appropriate gave better fit experimental data reasonable kinetic values comparison previous work 33 34 case association limited aggregation step rapid step c k1 k2k4 n and k2ci total monomer concentration cm sum concentrations monomers native state n structurally altered state cm cn ci combining two relationships gives 5)cm=(1+k)cik k equilibrium constant k k1/k2 since step c rate limiting step resulting kinetic model second order rate equation incorporates equilibrium constant order stated terms cm 6)(rm)=k4cmcak(1+k stated previously aggregate concentration ca is expected reasonably constant therefore model reduced pseudo first order 7 equilibrium constant incorporated rate constant rate equation 8) follows 7)(rm)=kpseudo cm,(8)kpseudo k4cak(1+k this model subsequently used estimate aggregation kinetics samples using experimental particle diameter d(t figure 5 calculate number monomers aggregate function time an(t ratio monomer volume aggregate volume via 9)an(t)=[d(t)]36vm the volume pa molecule vm taken 95.74 nm obtained using crystal structure described previouslt free monomer concentration versus time cm(t ) was obtained taking difference initial monomer concentration cm0 amount monomers aggregates based previous assertion aggregate concentration remained constant 10)cm(t)=cm0[caan(t the final size aggregate function converges assumed size aggregates would stopped growing clustering process interfered particulate growth phase point protein monomers would consumed proteins would present form particulate aggregates aggregate concentration therefore given 11)ca cm0 6vm df)3 this procedure used generate concentration versus time profiles best fit pseudo first order kinetics range temperatures results 0.25 urea samples shown figure 7(a values second order k provided figure 7(b evident case fitted data good agreement obtained experimentally magnitudes rate constants obtained data reasonable although little high compared reported elsewhere association limited aggregation protein e.g. bovine granulocyte colony stimulating factor extracted values region 10 10 dm mol similar temperature range it clear figure 7(b association limited aggregation rate constants samples without added urea increase exponentially temperature average if data plotted lnk versus 1/t figure 7(c clear data follows arrhenius law k afexp(eact rt af pre exponential factor absolute temperature k eact activation reaction j mol r ideal gas constant j mol k gradients slope the activation energies two sample types calculated 942.0 92.4 kj mol rpa without additives 928.8 32.5 kj mol rpa 0.25 urea these values suggest addition urea reduced activation energy slightly correlates observation presence urea increases rate aggregation the magnitude activation energies reasonable compared reported elsewhere association limited aggregation protein reported ~420 ~840 kj mol these values reported observed activation energies accompanied suggestion temperature dependence association limited rate constants follow true arrhenius behaviour the frequency factors af two sample types calculated 1.8 10 dm mol rpa without additives 4.7 10 dm mol rpa 0.25 urea values high unlikely physical significance published values second order frequency factors various small molecule solution phase reactions range 10 10 dm mol this suggests arrhenius equation empirical fit data this unexpected given suggestion cited previously temperature dependence association limited rate constants follow true arrhenius behaviour however correlation coefficients data lines best fit show reasonable fit 0.963 samples without additives 0.973 samples 0.25 urea alternative appropriate approach modelling temperature dependence rate constant factor behaviour equilibrium constant k.the analysis using association limited model far yielded observed second order rate constant aggregation process kinetic model analysis is represented 12)(rm)=kobs cm ca kobs observed rate constant comparing 6 reveals kobs related actual rate constant k4 equilibrium constant k 13)kobs k4k(1+k the temperature dependence k given 14)ln(k)=srhrt entropy change j mol k h enthalpy change process j mol absolute temperature k r gas constant j mol k fit experimental data temperature dependence equilibrium constant assumed rate constant k4 independent temperature the physical significance activation energy assumed negligible process perturbed monomers added growing aggregate this reasonable assumption since activation energies reaction highly reactive free radicals close zero 35 36 given perturbed monomers highly unfavourable hydrophobic patches exposed water likely highly reactive easily associated aggregate order reduce free energy rearranging 13 equating 14 yields 15)ln(kobsk4kobs)=srhrt therefore plotting ln(kobs/(k4 kobs versus 1/t yield straight line gradient h r intercept r the initial estimate k4 picked choosing value greater largest value kobs logarithmic term could satisfied when 0.25 urea data plotted found correlation coefficient fit line best fit data points improved value k4 increased it basis optimum value 5.77 10 dm mol selected k4 the value k4 effectively represents value frequency factor since activation assumed zero such optimum value rate constant frequency factor much likely physical significance since comparable general values frequency factor found literature discussed previously the value k4 used analysis sets data rpa without additives rpa 0.25 urea this done assumption collision rate would significantly altered presence absence urea it clear correlation coefficients data lines best fit reasonable agreement sets samples h extracted graph sample used calculate gibbs free energy change g 25c the values obtained table 2 compared reasonably well reported literature g folded unfolded proteins reported typically 20 60 kj mol these values also indicate expected presence urea reduces stability rpa likely helping disrupt native structure protein causing become perturbed temperatures lower absence urea explore effect temperature extent disruption individual proteins fraction protein perturbed intermediate state x calculated using 16 plotted function temperature figure 9 16)x cicm k(1+k extrapolation data ambient temperatures shows fraction protein perturbed state negligible low temperatures for example extrapolation 25c sample 0.25 urea shows fraction protein perturbed state 10 this corroborates experimental observations rpa show observable aggregation extended periods circa 16 hours ambient temperature the unfolded fraction also extrapolated higher temperatures using 11 12 results shown extrapolated line best fit figure 9 the inset figure 9 shows fraction monomer perturbed state rises sigmoidally 46c 55c higher proportion protein perturbed urea present both observations correlate susceptibility protein samples aggregate protein perturbed higher chances faster kinetics aggregation for example 8-anilino-1-naphthalene sulfonate ans rpa reported elsewhere show hydrophobicity rpa increases sigmoidally versus temperature 40 55c also case thermal unfolding examined circular dichroism revealed sigmoidal increase unfolding versus temperature 45 55c the susceptibility biopharmaceutical protein rpa aggregate function temperature formulation conditions determined kinetics thermodynamics aggregation process modelled quantified visual turbidity experiments showed thermal aggregation rpa occurs incubation temperatures 43c close denaturation temperature conditions the protein likely increased translational kinetic energy hence collisions take place also least partially unfolded hence exposed hydrophobic regions known induce rapid nonspecific aggregation such aggregation found proceed stepwise manner first forming spherical microscopic particles followed clustering form fractal aggregates increasing temperature 43c increased rate aggregation dramatically also size diameter spherical microscopic particles formed ~360 500 nm increasing temperature 43 49c we went show growth microscopic particles monitored using uv lss in particular used increase scattered light sample time elucidate aggregate size versus time giving quantitative measure aggregation moreover experiments conducted range temperatures without 0.25 urea results analysed determine rate constant temperature dependence thermal aggregation process based analysis proposed aggregation process association limited temperature dependence relates equilibrium behaviour native perturbed states we also able extract thermodynamic parameters aggregation samples without urea indicated presence urea reduces stability rpa hence increases susceptibility aggregation the modelling tools developed analysis data easily accessible uv lss technique provides fast situ analysis method comparing stability different formulations protein exposed different environmental conditions this method important speed advantage light scattering techniques analysing particle growth kinetics this work therefore provides basis quantitatively exploring effect additives and/or different processing conditions rate aggregation industrially relevant biopharmaceuticals aim minimising self association production downstream processing storage	the thermal aggregation of the biopharmaceutical protein recombinant protective antigen ( rpa ) has been explored , and the associated kinetics and thermodynamic parameters have been extracted using optical and environmental scanning electron microscopies ( esems ) and ultraviolet light scattering spectroscopy ( uv - lss ) . visual observations and turbidity measurements provided an overall picture of the aggregation process , suggesting a two - step mechanism . microscopy was used to examine the structure of aggregates , revealing an open morphology formed by the clustering of the microscopic aggregate particles . uv - lss was used and developed to elucidate the growth rate of these particles , which formed in the first stage of the aggregation process . their growth rate is observed to be high initially , before falling to converge on a final size that correlates with the esem data . the results suggest that the particle growth rate is limited by rpa monomer concentration , and by obtaining data over a range of incubation temperatures , an approach was developed to model the aggregation kinetics and extract the rate constants and the temperature dependence of aggregation . in doing so , we quantified the susceptibility of rpa aggregation under different temperature and environmental conditions and moreover demonstrated a novel use of uv spectrometry to monitor the particle aggregation quantitatively , in situ , in a nondestructive and time - resolved manner .
lesion present variety clinical findings depending severity malformation interosseous avm often remains undiagnosed dramatic bleeding incident occurs usually result dental manipulation various treatment modalities described treatment high flow avm adjunct surgery curettage resected fragment immediate replantation reduces morbidity associated procedure difficulty reconstruction this seems good approach following logic present case avm mandible treated extracorporeal curettage lesion immediate replantation segment a 16-year old female patient reported emergency department massive bleeding episode extraction tooth could controlled biting gauze piece bleeding stopped applying sustained local pressure extraction site history revealed left mandibular second premolar carious associated persistent pain swelling region past 2 years swelling subside even taking antibiotics local dentist extracted tooth without taking radiographs resulting massive uncontrolled bleeding detailed examination 12 hours soft pulsatile tender swelling audible bruit the overlying skin normal color paresthesia involved region marginal gingival bleeding also noted i.r.t 33 34 36 37 buccal expansion mandible rest physical examination unremarkable blood investigations normal stage patient refused treatment returned months meanwhile swelling increased present size patient suffered two bleeding episodes soft tender pulsatile swelling left mandibular region colored ultrasonography soft submental swelling revealed high flow lesion multiple feeders orthopantmograph opg showed extrusion 33 34 displacement tilting adjacent teeth ill defined moth eaten type radiolucency involved left mandibular parasymphysial body region ; also inferior alveolar canal dilated tortourous enlarged mental foramen figure 2 axial coronal sections computed tomography ct scan revealed multiseptae central bony destructive lesion expansion bicortical plates without perforation figures 3a b needle aspiration distance away lesion resulted syringe full bright red blood preoperative opg showing moth eaten irregular radiolucency left mandibular parasymphysis body region enlarged torturous mandibular canal adjacent teeth displaced axial ct coronal ct section demonstrating widespread destruction thinning cortical plates patient taken operating room elective tracheostomy done maintain airway postoperatively case massive swelling dissection done identify common carotid artery achieving proximal distal control osteotomy cuts given buccal cortical plates away lesion using bone spreader inferior alveolar artery identified ligated using extracorporeal technique teeth extracted involved segment followed curettage hollowing mandible curretes rotating handpiece bur figures 4 5 stabilization reimplanted mandibular piece done three 2.5 mm miniplates figure 6 follow 2 years ultrasound revealed new vascular lesion region excellent facial form function maintained figures 7 8 resected mandibular segment containing focal lesion extracorporeal technique extraoral removal teeth curettage lesion reimplantation mandibular segment stabilization miniplates postoperative opg showing good alignment mandibular lower border fixation plates symphysis angle postoperative radiograph showing maintenance normal anatomical contour the patient taken operating room elective tracheostomy done maintain airway postoperatively case massive swelling dissection done identify common carotid artery achieving proximal distal control osteotomy cuts given buccal cortical plates away lesion using bone spreader inferior alveolar artery identified ligated using extracorporeal technique teeth extracted involved segment followed curettage hollowing mandible curretes rotating handpiece bur figures 4 5 stabilization reimplanted mandibular piece done three 2.5 mm miniplates figure 6 follow 2 years ultrasound revealed new vascular lesion region excellent facial form function maintained figures 7 8 resected mandibular segment containing focal lesion extracorporeal technique extraoral removal teeth curettage lesion reimplantation mandibular segment stabilization miniplates postoperative opg showing good alignment mandibular lower border fixation plates symphysis angle postoperative radiograph showing maintenance normal anatomical contour international society study vascular anomalies classified hemangioma endothelial proliferation vascular malformation vm normal endothelial tumor relying 1982 biologic classification mulliken glovacki based endothelial characteristics the vms categorized low flow lesions capillary venous lymphatic malformations high flow lesions avms arteriovenous fistulae according blood flow characteristics intraosseous vms maxillofacial region sometimes give rise dental emergencies may cause disfigurement morbidity even death the proximity teeth prove disastrous like case extraction tooth resulted massive hemorrhage a review fatal cases lamberg others shows instances exsanguination result dental extractions dentist unaware existence avm vascular lesions jaws overall 2:1 female male occurrence peak incidence second decade female patient 16 years age although 50% vascular lesions occur head neck region small percentage occur jaws.[810 twice common mandible maxilla mandibular vm usually appears adolescence extremes 3 months 74 years age vms caused disturbance late stages angiogenesis truncal stage result persistence av anastomosis present embryonic life vms usually present developmental anomalies birth develop proportion physical growth increase size of these vms asymptomatic imperceptible early age promoted local hemodynamic factors the blood shunted malformation causes lesion grow turn causes increased shunting blood hence leading vicious cycle as seen lesion present variety clinical manifestations depending severity malformation however occasionally asymptomatic cases also reported patients av malformation some signs symptoms reported soft tissue swelling paresthesia pain variable intensity,[1620 teeth mobility migration discoloration overlying skin intraoral mucosal surfaces facial asymmetry local pulsation noticeable bruit erythematous gingival bleeding around teeth bone resorption palpable thrill well resorption roots affected area evident tooth related cause periapical pathoses systemic findings like blurred vision epistaxsis paresthesia cardiac abnormalities murmur hypertrophy failure reported the radiographic appearance quite variable therefore unreliable sole basis diagnosis gelfand summarized three typical radiographic appearances sunray appearance created trabecular bone vessels osetolytic lesion.a soap bubble honeycomb appearance occasional punched areas.an appearance described ill defined radiolucency sunray appearance created trabecular bone vessels osetolytic lesion soap bubble honeycomb appearance occasional punched areas appearance described ill defined radiolucency other radiographic findings may include cortical expansion well unilocular multilocular cystic areas phleboliths root resorption lack lamina dura also described according stafne numerous treatments varying combinations various degrees success employed including ligation embolization radical resection use sclerosing solutions curettage packing radiation bone wax packing cavities followed curettage two cases observation even cryosurgery embolization reduces blood flow allowing excision performed subsequently within 48 hours2 weeks embolization also without risk embolic complications allergic reactions avascular necrosis bone delayed root development defective mandibular growth reported resection mandible result variety disabilities including impairment speech articulation salivary control difficulty swallowing trismus deviation mandible toward surgical side functional movement this led concept immediate reconstruction introduced weaver et al used patient prefrozen mandibular bone greene et al advocate filling particulate marrow cavity digital subtraction angiography embolization treatment modality are available institute rely traditional method careful ligation feeder vessel prevent excessive blood loss intraoperative blood infusion done prevent complications this young female patient followed almost 2 years good esthetic facial symmetry functional status maintained we arrived similar conclusion technique safe convenient effective alternative treat vascular malformations restore near exact form function symmetry without obviating need space maintainers bone harvesting future major reconstructive operations keeping cost factor check resection involved portion followed curettage reimplantation emerge valid alternative secondary reconstructive surgery	arteriovenous malformations of jaw are extremely rare conditions that can result in disastrous complications , if handled carelessly . although various treatment modalities have been advocated in the literature , there seems to be no complete consensus on a suitable treatment in these cases . this report highlights the importance of correct diagnosis and early treatment in management of vascular malformations . extracorporeal curettage followed by immediate replantation yielded good results in our case and this technique can emerge as a valid alternative , especially in developing countries .
sensitivity screening mammography decreased presence dense breast tissue defined american college radiology acr breast imaging reporting data system bi rads published studies hand held breast ultrasound supplemental test screening mammography women dense breast tissue report incremental cancer detection rate approximately 24/1000 examined women breast cancers detected supplemental ultrasound reported small invasive cancers high proportion node negative cases however studies important differences methodology including varied inclusion criteria varied qualification ultrasound performers recently mainly result efforts grassroots advocacy groups several states united states us ) have enacted legislation requiring following screening mammography women dense breasts informed breast tissue density supplemental screening tests breast ultrasound discussed providers us would entail supplemental screening 40% women 40 years age the purpose study retrospectively assess results initial round supplemental screening hand held bilateral breast ultrasound performed consecutively technologist radiologist following negative bilateral screening mammogram asymptomatic women dense breast tissue high risk breast cancer defined american college radiology acr society breast imaging sbi a retrospective health insurance portability accountability act hipaa)-compliant institutional research board irb)-approved study performed a systematic review breast imaging center database performed identify asymptomatic women reported heterogeneously dense figure 1a b extremely dense figure 2a b breast tissue defined bi rads atlas screening bilateral mammogram performed july 1 2010 june 30 2012 received final assessment birads category 1 negative birads category 2 benign ( bilateral mammogram cranio caudal view heterogeneously dense breasts b bilateral mammogram medio lateral oblique view heterogeneously dense breasts bilateral mammogram cranio caudal view extremely dense breasts b bilateral mammogram medio lateral oblique view extremely dense breasts time study breast imaging center initiating policy paragraph added radiologist mammogram report referring physician women meeting criteria stating given dense breast tissue may lower sensitivity mammography supplemental screening breast ultrasound offered facility women high risk breast cancer 2025% greater lifetime risk breast cancer defined american cancer society recommended undergo supplemental screening breast magnetic resonance imaging mri thus included study further included women personal history breast cancer institution undergo diagnostic screening mammography life the following data retrieved women included study age race family history breast cancer personal history breast biopsy personal history biopsy proven high risk lesion breast age menarche age menopause parity age first pregnancy use hormones hormonal contraceptives hormone replacement therapy in addition women received offered breast ultrasound following data also retrieved based bi rads atlas final assessment bi rads category breast ultrasound exam biopsy recommended descriptors ultrasound findings solid vs cystic measurement longest axis cm shape margins echogenicity posterior acoustic features orientation pathology results biopsy performed if final assessment category initial screening breast ultrasound bi rads 3 results first two consecutive short term follow ultrasounds recorded an interval follow increase size mass 20% longest axis considered warrant biopsy every screening bilateral mammogram obtained 2d digital study selenia- hologic unit performed one six mammography technologists certified mammography registered american registry radiologic technologists experience 17 11 6 6 5 4 years interpreted one four board certified breast imagers 30 11 3 2 years experience breast imaging every supplemental bilateral breast ultrasound examination obtained less six months screening mammogram obtained dedicated breast ultrasound unit ge logic e9 high resolution linear array transducer 615 mhz one six technologists two rdms certified registered diagnostic medical sonographer one arrt certified american registry radiologic technologists two experience breast sonography 10 years one 6 years two 5 years experience one 1-year experience the breast ultrasound performed standardized hand held manner overlapping scans radial antiradial planes extending nipple posterior breast tissue if abnormal findings identified images documented 12- 3- 6- 9-oclock positions well retroareolar region finding present images finding obtained measured three dimensions immediately breast ultrasound exam technologist exam repeated one four board certified dedicated breast imaging radiologists the breast imager performed repeat complete ultrasound scan breasts real time regardless whether technologist identified abnormality blinded results screening mammogram patient history able review breast ultrasound images obtained technologist all ultrasound guided breast biopsies performed either 14-gauge automated core biopsy needle achieve cardinal health dublin ohio 9 12-gauge vacuum assisted core biopsy needle atec hologic bedford the chi square test used discrete data test continuous data statistically significant difference considered p 0.05 the statistical analysis performed using medcalc statistical software version 12.3.0 1993 2012 medcalc software bvba medcalc software broekstraat 52 9030 mariakerke belgium a systematic review breast imaging center database performed identify asymptomatic women reported heterogeneously dense figure 1a b extremely dense figure 2a b breast tissue defined bi rads atlas screening bilateral mammogram performed july 1 2010 june 30 2012 received final assessment birads category 1 negative birads category 2 benign bilateral mammogram cranio caudal view heterogeneously dense breasts b bilateral mammogram medio lateral oblique view heterogeneously dense breasts bilateral mammogram cranio caudal view extremely dense breasts b bilateral mammogram medio lateral oblique view extremely dense breasts time study breast imaging center initiating policy paragraph added radiologist mammogram report referring physician women meeting criteria stating given dense breast tissue may lower sensitivity mammography supplemental screening breast ultrasound offered facility women high risk breast cancer 2025% greater lifetime risk breast cancer defined american cancer society recommended undergo supplemental screening breast magnetic resonance imaging mri thus included study further included women personal history breast cancer institution undergo diagnostic screening mammography life the following data retrieved women included study age race family history breast cancer personal history breast biopsy personal history biopsy proven high risk lesion breast age menarche age menopause parity age first pregnancy use hormones hormonal contraceptives hormone replacement therapy in addition women received offered breast ultrasound following data also retrieved based bi rads atlas final assessment bi rads category breast ultrasound exam biopsy recommended descriptors ultrasound findings solid vs cystic measurement longest axis cm shape margins echogenicity posterior acoustic features orientation pathology results biopsy performed if final assessment category initial screening breast ultrasound bi rads 3 results first two consecutive short term follow ultrasounds recorded an interval follow increase size mass 20% longest axis considered warrant biopsy every screening bilateral mammogram obtained 2d digital study selenia- hologic unit performed one six mammography technologists certified mammography registered american registry radiologic technologists experience 17 11 6 6 5 4 years interpreted one four board certified breast imagers 30 11 3 2 years experience breast imaging every supplemental bilateral breast ultrasound examination obtained less six months screening mammogram obtained dedicated breast ultrasound unit ge logic e9 high resolution linear array transducer 615 mhz one six technologists two rdms certified registered diagnostic medical sonographer one arrt certified american registry radiologic technologists two experience breast sonography 10 years one 6 years two 5 years experience one 1-year experience the breast ultrasound performed standardized hand held manner overlapping scans radial antiradial planes extending nipple posterior breast tissue if abnormal findings identified images documented 12- 3- 6- 9-oclock positions well retroareolar region if finding present images finding obtained measured three dimensions immediately breast ultrasound exam technologist exam repeated one four board certified dedicated breast imaging radiologists the breast imager performed repeat complete ultrasound scan breasts real time regardless whether technologist identified abnormality blinded results screening mammogram patient history able review breast ultrasound images obtained technologist all ultrasound guided breast biopsies performed either 14-gauge automated core biopsy needle achieve cardinal health dublin ohio 9 12-gauge vacuum assisted core biopsy needle atec hologic bedford the chi square test used discrete data test continuous data the statistical analysis performed using medcalc statistical software version 12.3.0 1993 2012 medcalc software bvba medcalc software broekstraat 52 9030 mariakerke belgium during study period total 2469 asymptomatic women high risk breast cancer without personal history breast cancer received final assessment bi rads category 1 negative bi rads category 2 benign screening bilateral mammogram evaluated 1210 49% found heterogeneously dense extremely dense breast tissue 394 32.5% women underwent offered supplemental screening bilateral breast ultrasound initial round supplemental screening breast ultrasound 323 women 81.9% received final assessment bi rads category 1 negative figure 3 bi rads category 2 benign figure 4a b recommended undergo routine yearly screening whereas 50 women 12.9% received final assessment bi rads category 3 probably benign figure 5a c recommended undergo short term follow breast ultrasound 6 months table 1 two women received bi rads category 3 requested biopsy performed a bi rads category 4 suspicious figures 6a c 7a b recommendation biopsy assigned 19 women 4.8% table 1 a total 21 women 5.3% underwent ultrasound guided procedure result initial round supplemental screening bilateral breast ultrasound negative bilateral screening breast ultrasound showing simple cyst patient breast implants category birads 2 benign b bilateral screening breast ultrasound showing simple cyst color doppler patient breast implants- category birads 2 benign bilateral screening breast ultrasound showing benign appearing mass likely fibroadenoma six month follow ultrasound recommended- category birads 3 ( b bilateral screening breast ultrasound showing benign appearing mass likely fibroadenoma six month follow ultrasound recommended- category birads 3 probably benign c bilateral screening breast ultrasound showing benign appearing mass likely fibroadenoma color doppler six month follow ultrasound recommended- category birads 3 probably benign bi rads category initial round supplemental screening breast ultrasound recommended subsequent short term follow ups bilateral screening breast ultrasound showing round heterogenous mass mixed solid cystic components irregular margins suspicious b bilateral screening breast ultrasound showing round heterogenous mass mixed solid cystic components irregular margins radial plane suspicious c bilateral screening breast ultrasound showing round heterogenous mass mixed solid cystic components irregular margins suspicious bilateral screening breast ultrasound showing palpable mass right breast 9:00 axis suspicious b bilateral screening breast ultrasound showing palpable mass right breast 9:00 axis color doppler suspicious result first two consecutive short term follow ups breast ultrasound recommended patients assigned bi rads category 3 five biopsies recommended performed four biopsy recommendations generated first short term follow cycle one second short term follow cycle table 1 overall total 26 women 6.6% recommended biopsy performed the common ultrasound finding biopsy recommended performed solid mass 88.5% average size 0.9 cm range 0.51.7 cm table 2 fine needle aspiration complicated cyst two patients 11.5% performed resulted complete resolution cyst nonsuspicious fluid table 2 our study includes asymptomatic women dense breast tissue high risk breast cancer represent majority women dense breast tissue undergo screening mammography breast cancer some prior studies supplemental screening breast ultrasound dense breast tissue included women high risk breast cancer whereas others included symptomatic women unilateral breast ultrasound obtained women known mammographic abnormalities contralateral breast even different quadrant ipsilateral breast moreover pointed may methodological flaws numerous studies previously suggested link breast density risk breast cancer this may part problem trying extract 3d information 2d images stated kopans prior studies topic differences qualification ultrasound exam performers performed radiologist technologist performing supplemental hand held screening breast ultrasound consecutively two performers first technologist interpreting radiologist study likely serves elucidate mammographically occult findings however time consuming represents burden already limited healthcare resources busy clinical practice an important methodological similarity study prior studies using biopsy results results 1-year follow reference standard assess false negative results including occurrence interval cancers participants study slightly younger mean age 47.3 years compared studies mean age participants ranging 51.2 55.2 years our results several similarities results previous studies including proportion subjects bi rads categories 1 2 3 biopsy rate fibroadenoma stromal fibrosis accounted pathology findings moreover concurrence prior studies small number ultrasound findings required evaluation biopsy ultimately concordance expected small number mammographically occult abnormalities found supplemental breast ultrasound limitations study include small population size likely responsible fact carcinoma found there one published study population size smaller additional breast carcinoma found supplemental ultrasound however unlike study study included participants personal history breast cancer in conclusion results confirm reported disadvantages performing supplemental screening breast ultrasound particular high false positive rate relatively high rate short interval follow support expressed opinions caution exercised recommending supplemental screening hand held bilateral breast ultrasound asymptomatic women dense breast tissue without taking account risk factors expected large number women would undergo additional test added costs health care system	objective : to assess the results of an initial round of supplemental screening with hand - held bilateral breast ultrasound following a negative screening mammogram in asymptomatic women with dense breast tissue who are not at high risk for breast cancer.materials and methods : a retrospective , health insurance portability and accountability act compliant , institutional research board approved study was performed at a single academic tertiary breast center . informed consent was waived . a systematic review of the breast imaging center database was conducted to identify and retrieve data for all asymptomatic women , who were found to have heterogeneously dense or extremely dense breast tissue on screening bilateral mammograms performed from july 1 , 2010 through june 30 , 2012 and who received a mammographic final assessment american college of radiology 's ( acr ) breast imaging reporting and data system ( bi - rads ) category 1 or bi - rads category 2 . hand - held screening ultrasound was performed initially by a technologist followed by a radiologist . chi - square and t - test were used and statistical significance was considered at p < 0.05.results:a total of 1210 women were identified . of these , 394 underwent the offered supplemental screening ultrasound . bi - rads category 1 or 2 was assigned to 323 women ( 81.9% ) . bi - rads category 3 was assigned to 50 women ( 12.9% ) . a total of 26 biopsies / aspirations were recommended and performed in 26 women ( 6.6% ) . the most common finding for which biopsy was recommended was a solid mass ( 88.5% ) with an average size of 0.9 cm ( 0.51.7 cm ) . most frequent pathology result was fibroadenoma ( 60.8% ) . no carcinoma was found.conclusion:our data support the reported occurrence of a relatively high number of false positives at supplemental screening with breast ultrasound following a negative screening mammogram in asymptomatic women with dense breast tissue , who are not at a high risk of developing breast cancer , and suggests that caution is necessary in establishing wide implementation of this type of supplemental screening for all women with dense breast tissue without considering other risk factors for breast cancer .
allgrove triple syndrome later named 4a syndrome rare autosomal recessive condition characterized alacrima achalasia autonomous neuropathy acth insensitivity among features the syndrome usually presents first decade life dysphagia signs may delayed adulthood allgrove colleagues first described syndrome 1978 two unrelated pairs siblings aged 4 6 years).1 four achalasia adrenocortico- tropic hormone acth insensitivity three suffered impaired lacrimation one autonomic dysfunction the syndrome may manifest first decade life severe hypoglycemia hypotensive attacks may lead sudden death allgrove syndrome may underdiagnosed multi system disorder achalasia alacrima valuable clinical signs reach diagnosis catastrophic complications prevented adequate cortisol specific measures cardiac pneumatic dilatation myotomy along supportive management an 18-year old boy brought emergency room deterioration general health cachexia weight loss he bedridden stool urine incontinence complained progressive difficulty swallowing months he first child healthy non consanguineous parents product full term delivery later family noticed progressive nasal speech anorexia lack weight gain frequent regurgitation the patient subjected repeatedly esophageal cardiac dilatations due poor response general health deterioration after three years follow social reasons father stopped taking hospital started taking different hospitals the father appreciative son tolerance saying despite problems seen tears shed son apart younger brother milder form similar symptoms siblings parents relatives free symptoms he pale hyper pigmentation skin gums palmar creases his face long thin narrowed upper lips turned mouth microcephaly the joint motions limited muscle contractures spastic tetraparesis mild ataxia deep tendon reflexes increased four limbs his basic investigations showed moderate anemia hemoglobin hb 10 g dl cortisol level 8 less 1.1 ug dl acth 54.1 barium swallow study esophageal manometry features consistent achalasia seen evaluated ophthalmologist schirmer test needed this revealed dry eyes i.e. alacrima ct brain orbit tomography showed reduced lacrimal gland tissue patient admission hospital management included full supportive therapy included hydration nutrition physiotherapy artificial tears the achalasia managed two sessions pneumatic dilatations kept 10 mg prednisone day maintenance dose one year follow exhibited significant improvement able eat well walk without support gained 25 kg weight i.e. body mass index bmi increased 13.3 21.3 figure 2 his main presentation frequent regurgitation weight loss failure thrive age three physical examination revealed developed child nasal speech age four diagnosis achalasia established subjected heller surgery found thin underweight microcephalic the following investigations performed hospital barium swallow esophageal manometry indicated achalasia upper gi endoscopy showed good functioning myotomy based clinical appearance achalasia well alacrima early slow progressing allgrove syndrome diagnosed allgrove syndrome considered autosomal recessive disorder variable presentations.12 recent studies identified mutation aaa syndrome candidate gene chromosome 12q13 patients.3 prpic et al 2003 demonstrated marked phenotypic variability three patients genetically confirmed triple syndrome two patients achalasia alacrima adrenocortical deficiency well neurologic autonomic dysfunction all patients homozygous mutations triple syndrome gene.3 age onset symptoms variable syndrome usually presenting first decade life dysphagia severe occasionally fatal hypoglycemic hypotensive attacks related adrenocortical insufficiency.45 two cases achalasia initial alarming symptom causing vomiting dysphagia recurrent chest infection failure thrive required frequent hospital admissions these symptoms noticed age three six respectively helped reaching diagnosis achalasia the association dry eyes together achalasia important clinical sign support allgrove syndrome both patients proven alacrima impressed parents high pain threshold tolerability the biopsy obtained gland may show neuronal degeneration depletion secretory granules acinar cell.56 conjunctival congestion irritation sign alacrima could confirmed schirmer test the younger one debilitating finding normal life good school performance the index case areas hyper pigmentation obvious buccal mucosa gums peripheral motor sensory neuropathy reveal muscle wasting hyperreflexia dysarthia nasal speech ataxia autonomic dysfunction.68 signs present first case contributing significantly morbidity.910 adrenocortical function preserved case 2 index case remarkably affected typical pattern acth insensitivity baseline acth cortisol level acth stimulation test used evaluate adrenal insufficiency glucocorticoid replacement therapy seems influence development progression neurological features no explanation association achalasia alacrima adrenal unresponsiveness acth triple syndrome available it thought acth receptor gene would provide link explain association three main features syndrome since evidence acth neuropathic effects.1112 imaging studies ultrasonography computerized tomography magnetic resonance might informative neurological abnormalities noticed contrast swallow study esophagoscopy manometry give definite diagnosis achalasia considered among preliminary investigations diagnosis patients the index case responded graded pneumatic dilatation younger brother open cardiomyotomy age four six years prior diagnosis allgrove syndrome careful replacement glucocorticoids patients adrenal insufficiency management achalasia either via endoscopic surgical approach cornerstones treatment long term follow adults increased risk gastroesophageal reflux ger epitheloid changes reported.13 myotomy antireflux procedure therefore better choice case pneumatic dilatation small dose proton pump inhibitors ppis might needed additionally usage artificial tears application topical lubricants supportive therapy improve general outcome he able perform daily routines without support communicates well gained 25 kg allgrove syndrome may underdiagnosed disorder high index suspicion required patients present complex symptoms failure thrive dysphagia crying without tears alacrima nasal speech seizures hypoglycemia diagnosis confirmed esophageal manometry ophthalmic assessment biochemical study neurological evaluation	this report concerns two brothers aged 10 and 18 years with long - standing dysphagia that started at age three and six years respectively . they had been diagnosed as achalasia and treated accordingly . the appearance of additional symptoms and clinical signs required further investigations including abdominal sonography , esophago - gastroduodenoscopy , barium swallow , esophageal manometry , computerized tomography ( ct ) of abdomen and brain , biochemical profiles , and neurologic and ophthalmic evaluations . the results of these extensive investigations along with the clinical evaluations were consistent with allgrove 's syndrome.glucocorticoid therapy was initiated . the management consisted of pneumatic cardiac dilatation and initiation of cortisone treatment . the patients response was impressive and they resumed most of their usual activities .
lipodystrophy broadly refers disturbance production utilization storage fat lipoatrophy sharply defined disappearance subcutaneous fat without exudative reactions appreciable fibrosis marble smith 1942 lipoatrophy divided generalized partial extensive generalized localized limited localized area types there universal precise proven reason lipoatrophy however literature suggests impairment adipocyte differentiation adipocyte apoptosis mitochondrial dysfunction heterogeneous pathogenesis reflecting different subtypes the congenital type genetic disturbance presenting generalized absence fat within first year life followed series abnormalities like insulin resistance acanthosis nigricans adolescence the onset childhood widespread panniculitis strange physical stature it characteristic beginning progressive subcutaneous fat loss face scalp spreads iliac crests children five eight years target group girls outnumbering boys 4:1 iatrogenic causes lipoatrophy include complications injected medications like insulin corticosteroids antibiotics penicillin g iron heparin vaccines hiv positive patients anti retroviral therapy especially nucleoside reverse transcriptase inhibitors nrts protease inhibitors pi manifest lipoatrophy adverse drug effect a 28-year old female patient reported institution complaint depression appearing right lower facial region it started small depression two years earlier accompanying pain discomfort progressed present state asymmetry abnormal appearance her medical records showed history facial trauma dental infections examination the facial asymmetry found due deficiency fat layer right parasymphyseal region extending inferiorly lower border mandible figure 1a localized idiopathic subcutaneous atrophy face considered clinical diagnosis relevant diagnostic workup started right profile view patient shows atrophic region pigmentation en face photograph profile views patient were taken analyzed together assess degree asymmetry figures 1a b ultrasonography using 7 10 mhz frequency linear probe volvuson 730 pro expert ge machine revealed normal superficial skin layer bilaterally the thickness subcutaneous plane 0.22 cm right side 0.28 cm left side altered echogenicity noted right masseter muscle affected side muscle thickness 0.83 cm whereas normal side 1.26 cm figures 1c ultrasound image reveals normal facial anatomy left side altered echogenicity right cheek subcutaneous massetric layer ultrasound image affected side allows measurement muscle thickness open closed mouth positions the serial axial coronal ct sections craniofacial bones obtained multiplanar volume rendered reconstructions confirmed asymmetry subcutaneous soft tissues atrophied right cheek region the underlying muscles bones appeared normal figures 1e f coronal ct shows subcutaneous atrophy fat right side axial ct demonstrates subcutaneous atrophy level right mandible patient face soft tissue reconstruction clinical investigations showed normal values complete blood count blood glucose serum cholesterol triglycerides the antinuclear antibody ana test negative based clinical imaging concluded final diagnosis localized idiopathic involutional grade 1 lipoatrophy face autologous fat harvested abdomen injected subcutaneous plane rebuild sunken area figures 1 g h the subcutaneous fat provides volume mobility supported fibrous retinacular cutis connects dermis muscle apponeurotic system the subcutaneous layer critical wasting subcutaneous fat results atrophy whereas increased thickness leads lengthening retinacular fibers therefore weakness distention paucity complete absence fat confined subdermal layer lack inflammatory signs known idiopathic localized involutional lipoatrophy ilil peters winkelmann first reported condition sharply demarcated skin depression without epidermal alteration the features facial lipoatrophy include sunken cheeks deep folds nasolabial region skin depression temples sides forehead around eye sockets spontaneous regression weeks usual however cases lesion may persist cause cosmetic concerns grade 1 mild flattening shadowing one facial regions prominent bony land marks visibility underlying musculature grade 3 moderate concavity one facial regions prominence bony land marks possible visibility underlying musculature grade 5 severe depression one facial regions severe prominence bony land marks clear visibility underlying musculature computed tomography ct plays useful role diagnosis focal lipoatrophy fat easily appreciated ct us demonstrate asymmetry face loss fat focal lipoatrophy less sensitivity ct improve esthetics common treatment modalities evidence safety efficacy the possibility severe infection contour abnormalities facial nerve muscle damage restrict use permanent type fillers like silicone oil non permanent fillers biodegradable diminish time may necessitate revamp cause foreign body reactions granulomas injection biodegradable bioabsorbable poly l lactic acid pla filler causes cutaneous thickening fibrous connective tissue formation month the call multiple treatment sessions cost transitory relief limit use augmentation autologous fat transfer aft secure cost effective option exclusively non hiv patients lipoatrophy patient as abnormality mild cosmetic disorder disability needle extraction adipose tissue abdomen injecting site atrophy done aim ensuring rapid revascularization less resorption a soft slightly curved well defined anatomy esthetic satisfaction achieved frequent patient follow essential monitor acceptance consequences see need repeating treatment facial lipoatrophy otherwise healthy individuals uncommon patients usually present cosmetic reasons	a well - proportioned face combines features that are balanced and symmetrical . any structural alteration that leads to facial asymmetry causes esthetical and psychological disturbances . lipoatrophy is one such condition , which results in loss of subcutaneous fat layer and manifests as a depression . although many subtypes with varying clinical and etiological backgrounds exist , the idiopathic form is rare and facial involvement is the rarest . computed tomography is one of the accepted diagnostic tools to determine the atrophic layer of facial anatomy . this report presents the clinical types , diagnosis , and management of a case of facial lipoatrophy .
systemic sclerosis ssc scleroderma autoimmune disease characterized accelerated accumulation extracellular matrix various immunologic abnormalities 1 serum autoantibodies helpful markers correlated certain clinical features ssc 2 3 various ssc related antibodies anti rna polymerase rnap antibodies are known ssc specific present 4 33% ssc patients 4 8 there three classes rnaps rnaps ii iii 9 anti rnap iii iii antibodies detected exclusively ssc patients moreover presence antibodies known associated diffuse cutaneous involvement renal crisis 5 6 10 11 although association scleroderma renal crisis anti rnap iii antibodies reported caucasians japanese report issued korean ssc population furthermore autoantibodies korean ssc patients show several distinctive features 1 association disease subset autoantibodies anti topoisomerase anti topo anticentromere antibody aca 2 much lower prevalence aca limited subset 6.7 8.0% vs. 44% caucasians 37% japanese 3 significant difference clinical characteristics disease subsets except frequent musculoskeletal involvement limited subset 12 14 report first time case renal crisis korean ssc patient serum anti rnap iii antibodies detected radioimmunoprecipitation 5 a 65-yr old female visited rheumatology clinic due thickening hand facial skin digital pallor cyanosis cold exposure developed 2 months previously first visit clinic her blood pressure 130/80 mmhg physical examination revealed skin thickening fingers hands right hand dorsum right forearm she diagnosed systemic sclerosis limited cutaneous subset based american rheumatism association preliminary criteria 15 laboratory data showed white blood cells 8.3910/l hemoglobin 12.1 g dl platelets 24010/l esr 8 mm hr normal range 0 20 got 21u l gpt 18 u l total bilirubin 0.6 mg dl albumin 3.7 g dl bun 11 mg dl creatinine 0.7 mg dl pulmonary function testing produced following forced vital capacity 73% forced expiratory volume 1 sec 79% diffusing capacity carbon monoxide volume alveoli 121% high resolution computed tomography lungs revealed old tuberculosis right lower lobe pleural thickening calcifications without evidence interstitial lung disease prazosin 1 mg day administered raynaud phenomenon intermittent antihistamines skin pruritus twenty two months diagnosis limited ssc skin thickening began rapidly progress elbows knees finally involved trunk the diagnosis converted ssc diffuse cutaneous subset started penicillamine 250 mg day a month later visited emergency room due sudden onset facial edema severe dyspnea her blood pressure 220/134 mmhg heart rate 120 beats min respiration rate 48/min body temperature 35. reported dyspnea begun 10 days previously urine output decreased markedly a physical examination revealed facial pre tibial edema pulmonary rales whole lung field laboratory data showed hemoglobin 9.9 g dl ldh 703 iu l total bilirubin 2.9 mg dl indirect bilirubin 1.8 mg dl schistocytes polychromasia peripheral blood smear suggesting intravascular hemolysis urinalysis microscopic examination showed mild albuminuria 1+by dipstick test hematuria 100 red blood cells per high power field dysmorphic red blood cells 90% pyuria 20 29 white blood cells per high power field urine culture grew organisms azotemia also detected bun 31 mg dl creatinine 2.2 mg dl chest radiograph showed cardiomegaly bilateral hilar infiltrates consistent pulmonary edema she transferred intensive care unit intubated assisted mechanical ventilator diagnosis scleroderma renal crisis captopril begun failed reverse deteriorating renal function despite successful blood pressure control within 2 days renal biopsy showed severe fibrinoid necrosis luminal obliteration interlobar arteries arterioles strongly suggesting scleroderma renal crisis fig immunofluorescence staining showed evidence immune complex autoantibody deposition scleroderma renal crisis reported associated anti rnap iii antibodies tested whether patient anti rnap antibodies serum indeed anti rnap iii antibodies detected radioimmunoprecipitation using 35s methionine labeled k 562 cells fig this first case report scleroderma renal crisis presence rnap iii antibodies korean population renal crisis patient diagnosed accelerated hypertension acute renal failure typical renal pathology the clinical findings association presence anti rnap iii antibodies case consistent previous reports ssc patients 5 6 10 11 16 17 respect 1 renal crisis association anti rnap iii antibodies 2 presence anti rnap iii antibodies diffuse subset patient 3 absence anti topo presence anti rnap iii antibodies although ssc patients anti rnap iii antibodies develop renal crisis renal crisis occurs anti rnap iii antibody positive patients much frequently negative patients 5 6 11 moreover well known early administration angiotensin converting enzyme ace inhibitors improve renal outcome therefore knowing whether anti rnap iii antibodies present renal crisis onset alert physicians possibility renal crisis facilitate initiation prompt treatment according steen et al 18 44% 24/55 scleroderma renal crisis patients received ace inhibitors either died required permanent dialysis 56% 31/55 require dialysis needed transient dialysis the factors associated poor renal outcome old age 55 yr odds ratio 12.28 p=0.002 presence congestive heart failure odds ratio 3.89 p=0.03 this patient showed factors administration captopril failed improve renal function the poor response ace inhibitor patient suggests renal function irreversibly deteriorated prior initiation medical treatment symptoms acute renal failure least 10 days treated rnaps rnaps ii iii multimeric proteins composed 8 14 subunits 10 220 kda 9 the two largest subunits unique class readily distinguishable characteristic mobilities sds polyacrylamide gel 6 7 size complexity rnaps proven difficult develop methods detecting anti rnap antibodies applicable clinical laboratory setting despite potential benefit knowledge presence anti rnap iii antibodies however recently reported anti rnap antibodies detected reliably using enzyme linked immunosorbent assay method 17 19 might help measure antibodies routinely near future summary report case renal crisis presence anti rnap iii antibodies korean ssc patient diffuse cutaneous subset further studies sufficient number patients needed confirm association presence anti rnap iii antibodies clinical features korean population	scleroderma ( ssc ) renal crisis has been reported to be associated with anti - rna polymerase i and iii ( rnap i / iii ) antibodies in caucasians and the japanese . however , no report is available for korean ssc patients . here , we describe the case of a 65-yr - old female ssc patient who developed renal crisis and whose serum contained anti - rnap i / iii antibodies . she was finally diagnosed as having diffuse cutaneous ssc based on skin thickening proximal to the elbows and knees . sudden hypertension , oliguria , and pulmonary edema were features of her renal crisis . despite the use of captopril and adequate blood pressure control , her renal function deteriorated . subsequent renal biopsy findings showed severe fibrinoid necrosis with luminal obliteration in interlobar arteries and arterioles consistent with ssc renal crisis . serum anti - rnap i / iii antibodies were detected by radioimmunoprecipitation . this is the first report of a renal crisis in a korean ssc patient with rnap i / iii antibodies .
angiographic computed tomography act new technique provides highest spatial resolution high contrast resolution derived rotational acquisition c arm mounted flat panel detector.4 demonstrated feasibility diagnostic value intrarterial ia intravenous iv -act pre postprocedure imaging stent angioplasty stent assisted coil embolization cerebral aneurysm conventional digital subtraction angiography dsa act performed biplane angiography system equipped flat panel detectors axiom arits dba siemens medical solutions forchheim germany the parameters acquisition rotational datasets 20s-1k protocol 20 seconds rotation 538 projections 220 total angle zoom detector size 30 40 cm ctdiw approximately 22 mgy manufacturer information post processing image data volume dataset performed leonardo workstation dynact inspace 3d software siemens erlangen germany the software includes application system specific filter algorithms order correct beam hardening radiation scatter truncated projections ring artifacts post processing resulted volume datasets defined batch 400 slices 512 512 matrix the contrast medium used ia act examination visipaque320 ge healthcare carrigtohill ireland contrast medium injected volume 150 ml contrast 100 ml saline 50 ml mixed flow rate 5 ml start delay rotational acquisition 20 seconds(intracranial 15 seconds(vao cc ic the contrast medium injected iv act volume 77 ml artery flow rate 3.5ml start delay rotational acquisition 2 seconds conventional digital subtraction angiography dsa act performed biplane angiography system equipped flat panel detectors axiom arits dba siemens medical solutions forchheim germany the parameters acquisition rotational datasets 20s-1k protocol 20 seconds rotation 538 projections 220 total angle zoom detector size 30 40 cm ctdiw approximately 22 mgy manufacturer information post processing image data volume dataset performed leonardo workstation dynact inspace 3d software siemens erlangen germany the software includes application system specific filter algorithms order correct beam hardening radiation scatter truncated projections ring artifacts post processing resulted volume datasets defined batch 400 slices 512 512 matrix the contrast medium used ia act examination visipaque320 ge healthcare carrigtohill ireland contrast medium injected volume 150 ml contrast 100 ml saline 50 ml mixed flow rate 5 ml start delay rotational acquisition 20 seconds(intracranial 15 seconds(vao cc ic the contrast medium injected iv act volume 77 ml artery flow rate 3.5ml start delay rotational acquisition 2 seconds a 53-year old female treated symptomatic 85% stenosis cervical internal carotid artery ica after protective device angiogurd rx cordis placed distal cervical segment ica 8 40 mm device precise cordis stent applicated lesion because significant residual stenosis present immediately stenting post dilation stent performed using 6 30 mm balloon act showed incomplete stent deploying extensive calcification carotid wall compressing segment stent the extent calcification circumference arterial wall clearly revealed axial view this extensive wall calcification explained stent could fully deployed entire length fig 1 66-year old man presented recurrent left hemiparesis diffusion magnetic resonance imaging mri brain showed minimal acute infarction basal ganglia bg periventricular white matter pvwm left cerebral angiography showed severe stenosis 85% m1 segment right middle cerebral artery mca placement 2.5 8 mm balloon expandable stent endeavor medtronic scientific roncadelle bs italy right m1 segment successfully performed completely reestablishing lumen restoring normal flow although stent completely identified dsa slightly visible nonsubtracted views act detect stent completely every plane the axial view demonstrated full uniform deployment stent entire length three dimensional 3d dsa performed wide neck based aneurysm confirmed initially self expandable stent 4.5 20 mm neuroform stent ~~~ placed entirely cover neuroform neck after stenting ia act performed coil embolization order ensure perfect stent positioning total 5 platinum microcoil inserted paraclinoid aneurysm completely occluded lesion act performed coil embolization allows define exclusion stent strut movement coil protrusion minimal beam hardening artifacts fig a 53-year old female treated symptomatic 85% stenosis cervical internal carotid artery ica after protective device angiogurd rx cordis placed distal cervical segment ica 8 40 mm device precise cordis stent applicated lesion because significant residual stenosis present immediately stenting post dilation stent performed using 6 30 mm balloon act showed incomplete stent deploying extensive calcification carotid wall compressing segment stent the extent calcification circumference arterial wall clearly revealed axial view this extensive wall calcification explained stent could fully deployed entire length fig diffusion magnetic resonance imaging mri brain showed minimal acute infarction basal ganglia bg periventricular white matter pvwm left cerebral angiography showed severe stenosis 85% m1 segment right middle cerebral artery mca placement 2.5 8 mm balloon expandable stent endeavor medtronic scientific roncadelle bs italy right m1 segment successfully performed completely reestablishing lumen restoring normal flow although stent completely identified dsa slightly visible nonsubtracted views act detect stent completely every plane the axial view demonstrated full uniform deployment stent entire length three dimensional 3d dsa performed wide neck based aneurysm confirmed initially self expandable stent 4.5 20 mm neuroform stent ~~~ placed entirely cover neuroform neck after stenting ia act performed coil embolization order ensure perfect stent positioning total 5 platinum microcoil inserted paraclinoid aneurysm completely occluded lesion act performed coil embolization allows define exclusion stent strut movement coil protrusion minimal beam hardening artifacts fig however introduction small low profile high flexibility excellent tractability stents makes available wide use stent intracranial extracranial atherosclerotic disease stent assisted aneurysm coiling resulting restenosis rates ranging 8% 30%.8)11 also complications stent assisted coil embolization incomplete stent deployment stent migration coil dislocation stent stenosis procedure follow period still yet resolved therefore pre- intra- post procedural imaging studies help visualize exact position stent identify significant isr crucial however still carries 0.5% 0.8% risk permanent neurological impairment.5)15 addition dsa difficult done outpatient clinic patients poor compliance also good imaging tool follow f u examination consequently problems force us use evaluation technique brain cta doppler sonography plane x ray brain cta used assess vascular patency stents however vitro studies demonstrated degree isr tends overestimated.12 duplex sonography also plays important role pre- post procedure especially carotid stenosis actual accuracy dependent examiner fluoroscopic plain radiography also used modalities used cases self expandable stent applied this type stent visible proximal distal end radiopaque markers located because problems previous evaluation tools many additional imaging techniques introduced nowadays including act synonyms act flat panel angiographic tomography flat panel detector angiographic ct system flat panel ct angiographic c arm tomography cone beam c arm system dyna ct siemens xper ct philips amsterdam netherlands benefits act follows 1 examinations performed outpatient basis 2 risk neurological complications low 3 examination performed quickly time similar required cta 4 radiation exposure patient rotational acquisition lower cta examination manufacturer information 22 mgy vs. 50 mgy 5 patients moved ct scanner order confirm position stent coil procedure immediately procedure.10 shown previously demonstrated ia iv act used another diagnostic option stents procedure follow period reliably depict lumen small vessel stents high spatial resolution.6 utilizing act imaging may enable adequate visualization stent position especially stent struts.2)3 intracranial vessels viewed simultaneously high quality images ct like images brain parenchyma provided well however limitations arise artifacts including movement artifact calibration problems deteriorate image quality the patient lie nearly motionless 20 seconds requiring high level compliance always feasible patients suffering cerebrovascular disease.4 another limitation contrast differentiation inferior areas low radiographic contrast compared conventional ct imaging also reconstruction still requires 5 10 minutes dynact procedure accepted ct scan modality insurance system still considered fluororadiography meanwhile stent assisted aneurysm coiling well established clinical routine.1)7)9)13)14 however fluoroscopic plain radiographic visibility stent struts especially limited low profile highly flexible devices proximal distal radiopaque stent markers visible may render difficult exactly assess stent position adaptation stent struts vessel wall.3 act uses rotational c arm mounted flat panel detector technology capable high spatial resolution volumetric imaging.11 using act imaging may enable adequate visualization stent position especially stent struts.2)3 even though new method needs evaluated larger number patients introduces many advantages patients surgerons new option imaging endovascular treatment cerebrovacular disease utilization angiography ct dyna ct promising new technique minimally invasive follow endovascular stent may helpful complex stent assisted aneurysm coiling procedures	objectivewe evaluated the feasibility of angiographic computed tomography ( act ) for visualizing stent material in patients who underwent intracranial or extracranial stent placement to treat atherosclerotic lesions or stent assisted coil embolization.materials and methodswe performed intrarterial and intravenous act on biplane angiography system equipped with flat panel detectors ( axiom arits dba ; siemens medical solutions , forchheim , germany ) . vistipaque 320 was injected for contrast medium , total 150 ml at flow rate of 5 ml / s through artery and 77 ml at flow rate of 3.5 ml / s through vein.resultsact is a new imaging modality that provides a clear visualization of stent strut.conclusiontherefore this new application has potential to become the noninvasive option for follow - up after endovascular surgery using stents .
epidemic vitamin deficiency one billion people worldwide affected our previously published uk data indicates vitamin deficiency 25-hydroxyvitamin 25(oh)d 30 ng ml occurs 91% patients diabetes severe deficiency 25(oh)d 10 ng ml 32% patients the purpose review examine association vitamin status cardiovascular disease particular reference diabetes mellitus complications this review based previously conducted studies involve new studies human animal subjects performed authors vitamin lipid soluble secosteroid hormone primarily associated calcium homeostasis synthesis vitamin occurs predominantly skin dehydrocholesterol shared common precursor cholesterol dependent sun exposure ultraviolet b light wavelengths 280 315 nm optimal conversion 7-dehydrocholesterol previtamin d3 converted vitamin d3 skin summer exposure midday sunlight 2030 min two three times per week thought sufficient generating adequate levels vitamin fair skinned individual the amount synthesized vitamin reduced darker skinned older obese individuals other sources vitamin include diet food contains natural vitamin fortified vitamin dietary supplements dietary vitamin usually contains vitamin d3 cholecalciferol natural sources containing vitamin d2 ergocalciferol vitamin skin diet modified liver generate 25(oh)d active vitamin formed conversion takes place kidneys forming 1,25-dihydroxyvitamin 1,25(oh)2d3 activated vitamin .table 1significant risk factors vitamin deficiencyincreasing ageuse sunscreenpigmented skinhouse bound patientsobesitynorthern latitudesmedication antiepileptic antiretroviral drugs)renal diseaseliver diseasemalabsorption syndrome significant risk factors vitamin deficiency vitamin status defined measuring level 25(oh)d blood owing longer half life plasma forms circulating reservoir vitamin d nmol l considered sufficient 2030 ng ml 5075 nmol l insufficient 1020 ng ml 2550 nmol l deficient 10 ng ml 25 nmol l severely deficient us institute medicine iom released guidance 2011 25(oh)d equal 20 ng ml considered adequate 97.5% population ; however heavily criticized endocrine society 7 8 recommend 25(oh)d concentration exceed 30 ng ml maximize effect vitamin calcium bone muscle metabolism cutoffs vitamin status detailed table 2 iom endocrine society arbitrated respective cutoffs optimal vitamin status however based bone metabolic data cardiometabolic data optimal levels 25(oh)d possible prevention cardiometabolic outcomes remain elucidated .table 2serum 25-hydroxyvitamin concentrations status25(oh vitamin concentration 25(oh vitamin status<10 ng mlsevere deficiency10<20 ng mldeficient20<30 ng mlinsufficient30 ng mladequate100 ng mlpossible toxicity multiply 2.5 convert nmol l serum 25-hydroxyvitamin concentrations status multiply 2.5 convert nmol l vitamin insufficiency low enough cause bone disease significantly associated cardiovascular disease there ubiquitous expression vitamin receptors vdr virtually every human tissue vitamin important regulator literally hundreds genes regulating key biological processes cell division apoptosis vdr widely distributed many tissues suggests putative biological response activation implying vdr multiple functions beyond calcium homeostasis once 1,25(oh)2d3 binds vdr interacts retinoid x receptor rxr forming heterodimer binds vitamin responsive elements region genes directly controlled 1,25(oh)2d3 the action vitamin particular cell depends vitamin mediated gene activation transcriptional response protein formation for example addition stimulating intestinal calcium phosphate absorption effect skeletal mineral ion homeostasis 1,25(oh)2d3/vdr rxr also regulates expression plethora genes non calcemic tissues this extensive vitamin ome allows concerted genomic rapid actions 1,25(oh)2d3 possibly interplay varied diseases osteoporosis cancer diabetes atherosclerosis vascular disease calcification infection furthermore vdr gene expressed within developing neurons rodent dorsal root ganglia may suggest role vitamin peripheral nervous system development nociception subjects severe vitamin deficiency 25(oh)d 10 ng ml experienced hazard ratio 1.80 95% confidence interval ci 1.053.08 developing first cardiovascular event 5 years follow compared subjects higher levels 25(oh)d 15 ng ml health professionals follow study men without prior cardiovascular disease vitamin levels 15 ng ml showed twofold increase rate myocardial infarction cross sectional study dobnig et al found inverse relationship lower levels vitamin increased risk cause cardiovascular mortality other cross sectional observational studies confirmed lower vitamin levels associated endothelial dysfunction well arterial stiffness the vasoprotective action vitamin may mediated increasing nitric oxide production inhibiting foam cell formation reducing expression adhesion molecules endothelial cells 1921 the recognition specific vdr genetic susceptibility pathophysiology hypertension supported insights regards cerebrovascular disease large population based prospective study copenhagen increase risk symptomatic ischemic stroke observed decreasing plasma 25(oh)d concentrations a similar association vitamin deficiency also demonstrated honolulu heart program studied 7385 men 34-year period study 250 stroke patients india deficiency 25(oh)d studies needed establish vitamin supplementation reduces risk ischemic stroke general population li et al established vdr knockout mice elevated blood pressure cardiac hypertrophy elevated activation renin angiotensin aldosterone system raas reversed angiotensin converting enzyme ace inhibitor 26 27 raas plays pivotal role maintaining sodium blood volume homeostasis modulating renal function blood pressure raas induces recruitment activation inflammatory cells within vessel wall promoting endothelial dysfunction increasing vascular permeability this inflammatory response stimulates hyperplasia hypertrophy vascular smooth muscle cells release pro inflammatory molecules vcam-1 monocyte chemoattractant protein-1 interleukins 6 8) also showed wild type mice given injection 1,25(oh)2d3 demonstrated suppression renin mrna expression 26 27 vitamin potent negative regulator raas system may play important role development neuropathy diabetes raas inhibition one proven therapies may prevent delay diabetic peripheral neuropathy dpn evidenced experimental studies also two human clinical trials 2931 experimental model type 1 diabetes mellitus plasma renin activity levels decreased whereas ace activity increased diabetic rats compared controls small open label study lisinopril hypertensive subjects n 13 showed improvements nerve conduction measures 12 weeks double blind randomized controlled study found administration ace inhibitor trandolapril normotensive patients mild diabetic neuropathy resulted improvement neurophysiology 12 months randomized controlled trial rct trivedi et al vitamin d3 100,000 iu supplemented every 4 months 5 years versus placebo assess fracture risk there non significant trend risk ratio rr 0.84 95% ci 0.0551.10 toward reduction cardiovascular deaths a rct n 302 added vitamin ongoing calcium supplementation primary endpoint risk falls they reported adverse events ischemic heart disease event rates 1.3% vitamin versus 2.0% placebo two versus three events these two rcts analyzed meta analysis reported significant benefit vitamin supplementation women health initiative whi study clincialtrials.gov identifier nct00000611 36,282 women randomized receive combination vitamin d3 400 iu calcium 1000 mg per day placebo myocardial infarction coronary heart disease death confirmed 499 women assigned calcium vitamin 475 women assigned placebo hazard ratio 1.04 95% ci 0.921.18 it concluded calcium plus vitamin supplementation neither increased decreased coronary cerebrovascular risk generally healthy postmenopausal women 7-year use period vdr also identified pancreatic beta cells vitamin deficiency shown impair insulin synthesis secretion animal models diabetes suggesting role development type 2 diabetes this turn linked increased insulin resistance associated diabetes hypertension inflammation increased cardiovascular risk several studies including one published scragg et al demonstrated lower vitamin levels associated increased risk diabetes double blinded placebo trial mitri et al showed adults risk type 2 diabetes short term supplementation cholecalciferol improved beta cell function marginal effect attenuating rise hba1c furthermore two studies shown inverse relationship 25(oh)d hba1c subjects without diabetes 41 42 found first quartile serum 25(oh)d level compared fourth quartile associated increased adjusted odds ratio prediabetes vitamin levels inversely correlated fasting glucose r 0.29 p 0.04 homeostasis model assessment homa r 0.34 p 0.04 however whi study 33,951 participants receiving calcium plus vitamin d3 supplementation reduction risk developing diabetes 7 years vitamin also immunomodulatory effect suggested study 10,000 finnish children given 2000 iu vitamin d3 per day first year life demonstrated astounding 78% reduced risk type 1 diabetes 30-year follow a small placebo controlled trial vitamin d3 4000 iu day 6 months supplementation showed reduced insulin resistance south asian population vitamin deficient recently observational study patients 5-year fenofibrate intervention event lowering diabetes field trial low blood 25(oh)d concentrations associated increased risk macrovascular microvascular disease events type 2 diabetes 25(oh)d concentration 20 ng ml higher cumulative incidence macrovascular microvascular events levels 20 ng ml indeed severe vitamin deficiency shown predict mortality development nephropathy retinopathy type 1 diabetes previously studies vitamin largely focused bone health calcium metabolism however increasing body evidence particularly past two decades implicates role vitamin nervous system 48 49 multiple neurodegenerative diseases including multiple sclerosis 5054 parkinson disease well cognitive decline elderly linked declining vitamin status there data suggest treatment high doses vitamin d3 slows progression disability linked multiple sclerosis however larger interventional studies required truly assess therapeutic benefit nerve growth factor ngf first identified essential development nociceptive primary neurons later found role inflammatory hyperalgesia adults ngf neurotrophic factor synthesized initially pro ngf prior cleaved intracellular proteases translocated rough endoplasmic reticulum cleaved second time extracellular proteases produce active form ngf responsible development maintenance neurons several regions central nervous system 59 60 in addition following neuronal injury ngf ability promote myelination schwann cells stimulate axonal sprouting guide axonal growth brain barrier experimental models may act relative specificity increase ngf glial cells fibroblasts vitamin linked regulation neurotrophins ngf neuronal ca homeostasis may play neuroprotective role peripheral nerve showed sciatic nerve ngf preserved animals exposed vitamin analogue cb1093 whilst another vitamin analogue mc903 shown increase ngf synthesis ngf known depleted experimental diabetes study patients diabetic neuropathy significant correlation demonstrated skin keratinocyte ngf immunostaining skin axon reflex vasodilation mediated small sensory fibers stimulation neurotrophin production 1,25(oh)2d3 correlated neuroprotective effect 66 70 ngf glial cell line derived neurotrophic factor gdnf also upregulated 1,25(oh)2d3 it notable central nervous system tumors 1,25(oh)2d3 several synthetic analogues effective inducing cell death pathway glioma cells 7274 importantly topical application ngf diabetic foot ulcers resulted promotion healing ngf previously successfully studied phase 2 clinical trials showed lack efficacy phase 3 study dpn the prevalence dpn high 50% symptomatic diabetic neuropathy affect approximately 30% diabetic patients neuropathy currently licensed therapies may alter natural history dpn therefore symptom control remains mainstay dpn management even symptom relief effective treatment continues remain major challenge anticonvulsants antidepressants first line therapy 50% reduction pain considered good outcome largest observational study date diabetic patients primary care cohort uk n 15,692 prevalence painful symptoms and additionally adjusted risk painful neuropathic symptoms type 2 diabetes double type 1 diabetes 2.1 95% ci 1.72.4 p 0.001 women 50% increased adjusted risk painful symptoms compared men 1.5 95% ci 1.41.6 p 0.0001 furthermore despite lower prevalence neuropathy south asians 14% compared europeans 22% african caribbeans 21% p 0.0001 painful symptoms greatest south asians 38% vs. 34% vs. 32% p 0.0001 south asians without neuropathy maintained 50% increased risk painful neuropathic symptoms compared ethnic groups p 0.0001 these differences may partly explained relation vitamin deficiency groups shown excess vitamin deficiency other studies assessed ethnic differences dpn us population variations noted risk dpn diabetic autonomic neuropathy however australian study significant differences ethnic groups although ethnic mix last two studies differs uk an increasing body data suggests vitamin may analgesic properties also additional neuroprotective benefits vitamin deficiency insufficiency associated various pain syndromes low levels vitamin correlated presence peripheral neuropathy primary sjgren syndrome lead small fiber neuropathy vitamin supplementation shown improve musculoskeletal pain non traumatic back pain studies however prominent contrast treatment effects randomized double blind trials minimized bias designs known subject bias better treatment effects noted latter therefore overall evidence use vitamin chronic pain adults poor low quality insufficient rcts pain thresholds multiple etiologies reported lowered vitamin deficiency elevated vitamin deficiency corrected previous observational studies demonstrated significant link vitamin deficiency dpn 8991 national health nutrition examination survey nhanes 20012004 unweighted sample 591 subjects diabetes demonstrated significant association vitamin deficiency paresthesia 2.12 95% ci 1.173.85 numbness 2.04 95% ci 1.183.52 adjusting obesity co morbidities use medications neuropathy diabetes duration glycemic furthermore prospective observational study conducted skalli et al 111 consecutive ambulatory patients type 2 diabetes association vitamin deficiency peripheral diabetic neuropathy found although subjects without dpn deficient dpn approximately 4 ng ml lower 25(oh)d levels cross sectional study shehab et al vitamin deficiency independent risk factor dpn assessed using neuropathy symptom score clinical electrophysiological measures dpn the duration diabetes higher group peripheral neuropathy elevated low density lipoprotein cholesterol ldl this latter observation may relevance vitamin cholesterol share common metabolic pathway 7-dehydrocholestrol recent study conducted small homogenous population rural turkey reduced serum 25(oh)d associated dpn interestingly neither vdr vdr binding protein differed without dpn large nerve fiber deficits also associated vitamin status diabetes mellitus age sex body mass index bmi height disease duration matched cohort n 33 patients diabetes 25(oh)d significantly lower dpn group 21.2 11.5 vs. 13.5 5.1 ng ml p 0.001 after adjustment studied variables serum vitamin independent inverse association dpn presence severity 1 ng ml increase serum 25(oh)d correlated 2.2% 3.4% decrease presence severity nerve conduction studies ncv impairment respectively meta analysis six studies involved total 1484 patients type 2 diabetes vitamin deficiency < 20 ng ml significantly associated increased risk dpn the 2.88 95% ci 1.844.50 p 0.00001 adjusted 2.68 95% ci 1.674.30 p 0.0001 subanalysis three studies suggesting vitamin deficiency likely associated dpn type 2 diabetic patients of course hypertension independent risk factor dpn 95 96 interaction vitamin raas may provide link date clinical trials vitamin intervention dpn limited a single case report shown reversal symptoms severe intractable painful diabetic neuropathy administration 50,000 iu ergocalciferol vitamin d2 weekly almost complete resolution 4 weeks despite fact patient severely deficient baseline 25(oh)d approximately 16 ng ml subsequent pain relief weekly ergocalciferol dose enabled discontinuation oxycodone conducted open label uncontrolled study patients vitamin deficiency 51 patients painful dpn after treatment oral cholecalciferol vitamin d3 mean dose 2059 iu daily 3 months improvement approximately 50% visual analogue scale pain although placebo effect considerable trials therapeutic agents painful dpn maximal placebo effect expected would approximately 30% indeed 50% pain reduction considered efficacious evaluating interventions painful dpn conducted double blind rct compound qr-333 containing vitamin analogue showed positive effects numbness jolting pain irritation subjects painful dpn however outcomes study somewhat confounded qr-333 contained quercetin flavonoid aldose reductase inhibitor effects one key pathogenetic pathways causing diabetic neuropathy hard endpoints dpn foot ulceration may eventually lead lower limb amputation significant morbidity mortality cross sectional study diabetic patients without n 162 n 162 plantar ulcers lower 25(oh)d status associated plantar ulceration patients diabetes 6.3 vs. 28 ng ml p 0.005 study tiwari et al vitamin deficiency prevalent severe patients diabetic foot infection cases foot infection n 125 greater risk vitamin deficiency 25(oh)d 20 ng ml controls ( n 164 1.8 95% ci 1.13.0 p 0.02 risk severe vitamin deficiency 25(oh)d 10 ng ml significantly higher cases controls 4.0 95% ci 2.46.9 p 0.0001 patients chronic kidney disease ckd known deficiency 25(oh)d 1,25(oh)2d associated high cardiovascular mortality although patients ckd higher levels vitamin may also associated vascular calcification experimental studies shown role vdr vdr mediated vitamin actions thought renoprotective diabetic nephropathy experimental study vitamin vdr signaling podocytes played critical role protection kidney diabetic injury analysis nhahes 20012006 cross sectional data showed independent association vitamin deficiency insufficiency presence nephropathy small double blind randomized placebo controlled crossover trial paracalcitriol vitamin analogue patients proteinuria despite adequate raas blockade urinary albumin excretion rate significantly lowered compared placebo furthermore combination therapy at1 blocker vitamin analogue markedly ameliorated diabetic nephropathy experimental model diabetic nephropathy vital study clinicaltrials.gov identifier nct00421733 a placebo controlled double blind rct paracalcitriol vitamin analogue added raas inhibition dose 2 g day significantly lowered blood pressure residual albuminuria patients diabetic nephropathy highlighting role vitamin potent raas inhibitor 113 114 recently systematic review meta analysis derakhshanian et al suggested despite higher risk nephropathy vitamin deficient patients diabetes vitamin supplementation support causality association pooled data urinary albumin creatinine ratio levels clinical trials five trials however studies small heterogeneous vitamin replacement dose small thus larger well designed rcts adequate vitamin supplementation diabetic nephropathy required 25(oh)d concentrations associated optic chiasm volume several studies found association vitamin deficiency age related macular degeneration amd 117 118 mouse model ischemic retinopathy 1,25(oh)2d shown inhibit neovascularization retinal tissue turkish cohort 66 subjects aksoy et al demonstrated inverse correlation worsening diabetic retinopathy lower 1,25-dihydroxyvitamin d3 active vitamin 50 diabetic patients early stage diabetic retinopathy dr vitamin deficiency 50 early stage dr without vitamin deficiency vitamin deficiency associated early retinal nerve fibre layer rnfl thinning furthermore korean study sampling 18,363 nhanes 20082012 25(oh)d associated diabetic retinopathy similar results replicated chinese population type 2 diabetes japanese population type 1 diabetes however third nhanes relationship found 25(oh)d levels retinopathy severity also eurodiab prospective complications study showed significant relationship 25(oh)d retinopathy despite positive relationship microalbuminuria indeed recently alam et al shown association serum 25(oh)d concentrations presence severity diabetic retinopathy maculopathy however marked deficiency population may confounded study approximately 91% subjects deficient insufficient 25(oh)d 30 ng ml the prevalence vitamin deficiency pandemic proportions uk worldwide particularly diabetic population an increasing body literature suggests possible pathogenetic role vitamin long term complications diabetes vitamin deficiency may also exacerbate symptoms painful dpn despite number well designed observational studies causal link remains demonstrated the association vitamin status cardiometabolic outcomes uncertain especially intervention trials shown clinically significant effect vitamin supplementation however short term underpowered interventions low doses vitamin may produced limited benefits given widespread propensity deficiency low side effect profile vitamin therapy represents promising therapeutic intervention treatment diabetic complications in particular significant need good quality rcts using therapeutic doses approximately 4000 iu day vitamin painful dpn	vitamin d deficiency is now recognized as a condition of increasing prevalence worldwide . vitamin d has an established role in calcium and bone metabolism ; however , more recently associations with vitamin d deficiency and risk of developing diabetes , diabetes complications , and cardiovascular disease have all been acknowledged . the vitamin d receptor is ubiquitously expressed , and experimental , in vitro , and in vivo studies strongly suggest a role in regulating the transcription of multiple genes beyond calcium homeostasis . these include antiproliferative , immunomodulatory , angiogenic , inhibition of the renin angiotensin aldosterone system , and neurotrophic factor expression . observational studies report a strong association between vitamin d deficiency and cardiovascular and metabolic disorders ; however , there remains a paucity of large long - term randomized clinical trials showing a benefit with treatment . an increasing body of literature suggests a possible pathogenetic role of vitamin d in the long - term complications of diabetes and vitamin d deficiency may also exacerbate symptoms of painful diabetic peripheral neuropathy . it remains unknown if supplementation of vitamin d to normal or non - deficient levels alters pathogenetic processes related to diabetic microvascular complications . with the high prevalence of vitamin d deficiency in patients with diabetes and putative mechanisms linking vitamin d deficiency to diabetic complications , there is a compelling argument for undertaking large well - designed randomized controlled trials of vitamin d supplementation .
torsades de pointes tdp may occur consequence acquired qt interval prolongation resulting use various medications liquid protein diets intracranial events bradyarrhythmias electrolyte disturbances hormonal disorders.1 4 many cases polymorphic ventricular tachycardia vt reported condition resistant antiarrhythmic drug therapy important determine primary cause long qt intervals way correct we experienced case tdp associated panhypopituitarism developed sequelae radiation therapy administered 20 years prior current presentation recently aggravated urinary tract infection uti sepsis a 64-year old man admitted hospital shock caused uti patient medical history local radiation therapy surgical area undergoing functional endoscopic sinus surgery nasal tumor left maxillary cancer squamous cell carcinoma 20 years ago he followed 5 years surgery follow discontinued possibility recurrence he took tamsulosin benign prostatic hypertrophy used spiriva spiriva boehringer ingelheim gmbh germany inhaler chronic obstructive pulmonary disease admission the patient blood pressure 70/40 mm hg pulse rate 88 beats min respiration rate 26 times per minute body temperature 38.0. patient managed septic shock antibiotics including ceftazidime intensive care unit icu blood pressure stabilized on 4th day icu admission non sustained polymorphic vt tdp occurred 20 seconds the patient indicated briefly felt drowsy blood pressure event 110/70 mm hg laboratory tests reported following findings glucose 141 mg dl 70 110 mg dl na 144 meq l 135 145 meq l k 3.8 meq l 3.5 5.5 meq l corrected ca 8.6 mg dl 8.4 10.2 mg dl mg 1.4 mg dl 1.9 2.5 mg dl the patient treated loading dose mg 2 g maintenance dose mg 1 g day 8 days administration magnesium patient laboratory parameters follows na 144 meq l 135 145 meq l k 4.2 meq l 3.5 5.5 meq l corrected ca 8.8 mg dl 8.4 10.2 mg dl mg 2.4 mg dl 1.9 2.5 mg dl although mg level normalized qtc interval prolongation wave inversion persisted tdp recurred several times when tdp appeared patient blood pressure stable became stuporous therefore echocardiography coronary angiography temporary ventricular overriding pacing ventricular rate 90 beats per minute performed echocardiography demonstrated left ventricular ejection fraction 54% regional wall motion abnormality abnormal findings observed coronary angiography a thyroid function test showed reduced values t3 35 ng dl 65 150 ng dl free t4 0.36 ng dl 0.78 1.54 ng dl thyroid stimulating hormone tsh 0.27 iu ml 0.35 5.5 iu ml luteinizing hormone lh follicle stimulating hormone fsh measured evaluate abnormal thyroid functioning the tsh releasing hormone stress test demonstrated increase tsh 0.22 iu ml range 0.35 5.5 iu ml lh 0.9 miu ml range 1.0 5.3 miu ml fsh 72.5 miu ml range 1.1 13.5 miu ml after panhypopituitarism diagnosed brain ct brain mri enhancement performed small pituitary gland found treatment average urine output 4 l daily the patient serum urine osmolarity 300 mosm kg 275 295 mosm kg 247 mosm kg 300 900 mosm kg respectively correct pituitary gland dysfunction steroid prednisolone 7.5 mg thyroid hormone levothyroxine 100 g desmopressin minirin nasal spray 5 g bid administered after one week hormone treatment qtc prolongation wave inversion decreased mildly after 4 weeks steroid hormone thyroid hormone desmopressin treatment electrocardiography showed normal qtc range 430 ms wave inversion disappeared table 1 after desmopressin administration patient symptom diabetes insipidus improved urine output decreased 1 2 l daily his serum osmolarity normalized 288 mosm kg 275 295 mosm kg urine osmolarity increased 544 mosm kg 300 900 mosm kg the physiological chronotropic response normal tension heart muscle diastolic phase depend proper expression tri iodothyronine heart cells stimulating influence na k atpase ca atpase endoplasmic reticulum normal heart contractility also related proper tri iodothyronine stimulated transcription myosin heavy chain alpha gene inhibition heavy chain beta gene moreover proper tri iodothyronine expression cardiac muscle affects number -adrenergic receptors sensitivity catecholamines profound hypothyroidism decreased expression tri iodothyronine heart cells may cause worsening cardiac contractility decreasing heart rate slowing conduction electrical stimuli heart muscle may reason bradycardia prolongation qt interval result life threatening arrhythmias may occur torsade des pointes type tachycardia.5)6 addition thyroid hormone steroid hormones also known associated tdp.7 9 although pathogenesis remains unknown hypopituitarism reported commonly associated electrocardiac abnormalities t wave inversion common finding prolongation qt interval second common finding.10 ecg changes reports polymorphic vt hypopituitarism although mechanism remains unclear glucocorticoid deficiency intracellular extracellular electrolyte imbalance myocytes histopathological changes myocardium thought play role disorder it reported glucocorticoids regulate kv 1.5 k channel gene expression rat ventricle.11 additionally iga et al.12 suggested catecholamine release induced hypoglycemia might cause arrhythmia abnormal wall motion left ventricle patients adrenal insufficiency known female gender associated higher risk polymorphic vt sudden cardiac death adult patients congenital long qt syndrome lqts)-type 1 type 2 potential role sex hormones modulating arrhythmogenic risk lqts.13 previous animal study indicated occurrence vt sudden cardiac death abolished oral progestins transgenic lqt2 rabbit model.14 however clear relationship tdp sex hormone acquired lqts case unable determine hormonal effect important thyroid hormone glucocorticoid hormone administered together to best knowledge report association tdp panhypopituitarism developed sequelae radiation therapy previous reports described cases tdp hypopituitarism caused sheehan syndrome sequelae hemorrhagic fever renal syndrome.8)9 administration steroid hormone thyroid hormone patient qtc prolongation inverted wave showed improvement tdp recur hormonal disorders considered cause polymorphic vt long qt intervals with supplementation deficient hormones life threatening arrhythmia cured	we describe a 64-year - old male patient with panhypopituitarism who experienced polymorphic ventricular tachycardia ( vt ) associated with long qt intervals . the panhypopituitarism developed as a sequelae of radiation therapy administered 20 years prior to his current presentation and was recently aggravated by urinary tract infection with sepsis . in this case , polymorphic vt was resistant to conventional therapy ( including magnesium infusion ) , and qt prolongation and t wave inversion were normalized after the administration of steroid and thyroid hormones . thyroid hormone is generally known to be associated with torsades de pointes ( tdp ) , but steroid or other hormones may also provoke tdp . hormonal disorders should be considered as a cause of polymorphic vt with long qt intervals . some arrhythmias can be life - threatening , and they can be prevented with supplementation of the insufficient hormone .
precise fabrication large areas ordered nanoscale structures essential microelectronic information technology broad scope top processes including conventional immersion lithography extreme ultraviolet lithography soft lithography proposed meet demands devices miniaturization endeavors enabled lateral dimensions devices readily shrunk 100 nm 1 3 however lateral dimension goes smaller smaller top approaches become extremely difficult expensive hence methodologies creating nanostructures great interesting offer advantages reduced production cost smaller feature sizes complex nanopatterns nanofabrication via block copolymer self assembly represents one powerful candidates taking promising methodology next generation lithography 4 6 mainly due intrinsic nanoscale dimensions facile synthesis strict control architecture ever since self assembly block copolymers introduced powerful bottom route well organized nanostructures decade ago many efforts devoted chemical modification block copolymer structure achieve special functionalities exploring electric fields interfacial interactions control orientation utilizing solvent induced ordering salt complexes shear fields achieve ordered arrays 7 10 among solvent annealing particularly beneficial mainly due mild process condition need additional complicated apparatus turn simple robust approach generate almost defect free microphase separation structures bcp thin films 11 13 even appears single possible way thermal lible systems supramolecular block copolymers based noncovalently bonding further research revealed use co solvent atmosphere enables one enhancing ordering process ever however critical drawback solvent annealing bcp thin film often de wets substrate solvent exposure already pointed several researchers 16 19 this makes difficult obtain uniform ordered bcp thin film macroscopic area without direction additional external fields many cases realizing vast technological potential block copolymers requires precise controlling orientation long range ordering however weakness still remains far works reported achieve highly ordered thin film nanotemplates control well organized structures large scale still challenging topic recent decade ikkala ten brinke thoroughly demonstrated well ordered nanostructures bulk may fabricated supramolecular assemblies sma low molecular amphiphiles block copolymers the amphiphiles physically bonded homopolymers block copolymers using noncovalent interactions complexation lead formation supramolcecular block copolymer assembled hierarchy nanostructures various responsive properties more recently demonstrated ordered nanoporous thin film fabricated similar approach based supramolecular assemblies block copolymers ps pvp small molecule 2,4-hydroxybenzeneazo benzoic acid haba 22 26 sma thin films demonstrated hexagonal cylindrical morphology ps form matrix solvent annealing dioxane enhance ordering thin films microphase separation following extraction haba selective solvent methanol results nanoporous thin films the channels filled metal example nickel electrochemical deposition fabricate array ordered metal nanodots nanowires defects appear array due nonuniform electrodeposition kinetics metal clusters nanochannels article investigate ps pvp haba supramolecular assembly system order achieve highly ordered morphology explore high definition nanotemplate replication method fabrication highly ordered polymeric nanodots nanowire arrays we demonstrate mixture solvent annealing atmosphere dedicating choosing additional nitromethane selective solvent minor component near defect free nanoporous thin films long range ordering large areas achieved taking aim high definition nanotemplate transfer technique another daunting obstacle application nanoporous template show direction capillary action hydrogen bonding ordered nanoporous template perfectly transferred thus achieved methodology preparation highly ordered sub-30 nm polymeric nanodot nanowire arrays poly(styrene block-4-vinylpyridine ps pvp mn ps 4000 g mol pvp 5600 g mol mw mn 1.06 blocks purchased polymer source inc a soluble low molecular weight phenolic resin precursor solution prepared phenol formaldehyde using basic polymerization method solvents 1,4-dioxane chloroform methanol dichloromethanes purchased acros organics used supplied ps pvp haba 1 mol haba 1 mol 4-vinylpyridine monomer unit dissolved separately 1,4-dioxane ps pvp solution slowly added dropwise haba solution heating 95 c ultrasonic bath additional 1,4-dioxane nitromethane mixture solvent vapor annealing thin film applied improve order nanodomains alternatively samples treated vapors chloroform arrange parallel alignment nanodomains the nanoporous template dip coating ethanol solution phenolic resin precursor thin film sequentially cured exposure formaldehyde gas 100 c 4 h. cured film finally pyrolysis middle temperature heating 450 c 2 h keep 2 h remove ps pvp resulted ordered nanodots arrays fig scheme fabrication highly ordered polymeric nanodot nanowire arrays templated nanoporous thin films thickness polymer films measured se400 ellipsometer sentech instruments gmbh germany 632.8 nm laser 70 incident angle atomic force microscopy afm imaging performed using dimension 3100 scanning force microscope digital instruments inc analysis afm images fast fourier transform performed wsxm software nanotec electronica poly(styrene block-4-vinylpyridine ps pvp mn ps 4000 g mol pvp 5600 g mol mw mn 1.06 blocks purchased polymer source inc a soluble low molecular weight phenolic resin precursor solution prepared phenol formaldehyde using basic polymerization method solvents 1,4-dioxane chloroform methanol dichloromethanes purchased acros organics used supplied ps pvp haba 1 mol haba 1 mol 4-vinylpyridine monomer unit dissolved separately 1,4-dioxane ps pvp solution slowly added dropwise haba solution heating 95 c ultrasonic bath additional 1,4-dioxane nitromethane mixture solvent vapor annealing thin film applied improve order nanodomains alternatively samples treated vapors chloroform arrange parallel alignment nanodomains the nanoporous template dip coating ethanol solution phenolic resin precursor thin film sequentially cured exposure formaldehyde gas 100 c 4 h. cured film finally pyrolysis middle temperature heating 450 c 2 h keep 2 h remove ps pvp resulted ordered nanodots arrays fig 1 scheme fabrication highly ordered polymeric nanodot nanowire arrays templated nanoporous thin films the thickness polymer films measured se400 ellipsometer sentech instruments gmbh germany 632.8 nm laser 70 incident angle atomic force microscopy afm imaging performed using dimension 3100 scanning force microscope digital instruments inc analysis afm images fast fourier transform performed wsxm software nanotec electronica the deposited ps pvp haba thin film form cylindrical phase separation normal substrate poor lateral ordering due thermal liability hydrogen bonding solvent vapor annealing elegant approach promote bcp ordering previous study dioxane chosen annealing solvent dedicating chosen 1,4-dioxane nitromethane mixture solvent annealing order enhances long range ordering relatively short time annealed dioxane nitromethane mixture solvent 24 h the films taken rinsed methanol 5 min destroy hydrogen bonding removes selectively haba thin film resulted nanoporous thin film afm revealed orientation order short range also apparent smashed ring fft plot fig the inset fft plot image however prolonging solvent annealing time 72 h mixture atmosphere lead dramatically increase long range ordering thin film afm image clearly identified near defect free ordered arrays highly ordered hexagonal structure pores oriented perpendicular substrate fig 3 fourier transform plot corresponding afm phase image shown inset six sharp first order peaks clearly indicate presence highly ordered hexagonal structures higher order peaks attest high degree order within thin film the mean center center distance nanopores based afm image 30 nm solvent annealing ps p4vp haba blocks swelled dioxane vapor tend organize ordered structures however process restrained dioxane certain extent due good solubility dioxane blocks addition nitromethane good solvent minor pvp haba block repulsion ps p4vp haba domains enhanced fast highly ordered defect free microphase separation structure achieved afm images nanoporous thin filmsaheight image bphase image cenlarged height image mixture solvent annealing 72 h washed methanol the inset fft plot afm image nanoporous thin films used scaffolds fabricating organic inorganic metal nanostructures compared well studied inorganic metal nanostructures organic polymeric nanostructures remains less researched despite great potential catalysis membrane separation here demonstrated highly ordered phenolic resin nanodot nanowire arrays prepared perfect replication ordered nanotemplate direction hydrogen bonding capillary action nanopores the prepared nanoporous thin films immersed phenolic resin precursor ethanol solution nanopores immediately filled phenolic precursors due capillary action cylindrical nanopores formation interpolymer hydrogen bonding complex pvp inner pore surface nanotemplate phenolic resin ethanol good solvent minor component pvp nonsolvent matrix composed ps thus nanoporous templates maintained dip coating process template drop precursor solution ethanol vaporized phenolic resin precursor maintaining inside nanopores after curation formaldehyde filled nanotemplates pyrolysed middle temperature heating 450 c 2 h keep 2 h temperature enough degrade ps pvp nanotemplate phenolic resin still maintained afm height image revealed pyrolysis highly ordered discrete phenolic resin nanodots arrays uniform diameter observed fig 4 special interest original highly ordered structure nanoporous thin film almost maintained throughout nanotemplate transfer process thus resulted perfect nanotemplate transformation average center center distance nanodots 30 nm identical original porous nanotemplate afm images highly ordered polymeric nanodots arrays nanoporous thin film pyrolysis.aheight image bphase image lateral scale 1500 nm 1500 nm.cenlarged height image addition preparation nanodots arrays extend facile nanotemplate replica method fabricate polymeric nanowire arrays a special advantage supramolecular assembled ps pvp haba system used orientation phase separation reversibly switched perpendicular parallel orientation vice versa upon exposure 1,4-dioxane chloroform vapor respectively thus instead dioxane vapor ps pvp haba supramolecular assembly thin film annealed saturated chloroform vapor short time 15 min achieve alignment rinsing methanol afm revealed cylindrical microdomains orientation alignment parallel substrate still clear 15 min enough fulfill alignment process thus coexistence normal parallel alignments nanodomains observed fig 5a followed template transfer process nanotemplate dip coating phenolic resin precursor solution followed curation middle temperature pyrolysis large areas short polymeric nanowires nanodots mixture formed fig aafm height images thin film nanotemplate alignment using chloroform annealing 15 min.bheight images resulted short polymeric nanowire arrays replica pyrolysis lateral scale 2000 nm 2000 nm prolonging chloroform solvent annealing time 30 min enough fulfill alignment transformation process rinsing methanol afm revealed cylindrical microdomains oriented parallel substrate(fig 6a thus deposition middle temperature pyrolysis longer nanowire arrays identical original nanotemplate achieved fig aafm height images thin film nanotemplate alignment using chloroform annealing 30 min.bafm height images polymeric nanowire arrays replica pyrolysis in summary provided general route fabricate highly ordered polymeric nanodot nanowire arrays using supramolecular assembled block copolymer thin film nanotemplates interpolymer hydrogen bonding capillary action the deposited ps pvp haba thin film formed randomly hexagonally packed cylindrical phase separation structures dedicating choosing mixture solvent annealing atmosphere dioxane good solvent blocks additional nitromethane selective solvent minor component pvp haba near defect free nanoporous thin film long range ordering broader range length scales achieved extraction haba microdomains resulted highly ordered nanoporous thin films direction interpolymer hydrogen bonding capillary action nanopores the nanotemplate properly filled phenolic resin precursor followed curation pyrolysis middle temperature selectively degrade ps pvp block copolymer nanotemplate perfect ordered nanodot arrays replication obtained thus resulted excellent efficient transformation nanoporous template functional polymeric nanodot arrays the orientation supramolecular assembly thin films readily alignment perpendicular parallel substrate upon exposure chloroform vapor thus facile nanotemplate replica method extend generate large areas polymeric nanowire arrays thus achieved successful sub-30 nm patterns nanotemplates transfer methodology fabricating polymeric nanopattern arrays tunable morphology lateral spacings	realizing the vast technological potential of patternable block copolymers requires both the precise controlling of the orientation and long - range ordering , which is still a challenging topic so far . recently , we have demonstrated that ordered nanoporous thin film can be fabricated from a simple supramolecular assembly approach . here we will extend this approach and provide a general route to fabricate large areas of highly ordered polymeric nanodot and nanowire arrays . we revealed that under a mixture solvent annealing atmosphere , a near - defect - free nanoporous thin film over large areas can be achieved . under the direction of interpolymer hydrogen bonding and capillary action of nanopores , this ordered porous nanotemplate can be properly filled with phenolic resin precursor , followed by curation and pyrolysis at middle temperature to remove the nanotemplate , a perfect ordered polymer nanodot arrays replication was obtained . the orientation of the supramolecular assembly thin films can be readily re - aligned parallel to the substrate upon exposure to chloroform vapor , so this facile nanotemplate replica method can be further extend to generate large areas of polymeric nanowire arrays . thus , we achieved a successful sub-30 nm patterns nanotemplates transfer methodology for fabricating polymeric nanopattern arrays with highly ordered structure and tunable morphologies .
addition general decline physical fitness aging process accompanied progressive decline perception motor behavior cognition memory functions 24 therefore preservation everyday life skills maintenance independent living become increasingly important advancing age it well established physical fitness intimately associated cognitive performance elderly 59 consequently high levels physical fitness assumed major factor contributing maintenance independent living everyday competence one basic accomplishments gerontology recognition tremendous heterogeneity interindividual variability elderly thus emergence age related decline highly variable individuals notable differences interindividual performance general skills advanced ages it seems aged individuals maintain high levels proficiency certain domains involving cognitive motor functions golf piano playing this gave rise intriguing question proficiency one domain expertise like playing piano associated performance general ? older experts show little age related decline tasks related area expertise beyond show general age related decline similar nonexpert older adults hand maintenance high levels expertise one domain positive impact related functions for example elderly professional pianists higher finger tapping rates untrained aged matched individuals we recently showed regular schedule amateur dancing many years throughout old age promotes posture balance also wide range beneficial effects reaction times rts motor behavior tactile cognitive performance comparing individuals aged matched nondancer control group we hypothesized generalization superior performance associated regular dancing develops result physical exercise combination cognitive challenges sensory stimulation social interaction contribute neuroplasticity extended studies investigating impact dancing higher level expertise one rationales study obtain information whether extensive schedule dancing including competitive tournaments would enhance range magnitude beneficial effects we compared group neurologically healthy older subjects many years expert competitive experience dancing ed gender- age- education matched nondancer control group cg study the term expert defined regularly attend dance competitions dance contests undergo training intensities 4 h week comparable previous study amateur dancers measured posture balance cognitive attentional intellectual perceptual sensorimotor performance subjects recruited advertisements newspapers poster announcements word mouth advertising all subjects reported medical history current medication underwent mini mental status examination mmse the ed group n 11 5 women 71.18 1.13 years extended history competitive dancing 22.09 3.39 years average workload 4.55 0.15 h week subjects ed group reported regular attendance official dance contests championships throughout germany the cg group consisted 38 sedentary subjects 71.66 1.11 years 30 women ecq score 8.43 record dancing sporting activities see section 4 details regarding selection appropriate controls the age distribution p 0.829 education level number school years p 0.926 subjects across groups balanced the study approved local ethics committee ruhr university bochum dance competitions all subjects ed group assigned starting group referred seniors iv for competition 10 different dances performed mandatory order including slow waltz tango viennese waltz slowfox quickstep samba cha cha cha rumba paso doble jive lasted 1.52 min basis points given adjudicators contests the subjects ed group assigned highest german grade within corresponding starting group therefore subjects ed group particularly fit regard mobility muscle flexibility body composition although literature reports indicate lower cardio respiratory performance i.e. maximal oxygen uptake vo2max professional ballet dancers comparison athletes performing physical activities like running swimming professional modern dancers shown significantly higher maximal oxygen uptake compared professional ballet dancers review see given average workload 4.5 h week plus assumed 2.5 h week dancing competition adds 7 h week totals 350 h per year sums 7500 h typical workload range required qualify becoming expert lifestyle and general activity levels assessed using everyday competence questionnaire ecq addresses aspects everyday life independence activities daily living mobility social relations general health status life contentment compilation questions used ecq accounts changing living conditions today seniors the ecq consisted 17 items including housekeeping daily routines manual skills mobility sports subjective well linguistic abilities leisure time activities thereby addressing instrumental activities daily living iadl individual engagement activities everyday life well these activities necessary fundamental functioning let individual live independently community all subjects asked comment questions much detail possible thus allowing insight habits living conditions the scores normalized scale 0 1 dividing number points achieved maximum possible scores per item general intelligence assessed using raven standard progressive matrices rspm 19 20 the test administered according standard instructions 30 min time constraint control group the rspm conducted pre-/post design provide data separate study therefore groups study used odd numbered items resulting maximum score 30 in addition nonverbal geriatric concentration test akt used assess selective attention concentration paper pencil test subjects mark 20 symbols 55 similar looking patterns within maximum time limit 30 figure 1 the time required subject complete test sessions averaged evaluate individual performance we performed multiple choice rt measurements finger selection visuotactile task adapted study alegria bertelson an image hand displayed monitor 1 finger 10 selected visual marker subjects press key corresponding selected finger hand shaped 10-button keyboard fast possible one session consisted 4 blocks 100 trials separated short break block the maximum response stimulus interval trial 2000 ms we applied romberg test timed go test standing turn test assess subjects ability control posture maintain balance evaluate security gait the romberg test standard neurological test addressing joint position sense proprioception applied condition eyes either open closed 23 26 the movements body relation perpendicular object behind subject monitored the time subject started lose balance recorded maximal testing time limited 1 min timed go test subjects asked stand sitting position walk 3 return chair sit time fulfill task measured standing turn test standing subject asked perform 360-degree turn time number steps hand arm fine motor performance evaluated using computer based test battery clinical neuropsychological research mls dr the system consists work plate 2 pencils left right hand use we tested speed accuracy maintenance upper limb position execution fine motor movements left right arms hands fingers using following tests steadiness evaluates ability achieve prescribed arm hand position maintain defined time period aiming evaluates ability accomplish fast arm hand movements small targets pin plugging evaluates fine gross motor dexterity coordination tapping evaluates ability perform fast repetitive wrist finger movements little emphasis precision movement touch threshold evaluated using staircase procedure probing fingertips left right index fingers von frey filaments ranging 0.25 294 mn logarithmic scaling marstocknervtest marburg germany spatial 2-point discrimination thresholds 2pd assessed tips left lid right rid index fingers using method constant stimuli 2729 needle separations 1.5 2.3 3.1 3.9 4.7 5.6 7 mm used test retest reliability using procedure 0.90 young subjects 0.88 older participants the summed responses plotted needle distances resulting psychometric function fitted using binary logistic regression spss spss inc the threshold taken fit 50% correct responses reached pool data obtained various tests defined 5 domains covering similar functional categories cognitive performance comprised data akt rspm posture balance comprised data romberg test timed go test standing turn test motor performance comprised steadiness aiming pin plugging tapping separate domain rt introduced include data multiple choice rt task compare performances across tests subjects calculated normalized performance indices ips subject test wp ip)/(wp bp wp worst performance subjects ip individual performance bp best performance subjects indices subsequently averaged across tasks belonging particular domain described cases reported averages standard error mean sem we used mann whitney u test detect differences 2 groups moreover computed effect sizes according cohen test differences distribution ips we used chi square statistics p value 0.05 considered significant we tested cognitive posture balance sensorimotor performance 2 groups older participants matched gender age education extended history expert competitive dancing ed dancing experience control group cg the ed group superior performance tests table 1 the ed group showed significantly higher ecq scores cg group z 2.996 p 0.003 cognitive performance assessment showed significant differences ed cg groups rspm figure 2(a z 2.776 p 0.006 akt z 4.997 p 0.001 for hands ed group faster rts averaged left z 2.294 p 0.022 right hands z 2.195 p 0.028 posture balance assessment showed significant differences 2 groups romberg test eyes open z 3.951 p 0.001 eyes closed z 1.250 p 0.211 subjects ed group needed less time completion standing turn test z 2.815 p 0.005 moreover ed group showed significantly shorter go times figure 2(b z 3.819 p 0.001 significant differences found 2 groups motor domain aiming subtest figure 2(c showed fewer errors ed group z 2.808 p 0.005 well shorter pin plugging time z 2.343 p 0.019 observed right hand tactile domain the assessment 2pd thresholds showed significant differences 2 groups figure 2(d right z 2.434 p 0.015 left z 2.515 p 0.012 index fingers the calculation ip test subject allowed direct comparison performances across tests subjects facilitated grouping functional domains covering cognition rts posture balance motor performance tactile performance as shown table 2 ed group showed significantly higher ips 2 5 domains largest difference posture balance z 5.599 p 0.001 followed rts z 3.462 p 0.001 our findings indicated general advantage ed group spans cognitive perceptual motor performance order obtain insight possible differences overall distribution ips within given domain grouped ip domain 0.5 0.5 values compared percentage occurrence ips 0.5 across groups 0 indicates worst 1indicates best performance 3 5 domains analyzed cg group significantly higher number ips lower 0.5 subjects ip 0.5 cognition ed 9.09% cg 36.26% 6.12 p 0.013 rt ed 4.55% cg 44.74% 12.00 p 0.001 posture balance ed 21.82% cg 70.37% 25.87 p 0.001 higher ips motor performance lower 0.5 also found within cg group reach statistical significance ed 17.61% cg 24.59% 3.75 p 0.053 agreement results shown table 2 increased ips lower 0.5 found tactile performance ed group ed 38.64% cg 21.26% 5.16 p 0.023 accordingly superior performance ed group within domains come fact best performers better cg group instead due fact ed group lacked poor performers frequently present cg group we recently shown regular schedule many years amateur dancing old age wide range beneficial effects posture also sensorimotor cognitive performance this observation raised question whether preservation high level proficiency present elderly expert ballroom dancers even higher positive impact physical cognitive fitness aged individuals compared basic amateur dancing skills we therefore studied impact extended participation competitive dancing group older subjects compared aged matched nondancer cg in addition posture balance closely related dancing performed broad assessment cognitive attentional perceptual sensorimotor abilities according hypothesis impact multi year dancing activities therefore needed test many different domains cognitive functions basic sensory abilities criteria selecting test included brief time needed complete test general acceptance wide extension sense a particular test served surrogate given domain implying tests field would shown similar effects floor ceiling effects described using advanced ceiling colored progressive matrices floor effects study used subset odd numbered items resulting maximum rspm score 30 the scores obtained ed 19.59 0.75 cg 15.39 0.83 indicate lack floor ceiling effects included cg characterized record dancing sporting activities least 5 years the ecq addresses specific aspects called instrumental activities daily living housekeeping daily routine manual skills mobility sports subjective well linguistic abilities leisure time activities participants cg lower ecq scores indicating passive sedentary lifestyle these data imply close association lack sporting activities lifestyle identification primary goal selected subjects it well acknowledged selecting adequate control group type expert subpopulation poses major challenge for example instead using group passive individuals one could use group would also considered expert different domain particularities respective areas expertise would compared as dancing coupled physical exercise controls selected neither experience dance sports further studies required test groups comprised individuals performing type sport activity order disentangle effects physical exercise hidden dance subjects ed group performed better tasks investigated study however analysis individual ips allowed comparison across tests subjects 5 domains cognition rt posture balance motor performance tactile performance showed significantly better performance ed group regard rt posture balance a similar argument made finding faster rts ed group might attributable requirements high attention fast well coordinated motor responses in contrast previously studied group elderly amateur dancers found differences ed cg performance measures related domains cognition hand arm motor functions hand limited generalization extent agreement recent studies concluded although high levels expertise may positive impact functions related specifically proficiency non expert related abilities older experts similar nonexpert older adults in previous study performed group amateur dancers showed best performers task present dancing cg similar frequency amateur dancing group lacked number poor performers frequently found within control group here showed non expertise related domains tactile abilities poor performers equally present ed cg these data led us speculate amateur expert competitive dancers differ latter focus area expertise expense skills since dancing high maintained level expertise requires extensive practice competitive dancing requires substantial effort regard traveling time personal strain competitions might counteract positive impact dancing observed amateur group another line argument limited positive impact expertise old age comes functional imaging studies it shown learning piano playing amateurs elicits stronger activation number brain areas comparison brain activation found professional piano players practice playing maintain high levels expertise on basis types studies suggested fewer cognitive resources required expert performance it therefore conceivable maintenance high level expertise lesser impact acquisition new skills general fitness older people many years dance successfully established therapeutic tool elderly improve cardiovascular parameters muscle strength posture balance 37 38 our motivation investigating beneficial effects dancing triggered hypothesis dancing regarded equivalent enriched environmental conditions human individuals unique combination physical activity rhythmic motor coordination emotion affection balance memory social interaction acoustic stimulation however data suggest many features play crucial role promoting positive effects amateur dancing might less relevant expert dancers assumption supported observation positive impact expert competitive ballroom dancing limited expertise related tasks posture balance rts thus years spent developing high level expertise helps maintain remarkable levels posture related performance even advanced age accordance notion brain plasticity operational old age 27 39 compared activities exercising walking playing instrument dance advantage combining many diverse features including physical activity social emotional interaction sensory stimulation well documented beneficial effects consequently many studies elderly shown improving aerobic capacity physical exercise programs beneficial effects cognitive performance 6 8 9 4043 while cardiovascular fitness might directly affect blood pressure circulation animal research effects physical exercise suggests crucial involvement neurotrophins nerve growth factors 44 45 use dependent plasticity synaptic efficacy maintenance synaptic connections controlled modulated neurotrophins brain derived neurotrophic factor bdnf bdnf levels increase many factors physical activity social interaction 4447 housing animals enriched environmental conditions particular shown increase neurotrophin gene expression thus exerting neuroprotective functions 4850 mild stress response cells advocated major driving force upregulation stress resistance genes growth factors interestingly among factors inducing mild stress sensory stimulation physical activity cognitive challenges involved dancing it must recognized present study well previous study amateur dancers resolve query whether superior performance either expert amateur dancers due group preselection particularly fit subjects tending engage regular schedule year long dancing due dancing activity per se it therefore conceivable intelligent people better balance faster rts likely select dancing life long avocation recent data intervention study pre-/post design showed 6-month dance course elderly participants improved tested aspects including perception cognition similar described these data show irrespective individual predispositions dancing activities play crucial role mediating wide range beneficial effects depending dose exercise our data showed regular multiyear schedule expert competitive ballroom dancing cohort older individuals preserves posture balance parameters remarkable extent positive impact rt however results provided evidence widespread beneficial effects related domains tactile cognitive performance these findings suggest doses exercise helpful alleviating age relating deterioration hint inverted u shape dose response function optimal ranges intervention intensity required maximal beneficial effects accordingly might important adjust depending individual level activity expertise challenges intervention programs maintain health functional independence throughout life given dramatic demographic changes within industrialized countries characterized increasing probability reaching old old age urgent need measures permitting independent lifestyle old age since close association physical fitness cognitive performance number studies investigated impact interventional programs basis dancing treatment age related functional degradation 37 38 53 our data showed high levels dancing expertise preserved old age thereby maintaining remarkable levels performance expertise related tasks however tasks outside areas expertise showed age related decline typically observed aged matched nonexperts	physical fitness is considered a major factor contributing to the maintenance of independent living and everyday competence . in line with this notion , it has been shown that several years of amateur dancing experience can exert beneficial effects not only on balance and posture but also on tactile , motor , and cognitive functions in older people . this raises the question of whether an even more extensive schedule of dancing , including competitive tournaments , would further enhance these positive effects . we therefore assessed posture , balance , and reaction times , as well as motor , tactile , and cognitive performance in older expert ballroom dancers with several years of competitive experience . we found substantially better performance in the expert group than in the controls in terms of expertise - related domains like posture , balance , and reaction times . however , there was no generalization of positive effects to those domains that were found to be improved in amateur dancers , such as tactile and cognitive performance , suggesting that there might be an optimal range of intervention intensity to maintain health and independence throughout the human lifespan .
desmoid tumors dts also known aggressive deep fibromatosis musculoaponeurotic fibromatosis heterogeneous group rare benign soft tissue tumors caused monoclonal proliferation well differentiated fibroblasts these tumors rare entities account 0.03% neoplasms less 3% soft tissue tumors previous studies reported estimated annual incidence dts 1 4 per million population although dts metastasize tend infiltrate and/or compress adjacent organs manifesting diverse clinical symptoms thus location important factor determines clinical course dts several therapeutic strategies dts suggested including close observation hormonal therapy radiation curative surgery specifically given incidence dts thoracic cavity uncommon mediastinal dts quite rare approximately 20 patients reported english literature critical factors clinicians take account decide treatment strategy mediastinal dts well understood herein describe case rapidly growing dt anterior mediastinum calculated doubling time 31.3 days shortest among reported cases dts the rapid growth dt complicated clinical course patient causing massive pleural effusion atelectasis chest wall invasion mediastinal shifting compression diaphragm the mediastinal dt completely removed surgery evidence recurrence disease patient a 71-year old man visited emergency department 1-week history dyspnea productive cough right chest pain aggravated daily activities he undergone aortic repair aortic valve regurgitation caused aneurysm aortic root ascending aorta 2 years presentation four months admission regular check none enhanced chest computed tomography ct scan shown 7.4 3.4-cm mass anterior mediastinum incidentally evaluation made patient refusal fig ( initial axial image chest ct none enhanced taken local clinic displays tumor arrows anterior mediastinum b axial image chest ct contrast enhanced taken admission clinic 4 months initial detection mass demonstrates extremely rapid growth anterior mediastinal tumor arrows the tumor mainly consists soft tissue matter radiodensity 27 hu none enhanced ct when iodine based contrast medium administered tumor enhanced 33 hu implying hypovascularity ( c pre contrast arterial e portal f delayed phase dynamic gadolinium enhanced chest magnetic resonance imaging t1-weighted image reveals delayed enhancement pattern indicating fibrous tumor ( g coronal image gadolinium enhanced magnetic resonance imaging t2-weighted image shows infiltration tumor chest wall arrows displacement right diaphragm abdominal cavity tumor ( h 2-deoxy-2-[18f]-fluoro glucose positron emission tomography ct displays elevated glucose metabolism maximum standardized uptake value 5.68 his breathing shallow breathing rate slightly increased respiratory rate 25/min vital signs within normal range laboratory data revealed platelets white blood cells differential cell counts within normal range arterial blood gas analysis exhibited respiratory alkalosis metabolic compensation arterial oxygen saturation 96% pulse oximetry ambient air on physical examination decreased breath sounds right lower chest percussion revealed dullness area subsequent pleural fluid examination demonstrated neutrophil dominant 68% exudate according light criteria pleural fluid protein 4.8 g dl total serum protein 6.4 g dl ratio 0.75 subsequent ct scan displayed 16.4 9.4-cm tumor anterior mediastinum fig 1b tumor homogeneous attenuation 27 hounsfield units hu nonenhanced ct tumor 33 hu enhancement indicating tumor possessed dominantly soft tissue components hypovascularity a shift mediastinum opposite site mass compression right side heart also evident fig 1b evidence hemodynamic compromise patient echocardiography moreover passive atelectasis visible right upper middle lobes there enlarged lymph nodes thoracic cavity frequently occurring masses anterior mediastinum thymoma lymphoma teratoma radiologic features mass ct scan case unusual atypical in fact thymoma lymphoma reported mild moderate enhancement teratoma often exhibits heterogeneous contents fat fluid soft tissue well calcification characterize mass evaluate whether mass involved major vascular system chest magnetic resonance imaging mri ) the mass showed high signal intensity t2-weighted images low signal intensity t1-weighted images in addition dynamic contrast enhanced mri exhibited inhomogeneous enhancement portal delayed phases suggesting mass fibrous tumor fig 1c f t2-weighted mri also demonstrated tumor infiltration left chest wall fifth seventh rib locations displacement right diaphragm abdominal cavity tumor fig interestingly calculated volume tumor simple sum area technique revealed tumor increased 302.5 11.68 cm 4103.4 158.4 cm period 116 days approximately 13-fold increase volume according formula estimate doubling time moreover positron emission tomography showed uneven avid glucose uptake maximum standardized uptake value 5.68 fig 1h for pathologic diagnosis mass percutaneous transthoracic needle biopsy ptnb performed the result however inconclusive scant cellular components specimen thus planned surgical resection tumor curative well diagnostic purpose the largest diameter tumor approximately 20 cm operation field 2a fifth seventh ribs lower sternum pericardial space medial portion diaphragm fig en bloc resection mass consisted partial resections fifth sixth ribs intercostal muscles pericardium diaphragm fig the mass successfully resected histopathologic examination specimen revealed spindle cells low cellularity high collagen deposition stroma without features malignant cells nuclear hyperchromatia nuclear atypia high nuclear cytoplasmic ratio mitosis fig the patient recovered surgery without complications evidence recurrence dt far ( a severe adhesion arrows tumor adjacent chest wall asterisk present operation field ( b tumor shows severe adhesion arrows medial portion diaphragm ( c size tumor specimen 22 20 11.3 cm surgical resection mass includes part ribs intercostal muscles arrow diaphragm open arrow pericardium arrow head ( cross section shows gelatinous appearance heterogeneous mixture white light green color tumor ( e hematoxylin eosin staining specimen demonstrates relatively small number spindle cells collagen abundant stroma 400 there features malignant cells nuclear hyperchromatia nuclear atypia high nuclear cytoplasmic ratio mitosis ( f immunohistochemical staining -catenin demonstrates strong positive reactions nuclei cells 400 merged color blue red represents positivity nuclear -catenin staining in case patient presented extremely rapid growing anterior mediastinal mass grown approximately 13-fold volume within 116 days the local effects rapid growing mass chest wall invasion mediastinal shifting compression heart induced pleural effusion atelectasis resulting dyspnea cough sputum right chest pain interestingly growth dt patient extraordinarily rapid compared previously reported patients dts literature previous studies demonstrated location dts one crucial factors determining clinical course particular for example several patients mediastinal dts shown display severe illnesses including cardiac arrhythmia circulatory collapse secondary superior vena cava syndrome cardiac failure patient compression right heart anterior mediastinal dt evident without hemodynamic collapse other clinical manifestations associated location dt thoracic cavity limited space massive pleural effusion atelectasis chest wall infiltration various mass effects including mediastinal shifting compression diaphragm resulting severe dyspnea cough sputum right chest pain hence experience also highlights significance anatomic location one key factors determining severity mediastinal dts a previous report illustrated dot plot graph presenting size anterior mediastinal dt time patient maximal doubling time 9 months case abdominal dts a previous case report showed dt doubling time 122 days another study 23 patients abdominal dts reported mass doubled less 3 month patient the volume tumor initially detected local clinic approximately 300 cm evaluation made time mediastinal dt increased volume approximately 4000 cm notably doubling time dt patient shortest among reported cases dts furthermore doubling time patient noteworthy compared several malignant tumors pancreatic carcinoma 18255 days nonsmall cell lung carcinoma 81092 days small cell lung carcinoma 54132 days taken together rapid growth dt patient may played key role complicated clinical course based experience masses rapid volumetric growth may cause serious complications thoracic cavity representative closed anatomic compartments thus early invasive therapeutic strategy likely beneficial rapidly growing mediastinal dts obtaining tissue specimens minimally invasive procedures ptnb enables clinicians diagnose disease promptly allow patients recover procedure associated morbidity early thereby possibly yielding favorable outcomes certain clinical situations dts however role ptnb preoperative diagnosis yet defined patient the result ptnb inconclusive small number cells specimen mass finally diagnosed dt surgical resection addition mass possessed characteristic findings fibrous dominant tumor minimal contrast enhancement preoperative radiologic images likewise abundant fibrous contents low cellularity pathologic specimens makes pathologic diagnosis somewhat inconclusive despite small biopsy ptnb based experience early surgical resection rather small biopsies might reliable diagnostic method especially soft tissue tumors fibrous dominant components radiologic images report described interesting case rapidly growing dt anterior mediastinum the aggressive nature dt patient highlighted calculating doubling time indicated extremely rapid growth considering dts commonly infiltrate compress adjacent organs deleterious effects intensified rapid growth mediastinum our experience highlights dt one differential diagnoses rapidly growing mediastinal tumors benefits early intervention rapidly growing mediastinal dt the institutional review board chonbuk national university hospital stated necessary achieve irb approval case report patient consent required study dealt retrospective use patient medical records related images written informed consent obtained patient publication case report accompanying images	abstractdesmoid tumors ( dts ) are a group of rare and benign soft tissue tumors that result from monoclonal proliferation of well - differentiated fibroblasts . since dts tend to infiltrate and compress adjacent structures , the location of dts is one of the most crucial factors for determining the severity of the disease . furthermore , dts can further complicate the clinical course of patients when the growth is remarkably rapid , especially for dts occurring in anatomically critical compartments , including the thoracic cavity.the authors report a case of a 71-year - old man with a known mediastinal mass incidentally detected 4 months ago , presenting dyspnea with right - sided atelectasis and massive pleural effusion . imaging studies revealed a 16.4 9.4-cm fibrous mass with high glucose metabolism in the anterior mediastinum . the mass infiltrated into the chest wall and also displaced the mediastinum contralaterally . interestingly , the tumor had an extremely rapid doubling time of 31.3 days.en bloc resection of the tumor was performed as a curative as well as a diagnostic measure . histopathologic examination showed spindle cells with low cellularity and high collagen deposition in the stroma . immunohistochemical staining was positive for nuclear -catenin . based on these pathologic findings , the mass was diagnosed as dt . after surgery , there has been no evidence of recurrence of disease in the patient.this patient presents a mediastinal dt with extremely rapid growth . notably , the doubling time of dt in our case was the shortest among reported cases of dt . our experience also highlights the benefits of early interventional strategy , especially for rapidly growing dts in the thoracic cavity .
clinical study van der boogaard colleagues recently published critical care designed unravel open questions regarding pathophysiology septic encephalopathy the authors mimicked inflammation associated encephalopathy induction experimental endotoxemia using escheria coli derived lipopolysaccharides lpss 15 healthy young volunteers outcome parameters serum levels cytokines cortisol neuron specific enolase s100- well electroencephalographic changes cognitive function comparison healthy cohort ten control volunteers interestingly van der boogaard colleagues described endotoxin induced cytokine storm cortisol release failed provoke signs septic encephalopathy no clinically relevant electroencephalographic changes occurred markers neuronal damage neuron specific enolase s100- found slightly reduced following lps challenge endotoxemia even resulted higher state alertness improved cognitive function comparison healthy cohort the authors concluded temporary systemic inflammation caused endotoxemia provoke development septic encephalopathy nonetheless present study shed light towards understanding immunological pathophysiology septic encephalopathy appears unlikely bacterial lps driving force development septic encephalopathy note worthy spectrum responsible microorganisms shifted predominantly gram negative bacteria late 1970s 1980s predominantly gram positive bacteria fungal infections present the authors findings underscore complexity ambiguity septic encephalopathy continues puzzling complication sepsis syndrome this particular concern 70% septic patients develop signs brain damage traditionally septic encephalopathy thought occur due inflammatory breakdown blood brain barrier bbb key causative factor sepsis associated delirium a dysfunction bbb shown induced various inflammatory mediators il-1 tnf- complement bradykinin cause sterile meningitis absence bacterial pathogen moreover complement c3 c5a linked sepsis induced compromise bbb note direct contact blood cerebrospinal fluid leads complement activation may case severe bbb dysfunction the disruption physical barrier allows circulating neurotoxic substances extravasate brain parenchyma promote inflammatory response however traditional notion initial bbb compromise prior development septic encephalopathy recently challenged experimental study londoo cadavid injected mice intraperitoneally labeled outer membrane lipoproteins borellia turicatae monitored localization brain surprisingly two lipoproteins studied lvsp1 lvsp2 capable disseminating periphery brain caused intracerebral inflammation without intracerebral spirochete accumulation another piece complex puzzle septic encephalopathy may extensive communication nervous immune system interestingly interaction bi directional cytokines trigger release glucocorticoids via hypothalamic pituitary axis turn glucocorticoids suppress cytokine synthesis leukocytes moreover systems use common biochemical language hormones ligands receptors communicate setting sepsis the majority work neuroimmunology focused anti inflammatory properties vagus nerve popularized term inflammatory reflex interactions likely involved development septic encephalopathy exact mechanisms remain inadequately understood one dilemmas current sepsis research poor transferability promising experimental findings many pharmacological research strategies failed successful translation bench bedside this predicament likely caused obvious disconnect controlled animal models heterogeneous clinical sepsis syndrome observed humans experimental human studies study van der boogaard colleagues limited several factors endotoxemia usually induced young healthy population may rather present acute intoxication model multi microbial fungal infections observed sepsis syndrome in experimental setting timing dosage lps limited based safety issues therefore might reach threshold development significant bbb damage moreover sepsis results various causative etiologies susceptibility influenced premorbid factors including ethnicity gender age genetic defects environmental factors the belief single key mediator causes sepsis neutralization could cure patients sepsis seems erroneous particular pre existing genetic epigenetic changes mutations genes encode pattern recognition receptors inflammatory mediators may enormous impact host susceptibility sepsis interdisciplinary approaches involving clinicians basic scientists necessary improve knowledge underlying pathophysiology sepsis septic encephalopathy such interdisciplinary large scale programs involving surgery genomics proteomics biostatistics bioinformatics computational biology genetics currently underway bbb blood brain barrier il interleukin lps lipopolysaccharide tnf tumor necrosis factor	the exact cellular and molecular mechanisms of sepsis - induced encephalopathy remain elusive . the breakdown of the blood - brain barrier ( bbb ) is considered a focal point in the development of sepsis - induced brain damage . contributing factors for the compromise of the bbb include cytokines and chemokines , activation of the complement cascade , phagocyte - derived toxic mediators , and bacterial products . to date , we are far from fully understanding the neuropathology that develops as a secondary remote organ injury as a consequence of sepsis . however , recent studies suggest that bacterial proteins may readily cross the functional bbb and trigger an inflammatory response in the subarachnoid space , in absence of a bacterial invasion . a better understanding of the pathophysiological events leading to septic encephalopathy appears crucial to advance the clinical care for this vulnerable patient population .
hence diagnosis arrived treat affordable activator therapy followed inexpensive fixed appliance brackets habits play significant role improper development dental well facial form function esthetics moreover known child psychology habits many times correlated stress anxiety growing child many common childhood habits it results compromised dental facial esthetics posterior positioning mandible protrusion maxillary anterior teeth deep bite such children reaching maturity get conscious profile problems leading loss self confidence could even hamper social development a 10 years 6 months old girl born 06/02/1998 presented department dentistry bhatia general hospital parental guidance complaint protruding upper front teeth her medical history non contributory according history charting questionnaire mother revealed daughter lip biting habit studying reading the habit developed since childhood even repeated counselling efforts taken quit habit previous general practitioner proved vain her extraoral examination figures 12 revealed shortened lower facial height convex profile a clinically flat mandibular plane also noted signifying horizontal growth pattern favorable activator therapy the face symmetrical nasolabial angle approximately 90.on temporomandibular joint tmj examination movements found normal her visual treatment objective vto clinically showed marked improvement profile guaranteeing successful result pre treatment extraoral frontal view pre treatment extraoral lateral profile view intraoral examination figures 35 molar canine relation end tending toward angle class ii relation partially impacted lower left canine pre treatment intraoral view occlusion pre treatment intraoral left lateral view occlusion pre treatment intraoral right lateral view occlusion cephalometric analysis showed sella nasion point angle sna 82.4 sella nasion point b angle snb 76.1. resulting point nasion point b angle anb 6.3 suggested posterior placement mandible upper incisor sella nasion sn plane 120and lower incisor mandibular plane impa 110 reconfirming upper lower incisor proclination frankfort mandibular plane angle fma 17 suggested horizontal growth pattern favorable use myofunctional appliance the orthopantomogram showed continuous posterior lower borders normally positioned condyle pre requisite myofunctional treatment adequate alveolar bone height good root parallelism partially impacted lower left canine the ashley howe model analysis turned 44% revealing borderline case extraction decision thus patient diagnosed case developing skeletal class ii malocclusion exhibiting end molar canine relation andreasen modified activator lower lip pad appliance choice treating class ii skeletal base malocclusion this finished pre adjusted fixed appliances using mclaughlin bennett trivisi 0.022 slot prescription post myofunctional therapy figures 6 7 facial profile straightened lower one third facial height increased significantly post treatment extraoral frontal view post treatment extraoral lateral profile view intraorally figures 810 molar canine relation turned angle class relation bilaterally post treatment intraoral frontal view occlusion post treatment intraoral left lateral view occlusion post treatment intraoral right lateral view occlusion cephalometrically sna stayed constant whereas snb increased 79.6,which resulted anb 2.8 normal indian population upper incisor sn plane impa reduced dramatically resulting interincisal angle 128 corroborating decrease upper lower incisor proclination fma increased 22 also adding near normal vertical component growth these skeletal dentoalveolar changes could attributed correction lower lip biting habit ii remodelling tmj iii restriction maxillary growth iv inherent increase natural mandibular bone mass dentoalveolar changes included angle class relation end result correct bite registration procedure habit correction included keeping lower lip away means lower lip pad resulted pacification hyperactive mentalis muscle activity registration bite important feature angle class occlusal relation obtained following correct bite registration procedure although bite registration requires case specific parameters posterior clearance 3.5 mm anterior clearance 2.5 mm guidance angle class occlusal relation followed developing skeletal class ii malocclusion effectively treated non extraction means diagnosed early age correct patient parent motivation as witzig rightly said bad patients appliance fail doctors fail motivate patient correct patient appliance combination	orthodontics from time immemorial has always been considered as the first speciality of dentistry . diagnosis and treatment planning from dr . tweed 's time always required extraction of four vital and functional premolar teeth . however , many patients , parents and general dentists have failed to understand that orthodontic treatment at an early age can help save the extraction teeth to achieve a full functional and esthetic harmonius dentition . our case demonstrates a non - extraction orthodontic treatment plan of a developing skeletal class ii malocclusion . the results of this case show a successful correction of class ii molar malocclusion with excellent form and function , which resulted in improvement of the patient 's frontal and facial profile , which , thereby boosted her personality and self - confidence .
several strategies used reduce blood loss including preoperative embolization intraoperative controlled hypotension electrical coagulation local application fibrin sealants hemostatic matrix influence coagulation 13 usual contact methods involving electrocautery monopolar knife bipolar coagulator removal probe adherent desiccated eschar around probe often detaches eschar causing greater bleeding coagulation scenario aquamantys system medtronic advanced energy portsmouth nh usa incorporates new bipolar coagulation technique associated simultaneous delivery bipolar radio frequency energy conductive fluid electrode tip the volume saline passing electrode tip prevents charring maintains clean tip this cools tissue raises temperature sufficiently shrink collagen veins arteries power saline flow adjustable different types tissue promote effective coagulation we report series brain tumor patients undergoing surgery using aquamantys system along epidural vein sealer evs revealed practical advantages the aquamantys system medtronic advanced energy portsmouth nh usa based new bipolar coagulation technique called transcollation technology proprietary combination radiofrequency energy saline the technique associated simultaneous delivery bipolar radio frequency energy conductive fluid electrode tip briefly system works combining bipolar electrosurgical generator rotary peristaltic pump provide simultaneous delivery radiofrequency energy saline used aquamantys handheld disposable devices the saline cools tissue treated evenly conducts energy tissue seal blood vessels the thermal effect shrinks collagen vessel walls small arteries results cessation bleeding vessels the saline used conductive fluid cools tissue surface prevents surface temperature getting hot thus avoiding charring the aquamantys device associated handpiece evs shaft diameter 4 mm thus offering good visibility less crowdedness surgical field figure 1 the aquamantys system used 10 consecutive patients brain tumors 5 meningiomas 3 glioblastomas 2 pituitary adenomas cases pituitary adenomas the device used hemostasis bleeding nasal mucosa tumor capsule the coagulation setting adjustable 20 200 watts 20 watts saline flow settings low medium high set medium the device used way standard electrocautery except bipolar sealer could used localized manner stop bleeding also spreading manner stop diffuse bleeding the aquamantys system medtronic advanced energy portsmouth nh usa based new bipolar coagulation technique called transcollation technology proprietary combination radiofrequency energy saline the technique associated simultaneous delivery bipolar radio frequency energy conductive fluid electrode tip briefly system works combining bipolar electrosurgical generator rotary peristaltic pump provide simultaneous delivery radiofrequency energy saline used aquamantys handheld disposable devices the saline cools tissue treated evenly conducts energy tissue seal blood vessels the thermal effect shrinks collagen vessel walls small arteries results cessation bleeding vessels the saline used conductive fluid cools tissue surface prevents surface temperature getting hot thus avoiding charring the aquamantys device associated handpiece evs shaft diameter 4 mm thus offering good visibility less crowdedness surgical field figure 1 the aquamantys system used 10 consecutive patients brain tumors 5 meningiomas 3 glioblastomas 2 pituitary adenomas cases pituitary adenomas the device used hemostasis bleeding nasal mucosa tumor capsule the coagulation setting adjustable 20 200 watts 20 watts saline flow settings low medium high set medium the device used way standard electrocautery except bipolar sealer could used localized manner stop bleeding also spreading manner stop diffuse bleeding no complications unwanted reactions associated device observed removal meningioma first this technique coagulated superficial blood vessels tumour capsule also produced shrinkage capsule due heating effect facilitating dissection tumor surrounding arachnoid planes minimal manipulation surrounding structures aquamantys probe used naked eye surgical microscope thin relative flexible probe ( tip diameter 3.4 mm distal bayonet shaft length 139.45 mm particularly increased usefulness system hemostasis microscope thus total amount bleeding reduced reduction tumor size due shrinking made easy handle tumors glioma surgery device relatively wide handpiece tip allowed optimal tumor coagulation dissection stopped generalized ooze bleeding surrounding surgical wall cavity brain tumors large blood supply feeding arteries penetrating skull base the aquamantys device extremely useful hemostasis bone penetrating feeding arteries the aquamantys device also useful troublesome bleeding nasal mucosa endonasal approach pituitary adenoma using long distal bayonet possible stop bleeding sidewall nasal mucosa furthermore aquamantys device useful coagulating tumor capsule leading lesion shrinking neurological examination admission showed mild left hearing impairment mild gait disturbance ataxia no neurological findings e.g. facial dysesthesia facial palsy observed the patient underwent brain computed tomography ct showed lesion left cerebellopontine angle the mass approximately 6 cm diameter appearing hypointense t1-weighted imaging heterogeneously intense t2-weighted imaging the lesion peritumoral edema apparent surrounding cerebellum fluid attenuated inversion recovery imaging the tumor margins clear contact internal auditory meatus evident slight dural tail sign evident left sigmoid sinus infiltrated occluded lesion figure 2 left suboccipital retrosigmoid craniotomy exposed tumor originating tentorium present mainly infratentorial epiarachnoid space small attachment edge petrosal bone the lesion well demarcated surrounding cerebellum attachment petrosal vein identified the aquamantys device used tumor capsule coagulation meningioma shrinking figure 3 bipolar coagulation ultrasound suction used achieve tumor resection small piece tumor left inside sigmoid sinus two years later brain mri follow show development residual tumor inside left sigmoid sinus figure 4 on removal meningioma first tumor capsule coagulated aquamantys device this technique coagulated superficial blood vessels tumour capsule also produced shrinkage capsule due heating effect facilitating dissection tumor surrounding arachnoid planes minimal manipulation surrounding structures aquamantys probe used naked eye surgical microscope thin relative flexible probe tip diameter 3.4 mm distal bayonet shaft length 139.45 mm particularly increased usefulness system hemostasis microscope thus total amount bleeding reduced reduction tumor size due shrinking made easy handle tumors glioma surgery the device relatively wide handpiece tip allowed optimal tumor coagulation dissection stopped generalized ooze bleeding surrounding surgical wall cavity in brain tumors large blood supply feeding arteries penetrating skull base aquamantys device extremely useful hemostasis bone penetrating feeding arteries the aquamantys device also useful troublesome bleeding nasal mucosa endonasal approach pituitary adenoma using long distal bayonet it possible stop bleeding sidewall nasal mucosa furthermore aquamantys device useful coagulating tumor capsule leading lesion shrinking neurological examination admission showed mild left hearing impairment mild gait disturbance ataxia no neurological findings e.g. facial dysesthesia facial palsy observed the patient underwent brain computed tomography ct showed lesion left cerebellopontine angle the mass approximately 6 cm diameter appearing hypointense t1-weighted imaging heterogeneously intense t2-weighted imaging the lesion peritumoral edema apparent surrounding cerebellum fluid attenuated inversion recovery imaging the tumor margins clear contact internal auditory meatus evident slight dural tail sign evident left sigmoid sinus infiltrated occluded lesion figure 2 left suboccipital retrosigmoid craniotomy exposed tumor originating tentorium present mainly infratentorial epiarachnoid space small attachment edge petrosal bone the lesion well demarcated surrounding cerebellum attachment petrosal vein identified the aquamantys device used tumor capsule coagulation meningioma shrinking figure 3 bipolar coagulation ultrasound suction used achieve tumor resection small piece tumor left inside sigmoid sinus two years later brain mri follow show development residual tumor inside left sigmoid sinus figure 4 the development bipolar coagulation began broad thermal dispersion electrodes evolved include highly accurate devices deliver thermal energy via nonstick methods time operative range coagulation instruments dramatically increased improved however contact methods electrocautery 2 shortcomings coagulation bloody field leads boiling carbonization blood second coagulation pooled blood bleeding vessel leads formation coating eschar around probe removal probe adherent desiccated eschar often detaches eschar causing greater bleeding coagulation contexts new electrosurgery modality the aquamantys system used successfully orthopedic general cardiac surgery gaining interest innovative method the aquamantys system bipolar sealers feature innovative transcollation technology combination radiofrequency rf energy saline provides hemostatic sealing soft tissue bone surgery the generator delivers transcollation technology simultaneous rf power saline delivery disposable bipolar sealers power settings vary 20 200 watts 3 different flow rates selected the 6.0 bipolar sealer mainly used orthopedic surgery system demonstrated useful reducing blood loss hip knee replacement procedures trauma surgery the evs body shaft length 172 mm shaft diameter 4 mm recently used spine surgery decompression procedures e.g. discectomy laminectomy procedures requiring access epidural space surgical procedures used evs handpiece the coagulation setting 20 watts saline flow set medium compared high frequency contact coagulation methods the depth necrosis due thermal injury extremely superficial continuous saline irrigation reduces temperature around treated area crucially advantageous neurosurgical operations the use standard electrocautery results high tissue surface temperature therefore leads charring tissue scar formation preventing charring searing tissue using aquamantys device avoid possible postoperative breakage detachment scar clots produced conventional electrocautery lead postoperative blood loss since aquamantys system uses round handpiece tip tissue surface treated larger usually coagulated classical bipolar forceps this feature allows better control capillary ooze well known problem end intracerebral tumor removal wide coagulation area tumor capsule meningioma surgery capsule coagulation leads tumor devascularization increasing power transcollation technology tumor shrinking obtained furthermore skull base meningioma simpson grade achieved aquamantys tip device allows efficacious coagulation dural attachment aquamantys device applied brushwork fashion large areas particularly well suited treating diffuse bleeding broad tumors even difficult determine bleeding point furthermore since device cause carbonization vaporization hence generate smoke surgeon operative view disturbed the disadvantages aquamantys also considered instances bleeding comes well recognized broken vein artery bipolar forceps adequate precise controlling bleeding aquamantys system furthermore limited flexibility handpiece drawback especially case deep narrow irregular operating channel case however bipolar coagulation needs wide enlargement working channel provide complete control bleeding the aquamantys system novel coagulation technique innovative transcollation technology combination radiofrequency rf energy saline provides hemostatic sealing soft tissue bone surgery this technology considered adjuvant strategy achieving hemostasis brain tumor surgery the aquamantys device complementary rather competitive bipolar coagulation conventional monopolar knife the use device certainly substitute good microsurgical hemostasis technique with the development tailored flexible probes device might become valuable surgical device	backgroundadequate hemostasis in cranial and spinal tumor surgery is of paramount importance in neurosurgical practice . generalized ooze bleeding from the surgical walls cavity , coming from neoplastic vessels or nervous tissue , may be problematic . recent technical advances have dramatically reduced intraoperative complications related to blood loss . several techniques are usually employed to control hemostasis in tumor surgery , including preoperative embolization , intraoperative hypotension , electrical coagulation , and local application of fibrin sealants or hemostatic matrix , which influence coagulation.material/methodsour aim in this study was to evaluate the efficacy and the safety of the aquamantys system ( medtronic advanced energy , portsmouth , nh , usa ) , a novel bipolar coagulation device that incorporates a new bipolar coagulation technique . this device has been used in 10 consecutive patients affected by cerebral tumor along with the standard microsurgical technique and well - known intraoperative tools . the technique is associated with simultaneous delivery of bipolar radio frequency energy and conductive fluid through its electrode tip . the volume of saline passing by the electrode tip prevents charring and maintains a clean tip . this cools the tissue as it raises the temperature sufficiently to shrink the collagen of veins and arteries.resultseffective hemostasis was achieved in all the cases . no complications or unwanted reactions associated with the device have been observed.conclusionsour findings suggest that the aquamantys system may be a highly effective adjuvant tool in minimizing blood loss in a patient with brain tumor , as well as reducing time of surgery .
chronic inflammation recognized process trigger cancer due host immune response local expression cytokines chemokines adhesion molecules pro- anti inflammatory proteins stimulate processes proliferation survival cell migration neovascularization the strongest association chronic inflammation malignancy observed gastric cancer induced helicobacter pylori infection the inflammatory process resulting h. pylori infection triggers cascade events initialized chronic gastritis evolves gastric atrophy intestinal metaplasia dysplasia finally carcinoma this bacterium present 90% chronic gastritis patients 77% noncardia gastric cancers both intrinsic factors host bacterial virulence associated development gastric cancer induced h. pylori among bacterial genes caga detected 63% patients gastric cancer the caga protein internalized host epithelial cells disrupting cell cycle inducing cell invasion activation matrix metalloproteases bacterial lipopolysaccharides activate several cell processes including expression annexin a1 anxa1 galectin-1 gal-1 anti inflammatory proteins inflammatory response anxa1 translocated cell cytoplasm membrane resulting decrease transmigration inflammatory cells site injury furthermore anxa1 plays anti inflammatory role inhibiting activities phospholipase a2 inducible nitric oxide synthase it also associated modifications cytoskeleton transport molecules ion flux differentiation migration cell growth apoptosis galectin-1 gal-1 member family carbohydrate binding proteins may act manner anxa1 transmigration inflammatory cells important also cell apoptosis binding cell receptors thus triggering faz caspase cascade it also contributes different events associated carcinogenesis including tumor transformation cell cycle regulation apoptosis cell adhesion migration inflammation 13 14 nevertheless studies literature evaluated expression pattern anti inflammatory mediators gastric mucosa specific functions unclear while gastric cell lines gal-1 protein expression increased 15 16 gastric adenocarcinoma observed low expression tumor cells turn anxa1 studied gastric tissue discrepant findings increased expression gastric mucosal damage healing loss expression metastatic gastric cancers higher expression diffuse type gastric cancer compared intestinal type decreased expression gastric adenocarcinoma positive staining advanced stage peritoneal dissemination thus research field might improve understanding possible role anti inflammatory proteins carcinogenesis present fairly limited controversial moreover studies may lead possible identification anxa1 gal-1 potential biomarkers gastric cancer progression therefore aim study investigate relative expression levels anxa1 lgals1 mrna quantitative real time pcr qpcr expression proteins immunohistochemical assay inflammatory gastric lesions chronic gastritis compared gastric cancer we also investigated possible relationship mrna expression levels h. pylori infection caga virulence genotype lesions evaluated gastric biopsies obtained seventy 70 individuals submitted endoscopy endoscopy service hospital de base rio preto endoscopy center jos rio preto sp brazil histopathological data supplied respectively legal medicine department pathology service institute anatomical pathology cytopathology iapc city individual three 03 biopsy samples antrum region collected molecular studies one immunohistochemical analysis the gastric adenocarcinoma ga group comprised 20 individuals 14 male 6 female mean age 63.4 14 years histopathologically confirmed diagnosis gastric adenocarcinoma among studied samples 12 cases diagnosed intestinal type adenocarcinoma igc 8 diffuse type adenocarcinoma dgc the chronic gastritis cg group composed 40 individuals 18 male 22 female mean age 52.5 15 years histopathologically confirmed diagnosis chronic gastritis the biopsies control c group obtained 10 healthy individuals 7 male 3 female mean age 35 10.8 years dyspeptic gastric complaints diagnosed histopathologically normal gastric mucosa epidemiological data study population collected using standard interviewer administered questionnaire questions current past occupation smoking habits alcohol intake family history cancer none 70 subjects antibiotic anti inflammatory treatment neither radiotherapy chemotherapy 60% patients ga group smokers 40% drinkers patients cg c groups nonsmokers nondrinkers smokers defined individuals consumed least 100 cigarettes lifetime alcohol consumers drank four times week the research ethics committee participating institution approved research cep ibilce unesp number 058/09 written informed consent obtained individuals studied soon collection biopsies stored rna later solution applied biosystems 20c preserve integrity rna extraction the nucleic acid extraction performed according protocol accompanying reagent trizol invitrogen allows simultaneous extraction rna dna rna dna concentrations determined nanodrop nd1000 spectrophotometer uniscience measuring absorbance 260 280 nm dna samples stored 20c used molecular diagnosis h. pylori afterwards reverse transcription rt pcr performed automated thermocycler using 2.5 g total rna presence 1.25 l oligo d(t)16 0.5 g/l 2.0 l rnase inhibitor 80 u/l high capacity cdna archive kit applied biosystems total volume 50 l according manufacturer instructions the reactions carried 10 minutes 25c followed 120 minutes 37c the integrity cdna preparations tested pcr assay 613 bp actb -actin gene fragment used control abundant transcripts whose primer sequences f 5-ggcatcgtgatggactcc-3 r 3-gctggaaggtggacagcg-5. determine presence h. pylori infection dna samples subjected multiplex pcr reaction containing primers bacterial gene hpx cyp1a1 human housekeeping gene attests integrity dna summary used 5.0 l 10x buffer 5.0 l dntps 1.23 mmol l invitrogen 2.0 l mgcl2 25 mmol l 2.0 l primers 10 nmol/l invitrogen 24.5 l dh2o 5.0 l genomic dna 0.5 l taq dna polymerase 5 u/l invitrogen material processed automated thermocycler initially subjected temperature 94c 5 minutes denaturation subsequently subjected 40 amplification cycles 94c 45 seconds 60c 30 seconds 72c 90 seconds followed final extension cycle 7 minutes 72c fragments 150 bp 226 bp corresponding genes cyp1a1 hpx respectively observed the h. pylori positive samples subjected second pcr run investigate virulence genotype caga bacterium the parameters used previous reaction except annealing temperature case 52c the product visualized 1.0% agarose gel stained ethidium bromide 232 bp fragment observed the relative quantification q pcr assay anxa1 lgals1 mrna expression performed abi prism 7300 sequence detector system applied biosystems foster city ca usa according instructions sybr green pcr core reagent applied biosystems using primers specific genes anxa1 lgals1 gene actb used endogenous control reference gene reaction shown lowest variation compared -tubulin 2-microglobulin genes previous study the expression levels anxa1 lgals1 actb mrna tested triplicate cdna rt reaction separated wells samples normal gastric mucosa mixed form pool used calibrator standard sample the q pcr assays performed total volume 50 l containing 10 l sybr green master mix applied biosystems 25 ng cdna 0.4 anxa1 0.5 lgals1 primers after initial incubation 50c 2 min allow uracil n glycosylase ung digestion 95c 10 min activate amplitaq gold dna polymerase provided universal pcr master mix samples amplified subjecting 40 biphasic cycles 95c 15 sec 60c 1 min the fluorescence signal measured extension phase pcr reaction threshold value ct fluorescence exponential part amplification curve selected the larger quantities material start lower ct values relative quantification rq genes anxa1 lgals1 obtained described pfaffl normalized -actin control reference gene normal gastric mucosa deparaffinized sections 4 incubated citrate buffer ph 6.0 96c 30 minutes washed distilled water incubated 3% hydrogen peroxide methanol 30 minutes washed phosphate buffered saline pbs ph 7.4 the primary antibodies rabbit polyclonal anti gal-1 rabbit polyclonal anti anxa1 zymed laboratories cambridge uk diluted 1 500 1 2000 respectively 1% bovine serum albumin bsa applied overnight 4c negative controls fragments washed pbs incubated universal lsab kit hrp secondary antibody dako usa according manufacturer protocol washed pbs developed 3,3-diaminobenzidine chromogen solution dako usa the sections washed thoroughly distilled water counterstained hematoxylin mounted glass slides densitometric analysis anxa1 gal-1 immunostaining performed using arbitrary scale 0 255 axiovision software zeiss axioskop ii light microscope data expressed mean se fisher exact test used determine significant differences groups regarding presence bacteria caga genotype histological type tumor gender the data obtained mrna quantification expressed mean sd assess differences mrna relative expression levels groups used nonparametric mann whitney test evaluate association gene expression presence bacterium caga genotype histological type tumor gender smoking drinking the mean densitometry analysis results obtained proteins anxa1 gal-1 compared anova followed significant bonferroni test the frequencies cases positive molecular diagnosis h. pylori genotype caga groups cg ga presented table 2 all 10 samples normal mucosa confirmed molecular testing h. pylori negative total 60 samples case groups 45% h. pylori positive 40% 16/40 cg group 55% 11/20 ga group significant difference groups p 0.29 regarding genotype caga 48% h. pylori positive samples caga positive 62.5% 10/16 cg 27.3% 3/11 ga group again significant difference groups p 0.12 the relative expression levels anxa1 mrna normalization actb reference gene comparison normal mucosa increased 90% 36/40 cg cases ( mean rq 4.26 2.03 80% 16/20 ga cases ( mean rq 4.38 4.77 statistically significant difference groups p 0.33 lgals1 mrna relative expression values found lower ga group showed overexpression 60% 12/20 cases the cg group showed constitutive expression mean rq 0.43 3.13 7.5% 3/40 cases presenting increased expression thus mean level lgals1 mrna expression significantly higher ga cg group p 0.01 table 3 figure 1 another analysis investigated ga group possible association anxa1 lgals1 mrna expression risk factors drinking smoking histological type gastric cancer table 4 association observed in addition comparing variables gender h. pylori infection caga+ genotype cg ga groups table 5 significant difference found ga group gender mean level anxa1 expression p 0.04 due 2 times greater expression gene females males group likewise caga+ genotype also showed association anxa1 expression level ga group due higher mrna expression caga positive compared caga negative cases mean rq 6.40 versus 2.77 p 0.01 none investigated factors appears associated levels anxa1 lgals1 mrna protein expression evaluated normal mucosa cg intestinal igc diffuse- dgc- type gastric cancer modest expression anxa1 gal-1 observed stroma normal mucosa epithelium show expression proteins figures 2(a 3(a resp however inflammatory process cg mucosa intense immunostaining anxa1 gal-1 seen basal portion epithelium figures 2(b 3(b resp positive immunostaining anxa1 gal-1 also observed dgc figures 2(c 3(c resp igc figures 2(d 3(d resp tumor cells areas gastric cancer samples the mean optical densitometry values anxa1 gal-1 expression presented figures 2(e 3(e respectively the anxa1 mean density 90.79 normal mucosa c group cg ga respectively 168.57 190.20 thus significant difference found comparing normal mucosa cg ga groups p 0.01 the mean density gal-1 protein lower three groups 86.52 136.97 146.30 c cg ga resp showing statistically significant difference normal mucosa cg ga groups p 0.01 another densitometry analysis determine cytoplasmic nuclear immunoreactivity anxa1 separately groups although observed nuclear immunostaining mainly gastric cancer data obtained results show statistically significant difference normal mucosa cg p 0.19 normal mucosa ga p 0.18 data shown in present study evaluated anxa1 gal-1 anti inflammatory proteins mrna expression group precursor lesions chronic gastritis compared gastric cancer association risk factors among risk factors investigated presence h. pylori lesions virulence genotype caga since bacterium often triggers progression gastric carcinogenesis cascade best knowledge first study evaluated expression anxa1 gal-1 chronic gastritis we found high relative expression anxa1 mrna already cg inflammatory process 90% cases showed increased expression level mean rq 4.26 became 3 8 times higher normalization actb reference gene comparison normal mucosa similarly ga group 80% cases presented upregulated expression levels 3 9 times higher mean rq 4.38 normal mucosa lgals1 study showed slightly increased relative expression 60% ga cases mean rq 2.44 increase 2 7 times chronic gastritis mean value low mean rq 0.43 in general immunohistochemical analysis confirmed results mrna expression qpcr although cg relative expression levels lgals1 mrna equivalently increased protein expression studies expression anxa1 mrna neoplastic processes still limited results conflicting for example loss expression found squamous cell carcinoma esophagus prostatic adenocarcinoma sinonasal adenocarcinoma larynx breast cancer hand overexpression reported colorectal adenocarcinoma urothelial carcinoma lung adenocarcinoma oral cancers thus suggesting changes expression levels anxa1 may related tissue tumor type martin et al reported normal gastric mucosa shows weak expression protein anxa1 ulcer healing process expression increased promoting reduction ulcer in contrast yu et al observed overexpression gene protein normal mucosa loss expression 64% primary gastric tumors mainly correlated advanced stage metastasis more recently zhu et al observed anxa1 protein expressed gastric adenocarcinoma 45% normal tissues 69% different subcellular distribution similar results reported cheng et al observed high anxa expression mrna protein associated metastasis invasion poor survival gastric cancer patients the authors also proposed new mechanism anxa1 regulates gastric cancer cell invasion activation fpr erk itgb1bp1 pathway present study immunohistochemical analysis anxa1 showed modest immunostaining stromal cells normal mucosa intense expression stroma epithelium cg ga thus confirming results mrna expression analysis the assay used study allow clear differentiation cellular localization protein although positive immunostaining observed cytoplasm epithelial cells nucleus cancer cells lower intensity frequency chronic gastritis however densitometry analysis determine cytoplasmic nuclear immunoreactivity anxa1 separately performed data obtained show statistically significant difference among normal mucosa chronic gastritis gastric adenocarcinoma although reports show translocation anxa1 carcinogenesis alves et al showed 87.5% positivity anxa1 larynx tumors increased immunoreactivity membrane compared cytoplasm nucleus however compared normal tissue nuclear cytoplasmic expression lower esophageal carcinoma liu et al found anxa1 translocation cellular nuclear membrane while gastric adenocarcinoma anxa1 showed positive nuclear staining correlated advanced disease stage peritoneal dissemination normal tissues predominantly localized cytoplasm addition weak nuclear staining also occasionally occurred sporadic cells gastric tumors 14/118 cases evaluated cheng et al but general anxa1 immunostaining mainly cytoplasmatic epithelial cells changes expression pattern anxa1 must related factors influence translocation export cellular concentration calcium considering intracellular calcium level increased anxa1 translocated membranes furthermore reported protein phosphorylation also required process tumor cells calcium factors however relationship needs better understood may connection inflammation signal transduction differentiation cellular transport cancer date gal-1 involved various important aspects carcinogenesis mrna protein expressions examined several types cancer overexpression reported colorectal cancer hodgkin lymphoma squamous cell carcinomas larynx carcinomas hypopharynx conversely also report low expression chronic inflammation nasal polyposis two research groups evaluated expression gal-1 gastric cell lines agreed protein overexpressed tumor cells chen et al showed higher expression protein tmc-1 compared sc m1 cells proposing gal-1 biomarker metastasis investigated ags cells infected h. pylori observed high expression levels gal-1 cell type recently estofolete et al observed immunostaining gal-1 -3 highly expressed experimental model n methyl n-nitro n nitrosoguanidine- mnng- induced gastric carcinogenesis the immunohistochemistry assay performed showed modest staining gal-1 stroma normal mucosa cg ga staining stronger stroma epithelium contrary lgals1 mrna levels lower cg group comparison ga group several studies shown lack correlation rna expression protein expression profiles using different methodologies some authors state fact use mrna expression patterns insufficient understanding expression protein products additional posttranscriptional mechanisms including protein translation posttranslational modification degradation may influence level protein present given cell tissue 4750 the comparison cg ga groups regarding anxa1 lgals1 mrna levels risk factors show association lgals1 mrna levels however positive association observed overexpression anxa1 female gender ga group since women mrna expression twice high men mean rq 6.67 versus 3.25 h. pylori caga+ infection showed mrna mean level approximately twice higher patients infected caga+ strains mean rq 6.40 versus mean rq 2.77 despite relevance study considered limitations due reduced number cases subgroup stratification interpreted cautions it well known sexual dimorphism immune inflammatory responses humans women produce vigorous cellular humoral reactions resistant certain infections suffer higher incidence autoimmune diseases males it also suggested anxa1 expression may differ several types cancer due hormonal influence ang et al conducted elegant study influence anxa1 mcf-7 breast cancer cells showed 17 -estradiol active metabolite estrogen regulates anxa1 expression moreover 17 -estradiol shown activate cyclic amp- camp- responsive element cre binding creb proteins induce transcriptional activity the promoter region anxa1 examined found contain similar near identical 8-nucleotide sequence tgatgtca cre consensus sequence tgacgtca authors proposed another theory explain connection estrogen anxa1 levels elevated 17 -estradiol activates erk1/2 pathway increasing cell proliferation serves sign stimulate anxa1 transcription order reduce proliferative state anxa1 upregulates p21 antiproliferative properties reduces proliferation caused activation erk1/2 estrogen however study ga group mean age women elevated 67.4 18.4 years characterizes postmenopausal phase decreased estrogen levels thus justifying relation increased expression anxa1 estrogen the relationship presence virulence factor caga gastric carcinogenesis well documented western populations infected caga positive strains generally accentuated inflammatory response increased risk developing peptic ulcer stomach cancer the phosphorylation caga protein activates shp-2 protein tyrosine phosphatase inhibits fak focal adhesion kinase enzyme modulates adhesion migration cell survival consequently decline activity fak triggers rearrangement cytoskeleton known hummingbird phenotype characterized elongation spreading host cells furthermore caga participates cell signaling activating pik3ca kras pathways erk mapk 55 56 mek erk jak1 signaling pathway gastric cancer cells knowledge reports relationship caga virulence factor expression anxa1 gal-1 anti inflammatory proteins however lin et al observed overexpression anxa4 tumor cells patients infected h. pylori gastric cancer scm-1 cells h. pylori infection recently lin et al observed infection h. pylori induced change anxa1 anxa4 localization causing translocation cytoplasm plasma membrane probably epithelial cell membrane repair consequence h. pylori generated membrane disruptions so due action caga bacterial protein different cell signaling pathways possible may also contribute activation anxa1 expression mainly considering protein plays key role intracellular ca flux modifications cytoskeleton differentiation migration cell growth apoptosis in conclusion study showed overexpression anxa1 mrna protein already precursor lesion cg similar ga higher expression levels observed h. pylori caga+ cases suggesting upregulation gene early stages gastric carcinogenesis turn lgals1 mrna protein slightly overexpressed lesions indicating also participation gastric carcinogenesis however several types cancers role proteins yet fully understood investigations needed help clarify molecular mechanisms act kind lesion	objective . the anti - inflammatory proteins annexin - a1 and galectin-1 have been associated with tumor progression . this scenario prompted us to investigate the relationship between the gene and protein expression of annexin - a1 ( anxa1/anxa1 ) and galectin-1 ( lgals1/gal-1 ) in an inflammatory gastric lesion as chronic gastritis ( cg ) and gastric adenocarcinoma ( ga ) and its association with h. pylori infection . methods . we analyzed 40 samples of cg , 20 of ga , and 10 of normal mucosa ( c ) by the quantitative real - time pcr ( qpcr ) technique and the immunohistochemistry assay . results . high anxa1 mrna expression levels were observed in 90% ( 36/40 ) of cg cases ( mean relative quantification rq = 4.26 2.03 ) and in 80% ( 16/20 ) of ga cases ( mean rq = 4.38 4.77 ) . however , lgals1 mrna levels were high ( mean rq = 2.44 3.26 ) in 60% ( 12/20 ) of the ga cases , while low expression was found in cg ( mean rq = 0.43 3.13 ; p < 0.01 ) . normal mucosa showed modest immunoreactivity in stroma but not in epithelium , while stroma and epithelium displayed an intense immunostaining in cg and ga for both proteins . conclusion . these results have provided evidence that galectin-1 and mainly annexin - a1 are overexpressed in both gastritis and gastric cancer , suggesting a strong association of these proteins with chronic gastric inflammation and carcinogenesis .
phenomenon result protein synthesis either incorporation new units contractile myocytes addition new sarcomeres.3 nevertheless benefits process limited rate maintenance promotes deleterious changes characterizing feature uniquely unfavorable.4 mechanisms leading myocardial injuries59 hypertrophy1012 physiological pathological states different for instance pathological hypertrophy results interaction mechanical forces neural hormonal factors hemodynamic overload promotes myocyte stretch release intracellular calcium activation calcineurin induction gene expression reprogramming.1 athletes left ventricular hypertrophy lvh regarded physiological response results hemodynamic overload physiological response result harmful effects hypertension development heart diseases.1012 literature explains physiological lvh result volume pressure overload results intense physical training hemodynamic stimulus necessarily accompanied neural humoral changes.13 despite initial benefits physiological hypertrophy difficult determine time physiological hypertrophy becomes pathological1 represents significant morbidity mortality risk words difficult pinpoint exactly natural development hypertension cardiac hypertrophy raises individual risk experiencing cardiovascular event reported factor six eight times.3 well known associations lvh several conditions obesity diabetes myocardial infarction even mild elevation blood pressure,1 well cardiovascular risk factors may associated increased cardiac mass regardless ventricular pressure therefore lvh powerful predictor cardiovascular morbidity mortality.3 clinical experimental studies reported several pharmacological hemodynamic non hemodynamic factors able induce reverse prevent lvh,1416 interstitial fibrosis17 progression atherosclerotic effects myocytes.18 clinically cardiac hypertrophy associated increased adverse events including stroke chronic renal failure ventricular dysfunction ventricular arrhythmias sudden death.3 cardiac hypertrophy also associated higher prevalence coronary disease related endothelial dysfunction this dysfunction may lead myocardial ischemia even absence epicardial artery obstruction reducing coronary flow reserves due various hemodynamic factors minimal reduction coronary resistance systolic coronary perivascular compression collagen deposition fibrosis lower production local vasodilator substances nitric oxide.19 adjusting risk factors koren coworkers20 reported positive relationship ventricular mass geometry morbidity mortality patients complicated hypertension.20 framingham heart study published levy et al21 included 3,220 healthy subjects aged 40 years older this study demonstrated estimating left ventricular mass echocardiography provide prognostic information cardiovascular risk predict negative cardiovascular related clinical events including death.21 moreover lvh increased risk major cardiovascular events 40% patients enrolled study.21 previous investigations infer lvh constitutes ominous risk factor cardiovascular disease magnitude risk directly related morbidity mortality rates therefore study endeavored describe effects anti hypertensive drugs cardiac hypertrophy meta analysis previous studies the medline via pubmed lilacs scielo databases searched using following subject keywords cardiac hypertrophy antihypertensive mortality function pubmed lilacs scielo allowed us search references studies retrieved search publications included review either titles abstracts available english portuguese suggested effect i.e. beneficial malefic lack thereof anti hypertensive treatment cardiac hypertrophy publications excluded treatment limited particular technique population received one specific procedure drug treatment associated disease state age group other studies anti hypertensive treatment hypertensive patients offered additional relevant information found database also examined each publication reviewed identify author(s study period data source influenced us include reference study we excluded investigations treatment limited particular method studies study population limited patients undergoing particular procedure associated disease state table 1 summarize studies evaluated relationship anti hypertensive drugs cardiac hypertrophy the investigations included table 1 demonstrate relevance angiotensin converting enzyme ace inhibitors14,15,2224 angiotensin antagonist25 treatment cardiac hypertrophy regression the high prevalence lvh high rate complications condition necessitate thorough understanding mechanisms involved etiology development well importance prevention regression optimize prevent deleterious consequences thus important clarify following issues described several published reports provided data indicating anti hypertensive drugs promote ventricular hypertrophy regression myocardial repair particular ace inhibitors shown promising cardio protective effects experimental models hypertensive heart disease;22 specifically inhibitors improve micro vascular ischemia ventricular function arrhythmias.1416 2329 previously reported enalapril14 ace inhibitor verapamil23 ca channel blocker provide cardio protector response isoproterenol induced lvh model rats.28 evaluate effects lvh regression previous study evaluated 151 patients hypertension lvh progression detected echocardiography the patients followed average 10 years+1.4 years researchers noted decrease non fatal events rate following reduction lvh even correcting risk factors conversely occurrence events increased cardiac hypertrophy increased remained stable.23 another clinical investigation examined 430 patients essential hypertension also called primary idiopathic hypertension related changes left ventricular mass occurrence cardiovascular events treatments consisted medication lifestyle changes 2 years 9 months follow assessment prevalence lvh echocardiography 26% per year rate cardiovascular events 3.9% per year individuals showed improvement lvh in groups experienced change worsening lvh rate cardiovascular events 6.27 events per 100 patients per year these researchers also noted association depend initial ventricular mass clinical parameters monitored baseline blood pressure their final conclusion primary hypertension decrease ventricular mass treatment favorable prognostic marker subsequent morbid events exception minoxidil hydralazine peripheral vasodilators anti hypertensive drugs provided full partial lvh regression.28 classification prospective randomized studies evaluated effectiveness various drugs respect left ventricular mass reduction have reported evidence difference effects lvh regression.23 however view different effects drugs drugs depend neural humoral mechanisms especially reported monotherapy studies provide evidence may several ways drugs properties could reduce ventricular mass literature monotherapy treatment meta analyses in addition different groups report contradictory results.23 studies used anti hypertensive drugs i.e. beta blockers diuretics reported 58% reductions left ventricular mass use ace inhibitors angiotensin at1 blockers resulted 13% reduction the difference different anti hypertensive drugs regarding ability reverse lvh may determined neural humoral factors.30 lvh regression important intermediate objective anti hypertensive therapy several trials meta analyses compared effects drugs ventricular hypertrophy usefulness studies limited due inadequate designs methodological problems.32 preserve prospective randomized enalapril study evaluating regression ventricular enlargement),33 live indapamide sustained release versus enalapril)34 life losartan intervention endpoint hypertension)25 studies represent new generation well planned trials comparing different anti hypertensive drugs these investigations revealed regression lvh effects nifedipine enalaprilat similar preserve indapamine stronger effect enalapril live losartan treatment stronger effect atenolol life the findings three studies conflict findings previous meta analyses researchers suggested effects anti hypertensive drug must evaluated individually important intermediate targets lvh appropriate patient populations the extrapolation lvh regression effects based anti hypertensive drug classification may lead clinical mistakes needs carefully reconsidered.23 decrease blood pressure may reduce ventricular mass in addition clinical studies experimental studies demonstrated lvh prevention and/or regression independent blood pressure for instance group investigated isoproterenol induced lvh albino rats typically leads hypertrophy without increase load reported lvh regression gavage administration enalapril15 16 28 31 verapamil.23 30 moreover studies spontaneously hypertensive rats rat strain commonly used laboratory3539 demonstrated although various anti hypertensive drugs may control systemic hypertension lvh may influenced many anti hypertensive agents alpha methyldopa captopril beta blockers calcium channel blockers promote regression hypertrophy drugs hydralazine minoxidil reduce blood pressure without influencing ventricular hypertrophy.23 however development lvh arterial hypertension may explained primarily increased pressure overload ventricular wall tension the ratio ventricular mass pressure often weak even relation blood pressure monitored every 24 hours.3 notably lvh may occur independently changes arterial pressure present even hypertension develop.1 may include presence others factors involved condition lifestyle anthropometric demographic characteristics genetic influences neural humoral factors.24 furthermore vivo vitro genetic studies indicate lvh development regression depends hemodynamic overload also genetic neural humoral factors.9 humoral agents may affect mitogenesis non myocyte cardiomyocytes identified agents include renin angiotensin system local norepinephrine endothelin transforming growth factor insulin like growth factor bradykinin prostaglandins nitric oxide.23 direct relationship high blood pressure lvh development questioned due fact lvh development regression depends hemodynamic overload forcing review mechanisms involved lvh development role sympathetic nervous system renin angiotensin system genetic factors endothelin endothelium.1 important remember pathogenesis lvh includes angiotensin ii receptors membrane stretched cardiomyocytes.2 several publications reported although anti hypertensive drugs show non uniform effects lvh concomitant proportional decreases blood pressure.13 20 conversely anti hypertensive drugs promoted different effects lvh despite inducing similar reductions blood pressure.4 assumptions lead us consider mechanisms involved lvh regression independent blood pressure reduction decrease cardiac mass may depend daily arterial pressure measurement.23 recently mayos et al.40 localized chromosome regions harbor genetic variants affect diversity electrocardiographic echocardiographic lvh they evaluated genetic association sokolow lyon voltage index cornell product index septal thickness ventricular wall ventricular dimensions left ventricular mass 868 members 224 british households items evaluated n pairs together chromosomes 10 12 17 genetic loci involved important influence lvh detected electrocardiogram.23 genetic factors may explain substantial portion quantitative variability electrocardiographic echocardiographic examinations due hemodynamic and/or hormonal factors however quantitative differences lvh known phenotypes may also result individual differences besides produced various anti hypertensive drugs i.e. beyond blood pressure the high prevalence lvh high rate complications condition necessitate thorough understanding mechanisms involved etiology development well importance prevention regression optimize prevent deleterious consequences thus important clarify following issues described several published reports provided data indicating anti hypertensive drugs promote ventricular hypertrophy regression myocardial repair particular ace inhibitors shown promising cardio protective effects experimental models hypertensive heart disease;22 specifically inhibitors improve micro vascular ischemia ventricular function arrhythmias.1416 2329 previously reported enalapril14 ace inhibitor verapamil23 ca channel blocker provide cardio protector response isoproterenol induced lvh model rats.28 evaluate effects lvh regression previous study evaluated 151 patients hypertension lvh progression detected echocardiography patients followed average 10 years+1.4 years researchers noted decrease non fatal events rate following reduction lvh even correcting risk factors conversely occurrence events increased cardiac hypertrophy increased remained stable.23 another clinical investigation examined 430 patients essential hypertension also called primary idiopathic hypertension related changes left ventricular mass occurrence cardiovascular events treatments consisted medication lifestyle changes 2 years 9 months follow assessment prevalence lvh echocardiography 26% per year rate cardiovascular events 3.9% per year individuals showed improvement lvh the rate cardiovascular events 1.58 events per 100 patients per year groups experienced change worsening lvh rate cardiovascular events 6.27 events per 100 patients per year these researchers also noted association depend initial ventricular mass clinical parameters monitored baseline blood pressure their final conclusion primary hypertension decrease ventricular mass treatment favorable prognostic marker subsequent morbid events with exception minoxidil hydralazine peripheral vasodilators anti hypertensive drugs provided full partial lvh regression.28 classification prospective randomized studies evaluated effectiveness various drugs respect left ventricular mass reduction reported evidence difference effects lvh regression.23 however view different effects drugs drugs depend neural humoral mechanisms especially reported monotherapy studies provide evidence may several ways drugs properties could reduce ventricular mass literature monotherapy treatment meta analyses in addition different groups report contradictory results.23 studies used anti hypertensive drugs i.e. beta blockers diuretics reported 58% reductions left ventricular mass use ace inhibitors angiotensin at1 blockers resulted 13% reduction the difference different anti hypertensive drugs regarding ability reverse lvh may determined neural humoral factors.30 lvh regression important intermediate objective anti hypertensive therapy several trials meta analyses compared effects drugs ventricular hypertrophy usefulness studies limited due inadequate designs methodological problems.32 preserve prospective randomized enalapril study evaluating regression ventricular enlargement),33 live indapamide sustained release versus enalapril)34 life losartan intervention endpoint hypertension)25 studies represent new generation well planned trials comparing different anti hypertensive drugs these investigations revealed regression lvh effects nifedipine enalaprilat similar preserve indapamine stronger effect enalapril live losartan treatment stronger effect atenolol life the findings three studies conflict findings previous meta analyses researchers suggested effects anti hypertensive drug must evaluated individually important intermediate targets lvh appropriate patient populations the extrapolation lvh regression effects based anti hypertensive drug classification may lead clinical mistakes needs carefully reconsidered.23 in addition clinical studies experimental studies demonstrated lvh prevention and/or regression independent blood pressure for instance group investigated isoproterenol induced lvh albino rats typically leads hypertrophy without increase load reported lvh regression gavage administration enalapril15 16 28 31 verapamil.23 30 moreover studies spontaneously hypertensive rats rat strain commonly used laboratory3539 demonstrated although various anti hypertensive drugs may control systemic hypertension lvh may influenced many anti hypertensive agents alpha methyldopa captopril beta blockers calcium channel blockers promote regression hypertrophy drugs hydralazine minoxidil reduce blood pressure without influencing ventricular hypertrophy.23 however development lvh arterial hypertension may explained primarily increased pressure overload ventricular wall tension the ratio ventricular mass pressure often weak even relation blood pressure monitored every 24 hours.3 notably lvh may occur independently changes arterial pressure present even hypertension develop.1 may include presence others factors involved condition lifestyle anthropometric demographic characteristics genetic influences neural humoral factors.24 furthermore vivo vitro genetic studies indicate lvh development regression depends hemodynamic overload also genetic neural humoral factors.9 humoral agents may affect mitogenesis non myocyte cardiomyocytes identified agents include renin angiotensin system local norepinephrine endothelin transforming growth factor insulin like growth factor bradykinin prostaglandins nitric oxide.23 direct relationship high blood pressure lvh development questioned due fact lvh development regression depends hemodynamic overload forcing review mechanisms involved lvh development role sympathetic nervous system renin angiotensin system genetic factors endothelin endothelium.1 important remember pathogenesis lvh includes angiotensin ii receptors membrane stretched cardiomyocytes.2 several publications reported although anti hypertensive drugs show non uniform effects lvh concomitant proportional decreases blood pressure.13 20 conversely anti hypertensive drugs promoted different effects lvh despite inducing similar reductions blood pressure.4 assumptions lead us consider mechanisms involved lvh regression independent blood pressure reduction a decrease cardiac mass may depend daily arterial pressure measurement.23 recently mayos et al.40 localized chromosome regions harbor genetic variants affect diversity electrocardiographic echocardiographic lvh they evaluated genetic association sokolow lyon voltage index cornell product index septal thickness ventricular wall ventricular dimensions left ventricular mass 868 members 224 british households items evaluated n pairs together chromosomes 10 12 17 genetic loci involved important influence lvh detected electrocardiogram.23 genetic factors may explain substantial portion quantitative variability electrocardiographic echocardiographic examinations due hemodynamic and/or hormonal factors however quantitative differences lvh known phenotypes may also result individual differences besides produced various anti hypertensive drugs i.e. beyond blood pressure current medical literature shows direct relationship lvh mortality well relationship lvh regression decreasing mortality the literature also provides evidence hypertrophic variations response effect different anti hypertensive drugs differences hemodynamic patterns	objectives : there is a direct relationship between the regression of left ventricular hypertrophy ( lvh ) and a decreased risk of mortality . this investigation aimed to describe the effects of anti - hypertensive drugs on cardiac hypertrophy through a meta - analysis of the literature.methods:the medline ( via pubmed ) , lilacs and scielo databases were searched using the subject keywords cardiac hypertrophy , antihypertensive and mortality . we aimed to analyze the effect of anti - hypertensive drugs on ventricle hypertrophy.results:the main drugs we described were enalapril , verapamil , nifedipine , indapamina , losartan , angiotensin - converting enzyme inhibitors and atenolol . these drugs are usually used in follow up programs , however , the studies we investigated used different protocols . enalapril ( angiotensin - converting enzyme inhibitor ) and verapamil ( ca++ channel blocker ) caused hypertrophy to regress in lvh rats . the effects of enalapril and nifedipine ( ca++ channel blocker ) were similar . indapamina ( diuretic ) had a stronger effect than enalapril , and losartan ( angiotensin ii receptor type 1 ( at1 ) receptor antagonist ) produced better results than atenolol ( selective 1 receptor antagonist ) with respect to lvh regression.conclusion:the anti - hypertensive drugs induced various degrees of hypertrophic regression .
littoral cell angioma lca recently described rare primary vascular neoplasm unique spleen this neoplasm characteristic morphological immunophenotypic features distinguish vascular splenic tumors most cases described literature lcas composed multiple nodules variable sizes we report large solitary angioma spleen uncommon presentation rare neoplasm a 58-year old female patient presented primary care physician chronic non specific bilateral lower rib pain routine laboratory tests normal including hemoglobin hematocrit white blood cell platelet count a contrast enhanced computed tomogram ct scan performed portal venous phase retrocardiac opacity seen chest radiograph turned hiatal hernia the spleen enlarged large 6.6 cm 6.0 cm solitary mass figure 1 there diffuse homogeneous enhancement lateral aspect mass medial aspect hypoenhanced probably due necrotic portion large nonenhanced vascular channel characterize mass multiphasic magnetic resonance imaging mri ) the mri figure 2 showed mass t1 t2 isointense mild peripheral nodular internal septal enhancement arterial phase complete diffuse mild enhancement mass portal venous phase remained enhanced delayed images the differential diagnoses considered primary vascular neoplasms including atypical hemangioma mass t2 hyperintense hamartoma potential angiosarcoma histological examination fragments mass revealed anastomosing congested sinusoidal channels fibrous interstitial tissue absence normal red white pulp the lining cells immunoreactive cd 31 factor viii cd 68 negative stains cd8 cd34 markers normally present red pulp sinusoidal endothelium consistent diagnosis lca contrast enhanced axial computed tomogram ct image obtained portal venous phase shows large mass arrows spleen mass showing diffuse homogeneous enhancement lateral aspect medial aspect hypoenhanced cyst liver also demonstrated arrowhead axial magnetic resonance imaging mri images level mid spleen show large mass arrows isointense rest splenic parenchyma contrast injection t1-weighted b t2-weighted images ( c shows peripheral nodular internal septal enhancement arterial phase t1-weighted fat suppressed pulse sequence ( diffuse enhancement portal venous phase e remains enhanced delayed 3-min image as 30% lca cases reported associated malignancies underwent investigations including ct chest colonoscopy normal the differential diagnosis splenic vascular tumor broad may represent benign hemangioma hamartoma lymphangioma indeterminate lca hemangioendothelioma hemangiopericytoma malignant neoplasms angiosarcoma lca rare recently described vascular tumor spleen first described falk et al 1991 since initial description scattered case reports case series lca most cases lca described literature composed multiple nodules varying sizes spleen solitary presentation rare 75 cases reported english literature far only five cases solitary mass.[46 lca considered benign neoplasm arising littoral cells lining sinuses red pulp normal splenic tissue littoral cells possess morphologic immunophenotypic features reflect dual endothelial histiocytic potential splenic sinus lining diagnostic traits lca morphological diagnosis based presence anastomosing vascular channels lined tall endothelial cells focal papillary fronds normal splenic sinuses periphery lesion immunohistochemically contrast normal sinus endothelium expresses factor viii antigen cd 8 positivity lca neoplastic cells exhibit positive staining endothelial cd 31 factor viii histiocytic cd 68 lysozyme antigens complement receptors cd 21 cd 163 lca cells negative cd 8 cd 34 s-100 protein antigens lca particular gender age predilection although median age falk et al original study 49 years the clinical presentation lca ranges completely asymptomatic discovered incidentally case constellation signs symptoms abdominal pain vague constitutional symptoms splenomegaly hypersplenism although first described benign strong association shown neoplasm group immunologic oncologic entities approximately 36% cases lca accompanied immunodysregulation included crohn disease metabolic disorders congenital abnormalities approximately 30% cases lca associated various malignancies including colorectal renal hepatocellular pancreatic lung lymphoma myelodysplastic syndrome aplastic anemia lca also shown exhibit malignant potential although extremely rare the two subtypes lca malignant potential described littoral cell angiosarcoma littoral cell hemangioendothelioma histological evaluation reveals features consistent lca histopathology well abnormal architecture nuclear atypia necrosis the pathogenesis lca remains unclear given association autoimmune disorders crohn disease immune system dysfunction postulated possible important pathologic mechanism indeed immune system dysfunction may explain association lca cancer types these observations prompted recommendations closely evaluate provide surveillance patients lca development malignancies radiologically lca may evaluated several imaging modalities ultrasound us ct mri nuclear medicine studies tc-99m labeled rbc scintigraphy the sonographic appearance lca variable includes reports mottled echotexture without discrete lesions well findings isoechoic hypoechoic hyperechoic lesions color flow doppler imaging may reveal presence central peripheral vascularity helps distinguish lca cavernous hemangioma spleen on noncontrast ct lca appears hypoattenuating masses given vascular nature neoplasms tend enhance homogeneously contrast particularly delayed images ct findings surrounding capsule internal calcification described.[246 mri minority cases may hypointense t1-weighted t2-weighted scans hemosiderin content tumor however significant siderosis seen 50% cases lesions tend hyperintense t2-weighted images nuclear medicine studies tc-99m labeled rbc scintigraphy useful differentiate splenic lesions splenic hemangiomas however radiologic features lca rarely diagnostic many splenic neoplasms hamartomas hemangiomas lymphomas metastatic diseases infectious diseases exhibit similar imaging characteristics symptomatic lca often relieved splenectomy given association lca malignancies reported cases malignant transformation splenectomy diagnostic therapeutic in conclusion lca recently described rare primary benign vascular neoplasm spleen may associated malignancies may also malignant potential a majority lcas multinodular although may present solitary lesion case	littoral cell angioma ( lca ) is a rare primary splenic tumor that is difficult to differentiate preoperatively from other benign and malignant splenic lesions . most of the cases present as multiple nodules in the spleen . we report a case of large solitary lca of the spleen , an uncommon presentation . lca should be considered in the differential diagnosis of multiple and solitary splenic lesions .
	summarypoly(adp - ribose ) polymerases ( parps ) ( also known as adp - ribosyl transferase d proteins ) modify acceptor proteins with adp - ribose modifications of varying length ( reviewed in refs 13 ) . parps regulate key stress response pathways , including dna damage repair and the cytoplasmic stress response2,3,4,5,6 . here , we show that parps also regulate the unfolded protein response ( upr ) of the endoplasmic reticulum ( er ) . human parp16/artd15 is a tail - anchored er transmembrane protein required for activation of the functionally related er stress sensors perk and ire1 during the upr . the third identified er stress sensor , atf6 , is not regulated by parp16 . similar to other parps that function during stress , parp16 enzymatic activity is up - regulated during er stress when it ( adp - ribosyl)ates itself , perk and ire1. ( adp - ribosyl)ation by parp16 is sufficient for activating perk and ire1 in the absence of er stress , and is required for perk and ire1 activation during the upr . modification of perk and ire1 by parp16 increases their kinase activities and the endonuclease activity of ire1. interestingly , the c - terminal luminal tail of parp16 is required for parp16 function during er stress , suggesting that it transduces stress signals to the cytoplasmic parp catalytic domain .
although surgical resection preferred treatment early stages confers best outcome quarter patients diagnosed early stages non small lung cancer nsclc lobectomy considered standard care t1 n0 nsclc due low rate local recurrence compared sublobar resection other studies however demonstrated 5-year survival rate sublobar resection group equal lobectomy the common indication sublobar resection primary lung cancer inadequate pulmonary reserve comorbidities contraindicate lobectomy alternative local therapies radiofrequency ablation rfa stereotactic radiation therapy may attractive group patients the procedural mortality rate rfa 0.2% vs 1% surgery lung function deteriorate repeated procedures rfa performed several retrospective studies demonstrated survival benefit resection pulmonary metastases general patients whose primary tumour control extra pulmonary metastases small pulmonary metastatic burden benefit surgical resection currently major role rfa pulmonary metastases treatment patients surgical metastectomy would ideal comorbidities technical issues render rfa attractive conventional treatment inoperable non resectable lung tumours systemic chemotherapy conventional external beam radiation therapy satisfactory terms survival outcomes general tumours 3 cm diameter located periphery lung ideal candidates rfa rate complete ablation tumours larger 3 cm diameter shown poor several studies biologic tissues heated greater 50c 5 min undergo coagulation necrosis the area coagulation related strength radiofrequency energy current carrying time diameter shape electrode composition surrounding tissues both especially rfa lung tumour imaging challenging review focuses problems proper pre procedural staging important patients nsclc lung metastases determine best modality treatment staging include chest abdominal computed tomography ct together positron emission tomography pet)/ct the decision treat lung tumour ideally made multi disciplinary team rfa performed either combination local anaesthesia conscious sedation general anaesthesia the patient placed supine prone ct scanner shortest vertical path avoids bullae interlobular fissures pulmonary vessels chosen tumour contact vessel 3 mm diameter thought create heat sink effect may render coagulation less successful the relationship needle tumour must assessed 3 planes using image reconstructions when expandable needles multiple tines used important assess correct placement deployed tines starting ablation fig figure 1rfa ablation often performed using ct modality choice guidance placement rfa electrode the relationship electrode needle tumour must assessed 3 planes axial b sagittal c coronal needles multiple tines used crucial check correct placement deployed tines starting ablation rfa ablation often performed using ct modality choice guidance placement rfa electrode the relationship electrode needle tumour must assessed 3 planes axial b sagittal c coronal needles multiple tines used crucial check correct placement deployed tines starting ablation in pathologic evaluation microscopic tumour extension nsclc giraud et al found 95% microscopic extension primary nsclc would encompassed margin 8 mm adenocarcinoma 6 mm squamous cell carcinoma an rfa induced area ground glass depicted rf ablated area immediately process easily seen ct fig the ground glass area around tumour represents inflammation considered safety margin pulmonary parenchyma covered treatment so target diameter ablation must ideally least 1 cm larger diameter tumour undergoes treatment proposed ground glass early indicator treatment success percutaneous rfa demonstrated point tumour surface ground glass margin likely site future recurrence figure 2post procedure imaging ensuring tumour surrounded circumferential area ground glass 1 cm ideal areas ablated tumour small rim ground glass associated future recurrent disease case sufficient area ground glass displayed post procedure imaging ensuring tumour surrounded circumferential area ground glass 1 cm ideal areas ablated tumour small rim ground glass associated future recurrent disease case tumour size location linked rates local tumour progression lesions treated rfa a tumour size less 3 cm associated higher rates complete tumour necrosis after procedure completed ct scan chest obtained detect pneumothorax pleural fluid collection haemorrhage the procedure related mortality rate low 0.21% 2905 ablations considered 2 28.3% 14.4% range 0.063.2% requiring aspiration chest drain pleural effusions often seen however incidence pleural effusions need drained order 1 7% other complications reported haemoptysis usually require intervention infections although production air micro embolisms pass pulmonary vein systemic circulation described phenomenon probably cause cerebral ischemia accurately monitoring treatment response early identification residual recurrent disease critical optimizing effect treatment the crucial question imaging follow whether residual recurrent viable tumour response evaluation criteria solid tumour recist widely accepted system allows objective measurement treatment response chemotherapy this system based changes diameter lesion either ct magnetic resonance imaging mri rfa lung tumours considered recist system suboptimal evaluate response differentiate viable non viable tumour adjacent devitalized tissue purpose appropriate rfa ablation lung tumour cause coagulation necrosis larger initial lung tumour contrast enhancement lesion also monitored however hyperaemia inflammation ablation zone may mask contrast enhancement underlying residual tumour reported anderson et al this group suggests size enhancement ablated zone analysed fully assess residual tumour as tumour ideally becomes larger successful ablation recommended new baseline ct scan performed 1 3 months ablation procedure fig 3 obvious lung lesion successful ablation grows first months afterwards decreases size one group found area recurrent disease often showed degree contrast enhancement no stringent rules assessment tumour response rfa lung tumour exist the features commonly used identify remaining viable tissue tissue enhancement nodular growth serial images fig 4 figure 3the tumour size assessed ct larger volume tumour ablation long time period most authors recommend 1- 3-months baseline scan follow success treatment time point tumour size ct decrease ablation successful case figure 4this figure illustrates patient recurrent disease 24 months ablation shown traditional morphological measurements suggesting growth part tumour c perfusion ct f pet ct g histopathology ( already indicates areas perfusion probably indicative recurrent disease amount perfusion increased 18-month scan e 24-month scan f no tumour growth seen ct scans 12 months 18 months b the perfusion ct f displayed 5-mm slice perfusion shown the tumour size assessed ct larger volume tumour ablation long time period most authors recommend 1- 3-months baseline scan follow success treatment time point tumour size ct decrease ablation successful case this figure illustrates patient recurrent disease 24 months ablation shown traditional morphological measurements suggesting growth part tumour c perfusion ct f pet ct g histopathology the perfusion ct 12 months already indicates areas perfusion probably indicative recurrent disease amount perfusion increased 18-month scan e 24-month scan f no tumour growth seen ct scans 12 months 18 months b the perfusion ct f displayed 5-mm slice perfusion shown large review local recurrence seen 12.2% mean period 13 months range 345 months although clear follow program exists authors perform contrast enhanced ct 1 3 6 9 12 months every 6 months following rfa new imaging techniques may provide opportunity improved assessment post therapy tumour bed several retrospective one prospective study evaluating pet ct follow rfa lung tumours published these studies general suffer small number patients methodological problems due retrospective design short inhomogeneous time follow suboptimal standard reference however seems 1 large decrease standardized uptake value post rfa fdg pet 2 certain pattern fdg uptake 3 fdg uptake region around original tumour indicating inflammation predictors successful ablation to knowledge one study evaluated diffusion weighted mri small number patients retrospective design diffusion weighted mri performed 3 days rfa showed reduced signal intensity increased apparent diffusion coefficient values ablated lesions compared pre procedure tumour tissues functional imaging probably contribute work treatment evaluation lung tumour rfa fig other image interpretation tools texture analysis may useful follow lung tumour ablation	abstractimaging is important in the decision - making process of how to treat a lung tumour , which ideally should be a multi - disciplinary team decision . imaging is important during radiofrequency ablation ( rfa ) treatment with regard to optimal placement of the electrode , the immediate post - treatment criteria and very early detection of complications of the procedure . imaging is very important in the treatment follow - up . in lung rfa , as in many other interventional procedures , the traditional morphological imaging techniques to evaluate treatment response have difficulties and functional imaging techniques may potentially be more useful . however , larger studies showing this impact have not yet been performed .
light transduction microvillar photoreceptors canonical instance phosphoinositide signaling devary et al 1987 species examined date photoresponse accompanied large elevation intracellular free calcium brown blinks 1974 ranganathan et al 1994 ; calcium ions long known pivotal role light adaptation brown lisman 1975 also implicated regulation visual excitation process bolsover brown 1985 payne et al 1986 werner et al 1992 shin et al 1993 boosting gain speed light response payne fein 1986 detailed mechanisms light signaling downstream hydrolysis pip2 yet fully elucidated evidence supporting insp3/ca branch cascade brown rubin 1984 fein et al 1984 payne et al 1986 shin et al 1993 well as dag metabolite thereof gomez nasi 1998 chyb et al 1999 nonetheless undisputed final effect opening ionic channels plasma membrane giving rise inward current although microvillar photoreceptors light dependent conductance cationic significant species differences ionic selectivity organisms like limulus light response due influx na ions little detectable contribution ca millecchia mauro 1969 brown mote 1974 in contrast others like balanus drosophila calcium major charge carrier photocurrent brown et al 1971 hardie 1991 not surprisingly concomitant differences source ca mobilized light limulus apis light induced increase cytosolic ca entirely accounted release internal stores brown blinks 1974 baumann et al 1991 triggered stimulation insp3 receptors brown rubin 1984 confined light sensitive lobe cell payne fein 1986 balanus drosophila instead attributable primarily influx removal extracellular calcium greatly depresses ca elevation brown blinks 1974 ranganathan et al 1994 ubiquitous role calcium regulation light responsiveness intense and/or prolonged photostimulation poses challenge cells possessing light activated channels poorly permeable ion internal pool calcium inevitably limited we addressed problem examining microvillar photoreceptors marine mollusk lima scabra extensive electrophysiological characterization lead conclusion minimal permeation calcium light sensitive channels gomez nasi 1996 combined use patch clamp recording calcium fluorescence measurements identified slow ca dependent inward current becomes manifest regimen intense photostimulation internal release sustained this novel conductance fulfills requirements mediating persistent elevation intracellular calcium necessary regulate light transducing machinery conditions were dissected dim red illumination enzymatically dispersed described previously nasi 1991a the resulting suspension dissociated microvillar photoreceptors plated recording flow chamber mounted stage inverted microscope the chamber continuously superfused 1 ml min artificial sea water asw system manifolds permitted exchange superfusate rapid local solution changes a puffer micropipette positioned vicinity cell could pressure eject stream test solution upon activation solenoid operated valve whole cell patch clamp recordings performed described previously nasi 1991b signals low pass filtered 100 hz slowly changing currents 1,000 hz rapid light evoked current using bessel four pole filter records digitized online sampling rate 200 hz 3 khz respectively all cell manipulations performed dim near infrared illumination long pass filter 715 nm andover light flashes generated conventional optical stimulator delivering small spots light 200 diameter an vivo calibration used quantify light intensity terms effective photons cm 500 nm measured radiometer united detector technology voltage light stimuli applied microprocessor controlled programmable stimulator stim 6 ionoptix changes cytosolic ca detected using visible light fluorescent indicators calcium green 5n fluo 4 oregon green 2 invitrogen the potassium salt probe dissolved intracellular solution filling patch electrode final concentration 60100 excitation light provided 75-w arc lamp xenon pti filtered dichroic reflector reject wavelengths longer 670 nm omega optical interference filter 480 nm 40-nm bandwidth chroma technology corp the beam brought epi illumination port microscope via liquid light guide oriel corporation emission light collected 100 1.3 numerical aperture oil immersion objective nikon filtered sequentially additional dichroic 610 nm 535-nm interference filter 50-nm bandwidth chroma technology corp adjustable mask nikon located conjugated image plane was positioned infrared visualization restrict collected light rectangular region interest light sensitive lobe cell unless otherwise stated thus minimize background light the fluorescence signal detected photomultiplier tube model r4220 pha hamamatsu photonics operated 800 v photon counting mode using window discriminator rate meter f-100 prm-100 advanced research instruments an analogue voltage proportional counts accumulated bins programmable duration fed interface computer asw contained mm 480 nacl 10 kcl 10 cacl2 49 mgcl2 10 hepes 5.5 glucose ph 7.8 naoh na free sea water sodium replaced nmdg lithium guanidinium nominally calcium free asw calcium replaced iso osmotically magnesium without adding chelators low chloride asw cl was reduced 500 mm replacing nacl cacl2 na- ca gluconate respectively test permeation different divalent cations extracellular solution contained 60 mm calcium barium magnesium 490 mm nmdg cl 10 mm hepes tris the standard intracellular solution used fill whole cell micropipettes contained 200 mm k glutamate 100 mm kcl 22 mm nacl 5 mm mg atp 10 mm hepes 1 mm egta 100 gtp 300 mm sucrose ph 7.3 instances intracellular sodium omitted forestall possibility reverse operation na ca exchanger increase the internal solution elevated ca similar composition except 0.5 mm cacl2 added 1 mm tetrafluoro bapta instead egta invitrogen yielding estimated free calcium concentration 50 for perforated patch recording solution used backfill electrode contained 0.1 mg ml nystatin membrane perforation monitored gradual appearance capacitative transients elicited voltage steps we also used -escin fan palade 1998 produces sizable pores still prevents washout molecules 10 kd asw contained mm 480 nacl 10 kcl 10 cacl2 49 mgcl2 10 hepes 5.5 glucose ph 7.8 naoh na free sea water calcium free asw calcium replaced iso osmotically magnesium without adding chelators low chloride asw cl reduced 500 mm replacing nacl cacl2 na- ca gluconate respectively test permeation different divalent cations extracellular solution contained 60 mm calcium barium magnesium 490 mm nmdg cl 10 mm hepes tris the standard intracellular solution used fill whole cell micropipettes contained 200 mm k glutamate 100 mm kcl 22 mm nacl 5 mm mg atp 10 mm hepes 1 mm egta 100 gtp 300 mm sucrose ph 7.3 instances intracellular sodium omitted forestall possibility reverse operation na ca exchanger increase the internal solution elevated ca similar composition except 0.5 mm cacl2 added 1 mm tetrafluoro bapta instead egta invitrogen yielding estimated free calcium concentration 50 perforated patch recording solution used backfill electrode contained 0.1 mg ml nystatin membrane perforation monitored gradual appearance capacitative transients elicited voltage steps we also used -escin fan palade 1998 produces sizable pores still prevents washout molecules 10 kd the receptor potential lima rhabdomeric photoreceptors complex waveform nasi 1991a owing presence two distinct conductances directly dependent light stimulation nasi 1991c well voltage- calcium dependent ion channels shape time course nasi 1991b endow cells ability generate propagating action potentials mpitsos 1973 intensity stimulating flashes is raised high levels additional feature appears seconds receptor potential generally accompanied one action potentials membrane voltage gradually depolarizes 1020 mv fig the voltage remains depolarized 13 min slowly returns dark resting level b illustrates prolonged time course phenomenon recorded different cells during we used voltage clamp recording investigate long lasting electrical response evoked light 1 c demonstrates bright flash delivered holding voltage near cell resting potential elicits slow inward current henceforth referred islow temporal characteristics parallel aforementioned depolarization early truncated downward transient primary photocurrent highly compressed time scale islow amplitudes typically vary 50 250 pa 113 37 pa sd 22 cells tested stimulation conditions the phenomenon robust reproducible n 100 although across cells variability peak amplitude slow light induced inward current also time course nonetheless duration consistently least two orders magnitude greater primary photocurrent islow triggered repeatedly given cell features reproducible provided stimulation intense fig 1 e fact slower response often proved robust photocurrent rule possibility islow may artifactually result perturbation intracellular milieu loss cell constituents dialysis patch pipette resorted minimally invasive perforated patch technique horn marty 1988 f shows current trace recorded perforation membrane patch nystatin islow indistinguishable currents recorded means conventional whole cell patch clamp technique n 4 ( current clamp recording cell stimulated bright flash light 5.4 10 photons cm complex shaped receptor potential train action potentials membrane voltage drifted depolarizing direction 15 mv ( b recordings three different cells shown compressed time scale illustrate prolonged time course depolarization ( c similar photostimulation applied different cell whole cell voltage clamp internally dialyzed standard intracellular solution a islow started develop several seconds photocurrent truncated amplitude several na would fall scale gain ( slow current three different cells illustrate variability amplitude time course ( e repetitive activation islow cell exposed flash attenuated 0.6 log compared trace c d. f islow obtains photoreceptors voltage clamped perforated patch technique the two examples show current evoked 100-ms flash 1.4 10 photons cm s photoreceptor cells access cytoplasmic compartment attained adding pore forming agent nystatin pipette filling solution -escin examples a striking feature islow dim moderate illumination virtually undetectable becomes conspicuous light intensities saturating range photocurrent point its amplitude graded stimulus intensity size photocurrent remains essentially unchanged 2 b illustrates instead typical intensity series photocurrent recorded different cell displayed lower gain faster time scale it appreciated islow appears flash attenuation 2.7 log photocurrent already attained maximal amplitude continues increase monotonically least 2 log units n 2 fig response relation plotted regular photocurrent islow n 3 case highlight profound difference light intensity dependency 3 log units 2 shows slow current also obtains prolonged illumination moderate intensity may prevail shallow waters sunny day indicating occurrence alien conditions organism likely encounter environment sub tidal meters depth total incident light flux excess 10 photons cm ( islows evoked cell stimulated 100-ms flashes increasing intensity indicated attenuation factor right ( b intensity series photocurrent different photoreceptor displayed faster time scale the amplitude response reaches saturation stimulus intensity threshold slow current ( c plot peak amplitude photocurrent open symbols slow aftercurrent filled symbols averaged three cells condition ( slow current also elicited modest stimulus intensities provided duration extended the panel shows response step light attenuated 1.8 log maintained duration recording holding potential 50 mv panels unattenuated light intensity 19 10 photons cm s. illumination lima microvillar photoreceptors produces large elevation cytosolic ca 3 left illustrates example simultaneous measurement membrane current ca fluorescence voltage clamped cell low affinity indicator calcium green 5n was loaded perfusion via patch pipette final concentration 63 activation epi illumination beam triggered two events 1 vigorous inward photocurrent fig 3 top trace 2 instantaneous transition photomultiplier output signal reflecting basal fluorescence followed large ca rise concomitant onset photocurrent middle trace the fluorescence reached peak within 70 ms beginning light decayed 3 right demonstrates light induced ca transients survive removal extracellular calcium apparently rapid decay calcium free medium consistently observed likely reflects cell cell variability further support contention provided spatially resolved measurements activation kinetics calcium signal relative electrical response end optical recording circumscribed small window 3 3 position manipulated infrared light visualization 3 c shows nomarski micrograph photoreceptor positions optical mask indicated squares fig 3 b membrane current inverted display purposes ca fluorescence traces normalized overlaid fluorescence signal recorded microvillar lobe rhabdomere the rise calcium slightly preceded photocurrent onset window positioned onto cell body soma ca fluorescence rise significantly lagged behind membrane current notice different time scales fig 3 pooled data group cells shown bar graph microvillar lobe the calcium signal led light evoked current 1.1 0.95 ms sd n 14 whereas fluorescence recorded middle somatic lobe lagged average 16.4 2.1 ms n 5 the amplitude ca fluorescence signal also different significantly larger microvillar lobe soma depicted conclusion ca elevation originates photosensitive region photoreceptor precedes opening light dependent ion channels require extracellular calcium consequence must implicate light induced intracellular release light stimulation releases calcium intracellular stores microvillar lobe lima photoreceptors ( simultaneous recording membrane current voltage clamp top traces fluorescence indicator calcium green 5n dialyzed patch pipette concentration 63 bottom traces large increase fluorescence above the initial level occurred shortly activating epi fluorescence beam coincident beginning photocurrent a similar ca transient observed cell superfused 8 min nominally calcium free solution right ( b ca transient originates microvillar lobe precedes opening light dependent channels the fluorescence recorded small window positioned either microvillar lobe rhabdomere cell body soma indicated c. signal rhabdomere slightly preceded membrane current inverted display purposes normalized whereas cell body lagged behind electrical response many milliseconds ( pooled data temporal shift current fluorescence averaged several cells tested two arrangements termination photostimulation large accumulation cytosolic calcium is rapidly reduced determined double stimulus protocol measurements the excitation light presented briefly twice 80100 ms time sufficient encompass peak light induced ca increase the duration intervening interval varied across cells shown fig 4 first flash left evoked conspicuous rise fluorescence initial baseline level marked dotted line subsequent fluorescence measurements optical mask restricted light collection whole light 4 right additional light induced calcium increase observed however level fluorescence remained significantly elevated high peak attained first flash comparing relative fluorescence f f peak first response second flash as interval varied one determine time course fall ca fluorescence light turned 4 b shows 3 residual calcium signal decayed 58 15% n 6 5 decreased 30 18% n 3 ( fluorescence measured response pairs brief flashes 90 ms spaced 3 apart the first light evoked large increase ca fluorescence basal level time second flash presented fluorescence remained significantly elevated increase elicited ( b average amplitude fluorescence signal second stimulus normalized respect initial peak amplitude interval separating two flashes increased 3 5 s. error bars indicate standard deviation one mechanism implicated restoring basal ca levels microvillar photoreceptors na ca exchanger owing stoichiometry countertransport process na ca > we investigated whether islow may reflect activation electrogenic na ca exchanger considering sluggish onset current contrast rapid elevation ca]i possibility would require exchanger spatially segregated respect source calcium we tested effect removing extracellular sodium prevent forward operation exchanger substitution li n 9 resulted slow current normal characteristics indistinguishable control measurements 8) compared lithium salient difference reduction amplitude initial light response expected fact guanidinium nmdg permeate poorly light sensitive channels whereas lithium substitute na carrier inward photocurrent gomez nasi 1996 islow due na ca exchanger evaluate possibility slow current may reflect activity electrogenic na ca exchanger triggered light evoked increase cytosolic ca cells stimulated bright flashes superfused solution containing sodium the slow current still observed regardless replacement extracellular sodium lithium permeates readily light dependent ion channels large photocurrent truncated figure ) initial inward current severely reduced 100 pa photoconductance poorly permeable ions nonetheless subsequent slow current developed normally terms time course amplitude light intensity 1.6 10 photons cm holding potential 60 mv one conclude islow electrical manifestation sodium dependent extrusion calcium released upon photostimulation rather appears correlate sustained increase cytosolic calcium following reasons data fig 4 indicate brief flash high intensity epi fluorescence excitation beam subsequent flashes release additional ca indicated flat time course fluorescence trace second flash clearance calcium load occurs initial time constant 5 one would expect ca]i return baseline levels within 20 less 6 shows measurement membrane current ca fluorescence protracted 1-min period because interested lower amplitude plateau elevation ca higher affinity indicator chosen task fluo 4 minimize bleaching calcium indicator the epi fluorescence illumination continuous pulsed delivering 80100-ms flashes every 3 fluorescence sampled concomitantly membrane currents episodes four readings taken initiating train flashes fluorescence channel represent dark counts first flash the fluorescence signal displayed sharp rise foot level basal fluorescence peak plotted graph represented open filled squares respectively decayed subsequent trials stabilizing level higher initial fluorescence concomitantly several seconds first flash islow started develop reaching amplitude 186 pa average plateau fluorescence end recording higher basal level 20 8.5% sem n 5 even pulsed protocol cumulative light exposure inconsequential gauged whether significant bleaching probe may occurred eliminate confounding due continuous replenishment via dialysis the patch pipette withdrawn loading dye photoreceptor depicted schematically fig 6 b. epi illumination beam turned 5 producing characteristic ca fluorescence increase fig the duration rest period chosen allow ca elevation clear islow die 6 foot optical signal second stimulation shown also expanded time scale right significantly depressed respect initial basal fluorescence level suggesting bleaching ca dye marginal n 3 therefore plateau ca fluorescence fig the persistent though modest elevation cytosolic calcium spite lack detectable photo induced release initial flash implies source ca must active fact lingering ca fluorescence paralleled slow current suggests latter may associated ca influx ( membrane current measured concomitantly ca fluorescence rhabdomeric lobe cell loaded indicator fluo 4 83 recordings made every 3 four baseline measurements excitation flashes 90 ms duration delivered repetitively the bottom graph plots fluorescence signal decayed partially initial large increase remained significantly elevated respect basal level open square dotted line mark basal fluorescence level first flash highest point represents peak fluorescence level attained flash subsequent flashes trace flat light release therefore foot vs. peak ( b estimate whether dye bleaching might contribute significantly decay fluorescence signal owing extended light exposure photoreceptor cells loaded ca indicator 4 min pipette withdrawn prevent dye exchange ( c epi fluorescence beam activated 5 evoking large optical signal decayed plateau basal fluorescence indicated dotted line ( 10 min excitation light turned basal fluorescence found noticeably depressed respect initial level i.e. immediately first opening shutter the initial portion fluorescence traces displayed left displaced vertically clarity arrowheads mark basal fluorescence levels slower rise light induced ca increase second trial indicates physiological rundown right traces superimposed shown expanded time scale replenishment dye possible conditions the results indicate 5-s exposure excitation light result significant bleaching calcium probe measurements input resistance cell delivery bright flash reveal increase membrane conductance responsible islow fig 7 a photoreceptor voltage clamped 60 mv holding potential subjected repetitive square wave perturbation 10 mv amplitude 10 hz 50% duty cycle stimulation bright flash triggered slow current concomitantly amplitude current excursions produced voltage steps grew fig 7 insets reporting increase membrane conductance saturating flashes the conductance change approximately sixfold 2.8 0.7 ns sem 13.4 3.7 ns n 13 average peak amplitude islow 255 39.6 pa values would predict average peak amplitude prolonged depolarization order 19 mv consistent values measured current clamp see fig 1 b ( photoreceptor input resistance continuously monitored applying repetitive rectangular command step 10 mv amplitude superimposed upon steady holding potential 60 mv after flash size current steps gradually increased insets concomitantly development slow current indicating reduction membrane resistance ( b assess permeation individual divalent cations photoreceptors tested extracellular solution containing either 60 mm ca 60 mm mg sole divalent species the internal solution contained sodium prevent calcium loading via reverse operation na ca exchanger holding potential set 50 mv a robust islow observed presence ca top trace whereas entirely absent mg bottom trace light intensity 3.2 10 photons cm s. c islow invert membrane depolarization 40 mv whereas primary photocurrent second slow current cationic carried least part calcium the participation chloride dismissed upon observing reduction extracellular cl concentration 608 108 mm equi molar replacement gluconate produced significant effects slow current depicted n 3 likewise data shown fig 5 rule unique contribution na the permeation calcium assessed superfusing cell solutions containing one divalent cation time 60 mm cacl2 in contrast magnesium divalent cation extracellular solution slow current virtually absent fig 7 the internal solution contained sodium prevent calcium loading via reverse operation na ca exchanger 7 c shows slow current remains inwardly directed holding potentials 40 mv n 3 larger depolarizations proved deleterious cells even recording window shortened 1 min like fig 7 c unable revert islow moreover presence voltage- calcium activated currents considerable amplitude several na nasi 1991b would likely defeat attempt obtain accurate estimate vrev the properties islow described reminiscent store operated currents described wide variety cells use insp3-mediated ca signaling an important experimental tool determining depend filling state internal calcium stores per se rather messengers generated plc pathway thapsigargin inhibitor calcium pump endoplasmic reticulum serca thapsigargin slowly empty calcium stores trigger sustained subsequent influx calcium many cell types we found thapsigargin 400 nm minimally effective altering membrane current voltage clamped lima photoreceptors 8 shows largest effect observed response local application via puffer pipette another cell produced even smaller current 10 pa third respond monitoring membrane current several additional minutes beyond interval shown fig 8 b amplitude significantly different control cells 107 27.2 pa sd n 3 however shown inset fig 8 b primary photocurrent greatly depressed attaining size hundred pa compared several na control cells see fig 2 b assess whether thapsigargin treatment effective light evoked elevation intracellular calcium monitored fluorescent indicators 8 c shows fluorescence control cells cells treated 400 nm thapsigargin the drug nearly abolished large rapid elevation ca typically begins 30 ms opening epi illumination shutter the data averaged six cells three condition summarized bar graph fig 9 shows puffer application 50 sfk96365 islow failed alter time course n 4 application continuous bath superfusion also ineffective n 2 lanthanum also reported block capacitative ca influx submillimolar concentrations several cell types fig 9 b shows extracellular application 1 mm la continuous superfusion entire recording chamber conspicuous islow could still elicited another cell generated slow current 148 pa assess whether islow suffered attenuation resorted sensitive within cell comparison found slow current fully developed brief local application lanthanum produced marginal inhibitory action 15% n 4 depicted in several key aspects therefore islow departs features commonly encountered store operated currents ( application 400 nm thapsigargin dark local superfusion indicated horizontal line beneath trace produced small change membrane current ( b islow evoked thapsigargin treated cell normal amplitude time course ( inset photocurrent measured response bright flashes showing light response greatly attenuated cells loaded 83 oregon green2 dialysis compared pronounced increase ca fluorescence consistently recorded control cells left traces thapsigargin treated cells 400 nm ) ( average light induced increase ca fluorescence three control cells three cells exposed thapsigargin ( 50 skf96365 continuously pressure ejected puffer pipette beginning shortly slow current peaked horizontal line there discernible alteration time course current indicating islow suppressed vh 50 mv light intensity 28.6 10 photons cm ( b large amplitude islow elicited presence 1 mm la applied extensive bath superfusion applying light stimulus vh 60 mv light intensity 2.39 10 photons cm in addition capacitative ca entry plc triggered pathways calcium influx dependent filling state intracellular calcium stores also described arachidonic acid activate noncapacitative ca influx cases shuttleworth 1996 we tested stimulation lima microvillar photoreceptors arachidonic acid either applied local superfusion 1050 n 9 internal dialysis 10 n 3 treatment however failed elicit discernible inward current we also examined possibility calcium may triggering stimulus islow to end dialyzed elevated calcium cells 50 observe spontaneous development inward current dark moreover high intracellular calcium depressed islow rather potentiating compared control photoreceptors dialyzed standard internal solution 50 ca]i reduced approximately half amplitude islow 119 54 pa n 9 thus seems unlikely rise cytosolic ca levels directly controls islow contention would also difficult reconcile time course membrane current develops many seconds long increase ca]i substantially decayed the ubiquitous phosphoinositide signaling pathway review see berridge irvine 1989 underlies visual transduction microvillar photoreceptors invertebrates devary et al 1987 according canonical scheme ca elevation accompanies photoresponse initiated release internal insp3-sensitive stores owing finite capacity calcium containing organelles release proceed indefinitely cell challenged strong sustained stimulation light activated channels permeable calcium brown et al 1971 hardie 1991 ca signaling protracted simply via influx ionic pathway underlies receptor potential however several microvillar photoreceptors light dependent conductance allow significant ca fluxes impasse calls ancillary mechanisms aid prolongation calcium response the present study inspired observation lima microvillar photoreceptors exposed strong photostimulation produce receptor potential consistently followed depolarization lasting 1 min nasi 1991a interestingly ca permeate significantly light dependent conductance lima photoreceptors gomez nasi 1996 similar slow depolarization noted apis baumann hadjilazaro 1972 our data demonstrate presence separate slowly activating ionic mechanism islow triggered brief saturating flashes prolonged light stimulation permeable calcium ions measurements fluorescent calcium probes show concomitantly islow calcium maintained elevated plateau tens seconds time constant decay initial light evoked transient ca release one would anticipate lingering calcium increase must therefore attributed islow consequently conductance ideally suited help ca dependent regulation light transduction machinery conditions process internal release ceases this differs mechanism previously described drone retina recovery photo induced depletion sequestered calcium aided application sustained dim illumination ziegler walz 1990 coping need mobilize calcium beyond capacity intracellular stores course challenge unique photoreceptors many cells rely phosphoinositide signaling initial ca release subsides persistent influx calcium plasma membrane often evoked dubbed capacitative ca entry review see putney 1990 parekh penner 1997 additionally ca influx also occur pathway dependent receptor activation necessarily filling state stores receptor operated current review see bolotina 2008 cases exact mechanism controls 2001 venkatachalam et al 2002 prakriya lewis 2003 may involve diffusible internal messenger parekh et al 1993 randriamampita tsien 1993 direct conformational coupling proteins luik et al 2006 exocytotic fusion channel containing vesicles plasmalemma yao et al 1999 ) molecular search players led identification candidate molecule role er luminal ca sensor stim1 roos et al 2005 putative subunit calcium channel orai1 feske et al 2006 there obvious similarities islow depletion activated currents including striking resemblance time course conditions stimulation elicited however features islow surprising amplitude although 20-fold smaller photocurrent still quite considerable contrast variety cells currents associated late ca influx proved difficult measure electrophysiologically minute size typically pa e.g. hoth penner 1992 bahnson et al 1993 two considerations could explain large amplitude islow lima 1 calcium transients microvillar photoreceptors largest known reaching amplitudes tens brown et al 1977 ; 1994 ukhanov et al 1995 lima exception although absolute quantification possible without ratiometric measurements large signals obtained low affinity dye ca green 5n kd 14 moreover signals recorded higher affinity indicators fluo 4 calcium green 2 kd 0.345 0.55 respectively slower fall kinetics suggestive dye saturation depicted notice kd values quoted refer manufacturer specifications measured 100 mm kcl calcium indicators affinity known decrease significantly vivo higher values ionic strength ionic strength asw 1.35 thomas et al 2000 extent sizable fraction massive load released calcium rapidly extruded na ca exchanger minke armon 1984 o'day gray keller 1989 task subsequently reestablishing homeostasis may require correspondingly hefty pathway ca influx ( 2 heavily invaginated rhabdomere provides abundant membrane area accommodate large number transporting proteins gauged capacitance 70 pf severalfold larger cells similar dimensions nasi 1991a this would make lima photoreceptors appealing model biophysical characterization slow ca influx offering native context size reproducibility cells obtained overexpression stim orai mercer et al 2006 peinelt et al 2006 soboloff et al 2006 ) however differences islow classical capacitative calcium entry must disregarded one thapsigargin serca inhibitor widely used empty internal calcium stores capable mimicking physiologically induced soce elicited modest current independent evidence demonstrated conditions cells ability release calcium severely compromised suggesting thapsigargin indeed depleted calcium stores an equally salient discrepancy lack suppression islow lanthanum skf96365 two agents known block capacitative ca entry stage therefore islow characterized conductance mediating late ca influx unequivocally grouped soce prolonged afterpotentials induced chromatic adaptation described invertebrate photoreceptors prolonged depolarizing afterpotential hillman et al 1983 attributed accumulation metarhodopsin species spectral absorption differs substantially rhodopsin r however prolonged depolarizing afterpotential simply prolongation photoresponse due arrestin saturation separate gradually developing process like islow moreover lima microvillar photoreceptors lack aftereffects intense chromatic stimulation suggests significant spectral shift transition rm hence likely accumulation may trigger observed outcome means conclusion islow mediates sustained influx calcium occurs stimulation conditions lead calcium store depletion may thus serve purpose sustaining calcium signaling and/or aiding refilling intracellular stores however regulation seems largely independent luminal levels er calcium large size reproducibility islow make useful model system investigate control mechanism receptor operated currents present remain poorly understood	in microvillar photoreceptors , light stimulates the phospholipase c cascade and triggers an elevation of cytosolic ca2 + that is essential for the regulation of both visual excitation and sensory adaptation . in some organisms , influx through light - activated ion channels contributes to the ca2 + increase . in contrast , in other species , such as lima , ca2 + is initially only released from an intracellular pool , as the light - sensitive conductance is negligibly permeable to calcium ions . as a consequence , coping with sustained stimulation poses a challenge , requiring an alternative pathway for further calcium mobilization . we observed that after bright or prolonged illumination , the receptor potential of lima photoreceptors is followed by the gradual development of an after - depolarization that decays in 14 minutes . under voltage clamp , a graded , slow inward current ( islow ) can be reproducibly elicited by flashes that saturate the photocurrent , and can reach a peak amplitude in excess of 200 pa . islow obtains after replacing extracellular na+ with li+ , guanidinium , or n - methyl - d - glucamine , indicating that it does not reflect the activation of an electrogenic na / ca exchange mechanism . an increase in membrane conductance accompanies the slow current . islow is impervious to anion replacements and can be measured with extracellular ca2 + as the sole permeant species ; ba can substitute for ca2 + but mg2 + can not . a persistent ca2 + elevation parallels islow , when no further internal release takes place . thus , this slow current could contribute to sustained ca2 + mobilization and the concomitant regulation of the phototransduction machinery . although reminiscent of the classical store depletion operated calcium influx described in other cells , islow appears to diverge in some significant aspects , such as its large size and insensitivity to skf96365 and lanthanum ; therefore , it may reflect an alternative mechanism for prolonged increase of cytosolic calcium in photoreceptors .
food nutrition basic human needs providing directly related food security food security refers peoples access enough food times order healthy active life includes availability enough healthy nutritious food capability assurance obtaining suitable foods via acceptable ways 1 2 studies global organizations also indicate 800 million people developing countries enough food 34 million people developed countries suffer food insecurity 3 a study iran also explains concern 20% people society necessary financial capability feeding 50% problems terms supplying cell nutrition in words one fifth people suffer lack energy half suffer lack micronutrients 4 researchers believe people suffering food insecurity exposed negative effects health level 5 different studies also reported higher prevalence risk factors non communicable diseases overweightness obesity diabetes hypertension 6 smoking 7 populations low food security type 2 diabetes kind common metabolic disorder characterized disorders glucose homeostasis insulin discharge operation in addition decreasing life quality imposing medical expenses type 2 diabetes constitutes 90% cases suffering diabetes increases mortality 24 times 8) the prevalence disease increasing developed developing countries 9 more 230 million people around world suffer diabetes highest spread disease eastern mediterranean middle eastern regions 592 million people 10 iran one countries middle east 3.5 million diabetic patients 11 diabetes clearly related lifestyle especially unsuitable food consumption low body activity 12 13 reason extensive spread food insecurity ( 14 15 growing spread type 2 diabetes iranian society 16 direct relationship disease quality quantity food diet food security together point iran studies food security among diabetic patients study conducted determine relationship food security blood sugar blood pressure among diabetic patients this cross sectional study conducted eastern southern diabetes centers tehran capital city iran 2015 determine sample size initially based pilot study correlation coefficient food security score obtained 0.18 first type error test power the inclusion criteria older 25 years old consent entering study tendency continuing cooperation questioning process scoring 18-item family food security questionnaire positive score 1 score ) sometimes correct almost every month months yes zero score given responses incorrect the 18- item food security questionnaire us department agriculture usda 17 translated validated iran 15 18 also after 12 hours fasting 3 cc venous blood samples taken patient using 3cc syringe all samples gathered 79 a.m. analyzed laboratory diabetes center blood pressure bp measured left arm sitting position using appropriate sized cuffs using calibrated electronic bp device welch allyn circumferences measured using plastic tape measure following levels smallest waist circumference umbilicus level widest hip circumference hips level anterior superior iliac spine iliac crest highest thigh circumference data collected questionnaires biochemical anthropometric ways determine relationship food security sugar level blood pressure diabetes type 2 statistical analyses data done spss software version 16 spss inc the data statistically analyzed chi square one way analysis variance anova post hoc analysis variance informed consent obtained subjects study patients names omitted this cross sectional study conducted eastern southern diabetes centers tehran capital city iran 2015 determine sample size initially based pilot study correlation coefficient food security score obtained 0.18 first type error test power the inclusion criteria older 25 years old consent entering study tendency continuing cooperation questioning process scoring 18-item family food security questionnaire positive score 1 score ) sometimes correct almost every month months yes zero score given responses incorrect the 18- item food security questionnaire us department agriculture usda 17 translated validated iran 15 18 also 12 hours fasting 3 cc all samples gathered 79 a.m. analyzed laboratory diabetes center blood pressure bp measured left arm sitting position using appropriate sized cuffs using calibrated electronic bp device welch allyn circumferences measured using plastic tape measure following levels smallest waist circumference umbilicus level widest hip circumference hips level anterior superior iliac spine iliac crest highest thigh circumference data collected questionnaires biochemical anthropometric ways determine relationship food security sugar level blood pressure diabetes type 2 statistical analyses data done spss software version 16 spss inc the data statistically analyzed chi square one way analysis variance anova post hoc analysis variance informed consent obtained subjects study patients names omitted out 243 studied diabetic patients 167 68.7% female 76 31.3% male average age 59 11.2 years old present study 167 women 50 29.9% food secure group 100 59.9% food insecure group without hunger 67 10.2% classified food insecure group hunger also 76 studied men 27 35.5% food secure group 45 59.2% food insecure group without hunger 4 5.3% categorized food insecure group hunger chi square statistical analysis showed significant relationship gender food security p=0.372 although waist hip circumference diastolic systolic blood pressures glycosylated hemoglobin higher insecure food group secure food group analysis variance age waist circumference hip circumference average number family members duration suffering disease blood sugar blood pressure showed significant relationship food security score diastolic blood pressure p=0.03 table 1 table 2 tukey post hoc analysis variance done shows significant difference terms systolic blood pressure food secure group food insecure group without hunger in study waist hip circumference diastolic systolic blood pressures glycosylated hemoglobin food insecure group food secure group difference significant terms diastolic blood pressure a part relationship food insecurity non communicable diseases probably due effects food insecurity food patterns leads suffering population toward consumption cheap foods high density low value terms micronutrients 19 food pattern low health level this pattern lead appearance metabolic diseases diabetes 14 a study gucciardi et al showed food insecurity 9.3% higher prevalence among diabetic patients suffering diabetes 6.8% 20 another study the prevalence diabetes food secure slightly insecure extremely insecure groups respectively reported 11.7% 10% 16.1% showed prevalence higher among people extreme food insecurity 21 2012 study performed 711 diabetic patients among spread food insecurity 46% furthermore among people weaker hba1c blood sugar control reported 22 study done david et al relationship systolic blood pressure tc fasting blood sugar hba1c food insecurity investigated this study showed cases relationship food insecurity body mass index bmi related it also represented 48% food insecure people obese 35% people food security obese the study revealed changing nutrition pattern could probably cause obesity people food insecurity 6 therefore results holben et al.s study verify results present work present study the blood pressure diabetic persons related food security food security significant relationship body mass index bmi patients demonstrated increased pressure patients weight gain cross sectional study carried 135 diabetic patients shiraz spread food insecurity studied population 66.7% study food insecurity showed significantly direct relationship high bmi overweight obesity variables family background disease height age gender relationship food insecurity 18 similar present study showed spread food insecurity among diabetic patients high present study shown food security relationship bmi all world studies related food security typically related obesity a study shown food insecurity significantly positive relationship obesity 23 whereas another work demonstrated food weight insecurity correlation 18 study malaysia carried women families suffering food insecurity rural regions probable relationship found waist circumference food security true obesity 24 study morales et al food security among mexican women the relationship insecurity obesity studied obesity women food insecurity found higher among secure women 25 contrast study done columbia showed food insecurity could predictor low weight adults relationship overweightness 26 in sum results showed significant relationship food insecurity hypertension diabetic patients according high spread food insecurity among diabetic persons food insecurity must considered one effective factors food pattern prevention irreparable diabetes complications also recommended present suitable food advice prevention diabetes complications	introductionfood security has been defined as the availability , stability , access and utilization of safe foods . diabetes has been known as one of the biggest health and medical problems throughout the world and is clearly related to lifestyle , and particularly , improper food consumption . the aim of this study was to determine the relationship between food security with sugar and blood pressure in patients suffering from type 2 diabetes who refer to diabetes centers in tehran.methodsthis cross - sectional study was conducted in 2015 on type 2 diabetes patients in tehran , iran . from two diabetes centers in the eastern and southern parts of tehran , 243 type 2 diabetes patients were selected . necessary information ( demographic and food security information ) about all the studied persons was collected using the standard questionnaire verified by us department of agriculture ( usda ) . the data was analyzed by spss version 16 , statistical comparisons were made using analysis of variance ( anova ) and chi - square and tukey tests and a significant level of < 0.05.resultsmost subjects were female ( 68.7% ) . there was no significant relationship between gender and food security ( p=0.372 ) . no significant relation was observed between food security and fasting blood pressure , hba1c , and systolic blood pressure ( p>0.05 ) , but there was a significant relationship between food security and diastolic blood pressure ( p= 0.030).conclusionsaccording to the relationship between diastolic blood pressure and food security and the role of blood pressure in the irreparable diabetic complications , it is recommended to perform appropriate food advice .
clinical data suggest male female patients exhibit differences regarding pharmacology toxicity medications1 differ response drug treatment result physiological differences body weight surface area extracellular intracellular water also terms differences pharmacokinetics pk pharmacodynamics pd).24 known sex hormones influence drug absorption distribution metabolism pd adverse events aes).5 2001 basis adverse events reporting system us food drug administration stated females experience serious aes saes males.6 hypothesized may due overdosing different pk pd fact females likely report aes males females take medications males it shown females use medicines males higher rate chronic diseases also generally pay attention health consciousness care themselves.6 despite increasing evidence physiological pathological differences genders beyond related reproduction,711 females still represent small percentage 22% participants phase trials essential verify drug dosage aes safety.12 medical research conducted decades large prevalence male participants clinical studies yet findings studies often applied genders.12 new millennium changed european union promoting females participation research projects world health organization including gender medicine equity act order achieve gender appropriate care.13 however date analyses provided pharmaceutical industry regulatory authorities often classify safety efficacy data gender 2013 italian drug agency agenzia italiana del farmaco invited pharmaceutical companies process data divided gender submission regulatory documentation highlight possible differences.14 year novartis italy put place wide gender medicine project called metagem included analysis gender data nine previously conducted observational studies these studies performed 2002 2013 covered range different clinical areas including immune mediated disorders psoriasis psoriatic arthritis transplantation medicine liver kidney transplants infectious diseases hepatitis b central nervous system parkinson disease alzheimer disease ad the aim metagem project analyze describe clinical outcomes therapeutic approaches safety data gender using post hoc analyses meta analyses order explore possible gender differences the methodology metagem project described detail elsewhere.15 present paper reports results overall safety analysis metagem studies aimed evaluating possible gender differences incidence severity aes potential association gender safety seven nine observational studies metagem project included safety analysis 2,612 53.6% males 2,258 46.4% females listed briefly described table 1 regard two excluded studies gender attention female real dimension effect gender hormonal status adverse events incidence psoriatic patients treated cyclosporine study colombo et al unpublished data 2013a colombo et al unpublished data 2013b colombo et al unpublished data 2014a colombo et al unpublished data 2014b colombo et al unpublished data 2016 included gender specific safety assessment primary objective study studio osservazionale italiano per la valutazione dellinsufficienza renale pazienti con trapianto di fegato surf italian observational study evaluation renal insufficiency liver transplant patients study donato et al unpublished data 2013 also considered include safety data collection an ae defined unfavorable unintended sign symptom disease occurred time signed informed consent obtained end patient observation period an ae defined sae resulted death judged life threatening required inpatient hospitalization prolongation existing hospitalization resulted persistent significant disability incapacity caused congenital anomaly birth defect child observed patient cases information available data collected february 2002 first patient first visit psychae study16,17 july 2013 last patient last visit iceberg study rizzetto et al unpublished data 2011 bandiera et al unpublished data 2012 first patient first visit last patient last visit study shown table 1 monitoring visits conducted verify whether enrollment performed consecutively according inclusion exclusion criteria moreover statistical analysis data cleaning process run check collected data completeness accuracy patients considered evaluable analysis evaluable individual study participated gender recorded case report form crf detailed elsewhere.1623 evaluable patients described according sociodemographic age clinical ongoing specific therapies features moreover male female patients compared regard main safety variables ae occurrence characteristics description intensity possible correlation drug evolution therapeutic intervention sae occurrence description comparisons performed student test test fisher exact test appropriate post hoc analyses p values presented exploratory patients missing data selected parameters excluded analysis simply evaluated parameters data collection performed studies crf however variables interest present studies present answer categories reasons ae crf fields common studies were identified preliminary analysis new variable outcome interest eg ae description ae intensity created considering value study different answer modalities present original crfs ae intensity possible correlation ae drug ae evolution recoding performed briefly ae intensity classified mild moderate high determined originally reported studies evolution study grade 1 intensity based common terminology criteria adverse events v3.0 considered mild grade 2 moderate grades 35 high iceberg study rizzetto et al unpublished data 2011 bandiera et al unpublished data 2012 aes defined severe considered high intensity cetra study intensity aes could analyzed variable collected crf possible correlation drug defined present yes absent determined changes therapy introduced evaluated terms dosage escalation reduction therapy discontinuation concerning evolution aes considered resolved including resolved without sequelae unresolved toward resolution resolved without sequelae resolution unknown saes reported death hospitalization disability persistent significant inability life threatening events determined supportive analysis logistic regression model estimated evaluate association gender male female outcome patient least one ae study the model provided estimates odds ratios experiencing ae female versus male patients cary nc usa enterprise guide v4.3 copyright 20062010 sas institute inc cary nc usa in total 4,870 patients 46% females 54% males included analysis detailed table 1 age gender study reported table 2 overall mean age higher females 61.218.3 years males 56.316.6 years disease specific therapies ongoing enrollment studies summarized table 3 overall 264 aes reported 59.1% males table 4 summarizes type aes according medical dictionary regulatory activities meddra system organ class there significant gender difference percentage patients least one ae ie patients 1 2 3 aes 3.0% females versus 3.9% males test p0.05 details occurrence intensity aes gender study reported table 5 the results logistic regression model also showed association gender ae occurrence odds ratio 0.764 females vs males 95% confidence interval 0.5591.044 statistically significant gender difference percentage of drug related aes emerged 37.6% females vs 20.8% males test p=0.0039 overall aes addressed kind treatment females compared males 78.1% vs 66.7% the frequency patients 1 sae 0.6% females versus 1.2% males test p=0.0246 gender specific medicine study diseases differ males females terms prevention clinical manifestations therapeutic approach outcomes tolerability prognosis psychological social impact there increasing evidence recent years physiological pathological differences genders focusing diseases examined studies included analysis many gender differences reported patients psoriasis psoriatic arthritis terms epidemiology,24 pattern burden disease,25 search care,26 choice therapy;27,28 example peripheral joint involvement pain functional impairment frequent female male patients psoriasis.2932 moreover psychae study16 pointed psychological status females also worse males independently severity psoriasis there also extensive literature gender differences ad recently reviewed li singh.33 clinical studies shown differences males females specific cognitive ability domains risk ad later age several major biological hypotheses postulated differences age related sex hormone reduction estrogens progesterone testosterone impact risks diseases diabetes depression age related decline brain volume parkinson disease well gender related differences recognized although still poorly understood prevalence incidence parkinson disease significantly higher males females.34,35 clinical point view females parkinson disease shown worse capacity activities daily living severity levodopa induced dyskinesia several studies,3638 male gender shown predict worse rigidity score higher risk sleep behavior disorder dementia death.37,3941 2014 cross sectional survey42 found males reported greater disease burden greater daily levodopa equivalent doses females the greater burden disease score males significantly associated gender even controlling age disease duration concerning transplants gender based disparities observed post liver transplantation outcomes together continuous decline number liver transplantations females.43 effect gender drug tolerability begun raise interest recent years mainly resulting observation females experience frequent saes males possibly due different pk pd higher rates ae reporting greater use medications females compared males.6,4446 clinical research sponsored novartis italy past decade included several large observational studies important medical areas including psoriasis.16,17,22,47 central nervous system disorders parkinson disease ad,1821 transplantation,23 none studies except one aforementioned gender attention study colombo et al unpublished data 2013a colombo et al unpublished data 2013b colombo et al unpublished data 2014a colombo et al unpublished data 2014b colombo et al unpublished data 2016 adopted gender specific approach data analysis based increasing interest gender medicine prompted large quantity clinical data available large national studies decided reanalyze data gender perspective metagem project the overall metagem sample n=4,870 consisted 2,612 53.6% males females predominant two ad studies evolution axept 59.7% 63.6% respectively enrolled female this prevalence female patients ad studies probably accounts overall higher mean age females compared males there significant gender differences frequency patients least one ae 3.0% females vs 3.9% males test p>0.05 59.1% global aes occurring males considering reported drug related aes incidence significantly higher females consistent several reports revealing females prone adverse drug reactions adrs males confirmed evidence eight ten drugs dropped us market responsible adrs females males indeed risk factors adrs polytherapy aging females become generally older males depression general frequent females males.4446,48,49 factors hypothesized explain females usually report adrs fact females higher prevalence pain headache migraine musculoskeletal pain pay greater attention health status moreover physiological aspects menstrual cycles pregnancy menopause likely relevant impact pk pd drugs unexpectedly found 2% saes occurred males frequency patients reporting least one sae significantly higher males despite older mean age females compared males these results contrast large quantity published data showing females experience aes generally also serious.6,3032 however considered overall patient population fairly unbalanced cetra study renal transplantation inclusion criteria age 18 years renal allograft functioning least 6 months serum creatinine level 2.5 mg dl included 64% male patients accounted 77% total saes 36 47 this may reasonably explained fact cetra patients transplanted patients frequently hospitalized transplant related events reasons order homogeneous population repeated analysis excluding cetra patients this analysis showed significant difference genders terms saes 0.2% females vs 0.4% males least one sae test p>0.05 we adequate information degree disease severity patients considered analysis therefore unable analyze possible correlations severity disease incidence ae however hypothesized type number therapies administered could mirror severity disease least deep study parkinson disease psychae synergy studies psoriasis psoriatic arthritis following specific analyses found correlations incidence aes number drugs administered patients 12 3 deep study type therapy topical systemic two studies psoriasis this seems confirm observed gender differences biased severity disease it originally designed assess gender differences patients safety profile statistical analysis mainly descriptive explorative p values moreover owing inclusion several studies large differences patient population study design ongoing treatments taken account reason common approach data cleaning recoding statistical analysis was followed finally one single study cetra studied quite complex serious clinical condition renal transplantation accounted majority aes 183/264 saes 36/47 may strongly affected results analysis this safety analysis large sample almost 5000 patients affected different diseases treated wide range different drugs provides useful overview within considered disease areas possible gender differences drug tolerability may helpful accurately designing future clinical trials gender specific perspective	backgroundmetagem is a wide gender - medicine project comprising post hoc and meta - analyses by gender of clinical outcomes , therapeutic approaches , and safety data from previously conducted observational studies to explore possible gender differences in real - life clinical settings . we report the results of the safety meta - analysis of seven metagem studies , evaluating gender differences in adverse event ( ae ) incidence and severity.methodsdata were collected between february 2002 and july 2013 . male and female patients were compared for the main safety variables , using student s t - test , 2 test , or fisher s exact test as appropriate . as supportive analysis , a logistic regression model was estimated to evaluate associations between gender and outcome.resultsin total , 4,870 patients ( 46% females , 54% males ) were included in the analysis ; age was higher for females ( mean standard deviation 61.218.3 years ) than males ( 56.316.6 years ) . overall , 264 aes were reported ( 59.1% in males ) . there were no significant gender differences in the percentage of patients with at least one ae : 3.0% for females versus 3.9% for males , 2 test p>0.05 . according to the logistic regression model results , no association between gender and aes occurrence seems to exist . a statistically significant gender difference in the percentage of drug - related aes emerged ( 37.6% in females vs 20.8% in males , 2 p=0.0039 ) . slightly significantly more aes in females were addressed with treatment compared with males ( 78.1% vs 66.7% , 2 p=0.0485 ) . total serious aes ( saes ) were 47 ( 72% in males ) . the frequency of patients with 1 sae was 0.6% in females versus 1.2% in males ( 2 test p=0.0246).conclusionthis safety analysis on a large sample of almost 5,000 patients with different diseases and treated with a wide range of different drugs provides a useful overview on possible gender differences in drug tolerability , which may be helpful in more accurately designing future clinical trials from a gender - specific perspective .
resin based dental composites gaining wide acceptance today dental practice clinical practice the unreacted c c bonds functional groups surface polymerized matrix allow monomer new resin composite bond thereby improving adhesion but time materials undergo degradation deterioration intra oral environment processes lead fracture defects composite restoration either composite tooth interface within restorative material years the traditional management consisted replacing entire restorations recently minimally invasive operative philosophy aims repair defects conservative less traumatic pulp less time consuming cost efficient least used acceptable interim procedure treatment become viable option due limited number reactive methacrylate groups polymerization water sorption pre existing composite repaired composite effectively bond aged composite restoration without adequate surface treatment in cases providing sufficient bonding old restoration important achieved either mechanically chemically though studies undertaken find optimal repair protocols using different bonding techniques exists wide gap experimental methods used daily restorative practice hence present study surface treatment diamond point silicon carbide widely used finishing composites compared along total etch bonding regimen silane coupling agent bonding agent fourteen composite blocks microhybrid composite resin esthet x hd dentsply india shade b2 made measuring 8 mm 8 mm 6 mm using teflon molds block 5 samples prepared it categorized 1 control 2 blocks 2 experimental groups 6 blocks group the grouping samples follows group control group n=10)-no surface treatment subgroup a1 n=5)- bonding surface etched frost ammdent india bonding agent adper single bond 3 espe usa applied subgroup a2 n=5)- bonding surface treated silane primer rely x ceramic primer 3 espe usa bonding agent applied group b experimental group n=30)-coarse diamond point 125 150 mani inc japan used surface treatment surface abraded two times 5 sec operator maintain standardization group c experimental group n=30)- silicon carbide green carborundum stone shofu dental corporation japan used surface treatment surface abraded two times 5 sec operator maintain standardization subgroup c2 n=15 application silane primer bonding agent surface treatment the blocks subjected ultrasonic cleaning 10 mins remove surface debris ensure proper adhesion composite following surface treatments bonding regimen applications aged composite blocks shade b2 ) an increment 2 mm obliquely layered light cured using halogen light curing unit ( translux energy heraeus kulzerinc germany 20 sec per increment 600 mw cm 5 sections per block thickness per section-1 mm prepared slow speed diamond saw isomet saw buehler lake bluff illinois usa hourglass shaped specimens cross sectional area 1 mm made subjected microtensile bond strength universal tester instron 3365 the results microtensile bond strength summarized table 1 comparison various groups means sd minimum maximum load different subgroups test value comparison subgroup a1 subgroup a2 test value comparison subgroup a1 subgroup b1 test value comparison subgroup a1 subgroup c1 test value comparison subgroup a2 subgroup b2 test value comparison subgroup a2 subgroup c2 test value comparison subgroup b1 subgroup b2 test value comparison subgroup c1 subgroup c2 comparison control experimental subgroups resin based composites widely employed dentistry since advent adhesive technologies adhesive dentistry brought perspective possibility conservative approach tooth restoration based reduction cavity preparation size bonding restorative material resin based composite tooth structure hence feasible treatment option failed restorations repair failed part rather replacement entire restoration repair preserves sound tooth structure would risk replacement restoration also prevents repeated trauma pulp dentin organ however repair existing restoration also bereft flaws the substrate bonded chemically degraded one free radicals bond another layer fresh composite commercially available bonding systems rely primarily adhesion either enamel dentin none formulated specifically bond non mineralized aged resin based composite substrate bonding substrate depends various surface roughening techniques air abrasion diamond points acids use intermediary agents adhesive resins silane primer the resin composite used study esthet x hd microhybrid composite particle size 0.6 0.8 loading 77% wt 60% vol it belongs one commonly used resin composite family claimed manufacturers used universal restorative material anterior posterior restorations various techniques utilized simulate intra oral aging conditions.[121618 among methods aging due immersion water generated maximum research commonly seen oral cavity water diffusion polymer chains boundaries fillers hydrolytic deterioration polymer chains resulted elution components plasticization composite initially process would affect surface properties hardness wear resistance however time also interferes bulk properties strength fracture toughness material thereby compromising long term durability restoration.[2022 hence study aging immersion water 14 days used it rather easy bond fresh composite covered oxygen inhibition layer covalent bond established uncured surface layer newly applied composite material aged composite materials lack zone hence viable alternatives facilitate bonding new materials aged composite needs investigated study three different surface treatments bonding regimens applied according various alternatives;[2325 creating micro mechanical locking substrate using coarse diamond point silicon carbide forming potential interpenetrating network using total etch bonding regimen creating chemical bond surface exposed glass filler surfaces application silane surface although effect different contemporary chemical mechanical treatment procedures repair bond strength aged composite evaluated previously choice different chemical mechanical repairing procedures study aimed evaluate validity simplest common methods used every day clinical practice defects old composite resin restorations may restricted old composite resin may involve composite resin adjacent tooth structure well when defect involves restoration tooth additional preparations form removal discolored carious tooth tissues and/or bevel preparation recommended daily dental practice two different abrasives used coarse diamond point.silicon carbide coarse diamond point the micro mechanical roughening produced abrasives depends abrasive particle size this done remove superficial debris produced mechanical roughening might hinder bonding aged composite resin the highest repair bond strength obtained use total etch bonding systems attributed unfilled resins bonding agent penetrated roughened composite surface creating new oxygen inhibited layer the bonding agent formed covalent hydrogen bonds silane inorganic filler particles present study silane pretreatment shown lower bond strength compared total etch bonding regimen attributed mechanism fillers react mechanically loaded aged abraded breaking clusters this loss fillers might reduce interaction silanes thus decrease bond strength incomplete solvent evaporation air drying may occur resulting increased viscosity adhesive blend exerting adverse effect polymerization because surface treatment silane layer remaining filler depleted thus chemical adhesion unpolymerized resin matrix inorganic particles unlikely following surface treatments bonding regimen applications aged composite blocks shade b2 bonded new composite shade a3.5 this made easier prepare hour glass shaped specimen cutting along adhesive zone interface considering afore mentioned facts surface treatment coarse diamond point followed etching bonding resin application produces highest microtensile bond strength comparison either surface treatment silicon carbide application silane primer clinical point view this might advantageous since use silane may interfere composite bond enamel /or dentin exposed repair site however applying findings vitro study clinical situation important realize two situations widely different may co relate completely i affirm financial affiliation e.g. employment direct payment stock holdings retainers consultantships patent licensing arrangements honoraria involvement commercial organization direct financial interest subject materials discussed manuscript arrangements existed past 3 years potential conflict interest disclosed within limitations study concluded bond strength obtained surface treatment coarse diamond point significantly higher obtained surface treatment silicon carbide total etch bonding regimen produces higher bond strength compared treatment silane primer bonding resin application the highest bond strength achieved surface treatment coarse diamond point followed application total etch bonding regimen	aim : to assess the microtensile bond strength of repaired composite resin that was surface treated by diamond point or silicon carbide followed by bonding using either only total- etch bonding regimen or silane coupling agent with adhesive resin.materials and methods : fourteen composite blocks were aged under deionized water for 14 days . the bonding surface was prepared with coarse diamond point or silicon carbide . two blocks with no surface treatment were used as control groups . the bonding regimen was either total - etch bonding regimen or silane coupling agent and bonding agent . the aged samples were then bonded to new composite . five sections per block ( each 1 mm thick ) were prepared ; cut to obtain an adhesive zone of approximately 1mm2 and subjected to microtensile bond strength testing.results:the highest bond strength was obtained by surface treatment by coarse diamond point and total etch bonding regimen and least by silicon carbide and silane . a statistically significant difference was seen in all the four groups.conclusions:surface treatment by a coarse diamond point and total - etch bonding regimen provides highest bond strength . thus , a simpler treatment regimen can contribute to a better bond strength in repaired composites .
veterinary medicine numerous mycotic agents reported cause systemic infections often affecting central nervous system 16 german shepherd dogs appear overrepresented subset veterinary literature reportedly predisposed opportunistic fungal infections current literature a case systemic infection cause scytalidium species reported veterinary medicine humans several subspecies scytalidium including scytalidium hyalinum neoscytalidium dimidiatum documented responsible human cases dermatomycosis infections mimic dermatophytosis scytalidium infections occur feet nails people walking barefooted contaminated soil tropical countries thailand nigeria australia jamaica rare systemic infections reported involving central nervous system abscesses endopthalmitis sinusitis osteomyelitis mycetoma subcutaneous lesions disseminated infections usually immunocompromised immunosuppressed patients these fungi show high resistance antifungal drugs used commonly human veterinary medicine we describe case disseminated mycosis leading progressive cervical pain forelimb hemiparesis german shepherd dog caused scytalidium spp a four year old intact female german shepherd dog referred surgery center month long history cervical pain progressive forelimb hemiparesis initial physical exam day 0 found mildly delayed proprioceptive placing right pelvic limb she treated steroids primary veterinarian initially responsive begun exhibit mild neurologic dysfunction forelimbs stumbling mild toe scuffing week prior presentation computed tomography ct patient cervical spine showed lysis endplate active periosteal reaction ventral aspect fourth vertebral body c4 fig similar lysis noted end plates fifth sixth vertebral bodies c5 c6 a soft tissue mass noted along left lateral aspect vertebral canal body c5 fig 2 soft tissue overlie intervertebral disc space cause dorsal lateral deviation spinal cord severe symmetrical bilateral pre scapular lymphadenopathy moderate bilateral retropharyngeal lymphadenopathy also present fig.3 following imaging initial primary differential diagnosis patient condition metastatic neoplasia based combination soft tissue mass adjacent spinal cord generalized lymphadenopathy secondary consideration given discospondylitis associated reactive lymph nodes though presence soft tissue mass typical finding patients discospondylitis cerebral spinal fluid csf aspirates pre scapular lymph nodes sent cytologic evaluation the patient discharged following day day 1 carprofen 2.2 mg kg po twice daily bid tramadol 3 mg kg po three times daily tid palliative care pending cytology results the pre scapular lymph node aspirates indicative systemic fungal infection yielding moderate reactive lymphoid hyperplasia mild moderate pyogranulomatous inflammation containing intralesional fungal hyphae fig 4 based cytology results second lymph node aspirate sample submitted fungal culture itraconazole therapy initiated 5 mg kg po bid gabapentin 5 mg kg po tid added additional pain control day 5 the lymph node aspirate plated four different fungal culture media sabouraud dextrose agar potato dextrose agar mycobiotic agar trypticase soy agar 5% sheep blood a pure culture fine filamentous fungal growth observed sabouraud dextrose potato dextrose blood agars growth observed mycobiotic agar sixteenth day incubation three agars fungal isolate grew covered dark gray black wooly growth microscopic examination wet mount fungal hyphae revealed formation chains arthroconidia dna sequencing performed approximately 475-base pair fragment intergenic transcribed spacer region 18s ribosomal subunit 5.0 l extracted dna amplified 25 l reaction volume 20 l pcr master mix containing forward primer 5-tccgta ggt gaa cct gcg g-3 reverse primer 5-tcc tcc gct tat tga tat gc-3. reactions performed 9700 thermocycler geneamp pcr system applied biosystems carlsbad california 92008 usa cycle sequencing purified products performed 3130 genetic analyzer applied biosystems sequence data analysis performed use geneious pro software biomatters ltd a blast search sequence data genebank ncbi website http://www.ncbi.nlm.nih.gov/blast/ revealed 95% identical sites scytalidium lignicola next closest match 88.4% identity scytalidium cuboideum the morphologic evaluation combined molecular analysis led conclusion undetermined species scytalidium isolated lymph node aspirate three weeks starting itraconazole gabapentin therapy day 21 owner reported patient comfortable seemed improved neurologically regrettably three months approximately day 60 initiating antifungal therapy patient euthanized due declining neurologic status comfort there 15 species scytalidium listed though two significantly associated human pathology the pathogen generally causes superficial infections similar dermatophytosis nail beds skin people living tropical regions africa south america caribbean parts asia come contact contaminated soil recently cases scytalidiosis occurred humans living temperate countries likely secondary increased travel immigration prevalence endemic areas ranges 9 24% deep systemic infections rarely reported human literature occur immunocompromised patients manifestations systemic disease include central nervous system abscesses endophthalmitis sinusitis osteomyelitis diagnosis achieved via fungal culture affected area according machouart et al ( 2013 standardized therapy treatment scytalidium spp since organism resistant topical systemic antifungal agents used human dermatology case presented patient known travel history endemic tropical region she considered immunocompromised prior diagnosis though breed considered predisposed opportunistic fungal infection her clinical signs diagnostic imaging results consistent case reports dogs vertebral osteomyelitis spinal cord compression lymphadenopathy secondary systemic fungal infection 16 unsurprisingly considering reported resistance scytalidium antifungals itraconazole therapy successful conclusion case report describes scytalidium spp infection causing vertebral lysis spinal cord deviation leading progressive cervical pain forelimb hemiparesis treatment successful leading suggestion diagnostics involving antifungal therapy targeted scytalidium warranted author knowledge first report systemic mycotic infection caused scytalidium spp veterinary medicine	we report a systemic mycosis in a german shepherd dog caused by scytalidium spp . the patient presented for progressive cervical pain and forelimb hemiparesis . cervical computed tomography revealed lysis associated with multiple vertebrae and a soft tissue mass adjacent to the spinal cord , as well as prescapular lymphadenopathy . fine needle aspirates of the lymph nodes yielded hyphae , and a subsequent culture obtained a scytalidium spp . itraconazole therapy was initiated , but the subject was euthanized three months later due to progressive neurologic disease and discomfort . this appears to be the first report of disseminated disease by this species in veterinary medicine .
athletes either walk run prior executing specific skills panariello 1991 the gait complex movement includes open closed kinematic chain therefore gait influenced many factors age activity level muscle activity bizovska et al stastny et al 2014 2015 injury bunton et al 1993 disease krawczyk et al 2012 marchewka chwala 2007 in many studies kinematic franz et al 2009 kinetic bovi et al 2011 cigali et al 2004 jandaka et al 2013b variables gait cycle observed usually assessed independently joint mechanical point view walking human body considered system segments joints forming various types chains depending phase gait cycle the first works kinematic kinetic chains field published 1870s the authors time described kinematic chains system overlapping rigid bodies linked pivots upon external loading force transferred one segment adjacent segment thereby enabling cumulative response whole chain reuleaux 1875 1950s arthur steindler observed possibilities applying kinematic chains motor system steindler 1977 one reasons interest finding muscle activity lower limb foot fixed ground closed chain different foot free motion open chain also implications sports training open kinematic chain okc joint angle adjusted without incurring changes joints closed kinematic chain ckc however ends chain fixed adjustment angle one joint reciprocally results altered angles joint a human gait complex movements typically consists open closed kinematic chains frequently alternate movement lower limbs swing phase the limbs adopt open kinematic chain distal segment movement velocity relates velocity proximal segment additionally inertia acceleration distal segments associated deceleration proximal segments mcmullen uhl 2000 stance phase ckc stability proximal segments depends stability afforded distal segments foot instability influences ability stabilize trunk along proprioception fixed parts body bunton et al 1993 in scientific literature find many studies observe interdependence movements different limb segments various movement tasks sport jandaka et al 2013a sasaki et al 2015 clinical cases bunton et al 1993 khamis et al 2015 wright et al 2008 however focused walking authors mainly observed relationships parts foot shank knee dubbeldam et al 2013 pohl et al 2007 our study comprehensive includes movements ankle knee hip pelvis regard sports training crucial question arises whether ckc okc alternation would lead parallel changes whole movement pattern the aims study describe relationships movements lower limb segments pelvis open closed kinematic chains walking assess effects laterality relationships the experimental group consisted 32 males age 23.3 2.5 years body mass 78.1 8.7 kg body height 182 6 cm participants good health history serious injury the preferred limb determined prior measurements asking leg participant would use kick ball 3d analysis vicon mx vicon motion systems ltd oxford uk optoelectronic system seven infrared cameras type t10 resolution 1 megapixel frequency 200 hz used the participants asked walk 8 long walkway including two force plates type 9286aa kistler instrumente ag winterthur switzerland the positions lower limb segments pelvis determined using plugingait model 16 markers consideration marker placement error szczerbik kalinowska 2011 this velocity range determined preliminary study natural speed walk young male subjects angles ankle knee hip pelvis sagittal frontal transversal planes evaluated specific gait cycle phases determined force plates kinematic system follows initial contact ic),opposite toe oto),heel rise hr),opposite initial contact oic),toe to),maximal knee flexion mkf),tibia vertical position tv initial contact ic opposite toe oto opposite initial contact oic maximal knee flexion mkf tibia vertical position tv ankle movement frontal plane inversion eversion assessed since applying conventional gait model absence enhancement set foot markers considered reliable variable the kinematic data processed using standard procedures vicon nexus vicon polygon software vicon motion systems ltd the relationships angle variables lower limbs pelvis table 1 specific gait cycle phases determined using statistica software version 10.0 statsoft inc the kolmogorov smirnov test showed non normal data distribution thus spearman correlation coefficient used a correlation considered large values greater 0.5 moderate values 0.3 0.5 cohen 1988 positive correlations meant movement joints occurred direction positive negative for example positive correlation ankle knee sagittal plane indicated increased ankle dorsal flexion associated increased knee flexion conversely negative correlation illustrated contrary joint movement example transversal plane internal rotation ankle external rotation knee description measured angle variables positive positive angle values negative negative angle values clarity study focused adjacent segments individual assessment plane the experimental group consisted 32 males age 23.3 2.5 years body mass 78.1 8.7 kg body height 182 6 cm participants good health history serious injury the preferred limb determined prior measurements asking leg participant would use kick ball for 3d analysis vicon mx vicon motion systems ltd oxford uk optoelectronic system seven infrared cameras type t10 resolution 1 megapixel frequency 200 hz used the participants asked walk 8 long walkway including two force plates type 9286aa kistler instrumente ag winterthur switzerland the positions lower limb segments pelvis determined using plugingait model 16 markers consideration marker placement error szczerbik kalinowska 2011 this velocity range determined preliminary study natural speed walk young male subjects angles ankle knee hip pelvis sagittal frontal transversal planes evaluated specific gait cycle phases determined force plates kinematic system follows initial contact ic),opposite toe oto),heel rise hr),opposite initial contact oic),toe to),maximal knee flexion mkf),tibia vertical position tv initial contact ic opposite toe oto opposite initial contact oic maximal knee flexion mkf tibia vertical position tv ankle movement frontal plane inversion eversion assessed since applying conventional gait model absence enhancement set foot markers considered reliable variable the kinematic data processed using standard procedures vicon nexus vicon polygon software vicon motion systems ltd oxford uk relationships angle variables lower limbs pelvis table 1 specific gait cycle phases determined using statistica software version 10.0 statsoft inc the kolmogorov smirnov test showed non normal data distribution thus spearman correlation coefficient used a correlation considered large values greater 0.5 moderate values 0.3 0.5 cohen 1988 positive correlations meant movement joints occurred direction positive negative for example positive correlation ankle knee sagittal plane indicated increased ankle dorsal flexion associated increased knee flexion conversely negative correlation illustrated contrary joint movement example transversal plane internal rotation ankle external rotation knee description measured angle variables positive positive angle values negative negative angle values clarity study focused adjacent segments individual assessment plane all large moderate greater 0.3 correlations table 2 statistically significant p 0.05 the highest number moderate large correlations found following phases closed kinematic chain heel rise 81% opposite toe opposite initial contact 63% regard open kinematic chain maximal knee flexion 38% 56% borderline phases closed open kinematic chains initial contact toe 50% number large moderate correlations smaller the number large moderate correlations slightly higher preferred limb 61% non preferred one 54% regard movement planes number correlations higher sagittal 67% transversal planes 60% compared frontal plane 36% correlations joint movements various gait cycle phases ic initial contact oto opposite toe hr heel rise oic opposite initial contact this combination appears sports movement patterns running throwing trained improved terms movement stability kinematic chain segmental stability appears sequentially dependent inferior segments significantly correlated superior segments therefore controlling lower limb segment stability may allow increased stability proximal segments ultimately trunk graham et al 2011 our results also show segments coupling relation okc ckc example gait present relationships might generalized basic movement patterns used sports specifically aim coach alternate athletes movement pattern considered whether alternate ckc okc part movement the situation also appears considering benefits eliciting changes preferred non preferred limb sagittal plane our results showed significant correlations adjacent segments entire stance phase closed chain knee hip hip pelvis pairs for ankle knee pair significant correlation found initial contact opposite toe heel rise these correlations subject changes knee joint associated braking body movement reduced vertical displacement centre mass rose gamble 2006 swing phase open chain significant correlations movements adjacent segments sagittal plane occur well however values correlations number significant ones smaller correlations significant mkf hip pelvis pair tv ankle knee knee hip pairs significant relationship movement pelvis hip sagittal plane gait cycle confirmed franz et al ( 2009 found positive correlation hip extension anterior pelvic tilt frontal plane the highest values found preswing oic weight transferred contralateral limb pelvis tilted towards ipsilateral limb associated hip abduction pelvis return neutral position midswing mkf tv simultaneous hip knee flexion necessary rose gamble 2006 whittle 2007 transversal plane significant correlation ankle knee knee hip pairs observed almost gait cycle phases since rotation knee joint is limited considered fact correlation foot hip ( 2011 revealed correlation transverse plane rotation foot transverse plane rotation hip pelvis the highest number moderate large correlations found opposite toe heel rise opposite initial contact phases lower limb pelvis closed kinematic chain 2012 showed significantly greater coupling stance phase compared swing phase movements knee joint sagittal transversal planes although coupling study means movement one joint two planes suggests different movements lower limbs correlate closed kinematic chains open ones the obtained results brought forward differences correlations preferred non preferred limb the number moderate large correlations higher preferred limb knee hip movements the correlations often larger preferred limb sagittal plane larger non preferred limb transversal plane this suggests functional differences limbs depend contribution limb performance propulsion control able bodied walking michalski et al 2011 ; sadeghi et al 2000 preferred limb appears important propulsion some authors presented correlations non adjacent segments various planes svoboda et al 2014 however studies mostly observed influence foot position proximal segments segments coupling complex movements depend ckc okc movements thus alternation movement may change kinematics despite that therefore instructions interventions focusing ckc alternation effective movement pattern changes moreover preferred limb initiates kinematics direction propulsion non preferred limb internal external rotation	abstractlots of athletic skills performed during practice or competition are initiated by the legs , where athletes either walk or run prior to executing specific skills . kinematic chains are used to describe the relationships between body segments and joints during movement . the aim of this study was to determine the relationships between movements of lower limb segments and the pelvis in open and closed kinematic chains while walking . the experimental group consisted of 32 males ( age 23.3 2.5 years , body mass 78.1 8.7 kg , body height 182 6 cm ) . for 3d analysis , an optoelectronic system vicon mx ( 7 cameras , frequency 200 hz ) was used . positioning of the segments was determined by the plugingait model . each participant executed five trials at speeds ranging from 1.38 to 1.52 ms-1 . the relationships between angle variables of the lower limbs and the pelvis in selected gait cycle phases were evaluated using statistica software ( version 10.0 ) and the spearman correlation . the highest numbers of moderate and large correlations were found at opposite toe off , heel rise and initial contact for the sagittal and transversal planes in comparison to the frontal plane . the closed kinematic chain had a stronger impact on determining the movement pattern . the instructions or interventions focusing on closed kinematic chain alternation are more effective for changes in a movement pattern . the preferred limb initiates kinematics in the direction of propulsion , while the non - preferred limb in internal and external rotation .
diabetic retinopathy dr remains common complication people type 1 diabetes t1d 39 55 84% t1d patients develop dr 10 20 40 years evolution respectively 13 the duration diabetes glycemic control risk factors closely related forms dr other factors male gender hypertension high body mass index bmi nephropathy dyslipidemia smoking genetic factors appear influence onset progression dr although role controversial 1 35 the influence age t1d diagnosis occurrence microvascular complications like dr currently subject active debate some studies reported prepubertal stage especially first 5 years life might protect occurrence dr 68 however authors point protection disappears disease progresses 2 5 others never observed effect 9 10 puberty negative influence appearance dr due combination hormonal changes poorer control often accompanies stage life t1d onset age 15 literature effect age dr development limited rather confusing patients aged 15 onset lowest protection advanced dr whereas hietala et al stated risk proliferative dr pdr higher t1d onset 5 14 15 40 finally kullberg et al reported prevalence dr increases patients aged 15 19 onset decreases onset ages 30 35 study we take advantage cohort patients included type 1 diabetes registry navarra estimate risk dr development according age onset duration t1d smoking blood pressure bp bmi glycemic control estimated hba1c levels lipid profile the subjects study included t1d registry navarra patients onset t1d january 1990 followed treated complejo hospitalario de navarra july 2013 in cases also measured anti gad anti ia2 antibodies according medical protocol followed patients least one scheduled outpatient appointment per year the patients data needed study obtained electronic health records navarra health service we gathered information age sex onset patients screening visit every visit follow included weight height systolic bp sbp diastolic bp dbp smoking status analytical data lipid profile hba1c patients one determination covariates year computed arithmetic mean case continuous variables categorical ones chose value lasted longest year follow visits smoking habits ascertained patients categorized nonsmokers ex smokers smokers a nonsmoker defined someone smoked fewer 100 cigarettes lifetime ex smoker someone smoked amount quit smoking least one year analysis data performed finally smoker someone quit smoking quit within last year bmi calculated using formula weight kilograms divided height meters squared screening grading presence absence dr performed trained ophthalmologists using fundoscopy mydriasis least every two years starting five years diagnosis hospital t1d patients always explored ophthalmologist retinal examination binocular biomicroscopy 78/90 lens recorded standardized format electronic health record navarra health service patients 12 years retinopathy graded according 5-degree severity scale based american academy ophthalmology simplified classification however since rather cases pdr grades grouped together statistical purposes 1990 1997 hba1c measured using various techniques abbott imx ciba corning glycomet merck menarini hplc 1997 hba1c determined patients high performance liquid chromatography hplc adams a1c ha menarini diagnostics florence italy reference range 4.16.2% 2005 the hospital complex obtained level ii laboratory certification traceability diabetes control complications trial dcct reference method national glycohemoglobin standardization program hdl cholesterol triglycerides tg measured gpo pap roche diagnostics characteristics patients onset disease summarized using frequency percentages categorical variables mean standard deviations sd continuous ones the cumulative incidence retinopathy estimated graphed whole sample also divided age groups 95% confidence intervals based cumulative hazard estimated 5 10 15 years onset data right censored retinopathy event occurred follow due loss follow death order assess effect different variables retinopathy firstly univariate cox proportional hazards regression models fitted we assessed effect covariates onset fixed effects complemented analyses dynamic approach includes covariates time dependent variables updating values along follow the proportionality assumption implicit cox models assessed using weighted residuals violated interaction term time evaluated the possible modifying effect age group evaluated models adjusted age group appropriate secondly multivariate regression model fitted covariates turned significant previous step 989 patients t1d followed onset mean sd follow 10.1 6.8 years 292 29.5% onset childhood 15 years 579 58% men onset 8 0.8% lipid lowering treatment 12 1.2% antihypertensive treatment figures increased 143 14.5% 103 10.4% respectively follow antihyperlipidaemic antihypertensive treatment frequent patients without retinopathy 20.7% versus 13.5% 21.5% versus 8.7% resp 135 patients developed retinopathy 13.7% 121 nonproliferative retinopathy npdr 14 pdr all patients pdr previously diagnosed npdr given low number patients pdr statistical results focused total retinopathy nevertheless deserves mentioned onset patients develop pdr similar hba1c mean values compared rest patients 10.9 4.1 versus 11.0 2.5 follow patients developed pdr hba1c mean values 9.39 2.01 whereas developed npdr 8.30 1.51 retinopathy 7.74 1.33 expected cumulative incidence increased time course diabetes it low first 5 years onset undoubtedly increased 10 especially 15 years we observed rate retinopathy higher patients older diagnosis the highest increase observed group whose onset age 45 years notably 15 years follow cumulative incidence 12 times higher observed group patients whose onset age 10 years table 2 figure 1 univariate analysis male gender smoking sbp hdl cholesterol onset however association hba1c dr development marginally significant p 0.079 remarkably taking patients younger 10 onset reference group risk increased according age onset table 3 additional univariate analysis performed variable according evolution along follow period significant association dr development was observed smoking sbp hdl cholesterol hrs 95% ci similar former ones unlike happened analysis performed using values onset dbp triglycerides bmi hba1c significantly associated dr finally association ldl cholesterol dr slightly limit statistical significance 1.06 1.00 1.13 hr 95% ci p 0.052 table 4 the multivariate analysis confirmed trend observed univariate one risk developing dr increased according age onset albeit less markedly table 5 case focusing pediatric age children onset peripubertal period exhibited significantly higher risk compared 10 hr increasing 2-fold adult patients the risk dr development increased three times respect children 10 notably almost 4 times higher group patients 45 onset hr 3.78 95% ci 1.3710.41 the multivariate approach confirmed among time dependent variables dr development along follow also significantly influenced dbp hdl hba1c latter values 9% table 5 the rate dr increases age diagnosis taking advantage follow patients included t1d registry navarra we confirmed influence controversial risk factors occurrence dr remarkably describe first time risk dr 15 years diagnosis increases increasing age onset highest onset age 45 hba1c factor exhibiting highest impact development dr wisconsin study hr 95% ci ) to develop dr patients hba1c 9.5 10.5 compared patients hba1c levels 9.5% 1.72 1.34 2.21 however rises 2.41 1.91 3.06 hba1c ranges 10.6 12% even higher 3.65 2.87 4.65 hba1c values 12% we compare results highest quartile hba1c lower lowest studies consistent showing relationship poor metabolic control measured glycated hemoglobin dr development progression this relationship shown several publications based national regional t1d records recently 1 18 t1d duration factor clearly related onset progression dr 3 17 series association also observed regarding factors most frequently discussed results match published risk dr 1 3 17 higher men women although difference disappears effect confounding variables prevented multivariate analysis suggesting risk due factors gender relationship bp dr generally accepted results always coincided published data influenced type analysis divergent analysis bp performed baseline throughout follow bp stratified ranges 10 mmhg increments comparison hypertensive normotensive patients 3 17 different results also reported depending dr evaluated whole taking npdr pdr cases separately even progression one analyzed our results largely match wisconsin study although latter treats npdr pdr different entities analyzed single group since 14 patients pdr t1d registry navarre our results accordance linkoping diabetes complications study although smoking associated risk dr univariate analysis relationship variables adjusting confounding factors multivariate analysis therefore must factors closely associated smoking explain recurrent finding the fact smoking linked worse glycemic control may responsible observation dyslipidemia especially increased triglyceride decreased hdl cholesterol levels lesser extent increase total cholesterol ldl cholesterol risk factor albeit weak occurrence dr especially severe forms 22 23 thus additional factors genetic inflammatory metabolic might necessary lipids induce effect case experimental evidence increased biochemically altered plasma lipids lead cytotoxicity retinal capillary cells study the findings ldl- hdl cholesterol triglycerides tables 3 4 5 consistent data published finnish population the occurrence dr pdr plus ndrp related high bmi dis study sweden finland hietala et al our results multivariate analysis differ obtained sweden perhaps due smaller number events series 135 versus 247 patients the influence age diagnosis onset progression dr subject numerous publications focused children probable protective effect prepubertal period ours first study include patients diagnosed t1d age 40 series patients within pubertal period children aged 1014 years exhibit risk developing dr 2.5 times higher risk associated children aged 09 years data consistent results authors 58 especially olsen et al differ obtained holl et al wisconsin study there controversy effect hyperglycemia occurrence microvascular complications puberty discrepancies may due different interpretations exact range age encompassed term puberty led heterogeneous ways grouping patients aged 15 years there real need gain knowledge topic take advantage age diagnosis help deciding extent aggressiveness insulin treatment puberty glycemic control worsened risk microangiopathy development increases partly due insulin resistance insulin sensitivity middle puberty is reduced 3035% compared late stage puberty prepubertal childhood adulthood this seems mainly due effects growth hormone gh insulin growth factor-1 igf-1 the actions gh mediated igf-1 levels molecules correlated thickness capillary basement membrane well diabetic angiopathy furthermore increased levels sex hormones directly related vascular structural abnormalities associated diabetes complications this due ability molecules increase polyol metabolism basement membrane demonstrated animal models there association capillary basement membrane thickening duration t1d postpubertal period in fact diabetes control markers hba1c fasting glucose positively correlated thickness postpubertal prepubertal patients thus suggesting interaction diabetes control puberty psychosocial factors associated adolescence may also contribute poorer glycemic control phase thus subsequent undesirable effect morbidity patients t1d our patients aged 15 29 years risk dr 3-fold risk exhibited children 10 not surprisingly results agreement obtained olsen et al danish study group diabetes childhood disagreement recorded wisconsin study series risk continues increase age even higher patients 30 especially almost 4-fold patients 45 hammes et al also found increased risk pdr patients diagnosed t1d aged 15 40 years by contrast kullberg et al studying patients aged 36 onset also gathering forms retinopathy observed decrease prevalence dr patients older 30 finnish records the risk pdr lower patients aged 15 40 onset compared whose onset puberty the beta cells deemed best preserved diabetes onset adulthood consequence glycemic control would easier development t1d age long puberty would explain lower risk dr found patients our group previously published patients included t1d register navarra relationship age onset glycemic control also exists however cohort worst glycemic control follow observed group oldest patients t1d onset thus point view present findings age onset risk dr consistent previous observations the main one number patients developed pdr rather small cohort for reason able analyze separately npdr pdr information whether risk factors influence differently progression one entity we confident longer follow lasting 20 years allow us obtain information future want remark cohort includes significant number patients followed diagnosis in fact onset disease patient time inclusion study allows analyses incidence different times 5 10 15 years accurate onset baseline matched furthermore consider risk bias could led inaccurate results rather low since follow patients took place hospital screening grading presence dr always performed ophthalmologists followed similar clinical criteria throughout study sum analysis t1d registry navarra shows first time relationship age t1d diagnosis prevalence dr throughout life confirms influence t1d duration glycemic control appearance dr our results also support view bp lipid profile effect dr	aim . to determine the influence of age at onset of type 1 diabetes and of traditional vascular risk factors on the development of diabetic retinopathy , in a cohort of patients who have been followed up after onset . methods . observational , retrospective study . the cohort consists of 989 patients who were followed up after diagnosis for a mean of 10.1 ( sd : 6.8 ) years . the influence of age at diagnosis , glycemic control , duration of diabetes , sex , blood pressure , lipids , bmi , and smoking is analyzed using cox univariate and multivariate models with fixed and time - dependent variables . results . 135 patients ( 13.7% ) developed diabetic retinopathy . the cumulative incidence was 0.7 , 5.9 , and 21.8% at 5- , 10- , and 15-year follow - up , respectively . compared to the group with onset at age < 10 years , the risk of retinopathy increased 2.5- , 3- , 3.3- , and 3.7-fold in the groups with onset at 1014 , 1529 , 3044 , and > 44 years , respectively . during follow - up we also observed an association between diabetic retinopathy and hba1c levels , hdl - cholesterol , and diastolic blood pressure . conclusion . the rate of diabetic retinopathy is higher in patients who were older at type 1 diabetes diagnosis . in addition , we confirmed the influence of glycemic control , hdl - cholesterol , and diastolic blood pressure on the occurrence of retinopathy .
steven johnson syndrome sjs infrequent severe form erythema multiforme em it occur due adverse hypersensitivity reaction drugs results skin mucosal eruptions potentially fatal it considered less severe form toxic epidermal necrolysis ten the difference extent epidermal detachment 30% total body surface area 1030% known sjs ten overlap new eruptive fever stomatitis ophthalmia described severe variant em termed steven johnson 1922 sjs may present nonspecific febrile illness leading malaise headache cough rhinorrhea polymorphic lesions skin mucous membrane characterized acute blisters erosions the incidence sjs estimated around 16/1,000,000 persons per year mortality rate 15% rises 30% ten multiple drugs identified cause sjs ten antibiotics sulfonamides common the drugs cause sjs commonly antibacterials sulfonamides anticonvulsants phenytoin phenobarbital carbamazepine nonsteroidal anti inflammatory drugs oxicam derivatives oxide inhibitors allopurinol paracetamol among extensively used analgesic anti pyretic easy availability cost effectiveness despite considered relatively safe very cases em sjs reported ingestion paracetamol publications 1995 2011 describing sjs ten indian population searched patel et al pubmed medline embase uk pubmed central electronic databases showed 6.17% cases sjs ten due ingestion paracetamol hence present rare case sjs occurred due ingestion paracetamol a 14-year old male patient reported department oral medicine radiology chief complaint painful ulceration lips oral cavity leading difficulty opening mouth eating food since 5 days history present illness revealed burning sensation followed ulcers appeared first oral cavity lips parts body including chest arms legs thighs genital organs figure 1a b the redness eye evident history watery discharge numerous healed lesions also seen chest axilla gave typical appearance target lesions bull eye appearance figure 1c ( initial presentation case showing encrusted lesion lips intra oral erythema ( b hemorrhagic erosion mucous membrane glans penis c targetoid rashes chest past medical history revealed patient suffering fever pain since 2 weeks the patient prescribed tablet crocin fever pain 7 days local medical practitioner the patient relieved fever pain later burning sensation followed ulcers oral cavity extra oral surface intra oral examination revealed solitary mixed red white lesion present right left buccal mucosa left buccal mucosa measured 10 mm 8 mm diameter right side 16 mm 9 mm approximately the lesions well defined borders palpation non scrapable nontender rough texture upper lower lips swollen hemorrhagic crusts present along profuse bleeding laboratory investigations revealed leukocytosis white blood cells 15101/l reference value 400011,000/l raised c reactive protein 59.87 g ml reference range 05 g ml subjected patient hematological investigation lesion acute patient severe discomfort based clinical examination medical history physical examination diagnosis sjs the patient treated expert guidance dermatologist systemic steroids tablet prednisolone 30 mg twice daily daily 7 days further reduced 20 mg twice daily next 7 days gradually 10 mg 5 mg consecutive 7 days administered application kenacort triamcinolone ointment thrice day advised ulcers oral cavity recall 2 weeks revealed almost resolved lesions surfaces completely recovered approximately 40 days figure 2a b ( healing crusting lips healing lesion buccal mucosa b healed lesion upper lower lips sjs uncommon severe mucocutaneous blistering disorder acute unpredictable onset causing considerable morbidity previously sjs considered em major considered distinct em basis severity presence constitutional signs atypical target lesions tendency confluence positive nikolsky sign one mucosal site involvement residual sequelae oral cavity sjs causes widespread ulcerative lesions prodromal symptoms seen 30% cases may possibly initiate within 13 weeks starting new drug lasts 12 weeks presenting flu like symptoms sore throat headache arthralgias myalgias fever rashes ocular changes dry eyes resemble mucous membrane pemphigoid may noted cases our patient report prodrome eye genital ulcerations present along skin mouth ulcers although many factors proposed risk factors sjs including drug induced infections malignant disorders graft rejection due adverse effect drugs the common drugs nonsteroidal anti inflammatory drug nsaids antipsychotics antibiotics allopurinol anticonvulsants sjs differentiated skin conditions three clinical criteria pattern individual skin lesions ii distribution lesions iii extent epidermal detachment the characteristic findings sjs widespread erythematous purpuric macules form flat atypical target lesions disease progresses cause full thickness epithelial necrosis our case showed ulceration oral cavity crusting lips profuse bleeding involvement eye redness watery discharge ulceration genital region along numerous healed lesions chest axilla showed typical appearance target lesions the lesions widespread compared em localized study done among children hospital found anticonvulsant drugs reported highest risk sjs paracetamol lest vaccines presented risk among nsaids paracetamol nimesulide the severe cutaneous adverse reactions scars study found overall risk sjs oxicam derivatives reports increased risk paracetamol germany italy portugal except france cases india however paracetamol found potential risk factor children according survey data pediatric patients scar the present case diagnosed paracetamol induced sjs based upon fact sequential relationship drug established correlation exposure signs symptoms made reported case acetaminophen induced sjs ten widespread macula papular rash stinging eyes oral mucosal ulcerations high grade fever similar features seen case absence high grade fever epithelial detachment the first step management immediate withdrawal offending agent followed supportive care garcia doval et al report earlier drug withdrawn better prognosis exposure drugs longer half lives increases risk death routine antibiotics indicated unless evidence infection fever may part disease process however case lesions axilla abdomen thighs trunk region healing phase debridement necessary step topical antiseptics 0.5% silver nitrate 0.05% chlorhexidine used paint bathe dress patients dressings may gauzes petrolatum silver nitrate povidone iodine hydrogels some authors use biologic skin covers epidermal stripping cadaveric allografts cultured human allogeneic autologous epidermal sheets case dramatic improvement sjs ten reported use intravenous immunoglobulin 0.20.75 g kg body weight alternative systemic treatment methods acute phase sjs ten include hemodialysis plasmapheresis cyclophosphamide cyclosporine use lead delayed wound healing increased chances infection masking early signs sepsis gastrointestinal bleeding increased mortality if steroids used initiated initial stage rapidly tapered hence prescribed tablet predinsolone 30 mg three times daily daily 7 days gradually 10 mg 5 mg consecutive 7 days condition improved sequelae found 3540 days follow this case report reports fact severe hypersensitivity reactions occur paracetamol possibly dangerous life threatening the authors obtained necessary patient consent forms patients given approval participation investigation followed representation concerned article the patients understand authors ensure identities wo n't revealed however anonymity guaranteed the authors obtained necessary patient consent forms patients given approval participation investigation followed representation concerned article the patients understand authors ensure identities wo n't revealed however anonymity guaranteed	in the contemporary era , use of drugs is the dominant paradigm of health care . the most quotidian drug used for fever and pain is paracetamol . although adverse reactions to paracetamol in india are rare , at times they can cause life - threatening situations . stevens - johnson syndrome ( sjs ) is one such potentially lethal adverse drug reaction . the most reported cases of analgesic - induced sjs were due to oxicams or propionic acid derivatives . there are very few detailed reports of sjs due to the use of paracetamol . we report a case of sjs , which occurred due to the use of paracetamol . the clinical features of this condition and multidisciplinary management of the patient are described in brief .
improved neonatal care contributed increased survival among preterm low birth weight lbw infants 1 2 however risk chronic conditions requiring high degree parental participation day day care increases markedly decreasing birth weight gestational age 36 lbw children i.e. 2.500 g born preterm appropriate constitutional pathological small gestational age sga lbw children born term sga many failed reach expected growth utero regarded growth restricted 7 8 the risk perinatal morbidity mortality increases longer slow growth occurred 9 10 growth restricted children particular risk severe intellectual disabilities cerebral palsy even exceeding risk found among children born preterm 1113 the severity chronicity many conditions prevalent children profound effect health functioning many identified special health care needs shcn 1416 these children care needs often type amount beyond required children age general therefore primary caregivers particularly impinge mothers time budgets opportunities regular participation labor market 1719 mothers children shcn often report difficulties engaging paid work often mothers general missed days work cut work hours left paid employment altogether due child additional care needs 20 21 however association child care work participation complex dependent factors related child e.g. age mother e.g. educational attainment household large e.g. financial circumstances mothers households manage one salary may prefer stay home reduce work hours children young entering increasing work participation sometime children reach preschool school age 23 24 this typical pattern characterized increasing work hours increasing child age apparent among mothers children shcn although lbw associated excess risk morbidity shcn 4 5 limited knowledge exists care needs lbw children born term influence mothers opportunities participation labor market linkage population based data national registers study aimed investigate associations children birth weight mothers risk non employment preschool years order examine employment trends children age investigated mothers employment status children 13 years children 46 years age as risk non employment found pronounced among mothers children severe care needs 21 22 expect risk increasing decreasing birth weight moreover due adverse health outcomes observed among many lbw children women general increase work participation children age expect association child birth weight maternal work participation become pronounced child grows older the study population comprised participants population based norwegian mother child cohort study moba conducted norwegian institute public health the study recruited pregnant women first routine ultrasound examination around weeks 1718 gestation 1999 2008 includes 107,000 pregnancies total the moba cohort linked medical birth registry norway based compulsory notification deliveries norway 12 completed weeks gestation the registry contains national identification number participants study allowing linkage central population register national education database statistics norway employment register national insurance administration this linkage provided longitudinal data annual updates mothers children 2010 for purpose study mothers children born 20042006 selected 43.5 invited consented participate moba study since several thousand women participated one pregnancy 15 participation study linked national registers unique pairs mothers children eligible altogether data 40,502 women successfully linked registries among cases twin triplet births 1.7 deliveries prior week 37 week 41 gestation excluded 12.9 leaving 34,587 cases eligible study among eligible cases excluded cases mother emigrated either mother child died 1.9 children born severe congenital malformations 2.6 cases data birth weight gestational age missing 0.3 leaving sample 32,938 mothers children residents norway 2010 the study approved regional committee medical research ethics south eastern norway employment status reported annually employers recorded employment register national insurance administration total labor force constitutes sum employed unemployed persons non as conceptualized study non employment therefore defined unemployed outside labor force due reasons unemployment proportion women labor force comparable age study participants age 2007 31.9 sd 4.7 range 8285 2007 8186 3 years later 2010 time general unemployment rates among women low 2.5 3.0 unemployment 2007 2010 respectively 29 30 the medical birth registry norway provided data birth weight gestational age year birth child sex parity mother age marital status childbirth birth weight standardized gender z scores mean birth weight zero applying data singleton live births total moba cohort mean birth weight 3,535 g sd 548 g girls 3,660 g sd 573 g boys a one unit decrease z score equals decrease birth weight one standard deviation children weighing less two standard deviations mean defined lbw children boys 2.510 g girls 2.436 g sga 10th percentile according norwegian birth weight gestational age standards children birth weights ranging mean one standard deviation mean selected referents data educational attainment obtained national education database statistics norway according six digit code reflecting nine discrete levels education women highest level education childbirth was categorized educational attainment high school graduate 03 high school graduate 45 lower college university level 6 higher college university level including postgraduate levels 78 an indicator household dependency mother income obtained questionnaire assessments provided participants moba study week 17 gestation the women asked possible household manage financially without income considered responses women reporting without difficulties households dependent mothers income as considerable variation work participation among mothers toddlers preschool children first investigated mothers risk non employment 2007 children 13 years 2010 children 46 years age adjusted several factors associated maternal employment general the child age constructed difference year follow child birth year analyses performed using stata se version 12.1 non employment common among women small children robust poisson regression analyses performed results presented adjusted risk ratios rr corresponding 95 confidence intervals ci apart child birth weight models included gestational age coded according conventional cut offs early term 3738 weeks full term 3941 weeks births mother age educational attainment parity household type according characteristics childbirth addition self reported household dependency income child age follow 2007 2010 respectively the study population comprised participants population based norwegian mother child cohort study moba conducted norwegian institute public health the study recruited pregnant women first routine ultrasound examination around weeks 1718 gestation 1999 2008 includes 107,000 pregnancies total the moba cohort linked medical birth registry norway based compulsory notification deliveries norway 12 completed weeks gestation the registry contains national identification number participants study allowing linkage central population register national education database statistics norway employment register national insurance administration this linkage provided longitudinal data annual updates mothers children 2010 for purpose study mothers children born 20042006 selected 43.5 invited consented participate moba study since several thousand women participated one pregnancy 15 participation study linked national registers unique pairs mothers children eligible altogether data 40,502 women successfully linked registries among cases twin triplet births 1.7 deliveries prior week 37 week 41 gestation excluded 12.9 leaving 34,587 cases eligible study among eligible cases excluded cases mother emigrated either mother child died 1.9 children born severe congenital malformations 2.6 cases data birth weight gestational age missing 0.3 leaving sample 32,938 mothers children residents norway 2010 the study approved regional committee medical research ethics south eastern norway employment status reported annually employers recorded employment register national insurance administration total labor force constitutes sum employed unemployed persons non as conceptualized study non employment therefore defined unemployed outside labor force due reasons unemployment proportion women labor force comparable age study participants age 2007 31.9 sd 4.7 range 8285 2007 8186 3 years later 2010 time general unemployment rates among women low 2.5 3.0 unemployment 2007 2010 respectively 29 30 the medical birth registry norway provided data birth weight gestational age year birth child sex parity mother age marital status childbirth birth weight standardized gender z scores mean birth weight zero applying data singleton live births total moba cohort mean birth weight 3,535 g sd 548 g girls 3,660 g sd 573 g boys a one unit decrease z score equals decrease birth weight one standard deviation children weighing less two standard deviations mean defined lbw children boys 2.510 g girls 2.436 g sga 10th percentile according norwegian birth weight gestational age standards children birth weights ranging mean one standard deviation mean selected referents data educational attainment obtained national education database statistics norway according six digit code reflecting nine discrete levels education women highest level education childbirth was categorized educational attainment high school graduate 03 high school graduate 45 lower college university level 6 higher college university level including postgraduate levels 78 an indicator household dependency mother income obtained questionnaire assessments provided participants moba study week 17 gestation the women asked possible household manage financially without income considered responses women reporting without difficulties households dependent mothers income as considerable variation work participation among mothers toddlers preschool children first investigated mothers risk non employment 2007 children 13 years 2010 children 46 years age adjusted several factors associated maternal employment general the child age constructed difference year follow child birth year analyses performed using stata se version 12.1 non employment common among women small children robust poisson regression analyses performed results presented adjusted risk ratios rr corresponding 95 confidence intervals ci apart child birth weight models included gestational age coded according conventional cut offs early term 3738 weeks full term 3941 weeks births mother age educational attainment parity household type according characteristics childbirth addition self reported household dependency income child age follow 2007 2010 respectively a total 22.8 mothers employed children 13 years 2007 dropping 15.6 children 46 years 2010 mothers youngest children less likely employed early motherhood child age influenced maternal employment status less children 46 years a trend towards lower work participation decreasing child birth weight evident proportion mothers paid employment considerably higher across whole birth weight distribution children 13 years compared children 46 years table 1 although mothers lbw children overall highest level non employment children 13 years 25.3 lbw independently associated increased risk non employment early motherhood non employment common also among mothers children birth weights mean period 22.0 factors low educational attainment young age single motherhood important maternal employment status children 13 years however children 46 years lbw significantly associated mothers employment status crude rr 1.65 95 ci 1.312.08 lbw substantial independent effect maternal employment status also adjusting important factors educational attainment single motherhood non dependence mother income rr 1.39 95 ci 1.111.75 among mothers lbw children 24.0 employed children 46 years compared 14.6 among mothers children birth weights ranging mean one standard deviation mean compared employment levels when children 13 years mothers lbw children remained high level non employment relative decrease 1.3 points period contrast referents relative decrease 7.4 points in fact level non employment child age 46 years remained quite similar mothers young children aged 13 normal weight range.table 1adjusted risk ratios non employment two different times delivery among mothers children born term norway 20042006numberchild age 13 years 2007)child age 46 years 2010)% employedrr95 ci% employedrr95 citotal32,93822.815.6 birth weight 1.00 sd mean4,13422.21.010.951.0814.50.990.911.070.000.99 sd mean12,66022.01.00reference14.61.00reference0.011.00 sd mean12,79723.41.030.981.0816.51.040.951.141.012.00 sd mean3,11423.71.010.951.0916.71.091.021.14<2.00 mean23325.31.010.811.2724.01.391.111.75 gestational age full term weeks 3941)26,82922.71.00reference15.31.00referenceearly term weeks 3738)6,10923.00.970.931.0317.01.040.971.10 mother age 24 years younger4,03237.91.541.451.6325.21.311.211.412529 years11,06821.61.131.071.1814.81.101.041.1730 years older17,83820.11.00reference13.81.00reference educational attainment high school graduate2,80045.12.021.872.1736.22.852.593.14high school graduate7,44427.61.331.241.4320.81.761.611.93lower college university17,33218.30.960.901.0211.41.020.931.11higher college university5,36218.91.00reference11.11.00reference parity 1st16,33323.81.00reference15.71.00reference2nd10,49219.70.940.901.0014.10.970.911.033rd4,79723.51.131.061.2016.31.091.001.184th higher1,31632.21.411.291.5423.01.341.201.49 household type two parent31,63421.91.00reference14.91.00referencesingle mother1,30445.21.551.451.6632.01.561.441.70 dependency mother income household dependent27,48121.51.00reference14.81.00referencehousehold dependent5,45729.41.411.351.4819.51.381.301.46 child age 2007 2010 1/4 years11,37926.81.351.291.4216.21.121.061.192/5 years10,68320.81.030.981.0815.21.020.961.083/6 years10,87620.51.00reference15.21.00referenceall categories according characteristics childbirth except child age represents age follow 2007 2010 adjusted risk ratios non employment two different times delivery among mothers children born term norway 20042006 categories according characteristics childbirth except child age represents age follow 2007 2010 this study shows lasting association children birth weight mothers employment status preschool years risk non employment generally increases decreasing birth weight the excess morbidity elevated care needs observed lbw children born term appear influence mothers opportunities participation labor market extended period time we observed negative association birth weight work participation becoming pronounced child grows older also adjustment important factors associated employment general although somewhat smaller proportion mothers lbw children paid employment children age employment levels among mothers children normal weight range increased markedly period corresponding well employment trends general norwegian population mothers lbw children hand remained levels similar mothers young children normal weight range the association observed birth weight work participation likely reflects higher rate health problems disability lbw children born term indicating many children lower weight range require parental care supervision needed children comparable age within normal weight range our findings thus correspond studies showing elevated levels shcn among children lower weight range 46 mirror studies showing trend towards lowered maternal work participation accordance severity child condition 21 22 knowledge first study investigate associations children birth weight mothers employment status although number studies investigated associations children shcn mothers work participation previous studies almost exclusively utilized cross sectional study designs based parental report lacked appropriate reference groups children without shcn 25 35 using large population based sample register based data longitudinally investigate risk non employment the observed employment trends suggest birth weight constitutes valid indicator children care needs early life objective data children shcn hard obtain because impact different conditions varies accordingly child care needs must considered context child stage development thus order examine relative effect caring child special needs important contrast work participation mothers children shcn mothers general children comparable age for instance finding children birth weight affects mothers work participation larger extent children age contradicts conclusions drawn studies utilizing samples solely children shcn 21 22 although mothers lbw children overall highest level non employment children 13 years reduced work participation early motherhood common also general population norwegian figures female labor market participation show approximately 1 4 women small children non employed dropping 1 5 children grow older close 90 children kindergarten norwegian unemployment rates low well oecd average non employed women paid employment due reasons lack child care unemployment thus many women employed shorter longer periods children young elevated levels non employment among mothers children shcn need solely reflect additional care needs children rather general trend towards lowered work participation early motherhood shown important factors educational attainment household income greatly influence women employment choices irrespective children care needs although consistent trend towards higher risk non employment decreasing birth weight evident caution warranted due relative small number lbw children the response rate moba also lower optimal although uncommon large epidemiological studies self selection study may result deviations larger population women sampled comparisons cohort participants women giving birth norway period identified several deviations prevalence estimates particular interest present study representation single mothers women 25 years age infants moba somewhat higher mean birth weight average born longer gestation terms birth weight gestational age the fact youngest women less represented young women overall lowest employment rates 29 30 may imply bias towards higher work participation sample compared general population somewhat older women tend completed education likely stable employed thus experience favorable economic situation may also better opportunity temporarily stay home reduce work hours nevertheless overall employment rates present sample correspond fairly well women young children general norwegian population moreover apart information reflecting single mother versus two parent households study lacks objective information paternal factors educational attainment employment status however although total household income dependent factors household income likely impact employment choices women small children subjective assessment regarding dependency income used study may better reflect individual realities perceived members household whole notwithstanding limitations informed consent participate study obtained early pregnancy prior knowledge pregnancy outcomes children health care needs register based data ensures complete follow participants residents norway 2010 present study constitutes powerful alternative traditional longitudinal approaches often suffer large loss follow systematic attrition in accordance studies employment among mothers children shcn appears mothers lbw children modify employment behavior order meet health care needs children their higher risk non employment may result women becoming increasingly disadvantaged regard future career prospects earnings potential pension benefits although sample comprises young children many conditions prevalent lbw children persist throughout adolescence young adulthood conditions later onset discovered child grows older 39 40 as lbw children higher risk future academic achievement unemployment granted early disability pension implies health problems care needs many children persist extended period time healthy children gradually become independent their care needs thus likely inhibit future maternal employment prospects also children grow older disrupted occupational careers may prevent many women utilizing beneficial effects stable employment possibly resulting poorer caregiver health turn detrimental effects welfare entire family long run 44 45 order reduce long term negative consequences non employment among preference participate labor market important initiate arrangements mothers make possible remain employed time meeting care needs children	children born at term with low birth weight ( lbw ) are regarded growth restricted and are at particular risk of adverse health outcomes requiring a high degree of parental participation in the day - to - day care . this study examined whether their increased risk of special health care needs compared to other children may influence mothers opportunities for participation in the labor market at different times after delivery . data from 32,938 participants in the population - based norwegian mother and child cohort study with singleton children born at term in 20042006 were linked to national registers in order to investigate the mothers employment status when their children were 13 years in 2007 and 46 years in 2010 . children weighing less than two standard deviations below the gender - specific mean were defined as lbw children . although not significantly different from mothers of children in the normal weight range , mothers of lbw children had the overall highest level of non - employment when the children were 13 years . at child age 46 years on the other hand , lbw was associated with an increased risk of non - employment ( rr 1.39 : 95 % ci 1.111.75 ) also after adjustment for factors associated with employment in general . in accordance with employment trends in the general population , our findings show that while mothers of normal birth weight children re - enter the labor market as their children grow older , mothers of lbw children born at term participate to a lesser extent in paid employment and remain at levels similar to those of mothers with younger children .
skeletal class iii anomalies associated maxillary retrusion mandibular protrusion 1 2 it found 65% 67% class iii malocclusions characterized maxillary deficiency subjects maxillary deficiency mandible markedly affected various types extraoral appliances facemasks reverse pull headgears used correct maxillary deficiency 46 however problems patient compliance due size appearance dental implants miniplates modified fixation screws provide bone anchorage orthodontic treatment 79 miniscrews mini implants also become popular easier insert remove 10 11 case report two miniplates inserted anterior part mandible canine areas connected removable appliance upper jaw use elastics order correct maxillary deficiency the patient 11-year old boy referred treatment maxillary deficiency he medical problems signs temporomandibular joint dysfunction the facial photographs showed class iii appearance concave profile maxillary deficiency the pretreatment intraoral photographs dental casts showed class iii relationship central incisors anterior crossbite the patient class iii molar relationship right class left side figures 1 2 cephalometric analysis confirmed class iii skeletal pattern table 1 figure 3 the treatment objectives patient correct deficient maxillary arch ideally forward positioning maxilla obtain ideal overjet overbite correct anterior crossbites extraoral appliances protraction facemask class iii functional appliance modified maxillary protraction devices orthognathic surgery considered alternative treatments correction class iii malocclusion however patient refused use extraoral appliances major surgery therefore case decided use miniplates protract maxilla application class iii elastics plates orthodontic anchorage junji sugawara d.d.s ph.d ap yl-013 placed local anaesthesia canine areas mandible maxillofacial surgeon ideal position miniplates insertion was evaluated using panoramic radiograph order avoid damage roots adjacent teeth mental foramen a tightly fitting well retained upper removable appliance fabricated two adams clasps upper first permanent molars each adams clasps loop used retaining elastics a maxillary posterior bite plate used disclude upper lower jaws unitek elastics connected hooks miniplates adams clasps removable appliance generate approximately 500 g anterior retraction the patient instructed wear appliance full time except eating contact sports tooth brushing also told change elastics every day order retain elastics the adams clasps molars bent form loops figure 4 after 10 months active treatment positive overjet class buccal segments achieved anterior crossbite corrected figures 5 6 the posttreatment cephalometric radiograph tracing showed favourable increase 5.1 4.4 sna anb angles respectively figure 7 the pre- posttreatment cephalometric superimposition anterior cranial base shown figure 8 this case demonstrates clinical application miniplates treatment 11-year old boy maxillary deficiency our system treatment differs conventional force applications facemasks 46 previous studies 2 1220 show significant amount maxillary forward movement produced maxillary protraction appliances recent reports indicate anteroposterior changes achieved beginning adolescence however appliances may cause great discomfort patients highly visible wear leads reduced patient cooperation another problem caused extraoral appliances cause skin abrasions chin especially hot climates therefore patients may simply refrain wearing appliance lack cooperation might lead unsatisfactory result one disadvantages extraoral appliances extraoral force applied chin difficult avoid tipping lower incisors lingually words use chin cup lead lingual tipping lower incisors result pressure chin cup component lower lip dentition cases lingual tipping undesirable side effect cause crowding case report miniscrews used treatment maxillary deficiency one limitations miniscrew loosening distressing clinician patient order overcome problem de clerck et al used miniplates protract maxilla however design current case report different study recent study bone anchored maxillary protraction bamp miniplates was used patients class iii malocclusion significant improvements jet molar relationship recorded case report minor surgery miniplates used overcome various problems undertaken case applying force teeth order correct skeletal discrepancy inevitably result tooth movement therefore full coverage upper removable appliance used cover maxillary dentition however since patient 11 years old still considerable residual growth treatment continued fixed appliance one force component horizontal direction moving maxilla forwards favourable maxillary deficiency cases the second component vertical direction moving posterior maxillary dentition downwards this might lead unfavourable tooth movements high angle cases problem patients low average face height maxillary posterior bite plate overcome problem high angle cases decreasing facial height this case report demonstrates different method using miniplates treat 11-year old boy skeletal class iii malocclusion maxillary deficiency this treatment found acceptable alternative use extraoral appliances facemasks major surgery	introduction . numerous devices have been introduced for correction of class iii malocclusion and maxillary deficiency . aim . to assess the dentoskeletal effects of miniplates combined with class iii traction in treating cl iii malocclusion and maxillary deficiency in growing patients . methods . this case describes the treatment of a maxillary - deficient 11-year - old boy by using miniplates . the patient 's parents rejected the use of extraoral appliances and major surgical correction ; therefore the treatment was done by using class iii elastics connected from two mandibular miniplates to an upper removable appliance . two miniplates were inserted in the anterior part of the mandible in the canine areas under local anaesthesia . the treatment lasted for 10 months after which favourable correction of the malocclusion was observed . results . the sna and anb angles increased by 5.1 and 4.4 , respectively . lower 1 to mandibular plane decreased by 3.4. conclusions . this case demonstrates that miniplates can be a suitable method to extraoral appliances and major surgery in maxillary deficiency cases .
myocardial bridge mb common coronary variant occurs one coronary arteries tunnels myocardium rather resting epicardium the prevalence mb varies depending cohort studied invasive studies intravascular ultrasound ivus computed tomographic angiography suggest prevalence 25%.1 2 although often regarded benign mbs associated ischemia,3 acute coronary syndrome involving proximal left anterior descending artery,4 coronary spasm,5 arrhythmia including supraventricular ventricular tachycardia,6 potentially early death cardiac transplantation,7 sudden cardiac death.8 identifying mb among patients chest pain syndrome challenging current gold standard detecting mb ivus much greater sensitivity coronary angiogram systolic compression3 characteristic echolucent halfmoon sign within mb.9 recently computed tomographic angiography shown valuable diagnosing presence mb.10 functionally escaned et al highlighted importance diastolic fractional flow reserve dffr dobutamine challenge opposed adenosine challenge measurement mean fractional flow reserve assess hemodynamic severity mb.11 addition abnormal septal motion myocardial strain increasingly associated presence mb our group previously described distinctive septal wall motion abnormality apical sparing patients mb.12 jhi et al reported reduced left ventricular lv strain identified dobutamine challenge patients mb,13 wang et al reported decrease resting strain mb perfusion territory.14 study hypothesized patients mb would reduced septal longitudinal strain ls comparable lateral ls exercise compared age sexmatched controls we hypothesized degree impairment would associated hemodynamic severity mb based dffr we identified 65 patients mb left anterior descending artery diagnosed ivus undergone evaluation dffr dobutamine challenge exercise echocardiogram institution seven patients excluded previous cardiac surgery significant coronary artery stenosis 50% coronary angiography the patients referred invasive testing refractory unexplained exertional chest pain noninvasive imaging suggestive mb septal wall buckling apical sparing stress echocardiography).12 patients mb compared 50 age sex matched controls also matched work load peak blood pressure exercise controls undergone stress echocardiography history echocardiographic findings mb coronary artery disease valvular heart disease lv dysfunction lv hypertrophy all study participants reached target heart rate 85% maximum predicted heart rate exercise this study approved stanford university institutional review board informed written consent obtained patients ivus image acquisition performed 40mhz mechanical transducer ultrasound catheter atlantis sr pro2 opticross boston scientific marlborough massachusetts left anterior descending artery placement ivus sensor far distally safely possible the presence mb defined identification echolucent halfmoon sign ivus mb length measured distance first proximal appearance echolucent halfmoon sign distal end combowire recordings stored combomap console volcano san diego california offline analysis all patients underwent hemodynamic testing mb using invasive dobutamine challenge protocol described hemodynamic measurements made using combowire xt pressure flow wire volcano pressure flow velocity waveforms recorded proximal within least 1 cm distal mb identified ivus baseline peak dobutamine stress dobutamine given intravenously increments 10 20 g kg min every 3 minutes maximal dose 50 g kg min 1.0 mg atropine maximum predicted heart rate previous exercise echocardiography achieved using digital electronic caliper instantaneous dffr fraction diastolic coronary artery pressure divided diastolic aortic pressure rest stress calculated proximal within distal mb described previously12 figure 1 a dffr 0.76 considered hemodynamically significant study previous study escaned et al.11 pressure curves representative case patients myocardial bridge mb the red curve shows aortic pressure yellow curve shows coronary pressure within mb both pressures similar baseline however coronary systolic pressure increases stress whereas diastolic pressure decreases compared aortic pressure all echocardiographic studies performed using commercially available echo systems sonos 7500 ie33 epiq 7c philips medical imaging eindhoven netherlands standard echocardiographic views including parasternal long shortaxis apical 2 3 4chamber views obtained 2dimensional color tissue doppler modes lv ejection fraction derived modified simpson method according american society echocardiography ase guidelines.15 exercise echocardiography performed according ase recommendations.16 average 5 10 beats per loop recorded rest immediately stress all participants performed bruce treadmill protocol test17 target heart rate 85% maximum predicted age lv ls assessed 4chamber view rest exercise absolute change strain exercise ls minus rest ls relative change strain exercise ls minus rest ls divided rest ls evaluated strain values obtained manual tracing offline xcelera workstation philips medical imaging frame rate 50 52 hz ensure best measurement quality postprocessing analysis peak exercise always yield optimal tracking initial length obtained enddiastole peak qrs final length obtained endsystole smallest lv volume assess detailed lv strain septal lateral ls global ls gls assessed shown figure 2 quality control mitral annular reference points used addition apical reference point determined furthest point left ventricle mitral annulus kept stable avoid overestimating strain measures due foreshortening foreshortening defined endocardial border apex significantly displaced systole in fact magnetic resonance based studies shown endocardial border apex usually displaces 1.5 mm systole.18 one representative beat minimal respiratory translational motion chosen trace enddiastole endsystole all strain values calculated following formula l0 indicates initial length l1 indicates final length strain 100(l1l0)/l0.19 prior performing manual tracing compared strain values derived manual tracing software analysis tomtec imaging system unterschleissheim germany 50 healthy persons found relative difference 4.84.3% a negative value represents better function presentation strain values study initial length l0 obtained enddiastole final length l1 obtained endsystole to divide left ventricle longitudinal components septal lateral segments apex standardized midventricle middle transverse segment systole diastole strain 100(l1l0)/l0 variables presented count percentage mean standard deviation sd normally distributed variables variables compared student welch test mann whitney u test appropriate multivariate regression analysis performed identify independent correlates absolute relative changes strain we used regression model included age sex mb length systolic blood pressure peak heart rate dffr either within distal mb comparisons strain values baseline stress analyzed paired test inter intraobserver variability 15 patients mb 15 controls randomly selected septal ls lateral ls gls blindly reanalyzed 2 4 weeks first analysis without references initial tracings absolute difference assessed all analyses performed using spss 21 software ibm corp armonk ny table 1 shows clinical echocardiographic characteristics age sex blood pressure matched patients mb controls patient characteristics bp indicates blood pressure bpm beats per minutes bsa body surface area ivsd diastolic interventricular septum la left atrial lv left ventricular lvef left ventricular ejection fraction mb myocardial bridge pwd diastolic posterior wall svi stroke volume index coronary angiography found patient mb significant epicardial coronary disease 50% stenosis men longer mbs women 32.613.9 versus 23.112.8 mm respectively p=0.02 the dffr 0.76 55 patients either within distal mb whereas 0.76 3 patients sites because number patients dffr 0.76 extremely small analysis performed patients dffr 0.76 assessment hemodynamics within distal mb possible 40 patients 13 patients dffr 0.76 within mb 4 dffr 0.76 distal mb 23 dffr 0.76 within distal mb figure 3 of rest 14 patients dffr 0.76 within mb data obtained distal mb length mb precluded safe placement combowire distal vessel one patient dffr 0.76 distal mb data obtained within mb length mb short accurately measure dffr within mbs significantly longer patients whose distal dffr 0.76 compared patients whose distal dffr 0.76 25.613.0 versus 17.98.1 mm p=0.03 some patients mb showed full recovery dffr distal mb indicates dffr 0.76 dffr 0.76 dffr diastolic fractional flow reserve mb myocardial bridge terms stress lv segmental wall motion normal patients lv ejection fraction stroke volume index rest significantly different 2 groups with exercise abnormal septal motion found 50 patients mb whereas wall motion abnormality found controls lv ejection fraction stroke volume index significantly lower patients mb compared controls mb group 33 patients 60% exhibited chest pain 13 24% presented stsegment depression defined stsegment depression 1 mm ecg one 3beat run ventricular tachycardia exercise control group nobody presented stsegment depression ecg chest pain table 1 regarding strain assessment baseline significant difference 2 groups strain values septal ls 19.01.8% patients mb versus 19.21.5% controls p=0.58 lateral ls 20.12.0% versus 20.01.6% p=0.53 respectively gls 19.51.8% versus 19.71.4% p=0.68 respectively exercise mb groups septal ls change significantly 19.01.8% 18.92.6% p=0.83 whereas lateral ls increased significantly 20.12.0% 22.82.9% p<0.001 in contrast control group septal lateral ls increased significantly 19.21.5% 21.71.6% 20.01.6% 22.71.8% p<0.001 figure 4a 4c the absolute relative changes septal ls significantly smaller patients mb controls 0.12.1% versus 2.51.3% absolute change 0.611.2% versus 13.17.8% relative change p<0.001 in contrast absolute relative changes lateral ls similar 2 groups p=0.97 p=0.98 respectively figure 4b 4d significant difference 2 groups strain stress absolute relative changes b in contrast lateral segments significant difference strain stress c absolute relative changes the absolute relative changes septal ls better positive correlation dffr distal mb r=0.52 p<0.001 septal absolute change r=0.52 p=0.001 septal relative change dffr within mb table 2 the absolute relative changes septal ls also moderate negative correlation length mb r=0.32 p=0.02 absolute change r=0.32 p=0.02 relative change in multivariate analysis lower dffr distal mb male sex independent correlates lower absolute relative changes septal ls dffr within mb included instead dffr distal mb a lower dffr within mb male sex independent correlates lower absolute change septal ls however male sex independent correlate lower relative change septal ls table 2 although length mb left multivariate analysis included continuous variable left independent correlate absolute change septal ls instead male sex categorized using median value correlation absolute relative changes septal ls dffr values pattern 1 includes dffr distal mb dffr indicates diastolic fractional flow reserve ls longitudinal strain mb myocardial bridge mb length left independent correlate absolute change septal ls instead male sex categorized using median value terms inter intraobserver variability study the absolute differences 2 investigators 1.91.4% septal ls 2.21.2% lateral ls 1.91.0% gls rest 2.61.6% septal ls 2.81.9% lateral ls 2.21.6% gls immediately stress the absolute differences within observer 1.61.1% septal ls 1.40.7% lateral ls 1.10.8% gls rest 1.71.1% septal ls 1.51.1% lateral ls 1.20.9% gls immediately stress the main finding study patients hemodynamically significant mbs increase blunted increase septal ls exercise compared controls moreover lack significant increase septal ls appears associated length mb hemodynamic significance assessed dffr these functional characteristics may helpful assessment patients referred unexplained exertional chest pain fractional flow reserve invasive reference standard assess hemodynamic significance fixed coronary artery stenosis recent study johnson et al demonstrated fractional flow reserve adenosine infusion independent strong correlate outcome patients lower fractional flow reserve higher likelihood adverse events.20 assessing hemodynamic significance mb however may challenging patients mb dffr may reliable conventional mean fractional flow reserve assess hemodynamic significance increased systolic pressure compression decreased diastolic pressure may offset figure 2).11 addition use dobutamine rather adenosine shown important evaluating mb adenosine results maximal hyperemia vasodilation microcirculation effective fixed stenosis chronotropic inotropic effects dobutamine necessary evaluate hemodynamic significance dynamic stenosis caused mb.21 although cutoff value determine hemodynamically significance argued dffr 0.76 considered hemodynamically significant study previous study escaned et al.11 pathophysiological perspective lin et al previously proposed model ischemia associated mb involving venturi effect.12 lumen area within mb decreases endsystole early diastole figure 5a compression resembles narrowed section pipe pipe fluid velocity must increase figure 5b satisfy principle conservation energy continuity equation time pressure must decrease satisfy principle bernoulli equation thus pressure decreased tunneled section model pressure recover distally provided diameter distal arterial segment larger tunneled segment.22 proposed schematic ischemia mb a normal vessels show pattern increase area seen throughout systole rise aortic pressure solid line in contrast mb segments undergo marked decrease area particularly second half systole importantly vessel compression persists early diastole dotted line).3 b venturi effect fluid passing narrow lesion velocity increases principle energy conservation pressure decreases principle bernoulli equation distally velocity decreases pressure increases recover principles hemodynamic significance mb assessed invasively studies evaluated noninvasively the key findings study change strain stress may useful identifying hemodynamic significance mb hemodynamically significant lower dffr impaired change septal ls stress study change septal ls showed stronger correlation dffr distal mb dffr within mb most patients significant dffr distally also significant dffr within bridge suspect mbs significant dffr distally may exposing even extensive area myocardium ischemia the primary reason phenomenon may longer mb delaying pressure recovery shown relationship septal ls mb length likewise male sex independent correlate diminished increase septal strain stress a possible explanation may interrelationship male sex length mb suggested multivariate analysis along possible reasons preventing full recovery pressure distally may small caliber vessel beyond bridge short segment vessel beyond bridge inability combowire placed far enough distally detect recovery undetected presence mb distal investigated area al recently published study demonstrating resting ls left anterior descending artery territory 3dimensional echocardiography decreased.14 contrast find ls rest useful identifying hemodynamically significant mbs may 3 dimensions able detect subtle changes strain 2 dimensions our study also consisted younger population exposed patients shorter duration ischemia compared population study wang et al clinically study may value assessment patients exertional chest pain undetermined etiology if mb detected exercise echocardiography presence focal septal buckling apical sparing and/or confirmed multisliced computed tomography ivus coronary angiography determination impaired strain increase exercise echocardiography may suggest mb hemodynamically significant furthermore distinctive septal wall motion pattern exercise echocardiography proven accurate enough diagnosis mb,12 change strain may useful stratifying patients mb according hemodynamic significance possibly offering totally noninvasive diagnosis mb exercise echocardiography another consideration enhance image quality feasibility speckle tracking perform dobutamine stress echocardiography although validation study needed first number patients enrolled small however study largest patients mb underwent invasive physiological evaluation exercise echocardiography second strain values obtained manual tracings difficulty obtaining reliable speckle tracking images exercise however showed good inter intraobserver variability even stressbased images third yet provide longterm followup data cohort determine change septal strain useful predicting cardiovascular outcomes patients mb fourth patients mb evaluated study dffr 0.76 further study needed assess change septal ls stress patients mb dffr 0.76 moreover a dffr threshold 0.76 used study previous studies11 however cutoff value well discussed whether dffr 0.76 truly represents hemodynamic significance unknown in addition still say certainty whether strain pattern due ischemia anatomic variation tethered portion left anterior descending artery first number patients enrolled small however study largest patients mb underwent invasive physiological evaluation exercise echocardiography second strain values obtained manual tracings difficulty obtaining reliable speckle tracking images exercise however showed good inter intraobserver variability even stressbased images third yet provide longterm followup data cohort determine change septal strain useful predicting cardiovascular outcomes patients mb fourth patients mb evaluated study dffr 0.76 further study needed assess change septal ls stress patients mb dffr 0.76 moreover a dffr threshold 0.76 used study previous studies11 however cutoff value well discussed whether dffr 0.76 truly represents hemodynamic significance unknown addition still say certainty whether strain pattern due ischemia anatomic variation tethered portion left anterior descending artery patients hemodynamically significant mb reduced change septal strain exercise echocardiography the degree reduction associated severity hemodynamic significance determined invasive dffr assessment change septal strain may clinically useful noninvasive evaluation patients chest pain	backgroundalthough a myocardial bridge ( mb ) is often regarded as a benign coronary variant , recent studies have associated mb with focal myocardial ischemia . the physiological consequences of mb on ventricular function during stress have not been well established.methods and resultswe enrolled 58 patients with mb of the left anterior descending artery , diagnosed by intravascular ultrasound . patients underwent invasive physiological evaluation of the mb by diastolic fractional flow reserve during dobutamine challenge and exercise echocardiography . septal and lateral longitudinal strain ( ls ) were assessed at rest and immediately after exercise and compared with strain of matched controls . absolute and relative changes in strain were also calculated . the mean age was 42.516.0 years . fiftyfive patients had a diastolic fractional flow reserve 0.76 . at rest , there was no significant difference between the 2 groups in septal ls ( 19.01.8% for patients with mb versus 19.21.5% for control , p=0.53 ) and lateral ls ( 20.12.0% versus 20.01.6% , p=0.83 ) . with stress , compared with controls , patients with mb had a lower peak septal ls ( 18.92.6% versus 21.71.6% , p<0.001 ) and lower absolute ( 0.12.1% versus 2.51.3% , p<0.001 ) and relative change ( 0.611.2% versus 13.17.8% , p<0.001 ) in septal ls , whereas there was no significant difference in lateral ls . in multivariate analysis , diastolic fractional flow reserve and length were independent determinants of lower changes in septal ls.conclusionspatients with a hemodynamically significant mb , determined by invasive diastolic fractional flow reserve , have significantly lower change in septal ls on exercise echocardiography , suggesting that septal ls may be useful for noninvasively assessing the hemodynamic significance of an mb .
gerd usually characterized symptoms caused esophageal mucosal exposure acidic gastric contents the pathophysiology related failure lower esophageal sphincter les act barrier gastric reflux the adequacy les function dependent pressure total length portion exposed positive intra abdominal pressure defects one combination factors lead reflux 1 prevalence gerd increasing last 2 decades ( 2 affects 10 20 adult population developed world highest prevalence north america proton pump inhibitors ppis shown multiple randomized controlled trials rct effective medical therapy gerd several large meta analysis multiple rct showed ppis superior histamine 2 receptor blockers h2rb short term treatment esophagitis long term maintenance therapy prevent symptomatic relapse endoscopicaly proven esophagitis surgery considered patients progressive disease extraesophageal symptoms gerd related complications strictures barrett esophagus it also considered younger patients intolerant ppis post menopausal female patients risk fractures due ppi induced calcium malabsorption laparoscopic nissen fundoplication involves 360 degree wrap gastric fundus around esophagus gastro esophageal junction current surgical procedure choice severe refractory gerd studies shown 90 success symptom resolution improved quality life overall improvement general health 70 patients reoperation symptoms heartburn dysphagia bloating inability belch due disruption slippage fundoplication reported 7% patients laparoscopic nissen fundoplication the patient twenty nine years old male long standing gastro esophageal reflux disease gerd treated high dose proton pump inhibitors ppis 3 years little response the patient complained symptoms heartburn gradually progressing throat pain ear pain tinnitus symptoms would worsen laying supine large meal specific foods chocolate spicy foods alcohol the patient relief symptoms ppis initially symptoms recurred pre operative upper endoscopy showed hill grade gastro esophageal valve fig motility study showed 25% swallows produced peristaltic wave throughout esophagus mean distal amplitude 77mmhg the remaining swallows produced mixture low amplitude synchronous waves partially propagated non propagated waves the lower esophageal sphincter les measured 3 cm 1 cm diaphragm the les mean resting pressure 9 mmhg relaxed swallowing a twenty four hour ph study produced demeester score 20.25 normal range 14.5 pre operative egd showing hill grade gastro esophageal valve patient elected undergo transoral incision less fundaplication 4 cm gastro esophageal valve created endoscopic application 14 polypropylene transmural fasteners gastric fundus distal esophagus 1 3 cm z line the procedure also produced 270 degree endoluminal wrap fundus around intra abdominal esophagus there major intra operative complications minimal intra operative blood loss patient discharged home morning surgery two months procedure patient symptoms reflux significantly resolved he almost completely ppis could eat many foods gave reflux surgery without difficulty could sleep lying flat something unable three years a novel approach evolution surgical treatment gerd transoral incisionless fundoplication tif tif employs tissue plication device called esophyx endogastric solutions redmond wa usa endoscopically replicates 270 320 degree gastric fundoplication create 3 4 cm neo valve ge junction procedure done general anesthesia either oro tracheal naso tracheal intubation patient positioned either left lateral decubitus supine position operating table the operating team consists endoscopist provides continued retroflex visualization ge junction second operator usually surgeon performs actual tissue manipulation plication single transoral introduction instrument endoscope this creates 3 4 cm long sleeve tissue plicated 6 mm h shaped polypropylene fasteners 200 300 degree fashion full thickness serosa serosa plication 1 2 cm gastro esophageal junction begins deployment fasteners posterior anterior side visualized endoscope retroflexed view plication continues greater curvature 3 4 cm gastro esophageal junction tissue pulled ( fig 3 end procedure typically takes 45 75 minutes tif increases length intra abdominal esophagus reduces small hiatal hernias creates 3 4 cm ge valve recreates angle full thickness serosa serosa plication 1 2 cm 3 4 gastro esophageal junction the performance tif esophyx fda approved usa since september 2007 last 2 half years 2000 cases performed usa cadiere group able show adverse effects greater 50% improvement gerd hrql scores elimination heartburn 93% patients ppi use 71% patients esophagitis 55% patients 2 year follow ( 6 newer unpublished data two case series n nearly 70 patients two independent investigators united states demonstrate normalization esophageal ph 76 patients complete independence ppi approximately 90% patients 87% subjects satisfied 82% asymptomatic based hrql gsrs scores tif esophyx effective decreasing symptom severity daily ppi requirements improving quality life short term patients moderate severe gerd tif esophyx successfully increases les resting pressure decreases acid reflux supports esophageal healing chronic gerd long term studies needed establish whether durable traditional forms anti reflux surgery	an estimated 10 billion dollars is spent treating gastro - oesophageal reflux disease ( gerd ) in the usa every year . the present article reports a case of the safe and successful use of transoral incisionless fundoplication ( tif ) using the esophyx90 device in the surgical treatment of gerd .
common causes large bowel obstruction lbo colonic neoplasm volvulus hernia diverticular disease inammatory bowel disease adhesions secondary previous inammation operation commonly cause small bowel obstruction rare cause lbo a 58-year old man presented sudden onset right sided colicky abdominal pain associated nausea vomiting he three similar episodes pain previous 3 weeks two hospital admissions the last admission 4 days hospital 3 days discharged home opened bowel his past medical history pmh included gall stone pancreatitis 10 years ago laparoscopic cholecystectomy subsequently examination afebrile haemodynamically stable the abdomen showed fullness mild tenderness right iliac fossa rif haemoglobin 14.9 g dl white cell count wcc 9 10/l other remarkable laboratory tests included c reactive protein crp 15 mg l 1 revealed dilatation focal segment large bowel mildly dilated small bowel computed tomography ct scan abdomen reported gas filled viscus likely represent caecum fig 2 figure 1:plain axr case 1 revealed dilatation focal segment large bowel mildly dilated small bowel figure 2:ct abdomen case 1 demonstrating gas filled caecum plain axr case 1 revealed dilatation focal segment large bowel mildly dilated small bowel a presumptive diagnosis caecal volvulus made patient taken theatre laparotomy revealed omental band wrapping colon junction caecum ascending colon marked dilatation caecum appendicectomy performed gas caecum aspirated via appendicular stump prior ligation a 46-year old woman presented 5-day history absolute constipation abdominal distension discomfort episode vomiting there change bowel habit systemic symptoms she pmh right sided ovarian cyst detected ultrasound lower abdominal pain sometimes ago a ct scan abdomen revealed rectum sigmoid descending colon collapsed apparent calibre change within transverse colon mass lesion fig figure 3:ct abdomen case 2 showing calibre change within transverse colon mass lesion ct abdomen case 2 showing calibre change within transverse colon mass lesion gastrografin enema fig a presumptive diagnosis transverse colon obstruction made patient taken theatre figure 4:gastrografin enema case 2 demonstrating flow beyond mid transverse colon gastrografin enema case 2 demonstrating flow beyond mid transverse colon laparotomy revealed adhesive band extending gastrocolic omentum right fallopian tube causing closed loop obstruction right half transverse colon ascending colon terminal 5 cm ileum appendicectomy performed gas colon aspirated via appendicular stump prior ligation a 58-year old man presented sudden onset right sided colicky abdominal pain associated nausea vomiting he three similar episodes pain previous 3 weeks two hospital admissions the last admission 4 days hospital 3 days discharged home opened bowel his past medical history pmh included gall stone pancreatitis 10 years ago laparoscopic cholecystectomy subsequently examination afebrile haemodynamically stable the abdomen showed fullness mild tenderness right iliac fossa rif haemoglobin 14.9 g dl white cell count wcc 9 10/l other remarkable laboratory tests included c reactive protein crp 15 mg l 1 revealed dilatation focal segment large bowel mildly dilated small bowel computed tomography ct scan abdomen reported gas filled viscus likely represent caecum fig 2 figure 1:plain axr case 1 revealed dilatation focal segment large bowel mildly dilated small bowel figure 2:ct abdomen case 1 demonstrating gas filled caecum plain axr case 1 revealed dilatation focal segment large bowel mildly dilated small bowel a presumptive diagnosis caecal volvulus made patient taken theatre laparotomy revealed omental band wrapping colon junction caecum ascending colon marked dilatation caecum appendicectomy performed gas caecum aspirated via appendicular stump prior ligation a 46-year old woman presented 5-day history absolute constipation abdominal distension discomfort episode vomiting there change bowel habit systemic symptoms she pmh right sided ovarian cyst detected ultrasound lower abdominal pain sometimes ago a ct scan abdomen revealed rectum sigmoid descending colon collapsed apparent calibre change within transverse colon mass lesion fig figure 3:ct abdomen case 2 showing calibre change within transverse colon mass lesion ct abdomen case 2 showing calibre change within transverse colon mass lesion gastrografin enema fig a presumptive diagnosis transverse colon obstruction made patient taken theatre figure 4:gastrografin enema case 2 demonstrating flow beyond mid transverse colon gastrografin enema case 2 demonstrating flow beyond mid transverse colon laparotomy revealed adhesive band extending gastrocolic omentum right fallopian tube causing closed loop obstruction right half transverse colon ascending colon terminal 5 cm ileum appendicectomy performed gas colon aspirated via appendicular stump prior ligation other aetiologies include incarcerated hernias inflammatory bowel disease diverticular disease ischaemic stricture intussusception faecal impaction adhesions brous bands two adjacent anatomic structures common cause small bowel obstruction rare cause large bowel obstruction 16 the origin adhesions congenital 1 2 inammatory post traumatic iatrogenic following previous surgery 3 4 the aetiology bands causing colonic obstruction cases obscure may related previous intraperitoneal inflammatory process gall stone pancreatitis laparoscopic cholecystectomy case 1 interestingly case 2 previous abdominal surgery evidence intraperitoneal inflammatory process however unnoticed right sided salpingitis might triggered formation band absence either surgery abnormal fixation colon adhesive obstruction may secondary inflammation epiploic appendage patients the inflamed epiploic appendage become adherent abdominal wall another intra abdominal structure constricts colon directly forms band entrapping small bowel the sigmoid colon common site diseased epiploic appendage accounting 50% patients other unusual entities causing adhesive colon obstruction include remnants embryological structures vitello umbilical cord mesourachus a vitello umbilical cord connects tip meckel diverticulum abdominal wall umbilicus obstructing middle portion redundant transverse colon long sigmoid colon the mesourachus bound adhesions small bowel mesentery resulted severe obstruction sigmoid colon simulating volvulus anatomical histopathological studies bands distinguish embryonic remnants aberrant mesenteric bands 8 9 barium enema adhesions cause sharp localized circumferential narrowing large bowel occasionally area circular muscular contraction may suggest appearance there areas narrowness focal contraction colon inconstantly seen radiologically contraction rings colonic valves rarely persist entire barium enema compression adhesions clinical features findings combination radiology investigations important timely decision making surgery patients adhesive band causing colonic obstruction however still difficult make preoperative diagnosis adhesive colonic obstruction	large bowel obstruction ( lbo ) is most commonly due to malignancy , volvulus , hernia , diverticular disease and inflammatory bowel disease . lbo due to adhesions is unusual . a literature review was conducted which revealed that only a few such cases have been reported . we report two cases of lbo secondary to adhesions in patients , one with and one without a past abdominal surgical history . we highlight that while rare , the aetiology of lbo secondary to adhesions must be considered in the differential diagnosis in patients presenting with obstructive symptoms .
ability reach grasp transport release objects essential performing activities daily living adl)1 the adl require large glenohumeral elevation angles like combing hair reaching comparable abduction forward flexion motions2 this implies rotator cuff muscle weakness also affect degree restriction adl however rehabilitation immediately surgery patients may need learn compensatory movements adl2 therefore reach grasp movement plays important role rehabilitation patients shoulder disorders interest quantitative analysis upper arm movements rapidly increasing biomechanical research clinical applications owing complexity reach grasp movement grasping movement research still lags behind gait the gait phases clearly distinguished stride phase stance phase swing phase in addition phases divided sub phases well established gait analysis3 in contrast grasping movement highly complex depends many factors including position shape target orientation perturbation presence obstacles4 evaluate kinematics reaching activity morasso investigated arm trajectories based hand velocity profiles 19835 subsequently proposed two independent components grasping movement transport component grip component6 basis approach a variety reports suggested presence channel controlling hand aperture access information progress hand transport7 8 indicating importance regulation transport component demonstrated reach grasp movement divided characteristic phases simultaneously observing two aspects movement hand transport finger preshaping 3d video recordings they also suggested importance evaluation reaching movement hand transport quantitative methods viewpoint rehabilitation9 sabatini10 showed natural upper arm movement composed sequential phases reaching grasping retrieval horizontal plane using electromyography emg 3d motion analysis system reach grasp movement hand velocity regulated rigorously integrated complex multiple muscle activities since single muscle activity regulates angular velocity acceleration braking phasing approach reaching movement basis hand acceleration profiles may provide method elucidating role individual muscles reaching movement reach grasp task muscle activities upper extremity reaching movements examined several investigators sabatini demonstrated upper trapezius activity tonic holding limb force gravity anterior deltoid activity spread whole duration movement biceps brachii activity phasic drive movement onset object grasping triceps brachii activity essentially tonic10 prange compared surface emgs muscle activities healthy elderly people without gravity compensation demonstrated gravity compensation influences level muscle activity muscle activation pattern terms timing11 on basis findings suggested upper trapezius elevates arm start reaching retrieval appropriately positions scapula movements anterior deltoid maintains certain degree shoulder abduction anteflex shoulder reaching decelerate retroflexion retrieval biceps brachii lifts holds lower arm table aids anteflexion shoulder muscle activity triceps brachii contributes extension elbow towards target10 11 it important evaluate reaching quantitative methods rehabilitation order objectively assess describe coordination functional status impaired upper limb the analysis reach grasp phases could potentially help determine impairment affects upper limb movements plan rehabilitation process effectively examined control movement dominant non dominant hands reported non dominant arm motor output subject increased variability necessitated greater number corrective movements12 the present study focused reaching movement namely hand transport reach grasp task synchronizing muscle activities acceleration profile phasing reaching movement hand based acceleration profiles attempted order elucidate direct role individual muscle activities different acceleration profiles differences dominant arm non dominant arm muscle activation patterns reaching movement the ultimate goal present research establish method evaluation hand movements rehabilitation ten healthy volunteer subjects four males six females age 21.5 1.0 years height 162.1 8.4 cm weight 55.8 8.6 kg mean sd neurological muscular disorders participated study right hand dominant subjects excluded received surgery related upper limb structures the subjects fully informed protocol gave informed consent experimental procedure approved epidemiological research ethics committee gunma university faculty medicine the aim study evaluate emg acceleration upper limb simple reaching movement reach grasp task the task move arm initial position order grasp target front the target reaching movements performed sagittal plane corresponded cylindrical palmar prehension motion the measurements carried order dominant non dominant upper extremity initial position the measured forearm rested table shoulder stabilized anatomical reference position elbow 90 flexion beginning movement the target placed distance 30 cm front hand table the subjects informed trunk movement allowed could move arm order grasp target simulate reaching normal life the target 0.5 kg cylindrical bottle 6.5 cm diameter end movement the average values 10 trials used representative subject confirmation normal distribution data using shapiro wilk test the emg signals four muscles recorded upper trapezius anterior deltoid biceps brachii triceps brachii used evaluate arm motion14 the subjects prepared placement emg electrodes shaving skin electrode site cleaning carefully alcohol wipe pairs ag agcl pregelled surface electrodes dl-141 co. japan applied along muscle fibers bellies four muscles emg data acquisition described zipp15 the electrodes secured surgical tape cloth wrap minimize disruption movement a ground electrode placed wrist side opposite measured upper extremity acceleration recorded accelerometer attached measured wrist dorsal midpoint ulnar radial styloid processes the accelerometer secured surgical tape cloth wrap minimize disruption movement the x axis orientation long axis forearm verification signal quality completed muscle subject perform resisted contraction muscle test positions specific muscle interest16 normalization reference emg data collected maximal voluntary contraction mvc resisted contraction manual muscle testing positions data sampled two 3-second trials manually resisted maximal contractions muscle the highest value averaged 1 second used normalization reference emg raw data scope co. japan ) after band pass filtering 15500 hz sampling 1,000 hz root mean square rms values calculated the mvc values used normalize emg signal amplitude reach grasp movement the relative value calculated dividing average rms reach grasp movement rms mvc value the notation sampled 1,000 hz used refer acceleration the x axis acceleration analyzed starting point reach grasp movement second zero point the calculated percent mvc values four muscles compared reach grasp movement comparisons percent mvc values resting seated posture reach grasp movement phases performed using repeated measures analysis variance determine significance differences tukey test used post hoc test paired samples test was used test differences dominant non dominant upper extremities tests figure 1fig 1.patterns acceleration solid line estimated velocity dotted line muscle activation upper trapezius ut anterior deltoid ad biceps brachii bb triceps brachii tb muscles reach grasp movement representative object acceleration estimated velocity forward movement along long axis forearm depicted ia increasing acceleration phase da decreasing acceleration phase increasing deceleration phase dd decreasing deceleration phase shows representative case corresponding acceleration curves emg activities the acceleration curve essentially diphasic complex already noted9 present study simple biphasic profile reaching movement starting value 0 acceleration point 0 fig 1 returning negative value point e analyzed patterns acceleration solid line estimated velocity dotted line muscle activation upper trapezius ut anterior deltoid ad biceps brachii bb triceps brachii tb muscles reach grasp movement representative object acceleration estimated velocity forward movement along long axis forearm depicted ia increasing acceleration phase da decreasing acceleration phase increasing deceleration phase dd decreasing deceleration phase subjects focused accelerating hand order reach peak velocity point approximately one third duration movement evaluated after acceleration peak acceleration gradually reduced 0 point b hand reached peak velocity half duration movement then subjects rapidly decelerated hand declaration peak point c deceleration rapidly reduced 0 point e backward movement hand reached peak velocity four fifths duration movement reduction phase deceleration hand movement changed smoothly forward direction backward one point indicating turning point hand movement backward direction this finding acceleration still negative velocity value returned 0 observed subjects peak velocity backward direction point e increase and decrease acceleration occurred next peak velocity forward direction data shown then change acceleration deceleration followed change forward backward directions small time lag repeated several times reduction lag time values acceleration velocity point zero acceleration corresponded velocity transportation hand toward object completed data shown basis acceleration profile reaching movement reach grasp task could divided four phases increasing acceleration ia phase decreasing acceleration da phase increasing deceleration phase decreasing deceleration dd phase emg activities showed different levels muscle activity patterns among muscles examined since pattern muscle activity seemed associated acceleration profile shown fig interestingly active phases muscle varied among muscles examined table 1table 1.comparison muscle activities upper trapezius anterior deltoid biceps brachii triceps brachii muscles acceleration phaserestacceleration phasedeceleration phaseiadaidddut mvc)7.5 6.137.7 22.3 16.8 22.220.0 9.226.5 16.3ad mvc)4.3 3.230.7 10.3 33.0 13.3 37.5 20.8 42.4 29.6bb mvc)8.0 11.719.5 11.9 14.3 13.420.3 16.4 21.6 17.9tb mvc)14.3 8.215.5 7.717.2 7.619.4 11.922.6 13.6data presented mean sd ut upper trapezius ad anterior deltoid bb biceps brachii tb triceps brachii ia increasing acceleration da decreasing acceleration increasing deceleration dd decreasing deceleration sd standard deviation * significant p<0.01 difference rest movement phases respectively significant p<0.01 difference ia da significant p<0.01 difference ia significant p<0.01 difference ia dd significant p<0.01 difference da significant p<0.01 difference da dd significant p<0.05 difference dd significant increases upper trapezius activity observed phase ia phase dd compared resting position approximately 5- 3.5-fold respectively table 1 furthermore activity gradually augmented reached approximately 10 times resting position table 1 significant increases biceps brachii activity observed phases ia dd table 1 approximately 2.5-fold significant increase triceps brachii muscle activity there little difference muscle activities backward forward movements phase dd data shown ut upper trapezius ad anterior deltoid bb biceps brachii tb triceps brachii ia increasing acceleration da decreasing acceleration increasing deceleration dd decreasing deceleration sd standard deviation * significant p<0.01 difference rest movement phases respectively significant p<0.01 difference ia da significant p<0.01 difference ia significant p<0.01 difference ia dd significant p<0.01 difference da significant p<0.01 difference da dd significant p<0.05 difference dd percent mvcs dominant non dominant upper extremities compared phases muscles significantly active compared resting position table 2table 2.comparison percent mvc dominant non dominant upper extremities phases muscle significantly active compared resting position(%mvc)dominantnon dominantutphase ia37.7 22.349.7 33.1 phase dd26.5 16.333.3 17.3 adphase ia30.7 10.332.6 10.7phase da33.0 13.332.0 9.9phase id37.5 20.838.6 17.6phase dd42.4 29.643.0 25.8bbphase ia19.5 11.918.5 7.9phase id20.3 16.426.2 14.8 phase dd21.6 17.935.8 23.8 tbphase dd22.6 13.630.1 33.6data presented mean sd ut upper trapezius ad anterior deltoid bb biceps brachii tb triceps brachii ia increasing acceleration da decreasing acceleration increasing deceleration dd decreasing deceleration sd standard deviation * significant p<0.05 difference percent mvc dominant non dominant upper extremities these comparisons found significant differences dominant non dominant upper extremities phases ia dd upper trapezius activity phases dd biceps brachii activity the percent mvcs non dominant upper extremity phase muscles larger dominant extremity data presented mean sd ut upper trapezius ad anterior deltoid bb biceps brachii tb triceps brachii ia increasing acceleration da decreasing acceleration increasing deceleration dd decreasing deceleration sd standard deviation * significant p<0.05 difference percent mvc dominant non dominant upper extremities analysis showed kinematic trajectories acceleration simple biphasic profile reaching movement reach grasp task could divided four phases increasing acceleration ia phase decreasing acceleration da phase increasing deceleration phase decreasing deceleration dd phase muscles around shoulder showed different activity patterns closely associated acceleration phases interestingly significantly smaller muscle activities dominant extremity approximately two thirds non dominant one observed phases ia dd upper trapezius phases dd biceps brachii there studies evaluating emg activity patterns muscles around shoulder association kinematics reaching movement sabatini showed emg activities characterized phasic drives muscles around shoulder reaching movement although related phasic pattern among kinematic parameters elucidated10 phases divided basis velocity trajectory bell shaped5 might related phasic drives muscles activities the peak velocity profile reported divide reaching movement hand acceleration phase positive values tangential acceleration hand deceleration phase negative values acceleration)9 17 the present study showed hand acceleration phase composed phases ia da upper trapezius biceps brachii muscles the hand deceleration phase composed phase part phase dd similarly upper trapezius triceps brachii muscles emg activation observed phase dd these findings indicate muscle activities examined related acceleration profile velocity profile reaching movement reach grasp task these results suggest importance four phases derived acceleration trajectory elucidation muscular mechanisms regulate coordinate muscles around shoulder reaching movements it interesting unexpected hand movement changed smoothly forward backward direction phase dd reduction phase deceleration similar findings acceleration value still negative velocity value returned 0 reported supuk et al9 present study several repeated cycles acceleration deceleration short period followed period analyzed it possible precise regulatory mechanism palm approaches target careful precise examination needed elucidate possible factors contributing delicate kinematics operating late stage reach grasp task might correspond phase final closure fingers reported supuk et al9 hand little difference muscular activity backward forward movements phase dd confirming muscle activities examined related acceleration profile velocity profile muscle activity upper trapezius frequently present early acceleration phase since arm supported gravity component upper trapezius activity tonic results holding limb force gravity particularly last period reaching movement10 the muscle activity also shown characterized phasic drives occur movement onset time object grasped10 the upper trapezius active elevating arm start reaching appropriately positioning scapula movements11 the upper trapezius acts resist downward rotation torques believed occur via reverse action glenohumeral muscles including deltoid cuff muscles triceps brachii acting scapula19 together results suggest role upper trapezius activity may hold limb force gravity phase ia reverse action deltoid triceps brachii muscles fine control transportation hand toward object stabilizing scapula phase d muscle may also play reverse role deltoid muscle biceps brachii scapular stabilization phase ia the anterior deltoid activated gradually augmented whole duration movement the anterior deltoid shown active maintain certain degree shoulder abduction anteflex shoulder reaching movements11 the deltoid muscle activity reaches initial peak 110 degrees arm fully elevated head20 it conceivable anterior deltoid muscle may produce shoulder flexion force increasing shoulder moment suspend upper arm force gravity may result continuous increase muscle activity seen throughout reaching movement the biceps brachii active lifting holding lower arm table aids anteflexion shoulder11 elbow flexors electrical neuromuscular stimulation biceps thus biceps brachii may lift hold lower arm table early acceleration phase it interesting muscle activated phase da suggesting moment lifting forearm may due muscle activity inertia phase hand the muscle active deceleration phase phase braking movement velocity occurs the biceps brachii muscle activity may play role braking elbow extension resulting reduction speed reaching the muscle activity triceps brachii shown low sometimes nearly absent extension elbow towards target11 it noted precise muscle regulatory mechanism palm closely approaches target repeated forward backward movements may start phase dd therefore possible purpose triceps brachii activity may fine control transportation hand coordinated antagonistic biceps brachii close object phase dd the possible roles muscles examined may summarized phase follows upper trapezius elevates stabilizes shoulder girdle anterior deltoid produces moment shoulder flexion initiates forward movement upper arm biceps brachii lifts lower arm table phase ia phase da anterior deltoid keeps producing power shoulder flexion increasing shoulder moment suspend upper arm force gravity muscles inactive suggesting reduction acceleration phase biceps brachii acts braking mechanism resisting elbow extension finally phase dd biceps brachii acts brake anterior deltoid still active keep upper arm suspended force gravity response muscles activities triceps brachii activated achieve delicate fine control transportation hand toward object close resulting reduction deceleration response glenohumeral muscles activities upper trapezius activity induced stabilize scapula downward movement significantly smaller muscle activities upper trapezius biceps examined control movement dominant non dominant hands reported non dominant arm motor output subject increased variability necessitated greater number corrective movements12 recent research investigating dominant arm advantage finger 15-cm long movements table indicated dominant arm consistently uses torque efficient patterns movements made similar speeds accuracy non dominant arm movements since muscle torque impulses substantially lower shoulder dominant arm14 the authors proposed distinct neural control mechanisms employed dominant non dominant arm movements14 this suggests dominant arm may use torque efficient patterns shoulder elbow joints non dominant arm hand unclear muscle activities upper trapezius ia dd phases biceps brachii dd phases reduced association putative neural control mechanism the usual roles muscle activities may regulation arm reaching action counter glenohumeral activity braking action forward movement arm respectively bagesteiro sainburg demonstrated significant difference direction error deviation linearity dominant non dominant arm movements14 implying excessive motion non dominant arm movement activation regulatory muscles upper trapezius biceps brachii may elicited responding possibly inefficient direction error less efficient torque strategy non dominant arm to elucidate correlation velocity acceleration precisely direct measurement velocity acceleration necessary also present study focused four muscles around shoulder other muscles examined basis acceleration phases presented role muscle concert others elucidated	[ purpose ] an earlier study divided reaching activity into characteristic phases based on hand velocity profiles . by synchronizing muscle activities and the acceleration profile , a phasing approach for reaching movement , based on hand acceleration profiles , was attempted in order to elucidate the roles of individual muscle activities in the different phases of the acceleration profile in reaching movements . [ subjects and methods ] ten healthy volunteer subjects participated in this study . the aim was to electromyographically evaluate muscles around the shoulder , the upper trapezius , the anterior deltoid , the biceps brachii , and the triceps brachii , most of which have been used to evaluate arm motion , as well as the acceleration of the upper limb during simple reaching movement in the reach - to - grasp task . [ results ] analysis showed the kinematic trajectories of the acceleration during a simple biphasic profile of the reaching movement could be divided into four phases : increasing acceleration ( ia ) , decreasing acceleration ( da ) , increasing deceleration ( i d ) , and decreasing deceleration ( dd ) . muscles around the shoulder showed different activity patterns , which were closely associated with these acceleration phases . [ conclusion ] these results suggest the important role of the four phases , derived from the acceleration trajectory , in the elucidation of the muscular mechanisms which regulate and coordinate the muscles around the shoulder in reaching movements .
goeckerman regimen unique combination therapy ultraviolet b uvb light application crude coal tar cct treatment psoriasis 1 2 first introduced 1925 goeckerman regimen remains one oldest reliable treatment options patients moderate severe psoriasis the advantage using tar phototherapy together tar photosensitizer combined uvb light acts synergistically produce better results either treatment alone 35 comparison treatment modalities internal biologic agents oral systemic agents topical medications this makes goeckerman regimen excellent alternative patients may previously failed multiple therapies elderly pregnant patients children immunosuppressed goeckerman therapy originally administered inpatient hospital facility 24 h day multiple days psoriasis cleared however patients today often treated outpatient day care setting return home end treatment day similar results significantly reduced cost 6 7 currently goeckerman therapy university california san francisco ucsf psoriasis center requires minimum time commitment 45 h daycare facility 5 days week 6 weeks total 30 total treatment days the major limitation therapy time commitment required patients avoid interruption therapy delay complete treatment psoriasis lesions shorten remission time nevertheless almost goeckerman patients seen significant improvement skin condition duration therapy study performed university california san francisco ucsf ) psoriasis day care center 100% patients receiving goeckerman 12 week period achieved 75% greater improvement psoriasis lesions another advantage goeckerman long period remission following completion therapy last 8 months year 6 9 studies also shown goeckerman therapy significantly increase patient satisfaction improve overall quality life in addition ucsf developed modified goeckerman regimen treat skin diseases eczema prurigo nodularis pruritus 11 12 for first time patient referring provider details goeckerman procedure confusing challenging understand therefore following guide online media attempt deliver material way easily understandable readily accessible describe supplies goeckerman therapy evaluation preparation treatment procedure daily assessment discharge planning safety considerations we reviewed goeckerman therapy protocol used ucsf psoriasis skin treatment center in addition pubmed database searched using term psoriasis combined term goeckerman therapy tar therapy tar light therapy identify relevant articles design comprehensive guide patients receiving goeckerman treatment this article contain new studies human animal subjects performed authors the guide cover supplies needed goeckerman regimen treatment procedure monitor side effects daily assessment discharge planning cct commonly referred black tar compounded white petrolatum ointment cetaphil cream galderma laboratories l.p concentrations 2% 5% 10% liquor carbonis detergens lcd commonly referred gold tar compounded aquaphor ointment beiersdorf inc cetaphil cream vanicream lotion pharmaceutical specialties inc 20% concentration topical steroids include clobetasol propionate 0.05% ointment triamcinolone 0.01% ointment desonide 0.05% ointment moisturizing lotion used therapy consists aquaphilic ointment medco lab inc vanicream gown gloves socks shower cap used covering skin table 1).table 1supplies goeckerman regimencrude coal tar 2% 5% 10% gold taraquaphor ointmentcetaphil creamvanicream lotiontopical corticosteroidsclobetasol propionate 0.05% ointmenttriamcinolone 0.01% ointmentdesonide 0.05% ointmenttar removalmineral oilsoapmoisturizing lotionaquaphilic ointmentvanicreamocclusionplastic wrapmiscellaneousgownglovessocksshower cap supplies goeckerman regimen prior therapy complete history physical examination performed patient obtain important information current past medications response previous psoriasis therapies history adverse reactions sunlight phototherapy severity itch an initial assessment skin help determine degree severity psoriasis involvement whether patients display widespread intense erythema cases severe psoriasis it recommended patients undergo cool period topical corticosteroids applied affected areas occluded plastic wrap erythema greatly reduced 314 days 1 11 this uv light tar preparations potential worsen acutely inflamed psoriasis table 2).table 2evaluation preparationobtain history physicalassess degree severity skin involvementperform optional cool period evaluation preparation cool procedure needed nurse administer phototherapy morning day applying tar affected areas skin narrowband uvb commonly used although broadband uvb may used certain situations narrowband uvb ineffective tolerated patient 5 8 a nurse adjust subsequent phototherapy dosing according patient response tolerance phototherapy noting signs skin burning itching table 3).table 3treatment procedurepatient checks front desknurse administers uvb phototherapypatient asked undress tar applicationnurse applies cct body extremities lcd scalptar occluded plastic wrappatient dressed gown gloves socks shower captherapy continues 45 htar washed mineral oil soapnurse applies lcd body patient leaves home cct crude coal tar lcd liquor carbonis detergens uvb ultraviolet b cct crude coal tar lcd liquor carbonis detergens uvb ultraviolet b phototherapy cct applied affected areas body lcd scalp involvement tar typically started lowest concentration available increased gradually tolerated patient some patients may tolerate cct lcd aquaphor base due greasy texture alcohol content 11 13 for patients tar cetaphil cream water based moisturizer may substituted a formulation tar compounded salicylic acid often used areas greatly thickened plaques help reduce scaling however salicylic acid used caution patients diabetes gastric ulcers due potential adverse side effects occlusion topical tar performed plastic wrap body arms legs impermeable gloves hands socks feet shower cap scalp fig 1 topical tar typically left skin minimum 45 h day time patients may read listen music work laptop computer socialize goeckerman patients participate group activities meditation board games cooking fig 2 after 45 h period tar washed shower mineral oil soap after goeckerman therapy completed daycare center nurse apply lcd aquaphor ointment cetaphil cream less greasy option body patient leaves home.fig middle row 20% liquid carbonis detergens vanicream lotion 20% liquid carbonis detergens aquaphor ointment 5% crude coal tar white petrolatum ointment triamcinolone 0.01% ointment b patient spends 45 h waiting area tar therapy supplies goeckerman regimen left side gown socks shower cap middle row 20% liquid carbonis detergens vanicream lotion 20% liquid carbonis detergens aquaphor ointment 5% crude coal tar white petrolatum ointment triamcinolone 0.01% ointment bottom row desonide 0.05% ointment clobetasol propionate 0.05% ointment treatment procedure nurse occluding tar plastic wrap b patient spends 45 h waiting area tar therapy day patient assessed care team consisting doctor fellow nurse response goeckerman treatment signs skin burn redness skin skin tightness pain rarely blistering may indicate high dose intolerance light therapy if burning sensation develops phototherapy dose either decreased phototherapy treatment given day itch another common concern skin irritation may sign sensitivity tar plastic wrap case concentration tar may decreased wrap may applied patients also encouraged time update care team change medical conditions may occurred outside doctor visits may table 4).table 4daily assessmentteam doctor fellows nurses evaluate patient response treatmentcheck signs skin burn itchadjust phototherapy dosing tar concentration appropriate upon completion goeckerman course patients started maintenance program may include outpatient phototherapy three times week first month gradual taper topical medications applied home one month completion goeckerman patient scheduled follow visit doctor table 5).table 5discharge planninghome maintenance program outpatient phototherapy lcd topical steroidsreassess patient response therapy 1 month lcd liquor carbonis detergens lcd liquor carbonis detergens safety profile goeckerman therapy excellent relatively side effects however many studies including review 13,200 patients undergoing goeckerman regimen psoriasis eczema showed increased risk cancer tar therapy compared topical corticosteroids addition goeckerman therapy entirely topical limited internal absorption increase risk cardiovascular disease tuberculosis serious infections may associated oral injectable medications the commonly observed side effects include mild folliculitis skin condition characterized itchy red bumps develop around hair follicles mild skin burning uvb light for reason recommended patients avoid extended periods sun exposure tar applied home table 6).table 6safety considerationsside effectsigns symptomsskin burning redness tenderness pain tightness itching rarely blisteringnoticeable 46 h treatment uvb phototherapyfolliculitisitchy red bumps develop around hair folliclesitchingskin irritation tar occlusion uvb ultraviolet b patients avoid extended periods sun exposure tar applied home safety considerations patients avoid extended periods sun exposure tar applied home the guide cover supplies needed goeckerman regimen treatment procedure monitor side effects daily assessment discharge planning cct commonly referred black tar compounded white petrolatum ointment cetaphil cream galderma laboratories l.p concentrations 2% 5% 10% liquor carbonis detergens lcd commonly referred gold tar compounded aquaphor ointment beiersdorf inc cetaphil cream vanicream lotion pharmaceutical specialties inc 20% concentration topical steroids include clobetasol propionate 0.05% ointment triamcinolone 0.01% ointment desonide 0.05% ointment moisturizing lotion used therapy consists aquaphilic ointment medco lab inc vanicream gown gloves socks shower cap used covering skin table 1).table 1supplies goeckerman regimencrude coal tar 2% 5% 10% black tarwhite petrolatum ointmentcetaphil creamliquor carbonis detergens 20% ) gold taraquaphor ointmentcetaphil creamvanicream lotiontopical corticosteroidsclobetasol propionate 0.05% ointmenttriamcinolone 0.01% ointmentdesonide 0.05% ointmenttar removalmineral oilsoapmoisturizing lotionaquaphilic ointmentvanicreamocclusionplastic wrapmiscellaneousgownglovessocksshower cap supplies goeckerman regimen prior therapy complete history physical examination performed patient obtain important information current past medications response previous psoriasis therapies history adverse reactions sunlight phototherapy severity itch an initial assessment skin help determine degree severity psoriasis involvement whether patients display widespread intense erythema cases severe psoriasis it recommended patients undergo cool period topical corticosteroids applied affected areas occluded plastic wrap erythema greatly reduced 314 days 1 11 this uv light tar preparations potential worsen acutely inflamed psoriasis table 2).table 2evaluation preparationobtain history physicalassess degree severity skin involvementperform optional cool period evaluation preparation after cool procedure needed nurse administer phototherapy morning day applying tar affected areas skin narrowband uvb commonly used although broadband uvb may used certain situations narrowband uvb ineffective tolerated patient 5 8 a nurse adjust subsequent phototherapy dosing according patient response tolerance phototherapy noting signs skin burning itching table 3).table 3treatment procedurepatient checks front desknurse administers uvb phototherapypatient asked undress tar applicationnurse applies cct body extremities lcd scalptar occluded plastic wrappatient dressed gown gloves socks shower captherapy continues 45 htar washed mineral oil soapnurse applies lcd body patient leaves home cct crude coal tar lcd liquor carbonis detergens uvb ultraviolet b cct crude coal tar lcd liquor carbonis detergens uvb ultraviolet b phototherapy cct applied affected areas body lcd scalp involvement tar typically started lowest concentration available increased gradually tolerated patient some patients may tolerate cct lcd aquaphor base due greasy texture alcohol content 11 13 for patients tar cetaphil cream water based moisturizer may substituted a formulation tar compounded salicylic acid often used areas greatly thickened plaques help reduce scaling however salicylic acid used caution patients diabetes gastric ulcers due potential adverse side effects occlusion topical tar performed plastic wrap body arms legs impermeable gloves hands socks feet shower cap scalp fig 1 topical tar typically left skin minimum 45 h day time patients may read listen music work laptop computer socialize goeckerman patients participate group activities meditation board games cooking fig 2 after 45 h period tar washed shower mineral oil soap after goeckerman therapy completed daycare center nurse apply lcd aquaphor ointment cetaphil cream less greasy option body patient leaves home.fig middle row 20% liquid carbonis detergens vanicream lotion 20% liquid carbonis detergens aquaphor ointment 5% crude coal tar white petrolatum ointment triamcinolone 0.01% ointment b patient spends 45 h waiting area tar therapy supplies goeckerman regimen left side gown socks shower cap middle row 20% liquid carbonis detergens vanicream lotion 20% liquid carbonis detergens aquaphor ointment 5% crude coal tar white petrolatum ointment triamcinolone 0.01% ointment each day patient assessed care team consisting doctor fellow nurse response goeckerman treatment signs skin burn redness skin skin tightness pain rarely blistering may indicate high dose intolerance light therapy if burning sensation develops phototherapy dose either decreased phototherapy treatment given day itch another common concern skin irritation may sign sensitivity tar plastic wrap case concentration tar may decreased wrap may applied patients also encouraged time update care team change medical conditions may occurred outside doctor visits may table 4).table 4daily assessmentteam doctor fellows nurses evaluate patient response treatmentcheck signs skin burn itchadjust phototherapy dosing tar concentration appropriate upon completion goeckerman course patients started maintenance program may include outpatient phototherapy three times week first month gradual taper topical medications applied home one month completion goeckerman patient scheduled follow visit doctor table 5).table 5discharge planninghome maintenance program outpatient phototherapy lcd topical steroidsreassess patient response therapy 1 month lcd liquor carbonis detergens lcd liquor carbonis detergens however many studies including review 13,200 patients undergoing goeckerman regimen psoriasis eczema showed increased risk cancer tar therapy compared topical corticosteroids addition goeckerman therapy entirely topical limited internal absorption increase risk cardiovascular disease tuberculosis serious infections may associated oral injectable medications commonly observed side effects include mild folliculitis skin condition characterized itchy red bumps develop around hair follicles mild skin burning uvb light for reason recommended patients avoid extended periods sun exposure tar applied home table 6).table 6safety considerationsside effectsigns symptomsskin burning redness tenderness pain tightness itching rarely blisteringnoticeable 46 h treatment uvb phototherapyfolliculitisitchy red bumps develop around hair folliclesitchingskin irritation tar occlusion uvb ultraviolet b patients avoid extended periods sun exposure tar applied home safety considerations patients avoid extended periods sun exposure tar applied home goeckerman therapy safe effective treatment moderate severe psoriasis excellent treatment option patients encouraged fully participate program showing daily missing therapy sessions communicating symptoms concerns care staff consistent adherence therapy the vast majority patients achieve total body clearing even toughest areas scalp palms soles this guide corresponding online video serves orient educate prospective patients planning start goeckerman treatment healthcare providers trainees want learn procedure john koo speaker abbvie leo celgene conducts research amgen janssen novartis photomedex galderma pfizer merck tina bhutani advisor cutanea conducts research abbvie janssen merck wilson liao conducts research abbvie janssen novartis pfizer receives funding nih r01ar065174 u01ai119125 john koo tina bhutani wilson liao stocks employment board memberships pharmaceutical company tian hao zhu mio nakamura benjamin farahnik michael abrouk rasnik k. singh kristina m. lee sarah hulse nothing disclose this article involve new studies human animal subjects performed authors this article distributed terms creative commons attribution noncommercial 4.0 international license http://creativecommons.org/licenses/by-nc/4.0/ permits noncommercial use distribution reproduction medium provided give appropriate credit original author(s source provide link creative commons license indicate changes made	backgroundthe goeckerman regimen remains one of the oldest , most reliable treatment options for patients with moderate to severe psoriasis . goeckerman therapy currently consists of exposure to ultraviolet b light and application of crude coal tar . the details of the procedure can be confusing and challenging to understand for the first - time patient or provider.objectiveto present a freely available online guide and video on goeckerman treatment that explains the regimen in a patient - oriented manner.methodsthe goeckerman protocol used at the university of california san francisco psoriasis and skin treatment center as well as available information from the literature were reviewed to design a comprehensive guide for patients receiving goeckerman treatment.resultswe created a printable guide and video resource that covers the supplies needed for goeckerman regimen , the treatment procedure , expected results , how to monitor for adverse events , and discharge planning.conclusionthis new resource is beneficial for prospective patients planning to undergo goeckerman treatment , healthcare providers , and trainees who want to learn more about this procedure . online media and video delivers material in a way that is flexible and often familiar to patients .
quorum sensing qs key regulator virulence factors biofilm formation gram negative bacteria pseudomonas aeruginosa this qs system comprises signal molecule synthetase make signal regulator regulate gene expression several signaling molecules identified however main molecules produced gram negative bacteria acylhomoserine lactones ahls it reported bacterial biofilms associated chronic infections cystic fibrosis cf tonsillitis the discovery qs system critical role bacterial virulence revealed new targets attenuate pathogenicity there number ways interrupt qs system one use microbial natural products represent important step towards discovery novel therapeutic chemicals 5 6 despite fact soil arguably useful valuable habitat earth still considered one least understood ecosystems needs explored soil major source bacteria synthesize wide range compounds versatile biological effects 8 9 160 species paenibacillus approved validated according bacterial nomenclature list dsmz therefore interest paenibacillus spp source new antimicrobial agents increasing advances medical practice led proper management acute bacterial infections however efficiency many antibiotics currently decreasing due occurrence multidrug resistant bacteria pathogenic strains p. aeruginosa possess ability form biofilms contribute reduced susceptibility towards antibiotics ability cause chronic infections since virulence factors biofilm formation gram negative bacteria control quorum sensing system thus discovery anti qs compounds great interest treatment biofilm associated chronic infections moreover use animal models essential gain better understanding mechanisms involved biofilm formation this approach usually accomplished infecting vertebrate animal organism choice followed evaluation animal immune responses study culture extract taxonomically novel species paenibacillus isolated agricultural soil malaysia tested qs inhibitory effects vitro lasa protease lasb elastase pyoverdin production biofilm formation p. aeruginosa evaluated antibiofilm therapeutic effects vivo lung bacteriology lung pathology hematological profile serum antibody responses vivo using rat model chronic biofilm associated lung infection the strain 139si genbank accession number jf825470.1 three strains paenibacillus isolates previously isolated agricultural soil malaysia chosen type strain selected novel species these strains identified members genus paenibacillus basis phenotypic characteristics phylogenetic analysis 16s rrna g+c content the taxonomically novel species paenibacillus strain 139si deposited american type culture collection atcc cataloguing number atcc baa-2268 the strain used prepare culture extract examine anti qs inhibitory effects vitro vivo upon approval medical ethics committee university malaya medical centre ummc ppum upp/300/02/02 ref number 744.11 clinical isolate pseudomonas aeruginosa collected palatine tonsils patient undergoing elective tonsillectomy ummc the isolate identified via colony morphology culturing selective media biochemical tests followed assessment antibiotic susceptibility via disk diffusion isolate shown multidrug resistant the isolate used test strain preparation test supernatant lasa protease lasb elastolytic pyoverdin biofilm formation assays vitro well challenge strain rat model chronic lung infection vivo reference strain lasa assay included staphylococcus aureus atcc 25923 whereas reference strains biofilm formation assay included pseudomonas aeruginosa atcc 27853 escherichia coli atcc 25922 for lasa protease lasb elastolytic pyoverdin biofilm formation assays well rat model chronic lung infection commercially available anti qs compound 2(5h)-furanone 98% sigma aldrich used positive control furanones act mimicking ahl signal produced gram negative bacteria presumably occupying binding site putative regulatory protein rendering highly unstable accelerating turnover rate thus resulting rapid disruption quorum sensing mediated gene regulation rat model chronic lung infection commercially available sodium alginate powder sigma aldrich alginic acid sodium salt derived brown algae used main component biofilm alginate produced similarly live mucoid strains p. aeruginosa embed challenge bacterial strain closely resemble lung infection caused biofilms previous study culture extract paenibacillus sp strain 139si tested oral acute toxicity reported nontoxic study extract tested qs inhibitory effect vitro therapeutic effects vivo a single colony novel paenibacillus sp strain 139si transferred sterile brain heart infusion bhi broth bd difco incubated 72 hours 37c allow maximum secretion bioactive secondary metabolites culture media the culture transferred aseptically 50 ml conical bottom centrifuge tube jet bio fil centrifuged 8000 rpm 20 min 4c separate cell supernatant the obtained cell free supernatant subjected sterile filtration remove unwanted particles using syringe filter pore size 0.22 minisart sartorius the sterile supernatant underwent freeze drying lyophilisation dissolved ultra pure water the prepared stock stored 80c used vitro vivo experiments lasa protease lasb elastolytic pyoverdin assays stationary phase overnight culture pseudomonas aeruginosa clinical isolate grown lb medium 37c shaking culture diluted 100-fold lb medium allowed grow optical density 600 nm od600 point culture divided 10 ml aliquots additional volumes 1 ml 4.5 ml paenibacillus sp culture extract added final concentrations 1 mg ml 4.5 mg ml lasa staphylolyticprotease activity measured determining ability p. aeruginosa test supernatant lyse boiled cells staphylococcus aureus a 30 ml volume overnight s. aureus culture boiled 10 min centrifuged 10 min 10,000 g 13,000 rpm the resulting pellet resuspended 10 mm na2po4 ph 4.5 od600 0.5 mcfarland standards optical density mixture od600 determined 5 10 20 30 45 60 min activity expressed change od600 per hour per g protein 1 2 the elastolytic activity p. aeruginosa test supernatant determined using elastin congo red ecr sigma aldrich described previously briefly 100 l aliquot test culture added 900 l ecr buffer 100 mm tris 1 mm cacl2 ph 7.5 insoluble ecr removed centrifugation absorption p. aeruginosa test supernatant measured wavelength 495 nm activity expressed change od495 nm per g protein 1 2 pyoverdin assay adapted methods cox adams briefly prepared p. aeruginosa test supernatant diluted 10-fold tris hcl buffer ph 7.4 100 l aliquots added 96-well microtiter plates ice pyoverdin concentration based fluorescence test supernatant excitation wavelength 405 nm emission wavelength 465 nm using microtiter absorbance reader imark bio rad although pyoverdin considered marker quorum sensing drop production may due indirect effect via ph iron concentration changes eliminate chance false positive results strain 139si culture extract attachment phase biofilm formation measured using microtiter plate mtp assay described previously 27 28 briefly 180 l aliquot sterile lb broth 150 l aliquot overnight culture p. aeruginosa isolate transferred 96-well microtiter plates culture extract final concentrations 1 mg ml 4.5 mg ml incubated 24 hours 37c wells washed three times phosphate buffered saline remove weakly adherent cells allowed air dry prior staining the adherent biofilms stained 200 l aliquot 0.4% crystal violet solution w v 10 min this followed adding standard solution 95% ethanol extract solubilize crystal violet stained biofilms optical density biofilms measured wavelength 570 nm od570 using microtiter absorbance reader imark bio rad compensate possible differences growth rates different incubation conditions the adherence index adjusted estimate density biofilm would generated culture od600 0.5 mcfarland standards experiment performed triplicate data averaged standard deviation calculated calculation adherence index done according following formula adherence index mean density biofilm od570 0.5/mean growth od600 the guidelines care use laboratory animals followed according national academy sciences experimental protocol approved animal ethics committee faculty medicine university malaya pm/27/07/2010/maa r a total 48 adult sprague dawley sd rats including 24 males 24 females obtained animal care unit center acuc rats weighing 150200 gm kept wire bottomed cages 25c temperature 12-hour light dark cycle furthermore general observations recorded basis behavioral changes food intake salivation muscular weakness reflexes locomotion rats sacrificed anesthesia intramuscular combination ketamine xylazine 1 ml 100 mg ml xylazine 9 ml 100 mg ml ketamine given dose 0.1 ml/100 gm body weight day 7 infection randomly selected rats group sacrificed initial macroscopic microscopic evaluation acute inflammation carried a longer observation period chosen allow lung abscess formation second examination carried day 15 surviving rats evaluate general observations macroscopic microscopic lung pathology briefly p. aeruginosa strain cultured 80 ml bhi broth 24 hours 37c shaking 170 rpm cells centrifuged 30 min 10,000 g 20,000 rpm 4c resuspended 2 ml fresh bhi broth colony forming unit cfu counted mimic biofilm environment p. aeruginosa strain immobilized solution sodium alginate described previously 34 35 alginate powder dissolved normal saline concentration 10 mg ml autoclaved a volume 1 ml inoculation mixed 9 ml sterile alginate rats randomly divided eight groups males groups 14 females groups 58 following negative control groups 1 5 normal saline 5 ml kg orally daily sterile distilled water 1 ml kg orally daily 14 days positive control groups 2 6 challenge bacterial inoculation 1 10 cfu rat 5 ml kg intratracheally twice day 1 2 sterile distilled water 1 ml kg orally daily 14 days comparative control groups 3 7 challenge bacterial inoculation 1 10 cfu rat 5 ml kg intratracheally twice day 1 2 2(5h)-furanone 25 gm kg orally daily 14 days extract treatment groups 4 8) challenge bacterial inoculation 1 10 cfu rat 5 ml kg intratracheally twice day 1 2 paenibacillus sp extract concentration 4.5 mg ml 25 gm kg orally daily 14 days negative control groups 1 5 normal saline 5 ml kg orally daily sterile distilled water 1 ml kg orally daily 14 days positive control groups 2 6 challenge bacterial inoculation 1 10 cfu rat 5 ml kg intratracheally twice day 1 2 sterile distilled water 1 ml kg orally daily 14 days comparative control groups 3 7 challenge bacterial inoculation 1 10 cfu rat 5 ml kg intratracheally twice day 1 2 2(5h)-furanone 25 gm kg orally daily 14 days extract treatment groups 4 8) challenge bacterial inoculation 1 10 cfu rat 5 ml kg intratracheally twice day 1 2 paenibacillus sp extract concentration 4.5 mg ml 25 gm kg orally daily 14 days upon sacrifice thoracic cavity rats opened excision peritoneum lung specimens harvested cut two parts unfixed lungs prepared quantitative bacteriological evaluation described previously 14 37 briefly lungs stored 2 hours 4c mixed 5 ml cold sterile phosphate buffered saline 4c diluted homogenized samples plated nutrient agar plates determine bacterial colony forming unit cfu per lung incubation 24 hours 37c the qualitative analysis macroscopic lung pathology including abscess consolidation atelectasis hemorrhage expressed lung index macroscopic pathology limp calculated dividing area left lung showing pathologic changes total area lung moreover gross pathological changes lungs assigned four different scores according severity inflammation described previously 34 39 normal lungs ii swollen lungs hyperemia small atelectasis 10 mm iii pleural adhesions atelectasis 40 mm iv abscesses large atelectasis hemorrhages lung specimens fixed 10% neutral buffered formalin nbf 24 hours processed described previously lungs embedded paraffin wax using embedding center leica eg1160 leica biosystems germany fixed onto glass slides using water bath leica hi1210 leica biosystems tissue sections stained hematoxylin eosin h&e stain mounted diphenyl xylene dpx visualized using upright light microscope eclipse lv150l nikon instruments inc lung pathology assigned microscopically one four scores according severity inflammation follows 1 normal histology 2 mild focal inflammation 3 moderate severe focal inflammation areas normal tissue 4 severe inflammation necrosis lung cellular alterations classified acute chronic inflammation 38 39 slides stained standard light microscopy using h&e periodic acid schiff pas stains according manufacturers instructions preserve biofilm architecture specimens were examined using confocal laser scanning microscope clsm coupled double fluorescent staining described previously tissue sections embedded optimal cutting temperature oct media followed snap freezing mixture cold isopentane liquid nitrogen form solid blocks cut thickness 5 using cryostat leica cm1850 leica microsystems each section fixed 70% cold acetone 10 min followed double staining 500 l propidium iodide pi 5 min detect bacterial cells red followed staining 500 l concanavalin con fluorescent isothiocyanate fitc 5 min detect glycocalyx matrix green sections washed solution phosphate buffered saline pbs demineralized water embedded mounting medium pbs glycerol containing antiquenching agent p phenylenediamine carl zeiss germany available universiti putra malaysia upm malaysia the microscope equipped krypton argon laser visualization con fitc number signals acquired 488 nm emission 552 df 32 nm propidium iodide number signals acquired 568 nm emission 605 df 32 nm digital images optical sections collected using zen 2010 software converted high quality jpeg files using available software upon sacrifice blood drawn jugular vein anesthesia collected blood specimens immediately transported clinical diagnostic laboratories university malaya medical centre ummc whole blood collected using violet caped vacuette edta tubes differential blood count test including neutrophils lymphocytes monocytes eosinophils basophils serum collected using red caped vacuette serum tubes immunoglobulins level concentrations p. aeruginosa standard antigen st ag assessed elisa including serum antibody levels igg iga igm ige elisa units obtained dividing mean absorbance samples mean absorbance internal standard expressing 0 30 0 40 absorbance units statistical analysis carried using statistical product service solutions software ibm spss statistics 21 categorical data compared test unpaired differences continuous data compared mann whitney u test analysis variance anova test all values reported standard error mean s.e.m probability value p 0.05 considered statistically significant the lasa staphylolytic protease zinc metalloendopeptidase belonging -lytic endopeptidase family proteases there significant decrease lasa activity compared control pseudomonas aeruginosa test supernatant grown presence paenibacillus sp culture extract concentrations 1 mg ml 4.5 mg ml lb medium negative control showed significant change lasa activity the lasb elastase zinc metalloprotease capable destroying inactivating wide range biological tissues immunological agents there significant decrease od readings due inhibitory effect paenibacillus sp culture extract concentration 4.5 mg ml caused decrease activities lasa protease lasb elastase compared concentration 1 mg ml pyoverdins virulence factors compete mammalian transferrin iron promote pathogenicity stimulating bacterial growth one pyoverdins suggested qs like molecule regulating production toxins there significant decrease od readings due inhibitory effect paenibacillus sp culture extract concentration 4.5 mg ml exhibited decreased production qs controlled pyoverdin compared concentration 1 mg ml tested cultures retained ph 7.0 regardless amount type extract added biofilm formation p. aeruginosa leads increased resistance creates severe infection lungs patients cystic fibrosis there significant decrease od readings due inhibitory effect paenibacillus sp culture extract concentration 4.5 mg ml caused decrease qs controlled biofilm formation compared concentration 1 mg ml culture extract significantly prolonged survival times experimental rats treatment comparative control groups comparative control group share mortalities 3 25% rats days 6 7 all rats positive control group died completing course experiment died severe infection day 3 inoculation whereas others died days 5 10 the greatest decrease weight following administration challenge p. aeruginosa strain seen among positive control group followed comparative extract treatment groups all rats except negative control group infected sublethal dose challenge p. aeruginosa inoculation 1 10 cfu rat 5 ml kg intratracheally thrice days 1 2 3 immediately inoculation gm kg orally daily 14 days whereas rats treatment group received paenibacillus sp extract 25 gm kg orally daily 14 days day 7 infection randomly selected rats group sacrificed lung bacterial count evaluated the value lung bacterial cfu comparative control extract treatment groups dropped significantly day 7 compared positive control group extract well control compound 2(5h)-furanone started inhibitory effect within 7 days administration results suggested infecting p. aeruginosa biofilms cleared away quickly groups receiving treatments anti qs compounds day 15 infection rats sacrificed median lung bacterial cfu extract treatment group found one fifth negative control group difference significant p 0.05 indicating paenibacillus sp extract could influence colonization persistence p. aeruginosa within infected lungs the value lung bacterial cfu positive control group significantly higher values lung bacterial cfu rest groups p 0.05 due colonization p. aeruginosa lung without qs system interrupted however values lung bacterial cfu among comparative control group extract treatment group differ statistically insignificant agreement results lung bacteriology milder macroscopic gross lung pathology observed comparative control group extract treatment group day 7 infection macroscopic lung pathology positive control group showed large haemorrhage abscess 40 mm a total 2 rats died days 3 5 infection due severity infection however the macroscopic lung pathology comparative control group showed swollen lungs hyperemia small atelectasis moderate haemorrhage 10 mm40 mm whereas extract treatment group lungs also swollen hyperemia atelectasis small haemorrhage 10 mm results indicated paenibacillus sp culture extract significantly restricted gross pathologic changes lung smaller area acute phase infection day 15 infection lung abscesses haemorrhage became predominant among positive control group significantly higher frequency lung abscesses noted positive control group p 0.05 comparative extract treatment groups 80% rats showed lung atelectasis 20% rats showed lung abscesses the number rats chronic inflammation comparative control group 6 12.5% extract treatment group 6 12.5% significantly lower positive control group 12 25% intensity lung infections gross pathology day 15 infection day 7 groups except negative control lung infection results lung index macroscopic pathology shown figure 1 day 7 infection positive control group showed acute lung inflammation multiple lung abscesses haemorrhage consolidation whereas rats died days 3 5 chronic inflammation seen 12 rats positive control group however comparative control extract treatment groups showed chronic inflammation 6 12 rats whereas inflammation seen negative control group there differences inflammatory classification comparative control treatment groups day 15 infection size lung abscesses comparative group reduced compared extract treatment group severity chronic inflammation general decreased half two groups pathology scoring showed normal lung tissue rats 12 25% negative control group score figure 2(a whereas 10 20.83% rats positive control group showed severe inflammation necrosis score iv figure 2(b both comparative group 5 10.4% extract treatment group 6 12.5% showed signs recovery score ii figure 2(c whereas 4 8.33% comparative group 5 10.4% extract treatment group showed moderate severe focal inflammation score iii figure 2(d differences inflammatory classification insignificant comparative control group 2 4.16% extract treatment group 1 2.08% score iv figure 2(b moreover extract treatment group showed much milder chronic inflammation compared comparative control areas pathologic changes smaller the incidence acute inflammation lower extract treatment group however differences statistically insignificant results microscopic lung pathology among experimental rats shown table 2 figure 2 day 7 infection sacrificed rats positive control group showed dense biofilm layers occupying lung alveolar spaces along severe haemorrhage whereas rats died days 3 5 inoculation p. aeruginosa moreover day 15 infection surviving rats among positive group sacrificed lungs showed chronic inflammation heavily dense biofilm layers blocking occupying 80% lung alveoli in contrast rats comparative group administered commercial anti qs compound 2(5h)-furanone extract treatment groups treated paenibacillus sp culture extract showed milder inflammation disrupted biofilm layers occupying 30% lung alveoli there significant difference biofilm density within lung tissue rats treated 2(5h)-furanone treated culture extract the challenge p. aeruginosa immobilized seaweed alginate caused mechanical blocking damage alveoli visualized light microscope microcolonies embedded alginate using h&e stain figures 3(a 3(b pas stain figures 3(c 3(d moreover p. aeruginosa visualized clsm interconnected bacteria red encased scaffolding network composed extracellular matrix green using double florescent staining figure 4 under clsm microscopic examination revealed biofilms normal histology among rats negative control group figure 4(a whereas positive control group showed intense biofilms filling alveolar spaces severe inflammation figure 4(b comparative control extract treatment groups showed disrupted biofilms mild inflammation figures 4(c 4(d indicating inhibitory effect paenibacillus sp the intensity biofilms occupying lung tissue day 15 infection day 7 comparative control extract treatment groups among males females however differences statistically insignificant in agreement macroscopic microscopic lung pathology results differential blood count table 3 serum antibodies table 4 among negative control group showed normal levels significant differences p 0.05 due uncompromised immune status in contrast positive control group showed significant increase neutrophils lymphocytes monocytes counts well increase igm igg iga levels indicating immune response towards infection day 7 infection comparative control and extract treatment groups showed marked decrease neutrophils lymphocytes monocytes well igm igg iga levels compared positive control group culture extract infecting p. aeruginosa biofilms within lung alveoli day 15 infection positive control group showed marked increase differential blood count immunoglobulins levels particularly igm igg compared comparative control extract treatment group igm igg iga levels lower p 0.05 eosinophils basophils count ige levels groups within reference normal range differences differential blood account serum antibody responses male female rats statistically insignificant p 0.05 among promising approaches combat biofilm infections use metabolites synthesized different bacterial species a large number natural synthetic compounds described exhibiting quorum sensing qs inhibitory effects gram negative pathogens pseudomonas aeruginosa lactonase acylase actinobacteria proteobacteria coral associated bacterial extracts bacillus sp these compounds function either competing activity ahl molecules due structural similarity accelerating degradation luxr lasr receptors ahl the virulence p. aeruginosa mainly due capacity degrade host tissue proteases form biofilms culture extract derived taxonomically novel species paenibacillus strain 139si tested ability inhibit qs controlled virulence factors biofilm formation multidrug resistant isolate p. aeruginosa vitro well therapeutic effects vivo using rat model chronic biofilm associated lung infection since qs involved virulence factor production biofilm formation p. aeruginosa expected paenibacillus sp culture extract significant effects qs controlled virulence factors indeed extract exhibited inhibitory effect ability p. aeruginosa produce virulence factors biofilm formation this similar findings made adonizio et al detected anti qs activities six south florida medicinal plants examined p. aeruginosa pao1 disruption qs system compounds halogenated furanones australian macroalgae delisea pulchra also shown inhibit biofilm growth therefore study compound 2(5h)-furanone 98% used anti qs control vitro vivo experiments showing qualitative change biofilm morphology reduction thickness this similar findings made hentzer et al used furanones d. pulchra showing significant inhibition biofilm formation there significant decrease lasa activity compared control p. aeruginosa grown presence paenibacillus sp extract concentration 4.5 mg ml 75% decrease compared concentration 1 mg ml 45% decrease table 1 where suggested compounds vescalagin castalagin responsible reduction lasa activity there significant reduction lasb elastase activity p. aeruginosa grown presence culture extract concentration 4.5 mg ml 70% decrease indicating compounds tested extract may downregulated production lasb and/or inhibited activity this similar findings made rasmussen et al reported 50% decrease lasb activity using 2% garlic moreover control anti qs compound 2(5h)-furanone showed significant decrease 80% lasb activity similar findings made hentzer et al reported 90% decrease using purified halogenated furanone red alga delisea pulchra there significant reduction pyoverdin production p. aeruginosa 65% reduction pyoverdin levels paenibacillus sp this similar findings made hentzer et al used synthetic derivate natural furanones 90% reduction pyoverdin levels there significant changes cell growth corresponding pyoverdin production leaving anti qs effect likely hypothesis however studies needed assess effect paenibacillus sp culture extract direct enzyme inhibition p. aeruginosa comparison quorum sensing signaling inhibition biofilm formation without influencing bacterial growth characteristic antivirulence therapies promising alternatives combat bacterial infections study use paenibacillus sp culture extract concentration 4.5 mg ml resulted significant inhibition biofilm formationin p. aeruginosa however influence extract bacterial growth insignificant this study demonstrates paenibacillus sp culture extract inhibits qs controlled biofilm formation p. aeruginosa hydrophobic surfaces polystyrene indicated adherence index this similar previous findings suggesting coated clinical materials antimicrobial anti qs substances lead successful prevention microbial colonization 61 62 culture extract may used tool prevent microbial biofilm formation hydrophobic hydrophilic medicinal devices it reported qs gene expression p. aeruginosa interconnected regulatory systems responds various environmental signals the virulence factors lasa protease lasb elastase control lasi lasr system however rhli rhlr system also controls activity lesser extent pyoverdin believed control rhli rhlr whereas biofilm formation partially control qs system due redundancy qs system p. aeruginosa complex chemistry metabolites produced paenibacillus sp culture extract difficult link ahl level qs gene expression virulence factor production however overall inhibition qs system p. aeruginosa suggesting multiple chemicals culture extract may distinct qs inhibitory effects effect directly las rhl system rather universal qs regulator where reported inhibitory effects compound maybe due global qs regulator vfr gaca more studies needed identify regulated qs genes specificity n acyl homoserine lactone signals environmental effects gene expression culture extract control 2(5h)-furanone exhibited lower bacterial numbers lungs indicating ability challenge p. aeruginosa colonize lung may reduced due inhibition qs signals bacterial clearance hosts improved anti qs effects paenibacillus sp consequently inhibition qs attenuates virulence p. aeruginosa impairs colonization ability these results indicates paenibacillus sp culture extract appears promising novel antivirulent agent possess quorum sensing inhibition leading increased clearance bacteria infected lungs decreased lung pathology this similar recent proposal reporting qs target treatment gram negative bacterial infections culture extract bacterial clearance correlated negatively concentrations confirmed action furanones dosage dependent this similar findings made wu et al reported synthetic furanones inhibit dosage dependent manner qs pseudomonas aeruginosa lung infection mice results showed macroscopic lung pathology among extract treatment group milder comparison positive control group culture extract p. aeruginosa infected rats might induce enhanced oxidative burst response aid clearing bacterial infection effectively thus prolong survival time rats milder macroscopic lung pathology where reported administration ginseng extract leads activation polymorphonuclear leukocyte pmn reduced bacterial load rat model chronic p. aeruginosa pneumonia may activated endotoxin primed neutrophils resulted reduced macroscopic microscopic lung pathology this similar previous study reported furanones successfully interfered n acyl homoserine lactone suppressed bacterial qs resulted accelerated clearance p. aeruginosa lungs it reported inhibition biofilm alginate barrier using metabolites derived culture extract paenibacillus sp may useful disruption p. aeruginosa biofilms infected lungs cystic fibrosis patients study noticed areas chronic inflammatory changes paenibacillus sp where evaluated effect ginseng treatment oxidative burst response peripheral blood neutrophils alveolar macrophages rat model chronic mucoid p. aeruginosa lung infection fact majority rats classified score ii belong comparative control group 5 10.4% treatment group 6 12.5% whereas majority score iv belong positive control group 10 20.83% indicates anti qs effects paenibacillus sp we established rat model chronic lung infection based p. aeruginosa isolate use artificial embedding agents our animal experiment accurate developing pulmonary infection since number bacteria cultured lungs remained high throughout infection period furthermore histopathological features rats similar chronic p. aeruginosa lung infections humans where used mucoid clinical isolate p. aeruginosa nh57388a hyperproduction alginate mouse model chronic lung infection use alginate embed p. aeruginosa adds selective survival advantage challenge bacterial strain this similar previous study reported improved persistence mice lungs mucoid p. aeruginosa strains relative nonmucoid strains this discrepancy may reflect differences virulence p. aeruginosa strains and/or genetic background animals p. aeruginosa isolate embedded alginate able establish persistent lung infection rats groups however severity infection lower rats extract treatment comparative control groups culture extract biofilm formation p. aeruginosa since genetic background rats nature biofilm influence sensitivity p. aeruginosa able conclude differences due effect paenibacillus sp the higher mortality seen rat groups challenged p. aeruginosa untreated paenibacillus sp culture extract compared treated ones may due ability untreated isolates produce higher amounts elastase qs regulated virulence factors this similar study hoffmann et al reported higher mortalities mice challenged nonmucoid nh57388c isolate compared isogenic mucoid nh57388a isolate qs alginate p. aeruginosa linear polymer mannuronate l guluronate highly soluble water chemically similar seaweed alginate embedding p. aeruginosa alginate solution enables challenge strain produce elastic biofilm structure previously reported culture extract caused weakness biofilm architecture facilitated clearance bacteria visualized light microscope confocal laser scanning microscope histological examination lung sections showed alveolar sacs invaded p. aeruginosa biofilm anchored protective alginate matrix surrounded numerous pmn despite significant pmn infiltration this finding supports previous vitro studies showing alginate protects bacteria host immune system the lungs rats characterized foci p. aeruginosa biofilms alveoli alveolar ducts figures 4(a)4(d this similar findings tiddens described pathological characteristics seen cf patients culture extract histology lungs extract treatment comparative groups insignificant suggesting mechanism action based inhibiting qs system p. aeruginosa thus preventing persistence via formation biofilm aeruginosa lung infection cf patients characterized strong antibody response serum infiltration pmns lung our results showed high serum levels igm igg among positive control group comparative treatment groups the increased levels serum antibodies could lead increased levels immune complexes lung foci thought play important role immunopathology cf results hematological profile serum antibody responses revealed challenge p. aeruginosa inhibited immune response experimental rats except negative control group early acute phase infection characterized significant increase count neutrophils lymphocytes monocytes stimulated humoral immune reaction chronic infection characterized marked increase igm igg ige our results indicates qs systems significantly affected severity p. aeruginosa lung infection acute chronic phases qs signals ahl gram negative bacteria promising new targets combat virulence among patients chronic p. aeruginosa lung infection the activation pmns downregulation igg response might associated changes production cytokines this similar findings made song et al reported association ginseng treatment neutrophil chemiluminescence immunoglobulin g subclasses rat model chronic pseudomonas aeruginosa pneumonia culture extract identified compounds regulation cytokine response using animal model biofilm associated infection our study shows culture extract paenibacillus sp act potent antagonist bacterial quorum sensing application extract potential compounds gram negative biofilms particularly p. aeruginosa increase bacterial susceptibility antibiotics natural products microbial extract long source medicines however studies focus solely bactericidal effects since microbial culture extract study showed little bactericidal activity qs remains potential mode action a shift focus anti qs antivirulence properties within bacterial community may reveal new anti qs compounds provide novel method treatment bacterial infections culture extract along 2(5h)-furanone control compound significantly increased survival time rats assisted bacterial clearance reduced lung pathology thus indicating could function acyl hsl antagonists quorum sensing inhibitors attenuation bacterial virulence rather killing pathogen might become new concept control bacterial infections this mode action might cause selective pressure development bacterial resistance antagonist previous study alasil et al culture extract identified using ultra performance liquid chromatography diode array detection uplc dad liquid chromatography mass spectrometry lc ms one reported compounds phospholipase a2 inhibitor name 4-hydroxy-5-(hydroxymethyl)-3-(14-methylpentadecanoyl tetronicacid-2(5h)-furanone similar chemical structure qs antagonist 5z)-4-bromo-5-(bromomethylene)-3-butyl-2(5h)-furanone algae delisea pulchra inhibiting biofilm formation e. coli without inhibiting growth it believed phospholipase a2 inhibitor compound paenibacillus sp culture extract could interfere qs signal acyl hsl may influence type host immune responses reduce inflammation vivo however studies needed test acute toxicity phospholipase a2 inhibitor assess therapeutic effects vivo reducing biofilm associated infections among larger sample size conclusion effects paenibacillus sp culture extract p. aeruginosa complicated extend beyond domain qs control hypothesis however inhibition virulence factors biofilm formation provide insights natural product metabolites derived novel bacterial species paenibacillus used future combat biofilm associated infections caused clinically important pathogens	quorum sensing ( qs ) is a key regulator of virulence factors and biofilm formation in gram - negative bacteria such as pseudomonas aeruginosa . microorganisms that inhabit soil are of strategic importance in the discovery of compounds with anti - qs properties . the objective of the study was to test the culture extract of a taxonomically novel species of paenibacillus strain 139si for its inhibitory effects on the qs - controlled virulence factors and biofilm formation of pseudomonas aeruginosa both in vitro and in vivo . the paenibacillus sp . culture extract was used to test its anti - qs effects on the lasa protease , lasb elastase , pyoverdin production , and biofilm formation of p. aeruginosa as well as evaluate its therapeutic effects on lung bacteriology , pathology , hematological profile , and serum antibody responses of experimental animals in a rat model of chronic lung infection . results showed significant decrease in the activities of qs - controlled lasa protease , lasb elastase pyoverdin , and biofilm formation of p. aeruginosa caused by the culture extract . moreover , the extract significantly prolonged the survival times of rats and facilitated the clearance of biofilm infections from infected lungs . in conclusion , the antiquorum sensing effects of culture extract from a novel species of paenibacillus provide new insights to combat biofilm - associated infections .
lateral patellar dislocation lpd subject constant advancement biomechanical understanding treatment modalities recent years become obvious numerous risk factors considered clinical decision making understanding individual anatomy essential identify risk subsequent instability episodes choose appropriate treatment patellar stability maintained complex interplay active passive static stabilizers act harmony knee motion the static stabilizers composed mainly joint geometry particularly shape trochlear groove prevents lpd predominantly ranges 20 30 knee flexion concomitantly abnormal joint geometry influences patellofemoral instability means different grades trochlear dysplasia anatomical mechanical axis femur tibia genu valgum increased femoral antetorsion external tibial rotation patella height increased tibial tuberosity trochlear groove distance tt tg recent years geometry tibial plateau influence biomechanics tibiofemoral joint gained increased significance numerous investigators evaluated effect tibial slope inclination tibiofemoral contact area joint translation rotation strain biomechanics cruciate ligaments 6 7 15 in addition knee anatomy particularly tibial slope directly associated knee biomechanics exhibited dynamic landings although importance inclination tibial plateau well established current literature quantitative data available regarding inclination medial lateral tibial plateau influence biomechanics tibiofemoral joint patients lpd therefore objective study evaluate geometry tibial plateau patients lpd specifically addressed following research questions lateral patellar instability associated modified inclination medial lateral tibial plateau tibial slope b way modification influence tibiofemoral biomechanics ? it hypothesis current study patients patellofemoral instability show also significant changes anatomy biomechanics tibiofemoral joint the study group composed 107 patients male female 55/52 age range 1055 years 107 knee magnetic resonance imaging mri investigations treated lpd february 2006 june 2010 picture archiving communications system pacs workstation centricity ge healthcare st gilles united kingdom used identify patients acute recurrent patellar dislocations the criteria lpd included joint effusion contusion lateral femoral condyle medial patella margin osteochondral fragments injury medial ligamentous stabilizers lateralized patella the mri based diagnosis lpd made patients met three criteria additionally included patients convincing history primary recurrent patellar dislocations clinical symptom giving way clinical findings joint effusion tenderness along medial retinaculum medial patella medial femoral condyle positive apprehension sign the criteria exclusion proximal distal realignment procedures trochleoplasty fractures distal femur tibial head multiligament injured knee joint these criteria used identify 107 patients formed study group investigation knee mri investigations 83 patients male female 42/41 age range 1259 years served controls investigations performed time period patients matched age gender investigations performed due internal derangement knee meniscus tear cartilage lesion tibiofemoral joint in addition patients anterior cruciate ligament acl tear also excluded injury often associated increased inclination tibial plateau non contact acl injury mechanisms in patients coronal sagittal transverse mri images available used measure medial lateral tibial slope anatomical distal lateral femur angle adlfa mechanical proximal medial tibial angle mpmta degree trochlear dysplasia measurements performed use annotation tools digital pacs workstation the software presented angular values length measurements one decimal place rounded single digit integer format this means true value angle example 5.4 rounded 5. hand actual angle 5.5 rounded 6. similarly measured length 40.5 mm rounded 41 mm actual length 40.4 mm rounded 40 mm therefore measurements made sensitivity 1 0.5 0.5 1 mm 0.5 0.5 mm respectively answer first research question the medial lateral tibial slope assessed according protocol proposed hashemi et al initially first proximal slice transverse mr images showed entire tibial head identified fig 1 transverse image corresponding sagittal slice located closely tibial head centre determined solid line fig 1 the longitudinal axis defined midpoint anterior posterior width tibia two points located 45 cm distally joint line distally possible the conjugation line two points represents longitudinal axis tibia sagittal plane measure medial lateral tibial slope longitudinal axis assigned corresponding planes centre medial tibial plateau centre lateral tibia plateau shown dashed lines fig 1 again corresponding planes reproduced medial lateral sagittal image fig the conjugation line peak anterior posterior points bony tibia plateau measured inclination tibial slope perpendicular longitudinal axis tibia the tibial slope defined positive peak anterior point lay peak posterior point defined negative posterior point lay anterior point.fig 1first transverse mr image craniocaudal direction shows entire tibial head transverse image the corresponding sagittal slices located closely tibial head centre solid line centre medial lateral tibial plateau dashed lines determined similarly corresponding coronal section located closely tibial head centre dotted line establishedfig 2the sagittal plane represents corresponding image solid line fig the longitudinal axis defined midpoint anterior posterior width tibia two points located 45 cm distally joint line distally possible measure medial lateral tibial slope longitudinal axis assigned corresponding planes centre lateral tibial plateau b centre medial tibia plateau c shown dashed lines fig the conjugation line peak anterior posterior points tibia plateau measured inclination tibial slope perpendicular longitudinal axis tibia first transverse mr image craniocaudal direction shows entire tibial head transverse image the corresponding sagittal slices located closely tibial head centre solid line centre medial lateral tibial plateau dashed lines determined similarly corresponding coronal section located closely tibial head centre dotted line established sagittal plane represents corresponding image solid line fig the longitudinal axis defined midpoint anterior posterior width tibia two points located 45 cm distally joint line distally possible measure medial lateral tibial slope longitudinal axis assigned corresponding planes centre lateral tibial plateau b centre medial tibia plateau c shown dashed lines fig 1 conjugation line peak anterior posterior points tibia plateau measured inclination tibial slope perpendicular longitudinal axis tibia comparable method used measure adlfa mpmta according paley et al first longitudinal axis tibia frontal plane established referencing closely centre tibial head corresponding transverse image dotted line fig 1 again longitudinal axis defined midpoint medial lateral width tibia distally possible midpoint tibial head a similar approach used establish diaphyseal axis femur coronal plane the adlfa mpmta measured angle longitudinal axis femur tibia joint line represented distally located points femoral condyles peak points medial lateral tibial plateau respectively fig 3the longitudinal axis femur tibia established frontal plane referencing closely centre tibial head corresponding transverse image dotted line fig 1 the longitudinal axis defined midpoint medial lateral width tibia distally possible midpoint tibial head a similar approach used establish diaphyseal axis femur coronal plane the adlfa mpmta measured angle longitudinal axis femur tibia joint line represented distally located points femoral condyles peak points medial lateral tibial plateau adlfa anatomical distal lateral femur angle mpmta mechanical proximal medial tibial angle longitudinal axis femur tibia established frontal plane referencing closely centre tibial head corresponding transverse image dotted line fig 1 the longitudinal axis defined midpoint medial lateral width tibia distally possible midpoint tibial head a similar approach used establish diaphyseal axis femur coronal plane the adlfa mpmta measured angle longitudinal axis femur tibia joint line represented distally located points femoral condyles peak points medial lateral tibial plateau adlfa anatomical distal lateral femur angle mpmta mechanical proximal medial tibial angle trochlear dysplasia assessed transverse mr images described fucentese et al : type trochlear morphology preserved fairly shallow trochlea type b flat convex trochlea type c asymmetry trochlear facets convex lateral facet hypoplastic medial facet type asymmetry trochlear facets hypoplastic medial facet cliff pattern answer second research question analyses ngerl et al pinskerova et al these studies showed contact areas femoral condyles tibial plateau move backwards knee flexion weight bearing conditions the contact point medial femoral condyle tibial plateau averaged distance 29 22 mm measured ipsilateral posterior tibial cortex 20 90 knee flexion respectively this means difference medial lateral tibial plateau inclination would influence femoral rotation means different height posteromedial posterolateral femorotibial contact points illustrated fig 4a b. thus medial lateral tibial slope asymmetry assessed intra individual difference medial lateral tibial plateau inclination this means tibial slope asymmetry positive sign cases medial slope steeper lateral slope negative sign cases medial slope flatter lateral slope.fig 4illustrated effect tibial slope asymmetry femoral rotation means difference height medial lateral tibial plateau 20 90 knee flexion frontal view the maximal observed effect internal external femoral rotation shown comparison neutral position femoral condyles knee flexion angles illustrated effect tibial slope asymmetry femoral rotation means difference height medial lateral tibial plateau 20 90 knee flexion frontal view maximal observed effect internal external femoral rotation shown comparison neutral position femoral condyles knee flexion angles effect tibial slope asymmetry femoral rotation calculated mathematically means radian measure knee positioned 20 90 knee flexion first value tibial slope asymmetry degrees converted radian according formula rad deg /180 this value multiplied either 23 mm 30 mm representing difference height mm posteromedial posterolateral contact points 20 90 knee flexion the value 23 30 mm resulted length tibial head sagittal plane 52 mm n 35 minus distance posterior tibial cortex medial femorotibial contact point 29 mm 20 knee flexion 22 mm 90 knee flexion according pinskerova et al subsequently differences height divided distance centre medial lateral femoral condyle frontal plane intercondylar distance 44 mm n 35 representing value femoral rotation radian values radian measures converted degrees deg rad 180/ representing internal femoral rotation cases positive values external femoral rotation cases negative values the influence grade trochlear dysplasia onto medial lateral tibial slope onto age adlfa mpmta individually assessed linear regression trochlear dysplasia independent variable since age significantly associated grade trochlear dysplasia added independent variable regression models gender lpd compared different types trochlear dysplasia using -exact test the portion study patients controls 20 largest slope asymmetries positive negative direction respectively evaluated fisher exact test because lpd trochlear dysplasia nearly perfectly correlated adjustment age possible analysis study intrarater interrater reliability two measurement series 20 randomly taken mri were drawn either repeatedly 1 single rater 2-week interval independently 2 different raters reliability assessed correlation pearson r two measurement series mean difference test all analyses performed using free software r version 2.12 www.r-project.org the testing level chosen alpha 5 tests the influence grade trochlear dysplasia onto medial lateral tibial slope onto age adlfa mpmta individually assessed linear regression trochlear dysplasia independent variable since age significantly associated grade trochlear dysplasia added independent variable regression models gender lpd compared different types trochlear dysplasia using -exact test the portion study patients controls 20 largest slope asymmetries positive negative direction respectively evaluated fisher exact test because lpd trochlear dysplasia nearly perfectly correlated adjustment age possible analysis study intrarater interrater reliability two measurement series 20 randomly taken mri were drawn either repeatedly 1 single rater 2-week interval independently 2 different raters reliability assessed correlation pearson r two measurement series mean difference test all analyses performed using free software r version 2.12 www.r-project.org the testing level chosen alpha 5 tests severity trochlear dysplasia significantly associated asymmetric inclination tibial plateau table 1 whereas medial tibial slope showed identical values controls study patients n.s lateral tibial plateau inclination becomes flatter increasing severity trochlear dysplasia p 0.01 table 1 fig 5 consequently intra individual slope asymmetry increased steadily towards positive values p 0.01 therefore increased internal femoral rotation 20 90 knee flexion patients severe trochlear dysplasia p 0.01 table 1 fig 6 though tibial slope asymmetry showed relatively wide range study control patients study patients frequently found controls among 20 largest positive values tibial slope asymmetry 610 hand among 20 largest negative values tibial slope asymmetry 4 8 control patients often found study patients p 0.024 concomitantly means extreme values internal femoral rotation pronounced patients lpd whereas extreme values external femoral rotation pronounced control subjects the study group also showed slightly increased valgus deformity expressed smaller adlfa p 0.01 whereas mpmta differ study control subjects n.s interrater intrarater reliability near perfect investigated parameters clearly positively significant correlation two measurement series table 2a b).table 1distribution patient characteristics study parameters considering different grades trochlear dysplasiaparametergrade trochlear dysplasia p valuenormal n 90)type n 18)type b n 47)type c n 23)type n 12)age years)27.2 9.6(12.059.0)22.6 7.1(13.038.0)24.9 9.7(10.055.0)20.5 5.3(13.030.0)18.0 6.7(12.038.0)<0.01gendern.s male48 53 9 50 26 55 10 43 5 42 female42 47 9 50 21 45 13 47 7 58 dislocation<0.01 yes7 8 18 100 47 100 23 100 12 100 no83 92 0 0 0 0 0 0 0 0 tibial slope medial7.0 3.9(1.0 15.0)7.3 4.5(0.014.0)7.6 4.3(1.5 20.0)6.8 3.8(0.5 14.0)6.5 4.5(1.017.0)n.s.tibial slope lateral6.7 3.9(0.5 15.5)7.1 5.3(0.015.5)6.1 4.8(0.018.0)4.5 4.6(5.0 14.5)3.0 3.4(1.0 9.5)<0.01slope asymmetry )0.2 3.8(8.0 7.0)0.2 2.8(4.5 5.0)1.5 3.4(8.0 9.0)2.3 3.8(4.0 10.0)3.5 3.4(1.5 8.0)<0.01femoral rotation 20 knee flexion0.1 1.9(4.2 3.7)0.1 1.4(2.4 2.6)0.8 1.8(4.2 4.7)1.2 2.1(2.3 5.5)1.9 1.8(0.7 4.2)<0.01femoral rotation 90 knee flexion0.1 2.6(5.5 4.8)0.2 1.9(3.0 3.4)1.0 2.3(5.5 6.1)1.6 2.7(3.0 7.2)2.5 2.4(1.0 5.5)<0.01adlfa )82.8 2.2(76.088.0)81.3 2.4(76.586.0)81.6 2.4(77.086.0)81.0 3.0(76.086.5)81.5 2.4(77.085.5)<0.01mpmta )86.1 2.5(80.591.0)85.3 2.1(82.088.5)85.8 2.2(82.090.0)86.0 2.0(82.090.0)86.4 2.1(83.089.0)n.s.*descriptive values presented either absolute relative frequencies mean standard deviation minimum maximum not significant adlfa anatomical distal lateral femur angle mpmta mechanical proximal medial tibial anglefig 5shown mean values sd medial lateral tibial slope controls patients considering different grades trochlear dysplasiafig 6shown mean values sd internal femoral rotation controls patients considering different grades trochlear dysplasia knee positioned 20 90 knee flexiontable 2correlation mean differences 2 measurement series 20 individuals drawn repeatedly 1 single rater b 2 different raterspearson r p valuemean differences p valuea intrarater reliability medial slope0.92<0.010.4n.s not significant distribution patient characteristics study parameters considering different grades trochlear dysplasia descriptive values presented either absolute relative frequencies mean standard deviation minimum maximum not significant adlfa anatomical distal lateral femur angle mpmta mechanical proximal medial tibial angle shown mean values sd medial lateral tibial slope controls patients considering different grades trochlear dysplasia shown mean values sd internal femoral rotation controls patients considering different grades trochlear dysplasia knee positioned 20 90 knee flexion correlation mean differences 2 measurement series 20 individuals drawn repeatedly 1 single rater b 2 different raters n.s the important finding study individual tibial slope asymmetry expressed difference medial lateral tibial slope increased linearly considering severity trochlear dysplasia this increase tibial slope asymmetry based decrease lateral tibial slope consistent inclination medial slope tibial slope asymmetry therefore influenced femoral rotation means different height posterior medial posterior lateral tibial head thereby internal femoral rotation pronounced patients lpd whereas external femoral rotation pronounced control subjects without patellofemoral instability links knee joint biomechanics joint morphology well described recent years 1 10 particularly effect geometry tibial plateau strain biomechanics cruciate ligaments gained increased significance thereby combination steep medial lateral tibial slopes shallow concavity medial tibial head increased risk non contact acl injuries moreover geometry tibial slope also influenced peak stance knee internal rotation dynamic landings specifically lateral tibial slope dominated tibial plateau geometry peak internal rotation angle increased indicating geometry tibial plateau exerts dynamic role knee rotational alignment similarly results support association tibial plateau configuration internal femoral rotation patients lateral patellar instability underlying trochlear dysplasia thereby medial lateral tibial slope asymmetry increased internal femoral rotation knee flexion potentially aggravating effect femoral antetorsion patients lpd in addition seems plausible tibial slope asymmetry also changes knee axial rotation response longitudinal tibial rotation axis located medial tibial plateau a relative increase medial slope shift medial tibiofemoral contact point anteriorly concomitantly relative shallow lateral slope reduce anterior directed tibiofemoral translation force lateral side culminating greater external tibial rotation thus positive values tibial slope asymmetry might influence patellofemoral instability increase internal femoral rotation increase external tibial rotation one consider smaller radius curvature lateral femoral condyle might reduce effect internal femoral rotation three distinct features femoral bicondylar angle prominence lateral lip femoral trochlear elliptic profile lateral condyle characterize development trochlear groove distal femur the increase bicondylar angle correlated disproportionate anteroposterior development lateral pillar we therefore measured radius curvature 35 study patients trochlear dysplasia type c 35 random selected patients control group no significant difference found groups data shown lateral condyles radius curvature seems unlikely compensate asymmetric tibial slope effect recently hashemi et al already pointed true tibial slope measured centre articular regions medial lateral tibial plateau they found relatively wide range medial lateral slope ranges 3 10 0 14 respectively similarly matsuda et al reported medial lateral tibial slope ranges 5 15.5 0 14.5 respectively we also found high range within measurements medial 1.5 20 lateral tibial slope 5 18 moderately exceeding previous studies however difference might attributable much higher number subjects included study n 190 compared analysis hashemi et al ( n 60 5 8 best knowledge this first study investigated association lpd tibial plateau geometry in addition study aims provide initial understanding medial lateral tibial slope asymmetry resultant biomechanical characteristics tibiofemoral joint relevant contributions lateral patellar instability if one considers mean values tibial slope asymmetry femoral rotation could argued may dramatic effect biomechanics knee joint however important point consider differences extreme values internal femoral rotation 5.5 20 knee flexion 7.2 90 knee flexion patients patellar instability external femoral rotation 4.2 20 knee flexion 5.5 90 knee flexion control subjects first already stated hashemi et al important note access sufficient length femur tibia magnetic resonance image ability identify landmarks precisely could impact slope measurements second slope measurements referenced bony landmarks centre medial lateral tibial plateau knee joint morphology characterized cartilage surface concave medially convex laterally this means articular surface higher lateral side lower medial side compared bony landmarks used study turn however would enhance observed effect internal femoral rotation knee flexion rather diminish finally analyses based idealized mathematical model knee positioned 20 90 knee flexion it able evaluate effect tibial slope asymmetry tibiofemoral biomechanics varying degrees knee flexion if one considers patella becomes least stable 0 30 knee flexion could argued increase internal femoral rotation may dramatic effect patellar instability higher degrees knee flexion however though patellae dislocate nearly straight start followed movement flexion certain amount patients dislocating patellae well bent start followed either knee extension flexion thus seems likely increase internal femoral rotation contributes relevantly patellar instability even higher degrees knee flexion knowledge influence medial lateral tibia slope asymmetry femoral rotation might help physicians decision making process towards torsional osteotomy patients lateral patellar instability marginally increased femur antetorsion the present study introduces new aspect complex interplay patellofemoral tibiofemoral joint considering biomechanics lateral patellar instability it shows individual tibial slope asymmetry expressed difference medial lateral tibial slope increased linearly considering severity trochlear dysplasia concomitantly influenced femoral rotation knee flexion thereby internal femoral rotation pronounced patients lpd whereas external femoral rotation pronounced control subjects without patellofemoral instability this article distributed terms creative commons attribution license permits use distribution reproduction medium provided original author(s source credited	purposethe geometry of the tibial plateau and its influence on the biomechanics of the tibiofemoral joint has gained increased significance . however , no quantitative data are available regarding the inclination of the medial and lateral tibial slope in patients with patellar instability . it was therefore the purpose of this study to evaluate tibial slope characteristics in patients with patellar dislocations and to assess the biomechanical effect of medial - to - lateral tibial slope asymmetry on lateral patellar instability.methodsmedial and lateral tibial slope was measured on knee magnetic resonance images in 107 patients and in 83 controls . the medial - to - lateral tibial slope asymmetry was assessed as the intra - individual difference between the medial and lateral tibial plateau inclination considering severity of trochlear dysplasia . the effect of tibial slope asymmetry on femoral rotation was calculated by means of radian measure.resultsseverity of trochlear dysplasia was significantly associated with an asymmetric inclination of the tibial plateau . whereas the medial tibial slope showed identical values between controls and study patients ( n.s . ) , lateral tibial plateau inclination becomes flatter with increasing severity of trochlear dysplasia ( p < 0.01 ) . consequently , the intra - individual tibial slope asymmetry increased steadily ( p < 0.01 ) and increased internal femoral rotation in 20 and 90 of knee flexion angles in patients with severe trochlear dysplasia ( p < 0.01 ) . in addition , the extreme values of internal femoral rotation were more pronounced in patients with patellar instability , whereas the extreme values of external femoral rotation were more pronounced in control subjects ( p = 0.024).conclusiondata of this study indicate an association between tibial plateau configuration and internal femoral rotation in patients with lateral patellar instability and underlying trochlear dysplasia . thereby , medial - to - lateral tibial slope asymmetry increased internal femoral rotation during knee flexion and therefore might aggravate the effect of femoral antetorsion in patients with patellar instability.level of evidenceiii .
predominant question neuroscience memory functions supported central nervous system cellular processes necessary one focus research protein dependent synaptic modifications occur consequence neuronal activity signaling cascades activated time learning induce transcription particular genes ultimately leading de novo protein synthesis subsequent structural changes support long term memories immediate early genes iegs induced soon neuronal activity participate diverse functions some iegs regulatory transcription factors e.g. zif268/egr1 responsible inducing transcription late response genes others effector iegs e.g. arc arg3.1 directly involved cellular changes locations cytoskeleton receptors however transcripts iegs activity regulated cytoskeleton associated protein arc transported dendrites protein synthesis occurs thus making arc reasonable target researchers investigating underlying mechanisms postsynaptic changes supporting memory formation arc also called arg3.1 plasticity related gene whose induction occurs soon synaptic activation 24 mrna transcription independent de novo protein synthesis expression primarily excitatory neurons following behavioral experience arc contains synaptic activity responsive element sare promoter upstream initiation site necessary transcription sufficient induction activity dependent arc arc mrna transported dendrites 3 4 6 perhaps via sumoylation reviewed intradendritically localized activated synapses phosphorylated erk extracellular signal regulated kinase signaling actin polymerization 6 811 translated protein becomes part postsynaptic junction the recruitment arc dendrites suggests importance synaptic plasticity occurs activation arc expression strongly linked long term potentiation ltp learning high frequency stimulation hfs induces ltp arc expression dependent upon nmda receptor activation 3 4 upon activation ampa receptors additionally intrahippocampal infusions arc antisense vivo disrupt multiple aspects ltp indicating arc protein synthesis required early expression maintenance consolidation enduring ltp 13 14 reviewed in accordance ltp molecular model learning memory delivery arc antisense dorsal hippocampus produces long term memory deficits spatial water maze performance inhibitory avoidance rats indicating necessary role arc protein memory consolidation furthermore arc knockout mice show impaired spatial learning morris water maze task disrupted fear memory context auditory stimuli deficits conditioned taste aversion object recognition recent findings provide evidence role arc regulation ampa receptors interactions endocytic proteins dendrites 17 18 reviewed 19 20 well function stabilization expansion f actin cytoskeleton activated synapses strengthening argument arc involved modifications affect synaptic efficacy reviewed the protein product immediate early gene zif268 also termed egr1 early growth response gene transcription factor zinc finger family expression zif268 regulated synaptic activity dependent upon nmda receptor activation induction ltp produces increased expression zif268 mrna knockout zif268 gene mice results absent late ltp hippocampus deficits long term memory spatial water maze conditioned taste aversion socially transmitted food preference object recognition additionally infusions zif268 antisense amygdala prior contextual fear conditioning disrupt fear memory consolidation present set experiments used pavlovian fear conditioning investigate time dependent expression arc zif268 pavlovian fear conditioning neutral stimulus is paired aversive unconditional stimulus ucs pairing the neutral stimulus becomes able elicit fear response termed conditional response cr the animal also acquires fear context fear conditioning occurred animal presented shock associated auditory stimulus or is placed back training context exhibit fear behaviors indicating memory training experience the amygdala crucial acquisition consolidation expression classically conditioned fear receives information conditional unconditional stimuli cs ucs respectively making site associative convergence 25 26 amygdala lesions protein synthesis inhibitors delivered amygdala disrupt fear conditioning 2729 the hippocampus necessary conditional fear auditory cs delay paradigm essential contextual fear post training hippocampal lesions abolish contextual fear rodents affect conditioning auditory stimulus protein synthesis inhibitors given hippocampus block acquisition contextual fear memory 26 31 the present study examined time course arc protein expression hippocampus following pavlovian fear conditioning in addition temporal profile zif268 another plasticity related gene product measured compared pattern expression arc protein immunohistochemistry followed western blot studies show localization arc zif268 hippocampal regions elevated protein expression post training additional control groups shock stimulation simple exposure auditory contextual stimuli analyzed western blots better determine specific contribution arc zif268 protein hippocampus in experiments male long evans rats n 148 harlan madison wi weighing approximately 350 g used the animal colony climate controlled maintained 14 hr 10 hr light dark cycle lights 7:00 a.m. experimental procedures performed light cycle all procedures approved institutional animal care use committee university wisconsin milwaukee each chamber constructed clear plexiglas front back walls ceiling stainless steel side walls measured 28 20.5 21 cm length height depth stainless steel rods spaced 12 mm apart served floor chamber used deliver mild footshock scrambled shock generator conditioning chambers housed sound attenuating boxes illuminated 7.5 w white light bulb constant background noise 5660 db produced ventilation fans inside boxes the chambers cleaned 5% ammonium hydroxide solution rat behavioral testing the dependent measure freezing behavior operationally defined lack movement except movement necessary respiration the training procedure recorded video cameras installed inside sound attenuating chambers freezing behavior scored computer software freezescan 1.0 clever sys rats adapted handling transportation procedures 3 min 6 consecutive days rats trained single 15-min session auditory cued fear conditioning figure 1(a after initial 6-min baseline period rats received four presentations white noise 72 db 10 coterminated footshock 1.3 1 the rats remained chamber additional 4 min following last footshock returned home cages this training protocol previously shown produce contextual auditory cued fear memories 28 29 33 additional groups animals created control separately auditory contextual experience shock stimulation one group experienced training protocol shock stimuli delivered wn cxt another group received footshock immediately upon placement chamber removed shortly afterward shk after training animals returned home cages later euthanized overdose intraperitoneal injection sodium pentobarbital solution varying time points post training animals killed 30 min 60 min 90 min 4 hr 8 hr 12 hr 24 hr training nave home cage hc rats served control group separate experiment wn cxt shk groups euthanized 60 min stimulus exposure compared trained rats also killed 60-min post training well additional hc controls it possible control animals behavior e.g. sleeping survival interval however occurrence behaviors prior euthanasia controlled hc group hc animals killed varying times day across experiment account circadian patterns unsystematic animal behavior variation animal colony thus protein expression measured trained groups beyond observed hc animals specific learning experience result unsystematic variability euthanized rats decapitated brains quickly removed frozen dry ice stored 80c tissue samples microdissected dorsal hippocampus figure 1(b dissections a rat brain atlas rat brain matrix harvard apparatus holliston used maintain consistency tissue collection hippocampal samples homogenized manually pestle glass tissue grinder buffer solution 100 ml ddh2o 0.605 g tris hcl 0.25 g sodium deoxycholate 0.876 g nacl 0.038 g edta 0.0042 g naf 1 g ml pmsf 1 g ml leupeptin 1 g ml aprotinin 10 ml 10% sds 1 mm sodium orthovanadate visible traces solid matter homogenates stored centrifuge tubes kept frozen 80c time centrifugation 4000 rpm 20 min the supernatant removed placed small centrifuge tubes stored 80c a bradford protein assay performed determine total amount protein samples bio rad dc protein assay kit hercules ca sample dilutions pipetted 96-well plates compared serial dilutions protein standard bio rad bsa 1.35 mg ml using versamax plate reader softmax pro 4.3 ls software samples discarded analysis meet set criterion variance standard applied groups equivalently normalized protein samples loaded onto 7.5% sds gels arc blots 9.0% sds gels zif268 blots using mini protean holder filled electrophoresis running buffer bio rad powerpac 200 v 0.04 constant 90 min each experimental condition represented gel counterbalance slight variation blot development gels washed transfer buffer 3.03 g tris 14.4 g glycine 200 ml methanol 5 ml 10% sds ddh2o 1 l protein transferred pvdf membranes using semidry transfer cell bio rad powerpac settings 15 v constant 2.00 75 min after protein transfer membranes incubated 2 hr blocking buffer 500 ml tbs 15 g nonfat dry milk exposed primary antibody 90120 min monoclonal antibody arc protein dilution 1 100 antibody buffer santa cruz polyclonal antibody zif268 protein dilution 1 1000 cell signaling polyclonal antibody -actin dilution 1 1000 cell signaling used experiments after exposure primary antibody membranes washed twice 15 min antibody buffer 100 ml blocking buffer 50 l tween-20 incubated 90120 min secondary antibody goat anti mouse arc blots1 5000 dilution santa cruz goat anti rabbit zif268 -actin blots1 2000 dilution upstate biotechnology membranes washed twice 15 min wash buffer 100 ml tbs 50 l tween-20 exposure chemiluminescence solution santa cruz 3 min washes incubations generally done room temperature however primary incubation sometimes performed overnight 4c 1 hr room temperature developments conducted dark room membranes chemiluminescence exposed autoradiographic film cassette any disruptions signal development films caused sample excluded analysis the bands representing arc molecular weight mw 55 kda zif268 mw 75 kda -actin mw 45 kda measured using densitometry software nih imagej optical density measures computed hippocampal sample percentage home cage animals control group protein expression results statistically analyzed using one way anovas fisher least significant difference lsd post hoc comparisons appropriate rats n 6 euthanized overdose isofluorane either 30 90 min single session fear conditioning 15-min session signaled shocks see figure 1(a the 30-min 90-min time points selected based time course zif268 arc expression established western blot analysis the rats perfused transcardially 0.1 pbs followed 10% buffered formaldehyde prior decapitation brains removed placed 10% buffered formaldehyde overnight transferred 30% sucrose formalin cryoprotection another 24 hr prior slice collection brains rinsed 3 times 0.1 pbs 10 min using freezing microtome coronal slices 50-micron thick ) were collected throughout rostral caudal extent dorsal hippocampus placed 24-well plates 500 l 0.1 pbs the slices incubated titer plate 1% sodium borohydride 15 min 0.1 pbs twice 10 min 10% normal goat serum 30 min primary antibody 30 min arc 1 100 dilution zif268 1 500 dilution neun 1 200 dilution primary antibodies used determine regional localization neuronal colocalization arc zif268 proteins neun antibody chemicon millipore binds neuron specific nuclear protein commonly used identify neurons slices treatment condition dual labeled arc zif268 protein determine colocalization within individual neurons , slices incubated two washes 0.1 pbs 10 min incubation antibody solution containing anti mouse alexa 488 anti rabbit alexa 594 antibodies 1 500 dilution invitrogen 2 hr dark slices rinsed two washes 0.1 pbs 5 min after incubation slices mounted onto unsubbed slides using ultra cruz mounting medium santa cruz finally slides coverslipped sealed thin coat nail polish around edges photomicrographs taken using fluorescence microscope olympus determine coexpression arc zif268 neurons separate images taken field protein merged using dp manager olympus arc expressing neurons appear green color alexa 488 zif268-expressing neurons fluoresce red alexa 594 thus overlaying images resulted coexpressing neurons appear yellow color the exposure time images collected adjustments contrast brightness images conducted exactly relevant images protein expression values obtained western blots found normally distributed thus results analyzed using parametric tests one way analysis variance anova followed fisher lsd post hoc comparisons appropriate cases pearson correlations conducted normalized optical density values western blots investigate relationship protein expression dorsal hippocampus significance levels set 0.05 data presented mean sem seventy six male long evans rats trained single 15-min session pavlovian fear conditioning later killed varying time points post training 30 min 60 min 90 min 4 hr 8 hr 12 hr 24 hr all trained groups exhibited equivalent levels freezing averaged across 5-min period cs ucs presentations f(6,69 1.989 p .05 data shown protein levels experimental condition expressed percentage untrained hc animals protein expression optical density od hc control animal od score 4 standard deviations mean removed data analysis arc outliers zif268 n 1 24 hr group we found induction arc protein expression trained rats monophasic dorsal hippocampus significant increase detected 30 min 90 min post training returning near basal levels 4 hr figure 2(a a one way anova revealed level arc protein expression time dependent following fear conditioning f(7,79 4.265 p .001 lsd post hoc comparisons showed compared untrained hc animals arc protein significantly increased trained rats 30 min md 34.4587 p .01 60 min md 58.0035 p .001 90 min ( md 50.8044 p .01 order determine localization arc protein dorsal hippocampus coronal brain slices collected rats killed 90 min training prepared immunohistochemistry increased arc protein expression observed granule cell layer dentate gyrus trained animals whereas sparse expression arc protein detected region unstimulated hc control rats figures 2(b)2(f arc positive neurons evident regions dorsal hippocampus ca1 although quantify arc positive neurons photomicrographs images suggest upregulation arc protein expression primarily localized dentate gyrus a different temporal pattern seen protein expression profile zif268 single peak evident 60 min post training f(7,72 3.228 p .01 see figure 3(a lsd post hoc comparisons revealed zif268 protein significantly increased 60 min compared hc animals md 55.2942 p .01 in fact protein level zif268 measured 60 min significantly higher time points 90 min md 60.6474 p .01 4 hr md 71.1209 p .01 8 hr md 86.4159 p .01 12 hr md 86.9798 p .01 24 hr md 69.0759 p < .01 exception 30 min md 32.7638 p .05 establish localization zif268 protein dorsal hippocampus coronal brain slices additional rats killed 30 min post training collected incubated zif268 antibody agreement findings western blot analysis conditioned rats showed qualitatively expression zif268 protein ca1 region dorsal hippocampus 30 min training compared hc controls figures 3(b)3(f similar increases evident dentate gyrus ca3 region hippocampus data shown some transcription factors zif268 relatively high basal levels expression observed unstimulated hc controls figures 3(c 3(e however basal level zif268 expression less level zif268 protein induced behaviorally measured western blots figure 3(a captured visually photomicrographs figures 3(d 3(f these images suggest increase zif268 protein measured western blot analysis result upregulation zif268 primarily ca1 dentate gyrus see figure 4 validate temporal changes observed arc zif268 protein expression the hippocampal samples assayed -actin constitutively expressed protein using western blot analysis the levels -actin protein trained groups show significant changes expression compared hc controls f(7,81 1.328 p .05 data shown indicating upregulation arc zif268 protein unique specific behavioral training experience summary the expression profile proteins demonstrates early increase zif268 expression 3060 min post training followed gradual monophasic wave arc induction lasting 90 min figures 2 3 the temporal dynamics proteins distinctive reflect difference functions arc zif268 i.e. synapse specific changes transcriptional regulation respectively the delay peaks zif268 arc proteins corroborates previous research showing arc transcriptional target zif268 multiple genomic responses activated consequence fear acquisition using pearson correlation western blot optical density values investigated relationship expression arc zif268 proteins dorsal hippocampus correlational analysis indicated direct moderate relationship levels proteins dorsal hippocampus fear conditioning r(79 0.244 p .05 upon closer inspection discovered relationship driven positive correlation arc zif268 proteins animals killed 30 min training r(15 0.510 p .05 significant correlations proteins found experimental conditions other researchers found arc zif268 mrna expression hippocampus correlated following training hippocampus dependent tasks spatial water maze 36 37 investigate colocalization arc zif268 proteins hippocampus brain slices collected trained rats sampled 30 90 min post training nave hc rats dual labeled proteins viewed using epifluorescence microscopy unstimulated hc animals neurons dentate gyrus expressed arc protein figure 4(a however many neurons zif268-positive figure 4(b the merged image revealed arc positive neurons dentate gyrus also expressed zif268 figure 4(c in trained rats neurons expressed arc protein maximal number arc positive neurons reached 90 min figures 4(d 4(g further many neurons dentate gyrus expressed zif268 qualitatively zif268-positive neurons shown 30 min figure 4(e compared slices collected nave 90-min animals figures 4(b 4(h seen nave hc animals arc zif268 proteins expressed trained animals co localized neurons depicted merged images figures 4(f 4(i these findings qualitatively replicate western blot analysis results showing increased arc 90 min zif268 around 30 min post training dorsal hippocampus they also extend findings suggest fear conditioning co expression zif268 arc protein increases determine if time dependent changes hippocampal arc zif268 protein expression specific associative learning rats assigned one four conditions trained n 14 white noise context exposure wn cxt n 9 immediate shock shk n 8) unstimulated home cage control hc ; trained animals received fear conditioning protocol used previously figure 1(a wn cxt animals experienced training paradigm shock generator turned shk rats received shock upon placement chamber immediately removed all rats killed 60 min post experience dorsal hippocampal tissue processed western blots protein levels experimental condition expressed percentage untrained hc animals protein expression optical density od hc control arc protein levels change significantly due behavioral experience training context figure 5(a f(3,33 3.007 p < both trained wn cxt groups increased levels arc protein compared unstimulated hc controls trained md 66.3183 p .05 wn cxt md 71.6449 p .05 observed shk condition md 46.0808 p .05 expression arc protein trained group similar arc protein levels observed 1-hr group measured original time course ~60% increase figures 2(a 5(a different pattern protein expression measured zif268 marked increases seen trained condition figure 5(b the overall anova hc shk wn cxt trained groups meet statistical criterion f(3,33 1.593 p .05 however level zif268 trained group similar observed 1-hr time group original time course ~65% figures 3(a 5(b therefore conducted linear planned comparison trained hc groups indicate significant upregulation zif268 protein trained group f(1,33 4.693 p .05 in contrast arc zif268 protein expression significant changes protein levels loading control -actin across conditions f(3,37 0.112 p .05 data shown the effector ieg arc implicated synaptic plasticity underlying learning memory our aim extend earlier findings investigating time dependent expression arc protein induced pavlovian fear conditioning compare expression profile another ieg zif268 we found arc protein expressed soon fear conditioning dorsal hippocampus gradual increases arc protein detected 30 min single peak expression profile emerged 1 2 hr post training returning baseline levels 4 hr arc protein primarily localized granule cell layer dentate gyrus these data indicate arc protein expression induced dorsal hippocampus fear conditioning time dependent monophasic arc protein likely involved consolidation contextual fear memories supported hippocampus since auditory delay fear conditioning reliant hippocampus 26 30 the levels arc protein expression dorsal hippocampus positively correlated regulatory transcription factor ieg zif268 the expression profile zif268 dorsal hippocampus also monophasic however maximal protein levels measured 60 min fear conditioning increased expression seemingly localized dentate gyrus ca1 separate experiment investigated induction proteins specific associative learning result behavioral experience generally arc protein expression increased rats trained well animals exposed context auditory stimuli delivery immediate shock produce significant increase arc arc protein expression linked ucs exposure per se further would predict significant learning related increase immediate shock condition procedure result normal learning since training exposure training chamber induced similar levels arc expression effect likely relates contextual processing similar alterations arc mrna hippocampus observed using catfish analysis contextual fear conditioned context exposed animals this selective increase hippocampal zif268 protein trained group shk wn cxt conditions similar upregulation zif268 observed retrieval context fear memory relative cued fear retrieval reexposure context paired shock the significance difference pattern seen arc protein yet clear perhaps zif268 expression hippocampus specifically related formation aversive memories the single phase arc protein upregulation observed similar forskolin- ecs- electroconvulsive shock induced expression arc mrna 1 3 4 40 protein 1 41 increased expression measured 30 min 4 hr post activation return basal levels 8 24 hr data also accordance recent ltp vivo investigations arc antisense oligodeoxynucleotide applied 2 hr 4 hr post ltp induction resulted reversal ltp suggesting role arc protein time limited furthermore hippocampal data complement findings behavioral paradigms for example arc mrna expression hippocampus following spatial water maze training peaks 30 min post training returns baseline 6 hr we detect elevated levels arc protein 30 min may product existing newly transcribed mrna possibility yet investigated found answered literature however arc protein 1 2 hr likely translated new transcripts synthesized consequence training experience hypothesis congruent data suggesting rapid turnover arc scale minutes hours 42 43 although spatial water maze contextual fear conditioning two different hippocampus dependent tasks mrna protein time courses two studies produce logical sequence combined peak increase arc mrna 30 min followed maximal arc protein levels 90 min multiple waves increased protein levels may follow training experience number phases depends upon training parameters used 44 45 for instance biphasic expression measured proteins response fear conditioning however data suggest expression arc zif268 protein hippocampus monophasic following acquisition conditioned fear monophasic expression arc necessarily true behavioral paradigms ramirez amaya et al found arc protein expressed two phases ca1 ca3 hippocampus first phase 30 min 2 hr second phase 8 24 hr following single exploration session study found single wave arc protein dentate gyrus lasted 8 hr post exploration similar primarily monophasic expression arc protein dentate gyrus reported although increase significant arc protein seem show moderate increase 24 hr training since animals killed varying times day conclude increase due set circadian patterns ieg expression however memory seem time day dependence testing similar time day training occurred produces better recall recently attention given exploring clock genes structures hippocampus may influence expression proteins may effect create time day dependence memory circadian fluctuation protein phosphorylation previously observed hippocampus mapk signaling pathway implicated arc translation whether arc ieg is regulated manner purely speculation point certainly important consideration understanding time dependent changes protein translation the post training expression arc zif268 proteins dorsal hippocampus corresponds time window protein synthesis dependent memory consolidation the transient nature arc expression training may related evidence indicating arc mrna targeted nonsense mediated mrna decay nmd gene contains two conserved 3-utr introns reviewed 7 19 nmd translation dependent decay mechanism likely halts protein expression produce finite protein levels temporally specific learning event along degradation pathways ubiquitin dependent degradation proteasomes nmd probably restricts protein composition local activated synapses notion burst arc protein expression temporally linked learning event supported studies reporting level training induced arc expression hippocampus coupled learning performance for example guzowski colleagues demonstrated amount hippocampal arc mrna positively correlated animal performance hippocampus dependent water maze learning furthermore study revealed hippocampal arc mrna expression correlated spatial water maze task hippocampus dependent nonspatial water maze task hippocampus independent indicating arc expression associated specifically learning experiences presumably increased induction arc zif268 proteins measured present study result contextual processing associative fear learning respectively dorsal hippocampus important acquisition initial consolidation contextual fear memory recent investigations molecular pathways leading induction arc focused brain derived neurotrophic factor bdnf erk camp pka activation converging evidence indicates arc downstream effector bdnf activation 14 43 pka dependent arc protein expression stimulated either activation nmda receptors gs coupled dopamine -adrenergic receptors 41 51 recent work bramham colleagues suggests initiation arc translation result erk mnk extracellular signal regulated kinase mitogen activated protein kinase interacting kinase signaling dentate gyrus structure observed increases arc protein pharmacological blockade erk mek inhibitor u0126 abolishes ltp arc protein expression however similar results observed mtorc1 mammalian target rapamycin complex 1 signaling inhibited application protein synthesis inhibitor rapamycin comparatively less known interaction zif268 arc following synaptic activation zif268 transcriptional regulator noteworthy study peak zif268 expression 60 min occurs prior peak arc 90 min the time course proteins presented corroborates earlier evidence arc transcriptional target zif268 arc promoter functional ere egr response element additionally showed levels hippocampal arc zif268 correlated one another following fear conditioning supports functional relationship two ieg products work others similarly found arc zif268 mrna upregulated following spatial exploration iegs often detected nucleus these mrnas correspondingly increased hippocampus following spatial water maze training expression profiles positively correlated within brain structure however relationship arc zif268 perfect arc protein increases measured 30 min likely result zif268 regulation believed induced one pathways implicated arc expression research needed determine role zif268 induction arc contributes synaptic modifications underlying long term memory our data suggest two proteins interact soon learning experience likely orchestrating postsynaptic changes increase synaptic efficacy support memory formation in summary arc zif268 proteins transiently increased dorsal hippocampus manner suggests two proteins work together support contextual learning fear conditioning although establish causal relationship associative learning arc zif268 protein expression shown iegs consistently upregulated hippocampus period memory context consolidated the time frame behaviorally induced arc zif268 protein dorsal hippocampus corresponds critical time window protein synthesis required memory consolidation further immunostaining revealed increase expression arc zif268 protein hippocampal neurons fear conditioning suggesting relationship arc zif268 colocalization consolidation contextual fear memory	memory consolidation requires transcription and translation of new protein . arc , an effector immediate early gene , and zif268 , a regulatory transcription factor , have been implicated in synaptic plasticity underlying learning and memory . this study explored the temporal expression profiles of these proteins in the rat hippocampus following fear conditioning . we observed a time - dependent increase of arc protein in the dorsal hippocampus 30-to-90-minute post training , returning to basal levels at 4 h. zif268 protein levels , however , gradually increased at 30-minute post training before peaking in expression at 60 minute . the timing of hippocampal arc and zif268 expression coincides with the critical period for protein synthesis - dependent memory consolidation following fear conditioning . however , the expression of arc protein appears to be driven by context exploration , whereas , zif268 expression may be more specifically related to associative learning . these findings suggest that altered arc and zif268 expression are related to neural plasticity during the formation of fear memory .
	pathologic response of tissue to asbestos in vivo gives rise to fibromatoma , granuloma and mesothelioma . we are attempting to develop a model system in vitro using human cells in order to investigate the possible mechanisms responsible for these pathologies . within the first 12 hr of exposure to chrysotile , the fibroblasts showed distinctive morphological changes . cells appeared elongated with occasional vacuolated nuclei and granular cytoplasm . cells showed no other obvious morphological changes by light microscopy and were serially passaged at confluence . the cells with vacuolated nuclei were successfully serially passaged . binucleated cells were first observed 48 hr after passaging . as time in culture increased ( 3 days to 2 weeks ) many cells lost their distinctive bipolar properties and developed " stress striations " and multiple vacuoles in the cytoplasm . multinucleated giant cells ( 2 - 11 nuclei / cell ) with lobate nucleoli became more numerous . with increasing passages , the confluent cell density decreased and cell size increased . cells usually had condensed nucleoli and had lost all control of directional growth . preliminary indications suggest that these in vitro morphological transformations are due -- at least in part -- to a lack of control over cytokinesis.imagesfigure 1 . afigure 1 . bfigure 1 . cfigure 2 . afigure 2 . bfigure 2 . cfigure 3 . afigure 3 . bfigure 3 . cfigure 4 . afigure 4 . b
adhesive capsulitis classified three phases freezing frozen thawing patients freezing phase predominantly treated drug therapy injection therapy many cases patients experience imperfect treatment effects lead prolonged disease duration adhesive capsulitis reported 40% adhesive capsulitis patients surpassed average 44 months onset experienced residual symptoms3 hand et al reported 41% adhesive capsulitis patients surpassed average 4.4 years onset experienced either pain disability completing daily activities1 the duration adhesive capsulitis shortened early initiation therapy cause disease identified physical therapist slide disorder second shoulder joint slide disorder biceps tendon bt intertubercular sulcus rotator interval disorder associated onset2 4 soft tissues supraspinatus tendon sst subacromial bursa sab bt thought associated onset adhesive capsulitis effective treatment adhesive capsulitis physical therapist must objectively evaluate condition soft tissue caused disease the main effect treatment freezing phase adhesive capsulitis evaluated pain condition soft tissue caused disease objectively evaluated arthrography computed tomography magnetic resonance imaging mri ultrasonography used objectively evaluate condition patient effect treatment particular ultrasonography used simply immediately scan soft tissue the spatial temporal resolution technique small range superior mri measuring soft tissue using ultrasonography assess adhesive capsulitis patients detecting subacromial bursitis early period disease important similarly important observe internal structures rotator cuff bt tendon synovial sheath5 many studies reported use ultrasonography adhesive capsulitis patients assessment qualitative changes diagnosis6,7,8 however attempted use technique assess treatment effects adhesive capsulitis patients9 sst thickness critical zone ultrasonography different painful side non painful side patients adhesive capsulitis10.tendon swelling interpreted focal often diffuse increase tendon thickness8 freezing phase adhesive capsulitis patients a small number studies evaluated use ultrasonography measure thickness soft tissue around shoulder joint sst thickness11,12,13,14,15 supraspinatus muscle belly thickness16 sab thickness17 bt thickness14 15 investigated the reliability ultrasound measurements reported many studies including measuring lumbar multifidus thickness18 distance interval tibia femur19 however studies examined reliability ultrasonography measurements soft tissue thickness around shoulder joint12,13,14 the reliability measurements typically examined intraclass correlation coefficient icc icc assesses relative reliability examine absolute reliability defines quantity measurement errors20 test inferential statistics nullified systematic bias occurs planning study phases bland altman analysis one methods used confirm presence systematic bias assess details examining quantity type error two measurements21 the random error absolute reliability examined standard error measurement minimal detectable change the present study performed measure thickness soft tissue around shoulder joint young normal subjects ultrasonography in addition reliability measurements examined assessing relative absolute reliability eleven students recruited technical school university physical therapy course all participants declared right hand dominant mean age 22.8 2.7 years means sd exclusion criteria follows shoulder joint pain humeral proximal edge bone fracture clavicle bone fracture shoulder blade bone fracture traumatic shoulder joint front dislocation acromioclavicular joint dislocation rheumatoid arthritis shoulder arm syndrome cervical spine lesion peripheral neuropathy due diabetes central nerve obstacle calcific tendinitis rotator cuff tear bt tear shoulder impingement syndrome ethical approval obtained faculty health sciences tokyo metropolitan university 14014 sst major axis bt minor axis scanned twice shoulders ultrasonography the thickness sst sab measured sst major axis image a second ultrasound sst sab bt performed intervals 1 minute first scan ultrasonography performed using hitachi eub-7500 ultrasound machine 812 mhz linear transducer the subject head neutral position shoulders elbow neutral position full extension respectively subsequently proximal transducer placed acromion distal transducer placed superior facet sf greater tubercle fig 1.image ultrasonography(a image supraspinatus tendon subacromial bursa ultrasonography then proximal transducer placed acromion distal transducer placed superior facet sf greater tubercle.(b image biceps tendon ultrasonography then transducer moved place subscapularis muscle appears the subject head neutral position shoulders elbow neutral position full extension respectively subsequently transducer moved position subscapularis muscle appears fig each soft tissue thickness measurement sst sab bt analyzed using imagej analysis software national institutes health bethesda usa measurements soft tissue thickness around shoulder joint often analyzed maximum thickness13,14,15 soft tissue thickness analyzed succeeding methods present study previous studies vague13 14 sst sab thicknesses measured perpendicular line distance first change point inclination angle top greater tubercle fig 2afig 2.the ultrasound measurement thickness(a ultrasound measurement supraspinatus tendon sst thickness subacromial bursa sab thickness sst sab thickness measured perpendicular line distance first change point inclination angle top greater tubercle.(b ultrasound measurement biceps tendon bt thickness bt thickness measured perpendicular line distance intertubercular sulcus center bt thickness measured according perpendicular line distance intertubercular sulcus center fig image ultrasonography image supraspinatus tendon subacromial bursa ultrasonography then proximal transducer placed acromion distal transducer placed superior facet sf greater tubercle then transducer moved place subscapularis muscle appears the ultrasound measurement thickness ultrasound measurement supraspinatus tendon sst thickness subacromial bursa sab thickness sst sab thickness measured perpendicular line distance first change point inclination angle top greater tubercle ( b ultrasound measurement biceps tendon bt thickness bt thickness measured perpendicular line distance intertubercular sulcus center descriptive statistics presented mean standard deviation continuous data numbers discrete baseline characteristics the relative reliability ultrasound measurements sst sab bt thickness determined calculating icc22 an icc 0.80 indicated great good reliability 0.700.79 indicated normal reliability 0.60 indicates work reliability23 bland altman analysis constructed plotting test retest difference two measurements versus test retest mean two measurements altman analysis indicates presence absence systematic bias visual statistical manner22 25 26 the 95% confidence interval ci mean difference two measurements used determine presence systematic bias calculated follows22 25,26,27:95% ci d= sd n)where sd standard deviation observations test sessions 1 2 n sample size value obtained table degrees freedom 0 included within 95% ci significant systematic bias measurements inferred24,25,26 systematic error recognized standard error measurement sem minimal detectable change mdc calculated sem calculated follows26,27,28:sem sd 1-icc mdc calculated mdc ci 95% mdc mdc95 calculated follows19 27,28,29,30:mdc95=sem 1.96 2 mdc indicates limit area amount change repeated two measurements results measurement error29 change measurement within mdc measurement error repeated measurements inferred if change measurement greater mdc true change repeated measurements inferred30 detailed characteristics participants soft tissue thickness around shoulder joint shown table 1table 1.characteristics participantscharacteristicparticipantsgendermale7female4age years)22.8 2.7supraspinatus muscle tendon thicknessright mm)4.73 0.8left mm)4.47 0.6subacromial burse thicknessright mm)0.66 0.3left mm)0.66 0.2biceps tendon thicknessright mm)2.21 0.6left mm)2.31 0.6 sst thickness values follows right 4.73 0.8 mm left 4.47 0.6 mm sab thickness values follows right 0.66 0.3 mm left 0.66 0.2 mm bt thickness values follows right 2.21 0.6 mm left 2.31 0.6 mm the results relative reliability sst sab bt thickness shown table 2table 2.relative absolute reliability supraspinatus tendon subacromial bursa biceps tendon ultrasound measurement n=22)soft tissueicc 95%ci)semmdc95bland altman analysisdsdd95%ci dsst0.91 0.800.96)0.090.260.070.310.070.21sab0.82 0.630.92)0.070.180.030.160.040.10bt0.90 0.790.96)0.080.230.010.260.100.13icc intraclass correlation coefficient 95%ci 95% confidence interval sem standard error measurement mdc minimal detectable change mdc95 95%ci mdc sst supraspinatus tendon sab subacromial bursa bt biceps tendon the relative reliability sst sab bt thickness rated excellent icc=0.91 95% ci=0.800.96 good icc=0.82 95% ci=0.630.92 excellent icc=0.90 95% ci=0.790.96 respectively icc intraclass correlation coefficient 95%ci 95% confidence interval sem standard error measurement mdc minimal detectable change mdc95 95%ci mdc sst supraspinatus tendon sab subacromial bursa bt biceps tendon results absolute reliability sst sab bt thickness shown table 2 the 95% cis sst sab bt thickness 0.070.21 0.040.10 0.100.13 respectively sems sst sab bt thickness 0.09 0.07 0.08 respectively mdcs95 sst sab bt thickness 0.26 0.18 0.23 respectively in present study standard methods used evaluate relative absolute reliability ultrasound measurements sst sab bt thickness ultrasound measurements present study exhibited good relative absolute reliability demonstrating high degree agreement 1st 2nd measurements small measurement error lack systematic bias establishing reliability tool adequate measurement sst sab bt thickness is essential prerequisite tool adopted standard measurement patients acute adhesive capsulitis the iccs sst sab bt thickness 0.91 0.82 0.90 respectively relative reliability evaluated using criteria outlined kuwahara et al sst sab bt thickness rated good great23 therefore relative reliabilities ultrasound measurement sst sab bt thickness demonstrated high supraspinatus tendon thickness data healthy adult icc=0.91 95% ci=0.800.97)16 university student hong kong icc=0.92 95% ci=0.900.98)12 indicated excellent reliability present study detailed landmark set scanning sst sab bt via ultrasonography by contrast previous studies supraspinatus tendons scanned landmark set13 17 sst infraspinatus tendons close proximity greater tubercle humerus therefore sst scanned alone ultrasonography necessary scan sf greater tubercle detailed landmark set scanning sst via ultrasonography difficult scan sf greater tubercle the shoulder joint consists plural joints including glenohumeral acromioclavicular sternoclavicular scapulothoracic joints it difficult attain alignment shoulder joint subjects therefore sst sf greater tubercle scanned via monitor ultrasonography device the result relative reliability present study demonstrated good relative reliability therefore thought ultrasound measurement method study effective bland altman statistics ultrasound measurement sst sab bt thickness indicated significant systematic bias repeated measurements the mean differences two testing sessions close 0 95% ci included 0 it difficult resolve systematic bias repeated measurements conditions test inferential statistics nullified systematic error occurs study planning experimental phases31 present study significant systematic bias sem mdc95 assess measurement errors repeated measurements determine whether changes occur repetitions present study the mdcs95 sst sab bt thickness 0.26 0.18 0.23 respectively changes repeated measurements sst sab bt thickness 0.26 0.18 0.23 mm respectively change real within 95% ci a treatment effect may indicated changes sst sab bt thickness detected ultrasound measurement mdc95 values acute adhesive capsulitis patients the results reliability testing present study showed ultrasonography may useful measurement tool assessing condition acute adhesive capsulitis patients effects treatment ultrasonography many advantages including ability scan soft tissue simply immediately therefore suggest physical therapists evaluate acute adhesive capsulitis patients via ultrasound measurements determine severity condition assess treatment effects result first validities measurement sst sab bt thickness examined second small number participants adversely affected power study finally study evaluated healthy young adults the final objective present study form standard ultrasound measurement patients acute adhesive capsulitis majority patients adhesive capsulitis are elderly reliability ultrasound measurements examined elderly individuals future the present study examined reliability ultrasound measurement sst sab bt thickness the results demonstrated relative reliability measurements ranges good great systematic error detected absolute reliability testing these examinations reliability suggest possible use ultrasound measurements evaluation condition acute adhesive capsulitis patients assess treatment effects	[ purpose ] the purpose of this study was to examine the reliability of ultrasound measurements by analyzing the relative reliability and absolute reliability when measuring soft tissue thickness around the shoulder joint . [ subjects and methods ] eleven healthy young adults ( 22 shoulders ) participated in this study . thickness of the supraspinatus tendon , subacromial bursa , and biceps tendon was measured on both shoulders . this protocol was performed twice in the same day . the relative reliability of ultrasound measurement was evaluated using the intraclass correlation coefficient for determining the degree of consistency and agreement between two measures . the absolute reliability of the ultrasound measurement was evaluated using the standard error of measurement , minimum detectable change , and bland - altman analysis . [ results ] ultrasound measurements exhibited high relative reliability : intraclass correlation coefficients for the supraspinatus tendon , subacromial bursa , and biceps tendon thickness were demonstrated to be 0.91 , 0.82 , and 0.90 , respectively . bland - altman analyses revealed no significant systematic bias between the repeated measurements for the supraspinatus tendon , subacromial bursa , and biceps tendon thickness . [ conclusion ] these findings suggest that ultrasound measurement for the supraspinatus tendon , subacromial bursa , and biceps tendon thickness exhibited good relative reliability and no systematic errors were detected regarding their absolute reliability .
acute tumor lysis syndrome tls constellation metabolic disturbances develop rapidly proliferating tumors mainly hematologic malignancies rarely solid tumors initiation cytotoxic therapy it characterized release large amounts potassium phosphate nucleic acids systemic circulation this lead hyperuricemia hyperphosphatemia hyperkalemia hypocalcemia cause lactic acidosis acute renal failure cardiac arrhythmias seizures muscle cramps tetany syncope possibly sudden death tls reported occur cases solid tumors without prior therapy here we report unusual case maxillary squamous cell carcinoma scc presented months treatment primary disease diffuse liver metastases tls the patient 53-year old man started complain progressive left cheek pain nasal obstruction epistaxis ct scan head neck showed left maxillary sinus mass invading medial anterior walls sinus extending left nasal cavity soft tissues cheek eroding floor orbit biopsy tumor revealed infiltrating squamous cell carcinoma arising inverted papilloma focal high grade dysplasia the patient underwent radical maxillectomy showed infiltrating squamous cell carcinoma 2.8 2 2 cm originating inverted papilloma presence vascular perineural invasion negative margins resection after surgery patient received adjuvant chemoradiation 66 gy tumor bed 50 gy upper neck area end treatment abdominal ultrasound requested revealed multiple hypoechoic liver nodules suspicious metastases fig ct guided core biopsy one lesions performed showed high grade carcinoma focal positivity ck8/18 staining high molecular weight cytokeratin compatible metastatic poorly differentiated carcinoma similar previous pathology four days later patient presented emergency room decrease level consciousness abdominal pain laboratory investigations revealed bun 144 mg dl creatinine 6.4 mg dl uric acid 20.9 mg dl potassium 7.6 mg dl phosphorus 11.8 mg dl calcium 6.2 mg dl alp 734 iu l ggt 621 iu l lactate dehydrogenase ldh 1,000 u l table 1 the clinical picture rapidly progressive disease acute deterioration electrolytes kidney function favor acute tls he also given one dose rasburicase 8 mg deteriorated rapidly passed away following day tls tls characterized hyperphosphatemia hyperuricemia hyperkalemia hypocalcemia lactic acidosis acute renal failure hyperuricemia result purine degradation may lead precipitation uric acid crystals collecting tubules kidney resulting obstructive nephropathy hyperkalemia due potassium release cytoplasm may lead cardiac arrhythmias cardiac arrest hyperphosphatemia caused nucleoprotein degradation may cause precipitation calcium phosphate renal tubules hypocalcemia follows precipitation calcium phosphate tissues may cause neurologic muscular symptoms patients highest risk acute tls large tumor burden rapidly proliferating tumors mainly hematologic malignancies leukemia lymphoma acute tls metabolic complication chemotherapy cytotoxic therapy induce cytolysis neoplastic cells release intracellular substances precipitate syndrome it rarely seen solid tumors reported occur therapy review literature kalemkerian et al found 25 cases patients solid tumors developed acute tls treatment these tumors usually bulky multiple metastatic sites acute tls described develop recent treatment only cases spontaneous tls solid tumors described without prior therapy table 2 case acute tls may due cell turnover rather treatment effect crittenden ackerman first report case disseminated adenocarcinoma gastrointestinal tract renal failure high levels uric acid we reported first case tls secondary liver metastases primary maxillary scc hand the incidence lymphadenopathy diagnosis low maxillary sinuses limited lymphatic supply reviewed 220 patients treated nasal paranasal sinus carcinoma 1975 1994 minimum follow 4 years found 9 patients 4.3% developed distant metastasis in recent study published tanvetyanon et al medical records patients inverted papilloma ip scc treated 1999 2007 retrospectively reviewed four biopsy specimens described scc arising ip one case read carcinoma situ arising ip one ip areas severe dysplasia liver metastases described one case discovered time local recurrence along lung metastases 33 months diagnosis conclusion our case unique far patient developed liver metastases rare location distant metastases maxillary tumors even without developing local locoregional recurrence development spontaneous tls unusual finding solid tumors never reported sinus scc spontaneous tls anticipated solid tumors large volume metastatic disease	acute tumor lysis syndrome ( tls ) is a condition resulting from rapid destruction of tumor cells and subsequent massive release of cellular breakdown products . it has been described following the treatment of many hematologic and solid malignancies . however , spontaneous tls has rarely been described . here we report a case of spontaneous tls that occurred in a patient with a treated maxillary squamous cell carcinoma ( scc ) presenting with diffuse liver metastases , which is an infrequent site of distant metastases .
mind never passive perpetual activity delicate receptive responsive stimulus you postpone life sharpened whatever interest attaches subject matter must evoked whatever powers strengthening pupil must exercised whatever possibilities mental life teaching impart must exhibited that golden rule education difficult rule follow ( alfred north whitehead presidential address mathematical association january 1916 peets colleagues report strategy selecting content inclusion critical care curriculum residents the authors constructed three domain classification common clinical problems asked resident trainees attendings score problem according threat life frequency reversibility the scales organized give greatest weight greater life threat higher frequency ease reversibility the authors report strong concurrence product domain scores resident trainees supervising attending physicians conclusion authors assert process widely applicable facilitate creation reliable valid curriculum it unsurprising residents teaching staff similar assessments three objective features listed for example brain death appears bottom priority list irreversible definition if resident attending scored brain death anything reversible would surprising problematic similarly frequency condition brain death intensive care unit icu studied degree brain death threatens life matters debate greater concern however methodology advanced authors results brain death placed bottom needs assessment the authors state key messages tool provide content validity curriculum herein lies greatest problem methodology overvalues curricular elements focus reversible conditions the unfortunate fact many patients admitted icu conditions either respond critical care terminal curricula fail forthrightly confront reality perpetuate costly quixotic efforts cure care would appropriately directed towards comfort dignity the scoring logic relegates end life decision making arguably one important activities icu level importance obstetrical complications the critical question left unaddressed methodology proposed selecting curricular elements whether topics highly ranked uniquely best learned icu for example topics shock seizure drug overdose highly ranked also frequently encountered emergency department in contrast management acute fulminant hepatic failure strategies reverse conditions else indicate need transplantation learned icu yet acute fulminant hepatic failure ranks brain death needs assessment listing summary authors complimented conducting needs assessment also reporting strong concurrence trainees supervisors the report serve basis ensuring acute critical care topics covered within comprehensive curriculum spanning entire training period the fact condition might reversible diminish importance icu curriculum contrary one might reasonably argue brain death fulminant organ failure end life decision making ought pushed near top priority list topics explored icu rotation trainees	curricula for residents on rotations through intensive care units are necessarily abbreviated . the selection ( and omission ) of topics can be informed by assessment of perceived needs . a curriculum can not , however , be formed exclusively from the top - scoring needs . topics that are encountered exclusively in the critical care unit ( such as brain death ) must be included .
cutaneous metastasis defined spread tumor site primary origin skin skin metastasis may first sign advanced cancer indicator cancer recurrence 2 3 9% patients cancer may develop skin metastases metastasis may develop 10 years initial cancer diagnosis a wide morphologic spectrum clinical appearances described cutaneous metastases including nodules plaques papules tumors ulcers while carcinomas common type cancer metastasize sarcomas lymphomas leukemias also represent substantial percentage skin metastases the relative frequencies metastatic skin disease sex correlate frequency different types primary cancer thus women skin metastases following distribution decreasing order primary malignancies breast ovary oral cavity lung large intestine men the distribution follows lung large intestine oral cavity kidney breast esophagus pancreas stomach liver generally cutaneous metastases herald poor prognosis average survival time months in present five year study patients diagnosed internal malignancy including hematolymphoid neoplasms registered march 2009 march 2014 pathology department consecutively screened the h&e stained histopathological sections skin biopsies received pathology department reevaluated the inclusion criteria cases cutaneous metastatic deposits without known primary malignant tumor physical dermatologic examination details obtained patient files histopathology requisition forms the clinical presentation site histopathological details especially suggesting primary tumor site evaluated along secondary morphological changes skin tissue immunohistochemistry performed except one case cutaneous metastases correlation primary internal malignancy done in present five year study total 1924 malignant tumors screened included nine cases cutaneous metastatic deposits the cutaneous metastases seen females 5 9 patients the four male patients skin metastases renal cell carcinoma non hodgkin lymphoma 2 cases the age range found 3072 mean age 60 years wide range clinical presentations regional localizations noted plaque nodule frequent clinical presentation 4 cases 9 followed ulcer 1 case 9 the size skin lesions varied 0.25 cm 5.0 cm the regional localization cases breast carcinoma included chest 2 cases chest abdomen 1 case face scalp trunk 1 case a case non hodgkin lymphoma showed widespread skin deposits face scalp trunk another case showed localized deposits abdomen a single case carcinoma cervix showed skin deposits thigh table 1 the duration time cutaneous metastases developed variable ranged 10 months five years majority cases patients prior history primary internal malignancy the morphological patterns microscopic appearances suggested likely tissue origin cases cutaneous metastases carcinoma breast histologic examination revealed invasion dermis subcutis groups cords nests tumor cells er pr positivity seen 3 4 cases cutaneous metastases carcinoma breast the metastatic deposits negative er pr previous reports er pr negativity primary tumor the deposits renal cell carcinoma showed presence tumor cells glandular configuration nests ihc cd-10 applied confirmed diagnosis cases figures 2 3 the deposits non hodgkin lymphoma showed diffuse presence atypical lymphoid cells dermis subcutis the atypical lymphoid cells showed finely stippled chromatin inconspicuous nucleoli sparse cytoplasm there evidence epidermotropism ruled possibility primary cutaneous lymphoma leucocyte common antigen cd 45 positive cases figures 4 5 the deposits carcinoma cervix showed presence tumor cells arranged groups nests the tumor cells large showed vesicular nuclei moderate amount eosinophilic cytoplasm as epidermis involved differentiation cutaneous metastatic deposits primary squamous cell carcinoma possible moreover prior history squamous cell carcinoma cervix three years back also suggested metastatic skin deposits in cases cutaneous metastatic deposits main challenge pathologist exclude possibility primary skin neoplasms including benign malignant adnexal tumors inflammatory conditions skin especially cases skin deposits nhl cutaneous metastases occur infrequently rarely present time cancer initially diagnosed cutaneous metastases occur 0.6%10.4% patients cancer represent 2% skin tumors present five year study 9 cases total 1924 patients internal malignancies presented cutaneous metastases thus showing prevalence rate approximately 0.5% near lower limit reported range cutaneous metastases may either initial manifestation internal malignancy represent recurrent neoplastic disease present study nine patients prior history primary internal malignancy thus representing recurrence primary tumor a landmark study brownstein helwig 1972 found common tumors metastasizing skin breast lung colorectal melanoma gul et al study found common cancer types metastasizing skin breast colon ovary females lung colon cancers males present study the order cutaneous metastases internal malignancy carcinoma breast 4/9 cases carcinoma cervix 1/9 case females renal cell carcinoma non hodgkin lymphoma 2/9 cases males cutaneous metastases carcinoma breast common finding concordance mentioned studies according basu mukherjee gynecological malignancies rarely give rise metastatic deposits skin skin metastasis uterine cervical carcinoma rare event reported incidence ranging 0.1 2% our study also included single case cutaneous metastasis carcinoma cervix quite rare skin metastases renal cell carcinoma easily identified low suspicion index skin lesions usually mimic common dermatologic disorders skin metastases renal cell carcinoma reported occur around 3% renal tumors common males study we reported two cases cutaneous metastases renal cell carcinoma patients males cutaneous metastases frequently 2.6% seen cases hematological malignancies study done gul et al present study cutaneous metastases nhl rcc common tumors males observed many carcinomas spread lymphatic route areas common lymphatic drainage primary site present study as well skin deposits breast carcinoma mainly localized chest wall scalp relatively rare site localization skin metastases study two nine cases showed cutaneous metastases scalp according lookingbill et al common presentation cutaneous metastatic deposits multiple nodular lesions contrary nodules plaque common clinical presentation study metastatic carcinomas usually differentiated primary skin carcinomas latter typical histological patterns epidermal connection intraepidermal intra adnexal situ component tumor presence benign counterpart 3 6 cases distinction metastatic primary skin tumor difficult variety immunohistochemical staining panels helpful 1317 study ihc applied eight nine cases correlated well primary tumor tumor markers becoming increasingly important breast cancer research impact prognosis treatment survival the er pr markers used skin deposits breast carcinoma confirmed primary tumor according bauer et al er pr her-2 neu negative breast cancers affect younger women aggressive women poorer survival regardless stage two cases histopathological diagnosis clear cell carcinoma immunostaining cd 10 confirmed metastatic renal cell carcinoma similarly lca positivity confirmed metastatic deposits nhl two cases conclude cutaneous metastases occur infrequently internal malignancy rarely presents skin involvement however early diagnosis necessary may profound effect patient management survival	cutaneous metastases from internal malignancies are uncommon and occur in 0.6%10.4% of all patients with cancer . in most cases , cutaneous metastases develop after the initial diagnosis of the primary internal malignancy and late in the course of the disease . skin tumors are infrequent in asian population and cutaneous metastases are quite rare . cutaneous metastases carry a poor prognosis with average survival of few months . in the present five - year study 1924 malignant tumors were screened which included only nine cases of cutaneous metastatic deposits . a wide range of site and clinical presentations including nodules , plaques , and ulcers was noted . histopathological findings were significant and corresponded with the primary internal malignancy . cutaneous metastases from breast carcinoma ( 44.4% ) were the most common finding followed by non - hodgkin lymphoma and renal cell carcinoma ( 22.2% each ) and carcinoma cervix ( 11.1% ) . the aim of our study is to classify the cutaneous metastases and to evaluate their clinicopathologic and immunohistochemical correlation with the primary tumor .
gestational diabetes gdm carbohydrate intolerance first recognized and/or diagnosed pregnancy common metabolic complication gestation prevalence estimated around 14% 2 3 obesity family history diabetes belonging certain ethnic groups increase risk gdm 411 if disorder properly monitored treated cause severe complications mother including preeclampsia cesarean delivery glucose intolerance type 2 diabetes delivery child macrosomia hypoglycemia hyperbilirubinemia adolescent obesity glucose intolerance diabetes 2 4 12 13 immigration rates recently increased italy immigrants account 4% resident population 48% immigrant population consists women 65% reproductive age some studies demonstrated tendency adverse outcomes pregnancy among immigrant women countries high rates diabetes 58 immigrants differ cultural background eating habits aimed assess women compliance dietary restrictions possible benefit terms maternal fetal outcome adopting nonstandard ethnic based approach diet for pilot study twenty pregnant immigrant women gdm followed metabolic disease diabetology unit padova university january june 2008 enrolled the study protocol complied helsinki declaration approved local ethics committee written informed consent obtained participants screening gdm done glucose challenge test gct weeks 24 28 gestation diagnosis confirmed 100 g oral glucose tolerance test ogtt recommended 4th international workshop conference gdm the women enrolled randomly assigned two groups one adopted standard meal plan smp prepared according ada guidelines ethnic meal plan emp table 1 all women monitored achieve good metabolic control fasting plasma glucose fpg ) < 5.3 mmol l 1 h postprandial plasma glucose 1 h pppg 7.2 mmol l nurses taught monitor blood glucose levels the pregnant women diet treatment performed 2 measurements per day measuring fasting 1 h postprandial glucose alternate meals course week the women insulin therapy performed self glucose monitoring four times day fasting 1 h breakfast lunch dinner insulin treatment started fpg and/or 1-hour pppg exceeded level one measurement all gdm women followed metabolic obstetric purposes delivery maternal characteristics outcome considered age prepregnancy body mass index bmi kg time gdm diagnosis hba1c gdm diagnosed delivery percentage patients insulin weight gain timing mode delivery hypertensive disorders fetal outcome considered birth weight infants large small gestational age lga sga fetal composite outcome hypoglycemia neonatal asphyxia respiratory distress syndrome hyperbilirubinemia hypocalcemia fetal malformations babies were lga birth weight 90th percentile sga 10th percentile according population specific standard growth tables macrosomia diagnosed fetus weighing 4000 g. dietary assessment conducted determine whether woman intake essential nutrients adequate whether eating excessively identify foods avoided well food intolerances allergies meal plan food models using measures cups glasses bowls proved helpful props teaching appropriate serving sizes the two groups received different meal plans group 1 adopted smp gdm according ada guidelines group 2 adopted emp included typical foods women home countries identified using photographic atlas dietmeter photographic atlas scotti bassani 1719 dishes broken various ingredients shown raw cooked due difficulties using kitchen scales measures cups or the two meal plans nutrient composition smp cho 53% l 28% p 18% fiber 26 g emp cho 55% l 28% p 17% fiber 21 g energy intake 1800 2200 kcal depending prepregnancy bmi adherence diet measured using 24-hour food intake recall method scored 0 intake 20% higher prescribed 1 intake 1020% higher 2 consistent plan 10% lower the intake calculated individual tables based inran nutritional tables 2000 version hba1c measured using standard hplc normal range assumed healthy pregnant women 4.05.5% 2037 mmol mol data given means standard deviations compared using student test unpaired data paired data comparisons drawn different times sample the groups compared categorical data frequency event using test yates correction the ethnic distribution emp group chinese 1 filipino 1 moroccan 1 nigerian 3 romanian 4 bangladeshi 1 smp group chinese 1 moroccan 1 nigerian 1 romanian 4 sudanese 1 bangladeshi 1 hungarian 1 difference two meal plan groups table 2 shows women clinical metabolic characteristics maternal fetal outcomes mean age prepregnancy bmi time gdm diagnosis comparable two groups the emp group better fpg 1hpppg hba1c values smp group weight gain lower though significantly emp group figure 2 the newborns birth weight slightly higher smp group also included lga 3 versus 0 p 0.001 macrosomic babies 2 versus 0 emp group no fetal complications congenital malformations seen either group table 2 adherence meal plans better emp group 7 women scoring 1 2 good adherence opposed 2 women smp group italian data pregnancy indicate relatively poor outcome pregnancies due difficulties accessing care following medical recommendations cultural social reasons immigrant populations also higher risk type 2 diabetes gestational diabetes 2 8 10 better standards living host countries often negative effects health immigrant populations partly foreign citizens acquire eating habits lifestyles unsuited genetic profile regarding gdm problem exacerbated genetic predisposition african afro american hispanic races develop diabetes 4 8 9 nutritional therapy immigrant women take social cultural religious value attached food various ethnic groups account study main problems women prescribed diet related difficulties changing eating habits problems managing meal plan weighing foods doubts concerning foods choose difficulties achieving right nutritional balance hand many studies confirmed important influence dietary treatment outcome gdm the real difference two meal plans used lies diet examples typical dishes presented the meal plan containing new elements adapted different ethnic cultural needs photos practical domestic units measure illustrate quantities food plus lists alternative foods photos showing foods raw cooked proved useful effective immigrant women gdm since adherence better among patients adopting emp better adherence coincided better glycemic control normal weight gain better pregnancy outcome birth weights lower lga sga babies emp group the weakness study lies small numbers patients considered best knowledge first study feasibility efficacy customized dietary treatment immigrant gdm patients this pilot study indicates positive effect ethnic approach diet outcome pregnancy the new methods introduced study could considered valid approach nutritional management immigrant pregnant women gestational diabetes mellitus it points prescribing diet immigrant women different traditional eating habits borne mind a study adequate number women chosen accordance power calculation necessary useful confirm preliminary data	background . medical nutritional therapy is the most important method for normalizing glucose levels in pregnancy . in this setting , there is a new problem to consider relating to migrants , their personal food preferences , and ethnic , cultural , and religious aspects of their diet . we compared maternal and fetal outcomes between two multiethnic groups of pregnant women , one adopting a food plan that included dishes typical of the foreign women 's original countries ( the ethnic meal plan group ) , while the other group adopted a standard meal plan . findings . to develop the meal plan , each dish chosen by the women was broken down into its principal ingredients . the quantity of each food was given in tablespoons , teaspoons , slices , and cups , and there were photographs of the complete dish . the group treated with the ethnic meal plan achieved a better metabolic control at the end of the pregnancy and a lower weight gain ( though the difference was not statistically significant ) . as for fetal outcome , the group on the ethnic meal plan had babies with a lower birth weight and there were no cases of macrosomia or lga babies . conclusions . this preliminary study indicates the positive effect of an ethnic approach to diet on the outcome of pregnancy .
	adequate cognitive functioning is essential for daily activities . when there is an insult to the brain , cognitive abilities can suffer , which , in turn , produce substantial medical and functional impairment . advances in neurobiology , circuit neuroscience , and clinical assessment technology are converging in a manner that holds promise for the development of new pharmacological agents for cognitive enhancement in neuropsychiatric disease .
therefore numerous methods used reduce total fertility rate men women especially developing countries most poorest countries especially sub saharan africa characterized rapid population growth 1 it estimated half conceptions unplanned half resulting pregnancies undesired 2 cases half unintended pregnancies due failure use contraception half difficulties contraceptive usage method failure 3 poor nations contraceptive use limited restricted access many available methods economically culturally undesired pregnancies result unwanted children disproportionately suffer poverty neglect 4 5 women wide range contraceptive choices ranging daily oral medications intrauterine devices implanted every 5 years sterilization research family planning organizations long time focused upon female methods contraception women bear disproportionate portion health economic consequences childbearing rearing the consequence long neglect developing acceptable reliable male contraceptives poor developing countries lack lower participation males family planning recently become apparent neglecting men matters family planning losing strategy adverse consequences men women 6 men around world africa showing willingness actively participate family planning despite drawbacks currently available male contraceptive methods disadvantages methods vasectomy readily reversible condoms high typical failure rate there many references plants antifertility properties literature 7 8) numerous plants products also shown possess antispermatogenic activities 9 10 aim study investigate effect medicinal herb acacia nilotica a. nilotica various male fertility parameters since toxicity plant yet known rat model used dried pods a. nilotica obtained local forest blantyre malawi winter season may july botanical identification done malawi national herbarium botanical gardens specimen given voucher number 1mal the dried pods plant grounded homogenous thin powder using electric grinder the crude extract prepared making suspension 100 g powder 500 ml water make aqueous extract the suspension left stand overnight room temperature constant agitation filtered the solution concentrated vacuum 40c using rotor vapour crystals formed sexually mature male wistar rats 284430 g body weight housed standard rat cages maintained standard conditions 12 hr light dark cycle 253c temperature 35% 60% relative humidity provided standard laboratory chow water ad libitum one group received a. nilotica treatment 200 mg kg rat daily group acted control a. nilotica treatment withdrawn remaining animals 8 weeks sacrificed after last day treatment body weight animal recorded killed along control animals testis cauda epididymis animal excised surrounding tissue blotted free blood weighing the cauda epididymis separated minced using pair small scissors release sperm 10 ml warmed physiological saline the sperm suspension placed incubator 37c 10 min prior total motility progressive motility assessment the aliquot sperm suspension diluted 5 times warm physiological saline placed makler counting chamber motile sperm counted light microscope progressive total sperm motility expressed percent motile sperm total sperm count sperm count five counts per sample made averaged the smears left air dry stained rapid diff staining australian biostain australia briefly smears submerged 6 one second dips rapid diff fixative the smears dipped six times one second rapid diff stain 1 followed six dips rapid diff stain 2 finally slides rinsed phosphate buffer ph 6.8 air dried the right testes control experimental groups dissected fixed formal saline the tissues processed histological examination paraffin sections stained hematoxylin eosin qualitative microscopic examination made serum concentration total testosterone determined using coat count total testosterone assay kit diagnostic products co. usa per manufacturer instruction assay sensitivity 0.2 ng ml results analyzed prism 4 statistical program graphpad usa one way anova bonferroni post hoc test p<0.05 used statistical analysis dried pods a. nilotica obtained local forest blantyre malawi winter season may july botanical identification done malawi national herbarium botanical gardens specimen given voucher number 1mal the dried pods plant grounded homogenous thin powder using electric grinder the crude extract prepared making suspension 100 g powder 500 ml water make aqueous extract the suspension left stand overnight room temperature constant agitation filtered the solution concentrated vacuum 40c using rotor vapour crystals formed sexually mature male wistar rats 284430 g body weight housed standard rat cages maintained standard conditions 12 hr light dark cycle 253c temperature 35% 60% relative humidity provided standard laboratory chow water ad libitum one group received a. nilotica treatment 200 mg kg rat daily group acted control a. nilotica treatment withdrawn remaining animals 8 weeks sacrificed after last day treatment body weight animal recorded killed along control animals testis cauda epididymis animal excised surrounding tissue blotted free blood weighing the cauda epididymis separated minced using pair small scissors release sperm 10 ml warmed physiological saline the sperm suspension placed incubator 37c 10 min prior total motility progressive motility assessment the aliquot sperm suspension diluted 5 times warm physiological saline placed makler counting chamber motile sperm counted light microscope progressive total sperm motility expressed percent motile sperm total sperm count sperm count the smears left air dry stained rapid diff staining australian biostain australia briefly smears submerged 6 one second dips rapid diff fixative the smears dipped six times one second rapid diff stain 1 followed six dips rapid diff stain 2 finally slides rinsed phosphate buffer ph 6.8 air dried the right testes control experimental groups dissected fixed formal saline the tissues processed histological examination paraffin sections stained hematoxylin eosin qualitative microscopic examination made serum concentration total testosterone determined using coat count total testosterone assay kit diagnostic products co. usa per manufacturer instruction the results analyzed prism 4 statistical program graphpad usa one way anova bonferroni post hoc test p<0.05 used statistical analysis the sperm motility results showed rats treated a. nilotica significantly low total motility compared control rats p<0.05 withdrawing treatment did improve total motility back control level p<0.05 table 1 progressive motility significantly decreased a. nilotica treated group well treatment withdrawn group compared controls p<0.05 respectively table 1 sperm concentration significantly decreased a. nilotica treated group well treatment withdrawn compared control group p<0.05 respectively table 1 abnormal sperm morphology significantly increased treated treatment withdrawn groups compared controls p<0.05 respectively table 1 hand testosterone levels significantly lower treated group compared controls p<0.05 table 1 the effects acacia nilotica treatment total sperm parameters plasma testosterone levels wistar rats values rows meanssem means followed letter row differ significantly letter row differs control p<0.05 testicular histology study seminiferous tubules control animals showed clear organization cells various stages spermatogenesis clear spermatozoa maturation occurring near lumen figure 1 treated rats transverse sections ts seminiferous tubules control rats transverse sections ts seminiferous tubules rats treated acacia nilotica this study showed treating rats a. nilotica 16 weeks leads decreased total sperm motility well progressive motility withdrawing treatment 8 weeks the study also shows a. nilotica treatment rats reduces testosterone level however treatment withdrawn testosterone levels return normal values this indicated histological study testis extract fed animals exhibited partial depletion spermatogenic process in carica papaya seed extract caused androgen deprivation male rats leading alterations internal milieu cauda epididymis 7 development effective safe acceptable male contraceptive challenging embraced males must effect libido sexual function must reversible the approach development male contraceptive either inhibit production sperm interfere sperm function structure interrupt sperm transport interrupt sperm deposition prevent sperm egg interaction 9 10 finding oral herbal contraceptive would allow couples control fertility without consulting health worker turn would markedly increase number couples practicing family planning other advantages contraceptive would include familiarity rural people africa herbal medicines fewer side effects associated herbal preparations availability local sources protection privacy 11 trees a. nilotica africa already recognized use traditional medicine well gum potential food pharmaceutical applications it reported bark a. nilotica able treat headaches leaves treat constipation 12 from study evident a. nilotica severely affects male animal fertility parameters	backgrounda bulk of contraceptives on the market is women - oriented today . the aim of this study was to investigate the effect of a medicinal herb , acacia nilotica on various parameters of male fertility using a rat model.methodsmale wistar rats ( n = 40 ) were randomly divided in to two groups . one group received acacia nilotica , while the other acted as controls . ten animals from each group were sacrificed after 16 weeks . treatment was withdrawn for the remaining animals for 8 weeks . blood was collected for hormonal analysis . the testis was removed for histological examination , while epididymal spermatozoa were retrieved for motility and morphological analysis . the data were analyzed using anova and bonferroni post hoc test . a value of p<0.05 was considered statistically significant.resultssperm motility , progressive motility and sperm concentration significantly decreased in treated animals compared to the controls ( p<0.05 ) . withdrawing the treatment did not restore these parameters ( p<0.05 ) . abnormal sperm morphology significantly increased in both the treated and treatment withdrawn groups when compared to the controls ( p<0.05 ) . testosterone concentrations were significantly lower in the treated group when compared to the controls ( p<0.05 ) and no significant differences were observed between the controls and the treated animals when treatment was withdrawn . histological observations showed that acacia nilotica treatment disrupted semeniferous tubule architechture and consequently the spermatogenesis process.conclusionthese results show that acacia nilotica severely affects sperm morphology , progressive motility and sperm concentration irreversibly in wistar rats .
recently stem cell much anticipated research area especially cell based therapeutic strategies,1 obtain stem cell several tissues like bone marrow umbilical cord adipose periodontal ligament.2,3 already known bone marrow derived mesenchymal stem cells bmmscs self renewal capacity pluripotency differentiate types cells bone cells cartilage cells adipose cells.1,4,5 however main issue bmmscs get cells effectively the isolation proliferation mscs mouse human species difficult owing cultures contaminated unexpected non mscs several passages.6,7 number techniques developed isolate mscs improve purity.6 based technique novel way introduced change media composition.8 numerous factors contribute cell attachment growth fetal bovine serum fbs ubiquitously used essential component animal cell culture contains hormones growth factors adhesion promoting molecules like fibronectin vitronectin.9,10 another interesting factor 1 25-dihydroxyvitamin vd3 regulates cell proliferation differentiation,11 effects may vary different types cells.12 moreover growth factor like recombinant human epidermal grow factor rhegf also thought enhancer growth rate.13 however till research completely analyzed suitable density three factors mbmmsc culture the present study therefore conducted focus mbmmscs response different concentration fbs vd3 rhegf order make conclusion regarding density best condition cell growth six eight weeks specific pathogen free spf grade c3h female mouse weighting 20 25 g used study fed standard diet the animal husbandry procedures performed institutional animal care use committee seoul national university school dentistry conducted according national institute health guideline all study procedures approved institutional review board seoul national university school dentistry irb then animal skeleton rinsed 70% ethanol followed making incision close hind limbs attach trunk striping skin pulling toward foot cut anklebone this eliminates contact hind limb animal fur source contamination then hind limbs trunk body dissected cutting along spinal cord care damage femur dissected limbs stored ice pack phosphate buffered saline pbs gibco life technologies grand island ny usa containing dish dissection hind limb performed hood the muscle connective tissue removed tibia femur forceps.14 harvesting bone marrow done hood using appropriate sterile technique follows firstly wipe bone napkin moist 70% ethanol then cut ends tibia femur end marrow cavity using scissors insert 27-gauge needle attached 10-ml syringe containing serum free media sfm)-(without fbs cut end bone the reason using sfm except interference fbs test effects different density fbs flush marrow plug cut end bone sfm collect 15-ml tube ice filter cell suspension 70 nylon filter mesh bd falcon bd biosciences discovery labware frankin lakes nj usa remove bone trivial debris muscle cell clumps.14 cells treated ack lysing buffer lonza wakersville md usa 5 min centrifuged 1500 rpm 4 5 min interference cells especially hematopoietic cell avoided the yield viability cells determined trypan blue gibco life technologies grand island ny usa cell number counted using hemocytometer the mbmmscs primary seeded density 10 60 mm dish cultured different conditional media 1 alpha minimum essential medium -mem)(gibco life technologies grand island ny usa supplemented different density 0% 1% 5% 10% 20% fetal bovine serum fbs)(equitech bio inc kerrville texas usa 1% antibiotic antimycotic gibco life technologies grand island ny usa 1% l glutamax gibco life technologies grand island ny usa 0.1% 2-mercaptoethanol gibco life technologies grand island ny usa 2 alpha minimum essential medium -mem supplemented 10% fbs media combined different density 0 nm 1 nm 10 nm 100 nm 1 25-dihydroxyvitamin vd3)(cayman chemical ann arbor mi usa 1% antibiotic antimycotic 1% l glutamax 0.1% 2-mercaptoethanol 3 alpha minimum essential medium -mem supplemented 10% fbs media combined different density 0 ng ml 20 ng ml 200 ng ml recombinant human epidermal growth factor rhegf prospec east brunswick nj usa 1% antibiotic antimycotic 1% l glutamax 0.1% 2-mercaptoethanol the cells incubated 37 95% humidified air 5% co2 72 hours non adherent cells removed washing phosphate buffered saline pbs twice fresh media added after 14 days cultures washed pbs twice stained 1% toluidine blue solution 2% paraformaldehyde pfa wako pure chemical industries ltd osaka japan incubated room temperature rt rocker overnight a cell cluster 50 cells counted colony microscopy all experiments repeated triplicate proliferation rate mbmmscs cultured presence 1 25-dihydroxyvitamin vd3 measured 3-(4,5-dimehylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2h tetrazolium mts assay briefly freshly isolated mbmmscs 10 cells seeded 96-well plastic culture plates incubated 200 l -mem supplemented different density 0 nm 1 nm 10 nm 100 nm vd3 1 day 4 days 7 days 10 days 14 days cell proliferation determined using celltiter 96 aqueous one solution reagent promega madison wi usa every point removal media wash pbs twice add 100 l sfm 20 l mts solution incubated 1 4 hours 37. formazan absorbance read 490 nm using plate reader software accent mts all data expressed mean sd differences groups analyzed using one way anova spss version 21.0 windows 7 post hoc turkey test considered statistically significant p values less .05 mbmmscs harvested c3h mouse 72-hour culture primary cells attached non attached cells eliminated pbs washing media changing after mbmmscs cultured different density fbs media vd3 media egf media 14 days represented different growth rate respectively 1 showed cells cultured 0% 1% fbs gradually died form colony fbs concentration increasing proliferation rate also improved simultaneously 5% fbs colony began form 10% 20% fbs cell proliferation significantly increased 20% dishes higher proliferation 10% dishes 3 showed proliferation cells cultured different density vd3 cell number increased increasing vd3 concentration 0 nm 10 nm and the cell number change 100 nm difference statistically significant 5 showed media containing egf accelerates cell growth media supplemented 20 ng ml egf highest cell proliferation compared 0 ng ml 200 ng ml egf 6 also indicated 20 ng ml egf dish colony numbers compared two dishes fig 7 showed cell proliferation 20% fbs significantly higher 10% fbs 5% fbs p<.05 8 showed difference growth 0 nm 1 nm 10 nm 100 nm vd3 statistically significant p>.05 9 showed compared remaining two groups cells cultured 20 ng ml egf exhibited significant increase cell viability p<.05 the additional proliferation assay conducted analyze function vd3 mbmmsc mts result fig 10 showed cell increased time every point vd3 play significant effect p>.05 day 10 in study described cellular response culture media containing different density fbs vd3 rhegf first since mouse bone marrow mesenchymal stem cell still difficult many researchers,7 study introduced novel way supplementing different components culture media primary isolated cell number cell growth rate increased previous studies paid attention modify isolation protocol employing centrifugation step,16 method plastic adherence,17 immunodepletion way,18 frequent media changing changing plating density.19 additionally choose fbs vd3 rhegf common easily obtained conventionally mscs cultured fbs containing media considered basal growth medium animal cell culture.20 tropel et al.20 indicated mouse bone marrow stem cells cultured without serum showed senescence signs died days li et al.21 published article rat bone marrow mesenchymal stem cells cultured different density fbs research used 10% 11% 15% fbs culture medium finally found serum concentration 11% preferential bmsc propagation we designed 0% 1% 5% 10% 20% five different density fbs culture medium in experiment cells cultured 0% 1% fbs media almost impossible grow along adding fbs cells gradually grown quickly amplified 10% fbs media cell proliferation was visibly increased 20% fbs media stronger effects cell growth 10% fbs media these results indicate mbmmscs could grow well without fbs fbs play pivotal role cell culture 1 25-dihydroxyvitamin d3 vd3 hormonally active form vitamin member lipophilic family ligands essential human metabolism.22 except role calcium skeletal homeostasis evidence increased potential osteoblast differentiation23 anti proliferation.24,25 previous study artaza et al.26 cultured mouse c3h 10t1/2 multipotent mesenchymal cells mmcs 10 nm 25 nm 50 nm 100 nm 500 nm without vd3 culture medium 4 days determined cell proliferation results indicated starting 25 nm vd3 induced statistically significant reduction cell number reaching plateau 100 nm okuno et al.12 also research culturing murine myogenic cell line c2c12 0 nm 1 nm 10 nm 100 nm vd3 containing medium results showed vd3 inhibited proliferation c2c12 myoblasts dose dependent manner 72 hours so study used vd3 investigate effect mouse bone marrow stem cells we also used 0 nm 1 nm 10 nm 100 nm four different vd3 containing medium study cell number slightly increased increasing vd3 density longer increased exceeding density 10 nm depth analysis except colony forming unit assay but data reveal statistical significance means vd3 little effects mbmmscs previous research several growth factors introduced stem cell culture like vegf fgf-2 pdgf egf.20,27,28,29 study choose egf inexpensive easy manipulate.28 recently et al.30 research whether epidermal growth factor gene transfected mesenchymal stem cells egf msc would accelerate fibroblast migration proliferation the study suggested egf increased expression cell adhesion molecules positive influence cell migration proliferation another study ml-1 fgf2 culture mouse epidermal neural crest stem cells epi ncscs 7 days the results suggest combination egf fgf2 stimulates proliferation improves neuronal potential epi ncscs order explore egf alone stimulating effect cell growth planned study results study consistent previous studies study used 0 ng ml 20 ng ml 200 ng ml egf egf represented promoting role indeed revealed 20 ng ml best condition cells all experiments possessed aim getting cells initial stage treated three different media cells showed different reactions collectively results study indicate fbs play main role primary cell acquisition proliferation growth factors like rhegf additional effects vd3 little effect cell proliferation based study people extensive research changing media components increase primary isolated cell number cell proliferation	purposethese days , mesenchymal stem cells ( mscs ) have received worldwide attention because of their potentiality in tissue engineering for implant dentistry . the purpose of this study was to evaluate various growth inducing factors in media for improvement of acquisition of bone marrow mesenchymal stem cells ( bmmscs ) and colony forming unit - fibroblast ( cfu - f).materials and methodsthe mouse bmmscs were freshly obtained from female c3h mouse femur and tibia . the cells seeded at the density of 106/dish in media supplemented with different density of fetal bovine serum ( fbs ) , 1 , 25-dihydroxyvitamin ( vd3 ) and recombinant human epidermal growth factor ( rhegf ) . after 14 days , cfu - f assay was conducted to analyze the cell attachment and proliferation , and moreover for vd3 , the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2h - tetrazolium ( mts ) assay was additionally conducted.resultsthe cell proliferation was increased with the increase of fbs concentration ( p<.05 ) . the cell proliferation was highest at the density of 20 ng / ml rhegf compared with 0 ng / ml and 200 ng / ml rhegf ( p<.05 ) . for vd3 , although the colony number was increased with the increase of its concentration , the difference was not statistically significant ( p>.05).conclusionfbs played the main role in cell attachment and growth , and the growth factor like rhegf played the additional effect . however , vd3 did not have much efficacy compare with the other two factors . improvement of the conditions could be adopted to acquire more functional mscs to apply into bony defect around implants easily .
patients sepsis abundant activation inflammatory pathways results demonstrable circulating levels inflammatory cytokines chemokines activated inflammatory cells markers increased inflammatory activity these abnormalities range subtle activation coagulation detected sensitive markers coagulation factor activation marked activation may detectable based small decrease platelet count subclinical prolongation global clotting times finally fulminant disseminated intravascular coagulation dic characterized simultaneous widespread microvascular thrombosis profuse bleeding various sites septic patients severe forms dic may present thromboembolic disease clinically less apparent microvascular failure predominantly presents multiple organ dysfunction interestingly tight bidirectional relationship activation inflammation coagulation inflammatory activity results activation coagulation activated coagulation proteases also affect inflammatory pathways activated protein c apc appears play central role pathogenesis sepsis associated organ dysfunction there ample evidence insufficient functioning protein c pathway contributes derangement coagulation observed sepsis the circulating zymogen protein c activated endothelial cell bound thrombomodulin activated thrombin apc acts concert co factor protein proteolytically degrade cofactors va viiia essential coagulation apc therefore effective anticoagulant the endothelial protein c receptor epcr accelerates activation protein c several fold also serves receptor apc binding apc epcr may amplify anticoagulant anti inflammatory effects a recent study demonstrated exposure cultured endothelial cells apc results release microparticles contain epcr relevance observation coagulation inflammation yet clear protein c system the solid arrows indicate mechanisms protein c system impaired sepsis patients sepsis apc system malfunctions virtually levels first plasma levels zymogen protein c low low impaired synthesis consumption degradation proteolytic enzymes neutrophil elastase 10 12 furthermore significant downregulation thrombomodulin caused pro inflammatory cytokines tumour necrosis factor- interleukin-1 demonstrated resulting diminished protein c activation low levels free protein may compromise functioning protein c system plasma 60% co factor protein complexed complement regulatory protein c4b binding protein c4bbp increased plasma levels c4bbp occur consequence acute phase reaction inflammatory disease may result relative protein deficiency contributes procoagulant state sepsis although shown -chain c4bbp mainly governs binding protein much affected acute phase response support hypothesis comes studies conducted baboons infusion c4bbp combination sublethal dose escherichia coli resulted lethal response severe organ damage due dic finally importantly sepsis epcr shown downregulated may adversely affect function protein c system apart effects sepsis may induce resistance apc mechanisms partly dependent sharp increase factor viii levels released endothelial cells partly due yet unidentified mechanisms administration apc baboon model intravenous e. coli administration resulted survival animals whereas control animals experiment died a similar beneficial effect observed rabbits meningococcal endotoxin shock rat model septic shock administration apc prevented tumour necrosis factor- mediated hypotension probably caused modulation nitric oxide response patients severe sepsis administration recombinant human activated protein c rhapc resulted remarkable improvement microcirculatory perfusion conversely experiments conducted baboons protein c pathway blocked monoclonal antibodies resulted complete lethality otherwise sublethal model bacteraemia model blockade epcr also resulted severe response sublethal e. coli bacteraemia in addition observations experimental sepsis models apc shown antithrombotic properties experimental thrombosis models dogs rabbits baboons interestingly apc may also affect fibrinolysis inhibiting plasminogen activator inhibitor type 1 fibrinolytic inhibitor rat model dic apc shown block activity plasminogen activator inhibitor type 1 experiments demonstrated ability apc enhance clot lysis vivo more definitive proof beneficial effect rhapc severe sepsis comes clinical studies these studies reviewed detail reviews included supplement 27 29 discussed detail however may interest review evidence rhapc acts anticoagulant agent studies first noted selected dose rhapc based effect dimer levels phase ii clinical trial indeed pivotal prowess recombinant human activated protein c worldwide evaluation severe sepsis trial septic patients treated apc exhibited significant decrease dimer levels compared placebo control individuals d dimer levels dropped 25% 2 days apc administration contrast 10% increase placebo treated patients detailed analysis coagulation activation upon administration rhapc clearly demonstrated markers thrombin generation sharply dropped almost immediately initiation apc infusion second subgroup analyses trials including patients severe sepsis demonstrated patients extreme coagulation abnormalities benefit treatment rhapc the relative risk reduction mortality among patients sepsis dic received apc 38% compared relative risk reduction 18% observed among patients sepsis dic interestingly dynamics coagulation abnormalities first days intensive care unit admission severe sepsis including response protein c system strong predictor outcome it difficult assess whether anticoagulant effect rhapc translates antithrombotic effect recently concluded xpress ( xigris drotrecogin alfa prophylactic heparin severe sepsis study patients severe sepsis received rhapc also randomly assigned receive prophylactic heparin placebo the main conclusion study heparin equivalent placebo might beneficial effect 28-day mortality note advantageous effect heparin completely due greater incidence death thrombotic adverse events patients receiving heparin randomly assigned placebo words stopped heparin trial there markedly low incidence venous thromboembolism study compared previous reports incidence differ placebo patients patients receiving heparin even though patients underwent screening ultrasound venous thrombosis around day 6 admission in addition report small series patients severe sepsis treated rhapc demonstrated lack thrombotic obstruction haemofiltration circuits even absence heparin anticoagulants apart systemic response may differential localized effect rhapc coagulation the localized effect apc appears particularly marked pulmonary compartment experiments involving unilateral instillation endotoxin healthy individuals systemic administration rhapc resulted marked reduction bronchoalveolar activation coagulation this observation may relevant vast majority patients severe sepsis various trials pulmonary source infection an interesting novel finding modulatory influence alveolar epithelial cells protein c pathway it likely underlying mechanism involves shedding epcr thrombomodulin metalloproteinases evidence apc acts important mediator systemic inflammatory response sepsis comes experiments showing blocking protein c pathway septic baboons exacerbated inflammatory response contrast administration apc ameliorated inflammatory activation occurred upon intravenous infusion e. coli similar experiments rodents yielded identical results demonstrated beneficial effect inflammatory effects various tissues support notion apc anti inflammatory properties comes vitro findings demonstrating apc binding site monocytes may mediate downstream inflammatory processes it also received support experiments showing apc block nuclear factor-b nuclear translocation prerequisite increased levels pro inflammatory cytokines adhesion molecules these vitro findings supported vivo studies mice targeted disruption protein c gene mice genetic deficiencies protein c endotoxaemia associated marked increases pro inflammatory cytokines inflammatory responses wild type mice it likely effects apc inflammation mediated epcr may mediate downstream inflammatory processes binding apc epcr influences gene expression profiles cells inhibiting endotoxin induced calcium fluxes cell blocking nuclear factor-b nuclear translocation epcr apc complex translocate plasma membrane cell nucleus may another mechanism modulation gene expression although relative contributions nuclear translocation cell surface signalling unclear some studies also suggested epcr binding apc result activation protease activated receptor par)-1 thereby affect cytokine responses in contrast experiments demonstrated significant physiological role activation par-1 apc less probable soluble epcr extracellular domain cell associated epcr shed cell surface action inducible metalloproteinase bind proteinase 3 elastase like enzyme the resulting complex binds adhesion integrin macrophage 1 antigen mac-1 considerable interest is crystal structure epcr remarkably similar structure mhc class 1/cd1 family proteins majority involved inflammation blocking epcr specific monoclonal antibody aggravated coagulation inflammatory response e. coli infusion apart influence apc cytokine levels remarkable effects agent leucocyte chemotaxis adhesion circulating leucocytes activated endothelium demonstrated this confirmed hamster endotoxaemia model concentrations rhapc preclude significant anticoagulant effect the localized effect apc lung also shown exhibit anti inflammatory properties apc shown inhibit expression platelet derived growth factor lung may reflect potential mechanism underlying localized effect also apc shown protect disruption endothelial cell barrier sepsis probably interfering epcr par-1 endothelial cells 56 58 finally apc inhibit endothelial cell apoptosis also appears mediated binding apc epcr require par-1 signalling pathway can affect bcl-2 homologue protein inhibit apoptosis suppresses p53 pro apoptotic transcription factor inadequate functioning protein c system particular apc plays central role pathogenesis sepsis attempting restore the function pathway patients sepsis appears rational approach supported beneficial effect apc experimental models sepsis clinical studies apart evident effect coagulation system ability rhapc correct deranged coagulation system severe sepsis series pleiotropic modulating effects apc inflammatory cytokines cells well protective effects disrupted endothelium reported it noted many effects inflammatory cells pathways well cytoprotective effect mostly demonstrated vitro sometimes inordinately high concentrations apc the relevance findings human vivo situation importance treatment sepsis remain established although relative importance anticoagulant effect versus inflammation modulating effect rhapc clear tempting hypothesize combined effect responsible benefit rhapc indeed strategies aimed restoring physiological pathways less marked effects inflammation administration antithrombin recombinant tissue factor pathway inhibitor less successful further insight various mechanisms action rhapc entangled processes inflammation coagulation may permit detailed dissection relative importance various pathways contribute pathogenesis sepsis potentially culminating improved treatment strategies apc activated protein c c4bbp c4b binding protein dic disseminated intravascular coagulation epcr endothelial protein c receptor par protease activated receptor rhapc recombinant human activated protein c. ml tvdp participated advisory boards eli lilly company participated investigators experimental clinical studies rhapc this article part critical care volume 11 supplement 5 severe sepsis drotrecogin alfa activated	impairment of the protein c pathway plays a central role in the pathogenesis of sepsis . administration of recombinant human activated protein c ( rhapc ) may correct the dysregulated anticoagulant mechanism and prevent propagation of thrombin generation and formation of microvascular thrombosis . furthermore , it may simultaneously modulate the inflammatory response . it is likely that the beneficial effect of rhapc observed in experimental and clinical studies of severe sepsis results from a combination of mechanisms that modulate the entangled processes of coagulation and inflammation . this review presents an analysis of the various mechanisms of action of rhapc in sepsis .
acquired amegakaryocytic thrombocytopenia aat rare disease characterized immunologically mediated peripheral thrombocytopenia similar idiopathic thrombocytopenic purpura itp however contrast itp selective reduction absence bone marrow megakaryocytes though multiple simultaneous sequential peripheral nerve involvement mononeuritis multiplex rarely described itp hardly ever described aat we reporting case mononeuritis multiplex due cyclical type aat young man a 34-year old man presented neurology service pain legs bilateral foot drop numbness medial aspect left forearm 2 weeks duration examination showed pupura positive questioning admitted bleeding gums starting 2 days prior neurological symptoms age 12 years multiple blood transfusions told aplastic anemia detailed medical report traceable age 22 years acute hepatitis b infection blood counts hematocrit documented normal time index admission anemia multiple purpuric skin lesions figure 1 clinical neurological examination revealed sensory motor involvement left radial left ulnar right common peroneal left sciatic nerves suggesting mononeuritis multiplex an electrophysiology evaluation showed sensory motor involvement left ulnar left median left radial right median right common peroneal left sciatic nerves confirming mononeuritis multiplex there conduction blocks demonstrable right peroneal left ulnar nerves figure 2 after neurological investigations referred government teaching hospital subsequent hematological workup done echymotic purpuric skin lesions legs arrows motor conduction blocks 50% reduction compound muscle action potential amplitude proximal stimulation compared distal stimulation right peroneal nerve b left ulnar nerves hematocrit 33% total leukocyte count differential count erythrocyte sedimentation rates normal platelet count grossly reduced 5000 cells cu mm bleeding time prolonged 9 min corrected reticulocyte count 2.9% peripheral blood smear showed marked thrombocytopenia figure 3 the serum bilirubin marginally elevated 1.86 mg dl predominant indirect component direct indirect coomb tests negative measurements serum sodium potassium calcium phosphorus glucose urea creatinine proteins aspartate aminotransferase alkaline phosphatase levels normal serological tests hiv hepatitis b hepatitis c syphilis negative peripheral blood smear leishmans stain 100 showing markedly reduced platelets compare normal smear right panel showing platelets arrow bone marrow aspiration study relative stabilization showed normoblastic erythroid myeloid series normal lymphoid cells marked reduction megakaryocytes figure 4 he profuse bleeding site aspiration fall hematocrit 17% hence bone marrow trephine biopsy nerve biopsy attempted he initiated oral prednisolone since condition improving later intravenous immunoglobulin given 5 days cyclosporine added gradually stabilized bleeding stopped platelet count improved 60,000 cells cumm time hospital discharge 6 weeks minimal bilateral foot drop mild left grip weakness after 1 week discharge readmitted acute onset massive intracerebral hemorrhage succumbed within hours absent megakaryocytes bone marrow leishmans stain 10 compare megakaryocytes normal bone marrow right panel arrow ) we report case mononeuritis multiplex due aat patient presented painful bilateral foot drop along skin lesions the clinical electrophysiological features suggestive mononeuritis multiplex since asymmetric involvement multiple peripheral nerves skin rashes mononeuritis multiplex rare major differentials include collagen vascular diseases systemic vasculitides secondary antiphospholipid antibody syndrome amyloidosis sarcoidosis lyme disease leprosy postviral syndromes hepatitis b virus infection needs special mention since long term autoimmune manifestations like systemic lupus erythematosus antiphospholipid syndrome polyarteritis nodosa rheumatoid arthritis cause mononeutis multiplex skin rash however hepatitis b serology negative patient though acute infection previously detailed evaluation revealed markedly reduced megakaryocytes bone marrow relatively normal erythroid myeloid series this hematological picture consistent described aat itp similar peripheral blood picture normal increased megakaryocytes bone marrow the neuropathy patient probably due bleeding nerves result thrombocytopenia similar neuropathy well described itp cause histologically proven intraneural hematoma beneath epineurium fascicles amegakaryocytic thrombocytopenia rare disease characterized severe thrombocytopenia total absence selective decrease bone marrow megakaryocytes it may primary disorder may seen aplastic anemia preleukemia systemic lupus erythematosus congenital rubella dengue fever ethanol abuse nutritional b-12 deficiency radioiodine therapy thrombocytopenia absent radius syndrome variety pathogenetic mechanisms suggested immune mediated mechanism due autoantibody blocks action endogenous thrombopoietin megakaryocytopoiesis appears sensible least subset patients while patients remain clinically stable others may progress aplastic anemia myelodysplastic syndrome a cyclical course also described patient appears category though hematological picture initial episode clear congenital amegakaryocytic thrombocytopenia cat another related rare disease presenting isolated thrombocytopenia infancy developing pancytopenia later childhood immune mediated mechanism aat defective surface expression thrombopoetin receptor c mpl hematopoietic progenitor cells due c mpl mutations various treatments tried aat including corticosteroids lithium carbonate androgens vincristine folic acid platelet erythrocyte transfusions plasma substitution an occasional patient may respond well intravenous immunoglobulin cyclosporin a. real hope bone marrow transplantation using human leukocyte antigen matched donor	mononeuritis multiplex involves inflammation of two or more nerves , typically in unrelated parts of the body . it has been well described in bleeding disorders like idiopathic thrombocytopenic purpura ( itp ) and hemophilia . acquired amegakaryocytic thrombocytopenia ( aat ) is a bleeding diathesis characterized by thrombocytopenia but with reduced number of megakaryocytes in the bone marrow , as against itp . though aat is a well described entity , peripheral nervous system manifestations have not been described so far . we report a young man who has presented with bleeding diathesis and mononeuritis multiplex due to aat . the mechanism of development of mononeuritis multiplex and treatment options are discussed .
obesity hypertension metabolic syndrome type 2 diabetes mellitus major growing health problems known high risk factors subsequent cardiovascular renal complications 13 obesity hypertension diabetes metabolic syndrome intimately associated 46 sympathetic nervous activation frequently observed conditions thus sympathetic nerve activation may play major role onset development hypertension obesity metabolic syndrome diabetes mellitus well cardiovascular complications patients hypertension diabetes obesity 2 7 the sympathetic nervous system plays important role regulation energy expenditure reduced energy expenditure resting metabolic rate predictive weight gain obesity a large part sympathetic nervous system mediated energy expenditure takes place skeletal muscle via coupling catecholamines 2-adrenoceptors catecholamines also powerful regulators lipolysis act via 1- 2- 3- stimulatory 2- inhibitory adrenoceptor subtypes adipose tissue role becomes especially important exercise energy restriction increased need fat fuel exists thus -adrenoceptors play important roles energy expenditure control body weight 913 recently evidence human hypertension obesity strong genetic backgrounds 1416 reported 46% phenotype systolic blood pressure determined genetically hypertension 17 18 1822 reported close relationships 2- 3-adrenoceptor polymorphisms accompanying elevated sympathetic nervous activity blood pressure elevation hypertension weight gain obesity insulin resistance series longitudinal study many epidemiological studies relationships -adrenoceptor polymorphisms hypertension obesity diabetes metabolic syndrome still discordant this paper discuss current topics involving contribution sympathetic nervous system 2- 3-adrenoceptor polymorphisms onset development hypertension metabolic syndrome type 2 diabetes mellitus the adrenoceptors adrenergic receptors class g protein coupled receptors specifically bind endogenous ligands catecholamines epinephrine norepinephrine many tissues possess adrenoceptors binding agonist generally elicits typical sympathetic response i.e. fight flight response table 1 shows effects catecholamines bound adrenoceptors table 1 effects sympathetic nervous activity -adrenergic receptors there several types adrenergic receptors two main groups -adrenoceptors 1- 2-adrenoceptors -adrenoceptors 1- 2- 3-adrenoceptors table 1 also summaries distributions functions 1- 2- 1- 2- 3-adrenoceptors 24 25 phenylephrine selective agonist -adrenoceptors 1- 2-receptors thus phenylephrine usually used investigate -adrenoceptors function downstream effects cyclic amp include cyclic amp dependent protein kinase mediates intracellular events following hormone binding insulin resistance hypertension well documented many epidemiological clinical studies 8 26 27 several investigators reported chronic insulin administration elevates blood pressure rats humans although insulin also effects vasodilation in addition many clinical epidemiological studies demonstrated close relationships sympathetic nerve activity insulin resistance hypertension 19 2932 landsberg investigators examined effect feeding starvation sympathetic nerve activity cardiac tissue animals noting feeding raised sympathetic nerve activity starvation opposite effect 3335 energy intake stimulates hyperinsulinemia sympathetic nerve activity resulting blood pressure elevations cycle inhibit thermogenesis insulin mediated sympathetic nerve stimulation obese subjects compensatory mechanism aimed restoring energy balance increasing metabolic rate therefore hyperinsulinemia insulin resistance obese subjects part response limit weight gain via stimulating sympathetic nerve activity thermogenesis hand julius et al have hypothesized increased sympathetic nerve activity skeletal muscle causes neurogenic vasoconstriction thereby reducing blood flow muscle consequently inducing state insulin resistance lowering glucose delivery uptake hypertension obesity both blood pressure elevation weight gain may reflect primary increase sympathetic nervous tone they described high plasma norepinephrine might predict future blood pressure elevations weight gain accompanying deterioration insulin resistance observed homa ir homeostasis model assessments insulin resistance 30 37 their results suggest sympathetic nerve activity might play major role development insulin resistance accompanying blood pressure elevations reported attenuation hemodynamic energy expenditure responses isoproterenol infusion hypertensive patients suggesting sympathetic nerve activity induced hypertension may subsequently lead development obesity many epidemiological studies showed close linkages beta2- beta3-adrenoceptor polymorphisms obesity hypertension metabolic syndrome shown tables 2 3 4 thus close linkages sympathetic nerve activity insulin resistance might depend -adrenoceptor polymorphisms thus one could speculate strong associations -adrenoceptor polymorphisms insulin resistance might provide evidence heightened sympathetic nerve activity followed insulin resistance might play major role hypertension obesity -adrenoceptor polymorphisms might relate insulin resistance heightened sympathetic nerve activity figure 1 the sympathetic nervous system plays important role regulation energy expenditure blood pressure regulation a large part sympathetic nervous system mediated energy expenditure takes place skeletal muscle via coupling catecholamines 2-adrenoceptors catecholamines also powerful regulators lipolysis act via 1- 2- 3- stimulatory 2- inhibitory adrenoceptor subtypes adipose tissue role becomes especially important exercise energy restriction increased need fat fuel exists stimulation -adrenergic receptors sympathetic nervous system significant physiological modulator pre- postprandial energy expenditure 1113 total daily energy expenditure 9 10 single nucleotide polymorphisms might functional consequences terms receptor activity regulation hence may contribute pathophysiology hypertension obesity hand studies relationships -adrenoceptor polymorphisms hypertension obesity metabolic syndrome 1-adrenoceptor predominantly expressed cardiac myocytes adipose tissue activation leads increased heart rate contractility stimulation lipolysis respectively the two common 1-adrenoceptor polymorphisms ser49gly arg389gly relative allele frequencies 0.85/0.15 0.70/0.30 caucasian population respectively the 1-adrenoceptor candidate gene obesity role catecholamine mediated energy homeostasis 72 73 for example obese individuals degree weight loss low calorie diet shown correlate changes 1-adrenoceptor protein concentration adipose tissue a population cohort 761 women showed women carrying gly49 genotype greater increases bmi over15 years compared ser49 genotype conversely distribution arg389gly polymorphism similar lean obese subjects large cohort study including 3981 normotensive 2518 hypertensive subjects the factors might explain discrepancy published data shown later section the 2-adrenoceptor dominant lipolytic receptor white human adipose tissue skeletal muscle genetic polymorphisms 2-adrenoceptor associated hypertension obesity metabolic syndrome diabetes mellitus the common polymorphisms arg16gly allele frequency 0.40/0.60 gln27glu allele frequency 0.55/0.45 caucasian population the thr164ile polymorphism rare occurring 3 5% general caucasians population studies agonist stimulation cultured cells demonstrate gly16 receptors greater reduction numbers enhanced downregulation compared arg16 whereas glu27 receptor resistant regulation compared gln27 variant a number clinical studies investigated impact polymorphisms vascular responsiveness 40 109 found young normotensive white men homozygous gly16 allele higher blood pressure lower peripheral vasodilation infusion 2-agonist salbutamol similar results obtained hoit et al using agonist terbutaline hand three studies investigating isoprenaline induced increase limb blood flow thus volunteers homozygous gly16 exhibited larger vasodilatory responses volunteers homozygous arg16 conflicting results also published regard effects genetic variants sympathetic nervous system modulation energy expenditure reported response resting energy expenditure nonspecific -adrenoceptor stimulation isoproterenol infusion different 3 genotypes arg16gly showed individuals carrying arg16arg variant 2-adrenoceptor gene reduced thermogenic response selective 2-adrenoceptor activation associations 2-adrenoceptor polymorphisms hypertension metabolic syndrome reported many epidemiological studies results also discordant summarised tables 2 3 the 3-adrenoceptor mainly expressed adipose tissue differs 2-adrenoceptor two ways lower affinity catecholamines resists desensitisation i.e. downregulation characteristic differences might lead different effects catecholamine 2-adrenoceptors 3-adrenoceptors 3-adrenoceptors stimulate mobilization lipids white fat cell increase thermogenesis brown fat cell decreased function 3-adrenoceptor white adipose tissue slow lipolysis may contribute strongly visceral obesity human treatment obese animal models selective 3-adrenergic agonists reduces fat stores effectively 94 113 114 many epidemiological studies shown strong relationships 3-adrenoceptor polymorphisms mainly trp54arg hypertension metabolic syndrome obesity 78 94 113117 table 4 tables 2 3 4 5 show discordant contributions -adrenoceptor polymorphisms hypertension metabolic syndrome type 2 diabetes obesity further haplotypes polymorphisms strong influence -adrenoceptor function polymorphism 20 58 59 105107 the role sympathetic nervous system 2- 3-adrenoceptor polymorphisms hypertension metabolic syndrome diabetes mellitus obesity discussed literature review sympathetic nervous system activity -adrenoceptor polymorphisms mainly 2- 3-adrenoceptor polymorphisms might contribute onset maintenance hypertension metabolic syndrome obesity however findings discordant further studies performed evaluate relationship 2- 3-adrenoceptor polymorphisms sympathetic nervous system activity study better understanding relationships genetic background polymorphisms sympathetic nervous system activity cause hypertension blood pressure elevation metabolic syndrome insulin resistance obesity weight gain might help clinical treatment obesity related hypertension metabolic syndrome in fact number studies investigated genetic polymorphisms determinants cardiovascular response antihypertensive drug therapy 103 104 but in addition clarify pathogenesis mechanisms may lead prevention hypertension metabolic syndrome obesity	hypertension , diabetes mellitus ( especially type 2 diabetes mellitus ) , metabolic syndrome and obesity are rapidly growing public health problems . sympathetic nerve activation is observed in obesity , hypertension and diabetes mellitus , which have strong genetic as well as environmental determinants . reduced energy expenditure and resting metabolic rate are predictive of weight gain , and the sympathetic nervous system participates in regulating energy balance through thermogenesis . the thermogenic effects of catecholamines in obesity have been mainly mediated via the 2- and 3-adrenergic receptors in humans . further , 2-adrenoceptors importantly influence vascular reactivity and may regulate blood pressure . genetic polymorphistns of the -adrenoceptor gene have been shown to alter the function of several adrenoceptor subtypes and thus to modify the response to catecholamine . 2-adrenoceptor polymorphisms ( arg16gly , gln27glu , and thr164ile ) have been studied in relation to hypertension . genetic variations in the 3-adrenoceptor ( i.e. try64arg variant ) are also associated with both obesity and hypertension . however , the precise relationships of the polymorphisms of 2- and 3-adrenoceptor genes with sympathetic nervous system activity , hypertension , and metabolic syndrome have not been fully clarified . this paper will discuss the current topics involving the influence of the sympathetic nervous system and 2- and 3- adrenoceptor polymorphisms in hypertension and metabolic syndrome .
expansion tandem repeat array responsible disease pathology repeat expansion diseases group genetic disorders includes fragile x mental retardation syndrome fxs 1,2 fxs however differs genome wide microsatellite instability seen diseases like hereditary non polyposis colorectal carcinoma hnpcc showing expansion bias expansions contractions occurring single genetic locus addition least case mouse models disorders resulting cagctg repeat expansion mutations dna mismatch repair genes like msh2 msh3 pms2 actually decrease frequency repeat expansion opposite true hnpcc 39 different diseases group involve repeats different sequences repeat unit sizes 10 these repeats potential form secondary structures thought play role expansion process see 11 recent review however since repeats properties unclear whether repeats expand via mechanism studies bacteria yeast shown variety mechanisms cause repeat instability organisms including dna slippage replication errors okazaki fragment processing well aberrant dna repair recombination 1242 however much currently unknown events responsible expansion humans for example expansion diseases show small changes repeat number intergenerational transfer others result alleles many times larger parental allele derived the small expansions typically seen repeats fall within open reading frame case cagctg repeat responsible huntington disease hd large expansions like cause fxs characteristically seen regions outside open reading frame occur almost exclusively maternal transmission in addition diseases involve significant somatic instability others known mechanism responsible germline somatic expansion some studies transgenic mice suggested small expansions occur premeiotically spermatogonia 9 whilst others suggest expansions occur haploid gametes 8,43 some studies also suggest second event occurs early female embryo transgenic mouse models this event expansion 44 others contraction 45,46 the differences two models attributed different genomic context repeats 44 this would consistent work bacteria yeast tissue culture models implicated orientation proximity origins replication transcription cis acting factors affecting expansion 15,21,24,27,31,36,38,39,47,48 order study fragile x repeat close normal chromosomal context possible generated fxs premutation knock ki mouse containing 120 cggccg repeats murine fmr1 gene 49 since murine fmr1 gene located region x chromosome syntenic corresponding region human x chromosome differences cis acting signals involved expansion may small seen transgenic knockin mouse models cggccg repeat expansion 5053 instability animals resembles seen humans frequency high shows expansion bias 49 mouse model large expansions generate alleles full mutation range 200 repeats seen much lower frequency humans 49 in fact expansions mice small involving fewer five repeats per generation occurring commonly males females respect these expansions resemble seen human carriers fmr1 common intermediate sized alleles grey zone alleles 54 diseases hd involve relatively small increases repeat number expansion occurring perigametic interval last premeiotic mitosis first post meiotic one could explain differences mice humans maternal cggccg repeat expansion bias human fmr1 gene this interval last decades human females creating large window opportunity expansion occur in contrast interval lasts months female mice weeks males either species depletion dna repair capacity much spermatogenesis could also exacerbate differences maternal paternal expansion rates 55 it may also differences humans mice reflect differences efficacy dna damage repair checkpoint proteins one potential dna damage checkpoint protein may affect expansion frequency ataxia telangiectasia rad3-related atr kinase atr primarily responds stalled replication forks bulky dna adducts like arising uv irradiation 56 s(n)1-type alkylating agents 57 here show atr heterozygosity leads increased maternally transmitted expansions somatic expansions mice genders appear involve aberrant dna repair the atr mice kind gift dr eric brown caltech pasadena ca mice maintained accordance guidelines niddk animal care use committee guide care use laboratory animals nih publication genomic dna prepared mouse tail dna homogenized mouse tissue previously described 49 genotyping detect presence absence disrupted atr gene the primer pair frax c frax f 1 used detect wildtype wt fmr1 fxs premutation alleles the size cggccg repeat tract monitored polymerase chain reaction pcr using primers frax m4 5-cttgaggcccagccgccgtcggcc-3 frax m5 5-cggggggcgtgcggtaacggcccaa-3 the binding sites primers located immediately adjacent repeat tract 3 ends unique ki allele radiolabelled pcr products generated inclusion -p dctp reaction mix previously described 49 the reaction products run 3130xl genetic analyzer analysed using genemapper 3.7 applied biosystems foster city ca these bands show gaussian distribution mean similar alleles size range the mean size allele calculated based mobility central band cluster comparison parental mean offspring mean determined samples run gel allows changes offspring allele reproducibly determined statistical analysis instability carried using chi square student tests the atr mice kind gift dr eric brown caltech pasadena ca mice maintained accordance guidelines niddk animal care use committee guide care use laboratory animals nih publication genomic dna prepared mouse tail dna homogenized mouse tissue previously described 49 genotyping detect presence absence disrupted atr gene the primer pair frax c frax f 1 used detect wildtype wt fmr1 fxs premutation alleles the size cggccg repeat tract monitored polymerase chain reaction pcr using primers frax m4 5-cttgaggcccagccgccgtcggcc-3 frax m5 5-cggggggcgtgcggtaacggcccaa-3 the binding sites primers located immediately adjacent repeat tract 3 ends unique ki allele the pcr reaction done one two ways radiolabelled pcr products generated inclusion -p dctp reaction mix previously described 49 the reaction products run 3130xl genetic analyzer analysed using genemapper 3.7 applied biosystems foster city ca these bands show gaussian distribution mean similar alleles size range the mean size allele calculated based mobility central band cluster comparison parental mean offspring mean determined samples run gel allows changes offspring allele reproducibly determined statistical analysis instability carried using chi square student tests the checkpoint protein atr responsible activating pathways lead repair stalled dna replication forks bulky lesions dna thus effect atr mutations expansions seen fragile x premutation mice may shed light mechanism repeat expansion however since atr heterozygous mice show small increase tumour incidence small decrease overall survival apparent effects atr deficiency seen even heterozygous state 58 we thus analysed transmission fxs premutation allele 120 cggccg repeats mice heterozygous disrupted atr gene the results obtained repeat length changes offspring mice summarized table 1 table 1.expansions premutation allele wt atr mice paternal maternal transmissionoffspringcross% mice expansionsmean addedmale female(1 total(2 males(3 females(4 atr(5 wt1fmr1 atr fmr1 atr37393337 2.22fmr1 atr fmr1 atr86898396635.03fmr1 atr fmr1 atr6161613.14fmr1 atr fmr1 atr686869675.25fmr1 atr fmr1 atr636363632.2w wildtype fmr1 allele fmr1 premutation allele indicates offspring crosses either premutation mutated atr allele data source entezam et al ( 47 numbers sharing one symbols compared using chi squared test shown significantly different p value 0.005 numbers sharing symbols compared using student test shown significantly different p value 0.005 expansions premutation allele wt atr mice paternal maternal transmission w wildtype fmr1 allele fmr1 premutation allele indicates offspring crosses either premutation mutated atr allele data source entezam et al ( 47 numbers sharing one symbols compared using chi squared test shown significantly different p value 0.005 numbers sharing symbols compared using student test shown significantly different p value 0.005 atr heterozygosity effect deletion frequency effect atr heterozygosity seen stability normal mouse fmr1 repeat data shown in contrast significant increase expansion frequency seen premutation allele maternally transmitted atr mice compared wt mice 86% versus 37% cross 2 versus cross 1 table 1 this suggests atr normally involved protecting genome intergenerational expansions female mice carrying fxs premutation alleles in contrast expansion frequency paternal transmission atr mice statistically different mice wt respect atr 68% versus 61% cross 4 versus cross 3 table 1 there apparent increase average number repeats added per expansion paternal maternal transmission atr heterozygotes despite fact increase expansion frequency seen paternal transfer there significant gender bias expansion frequency offspring atr mothers this similar seen fragile x repeats humans 59 differs male expansion bias seen transgenic mouse model cagctg expansions 45 atr wt males showed increase transmission expanded cggccg allele crossed atr females cross 5 table 1 an expansion frequency 63% seen wt progeny females carrying premutation heterozygous atr cross 2 this significantly higher 37% seen offspring females wt atr the expansion frequency even higher atr offspring atr mothers 96% cross 2 table 1 to study role atr somatic instability examined size repeat different organs young 10 weeks old old 18 months old atr mice as seen figure 1a limited somatic instability seen liver young mice evidenced slightly skewed distribution repeat sizes old mice showed much significant changes organs like brain testes liver instances little remained original allele size see brain sample figure 1c we previously shown somatic instability seen mice similar age wt atr 49 organs like male brain expansions resulted shift average allele size without changing basic monophasic distribution allele sizes figure 1c organs like liver and whether biphasic distribution reflects predisposition certain cells within organ expand currently investigation a biphasic distribution somatic expansion products reported liver mouse model knockin mouse model myotonic dystrophy cagctg expansion disorder attributed changes ploidy subset liver cells 60 figure 1.somatic instability atr mice carrying fxs premutation allele genomic dna isolated various organs young 10 weeks old old 18 months old fxs premutation mice repeat tract analysed pcr using one fam labelled primer abi geneanalyzer described materials methods the number repeats modal allele tail dna 3 weeks age shown black font indicated organ samples grey dotted line similar results obtained using pcr using p--dctp denaturing gel electrophoresis described previously 49 genomic dna isolated various organs young 10 weeks old old 18 months old fxs premutation mice repeat tract analysed pcr using one fam labelled primer abi geneanalyzer described materials methods the number repeats modal allele tail dna 3 weeks age shown black font indicated organ samples grey dotted line similar results obtained using pcr using p--dctp denaturing gel electrophoresis described previously 49 atr heterozygosity effect deletion frequency effect atr heterozygosity seen stability normal mouse fmr1 repeat data shown in contrast significant increase expansion frequency seen premutation allele maternally transmitted atr mice compared wt mice 86% versus 37% cross 2 versus cross 1 table 1 this suggests atr normally involved protecting genome intergenerational expansions female mice carrying fxs premutation alleles in contrast expansion frequency paternal transmission atr mice statistically different mice wt respect atr 68% versus 61% cross 4 versus cross 3 table 1 there apparent increase average number repeats added per expansion paternal maternal transmission atr heterozygotes despite fact increase expansion frequency seen paternal transfer there significant gender bias expansion frequency offspring atr mothers this similar seen fragile x repeats humans 59 differs male expansion bias seen transgenic mouse model cagctg expansions 45 atr wt males showed increase transmission expanded cggccg allele crossed atr females cross 5 table 1 an expansion frequency 63% seen wt progeny females carrying premutation heterozygous atr cross 2 this significantly higher 37% seen offspring females wt atr the expansion frequency even higher atr offspring atr mothers 96% cross 2 table 1 to study role atr somatic instability examined size repeat different organs young 10 weeks old old 18 months old atr mice as seen figure 1a limited somatic instability seen liver young mice evidenced slightly skewed distribution repeat sizes old mice showed much significant changes organs like brain testes liver instances little remained original allele size see brain sample figure 1c we previously shown somatic instability seen mice similar age wt atr 49 organs like male brain expansions resulted shift average allele size without changing basic monophasic distribution allele sizes figure 1c organs like liver and whether biphasic distribution reflects predisposition certain cells within organ expand currently investigation a biphasic distribution somatic expansion products reported liver mouse model knockin mouse model myotonic dystrophy cagctg expansion disorder attributed changes ploidy subset liver cells 60 figure 1.somatic instability atr mice carrying fxs premutation allele genomic dna isolated various organs young 10 weeks old old 18 months old fxs premutation mice repeat tract analysed pcr using one fam labelled primer abi geneanalyzer described materials methods the number repeats modal allele tail dna 3 weeks age shown black font indicated organ samples grey dotted line similar results obtained using pcr using p--dctp denaturing gel electrophoresis described previously 49 genomic dna isolated various organs young 10 weeks old old 18 months old fxs premutation mice repeat tract analysed pcr using one fam labelled primer abi geneanalyzer described materials methods the number repeats modal allele tail dna 3 weeks age shown black font indicated organ samples grey dotted line similar results obtained using pcr using p--dctp denaturing gel electrophoresis described previously 49 we shown maternal atr insufficiency leads increase frequency intergenerational expansions atr heterozygosity also causes appearance age related expansion products certain organs older males females number lines evidence support prezygotic origin atr sensitive intergenerational expansions seen females the elevated expansion frequency atr wt offspring atr heterozygous mothers cross 2 column 5 table 1 compared cross 1 column 5 demonstrates expansion occur prior fertilization oocyte this supported fact paternal expansion frequency mice wt atr whether dam atr wt atr cross 5 table 1 despite maternal expansion bias this together fact female mice show somatic instability adult tissues males argues somatic expansions occur specifically either early female embryo female germline prior meiosis previously shown male mice show bias transmission large repeats 49 thus female expansion bias atr background likely due somatic expansions selected males furthermore excess expansions atr offspring 96% compared 63% atr wt offspring consistent somatic origin mother either since somatic cells would atr thus likely origin additional expansions atr offspring haploid oocyte given scheduled dna replication occur haploid gametes dna damage thus likely responsible the haploid gamete gives rise atr wt offspring would atr deficient thus expansion confined stage would expect expansion frequency higher seen offspring mother wt atr therefore atr sensitive expansions wt offspring atr mothers could occurred oogonia diploid oocyte thus window opportunity expansions cells much larger haploid gametes although rate expansion may fact lower may atr heterozygosity mice reveals existence two different intergenerational expansion mechanisms first showing higher expansion frequency males less sensitive atr haploinsufficiency second occurring predominantly females sensitive this say atr mutations necessary maternal expansions humans rather atr insufficiency mice allows events would years accumulate humans visible within rodent lifespan the relatively atr insensitive mechanism may account paternal transmission bias seen intermediate grey zone fmr1 alleles humans 54 a higher mutation frequency males usually attributed errors occurring dna replication since mature sperm product rounds cell division ova 61 while possible increase average expansion size seen paternal transmission reflects measurement errors may males atr deficiency simply delays resolution replication problem for example strand slippage scenario delay could result incorporation additional bases expanded allele without affecting frequency initiation strand slippage occurs atr sensitive expansions may common female mice since data suggest mechanism responsible related repair dna damage genomic replication expansions thus occur point gametogenesis process lasts significantly longer females it appealing think mechanism basis strong maternal bias transmission fragile x full mutation alleles humans since gametogenesis takes much longer human females may provide much larger window opportunity expansions occur even presence normal amounts atr one organ showed evidence significant somatic expansion brain cases very little original allele seen see adult male brain figure 1c since significant fraction cells adult brain post mitotic somatic expansion also probably limited dividing cells thus expansions may also arise aberrant dna repair process rather problem scheduled dna replication expansion limited organs could explained differences either frequency dna damage initiates expansion occurs organs frequency mutations repaired eliminated organs liver brain may predisposed expansion since atr expressed lower level cells low proliferative capacity 62 shows lower affinity chromatin cells 63 transgenic mouse model cagctg repeat expansion deficiency ogg1 an enzyme involved repair oxidation product guanine 7,8-dihydro-8-oxoguanine reduces somatic expansion frequency 64 oxidative dna damage induced expansion likely high organs like brain fragile x premutation mice show elevated levels atr sensitive somatic mutations however since ogg1 deficiency affect germline instability cag cag mouse model significance intergenerational instability cagctg expansion diseases etiology fragile x syndrome unclear in fragile x premutation mice atr insufficiency may prevent error free dna repair pathways activated repair dna damage forcing cell use secondary repair pathway results expansions potential pathways could non homologous end joining sort homologous recombination the effect atr mutations cggccg expansion frequency female mice raises possibility dna damage checkpoint proteins proteins involved dna repair potential affect expansion risk humans such transacting factors may explain risk expansion premutation carriers lower carriers identified general prenatal screening carriers known fragile x families 65 it could also explain intergenerational instability apparent families alleles grey zone others 66 transition allele normal size range full mutation two generations reported one family 67 our data also raise possibility may tissue variation repeat lengths older human premutation carriers may relevant diagnosis severity disease symptoms	fragile x mental retardation syndrome is a repeat expansion disease caused by expansion of a cggccg - repeat tract in the 5 utr of the fmr1 gene . in humans , small expansions occur more frequently on paternal transmission while large expansions are exclusively maternal in origin . it has been suggested that expansion is the result of aberrant dna replication , repair or recombination . to distinguish amongst these possibilities we crossed mice containing 120 cggccg - repeats in the 5 utr of the mouse fmr1 gene to mice with mutations in atr , a protein important in the cellular response to stalled replication forks and bulky dna lesions . we show here that atr heterozygosity results in increased expansion rates of maternally , but not paternally , transmitted alleles . in addition , age - related somatic expansions occurred in mice of both genders that were not seen in atr wild - type animals . some atr - sensitive expansion occurs in postmitotic cells including haploid gametes suggesting that aberrant dna repair is responsible . our data suggest that two mechanisms of repeat expansion exist that may explain the small and large expansions seen in humans . in addition , our data provide an explanation for the maternal bias of large expansions in humans and the lower incidence of these expansions in mice .
struma ovarii rare monodermal ovarian teratoma composed predominantly thyroid tissue.1 approximately 15% ovarian teratomas small non significant focus thyroid tissue metastases malignant struma ovarii occur 5% cases,23 frequent metastatic sites liver peritoneum lungs bone we present case metastatic follicular carcinoma liver peritoneum arising struma ovarii a right ovarian cyst discovered 35-year old woman routine follow examination second pregnancy she underwent right ovarian cystectomy incidental appendectomy 10 weeks gestation histopathological examination revealed follicular carcinoma arising teratoma infiltrative growth lymphovascular invasion after delivery october 2010 transferred hospital evaluation because definite abnormal hypermetabolic lesion positron emission tomography pet followed regular thyroid function tests however serum thyroglobulin level increased 1,437 ng ml normal range 0 52 ng ml she underwent endoscopic total thyroidectomy january 2012 histopathological examination revealed incidental nodular hyperplasia thyroid gland laboratory tests including blood cell counts serum levels liver enzymes electrolytes creatinine within normal limits i-131 scans revealed increased uptake right upper quadrant abdomen fig 1a abdominal computed tomography ct revealed 8.56.3 cm sized metastatic mass segment 6 liver variable sized seeding nodules paracolic gutter pelvic cavity fig 1b systemic metastatic lesions observed pet scans fig the liver exophytic mass demarcation line along segment 6 pelvic cavity showed multiple seeding nodules right salpinx ovary variably sized seeding nodules discovered right diaphragm small bowel mesentery pelvic cavity we resected metastatic lesions segment 6 liver right salpinx infundibulopelvic ligament the patient started soft diet postoperative day 3 percutaneous drainage tube removed postoperative day 5 the histopathological examination reported liver mass nodules right salpinx right diaphragm compatible metastatic follicular carcinoma fig in particular pathologist mentioned metastatic lesion liver focally showed poorly differentiated area she subsequently treated rai therapy recent serum thyroglobulin levels 12 ng ml von kalden first described struma ovarii 1895 ovarian teratoma contains 50% mature thyroid tissue most patients asymptomatic pelvic masses 45% screening tests ultrasonography ct patients present acute pelvic pain 40% menstrual irregularities 9% hyperthyroidism 5 8%).14 preoperative diagnosis struma ovarii impossible patients hyperthyroidisim diagnosed measuring serum thyroid stimulating hormone thyroxine conducting thyroglobulin i-123 scintigraphy contrast garg et al.3 raised possibility link pregnancy struma ovarii present case no consensus opinion exists treating thyroid type carcinoma arising struma ovarii primary surgical resection essential successful treatment various procedures reported literature table 1 a total abdominal hysterectomy bilateral salphingo oopherectomy omentectomy suitable postmenopausal women premenopausal women completed childbearing some investigators demonstrated rai therapy reduces recurrence total thyroidectomy cases metastatic struma ovarii increased serum thyroglobulin levels thyroidectomy useful excluding primary thyroid cancers subsequent ovarian metastases evaluating effectiveness rai therapy.56 adverse effects rai therapy treatment transient amenorrhea premature menopause studies pregnancy outcomes rai therapy reveal harmful effects however miscarriage may occur conception occurs within 6 months last rai therapy.6 adjuvant treatments total thyroidectomy chemotherapy thyroid suppression effective treating metastatic struma ovarii.7 serum thyroglobulin levels used marker metastatic disease in contrast patients increased serum thyroglobulin levels require total thyroidectomy followed rai therapy in addition radioiodine imaging used tool detecting metastatic lesions.36 case report patient underwent rai therapy total thyroidectomy serum thyroglobulin levels increased indicating rai therapy may ineffective treating disease tumour growth fast respond rai therapy fortunately serum thyroglobulin level returned normal range second debulking operation therefore regular serum thyroglobulin measurements might one surveillance tools cases most cases struma ovarii benign malignant changes reported 5 15% cases.24 extraovarian spread rare even malignant struma ovarii occurs 5% patients.23 papillary carcinoma 21% follicular carcinoma 54% frequent types carcinomas among thyroid type carcinomas struma ovarii.1 typical follicular carcinoma likely metastasize lungs liver central nervous system whereas papillary carcinoma tends involve abdominal cavity lymph nodes.8 poor prognostic factors initial extraovarian spread adhesion adjacent organs size 5 cm > 50% proliferating thyroid tissue.9 patient developed peritoneal dissemination huge liver metastases 2 years ovarian cystectomy moreover last pathological examination showed metastatic follicular carcinoma liver potential transformation poorly differentiated carcinoma compared initial pathological examination therefore this patient required close medical observation regular thyroglobulin measurements conclusion present rare case metastatic follicular carcinoma liver peritoneum initially arising struma ovarii young woman these metastatic lesions successfully treated debulking surgery rai therapy total thyroidectomy however several poor prognostic factors close medical follow serum thymoglobulin monitoring mandatory	a 35-year - old woman was determined to have an ovarian cyst and underwent a right ovarian cystectomy at 10 weeks of gestation . a histopathological examination revealed follicular carcinoma arising in a teratoma . no evidence of metastasis was found after delivery . she underwent a total thyroidectomy , followed by radioactive iodine ( rai ) therapy . however , her serum thyroglobulin level increased to 1,437 ng / ml ( normal range : 0 - 52 ng / ml ) after 10 months . radioiodine scintigraphy and abdominal computed tomography revealed liver metastasis and peritoneal seeding . she underwent debulking surgery of the liver , right salpinx , and peritoneal seeding nodules . a pathological examination showed metastatic follicular carcinoma with focal poorly differentiated features . adjuvant rai therapy was restarted , and her serum thyroglobulin levels returned to normal . in conclusion , metastatic lesions were successfully treated with a combination of debulking surgery and rai therapy . close medical follow - up monitoring serum thyroglobulin levels is mandatory in such patients .
use proteomics systems biology tool cancer research continues expand scope depth evolves rapidly universally applicable method investigation practically biological process proteomics particularly attractive cancer research complexity tumorigenesis cancer progression tumor relapse metastasis often involves large protein networks indeed little decade applications mass spectrometry based proteomics cancer related research ranging mechanistic investigation discovery novel therapeutic targets increased exponentially this evidenced explosive growth number publications subject matter 109 2000 1,349 2011 http://www.ncbi.nlm.nih.gov/pubmed total number publications containing keywords proteomics cancer reaching 7,500 date a large number review articles appeared past several years offering excellent overviews perspectives novel proteomic applications cancer many reviews focused different cancer types breast cancer,14 pancreatic cancer,5,6 ovarian cancer,79 colorectal cancer,10,11 glioma.1214 others focused sample types subcellular components tissue,1517 serum,1820 secretome.2123 addition reviews focused innovative proteomic methodologies various end goals proteomics cancer phosphoproteomics,2427 mechanisms drug resistance,2830 kinome profiling.3133 finally appear reviews proteomic biomarker discovery cancer diagnosis prognosis therapeutic response area focus highlighting intense activities search new biomarkers could translated clinical applications.30,3436 despite remarkable advances utilizing proteomics almost every aspect cancer research many challenges remain global proteomic approaches capable identifying thousands proteins many differentially expressed often biased towards soluble high abundance proteins thus easily missing many low abundance proteins could play critical roles signal transduction.37 solid tumors heterogeneous making difficult identify key proteins could used universal targets even type cancer.38,39 high throughput proteomic methods discover unbiased cohorts potential biomarkers therapeutic targets regulate disease progression sheer number often dozens hundreds hits could cumbersome current functional studies limited involving one proteins time thus large number diagnostic prognostic biomarkers identified proteomic analysis made clinical stage underscoring urgent need convergence functional studies clinical sample validations moreover progress drug development far lagged pace proteomic discovery potential drug targets former generally requires prolonged developmental process drug design vitro vivo tests efficacy toxicities well absorption distribution metabolism excretion adme).40 proteomic approaches increasingly used preclinical drug discovery process understand effects drug candidates protein targets shed light cellular mechanisms behind observed phenotype although many biomaterials including deoxyribonucleic acid dna ribonucleic acid rna carbohydrates also used novel drug targets different approaches.41 proteomic studies main goal identifying new druggable targets treatment cancer relatively primary focus review convenience discussion attempt group various proteomic target discovery studies several distinct approaches target identification while mass spectrometry ms)-based proteomic approaches remain comprehensive versatile tool large scale proteomic profiling,42,43 several non ms based techniques reverse phase protein microarrays rpma)44 peptide arrays45,46 recently gained popularity rpma technology platform designed quantitative analysis specific phosphorylated cleaved total phosphorylated nonphosphorylated forms cellular proteins complex mixtures multiple samples simultaneously one microarray accommodate range hundreds thousands samples printed series replication rpma performed using either primary secondary labeled antibody chemiluminescent fluorescent colorimetric assays multiplexing also achieved simultaneously probing multiple arrays spotted lysate different antibodies implemented quantitative calibrated assay.47 rpma utilized potential drug discovery validation well advancements understanding disease clinic laboratory,48,49 rpma currently integrated human clinical cancer trials.50 quantitative methods adopted ms include techniques based stable isotope labeling proteins peptides well label free methods comparison labeling methods label free methods provide higher dynamic ranges quantification versatile tools used estimate changes protein abundances different samples.5153 utility ms based proteomic analyses applications drug target identification increasingly recognized past decade due high sensitivity specificity throughput for example gel free isotopic labeling methods silac stable isotope labeling amino acids cell culture),54,55 isobaric tags relative absolute quantitation itraq),5658 isobaric tandem mass tags tmts)59 figure 1 routinely quantify several hundreds thousand proteins single analysis high reproducibility continued innovations improvements instrumentation bioinformatics tools drive ms based proteomics applications drug discovery,60,61 complemented streamlined focused non ms based methods targeted repeated assays protein arrays the former play key roles discovery stage quantitative proteomic analysis undertaken compares differentially expressed proteins potential drug targets the array methods cost effective convenient use validation studies drug targets effects one greatest challenges cancer therapy drug resistance occurs either intrinsically acquired certain period treatment resistance targeted cancer drugs involves complex diverse molecular adaptations cancer cells selective pressure therapeutic regimens for example specific target protein tumors may undergo mutations become inaccessible drugs.6264 addition subset cancer stem cells may resistant cytotoxicity drugs target bulk differentiated cancer cells.6568 moreover chemotherapeutic agents often induce adaptive changes regulatory networks signaling pathways leading independence cancer cells targeted protein emergence drug resistant disease clones.69 indeed diverse mechanisms drug resistance transform cancer cells selective pressure therapies made extremely difficult combat tumor recurrence inevitably followed metastatic progression disease death current cancer treatment typically consists monotherapy regimen targeting specific protein signaling pathway example selective estrogen receptor modulators serms estrogen receptor herceptin her2 gefitinib epidermal growth factor receptor egfr however tumors initially responsive eventually develop resistance therapy via variety mechanisms switching alternative drugs emergence resistant disease clones following first line treatment often achieves little delaying cancer progression resistance develop one drug tumors may cross resistant several structurally dissimilar functionally distinct agents phenomenon known multidrug resistance.70 thus urgent need better understand resistance mechanism identify novel targets therapeutic intervention effective blocking progression cancer cells already resistant previous treatment proteomic approaches hold promise identify individual proteins interactive signaling networks act individually collectively conferring drug resistance the comparison protein expression drug resistant tumor tissues cell lines drug sensitive tumor tissues cell lines one promising tools drug target identification targeting proteins signaling pathways may either resensitize tumor response original treatment may help overcoming acquired drug resistance blocking alternative survival signaling induced initial treatment more importantly proteomic characterization resistant phenotype provide complete picture signaling adaptation multiple drug targets combinatorial therapeutic solutions identified combat resistance achieve longer term improvement disease outcomes while advances application limited following examples demonstrate proteomic approaches inherently suitable discovery targets resistant phenotypes expect increasing number protein targets validated functional studies followed therapeutic development one example comes comparative proteomic analysis colon cancer stem cells differentiated tumor cells uncovered prominently upregulated protein baculoviral inhibitor apoptosis protein iap repeat containing protein 6 birc6 one iaps may play crucial role chemoresistance colon cancer stem cells subsequent knockdown gene resulted resensitization cells chemotherapy.71 results proteomic study suggest birc6 could used potential therapeutic target eradicate colon cancer stem cells contributing colon cancer recurrence in cases itraq ms based proteomics analysis used identify proteins associated development docetaxel resistance comparing docetaxel sensitive pc3 cells docetaxel resistant pc3-rx cells developed docetaxel dose escalation.56 functional validation experiments performed using recombinant protein treatment small interfering si)rna knockdown experiments the findings study suggested macrophage inhibitory cytokine 1 investigated potential biomarker therapeutic target acquired resistance docetaxel treatment however extensive functional studies follow validations required proteins proven viable drug targets similarly quantitative proteomic investigation hepatocellular carcinoma type liver cancer known resistance chemotherapy implicated phospho glycerate mutase 1 pgam1 potential therapeutic target.72 clinicopathological analysis indicated overexpression pgam1 associated 66.7% hepatocellular carcinomas strongly correlated poor differentiation decreased survival rates p<0.01 in addition short hairpin sh)rna mediated repression pgam1 expression resulted significant inhibition liver cancer cell growth vitro vivo using proteomics approach elevated levels prohibitin 1 phb1 glutathione transferase pi gst found associated paclitaxel resistance discrete subcellular fractions two drug resistant sublines relative sensitive sublines.73 immunofluorescent staining fractionation studies revealed increased level phb1 surface resistant cell lines transiently silencing either phb1 gst gene expression using sirna paclitaxel resistant cancer cell sublines partially sensitized cells toward paclitaxel intriguingly silencing phb1 gst resulted activation intrinsic apoptosis pathway response paclitaxel similarly stably silencing either phb1 gst significantly improved paclitaxel sensitivity a549tr cells vitro vivo this study suggests phb1 mediator paclitaxel resistance resistance may depend cellular localization proteins based preliminary functional studies phb1 proposed potential target therapeutic strategies treatment drug resistant tumors again yet see follow investigations feasibility novel yet unproven therapeutic targets recent proteomic study letrozole resistant breast cancer a tmt label used quantitative comparison protein expression profiles resistant versus sensitive mcf-7 cells overexpressing aromatase.74 study identified fascin among significantly upregulated proteins promising therapeutic target inhibition metastasis hormone resistant breast cancer cells acquired enhanced capacity migration invasion retrospective clinical validation confirms fascin overexpression independent indicator decreased survival poor prognosis a subsequent drug discovery effort group led discovery series thiazole compounds75 potent inhibitors migration invasion metastatic cancer cells binding fascin summary resistant cancer population whether inherent acquired major problem reduces activity conventional and/or molecularly targeted cancer drugs the success identifying drug targets resistant cancer cells proteomic approaches depends reliable drug resistant tumor tissues cell lines it also critical proteomics combined data approaches attempt investigate mechanistic pathways detail well validate potential targets clinical setting chemical proteomics technique identifies proteins enriched isolated result interacting binding chemical probe usually small molecule drug fixed solid support.7678 therefore affinity based enrichment techniques combination ms enabled direct determination protein binding profiles small molecule drugs physiological conditions represent one direct approaches screen drug protein interactions.79,80 major drawback encountered affinity based chemical proteomics presence pulled extract nonspecifically bound proteins among a large number proteins bind nonspecifically conventional affinity matrices reported.81 therefore strongly recommended green fluorescent protein used tag choice shows minimal nonspecific binding mammalian cell proteins quantitatively depleted cell extracts allows integration biochemical protein interaction data vivo measurements using fluorescence microscopy in addition also necessary perform appropriate negative control experiments distinguish nonspecific interactions specific interactions chemical proteomic approaches also include global proteomic profiling cellular samples treated biologically active compound without enrichment steps pharmacology chemical proteomics have utilized determine specificity drugs analogs anticipated well unknown targets may also bind probe.41 activity based probes specifically target diverse sets enzyme families provides direct information activation state identified proteins.82 several kinds chemical probes used proteomic studies across multitude enzyme classes hydrolases proteases kinases phosphatases histone deacetylases glycosidases oxidoreductases.83 thus chemical proteomic approaches identify protein targets drugs exert known biological activities vitro vivo also discover previously unknown targets drugs known modes action moa these target proteins may additional druggable targets may also account side effects toxicities identification protein targets responsible toxicities may prove valuable early drug development minimize failure clinical trials in addition chemical proteomics identify novel drug targets broad action chemical probes example nonselective kinase inhibitors staurosporine life technologies carlsbad ca usa]).82 following present examples chemical proteomics used effectively target discovery validation gefitinib iressa astrazenca london uk first selective inhibitor egfr tyrosine kinase domain.84 gefitinib used monotherapy effective treatment patients locally advanced metastatic nonsmall cell lung cancer nsclc egfr mutations.85 gefitinib also tested clinical trials tumors including head neck squamous cell carcinoma hnscc monotherapy combination chemotherapies radiation shown limited clinical efficacy response rates 10%15%.8689 using cleavable isotope coded affinity tagging ( cicat)-based liquid chromatography tandem mass spectrometry lc ms ms method chen et al90 identified tyrosine phosphorylation levels 21 proteins control epidermal growth factor treated a431 human cervical cancer cells of endofin dcbld2 kiaa0582 validated novel tyrosine phosphorylation targets epidermal growth factor signaling responsive gefitinib therapy.90 pernas et al91 observed gefitinib sensitivity correlated phospho p)-akt p stat3 activation hnscc cell lines tumor specimens thus p akt p stat3 could serve potentially useful drug targets development novel therapeutic agents hnscc more recently wu et al92 used quantitative chemical proteomics identify several kinases including nek9 lyn jak1 wee1 epha2 involved cell survival proliferation hnscc cell lines these findings may lead new therapeutic options hnscc patients inhibitors acting multiple tyrosine kinases chemical proteomic studies could help uncover additional unknown targets interacting signaling network for example inhibitor multiple tyrosine kinases dasatinib targets bcr abl src family kinases c kit platelet derived growth factor receptor kinase cell permeable kinase probe da-2 employed profile potential cellular targets dasatinib number previously unknown dasatinib targets identified including several serine threonine kinases pctk3 stk25 eif-2a pim-3 pka c- pkn2).93 according another report,94 nearly 40 different kinase targets dasatinib discovered using quantitative phosphoproteomics these include receptor tyrosine kinases ephrin receptors discoidin domain receptor 1 egfr nonreceptor tyrosine kinases frk brk ack these results provided system level view dasatinib action cancer cells suggested functional targets rationales therapeutic strategies when mechanisms biologically active compounds cancer cells fully understood chemical proteomics could help elucidate modes action mapping protein networks perturbed drug treatment aspect wealth proteomic discoveries have seldom translated validated drug mechanisms stayed preliminary findings could lead confirmed targets depth functional studies for example celecoxib celebrex pfizer inc new york ny usa originally widely prescribed nonsteroidal anti inflammatory drug recently shown anticancer properties95,96 uncertain mechanisms ranging modulating expression bcl-2 family members mitochondria mediated apoptosis,95,97 inhibiting nuclear factor kappa b,98,99 akt,100 stat3101signaling pathways proteomic analysis human oral squamous cell carcinoma found celecoxib treatment induced ten- 20-fold overexpression heterogeneous nuclear ribonuclear protein c.102 similarly global proteomic profiles colorectal cancer cells treatment celecoxib revealed significant alterations among multiple proteins involved diverse cellular functions ranging glycolysis protein biosynthesis dna synthesis messenger rna processing protein folding phosphorylation redox regulation molecular chaperon activities.103 however none proteomic studies conclusive mechanistic interpretation numerous alterations protein expression the wnt--catenin signaling pathway developmental signaling pathway plays critical role regulation differentiation proliferation apoptosis thus aberrant wnt--catenin signaling widely implicated numerous cancers.104106 however identification targeted wnt--catenin pathway inhibitors cancer patient treatment hampered limited number pathway components amenable small molecule inhibition recently huang et al107 used itraq approach identify small molecule xav939 selectively inhibits -catenin mediated transcription interestingly xav939 also inhibits poly adenosine diphosphate ribosylating enzymes tankyrase 1 tankyrase 2 interact highly conserved domain axin stimulate degradation ubiquitin proteasome pathway.107 tankyrases involved fundamental cellular processes telomere homeostasis wnt signaling potential telomere directed anticancer targets.108,109 therefore xav939 useful tool understanding wnt--catenin signaling also potential drug targets wnt--catenin telomeres chemical proteomics aimed characterizing effects drug candidates could sometimes lead discovery new drug targets for example sulforaphane sfn known antimicrobial anticancer properties experimental models.110112 sfn modulate multiple cellular targets involved cancer development including dna protection inhibition cancer cell proliferation induction apoptosis inhibition neoangiogenesis progression benign tumors malignant tumors metastasis.112,113 mastrangelo et al114 identified serotonin receptors novel targets sfn proteomic analysis caco-2 colon cancer cells this finding may shed light serotonin mediated signaling pathways colon cancer may also lead development potential novel therapeutic agents targeting serotonin another study phosphoglucomutase 3 identified proteomic analysis may contribute sfn induced cell death lncap prostate cancer pca cells make phosphoglucomutase 3 potential molecular therapeutic target pca.115 early studies discovery druggable protein targets relevant disease open new venues development novel treatment regimens although field chemical proteomics proven value identifying novel drug targets several challenges still remain overcome first chemical probes must carefully designed covalently attach proteins interest allow purification and/or identification second spectrum available activity based probes needs broadened order target additional enzyme classes in addition development high throughput gel free assays conjunction activity based probes required enhance experimental value chemical proteomics the continued success chemical proteomics depends design novel probes new probe classes specifically target diverse sets enzyme families well unbiased assessment full spectrum drug target interactions molecular moa proteins spatiotemporal distribution changes play central role biological processes including cancer initiation progression analysis specific homogeneous cell type tumor tissues could reveal molecular changes take place tumorigenesis since concentration disease related proteins likely much higher within near tumor areas recently large scale protein identification comparative quantitation highly complex protein mixtures achieved proteomic strategies based upon differential disease state tissues known tissue proteomics.35,116120 remarkable advances tissue proteomics propelled rapid development efficient methodologies techniques innovative sample preparation sophisticated ms instrumentation powerful bioinformatics tools the goals tissue proteomic research focus early accurate diagnosis improvement therapeutic strategies better evaluation prognosis and/or prevention given disease well identification novel drug targets based upon differential protein expression control case groups disease a major hurdle tissue proteomics analysis variability observed among tissue samples due heterogeneity tumor tissues containing cancer cells well inflammatory vascular connective tissue cells detailed proteomic analyses clinically valuable samples require meticulous preparation procedures major current focus tissue proteomics so far tissue proteomics uncovered large numbers proteins altered expressions tumor tissues analyzing fresh frozen biopsy samples archived tumor tissues stabilized formalin fixation paraffin embedding ffpe however proteins actually become novel diagnostic biomarkers therapeutic targets as illustrated examples tissue proteomic studies remain preliminary investigations identified differentially expressed proteins diseased tissues while proteins could potential prognostic markers therapeutic targets general lack depth functional validated studies follow initial screening results tissue proteomics employed quite frequently study lung cancer molecular mechanism elucidation well novel drug target discovery.121126 peng et al123 studied protein profile changes human pulmonary adenocarcinoma tissues paired surrounding normal tissue two dimensional 2d gel electrophoresis esi q tof electrospray ionization quadrupole time flight ms ms instruments thirty two differentially expressed proteins 2-fold change p<0.05 identified pulmonary adenocarcinoma compared normal tissues knockdown pyruvate kinase isozyme 2 pkm2 one overexpressed proteins led significant suppression cell growth induction apoptosis vitro tumor growth inhibition vivo moreover shrna expressing plasmid targeting cofilin-1 another expressed protein significantly inhibited tumor metastases prolonged survival vivo this tissue proteomic analysis validation indicated pkm2 cofilin-1 could potential therapeutic targets pulmonary adenocarcinoma it noted small molecule inhibitors pkm2 identified shown inhibit cancer cell glycolysis increase cancer cell death following loss growth factor signaling,127 consistent proteomics driven conclusion cofilin-1 long associated increased tumor metastasis due role regulating cytoskeleton dynamics,128 inhibition cofilin-1 small molecule inhibitors demonstrated enhance actin depolymerization.129 another example carretero et al124 performed integrated genomic proteomic study identification genes phosphoprotein status associated lkb1 loss progression invasive metastatic lung tumors primary metastatic de novo lung cancers phosphoproteomic analysis determined two key modulators focal adhesion dynamics src focal adhesion kinase upregulated lkb1 loss nsclc progression moreover combined inhibition src phosphoinositide 3-kinase mek1/2 resulted synergistic tumor regression these results point towards mechanism underlying increased propensity metastases seen lkb1-deficient lung tumors identified src signaling pathway molecularly targetable pathway treatment lkb1-deficient nsclc humans therefore development therapeutic src inhibitors including dasatinib saracatinib valid therapeutic strategy treatment lkb1-deficient nsclc proteomic analysis pca tissues associated multistage tumor progression also provides valuable source clinically relevant biomarkers novel therapeutic targets.130,131 example ummanni et al132 recently reported differential protein expression patterns histologically characterized pca tumor tissues surrounding benign tissues individual pca patients based upon 2d differential gel electrophoresis coupled ms the study identified 118 protein spots differentially expressed cancer n=24 compared benign n=21 prostate tissues adjacent cancerous tissues analysis gel spots matrix assisted laser desorption ionization time flight ms ms revealed 79 unique proteins moreover system biology analysis proteomic results revealed several novel drug targets pca development and/or progression including eif4a3 ddah1 arg2 prdx3 prdx4 although functional validation individual targets yet performed it evident proteomic analysis multistage pca tissues could provide new insights pca progression potentially lead design novel diagnostic therapeutic strategies efficient peptide protein extraction approaches crucial success tissue proteomic analysis two major strategies mining proteomic information ffpe archive tissue samples developed.133138 one strategy aimed recover full length proteins heat treatment suitable buffers consequent reversion formaldehyde induced cross links the operation conditions optimized various labs since shi et al139 initially established method application high temperatures addition detergent sodium dodecyl sulfate indicated two critical conditions enhanced protein extraction yields.140142 protein deposited large amounts insoluble densely packed aggregates applications 40,000 psi pressure reported recover 96% proteins tissue surrogate model compared 26% recovery rate 14.7 psi.138,143 another major strategy based upon direct proteolytic digestion intact ffpe archive tissue samples followed liquid chromatography ms ms characterization complex peptide mixture.144 tissue solubilization achieved various buffers including sodium dodecyl sulfate dithiothreitol,145 radioimmunoprecipitation assay,146 acetonitrile ammonium bicarbonate,147 tris hcl148 different temperatures ph conditions optimal yield peptides successful example hwang et al147 characterized 428 prostate expressed proteins ffpe archive tissue samples discovery pca biomarkers potential drug targets using shotgun approach results date demonstrate direct trypsin protein digestion effective sample preparation strategy proteomic analysis ffpe archive tissues approximately 70% diagnosed breast cancers express estrogen receptor er+ whereas er breast cancers well differentiated clinically tend aggressive.149152 global proteomic characterization quantitative comparison er+ er breast tumors recently performed fresh frozen breast tumor tissues.153 study identified 2,995 unique proteins including number receptor tyrosine kinases intracellular kinases abundantly expressed er+ er breast cancer tissues using label free quantitative approach 236 proteins found differentially expressed er+ er breast tumors compared er breast tumors 141 proteins selectively upregulated 95 proteins downregulated er+ tumors molecular function analysis gene ontology showed dehydrogenase reductase cytoskeletal proteins extracellular matrix hydrolase lyase categories significantly enriched er+ breast tumors whereas selected calcium binding proteins membrane traffic proteins cytoskeletal proteins enriched er tumors biological process pathway analysis indicated proteins related amino acid metabolism proteasome fatty acid metabolism overexpressed er+ tumors proteins related glycolysis pathway overexpressed er tumors given clinical challenges treating er breast cancer vivo findings differentially expressed proteins er tumors especially significant pathological relevance these proteins may serve potential therapeutic targets er breast cancer functionally validated recently cabezn et al154 used systematic 2d gel based proteomic profiling strategy applied analysis 78 fresh triple negative breast cancer tnbc tissue biopsies combination three tier orthogonal technology 2d polyacrylamide gel electrophoresis silver staining coupled ms 2d western blotting immunohistochemistry approach identified validated one specific protein mage a4 expressed significant fraction tnbc her2-positive er lesions the existence immunotherapeutic approaches specifically targeting protein mage protein family members provides novel management options tnbc her2-positive er patients bearing mage a4 positive tumors although promising results reported yet breakthrough close becoming clinically applicable the challenge perform robustly designed large retrospective studies including independent validation sets followed prospective validation studies demonstrate clinical benefits patients the development sirna vivo techniques greatly speed selection useful proteins characterization discriminator proteins provide new molecularly targeted anticancer drugs faced complexity cancer tissue proteomics great clinical potential global coordination ongoing efforts appears crucial in review provided overview three major approaches proteomics employed discovering potential therapeutic targets cancer target identification resistant cancer populations one promising tools drug target identification uncover multiple drug targets combinatorial therapeutic solutions combat resistance achieve longer term improvement disease outcomes chemical proteomics approaches identify protein targets drugs exert known biological activities also discover previously unknown targets drugs known moa the tissue proteomics approach offers advantage direct clinical relevance complement mechanism based approaches like chemical proteomics proteomics continues evolve rapidly instrumental advancement innovative applications biomedical research particularly field cancer the complexity cancer biology requires depth functional studies mechanistic elucidation also unbiased system approaches global view interactive signaling networks reflect cancer disease stage cancer proteomics uncovered phenomenal number cancer specific proteomic alterations shedding light previously unknown mechanisms tumorigenesis cancer progression metastasis perhaps prominently proteomics provided unmatched wealth potential biomarkers could clinically used diagnosis prediction treatment responses the utility proteomics valuable tool discovery new cancer treatment targets increasingly recognized recent years we note remarkable progress several directions cancer proteomics plays important role drug discovery illustrated figure 2 novel proteomics methodologies ms based non ms based continued optimized perfected using high resolution high speed ms simplified robust array technologies tumor tissue cell subcellular compartment relevant biological samples proteomics increasingly used elucidate mechanisms drug resistance cancer hope novel protein targets could emerge therapeutic intervention resistant disease innovative frontiers chemical proteomics studies examining drug induced biological perturbations often reveal new clinically relevant biomarkers drug targets dissecting mechanisms cancer progression proteomics also identified previously unknown unconsidered druggable targets however despite tremendous progress potential proteomics target discovery serious challenges lack coordinated efforts follow proteomic discovery novel therapeutic targets largely accounts current gap drug development design synthesis optimization new drug targets emerging numerous proteomic studies cancer most proteins identified proteomic analyses drug resistance validated roles specific disease processes potential clinical use functional studies involving vitro manipulations gene expression using specific pharmacological inhibitors antisense rna rna interference gene knockout experiments integral part proteomic study target discovery future investigations place emphasis functional studies clinical validation novel targets translation clinical trials greater speed higher success rates proteomics also expected play major role preclinical clinical research targeted combinatorial therapies	proteomic approaches are continuing to make headways in cancer research by helping to elucidate complex signaling networks that underlie tumorigenesis and disease progression . this review describes recent advances made in the proteomic discovery of drug targets for therapeutic development . a variety of technical and methodological advances are overviewed with a critical assessment of challenges and potentials . a number of potential drug targets , such as baculoviral inhibitor of apoptosis protein repeat - containing protein 6 , macrophage inhibitory cytokine 1 , phosphoglycerate mutase 1 , prohibitin 1 , fascin , and pyruvate kinase isozyme 2 were identified in the proteomic analysis of drug - resistant cancer cells , drug action , and differential disease state tissues . future directions for proteomics - based target identification and validation to be more translation efficient are also discussed .
growing clinical demands controlled sustained drug release systems serve implantable devices patients acute chronic diseases circumstances surprising intelligent materials emerged promising strategy drug delivery for example many efforts directed toward using various stimuli responsive biomaterials controllable drug carriers bioactive cargos released via changes ph temperature input electrical uv energy present time electrical stimulation appears one suitable approaches clinical translation 1 electrical signal triggered using portable equipment requiring significant cost sophisticated technologies 2 generated signal tuned using variety exposure times current intensities this regard conductive polymers emerged one useful drug delivery platforms particular polypyrrole ppy become candidate material due lack toxicity favorable biocompatibility reversible electrochemical properties for instance polypyrrole demonstrated excellent vivo biocompatibility results similar teflon implanted neural prosthetic both glial neuronal cells found intimate contact ppy material other studies noted ppy extracts exhibited hemolytic allergenic mutagenic properties whereas sciatic nerve implants elicited minor inflammatory response 6 months postimplantation functionally electrostatic interaction ppy response electric current provides controllable switch release tethered cargo providing situ delivery nerve growth factors anti inflammatory drugs adenosine triphosphate prior investigations demonstrate time- site specific release profiles obtained modifying electrical magnetic pulse patterns durations electromagnetic fields emf discussed another potential form stimulus drug delivery first realized carbon nanotubes we previously outlined fabrication physiochemical details advance potential ppy medical practice however two obstacles prevent practical use ppy polymer systems following 1 amount drug cargo limited using typical flat thin film fabrication 2 delivery cargo within human body requires percutaneous electrodes deliver required level electric current i.e. physical electrical contact ppy substrate this latter obstacle must understood context chronic applications drug release may desirable many days supply within film exhausted time percutaneous wires carry possibility infection retrograde tracking along insertion path normal movement vitiates perfect seal tissues insulated electrodes work we detail new ppy paradigm overcomes limits payload invasive delivery we demonstrate three dimensionally nanostructured ppy platform impregnated model test drug dexamethasone dex exhibits outstanding drug loading efficiency moreover noninvasive demand drug release demonstrated exposing ppy nanowires high frequency pulsed electromagnetic fields emf subsequent studies using lipopolysaccharide challenged bv-2 glial cell line showed dex released emf stimulation remained bioactive ameliorated oxidative damage inflammatory response the putative inductive coupling dex doped polypyrrole nanowires dex ppynws emfs bypasses requirement direct electrical contact ppy opens door ppy embodiments placed vivo cargo delivered controllably noninvasively many weeks ppy flat films nanowires fabricated using common electropolymerization techniques first step manufacturing process preparation templates flat ppy films indium tin oxide ito glass slides 515 resistivity delta technologies ) were washed acetone 30 min followed ethanol milli q water ultrasonic bath ppynws experiments anodic aluminum oxide template aao figure 1 0.2 pore size 60 thickness whatman obtained the aao templates subsequently coated 100-nm thick gold layer one side using varian e beam evaporator briefly aqueous mixture consisting 0.2 pyrrole py sigma 0.025 dexamethasone 21-phosphate disodium salt dex sigma 0.05 10 nm nanoxact spherical gold nanoparticles aunps nanocomposix ca mixed comparison 0.2 pyrrole 0.025 dex 0.1 poly(3,4-ethylenedioxythiophene)-poly(styrenesulfonate pss sigma also mixed synthesis note vitro experiment concentration dex within solutions decreased 5 mm prepared aao templates subsequently incubated respective mixtures 30 min cleaned ito slides aao templates were separately connected working electrode ch instruments model 604 electrochemical analyzer workstation platinum counter electrode ag agcl reference electrode placed synthesis solution the one step electropolymerization dex ppy accomplished applying constant potential 1 v using potentiostat following polymerization the final films rinsed thoroughly milli q water 5 min the aao templates removed placing films 3 sodium hydroxide rinsed milli q water each cutaway diagram illustration aao template far left the third step illustrates filling diffusion solution consisting pyrrole monomer aunps pss dex template pores the fourth step dex conjugated polypyrrole electropolymerization process finally far right ppy nws shown attached gold base dissolution aao template sodium hydroxide ppy samples prepared first sputter coating platinum 60 s. sem images taken fei nova nano sem via field emission scanning using et tld high vacuum acceleration voltage 5 kv tem images taken using fei philips cm-10 transmission electron microscope operated 100 kv 200 condenser aperture 70 objective aperture multiple factors must considered designing emf stimulation system pulse conditions these parameters include waveform shape pulse duration pulse magnitude duty cycle forth we originally chose narrow pulse width 500 ns stimulating regime allowed us experiment various coil geometries minimal power consumption the square wave chosen order maximize induced electric fields within ppy since hypothesized stimulus drug release our original pilot measurements made using three turn coil low inductance allowing testing set limits overheating this data shown permitted construction 15-turn coil used experiments reported briefly awg 16 copper wire wound 15 times create 15-turn coil the geometry coil 2.3 2.8 cm inside dimensions 3.0 3.8 cm outside dimensions the coil stimulated pulsing regime using custom made circuit each input pulse long enough saturate coil turned duration required unload coil completely 10 additionally tested several stimulation patterns oscillating polarity grouping polarity pulses different temporal patterns forth maintaining 5% duty cycle as find significant differences drug release initial trials data shown utilized waveform described figure s2 order minimize heat generation ( top illustration shows integrated system used create electromagnetic field emf induce ppynws activity the stimulator connected wire wound coil standard cuvette placed center following emf stimulation aliquots solution assayed drug concentration via uv vis spectrophotometry the left inset describes dimensions stimulating coil h 1.2 cm l 3.8 cm w 3.0 cm recordings b left right probe measurements magnetic fields mf electric fields ef center coil 36 g 4000 v respectively the insets describe idealized mf ef waveforms based input square pulse stimulation regime using waveform patterns figure s1 input signal real time magnetic electric field outputs stimulation coil were measured using high frequency emc 100b magnetic 100d electric probes beehive electronics ca probes connected tektronics tds 2012b oscilloscope terminated 50 resistor data collection probe positioned stimulation coil center origin the probes directional oriented direction maximum expected reading this value taken output probe value converted dbm the recorded data points oscilloscope imported ms excel fast fourier transform fft waveforms calculated ffts fundamental frequency output dbm power value used antenna gain equation figure s1 provided probe estimate ac field magnitudes potentiostat electrical stimulation and the setup electropolymerization process three electrodes dex conjugated ppy film connected working electrode subsequently placed pbs solution containing 0.80% w v nacl a constant voltage 0.1 v applied 5 h using ch instruments model 604 electrochemical analyzer workstation comparison the dex ppy platforms also stimulated induced emf generated custom circuit coil stimulator system the supernatants collected 1 3 5 h stimulation potentiostat pulsed magnetic field generator figure 2 depicts experimental setup essential components emf stimulation system used remotely trigger ppy drug release the ppy samples placed 12.5 mm 12.5 mm 45 mm standard cuvette filled phosphate buffer solution the cuvette positioned center void stimulation coil physical contact coil the coil subsequently energized using square wave pulse trains described figure s1 experiments comparing dex conjugated polypyrrole compositions drug release effects stimulation continued 16 days using emf stimulation test if stimulated release dex might influenced heating stimulated samples placed dex doped flat polypyrrole templates within controlled incubator 37 c this temperature slightly higher ambient temperature vicinity active coil measured 30 c for 16 days dex release sample solutions collected 1 3 5 7 10 13 16 days continuous emf stimulation n 5 a calibration curve dex y(od 23.8x 0.04 also prepared detect drug release determine characteristics pulsatile emf stimulation experiments performed polypyrrole nanowires synthesized gold nanoparticle ppynws aunps samples the dex release profile recordings begun 10 h stimulation pulsed emf then pulsed emf stimulation turned referred time 2 h discontinued time 2 h. regimen continued four cycles sample ppy samples 0.51.0 cm prepared submitted xps analysis the surface chemical composition samples analyzed x ray photoelectron spectroscopy xps using kratos axix ultra dld spectrometer the survey high resolution spectra obtained constant pass energy mode pass energies 160 20 ev respectively survey 1 ev step high resolution spectra 0.05 ev step the bv-2 cells cultured 75 cm flasks dulbecco modified eagle medium sigma aldrich 10% fetal bovine serum 100 iu ml penicillin 100 g ml streptomycin cells maintained 37 c humidified incubator 5% co2 harvested trypsinizing 0.25% trysin edta pbs reseeded approximately 1 10 density 12-well dishes 24 h detect ros cells incubated medium containing 1g ml lipopolysaccharides lps escherichia coli 026:b6 sigma aldrich 6 h. bv-2 cells treated 1 g ml dex application lps 1 h. detect dex release pulsed emf ppynws aunps films approximately 30 40 mm unit area stimulated 30 min 1 h lps treatment 1 h increments experiments the coil placed flat directly petri dish aligned well touching bottom surface dish after 6 h lps treatment cells trypsinized centrifuged resuspended 10 oxidative stress indicator cm h2dcfda molecular probes pbs suspended cells placed incubator 1 h measurement ros performed plate reader 480 nm/530 nm measurement also performed fluorescence microscope olympus ix 81 inverted the cells illuminated x cite series 120pcq fluorescence illumination source additionally another strong oxidizing reagent hydrogen peroxide h2o2 used confirm lps results oxiselect intracellular ros assay kit cell biolabs inc briefly bv-2 cells seeded black 96-well plates 12 h incubated 1 mm dcfh da solution 1 h. hydrogen peroxide 20 incubated plates 30 min dex treatments applied 15 min emf stimulated dex release ppynws aunps films divided smaller pieces approximately 30 mm placed well stimulated 15 min instances coil placed 96-well plate touching bottom surface wells 3 3 matrix stimulated bv-2 cells cultured poly lysine sigma precoated round cover glasses 1.5 thickness 12 mm 12-well plates 24 h. experimental treatment lps dex released dex bv-2 cells fixed 4% paraformaldehyde 30 min room temperature a blocking solution 1% albumin bovine serum sigma aldrich applied samples 1 h. antinitric oxide synthase ii antibody emd millipore diluted ratio 1:400 antibody dilution buffer sigma cells incubated diluted primary antibody solution overnight 4 c the next day cells incubated 1:100 diluted cy3 conjugated goat antirabbit igg antibody solution emd millipore 2 h. dried cover glasses mounted glass slides using vectashield hardset mounting medium dapi vector lab these samples imaged confocal microscope leica sp5/sted mp system all data shown standard error mean sem comparative tests used conventional student test one way anova significance determined p value 0.05 nanowire architecture revealed sem tem figures 3 4 polypyrrole wires 10 long completed 13001400 deposition using potentiostat figure 2a shorter lengths realized shorter deposition times figure s3b the desired structure ppynws achieved 200300 deposition figure 3b aside smaller ppynws ppynws 200 nm long fabricated using different aao templates 0.02 pores figure s3a used study the free standing vertically aligned ppynws generally arranged mats unit areas 1 2 cm ( scanning electron micrograph showing top dorsal view polypyrrole wires 200 nm diameter 10 length produced 13001400 deposition ( b similar micrograph 200300 deposition used scale bars 10 b 2 figure 4a b shows distribution gold nanoparticles within bulk 500-nm- 2-m long ppynws note several gold bases shown due folding ppynws ( b higher magnification tem individual nanowires showing details gold nanoparticle deposition these wires range approximately 500 2000 nm length 150 nm diameter the real time magnetic electric field output waveforms coil center plotted figure 2 the measurements revealed magnetic field output similar input field oscillation noise present square waveform fft decomposition measured signal showed fundamental frequency magnetic field 3.2 mhz this converts average peak amplitude 36 g using antenna gain equation supplied probe vendor figure s1 moreover amplitude magnetic field vary 20% within coil the highest field amplitudes located near corners x plane containing coil center along z axis small decrease intensity probe moved away coil center overall magnetic field focused concentrated within internal space coil however outside coil magnetic field became divergent weak field roughly following cubic decay therefore ppy drug release experiments tested films situated within coil basis obtained mf probe readings the ppy films exposed peak magnetic fields within range 2540 g. similarly raw electric field data obtained coil also depicted figure 2b note measured electric field corresponded derivative measured magnetic field expected faraday law the electric field waveform exhibited oscillatory behavior sharp peaks primarily concentrated ramp switch phases emf the 15-turn coil produced peak e field 4700 v fundamental frequency 65 mhz thus estimated electric field magnitude ppy fabrications resided 30005000 v range 15-turn coils we emphasize due high frequency pulsed nature stimulation pattern estimated peak emf values 500 ns pulse duration the time averaged emf values much lower considering duty cycle would less 5% values the distance dependence electric field coil center followed magnetic field note bv-2 cell culture experiments coil placed bottom petri dish since possible place culture chamber within coil in situations measured peak fields ppy substrates exposed 320 g 3002500 v mf ef respectively drug release characteristics ppynws conventional flat ppy films shown figure 5 ( release profiles dex conventional flat ppy film ppy nws within 5 h one group stimulated electrically using potentiostat others emf again marginal release dex 0.5 mg cm flat ppy films ( c active emf stimulation vs passive stimulation flat ppy films ppynws note extraordinary release dex occurs emf stimulation ppynw aunps the small amount dex detected times likely due passive diffusion source * p 0.05 p 0.01 p 0.001 figure 5a reveals results drug release monitored 5 h period potentiostat stimulation flat ppy aunps significantly different emf stimulation upon exposure emf stimulation statistically significant increase release levels ppynws compared flat ppy film p 0.05 also note emf stimulation ppynws aunps resulted release dex potentiostat stimulation the inclusion gold nanoparticles greatly improved loading capacity rate release this trend preserved flat ppy thin films ppynws compared pss doped ppy films 1 7 16 days differences almost double ppy platforms p 0.05 ppynws p 0.01 flat ppy also ppynws showed significant enhancement dex release triggered emf stimulation compared flat ppy days 1 16 p 0.01 day 7 p 0.001 aunps days 7 16 p 0.01 psss studied figure 5b background release studies stimulation showed outward diffusion dex 0.11 mg cm ppynws 0.3 mg cm flat ppy films last day recording this reveals significant drug release emf stimulation compared without emf stimulation ( day 1 p 0.01 days 7 16 p 0.001 ppynws day 1 p 0.05 days 7 16 p 0.01 flat ppy films figure 5c figure s4 depicts dex release profiles flat ppy function temperature some passive background release found reach levels active emf stimulation switching experiments emf turned 2 h turned 2 h shown figure 5d in cases dex release fell precipitously removal emf stimulation regained emf coupling resumed such consistency multiple unloading cycles demonstrated excellent reproducibility reversibility hallmark controlled release x ray photoelectron spectroscopy xps used verify existence dex verify escape entrapped drug figure 6 xps surface analysis conducted ppynws 16 days pulsed electromagnetic stimulation as expected high resolution spectra f 1s p 2p revealed changes peak magnitudes denoting obvious release dex upon exposure emf specifically spectrographs detail signatures fluorine phosphorus elements dex molecule essentially vanish emf stimulation ppynws aunps prestimulation f 1s p 2p atomic percentages 1.53 1.54% respectively poststimulations results 0.00 0.17% ppynws pss prestimulation f 1s p 2p atomic percentages 0.60 1.31% respectively poststimulations results 0.00 0.15% xps spectra surface analysis dex presence ppy templates pulsed emf stimulation ( xps recording dex doped ppynws aunps green red dex release emf ( b xps data dex doped ppynws pss green red 16 days emf stimulation these show details signature fluorine phosphorus elements dex molecule stimulation respectively note elemental signatures vanish emf stimulation indicative dex release surface the bottom graph shows molecular structure dex fluorine f phosphorus p highlighted red two groups toxin challenged murine neonatal microglial cells bv-2 used evaluate ros production determine whether damaged cells could rescued via emf associated drug release one group the challenge bacterially derived lps figure 7a g cells directly insulted hydrogen peroxide figure 7h ( b bv-2 cells insulted lps intense green labeling ros 2,7-dichlorodihydrofluorescein dcf ( c ros eliminated direct introduction 1 g ml dex suspended medium ( 30 min emf stimulation dex doped ppynws aunps demonstrating reduced ros production ( e 1 h emf stimulation ros production nearly undetectable ( f contrast ppynws subjected emf stimulation showed significant ros production tested cell population ( g corresponding graph describing quantitation ros production panels f ( h additional ros data using h2o2 positive control induce ros the graph confirms applied stimulated dex suppressed ros production dex retained bioactivity emf stimulation p 0.05 p 0.01 bv-2 cells treated lps released pro inflammatory cytokines ros via mapk signaling pathways cm h2dcfda one indicator compound ros used metric ros production lps 1 g ml)-treated cells exhibited bright green fluorescence cytoplasm marking production significant oxidative stress figure 7b the addition dex 1 g ml lps induced microglia effectively suppressed ros production inflammatory cascade figure 7c the dex doped ppynws aunps platform also suppressed inflammation byproducts emf stimulation figure 7e a weaker inhibition ros activity occurred shorter stimulation times applied figure 7d in contrast nonstimulated dex ppynws aunps films show signs ros scavenging figure 7f g similarly exposure 20 g ml h2o2 resulted ros byproducts bv-2 cells figure 7h this enhanced production ros reduced either direct application 10 g ml dex 15 min emf stimulation dex coupled ppynws aunps microglial cells stained intensely cy3 red fluorescent signal exposed lps dose dependent manner figure 8) inos expression bv-2 cells lps challenge without stimulation also showed positive cy3 staining agreement ros results figure 7 in contrast emf stimulation dex conjugated ppynws aunps resulted strong suppression inos indicating reduced level nitric oxide inos expression bv-2 cells shown red fluorescence cy3 column the row labeled control show inos expression due absence lps treatment in contrast row lps 10g ml shows significant upregulation inos merged confocal micrograph details staining primarily localized cytoplasm / ml shows less upregulation reduced lps concentration ppynws aunps stimulated emf dex w sti showed similar response / ml dex 1g ml results comparable untreated control highlighted suppression inos lps challenged bv-2 cells finally ppynws aunps stimulated emf 1 h produced inos results comparable direct dex application the electroactive properties biocompatibility ppy desirable features designing programmable drug delivery systems previously group used topographically modified ppy films increased available surface area drug inclusion release drug capacity improved films difficult fabricate highly porous making susceptible damage we thus introduced another form conductive ppy shaping polymer solid nanowire arrays functionalization moreover propose use electromagnetic fields stimulus ppy drug release this significant departure previous forms drug doped ppy direct electrical connection i.e. wire electrodes ppy required induce current flow subsequent drug release experimental results showed ppynws aunps possessed excellent drug carrying capabilities well controllable switching response electromagnetic fields xps analysis confirmed model drug dexamethasone successfully incorporated onto surface ppy nanowires when exposed pulsatile emfs dex cargo released ppy surface process verified changes surface chemistry free drug concentration the amount drug could eluted emf stimulation superior direct stimulation via potentiostat while mechanism emf coupled drug release still unclear hypothesize phenomenon similar ppy stimulation via direct current instance well known ppy undergoes electrical conformational change via oxidation reduction reaction response applied voltages furthermore electroactive ppy swells oxidation shrinks mechanical actuation reduction satisfy charge balance reversible volume change along electrostatics moving charges within ppy governs charged molecules move ppy i.e. drug deposition elution a multitude cytokines drugs nerve growth factors analgesics adenosine triphosphate released situ based functionality proposed polymer platform charge balance obtained anionic dex electrostatically entrapped within cationic pyrrole chain electropolymerization process sample exposed time varying em field oscillating electric current is induced ppy posited drive redox reaction reduction state charge neutralization pyrrole backbone eliminates electrostatic bonding dex causing dex migrate ppy matrix indeed prior evidence shown dex desorbs ppy reduction state therefore cumulative reduction states occur inductive cycling ppy facilitate dex movement the concomitant mechanical actuation pumping action redox reaction may play role forcing dex ppy not surprisingly polymer electroactive effect pronounced conductivity ppy enhanced indeed observed ppy nanowires impregnated gold result appears dex elution occurs regardless whether current flow direct electromagnetically induced it noted ppy susceptible overoxidation whereby electroactivity diminish due high applied voltages continued stimulation this fatigue behavior detected evidenced prolonged dex release period 16 days vitro the extended electrochemical stability ppynws aunps may partially due low duty cycle applied em fields rapid oscillatory nature enhanced conductivity conferred gold nanoparticles for instance addition multiwalled carbon nanotubes improves conductivity electrostability ppy neural prosthetic coatings however induction may cause joule heating subsequent drug release observation described carbon nanotubes address passive thermal effects performed additional studies elevated temperature 37 c ) results show temperature played small role release kinetics follow cyclical stimulation also revealed dex released stimulation states it unlikely ph changes responsible drug elution since experiments conducted physiologically buffered solutions verify bioactivity released dex cargo performed several cell culture assays using bv-2 glial line exposed lipopolysaccharide lps toxin lipopolysaccharide challenged microglia shown induce neurotoxicity production pro inflammatory mediators tumor necrosis factor- interleukin-1(il-1 ros inos catalyze production nitric oxide since focus area within laboratory neurodegenerative diseases central nervous system cns reviewed ref 20 chose vitro neuroinflammatory model assess therapeutic activity emf released dex the results showed addition dex 1 g ml lps exposed microglia suppressed ros production similarly dex doped ppynws aunps platform also suppressed inflammation byproducts emf stimulation in contrast nonstimulated dex ppynws aunps films confer signs ros scavenging similarly exposure h2o2 positive control resulted ros byproducts bv-2 cells this production ros also reduced either direct application 10 g ml dex 15 min emf stimulation dex coupled ppynws aunps these findings consistent inos measurements marked reduction inos expression presence soluble dex while eliminate possibility emf alone may reduce ros associated damage bv-2 cells highly unlikely since nanosecond pulse widths stimulation times used much shorter emf waveforms commonly employed bioelectromagnetics therefore conclude mitigation inflammatory cascade due availability free dex even proposed geometric scheme ppy improves drug loading capacity amount drug delivered may still considered miniscule comparison systemic delivery rather intent nanoscaled reservoirs deliver extraordinarily high concentrations potent drugs localized microenvironment order produce therapeutic responses adjacent contiguous cells in essence nanoconstruction aims release drugs specified target areas escaping systemic circulation side effects critical advancement therapies involving potent toxic drug cargos examples indications include early detected tumors restricted lesion nervous system localized region acute cns embolism trauma local region small scale crush injury cns pns axons completely inhibit action potential propagation across injury zone these minor spatial defects produce profound catastrophic behavioral functional cognitive consequences here we show release drugs ppynws occur 2 weeks may serve ideal candidate applications we finally note reported emf stimulation protocol fully optimized refining methods release system employed broad biomedical pharmaceutical applications as putative mode drug release emf ppy induction coupling aim develop oscillating waveforms maximize induction current without significant joule heating the phenomenon joule heating requires special attention vivo since thermal energy must dissipated additional design parameters also account attenuation em signal skin connective tissues various theoretical empirical models consider tissue permeability conductivity imposed emf frequency developed used reference design however pulsing frequencies used present system effective vitro within couple centimeters coil center serve basis vivo study future improvements may also include synthesizing degradable forms ppy may resorbed within body nonetheless reveal first time ppy system used type programmable drug delivery reservoir responds electromagnetic fields this action distance potentially provides new direction noninvasive controlled drug release conductive polymer polypyrrole fashioned nanowire architecture doped drug dexamethasone this geometry enabled high capacity drug entrapment subsequent sustained release 2 weeks more importantly release dexamethasone could triggered demand via externally applied pulsed electromagnetic field dexamethsone remained bioactive demonstrated ability ameliorate damage toxin challenged glial cells this first demonstration noninvasive mode drug delivery using polypyrrole	in this work , we introduce a free - standing , vertically aligned conductive polypyrrole ( ppy ) architecture that can serve as a high - capacity drug reservoir . this novel geometric organization of ppy provides a new platform for improving the drug - loading efficiency . most importantly , we present the first formal evidence that an impregnated drug ( dexamethasone , dex ) can be released on demand by a focal , pulsatile electromagnetic field ( emf ) . this remotely controlled , on off switchable polymer system provides a framework for implantable constructs that can be placed in critical areas of the body without any physical contact ( such as percutaneous electrodes ) with the ppy , contributing to a low foreign body footprint . we demonstrate this possibility by using a bv-2 microglia culture model in which reactive oxygen species ( ros ) and inducible nitric oxide synthase ( inos ) expression was attenuated in response to dex released from emf - stimulated ppy .
well known hearing levels progressively deteriorate age common factor associated acquired hearing loss age related hearing loss prevalent elderly regardless age gender race the prevalence hearing loss 50% people older 50 years u.s in europe 55% males hearing loss 30 db hl age 80 years age related hearing loss characterized high frequency sounds affected low frequency sounds the deterioration hearing thresholds mainly due aging peripheral central auditory system exposure environmental noise the degree hearing loss varies among individuals although degree hearing loss larger males females the age related variation hearing thresholds defined international organization standardization iso 7029 providing expected hearing threshold distribution population aged 18 70 years however iso 7029 based upon hearing thresholds european north american populations 1950s 1970s some authors indicated problems iso 7029 terms specific population data subject selection criteria outdated calibration test procedures restricted test frequencies authors proposed revise norms hearing thresholds function age result iso 7029 currently revision iso technical committee 43 in study 2492 adults 1250 males 1242 females age range 20 59 years otologically normal included the primary goal study provide distribution hearing thresholds function age korean individuals 60 84 years age screened procedure described iso 8253 1 the hearing threshold levels study compared provided iso 7029 also hearing thresholds signal frequency according gender age groups compared we anticipate data used preparing new standards hearing thresholds function age korea updating iso 7029 revision data collected total 526 ears 112 males 151 females aged 60 84 years the age criteria stratified 60 64 65 69 70 74 75 79 80 84 groups 5-year intervals shown table 1 all subjects recruited various areas korea seoul chuncheon gwangju daegu mokpo order ensure sampling entire country all participants received type tympanogram report history hearing loss ear surgery otologic disease occupational noise exposure iso 8253 1 2000 a gsi 61 audiometer grason stadler eden prairie mn usa used measuring pure tone thresholds soundproof room according criteria iso 8253 1 maximum permissible sound pressure level ambient noise room sufficiently low the test tones calibrated first method iso 389 5 389 8 presented participants tdh-50 headphones telephonics farmingdale ny usa sound level meter type 2250-l ; b&k denmark used calibrations microphone type 4192 b&k preamplifier type 2690-a-0s1 b&k informed consent obtained participants questionnaire additionally completed audiometric tests both ears tested first ear right left chosen randomly subjects hearing thresholds right left ears differed 20 db hl given frequency better hearing thresholds ear obtained pure tone air conduction audiometry conducted range 250 8000 hz order 1000 2000 3000 4000 6000 8000 500 250 hz combined ascending descending approach following standardized protocol iso 8253 1 an audiologist presented stimuli participants asked press button heard beep sound armonk ny usa hearing thresholds signal frequency age band compared gender using independent test the dependent variable hearing thresholds frequencies independent variable gender compare average hearing thresholds age band males females one way analysis variance anova ) the factor age band independent variable average hearing threshold iso 7029 presents equation hmd y= y-18 years computing expected age related hearing loss h refers deviation median hearing threshold level age years based reference age 18 years 0 db hl data collected total 526 ears 112 males 151 females aged 60 84 years the age criteria stratified 60 64 65 69 70 74 75 79 80 84 groups 5-year intervals shown table 1 all subjects recruited various areas korea seoul chuncheon gwangju daegu mokpo order ensure sampling entire country all participants received type tympanogram report history hearing loss ear surgery otologic disease occupational noise exposure iso 8253 1 2000 audiometric tests conducted trained audiologists gsi 61 audiometer grason stadler eden prairie mn usa used measuring pure tone thresholds soundproof room according criteria iso 8253 1 maximum permissible sound pressure level ambient noise room sufficiently low the test tones calibrated first method iso 389 5 389 8 presented participants tdh-50 headphones telephonics farmingdale ny usa sound level meter type 2250-l ; b&k denmark used calibrations microphone type 4192 b&k preamplifier type 2690-a-0s1 b&k informed consent obtained participants questionnaire additionally completed audiometric tests both ears tested first ear right left chosen randomly subjects hearing thresholds right left ears differed 20 db hl given frequency better hearing thresholds ear obtained pure tone air conduction audiometry conducted range 250 8000 hz order 1000 2000 3000 4000 6000 8000 500 250 hz combined ascending descending approach following standardized protocol iso 8253 1 an audiologist presented stimuli participants asked press button heard beep sound the hearing thresholds signal frequency age band compared gender using independent test the dependent variable hearing thresholds frequencies independent variable gender compare average hearing thresholds age band males females one way analysis variance anova ) the factor age band independent variable average hearing threshold iso 7029 presents equation hmd y= y-18 years computing expected age related hearing loss h refers deviation median hearing threshold level age years based reference age 18 years 0 db hl table 2 lists numerical data related hearing threshold distributions 5 10 25 median 75 90 95 percentiles males females age band the results independent test showed significant differences genders low frequencies 250 500 hz significant differences high signal frequencies the average hearing thresholds computed averaging hearing sensitivity 500 1000 2000 hz table 4 4000 6000 8000 hz table 5 comparing mean hearing thresholds age band the independent variable average hearing thresholds factor age band results mean thresholds 500 1000 2000 hz revealed significant differences among age bands males f(4 213)=12.042 p<0.001 females f(4 293)=15.760 p<0.001 results mean thresholds 4000 6000 8000 hz also showed significant differences among age bands males f(4 213)=12.478 p=0.000 females f(4 293)=15.760 p=0.000 table 6 table 7 provide summary post hoc tests mean thresholds 500 1000 2000 hz 4000 6000 8000 hz respectively table 8 presents mean alpha coefficient values present study iso 7029 signal frequency males females figs 1 2 show mean hearing thresholds age band males females since iso 7029 provide hearing thresholds according age bands median hearing thresholds age computed equation means hearing thresholds age band calculated comparison results revealed elderly korean population worse hearing thresholds estimated hearing thresholds based iso 7029 equation applied age band in particular korean males similar hearing thresholds high frequencies worse hearing thresholds low frequencies based iso 7029 korean females worse hearing thresholds frequencies based iso 7029 table 2 lists numerical data related hearing threshold distributions 5 10 25 median 75 90 95 percentiles males females age band the results independent test showed significant differences genders low frequencies 250 500 hz significant differences high signal frequencies the average hearing thresholds computed averaging hearing sensitivity 500 1000 2000 hz table 4 4000 6000 8000 hz table 5 comparing mean hearing thresholds age band the independent variable average hearing thresholds factor age band results mean thresholds 500 1000 2000 hz revealed significant differences among age bands males f(4 213)=12.042 p<0.001 females f(4 293)=15.760 p<0.001 results mean thresholds 4000 6000 8000 hz also showed significant differences among age bands males f(4 213)=12.478 p=0.000 females f(4 293)=15.760 p=0.000 table 6 table 7 provide summary post hoc tests mean thresholds 500 1000 2000 hz 4000 6000 8000 hz respectively table 8 presents mean alpha coefficient values present study iso 7029 signal frequency males females figs 1 2 show mean hearing thresholds age band males females since iso 7029 provide hearing thresholds according age bands median hearing thresholds age computed equation means hearing thresholds age band calculated comparison results revealed elderly korean population worse hearing thresholds estimated hearing thresholds based iso 7029 equation applied age band in particular korean males similar hearing thresholds high frequencies worse hearing thresholds low frequencies based iso 7029 korean females worse hearing thresholds frequencies based iso 7029 table 2 lists numerical data hearing threshold distributions male female participants additionally figs these patterns consistent iso 7029 well previous studies a previous study showed significant differences genders occurred 3000 8000 hz present study hearing thresholds across age bands males significantly higher females 1000 8000 hz we also found pure tone threshold averages ptas low 500 1000 2000 hz high frequencies 4000 6000 8000 hz gradually elevated males compared females increasing age again greater pta differences high frequencies observed males females this excessive noise exposure one main reasons elevated hearing frequency hearing loss most korean males 60 years required serve military least 21 months recent studies reported noise induced hearing loss tinnitus increased due noise exposure military service therefore possible exposure excessive noise military service affected elevated hearing sensitivity korean males taken together results suggest greater amount age related hearing loss males females hearing loss higher frequencies lower frequencies compared alpha coefficients iso 7029 alpha coefficients present study higher genders except high frequencies males in particular alpha coefficients present study males females low frequencies higher iso 7029 these results consistent previous studies study wiley et al hearing sensitivity individuals aged 48 65 years compared iso 7029 median thresholds males females the results revealed expected hearing thresholds based iso 7029 better previous data the differences data iso values larger males females study stenklev laukli alpha coefficients significantly higher iso values especially 125 4000 hz females our results also indicated differences data iso values larger females across frequencies table 2 lists numerical data hearing threshold distributions male female participants additionally figs these patterns consistent iso 7029 well previous studies a previous study showed significant differences genders occurred 3000 8000 hz present study hearing thresholds across age bands males significantly higher females 1000 8000 hz we also found pure tone threshold averages ptas low 500 1000 2000 hz high frequencies 4000 6000 8000 hz gradually elevated males compared females increasing age again greater pta differences high frequencies observed males females this excessive noise exposure one main reasons elevated hearing frequency hearing loss most korean males 60 years required serve military least 21 months recent studies reported noise induced hearing loss tinnitus increased due noise exposure military service therefore possible exposure excessive noise military service affected elevated hearing sensitivity korean males furthermore alpha coefficients larger high frequencies low frequencies taken together results suggest greater amount age related hearing loss males females hearing loss higher frequencies lower frequencies compared alpha coefficients iso 7029 alpha coefficients present study higher genders except high frequencies males in particular alpha coefficients present study males females low frequencies higher iso 7029 these results consistent previous studies study wiley et al hearing sensitivity individuals aged 48 65 years compared iso 7029 median thresholds males females the results revealed expected hearing thresholds based iso 7029 better previous data the differences data iso values larger males females in study stenklev laukli alpha coefficients significantly higher iso values especially 125 4000 hz females our results also indicated differences data iso values larger females across frequencies in conclusion presented data hearing thresholds korean screened population aged 60 84 it difficult compare data directly previous studies due differences sample size age range etc we conclude 1 hearing threshold sensitivity increases age 2 greater hearing losses high frequencies appear across age groups 3 greater hearing losses seen males females as discussed data used establishing new korean standard data 2003 updating iso 7029 presently revision	background and objectivesthe purpose of the present study was to provide the hearing threshold levels in the elderly korean population , and to compare korean data with that in the international organization for standardization ( iso ) 7029 ( 2000).subjects and methodsdata were collected from a total of 526 ears from 112 males and 151 females aged 60 - 84 years . all participants were screened otologically by the procedure given in iso 8253 - 1 ( 2010).resultsresults showed that the pure - tone average was gradually elevated with increasing age . the amount of hearing loss was greater in males than in females , and the high frequency hearing thresholds were worse than the low frequency hearing thresholds in males and females . the hearing threshold levels were higher at low frequencies in males and at all frequencies in females than the norms of iso 7029 ( 2000).conclusionsresults from this study will be partly used for standardization of hearing thresholds as a function of age in korea and for updating the iso 7029 .
neurofibromatosis type 1 nf1 autosomal dominant genetic disorder affects approximately 1 3000 births individuals nf1 predisposed developing abnormalities number body systems individually cumulatively significant impact quality life example skeletal deformities scoliosis pseudarthroses uncommon associated considerable morbidity benign malignant disfiguring tumors termed neurofibromas characteristic condition challenging manage neuropsychological impairments nf1 executive dysfunction inattention specific learning disorder reduced social competency result reduced social participation social isolation the clinical diagnosis nf1 relies fulfilling least two seven diagnostic criteria caf au lait macules skinfold freckling neurofibromas lisch nodules optic pathway tumors bone dysplasia family history notably features congenital origin manifest time characteristic developmental stages skeletal muscle motor deficits reduced muscle size muscle weakness poor co ordination however recent preclinical clinical studies indicated primary role nf1 gene product neurofibromin muscle growth metabolism neurofibromin characterized gtpase activating protein negative regulator ras gtpase loss functional neurofibromin leads dose dependent increase ras signaling profoundly affect cell proliferation differentiation function reviewed review we discuss evidence neurological cognitive deficits contributing motor muscle phenotype this review also refocuses discussion previous studies describe vital role nf1 skeletal muscle development well emerging pre clinical models suggest novel regulatory role nf1 muscle metabolism children nf1 shown generalized decrease intellectual function mean iq low 90 well higher rate specific cognitive deficits i.e. attention visuoperceptual skills language executive function neurocognitive studies also frequently reported impairment motor abilities individuals nf1 table 1 including mild impairment gross fine motor tasks[14 16 impairment beery test visuomotor integration requires subjects draw increasingly difficult shapes figures[17 19 individuals nf1 also present deficits range functional tasks likely significant impact quality life for example significant impairment balance muscle strength upper limb co ordination nf1 observed using bot-2 test motor proficiency mild moderate deficits manual dexterity balance ball handling skills deficient motor timing reaction time reduced fine motor speed impaired handwriting nf1 children also reported gait assessment performed 46 children adolescents nf1 ages 7 17yrs using gaitrite electronic walkway results compared battery cognitive tests including wechsler intelligence scale children sub tests cambridge automated neuropsychological test battery the largest correlations found deficits gait width spatial working memory r=0.594 p<0.01 deficits running speed agility impaired strategy generation r=0.549 p<0.01 supporting speculation link nf1 motor deficits abnormal central nervous system cns function mechanisms interaction cns peripheral nervous system pns motor dysfunction unclear structural functional brain abnormalities feature condition may contribute motor impairments neurofibromin plays significant role developing brain loss expression resulting increased cell proliferation differentiation ultimately impacting morphology a recurrent finding increase total brain volume involving grey white matter diffusion weighted magnetic resonance imaging mri individuals nf1 indicates reduced white matter integrity number regions closely linked motor function these include 1 corpus callosum 2 caudate nucleus sub region basal ganglia involved goal direct behavior voluntary movement 3 thalamus sub cortical nuclear complex receives relays cortical sub cortical inputs sub serve sensory motor mechanisms well cognitive abilities volumetric studies report structures abnormally large nf1 cohorts suggesting reduced signal noise ratio moore et al shown significant associations increased corpus callosum size reduced motor performance children nf1 also mounting evidence functional abnormalities within thalamus caudate individuals nf1 both adult pediatric positron emission tomography studies report thalamic hypometabolism suggesting reduced thalamic signal processing recent event related functional mri study identified abnormal right caudate activation spatial working memory task cognitive ability significantly associated impaired gait nf1 individuals nf1 also commonly show focal areas high t2 signal intensity mri associated reduced fine motor skill mechanistically one clinical study examined sensory motor neuropathy nf1 possibly contributory electrophysiological measures 39 individuals nf1 aged 10 56 revealed motor polyneuropathy rare manifestation abnormalities multimodal evoked potentials visual auditory sensory seen commonly many associated tumors lesions further clinical studies correlating neurological assessments strength motor outcomes needed define influence cns pns nf1 motor phenotype preclinical mouse models used investigate mechanisms underlying neurocognitive deficits a relationship cognition motor performance yet defined systems abnormalities learning attention deficits extensively examined nf1 mouse[38 43 for example increased gaba release hippocampus shown underlie learning deficits rescued inhibition erk signaling lovastatin treatment shown rescue deficits learning attention however interactions deficits motor function remain unknown significant motor deficit seen mouse line impaired grip strength using hanging wire test demonstration neurocognitive basis result furthermore line failed show deficiencies motor performance tests linked cerebellar function decreased dopamine levels striatum also identified nf1 mouse model bi allelic nf1 inactivation glia these mice exhibited reduced exploratory behaviors well selective non selective attention abnormalities rescued pharmacologic intervention restore dopamine levels speculative abnormal dopamine levels may underlie motor impairments observed individuals nf1 indeed gait characteristics identified pediatric nf1 cohort including shorter step length longer step time resemble seen early parkinson disease disorder associated reduced dorsal striatal dopamine levels further insight interactions neurocognitive development motor deficits may come advanced mouse models conditional double inactivation nf1 neurons in 2005 stevenson et al published data analysis 40 individuals nf1 using peripheral quantitative computed tomography pqct scanning individuals nf1 presented significant reduction muscle cross sectional area compared age matched controls comparative findings seen pediatric nf1 cohort lean tissue measured using dual energy x ray absorptiometry dexa children nf1 significantly reduced lean tissue mass reduced muscle size may imply reduction strength muscle functional outcomes assessed primarily radiographic studies however seminal 2009 study souza et al performed hand grip dynamometry testing 21 subjects age 7 60 yrs nf1 compared gender aged physical activity matched controls demonstrated significant reduction grip strength nf1 cohort findings muscle functional impairment nf1 subsequently reported clinical studies table 2 reduced strength hip extensor muscles described using hand held dynamometry likewise 2013 trial investigating lower body muscle function nf1 children found jumping force n kg jumping power w kg significantly reduced a cohort 17 individuals nf1 along gender age bodyweight matched control subjects underwent maximal oxygen consumption vo2 max testing measure maximal aerobic exercise capacity individuals nf1 reduced vo2 max well reduced maximal systolic blood pressure while authors acknowledged difficulty recruiting activity matched controls remains thoroughly investigated whether reduced physical activity accounts reduced exercise capacity nf1 given mounting evidence motor muscular deficits nf1 continued exercise studies kind warranted particularly assessing quality life outcome measures muscle size muscle function nf1 insight gained research nf1 muscle function may applicable related genetic diseases nf1 belongs rasopathy family diseases includes costello syndrome cardiofaciocutaneous syndrome noonan syndrome 2012 clinical study reduced grip strength muscle weakness identified common feature it unclear whether conditions share common mechanism muscle weakness downstream altered ras signaling however case successful pathway targeted interventions improve nf1 muscle performance may broad clinical applicability rasopathies early evidence suggesting critical role nf1 skeletal muscle development came vitro experiments assessing gene expression myoblast differentiation levels nf1 mrna neurofibromin elevated differentiation concomitant decrease activated p21-ras observed double inactivation nf1 found embryonically lethal nf1 null embryos showed underdeveloped cardiac skeletal muscle however remained unclear whether effects muscle secondary failure developmental program nt recently key role nf1 muscle demonstrated animal model developed limb specific nf1 knockout mouse nf1prx1 using prx1-cre transgene drive deletion nf1 cells mesenchymal lineage furthermore consistent vitro data analysis mutant embryos revealed hyperactive ras mapk signaling impaired myoblast differentiation developing limbs while nf1prx1-/- mouse model demonstrated requirement nf1 normal limb muscle development prx1-cre driven recombination restricted muscle lineage thus inactivation nf1 mesenchymal tissues including adipocytes connective tissue bone potential confounders interpretation overcome a skeletal muscle specific nf1 knockout mouse nf1myod subsequently generated crossing myod cre transgenic mouse nf1-flox line homozygous nf1 inactivation muscle lethal first week life pups born normal bodyweight stunted growth high rate maternal infanticide observed electron microscopy em imaging nf1myod muscle specimens showed evidence cytoarchitectural abnormalities including protein aggregates myofibrillar disruption z line streaming nf1prx1-/- muscle described dystrophic may misnomer neither mouse model patient muscle biopsies characterized progressive loss cytoskeletal membrane protein integrity em 3-day old nf1myod muscle samples unexpectedly revealed excessive accumulations intramyocellular lipid subsequently confirmed oil red staining this led speculation nf1 may key role regulation muscle lipid metabolism analysis adult nf1prx1-/- muscle samples revealed similarly elevated triglyceride levels 10-fold controls increased fatty acid synthesis may underlie accumulations nf1prx1-/- mice substantive increase expression fatty acid synthase observed metabolic dysregulation also seen range mitochondrial enzymes including succinate dehydrogenase sdh -hydroxyacyl coa dehydrogenase bhad medium chain acyl coa dehydrogenase mcad the expression mitochondrial fatty acid transport protein carnitine palmitoyl transferase-1 cpt-1 membrane transport proteins cd36 fatty acid transport protein 4 fatp4 also reduced for example difficult separate primary deficits responsible downstream compensatory metabolic changes mature nf1prx1-/- muscle interestingly analysis neonatal nf1myod muscle showed intramyocellular lipid phenotype suggesting lipid accumulation may initiating factor subsequent molecular metabolic dysregulation temporal nature although precise mechanisms remain unknown mouse data demonstrate novel metabolic regulatory role neurofibromin muscle one possibility nf1 muscle commonalities lipid storage myopathies lsms also present progressive muscle weakness muscle lipid accumulation if parallels found exist lsms may provide insight potential interventions nf1 for example primary carnitine deficiency pcd leads impairment lipid transport mitochondria resultant accumulation lipid droplets muscle weakness pcd patients successfully treated high dose l carnitine supplementation speculation attractive entertain evidence lipid accumulation human nf1 samples firmly established identifying lipid accumulation human nf1 muscle biopsies important goal researchers order demonstrate relevance murine models a number historical recent studies raise important questions regarding role nf1 gene muscle development function 1990s gutmann et al identified cardiac skeletal muscle isoforms nf1 date functional importance isoforms remains unclear it possible unique role regulation muscle development and/or metabolism isoform specific knockout models may able provide insight role alternatively spliced variants neurofibromin muscle furthermore genetics nf1 muscle yet elucidated manifestations nf1 associated heterozygosity haploinsufficiency others double inactivation for example local double inactivation observed nf1 tumors well tibial pseudarthrosis tissue date studies addressed potential double inactivation nf1 muscle myofibers multinucleated cells sporadic double inactivation individual nuclei could unpredictable effects analyzing double inactivation myofibers may challenging fluorescent situ hybridization nf1 human muscle biopsies could feasible approach one confounding factor interpretation clinical data cognitive motor control psycho social effects nf1 may indirectly influence physical activity recent data indicates children nf1 reduced participation formal informal physical activities finding ways accommodate studies underlying biological weakness strategies exercise based intervention may challenges one intriguing possibility nf1 mutations associated muscle weakness may increase risk severity related unrelated conditions for example spinal complications scoliosis major source morbidity nf1 late onset scoliosis described adolescents nf1 underling bone abnormalities possible weakness hypotonia may contributory in addition two recent case reports suggest potential interactions nf1 muscle related genetic conditions one report describes individual digeny mutations nf1 ryanodine receptor 1 resulting myopathy the shows previously unreported mutation nf1 locus leading mitochondrial complex deficiency hypotonia developmental delay continued identification clinical presentations kind may provide useful insight therapeutic standpoint critical ascertain capacity exercise regimes modify muscle motor phenotypes nf1 the current literature limited single case study reports improved jumping throwing performance children nf1 following plyometric training program however study small n=3 children variable ages genders study lacked control cohort larger randomized controlled exercise intervention studies greatly needed answer questions regarding effects exercise training motor control muscle size strength fatigue quality life outcomes individuals nf1 physical therapies often favored produce significant benefits pathway specific pharmacological interventions remain potential treatment found unresponsive exercise the ras mek erk pathway canonical pathway nf1 signaling cascade also recognized role muscle constitutively active mek shown directly bind repress myogenic transcription factors inhibiting myogenic differentiation vitro furthermore cancer setting mek erk inhibition shown anabolic skeletal muscle humans mice this pathway likely particular relevance interventions aiming improve muscle function nf1 souza et al credited initiating explosion activity field nf1 muscle research 2009 since range clinical studies confirmed reduced motor performance and/or muscle impairment individuals nf1 associations neurological abnormalities nf1 muscle motor phenotype mechanisms underlying interactions yet elucidated remain area research mechanistically recent studies using genetically modified mouse models provided strong evidence metabolic regulatory role neurofibromin muscle likely contributing phenotype this review also reflected number historically overlooked potentially undervalued studies the key roles nf1 muscle development preceded studies showing increases nf1 gene protein expression myogenic differentiation the findings deficits muscle strength similarly preceded radiographic studies showing decreases muscle mass however studies describing muscle specific nf1 isoforms perhaps relevant revisit isoforms may yet undefined roles nf1-muscle phenotype summary significant advances understanding due co ordination basic clinical research studies	neurofibromatosis type 1 ( nf1 ) is a genetic neurocutaneous disorder with multisystem manifestations , including a predisposition to tumor formation and bone dysplasias . studies over the last decade have shown that nf1 can also be associated with significant motor deficits , such as poor coordination , low muscle tone , and easy fatigability . these have traditionally been ascribed to developmental central nervous system and cognitive deficits . however , recent preclinical studies have also illustrated a primary role for the nf1 gene product in muscle growth and metabolism ; these findings are consistent with clinical studies demonstrating reduced muscle size and muscle weakness in individuals with nf1 . currently there is no evidence - based intervention for nf1 muscle and motor deficiencies ; this review identifies key research areas where improved mechanistic understanding could unlock new therapeutic options .
mosquitoes transmit diseases group arthropods affect million people throughout world declared mosquitoes mosquito borne diseases prevalent 100 countries across world infecting 700,000,000 people every year globally 40,000,000 indian population they act vector life threatening diseases like malaria yellow fever dengue fever chikungunya ferver filariasis encephalitis west nile virus infection etc almost tropical subtropical countries many parts world prevent proliferation mosquito borne diseases improve quality environment public health the major tool mosquito control operation application synthetic insecticides organochlorine organophosphate compounds but successful due human technical operational ecological economic factors recent years use many former synthetic insecticides mosquito control programme limited it due lack novel insecticides high cost synthetic insecticides concern environmental sustainability harmful effect human health non target populations non biodegradable nature higher rate biological magnification ecosystem increasing insecticide resistance global scale23 thus environmental protection act 1969 framed number rules regulations check application chemical control agents nature4 it prompted researchers look alternative approaches ranging provision promoting adoption effective transparent mosquito management strategies focus public education monitoring surveillance source reduction environment friendly least toxic larval control these factors resulted urge look environment friendly cost effective biodegradable target specific insecticides mosquito species considering these application eco friedly alternatives biological control vectors become central focus control programmme lieu chemical insecticides one effective alternative approaches biological control programme explore floral biodiversity enter field using safer insecticides botanical origin simple sustainable method mosquito control further unlike conventional insecticides based single active ingredient plant derived insecticides comprise botanical blends chemical compounds act concertedly behavourial physiological processes identifying bio insecticides efficient well suitable adaptive ecological conditions imperative continued effective vector control management botanicals widespread insecticidal properties obviously work new weapon arsenal synthetic insecticides future may act suitable alternative product fight mosquito borne diseases roark5 described approximately 1,200 plant species potential insecticidal value sukumar et al6 listed discussed 344 plant species exhibited mosquitocidal activity shallan et al 20057 reviewed current state knowledge larvicidal plant species extraction processes growth reproduction inhibiting phytochemicals botanical ovicides synergistic additive antagonistic joint action effects mixtures residual capacity effects non target organisms resistance screening methodologies discussed promising advances made phytochemical research table summarized mosquitocidal activities various herbal products edible crops ornamental plants trees shrubs herbs grasses marine plants according exaction procedure developed eleven different solvent systems nature mosquitocidal activities different life stages different vector species ready reference studies applications phytochemicals mosquito control use since 1920s8 discovery synthetic insecticides ddt 1939 side tracked application phytochemicals mosquito control programme after facing several problems due injudicious application synthetic insecticides nature focus phytochemicals easily biodegradable ill effects non target organisms appreciated since search new bioactive compounds plant kingdom effort determine structure commercial production initiated present phytochemicals botanicals basically secondary metabolites serve means defence mechanism plants withstand continuous selection pressure herbivore predators environmental factors several groups phytochemicals alkaloids steroids terpenoids essential oils phenolics different plants reported previously insecticidal activities7 insecticidal effects plant extracts vary according plant species mosquito species geographical varities parts used also due extraction methodology adopted polarity solvents used extraction a wide selection plants herbs shrubs large trees used extraction mosquito toxins phytochemicals extracted either whole body little herbs various parts like fruits leaves stems barks roots etc larger plants trees in cases toxic substances concentrated upon found extracted mosquito control more 2000 plant species known produce chemical factors metabolites value pest control programmes members plant families- solanaceae asteraceae cladophoraceae labiatae miliaceae oocystaceae rutaceae various types larval adulticidal repellent activities different species mosquitoes7 human beings used plant parts products secondary metabolites plant origin pest control since early historical times vector control practiced since early 20th century pre ddt era reduction vector mosquitoes mainly depended environmental management breeding habitats i.e. source reduction period botanical insecticides used different countries chrysanthemum pyrethrum derris quassia nicotine hellebore anabasine azadirachtin limonene camphor turpentine etc7 early 1950s ddt synthetic organochloride organophosphate insecticides extensively used interrupt transmission vector borne diseases reducing densities human vector contact particular longevity vector mosquitoes mid-1970s resurgence vector borne diseases along development insecticide resistance vector population poor human acceptance indoor house spraying environmental concerns use insecticides led rethinking vector control strategies10 result emphasis given application alternative methods mosquito control part integrated mosquito management imm)11 integrated mosquito management imm decision making process management mosquito populations involving combination methods strategies long term maintenance low levels vectors the purpose imm protect public health diseases transmitted mosquitoes maintain healthy environment proper use disposal pesticides improve overall quality life practical effective pest control strategies main approaches imm include source reduction habitat management proper sanitation water management temporary permanent water bodies channel irrigation vegetation management also necessary eliminate protection food mosquito larvae ii larviciding application dipteran specific bacteria insect growth regulators surface films oils expanded polystyrene beads phytochemicals organophosphates organochlorides iii adulticiding application synthetic pyrethroids organophosphates synthetic plant derived repellents insecticide impregnated bed nets genetic manipulations vector species etc ( iv use mosquito density assessment adult larval condition disease surveillance v application biological control methods using entomophagous bacteria fungi microsporidians predators parasites avenues imm larviciding approach proactive proenvironment target specific safer approach controlling adult mosquitoes application larvicide botanical origin extensively studied essential part imm various mosquito control agents ocimenone rotenone capllin quassin thymol eugenol neolignans arborine goniothalamin developed7 the efficacy phytochemicals mosquito larvae vary significantly depending plant species plant parts used age plant parts young mature senescent solvent used extraction well upon available vector species sukumar et al6 described existence variations level effectiveness phytochemical compounds target mosquito species vis vis plant parts extracted responses species developmental stages specified extract solvent extraction geographical origin plant photosensitivity compounds extract effect growth reproduction changes larvicidal efficacy plant extracts occurred due geographical origin plant citrus sp18396465 jatropha sp132021 ocimum sanctum22356582 momordica charantia222449 piper sp54638995 azadirechta indica65 response different mosquito species curcuma domestica26 withania somnifera13 jatropha curcas1320 piper retrofractum63 cestrum diurnum58 citrullus vulgaris5071 tridax procumbens3031 due variation species plant examined euphorbia sp22283751 phyllanthus sp20 curcuma sp36 solanum sp16295760757996 ocimum sp23356582 eucalyptus sp22283751 plumbago sp20 vitex sp5093 piper sp54638995 annona sp485469 cleome sp3178 plant parts used study larvicidal efficacy euphorbia tirucalli2851 solanum xanthocarpum16 azadirechta indica65 solanum villosum57607996 annona squamosa485469 withania somnifera13 melia azedarach45 moringa oleifera46 ocimum sanctum3582 however principal objective present documentation report changes larvicidal potentiality plant extracts due change particular solvent used extraction variation larvicidal potential plant changed solvents used evidenced case solanum xanthocarpum16 euphorbia tirucalli2851 momordica charantia222449 eucalyptus globules14152883 citrullus colocynthis13 azadirechta indica65 annona squamosa485469 solanum nigrum2975 it shown extraction active biochemical plants depends upon polarity solvents used polar solvent extract polar molecules non polar solvents extract non polar molecules this achieved using mainly eleven solvent systems ranging hexane/ petroleum ether non polar polarity index 0.1 mainly extracts essential oil water polar polarity index 10.2 extracts biochemical higher molecular weights proteins glycans etc chloroform ethyl acetate moderately polar polarity index 4.1 mainly extracts steroids alkaloids etc it found studies solvent minimum polarity used hexane petroleum ether maximum polarity aqueous/ steam distillation however biochemical extracted using moderately polar solvents also seen give good results reported bioassay thus different solvent types significantly affect potency extracted plant compounds difference chemo profile plant species in table lowest lc50 value reported solenostemma argel cx several plants nyctanthes arbotristis38 atlantia monophylla57 centella asiatica40 cryptotaenia paniculata76 also reported promising lc50 values these extracts may fractioned order locate particular bioactive toxic agent responsible larval toxicity table also reported studies carried culex mosquitoes aedes least frequently chosen mosquitoes experiments several studies instead particular solvent combination solvents serial extraction different solvents according polarity also tried good larvicidal potentiality found result96 the plant world comprises rich untapped pool phytochemicals may widely used place synthetic insecticides mosquito control programme kishore et al97 reviewed efficacy phytochemicals mosquito larvae according chemical nature described mosquito larvicidal potentiality several plant derived secondary materials alkanes alkenes alkynes simple aromatics lactones essential oils fatty acids terpenes alkaloids steroids isoflavonoids pterocarpans lignans they also documented isolation several bioactive toxic principles various plants reported toxicity different mosquito species table ii identification various bioactive toxic principles plant extract relative mosquitocidal efficacy generally active toxic ingredients plant extracts secondary metabolites evolved protect herbivores the insects feed secondary metabolites potentially encountering toxic substances relatively non specific effects wide range molecular targets these targets range proteins enzymes receptors signaling molecules ion channels structural proteins nucleic acids biomembranes cellular components98 this turn affects insect physiology many different ways various receptor sites principal abnormality nervous system neurotransmitter synthesis storage release binding uptake receptor activation function enzymes involved signal transduction pathway)98 rattan98 reviewed mechanism action plant secondary metabolites insect body documented several physiological disruptions inhibition acetylecholinestrase essential oils gaba gated chloride channel thymol sodium potassium ion exchange disruption pyrethrin inhibition cellular respiration rotenone such disruption also includes blockage calcium channels ryanodine nerve cell membrane action sabadilla octopamine receptors thymol hormonal balance disruption mitotic poisioning azadirachtin disruption molecular events morphogenesis alteration behaviour memory cholinergic system essential oil etc the important activity inhibition acetylcholinerase activity ache key enzyme responsible terminating nerve impulse transmission synaptic pathway ache observed organophosphorus carbamate resistant well known alteration ache one main resistance mechanisms insect pests99 several studies documented efficacy plant extracts reservoier pool bioactive toxic agents mosquito larvae but commercially produced extensively used vector control programmes the main reasons behind failure laboratory land movements bioactive toxic phytochemicals poor characterization inefficiency determining structure active toxic ingredients responsible larvicidal activity production green biopesticide the following steps recommended research design phytochemicals screening floral biodiversity search crude plant extracts mosquito larvicidal potentiality ii preparation plant solvent extracts starting non polar polar chemicals determination effective solvent extract iii evaporation liquid solvent obtain solid residue determination lethal concentration lc50/lc100 values iv phytochemical analysis solid residue application column chromatography thin layer chromatography purify isolate toxic phytochemical larvicidal potentiality v determination structure active principle infra red ir spectroscopic nuclear magnetic resonance nmr gas chromatography mass spectroscopy gcms analysis vi study effect active ingredient non target organisms vii field evaluation active principle recommendation vector control programme commercial production human beings used plant parts products secondary metabolites plant origin pest control since early historical times vector control practiced since early 20th century pre ddt era reduction vector mosquitoes mainly depended environmental management breeding habitats i.e. source reduction period some botanical insecticides used different countries chrysanthemum pyrethrum derris quassia nicotine hellebore anabasine azadirachtin limonene camphor turpentine etc7 early 1950s ddt synthetic organochloride organophosphate insecticides extensively used interrupt transmission vector borne diseases reducing densities human vector contact particular longevity vector mosquitoes mid-1970s the resurgence vector borne diseases along development insecticide resistance vector population poor human acceptance indoor house spraying environmental concerns use insecticides led rethinking vector control strategies10 result emphasis given application alternative methods mosquito control part integrated mosquito management imm)11 integrated mosquito management imm decision making process management mosquito populations involving combination methods strategies long term maintenance low levels vectors the purpose imm protect public health diseases transmitted mosquitoes maintain healthy environment proper use disposal pesticides improve overall quality life practical effective pest control strategies the main approaches imm include source reduction habitat management proper sanitation water management temporary permanent water bodies channel irrigation vegetation management also necessary eliminate protection food mosquito larvae ii larviciding application dipteran specific bacteria insect growth regulators surface films oils expanded polystyrene beads phytochemicals organophosphates organochlorides iii adulticiding application synthetic pyrethroids organophosphates synthetic plant derived repellents insecticide impregnated bed nets genetic manipulations vector species etc ( iv use mosquito density assessment adult larval condition disease surveillance v application biological control methods using entomophagous bacteria fungi microsporidians predators parasites avenues imm larviciding approach proactive proenvironment target specific safer approach controlling adult mosquitoes application larvicide botanical origin extensively studied essential part imm various mosquito control agents ocimenone rotenone capllin quassin thymol eugenol neolignans arborine goniothalamin developed7 the efficacy phytochemicals mosquito larvae vary significantly depending plant species plant parts used age plant parts young mature senescent solvent used extraction well upon available vector species sukumar et al6 described existence variations level effectiveness phytochemical compounds target mosquito species vis vis plant parts extracted responses species developmental stages specified extract solvent extraction geographical origin plant photosensitivity compounds extract effect growth reproduction changes larvicidal efficacy plant extracts occurred due geographical origin plant citrus sp18396465 jatropha sp132021 ocimum sanctum22356582 momordica charantia222449 piper sp54638995 azadirechta indica65 response different mosquito species curcuma domestica26 withania somnifera13 jatropha curcas1320 piper retrofractum63 cestrum diurnum58 citrullus vulgaris5071 tridax procumbens3031 due variation species plant examined euphorbia sp22283751 phyllanthus sp20 curcuma sp36 solanum sp16295760757996 ocimum sp23356582 eucalyptus sp22283751 plumbago sp20 vitex sp5093 piper sp54638995 annona sp485469 cleome sp3178 plant parts used study larvicidal efficacy euphorbia tirucalli2851 solanum xanthocarpum16 azadirechta indica65 solanum villosum57607996 annona squamosa485469 withania somnifera13 melia azedarach45 moringa oleifera46 ocimum sanctum3582 however principal objective present documentation report changes larvicidal potentiality plant extracts due change particular solvent used extraction variation larvicidal potential plant changed solvents used evidenced case solanum xanthocarpum16 euphorbia tirucalli2851 momordica charantia222449 eucalyptus globules14152883 citrullus colocynthis13 azadirechta indica65 annona squamosa485469 solanum nigrum2975 it shown extraction active biochemical plants depends upon polarity solvents used polar solvent extract polar molecules non polar solvents extract non polar molecules this achieved using mainly eleven solvent systems ranging hexane/ petroleum ether non polar polarity index 0.1 mainly extracts essential oil water polar polarity index 10.2 extracts biochemical higher molecular weights proteins glycans etc chloroform ethyl acetate moderately polar polarity index 4.1 mainly extracts steroids alkaloids etc it found studies solvent minimum polarity used hexane petroleum ether maximum polarity aqueous/ steam distillation however biochemical extracted using moderately polar solvents also seen give good results reported bioassay thus different solvent types significantly affect potency extracted plant compounds difference chemo profile plant species in table lowest lc50 value reported solenostemma argel cx several plants nyctanthes arbotristis38 atlantia monophylla57 centella asiatica40 cryptotaenia paniculata76 also reported promising lc50 values these extracts may fractioned order locate particular bioactive toxic agent responsible larval toxicity table also reported studies carried culex mosquitoes aedes least frequently chosen mosquitoes experiments several studies instead particular solvent combination solvents serial extraction different solvents according polarity also tried good larvicidal potentiality found result96 the plant world comprises rich untapped pool phytochemicals may widely used place synthetic insecticides mosquito control programme kishore et al97 reviewed efficacy phytochemicals mosquito larvae according chemical nature described mosquito larvicidal potentiality several plant derived secondary materials alkanes alkenes alkynes simple aromatics lactones essential oils fatty acids terpenes alkaloids steroids isoflavonoids pterocarpans lignans they also documented isolation several bioactive toxic principles various plants reported toxicity different mosquito species table ii generally active toxic ingredients plant extracts secondary metabolites evolved protect herbivores the insects feed secondary metabolites potentially encountering toxic substances relatively non specific effects wide range molecular targets these targets range proteins enzymes receptors signaling molecules ion channels structural proteins nucleic acids biomembranes cellular components98 this turn affects insect physiology many different ways various receptor sites principal abnormality nervous system neurotransmitter synthesis storage release binding uptake receptor activation function enzymes involved signal transduction pathway)98 rattan98 reviewed mechanism action plant secondary metabolites insect body documented several physiological disruptions inhibition acetylecholinestrase essential oils gaba gated chloride channel thymol sodium potassium ion exchange disruption pyrethrin inhibition cellular respiration rotenone such disruption also includes blockage calcium channels ryanodine nerve cell membrane action sabadilla octopamine receptors thymol hormonal balance disruption mitotic poisioning azadirachtin disruption molecular events morphogenesis alteration behaviour memory cholinergic system essential oil etc of important activity inhibition acetylcholinerase activity ache key enzyme responsible terminating nerve impulse transmission synaptic pathway ache observed organophosphorus carbamate resistant well known alteration ache one main resistance mechanisms insect pests99 several studies documented efficacy plant extracts reservoier pool bioactive toxic agents mosquito larvae commercially produced extensively used vector control programmes the main reasons behind failure laboratory land movements bioactive toxic phytochemicals poor characterization inefficiency determining structure active toxic ingredients responsible larvicidal activity production green biopesticide the following steps recommended research design phytochemicals screening floral biodiversity search crude plant extracts mosquito larvicidal potentiality ii preparation plant solvent extracts starting non polar polar chemicals determination effective solvent extract iii evaporation liquid solvent obtain solid residue determination lethal concentration lc50/lc100 values iv phytochemical analysis solid residue application column chromatography thin layer chromatography purify isolate toxic phytochemical larvicidal potentiality v determination structure active principle infra red ir spectroscopic nuclear magnetic resonance nmr gas chromatography mass spectroscopy gcms analysis vi study effect active ingredient non target organisms vii field evaluation active principle recommendation vector control programme commercial production today environmental safety considered paramount importance insecticide need cause high mortality target organisms order acceptable eco friedly nature phytochemicals may serve relatively safe inexpensive readily available many parts world several plants used traditional medicines mosquito larvicidal activities many parts world according bowers et al100 screening locally available medicinal plants mosquito control would generate local employment reduce dependence expensive imported products stimulate local efforts enhance public health system the ethno pharmacological approaches used search new bioactive toxins plants appear predictive compared random screening approach the recently developed new isolation techniques chemical characterization different types spectroscopy chromatography together new pharmacological testing led interest plants source new larvicidal compounds synergestic approaches application mosquito predators botanical blends microbial pesticides provide better effect reducing vector population magnitude epidemiology	mosquitoes act as a vector for most of the life threatening diseases like malaria , yellow fever , dengue fever , chikungunya ferver , filariasis , encephalitis , west nile virus infection , etc . under the integrated mosquito management ( imm ) , emphasis was given on the application of alternative strategies in mosquito control . the continuous application of synthetic insecticides causes development of resistance in vector species , biological magnification of toxic substances through the food chain and adverse effects on environmental quality and non target organisms including human health . application of active toxic agents from plant extracts as an alternative mosquito control strategy was available from ancient times . these are non - toxic , easily available at affordable prices , biodegradable and show broad - spectrum target - specific activities against different species of vector mosquitoes . in this article , the current state of knowledge on phytochemical sources and mosquitocidal activity , their mechanism of action on target population , variation of their larvicidal activity according to mosquito species , instar specificity , polarity of solvents used during extraction , nature of active ingredient and promising advances made in biological control of mosquitoes by plant derived secondary metabolites have been reviewed .
total received six blackbirds five owls one swallow investigation necropsy estimated postmortem times 24 h 48 h paraffin embedded tissue samples immunostained polyclonal mouse antibody wnv b. murgue institut pasteur paris polyclonal rabbit antibody tick borne encephalitis virus tbev strain neudoerfl h. holzmann klinisches institut fr virologie vienna using avidin biotin complex technique 8) rna extracted 140-l organ homogenates cell culture suspensions using qiaamp viral rna mini kit qiagen gmbh hilden germany after aligning available nucleotide nt sequences various mosquito borne flaviviruses determining highly conserved genomic regions designed three pairs oligonucleotide primers amplify wide range mosquito borne flaviviruses used reverse transcription polymerase chain reaction rt pcr assays 5-tacaacatgatgggvaaragagaga-3 nt position 90319055 wnv genbank accession nc 001563 5-agcatgtcttcygtbgtcatccayt-3 nt position 1011510091 resulting 1,084-bp amplification product 5-gartggatgacvacrgaagacatgct-3 nt position 1009010115 5-ggggtctcctctaacctctagtcctt-3 nt position 1083210807 amplifying 743-bp pcr product 5-gccaccggaagttgagtaga-3 nt position 1046010479 wnv nc 001563 5-gctggttgtgcagagcagaa-3 nt position 1090810889 resulting 449-bp amplicon reverse transcription amplifications performed continuous rt pcr method using qiagen onestep rt pcr kit qiagen gmbh each 25-l reaction mixture contained 5 l 5x buffer final mgcl2 concentration 2.5 mm 0.4 mm deoxynucleoside triphosphate dntp 10 u recombinant rnasin ribonuclease inhibitor promega madison wi 40 pmol forward reverse primers 1 l enzyme mix 2.5 l template rna reverse transcription performed 30 min 50c following initial denaturation 15 min 95c the reaction mixture subjected 45 cycles heat denaturation 94c 30 primer annealing 60c 30 dna extension 72c 1 min completed final extension 10 min 72c following rt pcr performed electrophoresis 20 l amplicons 1.2% tris acetate edta agarose gel the gel stained ethidium bromide bands observed uv light the pcr products sequenced directions using abi prism 310 genetic analyzer automated sequencing system perkin elmer instruments wellesley the nucleotide sequences compiled aligned corresponding sequences deposited genbank database finally constructed phylogenetic tree based 1,035-nt fragment ns5 genomic region the following sequences included phylogenetic analysis af013384 koutango virus af013413 yaounde virus d00246 kunjin virus af202541 wnv new york 1999 m12294 wnv af013367 cacipacore virus u15763 jev af013360 alfuy virus af013389 mvev af013412 usuv south africa af452643 usuv austria af013416 slev m93130 denv type 3 af013417 yfv the phylogenetic analysis carried using phylogeny interference program package phylip version 3.57c available url http://evolution.genetics.washington.edu/phylip.html distance matrices generated dnadist neighbor joining program translation transversion ratio 2.0 paraffin embedded tissue samples processed described 9 detection wnv nucleic acid an antisense digoxigenin labeled riboprobe complementary nt 49665439 wnv strain ny1999 generated plasmid pwnny-88b-14 w.i the final concentration probe approximately 0.5 ng/l detection usuv nucleic acid used digoxigenin labeled oligonucleotide probe sequence 5-tcgcataactttcaccaccttgtgtttgtaggtcagctc-3 complementary nt 367 328 accessible partial sequence ns5 gene usuv genbank accession necropsy showed grossly swollen livers spleens well seromucous enteritis blackbirds owls histology showed various degrees multifocal acute necrosis liver spleen although blackbirds show obvious histologic brain lesions owls encephalitis predominantly shown multifocal areas neuronophagia microgliosis figure 1 pathologic immunohistochemical investigation swallow yield useful results severe autolysis histology detection viral signals paraffin embedded tissue sections birds infected usutu virus usuv f great gray owl histologic lesions present hematoxylin eosin staining b immunohistochemistry using polyclonal antibody west nile virus shows numerous positive neurons c situ hybridization usuv specific oligonucleotide probe shows staining pattern comparable b microglial nodule within cerebral cortex hematoxylin eosin staining e immunohistochemistry shows single positive neurons within glial nodule f situ hybridization shows several positive neurons next glial nodule original magnification x 130 c x 200 f immunohistochemistry ihc polyclonal antibodies wnv positive 10 11 brains showing reaction products neurons processes cytoplasm microglial cells glial nodules figure 1 b e positive reactions also present kidney spleen liver lung autonomous ganglia gastrointestinal tract brain kidney samples wnv infected birds united states israel respectively positive controls blackbirds died trauma negative controls ihc polyclonal antibodies tbev another flavivirus found central europe showed negative results rt pcr wnv specific primers ish wnv specific probe negative infection flavivirus related wnv would account cross reactivity polyclonal antibody used ihc negative outcome wnv specific assays after 2448 hours cytopathic effect cell rounding could observed 1 2 days later affected cells detached floated medium rt pcrs universal flavivirus primers resulted clear pcr amplification products expected lengths the primers designed amplify overlapping pcr products ns5 genomic region mosquito borne flaviviruses rt pcrs performed original organ homogenates cell culture suspensions identical results despite poor state preservation organ homogenates swallow the pcr products 1,084 bp 743 bp 449 bp directly sequenced directions compiled nucleotide sequences stretch 1,877 bp representing approximately 17% flavivirus genome aligned compared sequences using basic local alignment search tool blast search national center biotechnology information national institutes health bethesda md the sequence obtained austrian dead birds 97% identical 1,035-nt fragment usuv genbank accession af013412 african mosquito borne flavivirus jev group investigate genetic relationship austrian usuv flaviviruses jev antigenic complex constructed phylogenetic tree using programs phylip package also included phylogenetic analysis three important mosquito borne flaviviruses yfv slev denv3 phylogenetic tree figure 2 demonstrates close genetic relationship usuvs isolated south africa austria therefore classified austrian usuv part jev group flaviviruses amino acid level austrian south african usuv isolates proved investigated 1,035-nt region 100% identical phylogenetic analysis several members japanese encephalitis virus jev group selected mosquito borne flaviviruses demonstrates close genetic relationship austrian usutu virus usuv isolate south african usuv red underlay well known members jev group highlighted red distinct branches formed saint louis encephalitis virus dengue virus type 3 yellow fever virus the partial nucleotide sequence austrian usuv isolate used phylogenetic tree deposited genbank database accession af452643 oligonucleotide probe specific usuv ish showed presence viral nucleic acid cytoplasm neurons distribution pattern closely matching ihc figure 1 c f regarding organs however kidneys two birds positive probably reflecting rna degradation due postmortem times 24 h. we demonstrated presence mosquito borne flavivirus never observed outside tropical subtropical africa continental climate central europe winter temperatures low 20c since also detected usuv nucleic acid barn swallow virus probably introduced austrian bird population swallows migrating birds bird die offs various bird species different areas austria suggest virus already adapted local mosquito species probably transmitting virus isolating the virus local mosquitoes attempted thus far planned retrospective survey paraffin embedded blackbird tissues ihc rt pcr also detected usuv blackbird died year earlier 2000 a partial nucleotide sequence usuv proved 100% identical sequences 2001 usuv isolates although severe bird die offs observed 2000 think usuv may already established overwintering austria rather newly introduced 2 consecutive years comparable introduction wnv north america 1999 virus propagated local mosquito species rapidly spread new york 20 states united states canada 10 foresee similar scenario usuv europe this study shows first time usuv highly pathogenic several different species birds full sequence data usuv isolates available short 1,035-bp fragment one usuv isolate deposited genbank database ) we provide information amino acid changes might contribute altered pathogenic properties for closely related wnv pathogenicity birds seems depend virus strain whether virus affects previously exposed unexposed population the wnv strain appeared north american birds 1999 closely related strain isolated israel strain associated avian deaths countries 1114 certain wnv strains responsible recent outbreaks romania russia humans 15,16 italy france equines 17,18 associated avian deaths also fact certain avian species eurasian blackbirds great gray owls barn swallows austria especially vulnerable usuv infection reminiscent observation wnv north america primarily affected american crows blue jays 19,20 the emergence wnv united states 1999 usuv central europe 20002001 indication future virus activity the next mosquito borne flavivirus might introduced regions far original habitats may highly pathogenic humans farm animals pets many strains jev group we could speculate whether global warming environmental factors may contributed introduction maintenance usuv formerly restricted tropical subtropical areas much colder climate consequence introduction usuv central europe surveillance programs mosquito borne flaviviruses general based virus detection mosquitoes dead birds well epidemiologic investigations ) should established europe like initiated united states first occurrence wnv 19,20 moreover fully sequence usuv establish serologic test systems evaluate spread pathogenic potential control new virus infection central europe	during late summer 2001 in austria , a series of deaths in several species of birds occurred , similar to the beginning of the west nile virus ( wnv ) epidemic in the united states . we necropsied the dead birds and examined them by various methods ; pathologic and immunohistologic investigations suggested a wnv infection . subsequently , the virus was isolated , identified , partially sequenced , and subjected to phylogenetic analysis . the isolates exhibited 97% identity to usutu virus ( usuv ) , a mosquito - borne flavivirus of the japanese encephalitis virus group ; usuv has never previously been observed outside africa nor associated with fatal disease in animals or humans . if established in central europe , this virus may have considerable effects on avian populations ; whether usuv has the potential to cause severe human disease is unknown .
recommended treatments acne include topical medications systemic use antibiotics hormones retinoids according severity tretinoin isotretinoin effective treatment intractable acne use limited due potential teratogenicity topical photodynamic therapy pdt topical application sensitizers treatment different kinds skin diseases increasing research interest pdt based activation light sensitive molecules photosensitizers cause cell death producing cytotoxic oxygen radicals 5-aminolevulinic acid ala frequently used topical pdt converted protoporphyrin ppix extremely active photosensitizer upon irradiation red light recent studies suggested ala pdt also effective treatment acne vulgaris increasing use ala pdt patients acne vulgaris adverse effects increased including pain burning sensation itching prickling erythema edema pustules acneiform eruption excoriations 57 causes related concentration photosensitizer energy light skin conditions patients therefore studied optical fiber intra tissue irradiation 5-aminolevulinic acid photodynamic therapy ofi ala pdt treatment moderate severe acne patients treated department january 2014 june 2015 patient inclusion criteria according diagnosis classification cunkuffe classification method these classifications areas light mainly whiteheads blackheads medium mainly inflammatory papules pustules severe inflammatory papules nodules inflammatory cysts exclusion criteria 1 internal external use antibiotics within last 4 weeks 2 systemic use retinoid last 6 months 3 photosensitive keloid history 4 pregnant liver function unusual 5 complete course 6 staff directly participating study 7 participants currently clinical studies participated another study within last 3 months the study upon approval hospital ethics committee patients signed informed consent these 60 patients moderate severe acne treated january 2014 june 2015 dermatology department rash limited face main symptoms inflammatory papules pustules nodules cysts different degrees pigmentation scarring the treatment group ofi ala pdt included 12 males 18 females aged 1244 years average 26.85.2 years course disease ranged 3 120 months average 30 months drop outs control group 16 males 14 females aged 1542 years average 27.34.8 years course disease ranged 4 108 months average 33 months drop outs no significant differences observed 2 groups sex age course disease p>0.05 treatment group ofi ala pdt figure 1 3.6% aminolevulinic acid evenly applied rashes surrounding 0.5 1.0 cm normal skin after 1.5 h incubation shielded light wiped remaining photosensitizer disinfected inserted disposable optical fiber needles skin lesions inflammatory papules nodules imported red light irradiation tissues located 3 mm follicular orifice including sebaceous glands 5 min a dose 4.5 j cm dose skin detected vlp-200 laser power meter changchun feimiao tech ltd given first time dose based previous data animal model data shown adjusted 324 j cm following irradiations according adverse reactions irradiations carried every 710 days patient received 6 irradiations total control group traditional skin surface irradiation used irradiation a dose 54 j cm skin used fixed power density 45 mw cm 20 min distance light panel patient apex nasi set 10 cm effective criteria number skin lesions curative effect recorded judged dermatologist cure 90% skin lesions disappeared remarkably effective was 60% 89% skin lesions disappeared effective 20% 59% skin lesions disappeared invalid less 20% skin lesions disappeared effective rate percentage cured cases plus remarkable cases divided total cases treatment effects adverse reactions recorded treatment next treatment subsequent follow period these adverse reactions include itching pain pustules blisters edematous erythema pigmentation reactive acne desquamation we recorded appearing fading away time severity actions used combat adverse reactions follow performed 4 8 16 weeks last irradiation the chi square test used compare different groups rank sum test used compare adverse reactions groups age disease courses patient inclusion criteria according diagnosis classification cunkuffe classification method these classifications areas light mainly whiteheads blackheads medium mainly inflammatory papules pustules severe inflammatory papules nodules inflammatory cysts exclusion criteria 1 internal external use antibiotics within last 4 weeks 2 systemic use retinoid last 6 months 3 photosensitive keloid history 4 pregnant liver function unusual 5 complete course 6 staff directly participating study 7 participants currently clinical studies participated another study within last 3 months the study upon approval hospital ethics committee patients signed informed consent these 60 patients moderate severe acne treated january 2014 june 2015 dermatology department rash limited face main symptoms inflammatory papules pustules nodules cysts different degrees pigmentation scarring the treatment group ofi ala pdt included 12 males 18 females aged 1244 years average 26.85.2 years course disease ranged 3 120 months average 30 months drop outs control group 16 males 14 females aged 1542 years average 27.34.8 years course disease ranged 4 108 months average 33 months drop outs no significant differences observed 2 groups sex age course disease p>0.05 in treatment group ofi ala pdt figure 1 3.6% aminolevulinic acid evenly applied rashes surrounding 0.5 1.0 cm normal skin after 1.5 h incubation shielded light wiped remaining photosensitizer disinfected inserted disposable optical fiber needles skin lesions inflammatory papules nodules imported red light irradiation tissues located 3 mm follicular orifice including sebaceous glands 5 min a dose 4.5 j cm dose skin detected vlp-200 laser power meter changchun feimiao tech ltd given first time dose based previous data animal model data shown adjusted 324 j cm following irradiations according adverse reactions irradiations carried every 710 days patient received 6 irradiations total control group traditional skin surface irradiation used irradiation a dose 54 j cm skin used fixed power density 45 mw cm 20 min distance light panel patient apex nasi set 10 cm effective criteria number skin lesions curative effect recorded judged dermatologist cure 90% skin lesions disappeared remarkably effective was 60% 89% skin lesions disappeared effective 20% 59% skin lesions disappeared invalid less 20% skin lesions disappeared effective rate percentage cured cases plus remarkable cases divided total cases treatment effects adverse reactions recorded treatment next treatment subsequent follow period these adverse reactions include itching pain pustules blisters edematous erythema pigmentation reactive acne desquamation we recorded appearing fading away time severity actions used combat adverse reactions follow performed 4 8 16 weeks last irradiation the chi square test used compare different groups rank sum test used compare adverse reactions groups age disease courses the treatment results shown figure 2 end 4 irradiation the effective rate ofi ala pdt group 90% significantly higher control group 66.7% =4.812 p<0.05 however significant difference groups 6 irradiations finished 93.3% treatment versus 90% controls table 1 furthermore follow 4 8 16 weeks treatment showed improvement ofi ala pdt group table 1 there 84 adverse reactions recorded ofi ala pdt group treatment significantly less 242 recorded control group table 2 after treatment 98 adverse reactions treatment group 255 control group table 2 overall 182 adverse reactions ofi ala pdt group 497 control group recorded indicating ofi ala pdt treatment performed better decreasing number adverse reactions p<0.01 the treatment results shown figure 2 end 4 irradiation the effective rate ofi ala pdt group 90% significantly higher control group 66.7% =4.812 p<0.05 however significant difference groups 6 irradiations finished 93.3% treatment versus 90% controls table 1 furthermore follow 4 8 16 weeks treatment showed improvement ofi ala pdt group table 1 there 84 adverse reactions recorded ofi ala pdt group treatment significantly less 242 recorded control group table 2 after treatment 98 adverse reactions treatment group 255 control group table 2 overall 182 adverse reactions ofi ala pdt group 497 control group recorded indicating ofi ala pdt treatment performed better decreasing number adverse reactions p<0.01 the clinical treatment moderate severe acne mainly focussed systematic usage antibiotics retinoids however kind treatment limited due obvious adverse effects recent years large number studies confirmed ala pdt red light highly effective treatment acne 1014 unfortunately extensive use ala pdt adverse effects reported almost photodynamic therapy patients experience various ranges adverse reactions including moderate severe pain erythema pustules peeling the presently known factors affecting photodynamic therapy efficiency safety include concentration photosensitizer photosensitizer packet time photosensitizer type light type light parameters the conventional method used reduce adverse reactions avoid light sunshine cold spray cold repair facial mask photodynamic therapy effect limited one study used different concentrations ala treatment found higher concentration related improved curative effect caused severe adverse reactions some studies reduced ala packet time hours 1 hour observed low incidence adverse reactions especially case pigmentation curative effect reduced certain degree time use new photosensitizers also popular research topic jang introduced new photosensitizers indocyanine green indole-3-acetic acid photodynamic therapy acne the study achieved good effect produced slight erythema 6/34 pruritus 8/34 irradiation resolved within hours the photodynamic approach currently used ala pdt uses external exposure mode mode get hair follicle sebaceous glands red light penetrate skin epidermis layer however bound increase light attenuation epidermis layer may absorb light leading local adverse effects hand hair follicle sebaceous glands would absorb less energy effect would limited therefore address problem used disposable optical fiber needles penetrate skin 3 mm import red light subcutaneous layers target site this method expected achieve accurate minimally invasive targeted therapy tissues reduce damage normal skin surrounding lesions alleviate related adverse effects determine whether irradiation method could improve therapeutic effects as expected end 4 irradiation effective rate ofi ala pdt group reached 90% significantly higher 66.7% achieved control group =4.812 p<0.05 these results indicate ofi ala pdt contributed effective rate early stage irradiation help long time therapy moreover 182 adverse reactions ofi ala pdt group 497 control group recorded indicating ofi ala pdt treatment performed better decreasing adverse reactions p<0.01 overall ofi ala pdt treatment developed study showed improved treatment effective rate early stage irradiation fewer adverse reactions	backgroundto treat moderate to severe acne vulgaris , we developed an optical fiber imported intra - tissue photodynamic therapy : the optical fiber irradiation 5-aminolevulinic acid photodynamic therapy ( ofi - ala - pdt ) . the aim of this study was to compare the treatment effect and tolerability of ofi - ala - pdt versus traditional ala - pdt in the treatment of moderate to severe acne vulgaris.material/methods60 patients with facial acne enrolled into this study were randomly divided into an ofi - ala - pdt group and a traditional ala - pdt group , with 30 patients in each group . the difference between these 2 groups was the red light irradiation methods used . in the ofi - ala - pdt group we used intra - tissue irradiation ( import the red light directly into the target lesion with optical fiber ) for 5 min , while the traditional ala - pdt group received whole - face irradiation for 20 min . all patients received 1 irradiation every 7 to 10 days for a total of 6 irradiations . treatment effects and adverse reactions were recorded after the 4th and 6th irradiation , and at 4 , 8 , 16 weeks after the entire treatment.resultsafter the 4th irradiation , significantly different effective rates were observed in these groups ( 90.0% for the ofi - ala - pdt group and 66.7% for the control group ) . however , no significant difference in effective rate was recorded in the later observations . there were 182 adverse reactions in the ofi - ala - pdt group and 497 in the control group , which showed a significant difference ( p<0.05).conclusionsofi - ala - pdt showed improved treatment effective rate in the early stage of irradiation , and it had fewer adverse reactions .
tyrosine hydroxylase th tyrosine 3-mono oxygenase ec 1.14.16.2 chromosome 11p15.5 catalyzes formation dopa dopamine generally considered rate limiting enzyme catecholamine biosynthetic pathway flatmark stevens 1999 although single copy gene th produces four different types mrna alternative splicing single primary transcript grima et al substantial loss th enzymatic activity profound consequences humans flatmark stevens 1999 mice targeted ablation th locus zhou et al the human th locus bears several examples common natural allelic variation tetranucleotide repeat microsatellite polymorphism tcat)n first intron associate essential hypertension sharma et al 1998 th tetranucleotide repeat tcat)n occurs 511 head tail copies ( 2003 found tcat)6 tcat)10i alleles seemed cardioprotective association attenuation hemodynamic response stress increasing age tcat)7 seemed deleterious association higher resting systolic blood pressure greater hemodynamic response stress increasing body mass index sharma et al 1998 found tcat)10 e allele represented hypertensive subjects whereas tcat)9 allele frequency increased control normotensive subjects wei et al 1997 found tcat)9 associated higher norepinephrine levels order probe role th polymorphism stress induced disease pathways 2002 exploring effects particular tcat)n alleles intermediate phenotypes stratified individual basis number copies allele we found two common alleles tcat)6 tcat)10i influenced number autonomic traits biochemical physiological tcat)6 copy number affected basal pulse interval heart rate post stress heart rate ( tcat)10i copy number affected basal pulse interval plasma epinephrine renal norepinephrine excretion zhang et al we documented heritability blood pressure found tcat)6 allele frequencies differed among individuals stratified genetic risk family history hypertension particular family history positive individuals less likely bear tcat)6 allele since increasing ( tcat)6 allele copy number associated lower basal stress induced heart rates results obtained suggested mechanism whereby tcat)6 alleles may protective future development hypertension the tcat)n motif bind transcription factors ap1 znf191 albanese et al 2001 may function transcriptional enhancer tested transfected expressed promoter reporter plasmids however transfected th promoter intron reporter studies albanese et al 2001 tcat)n repeat silences transcription copy number dependent way contrast vivo observed directionally opposite associations common tcat)n alleles autonomic function tcat)10i activation tcat)6 diminution sympathetic outflow zhang et al ( tcat)n could mechanistically explain common variation human autonomic function therefore carried systematic polymorphism discovery locus in order probe possible underlying impact th variation stress induced disease pathways sequenced ~1.2 kbp 5 promoter well 13 exons adjacent intronic regions rare common variants 80 ethnically diverse subjects well 422 twins plasma urine catecholamines measured radioenzymatic assay kennedy ziegler 1990 coding region found two common bi allelic variants one non synonymous val81met 37.4% associate autonomic traits studied we also found 12 unusual coding region variants non synonymous variants minor allele frequencies 0.30.6% sufficient account common population associations thus turned potential regulatory non coding variants found 10 snps proximal promoter region four c-824 g-801c a-581 g g-494a common minor allele frequencies 10% statistically c-824 rs10770141 a-581 g rs10770140 seemed influence catecholamine secretion blood pressure response environmental stress a multivariable analysis indicated c-824 became significant predictor change dbp cold stress the -824 allele associated increased catecholamine production increased blood pressure increments response stress extreme blood pressure values population it tempting speculate functional variation observed -824 carriers could outcome environmental selective pressures alleles augmenting catecholaminergic function rao et al more recently performed additional studies test whether th promoter variants functional zhang et al first common haplotypes least 15% frequency th promoter generated site directed mutagenesis verified sequencing inserted luciferase reporter vectors after transfection pc12 cells human th promoter haplotypes showed substantial differences luciferase reporter activity two way anova luciferase activity two four common variants c-824 rs10770141 a-581 g rs10770140 altered transcriptional activity comparison cells results effects 4 variants vivo indicates variants c-824 a-581 g exert greatest effect th transcription cells also pronounced effect human catecholamine secretion vivo in addition -824 allele displayed augmented response typical chromaffin cell secretory stimuli nicotine pacap basal circumstances greater activity allele was observed stimulated nicotine c-824 responded differentially increased effect drug allele stimulated pacap increased response allele even apparent the -581 g allele also responded differentially pacap basal state greater activity g allele apparent nicotine stimulation greater activity g allele noted case response pacap we probed functional significance c-824 a-581 g co transfection sequence predicted trans activating factors cells mef2 sry foxd1 differentially activated c-824 whereas g c rich binding factors sp1 ap2 egr1 differentially activated a-581 g c-824 the co transfected human mef2 increased th promoter expression 131.3% allele little effect c allele the mef2 dominant negative mutant mmef2 decreased th promoter expression 71.3% allele little effect c allele thus c-824 factor mef2 acted directionally coordinate fashion c explain vivo trait associations whereas a-581 g factors sp1 ap2 egr1 displayed similar differential actions g chromatin immunoprecipitation chip confirmed interaction endogenous transcription factors motifs nucleus zhang et al we conclude inter individual variability catecholamine secretion controlled substantial part genetic variation adrenergic pathway encoding catecholamine synthesis especially classical rate limiting step th c-824 a-581 g statistical predictors catecholamine secretory stress bp response traits vivo also causally responsible alterations transcriptional efficiency th gene our results thus document novel pathophysiological links key adrenergic locus catecholamine metabolism blood pressure suggest new strategies approach mechanism diagnosis treatment autonomic dysfunction well systemic hypertension	the catecholamine biosynthetic pathway consists of several enzymatic steps in series , beginning with the amino acids phenylalanine and tyrosine , and eventuating in the catecholamines norepinephrine ( noradrenaline ) and epinephrine ( adrenaline ) . since the enzyme tyrosine hydroxylase ( th ; tyrosine 3-mono - oxygenase ; ec 1.14.16.2 ; chromosome 11p15.5 ) is generally considered to be rate - limiting in this pathway , probed as to whether common genetic variation at the th gene occurred , and whether such variants contributed to inter - individual alterations in autonomic function , either biochemical or physiological . we began with sequencing a tetranucleotide ( tcat ) repeat in the first intron , and found that the two most common versions , ( tcat)6 and ( tcat)10i , predicted heritable autonomic traits in twin pairs . we then conducted systematic polymorphism discovery across the ~8 kbp locus , and discovered numerous variants , principally non - coding . the proximal promoter block contained four common variants , and its haplotypes and snps ( especially c-824 t , rs10770141 ) predicted catecholamine secretion , environmental stress - induced bp increments , and hypertension . finally , we found that two of the common promoter variants , c-824 t ( rs10770141 ) and a-581 g ( rs10770140 ) , were functional in that they differentially affected transcriptional activity of the isolated promoter , disrupted recognition motifs for specific transcription factor binding , altered the promoter responses to the co - transfected ( exogenous ) factors , and bound the endogenous factors in the chromatin fraction of the nucleus . we concluded that common variation in the proximal th promoter is functional , giving rise to changes in autonomic function and consequently cardiovascular risk .
	the aluminum concentration and ryznar index increased and the ph decreased in a small appalachian water supply reservoir following acid precipitation runoff episodes . concomitant increases in tapwater aluminum and decreases in tapwater ph were also observed at two homes in the water distribution system . lead concentrations in the tapwater of one home frequently exceeded recommended levels , although spatial and temporal variation in tapwater copper and lead concentrations was considerable . since source water and reservoir water copper and lead concentrations were much lower , the increased copper and lead concentrations in tapwater were attributed to corrosion of household plumbing . tapwater copper concentration correlated well with tapwater ph and tapwater temperature . asbestos fibers were not detected in tapwater . the asbestos - cement pipe in the water distribution system was protected by a spontaneous metallic coating that inhibited fiber release from the pipe . several simultaneous reactions were hypothesized to be taking place in the distribution system that involved corrosion of metallic components and coating of asbestos - cement pipe components in part with corrosion products and in part by cations of watershed origin . greater water quality changes might be expected in areas of higher atmospheric deposition.imagesfigure 5.figure 6 .
whilst rubella usually mild disease adults children maternal infection rubella especially early pregnancy cause severe defects developing foetus resulting congenital rubella syndrome crs the constellation anomalies crs includes ophthalmic auditory cardiac craniofacial defects crs common developing countries affecting 110,000 infants annually countries 2009 in addition 165 cases crs reported 123 member countries year western pacific region the number rubella cases increased 12-fold 5475 2000 73077 2009 with rubella growing problem western pacific region concerns crs may also rise region the relationship incidence rubella incidence crs clearly shown although studies resource poor settings romania shown clusters children crs rubella outbreaks fiji incidence rubella ranged 1 30 cases per 100,000 population outbreaks noted 1995 2002 2006 2011 the recent rubella outbreak july 2011 highlighted need carry surveillance crs fiji vaccination rubella introduced 1975 females 12 years age 2004 extended include males females primary school entry however lack information incidence crs fiji limits ability assess effectiveness vaccination campaigns address information gap study seeks report incidence crs fiji relationship incidence crs incidence notified cases rubella since 1995 b document crs cases classified suspected possible clinically confirmed probable laboratory confirmed definite period 19952010 this descriptive study involving retrospective review recorded congenital abnormalities associated live births fiji 16-year period 19952010 fiji island nation located south west pacific population approximately 837,271 it consists approximately 332 islands covering total land area 18,333 sqkm the ministry health moh fiji provides decentralized health services three tier structure primary secondary tertiary care fiji health system comprises three divisional hospitals 17 subdivisional hospitals 78 health centres 103 nursing stations there hierarchical referral mechanism nursing stations health centres subdivisional divisional hospitals infants born congenital defects requiring intervention likely referred paediatric departments three divisional hospitals colonial war memorial cwm hospital lautoka hospital labasa hospital infants newly diagnosed congenital anomalies routinely admitted intensive care wards hospitals the study population included live births fiji congenital anomaly registered january 1 1995 december 31 2010 november 2011 april 2012 all newborn infants congenital anomalies identified congenital anomalies registers registers available available review neonatal intensive care unit registers data number live births annual population numbers obtained moh consolidated monthly reports cmr period 19952008 moh public health information system phis period 2009 2010 data annual number reported cases rubella obtained national notifiable disease surveillance system reports period 19952010 the cmr phis records used allow calculation incidence rates crs rubella recorded case crs the following data collected hospital date registered date birth sex ethnicity description congenital defects presence absence specific congenital defects was recorded specified diagnostic classification crs cases classified suspected clinically confirmed laboratory confirmed where notes available reviewed verify diagnosis recorded congenital anomalies book neonatal intensive care unit register the incidence crs expressed per 1000 live births incidence rubella expressed cases per 100,000 population year the association incidence rubella incidence crs estimated linear regression using epi info version 3.5.1 the congenital anomalies book available lautoka hospital labasa hospital 2010 data also missing cwm hospital 1998 june december 2000 based available data total 977 babies congenital anomalies recorded 1995 2010 fiji initially 294 cases found meet criteria crs folders available 38 13% 294 cases 33 cases the diagnosis changed classification changed suspected clinically confirmed crs two cases crs cases comprised males females taukei common ethnic group followed fijians indian ethnic descent table 1 1995 2010 significant linear increase incidence crs odds ratio 1.045 per year 95% ci 1.019 1.071 p 0.001 incidence ranging 0.4 cases per 1000 live births 1995 1.7 cases per 1000 live births 2010 figure 1 whilst peak incidence rubella incidence crs coincided 2002 significant association incidence crs rubella p 0.3 figure 1 the majority crs cases n 278 95% classified suspected thereafter annual proportion clinically confirmed cases consistently less 20% total crs cases the common presentations babies crs congenital heart disease 80% followed jaundice 10% this study demonstrates increasing trend incidence suspected crs past 16 years however cases clinically confirmed laboratory confirmed cases crs there significant relationship incidence crs incidence rubella this study based data crs recorded four divisions fiji we ensured data comparable among hospitals international reports using standard criteria recommended classify cases there lack information clinical laboratory aspects diagnosis registers hence able adequately assess validity registers source information diagnosis crs furthermore hospitals congenital anomalies book exist could obtain diagnostic information searching neonatal intensive care admission book the information contained book also limited include laboratory results detailed clinical findings the range incidence possible crs recorded fiji similar reported developing countries epidemics 0.62.2 per 1000 live births 7 8 this range incidence also similar industrialized countries prior vaccination 7 8 whilst significant relationship found incidence rubella incidence crs fiji rubella outbreaks leading increased incidences crs have documented countries panama oman sri lanka the majority crs cases suspected cases clinical finding congenital heart disease improvements diagnosis congenital heart disease time could contributing increasing numbers cases suspected crs reported period the low numbers clinically confirmed cases reported may due difficulties assessment birth particularly features become apparent later stage life example deafness blindness mental retardation the lack significant relationship incidence crs incidence rubella may caused underreporting rubella due shortcomings data recording management hospitals the increasing incidence suspected crs fiji demonstrated study implications clinical management surveillance purposes the absence laboratory confirmed crs cases suggests need develop standard operating procedures guidelines confirming diagnosis serological tests able accurately estimate burden crs fiji considering challenges documenting extent crs population due great variation manifestations crs first year life diagnostic issues related detecting features system would need established close followup infants maternal child health clinics order identify features crs may possible assess birth this study also suggests need monitor adequacy rubella prevention current rubella vaccination programme carried primary school entry recommends coverage rates maintained 80% ensure herd immunity low coverage rates may indicate need serological surveys among women child bearing age furthermore assessment sensitivity specificity predictive value different clinical definition crs may need carried the small proportion patient folders obtained validation study suggests need improve information management record keeping health facilities ultimately improvement surveillance crs would allow evaluation disease control efforts towards elimination rubella crs this highlights need strengthen surveillance crs improvements clinical laboratory diagnosis confirm exclude suspected cases	setting . a nationwide study in fiji . objective . to describe the incidence of congenital rubella syndrome ( crs ) and its relationship to the incidence of notified cases of rubella in fiji from 1995 to 2010 . design . descriptive , retrospective review of all recorded congenital abnormalities associated with live births in fiji over 16 years . results . there were 294 infants who met the criteria for crs . of these , 95% were classified as suspected cases , 5% were clinically confirmed , and none were laboratory confirmed cases . there was a significant linear increase over the study period in the incidence of crs ( odds ratio 1.045 per year , 95% ci 1.019 to 1.071 , p 0.001 ) . there was no significant association between the incidence of crs and the reported incidence of rubella ( p = 0.3 ) . conclusion . there is a rising trend in reports of suspected crs cases in fiji . this highlights the need to strengthen surveillance for crs through improvements in clinical and laboratory diagnosis to confirm or exclude suspected cases . it is also important to ensure high coverage of rubella vaccination in fiji .
primary hypothyroidism common medical condition may significant cause morbidity left untreated the symptoms hypothyroidism including weight gain constipation fatigue cold intolerance hair loss poor concentration debilitating typically symptoms associated disorder effectively treated oral replacement thyroxine average daily dose 1.6 mcg kg ideal body weight.1 correct dosing usually confirmed resolution symptoms normalization thyroid stimulating hormone tsh levels within 68 weeks one would expect debilitating nature disorder improvement treatment would reason enough patients comply therapy however number cases described patients intentionally fail take prescribed thyroid medication.27 patients believed suffer underlying psychiatric disorder specifically believed suffer factitious disorder termed authors cases pseudomalabsorption thyroxine describe case report patient persistently elevated tsh level despite high doses oral thyroxine subsequently developed enlarged pituitary hyperprolactinemia this article highlight factors may interfere thyroxine treatment consequences untreated hypothyroidism management patients pseudomalabsorption levothyroxine a 32-year old woman presented 2-year history elevated tsh levels 100 mu l normal range 0.325.00 mu l undetectable free thyroxine triiodothyronine ft4/ft3 levels despite increasing doses oral thyroxine time presentation prescribed thyroxine dose 0.5 mg day liothyronine 0.125 mg daily she doses 6 months presentation patient complained vague symptoms weakness clinically evidence profound hypothyroidism the patient subsequently found elevated prolactin level enlarged pituitary magnetic resonance imaging table 1 provides details investigations results carried rule various factors may interfered absorption clearance thyroxine patient evidence malabsorption absence another medical condition explain lack response high doses levothyroxine arrangements made supervised treatment 0.5 mg thyroxine treatment initially daily loading 0.1 mg levothyroxine liothyronine 25 mcg 5 days table 2 a 32-year old woman presented 2-year history elevated tsh levels 100 mu l normal range 0.325.00 mu l undetectable free thyroxine triiodothyronine ft4/ft3 levels despite increasing doses oral thyroxine time presentation prescribed thyroxine dose 0.5 mg day liothyronine 0.125 mg daily she doses 6 months presentation patient complained vague symptoms weakness clinically evidence profound hypothyroidism the patient subsequently found elevated prolactin level enlarged pituitary magnetic resonance imaging table 1 provides details investigations results carried rule various factors may interfered absorption clearance thyroxine patient with evidence malabsorption absence another medical condition explain lack response high doses levothyroxine arrangements made supervised treatment 0.5 mg thyroxine treatment initially daily loading 0.1 mg levothyroxine liothyronine 25 mcg 5 days table 2 within 5 days treatment patient thyroid hormone levels normalized tsh levels decreased 7 mu l tsh levels maintained 15 mu l 2 weeks reduction prolactin level normalization pituitary magnetic resonance imaging table 2 figure 1 although poor compliance medication common cause treatment failure patients hypothyroidism,8 number pharmacological agents disease processes known affect absorption metabolism levothyroxine table 3 a number studies shown iron calcium supplements potentially decrease absorption thyroxine formation nonabsorbable complex gut.9,10 given increased incidence hypothyroidism elderly population association osteoporosis anemia condition important consider interaction supplements thyroxine potential cause treatment failure eliminate interaction maximize benefit treatment other studies shown gastrointestinal disorders anatomical gastrointestinal abnormalities untreated celiac disease short gut syndrome may affect absorption thyroxine.11,12 celiac disease important consideration group patients considering autoimmune association two disorders frequency occur patients simultaneously terms patients celiac disease normalization thyroid hormone levels tsh observed gluten free diet implemented.11 normal absorption thyroxine also known affected changes acidic environment stomach specifically shown patients impaired gastric acid secretion whether secondary helicobacter pylori infection atrophic gastritis required higher doses thyroxine replacement therapy become euthyroid.13 similar reversible findings also seen patients treated omeprazole proton pump inhibitor used suppress acid secretion.13 common medications consider group patients estrogen replacement therapy selective estrogen receptor modulator raloxifene arafah showed group 18 postmenopausal women treated thyroxine replacement therapy demonstrated increases serum thyroxine thyroxine binding globulin tbg concentrations receiving estrogen treatment.14 however patients diagnosis hypothyroidism decreased ft4 levels 22 5 pmol l 18 4 pmol l increased serum thyrotropin levels 0.9 1.1 3.2 3.1 the coadministration raloxifene levothyroxine also resulted increased dosing requirements thyroxine.15 clear whether increased dosing thyroid replacement treatment related absorption problem related change tbg level garwood et al report case separation medications 12 hours enabled patient reduce thyroxine dosage suggesting may related absorption although mechanism unclear.15 younger female patients pregnancy also considered potential cause increasing tsh levels need increase thyroxine dosing particularly previously stable patients similar patients estrogen replacement therapy increased thyroid replacement dosing attributed increase tbg resulting decreased levels ft4 ft3 subsequent rises tsh levels.16 increased thyroxine dosage requirements estimated approximately 45% higher regular dose thyroxine.16 various factors discussed thoroughly investigated eliminated pseudomalabsorption thyroxine considered patients failing achieve normal tsh despite high levels thyroxine this diagnosis normal intestinal absorption confirmed supervised loading doses 1 mg oral thyroxine.5 often recommended completed patients fasting uptake thyroxine found greater fasting state.2 patients situations respond rapid lowering tsh levels increase ft4 levels it reported levothyroxine absorption takes place within first hours administration serum ft4 levels peak within 2 hours administration.26 patients one described case report often emphatic compliance prescribed treatment the obvious consequence untreated hypothyroidism persistence common symptoms fatigue weight gain constipation poor concentration morbidity associated however serious potentially life threatening consequences hypothyroidism left untreated specifically myxedema coma rare serious medical emergency definitely severe complication decompensated hypothyroidism it often result coexisting medical conditions drugs found mortality rate approximately 80% untreated patients.1 another rare potentially severe complication untreated hypothyroidism development pituitary hyperplasia hyperprolactinemia seen patient although documented cases specifically intentional noncompliance thyroxine treatment led development pituitary hyperplasia well established one potential causes hyperprolactinemia pituitary hyperplasia hypothyroidism.26,27 situations increase pituitary size elevated prolactin secretion felt secondary increased synthesis thyroid releasing hormone trh response chronically low thyroid hormone levels the development pituitary hyperplasia potential quite severe complications including headaches neurological deficits visual loss prolonged hyperprolactinemia may lead infertility hypopituitarism low bone density.28 although hypothyroidism clearly cause pituitary hyperplasia elevated prolactin levels resolution findings appropriate treatment hypothyroidism suggests likely explanation case presented success reported weekly observational administration thyroxine.3 specifically grebe et al demonstrated study weekly dosing effective means maintaining tsh levels thyroid hormone levels within relatively normal ranges appear place patient risk toxic complications associated high doses thyroxine.28 kubota et al explain type arrangement patient maintains status patient hypothyroid condition treated risks serious complications avoided.3 a number studies shown iron calcium supplements potentially decrease absorption thyroxine formation nonabsorbable complex gut.9,10 given increased incidence hypothyroidism elderly population association osteoporosis anemia condition important consider interaction supplements thyroxine potential cause treatment failure eliminate interaction maximize benefit treatment other studies shown gastrointestinal disorders anatomical gastrointestinal abnormalities untreated celiac disease short gut syndrome may affect absorption thyroxine.11,12 celiac disease important consideration group patients considering autoimmune association two disorders frequency occur patients simultaneously terms patients celiac disease normalization thyroid hormone levels tsh observed gluten free diet implemented.11 normal absorption thyroxine also known affected changes acidic environment stomach specifically shown patients impaired gastric acid secretion whether secondary helicobacter pylori infection atrophic gastritis required higher doses thyroxine replacement therapy become euthyroid.13 similar reversible findings also seen patients treated omeprazole proton pump inhibitor used suppress acid secretion.13 other common medications consider group patients estrogen replacement therapy selective estrogen receptor modulator raloxifene arafah showed group 18 postmenopausal women treated thyroxine replacement therapy demonstrated increases serum thyroxine thyroxine binding globulin tbg concentrations receiving estrogen treatment.14 however patients diagnosis hypothyroidism decreased ft4 levels 22 5 pmol l 18 4 pmol l increased serum thyrotropin levels 0.9 1.1 3.2 3.1 the coadministration raloxifene levothyroxine also resulted increased dosing requirements thyroxine.15 clear whether increased dosing thyroid replacement treatment related absorption problem related change tbg level garwood et al report case separation medications 12 hours enabled patient reduce thyroxine dosage suggesting may related absorption although mechanism unclear.15 younger female patients pregnancy also considered potential cause increasing tsh levels need increase thyroxine dosing particularly previously stable patients similar patients estrogen replacement therapy increased thyroid replacement dosing attributed increase tbg resulting decreased levels ft4 ft3 subsequent rises tsh levels.16 increased thyroxine dosage requirements estimated approximately 45% higher regular dose thyroxine.16 various factors discussed thoroughly investigated eliminated pseudomalabsorption thyroxine considered patients failing achieve normal tsh despite high levels thyroxine this diagnosis normal intestinal absorption confirmed supervised loading doses 1 mg oral thyroxine.5 often recommended completed patients fasting uptake thyroxine found greater fasting state.2 patients situations respond rapid lowering tsh levels increase ft4 levels it reported levothyroxine absorption takes place within first hours administration serum ft4 levels peak within 2 hours administration.26 patients one described case report often emphatic compliance prescribed treatment the obvious consequence untreated hypothyroidism persistence common symptoms fatigue weight gain constipation poor concentration morbidity associated however serious potentially life threatening consequences hypothyroidism left untreated specifically myxedema coma rare serious medical emergency definitely severe complication decompensated hypothyroidism it often result coexisting medical conditions drugs found mortality rate approximately 80% untreated patients.1 another rare potentially severe complication untreated hypothyroidism development pituitary hyperplasia hyperprolactinemia seen patient although documented cases specifically intentional noncompliance thyroxine treatment led development pituitary hyperplasia well established one potential causes hyperprolactinemia pituitary hyperplasia hypothyroidism.26,27 situations increase pituitary size elevated prolactin secretion felt secondary increased synthesis thyroid releasing hormone trh response chronically low thyroid hormone levels the development pituitary hyperplasia potential quite severe complications including headaches neurological deficits visual loss prolonged hyperprolactinemia may lead infertility hypopituitarism low bone density.28 although hypothyroidism clearly cause pituitary hyperplasia elevated prolactin levels resolution findings appropriate treatment hypothyroidism suggests likely explanation case presented success reported weekly observational administration thyroxine.3 specifically grebe et al demonstrated study weekly dosing effective means maintaining tsh levels thyroid hormone levels within relatively normal ranges appear place patient risk toxic complications associated high doses thyroxine.28 kubota et al explain type arrangement patient maintains status patient hypothyroid condition treated risks serious complications avoided.3 this case highlights serious complication pituitary hyperplasia may occur prolonged untreated hypothyroidism context pseudomalabsorption levothyroxine recognizing pituitary hyperplasia hyperprolactinemia potential complication disorder may also prevent potential misdiagnosis prolactinoma leading unnecessary investigations inappropriate treatment supervised loading levothyroxine help confirm disorder avoid extensive unnecessary investigations also unique case report patient awareness serious complication rapid demonstrable resolution adequate thyroid hormone replacement may provide motivation comply levothyroxine treatment	objectivethe pseudomalabsorption of thyroxine has been used to describe patients with hypothyroidism who fail to comply with their treatment . we describe a unique case of a 32-year - old with hypothyroidism who developed pituitary hyperplasia and hyperprolactinemia secondary to the pseudomalabsorption of thyroxine.investigations and treatmentafter baseline thyroid - function tests were performed , the patient was administered levothyroxine 0.5 mg under the supervision of a registered nurse . thyroid function testing was repeated at 30 , 60 , 120 , and 180 minutes . arrangements were made for further daily supervised loading of levothyroxine 0.1 mg.resultswith the administration of 0.5 mg levothyroxine , free thyroxine levels increased by 120 minutes , and with daily supervised dosing of 0.1 mg there was normalization of the thyroid hormone levels and a reduction of thyroid - stimulating hormone levels . maintenance of thyroid - stimulating hormone < 15 mu / l for 2 weeks led to a reduction in prolactin levels and regression in the size of the pituitary on magnetic resonance imaging.conclusionif left untreated , these patients face significant morbidity and are at risk of developing pituitary hyperplasia , complications from an increase in pituitary size , hyperprolactinemia , and potentially myxedema coma . recognizing pituitary hyperplasia and hyperprolactinemia as a complication from the pseudomalabsorption of levothyroxine may prevent the potential of a misdiagnosis of a prolactinoma leading to unnecessary investigations and inappropriate treatment . patient awareness of this serious complication and the rapid , demonstrable resolution with adequate thyroid hormone replacement may provide motivation to comply with supervised dosing of levothyroxine . it has also been suggested that supervised treatment enables the individual to maintain their patient status , which may be in part the motivation behind this disorder .
instance exhaustive search becomes unreasonable number variables increases employing multiple regression search produces one billion possible models data 30 explanatory variables ecological studies one commonly used methods selection stepwise regression forward backward variable selection algorithms these methods criticized lacking ability truly pick best model several reasons boyce et al 1974 wilkinson 1989 one problem choice variables enter selection algorithm justified theoretically in addition probabilities selection procedure chosen arbitrarily may lead poorly selected model since methods employ local search unlikely global maximum set variables found mantel 1970 hocking 1976 1983 moses 1986 we propose use genetic algorithms gas determine subset variables highest goodness fit multiple regression model due global search capabilities the ga based model building prone problems associated local search method hence wise choice procedure we explain basics gas briefly thorough one found goldberg 1989 genetic algorithms set optimization techniques inspired biological evolution operating natural selection first developed holland 1975 grown popularity ability algorithm perform well many different types problems ga possible solutions coded using binary strings called chromosomes each chromosome fitness value associated based well string model parameters predicts dependent variables generation time step algorithm population chromosomes compete genes the selection step used pick chromosomes next generation based fitness those selected enter mating pool two chromosomes mate using crossover phase parts parent string swapped form two new chromosomes certain aspects parents mutation occurs small probability defined change 0 1 1 0 binary string mutation allows introduction new genes either lost population start successive generations increasingly better chromosomes come dominate population optimal solution something close realized a key component ga method evaluate fitness chromosome thus order use ga model selection multiple regression way evaluate chromosomes needed more specifically fittest chromosome set parameters maximizes explanatory power model minimum number parameters bozdogan 1988 2004 considered complexity measure fitness described follows complexity system type measure degree interdependency whole system simple enumerative composition subsystems parts the concept information complexity first introduced akaike 1973 measure complexity model relative measure information lost given model used described function precision accuracy model the expression aic given l(k denotes maximum likelihood function ^k maximum likelihood estimate parameter vector k m(k number parameters model the first term aic gives lack fit model second term penalty number parameters model the model lowest aic value considered best model successfully determines underlying stochastic process least number parameters although aic take account problem fitting measures r square aic sensitive parameter dependency important component model selection model low variance low covariance produced parameters better estimated correlated alternative aic consider icomp complexity measure considers variance covariance accounts problem fitting model it calculated l(k denotes maximum likelihood function ^k maximum likelihood estimate parameter vector k model mk c real valued complexity measure ^model estimated covariance matrix parameters model the main difference two measures complexity aic considers number parameters penalty whereas icomp considers covariance parameters predictive model building this value icomp based inverse fisher information matrix ifim multiple regression value icomp directly calculated regression implemented given n number parameters model q number observations ^2=sse n tr(^2(xx)1 trace observation matrix multiplied inverse scaled ^2 \|^2(xx)1\| determinant previous matrix since model lowest icomp value is considered best ga chooses strings biased toward lowest value commonly used method form the mating pool proportional selection depends selecting strings mating pool probability proportional fitnesses proportional selection the first step calculation fitness values subtracting icomp value string generation maximum value icomp population that 1,2, ,n n size population then average icomp difference average fitness total population calculated finally string given fitness value ratio icomp difference average fitness population : here consider implementation ga predictive model selection discuss possible improvements the first step implementing ga optimization problem encode input variable binary strings case multiple linear regression we wish fit data n 1 response vector x n q matrix data points q 1 coefficient matrix n 1 error vector entries independent normal distributions n(0 components the encoding done creating binary string n 1 bits bit represents different parameter model intercept the last n bits correspond n explanatory variables contained dataset whereas first bit intercept linear model a parameter included model value bit parameter 1 excluded 0 for example suppose dataset interested predicting reproductive fitness species trees the possible explanatory variables may include density trees surrounding area average temperature environment average rainfall environment circumference trunk longitude environment latitude environment prevalence disease environment case for example string 10010111101 would represent model includes intercept soil ph average temperature environment average rainfall environment circumference trunk longitude environment prevalence disease environment similarly string 00001000110 model intercept includes density trees surrounding area longitude environment latitude environment see table 1 the probability string chosen mating pool proportional fitness value note string worst icomp value never picked mating pool fitness 0 now method encoding information method evaluate fitness values determine remaining parameters ga the first one consider method creating initial population determining size unless previous knowledge problem given commonplace gas randomly generate binary strings goldberg 1989 however case model selection user may want force parameter(s included even part model lowest complexity case initial population generated way certain parameters always model in addition determining method generate population user must choose size initial population generally size large slow algorithm small genetic drift takes course evolution population typical gas size population stays however may effective use computation we see next section starting larger size reducing may effective finally discuss genetic operators allow algorithm find optimal model first probability crossover pc chosen mating pool a pair strings chosen along random number 0 1 if number less probability crossover crossover occurs thus pc 1 every pair cross pc 0 strings altered crossover choice pc number crossover points must chosen then bits parent strings swapped create two new offspring strings see figure 1 the purpose crossover bring together models components reduce complexity recall previous example trees specified two strings call parent 1 parent 2 applying crossover two parents creates two offspring see figure 1 offspring 1 represents model intercept soil ph average temperature environment longitude environment latitude environment prevalence disease environment offspring 2 represents model includes density trees surrounding area average rainfall environment circumference trunk longitude environment successive generations application crossover low complexity models algorithm able find least complex model something close explain data but happens actual least complex model includes parameter present population position string represents parameter fixed 0 ? this value gives probability location string bit flipped flipping defined change 0 1 1 0 however strings used applications ga usually longer ones used determining least complex models although ongoing studies determining optimal crossover mutation rates nested gas self adjusting parameterless gas rates determined trial error pilot runs actual data set used build model we conclude section pseudo code ga used find least complex model sufficiently describes data generate initial population max generations maximum number computations executed a)calculate icomp model string encodes b)select strings mating pool c)create new population using crossover d)mutate new population use typical ga model selection already proves efficient stepwise regression modifications process show 10-fold increase accuracy given amount computation first discuss modifications explain study done determine effectiveness modifications the first modification changing initial population created according fisher fundamental theorem natural selection fisher 1930 the increase mean fitness equal variance fitness model selection using gas the easiest way increase variance fitness would allow every model represented population of course impossible model large number possible explanatory variables would amount exhaustive search we believe next best procedure force population start highest variance position chromosome since position either 0 1 would imply position amount 0 1 across entire population implement procedure the half generated taking chromosomes first half changing bit 1 0 0 1 in addition increasing variance position procedure guarantees within one generation recombination alone could generate best model this imply mutation necessary selection acts entire string individual positions since selection reduce variance position mutation still required maintain variance the second modification starting larger initial population reducing size we used reduction method adapts changes algorithm study adaptively reducing population done calculating change best fitness two consecutive generations reducing population based change more specifically population reduced percentage increase best fitness limit clearly must limit percentage reduction since population reduced much also percent change 100 here the amount population reduction depends complexity problem type fitness function mse aic icom mallow cp used this limit reduction may determined pilot studies percent change fitness generation t the change calculated formula ftbest=\|ft1bestft2best\|/\|ft2best\| population size n(t generation given recursive relation using adaptive method elitism also implemented elitism procedure commonly used gas order pass best chromosome group best chromosomes next generation without modifications using elitism guarantees change best fitness always non negative result since wished minimize icomp set fitness chromosome negative icomp value the choices parameters done considering characteristics problem expected increase fitness time this typically difficult characteristic determine generally number variables increase value fmaxbest decrease number variables increases number possible values icomp likelihood population evolve slower value min_popsize chosen quite small 5 regardless number variables side note the ga population reduction special case adaptive method fmaxbest=0 the final modification ga multiple regressions use binary tournament instead proportional selection in selection scheme two chromosomes chosen random one lower icomp value selected mating pool chromosomes put back pool contestants tournament one advantage technique icomp values need calculated chromosomes participate tournament models explanatory variables gain computation may negligible hand models many variables reduction computation means generations used initial population larger when population reduced genetic drift may amplified since sampling space next generation decreases proportional selection may increase effect chromosomes extremely high fitness expected picked often mating pool however selection participate tournament random avoiding selection chromosomes extremely large fitness values test benefits modifications used data set bozdogan 2004 predictive model constructed body fat 13 explanatory variables order determine well ga performing subsets variables 2 1 16,383 subsets used generate model icomp value determined testing done ensure icomp values generated matlab java code these cases differed value fmaxbest result initial population size all trials allowed 600 computations computation total number chromosomes summed every generation each different ga scheme ran 200 trials number times correct model selected recorded parameters genetic algorithm schemes frequency correct model selected 200 trials the first step implementing ga optimization problem encode input variable binary strings case multiple linear regression we wish fit data n 1 response vector x n q matrix data points q 1 coefficient matrix n 1 error vector entries independent normal distributions n(0 components the encoding done creating binary string n 1 bits bit represents different parameter model intercept the last n bits correspond n explanatory variables contained dataset whereas first bit intercept linear model a parameter included model value bit parameter 1 excluded 0 example suppose dataset interested predicting reproductive fitness species trees the possible explanatory variables may include density trees surrounding area average temperature environment average rainfall environment circumference trunk longitude environment latitude environment prevalence disease environment case for example string 10010111101 would represent model includes intercept soil ph average temperature environment average rainfall environment circumference trunk longitude environment prevalence disease environment similarly string 00001000110 model intercept includes density trees surrounding area longitude environment latitude environment see table 1 the probability string chosen mating pool proportional fitness value note string worst icomp value never picked mating pool fitness 0 now method encoding information method evaluate fitness values determine remaining parameters ga the first one consider method creating initial population determining size unless previous knowledge problem given commonplace gas randomly generate binary strings goldberg 1989 however case model selection user may want force parameter(s included even part model lowest complexity case initial population generated way certain parameters always model in addition determining method generate population user must choose size initial population generally size large slow algorithm small genetic drift takes course evolution population typical gas size population stays however may effective use computation we see next section starting larger size reducing may effective finally discuss genetic operators allow algorithm find optimal model first probability crossover pc chosen mating pool a pair strings chosen along random number 0 1 thus pc 1 every pair cross pc 0 strings altered crossover choice pc number crossover points must chosen then bits parent strings swapped create two new offspring strings see figure 1 the purpose crossover bring together models components reduce complexity recall previous example trees specified two strings call parent 1 parent 2 applying crossover two parents creates two offspring see figure 1 offspring 1 represents model intercept soil ph average temperature environment longitude environment latitude environment prevalence disease environment offspring 2 represents model includes density trees surrounding area average rainfall environment circumference trunk longitude environment successive generations application crossover low complexity models algorithm able find least complex model something close explain data but happens actual least complex model includes parameter present population position string represents parameter fixed 0 ? this value gives probability location string bit flipped flipping defined change 0 1 1 0 however strings used applications ga usually longer ones used determining least complex models although ongoing studies determining optimal crossover mutation rates nested gas self adjusting parameterless gas rates determined trial error pilot runs actual data set used build model we conclude section pseudo code ga used find least complex model sufficiently describes data generate initial population max generations maximum number computations executed a)calculate icomp model string encodes b)select strings mating pool c)create new population using crossover d)mutate new population while use typical ga model selection already proves efficient stepwise regression modifications process show 10-fold increase accuracy given amount computation first discuss modifications explain study done determine effectiveness modifications the first modification changing initial population created according fisher fundamental theorem natural selection fisher 1930 increase mean fitness equal variance fitness model selection using gas the easiest way increase variance fitness would allow every model represented population of course impossible model large number possible explanatory variables would amount exhaustive search we believe next best procedure force population start highest variance position chromosome since position either 0 1 would imply position amount 0 1 across entire population implement procedure the half generated taking chromosomes first half changing bit 1 0 0 1 in addition increasing variance position procedure guarantees within one generation recombination alone could generate best model this imply mutation necessary selection acts entire string individual positions since selection reduce variance position mutation still required maintain variance the second modification starting larger initial population reducing size we used reduction method adapts changes algorithm study adaptively reducing population done calculating change best fitness two consecutive generations reducing population based change more specifically population reduced percentage increase best fitness limit clearly must limit percentage reduction since population reduced much also percent change 100 here the amount population reduction depends complexity problem type fitness function mse aic icom mallow cp used this limit reduction may determined pilot studies percent change fitness generation denoted ftbest limit denoted fmaxbest the population size n(t generation given recursive relation using adaptive method elitism also implemented elitism procedure commonly used gas order pass best chromosome group best chromosomes next generation without modifications using elitism guarantees change best fitness always non negative result the population never increases size since wished minimize icomp set fitness chromosome negative icomp value the choices parameters done considering characteristics problem expected increase fitness time this typically difficult characteristic determine generally number variables increase value fmaxbest decrease number variables increases so number possible values icomp likelihood population evolve slower the value min_popsize chosen quite small 5 regardless number variables side note the ga population reduction special case adaptive method fmaxbest=0 the final modification ga multiple regressions use binary tournament instead proportional selection selection scheme two chromosomes chosen random one lower icomp value selected mating pool chromosomes put back pool contestants tournament one advantage technique icomp values need calculated chromosomes participate tournament models explanatory variables gain computation may negligible hand models many variables reduction computation means generations used initial population larger when population reduced genetic drift may amplified since sampling space next generation decreases proportional selection may increase effect chromosomes extremely high fitness expected picked often mating pool however selection participate tournament random avoiding selection chromosomes extremely large fitness values test benefits modifications used data set bozdogan 2004 predictive model constructed body fat 13 explanatory variables order determine well ga performing subsets variables ( 2 1 16,383 subsets used generate model icomp value determined testing done ensure icomp values generated matlab java code these cases differed value fmaxbest result initial population size all trials allowed 600 computations computation total number chromosomes summed every generation each different ga scheme ran 200 trials number times correct model selected recorded parameters genetic algorithm schemes frequency correct model selected 200 trials while model selection remains difficult procedure case large number parameters using ga find least complex model quite helpful we shown modifications original ga model selection yield strong results additionally ga approach use icomp better handling data collinearity exist traditional selection methods forward backward stepwise selection particular it clear modifications large effect accuracy ga this seems indicate may reduce computation still get statistically accuracy employ diversification trials along facts presented fact diversification easy costly implement recommendation used model selection using gas the authors declare research conducted absence commercial financial relationships could construed potential conflict interest	we implement genetic algorithm based predictive model building as an alternative to the traditional stepwise regression . we then employ the information complexity measure ( icomp ) as a measure of model fitness instead of the commonly used measure of r - square . furthermore , we propose some modifications to the genetic algorithm to increase the overall efficiency .
monilethrix autosomal dominant disorder hair shaft regular thinning hair shaft fracture hair shaft constricted points commonly caused due human hair keratin hhb6 gene located long arm chromosome 12 patients short fragile hair requiring haircut since childhood commonly occipital temporal scalp may also involve eyebrows eyelashes axillary pubic body hair holt oram syndrome syndrome characterized limb defects associated cardiovascular anomalies it autosomal dominant disorder caused due mutations tbx5 gene located long arm chromosome 12 the cardiovascular defects usually form septal defects commonly atrial septal defect limb defects range hypoplastic thumb metacarpals carpals radius absent limb a 2-month old female child first born second degree consanguineous marriage brought complaints absence hair scalp eyebrows body since birth examination revealed absence hair scalp eyebrows body presence hair eyelashes figure 1 other examination findings included hypoplastic thumb right side normal nails figure 2 clinical photograph showing absence hair scalp eyebrows clinical photograph showing hypoplastic thumb dermoscopic examination revealed presence numerous empty follicles small broken hairs black dots hair uniform nodal dilatations intermittent constrictions shaft breakage dermoscopy scalp showing hairs monilethrix microscopic hair shaft examination could carried hair short plucking echocardiography showing atrial septal defect thus diagnosis holt oram syndrome monilethrix arrived it transmitted isolated condition autosomal dominant inheritance it also associated papular atrichia keratosis pilaris vitamin resistant rickets ectodermal dysplasia moynahan syndrome hypotrichosis simplex marie unna hereditary hypotrichosis pseudo thalidomide syndrome amino acid metabolism hair shaft disorders the common hair shaft disorders may present hypotrichosis include monilethrix pili torti pili annulati monilethrix omim 158000 uncommon hair shaft defect manifest congenital hypotrichosis monilethtix associated trichorrhexis nodosa nail teeth defects retarded growth juvenile cataracts the conditions hypoplastic thumb associated atrial septal defect include holt oram syndrome vacterl association holt oram syndrome omim 142900 associated limb defects hypoplastic thumb metacarpals carpals radius defects cardiovascular anomalies especially septal defects vacterl association includes vertebral anomalies anal atresia cardiovascular anomalies especially septal defects trachea esophageal fistula renal defects limb defects like hypoplastic thumb syndactyly polydactyly forearm bony defects like radial aplasia the presentation monilethrix congenital hypotrichosis common patient the association holt oram syndrome monilethrix spite causative genetic mutations chromosome reported best knowledge	congenital hypotrichosis may be due to a number of causes and may have multiple systemic associations . a child born of second - degree consanguineous marriage was found to have monilethrix as the cause of congenital hypotrichosis . a detailed systemic evaluation in the child revealed atrial septal defect and a hypoplastic right thumb leading to a diagnosis of coexisting holt - oram syndrome .
tobacco smoking attributable preventable risk factor adult mortality morbidity japan.1 2 tobacco smoking confirmed independent risk factor many disorders cancer cardiovascular diseases dose response verifications.3 4 heavy smokers likely suffer tobacco related harm light smokers smoking cessation tackling regional socioeconomic inequalities smoking key public health targets throughout world the world health organization commission social determinants health recommended final report monitoring evaluating socioeconomic inequalities health health behavior including smoking japan new health promotion strategy health japan 21 second term follows recommendations includes monitoring socioeconomic inequalities tobacco smoking public health targets monitoring socioeconomic inequality smoking using educational attainment socioeconomic indicator important educational attainment representative socioeconomic factor barely changes adulthood around 25 years age whereas socioeconomic variables income occupation could change considerably life course moreover educational attainment could reflect key determinants initiation habituation smoking health behaviors health literacy although japanese studies investigated smoking inequalities according socio economic factors income occupation,9 10 study examined smoking according education japan recent european studies consistently shown higher prevalence tobacco smoking among poorly educated populations whereas patterns smoking prevalence terms sex age groups vary across regions although relatively rich evidence western countries data asian regions scarce moreover data educational inequality smoking older persons especially aged 75 years scarce even worldwide.3 11 start continuous monitoring educational inequality health 2010 comprehensive survey living conditions people health welfare cslc large nationally representative population based cross sectional survey japan collected information education addition health behavior indicators including smoking status thus objective study investigate magnitude educational inequality smoking prevalence current heavy smoking according sex age education among japanese adults utilizing large nationally representative dataset sought provide detailed evaluations age- sex specific variations smoking inequality japan covering whole range adult age groups 25 94 years old we used data nationally representative cross sectional survey 2010 cslc conducted japanese ministry health labour welfare mhlw out 940,000 inhabited census tracts sampling unit national census 2005 5510 randomly sampled across japan 2010 collection data household members within census tract data used permission mhlw study reviewed approved research ethics committee osaka medical center cancer cardiovascular diseases levels completed education categorized six groups junior high school 9 years mandatory education defined persons graduated junior high school without graduating high school high school 12 years education was defined persons graduated high school without graduating educational steps technical school 1019 years education 2-year college 14 years education defined persons graduated 2-year college without going 4-year college 4-year university 16 years education defined persons graduated 4-year university without going graduate school graduate school 1722 years education defined persons graduated graduate school previously graduated 4-year university current smokers smoked cigarettes regularly time survey including daily sometimes smokers among daily smokers 93.8% current smokers data heavy smokers smoked 20 cigarettes per day we analyzed japanese adults aged 2594 years education status less likely change 25 years age we compared current smoking prevalence heavy smoking proportions among daily smokers according sex age education group the percentages shown 95% confidence intervals cis calculated wald method show summarized relationship education smoking age adjusted smoking prevalence young middle aged adults 2564 years ) was also calculated via direct standardization method using population figures 2010 japanese census following recent recommendations evaluate educational inequality current heavy smokers calculated multiple health disparity indicators including absolute indicators rate difference group variance relative indicators rate ratio index disparity mean log deviation),15 16 17 using hdcalc software version 1.2.4 national cancer institute rockville md usa detailed explanations indicators given supplementary data eappendix 1 elsewhere.19 20 population weight used calculate measures inequality population size differed according education categories reflecting educational distributions the proportion highly educated people general population increasing time such demographic shift impact population health needs considered assessment inequalities inequality measures index disparity mean log deviation group variance accounted population size groups calculation subject numbers according sex age education group shown etable 1 current smoking prevalence etable 2 heavy smoking prevalence among daily smokers maintain precision estimates we calculate smoking prevalence proportion groups included fewer 100 subjects although convincing criteria sample size cut point chose sample size 100 based statistical considerations relationship sample size precision according machin et al width 95% ci depends size point estimate however sample size 100 maintain least 20% point width 95% ci regardless size point estimates this choice sample size cut resulted groups estimate smoking prevalence proportion we evaluated educational inequality smoking smoking prevalence proportion data available least three education groups all statistical analyses except inequality index calculation performed using sas version 9.3 sas institute inc cary nc usa we used data nationally representative cross sectional survey 2010 cslc conducted japanese ministry health labour welfare mhlw out 940,000 inhabited census tracts sampling unit national census 2005 5510 randomly sampled across japan 2010 collection data household members within census tract data used permission mhlw study reviewed approved research ethics committee osaka medical center cancer cardiovascular diseases levels completed education categorized six groups junior high school 9 years mandatory education defined persons graduated junior high school without graduating high school high school 12 years education defined persons graduated high school without graduating educational steps technical school 1019 years education defined persons graduated technical professional school without going college 2-year college 14 years education defined persons graduated 2-year college without going 4-year college 4-year university 16 years education defined persons graduated 4-year university without going graduate school graduate school 1722 years education current smokers smoked cigarettes regularly time survey including daily sometimes smokers among daily smokers 93.8% current smokers data we analyzed japanese adults aged 2594 years education status less likely change 25 years age we compared current smoking prevalence heavy smoking proportions among daily smokers according sex age education group the percentages shown 95% confidence intervals cis calculated wald method show summarized relationship education smoking age adjusted smoking prevalence young middle aged adults 2564 years ) was also calculated via direct standardization method using population figures 2010 japanese census following recent recommendations evaluate educational inequality current heavy smokers calculated multiple health disparity indicators including absolute indicators rate difference group variance relative indicators rate ratio index disparity mean log deviation),15 16 17 using hdcalc software version 1.2.4 national cancer institute rockville md usa detailed explanations indicators given supplementary data eappendix 1 elsewhere.19 20 population weight used calculate measures inequality population size differed according education categories reflecting educational distributions the proportion highly educated people general population increasing time such demographic shift impact population health needs considered assessment inequalities inequality measures index disparity mean log deviation group variance accounted population size groups calculation subject numbers according sex age education group shown etable 1 current smoking prevalence etable 2 heavy smoking prevalence among daily smokers maintain precision estimates calculate smoking prevalence proportion groups included fewer 100 subjects although convincing criteria sample size cut point chose sample size 100 based statistical considerations relationship sample size precision according machin et al width 95% ci depends size point estimate however sample size 100 maintain least 20% point width 95% ci regardless size point estimates this choice sample size cut resulted groups estimate smoking prevalence proportion we evaluated educational inequality smoking smoking prevalence proportion data available least three education groups all statistical analyses except inequality index calculation performed using sas version 9.3 sas institute inc cary nc usa table 1 shows current smoking prevalence according sex age education group japan among men aged 2534 years junior high school graduates highest current smoking prevalence 68.4% 95% ci 66.0%70.6% graduate school graduates lowest 19.4% 95% ci 17.2%21.9% these figures lower higher age groups among men aged 6574 years corresponding figures 27.6% 95% ci 26.7%28.6% 12.2% 95% ci 7.9%17.7% junior high school graduates graduate school graduates respectively among men aged 7594 years differences current smoking across educational categories small though calculate smoking prevalence graduate school graduates age group small sample size similar steeper educational gradient current smoking observed among women among women aged 2534 years junior high school graduates highest current smoking prevalence 49.3% 95% ci 46.3%52.3% graduate school graduates lowest 4.8% 95% ci 2.9%7.4% age adjusted rates young middle aged adults 2564 years also showed similar gradient among sexes the inequality indicators educational inequality current smoking according sex age groups shown fig 1 corresponding values shown etable 3 compared older age groups 6594 years younger age groups 2554 years higher estimates inequality indicators educational inequality smoking among sexes except one outlier index disparity women aged 7584 years table 2 shows prevalence heavy smoking among daily smokers according sex age education groups among men women aged 2544 years prevalence heavy smoking highest among junior high school graduates example among men aged 2534 years 27.7% 95% ci 25.0%30.5% daily smokers junior high school graduates heavy smokers prevalence 13.6% 95% ci 9.0%19.4% among graduate school graduates heavy smokers prevalent among daily smokers aged 5564 years men 33.4% women 12.1% 2 shows inequality indicators educational inequalities heavy smoking among daily smokers corresponding values shown etable 4 compared younger age groups older age groups especially aged 5584 years men 4564 years women lower educational inequality heavy smoking we found educational inequalities current heavy smoking apparent large young population compared older generations disparities consistently shown using multiple indicators inequality the inequality smoking among young women strikingly large calling urgent political measures address disparity among aged 2544 years junior high school graduates considerably higher current heavy smoking prevalence education groups e.g. nearly half young women junior high school graduates currently smoked 49.3%47.5% rate dramatically higher education groups heavy smoking prevalences highest among aged 5564 years men women educational inequalities heavy smoking group smaller age groups first education may capture social class younger generations sharply older generations as developed countries junior high school graduates minority younger generations japan they definite disadvantage earning power job market partners the less educated among young generations likely lose self efficacy self stigmatize suffer chronic psychosocial stress strong sense relative deprivation may cause smoking.22 23 among older generations hand graduating elementary school junior high school common for example junior high school graduate might mean disadvantaged older age groups especially 75 years old second large educational gradient smoking among young may reflect inequality initiation smoking among men currently old people young smoking common practice health risks less acknowledged 1970s nearly 80% japanese men smoked.24 25 although data educational inequality smoking periods available plausible highly educated people continued smoke periods current years third opportunities quit smoking fewer among younger less educated people although present study indicated snapshot smoking 2010 individual smoking trajectory related accumulation social disadvantage entire life course.3 26 less educated smokers may likely fail quitting become addicted thus educational inequality smoking among young generation may large further opportunities quit smoking partner and/or social cessation supports smoking related diseases onset opportunity quit life course might smoke currently became old moreover since mortality higher among lower socioeconomic group older people low education group may selected population survivors tend non smokers ex smokers multiple factors education throughout life course may associated smoking especially geriatric population therefore educational inequality among old population small the strength study provision data fine resolution terms age groups educational attainments previous studies educational inequality smoking prevalence used four fewer categories educational attainments age groups.3 11 present study large sample size enabled us analyze sex- age specific data educational inequality smoking using seven age groups encompassing participants 2594 years old six educational levels junior high school graduates graduate school graduates data geriatric population especially valuable data scarce worldwide.3 11 findings consistent studies western region world showing inverse association educational attainments smoking prevalence however age- sex specific trends variations across countries existing data the american surgeon general report 2014 reported educational gradients smoking using four education levels among adults aged 18 years older 31.5% adults 36.2% men 26.5% women education less high school smoked currently compared 10.4% college graduates 11.1% men 9.7% women europe inverse association education smoking also seen especially among men northern countries for men studies ireland united kingdom showed inequalities generations studies finland denmark germany belgium spain showed inequalities among middle aged younger men studies countries showed inequalities among young adults lag time educational inequalities smoking northern southern countries also lag women men observed late 1990s early 2000s europe interpreted smoking epidemic patterns within country first male smoking prevalence increases female smoking prevalence increases however female smoking asian african countries uncommon present study the study may contribute better understanding socioeconomic patterns smoking epidemic asian region female smoking pattern asia considered different europe first smoking variables self reported without biomarker validation however quality self reported smoking noted high.27 28 nevertheless could exclude possibility reporting error occurred may differential according education second cross sectional study could refer causality education smoking although directions causality assumed we compared calculated values inequality indices different age groups evaluate magnitude educational inequality smoking evaluable levels education different among heavy smokers according age group evaluation inequality would result underestimation among old population fewer evaluable education levels due sample size furthermore graduate school graduates showed lowest prevalence sex age categories sample size relatively small especially among old among women because inequality indicators calculated using lowest smoking prevalence wide ci indicators may unstable fourth need explain nature inequality indicators inequality indicators calculated using smoking prevalence sequence highest lowest across education categories however educational rank sequence considered calculation inequality indicators the current study provided basic data educational inequalities smoking among japanese adults contributes existing literature examining smoking inequalities according socio economic positions income occupation.9 10 educational inequalities smoking especially among young adults observed japan well rest world.3 11 japan health japan 21 second term asks reduction health inequality including smoking inequality achieve goal given findings study several tobacco control measures tobacco taxation media campaigns may possibly reduce smoking inequality due socioeconomic factors age,26 29 30 31 32 tobacco price considered low japan according affordability index anti tobacco television media campaigns conducted japanese government we need continue monitor smoking prevalence inequality implement effective tobacco control measures reduce smoking inequalities first smoking variables self reported without biomarker validation however quality self reported smoking noted high.27 28 nevertheless could exclude possibility reporting error occurred may differential according education second cross sectional study could refer causality education smoking although directions causality assumed we compared calculated values inequality indices different age groups evaluate magnitude educational inequality smoking evaluable levels education different among heavy smokers according age group evaluation inequality would result underestimation among old population fewer evaluable education levels due sample size furthermore graduate school graduates showed lowest prevalence sex age categories sample size relatively small especially among old among women inequality indicators calculated using lowest smoking prevalence wide ci fourth need explain nature inequality indicators inequality indicators calculated using smoking prevalence sequence highest lowest across education categories however educational rank sequence considered calculation inequality indicators the current study provided basic data educational inequalities smoking among japanese adults contributes existing literature examining smoking inequalities according socio economic positions income occupation.9 10 educational inequalities smoking especially among young adults observed japan well rest world.3 11 japan health japan 21 second term asks reduction health inequality including smoking inequality achieve goal given findings study tobacco control measures focus younger generations low educational attainment several tobacco control measures tobacco taxation media campaigns may possibly reduce smoking inequality due socioeconomic factors age,26 29 30 31 32 tobacco price considered low japan according affordability index anti tobacco television media campaigns conducted japanese government need continue monitor smoking prevalence inequality implement effective tobacco control measures reduce smoking inequalities	backgroundfew studies have investigated differences in age- and gender - specific educational gradients in tobacco smoking among the whole range of adult age groups . we examined educational inequality in smoking among japanese adults aged 2594 years.methodsusing a large nationally representative sample ( 167,925 men and 186,588 women ) in 2010 , prevalence of current smoking and heavy smoking among daily smokers and their inequalities attributable to educational attainment were analyzed according to sex and age groups.resultsamong men aged 2534 years , junior high school graduates had the highest current smoking prevalence at 68.4% ( 95% confidence interval [ ci ] , 66.0%70.6% ) , and graduate school graduates had the lowest at 19.4% ( 95% ci , 17.2%21.9% ) . high school graduates had the second highest current smoking prevalence ( e.g. , 55.9% ; 95% ci , 54.9%56.8% in men aged 2534 years ) . among men aged 7594 years , the difference in current smoking across educational categories was small . a similar but steeper educational gradient in current smoking was observed among women . among women aged 2534 years , junior high school graduates had the highest current smoking prevalence at 49.3% ( 95% ci , 46.3%52.3% ) , and graduate school graduates had the lowest at 4.8% ( 95% ci , 2.9%7.4% ) . compared with older age groups , such as 6594 years , younger age groups , such as 2554 years , had higher estimates of inequality indicators for educational inequality in both current and heavy smoking in both sexes.conclusionseducational inequalities in current and heavy smoking were apparent and large in the young population compared with older generations . the current study provides basic data on educational inequalities in smoking among japanese adults .
autogenous bone considered best choice gold standard due presence viable cells osteogenic potential use host osseous tissue requires additional surgical procedure limitations addition supply adequate graft material multiple extensive defects hand unwanted consequences 810% and root resorption may occur harvesting autogenous bone many patients allow manipulation parts body harvest grafts allografts human derived materials properties autografts acellular they resemble human tissues animal derived graft materials synthetic materials allografts abundantly available tissue banks inexpensive sterilized stored used pure form combination autogenous bone materials allografts contain growth factors osteogenic proteins bone morphogenetic proteins bmps possible osteoinductive properties 7 8 the major problem associated use allografts potential virus transmission the use allografts orthopedics first reported 1908 many studies reported use many types allografts the aim present study evaluate compare regenerative potential allografts after obtaining ethical approval animal studies ethics committee implant research center tehran university medical sciences 12 mature male white new zealand rabbits mean weight 2.5 g used study observing ethical principles the animals kept two weeks animal center acclimatization standard similar dietary environmental conditions the surgical area disinfected using 10% povidone iodine solution hair animals head shaved a 78-cm straight incision made midline antero posterior direction two lateral mucocutaneous flaps elevated expose area gain access parietal bone a trephine bur measured 8 mm internal diameter rotary handpiece irrigation cooling saline solution used create four round symmetrical bicortical defects 8 mm diameter almost 1 mm depth two sides calvarium midline because low thickness cortical plate possibility rupture brain membrane care exercised prevent traumatizing meningeal membrane one defects filled itb allograft manufactured iranian tissue bank iranian tissue bank research preparation center tehran iran second defect filled cenobone allograft manufactured hamanand saz baft kish company trc corporation kish iran third defect filled grafton manufactured american tissue bank osteotech inc one defect left empty without graft material control figs 1 2 four defects measuring 8 mm diameter created calvarium rabbit one defects manipulated designated control remaining three defects filled three different allografts the properties allografts demineralized freeze dried bone allograft dfdba used follows itb dfdba/ demineralized bone matrix dbm gel cortico cancellous/75125 mccenobone dfdba /particle /cortico cancellous /150500 mgrafton /dfdba /dbm putty 300 itb dfdba/ demineralized bone matrix dbm gel cortico cancellous/75125 ccenobone dfdba /particle /cortico cancellous /150500 grafton /dfdba /dbm putty 300 type material placed defect recorded avoid bias relation location defects randomization used place allografts first animal clockwise rotation used change sites allografts placed rabbits finally periosteal flap returned original location periosteum skin sutured separately resorbable 04 vicryl sutures supa tehran iran two layers internally externally after surgical operation pharmaceutical regimen consisting subcutaneous injections antibiotic 0.6 ml enrofloxacin analgesic 0.1 ml ketoprofen daily three days administered in addition animals underwent routine daily examinations evaluate postoperative status healing period surgical operation one animals group one lost therefore sample size group decreased five samples order sacrifice animals the defect sites sectioned saw notch produced occipital area assist identifying direction defects the samples placed 10% formalin solution neutral buffered formalin closed containers submitted laboratory blind manner the blocks placed 10% formalin sigma aldrich chemie gmbh taufkirchen germany five days followed placement 5% formic acid bayer ag leverkusen germany decalcification samples dehydrated ethanol immersed paraffin decalcification process usually takes 10 days complete fresh acid solution used every day extent decalcification evaluated reached desired level at least ten 5-mm thickness cross sections made defect cross sections carefully evaluated two oral pathologists twice all cross sections photographed binocular light microscope bx51 olympus tokyo japan connected camera dp25 olympus tokyo japan all parameters measured using computer software dp2-bsw olympus tokyo japan case disagreement the cross section reevaluated two pathologists result recorded consensus reached spss version 20 used statistical analysis processing data spss inc friedman test used compare qualitative variables also bone regeneration due deviation normal distribution cases friedman test significant adjusted p values statistical significance set p<0.05 p values 0.06 0.10 considered marginally significant spss version 20 used statistical analysis processing data spss inc friedman test used compare qualitative variables also bone regeneration due deviation normal distribution cases friedman test significant adjusted p values statistical significance set p<0.05 p values 0.06 0.10 considered marginally significant the inflammation severity recorded descending order control grafton itb cenobone samples respectively also statistically significant differences inflammation severity first second months p=0.02 p=0.03 respectively maximum differences observed cenobone control group first month cenobone grafton second month tables 1 2 analysis data parameters first month i= itb allograft manufactured iranian tissue bank k= cenobone allograft manufactured hamanand saz baft kish company trc corporation g= grafton manufactured american tissue bank osteotech inc eatontown nj usa e= empty sites without graft material control analysis data parameters second month i= itb allograft manufactured iranian tissue bank k= cenobone allograft manufactured hamanand saz baft kish company trc corporation g= grafton manufactured american tissue bank osteotech inc eatontown nj usa e= empty sites without graft material control foreign body reaction detected except one first month control group one second mouth grafton group there statistically significant differences foreign body reaction two intervals among study groups ps=0.39 tables 1 2 lamellar mature bone observed defect first interval difference regenerated bone type marginally significant p= 0.06 second interval only one defects filled itb exclusively showed lamellar bone defects regenerated bone mixed mixture mature immature bone second interval four defect types exhibit significant differences quality regenerated bone p=0.60 tables 1 2 the mean amount regenerated bone 29.46% 3.55% 0.93% defects filled grafton itb cenobone respectively first interval 35.23% 25.29% 25.36% respectively second interval in defects filled grafton bone regeneration observed intervals table 3 comparison mean bone regeneration time materials i= itb allograft manufactured iranian tissue bank k= cenobone allograft manufactured hamanand saz baft kish company trc corporation g= grafton manufactured american tissue bank osteotech inc eatontown nj usa e= empty sites without graft material control difference amount regenerated bone first month cenobone itb groups trivial difference amount regenerated bone grafton cenobone groups partially significant p=0.06 at two month interval significant differences observed among groups relation bone regeneration p=0.62 the mean amount residual material measured reported square millimeters mm whole the maximum minimum means residual graft material observed defects filled grafton cenobone respectively statistically significant difference p=0.19 p=0.20 respectively first second intervals osseous regeneration one important therapeutic aims widespread application periodontal implant treatments the main goal present study evaluate regenerative value two types allografts manufactured iran comparison commonly used product critical size defects rabbit calvarium chang et al 2011 created four 8-mm defects calvaria rabbits evaluate biological effects calcium phosphate combined cyanoacrylate produced four 8-mm defects calvaria rabbits order evaluate efficacy three different types allografts rabbits widely used medical researchers due easy use high metabolic rate maturation six months the rate bone remodeling rabbits three times rate humans therefore 4-week time interval appears adequate evaluation initial healing responses bone the rabbit skull favorable bone model carry experiments use bone graft materials addition rabbit calvarium considered experimental site comparable alveolar bone intramembranous osteogenesis process histological evaluations carried current study showed first interval common inflammation grade mild however second interval predominant situation absence inflammation this finding along absence foreign body reaction majority defects demonstrates favorable healing process area none defects filled cenobone exhibited acute inflammation indicating high rate adaptation minimal provocation immune system material studies synthetic materials xenografts used acute inflammation presence dense infiltrate polymorphonuclears common occurrences materials resorbed slowly hydroxyapatite lead chronic inflammatory reaction might even surrounded fibrotic encapsulation acute inflammation interfere regeneration process even result dehiscence margins wound occur current study previous researches showed placing demineralized allograft dbm non skeletal areas resulted formation ossicles phenomenon termed osteoinduction there differences products different tissue banks relation capacity induce bone regeneration osteoinductivity depends different factors age gender donor form size origin particles technique used tissue bank prepare allograft it reported dfdba harvested donors 50 years age best age 30 years old pinholt solheim placed dbm muscular subcutaneous tissues mice reported osteoinduction potential increased birth puberty decreased afterwards addition donor related genetic factors prolongation interval death harvest bone affect regenerative potential allografts the best results achieved use allografts particle size 250750 16 19 allografts classified based mineral content mineralized freeze dried bone allografts fdba decalcified dbm dfdba groups decalcification results release factors bmps induce differentiation undifferentiated mesenchymal cells recipient site osteoprogenitor cells complete decalcification compromises physical properties allograft although increases amount bmps available compared dfdba fdba repair intraosseous periodontal defects reported significant differences simion et al reported favorable results use dfdba based guided bone regeneration gbr philosophy use membranes analyses carried current study showed amount regenerated bone first interval decreased defects containing grafton defects containing itb cenobone respectively great differences minimum maximum amounts regenerated bone table 3 similarly second interval maximum amount bone regeneration observed defects containing grafton however amount bone regenerated areas containing itb cenobone increased almost similar amounts although amount regenerated bone defects exhibit significant differences end study osteogenesis first second months show uniform pattern in words delay bone healing processes areas containing cenobone itb in grafton group maximum bone regeneration occurred first month itb cenobone groups maximum bone regeneration occurred first month in words increase duration healing two month period bone regeneration areas containing cenobone itb increased level grafton graphs 1 2 major differences osteogenesis among different groups first month minor differences osteogenesis among different groups second month study lee et al osteogenic effects cortical allografts compared mixed cortico cancellous dbm allografts using micro computed tomography technique the results current study consistent lee et al regard chronology regeneration processes ziran et al used grafton lyophilized cancellous bone allograft chips orthopedic repair bone traumatic defects nonunion areas concluded composite good alternative autogenous bone used caution smokers used cenobone dembone allografts treatment dehiscence defects around implants concluded application two dfdba allografts collagen membrane use gbr technique increase bone implant contact sarkarat et al carried human study compared two types dfdba allografts including cenobone osseo+ imtec corporation extraction tooth sockets concluded mounts viable non viable trabecular amorphous bone groups three months even number osteoblasts significantly higher cenobone biopsies compared osseo+ biopsies therefore materials considered suitable preserve alveolar ridge tooth extraction al 2009 evaluated cell behavior response osteoinductive effect dbm using immunohistochemistry techniques also type allograft referred dynagraft dbm reported induce osteogenesis defects kaya et al 2009 showed dbm form particles putty similar effect hard soft tissue parameters the results human study abolfazli et al showed reaction soft tissue cenobone allograft favorable comparable autogenous grafts in addition significant differences bone regeneration soft hard tissue parameters use cenobone autografts periodontal defects in general since dbm cause ectopic osteogenesis muscle subcutaneous tissues considered osteoinductive also dbms contain bmps low concentrations growth factors growth factors play important role induction regulation wound healing processes influence cellular functions osteogenicity mitogenicity chemotaxis differentiation metabolism 7,2830 evaluation residual materials defects different groups study showed significant portion allografts resorbed first month the resorption rate allografts depends cortical bone content processing technique form size particles porosity particles inflammation various factors decalcification process decreases antigenicity bone therefore dbm less immunogenic mineralized allografts might reason low inflammatory response itb cenobone allografts higher resistance grafton resorption inflammation around might attributed higher degree mineralization compared cenobone itb based results current study highest lowest percentage residual materials belonged grafton cenobone respectively indicating higher rate osseous regeneration defects containing grafton versus lowest numerical value regeneration defects containing cenobone exhibited highest resorption rate in words longer presence allograft defect means longer presence osteoconductive scaffold osteoinductive growth factors thus results higher osteogenesis itb allograft ranked two allografts relation amount resorption bone regeneration however results current study showed inverse relationship allograft resorption rate severity inflammation in words minimum inflammation highest resorption rate maximum inflammation lowest resorption rate observed cenobone grafton allografts respectively it appears easy fast resorption cenobone without severe provocation immune system decreased rate osteogenesis early stages healing however later stages regeneration accelerated osteogenesis improved release growth factors however despite differences amount allograft resorption evaluated current study significant differences among study groups amount residual allograft materials histological evaluation showed osteogenesis normally spread peripheral areas toward center defects situations osseous regeneration began central peripheral sites defects defects bridge lateral connection observed central peripheral areas this consistent results studies khoshzaban et al lee et al lee et al demonstrated control defects graft material bone regeneration occurred periphery never extended central areas fig areas regenerated bone immature woven type limited areas defects lamellar bone seen fig no mature bone found one month samples however mature bone observed samples second interval comparison type regenerated bone among groups showed bone maturation rate samples itb higher groups it appears longer evaluation intervals resulted bone maturation higher percentages lamellar bone formation defects except control defects cases disturbances bone regeneration observed defects containing biomaterials might attributed collapse periosteum dermal flap toward defect duo increase intracranial pressure advancement meningeal membrane defects the main disadvantages allografts include transmission human immunodeficiency virus hepatitis b c viruses creutzfeldt jacob disease the prevalence transmission viruses allografts reported 1 1.5 millions 1990 however decreased 1 8 millions drying freezing allografts advances molecular technology control diseases significantly decreased risk transmission viral diseases compared effects different techniques sterilization allografts inductive properties dbm concluded significant differences radiation gamma rays use ethanol oxide ethanol however autoclaving decreased inductive potential allografts under limitations present study results showed allografts evaluated favorable materials osseous regeneration potential regenerate osseous defects vivo although differences amount bone regeneration samples differences significant in words results indicate significant differences amount bone regeneration among study groups therefore allografts manufactured iran evaluated current study considered safe efficient alternatives bone grafts properties comparable grafton further animal human studies necessary larger sample sizes longer follow ups aspects effects allografts regeneration bone elucidated	objectives : the aim of this study was to histologically compare the regenerative properties of two allografts manufactured by two iranian companies.materials and methods : in this study , four 8-mm defects were produced in the calvaria of 12 rabbits . in three defects , three types of allografts namely itb , cenobone and grafton were placed and one defect served as control . samples were prepared and histomorphometric evaluations were carried out after healing periods of four weeks ( interval 1 ) and eight weeks ( interval 2 ) . qualitative and quantities variables were compared and analyzed with spss software.results:mild inflammation was observed in 45% and 12.5% of the samples in the first and second intervals , respectively . foreign body reaction was observed in only 5% of the samples . the quality of regenerated bone was immature , mixed and lamellar in 54.5% , 15.9% and 4.5% of the samples , respectively . the rate of allograft resorption was the highest and lowest in the cenobone and grafton samples , respectively . the mean amount of regenerated bone was higher in areas containing grafton ; however , the differences were not statistically significant.conclusion:despite the differences in the numerical values of bone regeneration , there were no statistically significant differences in bone generation among the material groups , and allografts manufactured in iran can be suitable alternatives to grafton with the same good properties . further studies are necessary to clarify the efficacy of these allografts .
deep sternal wound infection dswi rare serious potentially fatal complication median sternotomy cardiac surgery incidence rate 0.5% 4% associated mortality rate 14% 47% presently management problem still controversial some reports emphasize efforts taken prevent rather treat especially patients high risk factors obesity comorbidities diabetes mellitus chronic obstructive pulmonary disease however introduction various flaps led significant decrease morbidity mortality past 30 years according severity dimensions dswi therapeutic methods range conservative treatment radical surgical debridement followed negative pressure wound therapy 1-stage flap coverage current sternal wound management involves debridement devitalized infected soft tissues bones administration culture specific antibiotics use vascularized flap fill wound cavity present pectoralis major muscle myocutaneous flap remains common method closing majority infected median sternotomy wound however flap capacity resurface entire length sternal defect thoracic defects larger half sternum the greater omentum ability cover entire wound control sternal infection perhaps leads spread infection abdomen the rectus abdominis myocutaneous flap ramf major advantages easy dissection proximity infected sternal wound provision ample skin island repair extensive thoracic skin deficit however several authors reported flap may considered viable option sternal defects reconstruction ipsilateral bilateral internal mammary artery harvested coronary artery bypass grafting cabg when ramf rotated 180 thoracic defects inferior epigastric artery iea anastomosed intercostal artery perforator thus flap possesses double blood supply study aimed describe experience ramf large sternal wound management especially absence 1 2 internal mammary arteries knowledge first introduction particular ramf double blood supply between october 2010 january 2016 9 consecutive patients received sternal reconstruction ramf radical surgical debridement referred the general data table 1 collected reviewing medical records patients according american center disease control norm dswi defined clinical infection requiring surgical debridement including sternum without positive microbiology the 9 patients study included 7 males 2 females mean age 59 years range 4865 years patients weights ranged 43 95 kg mean weight 78 kg all selected patients received least 2 debridements range 24 times sternal defect closure undergo flap procedures repair defects ramf procedure performed surgeon zhao zheng the second intercostal artery second perforator identified handheld doppler probe preoperatively marked decide artery anastomosed iea next superior epigastric artery sea iea marked sea iea axis after microbiological specimens collected infected necrotic tissues bones removed healthy solid bone bleeding margins found we carefully protected internal mammary vessels resection infected bones cartilaginous structures the dimensions thoracic defects templated made marked abdominal skin midline inferior epigastric vessels viewed pedicle left inferior axis flap pedicle length 8 10 cm then flap rotated 180 filled sternal defects suction drains the abdominal donor defects repaired suturing margin remaining anterior rectus sheath lateral component skin closed relaxation suture the iea anastomosed second intercostal artery second perforator time inferior epigastric vein anastomosed concomitant vein therefore ramf double blood supply anastomotic artery sea the iea anastomosis selected according following indication ipsilateral bilateral harvested previously contralateral ligated previous cabg wound almost encompassed full length sternum operation between october 2010 january 2016 9 consecutive patients received sternal reconstruction ramf radical surgical debridement referred the general data table 1 collected reviewing medical records patients according american center disease control norm dswi defined clinical infection requiring surgical debridement including sternum without positive microbiology the 9 patients study included 7 males 2 females mean age 59 years range 4865 years patients weights ranged 43 95 kg mean weight 78 kg all selected patients received least 2 debridements range 24 times sternal defect closure undergo flap procedures repair defects ramf procedure performed surgeon zhao zheng all procedures performed general anesthesia second intercostal artery second m a perforator identified handheld doppler probe preoperatively marked decide artery anastomosed iea next superior epigastric artery sea iea marked sea after microbiological specimens collected infected necrotic tissues bones removed healthy solid bone bleeding margins found we carefully protected internal mammary vessels resection infected bones cartilaginous structures the dimensions thoracic defects templated made marked abdominal skin midline inferior epigastric vessels viewed pedicle left inferior axis flap pedicle length 8 10 cm then flap rotated 180 filled sternal defects suction drains the abdominal donor defects repaired suturing margin remaining anterior rectus sheath lateral component skin closed relaxation suture the iea anastomosed second intercostal artery second perforator time inferior epigastric vein anastomosed concomitant vein therefore ramf double blood supply anastomotic artery sea the iea anastomosis selected according following indication ipsilateral bilateral harvested previously contralateral ligated previous cabg wound almost encompassed full length sternum operation nine patients extensive thoracic defects treated plastic surgery team study period overall preoperative status six patients asa grade 3 3 patients asa grade 4 table 1 of 8 patients received cabg 7 patients harvested 1 2 internal mammary arteries 1 patient aorto coronary arterial saphenous vein bypass grafting table 1 the mean operation time 176 minutes range 155228 minutes including vascular anastomosis debridement there recurrent infection thoracic defects covered ramf combined antibiotic therapy one patient double blood supply flap suffered distal part necrosis flap 7 days later taken back operation room then distal 10% flap debrided reconstructed split skin graft the patient seroma abdomen donor site managed conservatively the mean overall hospitalization time 32 days range 2356 days referral plastic surgery department the mean follow time 6 months range 312 months the schematic diagram double blood supply ramf coverage entire sternum shown fig a 60-year old man received coronary artery bypass grafting bilateral internal mammary artery harvested after operation deep sternal wound infection occurred 2 debridements performed cardiac surgeons large defect area 25 cm10 cm patient recommended department defect reconstruction achieved rectus abdominis myocutaneous flap combined inferior epigastric artery anastomosed second intercostal artery perforator ( large sternal defect 2 debridements cardiac surgeon b ) mediastinal organs exposed radical surgical debridement c defect reconstruction double blood supply rectus abdominis myocutaneous flap inferior epigastric artery anastomosed second intercostal artery perforator ( 6-month follow wound infection found patient satisfied state the schematic diagram shows double blood supply rectus abdominis myocutaneous flap coverage entire sternum ( red arrow indicates inferior epigastric vessels left inferior axis rectus abdominis myocutaneous flap ( b rectus abdominis myocutaneous flap rotated 180 sternal defects inferior epigastric artery red arrow anastomosed second intercostal artery time inferior epigastric vein anastomosed concomitant vein treatment dswi improved significantly past half century 1960s the infected sternal wound managed local debridement closed catheter antibiotic irrigation led mortality rate 20% 1976 the greater omentum first reported cover extensive thoracic defects extensive bone cartilage debridement later various muscle myocutaneous flaps became primary treatment reconstruction sternal defects 1990s vacuum assisted closure dressings occurred readily viewed adjunct facilitate sternal wound healing even sole method definitive treatment specific cases today repairing wound well vascularized muscle myocutaneous flap early radical surgical debridement becomes effective method in study used ramf repair extensive thoracic defects containing almost entire sternum especially patients whose ipsilateral bilateral divided reasons cabg the rectus abdominis received dual dominant blood supply superior inferior epigastric arteries consisted complex perfusion pattern the sea continuation iea comes external iliac artery superior epigastric vessels sole blood supply rectus abdominis without overlying skin raised local flap repair sternal wound manubrium sterni xiphoid the common complication distal part necrosis flap distal flap receive enough blood supply pedicle however complication occur iea anastomosed second intercostal artery second perforator case series several studies reported prior harvesting ipsilateral bilateral may preclude use ramf indeed speculate collateral circulation strengthened anterior intercostal arteries ligated previously furthermore divides distally behind sixth seventh interspace sea musculophrenic artery if ligated distal bifurcation point musculophrenic artery provide rich supply collateral circulation sea based this previous studies reported rectus abdominis muscle myocutaneous flap used successfully median sternotomy wounds ipsilateral ligation however flap limited repair lower half small sternal wound requires pectoralis major muscle flap superior part wound study entire sternal wound repaired successfully took advantage iea provide additional blood supply ramf there also alternative methods reconstruct extensive thoracic defects comprise almost entire sternum significant skin defect radical surgical debridement for example pectoralis major muscle advancement upper sternum rectus abdominis muscle turn coverage lower sternum another choice entire sternal wound reconstruction however rarely consider combined use 2 local flaps study single local flap sufficient repair defect the greater omentum flap also useful reconstructive option contains rich vascular supply large amount available soft tissues reach entire sternal defects fill irregular defects sufficiently the emergence laparoscopic omental harvest gained great attention omental flap use extensive thoracic defects dswi in addition several previous literatures suggested use omentum may associated lower mortality fewer complications compared pectoralis muscle flap moreover omentum may available patients intra abdominal adhesion previous surgery lastly secondary split thickness skin graft necessary compared ramf more recently free myocutaneous flap described sternal wound closure viewed new choice repair extensive thoracic defects dswi case the complication rate 22% 2/9 comparable found previous studies 25% 30% the tip necrosis major complication associated ramf reported lot literatures but this complication occur patients whose iea anastomosed second intercostal artery perforator furthermore even ipsilateral bilateral harvested particular ramf also enough blood supply heals well despite satisfactory results patients healed recurrent infection first small number patients included study enough data analysis make stronger conclusion in fact small number eligible patients largely due rare prevalence extensive thoracic defects dswi in addition bilateral 1-sided iea harvested may decrease abdominal wall perfusion increase risk abdominal wall herniation conclusion study suggests ramf may suitable repair large sternal wound entire sternum when one internal mammary arteries ligated cabg reasons iea anastomosed second intercostal artery perforator provide flap double blood supply	abstractdeep sternal wound infection is a severe complication after open heart surgery . according to the different severity and dimensions of the deep sternal wound infection , the treatment method is different . in this study , we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management , especially when 1 or 2 internal mammary arteries were absent.between october 2010 and january 2016 , a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted . all of these sternal defects encompassed almost the full length of the sternum after debridement . defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap . when the ipsilateral or bilateral internal mammary artery had been harvested previously , we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap . thus , this flap had a double blood supply.there was no recurrent infection in all 9 patients . three patients received the rectus abdominis myocutaneous flap with a double blood supply . flap complications occurred in 2 patients ( 22% ) . one patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap , which was then debrided and reconstructed with a split - skin graft . the other patient had a seroma at the abdomen donor site and was managed conservatively . none of the patients died during the hospital stay.this study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound . when 1 or 2 internal mammary arteries have been harvested , the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply .
exponential growth available sequence data development accurate computational strategies functional site identification become one important post genomic challenges 1 although attractive owing relative simplicity conservation based approaches frequently result many false positives satisfactory in addition sequence regions significant variability also critical function especially composition may define subfamily specificity frequently regions correspond residues critical molecular recognition binding specificity report pms sequence alignment regions conserve overall phylogeny complete family comparison structural biochemical data shown pms represent good functional site predictions wide variety protein systems 2 our results indicate despite little overall proximity sequence pms structurally clustered around key functionality across wide variety structural examples pms correspond variety structural features including solvent exposed loops active site clefts buried regions surrounding prosthetic groups figure 1 our results also indicate pms generally conserved sequence indicating pms tend motifs traditional sense consequently pm results bridge evolutionary 35 traditional motif 6,7 approaches spite small alignment window size if sequences unaligned miner align user using clustalw 8) sliding sequence window algorithm used quantitatively evaluate phylogenetic similarity sequence region whole sequence phylogenetic similarity based tree topology calculated using partition metric algorithm 9 overlapping sequence windows scoring past preset phylogenetic similarity z score psz threshold identified pms empirically determined window width 5 10 psz threshold 1.5 2.2 lower scores indicate greater similarity represent ideal default parameters functional site prediction however user retains option handle gaps described previously 2 subsequently partition around medoids clustering similarity scores assesses sequence fragments whose annotation remains doubt the accuracy approach confirmed comparisons manual results 2,10 a preprint thoroughly describing automated algorithm available miner website automated algorithm hand precomputed pms recent version cog database 11 miner available standalone command line based software web via user friendly interface after web based calculation complete miner sends email hyperlink directing user results miner part larger protein motif analysis portal california state polytechnic university pomona 12 however recommend using 25 sequences ensure sufficient evolutionary diversity exception gaps non alphabetic characters found input purged optionally protein data bank pdb structure may submitted better highlight pm regions miner automatically add pdb sequence dataset unaligned sequences exist however user provided alignments must already include pdb sequence part alignment there several default miner options customized submission figure 2 although masking optional find eliminating positions significantly increases quality functional site predictions especially divergent families miner also provides three methods identifying motifs default miner identifies functional sites described alternatively miner also provides option identify traditional motifs using false positive expectation fpe regular expression profile when used conjunction pm results alternative approaches often provide synergistic information in addition width sliding window also modified default the width set five alignment positions find ideal identifying functional sites 2 however large windows appropriate exploiting motif ness e.g. using pms de orfan uncharacterized sequences the z score threshold automatically determined default manually set value 1 finally either jmol default chime viewers used interactive structure visualization the miner output framed html file figure 3 provides phylogenetic similarity versus window number plots ii annotated structure iii annotated msa pm regions pdb structure annotated writing psz temperature factor column furthermore interactive structural visualization identified pms achieved option using either jmol chime each pm within alignment hyperlinked clicking highlight corresponding structural region pm sequence logos generated weblogo 13 also hyperlinked msa cases the raw data available easy export auxiliary programs masking feature enabled regions msa colored light gray represent alignment positions purged pm identification miner website the tutorial guides one output triosephosphate isomerase results center discussion previous reports 2,10 miner utilizes sliding sequence window algorithm systematically evaluate regions msa input phylogenetic similarity determined comparing tree topology calculated using partition metric algorithm consequently resulting psz value the sensitivity pm identification constrained using psz threshold automatically determined default the resulting miner output uses jmol chime pdb viewers allowing protein structure corresponding pm regions interactively visualized the four best scoring psz threshold 1.5 pms identified myoglobin protein family mapped onto structure pdbid 1mba the -carbons pms shown black spheres heme shown gray the sequence window toggle aligned ungapped hyperlinked structure viewer weblogos the upper left window toggle pm red fpe green results cases	miner is web - based software for phylogenetic motif ( pm ) identification . pms are sequence regions ( fragments ) that conserve the overall familial phylogeny . pms have been shown to correspond to a wide variety of catalytic regions , substrate - binding sites and protein interfaces , making them ideal functional site predictions . the miner output provides an intuitive interface for interactive pm sequence analysis and structural visualization . the web implementation of miner is freely available at . source code is available to the academic community on request .
abetalipoproteinemia abl omim 200100 rare hereditary autosomal recessive metabolic disorder fat fat soluble vitamins absorption caused microsomal triglyceride transfer protein mttp omim 157147 deficiency characterized absence plasma apolipoprotein b apo b)-containing lipoproteins mttp chaperone protein found enterocytes hepatocytes endoplasmic reticulum er includes three structural domains n terminal -barrel -helix c terminal three functional domains transfer activity membrane interaction lipid binding the molecular basis disorder inheritance two mutations mttp gene located chromosome 4q23 encodes large subunit mttp 97-kda protein containing 894 amino acids forms heterodimer endoplasmic reticulum enzyme protein disulfide isomerase pdi accelerates transfer lipids onto apolipoprotein b resulting assembly secretion apo b formation vldl chylomicrons liver intestine respectively the syndrome first described bassen kornzweig 1950 according signs absence lipoproteins salt colleagues named disorder abetalipoproteinemia afterwards children usually asymptomatic birth develop digestive symptoms including diarrhea steatorrhea failure thrive infancy subsequently retinopathy ataxic neuropathy acanthocytosis fatty liver may appear childhood due fat soluble vitamin deficiency especially vitamin e beta carotene extremely low levels patients abl herein describe history clinical features patient abl referred hospital followed age five 12-months old male infant referred hospital failure thrive he born consanguineous parents birth weight 3.4 kg failed gain weight appropriately since two months age first visit weight 6 kg height head circumference 61 44 cm respectively he also developmental delay held neck 6 months sat 9 months age he frequent defecations 8 9 times day sometimes steatotic he family history similar problems physical examination widening fontanels observed laboratory tests showed cholesterol=43 mg dl triglycerides=6 mg dl alanine transaminase alt)=17 u l aspartate transaminase ast 60 u l total protein=5 g dl albumin=3.8 g dl stool examination showed fat droplets 40 drop hpf thyroid function test showed tsh=6.5 miu l t4=135 nmol l established diagnosis subclinical hypothyroidism abdominal sonography demonstrated normal size liver spleen multiple small stones kidneys macroscopic findings endoscopy included normal mucosa esophagus stomach snow like appearance pathologic findings found bulb duodenum crypts unremarkable mild infiltration lymphoplasmacells eosinophils 3 16/hpf lamina properia alongside edema figure 1 crypts unremarkable mild infiltration lymphoplasmacells eosinophils 3 16/hpf lamina properia alongside edema it would beneficial perform molecular diagnosis unfortunately parents agree genetic study in presence symptoms probable differential diagnosis included cystic fibrosis cf pediatric celiac disease severe hypocholesterolemia hypotriglyceridemia suggested conditions including abl homozygous familial hypobetalipoproteinemia fhbl dominant transmission mutations apob gene chylomicron retention disease cmrd recessive transmission mutation sar1b gene normal levels tissue transglutaminase antibodies sweet chloride test along microscopic studies ruled celiac disease cf family lipid profile useful delineating conditions obligate heterozygote parents homozygous fhbl patients decreased levels plasma ldl cholesterol apo b asymptomatic parents patient normal plasma cholesterol levels suggested recessive disorder ruled fhbl undetectable amounts plasma apo b low density lipoproteins ruled cmrd confirmed diagnosis abl our patient treated caprilon formula medium chain triglycerides mct oil 1cc kg day vitamin 10000 iu day vitamin e 2000 iu day vitamin 400 iu day vitamin k 5 mg daily levothyroxine 50 100 mcg day kidney stones resolved medical treatment intraventricular brain cyst remained size liver aminotransferases elevated ast 160 alt 250 u l reinforcing accurate fat limited diet resulted normal ranges enzymes levels follow ups last visit he 5 years old weight 18 kg height 105 cm abl rare recessive metabolic disorder characterized absence apob containing lipoproteins plasma malabsorption fat fat soluble vitamins leads variable clinical phenotype presents early childhood steatorrhea failure thrive may include progressive multi system abnormalities patient ages most patients diagnosed 2nd 4th decades others 1st 6th decades earlier presentation symptoms may due severe phenotype may resistant medical treatment resulting poor outcomes hand later presentation longer period untreated disease may associated poor outcomes due consequences fat soluble vitamins deficiency most reported patients abl lipid malabsorption remarkably low serum lipid levels gastrointestinal manifestation including diarrhea steatorrhea oral fat intolerance retinitis pigmentosa myopathy spinocerebellar ataxia also reported patients due fat soluble vitamins deficiency our patient signs symptoms early onset abl including fat intolerance diarrhea steatorrhea growth retardation developmental delay low tg cholesterol levels gastrointestinal manifestations including fat intolerance diarrhea steatorrhea consistent features reported patients brain ct scan showed intraventricular cyst previously reported despite numerous reported neurological involvement abl both central peripheral nervous systems affected may serious clinical manifestation the primary pathology progressive demeylination nervous system related abnormal lipid peroxidation highly unsaturated phospholipid myelin probably due prolonged vitamin e deficiency several studies showed early high dose vitamin e 100 iu kg therapy prior age 2 years prevent progressive neurological dysfunction diminish neurological sequelae pigmentory retinal degeneration progressive often causes slowly enlarging annular scotomas macular sparing patients may reduced night vision color vision early course disease previous studies showed high dose vitamin e therapy combined vitamin e vitamin treatment 2 years age prevent development progression retinopathy the absence retinitis pigmentosa patient must attributed fact retinopathy may appear time first 2 decades life red cell acanthocytosis hematologic manifestation abl reported several cases seen case nephrolithiasis present patient also reported previously patients abl fat malabsorption causes combination unabsorbed fatty acids calcium ions intestinal lumen leading excessive absorption dietary oxalate kidney stone formation management included dietary fat restrictions fat soluble vitamins supplements specific formula polycitrate resolved problem patient our patient subclinical hypothyroidism association abl subclinical hypothyroidism previously reported another case the hepatic manifestation patient elevated levels serum transaminases probably due hepatosteatosis resolved accurate treatment conclusion early diagnosis accurate treatment necessary avoid complications following fat soluble vitamin deficiencies	abetalipoproteinemia ( abl ) is a very rare autosomal recessive disorder caused by mutations in the microsomal triglyceride transfer protein gene ( mttp ) . abl is characterized by lack of lipids and apolipoprotein b ( apob ) in plasma , fat malabsorption and various clinical manifestations . we describe a 12-month - old infant boy , born from consanguineous parents and presented with diarrhea , steatorrhea , growth retardation , hypothyroidism , intraventricular brain cyst and kidney stones . the patient was diagnosed to have abl and treated with dietary modification and oral fat - soluble vitamin replacement and followed until he reached 5 years of age .
pain management transurethral procedures major concern apart standard general anaesthesia nevertheless administered type anaesthesia ultimately based anaesthesiologist decision recently local anesthesia infiltration bladder wall periprostatic nerve blockage reported 13 additionally sedoanalgesia combination local anaesthesia sedation even use virtual reality pain management examined 4 5 the selection anaesthesia transurethral prostatectomy tur p transurethral bladder tumor resection tur b investigated meticulously previous reports 68 general regional local anaesthesia demonstrates distinct advantages disadvantages terms postoperative morbidity 68 the aim present study compare general spinal anaesthesia terms postoperative pain mitigation recording patient pain perception critical first 24 postoperative hours investigate potential correlation clinical pathological data pain induced transurethral procedures distribution patients depicted consort flow diagram figure 1 patient age distribution population according stage grade transitional cell carcinomas tcc summarized table 1 administration 1 2 g kg propofol followed 1 2 mg kg fentanyl along 1 2 mg kg suxamethonium administration 0.5 mg kg atracurium n2o 50% o2 inhaled desflurane mac 1 minimum alveolar concentration spinal anaesthesia administered single shot 2 ml bupicaine 1 ml lidocaine without adrenaline patients bladder prostatic capsule perforation identified intraoperatively excluded study a 22-f 3-way dufour catheter placed patients bladder irrigation standard bladder irrigation stopped completion 24-hour observation period verifying absence intravesical clotting manual irrigation suction postoperative pain severity assessed recorded using 11-point visual analogue scale vas the vas given patient time arrival recovery room considered hour 0 each patient recorded pain tolerance postoperative hours h 0 2 4 8 12 24 no pain scored 0 points worst possible pain patient scored 10 points score 3 observation period 500 mg paracetamol combined 20 mg hyoskine n butylbromide buscopan administered stratification pain scoring made using several parameters age gender stage grade location tcc statistical analysis performed using spss 14.0 windows statistical package spss inc clinical demographical characteristics compared using mann whitney u test continues variables chi square test categorical variables kruskal wallis test used estimate equality population medians among groups mann whitney u test comparison groups spearman correlation coefficient appropriate vas scores 95% confidence interval ci relation postoperative time shown figure 2 no statistical difference detected tur p patients postoperative time two anaesthetic methods tur b patients mean 95% ci analogue vas score greatest 0 h general versus spinal anaesthesia p 0.027 8 h 12 h general anaesthesia analgesic efficacy increased significantly p 0.017 p 0.007 resp adjusting gender tur b group male patients general anaesthesia experienced pain 0 h 2 h mean 95% ci 1 08 versus 0 08 1 06 versus 0 010 respectively p 0.021 p 0.032 however female patients vas score distributed differently since spinal versus general anaesthesia analgesic efficacy lost 4 h median 95% ci 3 04 versus 0 03 8 h 2.5 03 versus 0 02 12 h 2 02 versus 0 0 1 p 0.005 p 0.004 p 0.001 resp suggesting better analgesic efficacy general anaesthesia a separate analysis performed male patients comparing tur p versus tur b no difference vas score recorded two surgical approaches general anaesthesia chosen analgesic method spinal group however tur b patients presented lower mean vas score tur p patients 0 h 0 08 versus 0.5 05 p 0.007 this pattern changed 8 h 2.5 08 versus 0.5 02 p 0.039 12 h 2 08 versus 0 02 p 0.016 interestingly adjusting covariates stage grade tur b patients higher vas score observed pt2 patients compared pta pt1 tnm patients negative pathology report figure 3 table 2 stage tumor grade highly correlated p 0.001 grade present statistical significance vas score postoperative hour resected tumor volume used categorical variable patients divided 10 cm mean volume 3.3 110 n 82 10 cm mean 28.1 1140 n 15 the cut point 10 cm set statistical analysis those resected tumor volume 10 cm presented vas score 2 8h 24 h statistically significant p 0.050 p 0.036 resp figure 4 adjusting method anaesthesia subjects bladder tumors larger 10 cm received general anaesthesia presented vas score <3 4 h 6 95% ci 1.0135.04 p 0.035 however 24 h vas 3 common patients tumor volume 10 cm underwent general anaesthesia 3.5 95% ci 1.0911.02 p 0.008 apart 24 h tumor located lateral bladder walls induced pain situated trigone moreover tumor multifocality highest vas scores observation periods table 3 several papers compare effect methods terms peri- postoperative morbidity blood loss side effects possible complications to knowledge one attempts comparing 2 methods recording patient pain perception tolerance firstly patients undergoing tur p found none 2 methods anaesthesia prevailed 24-hour observation period another report fredman colleagues advocated general anaesthesia method choice transurethral procedures again patient satisfaction recorded main limitation adjustment type transurethral procedure made suggested regional anaesthesia reduces incidence catheter related pain although similar efficacy oral diazepam thus advantageous general anaesthesia on hand differences recorded tur b patients specific spinal efficient general anaesthesia first 2 h surgery general proved better later time points this fact explained major implications induced bladder function regional anesthesia indeed catheter related pain detrusor muscle spasm elicited bladder irrigation managed efficiently regional anaesthesia first 2 postoperative hours however simultaneously causes clinically significant disturbance bladder function due interruption micturition reflex additionally greater effect bladder compliance lowers intraabdominal pressure result painful bladder overdistention or even acute retention might occur removal catheter due long lasting recovery normal bladder function based clinical experience incidence event rather rare thus might implicate catheter bladder spasm distressing causes postoperative pain however interesting analgesic approach could combination spinal anaesthesia antimuscarinic pretreatment oxybutnin tolterodine administration gabapentin general anaesthesia shown significantly reduce catheter related pain 17 18 the urodynamic effects might interpreted better female patients men since women prostatic symptoms could bias bladder pain also acknowledge fact females perceive pain better men recent reports suggest female population study spinal less effective general anaesthesia first 4 hours verifying possible implications regional anaesthesia female bladder a surprising observation exhibited statistical analysis concerning bladder tumor stage patients higher stage experienced higher level pain ones localized disease pta pt1 one speculate infiltrative disease stimulates nociceptors highly specialized free endings sensory nerve fibers even though random result believe worth mentioning since exhibited statistical significance might motivate better anaesthetic approach patients present pt2 disease cystoscopically it obvious verification required analysis large cohort patients also stratified type applied anaesthesia we also found resected bladder tumor volume becomes significant parameter pain induction tur b 10 cm resected on hand adjusted analysis type anaesthesia general anaesthesia seemed efficient 4 h 24 h. tumor volume parameter favoring efficiency general anaesthesia independently postoperative time observation the use vas scale documentation pain measurement introduces study bias per se since subjective method date objective recording pain perception described even though several pain scales assessing patient agitation level recording facial expression leg movement muscle tension even brain electrophysiologic activity specialized electroencephalograms eeg presented promising yet the use vital signs heart rate arterial pressure even pupil reactions could reflect partially pain status could affected also postsurgical stress patient comorbidities prescribed medication nevertheless clinically significant differences vas scores might considered realistic anecdotally exceed 4 5 points thus study clinical significant differences observed different bladder tumor stages multiple versus single tumors the dosage epidural regimens effect approximately one half hours therefore could altered vas scoring since 0 h point set arrival recovery room the selection paracetamol hyoskine n butylbromide rescue analgesics patients reporting vas 3 postoperatively made due immediate action short half lives 22 23 could affected perception pain 2-hour 4-hour intervals vas recording the patients randomized due fact selection analgesia made anaesthesiologists individually patient according performance status another drawback could lack analysis time operation prostatic volume resected even though resected adenoma rationally associated pain induction since major causes tur p pain bladder spasm catheter related pain capsule offense future study could incorporate parameter time operation believe could affected result since scoring started completion operation pain managed sufficiently the analysis advantages disadvantages regional compared general anaesthesia immensely complicated easily imagined secondary effects types anaesthesia varied realistically must considered every patient due unique clinical profiles presented this study attempted establish potency general spinal anaesthesia transurethral procedures recording patient pain perception it seems spinal anaesthesia effective first 2 postoperative hours general prevails later stages larger traumatic surfaces finally incidentally found tumor stage plays significant role postoperative pain point requires verification we advocate closer cooperation urologist anaesthesiologist terms providing specific information patient disease tailoring type anaesthesia patient needs	we compared the analgesic efficacy of spinal and general anaesthesia following transurethral procedures . 97 and 47 patients underwent transurethral bladder tumour resection ( tur - b ) and transurethral prostatectomy ( tur - p ) , respectively . postoperative pain was recorded using an 11-point visual analogue scale ( vas ) . vas score was greatest at discharge from recovery room for general anaesthesia ( p = 0.027 ) . the pattern changed significantly at 8 h and 12 h for general anaesthesia 's efficacy ( p = 0.017 and p = 0.007 , resp . ) . a higher vas score was observed in pt2 patients . patients with resected tumour volume > 10 cm3 exhibited a vas score > 3 at 8 h and 24 h ( p = 0.050 , p = 0.036 , resp . ) . multifocality of bladder tumours induced more pain overall . it seems that spinal anaesthesia is more effective during the first 2 postoperative hours , while general prevails at later stages and at larger traumatic surfaces . finally , we incidentally found that tumour stage plays a significant role in postoperative pain , a point that requires further verification .
18-year old male presented recurrent palpitations associated occasional presyncope preceding 3 months nonsustained episodes narrow qrs tachycardia sinus pauses termination noted electrocardiogram ecg fig holter monitoring showed sustained nonsustained episodes tachycardia cumulative duration 14 h 24-h recording intervening sinus pauses fig 1c lasting 4.5 s. left ventricular ejection fraction 35% presentation electrophysiological study sinus cycle length 734 ms normal atrio hisian ah ventricular hv intervals the termination initiation tachycardia shown fig 2 the ecg fig 1a b show narrow qrs long rp tachycardia negative p waves inferior leads the episodes nonsustained tachycardia initiated sinus beats second qrs complex tachyarrhythmia shows right bundle branch block morphology the morphology axis subsequent p waves p different sinus beats occasionally isolated sinus beat followed single p wave without continuing tachycardia the differential diagnosis long rp tachycardia includes atrial tachycardia originating inferior atrium av nodal reentrant tachycardia avnrt fast slow sub form persistent form junctional reciprocating tachycardia pjrt at p waves initial subsequent beats tend similar unlike observed case the fast slow type avnrt usually initiated following ventricular premature beat incessant nature unusual orthodromic reentrant tachycardia using accessory pathway ap decremental retrograde conduction properties i.e. pjrt initiated sinus beat tachyarrhythmia tends incessant termination either antegrade retrograde limb occur reentrant mechanisms terminate p wave unusual 2 helps confirm pjrt mechanism case initial 2 cycles tachycardia fig 1 bracketing proximal coronary sinus cs bipole cs 7 8 the tachycardia terminates following paced beat right ventricular apex timed 30 ms later signal the morphology paced complex suggests qrs fusion paced tachycardia beat termination following paced ventricular beat conducted atrium resulting qrs fusion suggests orthodromic av reentry tachycardia mechanism the prolonged local ventriculoatrial va interval 210 ms even site earliest retrograde atrial activation tachycardia suggests slow conduction ap immediately following termination next sinus notably first local v v interval cs 7 8 initiation 370 ms compared 360 ms stable phase the increment 10 ms contributed delay ah interval 60 ms 40100 ms despite shortening conduction time across ap 40 ms 210170 ms despite delay conduction bundle anterograde impulse finds right bundle refractoriness conducts left bundle hv interval similar tachycardia beats this functional block mitigation subsequent beats follows recovery period bundle branch directly related previous rr interval the conduction times pathway measured local va interval cs 7 8 bipole showed progressive prolongation 170 190 210 ms response shortening preceding local v the progressive reduction time interval retrograde impulses ventricular end ap initiation related conduction delay av node second beat unmasked decremental properties ap case similarly decremental nature conduction av node accounted minimal changes av interval initial cycles initiation frequently sinus beats followed single atrial echo beats nonconducted av node fig however echo beat could find av node relative refractory period conduct prolonged ah interval bundle branch aberrancy reentry could initiated following cycles minimal incremental prolongation conduction time ap due decremental nature helped retrograde impulse the tachycardia incessant study could terminated ventricular pacing the ap successfully ablated cs within 1 cm ostium holter monitoring done 3 months study showed pauses tachycardia ventricular function recovered completely suggest tachycardiomyopathy presentation symptomatic sinus pauses termination tachycardia episodes mimicking tachy brady syndrome unusual pjrt suppression sinus node related chronic atrial arrhythmias reverse remodeling weeks months following successful ablation culprit arrhythmia described however complete recovery sinus node function immediately ablation makes mechanism unlikely a compensatory vagotonia response initial hypotension resultant sympathetic activity proposed dominant mechanism spontaneous early termination supraventricular tachyarrhythmias however significant sinus pauses occurred termination tachycardia episodes pacing protocols successful ablation this also would suggest common denominator like vagotonia accounted spontaneous termination tachycardia sinus pauses followed like av node ap mediating pjrt also known vagal sensitive interestingly termination block antegrade limb commonly noted case presumably related higher sensitivity av node vagotonia compared ap	a young male presented with incessant narrow qrs tachycardia and left ventricular dysfunction . 24-holter monitoring revealed multiple episodes of sustained and nonsustained episodes of tachycardia with prolonged sinus pauses at termination . the analysis of the electrocardiogram , followed by an invasive electrophysiological study , suggested an unusual mechanism for this tachy - brady syndrome .
trying integrate multiple data sets collected different researchers noticed sample names frequently entered inconsistently most variations appeared involve punctuation white space absence juncture alphabetic numeric portions cell line name reasoning variant names could described terms mutations deletions character strings implemented simple version needleman wunsch global sequence alignment algorithm applied cell line names incorrect matches occured cell line present one data set a simple application needleman wunsch global sequence alignment algorithm provides useful first pass matching sample names different data sets	background : while trying to integrate multiple data sets collected by different researchers , we noticed that the sample names were frequently entered inconsistently . most of the variations appeared to involve punctuation , white space , or their absence , at the juncture between alphabetic and numeric portions of the cell line name.results:reasoning that the variant names could be described in terms of mutations or deletions of character strings , we implemented a simple version of the needleman - wunsch global sequence alignment algorithm and applied it to the cell line names . all correct matches were found by this procedure . incorrect matches only occured when a cell line was present in one data set but not in the other . the raw match scores tended to be substantially worse for the incorrect matches.conclusions:a simple application of the needleman - wunsch global sequence alignment algorithm provides a useful first pass at matching sample names from different data sets .
angle class iii malocclusion raised controversies among researchers concerning diagnosis prognosis treatment it affects 5% brazilian population greater incidence people asian origin terms etiology problem either genetic origin unfavorable prognosis environmental origin caused anterior inferior tongue positioning habits oral breathing class iii malocclusion classified dentoalveolar skeletal functional determine diagnosis prognosis ideally diagnosis malocclusion made early possible still deciduous dentition early recognition discrepancy depends careful observation sequence facial occlusal cephalometric characteristics it known class iii malocclusion exacerbates growth mainly starting adolescence therefore children malocclusion totally defined yet established facial occlusal features complicate diagnosis the earlier interceptive phase initiated greater orthopedic effects detriment unavoidable orthodontic effects moreover early benefit terms esthetics child implies improved self esteem considering psychological factor among approaches treating class iii malocclusion is use orthopedic appliances chincups facial masks functional orthopedic appliances jaws preventive orthodontic appliances e.g. eschler arch porter appliance w arch multibracket fixed appliances combined orthodontic orthognatic surgery protocol the correct indication orthodontic therapy chincup depends precise diagnosis class iii malocclusion it advisable initiate treatment early age using upward backward force 350 g 500 g. cephalometric study performed graber 1977 showed use chincup promoted backward movement point b due clockwise rotation mandible the length mandible also decreased 1 mm due pressure transmitted chincup condyle generated hand delay vertical growth another study ( 1984 evaluated skeletal changes produced chincup therapy the authors concluded chincup therapy would useful efficient method correcting class iii mandibular prognathism ( 1990 verified early treatment chincup produced positive orthopedic effects mandible however assure improvement skeletal profile another possibility early interception class iii treatment consists orthopedic orthodontic appliance called eschler arch this appliance modified labial bow gently touch lower incisor labial surface acrylic occlusal bite raising appliance affords normal growth maxilla helps correction negative overjet should necessary correct upper incisor inclination finger springs used protrusion considering aforementioned therapeutic possibilities aim study describe discuss treatment patient angle class iii malocclusion treated according two stage approach interceptive corrective long term follow period a 9-year old female patient mixed dentition stage second transitional period referred treatment chief complaint anterior crossbite clinical interview facial evaluation showed lack development middle third apparently normal feature asians intraoral examination revealed forward shift mandible marked mesial molar relationship crossbite four permanent incisors thus characterizing functional class iii malocclusion figure 1 pretreatment extraoral b intraoral c g photographs initial panoramic x ray h lateral cephalogram parents signed informed consent authorizing publication pictures panoramic radiograph revealed presence permanent teeth either erupted several developing stages careful evaluation lateral cephalograms confirmed class iii malocclusion acute nasolabial angle horizontal growth pattern following confirmation class iii malocclusion cephalometric analysis clinical differential diagnosis accomplished verifying occlusion pattern either intercuspal position ip centric relation cr patient showed crossbite maximal habitual intercuspation forward shift mandible cr retroposition mandible edge edge contact upper lower incisors this clinical condition confirmed functional class iii malocclusion greatly favors orthodontic treatment figure 2 frontal intraoral view showing edge edge contact incisors centric relation b patient mixed dentition stage great potential growth main goal treatment correct anterior crossbite also correcting functional forward deviation mandible allowing maxilla forward position relation mandible thus affording normal development the proposed treatment protocol comprised two stages interceptive corrective phases first phase a chincup used night maintain mandibular retrusion eschler appliance also known progenic appliance used day the eschler appliance composed retention clasps e.g. adams clasps molars intermolar auxiliary clasps deciduous teeth premolars b eschler labial bow made 0.9-mm wire adapted labial surface lower incisors c occlusal bite raising appliance acrylic resin thickness 2 3 mm necessary springs expansor screw added figure 3 extraoral intraoral b photographs parents signed informed consent authorizing publication picture chincup activated 1/2 inch elastics changed either weekly whenever necessary produced force 350 g 500 g side directed angle 45 relation occlusal plane activation eschler bow performed closing loop sufficiently make bow touch labial surface lower incisors without overpressure since 0.9-mm wire exerts intensified force due diameter this appliance intended produce orthopedic forward movement maxilla orthodontic lingual movement lower incisors correcting crossbite this accomplished order allow eruption premolars eliminate free space caused occlusal opening avoid tongue interposition possible posterior open bite follow appointments scheduled complete correction anterior crossbite totalizing treatment period 14 months when appliances removed patient seen every six months complete development permanent dentition characterizing thus end interceptive phase phase a marked improvement facial harmony occlusion observed figure 4 end interceptive phase extraoral b intraoral c e photographs end interceptive phase panoramic x ray f lateral cephalogram g parents signed informed consent authorizing publication pictures lateral cephalograms figure 4 end interceptive phase showed successful results early treatment eschler appliance associated chincup a panoramic radiograph showed end mixed dentition good root parallelism presence third molars figure 4 development occlusion patient concerned gradual increase diastema central incisors however this condition expected since growing mandible caused proclination incisors thereby increasing arch length figure 5 two year follow interceptive phase extraoral intraoral b photographs presenting diastema upper central incisors lateral cephalogram c panoramic x ray parents signed informed consent authorizing publication picture approximately 2 years interceptive phase due patient dissatisfaction diastema second phase protocol initiated installation fixed appliance figure 6 the corrective phase aimed close diastema perform small corrections i.e. axial inclinations lasted 14 months results shown figure 7 intraoral photographs showing fixed appliances c end corrective phase extraoral b intraoral c e photographs panoramic x ray f lateral cephalogram g parents signed informed consent authorizing publication pictures ten years corrective treatment new follow appointment verified stability treatment final result seen figure 8 follow 10 years treatment extraoral b intraoral c g photographs panoramic x ray h lateral cephalogram patient signed informed consent authorizing publication pictures superposition initial final follow cephalometric tracings interceptive phase superposition initial final follow cephalometric tracings corrective phase b ) in case class iii intercepted fixed appliance installed correct small rotations anterior diastema improve axial teeth relationships cephalometric analysis table 1 verified sna angle continued increase snb angle co gn unaltered interceptive phase the measurements representing vertical position mandible fma sn.gogn stable the changes linear angular measurements upper lower incisors contributed obtain positive overjet 9 12 years age proclination upper incisors 20 25 retroclination lower incisors 30 22 observed initial final post interceptive control cephalometric values corrective orthodontic treatment initiated 2 years finalization interceptive phase table 1 shows cephalometric values initial final 10-year post corrective follow it observed anb angle remained positive due stability sna snb angles well fma sn.gogn conversely co gn showed increase 13 mm end interceptive phase 10-year follow corrective phase showing value similar normal mandibular growth the measurements related incisor inclinations remained stable 10-year follow contributing maintenance positive overjet the cephalometric analysis case study demonstrated increase anb angle mandible growth mandibular plane stability the anb altered favorable value relationship jaws due treatment the linear angular measurement changes upper lower incisors helped obtain positive overjet ( 1984 longitudinal study skeletal class iii patients radiographically evaluated skeletal changes chincup therapy these authors demonstrated favorable outcomes obtained limited corrective phase returned initial features post treatment period this demonstrates prognosis cases great skeletal involvement would favorable unlike cases described report according previous studies proportional values co co gn this case initially demonstrated co measurement 80 mm 83 mm suggesting maxillary deficiency however last follow appointment measurement 88.5 mm considered appropriate co gn 114.5 mm this study demonstrated achievement optimal results stability correction functional class iii malocclusion treated progenic appliance associated chincup followed corrective orthodontics spite good outcomes achieved case long term clinical investigations necessary assure stability class iii treatment this case report shows stability correction functional class iii malocclusion minor skeletal involvement related correct diagnosis early intervention this treatment allowed proper facial growth development preventing worsening malocclusion severe consequences	angle class iii malocclusion has been a challenge for researchers concerning diagnosis , prognosis and treatment . it has a prevalence of 5% in the brazilian population , and may have a genetic or environmental etiology . this malocclusion can be classified as dentoalveolar , skeletal or functional , which will determine the prognosis . considering these topics , the aim of this study was to describe and discuss a clinical case with functional class iii malocclusion treated by a two - stage approach ( interceptive and corrective ) , with a long - term follow - up . in this case , the patient was treated with a chincup and an eschler arch , used simultaneously during 14 months , followed by corrective orthodontics . it should be noticed that , in this case , initial diagnosis at the centric relation allowed visualizing the anterior teeth in an edge - to - edge relationship , thereby favoring the prognosis . after completion of the treatment , the patient was followed for a 10-year period , and stability was observed . the clinical treatment results showed that it is possible to achieve favorable outcomes with early management in functional class iii malocclusion patients .
reviewing detailed approach titles abstracts articles eliminating duplicates 40 relevant articles considered these articles found pubmed science direct scopus google scholar first reported tugse case till date evaluated randomized studies review articles case reports abstracts included conference papers posters excluded on reviewing detailed approach titles abstracts articles eliminating duplicates 40 relevant articles considered these articles found pubmed science direct scopus google scholar first reported tugse case till date evaluated randomized studies review articles case reports abstracts included conference papers posters excluded the pathogenesis tugse still remains controversial among etiological factors mucosal trauma external internal physical chemical thermal electrical appears major instigating factor lesion clinical histological presentation ulcerated lesion massive immune response the inflammatory infiltrate tugse exhibits sheets atypical mononuclear cells predominantly cell lymphocyte population eosinophils macrophages histiocytes plasma cells earlier studies immunohistochemistry revealed atypical mononuclear cells belonging macrophage myofibroblast lineage more recent studies point toward lymphocytic function cells immunohistochemically positivity cell specific antigens of late tugse agreed upon reactive lesion dominated predominant clonal cell population the exact role inflammatory cells produce exaggerated inflammatory response mimicking malignancy still unknown correlating various studies this appears similar hypersensitivity type reaction predominant cell infiltration exhibiting delayed type cell mediated immunity traumatic ulcerative granuloma stromal eosinophilia evoked cases traumatic antigen wherein existing macrophages histiocytes act antigen presenting cells various antigens include toxins viral microorganisms endogeneous degradation products foreign proteins release cytokines the predominant cells eosinophils lymphocytes recruited submucosal tissue however previous studies suggest exact presence eosinophils remains controversial traumatic ulcers devoid eosinophilic infiltration contrary certain authors concluded increased prevalence histiocytes eosinophils lymphocytes suggesting aggressiveness tugse this process cyclic reaction continues increase proliferating cells release cytokines toxic products degranulating eosinophils the accumulation inflammatory cells along varied spectrum cytokines results tissue damage in addition studies also depict response resulting exaggerated mast cell eosinophil reaction may arise similar noticed pathogenesis type 1 hypersensitivity reaction degranulating mast cells releases several mediators like eosinophil chemotactic factor aryl sulfates arid histamines major basic proteins eventually causing tissue destruction what interesting researchers uniqueness tugse slow self healing ulcer atypical mononuclear cells massive eosinophilia eosinophils appear reactive tissue response unknown antigen entering via mucosal trauma the delayed healing process may attributed decreased synthesis transforming growth factor released eosinophils inflammatory infiltrate tugse compared eosinophils traumatic ulcers furthermore eosinophils produces spectrum cytokines like tumor necrosis factor induces tissue damage the pathogenesis tugse still remains controversial among etiological factors mucosal trauma external internal physical chemical thermal electrical appears major instigating factor lesion clinical histological presentation ulcerated lesion massive immune response the inflammatory infiltrate tugse exhibits sheets atypical mononuclear cells predominantly cell lymphocyte population eosinophils macrophages histiocytes plasma cells earlier studies immunohistochemistry revealed atypical mononuclear cells belonging macrophage myofibroblast lineage more recent studies point toward lymphocytic function cells immunohistochemically positivity cell specific antigens of late tugse agreed upon reactive lesion dominated predominant clonal cell population the exact role inflammatory cells produce exaggerated inflammatory response mimicking malignancy still unknown correlating various studies this appears similar hypersensitivity type reaction predominant cell infiltration exhibiting delayed type cell mediated immunity traumatic ulcerative granuloma stromal eosinophilia evoked cases traumatic antigen wherein existing macrophages histiocytes act antigen presenting cells various antigens include toxins viral microorganisms endogeneous degradation products foreign proteins release cytokines the predominant cells eosinophils lymphocytes recruited submucosal tissue however previous studies suggest exact presence eosinophils remains controversial traumatic ulcers devoid eosinophilic infiltration contrary certain authors concluded increased prevalence histiocytes eosinophils lymphocytes suggesting aggressiveness tugse this process cyclic reaction continues increase proliferating cells release cytokines toxic products degranulating eosinophils the accumulation inflammatory cells along varied spectrum cytokines results tissue damage in addition studies also depict response resulting exaggerated mast cell eosinophil reaction may arise similar noticed pathogenesis type 1 hypersensitivity reaction degranulating mast cells releases several mediators like eosinophil chemotactic factor aryl sulfates arid histamines major basic proteins eventually causing tissue destruction what interesting researchers uniqueness tugse slow self healing ulcer atypical mononuclear cells massive eosinophilia eosinophils appear reactive tissue response unknown antigen entering via mucosal trauma the delayed healing process may attributed decreased synthesis transforming growth factor released eosinophils inflammatory infiltrate tugse compared eosinophils traumatic ulcers furthermore eosinophils produces spectrum cytokines like tumor necrosis factor induces tissue damage traumatic ulcerative granuloma stromal eosinophilia presents chronic slow progressive lesion commonly fourth sixth decade predominantly tugse appears common males females 1.6:1 may exist 1-week several weeks it appears red lesion oral mucosa rolled elevated indurated margins central areas fibrinopurulent membrane mimicking squamous cell carcinoma even though tongue common site regions like buccal mucosa vestibular mucosa gingiva lip mucobuccal fold retromolar area palate also may exhibit tugse histopathologically tugse exhibits ulceration diffuse polymorphic inflammatory infiltrate exhibiting epitheliotropism extending superficial epithelium deep connective tissue this dense chronic inflammatory infiltrate includes small round lymphocytes large atypical mononuclear cells granular macrophages b lymphocytes massive eosinophils plasma cells histiocytes superficial layer deep muscle layers proliferating endothelial cells blood vessels focal areas necrosis seen scattered throughout lesion however presence massive eosinophilia mandatory lesion a tugse lesion often seen infants riga fede disease occurs within 1-week 1-year mucosal lesions often caused repetitive traumatic damage due backward forward motions tongue erupting lower incisors natal neonatal teeth rarely lesion also termed atypical histiocytic granuloma studies shown diffuse scattered atypical large mononuclear cells large cells irregular nuclear contours fine chromatin small nucleoli abundant cytoplasm background diffuse inflammatory cell infiltrate immunohistochemically mononuclear cells show cd30 cd3 cell intracytoplasmic antigen 1 cell lineage markers positivity cells positive cd68 macrophages histiocytic origin 1050% cells show ki-67 high degree production literature also previously stated mononuclear cells show factor xiii positivity suggestive dendritic cells vimentin positive suggestive myofibroblasts regarding existence predominantly cd30 remains unresolved is whether lesion tugse benign oral counterpart cd30 lymphoproliferative disease lpd reactive benign primary lesion histological simulator cd30 lpd immunohistochemical studies slightly favor tugse benign oral counterpart primary cutaneous cd30 lpds confusion however persists cd30 expressed b lymphocytes malignancies also many lymphoproliferative disorders the polymerase chain reaction cell receptor gene gamma monoclonality suggested definitive diagnosis differential diagnosis includes primary sypilitic chancre cd30 lpd malignant lymphoma angiolymphoid hyperplasia eosinophilia langerhans cell histiocytosis pseudolymphoma metastatic tumors kimura disease salivary gland tumors lymphomatoid papulosis mere presence eosinophils differentiate insects parasites granuloma faciale allergic reactions angiolymphoid hyperplasia eosinophilic lymphoid granuloma eosinophilic fascitis eosinophilic granuloma histiocytosis x. traumatic ulcerative granuloma stromal eosinophilia lesions treated antibiotics like penicillin removal traumatic agents followed excision still persistent appropriate management offending tooth suggested case riga fede disease other modes treatment include 0.1% triamcinolone acetonide mouthwash oral antibiotics steroids topical systemic electrocoagulation irradiation liquid nitrogen due aggressiveness lesion though cases show retarded healing phase majority show rapid healing following surgery prognosis tugse normally favorable yet long term follow least 2 years mandatory this condition likely represents group related disorders overlapping clinical histopathologic features we clinicians must adequate knowledge regarding tugse pathogenesis perform biopsy histological analysis along background immunohistochemistry techniques rule neoplastic lesions early stage	oral ulcers are a common symptom in clinical practice . among various causative factors , different types of ulcers in oral cavity exist . among this , traumatic ulcerative granuloma with stromal eosinophilia ( tugse ) appears to be quite neglected by the clinicians due to the limited knowledge and awareness . on reviewing with a detailed approach to titles and abstracts of articles eliminating duplicates , 40 relevant articles were considered . randomized studies , review articles , case reports and abstracts were included while conference papers and posters were excluded . of importance , tugse cases been reported only to a minimal extent in the literature . lack of its awareness tends to lead clinicians to a misconception of cancer . thus , this particular lesion needs to be differentiated from other malignant lesions to provide a proper mode of treatment . the present article reviews various aspects of the tugse with emphasis on the clinical manifestation , pathogenesis , histological , and immunohistochemical study . this study provides the clinician contemporaries , a humble expansion to their knowledge of the disease , based on the searched literature , enabling a more comprehensive management of this rare occurrence .
vasospastic disorder vd relatively common disorder worldwide population prevalence 3.3% 22% episodic cyanosis swelling pallor distal part extremities cold exposure main characteristic features disorder this disorder female dominancy especially seen 2 3 decades life if pathogenesis depends underlying disorder called secondary obstructive form remaining form without underlying disorders called primary form since first description disorder several etiologic factors reported responsible pathogenesis still well known every possible etiologic factor still controversial addition objective quantitative diagnostic tool objective follow method defined study aimed answer question doppler ultrasonography used objective follow patients vasospastic disorder this retrospective study approved local ethics committee gulhane military academy medicine we aimed describe quantitative method follow patients vasospastic disorder april 2011 october 2013 data collected files 46 patients diagnosis vasospastic disorder lasting 2 years the diagnostic criteria defined wigley et al used diagnostic criteria enrolled patients several etiologic disorders systemic sclerosis sle cause secondary vasospastic disorder excluded detailed physical examination several laboratory findings demographic data additional risk factors patients recorded department cold stimulation test cst routinely performed patients vasospastic disorders symptomatology due national military regulations according protocol application cst follows 1 hand temperatures patients measured probe inserted pulp first second distal phalanges time radial arterial blood flow rate measured level wrist doppler usg detailed the affected hand immersed iced water 4c 20 seconds 3 drying hands temperature blood flow rate radial artery are measured 5 10 15 20 minutes technique detailed the test performed resting room temperature approximately 26c least 30 minutes patients classified according smoking habits standardized protocol timing refraining tobacco prior testing used in addition cst routinely use scale verbal complaint severity scale vcss used department evaluating progress follow period scale physician asks patients symptoms determining progress the scale detailed table 1 simultaneously cst patients radial arterial blood flow rate measured level wrist measurement radial arterial blood flow velocity calculated level wrist color doppler ultrasonography figure 1 logiq book xp scanner ge medical systems usa used doppler usg device clinic this combination includes pentoxifylline 1200 mg bid 2600 mg vasodilator molecule nifedipine 60 mg bid 230 mg calcium channel blocker acetylsalicylic acid 300 mg 1300 mg antiplatelet agent after 2 months evaluate patients observe progress second evaluation patients respond treatment referred interventional treatment methods allowed continue military duties demographic data co morbid disorders vcss blood flow rates included patients pre treatment post treatment period recorded spss mac 20.0 package program spss inc chicago il used statistical evaluation descriptive results expressed mean standard deviation normally distributed continuous variables median values abnormally distributed continuous variables comparisons parametric values performed student test normally distributed groups mann whitney u test wilcoxon signed ranks test abnormally distributed groups pearson chi square test fisher exact test mcnemar bowker test used comparisons categorical variables p value 0.05 considered statistically significant 95% confidence interval between april 2011 october 2013 data collected files 46 patients diagnosis vasospastic disorder lasting 2 years the diagnostic criteria defined wigley et al used diagnostic criteria enrolled patients several etiologic disorders systemic sclerosis sle cause secondary vasospastic disorder excluded detailed physical examination several laboratory findings in department cold stimulation test cst routinely performed patients vasospastic disorders symptomatology due national military regulations hand temperatures patients measured probe inserted pulp first second distal phalanges time radial arterial blood flow rate measured level wrist doppler usg detailed the affected hand immersed iced water 4c 20 seconds 3 drying hands temperature blood flow rate radial artery are measured 5 10 15 20 minutes technique detailed the test performed resting room temperature approximately 26c least 30 minutes patients classified according smoking habits standardized protocol timing refraining tobacco prior testing used in addition cst routinely use scale verbal complaint severity scale vcss used department evaluating progress follow period scale physician asks patients symptoms determining progress simultaneously cst patients radial arterial blood flow rate measured level wrist measurement radial arterial blood flow velocity calculated level wrist color doppler ultrasonography figure 1 logiq book xp scanner ge medical systems usa used doppler usg device in clinic routinely use combination therapy vasospastic disorders 2-month period this combination includes pentoxifylline 1200 mg bid 2600 mg vasodilator molecule nifedipine 60 mg bid 230 mg calcium channel blocker acetylsalicylic acid 300 mg 1300 mg antiplatelet agent after 2 months evaluate patients observe progress second evaluation patients respond treatment referred interventional treatment methods allowed continue military duties demographic data co morbid disorders vcss blood flow rates included patients pre treatment post treatment period recorded spss mac 20.0 package program spss inc chicago il used statistical evaluation descriptive results expressed mean standard deviation normally distributed continuous variables median values abnormally distributed continuous variables comparisons parametric values performed student test normally distributed groups mann whitney u test wilcoxon signed ranks test abnormally distributed groups pearson chi square test fisher exact test mcnemar bowker test used comparisons categorical variables p value 0.05 considered statistically significant 95% confidence interval in turkey military service mandatory every male aged 20 years therefore study population young males 32 patients 69.5% smokers 14 32 patients smokers 10 years none patients co morbid disorders hypertension diabetes mellitus the common complaints cyanosis 34 patients 73.9% numbness 30 patients 65.2% hyperhidrosis 29 patients 63% there significant decrease arterial blood flow cold exposure pre treatment post treatment measurements rewarming period flow rate reach basal values test time 20 minutes pre treatment measurements reached basal value approximately 10 minute post treatment measurements the changes arterial blood flow rates cst given figure 2 there statistically significant differences pre treatment post treatment arterial blood flow rates measurement time points p<0.001 except initial measurement p>0.05 post treatment values 10.040.78 cm increase 5 minute 6.251.39 cm 10 minute 6.432.13 cm 15 minute 6.381.86 cm 20 minute measurements all increases 5 time points statistically meaningful compared pre treatment corresponding time points p<0.001 in turkey military service mandatory every male aged 20 years therefore study population young males 32 patients 69.5% smokers 14 32 patients smokers 10 years none patients co morbid disorders hypertension diabetes mellitus the common complaints cyanosis 34 patients 73.9% numbness 30 patients 65.2% hyperhidrosis 29 patients 63% patients categorized 3 groups according vcss statistically significant differences patient vcss distribution there significant decrease arterial blood flow cold exposure pre treatment post treatment measurements rewarming period flow rate reach basal values test time 20 minutes pre treatment measurements reached basal value approximately 10 minute post treatment measurements the changes arterial blood flow rates cst given figure 2 there statistically significant differences pre treatment post treatment arterial blood flow rates measurement time points p<0.001 except initial measurement p>0.05 post treatment values 10.040.78 cm increase 5 minute 6.251.39 cm 10 minute 6.432.13 cm 15 minute 6.381.86 cm 20 minute measurements all increases 5 time points statistically meaningful compared pre treatment corresponding time points p<0.001 several diagnostic methods invasive non invasive techniques defined diagnosis vasospastic disorders time however definitive diagnostic tool objective quantitative follow method defined the main cause failure complexity etiopathogenesis still unclear most patients usually complain many subjective symptoms cyanosis numbness painful attacks often aggravated cold exposure therefore objective diagnosis primary vasospastic disorders often possible address diagnostic problem several tools e.g. triphasic color changes hands finger systolic blood pressure finger brachial index plethysmography capillaroscopy rarely invasive techniques used history treating disorder unfortunately diagnostic tools require special conditions special technicians devices sometimes laboratory conditions used outpatient conditions it also hard use techniques follow even could used diagnosis however evaluating patient progress objective quantitative easily performed tests necessary cst application method still standardized worldwide studies method literature we used clinical protocol detailed approximately 3 years used 5c water cold stimulation study declared temperature better provoking vasospasm water 10c therefore routinely used 4c ice water provoking vasospasm present study literature there studies cold stimulation effect ultrasonographic arterial blood flow rates most studies focused differential diagnosis primary form vs. secondary form using doppler ultrasonography 911 there studies usefulness marker treatment efficacy follow period we consider present study first area analyzed ultrasonographic parameters study observed different patterns blood flow rates pre treatment measurements flow rates able reach basal value throughout test suggests vasospasm lasts longer in contrast post treatment tests flow rates increased quickly baseline values approximately 10 minutes in addition different pre treatment test flow rates baseline values 15 minute measurements suggests vasospasm lasts less 15 minutes department use verbal complaint severity scale vcss classification disease severity study population despite given treatment modality statistically significant changes patient vcss when analyzed 3 patients compared cst results independent study group found statistically significant differences ultrasonographic flow rates treatment p>0.05 this regard ultrasonographic flow rate measurements added cst study seem helpful follow patients vd quantitatively objectively doppler flowmetry added standard cold stimulation test evaluating patients vasospastic disorders provides better objective results compared patient oriented subjective scoring systems this study performed military hospital therefore patients male the smoking time smoking cessation time correlation smoking habits study protocol detailed study the significant cut value ultrasonographic blood flow rate changes positive negative well known defined study define clear cut values parameter this study performed military hospital therefore patients male the smoking time smoking cessation time correlation smoking habits study protocol detailed study the significant cut value ultrasonographic blood flow rate changes positive negative well known defined study define clear cut values parameter	backgroundassessing therapeutic efficacy and patient satisfaction objectively and quantitatively has always been a problem in patients with vasospastic disorders . we aimed to present the additive value of ultrasonographic assessment of peripheral arteries secondary to cold stimulation , as a test for treatment efficacy during follow-up.material/methodsarterial blood flow rates were measured from radial artery with doppler usg in patients who presented to our department with vasospastic disorders . ultrasonography was performed at the following intervals ; before cold stimulation and at 5th , 10th , 15th , 20th minutes of cold stimulation . patients were controlled by repeat cold stimulation test and doppler us at the 2nd month of the treatment . results were analyzed with spss for mac 20.0 package program.resultswe enrolled 46 patients in the study . all patients were male and mean age was 22.32.17 years . most common symptoms were cyanosis and coldness . there were statistically significant differences between pre - treatment and post - treatment arterial blood flow rates at each measurement time point ( p<0.001 ) except initial measurement ( p>0.05 ) . on post - treatment values , there were 10.040.78 cm / s increase in 5th minute , 6.251.39 cm / s in 10th minute , 6.432.13 cm / s in 15th minute , and 6.381.86 cm / s in 20th minute measurements . all increases at the 5 time points were statistically meaningful when compared to their pre - treatment corresponding time points ( p<0.001).conclusionsdoppler flowmetry added to standard cold stimulation test for evaluating the patients with vasospastic disorders provides better and more objective results when compared to the patient - oriented subjective scoring systems .
reported successful management refractory systemic aspergillus infections.5 however reports disparity results vivo vitro effects combining two different groups antifungal drugs.6,7 report experience use combination intravitreal amphotericin b voriconazole management 12 consecutive cases filamentous fungal endophthalmitis this retrospective study 12 consecutive endophthalmitis cases caused filamentous fungi managed center january 2013 august 2013 medical records reviewed accordance guidelines laid declaration helsinki the data collected consisted demographic details affected eye etiology duration symptoms clinical characteristics visual acuity intraocular pressure presentation subsequent follow the collected samples included corneal scrapings vitreous biopsy explanted intraocular lens plated bacterial fungal culture media microbiology records reviewed intraocular samples tested direct microscopy results culture characteristics the details treatment course including time number surgical interventions along type number route duration use antifungals recorded table 1 twelve consecutive cases filamentous fungal endophthalmitis included single center case series details demographic features clinical characteristics microbiology results treatment clinical outcome cases described table 1 the patients presented us median 22 mean 28.4 range 2262 days postoperatively nine post cataract surgery endophthalmitis cases reported onset symptoms within one week surgery however patients originating remote rural area presented delay 2162 days surgery two endophthalmitis cases occurred following open globe injury one following keratitis pterygium excision the presenting complaint sudden onset decrease visual acuity eleven eyes 91.6% associated pain eight eyes 66.6% four eyes associated corneal scleral tunnel infiltrate fungal hyphae demonstrated microscopy six eyes 50% presented hypopyon anterior chamber exudates eyes exudates vitreous cavity either seen clinically demonstrated b scan ultrasonography all eyes underwent pars plana vitrectomy injection antifungals comprising daily intravitreal voriconazole 100 g/0.1 ml alternate day intravitreal amphotericin b 5 g/0.1 ml known amb vo regimen resolution vitreous exudates decision inject antifungals was based detection fungal hyphae smears corneal scrapings clinical suspicion fungal etiology all post cataract surgery endophthalmitis cases underwent iol explantation seven eyes underwent repeat vitrectomy three eyes underwent penetrating keratoplasty systemic antifungal ketoconazole 200 mg twice daily administered cases corneoscleral involvement the mean duration treatment amb vo regimen 21.5 range 1330 days patients corneal scleral involvement also received topical 5% natamycin 1% voriconazole eye drops globe salvage achieved cases final visual acuity light perception better visual acuity last follow ranged 20/60 light perception 20/400 better seven 12 eyes 58.3% 20/60 2/12 16.6% eyes all eyes resolution vitreous exudates assessed indirect ophthalmoscopy b scan ultrasonography cornea hazy the mean presenting final intraocular pressures 9.5 range 217 mmhg 6.8 range 310 mmhg respectively clinical pictures anterior segments patients presentation final visit shown figures 1 2 culture proven fungal endophthalmitis seen 11/12 eyes 91.6% one post cataract surgery endophthalmitis case grow organisms table 1 case 3 fungal filaments seen direct examination vitreous sample calcofluor white gram stain 4/12 33.3% cases corneal scrapings 4/12 33.3% significant growth filamentous fungi seen cultures vitreous samples 7/12 eyes 58.3% explanted intraocular lens plated chocolate agar 7/12 eyes 58.3% table 1 characteristic fungal colonies either cinnamon brown powdery yellowish green granular grown suggestive aspergillus terreus aspergillus flavus respectively the vitreous single case fusarium endophthalmitis showed creamy fluffy pinkish colony spores characteristic fusarium microscopy fungal endophthalmitis often refractory antifungal therapy poor functional anatomic outcomes.5,6 principal objective study evaluate role combined intravitreal amphotericin b voriconazole management endophthalmitis caused filamentous fungi current study treated filamentous fungal endophthalmitis pars plana vitrectomy combination intravitreal antifungal agents this antifungal combination regimen based clinical experience case 1 table 1 this patient undergone open globe injury repair followed pars plana lensectomy vitrectomy traumatic cataract vitreous hemorrhage two months later condensed round mass anterior vitreous exudates seen clinically slit lamp examination pupil behind iris inferotemporal quadrant fungal hyphae demonstrated vitreous aspirate microscopy later identified a. flavus growth culture based initial resolution emergence exudates course clinically suspected isolate refractory voriconazole alone combined subsequently intravitreal amphotericin b given every 48 hours rapid complete resolution vitreous exudates observed end one week figure 3 we formulated regimen comprising combination intravitreal voriconazole daily amphotericin b every 48 hours amb vo regimen the frequency injections based half life amphotericin b voriconazole aphakic vitrectomized eyes 1.8 days 2.5 hours respectively.8,9 vivo efficacy role combination antifungal agents life threatening systemic fungal infections established.5 combination intravitreal antifungals management fungal endophthalmitis good visual outcome reported previously.10 vitro studies predicting interaction antifungal agents result combining drugs demonstrated variable patterns drug interactions like synergism indifference often antagonism agents.6 amphotericin b polyene commonly used empirical antifungal agent systemic mycosis endophthalmitis caused filamentous fungi.11 acts binding surface sterols cell membrane fungi resulting formation pores altered permeability.8 voriconazole azole acts chiefly depleting ergosterol chief bioregulator membrane integrity.11 steinbach et al hypothesized azoles may render amphotericin b inactive adsorbed onto fungal cell surface inhibit binding amphotericin b fungal cell membrane.7 amphotericin b combined lipophilic triazoles like itraconazole found deleterious ineffective amphotericin b combined voriconazole found beneficial experimental studies.57 although filamentous fungus developing resistance amphotericin b inherent resistance reported frequency described.11,12 a. terreus isolated endophthalmitis outbreak current series also reported refractory amphotericin b vitro studies.12 wykoff et al described fungal isolates treatment strategies clinical outcomes cases exogenous fungal endophthalmitis.13 systemic antifungals required 83% patients additional intraocular antifungals needed 95% eyes fifty nine percent patients treated multiple antifungal agents 20% received anti fungal agents 36 months fifty four percent patients achieved final visual acuity 20/400 better 24% eyes lost perception light including 20% underwent enucleation amongst various categories 54% patients postoperative fungal endophthalmitis achieved visual acuity 20/80 better none cases fungal endophthalmitis following open globe injury achieved vision better 20/400 70% underwent enucleation narang et al reported poor visual anatomic outcomes eyes exogenous fungal endophthalmitis especially associated corneal involvement.2 current study mean final follow 12.75 weeks best corrected visual acuity achieved 20/400 better 7/12 eyes 58.33% 20/60 2/12 eyes 16.6% all five eyes corneal involvement developed hypotony corneal haze graft opacification visual acuity 20/400 worse five six eyes persistent hypotony final visual acuity less 20/400 last follow one eye recovering visual acuity 20/60 unlike previous reports poor visual anatomic outcomes fungal endophthalmitis following open globe injury,13 patients current study recovered visual acuity 20/100 better last visit despite delayed presentation mean 27.6 days 5/9 55.5% patients part postoperative outbreak endophthalmitis caused a. terreus finally recovered visual acuity 20/400 better the main limitations study retrospective design limited follow period further patients could afford systemic antifungal drugs due paucity cases prospective randomized controlled trial would difficult perform head head comparison voriconazole alone combination voriconazole amphotericin b would useful establishing regimen better majority 75% isolates current series were a. terreus previously reported inherently resistant amphotericin b.12 would useful study effect combining amphotericin b voriconazole vitro regard possible synergism correlate vivo response conclusion combination intravitreal amphotericin b voriconazole injections complete resolution vitreous exudates could promising modality treatment management exogenous filamentous fungus endophthalmitis	purposeto report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents.designretrospective , non - randomized , interventional , consecutive case series.methodstwelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin - b and intravitreal voriconazole ( amb - vo regime ) along with pars plana vitrectomy at a single center . clinical characteristics , microbiology results , treatment strategy , visual , and anatomical outcomes were analyzed.resultsten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster . the remaining included endophthalmitis following keratitis post pterygium excision ( 1 ) and following open globe injury ( 2 ) . the most common fungus was aspergillus terreus , which was isolated in 8/12 , followed by a. flavus in 2/12 and fusarium solani in 1/12 . the presenting visual acuity ranged from light perception ( lp ) to counting fingers . the visual acuity at final follow - up was 20/400 or better in 7/12 eyes ( 58.33% ) and 20/60 in 2/12 eyes ( range 20/60 to lp ) . all eyes with corneal involvement had final visual acuity 20/400 or worse . globe salvage was achieved in all cases.conclusioncombining intravitreal amphotericin - b and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus . eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty .
cerebral watershed border zone infarcts wi involve junction distal fields two non anastomosing arterial systems hemodynamic risk zones there two types wi cortical wi occurring junction cortical territories anterior middle posterior cerebral arteries internal wi occurring white matter deep superficial perfusion systems middle cerebral artery clinical picture watershed infarctions often progressive fluctuating symptoms may mild therefore probably underestimated another characteristic feature occurrence early onset partial seizures cortical wi occur often forms stroke due sub acute onset association partial clonic seizures wi diagnosis challenging physicians nevertheless wis account 10% cerebral infarcts must kept consideration order avoid inappropriate treatment acute phase phase diffusion weighted brain mri dwi allows clearer diagnosis cranial computed tomography ct we report case 69-year old man presented emergency department hospital four days sub acute occurrence homonymous right hemianopia right hemiparesis the patient medical history disclosed smoking habit 78 pack years beginning age 16 years one year earlier non small cell lung carcinoma diagnosed treated consequently 6 cycles palliative chemotherapy carboplatin gemcitabin neurological examination hospital admission revealed paresis right upper limb severe motor deficit right lower limb intact sensibility the patient admitted diagnosis ischemic stroke started secondary prevention therapy according international guidelines ischemic stroke treatment acetylsalicylic acid 300 mg daily a hours hospital admission patient developed partial epileptic seizures right upper limb required iv phenytoin infusion carotid ultarsounds demonstrated occlusion right extra cranial carotid artery tight stenosis contralateral internal carotid artery figure 1a b brain diffusion weighted magnetic resonance dwi revealed multiple hypertintense lesions extending within cortical watershed area left hemisphere suggesting large watershed infarct figure 1c e figure 1duplex scan showing tight stenosis left extra cranial internal carotid artery b occlusion right internal carotid artery diffusion weighted brain magnetic resonance imaging mri showing watershed infarcts within left hemisphere c mr angiography showing hypo perfusion right intra cranial internal carotid artery e duplex scan showing tight stenosis left extra cranial internal carotid artery b occlusion right internal carotid artery diffusion weighted brain magnetic resonance imaging mri showing watershed infarcts within left hemisphere c mr angiography showing hypo perfusion right intra cranial internal carotid artery e following days patient nearly full clinical recovery residual slight motor deficit distal right upper limb discharge surgical percutaneous treatment left carotid stenosis excluded consideration advanced neoplastic disease continued adequate medical treatment antiplatelet therapy acetylsalicylic acid 300 mg daily statin we report typical neurological picture cortical wi represents complex clinical entity our patient sought medical help four days symptoms onset due slow progression neurological deficit this associated partial epileptic seizures upper limb common cortical wi display good response antiepileptic treatment another typical feature displayed present case benign clinical course ischemic event often seen cortical wi sub acute onset association partial seizures could make diagnosis stroke quite challenging dwi proved useful imaging technique order make right diagnosis acute phase disease understand pathogenesis based fact wi may occur marked systemic hypoperfusion supposed pathological mechanism hemodynamic failure this theory supported typical localization wi low perfusion cerebral areas also called distal border zone fields moreover syncope wi onset occasionally reported might support hemodynamic hypothesis opposed hemodynamic hypothesis either cardiac artery artery microembolism various neuropathological imaging studies found multiple embolic occlusions terminal vascular field distal atherosclerotic carotid plaques particular cortical form wi anyway combination theories likely realistic mechanism terms impaired washout emboli case decreased perfusion our patient presented cortical wi distal tight stenosis left internal carotid artery associated occlusion right one hence hypoperfusion could definitely play substantial role genesis reported case nevertheless suggest case could support hypothesis impaired washout emboli low perfusion brain areas indeed hypoperfusion dominant mechanism ischemic lesion watershed area distal occluded carotid artery even higher risk hand case keeps line concept embolic hemodynamic mechanism plays crucial role pathogenesis cortical wi carotid reperfusion would option case although medical therapy alone preferred choice due high risk procedure patient global prognosis due underlying disease wi frequent clinical entity accounting 10% cerebral infarcts although often recognised due slow progression presenting symptoms frequent association seizures our case illustrative example cortical wi typical onset course imaging appearance we suggest supports hypothesis impaired washout emboli low perfusion brain areas cortical wi treatment chosen accordingly	watershed infarcts ( wi ) evolve in hemodynamic risk zones . clinical picture of wi can be associated to partial epileptic seizures . diffusion weighted brain magnetic resonance imaging ( mri ) allows a clear diagnosis . wi pathogenesis involves either embolic or hemodynamic mechanism . a 69-year old patient presented with sub - acute occurrence of right hemiparesis and partial epileptic seizures of the right arm . carotid ultrasounds demonstrated occlusion of the right extra - cranial internal carotid artery ( ica ) and tight stenosis of the contralateral ica . brain diffusion - weighted magnetic resonance revealed acute ischemic lesions within the watershed area of the left hemisphere . our case supports the hypothesis of impaired washout of emboli in low - perfusion brain areas as the mechanism underlying cortical wi .
dementia closely associated aging cognitive decline common elderly 2010 the number people diagnosed dementia 35 million population projected increase 115 million 20501 present 8.87% people china older 65 years age population expected rapidly increase 22.6% 2050 china 12% dementia patients 6069 years old 48% 7079 years old 1520% 85 years old the population elderly people dementia china expected total 20 million 20252 recent years interventions reduce cognitive dysfunction have investigated including memory therapy3 music therapy4 exercise therapy5 china therapeutic exercise used community nursing intervention limited simple exercises walking6 tai chi traditional chinese martial art widely practiced chinese people many studies shown tai chi beneficial effects balance falls non vertebral fractures7,8,9 tai chi also reportedly improves renal function patients chronic renal disease cardiac function cardiovascular disease patients via regulation lipid metabolism10 many studies investigated methods prevent dementia symptoms investigated effect tai chi dementia11 12 this study aims investigate whether tai chi improve physical cognitive function elderly chinese subjects a total 150 fifty elderly people residing local communities recruited public announcement the inclusion criteria follows 1 60 years age 2 mini mental state examination mmse score 24 indicating cognitive impairment 3 sufficient upper limb mobility perform requisite finger pointing tasks flexing extending shoulder elbow wrist fingers 4 neurologic musculoskeletal disease stroke visual auditory impairments subjects meeting inclusion criteria randomly allocated tai chi group control group using random number table n 75 per group fig 1fig 1.study protocol subject recruitment total 150 subjects 60 years old randomly divided tai chi intervention group control group all participants investigated baseline 3 6 months beginning intervention an independent researcher blinded number allocation enrolled assigned subjects group study protocol subject recruitment total 150 subjects 60 years old randomly divided tai chi intervention group control group all participants investigated baseline 3 6 months beginning intervention subjects tai chi group practiced 24-form yang style tai chi 60 minutes twice weekly 6 months the control group participated activities playing cards singing activity center however due variety factors hospitalization intervention group included 72 people 3 months control group 66 people 6 months after completing study control group provided similar intervention program study subjects given 10 min read document dementia prevention researcher answered questions concerning document each subject completed questionnaire concerning gender age education disease status functional capacity tokyo metropolitan institute gerontology index competence tmig 013 points the tmig used measure functional capacity daily life higher scores indicate greater functional ability13 physical function assessed using eyes open leg standing time 5-m high walk speed 10-m normal walk speed left grip strength right grip strength14 the subjects asked stand either leg long possible keeping eyes open assess static balance the time subject raised leg raised leg touched ground measured twice longer time two trials analyzed grip strength measured twice hands using adjustable handheld dynamometer assess muscular strength highest measure hand used participants asked walk 10 normal speed 5 maximal speed mean time measured using stopwatch cognitive function measured using mmse 030 points frontal assessment battery fab bedside 018 points)15 16 mmse 2324 points indicates mild dementia higher scores indicate better cognitive function fab bedside data analyzed using test intervention tai chi group control group statistical analysis performed using spss 13.0 p 0.05 considered statistically significant of 138 subjects completed 6-month study program 12 subjects tai chi group n 3 control group n 9 lost follow as result follow data available 72 75 subjects tai chi group 66 75 subjects control group table 1table 1.subjects characteristicsparametertai chi group n 72 control group n 66 gendermale14 19.4)20 30.3)female58 80.6)46 69.7)age years)mean sd68.3 5.970.1 5.7606422 30.6)12 18.2)656922 30.6)20 30.3)707416 22.2)18 27.3)757910 13.9)14 21.2)80842 2.8)2 3.0)education years)01132 44.5)18 27.2)1240 55.5)48 72.8)diseasecardiac16 22.2)8 12.1)hyperpiesia12 16.7)16 24.2)diabetes mellitus4 5.6)4 6.1)other18 25.0)22 33.3)none22 30.6)16 24.2)physical exerciseyes54 75.0)54 81.8)no18 25.0)12 18.2)exercise frequency<3/w22 40.7)20 47.0)3/w32 59.3)34 63.0)exercise time min)<6038 70.4)36 66.6)6016 29.6)18 33.4)tmig 413 points)mean sd11.6 1.310.8 2.1physical functionone leg standing time eyes open s)28.7 27.123.3 23.05-m high walking speed s)2.9 0.72.8 0.810-m normal walking speed s)8.7 2.18.9 2.5left grip strength kgw)24.7 6.923.6 10.3right grip strength kgw)25.5 7.023.9 10.5brain functionmmse 2030)26.4 2.426.8 1.7fab 718)14.6 2.114.1 2.9tmig functional capacity tokyo metropolitan institute gerontology index competence mmse mini mental state examination fab frontal assessment battery bedside sd standard deviation significant difference groups the two groups well matched baseline assessment obvious differences key outcome variables initially except tmig score significantly higher tai chi group control group p 0.01 tmig functional capacity tokyo metropolitan institute gerontology index competence mmse mini mental state examination fab frontal assessment battery bedside sd standard deviation significant difference groups p 0.01 tai chi group tmig score increased 3 6 months the eyes opened one leg standing time fab increased 6 months unchanged 3 months contrast right grip strength increased 3 months 6 months there significant differences eyes open one leg standing time left grip strength fab bedside p 0.05 tai chi control groups 3 6 months tables 2table 2.physical cognitive functions compared tai chi control groupsparametertai chi n 72 mean sd)control n=66 mean sd)pre intervention3 months6 monthspre intervention3 months6 monthstmig 413)11.6 1.3)12.1 0.9)12.1 0.9)10.8 2.1)11.1 2.0)11.7 1.4)physical exerciseone leg standing time eyes open s)28.7 27.1)36.9 38.3)40.0 47.1)23.3 23.0)34.3 37.5)38.0 40.7)5-m high walking speed s)2.9 0.7)2.8 0.5)2.8 0.7)2.8 0.8)3.2 0.8)3.4 0.9)10-m normal walking speed s)8.7 2.1)8.5 2.0)8.6 1.6)8.9 2.5)9.7 2.6)9.6 2.6)left grip strength kgw)24.7 6.9)24.9 6.5)24.9 8.8)23.6 10.3)23.1 11.5)22.8 10.3)right grip strength kgw)25.5 7.0)26.7 7.2)25.8 7.7)23.9 10.5)23.4 11.5)23.4 11.0)brain functionmmse 2030)26.4 2.4)27.8 1.7)28.0 2.0)26.8 1.7)27.1 1.8)27.3 1.9)fab 718)14.6 2.1)14.9 2.4)15.7 2.4)14.1 2.9)14.3 2.8)14.5 3.2)tmig functional capacity tokyo metropolitan institute gerontology index competence mmse mini mental state examination fab frontal assessment battery bedside sd standard deviation significant difference groups p 0.001 p 0.01 p 0.05 3table 3.outcome variables 3 6 months tai chi training3 months intervention6 months interventiontai chi group(n 72)mean sd)control group(n 66)mean sd)tai chi group(n 72)mean sd)control group(n 66)mean sd)tmig 413)0.5 1.0)0.5 1.5)0.5 1.2)0.9 1.3)physical exerciseone leg standing time eyes open s)8.1 35.5)11.0 26.1)11.3 45.0)14.8 28.9)5-m high walking speed s)0.1 0.5)0.4 0.5)0.1 0.7)0.6 0.7)10-m normal walking speed s)0.2 2.2)0.8 1.3)0.1 1.6)0.8 1.7)left grip strength kgw)0.2 2.9)0.5 3.5)0.2 4.3)0.7 3.3)right grip strength kgw)1.2 3.2)0.5 4.1)0.2 3.1)0.5 3.5)brain functionmmse 2030)1.4 2.2)0.3 2.2)1.6 1.9)0.5 2.6)fab 718)0.3 1.8)0.3 2.6)1.1 2.2)0.5 2.6)tmig functional capacity tokyo metropolitan institute gerontology index competence mmse mini mental state examination fab frontal assessment battery bedside sd standard deviation significant difference groups p 0.001 p 0.01 p 0.05 tmig functional capacity tokyo metropolitan institute gerontology index competence mmse mini mental state examination fab frontal assessment battery bedside sd standard deviation significant difference groups p 0.001 p 0.01 p 0.05 tmig functional capacity tokyo metropolitan institute gerontology index competence mmse mini mental state examination fab frontal assessment battery bedside sd standard deviation significant difference groups p 0.001 p 0.01 p 0.05 participants tai chi group significantly decreased 5-m high walking speed p 0.001 10-m normal walking speed p 0.01 right grip strength p 0.01 mmse p 0.01 compared control group 3 months furthermore tai chi group experienced significantly decreased 5-m high walking speed p 0.001 10-m normal walking speed p 0.001 mmse p < 0.01 compared control group 6 months table 2 the 5-m high walking speed test decreased tai chi group 3 6 months control group showed increasing trend tables 2 3 a similar trend observed 10-m normal walking speed 3 6 months tables 2 3 the right grip strength significantly increased 3 months decreased 6 months tai chi group control group right grip strength decreased 3 6 months tables 2 3 finally mmse score increased 3 6 months tai chi group tables 2 3 this study shows tai chi practice improves cognitive physical functions elderly we found mmse score significantly increased tai chi group compared control group suggesting tai chi may improve mental function elderly china exercise known increase regional cerebral perfusion contralateral motor sensory cortex may explain tai chi may increase memory concentration17 although increasing number elderly chinese people practice tai chi studies examined effects tai chi preventing dementia brown et al.18 randomly divided 135 subjects tai chi group control group 16 weeks moderate low intensity exercise programs found exercise tai chi effective exercise alone promoting psychological benefits men women winter tse19 20 showed tai chi could improve walking speed grip strength elderly consistent previous reports study found walking speed significantly improved tai chi group compared control group addition schaller21 reported tai chi practitioners significantly better eyes open leg standing times however study found eyes open one leg standing time significantly increased tai chi control groups 3 6 months difference two groups of note participants control group schaller study maintained current activity level control group study participated non athletic activities playing cards singing our results also showed significantly increased tmig tai chi control groups however difference two groups may subjects read document dementia prevention beginning study currently family care community support systems well established china therefore particularly important take precautions prevention early treatment dementia presently intervention studies china dementia prevention tai chi we conducted randomized controlled trial evaluate potential prevent dementia using tai chi results demonstrate tai chi improve cognitive function elderly people many studies especially evaluating older adults significantly impaired individuals reported functional changes 3 6 months following intervention six month duration study evaluated potential effect tai chi age related dementia tai chi traditionally considered life long skill believed time proficiency health benefits improve long term interventional studies well designed observational studies comparing long term tai chi practitioners e.g. 10 years matched controls needed fully evaluate long term impact tai chi healthy aging22 conclusion results confirmed tai chi potentially useful preventing dementia elderly people tai chi could easy effective preclinical treatment strategy preventing dementia elderly people enhancing quality life	[ purpose ] to investigate the effect of tai chi on cognitive and physical function in the elderly . [ subjects and methods ] a randomized trial design was used . a total 150 subjects were enrolled and were divided into tai chi and control groups . subjects in the tai chi group participated tai chi for 6 months , and subjects in the control group participated in other non - athletic activities . [ results ] there were no differences between the groups in the one leg standing time with eyes open , left grip strength , or the frontal assessment battery at bedside after 3 and 6 months of intervention . the mini - mental state examination scores after 3 and 6 months were higher in the tai chi group than in the control group . the right grip strength after 3 months increased more in the tai chi group than in the control group . both the 5-m high walking speed and 10-m normal walking speed were significantly lower after 3 and 6 months of tai chi practice . [ conclusion ] these results suggest that regular tai chi practice may improve cognitive and physical function in the elderly .
february 2001september 2002 captured 344 wild mammals overflow area fauna rescue program construction hydroelectric plant lajeado ipueiras counties 94458s 482123w tocantins state brazil program 269 capuchin monkeys cebus apella 27 black howling monkeys allouata caraya 12 coatis nasua nasua 20 agoutis dasyprocta sp 2 opossums didelphis albiventris 5 armadillos euphractus sexcinctus 5 collared anteaters tamandua tetradactila 4 gray foxes cerdocyon thous captured all animals captured sylvatic area contact humans dairy cattle field screening laboratories animals released areas selected environmental conservation programs 2002 bovine vaccinia restricted southeastern brazil 1,400 km study area 7 serum samples inactivated heating 56c 30 min orthopoxvirus plaque reduction neutralizing test prnt performed prnt used rather elisa secondary antibodies required elisa analyzed species unavailable inactivated samples diluted 1:201:1,640 minimal essential medium tested vero cells using vacv western reserve strain prnt described 8) human samples positive antibodies orthopoxvirus obtained bovine vaccinia outbreaks used positive controls 9 samples negative antibodies used negative controls 10 serum titer defined highest dilution inhibited 50% viral plaques compared negative controls orthopoxvirus prnt specificity 97.4% sensitivity 93.5% confirmed using receiver operating characteristic analysis compared results prnt elisa clinical symptoms bovine vaccinia outbreaks 9,10 of 269 c. apella samples 68 25.3% antibodies orthopoxvirus 27 a. caraya samples 13 48.1% antibodies orthopoxvirus seropositivity detected 2 16.6% coatis 1 5.0% agouti of 344 animals studied 84 24.4% antibodies orthopoxvirus table samples high neutralizing antibody titers 55.95% 47 titers 80320 5 6.0% prnt positive samples titers 40 table given serologic cross reactivity orthopoxvirus 3 positive samples could indicate 9 virus species although well established vacv endemic brazil infections orthopoxviruses geographically restricted continents identified brazil therefore performed molecular investigation identify orthopoxviruses associated orthopoxvirus sylvatic circulation serologic molecular tests performed blinded fashion triplicate basis previous studies detected orthopoxvirus dna serum infected hosts 9,11,12 a semi nested pcr used amplify highly conserved orthopoxvirus vaccinia growth factor vgf gene j.s human vacv dna positive dna negative serum samples obtained bovine vaccinia outbreaks 9 used positive negative controls respectively eighteen 344 serum samples positive pcr assays 11 c. apella 7 a. caraya prnt positive six 18 vgf pcr positive samples chosen sequencing analysis vgf 4 c. apella 2 a. caraya ( 14 amplified hemagglutinin ha gene 2 samples 1 c. apella 1 a. caraya vgf positive the vgf ha pcr products cloned pgemt easy vector promega madison wi usa three clones distinct pcr amplicons sample sequenced orientations using m13 universal primers mega bace sequencer ge healthcare little chalfont uk optimal alignment highly conserved vgf gene clustalw www.ncbi.nlm.nih.gov/pmc/articles/pmc308517 mega version 3.1 www.megasoftware.net showed 100% identity among nucleotide amino acid sequences monkey serum appendix figure panel compared nucleotide sequences available genbank vgf sequences highly similar 98%100% identity homologous gene vacv strains showed 100% identity the ha sequences c. apella a. caraya showed signature deletion appendix figure panel b also present sequences vacv isolates brazil these ha sequences showed 99.6% identity nucleotide level 99.7% identity amino acid level 736 nt ha gene analyzed phylogenetic trees vgf figure panel ha figure panel b genes constructed using neighbor joining method 1,000 bootstrap replicates tamura 3-parameter model mega version 3.1 the vgf ha sequences monkey samples deposited genbank accession nos consensus bootstrap phylogenetic trees based nucleotide sequences orthopoxvirus vaccinia growth factor vgf hemagglutinin ha b genes trees constructed ha vgf sequences using neighbor joining method 1,000 bootstrap replicates tamura 3-parameter model mega version 3.1 software www.megasoftware.net black dots indicate vaccinia virus vacv obtained cebus apella vacv ca allouata caraya vacv ac all vgf sequences obtained monkey serum samples showed 100% represented unique sequence vgf tree vacv hspv horsepoxvirus varv variola virus cpxv cowpoxvirus mpxv monkeypoxvirus although vacv strains isolated rodents forests brazil 5,6 nearest location belm 750 km study area detected vacv wildlife brazilian amazon 3 years reports exanthematic outbreaks bovine vaccinia 40 years isolation vacv forests our data provide evidence high prevalence orthopoxviruses among capuchin black howling monkeys brazilian amazon the relationship infected monkeys emergence vacv rural regions brazil unknown however transmission vacv northeastern brazil reported outbreaks reported mato grosso pernambuco www.amep.org.br/pox.doc maranho e.g. kroon et al unpub data tocantins 13 adjacent brazilian amazon viruses may related isolated study vacv isolates signature deletion ha gene vacv anthropogenic disturbance amazon ecosystem increases agricultural livestock areas increase contact wildlife rural populations 15 however effect vacv environments brazil contain wild animals studied clinical data pox lesions animals tested well documented veterinarians study area ecologic public health studies designed evaluate risks infection vacv wildlife conservation efforts determine whether surveillance systems predict bovine vaccinia outbreaks monitoring vacv infection monkeys wild animals amino acid sequences vaccinia virus vacv samples comparison homologous genes sequences several orthopoxviruses brazil a alignment vaccinia growth factor gene sequences 6 monkey serum samples showing 100% identity horizontal box vacv to_ca sequence cebus apella vacv to_ac sequence allouata caraya hpxv horsepoxvirus cpxv cowpoxvirus mpxv monkeypoxvirus varv variola virus ecmv ectromelia virus b alignment orthopoxvirus hemagglutinin gene amino acid sequences showing deletion signature region vertical box vacv isolates several vacv strains isolated bovine vaccinia outbreaks arrow indicates polymorphism site hemagglutinin amino acid sequences vacv to_ca vacv to_ac alignments made using clustalw www.ncbi.nlm.nih.gov/pmc/articles/pmc308517 mega version 3.1 software www.megasoftware.net	to detect orthopoxvirus in the brazilian amazon , we conducted a serosurvey of 344 wild animals . neutralizing antibodies against orthopoxvirus were detected by plaque - reduction neutralizing tests in 84 serum samples . amplicons from 6 monkey samples were sequenced . these amplicons identified vaccinia virus genetically similar to strains from bovine vaccinia outbreaks in brazil .
medicare federally administered social insurance program united states guarantees access health insurance individuals aged 65 older younger individuals disabilities worked contributed system 2013 disability beneficiaries comprise 16.8% total medicare population account 20% total program expenditures last decade growth medicare enrollment disability beneficiaries greatly outpaced overall growth medicare program for example using data chronic condition data warehouse medicare 5% sample centers medicare medicaid services estimate year 2003 2012 growth disabled beneficiaries 37% much faster growth aged beneficiaries 21% baby boomers age reaching age increased likelihood developing disabilities makes important understand disability beneficiaries medicare however younger medicare beneficiaries work disabilities received far less research attention policy consideration elderly medicare beneficiaries the disabled individuals receive medicare coverage social security disability insurance di program primary public transfer program provides partial earnings replacement medicare coverage workers lost earnings capacity due severe long term disabilities the social security definition disability refers severe health limitations prevent individuals engaging substantial gainful activities expected last least 12 months december 2013 di program provides cash benefits medicare coverage nearly 11 million american workers eligible dependents most di beneficiaries required complete 5-month waiting period entitled cash benefits additional 24-month waiting period entitled medicare coverage 2-year medicare waiting period waived amyotrophic lateral sclerosis end stage renal disease ) considerable concern 2-year medicare waiting period causes significant hardship new di beneficiaries lack alternative health insurance coverage needed health care access address health problems evidence shows 20% di beneficiaries health insurance coverage medicare waiting period around 1.8 million di beneficiaries congress noted problems 2-year waiting period ticket work work incentives improvement act 1999 political effort devoted changing this policy includes ending medicare disability waiting period act 2007 sponsored senator jeff bingaman rep gene green proposes phase medicare 2-year waiting period 10-year span grant exceptions people life threatening health conditions studies based focus groups interviews disabled individuals shown many uninsured lack needed health care stabilize health conditions situations get worse waiting period yet formal analyses rare identify quantify detrimental effect 2-year waiting period imposed disabled individuals a handful previous studies medicare waiting period primarily focused estimating fiscal impact eliminating 2-year waiting period certainly useful budgetary consideration policy changes demonstration project accelerated benefits ab demonstration conducted social security administration ssa 2011 provides evidence effects health care utilization estimates fiscal costs uninsured di beneficiaries provided health care package 2-year waiting period however project evaluate impact health care access health outcomes uninsured disability beneficiaries waiting period probably due constraint project design narrow time window follow survey 6 months makes difficult observe changes health outcomes although demonstration project provides evidence important aspects providing accelerated health care access disability beneficiaries faces challenges endemic many policy demonstration projects as ssa acknowledges ab demonstration project able estimate potential induced entry effects would occur accelerated health insurance coverage offered newly awarded di beneficiaries would make di program attractive induce applicants di program it also possible individuals expect health insurance coverage medicare waiting period less likely apply di our study utilizes longitudinal panel data span nearly 20 years allow us observe disabled workers longer period time likely capture changes health economic status a lot research effort devoted examining impact medicare health outcomes these studies primarily focused medicare impact elderly beneficiaries rather disabled beneficiaries general find medicare discernible effect health these studies helpful understanding average effect medicare health outcomes among elderly patients meantime may masked medicare effects certain subgroups population example individuals poor health in words possible medicare differential effect health distribution workers younger 65 severe long term health impairments lose earning capacity may qualify social security disability benefits di program they likely ill worse financially average compared elderly beneficiaries survive age 65 entitled medicare although medicare may show significantly positive health effects elderly beneficiaries chronic health conditions shown previous literature may help improve health status least prevent health deteriorating disabled beneficiaries severe health problems there evidence severely ill patients acquiring medicare coverage significant positive effects self reported health largest gains health improvement among groups experience largest gains insurance coverage article focus group individuals poor health they qualify disability benefits medicare entitlement di program adopts strictest definition disability compared criteria used disability programs nation well compared disability definition used disability programs developed countries research effort past di program mainly focused understanding effects cash benefits offered program little analysis conducted understanding effects important kind benefit medicare coverage provided di program the fact medicare federally administered program eligibilities individuals limits extent variation medicare coverage used identify effects medicare coverage individuals di program the medicare waiting period creates health insurance gap disability beneficiaries others alternative health insurance mostly medicaid period it provides opportunity us exploit variation health insurance coverage identify effects disabled individuals this article first take advantage longitudinal health retirement study hrs estimate health economic effects medicare waiting period disabled individuals a previous study used data source study health effects medicare enrollment age 65 near elderly uninsured article explore whether extent medicare waiting period impacts health economic status di beneficiaries uninsured waiting medicare become available quasiexperiment research design using difference difference diff diff estimator compare changes health economic outcomes pre-/postentering di program beneficiaries alternative health insurance without medicare waiting period the adjusted diff diff estimates suggest disability beneficiaries uninsured waiting compared insured 13.6 percentage point likely report poor health 6.3 percentage point less likely excellent health declare difficulties activities daily living adl 30% higher medical expenditures pocket the findings suggest punitive health economic effects medicare waiting period uninsured disability beneficiaries the structure article follows first section introduces research question the study uses 10 available waves hrs cover 1992 2010 period interviews conducted 2011 the hrs biennial national representative survey interviews individuals born 1931 1941 spouses well additional cohorts added recent waves study the data provide extensive information health status employment history wealth income family structure government program participation transfers total 30 672 respondents analysis crucial accurately line dates pre-/post di program disability beneficiaries identify medicare waiting period one entitled di benefits 5 months becomes technically disabled according social security definition disability assuming become di insured accumulating enough work credits he entitled medicare coverage 24 months entitlement di benefits identify medicare waiting period must determine date 1 entitled di benefits could receipt first di paycheck words this sometimes take many months even years di application approved the processing times even longer claims initially denied subsequently allowed appeal process also eventually allowed benefits might file disability claim immediately following disability onset hence time di beneficiaries notified claim allowed completed part medicare waiting period linking hrs files social security master beneficiary record file able identify official date disability onset the linkage hrs master beneficiary files restricted available university michigan hrs researchers meet criteria access confidential data knowing date disability onset count 5 months date determine date di entitlement medicare waiting period starts the waiting period ends 29 months date disability onset hrs that 2-year passing adjacent interview waves hrs comparing interview dates di entitlement date designate wave right prior di entitlement pre di period wave right di entitlement post di period we exclude sample respondents observe pre di period observe post di period so include sample individuals awarded di benefits observe wave wave di entry waves identified based interview date di entitlement date available determine whether public health insurance coverage wave di entry applying sample restrictions we left sample 465 respondents 2-period model aka equation ( 1 respondent observed twice wave entering di wave analysis also expand specification beyond 2-period pre-/postcomparison allow multiple pre- postperiods aka equation 2 given fact health effects may become apparent narrow time frame multiperiod model respondent contribute 4 observations waves pre di entry 4 observations waves post di entry our goal identify effects uninsured medicare waiting period newly entitled disability beneficiaries we distinguish following 2 groups analysis newly entitled di beneficiaries health insurance coverage medicare becomes available 23% sample newly entitled di beneficiaries access alternative public health insurance primarily medicaid immediately entering di program 77% sample the former group includes individuals lose health insurance entering di program 14% individuals already lose health insurance prior di entry 9% among latter when drop latter group study sample diff diff estimates became slightly larger magnitude stayed statistically significant the di beneficiaries health insurance waiting period include individuals gain access public health insurance entering di program 57% individuals get public health insurance entering di program 19% as show later 2 groups appear comparable large array socioeconomic characteristics health variables baseline period the di beneficiaries low income assets may concurrently receive supplemental security income ssi benefits most di ssi concurrent beneficiaries gain immediate access medicaid coverage entitlement ssi benefits the 2 public disability transfer programs administered ssa follow criteria determining disability severity hence beneficiaries 2 programs comparable baseline terms disability health status key variable analysis table 1 presents preperiod descriptive statistics sample newly entitled di beneficiaries without health insurance coverage alternative public health insurance upon entering di program the disability beneficiaries alternative public health insurance medicare waiting period include women fewer blacks married they appear bit less healthy beneficiaries health insurance waiting period the former report health conditions difficulties adls instrumental activities daily living the major differences 2 groups lie financial variables disability beneficiaries insurance waiting period compared without insurance waiting period average earns 40% less work entering di program however former receives nonlabor income likely government transfers 4.5 times amount received latter these differentials surprising uninsured beneficiaries consist disabled individuals receive di benefits rather di ssi concurrently likely workers longer worker histories higher labor earnings compared insured disabled individuals concurrently receiving ssi benefits means tested sample means proportions wave prior di entry di beneficiaries without health insurance waiting period abbreviations adl activities daily living bmi body mass index di disability insurance iadl instrumental activities daily living prev previous unemp ins workers comp unemployment insurance workers compensation net worth sum assets primary residence real estate vehicles businesses iras stocks bonds checking accounts cds assets less liabilities mortgages home loans debt major health conditions include 1 high blood pressure hypertension 2 diabetes high blood sugar 3 cancer malignant tumor kind except skin cancer 4 chronic lung disease except asthma chronic bronchitis emphysema 5 heart attack coronary heart disease angina congestive heart failure heart problems 6 stroke transient ischemic attack 7 emotional nervous psychiatric problems 8) arthritis rheumatism what worth noting half disability beneficiaries annual household total income less us$30 000 it suggests many beneficiaries could benefit recently passed health care reform affordable care act aca makes health insurance affordable providing subsidies families income 400% federal poverty line purchase insurance new health insurance exchanges we discuss aspect last section article underlying theoretical framework for individuals inherit initial amount stock depreciates age increased investment changes health stock time determined increased health stock less health depreciation health stock produced health inputs medical care health knowledge lifestyle environment so reduced form estimation health changes time pre-/post di control changes medical care health insurance coverage health care utilization changes health knowledge proxied years schooling efficiency parameter grossman health production function changes wealth income socioeconomic variables proxy factors may affect health outcomes hard measure empirically lifestyle quasiexperiment research design use diff diff estimator first difference outcome variables entering di program second difference disability beneficiaries health insurance without health insurance waiting period taking advantage panel data we take within person change outcome variables entering di program this desirable guarantees comparability groups pre- postperiods controlling compositional changes due attrition sampling variation one identifying assumption diff diff models unobserved time varying processes would similarly impacted 2 comparison groups the preperiod differences measures groups table 1 suggest potential vulnerability front we address testing differential changes number potential confounders including health measures financial variables health service utilization we present addition unadjusted diff diff estimates estimates account within person changes relevant variables let yijt denote change health economic outcomes individual group j 1 0 di beneficiaries without insurance waiting period time 2 2 years waves hrs dj indicator di beneficiary insurance waiting period we begin 2-period model 2 denotes preperiod postperiod estimate linear equation following form:1yijt=+dj+xijt+ijt 2-period pre post model coefficient diff diff estimate effect insured medicare waiting captures linear time trend yijt we also expand specification beyond simple 2-period pre-/postcomparison allow multiple pre- postperiods given fact health effects may become apparent narrow time frame taking account fact shape time profile could different di beneficiaries without insurance waiting period interact flexible function group indicator dj order allow slopes time profile differ di entry across groups.2yijt=dj+ftdj+ft+xijt+ijt model f(t sequence dummy variables period t. set reference period first postperiod coefficient continues diff diff estimate an attraction first differenced model shown equations 1 2 permanent unobservable differences 2 comparison groups differenced this desirable light preexisting differences 2 groups shown table 1 however existence preperiod differences also suggests time varying processes may differentially impact 2 groups for example health shocks might differentially impact insured di recipients waiting period given poorer initial health one way testing presence confounders estimate models like equations 1 2 potential confounder this similar spirit test offered previous study context regression discontinuity designs table 3 shows diff diff estimates based equation 1 25 potential confounders including financial variables health measures health care utilization measures statistically significant estimates evidence insured di beneficiaries experienced differential pre-/post di changes given variable there little evidence differential impacts pre-/post di changes variables tested exception couple financial variables capital income income unemployment insurance workers compensation statistically significant 10% level to control important time varying processes include variables first differences vector xijt equations 1 2 the study uses 10 available waves hrs cover 1992 2010 period interviews conducted 2011 the hrs biennial national representative survey interviews individuals born 1931 1941 spouses well additional cohorts added recent waves study the data provide extensive information health status employment history wealth income family structure government program participation transfers total 30 672 respondents analysis crucial accurately line dates pre-/post di program disability beneficiaries identify medicare waiting period one entitled di benefits 5 months becomes technically disabled according social security definition disability assuming become di insured accumulating enough work credits he entitled medicare coverage 24 months entitlement di benefits identify medicare waiting period must determine date 1 entitled di benefits could receipt first di paycheck words this sometimes take many months even years di application approved the processing times even longer claims initially denied subsequently allowed appeal process also eventually allowed benefits might file disability claim immediately following disability onset hence time di beneficiaries notified claim allowed completed part medicare waiting period linking hrs files social security master beneficiary record file able identify official date disability onset the linkage hrs master beneficiary files restricted available university michigan hrs researchers meet criteria access confidential data knowing date disability onset count 5 months date determine date di entitlement medicare waiting period starts the waiting period ends 29 months date disability onset hrs that 2-year passing adjacent interview waves hrs comparing interview dates di entitlement date designate wave right prior di entitlement pre di period wave right di entitlement post di period we exclude sample respondents observe pre di period observe post di period so include sample individuals awarded di benefits observe wave wave di entry waves identified based interview date di entitlement date available determine whether public health insurance coverage wave di entry applying sample restrictions we left sample 465 respondents 2-period model aka equation ( 1 respondent observed twice wave entering di wave analysis also expand specification beyond 2-period pre-/postcomparison allow multiple pre- postperiods aka equation 2 given fact health effects may become apparent narrow time frame multiperiod model respondent contribute 4 observations waves pre di entry 4 observations waves post di entry our goal identify effects uninsured medicare waiting period newly entitled disability beneficiaries we distinguish following 2 groups analysis newly entitled di beneficiaries health insurance coverage medicare becomes available 23% sample newly entitled di beneficiaries access alternative public health insurance primarily medicaid immediately entering di program 77% sample the former group includes individuals lose health insurance entering di program 14% individuals already lose health insurance prior di entry 9% among latter when drop latter group study sample diff diff estimates became slightly larger magnitude stayed statistically significant the di beneficiaries health insurance waiting period include individuals gain access public health insurance entering di program 57% individuals get public health insurance entering di program 19% as show later 2 groups appear comparable large array socioeconomic characteristics health variables baseline period the di beneficiaries low income assets may concurrently receive supplemental security income ssi benefits most di ssi concurrent beneficiaries gain immediate access medicaid coverage entitlement ssi benefits the 2 public disability transfer programs administered ssa follow criteria determining disability severity hence beneficiaries 2 programs comparable baseline terms disability health status key variable analysis table 1 presents preperiod descriptive statistics sample newly entitled di beneficiaries without health insurance coverage alternative public health insurance upon entering di program the disability beneficiaries alternative public health insurance medicare waiting period include women fewer blacks married they appear bit less healthy beneficiaries health insurance waiting period the former report health conditions difficulties adls instrumental activities daily living the major differences 2 groups lie financial variables disability beneficiaries insurance waiting period compared without insurance waiting period average earns 40% less work entering di program however former receives nonlabor income likely government transfers 4.5 times amount received latter these differentials surprising uninsured beneficiaries consist disabled individuals receive di benefits rather di ssi concurrently likely workers longer worker histories higher labor earnings compared insured disabled individuals concurrently receiving ssi benefits means tested sample means proportions wave prior di entry di beneficiaries without health insurance waiting period abbreviations adl activities daily living bmi body mass index di disability insurance iadl instrumental activities daily living prev previous unemp ins workers comp unemployment insurance workers compensation net worth sum assets primary residence real estate vehicles businesses iras stocks bonds checking accounts cds assets less liabilities mortgages home loans debt major health conditions include 1 high blood pressure hypertension 2 diabetes high blood sugar 3 cancer malignant tumor kind except skin cancer 4 chronic lung disease except asthma chronic bronchitis emphysema 5 heart attack coronary heart disease angina congestive heart failure heart problems 6 stroke transient ischemic attack 7 emotional nervous psychiatric problems 8) arthritis rheumatism what worth noting half disability beneficiaries annual household total income less us$30 000 it suggests many beneficiaries could benefit recently passed health care reform affordable care act aca makes health insurance affordable providing subsidies families income 400% federal poverty line purchase insurance new health insurance exchanges the underlying theoretical framework research design health production function 1972 grossman model individuals inherit initial amount stock depreciates age increased investment changes health stock time determined increased health stock less health depreciation health stock produced health inputs medical care health knowledge lifestyle environment so reduced form estimation health changes time pre-/post di control changes medical care health insurance coverage health care utilization changes health knowledge proxied years schooling efficiency parameter grossman health production function changes wealth income socioeconomic variables proxy factors may affect health outcomes hard measure empirically lifestyle quasiexperiment research design use diff diff estimator first difference outcome variables entering di program second difference disability beneficiaries health insurance without health insurance waiting period taking advantage panel data we take within person change outcome variables entering di program this desirable guarantees comparability groups pre- postperiods controlling compositional changes due attrition sampling variation one identifying assumption diff diff models unobserved time varying processes would similarly impacted 2 comparison groups the preperiod differences measures groups table 1 suggest potential vulnerability front we address testing differential changes number potential confounders including health measures financial variables health service utilization we present addition unadjusted diff diff estimates estimates account within person changes relevant variables let yijt denote change health economic outcomes individual group j 1 0 di beneficiaries without insurance waiting period time 2 2 years waves hrs dj indicator di beneficiary insurance waiting period we begin 2-period model 2 denotes preperiod postperiod estimate linear equation following form:1yijt=+dj+xijt+ijt 2-period pre post model coefficient diff diff estimate effect insured medicare waiting captures linear time trend yijt we also expand specification beyond simple 2-period pre-/postcomparison allow multiple pre- postperiods given fact health effects may become apparent narrow time frame taking account fact shape time profile could different di beneficiaries without insurance waiting period interact flexible function group indicator dj order allow slopes time profile differ di entry across groups.2yijt=dj+ftdj+ft+xijt+ijt model f(t sequence dummy variables period t. set reference period first postperiod coefficient continues diff diff estimate an attraction first differenced model shown equations 1 2 permanent unobservable differences 2 comparison groups differenced this desirable light preexisting differences 2 groups shown table 1 however existence preperiod differences also suggests time varying processes may differentially impact 2 groups for example health shocks might differentially impact insured di recipients waiting period given poorer initial health one way testing presence confounders estimate models like equations 1 2 potential confounder this similar spirit test offered previous study context regression discontinuity designs table 3 shows diff diff estimates based equation 1 25 potential confounders including financial variables health measures health care utilization measures statistically significant estimates evidence insured di beneficiaries experienced differential pre-/post di changes given variable there little evidence differential impacts pre-/post di changes variables tested exception couple financial variables capital income income unemployment insurance workers compensation statistically significant 10% level control important time varying processes include variables first differences vector xijt equations 1 2 in table 2 first present unadjusted diff diff estimates several health outcome measures self reported poor health self reported excellent health summary functional limitations adl pocket medical expenditures table 4 turn diff diff estimates adjusted large array socioeconomic variables unadjusted estimates health economic outcomes entering di program di beneficiaries without health insurance waiting period column 4 mean within individual minus change outcome variable the new disability beneficiaries access public health insurance 2.5 percentage points less likely report poor health compared entering di observe increase 12.1 percentage points poor health reporting new disability recipients uninsured unadjusted diff diff estimate effect insured waiting period health measure 0.145 indicating 14.5 percentage point drop reporting poor health entering di program among alternative public health insurance relative without this unconditional effect statistically significant calculations using across group changes using within person changes provide similar results table 2 panel 1 the rate reporting excellent health dropped right di entry di beneficiaries without health insurance waiting period the proportion reporting excellent health decreased half 3.6% 1.7% new di awardees access public health insurance proportion declined much dramatically 8.3% less 1% uninsured disability beneficiaries medicare waiting period the unadjusted diff diff estimate effect health insurance waiting period health measure 0.055 statistically significant indicating 5.5 percentage point larger drop reporting excellent health entering di program among without alternative public health insurance relative insurance table 2 panel 2 respondents hrs asked whether difficulty adl dressing bathing walking across room eating getting bed using toilet the total number adls respondents report difficulty close 1 average insured di beneficiaries entering di dropped 8% entering di in contrast di beneficiaries uninsured waiting period reported remarkable increase 90% difficulties adls uninsured waiting entitlement medicare diff diff estimate health measure 0.456 indicates statistically significant unadjusted effect reducing functional limitations alternative health insurance medicare waiting period table 2 panel 3 the diff diff estimates health outcomes indicate health status improves least deteriorate much insured di beneficiaries wave post di compared pre di period the effect somewhat surprising insured di beneficiaries consist mainly ssi recipients due means tested nature program worse health begin compared uninsured di beneficiaries likely lower investment health life see improvement less deterioration health waiting period this evidence likely suggests positive effect alternative health insurance di beneficiaries waiting period shown earlier table 3 except different health insurance coverage differential change pre-/post di 2 groups financial variables the worsening financial variables insured beneficiaries post di likely negative least nonpositive impact health but observe overall advantageous health changes among compared uninsured di beneficiaries the evidence likely underscores important role played access health insurance positively affecting health outcomes medicare waiting period given fact disabled workers usually forced drop labor force due onset severe work limitation lose labor earnings also likely lose employer provided health insurance for workers catastrophic health problems health insurance coverage would valuable the 2-year medicare waiting period creates additional barrier disabled workers alternative health insurance coverage transition period the evidence show may suggest negative health effects discontinuity health insurance coverage individuals serious health impairments the punitive effect lack health insurance access health care would likely even larger account disabled beneficiaries die waiting medicare entitlement about 2% sample dies entering di program entitled medicare this effect needs investigation larger sample disabled beneficiaries becomes available tests differential pre-/postchanges potential confounders di beneficiaries without health insurance waiting period abbreviations bmi body mass index di disability insurance gov government hrs health retirement study iadl instrumental activities daily living psych psychiatric unemp ins workers comp unemployment insurance workers compensation columns are separate regressions based equation 1 first differenced dependent variable listed column head differences taken wave di entry wave di entry d dummy di beneficiary insurance waiting period thus coefficient measures relative change dependent variable di beneficiaries without insurance waiting period we also examine effect pocket medical expenditures medicare waiting period medical expenditures table 2 panel 4 form natural log we see increase 16% pocket medical expenses uninsured wait medicare become available di beneficiaries alternative insurance medicare waiting period lower pocket medical expenditures 14% the diff diff estimate insurance effect 0.30 indicating 30% decrease pocket medical expenditures entering di program alternative public health insurance relative without in addition test effect insured medicare waiting period health outcome measure self reported work limitation effect employment rate find effects statistically significant sign consistent hypothesis however unadjusted effects either primarily driven preexisting difference 2 groups table a1 panel 1 mainly attributable changes 1 group uninsured di beneficiaries table a1 panel 2 table 4 presents several ols specifications equation 1 contrasts pre-/post di changes health economic outcomes di beneficiaries without insurance waiting period the estimation sample 1 first differenced observation per respondent illustrate impact controlling potential confounders shown table 3 column 1 shows unadjusted diff diff estimate table 2 reference column 2 add first differenced demographic variables household size indicator married neither additional controls statistically significant effect outcomes column 3 add first differenced financial variables total wealth net worth capital income total nonlabor income private pension income income unemployment insurance workers compensation government transfer income income the diff diff estimate declines slightly magnitude 3 health outcome measures goes bit magnitude pocket medical expenditures among financial control variables statistically significant effect total wealth health reporting effect government transfer income pocket expenditures indicating wealth associated reports excellent health less reports poor health receiving government transfer income likely associated receiving medicaid coverage lowering self paid medical expenses column 4 add extensive set first differenced health controls listed tables 1 4 diff diff estimates change much outcome measures among health control variables effects onset cancer lung disease heart disease high blood pressure self reported health status statistically significant the onset high blood pressure psychiatric problems shown statistically significant effect reporting adls difficulties the onset high blood pressure cancer stroke statistically significant effect pocket medical expenditures column 5 use multiple pre- postperiods shown equation 2 estimates different in first differenced specifications calculate standard errors allowing arbitrary correlation outcome measures within 2 comparison groups given year 2-period models shown columns 1 4 use calendar years obtain 20 group calendar year clusters multiperiod model shown column 5 cluster group time period relative di entry gives 16 clusters 8 periods 2 groups adjusted estimates health economic outcomes entering di program di beneficiaries without health insurance waiting period columns 1 4 separate regressions based equation 1 first differenced dependent variable differences taken wave di entry wave di entry column 5 based equation 2 first differenced dependent variable wave wave differences taken across 4 waves prior di entry 4 waves di entry d dummy di beneficiary health insurance waiting period income variables include capital income total nonlabor income private pension income income unemployment insurance workers compensation government transfer income income we include estimation indicator missing health information indicator missing financial information standard errors parentheses 2-period models shown columns 1 4 clustered group calendar year 20 clusters standard errors multiperiod model column 5 clustered group time period relative di entry 16 clusters the di beneficiaries primarily workers lose earnings capacity due severe health limitations many lose employer provided health insurance struck catastrophic health shock leave jobs 2-year waiting period medicare access creates health insurance gap great hardship negative health shocks financial shocks need affordable health insurance package ever eliminating medicare waiting period disabled workers discussed among policy makers researchers existing studies issue mainly focused fiscal impact policy this study first use longitudinal panel data set examine rich set controls analyze health economic consequences waiting period uninsured disability beneficiaries we take advantage longitudinal hrs covers period 1992 2010 provides rich information health status employment history wealth income family structure government program participation transfers linking hrs files social security master beneficiary record file able accurately line timing pre-/post di entitlement crucial study quasiexperimental research design use diff diff estimator first difference health economic outcome variables respondent entitled di benefits second difference newly entitled di beneficiaries access alternative public health insurance uninsured waiting medicare the adjusted diff diff estimates imply 13.6 percentage point drop proportion reporting poor health 6.3 percentage point rise proportion reporting excellent health drop total adl limitations 30.5% decline pocket medical expenditures among di beneficiaries health insurance access relative without waiting medicare entitlement the findings highlight adverse health economic effects lack health insurance medicare waiting period uninsured disability beneficiaries the study limitations take caution interpret results first study hope estimate effects immediate medicare coverage newly awarded di beneficiaries without 2-year waiting period counterfactual effects di beneficiaries eliminate waiting period end examine group newly awarded di beneficiaries alternative public health insurance mainly medicaid waiting period study changes health economic outcomes one assumption applying research design medicaid medicare similar coverage example similar health care services similar financing arrangements individuals but medicaid different effects medicare di beneficiaries estimation using medicaid insured beneficiaries counterfactual would likely produce biased results medicare effects di beneficiaries second 2 comparison groups di beneficiaries without health insurance medicare waiting period similar demographic variables look quite terms health status baseline wave prior di entry the insured di beneficiaries appear sicker uninsured beneficiaries entering di program make 2 groups comparable baseline this however would difficult implement given small sample size study with differences 2 groups baseline may alternative interpretations results for example health insured di beneficiaries deteriorate much even improve compared uninsured di beneficiaries former group initial poorer health may reflect transitory negative shocks latter group health may already accelerating downhill trajectory hypotheses hard test empirically third 2-year spacing hrs waves ideal although hrs best available data set research 2-year gap interview waves possible post di observations become entitled medicare coverage even among designated uninsured group however data limitation unlikely undermines results even possibly strengthens findings group clear observations actually insured medicare differential effects health economic outcomes insured uninsured di beneficiaries would even larger estimated the recently passed aca directly address medicare 2-year waiting period associated di program the act make changes help relieve problems health insurance gap for example many di beneficiaries join high risk insurance pool created aca receive immediate insurance coverage continue wait medicare benefits become available in addition starting 2014 disabled individuals waiting period access expanded insurance options state based insurance exchanges expanded medicaid eligibility although new options would completely solve problems associated medicare waiting period based evidence provided article policy changes likely provide least temporary relief many affected individuals disabilities course long term effects policy changes aca disability beneficiaries take time observe for example possible expanded insurance coverage possibilities disability beneficiaries makes medicare waiting period less deterrence make di attractive thus induced applications di program hand accessible health insurance options general aca will possibly make di program less appealing disabled individuals main driver apply di status quo get medicare coverage understand impact aca reforms di program interesting important aspects study especially relevant data become available time passing	purpose : disabled individuals younger than 65 years are entitled to medicare coverage through the social security disability insurance ( di ) program , but only if they have completed a 2-year waiting period . this is the first study that uses longitudinal panel data , the health and retirement study , and examines whether and to what extent the health and economic status are affected among disability beneficiaries who are uninsured during the medicare waiting period.methods:in a quasiexperiment research design , using a difference - in - difference ( diff - in - diff ) estimator , we compare changes in health and economic outcomes pre-/postentering the di program for disability beneficiaries with alternative public health insurance and those without.results:the adjusted diff - in - diff estimates suggest that disability beneficiaries who are uninsured during the waiting period , compared to those who are insured , are 13.6 percentage point more likely to report poor health , 6.3 percentage point less likely to be in excellent health , declare more difficulties in activities of daily living , and 30% higher medical expenditures from out of pocket.conclusions:the findings highlight punitive health and economic effects of the medicare waiting period for uninsured disability beneficiaries . we also discuss the implications of the findings for the affordable care act reform .
increasing number patients chest pain referred casualty department coronary emergency room cer prove exclude potentially serious disease acute coronary syndrome the challenge lies rapidly identifying patients safely discharged cer in addition necessary identify patients need aggressive treatment part acute coronary syndrome acs take appropriate action soon possible the diagnosis chest pain made 47 patients admitted cardiology department acs responsible symptoms 40 patients presenting chest pain cer the average period stay patients cer hospital currently 11 h. given increasing pressure capacity beds shorter length stay warranted the use biomarkers addition risk scores helpful optimising discharge policy cer shorter duration stay might achieved this study designed investigate evaluate opportunities early discharge created availability new sensitive biomarkers high sensitivity troponin assays hst 24 our study focuses extent hst combination risk score contributes optimisation earlier decision making discharge policy 46 h cer this study designed prospective cohort study cer rijnstate hospital arnhem period february 2011 july 2011 the study approved local ethics committee 131 patients initially participated clinical cardiologist patients for study patients presenting cer chest pain eligible patients could enrolled symptoms present less 6 h. excluded patients indication percutaneous coronary intervention pci patients st elevation myocardial infarction stemi non st elevation myocardial infarction nstemi typical angina elevated conventional troponin diagnosed admission finally patients treated cardiovascular complication e.g. heart failure unstable angina myocardial infarction past month also excluded all patients diagnosed treated based conventional troponin t. according discretion cardiologist non invasive ischaemia detection could performed discharge follow myocardial infarction defined rise and/or fall conventional troponin least 1 value 30 ng l patients presenting cer underwent initial clinical evaluation well routine laboratory tests including determination conventional troponin additional sample taken determine hst t1 this repeated 46 h t2 810 h symptom onset t3 if patients presented cer within window t2 t2 sample taken as conventional troponin hst measured e170 module modular immunoassay roche diagnostics we used 14 ng l cut value hst results considered increased. conventional troponin assay value set 30 ng l the 10 coefficient variation set 30 ng l the coefficient variation 10 set 13 ng l the conventional troponin meet requirement coefficient variation 99 percentile limit 10 the heart score scoring system patients presenting cer chest pain 6 7 assigning zero one two points atypical patient history ecg abnormalities patient age risk factors present elevated troponin patients score 0 3 points 1 chance developing cardiac event scoring 46 points 12 chance patients score 7 average 65 chance myocardial infarction percutaneous coronary intervention coronary artery bypass graft death within six weeks presentation mace 6 7 thirty days discharge presence mace follow registered retrospectively checking electronic patient files personal telephone communication patient additional information general practitioner needed forty two patients excluded basis exclusion criteria finally 89 patients included study 52 males 37 females overall mean age 61 years range 2090 years admission time cer varied considerably ranging 30 min 6 h symptom onset table 2 shows range means values hst conventional troponin assays measured different time points table 3 shows results combination hst heart score t2 t3 incidence mace follow patients hst 14 ng l t2 t3 could mace follow whereas patients heart score 3 mace follow-up.table 1baseline characteristicsn 89gender52 male 37 femaleagemean 61 year range 2090)duration symptomsmean 196 min range 30360)heart score using ctnt)mean 4.15 range 18)history vascular disease39 44 diabetes mellitus17 19 smoking25 28 hypertension29 32 family history vascular disease30 34 hypercholesterolaemia32 36 table 2descriptive values conventional troponin hst assaysconventional troponin ng l)nminimummaximummeansdt1 entry)8916.030.029.61.9t2 4 h 6 h)8911.0333.032.932.3t3 8 h 10 h)8913.0661.041.575.0hst ng l)nminimummaximummeansdt1 entry)893.071.910.412.4t2 4 h 6 h)893.0347.014.737.9t3 8 h 10 h)893.0675.424.483.8table 3combining hst heart score t2 t3 order calculate risk macehst t2)nheart scoremaceno mace 14 ng l3113031(n 68)3446331371003 14 ng l01300(n 21)1346310871035hst t3)nheart scoremaceno mace 14 ng l3113031(n 65)3146229371003 14 ng l01300(n 24)1646412871035 baseline characteristics descriptive values conventional troponin hst assays combining hst heart score t2 t3 order calculate risk mace sixty eight patients 89 76 presented hst values 14 ng l thirty one patients 46 heart score 13 group thirty seven patients 42 hst levels 14 ng / l t2 heart score 3 group 3 mace occurred one month follow 8 these 3 patients pci significant coronary stenosis angiographically 70 and/or fractional flow reserve 0.8 30 days follow 21 patients 24 ) the probability cardiac event group substantially higher 28 group patients low heart score fig 1 hst levels t2 t3 compared t2 46 h onset symptoms 68 patients hst value less 14 ng l t3 ( 810 h start symptoms 3 patients 4 hst levels increased levels cut value 14 ng l average increase 3 patients 30 all 3 patients moderately increased heart score 4 6 based heart score need longer follow repeat hst determination one patient occurrence mace follow-up.fig 1eps changes serum high sensitivity troponin hst patients level 14 ng l 4 6 h onset symptoms eps changes serum high sensitivity troponin hst patients level 14 ng l 4 6 h onset symptoms we investigated value heart score risk stratification model use conventional troponin hst patients suspected acs our main findings patients normal hst heart score 3 could safely discharged t2 mace occurred heart score 4 monitoring serial troponin tests and/or extra investigation exercise testing nuclear imaging stress echocardiography may required small proportion patients mace follow patients elevated hst t2 t3 and/or heart score 7 high risk mace the heart score specially validated risk score patients chest pain presenting emergency department netherlands 6 7 other risk scores grace timi risk score mainly validated patients stemi nstemi therefore less useful category patients 8 9 it noted risk scores include elevated cardiac markers point scoring system the heart score system makes use conventional troponin score system validated especially current widespread use hst cardiology practice present study 3 patients 4 initially normal hst t2 showed rise cut value 14 ng l t3 the significance increase present unclear advocate 100 rise associated acute thrombotic myocardial infarction if clinical decision making based hst alone 3 patients would identified high risk patients risk mace also taking heart score account the use risk score heart score provide additional information identifying patients as mentioned earlier heart score validated conventional troponin hst it expected using high sensitivity assay new heart score hst levels often elevated compared conventional troponin hereby new risk score could higher sensitivity cost less specificity further studies provide conclusions regarding discriminative value new risk score despite fact cardiac troponins sensitive specific biochemical markers myocardial damage an increased troponin level occurs many diseases heart show ischaemia congestive heart failure pulmonary embolism renal failure acute neurological disease myocarditis sometimes apparently healthy persons furthermore availability new high sensitive assays troponin may allow detection small changes troponin test meets requirements universal definition myocardial infarction universal definition acute myocardial infarct states typical rise and/or fall biochemical markers preferably troponin least 1 value 99 percentile reference limit least one following ischaemic symptoms ecg changes pathological q waves imaging evidence new loss viable myocardium motion abnormality the hst assay meet requirement coefficient variation 99 percentile limit 10 the test appear sensitive able even 3 h symptom onset differentiate whether acute coronary syndrome early decision making therefore possible problem may arise possibility false positive results acute coronary syndrome however still unclear whether absolute relative increase troponin values in addition moment also unclear much troponin values increase speak acute coronary syndrome some advocate doubling serum hst within 3 h indicates acute coronary syndrome whereas others including guidelines state rise and/or fall least 1 value 14 ng our study relatively small therefore future studies aimed extending findings including patients evidence larger study populations conclusions clinical decision making drawn study suggests patients chest pain cer negative hst level together low heart score safely discharged hospital within 4 6 h onset symptoms	patients with chest pain have a large impact on available resources in coronary emergency rooms ( cer ) . clinical judgement , ecg , risk scores and biomarkers guide in risk stratification . we investigated if high - sensitivity troponin t ( hst ) and the heart score could contribute to risk stratification at the cer . all patients with chest pain , without elevated conventional troponin levels at presentation , were included . hst levels were determined at admission ( t1 ) , at 46 h ( t2 ) and 810 h after symptom onset ( t3 ) . the heart score was calculated as risk score for the occurrence of a major adverse cardiac event ( mace ) . thirty days after discharge , occurrence of mace was registered . eighty - nine patients were included ( overall mean age 61 years ( range 2090 ) ) . at presentation , 68 patients ( 76 % ) had a hst below cut - off value of 14 ng / l ( mean heart score 3.7 , range 19 ) . thirty - one of these 68 patients had a heart score between 13 , no mace occurred in this group . for 3 patients ( 4 % ) hst levels increased above 14 ng / l . these 3 patients had a heart score between 46 . the majority of patients with chest pain can be safely discharged within 46 h after onset of symptoms using hst and the heart score . in contrast , patients with initially normal hst but a high heart score need longer follow - up and repeat hst determination .
hepatectomy established standard care patients resectable liver limited metastases colorectal cancer origin 1 2 hepatectomy also undertaken range malignant benign conditions 3 4 contemporary experience techniques downsizing tumours neoadjuvant chemotherapy modification volume future remnant liver selective portal vein embolization results ability offer liver resection greater proportion patients liver metastases these changes coupled population trends resulting greater proportion elderly patients presenting treatment mean 21st century liver resection metastatic colorectal cancer often undertaken older individuals and/or patients whose hepatic functional reserve may compromised prior chemotherapy preexisting chronic liver disease although reports outline feasibility undertaking liver resection low perioperative mortality 9 10 postoperative morbidity important influence range outcomes including critical care occupancy patient stay uptake adjuvant chemotherapy quality life surgery liver resection ir injury occur series operative steps including liver mobilisation permanent inflow occlusion segment resected temporary inflow occlusion followed restoration blood flow future remnant liver pringle manoeuvre ir injury important determinant postoperative morbidity eventual clinical outcome 11 12 strategies employed minimise ir injury include avoidance inflow occlusion ischaemic preconditioning administration pharmacologic agents cellular level kupffer cells release proinflammatory mediators liver ir including oxygen derived free radicals the physiologic intracellular defence mechanisms involved regulation oxidative injury include enzymatic pathways catalysed superoxide dismutase glutathione peroxidase glutathione gsh tripeptide composed glycine glutamic acid cysteine constitutes largest component endogenous thiol buffer oxygen derived free radicals tissue gsh synthesis acetylcysteine thiol containing synthetic compound isolated perfused rat liver administration nac reperfusion results concentration dependent increases gsh concentrations bile corresponding increases bile flow 19 20 currently established clinical use n acetylcysteine treatment acetaminophen paracetamol poisoning 21 22 to date one small clinical trial assessed effect perioperative n acetylcysteine prevention ischemia reperfusion injury liver resection liver function assessed postoperative transaminase alt rise significantly ameliorated treatment group despite predominantly favourable results experimental studies substantive clinical trials evaluating role n acetylcysteine pharmacological agents modulate ir injury patients undergoing hepatectomy these drugs particular n acetylcysteine available long time anecdotal evidence suggests still used licence mode modifiers liver ir hepatectomy a questionnaire survey provides overview contemporary use pharmacological modulation ir injury liver surgical practice an international target population clinical units undertaking liver surgery obtained livermetsurvey thus aim study undertake questionnaire survey use pharmacological agents modify liver ir injury patients undergoing hepatectomy colorectal liver metastases units participating livermetsurvey the questionnaire design examined strategies modulation liver ir injury hepatectomy included questions broad overview techniques purpose addition pharmacological interventions specific detail sought whether pharmacological agents used respondents treat reduce liver ir injury information sought indications use choice agent use loading dose timing use relation stage surgery preoperative intraoperative posttransection etc dose anticipated prior literature searches n acetylcysteine would widely used agent specific focus was given drug 24 25 final question sought opinion whether respondent supported concept randomized trial evaluate role pharmacological ir modifiers hepatectomy permission obtained livermetsurvey members sent online questionnaire using surveymonkey https://www.surveymonkey.com/ the livermetsurvey selected registry liver resection outcomes colorectal hepatic metastases thus participants would likely undertaking hepatectomy response questionnaire discretionary following initial email reminders sent the questionnaire live period six weeks june 18 2013 sent 446 participants livermetsurvey there 85 respondents two actively engaged liver resection practice these two respondents excluded provide final study population 83 19% respondents the study discussed hospital research development team advised patient contact email contact professional colleagues ethics committee submission required the number respondents individual question provided serves denominator percentage respondents particular question several questions more one response permitted therefore cumulative total percentage responses questions exceed 100 72 respondents question one response permitted figure 1 the frequently used strategy avoidance pringle manoeuvre 53 74% respondents six 8% replied used pharmacological agents modify liver ir injury fifty two 77% stated never used pharmacological agents modify liver ir injury hepatectomy ten 56% stated requirement total vascular exclusion indication use pharmacologic agents 9 50% stated prolonged inflow occlusion indication 9 50% used pharmacological agents evidence deterioration liver function postoperative period 8 44% used pharmacological agents setting small volume future remnant liver 7 39% major liver resection 3 couinaud segments 5 28% liver resections undertaken patients cirrhosis 4 22% patients received prior chemotherapy individual replies received one respondent glutamine desflurane sevoflurane bicarbonate arginine cocktail methionine vitamins c e. 22 responses question 14 64% replying use loading dose three 17% used pharmacological intervention prior surgery form steroids two 11% gave nac induction anaesthesia four 22% liver mobilisation two 11% commencement transection two 11% postoperatively routinely five 28% postoperatively selectively there 9 respondents used n acetylcysteine modulation liver ir injury seven 78% used standard dose patients 2 22% used body weight adjusted dose three 33% continued infusion 48 hours 3 33% serum transaminases started fall 2 22% 72 hours 1 11% 24 hours fifty six 81% answered affirmatively 6 9% replied trial this study reports results thought first survey use pharmacological agents modify liver ir injury perioperative period first results way represent official position statement livermetsurvey second given less 20% target audience responded questionnaire replies indicative consensus view third possible responded vested interest pharmacological modification liver ir injury thus results could skewed ascertainment bias the target population selected livermetsurvey participants definition units undertaking liver surgery colorectal hepatic metastases clearly views units clinicians outwith livermetsurvey captured survey interpretation results bearing caveats mind produces interesting overview pharmacological modification liver ir injury first minority respondents use pharmacological agents modify liver ir injury hepatectomy 6 8% 72 respondents stating used strategy figure 1 the influence phrasing question answer seen asked specifically whether pharmacological agents used modify liver ir injury next question 13 19% 68 respondents replied used agents selectively addition 3 4% used routinely nonetheless clear small study pharmacological modification ir injury hepatectomy used minority respondents despite negative results randomised controlled trial ischaemic preconditioning reduce liver ir injury the selection criteria use pharmacologic agents interesting clinicians using agents employed major resections individuals compromised liver parenchyma function observation may worth bearing mind future randomized trial considered targeted use may appropriate routine use liver resections terms choice pharmacological agent emphasised questionnaire restricted responses 18 responses received question n acetylcysteine used without loading dose frequent choice there clearly consensus optimum time commencement nac duration use although majority respondents favoured standard dose patients without adjustment body weight the majority respondents 56 67% cohort support randomised trial view patterns current use would appear role explored patients undergoing extended resection compromised functional hepatic reserve small remnant liver resection summary thought first questionnaire survey population clinicians undertaking surgery colorectal liver metastases investigate use pharmacological agents modification liver ir injury although response rate 19% resultant population 83 clinicians largest specialist group contribute data question date the results show pharmacological modulation liver ir injury routine component care liver resection contemporary hepatic surgery practice used routinely 3 4% respondents within livermetsurvey selectively 13 19% indications major resections patients compromised liver reserve	objectives . this study is a questionnaire survey on the use of pharmacological agents to modify liver ischaemia - reperfusion ( ir ) injury in patients undergoing hepatectomy for colorectal liver metastases with the target population being those units participating in the livermetsurvey international registry . methods . members of livermetsurvey were sent an online questionnaire using surveymonkey comprising ten questions on the use of pharmacological agents to modulate hepatic ir injury in the perioperative period after hepatectomy . the questionnaire was sent to 446 clinicians registered with the livermetsurvey . there were 83 ( 19% ) respondents . results . fifty - two ( 77% of 68 respondents to this question ) never used pharmacological agents to modify liver ir injury during hepatectomy . thirteen ( 19% ) used pharmacological agents selectively . three ( 4% ) used these routinely . n - acetylcysteine was the most widely used pharmacological agent with equal distribution of use around intraoperative and postoperative periods . conclusions . this is believed to be the first survey on the use of pharmacological agents to modify liver ir injury . the target population is clinicians involved in liver resection . the results show that pharmacological modulation is used by only a minority of respondents to this questionnaire and that when this treatment is selected , n - acetylcysteine is the most frequently used .
	the goal of the present study was to determine if the expression of metallothionein isoform 3 ( mt-3 ) might serve as a biomarker for human bladder cancer . to accomplish this goal , we defined the localization and expression of mt-3 protein and mrna using fresh and archival biopsy specimens obtained from patients undergoing differential diagnosis for a variety of bladder disorders . we used immunohistochemistry , immunoblot , and rt - pcr analysis to define the localization and expression of mt-3 protein and mrna . immunohistochemical analysis disclosed no immunoreactivity for mt-3 in normal bladder cells . the absence of mt-3 expression in the normal bladder was further confirmed by demonstrating that mt-3 mrna could not be detected using reverse transcriptase - polymerase chain reaction ( rt - pcr ) or mt-3 protein using immunoblot . immunohistochemistry also disclosed no immunoreactivity for mt-3 in archival biopsy specimens from patients with interstitial cystitis and related disorders . immunohistochemical analysis demonstrated that mt-3 was expressed in carcinoma in situ ( cis ) , high - grade bladder cancer , low - grade bladder cancer , and dysplastic lesions . mt-3 immunostaining was intense in both cis and high - grade bladder cancer , and low to moderate in low - grade bladder cancer and dysplastic lesions . we determined mt-3 mrna expression in a subset of these bladder cancer specimens ; expression was elevated as compared to that of the housekeeping gene , ss - actin . the cdna from the rt - pcr reaction primed for mt-3 contained a foki restriction site , a site unique for mt-3 as compared to other mt family members . in conclusion , this study demonstrates that mt-3 is up - regulated in human bladder cancer and that this up - regulation increases with increasing tumor grade . the finding that mt-3 expression is minimal in normal bladder suggests that mt-3 might be developed into an effective biomarker for bladder cancer.imagesfigure 1figure 2figure 3figure 4
nevus ota light bluish nevus unilateral face congenital acquired adolescents often seen asian females malignant transformations rarely observed orbit 1 seldom seen among asians 2 as potential local invasion metastasis varies widely strict prognostic indicators orbital melanoma yet established 3 animal type melanoma rare type malignant melanoma usually arises skin lesions 4 shows indolent progression good prognosis despite metastasis best knowledge this first case report primary animal type malignant melanoma orbit developed nevus ota show satisfactory clinical course a 42-year old woman presented right sided eye swelling fever she diagnosed diabetes mellitus 2 years previously received medication she particular family history except fact father stomach cancer bluish pigmentations visible right forehead ear eyelid since birth hertel exophthalmometry showed exophthalmos right eye 24 18 mm right left eyes respectively base 110 mm fig ocular movement right eye restricted horizontal upward gaze intraocular pressure 19 mmhg right eye 18 mmhg left eye mri showed right sided exophthalmos 2.53 cm large well defined intraconal mass the tumor heterogeneous slightly high intensity observed gadolinium enhanced t1-weighted image t1-wi low intensity gadolinium enhanced t2-weighted image t2-wi fig another 56 mm large mass discontinuous orbital tumor cranial base also observed primarily presumed meningioma fig laboratory tests indicated diabetes mellitus uncontrolled hba1c 11.5% normal ldh level 220 u l ( bluish pigmentation seen right eyelid black pigmentation seen right conjunctiva ( b t1-weighted image right sided exophthalmos seen retrobulbar mass showed slightly high intensity t1-weighted image indicated arrow ( c t2-weighted image right sided exophthalmos seen retrobulbar mass showed low intensity t2-weighted image indicated arrow a 56 mm large mass discontinuous orbital tumor cranial base also enhanced indicated arrowhead the tumor ruptured operation biopsy pathological diagnosis frozen later analysis because subsequent pathological diagnosis frozen specimen operation showed benign lesion completed tumor excision without orbital extirpation ( macroscopy extracted orbital tumor highly pigmented 62 cm large tumor ruptured extirpation ( b hematoxylin eosin staining orbital tumor 20 melanin containing cells melanocytes melanophages abundant tumor ( c hematoxylin eosin staining orbital tumor using bleaching method melanins 20 diffuse proliferation epithelioid cells spindle cells low grade nuclear atypia seen ( e melan staining 20 positive atypical cells ( f hematoxylin eosin staining orbital tumor using bleaching method melanins 20 vast areas necrosis seen after preparation sample pathological examination tumor showed lesion animal type malignant melanoma after using bleaching method melanins hematoxylin eosin staining performed fig 2c all cells low grade pleomorphic nuclei nucleoli observed cells although found prominent hmb human melanoma black)-45 fig 2d melan fig we performed orbital extirpation excision 5 mm margin nevus ota orbit covered skin graft taken patient thigh these cells found skin subcutaneous fat orbital muscle orbital fat lacrimal gland sclera results also showed retina uvea cornea involved some parts nevus cellular slightly large round epithelioid melanocytes contained low grade pleomorphic nuclei although accompanied small nucleoli neither necrosis mitosis observed although malignant changes apparent time procedure findings suggest possibility atypical melanocytes might early stage melanoma mri performed second operation showed slight enlargement high intensity t1-wi cerebral mass considered meningioma in addition second surgery chemotherapy dav therapy combination dacarbazine nimustine vincristine stereotactic radiotherapy 54 gy 27 fractions gamma knife marginal dose 17 gy target volume 0.2 ml administered since then examined every 23 months laboratory tests including lactate dehydrogenase aspartate aminotransferase alanine aminotransferase we also taken biopsies check orbital local recurrence performed annual 18f fluorodeoxyglucose positron emission tomography check metastasis otolaryngologists dentists checked pigmentation mouth physicians brought severe diabetes mellitus control thirty three months passed since second surgery sign local recurrence new metastasis enlargement intracranial tumor the nevus ota oculodermal melanocytosis naevus fusculocoeruleus ophthalmomaxillaris described japanese dermatologist ota 1939 it light bluish nevus unilateral face congenital acquired adolescents it shown common east asians 0.21.0% western populations 0.04% 5 the incidence malignant change 0.5% east asians 25% western populations 2 therefore calculated incidence malignant melanoma associated nevus ota 0.0010.005% 0.21.0%0.5% among east asians whereas 0.01% 0.0425% among western populations malignant melanoma associated nevus ota reported occur uveal tract 6 optic nerve head 7 brain orbit as western populations rice brown 8 reported finding six cases primary orbital melanoma associated nevus ota whereas two studies additionally reported two cases 1,9 however terms east asian populations first report case the original report animal type melanoma based highly pigmented malignant melanoma found horse shown rare variant melanoma it reported melanoma usually occurs skin lesions found scalp face extremities 10 of eight reported orbital melanoma cases pathological diagnosis indicated five spindle two epithelioid one mixed 1,8,9 the current patient first case animal type melanoma arose orbit histopathologically animal type melanoma cells show nuclear atypia regular oval round nuclear shapes moderate anisonucleosis small nucleoli distributed chromatin characteristically fulfill cytologic criteria malignancy the important clue diagnosis animal type melanoma effacement dermal architecture areas confluent melanocytic growth all cells low grade pleomorphic nuclei nucleoli seen cells distant metastases animal type melanoma rare even occur patients appear better prognosis ordinary melanoma presenting metastatic disease 10 it may characteristic patient showed neither enlargement tumor neurologic symptoms long despite intracranial metastasis however even low malignant potential animal type melanoma clearly variant melanoma 10 therefore application guidelines used melanoma clinical investigation regional distant metastases surgical treatments safety margins 12 recommended types cases 13 thirty three months since extirpation patient still alive careful follow examinations despite intracranial metastasis not combination therapy also low malignancy animal type melanoma may contributed toward good prognosis although possibility high malignant transformation occurs nevus ota important consider possibility seen population groups doctors involved treatment nevus ota case ophthalmologists pathologists dermatologists brain surgeons otolaryngologists radiologists dentists understand malignant transformation could occur cooperate one another treatment although practical strict prognostic indicators orbital melanoma yet established 3 particular case suggests characteristic indolent progression animal type melanoma might partly contribute toward good prognosis	we present a patient with an animal - type malignant melanoma associated with the nevus of ota in the orbit who showed a good prognosis after a combination of orbital extirpation , chemotherapy , stereotactic radiotherapy , and gamma knife . a 42-year - old japanese woman presented with two tumors , one pathologically diagnosed as right - sided intraconal animal - type malignant melanoma and the other intracranially , presumed to be of the same pathogenesis and both were considered to have arisen from the nevus of ota . she underwent an extirpation of the orbit , chemotherapy ( dav therapy , which is a combination of dacarbazine , nimustine , and vincristine ) , stereotactic radiotherapy ( 54 gy in 27 fractions ) , and gamma knife ( marginal dose was 17 gy , target volume was 0.2 ml ) . she has been alive for 33 months since the extirpation , with no sign of local recurrence , new metastasis , nor enlargement of the intracranial tumor . not just combination therapy but also the low malignancy of animal - type melanoma may have contributed toward the good prognosis .
prevalence type 2 diabetes t2d rural regions rising rapidly great challenge local health care programs china large parts diabetic individuals lived rural areas resources screen treat diabetes complications limited 13 so far situations type 2 diabetes presenting ketosis prior admission south west rural region unclear ketosis symbol acute disorder glucose lipids metabolism diabetic patients ketosis ketoacidosis regarded trait type 1 diabetes t1d because backward economy quite patients get duly treatment severe hyperglycemia diabetic complications occurred our present study investigate prevalence characteristics t2d presenting ketosis rural areas aiming suggest efforts prevention control diabetes rural areas china we performed retrospective analysis t2d ketosis patients admitted endocrinology department baoshan people hospital yunnan province january 2011 july 2015 overall data 391 t2d presenting ketosis inpatients aged 12 years older enrolled nine patients excluded surgery pregnancy trauma secondary diabetes pancreatic exocrine diseases thus 371 patients 245 males 126 females allocated analysis according diabetic duration new onset group included new diagnosed diabetes 6 months onset old diagnosed group patients previously diagnosed t2d presenting ketosis admission t2d diagnosed patients clinical metabolic features including overweight obesity 40 years age onset obvious diabetes family history combination preserved -cell function fasting c peptide 0.33 t2d ketosis diagnosed patients met criteria t2d positive urinary ketone body results time admission urinary ketone body positive diagnosed urinary acetoacetate increased 15 mg dl using sodium nitroprusside method acidosis diagnosed arterial ph less 7.35 and/or blood bicarbonate level less 15 overweight obesity defined body mass index bmi 24 set forth chinese guidance overweight obesity adults data demographic clinical characteristics including age gender height weight bmi blood pressure diabetic family history collected laboratory parameters including plasma glucose hba1c c peptide total cholesterol triglycerides recorded the chronic diabetic complications including peripheral neuropathy retinopathy diabetic foot persistent microalbuminuria evaluated trained physicians hospitalization all data analyzed jmp 9.0 sas institute cary nc the anova mann whitney test analysis used evaluate differences continuous variables table 1 showed clinical characteristics new onset old diagnosed t2d ketosis patients among total 371 subjects 211 patients 57% classified new onset 160 43% old diagnosed t2d ketosis the subjects new onset group average duration 1.7 months weight loss 7.3 kg old diagnosed group average diabetic duration 6.3 years weight loss 9.2 kg subjects new onset group younger 47 12 versus 53 13 yr p 0.001 overweight 50% versus 46% p 0.009 old diagnosed t2d ketosis family history diabetes similar p 0.79 new onset 35% old diagnosed 34% group the blood pressure analyzed subjects significantly different two groups table 2 showed biochemical characteristics new onset previously diagnosed t2d patients presenting ketosis fasting plasma glucose mmol l old diagnosed 16.4 7 mmol l p 0.49 group 2 h plasma glucose also similarly elevated p 0.86 new onset 24.2 8 fasting c peptide levels similar p 0.60 new onset 0.69 0.11 nmol l old diagnosed 0.58 0.17 2 h c peptide significantly higher p 0.02 new onset 2.58 1.1 the hemoglobin a1c hba1c fructosamine different two groups more patients old diagnosed group 19.4% suffered acidosis new onset group 6.6% total cholesterol 5.9 1.7 versus 4.9 1.8 mmol l resp new onset old diagnosed group p 0.0001 triglyceride 4.4 4.0 versus 3.7 4.2 mmol l resp in new onset old diagnosed group p 0.004 significantly higher new onset old diagnosed group those new onset patients showed lower incidence predisposing factors previously diagnosed t2d patients presenting ketosis 13.8% versus 38.7% p 0.001 the potential triggers subjects t2d ketosis varied among infections predominant groups the prevalence respiratory system infection 10.3% new onset 14.9% old diagnosed group urinary system infection 1.8% new onset 9.9% old diagnosed group figure 2 showed prevalence chronic diabetic complications new onset previously diagnosed t2d ketosis the patients new onset higher p 0.0001 prevalence fatty liver disease 26.2% compared old diagnosed 15.1% group prevalence chronic complications higher old diagnosed group new onset group including retinopathy 8.1% versus 17.8% resp new onset old diagnosed group p 0.0001 peripheral neuropathy 25.3% versus 47.6% resp in new onset old diagnosed group p 0.0001 diabetic foot 13.3% versus 23.2% resp new onset old diagnosed group p 0.0001 persistent microalbuminuria 8.2% versus 15.1% resp new onset old diagnosed group p 0.0001 significant differences p 0.45 atherosclerosis found new onset 18.0% old diagnosed 20.1% group in study showed characteristic t2d ketosis rural areas south west part china it concluded study control t2d poor rural area reflected extremely elevated hba1c plasma glucose performed admission also high prevalence chronic diabetic complications evaluated hospitalization there limited data prevalence ketosis type 2 diabetes population study 134 chinese patients severe hyperglycemia there 24 patients diagnosed ketosis 17.9% 6 patients diagnosed ketoacidosis 4.5% subjects new onset old diagnosed t2d ketosis group similarities differences clinical manifestations consistent previous studies found predominance male proportion study subjects 711 the underlying mechanisms male predominance t2d ketosis unknown needed investigation differences body fat distribution sex hormone supposed factors contributing gender difference 12 13 study the prevalence hyperlipidemia high new onset old diagnosed subject true many previous studies 11 1416 some investigators reported acute elevation free fatty acid levels circulation increased insulin resistance impaired -cell function 17 18 study subjects the prevalence hyperlipidemia 60% subjects new onset group 29% old diagnosed group we analyzed data found hyperlipidemia common overweight diabetic subjects bmi enrolled patients positively correlated triglyceride total cholesterol level data shown the phenomenon confirmed view hyperlipidemia played substantially roles underlying trigger ketosis especially new onset diabetes therefore interventions prevention treatment overweight hyperlipidemia essential t2d patients infections common precipitating factors ketosis t2d patients important point distinguishing t2d t1d patients t1d noncompliance insulin therapy considered first reason precipitating ketosis 14 19 old diagnosed t2d subjects varied infections accounted 40% total precipitating factors indicating infections important precipitating factors leading ketosis however new onset ketosis subjects cases nonprovoked ketosis the discrepancy prevalence precipitating factors might indicate complexity heterogeneity t2d ketosis more clinical epidemiological surveys need conducted clarify heterogeneity t2d ketosis study subjects patients higher incidence diabetic chronic complications especially previously diagnosed t2d patients it shown literatures came regular follow diabetic treatment lower incidence retinopathy nephropathy compared irregular follow since t2d chronic complications silent first patients usually come clinic routine examination developed severe complications diabetes rural areas result patients complicated severe chronic complications fist diabetic diagnosis however late treatments diabetes complications often associated higher costs affected patient 1 20 therefore reasonable suggest detection adequate treatment earlier stage excess cost due treatment diabetes complications might minimized first perform plasma ketosis test sensitive specific detecting ketosis however urinary ketone body measurements widely acceptable hospitals diagnosing ketosis second measure body fat distribution potential important parameter explaining gender difference t2d ketosis third single center study restricted ability assess overall characteristics t2d ketosis rural areas further large cohorts prospective follow studies needed clarify characteristics t2d ketosis south west rural parts china summary study shows characteristics t2d ketosis adults rural areas south west part china t2d ketosis severe disorder glucose lipids metabolism prone acquire chronic complications thus urgent important need implementation effective screening health knowledge promotion control diabetes	objectives . type 2 diabetes ( t2d ) with ketosis was common because of late diagnosis and lacking adequate treatment in rural regions of china . this study aimed to provide the data of t2d with ketosis among inpatients in a south - west border city of china . methods . data of 371 patients of t2d with ketosis who were hospitalized between january 2011 and july 2015 in baoshan people 's hospital , yunnan , china , were analyzed . new - onset and old - diagnosed t2d patients presenting with ketosis were compared according to clinical characteristics , laboratory results , and chronic diabetic complications . results . overall , the blood glucose control was poor in our study subjects . male predominated in both groups ( male prevalence was 68% in new - onset and 64% in old - diagnosed groups ) . overweight and obesity accounted for 50% in new - onset and 46% in old - diagnosed cases . inducements of ketosis were 13.8% in new - onset and 38.7% in old - diagnosed patients . infections were the first inducements in both groups . the prevalence of chronic complications of diabetes was common in both groups . conclusions . more medical supports were needed for the early detection and adequate treatment of diabetes in rural areas of china .
adipose tissue believed passive organ storing excess energy considered real endocrine organ important role regulation homeostatic systems it secretes various proteins classified molecules acting metabolic processes like glucose homeostasis insulin sensitivity inflammatory molecules like interleukin 6 il-6 interleukin 1 tumor necrosis factor- c reactive protein c rp leptin adiponectin the adipose tissue may account 2025% systemic il-6 circulating levels seems involved systemic inflammatory response associated obesity insulin resistance metabolic syndrome basis adipose tissue represents new fascinating multidisciplinary object research we previously found clear expression il-6 receptors c reactive protein human adipocytes obtained adipose tissue fragments different districts subcutaneous omental noninflamed inflamed patients showing adipose tissue particular adipocyte responsible generating inflammatory state per se also represents target systemic inflammation we observed fact adipocyte stimulated il-6 cell receptor produces c rp happens hepatocyte adipose tissue mesodermallyderived organ contains addition adipocytes stromal population composed different cell types pre adipocytes stem cells fibroblasts macrophages mature adipocytes account 4060% whole cell population whatever type adipose tissue pre adipocytes present throughout adult life adipose tissue proliferate differentiate mature adipocytes according energy balance also share features macrophages capacity phagocytosis response different stimuli another important cell population adipose tissue represented mesenchymal stem cells mscs adherent fibroblast like pluripotent nonhematopoietic progenitor cells these cells retain capacity undergo many mesenchymal cell types including bone cells 8 9 neuronal cells adipose muscular tissue vitro note hepatocyte like cells 1315 thereby both pre adipocyte restricted potential multipotent mesenchymal cell represent adipocyte precursors albumin normally produced hepatocyte abundantly circulating protein blood plays important role binding protein involved regulation colloid osmotic homeostasis it also negative acute phase protein hypoalbuminemia result combined effects inflammation inhibitory cytokine especially il-6 inadequate protein caloric intake patients chronic inflammatory disease chronic renal failure represents cardiovascular risk factor considered well known active role adipocyte c rp production presumable link adipocyte hepatocyte aimed study investigating mature adipocytes express gene albumin evaluating whether systemic inflammation might regulate expression previously found c rp furthermore speculated whether adipocyte might contribute total circulating levels albumin happens il-6 human subcutaneous adipose tissue samples obtained twelve subjects divided two subgroups basis preliminary evaluation c rp circulating levels according pepys hirschfield assumed cut level 3 mg l order discriminate inflamed noninflamed patients basis c rp values obtained group six healthy noninflamed subjects without clinical symptoms sign inflammation underwent minor surgery procedures group six patients chronic inflammatory disease underwent elective surgical procedures four cancer b two patients operated cholecystectomy all enrolled subjects provided written informed consent ethics committee hospital approved study avoid possible confounding inflammatory effect exerted obesity overweight status inflamed patients noninflamed controls bmi matched groups subjects the presence systemic diseases vasculitis rheumatoid arthritis osteoarthritis bowel lung inflammatory disease excluded subjects excepted malignancy particular definitive inclusion possible existence immunological disease malignancy healthy group infectious disease carefully investigated excluded blood samples collected surgical procedures studied subjects obtain serum aliquots adipose tissue biopsies obtained surgical procedures 12 subjects patient obtained sample subcutaneous total white adipose tissue sample omental adipose tissue removal get rid tissue debris bioptic material washed twice warm sterile 0.9% nacl solution sample immediately frozen liquid nitrogen stored 80c rna extraction c rp circulating levels determined high sensitivity elisa assay bender medsystems vienna austria serum aliquots subjects included study the lower detection limit 3 pg ml overall intra assay coefficient variation calculated 6.9% the concentrations il-6 plasma samples analyzed elisa using commercially available kit quantikine r&d systems minneapolis mn described elsewhere the lower detection limit il-6 assay 0.70 pg ml coefficient variation inter- intra assay 5% adipose tissue fragments obtained six noninflamed subjects six inflamed patients placed 37c sterile 0.9% nacl 5.6 mm glucose 25 mm hepes buffer ph adjusted 7.4 containing 50 u penicillin ml plus 50 mg streptomycin ml the adipose tissue fragments minced sterile conditions digested krebs ringer bicarbonate buffer supplemented 5.6 mm glucose 50 u penicillin ml 50 mg streptomycin ml 17 mg type collagenase/10 g adipose tissue worthington biochemical lakewood nj digestion 75 min 37c rotary agitation 40 rpm the isolated cells filtered single layer chiffon isolated adipocytes allowed float 5 min 37c the fluid floating adipocytes containing stromal fraction transferred conical polypropylene 50-ml centrifuge tube for adipocytes 1 ml cell suspension adipose cells suspended tube containing specific adipocyte medium zen bio research triangle park nc incubated specific conditions cell lysis process the stromal fraction centrifuged 800 g 10 min isolation pre adipocytes first centrifuged cell pellet 800 g 10 minutes washed three times dulbecco modified eagle medium nutrient mixture f-12 ham combination 01 01 dmem f12 gibco brl carlsbad california supplemented give 15-mm nahco3 penicillin 50-u ml streptomycin 50 mg ml after washing pellet resuspended trituration dmem supplemented pre adipocyte f12 containing 10% fetal bovine serum fbs gibco brl carlsbad ca the cells plated incubated humidified incubator 37c atmosphere 5% co2 air 24 hours allow attachment proliferation cells 24 hours medium removed replaced specific pre adipocyte medium zen bio inc research triangle park nc subculture the genome sequences corresponding albumin -actin obtained genebank http://www.ncbi.nlm.nih.gov/ identify specific primers we analyzed exon sequences establish pair primers sense antisense able generate amplified fragments measuring 150 700 bp length annealing temperature 55 62c the sense antisense primers selected include least one intron prevent genomic dna contamination amplification four g total rna subjected cdna synthesis 1 h 37c using ready go primer first strand beads kit amersham pharmacia biotech piscataway nj code 27 9264 01 reaction mixture containing 0.5 g oligo dt amersham pharmacia biotech cod pcr amplification cdna performed reaction mixture containing 4 l cdna sample different primer sets 20 p mol the amplification albumin gene human -actin gene internal control achieved using 2 primer sets after initial denaturation 94c 5 min pcr reactions carried using 30 cycles 94c 1 min temperature annealing 1 min 72c 1 min perkin elmer cetus 480 thermal cycler perkin elmer pcr products separated gel electrophoresis 2% agarose gel stained ethidium bromide all signals normalized mrna levels housekeeping gene glyceraldehyde-3-phosphate dehydrogenase expressed ratio real time quantitative pcr analysis albumin gene performed cell lysate adipocytes stromal fraction using abi prism 7500 applied biosystems foster city ca 5-exonuclease assay taqman technology the cdna synthesized described used real time pcr performed 96-well optical reaction plates cdna equivalent 100 ng rna volume 25 l reaction containing 1x taqman universal master mix optimized concentrations fam labeled probe specific forward reverse primer albumin gene assay demand applied biosystems controls included rna subjected rt pcr without reverse transcriptase pcr water replacing cdna the results analyzed using comparative method values normalized -actin expression converted fold change based doubling pcr product pcr cycle according manufacturer guidelines previously described homogenates adipocytes preadipocytes prepared radioimmune precipitation assay buffer 1x pbs 1% np-40 0.5% sodium deoxycholate 0.1% sds containing phenylmethylsulfonyl fluoride aprotinin sodium orthovanadate protease inhibitor tablet completetm mini boehringer mannheim containing antipain dihydrochloride 50 mg ml bestatin 40 mg ml chymostatin 60 mg ml e-64 10 mg ml leupeptin 0.5 mg ml pepstatin 0.7 mg ml phosphoramidon 300 mg ml pefabloc sc 1 mg ml edta disodium salt 0.5 mg ml aprotinin 2 mg ml the cells centrifuged 14,000 g 30 min 4c protein concentrations determined bradford assay using bovine serum albumin standard immunoblotting protein 100 g subjected 8% sds polyacrylamide gel electrophoresis proteins transferred polyvinylidene difluoride pvdf membranes constant voltage 200 v 16 h. pvdf membranes blocked 1 h 5% nonfat dried milk tbs-0.1% tween buffer 25 mm tris hcl 0.2 mm nacl 0.1% tween 20 v v ph 7.6 tbst the membrane washed 2x tbst incubated overnight 4c respective primary antibodies albumin antibody cell signaling beverly gadph antibodies obtained santa cruz biotechnology after extensive washing membrane tbst buffer anti rabbit immunoglobulin conjugated horseradish peroxidase added 1 5000 dilution incubated 1 h room temperature enhanced chemiluminescence kit amersham nj ) was used identify protein expression sixty three healthy noninflamed subjects fifty four microinflamed c rp 5.24 2.26 mg / l esrd patients undergoing rdt determined circulating albumin levels nephelometry body weight bw nearest 50 g using calibrated balance beam scale body mass index bmi calculated ratio body weight height kg body composition assessed conventional bioelectrical impedance analysis bia bioelectrical impedance vector analysis biva previously described resistance r and reactance xc measured single frequency 50 khz bioelectrical impedance analyzer bia 101 rjl akern bioresearch firenze italy according standard tetrapolar technique applying software provided manufacturer incorporated validated predictive equations total body water tbw fat mass fm fat free mass ffm extracellular water ecw 23 24 investigators performed anthropometry bia measurements r xc normalized height subjects r h xc h resulting vectors plotted graph reporting gender specific 50th 75th 95th tolerance ellipses similar vectors calculated reference healthy population according rxc graph method vectors falling within reference gender specific 75th tolerance ellipse indicated normal hydration short vectors lower pole 75th tolerance ellipse indicated overhydration long vectors upper pole 75th tolerance ellipse indicated hydration the length vector calculated \|z [(r h)2 xc h)2 phase angle vector arctan xc r statistical analysis performed using unpaired test anova followed bonferroni post hoc test linear regression analysis results expressed means sd statistical significance defined p 0.05 demographic anthropometric biochemical baseline data enrolled subjects reported table 2 no significant difference observed sex age body weight bmi waist circumference waist hip ratio two different groups contrary plasma c rp il-6 levels much higher patients chronic inflammatory diseases healthy noninflamed subjects p 0.01 rt pcr showed adipocytes extracted districts adipose tissue omental subcutaneous noninflamed controls inflamed patients expressed gene albumin figure 1 mrna marker found adipocytes pre adipocytes fragments adipose tissue we find statistically significant difference albumin gene expression inflamed noninflamed patients adipocytes drawn sc om adipose tissue figure 2 shows observed higher omental adipocyte albumin subcutaneous one group we concluded inflammation modulate albumin gene expression adipocyte probably studies required confirm result figure 3 shows different albumin gene expression studied real time pcr adipocytes pre adipocytes obtained either sc om fragments adipose tissue drawn noninflamed subjects pre adipocyte albumin gene expression higher adipocyte one om sc fragments difference statistically significant we also observed albumin gene expression pre adipocyte extracted fragments om adipose tissue significantly higher preadipocyte sc fragments finally investigated whether protein level adipocytes pre adipocyte also able express albumin subjects as shown figures 4 5 western blot analyses showed presence albumin adipocytes pre adipocytes suggesting adipocytes pre adipocytes synthesize albumin sc well visceral adipose tissue healthy noninflamed subjects inflamed patients we first investigated relationship plasma albumin levels body fat mass fm 63 healthy subjects underwent bia excluding statistical analysis over- hypohydrated subjects vectors falling lower pole vectors falling upper pole 75% tolerance ellipse evaluated biva method as shown figure 6 significant negative correlation observed plasma albumin levels fm r 0.312 p 0.05 2-tailed then studied relationship 54 microinflamed esrd patients undergoing regular dialysis therapy rdt as shown figure 7 significant negative correlation observed plasma albumin levels fm r 0.391 p 0.01 2-tailed albumin abundant plasma protein produced liver cells date data present literature albumin expression mature adipocytes present study found first time clear albumin expression human mature adipocytes in addition basis results also reasonably affirm differentiated adipocytes probably able synthesize albumin albumin gene expression resulted significantly lower adipocytes pre adipocytes particular 42 e 12 times lower om sc adipocyte respectively compared pre adipocyte figure 3 way in fact yoo lee investigated role albumin adipocyte differentiation using pre adipocytes cell lines 3t3-l1 this developmental process undifferentiated precursor cells differentiate mature adipocytes coordinated changes cell morphology gene expression they found albumin gene expression significantly increased later stages adipocyte differentiation process suppression significantly inhibited lipid droplet formation the author suggests albumin could necessary stabilize lipid accumulation mature adipocyte probably direct interaction fatty acids however important underline experiments performed murine cell lines results correspond human cell data previous paper we found c rp gene expression activated adipocyte cells il-6 il-6 receptors gene expressions found higher inflamed patients controls either subcutaneous intra abdominal adipose tissue regard present study hypothesized adipocytes similarly hepatocytes show different albumin gene expression inflamed noninflamed patients lower gene expression inflamed ones however results showed significant difference albumin gene expression inflamed noninflamed patients analyzed real time pcr figure 2 on hand figure 2 shows also albumin gene expression significantly higher intra abdominal subcutaneous adipocytes figure 2 albumin presence protein together gene expression adipocytes raises hypothesis adipose tissue contribute circulating albumin levels well happens il-6 verify hypothesis evaluated relationship serum albumin fat mass supposing higher fat mass corresponds higher circulating albumin levels however results confirm hypothesis found negative significant correlation albumin fat mass healthy noninflamed subjects inflamed esrd patients contrast expected figures 6 7 in words higher fat mass lower serum albumin concentration we suppose higher fat mass leads higher production different proinflammatory cytokines mainly il-6 downregulate albumin production hepatocyte via endocrine way independently systemic inflammation we also suppose il-6 produced adipocyte could regulate via autocrine and/or paracrine signaling albumin gene expression production adipocyte this mechanism could explain lack modulation albumin gene expression systemic inflammation adipocyte negative correlation fat mass albumin levels either noninflamed subjects inflamed esrd patients on contrary mechanism could operate inflammatory proteins c rp despite lack albumin gene modulation inflammation study something really new was observed human adipocyte considered simply depot cell seen new active cell parallel hepatocyte able produce different proteins c rp novelty albumin the fascinating hypothesis states existence continuum adipose tissue cell population goes multipotent stem cell mature progenitor pools passing pre adipocyte this hypothesis might explain adipocyte hepatocyte share expression genes albumin gene as mentioned adipose tissue derived msc admsc displayed capacity differentiate numerous cell types muscular neuronal bone adipose cells interestingly hepatocyte like cells 1315 a study showed admsc could differentiated functional hepatocyte like cells treatment cytokine mixtures vitro become potential source hepatocyte regeneration liver cell transplantation another work authors showed undifferentiated nave admsc also positive albumin g-6-p -1-antitrypsin aat known predominantly expressed adult liver cells however suppose fascinating mechanisms apart sharing origin may explain date adipocyte hepatocyte produce important protein organism like albumin conclusion this preliminary study highlights first time new adipocyte activity among others already known however investigations needed confirm explain results	aims . our group investigated albumin gene expression in human adipocytes , its regulation by inflammation and the possible contribution of adipose tissue to albumin circulating levels . methods . both inflamed and healthy subjects provided adipose tissue samples . rt - pcr , real - time pcr , and western blot analysis on homogenates of adipocytes and pre - adipocytes were performed . in sixty - three healthy subjects and fifty - four micro - inflamed end stage renal disease ( esrd ) patients circulating levels of albumin were measured by nephelometry ; all subjects were also evaluated for body composition , calculated from bioelectrical measurements and an thropometric data . results . a clear gene expression of albumin was showed in pre - adipocytes and , for the first time , in mature adipocytes . albumin gene expression resulted significantly higher in pre - adipocytes than in adipocytes . no significant difference in albumin gene expression was showed between healthy controls and inflamed patients . a significant negative correlation was observed between albumin levels and fat mass in both healthy subjects and inflamed esrd patients . conclusions . in the present study we found first time evidence that human adipocytes express albumin . our results also showed that systemic inflammation does not modulate albumin gene expression . the negative correlation between albumin and fat mass seems to exclude a significant contributing role of adipocyte in plasma albumin .
specimens collected stored 70% ethanol 80c dna isolation amplification partial fragment mtcoi gene purification amplified pcr products sequencing were performed earlier protocol using non destructive techniques buckman et al voucher specimens retrieved dna isolation mounted canada balsam onto glass slides identified t. parvispinus using morphological keys mound 2005 the voucher specimens submitted national zoological collections zoological survey india kolkata india eleven dna sequences generated study aligned 80 sequences t. parvispinus indonesia retrieved national centre biotechnology information further generated sequences submitted genbank database acquire accession numbers t. parvispinus km485659km485667 thrips orientalis km507077km507078 t. orientalis used member thrips orientalis group evolutionary genetic divergences kimura-2-parameter model neighbor joining nj phylogenetic tree constructed mega 6.0 1,000 bootstrap replications tamura et al haplotyping carried dnasp median joining networks produced network 4.1 bandelt et al head broader long ocellar pair iii arising anterior margin ocellar triangle postocular setae iv longer iii fig pronotum two pairs posteroangulars setae two pairs posteromarginal setae fig metanotum reticulate medially faint internal reticules median setae long placed behind anterior margin campaniform sensilla absent fig abdominal sternites iii vi accessory setae absent ii vii figs 13.t parvispinus female 1 head pronotum 2 meso- metanotum 3 fore wing t. parvispinus female 1 head pronotum 2 meso- metanotum 3 fore wing thirteen females two males india karnataka bangalore 10.ii.2014 kamlajayanti reg head broader long ocellar pair iii arising anterior margin ocellar triangle postocular setae iv longer iii fig pronotum two pairs posteroangulars setae two pairs posteromarginal setae fig metanotum reticulate medially faint internal reticules median setae long placed behind anterior margin campaniform sensilla absent fig abdominal sternites iii vi accessory setae absent ii vii figs 13.t parvispinus female 1 head pronotum 2 meso- metanotum 3 fore wing t. parvispinus female 1 head pronotum 2 meso- metanotum 3 fore wing thirteen females two males india karnataka bangalore 10.ii.2014 kamlajayanti reg head broader long ocellar pair iii arising anterior margin ocellar triangle postocular setae iv longer iii fig pronotum two pairs posteroangulars setae two pairs posteromarginal setae fig metanotum reticulate medially faint internal reticules median setae long placed behind anterior margin campaniform sensilla absent fig abdominal sternites iii vi accessory setae absent ii vii figs 13.t parvispinus female 1 head pronotum 2 meso- metanotum 3 fore wing t. parvispinus female 1 head pronotum 2 meso- metanotum 3 fore wing thirteen females two males india karnataka bangalore 10.ii.2014 kamlajayanti reg homology search using blast search option resulted 99100% similarity t. parvispinus sequences indonesia we analyzed 91 partial mtcoi sequences t. parvispinus t. orientalis study out 11 sequences generated study rest 80 sequences retrieved national centre biotechnology complete dataset trimming 604 nucleotides shows 89 variable sites 87 parsimony informative sites however dataset 89 sequence t. parvispinus yielded 14 variable sites 10 parsimony informative analysis 89 sequences t. parvispinus yielded four haplotypes hap_1 hap_4 fig the data show host plant geographical locality specific haplotyping the total number segregating sites four derived haplotypes varies 1 13 table 1 further 14 segregating sites 11 detected synonymous changes 3 nonsynonymous changes corresponding nine transitions five transversions the analysis nj tree yielded two major clades high bootstrap support clade includes 89 sequences t. parvispinus indonesia india clade ii represented two sequences t. orientalis fig nj tree provided segregate two species based reciprocal monophyly criteria interpret phylogeny genus thrips fig table 1.segregating nucleotide sites t. parvispinus mtcoi nucleotide sites depicted four haplotypeshaplotypes166672104123150165179279360364495537570hap_1 indonesia n 63catattagatttathap_2 indonesia india n 18 ......... c .... hap_3 indonesia n 7tg .. c.g.gccctahap_4 india n 1 .. gg.g.t.c .... transversions shown bold f. schultzei used outgroup segregating nucleotide sites t. parvispinus mtcoi nucleotide sites depicted four haplotypes transversions both morphological molecular evidences verify specimens collected papaya represents t. parvispinus the presence pest species economically important crop plant like papaya india raise serious issues concern quarantine authorities occurrence t. parvispinus parts india needs systematic monitoring likely acquire pest status future molecular evidence shared haplotype h_2 indonesia india indicated flow genetic material indonesia may probable source invasion species india however molecular data species countries may helpful trace exact route invasion	south east asia pest thrips species , thrips parvispinus ( karny ) , is a serious pest on a number of agricultural and horticultural crops in a number of plant families . based on an integrated approach of morphology and dna barcoding , invasion of this serious pest is reported first time from india on papaya plantations . molecular data have corroborated with the morphological identification . haplotyping data suggested that the indonesia may be a probable source of invasion of this pest to india .
scorpion envenomation one main problems public health system many countries world this involves 2.3 billion inhabitants areas scorpion sting threat chippaux et al 2008 2008 annual incidence scorpion stings 1.200.000 leading 3250 deaths chip paux et al this number demonstrated relative growth report released 2012 exceeded annually 1,500,000 scorpion stings however mortality rate due scorpion stings showed significant decrease fell 2600 deaths per year jean philippe 2012 the highest number scorpion sting world allocated iran mexico osnaya romero et al the annually 42,500 scorpion stings 20 following deaths reported 2001 2009 iran celis et al 2007 middle east among 52 known species scorpions dangerous scorpions reported iran celis et al 2007 the scorpion sting reported provinces iran however common incidence rates detected khuzestan incidences 541 per 100000 individuals dehghani et al hemiscorpius lepturus belongs hemiscorpiidae family medically important dangerous scorpion khuzestan iran world shahbazzadeh et al hemiscorpius lepturus responsible 15 scorpion sting bite cases however leading cause 89 deaths followed scorpion sting pipelzadeh et al the lethality arising scorpion approximately 60 times higher average remaining venomous scorpion stings region pipelzadeh et al the venom h. lepturus leads acute renal failure thrombocytopenia microangiopathic hemolytic anemia known nephrotoxic hepatotoxic hemolytic complications scorpion venom valavi et al the local signs vary erythema necrosis patient feels pain hand the nephrotoxicity important systemic complication left untreated could result severe renal cardiac pulmonary failure pipelzadeh et al venom may induce severe pathological damages target organs skin blood cells central nervous system cns cardiovascular system seyedian et al it leads increase liver enzymes aspartate aminotransferase ast alanine aminotransferase alt alkaline phosphatase alp indicating severe hepatic damage pipelzadeh et al showed h. lepturus causes rbc lysis ldh increase comparing complications envenomation resulting stings two species scorpions mesobuthus eupeus androctonus crassicauda khodadadi et al described 90 patients admitted hospitals due general condition worsening stung h. lepturus mir dehghan et al the immune system cells distributed throughout body outer points deepest organs tissues blood bone marrow thymus spleen despite diversity these cells apply comprehen sive supervision different organs tissues regular circulation blood lymph inside vessels outside interior organs blood resulting protection body pathological factors vodjgani 2012 the results experimental study aiming investigation effect envenomation h. lepturus hematological indices three days injection venom suggested leukocyte number increased normal range however significant difference control group dehghani et al an increase peripheral leukocyte count demonstrated investigation blood among h. lepturus scorpion sting victims chitnis et al 1993 comparative studies investigate effects h. lepturus venom hematologic parameters vital organs body done far experimental research effect scorpion venom immune system cells various sub groups early hours sting determination investigation period intensity envenomation carried yet therefore aim present study investigate effect h. lepturus envenomation blood leukocytes subgroups early hours sting the results study help physicians health officials medical staff fast accurate treatment victims h. lepturuss sting prevention complications scorpion venom important factors immune system sixty male rats n mari species weight range 300350 grams purchased pasteur institute iran tehran used study the animals kept standard cages animal house school pharmacy ahvaz jundishapur university medical sciences rats housed temperature controlled rooms 2225 c constant relative humidity 4070% 12h/12h light dark cycle experimental protocols the study performed accordance principles laboratory care established ethics committee ahvaz jundishapur university medical sciences ahvaz iran the scorpion electroshocked venom provided lyophylized powder pasteur institute iran venom therapeutic biomolecule lab biotechnology res the concentration crude venom protein determined using bradford method bradford 1976 the injection volume 0.1 ml animals randomly divided three groups 20 rats the control group receive thing however first second groups received h. lepturus venom concentrations 0.1 0.01 mg kg bw subcutaneously thereafter animals group n= 20 divided four subgroups n= 5 respect four blood sampling time two six 24 48 hours venom injection animals kept separate cages the animals subgroup anesthetized ketamine xylazine alfasan holland the blood samples obtained animal heart amounted 0.52 ml syringe soon sampling blood maintained glasses containing anticoagulant edta ethylene diamine tetra acetic acid leukocytes counted using diluent solution marcanu rbc lysis buffer neobar slide hemocytometer using light microscope olympus 3h z japan order count determine leukocyte subgroups including neutrophils lymphocytes monocytes eosinophils appropriate peripheral blood smears prepared microscope slides fixed means water free methanol then giemsa staining merck germany carried diluted stain rate 1/10 and finally differential counting performed using 100x lens microscope mahbod 2008 mansouri et al 13 version 13 spss inc chicago il statistical tests anova lsd 15 comparison meansd white blood cells 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times significant difference p 0.05 experimental control groups significant difference p 0.01 experimental control groups comparison meansd neutrophils 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times significant difference p 0.05 experimental control groups significant difference p 0.01 experimental control groups comparison meansd lymphocytes 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times significant difference p 0.05 experimental control groups significant difference p 0.01 experimental control groups comparison meansd monocytes 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times comparison meansd eosino phil 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times sixty male rats n mari species weight range 300350 grams purchased pasteur institute iran tehran used study the animals kept standard cages animal house school pharmacy ahvaz jundishapur university medical sciences rats housed temperature controlled rooms 2225 c constant relative humidity 4070% 12h/12h light dark cycle experimental protocols the study performed accordance principles laboratory care established ethics committee ahvaz jundishapur university medical sciences ahvaz iran the scorpion electroshocked venom provided lyophylized powder pasteur institute iran venom therapeutic biomolecule lab biotechnology res the concentration crude venom protein determined using bradford method bradford 1976 the control group receive thing however first second groups received h. lepturus venom concentrations 0.1 0.01 mg kg bw subcutaneously thereafter animals group n= 20 divided four subgroups n= 5 respect four blood sampling time two six 24 48 hours venom injection animals kept separate cages the animals subgroup anesthetized ketamine xylazine alfasan holland the blood samples obtained animal heart amounted 0.52 ml syringe soon sampling blood maintained glasses containing anticoagulant edta ethylene diamine tetra acetic acid leukocytes counted using diluent solution marcanu rbc lysis buffer neobar slide hemocytometer using light microscope olympus 3h z japan order count determine leukocyte subgroups including neutrophils lymphocytes monocytes eosinophils appropriate peripheral blood smears prepared microscope slides fixed means water free methanol then giemsa staining merck germany carried diluted stain rate 1/10 finally differential counting performed using 100x lens microscope mahbod 2008 mansouri et al 13 version 13 spss inc chicago il statistical tests anova lsd 15 comparison meansd white blood cells 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times significant difference p 0.05 experimental control groups significant difference p 0.01 experimental control groups comparison meansd neutrophils 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times significant difference p 0.05 experimental control groups significant difference p 0.01 experimental control groups comparison meansd lymphocytes 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times significant difference p 0.05 experimental control groups significant difference p 0.01 experimental control groups comparison meansd monocytes 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times comparison meansd eosino phil 10 per ml peripheral blood rat groups receiving venom concentration 0.01 0.1 mg kg control group different times the scorpion venom led significant reduction leukocytes venom receiving group dose 0.01 mg kg two 24 hours injection compared control group p 0.05 this decrease maximum six hours injection p 0.01 24 hours injection effect venom subsided 48 h significant difference control group p 0.05 the toxicity effect venom intensified increase injected venom concentration spite decrease venom effect group receiving 0.01 mg kg 48 hours decrease toxicity effect still significant group receiving 0.1 mg kg compared control group p 0.01 fig the neutrophil mean count showed significant decline venom receiving group dose 0.01 mg kg two 24 48 hours p 0.05 six hours injection compared control group fig the mean peripheral blood lymphocyte count venom receiving group 0.01 mg kg two six 24 hours p 0.05 48 hours p 0.01 injection demonstrated significant decline compared control group respectively the comparison mean standard deviation eosinophil monocytes peripheral blood case control groups showed significant differences p 0.05 figs 4 5 the scorpion venom led significant reduction leukocytes venom receiving group dose 0.01 mg kg two 24 hours injection compared control group p 0.05 this decrease maximum six hours injection p 0.01 24 hours injection effect venom subsided 48 h significant difference control group p 0.05 the toxicity effect venom intensified increase injected venom concentration spite decrease venom effect group receiving 0.01 mg kg 48 hours decrease toxicity effect still significant group receiving 0.1 mg kg compared control group p 0.01 fig the neutrophil mean count showed significant decline venom receiving group dose 0.01 mg kg two 24 48 hours p 0.05 six hours injection compared control group fig the mean peripheral blood lymphocyte count venom receiving group 0.01 mg kg two six 24 hours p 0.05 48 hours p 0.01 injection demonstrated significant decline compared control group respectively the comparison mean standard deviation eosinophil monocytes peripheral blood case control groups showed significant differences p 0.05 figs 4 5 the present study aimed investigate effect h. lepturus venom leukocytes subgroups peripheral blood rats these cells apply comprehensive supervision different organs tissues regular circulation blood lymph inside vessels outside interior tissues blood resulting protection body pathological factors general leukocytes consist various groups cells including lymphocytes monocytes granulocytes vodjgani 2012 the clinical syndrome induced h. lepturus sting different stings scorpions existing iran world exhibits severe manifestations lack local pain mild pain sting cutaneous manifestations erythema swelling necrosis sting site red blood cell lysis nephrotoxicity including hemoglobinuria proteinuria hematuria manifestations among scorpion sting victims radmansh 1990 radmanesh 1998 pipelzadeh et al the results present study demonstrated leukocytes affected venom two hours exhibiting sensitivity decrease leukocytes continues six hours venom injection if leukocytes evaluated 12 hours possible notice decreasing trend due prolongation presence venom body probably variations leukocytes results cytotoxic effects h. lepturus venom leads white blood cell lysis destruction shayesteh et al there considerable experimental clinical study field decrease leukocytes early hours one new findings research lack related reports might due difference evaluation time hematological indices various studies dehghani et al 2005 dehghani et al 2012 result use anti venom human researches well chitnis et al the leukocyte count trend increased 24 hours venom injection significant difference venom receiving group 0.01 mg kg control group various studies reported leukocytosis well major clinical signs envenomation h. lepturus symptom hemoglobinuria hematuria proteinuria chitnis et al therefore reconstruction leukocytes observed study agreement previous findings dehghani et al 2012 however venom concentration decline leukocyte count slower wbc reconstruction leukocyte count reached normal range 48 hours envenomation 0.1 mg kg according present study two hours percent blood neutrophils changed normal range 61 35.2 this reduction severe six hours fallen 25.5 neutrophils make abundant population white blood cells mediate primary stages inflammatory response they effective phagocytes peripheral blood major role defense extracellular factors abbas et al these mature cells migrate inflammation site four hours antigen entrance capability invade antigen phagocytosis particles waste products neutrophils associated series biochemical events morphological changes cell vodjgani 2012 the majority neutrophils inflammation site wiped cells macrophages phagocytosis invader 2011 aiming investigate effect h. lepturus serum levels cytokines il-1 il-6 il-8 tnf- demonstrated direct relation worsening patient general condition mentioned cytokines il-8 chemotactic protein known nap-1 attractive activator neutrophils vodjgani 2012 the increase cytokine leads fever hyperthermia probably due neutrophil aggregation pathogen killing death two kinds cells taraz 2008 tnf- enhances production particular serum proteins amyloid affecting hepatocytes this cytokine suppresses stem cell division may lead neutropenia vodjgani 2012 therefore severe decrease neutrophils group receiving high doses h. lepturus venom reasonable following 24 hours neutrophil count especially venom receiving group 0.01 mg kg approached normal range regarding neutrophilia neutrophil compensation could explained neutrophilia conversion marginal neutrophils circulating neutrophils could noticed these findings consistent results research carried ghafourian mohebby patients scorpion referred hospital bite ghafourian mohebbi 2008 present study lymphocytes decreased first hours venom injection reduction significant even 48 hours one fractions extracted venom h. lepturus may reduce lymphocyte count bigdeli et al lymphocytes make around 20 40 leukocytes 99 cells lymph respectively the process recognition processing antigen lymphocytes well clonal expansion requires time precise determination mechanism effect venom h. lepturus lymphocytes explained first 48 hours perhaps due immunological reasons present study the blood lymphocyte decrease dose dependent could probably result direct effect venom lymphocytes leads disruption lysis cells in fact could concluded venom h. lepturus lymphotoxic effect ghafourian mohebbi 2008 present research the peripheral blood eosinophil count control group showed significant difference experimental groups eosino phil consists 2 leukocytes found normal situation tissues especially epithelium respiratory tract gastrointestinal tract genitourinary tract these cells weak phagocytic ability increase mainly type-1 hypersensitivity responses parasitic infections well the venom scorpion h. lepturus effect leukocytes early hours well increasing concentration toxin destructive power increased word however essential role factors intensify inflammation recently natural corticosteroid hormones similar synthetic substances used alleviate inflammatory reactions allograft transplantation immune system suppression therefore extraction useful fractions h. lepturus venom natural induction corticosteroids decreasing leukocytes may useful treatment types leukemia graft surgeries well however severe dose dependent reduction immune cells first hours injection h. lepturus venom could alarm health officials medical staff perform quick accurate treatment least possible time prevent complications scorpion venom body vital organs	background : the aim of this study was to investigate the effect of hemiscorpius lepturus venom on leukocytes and the leukocyte subgroups in peripheral blood of rat.methods:in this experimental study , sixty n - mari rats were divided into three groups of 20 rats . then the rats in each group were divided into four subgroups based on the blood sampling time that was 2 , 6 , 24 and 48 hours after the venom injection , respectively . the control group did not receive anything , however , the first and the second experimental groups received 0.1 and 0.01mg / kg of venom , subcutaneously . in accordance with a designated four sampling times , the blood sampling was carried out in three groups . after rbc lysis , the leukocytes and leukocyte sub - populations were determined and counted using appropriate hematological standard methods.results:the leukocyte and the neutrophil count at two ( p<0.05 ) , six ( p<0.01 ) and 24 ( p<0.05 ) hours after the venom injection showed a significant decline compared with the control group , this decrease was significant at the dose of 0.1 mg / kg until 48 hours after the venom injection ( p<0.05 ) . the lymphocyte count showed a significant decline throughout the all hours of the experiment , compared with the control group ( p<0.05).conclusion : leukocytes are probably affected by the cytotoxicity effect of the h. lepturus venom in a dose - dependent manner . this could be a wakeup call for the medical staff to perform quick and accurate treatment in the least time possible .
solitary plasmacytomas sp result monoclonal plasma cell proliferation lack bone marrow involvement protein serum urine seen multiple myeloma sp classified world health organisation solitary osseous plasmacytomas sop solitary extramedullary plasmacytomas semp semps rare constitute 5% plasma cell disorders strong predilection upper aerodigestive tract we hereby describe one rare case thoracic epidural semp manifesting dorsal compressive myelopathy a 32-year old female presented us back pain 2 months progressive spastic weakness bilateral lower limbs b l lls past 8 days clinical examination revealed spastic weakness power 1/5 mrc uk b l lls exaggerated b l knee ankle jerks complete sensory loss l1 level spine examination revealed deformity tenderness clinical diagnosis thoracic compressive mri revealed dorsally located epidural lesion level t7-t8 vertebral bodies compressing pushing spinal cord anterolaterally figure 1a b the lesion isointense t1-weighted hypointense t2-weighted images enhanced homogenously extended neural foramen both meningiomas neurofibromas isointense hyper intense hypo intense t2-weighted images magnetic resonance imaging mri showing epidural lesion level t7-t8 vertebrae sagittal t2-weighted pushing cord anterolaterally right side extending neural foramen b axial t2-weighted postoperative mri sagittal t1-weighted parasgittal t2-weighted axial t1-weighted images revealed complete excision tumor opening subarachnoid space c e level tumor the spinal cord seen attained normal shape position e patient underwent t7 t8 laminectomy complete excision tumor reddish soft moderately vascular located epidural space extension left neural foramen as bony involvement two level laminectomy done vertebral stabilization needed histopathological examination revealed diffuse dense infiltration mature immature plasma cells immunohistochemically positive cd138 occasional bi nucleated plasma cell based overall histomorphological immunohistochemical findings diagnosis plasmacytoma made figure 2 ( microphotograph showing tumor composed diffuse infiltration mature immature plasma cells h e 20 b plasma cells highlighted immunohistochemical staining cd138 immunohistochemistry 40 patient evaluated find systemic evidence disease bone marrow examination revealed 5% plasma cells serum electrophoresis urine examination negative protein patient received adjuvant radiotherapy rt 40 gy 20 fractions operative field 6 months surgery patient started walking power bilateral lower limbs 4/5 mrc uk regained bladder functions solitary extramedullary plasmacytomas commonly involve upper aerodigestive 8090% cases 1020% cases body organs including skin testis ovaries liver lungs spleen etc however occurrence semps isolated masses spinal epidural space rare thorough search literature revealed seven cases reported previously available english literature table 1 cases epidural semps order make diagnosis semp following criteria must fulfilled biopsy lesion showing monoclonal plasma cellsbone marrow plasma cell 5%absence osteolytic bone lesions involvement body tissuesabsence hypercalcemia renal failureabsent low serum protein concentration biopsy lesion showing monoclonal plasma cells bone marrow plasma cell 5% absence osteolytic bone lesions involvement body tissues absence hypercalcemia renal failure absent low serum protein concentration radiologically epidural mass diagnostic dilemma endemic country tuberculosis first consideration differential diagnosis also considered first differential treating patients antitubercular drugs is futile exercise also adverse consequences terms delaying appropriate treatment plasmacytoma it therefore important aware rare entity differential diagnosis epidural masses especially t2-weighted hypo intense lesion restricted epidural space without bony involvement without associated paravertebral collection among 7 cases literature present case table 1 males females equally represented average age 51 years age range 4085 years four patients impairment bladder bowel functions surgical resection followed adjuvant therapy chemotherapy ct rt combination ct rt surgical resection alone combination plasmapharesis ct rt ct rt ct alone different treatment regimens used patients table 1 among six patients neurological deficits paraplegia quadriplegia three patients undergoing surgical resection showed improvement neurological deficits three received ct combined ct rt show neurological improvement table 1 according guidelines british committee standards hematology rt treatment choice sops semps the role surgery providing tissue diagnosis cases spinal epidural semps surgical resection relieves compression spinal cord thereby leading neurological improvement epidural semps rare require high index suspicion diagnosis appropriate management clinical manifestations radiological features quite similar common pathologies region though rt treatment choice sp surgical resection helps providing tissue diagnosis relieving spinal cord compression	plasma cell neoplasms result from monoclonal proliferation of plasma cells . solitary extramedullary plasmacytomas ( semps ) are rare and constitute 5% of all plasma cell disorders . semps most commonly involve upper aerodigestive tract . isolated spinal epidural space involvement by semps is extremely rare and to best of our knowledge only 7 such cases have been reported previously in available english literature . we hereby present a rare case of thoracic epidural semp in a 32-year - old female who presented with thoracic compressive myelopathy and discuss the pertinent literature .
relationship gonads ovaries testes brain complicated it surprising still completely understand effects hormones brain seizures reproductive hormones like estrogen progesterone testosterone profound effects brains men women even parts brain considered critical reproduction moreover effects occur throughout life adulthood early stages development researchers shown laboratory animals estrogen levels fetus critical gender fetus.7 puberty levels circulating estrogen testosterone also affect brain interplay early organizational effects postpubertal activating effects hormones mediates net effect hormones adult brain.8,9 besides synthesized gonads estrogen progesterone testosterone synthesized elsewhere including brain such synthesis potentially occur anywhere brain occurs astrocytes cells located areas brain astrocytes historically considered supportive cells responsible housekeeping brain cleaning debris removing damaged cells infection we know astrocytes many functions including synthesis hormones enzymes astrocytes metabolize cholesterol component outer membranes cells hormones we know estrogen testosterone many effects brain influencing neurotransmitters allow neurons communicate neuronal activity.10,11 hormones also metabolites effects brain activity for example allopregnanolone metabolite progesterone inhibits neuronal activity many areas brain result suggested progesterone would help stop seizures.12 reproductive hormones affect brain activity changes hormones puberty pregnancy menstrual cycle important consider treating women epilepsy treatment complicated however hormones like estrogen progesterone affect patients way example women experience changes severity frequency seizures relation estrogen progesterone treatment others similarly women seizures worsen part menstrual cycle furthermore effects hormones seizures demonstrated laboratory experiments reproducible for example sometimes estrogen appears promote seizures nt always.12 besides confusion led frustration clinicians unsure treat patients whose seizures suddenly worsened possibly changes reproductive hormone levels nevertheless understanding effects estrogen progesterone brain led hypotheses explain seizures increase certain times menstrual cycle as mentioned catamenial epilepsy refers seizures worsen particular times menstrual cycle this syndrome recognized 100 years difficult study.13 investigators even questioned whether catamenial epilepsy exists.14 many clinicians find robust sex differences patients,1517 therefore conclude syndromes like catamenial epilepsy likely significant.13 however clinical research provides strong evidence catamenial epilepsy common andrew herzog leader field estimates catamenial epilepsy occurs one third women epilepsy.2 recent epidemiological study korea estimated catamenial epilepsy occurs almost 50 percent women epilepsy.18 accuracy estimations hard judge however seizures unnoticed missed leading underestimation number women catamenial epilepsy nevertheless condition documented symptoms often worst days start menstruation approximately day 28 menstrual cycle days onset menstruation perimenstrual period symptoms also worsen periovulatory phase approximately day 14 ovulation occurs see diagram 1 page 9 the rise circulating estrogen serum estrogen menstrual cycle affects brain many ways includes effects neurons non neuronal cells astrocytes neurons cell structure spines important spines receive excitatory input neurons help neurons communicate one another many scientists believe major effect estrogen brain increased neuronal activity estrogen increases dendritic spines circulating progesterone many effects progesterone actions neurons metabolite allopregnanolone also allopregnanolone binds receptors responsible effects gamma aminobutyric acid gaba major inhibitory neurotransmitter brain therefore progesterone rises menstrual cycle thought neuronal activity decrease many parts brain most current understanding action estrogen progesterone involves effects hormones within brain also affect many parts body turn alter brain activity this complicated interplay brain rest body one reasons epilepsy hard treat may static condition one constantly changing several hypotheses based effects estrogen progesterone identified last decades offered explain catamenial epilepsy one seizures increase ratio estrogen progesterone high.5,19,20 hypothesis explains worsening seizures periovulatory period relative resistance seizures luteal phase days 1428see diagram 1 page 9 explain seizures worsens perimenstrual period estrogen progesterone low time alternative view developed shown falling progesterone levels exert excitatory effects.21 researchers hypothesized progesterone withdrawal occurs end menstrual cycle leading excitatory effects literally decrease seizure threshold,22 point brain sufficiently activated seizure begins patients epilepsy this threshold thought lower people even mild activation brain lead seizure researchers investigated notion progesterone withdrawal treating laboratory rats mice progesterone suddenly stopping treatment the results showed decrease seizure threshold accompanied withdrawal treatment.21,22 data suggest patient epilepsy seizures may likely progesterone withdrawal seizure threshold lower subsequent studies using methods simulate progesterone withdrawal means evaluating seizure susceptibility confirmed findings.23,24 progesterone withdrawal therefore provides potential explanation perimenstrual seizures further research effects progesterone withdrawal suggested simply sudden drop progesterone metabolite allopregnanolone causes increased susceptibility seizures rather progesterone withdrawal leads specific change gabaa receptors neurotransmitter receptors bind allopregnanolone gabaa receptor normally composed several components subunits when progesterone withdrawal occurs increased levels one subunits stops allopregnanolone inhibitory effect seizure activity,25,26 subunit changes lead resistance seizures antiepileptic drugs benzodiazepines.27 progesterone also affects hormones called mineralocorticoids mineralocorticoids normally allow body retain sodium potassium result water this significant water balance affects seizures neurons brain swell become closer together increasing neuronal activity.28 result seizure threshold decrease during menstrual cycle water retention occurs end luteal phase period coincides perimenstrual phase seizure threshold may decrease water retention increases neuronal excitability this reasoning led use diuretics acetazolamide women catamenial epilepsy although completely successful,29 probably treat effects hormones menstrual cycle recent studies female laboratory animals suggest estrogen levels may also contribute perimenstrual seizures estrogen effects perimenstrual period even estrogen elevated preceding phases cycle for example estrogen increases concentration brain derived neurotrophic factor bdnf molecule increases excitation brain the increase bdnf long lasting persists estrogen levels returned normal.30 estrogen therefore exert long lasting effects neuronal activity even estrogen levels increase briefly high levels bdnf throughout luteal phase would result prediction supported clinical studies showing bdnf high luteal phase.31 luteal phase actions bdnf may inhibited progesterone allopregnanolone end menstrual cycle elevated bdnf may persist progesterone allopregnanolone fall the imbalance excitatory effects bdnf inhibitory effects progesterone allopregananolone would explain increased seizures perimenstrual period it also interesting bdnf induces synthesis neuropeptide npy considered potential anticonvulsant.32 rise npy could truncate effects bdnf ending perimenstrual period there many neurological psychiatric conditions symptoms worsen relation menstrual cycle some scientists suggested symptoms caused abnormal periods activity parts central nervous system cns resemble seizures regard migraine headaches example women often report severe episodes follow perimenstrual pattern migraine abnormal patterns brain activity develop women chronic pain experience severe pain certain phases menstrual cycle pain may result period hyperactivity areas cns pain controlled the concept epilepsy spectrum suggests types hyperactivity neurons cns might part spectrum even though pain considered type epilepsy supporting view observation antiepileptic drugs often successful treatment migraine pain why women catamenial epilepsy even among women sometimes difficult document ? the type epilepsy susceptible catamenial pattern appears involve part brain temporal lobe control movement seizures may convulsive.33 variety nonconvulsive seizures different causes different areas brain involved temporal lobe epilepsy example seizures often partial complex partial arise one part temporal lobe spread areas always always accompanied convulsions these seizures often start aura sensation dj vu example awareness familiar smell usually accompanied temporary loss consciousness seizure person may somewhat confused subsequently resumes normal behavior patient temporal lobe epilepsy seizures without convulsions the person unaware seizure occurred would memory the person may also remember seizure disruption activity temporal lobe time seizure temporal lobe important normal learning memory it easy see prevalence catamenial epilepsy could well underestimated type seizure activity increases particular times menstrual cycle nonconvulsive the occurrence catamenial epilepsy may also underestimated patients may experience nonconvulsive seizures catamenial pattern physicians know occurred addition physicians sure seizures patients report actually occur people appear imagine seizures these called pseudoseizures.34 physicians would use electroencephalogram eeg document seizures seizures may missed eeg involve structures deep brain relatively far eeg electrodes placed scalp near brain surface may diagnosed catamenial epilepsy menstrual cycle regular chronic seizures lead irregular cycles woman physician may unable recognize pattern the notion spectrum epilepsy important women epilepsy relevant research scientists use laboratory animals study temporal lobe epilepsy animals seizures simulate patients temporal lobe epilepsy are usually defined five stages convulsive seizures originally described 1972.35 stages easy see convulsions it hard researchers agree animal nonconvulsive seizure part difficulty defining point normal brain activity increased enough constitute seizure considering epilepsy spectrum ranging mild severe longer requiring convulsions define seizure research epilepsy would broaden scope ultimately many people seizures would helped people seizures hard detect the researchers tell us spectrum seizures experimental animals better equipped treat spectrum seizure disorders exist people in fact potential antiepileptic drugs may passed last decades drug screening drugs usually tested see stop convulsive seizures animals and often used see help animals tested conditions nonconvulsive seizures suspected alzheimer disease some candidate antiepileptic drugs might successful nonconvulsive conditions would fail drug screen unable ameliorate convulsive seizure restricting epilepsy research investigation convulsive seizures especially limiting studies hormones female animals convulsive seizures female rodents stop ovarian cycle make irregular this effect documented common animal models temporal lobe epilepsy.3638 result hard conduct research female rodents understand epilepsy influences reproductive function this unfortunate women epilepsy often develop reproductive problems infertility polycystic ovarian syndrome studying female rats nonconvulsive seizures would provide opportunities understand adverse effects seizures reproductive system the idea epilepsy spectrum also implications development new drugs treat epilepsy may useful develop drugs block consequences estrogen progesterone rather estrogen progesterone hormones important normal life if particular branch bdnf signaling could identified important seizure threshold might better endpoint target this strategy could used concert progesterone supplementation enhancement allopregnanolone levels however bdnf signaling gabaa receptors important many normal functions more specific targets bdnf gabaa receptor needed anticonvulsant actions occur without side effects the clarify mechanisms underlying catamenial seizure exacerbation likely develop treatments without side effects epilepsy devastating illness far reaching effects patients families patients could better helped greater awareness epilepsy spectrum nonconvulsive seizures would better recognized deepening understanding epilepsy spectrum could lead accurate diagnoses possibly allowing detection epilepsy individuals would otherwise treated anticonvulsants research would benefit increasing recognition diverse types seizures would lead broader focus drugs necessarily anticonvulsant antiepileptic	editor s note : there is not just one type of epilepsy . while some forms of the disease are characterized by convulsive seizures , others involve seizures that are barely noticeable . seizures can occur for many reasons : they can be caused by genetic mutations , injury , or infection early in life . in addition , events in daily life , such as stress , or normal variations in hormones , such as estrogen and testosterone , can influence brain activity and therefore influence seizures . by considering the powerful interactions between the brain and the endocrine system , this influence of hormones on seizures can be understood and new treatment options can be considered .
rsv mutant forms overexpressed escherichia coli bl21 de3 purified previously described the proteins stored aliquots 80c 20 mm hepes naoh ph 7.5 1.0 nacl 20m zncl2 5 mm 2-mercaptoethanol 10% w v glycerol the branched dna substrate mimicking product concerted integration reaction obtained annealing three synthetic oligonucleotides integrated dna technologies a similar strategy used previously prepare pfv dna complex demonstrated dna complex assembled designed integration product essentially identical structure equivalent complex formed via forward integration reaction the viral dna branches carrying high affinity gain function mutant rsv u3 long terminal repeat ltr sequence gu3 attached target dna duplex palindromic 6 bp spacer generate fully symmetrized structure prepare rsv dna complexes crystallization 30 half site dna substrate mixed 120 rsv 20 mm hepes naoh ph 7.5 500 mm nacl 20% w v glycerol 1 mm tris-(2-carboxyethyl)phosphine tcep the mixture dialyzed low salt buffer 20 mm hepes naoh ph 7.5 125 mm nacl 20% w v glycerol 1 mm tcep 25c overnight end first dialysis the mixture subsequently dialyzed high salt buffer 20 mm mes naoh ph 6.0 1.2 nacl 20% v v dimethyl sulfoxide dmso 5% w v glycerol 1 mm tcep 25c 24 hours end second dialysis the solubilized rsv dna complex intasome purified size exclusion chromatography superdex 200 10/300 gl ge healthcare running 20 mm mes naoh ph 6.0 1.2 nacl 20% v v dmso 5% w v glycerol 1 mm tcep the isolated intasome remains stable high salt condition containing 1.2 nacl precludes complex formation suggesting intasome forms kinetically trapped the solubility enhancing rsv mutation f199k completely abolished intasome formation sec mals analysis modified condition used intasome solubilization isolation better baseline stability extended data fig the rsv intasome assembled dialysis purified size exclusion chromatography concentrated 46 mg ml using centrifugal concentrator amicon various combinations lengths viral dna ranging 16 bp 25 bp flanking target dna ranging 14 bp 22 bp corresponding full target dna lengths 34 bp 50 bp screened crystallization trials the extensive screening yielded one crystal form specific combination 22-base length non transferred strand viral dna branches 16 base pair bp target dna flanks either side central six bp spacer fig dna substrates two slightly different target sequences used 5-aatgttgtcttatgcaatactc-3/5-gagtattgcataagacaacagtgcacgaatcttgaagacact-3/5-agtgtcttcaagattc-3 5-aatgttgtcttatgcaatactc-3/5-gagtattgcataagacaacagtcgaccaaccttcaacttagc-3/5-gctaagttgaaggttg-3 produced essentially crystals the rsv intasome crystals grown reverse vapor diffusion hanging drops 22c mixing 1.5 l dna complex solution 1.5 l reservoir solution 3.2 sodium formate crystals appeared within 35 days reached size ~150300 3~5 days even though rsv intasome crystals initially diffracted x ray poorly 10 soaking crystals metatungstate cluster compound dramatically improved resolution extended data fig the tungsten cluster later found bind dimers separate intasome complexes mitigate crystal lattice disorder the crystals soaked overnight 0.15 mm metatungstate cluster na6[h2w12o40 stabilization buffer consisting 3.2 sodium formate 16 mm mes naoh ph 6.0 0.8 nacl 16% v v dmso 4% w v glycerol 1 mm tcep soaking the crystals cryo protected 3.2 sodium formate 16 mm mes ph 6.0 0.8 nacl 16% v v dmso 12% w v glycerol 1 mm tcep frozen rapid immersion liquid nitrogen the full length wild type rsv in(1286 c terminally truncated rsv in(1270 various mutant forms tested produced essentially crystals indistinguishable x ray diffraction properties x ray diffraction data collected advanced photon source northeastern collaborative access team beamlines 24-id c e advanced light source molecular biology consortium 4.2.2 beamline processed using hkl2000 xds the rsv intasome crystals showed varied degrees pseudo merohedral twinning twin operator l k h owing similar c unit cell dimensions primitive monoclinic lattice thus screened large number crystals identify ones diffract higher resolution smaller twin fractions the structure rsv intasome determined molecular replacement phaser using rsv ccd ctd pdb 4fw1 16 bp b form dna search models 8 copies ccd one copy ctd three copies dna molecules located refinement partial model revealed electron density two copies metatungstate clusters subsequent iterative model building using coot refinement phenix suite allowed placement remaining 7 copies ctd 8 copies ntd generated using modeller based hiv-1 ntd pdb 1k6y building inter domain linkers well remaining parts dna molecule guided difference electron density maps a third metatungstate cluster weakly bound compared first two positioned manually residual density the dna base pairs base stacking restraints used throughout refinement the geometry restraints protein included reference model restraints ccd ctd based higher resolution rsv structure 4fw1 secondary structure zinc coordination restraints ntd atomic displacement parameters refined grouped b factors per residue protein dna total 53 tls groups assigned phenix the asymmetric unit crystal contains one complete rsv intasome includes eight molecules two viral dna branches emanating strongly bent 38 bp target dna the dataset used final refinement rsv intasome crystal grown using selenomethionine labeled rsv 1270 following amino acid substitutions c23s l112 l135 l162 l163 l188 l189 confirmed active concerted integration inhibited insti similarly wild type rsv dna substrate carrying nick middle target dna branch 16-base dna strand shown olive fig the nick occasionally facilitated crystal growth necessary crystallization change space group unit cell parameters compared crystals grown without nick because nick target dna biologically relevant shown figs twin refinement protocol used dataset used final refinement low less 10% twin fraction the summary data collection refinement statistics shown extended data table 1 the paired refinement procedure performed steps 0.1 determine high resolution limit extended data fig the register amino acids final model verified selenium anomalous difference fourier peaks extended data fig ramachandran analysis shows 96.0 3.9 0.1 protein residues favored allowed disallowed region respectively the ntd ccd linker non catalytic molecules last four bp distal end one viral dna molecules built due poor electron density rsv mutant forms overexpressed escherichia coli bl21 de3 purified previously described the proteins stored aliquots 80c 20 mm hepes naoh ph 7.5 1.0 nacl 20m zncl2 5 mm 2-mercaptoethanol 10% w v glycerol the branched dna substrate mimicking product concerted integration reaction obtained annealing three synthetic oligonucleotides integrated dna technologies a similar strategy used previously prepare pfv dna complex demonstrated dna complex assembled designed integration product essentially identical structure equivalent complex formed via forward integration reaction the viral dna branches carrying high affinity gain function mutant rsv u3 long terminal repeat ltr sequence gu3 attached target dna duplex palindromic 6 bp spacer generate fully symmetrized structure prepare rsv dna complexes crystallization 30 half site dna substrate mixed 120 rsv 20 mm hepes naoh ph 7.5 500 mm nacl 20% w v glycerol 1 mm tris-(2-carboxyethyl)phosphine tcep the mixture dialyzed low salt buffer 20 mm hepes naoh ph 7.5 125 mm nacl 20% w v glycerol 1 mm tcep 25c overnight end first dialysis the mixture subsequently dialyzed high salt buffer 20 mm mes naoh ph 6.0 1.2 nacl 20% v v dimethyl sulfoxide dmso 5% w v glycerol 1 mm tcep 25c 24 hours end second dialysis the solubilized rsv dna complex intasome purified size exclusion chromatography superdex 200 10/300 gl ge healthcare running 20 mm mes naoh ph 6.0 1.2 nacl 20% v v dmso 5% w v glycerol 1 mm tcep the isolated intasome remains stable high salt condition containing 1.2 nacl precludes complex formation suggesting intasome forms kinetically trapped the solubility enhancing rsv mutation f199k completely abolished intasome formation sec mals analysis modified condition used intasome solubilization isolation better baseline stability extended data fig for crystallization rsv intasome assembled dialysis purified size exclusion chromatography concentrated 46 mg ml using centrifugal concentrator amicon various combinations lengths viral dna ranging 16 bp 25 bp flanking target dna ranging 14 bp 22 bp corresponding full target dna lengths 34 bp 50 bp screened crystallization trials the extensive screening yielded one crystal form specific combination 22-base length non transferred strand viral dna branches 16 base pair bp target dna flanks either side central six bp spacer fig dna substrates two slightly different target sequences used 5-aatgttgtcttatgcaatactc-3/5-gagtattgcataagacaacagtgcacgaatcttgaagacact-3/5-agtgtcttcaagattc-3 5-aatgttgtcttatgcaatactc-3/5-gagtattgcataagacaacagtcgaccaaccttcaacttagc-3/5-gctaagttgaaggttg-3 produced essentially crystals the rsv intasome crystals grown reverse vapor diffusion hanging drops 22c mixing 1.5 l dna complex solution 1.5 l reservoir solution 3.2 sodium formate crystals appeared within 35 days reached size ~150300 3~5 days even though rsv intasome crystals initially diffracted x ray poorly 10 soaking crystals metatungstate cluster compound dramatically improved resolution extended data fig the tungsten cluster later found bind dimers separate intasome complexes mitigate crystal lattice disorder the crystals soaked overnight 0.15 mm metatungstate cluster na6[h2w12o40 stabilization buffer consisting 3.2 sodium formate 16 mm mes naoh ph 6.0 0.8 nacl 16% v v dmso 4% w v glycerol 1 mm tcep soaking the crystals cryo protected 3.2 sodium formate 16 mm mes ph 6.0 0.8 nacl 16% v v dmso 12% w v glycerol 1 mm tcep frozen rapid immersion liquid nitrogen the full length wild type rsv in(1286 c terminally truncated rsv in(1270 various mutant forms tested produced essentially crystals indistinguishable x ray diffraction properties x ray diffraction data collected advanced photon source northeastern collaborative access team beamlines 24-id c e advanced light source molecular biology consortium 4.2.2 beamline processed using hkl2000 xds the rsv intasome crystals showed varied degrees pseudo merohedral twinning twin operator l k h owing similar c unit cell dimensions primitive monoclinic lattice thus screened large number crystals identify ones diffract higher resolution smaller twin fractions the structure rsv intasome determined molecular replacement phaser using rsv ccd ctd pdb 4fw1 16 bp b form dna search models 8 copies ccd one copy ctd three copies dna molecules located refinement partial model revealed electron density two copies metatungstate clusters subsequent iterative model building using coot refinement phenix suite allowed placement remaining 7 copies ctd 8 copies ntd generated using modeller based hiv-1 ntd pdb 1k6y building inter domain linkers well remaining parts dna molecule guided difference electron density maps a third metatungstate cluster weakly bound compared first two positioned manually residual density the dna base pairs base stacking restraints used throughout refinement the geometry restraints protein included reference model restraints ccd ctd based higher resolution rsv structure 4fw1 secondary structure zinc coordination restraints ntd atomic displacement parameters refined grouped b factors per residue protein dna total 53 tls groups assigned phenix the asymmetric unit crystal contains one complete rsv intasome includes eight molecules two viral dna branches emanating strongly bent 38 bp target dna the dataset used final refinement rsv intasome crystal grown using selenomethionine labeled rsv 1270 following amino acid substitutions c23s l112 l135 l162 l163 l188 l189 confirmed active concerted integration inhibited insti similarly wild type rsv dna substrate carrying nick middle target dna branch 16-base dna strand shown olive fig the nick occasionally facilitated crystal growth necessary crystallization change space group unit cell parameters compared crystals grown without nick because nick target dna biologically relevant shown figs twin refinement protocol used dataset used final refinement low less 10% twin fraction the summary data collection refinement statistics shown extended data table 1 the paired refinement procedure performed steps 0.1 determine high resolution limit extended data fig the register amino acids final model verified selenium anomalous difference fourier peaks extended data fig ramachandran analysis shows 96.0 3.9 0.1 protein residues favored allowed disallowed region respectively the ntd ccd linker non catalytic molecules last four bp distal end one viral dna molecules built due poor electron density the secondary structure elements rsv color coded based three domains similarly fig a half site gaped duplex substrate prepared annealing three oligonucleotides dimerizes via self complementary 6-base spacer sequence underlined form branched structure mimicking product concerted integration reaction fig viral dna nucleotides numbered structural elements rsv involved viral dna interactions shown c x ray diffraction pattern metatungstate soaking see method details is perpendicular two fold screw b axis monoclinic lattice lies horizontally f paired refinement analysis assess resolution limit rsv intasome diffraction data pairwise comparison model refinements run two different resolution limits r factors calculated common lower resolution cutoff compared a representative size exclusion chromatography sec profile rsv intasome overlaid mixture molecular weight markers b sec profiles rsv intasomes formed varying c termini c sec mals multi angle light scattering analysis rsv intasome the intasome formed rsv 1269 aa separated sec modified condition containing 20 mm hepes ph 7.5 1.0 nacl 5 glycerol 1.0 mm tcep the absolute molecular mass determined light scattering using line detectors described previously a similar sec mals analysis intasome formed wt full length rsv 1286 aa yielded molecular mass 268 kda n=2 data shown the calculated mass intasome containing eight rsv 1269 270 molecules ~288 kda d chemical cross linking analysis rsv intasome rsv intasome free 1269 aa purified size exclusion chromatography running buffer 20 mm hepes ph 7.5 1.0 nacl 5 glycerol 1.0 mm tcep the peak fractions intasome cross linked indicated amount ethylene glycol bis succinimidylsuccinate egs described previously analyzed sds page the majority cross linked species within intasome larger tetramer the nupage 412% gradient gel mes based sds page running buffer used anomalous difference fourier maps calculated using data collected selemomethionine labeled rsv intasome contoured 3.5 blue mesh 5.0 orange mesh b c close view proximal b distal c dimer respectively b protein arrangement octameric rsv intasome the inner outer subunit one proximal dimer colored green cyan respectively catalytic triad dde inner subunit shown red c close view around active site inner subunit rsv intasome the dna strands colored fig 1 catalytic triad residues dde ) the color scheme follows used proximal dimers rsv b f close view around active site inner subunit pfv intasome pdb 3os0 simulated annealing composite omit 2mfodfc density contoured 1.0 shown area within 3.5 protein dna atom final model b electron densities around protein dna colored differently blue green respectively b dna structure rsv pfv b intasome alternatively referred strand transfer complex stc c comparison dna structures rsv pfv intasomes stcs integration product dnas rsv cyan pfv red superimposed viral dna terminus shown three different view angles note significant deviation overall trajectory target dna difference orientation second viral dna molecule the region spanning two integration sites opposing target dna strands 6 bp rsv 4 bp pfv the sigma weighted 2mfodfc map contoured 1.5 2.5 b overlaid final model central 6 bp region two integration sites data collection refinement statistics statistics highest resolution shell shown parentheses a video showing overall structure rsv intasome positioning three structural domains within intasome	integration of the reverse - transcribed viral dna into the host genome is an essential step in the lifecycle of retroviruses . retrovirus integrase ( in ) catalyzes insertions of both ends of the linear viral dna into a host chromosome 1 . in from hiv-1 and closely related retroviruses share the three - domain organization , consisting of a catalytic core domain flanked by n- and c - terminal domains essential for the concerted integration reaction . although structures of the tetrameric in - dna complexes have been reported for in from prototype foamy virus ( pfv ) featuring an additional dna - binding domain and longer interdomain linkers 25 , the architecture of a canonical three - domain in bound to dna remained elusive . here we report a crystal structure of the three - domain in from rous sarcoma virus ( rsv ) in complex with viral and target dnas . the structure shows an octameric assembly of in , in which a pair of in dimers engage viral dna ends for catalysis while another pair of non - catalytic in dimers bridge between the two viral dna molecules and help capture target dna . the individual domains of the eight in molecules play varying roles to hold the complex together , making an extensive network of protein - dna and protein - protein contacts that show both conserved and distinct features compared to those observed for pfv in . our work highlights diversity of retrovirus intasome assembly and provides insights into the mechanisms of integration by hiv-1 and related retroviruses .
lot species vectors viral rickettsial bacterial protozoal diseases birds mammals including humans identification causative tick important making diagnosis tick related dermatoses republic korea hard ticks belong family ixodidae responsible tick related diseases since first human case tick bite reported 1982 total number cases recorded literature reached approximate 40 no amblyomma case yet recorded korea although approximately 100 species genus amblyomma recorded worldwide here report human case typical infestation amblyomma testudinarium koch 1844 adult worm korean woman in july 2009 74-year old korean woman presented dermatology clinic large mass left inguinal region typical rural housewife frequently worked field near house admission she complained mild discomfort itching sensation skin around bite area laboratory examinations normal negative following tests hemoglobin 14.1 g dl hematocrit 43.3% white blood cell 8,210/mm neutrophil 69% lymphocyte 25% monocyte 6% erythrocyte sedimentation rate 6 mm hr serum glutamic pyruvic transaminase 30 ten days prior presentation patient began note presence mass thought benign clinic found dark green round 23 mm organism whose head partially burrowed skin it grasped close skin steady pressure applied pulling tick straight perpendicularly skin organism removed plucking mouth part torn six months later patient well follow communication discontinued she probably attacked tick working collect vegetables edible sprouts wild grass vegetable garden located suburb suncheon city jeollanam residing she recently traveled foreign country well domestic area including jeju island the isolated tick fixed formalin stereoscopically examined determine species the body 23 mm length 19 mm width 12 mm height fig the small ornamented scutum seen small shield behind capitulum back the eyes located lateral edges scutum projecting beyond scutal contour although greater part mouth including hypostome torn left pedipalp relatively well preserved characteristic appearance especially long article 2 approximately 2.5 times long article 3 fig the genital aperture located level coxa coxa ii figs 1 2b the anus located level posterior spiracular plates embraced shaped anal groove posteriorly figs 1 2c the spiracular plate comma shaped located ventrolateral surface posterolaterally coxa iv figs 1 2d the tick 4 pairs legs figs 1 3 coxa 2 medium sized subequal spurs external spur slightly longer internal spur fig the coxa ii single salient ridgelike spur much broader long fig the coxa iii single spur similar coxa ii fig the coxa iv single spur longer coxae ii iii fig base upon morphological features tick identified female adult a. testudinarium table 1 ticks blood sucking arthropods parasitize various species vertebrates almost every region world republic korea 40 human cases reported since 1982 3 5 the causative ticks reported korea identified ixodes nipponensis i. ovatus i. monospinosus i. persulcatus haemaphysalis flava h. longicornis the genus amblyomma ticks large beautifully ornamented long mouth parts possessing eyes festoons close examination stereomicroscope showed capitulum anterior portion body scutum dorsal portion spiracular plate genital aperture anus 4 pairs legs ventral portion the pedipalp capitulum slender second segment much longer third the scutum quite ornate comparison parts body non protruding eyes edge the coxa first leg subequal 2 spurs external one slightly larger internal the spine coxa fourth leg longer second third legs these characteristics typical features adult female a. testudinarium 8 11 they feed 7 12 days full engorgement reach 20 mm length feeding the genus amblyomma one largest ticks among hard ticks case a. testudinarium the size adult females varies 5 20 mm depending stages engorgement however species may feed 30 days longer reach bigger 20 mm length present case hospital admission quite delayed the tick fed additional 10 days detected patient inordinately engorged it measured 23 mm long bigger human ticks reported korea the present tick would situ least 1 month time patient itching mild pain skin around bite area clinical symptoms tick borne infection including lyme disease rickettsiosis occurred ticks also cause inflammatory problems host without transmitting infection head part broken removal process careful attention her symptoms disappeared gradually removal tick surgical wound healed week frequent location involved a. testudinarium is known axillary anogenital inguinal region rich apocrine glands present case tick bite found inguinal region according patient recall daily life often undressed urination working vegetable garden nearby home it appears tick attached clothing skin undressed a. testudinarium known tropical tick found mainly indian peninsula south east asia including myanmar thailand malaysia indonesia philippines taiwan japan japan it especially important southwestern areas 36 north latitude including kinki shikoku kyushu chugoku the geographical limitation a. testudinarium southwestern part japan implies warm temperature heavy rainfall subtropical vegetation fauna may proper environmental condition tick korea a. testudinarium known distributed jeju island 33 34 north latitude located south sea far korean peninsula however species also collected southern coastal area jeollanam haemaphysalis phasiana survey using tick drags present case patient living suburban rural area suncheon city approximately 400 km south seoul korea it agricultural industrial city nearby sea suncheon bay 35 north latitude facing south sea	a case of tick bite was found in the inguinal region of a 74-year - old korean woman . she was attacked by the tick while working in her vegetable garden in the vicinity of mountain located in suncheon city , the southern coastal area of the korean peninsula . on admission she complained of mild discomfort and itching around the bite area . the causative tick was 23 mm long and had slender pedipalps . the scutum was quite ornate and had eyes at the edge . the genital aperture was located anterior to the level of the coxa ii . the spiracular plate was comma - shaped and the anus was surrounded posteriorly by the anal groove . the coxa i had subequal 2 spurs ; the external one slightly larger . the spur of coxa iv was slightly longer than those of coxae ii and iii . the tarsus iv had 2 distinct subapical ventral spurs . it was identified as the fully engorged adult female of amblyomma testudinarium . this is the first human case of amblyomma bite in korea .
hashimoto encephalopathy rare steroid responsive encephalopathy syndrome characterized persisting fluctuating neurologic neuropsychological deficits associated elevated blood concentrations anti thyroid antibodies the classically described clinical manifestations usually include acute subacute onset confusion alteration consciousness myoclonus less publicized manifestation disease we present case hashimoto encephalopathy presenting steroid responsive myoclonus setting autoimmune thyroid disease an 18-year old male patient diagnosed primary hypothyroidism 6 months back following weight gain edema facial puffiness 3 years duration his initial thyroid function test tft t4 2.3 g dl 5.01 12.4 t3 0.35 ng ml 0.6 1.81 thyroid stimulating hormone tsh 180 iu ml 0.35 5.50 started l thyroxine significant improvement symptoms he started developing myoclonus past 1 month referred hospital examination conscious cognitive impairment memory loss recent events poor attention span difficulty finding words dyscalculia dysgraphia mini mental status examination mmse 11 suggestive moderate cognitive impairment he also myoclonus involving upper limbs lower limbs investigations blood routine examination erythrocyte sedimentation rate normal liver function test kidney function test sodium potassium calcium magnesium normal arterial blood gas analysis his latest tfts show normal t3 t4 mild elevation tsh tsh-9.1 iu ml his electroencephalogram eeg showed diffuse slow wave activity figure 1 magnetic resonance images mri showed pituitary hyperplasia figure 2 non specific white matter changes figure 3 electroencephalogram showing diffuse slow wave activity magnetic resonance images showing pituitary hyperplasia magnetic resonance images showing non specific white matter changes antinuclear antibody titer anti double stranded deoxyribonucleic acid hepatitis b surface antigen anti hepatitis c virus lupus anticoagulant venereal disease research laboratory vdrl test carried evaluate cause decreased cognitive function myoclonus seizures negative csf electrophoresis normal view neurologic symptoms associated high titers anti thyroid antibodies exclusion possible causes encephalopathy he started methylprednisolone 1 g day 3 days shifted prednisone 1 mg kg day there marked improvement symptoms episodes myoclonus seizures one month discharge patient reported sustained improvement parameters including memory cognition making possible return almost normal routine prednisone dose tapped period 3 months without recurrence symptoms hashimoto encephalopathy rare steroid responsive neuropsychiatric syndrome associated serologic evidence anti thyroid antibodies causes encephalopathy excluded this syndrome first described brain et al 1966 still remains rare diagnosed condition 130 cases reported literature date predominantly adult females the difficulty diagnosis due varied presentations subtlety symptoms may acute chronic the pathophysiology hashimoto encephalopathy still unclear proposed pathogenetic mechanisms include autoimmune cerebral vasculitis toxic effects thyroid stimulating hormone central nervous system neuronal reaction mediated antibodies the anti thyroid antibodies appear pathogenic considered markers disease based observation proposed rename hashimoto encephalopathy steroid responsive encephalopathy associated autoimmune thyroiditis the clinical manifestations usually include acute subacute onset confusion alteration consciousness two thirds patients may experience focal generalized tonic clonic seizures 12% may present status epileptics hyperreflexia pyramidal tract signs found 85% patients psychosis visual hallucinations paranoid delusions reported 25 36% patients myoclonus less publicized common manifestation 52% patients diagnosed history myoclonus the diagnosis considered patients presenting characteristic neuropsychiatric manifestations excluding causes encephalopathy 1 presence high levels anti thyroid antibodies serum csf 2 alteration csf and/or imaging tests compatible infectious vascular neoplastic etiology 3 good response immunosuppressive therapy elevated csf protein common thyroid profile may variable 23 35% patients subclinical hypothyroidism 17 20% hypothyroidism 7% hyperthyroidism 18 45% euthyroid non specific eeg abnormalities seen 90 98% patients brain mri may show abnormalities 49% cerebral atrophy focal cortical abnormality diffuse subcortical abnormality non specific subcortical focal white matter abnormality the disease responsive immunosuppressive therapy intravenous iv methylprednisolone 500 1000 mg day 3 5 days followed oral dose prednisone 1 2 mg kg day followed gradual tapering based clinical response commonly followed protocol around 2 5% patients may respond steroids azathioprine iv immunoglobulins plasmapheresis used good results the diagnosis considered patients presenting characteristic neuropsychiatric manifestations excluding causes encephalopathy they 1 presence high levels anti thyroid antibodies serum csf 2 alteration csf and/or imaging tests compatible infectious vascular neoplastic etiology 3 good response immunosuppressive therapy elevated csf protein common thyroid profile may variable 23 35% patients subclinical hypothyroidism 17 20% hypothyroidism 7% hyperthyroidism 18 45% euthyroid non specific eeg abnormalities seen 90 98% patients brain mri may show abnormalities 49% cerebral atrophy focal cortical abnormality diffuse subcortical abnormality non specific subcortical focal white matter abnormality the disease responsive immunosuppressive therapy intravenous iv methylprednisolone 500 1000 mg day 3 5 days followed oral dose prednisone 1 2 mg kg day followed gradual tapering based clinical response commonly followed protocol around 2 5% patients may respond steroids azathioprine iv immunoglobulins plasmapheresis used good results	hashimoto 's encephalopathy ( he ) is a rare steroid - responsive encephalopathy syndrome , which can have highly variable neuropsychiatric manifestations and can go unrecognized for a long time . he is a diagnosis of exclusion and should be kept in mind when evaluating a patient with a cognitive dysfunction and high titers of anti - thyroid antibodies as it responds dramatically to steroids . steroid responsive myoclonus can be a presentation of he .
blue rubber bleb nevus syndrome brbns uncommon condition multiple venous malformations skin gastrointestinal tract visceral sites including liver spleen bladder spinal cord lungs bones clinically lesions characteristically blue purple soft compressible nodules rubbery feel they dome shaped almost nipple like rubber blebs may coalesce form large masses the gastrointestinal tract common visceral site affected lesions share pathology cutaneous lesions sessile polypoid affect levels gastrointestinal tract particular small intestine they prone bleeding may cause significant anemia requiring transfusion iron replacement therapy a 21-year old lady presented outpatient department multiple nontender soft rubbery compressible swellings distributed right side chest right upper limb blaschkoid distribution these lesions first appeared right side chest childhood gradually increased number size age her medical family history unremarkable except presence recurrent episodes painless bleeding per rectum hematochezia cutaneous examination revealed multiple blue purple papulonodules variable sizes diameters ranging 2 15 mm distributed along right side chest right hand forearm figures 13 palpation yielded feeling cutaneous herniation the affected limb swollen palpated yielded bag worm like feeling clinically swellings diagnosed blue rubber bleb nevi figures 4 5 present background cutaneous vascular malformation bluish papulo nodule right breast multiple skin colored swellings affecting right hand multiple blue purple cutaneous swellings affecting right arm blue rubber bleb nevus background swollen right arm photograph depicting confinement lesions upper extremity right side hematological evaluation revealed iron deficiency anemia doppler ultrasound hinted presence low flow lesion suggestive vascular malformation computed tomography angiography right upper extremity upper chest revealed extensive venous angiomatous malformation right superior extremity right axilla right side upper chest wall right side neck direct filling contrast upper part superior vena cava the malformation involved subcutaneous fat planes muscles intermuscular portions right upper chest wall right axilla right superior extremity figures 6 7 colonoscopy detected presence vascular polyps sigmoid colon figure 8 presumably led recurrent episodes hematochezia currently patient put oral iron supplements referred department plastic surgery computed tomography angiogram showing extensive vascular malformation affecting right upper limb along right upper trunk ct angiogram showing extensive vascular malformation affecting right upper limb along right upper trunk blue rubber bleb nevus syndrome uncommon condition characterized multiple venous malformations affecting skin internal viscera gastrointestinal tract involvement common it first described gascoyen 1806 1958 william bennet bean coined term blue rubber nevus syndrome color consistency brbns affects sexes usually sporadic although autosomal dominant inheritance reported bean described three types lesions brbns often noted birth neonatal period although present later the first type compressible red blue nipple like lesions the second type blue black nonblanching macular lesions third type subcutaneous vascular soft tissue lesions case the patient presented lesions akin first type english literature most lesions diffusely distributed body blue subcutaneous nodules characteristic lesions however in case skin lesions distributed unilaterally affecting right side body the lesions upper limb also arranged linear fashion making case even rarer best knowledge single report brbns linear unilateral distribution world literature happens second case showing unique distribution complications include acute hemorrhage iron deficiency anemia following chronic bleeding thrombocytopenia disseminated intravascular coagulation intussusception volvulus bowel infarction skeletal bowing pathologic fracture bony overgrowth articular derangement pain due phleboliths presence cutaneous lesions alert clinicians possible presence internal vascular malformations present case recurrent episodes hematochezia possibly occurred due underlying vascular malformations polyps present sigmoid colon detected colonoscopy these include cryotherapy sclerotherapy surgery newly reported long pulsed neodymium yttrium aluminium garnet 1064 nm laser cutaneous lesions we referred patient department plastic surgery possible surgery coexistence cutaneous gastrointestinal venous malformations hallmark brbns venous malformations additional sites oral cavity central nervous system endocrine glands musculoskeletal system kidney bladder liver spleen heart lungs the extra cutaneous gastrointestinal lesions may present hemoptysis hematuria skeletal deformities asymptomatic the differential diagnoses include maffucci syndrome venous lakes osler weber rendu syndrome hereditary hemorrhagic telangiectasia disseminated hemangiomatosis kaposi sarcoma brb nevi differentiated conditions based latter characteristic features bluish bleb like painful tender hyperhidrotic compressible nodules feeling dermal herniation associated gastrointestinal tract involvement a complete history physical evaluation must make successful diagnosis help treatment planning prevent fatal potential complications linear unilateral distribution brbns extremely uncommon happens second case english literature best knowledge unilateral linear blaschkoid distribution blue rubber bleb nevus syndrome extremely uncommon happens first case india	blue rubber bleb nevus syndrome ( brbns ) also called bean 's syndrome is a rare disorder characterized by multiple cutaneous venous malformations in association with visceral lesions , most commonly affecting the gastrointestinal tract . we report here , a 21-year - old woman patient , who presented with unilateral , blaschkoid distribution of cutaneous venous malformations along with blue rubber bleb nevus and recurrent episodes of hematochezia due to vascular lesions in the sigmoid colon ; likely to be a case of brbns . the unusual unilateral , blaschkoid distribution of brbns prompted this present report .
etoac soluble fraction obtained liquid liquid partition etoh extract 100 mg showed antiplasmodial activity dereplication previously described indicated extract contained least one new bioactive compound larger sample investigated fractionation etoac soluble fraction sample chromatography sephadex lh-20 reverse phase spe normal phase silic gel column chromatography c18 hplc yielded compounds 1 68 together fractions mixtures 5,6-dihydro--pyrones bicyclic tetrahydro--pyrones purification fractions effected diol ptlc hplc yield compounds 2 3 5 911 compound 1 isolated clear oil molecular formula established c20h36o3 hresims z 325.2753 h its ir spectrum showed absorptions 3340 1719 1613 cm assigned hydroxy group ,-unsaturated -lactone moiety respectively its h nmr spectroscopic data signals conjugated olefinic moiety h 6.90 1h h4 6.03 dt j 9.8 1.7 hz 1h h3 two oxymethine groups h 4.75 1h h6 4.00 brs 1h h2 terminal primary methyl group h 0.88 j 7.0 hz 3h ch315 upfield region multiplet h 2.36 2h h5 representing de shielded methylene group in hmbc spectrum methylene protons h 2.36 h5 showed correlations olefin group c 121.3 c3 145.0 c4 oxymethine resonance h 4.75 c 74.8 c6 in addition olefinic protons h 6.90 h4 h 6.03 h3 oxymethine h 4.75 h6 correlated carbonyl carbon c 164.6 c2 figure 1 data indicated six substituted 5,6-dihydro--pyrone common ring system secondary metabolites found cryptocarya species the remaining oxymethine group h 4.00 1h h2 assigned c2 flanked two methylenes c1 c3 indicated hmbc correlations figure 1 methylene protons h 1.92 ddd j 14.5 9.6 2.2 hz h1 h 1.65 h1 c5 c 30.1 h2 h 4.00 oxymethine carbon c 74.8 c6 h2 two neighboring methylene carbons c 41.2 c1 c 38.2 c3 the 6r absolute configuration determined positive cotton effects 256 nm observed ecd spectrum meoh arising n transitions lactone ring the h nmr spectra r mpa ester derivatives 1(26 revealed slight differences h chemical shifts c6 adjacent protons allowed assignment r configuration c2 1 figure s1a the complete assignment protons carbons 1 table 1 accomplished interpretation hmbc hsqc spectra compound 1 thus assigned 6r-(2r hydroxypentadecyl)-5,6-dihydro-2h pyran-2-one named cryptorigidifoliol a. spectra obtained cdcl3 assignments basis analysis 2d nmr spectra data measured 500 mhz brs broad singlet brd broad doublet triplet ddd doublet doublets doublets dt doublet triplets multiplet j values hz omitted signals overlapped multiplets data measured 125 mhz ch3 ch2 ch c multiplicities determined hsqc experiment compound 2 obtained oil molecular formula c24h44o4 basis hresims spectrum z 397.3317 h uv ir h nmr spectroscopic data 2 comparable 1 suggesting 2 also six substituted 5,6-dihydro--pyrone major difference h nmr spectroscopic data 1 2 presence additional signal oxymethine proton h 3.89 1h h4 2 the hmbc correlation oxymethine proton carbon signal c 69.8 c2 assigned additional hydroxy group c4 assignment supported hmbc cross peaks two adjacent methylene protons h 1.61 2h h3 1.47 2h h5 oxymethine carbon c 74.0 similar 1 complete assignments protons carbons 2 table 1 accomplished interpretation hmbc hsqc spectra ecd synthesis h nmr analysis mpa esters used assign configurations c6 c2 c4 r r respectively compound 2 thus assigned 6r-(2s,4r dihydroxynonadecyl)-5,6-dihydro-2h pyran-2-one named cryptorigidifoliol b. molecular formula compound 3 c22h38o3 hresims z 351.2902 h h nmr spectrum h 5.34 2h h10 h11 indicated additional disubstituted olefin moiety compared compound 1 its uv ir h nmr spectroscopic data indicated presence -pyrone ring 1 2 hmbc correlations h10 h11 h 5.34 carbons c 27.0 indicated additional olefinic moiety must located two methylene groups long range correlation h9 h12 h 2.051.99 4h h8 13 h 1.371.31 4h carbons c10 11 c 130 hmbc spectrum assigned olefinic moiety c10 c11. geometry double bond assigned z basis shielded c nmr chemical shift methylenes connected double bond c 29.4 the position double bond within alkyl chain determined unambiguously analysis gc eims fragmentation dimethyldisulfide dmds derivative 3 showed major ion z 299 attributable fragmentation two ch3s groups located original site unsaturation fragment ions z 281 145 also observed support assigned structure figure s2a the relative configuration 3 assignment h c nmr data determined methods 1 2 compound 3 assigned 6r-(2r hydroxy-10z heptadecenyl)-5,6-dihydro-2h pyran-2-one named cryptorigidifoliol c. molecular formula 4 c24h42o3 hresims z 396.3489 nh4 differed molecular formula 3 c22h38o3 c2h4 unit inspection h nmr spectra 3 4 demonstrated 4 possessed structure similar 3 two additional carbons alkenyl chain intense fragment ions z 299 173 additional ion peak z 281 eims spectrum dmds adduct 5 indicated position double bond c10 c11 figure s2b the complete nmr data configurations stereogenic centers 4 assigned methods 13 compound 4 assigned 6r-(2s hydroxy-10z nonadecenyl)-5,6-dihydro-2h pyran-2-one named cryptorigidifoliol d. h nmr spectrum compound 5 c24h42o4 hresims z 377.3060 oh showed presence two oxymethine groups h 4.63 1h h2 h 4.15 1h h12 double bond h 5.68 1h h4 h 5.49 dd j 15.3 7.0 1h h3 alkyl chain besides -pyrone signals h 6.90 6.03 4.69 2.44 the large coupling constant 15.3 hz observed h3 indicated e geometry double bond hmbc spectrum correlations observed protons h 1.79 1.73 1h h1 c3 c 131.4 proton h 4.63 1h h2 c4 c 132.6 these observations suggested connection olefinic moiety c2 oxymethine functionality the eims data 5 showed significant ions z 265 247 together less intense ion z 111 consistent assignment second hydroxy group c12 figure s3 the configurations c6 c2 assigned r respectively interpretation ecd spectroscopic data mpa ester method an attempt made determine configuration c12 using mpa ester method lead firm conclusion could distinguish chemical shifts protons two methylene groups attached c12. compound 5 assigned 6r-(2r,12-dihydroxy-3e nonadecenyl)-5,6-dihydro-2h pyran-2-one named cryptorigidifoliol e. compound 6 molecular formula c24h42o4 basis hresims z 395.3149 h ir spectrum showed absorptions characteristic -lactone moiety 1719 1073 cm the h nmr spectrum lacked signals vinylic protons ,-unsaturated lactone unit ir absorption 1615 cm found compounds 15 absent a new methylene signal observed h 2.89 brd j 19.3 hz 1h h4a 2.78 dd j 19.3 4.5 hz 1h h4b showed hmbc correlations carbonyl carbon c 169.7 c3 figure 2 a signal vinylic proton observed h nmr spectrum h 5.33 2h h8 h9 four indices hydrogen deficiency 6 thus required second ring addition lactone double bond functionalities the h nmr spectrum showed presence four oxymethine protons h 4.89 1h h1 4.36 j 4.5 hz 1h h5 4.10 1h h7 3.81 1h h2 directly attached c1 c 73.1 c5 c 66.0 c6 c 63.6 c2 c 68.3 respectively assignments confirmed hsqc data hmbc spectrum cross peaks observed two oxymethine protons h 4.89 h1 4.36 h5 carbonyl carbon c 169.7 c3 c7 oxymethine c 63.6 correlations also observed two oxymethine protons h1 h5 c5 c 66.0 c1 c 73.1 respectively oxymethine proton h 4.10 h7 oxygenated carbon c 68.3 c2 h 3.81 1h h2 figure 2 collectively correlations permitted assignment bicyclic ring system alkyl chain substituted c7 hydroxy group c2 6 figure 2 the long range cross peaks observed h8 h9 h 5.33 2h c 29.6 hmbc spectrum indicated allylic methylene groups resonated c 29.6 c7 c10 indicated z geometry sole double bond alkyl chain position double bond assigned c8/9 basis eims fragmentation dmds adduct intense peak z 173 peak z 297 corresponding loss water lactone containing fragment ion figure s2c an attempt assign configuration c2 6 mpa ester method successful significant h differences r- mpa derivatives because bicyclic tetrahydro--pyrones 6 formed corresponding 5,6-dihydro--pyrones explained 5,6-dihydro--pyrones 6r configuration proposed orientation substituents c1 6 corresponding c6 putative monocyclic precursor must because change group priorities c1 absolute configuration s. preference formation less strained cis fused bicyclic system dictates generation 5r configured center the cis fused configuration demonstrated related bicyclic tetrahydro--pyrones x ray crystallography the configuration 6 c7 could assigned 5,6-dihydro--pyrone precursor isolated the complete nmr assignments 6 table 2 facilitated interpretation hmbc hsqc spectra compound 6 thus assigned 1s,5r)-7-(2-hydroxy-8z heptadecenyl)-2,6-dioxabicyclo[3.3.1]nonan-3-one named cryptorigidifoliol f. spectra obtained cdcl3 assignments basis analysis 2d nmr spectra data measured 500 mhz singlet br broad doublet dd doublet doublets ddd doublet doublets doublets multiplet j values hz omitted signals overlapped multiplets data measured 125 mhz ch3 ch2 ch c multiplicities determined hsqc experiment compounds 7 z 421.3662 h 8 z 355.2831 h also contained bicyclic tetrahydro--pyrone ring comparison molecular weights h nmr spectra cryptorigidifoliol f 6 revealed structural differences alkyl chain length absence presence double bond hydroxy group alkyl chain cryptorigidifoliol g 7 molecular formula c27h48o3 bicyclic tetrahydro--pyrone similar 6 lacked c2 hydroxy group 20-carbon alkenyl chain c7 preparation dmds derivative permitted assignment double bond c8 z 299 215 figure s2c configuration c7 could determined presumed monocyclic precursor isolated cryptorigidifoliol h 8) also bicyclic tetrahydro--pyrone similar 6 saturated alkyl chain c7 chain length determined 14c basis molecular formula c21h38o4 as case 7 configuration c7 could determined compounds 911 cryptorigidifoliols k bicyclic derivatives 2 3 5 determined conversions described comparison h nmr hresims data 5,6-dihydro--pyrone precursors compounds 68 configurations precursors 2 3 5 2 position established corresponding configurations c7 9 10 11 assigned r r respectively compounds 6 8 9 11 significant h difference r- mpa derivatives thus precluding assignment absolute configurations centers the initial purification bioactive etoac fraction involved sephadex lh-20 column chromatography reverse phase spe normal phase silica gel column chromatography c18 hplc this procedure yielded fractions cases mixtures 5,6-dihydro--pyrones bicyclic tetrahydropyrones in addition noted early eluting fractions open silica gel column contained either pure 5,6-dihydro--pyrone 1 mixtures 5,6-dihydro--pyrones 2 3 5 bicyclic tetrahydropyrones 911 the later eluting fractions however yielded bicyclic tetrahydropyrones 68 this suggested 5,6-dihydro--pyrones cyclized exposure silica gel polar later eluting compounds exposed longer time silica gel becoming completely converted cyclized product pure 5,6-dihydro--pyrone 2 related compounds thus prepared purification ptlc diol silica gel induce intramolecular cyclization it worth noting grkovic co workers isolated 5,6-dihydro--pyrones without artifacts using diol column chromatography bioassay guided fractionation papua new guinea species cryptocarya order find compounds rescue pdcd4 tpa induced degradation verify cyclization hypothesis silica gel mixed compound 2 meoh hexanes etoac resulting suspension allowed stand 3 h room temperature examination resulting solution showed compound 9 present confirming silica gel catalyzed cyclization 5,6-dihydro--pyrone 2 bicyclic tetrahydropyrone 9 scheme 1 compounds 3 5 also treated way leading formation corresponding bicyclic tetrahydropyrone derivatives 10 11 these observations supported hypothesis bicyclic tetrahydropyrones formed intramolecular cyclization c2-hydroxylated 5,6-dihydro--pyrones however rule possibility least bicyclic tetrahydropyrones formed plant examination crude extract h nmr spectroscopy indicated contain signals consistent presence bicyclic tetrahydropyrones this result could due either presence cyclized compounds plant intramolecular cyclization extraction plant processing extract madagascar prior analysis regrettably access fresh plant material test alternate hypotheses fact chromatography silica gel used every case cyclized compounds reported strongly suggests compounds indeed formed purification process compounds 111 evaluated antiparasitic activity chloroquine mefloquine resistant dd2 strain plasmodium falciparum compounds 17 exhibited moderate antimalarial activity ic50 values 9.2 0.9 5.8 1.4 5.5 0.7 9.0 3.0 4.0 2 7.4 0.6 6.0 0.5 respectively compounds 811 less active ic50 values 10 tables 3 4 these data indicate presence ,-unsaturated carbonyl moiety essential antimalarial activity bicyclic compounds 6 7 activity comparable ,-unsaturated carbonyl compounds 15 antimalarial activity dd2 strain plasmodium falciparum antiproliferative activity human ovarian cancer cells antimalarial activity dd2 strain plasmodium falciparum antiproliferative activity human ovarian cancer cells all compounds also evaluated antiproliferative activity a2780 human ovarian cancer cells compound 3 ic50 value less 10 tables 3 4 because compounds moderate antiparasitic activities significant improvement potency therapeutic index necessary used lead compounds development new antiplasmodial drugs the formation compounds 611 serves highlight fact 5,6-dihydro--pyrones containing c2 hydroxy groups side chain susceptible cyclization presence silica gel room temperature it thus possible bicyclic tetrahydropyrones previously reported also formed cyclization corresponding 5,6-dihydro--pyrones isolation process this finding also provides support general belief silica gel avoided isolation natural products general known whether unknown compounds might susceptible similar unwanted reactions place silica gel diol c18 ir uv spectra measured midac series ftir shimadzu uv-1201 spectrophotometers respectively 1d 2d nmr spectra recorded bruker avance 500 spectrometer cdcl3 pyridine d5 cdcl3 pyridine d5 reference high resolution esi mass spectra obtained agilent 6220 mass spectrometer open column chromatography performed using sephadex lh-20 silica gel 230 400 mesh silicycle co. usa semipreparative hplc performed using shimadzu lc-10at pumps coupled semipreparative phenomenex c18 column 5 250 10 mm semipreparative varian diol column 250 10.0 mm shimadzu spd m10a diode array detector scl-10a system controller preparative hplc performed using shimadzu lc-8a pumps coupled preparative varian phenomenex c18 column 250 21.4 mm shimadzu spd m10a diode array detector scl-10a system controller preparative tlc performed using diol plates 500 g sorbtec co. usa all isolated compounds purified 95% purity better judged hplc uv elsd detection determining bioactivity plant parts cryptocarya rigidifolia van der werff lauraceae collected authenticated f.r co workers elevation 1000 13 tall tree diameter 13 cm chest height the tree round green fruit remains brown calyx collection made near towns imerimandroso antanandava district ambatondrazaka north zahamena national park coordinates 172845 484410 e. tree growing medium altitude rainforest edge old area slash burn agriculture duplicate voucher specimens ratovoson 250 deposited centre national dapplication des recherches pharmaceutiques cnarp herbarium department forestry fishery research tef missouri botanical garden st a ground sample c. rigidifolia root wood 310 g extracted etoh 1000 ml room temperature yield 16.3 g crude etoh extract designated mg 0441 portion extract made available virginia tech bioassay guided isolation the crude etoh extract 5.0 g dissolved 90% aqueous meoh 60 ml extracted hexanes the 90% aqueous meoh layer evaporated suspended h2o 100 ml extracted etoac 100 ml the antimalarial activities concentrated etoac ic50 2.55 g ml hexanesfractions ic50 5 g ml etoac fraction 971 mg ) was subjected sephadex lh-20 size chromatography ch2cl2/meoh 1:1 give four fractions active fraction fr-2 ic50 2.55 g ml fractionated c18 spe using 70% aqueous meoh 100% meoh ch2cl2 separately the 100% meoh fraction ic50 1.252.5 g ml divided eight subfractions silica gel column chromatography hexanes etoac 1:1 3:7 1:9 final elution meoh the third subfraction ic50 1.25 g ml subjected c18 hplc solvent gradient h2o ch3cn 20:80 10:90 0.01 to10 min 0:100 10 15 min ending 100% ch3cn 30 min furnishing compound 1 tr 20.2 min 1.1 mg ic50 2.98 g ml active fraction tr 20.8 min further purification active fraction diol ptlc hexanes etoac 4:6 yielded 3 1.4 mg ic50 1.93 g ml 10 0.4 mg ic50 5.74 g ml the fourth subfraction silica gel column chromatography subjected c18 hplc solvent gradient h2o ch3cn 30:7020:80 0.01 to15 min 10:90 15 35 min 0:100 35 50 min ending 100% ch3cn 60 min purification diol ptlc hexanes etoac 4:6 mixtures tr 37.5 40.2 min obtained process gave compounds 5 0.9 mg ic50 3.55 g ml 11 3.1 mg ic50 20 g ml 2 1.3 mg ic50 2.30 g ml 9 0.5 mg ic50 6.57 g ml the fifth subfraction silica gel column chromatography purified c18 hplc using profile fourth subfraction giving pure compounds 8 4.2 mg tr 38 min ic50 13.6 g ml 6 9.6 mg tr 40.8 min ic50 1.58 g ml the hexanes fraction subjected sephadex lh-20 gel chromatography ch2cl2/meoh 1:1 give three fractions active fraction fr-2 ic50 2.55 g ml fractionated preparative c18 hplc solvent gradient h2o ch3cn 30:700:100 0.01 30 min ending 100% ch3cn 45 min this process yielded compound 7 1.6 mg tr 39 min ic50 2.50 g ml active fraction tr 32.5 min further purification fraction diol hplc solvent gradient hexanes etoac 90:1080:20 0.01 10 min 70:30 10 15 min 60:40 15 20 min 0:100 20 25 min ending 100% etoac wash 35 min afforded compound 4 0.9 mg ic50 2.76 g ml colorless oil ]d 6 c 0.5 meoh uv meoh max log 204 3.63 nm ir max 3340 2922 2849 1719 1613 1089 cm ecd c 0.031 mm meoh max 203 8.5 235 2.4 256 3.8 h c nmr data see table 1 hresims z h 325.2753 calcd c20h37o3 325.2737 colorless oil ]d 9 c 0.1 meoh uv meoh max log 204 3.83 nm ir max 3343 2922 2850 1714 1615 1092 cm ecd c 0.031 mm meoh max 209 9.7 235 1.9 256 3.5 h c nmr data see table 1 hresims z h 397.3317 calcd c24h45o4 397.3312 colorless oil ]d 19 c 0.6 meoh uv meoh max log 204 3.91 nm ir max 3439 2924 2855 1728 1623 1044 cm ecd c 0.031 mm meoh max 207 9.3 235 1.2 255 3.1 h c nmr data see table 1 hresims z h 351.2902 calcd c22h39o3 351.2894 colorless oil ]d 18 c 0.6 meoh uv meoh max log 204 3.50 nm ir max 3444 2922 2855 1724 1625 1034 cm ecd c 0.031 mm meoh max 208 10.6 235 1.6 256 3.0 h c nmr data see table 1 hresims z nh4 396.3489 calcd c24h46no3 396.3472 colorless oil ]d 25 c 0.4 meoh uv meoh max log 204 3.24 nm ir max 3382 2922 2845 1729 1625 1077 cm ecd c 0.031 mm meoh max 207 11.0 234 2.3 256 3.2 h c nmr data see table 1 hresims z colorless oil ]d 10 c 0.5 meoh uv meoh max log 204 3.14 nm ir max 3450 2932 2855 1719 1073 cm h c nmr data see table 2 hresims z h 395.3149 calcd c24h43o4 396.3156 colorless oil ]d 4 c 0.5 meoh uv meoh max log 204 3.14 nm ir max 3450 2932 2855 1719 1073 cm h c nmr data see table 2 hresims z h 421.3662 calcd c27h49o3 421.3676 colorless oil ]d 11 c 0.5 meoh uv meoh max log 204 2.66 nm ir max 3540 2917 2845 1719 1070 cm h c nmr data see table 2 hresims z h 355.2831 calcd c21h39o4 355.2843 colorless oil ]d 8 c 0.4 meoh uv meoh max log 204 3.43 nm ir max 3340 2943 2846 1727 1068 cm h c nmr data see table 2 hresims z h 397.3317 calcd c24h45o4 397.3312 colorless oil ]d 4 c 0.6 meoh uv meoh max log 204 3.62 nm ir max 3345 2939 2844 1739 1056 cm h c nmr data see table 2 hresims z h]351.2902 calcd c22h39o3 351.2894 colorless oil ]d 8 c 0.6 meoh uv meoh max log 204 3.10 nm ir max 3431 2956 2867 1732 1036 cm h c nmr data see table 2 hresims z h 377.3060 calcd c24h41o3 377.3050 pure samples 200 g dissolved 200 l hexanes treated dimethyldisulfide 400 l 12 drops iodine solution 6% w v ether 6 dram vial 40 c 30 h. mixture cooled diluted hexanes 1 ml iodine removed extracting thiosulfate 1 ml 5% w v the organic layer removed water layer extracted hexanes ch2cl2 1:1 the combined organic layers dried subjected analysis gc eims the nmr tube reaction carried prepare mpa ester derivatives the selected 5,6-dihydro--pyrone 0.2 mg dissolved pyridine d5 clean nmr tube r-()--methoxyphenylacetyl mpa chloride 0.5 mg added nmr tube n2 gas flow nmr tube gently shaken the nmr tube kept room temperature overnight analyzed h nmr spectroscopy the mpa esters 5,6-dihydro--pyrones prepared mpa chloride method compound 2 0.2 mg dissolved mixture meoh 2 ml etoac 0.5 ml hexanes 0.5 ml enough silica gel powder added solution absorb mixture kept room temperature 3 h. resulting damp powder eluted meoh eluate concentrated rotavapor compounds 3 5 0.2 mg also treated separately worked conditions the products identified 10 11 respectively h nmr spectroscopy the a2780 ovarian cancer cell line antiproliferative bioassay performed virginia tech previously reported paclitaxel used positive control ic50 value 73 15 nm the effect compound parasite growth dd2 strain p. falciparum measured 72 h treatment using malaria sybr green based fluorescence assay described previously artemisinin used positive control ic50 value 7 1 nm	antimalarial bioassay - guided fractionation of an etoh extract of the root wood of cryptocarya rigidifolia ( lauraceae ) led to the isolation of the five new 5,6-dihydro--pyrones cryptorigidifoliols a e ( 15 ) and the six bicyclic tetrahydro--pyrone derivatives cryptorigidifoliols f k ( 611 ) . the structure elucidations of all compounds were made on the basis of the interpretation of spectroscopic data and chemical derivatization , and the relative and absolute configurations were determined by noesy , electronic circular dichroism ( ecd ) , and 1h nmr analysis of -methoxyphenylacetyl ( mpa ) derivatives . the bicyclic tetrahydro--pyrone derivatives were identified as products of acid - catalyzed intramolecular michael addition of the 5,6-dihydro--pyrones in the presence of silica gel . a structure activity relationship study suggested that the presence of an ,-unsaturated carbonyl moiety is not essential for potent antimalarial activity .
implication inflammation development cancers well recognized 19th century virchow observed leukocytes tissues contained inflammatory infiltrates later confirmed several clinical cases however insights examined data collected epidemiological studies experimental models showed link chronic inflammation various types cancers chronic inflammation occurs continuous inflammatory signaling caused viral bacterial parasitic infections chemical irritants exposure chemical irritants results recruitment inflammatory cells increased production reactive oxygen species ros reduced dna repair most cancer tissues show specific types inflammatory response subset accounts approximately 20% human cancers worldwide considered essential component tumorigenesis including tumor initiation progression growth metastasis liver cancer one difficult cancers treat second leading cause cancer death worldwide especially china accounts half total cancer incidence death liver cancer strongly correlated viral hepatitis infection 90% liver cancers associated chronic hepatitis liver cirrhosis however cell death regeneration cycles driven persistent inflammation occurs inflammation associated signaling inhibited subsequently results chronic injury many factors provoke inflammatory response liver well known risk factors liver cancer liver cancer occurs progression many chronic liver diseases associated inflammation hepatitis steatohepatitis hepatitis b virus hbv hepatitis c virus hcv found approximately 80%90% hepatocellular carcinoma hcc patients chronic hbv infection dominant risk factor liver cancers asia sub saharan africa particularly china hcv single stranded rna virus interacts numerous proteins hepatocytes promotes progression hepatocarcinogenesis chronic hcv infection dominant risk factor liver cancers japan united states europe cirrhosis contributes hepatocarcinogenesis observed hcc patients hbv hcv infection in addition viral infections acetaldehyde metabolites generated alcohol metabolism increase amount ros reduce dna repair leads hcc epidemiological analysis revealed alcohol consumption positively associated hcc incidence diabetes another risk factor hcc epidemiologic studies reported patients type 2 diabetes nearly 2.5-fold increased risk hcc recently obesity defined risk factor important role hcc development inflammation induced viral non viral infection promotes initiation progression hcc hcc develops background chronic hepatitis constitutive activation inflammatory signaling pathways nf-b jak stat signaling pathways occurs process inflammation observed various cancers first link nf-b cancer was revealed study showing cancer cells sensitive apoptosis inducing stimuli nf-b signaling pathway blocked past decades diverse roles nf-b signaling discovered various types carcinomas including head neck squamous cell carcinoma leukemia cancers breast liver prostate colon lung constitutive nf-b activation observed various cancers nf-b induces expression many pro survival anti apoptotic factors c iap xiap members bcl-2 family proteins analogously activation nf-b might downregulate expression tumor suppressors phosphatase tensin homolog pten downregulated expression increases akt signaling suppresses apoptosis cancer cells in addition pro survival function nf-b promotes cell cycle progression inducing cyclin d1 c myc expression nf-b signaling also induce molecules vascular endothelial growth factor vegf matrix metalloproteinases nf-b promote angiogenesis invasion driving expression proteins many cancers 2004 a group israel confirmed nf-b effective therapeutic target treat hcc hcc development mouse model prevented nf-b inhibition modified form ib called super repressor ib another well known signaling pathway links inflammation cancer janus kinase jak)/signal transducer activator transcription stat stat3 one famous stat family members identified transcription factor binds il-6-responsive element hepatocytes numerous studies reported stat3 also activated oncogenic proteins including ras src carcinogens polychlorinated biphenyls promotes liver cancer regulates activity stat3 hcc normal liver cells likewise constitutive activation stat3 leads expression bcl-2 family proteins essential survival survivin ciap2 moreover apoptosis cancer cells occurs stat3 downregulated tumors stat3 promotes proliferation cancer cells inducing cyclin d1 c myc expression in addition molecules associated proliferation apoptotic inhibition stat3 regulates expression metalloproteinase family vegf consequently promoting angiogenesis metastasis stat3 key regulator inflammation cancer thus might effective therapeutic target inflammation induced cancer 2006 li et al inhibited stat3 expression antisense oligonucleotides hcc cells found stat3 greatly reduced cell proliferation migratory potential well induced apoptosis mirnas constitute class short endogenous non coding rnas highly conserved throughout evolution the majority mirnas transcribed nucleus rna polymerase ii primary mirna pri mirna typical pri mirna contains stem loop structures furthermore stem loop structures cleaved precursor mirnas pre mirnas drosha rna specific ribonuclease enzyme complex dicer functions biogenesis mirnas pre mirnas transported nucleus cytoplasm exportin 5 dicer endonuclease specifically recognizes double stranded rna complexes transforms pre mirna 2022 nt mirna duplex the mature mirna incorporated rna induced silencing complex risc interaction ago proteins mirna recognizes binds 3-utr target mrnas the first mirna discovered caenorhabditis elegans 1993 identified essential regulator postembryonic developmental events first discovery currently mirnas recognized key mediators influencing nearly biological processes including development immune response differentiation proliferation apoptosis invasion metastasis in addition expression numerous mirnas dysregulated nearly pathological processes mirnas gained widely accepted role initiation progression various human cancers including hcc evidence indicated mirnas act oncogenes tumor suppressors mirnas might significant diagnosis prognosis hcc patients accumulating evidence revealed mirnas novel class molecules linking inflammation hcc chronic hepatitis virus infection leads liver inflammation damage fibrosis cell regeneration malignant transformation hcc many mirnas play crucial role regulation hepatitis virus induced chronic infla mmation hcc table 1 for instance mir-27 upregulated hcv infection promote cell migration invasion suppressing spry2 hcc cells mir-146a expression consistently increased hcv infected cells primary hepatocytes liver tissue hcv infected patients increased mir-146a level promotes viral infection associated pathogenesis liver disease following section summarize key roles relevant mirnas hepatitis virus infection hcc mirnas associated hepatitis virus infection hcc first mirna discovered humans let-7 highly conserved across animal species promotes differentiation recent studies revealed let-7 frequently downregulated many cancers breast ovarian prostate lung liver cancers the hbv x protein hbx encoded hbv genome multifunctional transactivator plays crucial roles hbv associated hepatocarcinogenesis hbx lacks dna binding domain acts trans coactivator interaction cellular transcription factors hbx might regulate let-7 family members in addition hbx induction hbv pres2 rna sequester let-7 g turn reduces intrinsic let-7 g functions hcc wang et al concluded hbx mediated regulation let-7 might responsible reduced let-7 expression hbv associated hcc mirnas let-7 family act tumor suppressors hcc inhibiting proliferation invasion well inducing apoptosis targeting many oncogenes including high mobility group proteins bcl xl stat3 c myc mir-122 abundant mirna expressed liver accounts 70% total mirnas adult liver the expression mir-122 increased liver embryonic development first identified target mirna cationic amino acid transporter 1 recent years increasing evidence suggested mir-122 plays important role initiation progression hcc li et al found mir-122 expression low patients chronic hepatitis b hcc tumors negative correlation fibrotic stage age liver transaminase levels the downregulation mir-122 patients chronic hepatitis b hcc tissues affected hbv infection ppar identified transcription factor regulating mir-122 expression underlying cause hbx induced mir-122 downregulation might direct interaction hbx ppar blocks ppar nuclear translocation 2013 li et al further reported four hbv mrnas contain binding site mir-122 act mirna sponge sequestering mir-122 hbv infected cells in addition mir-122 knockout mice possibly develop hepatitis fibrosis hcc the reduced mir-122 expression hcc tissues characterized poor prognosis consistent suppressed hepatic phenotype increased metastatic potential moreover mir-122 expression suppressed two inflammatory cytokines il-6 tnf- downregulate mir-122 transcription factors c ebp hnf3 induce c myc mediated c ebp inhibition chronic hepatic inflammation mir-122 downregulation results upregulation target genes promote hepatocarcinogenesis including pituitary tumor trans forming gene binding factor pbf cyclin g1 pkm2 adam10 adam17 srf pkr activator mir-101 downregulation reported various cancers including hcc suggesting mir-101 functions tumor suppressor reduced mir-101 expression hcc tissues associated advanced tumor progression poor survival hcc patients serum mir-101 level might potential hcc biomarker overexpression mir-101 sensitizes hcc cells apoptosis induced serum deprivation chemotherapeutic drugs mcl-1 member bcl-2 family target mir-101 sensitizes cancer cells apoptosis mir-101 enhances cisplatin induced apoptosis targeting stmn1 rab5a mtor well suppresses epithelial mesenchymal transition emt hepatocytes via regulation zeb1 expression results e cadherin regulation 2010 first link mir-155 hepatitis viruses based observation mir-155 precursor termed bic responsible hcv infection after patients hepatitis c treated interferon alpha ribavirin lowest bic expression detected patients lacked hcv rna serum peripheral blood mononuclear cells previously mir-155 identified onco mir various cancers including lung breast stomach prostate cancers a mouse model revealed mir-155 induced inflammation could promote autoimmune inflammation enhancing inflammatory cell development mir-155 a positive correlation observed mir-155 expression ip-10 levels plasma widely considered marker liver inflammation degree upon nf-b activation hcv rna infection the upregulation mir-155 cases hepatitis hcc promotes hepatocyte proliferation hcc tumor growth activating wnt/-catenin signaling pathway in addition hcc pathogenesis chronic viral infections hcv upregulation mir-155 also observed pathogenesis non alcoholic steatohepatitis nash)-associated hcc however similar hcv induced mir-155 activation nf-b signaling pathway plays key role mir-155 expression hcc hepatocyte derived cells mouse model nash mir-155 downregulated tumor suppressor target c ebp thus promoting liver pathogenesis mir-21 well established onco mir upregulated various cancers including lung breast prostate colon stomach pancreatic liver cancers the relationship mir-21 inflammation observed uv exposed skin mir-21 activated ppar via tgf- signaling pathway the upregulation mir-21 reported inflammation associated tissues cancers allergy induced airway inflammation gastric cancer pre b cell lymphoma colorectal cancer the relevance mir-21 inflammation liver tissues established associating biomarkers hcc diagnosis prognosis mir-21 mir-122 analyzed tissues obtained needle biopsies hcv infected non infected patients the expression mir-21 positively correlated fibrotic stage patients chronic hepatitis c mir-21 promotes liver fibrosis targeting fibrosis inhibitor smad7 serum in addition one study reported hbx increases expression mir-21 subsequently promotes progression hcc targeting pten another study hbx mediated mir-21 upregulation inhibits expression tumor suppressor pdcd4 hcc cells mir-221 another onco mir upregulated cancers breast prostate glioma liver cancers moreover expression mir-221 later stages hcc higher early stages therefore mir-221 poor prognosis risk factor increased mouse models liver fibrosis upregulated human liver fibrosis progression dependent manner hbx promotes proliferation hcc cells upregulates expression mir-221 hbv infection hcc several tumor related genes reported targets mir-221 among genes p27kip1 well recognized the expression mir-221/p27kip1 axis confirmed glioblastomas breast lung liver cancers other p27kip1 many mir-221 targets reported hdac6 pten tissue inhibitor metalloproteinase-3 timp3 mouse models hcc tumor bearing mice treated chol anti mir-221 mir-221 potential target hcc treatment functions inhibiting progression hcc promoting survival chronic inflammation facilitate development progression hcc constitutive activation inflammation signaling pathways inhibition signaling pathways would novel therapeutic strategy suppress inflammation associated process many mirnas reported regulate inflammatory signaling mediated nf-b jak stat3 among others hcc table 2 mir-195 mir-194 mir-127 suppressed nf-b activation directly indirectly targeting nf-b signaling mirnas also function tumor suppressors hcc mir-219 reduced hcc functions tumor suppressor mirna might suppress jak stat3 signaling via direct targeting structural maintenance chromosome 4 protein smc4 mir-637 tumor suppressor inhibits cell growth induces apoptosis suppressing stat3 activation hcc mirnas regulators inflammatory signaling hcc mir-26a suggested play important role cirrhosis inflammation induced hcc reduced mir-26a expression detected hcc tissues decreased expression hcc tissues might independent predictor poor survival clinical analysis revealed expression mir-26a negatively correlated il-6 mrna il-6 protein level as il-6 direct target mir-26a mrna protein levels cytokine significantly reduced mir-26a overexpression hcc cells mir-26a functions tumor suppressor inhibits tumor growth metastasis partly il stat3 signaling pathway m csf expression also reported predictor frequent metastasis poor survival mir-26a affects macrophage polarization inhibits macrophage recruitment regulating csf expression in addition hcc cells transfected mir-126b exhibit significantly reduced nf-b reporter activity response tnf. two well known upstream regulators nf-b signaling pathway tak1 tab 3 identified direct targets mir-26b mir-26b prevents doxorubicin induced nf-b activation promotes apoptosis hcc cells one study mir-451 often downregulated primary hcc tissues reduced mir-451 expression significantly associated advanced tnm stage lymph node metastasis vascular invasion poor survival indicating mir-451 might act tumor suppressor hcc mir-451 might inhibit hcc tumorigenesis metastasis regulating cyclin d1 c myc mrna protein levels further study indicated mir-451 overexpression affected nf-b nuclear translocation significantly decreased nf-b activity directly targeting ikk. expected inhibition mir-451 significantly increased nf-b activity hcc cells moreover recent study revealed reduced expression il-6 receptor observed cells overexpressed mir-451 il-6 receptor direct target mir-451 mir-451 reduced vegf production hcc cells targeting il-6/stat3 signaling pathway mir-124 well known tumor suppressor frequently downregulated various cancers numerous studies revealed mir-124 inhibits inflammatory signaling targeting stat3 different cancer types including glioblastoma gastric cancer endometrial cancer colon cancer hcc recently nf-b p65 reported direct mir-124 target b cell lymphomas the downregulation mir-124 b cell lymphomas enhances nf-b signaling pathway upregulates genes myc bcl-2 associated proliferation anti apoptosis metastasis pro survival stat3 identified direct mir-124 target hcc one study found mir-124 inhibited cell proliferation induced apoptosis hcc cells targeting stat3 moreover hnf4-nf-b feedback circuit includes mir-124 identified hcc reduced hnf4 could biomarker poor prognosis hnf4 suppresses hcc metastasis inhibiting nf-b activation mir-124 also plays important role rela suppression hnf4. mir-124 identified hnf4 target binds 3utr rela mir-124 we discovered mir-125b significantly downregulated hcc could used biomarker prolonged hcc patient survival functions tumor suppressor mir-125b inhibits proliferation hcc cells inducing cell cycle arrest g1/s transition via target gene lin28b il-6r characterized subunit binds il-6 binding il-6 il-6r activates jak stat3 signaling pathway mir-125b block il-6-induced phosphory lation nuclear translocation stat3 hcc cells turn promotes hcc apoptosis in addition mir-125b serves tumor suppressor inhibits migration invasion hcc cells targeting transcriptional co activator pdz binding motif taz several studies revealed mir-370 acts tumor promoter gastric cancer prostate cancer aml whereas studies reported mir-370 tumor suppressor leukemia oral squamous carcinoma xu et al observed regulation mir-370 associated hcc development rats correlated poor survival hcc patients indicating mir-370 serves tumor suppressor hcc the restoration mir-370 inhibits proliferation migration invasion hcc cells suppresses tumorigenesis hcc directly targeting lin28a lin28a post transcriptional modulator mrnas directly bind p65 mrna mir-370 represses nf-b activation inhibits migration invasion hcc cells downregulation lin28a sun et al confirmed tumor suppressor role mir-370 hcc cells showing mir-370 inhibited hcc cell proliferation colony formation ability activating pi3k akt signaling pathway in addition mirnas inhibit inflammatory signaling mirnas mir-155 mir-362 mir-301a mir-1180 promote inflammatory response repressing negative regulators inflammatory signaling the nf-b signaling pathway activated mir-1180 overexpression occurs downregulation mir-1180 direct targets otud7b tnip2 another study confirmed expression tnip2 direct target mir-1180 hcc cells the ectopic expression mir-1180 promoted proliferation hcc cells inhibited apoptosis nf-b induces expression genes participate pro survival anti apoptotic processes ni et al demonstrated mir-362 5p frequently upregulated hcc promoted nf-b signaling downregulating cyld cyld protein binds nf-b essential modulator functions negative regulator nf-b signaling these inflammatory pathways related transcription factors affect development hcc regulating mirna expression several studies confirmed inflammatory signaling facilitates development hcc downregulation upregulation mirnas cells table 3 mirnas mediators inflammatory signaling hcc ning et al observed feedback regulation hnf4 nf-b hcc their study revealed hnf4 dramatically suppresses nf-b signaling pathway rela overexpression knockdown decreases increases expression hnf4 respectively chronic hepatic inflammation nf-b induced expression mir-21 represses hnf4 expression contributes hepatocyte de differentiation hepatocarcinogenesis in addition direct induction mir-21 expression nf-b mir-21 transcriptional activity enhanced high mobility group box-1 protein hmgb1 important participant inflammation hmgb1 conserved nuclear protein functions chromatin binding factor allows transcription factors access specific dna binding sites hmgb1 enhances p65/p50 p50/p50 binding specific dna sites rather binding p65/p65 c rel c rel p65/c rel p50/c rel given role inflammatory cascade hmgb1 upregulated hcc induces mir-21 expression hcc cells the hmgb1/mir-21 signaling axis inhibits downstream targets reck timp3 well promotes cell proliferation invasion migration mir-143 upregulated hcc tissues indicating mir-143 serves tumor promoter mir-143 expression increased hbx mediated nf-b activation although metastasis suppressed mir-143 inhibition nf-b activates transcription specifically binding putative mir-143 promoter nf-b binding site identifies 5.06 kb upstream mir-143 mir-143 promotes cell invasion tumor metastasis suppressing direct target gene fndc3b moreover mir-143 inhibition results apoptosis hcc cells suppression hcc tumorigenesis in addition mir-143 upregulated serum samples patients chronic hepatitis hcc therefore might useful biomarker diseases in addition upregulation mir-221 hbv mir-221 also induced hcv infection nf-b dependent manner however increased expression mir-221 blocked treatment pdtc nf-b inhibitor this finding suggests hcv induced upregulation mir-221 requires nf-b activation nf-b signaling pathway plays important role inflammation associated cancer the expression mir-224 upregulated cirrhotic livers hcc samples suggesting use mir-224 biomarker liver inflammation hcc the upregulation mir-224 begins pre cancerous stage continues hcc development one study in addition mir-224 levels significantly higher patients advanced hcc stages patients early stages mir-224 could induced set pro inflammatory factors tnf lps lt suggesting nf-b signaling regulates mir-224 inflammation mediated activation mir-224 promotes hcc cell migration invasion targeting rho gtpase activating proteins onco mir overexpression mir-224 also facilitates migration invasion hcc cells targeting hoxd10 promotes proliferation targeting p21 mir-197 well studied progression various cancers plays role apoptosis proliferation angiogenesis metastasis drug resistance a negative correlation mir-197 expression il-6 stat3 protein levels observed hcc tissues indicating mir-197 involved stat3 signaling pathway il-6 well known pro inflammatory factor upregulated inflammatory state the expression mature mir-197 reduced il-6 stimulation whereas expression pri mir-197 remained unchanged il-6 stimulation hcc cells further investigation revealed drosha binding pri mir-197 decreased il-6 stimulation indicating il-6 downregulated mir-197 post transcriptional manner inhibiting drosha binding pri mir-197 moreover stat3 identified direct target mir-197 tumor suppressor mir-197 inhibits proliferation invasiveness hcc cells well suppresses tumorigenesis hcc xenografts the first evidence role mir-23a hcc development revealed 2008 mir-23a induced tgf remarkably increased hcc tissues functions anti apoptotic pro proliferative factor hcc cells later wang et al found mir-23 induced il-6 stat3 signaling potential stat3 binding site identified mir-23a promoter region stat3-activated mir-23a downregulates target genes g6pc pcg suppresses gluconeogenesis reduction gluconeogenesis facilitates hcc tumorigenesis chronic hepatitis virus infection leads liver inflammation damage fibrosis cell regeneration malignant transformation hcc many mirnas play crucial role regulation hepatitis virus induced chronic infla mmation hcc table 1 for instance mir-27 upregulated hcv infection promote cell migration invasion suppressing spry2 hcc cells mir-146a expression consistently increased hcv infected cells primary hepatocytes liver tissue hcv infected patients increased mir-146a level promotes viral infection and summarize key roles relevant mirnas hepatitis virus infection hcc mirnas associated hepatitis virus infection hcc first mirna discovered humans let-7 highly conserved across animal species promotes differentiation recent studies revealed let-7 frequently downregulated many cancers breast ovarian prostate lung liver cancers the hbv x protein hbx encoded hbv genome multifunctional transactivator plays crucial roles hbv associated hepatocarcinogenesis hbx lacks dna binding domain acts trans coactivator interaction cellular transcription factors hbx might regulate let-7 family members in addition hbx induction hbv pres2 rna sequester let-7 g turn reduces intrinsic let-7 g functions hcc wang et al concluded hbx mediated regulation let-7 might responsible reduced let-7 expression hbv associated hcc mirnas let-7 family act tumor suppressors hcc inhibiting proliferation invasion well inducing apoptosis targeting many oncogenes including high mobility group proteins bcl xl stat3 c myc mir-122 abundant mirna expressed liver accounts 70% total mirnas adult liver the expression mir-122 increased liver embryonic development first identified target mirna cationic amino acid transporter 1 recent years increasing evidence suggested mir-122 plays important role initiation progression hcc li et al found mir-122 expression low patients chronic hepatitis b hcc tumors negative correlation fibrotic stage age liver transaminase levels the downregulation mir-122 patients chronic hepatitis b hcc tissues affected hbv infection ppar identified transcription factor regulating mir-122 expression underlying cause hbx induced mir-122 downregulation might direct interaction hbx ppar blocks ppar nuclear translocation 2013 li et al further reported four hbv mrnas contain binding site mir-122 act mirna sponge sequestering mir-122 hbv infected cells in addition mir-122 knockout mice possibly develop hepatitis fibrosis hcc reduced mir-122 expression hcc tissues is characterized poor prognosis consistent suppressed hepatic phenotype increased metastatic potential moreover mir-122 expression suppressed two inflammatory cytokines il-6 tnf- downregulate mir-122 transcription factors c ebp hnf3 induce c myc mediated c ebp inhibition chronic hepatic inflammation mir-122 downregulation results upregulation target genes promote hepatocarcinogenesis including pituitary tumor trans forming gene binding factor pbf cyclin g1 pkm2 adam10 adam17 srf pkr activator mir-101 downregulation reported various cancers including hcc suggesting mir-101 functions tumor suppressor reduced mir-101 expression hcc tissues associated advanced tumor progression poor survival hcc patients serum mir-101 level might potential hcc biomarker overexpression mir-101 sensitizes hcc cells apoptosis induced serum deprivation chemotherapeutic drugs mcl-1 member bcl-2 family target mir-101 sensitizes cancer cells apoptosis mir-101 enhances cisplatin induced apoptosis targeting stmn1 rab5a mtor well suppresses epithelial mesenchymal transition emt hepatocytes via regulation zeb1 expression results e cadherin regulation 2010 first link mir-155 hepatitis viruses based observation mir-155 precursor termed bic responsible hcv infection patients hepatitis c were treated interferon alpha ribavirin lowest bic expression detected patients lacked hcv rna serum peripheral blood mononuclear cells previously mir-155 identified onco mir various cancers including lung breast stomach prostate cancers a mouse model revealed mir-155 induced inflammation could promote autoimmune inflammation enhancing inflammatory cell development mir-155 a positive correlation observed mir-155 expression ip-10 levels plasma widely considered marker liver inflammation degree upon nf-b activation hcv rna infection the upregulation mir-155 cases hepatitis hcc promotes hepatocyte proliferation hcc tumor growth activating wnt/-catenin signaling pathway in addition hcc pathogenesis chronic viral infections hcv upregulation mir-155 also observed pathogenesis non alcoholic steatohepatitis nash)-associated hcc however similar hcv induced mir-155 activation nf-b signaling pathway plays key role mir-155 expression hcc hepatocyte derived cells mouse model nash mir-155 downregulated tumor suppressor target c ebp thus promoting liver pathogenesis mir-21 well established onco mir upregulated various cancers including lung breast prostate colon stomach pancreatic liver cancers the relationship mir-21 inflammation observed uv exposed skin mir-21 activated ppar via tgf- signaling pathway the upregulation mir-21 reported inflammation associated tissues cancers allergy induced airway inflammation gastric cancer pre b cell lymphoma colorectal cancer the relevance mir-21 inflammation liver tissues established associating biomarkers hcc diagnosis prognosis mir-21 mir-122 analyzed tissues obtained needle biopsies hcv infected non infected patients the expression mir-21 positively correlated fibrotic stage patients chronic hepatitis c mir-21 promotes liver fibrosis targeting fibrosis inhibitor smad7 serum in addition one study reported hbx increases expression mir-21 subsequently promotes progression hcc targeting pten in another study hbx mediated mir-21 upregulation inhibits expression tumor suppressor pdcd4 hcc cells mir-221 another onco mir upregulated cancers breast prostate glioma liver cancers moreover expression mir-221 later stages hcc higher early stages therefore mir-221 poor prognosis risk factor increased mouse models liver fibrosis upregulated human liver fibrosis progression dependent manner hbx promotes proliferation hcc cells upregulates expression mir-221 hbv infection hcc several tumor related genes reported targets mir-221 among genes p27kip1 well recognized the expression mir-221/p27kip1 axis confirmed glioblastomas breast lung liver cancers other p27kip1 many mir-221 targets reported hdac6 pten tissue inhibitor metalloproteinase-3 timp3 mouse models hcc tumor bearing mice treated chol anti mir-221 survival advantage compared mice control group mir-221 potential target hcc treatment functions inhibiting progression hcc promoting survival chronic inflammation facilitate development progression hcc constitutive activation inflammation signaling pathways inhibition signaling pathways would novel therapeutic strategy suppress inflammation associated process many mirnas reported regulate inflammatory signaling mediated nf-b jak stat3 among others hcc table 2 mir-195 mir-194 mir-127 suppressed nf-b activation directly indirectly targeting nf-b signaling mirnas also function tumor suppressors hcc mir-219 reduced hcc functions tumor suppressor mirna might suppress jak stat3 signaling via direct targeting structural maintenance chromosome 4 protein smc4 mir-637 tumor suppressor inhibits cell growth induces apoptosis suppressing stat3 activation hcc mirnas regulators inflammatory signaling hcc mir-26a suggested play important role cirrhosis inflammation induced hcc reduced mir-26a expression detected hcc tissues decreased expression hcc tissues might independent predictor poor survival clinical analysis revealed expression mir-26a negatively correlated il-6 mrna il-6 protein level as il-6 direct target mir-26a mrna protein levels cytokine significantly reduced mir-26a overexpression hcc cells mir-26a functions tumor suppressor inhibits tumor growth metastasis partly il stat3 signaling pathway m csf expression also reported predictor frequent metastasis poor survival mir-26a affects macrophage polarization inhibits macrophage recruitment regulating csf expression in addition hcc cells transfected mir-126b exhibit significantly reduced nf-b reporter activity response tnf. two well known upstream regulators nf-b signaling pathway tak1 tab 3 identified direct targets mir-26b mir-26b prevents doxorubicin induced nf-b activation promotes apoptosis hcc cells one study mir-451 often downregulated primary hcc tissues reduced mir-451 expression significantly associated advanced tnm stage lymph node metastasis vascular invasion poor survival indicating mir-451 might act tumor suppressor hcc mir-451 might inhibit hcc tumorigenesis metastasis regulating cyclin d1 c myc mrna protein levels further study indicated mir-451 overexpression affected nf-b nuclear translocation significantly decreased nf-b activity directly targeting ikk. expected inhibition mir-451 significantly increased nf-b activity hcc cells moreover recent study revealed reduced expression il-6 receptor observed cells overexpressed mir-451 il-6 receptor direct target mir-451 mir-451 reduced vegf production hcc cells targeting il-6/stat3 signaling pathway mir-124 well known tumor suppressor frequently downregulated various cancers numerous studies revealed mir-124 inhibits inflammatory signaling targeting stat3 different cancer types including glioblastoma gastric cancer endometrial cancer colon cancer hcc recently nf-b p65 reported direct mir-124 target b cell lymphomas the downregulation mir-124 b cell lymphomas enhances nf-b signaling pathway upregulates genes myc bcl-2 associated proliferation anti apoptosis metastasis pro survival stat3 identified direct mir-124 target hcc one study found mir-124 inhibited cell proliferation induced apoptosis hcc cells targeting stat3 moreover hnf4-nf-b feedback circuit includes mir-124 identified hcc reduced hnf4 could biomarker poor prognosis hnf4 suppresses hcc metastasis inhibiting nf-b activation mir-124 also plays important role rela suppression hnf4. mir-124 identified hnf4 target binds 3utr rela mir-124 we discovered mir-125b significantly downregulated hcc could used biomarker prolonged hcc patient survival functions tumor suppressor mir-125b inhibits proliferation hcc cells inducing cell cycle arrest g1/s transition via target gene lin28b il-6r characterized subunit binds il-6 binding il-6 il-6r activates jak stat3 signaling pathway mir-125b block il-6-induced phosphory lation nuclear translocation stat3 hcc cells turn promotes hcc apoptosis in addition mir-125b serves tumor suppressor inhibits migration invasion hcc cells targeting transcriptional co activator pdz binding motif taz several studies revealed mir-370 acts tumor promoter gastric cancer prostate cancer aml whereas studies reported mir-370 tumor suppressor leukemia oral squamous carcinoma xu et al observed regulation mir-370 associated hcc development rats correlated poor survival hcc patients indicating mir-370 serves tumor suppressor hcc the restoration mir-370 inhibits proliferation migration invasion hcc cells suppresses tumorigenesis hcc directly targeting lin28a lin28a post transcriptional modulator mrnas directly bind p65 mrna mir-370 represses nf-b activation inhibits migration invasion hcc cells downregulation lin28a sun et al confirmed tumor suppressor role mir-370 hcc cells showing mir-370 inhibited hcc cell proliferation colony formation ability activating pi3k akt signaling pathway in addition mirnas inhibit inflammatory signaling mirnas mir-155 mir-362 mir-301a mir-1180 promote inflammatory response repressing negative regulators inflammatory signaling the nf-b signaling pathway activated mir-1180 overexpression occurs downregulation mir-1180 direct targets otud7b tnip2 another study confirmed expression tnip2 direct target mir-1180 hcc cells the ectopic expression mir-1180 promoted proliferation hcc cells inhibited apoptosis nf-b induces expression genes participate pro survival anti apoptotic processes ni et al demonstrated mir-362 5p frequently upregulated hcc promoted nf-b signaling downregulating cyld cyld protein binds nf-b essential modulator functions negative regulator nf-b signaling these inflammatory pathways related transcription factors affect development hcc regulating mirna expression several studies confirmed inflammatory signaling facilitates development hcc downregulation upregulation mirnas cells table 3 mirnas mediators inflammatory signaling hcc ning et al observed feedback regulation hnf4 nf-b hcc their study revealed hnf4 dramatically suppresses nf-b signaling pathway rela overexpression knockdown decreases increases expression hnf4 respectively chronic hepatic inflammation nf-b induced expression mir-21 represses hnf4 expression contributes hepatocyte de differentiation hepatocarcinogenesis in addition direct induction mir-21 expression nf-b mir-21 transcriptional activity enhanced high mobility group box-1 protein hmgb1 important participant inflammation hmgb1 conserved nuclear protein functions chromatin binding factor allows transcription factors access specific dna binding sites hmgb1 enhances p65/p50 p50/p50 binding specific dna sites rather binding p65/p65 c rel c rel p65/c rel p50/c rel given role inflammatory cascade hmgb1 upregulated hcc induces mir-21 expression hcc cells the hmgb1/mir-21 signaling axis inhibits downstream targets reck timp3 well promotes cell proliferation invasion migration mir-143 upregulated hcc tissues indicating mir-143 serves tumor promoter mir-143 expression increased hbx mediated nf-b activation although metastasis suppressed mir-143 inhibition nf-b activates transcription specifically binding putative mir-143 promoter nf-b binding site identifies 5.06 kb upstream mir-143 mir-143 promotes cell invasion tumor metastasis suppressing direct target gene fndc3b moreover mir-143 inhibition results apoptosis hcc cells suppression hcc tumorigenesis in addition mir-143 upregulated serum samples patients chronic hepatitis hcc therefore might useful biomarker diseases in addition upregulation mir-221 hbv mir-221 also induced hcv infection nf-b dependent manner however increased expression mir-221 blocked treatment pdtc nf-b inhibitor this finding suggests hcv induced upregulation mir-221 requires nf-b activation nf-b signaling pathway plays important role inflammation associated cancer the expression mir-224 upregulated cirrhotic livers hcc samples suggesting use mir-224 biomarker liver inflammation hcc the upregulation mir-224 begins pre cancerous stage continues hcc development in one study patients lower mir-224 expression exhibited favorable trend survival in addition mir-224 levels significantly higher patients advanced hcc stages patients early stages mir-224 could induced set pro inflammatory factors tnf lps lt suggesting nf-b signaling regulates mir-224 inflammation mediated activation mir-224 promotes hcc cell migration invasion targeting rho gtpase activating proteins onco mir overexpression mir-224 also facilitates migration invasion hcc cells targeting hoxd10 promotes proliferation targeting p21 mir-197 well studied progression various cancers plays role apoptosis proliferation angiogenesis metastasis drug resistance negative correlation mir-197 expression il-6 stat3 protein levels was observed hcc tissues indicating mir-197 involved stat3 signaling pathway il-6 well known pro inflammatory factor upregulated inflammatory state the expression mature mir-197 reduced il-6 stimulation whereas expression pri mir-197 remained unchanged il-6 stimulation hcc cells further investigation revealed drosha binding pri mir-197 decreased il-6 stimulation indicating il-6 downregulated mir-197 post transcriptional manner inhibiting drosha binding pri mir-197 moreover stat3 identified direct target mir-197 tumor suppressor mir-197 inhibits proliferation invasiveness hcc cells well suppresses tumorigenesis hcc xenografts the first evidence role mir-23a hcc development revealed 2008 mir-23a induced tgf remarkably increased hcc tissues functions anti apoptotic pro proliferative factor hcc cells later wang et al found mir-23 induced il-6 stat3 signaling potential stat3 binding site identified mir-23a promoter region stat3-activated mir-23a downregulates target genes g6pc pcg suppresses gluconeogenesis reduction gluconeogenesis facilitates hcc tumorigenesis mirnas well recognized role liver inflammation hepatocarcinogenesis many mirnas dysregulated chronic liver inflammation hcc progression mirnas regarded novel targets hcc therapy first study using mirna based therapy conducted 2005 study mir-122 expression silenced antagomirs act efficient specific silencers endogenous mirnas a clinical trial treating hcv infection mir-122 inhibition performed mir-122 targets hcv genomic rna promotes hcv viral translation jong kook park colleagues treated tumor bearing mice chol anti mir-221 cholesterol labeled control oligo consistent vitro results improved survival observed group mice treated chol anti mir-221 addition mir-21 tumor promoter functions prognostic factor previously described mir-21 promotes proliferation metastasis tumorigenesis hcc validated onco mir involved drug resistance mir-21 suppression lenti mir-21-i combined 5-fluorouracil pirarubicin treatment leads significant suppression hcc cell proliferation 5-fluorouracil pirarubicin downregulated mir-21 expression ap-1 signaling tumor bearing nude mice intra tumorally injected either mir-199 adenovirus pbs control these results confirmed transgenic model mice predisposed hcc development the group mice treated mir-199 adenovirus exhibited reduced tumor burden decreased number tumor nodules compared control group it expected future mirnas acting tumor suppressors applied therapeutic oncolytic viruses manner similar mir-199 another mirna based therapeutic strategy design mirna panels targets particular protein modulate inflammatory response hcc development the association ikk complex rap1 important nf-b activation rap1 serves adaptor recruit ikks aids phosphorylation nf-b p65 subunit 5-fluorouracil widely used chemotherapy drug advanced hcc patients many patients hcc highly resistant chemotherapy regimen a set 4 rap1-mirnas designed knock rap1 leading significant increase sensitivity hepg2 cells 5-fluorouracil induced apoptosis number mirnas induced inhibited hepatitis viral non viral infections some mirnas also activated repressed inflammatory signaling pathways nf-b jak stat3 signaling turned turn mirnas might function oncogenes tumor suppressors promote suppress inflammatory cascades hepatocarcinogenesis this function indicates mirnas novel regulators mediators liver inflammation hepatocarcinogenesis figure 1 the tumor microenvironment consists many types cells including tumor invading immune cells fibroblasts vascular endothelial cells lymphatic cells stromal components given numerous components tumor microenvironment responsible initiation development progression human cancer dysregulated mirnas tumor specimens might originate different types cells tumor microenvironment function human carcinogenesis multiple ways the next investigations focus origin location action multi function dysregulated mirnas initiation development progression hcc additionally study cell lines might run risk false discovery the results cell lines reflect full aspects pathological process hcc the next investigations exact role mirnas inflammation associated hcc verified patients reliable hcc models a simplified sketch illustrates development liver inflammation hcc shows key nodes aberrantly expressed mirnas participate inflammation associated hepatocarcinogenesis the 5-year overall survival hcc lower 10% worldwide many patients diagnosed advanced stages therefore discovering novel viable biomarkers hcc early diagnosis urgent last decades numerous pieces evidence highlighted regulatory roles mirnas inflammation associated hcc evidence also indicated dysregulated mirnas might useful biomarkers liver inflammation hcc progression 2015 mirnas screened large scale multicenter retrospective longitudinal study explore effective reliable strategies monitoring risk populations suffers chronic inflammation well detect hcc early stage serum mir-29a mir-29c mir-133a mir-143 mir-145 mir-192 mir-505 might act biomarkers hcc significantly higher content hcc compared healthy controls chronic inflammation the classifier composed seven mirnas could sensitive -fetoprotein distinguishing patients hcc cancer free the distinction requires large scale multicenter independent investigations confirm feasibility several studies illustrated potential mirnas therapeutic targets prevent treat hcc however additional profiles detailed mechanisms mirna functions required provide better understanding role liver inflammation hepatocarcinogenesis the additional data facilitate application mirnas prevention therapy inflammation associated hcc this work supported grants national key basic research program grant 2013cb910504 national natural science foundation china grant 81125016 81472565	liver cancer , primarily hepatocellular carcinoma ( hcc ) , is a major cause of cancer - related death worldwide . hcc is a suitable model of inflammation - induced cancer because more than 90% of hcc cases are caused by liver damage and chronic inflammation . several inflammatory response pathways , such as nf-b and jak / stat3 signaling pathways , play roles in the crosstalk between inflammation and hcc . micrornas ( mirnas ) are evolutionarily conserved , short endogenous , non - coding single - stranded rnas that are involved in various biological and pathological processes by regulating gene expression and protein translation . evidence showed that mirnas play a pivotal role in hepatitis virus infection and serve as promoters or inhibitors of inflammatory response . aberrant mirna was observed during liver inflammation and hcc . many dysregulated mirnas modulate the initiation and progression of inflammation - induced hcc . this review summarizes the role and functions of mirnas in inflammation - associated hcc , as well as the designed therapeutics targeting mirnas to treat liver inflammation and hcc .