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hypertension common hemolytic uremic syndrome hus often difficult control acute stage malignant hypertension associated hus leads reversible posterior encephalopathy syndrome seizures heart failure adverse consequences increase morbidity mortality disease renin mediated mechanism believed main factor responsible hypertension seen cases drugs act blocking renin angiotensin axis ras thus ideal cases however due concern progression renal failure lack experience agents children preferred used commonly acute stages we hereby report two cases hus severe refractory malignant hypertension targeted ras using intravenous iv enalaprilat oral aliskiren oral enalapril quick dramatic response blood pressure bp a 6-year old male admitted history vomiting fever since 2 weeks hematuria decreased urine output since 1 week evaluation local practitioner found anemia hemoglobin hb 6.3 g dl thrombocytopenia platelet 72,000/mm active urine sediment red blood cell rbc 4060/hpf albumin 3 azotemia blood urea 200 mg dl creatinine 4.2 mg dl he episode seizure due accelerated hypertension hence brought hospital management evaluation hypertensive bp 150/100 mmhg generalized edema oliguria normal systemic examination investigations suggestive hus hb 4.8 g dl white blood cell wbc 11,190 cmm platelet 1.84/mm peripheral smear schistocytes positive reticulocyte count 6.8% lactate dehydrogenase ldh 4300 u l direct coombs test indirect coombs tests negative urea 67 mg dl creatinine 2.6 mg dl septic work dengue serology malarial antigen negative became afebrile 4 day admission his antinuclear antibodies ana antineutrophil cytoplasmic antibody anca negative he started empiric antibiotics injection ceftriaxone daily plasmapheresis hus detailed complement regulator assay showed high anti factor h antibody 41,000 iu c3 c4 antigenic levels factor h factor factor b cd46 normal table 1 he given blood transfusion initiated hemodialysis daily plasma exchanges view oligo anuric acute kidney injury aki complement assay cases child height percentile bp percentiles 90 percentile 113/72 mmhg 95 percentile 117/76 mmhg blood pressure references used per fourth report arterial hypertension figure 1 started sustained release nifedepine clonidine metoprolol subsequently prazosin gradual increase dosage however arterial bp remained persistently high 99 centile 170/120 mmhg developed blurring vision abdominal pain vomiting 3 day admission necessitating need iv nitroglycerine 5 mcg kg min subsequently labetolol infusion 2 mg kg h refractory hypertension child persistent arterial hypertension 99 centile age despite vigorous fluid removal hemodialysis sessions response antihypertensive medications case 1 oral enalapril minoxidil also added dosage oral antihypertensives optimized maximal doses figure 1 arterial bp remained high difficult control but since within 48 h adding oral enalapril oral minoxidil child went hypertensive emergency bp 180/120 mmhg hallucinations visual blurring iv enalaprilat added hypertension showed significant improvement addition iv enalaprilat 10 g kg dose q 8 hourly 5 day admission there consistent fall bp within hours giving individual iv enalaprilat boluses average fall mean bp 9.5 mmhg arterial bp decreased 110/78 mmhg patient became asymptomatic nitroglycerine labetolol infusions tapered successfully he developed neutropenia week following enalaprilat therapy wbc 1500 cmm 50% neutrophils could attributed cause hence stopped followed rebound hypertension arterial bp 190/136 mmhg he dialysis dependent stage good urine output serum creatinine fallen 0.6 mg dl hemodialysis catheter removed aliskiren 2 mg kg dose added good response arterial bp decreased 150/110 mmhg 24 h 138/110 mmhg 48 h however withdrawn 4 days due hyperkalemia serum potassium 6.5 mmol l improvement neutopenia oral enalapril reintroduced along telmisartan bp control improved within 48 h angiotensin converting enzyme inhibitor angiotensin receptor blockade acei arb combination bp 90 percentile age along oral antihypertensive agents he received seven daily plasmapheresis sessions till active hemolysis subsided followed alternate day sessions he received prednisolone 1 mg kg day iv immunoglobulin 2 g day day 10 admission iv cyclophosphamide hospital stay he received total six doses iv cyclophosphamide followed maintenance azathioprine 1 year follow well normotensive bp 90 percentile age proteinuria urine protein creatinine ratio 0.2 normal urine examination angiotensin converting enzyme ace arb combination a 7-month old male admitted history vomiting fever since 5 days anuria since 2 days hypertensive bp 130/60 mmhg pallor facial puffiness normal systemic examination investigations suggestive atypical hus microangiopathic hemolytic anemia aki hb 7 g dl wbc 13,280/mm platelets 100,000/mm peripheral smear schistocytes elliptocytes reticulocyte count 5.6% ldh 4300 u l active urine sediment rbc 1020/hpf albumin 2 the child evidence pneumonia sepsis clinical evaluation cultures sterile the child advanced azotemia urea 216 mg dl creatinine 7.2 mg dl severe hyperkalemia metabolic acidosis for hus evidence ongoing hemolysis dialysis dependence started daily plasmapheresis a detailed complement assay including c3 c4 antigenic levels factor h factor factor b cd46 autoantibodies factor h normal table 1 bp observed high since admission increased 160/110 mmhg serial monitoring although patient remained asymptomatic for arterial hypertension 99 centile age figure 2 started amlodipine prazosin initially dosage increased maximal dose clonidine oral enalapril added 3 4 day admission respectively despite addition multiple antihypertensive agents dosage optimization aggressive ultrafiltration hemodialysis sessions arterial bp showed marginal decrease mean arterial bp remained high 99 centile age 100110 mmhg intravenous enalaprilat 10 g kg dose q 8 hourly added day 6 admission the mean arterial bp improved 80 mmhg within 12 h addition enalaprilat arterial bp controlled increase dose oral enalapril maximized tapering iv enalaprilat antihypertensive medications continued response antihypertensive medications case 2 daily hemolytic parameters renal function monitored he discharged 2 weeks time stable condition adequate urine output bp controlled oral antihypertensive therapy follow 1 year currently infant well serum creatinine 0.7 mg dl urine protein creatinine ratio 1.5 normal bp bp 90 percentile age oral enalapril 0.4 mg kg day a 6-year old male admitted history vomiting fever since 2 weeks hematuria decreased urine output since 1 week evaluation local practitioner found anemia hemoglobin hb 6.3 g dl thrombocytopenia platelet 72,000/mm active urine sediment red blood cell rbc 4060/hpf albumin 3 azotemia blood urea 200 mg dl creatinine 4.2 mg dl he episode seizure due accelerated hypertension hence brought hospital management evaluation hypertensive bp 150/100 mmhg generalized edema oliguria normal systemic examination investigations suggestive hus hb 4.8 g dl white blood cell wbc 11,190 cmm platelet 1.84/mm peripheral smear schistocytes positive reticulocyte count 6.8% lactate dehydrogenase ldh 4300 u l direct coombs test indirect coombs tests negative urea 67 mg dl creatinine 2.6 mg dl septic work dengue serology malarial antigen negative became afebrile 4 day admission his antinuclear antibodies ana antineutrophil cytoplasmic antibody anca negative he started empiric antibiotics injection ceftriaxone daily plasmapheresis hus detailed complement regulator assay showed high anti factor h antibody 41,000 iu c3 c4 antigenic levels factor h factor factor b cd46 normal table 1 he given blood transfusion initiated hemodialysis daily plasma exchanges view oligo anuric acute kidney injury aki complement assay cases child height percentile bp percentiles 90 percentile 113/72 mmhg 95 percentile 117/76 mmhg blood pressure references used per fourth report arterial hypertension figure 1 started sustained release nifedepine clonidine metoprolol subsequently prazosin gradual increase dosage however arterial bp remained persistently high 99 centile 170/120 mmhg developed blurring vision abdominal pain vomiting 3 day admission necessitating need iv nitroglycerine 5 mcg kg min subsequently labetolol infusion 2 mg kg h refractory hypertension child persistent arterial hypertension 99 centile age despite vigorous fluid removal hemodialysis sessions response antihypertensive medications case 1 oral enalapril minoxidil also added dosage oral antihypertensives optimized maximal doses figure 1 arterial bp remained high difficult control but since within 48 h adding oral enalapril oral minoxidil child went hypertensive emergency bp 180/120 mmhg hallucinations visual blurring iv enalaprilat added hypertension showed significant improvement addition iv enalaprilat 10 g kg dose q 8 hourly 5 day admission there consistent fall bp within hours giving individual iv enalaprilat boluses average fall mean bp 9.5 mmhg arterial bp decreased 110/78 mmhg patient became asymptomatic nitroglycerine labetolol infusions tapered successfully he developed neutropenia week following enalaprilat therapy wbc 1500 cmm 50% neutrophils could attributed cause hence stopped followed rebound hypertension arterial bp 190/136 mmhg he dialysis dependent stage good urine output serum creatinine fallen 0.6 mg dl hemodialysis catheter removed aliskiren 2 mg kg dose added good response arterial bp decreased 150/110 mmhg 24 h 138/110 mmhg 48 h however withdrawn 4 days due hyperkalemia serum potassium 6.5 mmol l improvement neutopenia oral enalapril reintroduced along telmisartan bp control improved within 48 h angiotensin converting enzyme inhibitor angiotensin receptor blockade acei arb combination bp 90 percentile age along oral antihypertensive agents he received seven daily plasmapheresis sessions till active hemolysis subsided followed alternate day sessions he received prednisolone 1 mg kg day iv immunoglobulin 2 g day day 10 admission iv cyclophosphamide hospital stay he received total six doses iv cyclophosphamide followed maintenance azathioprine 1 year follow up well normotensive bp 90 percentile age proteinuria urine protein creatinine ratio 0.2 normal urine examination angiotensin converting enzyme ace arb combination a 7-month old male admitted history vomiting fever since 5 days anuria since 2 days history diarrhea dysentery past admission hypertensive bp 130/60 mmhg pallor facial puffiness normal systemic examination investigations suggestive atypical hus microangiopathic hemolytic anemia aki hb 7 g dl wbc 13,280/mm platelets 100,000/mm peripheral smear schistocytes elliptocytes reticulocyte count 5.6% ldh 4300 u l active urine sediment rbc 1020/hpf albumin 2 child evidence pneumonia sepsis clinical evaluation cultures sterile the child advanced azotemia urea 216 mg dl creatinine 7.2 mg dl severe hyperkalemia metabolic acidosis for hus evidence ongoing hemolysis dialysis dependence started daily plasmapheresis a detailed complement assay including c3 c4 antigenic levels factor h factor factor b cd46 autoantibodies factor h normal table 1 bp observed high since admission increased 160/110 mmhg serial monitoring although patient remained asymptomatic echocardiography fundus normal arterial hypertension 99 centile age figure 2 he started amlodipine prazosin initially dosage increased maximal dose clonidine oral enalapril added 3 4 day admission respectively despite addition multiple antihypertensive agents dosage optimization aggressive ultrafiltration hemodialysis sessions arterial bp showed marginal decrease mean arterial bp remained high 99 centile age 100110 mmhg intravenous enalaprilat 10 g kg dose q 8 hourly added day 6 admission the mean arterial bp improved 80 mmhg within 12 h addition enalaprilat once arterial bp controlled increase dose oral enalapril maximized tapering iv enalaprilat antihypertensive medications continued response antihypertensive medications case 2 daily hemolytic parameters renal function monitored he discharged 2 weeks time stable condition adequate urine output bp controlled oral antihypertensive therapy follow 1 year currently infant well serum creatinine 0.7 mg dl urine protein creatinine ratio 1.5 normal bp bp 90 percentile age oral enalapril 0.4 mg kg day the extent renal microangiopathic involvement appears responsible development hypertension renal failure atypical hus renal ischemia triggered leads maximal activation ras resulting accelerated hypertension often severe resistant antihypertensive therapy local ras activation believed important key factor thrombotic microangiopathy hus leading intractable hypertension this demonstrated occur via enhanced tissue factor expression glomerular endothelial cells enhanced angiotension ii hand two studies shown elevated plasma renin levels children hus irrespective systemic hypertension severe hypertension ensues clinician nightmare hard control despite use multiple drug combinations careful drug titration extreme cases bilateral nephrectomy ultimately required life saving measure achieving control bp thus underlining pivotal role hyperreninemia development hypertension hus although plenty evidence favor renin mediated mechanism pathogenesis hypertension hus practice hesitation use ras inhibitors combinations acute stage hypertension this due fear worsening renal failure lack pediatric experience newer ras inhibitors oral aceis enalapril captopril shown renoprotective benefit long term bp control reduction proteinuria patients persistent disease however preferred acute stage disease used great caution generally initiated improvement renal function moreover aceis including enalaprilat seldom used hypertensive emergencies due concerns regarding slow onset action variable effectiveness especially children we used iv enalaprilat patients acute hypertension showed significant consistent decline bp it helped successful reversal hypertensive urgency older child whose bp remained high extremely difficult control despite multiple drugs including iv nitroglycerine labetolol the onset action begins 15 min peak effect may take 14 h. duration action usually 46 h. half life drug usually 11.1 h infants children there one case series reporting neonatal use enalaprilat reported doses even lower end used cohort may lead significant prolonged hypotension oliguric acute renal failure used newborn children used caution ongoing monitoring bp serum potassium renal function the adverse effects enalaprilat hyperkalemia hypotension cough diarrhea angioedema leucopenia agranulocytosis we encountered neutropenia one patients week initiation iv enalaprilat reversed quickly drug withdrawal however severe rebound hypertension also occurred stopping enalaprilat drugs continued reiterates effectiveness management hypertensive urgency studied bp response iv enalaprilat 35 patients hypertensive crisis found extent systolic diastolic bp reduction correlated well pretreatment plasma renin angiotensin ii levels thus appears status ras determines efficacy iv enalaprilat hence successful patients hus induced hypertension therapeutic enalaprilat levels probably achieved 1/4 total cumulative dose enalapril administered 6 hourly enalaprilat recommended pediatric dosing 510 mcg kg dose we used dose 10 mcg kg dose q 8 hourly cases based previous report we used aliskiren older child effective lowering bp aliskiren first direct renin inhibitor available oral form approved adults us food drug administration 2007 as renin first rate limiting step angiotensin ii synthesis ras direct inhibition theoretically advantageous compared ace inhibition arb nonpeptide molecule better bioavailability long half life therefore lower bp effectively once administered orally effect drug peaks 13 h achieves steady state 57 days half life 40 h. aliskiren produces dose dependent bp reduction potency shown equivalent better aceis arbs various trials moreover when administered combination acei helps block increase plasma renin activity induced acei monotherapy combination therapy aliskiren acei demonstrated greater bp lowering potential compared either alone dual ras blockade however must cautiously monitored higher chance adverse effects case series children chronic kidney disease receiving combination aliskiren acei showed 45% proteinuria reduction however side effects form hyperkalemia worsening renal function hypotension seen mild hyperkalemia seen patient asymptomatic potassium normalized quickly stopping drug other adverse effects including nausea angioedema diarrhea abdominal pain headache may seen aliskiren usually mild dose related adult studies shown aliskiren safe effective antihypertensive drug however use children restricted far due paucity data recent prospective randomized controlled children ages 6 17 years concluded aliskiren daily doses 2 mg kg 6 mg kg well tolerated safe we used dose 2 mg kg case 1 two patients used two unconventional drugs aliskiren iv enalaprilat quick effective controlling high bp refractory multiple antihypertensive medications aggressive ultrafiltration dialysis sessions the limitation report small number multiple antihypertensives patients simultaneous use plasma exchanges immunosuppression anti factor h antibody positive case 1 help resolution illness might make interpretation difficult these appear promising alternatives treatment severe atypical hus induced hypertension hypertensive emergency need trials targeting renin cases

hypertension is common in hemolytic uremic syndrome ( hus ) and often difficult to control . local renin - angiotensin activation is believed to be an important part of thrombotic microangiopathy , leading to a vicious cycle of progressive renal injury and intractable hypertension . this has been demonstrated in vitro via enhanced tissue factor expression on glomerular endothelial cells which is enhanced by angiotensin ii . we report two pediatric cases of atypical hus with severe refractory malignant hypertension , in which we targeted the renin - angiotensin system by using intravenous ( iv ) enalaprilat , oral aliskiren , and oral enalapril with quick and dramatic response of blood pressure . both drugs , aliskiren and iv enalaprilat , were effective in controlling hypertension refractory to multiple antihypertensive medications . these appear to be promising alternatives in the treatment of severe atypical hus - induced hypertension and hypertensive emergency .

2009 52-year old woman presented single lesion nose started papule referred sedighe tahereh clinic isfahan iran lesion existed period 14 months slowly increasing size enlarging plaque the diagnosis leishmaniasis confirmed positive smear lesion showing leishmania bodies 1 year all five members family history proven leishmaniasis past medical history the patient renal failure case since 11 years received renal transplant 4 years diagnosis renal failure she receiving oral mycophenolate mofetil 2 g daily cyclosporine 100 mg daily a 33 cm indurated ulcer elevated borders present tip nose figure 1 her therapeutic plan intralesional glucantime injection approximately 1 ml 1.5 g vial per week intralesional injection after completing therapeutic course 20 sessions receiving intralesional glucantime injections considered glucantime therapy resistant the occurrence malignant neoplasms sites scars infrequent well known phenomenon.5 although coexistence cutaneous leishmaniasis bcc may coincidental studies suggest association two entities exist.6 leishmaniasis directly indirectly alter diagnosis course different malignancies.7 reports bcc chronic leg ulcers.8 cases bcc developing leishmania scar also documented,9 knowledge cases leishmaniasis bcc site lesion rare.10 however case solid organ transplantation long term immuno suppressive therapy considered risk factors malignancy advances effective immuno suppression organ transplantation led increased risk malignancies particularly skin cancers11 including squamous cell carcinoma basal bcc malignant melanoma.12 thus malignancies considered differential diagnosis leishmaniasis lesions difficult treat the possible role cutaneous leishmaniasis predisposing factor skin cancer also kept mind aa main therapeutic physician helped write manuscript pk contributed writing manuscript

leishmaniasis is a protozoan infection due to organisms of the genus leishmania . the differential diagnosis of cutaneous leishmaniasis includes arthropod bites , basal cell carcinoma ( bcc ) and other malignancies . bcc is the most common form of skin cancer . we present a case of cutaneous leishmaniasis resistant to standard intralesional glucantime injection in an immunocompromised patient , which was proved to be bcc after surgical excision .

60-year old man admitted visual disturbances ocular pain following penetrating keratoplasty right eye corneal chemical burn slit lamp examination observed feather like corneal opacity corneal infiltrations epithelial defects subconjuctival amphotericin b 1 mg topical amphotericin b 0.125% levofloxaxin 0.5% subsequently administered every hour 16 weeks the patient restarted maintained topical amphotericin b treatment 0.125% twice daily 1 year in addition levofloxaxin 0.5% three times daily fluorometholone 0.1% twice daily administered 1 year the lesion progress change corneal infiltration examination one year later elevated corneal lesion increased corneal infiltration yellow color observed despite topical amphotericin b treatment seven days later anterior chamber hypopyon vitreous opacity b scan observed fig we immediately performed intravitreal injection amphotericin b 5 g/0.1ml vancomycin 1 mg/0.1ml intravitreal voriconazole 80 g/0.1ml ceftazidime 2 mg/0.1ml injected topical voriconazole 1% administered every 2 hours the patient discontinued oral voriconazole abdominal pain dry mouth scaling oral mucosa the patient treated topically 6 weeks corneal lesion endophthalmitis improved the patient subsequently underwent another penetrating keratoplasty demonstrated visual acuity 0.1 10 months follow signs recurrence a 60-year old man referred us lack improvement month empiric treatment topical amphotericin b fungal keratitis initial examination after 10 days culture revealed growth corneal epithelium appeared healed however change corneal infiltration fig because lack improvement corneal lesion month later new treatment regimen initiated topical voriconazole 1% administered every hour six weeks later observed decreasing density infiltrate healing corneal epithelium topical voriconazole decreased twice daily following completion therapy complete healing corneal epithelium resolution corneal infiltrate observed however corneal opacity persisted fig 2c ) voriconazole derivative fluconazole new triazole antifungal agent.4 like triazoles voriconazole inhibits cytochrome p450 demethylase essential synthesis ergosterol hypothesized adversely affects permeability fungal cell membrane.7 voriconazole excellent oral bioavailability broad spectrum activity therapeutic aqueous vitreous levels achieved oral administration voriconazole.8 voriconazole showed lower mics compared antifungal agents tested five corneal isolates scedosporium apiospermum,2 best vitro susceptibility profile 34 common fungal pathogens compared antifungal agents.9 gao et al.10 reported direct intravitreal voriconazole injections 25 g ml equivalent 100 mg per injection human eye caused electroretinographic histopathologic abnormalities rodent retinas kramer et al.11 reported intravitreal injection voriconazole 100 g/0.1ml pars plana vitrectomy effective therapy aspergillus endophthalmitis lee et al.7 reported case drug resistant penicillium endophthalmitis treated intravitreal voriconazole injection 50 g/ 0.1ml cases voriconazole shown highly effective filamentous organisms potent invasive aspergillosis amphotericin b.12,13 according report jang et al.,5 voriconazole also effective candida chorioretinitis ozbek et al.14 reported one case alternaria keratitis showed improvement 1% topical voriconazole in contrast giaconi et al.15 reported two cases fungal keratitis caused fusarium oxysporum colletotrichum dematium respond treatment 1% topical voriconazole our report indicates 1% voriconazole effective treatment candida spp unknown fungal keratitis conclusion voriconazole new promising therapy fungal keratitis refractory standard antifungal agents nevertheless clinical trials necessary investigate effectiveness systemic voriconazole corneal transplantation

we describe two patients with fungal keratitis refractory to standard antifungal therapy whose conditions were managed with voriconazole.the first case is a patient with endophthalmitis and corneal ulcer due to candida parapsilosis after receiving a corneal transplant . the patient was treated with amphotericin but showed no signs of improvement . topical voriconazole , oral voriconazole , and intravitreal voriconazole yielded signs of improvement . the second case is a 63-year - old male who underwent a month of empiric treatment with 0.2% topical amphotericin for fungal keratitis but showed no signs of improvement . treatment was then provided with 1% voriconazole . both cases showed effective treatment with voriconazole.voriconazole may be considered as a new method to treat fungal keratitis refractory to standard antifungal therapy .

liver plays pivotal role detoxification xenobiotics environmental pollutants chemotherapeutic agents reason organ acetaminophen apap widely used antipyretic analgesic currently frequent cause drug induced hepatic failure united states intentional unintended overdose cytochrome p450 enzymes convert relatively minor portion apap highly reactive intermediate metabolite n acetyl p benzoquinone imine napqi normal physiological conditions apap overdose increased napqi formation exceeds rate detoxification gsh recent times much attention attracted herbal medicines alternative medicines quite plant remedies examined treatment liver disorders centuries prosopis farcta pf figure 1 leguminosae sub family mimosoideae medicinal properties antiinflammatory effects treating gastric ulcers fetus abortion dysentery arthritis larynx inflammation heart pains asthma this plant indigenous dry semi dry areas america asia africa compounds existing prosopis plant quercetin flavonoids tryptamine apigenin 5-hydroxytryptamine alkaloids l arabinose lectin moreover number phenolic compounds strong antioxidant activity identified extracts plant vicenin-2 apigenin c glycoside iso orientin vitexin luteolin 7-o glucoside isovitexin quercetin 3-o glucoside rutin kaempferol 3-o rutonoside caffeic acid derivative luteolin antioxidants play important role inhibiting scavenging free radicals thus providing protection infections degenerative diseases there vitro vivo report show academic research evaluate protective effect plant far since pfe antioxidant property may alleviate hepatotoxicity study evaluated possible preventive hepatoprotective effect pfe liver injury induced apap rat thirty six male rats wister strain weighing 220 30 g randomly assigned six groups six all animals housed individually 12 h alternating light dark cycle free access food water ambient temperature animal facility kept 22c 2c humidity 30% 50% pf beans collected outskirts qom iran coded university birjand iran herbarium herbarium code 1952 the fruit pf crushed moderately coarse powder extraction 50 g powder dissolved 1000 ml ethanol 80% placed shaker 24 h. 24 h solution passed filter paper remove solvent the solution filtered placed oven 1 2 days 40c after evaporation solvent samples maintained 20c stock solution 1 g ml 0.9% w v normal saline after 2 weeks adaptation animals orally administered pfe 50 75 mg kg saline daily 7 consecutive days induce hepatotoxicity 1-h last pretreatment pfe 5 6 ml blood obtained cardiac puncture 24 h induction hepatotoxicity plasma samples separated heparinized syringe analyzed various biochemical parameters total cholesterol tc triglycerides tg high density lipoprotein cholesterol hdl c low density lipoprotein cholesterol ldl c total protein albumin alanine aminotransferase alt aspartate aminotransferase ast concentrations measured using standard techniques commercial kits pars azmoon co. iran auto analyzer gcsan chem 2000 spain very low density lipoprotein vldl calculated deduction sum cholesterol fractions tc plasma concentration described salau et al statistical significance two groups parametric data analyzed using one way analysis variance followed tukey multiple comparisons test the experiment approved animal welfare committee agriculture faculty birjand university research project number 2131336 tables 1 2 reveal plasma ast alt levels increased rats administered apap compared controls indicating reliable induction hepatotoxicity apap p 0.01 groups received pfe dose alone showed significant changes biochemical parameters treatment rats pfe apap administration dose dependently prevented increase ast alt furthermore administration apap significantly decreased plasma total protein albumin levels p 0.05 well shown pretreatments different doses extract attenuated reduction plasma levels total protein albumin extent moreover plasma cholesterol tg ldl vldl levels markedly increased rats administered apap compared controls p 0.05 pretreatment pfe especially 75 mg kg provided marked protective effect comparable improvement biochemical indices effect prosopis farcta liver enzymes rats effect prosopis farcta liver enzymes total protein albumin lipid profile rats the present study first time brings potential hepatoprotective activity pfe apap induced hepatotoxcity the results study indicated pfe significantly reversed enhancement ast alt levels necrosis membrane damage releases intracellular enzymes circulation hence measured plasma elevated levels plasma enzymes indicative cellular leakage loss functional integrity cell membrane liver prior indicators liver function tests the important enzymes alt ast present liver parenchyma alt predominantly found liver unlike ast also abundantly present organs namely cardiac muscle kidneys for reason alt specific indicator liver inflammation ast though parallel increases alt ast often observe present study this enhancement may due disruption hepatic cell result necrosis consequence altered membrane permeability pretreatment oral doses p. farca extract attenuated enzyme activities indications protective activities pfe apap hepatotoxicities the critical assessment intervention used pretreatment evaluation metabolic activation gsh depletion protein adduct formation assessed study metabolism paracetamol produces highly toxic metabolite napqi via cytochrome p450 pathway induces process lipid peroxidation although accumulation napqi occurs rate formation exceeds rate detoxification gsh depletion gsh stores in addition covalent bindings napqi hepatocyte macromolecules cause necrosis liver cell consequent release cytosolic liver enzymes particularly aminotransferases regarded signs hepatocellular injury given large number compounds present extract highly likely several p450 inhibitors present quercetin flavonoid antioxidant one compounds found prosopis excellent radical scavenger activity attenuated oxidative stress induces apap well chemical it possible presence polyphenols flavonoids pf might responsible protective effect apap induced liver damage rats concerning plasma lipid profile oral administration apap increased plasma cholesterol tg ldl significant alteration plasma hdl level lipid deposition liver may result excessive supply lipids liver interference lipid deposition formation phenoxyl radicals presence peroxidases act ldl prooxidant responsible ldl elevation apap animals it documented lipid lowering drugs antioxidant properties prevent ldl peroxidation pf antioxidant property capable preventing ldl peroxidation inhibiting elevation ldl apap three molecules acetyl coa combined produce 3-hydroxy-3-methyl glutaryl coa affected different enzymes converted malonic acid different reactions convoluted converted cholesterol hdl c responsible reverse transport cholesterol peripheral cells liver cells cholesterol transformed bile acids excreted intestine via biliary tract the findings omidi et al preliminary suggests efficacy pf beans powder beneficial agent decrease ldl c increase hdl c concentration it produces proteins cellular needs well secretory proteins released circulation one important secretory proteins albumin study the decreased total protein albumin levels apap significantly improved pfe treated groups indicating hepatoprotective effect based results present study concluded aqueous extracts pf beans exhibit hepatoprotective activity apap however mechanism pfe exhibited protection clear present study further investigations cellular molecular mechanism plant may throw light use pf hepatoprotective activity

background : hepatotoxicity by acetaminophen is the most frequent cause of acute liver failure in many countries . prosopis farcta beans extract ( pfe ) has some antioxidant property and may alleviate hepatotoxicity . therefore , the aim of this study was to evaluate effects of pfe against acetaminophen - induced hepatotoxicity.methods:thirty-six male wistar albino rats weighing 220 30 g were distributed into six groups . two groups were pretreated with pfe ( 50 and 75 mg / kg ) for 7 days before administration of acetaminophen ( 600 mg / kg ) . two were given acetaminophen or pfe ( 50 and 75 mg / kg ) alone , and the control received normal saline . one day after acetaminophen , administration blood samples were collected by cardiac puncture to determine liver function enzymes markers ; aspartate aminotransferase and alanine aminotransferase ( ast and alt ) , cholesterol , triglyceride ( tg ) , high , low , and very low density lipoproteins ( ldl and vldl).results : in acetaminophen - treated rat plasma ast ( 314 18.54 vs. 126.37 4.13 ) , alt ( 304 49.24 vs. 187.33 3.71 ) , cholesterol , tg , ldl , and vldl were increased by 149 , 160 , 37 , 92 , 60 , and 94% , respectively . pfe at both doses significantly ( p < 0.05 ) attenuated the above biochemical indices to near normal.conclusions:prosopis farcta beans extract ( 50 and 75 mg / kg ) exhibited hepatoprotective activity against apap .

melamine 2,4,6-triamino-1,3,5-triazine cas 108 78 1 first prepared described liebig 1834 1 since become increasingly important chemical commodity most melamine production used fabrication melamineformaldehyde resins 2 the first analytical methods related food therefore developed detect melamine migration resins used food contact materials 3 recently melamine become infamous one effective adulterants used increase nitrogen content foods feeds melamine contains 66.6% nitrogen addition 1% melamine protein leads false increase kjeldahl protein content 4.16% 6 the first cases melamine adulteration detected fish meals italy late 1970s 7,8 methods detect melamine potato proteins developed switzerland 1980s 6 since melamine adulteration cases reported literature 2004 2007 melamine found pet foods causing renal failure dogs cats 9,10 nephrotoxicity also appears major toxic effect humans 11,12 intentional adulteration human foods including baby foods melamine the economically motivated fraud food chain reached new dimension food control systems unprepared the problem first became evident china increase urinary tract stone formation infants beginning spring 2008 13 more 294,000 children reportedly affected adulterated formula 50,000 hospitalized least 6 deaths 14 twenty two dairy companies implicated melamine fraud sanlu company identified one seriously violated law 13 apparently adulterations occurred raw milk collection stations systematic state surveillance implemented 13 the adulterators ostensibly used relatively sophisticated techniques special protocols premixes said provided training regarding use premixes diluting milk water 15 globalization worldwide food trade the melamine contaminated foods detected large number countries including united states 14 european union 16 some commentators expect similar cases future even improved techniques 15 this crisis highlighted hazards increasingly globalized food chain also weaknesses control systems 17 we think order improve consumer protection future completely new strategies food surveillance must developed the current food control system generally target oriented meaning quantitative analyses certain health relevant compounds heavy metals pesticides carcinogenic contaminants conducted 18 while current system paid great attention intentional adulterations 17 testing laboratories also faced problem choosing parameters spot checks systematic full analyses possible economical reasons 19 therefore analysis parameters usually chosen purely arbitrary choices 19 risk oriented approach 20 certainly would include novel high tech adulterants 15 chosen specifically intent evading food control system reasons propose future food control must implement call nontargeted approach this approach must able detect deviations food composition even compounds specifically searched ones unknown analyst this would enable food control work proactively rather one step behind adulterators currently case the preferred form nontargeted analysis would screening technique would allow measurement large number samples short time frame nuclear magnetic resonance nmr spectroscopy proposed probably best nontargeted technique use screening food extracts 21 comparison spectroscopic screening techniques much richer information provided using nmr comparison near infrared fourier transform infrared spectroscopy selective sensitive qualitative quantitative information could gathered spectra 22 even though 400 mhz nmr machines still expensive compared cost analytical systems cost per sample nmr low depending turnover achieved the successful application nontargeted screening approaches food analysis previously demonstrated number food matrices 21 however focus always placed authenticity control detection health relevant compounds study basis experience beer 23 fruit juice screening 19,24 demonstrate first time nmr useful nontargeted screening baby food formula health relevant compounds melamine also labeling controls e.g. lactose free products additionally provide information 400 mhz nmr spectra liquid sample extracts also used quantification melamine using 700 mhz high resolution magic angle spinning hrmas nmr we demonstrate melamine quantitatively detected complicated food matrices without sample preparation authentic chinese infant formulas n 9 including one contaminated sanlu infant formula purchased beijing china september 2008 melamine crisis german infant formulas n 13 sampled context official food control governmental food inspectors german federal state baden wrttemberg december 2008 melamine positive chinese candy german market also included study all nmr measurements performed bruker avance 400 spectrometer bruker biospin rheinstetten germany equipped 5-mm bbi inverse probe z gradient coils using bruker automatic sample changer b acs 60 all spectra acquired 300.0 k. h spectra acquired using one dimensional 1d nuclear overhauser enhancement spectroscopy noesy pulse sequence implemented low power continuous wave presaturation relaxation delay mixing time relaxation delay mixing time the data acquired automatically control icon nmr bruker biospin rheinstetten germany requiring 12 min per sample the proton hrmas experiments carried using 700 mhz av iii nmr spectrometer bruker biospin rheinstetten germany 4 mm hrmas standard bore probe h c p h lock gradient the temperature controlled 300.0 k using bcu05 precooling unit n2 bearing gas flow temperature control unit bvt300 mas the rotor spin rate 7000 hz therefore spectral window free spinning side bands single pulse proton experiment 30 flip angle executed 4 acquisition time relaxation delay 4 sweep width 20 ppm the number scans standard experiments ns 64 experimental time 9:15 min the processing done zero filling 128k data points exponential multiplication lb 1 the chemometrical analyses spectra performed using matlab mathworks version r2008a routines developed house quantitation melamine concentrations the signal nh2-groups 5.93 ppm figure 1 investigated its intensity derived fitting theoretical signal spectrum minimized sum squares residues therefore optimally explained melamine influence nmr spectrum the integral value fitted signal linearly dependent melamine concentration require calibration sample fixed acquisition preparation parameters used the fitting done fully automated mode using nonlinear bound optimization algorithm optimized parameters line shape position height signal underground baseline comparison melamine contaminated sanlu sample reference distribution collection infant formulas measurement dmso d6 400 mhz the nontargeted analysis data performed using simple robust techniques describe univariate distributions nmr spectra ppm value figure 1 illustrates method uses quantiles distributions reference samples estimate medians corresponding variances chemical shift since procedure yields robust description atypical samples reference group the melamine signal sanlu infant formula easily detected manually automation since intensity translates z score larger 56 medianreference z stdreference z score 3 would cover 99% samples normal distribution assumption this approach emphasizes deviating spectral regions signals investigated sophisticated nmr experiments conventional analyses nondeviating samples pass screening adulterations certain limit ruled in first stage nontargeted analysis 20 0.4 mg infant powder weighed dissolved 2 ml waterbuffer solvent 90% distilled water 10% buffer 1.5 kh2po4/d2o 0.1% tsp ph 7.0 obtain final concentration 10 0.2 this solution shaken 1 min vortex mixer 3 min ultrasonic homogenizer then 600 l homogenized solution transferred standard 5 mm nmr tube analysis became evident melamine peak could measured water sample preparation was repeated 99.8% dmso d6 deutero gmbh 20 0.4 mg infant powder dissolved 2 ml dmso d6 calibration melamine standards dmso d6 concentration range 2 200 mg l measured determine limit detection separate calibration curve range 0.2 2 was filled 50 l hr mas rotor 45 l dmso d6 added stirred rotor prepared 50 l upper spacer placed 3.0 mm depth sealed teflon screw the material white rabbit candy scraped powdered mortar analysis hrmas calibration a blank matrix nestl student sweetened milk powder nestl china absence melamine confirmed reference analysis filled rotor 45 l melamine standard solution dmso d6 added the calibration range 9 900 mg kg second curve determination limit detection range 0.9 9 mg kg infant formula 1 g sample added centrifuge tube 10 ml acetonitrile added ten milliliters deionized water small amount covering tip spatula ammonium acetate 0.2 ml glacial acetic acid added tube the solution vortexed 1 min centrifuged 10 min 4000 g a 2.5 ml aliquot supernatant placed conditioned solid phase extraction spe tube strata x c 200 mg/6 ml tubes phenomenex aschaffenburg germany candy a different sample preparation conducted soluble cold solvents therefore 1 g candy sample dissolved 50 ml hot water addition 1 ml acetic acid cooling 30 ml acetonitrile added solution ultrasonicated 15 min after adjustment acetonitrile 100 ml aliquot extract centrifuged transferred spe tube described the spe tubes conditioned using 15 ml methanol followed 15 ml water cleanup conducted using 6 ml hcl 0.1 3 ml methanol after elution step extract dried 5060 c using nitrogen stream then 500 l acetonitrile water 1:1 added solution membrane filtered 0.2 used chromatography injection volume 20 l the lc ms ms system consisted agilent waldbronn germany 1100 hplc system binary pump degasser autosampler coupled thermo fisher scientific formerly thermo finnigan dreieich germany tsq 7000 mass spectrometer 3 125 c18 column phenomenex aschaffenburg germany 30 c using mobile phase acetic acid 0.1% mobile phase b acetic acid methanol 0.1% following gradient program flow rate 0.2 ml min 05 min 90% 55.5 min 90% 20% 5.57.5 min 20% 7.58 min 20% 90% 813 min 90% a. atmospheric pressure chemical ionization apci used capillary temperature 270 c vaporizer temperature 400 c corona discharge current 2.0 the sheath gas nitrogen 50 psi argon used collision gas the collision cell triple quadrupole operated collision energy 35 ev transitions quantitative analysis the following fragmentations monitored selected reaction monitoring srm mode z 127 85 z 127 68 z 127 43 melamine calibration range 5 1000 ng ml melamine exhibited good linearity regression coefficients greater 0.99 the limit detection 10 ng ml limit quantitation 30 ng ml the recovery 105 5% spiked baby formula n 8) 81 13% spiked ready eat baby purees n 6 98 3% different spiked egg powders n 4 92 6% candy n 11 the precision expressed coefficient variation 7.5% n 6 bakery products 5.1% n 8 baby formula 6.4% n 11 candy at point time one study literature presented h nmr data melamine context kinetic study 25 the signal assignment dmso d6 6.02 nh2 reported previously corresponds excellently findings study the identification singlet peak nh2 5.93 ppm dmso d6 melamine confirmed using measurements pure standards well standard addition positive samples other studies used hrmas nmr study structure cyanuric acidmelamine system 26 formation melamine condensation products 27 however h data presented either study could used comparison results table 1 shows comparison sensitivities different methodologies investigation methods evaluated the reference lc ms ms procedure sensitive followed 700 mhz hrmas 400 mhz liquid nmr this unexpected basis physical characteristics methods the results clearly show nmr used screening purposes levels lower mg kg range for example melamine recommendations 1 mg kg powdered infant formula 2.5 mg kg foods 28 reached hrmas the sensitivity 400 mhz procedure could increased optimized sample extraction sample preconcentration step included e.g. spe procedure similar conducted prior lc ms ms however intention leave sample preparation simple possible in contrast previous belief nmr suitable structure verification elucidation purity analysis 24 results clearly demonstrate nmr used quantitative analysis foods health relevant compounds of course power nmr resides nontargeted approach see also previously demonstrated beer fruit juice analysis 19,23,24 spectra used acquire quantitative data along results multivariate analysis determined according din 32645 using separate calibration curve range lod measuring solution final sample extract filled nmr tubes injected lc ms ms system calculated sample weight 10 mg 1 ml dmso d6 determined using hrmas rotor filled 10 mg authentic matrix calculated sample weight 1 g reconstituted 500 l spe cleanup regarding precision methods 400 mhz method showed coefficient variation 3.2% n 9 replicated measurement authentic contaminated sanlu sample coefficient variation hrmas 700 mhz method 2.6% measurement spiked infant formula n 11 the precision nmr judged sufficient purposes food analysis the lc ms ms procedure comparison also precisions order magnitude due complicated sample preparation procedure regarding accuracy nmr results compared lc ms ms reference procedure contaminated sanlu formula 400 mhz nmr 700 mhz nmr lc ms ms melamine results 412 mg kg 460 mg kg 470 mg kg respectively contaminated candy melamine results 47 mg kg 74 mg kg 68 mg kg respectively the 400 mhz procedure showed lower results either procedures judged due incomplete extraction sample preparation this exemplifies advantages hrmas procedure gave results similar reference procedure nevertheless also judge 400 mhz procedure current form suitable food screening amount melamine course admissible even qualitative result would sufficient e.g. context raw product screening industry our study first apply hrmas nmr quantitatively determine melamine authentic food matrices hrmas appears eminently suitable analyzing complicated matrices solid semisolid foods difficult extract conventional means many foods form emulsions completely soluble organic solvents case candy hrmas form gel phase nmr sample mixed solvent swells matrix using rotation sample obtain high resolution h spectra routine manner 29 a major application hrmas appears detection tumor tissues 3033 so far relatively applications field food control presented involved authentication cereal foods 34,35 cheese 3638 beef 39 lc ms ms spe extraction clearly preferred method melamine quantification kinds foods 4043 according experience the advantage nmr especially hrmas minimal time sample preparation compared tedious lc ms ms procedure unfortunately melamine contamination first instance unsafe milk formula china 2003 12 children died malnutrition anhui province result fed infant formula poor quality incident 55 different infant formulas 40 corporations 10 provinces involved exposed key public health gaps food safety public protection 44 this incident might even indirectly led melamine crisis government directives diluted preparations implemented the fact melamine could increase apparent protein content furthermore could make product look milky may irresistible would adulterate milk formulas 14 detailed consumer safety ensured targeted analysis compounds melamine adulterators always one step ahead research establish quantitative method nmr analysis melamine became quickly evident even simple visual inspection nmr spectra sanlu sample showed differences these observed several spectral ranges even analysis aqueous solutions melamine peak 5.93 ppm visible rapid proton exchange nh2 groups solvent protons for example sanlu sample showed deviations range 3.6 4.2 ppm a search library nmr spectra pure compounds showed spectral pattern assigned sucrose figure 2 upper panel comparison melamine contaminated sanlu sample reference distribution collection infant formulas measurement water 400 mhz lower panel reference measurement sucrose spectral library fashion found one german infant formula samples diverged samples case this finding shows nmr method also allow one check recipes labeling claims lactose free hypoallergenic etc confirming factors comparably important ensure health subgroups consumers special nutritional needs we therefore conclude routine application nmr screening baby food products would provide considerable improvement consumer protection similar shown screening fruit juices beer chemometric approach allows establishment standard model typical infant formula this model used without manual intervention provide judgment sample regarding whether correspond typical composition case noncompliance large depth spectral information nmr allows one make assignment compounds using databases case lactose sucrose case compounds databases e.g. melamine started study the option nontargeted screening along structural information inside spectra certainly major advantage nmr techniques recently proposed for example surface desorption mass spectrometry 4547 enzyme linked immunosorbent assays 48 disadvantage focused sensitive target analysis these certainly detect melamine miss novel adulterants might used place future the proposals literature might usable nontargeted approach several infrared spectroscopy methods 4951 multivariate regression analysis able derive models quantify melamine raman mid near infrared spectra so far nmr seen holistic approach detecting adulteration infant formula

the recent melamine crisis in china has pointed out a serious deficiency in current food control systems , namely , they specifically focus on selected known compounds . this targeted approach allowed the presence of melamine in milk products to be overlooked for a considerable time . to avoid such crises in the future , we propose that nontargeted screening methods need to be developed and applied . to this end , nmr has an extraordinary potential that just started to be recognized and exploited . our research shows that , from the very same set of spectra , 1h nmr at 400 mhz can distinguish between melamine - contaminated and melamine - free infant formulas and can provide quantitative information by integration of individual lines after identification . for contaminated chinese infant formulas or candy , identical results were obtained when comparing nmr with spe - lc / ms / ms . nmr was found to be suitable for routine nontargeted and targeted analyses of foods , and its use will significantly increase food safety .

fatigue transitional state awake sleep manifests lack alertness deteriorated mental physical performance often associated drowsiness road accidents due fatigue often much severe crashes since driver reaction time increases 1 driver fatigue deemed account 40% road accidents 2 it conjectured 1030% road deaths related driver fatigue 3 mental fatigue causes reactions become prolonged fluctuable error tending 4 5 grandjean defined fatigue state decreased efficiency lack general willingness work 6 7 these classified subjective psychological performance physiological methods subjective methods standard questionnaires f vas and moreover use behavioral psychological techniques mental fatigue investigation adopted several preceding studies 1417 among studies set video recordings facial expressions mannerisms personality traits questionnaires common methodologies high reliability validity 17 in addition fatigue studies driving simulator exploited performance features steering wheel angle lane departure 1820 some researchers focused driver physiological changes measurement eye activity heart rate skin electrical potential specially eeg activity means detect cognitive states 21 22 although several physiological indices available assessing alertness level eeg signal may one safest predictive 2325 since immediately reflects brain activity driving involves several tasks motion reasoning visual auditory processing decision making perception cognition driving also influence emotion anxiety many psychological factors 24 the brain electrical activity rhythms classified according frequency bands including delta theta alpha beta waves 26 alpha rhythm frequency range 813 hz occurs wakefulness especially occipital cortex area brain it typically appears eye closure reduced eyes open attenuates severely attention tasks 27 previous researches it known increase delta power internal processing associated mental task performance 28 other researchers reported increase eeg theta power depends decreased performance monotonous tasks 29 although definite trends observed delta theta alpha power frequency bands fatigue results different studies may influenced inter individual intra individual variations eeg data 30 changes eeg power spectra associated fluctuations alertness state 31 monitoring physiological signals driving provide possibility detect warn fatigue 32 most investigations revealed changes delta theta activity related transition fatigue therefore eeg monitoring driving may promising variable using fatigue countermeasure devices 24 it suggested driving night delta band varies significantly degree fatigue 33 some researchers presented eeg based cerebral workload index based increase eeg power spectra theta band prefrontal areas immediate decrease eeg power spectra parietal areas alpha band driving 34 physiological mental fatigue level increases relative power theta alpha beta rhythms decrease relative power delta rhythm increases 35 the relative power alpha increased attention level driver decreased 36 however research physiological links specially eeg frequency bands driver fatigue still exploratory important area needs investigation therefore study attempted detect driver mental fatigue changes eeg alpha power activity twelve healthy male volunteer car drivers ranging 20 30 years old participated overnight study 2 6 a.m. virtual reality laboratory khaje nasir toosi university technology 2013 all subjects held valid driving license least 2 years driving experience history prior brain injuries epworth sleepiness scale used measure participants trait sleepiness taking informed written consent subjects requested stay awake 18 h experiments refrain caffeinated drinks stimulant well cigarette smoking 12 h prior experiments the drivers regular sleep pattern i.e. sleeping later 1 a.m. awaking later 9 a.m. get used daily napping studied sleep diary one week experiment this research employed fixed based car driving virtual reality simulator ci004 semi calm controlled room fixed temperature illumination conditions 1 shows snapshot car driving simulator developed mechatronics department k.n snapshot car driving simulator used implementation proposed protocol set 110 km road sceneries designed simulated the first 90 km road monotonous straight minimal side components induce fatigue last 20 km winding mountainous road see fig 2 scenery road captured car simulator lcd designed road dangerous parts real road pattern iran so called haram haram road photographed google maps using autodesk autocad civil 3d version 2013 autodesk 3ds max version 2012 softwares a portable g.usb amp bio signal amplifier 16 channels used 256 hz sampling rate 24 bit quantification active electrodes signal acquisition driving simulator eeg and the electrode positions different areas scalp based 1020 international electrodes placement guideline the main eeg signal channels o1 o2 p3 p4 p7 p8 oz fp1 fp2 cz fz t7 t8 the eeg data analysis involved pre processing artifact removal features extraction the eeg signal first processed executing band pass filter 0.5 60 hz eeglab version 10.2.5.6a utilized remove muscular ocular artifacts visual inspection all signals sequenced epochs lasting two seconds 1 epoch consisting 512 samples 2 seconds this research exploits power spectrum density fast fourier transform fft analyzing technique determine absolute relative powers alpha frequency band relative alpha power computed ratio absolute alpha power total spectral power signal we compared absolute relative alpha power variations first last 10 minutes driving f vas scores for certainty study employed double check validity method comparing extracted features eeg signals video rating scores resuming experiments then eeg eog signals recorded subjects relaxed sitting posture 3 minutes closed eyes imagining driving highway 3 minutes open eyes looking road picture screen baseline alertness the subjects asked drive monotonous road constant speed 90 km h time continuous eeg eog records taken driving car simulator meanwhile drivers faces behaviors monitored via video recordings lateral front views these videos used rate fatigue level drivers four point scale 1(alert 4 tired two trained observers moreover the self rating fatigue performed driving using fvas scored 0 fatigue energetic 10 worst possible fatigue every 10 minute interval the descriptive statistics central scattered indices computed order describe variables pearson spearman correlation coefficients employed explore associations f vas scores video ratings fvas absolute relative alpha powers paired sampled test utilized compare means f vas scores video ratings absolute relative alpha powers initial final 10 minutes driving twelve healthy male volunteer car drivers ranging 20 30 years old participated overnight study 2 6 a.m. virtual reality laboratory khaje nasir toosi university technology 2013 all subjects held valid driving license least 2 years driving experience history prior brain injuries epworth sleepiness scale used measure participants trait sleepiness taking informed written consent subjects requested stay awake 18 h experiments refrain caffeinated drinks stimulant well cigarette smoking 12 h prior experiments the drivers regular sleep pattern i.e. sleeping later 1 a.m. awaking later 9 a.m. get used daily napping studied sleep diary one week experiment this research employed fixed based car driving virtual reality simulator ci004 semi calm controlled room fixed temperature illumination conditions 1 shows snapshot car driving simulator developed mechatronics department k.n snapshot car driving simulator used implementation proposed protocol set 110 km road sceneries designed simulated the first 90 km road monotonous straight minimal side components induce fatigue last 20 km winding mountainous road see fig 2 scenery road captured car simulator lcd designed road dangerous parts real road pattern iran so called haram haram road photographed google maps using autodesk autocad civil 3d version 2013 autodesk 3ds max version 2012 softwares a portable g.usb amp bio signal amplifier 16 channels used 256 hz sampling rate 24 bit quantification active electrodes signal acquisition driving simulator eeg and the electrode positions different areas scalp based 1020 international electrodes placement guideline the main eeg signal channels o1 o2 p3 p4 p7 p8 oz fp1 fp2 cz fz t7 t8 the eeg data analysis involved pre processing artifact removal features extraction the eeg signal first processed executing band pass filter 0.5 60 hz eeglab version 10.2.5.6a utilized remove muscular ocular artifacts visual inspection all signals sequenced epochs lasting two seconds 1 epoch consisting 512 samples 2 seconds this research exploits power spectrum density fast fourier transform fft analyzing technique determine absolute relative powers alpha frequency band relative alpha power computed ratio absolute alpha power total spectral power signal we compared absolute relative alpha power variations first last 10 minutes driving f vas scores for certainty study employed double check validity method comparing extracted features eeg signals video rating scores before resuming experiments car driver sleepiness propensity measured epworth sleepiness scale eeg eog signals recorded subjects relaxed sitting posture 3 minutes closed eyes imagining driving highway 3 minutes open eyes looking road picture screen baseline alertness the subjects asked drive monotonous road constant speed 90 km h time continuous eeg eog records taken driving car simulator meanwhile drivers faces behaviors monitored via video recordings lateral front views these videos used rate fatigue level drivers four point scale 1(alert 4 tired two trained observers moreover self rating fatigue performed driving using fvas scored 0 fatigue energetic 10 worst possible fatigue every 10 minute interval the descriptive statistics central scattered indices computed order describe variables pearson spearman correlation coefficients employed explore associations f vas scores video ratings fvas absolute relative alpha powers paired sampled test utilized compare means f vas scores video ratings absolute relative alpha powers initial final 10 minutes driving the drivers mean age 23.8 years sd 1.44 years mean body mass index bmi 21.57 sd 2.01 demographic characteristics work related information drivers drivers demographic background characteristics data shown table 2 self report scale measured means f vas suggested participants fatigued first 10 minutes driving moderately extremely fatigue final section driving compared initial section the f vas scores increase significantly p 0.001 final section driving task demonstrates continuous monotonous driving may predispose subjects cognitive fatigue different fatigue measures i10d f10d i10d initial 10 min driving f10d final 10 min driving furthermore table 2 presents video scores rated trained observers initial final 10 minutes driving paired sampled test suggests significant increase final 10 minutes driving p 0.001 the results showed mild significant correlation f vas video rating scores initial 10 minutes driving r 0.404 p 0.001 meanwhile spearman correlation test showed relatively strong significant association f vas video rating scores final 10 minutes driving r 0.62 p 0.001 table 2 also indicates absolute relative alpha powers initial final 10 minutes driving there significant increase absolute alpha power final 10 minutes driving p=0.006 moreover findings showed differences absolute alpha power different areas scalp initial final 10 minutes driving except parietal area brain p=0.005 paired sampled test suggests statistically significant difference p4 site absolute alpha powers initial final 10 minutes driving p 0.026 this study attempted present simple reliable method early detection driver mental fatigue based eeg alpha power healthy sleep deprived drivers experiment different fatigue outcome measures including subjective self report fatigue f vas video ratings well eeg alpha powers employed evaluate change fatigue drivers initial final 10 minutes driving the experimental results suggested significant increase subjective self report fatigue fvas scores final 10 minutes driving the results obtained zhang 2008 study found level subjective sleepiness fatigue increase significantly pre task post task 37 they studied impacts visual display terminal vdt task autonomic nervous system central nervous system subjective self report sleepiness physiological measures power spectral indices hrv wavelet packet parameters eeg it regarded findings fvas scores showed lowered variability participants reached state fatigue extremely fatigue final section driving this may subject fatigue less likely evaluate state sufficiently words mental fatigue may impact drivers judgment existing state the findings preliminary research indicated significant increase absolute alpha power final section driving this consistent known aspects eeg alpha rhythm 38 39 the increase alpha rhythm final 10 minutes driving depicted decrease level alertness attention commencement fatigue drowsiness the findings present study well line findings researchers found significant difference alpha frequency band first fifth section driving 40 another study delta and theta activity increased final 3 hours 7 truck drivers night driving 41 nevertheless results revealed significant difference relative alpha powers initial final 10 minutes driving the reason may due increase delta theta rhythms causes less relative alpha variability final section driving study changes occurred right parietal region p4 contrast schier 2000 study showed greatest changes right frontal region f4 scalp 36 however consistent reported role right hemisphere via blood flow measurement attention demanding tasks 42 since subjective self report fatigue measured initial final 10 minutes driving sudden variations detected using f vas technique another limitation employing scale drivers verbal expression level fatigue may alert thereby decreasing fatigue level meanwhile almost unfeasible obtain fatigue feedback driver real driving conditions unless significantly distracting driver attention driving task study benefited using video rating facial expressions driver behaviors trained observers might able see goes behind facial behavior expression placing electrodes scalp obtain signals intrusive technique addressed another limitation researches using wired biological signals therefore future projects make use less intrusive systems wireless electrodes benefit strengths various fatigue monitoring methodologies hybrid system develop efficient fatigue detection device real driving situations the present study specifically deals eeg alpha power initial final section driving partially sleep deprived drivers prominent aspect driver fatigue analysis the results study may serve baseline development anin vehicle device preventing fatigue related crashes monotonous roads greatly improving transport industry terms socio economic benefits safety this study suggests alpha brain wave rhythm good indicator early prediction driver fatigue meanwhile image processing facial expressions may complementary method road accident prevention these indicators incorporated develop fatigue countermeasure device prevent road accidents reduce fatigue related costs ethical issues including plagiarism informed consent misconduct data fabrication and/or falsification double publication and/or submission redundancy etc completely observed authors

background : driver fatigue is one of the major implications in transportation safety and accounted for up to 40% of road accidents . this study aimed to analyze the eeg alpha power changes in partially sleep - deprived drivers while performing a simulated driving task.methods:twelve healthy male car drivers participated in an overnight study . continuous eeg and eog records were taken during driving on a virtual reality simulator on a monotonous road . simultaneously , video recordings from the driver face and behavior were performed in lateral and front views and rated by two trained observers . moreover , the subjective self - assessment of fatigue was implemented in every 10-min interval during the driving using fatigue visual analog scale ( f - vas ) . power spectrum density and fast fourier transform ( fft ) were used to determine the absolute and relative alpha powers in the initial and final 10 minutes of driving.results:the findings showed a significant increase in the absolute alpha power ( p = 0.006 ) as well as f - vas scores during the final section of driving ( p = 0.001 ) . meanwhile , video ratings were consistent with subjective self - assessment of fatigue.conclusion:the increase in alpha power in the final section of driving indicates the decrease in the level of alertness and attention and the onset of fatigue , which was consistent with f - vas and video ratings . the study suggested that variations in alpha power could be a good indicator for driver mental fatigue , but for using as a countermeasure device needed further investigations .

many published reports malfunction inner tube bain co axial circuit potentially lethal complications patient the following case report describes case profound hypercapnia occurred consequent avulsion inner tube co axial circuit machine end circuit neither apparent visible anaesthesiologist this report therefore emphasizes need testing co axial circuit circuit malfunction use a 30 year old male presented emergency repair crush injury left hand induction done thiopentone sodium 5 mg kg fentanyl citrate 1.5 mg kg achieving muscle relaxation succinylcholine 1 mg kg anaesthesia maintained oxygen nitrous oxide isoflurane intermittent doses vecuronium bromide the vital signs monitored blood pressure oxygen saturation electrocardiogram temperature end tidal carbon dioxide etco2 the gas flows airway pressure temperature chest expansion bilateral air entry lungs checked found normal we changed fend side stream capnograph new one etco2 continued rise the heart rate rose baseline 80 per minute 110 per minute blood pressure rose baseline 110/70 mmhg 140/94 mmhg however oxygen saturation 100% not finding cause rise etco2 decided change circuit following etco2 curve began fall reached normal value 40 mmhg next couple minutes inspiratory carbon dioxide baseline returned zero close examination original circuit revealed inner tubing co axial tube become disconnected seat machine end circuit figure 1 this previously unused bain circuit checked integrity inner tubing inducing patient the inner coloured tube carries inspiratory gases tube become disconnected develop breach integrity huge increase dead space consequent hypercapnia complications four main causes development hypercapnia anaesthesia described 1)reduced alveolar ventilation rise partial pressure co2(2)inhalation exhaled co2 noted association defective fresh gas flow tube bain circuit)(3)inhalation exogenous co2(4)increased metabolic rate malignant hyperthermia reduced alveolar ventilation rise partial pressure co2 inhalation exhaled co2 noted association defective fresh gas flow tube bain circuit inhalation exogenous co2 increased metabolic rate malignant hyperthermia hypercapnia leads sympathetic system stimulation tachycardia hypertension arrhythmias excessive sweating peripheral vasodilatation may lead excessive intraoperative blood loss our patient significant increase heart rate blood pressure initially erroneously attributed light plane anaesthesia a number tests described assess co axial circuit malfunction include 1)visual inspection tubing obvious disruption obstruction.(2)pethick test tests low pressure system integrity inner tube collapse reservoir bag due creation venturi effect outer tube indication inner tube intact this test detect system inner tube omitted extend patient port one holes patient end inner tube.(3)foex crampton smith manoeuvre manoeuvre assesses gas flow line flowmeters machine patient end circuit oxygen flow 2 litres minute patient end inner tube occluded briefly 23 seconds using forefinger a positive test indicated descent rotameter bobbin due back pressure removal finger bobbin ascends original position ghani suggested use plunger 3-ml syringe occlude inner tube precisely pethick test tests low pressure system integrity inner tube collapse reservoir bag due creation venturi effect outer tube indication inner tube intact this test detect system inner tube omitted extend patient port one holes patient end inner tube foex crampton smith manoeuvre manoeuvre assesses gas flow line flowmeters machine patient end circuit oxygen flow 2 litres minute patient end inner tube occluded briefly 23 seconds using forefinger a positive test indicated descent rotameter bobbin due back pressure removal finger bobbin ascends original position ghani suggested use plunger 3-ml syringe occlude inner tube precisely this case report highlights possibility severe hypercapnia due dead space rebreathing result disconnection inner tube co axial circuit we present warning reminder integrity co axial circuit must always checked visually well mechanically regard foex crampton smith manoeuvre ghani modification appears satisfactory method assessing integrity gas line flowmeter patient end bain circuit

the bain co - axial circuit is fully established in general anaesthesia practice . a major concern is the potential malfunctioning of the circuit due to avulsion of the inner fresh gas delivery tube at the machine end of the circuit . the following case report presents a case in which a patient connected to the bain circuit developed severe hypercapnia in the early intraoperative period due to the above mentioned defect .

attempted estimate perceived degree urgency visit identify reasons seeking non urgent care ped patients parents a prospective survey completed parents children 17 younger patients 18 21 presenting suburban academic ped sees approximately 15,000 patients per year three hundred five 334 surveys completed 91% response rate 3-month period twenty four percent chief complaints perceived surveyed emergent possibly life threatening 23% felt urgent 52% deemed somewhat urgent minor twenty five percent minor somewhat urgent complaints arrived ambulance overall 79% surveyed identified primary care provider pcp child of 54% attempted contact pcp prior coming ped six percent attempted reach primary care providers able contact 52% told come ped more half patients parents presenting ped believed minor somewhat urgent complaints while majority patients regular provider limited access timely primary care convenience may make ped attractive care option primary care many parents patients

objectives : pediatric emergency department ( ped ) patients often present with non - urgent complaints . we attempted to estimate the perceived degree of urgency of the visit and to identify reasons for seeking non - urgent care in the ped by patients and parents.methods:a prospective survey was completed by parents ( for children 17 and younger ) and patients ( 18 - 21 ) presenting to a suburban academic ped that sees approximately 15,000 patients per year . a convenience sample of participants was enrolled.results:three hundred and five of 334 surveys were completed ( 91% response rate ) over a 3-month period . twenty - four percent of the chief complaints were perceived by those surveyed as emergent or possibly life - threatening , 23% were felt to be very urgent , and 52% were deemed somewhat urgent or minor . twenty - five percent of those with minor or somewhat urgent complaints arrived by ambulance . weekend visits and minority race correlated with a lower degree of perceived urgency . overall , 79% of those surveyed identified a primary care provider ( pcp ) for themselves or their child . of those , 54% had attempted to contact the pcp prior to coming to the ped . six percent of those who attempted to reach their primary care providers were able to contact them and 52% were told to come to the ped.conclusions:more than half of patients and parents presenting to the ped believed they had minor or somewhat urgent complaints . while the majority of patients have a regular provider , limited access to timely primary care and convenience may make the ped a more attractive care option than primary care for many parents and patients .

suicide literal meaning kill oneself act intentionally causing one death the reasons mostly related mental disorders depression bipolar disorder schizophrenia alcoholism sometime drug abuse the triggering factor stress many times related either financial difficulties troubles within personal relationships it 10 leading cause death worldwide around 800,000 million people die every year estimated 10 20 million nonfatal attempted suicides occur year india suicides reported little data available attempted suicides indian union health ministry estimated around 1.2 lakh people commit suicide 4 lakhs people attempt suicide india unfortunately 11% cases reported andhra pradesh state india national crime record bureau india reported last three half decades increase 175% suicidal rate observed one suicide occurs every 5 min india although suicidal act made illegal country section 309 306 indian penal code ipc even attempt commit suicide part criminal activity section 309 ipc number suicidal incidences proportional attempted suicide cases hence attempt cases reduced number suicidal death also decreased purpose risk factors identified reduced there number risk factors suicide varies according country culture religion gender age social values hence present study planned identify risk factors among lower socioeconomic rural population genders surrounding areas hyderabad region india little data available moreover hyderabad important densely populated metropolitan city south india surrounding rural population including rural population adjoining districts therefore important properly understand risk factors attempted suicide cases little studied lower socioeconomic class rural population suitable policies programs initiated prevention this prospective study suicide attempt cases reported bhaskar medical college general hospital included it conducted period january 2013 july 2013 studied population belongs surrounding rural areas hyderabad region india all cases diagnosed managed emergency general medicine department institute per routine standard protocol referred psychiatric outpatient department evaluation intervention patients medically became fit psychiatric interview all patients clearly making attempt life assisted someone included accidental cases poisoning excluded study these patients undergone detailed psychiatric interview including demographic details complete suicide risk assessment done using beck suicide intent scale the end point psychiatric management counseling treatment form medication follow management in study total 36 patients studied 20 females 16 males mean age 25 years female 34 years males age difference statistically significant p 0.05 minimum age female 16 years maximum 40 years male 18 years 70 years respectively groups most cases age group 21 30 years table 1 age group distribution female n=20 male n=16 50% subjects uneducated groups females majority subjects 75% category uneducated secondary education males trend seen numbers much higher 93.75% moreover female group substantial number subjects 20% intermediate passed males intermediate qualified subject seen far profession is concerned subjects housewife laborer students low income self employed farmers about 25% male subjects farmers 50% laborer female group 35% housewife 45% laborer table 2 their married life ranged 1 10 years marriage male group almost 40% subjects majority females 75% males 56.25% subjects dependent children 1 3 kids table 3 marital status children majority subjects attempted suicide 1 time although 10% female 6.25% male attempted 2 time most females 75% free kind substance use 25% occasionally took toddy case males most 62.5% consuming alcohol regularly although 25% males nonalcoholics rest 12.5% occasional users apart alcohol toddy subjects groups involved kind drug substance use time attempt attempts substance use substance influence males took organophosphorus 87.5% suicide attempt followed calotropis 12.5% majority females also took organophosphorus 45% followed rat poison 15% known unknown tablets 15% phenyl 10% animal plant energy mix 10% calotropis 5% table 5 methods substances suicide attempt among study population 10 individuals met criteria alcohol dependence syndrome 14 depression most depressive disorder 38.9% followed alcohol dependence syndrome 27.8% together present 13.8% individuals table 6 prevalence psychiatric disorders suicide assessment scale isolation parameter score 2 predominantly observed females 70% males scores 2 3 equal 43.8% timing parameter score 2 mainly seen genders 65% females 56.3% males precautions discovery intervention parameter score 1 predominant genders 70% females 68.8% males score 2 also common acting get help attempt parameters groups tables 7 11 scores suicide assessment scale score 1 mainly observed final acts anticipation death female 95% male 93.8% active preparation attempt female 90% male 56.3% suicide note 100% groups parameters although 31.3% males scored 2 active preparation attempt parameter most female male subjects score 2 overt communication intent attempt parameter female 80% male 75% alleged purpose intent parameter score 3 common females 70% males score 3 observed 50% subjects score 2 43.8% individuals tables 8 11 scores suicide assessment scale expectations fatality parameter score 3 common females 60% males score 2 common 68.8% conception method lethality parameter score 2 common genders females 65% males 68.8% also seriousness attempt parameter score 3 common genders females 60% males 68.8% we observed score 3 predominantly females 60% males 60% attitude toward living dying parameter although score 2 also seen high number subjects females 40% males 43.8% score 2 predominant genders females 80% males 68.6% although number female subjects higher comparison male counterparts parameter conception medical rescuability subjects genders females 75% males 68.6% scored 1 degree premeditation parameter tables 9 11 scores suicide assessment scale total score suicide assessment scale scores suicide assessment scale assessed total score parameters suicide assessment scale found female group equal number 50% cases medium total score 20 28 high risk 28 categories male group number males medium risk slightly 56.3% comparison high risk group 43.8% groups not single case found low risk category tables 10 12 this prospective study conducted explore sociodemographic variables individuals suicidal attempt females n 20 outnumbered males n 16 kessler et al also found female dominance study das et al have reported higher incidence suicide attempts males compared females indian population contrast finding south india das et al suggested trend might higher responsibility males family financial issues contributes increased exposure stressful events bashir et al kiran et al also observed male dominance respective studies tribal urban regions india but study difference could study population considered most study population rural background husband wife work daily laborers sharing equal amount stress work besides females additional family responsibilities home fact make prone stress males joseph et al also found female dominance rural regions india increasing age decline number individuals attempted suicide people 21 30 years age group suicidal rate belonging age groups increasing age individuals develop adaptability stressful conditions helping encounter challenging situations better way thus contributing lesser incidence suicides incidence rates suicide west bengal concluded vulnerable age group ages 18 30 years high proportion 87.5% individuals committed suicide married total married females 15% pregnant time attempt marital conflicts family stress financial issues would contributed increased number suicides married group ramdurg et al also found predominance married individuals study conducted find sociodemographic profile clinical factors mode attempt suicide attempt observed people developing countries live rural regions involved agriculture farm small areas land these farmers keep agriculture materials including pesticides commonly within close household the easy availability pesticides individual impulsive would contributed high number attempting method most individuals 62.5% regular intake alcohol 31.25% study population attempted suicide influence alcohol this could probably impulsivity lack ability think logically intoxicated state hufford study found alcohol intoxication increases suicide risk 90 times comparison abstinence also reported constructs related aggression impulsivity confers additional risk suicidal behavior among persons alcohol dependence this accordance study conducted potukuchi rao high prevalence alcohol intake females rural population region study diverse precipitating factors suicide attempt observed including quarrel close relatives husbands fathers alcoholic abusive family disputes stand major reason suicidal attempt this finding harmony findings siwach gupta reported marital disharmony economic hard ships disagreement family members major precipitating factors suicide depressive disorders diagnosed 38.9% individuals stands common associated disorder parkar et al mumbai region indian also observed similar trend studied population 40% individuals intentional self harm suffering depression significant number also alcohol use related disorders increased risk suicide alcohol intake the individuals included study referred departments institute therefore may represent individuals attempted suicide chance people consulting psychiatry department a individuals referred health care institutes expired medical management included study we conclude studied population risk suicide attempt almost equal terms medium high category suicide assessment scale genders females age group 20 30 years uneducated married daily laborers occupation involved males thus category females greater risk suicide attempt depressive disorders are common associated psychiatric disorders genders followed alcohol use related problems we suggest individuals alcohol related disorders must screened suicidal ideation appropriate methods adopted reduce risk

background : suicide is an act of intentionally causing one 's own death . number of suicidal incidences is proportional to attempted suicide cases hence if attempt cases are reduced , number of suicidal death can also be decreased and for that purpose risk factors should be identified and reduced . therefore , this study is planned to identify risk factors among lower socioeconomic rural population of surrounding areas of hyderabad in india.materials and methods : this was a prospective study in which all the suicide attempt cases reported at bhaskar medical college and general hospital were included . the study period was from january 2013 to july 2013 . they were undergone a detailed psychiatric interview , including their demographic details , and complete suicide risk assessment was done using beck 's suicide intent scale.results:it was found that females in the age group of 20 - 30 years , uneducated , married and daily laborers by occupation had higher incidence of suicidal attempts . depressive disorder is the most common associated psychiatric disorder in both the genders , followed by alcohol use related problems . family disputes are the other major risk factors . most common mode for attempt was organophosphorous poisoning followed by ingestion of calotropis.conclusion:risk of suicide attempt is almost equal in terms of medium and high category of suicide assessment scale in both genders . we suggest that all individuals with alcohol related disorders must be screened for suicidal ideation so that appropriate methods can be adopted to reduce the risk .

single cell microorganisms scm constitute emerging alternative source high value lipids series growing markets demanding low cost high quality alternatives scm broad class display series advantages compared plants animals lipid sources in addition genetically accessible scm capable producing greater diversity storing higher percentages lipids therefore productivity per volume energy input 5 6 times plants even compared animal sources additionally single cell microorganism architecture circuitry tend straightforward plant animal cells for example fewer organelle compartments fungal cells plant cells microalgal metabolic pathways e.g. fatty acid synthesis encoded single copy genes whereas plants multiple genes encoding proteins redundant enzymatic activities scm readily grown controlled conditions key metabolic biochemical questions answered simply quickly complex multicellular systems principle scm achieve greater sustainability alleviate increasing problem sourcing oils fuel human consumption markets thus mitigating continuous increase commodity oil prices microbial lipids also become sources safe clean biomaterials e.g. biosurfactants reduced costs continuous availability a complete mechanistic understanding cellular machinery key moving principle practice lipid production the purpose paper provide overview current knowledge different cellular biochemical mechanisms involved neutral polymeric lipid accumulation within four main single cell microbial groups yeasts microalgae bacteria archaea special emphasis given production triacylglycerols tag polyhydroxyalkanoates pha hallmark lipids accumulated eukaryotes prokaryotes respectively insights provided mechanistic differences existing group transformation substrates e.g. acetyl coenzyme formation intermediate pools e.g. fatty acyl chains allocation intracellular lipid pools e.g. polar lipid pools neutral lipid pools architecture lipid accumulation storage e.g. lipid droplets microorganisms different types neutral lipids accumulated different types scm for example oleaginous yeast tag and/or sterol esters se primary neutral lipids accumulated inside cell whereas specific types bacteria archaea polyhydroxyalkanoates pha lesser extent tag wax esters preferentially stored these lipids currently viewed valuable potential biofuel sources high value compounds food pharmaceutic industries building blocks biomaterials potential tools treat chronic diseases natural alternatives production oleochemicals among many uses neutral lipids follow distinct cellular accumulation strategies compared polar lipids phospholipids pl galactolipids sulfolipids among others however cases classes share key biosynthetic steps depending cell needs cell capable transforming polar lipids neutral lipids vice versa due different pools present strategic cellular locations for instance polar lipids pooled may mobilized different cell membranes key membranes involved accumulation lipids include plasma membrane eukaryotes prokaryotes case eukaryotes endoplasmic reticulum er peroxisome mitochondrial plastidial variants apicoplastidial even thylakoid membranes depending organism key intermediates acetyl coenzyme ac coa malonyl coenzyme mal coa acyl coenzyme acyl coa glycerol-3-phosphate g3p also pooled strategic cellular locations cytosol plastidial stroma mitochondrial intermembrane space the distribution different biosynthetic enzymes plays key role achieving correct lipid traffic toward accumulation the accumulation intracellular neutral lipid highly reductive process requiring nadph atp storage glucose glucose derivatives accumulation lipids biological process fulfills several roles microorganisms storage lipids contributes cell growth cell division stress response energy storage survival cases some scm capacity accumulate lipids 20% weight exposed environmental stress lack key nutrient when growing limiting concentrations key nutrient typically nitrogen sufficient excess carbon sources oscm stop replication processes utilize available carbon synthesize store way reduced lipids case tag se oscm shift metabolic machinery generate pool ac coa well nadph reducing power driving fatty acid fa synthesis forward strategies vary among different classes oscm details discussed following sections second stage ac coa carboxylated produce mal coa transferred acyl carrier protein acp transformed acyl acp sequential turns within fatty acid synthase fas there two types fas type integrated enzyme complex common eukaryotic cytoplasm type ii dissociated version subunits independent common prokaryotes organelles prokaryotic origin primary secondary endosymbionts plastids mitochondria type subdivided type ia present fungi 66 complex cytoplasm type ib present animals cytoplasmic 2 dimers reviews describing type i fas type ii fas reader referred works schweizer lu et al depending cell needs type scm acyl chain might end specific type lipid pool membrane lipid coupling acyl chain g3p ac coa glycerol based backbone form pl types polar lipid eventually incorporated neutral lipid droplet core via construction tag se molecules the nature location dynamics stage vary among species explained detail following sections stage elongation desaturation acyl chains may also occur phenomena vary throughout different domains life finally fourth stage involves formation intracellular lipid droplets ld variations occur depending organism environmental conditions case prokaryotes accumulation tag se less common members gram positive actinomycete group mycobacterium rhodococcus nocardia dietzia streptomyces tag interestingly bacterial tag biosynthesis occurs frequently environment actinomycetes abundant microorganisms soil accumulation tag gram negative bacteria reported species genus acinetobacter minor component neutral accumulated lipid wax esters main compound stored species rest gram negative bacteria however several studies successfully transformed model bacteria escherichia coli inserting required genes become oleaginous remarkable success in addition tag reported major components neutral lipid cyanobacterium nostoc commune although indications obtained storage lipid inclusions cells case archaea it common prokaryotes accumulate pha comprising specialized lipids poly(3-hydroxybutyrate p3hb polyhydroxyvalerate phv copolymers poly(3-hydroxybutyrate co-3-hydroxyvalerate phbv pha possess thermoplastic elastomeric properties recyclable materials easily degraded carbon dioxide water the promising film formation paper coating foils diaphragms multiple use packages melted polymers low viscosity permitting injection molding objects thin walls the end product hard used temperatures 30 120 c chemical structures three different types pha synthesized accumulated certain prokaryotes the first stage involves generation suitable cytoplasmic ac coa pool the second one involves synthesis hydroxyalkanoate ha monomer monomers change depending species substrates the third stage consists polymerizing copolymerizing monomers pha chains fourth one involves formation intracellular pha ld prokaryotes eukaryotes accumulation neutral lipids results formation intracellular fat bodies typically called lipid droplets ld ld also called lipid bodies fat bodies adiposomes case plants also termed oleosomes spherosomes plastoglobules latter location inside plastid present discussion term lipid droplet used eukaryotes ld intracellular sphere like particles composed core neutral lipids tag se coated monolayer polar lipids mainly pl decorated series proteins the polar heads face cytoplasm nonpolar tails face inside neutral lipids reside the inserted proteins within polar lipid monolayer play functional structural regulatory roles life cycle ld case polyhydroxyalkanoate accumulating prokaryotes form ld also called lipid granules carbonosomes higher organisms e.g. humans lipid droplet interaction cellular organelles dynamics is closely related progression metabolic diseases obesity fatty liver type 2 diabetes mellitus atherosclerosis therefore become apparent ld static storage compartment cell rather dynamic organelle interacts organelles within cell actively participates intricate cellular processing symphony point authors consider ld specialized organelles cells described later sections strategies lipid accumulation scm vary among different types scm important understand differences improve and/or create productive strategies become economically well technologically feasible generation biofuels well nutritional lipid metabolites long chain polyunsaturated fatty acids lc pufa thus capable metabolizing carbon simple sugars simple compounds glycerol when oleaginous yeasts encounter environmental stress limiting nutrient e.g. nitrogen shift metabolic machinery stop synthesizing proteins nucleic acids thus begin allocate available carbon form reduced lipids other examples limiting nutrients phosphorus magnesium practice date nitrogen extensively used seems yield higher lipid accumulation compared nutrients the carbon nitrogen ratio useful tool construct nitrogen rich nitrogen depleted media for example shown yeasts poor lipid accumulation occurs media carbon nitrogen c n ratio 20 whereas ideal lipid production occurs c n ratio range 3080 the optimal c n ratio lipid accumulation varies greatly microbial species strain carbon sources present growth medium yeasts oleaginicity depends ability produce ac coa necessary precursor fatty acids effective manner the conversion 1 mol ac coa fatty acids requires formation 2 mol nadph constitutes reducing power necessary drive reaction forward the metabolic steps lipid accumulation yeast divided four main stages mentioned see figure 2 the diagram also includes connection fatty acid synthesis triacylglycerol synthesis lipid droplet formation abbreviations malic enzyme cytosolic 2 malic enzyme er membrane responsible fatty acid desaturation acl atp citrate lyase isocitrate dehydrogenase nld nascent lipid droplet ld lipid droplet er endoplasmic reticulum lpa lysophosphatidic acid pa phosphatidic acid fas fatty acid synthase dag diacylglycerol tag triacylglycerol ampd amp deaminase the cell responds activating amp deaminase inducing acute decrease cellular amp content mitochondria oleaginous species the decrease cellular amp levels causes isocitrate dehydrogenase idh activity decrease even stop consequence production -ketoglurarate drops tricarboxylic cycle tca dramatically reduced even stopped to reverse situation aconitase transforms isocitrate back citrate cit leading accumulation cit mitochondria cit transported antiport protein known citrate malate translocase cmt mitochondria cytoplasm cytoplasm cit cleaved form oxaloacetate ac coa atp citrate lyase acl cytosolic malate converted pyruvate malic enzyme encoded me1 this reaction generates nadph coupled series parallel reactions well the first carboxylation pyruvate form oxaloacetate pyruvate carboxylase inside mitochondria this nadph reducing power required convert ac coa fatty acids thus pyruvate carboxylase md known transhydrogenation machinery the resulting pyruvate completes cycle goes inside mitochondria figure 2 me present fungi role supplying nadph de novo lipogenesis preponderant oleaginous species it found upon nitrogen limitation changes isoform isoform e supplies nadph de novo lipogenesis ac coa converted acetyl coa carboxylase acc mal coa used synthesize fatty acids yeast cytosolic acc the mitochondrial version closely resembles molecular mass amino acid sequence cytoplasmic one acc uses biotin cofactor transfer co2 ac coa two step process it trifunctional enzyme harboring biotin carboxyl carrier protein domain biotin carboxylase domain co2 binds biotin carboxyl transferase domain co2 transferred ac coa yield mal coa the fatty acyl chain built type cytosolic fatty acid synthase fas it 66 complex encoded two genes fas1 subunit fas2 subunit it suggested contain 6 equivalent sites fa synthesis total 42 catalytic domains organized ring like structure however variations architecture exist probably may affect performance de novo lipogenesis for example ac coa always basis fa biosynthesis substrate -ketoacyl acp synthase ksa bacteria the sequence reactions yeast fas ii condensation ac coa mal coa via ks reduction via ketoacyl reductase kr dehydration via dehydratase dh reduction via enoyl reductase ear repetitive manner palmitoyl acp formed release acyl moiety key step differs species currently subject intense research yeasts employ malonyl palmitoyl transacylase mpt transfer acyl chain acyl acp acyl coa algae acyl chain released three ways depending cell needs first hydrolyzed acp free fatty acid means thioesterase te second transferred either g3p monoacylglycerol-3-phosphate mag3p acyltransferase chloroplast lastly acyl chain destined leave plastid also released acyl coa form acyl coenzyme synthetases acs it found acs play key role regulating compartment internal acyl coa pools esterification fa coa the localization pools maintained due acyl coa able cross intracellular membranes the final fatty acid composition different types microalgae great part dependent activity enzymes for example microalgal chain length specific te reported release acyl moieties specific length e.g. c 12:0 even c 8:0 this type fatty acid suitable production gasoline jet fuel in contrast gram positive bacteria first form acyl phosphate acyl coa via plsx transferred onto g3p plsy gram negative species use plsb acyltransferase load acyl group directly onto g3p acyl acp yeast acyl coas released cytosolic fas system there series esterifications g3p backbone occur also known kennedy pathway the first step consists esterifying acyl moiety acyl coa g3p dihydroxyacetone 3-phosphate via glycerol-3-phosphate acyl transferase g3pat sn-1 position g3pat encoded yeast gat1 ayr1 acceptor g3p dihydroxyacetone 3-phosphate respectively gat1 exhibit particular preference acyl coa whereas ayr1 prefers palmitoyl coa thus defining fa composition a second acyl moiety attached sn-2 position generate phosphatidate pa catalyzed acyl coa lysophosphatidic acyltransferase lpaat pa plays key role regulation acc1 fas1 fas2 genes involved autoregulatory loop directed concentrations inositol choline cytosol pa er membrane expression upstream activating sequence uasino)-operated genes changes parallel pa inositol choline concentrations case pa going transformed tag first phosphate group directly hydrolyzed phosphatidate phosphatase pap create dag the second one involves synthesizing cytidine diphosphate dag cdp dag pa catalyzed cdp dag kinase encoded cds1 cdp dag precursor different pl er membrane it thus stays either phosphatidylcholine pc phosphatidylethanolamine pe another type pl eventually dag generated cleavage pl via phospholipase c. alternatives metabolic interlock this creates positive feedback system channels pa tag pathway cdp dag concentration higher dag concentration directs pa membrane pool opposite situation lastly dag transformed tag esterifying acyl moiety acyl coa catalyzed acyl coa dag acyltransferase adat encoded either dga1 lro1 depending whether dag generated directly pa via pap comes er membrane pl pool respectively another different cytosolic malic enzyme catalyzes conversion malate pyruvate consequent reduction nadp nadph nadph couples series electron transfer reactions involving cytochrome b5 reductase activating desaturase adds double bond fatty acid chain expense converting 1 mol oxygen mole water ergosterol major sterol present yeast review biosynthesis ergosterol backbone yeast se synthesized via transesterification ergosterol acyl coa yeast two acyl coa cholesterol acyltransferase acat related enzymes are1p are2p encoded are1 are2 catalyze reaction microscopic localization green fluorescent protein hybrids enzyme measurements showed are1p are2p localized er are1p esterifies ergosterol precursors nearly equal efficiency slight preference lanosterol whereas are2p uses ergosterol preferred substrate an acyl coa independent pathway formation ses identified yeast lipid droplet biogenesis area intensive current research emerging scientific evidence showing yeast takes place two membrane leaflets er mechanisms still clearly understood spots er membrane concentration adats dga1 lro1 the first one responsible tag synthesis outer leaflet endoplasmic reticulum whereas second responsible tag synthesis inner leaflet er synthesized tag begin accumulate generating lens like protrusion promoting recruitment structural proteins yeast pat proteins initials perilipin adipocyte differentiation related protein tip47 accumulate outer leaflet see figure 3 whereas plants role played oleosins when enough accumulation tag leaflets outer buds lipid droplet formed figure 3 model lipid droplet formation er membrane adapted ref 11 there seems functional relationship lipid droplet membrane er membrane several studies shown certain functional proteins migrate lipid droplet er membranes mechanisms require energy expenditure yeast for example experiments using yeast mutants unable synthesize tag revealed ld formed however proteins present wild forms ld also present er yeast mutants suggesting relationship er proteins lipid droplet proteins cases lipid droplet localized proteins relocate back er indicating continuity two organelles maintained even transiently way allows two way partitioning proteins two compartments describing functions proteins embedded droplet monolayers two mechanisms proposed examples strategy multifunctional caveolin protein localized plasma membrane ld dga1 major enzyme catalyzing triacylglycerol synthesis their long internal hydrophobic stretch may enable embedded either bilayers monolayers the second mechanism best represented previously mentioned pat protein family they display four helix bundle great similarity n terminal domain apolipoprotein e. upon binding lipids apoe four helix bundle opens expose amphipathic helices bind monolayer surfaces lipoproteins analogous manner pat proteins may bind lipid droplets embedding hydrophobic helices droplet surface pat proteins also share common structural element n terminal 11-mer repeats amphipathic helical structure it still unclear specific case perilipins members pat family there five groups abundance correlated abundance tag lipid droplet well it important mention perilipin like proteins found plants as already mentioned functionally similar oleosins caleosins present plants instead the accumulation lipids promote concavity decreases energy burden required budding it shown lipid droplet pl contain lysophospholipids less sphingomyelin pa compared total membrane silico studies proposed packing parameter quantify degree convexity concavity pl lysophosphatidylcholine phosphatidylinositol pi promote convex shape lipid footprint areas much smaller headgroup areas lipids values 1 adopt convex surface favoring lipid droplet formation configurations adopted different phospholipids affect curvature lipid droplet formation eukaryotic microalgae classified nine divisions glaucophyta rhodophyta red algae heterokontophyta haptophyta cryptophyta dinophyta dinoflagellates euglenophyta chlorarachniophyta chlorophyta green algae divisions include single cell strains either motile nonmotile terms nutritional strategies microalgae divided obligate heterotrophs obligate photoautotrophs facultative mixotrophs obligate mixotrophs most algal divisions contain colorless heterotrophic species obtain organic carbon external environment either taking dissolved substances osmotrophy engulfing bacteria cells particulate prey phagotrophy cases lipid accumulation strategies microalgae and some single cell protists primary secondary endosymbionts follow four stage lipid accumulation strategy described yeast studies demonstrating lipid biosynthesis pathways microalgae simple mirror image happens higher plants thoroughly studied it seems likely regulation triacylglycerol synthesis breakdown microalgae tends obey stress response phenomenon whereas plants follows developmental phenomenon review comparing lipid metabolism microalgae plants see liu microalgae differ yeast location acetyl coa pools within cell microalgae display plastidial cytosolic acetyl coa pools key lipid accumulation in contrast yeast main acetyl coa pool used lipid accumulation located cytosol there additional acetyl coa pool present mitochondria well mitochondrial lipid biosynthesis pathway employing type ii fas different plastidial fas ii algae yeasts they play important roles different cell processes rna processing mitochondrial lipoic acid synthesis protein lipoylation however mitochondrial lipid synthesis main avenue lipid accumulation covered present work review mitochondrial lipid biosynthesis relevance cell function plastids present algae play key role de novo lipid biosynthesis review plastid evolution diversification see work keeling photoautotrophic microalgae photosynthesis provides endogenous source plastidial acetyl coa although one pathway may contribute maintaining acetyl coa pool for instance photoautotrophic microalgae plastidial pyruvate sourced via transformation photosynthesis derived glyceraldehyde-3-phosphate phosphoenolpyruvate pep pep irreversibly converted pyruvate see figure 5 pyruvate kinase pk finally plastidial pyruvate dehydrogenase complex pdh catalyzes oxidative decarboxylation pyruvate produce plastidial ac coa co2 nadh pdh contains three components e1 pyruvate dehydrogenase composed e1 e1 subunits e2 dihydrolipoyl acyltransferase e3 dihydrolipoamide dehydrogenase it possible photosynthesis derived pyruvate major contributor plastidial ac coa de novo fatty acid synthesis however mixotrophic grown cultures heterokonts nannochloropsis sp incorporation acetate directly lipids occurs the acetyl coa synthetase acsin converts acetate plastidial ac coa additionally study showed nitrogen deprivation chlamydomonas capable changing metabolism converting acetate glucose direct incorporation acetate fatty acids regulating glyoxylate cycle activity gluconeogenesis abbreviations er endoplasmic reticulum accase acetyl coa carboxylase acp acyl carrier protein dagat diacylglycerol acyltransferase dhap dihydroxyacetone phosphate enr enoyl acp reductase fat fatty acyl acp thioesterase g3pdh glycerol-3-phosphate dehydrogenase gpat glycerol-3-phosphate acyltransferase hd 3-hydroxyacyl acp dehydratase kar 3-ketoacyl acp reductase kas 3-ketoacyl acp synthase lpaat lysophosphatidic acid acyltransferase lpat lysophosphatidylcholine acyltransferase mat malonyl coa acp transacylase pdh pyruvate dehydrogenase complex microalgae cytosolic ac coa pool mainly fueled release mitochondrial cit cytosol cleaved oxaloacetate ac coa acl cytosolic ac coa building block used lc pufa elongation er concomitant production nadph generates reductive power necessary drive plastidial de novo fatty acid synthesis forward availability nadph increase reaction velocity acc 2 see stage 2 acl fatty acid synthesis energy demanding process due activity elongases desaturases for instance formation c18 fa requires 54 nadph oxygenic photosynthesis other functions malic enzyme algae may include delivery co2 tca plastidial ribulose-1,5-bisphosphate carboxylase rubisco studies also suggest existence plastidial absent yeast provide electrons plastidial fa synthesis review about some microalgae capable accumulating intracellular starch thoroughly studied microalgal model chlamydomonas starch synthesis example carbon partitioning might play key role lipid accumulation one study showed wild type chlamydomonas tag accumulated maximum amount starch reached whereas starchless chlamydomonas mutants initiated tag accumulation earlier reached higher level wild type strain therefore possible engineer high tag algal strains eliminating competing carbon utilization pathways starch synthesis maximize lipid biosynthesis algae the committed step plastidial fatty acid synthesis conversion plastidial ac coa mal coa acc1 the three domains homomeric acc1 located multifunctional polypeptide encoded nuclear gene others t. pseudonana p. tricornutum contain two homomeric accases acc1 described cytosolic acc acc2 uses cytosolic ac coa generate mal coa the latter plays role lc pufa elongation er membrane fas synthesized microalgae plastid via dissociated type ii fas containing discrete monofunctional enzymes encoded distinct genes in plastidial fas ii mal coa loaded acp via malonyl coa acp transacylase encoded fabd malonyl acp used cyclic condensation reactions extend acyl group palmitoyl acp stearoyl acp the acyl acp released fas ii several ways hydrolyzed fatty acyl acp thioesterase located chloroplast envelope forming free fatty acid transesterified acp coa via acs even coupled either g3p mag3p chloroplast there heterotrophic microalgal species contain cytosolic type fas synthesized one two polypeptides different plastidial type ii fas for example aurantiochytrium(100 contains type fas synthesizes saturated c14:0 c16:0 the synthesized free fas absence genes homologous type ii te may indicate integration te activity synthase several attempts made overexpress specific enzymes lipid biosynthetic pathways cases acc ks ks iii overexpression failed increase lipid accumulation the released acyl moieties free fatty acids destined stay within plastid may desaturated typically hexadecatrienoic acid hdt c16:3n-4 coupled monogalactosyldiacylglycerol mgdg backbone mgdg along types galactosylglycerides gg major component photosynthetic membranes microalgae cases may even abundant pl plants the fa combination gg traced back biosynthetic pathways called eukaryotic molecular species c18/c18 gg synthesized outside chloroplast eukaryotic pathway prokaryotic molecular species c18/c16 synthesized plastid via prokaryotic pathway microalgae differ plants c20 fas synthesized outside chloroplast present eukaryotic like c20/c20 c18/c18 prokaryotic like c18/c16 c20/c16 molecular species c20/mlc mlc means medium long chain rather eukaryotic- prokaryotic like gg when acyl acp esterified either g3p mag3p join plastidial pl pool plants two ats the second one resides inner chloroplast envelope membrane preferentially selects palmitoyl acp algal species c. reinhardtii p. lutheri pc absent plastidial extraplastidial phospholipid pools instead contain non phosphorus betaine lipid diacylglyceryl n n n trimethylhomoserine dgts similar physicochemical properties major membrane component it suggested dgts may role lipid droplet formation similar pc higher plants however contain types phospholipids pa pe pi acyl acps synthesized plastidial type ii fas transesterified coa via acs thus stearoyl acp leave fas ii complex via transesterification series acs responsible maintaining intraplastidial cytosolic acyl coa pools in cases acyl coa destined leave plastid enter er membrane oxygen dependent elongation desaturation become long chain polyunsaturated fatty acids lc pufa eicosapentaenoic acid epa docosahexaenoic acid dha the first front end desaturases containing n terminal cytochrome b5 domain insert new double bond fa carboxyl group possible existing double bond one example high substrate specific plastidial located 12 desaturase identified p. tricornutum desaturates palmitoleic acid c16:1n-7 hexadecadienoic acid 16:2n-4 the second group comprises less common 6/3 desaturases capable inserting new double bond fa methyl end pre existing double bond stearoyl coa desaturated er membrane bound 9 desaturase oleyl coa linked glycerol backbone processing some microalgae contain plastidial 9 desaturase capable direct desaturation stearoyl acp transesterified coa sent er elongation desaturation microalgae n-3 lc pufa abundant n-6 lc pufa whereas filamentous fungi mortierella mucor n-6 lc pufa common microalgae common pathways epa and dha synthesis n-3 n-6 pathways variations theme occur n-3 pathway oleic acid already linked glycerol backbone er membrane desaturated linoleic acid la via 12 desaturase encoded fad2 a third double bond inserted n-3 15 desaturase gives -linolenic acid lna desaturated produce stearidonic acid sa 6 desaturase sa elongated c20:4 n-3 eicosatetraenoic acid ea finally desaturated 5 desaturase produce epa dha producing microalgae this different less complicated strategy dha synthesis epa compared sprecher pathway present mammals involves additional elongation -oxidation in contrast n-3 pathway microalgae synthesize epa via n-6 pathway following 6 desaturation la -linolenic acid gla elongation dihomo--linolenic acid dgla creation fourth double bond 5 desaturase produce arachidonic acid ara final desaturation create epa via n-3 17 desaturase microalgae express 9 elongase 8 desaturase allowing synthesize epa different way compared n-3 n-6 pathways variation n-3 pathway lna elongated 9 elongase eicosatrienoic acid eta desaturated 8 desaturase creating ea hand variation n-6 pathway using pair enzymes involves 9 elongation la eicosadienoic acid eda 8 desaturation dgla thus microalgae switch n-6 fatty acids n-3 fatty acids via n-3 15 desaturase n-3 17 desaturase species thraustochytrids also possible switch n-6 docosapentaenoic acid dpa dha via n-3 4 desaturase in addition pathways different n-3 lc pufa biosynthetic pathway present one three genera heterotrophic thraustochytrids namely auranthiochytrium based anaerobic polyketide synthase pathway pks large multifunctional enzyme complex carries multitude individual reactions utilizing mal coa producing free n-3 lc pufas major free fas dpa 22:5n-6 dha 22:6n-3 ) are activated acyl coa incorporated tags pks require aerobic desaturation pathway energetically favorable compared membrane bound desaturases elongases tag synthesis microalgae follows kennedy pathway er similar fashion yeast see figure 5 however acyl coa independent mechanism triacylglycerol synthesis plants yeast reported this pathway uses pl acyl donors dag acceptor reaction catalyzed enzyme phospholipid dag acyltransferase there two diacylglycerol acyltransferase families identified chlamydomonas involved final step triacylglycerol synthesis type one dgat encoded dgat1 type two dgtt encoded five dgtt genes share sequence similarity two independent studies showed expression levels dgat1 dgtt1 increased considerably following nitrogen deprivation however remains unclear dgats primarily responsible accumulation tags condition whether individual isoforms specific roles triacylglycerol synthesis also occur within plastid series acyl acp esterifications plastidial g3p catalyzed plastidial ats similar kennedy pathway er involvement gg major polar lipid family plastidial membranes several microalgae process remains elucidated light dark cycles many microalgae initiate triacylglycerol storage day deplete stores night support cellular atp demands and/or cell division this cycling taken account scaling processes production lipids algae this variable may key overall success open pond process closed photoreactor process they grow facing cytosol toward inside plastid facing stroma major aqueous fluid surrounding thylakoids inside chloroplast the mechanisms underlying orientation lipid droplet growth plastid membranes well understood ld grow toward inside plastid facing stroma also called plastoglobules ptg ptg considered functionally equivalent cytosolic ld differ three major respects second assume several different forms including rods fibers globules third bound specific family proteins variously termed plastoglobulins plastid lipid associated proteins fibrillins oleosins major lipid droplet proteins present plants present green algae major lipid droplet protein identified applying proteomics chlamydomonas shown modulate lipid droplet size a wide variety parameters affect abundance ld chlamydomonas ample evidence turnover ld plays crucial roles cellular lipid carbon homeostasis in bacteria frequent types neutral polymeric lipids synthesized accumulated pha tag wax esters lesser extent se however special situation occurs bacteria rhodococcus ruber related bacteria capable accumulating types lipids unrelated carbon sources glucose the mechanisms wax ester accumulation reviewed elsewhere nutshell an acyl coa transformed aldehyde via nadph dependent acyl coa reductase encoded acr1 reduced alcohol via also nadph dependent fatty aldehyde reductase the alcohol transesterified acyl coa via enzyme displaying wax ester synthase ws acyl coa diacylglycerol acyltransferase dgat activities abbreviated ws dgat ) report presence sterol ester synthesizing enzyme prokaryotes provided thornton et al date triacylglycerol biosynthesis detected aerobic heterotrophic bacteria cyanobacteria bacteria accumulation tag neutral lipids stimulated carbon source present excess together limited nitrogen medium structurally fluorescence staining experiments showed lipid biosynthesis starts peripheral lipid domains close cytoplasm membrane biochemically fatty acid biosynthesis begins bacteria acc heterotetrameric enzyme encoded four genes acca accb accc accd ac coa converted mal coa transferred acp malonyl coa acp transacylase fabd bacteria form malonyl acp a first condensation malonyl acp acetyl coa -ketoacyl acp synthase iii fabh form -ketobutyryl acp co2 initiates cycle elongate fatty acyl acp two carbon units cycle saturated fatty acid 16 18 carbons made ksi fabb ksii fabf responsible subsequent elongation cycles growing acyl acp chain to balance chain initiation growth utilization bacterial fasii ksiii enoyl acp reductase fabi bacteria -ketoacyl acp reductase fab g bacteria negative feedback control long chain acyl acps long chain acyl acps directly control reductase activities consequently fasii biased catalyze forward products withdrawn system conversion including phospholipid triacylglycerol synthesis bacteria fas ii yields unsaturated fatty acids play key role bacterial membrane fluidity function unlike er desaturases present microalgae yeast introduce double bonds completed fatty acid chains expense oxygen bacterial fas ii system also desaturate fatty acids anaerobically require molecular oxygen faba introduces double bond 10-carbon intermediate forming cis-2-decenoyl acp it additionally isomerizes trans-3-decenoyl acp elongated fabb two genes faba fabb key players pathway occur together bacteria produce unsaturated fatty acids rhodococcus nocardia bacteria capable incorporating branched phenylic groups intracellular tag corresponding substrate fed medium for example nocardia globerula strain 432 accumulated tag containing branched fatty acid 4,8,12-trimethyltridecanoic acid cells fed pristane branched alkane tag subfraction containing phenyldecanoic acid residues detected cells r. opacus pd630 phenyldecane fed sole carbon source the enzymes involved esterification glycerol moiety probably act via sequential acylation sn-1 -2 -3 positions g3p removal phosphate group occurring final acylation step the first esterification catalyzed g3pat using either acyl coa acyl acp form lysophosphatidic acid a second acylation lysophosphatidic acid gives pa first branchpoint synthesis tag pl converted cdp dag precursor different pl species bacterial membranes dag also metabolic branchpoint divides phospholipid triacylglycerol formations acts precursor tag pc pe biosynthesis in addition dag also derived pl action phospholipase c distribution acyl groups hydroxyl groups glycerol backbone nonrandom demonstrated r. opacus pd630 the shorter saturated fatty acids esterified hydroxyl group position 2 whereas unsaturated fatty acids preferentially found position 3 this distribution bacterial tag different tag mammals plants longer unsaturated fatty acids found position sn-2 the final step wax ester triacylglycerol biosyntheses bacteria catalyzed ws dgat ws dgat encoded atfa related known involved formation tag eukaryotes it also shown ws dgat localized bacterial cytoplasmic membrane presumably attached inner leaflet membrane probably via ionic interactions for detailed review ws dgat reader referred work waltermann et al alternative pathways triacylglycerol synthesis involve dag bacteria also reported may involve enzyme similar reported dalquist yeast catalyzes formation tag transesterification acyl donor e.g. acyl coa pl this follows observations following double knockout ws dgat genes a. borkumensis cells still capable substantial triacylglycerol accumulation ld triacylglycerol wax ester lipid droplet biogenesis presumably begins allocation newly formed tag hydrophobic zone within ws dgat as time goes ws dgat attaches membrane cumulative synthesis advances presumably leading formation small triacylglycerol agglomerates depicted wltermann et al small lipid droplets sld sld apparently recruit pl membrane mechanism still well understood forming layer toward cytoplasmic side see figure 6 the agglomeration phospholipid coated sld appears microscopy oleaginous layer parallel membrane then accumulation sld given point gives birth ld coated pl detach oleaginous layer it suggested acquisition additional tag merging ld freshly synthesized oleaginous layer via coalescence and/or protein identified tada an interesting study ding co workers examined proteome rhodococcus sp rha 1 gram positive bacteria capable accumulating tag grown nitrogen abundant favoring lipid accumulation nitrogen depleted conditions favoring lipid accumulation using combination techniques including lc ms sds page immunoblot assays reported 228 lipid droplet associated proteins clustered primarily metabolism related enzymes transcriptional regulators ribosome proteins cell division related proteins interestingly identified two major proteins ro02104 pspa constituted 15% total lipid droplet protein according findings the structure predicted ro02104 resembles apolipoproteins structural proteins plasma lipoproteins mammals suggested mechanisms neutral ld formation bacteria adapted ref pha comprise complex class storage polyesters almost 150 different hydroxyalkanoic acids known constituents a wide variety gram positive well gram negative bacteria synthesize pha examples include pseudomonas bacillus ralstonia aeromonas rhodobacter among others pha divided two groups basis number constituent carbon atoms monomer units short chain length phas scl pha medium chain length phas mcl pha monomers scl pha 35 carbon atoms long compared 614 carbon atoms mcl pha addition scl pha stiff brittle high degree crystallinity whereas mcl pha flexible low crystallinity tensile strength melting point accumulation pha starts creation hydroxyalkanoate monomers three different biosynthetic pathways the first one involves incorporation two acetyl coas form acetoacetyl coa enzyme -ketothiolase this pathway creates hydroxybutyrate hb monomers exclusively used bacteria cupriavidus necator azotobacter beijerinckii see figure 7 second pathway involving de novo fatty acid biosynthesis monomers different lengths formed transesterifying 3-hydroxyacyl acp intermediate fas ii 3-hydroxyacyl coa presumably enzyme acyl acp coa transacylase encoded phag enzyme key link de novo fatty acid synthesis polyhydroxyalkanoate biosynthesis this pathway biotechnological interest helps generate monomers polyhydroxyalkanoate synthesis structurally unrelated simple inexpensive carbon sources glucose related simple sugars third embodiment monomers different lengths can also sourced fatty acid -oxidation pathway either conversion 2-enoyl coa r specific enoyl coa hydratase encoded phaj reduction 3-ketoacyl coa presumably fabg phab case the ability microorganisms synthesize particular form polyhydroxyalkanoate mainly due substrate specificity polyhydroxyalkanoate synthases these enzymes divided four classes depending structure specificity class enyzmes utilize coa thioesters 3-hydroxyalkanoates 3-has 4-has 5-has comprising three five carbon atoms members class ii display major specificity monomers ranging 6 14 carbon atoms enzymes classes consist single subunit average size 6070 kda encoded phac in contrast class iii class iv synthases encoded two genes phac phae phac phr respectively consist two subunits class iii members capable polymerizing preferably monomers ranging three five carbons yet utilize monomers six eight carbons well species allochromatium vinosum contain class iii synthases whereas class iv reported bacillus sp polyhydroxyalkanoate synthases share conserved cysteine catalytic site growing polyhydroxyalkanoate chain covalently attached the active site cysteine histidine aspartate constitute catalytic triad similar esterases two models currently exist may explain formation vivo polyhydroxyalkanoate ld also called granules carbonosomes micellar budding models the first one based assumption polyhydroxyalkanoate synthase present cell soluble enzyme distributed throughout cytoplasm once polymerization substrate molecules coa thioesters suitable hydroxyalkanoic acids starts nascent polyester chain converts initially soluble enzyme amphipathic molecule increasingly hydrophobic polyhydroxyalkanoate chains aggregate micelle like structure polyhydroxyalkanoate synthase remains attached surface granule therefore becomes insoluble see figure 8) model pl proteins surrounding layer would gradually become incorporated self assembled polyhydroxyalkanoate inclusion increases size model requires polyhydroxyalkanoate granule localized cytoplasm stages formation in contrast budding model assumes polyhydroxyalkanoate synthase associated inner face cytoplasmic membrane either inherently soon polyhydroxyalkanoate chain emerges enzyme case biosynthesis polyester would directed intermembrane space extending chains would accumulate eventually granules detach membrane polyhydroxyalkanoate specific surface proteins attached growing granules although micelle model supported fact polyhydroxyalkanoate granules produced vivo absence membranes recently emerging evidence favor budding model phas may constitute approximately 5% w w total cellular proteins play main structural role preventing polyhydroxyalkanoate granules aggregating preventing nonspecific attachment proteins polyhydroxyalkanoate granules in addition phasins presumably involved regulation polyhydroxyalkanoate synthesis polyhydroxyalkanoate degradation polyhydroxyalkanoate granule size control formation networks polyhydroxyalkanoate granule surface distribution polyhydroxyalkanoate granules cell division another important group proteins present external granule layer depolymerases responsible catalyzing polyhydroxyalkanoate breakdown this relevant step role polyhydroxyalkanoate accumulation survival mechanism absence suitable energy carbon sources demonstrated many years ago r. eutropha phazs investigated much less extracellular depolymerases mechanism intracellular native polyhydroxyalkanoate granules reutilized still well understood interestingly gene coding phazs located two copies phac1 phac2 polyhydroxyalkanoate synthase genes investigated bacteria accumulate mcl pha in contrast secreted depolymerases used bacteria assimilate pha present environment example nonliving cells proposed mechanism pha containing lipid droplet formation bacteria micelle model adapted ref 22 polyhydroxyalkanoate granule synthesis phasin production tightly regulated effectiveness transcriptional regulator phar genes encoding proteins homologous phar widely distributed among scl pha producing bacteria indicating important role regulation scl pha biosynthesis the discovery archaea domain 1977 revealed novel class microorganisms encountered exceptional ecological niches high thermophiles hyperthermophiles low psychrophiles temperatures acidic media acidophiles thermoacidophiles anaerobic atmosphere methanogens high salinity halophiles the unique chemical structure core membrane lipids part responsible adaptation hostile environments archaeal membrane lipids contrast bacteria eukaryotes made saturated chains containing methyl branches attached glycerol ether linkages stereochemistry 2-position glycerol opposite conventional mesophilic lipids ( review archaeal ether lipid structures reader referred work jacquemet et al moreover archaea synthesize fatty acyl esters common constituents ld instead lipids based isoprenoid chains therefore accumulation tag reported yet archaea despite differences however evidence polyhydroxyalkanoate accumulation first reported haloarchaea back 1972 the strains called time halobacterium sp dead sea later identified haloarcula marismortui since strains several haloarchaeal genera including haloferax halobiforma haloquadratum found accumulate pha bacteria archaea produce pha conditions nutrient limitation carbon available excess the mechanisms polyhydroxyalkanoate accumulation within archaea beginning understood work underway elucidate type proteins involved archaeal polyhydroxyalkanoate accumulation genes involved polyhydroxyalkanoate biosynthesis haloarchaea recognized recently polyhydroxyalkanoate synthase genes identified characterized haloarcula marismortui haloferax mediterranei these archaeal polyhydroxyalkanoate synthases composed two subunits phae phac homologous class iii bacterial polyhydroxyalkanoate synthases longer c terminal extension phac subunit the close similarity archaeal bacterial type iii polyhydroxyalkanoate synthase genes lack polyhydroxyalkanoate gene types archaea suggest archaeal pha originated horizontal transfer ancestral type iii gene bacterium some authors suggest transfer occurred already permian times genome wide analysis h. marismortui atcc 43049 revealed eight paralogues short chain dehydrogenase reductase responsible reduction acetoacetyl coa r)-3-hydroxybutyryl coa 3-hb coa monomer used polyhydroxyalkanoate synthase produce polyhydroxybutyrate phb another study demonstrated similar paralogue h. hispanica namely fabg1 encodes pha specific acetoacetyl coa reductase responsible providing 3-hb coa polyhydroxyalkanoate biosynthesis haloarcula species the authors concluded polyhydroxyalkanoate biosynthesis pathway ac coa catalyzed -ketoacyl thiolase acetoacetyl coa reductase polyhydroxyalkanoate synthase distributed bacteria likely also exists domain archaea nonetheless pointed phb accumulating haloarchaeal natrialba strain 56 enzyme activity acetoacetyl coa reductase -ketoacyl thiolase detected crude extract indicating different metabolic route toward production phb might employed polyhydroxyalkanoate synthase putative enoyl coa hydratase two structural phasin like proteins identified haloarchaeal polyhydroxyalkanoate granule surfaces the phasin like proteins haloarchaea share structural features bacterial phas presence hydrophobic domains high -helix content genome wide investigation 12 haloarchaea harbored phap gene most archaea found possess similar pha cluster five genes namely maoc gap12-phap phae phac organization h. mediterranei extensive existence pha gene cluster suggested indication evolutionarily conserved pha gene cluster unique haloarchaea a promising approach develop archaeal species industrial scale polyhydroxyalkanoate producers in particular several halophilic archaea advantages utilizing much cheaper carbon sources including waste materials well less strict sterilization requirements plus easier efficient methods polyhydroxyalkanoate extraction microorganisms provide exciting platform development lipid technologies course evolution developed elegant pathways synthesize wide array lipids providing versatile cost effective approach sourcing lipids virtually sectors industry the understanding biochemical cellular mechanisms lipid production accumulation secretion provide valuable insights innovations overcome hurdles microbial lipid utilization ongoing studies using different omics approaches provide holistic view flows interactions different metabolic pathways involved lipid accumulation tools next generation sequencing transcriptome analysis proteomics mass spectrometry already clearing missing links single cell lipid biosynthesis information permeate creation scaleup efficient processes it thus important project potential applications envision frontiers valuable toolset lead diverse fields lipid technology for example field biotherapeutics microbial based approaches flexibility construct platforms manufacture personalized lipid therapies starting simply lc pufa combinations appropriate metabolic phenotype individual eventually becoming complex selective personalized cancer interventions this approach personal medicine carry improved benefits treatment range conditions immunological diseases infections autoimmunities metabolic conditions diabetes cardiometabolic diseases microbiota dysbiosis ibs ibd microbial technologies also provide alternative pathway sourcing promising lipids fatty acids unavailable market present for example oil producing microbes considered appropriate vehicles foreign plant genes could cloned production commercially attractive fatty acids nervonic acid c24:1 15 obtained honesty lunaria used small amounts treatment particular neuropathies another example sterculic acid -(2n octylcycloprop-1-enyl)-octanoic acid considered treatment certain cancers bowel one promising example represented non methylene interrupted fatty acids e.g. c20:3 5 11 14 obtained juniperus chinensis seed oil known reduce amount arachidonic acid certain phospholipid pools thus act alter eicosanoid signaling field energy biofuels understanding mechanisms group microorganisms generates highly combustible lipids foster production cost effective fuels sustainable processing improved performance it yet tested whether biochemical mechanisms amphipathic lipid secretion present microorganisms would work secretion neutral lipids this concept brought practice significantly reduce processing costs render high quality combustible lipids production biofuels case food industry microbial based approach allow food companies expand core businesses creating new product portfolios current byproducts two promising examples production cocoa butter analogues production high value oils spent agricultural materials field biomaterials microbial lipids already used producing biosurfactants bioplastics replacing synthetic analogues due improved biodegradability reduced cost products metabolix pha biomer examples microbial derived plastics gaining momentum market their specific modes action low toxicity relative ease preparation widespread applicability increasing use applications emulsifiers wetting foaming agents functional food ingredients detergents petroleum petrochemicals environmental management agrochemicals cosmetics pharmaceuticals commercial laundry detergents mining metallurgical industries overview microbial surfactant applications see mukherjee the scope applications goes extent petroleum extractive industry already researching use microbial lipid based biosurfactants increasing oil recovery yields subterranean depots the great era chemistry culminating restructuring human condition 20th century defined principles reductionism simplicity in contrast 21st century heralds era complexity inherent biological diversity information content microorganisms key adding value industrial chains search performed july 6 2013 terms microbial lipids u.s patent publication since 2008 showing increasing interest generation intellectual property around area research the estimated patents end 2013 according current trend around 1420 almost doubling number registered 2009 the next step microbial lipid technology integration processes applications generate comprehensive sustainable solutions the immediate challenge combine desired metabolic pathways present different species strains generate superior microbial species benefits include improved yields targeted lipidomic profiles structural features synthesize sustainable cost effective way lipid structures necessary satisfy breadth needs 21st century industry for example appropriate integration microbial based lipid technologies allow delivery smart biofuels even personalized edible oils derived microorganisms reporter equipped biodegradable containers also derived microorganisms currently used packaging material commercial edible oils polyethylene terephthalate virtually nondegradable plastic appropriate use microbial pha could possible see facility production high value microbial oils rich combination lc pufa along production polyhydroxyalkanoate based bottles commercialization furthermore additional microbial biotechnology platforms integrated transform byproducts either biomass nutrients make process sustainable even another portfolio high value products way increase business profitability figure 10 conceptual flowchart integral sustainable microbial based edible oil process microbial lipid technologies valuable toolset available future generation scientists help push boundaries production solutions ultimately toward sustainable society

in recent years attention has been focused on the utilization of microorganisms as alternatives for industrial and nutritional applications . considerable research has been devoted to techniques for growth , extraction , and purification of high - value lipids for their use as biofuels and biosurfactants as well as high - value metabolites for nutrition and health . these successes argue that the elucidation of the mechanisms underlying the microbial biosynthesis of such molecules , which are far from being completely understood , now will yield spectacular opportunities for industrial scale biomolecular production . there are important additional questions to be solved to optimize the processing strategies to take advantage of the assets of microbial lipids . the present review describes the current state of knowledge regarding lipid biosynthesis , accumulation , and transport mechanisms present in single - cell organisms , specifically yeasts , microalgae , bacteria , and archaea . similarities and differences in biochemical pathways and strategies of different microorganisms provide a diverse toolset to the expansion of biotechnologies for lipid production . this paper is intended to inspire a generation of lipid scientists to insights that will drive the biotechnologies of microbial production as uniquely enabling players of lipid biotherapeutics , biofuels , biomaterials , and other opportunity areas into the 21st century .

large elastic arteries central region medium sized muscular arteries two functions i.e. act low resistance conduits flow pulsation buffers 1 moreover reduction buffering capacity may increase systolic blood pressure bp left ventricular afterload pulsatile flow capillary beds reduce diastolic contribution blood flow coronary artery 2 arterial stiffness determined properties arterial wall matrix vascular smooth muscle tone may changed immediately alteration vascular smooth muscle tone caused exercise 3 exercise training induced alterations arterial stiffness would great benefit coronary artery disease cad would potentially reduce myocardial oxygen demand ischemic symptoms 4 present study investigated effect short duration exercise arterial stiffness patients coronary artery disease repeatedly measuring brachial ankle ba pulse wave velocity pwv established non invasive means assessing arterial stiffness fifty patients underwent percutaneous coronary intervention cad group 50 patients without history cardiovascular disease control group referred treadmill testing physicians mostly due atypical chest pain prospectively enrolled patients positive myocardial ischemia treadmill tests comorbid conditions limited exercise excluded ensure adequate exercise duration thus patients residual ischemia pci excluded cad group patients overt clinical coronary artery disease excluded control group brachial ankle pwv measured using automatic pwv measurement system form pwv abi colin komaki japan brachia ankles treadmill exercise testing this instrument simultaneously records bapwv brachial ankle blood pressures left right sides provides electrocardiogram heart sounds baseline measurements each subject performed symptom limited treadmill exercise testing according bruce protocol 10 min completion exercise bapwv remeasured heart rate blood pressure bp continuously monitored exercise analysis statistical analysis performed using sas sas system windows 9.00 cary nc u.s.a chi square test unpaired test the paired test used compare pre- post exercise results independent test used compare effect exercise groups multiple linear regression analysis used evaluate associations bapwv changes independent variables stepwise regression used select independent variables fifty patients underwent percutaneous coronary intervention cad group 50 patients without history cardiovascular disease control group referred treadmill testing physicians mostly due atypical chest pain prospectively enrolled patients positive myocardial ischemia treadmill tests comorbid conditions limited exercise excluded ensure adequate exercise duration thus patients residual ischemia pci excluded cad group patients overt clinical coronary artery disease excluded control group brachial ankle pwv measured using automatic pwv measurement system form pwv abi colin komaki japan brachia ankles treadmill exercise testing this instrument simultaneously records bapwv brachial ankle blood pressures left right sides provides electrocardiogram heart sounds baseline measurements each subject performed symptom limited treadmill exercise testing according bruce protocol 10 min completion exercise bapwv remeasured heart rate blood pressure bp continuously monitored exercise analysis statistical analysis performed using sas sas system windows 9.00 cary nc u.s.a chi square test unpaired test the paired test used compare pre- post exercise results independent test used compare effect exercise groups multiple linear regression analysis used evaluate associations bapwv changes independent variables stepwise regression used select independent variables the clinical characteristics laboratory findings study subjects shown table 1 mean age higher cad group cad group contained male patients hypertensive patients control group the cad group lower mean left ventricular ejection fraction lower mean ldl cholesterol higher bapwv shorter treadmill exercise duration control group the patients cad took medicines aspirin -blockers renin angiotensin system inhibitors hmg coa reductase inhibitors baseline bapwv values found correlate significantly age systolic bp sbp mean arterial pressure map diastolic bp dbp table 2 brachial ankle pwv values significantly lower 10 min exercise baseline groups however decrease significantly larger cad group thus bapwv cad group initially higher control group became similar exercise control group sbp map were significantly lower 10 min exercise baseline dbp cad group map significantly lower 10 min exercise baseline table 3 whereas sbp marginally lower dbp significantly different heart rates higher 10 min exercise baseline groups table 3 multivariate analysis cad group showed larger decrease bapwv exercise control group adjusting age bmi sbp map map reduction baseline bapwv table 4 arterial stiffness increases left ventricular afterload alters coronary perfusion 5 independently associated target organ damage increased cardiovascular morbidity mortality 6 brachial ankle pwv simple marker arterial stiffness 7 8) mainly reflects large artery stiffness although also reported reflect endothelium dependent peripheral vasodilation changes vascular wall distensibility may induced changes quality quantity vascular fibrous matrix e.g. elastic fibers collagen fibers media organic factor changes smooth muscle tone functional factor elastic fiber primary determinant vascular distensibility physiologic conditions 9 10 moreover elastin collagen compositions arterial walls represent chronic component arterial stiffness changes years thus unlikely short duration aerobic exercise changes structural components 11 instead arterial compliance probably altered short terms even acutely via modulation sympathetic adrenergic tone smooth muscle cells arterial walls 12 affected autonomic nervous activity vasoactive agents derived vascular endothelial cells e.g. nitric oxide prostacyclin endothelium derived hyperpolarizing factor 13 particular production important potent endothelium dependent vasodilator reduces vasoconstrictor response -adrenergic receptor stimulation 14 moreover pulsatile flow aorta associated exercise training might evoke acute release upregulate production increase productions vasodilatory factors 15 17 cad patients endothelial dysfunction develops secondary reduced production early reactivation reactive oxygen species 18 present study bapwv higher cad group baseline was found reduced significantly 10 min exercise groups decrease larger cad group difference bapwv observed two groups exercise these observations suggest short duration exercise affects arterial stiffness even patients cad we speculate mechanism involved may related restoration equilibrium production inactivation reactive oxygen species also appears primary mechanism underlying exercise training mediated perfusion improvements cad patients 18 bp age reported important determinants bapwv healthy individuals 7 19 consistent findings present study exercise duration significantly different two groups might confounding factor however exercise duration longer proportional change bapwv smaller control group moreover exercise duration correlated absolute relative change bapwv data shown thus probable different exercise duration significant confounding factor mentioned cad group members taking medications unclear whether findings suggest patients stable cad potential reverse arterial stiffness exercise despite presence disease whether reflect effect medications taken aspirin -blocker renin angiotensin system inhibitor hmg coa reductase inhibitor lower level ldl cholesterol cad group probably due hmg coa reductase inhibitors however considering higher baseline bapwv value cad group appears medications completely normalize arterial stiffness cad patients short duration exercise seems independently improve arterial stiffness immediately majority patients cad group small number persons control group taking one drugs influence endothelial functions statistical adjustment feasible data complete exclusion effects medication probably performed experimental design normal control group given medications still rather puzzling cad patients showed prominent reduction bapwv control group resulted similar level bapwv exercise this apparent reversibility arterial stiffness might related duration extent atherosclerosis discussed above we speculate relatively early course cad may reversible component related endothelial dysfunction less irreversible component structural change vascular wall this group patients higher baseline bapwv due endothelial dysfunction much functional abnormality might reversible intervention short duration exercise study patients cad group undergone percutaneous coronary intervention findings residual ischemia excluded exercise test this exclusion may resulted selection patients lower risk less extensive coronary artery disease however limitation study enough information duration extent cad patient group also possible investigate speculation measuring biomarkers production oxidative stress if markers central blood pressure 20 21 measured different findings might found previous studies aerobic exercise improved peripheral arterial stiffness central arterial stiffness 22 central arterial stiffness better prognostic factor peripheral arterial stiffness 23 however mean peripheral arterial stiffness meaningless shown prognostic value another study 24 also shown correlated central arterial stiffness 8) likely central arterial stiffness better index peripheral arterial stiffness measured bapwv convenient alternative another weakness study data heart rate blood pressure time pwv measurement because variables acutely influence bapwv potential source confounding however assume heart rate blood pressure probably different baseline 10 min post exercise though study showed immediate short term response exercise evidence scarce whether repeated short duration exercise may result persistent long term improvement arterial stiffness further study needed question considering frequent short bout exercise discussed practical alternative conventional long duration exercise 25 26 conclusion in present study prospectively investigated effects short duration exercise arterial stiffness measuring bapwv patients without cad a significant reduction bapwv observed 10 min short term aerobic exercise groups cad group decrease prominent these observations suggest short duration exercise training may effective improving arterial stiffness even patients coronary artery disease least short term clinical study needed see whether repeated short duration exercise improve arterial stiffness cad patients long term

arterial stiffness is an important contributor to the development of cardiovascular disease . we investigated the effect of short duration exercise using the treadmill test on arterial stiffness in the presence of coronary artery disease . we enrolled patients with and without coronary artery diseases ( cad and control group , 50 patients each ) referred for treadmill testing . brachial - ankle pulse wave velocity ( bapwv ) were measured before and after treadmill testing . values of bapwv were significantly reduced at 10 min after exercise in both groups , more in the cad group than in the control group ( baseline bapwv and post - exercise change [ cm / sec ] : 1,527245 and -132155 in the cad group , 1,439202 and -7793 in the control group , respectively , p for change in each group < 0.001 , p for difference in changes between the two groups < 0.001 ) . these findings persisted after adjusting for age , body mass index , systolic blood pressure , mean arterial pressure ( map ) , map decreases , and baseline bapwv . significant post - exercise bapwv reductions were observed in both groups , and more prominently in the cad group . this finding suggests that short - duration exercise may effectively improve arterial stiffness even in patients with stable coronary artery disease .

cataract surgery regarded widely performed surgical procedure demand exists continued innovation technology the latest advances evolved application well defined principles current surgical goals patient expectations for example femtosecond laser technology emerged fifty years employing laser technology ophthalmology theodor scheimpflug described principle scheimpflug images 1904 actually austrian army captain spent life work dedicated designing methods tools create maps depicting aerial photography application principles ophthalmology last years advanced understanding corneal biomechanics the latest highlights technology include advances preoperative intraoperative diagnostics femtosecond laser assisted cataract surgery flacs new generation intraocular lenses iols more ever patients desire reduce dependence spectacles cataract surgery physicians access advanced diagnostics better quantify conditions dry eye light scatter posterior corneal astigmatism mcdonald recently reported postoperative prevalence dry eye related symptoms approximately 88% analysis optimization dry eye preoperatively postoperatively beneficial impact visual outcomes cataract surgery therefore increased interest among ophthalmologists utilize objective measurements assess ocular surface exists the acutarget hd visiometrics sl spain assesses objective scatter index objectively evaluate dry eye disease severity using degradation image quality time figure 1 the keratograph oculus germany noninvasively measures tear break time tear meniscus height meibography providing functional qualitative analysis corneal surface tear film 8 9 the tearlab osmolarity system tearlab corporation san diego california uses small tear sample measure tear osmolarity using microelectrode compared commonly used diagnostic tests dry eye disease test results better predicting dry eye severity lipiflow tearscience morrisville north carolina combines heat eyelid pressure treat dry eye disease due meibomian gland dysfunction recent studies showed consistent improvement meibomian gland function 12 months treatment evaluation optical quality also aids decision making corneal lens based procedures the c quant oculus germany optikgenrate gmbh assesses straylight subjectively utilizing compensation comparison method the acutarget hd visiometrics sl spain uses double pass system measure point spread function psf modulation transfer function mtf strehl ratio intraocular scattering light these data allow clinicians evaluate quality patient optical system objectively another objective functional diagnostic salzburg reading desk srd vision vienna austria allows measurement variable read print sizes distances differences contrast sensitivity luminance both anterior posterior corneal astigmatism taken account iol planning particularly patients desiring astigmatic correction inaccuracies arise posterior corneal astigmatism measured based assumption fixed ratio relationship anterior curvature the cassini corneal shape analyzer optics bv hague netherlands new topographer uses led ray tracing technology 700 diode lights measure anterior posterior corneal astigmatism these advances cylinder axis measurement precision useful preoperative planning toric iol implants postrefractive surgery patients 1517 patients history corneal refractive surgery expect reduced dependence spectacles cataract surgery the optiwave refractive analysis ora alcon fort worth tx uses wavefront interferometry produce fringe pattern distortions pattern translated refractive values aphakic pseudophakic readings figure 2 studied mean postoperative residual refractive astigmatism patients receiving toric iols power selection aided intraoperative aberrometry surgeons altered cylindrical power 24% time spherical power 35% time patients 2.4 times likely less 0.50 residual refractive astigmatism intraoperative aberrometry used in contrast huelle et al published study aphakic spherical equivalent- se- based iol formulas generated repeated intraoperative wavefront aphakic measurements se the agreement repeated aphakic se readings ranged 0.69 diopters 0.66 diopters the authors concluded measurement precision limiting reliability intraoperative aberrometry application routine cataract surgery however may useful guiding limbal relaxing incision enhancements resulted need fewer subsequent laser enhancements this technology particularly useful postrefractive patients astigmatism uncertainty corneal pathology other intraoperative inconsistencies include cyclotorsion variable anterior chamber depth intraocular pressure variability wound hydration use viscoelastic device versus balanced salt solution although limitations may exist quality measurement precision future technology promising the use electroretinogram erg well described may novel application refractive cataract surgery richard mackool described use flash erg testing office based electroretinography diopsys pine brook new jersey preoperative cataract evaluation it provide objective evaluation macular function could useful influencing lens selection patients conditions epiretinal membrane diabetic retinopathy age related macular degeneration more studies evaluating ergs preoperative cataract assessment need done assess value implications noninferiority established relative manual cataract surgery reports suggested superiority relative manual methods potential advantages include customized corneal incisions capsulotomy position precision shape size capsulotomy custom lens fragmentation patterns endothelial cell loss reduction better refractive stability predictability after food drug administration fda approval laser assisted capsulotomy lens fragmentation 2010 five platforms released lensx alcon fort worth tx lensar lensar orlando fl catalys abbott optimedica north chicago il victus bausch lomb rochester ny ldv z8 ziemer port switzerland figure 3 the docking process using femtosecond laser eye interface uses suction ring stabilize eye thereby allowing imaging laser delivery clear optical pathway considerations docking include complete coupling patient comfort intraocular pressure elevation minimal distortion anatomy avoid disruption beam path study using alcon lensx platform compare curved direct contact modified soft interfaces softfit alcon mayer et al showed redocking unnecessary modified soft interface used even though cases resulted incomplete incisions requiring manual opening schultz et al found significantly fewer intraocular pressure elevations docking using liquid interface liquid optics interface catalys precision laser system comparison flat curved interfaces docking necessary step femtosecond laser technology laser incisions optional flacs comparatively analyzed femtosecond laser incisions manual incisions cited better tunnel morphology flacs incisions flacs theoretically decreases endothelial cell loss relative manual techniques reducing use ultrasound energy however krarup et al compared endothelial cell loss rates phacoemulsification flacs showed differences modalities published similar findings cite difference favor flacs limited early postoperative period they also showed laser corneal incisions may influence endothelial cells may disturbance postoperative inflammatory response laser application 3032 new surgical techniques combination advanced lens fragmentation patterns allow lens extracted aspiration mechanism may reduce endothelial cell loss the size shape position capsulotomy theoretically lead predictable lens position enhancing uniform capsule optic overlap thereby reducing incidence lens tilt leading overall better effective lens position visual outcome figure 4 recently toto colleagues found difference prediction error comparing traditional phacoemulsification flacs find higher refractive stability iol centration flacs this similarity prediction error may consequence unexplored potential iol calculations algorithms ma approached prediction true lens position using algorithm based oct anterior segment 3-d reconstruction this prediction model could great potential consistent alliance oct measurements flacs provide precise outcomes this particularly relevant premium iols lower tolerance threshold minor unanticipated miscalculation decentration okulix tedics peric joher gbr dortmund germany innovative software program calculates iol power using ray tracing combined corneal topography evaluated accuracy post lasik eyes comparison camellin calossi shamas pl haigis l formulas double k srk method they reported technology provides sufficient predictability outcomes postrefractive myopic lasik even though small hyperopic shift tendency noted study g6 lens professional ziemer port switzerland optical biometer integrates placido rings dual rotating scheimpflug camera well optical coherence tomography based scan single device shin et al compared accuracy lenstar ls 900 haag streit koeniz switzerland intraocular lens iol power calculation they noted axial length lens thickness lt white white wtw values statistically different thus even though high repeatability present iol powers statistically different two devices values provided galilei g6 interchangeable lenstar clinical setting the goal appropriate iol selection provide best visual outcome meets patient individualized goals expectations variability materials optical properties designs important factors consider patient specific selection iol advancements iol technology aim improve visual functionality creating customized iols modifying optical power postoperatively the concept adjustable iols involves correction residual refractive error postoperatively customization lens implantation this new paradigm iol manufacturing may subdivided two major categories modular multicomponent category requiring separate intraocular procedure another category optic adjusted postoperatively secondary device the first category includes multicomponent iols clarvista harmoni modular iol system clarvista medical aliso viejo ca omega lens omega ophthalmics lexington ky infinite vision iol infinite vision optics france mechanically adjustable iols acritec ar-1 pc iol acri.tec hennigsdorf germany the second category includes magnetically adjustable iols university missouri rolla rolla eggleston adjustable lens st louis mo light adjustable iols calhoun vision pasadena ca perfect lens perfect lens llc irvine ca the latter novel platform adjusted femtosecond laser based concept refractive index shaping its mechanism involves use infrared light polymerize photosensitive silicone macromers results changes lens morphology optical properties new generation optics extended depth focus multifocal rotational symmetry asymmetry accommodating capabilities offers promising strategies advance functional vision refractive cataract surgery the tecnis symfony amo extended depth focus iol works correcting chromatic aberration using diffractive optics reduces glare halo symptoms classically associated conventional multifocal iols multifocal lenses bifocal trifocal designs include rotationally asymmetric lentis mplus topcon europe medical bv netherlands rotationally symmetric finevision physiol liege belgium lisa zeiss oberkochen germany found trifocal lenses provide satisfactory intermediate vision without compromising near far distance visual acuity the fluidvision iol powervision belmont ca silicone oil inside lens moves response ciliary contraction forces an electroactive iol liquid crystal sensitive electric current also development sapphire autofocal iol elenza roanoke va dual accommodating iols designed sulcus placement include dynacurve iol nulens israel lumina iol akkolens netherlands the injectable polymer smartiol medennium irvine ca thermodynamic pliable capsule filling iol bag filling technology development the future refractive cataract surgery exciting time new technologies may standard care refinements latest technology flacs parallel advances provide surgeons potential perform even safer predictable effective surgery

technology in cataract surgery is constantly evolving to meet the goals of both surgeons and patients . recent major advances in refractive cataract surgery include innovations in preoperative and intraoperative diagnostics , femtosecond laser - assisted cataract surgery ( flacs ) , and a new generation of intraocular lenses ( iols ) . this paper presents the latest technologies in each of these major categories and discusses how these contributions serve to improve cataract surgery outcomes in a safe , effective , and predictable manner .

epilepsy common serious neurological disorder young people affecting nearly 3.4 million individuals europe societal costs considerable individuals medically intractable seizures make third epilepsy population eu15 billion spent annually treatment epilepsy europe financial burden comparable lung breast cancer combined 2 3 recent irish prevalence study estimated 40,000 children adults ireland disorder gives point prevalence 0.9% line industrialized nations studies last decade shown majority patients epilepsy urgently admitted secondary tertiary care institutions mostly ed point history illness significant proportion require multiple visits furthermore symptomatic seizures secondary acute medical surgical illness alcohol drug intoxication brain trauma stroke add burden seizure pathology ed finally range mimic disorders psychogenic nonepileptic seizures pnes blackouts caused impaired vascular responsiveness contribute diagnostic therapeutic challenges despite heavy burden seizures ed international studies suggest majority patients referred unnecessarily admission acute treatment seizures often ineffective indicating seizure admissions cause unnecessary medical intervention delayed diagnosis prolonged length stay 5 6 beginning 2006 first sought determine impact emergency seizure admissions resources large irish teaching hospital on basis two baseline audits identified number areas could improve quality service patients seizures employment evidence based seizure care pathway emergency department ed acute medical admissions unit amau this report preliminary quality safety metrics accrued intervention 12-month period november 2008 2009 the study consisted three parts retrospective audit admissions seizures emergency department 2004 measurement quality safety metrics implementation evidence based seizure care pathway november 2008 november 2009 the first study group restricted patients discharged 2004 diagnosis seizure convulsion these patients identified hospital patient enquiry hipe system national coding system hospital discharges ireland identified 341 patients epilepsy seizure primary reason admission particular attention paid investigations diagnosis specialist referral follow the charts also examined designated necessity admission an admission deemed medically necessary history prolonged 5 minutes clustered 2 events history status epilepticus 30 minutes seizure activity abnormal neurological exam 90 minutes arrival ed hipe system used determine patients readmitted died one year period following admission the second study group represented patients attended ed event deemed likely seizure aftermath one calendar month 2006 patients presented complaint seizure weakness confusion head injury dizziness collapse unknown cause examined possible inclusion study similar vein to part 1 study attention paid investigations diagnosis referral follow patients after baseline audits seizure care pathway designed implemented neurology service cooperation ed staff the pathway required early rapid access ambulatory follow patients fit discharge ed rapid access clinic rac established run existing epilepsy nurse specialist ens in addition patients discharged wards ed clinic also reviewed new referrals gps patients established diagnosis epilepsy exacerbations illness designed avoid ed referrals education sessions provided ens also provided phone help line e mail service facilitate follow care patients presenting ed admitted amau overnight seizures seen seizure service fellow patients managed according locally designed evidence based seizure care pathway figure 1 the pathway clearly laid criteria admission discharge follow the pathway designed reference published international guidelines care scottish intercollegiate guideline network sign 2003 8) national institute clinical excellence nice 2005 9 all patients seen seizure service provided printed cards full details phone e mail contact length stay time ct mri eeg analysed using kruskal wallis test nonparametric data the rate representation analysed using pearson chi square test times follow up the reduction admission rates analysed using chi square test yates correction during 2004 hipe data identified 341 admissions specific diagnosis epilepsy seizure total 11,721 admissions causes ed in 50 charts randomly selected group 34% patients previously documented diagnosis epilepsy presentation investigations performed included ct brain 84% mri brain 28% eeg 56% median delay ct mri eeg 2 days 5 days 5 days respectively ambulatory follow evenly divided neurology 28% general medicine 28% general practitioner 20% 24% follow whatsoever 23/50 patients 46% represented emergency department seizures next 12 months using criteria necessity admission we concluded 36% could discharged earlier ed appropriate investigations neurological opinion available timely manner of 341 patients diagnosis epilepsy 10 died subsequent year one presented status epilepticus died direct result epilepsy 20 19% 102 patients included study previously established diagnosis epilepsy of special investigations required epilepsy ct brain one conducted day admission 5.8% cases neither mri eeg performed patient day presentation ultimately 34 admitted 14 41% eeg 21 61% patients ct brain 4 12% mri brain median delay eeg 2 days ct brain 1 day mri 2.5 days no data collected mortality follow designed primarily gather data patients presenting ed 2009 276 admissions primary diagnosis epilepsy 12 607 admissions causes ed 350 patients presented ed november 2008 november 2009 seizures forms collapse referred seizure team assessment seizure care pathway applied 97 patients established history either generalised focal epilepsy 72 patients epilepsy associated significant medical surgical comorbidities 34 patients referred undefined collapse 12 patients referred confusion 4 patients myoclonic jerks of 181 eegs requested intervention study period 99 55% done day 66 36% done within 1 3 days 16 9% done outpatients within 4 weeks 150 patients ct brain requested 140 93% performed day median delay ct brain zero days 2008 2009 68 19% total cohort 350 mr imaging brain requested same day mr brain acquisition however went 0% 2004 7.2% 2008 2009 another 8.8% cases done within 1 3 days of 57 patients nonepileptic collapse 12 eeg 18 patients ct brain one patient mri brain performed 110 patients 31.4% seen rapid access clinic rac 64 patients 18% seen subspecialty epilepsy clinic median follow time stable group 8 weeks 6 patients 1.71% followed hospitals 31 8.9% total study group readmitted 12-month follow period patients seen study period 19 5.4% ) the neurological causes death herpes encephalitis obstructive hydrocephalus nonconvulsive status epilepticus subdural haematoma three patients died direct seizure related causes two nonconvulsive status epilepticus one convulsive status epilepticus intervention study period patient discharged ed within 2 days admission died the number admissions epilepsy seizure dropped significantly 341 11,721 2.9% 2004 276 12 607 2.2% 2009 p 0.0006 there significant reduction median length stay first 2 audits intervention study p 0.001 figure 2 summarises median length stay 3 studies significant improvement time diagnostic investigations ct brain mri brain electroencephalography first two audits intervention study p 0.001 p 0.048 p 0.001 figure 3 summarizes median delay investigations admitted patients across three studies significant reduction follow times median 16 weeks 5 weeks p 0.001 figure 4 shows median times follow baseline audit 2004 intervention study 2008 2009 significant reduction readmission rates 45.1% 8.9% p 0.001 figure 5 shows change readmission rates 2004 intervention study 2008 2009 the use care pathways modern healthcare delivery somewhat controversial since expected gains always forthcoming for instance cochrane review implementation care pathway stroke rehabilitation endorse benefit patient care nevertheless given highly variable care delivered ed relation seizure care felt care pathway could provide much needed improvement the aim study demonstrate improvements patients presenting ed seizures related disorders without compromising safety use evidence based seizure care pathway the main quality indicators measured requirement admission median length stay time diagnostic tests specialist follow readmission rates mortality the main findings study utilization seizure care pathway ed amau reduce unnecessary admissions safely discharge patients early follow significant impact reducing representation rates timely decision support effect significantly reducing time diagnostic tests particularly eeg thus reducing median length stay 3 days all outcomes significant statistically support use care pathways patients presenting ed seizures without increase mortality it suggested admission seizure patients warranted patients high risk events remain drowsy comatose following period ed neurological exam reveals signs indicative underlying lesion treatable infective cause however international studies suggest majority patients referred unnecessarily house medical neurological services admission 5 6 9 10 original retrospective audit part 1 using set criteria based indications admission determined 36% could avoided admission the intervention study showed stability figure 31% patients actually discharged ed 8.5% within 24 hours admission comparison hipe data 2004 2009 following implementation seizure care pathway shows reduction number admissions specific diagnosis epilepsy 2.9% 341 total hospital admissions 2.2% 276 this despite increase overall admission rates ed 7.56% 11,721 2004 12,607 2009 had admissions continued rate 2.9% seizure care pathway place would resulted 365 epilepsy related admissions 2009 suggesting 89 epilepsy specific admissions avoided due implementation seizure care pathway 2008 2009 consider median los 4 days without seizure care pathway applied would resulted 356 bed days saved combining figure 478 bed days saved overall median reduction los 2 days total 834 projected bed days saved one 12-month period direct result implementation seizure care pathway the reduction median length stay 4 days 2004 5 days 2006 2 days intervention study 2008 2009 made possible emphasis upon early safe discharge pathway eye reduce bed occupancy days establishment separate rapid access follow clinic made routine even unscheduled early follow possible increased safety ease early discharge reductions length stay secondary implementation care pathways reported areas heath care case patients seizures 1113 discharged patients the readmission rates show significant drop 47% 8.9% 2004 2008 2009 it possible unobserved bias meant patients likely return seen 2004 audit may due combination timely effective inpatient management including delivery inpatient ens education provision phone e mail advice services use rapid access ambulatory clinics exacerbations existing epilepsy improved timely communication primary care teams the reduction median follow time 16 weeks 2004 5 weeks 2008 09 may also helped reducing admissions ed relation overall safety seizure service emphasis reducing admissions length stay found three 19 deaths study group directly attributable epilepsy 2004 one death attributable epilepsy slight increase epilepsy related deaths excess mortality patients discharged ed within 2-day median length stay window accurate diagnosis classification seizure type essential provision quality patient care good control eeg described important aid evaluation seizure patients relation baseline audit the median waiting time eeg 5 days demonstrating patients tested soon seizure period such waiting times observed baseline audits suggested eeg contributed significantly length stay individual patients intervention study involvement early specialist opinion allowed streamlining required eeg occurred day admission approximately 54% study group total 90% test done 3 days less neuroimaging essential identify structural lesions may result development seizure disorder despite strong consensus within literature performing mri ct especially focal seizures 5 15 16 ct preferred modality neuroimaging within study groups this largely ease access ct mri institution changed significantly since 2004 84% retrospective sample ct performed whilst 28% mri intervention study 42% patients had a ct requested reflecting fact number cases either established epilepsy indeed eeg proven primary generalized epilepsy pathway able obviate need ct an improvement time brain imaging demonstrated intervention study 93% patients ct day request unusually mean wait time mri brain increased 2009 compared 2004 this believe due steadily increasing demand mri brain acute presentations seizure years coupled limited availability mri resource one magnet open office hours this ameliorated lately addition second scanner outlined sign nice guidelines adults epilepsy specialist expert opinion ambulatory setting including regular structured annual review retrospective 2004 audit mean time neurology clinic follow was the lack decision support expert neurological opinion two thirds 2004 study group may contributed longer length stay group may delay diagnosis pursuing appropriate investigations only 28% group followed neurology service outpatient clinics speculate may contributed return ed presentations readmission rates the intervention study suggests decision support embodied seizure care pathway early follow contributed significantly reduction readmission rates retrospective chart reviews formed basis initial baseline data hazardous deciding service provision due unreliability potential bias data furthermore initial analysis relatively small number charts study complimented retrospective audit short prospective audit validated retrospective audit independently verified characteristics patients admitted epilepsy course hospital the intervention study large enough draw conclusions comparison two prior audits must done caution patient characteristics may biased smaller studies this exemplified significant differences readmission rates two audits intervention study difference undoubtedly due service improvements finally system wide change decisions contributed improved quality metrics would ideally made ed acute medical staff specialist nurses applying principles seizure care pathway this study pathway implemented specialist service thus generalizability results unclear however lack widespread use pathways seizure presentations requited proof principle study required future study focus use integrated care pathway icp without resource necessarily specialist ed amau interface it appears large proportion seizure related presentations referred house medical neurological teams admission due large part lack access appropriate algorithms admission decision support early treatment diagnostic investigation difficulty obtaining outpatient investigations specialist epilepsy follow reasonable length time this study conducted 12 month period using baseline data collected 2004 2006 shows using evidence based care pathway early specialist advice follow along directed patients education range communication tools aid self management telephone e mail advice contribute significantly quality value improvements epilepsy care without compromising safety we recommend study programme embedded continuous improvement cycle prospective audit

aim . to evaluate the utility of a seizure care pathway for seizure presentations to the emergency department ( ed ) in order to safely avoid unnecessary admission and to provide early diagnostic and therapeutic guidance and minimize length of stay in those admitted . methods . 3 studies were conducted , 2 baseline audits and a 12-month intervention study and prospective data was collected over a 12-month period ( nov 2008 - 09 ) . results . use of the pathway resulted in a reduction in the number of epilepsy related admissions from 341 in 2004 to 276 in 2009 ( p = 0.0006 ) ; a reduction in the median length of stay of those admittedfrom 4 - 5 days in the baseline audits to 2 days in the intervention study ( p 0.001 ) ; an improvement in time to diagnostic investigations such as ct brain , mri brain and electroencephalography ( p 0.001 , p 0.048 , p 0.001 ) ; a reduction in readmission rates from 45.1% to 8.9% ( p 0.001 ) ; and an improvement in follow - up times from a median of 16 weeks to 5 weeks ( p < 0.001 ) . from a safety perspective there were no deaths in the early discharged group after 12 months follow - up . conclusion . the burden of seizure related admissions through the ed can be improved in a safe and effective manner by the provision of a seizure care pathway .

getting university ethics committee approval prospective case control study conducted all patients admitted boo ali hospital zahedan southeastern iran clinical suspicion pulmonary tuberculosis non tuberculous pulmonary infections september 2006 august 2007 included comparison one hundred seventy eight patients included study 67 documented cases ptb 111 patients pulmonary infections tuberculosis control group mostly acute pneumonia acute exacerbation chronic bronchitis figure 1 multiple sputum samples usually collected single patient process tb diagnosis patho tb test ziehl neelsen staining culture mycobacterium tuberculosis done specimens polymerase chain reaction based detecting 123-bp dna segment belonging insertion sequence is6110 specific mtb done 42 sputum smear negative samples analysis data performed confirmed ptb patients 63 culture positive 4 pcr positive cases patients pulmonary infections negative acid fast bacilli afb smear culture results included control group forty three patients tb group sputum smear positive rest sputum smear negative we used patho tb kits anda rt mycobacteria patho tb anda biologicals strasbourg france developed collaboration pasteur institute iran the patho tb test performed manufacturer brochure following stages 1- sample decontamination neutralization sputum sample treated decontamination kubica method 2 ml sample put 50 ml conical centrifuge tube an equal volume solublization decontamination solution added mixed well vortexing incubating 20 minutes orbital turning agitator at least 0.2 ml aliquot suspended pellet kept perform rapid patho tb test rest used seed culture perform required diagnostic test 2- suspended pellet treatment suspended 0.2 ml aliquot diluted 1 5 volumes dns subsequently equal volume negative control rehydrated positive control transferred two boiling resistant microtubes dissolving solution the rapid patho tb test performed treated samples following procedure presented following section 3- rapid test cartridge one pre filter placed center cartridge filtering unit this pre filter essential retain large particulate matter would clog filter a funnel made pre filter snapping securely place cartridge without damaging pre filter thereafter funnel pre filter removed second wash done 2 drops washing solution 3 drops antibody solution added a red pink color filter center mentioned earlier indicated presence tuberculous bacilli processed sample 4- result interpretation color intensity proportional number antigens sample it classified three categories visible central pinkish color lighter control pronounced central pinkish red color similar control central purple red color darker control result test compatible first category test repeated the appearance red pink ring without red pink central area artifact influence results considered negative data analyzed using spss software windows version 11.5 spss inc chicago il usa the diagnostic performances test characteristics including sensitivity specificity positive negative predictive values measured two sided significance level 0.05 used the patho tb test performed manufacturer brochure following stages 1- sample decontamination neutralization sputum sample treated decontamination kubica method 2 ml sample put 50 ml conical centrifuge tube an equal volume solublization decontamination solution added mixed well vortexing incubating 20 minutes orbital turning agitator at least 0.2 ml aliquot suspended pellet kept perform rapid patho tb test rest used seed culture perform required diagnostic test 2- suspended pellet treatment suspended 0.2 ml aliquot diluted 1 5 volumes dns subsequently equal volume negative control rehydrated positive control transferred two boiling resistant microtubes dissolving solution the rapid patho tb test performed treated samples following procedure presented following section 3- rapid test cartridge one pre filter placed center cartridge filtering unit this pre filter essential retain large particulate matter would clog filter a funnel made pre filter snapping securely place cartridge without damaging pre filter thereafter funnel pre filter removed second wash done 2 drops washing solution 3 drops antibody solution added a red pink color filter center mentioned earlier indicated presence tuberculous bacilli processed sample 4- result interpretation color intensity proportional number antigens sample it classified three categories visible central pinkish color lighter control pronounced central pinkish red color similar control central purple red color darker control result test compatible first category test repeated the appearance red pink ring without red pink central area artifact influence results considered negative data analyzed using spss software windows version 11.5 spss inc chicago il usa the diagnostic performances test characteristics including sensitivity specificity positive negative predictive values measured the patho tb test performed manufacturer brochure following stages 1- sample decontamination neutralization sputum sample treated decontamination kubica method 2 ml sample put 50 ml conical centrifuge tube an equal volume solublization decontamination solution added mixed well vortexing incubating 20 minutes orbital turning agitator at least 0.2 ml aliquot suspended pellet kept perform rapid patho tb test rest used seed culture perform required diagnostic test 2- suspended pellet treatment suspended 0.2 ml aliquot diluted 1 5 volumes dns subsequently equal volume negative control rehydrated positive control transferred two boiling resistant microtubes dissolving solution the rapid patho tb test performed treated samples following procedure presented following section 3- rapid test cartridge one pre filter placed center cartridge filtering unit this pre filter essential retain large particulate matter would clog filter a funnel made pre filter snapping securely place cartridge without damaging pre filter thereafter funnel pre filter removed second wash done 2 drops washing solution 3 drops antibody solution added a red pink color filter center mentioned earlier indicated presence tuberculous bacilli processed sample 4- result interpretation color intensity proportional number antigens sample it classified three categories visible central pinkish color lighter control pronounced central pinkish red color similar control central purple red color darker control result test compatible first category test repeated the appearance red pink ring without red pink central area artifact influence results considered negative data analyzed using spss software windows version 11.5 spss inc chicago il usa the diagnostic performances test characteristics including sensitivity specificity positive negative predictive values measured two sided significance level 0.05 used one hundred seventy eight patients enrolled study finally classified two groups group documented pulmonary tuberculosis n 67 group non tuberculous pulmonary infection n 111 mean age tb patients 58 17 years 42% 28 patients men the mean age non tb patients 60 15 46% 51 patients men twenty 11% patients afghanistan rest iranian anorexia weight loss hemoptysis malaise significantly higher tb group fever presented non tb group table 1 positive reactions ppd skin test 10 mm presence bcg scar seen 62% 37% ptb group comparing 54% 45% non tb group respectively p 0.05 table 1 the sensitivity specificity ppv npv ppd test versus culture 63% 46% 41% 67% respectively shown table 1 43 67 ptb patients positive direct smear examination the sensitivity sputum smear examination 64% versus 90% patho tb test specificity 100% versus 70% the common clinical findings pulmonary tuberculosis non tuberculous patients results patho tb test positive 40 smear positive 20 smear negative tuberculous patients 33 cases non tuberculous control group four specimens control group positive retested one specimen reported positive end the sensitivity patho tb test sputum smear positive negative ptb 93% 83% respectively specificity test 70% positive predictive value ranged 38% sputum smear negative ptb 65% total number ptb patients the negative predictive value 90% group table 2 among communicable diseases tuberculosis tb second leading cause death worldwide killing nearly 2 million people year about one third world population infected tb 10% progress toward active disease most patients living underdeveloped countries world.10 incidence total ptb sputum smear positive ptb estimated 53.4 22.4 per 100,000 respectively study region 2006.11 definite diagnosis pulmonary tuberculosis difficult low sensitivity sputum direct examination despite low cost easy performance direct sputum smear microscopy sensitivity 61.3 63.4% specificity 97.3 97.4% used primary diagnostic test diagnosis ptb.12 culture requires several weeks provide results complex tests pcr expensive rarely available low income countries world health organization targets 70% case detections 85% successful treatments likely achieved existing methods diagnosis.13 attempts develop rapid inexpensive diagnostic method high sensitivity specificity still highly desirable diagnosis ptb different methods using new reagents purified antibodies try provide high sensitivity specificity tests comparable direct smear microscopy afb culture.14 many different free mycobacterial antigens detected different types body fluid the commonly used antigens lipoarabinomannan lam mycodot serologic test antigen 5 38 kda pathozyme tb elisa test ict diagnostics lam 38 kda pathozyme myco elisa test a-60 antigen antigen a-60 elisa test 45/47 kda antigen kp90 antigen 30 kda antigen p32 antigen antigens.the standard methods used different antigen assays include sandwich elisa inhibition elisa latex agglutination reverse passive hemagglutination tests.1416 dipstick method sensitivity specificity 93% 95% respectively.17 recently reported patho tb test reasonable sensitivity specificity among 310 tb patients the sensitivity patho tb 91.1% comparing direct examination 91.8% specificity 85.5% versus 100%.18 direct examination study done auramine staining confirmed ziehl neelsen positive specimens present study ziehl neelsen staining direct examination performed sensitivities studies revealed approximately similar results specificity lower present study present study sensitivity patho tb test 90% contrast 64.1% direct smear method the higher sensitivity coupled prompt response low cost easy performance enable identification sizeable number pulmonary tuberculosis another advantage test using small amount sputum 0.2 ml order good sensitivity antibodies used test polyclonal antibodies raised purified tb bacilli especially 35 65 85 kda mycobacterial antigens also react mycobacterial species thus necessary analyze results together clinical data patient obtain complete diagnosis concerning high number false positive using confirmatory diagnostic procedure like culture association clinical features mandatory none patients study hiv positive study immune compromised patients several opportunistic infections recommended as mentioned earlier performance anti mycobacterial antibody test revealed contradictory results regardless type tuberculosis the value detection specific igg igm antibodies antigenic particles mycobacterium tuberculosis revealed different results.1923 rapid immunochromatographic test ict detection antibodies directed mtb antigens mtb specific enzyme linked immunospot assay early antigenic target-6 culture filtrate protein-10 peptides two different new diagnostic methods tb.2425 despite different types rapid diagnostic tests newer accurate methods diagnosis still needed although clinical manifestations table 1 malaise anorexia weight loss hemoptysis showed significant difference ptb control groups characteristic tb positive tuberculin skin test study also show significant difference results diagnostic performance characteristics much lower patho tb test results although sputum smear examination highly specific 100% 64% sensitive higher sensitivity new rapid flow method comparing direct smear microscopy afb might enable using patho tb test rapid diagnosis ptb screening test along traditional diagnostic tests positive predictive values test low therefore patients positive patho tb test need confirmatory test sputum culture confirm diagnosis ptb concerning high percentage npvs it would possible rely patients negative patho tb test clinical manifestations suggestive ptb further studies larger number sputum smear negative ptb patients required clear characteristic performance patho tb test ran main researcher wrote manuscript coordinated experiments

background : despite recent technologic improvements in identifying mycobacterium tuberculosis , we are still facing problems in rapid diagnosis of tuberculosis . the objective of this study is to determine the diagnostic value of a new rapid screening test ( patho - tb ) for diagnosis of pulmonary tuberculosis.methods:between september 2006 to august 2007 , 178 patients were enrolled in the study who were finally classified into two groups ; a group of documented pulmonary tuberculosis ( n = 67 ) and a group of non - tuberculous pulmonary infection ( n = 111 ) . patho - tb test , ziehl - neelsen staining and culture were done on all specimens.results:of all , 43 patients with pulmonary tuberculosis were sputum smear positive for acid fast bacilli and the rest were smear negative . mean age of the patients was 59.8 16.1 years and 44% of them were men . the results of patho - tb test were positive in 40 of smear positive and 20 of smear negative tuberculous patients and 33 cases of non - tuberculous control group . the sensitivity , specificity , positive and negative predictive values and accuracy of patho - tb test were estimated 89.5% , 70.2% , 64.5% , 91.7% and 77.5% , respectively.conclusions:according to the present study it would be suggested that patho - tb test could be a rapid and inexpensive method for diagnosis of pulmonary tuberculosis , given by its high sensitivity and negative predictive value . concerning the high number of false positive results , using a confirmatory diagnostic procedure is mandatory .

14-year old domestic shorthair cat treated transient diabetes mellitus 3 months glargine insulin discontinued diabetes mellitus resolved approximately 36 months later diabetes mellitus recurred glargine insulin restarted within 23 mins first injection cat collapsed developed profuse vomiting diarrhea well facial swelling diffuse erythema a hypersensitivity reaction suspected cat treated antihistamines aggressive fluid therapy gastrointestinal support six months later cat presented relapse diabetes mellitus intradermal skin challenge 1:20 diluted insulin performed confirming hypersensitivity glargine the cat continues well regulated porcine zinc insulin without hypersensitivity reactions noted this first reported case hypersensitivity reaction secondary glargine insulin cat clinicians aware potential complication particularly animals previous history insulin administration potential utilize intradermal testing insulin hypersensitivity reactions hrs commonly occur allergen binds ige surface mast cells basophils precipitating release vasoactive substances histamine chymase tryptase chemokines it usually associated prior exposure antigen causing sensitization immune system clinical manifestations range facial pruritis urticaria cardiovascular collapse death previous reports suspected hrs pharmaceuticals veterinary medicine include dexamethasone ophthalmic medication human albumin among others the purpose case report describe clinical manifestation management cat hr subcutaneous glargine insulin gi administration a 14-year old female spayed domestic shorthair cat weighing 5.68 kg presented referral hospital evaluation acute collapse the cat history diabetes mellitus dm first treated gi 2013 the cat treated diabetes became transient 3 months treatment one week prior presentation institution dm recurred initiation gi recommended the bottle opened prior use stored refrigerator the evening presentation cat ingested meal changed year according owner received 1 unit gi subcutaneously first time since 2013 approximately 23 mins administration cat collapsed started panting the cat also demonstrated projectile vomiting diarrhea presentation primary veterinarian cat noted laterally recumbent exhibiting horizontal nystagmus blood glucose bg ) was obtained cat given dextrose submucosally concerns hypoglycemic crisis the cat referred facility presentation institution cat noted obtunded tachycardic heart rate 220 beats per minute tachypneic respiration 50 breaths per minute the respiratory effort increased infrequent stridor noted face muzzle swollen edematous the cat produced large amount vomiting diarrhea time hematochezia also noted though mentation dull nystagmus resolved cranial nerve deficits noted bg measured presentation handheld glucometer alphatrak abbott animal health noted 517 mg dl reference interval ri 75116 mg dl approximately 2 h gi administered the cat measurable systolic blood pressure doppler measurement parks doppler machine 10 ml kg bolus crystalloids administered owing concerns hr insulin diphenhydramine 2 mg kg administered intramuscularly within hour muzzle swelling erythema improved antihistamine administration the cat continued experience recurrent systemic hypotension subsequent hours receiving 3 ml kg synthetic colloid bolus started continuous crystalloid 75 ml kg day colloid infusion 8 ml kg day systemic hypotension resolved blood work performed admission revealed hyperglycemia 666 mg dl ri 75116 mg dl hypokalemia 3.36 meq l ri 3.624.60 treatment gastrointestinal signs consisted maropitant 1 mg kg sc q24h dolestron 0.6 mg kg iv q24h ampicillin 20 mg kg iv q8h).the cat continued experience large volume diarrhea hematochezia first 24 h admission vomiting resolved an abdominal ultrasound performed 1 day presentation revealed enlarged hyperechoic liver small hypoechoic nodules throughout parenchyma assessed consistent diabetic hepatopathy both kidneys mild decrease corticomedullary definition left right adrenal glands noted normal shape size blood work also repeated time showed normalization lactate potassium levels hospitalization the bg continued monitored ranged 107355 mg dl cat appetite remained poor no insulin administered hospitalized owing poor appetite persistent diarrhea concerns hr gi the cat discharged 3 days presentation metronidazole 10 mg kg po q12h famotidine 1 mg kg po q24h the owners continued monitor cat bg home handheld glucometer ranged 88 380 mg dl the owners tended measure bg felt cat appeared lethargic set protocol frequently measure bg time the cat still consuming full caloric needs recommended owners continue monitor cat bg home determine would require insulin the owners infrequently measured cat bg 12 times weekly never greater 200 mg dl six months later cat presented recurrence polyuria polydipsia lethargic home the owners continuing measure cat bg time intermittently obtaining values greater 250 mg dl the cat sedated ketamine 0.5 mg kg iv valium 0.3 mg kg iv fur lateral left thorax clipped one unit gi porcine zinc insulin pzi diluted 20 units/0.2 ml 0.9% nacl mixtures 0.05 ml/5 units injected intradermally negative control within 30 mins procedure palpable swelling noted gi site the cat also developed erythema swelling muzzle figure 1 vomited diphenhydramine 2 mg kg administered clinical signs resolved two hours procedure cat bg 410 mg dl ri 90180 mg dl elected administer 0.5 units pzi subcutaneously owing hyperglycemia the cat kept overnight monitoring noted painful intermittently pruritic injection site the cat discharged following day continues subcutaneous pzi every 12 h exhibited recurrent signs systemic cutaneous hr evidence cutaneous anaphylaxis administration glargine insulin note generalized erythema swelling muzzle periocular regions type hrs previously noted vary severity urticaria anaphylaxis this occur biphasic reaction immediate itching burning injection site followed sustained generalized reaction 48 h later combination cutaneous gastrointestinal and/or respiratory symptoms reported this presents small localized tenderness painful non erythematous nodules central hematomas injection sites occurring around 68 h insulin injection lasting 48 h. clinical examples type iii hrs include serum sickness adenopathy insulin resistance the cutaneous nodules associated type iv hr distinguished type iii hr former usually occurs 24 h insulin injection last 47 days humans type iv hrs it appears given acute presentation history prior exposure insulin cat case demonstrated type hr conclusively proven severe anaphylactic reactions cats cause multitude signs dyspnea common lungs believed shock organ cats case previous case reports anaphylactic reactions cats also shown also exhibit simultaneous gastrointestinal respiratory signs while gastrointestinal infection toxin fully ruled cat diet strictly controlled owners owing dm infection also seemed less likely kept indoors pets house also association signs administration gi also indicative hr confirmation cutaneous hr insulin administration performed intradermal testing using 1:20 dilution insulin preparation appearance cutaneous lesion within 60 mins injection indicates type hr exhibited cat case whereas type iii iv hr would suggested response seen 2 24 h. human protocols used intradermal testing insulin never performed cat prior there subjectively swelling discomfort noted gi injection site gi site also appeared erythematous the increased swelling erythema gi site also provides evidence cat sensitive gi pzi the cat case exhibited severe cutaneous gastrointestinal signs typical human patients undergo intradermal testing should protocol utilized future small animal patients insulin may need diluted reduce severity adverse effects other diagnostic modalities hrs reported dogs include identification elevated alanine transaminase increased gallbladder wall thickness striated wall pattern abdominal ultrasound it unknown abnormalities identified cases feline insulin hr abdominal ultrasound performed cat reported failed identify gall bladder abnormalities management insulin hr involves exclusion poor injection technique use alternative forms insulin splitting dose injection separate sites addition antihistamines if methods fail local injection dexamethasone combination insulin sometimes used steroid therapy pursued cat concerned would complicate management dm similarly also attempt divide dose inject separate sites cat exhibited severe clincial signs hypersensitivity initially poor injection technique improper storage insulin considered likely owners successfully managed cat dm 3 years desensitization using gradually increasing dilutions insulin intradermally controlled setting successful type hr require long periods time beneficial desensitization people appears less successful patients biphasic type hr use newer insulins aspart gi also recommended hrs insulins also recently recognized human medicine cat corticosteroids epinephrine recommended hrs veterinary patients considered potentially contraindicated given pre existing dm severe hyperglycemia potential cause ketosis the cat appears well managed pzi without reported signs hr insulin hrs much common human patients prior use human insulin analogues bovine porcine insulin commonly administered it believed humans hr insulin reacting type protein insulin given molecular differences insulin different species we elected use pzi protamine containing recombinant human insulin cat rather gi recombinant human insulin analogue contains different form protein both gi pzi also contain different adjuvants pzi mostly containing zinc gi mainly containing metacresol as unclear hr developed secondary adjuvants rather different insulin protein molecules human medicine it much common react insulin molecule rather adjuvants furthermore completely rule improper storage poor administration bottle gi newly purchased stored refrigerator never used prior suspect hr event the owners also successfully managed cat dm 3 years well versed subcutaneous administration insulin poor technique seem likely we rule cats naturally develop pruritis erythema intradermal gi injections studies evaluate intradermal gi injections healthy cats clinicians aware possibility hrs insulin administration cats particularly cats previous history insulin administration the incidence hrs insulin use intradermal insulin testing confirmation veterinary medicine requires evaluation

case summarya 14-year - old , domestic shorthair cat was treated for transient diabetes mellitus for 3 months with glargine insulin , which was discontinued when the diabetes mellitus resolved . approximately 36 months later the diabetes mellitus recurred and glargine insulin was restarted . within 23 mins of the first injection the cat collapsed , developed profuse vomiting and diarrhea , as well as facial swelling and diffuse erythema . a hypersensitivity reaction was suspected and the cat was treated with antihistamines , aggressive fluid therapy and gastrointestinal support . the cat made a full recovery and was discharged 3 days later . six months later the cat re - presented for relapse of its diabetes mellitus and an intradermal skin challenge with 1:20 diluted insulin was performed confirming a hypersensitivity to glargine . the cat continues to be well regulated on porcine zinc insulin without any hypersensitivity reactions noted.relevance and novel informationhypersensitivity reactions to insulin administration are rarely described in human medicine . this is the first reported case of a hypersensitivity reaction secondary to glargine insulin in a cat . clinicians should be aware of this potential complication , particularly in animals with a previous history of insulin administration and the potential to utilize intradermal testing with insulin .

furthermore common cause antenatal hospital admission.1 incidence preterm birth rate us 12% 2011.2,3 siriraj hospital tertiary care central part thailand preterm birth rate 9.4% 2004 13.7% 2010.4 srinagarind hospital another tertiary care center northeastern part thailand preterm birth rate high 11.5% 2013 unpublished data the complications preterm births arise immature organ systems yet ready support life extrauterine environment for instance respiratory distress syndrome caused lack surfactants lung epithelium antenatal administration corticosteroids women expected give preterm birth associated significant reduction neonatal morbidity mortality respiratory distress syndrome intraventricular hemorrhage necrotizing enterocolitis preterm infants national institute health american college obstetrician gynecologists recommended single course corticosteroids pregnant women 24 34 weeks gestation risk preterm delivery within 7 days.5,6 use tocolytic agents suppress preterm uterine contraction delay delivery least 48 hours prolongation enable complete administration corticosteroids obtain maximum effect gestational age 2434 weeks.6 despite available modalities prevent preterm birth consequences proportions preterm birth reduced.7 therefore planned evaluate success rate preterm uterine contraction inhibition tocolytic agents factors associated inhibition failure aware possibility preterm delivery this observational retrospective study approved khon kaen university ethics committee human research based declaration helsinki ich good clinical practice guidelines he571337 reviewing data collection forms medical records project the ethics committee deemed patient written informed consent required retrospective study we reviewed medical records singleton pregnant women 24 33 weeks gestation admitted labor room srinagarind hospital khon kaen university thailand january 2013 july 2014 selected patients received uterine contraction inhibition tocolytic drugs diagnosis preterm labor threatened preterm labor multiple pregnancies women diagnosis dead fetus utero lethal fetal anomalies excluded preterm labor defined regular uterine contractions accompanied change cervical dilatation effacement both.6 threatened preterm labor defined regular uterine contractions occurring frequency least every 10 minutes 30 minutes monitoring dilatation effacement cervix.4 high risk preterm delivery defined group women history obstetric medical surgical complication pregnancy the gestational age determination based certain date last menstrual period first trimester ultrasound examination their medical records assessed baseline characteristics including age weight gravidity parity gestational age admission numbers antenatal care visit characteristics uterine contraction cervical status classify studied women preterm labor threatened preterm labor the types modes duration administration adverse effects tocolytic agents used uterine contraction inhibition also retrieved the pregnancy prolongation measured terms duration days gestational age complete weeks whether beyond 34 37 weeks additionally also reviewed neonatal outcomes including gestational age route delivery appearance pulse grimace activity respiration apgar scores birth weight the tocolytic agents commonly used srinagarind hospital adalat nifedipine bricanyl terbutaline ventolin salbutamol the course oral nifedipine 10 mg started initial load every 15 minutes maximum dose 40 mg uterine contraction observed followed maintenance dose 10 mg every 6 hours 24 hours tapered every 8 hours 24 hours every 12 hours 24 hours daily discontinue contraction for terbutaline 4 ampules 2 mg added 5% w 100 ml intravenously dripped beginning rate 5 microdrops min increased 5 microdrops min every 30 minutes uterine contraction getting maximum rate 45 microdrops min if uterine contraction 24 hours dripping rate would reduced 5 microdrops min case salbutamol 1020 mg salbutamol if preterm pregnant women still uterine contraction using drug regimens intolerable side effects classified inhibition failure attending physicians would change drugs none doses drugs could modified cases depending associated maternal fetal conditions judgment attending physicians since setting preterm pregnant women 24 33 weeks gestation would receive course antenatal corticosteroid administration accelerate fetal lung maturation so success preterm uterine contraction inhibition assessed delay delivery least 48 hours tocolytics administration 24 33 week gestation inhibition failure defined delay delivery 48 hours the risk factors inhibition failure also analyzed study sample size calculation based objective assess success rate preterm uterine contraction inhibition maximal proportion defined women 0.5% 10% allowance error the study required least 96 singleton pregnant women admitted labor room preterm uterine contraction received tocolytic agents inhibition for statistical analysis mean standard deviation sd number percentage calculated the chi square fisher exact test used evaluate risk factors labor inhibition failure these variables included p value 0.20 stepwise logistic regression analysis determine factors independently associated risk labor inhibition failure adjusted odds ratio 95% confidence interval ci include unity considered statistically significant during studied period total 424 pregnant women met diagnosis preterm labor threatened preterm labor after exclusion 39 multiple pregnancies women dead fetus utero 2 women lethal fetal anomalies 3 women whose medical records lost 262 women 34 36 weeks gestation also 14 women 24 33 weeks gestation whose uterine contractions inhibited 103 singleton pregnant women 24 33 weeks gestation received tocolytic agents reviewed around three fourth 77.7% met clinical criteria threatened preterm labor 22.3% met diagnosis preterm labor there histories obstetrical medical and/or surgical complications pregnancy among studied women anemia frequently associated condition 34% followed previous abortion 29.1% preterm pre labor rupture membranes 17.5% urinary tract infection asymptomatic bacteriuria 15.5% history preterm labor delivery 11.7% vaginal bleeding 9.7% few cases complications autoimmune diseases 3 cases genital tract infection 3 cases infective diarrhea food poisoning 3 cases polyhydramnios 3 cases 1 case chorioamnionitis sepsis uterine leiomyoma abdominal surgery pregnancy uterine cervical surgery table 2 the overall success rate preterm uterine contraction inhibition prolongation pregnancy least 48 hours 86.4% the success rate among diagnosed threatened preterm labor admission high 93.8% success rate among diagnosed preterm labor admission low 60.9% approximately half studied women 55.3% prolonged pregnancy beyond 34 weeks one third 38.8% gave birth 37 weeks gestation regarding type tocolytic agents terbutaline frequently selected tocolytic agent followed nifedipine intolerable side effects tocolytic agents observed 13 cases whose medication discontinued among 13 cases 5 cases developed hypotension nifedipine treatment 8 cases showed maternal tachycardia dyspnea fetal tachycardia terbutaline treatment duration tocolytic agent administration labor inhibition 25 days median 4 days mean baby birth weight 2,370.9 g sd 833.6 mean gestational age birth 34.4 weeks sd 3.5 almost half 49.5% low birth weight 2,500 g babies there 4 cases severe birth asphyxia whose apgar score 4 5 minutes birth univariate analysis risk factors including preeclampsia severe feature history abortion 24 hours uterine contraction history cervical surgery significantly associated inhibition failure p value 0.20 using multivariate logistic regression analysis preterm labor statistical significant associated inhibition failure estimated worldwide incidence preterm birth 9.6% 2005 mostly occurred africa asia.8 2010 low birth weight babies worldwide estimated around 18 million 59% small gestational age term 41% preterm two third small gestational age infants born asia.9 understanding causes premature delivery low birth weight babies improvement effectiveness available modality intervention needed improve birth outcomes the results study tertiary care hospital northeastern thailand showed tendency worldwide burden preterm pregnancy complications women uterine contraction 34 weeks gestation admitted hospital prolong pregnancy tocolytic agents the majority 86.4% could continue pregnancy least 48 hours receiving tocolytic agents receive completed corticosteroids course accelerate fetal lung maturity however 77.7% studied women presented threatened preterm labor defined uterine contraction without cervical dilatation the significant risk factor inhibition failure preterm uterine contraction cervical dilatation preterm labor similar authors present results motazedian et al reported 48-hour prolongation pregnancy achieved 87% patients receiving terbutaline 84% patients receiving salbutamol.10 likewise study siriraj hospital bangkok thailand revealed success rate threatened preterm labor inhibition 12 hours nifedipine 80%.11 however cases women advanced cervical dilatation 48 cm received one tocolytics magnesium sulfate indomethacin nifedipine 23% could prolong pregnancy least 48 hours admission.12 similarly cases women diagnosis preterm labor based presence uterine contraction documented cervical change success rate nifedipine 70%.13 two studies lower success rates patients presented preterm labor apparent cervical changes we noticed regardless number type tocolysis success rate higher uterine contraction inhibition applied women preterm uterine contraction without cervical changes present study the success rate prolong pregnancy least 48 hours 93.8% threatened preterm labor group preterm labor group 60.9% furthermore authors data revealed preterm labor uterine contraction cervical change significant risk factor labor inhibition failure the main rationale tocolysis preterm labor delay delivery least 48 hours allow completed course corticosteroids accelerate fetal lung surfactant production allow transfer mother tertiary facility betamimetics calcium channel blockers reduce number preterm labor women give birth within 48 hours nevertheless tocolysis appear significantly lengthen gestational age beyond 7 days.14 known nifedipine easy administer fewer side effects relative betamimetics.15 authors results also support notion intolerable side effects occurred cases betamimetics treatment spite success rate preterm uterine contraction inhibition high 86.4% study for example mean birth weight babies approximately 2,300 g half low birth weight 2,500 g severe birth asphyxia seen 3.9% half 58.3% delivery required surgical intervention thus provide advanced neonatal care prepare complicated delivery pregnancy complicated preterm uterine contraction without cervical dilatation limitations study inherent retrospective study made difficult gain complete data fortunately outcomes interest available retrieved medical records another limited number studied women majority women enrolled study threatened preterm labor would lead overestimation overall success rate uterine contraction inhibition however tried minimize effects separating patients threatened preterm preterm labor groups outcome analysis regarding evaluation pregnancy outcomes uterine contraction inhibition tocolytic agents research threatened preterm labor without tocolysis would necessary also whether preterm uterine contraction cervical change get high success rate preterm uterine contraction without cervical change tocolytics could attenuate uterine contraction explored future the success rate preterm uterine contraction inhibition tocolytic agents delay delivery least 48 hours high threatened preterm labor low preterm labor a significant risk factor inhibition failure preterm uterine contraction cervical change

objectivethis study aims to assess the success rate of inhibiting preterm uterine contraction with tocolytic agents to delay delivery for at least 48 hours and risk factors of failure inhibition.materials and methodsbetween january 2013 and july 2014 , medical records of all singleton pregnant women between 24 0/7 and 33 6/7 weeks of gestation with the diagnosis of preterm labor ( with cervical dilatation ) or threatened preterm labor ( without cervical dilatation ) who received tocolytic agents were reviewed . the success rate of preterm uterine contraction inhibition was accounted in patients with 48 hours delayed delivery . the risk factors of the inhibition failure and neonatal outcomes were also investigated in this study.resultsamong 424 pregnant women diagnosed of preterm labor or threatened preterm labor , 103 singleton pregnant women met the study criteria . overall success rate of preterm uterine contraction inhibition to prolong pregnancy for at least 48 hours was 86.4% ( 95% confidence interval [ ci ] : 78.3 , 92.3 ) . however , the success rate among the threatened preterm labor group was 93.8% ( 95% ci : 88.3 , 99.1 ) while the preterm labor group was 60.9% ( 95% ci : 39.3 , 82.4 ) . the significant factor associated with inhibition failure was preterm labor ( adjusted odds ratio 7.22 ; 95% ci : 1.99 , 26.20).conclusionthe success rate of preterm uterine contraction inhibition with tocolytic agents to delay delivery for at least 48 hours was high in threatened preterm labor and low in preterm labor . a significant risk factor for inhibition failure was the preterm uterine contraction with cervical change .

achalasia primary esophageal motor disorder unknown etiology characterized selective loss inhibitory neurons esophageal wall resulting insufficient relaxation lower esophageal sphincter loss esophageal peristalsis.1,2 jackhammer esophagus newly introduced term describe patients least 20% swallows distal contractile integral dci 8000 mmhg.sec.cm.3 several reports described patients diffuse esophageal spasm des non specific esophageal motor disorder nsemd nutcracker esophagus gastroesophageal reflux disease gerd progressing achalasia.49 although causal relationship identified reports suggest different esophageal motor disorders represent spectrum rather unique stable disorders we describe first time case patient progressed jackhammer esophagus type ii achalasia a 66 year old woman history atrial fibrillation hypertension gastritis hypothyroidism presented clinic july 2014 progressive dysphagia solids liquids 18 months her symptoms occurred daily resulted 11-kg weight loss period time she denied heartburn regurgitation choking coughing eating chest pain vomiting abdominal pain change bowel habits the barium swallow showed mildly dilated esophagus tertiary contractions delayed emptying esophagus narrowed gastroesophageal junction fig 1 upper endoscopy demonstrated mild moderate antral gastritis normal appearing esophageal mucosa noted patient might tight gastroesophageal junction unfortunately completing tests missed 3 follow appointments seen clinic one year later given progressive dysphagia symptoms weight loss high resolution esophageal manometry hrem performed fig the study showed normal median integrated residual pressure 8 mmhg normal mean resting pressure 21 mmhg normal mean residual pressure 7 mmhg mean dci 10 770 mmhg sec cm of 10 swallows 30% hypercontractile 8000 mmhg sec cm 50% normal 20% simultaneous overall findings consistent jackhammer esophagus based chicago classification motility disorders.3 pantoprazole increased 40 mg twice daily plan add pain modulator symptoms recurred unfortunately lost follow seen clinic year later june 2015 she continued worsening dysphagia lost additional 7 kg reported new onset occasional post prandial chest tightness point 3 study demonstrated diffuse esophageal dilatation retained secretions barium 020% change esophageal volume 5 minutes in addition tertiary peristaltic waves within distal esophagus limited emptying contrast stomach air fluid level also noted 4 revealing median integrated residual pressure 71.5 mmhg mean resting pressure 97 mmhg mean residual pressure 90 mmhg there panesophageal pressurization every swallow 80% swallows demonstrated prolonged pan pressurization consistent type ii achalasia therapeutic options discussed patient elected undergo heller myotomy the patient referred general surgery presented urgently gi clinic 2 weeks later worsening dysphagia dehydration weakness inability tolerate oral intake additional 7-kg weight loss the patient admitted hospital noted develop acute kidney injury in addition nasogastric tube placed started tube feeds optimize nutritional status week discharge patient underwent heller myotomy dor fundoplication follow visit general surgeon reported tolerating liquids without difficulties to knowledge first case describes progression jackhammer esophagus achalasia period one year smart et al5 reported 5 patients gerd subsequently developed achalasia period 210 years robson et al4 reported patient gerd developed des one year initial diagnosis achalasia one year later several reports describe progression des achalasia.68 khatami et al10 conducted first prospective cohort study 12 patients they observed progression des achalasia one patient 10.6 years they also noted low esophageal body amplitude contractions predictor progression fontes et al11 conducted largest prospective study date assess progression des achalasia patients gerd confirmed ph monitoring systemic diseases may affect esophagus excluded five 14% patients progressed achalasia mean follow 2.1 years although demographic characteristics predictive transition achalasia authors observed amplitude contractions less 50 mmhg predictive factor p 0.002 anggianash et al9 described progression nutcracker esophagus achalasia one patient 3 years vantrappen et al13 described six patients nsemd progressed achalasia patient presented symptoms could considered classic achalasia initial conventional manometry consistent nsemd only second hrem well timed barium esophagram consistent achalasia this progression within one year esophageal motor disorder faster documented previous reports however case suggests esophageal motility disorders represent spectrum disorders patients may progress time one another this case also demonstrates importance following patients diagnosed non achalasia motility disorders repeat hrem one year assess progression shift different esophageal motility disorder studies documenting progression motility disorder achalasia case reports using conventional manometry long term studies evaluating progression hrem needed perhaps current availability hrem researchers may able identify predictive factors associated progression certain esophageal motility disorders achalasia

it has been suggested that patients with certain motility disorders may progress overtime to develop achalasia . we describe a 66 year - old woman who presented with dysphagia for solids and liquids for a period of 18 months . her initial workup showed normal endoscopy and non - specific esophageal motility disorder on conventional manometry . six months later , due to persistence of symptoms , the patient underwent a high resolution esophageal manometry ( hrem ) demonstrating jackhammer esophagus . the patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms . during the last year , the patient reported repeated episodes of food regurgitation and a significant weight loss . a repeat hrem revealed type ii achalasia . multiple case reports , and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia . however , this report is the first to describe a case of jackhammer esophagus progressing to type ii achalasia .

international cancer genome consortium icgc multidisciplinary multi institutional collaborative effort aiming systematically comprehensively characterize somatic mutations 50 different cancer types subtypes 1 five hundred tumor genomes well matched normal control genomes cancer type analyzed using high throughput next generation sequencing technologies detect wide range somatic mutations including single nucleotide mutations small insertions deletions copy number alterations translocations chromosomal structural rearrangements genome wide methylation state analysis whole transcriptome sequencing also planned provide additional molecular level characterizations make effort scalable member institution specializes generating data particular tumor type time writing figure 1.international cancer genome consortium icgc projects march 2011 international cancer genome consortium icgc projects march 2011 one major goals icgc rapidly bring data cancer research community order accelerate studies discovery cancer causes enhance accuracy diagnoses improve treatments order achieve task data generated consortium members managed efficiently amongst important data management challenges faced consortium high complexity heterogeneity data types involved necessity link different data types need protect controlled data furthermore high volume data distributed nature sources make traditional centralized approaches data management impractical consequently icgc adopted federated data architecture address data management needs the scalability system improved member institution store process data locally data federation software presents separate sources single access point remote data access biomart open source data federation system 2 chosen icgc data management platform biomart flexible data model makes generally applicable wide range biological data types built query optimizations make suitable large data sets in addition biomart supports industry standard security framework needed provide secure access controlled data finally large number existing expert maintained public annotation databases readily federated adding value interpretation icgc experimental data the architecture icgc data management system modeled biomart central portal 3 4 number years portal successfully providing single point access large number biological databases distributed across world each biomart database federated portal maintained independently released updated schedule similarly icgc member maintains local biomart database clinical annotations data produced genomic analyses deposited however order make data comparable across different cancer projects create unified icgc data set mechanism enforcing uniformity required thus set data models controlled vocabularies ontologies reference data sets used icgc member databases furthermore gene centric data model adopted ensembl mart 5 used reference experimental data set annotated genes order link individual biomart databases unified system these servers access data three ways access local databases directly communicate icgc biomart servers order retrieve data remote databases communicate non icgc biomart servers cosmic 6 reactome 7 retrieve publicly available annotation data manner biomart server maintained icgc member acts fully featured icgc data portal providing unified access consortium data the users select combination different data sets specify query criteria using variety graphical user interfaces analysis tools available portal application programming interfaces apis java rest soap sparql also available programmatic access behind scenes biomart software breaks query smaller parts distributed remote data sources the results collected compiled single unified results set presented user some data portal access restrictions order preserve patient privacy protect sensitive data communication biomart servers when user logs icgc data portal server using openid server consult central registry ensure user authorized access data figure 2 at present portal contains data 24 cancer projects consisting 3478 genomes 13 cancer types subtypes this includes data generated seven studies performed five icgc participating institutions located four countries the data portal also hosts data large scale cancer genome projects including cancer genome atlas tcga 8 9 tumor sequencing project tsp)(10 johns hopkins university 1114 open access data sets include simple somatic mutations ii copy number alterations iii structural rearrangements iv gene expression v mirna vi dna methylation vii exon junctions secure access controlled data sets germline variations available authorized users a summary data currently available data portal shown table 1 in addition cancer genomic data data portal also federates several public databases table 2 currently includes ensembl genome database 5 kyoto encyclopedia genes genomes kegg 1517 reactome 7 cosmic 6 pancreatic expression database 18 breast cancer campaign tissue bank 19 number resources continuously growing table 1.the summary data available icgc data portal divided cancer projectsourcecancer projectdata setsimple mutationscopy number alterationsstructural rearrangementsgene expressionmirna expressionexon junctionsdna methylationgermline variationsicgcbreast carcinoma wtsi uk)liver cancer ncc jp)liver cancer riken jp)malignant melanoma wtsi uk)pancreatic cancer oicr ca)pancreatic cancer qcmg au)small cell lung carcinoma wtsi uk)tcgaacute myeloid leukemiabreast invasive carcinomacolon adenocarcinomaglioblastomamultiformekidney renal clear cell carcinomakidney renal papillary cell carcinomalung adenocarcinomalung squamous cell carcinomaovarian serous cystadenocarcinomarectum adenocarcinomastomach adenocarcinomauterine corpus endometrioid carcinomaotherbreast cancer jhu us)colorectal cancer jhu us)glioblastomamultiforme jhu us)lung adenocarcinoma tsp us)pancreatic cancer jhu us) table 2.public databases federated icgc data portalsourceurldescription contentsensemblwww.ensembl.orggenome annotationreactomewww.reactome.orgpathway annotationkeggwww.genome.jp/keggpathway annotationcosmicwww.sanger.ac.uk/genetics/cgp/cosmic/somatic mutations cancerpancreatic expression databasewww.pancreasexpression.orgpancreatic cancer expression databreast cancer campaign tissue bankwww.breastcancertissuebank.org/bio-informatics.phpbreast cancer expression data summary data available icgc data portal divided cancer project public databases federated icgc data portal the data portal provides three major interactive entry points identifier search analysis database search figure 3 identifier search figure 3a lets users input identifiers commonly used public annotation databases e.g. hgnc gene symbol ensembl refseq uniprot accessions returns links corresponding gene report page displays basic gene description pathway annotation mutations found cosmic database well pancreas breast cancer expression data figure 4 addition gene report displays summary mutation frequencies selected gene across cancer projects figure 4d records gene report i.e. genomic coordinates pathway name publication linked appropriate resources available allowing users easily retrieve additional information data interest three main entry points available identifier search b analysis c database search figure 4.gene report kras includes gene annotation data ensembl pathway annotation b kegg c reactome summary mutation frequencies cancer project e mutation data cosmic expression data f pancreatic expression database g breast cancer campaign tissue bank bcctb different sections page come federated biomart sources three main entry points available identifier search b analysis c database search gene report kras includes gene annotation data ensembl pathway annotation b kegg c reactome summary mutation frequencies cancer project e mutation data cosmic expression data f pancreatic expression database g breast cancer campaign tissue bank bcctb different sections page come federated biomart sources help interpretation cancer data gene pathway analysis tools available analysis section data portal figure 3b these tools enable users view commonly affected genes pathways one cancer projects results presented easy follow chart exported image file numerical data also downloaded processing figure 5 ( affected pathways shown chart bars representing number affected genes pathway ( b clicking bar users able view download genes mutated pathway ( affected pathways shown chart bars representing number affected genes pathway ( b clicking bar users able view download genes mutated pathway using database search entry point figure 3c users interactively query database several data types genes samples simple mutations copy number alterations structural rearrangements gene expression mirna dna methylation exon junctions the quick interface contains pre selected set commonly used filters gene type mutation type chromosome outputs fixed set attributes the flexible interface contains additional filters selection attributes allowing user choose data displayed output the advanced interface contains complete set filters attributes including technological platforms used sequencing clinical parameters patient gender tumor histopathology demonstrate utility icgc data portal present several queries performed using different query interfaces search genes affected copy number loss also detected deletion structural rearrangement analysis. figure 6 data setscancer projectsfiltersattributesgenespancreatic cancer qcmg au)rearrangement type deletionensembl gene idcopy number alteration type lossgene symbolgene description figure 6.a screenshot quickquery interface query 2 flexible search retrieve clinical staging data colorectal cancer patients non synonymous simple mutations genes involved wnt signaling pathway. figure 7 data setscancer projectsfiltersattributesgenescolorectal cancer jhu us)pathway signaling wnttumor sample idconsequence type non_synonymous codingmutation idmutation typedonor iddiagnosis idclinical staging who)ensembl gene idgene symbol figure 7.a screenshot flexiblequery interface screenshot flexiblequery interface query 3 advanced search pancreatic cancer data set retrieve rna seq expression data genes affected copy number gains. figure 8) data setscancer projectsfiltersattributesgenespancreatic cancer qcmg au)copy number alteration type gainensembl gene idplatform solid sequencinggene expression sample idnormalized read countraw read count figure 8.a screenshot advancedquery interface the icgc data portal first project successfully federate large amounts cancer genomics data rich annotation data single access point it presents scalable approach traditional sense parallelizing data processing storage also general sense outsourcing external annotation expertise federating annotations independently maintained databases this approach proved successful addressing icgc data management needs useful similar large scale collaborative projects the icgc data portal continue expand adding data within project form new cancer genomics data icgc members integrating public annotation databases depth analysis possible data portal additionally new tools developed increase flexibility utility system this includes tools icgc deployers streamline data processing transformation loading processes tools users add new methods data visualization analysis portal

the international cancer genome consortium ( icgc ) is a collaborative effort to characterize genomic abnormalities in 50 different cancer types . to make this data available , the icgc has created the icgc data portal . powered by the biomart software , the data portal allows each icgc member institution to manage and maintain its own databases locally , while seamlessly presenting all the data in a single access point for users . the data portal currently contains data from 24 cancer projects , including icgc , the cancer genome atlas ( tcga ) , johns hopkins university , and the tumor sequencing project . it consists of 3478 genomes and 13 cancer types and subtypes . available open access data types include simple somatic mutations , copy number alterations , structural rearrangements , gene expression , micrornas , dna methylation and exon junctions . additionally , simple germline variations are available as controlled access data . the data portal uses a web - based graphical user interface ( gui ) to offer researchers multiple ways to quickly and easily search and analyze the available data . the web interface can assist in constructing complicated queries across multiple data sets . several application programming interfaces are also available for programmatic access . here we describe the organization , functionality , and capabilities of the icgc data portal.database url : http://dcc.icgc.org

64-year old male patient diabetes medication particular medical history visited clinic symptoms chillness temperature measured 38.8. abdomical ct revealed 6-cm abscess surrounding pseudoaneurysm 4 cm near right internal iliac artery mycotic aneurysm diagnosed although particular strain identified blood culture test conducted time clinic visit based week old abdominal ct results clearly showed growing aspect aneurysm risk death due rupture judged high conducting femoral artery bypass a distal part right internal iliac artery occluded using 10-mm amplatzer vascular plug the right common iliac artery external iliac artery also occluded succession using 14-mm 12-mm amplatzer vascular plugs respectively the patient immediately moved left fermoral artery right femoral artery bypass performed using 10-mm ringed gore tex graft third day post operation pigtail catheter inserted abscess near mycotic aneurysm mycotic aneurysm right iliac artery surrounding abscess drained postoperative abdominal ct showed complete occlusion right iliac artery internal external iliac arteries compared preoperative abdominal ct mycotic aneurysm abscess found completely removed fig the patient discharged 4 weeks antibiotic treatment symptomatic exacerbation found currently antibiotics one year complications detected outpatient monitoring a 56-year old female visited clinic symptoms fever coughing chillness 5 days her temperature time visit 38.2. complained pain left leg two years 5 months visit clinic patient diagnosed perforated appendicitis received appendectomy however postoperative complications including intraperitoneal abscess enterocutaneous fistula resulted treatments including right hemicolectomy oophorectomy colostomy in addition histopathology tests patient time resulted diagnosis stage iia cecal cancer received adjuvant concurrent chemo radiotherapy 12 months thereafter since pet scan post treatment evaluation showed lump soft tissue right anterior abdominal wall upon removal the patient received chemotherapy additional 11 months discharged ct scan determine cause pain left lower limb time visit revealed deep vein thrombosis in addition part small intestine creating enterocutaneous fistula removed following previous operation detaching severe adhesion abdominal wall the right external iliac artery damaged sutured tenth day post operation lower right abdominal pain wound infection found ct scan conducted conservative treatment an 8-cm lump suggestive acute hematoma right external iliac fossa false aneurysm connected right external iliac fossa found an s&g stent graft 10-mm diameter 40-mm length promptly inserted right external iliac fossa although strains identified blood culture testing joining infected area lower right abdomen false aneurysm observed resulting diagnosis mycotic aneurysm a 10-mm long amplatzer vascular plug inserted right proximal external iliac artery the patient immediately moved right distal external iliac artery ligated a 12-mm ringed gore tex graft used perform left femoral artery right femoral artery bypass a postopeative lower extremity vascular ct scan showed complete withdrawal mycotic aneurysm previously present right external iliac artery fig the patient discharged 18 days operation without specific symptoms remote metastasis cecal cancer aggravated died 4 months a 64-year old male patient diabetes medication particular medical history visited clinic symptoms chillness temperature measured 38.8. abdomical ct revealed 6-cm abscess surrounding pseudoaneurysm 4 cm near right internal iliac artery mycotic aneurysm diagnosed although particular strain identified blood culture test conducted time clinic visit based week old abdominal ct results clearly showed growing aspect aneurysm risk death due rupture judged high conducting femoral artery bypass a distal part right internal iliac artery occluded using 10-mm amplatzer vascular plug the right common iliac artery external iliac artery also occluded succession using 14-mm 12-mm amplatzer vascular plugs respectively the patient immediately moved left fermoral artery right femoral artery bypass performed using 10-mm ringed gore tex graft third day post operation pigtail catheter inserted abscess near mycotic aneurysm mycotic aneurysm right iliac artery surrounding abscess drained postoperative abdominal ct showed complete occlusion right iliac artery internal external iliac arteries compared preoperative abdominal ct mycotic aneurysm abscess found completely removed fig the patient discharged 4 weeks antibiotic treatment symptomatic exacerbation found currently antibiotics one year complications detected outpatient monitoring a 56-year old female visited clinic symptoms fever coughing chillness 5 days her temperature time visit 38.2. complained pain left leg two years 5 months visit clinic patient diagnosed perforated appendicitis received appendectomy however postoperative complications including intraperitoneal abscess enterocutaneous fistula resulted treatments including right hemicolectomy oophorectomy colostomy in addition histopathology tests patient time resulted diagnosis stage iia cecal cancer received adjuvant concurrent chemo radiotherapy 12 months thereafter since pet scan post treatment evaluation showed lump soft tissue right anterior abdominal wall upon removal the patient received chemotherapy additional 11 months discharged ct scan determine cause pain left lower limb time visit revealed deep vein thrombosis in addition part small intestine creating enterocutaneous fistula removed following previous operation detaching severe adhesion abdominal wall right external iliac artery damaged sutured tenth day post operation lower right abdominal pain wound infection found ct scan conducted conservative treatment 8-cm lump suggestive acute hematoma right external iliac fossa false aneurysm connected right external iliac fossa found an s&g stent graft 10-mm diameter 40-mm length promptly inserted right external iliac fossa thereafter false aneurysm found disappeared however profound amount hematoma present affected area although strains identified blood culture testing joining infected area lower right abdomen false aneurysm observed resulting diagnosis mycotic aneurysm a 10-mm long amplatzer vascular plug inserted right proximal external iliac artery the patient immediately moved right distal external iliac artery ligated a 12-mm ringed gore tex graft used perform left femoral artery right femoral artery bypass postopeative lower extremity vascular ct scan showed complete withdrawal mycotic aneurysm previously present right external iliac artery fig the patient discharged 18 days operation without specific symptoms remote metastasis cecal cancer aggravated died 4 months mycotic aneurysm constitutes 1% aneurysms high risk rupture requires immediate treatment it tends occur wide range arteries including lesser curve aortic arch opposite side visceral branch vessel abdominal aorta although condition often thought related structural characteristics artery turbulent blood flow occurs opposite side abdominal branching blood vessels actual cause condition still unknown the major bacterial strains known cause mycotic aneurysms e. coli staphylococcus salmonella streptococcal species these strains related atherosclerotic ulcers inner arterial membrane act nidus invading secondarily infected arterial wall triggering false aneurysm rupture artery although onset rate mycotic aneurysm comparatively low difficulty diagnosis often results late discovery disease serious advancement condition the mortality rate fairly high since often develops patients lowered immunity underlying diseases diagnosis mycotic aneurysm done identifying three typical symptoms abdominal pain fever pulsating lump however unusual find symptoms symptoms often nonspecific a ct scan subject suspected mycotic aneurysm reveal detailed information lesion diagnosis done blood culture testing however 10~27% postoperative mycotic aneurysms found benign tissue culture testing reports relationship prognosis postoperative infection graft treatment mycotic aneurysm includes early diagnosis well broad removal lesion surgically following artificial blood vessel placement long term use antibiotics although treatment plays critical role patient prognosis several studies reported high postoperative death rates 16~44% despite ongoing technical advancement unlike general aneurysm mycotic aneurysm is often located near upper portion renal arteries case situ graft placement is preferred since range lesion broad reconstruction blood vessels reach surrounding organs required hand cases mycotic aneurysm lower portion renal arteries extra anatomic artificial blood vessel bypass recognized appropriate treatment cases staphylococcus aureus salmonella species pyogenic infection grossly suspected situ graft placement forbidden since chance postoperative graft infection high variety vascular embolizations reported recently extra anatomic artificial vessel bypass mycotic aneurysms inferior renal artery vascular embolization known suitable treatment aneurysms blood vessels average size since operational approach difficult however controversial place foreign material infected artery treatment mycotic aneurysm risk post treatment complications rupture increase due weakening arterial wall therefore treatments applied patients low chance continuous exacerbation infection case report authors planned treatments comprehensive consideration patients clinical symptoms well location lesions we would like introduce bypass surgery bilateral femoral arteries following vascular embolization successful treatment option mycotic aneurysm

mycotic aneurysm is a disease requiring immediate treatment because of the high risk of rupture . a difficult surgical approach , especially in the case of occurrence on the iliac artery , involving endovascular embolization and extra - anatomic bypass grafting , is known to be a suitable treatment . we performed extra - anatomic bypass grafting after endovascular embolization successfully in two patients . the postoperative computed tomography of both patients showed complete exclusion of the mycotic aneurysm .

microarray data deposited ncbi gene expression omnibus geo database geo series accession number gse52552 http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=gse52552 to gain insight mechanisms complement resistance m. catarrhalis transcriptional response m. catarrhalis strain bbh18 complement resistant isolate upon exposure 10% pooled normal human serum nhs analyzed microarray expression profiling this concentration chosen test experiments demonstrated m. catarrhalis bbh18 gene deletion mutant lacking key complement resistance factor uspa2h rapidly killed 10% nhs data shown reduce effect day day variation two fully independent microarray expression profiling experiments performed indicated hereafter experiments b table 1 m. catarrhalis bbh18 pre cultured overnight brain heart infusion bhi agar plates 37 c atmosphere containing 5% co2 bacteria harvested plates resuspended pbs supplemented 0.15% gelatin pbs g next 5 ml bhi medium inoculated od600 nm 0.075 cultured mid log phase od600 nm 1.0 obtaining cultures density 6 10 cfu ml culture 4 ml harvested centrifugation washed 16 ml pbs g resuspended 20 ml pbs g 0.2 mm mgcl2 1 mm cacl2 ca mg 5.5 ml suspension mixed 5.5 ml either pbs g ca mg control experiment n 3 experiment b n 2 20% pooled nhs gti diagnostics pbs g ca mg experiment n 3 experiment b n 3 incubated 37 c agitation 200 rpm after 0 30 experiment 60 min 3.5 ml aliquot taken harvested centrifugation immediately treated 1 ml rnaprotect bacteria reagent qiagen total rna isolated using rneasy mini kit qiagen according manufacturer instructions co purified genomic dna removed double dnase treatment using dna free kit ambion five micrograms total rna obtained samples exposed 60 min nhs control conditions used microarray expression profiling rna reverse transcribed labeled microarray hybridization according standard nimblegen gene expression array protocols two micrograms cy3-labeled cdna probes hybridized overnight 42 c custom designed nimblegen m. catarrhalis bbh18 expression arrays 4 plex arrays 72 k subsequently washed procedures performed according manufacturer instructions array images acquired nimblegen ms200 scanner images first processed nimblescan software raw expression data .pair files ) were processed using arraystar dnastar normalized using quantile rma method yielding average signal intensity per cds identify genes differentially expressed 10% nhs compared control condition statistical analysis executed using cybert unpaired two condition data analysis http://cybert.ics.uci.edu/ genes considered differentially expressed expression increased decreased 2.5-fold bonferroni corrected p 0.05 eliminate genes low expression analysis generated frequency plots log2 average probe signal intensity per gene two distributions could observed data shown based frequency plots eliminated genes average normalized probe signal intensity log2 6 tested conditions analysis using criteria identified 84 genes 2.5 fold increased expression 134 genes showed 2.5 fold reduced expression 10% nhs compared incubation pbs g nhs dilution buffer determine exposure 10% nhs resulted increased expression genes grouped functional classes potential enrichment analyzed fishers exact one tail test corrected multiple testing according storey tibshirani validate microarray expression data real time quantitative pcr rt qpcr analysis performed selection 18 genes samples obtained 60 min exposure nhs pbs g experiment b a sub selection 11 genes tested samples obtained 30 min experiment table 1 dna free total rna 500 ng reverse transcribed cdna using iscript cdna synthesis kit bio rad rt qpcr performed duplicate sample using ssoadvanced sybr green supermix bio rad analyzed cfx96 real time pcr machine bio rad expression fold changes nhs versus pbs g different groupings calculated using ct method gyra gene used normalization correlation microarray rt qpcr data assessed two tailed pearson correlation test using graphpad prism software to gain insight mechanisms complement resistance m. catarrhalis transcriptional response m. catarrhalis strain bbh18 complement resistant isolate upon exposure 10% pooled normal human serum nhs analyzed microarray expression profiling this concentration chosen test experiments demonstrated m. catarrhalis bbh18 gene deletion mutant lacking key complement resistance factor uspa2h rapidly killed 10% nhs data shown reduce effect day day variation two fully independent microarray expression profiling experiments performed indicated hereafter experiments b table 1 m. catarrhalis bbh18 pre cultured overnight brain heart infusion bhi agar plates 37 c atmosphere containing 5% co2 bacteria harvested plates resuspended pbs supplemented 0.15% gelatin pbs g next 5 ml bhi medium inoculated od600 nm 0.075 cultured mid log phase od600 nm 1.0 obtaining cultures density 6 10 cfu ml culture 4 ml harvested centrifugation washed 16 ml pbs g resuspended 20 ml pbs g 0.2 mm mgcl2 1 mm cacl2 ca mg 5.5 ml suspension mixed 5.5 ml either pbs g ca mg control experiment n 3 experiment b n 2 20% pooled nhs gti diagnostics pbs g ca mg experiment n 3 experiment b n 3 incubated 37 c agitation 200 rpm after 0 30 experiment 60 min 3.5 ml aliquot taken harvested centrifugation immediately treated 1 ml rnaprotect bacteria reagent qiagen total rna isolated using rneasy mini kit qiagen according manufacturer instructions co purified genomic dna removed double dnase treatment using dna free kit ambion five micrograms total rna obtained samples exposed 60 min nhs control conditions used microarray expression profiling rna reverse transcribed labeled microarray hybridization according standard nimblegen gene expression array protocols two micrograms cy3-labeled cdna probes hybridized overnight 42 c custom designed nimblegen m. catarrhalis bbh18 expression arrays 4 plex arrays 72 k subsequently washed procedures performed according manufacturer instructions array images acquired nimblegen ms200 scanner images first processed nimblescan software raw expression data .pair files ) were processed using arraystar dnastar normalized using quantile rma method yielding average signal intensity per cds identify genes differentially expressed 10% nhs compared control condition statistical analysis executed using cybert unpaired two condition data analysis http://cybert.ics.uci.edu/ genes considered differentially expressed expression increased decreased 2.5-fold bonferroni corrected p 0.05 eliminate genes low expression analysis generated frequency plots log2 average probe signal intensity per gene ; based frequency plots eliminated genes average normalized probe signal intensity log2 6 tested conditions analysis using criteria identified 84 genes 2.5 fold increased expression 134 genes showed 2.5 fold reduced expression 10% nhs compared incubation pbs g nhs dilution buffer determine if exposure 10% nhs resulted increased expression genes grouped functional classes potential enrichment analyzed fishers exact one tail test corrected multiple testing according storey tibshirani to validate microarray expression data real time quantitative pcr rt qpcr analysis performed selection 18 genes samples obtained 60 min exposure nhs pbs g experiment b a sub selection 11 genes tested samples obtained 30 min experiment table 1 dna free total rna 500 ng reverse transcribed cdna using iscript cdna synthesis kit bio rad rt qpcr performed duplicate sample using ssoadvanced sybr green supermix bio rad analyzed cfx96 real time pcr machine bio rad expression fold changes nhs versus pbs g different groupings calculated using ct method gyra gene used normalization correlation microarray rt qpcr data assessed two tailed pearson correlation test using graphpad prism software

the complement system is an important part of the innate defense against invading pathogens ( blom et al . , 2009 ; [ 1 ] ) . the ability to resist complement - mediated killing is considered to be an important virulence trait for the human - restricted respiratory tract pathogen moraxella catarrhalis , as most disease - associated m. catarrhalis isolates are complement - resistant ( wirth et al . , 2007 ; [ 2 ] ) . here we provide a detailed overview of the experimental methods that we have used to study the molecular basis of m. catarrhalis complement - resistance by transcriptome profiling of the bacterium upon exposure to 10% normal human serum ( nhs ) , associated with the study of de vries et al . published in molecular microbiology in 2014 [ 3 ] .

rectal varices uncommon manifestation cirrhosis portal hypertension however serious bleeding rectal varices uncommon rarity several authors reported utility transjugular intrahepatic portosystemic shunt tips placement control bleeding local therapy endoscopic sclerotherapy banding fails 2 3 4 5 however experienced case massive bleeding large rectal varices could controlled tips placement despite normalization portosystemic pressure gradient furthermore observed rapid decompensation cirrhosis led severe encephalopathy death tips placement we report case highlight discuss potential pitfalls tips placement using technique treat rectal variceal bleeding a 59-year old man history alcoholic cirrhosis hospitalized outside facility massive hematochezia fainting he underwent upper endoscopy tagged red blood cell scan negative active bleeding a computed tomography abdomen performed reveal source gastrointestinal bleeding nodular liver splenomegaly consistent liver cirrhosis seen markedly dilated inferior mesenteric vein also noted 5-day hospitalization approximately 1015 bloody bowel movements received total 6 units packed red blood cells 2 units fresh frozen plasma the patient transferred institution management persistent hematochezia his admission laboratory tests showed hemoglobin level 8.3 g dl serum ammonia level 45 g dl total bilirubin level 2.8 mg dl model end stage liver disease meld score 18 however another episode massive hematochezia following day decrease hemoglobin level 5.0 g dl therefore decision made proceed emergent tips placement a tips successfully created 10 90 mm viatorr stent graft gore associates flagstaff ariz this resulted decrease portosystemic pressure gradient 12 6 mm hg after tips placement brisk hepatopetal flow tips seen portogram despite successful normalization portosystemic pressure gradient another episode massive bleeding following day an angiogram superior rectal vein performed showed tortuous large rectal varices brisk hepatofugal flow fig 2 flow internal iliac vein branches observed confirming portosystemic shunting embolization rectal varices performed necessitated multiple coils 1 ml n butyl cyanoacrylate glue 5,000 units thrombin several sheets gelfoam fig 3 procedure patient bleeding episodes serial hemoglobin levels remained stable the remaining hospital course significant rapid decompensation cirrhosis increase total bilirubin level 8.7 mg dl ammonia level 121 g dl meld score 28 he developed acute hypoxic respiratory failure secondary multiple causes including progressive liver failure this case highlights two potential pitfalls tips placement using technique treatment rectal variceal bleeding first tipss may always successful controlling serious bleeding rectal varices despite optimal portosystemic pressure reduction we observed rebleeding tips placement despite 50% reduction pressure gradient final pressure gradient 6 mm hg some authors also reported tips failed control bleeding rectal varices 6 7 recurrent bleeding rectal varices tips placement may related large size varices rectal varices unlike esophageal varices true veins likely larger diameters according laplace equation the tension varix wall proportional radius vessel given transmural pressure recommended decrease portosystemic pressure gradient 12 mm hg esophageal variceal bleeding however targeted pressure gradient may adequate controlling bleeding rectal varices some authors advocate embolization rectal varices time tips placement even normalization portal hypertension achieved 7 10 given successful control bleeding following embolization case concomitant variceal embolization time tips placement may necessary control massive bleeding especially rectal varices large second tipss associated life threatening complications possibly lead early mortality since first application tips treatment recurrent bleeding anorectal varices 1993 tips alone tips combined variceal embolization reported useful controlling bleeding without significant morbidity mortality 2 3 4 5 10 however tipss inherently associated risks procedure related complications hepatic encephalopathy progressive liver failure godil mccracken reported case rapid liver function decompensation encephalopathy following tips placement 73-year old woman rectal variceal bleeding although recurrent bleeding seen patient died 4 weeks tips procedure according american association study liver diseases practice guidelines tips recommended absence options patients 30-day predicted mortality meld 1518 serum bilirubin 4.0 mg dl although emergent tips placement last resort control massive bleeding rectal varices even high risk patients must used cautiously lead life threatening complications seen case despite minimally invasive nature tips placement associated 30-day mortality rate high 36% used control acute gastroesophageal variceal bleeding one alternative tips placement high risk patients may percutaneous embolization rectal varices via transhepatic approach although reports use technique bleeding rectal varices limited could useful controlling initial acute bleeding stabilizing patient without affecting liver function however collaterals redevelop embolization recurrent bleeding requiring repeated intervention reported some authors reported several cases obliteration bleeding large rectal varices use balloon occluded antegrade transvenous sclerotherapy without coil embolization 14 15 technique sclerosing agent ethanolamine oleate was injected varices superior rectal vein occluded using balloon catheter further research needed determine efficacy conclusion although tipss reported useful controlling bleeding rectal varices potential pitfalls using technique treat rectal variceal bleeding a tips may always successful controlling massive bleeding large rectal varices even normalization portal hypertension concomitant variceal embolization may necessary furthermore tipss associated life threatening complications may lead early mortality

in patients with portal hypertension , bleeding from rectal varices is rare . however , it can be life - threatening . we report a case of massive bleeding from large rectal varices in a 59-year - old man with alcoholic cirrhosis . emergent transjugular intrahepatic portosystemic shunt ( tips ) placement was performed following failed local endoscopic therapy . despite normalization of the portosystemic pressure gradient , the patient had another episode of massive bleeding on the following day . embolization of the rectal varices via tips successfully stopped the bleeding . after the procedure , rapid decompensation of the cirrhosis led to severe encephalopathy , and death was observed . although tipss have been reported to be useful in controlling bleeding from rectal varices , our case illustrates the potential pitfalls in using this technique in the treatment of rectal variceal bleeding . tipss may not be always successful in controlling massive bleeding from large rectal varices , even after normalization of portal hypertension . tipss can also be associated with life - threatening complications that may lead to early mortality .

ageing population alzheimer disease ad related neurodegenerative disorders represent serious social economic threat societies the cost caring increasing number people dementia continues rise present estimated 30 million people dementia worldwide numbers expected increase 80 million 2040 countries regions largest numbers affected individuals china developing western pacific western europe unites states the two core histopathological hallmarks ad amyloid- plaques tau containing neurofibrillary tangles nfts described alois alzheimer century ago disease causing mutations familial cases ad described two decades ago yet still cure debilitating disease the current treatment limited acetylcholine esterase ache inhibitors donepezil rivastigmine galantamine nmda receptor antagonist memantine yet neither strategies halts degenerative process characterizes ad what characteristics major component two hallmark lesions ad causes familial cases ? the 3942 amino acid peptide plaques fibrillar tau microtubule associated protein becomes hyperphosphorylated disease process eventually aggregates form nfts neuropil threads abnormal neurites associated amyloid- plaques although tau generally perceived neuronal protein mainly axonal localization recently challenged view demonstrating essential dendritic function physiological conditions mediating toxicity 5 6 in addition plaques nfts ad brain characterized massive neuronal cell synapse loss tau pathology absence overt plaques characterizes series diseases collectively known tauopathies this includes ftld tau frontotemporal lobar degeneration tau inclusions inherited form known ftdp-17 frontotemporal dementia parkinsonism linked chromosome 17 there second major subset ftld characterized tau negative yet ubiquitin positive lesions subset transcription splicing factor tdp-43 tar dna binding protein 43 identified aggregating protein consequently form ftld named ftld tdp similar tau tdp-43 aggregates hyperphosphorylated fragmented process believed linked toxicity 811 finally third subset ftld ftld fus nuclear protein fus fused sarcoma identified aggregated protein proteins form also aggregates subsets amyotrophic lateral sclerosis als the majority ad cases sporadic sad familial fad cases likely accounting less 1% three genes autosomal dominant mutations identified amyloid precursor protein app presenilin 1 psen1 well presenilin 2 psen2 it amyloid precursor protein app peptide derived proteolytic cleavage presenilins components multimeric -secretase complex generates a. addition three fad genes apolipoprotein e apoe unanimously confirmed susceptibility gene sporadic ad sad more recently additional risk factor genes identified clu encoding clusterin picalm phosphatidylinositol binding clathrin assembly protein cr1 complement component 3b/4b receptor 1 tomm40 channel forming subunit translocase mitochondrial outer membrane tom complex 1517 present total ten genes mostly roles immune system cholesterol metabolism established risk genes ad compared ad ftld heterogeneous disorder variants example characterized language behavioural problems ad ftld present progressive decline memory function leading dementia although ftld often preceded motor symptoms parkinsonism it several years first mutations identified app psen genes ad first mutations identified subset ftld tau ftdp-17 found exonic intronic sequences mapt gene encodes tau another subset familial ftld characterized mutations pgrn gene encodes pleiotropic protein progranulin vcp gene encodes valosin containing protein also tardp encoding tdp-43 ftld tdp cases characterized inclusions tdp-43 finally mutations chmp2b encoding chromatin modifying protein 2b lead ftld absence either tau tdp-43 inclusions paper discussing selected tau transgenic mouse models memory motor phenotypes one k369i mutant human tau expressing k3 strain employed enu modifier screen outlining strategy breeding gene identification as focus review article application enu mutagenesis one mutant tau transgenic mouse strains k3 comparing particular strain tau transgenic strains established past mouse strains otherwise available field including characterized plaque formation discussed us detail elsewhere 2427 ambition developing transgenic mouse strains tau pathology ad first place ? the aim always authentically model human pathology gain deeper understanding causes tau pathology related neurodegeneration functional impairment ultimately pathogenic processes prevented delayed when generated first tau transgenic mouse model 1995 expressing longest human tau isoform mice reproduced major aspect human pathology subset neurons somatodendritic accumulation hyperphosphorylated forms tau feature pathological tau ad brains we failed however reproduce nft formation neurodegeneration functional impairment even using stronger promoter drive human tau expression this goal early days achieved although mice developed motor phenotype amyotrophy 29 30 identification pathogenic mutations ftld tau mapt gene encoding tau expressing mutant forms g272v p301l tau achieved nft formation determined gallyas silver impregnations electron microscopy 31 32 while discontinued g272v mutant mice p301l tau transgenic pr5 strain employed provide support amyloid cascade hypothesis places upstream tau reveal behavioural impairments amygdala- hippocampus dependent tasks 34 35 assess role site specific phosphorylation particular protein phosphatase 2a pp2a process 36 37 determine degree cholinergic pathology reveal impaired stress related unfolded protein response mitochondrial dysfunction caused pathological tau 4042 assessing role mirnas ad adds additional level complexity 43 44 while pr5 mice display memory impairment major clinical feature ad another feature parkinsonism characterizes significant subset ftld cases modelled k369i mutant tau transgenic k3 mice we established strain based identification k369i mutation tau single patient pick disease pid form ftld as known pid general tau lesions mutation carrier brain showed remarkable feature analysed histologically silver impregnation revealed tau lesions bielschowsky positive gallyas negative moreover tau phosphorylated many epitopes 12e8 ser262/ser356 we succeeded reproducing distinct pathology fully k3 mice express k369i mutant tau owing unique expression pattern k369i transgene includes substantia nigra k3 transgenic mice also modelled early onset parkinsonism resting tremor bradykinesia postural instability gait anomalies they showed increased cataleptic response haloperidol early late response l dopa indicating dopaminergic system impaired mice recent years impaired axonal transport identified central pathomechanism ad 4651 conceptually impaired axonal transport linked oxidative stress mitochondrial dysfunction mitochondria need efficiently transported along long axonal processes neurons function furthermore major source reactive oxygen species ros 53 54 we found selectively impaired axonal transport distinct cargos including mitochondria th- tyrosine hydroxylase- containing vesicles molecular level found impaired transport phenotype due trapping component kinesin motor machinery adapter protein jip1 elevated levels phosphorylated tau preventing jip1 executing physiological function axon a pathological interaction tau jip1 revealed ad control brain highlighting validity transgenic animal models dissecting pathomechanisms ad as tau traps jip1 hyperphosphorylated study presents inhibition abnormal hyperphosphorylation tau promising therapeutic strategy ad with pr5 k3 mice two complementary models hand present therapeutic intervention strains characterized hyperphosphorylation increased insolubility tau well silver positive inclusions gallyas positive nfts case r5 mice bielschowsky positive inclusions predominantly resembling pick bodies k3 mice the pr5 mice show accelerated extinction conditioned taste aversion cta paradigm k3 mice memory phenotype determined novel object recognition test well motor phenotype easily monitored either scoring clasping gait tremor table 1 rota rod 22 57 in addition k3 mice age lose substantial numbers neurons substantia nigra th positive neurons cerebellum basket cells 22 57 experimental diabetes exacerbates tau pathology shown pr5 mice therapeutic strategies different approaches envisaged transplantation cells potential differentiate situ either neuronal glial cell types this strategy successfully applied mice combined tau pathology neuronal stem cell transplantation shown improve cognition via brain derived neurotrophic factor bdnf we used active passive immunization monitored efficacy approach biochemically histologically behaviourally we also testing small bioavailable compound sodium selenate supplied drinking water chronic treatment period four months significantly improved pathology young old k3 mice this associated reduced tau hyperphosphorylation decreased numbers tau inclusions including spheroids in fact spheroids completely absent frontal cortex suggesting selenate reverts functional impairment leading spheroids k3 mice characterized substantial age dependent degeneration cerebellar basket neurons resulting absence pinceau terminals formed clustered axons surrounding purkinje cells these findings show selenate reduces tau phosphorylation deposition mitigates pathological spheroid formation prevents axonal degeneration distinct neuronal populations k3 mice we also treated 8-month old pr5 mice sodium selenate found treatment caused significant impairment cta paradigm as k3 mice selenate caused reduced hyperphosphorylation numbers tau deposits nfts well increased tau solubility nft numbers 12-month old selenate treated pr5 mice similar 8-month old untreated pr5 mice suggesting treatment halted disease progression we showed selenate induced improvements require protein phosphatase 2a pp2a performing vitro experiments showing inefficacy selenate mice combined tau pathology reductions pp2a activity 66 67 while ad ageing field mouse strains available traits arose spontaneously established specific breeding programs senescence accelerated sam mice rate new models arise spontaneously means even concerted effort discovery asymptomatic trajectory towards phenotype gap the concept genomewide mutagenesis well established invertebrates fruit fly drosophila melanogaster nematode worm caenorhabditis elegans enu mutagenesis mainly producing transversions this mutagenesis strategy used create first genetic maps mendelian inheritance drosophila revealing many key genes controlling early embryonic patterning development what makes possible carry comparable efforts mice extraordinary mutagenic efficiency enu mouse spermatogonial stem cells expanding library alleles chemical mutagenesis using - ethyl n nitosourea enu identification single nucleotide changes result particular phenotype feasible mice providing novel insights immunity approach used widely also functioning brain genomewide random mutagenesis ethylating chemical enu provides way produce screen genetic variants mouse intraperitoneal injection male founder mice g0 causes random base pair substitutions dna spermatogonial stem cells informative mutations identified screening members pedigrees propagated founders phenotypes interest introducing point mutations advantage often inactivates alters function individual protein domains rather eliminating protein altogether case complete knock outs making harder related proteins compensate better mimicking effects drugs natural genetic variants illuminating active sites proteins revealing specific functions alternatively spliced forms we investigating phenotype modulation k3 mice crossing enu male founder mice k3 females discussed hereinafter general dominant mutations expected manifest first generation offspring g1 recessive mutations brought homozygosity g3 mice either g1 rate recessive mutations established based genotype driven projects using libraries g1 gametes generated enu treated founder sequencing sentinel regions genome g1 sperm provides quantitative qualitative characteristics enu mutagenesis information probable yield mutations phenotype driven screens the consensus mutation rate 0.51.0 mutations mbp 7.5 107 mutations bp g0 gamete 15003000 mutations g1 standard regimen 100 mg kg week 3 c57bl/6 founder assuming 1600 cm 2.6 gb haploid mouse genome of approximately 1.5% coding comes approximately 50 functional mutations g1 the efficiency enu induced mutation means generation allelic series highly feasible based conservative estimate 20 point mutations per g1 gamete survey 17400 g3s would yield series 5 functional alleles per gene 99% probability limiting factors enu mutagenesis approach infertility lethality standard enu regimen resulting azoospermia absence motile sperm semen 10 weeks fertility resumed testes repopulated spermatogonia the presence mutations confer lethality weaning sets workable upper limit enu dose even stringently for example one study found 1/13 g1 mice contained lethal mutations balancer chromosome 11 region contains 5% genome consequence 18% g3 population survive lethal mutations for phenotype driven strategies motor phenotype see following f1 f3 mice examined dominant acting recessive acting mutations respectively 23 82 the recovery rate dominant mutations low 2% hand however costs identifying recessive mutations much higher due much higher mouse numbers sample size screened sequenced ideal screen the phenotypes qualtitative motor phenotype binomial rejection transplanted tissue free false positives sufficiently penetrant permit meiotic mapping the latter typically achieved first outcrossing f1 intercrossing yield f2 mice 50 f2 mice required obtain 10 mb mapping resolution 95% confidence although haplotype mapping might enable estimation chromosomal location using 10 affected f2 mice detailed discussion likelihood confounding mutation cosegregating phenotype the reader referred two excellent reviews topic 23 69 what makes approach feasible simple read respect motor phenotypes much easier monitor memory phenotypes k3 mice k369i mutant tau expression causes motor memory impairment changes motor phenotype intervention although interesting also serve surrogate marker changes memory functions we initiated enu mutagenesis program k3 mice generated transgene dependent -independent pedigrees following discussing five pedigrees enu164 partial rescue transgene related enu67 slow weight gain transgene related enu37 circling transgene related enu12/30a motor phenotype transgene related enu16/069 motor phenotype transgene related first establish k3 phenotype fully penetrant background chosen enu mutagenesis established backcrosses 20 mice using c57bl/10 c3h h3h fvb c57led balb b mice established enu strains apf australian phenomics facility canberra we decided use balb b strain enu mutagenesis k3 phenotype parkinsonism fully penetrant background regards phenotype age onset therefore balb b males injected enu paired k3 mice c57bl/6 background f1 offspring analyzed the litters born scored three read outs parkinsonism mice tremor staging 03 gait anomalies staging 03 limb clasping staging 05 well body weight table 1 we previously phenotyped wild type balb b mice three parkinsonism characteristics weight although none displayed abnormal gait resting tremor 37% clasp hind limbs stimulated 5% clasped hind limbs without stimulation front paws grasped cage wire therefore ensure accurate identification phenotype hindlimb clasping alone used sole indicator conjunction tremor abnormal gait phenotyping done weaning one week intervals around 8 weeks age depending scoring outcome any mice exhibiting three phenotypes genotyped k3-tau positive culled mice failing display phenotypes genotyped k3-tau negative mice showed genotype phenotype mismatch genotyped second time confirmation phenotyped 3 months any mice display phenotype 5 weeks age also noted delayed onset phenotype flagged putant potential mutant interest this followed next generation whole exome sequencing means identifying mutations we would like make comment previously mapping enu mutations chromosomal region strains days much faster directly next generation sequence exomes one two affected mice instead this greatly accelerated speed discovery years months reduced costs identifying causal mutations the snps identified sequencing validated phenotype amplifluor snp assay snp hereinafter discussing five pedigrees arrived different stages crossing identification underlying gene mutations starting pedigrees least progressed enu164 pedigreethis pedigree characterized partial rescue parkinsonism phenotype characterizes k3 mice transgene positive mice pedigree showed improvement vigorous weekly scorings example week 6 would show scoring 1/2/1 gait clasp tremor instead 3/4/3 typical k3 mice as mentioned consecutive backcrossing onto c57bl/6 reduces number functional enu induced point mutations 3rd generation f3 reduced 3 4 mutations k3 mice generated c57bl/6 background enu mutagenesis balb b inbred genetic background strain specific snp detection enabled genomic mapping causative mutation location balb b background this narrows linked mutation carrying region less 20 mb point candidate genes region sequenced detect mutant alleles eventually causative mutation 6 showed inherited partial rescue phenotype ~15% inheritance f2 483 we screened 11 k3-positive mice 3 showing partial rescue ~27% f2 430 20 k3-positive mice ~35% exome ngs next generation sequencing ongoing identify one single gene mutation causes k3 modulating phenotype this pedigree characterized partial rescue parkinsonism phenotype characterizes k3 mice transgene positive mice pedigree showed improvement vigorous weekly scorings example week 6 would show scoring 1/2/1 gait clasp tremor instead 3/4/3 typical k3 mice as mentioned consecutive backcrossing onto c57bl/6 reduces number functional enu induced point mutations 3rd generation f3 reduced 3 4 mutations k3 mice generated c57bl/6 background enu mutagenesis balb b inbred genetic background strain specific snp detection enabled genomic mapping causative mutation location balb b background this narrows linked mutation carrying region less 20 mb point candidate genes region sequenced detect mutant alleles eventually causative mutation 6 showed inherited partial rescue phenotype ~15% inheritance f2 483 we screened 11 k3-positive mice 3 showing partial rescue ~27% f2 430 20 k3-positive mice ~35% exome ngs next generation sequencing ongoing identify one single gene mutation causes k3 modulating phenotype enu67 pedigreethis pedigree shows worsening weight phenotype characterises k3 mice for example average weight transgene negative mice 19,0 grams six weeks age reduced 15.8 grams transgene positive k3 mice even reduced enu67 pedigree k3-positive shows average weight 11.7 grams both k3-positive mice 347 350 identified slow gain weight currently crossing determine underlying gene mutation for example average weight transgene negative mice 19,0 grams six weeks age reduced 15.8 grams transgene positive k3 mice even reduced enu67 pedigree k3-positive shows average weight 11.7 grams both k3-positive mice 347 350 identified slow gain weight currently crossing determine underlying gene mutation the trait shows mendelian inheritance three generations following deep sequencing exome 2 affected mice identified possible causal point mutations following genes:5730455p16rik riken cdna);tcof1 treacher collins franceschetti syndrome 1 responsible production treacle plays role formation tissue face the human disease also autosomal dominant;tbx1 box 1 gene box genes encode transcription factors involved regulation developmental processes chromosomal deletions region linked neural crest related defects a point mutation could potentially cause mild neural phenotype;senp7 sumo1/sentrin specific peptidase 7 gene involved posttranslational modification proteins addition ubiquitin like sumo proteins;ggt7 gamma glutamyltransferase 7 gene gene member family encodes enzymes involved metabolism glutathione transpeptidation amino acids changes activity -glutamyltransferase may signal preneoplastic toxic conditions liver kidney humans;hkdc1 hexokinase domain containing 1 gene chrna4 cholinergic receptor nicotinic alpha polypeptide 4 gene gene encodes nicotinic acetylcholine receptor polymorphisms gene provide protection nicotine addiction humans.amplifluor primers designed snps affected unaffected mice genotyped led confirmation causal mutation tbx1 gene substitution bp 857 coding position resulting asn ile change amino acid 276 a complete knock tbx1 available model digeorge syndrome characterized perinatal death 87 88 the digeorge syndrome caused 1.5 3.0 mb hemizygous deletion chromosome 22q11.2 haploinsufficiency tbx1 gene particular responsible physical malformations there evidence point mutations tbx1 gene also cause disorder digeorge syndrome frequent microdeletion syndrome humans characterized cardiovascular thymic parathyroid craniofacial anomalies the underlying cause disturbed formation pharyngeal apparatus transient structure present vertebrate development gives rise endocrine glands craniofacial tissue cardiac outflow tract the pharyngeal apparatus composed derivatives ectoderm endoderm mesoderm neural crest thus complex interactions cell types different origins orchestrated correct spatiotemporal manner establish proper formation pharyngeal system the analysis engineered mouse mutants developing phenotype resembling digeorge syndrome revealed genes signalling pathways crucial process intriguingly mouse models reveal interference either two distinct phases pharyngeal apparatus development contribute aetiology digeorge syndrome regards ad furthermore string 9.0 known predicted protein protein interactions tbx1 identify sept5 also among 29 genes deregulated pr5 tau transgenic mice jg lim manuscript submitted the value enu37 strain lies absence perinatal phenotype allows studies feasible complete knockout the trait shows mendelian inheritance three generations following deep sequencing exome 2 affected mice identified possible causal point mutations following genes:5730455p16rik riken cdna);tcof1 treacher collins franceschetti syndrome 1 responsible production treacle plays role formation tissue face the human disease also autosomal dominant;tbx1 box 1 gene box genes encode transcription factors involved regulation developmental processes chromosomal deletions region linked neural crest related defects a point mutation could potentially cause mild neural phenotype;senp7 sumo1/sentrin specific peptidase 7 gene involved posttranslational modification proteins addition ubiquitin like sumo proteins;ggt7 gamma glutamyltransferase 7 gene gene member family encodes enzymes involved metabolism glutathione transpeptidation amino acids changes activity -glutamyltransferase may signal preneoplastic toxic conditions liver kidney humans;hkdc1 hexokinase domain containing 1 gene chrna4 cholinergic receptor nicotinic alpha polypeptide 4 gene gene encodes nicotinic acetylcholine receptor polymorphisms gene provide protection nicotine addiction humans.amplifluor primers designed snps affected unaffected mice genotyped led confirmation causal mutation tbx1 gene substitution bp 857 coding position resulting asn ile change amino acid 276 a complete knock tbx1 available model digeorge syndrome characterized perinatal death 87 88 the digeorge syndrome caused 1.5 3.0 mb hemizygous deletion chromosome 22q11.2 haploinsufficiency tbx1 gene particular responsible physical malformations there evidence point mutations tbx1 gene also cause disorder digeorge syndrome frequent microdeletion syndrome humans characterized cardiovascular thymic parathyroid craniofacial anomalies the underlying cause disturbed formation pharyngeal apparatus transient structure present vertebrate development gives rise endocrine glands craniofacial tissue cardiac outflow tract the pharyngeal apparatus composed derivatives ectoderm endoderm mesoderm neural crest thus complex interactions cell types different origins orchestrated correct spatiotemporal manner establish proper formation pharyngeal system the analysis engineered mouse mutants developing phenotype resembling digeorge syndrome revealed genes signalling pathways crucial process intriguingly mouse models reveal interference either two distinct phases pharyngeal apparatus development contribute aetiology digeorge syndrome regards ad furthermore string 9.0 known predicted protein protein interactions tbx1 identify sept5 also among 29 genes deregulated pr5 tau transgenic mice jg lim manuscript submitted the value enu37 strain lies absence perinatal phenotype allows studies feasible complete knockout 5730455p16rik riken cdna tcof1 treacher collins franceschetti syndrome 1 responsible production treacle plays role formation tissue face the human disease also autosomal dominant tbx1 box 1 gene box genes encode transcription factors involved regulation developmental processes chromosomal deletions region linked neural crest related defects a point mutation could potentially cause mild neural phenotype senp7 sumo1/sentrin specific peptidase 7 gene involved posttranslational modification proteins addition ubiquitin like sumo proteins ggt7 gamma glutamyltransferase 7 gene gene member family encodes enzymes involved metabolism glutathione transpeptidation amino acids changes activity -glutamyltransferase may signal preneoplastic toxic conditions liver kidney humans hkdc1 hexokinase domain containing 1 gene chrna4 cholinergic receptor nicotinic alpha polypeptide 4 gene gene encodes nicotinic acetylcholine receptor enu12/301 pedigree short enu12)enu12 mice mild stress show sudden jerky movements moving around cage appear tremor constantly some mice show could described opisthotonus type spasm head heels arch backwards extreme hyperextension body forms reverse bow mice display varying degrees severity even severely affected able move freely quickly around cage they occasionally fall either side circle around cage fast movements highly stressed cage changed the enu12 phenotype recognised weaning.deep sequencing identified substitution bp 1408 exon 10 kcnq1 gene results lys stop change amino acid 435 the kcnq1 gene encodes voltage gated potassium channel protein required repolarisation phase cardiac action potential the gene product form multimers two potassium channel proteins kcne1 kcne3 inherited forms human condition known long qt syndrome lqts an abnormality cardiac ventricular repolarisation characterised qt interval prolongation abnormal waves electrocardiogram ecg commonly associated mutations kcqn1 some patients show cardiac defect romano ward syndrome rws dominant others may suffer severe deafness due lack endolymph vestibular auditory compartment jervell lange nielsen syndrome jlns recessive .the complete knockout model jnls mice show additional circling shaker waltzer rapid head blobbing phenotype introducing familial a340e point mutation knock approach models rws cardiac phenotype inner ear defect this point mutation amino terminus kcnq1 contains six transmembrane domains s1-s6 pore domain p a comparative analysis strains allowed authors draw conclusions regards etiology cardiac phenotype the k434stop mutation enu12 mice carboxy terminus contains four helical regions two form coiled coil assemblies the enu12 strain phenotype similar complete knock demonstrating essential role helical domain kcnq1 function enu12 mice mild stress show sudden jerky movements moving around cage appear tremor constantly some mice show could described opisthotonus type spasm head heels arch backwards extreme hyperextension body forms reverse bow mice display varying degrees severity even severely affected able move freely quickly around cage they occasionally fall either side circle around cage fast movements highly stressed cage changed deep sequencing identified substitution bp 1408 exon 10 kcnq1 gene results lys stop change amino acid 435 the kcnq1 gene encodes voltage gated potassium channel protein required repolarisation phase cardiac action potential the gene product form multimers two potassium channel proteins kcne1 kcne3 inherited forms human condition known long qt syndrome lqts an abnormality cardiac ventricular repolarisation characterised qt interval prolongation abnormal waves electrocardiogram ecg commonly associated mutations kcqn1 some patients show cardiac defect romano ward syndrome rws dominant others may suffer severe deafness due lack endolymph vestibular auditory compartment jervell lange nielsen syndrome jlns recessive the complete knockout model jnls mice show additional circling shaker waltzer rapid head blobbing phenotype introducing familial a340e point mutation knock approach models rws cardiac phenotype inner ear defect this point mutation amino terminus kcnq1 contains six transmembrane domains s1-s6 pore domain p a comparative analysis strains allowed authors draw conclusions regards etiology cardiac phenotype the k434stop mutation enu12 mice carboxy terminus contains four helical regions two form coiled coil assemblies the enu12 strain phenotype similar complete knock demonstrating essential role helical domain kcnq1 function enu16/069 pedigree short enu16)with minimal stress enu16 mice display mild action tremor moderate stress tremor worsens mice display unusual hypermetric gait hind limbs upon restraining tail either one or both hind limbs show dramatic clasping returned cage takes time mice regain control limbs looks sporadic short term lack control hind limbs within seconds being returned cage post restraint gait appears improve persist quite unsteady waddle like the phenotype noticeable 4 5 weeks age.deep sequencing identified g substitution bp 530 exon 5 mpz myelin protein zero gene resulting asp gly change aa 121 aliases mpz mpp p zero p0 among others schwann cells glia peripheral nervous system pns play pivotal roles development maintenance pns in addition forming myelin sheath schwann cells involved neuronal survival also provide support axons development throughout adulthood the mpz gene encodes transmembrane glycoprotein major structural protein peripheral myelin mutations mpz gene result autosomal dominant form charcot marie tooth disease type 1 cmt1b this domain important homotypic interactions convey self adhesive properties essential maintain myelin compaction integrity .the complete p0 knockout causes severe demyelinating neuropathy function p0 still fully resolved axons peripheral nerves severely hypomyelinated subset contain myelin like figures axons degenerate a second strain available jackson laboratories b6.cg-mpz/grsrj mice carry spontaneous totterer mutation homozygous mice poor breeders reproducing twice females poor mothers use strain limited besides totterer strain p0 complete knock available knock strain the enu16 strain n121 g point mutation juxtaposed known glycosylation site protein we found however immunohistochemistry western blot analysis mutated protein p0 n121 g expressed pattern levels similar wild type this allows us employ enu16 strain studies adhesion feasible complete knockout minimal stress the tremor worsens mice display unusual hypermetric gait hind limbs upon restraining tail either one hind limbs show dramatic clasping returned cage takes time mice regain control limbs looks sporadic short term lack control hind limbs within seconds being returned cage post restraint gait appears improve persist quite unsteady waddle like deep sequencing identified g substitution bp 530 exon 5 mpz myelin protein zero gene resulting asp gly change aa 121 aliases mpz mpp p zero p0 among others schwann cells glia peripheral nervous system pns play pivotal roles development maintenance pns in addition forming myelin sheath schwann cells involved neuronal survival also provide support axons development throughout adulthood the mpz gene encodes transmembrane glycoprotein major structural protein peripheral myelin mutations mpz gene result autosomal dominant form charcot marie tooth disease type 1 cmt1b this domain important homotypic interactions convey self adhesive properties essential maintain myelin compaction integrity the complete p0 knockout causes severe demyelinating neuropathy function p0 still fully resolved axons peripheral nerves severely hypomyelinated subset contain myelin like figures axons degenerate a second strain available jackson laboratories b6.cg-mpz/grsrj mice carry spontaneous totterer mutation homozygous mice poor breeders reproducing twice females poor mothers use strain limited besides totterer strain p0 complete knock available knock strain the enu16 strain n121 g point mutation juxtaposed known glycosylation site protein we found however immunohistochemistry western blot analysis mutated protein p0 n121 g expressed pattern levels similar wild type this allows us employ enu16 strain studies adhesion feasible complete knockout this overview pedigrees motor phenotypes reveals mice amenable enu mutagenesis possible establish interesting phenotypes compared functional genomics approaches pursued past 99102 enu mutagenesis directed identifies gene mutations modulate existing pathology also added advantage establishing mutant mouse strains time as outlined enu tends introduce point mutations rather causing deletions results expression mutant proteins levels high enough perform functional studies a limitation wide spread application enu mutagenesis though mice high costs associated establishing mutants identifying underlying gene mutation fact phenotypes amenable robust fast read therefore using motor phenotype surrogate marker memory functions k3 transgene dependent pedigrees avenue pursued field ad mouse models what challenges enu mutagenesis transgenic models neurodegeneration issues practical conceptual encounter studies ? in hindsight appears preferred strategy start many enu mutagenised males cross breeding k3 mice possible order saturate genome mutations also initially planned identify dominant recessive mutations considering extensive breeding needed realised undertaking affordable therefore concentrated solely dominantly inherited traits principle the question may raised transgenic models could easily screened used enu mutagenesis we believe strain phenotype easily picked amenable strategy case we using mice characterized robust tau dependent motor memory phenotype assumed modification motor phenotype would also modify memory functions trait would tested modification motor phenotype confirmed another question expectations beyond finding possible new targets see field evolving years ahead we started establish caenorhabditis elegans laboratory system complementary mice seems overall mutagenesis screen roundworm system easier still believe potential applying enu mutagenesis mouse models models might nicely complement ongoing concerted efforts international knockout mouse consortium http://www.knockoutmouse.org/ the main objectives consortium generate archive distribute worldwide 12.000 conditional mutations across mouse genome mouse embryonic stem es cells the main mutagenesis strategies pursued conditional gene trapping random approach expressed genes ii conditional targeted trapping a directed approach used expressed genes iii conditional gene targeting directed approach used non expressed genes hopefully concerted efforts help developing cure disease symptomatic treatment available

modifier screening is a powerful genetic tool . while not widely used in the vertebrate system , we applied these tools to transgenic mouse strains that recapitulate key aspects of alzheimer 's disease ( ad ) , such as tau - expressing mice . these are characterized by a robust pathology including both motor and memory impairment . the phenotype can be modulated by enu mutagenesis , which results in novel mutant mouse strains and allows identifying the underlying gene / mutation . here we discuss this strategy in detail . we firstly obtained pedigrees that modify the tau - related motor phenotype , with mapping ongoing . we further obtained transgene - independent motor pedigrees : ( i ) hyperactive , circling enu 37 mice with a causal mutation in the tbx1 gene the complete knock - out of tbx1 models digeorge syndrome ; ( ii ) enu12/301 mice that show sudden jerky movements and tremor constantly ; they have a causal mutation in the kcnq1 gene , modelling aspects of the romano - ward and jervell and lange - nielsen syndromes ; and ( iii ) enu16/069 mice with tremor and hypermetric gait that have a causal mutation in the mpz ( myelin protein zero ) gene , modelling charcot - marie - tooth disease type 1 ( cmt1b ) . together , we provide evidence for a real potential of an enu mutagenesis to dissect motor functions in wild - type and tau mutant mice .

fluoro refers to both fluorescent and fluorinated compounds . despite the shared prefix , there are very few fluorescent molecules that are soluble in perfluorinated solvents . this paucity is surprising , given that optical microscopy is a ubiquitous technique throughout the physical sciences and the orthogonality of fluorous materials is a commonly exploited strategy in synthetic chemistry , materials science , and chemical biology . we have addressed this shortage by synthesizing a panel of fluorofluorophores , fluorescent molecules containing high weight percent fluorine with optical properties spanning the visible spectrum . we demonstrate the utility of these fluorofluorophores by preparing fluorescent perfluorocarbon nanoemulsions .

number patients unruptured cerebral aneurysms increased attention given primary prevention aneurysm rupture4 endovascular intervention one major treatment modalities begun catch surpass surgery number cases treated based favorable outcomes reduced morbidity mortality21220 addition recently patients shown preference endovascular intervention surgery cosmetic psychological aspects scalpel surgeons asked enhance competitiveness develop novel surgical devices skills minimally invasive keyhole surgery81519 neuroendoscopic systems7 indocyanine green icg fluorescence angiography518 intraoperative neurophysiological monitoring16 intraoperative cerebral angiography1 microscopic icg fluorescence angiography helpful detecting readjusting unexpected arterial occlusion incomplete clipping cerebral aneurysms however usefulness icg fluorescence angiography limited microscopic view poorly visualized icg absorb sufficient light emit fluorescence therefore limitations overcome using endoscopic systems provide sufficient light illumination excellent visualization operative fields thus icg fluorescence angiography would useful supplement shortcomings microscopic icg fluorescence to date 3 clinical reports regarding endoscopic icg fluorescence angiography japan europe51114 we independently developed endoscopic camera system icg fluorescence angiography show real time simultaneous visible fluorescent imaging using system all procedures approved local institutional animal care use committee conducted according international guidelines a male crossbred swine landraceyorkshireduroc aged 3 months weight 38.5 kg used study anesthesia induced intramuscularly 5 mg kg zoletil 2 mg kg xylazine the swine intubated intravenous 0.9% normal saline administered via ear vein rate 5 ml kg hr anesthesia maintained 2% 4% isoflurane rate 23 l min oxygen nitrogen rate 3 l min vital parameters arterial blood pressure heart rate carbon dioxide levels continuously recorded a 12 cm small craniotomy performed distance 2 cm midline 3 cm anterior bregma the icg dye injected ear vein dose 0.3 mg kg 25 mg dissolved 5 ml sterile normal saline the endoscopic icg system consists endoscope light source camera display computer software fig 1 although types endoscopes size optical adaptor adjustable endoscope 4 mm diameter 30 angle mgb endoskopische gerate gmbh berlin berlin germany used study the light source composed white light source near infrared nir laser source fig we developed white light source installed hxp 120w/45c vis mercury lamp osram gmbh munich germany we also developed nir laser source installed 805 nm wavelength laser diode reallight beijing china fwhm 2 nm icg fluorophore binds hydrophobic core human serum proteins shifts absorption emission spectra icg after intravenous injection icg main peak absorption spectrum icg moves 805 nm chose 805 nm laser wavelength icg absorption peak6 deliver combined light light source endoscope selected 3 mm liquid light guide newport corporation irvine ca usa simultaneously obtain visible icg fluorescence images used fluorescence navigation surgery fns camera developed korea electrotechnology research institute keri fig this camera two charge coupled device ccd image sensors one visible color imaging nir fluorescence imaging a cube beam splitter installed divide visible color image nir fluorescence image the reflected visible color image passes infrared ir cut filter color image sensor penetrated nir image goes mono image sensor the two images processed image capture board data transfer board delivers real time imaging computer usb 3.0 interface we used 1634 mm zoom optical adaptor mgb endoskopische gerate gmbh berlin berlin germany make optical connection endoscope camera the image monitoring program developed keri show record single simultaneous images visible light fluorescence visible fluorescence overlay image all procedures approved local institutional animal care use committee conducted according international guidelines a male crossbred swine landraceyorkshireduroc aged 3 months weight 38.5 kg used study anesthesia induced intramuscularly 5 mg kg zoletil 2 mg kg xylazine the swine intubated intravenous 0.9% normal saline administered via ear vein rate 5 ml kg hr anesthesia maintained 2% 4% isoflurane rate 23 l min oxygen nitrogen rate 3 l min vital parameters arterial blood pressure heart rate carbon dioxide levels continuously recorded a 12 cm small craniotomy performed distance 2 cm midline 3 cm anterior bregma the icg dye injected ear vein dose 0.3 mg kg 25 mg dissolved 5 ml sterile normal saline the endoscopic icg system consists endoscope light source camera display computer software fig although types endoscopes size optical adaptor adjustable endoscope 4 mm diameter 30 angle mgb endoskopische gerate gmbh berlin berlin germany used study the light source composed white light source near infrared nir laser source fig we developed white light source installed hxp 120w/45c vis mercury lamp osram gmbh munich germany we also developed nir laser source installed 805 nm wavelength laser diode reallight beijing china fwhm 2 nm icg fluorophore binds hydrophobic core human serum proteins shifts absorption emission spectra icg after intravenous injection icg main peak absorption spectrum icg moves 805 nm chose 805 nm laser wavelength icg absorption peak6 deliver combined light light source endoscope selected 3 mm liquid light guide newport corporation irvine ca usa simultaneously obtain visible icg fluorescence images used fluorescence navigation surgery fns camera developed korea electrotechnology research institute keri fig this camera two charge coupled device ccd image sensors one visible color imaging nir fluorescence imaging a cube beam splitter installed divide visible color image nir fluorescence image the reflected visible color image passes infrared ir cut filter color image sensor penetrated nir image goes mono image sensor the two images processed image capture board data transfer board delivers real time imaging computer usb 3.0 interface we used 1634 mm zoom optical adaptor mgb endoskopische gerate gmbh berlin berlin germany make optical connection endoscope camera the image monitoring program developed keri show record single simultaneous images visible light fluorescence visible fluorescence overlay image icg fluorescence began appear cerebral cortex endoscopy approximately 25 seconds icg dye injection became peak 1 minute became pale approximately 5 minutes visible color icg fluorescent endoscopic images cortical vessels simultaneously observed display monitor high resolution in addition real time merging images fluorescent cortical vessels could made marked purple color the real time merging visible color fluorescent images corresponded well fig since raabe et al.17 introduced microscopic icg fluorescence angiography cerebrovascular surgery 2003 become ubiquitous piece equipment aneurysm surgery well micro anastomosis surgery arteriovenous fistulas malformations aneurysm surgery real time identification blood flow vasculature within operative field helps improve surgical outcomes reduce perioperative complications this repositioning addition clips promptly determined occlusion parent arteries perforators incomplete clipping aneurysms however invasive limitation visualize small perforators around aneurysms spite superiority acquisition 3-dimensional imaging around clipped aneurysms in addition supplementary facilities intraoperative cerebral angiography needed time lag identification compromise normal arteries repositioning clips result irreversible ischemic complication hand microscopic icg angiography also shortcomings vascular structures beyond line microscopic view hard visualize icg fluorescence weakly detected deeply located structures limited spatial resolution light illumination microscopy when keyhole surgery performed limitations microscopic icg angiography become profound overcome drawbacks microscopic icg angiography in fact endoscopic icg angiography applied surgical fields introduced field neurosurgery based property icg circulated blood vessels metabolized liver excreted via bile duct intestines examples surgical applications technique include detection sentinel lymph nodes patients gastric cancer13 visualization bleeding points gastrointestinal tract9 assessment tissue perfusion bile tree hepatopancreatobiliary surgery22 evaluation free flap perfusion3 neuroendoscopy used mainly skull base surgery via transnasal approach aneurysm surgery71021 meanwhile use endoscopic icg angiography aneurysm surgery recently introduced5614 the authors consider endoscopic icg angiography useful confirming occlusion aneurysms patency blood flow parent arteries perforators could visualized microscopy icg angiography moreover possible endoscopic icg angiography better magnify areas interest5 obtain longer icg fluorescence duration useful ruptured aneurysms11 compared microscopic system light illumination microscopy alone the advantage endoscopic icg angiography system icg fluorescence visible color imaging simultaneously visualized merged real time manner previous microscopic endoscopic icg angiography systems help demonstrate visible color nir fluorescence imaging one time surgeons may feel difficulty comparing real structures fluorescence images surgery however size prototype camera larger previous one improvement first endoscope smaller diameter flexibility may useful operative space narrow without retracting brain tissue drilling bony structures as diameter becomes smaller imaging resolution transmission light illumination emitting fluorescence tend diminished second distinct endonasal approach performed bony nasal cavity endoscopy icg angiography aneurysm surgery reaches stays around targeted vascular structures intradurally adjacent brain microscopic inspection separate displays microscopy endoscopy may detrimental time consuming endoscopy damage adjacent cerebrovascular structures a unified display system visualize microscopic endoscopic imaging one piece may useful terms safety convenience different previous systems possible simultaneously display visible color icg fluorescent images make real time merging images technical supplementation approval clinical implication expected support application aneurysm surgery well surgery cerebrovascular diseases

objectivemicroscopic indocyanine green ( icg ) angiography is useful for identifying the completeness of aneurysm clipping and the preservation of parent arteries and small perforators . neuroendoscopy is helpful for visualizing structures beyond the straight line of the microscopic view . we evaluated our prototype of endoscopic icg fluorescence angiography in swine , which we developed in order to combine the merits of microscopic icg angiography and endoscopy.methodsour endoscopic icg system consists of a camera , a light source , a display and software . this system can simultaneously display real - time visible and near infrared fluorescence imaging on the same monitor . a commercially available endoscope was used , which was 4 mm in diameter and had an angle of 30. a male crossbred swine was used.resultsunder general anesthesia , a small craniotomy was performed and the brain surface of the swine was exposed . icg was injected via the ear vein with a bolus dose of 0.3 mg / kg . visible and icg fluorescence images of cortical vessels were simultaneously observed on the display monitor at high resolution . the real - time merging of the visible and fluorescent images corresponded well.conclusionsimultaneous visible color and icg fluorescent imaging of the cortical vessels in the swine brain was satisfactory . technical improvement and clinical implication are expected .

red eye common eye sign symptom presenting general physicians eye care workers ophthalmologist this symptom accounts approximately 15% consultations ophthalmologists 6% general medical practitioners eastern europe it also accounted 40% outpatients seen bawku hospital ghana 2004 10 district hospitals pakistan nigeria lawan reported 14.8% patients attending teaching hospital eye clinic presenting red eye studies done port harcourt ile ife nigeria showed red eye accounted 19.61% 54.9% pediatric ophthalmic eye diseases respectively a major cause concern health workers late presentation patients condition standard health facility oftentimes developing countries nigeria individuals commence various forms medications orthodox traditional consider first aid measures the causes red eye many including mild serious conditions may threaten vision even managed emergencies treated ophthalmologist these include conjunctivitis corneal ulcer iritis trauma acute glaucoma use traditional eye medicine tem by far common cause conjunctivitis could infective allergic study done ile ife nigeria among pediatric age group ocular trauma common cause red eye followed allergic conjunctivitis infections eye adnexa however developing countries individuals communities often commence first aid presenting health practitioner researchers ghana studied pattern eye care services sought outside orthodox health system cataracts eye injuries ocular conditions reportedly managed herbalists often instilled herbal mixtures directly eyes knowledge attitude community regarding disease often influence members practices including health seeking behavior studies carried developing countries sub saharan africa showed sub optimal level knowledge attitude perception ocular conditions eye health general cape coast ghana a study eye care seeking behavior populace showed 23.3% respondents practiced self medication last episode eye disorder whereas 5.5% visited traditional healer only 32.5% reported health facility management last episode eye disorder the main reason self medication among respondents poor perception severity ocular condition abubakar found 62.3% secondary school students kano poor knowledge 58.2% poor attitude toward ocular disorders especially blindness prevention limpopo province south africa perception ocular manifestation hiv aids assessed among 2659 high school students results showing need better health communication involving population group almost two third 65.6% respondents felt ophthalmologist optometrist consulted ocular problems whereas 16.5% felt traditional healers could considered researchers ile ife southwest nigeria reported 49% secondary school students participating screening exercise allergic conjunctivitis 6% infective conjunctivitis more females males one form ocular disorder among allergic conjunctivitis 12.5% visited eye specialist prior conducting research in addition health habits formed period often carried adulthood passed next generation largely influenced perception attitude toward disease conditions school early detection quality treatment often positively influence outcome episode red eye period presentation health facility dependent several factors including patients knowledge perception symptom involved no previous study examined perception practice senior secondary ss school students sagamu concerning red eye findings perception practice regarding health related conditions tools provide education treatment plans ultimately improve patient care quality life this study therefore planned determine attitude ss school students sagamu local government red eye the result useful health planners planning interventional programs reduce blindness visual impairment red eye within local government area lga state country large developing countries sagamu peri urban area consisting 15 wards diverse population terms ethnicity occupation age structure socioeconomic status the town serves transit zone southwest south south regions country ss school students attending public secondary schools sagamu lga recruited study ss-3 students exempted participating study final examinations going thus unavailable a cross sectional descriptive study carried among 1082 ss ss school students sagamu lga using formula descriptive studies assuming prevalence 50% since previous study carried subject matter environment well nonresponse rate 10% sample size 420 calculated however this exceeded 1082 students recruited study multi stage sampling technique used selection study participants the first stage involved selection three wards 15 existing wards sagamu lga simple random sampling the second stage involved selection one ss school preselected wards also simple random sampling the third stage involved selection three arms five existing arms ss-1 ss-2 school all consenting students selected arms recruited study validated semi structured self administered questionnaire used data collection among study participants the questionnaire obtained information sociodemographic data perception attitude toward red eye respondents data analyzed ibm statistical package social sciences spss version 20 ibm corp a score 50% graded good whereas 50% graded poor attitude scores also calculated scale 100% good attitude score 50% whereas score 50% graded poor chi square test used test association categorical variables level significance p set 0.05 approval obtained zonal education office state ministry education science technology this study followed ethical standards issued nuremberg code declaration helsinki research humans participation fully voluntary respondents free withdraw study wished sagamu peri urban area consisting 15 wards diverse population terms ethnicity occupation age structure socioeconomic status the town serves transit zone southwest south south regions country ss school students attending public secondary schools sagamu lga recruited study ss-3 students exempted participating study final examinations going thus unavailable a cross sectional descriptive study carried among 1082 ss ss school students sagamu lga using formula descriptive studies assuming prevalence 50% since previous study carried subject matter environment well nonresponse rate 10% sample size 420 calculated the first stage involved selection three wards 15 existing wards sagamu lga simple random sampling the second stage involved selection one ss school preselected wards also simple random sampling the third stage involved selection three arms five existing arms ss-1 ss-2 school a validated semi structured self administered questionnaire used data collection among study participants the questionnaire obtained information sociodemographic data perception attitude toward red eye respondents data analyzed ibm statistical package social sciences spss version 20 ibm corp amonk ny a score 50% graded good whereas 50% graded poor attitude scores also calculated scale 100% good attitude score 50% whereas score 50% graded poor chi square test used test association categorical variables level significance p set 0.05 approval obtained zonal education office state ministry education science technology this study followed ethical standards issued nuremberg code declaration helsinki research humans participation fully voluntary respondents free withdraw study wished the female students 593 54.8% males 489 45.2% study many students christians 66.5% ss-2 51.1% table 1 demographic characteristics respondents majority 81% heard red eye mainly neighbors table 2 whereas 216 19% four hundred fifteen 38.4% know cause red eye 99 9.1% thought trauma cause 147 13.6% infection 73 6.7% allergy 21 1.9% sunlight whereas causes drugs forms 327 30.2% two hundred seventy six 25.5% knew infected someone red eye 632 58.4% says infected someone red eye whereas 174 16.1% know whether could infected figure 1 about 35% would instill onion red eye figure 2 followed urine 21.9% breast milk 12.9% other things likely instill salt water 4.6% sugar water 4.6% battery water 1.5% whereas 19.4% use substances though majority says doctor one takes care red eye 24 says self 19 says parent 55 says chemist 58 nurses whereas 12 says herbalist care red eye source respondent information red eye someone red eye infect ? traditional medications used red eye awareness red eyes associated age p 0.005 sex religion table 3 perception grade good 49 4.5% poor 1033 95.5% five hundred forty three 50.2% felt red eye could lead blindness figure 3 perception red eye associated age p 0.027 class p 0.001 the factors associated attitude toward red eye shown table 3 statically significant class p 0.001 factors associated awareness perception attitude toward red eyes red eye lead blindness ? attitude refers feelings toward subject well preconceived ideas one may toward practice refers ways people demonstrate knowledge attitudes actions subject matter it surprising many respondents heard red eye epidemic conjunctivitis called apollo common cause red eye nigeria especially west africa coast study majority heard red eye neighbors show impact community people health 13.9% heard health workers shows need eye care workers intensify health education especially among students only 13.6% aware red eye could caused infections may also influence attitude red eye this might explain half students say infected someone red eye it comparable findings limpopo south africa 31.4% felt hiv infection sequelae could result red eyes most 96.2% respondents attitude toward red eye poor finding quite different reported kano 52.8% students poor attitude toward severe ocular disorders the observed difference might due fact study focused solely red eyes whereas study carried kano assessed knowledge attitude toward causes blindness prevention usually developing countries people usually use traditional eye medication unprescribed medications treat red eye these medications used red eye found study include onion urine breast milk salt water sugar water battery water these cause chemical conjunctivitis infective conjunctivitis especially gonococcal conjunctivitis infected urine used detected treated early result blindness this finding also confirms report researchers shown people seek alternative eye care treatment instead orthodox treatment implications ocular health there report usage herbal preparation eye resultant blindness health education done schools assembly especially eye care workers go long way help reduce among students communities children turn tell parents taught school furthermore incorporation school eye health program existing school health program immense benefit perception grade attitude population poor may mean perception attitude red eye even though common low general population students actually reflecting learnt homes intensive effort enlighten population therefore help reduce blindness visual impairment community these enlightenment programs taken religious houses i.e. mosques churches wider coverage we therefore conclude secondary school students sagamu poor perception attitude red eye appropriate eye health services education included school health services early presentation eye care centers treatment encouraged

background : red eye is a very common presenting complaint in clinical practice among all age groups , including adolescents . health habits formed during adolescence is carried to adulthood and is often a consequence of their perception . this study , therefore , determined the perception of students toward the red eye.aim:to determine the perception of red eye and its associated factors among secondary school students in sagamu.methods:a cross - sectional descriptive study was carried out among 1082 senior secondary school students in sagamu local government area , using a semi - structured self - administered questionnaire . data were analyzed using spss version 20 . relevant descriptive and inferential statistics were calculated.results:the mean age of respondents was 15.27 1.48 years . there were more females ( 54.8% ) than males . majority ( 81% ) had heard of red eye , and this was mainly from neighbors ; 58.4% felt they could not contact red eye from an infected person . about 35% would instill onion if they had a red eye . about 50.2% felt red eye could lead to blindness . awareness of red eye was associated with age ( p = 0.005 ) , but not with sex and religion . among respondents , 95.5% and 96.2% had a poor perception as well as a poor attitude toward red eye , respectively.conclusion:the perception and attitude of senior secondary school students in sagamu to red eye is poor . appropriate eye health education and promotional services , including periodic eye examination of students , should be carried out in school health services . early presentation to eye care centers for its treatment should be encouraged .

auricular acupuncture diagnostic treatment system based normalizing body dysfunction stimulation points ear resulting amelioration pain illness is believed reticular formation sympathetic parasympathetic nervous systems 1 ear acupuncture acupuncture technique similar reflexology speculated technique works groups pluripotent cells contain information whole organism create regional organization centers representing different parts body recruitment cortex cells dedicated specific areas body thus stimulation reflex point ear relieve symptoms distant pathology reliable duration rudimentary forms acupuncture probably arose stone age survived many parts world right present day primitive sharp stones bamboo replaced fish bones bamboo clips later various shapes needles made metal stones arrows tools war warriors wounded war found diseases affected many years gone probably testify scars skin mummified body similaun italy the bantus south africa scratch certain areas skin allay symptoms many illnesses brazil tribe whose method treating illness shoot tiny arrows blowpipe specific areas skin the practice cauterizing part ear hot metal probe also reported among certain tribes arabia this probably vestige acupuncture practiced ancient egypt saudi arab ( british museum describes system channels vessels body approximates closely chinese system channels known system blood vessels lymph vessels nerves the egyptologist alexandre varille 19091951 documented women ancient egypt want children external ear pricked needle cauterized heat gold earrings worn mediterranean sailors used decorations said improve vision hippocrates father greek medicine reported doctors made small openings veins situated behind ear facilitate ejaculation reduce impotency problems the greek physician galen introduced hippocratic medicine roman empire second century ce commented healing value scarification outer ear after fall roman empire medical records egyptian greek roman medicine best preserved ancient persia arabian world included persian records specific references medical treatments sciatic pains sexual related disease produced cauterization external ear renaissance sporadic clinical reports europe the dutch east india company actively engaged trade china 1600s 1800s merchants brought chinese acupuncture practices back europe doctors working company become impressed effectiveness needles moxa cauterization external ear cutting veins behind ears relieving conditions sciatic pains arthritis hip 1637 probably first time europe was described portugese physician zacatus lusitanus treatment sciatic pain cauterization ear bloodletting failed the italian anatomist surgeon antonio maria valsalva 16661723 made first modern anatomical description ear 1717 published aura humanus tractatus describes treatment toothache scarification antitragus 1810 ignazio colla parma italy reported observation man stung bee antehelix resulted dramatic relief pain legs year dr cecconi another italian physician performed cauterization help treatment sciatic pain 1850 the french journal des connaissainces medico chirurgicales reported 13 different cases sciatic pain treated cauterization hot iron applied ear but century later paul nogier rediscovered type treatment in 1957 dr paul nogier physician resident lyons france first presented observations somatotopic correspondences ear dr nogier 2 originated concept inverted fetus map external ear fig he developed theory noticing patients attending clinic small scar burn part ear on inquiring told small area ear cauterized certain madame barrin treatment sciatic pain treatment proved rapid effective later first great insight recognition homunculus man ear representation anatomical correlation inverted fetus ear points body example knee corresponded precisely fetal representation knee auricle auriculotherapy following nogier theory uses ear help determine whether right left hemispheres brain functioning dynamic whole whether specific neurological musculo skeletal organ systems imbalance whether blockages treatment scar tissue emotional disorders new diagnostic system 2,3 figure 1.this drawing illustrates concept inverted fetus map external ear then dr nogier noticed distinct change amplitude dimension pulse certain points auricle stimulated being able detect vas radial pulse patients left hand enables practitioner precisely determine location point whether pathology region body relates specific points whether certain substances indicated accurate employment vas would essential diagnosis treatment following principles nogier auricolomedicine nogier collaborated group medical colleagues spirit cooperation discovery shared experiences one colleagues dr jacques niboyet convinced nogier introduce discoveries congress mediterranean society acupuncture february 1956 attending congress dr grard bachmann published nogier research translated german acupuncture journal 1957 this journal international circulation long japanese acupuncturists became familiar nogiers reflex system the discovery system spread china led intensive research chinese medical authorities time renewed interest traditional chinese medicine after learning nogier ear charts 1958 massive study initiated nanjing army ear acupuncture research team this chinese medical group verified clinical effectiveness nogier approach assessed conditions 2000 clinical patients recording ear points corresponded specific diseases the outcome research positive resulted utilization therapy was published ear chart remarkably similar dr nogier 1958 4 nogier acknowledged chinese traditional medicine using ear points acupuncture prior discovery considered empirical points particular treatments associated somatotopic representation homunculus ear this oversight appears inhibited awareness options laid open recognize treat points ear following anatomical relationship points already known time later american physician td oleson published important paper real milestone ear acupuncture 5 experimentally evaluate claims french chinese ear acupuncture somatotopic mapping body represented external ear 40 patients examined determine areas body musculoskeletal pain each patient draped sheet physician conducting auricular diagnosis prior knowledge patient medical condition simply examined patient ear areas elevated skin conductivity tenderness the concordance established medical diagnosis auricular diagnoses 75.2% 5 these results thus supported hypothesis somatotopoic organization body represented upon human auricle represented following definite areas meridian lines energetic concepts last years modern clinical basic research confirming efficacy ear acupuncture mostly treatment pain acute chronic 69 anxiety related disorders 1012 treatment irritable bowel syndrome obesity smoke cessation alcohol withdrawal types substance abuse disease still waiting definitive confirmation 1317 basic research trying explain effect therapeutic reflexes induced ear acupuncutre behavioral analgesia produced auricular acupuncture blocked opiate antagonist naloxone indicating role endorphinergic systems understanding underlying mechanisms auriculotherapy analgesia 18 ear stimulation healthy persons associated changed activity sympathetic parasympathetic nervous system depending site stimulation period observation 19 auricolotherapy treatment diffusing world patterns follow principles chinese acupuncture revised updated chinese maps ear principles paul nogier also principles reflexology basing somatotopic maps recognize energetic based stimulation evocation reflex stimulating precise areas ear moreover used stimulation ear skin many different tools finger acupressure laser electricity different types needles magnetic balls seeds actually one many methodological problems auricular acupuncture many maps ear little agreement exists regarding point location lacking definitive anatomic study ear skin somatotopic correspondences another problem correspondence reflex systems correlate knowledge anatomy physiology based patterns mainstream medicine 20

auricular acupuncture is a diagnostic and treatment system based on normalizing the body 's dysfunction through stimulation of definite points on the ear . rudimentary forms of acupuncture which probably arose during the stone age have survived in many parts of the world right down to present day . it was used in the ancient egypt , rome , greece and all the mediterranean area . it is a microacupuncture technique similar to reflexology , and was first described in france in 1950 by paul nogier who is considered the father of modern ear acupuncture . it was speculated that the technique works because groups of pluripotent cells contain information from the whole organism and create regional organization centers representing different parts of the body . nevertheless stimulation of a reflex point in the ear seems relieve symptoms of distant pathologies . modern research is confirming the efficacy of ear acupuncture for analgesia and anxiety related disease , while tobacco dependence and other substance abuse still need confirmation . actually main methodological problems with auricular acupuncture are that exist too many maps with little agreement regarding point location in the ear , and that the correspondence or reflex systems does not correlated with modern knowledge of anatomy and physiology .

dataview look sponsors health care providing statistics business household government health spending companion article national health expenditures 1995 ( levit et al 1996 presents health care expenditure data accounting structure describes size current growth historical trends health care service matched sources pay health care bill private health insurance phi government programs like medicaid medicare national health expenditures nhe structure provides policymakers researchers public valuable health care expenditure statistics however provide information size impact rising health costs sponsors health care accounting structure used this dataview breaks apart nhe examine effects health care expenditures sponsoring sectors business households government finance health care bill payers taxes premium payments private public health insurance general revenues sectors also make direct payments providers 1990 1995 present statistics much sponsor spent health care impact expenditures ability pay since 1993 a combination slower health care cost growth upswing economy stabilized eased burden business households government faced financing health care business especially benefiting changing health care cost environment period spending health services supplies hss subset nhe reached 957.8 billion 1995 business paid 26 percent hss households paid 34 percent public sector paid 38 percent another component non patient revenues made remaining 2 percent time relationship among sponsors changed 1965 households primary sponsors health care since households gradually paying smaller proportion hss business public sector paying larger proportion however aggressively controlling health care expenses business decreased share hss 1990s actions public sector less dramatic result pubic sector share health care costs increased significantly period nearly 20 years relative stability 1991 business spent 249.4 billion health care 1995 including 183.8 billion employer sponsored health insurance the 1993 1995 average annual growth 4.3 percent slowest since began measure business health spending 1965 the burden placed business eased years 1993 1995 time overall health care costs grew slow rate also enrollment managed care plans grew these plans generally charged lower premiums traditional fee service plans highly competitive markets managed care plans also kept premiums low increase enrollment boost market share this turn forced traditional indemnity insurance companies competing managed care plans develop new low cost products lose market share these marketplace changes contributed health care costs consuming less business compensation costs profits according bureau labor statistics employment cost index eci civilian workers the primary driver slowdown benefits growth decline cost health benefits although separate health insurance benefit index available eci program publish employer compensation cost levels using current employment weights based eci measure average civilian employer health insurance costs fell 6.2 percent 1.29 1.21 per hour worked march 1994 1995 period wages salary costs grew 0.5 percent 13.06 13.12 per hour worked private health insurance obtained primarily employer sponsored health plans health plans purchased separately individuals 1995 private health insurance premiums continued grow slow rate increasing 2.6 percent previous year however employee share employer sponsored health insurance increased 8.1 percent 1994more twice growth rate employer contribution premiums result share health plan premium costs paid employers inched downward recent years many employers shifted premium burden employees either requiring workers contribute health insurance premiums raising required employee premium rapidly overall premium cost growth one factor contributing premium cost shift employers employees migration covered workers lower cost managed care plans health maintenance organizations preferred provider organizations point service plans although employees generally incurred reduced pocket costs expanded services managed care plan employers typically paid smaller portion total premium plans traditional indemnity fee service plans therefore likely rapid expansion managed care enrollment 1990s effect boosting employee share total premiums the majority spending 182.6 billion pocket health care expenses covered insurance copayments deductibles the remainder spent phi premiums 68.5 billion premiums contributions medicare trust funds 72.2 billion the switch managed care affected level household pocket payments starting late 1980s growth pocket expenses health care lowest since 1970 this coincides increased enrollment managed care plans lower deductibles copayments traditional fee service plans households paid approximately 5.5 percent income taxes health care u.s bureau labor statistics 1990 95 according consumer expenditure survey data elderly households ( households reference persons 65 years age spend three times much income taxes health care non elderly households in 1995 public sector paid 38 percent 360.4 billion hss the federal government paid 203.4 billion state local government paid 157.0 billion the portion federal government revenues financing health care costs declined slightly 1994 1995 several years significant growth the decrease 24.0 percent 1993 22.8 percent 1995 primarily due increase federal revenues rather slowdown federal health spending medicare incurred expenditures 187.0 billion 1995 11.6 percent previous year the medicare program funded 3 sources 1 payroll taxes paid employers households 2 premiums income taxes social security benefits paid households 3 income federal government accounting scheme federal government contributions medicare program include trust fund interest income net changes trust fund balances transfers general fund treasury board trustees federal hospital insurance trust fund 1996 board trustees federal supplemental insurance trust fund 1996 1995 medicare hospital insurance hi benefit payments administrative expenses exceeded income 2.6 billion this financing shortfall met redeeming 2.6 billion treasury securities held hi trust fund this necessity contributed increase government share total expenditures 1995 the disparity income expenses expected grow rapidly assets hi trust fund becoming exhausted 2001 absence corrective legislation

for the period 1990 - 95 , we will present data on health care spending by business , households , and government . in addition , we will measure the relative impact of these expenditures on each sector 's ability to pay . in 1994 and 1995 , health care costs experienced the slowest growth in 3 decades . combined with healthy revenue growth , slow cost growth helped ease or stabilize the financing burden faced by business , households and government .

we developed a sensitive and accurate analytical method for quantifying methyleugenol ( me ) in human serum . our method uses a simple solid - phase extraction followed by a highly specific analysis using isotope dilution gas chromatography - high resolution mass spectrometry . our method is very accurate ; its limit of detection is 3.1 pg / g and its average coefficient of variation is 14% over a 200-pg / g range . we applied this method to measure serum me concentrations in adults in the general u.s . population . me was detected in 98% of our samples , with a mean me concentration of 24 pg / g ( range < 3.1 - 390 pg / g ) . lipid adjustment of the data did not alter the distribution . bivariate and multivariate analyses using selected demographic variables showed only marginal relationships between race / ethnicity and sex / fasting status with serum me concentrations . although no demographic variable was a good predictor of me exposure or dose , our data indicate prevalent exposure of u.s . adults to me . detailed pharmacokinetic studies are required to determine the relationship between me intake and human serum me concentrations.imagesfigure 1figure 2figure 3figure 4figure 5figure 6figure 7

developmental acquired rarely may associated temporomandibular joint tmj ankylosis it occasionally reported since probably due usually asymptomatic nature 1941 hrdlicka reported first cases bmc 21 specimens unspecified number dried skulls 1948 sicher first reported anomaly living person honee bloem described case bifid condyle cadaver 71-year old patient although type morphologic change generally associated trauma conditions teratogenic drug use genetic inheritance infection exposure radiation also cause development anomaly the first patient 14-year old female history extraction lower decayed painful left first molar done 3 months earlier the patient continued pain recurrent swelling extraction managed treating dentist medications the patient presented department dull pain facial swelling relation lower left molar region extending angle mandible axial coronal computed tomography ct images bilateral tmj mandible multiplanar reformatting mpr done evaluating pathologic fracture tmj pathosis these findings best seen axial sagittal images figure 1 coronal axial ct images demonstrate left bmc oriented anteroposteriorly articular surface irregularity second patient 12-year old female patient referred ct examination evaluation mild facial asymmetry suspected tmj ankylosis she reduced degree jaw opening since childhood subsequently developed midline deviation left along difficulty mastication these images demonstrated sagittal splitting left mandibular condyle medial lateral condylar head the first patient 14-year old female history extraction lower decayed painful left first molar done 3 months earlier the patient continued pain recurrent swelling extraction managed treating dentist medications the patient presented department dull pain facial swelling relation lower left molar region extending angle mandible axial coronal computed tomography ct images bilateral tmj mandible multiplanar reformatting mpr done evaluating pathologic fracture tmj pathosis these findings best seen axial sagittal images figure 1 the second patient 12-year old female patient referred ct examination evaluation mild facial asymmetry suspected tmj ankylosis she reduced degree jaw opening since childhood subsequently developed midline deviation left along difficulty mastication these images demonstrated sagittal splitting left mandibular condyle medial lateral condylar head szentpetery et al study 1882 cadaveric skulls found incidence bmc 0.48% a report four cases bifid condyles presented loh yeo included one involving edentulous cadaver literature review reported cases living patients subsequently four cases stefanou et al two cases reported recently artvinli kansu 2003 antoniades et al 2004 reported first two cases trifid condyle patients also bifid condyles side described first case bilateral bifid condyles living patient since 10 cases reported current literature review living patients revealed total 45 cases bifid condyle 11 cases bilateral giving ratio approximately 3:1 however survey dry skulls cadaveric reports included total number 84 cases 15 bilateral they appear common left side unilateral cases ratio 2:1 most cases 67% asymptomatic found routine dental radiographic examination however reported patients presenting tmj symptoms swelling trauma ankylosis the embryologic theory suggests due obstruction blood supply condyle persistence vascularized fibrous septa another theory postulates trauma cause disruption dislocation joint integrity due birth trauma condylar fractures surgical condylectomy separate studies conducted loh yeo antoniades et al found cases bifid condyle asymptomatic associated history trauma .. site fracture mandibular condyle relation insertion lateral pterygoid muscles factors determining future development bifid condyle other causes proposed include genetics endocrine disturbances infection radiation nutritional deficiencies exposure teratogenic substances support latter suggestion comes work gundlach et al experimentally induced bifid condyles rats injecting teratogenic substances n methyl n nitrosourea formhydroxamic acid different concentrations various stages pregnancy the extent bifid condyle may range shallow groove discrete condylar heads orientation may anteroposterior mediolateral it postulated anteroposterior splitting usually occurs patients identifiable antecedent trauma mediolateral splitting usually developmental origin but here patient seen history trauma mediolaterally splitted condyle anteroposterior splitting osteomyelitis patient denied previous trauma life szentpetery et al suggested two condylar parts lie sagittal plane trauma indicated cause parts lie coronal plane persistence fibrous septa condylar cartilage likely cause while may true majority cases mediolateral bifid condyles reported following sagittal fracture condylar head according blackwood two articulating surfaces bmc divided groove could orientated mediolaterally anteroposteriorly characterizing specific entity case report as postulated groove formation presence medial lateral head condyles clearly demonstrated formation bmc majority cases detected routine radiographic examination cases however bmc reported associated pain swelling restricted mouth opening commonly tmj clicking case due lack clinical symptoms diagnosis made radiographic findings ct scan best radiograph detection bmc allows detailed evaluation condylar morphology however bmc also seen opg sometimes overlapping anatomic structures hide bifidity summary bmc an anatomic variation condyle rare anomaly whose etiology unknown present case literature says commonly due facial trauma early stages development patients internal articular derangement treated occlusal splints arthroscopic surgery patients associated articular ankylosis may need surgical condylectomy arthroplasty awareness abnormality help avoid mistaking fracture tumor our first case also illustrates point bmc may associated tmj ankylosis such case requires detailed clinical examination evaluation ct management prognosticating outcome

bifid condyle is a rare anatomic variation of mandibular condyle . it can be symptomatic or diagnosed incidentally on routine radiographic examination . no definite etiologic factor has been identified . it is suggested that bifid condyle could be a developmental anomaly or secondary to trauma . we are reporting two cases of bifid mandibular condyle . both were diagnosed using computed tomography scan , which additionally revealed the associated pathosis in the angle of the mandible in first patient and the ankylosis of temporomandibular joint in the second patient .

retrospective study included 343 glaucoma subjects examined glaucoma clinic asan medical center patients met inclusion criteria least three years follow seven reliable vf measurements consecutively enrolled medical record review eyes underwent intraocular surgery including cataract glaucoma filtering procedures follow period excluded initial diagnosis each patient received comprehensive ophthalmologic examination included review medical history presence systemic diseases like systemic hypertension diabetes cerebrovascular accident dyslipidemia migraine measurement best corrected visual acuity confirm visual acuity adequate automated perimetry performance slit lamp biomicroscopy goldmann applanation tonometry gonioscopy dilated fundoscopic examination using 90- 78-diopter lens stereoscopic optic disc retinal nerve fiber layer rnfl photography vf examination standard automated perimetry humphrey swedish interactive threshold algorithm standard strategy 24 2 carl zeiss meditec dublin ca usa measurement central corneal thickness cct dgh-550 instrument dgh technology inc all included patients met following criteria baseline exam best corrected visual acuity 20 30 better spherical equivalent se within 5 diopters cylinder correction within 3 diopters vf mean deviation md higher -20 db presence normal anterior chamber open angle slit lamp gonioscopic examinations diagnosis glaucoma based presence typical glaucomatous changes optic disc glaucomatous vf defect thus eyes glaucomatous optic disc normal vf defined glaucoma glaucomatous optic disc change included increased cupping vertical cup disc ratio 0.7 difference vertical cup disc ratio 0.2 eyes diffuse focal neural rim thinning disc hemorrhage rnfl defects eyes defined glaucomatous vf defects met two following three criteria confirmed two reliable consecutive tests 1 cluster three points probability less 5% pattern deviation map least one hemifield including least one point probability less 1% cluster two points probability less 1% 2 glaucoma hemifield test result outside normal limit 3 pattern standard deviation result less 5% reliable vf assessment defined vf test false positive error less 15% false negative error less 15% fixation loss less 20% if least one eye showed glaucomatous changes patient included analysis iop lowering medication prescribed eyes showed glaucomatous optic disc changes glaucomatous optic disc vf changes all procedures conformed declaration helsinki study approved institutional review board asan medical center since glaucomatous damage involves structural functional changes may appear time glaucoma progression determined either structural functional measures structural progression assessed using stereoscopic optic disc red free rnfl photographs two glaucoma experts krs jhn independently assessed photographs order estimate glaucoma progression patients first last visits both graders blind progression assessments clinical vf information photographs presented chronological order masking patient identification age test date each grader viewed photographs eye making assessment asked determine possible presence glaucomatous optic disc rnfl progression revealed increase extent neuroretinal rim thinning enhancement disc excavation widening deepening rnfl defect and/or appearance new disc hemorrhage if opinions two observers differed third examiner dj made final decision commercial software guided progression analysis carl zeiss meditec used determine progressive functional loss vf vf defect progression defined significant deterioration baseline pattern deviation three test points evaluated three consecutive examinations one eye showed progression either structural functional assessment follow period patient included upg group in contrast eyes showed progression patient included bpg group age gender prevalence systemic diseases systemic hypertension diabetes cerebrovascular accident migraine dyslipidema compared upg bpg groups upg group pre treatment iop mean post treatment iop cct se baseline vf md vf pattern standard deviation progression rates compared pe npe within patient the progression rates md slope determined linear regression analysis md values serial vf analyses bpg group the parameters compared fpe spe within patient normally distributed data compared upg bpg groups using unpaired tests non normally distributed data compared using either mann whitney wilcoxon signed rank test this retrospective study included 343 glaucoma subjects examined glaucoma clinic asan medical center patients met inclusion criteria least three years follow seven reliable vf measurements consecutively enrolled medical record review eyes underwent intraocular surgery including cataract glaucoma filtering procedures follow period excluded initial diagnosis each patient received comprehensive ophthalmologic examination included review medical history presence systemic diseases like systemic hypertension diabetes cerebrovascular accident dyslipidemia migraine measurement best corrected visual acuity confirm visual acuity adequate automated perimetry performance slit lamp biomicroscopy goldmann applanation tonometry gonioscopy dilated fundoscopic examination using 90- 78-diopter lens stereoscopic optic disc retinal nerve fiber layer rnfl photography vf examination standard automated perimetry humphrey swedish interactive threshold algorithm standard strategy 24 2 carl zeiss meditec dublin ca usa measurement central corneal thickness cct dgh-550 instrument dgh technology inc all included patients met following criteria baseline exam best corrected visual acuity 20 30 better spherical equivalent se within 5 diopters cylinder correction within 3 diopters vf mean deviation md higher -20 db presence normal anterior chamber open angle slit lamp gonioscopic examinations diagnosis glaucoma based presence typical glaucomatous changes optic disc glaucomatous vf defect thus eyes glaucomatous optic disc normal vf defined glaucoma glaucomatous optic disc change included increased cupping vertical cup disc ratio 0.7 difference vertical cup disc ratio 0.2 eyes diffuse focal neural rim thinning disc hemorrhage rnfl defects eyes defined glaucomatous vf defects met two following three criteria confirmed two reliable consecutive tests 1 cluster three points probability less 5% pattern deviation map least one hemifield including least one point probability less 1% cluster two points probability less 1% 2 glaucoma hemifield test result outside normal limit 3 pattern standard deviation result less 5% reliable vf assessment defined vf test false positive error less 15% false negative error less 15% fixation loss less 20% if least one eye showed glaucomatous changes patient included analysis iop lowering medication prescribed eyes showed glaucomatous optic disc changes glaucomatous optic disc vf changes all procedures conformed declaration helsinki study approved institutional review board asan medical center since glaucomatous damage involves structural functional changes may appear time glaucoma progression determined either structural functional measures structural progression assessed using stereoscopic optic disc red free rnfl photographs two glaucoma experts krs jhn independently assessed photographs order estimate glaucoma progression patients first last visits both graders blind progression assessments clinical vf information photographs presented chronological order masking patient identification age test date each grader viewed photographs eye making assessment asked determine possible presence glaucomatous optic disc rnfl progression revealed increase extent neuroretinal rim thinning enhancement disc excavation widening deepening rnfl defect and/or appearance new disc hemorrhage if opinions two observers differed third examiner dj made final decision commercial software guided progression analysis carl zeiss meditec used determine progressive functional loss vf vf defect progression defined significant deterioration baseline pattern deviation three test points evaluated three consecutive examinations if one eye showed progression either structural functional assessment follow period patient included upg group contrast eyes showed progression patient included bpg group age gender prevalence systemic diseases systemic hypertension diabetes cerebrovascular accident migraine dyslipidema compared upg bpg groups upg group pre treatment iop mean post treatment iop cct se baseline vf md vf pattern standard deviation progression rates compared pe npe within patient the progression rates md slope determined linear regression analysis md values serial vf analyses bpg group the parameters compared fpe spe within patient normally distributed data compared upg bpg groups using unpaired tests non normally distributed data compared using either mann whitney wilcoxon signed rank test a total 343 korean patients included final analysis 182 men 161 women the mean follow period 4.2 years baseline 134 patients unilateral glaucoma among 134 patients 102 showed glaucomatous optic disc changes normal vf fellow eye remaining 32 patients normal appearing optic disc normal vf fellow eye among 134 unilateral glaucoma patients 25 patients showed unilateral progression follow 6 patients showed bilateral progression ; thus 31 patients either unilateral bilateral progression 103 patients stable among 32 patients unilateral glaucoma normal optic disc vf fellow eye none fellow eyes showed progression at baseline 209 patients bilateral glaucoma 43 showed progression 25 showing bilateral progression 1 hence bpg group consisted 31 patients 6 unilateral glaucoma baseline group 25 bilateral glaucoma baseline group upg group consisted 43 patients 25 unilateral glaucoma baseline 18 bilateral glaucoma baseline the mean age significantly higher upg group bpg group 58.7 10.0 vs. 52.6 3.9 years p 0.035 however prevalence analyzed systemic diseases different two groups table 1 all pes upg group showed severe clinical characteristics terms baseline vf parameters however baseline iop mean follow iop cct se significantly different pe npe table 2 the progression rate determined md slope compared fpe spe within patient bpg group expected progression rate higher fpe parameters differ significantly table 3 when pe upg group compared fpe eye bpg group progression rate significantly higher fpe bpg group parameters differed table 4 according data 343 patients analyzed study 134 39.1% presented unilateral glaucoma baseline among unilateral glaucoma patients 76.1% showed glaucomatous optic disc changes fellow eye 32 patients glaucomatous patients 9.3% completely unilateral glaucoma normal optic disc normal vf fellow eye among 134 unilateral glaucoma patients 23.1% showed progression follow period the fellow eye 32 patients unilateral glaucoma show progression follow although iop lowering treatment performed eyes among 209 bilateral glaucoma patients 20.6% showed progression thus overall prevalence progression similar patients unilateral glaucoma bilateral glaucoma interestingly 80.6% patients progressing disease unilateral glaucoma group demonstrated unilateral progression 58.1% patients progressing disease bilateral glaucoma group showed bilateral progression chen park showed 6.2% fellow eyes progressed period 8.7 years among 134 unilateral perimetric glaucoma patients 6 4.5% showed progression fellow eye present study the results current study indicated significant differences prevalence analyzed systemic disease upg bpg groups overall prevalence systemic disease low groups may affect statistical analysis contribute lack significance data in contrast present data study kim kim showed prevalence systemic disease different patients unilateral bilateral glaucoma discrepancy likely due fact systemic disease affect development bilateral glaucoma progression disease modulated various factors thus reducing effect systemic disease glaucoma progression for instance myopia known risk factor development glaucoma progression disease although remains debate when compared pe npe upg group pe showed advanced disease status baseline however difference iop cct se fpe spe bpg group comparison pe npe upg group iop similarly iop differ fpe spe bpg group as shown mean baseline iop measurements patients current study low iop categorized normal tension low tension glaucoma whether correlation exists iop asymmetry glaucoma severity cases normal tension glaucoma debate previous studies some studies shown higher iop related advanced stages glaucoma however low pressure glaucoma treatment study reported iop asymmetry unrelated vf asymmetry the present study revealed differences iop pe npe upg group fpe spe bpg group while iop reduction substantially decreased progression rate collaborative normal tension glaucoma study treated eyes also showed progression randomized clinical trial thus taken together results previous studies suggest factors iop may affect progression glaucoma lower iop readings investigated future studies furthermore differences noted baseline vf defect severity iop values pe upg group fpe bpg group however progression rate significantly higher fpe bpg group the progression rate pe upg group -0.70 db year approximately two times higher usual progression rates reported previous randomized clinical trials -0.36 -0.41 db yr the progression rate fpe bpg group approximately five times higher -3.43 vs. -0.70 db yr pe upg group thus speculate simultaneously bilaterally progressing patients eyes progress faster pe upg contrast baseline vf defect severity different pe upg group fpe bpg group first prevalence systemic disease determined self reported histories patients second follow period mean 4.2 years relatively short considering slow progressing nature glaucoma period may sufficient observe natural progression disease some cases unilateral glaucoma may eventually progress bilateral glaucoma cases unilaterally progressing eye may show progression fellow eye time however four years observation study unilateral glaucoma tended progress glaucomatous eye simultaneously bilaterally progressing patients showed much faster progression rates unilaterally progressing eye no systemic factors analyzed study significantly differed prevalence upg bpg groups therefore glaucoma patients simultaneous bilateral progression treated caution clinical practice cases show relatively rapid progression

purposeto compare the clinical characteristics of unilaterally progressing glaucoma ( upg ) and simultaneously bilaterally progressing glaucoma ( bpg ) in medically treated cases.methodsprimary open angle glaucoma patients were classified as having upg or bpg according to an assessment of optic disc and retinal nerve fiber layer photographs and visual field analysis . risk factors including the presence of systemic diseases ( hypertension , diabetes , cerebrovascular accident , migraine , and dyslipidema ) were compared between the upg and bpg groups . baseline characteristics and pre- and post - treatment intraocular pressure ( iop ) were compared between the progressing eye ( pe ) and the non - progressing eye ( npe ) within the same patient in the upg group and between the faster progressing eye and the slower progressing eye in the bpg group.resultsamong 343 patients ( average follow - up period of 4.2 years ) , 43 were categorized into the upg group and 31 into the bpg group . the prevalence of all analyzed systemic diseases did not differ between the two groups . pes in the upg group had more severe pathology in terms of baseline visual field parameters than npes ( mean deviation -6.9 5.7 vs. -2.9 3.9 db , respectively ; p < 0.001 ) . however , baseline iop , mean follow - up iop , and other clinical characteristics were not significantly different between the pe and the npe in the upg group . the progression rate was significantly higher in the faster progressing eye in patients with bpg than in the pe for patients with upg ( -3.43 3.27 vs. -0.70 1.26 db / yr , respectively ; p = 0.014).conclusionsthere were no significant differences in the prevalence of systemic diseases between the upg and bpg groups . simultaneously bilaterally progressing patients showed much faster progression rates than those with a unilaterally progressing eye .

diabetes common metabolic disease increasing prevalence reduces life expectancy third 1 2 there 200 million people diabetes worldwide 5% adult population 3 according nationwide study 2001 the prevalence diabetes iran estimated 4.67% among population older 20 years 4 diabetes usually associated short term complications hypoglycemia long term complications like cardiovascular diseases neuropathy nephropathy retinopathy amid patients diabetes twice exposed risk psychiatric diseases compared normal population according studies one every 5 patients diabetes suffer depression 5 6 symptoms depression observed 29% men 30.5% women diabetes bangladesh villages 7 khamseh study 71.8% patients diabetes major depression 8) sepehrmanesh study kashan rate 57.7% among women 41% among men 9 many factors affected treatment disease including physical function daily activity social relationships quality life personal mood as disease affects patient self confidence increase fear worsening complications risk psychiatric diseases increases 10 depression associated increased risk high blood glucose complications diabetes cardiovascular diseases possibly patient reduced compliance 11 14 furthermore diabetic patients depression greater burden treatment costs referrals patients without depression 15 various studies shown unlike normal people patients diabetes lower quality life much pronounced suffering complications diabetes depression also significant effect patients quality life 16 18 study yazd the mean score quality life studied patients 25.65 60 patients complications like retinopathy neuropathy score lower compared patients without complications 19 comorbidity depression diabetes cumulative effect people functions 20 diagnosis depression patients particularly important order reduce complications improve quality life li et al reported depression diagnosed 45% diabetic patients 21 depression leads patient noncompliance blood glucose mismanagement physical complications 11 19 22 ciechanowski et al reported depressed patients unable comply dietary regimen manage blood glucose respect clearly different non depressed patients 23 regard effect diabetes depression quality life 2004 filakovic et al demonstrated comorbidity depression diabetes lowers patients quality life many folds 24 ) although several studies conducted either quality life depression diabetic patients studies relationship quality life depression diabetic patients moreover given failure diagnose depression diabetic patients commonplace need identify screen psychiatric disorders patients chronic diseases especially diabetes impact depression quality life article aimed investigate relationship depression quality life patients diabetes using medical records diabetics clinic gorgan the current survey approved 46 ethics committee golestan university medical sciences 327123847 total 330 eligible patients diabetes selected patients admitted specialized diabetic clinic city gorgan north iran 5th azar hospital first 6 months 2012 inclusion criteria confirmed diabetic record clinic specialist age range 25 75 years regular visits clinic treatment insulin oral medication type diabetes treated psychological health problems patients assured confidentiality data informed consents obtained according ethics committee guidelines study 25 correlation depression quality life r 0.39 95% confidence interval 90% power test 66 diabetic patients depression needed achieve respect 20% estimation depression patients diabetes 5 7 330 patients type 2 diabetes clinic specialized state referral clinic gorgan supported 5th azar hospital also one 3 state hospitals belonged golestan university medical sciences since 80% attended patients diabetes health centers visited aforementioned clinic continuous access according patients record n 1150 330 subjects finally selected using systematic sampling interval 3 k / n 3 way first patient randomly selected then number selected 1 3 second patient selected cases respect sampling interval 3 samples included number 5 8 989 demographic questionnaire completed presence patients related data disease complications obtained records beck depression inventory bdi used assess depression short version 26 items world health organization quality life questionnaire whoqol bref used assess quality life bdi contains 21 items evaluates signs depression including sadness guilt loss interest social isolation suicidal ideation each item rated 4-point likert scoring style 0 lowest 3 highest each option determined mild severe 0 psychological health scores 1 2 3 mild moderate severe disorders respectively overall depression score patient found summing scores items ranging 0 63 higher scores indicate severe depression follows 0 15 means depression 16 31 mild depression 32 47 moderate depression 48 63 severe depression its reliability determined internal consistency using cronbach 84% correlation obtained 70% using split half method 26 study cronbach reliability questionnaire diabetic patients found 0.77 indicates questionnaire suitable study diez quevedo et al also studied diagnosing mental disorders 1003 general hospital spanish inpatients 2001 27 26-item whoqol bref the first two items assess general health status quality life next 24 items assess quality life 4 domains physical health psychological health social relationships environment using 3 6 7 8 items respectively study the 5-point likert scale applied items 1 15 bad bad bad good good items 2 16 25 unhappy unhappy unhappy happy happy items 3 14 little medium high high item 26 never rarely occasionally often always scoring items 3 4 26 reverse compare domains first two items depressed non depressed groups patients quality life score patient xi ) was converted scores 0 100 using following equation 2 28 31 validity reliability whoqol bref reported favorable many native foreign studies 17 30 32 present study validity questionnaire estimated according internal consistency whole scale 85% physical health 78% psychological health 80% social relationships 69% environment 84% the normality qol scores dimensions tested confirmed kolmogorov smirnov test where item missing substituted mean items domain also 2 items missing domain calculate domain score the missing data bdi questionnaire replaced using median near points describe data central dispersion indicators mean standard deviation calculated compare qualitative characteristics depressed non depressed patients chi square test used mean scores qol sub domains age duration disease two groups analyzed using independent test we conducted multiple linear regression analyses assess prediction qol scores relationship variables in addition used scatter diagrams visualize relationship dependent variable metric independent variable sure linear in addition also checked whether relationship dependent variable categorical independent variables homoscedastic the current survey approved 46 ethics committee golestan university medical sciences 327123847 in total 330 eligible patients diabetes selected patients admitted specialized diabetic clinic city gorgan north iran 5th azar hospital first 6 months 2012 inclusion criteria confirmed diabetic record clinic specialist age range 25 75 years regular visits clinic treatment insulin oral medication type diabetes treated psychological health problems patients assured confidentiality data informed consents obtained according ethics committee guidelines study 25 correlation depression quality life r 0.39 95% confidence interval 90% power test 66 diabetic patients depression needed achieve respect 20% estimation depression patients diabetes 5 7 330 patients type 2 diabetes clinic specialized state referral clinic gorgan supported 5th azar hospital also one 3 state hospitals belonged golestan university medical sciences since 80% attended patients diabetes health centers visited aforementioned clinic continuous access according patients record n 1150 330 subjects finally selected using systematic sampling interval 3 k / n 3 way first patient randomly selected then number selected 1 3 second patient selected in cases respect sampling interval 3 samples included number 5 8 989 demographic questionnaire completed presence patients related data disease complications obtained records beck depression inventory bdi used assess depression short version 26 items world health organization quality life questionnaire whoqol bref used assess quality life bdi contains 21 items evaluates signs depression including sadness guilt loss interest social isolation suicidal ideation each item rated 4-point likert scoring style 0 lowest 3 highest each option determined mild severe 0 psychological health scores 1 2 3 mild moderate severe disorders respectively overall depression score patient found summing scores items ranging 0 63 higher scores indicate severe depression follows 0 15 means depression 16 31 mild depression 32 47 moderate depression 48 63 severe depression its reliability determined internal consistency using cronbach 84% correlation obtained 70% using split half method 26 study cronbach reliability questionnaire diabetic patients found 0.77 indicates questionnaire suitable study diez quevedo et al also studied diagnosing mental disorders 1003 general hospital spanish inpatients 2001 27 26-item whoqol bref the first two items assess general health status quality life next 24 items assess quality life 4 domains physical health psychological health social relationships environment using 3 6 7 8 items respectively study the 5-point likert scale applied items 1 15 bad bad bad good good items 2 16 25 unhappy unhappy unhappy happy happy items 3 14 little medium high high item 26 never rarely occasionally often always scoring items 3 4 26 reverse compare domains first two items depressed non depressed groups patients quality life score patient xi ) was converted scores 0 100 using following equation 2 28 31 validity reliability whoqol bref reported favorable many native foreign studies 17 30 32 present study validity questionnaire estimated according internal consistency whole scale 85% physical health 78% psychological health 80% social relationships 69% environment 84% the normality qol scores dimensions tested confirmed kolmogorov smirnov test where item missing substituted mean items domain also 2 items missing domain calculate domain score the missing data bdi questionnaire replaced using median near points describe data central dispersion indicators mean standard deviation calculated compare qualitative characteristics depressed non depressed patients chi square test used mean scores qol sub domains age duration disease two groups analyzed using independent test we conducted multiple linear regression analyses assess prediction qol scores relationship variables in addition used scatter diagrams visualize relationship dependent variable metric independent variable sure linear in addition also checked whether relationship dependent variable categorical independent variables homoscedastic a total 330 diabetic patients 35.5% men 64.5% women studied mean standard deviation age history disease 50.6 9 5.4 4.5 years respectively age range 25 75 years the prevalence depression diabetic patients 58.2% 124 patients 64.6% mild depression 56 29.2% moderate depression 12 6.2% severe depression this 64.8% men 61.5% women insignificant differences depression observed 45.1% single diabetic patients 60.6% married ones significant difference p 0.039 more 50% depressed diabetic patients 62.5% non depressed diabetic patients literate difference two groups significant however insignificant differences two groups terms employment status table 1 ( mean standard deviation depression score according bdi 29.4 10.1 depressed patients 8.1 4.1 non depressed patients significant difference p 0.001 comparison relationship clinical characteristics depression patients diabetes showed insignificant differences two groups respect dietary regimen diabetes complications retinopathy neuropathy nephropathy duration disease however hypertension 13.9% p 0.001 physical activity 24.7% less diabetic patients depression difference groups significant p 0.01 table 2 comparing scores various domains quality life depressed non depressed patients diabetes using independent test indicated significant lower mean scores subscales general health quality life general psychological health environment overall score quality life depressed diabetic patients error level 0.001 however physical health domain mean score lower depressed patients significant difference p 0.009 table 3 linear regression model prediction quality life score independent variables age gender duration disease hypertension diabetes complications education marital status occupation physical activity depression score showed significant inverse relationship overall score quality life variables physical activity diabetes complications otherwise depression score p 0.01 table 4 the present study results line results studies suggest high prevalence depression among patients diabetes 7 9 19 according present study 58.2% participants moderate severe depression 15.5% mild depression i.e. 73.7% patients likely depression study nedjat et al ( 28 28% patients depressed 38% mild depression making total 66% the rate depression 41.9% larijani 53.3% sepehrmanesh studies 9 19 21 kahn et al argue depression could result diabetes also risk factor onset diabetes 22 depression associated 60% increased risk type 2 diabetes diabetes causes increased risk depression 15% 23 however present study insignificant difference sexes prevalence depression line results pinquart et al the mean overall quality life score depressed patients 50.68 14.04 significantly lower non depressed patients 60.46 13.27 close results found nedjat et al ( 28 psychiatric habitat areas overall score differences groups significant among depressed patients mean score lower line studies 6 25 28 social relationships domain difference two groups insignificant perhaps could attributed rich relationships patients family relatives often become richer times disease depression affect physical outcomes myocardial infarction life expectancy cancer patients infections also explains effect depression immune system other reasons effect due fact depression diabetic patients affects compliance proper dietary regimen smoking exercise 7 study lin et al confirmed depressed patients perform poorly patients compliance personal care including proper nutrition exercise compliance treatment prevention 34 another study it found regarding incident disability mortality effects interaction diabetes depression seemed synergistic greater additive main effects diabetes depression compared depressed patients 8 groups patients chronic diseases found depressed patients showed greater reduction quality life 8 groups effect remained even eliminating factors age gender chronic diseases 35 present study high prevalence comorbidity depression diabetes patients indicates effect depression comorbidity quality life significantly affect outcomes disease early diagnosis depression improve quality life 25 study limitations included lack measurement hba1c could help assess better patients blood glucose effect disease complications it therefore suggested measurement taken consideration future similar studies given results studies seems high prevalence depression among patients diabetes significant effect diabetes outcomes quality life it recommended besides regular doctors visits terms physical problems psychiatric problems quality life patients also considered regular psychiatrist visits psychological assessments screening mental disorders help early diagnosis disorders our survey weaknesses follow 1 used self administered questionnaire could include patients bias 2 participants may fully understood misinterpreted questions might biased responses 3 conducted cross sectional method provided us information particular issue time however study strong points mentioned covering 80% patients diabetes golestan province attended specialized diabetes clinic supported golestan university medical sciences

background : frequency of mood disorders in patients with chronic diseases , especially diabetes and its effects on life quality are dramatically increasing.objectives:this study aimed to investigate the relation between depression and quality of life in patients with diabetes.patients and methods : this is a cross sectional survey . subjects were selected from 330 eligible people referred to the only diabetes clinic in gorgan city during 6 months , using systematic random sampling . beak depression questionnaire and the brief questioner with 26 questions recommended by the world health organization ( whoqol - bref ) were used to measure depression and quality of life , respectively . data were analyzed through descriptive methods , chi - square , independent t test and linear regression model using spss16 ; moreover , p value < 0.05 was considered as significant.results:in total , 330 patients with diabetes ( 35.5 % male and 64.5% women ) were studied . the mean and standard deviation of their age and years involved with diabetes were 50.6 9.0 and 5.4 4.5 years , respectively . range of age was 25 - 75 years , as well . the prevalence of depression in all patients with diabetes was 58.2% ( 124 mild , 56 medium , and 12 with severe depression ) . hypertension was 13.9% more in diabetic patients with depression ( p value < 0.001 ) and physical activity in 24.7% of the cases was less with a meaningful difference ( p value = 0.01 ) . the mean and standard deviation of quality of life in diabetic patients with and without depression was 50.7 14 and 60.5 13.3 , respectively that was significant in two groups ( p < 0.0001).conclusions : the prevalence of depression is high in patients with diabetes and has a considerable impact on the consequences of diabetes and quality of life too .

first tested proposed strategy designing symmetric rna dna hybrid dx motif fig two parallel hetero duplexes joined together two points strands cross one duplex the dx motif composed five nucleic acid strands one central long two times repetitive dna strand l2 two identical short peripheral dna strands two rna strands r although strands l cross duplexes r strand continuously extends one duplex one end twofold rotational axis passes centre motif perpendicular tile plane symmetry two strands identical two r strands each dx tile needs three unique component strands l r s. strand r rna molecule strands l dna molecules the dx tiles single stranded overhangs sticky ends end two duplexes two neighbouring dx tiles associate hybridization sticky ends the distance two crossover points tile set two turns 22 bp allow dx tiles tessellate plane instead forming one dimensional arrays essential keep two adjacent interacting dx tiles coplanar requires distance two adjacent crossover points two interacting dx tiles n 0.5 turns n integer current design the self assembly rna dna hybrid nanostructures one pot process an aqueous solution mixture component dna rna strands designated ratio slowly cooled 70 c 25 c 24 h. process dna rna strands recognize associate first individual dx tiles large assemblies the assemblies analysed native polyacrylamide gel electrophoresis page visualized atomic force microscopy afm native page supplementary fig s2 dna rna complexes appeared sharp bands expected mobility indicating hybrid complexes formed stable large two dimensional crystals tubular structures clearly visible fig 1 supplementary fig the apparent height single layered two dimensional crystals 2.1 nm reasonable value diameter 2.5 nm form duplexes rna the two dimensional crystals showed clear periodicities along perpendicular helical axes the distance two adjacent crossover points two interacting dx tiles 2.5 turns 29 bp indicated fig 1b inset important ensuring dx tiles coplanar final assemblies if distance deviates value helical nature duplexes would cause two interacting tiles different planes promote formation tubular structures when distance decreased 1 2 bp 29 bp hybrid dx tiles still able assemble large structures predominantly tubular heights much higher 2.5 nm diameter form duplex sometimes extended two dimensional crystals tubular structures occasionally ripped monolayers regular patterns observed when distance increases 1 bp decreases 3 bp hybrid dx tiles form large regular assemblies overall formation tubules preferred two dimensional arrays cases rna dna hybrid dx tiles prone pure dna dx tiles form tubular structures the strategy using dna program rna self assembly general approach used construction variety structures demonstrate capability engineered two rna dna hybrid star motifs symmetric dna star motifs family related nanostructures different numbers branches 3 4 5 6 each motif assembled three different strands long repetitive strand l medium strand short peripheral strand all star motifs share strands differ one another strand l. sequence repeating time l strand determines branch number motif current work the strand replaced rna strand r resulting rna dna hybrid star motifs rna residues comprise half nanomotifs appropriate sticky ends present peripheral ends duplexes hybrid motifs associate two dimensional arrays figs 2 3 the l strands contain unpaired single stranded loops shown orange figs 2 3 three four bases long three- four pointed star respectively centre the short loops long enough prevent branches stacking one another centre short enough prevent tiles flexible to prevent intrinsic curvatures tiles accumulating one direction corrugation strategy also applied12,33,34 any two interacting tiles separated 4.5 turns two adjacent tiles related twofold rotational axis perpendicular molecular plane this arrangement cancels intrinsic curvatures tiles promotes tiles form extended two dimensional arrays slow cooling rna dna hybrid star tiles readily assemble two dimensional crystals visualized means afm imaging the four point star tiles assemble periodic two dimensional arrays fig 2 apparent height 2.2 nm cavities resulting two dimensional crystals surprise squares instead their dimensions 27.2 1.6 nm 19 1.4 nm this observation suggests overall geometry individual rna dna hybrid tile skewed four point star four leafed pinwheel fig any two opposite leafs hybrid star shifted away 4 nm one another direction perpendicular helical axes the overall tile structure quite different homo dna counterpart it unlikely due surface phenomenon differential adsorption onto mica substrate the two faces two dimensional arrays identical many twofold rotational symmetry axes example twofold rotational axes indicated bold black arrows shown figs 2b 3b exist plane similar phenomenon although less obvious observed rna dna hybrid three point star motif fig its overall geometry skewed three point star three leafed pinwheel threefold rotational symmetry consequently two dimensional arrays tiles threefold instead sixfold rotational symmetries the strategy dna programmed rna self assembly limited two dimensional self assembly also applied three dimensional self assembly demonstrate three dimensional assembly each vertex connectivity 3 represented three point star tile the hybrid three point star similar one used assembling trigonal two dimensional arrays however three point star tiles dodecahedra significantly bent away planar structure provide enough flexibility tile bend central single stranded loops l strand elongated 3 11 bases addition two interacting tiles designed separated four turns integral number turns separation two interacting tiles face side tile plane intrinsic tile curvatures accumulate direction turn promote tiles assemble closed discrete structures17 similarly two dimensional self assembly assembly process three dimensional structures simple one pot process dna hybrid dodecahedra characterized dynamic light scattering dls cryogenic electron microscopy cryoem imaging the hydrodynamic radius hybrid complex 20.7 1.3 nm measured dls the value consistent radius 20.5 nm circumscribed sphere hybrid dodecahedron model assuming pitch 0.26 nm bp diameter 2.3 nm rna 4 raw images randomly distributed dodecahedral particles observed expected size small fragments and large aggregates also exist clear whether undesired structures formed assembly process result damage accompanying sample preparation the yield correctly formed particle 40% based visual observation cryoem images significantly lower assembly yield pure dna dodecahedrons experimentally observed particles three dimensional map rna dna hybrid dodecahedron generated single particle three dimensional reconstruction powerful technique routinely used structural virologists35 the map resolution determined 2.5 nm using fourier shell correlation 0.5 threshold criterion two three dimensional maps independently built half data sets there clear similarity computer generated two dimensional projections reconstructed structural model raw individual particle images fig 4e class averages raw particle images similar views supplementary fig the radius reconstructed dodecahedron model 20.5 nm consistent design dls data the skewness star motif observed reconstructed structural model two dimensional arrays presumably due low resolution cryoem data when considering strand overall assembly rna guideline make sure every helical domain composed one dna strand one rna strand this ensures helical domains uniform hybrid form duplexes red strands tiles green black strands according colour code figures theoretically also possible simultaneously use rna green black strands dna red strand it also possible use rna three strands green red black however experimentally explored possibility intention either general rna strands difficult prepare much less stable much expensive dna strands exactly sequence thus decided use minimum number one rna strands current study two dimensional self assembly star motifs either homo dna rna dna hybrid the symmetry remains three- fourfold rotational symmetry figs 2 3 design star motifs each branch identical crossover structure three- fourfold rotational symmetries expected previous homo dna structures star motif exhibits near d3 d4 symmetry those higher degree symmetries surprising finding results expected design dna structures likely due subtle difference a- b form duplexes central region tile supplementary fig the base pairs stack directly onto one another go centre dna helix in contrast base pairs form duplex shifted one another cavity appears centre duplex looking duplex in addition negative charges phosphate groups distributed differently along different forms duplexes electrostatic interactions would affect homo- hybrid duplexes differently causing structural adjustment minimize electrostatic repulsion single stranded loops 11 bases long orange segments strand l3 used centre provide enough flexibility motif bend dodecahedron formed instead tetrahedron dna hybrid star motifs rigid corresponding homo dna star motifs the important challenge rna self assembly rationally design construct well defined stiff branching motifs basic building blocks nanoconstruction appreciate level challenge four arm dna junction always adopts right handed x shaped structure dna hybrid junction either right- left handed36,37 compared challenge it simple straightforward adjust repeating length different duplex forms present study we also observed numerous different behaviours a- b form duplexes nanoconstruction including strong tendency hybrid dx form tubular structures skewed appearance star motifs surprising three dimensional assembly results star motifs four base long sticky ends associate one another form low mobility high molecular weight species smears absence divalent cations supplementary fig under conditions corresponding homo dna motifs associate dna hybrid structures current study chemically less stable corresponding homo dna structures for example homo dna structures change noticeably afm imaging stored one week 4 c rna dna hybrid structures degrade well defined nanoarray found afm imaging storage well current approach introducing rna dna nanostructures straightforward method simply create dna nanostructures appended single stranded oligonucleotides rna strands hybridize furthermore rna moieties fully accessible surrounding solvent harsh chemicals degrading enzymes rnases therefore prone degradation strategy reported it possible tightly fold rna deep inside nanostructures prevent rnase accessibility study plan summary the presented strategy using dna program rna self assembly comprises versatile method assembling rna molecules range nanostructures we believe strategy applied established dna nanomotifs dna origami unexpected phenomena fact star motifs straight also emerged fully understand phenomena achieve tight structural controls systematic theoretical modelling experimental studies necessary we expect strategy provide unified platform assembling rna dna large nanostructures multifunctional rna modalities sirnas micrornas antisense rnas ribozymes aptamers dna nanoparticles cellular deliveries small rnas aptamers cellular targeting small rna rna molecules transcribed t7 rna polymerase corresponding dna templates designed sequin38 computer program purified page form designed nanostructures rna dna strands were combined according correct molecular ratios tris acetic edta mg tae mg buffer slowly cooled 70 c room temperature after annealing samples visualized tapping mode afm multimode afm nanoscope iiia controller veeco air 22 c cryoem imaging rna dna sample solutions were concentrated 3 spread onto quantifoil grids plunge frozen data recorded using gatan 4k 4k charge coupled device ccd camera philips cm200 transmission electron microscope three dimensional reconstructions dna dodecahedra used single particle image processing software eman39 icosahedral symmetry polyhedra was established processing images assuming different symmetries finding symmetry yielded three dimensional reconstruction consistent particle images rna molecules transcribed t7 rna polymerase corresponding dna templates designed sequin38 computer program purified page form designed nanostructures rna dna strands were combined according correct molecular ratios tris acetic edta mg tae mg buffer slowly cooled 70 c room temperature after annealing samples visualized tapping mode afm multimode afm nanoscope iiia controller veeco air 22 c cryoem imaging rna dna sample solutions were concentrated 3 spread onto quantifoil grids plunge frozen data recorded using gatan 4k 4k charge coupled device ccd camera philips cm200 transmission electron microscope three dimensional reconstructions dna dodecahedra used single particle image processing software eman39 icosahedral symmetry polyhedra was established processing images assuming different symmetries finding symmetry yielded three dimensional reconstruction consistent particle images

dna has recently been used as a programmable smart building block for the assembly of a wide range of nanostructures . it remains difficult , however , to construct dna assemblies that are also functional . incorporating rna is a promising strategy to circumvent this issue as rna is structurally related to dna but exhibits rich chemical , structural and functional diversities . however , only a few examples of rationally designed rna structures have been reported . herein , we describe a simple , general strategy for the de novo design of nanostructures in which the self - assembly of rna strands is programmed by dna strands . to demonstrate the versatility of this approach , we have designed and constructed three different rna dna hybrid branched nanomotifs ( tiles ) , which readily assemble into one - dimensional nanofibres , extended two - dimensional arrays and a discrete three - dimensional object . the current strategy could enable the integration of the precise programmability of dna with the rich functionality of rna .

consequently safer alternative anti inflammatory agents prevent treat excessive postoperative inflammation pain following cataract surgery would advantageous cyclo oxygenase cox important enzyme inflammatory process catalyzes biosynthesis prostaglandins thromboxanes arachidonic acid.1 two main isoforms cox-1 cox-2 well characterized cox-1 constitutively expressed mammalian cells including kidney gastrointestinal tract platelets vascular endothelium plays pivotal role normal physiological function cox-2 hand inducible enzyme thought primarily responsible inflammatory mediated reactions nonsteroidal anti inflammatory drugs nsaids potent inhibitors cox enzymes thereby synthesis prostaglandins while anti inflammatory actions corticosteroids part inhibition phospholipase a2 preventing release arachidonic acid membrane bound phospholipids nsaids act downstream cascade directly inhibit cox-1 cox-2 enzymes within eye firmly established prostaglandins disrupt blood ocular barrier increase vasodilation facilitate leukocyte migration promote pain.1 consequently inhibition favorable effects intraocular inflammation pain in support several randomized prospective double masked placebo controlled studies shown topically applied indomethacin 1% flurbiprofen 0.03% ketorolac 0.4% 0.5% diclofenac 0.1% nepafenac 0.1% bromfenac 0.09% reduce postoperative inflammation following cataract surgery.1 similarly prospective randomized studies demonstrated diclofenac 0.1% ketorolac 0.4% nepafenac 0.1% bromfenac 0.09% reduce ocular discomfort cataract surgery.1 commercially available ophthalmic nsaids ketorolac tromethamine ketorolac possesses greatest number studies supporting efficacy preventing treating postoperative inflammation pain cataract surgery table 1).521 ketorolac 0.5% acular allergan inc irvine ca approved food drug administration fda seasonal allergic conjunctivitis inflammation following cataract surgery ocular discomfort refractive surgery.22 reduce incidence burning stinging 0.4% concentration ketorolac acular ls allergan inc formulated appears similar therapeutic effect.18,23 ketorolac 0.4% approved fda reduction ocular pain burning following corneal refractive surgery more recently preservative free 0.45% preparation ketorolac acuvail allergan inc carboxymethylcellulose approved fda 2009 treatment pain inflammation following cataract surgery dosed twice daily.24 specific intent review assess available evidence supporting efficacy acuvail treatment pain inflammation cataract surgery nsaids chemically heterogenous group compounds inhibit formation prostaglandins lack steroid nucleus biosynthetically derived cholesterol there six major classes topical formulations limited relatively water soluble classes ie indole acetic aryl acetic aryl propionic acids.25 ketorolac tromethamine aryl acetic acid derivative the chemical name )-5-benzoyl-2,3- dihydro-1h pyrrolizine-1-carboxylic acid compounded 2-amino-2-(hydroxymethyl)-1,3-propanediol 1:1 current preparations consist racemic mixture r-(+ s-( ketorolac tromethamine when administered systemically ketorolac proven analgesic anti inflammatory antipyretic activity.1 mechanism action nsaids presumed due inhibition prostaglandin biosynthesis however systemic administration thought achieve sufficient intraocular drug levels inhibit prostaglandin synthesis completely ciliary body iris.1 topical administration ketorolac hand reaches adequate levels inhibit prostaglandin synthesis target tissues one study single topical application ketorolac 0.4% peak aqueous concentration 57.5 ng ml achieved 60 minutes.26 another study demonstrated mean aqueous concentration 1079 ng ml total 12 doses ketorolac 0.4% administered 2 days.27 original ophthalmic formulation ketorolac 0.5% solution marketed acular 0.4% formulation acular ls ) the 0.5% 0.4% preparations supplied isotonic aqueous mixture ph 7.4 osmolality approximately 290 mosmol kg however both 0.4% 0.5% solutions contain benzalkonium chloride preservative surfactant octoxynol-40 sodium edetate metal chelating agent associated high incidence burning stinging instillation high 40%).22,23,28 effort increase ocular bioavailability new formulation ketorolac developed preserve efficacy prior formulations enhancing tolerability less frequent dosing regimen.21 compared ketorolac 0.4% formulation concentration acuvail 12% greater 0.45% carboxymethylcellulose added emulsion allow greater drug retention ocular surface improve comfort drug penetration other key changes include lower ph absence surfactant metal chelating agents preservatives as acuvail supplied sterile isotonic preservative free solution ph osmolality approximately 6.8 285 mosmol kg respectively approved fda treatment pain inflammation following cataract surgery study attar et al evaluating pharmacokinetics ketorolac 0.45% versus 0.4% addition carboxymethylcellulose combination 12% increase concentration resulted 35% enhancement bioavailability aqueous humor 0.45% preparation.29 furthermore decreasing ph 7.4 6.8 combination addition carboxymethylcellulose enhanced bioavailability aqueous humor two fold iris ciliary body three fold time writing the pharmacokinetics acuvail assessed humans acular ls acuvail formulations directly compared single topical application 35 l.29 peak concentration aqueous humor iris ciliary body 389 ng ml 450 ng g respectively acuvail 211 ng ml 216 ng g respectively acular ls this study concluded acuvail delivered significantly higher concentrations ketorolac aqueous humor iris ciliary body waterbury et al directly compared peak trough intraocular levels acuvail bromfenac 0.9% xibrom ista pharmaceuticals inc irvine ca placebo three applications 35 l every 20 minutes animal model lipopolysaccharide induced inflammation.30 peak concentrations aqueous humor iris ciliary body 738 ng ml 556 ng g respectively acuvail 94 ng ml 46 ng g respectively bromfenac 0.9% trough concentrations aqueous humor iris ciliary body 127 ng ml 59 ng g respectively acuvail 17 ng ml 8 ng g respectively bromfenac 0.9% the study concluded acuvail achieved aqueous iris ciliary body concentrations exceeded inhibitory concentration 50% ic50 values cox-1 cox-2 peak trough table 2).1,26,31,32 addition nsaids inhibited lipopolysaccharide induced aqueous prostaglandin e2 elevation acuvail significantly prevented vascular leakage measured fluorescein isothiocyanate dextran leakage trough levels although suggestive number animals used studies small therefore additional studies larger sample sizes needed confirm initial results furthermore studies used new zealand white rabbits lack pigment blink infrequently unusually unstable blood aqueous barrier results extrapolated humans caution given favorable pharmacokinetic data acuvail approval granted twice daily dosing contrast four times daily dosing acular ls this reduced dosing regimen offers distinct therapeutic advantage acuvail addition patient convenience several studies suggested increased patient compliance less frequent dosing.33 the efficacy acuvail assessed two identical multicenter double masked randomized placebo controlled parallel studies specifically conducted evaluate effects acuvail relief pain inflammation cataract surgery.21 results parallel studies analyzed together collectively involved 511 patients patients randomized 2:1 ratio receive either acuvail vehicle operative eye 16 days patients dosed twice daily day surgery day surgery patients one drop upon awakening three drops 20 minutes apart starting two hours surgery one drop discharge one drop 12 hours first dose upon awakening resulting total six drops study medication patients continued one drop twice daily study medication 14 days surgery all patients underwent elective unilateral uncomplicated extracapsular cataract extraction posterior chamber intraocular lens implantation the primary efficacy endpoint percentage patients summed ocular inflammation score sois 0 anterior chamber cell flare day 14 the main secondary efficacy endpoint percentage patients pain grade 0 postoperative day 1 study anterior chamber cell graded six point scale anterior chamber flare graded five point scale the sois calculated sum scores anterior chamber cell flare assess degree pain patients called interactive voice response system diary twice daily two weeks day surgery instructed rate level ocular pain five point scale 0 none 1 mild 2 moderate 3 severe 4 intolerable the acuvail group significantly higher percentage patients sois score 0 compared vehicle days 7 14 day 7 acuvail vehicle sois score 0 32% 102/318 17% 26/155 patients respectively p 0.001 day 14 acuvail vehicle sois score 0 53% 167/318 27% 41/155 patients respectively p 0.001 a pain score 0 day 1 reported 72% 233/322 acuvail patients versus 40% 62/156 vehicle patients p 0.001 the median time postoperative ocular pain resolution one day patients treated acuvail two days patients treated vehicle p 0.001 although combined results controlled studies demonstrate efficacy acuvail prevention treatment postoperative inflammation pain cataract surgery results interpreted caution the importance achieving median one less day pain acuvail versus placebo needs assessed appropriate context treatment cost clinical impact absence concomitant corticosteroid use moreover cell flare combined together contrast grading outcome independently summation may amplified treatment differences observed acuvail vehicle group addition corticosteroids used concomitantly information discerned additive benefits acuvail corticosteroid regards inflammation pain following cataract surgery study comparing efficacy ketorolac 0.5% prednisolone acetate 1% simone et al observed prednisolone acetate effective reducing intraocular inflammation day 7 cataract surgery ketorolac although difference resolved day 28.10 several studies demonstrated additive benefit topical nsaid corticosteroid combined use therefore common clinical practice.1 therefore results study directly applied setting concomitant corticosteroid use nevertheless previous studies demonstrated additive benefit ketorolac 0.5% 0.4% used conjunction corticosteroids reducing inflammation pain cme following cataract surgery thus given favorable pharmacokinetics acuvail comparison older formulations similar therapeutic benefit may likely.521 several vitro studies indicate ketorolac potent inhibitor cox-1 amfenac active component nevanac alcon laboratories inc fort worth tx bromfenac reported potent inhibitors cox-2.1,26,31,32 bromfenac may 318 times potent inhibitor cox-2 diclofenac amfenac ketorolac.25,32 another study found amfenac potent inhibitor cox-2 bromfenac therefore anti inflammatory actions nsaids presumed relate ability inhibit isoform however paradigm consistently demonstrated clinical trials possibility exists cox-1 also plays important role inflammation presence substrate may readily convert arachidonic acids prostaglandins thus clinical importance selective cox-1 versus cox-2 inhibition ocular disease remains unproven although ketorolac approximately six times potent inhibitor cox-1 cox-2 table 2 nevertheless potent inhibitor cox-2 ic50 range 0.090.12 33.945.2 ng ml).32 allows ketorolac inhibit cox-2 iris ciliary body topical application important fact overlooked relative cox-1/cox-2 potencies ocular nsaids emphasized hand ketorolac approximately 550 times potent inhibitor cox-1 diclofenac bromfenac amfenac the ability inhibit isoforms cox short periods time may advantageous allowing rapid complete inhibition prostaglandin production long term inhibition cox-1 may desirable involved normal physiologic function the combination use topical nsaids corticosteroids sometimes referred synergistic literature this clinical impression synergy remains unproven would seem unlikely given fact drug classes inhibit prostaglandin production figure 1 synergy defined general two agents working combination produce effect could obtained agent independently a classic example synergy involves penicillin aminoglycoside antibiotics use antibiotics combination significantly lowers ic50 antibiotic given organism although large randomized prospective study demonstrated ketorolac 0.5% effective dexamethasone sodium phosphate 0.1% solution facilitating establishment blood aqueous barrier surgery differences drug formulation intraocular concentration preclude conclusions synergy.3436 furthermore although many prospective studies confirmed combination use nsaid corticosteroid superior corticosteroid alone pain inflammation cme visual improvement intraocular surgery findings explained additive effect second anti inflammatory agent.1,17,37 distinction synergistic effect additive effect important implications synergy implies nsaid used combination corticosteroid provides therapeutic effect replicated simply increasing dosing regimen corticosteroid although topical administration nsaids provides aqueous humor levels adequate suppress prostaglandin synthesis iris ciliary body ability suppress prostaglandin synthesis retina choroid less certain animal model ketorolac 0.5% could detected vitreous topical administration small prospective comparative study patients undergoing vitrectomy ketorolac 0.4% could detected vitreous 2.8 ng ml reduced vitreous prostaglandin e2 levels.38,39 observed reduction presumably inhibition iris ciliary body prostaglandin e2 production measured vitreous concentration ketorolac considerably less ic50 cox-1 cox-2 inhibition therefore unlikely inhibited cox activity retinal cells accumulating evidence indicates cox-2 important implications retinal disease.1,40 cox-2 predominant isoform human retinal pigment epithelial cells significantly upregulated response proinflammatory cytokines.41 cox-2 also present choroidal neovascularization well highly vascularized lesions expression increases diabetic retinopathy.1,42 variety experimental systems cox-2 inhibition suppresses angio genesis.43 regard nepafenac 0.1% bromfenac 0.09% could detected rabbit retina topical administration one study nepafenac inhibited 55% retinal prostaglandin synthesis.31,44 another study topical ketorolac 0.4% inhibited experimentally induced choroidal neovascularization reduced retinal prostaglandin e2 vascular endothelial growth factor levels 30%.45 interesting results obtained animal models directly extrapolated humans given favorable pharmacokinetics acuvail versus acular ls worth speculating clinically meaningful retinal cox inhibition may achievable the overall incidence treatment related adverse events significantly higher vehicle group 14% acuvail group 6%).21 common adverse events reported increased intraocular pressure conjunctival hyperemia and/or hemorrhage corneal edema ocular pain headache tearing blurred vision the common adverse events reported higher frequency vehicle included increased intraocular pressure 5.8% versus 1.8% conjunctival hemorrhage 1.2% versus 0.6% blurred vision 1.2% versus 0.6% generally considered clinical investigators consequence cataract procedure adverse events burning stinging low 1.5% patents acuvail group 0.6% vehicle group reporting occurrence ketorolac 0.5% topically applied one eye three times daily five 26 subjects detectable amount ketorolac plasma range 10.722.5 ng ml day 10 in contrast ketorolac 10 mg administered systemically every six hours peak plasma levels around 960 ng ml given possibility systemic absorption topical application techniques lid closure nasolacrimal occlusion may used decrease systemic exposure nsaids acuvail may slow delay healing susceptible patients continued use topical nsaids may result epithelial breakdown corneal thinning corneal erosion corneal ulceration corneal perforation there exists potential cross sensitivity acetylsalicylic acid phenylacetic acid derivatives nsaids therefore caution used treating individuals previously exhibited sensitivities drugs therefore recommended topical nsaids used caution patients known bleeding tendencies receiving anticoagulation there adequate well controlled studies topical nsaids pregnant woman medications classified category c. known effects prostaglandin inhibiting drugs fetal cardiovascular system closure ductus arteriosus use topical nsaids avoided late pregnancy severe corneal toxicity reported diclofenac 0.1% ketorolac 0.5% nepafenac 0.1% bromfenac 0.09%.1 although uncommon dramatic events referred corneal melt however definite link nsaid use corneal melt remains unproven still prudent avoid nsaid use patients severe corneal surface disease older formulations ketorolac incidence transient burning stinging instillation approximately 20%40% 0.4% concentration 40% 0.5% concentration.22,23 contrast acuvail associated substantially lower rates 1.5% burning stinging.21 importantly significantly higher percentage patients randomized acuvail 3-line improvement vision baseline compared treated vehicle.21 least two previously published studies using ketorolac 0.4% demonstrated similar beneficial effect upon visual acuity following cataract vitreoretinal surgery.17,37 patients undergoing routine vitreoretinal surgery patients randomized ketorolac 0.4% experienced average 4.3-line improvement baseline compared 2.5-line improvement placebo.37 greater improvement vision ketorolac group observed despite concomitant corticosteroid use groups excessive postoperative inflammation pain cataract surgery delay visual recovery affect long term outcomes there substantial evidence well designed studies sufficient numbers patients ketorolac formulations 0.4% 0.5% effectively treat inflammation pain cataract surgery given favorable pharmacokinetics better tolerance reduced dosing requirement acuvail additional clinical studies comparing acuvail nsaids treatment inflammation pain cataract surgery indicated confirm promising results

background : the purpose of this review was to provide a critical appraisal of the literature supporting the efficacy of ophthalmic ketorolac ( acuvail ) in the treatment of pain and inflammation after cataract surgery.methods:literature search and expert opinion of the authors.results:recent studies indicate greater intraocular drug levels in the anterior chamber and iris - ciliary body after topical application of acuvail in comparison with older formulations of ketorolac . a large randomized , multicenter , placebo - controlled study demonstrated significantly less inflammation and pain after cataract surgery using acuvail.conclusion:acuvail appears to be effective in reducing post - cataract surgery pain and inflammation .

malaria caused protozoan parasite plasmodium genus represents serious global health concern given nearly half world population risk infection 2014 although several anti malarial drugs treating symptomatic stage blood stage malarial infection commercially available antony parija 2016 efficacy declined appreciably last decades owing widespread drug resistance developed parasite breman et al chloroquine first line malaria treatment many decades drug resistant p. falciparum strains became common the drug causes dose dependent decrease hemozoin formation chou fitch 1992 slater cerami 1992 associated increase toxic free heme food vacuole parasite combrinck et al 2013 loria et al 1999 past decades researchers proposed many different mechanisms chloroquine action including 1 dna intercalation meshnick 1990 2 alteration digestive food vacuole ph yayon et al 1985 3 inhibition heme polymerase yayon et al 1985 4 formation toxic chloroquine ferriprotoporphyrin ix complex sugioka et al yet consensus exact mechanisms chloroquine kills parasite circumstances operate shedding light possible actions chloroquine critical developing potent drugs combination drug treatments parasite understanding parasite develop resistance here used systems biology model transcriptional profiles p. falciparum obtain information metabolic biological precursors determine physiological pathophysiological state parasite specifically used p. falciparum transcriptomic data obtained hu colleagues intraerythrocytic development cycle idc different concentrations chloroquine hu et al 2010 our primary goal use data investigate effect chloroquine p. falciparum dna replication we chose study effect proposed mechanism chloroquine action different plasmodium species gutteridge et al 1972 meshnick 1990 polet barr 1968a polet barr 1968b bacteria ciak hahn 1966 bioassays examining effect chloroquine rna dna polymerases cohen yielding 1965 o'brien et al we first developed method integrates information embedded transcriptome data whole genome metabolic network model p. falciparum fang et al 2014 predict metabolic phenotype corresponding transcription data we validated developed method using data set independent study jointly capture transcriptomic metabolomic data p. falciparum correctly predict metabolic phenotype tied genetic perturbation two krebs cycle enzymes ke et al 2015 we focused inhibition dna replication p. falciparum consequence chloroquine treatment critical metabolic phenotype ciak hahn 1966 cohen yielding 1965 polet barr 1968a used method simulate effect chloroquine metabolic fluxes p. falciparum idc we identified genes substantially altered response chloroquine treatment linked inhibition p. falciparum dna replication the cohort identified genes suggests dna replication inhibited downstream effect heme accumulation specifically analysis suggests continuous accumulation heme inhibits redox metabolism carbon fixation pyrimidine metabolism leads inhibition dna replication facilitates death parasite our results provide mechanistic explanation parasites efficient redox metabolism may lower sensitivity chloroquine kasozi et al 2013 lehane et al 2012 metabolic flux profiles p. falciparum strains 3d7 pf3d7 dd2 pfdd2 idc estimated using transcriptome data previously reported llinas colleagues llinas et al 2006 extracted cdna parasites cultured erythrocytes hybridized dna microarrays yield hourly levels gene expression pf3d7 pfdd2 strain idc the temporal resolution hourly gene expression profiles allowed us make high resolution time dependent metabolic flux predictions idc we used previously reported gene expression data hu et al 2010 simulate effect chloroquine time dependent metabolic fluxes pf3d7 pfdd2 idc briefly hu colleagues hu et al 2010 administered chloroquine 18 h erythrocyte invasion concentrations 41 72 144 nm pf3d7 43 nm pfdd2 obtained gene expression profiles every hour 8 h idc following chloroquine treatment the model identical previously published model fang et al 2014 one minor modification added reactions explicitly carried pdx2 pf11_0169 pdx1 mal6p1.215 this done 1 modifying old reaction incorrectly assumed pyridoxal 5-phosphate plp synthesized ribulose 5-phosphate 2 adding new separate reaction pdx1 experiments suggest synthesize plp independent ammonia generated pdx2 hanes et al 2008 updated model pdx2 hydrolyzes l glutamine yield glutamate ammonia pdx1 incorporates ammonia generated pdx2 yield plp substrates ribose 5-phosphate glyceraldehyde 3-phosphate gengenbacher et al 2006 isomerization ribose 5-phosphate ribulose 5-phosphate side reaction we used gene reaction mappings available metabolic network model obtain reaction expressions rexp depend expression gene genes catalyzing particular metabolic reaction reaction catalyzed single enzyme rexp equal expression gene catalyzing reaction however reaction associated one gene gene reaction mappings defined using boolean operators implemented operations taking minimal operator maximal operator values associated gene expression data song et al 2014 2014 integrates hourly gene expression data whole genome metabolic network model estimate hourly metabolic flux profiles p. falciparum 48-h long idc period take advantage additional studies collect gene expression data function genetic chemical perturbations modified method studies usually provide granularity density gene expression data fully cover entire idc therefore aimed develop method could utilize reduced transcriptomic data set predict alterations metabolic flux profiles idc briefly used following steps estimate metabolic fluxes stress conditions step 1 estimate nutrient fluxes sufficient nominal growth rate 40% maximum growth rate).step 2 estimate reaction fluxes vin metabolite corresponding nominal growth rate constrained nutrient fluxes obtained step 1.step 3 estimate reaction fluxes vit reaction time point idc incorporating time dependent transcriptomic profiles stoichiometric nutrient uptake constraints step 1 estimate nutrient fluxes sufficient nominal growth rate 40% maximum growth rate step 2 estimate reaction fluxes vin metabolite corresponding nominal growth rate constrained nutrient fluxes obtained step 1 step 3 estimate reaction fluxes vit reaction time point idc incorporating time dependent transcriptomic profiles stoichiometric nutrient uptake constraints the last step achieved globally minimizing reactions time points value minimized weighted absolute difference ig|vitritvin| g represents set unidirectional reactions known gene reaction mapping the factor rit rexp itmin(rexp it)mean(rexp it)min(rexp rexp represents reaction expression ith reaction time obtained gene reaction mapping p. falciparum metabolic network according approach outlined section 2.2 this factor rit ensured mean ith reaction idc equal vin estimated organism level impact drug metabolism using transcriptomic data obtained drug treatment the original formulation outlined steps 13 directly translated stress conditions unless complete transcriptomic profile stress condition entire idc available fang et al 2014 therefore introduced parameter account up- regulation individual reactions response stress simulate effect exogenous stress metabolic flux profiles idc we modified factor rit iritmin(irit)mean(rit)min(irit denotes median relative change reaction expression ith reaction following chloroquine treatment observed previous experiments hu et al 2010 note mean individual modifying factor rit i.e. 1nj=1tnrij obtained summing values across time points idc tracks mean less one greater one equal one i<1 i>1 i=1 respectively words increases decreases nominal flux ith reaction entire idc depending relative increase decrease ith reaction expression principle a drug may differentially affect gene transcription different time points idc here assumed median change gene transcription stress treatment representative transcriptional response throughout idc we used previously published data set ke et al 2015 validate methodology simulate effect external stress metabolic fluxes idc ke colleagues ke et al 2015 constructed p. falciparum mutant two tricarboxylic acid tca cycle enzymes deleted idh/kdh cultured wild type mutant parasites erythrocytes obtained matched transcriptomic metabolomic data we used data set describes changes gene expression transcriptomics phenotype metabolomics experimental stress conditions reaction fluxes estimated previously reported transcriptome data ke et al 2015 adequately represent reaction fluxes vitro predicted changes reaction fluxes sufficient predict changes observed corresponding metabolomic data we used computer model mitochondrial oxidative phosphorylation tca cycle wu et al 2007 predict changes tca cycle metabolites response changes estimated reaction fluxes ke et al the kinetic parameters computer model determined validated using extensive experimental data we simulated wild type reactions running model default parameters 2000 time required reach steady state condition stored concentrations tca cycle metabolites we performed simulations mutant parasite way albeit scaling model parameters govern tca cycle enzyme activities estimated increase decrease reaction fluxes enzymes we used freely available software package called bisen vanlier et al 2009 implement tca cycle computer model wu et al 2007 p. falciparum takes nutrients synthesize dna rna proteins phospholipids these processes constitutively activated parasite synthesize needed throughout idc we used validated house developed method fang et al 2014 simulate time dependent dna synthesis idc comprehensiveness introduce constraint governing rate dna synthesis metabolic network model cdatpdatp+cdctpdctp+cdgtpdgtp+cdttpdttpdna+(cdatp+cdctp+cdgtp+cdttp)diphosphate datp dctp dgtp dttp refer deoxyadenosine deoxycytidine deoxyguanosine deoxythymidine triphosphates respectively we refer reader original article fang et al 2014 details method simulating time dependent p. falciparum macro molecules idc the criticality gene determined optimizing following objective function idnacimi subjected smxnvnx1=0 vlbvvub dna gene set containing metabolites contribute dna synthesis introduced ci contribution ith metabolite mi in addition stoichiometry matrix v vector containing metabolic reactions p. falciparum metabolic network model number metabolites network n number reactions network vlb vub upper lower bounds respectively metabolic reactions deemed reaction critical dna synthesis knocking reaction silico chloroquine administration inhibits dna replication malaria parasites cohen yielding 1965 polet barr 1968a 2010 also show metabolic genes critical p. falciparum dna synthesis suppressed chloroquine treatment we sought identify genes substantially altered response chloroquine cause inhibition p. falciparum dna synthesis obvious candidates genes regulated critical p. falciparum dna synthesis however genes pronounced effect dna synthesis depends extent individual gene regulated and/or individual contribution gene dna synthesis parasite this suggests many combinations genes may underlie metabolic response associated chloroquine treatment 1990 aimed identifying minimal number genes hereinafter referred core genes sufficient completely account effect chloroquine dna synthesis parasite we identified core genes based bayesian information criteria bic score schwarz 1978 given nln(ssen)+kln(n sse=i=1n(victlvicqn)2max(vctl)min(vctl n denotes number time points k number genes tested vctl estimated rate dna synthesis control conditions vcqn estimated rate dna synthesis chloroquine treatment =1 k genes tested we implemented algorithm starts set size k=1 increases size test set long given combination genes new set size k+1 bic score lower minimal bic score previous size we exhaustively repeated process chloroquine dose 41 72 144 nm pf3d7 43 nm pfdd2 we modified previous approach fang et al 2014 simulate effect external stress depicted fig 1 described materials methods section we validated methodology demonstrating reaction fluxes obtained response stress sufficient predict metabolic phenotypes corresponding stress 2a shows biochemical pathways incorporated computer model used predict functional consequences altered fluxes tca cycle enzymes response previously studied genetic perturbations ke et al 2015 2b shows predicted alterations tca cycle metabolites response genetic perturbations tca cycle enzymes fig 2a red circles we calculated altered metabolite concentrations scaling control parameters tca cycle model wu et al 2007 median predicted changes tca cycle enzyme activities fig 2c 2b filled bars qualitatively captured trends relative change experimentally measured tca cycle metabolites fig 2b open bars 2b filled bars within margin error experimental measurements fig 2b open bars we examined possible enzymes transporters e.g. citrate synthase pyruvate dehydrogenase aspartate aminotransferase citrate malate antiporter whose perturbation could yield mitochondrial citrate levels higher wild type system scenario either predicted citrate levels increase predicted oxaloacetate levels increased therefore based model analysis source increase experimentally reported citrate level appears non mitochondrial nature agreement previous experimental observations cohen yielding 1965 polet barr 1968a simulations suggested chloroquine treatment results dose dependent inhibition dna replication fig a blue diamonds 43 nm pfdd2 panel b blue diamonds rate dna synthesis ring stage first 18 h infection less inhibited late trophozoite early schizont phases beyond 30 h infection these results agreement previous observations yayon et al 1983 many studies suggest pfdd2 less sensitive chloroquine pf3d7 moneriz et al 2011 ) dna synthesis might expected inhibited pf3d7 pfdd2 simulations however similar concentration chloroquine resulted greater dna synthesis inhibition pfdd2 fig 3b blue diamonds versus black circles paired sample test p 0.0001 pf3d7 fig 3a blue diamonds versus black circles paired sample test p 0.15 these differences likely stem differences relative gene expression ratios pfdd2 pf3d7 notably transcriptional profile pfdd2 regulated pf3d7 similar concentration chloroquine words percentage regulated genes critical p. falciparum dna synthesis greater pfdd2 pf3d7 table s1 together highly similar ic50 values reported previously hu et al 2010 pf3d7 41 nm and pfdd2 43 nm results suggest pfdd2 strain used may diverged true chloroquine resistant phenotype we found 81 metabolic reactions network model critical p. falciparum dna synthesis we denoted reactions critical elimination resulted abolished dna synthesis see section 2.6 of 81 reactions 64 known gene association whereas 17 these genes belonged pathways involved glycolysis pentose phosphate synthesis pyruvate metabolism purine metabolism pyrimidine metabolism redox metabolism mitochondrial metabolism online supplement see spreadsheet provide detailed information including reaction name chemical reaction gene association pathway reactions critical p. falciparum dna synthesis experimental observations cohen yielding 1965 polet barr 1968a present simulations fig 3 indicate chloroquine treatment inhibits replication p. falciparum dna turn suggests pathways essential dna synthesis inhibited 4 shows relative change amount dna synthesized parasite idc period response chloroquine treatment table s2 lists actual amounts synthesized dna strains simulated condition we observed dose dependent decrease amount dna synthesized parasite idc fig 4 red markers we used bic scores schwarz 1978 employed algorithm described section 2.7 identify core genes caused net decrease synthesized dna preventing core genes regulated chloroquine sufficient restore amount dna synthesized control values fig 4 green markers ; for simulations reaction expressions core genes set equal control chloroquine treated conditions a list core genes identified strain chloroquine dose table s3 suggests thioredoxin reductase ribonucleotide reductase substantially affect amount synthesized dna for pfdd2 two genes thioredoxin reductase ribonucleotide reductase caused nearly 50% reduction net amount synthesized dna table s3 fig 4 these genes mentioned original transcriptome analysis hu colleagues used fundamentally different approach interpret transcriptome data hu et al 2010 these authors focused genes either co regulated showed strongly differential expression 8 log2-fold change response drug contrast methodology coupling transcriptomic changes metabolic network model predict physiological outcomes relate parasite metabolism regardless magnitude transcriptional change individual gene transcriptional changes proportional changes metabolic reaction fluxes moxley et al 2009 our analysis suggests low amplitude alterations identified genes table s3 sufficient cause significant reduction parasite dna synthesis several existing methods integrate whole genome metabolic networks transcriptome data colijn et al 2009 song et al 2014 recently developed method predicts metabolic flux profiles p. falciparum idc fang et al the transcriptome data p. falciparum obtained different stress conditions e.g. drug exposure genetic mutation etc contain information functional state used predict qualitative alterations metabolic flux profiles idc however data often collected limited number time points instance hu colleagues hu et al 2010 obtained p. falciparum transcriptome data 8 selected time points idc currently approach integrate limited data reported previously hu et al 2010 whole genome network predict metabolic flux profiles idc this mainly approach requires gene expression data throughout idc predict corresponding metabolic flux profiles therefore developed approach uses gene expression data obtained stress condition predict alterations metabolic fluxes correspond condition we validated developed method integrating transcriptome data obtained given stress condition predicting metabolomic data corresponding stress ke et al simulated effect chloroquine metabolic flux profiles p. falciparum idc chloroquine inhibits formation hemozoin leads heme accumulation toxic parasite fitch 1998 however specific mechanism underlying toxicity known ginsburg et al 1998 some experiments suggest inhibition dna replication potential mechanism chloroquine action cohen yielding 1965 kwakye berko meshnick 1989 polet barr 1968a we developed method successfully predicted reduction ability parasite synthesize dna response chloroquine treatment see fig we identified twelve distinct genes substantially affected pf3d7 pfdd2 chloroquine treatment importantly preventing regulation response chloroquine treatment sufficient restoring p. falciparum dna synthesis inhibited chloroquine treatment see table 1 these genes belonged pathways involved glycolysis redox metabolism pyrimidine metabolism a closer look genes reveals potential mechanism chloroquine action unifies previous theories observations involving heme fitch 1998 dna replication polet barr 1968a oxidative stress lehane et al 2012 radfar et al 5 suggests administration chloroquine two major metabolic effects i.it interferes function glyceraldehyde 3-phosphate dehydrogenase gapdh reduces synthesis phosphoenolpyruvate whose carbon fixation activity essential anaplerotic tca metabolism redox balance storm et al 2014).ii.its interference thioredoxin reductase trxr reduces conversion oxidized thioredoxin trx s2 reduced thioredoxin trx sh2 essential donating electrons reactions catalyzed thioredoxin peroxidase tpx ribonucleotide reductase rnr tpx essential converting h2o2 reactive h2o harmless pannala dash 2015 rnr converting ribonucleoside 5-diphosphates species adp udp gdp cdp deoxy species dadp dudp dgdp dcdp used dna synthesis munro silva 2012 it interferes function glyceraldehyde 3-phosphate dehydrogenase gapdh reduces synthesis phosphoenolpyruvate whose carbon fixation activity essential anaplerotic tca metabolism redox balance storm et al 2014 its interference thioredoxin reductase trxr reduces conversion oxidized thioredoxin trx s2 reduced thioredoxin trx sh2 essential donating electrons reactions catalyzed thioredoxin peroxidase tpx ribonucleotide reductase rnr tpx essential converting h2o2 reactive h2o harmless pannala dash 2015 rnr converting ribonucleoside 5-diphosphates species adp udp gdp cdp deoxy species dadp dudp dgdp dcdp used dna synthesis munro silva 2012 for example analysis points trxr gapdh candidate molecules determine efficacy chloroquine focused candidates susceptible low dose chloroquine several pathways inhibited higher concentrations see table s3 chloroquine 144 nm in addition proteins transport chloroquine food vacuoles decrease effective concentration chloroquine targeting pathways administering chloroquine treatment enhance efficacy chloroquine given effective concentration the hypothesis chloroquine kills malarial parasite dna intercalation decades old meshnick 1990 although prime candidate mechanism chloroquine 1950s 1970s largely abandoned past two decades our model analyses identify drug target targets however suggest effect chloroquine administration leads inhibition dna synthesis according model parasite responds chloroquine reducing expression genes critical dna synthesis although chloroquine could specifically intercalate identified core gene set accord dna intercalation theory chloroquine meshnick 1990 o'brien et al 1966a heme plausible molecular inhibitor given accumulates large amounts within parasite food vacuole capable causing dna damage ishikawa et al 2010 rahman et al 1997 protein oxidation kitatsuji et al 2016 nadph oxidation bodaness 1983 apoptosis chiabrando et al 2014 however direct evidence suggesting heme causes damages p. falciparum chloroquine highly effective drug abandoned many malaria endemic regions widespread resistance knowledge mechanism allowed us identify metabolic pathways could exploited increase chloroquine efficacy for example model analyses suggest administration h2o2 would potentiate parasite killing chloroquine consistent vitro experiments malhotra et al similarly analyses suggest hypothesis targeting parasite specific pathways synthesize phosphoenolpyruvate reduce thioredoxin would potentiate parasite killing targeting pathways while administering amodiaquine chloroquine analogue result higher efficacy administering chloroquine especially amodiaquine accumulates chloroquine parasite food vacuole mechanism similar chloroquine hawley et al 1996 our aim identify investigate enzymes contribute decreased dna replication response chloroquine treatment using transcriptomics based approach identify cellular responses specific chloroquine expression data taken chloroquine treated parasites although antimalarial drugs may activate similar stress pathways details response specific particular conditions the approach makes assumptions underlying molecular actions cause affect response the effect chloroquine dna replication likely indirect mediated heme accumulation evokes multiple toxic effects cell we simulated effect chloroquine entire idc based available transcriptome data taken eight hour window trophozoite stage ideally specific inhibitor desirable hourly transcriptional readouts predict effect systemic perturbation throughout entire idc case presented largest effect chloroquine occurs trophozoite stage protocol collecting experimental transcriptomic data designed characterize transcriptional changes stage our use data identify changes metabolite fluxes throughout idc relative untreated controls rests assumption altering expression genes associated biological function specific particular stage minimal physiological effects stages this assumption specific p. falciparum malaria relies execution highly regimented transcriptional program idc initiates specific stage dependent cellular functions these assumptions ultimately corroborated observed metabolite phenotype changes mainly associated trophozoite stage metabolic alterations previous time points non existent immaterial dna synthesis herein investigated potential mechanism chloroquine inhibits dna synthesis p. falciparum kills parasite we first developed approach requires limited transcriptome data simulate effect exogenous stress p. falciparum metabolic fluxes idc we developed algorithm employing bayesian information theory identify potential pathways inhibit dna synthesis response chloroquine treatment our analysis suggests 1 chloroquine inhibits dna synthesis via inhibition redox metabolism carbon fixation anaplerotic tca cycle metabolism 2 p. falciparum may maintain dna synthesis chloroquine treatment preserving reduced pool thioredoxin invoking alternate mechanisms synthesizing phosphoenolpyruvate 3 drug combination drugs target redox metabolism carbon fixation heme accumulation could effective way target parasite the method developed used limited transcriptome data identify pathways underlie inhibition dna synthesis p. falciparum response chloroquine treatment this suggests developed method could also suitable simulate capture effect drugs stress conditions complex metabolic physiological responses p. falciparum based solely transcriptome data

chloroquine , long the default first - line treatment against malaria , is now abandoned in large parts of the world because of widespread drug - resistance in plasmodium falciparum . in spite of its importance as a cost - effective and efficient drug , a coherent understanding of the cellular mechanisms affected by chloroquine and how they influence the fitness and survival of the parasite remains elusive . here , we used a systems biology approach to integrate genome - scale transcriptomics to map out the effects of chloroquine , identify targeted metabolic pathways , and translate these findings into mechanistic insights . specifically , we first developed a method that integrates transcriptomic and metabolomic data , which we independently validated against a recently published set of such data for krebs - cycle mutants of p. falciparum . we then used the method to calculate the effect of chloroquine treatment on the metabolic flux profiles of p. falciparum during the intraerythrocytic developmental cycle . the model predicted dose - dependent inhibition of dna replication , in agreement with earlier experimental results for both drug - sensitive and drug - resistant p. falciparum strains . our simulations also corroborated experimental findings that suggest differences in chloroquine sensitivity between ring- and schizont - stage p. falciparum . our analysis also suggests that metabolic fluxes that govern reduced thioredoxin and phosphoenolpyruvate synthesis are significantly decreased and are pivotal to chloroquine - based inhibition of p. falciparum dna replication . the consequences of impaired phosphoenolpyruvate synthesis and redox metabolism are reduced carbon fixation and increased oxidative stress , respectively , both of which eventually facilitate killing of the parasite . our analysis suggests that a combination of chloroquine ( or an analogue ) and another drug , which inhibits carbon fixation and/or increases oxidative stress , should increase the clearance of p. falciparum from the host system .

governments across developed world concerned enabling older people maintain active contribution society thereby quality life qol).1 qol become commonly used end point evaluation multisector public policy including health social community environmental policy actions policy outcomes measured validity measures qol need social well policy relevance meaningful people lives carefully conceptualised constructed lawton26 developed popularly cited quadripartite concept qol proposing good life qol may represented behavioural social competence health cognition time use social behaviour perceptions qol subjective evaluation domain life psychological well mental health cognitive judgements life satisfaction positive negative emotions external objective physical environment housing economic indicators however consensus conceptual definition measurement,7 investigators based concepts expert opinions rather perspectives lay people this consequence empirical data extent items included measurement scales relevance people thus increasingly important develop multidimensional model measure quality life use descriptive evaluative multisector policy research reflects views population concerned cross sectional longitudinal applicability elicitation people views qol process particularly important qol subjective concept survey qualitative research people aged 65 living home britain reported central planks qol emphasised respondents psychological well positive outlook health functioning social relationships leisure activities neighbourhood resources adequate financial circumstances independence.710 research led development older people quality life questionnaire opqol unique derived views representative sample older people cross checked theoretical models assessment comprehensiveness the aim compare psychometric properties opqol casp-19 whoqol old among people 65 participating three national surveys older people living home britain two three surveys cross sectional third longitudinal see supplementary appendix 1 ethnibus survey people aged 65 responding two waves national ethni surveys http://www.ethnicfocus.com 2008 rolling face face interview survey adults aged 16 living home based focused enumeration stratified random sampling postcodes britain statistically robust sampling people common ethnic minority groups britain response rate 70% n=400 ons survey people aged 65 responding two waves office national statistics ons national omnibus survey http://www.statistics.gov.uk 2008 this rolling face face interview survey adults aged 16 living home based stratified random sample postcodes across britain response rate 61% n=589 qol follow survey 20072008 people living home britain aged 65 baseline responded four ons national omnibus interview surveys these based stratified random samples postcodes across britain 1999/2000 response 77% n=999 baseline 58% among survivors n=287 20072008 follow the qol follow survey included longitudinal design provided opportunity test causal model opqol well willing sample test retest reliability assessment the opqol administered three surveys prior administration surveys reported here items opqol pretested 179 older people three focus groups reduced 32-item 35-item versions statistical tests reliability validity applied the casp-1911 whoqol old12 13 administered two face face interview surveys would cognitively burdensome included three scales postal self administration mode supplementary appendix 2 displays opqol summarises development briefly summarises casp-19 whoqol old independent self ratings global qol domains included questionnaire order distinguish constituents influences qol.14 also included standard sociodemographic items self rated active ageing items measuring health psychosocial circumstances.7 ethnic status measured using standard item ethnic identity uk this would necessarily applicable populations countries reflects close connections new commonwealth countries ethnic minority groups uk.15 descriptive analyses included frequencies tests spearman r correlations tests scale reliability applied order assess extent scale items measure construct freedom random error internal consistency this strength association scale item full scale item item item total correlations test retest reliability stability newly developed opqol assessed mailing second copy questionnaire random subsample 50 follow qol survey respondents 4 weeks return first questionnaire response rate 76%/38 criterion concurrent validity independent corroboration scale measuring intends measure this measured proxy subjective measures gold standard proxy variables used included independent self ratings qol overall qol domains health social relationships independence control life freedom home neighbourhood psychological emotional well financial circumstances social leisure activities construct convergent discriminant validity requires corroboration scales measure underlying construct purport measure this tested assessing spearman r correlations qol scales similar variables convergent validity scale correlate similar hypothesised variables dissimilar variables discriminant validity low correlations scales variables expected associated multiple regression used assess validity examining ability theoretically relevant variables predict total qol scores a hierarchical approach used independent variables entered theoretical order importance statistical significance set p<0.05 the variables entered correlate 0.732 tests multicollinearity satisfied the opqol administered three surveys prior administration surveys reported here items opqol pretested 179 older people three focus groups reduced 32-item 35-item versions statistical tests reliability validity applied the casp-1911 whoqol old12 13 administered two face face interview surveys would cognitively burdensome included three scales postal self administration mode supplementary appendix 2 displays opqol summarises development briefly summarises casp-19 whoqol old independent self ratings global qol domains included questionnaire order distinguish constituents influences qol.14 also included standard sociodemographic items self rated active ageing items measuring health psychosocial circumstances.7 ethnic status measured using standard item ethnic identity uk this would necessarily applicable populations countries reflects close connections new commonwealth countries ethnic minority groups uk.15 tests scale reliability applied order assess extent scale items measure construct freedom random error internal consistency this strength association scale item full scale item item item total correlations test retest reliability stability newly developed opqol assessed mailing second copy questionnaire random subsample 50 follow qol survey respondents 4 weeks return first questionnaire response rate 76%/38 criterion concurrent validity independent corroboration scale measuring intends measure this measured proxy subjective measures gold standard proxy variables used included independent self ratings qol overall qol domains health social relationships independence control life freedom home neighbourhood psychological emotional well financial circumstances social leisure activities construct convergent discriminant validity requires corroboration scales measure underlying construct purport measure this tested assessing spearman r correlations qol scales similar variables convergent validity scale correlate similar hypothesised variables dissimilar variables discriminant validity low correlations scales variables expected associated multiple regression used assess validity examining ability theoretically relevant variables predict total qol scores a hierarchical approach used independent variables entered theoretical order importance the variables entered correlate 0.732 tests multicollinearity satisfied just half sample comprised women 52%/207 ethnibus 55%/324 ons 54%/154 qol follow whereas ethnibus respondents aged 65<75 91%/363 half ons omnibus 55%/326 less fifth qol follow respondents 17%/47 aged 65<75 thirty eight per cent 152 ethnibus sample indian 29% 117 pakistani 22% 86 black caribbean 11% 45 chinese most 94% 555 ons omnibus sample white british qol follow respondents white british reflection younger age ethnibus respondents married cohabiting 58%/230 49%/285 49%/138 respectively fewer ethnibus respondents home owners 532%/208 73%/429 85%/239 respectively fewer lived alone 5%/19 48%/286 49%/137 respectively differences statistically significant least p<0.01 detailed characteristics samples see supplementary table 1 few 12%/70 ons omnibus sample compared 45%/113 older qol follow sample 73%/290 ethnibus sample lowest two opqol categories 119 indicating worse qol see supplementary table 2 the ethnibus ons cross sectional samples administered casp-19 whoqol old consistent opqol findings 23%/94 ethnibus respondents worst two casp-19 categories 29 compared 8%/43 ons respondents 25%/100 ethnibus sample fell worst two whoqol old categories compared 15%/80 ons respondents see supplementary tables 3 4 further analyses total qol scores ethnicity ethnibus sample showed 58% 26 chinese people scored good qol opqol compared 28% 33 pakistani 20% 31 indian 23% 31 black caribbean people test 28.064 2 degrees freedom differences ethnicity analysed samples due low numbers ethnic minority groups the reliability criterion item total correlations correlation item scale total item omitted item correlate total scale least 0.20 three exceptions 35 full opqol items met criterion three samples exceptions ethnibus sample items 10 12 32 cronbach improved removal performed well validity tests retained six 19 casp items failed meet criterion ethnibus items 1 2 5 17 18 ons item 6 fourteen 24 whoqol old items failed criterion ethnibus sample expected items correlated highly similar dissimilar items scales cronbach opqol three samples satisfied 0.70<0.90 threshold internal consistency 0.748 ethnibus survey 0.876 ons omnibus survey 0.901 qol follow survey the casp-19 whoqol old satisfied threshold cronbach ons sample 0.866 0.849 respectively neither met ethnibus 0.553 0.415 respectively see earlier neither administered qol follow sample the 4 week test retest correlations assessed among qol follow survey respondents ranged moderate high r 0.4030.782 lower correlations explained reported life changes intervening month demonstrating difficulties test retest exercises older populations respondents comments follow life changes last 4 weeks illustrate this:about 4 days ago plaster taken left hand go buses means regular transport apart volunteer drivers friends taxis anyway means free;my husband nearly 60 years told lung cancer changed much feel we trying normal possible hard;my daughter young son left home acquired house we miss lot;my husband come home spending another 2 weeks hospital suspected heart attack). 4 days ago plaster taken left hand go buses means regular transport apart volunteer drivers friends taxis anyway means free husband nearly 60 years told lung cancer changed much feel we trying normal possible hard daughter young son left home acquired house we miss lot husband come home spending another 2 weeks hospital suspected heart attack). order test criterion also known concurrent validity qol scales respondents asked rate qol lives overall area life qol domain using five point scales good bad. criterion validity three qol scales indicated moderate strong significant correlations global self rated qol spearman r correlations opqol self rated qol overall sample ethnibus 0.347 ons 0.602 qol follow 0.659 casp in two cross sectional samples ethnibus 0.273 ons 0.577 whoqol old two cross sectional samples ethnibus 0.128 ons 0.466 all correlations significant least p<0.01 exception whoqol old ethnibus sample p<0.05 the validity opqol supported significant correlations subscales independent qol domain ratings theoretically expected similar directions7 eg opqol health functioning subscale correlated self rated health spearman r ethnibus 0.122 p<0.05 ons omnibus 0.679 p<0.01 qol follow 0.713 p<0.01 significant correlations dissimilar pairs eg health religion expected the casp-19 control autonomy subscales whoqol old autonomy subscale also correlated significantly expected similar directions self rated independence control life freedom ons sample r 0.472 p<0.01 r 0.466 p<0.01 respectively ethnibus sample the whoqol old sensory abilities subscale correlated significantly expected self rated health ons r 0.322 p<0.01 ethnibus sample the whoqol old intimacy subscale correlated significantly also expected social relationships domain ons sample r 0.330 p<0.01 ethnibus sample support construct convergent ) validity opqol correlated moderately strongly direction hypothesised,7 self rated health status compared others age sample opqol ethnibus 0.364 ons 0.543 qol follow 0.628 the casp-19 whoqol old correlations two cross sectional samples also direction significant although slightly weaker casp-19 ethnibus 0.238 ons 0.530 whoqol old ethnibus 0.138 ons 0.465 p<0.01 multivariable analyses conducted sample order examine independent predictors opqol casp-19 whoqol old comparability independent variables entered model basis literature,7 optimum scores measure were hypothesised associated optimum qol self rated active ageing independent self ratings qol domains social activities help social network members self rated health status physical functioning adl age sex marital status housing tenure the qol follow sample also provided opportunity test causal model underpinning opqol the cross sectional model qol follow sample highly significant see table 1 perceptions ageing actively optimal self ratings health independence home neighbourhood psychological well finances social activities female sex significantly independently predicted optimal opqol scores the amount explained variance opqol scores model high 77% adjusted r 0.774 multiple regression predictors opqol qol follow sample final model adl activities daily living ns significant opqol older people quality life qol quality life the opqol models ons ethnibus samples also highly significant optimal ratings active ageing self rated qol domains also self rated health status significant samples the model explained 65% variance opqol scores adjusted r 0.653 ons sample 43% adjusted r 0.430 ethnibus sample table 2 multiple regression predictors opqol ons omnibus ethnibus samples final models adl activities daily living ns significant qol quality life the variables included test causal model underpinning opqol qol follow sample baseline indicators reflected components chosen opqol domains health functional status practical help received social support activities perceived quality neighbourhood psychological outlook gap score social comparisons expectations self efficacy plus standard sociodemographic indications control effects this model explained 56% variance opqol scores adjusted r 0.563 as number different social activities significant model reduced model conducted excluding variable health status number diagnosed medical conditions help social support perceptions neighbourhood feeling safe social comparisons comparing one financial living circumstances others worse feelings self efficacy control explained 48% variance opqol scores expected directions adjusted r 0.481 the overall model highly significant general support opqol see table 3 causal model underpinning opqol adl activities daily living ns statistically significant least 0.05 level opqol older people quality life multiple regression baseline 1999/2000 predictors opqol follow 2007/2008 qol follow sample final model the amount explained variance casp-19 scores ons sample explained model 57% adjusted r 0.568 model highly significant expected directions the variables retained significance model five domain ratings health functioning in contrast casp-19 model ethnibus sample weak amount explained variance casp-19 scores 14% adjusted r 0.141 although model still significant the variables significant self rated active ageing three seven qol domain self ratings health status physical functioning see table 4 multiple regression predictors casp-19:ons omnibus ethnibus final models adl activities daily living ns significant qol quality life the whoqol old assessed ons ethnibus samples amount explained variance whoqol old scores ons omnibus survey 45% adjusted r 0.448 model highly significant expected directions the significant variables self rated active ageing three seven qol domain ratings number social activities helpers health status housing tenure however whoqol old model ethnibus sample weak although significant amount explained variance whoqol old scores 5% adjusted r 0.048 the significant variables three seven domain ratings number social activities see table 5 multiple regression predictors whoqol old ons omnibus ethnibus final model adl activities daily living ns significant qol quality life just half sample comprised women 52%/207 ethnibus 55%/324 ons 54%/154 qol follow whereas ethnibus respondents aged 65<75 91%/363 half ons omnibus 55%/326 less fifth qol follow respondents 17%/47 aged 65<75 thirty eight per cent 152 ethnibus sample indian 29% 117 pakistani 22% 86 black caribbean 11% 45 chinese most 94% 555 ons omnibus sample white british qol follow respondents white british reflection younger age ethnibus respondents married cohabiting 58%/230 49%/285 49%/138 respectively fewer ethnibus respondents home owners 532%/208 73%/429 85%/239 respectively fewer lived alone 5%/19 48%/286 49%/137 respectively differences statistically significant least p<0.01 detailed characteristics samples see supplementary table 1 few 12%/70 ons omnibus sample compared 45%/113 older qol follow sample 73%/290 ethnibus sample lowest two opqol categories 119 indicating worse qol see supplementary table 2 the ethnibus ons cross sectional samples administered casp-19 whoqol old consistent opqol findings 23%/94 ethnibus respondents worst two casp-19 categories 29 compared 8%/43 ons respondents 25%/100 ethnibus sample fell worst two whoqol old categories compared 15%/80 ons respondents see supplementary tables 3 4 further analyses total qol scores ethnicity ethnibus sample showed 58% 26 chinese people scored good qol opqol compared 28% 33 pakistani 20% 31 indian 23% 31 black caribbean people test 28.064 2 degrees freedom differences ethnicity analysed samples due low numbers ethnic minority groups the reliability criterion item total correlations correlation item scale total item omitted item correlate total scale least 0.20 three exceptions 35 full opqol items met criterion three samples exceptions ethnibus sample items 10 12 32 cronbach improved removal performed well validity tests retained six 19 casp items failed meet criterion ethnibus items 1 2 5 17 18 ons item 6 fourteen 24 whoqol old items failed criterion ethnibus sample as expected items correlated highly similar dissimilar items scales cronbach opqol three samples satisfied 0.70<0.90 threshold internal consistency 0.748 ethnibus survey 0.876 ons omnibus survey 0.901 qol follow survey the casp-19 whoqol old satisfied threshold cronbach ons sample 0.866 0.849 respectively neither met ethnibus 0.553 0.415 respectively see earlier neither administered qol follow sample the 4 week test retest correlations assessed among qol follow survey respondents ranged moderate high r 0.4030.782 lower correlations explained reported life changes intervening month demonstrating difficulties test retest exercises older populations respondents comments follow life changes last 4 weeks illustrate this:about 4 days ago plaster taken left hand go buses means regular transport apart volunteer drivers friends taxis anyway means free;my husband nearly 60 years told lung cancer changed much feel we trying normal possible hard;my daughter young son left home acquired house we miss lot;my husband come home spending another 2 weeks hospital suspected heart attack). 4 days ago plaster taken left hand go buses means regular transport apart volunteer drivers friends taxis anyway means free husband nearly 60 years told lung cancer changed much feel we trying normal possible hard daughter young son left home acquired house we miss lot husband come home spending another 2 weeks hospital suspected heart attack). in order test criterion also known concurrent validity qol scales respondents asked rate qol lives overall area life qol domain using five point scales good bad. criterion validity three qol scales indicated moderate strong significant correlations global self rated qol spearman r correlations opqol self rated qol overall sample ethnibus 0.347 ons 0.602 qol follow 0.659 for casp two cross sectional samples ethnibus 0.273 ons 0.577 whoqol old two cross sectional samples ethnibus 0.128 ons 0.466 all correlations significant least p<0.01 exception whoqol old ethnibus sample p<0.05 the validity opqol supported significant correlations subscales independent qol domain ratings theoretically expected similar directions7 eg opqol health functioning subscale correlated self rated health spearman r ethnibus 0.122 p<0.05 ons omnibus 0.679 p<0.01 qol follow 0.713 p<0.01 significant correlations dissimilar pairs eg health religion expected the casp-19 control autonomy subscales whoqol old autonomy subscale also correlated significantly expected similar directions self rated independence control life freedom ons sample r 0.472 p<0.01 r 0.466 p<0.01 respectively ethnibus sample the whoqol old sensory abilities subscale correlated significantly expected self rated health ons r 0.322 p<0.01 ethnibus sample the whoqol old intimacy subscale correlated significantly also expected social relationships domain ons sample r 0.330 p<0.01 ethnibus sample support construct convergent validity opqol correlated moderately strongly direction hypothesised,7 self rated health status compared others age sample opqol ethnibus 0.364 ons 0.543 qol follow 0.628 the casp-19 whoqol old correlations two cross sectional samples also direction significant although slightly weaker casp-19 ethnibus 0.238 ons 0.530 whoqol old ethnibus 0.138 ons 0.465 p<0.01 multivariable analyses conducted sample order examine independent predictors opqol casp-19 whoqol old comparability independent variables entered model basis literature,7 optimum scores measure were hypothesised associated optimum qol self rated active ageing independent self ratings qol domains social activities help social network members self rated health status physical functioning adl age sex marital status housing tenure the qol follow sample also provided opportunity test causal model underpinning opqol the cross sectional model qol follow sample highly significant see table 1 perceptions ageing actively optimal self ratings health independence home neighbourhood psychological well finances social activities female sex significantly independently predicted optimal opqol scores the amount explained variance opqol scores model high 77% adjusted r 0.774 multiple regression predictors opqol qol follow sample final model adl activities daily living ns significant opqol older people quality life qol quality life the opqol models ons ethnibus samples also highly significant optimal ratings active ageing self rated qol domains also self rated health status significant samples model explained 65% variance opqol scores adjusted r 0.653 ons sample 43% adjusted r 0.430 ethnibus sample table 2 multiple regression predictors opqol ons omnibus ethnibus samples final models adl activities daily living ns significant qol quality life the variables included test causal model underpinning opqol qol follow sample baseline indicators reflected components chosen opqol domains health functional status practical help received social support activities perceived quality neighbourhood psychological outlook gap score social comparisons expectations self efficacy plus standard sociodemographic indications control effects this model explained 56% variance opqol scores adjusted r 0.563 as number different social activities significant model reduced model conducted excluding variable health status number diagnosed medical conditions help social support perceptions neighbourhood feeling safe social comparisons comparing one financial living circumstances others worse feelings self efficacy control explained 48% variance opqol scores expected directions adjusted r 0.481 the overall model highly significant general support opqol see table 3 causal model underpinning opqol adl activities daily living ns statistically significant least 0.05 level opqol older people quality life multiple regression baseline 1999/2000 predictors opqol follow 2007/2008 qol follow sample final model the amount explained variance casp-19 scores ons sample explained model 57% adjusted r 0.568 model highly significant expected directions the variables retained significance model five domain ratings health functioning in contrast casp-19 model ethnibus sample weak amount explained variance casp-19 scores 14% adjusted r 0.141 although model still significant the variables significant self rated active ageing three seven qol domain self ratings health status physical functioning see table 4 multiple regression predictors casp-19:ons omnibus ethnibus final models adl activities daily living ns significant qol quality life the whoqol old assessed ons ethnibus samples amount explained variance whoqol old scores ons omnibus survey 45% adjusted r 0.448 model highly significant expected directions the significant variables self rated active ageing three seven qol domain ratings number social activities helpers health status housing tenure however whoqol old model ethnibus sample weak although significant amount explained variance whoqol old scores 5% adjusted r 0.048 the significant variables three seven domain ratings number social activities see table 5 multiple regression predictors whoqol old ons omnibus ethnibus final model adl activities daily living ns significant qol quality life the cross sectional model qol follow sample highly significant see table 1 perceptions ageing actively optimal self ratings health independence home neighbourhood psychological well finances social activities female sex significantly independently predicted optimal opqol scores the amount explained variance opqol scores model high 77% adjusted r 0.774 multiple regression predictors opqol qol follow sample final model adl activities daily living ns significant opqol older people quality life qol quality life the opqol models ons ethnibus samples also highly significant optimal ratings active ageing self rated qol domains also self rated health status significant samples the model explained 65% variance opqol scores adjusted r 0.653 ons sample 43% adjusted r 0.430 ethnibus sample table 2 multiple regression predictors opqol ons omnibus ethnibus samples final models adl activities daily living ns significant qol quality life the variables included test causal model underpinning opqol qol follow sample baseline indicators reflected components chosen opqol domains health functional status practical help received social support activities perceived quality neighbourhood psychological outlook gap score social comparisons expectations self efficacy plus standard sociodemographic indications control effects this model explained 56% variance opqol scores adjusted r 0.563 as number different social activities significant model reduced model conducted excluding variable health status number diagnosed medical conditions help social support perceptions neighbourhood feeling safe social comparisons comparing one financial living circumstances others worse feelings self efficacy control explained 48% variance opqol scores expected directions adjusted r 0.481 the overall model highly significant general support opqol see table 3 causal model underpinning opqol adl activities daily living ns statistically significant least 0.05 level opqol older people quality life multiple regression baseline 1999/2000 predictors opqol follow 2007/2008 qol follow sample final model the amount explained variance casp-19 scores ons sample explained model 57% adjusted r 0.568 model highly significant expected directions the variables retained significance model five domain ratings health functioning in contrast casp-19 model ethnibus sample weak amount explained variance casp-19 scores 14% adjusted r 0.141 although model still significant the variables significant self rated active ageing three seven qol domain self ratings health status physical functioning see table 4 multiple regression predictors casp-19:ons omnibus ethnibus final models adl activities daily living ns significant qol quality life the whoqol old assessed ons ethnibus samples amount explained variance whoqol old scores ons omnibus survey 45% adjusted r 0.448 model highly significant expected directions the significant variables self rated active ageing three seven qol domain ratings number social activities helpers health status housing tenure however whoqol old model ethnibus sample weak although significant amount explained variance whoqol old scores 5% adjusted r 0.048 the significant variables three seven domain ratings number social activities see table 5 multiple regression predictors whoqol old ons omnibus ethnibus final model adl activities daily living ns significant qol quality life this study describes psychometric performance qol questionnaire developed perspectives older people opqol it tested two cross sectional one longitudinal surveys older people across britain the longitudinal survey enabled opqol tested dynamic ageing population assessment underlying model although self administration mode necessitated assessment opqol casp-19 whoqol older sample the surveys used statistically robust sampling methods response rates fairly good the characteristics respondents ons omnibus ethnibus surveys qol survey baseline comparable population estimates last census the qol follow sample longitudinal design reflected healthy survivors also although sampling approach ethnibus survey statistically robust used focused enumeration there practical methodology attempting obtain representative samples people ethnic minority groups national samples this study reported ethnibus respondents obtained poorer worse qol scores sample respondents opqol casp-19 whoqol old this unexpected given people ethnic minority groups often economically disadvantaged wider population.15 research needed examine whether differences qol reflect real variations methodology cultural variations expectations reporting ethnic minority groups britain live wide range different communities diversity may also affected responses way it also noted standard question ethnic status used largely reflected britain new commonwealth groups may appropriate use countries multiple regression models supported validity underlying constructs despite ethnibus sample consistently worse qol scores compared samples casp-19 whoqol old meet criteria internal consistency reliability ethnically diverse ethnibus sample the casp-19 whoqol old also relatively large numbers items failed meet reliability criterion item total scale correlations frequently failed correlation tests validity ethnibus sample this may due sample ethnic diversity casp-19 whoqol old sufficiently sensitive the opqol currently tested older people living italy initial results cultural equivalence understanding positive personal communication dr claudio bilotta university milan).what already known subjectincreasing numbers older people higher expectations good life demands health social care led international interest enhancement measurement quality life qol older age.qol subjective concept yet measures qol based primarily partly expert opinions.what study addsthis study focuses testing new measure qol older people qol questionnaire opqol derived entirely views older people britain cross checked theoretical models comprehensiveness.the opqol performed well three samples older people britain one comprised people ethnic minority groups it potential value outcome assessment health social interventions multidimensional impact people lives increasing numbers older people higher expectations good life demands health social care led international interest enhancement measurement quality life qol older age qol subjective concept yet measures qol based primarily partly expert opinions this study focuses testing new measure qol older people qol questionnaire opqol derived entirely views older people britain cross checked theoretical models comprehensiveness the opqol performed well three samples older people britain one comprised people ethnic minority groups it potential value outcome assessment health social interventions multidimensional impact people lives

backgroundmost measures of quality of life ( qol ) are based on expert opinions . this study describes a new measure of qol in older age , the older people 's qol questionnaire ( opqol ) , which is unique in being derived from the views of lay people , cross - checked against theoretical models for assessment of comprehensiveness . its performance was assessed cross - sectionally and longitudinally . it was compared with two existing qol measures in the cross - sectional studies in order to identify the optimal measure for use with older populations.methodsdata were taken from three surveys of older people living at home in britain in 20072008 : one population survey of people aged 65 + , one focused enumeration survey of ethnically diverse older people aged 65 + , one follow - up of a population survey of people aged 65 + at baseline in 1999/2000 . measures were qol ( using opqol , control , autonomy , satisfaction , pleasure - 19 items ( casp-19 ) , world health organization quality of life questionnaire - version for older people ( whoqol - old ) ) , health , social and socioeconomic circumstances . the casp-19 and whoqol - old were not administered to the longitudinal sample in order to reduce respondent burden.resultspsychometric tests were applied to each qol measure . the opqol , casp-19 and whoqol - old performed well with the cross - sectional samples ; however , only the opqol met criteria for internal consistency in the ethnibus samples.conclusionthe opqol is of potential value in the outcome assessment of health and social interventions , which can have a multidimensional impact on people 's lives . further research is needed to examine whether differences by ethnicity reflect real differences in qol , methodological issues , variations in expectations or cultural differences in reporting .

myiasis infestation organs tissues human animals fly larvae common phenomenon especially people tropical subtropical areas spite occasional reports obligatory myiasis the majority reported cases facultative myiasis dozen families flies cause form gullan durden 2009 phoridae commonly known humpback scuttle flies important family dipteran causes myiasis various problems human family genus megaselia perhaps largest genera living organisms wide variety life styles polyphagus diet disney 2008 among identified species genus it unwittingly carried around world human disney 2008 previously reported alborz province iran zamani 2009 adults scuttle flies small 24 mm length explore large variety environmental ecological habitats females flies highly attracted strong foul odors lay eggs different decomposing materials fruits stole meat excrement carrions disney 2008 the scuttle flies important agent human facultative myiasis exhibit greater diversity larval habitat insects these flies explore large variety environmental ecological niches disney 2008 spite predation parasitation arthropods species costa et al 2007 previous studies showed cause human myiasis francesconi lupi 2012 moreover already polyphagus species may harmful health become vector pathogens disney 2008 1978 carpenter chastain 1992 hira et al 2004 intestinal kaneko et al 1975 sing et al however urogenital form rarely seen reported cases restricted females so study men clinical manifestation well morphology third instars larvae flies seems important the aim paper report case man urogenital myiasis involving discourse importance diagnosis management clinical science an 18 year old man living zanjan city northwest iran presented ayatollah mosavi hospital zanjan university medical sciences history difficulty urination maggot discharging medicated venlafazine alpirazolam nortriptrin physical examination sonography cortex bladder kidneys he received mebendazole 2 mg tablet orally washed urogenital area solution xylocain 2% iodine 1% the urine yellow color laboratory examination showed microhematuria proteinuria leukocyturia the larvae forwarded department medical entomology vector control studies sonography cortex bladder small echogenous floating particles microscopic examination showed larvae alive whitish color pale intestinal content third terminal part fig one larva preserved 70 ethylic alcohol cultured nutrient rich medium complete life cycle died 1 day length width larvae ranged 6.8 6.9 0.68 0.69 mm respectively fig precision microscopic examination larvae revealed presence short spinous peglike processes integument the larval head noncapsulate reduced mouth hooks supporting cephalopharyngeal skeleton developed supported large areas head fig the anterior spiracles located latero posterior edge prothorax 810 rays a pair posterior spiracles protruded dorsally 12 segment appears large slender plate in addition anterior posterior union dorsal lateral trunks joined transverse connectives fig 4 third instars larva megaselia scalaris anterior section third instars larva megaselia scalaris posterior section third instars larva megaselia scalaris based characters previous descriptions researchers sukantason et al 2004 disney 2008 larvae definitely identified megaselia scalaris facultative myiasis parasite belonging phoridae family the voucher specimens retained department entomological systematics university tarbiat modarres urogenital myiasis infestation genitourinary organs maggots based anatomical location could classified external internal myiasis external urogenital myiasis clinically epidemiologically entomologically similar wound myiasis affects women commonly internal urogenital myiasis rare event occurs maggot reaches internal genitourinary organ all described cases considered accidental cases uncommon myiasis agents associated m. scalaris psychoda albipenis muscoid flies francesconi lupi 2012 several previous researchers reported cases wound disney 2008 intestinal mazyard rifaat 2005 nasocominal myiasis hira et al 2004 due m. scalaris however published cases genital myiasis number reports refer patients various ages the first report human urogenital myiasis due species reported 1978 disney kurahashi cases reported ramalingam et al 1997 delir et al 1999 perez eid c mouffok 1999 rodriguez rashid 2001 passos et al 2002 there paucity information country probably specimens tend discarded without study due lack experience identifying fly larvae absence reference center we hope report stimulate others present similar clinical findings contribute pool knowledge subject iran best knowledge so hope coming future special aspects species studied iran the identification larvae megaselia sp posed difficulties none could reared adult conformation based adult morphology the passing live m. scalaris larvae urine indicated infestation urogenital system reported infestations priyanond et al 1973 biery et al 1989 normally secondary consequence obstructions normal flow urine stone formation bladder our microscopic examination showed larvae probably mature least second third instars transition may seeking place pupate it worth mentioning identification immature larvae parasite causing myiasis posed difficulties particularly parasite little available knowledge however available morphological characters larvae especially cephalopharyngeal skeleton structure spiracles used differentiation specimens however global warming globalization commerce established conditions suitable expand wider distribution the flies infesting patients probably originated natural population near home residential area it likely female megaselia deposited eggs underwear clothing directly urogenital area attracted urine odor the rational treatment genitourinary myiasis remove offending larvae many cases diagnosis done several substances antiseptic anesthetic solutions used form lavage francesconi lupi 2012 it seems case oral administration 2 mg mebendazole washing urogenital area solution xylocain 2% iodine 1% cured myiasis since urogenitoury tract inaccessible area removed maggots difficult conventional instruments overcome problem used urogenital lavage xylocaine iodine solution patient xylocaine causes spastic paralysis parasites straight muscles way paralyzed larva easily removed medical personnel take care susceptible patients especially nocturnal enuresis need bear mind possibility infestation scuttle flies larvae able make prompt diagnosis myiasis implement relevant intervention prevent tissue infestation prevention condition important involves use insect repellents insecticides control fly population adequate protective clothing good skin wound hygiene keep flies reaching skin covering open wounds change dressing daily hang clothes dry bright sunlight and/or iron improve hygiene sanitation size gravid flies small besides much attention paid large muscoid flies may cause myiasis likely small phorids unnoticed ignored may lead increase occurrence phorid myiasis we need emphasize myiasis rarely occurs healthy individuals neglected personal hygiene single important factor human infestation nowadays global warming commerce globalization change geographical map scuttle flies observation scarce case urogenital myiasis iran represents wide distribution since m. scalaris possess considerable larval habitat creation various clinical forms myiasis imminent therefore hope reported case stimulate researches present similar findings expect several aspects species studied future addition medical personell take special attention susceptible cases able diagnose myiasis well implicate relevant interventions prevent new infections

myiasis is the infestation of organs and tissues of human and animals with fly larvae . this article reports an 18 year - old man with urogenital myiasis , the passing of live megaselia scalaris larvae in the urine , from zanjan city , northwest of iran . we discourse the importance of diagnosis and management of urogenital myiasis in medicine .

although malaria preventable curable still causes high morbidity mortality 1 according recent 2013 report globally estimated 3.4 billon people risk malaria report estimated 207 million malaria cases 627,000 deaths occurred globally 2012 2 ) the majority global burden human malaria caused plasmodium falciparum p. vivax 3 p. falciparum deadly plasmodium species responsible 90% malaria deaths mainly africa 4 p. vivax cause malaria infection world 1 p. vivax accountable 2540% annual bouts malaria worldwide 4 iran 2,714,648 individuals 4% total population mainly living southern provinces namely sistan baluchistan kerman hormozgan risk malaria 5 p. vivax prevalent species reported among malaria patients iran annually 6 however considerable decrease malaria cases reported within past years iran since malaria elimination program commence years ago country 7 steady continuation program rapid accurate diagnosis malaria parasites play important role opportune case finding treatment result time control elimination infection conventional microscopic examination giemsa stained thick thin blood smears accepted golden standard method malaria diagnosis although malaria microscopy contains advantages including cost availability relative sensitivity 810 bears disadvantages time consuming labor intensity 9 the recently reiterated urgent need simple cost effective diagnostic tests malaria overcome deficiencies light microscopy clinical diagnosis 10 11 based advise rapid diagnostic tests replaced microscopic method remote isolated areas particularly trained skilled personnel available 1214 utilizing parasite lactate dehydrogenase pldh rdts has shown better sensitivity diagnosing low level parasitemia comparison malaria proteins moreover amount pldh indicates metabolically presence p. vivax due short stability pldh body 13 pldh plays role coenzyme due involving oxidation lactate pyruvate nicotinamide adenine dinucleotide nad 15 inhibition malarial ldh enzyme prevents production atp results death plasmodium parasites 13 becomes attractive drug target candidate 16 the genetic diversity pldh might influence drug target candidacy sensitivity rdt kits far know genetic variation pldh gene p. vivax p. falciparum infections reported iran this study aimed detect polymorphism pldh gene iranian strains p. vivax p. falciparum obviously understanding polymorphism important designing improving rdt kits it also give information molecular details p. falciparum ldh pfldh p. vivax ldh pvldh genes designing new drug totally 43 whole blood samples collected p. vivax p. falciparum infected patients sistan baluchestan province located southeast iran 2012 2013 sistan baluchestan province bordered afghanistan pakistan east oman sea south thirty three samples p. vivax 10 samples p. falciparum confirmed positive light microscopic examination giemsa stained thick thin blood smears one ml blood collected tubes containing edta anticoagulant placed immediately 20 c analysis dna extracted 200 l whole blood samples 33 p. vivax 10 p. falciparum malaria infected patients using accu prep kit genomic dna extraction kit bioneer seoul korea based manufacturer instructions nucleotide sequences corresponding pvldh pfldh genes amplified using following sets primers using conventional pcr pvldh gene amplification conducted using forward 5-atgacgccgaaacccaaaat-3 reverse 5-acctttaaatgagcgccttcat-3 hand pfldh gene also amplified f 5-agatggcaccaaaagcaaaaat-3 r 5-acctttaagctaatgccttcat-3. pvldh primers designed based p. vivax sal-1 xm_001615570.1 p. vivax belem dq060151.1 strains genbank whereas pfldh primers designed based reference sequence p. falciparum 3d7 xm_001349953.1 strain genbank dna extracted whole blood healthy person living non endemic area negative control using amplification process pcr reaction performed 25l reaction volumes containing 1lof forward reverse primers 10 pmol 10 l ready use master mix ampliqon denmark contains tris hcl ph 8.5 1.5 mm mgcl2 dntps taqdna polymerase 3 l genomic dna samples 10 l distilled water pcr cycle parameters pvldh gene amplification follows 5minutes initial denaturation 95 c followed 30 cycles 30 95 c 30 56 c 1 72 c final extension 72 c 5 min all pcr parameters pfldh gene amplification except annealing temperature 58 c the fragment sizes pcr products determined using 1 kb dna ladder marker solis biodyne estonia twenty two sequences including 15 p. vivax 7 p. falciparum analyzed investigate polymorphism pvldh pfldh genes respectively these genes sequenced applied biosystems 3730/3730xl dna analyzers bioneer seoul korea using sanger method nucleotide sequences pvldh pfldh aligned compared using clustal w2 software embl ebi http://www.ebi.ac.uk/tools/msa/clustalw2/ pvldh gene sequences compared genbank sequences p. vivax belem dq060151.1 p. vivax sai-1 xm_001615570.1 hand pfldh gene sequences compared p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 moreover amino acid sequences related samples p. vivax p. faliparum derived using expasy translate tool http://web.expasy.org/tran-slate/ pvldh amino acid sequences compared p. vivax sai-1 xm_001615570.1 p. vivax belem dq060151.1 whereas pfldh amino acid sequences compared p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 strains registered genbank finally phylogenic tree prepared illustrate distance among sequences isolates using average distance ad method clustal w2 jalview software http://www.eb-i.ac.uk/ thelactate dehydrogenase gene iranian plasmodium strains submitted accession numbers km226649-km226654 km226656-km226664 p. vivax km226665-km226671 p. falciparum genbank blast dna extracted 200 l whole blood samples 33 p. vivax 10 p. falciparum malaria infected patients using accu prep kit genomic dna extraction kit bioneer seoul korea based manufacturer instructions nucleotide sequences corresponding pvldh pfldh genes amplified using following sets primers using conventional pcr pvldh gene amplification conducted using forward 5-atgacgccgaaacccaaaat-3 reverse 5-acctttaaatgagcgccttcat-3 hand pfldh gene also amplified f 5-agatggcaccaaaagcaaaaat-3 r 5-acctttaagctaatgccttcat-3. pvldh primers designed based p. vivax sal-1 xm_001615570.1 p. vivax belem dq060151.1 strains genbank whereas pfldh primers designed based reference sequence p. falciparum 3d7 xm_001349953.1 strain genbank dna extracted whole blood healthy person living non endemic area negative control using amplification process pcr reaction performed 25l reaction volumes containing 1lof forward reverse primers 10 pmol 10 l ready use master mix ampliqon denmark contains tris hcl ph 8.5 1.5 mm mgcl2 dntps taqdna polymerase 3 l genomic dna samples 10 l distilled water pcr cycle parameters pvldh gene amplification follows 5minutes initial denaturation 95 c followed 30 cycles 30 95 c 30 56 c 1 72 c final extension 72 c 5 min all pcr parameters pfldh gene amplification except annealing temperature 58 c the fragment sizes pcr products determined using 1 kb dna ladder marker solis biodyne estonia twenty two sequences including 15 p. vivax 7 p. falciparum analyzed investigate polymorphism pvldh pfldh genes respectively these genes sequenced applied biosystems 3730/3730xl dna analyzers bioneer seoul korea using sanger method nucleotide sequences pvldh pfldh aligned compared using clustal w2 software embl ebi http://www.ebi.ac.uk/tools/msa/clustalw2/ pvldh gene sequences compared genbank sequences p. vivax belem dq060151.1 p. vivax sai-1 xm_001615570.1 hand pfldh gene sequences compared p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 moreover amino acid sequences related samples p. vivax p. faliparum derived using expasy translate tool http://web.expasy.org/tran-slate/ pvldh amino acid sequences compared p. vivax sai-1 xm_001615570.1 p. vivax belem dq060151.1 whereas pfldh amino acid sequences compared p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 strains registered genbank finally phylogenic tree prepared illustrate distance among sequences isolates using average distance ad method clustal w2 jalview software http://www.eb-i.ac.uk/ thelactate dehydrogenase gene iranian plasmodium strains submitted accession numbers km226649-km226654 km226656-km226664 p. vivax km226665-km226671 p. falciparum genbank blast a 955 bp band observed gel electrophoresis pcr products pfldh pvldh amplified genes fig 1 fig the amplified pvldh gene yielded approximately 955 base pairs coding 316 amino acids fifteen amplified genes sequenced analyze genetic variation pvldh gene using clustal w2 software comparing sequences chromatogram p. vivax sal-1 reference sequence two single nucleotide substitution detected 666 899 positions g c c respectively fig thirteen 15 isolates displayed 100% nucleotide sequence homology p. vivax sai-1 xm_001615570.1 p. vivax belem dq060151.1 table 1 fig was brought amino acid change neutral polar amino acid non polar amino acid whereas nucleotide substitution 666 positions g c result change amino acid fig dna extracted 10 p. falciparum confirmed whole blood samples pfldh gene amplified using specific primers dna sequences pfldh gene displayed three nucleotide substitutions 36 814 891positions g g g respectively fig five 7 isolates 100% nucleotide homology p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 strains submitted genbank table 3 : accession number iran baluchistan falciparum one nucleotide changes 814 positions g brought amino acid change aspartic acid acidic polar amino acid n neutral polar amino acid fig 7 the rest six isolates showed 100% amino acid homology withpfmzr-1 pf3d7 strains genbank table 4 : accession number iran baluchistan falciparum nucleotide homology pvldh pfldh iranian isolates p. vivax p. falciparum 75.876% all p. vivax ldh nucleotide sequences 75.79% homology six p. falciparum isolates the amino acids sequence homology pvldh pfldh iranian isolates 90.4% exception one isolate 90.76% homology generally amino acids sequence homology pvldh pfldh iranian isolates 90% the amplified pvldh gene yielded approximately 955 base pairs coding 316 amino acids fifteen amplified genes sequenced analyze genetic variation pvldh gene using clustal w2 software comparing sequences chromatogram p. vivax sal-1 reference sequence two single nucleotide substitution detected 666 899 positions g c c respectively fig thirteen 15 isolates displayed 100% nucleotide sequence homology p. vivax sai-1 xm_001615570.1 p. vivax belem dq060151.1 table 1 fig was brought amino acid change neutral polar amino acid non polar amino acid whereas nucleotide substitution 666 positions g c result change amino acid fig 5 dna extracted 10 p. falciparum confirmed whole blood samples pfldh gene amplified using specific primers dna sequences pfldh gene displayed three nucleotide substitutions 36 814 891positions g g g respectively fig five 7 isolates 100% nucleotide homology p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 strains submitted genbank table 3 : accession number iran baluchistan falciparum one nucleotide changes 814 positions g brought amino acid change aspartic acid acidic polar amino acid n neutral polar amino acid fig 7 the rest six isolates showed 100% amino acid homology withpfmzr-1 pf3d7 strains genbank table 4 the nucleotide homology pvldh pfldh iranian isolates p. vivax p. falciparum 75.876% all p. vivax ldh nucleotide sequences 75.79% homology six p. falciparum isolates the amino acids sequence homology pvldh pfldh iranian isolates 90.4% exception one isolate 90.76% homology generally amino acids sequence homology pvldh pfldh iranian isolates 90% pldh antigen assumed specific marker presence viable plasmodium blood used screening malaria endemic countries 17 inhibition malarial ldh enzyme prevents producing atp causes death plasmodium parasites,(13 becomes attractive drug target candidate 16 therefore protein obtained gene used diagnostic test 18 diversity pldh gene may influence specificity sensitivity rdts malaria endemic area investigation polymorphism p. vivax p. falciparum lactate dehydrogenase gene lead produce specific sensitive rdts kit nucleotide homology among 15 pvldh sequences p. vivax 100% exception two isolates displayed 99.9% homology table 1 2 fig 100% pvldh nucleotide sequence homology reported among chinese p. vivax sal-1 belem 19 another study done china reported 99.89% nucleotide identity chinese isolates belem strain 20 this point iranian pvldh nucleotide sequences homology belem strain chinese isolates reported pvldh genes chinese p. vivax anhui isolates 99% sequence homology compared strains gene bank 21 this outcome strongly agreed findings study also showed 99% homology compared p. vivax strains registered genbank present study pvldh gene sequences showed two nucleotide substitutions one resulted amino acid change neutral polar amino acid non polar amino acids antigen variability unlikely explain variability implementation rdts detecting pldh p. falciparum p. vivax cases 22 in contrast finding shin et al korea reported one snp bring change amino acid 23 jianget al china also reported single nucleotide difference position 666 pvldh gene p. vivax belem dq060151)(24 pvldh genes iranian isolates p. vivax displayed nucleotide changes korean chinese isolates earlier chinese studies jianghuai region anhui isolates p. vivax nucleotide changes among isolates 21 25 compared reports the nucleotide changes among pvldh iranian isolates p. vivax higher jianghuai region anhui isolates p. vivax talman et al reported four different type dna sequence p. vivax 10 isolates mutations synonymous 22 study less number nucleotide changes seen mutations synonymous fourteen isolates amino acid sequences p. vivax sai-1 xm_001615570.1 p. vivax belem dq060151.1 this finding agreed study conducted china reported 100% pvldh gene homology among chinese isolates p. vivax sal belem 19 studies done korea china korean hainan isolates respectively also reported 100% amino acid homology p. vivax belem dq060151.1 20 23 this indicated rdts produced korean chinese isolates used iran hand pfldh homology among iranian strains p. falciparum 100% exception two isolates in contrast finding talman et al reported variability among sequences p. falciparum n 49 worldwide isolates plasmodium spp 22 five seven isolates 100% nucleotide identity p. falciparum 3d7 xm_001349953.1 p. falciparum mzr-1 jn547219.1 strains registered genbank iranian pfldh genes reference sequence pf3d7 high homology 99.9%100% table 1 2 fig 8) indicated pfldh gene relatively conserved good target antimalarial drug producing rdt study these amino acid sequences also 100% homology p. falciparum mzr-1 p. falciparum 3d7 strains gen bank our finding supported study conducted indonesia reported 100% amino acid sequences indonesian pfldh pf 3d7 reference sequence 26 study however substitution 891 positions g brought amino acid change aspartic acid asparagine acidic polar amino acid n neutral polar amino acid madagascar two snps 73 814 positions among 137 dna sequences p. falciparum isolates displayed the nucleotide change 10 isolates 814 position resulted amino acid change acidic polar amino acid n neutral polar amino acid in addition another amino acid change codon 25 q neutral polar amino acid basic polar amino acid seen due snp 73 position 18 the position nucleotide change 814bp resulted amino acid change aspartic acid asparagine n one isolates study madagascar study the nucleotide change 814 positions study might single nucleotide polymorphism given madagascar study snp report position iranian pfldh demonstrated less number amino acid changes comparison report released madagascar study the nucleotide sequences homology iranian isolates pvldh pfldh 75.7976% china jiang et al akbulut et al also reported 74.8% homology pvldh pfldh 27 compared jiang et al akubulut et al report homology iranian pvldh pfldh high study amino acid sequences homology among iranian isolates pvldh pfldh 90.4% exception one isolate reported 89.5% 90.2% amino acid sequence homology pvldh pfldh respectively 23 28 this indicated amino acid homology pvldh pfldh genes iranian isolates p. vivax p. falciparum higher previously reports generally study amino acid homology pvldh pfldh 90% pldh gene iranian p. falciparum p.vivax isolates displayed 98.8100% homology 13 nucleotide substitutions this relatively stability indicated pvldh pfldh genes good antimalaria target used producing rdt kits this indicated techniques like drug discovery vaccine development activities applied p. falciparum could also tried p. vivax the homology among pldh p. vivax p. falciparum investigated large enough sample size general using pldh producing rdt kits genetic variation gene investigated since polymorphism varies geographical locations

background : parasite lactate dehydrogenase ( pldh ) is extensively employed as malaria rapid diagnostic tests ( rdts ) . moreover , it is a well - known drug target candidate . however , the genetic diversity of this gene might influence performance of rdt kits and its drug target candidacy . this study aimed to determine polymorphism of pldh gene from iranian isolates of p. vivax and p. falciparum.methods:genomic dna was extracted from whole blood of microscopically confirmed p. vivax and p. falciparum infected patients . pldh gene of p. falciparum and p. vivax was amplified using conventional pcr from 43 symptomatic malaria patients from sistan and baluchistan province , southeast iran from 2012 to 2013.results:sequence analysis of 15 p. vivax ldh showed fourteen had 100% identity with p. vivax sal-1 and belem strains . two nucleotide substitutions were detected with only one resulted in amino acid change . analysis of p. falciparum ldh sequences showed six of the seven sequences had 100% homology with p. falciparum 3d7 and mzr-1 . moreover , pfldh displayed three nucleotide changes that resulted in changing only one amino acid . pvldh and pfldh showed 75%76% nucleotide and 90.4%90.76% amino acid homology.conclusion:pldh gene from iranian p. falciparum and p. vivax isolates displayed 98.8100% homology with 13 nucleotide substitutions . this indicated this gene was relatively conserved . additional studies can be done weather this genetic variation can influence the performance of pldh based rdts or not .

fundamental problems personality disorders pd diagnostic system previous version dsm nothing diagnostic categories considerable heterogeneity within categories extensive overlap comorbidity among categories indistinct boundaries normal personality incomplete coverage personality psychopathology led revision dsm approach 1 2 since 2000 revision dsm iv pd researchers largely agree personality pathology represented dimensionally rather categorically 3 thus many alternative dimensional models personality considered 4 7 ongoing research performed delineate conceptual empirical structure personality traits pathological range 6 8) finally multidimensional system proposed representing diagnosis personality disorder features dsm-5 the new approach assessment personality pathology identifies core impairments levels personality functioning pathological personality traits prominent personality pathology types 9 however wide consensus severity assessment essential dimensional system personality psychopathology 10 moreover dsm-5 personality disorders work group proposed impairments personality functioning central element pd 11 thus dimensional model personality disorder pd schizotypal antisocial borderline narcissistic obsessive compulsive avoidant associated fundamental disturbances self interpersonal relations problems identity self direction empathy intimacy the review literature showed levels personality functioning self approach diagnosis informative determining type severity personality pathology 12 14 the severity impairment personality functioning also shown important planning treatment predicting outcome despite good advantages empirical background levels personality functioning practical studies clinical settings specific pds cross cultural studies field also researchers need determine levels personality functioning better predict explain severity others the purpose current study firstly examine relationship dsm-5 levels personality functioning iranian sample antisocial borderline personality disorders second explore levels personality functioning patients antisocial borderline personality disorders better predict severity of 300 participants 252 individuals antisocial n 122 borderline personality disorders n 130 selected september november 2013 regard 0.05 and based partial r 0.095 sample size antisocial personality disorder aspd calculated 119 borderline personality disorder bpd 0.05 80% respectively four variables tested multiple regression analysis based partial r 0.1 adequate sample size bpd 113 participants selected prisoners 48.8% outpatients 16.5% inpatients 7.5% they recruited tehran prisons clinical psychology psychiatry centers razi psychiatric hospital taleghani general hospital tehran iran inclusion criteria diagnosis antisocial borderline personality disorders personality disorders least 18 years old least secondary education exclusion criteria presence psychotic disorder presence severe mood disorder presence mental retardation presence physical condition impairs person mental state participants 90.5% males 9.5% females aged 18 60 years sd 1.37 guidance school degree education level higher disorders axis 106 patients 42.06% impairment 78 patients 30.97% history substance related disorders 35 patients 13.88% mood disorder 15 patients 5.96% anxiety disorders 8 patients 3.17% history psychotic spectrum disorder 10 patients 3.96% disorders data gathering measurements included psychological reports scid ii pq scid ii dsm-5 levels personality functioning checklist the scid versions considered comprehensive structured diagnostic interviews currently available in fact 1987 new wide range instruments spitzer gibbon williams built compliance criteria dsm iv 16 this instrument established gold standard reliable assessment psychiatric disorders inter rater reliability scid 70 mood anxiety schizophrenic disorders alcohol abuse somewhat lower disorders 17 scid ii reported 0.48 0.98 categorical diagnoses cohen 0.90 0.98 dimensional judgments intra class correlation coefficient 18 cronbach found 0.71 0.94 scid ii personality disorder scales 18 due high accuracy diagnostic criteria extraordinary compliance dsm iv criteria translated adapted different languages iran scid ii scid ii pq the duration scid 30 90 minutes duration scid ii 30 60 minutes severity determined study scores obtained scid ii levels personality functioning refer core capacities personality related self interpersonal functioning determining severity impairment areas 12 the dsm-5 levels personality functioning include identity self direction empathy intimacy the levels personality functioning scale use elements differentiate five levels impairment continuum severity ranging impairment i.e. healthy functioning level 0 extreme impairment level 4 11 the impairment areas likely person pd preliminary analysis sample 424 psychiatric patients morey et al ( 14 found score greater three five short five item scale sensitivity 79% specificity 54% semi structured interview diagnosis pd ( 20 translated dsm-5 levels personality functioning scale farsi developed semi structured interview inter rater reliability semi structured interview dsm-5 levels personality functioning items 0.80 the dsm-5 levels personality functioning scale domains correlation dsm iv 0.30 0.69 the duration semi structured interview dsm-5 levels personality functioning 15 25 minutes implementation process the researchers included three post graduates clinical psychology avoid probable bias outcome people they informed exact goal research detail told research goal study personality disorders they entirely uninformed concerned disorder types control probable bias research associates began collect data periodically per step blinded outcome previous next step the colleagues trained use instruments training supervision researcher people actually interviewed interviewers bug fixed mentioned there two groups patients patients personality disorders normal subjects prior research onset participants fully informed provided written consent avoid fatigue increase motivation subjects study subject was conducted two days days following completion demographic questionnaire furthermore cases symptoms antisocial borderline personality disorders examined structured clinical interview personality disorders scid ii after definitive diagnosis antisocial personality disorder borderline invited attend next stage interview process based dsm-5 levels personality functioning ethics approval obtained university social welfare rehabilitation sciences research ethics committee registered ethical code 92/801/3110/2/a we computed bivariate correlations dsm-5 levels personality functioning aspd bpd symptoms examine levels personality functioning patients antisocial borderline personality disorders better predicted severity stepwise regression analysis used scid ii results aspd bpd severity dependent variables levels personality functioning predictors of 300 participants 252 individuals antisocial n 122 borderline personality disorders n 130 selected september november 2013 regard 0.05 and based partial r 0.095 sample size antisocial personality disorder aspd calculated 119 borderline personality disorder bpd 0.05 80% respectively four variables tested multiple regression analysis based partial r 0.1 adequate sample size bpd 113 participants selected prisoners 48.8% outpatients 16.5% inpatients 7.5% they recruited tehran prisons clinical psychology psychiatry centers razi psychiatric hospital taleghani general hospital tehran iran inclusion criteria diagnosis antisocial borderline personality disorders personality disorders least 18 years old least secondary education exclusion criteria presence psychotic disorder presence severe mood disorder presence mental retardation presence physical condition impairs person mental state participants 90.5% males 9.5% females aged 18 60 years sd 1.37 guidance school degree education level higher disorders axis 106 patients 42.06% impairment 78 patients 30.97% history substance related disorders 35 patients 13.88% mood disorder 15 patients 5.96% anxiety disorders 8 patients 3.17% history psychotic spectrum disorder 10 patients 3.96% disorders data gathering measurements included psychological reports scid ii pq scid ii dsm-5 levels personality functioning checklist the scid versions considered comprehensive structured diagnostic interviews currently available in fact 1987 new wide range instruments spitzer gibbon williams built compliance criteria dsm iv 16 this instrument established gold standard reliable assessment psychiatric disorders inter rater reliability scid 70 mood anxiety schizophrenic disorders alcohol abuse somewhat lower disorders 17 scid ii reported 0.48 0.98 categorical diagnoses cohen 0.90 0.98 dimensional judgments intra class correlation coefficient 18 cronbach found 0.71 0.94 scid ii personality disorder scales 18 due high accuracy diagnostic criteria extraordinary compliance dsm iv criteria translated adapted different languages iran scid ii scid ii pq the duration scid 30 90 minutes duration scid ii 30 60 minutes severity determined study scores obtained scid ii levels personality functioning refer core capacities personality related self interpersonal functioning determining severity impairment areas 12 the dsm-5 levels personality functioning include identity self direction empathy intimacy the levels personality functioning scale use elements differentiate five levels impairment continuum severity ranging impairment i.e. healthy functioning level 0 extreme impairment level 4 11 the impairment areas likely person pd preliminary analysis sample 424 psychiatric patients morey et al ( 14 found score greater three five short five item scale sensitivity 79% specificity 54% semi structured interview diagnosis pd ( 20 translated dsm-5 levels personality functioning scale farsi developed semi structured interview inter rater reliability semi structured interview dsm-5 levels personality functioning items 0.80 the dsm-5 levels personality functioning scale domains correlation dsm iv 0.30 0.69 the duration semi structured interview dsm-5 levels personality functioning 15 25 minutes scid versions considered comprehensive structured diagnostic interviews currently available fact 1987 new wide range instruments spitzer gibbon williams built compliance criteria dsm iv 16 this instrument established gold standard reliable assessment psychiatric disorders inter rater reliability scid 70 mood anxiety schizophrenic disorders alcohol abuse somewhat lower disorders 17 scid ii reported 0.48 0.98 categorical diagnoses cohen 0.90 0.98 dimensional judgments intra class correlation coefficient 18 cronbach found 0.71 0.94 scid ii personality disorder scales 18 due high accuracy diagnostic criteria extraordinary compliance dsm iv criteria translated adapted different languages iran scid ii scid ii pq the duration scid 30 90 minutes duration scid ii 30 60 minutes levels personality functioning refer core capacities personality related self interpersonal functioning determining severity impairment areas 12 the dsm-5 levels personality functioning include identity self direction empathy intimacy the levels personality functioning scale use elements differentiate five levels impairment continuum severity ranging impairment i.e. healthy functioning level 0 extreme impairment level 4 11 impairment areas the likely person pd preliminary analysis sample 424 psychiatric patients morey et al ( 14 found score greater three five short five item scale sensitivity 79% specificity 54% semi structured interview diagnosis pd ( 20 translated dsm-5 levels personality functioning scale farsi developed semi structured interview inter rater reliability semi structured interview dsm-5 levels personality functioning items 0.80 the dsm-5 levels personality functioning scale domains correlation dsm iv 0.30 0.69 the duration semi structured interview dsm-5 levels personality functioning 15 25 minutes in implementation process researchers included three post graduates clinical psychology avoid probable bias outcome people they informed exact goal research detail told research goal study personality disorders they entirely uninformed concerned disorder types control probable bias research associates began collect data periodically per step blinded outcome previous next step the colleagues trained use instruments training supervision researcher people actually interviewed interviewers bug fixed mentioned there two groups patients patients personality disorders normal subjects prior research onset participants fully informed provided written consent avoid fatigue increase motivation subjects study subject was conducted two days days following completion demographic questionnaire furthermore cases symptoms antisocial borderline personality disorders examined structured clinical interview personality disorders scid ii after definitive diagnosis antisocial personality disorder borderline invited attend next stage interview process based dsm-5 levels personality functioning ethics approval obtained university social welfare rehabilitation sciences research ethics committee registered ethical code 92/801/3110/2/a we computed bivariate correlations dsm-5 levels personality functioning aspd bpd symptoms examine levels personality functioning patients antisocial borderline personality disorders better predicted severity stepwise regression analysis used scid ii results aspd bpd severity dependent variables levels personality functioning predictors data presented mean standard deviation sd the mean standard deviation scores levels personality functioning antisocial borderline personality disorder groups showed table 2 bivariate correlation dsm-5 levels personality functioning identity self directedness intimacy empathy antisocial borderline personality symptoms presented table 3 as seen table 3 positive significant correlations found antisocial personality symptoms dsm-5 levels personality functioning the total levels highly correlated aspd symptoms p value 0.001 borderline personality disorder except identity empathy variables significant correlations bpd symptoms p value 0.001 0.05 examine relationship dsm-5 levels personality functioning aspd bpd severity a stepwise regression analysis conducted aspd bpd severity dependent variables levels personality functioning identity self directedness intimacy empathy independent variables the results regression analysis levels personality functioning aspd severity presented table 4 these results indicate approximately 21.7% 31.4% 33% variance aspd severity could accounted identity intimacy self directedness respectively the data showed identity intimacy self directedness significantly predicted antisocial personality disorder severity the results regression analysis levels personality functioning bpd severity displayed table 5 the results showed intimacy empathy good predictors borderline personality disorder severity this means approximately 16.5% 25.1% variance bpd severity could accounted variables the first aim study examine dsm-5 levels personality functioning iranian sample antisocial borderline personality disorders the study findings revealed levels personality functioning significant positive correlations aspd this means dsm-5 levels personality functioning good relationship antisocial personality disorder symptoms iranian sample also findings indicate except identity intimacy variables self directedness empathy significant correlation borderline personality symptoms it seems study population could one reasons findings previous studies indicated severity important single predictor concurrent prospective dysfunction assessing personality psychopathology 11 21 22 therefore second aim study explore levels personality functioning patients antisocial borderline personality disorders better predict severity the stepwise regression analysis results showed identity intimacy self directedness positively significantly correlated antisocial personality disorder severity indicating higher scores variables tend higher symptoms aspd the analysis showed intimacy empathy significant association borderline personality disorder severity it means interpersonal level personality functioning intimacy empathy could explain severity patients bpd study in addition results showed dsm-5 levels personality functioning essential part antisocial borderline personality disorders also results revealed levels personality functioning cultures iranian sample the present study one first researchers examined dsm-5 levels personality functioning relationship severity first study iranian patients personality disorders based dsm-5 approach overall findings showed levels personality functioning significant predictor antisocial borderline personality disorders severity nevertheless number important limitations work future research required overcome limitations firstly results based relatively small number cases caution taken interpreting data secondly data gathered semi structured interview designed assess dimensional model personality disorders future work focus relevant instruments the third limitation current study nature sample drawn antisocial borderline personality disorders thus future research examine role axis disorders personality disorders severity fifth participants study males therefore research needed investigate dsm-5 levels personality functioning severity females seventh finally work focused assessment dsm-5 levels personality functioning severity adults

background : fundamental problems with personality disorders ( pd ) diagnostic system in the previous version of dsm , led to the revision of dsm . therefore , a multidimensional system has been proposed for diagnosis of personality disorder features in dsm-5 . in the dimensional approach of dsm-5 , personality disorders diagnosis is based on levels of personality functioning ( criteria a ) and personality trait domains ( criteria b).objectives : the purpose of this study was firstly , to examine the dsm-5 levels of personality functioning in antisocial and borderline personality disorders , and second , to explore which levels of personality functioning in patients with antisocial and borderline personality disorders can better predicted severity than others.patients and methods : this study had a cross sectional design . the participants consisted of 252 individuals with antisocial ( n = 122 ) and borderline personality disorders ( n = 130 ) . they were recruited from tehran prisoners , and clinical psychology and psychiatry centers of razi and taleghani hospitals , tehran , iran . the sample was selected based on judgmental sampling . the scid - ii - pq , scid - ii and dsm-5 levels of personality functioning were used to diagnose and assess personality disorders . the data were analyzed by correlation and multiple regression analysis . all statistical analyses were performed using the spss 16 software.results:firstly , it was found that dsm-5 levels of personality functioning have a strong correlation with antisocial and borderline personality symptoms , specially intimacy and self - directedness ( p < 0.001 ) . secondly , the findings showed that identity , intimacy and self - directedness significantly predicted antisocial personality disorder severity ( p < 0.0001 ) . the results showed that intimacy and empathy were good predictors of borderline personality disorder severity , as well ( p < 0.0001).conclusions : overall , our findings showed that levels of personality functioning are a significant predictor of personality disorders severity . the results partially confirm existing studies .

homeostasis brain maintained owing rigidly controlled communication peripheral tissues entry metabolites periphery brain controlled blood brain barrier bbb the major structural constituents bbb cerebral microvascular endothelial cells barrier function relies so- called tight junctions tjs consisting transmembrane components junctional adhesion molecule jam)-1 occludin claudins intracellular proteins zo-1 zo-2 zo-3 link transmembrane proteins actin filaments cytoskeleton way improve stability functioning tj adherent junctions located basal region tjs also contribute barrier function cadherins stabilize adhesion neighboring endothelial cells intracellularly catenins link cadherins cytoskeleton fig 1 physically tjs limit free paracellular diffusion low molecular weight compounds make transcellular transport larger molecules dependent specific transport systems grouped accordingly class molecules transported hawkins davis 2005 carvey et al these transport systems located endothelial cells modulated intrinsically cells neurovascular unit astrocytes pericytes simard nedergaard 2004 fine tuning transport involves polarization differential location transport systems luminal versus abluminal membranes holds particular different amino acid transport systems hawkins et al two ultimate complementary goals reached control inflow outflow metabolic precursors products ii prevention entry brain undesired compounds.fig 1composition tight junction adherence junction collectively restrict paracellular passage solutes across bbb composition tight junction adherence junction collectively restrict paracellular passage solutes across bbb sections describes evolution views role bbb changes pathogenesis diseases associated increased exposure brain blood derived ammonia studies bbb penetration different compounds models historical account section gives historical perspective experimental studies ammonia- induced changes bbb penetration different compounds without emphasis underlying mechanisms transcellular passage different molecules across endothelium roles active transport section review elaborate relatively well explored subject modulation transcellular passage represents active transport medium- large molecules channel- transporter mediated ion fluxes across capillary endothelial cell membranes bbb leakage induced ammonia inflammatory molecules new vistas underlying mechanisms section devoted new findings regarding mechanisms underlying alterations paracellular transport defined bbb leakage role ammonia neurotoxicity far underestimated pioneering studies pertinent effect ammonia bbb permeability performed animals portacaval anastomosis pca)a model mimics condition portal systemic shunting patients liver cirrhosis ( 1975 showed bbb pca rats leaky horseradish peroxidase hrp this observation confirmed sumner 1982 similar experimental setting others using different bbb permeability markers and/or models zaki 1983 also pca rats measured amino acid influx using oldendorf perfusion technique oldendorf 1971 horowitz et al ( 1983 galactosamine induced animal model acute liver failure alf permeability changes aminoisobutyric acid measured however contemporary animal studies often performed similar models using similar markers revealed brain vascular permeability changes examples include absence changes sucrose methyl aminoisobutyric acid permeation galactosamine induced lo et al 1987 mannitol ions pca model sarna et al 1977 alexander et al transcellular passage different molecules across endothelium roles active transport bbb leakage induced ammonia inflammatory molecules new vistas underlying mechanisms sections controversies bbb status assessed different compounds lasted present time bbb changes either confirmed wang et al incoherent results also obtained regard passage ammonia bbb monitored n labeled ammonia pet technique lockwood et al 1991 showed ammonia enters brain easily advanced patients healthy controls ( 2010 see differences bbb permeability ammonia patients without liver failure ( 2007 observed increased ammonia accumulation cirrhotic patients hands increase solely attributable increased blood ammonia content understanding effects hyperammonemia ammonia passage require separate analysis two different forms ammonia physiological ph overwhelming proportion ammonia occurs cation warren 1962 enters brain mainly transcellular route using array potassium channels transporters substituting cations similar hydrated radius ott larsen 2004 one article indicated presence specific nh4 carrier rhesus associated glycoprotein rhcg brain capillaries huang liu 2001 location luminal vs. abluminal side functionality remains confirmed however recently pericellular penetration gaseous ammonia taken consideration significant alternative ott larsen 2004 it known two routes would affected excessive ammonia load top controversies increased vesicular transport across endothelial cells swelling astrocytic end feet observed different models pilbeam et al 1983 tjs remaining intact kato et al it would thus appear altered transcellular passage maybe frequent phenomenon albeit bbb changes often subtle detected markers gross bbb leakage pca rats associated amino acid imbalance csf brain due enhanced blood brain transport tryptophan members large neutral amino acid group lnaa james et al in addition increased concentration aromatic amino acids aaa found brains rats pca level branched chain amino acids decreased smith et al the observations prompted hypothesis alterations may contribute impaired neurotransmission producing excessive amounts neurotransmitters derive and/or ii false instead authentic neurotransmitters similar structure either active postsynaptic membrane activity differs true counterparts curzon et al 1975 hypothesis appears attractive aaa also precursors false modulators tyrosine octopamine phenylalanine phenylethanolamine ( 1982 showed elevated brain octopamine phenylethanolamine levels brains pca rats hilgier et al however contribution false neurotransmitters neurotransmission imbalance associated insofar examined detail plausible explanation ammonia induced increase blood brain aaa transport activity proposed james colleagues 1979 hypothesized hyperammonemia increased brain glutamine gln production followed increased gln efflux brain resulting increased inward transport amino acids this inference proven directly studies increased tryptophan try uptake exchange gln via l transport system recorded cerebral capillary microvessels isolated pca rats cangiano et al vice versa release newly loaded gln capillaries promoted try leucine leu effect pronounced capillaries isolated taa rats following incubation ammonia control preparations hilgier et al ( 1985 showed treatment pca rats inhibitor gln synthesis methionine sulfoximine mso reduced increased accumulation aaa brain manner correlated increased ammonia accumulation ( 1993 showed administration mso pca rats normalized amino acid imbalance ascribed excessive gln production hyperammonemia shown directly responsible pca induced alterations metabolism transport amino acids jessy et al 1990 including elevated brain try content rise brain level serotonin metabolite 5-hydroxyindoleacetic acid these effects appeared due ammonia induced functional impairment lnaa transport bbb rats ha executed urease administration impairment found closely correlated rise brain gln content bachmann colombo 1983 cortical capillaries increased try gln exchange could related raised -glutamyl transpeptidase ggt activity stastn et al 1988 ggt participates lnaa transport activity found increased brain capillaries hyperammonemic rats hypothesis put forward ggt involved triggering outward transport excess gln brain gorgievski hrisoho et al 1986 way enhanced activation ggt could contribute raised try lnaa levels observed rats taa induced alf hilgier et al the speculations confirmed follow study author laboratory showing ggt affects l system mediated amino acid exchange hilgier et al the bbb transport cationic amino acids arginine arg ornithine orn investigated different models contradictory results obtained zaki et al 1984 showed 30% increase brain uptake arg galactosamine model hepatic failure however effect specific amino acid possibly secondary bbb leakage also revealed high molecular weight markers by contrast arg uptake blood brain found decreased chronic pca rats zanchin et al 1979 rats thioacetamide taa)-induced albrecht et al 1996 regard orn increased brain uptake index amino acid coincident increased content blood found taa model albrecht hilgier 1986 albrecht et al increased bbb transport orn taa model considered auto protective response line speculated facilitate intracerebral therapeutic action ammonia trapping drug l ornithine l aspartate lola albrecht et al however benefits orn may apply chronic setting blood brain transport orn appears remain unchanged zanchin et al the mechanism underlying alterations bbb transport arg orn hypothesized involve changes basic amino acid transporter activity competition two amino acids transport site albrecht et al 1996 experimental evidence support hypothesis provided yet the effects arg transport also likely mediated gln accumulates intracerebrally consequence increased ammonia influx cooper plum 1987 overloading different cellular subcellular compartments cns albrecht 2010 it shown gln added exogenously reduces generation brain inhibiting arg transport via arg gln exchanger ylat2 effect potentiated ammonia infused directly brain hilgier et al if mechanism operates cns cells also cerebral capillary endothelial cells forming bbb enhanced gln accumulation would modulate arg transport cells the final outcome interaction would depend whether gln accumulates intra- extra cellularly a hypothesis interaction may occur supported observation gln infusion absence hyperammonemia impairs cerebrovascular co2 reactivity likely reducing arg availability synthesis co infusion arg counteracts effect caused glutamine okada et al consistent role arg gln exchange bbb preliminary data indicate ammonia increases expression ylat2 transporter cerebral capillary endothelial cell line manuscript preparation brain course ha situ zieliska et al further studies mechanisms pathophysiological implications changes arg orn influx brain warranted view proven suspected contributions amino acids pathogenesis arg precursor compound whose increased accumulation engaged inflammatory response brain ammonia jalan et al 2011 ammonia induced brain swelling hussinger grg 2010 decreased synthesis implicated impairment cognition associated prolonged hyperammonemia felipo 2006 moreover ha increases arg uptake different cell types within cns rao et al 1998 taa model stimulates arg conversion neurotransmitter amino acids glu gaba measured whole brain albrecht hilgier 1986 synaptosomes derived rats likely alter balance inhibitory excitatory neurotransmission albrecht et al evaluation contribution changes arg transport across bbb availability amino acid brain accomplished without accounting variability blood arg content different hyperammonemic models the plasma arg level shown decreased pca rats zanchin et al 1979 elevated rats subjected prolonged hyperammonemia ishihara et al 1998 fluctuated increase decrease development taa induced albrecht hilgier 1986 orn plays role ammonia detoxification gives rise polyamines exert hepato- neuroprotection sikorska et al treatment lola orn contributes urea formation reduces blood ammonia level consequence improves general condition patients kircheis et al increased brain uptake orn found taa model would promote protection albrecht et al orn also contributes degree biosynthesis neurotransmitter amino acids glu gaba shank campbell 1983 similar arg conversion product orn glu gaba stimulated albrecht hilgier 1986 albrecht et al however implications increased conversion neurotransmission imbalance associated known taurine tau sulfur amino acid largely implicated osmoregulatory neuroprotective responses brain various diseases including hyperammonemia bosman et al volume regulatory properties tau thought particular importance case brain edema major consequence hyperammonemia results impaired water homeostasis followed swelling astrocytes blei 2005 he ha associated elevated blood content increased brain uptake blood brain tau collectively contributed increase tau level cerebral cortex hilgier et al similar observation liver failure induces elevation tau blood also made authors hamberger nystrm 1984 zimmermann et al because increased passage tau due massive breakdown bbb manifested absence penetration l aspartate transported intact capillary endothelial cells believed reflect activation tau transport system hilgier et al of note context treatment endothelial cell line ammonia led regulation increased function tau transporter blanger et al hyperammonemia affecting bbb transport different substances molecules also lead disturbances cerebral energy homeostasis hepatic encephalopathy evoked pca demonstrated associated decreased brain glucose use energy metabolism dejoseph hawkins 1991 similar effect noted rats taa induced hilgier et al brain uptake index glucose reduced pca rats sarna et al 1979 crinquette et al 1982 decrease almost entirely due decrease plasma glucose concentrations mans et al glut-1 principal glucose transporter bbb responsible supplying cns cells blood borne glucose demonstrated induced alf blanger et al 2006 since inhibition glucose oxidative metabolism subsequent activation cerebral glycolysis hallmark brain energy metabolism animals zwingmann et al 2003 rao norenberg 2001 increased expression glut-1 maybe considered compensatory response aimed supporting higher glycolysis maintaining brain atp levels creatine cr key substrate creatine phosphocreatine creatine kinase pathway involved regeneration atp way also contributes brain energy metabolism moreover cr shown affect gaba ergic neurotransmission acting partial agonist post synaptic gaba(a receptors cupello et al 2008 crucial dendritic axonal elongation braissant et al 2002 exposure ammonia shown generate deficiency cr cns cells lead neuronal cell loss co treatment cr neuroprotective ammonia exposure presence astrocytes braissant 2002 ammonia treatment demonstrated increase cr uptake cultured microcapillary brain endothelial cells blanger et al pca rats associated amino acid imbalance csf brain due enhanced blood brain transport tryptophan members large neutral amino acid group lnaa james et al in addition increased concentration aromatic amino acids aaa found brains rats pca level branched chain amino acids decreased smith et al the observations prompted hypothesis alterations may contribute impaired neurotransmission producing excessive amounts neurotransmitters derive and/or ii false instead authentic neurotransmitters similar structure either active postsynaptic membrane activity differs true counterparts curzon et al 1975 hypothesis appears attractive aaa also precursors false modulators tyrosine octopamine phenylalanine phenylethanolamine ( 1982 showed elevated brain octopamine phenylethanolamine levels brains pca rats hilgier et al however contribution false neurotransmitters neurotransmission imbalance associated insofar examined detail plausible explanation ammonia induced increase blood brain aaa transport activity proposed james colleagues 1979 hypothesized hyperammonemia increased brain glutamine gln production followed increased gln efflux brain resulting increased inward transport amino acids this inference proven directly studies increased tryptophan try uptake exchange gln via l transport system recorded cerebral capillary microvessels isolated pca rats cangiano et al vice versa release newly loaded gln capillaries promoted try leucine leu effect pronounced capillaries isolated taa rats following incubation ammonia control preparations hilgier et al ( 1985 showed treatment pca rats inhibitor gln synthesis methionine sulfoximine mso reduced increased accumulation aaa brain manner correlated increased ammonia accumulation ( 1993 showed administration mso pca rats normalized amino acid imbalance ascribed excessive gln production hyperammonemia shown directly responsible pca induced alterations metabolism transport amino acids jessy et al 1990 including elevated brain try content rise brain level serotonin metabolite 5-hydroxyindoleacetic acid these effects appeared due ammonia induced functional impairment lnaa transport bbb rats ha executed urease administration impairment found closely correlated rise brain gln content bachmann colombo 1983 cortical capillaries increased try gln exchange could related raised -glutamyl transpeptidase ggt activity stastn et al 1988 ggt participates lnaa transport activity found increased brain capillaries hyperammonemic rats hypothesis put forward ggt involved triggering outward transport excess gln brain gorgievski hrisoho et al 1986 way enhanced activation ggt could contribute raised try lnaa levels observed rats taa induced alf hilgier et al the speculations confirmed follow study author laboratory showing ggt affects l system mediated amino acid exchange hilgier et al the bbb transport cationic amino acids arginine arg ornithine orn investigated different models contradictory results obtained zaki et al 1984 showed 30% increase brain uptake arg galactosamine model hepatic failure however effect specific amino acid possibly secondary bbb leakage also revealed high molecular weight markers by contrast arg uptake blood brain found decreased chronic pca rats zanchin et al 1979 rats thioacetamide taa)-induced albrecht et al 1996 regard orn increased brain uptake index amino acid coincident increased content blood found taa model albrecht hilgier 1986 albrecht et al increased bbb transport orn taa model considered auto protective response line speculated facilitate intracerebral therapeutic action ammonia trapping drug l ornithine l aspartate lola albrecht et al however benefits orn may apply chronic setting blood brain transport orn appears remain unchanged zanchin et al the mechanism underlying alterations bbb transport arg orn hypothesized involve changes basic amino acid transporter activity competition two amino acids transport site albrecht et al 1996 experimental evidence support hypothesis provided yet the effects arg transport also likely mediated gln accumulates intracerebrally consequence increased ammonia influx cooper plum 1987 overloading different cellular subcellular compartments cns albrecht 2010 it shown gln added exogenously reduces generation brain inhibiting arg transport via arg gln exchanger ylat2 effect potentiated ammonia infused directly brain hilgier et al if mechanism operates cns cells also cerebral capillary endothelial cells forming bbb enhanced gln accumulation would modulate arg transport cells the final outcome interaction would depend whether gln accumulates intra- extra cellularly a hypothesis interaction may occur supported observation gln infusion absence hyperammonemia impairs cerebrovascular co2 reactivity likely reducing arg availability synthesis co infusion arg counteracts effect caused glutamine okada et al consistent role arg gln exchange bbb preliminary data indicate ammonia increases expression ylat2 transporter cerebral capillary endothelial cell line manuscript preparation brain course ha situ zieliska et al further studies mechanisms pathophysiological implications changes arg orn influx brain warranted view proven suspected contributions amino acids pathogenesis arg precursor compound whose increased accumulation engaged inflammatory response brain ammonia jalan et al 2011 ammonia induced brain swelling hussinger grg 2010 decreased synthesis implicated impairment cognition associated prolonged hyperammonemia felipo 2006 moreover ha increases arg uptake different cell types within cns rao et al 1998 taa model stimulates arg conversion neurotransmitter amino acids glu gaba measured whole brain albrecht hilgier 1986 synaptosomes derived rats likely alter balance inhibitory excitatory neurotransmission albrecht et al evaluation contribution changes arg transport across bbb availability amino acid brain accomplished without accounting variability blood arg content different hyperammonemic models the plasma arg level shown decreased pca rats zanchin et al 1979 elevated rats subjected prolonged hyperammonemia ishihara et al 1998 fluctuated increase decrease development taa induced albrecht hilgier 1986 orn plays role ammonia detoxification gives rise polyamines exert hepato- neuroprotection sikorska et al treatment lola orn contributes urea formation reduces blood ammonia level consequence improves general condition patients kircheis et al increased brain uptake orn found taa model would promote protection albrecht et al orn also contributes degree biosynthesis neurotransmitter amino acids glu gaba shank campbell 1983 similar arg conversion product orn glu gaba stimulated albrecht hilgier 1986 albrecht et al however implications increased conversion neurotransmission imbalance associated known taurine tau sulfur amino acid largely implicated osmoregulatory neuroprotective responses brain various diseases including hyperammonemia bosman et al volume regulatory properties tau thought particular importance case brain edema major consequence hyperammonemia results impaired water homeostasis followed swelling astrocytes blei 2005 he ha associated elevated blood content increased brain uptake blood brain tau collectively contributed increase tau level cerebral cortex hilgier et al similar observation liver failure induces elevation tau blood also made authors hamberger nystrm 1984 zimmermann et al because increased passage tau due massive breakdown bbb manifested absence penetration l aspartate transported intact capillary endothelial cells believed reflect activation tau transport system hilgier et al of note context treatment endothelial cell line ammonia led regulation increased function tau transporter blanger et al hyperammonemia affecting bbb transport different substances molecules also lead disturbances cerebral energy homeostasis hepatic encephalopathy evoked pca demonstrated associated decreased brain glucose use energy metabolism dejoseph hawkins 1991 similar effect noted rats taa induced hilgier et al 1991 brain uptake index glucose reduced pca rats sarna et al 1979 crinquette et al 1982 decrease almost entirely due decrease plasma glucose concentrations mans et al glut-1 principal glucose transporter bbb responsible supplying cns cells blood borne glucose demonstrated induced alf blanger et al 2003 rao norenberg 2001 increased expression glut-1 maybe considered compensatory response aimed supporting higher glycolysis maintaining brain atp levels creatine cr key substrate creatine phosphocreatine creatine kinase pathway involved regeneration atp way also contributes brain energy metabolism moreover cr shown affect gaba ergic neurotransmission acting partial agonist post synaptic gaba(a receptors cupello et al 2008 crucial dendritic axonal elongation braissant et al exposure ammonia shown generate deficiency cr cns cells lead neuronal cell loss co treatment cr neuroprotective ammonia exposure presence astrocytes braissant 2002 ammonia treatment demonstrated increase cr uptake cultured microcapillary brain endothelial cells blanger et al recent studies confirmed view hyperammonemia produces subtle changes bbb integrity partly unraveled underlying mechanism brain extravasation edema azoxymethane induced alf found secondary tight junction tj protein degradation mediated activation matrix metalloproteinase-9 mmp-9 nguyen et al specifically shown tj proteins occludin claudin-5 significantly degraded brains mice galactosamine induced alf effect reversed treatment inhibitor mmp-9 gm6001 chen et al 2009 a recent study delineated likely sequence events linking activation mmp-9 occludin degradation alf mice intermediate steps include transactivation epidermal growth factor receptor egfr p38 mapk nfb mitogen activated protein kinase nuclear factor kappa b chen et al 2011 ( 2011 observed progression intracranial pressure course alf strictly correlated increase bbb permeability mmp-9 content basing study authors proposed sequence events alf induced brain damage increase bbb permeability initial step leading vasogenic edema followed ammonia excitotoxicity cytotoxic edema inflammatory molecules including cytokines il-1 and/or il-6 tumor necrosis factor alpha tnf- increased plasma acute chronic liver failure patients tilg et al 2007 animals experimentally induced jiang et al 2009 circulating levels tnf- correlate positively severity odeh et al 2005 moreover involvement development intracranial pressure patients alf demonstrated jalan et al plasma il-6 level also found well correlated severity morbidity patients sheron et al because massive breakdown bbb observed believed effects inflammatory cytokines transduced cns vaso active agents nitric oxide prostanoids synthesized bbb forming endothelium licinio wong 1997 brain barrier permeability alf animals galactosamine lv 2010 apap model wang et al 2011 human alf patients lv 2010 disrupting tjs inducing loss tj associated protein occludin lv 2010 data presented review provide considerable evidence ammonia alters passage different molecules across bbb transcellular route representing active facilitated transport paracellularly occurs due changes integrity bbb constituents thus reflects bbb leakage discussed increased bbb permeability adds vasogenic component cytotoxic brain edema associated cauli et al the effects ammonia carrier mediated transport different molecules cerebral endothelial cells studied considerable detail outlines changes amino acid energy metabolite transport relatively well described contrast transcellular transport long given little consideration mainly models ammonia induced changes subtle spatially restricted visualized standard light- electron microscopic techniques the advent sensitive techniques made possible identify changes tj proteins environment microscale provided tools bridge observations molecular mechanisms underlying bbb leakage further studies direction allow distinguish bbb changes induced directly ammonia related inflammatory toxins mostly cytokines one aspect deserving consideration future studies potential role free radicals oxygen nitrogen found generated excess ammonia different models cell types cns responsible oxidative nitrosative stress ons bemeur et al 2010 hussinger 2010 skowroska et al preliminary results laboratory disclosed ons markers accumulate ammonia treated brain microvascular endothelial cell line increase permeability cells high molecular weight marker skowroska et al this line investigation appears attractive view fact ons causes bbb dysfunction brain pathologies varying etiology severity lehner et al many intracellular derangements known induced ammonia cells within cns peripheral tissues likely hold bbb forming cerebral vascular endothelial cells may converge events triggered different cells ons note activation p38 mapk nfb pathway underlies mmp-9-induced tj protein damage chen et al 2011 also involved ammonia induced oxidative damage astrocytes jayakumar et al other targets may include instance altered nrf2-mediated synthesis heme oxygenase effect common response various blood brain barrier damaging conditions lehner et al 2011 ammonia induced ons astrocytes warskulat et al clearly described mechanisms exhaust list possibilities worth investigation data presented review provide considerable evidence ammonia alters passage different molecules across bbb transcellular route representing active facilitated transport paracellularly occurs due changes integrity bbb constituents thus reflects bbb leakage discussed increased bbb permeability adds vasogenic component cytotoxic brain edema associated cauli et al 2011 the effects ammonia carrier mediated transport different molecules cerebral endothelial cells studied considerable detail outlines changes amino acid energy metabolite transport relatively well described contrast transcellular transport long given little consideration mainly models ammonia induced changes subtle spatially restricted visualized standard light- electron microscopic techniques the advent sensitive techniques made possible identify changes tj proteins environment microscale provided tools bridge observations molecular mechanisms underlying bbb leakage studies direction allow distinguish bbb changes induced directly ammonia related inflammatory toxins mostly cytokines one aspect deserving consideration future studies potential role free radicals oxygen nitrogen found generated excess ammonia different models cell types cns responsible oxidative nitrosative stress ons bemeur et al preliminary results laboratory disclosed ons markers accumulate ammonia treated brain microvascular endothelial cell line increase permeability cells high molecular weight marker skowroska et al this line investigation appears attractive view fact ons causes bbb dysfunction brain pathologies varying etiology severity lehner et al many intracellular derangements known induced ammonia cells within cns peripheral tissues likely hold bbb forming cerebral vascular endothelial cells may converge events triggered different cells ons note activation p38 mapk nfb pathway underlies mmp-9-induced tj protein damage chen et al 2011 also involved ammonia induced oxidative damage astrocytes jayakumar et al other targets may include instance altered nrf2-mediated synthesis heme oxygenase effect common response various blood brain barrier damaging conditions lehner et al 2011 ammonia induced ons astrocytes warskulat et al clearly described mechanisms exhaust list possibilities worth investigation

ammonia is a neurotoxin involved in the pathogenesis of neurological conditions associated with hyperammonemia , including hepatic encephalopathy , a condition associated with acute(alf ) or chronic liver failure . this article reviews evidence that apart from directly affecting the metabolism and function of the central nervous system cells , ammonia influences the passage of different molecules across the blood brain barrier ( bbb ) . a brief description is provided of the tight junctions , which couple adjacent cerebral capillary endothelial cells to each other to form the barrier . ammonia modulates the transcellular passage of low - to medium - size molecules , by affecting their carriers located at the bbb . ammonia induces interrelated aberrations of the transport of the large neutral amino acids and aromatic amino acids ( aaa ) , whose influx is augmented by exchange with glutamine produced in the course of ammonia detoxification , and maybe also modulated by the extracellularly acting gamma - glutamyl moiety transferring enzyme , gamma - glutamyl - transpeptidase . impaired aaa transport affects neurotransmission by altering intracerebral synthesis of catecholamines ( serotonin and dopamine ) , and producing false neurotransmitters ( octopamine and phenylethylamine ) . ammonia also modulates bbb transport of the cationic amino acids : the nitric oxide precursor , arginine , and ornithine , which is an ammonia trap , and affects the transport of energy metabolites glucose and creatine . moreover , ammonia acting either directly or in synergy with liver injury - derived inflammatory cytokines also evokes subtle increases of the transcellular passage of molecules of different size ( bbb leakage ) , which appears to be responsible for the vasogenic component of cerebral edema associated with alf .

focal diffuse mesangial proliferative glomerulonephritis reveal common histologic lesions observed renal biopsies patients iga nephropathy igan however histologic variability also observed disease lupus nephritis cases endocapillary hypercellularity accompanied segmental duplication glomerular basement membrane rarely diffuse endocapillary proliferation lobular accentuation multiple double contours resembling type membranoproliferative glomerulonephritis mpgn tanaka waga reported biopsied patient acute igan following formation keloid scars due burn injury however reports regarding correlation igan burn injury rare a 46-year old male patient scrotal pedal edema admitted department august 2012 laboratory examination showed proteinuria 4 775 red blood cells urine without casts this patient treated 2nd- 3rd degree burn injuries local burn center he inhalation injury sepsis whole treatment process admission time body temperature 36.6c pulse rate 75 beats min respiratory rate 16/min blood pressure 118/80 mm hg physical examination revealed cutaneous convalescence full thickness burns hands coronal plane body legs the skin showed fuscous slight exudation bleeding cracks mild scaling itch treatment process fig the laboratory test results urine blood patient listed table 1 he diagnosed nephrotic syndrome basis diminished serum albumin level 23 g l increased proteinuria excretion 10.0 g/24 h. treatment course microbiological examination wound secretion performed twice week infection observed a percutaneous renal biopsy performed september 11 2012 day 57 burn injury explore cause proteinuria the examination light microscopy revealed diffuse moderate proliferation mesangial cells endothelial cells without observable crescents 20 glomeruli arterioles presented normal status neither tubular atrophy interstitial fibrosis found shown figure 2a c immunofluorescence revealed iga 3 trace igm c3 3 igg c4 c1q coarse granular pattern mesangial capillary distribution fig 2d e inconspicuous staining igm along glomerular capillary walls granular pattern addition patient showed negative staining hbsag hbcag the mesangial hypercellularity increased mesangial matrix present glomerular basement membrane glomerular endothelium the thickened capillary wall composed basement membrane like materials interposed mesangial cells electron dense immune type deposits fig based proliferative properties glomerular lesions patient started therapy oral prednisone dose 1 mg kg day after treatment excretion urinary protein revealed significant decrease 10.0 5.20 g/24 h 2 weeks the patient followed date showed normal renal function mild proteinuria the glomerular filtration rate increased burn injuries accompanied vascular dysfunction increased cardiac output renal disease acute kidney injury remains prevalent associated increased mortality patients severe burn injuries this case shows pattern diffuse proliferative type mpgn like symptoms mesangial interposition double contours glomerular basement membrane present periodic acid schiff silver stains fig the following reasons considered close correlation burn injury onset igan first patient urinary abnormalities chronic kidney diseases early stage burn injury second nephrotic syndrome observed 2nd week injury patient history infection inflammation respiratory tract although concurrent nephrotic syndrome convalescence observed in addition patient suffered skin problems slight exudation bleeding cracks mild scaling itch treatment process fig although causal relationship igan burn injury established association cutaneous lesions burn injury igan reported patients 2 4 tanaka waga mentioned biopsied patient acute igan following formation keloid scars due burn injury the patient revealed rapid recovery complete removal scars without medication wang et al reported acute igan closely related high voltage electrical burn injury study all case reports revealed close relationship igan burn injury trauma infection tissue necrosis allogeneic plasma transfusion increased concentrations circulating immune complexes observed this situation similar immune dysfunction igan inherent genetic predisposition external infections may induce igan pathogenesis igan correlated concurrent burn injury cause nephrotic sydrome ? we hypothesize autoimmune dysregulation due sequestered antigen induced skin infection pruritus burn injury may important role pathogenesis igan the persistent skin lesions dry itch crusting properties trigger iga deposition promote depositions mesangium subendothelium patient after serious burns immune system disordered immune complex increased circulation macrophages excessively activated numerous studies provided evidence burns upregulate inflammatory cytokines tnf- il-1 those cytokines interfere hemodynamics intraglomerular microcirculation coagulation fibrinolysis system infiltration inflammatory cells burns nephritis rare complication burn injury happens affect recovery prognosis patient regular urine analysis contribute early detection diagnosis glomerular diseases treating burn injury it difficult measure blood pressure burned patients blood pressure monitored early possible wound exudation infection reasons patients large burned areas often degree hypoalbuminemia persistent hypoalbuminemia exist burned patients need examination diagnose whether chronic glomerulonephritis nephrotic syndrome burned patient nephrotic syndrome enough glucocorticoid administered order alleviate proteinuria effectively recovery burn wounds the casual relationship onset igan burn injury remains speculative needs explored

iga nephropathy ( igan ) is the most common primary glomerulonephritis worldwide , accounting for approximately 3040% of patients undergoing renal biopsy in asia . the characteristic and diagnostic lesion of igan is the deposition of glomerular iga . the morphological lesions observed by light microscopy are extremely variable . a causal relationship between igan and burn injury has not been established , and the correlation between them is not clear if they appear at the same time . we have explored the cause of severe proteinuria of a chinese patient with burns of 2nd or 3rd degree after a gas leakage accident 2 weeks ago . the diffuse proliferative glomerulonephritis of this patient revealed type i membranoproliferative glomerulonephritis - like symptoms . moreover , this patient showed a sensitive response to prednisone . this case report demonstrates the intrinsic relationship between kidney disease and burn injury , which will facilitate a feasible treatment strategy for proteinuria after burn injury .

chronic total occlusion coronary arteries cto observed 35%50% patients significant coronary artery disease cad undergoing diagnostic angiography percutaneous coronary intervention pci cto become widely accepted treatment strategy accounts 20% pcis 36 successful pci cto associated improved left ventricular lv systolic function reduced anginal symptoms increased exercise capacity decreased need bypass surgery importantly increase survival qt dispersion qtd first introduced campbell et al maximum inter lead variation longest shortest qt intervals recorded standard 12-lead electrocardiogram ecg ventricular contraction recovery recorded qt interval ecg hence qtd represents regional heterogeneity ventricular repolarization duration 3-dimensional structure ventricular myocardium 1012 it previously demonstrated many studies defect myocardial microvascular perfusion presented increase qtd 1315 qtd decreased following successful revascularization heart rate variability hrv ) has shown reliable non invasive technique quantitative analysis activity components autonomic nervous system analysis hrv consists series measurements successive rr interval variations sinus origin provide information autonomic tone increased sympathetic tone may increase incidence severity arrhythmias setting ischemia the significance autonomic factors arrhythmogenesis following early reperfusion ctos yet well established the myocardial defect and/or ongoing myocardial ischemia cto patients may lead impairment ventricular repolarization the change autonomic tone patients may also related ventricular arrhythmias the aim study assess short term changes qtd hrv parameters successful pci cto patients in prospective observational study conducted april 2011 february 2013 enrolled 139 successfully revascularized patients cto all patients underwent physical examination chest x ray ecg transthoracic echocardiographic evaluation cto defined lumen compromise resulting either thrombolysis myocardial infarction timi flow grade 0 1 likely duration 3 months all patients included native vessel occlusion estimated least 3-month duration basis history sudden chest pain previous myocardial infarction mi target vessel territory time diagnosis made coronary angiography pci we excluded patients mi within previous 6 months second third degree atrioventricular conduction disturbances atrial fibrillation flutter frequent 10/min ventricular extrasystoles sinus node disease lv hypertrophy permanent st changes ecg permanent cardiac pacemaker abnormal serum electrolyte levels congenital long qt syndrome ecg 6 missing leads patients taking drugs modify qt interval after pci patients prescribed lifelong aspirin addition clopidogrel prescribed least 12 months participating sites procedural success defined successful recanalization dilation least 1 cto per patient without stent implantation residual stenosis 50% timi flow 2 the study protocol approved institutional ethics committee patients provided written informed consent the qt intervals qtd measured manually standard ecgs available pci standard 12-lead ecg recorded 25 mm paper speed gain 10 mm mv montara instrument eu 250 electrocardiograph milwaukee wi usa all ecgs scanned 600 dpi resolution computer based analysis performed 2 independent cardiologists blind timing ecgs patients data measure qtd qt interval defined interval beginnings qrs complex point wave returned isoelectric line lead mean qt interval 4 consecutive beats measured when u wave present end wave defined nadir curve u waves dispersion qt interval measured difference maximum minimum mean qt intervals recorded 12 leads standard ecg patient qtd measured twice 612 hours 6 hours pci both qt interval qtd rate corrected modification bazett formula corrected qt interval qt square root rr interval qtcd completing computer based measurements qtd tested identify intra observer variability 25 randomly selected patients using bland altman method the 95% limit agreement qtd acceptable 7.4 7.1 ms respectively figure 1a the 95% limit agreement qtd 9.2 5.8 ms respectively figure 1b hrv analyzed using data holter recordings synetec version 1.10 ela medical montrouge france started hospital admission r data holter recordings assessed using power spectral analysis within 24 hours pci we calculated time domain hrv indices standard deviations normal normal qrs intervals sdnn square roots mean squared differences successive n n intervals rmssd percentage consecutive rr differences 50 ms pnn50 frequency domain hrv indices used fourier transform method spectral measurements heart rate spectrum 0.003 0.40 hz defined total energy ms this energy divided 2 components low frequency lf 0.040.15 hz high frequency hf 0.160.40 hz continuous variables reported mean standard deviations sd categorical variables expressed percentages comparison categorical continuous variables 2 groups performed using test unpaired test respectively the qt intervals qtd measured manually standard ecgs available pci standard 12-lead ecg recorded 25 mm paper speed gain 10 mm mv montara instrument eu 250 electrocardiograph milwaukee wi usa all ecgs scanned 600 dpi resolution computer based analysis performed 2 independent cardiologists blind timing ecgs patients data measure qtd qt interval defined interval beginnings qrs complex point wave returned isoelectric line lead mean qt interval 4 consecutive beats measured when u wave present end wave defined nadir curve u waves dispersion qt interval measured difference maximum minimum mean qt intervals recorded 12 leads standard ecg patient qtd measured twice 612 hours 6 hours pci both qt interval qtd rate corrected modification bazett formula corrected qt interval qt square root rr interval qtcd completing computer based measurements qtd tested identify intra observer variability 25 randomly selected patients using bland altman method the 95% limit agreement qtd acceptable 7.4 7.1 ms respectively figure 1a the 95% limit agreement qtd 9.2 5.8 ms respectively figure 1b hrv analyzed using data holter recordings synetec version 1.10 ela medical montrouge france started hospital admission r data holter recordings assessed using power spectral analysis within 24 hours pci we calculated time domain hrv indices standard deviations normal normal qrs intervals sdnn square roots mean squared differences successive n n intervals rmssd percentage consecutive rr differences 50 ms pnn50 frequency domain hrv indices used fourier transform method spectral measurements heart rate spectrum 0.003 0.40 hz defined total energy ms this energy divided 2 components low frequency lf 0.040.15 hz high frequency hf 0.160.40 hz continuous variables reported mean standard deviations sd categorical variables expressed percentages comparison categorical continuous variables 2 groups performed using test unpaired test respectively the mean patient age 58.39.6 years 118 84 male 59 42 diabetes mellitus the cohort included 47 patients 34% prior mi 14 patients 10% history congestive heart failure baseline patients aspirin n=139 100% angiotensin converting enzyme ace inhibitors n=98 70% lipid lowering medications n=113 81% -blockers n=124 89% ) however use nitrate n=29 20% calcium channel blockers n=23 16% angiotensin receptor blockers n=34 24% limited both qtd qtcd showed significant improvement following successful revascularization cto 55.8314.79 vs. 38.8711.69 p<0.001 61.0216.28 vs. 42.9213.41 p<0.001 respectively regarding hrv parameters revascularization left coronary artery lad n=38 resulted decrease hrv indices including sddn rmssd pnn50 none reached statistical significance similar findings observed revascularization circumflex branch left coronary artery cx n=28 right coronary artery rca n=73 lesions table 3 we investigated changes qtcd hrv parameters cto patients undergoing successful percutaneous revascularization the major findings study 1 successful revascularization may improve qtcd patients cto 2 revascularization cto lesions seem significant impact hrv 3 impact hrv change intervention lad cx rca myocardial necrosis reversible myocardial ischemia impact qtd direct relationship prolongation qt interval myocardial ischemia reported roukema et al observed increased qtd patients exercise induced myocardial ischemia in experimental animal studies human studies shown qt interval shortened acutely hypoperfused areas whereas infarcted myocardium prolonged repolarization time associated qt prolongation ecg the heterogeneity ventricular excitability presumed increase propensity arrhythmic manifestations arrhythmic death especially patients previous mi history cad reported increased qtd related susceptibility reentry ventricular tachyarrhythmias independent degree lv dysfunction clinical characteristics patient suggesting simple noninvasive measurement interval standard 12-lead ecg significantly contributes identifying patients risk life threatening arrhythmias previous mi the strong heart study assessment qt interval qtd prediction cause cardiovascular cv mortality showed qtcd strong predictor cause mortality weaker predictor cv mortality qtd significant predictor cv mortality present study showed successful revascularization ctos resulted significant decrease qtd qtcd our results consistent data reported yunus et al assessed qtd patients ischemia due 1-vessel cad without prior mi underwent successful pci however patient population included patients ctos demonstrated improvement qtd challenging group we suggest electrophysiological mechanism action based decrease ischemia induced prolongation conduction dispersion conduction times the improvement qtd pci may suggest role revascularization achieving homogenous repolarization perhaps greater clinical stability cto patients hrv analysis safe convenient method evaluation function autonomic nervous system activity accordance guidelines standardization significant decrease autonomic tone shown independent predictor mortality patients cad it shown hrv indices decreased following coronary revascularizations study although trend decrease hrv parameters following pci cto none parameters reached statistical significance similar results also reported szwoch et al repeated hrv analysis 3 months observed improvement parameters we speculate decrease hrv parameters early periods following recanalization ctos could transient might associated acute endothelial injury procedure microembolization vascular bed previously protected ischemia collateral support consistent results previous study localization totally occluded coronary arteries study significant impact hrv results revascularization procedure sinus node blood supply primarily comes artery significant change hrv following successful pci rca might expected the reason may incomplete disclosed mechanisms hrv also common impact artery sinus node artery mechanisms might responsible hrv changes addition changes blood supply the main limitations study lack long term follow heterogeneous patient population concomitant diseases nearly half patients 42% diabetes diabetes may associated depressed hrv due diabetic autonomic neuropathy may result reduced hrv inducing hemodynamic changes involve adrenergic activation vagal tone reduction however patient group may representative overall patient population cad we analyzed hrv parameters pci measure respiratory rate in addition hrv affected various factors age patient use ace inhibitors -blockers factors might affected results 3436 in conclusion successful pci cto patients may improve ventricular repolarization abnormalities thus may reduce incidence ventricular arrhythmias early assessment hrv parameters seem changed following recanalization cto lesions

backgroundqt dispersion ( qtd ) , which is a measure of inhomogeneity of myocardial repolarization , increases following impaired myocardial perfusion . its prolongation may provide a suitable substrate for life - threatening ventricular arrhythmias . we investigated the changes in qtd and heart rate variability ( hrv ) parameters after successful coronary artery revascularization in a patient with chronic total occlusions ( cto).material / methodsthis study included 139 successfully revascularized cto patients ( 118 men , 21 women , mean age 58.39.6 years ) . qtd was measured from a 12-lead electrocardiogram and was defined as the difference between maximum and minimum qt interval . hrv analyses of all subjects were obtained . frequency domain ( lf : hf ) and time domain ( sdnn , pnn50 , and rmssd ) parameters were analyzed . qt intervals were also corrected for heart rate using bazett s formula , and the corrected qt interval dispersion ( qtcd ) was then calculated . all measurements were made before and after percutaneous coronary intervention ( pci).resultsboth qtd and qtcd showed significant improvement following successful revascularization of cto ( 55.8314.79 to 38.8711.69 ; p<0.001 and 61.0216.28 to 42.9213.41 ; p<0.001 ) . the revascularization of lad ( n=38 ) , cx ( n=28 ) and rca ( n=73 ) resulted in decrease in hrv indices , including sddn , rmssd , and pnn50 , but none of the variables reached statistical significance.conclusionssuccessful revascularization of cto may result in improvement in regional heterogeneity of myocardial repolarization , evidenced as decreased qtcd after the pci . the revascularization in cto lesions does not seem to have a significant impact on hrv .

ocular cicatricial pemphigoid ocp uncommon chronic autoimmune disease affects mucous membranes particularly conjunctiva.1 disease typically results chronic conjunctivitis causes conjunctival corneal scarring result limbal stem cell deficiency blindness.2 adequate control ocular inflammation usually requires systemic well topical immunosuppressants commonly used systemic medications include prednisone methotrexate mycophenolate mofetil mmf cyclophosphamide.3 porphyrias metabolic disorders caused defective enzymes within heme synthetic pathway.4 defective enzymes cause accumulation intermediates heme synthetic pathway results various clinical manifestations.4,5 porphyria cutanea tarda common porphyrias results deficiency uroporphyrin decarboxylase fifth enzyme heme synthetic pathway.6 deficiency results accumulation porphyrins liver plasma exposure light wavelength near 400 nm the porphyrins enter excited state lead damage proteins lipids basement membranes.6 process results blisters fibrosis scarring skin areas body exposed sunlight.6 park et al7 reported case 31-year old cicatricial conjunctivitis biopsy negative ocp later diagnosed porphyria cutanea tarda case patient clinical symptoms significantly improved initiating phlebotomy treatments the present authors report similar case pathology direct immunofluorescence confirmed diagnosis ocp patient clinical condition also improved significantly upon diagnosis treatment porphyria cutanea tarda a 64-year old caucasian male complaining redness tearing 3 years eyes referred evaluation cicatricial conjunctivitis he treated tobramycin dexamethasone ophthalmic ointment eyes needed doxycycline 100 mg mouth daily improvement symptoms on slit lamp examination patient subconjunctival fibrosis symblepharon forniceal foreshortening trichiasis eyes figure 1 examination corneas revealed multiple punctate epithelial erosions schirmer test performed without anesthesia showing 22 mm wetting right eye 13 mm left 5 minutes direct immunofluorescence studies conjunctival biopsy specimen revealed immunoglobulin g4 deposits basement membrane zone junctional area figure 2 consistent ocp given findings subconjunctival fibrosis symblepharon formation eyes patient diagnosed bilateral stage iii pemphigoid patient started methotrexate 15 mg mouth weekly prednisone 20 mg mouth daily the patient demonstrated gradual improvement conjunctival inflammation starting methotrexate prednisone the patient subsequently tapered prednisone methotrexate 15 mg mouth weekly continued after 4 months treatment methotrexate patient conjunctival inflammation began worsen regimen subsequently changed methotrexate mmf 1000 mg mouth twice daily approximately 3 months initiating mmf treatment patient diagnosed porphyria cutanea tarda the patient conjunctival inflammation appeared stable following initiation phlebotomy treatments mmf subsequently discontinued approximately 6 weeks following discontinuation mmf patient returned mildly increased conjunctival injection trichiasis eyes epilation performed patient started 1% prednisolone acetate one drop eyes twice daily the patient conjunctival inflammation stabilized tapered one drop 1% prednisolone acetate eyes daily since initiation phlebotomy treatments patient conjunctival inflammation and subconjunctival fibrosis remained quiescent 4 months without requiring mmf figure 3 ocp believed autoimmune disease genetic predisposition likely second hit environmental trigger required initiate onset disease.1 thought could include chemical exposure microbial environmental triggers the present case suggests patient porphyria could causal factor associated ocp could even environmental trigger stimulated disease occur the porphyrins present plasma therefore would present ocular surface vasculature.5 ocular surface constantly exposed light exposure ultraviolet light would lead porphyrins enter excited state resulting inflammation damage ocular surface . process could trigger either initiate exacerbate ocp present case the patient conjunctival inflammation observed significantly improve following initiation treatment porphyria a similar response observed aforementioned case reported park et al,7 although particular patient biopsy negative ocp positive hepatitis c virus infection addition patient remained methotrexate the patient present case unique biopsy positive ocp clinical improvement significant enough starting phlebotomy treatments mmf discontinued the authors consider case well case reported park et al,7 sheds new light search etiology ocp subsequent treatment options patients disease

a 64-year - old caucasian male complaining of redness and tearing for 3 years in both eyes was referred for evaluation of cicatricial conjunctivitis . ocular cicatricial pemphigoid was suspected and this diagnosis was confirmed through biopsy . the patient s condition showed moderate improvement following treatment with methotrexate and mycophenolate mofetil . the patient was later diagnosed with porphyria cutanea tarda and phlebotomy treatments were subsequently initiated . the patient s ocular symptoms improved further after he began receiving these phlebotomy treatments , and conventional treatment was discontinued . the authors hypothesize that circulating porphyrins activated by ultraviolet light could be the cause of the ocular cicatricial pemphigoid in this patient .

incidence endometrial cancer remained stable number deaths annually disease doubled since 1987 despite fact many gynecologists believe endometrial cancer harmless compared stage stage 5-year survival identical cervical cancer considered virulent thus obligated reassess screening diagnostic staging therapeutic aspects importantly debate lymphadenectomy hysterectomy currently extremely low prevalence inferred lymph node involvement stages ia ib grade 1 neoplasm comprises 40% 60% newly diagnosed patients furthermore postulated early disease stages regional nodes clinically unaffected nodes sampled prognostic significance removed radically vain hope curing patient indeed evidence laboratory studies shown many lymphatic lymphatico venous shunts bypass regional lymph nodes exist allow early stage lymphatic hematogenous dissemination malignant cells on hand removal lymph nodes grossly positive lessening tumor burden decrease amount suppressive tumor antigens present host reduce amount adjunctive therapy required treat residual disease indeed ineffective nodes longer useful host contribute increased tumor induced immunologic suppression tumors infiltrating inner third myometrium the actual risk node metastases substantial grade 3 histologic type tumors middle third invasion risk node metastases substantial grade 2 3 lesions tumors infiltrating outer third thus risk ignorable superficial invasion substantial deep myometrial invasion grades 20% 45% the negligible risk node metastases 0% 4% also valid inner one third myometrial involvement grades 1 2 middle one third involvement grade 1 tumors aforementioned conditions vascular space involvement spread cervix adnexa histologic type adenocarcinoma adenoacanthoma this group comprises 75% patients nevertheless common belief among gynecologists take uterus small well differentiated valid 10% 15% grade 1 lesions substantial myometrial invasion exposing patient substantial risk node metastases thereby necessitating intraoperative assessment myometrial invasion instances well thus need lymph node assessment surgery challenging issue among gynecologists several methods lymph node dissection proposed different situations although differ one surgeon next the adequacy clinical assessment lymph nodes sampling lymphadenectomy subject controversy years meticulous inspection palpation bidigitally refined exercises gynecologic oncologist slightly one half suspicious pelvic paraaortic nodes reveal metastases 5% unsuspicious nodes bear malignant cells thus one bear mind possibility undetected metastases regional nodes traditional methods surgery addition tumor cells detected immunohistochemical analysis thereby pass unrecorded thus real incidence tumor involvement might underestimated due technique used pathologic assessment limited node dissection do need complete dissection positive detection negative staging necessarily identify subset need therapy another debate hand concern would false negativity rate accepted surgeon patient another important issue hence prevalent gynecological cancer endometrial cancer require radical hysterectomy lymph node evaluation early stage as gynecologic oncology surgeons gained experience skill different techniques procedures interest minimally invasive surgery laparoscopic approach found applications treatment endometrial cancer application video improvement armamentarium video laparoscopic surgery changed performed operating room one man frustrated lack ability operating room staff follow participate surgical procedure performed amphitheater allowing assistant operating room staff see actual procedure follow sequences but these advances resulted accelerated improvement operative laparoscopy proved important aid education advantage using monitors operation taping surgery repetitive education laparoscopic assisted surgical staging lass early stage endometrial cancer although remaining controversial subject attractive alternative traditional laparotomic approach nevertheless one bear mind first purpose staging provide common language uniformity comparison instead aiding therapy management issues staging must first aim despite still existing conflicting ideas regarding system staging laparoscopy similar success rate compared laparotomic staging accepted less invasive studies shown lymph node yield laparoscopy equivalent laparotomy feasibility laparoscopic staging incompletely staged endometrial cancer patients another subject interest although laparoscopic pelvic paraaortic lymphadenectomy accepted feasible randomized studies still awaited standardize indications applications the patient population consisted 52 early stage endometrial cancer patients presented akdeniz university obstetrics gynecology department 1998 2002 underwent staging surgery comprising total hysterectomy bilateral salpingo oophorectomy pelvic lymph node sampling 2 surgeons cgz ts using technique instruments the patients randomly assigned surgical approach informed surgery type surgery undergo one group comprised 26 patients managed traditional laparotomic surgery comprised 26 patients underwent laparoscopic surgery the patients clinically thought advanced disease included study the main outcomes studied operative time blood transfusion intraoperative postoperative complications duration hospital stay number lymph nodes obtained lymph node positivity statistical analysis performed mann whitney u test p values 0.05 considered statistically significant the laparotomy group average age 54.9 range 36 to77 average gravidity 3.8 range 0 9 the laparoscopy group average age 56.6 range 40 72 average gravidity 3.6 range 0 8) body mass indexes significantly different laparotomy laparoscopy groups 26.2 vs 24.4 respectively the majority patients stage disease 67.3% endometrioid type endometrial cancer common tables 1 2 3 the number lymph nodes significantly different groups p>0.05 the laparoscopic group average number 18.2 range 9 31 laparotomic group 21.1 range 9 38 two 7.7% patients laparoscopy group 4 15.4% laparotomy group pelvic lymph node metastasis eleven patients 42.3% laparoscopy group 10 38.5% laparotomy group later scheduled adjuvant radiation therapy study groups compared according stage histologic grades study groups histologic types endometrial cancer study groups laparoscopic group significantly shorter hospitalization laparotomy group 4.1 vs 8.2 days z 1.96 p<0.05 operative time laparoscopy close laparotomy encouraging 155 vs 144 minutes p>0.05 terms postoperative intraoperative complications the laparoscopic approach none wound complications occurred 5 patients laparotomy group one evisceration needed reoperation closure eight units red blood cell suspension transfused laparotomy group patients 6 units laparoscopy group patients nowadays laparoscope allows us carry almost procedure done laparotomy gynecologic practice laparoscopically assisted vaginal hysterectomies laparoscopic total hysterectomies benign conditions applied widely even patients large uteri however management gynecologic cancers laparoscope lesser role pelvic paraaortic lymph node dissections became feasible 1990s following achievement the laparoscope gained importance among gynecologic oncologists especially patients early endometrial cervical cancers every surgeon doubtful outcome type surgery doubt many institutions established pilot studies prospective small scale trials rate successful speeded publication encouraging surgeons switch type surgery laparoscopically assisted vaginal hysterectomy lymph node evaluation alternative treatment endometrial cancer properly selected patients the goal minimize morbidity treatment instead satisfying surgeons new enthusiasm use technique laparoscopically assisted surgical staging endometrial cancer experienced hands performed equal success safety minimal morbidity it advantages less pain early resumption normal activities overall improved quality life many authors agreement results significantly less blood loss shorter hospitalization scribner et al compared laparoscopy laparotomy similar number patients study they concluded although early hospital discharge advantage longer surgical time higher anesthetic costs laparoscopic approach offset gain total costs appear differ statistically in contrast scribner study gemignani et al found overall charges laparoscopy group significantly lower laparotomy group considering fewer postoperative complications seen laparoscopic approach factor lowers overall hospital charges 2 studies the laparoscopy group significantly longer operating room time 237 vs 157 minutes scribner study 214 vs 144 minutes gemignani study however study duration operation 2 groups similar 155 vs 144 minutes another randomized study comparing laparoscopicvaginal approach conventional abdominal approach treatment patients endometrial cancer performed including 70 patients endometrial cancer figo stage iii thirty seven patients treated laparoscopic group versus 33 patients laparotomy group lymph node dissection performed 25 patients laparoscopy 24 patients laparotomy blood loss and yield pelvic paraaortic lymph nodes duration surgery incidence postoperative complications similar groups while comparing laparotomy laparoscopy number residual nodes following lymphadenectomy also studied lymph nodes left situ might microscopic metastases review lecuru taurelle laparoscopic pelvic lymphadenectomy declared able retrieve 90% 95% nodes similar laparotomy laparoscopic paraaortic lymphadenectomy substituted open counterpart regarding lymph node yield accuracy recovery positive nodes well port site metastases one often addressed issues patients undergoing laparoscopic procedure kind gynecologic cancer dragging cancerous tissue small incision exfoliation surface implantation healing wounds main reasons increased likelihood metastases recurrences sites however gynecologic cancers port site recurrences always associated either disseminated intraperitoneal disease cyst rupture the question contamination increasing tumor growth co2 laparoscopy effect pneumoperitoneum survival remains obscure however surgeons take preventive measures avoiding cyst rupture gentle handling cancerous tissue avoiding rupture lymph node capsule including port sites radiation field patients undergoing postoperative irradiation study morbidities related laparoscopic surgery concern injuries generally related trocar installation these morbidities mostly bowel vascular bladder injuries increasing numbers advanced laparoscopic applications like expanded lymph node dissections radicalness treating gynecologic cancers caused surgeons face complications well injury vein tributaries laparoscopic lymphadenectomy may cause major hemorrhage adjacent veins it might easy sometimes overcome bleeding even laparotomy depth location bleeding preventing easy access area laparoscope 5-to 7-fold magnification could sometimes superior identifying deep bleeding locations however difficulty suturing unavailability vascular clamps may prevent appropriate approach study group almost 90% patients laparoscopy group stage ii disease following surgical staging whereas 70% patients laparotomy group early stage disease however breakout stage iii subsets showed us patients identifiable surgery therefore could incidental never felt we 're glad opened patient would dreadful put scope first time surgery we conclude laparoscope seems useful select group reduces postoperative morbidity offering quick recovery success efficacy however experience utmost importance way start scoping without proper training feeling ready mean one good operating room thus supervised overlooked integrating procedure clinical practice shorter hospital stay less postoperative morbidity advantages laparoscopic surgery duration laparoscopic surgery seem different laparotomy

objective : the aim of this study was to evaluate the feasibility of laparoscopy in the management of early stage endometrial cancer.methods:fifty-two patients with endometrial cancer who underwent surgical staging consisting of total hysterectomy , bilateral salpingo - oophorectomy with pelvic lymph node dissection , and cytology between 1998 to 2002 were included in the study . laparotomy and laparoscopy were randomly offered to patients upon admittance.results:of 52 patients , 26 underwent laparotomy and the remaining 26 underwent laparoscopic staging surgery . no significant difference existed between the demographic characteristics of the 2 groups . the mean number of harvested lymph nodes was 18.2 in the laparoscopic group and 21.1 in the laparotomic group ( p>0.05 ) . pelvic lymph node metastases were detected in 7.7% of the patients in the laparoscopy group and 15.4% in the laparotomy group , and the difference was not significant . adjuvant radiotherapy was applied later to 42.3% of the laparoscopy group and 38.5% of the laparotomy group . operative morbidity was higher in the laparotomy group mainly because of postoperative wound infection , and the patients in the laparotomy group had a longer hospital stay.conclusion:laparoscopic surgery is a method that can be applied as well as laparotomy in the management of endometrial cancer . lymph node number and detection of lymph node metastasis did not differ significantly in laparotomic and laparoscopic approaches . wound infections were more frequent in laparotomies .

a mild catalytic asymmetric direct fluoro - arylation of styrenes has been developed . the palladium - catalyzed three - component coupling of selectfluor , a styrene and a boronic acid , provides chiral monofluorinated compounds in good yield and in high enantiomeric excess . a mechanism proceeding through a pd(iv)-fluoride intermediate is proposed for the transformation and synthesis of an sp3 c f bond .

genetic analysis phenotypes diseases traditionally followed two approaches family based linkage analysis population based association studies linkage analysis co segregation alleles families measured population based studies use non random associations phenotypes alleles populations identify causative genes linkage analysis proven immensely successful means identifying genes number single gene diseases simple mendelian inheritance eg see omim database complex diseases multifactorial polygenic often characterised late age onset incomplete penetrance locus heterogeneity environmental exposures despite significant efforts amenable family based mapping linkage disequilibrium ld important aspect genetic association studies generated population mutation selection drift non random mating admixture allelic associations due ld significant correlated physical distance within small genomic regions decay time due recombination 2 4 ld based association studies successful fine scale mapping initial disease gene mapping homogeneous populations undergone recent bottlenecks eg hirschsprung disease mennonites bardet- beidle syndrome bedouins allelic associations result either direct functional effects alleles tested indirectly non random associations allele measured nearby functional alleles since functional alleles genes still unknown indeed object research ld important feature genes screened alleles alter disease risk thus substantial focus extent ld across genome definition statistical methods disease gene mapping using ld 9 11 large cosmopolitan populations however ld may difficult detect mutation old since amount remaining ld may small additionally false positive associations due population stratification important confounders ld based association studies the process admixture creates ld loci linked unlinked different allele frequencies parental populations the magnitude admixture linkage disequilibrium ald admixed population depends allele frequency differential parental populations level admixture admixture dynamics time since admixture recombination rate loci ald unlinked markers decays rapidly within two four generations ) the exponential decrease ald genetic distance facilitates differentiation ald high markers close together genetically linked ald generated unlinked loci thus parental populations differ trait disease due different frequencies risk alleles possible identify loci containing alleles using admixture mapping 12 14 the european colonial period started late 1400s brought together new world populations geographically isolated namely europeans west africans native americans given recent common origin human populations admixture small average effect gene pools new populations in words genomic regions pre colonial parental populations similar allele frequencies admixture little consequence loci however there change allele frequency time since separation parental populations loci admixture important effect since populations like african americans african caribbeans mexican americans were formed recent past allelic associations populations created admixture extend large distances admixed populations represent useful resource mapping complex disease genes using long range ald requires fewer markers screen genome populations approaches understanding genetic consequences admixture is important confounding factor source statistical power gene identification studies two models admixture dynamics described represent extremes process admixed population formed continuous gene flow cgf model hybrid isolation hi model hi model admixture occurs immediately single generation without contribution either parental population hence ald generated single generation gradually decays successive generations independent assortment recombination loci few false positive results thus expected association study hi model alternatively cgf model represents situation admixture occurs steady rate generation contributions one parental populations admixed population ald cgf model increases generation since new admixture constantly occurring a point reached however admixture proportion 0.5 continued admixture actually decrease ald since added gene flow result conversion admixed population introgressing parental population figure 1 shows amount ald expected two models linked unlinked loci models association markers simulation studies shown populations demographic history consistent cgf model admixture retain ald larger chromosomal regions show significant associations unlinked marker loci associations unlinked markers could potentially lead false positives conditioning upon parental admixture allows distinction associations arising due true linkage due cgf stratification made thereby providing greater power detecting ald larger chromosomal distances the amount admixture linkage disequilibrium ald expected continuous gene flow cgf hybrid isolation hi models admixture unlinked loci loci linked 5 cm the results shown two loci 0.54 0.49 50 per cent admixture first generation hi model 1.9 per cent admixture 36 generations cgf model equivalent 50 per cent total ald hi model decreases linked unlinked loci whereas ald cgf model linked unlinked loci increases initially decreases adapted pfaff et al 2001 several ways admixture important resource elucidation genetic factors contribute risk common disease common diseases often environmental components risk clinical phenotype results currently unknown interactions environmental factors underlying genotypes decomposing sources variation it possible distinguish genetic environmental explanations ethnic differences disease risk investigating mode inheritance studying relationship disease risk individual admixture 14,17 19 for example recent studies demonstrated strong relationship proportional west african ancestry risk systemic lupus erythematosus admixed populations trinidad several common diseases eg hypertension diabetes obesity prostate cancer osteoporosis differences risk among population groups see table 1 situations differences genetic basis genes underlying differences identified testing locus ancestry conditioning parental admixture detailed shriver et al approach greater statistical power family linkage studies mapping polygenic traits estimates biogeographical ancestry bga proportional ancestry levels individual used conjunction measured environmental effects investigating roles environmental inherited risks underlying complex traits 18 20 it important recognise associations individual admixture disease risk might reflect correlations bga socio cultural variables exposures for example hypothetically bga years education correlated hypertension might correlated bga even though causal risk factor years education vice versa diseases possible genetic components based ethnic differences disease rates hence amenable admixture mapping admixture based methods rely using suitable markers estimates allele frequencies appropriately identified parental populations since ald fairly new extends larger distances fewer markers required studies markers informative ancestry used several contexts referred ideal private unique informativeness markers measured allele frequency differential absolute value difference particular allele populations microsatellites insertion deletion polymorphisms 0.3 recently called ethnic difference markers edms suitable mapping admixture linkage disequilibrium mald additionally markers high high log likelihood allelic ratio llar populations designated population specific alleles psas this report followed earlier work markers large allele frequency difference identified appropriate admixture studies 95 per cent arbitrarily identified biallelic markers 50 per cent thus authors proposed ideal psas 50 per cent also indicated multiallelic loci composite could estimated one half summation absolute value allelic frequency differences alleles locus it also shown markers lower values approximately 30 per cent provide 80 per cent power detecting associations distances 5 cm large enough sample size n 1,000 pfaff et al suggested referring markers suitable admixture studies ancestry informative markers aims given central feature markers ancestry information content f the present authors agree term aim accurately describes markers using language less likely misunderstood misinterpreted marker information content f denotes locus specific fst value representative differentiation two populations single locus simulation studies estimating information content markers varying levels f shown 1,000 markers average information content ancestry 40 per cent two ancestral subpopulations approximately 80 per cent information ancestry extracted initial genome screen initial identification regions showing admixture markers typed regions increase extraction information nearly 100 per cent it well established however 5 15 per cent total genetic variation results differences among human populations 30 32 moreover alleles shared populations alleles common one population also common populations thus genetic markers unaffected admixture imperative choose markers show high levels f parental populations recent studies several groups focused identifying panels markers suitable admixture studies one notable study screened 744 microsatellite markers composite values llar four different populations identified genome spanning set 315 markers average spacing 10 cm 0.3 mapping african americans 214 markers average spacing 16 cm 0.25 mapping hispanics a dna pooling method used identify 151 aims microsatellites short insertion deletion polymorphisms 0.3 mapping mexican american populations distinguish european american native american contributions ninety seven aims identified mapping african american populations show limited variation within africa additional resources available obtaining marker frequency genotype haplotype information snp consortium tsc http://snp.cshl.org national center biotechnology information dbsnp website http://www.ncbi.nlm.nih.gov/snp marshfield database http://research.marshfieldclinic.org/genetics/default.htm ongoing hapmap project since amount ald created proportional level admixture population important briefly review studies admixture levels across populations those populations likely useful admixture studies include african americans mexican americans cubans puerto ricans usa african caribbeans various latin american populations various groups central south america caribbean islands anglo indians india coloured populations south africa various statistical approaches used estimate admixture proportions populations reviewed detail elsewhere these include least squares method weighted least squares method likelihood methods a recent review admixture studies admixture proportions various latin american populations provided sans african americans well studied group substantial european west african contributions smaller native american contribution a survey current literature indicates european admixture ranges 3.5 per cent gullah sea islanders south carolina 28 per cent new orleans admixture estimates african american populations highly variable across usa likely reflect local variation demographic histories social norms us hispanics form complex socio political conglomerate including puerto ricans cubans spanish americans mexican americans the proportional contributions parental europeans estimated largest followed substantial native american ancestry varying amounts west african ancestry sample mexican americans arizona the admixture estimates obtained using weighted least squares method showed 29 4 per cent native american 68 5 per cent european 3 2 per cent west african contribution a recent study reports following estimates hispanic population san luis valley colorado 62.7 2.1 per cent european 34.1 1.9 per cent native american 3.2 1.5 per cent west african puerto ricans new york city the estimates obtained 53.3 2.8 per cent european 29.1 2.3 per cent west african 17.6 2.4 per cent native american separate mexican american population sample california european ancestry estimated 60 per cent native american contribution estimated 40 per cent from results evident studying new admixed population sample important accurately determine proportional contributions rely previously obtained estimates similar population additionally instructive information levels stratification related admixture present population consideration traits diseases prevalent one population others amenable admixture analysis examples listed table 1 most diseases shown table complex aetiology affected multiple genes environmental factors earlier studies focused admixed populations units analysis exploring relationships ancestry phenotypes these authors showed non insulin dependent type 2 diabetes mellitus prevalence correlated admixture proportions among selection populations varying levels native american ancestry data like provide compelling evidence frequency differences risk modifying alleles data collected many diseases another related approach test individual admixture phenotype correlations within admixed population correlations ancestry phenotypes detected reported various authors 14,17 19,44,45,47 prerequisite testing ancestry phenotype correlations is presence stratification related admixture evident variation individual ancestry levels figure 2 shows distribution bga estimates three examples hispanic population samples puerto ricans new york mexicans tlapa mexico hispanics san luis valley colorado substantial variation observed three samples san luis valley group more variability observed european native american axis new york group variable european west african axis following argument chakraborty weiss admixture proportions correlated diseases traits differ populations due underlying genetic differences population samples strong positive correlation observed individual ancestry skin pigmentation measured melanin index lightness index l figures 3a 3b 3c a significant negative correlation also observed proportion west african ancestry bone mineral density bmd puerto rican sample proportion west african ancestry skin pigmentation measured melanin index individuals also correlated african americans washington dc african caribbeans uk european americans state college pennsylvania figure 4 recently correlations observed proportion west african ancestry lower insulin sensitivity higher fasting insulin acute insulin response glucose combined sample african american european american children separate sample african american females west african admixture associated body mass index fat mass fat free mass bmd it important keep mind ancestry pheno type correlations dependent existence functional alleles different frequencies parental populations significant stratification related admixture although admixed populations tested date structured variation amount stratification present structure tested explicitly investigating new population each vertex represents parental population plot europeans west africans native americans the three populations shown hispanics san luis valley blank circles puerto ricans new york city grey diamonds mexicans tlapa mexico grey triangles adapted bonilla 2003 relationship proportional ancestry skin pigmentation three hispanic populations populations proportional ancestry estimated using maximum likelihood ml method adapted bonilla 2003 ( percent native american ancestry versus lightness index l hispanics san luis valley colorado ancestry estimated using 22 aims ( b percent native american ancestry versus melanin index mexicans tlapa mexico ancestry estimates using 29 aims ( c percent african ancestry versus melanin index puerto ricans new york city ancestry estimated using 35 aims relationship percent african ancestry skin pigmentation three populations percent african ancestry obtained using 34 aims calculated maximum likelihood ml method melanin index shown three populations european americans state college pennsylvania diamonds african americans washington dc state college pennsylvania squares african caribbeans britain triangles 2003 theoretical experimental studies explored parameters characterise affect admixture studies the acronym mald proposed designate mapping method proposed originally chakraborty weiss exploited long range allelic associations created ald parameters critical mald include genetic distance markers disease locus number generations since admixture proportion admixture one parental population allele frequency differential parental populations sample size n simulation studies suggest sample sizes 200 300 patients typed 200 300 evenly spaced markers allele frequency differentials 0.3 95 per cent chance locating causative gene new admixture parental population last four generations sources population structure sample heterogeneity other approaches proposed using admixture include method based transmission disequilibrium test tdt assesses excess transmission alleles derived high risk ancestors affected offspring parents heterozygous marker locus containing one allele two ancestral populations a second tdt based likelihood approach developed compared transmission haplotypes non transmission affected offspring admixed population following multipoint method it obtained likelihood statistic determine significance various models different scenarios one fundamental limitation mald initially described early extensions effects stratification causing false positive association marker data loci combined estimate ancestry alleles locus allelic ancestry marker loci known approach analogous linkage analysis hence term appropriate mald describing method distinguish ld approaches the underlying variation ancestry chromosomes mixed descent modelled extract information linkage generated admixture for example locus assumed account variation skin pigmentation two parental groups eg west africans europeans individuals classified according whether 0 1 2 alleles west african descent locus comparing three groups mean pigmentation level holding factors constant variation pigmentation observed depending upon number alleles west african ancestry individual controlling parental admixture eliminates association trait ancestry unlinked loci removing background effects ancestry possible observe locus specific effects trait disease allelic ancestry locus inferred marker using conditional probability allelic state given ancestry specific allele frequencies complex hierarchical model many nuisance parameters this implemented using admixmap program http://www.lshtm.ac.uk/eph.eu/geneticepidemiologygroup/htm follows bayesian approach markov chain simulation incorporates admixture individual parents random variation ancestry chromosomes inherited parents model variation individual admixture introduces population stratification turn inflate number significant associations observed potential confounder association studies 29,57 59 various statistical approaches developed detect control stratification within population sample 14,15,17,42,60 62 for example dt d0 test examines relationship observed ld predicted ald unlinked marker pairs detecting structure within sample using individual ancestry conditioning variable analysis variance tests the bayesian approaches implemented mckeigue et al pritchard et al offer advantage classical maximum likelihood based methods allowing missing genotype ancestry data modelling admixture hierarchically methods developed control parental admixture account uncertain bga estimation admixture based methods rely using suitable markers estimates allele frequencies appropriately identified parental populations since ald fairly new extends larger distances fewer markers required studies markers informative ancestry used several contexts referred ideal private unique informativeness markers measured allele frequency differential absolute value difference particular allele populations microsatellites insertion deletion polymorphisms 0.3 recently called ethnic difference markers edms suitable mapping admixture linkage disequilibrium mald additionally markers high high log likelihood allelic ratio llar populations designated population specific alleles psas this report followed earlier work markers large allele frequency difference identified appropriate admixture studies 95 per cent arbitrarily identified biallelic markers 50 per cent thus authors proposed ideal psas 50 per cent also indicated multiallelic loci composite could estimated one half summation absolute value allelic frequency differences alleles locus it also shown markers lower values approximately 30 per cent provide 80 per cent power detecting associations distances 5 cm large enough sample size n 1,000 pfaff et al suggested referring markers suitable admixture studies ancestry informative markers aims given central feature markers ancestry information content f the present authors agree term aim accurately describes markers using language less likely misunderstood misinterpreted marker information content f denotes locus specific fst value representative differentiation two populations single locus simulation studies estimating information content markers varying levels f shown 1,000 markers average information content ancestry 40 per cent two ancestral subpopulations approximately 80 per cent information ancestry extracted initial genome screen initial identification regions showing admixture markers typed regions increase extraction information nearly 100 per cent it well established however 5 15 per cent total genetic variation results differences among human populations 30 32 moreover alleles shared populations alleles common one population also common populations thus genetic markers unaffected admixture imperative choose markers show high levels f parental populations recent studies several groups focused identifying panels markers suitable admixture studies one notable study screened 744 microsatellite markers composite values llar four different populations identified genome spanning set 315 markers average spacing 10 cm 0.3 mapping african americans 214 markers average spacing 16 cm 0.25 mapping hispanics a dna pooling method used identify 151 aims microsatellites short insertion deletion polymorphisms 0.3 mapping mexican american populations distinguish european american native american contributions ninety seven aims identified mapping african american populations show limited variation within africa additional resources available obtaining marker frequency genotype haplotype information snp consortium tsc http://snp.cshl.org national center biotechnology information dbsnp website http://www.ncbi.nlm.nih.gov/snp marshfield database http://research.marshfieldclinic.org/genetics/default.htm ongoing hapmap project since amount ald created proportional level admixture population important briefly review studies admixture levels across populations those populations likely useful admixture studies include african americans mexican americans cubans puerto ricans usa african caribbeans various latin american populations various groups central south america caribbean islands anglo indians india coloured populations south africa various statistical approaches used estimate admixture proportions populations reviewed detail elsewhere these include least squares method weighted least squares method likelihood methods a recent review admixture studies admixture proportions various latin american populations provided sans african americans well studied group substantial european west african contributions smaller native american contribution a survey current literature indicates european admixture ranges 3.5 per cent gullah sea islanders south carolina 28 per cent new orleans admixture estimates african american populations highly variable across usa likely reflect local variation demographic histories social norms us hispanics form complex socio political conglomerate including puerto ricans cubans spanish americans mexican americans the proportional contributions parental europeans estimated largest followed substantial native american ancestry varying amounts west african ancestry sample mexican americans arizona the admixture estimates obtained using weighted least squares method showed 29 4 per cent native american 68 5 per cent european 3 2 per cent west african contribution a recent study reports following estimates hispanic population san luis valley colorado 62.7 2.1 per cent european 34.1 1.9 per cent native american 3.2 1.5 per cent west african puerto ricans new york city the estimates obtained 53.3 2.8 per cent european 29.1 2.3 per cent west african 17.6 2.4 per cent native american separate mexican american population sample california european ancestry estimated 60 per cent native american contribution estimated 40 per cent african american populations substantial variation across populations results it evident studying new admixed population sample important accurately determine proportional contributions rely previously obtained estimates similar population additionally instructive information levels stratification related admixture present population consideration traits diseases prevalent one population others amenable admixture analysis examples listed table 1 most diseases shown table complex aetiology affected multiple genes environmental factors earlier studies focused admixed populations units analysis exploring relationships ancestry phenotypes these authors showed non insulin dependent type 2 diabetes mellitus prevalence correlated admixture proportions among selection populations varying levels native american ancestry data like provide compelling evidence frequency differences risk modifying alleles data collected many diseases another related approach test individual admixture phenotype correlations within admixed population correlations ancestry phenotypes detected reported various authors 14,17 19,44,45,47 prerequisite testing ancestry phenotype correlations is presence stratification related admixture evident variation individual ancestry levels figure 2 shows distribution bga estimates three examples hispanic population samples puerto ricans new york mexicans tlapa mexico hispanics san luis valley colorado substantial variation observed three samples san luis valley group more variability observed european native american axis new york group variable european west african axis following argument chakraborty weiss admixture proportions correlated diseases traits differ populations due underlying genetic differences population samples strong positive correlation observed individual ancestry skin pigmentation measured melanin index lightness index l figures 3a 3b 3c a significant negative correlation also observed proportion west african ancestry bone mineral density bmd puerto rican sample proportion west african ancestry skin pigmentation measured melanin index individuals also correlated african americans washington dc african caribbeans uk european americans state college pennsylvania figure 4 recently correlations observed proportion west african ancestry lower insulin sensitivity higher fasting insulin acute insulin response glucose combined sample african american european american children separate sample african american females west african admixture associated body mass index fat mass fat free mass bmd it important keep mind ancestry pheno type correlations dependent existence functional alleles different frequencies parental populations significant stratification related admixture although admixed populations tested date structured variation amount stratification present structure tested explicitly investigating new population each vertex represents parental population plot europeans west africans native americans the three populations shown hispanics san luis valley blank circles puerto ricans new york city grey diamonds mexicans tlapa mexico grey triangles adapted bonilla 2003 relationship proportional ancestry skin pigmentation three hispanic populations populations proportional ancestry estimated using maximum likelihood ml method adapted bonilla 2003 percent native american ancestry versus lightness index l hispanics san luis valley colorado ancestry estimated using 22 aims ( b percent native american ancestry versus melanin index mexicans tlapa mexico ancestry estimates using 29 aims ( c percent african ancestry versus melanin index puerto ricans new york city ancestry estimated using 35 aims relationship percent african ancestry skin pigmentation three populations percent african ancestry obtained using 34 aims calculated maximum likelihood ml method melanin index shown three populations european americans state college pennsylvania diamonds african americans washington dc state college pennsylvania squares african caribbeans britain triangles theoretical experimental studies explored parameters characterise affect admixture studies acronym mald proposed designate mapping method proposed originally chakraborty weiss exploited long range allelic associations created ald parameters critical mald include genetic distance markers disease locus number generations since admixture proportion admixture one parental population allele frequency differential parental populations sample size n simulation studies suggest sample sizes 200 300 patients typed 200 300 evenly spaced markers allele frequency differentials 0.3 95 per cent chance locating causative gene new admixture parental population last four generations sources population structure sample heterogeneity other approaches proposed using admixture include method based transmission disequilibrium test tdt assesses excess transmission alleles derived high risk ancestors affected offspring parents heterozygous marker locus containing one allele two ancestral populations a second tdt based likelihood approach developed compared transmission haplotypes non transmission affected offspring admixed population following multipoint method it obtained likelihood statistic determine significance various models different scenarios one fundamental limitation mald initially described early extensions effects stratification causing false positive association marker data loci combined estimate ancestry alleles locus allelic ancestry marker loci known approach analogous linkage analysis hence term appropriate mald describing method distinguish ld approaches the underlying variation ancestry chromosomes mixed descent modelled extract information linkage generated admixture for example locus assumed account variation skin pigmentation two parental groups eg west africans europeans individuals classified according whether 0 1 2 alleles west african descent locus comparing three groups mean pigmentation level holding factors constant variation pigmentation can observed depending upon number alleles west african ancestry individual controlling parental admixture eliminates association trait ancestry unlinked loci removing background effects ancestry possible observe locus specific effects trait disease allelic ancestry locus inferred marker using conditional probability allelic state given ancestry specific allele frequencies complex hierarchical model many nuisance parameters this implemented using admixmap program http://www.lshtm.ac.uk/eph.eu/geneticepidemiologygroup/htm follows bayesian approach markov chain simulation incorporates admixture individual parents random variation ancestry chromosomes inherited parents model variation individual admixture introduces population stratification turn inflate number significant associations observed potential confounder association studies 29,57 59 various statistical approaches developed detect control stratification within population sample 14,15,17,42,60 62 for example dt d0 test examines relationship observed ld predicted ald unlinked marker pairs detecting structure within sample using individual ancestry conditioning variable analysis variance tests possible eliminate association trait unlinked alleles offer advantage classical maximum likelihood based methods allowing missing genotype ancestry data modelling admixture hierarchically methods developed control parental admixture account uncertain bga estimation several theoretical practical studies indicate approaches promise suitable identifying genes causing complex diseases methodological advancements made offset potential problems arising association unlinked loci conditioning parental admixture detect correct population stratification use bayesian take consideration various uncertainties including missing data values estimating admixture proportions overcome problems arising mis specification parental allele frequencies promises effective tool admixture studies this method different classical disequilibrium based approach commonly used perhaps suitable disease gene mapping admixed populations already successfully used mapping table 2 summarises recent studies showing associations ancestry phenotypes diseases instances used identify genes currently primary impediment exhaustive genome scans lack verified aim panels sufficient numbers markers available candidate aims effort resources required confirm markers generate accurate parental allele frequencies it seems inevitable studies carried near future utilise immense potential approach diseases showing ancestry phenotype correlation r b risk ratio c rank order correlation we thank dr paul mckeigue dr esteban parra helpful discussions subject we also acknowledge helpful comments unknown reviewer work supported part grants nih

admixture is an important evolutionary force that can and should be used in efforts to apply genomic data and technology to the study of complex disease genetics . admixture linkage disequilibrium ( ald ) is created by the process of admixture and , in recently admixed populations , extends for substantial distances ( of the order of 10 to 20 cm ) . the amount of ald generated depends on the level of admixture , ancestry information content of markers and the admixture dynamics of the population , and thus influences admixture mapping ( am ) . the authors discuss different models of admixture and how these can have an impact on the success of am studies . selection of markers is important , since markers informative for parental population ancestry are required and these are uncommon . rarely does the process of admixture result in a population that is uniform for individual admixture levels , but instead there is substantial population stratification . this stratification can be understood as variation in individual admixtures and can be both a source of statistical power for ancestry - phenotype correlation studies as well as a confounder in causing false - positives in gene association studies . methods to detect and control for stratification in case / control and am studies are reviewed , along with recent studies showing individual ancestry - phenotype correlations . using skin pigmentation as a model phenotype , implications of am in complex disease gene mapping studies are discussed . finally , the article discusses some limitations of this approach that should be considered when designing an effective am study .

acyl coa thioesterases acots represent group enzymes metabolise acyl coa esters corresponding non esterified fatty acid coenzyme coash in addition acyl coa thioesterases enzymes also described acyl coa hydrolases acyl coa thioester hydrolases deacylases the reaction catalysed acot enzymes important fatty acid metabolism such acyl coa thioesterase expression widespread activity detectable within many tissues cell types acot activity helps regulate cellular pools well proper ratios activated fatty acyl coas acyl coa esters free fatty acids non esterified fatty acids coash these enzymes found within number subcellular locations including peroxisomes mitochondria cytosol peroxisomal mitochondrial acots thought play major role fatty acid degradation via -oxidation provides energy citric acid cycle well ketone body formation order fatty acid transported peroxisome -oxidation must first activated coenzyme ester acyl coa synthetases some acyl coa esters undergo -oxidation much slowly others -- effectively sequester large amounts coash limit activity acyl coa synthetases rate subsequent fatty acid -oxidation conditions acots may act increase levels free coash thereby restoring fatty acid -oxidation mammalian acots capable metabolising wide variety compounds including short- medium- long chain acyl coas they also metabolise polyunsaturated fatty acyl coas branched chain acyl coas aromatic acyl coas these compounds utilised -oxidation fatty acid degradation also roles inflammation ion channel opening signal transduction lipid biosynthesis gene regulation ten human acot genes identified date compared 13 mice 12 rats these genes divided two groups based upon differences sequence structure these enzymes members /-hydrolase fold enzyme superfamily includes esterase activity exhibiting enzymes carboxylesterases lipases type ii acots make second group enzymes members hot dog fold enzyme superfamily includes wide variety functionally diverse proteins despite catalysing reaction type type ii enzymes share similarity terms structure sequence this observation reminiscent cytochrome p450 cyp nitric oxide synthase nos gene families studies purified nos proteins revealed possess p450-like activity however detailed alignment analyses showed 15 per cent amino acid identity thereby confirming two gene families evolutionarily related it thus concluded example convergent evolution words evolution enzyme activities needed particular subcellular location probably 1 billion years ago mother nature needed p450-like activity assigned task nearest protein happened nos the revised nomenclature human mouse rat acyl coa thioesterase genes established hunt et al accepted hugo gene nomenclature committee recent years number human acots recombinantly expressed enzymatically characterised although exact physiological function importance many enzymes remain unknown to date total ten genes identified within human genome exhibit acyl coa thioesterase activity table 1 these ten genes sub divided two distinct groups type type ii based sequence structural homology type acots comprise smaller group contains four genes acot1 acot2 acot4 acot6 the larger group includes six genes members referred type ii there sequence homology two groups translated proteins different domain architecture indicating two distinct evolutionarily unrelated origins figure 1 likely example convergent evolution list human acot full gene name aliases chromosomal location isoforms ncbi refseq mrna accession number ncbi refseq protein accession number total amino acid number aa domain organisation human type type ii acyl coa thioesterases acots abbreviations acth acyl coa thioester hydrolase domain baat bile acid coa amino acid n acyltransferase el esterase lipase domain hd hot dog fold domain start steroidogenic acute regulatory protein star)-related lipid transfer start domain thioesterase superfamily member the type proteins acot1 acot2 acot4 acot6 share high degree sequence homology table 2 acot1 acot2 closely related 98 per cent amino acid sequence identity acot6 least homologous still shares 54 57 per cent sequence identity members the four type genes form 80 kilobase gene cluster chromosome 14q24.3 indicating likely arisen result gene duplication amino acid sequence identity type type ii human acyl coa thioesterases acots homology considered significant left blank observed identity less 15 per cent abbreviations baat bile acid coa amino acid n acyltransferase thioesterase superfamily member similar situation observed within mouse rat orthologues acot1 acot2 acot3 acot4 acot5 acot6 clustered chromosomes 12 d3 6q31 respectively cladogram depicting evolutionary relationships observed human mouse rat type proteins shown figure 2a this cladogram clearly shows prior mammalian radiation approximately 75 million years ago mya single ancestral acot1 -2 gene mammalian radiation mouse rat split approximately 15 mya single ancestor divided twice become four rodent acot functional genes named acot1 acot3 acot4 acot5 contrast mammalian radiation human single ancestor duplicated second functioning gene leading acot1 acot2 hand acot4 acot6 existed mammalian radiation and cladograms depicting evolutionary relationships human mouse rat r orthologous protein sequences type type ii b acots human carboxylesterase 1 ces1 unrelated esterase added simply ground tree mouse acot3 acot4 acot5 enzymes exhibit specific expression patterns enzyme substrate specificity the lack human orthologue mouse acot3 acot5 suggested result convergent evolution hypothesised convergent functional evolution led reduced need multiple enzymes humans the protein basic local alignment search tool blastp analysis non redundant protein sequences however failed identify orthologues acot3 acot5 non rodent species this finding suggests acot4 ancestral gene encoding acot4 enzyme broad substrate recognition gene duplication events led acot1 -2 duplication events led mouse acot3 acot5 genes encoding acot3 acot5 enzymes similar substrate specificity mouse acot4 human acot4 analysis genomic acot6 sequence indicates transcription complete mrna containing three exons however full length mrna detectable subsequent translation begins methionine located within second exon producing truncated protein lacks n terminal acyl coa thioester hydrolase domain found within type proteins the truncated protein contains residues required catalysis could therefore still produce active acyl coa thioesterase the blast results indicate bile acid coa amino acid n acyltransferase baat enzyme share significant sequence homology type acots baat known participate transfer bile acids acyl coa thioester either glycine taurine used bile salt secretion baat contains domain architecture acot1 acot2 acot4 however catalytic triad found within esterase lipase domain contains cysteine instead highly conserved serine residue this substitution may explain difference activity ie transferase versus hydrolase observed two enzymes despite sharing catalytic domains /-hydrolase fold enzyme superfamily esterases carboxylesterase 1 ces1 acetylcholinesterase ache share little sequence homology acyl coa thioesterase relatives ces1 thus added evolutionarily unrelated gene figure 2a simply ground dendrogram none type ii proteins shares 25 per cent identity many share significant sequence similarity table 2 unlike type i genes type ii acots widely distributed throughout genome exception acot13 all type ii proteins contain double hot dog domains may evolved gene duplication event allowed accommodation bulky substrates acot7 shares 19 per cent identity acot9 22 per cent acot11 24 per cent identity acot12 acot11 acot12 share 51 per cent sequence identity enzymes contain c terminal steroidogenic acute regulatory protein star)-related lipid transfer start domain seems specific mammalian evolution the n terminal region acots unrelated start containing enzymes suggesting proteins may result gene fusion event acyl thioesterase start domain containing sequences like acot8 blast results identify 22 per cent sequence identity thioesterase superfamily member 4 them4 official name -- also known akt c terminal modulator protein ctmp this small degree homology suggests two proteins may share common evolutionary ties another protein thioesterase superfamily member 5 them5 shares 37 per cent identity them4 lacks significant sequence homology acot13 similar acot13 them4 them5 contain single hot dog domain furthermore type ii proteins them4 them5 share sequence homology hot dog domain superfamily members the hot dog fold containing proteins possess highly conserved structural elements created highly divergent sequences this high degree divergence makes evolutionary comparisons difficult without three dimensional structures conservation structural interactions directly associated residue conservation a cladogram depicting evolutionary relationships observed human mouse rat type ii protein shown figure 2b the mouse genome contains additional type ii acot acot10 shares approximately 95 per cent mrna nucleotide identity acot9 unlike acot3 acot5 however found mouse rat acot10 identified mice indicating gene duplication event occurred less 17 mya -- mouse rat split mouse acot9 located chromosomal location x f3 acot10 found 15 a2 the amplification movement genes new chromosomal location often facilitated transposable elements opposed duplications occurring within close proximity chromosome attributed errors meiosis the remaining seven type ii acot genes highly conserved among human mouse rat confirming genes present ancestor prior mammalian radiation type type ii acyl coa thioesterases represent two structurally distinct enzyme groups an unrooted dendrogram -- created using protein sequences type type ii enzymes closest related homologues baat them4 them5 distant /-hydrolase fold homologues ces1 ache -actin actb unrelated sequence -- exemplifies dissimilar two groups one another figure 3 it also illustrates type ii proteins must originated common evolutionarily distant predecessor reflected individual branch proximity origin tree bile acid acetyl co amino acid n acyltransferase baat thioesterase superfamily members 4 5 them4 them5 closest related homologues type baat type ii sequences them4 them5 type acot branches highlighted blue whereas type ii red acot1 acot2 acot4 contain n terminal acyl coa thioester hydrolase domain pfam 04775 this domain participate directly catalysis studies indicate n terminus plays important role regulating enzyme activity all type proteins also contain c terminus esterase lipase superfamily domain all residues required catalysis located within domain also known /-hydrolase fold proteins share common structural element make functionally diverse /-hydrolase fold superfamily enzymes within family are number distantly related proteins exhibit esterase activity including carboxylesterases ache lipases the superfamily diverged greatly many members share little sequence homology considered evolutionarily linked based structural homology the enzyme activity dependent catalytic triad composed highly conserved serine histidine aspartate residues found within active site the crystalline structure acot2 indicates enzyme likely biologically active monomer the structure also reveals n terminal acyl coa thioester hydrolase domain connected active site long loop postulated contributes substrate specificity although yet verified experimentally genomic analysis suggests acot6 encode similar 3 exon transcript however detectable transcript truncated utilises start codon located within 3 end exon two resulting synthesis truncated protein in addition four protein coding genes one intronless pseudogene referred acot4p located chromosome 19q13.12 acotp4 likely result retroviral action inserted dna segment elsewhere genome acot1 cytosolic primarily responsible metabolism long chain acyl coas acot2 acot1 metabolise similar range substrates however acot2 contains n terminal mitochondrial targeting signal directs transport mitochondria acot4 contains c terminal peroxisomal targeting signal directing transport peroxisomes exhibits high activity succinyl coa well wide variety short chain dicarboxylic coas as previously mentioned acot6 lacks n terminal acyl coa thioester hydrolase domain although studies yet confirm enzymatic activity acot6 fact contains complete c terminal esterase lipase domain supports role functional esterase acot6 predicted cytosolic due missense mutation alters peroxisomal targeting signal found acot6 mouse ortholog the subcellular localisation substrate specificity enzyme suggest plays important non redundant function within cell the type ii enzymes distantly related type ii acots indicated relatively low degree sequence conservation observed proteins despite low degree sequence homology enzymes structurally related capable metabolising similar substrates acot7 formerly called brain acyl coa hydrolase bach extensively characterised owing recent studies indicate arachidonoyl coa preferred substrate the metabolism arachidonoyl coa acot7 gives rise arachidonic acid coenzyme a. arachidonic acid serves precursor number compounds associated inflammation including prostaglandins leukotrienes thromboxanes acot8 found peroxisomes metabolises diverse range acyl coa compounds acot8 also high activity towards branched- methyl branched chain acyl coas acot9 contains mitochondrial targeting signal metabolises medium- long chain acyl coas acot9 exhibits highest activity towards myristoyl coa used n myristoyltransferase modify proteins posttranslationally expression mouse acot11 formerly referred brown fat inducible thioesterase bfit increases cold shock this protein found play role regulating thermogenesis helps maintain body temperature the start domain animals commonly found within homeodomain transcription factors lipid binding regulates transcription the binding lipids start domain acot11 acot12 acts mechanism regulating activity allowing rapid enzyme activation acot13 previously called thioesterase superfamily member 2 them2 differs type ii acots contains single hot dog domain were recently determined using recombinant protein results indicate acot13 prefers medium- long chain acyl coa thioesters this finding suggests start domains identified acot11 acot12 could similar effect enzyme activity recent vitro kinetic activity studies revealed them4 broad range high activity acyl coa thioesterase similar acot13 them4 preferentially metabolises medium- long chain acyl coa thioesters as recommend enzyme renamed acot14 according accepted nomenclature established hunt et al acyl coa thioesterase activity verified them5 however activity probably based high degree sequence identity them4 exact role protein might play fatty acid metabolism yet determined the human acyl coa gene family represents diverse group enzymes catalyse hydrolysis acyl coa thioesters corresponding free fatty acids coenzyme a. enzymes involved number cellular processes primarily thought play important role lipid metabolism despite catalysing enzymatic reaction acyl coa thioesterase family members divided two distinct groups type type ii two groups share common structural elements sequence homology therefore considered analogous rather homologous enzymes probably another example convergent evolution type proteins belong /-hydrolase fold superfamily whereas type ii proteins fall hot dog fold superfamily date four type six type ii genes identified within human genome there two additional genes them4 them5 gene products share structural sequence homology type ii proteins them4 identified acyl coa thioesterase activity considered new family member future perhaps them5 also considered type ii acot family member recent studies greatly expanded current understanding acyl coa thioesterases however many precise physiological functions completely understood warrant investigation we would like thank colleagues valuable discussion critically reviewing manuscript this work supported part following nih grants r01ey17963 r21aa017754 v.v p30es06096 d.w.n

the acyl - coa thioesterase gene ( acot ) family encodes enzymes that catalyse the hydrolysis of acyl - coa thioester compounds , also known as activated fatty acids , to their corresponding non - esterified ( free ) fatty acid and coenzyme a ( coash ) . these enzymes play a very important role in lipid metabolism by maintaining cellular levels and proper ratios of free and activated fatty acids , as well as coash . within the acyl - coa family there are two distinct subgroups , type i and type ii . despite catalysing the same reaction , the two groups are not structurally similar and do not share sequence homology , strongly suggesting convergent evolution . this suggestion is further supported if one compares the human with the mouse and rat acot gene families . to date , four human type i acots have been identified which belong to the /-hydrolase fold enzyme superfamily . type ii acots fall into the ' hot dog ' fold superfamily . there are currently six human type ii genes ; however , two homologous proteins , thioesterase superfamily members 4 ( them4 ) and 5 ( them5 ) share common type ii structural features and , in the case of them4 , acyl - coa thioesterase activity -- suggesting that the family may be larger than previously realised . although recent studies have greatly expanded the current understanding of these proteins and their physiological importance , there are a number of members whose functions are relatively unexplored and which warrant further investigation .

colony established soybean cowpea field collections n. viridula stoneville ms spring summer 2010 this colony maintained culture 5 years usda ars national biological control laboratory after approximately 40 generations culture three orange morph adult males detected colony the orange morph males paired green females two females per male sex ratio represent parent population f0 allowed reproduce using rearing methods described rojas morales ramos 2014 cages constructed clear plastic boxes l 320 w 260 h 100 mm part 048-c pioneer packing dixon ky modified ten windows 27 mm dia sides four windows 65 mm dia top covered nylon screen mesh 500 adults study were reared environmentally controlled room 26 1 c 50 5% rh 14 h photophase provisioned peanuts broccoli diet supplement fresh bean pods diet supplement replaced 3 days intervals eggs collected daily hatching nymphs f1 allowed develop conditions the number males females coloration type recorded generation study resulting f1 adults paired reared conditions obtain f2 generation resulting f2 adults consisted green females green orange males f2 orange males app 25% total numbers retained mate f2 females two females per male sex ratio produce f3 eggs collected daily enclosing nymphs reared adult stage conditions described f3 colony become considerably larger resulting f3 adults first three emerging dates counted sexed phenotype sex frequencies observed generation compared frequencies expected assuming orange color phenotype determined single sex linked recessive allele reported follett et al the test used compare observed versus expected frequencies within generation cross resulting f3 adults divided form two different colonies orange type green type the pure orange type colony established using solely f3 orange type adults the f4 pure orange type colony used generate pure orange type f5 the reproductive potential f5 pure orange colony compared pure green stock parental colony newly emerging f5 orange type adults collected grouped cohorts emerging date a total three cohorts obtained green type stock colony 209 adults total four cohorts f5 orange type 168 adults total adults reared described monitored oviposition mortality recorded daily egg masses collected day recorded labeled allowed develop 3 days counting eggs embryos developing eggs 3 days old showed noticeable red eye coloration made visible allowed discrimination fertilized unfertilized eggs the fertility ratio calculated fertile eggs total eggs fertility ratio compared color types using z test the mean number eggs per mass compared treatments using anova student test fertility tables produced type using methods reported portilla et al the f1 generation resulted green morphs 590 684 expected recessive orange allele single gene character however f2 generation produced 672 green females 351 green males 298 orange males orange females these ratios significantly different expected recessive allele sex linked gene table 1 consistent follett et al the first three cohorts f3 generation consisted 345 green females 346 green males 100 orange females 85 orange males the difference observed expected ratios significant =8.067 df 3 p 0.046 table 1 difference could explained significant deviations expected sex ratio f3 orange types |z| 2.38 p 0.0087 resulting slight bias 1.17 females per male similar female bias sex ratio observed follett et al ( 2007 bias explained higher mortality males occurring development table 1.expected progeny ratios observed frequencies resulting f1 f2 f3 generations cross orange males green females parent generation f0).expected phenotype ratios progenyobserved phenotype frequencies progenygeneration parent progeny)assumed genotypesg g g g f0 f1)xx x xy0.50.500590684006.936f1 f2)xx x xy0.50.2500.2567235102984.653f2 f3)0.5 xx x xy 0.5 xx x xy0.3750.3750.1250.125345346100858.067*degrees freedom df 3 values show significant deviation expected ratios.f2 green males removed leaving orange males cross green females expected progeny ratios observed frequencies resulting f1 f2 f3 generations cross orange males green females parent generation f0 degrees freedom df 3 values show significant deviation expected ratios mean oviposition rate sem measured eggs per female per day significantly higher green type stock colony females 2.76 0.29 compared f5 orange type females 1.17 0.27 |t| 2.456 df 222 p 0.0148 there significant difference number eggs per egg mass parental stock green 27.14 1.26 f5 orange 26.39 1.62 types also proportion fertile eggs significantly different green 0.718 0.0094 orange 0.726 0.0058 types however green type females produced significantly higher number egg masses per day 2.09 0.16 orange type females 0.71 0.15 |t| 6.14 df 222 p 0.0001 ) reproductive output green type females higher measured ro value 20.67 compared orange type females 13.71 fig in addition reduced expected phenotypic ratio natural populations consisting mostly males due sex linked recessive nature orange allele lower reproductive output orange types may explanation rarity natural populations 1.cumulative lxmx reproductive output fertility tables green pure orange types nezara viridula cumulative lxmx reproductive output fertility tables green pure orange types nezara viridula

nezara viridula adult coloration can vary , including a rare orange - colored type ( i.e. , n. viridula f. aurantiaca ) . in november 2015 , three nezara viridula males displaying orange coloration were found in an established colony in stoneville , ms . the objectives of this study were to determine if alleles of these orange types conformed to the allele characteristics previously reported for n. viridula f. aurantiaca and to determine if there were any differences in reproductive output compared with the green - colored type . the three orange - type males were crossed with green - type females to produce a hybrid f1 . the f1 progeny was allowed us to cross to produce an f2 . the f2 progeny consisted of 672 green females , 351 green males , 298 orange males , and 0 orange females . these ratios did not differ significantly from the expected 50:25:25:0 ratios for a single recessive sex linked allele for color phenotype . the f2 cross of green females and orange males produced an f3 consisting of 345 green females , 346 green males , 100 orange females , and 85 orange males . these ratios also conformed to the expected ratios ( 0.375:0.375:0.125:0.125 ) with the exception of orange males , which numbers were slightly lower than expected . the pure orange type n. viridula produced significantly less egg masses ( 0.71 0.15 ) per day than green types ( 2.09 0.16 ) and their reproductive output , measured as net reproductive rate ( ro ) , was lower in orange ( 13.71 ) compared with green ( 20.67 ) types .

peritoneal dialysis pd therapy increased popularity since end 1970s the method developed alternative hemodialysis hd presenting patient survival rate equivalent hd better preservation residual renal function currently two principal causes technique failure order importance peritonitis important medical problem also represent nearly 16% causes death b ultrafiltration failure multifactorial complication affect 40% patients 3 years therapy these proinflammatory stimuli induce lymphokine secretion macrophages turn activate fibroblasts fibroblast activation associated structural alterations peritoneal membrane varying intensity these alterations seen figure 1 extracted submitted study group prospective controlled study 20 nonuremic wistar rats peritoneal fibrosis occurs exposure glucose based pd solutions regardless use simvastatin eps clinical syndrome leads persistent recurrent intestinal obstruction without inflammatory parameters peritoneal thickening sclerosis calcification encapsulation inferred clinical symptoms radiology confirmed direct visualization laparotomy 2 3 incidence eps heterogenous reported vary 6 20% eight years depending region causes inflammation peritoneal dialysis range traditional factors related chronic kidney disease per se well peritoneal dialysis treatment uremia factor present pd patients generates inflammatory state causing stress peritoneum due formation carbonyl products it accelerates formation advanced glycation end products ages induces upregulation receptors advanced glycation end products rage the peritoneal dialysis catheter first proinflammatory factor associated pd patient comes contact after implantation peritoneum catheter induce inflammatory reaction demonstrated flessner et al in addition catheter occasionally site bacterial biofilm formation several pd solutions available market today varying degrees associated peritoneal inflammation such inflammation generated several characteristics solutions varying low ph presence lactate hyperosmolality increased glucose concentration presence glucose degradation products gdp advanced glycation end products ages icodextrin metabolites among others 6 7 currently available glucose based pd solutions the glucose load offered daily traditional pd prescription usually ranges 120 g 400 g. majority pd solutions prescribed today markedly acidify ph nearly 5.7 approximately 2 3 minutes ph decreases viability neutrophils mesothelial cells thus decreasing cytokine production phagocytosis capacity its bioincompatibility peritoneal membrane well known well capacity stimulate production fibroblast growth factors contributing peritoneal fibrosis some studies associated osmotic agent eps development others shown distinct confirming safety even long term utilization even experimental studies rats addressing question compromised increased -amylase activity animals the presence enzyme plasma peritoneal cavity provokes rapid drop peritoneal icodextrin concentration chronic exposure high glucose load traditional pd solution induces significant inflammation peritoneal membrane these solutions induce several proinflammatory factors pga vascular endothelial growth factors vegfs fibroblast growth factor tgf-1 ages upregulation rages glucose degradation products gdps methylglyoxal glyoxal 3-deoxyglucosone generated heat sterilization process increase inflammation inducing oxidative stress thus causes damage mesothelial cells leads apoptosis mesothelial denudation substituting traditional solutions biocompatible solutions it suggested years pathway transforming growth factor 1/smad plays part development peritoneal fibrosis the latter recognized playing role angiogenesis histological characteristic allows differentiation simple peritoneal fibrosis eps the endothelial system another known factor potent profibrotic characteristics plays role development peritoneal fibrosis this system activated two receptors endothelial receptors b. however endothelial receptor b apparently play role peritoneal membrane thickening experimental studies inducing deficiency endothelial receptor b. finally extreme importance infectious peritonitis obvious cause peritoneal inflammation associated eps development gram positive organisms remain prevalent peritonitis agents past decades representing 60% cases followed gram negative organisms however prevalence peritonitis due gram negative organisms growing fast development efficient strategies control gram positive infections despite efforts made past decades mentioned factors contribute release proinflammatory cytokines interleukin 1 il 1 tumor necrosis factor tnf- il-6 il-18 thickening cubic transformation mesothelial cells occurs accentuated parietal peritoneum human peritoneal mesothelial cells hpmcs also suffer structural alterations prominent transdifferentiation hpmc myofibroblasts occurs histological alterations peritoneal membrane observed eps cases nonspecific masked alterations commonly observed patients ultrafiltration failure infectious peritonitis long term the common findings fibrin deposition fibrous capsule formation perivascular bleeding interstitial fibrosis presence tissue granulation vascular proliferation submesothelial tissue thickening also occurs increase deposition mesothelial conjunctive tissue 19 20 fibrosis characterized accumulation extracellular matrix ecm resulting disequilibrium synthesis degradation expression collagen types 1 3 significantly increased well collagen type 4 one clinical manifestations ultrafiltration uf failure occur 30% patients pd five years treatment one presentations uf failure occurs due increase pores peritoneal membrane turn accelerates small solute transport dissipating osmotic gradient necessary maintain adequate fluid balance this increase vascular surface observed conjunction increase density interstitial fibers these findings help justify increase transport small molecules alterations uf coefficient moderate in addition uf failure clinical manifestations severe malnutrition subocclusion intestinal occlusion ascites suggest presence eps even discontinuation pd prescribing hypertonic glucose solutions common strategy counter drop uf primarily available icodextrin this intensifies perpetuates inflammatory disturbances direct impact dialysis adequacy fluid balance the final consequence inevitable transfer hd despite damage peritoneal membrane therapies performed today large observational studies shown important evolution pd patient survival compared hd past years pd initiation increases inflammatory stimuli chronic kidney patient presence peritoneal catheter use bioincompatible solutions possible infectious peritonitis these manifestations frequently observed range difficulties obtaining adequate fluid balance dreaded encapsulant peritoneal sclerosis an understanding mechanisms involved peritoneal inflammation fundamental development new strategies this knowledge provide better technique survival also improvements patient survival better quality life

peritoneal dialysis therapy has increased in popularity since the end of the 1970s . this method provides a patient survival rate equivalent to hemodialysis and better preservation of residual renal function . however , technique failure by peritonitis , and ultrafiltration failure , which is a multifactorial complication that can affect up to 40% of patients after 3 years of therapy . encapsulant peritoneal sclerosis is an extreme and potentially fatal manifestation . causes of inflammation in peritoneal dialysis range from traditional factors to those related to chronic kidney disease per se , as well as from the peritoneal dialysis treatment , including the peritoneal dialysis catheter , dialysis solution , and infectious peritonitis . peritoneal inflammation generated causes significant structural alterations including : thickening and cubic transformation of mesothelial cells , fibrin deposition , fibrous capsule formation , perivascular bleeding , and interstitial fibrosis . structural alterations of the peritoneal membrane described above result in clinical and functional changes . one of these clinical manifestations is ultrafiltration failure and can occur in up to 30% of patients on pd after five years of treatment . an understanding of the mechanisms involved in peritoneal inflammation is fundamental to improve patient survival and provide a better quality of life .

incidence cancer varies throughout world highest rates developed communities 1 the gold standard detection surveillance bladder cancers cystoscopy urine cytology 2 despite benefit cytology low sensitivity particularly detection low grade cancers cystoscopy costly invasive procedure hence need develop simple non invasive diagnostic methods used prolong intervals cystoscopies disease monitoring 3 an ideal bladder cancer screening monitoring test non invasive easy perform high sensitivity specificity recent years various markers these include bladder tumor antigen bta nuclear matrix protein 22 nmp22 survivin telomerase cytokeratins cks 2 4 cks family 20 intermediate filament proteins expressed cells epithelial origin well endothelial cells cks1 8 type ii group comprise neutral basic proteins whereas cks 9 20 type group include acidic proteins 5 epithelial tumors largely maintain features specific ck expression normal epithelial origin therefore molecules extensively used immunohistochemical markers diagnostic tumor pathology 6 these three markers expressed types carcinomas including breast prostate lung colon ovarian 6 7 their main use immunohistochemical markers monitor treatment evaluate response therapy provide early prognostic information tumor progression metastasis formation 8).circulating cks result release intact proteins rapidly proliferating tumor dead cells 9 several monoclonal anti cks antibodies available recognize ck8 ck18 ck19 10 the presence ck18 fragments cancerous epithelial cells reported 5 11 termed m30 specific monoclonal antibody available well another one m65 recognizes total soluble ck18 fragments using monoclonal antibodies possible determine different circulating forms ck18 plasma serum 12 13).the m30 antibody detects ck18 fragments contain neo epitope positions 387 396 generated action caspases 3 7 9 activated early stages apoptosis the m65 antibody also detects cleaved fragments distinguish full length protein fragments 14 thus m65 enzyme linked immunosorbent assay elisa theoretically measures caspase cleavage apoptosis cellular release intact ck18 necrosis the potential diagnostic prognostic significance circulating m30 m65 investigated patients non small cell lung cancer nsclc colon cancer 15 16 their levels correlated disease stage recurrence malignancies lung cancer 17 pancreatic cancer 18 high pretreatment ck18 levels indicated larger tumor burden less favorable prognosis number clinical trials breast 19 20 prostate 21 small cell lung 22 testicular 23 cancers used m30 m65 biomarkers cell death variety different chemotherapeutic agents it claimed m30 assay predictive value drug response 24 prognostic value survival 17 25 m30 m65 used markers host tissue toxicity number different clinical conditions acute myocardial infarction 26 chronic liver disease 27 hepatitis c 28 however scant information prognostic application markers bladder cancer the current study aims characterize baseline levels post surgical changes circulating serum m30 m65 levels patients tcc examine correlation various clinical features this study enrolled 60 tcc patients 49 male 11 female aged 35 85 years referred nemazi hospital shiraz iran tumor staging determined according tumor node metastases tnm classification grading confirmed pathologist all protocols approved ethics committee shiraz university medical sciences informed consent obtained patients blood samples collected 7 10 days operation obtained sera stored -70c analyzed the level ccck18 total ck18 sera determined using m30- apoptosense elisa m65-elisa assay kits peviva sweden respectively according protocols described manufacturer briefly 25 l standard solutions low high controls samples added wells pre coated mouse monoclonal ck18 antibody m5 catcher antibody then 75 l diluted horseradish peroxidase hrp)-conjugated monoclonal antibody m30 detector added the samples incubated 4 hours room temperature constant shaking excess unbound conjugate removed five washing steps color development achieved addition 200 l tmb 3 3 5 5-tetramethyl benzidine solution incubation 20 minutes dark the reaction stopped addition 50 l stop solution absorbance measured elisa reader anthos 2020 australia 450 nm total level ccck18 samples measured plotting standard curve known concentrations antigen absorbance respect m65elisa monoclonal m5 m6 antibodies directed two different epitopes ck18 intact caspase cleaved forms used twenty five l standard solution controls samples added wells pre coated mouse monoclonal ck18 antibody m6 followed addition diluted hrp conjugated monoclonal antibody m5 detector the procedure continued described m30 elisa method ck18 quantity calculated plotting standard curve correlation ccck18 m30 ck18 m65 levels clinical characteristics patients evaluated statistical analysis performed using graphpad prism version5.00 windows graphpad software san diego ca usa relationship m30 m65 levels pre- post operative sera analyzed paired test two tailed wilcoxon signed rank test spearman correlation test used determining association either m30 m65 age mann whitney test used relation m30 m65 level m30:m65 ratio gender comparing markers two groups when two groups nonparametric kruskal wallis performed test significant differences among groups compare m30 m65 pre operative post operative levels unpaired test welch correction performed this study enrolled 60 tcc patients 49 male 11 female aged 35 85 years referred nemazi hospital shiraz iran tumor staging determined according tumor node metastases tnm classification grading confirmed pathologist all protocols approved ethics committee shiraz university medical sciences informed consent obtained patients blood samples collected 7 10 days operation obtained sera stored -70c analyzed the level ccck18 total ck18 sera determined using m30- apoptosense elisa m65-elisa assay kits peviva sweden respectively according protocols described manufacturer briefly 25 l standard solutions low high controls samples added wells pre coated mouse monoclonal ck18 antibody m5 catcher antibody then 75 l diluted horseradish peroxidase hrp)-conjugated monoclonal antibody m30 detector added the samples incubated 4 hours room temperature constant shaking excess unbound conjugate removed five washing steps color development achieved addition 200 l tmb 3 3 5 5-tetramethyl benzidine solution incubation 20 minutes dark the reaction stopped addition 50 l stop solution absorbance measured elisa reader anthos 2020 australia 450 nm total level ccck18 samples measured plotting standard curve known concentrations antigen absorbance respect m65elisa monoclonal m5 m6 antibodies directed two different epitopes ck18 intact caspase cleaved forms used twenty five l standard solution controls samples added wells pre coated mouse monoclonal ck18 antibody m6 followed addition diluted hrp conjugated monoclonal antibody m5 detector the procedure continued described m30 elisa method ck18 quantity calculated plotting standard curve correlation ccck18 m30 ck18 m65 levels clinical characteristics patients evaluated statistical analysis performed using graphpad prism version5.00 windows graphpad software san diego ca usa relationship m30 m65 levels pre- post operative sera analyzed paired test two tailed wilcoxon signed rank test spearman correlation test used determining association either m30 m65 age mann whitney test used relation m30 m65 level m30:m65 ratio gender comparing markers two groups when two groups nonparametric kruskal wallis performed test significant differences among groups compare m30 m65 pre operative post operative levels unpaired test welch correction performed sera 60 patients tcc bladder assessed m30 m65 serum levels abbreviation nd determined wide range m30 values 25 724 u l observed total patients mean 148 16 u l median 118 u l females 152 50 u l median 122 u l patients categorized three groups according age 35 49 50 69 70 years the levels soluble m30 m65 molecules determined patients sera pre- n 60 post operation n 26 elisa method differences pre- post operative m30 pre- post operative m65 significant ns m65 levels also showed wide range values 80 1375 u l mean 318 34 the m65 level males 305 35 u l compared females 376 108 u l p 0.53 the level molecule significantly correlated age p 0.03 spearman r 0.27 appeared increase age as shown table 1 majority patients stages t1 t2 61.7 grades iii iv 55% tumors figure 2 shows results m30 m65 analyses patients according tumor stage as shown significant differences m30 levels patients different tumor stages similarly level m30 showed significant difference patients various tumor grades figure 3 in contrast m30 m65 levels showed significant relation tumor stage grade as shown figure 2 quantity molecule patients t3/t4 stages 350 42 u l higher patients t1/t2 stages 293 45 u l p 0.038 patients tumor grades iii iv higher levels m65 383 58 u l compared grades ii tumors 231 26 u l p 0.04 figure 3 the m65 m30 levels significantly higher group patients higher tumor stages p= 0.038 the m65 m30 levels significantly higher group patients higher tumor grades p= 0.04 as shown figure 4 ratio patients 0.54 0.04 there significant difference ratio males 0.55 0.05 females 0.46 0.09 this ratio 0.84 0.20 patients aged 35 49 years 0.53 0.04 50 69 year old patients 0.41 0.04 patients 70 years age p 0.02 this ratio 0.61 0.04 patients stage t1 decreased 0.260.008 patients stage t4 disease p 0.002 as shown figure 5 m30:m65 ratio lower patients t3/t4 stages 0.38 0.04 compared t1/t2 stages 0.59 0.06 p 0.002 similarly observed lower m30:m65 ratio patients grades iii iv 0.48 0.07 compared grades /ii tumors 0.64 0.04 p 0.01 figure 5 data presented mean m30:m65 ratio standard error patients according sex age a significant higher m30:m65 ratio younger group patients 30 49 years vs. older ones 70 years observed p 0.02 data presented mean m30:m65 ratio standard error patients different stages grades significant lower m30:m65 ratio patients higher stages p 0.002 grades tcc p 0.01 observed as shown figure 1 m30 level patients surgery 133 19 u l showed significant difference pre operative value 148 30u l group patients the corresponding value post operative m65 levels 240 21 u l compared pre operative level 319 63 there correlation pre operative m30 m65 p 0.0001 spearman r 0.51 figure 6a post operative m30 m65 values p 0.02 spearman r 0.45 figure 6b however found significant difference m30 m65 levels surgery the m30:m65 ratios surgery showed significant correlation older patients 70 years p 0.009 a significant correlation pre operative m30 m65 levels p 0.0001 spearman r 0.51 post operative values p 0.023 spearman r 0.45 observed a wide range m30 values 25 724 u l observed total patients mean 148 16 u l median 118 u l females 152 50 u l median 122 u l patients categorized three groups according age 35 49 50 69 70 years the levels soluble m30 m65 molecules determined patients sera pre- n 60 post operation n 26 elisa method differences pre- post operative m30 pre- post operative m65 significant ns m65 levels also showed wide range values 80 1375 u l mean 318 34 u l compared females 376 108 u l p 0.53 the level molecule significantly correlated age p 0.03 spearman r 0.27 appeared increase age as shown table 1 majority patients stages t1 t2 61.7 grades iii iv 55% tumors figure 2 shows results m30 m65 analyses patients according tumor stage as shown significant differences m30 levels patients different tumor stages similarly level m30 showed significant difference patients various tumor grades figure 3 in contrast m30 m65 levels showed significant relation tumor stage grade as shown figure 2 quantity molecule patients t3/t4 stages 350 42 u l higher patients t1/t2 stages 293 45 u l p 0.038 patients tumor grades iii iv higher levels m65 383 58 u l compared grades ii tumors 231 26 u l p 0.04 figure 3 the m65 m30 levels significantly higher group patients higher tumor stages p= 0.038 the m65 m30 levels significantly higher group patients higher tumor grades p= 0.04 we determined ratio m30 m65 patient shown figure 4 ratio patients 0.54 0.04 significant difference ratio males 0.55 0.05 females 0.46 0.09 this ratio 0.84 0.20 patients aged 35 49 years 0.53 0.04 50 69 year old patients 0.41 0.04 patients 70 years age p 0.02 this ratio 0.61 0.04 patients stage t1 decreased 0.260.008 patients stage t4 disease p 0.002 as shown figure 5 m30:m65 ratio lower patients t3/t4 stages 0.38 0.04 compared t1/t2 stages 0.59 0.06 p 0.002 similarly observed lower m30:m65 ratio patients grades iii iv 0.48 0.07 compared grades /ii tumors 0.64 0.04 p 0.01 figure 5 data presented mean m30:m65 ratio standard error patients according sex age a significant higher m30:m65 ratio younger group patients 30 49 years vs. older ones 70 years observed p 0.02 data presented mean m30:m65 ratio standard error patients different stages grades significant lower m30:m65 ratio patients higher stages p 0.002 grades tcc p 0.01 observed as shown figure 1 m30 level patients surgery 133 19 u l showed significant difference pre operative value 148 30u l group patients the corresponding value post operative m65 levels 240 21 u l compared pre operative level 319 63 there correlation pre operative m30 m65 p 0.0001 spearman r 0.51 figure 6a post operative m30 m65 values p 0.02 spearman r 0.45 figure 6b however found significant difference m30 m65 levels surgery the m30:m65 ratios surgery showed significant correlation older patients 70 years p 0.009 a significant correlation pre operative m30 m65 levels p 0.0001 spearman r 0.51 post operative values p 0.023 spearman r 0.45 observed in present study examined sera tcc patients levels circulating m30 m65.during apoptosis ck18 cleaved caspases subsequently released extracellular environment blood 9 29 these fragments detected elisa using m30 monoclonal antibody recognizes ck18asp396 neo epitope the m65 assay based two antibodies m5 m6 directed two different epitopes ck18 all ck18 fragments contain epitopes 300 390 amino acid region protein recognized in addition apoptosis m65 thought measure intact ck18 released cell necrosis 30 32 therefore ck18 levels considered surrogate marker cell death activity tumors non tumor conditions determining level patients useful diagnosis tumor recurrence prognosis monitoring additionally experiments circulating ck18 used assess efficiency different anticancer drugs chemotherapy 14 olofsson et al suggested ck18 marker could useful early prediction response chemotherapy breast cancer useful biomarker clinical trials 33 circulating ck18 considered biomarker chemotherapy induced cell death testicular cancer 23 post surgical plasma ck18 levels showed correlation tumor recurrence presence residual disease colorectal cancer 34 the first report using ck18 diagnostic value tcc patients 2002 ramazan sekeroglu et al these researchers used solid phase two site chemiluminescence assay measure ck18 levels the results suggested serum ck18 could diagnostic screening tool early stages bladder cancer helpful diagnosis higher tumor stages they determined significant relationship urinary nmp 22 tumor marker bladder cancer ck18 levels existed suggested nmp22 ck18 useful markers diagnosis monitoring tcc levels urinary ck18 significantly differed according pathological grade stage patients tumors 36 phase study intravesical adenoviral transduction human bladder cells human interferon- ad ifn- treatment patients bladder cancer 37 significant apoptosis necrosis patients tumors this study first suggest analysis urinary m30 m65 levels might used potential surrogate biomarker tumor cell death prognosis treatment non muscle invasive bladder cancer therapeutic agent however best knowledge studies examined m30 m65 levels serum tcc patients current study evaluated m30 m65 serum levels group iranian patients tcc we sought insight regarding relationship markers patient characteristics prognostic factors tumor stage grade moreover measured changes quantity markers number patients surgery determine value disease monitoring the results study showed significant correlation m30 m65 levels patients prior surgery the levels m65 m30 significantly related stage grade patients tumors emphasized importance cell necrosis tcc biology higher levels m65 patients greater stages grades might suggest relation biomarker tumor progression these results consistent results obtained ramazan sekeroglu et al reported serum ck18 could helpful diagnosis higher stage tumors 35 in previous studies serum levels m30 and/or m65 significantly correlated tumor stage breast 24 colorectal cancers 38 unlike studies ozturk et al observed difference serum m30 m65 levels patients stages iii iv locally advanced head neck tumors 39 showed colorectal cancer patients despite tendency m65 decrease increasing tumor grade differences groups reach statistical significance withm30 34 we measured post operative m30 m65 levels determine possible relation marker levels tumor burden ( 38 colorectal cancer patients showed good correlation m30 m65 levels plasma patients surgical resection in addition measured m30 m65 levels surgery possibly measuring markers different time intervals higher number patients different results would obtained various studies conducted different tumors compared extent apoptosis total cell death calculating m30:m65 ratio this ratio might important factor select appropriate treatment strategy patients the m30:m65 ratio decreased endometrial cancer stages iii iv compared stage ii indicated less apoptosis and/or necrosis tumor progression 14 colorectal cancer 38 ) our results showed relationship ratio age tumor stage grade this finding line positive correlation obtained study m65 levels age might suggest predominance apoptosis younger patients versus necrosis older patients the pre operative m30:m65 ratio shown tendency decrease increase tumor stage tumor grade regard m30 considered indicator apoptosis assumed tcc patients aggressive tumors rate apoptosis may lower less aggressive tumors cell death mostly due necrosis types tumors we find significant difference pre- post operative m30:m65 ratio total patients p 0.08 however correlation pre post operative ratio patients 70 years observed conclusion serum levels m65 m30 showed significant correlation stage grade patients tumors the pre operative m30:m65 ratio shown tendency decrease increase tumor stage tumor grade the significantly decreased ratio surgery older group patients may imply importance ratio tumor monitoring group patients further studies larger number patients along follow patients tumor recurrence presence residual disease determine exact value markers tcc monitoring

backgroundvarious markers are suggested for diagnosis and monitoring of transitional cell carcinoma of the bladder ( tcc ) , including cytokeratins ( cks).objectivesin the present study , the circulating ck18 ( m65 ) and its caspase - cleaved form , ccck18 ( m30 ) , have been investigated in a group of patients with tcc.patients and methodsserum samples were obtained from 60 patients before surgical resection , among which the samples of 26 patients after resection were also included . we measured the levels of soluble m30 and m65 molecules by enzyme - linked immunosorbent assay . the relation between these markers and patients clinical characteristics was evaluated.resultsm30 and m65 in total patient sera were 148 16 u / l and 318 34 u / l , respectively . a correlation existed between pre - operative m30 and m65 levels ( p < 0.0001 , spearman r = 0.51 ) . m65 , but not m30 , showed a significant relation to tumor stage and grade . the m65 quantity in patients with t3/t4 tumor stages ( 350 42 u / l ) was higher than that of patients with t1/t2 stages ( 293 45u / l ; p < 0.038 ) . patients with tumor grades iii / iv also showed higher levels of m65 compared to patients with tumor grades i / ii ( p < 0.04 ) . the m30:m65 ratio in all patients was 0.54 0.04 . there was a lower m30:m65 ratio in patients with t3/t4 stage tumors and those with tumor grades iii / iv ( p < 0.02 ) . the m30 ( 133 19 u / l ) and m65 levels ( 240 21 u / l ) after surgery did not significantly differ compared to their pre - operative values . however , a correlation between the pre- and post - operative m30:m65 ratio in patients 70 years was seen ( p = 0.009).conclusionsthese data suggested a relationship of both m65 and the m30:m65 ratio to tumor progression which might imply their importance in tcc monitoring .

spinal dural arteriovenous fistula sdavf rare neurological disease estimated frequency 510 cases per million per year it caused subdural shunt radiculomeningeal artery radicular vein leading impaired venous drainage spinal cord arterialization vein due increased venous pressure the time diagnosis often delayed due unspecific neurological complaints long 1015 years onset symptoms therefore 40% patients severely disabled time diagnosis the common location sdavf lower thoracic lumbar region accompanied complaints lower extremities sdavf cervical level c sdavf extremely rare accounting approximately 2% sdavf patients lead quadriplegia respiratory insufficiency early clinical features nonspecific include gait claudication worsened exercise time diagnosis triad consisting 1 motor deficits leg arm weakness muscle cramps 2 sensory disturbances paresthesia numbness pins needles sensation back pain 3 cauda syndrome micturition problems erectile dysfunction anal sphincter disturbances present 70% patients characteristic mri features include 1 engorged perimedullary veins 2 central medullary edema 3 swelling caudal segments spinal cord absence findings diagnosis difficult make solely based clinical symptoms usually erroneous differential diagnoses may include medullary pathology myelitis medullary tumors disc herniation peripheral pathology sensory polyneuropathy chronic inflammatory demyelinating polyneuropathy table 1 evidence bladder bowel dysfunction share evident relation site medullary pathology could useful suggesting diagnosis the association cauda symptoms considered red flag sdavf guide physician toward correct diagnosis the treatment involves either superselective catheterization endovascular embolization fistula neurosurgical occlusion arterialized vein if successful treatment usually stops progression symptoms leads improvement neurological deficits therefore utmost importance diagnosis established soon possible order avoid permanent handicap a 56-year old man complained sensory symptoms pins needles sensation pain legs right arm progressively worsened 4 months the patient difficulty performing daily work bus driver noticed impaired foot sensation arm weakness changing gears pressing pedals the patient past medical history unremarkable except hypertension hypercholesterolemia treated statins oral antihypertensive drugs neurological examination showed generalized weakness lower limbs right arm medical research council grade 4 hyperreflexia bilateral plantar reflexes sensory exam showed generalized sensation loss involving dorsal columns spinothalamic tract subjective pins needles sensations feet right arm given association lower upper limb involvement hyperreflexia cervical lesion suspected the patient underwent diagnostic brain spinal cord mri showed elongated intramedullary hyperintensity foramen magnum c4 t2-weighted images fig 1 small contrast enhancement junction brainstem cervical spinal cord transverse myelitis suspected patient treated high intravenous corticosteroid dose 7 8 9 10 the patient developed quadriplegia severe generalized weakness sensation loss legs arms inspiratory muscle weakness dysphonia high urinary retention an allergic reaction excluded patient transferred intensive care unit assisted breathing a cervical mri performed showing varicose dilatations irregular cervical veins central medullary edema fig 2 characteristic cervical sdavf 4 5 6 superselective angiography confirmed presence sdavf patient successfully underwent open spine surgery ligation coagulation arterialized communicating vein ten days surgical treatment almost completely regained neurological functions referred intensive rehabilitation program specialized clinic time discharge neurology ward 2 weeks surgery could walk 30 rollator support mild numbness feet difficulty voiding sdavf may present wide range clinical features motor sensory deficits often associated cauda equina syndrome neurological deficits due perimedullary venous congestion leading intramedullary edema ischemia severe cases direct compression nerve roots level fistula abnormal communication radiculomeningeal artery radicular vein leads increased venous pressure dural sleeve impairing normal venous return intramedullary capillaries level fistula causing medullary edema furthermore decreased pressure gradient capillary level accounts decreased gas exchange medullary hypoxia acute increase venous hypertension due sudden volume or pressure overload may exacerbate neurological deficits hampering already decreased venous drainage level sdavf causing transitory medullary ischemia previous publications report clinical worsening related acute increase intrathoracic venous pressure singing valsalva maneuvers abdominal muscle compression exercise addition current paper several publications report rapid worsening symptoms patients receiving corticosteroids intravenously presumed diagnoses commonly myelitis 12 13 14 15 16 although exact mechanism leads worsening spinal cord dysfunction yet understood possible corticosteroid intravenous saline administered could play role in addition anti inflammatory effects corticosteroids also play role regulating water mineral metabolism mineralocorticoid effects causing fluid retention this compromise already fragile venous return dural sac leading medullary hypoxia worsening sdavf symptoms furthermore steroids administered via intravenous line placed upper extremity eventually drain via cephalic veins brachiocephalic veins the azygos semiazygos veins collect venous blood spinal cord also tributaries brachiocephalic veins therefore rapid rise venous return upper extremities brachiocephalic vein could also directly diminish venous return medullary level exacerbate symptoms this theory supported mri findings corticoid treatment patient the cervical mri intravenous treatment shows evident perimedullary venous abnormalities whereas treatment engorged veins clearly identified subdural space evidence acute venous hypertension subdural sac fig 3 we would like conclude study stressing importance early diagnosis treatment patients sdavf therefore presence red flags extremely useful guiding physician toward correct diagnosis acute neurological worsening intravenous steroid administration presumed diagnosis considered red flag raise suspicion sdavf

subdural arteriovenous fistula ( sdavf ) is a rare condition characterized by clinical manifestations ranging from mild bilateral sensory deficits to quadriplegia . the diagnosis is often delayed due to unspecific neurological symptoms , initially diagnosed as polyneuropathy or myelopathy . the diagnosis can be delayed for as long as 115 years . the following report describes a cervical sdavf case initially misdiagnosed as myelitis transversa and treated with intravenous steroids . a 56-year - old male presented with sensory deficits and mild leg and right arm weakness . cervical mri showed a central medullary hyperintense lesion with contrast enhancement . after metabolic , infectious , and malignant causes were excluded , myelitis transversa was presumed and the patient was treated intravenously with methylprednisolone . shortly after that , he developed quadriplegia . cervical mri imaging showed engorged cervical perimedullary vessels , which were not visible on the initial mri . the diagnosis was revised and a sdavf identified . prompt surgical treatment led to a complete recovery . the effect of intravenous steroids in sdavf is controversial . acute clinical worsening after steroid administration is previously reported in several publications ; however , due to the paucity of clinical studies on sdavf , this effect remains mostly overlooked or unknown . the findings in this patient support the causative relation between sdavf clinical worsening and steroid administration . we propose that acute clinical worsening under steroids in patients initially diagnosed with myelitis should raise suspicion of an sdavf .

world health organization estimated 17 million people die annually cardiovascular disease worldwide accounts approximately 33% deaths in addition 9.4 million deaths attributed complications hypertension according statistics 2008 hypertension diagnosed almost two fifths people aged 25 years older worldwide if current trends continue number patients hypertension increse 500 million reach total 1.56 billion 2025 there 639 million hypertensive people equals almost 75% population developing countries limited resources hypertensive persons also low awareness condition well poor blood pressure bp control non optimal bp control accounts 66.6% strokes 50% coronary artery disease cases furthermore hypertension known one main risk factor deaths south asia according study conducted december 2011 march 2012 kabul afghanistan prevalence hypertension 46.2% age group 40years older several epidemiological studies reported association proteinuria poor prognosis hypertensive patients the burden proteinuria association hypertension studied adult hypertensive population afghanistan therefore study aimed determining prevalence proteinuria association different variables proteinuria among adult hypertensive patients attending outpatient clinic afghanistan five hundred fifty five patients high bp recorded outpatient clinic andkhoy afghanistan december 2014 may 2015 the case subjects included patients aged 18 years older receiving treatment newly diagnosed arterial hypertension defined seated systolic diastolic hypertension 140/90 mm hg rest day study visit patients engaged strenuous physical activity preceding 24 h well female participants pregnant menstruating ineligible likely presence false positive results the subjects evaluated clinic visit study protocol included assessment data obtained patient including demographic characteristics body mass index bmi weight kilograms divided height meters squared bp pattern cardiovascular history presence cardiovascular risk factors comorbidity current drug therapy the study approved scientific review committee balkh regional hospital study diabetes defined fasting blood sugar level 126 mg dl visit self reported use hypoglycaemia medications the results obtained using reagent tests strips accu trend plus kit cholesterol glucose roche diagnostic usa definitions obesity varies across studies even among country study overweight defined bmi 25 30 kg/ obesity bmi 30 dipstick screening proteinuria glycosuria performed reagent strips roche diagnostic usa the urinary protein levels dipstick urinary analyses recorded follows negative trace proteinuria 1 2 3 4 cigarette smoking assessed face face interview patients grouped three categories patients smoked 100 cigarettes lifetime currently smokes cigarettes current smoker ii patients smoked least 100 cigarettes lifetime stopped smoking time interview past smokers iii patients never smoked smoked 100 cigarettes lifetime non smoker other factors considered regular aerobic physical activity minimum 30 min 5 days week vigorous physical activity minimum 20 min 3 days week results measurement entered onto patient case report form univariate multivariate logistic regression analyses performed observe association proteinuria risk factors well target organ lesions odds ratios ors 95% confidence intervals cis estimated using logistic regression model all prognostic valuables p 0.05 univariate logistic regression analysis entered multivariate logistic regression analysis order determine independent predictors p value 0.05 considered statistically significant all analyses performed spss 20.0 software package spss chicago il usa five hundred fifty five patients high bp recorded outpatient clinic andkhoy afghanistan december 2014 may 2015 the case subjects included patients aged 18 years older receiving treatment newly diagnosed arterial hypertension defined seated systolic diastolic hypertension 140/90 mm hg rest day study visit patients engaged strenuous physical activity preceding 24 h well female participants pregnant menstruating ineligible likely presence false positive results the subjects evaluated clinic visit study protocol included assessment data obtained patient including demographic characteristics body mass index bmi weight kilograms divided height meters squared bp pattern cardiovascular history presence cardiovascular risk factors comorbidity current drug therapy the study approved scientific review committee balkh regional hospital study diabetes defined fasting blood sugar level 126 mg dl visit self reported use hypoglycaemia medications the results obtained using reagent tests strips accu trend plus kit cholesterol glucose roche diagnostic usa definitions obesity varies across studies even among country study overweight defined bmi 25 30 kg/ obesity bmi 30 dipstick screening proteinuria glycosuria performed reagent strips roche diagnostic usa the urinary protein levels dipstick urinary analyses recorded follows negative trace proteinuria 1 2 3 4 cigarette smoking assessed face face interview patients grouped three categories patients smoked 100 cigarettes lifetime currently smokes cigarettes current smoker ii patients smoked least 100 cigarettes lifetime stopped smoking time interview past smokers iii patients never smoked smoked 100 cigarettes lifetime non smoker other factors considered regular aerobic physical activity minimum 30 min 5 days week vigorous physical activity minimum 20 min 3 days week results measurement entered onto patient case report form univariate multivariate logistic regression analyses performed observe association proteinuria risk factors well target organ lesions odds ratios ors 95% confidence intervals cis estimated using logistic regression model all prognostic valuables p 0.05 univariate logistic regression analysis entered multivariate logistic regression analysis order determine independent predictors p value 0.05 considered statistically significant all analyses performed spss 20.0 software package spss chicago il usa the mean age patients 57.9 13.3 years range 1892 years most patients 59.1% aged 40 65 years 222 men 40.0% 333 women 60.0% the prevalence current smokers among female patients 18.6% significantly p 0.001 lower among male patients 37.8% the prevalence proteinuria 67.2% considerably higher male female patients p 0.001 among patients 14.9% family history ischemic heart disease 14.8% family history diabetes 53.4% family history hypertension of patients 26.3% current smokers 33.7% bmi 25 78.2% uncontrolled bp 59.2% regular physical exercise fequency distribution sociodemographic characteristics study participants n=555 mean age patients proteinuria non proteinuria groups 62.0 13.6 years 57.7 13.4 years respectively the male female ratio proteinuria group 1.15 nonproteinuria group 2.81 smokers higher rates proteinuria non smokers 30.7% vs. 17.5% p 0.03 patients proteinuria substantially increased levels systolic bp diastolic bp 155.0 24.8 vs.146.2 24.0 mm hg 94.6 13.8 vs. 88.6 10.8 mm hg p 0.001 respectively the fasting blood glucose levels 115.1 34.9 versus 104.5 23.7 p 0.001 the prevalence proteinuria significantly higher among diabetic patients non diabetic patients 14.7% vs. 3.8% p 0.001 patients myocardial infarction significantly higher proteinuria levels without myocardial infarction 25.7% vs.13.2% p 0.001 proteinuria common patients heart failure 15.2% vs. 6.6% p 0.04 physical activity inversely associated proteinuria 45.0% vs. 25.9% p 0.001 there also considerable difference regard use angiotensin receptor blockers arbs angiotensin converting enzyme ace inhibitors calcium channel blockers ccbs beta blockers bbs patients without proteinuria table 2 comparison factors associated proteinuria among hypertensive patients multivariate logistic regression analysis used determine association proteinuria smoking heart failure myocardial infarction diabetes mellitus stroke hypercholesterolemia regular physical activity the odds proteinuria among smokers 1.88 times greater non smokers 95%ci 1.102.95 patients heart failure two fold increase odds proteinuria without heart failure 95%ci 1.134.45 patients aged 65 years showed 1.02 times increase odds proteinuria 65 years 95%ci 1.001.04 the odds proteinuria among diabetic patients 3.41 times higher patients without diabetes 95%ci 1.497.80 myocardial infarction regular physical activity diabetes mellitus variables significant association proteinuria univariate logistic regression model however multivariate model association significant table 3 there lack data prevalence proteinuria afghanistan important information evaluation hypertensive patients the presence proteinuria helps identifying patients high risk need receive aggressive treatment risk factors the prevalence proteinuria among patients hypertension northern part afghanistan 67.2% similar prevalence 67.8% reported morocco part search survey evaluating microalbuminuria routinely cardiologists patients hypertension study data collected 40 cardiology centers population 476 patients another search study performed turkey international multi center the study designed evaluate frequency microalbuminuria observed large number outpatient clinics total 21,050 patients receiving treatment hypertension 26 countries however study prevalence proteinuria higher seen another study tertiary hospital uganda 39.5% these differences likely associated different criteria used patient selection age severity hypertension race coexisting cardiovascular risk factors e.g. diabetes mellitus renal disease dyslipidemia obesity well technique used proteinuria determination moreover study conducted 26 countries highest rates microalbuminuria observed asia the prevalence smoking among female patients lower among male patients similar this low prevalence smoking among female patients may due social factors discourage smoking women study found significant association proteinuria male comparable results others studies this discrepancy probably due combination risk factors i.e. diabetes smoking obesity fact ischemic heart disease frequent men women present investigation found association high systolic bp diastolic bp proteinuria a similar result obtained ya pan et al found increase systolic bp diastolic bp related prevalence proteinuria however al saffar et al the likely reason might due substantial reduction renal perfusion leads proteinuria according study there substantial statistically difference proteinuria patient age agreement studies this could explained relevant studies found advancing age risk factor higher prevalence proteinuria therefore early detection proteinuria screening hypertensive patients might prevent complication renal cardiovascular diseases the prevalence proteinuria higher smoking hypertensive patients smoke this could explained presence endothelial dysfunction involves imbalance contracting relaxing substances produced endothelium for example plasma concentration endothelin-14 higher smokers nonsmokers the present study shown independent relationship proteinuria presence concomitant diseases diabetes congestive heart failure myocardial infarction this observation agreement studies found relationship albuminuria cardiovascular risk this relationship could explained relevant studies microalbuminuria found indicate generalized dysfunction vascular endothelium permeability changes leads leakage albumin glomerular membrane furthermore finding prevalence proteinuria higher among patients diabetes likely attributable fact patients diabetes nephropathy the result study also showed physical activity decreased risk proteinuria hypertensive patients this association previously demonstrated reports showing physical activity inversely associated microalbuminuria physical activity protective effects vascular endothelium among patients cardiac diseases we found significant association use ccbs proteinuria risk present study this explained dilating effect ccbs efferent glomerular arterioles the present study also shows use bbs associated proteinuria however kozan et al could find significant association use bbs microalbuminuria risk the reason association illustrated observations different mechanisms identified explain beneficial effect ace inhibitors arbs proteinuria second group drugs reduce permeability basement membrane glomerulus both hemodynamic non hemodynamic effects ace inhibitors arbs renal activity lead reduction proteinuria among patients hypertension the samples consisted patients referred outpatient clinic treatment addition data source single center study design observational analysis patients randomly selected study therefore might selection bias furthermore examination proteinuria using data demonstrate proportion patients positive negative results based retesting moreover concerning study sample patients selected convenience basis finally study included uzbek turkmen ethnic group findings may generalizable general population we conclude results confirm presence high incidence proteinuria among hypertensive outpatients clinic andkhoy afghanistan especially high cardiovascular risk therefore frequent screening proteinuria might imperative evaluation this project supported part non profit organization epidemiological clinical research information network ecrin we would like thank dr.mirwais rabi dr.ahmad arsalam karimi cooperation study

abstractproteinuria in hypertension is an early marker of renal disease and a predictor for the progression of end stage renal disease , and cardiovascular diseases . this study was designed to determine the prevalence of proteinuria and its association with cardiovascular risk factors among adult hypertensive patients in afghanistan . five hundred fifty - five patients with a high blood pressure recorded in an outpatient clinic in andkhoy , afghanistan from december 2014 to may 2015 , were included in this study . data obtained from each patient , included demographic characteristics , body mass index , blood pressure patterns , cardiovascular history , cardiovascular risk factors , comorbidity , and current drug - therapy . dipstick screening for proteinuria was performed with reagent test strips . the mean age of the patients was 57.9 13.3 years , and a female predominance was observed ( n = 333 , 60% ) . the prevalence of proteinuria was 67.2% . the predictors of proteinuria were found to be age 65 years ( odds ratio [ or ] 1.02 , 95% confidence interval [ ci ] 1.001.04 ) , smoking ( or 1.88 , 95% ci 1.173.02 ) , heart failure ( or 2.23 , 95% ci 1.134.41 ) , and diabetes mellitus ( or 3.41 , 95% ci 1.497.81 ) . in conclusion , this study shows that proteinuria is highly prevalent among hypertensive outpatients in an outpatient clinic in andkhoy , afghanistan , especially in those with high cardiovascular risk .

vast majority cancers oral cavity squamous cell carcinomas scc)its evolution influenced host immune response cells e.g. cd8 cd4 natural killer cells nk dendritic cells dc macrophages eosinophils the eosinophils considered destructive effector leukocytes cytotoxic activities mainly implicated parasitic infections e.g. helminthic infections allergic diseases e.g. bronchial asthma allergic dermatitis etc however studies shown also involved tissue remodelling innate acquired immunity response modulation 2 3 figure 1 diverse stimuli e.g. infections tumours etc ) eosinophils able release different substances eosinophil cationic protein ecp major basic protein mbp eosinophil peroxidise epo eosinophil derived neurotoxin edn il-1 il-2 il-4 il-5 il-6 il-8 il-10 il-12 il-13 il-18 interferon inf)- tumor necrosis factor tnf)- transforming growth factor tgf)- tgf- chemokines rantes endotaxin-1 platelet activating factor paf leukotriene c4 ltc4 neuromediators indoleamine 2,3-dioxygenase ido 4 5 these substances may cause cell death induction inflammatory symptoms well contribute tumour progression regulation furthermore eosinophils present membrane receptors e.g. il-1 3 4 5 8 10 12 13 granulocyte monocyte colony stimulating factor gm csf ifn- tnf- macrophage inflammatory protein-1 confer survival recruitment capacity eosinophils oral scc several studies shown eosinophils associated improved prognosis studies however showing association poor prognosis well 6 7 short review we summarize briefly role eosinophils general context immunoregulation relation oral squamous cell carcinoma under specific stimulus nave cd4 cd8 cell differentiated respectively th2 tc2 cells secrete mainly cytokines involved humoral immunity il-4 il-5 il-10 il-13 8 9 initial recruitment activation eosinophils towards tumour microenvironment principally related th2 response although necrotic cells stimulate migration activation eosinophils 10 11 according literature th2 response may eliminate cancer dependence eosinophils macrophages 8 1214 il-4 il-13 potent inducers eotaxin chemokines explain eosinophilia associated th2 responses oral squamous cell carcinoma the eotaxin expressed tumour cells eosinophils involved mechanisms eosinophil chemotaxis tumour . il-13 also involved antitumour immune response mediated mainly neutrophils gr-1 macrophages mac-3 however il-13 also inhibit ifn- secretion cd8 cytotoxic lymphocyte ctl activity compromise anti tumour immunity response studies also shown eosinophils process present histocompatibility complex ii mhc class ii molecules polarize th2 response upon stimulation ifn- il-3 gm csf human eosinophilc cell line differentiated dibutyryl cyclic amp deol-1 human peripheral blood pb eosinophils able respond lymphoid chemokines e.g. ccl11 ccl21 ccl25 in addition cytokine stimulated deol-1 cells expressed human leukocyte antigen hla)-dr costimulatory molecules cd80 cd86 cd40 therefore eosinophils migrate lymphoid chemokine microenvironment express antigen presenting cells apcs)- related costimulatory molecules however experimental models suggested eosinophils inefficient antigen presenting cells compared macrophages dendritic cells the eosinophil derived neurotoxin stored eosinophils granules able induce dc maturation activation regulation mitogen activated protein map kinases nuclear factor kappa b nf kappa b cd83 cd86 costimulatory molecules mhc class ii expression 27 28 edn treated human dcs stimulated th2 immune response via toll like receptor tlr)2-myd88 signal they may express ifn- well il-4 il-5 il-10 suggesting subpopulation human eosinophils expresses th1 th2 cytokines respectively it shown th1 response able eradicate tumour cellular immunity response also th2 response via tumour necrosis contrarily eosinophils capable downregulate antitumour immunity mainly il-10 ido production il10 potent inhibitor mhc complex cd80 cd86 expression dc well suppresses dc differentiation contrarily il-10 play role b cell activation survival indoleamine this enzyme catalyzes amino acid tryptophan kynurenine able cause cycle arrest apoptosis uncommitted cd4 cells well maintenance th2 response the ido correlated poor prognosis non small cell lung cancer it shown eosinophils capable producing various substances e.g. vascular endothelial growth factor vegf fibroblast growth factor fgf tnf- gm csf nerve growth factor ngf tgf- il-8 promote angiogenesis produce collagenous fibers in head neck scc shown th1 response mainly associated better prognosis th2 response 38 39 according argarwal colleagues early stage oral scc expressed mainly inf- il-2 genes th1 responses whereas advanced stage tumours presented il-4 il-10 expression th2 response in addition advancing lesions tongue squamous cell carcinoma induced 4-nitroquinoline-1-oxide downregulated th1-type upregulated th2-type cytokine production regarding studies eosinophils blood presence eosinophils th2 cells related tumour progression poor prognosis 43 44 peripheral blood analyses intraoral squamous cell carcinoma history tobacco use presented enhanced expression th2 cytokine however patients malignant disease e.g. acute lymphoblastic leukemia acute myelogenous leukemia underwent stem cell transplantation patients cervical cancer treated whole pelvic irradiation presented increased blood eosinophilia better overall survival tumour associated tissue eosinophilia tate reported diverse sites 14 35 4753 including head neck region 6 7 5465 figure 2 head neck region some studies shown tate favourable prognosis suggesting eosinophils may play protective role epithelial tumours 6 55 60 62 other studies however suggest eosinophils may play role promoting epithelial tumour growth accounting poor prognosis 7 57 58 even effect tumour evolution 54 56 59 63 regard good prognosis shown oral scc patients tate presented higher overall survival less incidence distant metastasis head neck tumours nevertheless tadbir colleagues shown tate associated vascular perineural muscle invasion locoregional metastasis scc oral cavity similar results observed nasopharyngeal carcinoma oral ssc eosinophils associated local recurrence distant metastases survival another study laryngeal squamous cell carcinoma tate associated age tate positive patients presented 50 60 years age whereas tate negative patients 60 70 years age according oliveira colleagues cormier colleagues presence eosinophis damaged striated muscular fibers oral cancer capsule b16-f10 melanoma cell derived tumours respectively could related tissue remodelling hand presence eosinophils also related poor prognosis oral scc eosinophilic infiltration hla dr expression tumour cells related unfavourable prognosis experimental studies oral carcinoma depletion tate anti il-5 mab associated delayed development tumours according falconieri colleagues oliveira colleagues eosinophil presence scc oral cavity similar results observed head neck carcinoma 57 58 cervix eosinophils infiltrate increased suspicion invasion the presence 3 eosinophils high power field hpf 5/hpf 10/10 hpf cervical incisional biopy excisional specimens associated invasion according dorta colleagues the prognosis related tate controversial due different methodology utilized count tumour associated tissue eosinophila thereby prejudicing comparison results for reason alkhabuli high suggested counting eosinophils density method utilizes highest density eosinophils per surface area preference classic method counts eosinophils hpf in general presence well state activation immunologic cells plays important role tumour cell progression further studies eosinophils state activation necessary order elucidate findings

the eosinophil cell has been related as a prognostic indicator for cancers . however , its exact function in tumour behaviour is still not clearly defined . in the oral cavity the presence of eosinophils can be a favourable prognostic indicator as well as it may be associated with a poor prognosis . in this short review , we briefly summarize the role of the eosinophils in the general context of immunoregulation and its relation to oral squamous cell carcinoma .

kcps prospective cohort study korean government employees public private school teachers dependents insured korean medical insurance corporation former national health insurance corporation 16,17 the cohort includes 1,329,525 koreans 846,907 men 482,618 women aged 3095 years 784,870 59% subjects enrolled 1992 367,903 27.7% enrolled 1993 98,417 7.4% enrolled 1994 78,335 5.9% enrolled 1995 follow began 1 january 1993 904 people enrolled 1992 died year excluded avoid confounding association fasting serum glucose risk death preexisting disease 88,420 reported cvd liver disease cancer respiratory disease diabetes diagnosed initial study visit excluded in addition 42,817 people missing information fasting serum glucose total cholesterol systolic blood pressure alcohol intake extremely low bmi 16.0 kg exceptionally short stature 130 cm also excluded people insured korean medical insurance corporation required biennial medical examinations conducted designated hospitals clinics nationwide medical staff following guidelines provided korean medical insurance corporation participants asked provide medical history respond lifestyle questionnaire included items smoking alcohol drinking performance regular exercise the examination included height weight blood pressure measurements urinalysis blood cell count routine blood chemistries overnight fasting incident events determined diagnoses discharge summaries inpatient hospital records korea certified medical chart recorders review abstract medical chart assign discharge diagnoses standardized form using international classification diseases 10th revision world health organization 1992 vital status cause death determined computerized searches death certificate data korean national statistical office study outcomes defined hospitalization mortality attributable ischemic heart disease international classification diseases 10th revision codes i20i25 stroke codes i60i69 atherosclerotic cvd included ischemic heart disease codes i20i25 stroke codes i60i69 hypertensive heart disease codes i10i15 forms heart disease likely related atherosclerosis codes i44i52 disease arteries codes i70i74 sudden death cause unknown code r96 cardiovascular outcomes included hemorrhagic stroke i60i62 ischemic stroke i63i66 one event follow up an ischemic heart disease event validation study conducted collaboration korean society cardiology formation event validation committee july 2008may 2009 673 participants ischemic heart disease event review individual hospital records showed 73% myocardial infarction diagnoses valid 18 proportional hazards models used evaluate association baseline fasting serum glucose levels atherosclerotic cvd fasting serum glucose levels categorized 70 7084 8599 100109 110125 126139 140 mg dl used group fasting glucose level 8599 mg dl reference category all analyses conducted separately men women adjusted following covariates age enrollment bmi systolic blood pressure total cholesterol alcohol intake five categories based grams consumed per day 0 124 g 2549 g 5099 g 100 g participation regular physical activity yes smoking status never smoker former smoker current smoker number cigarettes smoked daily among current smokers 19 1019 20 detailed analyses dose response trends also used restricted quadratic spline models knots fasting glucose plasma levels 70 85 100 110 126 140 mg dl the kcps prospective cohort study korean government employees public private school teachers dependents insured korean medical insurance corporation former national health insurance corporation 16,17 the cohort includes 1,329,525 koreans 846,907 men 482,618 women aged 3095 years 784,870 59% subjects enrolled 1992 367,903 27.7% enrolled 1993 98,417 7.4% enrolled 1994 78,335 5.9% enrolled 1995 follow began 1 january 1993 904 people enrolled 1992 died year excluded avoid confounding association fasting serum glucose risk death preexisting disease 88,420 reported cvd liver disease cancer respiratory disease diabetes diagnosed initial study visit excluded in addition 42,817 people missing information fasting serum glucose total cholesterol systolic blood pressure alcohol intake extremely low bmi 16.0 kg exceptionally short stature 130 cm also excluded people insured korean medical insurance corporation required biennial medical examinations conducted designated hospitals clinics nationwide medical staff following guidelines provided korean medical insurance corporation participants asked provide medical history respond lifestyle questionnaire included items smoking alcohol drinking performance regular exercise the examination included height weight blood pressure measurements urinalysis blood cell count routine blood chemistries overnight fasting incident events determined diagnoses discharge summaries inpatient hospital records korea certified medical chart recorders review abstract medical chart assign discharge diagnoses standardized form using international classification diseases 10th revision world health organization 1992 vital status cause death determined computerized searches death certificate data korean national statistical office study outcomes defined hospitalization mortality attributable ischemic heart disease international classification diseases 10th revision codes i20i25 stroke codes i60i69 atherosclerotic cvd included ischemic heart disease codes i20i25 stroke codes i60i69 hypertensive heart disease codes i10i15 forms heart disease likely related atherosclerosis codes i44i52 disease arteries codes i70i74 sudden death cause unknown code r96 cardiovascular outcomes included hemorrhagic stroke i60i62 ischemic stroke i63i66 one event follow used first event analysis an ischemic heart disease event validation study conducted collaboration korean society cardiology formation event validation committee july 2008may 2009 673 participants ischemic heart disease event review individual hospital records proportional hazards models used evaluate association baseline fasting serum glucose levels atherosclerotic cvd assumption proportional hazards tested met fasting serum glucose levels categorized 70 7084 8599 100109 110125 126139 140 mg dl used group fasting glucose level 8599 mg dl reference category all analyses conducted separately men women adjusted following covariates age enrollment bmi systolic blood pressure total cholesterol alcohol intake five categories based grams consumed per day 0 124 g 2549 g 5099 g 100 g participation regular physical activity yes smoking status never smoker former smoker current smoker number cigarettes smoked daily among current smokers 19 1019 20 detailed analyses dose response trends also used restricted quadratic spline models knots fasting glucose plasma levels 70 85 100 110 126 140 mg dl on enrollment average age study participants 45.0 years men 49.4 years women average bmi 23.2 kg sexes the average fasting glucose values 91.1 mg dl 94.4 mg dl men women respectively the percentages study participants fasting serum glucose 100 100125 126 mg dl 76.8 19.3 3.9% men 82.0 14.8 3.2% women among men 60.2% current smokers 20.8% never smokers among women corresponding figures 4.1 93.9% respectively cross sectional baseline data men women higher fasting glucose likely older higher bmi higher systolic diastolic blood pressure total cholesterol levels supplementary tables 1 2 participants higher fasting glucose categories also likely report physically active men the prevalence current smoking inversely weakly associated fasting glucose level positively also weakly positively associated glucose level women we separately assessed association fasting serum glucose risk various cvd outcomes men women finding similar patterns association sex fatal nonfatal events combined tables 1 2 the risks various cvd outcomes lowest sexes serum glucose range 70109 mg dl increased range fasting glucose levels 70 mg dl associated slightly increased risk atherosclerotic cvd men hazard ratio hr 1.04 95% ci 1.011.08 women hr 1.06 1.021.10 fasting glucose levels 70 mg dl associated increased risk stroke men hr 1.06 1.011.11 women hr 1.11 1.051.17 categories > 100109 mg dl group hrs increased progressively increasing serum glucose except hemorrhagic stroke the results similar exclusion first 5 years follow data shown fasting serum glucose levels enrollment risk cardiovascular diseases male participants korean cancer prevention study 19932010 fasting serum glucose levels enrollment risk cardiovascular diseases female participants korean cancer prevention study 19932010 cardiac outcomes thrombotic stroke general patterns association quite comparable participants glucose level range 110125 mg dl hr increased 1020% highest category experienced doubling risk cvd event in restricted quadratic spline models risks cardiac outcomes thrombotic stroke lowest fasting serum glucose levels 90 mg dl increased sharply levels men women figs 1 2 hrs cardiovascular outcomes fasting serum glucose levels male participants kcps convert glucose mg dl mmol l hrs cardiovascular outcomes fasting serum glucose levels female participants kcps convert glucose mg dl mmol l we repeated analyses fatal nonfatal events separately supplementary tables 36 for men results fatal nonfatal events generally comparable women the risks associated low blood glucose greater fatal compared nonfatal events we also assessed potential effect modification risk cvd outcomes risk factors age sex general found little indication substantial effect modification supplementary table 7 there significant overall interactions hypertension present versus absent age younger 55 years versus 55 years older differences hrs small for men women hrs changed similar pattern fasting glucose concentration across two strata age in large cohort korean men women found fasting glucose level associated higher risk major cvd outcomes increasing level 90 mg dl controlling risk factors the dose response curves showed progressive increments hrs value higher lower levels increased risk greatest stroke the patterns association similar men women associations stronger women experimental studies show abnormal glucose metabolism impairs normal endothelial function accelerates atherosclerotic plaque formation contributes plaque rupture thrombosis epidemiological studies provide complementary evidence rotterdam study among elderly participants fasting blood glucose 110 mg dl without diabetes higher blood glucose levels higher levels arterial stiffness 20 the cathay study found higher levels glycemia 102124 mg dl associated arterial endothelial dysfunction intima media thickening 21 biomarker study italy number cvd biomarkers showed positive dose response relationships fasting glucose across three strata 100 100109 110125 mg dl 22 our study adds increasing evidence ifg independent risk factor incident cvd including ischemic heart disease stroke 7 in addition effects cvd risk factors may enhanced abnormal glucose metabolism 2325 1997 american diabetes association expert committee introduced ifg category defined time fasting plasma glucose level 110 125 mg ml 2-h value oral glucose tolerance test 140199 mg dl 26 ifg clinical entity risk category development diabetes cvd 10 2003 american diabetes association expert committee lowered cut point ifg 100 mg dl align proportion population would included category using fasting glucose oral glucose tolerance test indicate glucose levels 110 mg dl predictive diabetes development 26,27 although previous studies also identified increased risk cvd associated ifg 100125 mg dl 3,5,28,29 size kcps provides much precise characterization turn risk relation blood glucose level placing 90 mg dl consequence findings support lowering current american diabetes association ifg cut 100 mg dl also open possibility low fasting glucose levels may identify people increased risk cvd severe hypoglycemia diabetes known increase risks vascular events 3032 low fasting glucose levels nondiabetic population associated increased mortality several studies 5,15 study lowest risk cvd mortality occurred interval 8599 mg dl nadir 90 mg dl suggesting range fasting glucose levels associated lowest risk cvd narrow prospective cohort study 40,000 people the lowest total mortality associated fasting plasma glucose 79109 mg dl 15 study balkau et al ( 33 interval lowest total mortality 94103 mg dl decode study 8190 mg dl 34 the pooled analysis performed emerging risk factors collaboration described nonlinear relationship fasting glucose coronary heart disease configuration kcps analysis 3 atherosclerosis risk communities aric study selvin et al ( 35 found j shape relationship glycated hemoglobin risk death attributable coronary heart disease fasting blood glucose level 100 mg dl associated coronary heart disease death 35 different studies used different categories fasting glucose perhaps pooled analyses data large studies should performed using flexible models dose response analysis confirm findings narrow range fasting glucose levels lowest mortality the basis association low fasting glucose levels risk cvd people without diabetes unclear wei et al 15 hypothesized long term exposure low fasting plasma glucose may serve risk factor cvd mortality perhaps abnormal cardiac activity thrombosis particularly patients atherosclerosis ( 36 reported j shape relationship fasting plasma glucose incident ischemic cerebrovascular events patients preexisting atherothrombotic disease suggested hypoglycemia rapid changes plasma glucose may lead elevations counter regulatory hormones epinephrine norepinephrine increases induce vasoconstriction platelet aggregation 36 pooled analysis data 97 cohorts involving people without vascular disease enrollment increase risk vascular disease death was observed blood glucose level 70 mg dl enrollment 7 because cvd risk factors development cvd usually associated metabolic abnormalities increase fasting plasma glucose additional studies need conducted understand low fasting plasma glucose levels consequence impending disease i.e. reverse causation role precipitating acute cvd events limitations findings need considered first single fasting glucose measurements subject substantial within person variation perform 2-h glucose tolerance testing measurement error study variability may attenuated results adding identification narrow range fasting glucose levels optimal survival additionally measured serum glucose currently recommended plasma glucose 37,38 however measurements serum glucose findings biased second lacked information evolution fasting glucose levels incidence diabetes follow identify increased risk associated ifg depends future evolution diabetes pathways third lacked data metabolic abnormalities associated overweight obesity fat distribution fourth outcomes obtained admission records death certificates outpatient records included incidence cvd morbidity study may lower actual incidence with regard generalizability findings kcps population differs investigations several ways of course participants asian population also leaner studies blood glucose cvd risk fasting glucose readily widely measured early detection prevention diabetes beyond risk diabetes also conveys information cvd risk additionally findings suggest optimal glucose level may current cut offs used identify people risk cvd health care providers recognize j shape relationship fasting blood glucose cvd risk interpreting communicating clinical data

objectivealthough diabetes increases the risk of cardiovascular disease ( cvd ) and mortality , the dose - response relationship between fasting glucose levels below those diagnostic of diabetes with cardiovascular events has not been well characterized.research design and methodsa prospective cohort study of more than one million koreans was conducted with a mean follow - up of 16 years . a total of 1,197,384 korean adults with no specific medical conditions diagnosed were classified by baseline fasting serum glucose level . associations of fasting glucose level with cvd incidence and mortality , stroke incidence and mortality , and all - cause mortality were analyzed using multivariate proportional hazards regression.resultsthe relationships between fasting glucose levels and cvd risks generally followed j - shape curves , with lowest risk in the glucose range of 8599 mg / dl . as fasting glucose levels increased to > 100 mg / dl , risks for cvd , ischemic heart disease , myocardial infarction , and thrombotic stroke progressively increased , but risk for hemorrhagic stroke did not . fasting glucose levels < 70 mg / dl were associated with increased risk of all stroke ( hazard ratio 1.06 , 95% ci 1.011.11 ) in men and ( hazard ratio 1.11 , 1.051.17 ) in women.conclusionsboth low glucose level and impaired fasting glucose should be considered as predictors of risk for stroke and coronary heart disease . the fasting glucose level associated with the lowest cardiovascular risk may be in a narrow range .

october 2011 u.s national science advisory board biosecurity nsabb asked review two papers potential dual use research concern durc these papers contained results adaptation highly pathogenic avian influenza h5n1 virus mammalian hosts could transmitted via respiratory droplets animal animal we found work great potential harm misuse recommended general conclusions highlighting novel outcome published manuscripts include methodological details could enable replication experiments would seek harm the recommendation publish scientific results highly unusual first recommendation nsabb membership we primarily group actively practicing basic research scientists consistently advocated open publication practices per advisory nature u.s there agreement nsabb voting members recommendations though rationale individual members arrived conclusions varied we judge beneficial attributes research results potential cause harm last 7 years nsabb studied issues associated dual use research including risk benefit assessments developed principles tools guide deliberative process much formalized series reports recommendations available public website http://oba.od.nih.gov/biosecurity/biosecurity.html despite experience carefully crafted guidance points deliberations uncertainties even contradictory information necessitate subjective decisions is clear bright line crossed nebulous fuzzy region yes research ? i present personal rationale came strong conclusion work potential dangerous communication restricted time i heard members influenza research community reviewed world health organization data indicating avian virus high mortality rate humans influenza h5n1 virus rarely infects humans causes catastrophic disease we aware rapid global spread human adapted influenza yearly basis less common pandemics the documented devastation 1918 influenza pandemic even lower mortality rate testament powerful potential influenza the thought combining high human mortality influenza h5n1 highly transmissible human adapted phenotype sobering a pandemic pathogen could reasonably concluded cause devastation prevented costs i carefully considered restricting information would compromise scientific research progress even would hinder public health efforts prevent horrific pandemic i know firsthand experience free flow information part best productive research endeavors restrictions burden progress the conclusion virus could adapted mammal mammal respiratory transmission mind foremost beneficial part research with firm conclusion hand policy makers granting agencies public health officials vaccine drug developers motivation compelling argument move forward improve influenza fighting infrastructure the details research hand would add little short term effort could enable someone replicate work short period time the short term negative consequences restricting experimental details seemed small contrast large consequences facilitating replication experiments someone nefarious intent current public health surveillance public health responses would enhanced little details this comes professional experience globally tracking dangerous pathogens also personally watching 2009 h1n1 influenza pandemic spread globally it impossible contain believe would true h5n1 influenza pandemic we lucky h1n1 virus low virulence best current data suggest would case h5n1 virus publishing detailed experimental protocol produce highly transmissible h5n1 virus highly regarded scientific journal bad idea since recommendations announced mid december considerable response scientists policy makers funding agencies global health organizations there criticisms restriction publications insufficient even performing experiments restricted the debate touched upon biosafety biosecurity aspects calling destruction virus moving research highest safety level biosafety level 4 bsl-4 the nsabb yet offered specific recommendations concerning statements personal opinions relatively unimportant what gratifying essential debate occurring occurring international stage occurring rapidly midst nsabb deliberations formulation recommendations the need global debate develop policy always discussions why nsabb telling world world already discussions debates ? how could nsabb stimulate process global leaders science policy public health engage broad based conversation issues ? the specific nsabb recommendations seem accepted implemented two research groups two scientific journals importantly research issue adapting avian virus mammals potentially humans topic widely discussed the agreed participate facilitate policy development u.s research public policy developed global engagement process process increase public confidence scientific endeavor scientists ethical behavior transparency free research environment embraces

abstractthe national science advisory board for biosecurity ( nsabb ) has recommended that two scientific papers concerning the laboratory adaptation of avian h5n1 influenza virus to mammal - to - mammal respiratory transmission restrict their content to prevent others from replicating their work . after hearing from experts in the field of influenza research and public health , the benefits of the research were deemed less important than the potential negative consequences . the evaluation followed established nsabb procedures and prior policy recommendations for identifying dual use research of concern ( durc ) . this recommendation was received by the united states government , endorsed and forwarded to the research teams and scientific journals involved with the publications .

pneumococcal infections especially dangerous children adults immunodeficiencies hiv illnesses chronic cardiac disease diabetes.1 pneumococcal vaccination therefore recommended persons high risk severe illness complications asthma first identified independent risk factor pneumococcal disease pd 2005 talbot et al2 reported asthma associated 2.4-fold increased odds pd among persons 249 years old enrolled tennessee medicaid program 1994 2002 several studies conducted since provided additional evidence asthma associated increased risk pd adults,35 study provided convincing evidence asthma associated increased risk pd children.6 currently pneumococcal vaccination recommended asthmatic adults specifically recommended asthmatic children asthma common chronic disease children,7 prevalence asthma increasing worldwide.812 prevalence asthma increases importance understanding whether children asthma increased risk pd the aim current study evaluate association asthma development pd among danish children born 1994 2007 the study population included singleton live births denmark january 1 1994 december 31 2007 routine childhood pneumococcal vaccination 7-valent pneumococcal conjugate vaccine pcv7 begin denmark october 2007,13 children study population expected vaccinated we used unique civil personal registry number assigned danish citizens birth residents upon immigration used public records since 1968 identify live births danish civil registration system this continually updated national registration system includes information date place birth immigration sex marital status citizenship emigration vital status.14 study children followed birth diagnosis pd removal danish civil registration system due cause december 31 2007 whichever came first the danish data protection agency provided permission use data record number 1 16 02 1 08 because study based data extracted registries exempt human subjects review members study population provide informed consent ascertain pd used subject unique civil personal registry number link danish civil registration system data danish national registry patients the danish national registry patients began 1977 includes inpatient diagnoses made nonpsychiatric hospitals beginning 1995 diagnoses made outpatient specialist clinics emergency room visits.15 used danish version international classification diseases icd)-10 codes g00.1 a40.3 j13.9 ascertain pneumococcal meningitis pneumococcal septicemia pneumococcal pneumonia respectively diagnosis pneumococcal pneumonia using icd codes validated prior study 64% icd-10-identified cases microbiologic radiologic clinical evidence consistent pd remaining 36% classified probable pd.16 used icd-10 codes j45 j46 recorded danish national registry patients ascertain asthma registry based asthma diagnoses previously validated denmark determined high quality.17,18 classified study subjects asthma least one diagnosis code indicating asthma hospitalization emergency outpatient visits time diagnosis pd end follow children develop pd information obtained danish medical birth registry included place birth gestational age fetal presentation mode delivery birth weight 5-minute apgar score maternal place birth maternal age time delivery maternal cohabitation status maternal parity.19 maternal smoking status pregnancy based self report first antenatal visit classified yes presence absence congenital malformations selected underlying comorbidities ascertained using icd-10 codes recorded danish national registry patients table s1 children accumulated unexposed person time birth asthma diagnosis exposed person time thereafter we calculated frequency proportion children without asthma within categories demographic variables birth outcomes well age specific incidence rates pd we used poisson regression estimate crude adjusted incidence rate ratios irrs 95% confidence intervals cis associating childhood asthma pd we included covariates changed crude association asthma pd 10% adjusted models child sex retained adjusted models regardless impact unadjusted measures because underlying comorbidity known substantially increase risk pd children,20 strongly associated childhood asthma exposure study population evaluated impact comorbidity association asthma pd stratified analyses the impact congenital malformations also assessed analyses used poisson regression calculate crude adjusted irrs 95% cis stratified presence absence congenital malformations selected underlying comorbidities we evaluated observed effect measure modification evidence biologic interaction using standard measures supplementary materials).21,22 conducted statistical analyses using sas stat software version 9.2 sas institute inc cary nc usa).23 the study population included singleton live births denmark january 1 1994 december 31 2007 routine childhood pneumococcal vaccination 7-valent pneumococcal conjugate vaccine pcv7 begin denmark october 2007,13 children study population expected vaccinated we used unique civil personal registry number assigned danish citizens birth residents upon immigration used public records since 1968 identify live births danish civil registration system this continually updated national registration system includes information date place birth immigration sex marital status citizenship emigration vital status.14 study children followed birth diagnosis pd removal danish civil registration system due cause december 31 2007 whichever came first the danish data protection agency provided permission use data record number 1 16 02 1 08 because study based data extracted registries exempt human subjects review members study population provide informed consent to ascertain pd used subject unique civil personal registry number link danish civil registration system data danish national registry patients the danish national registry patients began 1977 includes inpatient diagnoses made nonpsychiatric hospitals beginning 1995 diagnoses made outpatient specialist clinics emergency room visits.15 used danish version international classification diseases icd)-10 codes g00.1 a40.3 j13.9 ascertain pneumococcal meningitis pneumococcal septicemia pneumococcal pneumonia respectively diagnosis pneumococcal pneumonia using icd codes validated prior study 64% icd-10-identified cases microbiologic radiologic clinical evidence consistent pd remaining 36% classified probable pd.16 used icd-10 codes j45 j46 recorded danish national registry patients ascertain asthma registry based asthma diagnoses previously validated denmark determined high quality.17,18 classified study subjects asthma least one diagnosis code indicating asthma hospitalization emergency outpatient visits time diagnosis pd end follow children develop pd information obtained danish medical birth registry included place birth gestational age fetal presentation mode delivery birth weight 5-minute apgar score maternal place birth maternal age time delivery maternal cohabitation status maternal parity.19 maternal smoking status pregnancy based self report first antenatal visit classified yes presence absence congenital malformations selected underlying comorbidities ascertained using icd-10 codes recorded danish national registry patients table s1 children accumulated unexposed person time birth asthma diagnosis exposed person time thereafter we calculated frequency proportion children without asthma within categories demographic variables birth outcomes well age specific incidence rates pd we used poisson regression estimate crude adjusted incidence rate ratios irrs 95% confidence intervals cis associating childhood asthma pd we included covariates changed crude association asthma pd 10% adjusted models child sex retained adjusted models regardless impact unadjusted measures because underlying comorbidity known substantially increase risk pd children,20 strongly associated childhood asthma exposure study population evaluated impact comorbidity association asthma pd stratified analyses the impact congenital malformations also assessed analyses used poisson regression calculate crude adjusted irrs 95% cis stratified presence absence congenital malformations selected underlying comorbidities we evaluated observed effect measure modification evidence biologic interaction using standard measures supplementary materials).21,22 conducted statistical analyses using sas stat software version 9.2 sas institute inc cary nc usa).23 there 890,681 singleton live births study period excluding 2,026 records records excluded child 0 days follow number n 1,228 birth weight 500 g n=90 gestational age 25 completed weeks 45 completed weeks n=510 n=5 respectively implausible gestational age birth weight combinations n=70 met 1 exclusion criteria n=123 mean median follow up periods 8.0 years interquartile range 4.411.6 years among 888,655 children study population 6.0% n=53,024 received asthma diagnosis end follow the mean age asthma diagnosis 31 months standard deviation 31.0 months median 18.7 months interquartile range 10.739.6 months a total 6,641 children recorded comorbidity cardiac disease common comorbidity 32.8% followed renal disease 21.5% type 1 diabetes 20.3% compared children without asthma children asthma diagnosis likely male born preterm 37 weeks low birth weight 2,500 g born mother reported smoking first prenatal visit table 1 in addition asthmatic children congenital malformations 6.7% versus 4.4% respectively selected underlying comorbidities 2.4% versus 0.6% respectively compared nonasthmatic children a total 2,253 children diagnosed pd follow period admitted inpatients 96.3% pneumonia accounted majority cases 72.9% followed septicemia 14.6% meningitis 12.5% most pd diagnoses occurred 6 months 24 months birth n=1,180 52.7% fewest occurred 60 months birth n=255 11.3% there trend toward increasing decreasing incidence throughout study calendar period the rate pd highest among children 6 24 months old 91.2 cases per 100,000 child years followed children 0 6 months old 78.8 cases per 100,000 child years children 24 60 months old 21.5 cases per 100,000 child years children oldest age group lowest pd rates 8.0 cases per 100,000 child years pd incidence rates asthmatic children consistently higher nonasthmatic children exception children aged 0 6 months the unadjusted irr associating asthma incident pd among children 2.4 95% ci 2.1 2.6 age specific measures association confounded year birth birth weight congenital malformations underlying comorbidities the adjusted irr associating asthma incident pd among children 2.2 95% ci 2.0 2.5 order increasing age strata adjusted irrs 0.4 95% ci 0.2 0.8 children 0 6 months old 2.1 95% ci 1.8 2.5 children 6 24 months old 4.1 95% ci 3.3 5.1 children 24 60 months old 2.3 95% ci 1.6 3.2 children 60 months old table 2 restricting study population children without selected comorbidities malformations substantially change irrs associating asthma incident pd age strata restricting study population children selected comorbidities malformations however revealed comorbidity effect modifier association asthma pd children aged 24 60 months 60 months table 3 evaluation biologic interaction asthma comorbidity incidence pd age groups showed rate pd greater among recorded diagnosis asthma comorbidity compared rate would expected based independent effects asthma comorbidity alone figure 1 shows among children aged 24 60 months old unadjusted incidence rate pd children asthma comorbidity 7.5 times rate children asthma alone adjusting confounding variables 55% 95% ci 31 79 pd cases among asthmatic children could attributed presence asthma comorbidity time among children aged 60 months old the unadjusted irr pd children asthma comorbidity 14 times rate children asthma alone adjusted percentage pd cases attributable biologic interaction increased 73% 95% ci 52 93 there 890,681 singleton live births study period excluding 2,026 records records excluded child 0 days follow number n 1,228 birth weight 500 g n=90 gestational age 25 completed weeks 45 completed weeks n=510 n=5 respectively implausible gestational age birth weight combinations n=70 met 1 exclusion criteria n=123 mean median follow up periods 8.0 years interquartile range 4.411.6 years among 888,655 children study population 6.0% n=53,024 received asthma diagnosis end follow the mean age asthma diagnosis 31 months standard deviation 31.0 months median 18.7 months interquartile range 10.739.6 months a total 6,641 children recorded comorbidity cardiac disease common comorbidity 32.8% followed renal disease 21.5% type 1 diabetes 20.3% compared children without asthma children asthma diagnosis likely male born preterm 37 weeks low birth weight 2,500 g born mother reported smoking first prenatal visit table 1 in addition asthmatic children congenital malformations 6.7% versus 4.4% respectively selected underlying comorbidities 2.4% versus 0.6% respectively compared nonasthmatic children a total 2,253 children diagnosed pd follow period admitted inpatients 96.3% pneumonia accounted majority cases 72.9% followed septicemia 14.6% meningitis 12.5% most pd diagnoses occurred 6 months 24 months birth n=1,180 52.7% fewest occurred 60 months birth n=255 11.3% there trend toward increasing decreasing incidence throughout study calendar period the rate pd highest among children 6 24 months old 91.2 cases per 100,000 child years followed children 0 6 months old 78.8 cases per 100,000 child years children 24 60 months old 21.5 cases per 100,000 child years children oldest age group lowest pd rates 8.0 cases per 100,000 child years pd incidence rates asthmatic children consistently higher nonasthmatic children exception children aged 0 6 months the unadjusted irr associating asthma incident pd among children 2.4 95% ci 2.1 2.6 age specific measures association confounded year birth birth weight congenital malformations underlying comorbidities the adjusted irr associating asthma incident pd among children 2.2 95% ci 2.0 2.5 order increasing age strata adjusted irrs 0.4 95% ci 0.2 0.8 children 0 6 months old 2.1 95% ci 1.8 2.5 children 6 24 months old 4.1 95% ci 3.3 5.1 children 24 60 months old 2.3 95% ci 1.6 3.2 children 60 months old table 2 restricting study population children without selected comorbidities malformations substantially change irrs associating asthma incident pd age strata restricting study population children selected comorbidities malformations however revealed comorbidity effect modifier association asthma pd children aged 24 60 months 60 months table 3 evaluation biologic interaction asthma comorbidity incidence pd age groups showed rate pd greater among recorded diagnosis asthma comorbidity compared rate would expected based independent effects asthma comorbidity alone figure 1 shows among children aged 24 60 months old unadjusted incidence rate pd children asthma comorbidity 7.5 times rate children asthma alone adjusting confounding variables 55% 95% ci 31 79 pd cases among asthmatic children could attributed presence asthma comorbidity time among children aged 60 months old the unadjusted irr pd children asthma comorbidity 14 times rate children asthma alone adjusted percentage pd cases attributable biologic interaction increased 73% 95% ci 52 93 this study provides evidence asthma important risk factor development pd children provides new insight potentially meaningful interaction asthma comorbidity risk pd consistent data presented talbot et al,2 observed twofold increased rate pd among children 18 years old following childhood asthma diagnosis compared person time asthma diagnosis children never asthma diagnosis adjusting confounding factors the highest rate ratio occurred among children 24 60 months old twice large rate ratios observed among children 6 24 months old 60 months old we also observed rate ratio less 1 among children 0 6 months old emphasize believe indicates asthma protective pd age group instead suspect observation due difficulty reliably diagnosing asthma young children.24 evaluation biological interaction childhood asthma comorbidity incidence pd revealed combined effect two exposures synergistic older children high proportion 55% children aged 24 60 months 73% children aged 60 months pd incidence among asthmatic children comorbidities attributable interaction no synergy childhood asthma comorbidity observed children less 2 years old these results suggest children 2 years old underlying comorbidities sensitive effect asthma pd children 2 years old without comorbidities juhn et al3 also identified comorbidity effect modifier association asthma pd among minnesota adults they reported odds ratio effect asthma pd among adults high risk conditions lower 1.2 p=0.86 among without high risk conditions 2.9 p=0.04 similar results observed study children 2 years 5 years old association asthma incident pd lower among children underlying comorbid conditions compared children without underlying illnesses adjusted irr 2.9 versus 4.2 respectively lower rate ratios among children comorbid conditions probably results higher risk pd sometimes called modification baseline risk juhn et al3 assess biological interaction additive scale study instead reported statistical interaction asthma illnesses based addition interaction term log linear multivariate model departure additivity better measure biologic interaction lack statistical interaction measured interaction term log linear multiplicative multivariate model easily mistaken lack biologic interaction.22 several investigators identified potential biologic mechanisms may explain asthma increases risk pd two studies identified associations asthma increased carriage streptococcus pneumoniae nasopharynx,25,26 suggesting children asthma may increased risk pd likely colonized pneumococci other proposed mechanisms include asthma induced pathologic alterations impair clearance pathogenic bacteria airway27,28 chronic airway inflammation leading impaired respiratory immunity.29,30 several limitations considered interpreting results study first use registry based icd-10 codes identify children asthma likely result misclassification underascertainment asthma possible less severe cases asthma missed likely due diagnosis treatment general practitioner such underascertainment would bias irrs describing association asthma pd toward null exposed children would misclassified unexposed overascertainment also possible children wheezing due causes example respiratory syncytial virus classified asthma although one way increase sensitivity specificity asthma exposure would incorporate use prescription asthma medications classification scheme asthma exposure access data study we also unable include mechanism reclassify asthma exposed children unexposed grew asthma diagnosis although imperfect sensitivity specificity exposure classification possible several studies recently evaluated quality icd-10-based asthma diagnoses danish national registry patients found diagnosis codes accurate.17,18 one study used 3,550 medical records gold standard validate icd-10 inpatient asthma diagnoses recorded danish national registry patients reported 90% sensitivity 99% specificity asthma diagnoses among children aged 614 years old.17 another study reported 44% sensitivity 98% specificity asthma diagnoses recorded among 18-year old men reporting mandatory medical evaluation danish military draft board the authors study subsequently demonstrated level nondifferential asthma misclas sification present danish national registry patients sufficient nullify association asthma various skin cancers examined.18 observed 6% prevalence asthma study population less estimated asthma prevalence 10%12% based questionnaire data collected parents danish children aged 517 years.31,32 determine potential impact imperfect sensitivity specificity exposure ascertainment results performed bias analysis calculating irr would observed asthma ascertainment sensitivity equal 50% specificity equal 97% this sensitivity consistent differences asthma prevalence recorded study recorded published reports specificity minimum specificity resulted negative cell frequency corrected table we assumed exposure misclassification nondifferential independent cases noncases data study prospectively collected the results analysis indicated minimal impact age specific irrs unadjusted irr children aged 6 24 months old would increase 2.3 2.4 irr among children 24 60 months old would increase 4.8 5.0 unadjusted irrs among children 0 6 months old 60 months old would change second exclusive use icd-10 codes identify pd cases creates potential misclassification some pd cases could missed resulting illness mild cultures falsely negative due recordkeeping errors however pd serious disease typically requiring medical treatment icd-10 codes likely capture important costly infections if underascertainment pd occur likely nondifferential due prospective nature data turn expected produce unbiased ratio effect estimates33 absence false positives it however possible cases could falsely attributed pd fact caused bacterial infections although independently verify case status study discharge diagnoses pd found high specificity validation studies conducted investigators.16,34 third although able collect extensive information pregnancy- birth related characteristics able capture complete information social factors associated pd misclassification exposure secondary tobacco smoke35 may occurred study information smoking available mothers beginning pregnancy information available fathers childcare providers despite limitations current study important contribution current knowledge association asthma pd the evidence presented indicates asthmatic children likely develop pd compared nonasthmatic children thereby providing support addition asthma list pneumococcal vaccine eligible conditions older children these results also indicate children asthma another underlying comorbidity may especially high risk pd carefully assessed clinic presenting bacterial illnesses effect measure modification observed stratified analyses evaluated evidence biologic interaction using three standard measures1,2 determine whether independent effects asthma comorbidity summed total effect factors together first interaction contrast ic asthma comorbidity calculated applying following formula crude pneumococcal disease pd incidence rates per 100,000 person years ic re+c+re+crec++rec(1)where r represents rate disease e represents exposure asthma c modifying covariate case comorbidity the ic represents number cases disease per 100,000 child years accounted baseline factors among children without asthma comorbidity asthma comorbidity therefore presumed attributable biological interaction asthma comorbidity next interaction contrast ratio icr 95% confidence interval around icr calculated quantify excess rate asthma comorbidity present time relative baseline rate disease occurred neither present adjusting important confounders association asthma pd:3 icr icrec=irre+c+irre+cirrec++1(2 icrs study adjusted sex birth weight child year birth congenital malformation we used icr account confounders calculate attributable proportion due interaction ap quantifies proportion disease among exposed persons attributable interaction exposure modifying covariate the ap calculated dividing icr irr comparing children asthma comorbidity children without either these:3 ap icrirre+c+=irre+c+irre+cirrec++1irre+c+(3 icd-10 codes used identify asthma pneumococcal disease comorbidities danish registries abbreviation icd international classification diseases effect measure modification observed stratified analyses evaluated evidence biologic interaction using three standard measures1,2 determine whether independent effects asthma comorbidity summed total effect factors together first interaction contrast ic asthma comorbidity calculated applying following formula crude pneumococcal disease pd incidence rates per 100,000 person years ic re+c+re+crec++rec(1)where r represents rate disease e represents exposure asthma c modifying covariate case comorbidity the ic represents number cases disease per 100,000 child years accounted baseline factors among children without asthma comorbidity asthma comorbidity therefore presumed attributable biological interaction asthma comorbidity next interaction contrast ratio icr 95% confidence interval around icr calculated quantify excess rate asthma comorbidity present time relative baseline rate disease occurred neither present adjusting important confounders association asthma pd:3 icr icrec=irre+c+irre+cirrec++1(2 icrs study adjusted sex birth weight child year birth congenital malformation we used icr account confounders calculate attributable proportion due interaction ap quantifies proportion disease among exposed persons attributable interaction exposure modifying covariate the ap calculated dividing icr irr comparing children asthma comorbidity children without either these:3 ap icrirre+c+=irre+c+irre+cirrec++1irre+c+(3 icd-10 codes used identify asthma pneumococcal disease comorbidities danish registries abbreviation icd international classification diseases

backgroundalthough asthma has recently been established as a risk factor for pneumococcal disease ( pd ) , few studies have specifically evaluated this association in children.methodswe conducted a nation - wide population - based cohort study of the effect of asthma on childhood pd among all singleton live births in denmark from 1994 to 2007 , before the introduction of the 7-valent pneumococcal conjugate vaccine . all data were abstracted from danish medical registries . because underlying comorbidity substantially increases the pd risk in children , standard methods were used to assess the evidence of biologic interaction between comorbidity and asthma on the risk of pd.resultsthere were 2,253 cases of childhood pd among 888,655 children born in denmark from 1994 to 2007 . the adjusted incidence rate ratio of the effect of asthma on childhood pd was 2.2 ( 95% confidence interval [ ci ] : 2.0 , 2.5 ) . age - stratified incidence rate ratios were 2.1 ( 95% ci : 1.8 , 2.9 ) in children 6 months to < 24 months , 4.1 ( 95% ci : 3.3 , 5.1 ) in children 24 months to < 60 months , and 2.3 ( 95% ci : 1.6 , 3.2 ) in children 60 months . evaluation of the biologic interaction between asthma and comorbidity in older children revealed that 55% ( 24 months to < 60 months ) to 73% ( 60 months ) of cases among asthma - exposed children can be accounted for by the interaction between asthma and comorbidity.conclusionthese results confirm that asthma is an important risk factor for pd in children and suggest that children with underlying comorbidities are more sensitive to the effect of asthma on pd than children without comorbidities .

according protocol analysis co variance reduced antigen content diphtheria tetanus acellular pertussis vaccine filamentous hemagglutinin geometric mean concentration serious adverse event total vaccinated cohort pertussis highly infectious disease remains important worldwide public health problem even countries sustained high vaccination coverage despite established infant immunization programmes pertussis continues circulate predominantly due waning immunity beyond childhood disease transmission adolescents adults vulnerable infants the need maintain antibody levels pertussis beyond childhood booster vaccines therefore increasingly recognized reduced antigen content combined diphtheria tetanus acellular pertussis dtpa vaccines boostrix dtpa glaxosmithkline gsk vaccines specifically developed immunize older children age 4 years adolescents adults boostrix first licensed 1999 currently available 70 countries well established immunogenicity tolerability profile populations ranging school age elderly traditionally boostrix available single dose vial prefilled disposable syringe tip cap plunger stopper contained methylester w1883 however following discontinuation w1883 production manufacturer west syringe presentation recently replaced using prefilled syringes different manufacturer wherein tip cap component contains fm27 latex free non cytotoxic rubber compound plunger stopper component contains fm457 ultra low extractable bromobutyl compound although presentation change approved basis technical variation non inferiority study conducted evaluate impact safety immunogenicity due change material used rubber plunger prefilled syringe required regulatory agency compared immunogenicity safety dtpa vaccine injected using old new syringe presentations thereby support change clinical data this phase iv randomized single blind parallel group study nct01362322 funded glaxosmithkline biologicals sa conducted across 3 centers chile mexico july 2011 september 2012 francisco madero pte n dr e aguirre pequeno col mitras centro monterrey mexico subcomite de etica en investigacion hospital general de ecatepec las america estado de mexico comit de tica en investigacin facultad de medicina pontificia universidad catlica de chile comit tico cientfico del servicio de salud metropolitano central santiago institute public health chile adhered declaration helsinki good clinical practice guidelines written informed consent obtained parents guardians assent subjects enrolment healthy adolescents aged 1015 years received 5 6 previous doses dt(p)/dt(pa vaccine randomized 1:1 receive dtpa booster via new dtpa new previous dtpa previous syringe presentations due visual differences presentation 2 syringes study conducted single blind manner each 0.5 ml dtpa vaccine dose contained 2 iu diphtheria toxoid 20 iu tetanus toxoid 8 g pertussis toxin pt 8 g filamentous hemagglutinin fha 2.5 g pertactin prn vaccine supplied 2 prefilled syringe presentations dtpa previous group syringes w1833 tip caps plunger stoppers lot no dc37a005b expiry date 31 aug 2013 dtpa new group syringes fm27 tip caps fm457 plunger stoppers lot a single booster dtpa dose injected intramuscularly deltoid region non dominant arm using needle 2.54 cm length 2225 gauge blood samples 5 ml collected subjects one month post booster dosing antibodies diphtheria tetanus pertussis antigens measured using standard enzyme linked immunosorbent assay elisa seroprotection diphtheria tetanus antigens defined antibody concentration 0.1 iu ml booster response diphtheria tetanus antigens defined antibody concentrations 4-fold assay cut initially seronegative subjects 4-fold increase pre vaccination antibody concentrations initially seropositive subjects seropositivity pertussis antigens defined antibody concentration 5 el.u ml per antigen booster response antigens defined antibody concentrations 4-fold assay cut initially seronegative subjects 4-fold increase pre vaccination antibody concentrations initially seropositive subjects pre vaccination concentrations 5 20 el.u ml 2-fold increase pre vaccination antibody concentrations initially seropositive subjects pre vaccination concentrations 20 el.u ml diary cards used assess solicited local injection site pain redness swelling general fatigue headache fever axillary temperature 37.5c gastrointestinal gi symptoms adverse events 4 days day 03 vaccination the intensity symptoms graded 3-point scale grade 3 redness swelling diameter 50 mm grade 3 fever axillary temperature 39.0c symptoms large injection site reactions defined swelling diameter 100 mm noticeable diffuse swelling noticeable increase limb circumference evaluated investigator all symptoms including serious adverse events saes occurring within 31 days vaccination recorded the primary objective study demonstrate dtpa new non inferior dtpa previous terms immune response vaccine antigens one month booster vaccination the criteria evaluation upper limit ul 95% confidence interval ci gmc ratios dtpa previous dtpa new anti diphtheria anti tetanus anti pt anti fha anti prn antibodies 1.5 clinical limit non inferiority the 95% cis gmc ratio 2 study groups computed using analysis co variance ancova model including group number previous dt doses 5 6 fixed effects log transformed pre vaccination concentration co variable minimum 600 evaluable subjects the study 94% power bonferroni adjustment achieve primary objective assuming dropout rate around 10% total 670 subjects 335 subjects group randomized ensure sufficient number evaluable subjects available inclusion atp cohort analysis immunogenicity secondary objectives included evaluation seroprotection seropositivity rates booster response safety analysis one month booster vaccination the primary analysis immunogenicity performed according protocol atp cohort comprising vaccinated subjects met eligibility criteria complied protocol defined procedures immunogenicity data available the analysis safety performed total vaccinated cohort tvc comprised study participants safety data available the safety results described 671 subjects enrolled current study 376 pontificia universidad catolica de chile santiago 93 hospital universitario de la uanl monterrey mexico 202 hospital general de ecatepec las americas estado de mexico mexico 335 received dtpa new 336 received dtpa previous included tvc one subject dtpa previous group eliminated atp cohort safety receiving vaccine forbidden protocol fourteen subjects eliminated atp cohort dtpa new group due non compliance blood sampling 8) missing serological data 6 16 eliminated atp cohort dtpa previous group due protocol violation 1 non compliance blood sampling 8) missing serological data 7 the atp cohort immunogenicity therefore included 321 319 subjects dtpa new dtpa previous groups respectively the mean age subjects atp cohort immunogenicity 11.9 years standard deviation 1.61 50.6% subjects hispanic origin 53.0% female booster vaccination 88.5% subjects groups seroprotected diphtheria 96.9% subjects groups seroprotected tetanus table 1 at least 54.7% seropositive pertussis antibodies booster dose groups table 1 table 1.seroprotection/seropositivity rates gmcs one month booster vaccination atp cohort immunogenicity)dtpa newdtpa previousantibodytimingnnseroprotection 95% ci)gmc(95% ci)nnseroprotection 95% ci)gmc(95% ci)anti diphtheriapre32128488.5 84.591.8)0.472 0.4030.553)31928689.7 85.892.8)0.456 0.3920.530)post32132099.7 98.3100)6.784 6.1787.450)319319100 98.9100)6.493 5.9157.128)anti tetanuspre32131196.9 94.398.5)0.956 0.8351.095)31931498.4 96.499.5)0.899 0.7891.026)post321321100 98.9100)18.937 17.31320.713)319319100 98.9100)18.515 16.85120.342)dtpa newdtpa previousantibodytimingnnseropositivity 95% ci)gmc(95% ci)nnseropositivity 95% ci)gmc 95% ci)anti ptpre32017554.7 49.160.2)7.5 6.68.7)31917554.9 49.260.4)7.2 6.38.2)post31831699.4 97.799.9)140.2 126.0156.1)31831599.1 97.399.8)125.9 112.7140.7)anti fhapre31631098.1 95.999.3)48.9 43.355.2)31531098.4 96.399.5)49.4 43.656.0)post319319100 98.9100)1080.2 995.21172.5)319319100 98.9100)1013.7 940.01093.2)anti prnpre32126983.8 79.387.7)14.0 12.315.9)31927285.3 80.989.0)13.4 11.915.0)post321321100 98.9100)652.4 572.1743.9)318318100 98.8100)619.2 546.0702.2)dtpa new subjects received boostrix new syringe presentation dtpa previous subjects received boostrix previous syringe presentation.n number subjects pre- post vaccination results available 95% ci 95% confidence interval diphtheria tetanus pt pertussis toxin fha filamentous hemagglutinin prn pertactin iu international unit el.u elisa unit gmc geometric mean concentration calculated subjects.*seroprotection anti diphtheria anti tetanus antibody concentration 0.1 iu ml.**seropositive anti pt anti fha anti prn antibodies 5 eu ml seroprotection seropositivity rates gmcs one month booster vaccination atp cohort immunogenicity dtpa new subjects received boostrix new syringe presentation dtpa previous subjects received boostrix previous syringe presentation number subjects pre- post vaccination results available 95% ci 95% confidence interval diphtheria tetanus pt pertussis toxin fha filamentous hemagglutinin prn pertactin iu international unit el.u elisa unit gmc geometric mean concentration calculated subjects seroprotection anti diphtheria anti tetanus antibody concentration 0.1 iu ml seropositive anti pt anti fha anti prn antibodies 5 eu ml one month booster vaccination 99.7% subjects groups seroprotected diphtheria antigens subjects seroprotected tetanus antigens 99.4% seropositive pertussis antigens table 1 uls 95% ci gmc ratios dtpa previous dtpa new antigens 1.5 table 2 non inferiority dtpa injected via new syringe presentation dtpa new previously used syringe presentation dtpa previous ) table 2.adjusted gmc ratios groups dtpa previous divided dtpa new one month booster vaccination atp cohort immunogenicity)dtpa previousdtpa newadjusted gmc ratio dtpa pre group/ dtpa new group)antibodynadjusted gmcnadjusted gmcvalue 95% ci)anti diphtheria3196.5213216.7650.96 0.851.09)anti tetanus31918.67232119.1710.97 0.861.10)anti pt318128.340317138.8320.92 0.821.04)anti fha3151013.1673141096.8270.92 0.831.03)anti prn318634.592321645.5040.98 0.851.13)dtpa new subjects received boostrix new syringe presentation dtpa previous subjects received boostrix previous syringe presentation.n number subjects pre- post vaccination results available 95% ci 95% confidence interval adjusted gmc ratio ancova model adjusted pre booster concentration number previous dt(p)/dt(pa doses 5 6 pooled variance lower limit ul upper limit.adjusted gmc geometric mean antibody concentration obtained ancova model adjusted pre booster concentration number previous dt(p)/dt(pa doses 5 6 adjusted gmc ratios groups dtpa previous divided dtpa new one month booster vaccination atp cohort immunogenicity dtpa new subjects received boostrix new syringe presentation dtpa previous subjects received boostrix previous syringe presentation number subjects pre- post vaccination results available 95% ci 95% confidence interval adjusted gmc ratio ancova model adjusted pre booster concentration number previous dt(p)/dt(pa doses 5 6 pooled variance lower limit ul upper limit adjusted gmc geometric mean antibody concentration obtained ancova model adjusted pre booster concentration number previous dt(p)/dt(pa doses 5 6 irrespective different syringe presentation used vaccine delivery robust immune responses observed booster response rates antigens ranged 79.0% 99.7% 2 study groups data shown 4-day post vaccination follow period 78.8% 83.0% subjects reported least one symptom dtpa new dtpa previous groups respectively injection site pain commonly reported solicited local symptom 71.8% 7.3% grade 3 75.4% 6.1% grade 3 subjects dtpa new dtpa previous groups respectively headache reported 26.7% 32.8% subjects fatigue reported 25.2% 26.1% subjects frequently reported solicited general symptoms dtpa new dtpa previous groups respectively fig 1 figure 1.incidence solicited local general symptoms reported 4-day post vaccination follow period total vaccinated cohort incidence solicited local general symptoms reported 4-day post vaccination follow period total vaccinated cohort 31-day post vaccination follow period least one unsolicited symptom reported 13.1% 2.4% grade 3 13.4% 2.7% grade 3 subjects dtpa new dtpa previous groups respectively one subject dtpa new group suffered accidental injury 13 days vaccination sae considered unrelated vaccination have distributed data file immunogenicity reactogenicity safety vaccine well established clinical trials routine practice across broad age range owing recent technical change boostrix syringe presentation study undertaken compare immunogenicity safety new previous syringe presentations differed nature compounds present tip caps plunger stoppers study the dtpa vaccine immunogenic regardless syringe presentation used administer vaccine the results consistent previous reports adolescents non inferiority new presentation compared old presentation demonstrated dtpa administered using new dtpa syringe presentation also well tolerated incidence nature adverse events similar irrespective syringe presentation comparable previous studies large swelling reactions associated repeated booster doses dtpa vaccines observed either study group due resurgence pertussis adolescents adults need maintain antibody levels pertussis beyond childhood booster vaccines although limited single blind design inconsistent vaccination history subjects received either 5 6 previous dt(p)/dt(pa vaccine doses demonstrated single dtpa booster dose highly immunogenic well tolerated healthy adolescents chile mexico irrespective syringe presentation employed conclusion clinical data study support technical data use new syringe presentation fm27 tip caps fm457 plunger stoppers deliver dtpa vaccine hhh sk gj kh yc al employees glaxosmithkline vaccines hhh gj kh al declare glaxosmithkline stocks ka received grants personal fees non financial support glaxosmithkline np r received research support glaxosmithkline glaxosmithkline vaccines involved stages study conduct analysis also took charge costs associated developing publishing manuscript

reduced - antigen - content diphtheria - tetanus - acellular pertussis ( dtpa ) vaccine , boostrix , is indicated for booster vaccination of children , adolescents and adults . the original prefilled disposable dtpa syringe presentation was recently replaced by another prefilled - syringe presentation with latex - free tip - caps and plunger - stoppers . 671 healthy adolescents aged 1015 years who had previously received 5 or 6 previous dt(p)/dt(pa ) vaccine doses , were randomized ( 1:1 ) to receive dtpa booster , injected using the new ( dtpa - new ) or previous syringe ( dtpa - previous ) presentations . immunogenicity was assessed before and 1-month post - booster vaccination ; safety / reactogenicity were assessed during 31-days post - vaccination . non - inferiority of dtpa - new versus dtpa - previous was demonstrated for all antigens ( uls 95% cis for gmc ratios ranged between 1.03 - 1.13 ) . 1-month post - booster , immune responses were in similar ranges for all antigens with both syringe presentations . dtpa delivered using either syringe presentation was well - tolerated . these clinical results complement the technical data and support the use of the new syringe presentation to deliver the dtpa vaccine .

identify possible barriers implementation pharmaceutical care among community hospital pharmacists enugu state using nsukka enugu metropolis case study the questionnaires distributed community hospital pharmacists designated areas one quarterly meeting practice sites 2009 eighty completed questionnaires collected 22.8% community pharmacists 77.2% hospital pharmacists the important barriers identified lack space enough personnel pharmacy handle routine technical tasks time need much effort need payment services the opinions barriers pharmaceutical care pharmacists community hospital practice areas two metropolises enugu state majorly lack time space routine technical task personnel

objective : to identify the possible barriers to the implementation of pharmaceutical care among community and hospital pharmacists in enugu state using nsukka and enugu metropolis as a case study.method:a semi structured questionnaire was designed to carry out a cross sectional descriptive study . the questionnaires were distributed to community and hospital pharmacists from designated areas during one of their quarterly meeting and their practice sites in 2009.results:eighty completed questionnaires were collected with 22.8% from community pharmacists , and 77.2% from hospital pharmacists . the important barriers identified were lack of space , enough personnel in pharmacy to handle routine technical tasks , time , need for too much effort , and need for payment for services.conclusion:the opinions on barriers to pharmaceutical care of pharmacists from community and hospital practice areas in these two metropolises of enugu state are majorly lack of time , space and routine technical task personnel .

retrospectively evaluated 128 consecutive young adults 40 years age undergone ccta evaluation 64-slice multidetector ct mdct screening test detecting cad general health evaluation january 2006 may 2008 we excluded 16 subjects chest pain discomfort n 15 history acute coronary syndrome n 1 none subjects excluded due nondiagnostic ccta image quality result 112 asymptomatic young adults 90 men 22 women finally enrolled the mean age study population 35.6 3.7 years range 28 40 years all subjects conventional coronary risk factors diabetes mellitus n 8) cigarette smoking n 54 hypertension n 36 obesity n 62 there 77 subjects low cad risk 27 moderate risk eight high risk a single oral dose 20 mg -blocker propranolol pranol daewoong korea administered one hour mdct patients heart rate 65 beats per minute bpm heart rate still greater 65 bpm additional 20 mg oral propranolol administered one hour administration first dose oral -blocker ccta performed patients heart rates 70 bpm repeated drug administration intermittent arrhythmia coronary vasodilatation achieved administering 0.6 mg nitroglycerin myung moon seoul korea sublingually ccta obtain maximum coronary artery opacification all examinations performed using 64-slice mdct somatom sensation 64 siemens medical solutions germany following scan parameters used tube voltage 120 kvp tube current 750 effective mas detector collimation 64 0.6 mm gantry rotation 370 msec pitch 0.24 a bolus 70 ml iopamidol 370 mg iodine per milliliter iopamiro 370 bracco milan italy injected intravenously antecubital vein flow rate 4 ml sec followed 40 50 ml saline chaser using bolus tracking technique the images initially reconstructed mid diastolic phase 60 70% rr interval cardiac cycle transferred computed workstation leonardo siemens medical solutions germany all scans retrospectively analyzed three dimensional workstation two radiologists 14 7 years experience chest ct respectively using multiplanar reformation technique maximum intensity projection technique volume rendering technique short axis two chamber four chamber views the coronary artery tree segmented according modified american heart association classification 15 segments segments subsequently investigated presence characteristics coronary plaques 6 the degree stenosis classified significant patient 75% area stenosis cross sectional images 50% diameter stenosis longitudinal images coronary plaques classified non calcified plaques without visible calcification mixed plaques non calcified calcified components calcified plaques completely calcified plaques according calcified component plaques seen ccta plaque densities 130 hu hounsfield unit native scans classified calcified fig changes coronary artery diameter measured determine remodeling index ri the maximum outer diameter lesion proximal reference site measured calculate ri i.e. ri maximum outer diameter plaque site maximum outer diameter reference vessel maximum outer diameter reference vessel positive remodeling defined ri 0 negative remodeling ri 0 the degree remodeling calculated percentage i.e. mean values standard deviations measurements vascular diameter obtained manually traced maximal diameters taken longitudinal source images fig all study related data including demographics symptoms medical histories laboratory results systemically acquired hospital database chart review the conventional coronary risk factors obesity cigarette smoking hypertension hypercholesterolemia diabetes mellitus assessed serum biomarkers homocysteine c reactive protein triglyceride measured the framingham risk scores used national cholesterol education program ncep guidelines also calculated 7 all subjects assigned one three different risk groups according revised ncep guidelines high risk group cad risk equivalents 10-year risk 20% moderate risk group two risk factors 10-year risk 20% low risk group 0 1 risk factors 112 subjects 109 underwent abdominal ultrasonography part general health evaluation within one week ccta presence absence fatty liver determined the degree fatty liver ultrasonography classified follows 1 mild minimal diffuse increase hepatic echogenicity normal visualization diaphragm intrahepatic vessel borders 2 moderate moderate diffuse increase hepatic echogenicity slightly impaired visualization intrahepatic vessels diaphragm 3 severe marked increase echogenicity poor visualization nonvisualization hepatic vessels diaphragm we also compared patients cad normal subjects respect coronary risk factors fatty liver the clinical follow data range 10 39 months obtained patients exhibited cad ccta based cardiac events treatment laboratory findings all statistical analyses performed using spss version 17.0 windows spss inc the differences categorical variables analyzed using chi square fisher exact tests differences continuous variables analyzed using unpaired student test mann whitney test appropriate we retrospectively evaluated 128 consecutive young adults 40 years age undergone ccta evaluation 64-slice multidetector ct mdct screening test detecting cad general health evaluation january 2006 may 2008 we excluded 16 subjects chest pain discomfort n 15 history acute coronary syndrome n 1 none subjects excluded due nondiagnostic ccta image quality result 112 asymptomatic young adults 90 men 22 women finally enrolled the mean age study population 35.6 3.7 years range 28 40 years all subjects conventional coronary risk factors diabetes mellitus n 8) cigarette smoking n 54 hypertension n 36 obesity n 62 there 77 subjects low cad risk 27 moderate risk eight high risk a single oral dose 20 mg -blocker propranolol pranol daewoong korea administered one hour mdct patients heart rate 65 beats per minute bpm heart rate still greater 65 bpm additional 20 mg oral propranolol administered one hour administration first dose oral -blocker ccta performed patients heart rates 70 bpm repeated drug administration intermittent arrhythmia coronary vasodilatation achieved administering 0.6 mg nitroglycerin myung moon seoul korea sublingually ccta obtain maximum coronary artery opacification all examinations performed using 64-slice mdct somatom sensation 64 siemens medical solutions germany following scan parameters used tube voltage 120 kvp tube current 750 effective mas detector collimation 64 0.6 mm gantry rotation 370 msec pitch 0.24 retrospective electrocardiogram ecg gating ecg gated dose modulation used a bolus 70 ml iopamidol 370 mg iodine per milliliter iopamiro 370 bracco milan italy injected intravenously antecubital vein flow rate 4 ml sec followed 40 50 ml saline chaser using bolus tracking technique the images initially reconstructed mid diastolic phase 60 70% rr interval cardiac cycle transferred computed workstation leonardo siemens medical solutions germany all scans retrospectively analyzed three dimensional workstation two radiologists 14 7 years experience chest ct respectively using multiplanar reformation technique maximum intensity projection technique volume rendering technique short axis two chamber four chamber views the coronary artery tree segmented according modified american heart association classification 15 segments segments subsequently investigated presence characteristics coronary plaques 6 the degree stenosis classified significant patient 75% area stenosis cross sectional images 50% diameter stenosis longitudinal images coronary plaques classified non calcified plaques without visible calcification mixed plaques non calcified calcified components calcified plaques completely calcified plaques according calcified component plaques seen ccta plaque densities 130 hu hounsfield unit native scans classified calcified fig 1 changes coronary artery diameter measured determine remodeling index ri the maximum outer diameter lesion proximal reference site measured calculate ri i.e. ri maximum outer diameter plaque site maximum outer diameter reference vessel maximum outer diameter reference vessel positive remodeling defined ri 0 negative remodeling ri 0 the degree remodeling calculated percentage i.e. mean values standard deviations measurements vascular diameter obtained manually traced maximal diameters taken longitudinal source images fig all study related data including demographics symptoms medical histories laboratory results systemically acquired hospital database chart review the conventional coronary risk factors obesity cigarette smoking hypertension hypercholesterolemia diabetes mellitus assessed serum biomarkers homocysteine c reactive protein triglyceride measured the framingham risk scores used national cholesterol education program ncep guidelines also calculated 7 all subjects assigned one three different risk groups according revised ncep guidelines high risk group cad risk equivalents 10-year risk 20% moderate risk group two risk factors 10-year risk 20% low risk group 0 1 risk factors 112 subjects 109 underwent abdominal ultrasonography part general health evaluation within one week ccta presence absence fatty liver determined the degree fatty liver ultrasonography classified follows 1 mild minimal diffuse increase hepatic echogenicity normal visualization diaphragm intrahepatic vessel borders 2 moderate moderate diffuse increase hepatic echogenicity slightly impaired visualization intrahepatic vessels diaphragm 3 severe marked increase echogenicity poor visualization nonvisualization hepatic vessels diaphragm we also compared patients cad normal subjects respect coronary risk factors fatty liver the clinical follow data range 10 39 months obtained patients exhibited cad ccta based cardiac events treatment laboratory findings all statistical analyses performed using spss version 17.0 windows spss inc the differences categorical variables analyzed using chi square fisher exact tests differences continuous variables analyzed using unpaired student test mann whitney test appropriate atheromatous plaques noted 15 segments 12 112 subjects 11% nine patients single vessel disease three two vessel disease there 11 men one woman age range 31 40 years mean age 36.8 2.6 years atheromatous plaques the patient population included four 77 subjects 5% low cad risk six 27 22% moderate risk two eight 25% high cad risk the prevalence cad significantly higher moderate cad risk group low risk group p 0.018 however significant difference moderate high risk groups p 0.604 fig the presence obesity hypertension hypercholesterolemia high triglycerides fatty liver significantly higher patients cad normal individuals there also tended higher incidence cigarette smoking high ldl low density lipoprotein cholesterol low hdl high density lipoprotein cholesterol diabetes mellitus high c reactive protein patients cad however statistical significance identified table 1 the location degree stenosis well type plaque shown table 2 the coronary plaques located left anterior descending lad n 11 73% left main lm n 4 27% arteries common location proximal lad n 9 60% fig the types plaque included non calcified n 4 27% mixed n 7 47% calcified n 4 27% the changes vascular diameter cad site measured four coronary segments noncalcified plaque seven mixed plaques this measure evaluated segments calcified plaques exact measurement vascular diameter unavailable due beam hardening blooming artifacts positive remodeling identified segments noncalcified mixed plaques degree positive remodeling tended higher patients noncalcified plaques mixed plaques table 3 however statistically significant difference two groups p 0.471 twelve patients cad free cardiac events 10 39 months ccta four five patients hypercholesterolemia started antihypercholesterolemic medication based results ccta showed improvement hypercholesterolemia follow tests early detection cad provides opportunity initiate interventions stabilize existing lesions including ldl lowering drug therapy statins smoking cessation intervention cigarette smokers blood pressure lowering persons hypertension lifestyle intervention physically inactive obese such interventions reduce risk developing acute coronary syndromes later life current approach managing asymptomatic individuals risk cad is based traditional clinical risk assessments framingham risk score ncep guidelines 7 however growing evidence traditional risk assessment tools based risk factor analysis substantial limitations used guide individual therapy 8 9 recently published study choi et al ( 10 cad evaluated using ccta 1,000 middle aged asymptomatic adults mean age 50 years cad noted 215 subjects 22% rate higher observed earlier studies 3 5% results confirmed coronary angiography asymptomatic individuals 11 13 date paucity data regarding prevalence atherosclerotic plaques detected ccta asymptomatic young adults largely asymptomatic young adults typically undergo medical evaluations cad study enrolled asymptomatic young adults i.e. 40 years age risk cad coronary plaques demonstrated 11% subjects prevalence cad significantly higher subjects moderate 22% high 25% risk subjects low risk 5% positive remodeling noted coronary segments exhibited noncalcified mixed plaques non significant stenosis this finding may indicate important cause underestimating cad coronary angiography may explain acute coronary syndrome young patients angiographically normal coronary arteries 14 16 positive remodeling occurs early stages coronary plaque development well known positive remodeling related plaque instability suggesting prone rupture erosion subsequent coronary events 17 19 nakamura et al 19 reported positive remodeling observed frequently patients acute coronary syndrome 78 82% patients stable cad 33 40% significantly higher degree positive remodeling noted patients acute myocardial infarction remodeling index 1.26 0.15 elderly patients unstable angina pectoris 1.11 0.10 stable angina pectoris 0.94 0.11 mean age 63 10 years tanaka et al 18 demonstrated lipid core plaques showed positive vascular remodeling contrast severely calcified plaques show positive remodeling furthermore well known angiographic studies myocardial infarctions occur sites previously caused mild moderate luminal stenosis 20 21 taken together studies demonstrate clinical significance importance early plaques mild stenosis choi et al 10 also reported 85% cad presented lad study plaques observed left circumflex artery peripheral branches coronary arteries diagonal branches this may resulted limited temporal resolution ccta would underestimate small branches coronary arteries may also result lower prevalence plaques segments patients early stage cad coronary calcium score intimately associated total plaque burden 22 strong predictor coronary events coronary calcium score independent traditional coronary risk factors risk factor scores 23 however sometimes fails predict acute coronary events significant stenosis significant numbers vulnerable plaques tend predominantly noncalcified nonstenotic lesions 20 the absence coronary calcification described 1% male patients significant coronary stenosis 24 4% patients suffering unheralded myocardial infarction 25 study 27% patients cad noncalcified plaques slightly higher 19% reported choi et al this may linked observation plaques young patients probably early stages less calcification older individuals therefore coronary calcium score may underestimate cad young adults greater degree older individuals obesity smoking hypertension hypercholesterolemia well known risk factors cad incidences significantly higher patients cad normal subjects study recent report fatty liver demonstrated associated risk cad early atherosclerosis middle aged individuals 26 current study able evaluate incidence fatty liver almost subjects underwent abdominal ultrasonography ccta part general health evaluation as also found fatty liver significantly prevalent patients cad 83% normal individuals 39% the study population small included koreans living urban areas subjects self referred therefore actual prevalence cad young asymptomatic subjects various ethnic groups geographic regions may differ results although evaluated relation ncep cad risk categories in conclusion prevalence occult cad negligible asymptomatic young adults prevalence cad significantly higher subjects moderate high risks low risk additionally patients single vessel disease plaques various composition non significant stenosis positive vascular remodeling one fourth patients non calcified plaques finally common location plaques proximal lad this study suggests importance management risk factor modification asymptomatic young adults moderate high risk cad

objectivewe aimed at evaluating the prevalence and ct characteristics of occult coronary artery disease ( cad ) in young korean adults under 40 years of age by performing coronary ct angiography ( ccta).materials and methodswe retrospectively enrolled 112 consecutive asymptomatic subjects ( 90 men , mean age : 35.6 3.7 years ) who underwent ccta as part of a general health evaluation . we classified the subjects into three national cholesterol education program risk categories and we assessed the plaque characteristics on ccta according to the number of involved vessels , the location and type of plaques and vascular remodeling.resultstwelve individuals had cad ( 11% , 11 men ) . the prevalence of cad was significantly higher in the subgroups with moderate ( 22% ) or high ( 25% ) risk than that in the low risk subgroup ( 5% ) ( p < 0.05 ) . nine patients had single - vessel disease and three patients had two - vessel disease . the most common location for plaque was the proximal left anterior descending coronary artery ( 60% ) . all the patients had non - significant stenosis and plaque , including the non - calcified ( 27% ) , mixed ( 47% ) and calcified ( 27% ) types . positive vascular remodeling was identified in all the patients with non - calcified or mixed plaques.conclusionthe prevalence of occult cad was not negligible in the asymptomatic young adults with moderate to high risk , and this suggests the importance of management and risk factor modification in this population . all the patients had non - significant stenosis , and one fourth of the plaques did not show calcification .

several risk factors contact lens wear trauma ocular surface disease ocular surgery systemic disease reported predispose patients corneal infections management microbial keratitis commonly involves obtaining corneal scrapings microbiological studies empiric broad spectrum treatment typically initiated culture results available appropriate empiric therapy selected practitioners basis epidemiological information predisposing factors spectrum causative organisms for example trauma common risk factor fungal keratitis developing agricultural countries whereas contact lens wear main risk factor bacterial keratitis developed countries thus essential establish related information microbial keratitis including patient specific risk factors likely causative organisms would facilitate development effective strategies prevention diagnosis treatment microbial keratitis taiwan study university hospital reported contact lens related pseudomonas keratitis common form microbial keratitis 1992 2001 conducting periodic surveys infectious keratitis crucial updating local information reference clinicians epidemiologic patterns may change time therefore present study collected data predisposing factors clinical manifestations spectrum microorganisms treatments patients microbial keratitis admitted treated chang gung memorial hospital cgmh major teaching hospital northern taiwan 2003 2012 this study conducted retrospective cross sectional design accordance declaration helsinki approved institutional research ethics board cgmh taiwan irb102 4073b consent waived retrospective design project anonymous analysis data we retrospectively reviewed medical records 558 patients infectious keratitis admitted cgmh january 1 2003 december 31 2012 we included patients negative culture results presented epithelial defect stromal infiltrate responded favorably antimicrobial treatment admission criteria primarily severe ie potentially sight threatening keratitis need intensive topical antimicrobials information age sex predisposing factors clinical features microbiological results treatments visual acuity recorded collected we defined ulcer central encroached within 2 mm fixation peripheral involved zone within 2 mm limbus paracentral central peripheral zone corneal ulcers defined small 2 mm medium 26 mm large 6 mm corneal scrapings obtained using surgical blade directly inoculated blood agar chocolate agar modified sabouraud agar lowenstein corneal scrapings patients clinical characteristics suggestive acanthamoeba keratitis inoculated nonnutrient agar seeded escherichia coli the various media routinely incubated week longer depending media final culture result obtained a positive culture defined growth least 3 colonies along line inoculation one solid medium basis criteria previous study result corneal ulcer culture could obtained levofloxacin 0.5% alone combination 2 fortified antibiotics 25 mg ml cefazolin 25 mg ml amikacin administered topically per hour topical natamycin amphotericin b 0.1% applied hourly mold yeast infection respectively topical polyhexamethylene biguanide 0.02% applied acanthamoeba keratitis data presentation arbitrarily divided study years 2 periods first half 2003 2007 second half 2008 2012 mantel haenszel linear linear association test used detect trends 10-year period categorical variables analyzed using test continuous variables analyzed using analysis variance anova simple linear regression univariate analysis used identify factors associated hospital stay all statistical analyses performed using spss software version 22 ibm armonk ny this study conducted retrospective cross sectional design accordance declaration helsinki approved institutional research ethics board cgmh taiwan irb102 4073b consent waived retrospective design project anonymous analysis data we retrospectively reviewed medical records 558 patients infectious keratitis admitted cgmh january 1 2003 december 31 2012 we included patients negative culture results presented epithelial defect stromal infiltrate responded favorably antimicrobial treatment admission criteria primarily severe ie potentially sight threatening keratitis need intensive topical antimicrobials information age sex predisposing factors clinical features microbiological results treatments visual acuity recorded collected we defined ulcer central encroached within 2 mm fixation peripheral involved zone within 2 mm limbus paracentral central peripheral zone corneal ulcers defined small 2 mm medium 26 mm large 6 mm corneal scrapings obtained using surgical blade directly inoculated blood agar chocolate agar modified sabouraud agar lowenstein corneal scrapings patients clinical characteristics suggestive acanthamoeba keratitis inoculated nonnutrient agar seeded escherichia coli the various media routinely incubated week longer depending media final culture result obtained a positive culture defined growth least 3 colonies along line inoculation one solid medium basis criteria previous study result corneal ulcer culture could obtained levofloxacin 0.5% alone combination 2 fortified antibiotics 25 mg ml cefazolin 25 mg ml amikacin administered topically per hour topical natamycin amphotericin b 0.1% applied hourly mold yeast infection respectively arbitrarily divided study years 2 periods first half 2003 2007 second half 2008 2012 mantel haenszel linear linear association test used detect trends 10-year period categorical variables analyzed using test continuous variables analyzed using analysis variance anova simple linear regression univariate analysis used identify factors associated hospital stay all statistical analyses performed using spss software version 22 ibm armonk ny during 10-year study period 558 patients included study 285 51.1% 273 48.9% male female respectively table 1 the mean age patients 50.3 22.7 years range 2100 yr the right eye involved 287 patients left eye involved 271 patients the corneal ulcer small 192 eyes 37.7% medium 267 eyes 52.5% large 50 eyes 9.8% the location corneal ulcer central 238 eyes 47.1% paracentral 206 eyes 40.8% peripheral 61 eyes 12.1% the presence hypopyon noted 153 eyes 33.8% except laterality trends demographics clinical features statistically significant demographics clinical features microbial keratitis risk factors microbial keratitis identified 426 patients 76.3% the common risk factor contact lens wear 31.4% followed systemic ocular diseases 26.3% trauma 23.5% previous ocular surgery 12.7% table 2 a total 54 patients 12.7% least 2 predisposing factors corneal ulcers materials causing ocular trauma included plant n 24 iron n 16 mud n 5 chemical n 4 wood n 3 unidentified sources n 48 lagophthalmos n 16 dry eye n 14 common ocular surface diseases the trend test showed 10-year study period proportion patients wearing contact lenses trauma increased p 0.011 p 0.035 respectively rate previous ocular surgery decreased p 0.027 predisposing factors microbial keratitis positive culture results obtained 353 patients 63.3% two hundred thirty eight 42.7% patients administered topical antibiotics referral 88 patients negative culture results regarding isolates 210 bacterial isolates 59.9% 62 fungal isolates 17.6% 8 nontuberculous mycobacteria ntm isolates 2.3% 2 acanthamoeba isolates 0.6% identified table 3 seventy one patients polymicrobial infections 20.1% among bacterial isolates gram negative bacteria 37.4% common gram positive bacteria 22.1% the commonly isolated bacterium pseudomonas aeruginosa 28% followed coagulase negative staphylococcus cns 5.4% staphylococcus aureus 4.5% the percentage serratia marcescens decreased significantly p 0.033 identified organisms change 10 years isolated organisms microbial keratitis table 4 lists isolated organisms patients different risk factors microbial keratitis gram negative bacteria particularly p. aeruginosa mainly accounted contact lens related keratitis 52.9% keratitis associated ocular systemic diseases mainly caused bacteria 33.8% 29.4% gram positive gram negative bacteria respectively risk factors versus isolated organisms microbial keratitis patients initially treated empiric antimicrobials adjusted basis clinical response results drug susceptibility test medical treatment successful patients gram positive bacterial infections 62.8% gram negative bacterial infections 78% ntm infections 75% acanthamoeba infections 100% polymicrobial infections 74.6% table 5 surgical procedures included amniotic membrane transplantation patch graft lamellar keratectomy penetrating keratoplasty evisceration one patient fungal keratitis 2 patients pseudomonal keratitis 3 patients polymicrobial infections underwent evisceration eradicate infections treatment microbial keratitis mean hospital stay 13.7 11.5 days longer hospital stay correlated previous steroid use ocular systemic diseases longer interval symptom presentation admission previous ocular surgery large ulcer size fungal infection ntm infection poor visual acuity presentation old age surgery admission p 0.05 simple linear regression multiple linear stepwise regression analysis 4 factors including previous ocular surgery large ulcer size ntm infection surgery admission associated longer hospital stays table 6 during 10-year study period 558 patients included study 285 51.1% 273 48.9% male female respectively table 1 the mean age patients 50.3 22.7 years range 2100 yr the right eye involved 287 patients left eye involved 271 patients the corneal ulcer small 192 eyes 37.7% medium 267 eyes 52.5% large 50 eyes 9.8% the location corneal ulcer central 238 eyes 47.1% paracentral 206 eyes 40.8% peripheral 61 eyes 12.1% the presence hypopyon noted 153 eyes 33.8% except laterality trends demographics clinical features statistically significant the common risk factor contact lens wear 31.4% followed systemic ocular diseases 26.3% trauma 23.5% previous ocular surgery 12.7% table 2 a total 54 patients 12.7% least 2 predisposing factors corneal ulcers materials causing ocular trauma included plant n 24 iron n 16 mud n 5 chemical n 4 wood n 3 unidentified sources n 48 lagophthalmos n 16 dry eye n 14 common ocular surface diseases the trend test showed 10-year study period proportion patients wearing contact lenses trauma increased p 0.011 p 0.035 respectively rate previous ocular surgery decreased p 0.027 two hundred thirty eight 42.7% patients administered topical antibiotics referral 88 patients negative culture results regarding isolates 210 bacterial isolates 59.9% 62 fungal isolates 17.6% 8 nontuberculous mycobacteria ntm isolates 2.3% 2 acanthamoeba isolates 0.6% identified table 3 seventy one patients polymicrobial infections 20.1% among bacterial isolates gram negative bacteria 37.4% common gram positive bacteria 22.1% the commonly isolated bacterium pseudomonas aeruginosa 28% followed coagulase negative staphylococcus cns 5.4% staphylococcus aureus 4.5% the percentage serratia marcescens decreased significantly p 0.033 identified organisms change 10 years isolated organisms microbial keratitis table 4 lists isolated organisms patients different risk factors microbial keratitis gram negative bacteria particularly p. aeruginosa mainly accounted contact lens related keratitis 52.9% keratitis associated ocular systemic diseases mainly caused bacteria 33.8% 29.4% gram positive gram negative bacteria respectively all patients initially treated empiric antimicrobials adjusted basis clinical response results drug susceptibility test medical treatment successful patients gram positive bacterial infections 62.8% gram negative bacterial infections 78% ntm infections 75% acanthamoeba infections 100% polymicrobial infections 74.6% table 5 surgical procedures included amniotic membrane transplantation patch graft lamellar keratectomy penetrating keratoplasty evisceration one patient fungal keratitis 2 patients pseudomonal keratitis 3 patients polymicrobial infections underwent evisceration eradicate infections treatment microbial keratitis mean hospital stay 13.7 11.5 days longer hospital stay correlated previous steroid use ocular systemic diseases longer interval symptom presentation admission previous ocular surgery large ulcer size fungal infection ntm infection poor visual acuity presentation old age surgery admission p 0.05 simple linear regression multiple linear stepwise regression analysis 4 factors including previous ocular surgery large ulcer size ntm infection surgery admission associated longer hospital stays table 6 severe infectious keratitis leading cause corneal blindness optimal clinical practice prevention treatment microbial keratitis account patient specific risk factors possible causative organisms different regions in study focused patients admitted microbial keratitis first ensured patients severe infection leading admission included study second used similar possible criteria used previous report conducted another university hospital northern taiwan 1992 2001 provide updated regional epidemiological information our findings showed contact lens wear remained leading risk factor inpatient microbial keratitis trend increased significantly 10-year study period p. aeruginosa common causative organism current study risk factors microbial keratitis 2003 2012 contact lens wear ocular systemic diseases trauma previous ocular surgery descending order similar results previous taiwanese report taiwan leading risk factor microbial keratitis still contact lens wear also reported united states western europe australia hong kong rattanatam et al found number patients contact lens related microbial keratitis decreased hospital suggesting higher number patients treated community introduction fluoroquinolones by contrast study demonstrated increasing trend rate contact lens related microbial keratitis hospital 10-year study period p 0.011 prospective population based study contact lens related microbial keratitis australia risk factors infections included overnight use poor storage case hygiene smoking internet purchase contact lenses less 6 months wear experience higher socioeconomic class however new lens types reduce incidence infection because retrospective design study difficult correlate contact lens wearing modalities hygiene factors infections however approximately 35.8% patients overnight use study wearing contact lenses popular taiwan country high prevalence refractive errors contact lens related microbial keratitis become public health concern 2012 corneal health care network advocate 3 c contact lens wearers consulting physician fit contact lenses correctly correct cleaning maintaining contact lens care receiving regular health check ups check this campaign anticipated facilitate decreases rate contact lens related microbial keratitis taiwan study the common causative organisms bacteria followed fungi gram negative bacteria common gram positive bacteria p. aeruginosa commonly identified isolate the spectrum microorganisms accounting microbial keratitis differ depending geographic location climate etiology for example gram positive bacteria predominant temperate climate regions whereas gram negative bacteria fungi prevalent tropical regions;pseudomonas species associated contact lens related infections whereas fungi related trauma caused plants the predominance p. aeruginosa infection taiwanese studies may reflect geographic prevalence microorganism contact lens related keratitis fungi also crucial causative organisms microbial keratitis taiwan similarly might due geography climate injury caused plant materials notably 4 5 previous studies europe taiwan investigating microbiological findings hospitalized patients microbial keratitis reported gram negative bacteria common causative organism this finding might suggest microbial keratitis caused gram negative bacteria particularly pseudomonas species tends severe progresses rapidly thus requiring admission current study medical treatment successful 69.5% patients half patients fungal keratitis required additional surgical interventions control infections medical treatment fungal keratitis particularly deep seated infections often unsatisfactory delayed diagnosis inadequate drug penetration slow response therapy surgical intervention remove infectious elements necrotic tissue may increase drug penetration shorten clinical course however therapeutic corneal transplantation even destructive surgery may indicated severe keratitis poor response medical therapy severe complications supervene long hospital stay also effects financial resources staffing turnover rate beds public health service study the mean hospital stay 13.7 days longer hospital stays associated previous ocular surgery large ulcer size ntm infection surgery admission a study hospitalized patients infectious keratitis new zealand reported longer hospital stay associated presence hypopyon larger ulcers previous ocular surgery poor visual acuity as expected large ulcers surgery admission prolonged hospital stay older age longer duration symptom onset diagnosis were noted patients previous ocular surgery data shown might explain relationship longer hospital stay previous ocular surgery ntm relatively slow growth rate infection mimic caused pathogens thus delay diagnosis treatment ntm infections might prolong hospital stay morbidities caused microbial keratitis assessed basis surgical intervention hospital stay visual loss study analyze predictors poor visual outcome microbial keratitis visual assessments variable follow intervals however study new zealand reported longer hospital stays associated poor visual acuity presentation final assessment we included cases positive negative culture results could exclude possibility cultured isolates contaminated because patients admitted tertiary referral hospital taiwan results generalized conclusion p. aeruginosa common causative organism contact lens wear common risk factor microbial keratitis significant increase percentage contact lens related keratitis 10-year study period taiwan the majority patients microbial keratitis cured medical treatment high proportion patients fungal keratitis required surgical interventions microbial keratitis potential cause devastating visual impairment major costs public health system findings provide updated information facilitate future prevention treatment microbial keratitis taiwan

abstractwe conducted a retrospective , cross - sectional study to analyze predisposing factors , clinical features , and microbiological characteristics of patients with microbial keratitis hospitalized over 10 years.the medical records of 558 patients who were diagnosed with microbial keratitis and admitted to chang gung memorial hospital ( cgmh ) , a referral center in taiwan , from january 1 , 2003 to december 31 , 2012 were reviewed . demographics , predisposing factors , isolated organisms , treatment , and hospital stay were recorded . yearly trends were tested using a linear - by - linear association.contact lens wear was the most common predisposing factor ( 31.4% ) , followed by ocular and systemic diseases ( 26.3% ) and trauma ( 23.5% ) . contact lens - related infectious keratitis increased year by year ( p = 0.011 ) . pseudomonas aeruginosa was the most commonly isolated organism ( 28% ) , followed by fungi ( 17.6% ) and coagulase - negative staphylococcus ( 5.4% ) . except for serratia marcescens , the identified organisms did not change over 10 years . most bacterial infections were controlled using antimicrobial treatment , but more than half of patients with fungal keratitis required surgical interventions . the mean hospital stay was 13.7 11.5 days . previous ocular surgery , large ulcer size , nontuberculous myycobacteris infection , and surgery during admission were related to prolonged hospital stay.in taiwan , contact lens - related pseudomonal keratitis remained the most common cause of microbial keratitis in patients hospitalized from 2003 to 2012 .

human rights act 1977 followed privacy act 1982 first legislative acts protect personal information across canadian public sector peekhaus 2008 1987 time hiv epidemic gaining momentum across canada freedom information protection privacy act first legislation outline principles conscientious cautious handling phi institutions responsible adhere cavoukian 1990 what followed legislation extended protection personal information private sector canada 2001 personal information protection electronic documents act pipeda came effect canadian hiv aids legal network 2004 peekhaus 2008 since 1997 provinces adopted privacy legislation specifically applies healthcare providers regardless whether engaged commercial activities peekhaus 2008 currently nine provinces specific laws protect phi impose obligations healthcare providers protect information canadian hiv aids legal network 2014 the personal health information protection act phipa enacted 2004 governs collection use disclosure phi within ontario health sector aims keep phi confidential secure allowing effective delivery healthcare effective operation healthcare system beardwood kerr 2004 2005 cavoukian 2008 oipc n.d phi broadly defined phipa identifying information individual oral recorded form could used identify specific individual example physical and/or mental health individual including health history individual family provision healthcare individual payments eligibility healthcare individual health number beardwood kerr 2004 hiv status included definition canadian hiv aids legal network 2004 phipa persons organizations provide healthcare collectively known health information custodians hics oipc n.d peekhaus 2008 custody control personal health information connection performing duties work ( beardwood kerr 2004 63 whether individuals hics agents hic obligation abide phipa ensure security confidentiality accuracy integrity phi custody fletcher 2014 peekhaus 2008 phipa requires hics take reasonable steps ensure phi protected theft loss unauthorized use disclosure regardless type records used beardwood kerr 2005 cavoukian rossos 2009 consent disclosure circle care key constructs outlined phipa important implications activities decision making hics regard phi hics may imply consent collection use disclosure phi delivery healthcare services cavoukian 2008 example consent implied patient accepts referral shows care fletcher 2014 regard disclosure phipa phi may disclosed hics individual consents phipa specifically permits disclosure without consent oipc n.d phipa specifically designed would prevent barrier disclosure personal health information among healthcare providers , hics permitted disclose phi purposes providing assisting providing care basis implied assumed implied consent canadian hiv aids legal network 2014 cavoukian rossos 2009 a patient express consent verbal written consent required share information within circle care healthcare providers canadian hiv aids legal network 2014 time phipa permits disclosure phi without implied consent number vague unspecified circumstances including providing healthcare individual healthcare provider facility managing risks error beardwood kerr 2004 planning management health system analysis health system etc the assumption implied consent longer true however hic aware individual wishes withhold withdraw consent furthermore phi disclosed non hic outside circle care purposes delivery healthcare express consent required beardwood kerr 2004 cavoukian 2008 implied consent disclosure within circle care purposes providing assisting provision healthcare arguably significant provision phipa yet buried sub section legislation beardwood kerr 2004 65 permitting disclosure phi variety circumstances broad purposes providing healthcare vis vis focus implied consent means hics need use little effort comply requirements phipa ( beardwood kerr 2004 67 therefore essential people use health services trust privacy protected time delivery high quality healthcare depends availability accurate complete health information phipa attempts strike balance protecting privacy facilitating care delivery fletcher 2014 although identifying information oral form falls category phi beardwood kerr 2004 appears sharing information verbally amongst hics non hics central focus phipa explicitly mentioned legislation compared forms information sharing practices instead phipa focuses health records particular paper electronic records cavoukian rossos 2009 furthermore phipa lend information currently exchanged healthcare institutions advent new technologies increasing use e mail digital interfaces facilitate communication amongst hics fletcher 2014 although healthcare providers may mention hiv status process delivering care patient may result disclosure phi non hic someone outside circle care example hospital visitors healthcare providers may use hiv status label reminder and/or communication tool within healthcare team prevent risks error process delivering care beardwood kerr 2004 employing hiv way may help providing care ensure appropriate checks balances within woman care plan gagnon 2014 2015 healthcare providers may also assume hospital visitors aware one hiv status especially patient explicitly discuss importance keeping private regardless whether patient articulates safe disclose hiv status point hiv status disclosed without person express consent attempt strike balance maintaining privacy delivering high quality healthcare achieved what mechanisms place service users take action event privacy breached ? how would management institution care provided respond situation take reasonable steps right wrong ? there many consequences privacy respected including reputational consequences changes therapeutic relationships healthcare providers fletcher 2014 most privacy breaches avoidable even conducted well intentioned healthcare providers regardless intention behind behaviour effect consequences fletcher 2014 hics willfully collect use disclose phi contravention phipa found liable beardwood kerr 2005 provincial level enforcement phipa individuals one year file complaint concerning breach privacy phipa canadian hiv aids legal network 2012 enforcement involves adversarial system whereby commissioner viewed impartial adjudicator discretion determine course action including initiating review ordering hic modify cease implement particular information practice beardwood kerr 2005 patients choice withdraw consent use disclosure phi healthcare providers deliver care details would achieved well hic would monitor patient consent unclear how policies practices align phipa disseminated interpreted enforced hic agents especially within fast paced overburdened healthcare system presents whole different set challenges the bottom line healthcare institutions implicated phipa optimal job keep phi private patients encouraged stand assert rights privacy canadian hiv aids legal network 2014 fletcher 2014 realistic expectation outcome ? although disclosure phi often occurs well intentioned healthcare providers wlwh believe serious repercussions call healthcare providers disclosed hiv status account inappropriate behaviour ion et al many wlwh experience disclosure phi report actions healthcare providers is something unique hiv positions wlwh particular way hospital ? early hiv epidemic virtually privacy protection living hiv fear ignorance aids hysteria within healthcare system despite significant advances clinical management hiv evolution complex chronic illness scandlyn 2000 thompson et al 2010 wlwh around world continue face number health social legal challenges including access hiv treatment hiv related stigma discrimination criminalization hiv debruyn 2004 greene et al wlwh continue report stigmatizing interactions healthcare providers example treated differently labour delivery unit hiv status societal perception wlwh children greene et al the current experiences wlwh may reflect long enduring history fear ignorance hiv within healthcare system women experiences may also reflect enduring lack knowledge awareness hiv amongst healthcare providers work settings specialize hiv care it critical consider legislative frameworks pertaining privacy lens hiv hiv classified phi particularly sensitive cavoukian 1990 gostin 1995 it also apparent healthcare practices within non hiv specific services kept pace evolution hiv chronic condition it clear wlwh continue perceive hiv related stigma access care particular pregnancy early postpartum well climate fear ignorance stigma continues surround hiv epidemic across canada canadian hiv aids legal network 2004 although patients every right hold hics accountable expecting health service users stand rights always optimal possible especially ill hospital comfortable speaking feel powerless fletcher 2014 greene et al 2015 ion elston 2015 ion et al moreover healthcare providers trainees may truly understand accountability duty confidentiality requirements canadian hiv aids legal network 2004 power dynamics may play wlwh healthcare providers within healthcare system the choice wlwh respond hold healthcare providers accountable disclosing hiv status sheds light power dynamics may flourish within healthcare systems may always position patient centre care furthermore expecting patients express privacy complaints individual healthcare providers channel complaints upper echelons healthcare corporation well provincial body like office information privacy commissioner tall order although hics may optimal job protect privacy patients fletcher 2014 expecting patients advocate privacy concerns arise submit complaints adversarial system disclosure occurred may perfect solution could healthcare system organized differently decrease chance privacy breach facilitate appropriate collection use disclosure phi including hiv status ? a number steps taken optimize information practices ensure phi wlwh protected remains confidential these steps relevant wlwh people living hiv plwh patients experience challenges related privacy confidentiality navigating healthcare system any system changes must first grounded perspective matter public policy right privacy fundamental human right plwh canadian hiv aids legal network 2004 privacy essential freedom revolves around personal control freedom choice cavoukian 2014 it must also recognized plwh right privacy regarding phi hics owe duty plwh keep phi confidential canadian hiv aids legal network 2004 confidentiality phi fundamental preservation ethical values autonomy dignity respect individual patient confidentiality essential pre condition successful treatment issue human dignity respect the concept privacy design pbd offers framework ensuring privacy embedded directly design specifications information technologies business practices operational processes cavoukian 2014 pbd emphasizes service user privacy need embed privacy default condition transforming service user privacy issues pure policy compliance issue business imperative cavoukian 2014 13 pbd focused process rather singular technical outcomes recognizes need introduce privacy principles architecture planning system design including networked infrastructure development operational procedures including work processes management structures cavoukian 2014 scholars suggested number recommendations macro- meso- microlevels policy practice regarding information practices could optimized ensure appropriate collection use disclosure phi macro level legislation the canadian hiv aids legal network taken issue discretionary disclosure clauses inherent health privacy legislation noting clauses fail provide level privacy protection accorded health information canadian charter rights freedoms canadian hiv aids legal network 2004 as canadian hiv aids legal network 2004 recommends exceptional circumscribed situations hic permitted disclose health information without express informed consent plwh rather vague unspecified circumstances currently permitted the legal network also recommends hics prohibited disclosing information may reasonably reveal person health information family friends without person consent canadian hiv aids legal network 2004 meso level systems buffet kosa 2006 ) have investigated hics ensure patient preferences regarding disclosure phi acted upon the authors note heath information network providers example digital interfaces used facilitate communication hics agents bear responsibility tracking monitoring patient consent buffet kosa 2006 the authors propose systematic consent management program believe minimize eliminate risk hic health information network provider buffet kosa 2006 the consent management system relies utilities assigns valuation patient attitudes regard handling phi the utilities applied part risk based consent management framework could updated reviewed time patient records accessed time hic performs action involves patient phi analysis would conducted help hic determine whether proceed based patient valuations likelihood patient preferences would violated process buffet kosa 2006 the system consent risk management would assist hics meet legal obligations phipa managing patient consent releasing phi scholars also highlighted training professional development initiatives healthcare providers learners important domains pbd framework could enacted for example privacy may small portion orientation modules trainees expected complete modules may present privacy theoretical terms lack practical applied elements fletcher 2014 training programs could redesigned better prepare orient healthcare providers learners privacy protection duty confidentiality concrete examples privacy breaches could included way apply knowledge practice including nuances privacy context hiv chronic and/or stigmatizing health conditions fletcher 2014 health professional licensing bodies also need educate members legal ethical obligations regarding privacy confidentiality for example discretionary disclosure clauses permit disclosure phi privacy legislation mean disclosure necessary valuable provision care canadian hiv aids legal network 2004 regulatory bodies could make protection phi performance metric meeting licensing requirements enhancing education training resources healthcare providers within regulatory licensing bodies well healthcare corporations could result important meso- macro level changes the canadian hiv aids legal network 2004 offered recommendations regarding healthcare system legislative regulatory structures could better organized protect privacy plwh the legal network believes meso level remedies currently place plwh whose privacy rights violated could improved the current adversarial system ontario example investigates complaints brought forward service users could made accessible vis vis increasing modes people could file complaint audio videotape addition written form eliminating fees associated filing complaint canadian hiv aids legal network 2004 accessibility could also enhanced increasing public awareness system improving transparency example privacy commission ontario could develop education programs inform public existence rights privacy legislation including information complaint process remedies canadian hiv aids legal network 2004 the legal network 2004 believes remedies currently available plwh whose privacy rights violated also strengthened example system deterrents implemented hics improperly use disclose phi including increased enforcement compensation patients micro level patient provider legal network 2014a ) reminds us healthcare providers ask questions relevant providing care example need ask hiv status information required examine treat someone plwh often remarked asked acquired hiv routine clinical encounter telling stories always outraged annoyed healthcare providers often never met driven curiosity delivering high quality patient centred care asking relevant questions healthcare encounter incredibly important plwh highlights one nuanced ways sensitivity hiv considered practice prioritizes person privacy healthcare providers confidential one one conversation patients advance plan maintain privacy respect confidentiality co created agreed how get especially considering policies current political climate considered within micro space marginal incremental objectives continually building current situation lindblom 1959 time healthcare decisions also influenced economic social environmental political forces policy makers governments make decisions based public opinion electoral considerations personal preferences crisis management fafard 2008 luckily pbd received global acceptance endorsement public private sector privacy regulators around world cavoukian 2014 also number scholars spoken highlight public opinion regarding governments handle phi peekhaus 2008 hiv framed health information particularly sensitive canadian hiv aids legal network 2004 2012 2014 issues privacy hiv related stigma complicate access care result negative care experiences plwh carter et al forthcoming mccoy 2005 ohtn 2010 wong wylie jevne 1997 result community champions social workers researchers activists legal experts working hiv sector well concerned privacy protection broadly positioned sufficient ammunition enable paradigm shift the time ensure policy practice decisions affect privacy micro- meso- macro levels government agenda least informed evidence fafard 2008 grounded lived experiences current realities service users

in the process of receiving perinatal care , women living with hiv ( wlwh ) in canada have experienced disclosure of their hiv status without their express consent . this disclosure often occurs by well - intentioned healthcare providers ; however , from the perspective of wlwh , it is a breach of confidentiality and leaves wlwh to manage the consequences . this paper is a critical review of the regulatory and legislative infrastructure that exists to protect the personal health information of wlwh in ontario and canada ; the recourse that wlwh have in the event that their confidentiality is breached ; and potential approaches that could be applied to organize the system differently to decrease the chance of a privacy breach and to facilitate appropriate collection , use and disclosure of personal health information .

2005 cardiovascular disease cvd underlying cause death 864,480 approximately 2.5 million total deaths united states 1 2 cvd leading cause death costly disease america expected increase costs 1.48 trillion 2030 although focus reduce modifiable risk factors cardiovascular disease lipid levels diabetes sedentary lifestyle unmodifiable risk factor aging major risk factor coronary disease hypertension congestive heart failure stroke the number aged united states projected increase 20% year 2030 this growth elderly population expected significantly test already overloaded health care system although years research conducted regard aging still long way understanding intricacies age related changes human physiology particular cardiovascular system whether aging animal models mimics many cardiovascular changes seen humans well understood in addition process delineating effect gender aging provides yet another variable considered aging believed progressive disorder decreases organism ability maintain reproductive capacity normostasis indeed strong correlation exists aging higher incidence several diseases including dementia parkinson disease diabetes cancer alzheimer disease cardiovascular system aging positively correlated increasing risk cardiac problems including arrhythmias major independent risk factor cardiovascular related morbidity mortality indeed 70% males females 75 years age present clinically evident cardiovascular disease cvd cvd number one killer women western nations among women 200,000 454,613 total cvd deaths occurred 85 years age although cardiovascular risk increases age sexes increase age associated risk appears sharper women why cvd risk may differ men women well understood may related differences age associated cardiovascular function whereas congestive heart failure men oftentimes due systolic insufficiencies congestive heart failure women often related diastolic dysfunction 10 11 the incidences ischemia cardiac failure cardiac rupture addition ventricular remodeling also shown differ genders aging often lead worse outcomes women 1215 recent data suggests premenopausal women decreased risk cvd compared men comparable age 16 17 this cardioprotective benefit appears lost time risk developing cardiovascular disease postmenopausal women increases rate similar observed men the reason(s increase cvd risk following menopause currently unclear however well known early menopause associated increased risk coronary heart disease cardiovascular disease death 1921 this finding thought related least part diminished estrogen exposure consistent notion year increasing age natural menopause found associated 2% increase total cardiovascular mortality 22 23 whether differences estrogen alone changes estrogen along factors fully explain sex related differences age related cardiovascular function unknown requires investigation human aging research limited due cost differences lifestyle history importantly time required data collection well analysis particular system importantly number different animal models used acquire information aging affects female cardiovascular system primates closest regard female human aging due fact species undergo menstrual sloughing endometrial lining nonetheless important note female primates experience menopause rats widely used aging research exhibit relatively short lifespan genetically quite homogenous among various strains rats wistar f344 f344/brown norway are although rats experience menses experience estrus cycling ovarian aging table 1 presents stages ovarian aging female rats reproductive maturity reached five months estrous cycle lasts four five days aging rats exhibit periods persistent estrous cycle consists elevated constant levels estradiol low levels progesterone lack luteinizing hormone lh surges addition ovulation 24 31 32 ovarian decline occurs six eighteen months depending rodent strain characterized low levels estradiol progesterone little developing follicles increased prolactin secretion 24 31 32 comparisons aging research female rats models humans complicated due differences mechanisms ovarian hormone aging human females potential impact cardiovascular disease though fully understood thought loss hormones estrogen progesterone aging human females due decrease ovarian follicular reserve conversely aging female rats experience persistent estrous cycle due chronic anovulation consist pseudopregnant disestrus estrogen levels well high progesterone levels increased ovulation corpora lutea therefore reproductive senescence female rats consists alterations hypothalamic pituitary axis reproductive senescence human females classified ovarian follicle depletion due reasons others although estrogen secretion ovary promotes hypothalamic changes chronic administration estrogen damage neurons arcuate nucleus medial basal hypothalamus therefore important remember surgical removal ovaries lead neurological changes may affect organs aging process pharmacological acceleration ovarian aging using 4-vinylcyclohexene diepoxide vcd accelerated ovarian failure aof model ovariectomy ovx procedures often performed due lack natural menopause rat research models believed better mimic hormone milieu seen aging human females vcd shown target plasma membrane primordial primary follicles direct inhibition autophosphorylation oocyte associated receptor kit kit acts antiapoptotic factor primordial follicular survival 36 37 although effective model chemical ovotoxicity limited research performed using female rat models 3841 date published data exist regarding vcd rat cardiovascular aging vcd juvenile 1 month adult 3 months sprague dawley rats depleted follicles effect duration onset persistent estrus however fsh levels significantly high vcd treated animals change cyclicity serum levels 17-estradiol the absence human based clinical menopausal hormone profile aof model brings question ability apply data derived model translational relevant treatment cardiovascular human based menopausal pathologies an ovariectomy removal ovaries induces surgical menopause characterized cessation estrogen progesterone well reduced production testosterone surgical menopause leads severe sudden symptoms compared observed natural human menopause ovaries produce lower levels hormones time like that seen menopausal human females ovariectomy rats also increases cardiovascular risk 42 43 studies found majority human females undergo natural menopause exhibit different age associated cardiovascular alterations underwent ovariectomy induced menopause elective bilateral removal ovaries young age associated increased risk cardiovascular disease premature death in addition declines well sexual function thought elective oophorectomies also associated elevated risk cognitive impairment dementia parkinsonism it known whether increased risk cardiovascular disease due alterations hormones hypothalamic pituitary axis as expected bilateral oophorectomy associated different hormonal alterations including changes estrogen production reduced levels progesterone testosterone well increases gonadotropins lh follicle stimulating hormone fsh compared occur human females experience natural menopause 45 46 rats ovariectomy causes alterations heart structure function include increases cardiac interstitial space cardiac fibrosis heart weight left ventricular weight ovariectomized rats appear exhibit increased evidence oxidative stress cardiac apoptosis 4751 rats cytokine expression tumor necrosis factor alpha tnf- interleukin-1 beta il-1 angiotensin converting enzyme ace angiotensin ii type 1 receptor gene expression also appear increased following ovariectomy 48 50 when estradiol treatment given ovariectomized rats prevented reduction cardiac contractility well increase apoptosis cytokine expression 48 51 research rats namely aging female dahl salt sensitive rats shown female rats likely develop hypertension ovariectomy the researchers postulated estrogen protects increased activity renin angiotensin system however human females research shown postmenopausal hypertension occurs approximately five 10 years menopause immediately starting menopause therefore age related causes must occur independently estrogen loss promotes cvd postmenopausal human females shown fact estrogen replacement therapy cardioprotective menopause 53 54 interestingly natural surgically induced reproductive senescence rats exhibit increased fsh well decreased levels estradiol inhibin b surgically induced reproductive senescence rats also shown alter dopamine receptor affinity heart alterations cardiac structure function alterations found ovariectomy compared aged controls human females underwent prophylactic bilateral salpingo oophorectomy exhibit increased total low density lipoprotein cholesterol levels light fact within human females natural menopause ovariectomy results altered hormonal profiles cardiovascular risk data suggest age associated cardiovascular disease human females may associated time dependent hormone deprivation age associated changes structure function protein signaling note fact studies used ovariectomized female rats young ages 612 weeks old examine effects hormone deprivation cardiovascular system lead unreliable results given cardiovascular system yet aged . increased risk cvd human females may due differences type magnitude age associated alterations cardiac structure function olivetti colleagues demonstrated small decrease human heart weight aging males females additionally significant change noted myocardium left ventricular right ventricular free wall weight aging human female heart underlying cardiovascular pathology age associated changes detected proportion shapes size number mononucleated binucleated cardiac myocytes given information appears natural aging human females associated cardiac remodeling menopause absence preexisting pathologies loading abnormalities although limited number studies looked cardiac structure function change age female rats directly investigated sex may affect cardiac structure function go demonstrated cardiovascular aging male female rats demonstrated significant gender differences lv size function boluyt colleagues investigated aging may affect cardiac structure function female f344 rats using echocardiography aging female rat cardiac structural changes included dilatation left ventricle 13 22 months age this dilatation characterized increases posterior septal wall thickness diastole 22 30 months age aging female f344 also associated increases collagen content collagen cross linking addition boluyt colleagues demonstrated mild systolic dysfunction decline left ventricle ejection fraction fractional shortening velocity circumferential fiber shortening female 22-month old animals compared young adults changes preceded development mild diastolic dysfunction 61 63 these authors suggested modest decline systolic function due least part shift amount alpha beta myosin heavy chains 61 62 similar seen human failing heart additional work perhaps using rat models needed order truly distinguish alterations due increasing age simply specific f344 strain fannin colleagues found increased age female f344xbn associated increases oxidative stress damage age related changes cardiac structure also found increase heart body weight ratio cardiomyocyte cross sectional area posterior wall thickening left ventricle chamber dilatation further increased age also associated diastolic dysfunction alterations heart rhythm intervals alternations connexin 43 expression the presence age associated cardiac structural changes f344 f344xbn animal models calls question use strains translational data light absence age associated change human females reported olivetti et al additionally menstrual cycle induced hormonal changes shown cause cardiac functional fluctuations this fact could indicate time functional measurements taken may impact results must consideration comparing female derived cardiac functional data in addition aging also associated increase percentage incidence atrial fibrillation 60 69 male rats age associated increases cardiac fibrosis well changes gap junction morphology have hypothesized cause changes cardiac conduction addition incidence arrhythmias death 68 70 humans age increase ekg abnormalities associated increased mortality men tend experience atrial fibrillation early repolarizations brugada syndromes sudden cardiac death women women likely risk develop long qt syndrome based arrhythmias well bradycardia induced torsades de pointes although sex related differences cardiac electrocardiogram parameters observed electrocardiogram abnormalities seem vary studies men increase qrs duration sinus cycle length women tended higher maximum heart rate 73 74 electrocardiogram analysis elderly men women demonstrated large intermediate q waves left axis deviation negative waves complete right bundle branch block well atrial fibrillation flutter aging men qrs complex found narrowed aged men women shown undergo leftward shift qrs axis another work suggested puberty men associated shortened qt interval present women aging men demonstrates increase pr intervals prolongation qt interval conversely another research found aging appear alter ekg tracings either men women similar alterations electrocardiogram parameters also found aging rats male wistar rats pr corrected qt intervals alterations aging electrocardiogram parameters shown rat strain dependent could detected subsequently heart failure male shhf mcc cp rat strain 19 months age though fully understood differences gender associated gonadectomy induced arrhythmia frequency attributed higher heart rates male animals longer qt intervals well gender differences ion channel expression fannin colleagues found arrhythmias significantly higher older female f344xbn rats compared younger rats however study find valvular dysfunction increased older rats compared younger ones the exact mechanisms gender associated reduction arrhythmias humans role estrogen may play fully understood two potential indirect mechanisms proposed one potential indirect mechanism may related ability estradiol reduce incidence cardiac ischemia other works suggested high levels estradiol female male rats may directly reduce arrhythmias possibly causing slowing inward calcium current 80 81 although multiple studies investigated ekg changes aging rats parameters determined nia approved aging f344xbn rat model however according ich s7b use rats safety testing drugs considered appropriate due differences ionic mechanisms repolarization arrhythmia mechanisms resting heart rate ca homeostasis action potential configuration important differences limit translational relevance rat generated cardiovascular data human application aging male rat heart is associated accumulation oxidative damage lipids proteins well decline mitochondrial enzymes in addition increasing number mutations mitochondrial dna mtdna gradually observed aging the level 8-ohdg mtdna adducts deletions increase exponentially age human muscle liver brain tissue complex iv mitochondrial oxidative phosphorylation this decline function correlated accumulation mtdna mutations including deletions base substitutions similarly aged male rat hearts exhibit increase superoxide 4-hydroxynonenal 4-hne nitrosative stress levels appear highly correlated increases left ventricular thickness the exact role increased levels oxidative stress may play development progression age associated cardiovascular disease remains determined compared observed females hearts aging male rats exhibited increases protein carbonylation advanced oxidation protein products nitrotyrosine nonprotein thiol reduced glutathione iron levels although aging associated increases oxidative stress male female rat hearts female rat hearts exhibited lower mitochondrial hydrogen peroxide production oxidative damage greater mitochondria differentiation compared seen male animals it thought higher mitochondrial differentiation metabolic adaptation increase energy efficiency associated lower mitochondrial free radical production oxidative damage in addition differences sex also likely reactive oxygen species ros levels vary animal strain female wistar f344 rats exhibit lower ros production indices oxidative damage seen female sprague dawley rats may help explain greater mean lifespan 91 92 the mitogen activated protein kinase mapk cascades evolutionary conserved serine threonine protein kinases regulate several important cellular functions including proliferation differentiation development cell cycle cell death the major mapk signaling pathways extracellular signal regulated protein kinase cascade p44/42 c jun amino terminal kinase stress activated protein kinase cascade jnk sapk p38 cascade stimuli include stress injury typically activate jnk p38 mapk kinases p44/42 mapks stimulated mitogenic growth factors 94 95 mapk signaling involved many age associated physiological changes hypertrophy oxidative stress apoptosis well cardiac pathologies works investigating mapk signaling aging human hearts demonstrated reduced p38 mapk activity signaling heart failure impaired activation mapk target genes following increase oxidative stress 9698 it well recognized increases cellular stress cause upregulation heat shock protein hsp hsps range size 10 150 kda function prevent protein aggregation assist ensuring proper protein folding well helping mediate translocation damaged proteins hsps also involved cardiac hypertrophy response vascular wall injury ischemic preconditioning aging aging accumulation damaged misfolded proteins may cause burden maintaining proteostasis 102104 an important function heat shock proteins protect age related protein misfolding 103105 aged male f344 rats 24 months ) appears aging decreases hsp70 upregulation following chronic exercise heat stress 106108 similar mapk proteins nuclear factor-b nf-b pathway thought play role cardiac remodeling apoptosis acute ischemia reperfusion unstable angina well heart failure humans rodents 109112 the nf-b family consists rela p65 c rel rel relb nf-b1 p50 nf-b 2 p52 figure 1 presents nf-b signaling pathway cytoplasm the p50 p65 found inactive heterodimer due binding ib kinase inhibitory proteins ikk ikk cellular stimuli known activate nf-b pathway include ros tnf- il-1 bacterial lipopolysaccharides it shown ibs must first become phosphorylated degraded p50/p65 activation occur the p50/p65 phosphorylated activated translocates nucleus induce transcription chemokines il-8 mcp-1 cytokines tnf- il-1 il-2 il-6 adhesion molecules icam-1 vcam-1 e selectin acute phase proteins antimicrobial peptides secondary inflammatory enzymes cox-2 inos pla2 mnsod antiapoptotic factors upon termination nf-b stimuli p50/p65 binds new ibs complex it thought mapk pathway works concert nf-b pathway increase transcription inflammatory genes extensively review role sex hormones intracellular signaling mechanisms within myocardial inflammation although effects estrogen mapk signaling studied several pathological processes example breast cancer migraines polycystic ovarian syndrome little known regarding molecule affects mapk signaling heart it thought differences mapk activation male females may regulated least part influence estrogen 66 115 116 estrogen shown stimulate activation p44/42 mapk jnk mapk different model systems including cardiomyocytes mammary cancer cells pituitary tumor cells tissue slices hippocampus endometriotic stromal cells 117119 males well ovariectomized females mapk signaling decreased acute ischemia 115 116 model cardiac pressure overload estradiol treatment appeared exhibit antihypertrophic effects increasing expression atrial natriuretic peptide anp inhibiting p38-mapk activation in addition regulation mapk proteins evidence suggest gender also effect hsp response hearts exposed increased cellular stress male hearts half much hsp72 expression compared observed female heart estradiol treatment also found increase hsp27 hsp70 hsp72 hsp90 expression heart 122124 knowledge studies looked hsp27 hsp70 hsp90 aging female heart aging female male hearts shown increased apoptosis inflammation well age associated gender differences nf-b signaling knowledge studies investigated changes nf-b expression activity aging female rat heart apoptosis programmed cell death highly conserved regulated cell response inhibit abnormal proliferation cells cardiomyocytes capable self regeneration terminally differentiated undergo apoptosis necrosis autophagy unduly stressed apoptosis increased many cardiovascular diseases dilated ischemic cardiomyopathy hypertrophic heart disease arrhythmias 126 128 129 rats increased age shown cause apoptotic susceptibility heart following oxidative injury 130 131 aging male f344xbn heart characterized increases amount cytochrome c aif bax rate permeability transition pore opening fragmented dna the age associated increase apoptosis appears due activation proapoptotic molecules also decreases antiapoptotic nf-b bcl xl grx1 signaling another work demonstrated aging male f344xbn rat heart characterized increases tdt mediated dutp nick end labeling- tunel- positive nuclei caspase-3 activation caspase dependent cleavage alpha fodrin diminished phosphorylation protein kinase b akt thr308 the increase apoptosis aging male f344xbn highly correlated age associated increases oxidative nitrosative stress though demonstrating cause effect results suggest increased cellular ros cardiomyocyte apoptosis may play role age related cardiac remodeling incidence cells undergoing apoptosis heart shown differ sex humans rats humans higher number tunel positive myocytes seen young males compared females aging appears increase cardiac apoptosis male female however gender difference apoptosis male female f344 rat 92 135 structural changes found aging vasculature include enlarged lumen media intimal thickening irregularly shaped endothelial cells migration proliferation vascular smooth muscle cells increased deposition extracellular matrix increased expression adhesion molecules alterations expression metalloproteinases well cytokines 4 136138 functional changes age vasculature consist impaired distensibility increased stiffness increased endothelial permeability attenuation 2-adrenoceptor vasodilator response agonists diminished response adrenergic receptor stimulation 4 139 like humans rats also appear exhibit several age associated changes vascular structure function including changes intimal thickening elevations inflammation associated molecule expression increased evidence oxidative stress 4 140 similar seen parts cardiovascular system differences aortic structure function genders also observed aging human animals males aortic wall intimal medial thickness greater aging observed women however stiffness different men women similarly differences distensibility aging aorta men women although human aging aorta show increases aortic stiffness documented increased vascular stiffness aging prominent male female animal models 143 144 this may due part lower total peripheral resistance higher cardiac output seen women compared men similar arterial pressure age abnormal proliferation migration vascular smooth muscle cells vsmcs play important roles pathophysiology atherosclerotic diseases previous studies shown vsmcs isolated old animals replicate actively obtained young animals 145 146 similarly aging shown associated increased proliferative response vsmcs balloon angioplasty endothelial dysfunction considered common early feature vascular disease impaired endothelium dependent relaxation demonstrated several rat models hypertension experimental diabetes atherosclerosis high salt diet well aging the factors regulating endothelial dysfunction likely complex may vary models aging nitric oxide vasodilator produced endothelial nitric oxide synthase enos plays crucial role blood pressure regulation no production stimulated shear stress cyclic strain acetylcholine vascular endothelial growth factor bradykinin estrogen sphingosine-1 phosphate s-1p hydrogen peroxide angiotensin ii it thought enos activity regulated enos phosphorylation serine 1177 serine 635 serine 617 phosphatidylinositol 3-kinase pi3k)/akt adenosine monophosphate activated protein kinase ampk cyclic amp dependent protein kinase signaling 149 150 given important role regulating vascular function surprising abnormalities vascular production thought contribute pathogenesis atherosclerosis hypertension 151 152 advanced age found associated impaired endothelial synthesis endothelial dysfunction 153 154 the mechanisms responsible age associated alterations synthesis fully known may include changes activity expression enos increased breakdown due oxidative stress oxidative injury changes antioxidant defense systems decreased availability enos substrate l arginine although activity enos generally thought diminished aging aorta in addition changes enos activity decreased availability aging also caused oxidative stress alterations enos structure 155 156 although estrogen 17- estradiol shown activate enos estrogen studies rats shown effect increased enos expression following estrogen treatment conversely humans estrogen replacement appears largely ineffective means decreasing cvd risk 159 160 women incidence vascular dysfunction thought related least part cessation ovarian hormone production vascular smooth muscle cells young female wistar kyoto rats estrogen inhibited vsmc proliferation following stimulation fetal calf serum similar decreases vsmc proliferation estrogen treatment following cell stimulation growth factors mechanical stress also noted 161 163 like estrogen progesterone is also thought inhibit proliferation aortic vsmc likely via ability inhibit dna synthesis nonetheless noted effects estrogen vivo likely complex seen cell culture for example aortas diabetic female rats estrogen failed reverse impaired basal release nitric oxide abnormal relaxation histamine the mapk signaling pathways function regulate many processes aorta including vsmc proliferation contraction migration differentiation cell survival 166168 aging also shown increase activation phosphorylation p44/42 jnk mapks aorta another work shown aging affects ability aged aorta activate p38 jnk mapk signaling following mechanical loading aged animals the activation p44/42 mapk vascular smooth muscle increased compared young animals 145 171 similar observed heart age associated changes expression activity nf-b found vascular smooth muscle cells aorta aging found increase sensitivity nf-b glucose aortic vscm cells another research shown vscm proliferation nf-b activation stimulated interleukin-1 increased aged female rats young female rats premenopausal women receiving hormone treatment appeared reduce nf-b activation suggesting estradiol reduces nf-b activation how estrogen may inhibit nf-b activity currently unclear may related increased ib levels decreased levels circulating tnf- in summary loss ovarian function aging may influence cardiovascular structure function however fact human females display cardiac hypertrophy myocyte loss absence loading abnormalities aging may suggest presence estrogen prior menopause acts attenuate cardiac response preexisting underlying pathologies due complexities aging process studies needed distinguish whether observed differences due aging alone hormone deprivation combination order overcome difficulties found aging human research ethics cost long lifespan rat models used provide great insight investigating age related changes cardiovascular structure function however additional research examining aging may affect cardiac structure function rats needed determine whether alterations seen rats mimic changes seen humans because systemic nature reproductive senescence use surgical practices induce pseudomenopause ovariotoxicity may incomplete overall approach female aging cardiovascular changes global changes body age may play cumulative role combination hormonal changes seen reproductive senescence aging associated increases oxidative stress lead alterations cardiac cell signaling may lead deleterious changes heart because cardiac structure function signaling hormonal response appear differ male female rats humans aging care must taken evaluating current literature regard specific finding gender studies investigating details cardiac signaling gender aging likely lead better understanding mechanisms responsible cardiovascular diseases male females these findings may prove critical application current prophylactic practices pharmaceutical interventions patient outcomes

cardiovascular disease is the leading cause of death in women in the united states . aging is a primary risk factor for the development of cardiovascular disease as well as cardiovascular - related morbidity and mortality . aging is a universal process that all humans undergo ; however , research in aging is limited by cost and time constraints . therefore , most research in aging has been done in primates and rodents ; however it is unknown how well the effects of aging in rat models translate into humans . to compound the complication of aging gender has also been indicated as a risk factor for various cardiovascular diseases . this review addresses the systemic pathophysiology of the cardiovascular system associated with aging and gender for aging research with regard to the applicability of rat derived data for translational application to human aging .

mycotoxic nephropathy mn renal disorder caused alimentary ingestion secondary fungal metabolites possessing nephrotoxic properties encountered feeds foods forages made mainly cereals fibrous plants kept storehouse conditions increased humidity since discovering disease described using various names nephrosis provoked moulds chronic interstitial fibrosis kidneys chronic interstitial nephritis etc recently terms ochratoxicosis mycotoxic nephropathy frequently used ones describing nephropathy last years kidney disease gained high publicity countries well developed stock breeding especially pig breeding denmark sweden bulgaria etc order prevent human exposure various nephrotoxic mycotoxins mainly ochratoxin ota via consuming meat animals nephropathy timely diagnosis disease meat inspection slaughterhouses important in such way exposure humans hazardous relatively heat stable toxin chicken pigs meat prevented there variances manifestation disease especially clinicomorphological picture lot cases influenced secondary bacterial infections result pronounced immunosuppression affected animals 2 3 4 5 6 therefore review paper could contribute timely diagnostics mycotoxic nephropathy farm animals mnfa well could help organization prophylactic measures disease in addition information given make evaluation human exposure ota base found concentrations ota human serum via calculating daily ota intake humans endemic areas although many nephrotoxic fungal compounds fumonisins known ota partly citrinin firmly associated spontaneous cases mn the first toxic compound discovered ota isolated aspergillus ochraceus chemiclly defined 1965 several south african scientists 811 ota consists dihydroisocoumarin moiety linked 7-carboxyl group amide bond one molecule l- phenylalanine 7-carboxy-5-chloro-8-hydroxy-3 4-dihydro-3r methylisocoumarin citrinin discovered 1931 hetherington raistrick isolated compound several strains penicillium citrinum fungi produce ota widespread nature various foods drinks 13 14 15 commonly contaminate stored grain penicillium viridicatum predominantly storage fungus mould usually develops grains low temperatures also major producer ota colder areas world northern europe canada on the hand aspergillus ochraceus probably impotant producer ota tropical semitropical areas 16 17 however growth a. ochraceus natural substrates associated natural occurrence ota not isolates p. viridicatum a. ochraceus ota producers produce toxic compounds e.g. citrinin penicillic acid pa hydroxyaspergillic acid secalonic acid a positive correlation observed frequency spontaneous porcine nephropathy bulgaria rate ota corresponding feed samples however analysis ota various feed samples farms high frequency spontaneous mycotoxic porcine nephropathy mpn revealed values substantially low ranged 38 552 mean 207.1 65.14 ng g 1993 42 427 mean 114.06 35.79 ng g 1994 respectively sometimes problem seemed come certain feed plants whose grains collected moist rainly days properly dried all farms supplied plants subsequently produced pigs nephropathy growth depression changing certain suspected feeds problems poor growth pigs disappeared whole frequency duration observed nephropathy different batches slaughtered pigs varied significantly 12% 8090% frequency depended duration feeding various suspected feeds stored long time poor conditions high humidity 1821 it important mention kidney damages spontaneous mpn bulgaria figure 1 similar balkan endemic nephropathy ben humans danish mpn for example fibrotic changes contraction kidneys end stages mpn bulgaria comparable ben humans whereas changes seen classical description mpn made denmark in addition contraction kidneys later stages bulgarian mpn ben various similarities ben humans bulgarian mpn low contamination levels ota feeds foods serum neoplastic changes kidneys pigs figure 2 urinary tract humans retention cyst formation proximal tubules kidneys vascular lesions kidneys electron dense formations myelin like figures mitochondria epithelial cells figure 3 however pathological changes observed classical mpn described denmark elsewhere this circumstance addition low feed food levels ota bulgarian mpn ben suggest possible interaction ota mycotoxins needs proved figure 3 recently found pathomorphological changes including electron dense formation myelin like figures induced pig kidneys combined exposure low contamination levels ota together pa similar spontaneous mpn bulgaria classical danish mpn all feed samples originating farms high frequency spontaneous avian nephropathy bulgaria also positive ota similarly pig farms levels ota substantially low values ranged 90.8 310 ng g mean 196.2 ng g 45.9 the nephropathy chickens usually observed spring summer similarly porcine nephropathy regions well the occurrence nephropathy different batches slaughtered chickens varied 12 per cent 90100 per cent the continuance nephropathy also differed widely one month 56 months even throughout year it known experimental pigs exposed ota contaminated feed levels 200 ppb develop microscopic lesions period 34 months 24 25 the average contamination level ota bulgarian feeds pigs 1993 exceeded 200 ppb ota on hand low contamination levels ota pigs chicks feeds suggest possible synergism ota compounds produced ochratoxinogenic fungi it likely feeds contain nephrotoxic mycotoxins compounds enhance toxicity produce synergistic interaction ota pa fumonisin b1 fb1 citrinin viomelein xanthomegnin etc several years ago found toxicity various strains aspergillus ochraceus group different independently capacity ota production 22 26 27 a potent synergistic effect found ota pa mycotoxins produced ochratoxinogenic fungi mycotoxins given simultaneously pigs chickens 22 2630 the production multiple toxins single organism aspergillus ochraceus produces ota pa simultaneously mixture fungi presents problem sufficiently investigated pa suspected carcinogenic found dna attacking ability rec assay well induce chromosome aberations some data suggest feed contamination levels pa 4000 ppb little toxicity mostly hepatotoxicity adversely affect body organ weights biochemical parameters chickens only dna breaks mammalian cell lines 36 37 inhibition rat liver glutathione transferase activity crude extracts vitro well pa induced hepatobiliary excretory dysfunction liver hemorrhages found far the higher toxicity ota mentioned studies might due synergistic toxic effects ota pa reported mice 41 42 poultry previous studies suggested important role pancreatic enzyme carboxypeptidase detoxification ota small intestine 43 44 parker colleagues showed pa inhibits carboxypeptidase activity vitro vivo inhibition may significantly impair primary detoxification ota intestinal tract partly responsible enhanced toxicity ota observed combination pa 22 2630 the pa induced hepatobiliary excretory dysfunction may also result decreasing hepatobiliary excretion ota such synergism ota pa mycotoxins field conditions may responsible spontaneous mycotoxic nephropathy bulgaria caused relatively low contamination levels ota feed 18 21 23 this could explain low levels ota bulgarian feeds pigs 18 21 chickens humans high toxic effect kidneys ingested spontaneous contaminated feeds the concentration ota feeding forages probably important pa higher contamination levels pa 60000 ppb pa combine 1000 ppb ota able produce significant toxic effects this findings clearly suggest increase ota toxicity probably due impaired detoxification ota via pa inhibited carboxypeptidase activity intestinal tract several years ago stoev collaborators induced macroscopic kidney damages pigs fed mouldy diet containing low levels ota 180 ppb combination pa 3 months feeding period whereas microscopic lesions kidneys experiment observed pigs fed diet containing 90 ppb ota combination pa the observed changes similar caused pigs end 4-month period exposure higher levels markedly 200 ppb pure ota feed it therefore important investigate effect combined administration ota mycotoxins produced ochratoxinogenic fungi occur field combined administration ota pa much lower concentrations ota 100 ppb enough significant toxic effect chickens expressed degenerative changes internal organs depletion cells lymphoid tissue decrease lymphoid organ weight well known changes various biochemical parameters moreover degenerative weight changes kidneys liver lymphoid organs well immunosuppression seen recently chickens 0.2 0.3 ppm ota combination pa 26 27 29 30 47 whereas changes seen chickens exposed significantly higher levels pure ota 4 ppm feed 4851 according authors similar less pronounced synergistic toxic effect observed higher contamination levels ota 1000 ppb the mentioned low experimental levels ota correspond well feed levels ota found spontaneous cases mycotoxic avian nephropathy man bulgaria 0.090.31 ppm suggests possible multicausal nature man bulgaria furthermore ascribe source ota a. ochraceus group fungi unwise ochratoxinogenic forms isolated rarely 18 52 therefore already great importance carry mycological investigations order isolate ochratoxinogenic fungi bulgarian feeds in addition overall concentration ota feed samples 0.38 0.552 ppm substantially lower 1 2 ppm required reproduce mpn man severity similar observed spontaneous cases 18 21 23 53 it seems therefore mpn man bulgaria may multitoxin multifactor etiology explained concentration ota alone the multimycotoxin etiology mpn man bulgaria recently confirmed high contamination levels pa 838,6 223,9 g kg 88% positives fb1 5564,1 584 g kg 96% positives bulgarian feed samples farms mycotoxic porcine nephropathy found whereas levels ota 188,8 27,3 g kg 100% positives feeds consecutively lower unpublished personal data a similar multimycotoxin etiology also found south african mpn mixture mycotoxins 67,8 39,2 g kg ota 83,3% positives 149,2 64,1 g kg pa 41,7% positives 5046,2 1301 g kg fb1 80% positives found south african feed samples pig farms nephropathy problems unpublished personal data some mycological investigations ota contaminated feeds bulgaria revealed common presence p. aurantiogriseum complex potent producer pa pa produced numerous species penicillium especially p. aurantiogriseum aspergillus temperatures ranging 4c 30c maximum rate production occurring 25c the production pa decreased sharply low oxygen concentrations fungal growth noticeably influenced the rate toxin coupling -sh radicals increases ph well high temperature the resulting complexes much less toxic uncoupled molecules resulting actual detoxification result toxin usually accumulates relatively low temperatures winter detoxification reduced toxin production could explain bulgarian nephropathy pigs chickens usually observed spring summer it recently found administration p. polonicum extract containing ota rats provoke profound persistent histopathological damages apoptic karyomegalic mitotic changes nuclei tubular epithelium kidneys rats including dna adducts formation the p. polonicum strain common food feed spoilage mould warm temperate latitudes found frequent contaminant bulgarian feeds suspected causing spontaneous porcine nephropathy 18 52 it known p. aurantiogriseum group including p. polonicum strain potent producer pa also provoke dna breaks mammalian cell lines reported in way could appear source pa bulgarian feeds different source ota also changes apoptosis karyomegaly tubular epithelium provoked p. polonicum extract could induced another unknown mycotoxin would interest mycotoxin could partly responsible nephrotoxic damages described bulgarian nephropathy moreover quiet apoptosis induced p. polonicum nephrotoxin could possible model cryptic clinically silent onset renal atrophy idiopathic balkan endemic nephropathy humans on hand reported ota high potential induce apoptosis dna adducts vitro 61 62 rodent vivo also rahimtula et al showed lipid peroxidation kidney microsomes enhanced ota produced malondialdehyde in way extent ota may interact components commercial chicken pig rations human food compounded agricultural produce may also influence significance relatively lower doses ota commercial chickens 23 27 pigs 18 21 humans may encounter feed food various different strategies employed reduce human animal exposure ota reduce toxic effects fed animals the include use management practices prevent production ota storage fungi feeding contaminated grain animal species less susceptible toxic effects ota ruminants modification diet promote enhanced hydrolysis ota gastrointestinal tract reduced absorption use feeding regimen counteract metabolic effects ota use various procedures destroy ota physical chemical methods decontamination commodities well use various feed additives protect toxic effects ota etc gastrointestinal microorganisms large effect disposition ota promote hydrolysis ota nontoxic form ot. particularly important ruminants therefore less susceptible ota toxicity addition type diet also affects disposition ota rumen 67 68 ruminal fluid obtained hay fed animals ph 7.0 able hydrolyze ota ochratoxin ot vitro five times faster ruminal fluid obtained grain fed animals ph 5.5 disappearance ota rumen corresponding formation ot also much faster hay fed grain fed sheep the bioavailability ota sheep fed grain 4.3 times greater sheep fed hay thus rumen sheep important role detoxification ota type diet affects rate extent process result bioavailability ota probably toxicity ruminants decreased in addition intestinal microflora nonruminant animals also affect bioavailability ota microorganisms intestines particularly caecum large intestine also responsible hydrolysis ota nontoxic form ot another way prevent production ota prevention growth storage fungi the important factors safeguarding stored feedstuffs foodstuffs ota prodution moulds moisture content water activity temperature large quantities ota produced intermediate high ambient temperatures high moisture contents species belonging penicillium aspergillus whereas lower ambient temperature toxin produced penicillium spp addition moulds corn stored 21% moisture produced large quantity ota 3.6 ppm whereas none toxin found corn stored 16% moisture these studies indicate fungi cereal grains stored moisture contents lower 15% generally produce ota suggests moisture content cereal grains decreased 15% via various drying procedures storage storage higher moisture levels requires grain maintained anaerobic conditions prevent growth fungi otherwise combination mould inhibitors sterilization techniques possibly coupled inoculation nontoxigenic competitive microflora applied prevent growth ota producing fungi chelack collaborators 72 73 used another way control growth ota producing fungi they demonstrated gamma electron beam irradiation highly effective means destroying spores ota producing fungi a. alutaceus 72 73 various types radiation x rays ultraviolet light microwaves addition -irradiation also used means detoxification mycotoxins well control growth fungi 74 75 leitao collaborators demonstrated phosphine ph3 effective inhibiting fungal growth sterigmatocystin production a. versicolor could considered another specific way control growth ota producing fungi foods ph values 5 6 cereals sorghum antimicrobial agent food additive able prevent growth and ota production aspergillus penicillium species methyl paraben potassium sorbate small concentrations compounds able completely inhibite growth genera fungi ota production ph 4.5 occurs silage fungal growth ota production completely inhibited 0.02% potassium sorbate 0.7% methyl paraben 0.2% sodium propionate the use various procedures destroy ota physical chemical methods decontamination commodities considered another important way safely utilizing feedstuffs madsen collaborators reported treatment ota contaminated barley 5% nh3 96 h 70c warming grain 105c presence 0.5% naoh well autoclaving 132c 0.5 h destroy main part ota barley treatments practical able effectively reduce concentration ota grain chelkowski collaborators reported treatment ota contaminated grain ammonia reduced ota concentrations undetectable levels moreover weight gains chickens fed ota contaminated grain markedly decreased whereas reduction weight gains chickens fed ota contaminated grain ammoniated they concluded ammoniation grain detoxifies several mycotoxins including ota also inhibits mould growth feeding studies shown toxic effects related ammoniation process changes nutritional quality feed decrease lysine sulfur containing amino acids in addition adequate aeration ammoniation necessary acceptance feed animals however ammoniation many techniques proposed remove mycotoxins currently perceived impractical ineffective and/or potentially unsafe largescale use rotter collaborators demonstrated inoculation barley lactobacillus species followed ensiling decreasing ph reduced concentration ota approximately 50% also scott reported ota completely destroyed malting barley according laciakova collaborators formic acid 0.25% concentration degraded ota 3 h exposure propionic sorbic acids 1% concentration 24 h exposure benzoic acid 0.5% concentration 24 h exposure several different approaches used reduce ota absorption including use hydrated sodium calcium aluminosilicate hscas bentonite charcoal cholestyramine the addition hscas 1% bentonite 1% 10% diet containing ota effect ota concentration swine blood serum tissues bile the addition 1% activated charcoal diet contrast caused slight decrease concentration ota swine blood whereas 10% charcoal decreased concentration ota blood liver kidney spleen heart 50% 80% however supplementation ota contaminated diet activated charcoal considered impractical method reducing ota toxicity chicks pigs continuously consuming ota cholestyramine contrast nonspecific absorbent discussed seems effective absorbent ota gastrointestinal tract nonruminant animals cholestyramine commercial anion exchange resin shown reduce blood ota concentrations 50% included 0.5% rat diet containing 1 ppm ota in addition faecal excretion ota significantly increased rats given single oral dose ota fed diet containing cholestyramine another way reduce ota toxicity supposed good understanding mechanisms ota toxicity inhibition phenylalanine metabolizing enzymes mind phenylalanine moiety ota enhancing lipid perooxidation inhibition mitochondrial atp production it well known phenylalanine moiety ota competitively inhibits least two enzymes phenylalanyl trna synthetase phenylalanine hydroxylase resulting reduced protein synthesis altered rates tyrosine production phenylalanine the addition phenylalanine cell cultures containing ota vitro coadministration phenylalanine ota 88 89 reduced ota induced inhibition protein synthesis in vivo experiments show injection phenylalanine also prevented ota induced immunosuppression mice 90 91 92 partially reduced teratogenesis rats the phenylalanine used 5:1 molar ratio towards ota found phenylalanine given higher doses 10:1 molar ratio provides slight protection ota increasing absorption ota stomach intestine moreover higher supplementation pure phenylalanine chick diets contaminated ota also tended create amino acid imbalance reduced b. w. gain feed conversion efficiencies 95 96 these studies suggest little benefit obtained supplementing ota contaminated diets phenylalanine the concentration protein diet growing chicks also shown ameliorate toxicity ota 97 98 the consumption high protein diets 26% growing chicks three week period compared diet containing lower concentration protein 14% decreased toxicity 5 ppm ota diet indicated rate growth mortality relative organ weights chicks 97 98 this treatment however may practical large change protein concentration diet may costly produces relatively small benefits ascorbic acid supplementation 300 mg kg laying hen diet contained 3 ppm ota reported good protective effect ota action partially ameliorate ota toxicity including negative effect ota eggs production weight eggs 99 100 the mechanism protective effect clear supposed affect production lipid peroxides ota improve membrane integrity cell organelles always affected ota action the use various feed additives also protect toxic effects ota reduce farm losses decrease weight gain stock chicks avoiding rejecttion condemnation ota contaminated feed 27 30 94 sesame seed rich proteins 20% relatively rich l- phenylalanine 4.3% given 8% feed offered cheaper agronomic additive supply animals phenylalanine thereby protect toxicity ota it might also avoid increase ota absorption stomach intestine provoked pure phenylalanine feeds simultaneously increase urinary excretion ota presence phenylalanine could preserved later stage moreover sesame seed 8% feed increases energy metabolism animals usually disturbed ota ( hofmann la roche grenzach wyhlen austria polyenzyme complement produced fungi trichoderma contains cellulase xylanase endo beta 1,3 1,4 glucanase pectinase amylase roxazyme g given concentration 0.2g kg feed reported improve digestive dissimilation polysaccharides easily assimilated substances could improve utilization feed increasing digestible energy production 813% thereby counteracting ota impairment energy production chicks artichoke extract complex containing compounds might protect ota intoxication 26 27 30 94 the 5% total water extract artichoke cynara scolymus l prepared steam infusion dried leaves artichoke given chicks concentration 5 ml kg.b.w via feed water usually contains various biologically active compounds cynarine flavonoids cynaropicrin dehydrocynaropicrin grosheimin well high content calcium ascorbic acid it recommended diuretic agent cardiac renal insufficiency might accelerate urinary route excretion ota 26 27 30 moreover the cynarine content extract stimulates metabolism cholesterol decreases serum urea lipids improves diuresis increases biliary secretion probably augment hepatobiliary route excretion ota ota mainly eliminated via bile urine thereby found protect ota nephrotoxicity hepatotoxicity 26 27 29 30 94 well immunosuppressive effect ota 27 94 104 ota induced anaemia cynarine flavonoids well medical preparations prepared artichoke extract chophytol chophytamine potent hepatoprotective effect hepatotoxic damage 105107 also antipermeability vasoconstrictive effects water extract artichoke could decrease oedema various internal organs provoked ota 18 27 29 30 94 the high content calcium vitamin c steam extract probably also protective effect ota toxicity via improving membrane integrity cell organelles skeleton strength chicks via ways 27 29 94 since authors reported ascorbic acid supplementation 300 mg kg laying hen diet contained ota 3.0 mg kg partially reduced ota toxicity rosallsat another plant extract polyextract bulbus alii sativi seminum rosai canina seen also protective effect ota toxicity given per os 0.6 ml per kg body mass daily supplement feed the rosallsat new natural galenic phytosubstance balanced polyvitamine phytoncide steroid saponine composition described completely patent 98915 bg 1994 contains biological active compound allicin 12.08 mg g well large quantities vitamins 0.0332 mg g f 0.8112 mg g e 0.1548 mg g furostanic sapogenine c57h96o30 26 29 30 the allicin study formed advance included natural oil extract commercial lots stabilized natural antioxidants this advantage compared fresh dried garlic cloves since thiosulphinate hardly formed ph conditions stomach intestine eating fresh dried garlic the precise mechanism protection rosallsat ota toxicity investigated depth supposed biological active compound allicin high quantities vitamins f e plant extract probably great importance 26 29 30 the rosallsat found inhibit lipid peroxidation unpublished personal data way prevents one mechanism ota toxicity it found intensity macroscopical histopathological changes deviations relative organs weight body weight table 1 decrease antibody titer table 2 well intensity changes various haematological biochemical parameters table 3 slighter chicks treated antidotes 5% artichoke extract 0.02% roxazyme g 8% sesame seed 0.0025% phenylalanine addition 5 ppm ota chicks treated 5 ppm ota chicks groups treated sesame seed artichoke extract described changes especially antibody titer newcastle disease similar ones observed chicks exposed approximately 5 times lower contamination levels ota 1 ppm table 2 moreover appeared mentioned antidotes used supplements feeds especially sesame seed artichoke extract potent protective effect ota induced toxicity could used practical approach safely utilizing ota contaminated feed way rejection condemnation feed avoided well need eliminate ota feed contamination levels similar encountered practice normally upto 12 ppm ota however pigs sensitive ota levels 1 ppm ota dangerous 2 22 108 requires additional experimentation clarify antidote effect additives animals a protective effect ota induced decrease total serum protein found chicks antidote treated groups mentioned protection increase serum glucose seen groups treated roxazyme g artichoke extract also protective effect ota indiced increase serum creatinine urea seen antidote treated groups especially day 70 in addition protective effect increase serum values uric acid creatinine strongest group treated sesame seed table 3 however appeared protective effect phenylalanine slighter expected one contrast studied antidotes the main reason could circumstance phenylalanine found increase absorption ota stomach intestine well gastrointestinal transit ota this resulted eightfold fourfold higher levels ota serum liver mice respectively first 12 h could also increase elimination therefore phenylalanine given changing feed source stopping ota exposure animals the strong protection roxazyme g ota induced increase serum glucose could due improved energy metabolism whereas protection artichoke extract increase could due improvement diuresis the protective effect sesame seed phenylalanine ota provoked immunosuppression humoral immune response changes differential wbc count might due improvement protein synthesis usually disturbed ota subsequently improvement ota induced delay division cells immune system it known ota induces increase weight organs taking part detoxification elimination kidneys liver well decrease lymphoid organs weight body weight whereas studied feed additives 5% artichoke extract 0.02% roxazyme g 8% sesame seed 0.0025% phenylalanine significantly protects weight changes protective effect sesame seed roxazyme g weight changes stronger protective effect artichoke extract phenylalanine experiments 26 30 110 it also confirmed artichoke extract significant protective effect ota toxicity studies another plant extract rosallsat also seen protect ota toxicity expressed statistically significant protection ota induced changes serum levels total protein uric acid cholesterol table 4 the serum levels uric acid significantly influenced quantity ota fed forages usually give exact assessment impairment kidney function chicks the absence confident increase parameters artichoke extract rosallsat treated groups suggests slight impairment kidney function groups confirms protective effects feed additives ota toxicity hand the protective effect artichoke extract rosallsat liver function may contribute higher cholesterol levels groups chicks treated antidotes in addition toxicological investigations experiments revealed contamination levels ota kidneys lower chicks treated artichoke rosallsat addition ota chicks treated feed level ota by 1990 least nine countries regulations ota levels proposed enforced official limits ota regulatory control nephrotoxic mycotoxins animal feeds european countries summarized van egmond later boutrif canet hand european union decided official limit ota cereals designed direct consuming 5 g kg the official limits ota cereals countries seen various fao reports commonly ranged 2 g kg switzerland 20 g kg czech republic rarely reached 50 g kg uruguay countries wide spreading mpn man residues ota often found animal tissues samples meat inspection 18 23 114 115 116 the contamination levels ota liver muscles fat tissues pigs easily found using following experimental calculations 1990 least nine countries regulations ota levels proposed enforced official limits ota regulatory control nephrotoxic mycotoxins animal feeds european countries summarized van egmond absence correlation macroscopic changes concentration ota pig kidneys difficult prevent exposure humans toxin pork toxicological investigations pale mottled kidneys occurred denmark the practice denmark monitoring kidney tissues pigs detectable kidney lesions could provide good basis condemnation carcases intake ota may sufficient duration produce detectable lesions therefore regulations denmark according enlarged mottled kidneys investigated residues ota slaughter time carcasses whose kidneys contained ota levels 10 g kg condemned safe clever macrscopic changes kidneys found 13 months ota exposure via feeds 22 118 some investigations made various authors revealed least 12 months needed develop characteristic macroscopical renal lesions pigs exposed natural experimental ota contaminated barley 24 119 unfortunately characteristic mpn macroscopic changes kidneys found shorter period ota exposure via feeds even high levels 1000 ppb ota animal products containing dangerous ota contamination levels could easily pass meat inspection slaughterhouses on hand renal lesions kidneys mottled appearance induced early age disappear pigs fed ota free diet also indicates lack efficiency control system implementation unnecessary toxicological investigations could avoided 21 22 spite toxicological investigations kidneys ota contaminated pork may enter human food chain thus represents potential public health hazard since toxin relatively heat stable limited occurrence ota might anticipated prepared food animals assumption mycotoxins especially ota involved etiology balkan endemic nephropathy 1 122124 exposure humans hazardous toxin pork chicken meat way feed pork chicken food need prevented a much better procedure preventing exposure humans toxin meat would toxicological analysis blood samples pigs chicken farms suspected mn several weeks pigs several days chicken slaughter change feed source week pigs 23 days chicken necessary also the period feed deprivation pigs chicken slaughter could prolonged 21 23 short half life ota pigs 72 120 hours especially chickens 4 hours concentration blood various tissues quickly decreases changing feed source prolonging period feed deprivation slaughtering thus loss condemnation pig chicken production would prevented better procedure toxicological invesigations enlarged mottled kidneys accepted denmark would realized preventing exposure humans ota meat 2123 114 the preventive measures already slaughtered chicks could include condemnation removing kidneys liver ota accumulated however mind combined administration ota mycotoxins pa often occurrs practice synergistic effects ota mycotoxins reported lower contamination levels ota food feed would also dangerous human animal health 22 30 balkan endemic nephropathy ben humans another renal disorder similar pathological characteristics mpn it commonly observed farmers ages 30 50 years oligosymptomatic clinical picture silent onset poor prognosis progresses slowly manifests function majority nephrons become impaired time there agreement disease represents unusual type chronic interstitial nephropathy unknown etiology although assumption mycotoxins involved the disease strict endemic character encountered rural populations bulgaria romania ex yugoslavia the high humidity poor food storage conditions endemic villages low living hygienic standard well consumption home prepared food crops bread bean others 123 127 correspond fact moulds producing mycotoxins contaminate mostly home produced grain feeds stored bad conditions high humidity situation towns markedly different foodstuff supply centralized quality controlled explain family character ben rural inhabitants also focality zonality characteristic ben typical mycotoxicosis i. e. endemic dissemination determined mainly ecological conditions regions optimal development corresponding fungi altitude the seasonal yearly variations incidence prevalence disease ota content human food well positive correlation excess rainfall number patients suffering ben died following two years probably additional intake moulded food provoking new degenerative damages kidneys impairing disease state give additional support mycotoxin hypothesis ben however etiology disease still unknown spite various etiological investigations including search heavy metals trace elements infectious agents genetic factors well various bacteriological toxicological hydrological investigations water nephrotoxic mycotoxin ota suggested one possible disease determinants ben based comparison morphological functional kidney impairment ota induced mpn ben endemic areas ota found human blood well human food 123 126 130 131 132 animal feed higher concentrations nonendemic areas countries without ben it important mention feed levels ota animal feeds endemic mpn regions 38552 ppb approximately foods endemic ben regions 10890 ppb additionally suggest possible common etiology the mean concentration ota human blood bulgarian endemic areas ranges respectively 20 g l 1986 27.2 g l 1989 130 132 these high concentrations suggest possible role ota disease causation ben however ota detected concentration range 5100 g l 0.4 2.5% total 13,797 analysed blood samples 14 endemic areas slavonski brod croatia 9-year 19811989 period concentration range 250 g l 0.2 4.5% total 6,910 analysed serum samples endemic village kaniza 10-year 19851994 period these concentrations ota human blood significantly lower towards ones bulgaria correspond quite well prevalence disease ranged 1% 4.5% last 15 years incidennce newly recorded ben suffering patients ranged 1.0 2.5 per thousand endemic areas the disease also closely associated high frequency carcinoma renal pelvis ureter urinary bladder 135 136 could due carcenogenicity nephrotoxic mycotoxin ota 125 137 138 working group evaluated carcinogenicity ota humans could draw conclusion interestingly some tumors kidneys bladders patients living areas associated balkan endemic nephropathy found contain dna adducts similar obtained kidneys mice exposed ota provides new evidence possible role ota development tumors urinary tract moreover 11 31 patients urinary tract tumors france exhibited ota specific dna adduct pattern similar found bulgarians suffering ben ota treated rodent bulgarian pig suffering nephropathy it found changes debrisoquine 4-hydroxylation vivo occur rat response mouldy food patients suffering ben and/or upper urothelial tumors frequently extensive metabolizers debrisoquine db recent study egypt revealed positive correlation ota end stage renal disease esrd urothelial tumors humans patients esrd well patients nephrotic syndrom urothelial tumors significantly higher mean concentrations ota blood 0.52 2.19 ng ml urine 0.36 3.09 ng ml patients control groups 0 0.08 ng ml blood 0.01 0.26 ng ml urine it established ota decreases natural killer cell activity specific inhibition endogenous interferon levels natural killer cells involved distribution tumor cells ability ota modulate activity cells might contribute capacity induce renal hepatic carcinomas recently found ota significantly longer plasma half life humans 33.55 days animals a slow excretion ota suggests tendency increase toxin levels serum well assumes constant rate ota human blood long period time even repeated exposure low concentrations way the humans influenced dose less influenced frequency duration quantity quantity toxin ingested comparatively low ota exposure species humans ota constant continuous effect proximal tubules even little amounts low unbound free fraction ota blood it supposed free ota macroorganism toxic effect tissues well continuous persistence ota human blood slow excretion via kidneys may influenced slow progression ben thus consumption food containing low concentrations ota long period time may become toxicologically significant a method also presented calculating daily consumption ota various food products basis measured content plasma even though toxicokinetic constants unknown the renal filtration rate ota humans calculated glomerular filtration rate inulin free fraction ota 0.67 ml kg body weight per day the kidney filtration found correspond total plasma clearance ota almost 100% monkeys 10% mice rats pigs the equation k0 clp.cp/a shows relationship continuous intake k0 ng kg b. w. per day plasma clearance clp ml kg b. w. per day plasma concentration ota cp ng ml bioavailability proportion toxin absorbed 50% the equation used calculate daily intake ota concentration toxin plasma humans endemic regions bulgaria the daily intake humans calculated basis average plasma levels ota endemic area bulgaria found 26.8 36.4 ng kg b. w. seen table 5 1 124 it important mention calculation give underestimate intake since value used plasma clearance involves glomerulal filtration this underestimate could much ten times ota clearance man similar rat mouse pig monkey because increase scientific reports ota contamination beverages many kinds food fao joint expert committee food additives jecfa assessed available information proposed 112 ng kg b.w having mind strong carcinogenic effect ota ptwi later decreased 100 ng kg b.w corresponds 14 ng kg body weight per day it concluded average daily intakes endemic areas bulgaria 26.8 ng kg b. w. 1988 1 124 36.4 1989 34.2 1990 respectively exceeds strongly ptwi 100 ng kg b. w. 14 ng kg b. w. per day proposed jecfa jecfa bases calculation tolerable intake mainly nephrotoxicity ota address question toxin carcenogenic effect kuiper goodman scott however regard carcinogenic effect important effect base analysis tolerable daily intakes tdis depending method used calculated base carcinogenic effect ota range 0.2 4,2 ng kg b. w. concluded maximum tolerable daily intake ota 5 ng kg b. w. seen average daily intake endemic extent nonendemic areas exceeds strongly tdi calculated base cancerogenic effect ota the performed calculations tdis show ota contamination food feed constitutes public health problem unknown dimensions therefore quite relevant investigate extent ota hazardous humans high thermal stability mycotoxin ordinary cooking eliminate recently however evidences appeared exposure one mycotoxin may important factor etiology ben mpn moreover synergism ota various mycotoxins pa citrinin fb1 field conditions may responsible enhanced toxicity ota 22 27 30 due potent toxic synergistic effects ota pa citrinin 22 150 well ota fb1 151 152 simultaneous exposure mycotoxins might important factor development chronic renal diseases animals humans especially long term exposure the mycotoxins recently found high contamination levels especially fb1 pa feeds originated farms mycotoxic porcine avian nephropathy bulgaria unpublished personal data great importance investigate combined effect ota mycotoxins produced species occurred field conditions

various etiological factors contributing to the development of mycotoxic nephropathy in farm animals and humans are reviewed . the possible synergistic effect between ochratoxin a ( ota ) and other mycotoxins , as penicillic acid ( pa ) and fumonisin b1 ( fb1 ) , contributing to this nephropathy is also considered and discussed . the most convenient ways of prophylaxis and various preventive measures against ota contamination of feeds or foods are reviewed . a reference is made concerning the most successful methods of veterinary hygiene control in the slaughterhouses in order to prevent the entering of ota in commercial channels with a view to human health . the economic efficacy of these prophylactic procedures is also considered . an evaluation of human exposure to ota is made .

distal anterior cerebral artery aneurysms also known pericallosal artery pa aneurysms located anterior cerebral artery distal anterior communicating artery these aneurysms represent approximately 6% intracranial aneurysms 4% rupture49 furthermore similarly represented international subarachnoid aneurysm trial isat study population accounted 95 2143 patients randomized 4.4%)14 pa aneurysms present several problems direct surgical clipping difficult exposure via interhemispheric approach especially swollen brain subarachnoid hemorrhage sah sacrifice bridging vein adequate surgical exposure thus increasing risk postoperative morbidity difficult controlling parent artery unfavorable orientation aneurysm fundus consequence surgical morbidity reported relatively high incidences ranging 0 25%141221 advances endovascular techniques devices led rapid evolution coil embolization ruptured unruptured intracranial aneurysms become efficient treatment technique comparable surgical clipping however distal location small diameter parent vessel pa aneurysms pose technical challenge endovascular therapy case bifurcation cerebral aneurysms potential high recurrence rate18 search literature revealed relatively studies performed endovascular treatment ruptured pa aneurysms studies performed involved relatively small numbers patient accordingly evident effectiveness safety endovascular treatment ruptured pa aneurysms well defined here present 30 patients treated endovascularly ruptured pa aneurysm describe clinical radiologic outcomes we retrospectively analyzed angiographic clinical records patients underwent endovascular treatment ruptured pa aneurysm institution september 2003 december 2013 the treatment strategy ruptured pa aneurysm institution attempt endovascular treatment first line treatment this strategy applied accompanied intraparenchymal hematoma ich surgical evacuation necessary performed immediately following coiling however microsurgery used early years study technology coiling distally located aneurysms infancy therefore surgical clipping first attempt 6 cases period there technical failure clipping coiling groups due retrospective nature the present study exempt accord institutional review board standards institution thirty ruptured pa aneurysms 30 patients treated endovascularly 10 males 20 females mean age 55.9 years range 24 88 years dissecting fusiform aneurysms aneurysms associated brain arteriovenous malformation traumatic mycotic aneurysms excluded size aneurysms parent arteries measured automatically manually two dimen sional digital subtraction angiography working views aneurysm size defined maximum distance dome neck plane aneurysm neck sizes ranged 2.5 10.4 mm mean 5.0 mm 0.9 6.1 mm mean 2.2 mm respectively 21 30 saccular aneurysms defined wide neck aneurysms large neck size 4 mm and/or dome neck ratio 2 of 30 pa aneurysms 23 76.7% located pericallosal callosomarginal junction 7 23.3% pericallosal frontopolar junction fifteen pa aneurysms left side 13 right 2 midline azygos artery all patients clinically assessed admission using hunt hess grades 12 patients 40.0% grade ii 9 30.0% grade iii 6 20.0% grade v 3 10.0% grade iv fifteen patients 50.0% concomitant ich managed conservatively two cases required surgical evacuation in general endovascular treatment performed soon possible sah regardless clinical condition coiling aneurysms performed local anesthesia intravenous bolus injection standard heparin performed procedure however drip infusion heparin carried employing catheter pressure infusion systems continuous infusion 1000 u heparin per 1000 ml saline the aim coiling obtain packing aneurysm attenuated possible the remodeling techniques using balloon stent multiple catheters unavailable aneurysms treated early part series however recently favored remodeling techniques achieve higher postoperative occlusion rates aneurysm could reached using standard procedures distal location instability microcatheter guiding catheter placed distal internal carotid artery care taken interfere flow carotid parent artery using means aneurysms reached microcatheter case intraprocedural thromboembolic complication various strategies thrombolysis applied mechanical thrombolysis intra arterial intravenous abciximab heparin infusion procedure immediately procedure furthermore patients underwent non enhanced brain computed tomography ct scan evaluate possible hemorrhagic complications unless thromboembolic complication occurred stent used antiplatelet anticoagulant medications administered the indications long term antiplatelet therapy acetylsalicylic acid and/or clopidogrel formation thrombus end coil thromboembolic events stent assisted coiling coil protrusion parent artery occlusion classified complete contrast filling aneurysmal sac neck observed near complete contrast filling neck aneurysm slow partial degree contrast filling observed within aneurysm sac clinical results assessed upon discharge hospital last visit using modified rankin scale mrs follows 0 symptoms 1 significant disability 2 slight disability 3 moderate disability 4 moderately severe disability 5 severe disability 6 death complications defined adverse events related procedure studied retrospectively using medical operative reports early rebleeding defined expanding hemorrhage worsening patient condition within 30 days coiling diagnostic confirmation made ct showed increased amount hemorrhage compared immediate postprocedural ct univariate multivariate logistic regression analyses used identify risk factors associated periprocedural rebleeding poor clinical outcome results presented odds ratios ors 95% confidence intervals cis variables showing univariate association dependent risk factor p<0.10 included multivariate logistic analysis chicago il usa statistical significance accepted p values 0.05 we retrospectively analyzed angiographic clinical records patients underwent endovascular treatment ruptured pa aneurysm institution september 2003 december 2013 the treatment strategy ruptured pa aneurysm institution attempt endovascular treatment first line treatment this strategy applied accompanied intraparenchymal hematoma ich surgical evacuation necessary performed immediately following coiling however microsurgery used early years study technology coiling distally located aneurysms infancy therefore surgical clipping first attempt 6 cases period there technical failure clipping coiling groups due retrospective nature the present study exempt accord institutional review board standards institution thirty ruptured pa aneurysms 30 patients treated endovascularly 10 males 20 females mean age 55.9 years range 24 88 years dissecting fusiform aneurysms aneurysms associated brain arteriovenous malformation traumatic mycotic aneurysms excluded size aneurysms parent arteries measured automatically manually two dimen sional digital subtraction angiography working views aneurysm size defined maximum distance dome neck plane aneurysm neck sizes ranged 2.5 10.4 mm mean 5.0 mm 0.9 6.1 mm mean 2.2 mm respectively 21 30 saccular aneurysms defined wide neck aneurysms large neck size 4 mm and/or dome neck ratio 2 of 30 pa aneurysms 23 76.7% located pericallosal callosomarginal junction 7 23.3% pericallosal frontopolar junction fifteen pa aneurysms left side 13 right 2 midline azygos artery all patients clinically assessed admission using hunt hess grades 12 patients 40.0% grade ii 9 30.0% grade iii 6 20.0% grade v 3 10.0% grade iv fifteen patients 50.0% concomitant ich managed conservatively two cases required surgical evacuation in general endovascular treatment performed soon possible sah regardless clinical condition coiling aneurysms performed local anesthesia intravenous bolus injection standard heparin performed procedure however drip infusion heparin carried employing catheter pressure infusion systems continuous infusion 1000 u heparin per 1000 ml saline the aim coiling obtain packing aneurysm attenuated possible the remodeling techniques using balloon stent multiple catheters unavailable aneurysms treated early part series however recently favored remodeling techniques achieve higher postoperative occlusion rates aneurysm could reached using standard procedures distal location instability microcatheter guiding catheter placed distal internal carotid artery care taken interfere flow carotid parent artery using means all aneurysms reached microcatheter case intraprocedural thromboembolic complication various strategies thrombolysis applied mechanical thrombolysis intra arterial intravenous abciximab heparin infusion procedure immediately procedure furthermore patients underwent non enhanced brain computed tomography ct scan evaluate possible hemorrhagic complications unless thromboembolic complication occurred stent used antiplatelet anticoagulant medications administered the indications long term antiplatelet therapy acetylsalicylic acid and/or clopidogrel formation thrombus end coil thromboembolic events stent assisted coiling coil protrusion parent artery occlusion classified complete contrast filling aneurysmal sac neck observed near complete contrast filling neck aneurysm slow partial degree contrast filling observed within aneurysm sac clinical results assessed upon discharge hospital last visit using modified rankin scale mrs follows 0 symptoms 1 significant disability 2 slight disability 3 moderate disability 4 moderately severe disability 5 severe disability 6 death complications defined adverse events related procedure studied retrospectively using medical operative reports early rebleeding defined expanding hemorrhage worsening patient condition within 30 days coiling diagnostic confirmation made ct showed increased amount hemorrhage compared immediate postprocedural ct univariate multivariate logistic regression analyses used identify risk factors associated periprocedural rebleeding poor clinical outcome results presented odds ratios ors 95% confidence intervals cis variables showing univariate association dependent risk factor p<0.10 included multivariate logistic analysis chicago il usa statistical significance accepted p values 0.05 the microcatheter navigated lumen pa aneurysm coils delivered 30 patient the treatment 19 aneurysms straightforward 11 required adjunctive technique double catheter balloon assisted stent assisted technique immediate post procedural angiograms showed complete aneurysm occlusion 21 21/30 70.0% near complete occlusion 9 9/30 30.0% procedure related thromboembolic complications developed two patients 2/30 6.7% one patient occlusion callosomarginal artery occurred due thrombus formation artery origin resulted right leg monoparesis the thromboembolism occurred inferior m2 segment middle cerebral artery procedure relevant infarction observed 2 days coiling diagnosis intraprocedural rupture made based angiographic visualization contrast material extravasation two cases the coil observed partially outside aneurysm sudden rise arterial blood pressure without angiographic demonstration extravasation contrast medium one case the mean delay coiling early rebleeding 31 hours range 2 83 hours in three patients intravenous bolus 3000 iu heparin injected procedure one case needed stent besides drip infusion heparin procedure antiplatelet anticoagulant medications administered two cases of six patients periprocedural rebleeding five small 4 mm aneurysms one large 9.9 mm multi lobulated aneurysm furthermore five patients 5/6 83.3% concerned adjacent hematoma initial ct scans three 3/6 50.0% showed contrast retention delayed washout aneurysm preprocedural digital subtraction angiography in six patients periprocedural rebleeding new neurologic deficit developed three patients 3/6 50.0% deterioration consciousness resulting death occurred two patients 2/6 33.3% it could questioned whether early rebleeding worsened clinical status one patient patient initial severe sah died within 5 days sah onset thus periprocedural mortality cohort 6.7% 2/30 morbidity 3.3% 1/30 table 3 provides summary risk factors found associated periprocedural rebleeding the associations variables periprocedural rebleeding examined univariate logistic regression analysis contrast retention found associated increased risk periprocedural rebleeding 23.000 95% ci 1.773 298.446 p=0.016 furthermore multivariate logistic regression analysis adjusted adjacent hematoma confirmed validity relationship 21.352 95% ci 1.310 347.917 p=0.032 one patient 1/30 3.3% suffered symptomatic vasospasm fortunately negative long term effects observed clinical results assessed upon discharge hospital last follow visit using mrs end observational period 18 patients independent mrs score 0 2 18/30 60.0% 12 12/30 40% dependent mrs score 3 6 seven 12 mrs score 6 due poor preoperative status five procedure related rebleeding two three mrs score 5 due poor preoperative status old age one mrs score 4 due old age one mrs score 3 due large ich the 23 surviving patients followed 6 68 months mean 32.7 months no neurologic deterioration hemorrhagic complication occurred follow period patients univariate logistic regression analysis showed age 1.080 95% ci 1.003 1.163 p=0.043 adjacent hematoma 13.000 95% ci 2.074 81.479 p=0.006 hunt hess grade 3 5 13.750 95% ci 1.452 130.239 p=0.022 associated poor clinical outcome however multivariate logistic regression analysis adjusted age hunt hess grade 3 5 showed adjacent hematoma associated poor clinical outcome 47.734 95% ci 1.596 1427.240 p=0.026 seventeen 23 surviving patients underwent follow conventional angiography 1 65 months postoperatively mean 16.5 months according follow images obtained 9 10 initially occluded aneurysms remained completely occluded remaining one showed partial recanalization due coil compaction repeat follow angiography 20 months showed patient condition stable patient concerned declined additional therapy five 7 aneurysms initially showing near complete occlusion remained stable follow recoiling undertaken patient showing major recanalization 13 months postoperatively complete occlusion achieved thus overall stable occlusion rate 82.4% 14/17 recanalization rate 17.6% 3/17 parent arteries aneurysm treated stent assisted coiling remained patent evidence intimal hyperplasia stent stenosis the microcatheter navigated lumen pa aneurysm coils delivered 30 patient the treatment 19 aneurysms straightforward 11 required adjunctive technique double catheter balloon assisted stent assisted technique immediate post procedural angiograms showed complete aneurysm occlusion 21 21/30 70.0% near complete occlusion 9 9/30 30.0% procedure related thromboembolic complications developed two patients 2/30 6.7% one patient occlusion callosomarginal artery occurred due thrombus formation artery origin resulted right leg monoparesis the thromboembolism occurred inferior m2 segment middle cerebral artery procedure relevant infarction observed 2 days coiling however patient concerned experience neurological symptom diagnosis intraprocedural rupture made based angiographic visualization contrast material extravasation two cases the coil observed partially outside aneurysm sudden rise arterial blood pressure without angiographic demonstration extravasation contrast medium one case the mean delay coiling early rebleeding 31 hours range 2 83 hours in three patients intravenous bolus 3000 iu heparin injected procedure one case needed stent besides drip infusion heparin procedure antiplatelet anticoagulant medications administered two cases of six patients periprocedural rebleeding five small 4 mm aneurysms one large 9.9 mm multi lobulated aneurysm furthermore five patients 5/6 83.3% concerned adjacent hematoma initial ct scans three 3/6 50.0% showed contrast retention delayed washout aneurysm preprocedural digital subtraction angiography in six patients periprocedural rebleeding new neurologic deficit developed three patients 3/6 50.0% deterioration consciousness resulting death occurred two patients 2/6 33.3% it could questioned whether early rebleeding worsened clinical status one patient patient initial severe sah died within 5 days sah onset thus periprocedural mortality cohort 6.7% 2/30 morbidity 3.3% 1/30 table 3 provides summary risk factors found associated periprocedural rebleeding the associations variables periprocedural rebleeding examined univariate logistic regression analysis contrast retention found associated increased risk periprocedural rebleeding 23.000 95% ci 1.773 298.446 p=0.016 furthermore multivariate logistic regression analysis adjusted adjacent hematoma confirmed validity relationship 21.352 95% ci 1.310 347.917 p=0.032 only one patient 1/30 3.3% suffered symptomatic vasospasm fortunately negative long term effects observed clinical results assessed upon discharge hospital last follow visit using mrs end observational period 18 patients independent mrs score 0 2 18/30 60.0% 12 12/30 40% dependent mrs score 3 6 seven 12 mrs score 6 due poor preoperative status five procedure related rebleeding two three mrs score 5 due poor preoperative status old age one mrs score 4 due old age one mrs score 3 due large ich the 23 surviving patients followed 6 68 months mean 32.7 months no neurologic deterioration hemorrhagic complication occurred follow period patients univariate logistic regression analysis showed age 1.080 95% ci 1.003 1.163 p=0.043 adjacent hematoma 13.000 95% ci 2.074 81.479 p=0.006 hunt hess grade 3 5 13.750 95% ci 1.452 130.239 p=0.022 associated poor clinical outcome however multivariate logistic regression analysis adjusted age hunt hess grade 3 5 showed adjacent hematoma associated poor clinical outcome 47.734 95% ci 1.596 1427.240 p=0.026 seventeen 23 surviving patients underwent follow conventional angiography 1 65 months postoperatively mean 16.5 months according follow images obtained 9 10 initially occluded aneurysms remained completely occluded remaining one showed partial recanalization due coil compaction repeat follow angiography 20 months showed patient condition stable patient concerned declined additional therapy five 7 aneurysms initially showing near complete occlusion remained stable follow recoiling undertaken patient showing major recanalization 13 months postoperatively complete occlusion achieved thus overall stable occlusion rate 82.4% 14/17 recanalization rate 17.6% 3/17 parent arteries aneurysm treated stent assisted coiling remained patent evidence intimal hyperplasia stent stenosis ruptured pa aneurysms may technically difficult clip narrow exposure afforded interhemispheric approach difficulty control parent artery sacrifice bridging vein achieve adequate surgical exposure surgical morbidity reported relatively high incidences ranging 0 25%141221 endovascular treatment ruptured pa aneurysms reported technically difficult primarily long access route complicates microcatheter manipulation small aneurysmal lumen the introduction new microcatheter microguidewire improved trackability pushability torque novel hydrophilic coatings facilitated navigation distant cerebral arteries pa furthermore availabilities various soft coils may contributed higher success rate small aneurysm coiling without intraoperative rupture we found pa could reached coiling aneurysm accomplished 30 patients in fact even 2.5 mm sized aneurysm located distal junction occluded successfully series an independent daily living activity level mrs score 0 2 achieved 60% patients 18/30 the poor clinical outcomes mrs score 3 6 12 patients resulted poor preoperative status periprocedural rebleeding old age large ich waldenberger et al.25 reported important negative contributor outcome pa aneurysm coiling presence ich followed thromboembolic complications poor preoperative status ruptured pa aneurysms cause ich addition sah one half cases associated poorer outcomes rupture aneurysms locations311 in present study 15 30 patients 50.0% concomitant ich visualized initial ct scans 10 patients 10/15 66.7% poor clinical outcome mrs score 3 6 furthermore multivariate logistic regression analysis showed adjacent hematoma independent predictor poor clinical outcome 47.734 95% ci 1.596 1427.240 p=0.026 other variables age hunt hess grade borderline significance possibly due small number patients enrolled table 4 we summarized reported studies 10 patients ruptured pericallosal artery aneurysms treated endovascular treatment table 5 recently reported meta analysis endovascular treatment pa aneurysms including 16 studies authors concluded endovascular treatment pa aneurysms associated high angiographic occlusion rates complication rates higher compared aneurysms circle willis procedure related ischemia iatrogenic rupture occurred 5% 7% patients respectively procedure related permanent morbidity rate 8%23 present study overall procedure related complication rate 26.7% 8/30 cases two patients experienced thromboembolic events acute infarctions developed corresponding neurologic deficits though fortunately showed neurological deficit follow intraprocedural rupture occurred three aneurysms 10.0% markedly greater anticipated a review literature revealed pa aneurysms higher procedure related rupture rate non pa aneurysms keston et al.9 reported intraprocedural rupture rate 18% 3/17 patients pa aneurysms compared overall departmental five year 1999 2003 inclusive intraprocedural rupture rate 1.1% 7/640 patients non pa aneurysms nguyen et al.15 reported 12% 3/25 patients procedure related perforation rate endovascular series pa aneurysms based reports fact previous reports included unruptured cases whereas believe intraprocedural rupture rate excessive it well known pa aneurysms smaller non pa aneurysms tend tend rupture smaller size101327 study large number aneurysm cases average diameter ruptured aneurysms reported 8.2 mm8 whereas average aneurysm diameter patients 5.0 mm we believe difference could explain higher intraprocedural rupture rate endovascular treatment ruptured pa aneurysms in addition aneurysm size risk procedure induced perforation may also related anatomical peculiarities a distal location leads catheter positioning via longer segment small caliber vessel reduces degree catheter deflection coil encounters resistance15 prior studies early rebleeding coiling reported rupture rates 1.4% 2.6%6722 incomplete embolization adjacent hematoma small aneurysms post procedural anticoagulation reported associated early rebleeding coiling the cerebral aneurysm rerupture treatment study reported risk posttreatment rebleeding closely associated degree aneurysm occlusion7 however experienced three cases early rebleeding coiling 10.0% despite three aneurysms complete embolized procedure the presence adjacent hematoma strong independent risk factor early rebleeding thrombosed pseudoaneurysm hematoma could cause early reopening rehemorrhage22 series three cases early rebleeding accompanied adjacent hematoma coiling a pseudoaneurysm may may visible angiography pseudoaneurysm apparent angiography coiling true aneurysm pseudoaneurysm considered fragile wall pseudoaneurysm prone perforation prompted advise catheterization false lumen16 hand cho et al.2 reported early recurrent hemorrhage coil embolization ruptured intracranial aneurysms hypothesized another possibility rebleeding ich may caused delayed hemorrhage propagation initial ich due vulnerability parenchyma adjacent ich rather rebleeding coiled aneurysm early rebleeding coiling ruptured aneurysm intra procedural rupture major concerns associated mortality rates high when ruptured pa aneurysm accompanied adjacent hematoma decisions regarding endovascular treatment taken carefully considering possibility periprocedural rebleeding therefore may better consider surgical clipping ruptured pa aneurysm adjacent hematoma first option prevent periprocedural rebleeding regard treatment durability recurrence requiring recoiling due risk rupture developed one 17 cases developed major recanalization present study the overall recanalization rate 17.6% 3/17 major recanalization rate 5.9% 1/17 recurrence coiling reported associated primarily aneurysm size7162226 one study follow angiographic studies complete occlusion showed recurrence rates 14% aneurysms 5 mm 27% aneurysms 5 10 mm 57% aneurysms 10 mm23 therefore lower rate recurrence series could due lower proportion cases aneurysms 5 mm 9/30 30.0% however recent series 16 cases pa aneurysm coiling comparatively high recurrence rate one major five minor recurrences 37.5% attributed loose coil packing rate19 this study limited retrospective design patient selection bias small cohort relatively short angiographic follow fact conducted single institution nonetheless findings suggest endovascular treatment ruptured pa aneurysms appears valid treatment strategy given suitable levels institutional operator expertise our experiences show endovascular treatment ruptured pa aneurysms feasible effective however show periprocedural rebleeding occur far frequently 20.0% generally considered rebleeding associated preprocedural contrast retention accordingly findings caution decisions regarding endovascular treatment cases showing preprocedural contrast retention approached carefully considering possibility periprocedural rebleeding furthermore existing adjacent hematoma found severe negative influence clinical outcome

objectiveaneurysms arising from the pericallosal artery ( pa ) are uncommon and challenging to treat . the aim of this study was to report our experiences of the endovascular treatment of ruptured pa aneurysms.methodsfrom september 2003 to december 2013 , 30 ruptured pa aneurysms in 30 patients were treated at our institution via an endovascular approach . procedural data , clinical and angiographic results were retrospectively reviewed.resultsregarding immediate angiographic control , complete occlusion was achieved in 21 ( 70.0% ) patients and near - complete occlusion in 9 ( 30.0% ) . eight procedure - related complications occurred , including intraprocedural rupture and early rebleeding in three each , and thromboembolic event in two . at last follow - up , 18 patients were independent with a modified rankin scale ( mrs ) score of 0 - 2 , and the other 12 were either dependent or had expired ( mrs score , 3 - 6 ) . adjacent hematoma was found to be associated with an increased risk of poor clinical outcome . seventeen of 23 surviving patients underwent follow - up conventional angiography ( mean , 16.5 months ) . results showed stable occlusion in 14 ( 82.4% ) , minor recanalization in two ( 11.8% ) , and major recanalization , which required recoiling , in one ( 5.9%).conclusionour experiences demonstrate that endovascular treatment for a ruptured pa aneurysms is both feasible and effective . however , periprocedural rebleedings were found to occur far more often ( 20.0% ) than is generally suspected and to be associated with preoperative contrast retention . analysis showed existing adjacent hematoma is predictive of a poor clinical outcome .

cardiac implantable electronic device cied implantation continues grow permanent pacemaker implantation usa increasing 56% 1993 2009 europe 75 115% increase implantable cardiac defibrillator icd cardiac resynchronization therapy pacemaker defibrillator crt p crt implants 2004 2008 result increasing indications complex pacing expanding need patients pre existing devices undergo system revision due lead failure upgrade allow icd and/or crt implant recent european survey 28% crt implants were performed patients pre existing devices recent lead advisories necessitated increase lead extraction cases the combination factors means need system revision upgrade likely increase future major obstacle device revision and/or upgrade presence asymptomatic ipsilateral central venous obstruction older reports suggested obstruction occurred 50% cases symptoms affecting 13% contemporary reports demonstrated lower incidence closer 30% this perhaps reflects improvements lead design time remains clear asymptomatic venous obstruction infrequently encountered various strategies overcome venous occlusion exist including contralateral lead device implantation venoplasty surgical epicardial lead implantation the addition extra pacemaker and/or icd leads without drawbacks recent prospective us registry pacemaker icd generator replacements the need additional lead increased rate major complications 4.0 15.3% lead extraction may alternative option overcome problem without risk weighed benefits removing leads also likelihood symptom recurrence cases symptoms venous occlusion the practice laser lead extraction canalize venous obstruction previously described limited number patients suitability technique larger scale reported we describe experience using laser lead extraction overcome venous occlusion enable ipsilateral device revision and/or upgrade guy st thomas hospital quaternary referral centre cied extraction all patients undergoing device extractions prospectively entered computer database recording patient demographics comorbidities device lead type reason extraction procedural success complications complications classified according recommended heart rhythm society consensus report transvenous lead extraction deaths adjudicated senior cardiologists within department none input current study patients database included present study indication lead extraction upgrade revise existing device presence ipsilateral venous obstruction cases venous obstruction identified basis venography performed either radiology department least 1 day prior procedure cardiac catheter laboratory day procedure prior procedure ascertain patency venous system figure 1 all patients provided written informed consent procedures performed cardiac catheter laboratory general anaesthesia patients ipsilateral venous occlusion stenoses severe enough hydrophilic guide wire would cross obstruction laser lead extraction retention outer sheath vascular tree performed cases device upgrade non functional leads removed non functional lead example upgrade dual chamber pacing crt p atrial lead extracted attempt preserve existing right ventricular rv pacing lead any redundant leads also extracted cases device upgrade also failed lead need extraction failed lead extracted two hydrophilic wires passed outer sheath laser after opening existing generator pocket disconnecting leads generator suture sleeve lead extracted released the proximal end lead cut locking stylet liberator beacon cook medical inc lld ez lead locking device spectranetics advanced distally possible locked place a silk suture tied lead aid traction fed laser sheath sls ii excimer laser sheaths spectranetics outer sheath also position both sheaths advanced lead inner sheath advanced resistance met point laser energy applied short pulses free lead body surrounding vessel wall cardiac musculature cvx-300 excimer laser system spectranetics lasing performed necessary final 1 cm proximal distal electrode lead freed counter traction using outer sheath the lead inner sheath removed entirety leaving outer sheath place thereby maintaining vascular access a venogram performed ensure sheath remained vascular cardiac space hydrophilic wire terumo passed outer sheath intravascular position confirmed a long haemostatic sheath(s placed allow lead implantation standard fashion see figure 2 ( suggestive collateral formation white arrow confirmed medial panning venogram white arrows b figure 2sequential images steps taken successfully extract atrial pace sense patient atrial fibrillation need upgrade biventricular pacemaker maintenance venous access across level occlusion ( inner sheath advanced outer sheath trailing demonstrated case the laser often required overcome fibrosis clavicular level outer sheath advanced b ( c lasing upto beyond point occlusion passage outer sheath beyond occlusion aided rotational torque ( e atrial lead successfully extracted entirety using combination forward pressure outer sheath manual traction locking stylet ( f inner sheath lead removed leaving outer sheath vascular space beyond level occlusion ( g hydrophilic wire passed outer sheath allowing passage introducer sheath subsequent lv lead placement h ( suggestive collateral formation white arrow confirmed medial panning venogram white arrows b sequential images steps taken successfully extract atrial pace sense patient atrial fibrillation need upgrade biventricular pacemaker maintenance venous access across level occlusion ( inner sheath advanced outer sheath trailing demonstrated case the laser often required overcome fibrosis clavicular level outer sheath advanced b ( c lasing upto beyond point occlusion passage outer sheath beyond occlusion aided rotational torque ( e atrial lead successfully extracted entirety using combination forward pressure outer sheath manual traction locking stylet ( f inner sheath lead removed leaving outer sheath vascular space beyond level occlusion ( g hydrophilic wire passed outer sheath allowing passage introducer sheath subsequent lv lead placement h between july 2004 april 2012 242 upgrade revision procedures performed 71 29% performed patients occluded severely stenosed venous anatomy complete ipsilateral occlusion present 52 71 patients 73% series the remainder severe stensoses allow passage hydrophilic guide wires and/or introducer sheaths taken indicating functional obstruction the vast majority obstructions identified subclavian vein 67 71 remainder junction subclavian vein superior vena cava svc see figure 1 twenty nine 41% patients history ischaemic heart disease 19 27% prior cardiac surgery coronary artery bypass surgery valve surgery the mean left ventricular lv ejection fraction 38% derived 2d echocardiography using simpson biplane method three patients 4% symptoms venous occlusion arm swelling pain side device implant table 1patient characteristicscharacteristicage years)62 15gender n male 55 77)female 16 23)ejection fraction 38 15comorbiditiesihd n 29 41)cardiac surgery n 19 27)diabetes n 5 7)hypertension n 16 23)pvd n 3 4)stroke n 5 7)copd n 14 20)ckd n 12 17)ihd ischaemic heart disease pvd peripheral vascular disease copd chronic obstructive pulmonary disease ckd chronic kidney disease patient characteristics ihd ischaemic heart disease pvd peripheral vascular disease copd chronic obstructive pulmonary disease ckd chronic kidney disease most extractions performed patients existing dual chamber pacemakers icds crt ds 24 37 27% respectively total 129 leads extracted 71 patients see table 2 40 31% passive fixation right atrial ra rv pacemaker leads 33 26% active fixation ra rv pacing leads 41 31% single- dual coil defibrillator leads 15 12% coronary sinus lv pacing leads extracted due sub optimal function phrenic nerve capture sub optimal lead positioning the commonest indications extraction lead malfunction 56% need device upgrade 40% table 2device characteristicscharacteristicdevice n vvi2 3 ddd17 24 icd26 37 crt p7 9 crt d19 27)indication extraction n lead failure40 56 upgrade28 40 symptoms3 4)nature upgrade n ppm icd8 29 ppm crt p9 32 icd crt d11 39)number leads extracted n total129 passive v40 31 active v33 26 icd41 31 cs15 12)mean duration lead implant months)80 62vvi single chamber pacemaker lead rv ddd dual chamber pacemaker icd implantable cardioverter defibrillator crt p cardiac resynchronization therapy pacemaker crt cardiac resynchronization therapy defibrillator ppm permanent pacemaker passive v passive fixation atrial ventricular leads active v active fixation atrial ventricular leads cs coronary sinus device characteristics vvi single chamber pacemaker lead rv ddd dual chamber pacemaker icd implantable cardioverter defibrillator crt p cardiac resynchronization therapy pacemaker crt cardiac resynchronization therapy defibrillator ppm permanent pacemaker passive v passive fixation atrial ventricular leads active v active fixation atrial ventricular leads cs coronary sinus it necessary snare leads femoral venous approach two cases following unsuccessful laser extraction lead fragmented despite obstruction crossed new leads successfully implanted via laser sheath across venous obstruction stenosis 67 94% cases four cases the laser sheath unable pass obstruction due intense fibrosis calcification three cases subclavian vein puncture medial venous occlusion performed obtain venous access successfully place lead one case transvenous lead could placed epicardial lv pacing lead surgically implanted later procedure mean fluoroscopic screening time 16 13 min mean radiation dose 837 1269 cgycm two major complications 3% cases infection previously sterile site four 6% minor complications ipsilateral pneumothorax phrenic nerve palsy acute renal failure pocket haematoma table 3procedural characteristics outcomecharacteristicobstruction crossed n 67 94)lead successfully extracted via laser sheath n 69 97)transvenous lead successfully sited70 ( 99)procedural time min)116 32fluoroscopy time min)16 13radiation dose cgycm)837 1269complications major n 2 3 minor n 4 5 30-day mortality n 2 3 procedural characteristics outcome medium- long term device follow available 65 71 92% cases mean follow 26 19 months one patient developed non procedure related sepsis urinary sepsis following urethral instrumentation urinary retention recuperating procedure the second death occurred patient severe heart failure new york heart association iv pre existing crt non functioning lv pacing lead the patient refractory hypotension hyponatraemia limiting use medical therapy decision made attempt revision crt device procedure last resort the patient died hospital end stage heart failure despite successful lead extraction both deaths adjudicated senior physicians within department blinded interventions current study it necessary revise cied implants following index procedure four 6% cases two cases required intervention defibrillator leads diminished sensing one patient developed phrenic nerve capture lv pacing lead one patient deteriorated sub optimal lv lead position required revision twenty nine 41% patients history ischaemic heart disease 19 27% prior cardiac surgery coronary artery bypass surgery valve surgery the mean left ventricular lv ejection fraction 38% derived 2d echocardiography using simpson biplane method three patients 4% symptoms venous occlusion arm swelling pain side device implant table 1patient characteristicscharacteristicage years)62 15gender n male 55 77)female 16 23)ejection fraction 38 15comorbiditiesihd n 29 41)cardiac surgery n 19 27)diabetes n 5 7)hypertension n 16 23)pvd n 3 4)stroke n 5 7)copd n 14 20)ckd n 12 17)ihd ischaemic heart disease pvd peripheral vascular disease copd chronic obstructive pulmonary disease ckd chronic kidney disease patient characteristics ihd ischaemic heart disease pvd peripheral vascular disease copd chronic obstructive pulmonary disease ckd chronic kidney disease most extractions performed patients existing dual chamber pacemakers icds crt ds 24 37 27% respectively total 129 leads extracted 71 patients see table 2 40 31% passive fixation right atrial ra rv pacemaker leads 33 26% active fixation ra rv pacing leads 41 31% single- dual coil defibrillator leads 15 12% coronary sinus lv pacing leads extracted due sub optimal function phrenic nerve capture sub optimal lead positioning the commonest indications extraction lead malfunction 56% need device upgrade 40% table 2device characteristicscharacteristicdevice n vvi2 3 ddd17 24 icd26 37 crt p7 9 crt d19 27)indication extraction n lead failure40 56 upgrade28 40 symptoms3 4)nature upgrade n ppm icd8 29 ppm crt p9 32 icd crt d11 39)number leads extracted n total129 passive v40 31 active v33 26 icd41 31 cs15 12)mean duration lead implant months)80 62vvi single chamber pacemaker lead rv ddd dual chamber pacemaker icd implantable cardioverter defibrillator crt p cardiac resynchronization therapy pacemaker crt cardiac resynchronization therapy defibrillator ppm permanent pacemaker passive v passive fixation atrial ventricular leads active v active fixation atrial ventricular leads cs coronary sinus device characteristics vvi single chamber pacemaker lead rv ddd dual chamber pacemaker icd implantable cardioverter defibrillator crt p cardiac resynchronization therapy pacemaker crt cardiac resynchronization therapy defibrillator ppm permanent pacemaker passive v passive fixation atrial ventricular leads active v active fixation atrial ventricular leads cs coronary sinus all 129 leads successfully extracted entirety necessary snare leads femoral venous approach two cases following unsuccessful laser extraction lead fragmented despite obstruction crossed new leads successfully implanted via laser sheath across venous obstruction stenosis 67 94% cases four cases the laser sheath unable pass obstruction due intense fibrosis calcification three cases subclavian vein puncture medial venous occlusion performed obtain venous access successfully place lead one case a transvenous lead could placed epicardial lv pacing lead surgically implanted later procedure mean fluoroscopic screening time 16 13 min mean radiation dose 837 1269 cgycm there two major complications 3% cases infection previously sterile site four 6% minor complications ipsilateral pneumothorax phrenic nerve palsy acute renal failure pocket haematoma table 3procedural characteristics outcomecharacteristicobstruction crossed n 67 94)lead successfully extracted via laser sheath n 69 97)transvenous lead successfully sited70 ( 99)procedural time min)116 32fluoroscopy time min)16 13radiation dose cgycm)837 1269complications major n 2 3 minor n 4 5 30-day mortality n 2 3 procedural characteristics outcome medium- long term device follow available 65 71 92% cases mean follow 26 19 months one patient developed non procedure related sepsis urinary sepsis following urethral instrumentation urinary retention recuperating procedure the second death occurred patient severe heart failure new york heart association iv pre existing crt non functioning lv pacing lead the patient refractory hypotension hyponatraemia limiting use medical therapy decision made attempt revision crt device procedure last resort the patient died hospital end stage heart failure despite successful lead extraction both deaths adjudicated senior physicians within department blinded interventions current study it necessary revise cied implants following index procedure four 6% cases two cases required intervention defibrillator leads diminished sensing one patient developed phrenic nerve capture lv pacing lead one patient deteriorated sub optimal lv lead position required revision we described experience using laser lead extraction overcome ipsilateral venous obstruction patients undergoing device revision and/or upgrade date largest series cases laser lead extraction used overcome venous obstruction thereby allowing ipsilateral lead revision device upgrade we shown technique feasible vast majority cases 100% cases targeted lead(s ) were completely extracted 94% canalization obstructed vein allowed successful lead implantation via laser sheath remaining patients transvenous lead implantation successful ipsilateral side medial puncture one case patient need procedure surgical lv lead implant achieve implant success complication rate low even cohort patients reduced lv systolic function significant comorbidities the heart rhythm society hrs consensus statement lead extraction relation venous obstruction states lead removal class recommendation patients ipsilateral venous occlusion preventing additional lead placement contraindication using contralateral side e.g. contralateral atrioventricular fistula shunt vascular access port mastectomy lead removal patients ipsilateral venous occlusion contraindication using contralateral side class iia indication obstruction thrombosis access vein implantation permanent pacing defibrillator leads well described the reported incidence asymptomatic cases 50% older series 30% contemporary series symptomatic occlusion occurs 13% thus highlighting importance developing strategies overcoming obstacles time device upgrade lead revision study finding venous obstruction precluding device revision upgrade 29% keeping recent reports in cases may possible obtain venous access de novo puncture often possible advance introducer sheaths across tight stenosis added risk increased lead lead interaction these issues avoided using technique described report demonstrated procedure performed safely laser technology increasingly used facilitate lead extraction plexes trial use laser sheath resulted complete removal 94% leads compared 64% non laser tools used predominantly telescoping sheaths more recently bordachar et al showed laser extraction results shorter procedures lower radiation exposure operators compared femoral snare techniques the lexicon study observational retrospective study 1449 consecutive laser lead extractions north america confirmed high success rates low complication rates particularly high volume centres the use laser sheath overcome venous obstruction first described bracke et al three patients laser used point obstruction lead left situ the largest previous series gula et al included 18 patients laser lead extraction performed facilitate system upgrade presence central venous occlusion earlier reports our current study provides expanded assessment technique larger number patients procedures performed three experienced operators single centre extensive experience laser lead extraction our patients tended longer duration lead implant 80 62 vs. 70.8 43.5 months series gula et al in addition cohort patients typical procedures performed namely depressed ejection fraction attendant comorbidities no outer sheath used minority cases tissue build tip laser sheath prevented withdrawal lead tip laser sheath this necessitated extraction functional atrial lead ensure maintenance venous patency also study included patients requiring non functional lead extraction rather device upgrade in cases extraction may preferable adding extra leads study leads removed entirety necessary snare two leads femoral venous route therefore 98% leads removed using laser sheath alone total venous access maintained outer sheath 94% cases no leads unintentionally damaged necessary extract extra leads this important may implications reducing risk procedure there inherent risks extracting leads particularly thin walled ra extraneous extraction avoided preferable current study leads successfully extracted cases laser sheath successfully overcome fibrosis subclavicular level there two major procedural complications cases infection previously sterile site possibly reflects added risk performing upgrade revision procedures of four minor complications none specifically related use laser sheath overcome obstruction the alternative options available ipsilateral venous occlusion present include insertion new leads via contralateral subclavian vein either tunnelling leads across sternum abandonment pre existing leads;venoplasty occluded vessels;alternative venous access;surgical epicardial lead implant.each techniques listed specific drawbacks the practice adding leads without risk replace registry 15.3% major complication rate 1.1% 6-month mortality rate patients undergoing generator change planned lead addition revision the hrs lead extraction consensus statement states lead removal reasonable patients cied implantation would require four leads one side five leads svc class iia recommendation the presence redundant leads also associated increased risks infection erosion tunnelling across sternum contralateral position existing generator potentially avoids risk svc syndrome heightened risk lead erosion patient discomfort bilateral occlusion venoplasty previously described wire passed occlusion balloon venoplasty performed open patent channel the results procedure encouraging lead implantation possible 96% patients recent report the technique may ideal cases indication lead revision defibrillator lead failure extraction malfunctioning lead may preferred option lead malfunction primary indication revision 56% cases use laser sheath overcome obstruction remove malfunctioning lead represents attractive option cases use venous access sites internal jugular vein subsequent tunnelling leads described however lead erosion remains issue surgical implantation epicardial leads negates need transvenous approach requires thoracotomy lead failure uncommon insertion new leads via contralateral subclavian vein either tunnelling leads across sternum abandonment pre existing leads venoplasty occluded vessels alternative venous access surgical epicardial lead implant this study single centre experience experienced operators therefore results may widely applicable less experienced centres lead extraction without risk performed centres experienced staff necessary equipment tools access onsite emergency surgery a prospective study laser extraction treat venous obstruction would necessary extrapolate results our results suggest laser lead extraction overcome ipsilateral venous obstruction effective safe therefore represents attractive approach deal device upgrade lead revision patients obstructed severely stenosed venous anatomy m.o.n received research funding st jude medical biosense webster j.g received research funding biosense webster st jude medical c.a.r is consultant spectranetics received research funding st jude medical boston scientific medtronic m.s

aimsthe number of procedures involving upgrade or revision of cardiac implantable electronic devices ( cieds ) is increasing and the risks of adding additional leads are significant . central venous occlusion in patients with pre - existing devices is often asymptomatic and optimal management of such patients in need of device revision / upgrade is not clear . we sought to assess our use of laser lead extraction in overcoming venous obstruction.methods and resultspatients in need of device upgrade / revision underwent pre - procedure venography to assess venous patency . in patients with venous occlusion or stenosis severe enough to preclude passage of a hydrophilic guide wire , laser lead extraction with retention of the outer sheath in the vasculature was performed with the aim of maintaining a patent channel through which new leads could be implanted . data were recorded on a dedicated database and patient outcomes were assessed . between july 2004 and april 2012 , laser lead extractions were performed in 71 patients scheduled for device upgrade / revision who had occluded or functionally obstructed venous anatomy . new leads were successfully implanted across the obstruction in 67 ( 94% ) cases . there were two major complications ( infection ) and four minor complications with no peri - procedural mortality . device follow - up was satisfactory in 65 ( 92% ) cases with mean follow - up up to 26 19 months.conclusionlaser lead extraction is a safe and effective option when managing patients with central venous obstruction in need of cied revision or upgrade .

incidence age related diseases rising seriously affecting health millions people around world according united nations un world health organization musculoskeletal rheumatic arthritic conditions leading causes morbidity disability throughout world giving rise enormous healthcare expenditures loss work woolf pfleger 2003 source http://www.arthritis.org/ many types rheumatic diseases arthritic conditions essentially age related inflammatory disorders inflammation facilitates disease progression the term arthritis characterizes group conditions involving inflammatory damage synovial joints di paola cuzzocrea 2008 it involves pain redness heat swelling harmful effects inflammation within joint however common important form arthritis osteoarthritis oa also known osteoarthrosis degenerative joint disease djd oa prevalent chronic diseases affecting elderly aigner et al 2004 the majority population 65 years age demonstrate radiographic evidence oa least one joint although oa rare people 40 becomes much common age a 2005 study usa estimated oa one top five causes disability amongst non hospitalized adults source center disease control cdc usa 2006 it estimated around 35 million 40 million europeans suffer oa nearly 25% people aged 60 suffer oa induced disability it also anticipated year 2030 20% adults developed oa western europe north america therefore oa expected place heavy economic burden healthcare systems community services throughout world the risk factors oa well known include age overweight obesity underlying metabolic endocrine disease genetics joint trauma lotz kraus 2010 increasing life expectancy growth elderly population alarming escalation chronic inflammatory age related conditions oa it mechanically unique resilient connective tissue responsible load bearing low friction movement synovial joints vertebrates buckwalter et al cartilage avascular consequence limited capacity intrinsic repair brittberg 1999 tew et al 2001 it highly prone structural degradation making particularly difficult restore damaged lost the ecm consists three classes molecules collagens aggregating proteoglycans non collagenous proteins type ii ix xi collagens form fibrillar framework macromolecules give tissue form tensile stiffness mechanical strength buckwalter mankin 1998b eyre 2004 large aggregating proteoglycans predominantly aggrecan allow cartilage swell resist compressive forces hardingham fosang 1992 kuettner 1992 small proteoglycans including decorin biglycan fibromodulin bind matrix macromolecules help stabilize ecm other collagenous non collagenous macromolecules present within ecm perform variety structural informational roles facilitate cell cell cell matrix interactions bind growth factors hardingham fosang 1992 feng et al 2006 the chondrocyte cell type present articular cartilage archer francis west 2003 embryonic development chondrocytes synthesize cartilaginous template endochondral ossification skeletal development postnatal life maintain ecm regulating turnover matrix components response biomechanical biochemical endocrine signals goldring marcu 2009 chondrocytes actively synthesize new ecm components well proteolytic enzymes matrix metalloproteinases mmps disintegrin metalloproteinase adams disintegrin metalloproteinase thrombospondin motifs adamtss responsible tissue remodeling development these enzymes also involved catabolic breakdown cartilage oa aigner et al osteoarthritis degenerative disease involves joint inflammation bone remodeling catabolic destruction articular cartilage component goldring goldring 2007 samuels et al 2008 in oa imbalance synthesis degradation ecm macromolecules felson 2004 this due increased enzymatic activity mmps okada et al 1992 pro inflammatory mediators cytokines goldring goldring 2004 prostaglandins nitric oxide goldring berenbaum 2004 coupled reduced anabolic capacity chondrocytes aigner et al 1997 tissue inherently poor reparative capacity due avascular nature archer francis west 2003 the degradation release proteins glycoproteins cartilage oa vary according stage disease process for example elevated serum cartilage oligomeric matrix protein comp correlated presence oa disease severity clark et al 1999 aging major contributor musculoskeletal degeneration development oa hamerman 1998 lotz carames 2011 age related changes articular cartilage contribute development progression oa although degeneration articular cartilage simply result aging mechanical wear aging nevertheless modifies articular joint including cartilage subchondral bone muscle soft tissues synovial membrane synovial fluid buckwalter mankin 1998a hamerman 1998 although older age greatest risk factor oa oa inevitable consequence growing old shane anderson loeser 2010 cell stress oxidative damage contribute chronic inflammation promotes age related diseases oa this results senescence associated secretory phenotype many characteristics osteoarthritic chondrocyte terms cytokines chemokines proteases produced loeser 2011 a major focus clinical research recent years identification new disease markers facilitate early diagnosis optimize individualized treatments such markers also facilitate drug discovery process reducing high levels attrition clinical trials a biomarker classically defined biochemical entity used measure progress disease effects treatment clinical outcome biochemical markers measured blood serum urine variety body fluids tissues the national cancer institute nci defines biomarker biological molecule found blood body fluids tissues sign normal abnormal process condition disease terms molecular markers signature molecules also used describe markers the term biomarker encompassing include proteins protein fragments metabolites carbohydrates nucleic acids rna dna cellular features images osteoarthritis unambiguously diagnosed detected best available test thus far the best test purpose radiography called gold standard this process also requires clinical signs patient often occur well progression disease however often early pre clinical evidence disease provided various biomarkers detected may facilitate earlier diagnosis treatment such approach particularly pertinent case oa disease often characterized prolonged pre clinical molecular phase pre radiographic phase recalcitrant radiographic phase time structural changes joints along pain loss function biomarkers potential provide early warning joint degeneration could prompt earlier targeted treatment prevent tissue destruction results characteristic chronic disability associated oa context biomarkers could make significant contribution early diagnosis oa well informing key aspects disease prognosis monitoring therapy the national institute arthritis musculoskeletal skin diseases niams established osteoarthritis biomarkers network develop validate standardized sensitive biomarker assays blood urine facilitate diagnosis pre radiologic stage oa humans animal models such markers help us understand biological processes involved disease progression allow us monitor effects surgical pharmacological treatment thus accelerating pace drug discovery such biomarkers could also potentially used identify patients increased risk developing oa existing biomarkers oa major limitations flag pre radiographic phase disease specific various stages oa cases may even specific oa considering challenges osteoarthritis research society international oarsi us food drug administration fda recently established new oa biomarkers working group proposed division potential markers two major groups called soluble biomarkers typically reflect modulation endogenous substance body fluids blood serum plasma urine synovial fluid dry biomarkers usually consist visual analog scales performed tasks images joints kraus et al 2011 therefore ability detect biomarkers cartilage degradation and/or inflammation biological samples serum urine synovial fluid may enable clinicians diagnose sub clinical oa well determining disease stage human companion animals identifying biomarkers will also aid drug discovery drug safety efficacy monitoring patients animal models using combinations biomarkers may effective achieving goals thus panel biomarkers help researchers pharmaceutical industry monitor disease progression well assess responses treatment experimental models oa rousseau delmas 2007 williams 2009 systems biology increasingly applied orthopedics rheumatology cartilage synovium arthritis these techniques include genomics transcriptomics proteomics metabolomics glycomics bioinformatics applied study cartilage synovium synovial fluid even blood serum urine oa patients proteomics involves application specialized analytical techniques allow evaluation protein composition tissues cells culture supernatants proteomics increasingly applied basic cartilage biology polacek et al 2010 oa research ruiz romero et al 2010 characterization cell lysates isolated chondrocytes yielded valuable information regarding intracellular proteins chondrocyte proteome paved way future studies cartilage pathologies oa ruiz romero et al 2005 ruiz romero blanco 2010 studies soluble proteins cartilage tissue oa patients increased knowledge proteins contained within ecm diseased versus normal tissue wu et al 2007 a number papers reported proteins secreted cartilage ecm response pathological insults interleukin il)-1 trans retinoic acid wilson et al 2008a b ruiz romero blanco 2010 il-1 tnf- cillero pastor et al 2010 mechanical compression stevens et al 2008 ; identifying proteins released cartilage potential give indication disease biomarkers likely present synovial fluid blood patients early stages oa understanding healthy aging key research priority along better understanding pathophysiology aging occurs number age related diseases arthritis gaining better understanding healthy musculoskeletal aging provide better care new therapies common musculoskeletal problems physiology pathophysiology musculoskeletal aging research topic intended bring together basic researchers clinicians working broad area musculoskeletal aging the topic includes mechanisms healthy aging tissues musculoskeletal system i.e. skeletal muscle articular cartilage subchondral bone tendon ligament the discovery validation biomarkers oa accelerated significantly understanding joint tissue molecules complex interactions increased kraus 2005 one main drivers context urgent need improved oa outcome measures clinical trials kraus 2005 hunter et al in particular pressing need new biomarkers indicate early responses joint cartilage degeneration useful detecting early pre radiographic changes novel markers characterize status prognosis oa used monitor response therapy also required mobasheri henrotin 2010 research aims develop analytical toolbox hoped contribute clinical development process bay jensen et al 2010 ; combinations existing biomarkers may improve prognostic accuracy help identify risk patients williams 2009 omics based technologies order identify sensitive reliable pre radiographic biomarkers accurately reproducibly measured body fluids biomarkers flag early stage oa particularly useful curbing disease progression identifying patients would benefit early therapeutic intervention research topic gharbi co workers gharbi et al 2011 ) their aim improve understanding physiopathology disease underlying mechanisms discover disease specific biomarkers identify new therapeutic targets this timely focused review summarizes currently available data regarding proteomic techniques applications oa research the authors discuss technical limitations solutions real practical problems including sample preparation although proteomics many potential applications area technical challenges still remain the author declares research conducted absence commercial financial relationships could construed potential conflict interest

the incidence of age - related musculoskeletal impairment is steadily rising throughout the world . musculoskeletal conditions are closely linked with aging and inflammation . they are leading causes of morbidity and disability in man and beast . aging is a major contributor to musculoskeletal degeneration and the development of osteoarthritis ( oa ) . oa is a degenerative disease that involves structural changes to joint tissues including synovial inflammation , catabolic destruction of articular cartilage and alterations in subchondral bone . cartilage degradation and structural changes in subchondral bone result in the production of fragments of extracellular matrix molecules . some of these biochemical markers or biomarkers can be detected in blood , serum , synovial fluid , and urine and may be useful markers of disease progression . the ability to detect biomarkers of cartilage degradation in body fluids may enable clinicians to diagnose sub - clinical oa as well as determining the course of disease progression . new biomarkers that indicate early responses of the joint cartilage to degeneration will be useful in detecting early , pre - radiographic changes . systems biology is increasingly applied in basic cartilage biology and oa research . proteomic techniques have the potential to improve our understanding of oa physiopathology and its underlying mechanisms . proteomics can also facilitate the discovery of disease - specific biomarkers and help identify new therapeutic targets . proteomic studies of cartilage and other joint tissues may be particularly relevant in diagnostic orthopedics and therapeutic research . this perspective article discusses the relevance and potential of proteomics for studying age - related musculoskeletal diseases such as oa and reviews the contributions of key investigators in the field .

patient journey may begin transfer ambulance emergency room sometimes continues surgery intensive care followed general ward intensive care designed meant sickest patients potential life threats vital organs dysfunction requires advanced monitoring technique diagnosis treatments organizing performing patient transfers continuum care part work nurses staff multiprofessional healthcare team whittaker ball 2000 argue important perform preparations transfer general ward accurately correctly if done patient must readmitted intensive care unit icu exposed stress this depending multiple reasons common causes could present sedation altered mental status discharge planning general described process provide continuity care patients study icu transitional care defined care provided transfer icu patient another care unit aim ensuring minimal disruption optimal care patient this care may provided icu nurses acute care nurses physicians healthcare professionals hence study care defined mix nursing care medical care it important patients transfers icu done properly right time longer need intensive care 4 5 patients want feel safe secure transfer easily become dependent staff there studies describe patients perceive safety transfer feel recovery also reported perceived physical illness affect experiences displacement patients sometimes also struggle feelings abandonment vulnerability helplessness unimportance ambivalent feelings upcoming transfers also shown common positive negative emotions reported 911 different factors impact patients recovery intensive care premorbid state social family psychological physical status employment the struggle hospital bed placement becoming frequent nowadays hospitals often overcrowded also implies organization transfers especially important patient safety discharge guidelines policies seen important management transfers 14 15 also considered effective management tool reduce length stay icu improve utilization icu resources 16 17 however results previous studies indicate discharge planning often lacks guidelines tends ad hoc influenced patient acuity 18 19 priorities icu may necessary enable admission ill patients leading unplanned discharges even night related higher risks a study goldfrad rowan 2000 found overall icu mortality 25 times higher patient discharged night study staff estimated 44% patients fully ready transfer compared 80% patients transferred day discharging patients recently discharged icu may particularly risk adverse events readmissions icu complete patient transfer high technological icu general ward many studies demonstrate experiences transition clear description process could organized order safe 511 based experiences described involved process argued important learn enhance organize icu transitional care therefore aim study describe experienced intensive care general ward staff strategies could used organizing patient care transfer intensive care transfer icu general ward patients experience transition process the patients transferred context high technology culture general ward the specific process transition icu general ward become topic interest difficulties arise process increasingly frequent transitions initiated events acute illness injury also explains concept nursing concern the process requires beginning middle end person feels perceives situation critical process continues transition could result feeling displacement lack control lives the situation time span vary may consist short periods months years example transition hospitalization acute injury illness the study approved northern ethical committee sweden number 07 159 first author informed asked nurses participation study accordance verbal written criteria they informed confidentiality rights withdraw participation without giving reason as aim study describe illuminate transition process icu general ward qualitative content analyses considered 25 26 the data also used larger study aimed generate theories main concerns icu transitional care data collected 2008 2010 two hospitals located sweden different sizes the participants recruited three icus five general wards specializing surgical medical general fields one hospitals step unit second step unit all interviews conducted first author totally 15 individual interviews seven icu nurses three icus sweden one anesthesiologist one en enrolled nurse icu six rns working different surgical medical wards two hospitals the participants different genders lengths experience 125 years 3 males 12 women their ages varied 25 62 years staff general wards registered nurses nurses worked icu one year specialist certification intensive care the interviews performed quiet place unit hospital lasted 30 50 minutes the focus study organize patient transfer ward care rehabilitation patients transferred palliative end life care could please tell transfer process icu patients organized unit feelings clarifying questions mean when tell asked necessary encourage interviewees narrate experiences the data analyses inspired elo kyngs 2008 description content analysis interview text read several times get sense whole the manifest analyses started sorting data content areas transfer icu general ward this followed open coding handwritten notes headings text using many headings possible close text order describe aspects content with abstraction codes divided subcategories categories similar incidents named content characteristic words relevant aim research topic the results show categories secure encourage collaborate strategies used three phases icu transitional care process transfer icu table 1 the main category safe interactive rehabilitation process illustrates strategies characterized intention create maintain safety process it also included attempts help patient reach best possible condition different phases recovery rehabilitation proceeded planned one nurse stated goal care process patients going better ways physical physiological the goal care process patients going better ways physical physiological the main category strategies also illustrated three way interaction process staff patient families team members involved units patient family environment the first category secure included activities aimed preserving patient safety transfer preventing adverse events immediately transfer later the second category encourage included activities focused strengthening inspiring giving hope courage patients families the third category collaborate included activities aimed intertwining process coordination cooperation communication icu general wards first phase icu transitional care included secure optimizing vital signs reducing adjusting intensive care encourage promoting self ability customizing information collaborate communicating coordinating ward arranging pretransfer meeting optimize vital functions securing patients care preserving patient safety icu transitional care one essential issue optimize patient vital functions prior transfer key component minimize risk adverse readmissions commonly referred interviews the icu staff interacted technology senses assess perform clinical judgments the patient pain relief vital signs especially respiration hemodynamic focus point decision patient could transferred intensive care.the important transfer process patients vital signs stable enough observe extremely carefully the important transfer process patients vital signs stable enough observe extremely carefully decision transfer mostly anesthesiologists consultation responsible physician ward however icu nurses felt involved interacted physicians decision either confirming patients stable enough postponing transfer patient respiratory issues fever problematic clinical symptoms if patient fragile weak seen important couple extra days icu possible intermediary unit reassuring intensive care needed anymore this expressed one important strategy prevent readmission also something often could done timing for transfer crucial interviews revealed patients remain either long short time icu the nurses expressed compromised patient safety transferred early stable enough transferred later needed made immobilized susceptible infections symptoms reduce adjust secure patient care prevent adverse events later icu transitional care process necessary reduce technology adjust medication administrated weaning timing extubation one important part expressed often time consuming difficult less experienced nurses the staff stated patients time recover state full respiratory support proceed minor support noninvasive respiratory support finally manage breathe least 24 hours without respiratory support it also expressed important reduce adjust care patient safety prevention central line infections suiting upcoming level care competence ward not ward nurses example managed multilumen central lines like interview also apparent technology reduced used needed icu since environment icu could cause trouble individual patient instead use technology follow need hemodynamic assessment patients families became used fewer observations monitoring patients transferred adjustments care often done interaction ens rns physicians needed documented patient record maintain consistency it also considered essential administration medications altered prepare patients upcoming level care example shifting sleeping pills instead infusions prior transfer.i think patients try wean long time also used full monitoring often enough pulse oximetry part day i think patients try wean long time also used full monitoring often enough pulse oximetry part day this included supporting patient initiative promoting self ability since icu period often negative impact patient muscle mass initiative ability it expressed patient self ability phase influenced following phases transfer process the staff meant patient self ability strengthened prior transfer part rehabilitation process step toward managing altered level care promoting patient ability required lot persuasion sensitive interaction patient the icu staff tried support patients manage small things example use bed alarm would familiar later receive help ward the staff described tried daily basis encourage patients sit bedside chairs would immobilized bed times it also considered essential helpful patients got early frequent physiotherapy icu.we help patient drink water includes helping grip glass set mouth tell everything better nothing way we help patient drink water includes helping grip glass set mouth tell everything better nothing way encouragement based providing repeated customized information patients families considered staff important tool organizing icu transitional care it important adjust customize information specific patient needs inform families time upcoming transfer it expressed essential interact families inform several times progress care plans goals the icu general ward staff expressed anxiety could minimized patients families encouraged informed repeatedly condition stabilized transfer would soon occur patients families needed hear information often asked repeatedly things related medical status upcoming transfer others asked nothing it expressed important give consistent responses differ could include visual information environment routines ward preferably form brochure something similar the staff experienced patients and/or families experience encouragement participation care depended well clearly information given.i think even better especially work individualized information families i think even better especially work individualized information families the staff described coordination icu department patient would transferred foundation collaboration especially patient cared icu long time collaborating involved communicating coordinating care units transferred patients the communication involved information patient needs preparing unit consider patient arrived ward cases also involved care planning meetings families different physicians this made common view patients planning expressed wish mutuality icu ward allotting responsibility planning patients transfer coordination described better done early possible especially patient long length stay icu one unit used liaison nurse person specific responsibility collaboration experienced facilitating communication planning specific needs the nurses expressed patient specific needs must planned taken care strategy manage care must prepared collaboration could also include planning room patient placed ward considering individual needs possible nurse responsible one icu nurse said important communicate early tell staff ward every need patient may cover exclude anything especially patient long time icu it important communicate early tell staff ward every need patient may cover exclude anything especially patient long time icu arrange pretransfer meeting collaborating arranging pretransfer meeting ward staff patients families transfer expressed one appreciated strategy this described extra important patient family anxious patient cared icu long time extended needs the ward nurses meant pretransfer meeting valuable patient since opportunity create contact patient family transfer the meeting also provided possibility ask questions get picture patient care needs the meeting described two ways icu general ward depending patient status the nurses expressed pretransfer meeting organized helped intertwine healthcare chain.right example gentleman ward 4 5 months icu probably length stay 8 months hospital came introduced us told would responsible ward right example gentleman ward 4 5 months icu probably length stay 8 months hospital came introduced us told would responsible ward the strategies phase included secure assess summarize hand responsibility arrange safe transfer encourage give confidence collaborate negotiate facilitate the staff expressed important prior transfer take time assess summarize patient discharge status different nursing phenomena actions taken patient if transfer planned advance phase also included examining equipment patient still considering removing measurement technology specific intensive care wanted needed general ward.i think easier someone responsible keeps documentation prepares discharge we really want patient record clear obvious planned i think easier someone responsible keeps documentation prepares discharge we really want patient record clear obvious planned the report mentioned staff essential tool maintain continuity care experienced way hand patient without loose ends the staff general ward tried prepare taking part patient documents got icu always opportunity.i try keep reading patient transfer n't start zero knowledge for example surgery 've done drains also quickly check latest values i try keep reading patient transfer n't start zero knowledge example surgery 've done drains also quickly check latest values the handover often included nurse nurse report intended focus briefly history specifically actual status planned care the icu nurses expressed handover adjusted adequate information wanted tell much possible loose ends would left ward nurses expressed wanted less history actual status planned x rays medications iv fluids well description patient ability problems sometimes nurses general ward felt insecure dare ask icu nurses patient since want seem incompetent most icu patients fragile safe transfer maintains patient safety expressed essential the patient often received oxygen transfer avoid desaturation sometimes portable monitors used control vital signs interviews one nurse described example adverse events related transfer well n't want something critical happen transfer always remember one time got get patient icu i directly saw hugely fragile wondered really move icu physician icus physician insisted took patient went away immediately came elevator patient vital signs deteriorating we hurried soon could ward get help alarm assistance well n't want something critical happen transfer always remember one time got get patient icu i directly saw hugely fragile wondered really move icu physician icus physician insisted took patient went away immediately came elevator patient vital signs deteriorating we hurried soon could ward get help alarm assistance the staff experienced essential give confidence prior transfer talk positive way patients families the nurses expressed patients anxious showed feelings disconnectedness leaving environment felt safe staff knew the staff felt patients families also needed feel transfer step forward positive sign.when day transfer comes may ridden anxiety patient either play whole try make easier might grief leave place long become better that try focus important positive sign patient transferred ward emphasize worst crisis day transfer comes may ridden anxiety patient either play whole try make easier might grief leave place long become better that try focus important positive sign patient transferred ward emphasize worst crisis collaboration described staff essential day transfer included negotiating suitable time transfer facilitating transfer involved staff members it important seek resolutions problems see equal the staff expressed barriers could occur collaboration instead complicate transfer example blaming trying understand work situation hence interprofessional respect staff units essential facilitated process the actual day transfer expressed less planned depending acute situation unit the nurses general wards said obvious icu rapid decision making led rapid transfers sometimes unplanned they wished involved deciding time transfer possible time suited staff general ward icu the staff general ward considered extremely important opportunity prepare get patient icu since often time consuming if knew time could plan work made process feel easier safer when staff communicated suitable time transfer also informed specific equipment needed oxygen.most times influence time transfer think often possible communicate make suit us most times influence time transfer think often possible communicate make suit us the third phase included strategies secure take charge encourage create good encounter instill hope courage collaborate prepare discharge follow when patient arrived general ward staff stated important get grip whole situation take charge patient it involved overall view clinical judgments take control paperwork plan future care actions described time consuming depending patient status ward nurses spent less time continuing care example supplying oxygen controlling wounds drains drain holes monitoring feeding tubes intravenous lines calculating fluid balance checking vital signs the nurses expressed also vital physician ward checked ordinations wrote updated status patient record tool managing care.it's patient must good condition discharged icu care must also continue high quality general ward it patient must good condition discharged icu care must also continue high quality general ward sometimes necessary change equipment time medication suit care ward some ward nurses expressed felt often patients shorter length stay icu hemodynamically unstable readmitted according experience patients longer length stay often better optimized vital functions the ward nurses mentioned control vital signs sometimes required alarm specific outreach team this team included staff icu nurse physician could initiate treatment patient ward decide readmit patient icu they expressed outreach team helpful tool made feel safer care also meant important personal clinical judgment.there always warning clocks checking vital signs something wrong sometimes feel something breaking something wrong patient i think depends combination intuition patient history there always warning clocks checking vital signs something wrong sometimes feel something breaking something wrong patient i think depends combination intuition patient history instill hope courage creating good encounter patients families first meeting either icu arriving general ward ) a good encounter included personal meeting introducing responsible staff interacting supporting individual needs the ward nurses wanted time communicate sense needs first encounter could calm patients families they expressed families often displayed anxiety questions differences environments it also important inform patient family members staff members available ward even though physically present patient room time it took time establish hope courage difficult others.the patients families shock reaction arrive still try process understand happened according experience often seen intensive period short the patients families shock reaction arrive still try process understand happened according experience often seen intensive period short the ward nurses expressed early mobilization icu vital patient rehabilitation process proceeded the nurses expressed patient ability take initiative needed supported depending diagnosis ability differed ward nurses expressed care icu often made patients immobilized used others taking care hygiene nurses ward felt patients become apathetic stepped aside others still responsible body.some stand legs immediately must first mobilized bed really tell 've working early mobilization icu some stand legs immediately must first mobilized bed really tell 've working early mobilization icu collaboration phase included planning discharge patient depended individual patient status home situation sometimes patients needed extensive planning interaction community nurses patients could directly transferred home without extended help the nurses explained planning often took time important part patient healthcare chain the icu general ward staff often continued collaboration around patient following transfer strategy intertwined icu transitional care process sometimes ward visit made icu staff primarily meet patient also give staff opportunity ask questions give medical advice needed one hospitals patients followed within postintensive care meetings discharged left hospital.we try go visit patient ward days transfer time appreciated patient staff since may ask something missed we try go visit patient ward days transfer time appreciated patient staff since may ask something missed the main category study showed strategies used staff transfer aimed contribute safe interactive rehabilitation process the results showed strategies secure encourage collaborate could used enhance organize icu transitional care patient safety interaction patient family environment team members essential icu transitional care the main category also illustrates three way interaction process staff patients families different team members involved units patient family environment the interaction environment patients also illuminated theorists rogers king nightingale claimed patient constant interaction environment icu staff interacted technology tool determine patients stable enough weaning transfer the staff felt environmental differences icu general wards often cause concern patients families according meleis therefore assumed care must individualized even routines procedures follow transition stands change health status role relationships expectations abilities the transition event dependent instance suddenness personal meaning level well hence argued logical strive strengthening process considers needs involves active plan smoother transition it important clarify explain patient family observations monitoring reduced adapted patient current health status may reduce perceived stress transitional phase overall results indicate transition experience dependent preparation patient families first contact team ward time transfer therefore planning must taken seriously timing seemed critical point confirmed study garland connors 2013 their study indicated 30-day mortality increased patients leave earlier planned icu also transfer delayed leave later optimal this accordance researches confirms weaning vital patient safety ( 2003 showed readmission often seen time extubation discharge icu short recent study including patients traumatic brain injuries showed reintubations within 48 hours i.e. extubation failure significantly associated lengthened hospital stays increased frequency tracheotomy pulmonary complications worsened functional outcomes increased mortality intermediary units used way reduce care prepare patients altered level 32 33 hospitals kind unit however icus identify beds unit aimed intermediary care patient care proceed less technology staff the necessity avoiding miscommunication clinical handovers also described several studies miscommunication lead risk prolonged stay lack continuity care suboptimal patient flow readmissions patient dissatisfaction reports 34 35 systematic review foster manser 2012 handovers transfer patients acute care studied the results showed handover process multifacetted therefore difficult compare evaluate also show standard report pages one way facilitate reporting boutilier 2007 concluded important thing icu transitional care process systematically communicate necessary information receiving device patient safety threatened ensure necessary continuity care the second strategy found study encourage often mentioned nursing encourage meant instill hope identity confidence patients families the results study illustrate importance pep talk supportive strategies encourage patient manage transition recover critical illness according nurses patients need feel safe result also described hupcey 2000 psychosocial need icu patients one characteristic transition disconnectedness associated disruption links person feelings security depend the nurses study wanted able offer customized information prior transfer since thought anxiety could reduced information this compared result strahan brown 2004 found patients often anxious transfer process done wish receive detailed information happen the nurses expressed patients families part transfer presence relatives affect patient sense participation contribute feelings cared safety it important minimize experiences gap icu general wards health illness transitions include sudden role change result moving well state acute illness the results study indicate patient role changes arriving general ward less passive seen active furthermore patients desire normality independence wish able personal contacts also seen study mckinney deeny 2002 the results also illustrate importance team receiving ward opportunity devote time patient family first arrive the ward nurses study expressed patients showed mixed feelings transfer general ward needed instill hope courage our study indicated immediate later follow leaving icu could useful helping patients identify problems find routes rehabilitation support a study schandl 2011 actually showed multidisciplinary icu follow first six months discharge important follow the results study showed icu transitional care complex multidisciplinary process involves collaboration within icu within units involved the findings study show collaboration includes respectful functional communication units different actions aimed intertwine healthcare chain effective teamwork coordination among staff improve icu patient discharge process also reduce gap separating icu general ward 14 21 our study indicates team members unit units need treat respect everyone ask questions without fear ridicule contempt the results study showed study respect equality important previous studies focused specific liaison nurse used facilitate collaboration a liaison nurse coordinates transfer helpful patients families 43 44].the results study indicate benefits function like many strategies process focus identifying minimizing risks complications pneumonia central line infections also strengthening mind body this process described active unique nonlinear process stages phases the results study follow model called chime connectedness hope optimism identity meaning life empowerment one important part icu transitional care promote patients self care capability encourage patients autonomy this confirmed chick meleis 1986 also claim transitions linked shifts self care capability orem 1980 writes independence recognized early nursing theorists important patients well closely connected ability perform daily activities meet care needs however nature intensive care environment makes independence autonomy difficult hughes 2004 emphasized degree autonomy connected ability actually independent also healthcare staff perception understanding need assessment the nurses study expressed early mobilization felt important least patients ability things manage upcoming care this compared results intervention study korupolu et al they saw early mobilization icu strategy whole body rehabilitation early stage critical illness showed better functional outcomes hospital discharge shorter duration delirium ventilator free days compared standard care mcfetridge 2011 discussed importance structured patient centered rehabilitation program patients follow journey critical care ward finally discharge hospital mcfetridge also claims interaction care essential prevent actions taken becoming fragmented hence process seamless transparent persons involved patient care journey include multidiscipline approach family perspective this study illustrates strategies secure encourage collaborate summarize specific actions used basis patient centered guideline icu transitional care however fact guidelines solution minimize gap icu general wards must discussed a cultural gap identified icu general wards study van sluisveld et al ( 2013 implies social cultural barriers implementation guidelines effective icu discharge summarize guidelines clinical practice useful low adherence also important resources time staffing knowledge essential components order manage organization safe transfer process icu general ward nurses intention support patients icu transitional care often balanced organization demands work stress time restraint a recent study showed nursing care hours per patient icu skill mix significantly contribute prevention bloodstream infections shorter length stay icu ( 2011 found caring increasing number patients complex problems caused stress nursing staff already facing work overload wards qualitative content analysis used study well suited since aim describe experiences intensive care general ward staff the results derived data three icus six general wards therefore hospitals may strategies icu transitional care described study the first second author experiences rns icu general wards preconceptions bridled thorough data analysis discussion open possible new perspective this study involved staff different professions different hospitals order enhance variety experiences both authors familiar chosen method analysis part process discussed label codes subcategories categories agreement presenting process analysis presenting result quotes text possible readers create value important study credibility the results study conclude secure encourage collaborate called sec model illustrates essential strategies suggested use organizing care transfer icu general ward the result concordance researches meeting needs patients families a recent review described patients families experiences transfers icu themes physical responses psychological responses information communication safety security needs relatives addressed sec model developed study the significance study also strengthened study lin et al ( 2009 claim clarification guidelines standardization discharge decision making handover needed research also indicates care acute ill ward patients suboptimal implies crucial link needs safer according massey et al ( 2008 suboptimal care wards depends failure seek advice failure appreciate clinical urgency lack knowledge failure organization lack supervision ensure safe effective care transitions strategies needed improve shared situational awareness teamwork patient flow resource efficiency icu transitional care 59 60 the result indicates successful icu transitional process aims create interactive safe forward thinking process influenced actions preserve patient safety promote individualized care sum up safe transition involves coordination optimal timing early mobilization participation multidiscipline approach also relatives perceive safety continuing care important icu transitional care process want participate a recommendation future studies explore safe transitions family perspective systemic way

background . organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team . an understanding of discharge practices is needed in order to ultimate patients ' transfers from high technological intensive care units ( icu ) to general wards . aim . to describe , as experienced by intensive care and general ward staff , what strategies could be used when organizing patient 's care before , during , and after transfer from intensive care . method . interviews of 15 participants were conducted , audio - taped , transcribed verbatim , and analyzed using qualitative content analysis . results . the results showed that the categories secure , encourage , and collaborate are strategies used in the three phases of the icu transitional care process . the main category ; a safe , interactive rehabilitation process , illustrated how all strategies were characterized by an intention to create and maintain safety during the process . a three - way interaction was described : between staff and patient / families , between team members and involved units , and between patient / family and environment . discussion / conclusions . the findings highlight that icu transitional care implies critical care rehabilitation . discharge procedures need to be safe and structured and involve collaboration , encouraging support , optimal timing , early mobilization , and a multidiscipline approach .

microglia macrophage like resident immune cells central nervous system cns possess neurotoxic neuroprotective function microglia accumulate lesions variety neurodegenerative disorders alzheimer disease ad parkinson disease multiple sclerosis thought play toxic protective functions neuronal survival microglia considered first line defense respond quickly various stimuli when activated microglia undergo morphological changes ameboid proliferate migrate toward injured areas release many soluble factors phagocytosis foreign substances unwanted self debris appropriate migration microglia damaged area controlled chemokines nucleotide atp 2 3 phagocytosis seems important prevent senile plaque expansion ad removing amyloid deposit microglia engulf protein also phagocytose apoptotic cells degenerated neuronal debris phagocytosis apoptotic degenerated neuronal debris crucial reduce inflammation maintain healthy neuronal networks another type phagocytosis phagocytosis inflammation occurs chronic inflammatory related neurodegenerative disorders including alzheimer disease 57 degenerated neurons releases several signaling molecules including nucleotides cytokines chemokines recruit microglia enhance activities 8 9 the phenomenon termed find eat help signals paper focused find eat signals degenerated neurons microglia distinguished examined eat signal phosphatidylserine ps component cellular membrane everted apoptotic cell membrane 10 11 nucleotides also considered eat signal lately microglia expresse various p2x p2y receptors nucleotide receptors regulate chemotaxis also phagocytosis 8 12 microglia express many surface receptors direct interaction target initiate phagocytosis including ps receptor lipopolysaccharide lps receptor cd14 scavenger receptor cd36 purine receptor p2y6 toll like receptors tlrs table 1 figure 1 another surface receptor cx3c chemokine fractalkine receptor cx3cr1 almost exclusively expressed microglia throughout cns involved progression neurodegenerative disease altering microglial activities 16 17 figure 2 deletion cx3cr1 expression microglia results progressive neuronal cell death animal model neurodegenerative disease inducing microglial dysfunction it identified recently neurons produce cytokine chemokine fractalkine shown figure 2 previously reported interleukin-34 il-34 newly discovered cytokine produced neurons receptor colony stimulating factor 1 receptor primarily expressed microglia fractalkine il-34 might important mediator neurons microglia important clarify cellular crosstalk signaling pathways seeking future therapeutic target neurodegenerative diseases including ad following sections discuss recent advances microglial chemotaxis phagocytosis implications ad therapy the expression levels increased pathological conditions seem facilitate recruitment trafficking glial cells damaged area microglia constitutively express several chemokine receptors table 1 implicated recruitment accumulation microglia ad lesions exposed microglia are induced produce several chemokines ccl2 ccl4 cxcl12 ccr2 receptor ccl2 deficiency resulted reduction microglial accumulation higher brain levels mouse model ad might mediated via suppression anti inflammatory molecule transforming growth factor tgf- however conflicting report showing increased tgf- signaling microglia surrounding plaques ccr2 knockout ad model mouse appswe ps1/ccr2/ this ad model shown accumulation oligomeric memory impairment ccl2 expression level also related another neurodegenerative disorder multiple sclerosis ms ccl2 level downregulated cerebrospinal fluid ms patients ccl21 triggers chemotaxis microglia cxcr3 ccr7 implicated peripheral lymphoid organs neuronal ccl21 upregulates p2x4 receptor nucleotide receptor expressed microglia cascade implicated pathophysiology tactile allodynia cause chronic neuropathic pain a-induced microglial activation mediated p2x7 receptor reported proinflammatory response conductive receptor atp predominantly induced microglial migration among nucleotides p2y receptors especially p2y12 2 37 following cns injury expression p2y12 microglia drastically reduced microglial activation suggesting p2y12 primary temporary receptor induce microglial chemotaxis early stages local cns injury the nucleotide udp increases mainly microglial phagocytosis uptake microspheres via p2y6 receptor condition brain damage kainic acid administration the cx3c chemokine cx3cl1 fractalkine also called neurotactin identified two forms soluble membrane anchored forms plays pivotal role signaling degenerating neurons microglia cx3cl1 receptor cx3cr1 are highly expressed brain tissue particularly neurons microglia 4042 cx3cl1 directly induces various microglial functions including migration proliferation inhibition fas ligand induced cell death glutamate induced neurotoxicity 45 46 inhibition proinflammatory cytokine production 42 47 recently shown soluble form cx3cl1 also directly enhances microglial clearance degenerated neuronal debris mediated phosphatidylserine ps receptor production milk fat globule egf factor 8 protein mfg e8 figure 2 the membrane anchored cx3cl1 cleaved several proteases including disintegrin metalloprotease adam family adam-10 adam-17 4850 cathepsin when neurons injured exposed glutamate shedding cx3cl1 occurs immediately 41 52 however little known direct connection a-induced neuronal toxicity cx3cl1-shedding another important function adam family enzyme except cx3cl1 shedding -secretase it cleaves app centre domain generated -app considered neurotrophic function 5356 cathepsin expressed predominantly microglia implicated microglial activation neuropathic pain therefore cx3cl1-shedding proteases may regulate microglial phagocytosis directly indirectly cx3cl1 expression may also play role pathogenesis ad there reports showing ccl2 activates cx3cr1 expression induction cx3cr1 expression ccl2-ccr2 axis mediated p38 mapk activation cx3cr1 deficiency increases susceptibility neurotoxicity mouse models parkinson disease amyotrophic lateral sclerosis systemic lps administration cx3cl1-induced neuroprotection rat model parkinson disease also reported recently in addition reports showing pathologic features ad mouse model worsened knockout cx3cr1 17 61 the receptor leading inflammatory status includes cd14 cd36 receptor advanced glycation end products rages toll like receptor tlr 1 tlr2 tlr4 tlr6 the receptor leading anti inflammatory status includes triggering receptor expressed myeloid cells 2 trem2 ps receptor psr mfg e8 microglia also express many phagocytosis related receptors yet unclear correlation inflammatory status cr3microglia express classical phagocytosis related receptor 2 integrin complement receptor-3 cr3 mac-1 cd11b cd18 scavenger receptor sr)-ai ii sr ai ii cd204 cr3 synergistically activated sr ai ii mediated myelin phagocytosis microglia 63 64 cr3 implicated clearance bacteria induction major histocompatibility complex class ii mhc ii antigens cr3 involved endocytosis normal conditions mhc ii antigens inflammatory state microglia express sr ai ii sr bi neonatal period adult lack expression microglia express classical phagocytosis related receptor 2 integrin complement receptor-3 cr3 mac-1 cd11b cd18 scavenger receptor sr)-ai ii sr ai ii cd204 cr3 synergistically activated sr ai ii mediated myelin phagocytosis microglia 63 64 cr3 implicated clearance bacteria induction major histocompatibility complex class ii mhc ii antigens cr3 involved endocytosis normal conditions mhc ii antigens inflammatory state microglia express sr ai ii sr bi neonatal period adult lack expression cd14cd14 lps receptor also considered classical phagocytosis related receptor macrophage microglia cd14-mediated phagocytosis require expression ps receptor possibly induces inflammatory conditions activation cd14 signaling the authors suggested might due reduction insoluble soluble cd14 lps receptor also considered classical phagocytosis related receptor macrophage microglia cd14-mediated phagocytosis require expression ps receptor possibly induces inflammatory conditions activation cd14 signaling the authors suggested might due reduction insoluble soluble fcreceptorexposure fibrillar microglia induces phagocytosis receptors distinct used classical phagocytosis immunoglobulin receptors fcri fcriii complement receptors exposure fibrillar microglia induces phagocytosis receptors distinct used classical phagocytosis immunoglobulin receptors fcri fcriii complement receptors cd36 cd47a directly interacted microglial cell surface receptor complex comprising class b scavenger receptor cd36 6 1 integrin integrin associated protein cd47 involved migration phagocytosis microglia 7072 cd36 required fibrillar a-induced chemotaxis proinflammatory molecules including reactive oxygen species ros tnf il-1 several chemokines microglia a activates microglial recruitment amyloid deposition site cd36-dependent signaling cascade involving src kinase family members lyn fyn erk1/2 cd47 membrane glycoprotein broadly expressed various cell types cns including neurons microglia signal regulatory protein- sirp cd172a receptor binding cd47 also expressed neurons myeloid cells sirp inhibitory molecule cd47 downregulates mapk phosphorylation downstream pathway cd47 sirp interacts protein tyrosine phosphatases shp-1 shp-2 predominantly expressed neurons dendritic cells macrophages therefore cd47 functions normally marker self protect intact body component 76 77 a directly interacted microglial cell surface receptor complex comprising class b scavenger receptor cd36 6 1 integrin integrin associated protein cd47 involved migration phagocytosis microglia 7072 cd36 required fibrillar a-induced chemotaxis proinflammatory molecules including reactive oxygen species ros tnf il-1 several chemokines microglia a activates microglial recruitment amyloid deposition site cd36-dependent signaling cascade involving src kinase family members lyn fyn erk1/2 cd47 membrane glycoprotein broadly expressed various cell types cns including neurons microglia signal regulatory protein- sirp cd172a receptor binding cd47 also expressed neurons myeloid cells sirp inhibitory molecule cd47 downregulates mapk phosphorylation downstream pathway cd47 sirp interacts protein tyrosine phosphatases shp-1 shp-2 predominantly expressed neurons dendritic cells macrophages therefore cd47 functions normally marker self protect intact body component 76 77 ragein reported direct interaction peptide receptor rage important ad pathophysiology ad brains rage expression increased rage directly induces neurotoxicity production oxidative stressors indirectly activating microglia rage increases macrophage colony stimulating factor csf neurons via nuclear factor-b- nf-b- dependent pathway released csf induced interaction cognate receptor c fms microglia prolongs survival microglia rage recognizes multiple ligands peptide advanced glycation end products ages ps high mobility group box 1 protein hmgb1 80 81 these molecules act agonist rage microglia inducing proinflammatory molecules tnf- il-1 il-6 via map kinase kinase mek phosphatidylinositol 3-kinase pi3k pathways activation rage leaded nf-b mapk mediated signaling propagate perpetuate inflammation status rage also mediates transport peripheral brain across blood brain barrier bbb in has reported direct interaction peptide receptor rage important ad pathophysiology ad brains rage expression increased rage directly induces neurotoxicity production oxidative stressors indirectly activating microglia rage increases macrophage colony stimulating factor csf neurons via nuclear factor-b- nf-b- dependent pathway released csf induced interaction cognate receptor c fms microglia prolongs survival microglia rage recognizes multiple ligands peptide advanced glycation end products ages ps high mobility group box 1 protein hmgb1 80 81 these molecules act agonist rage microglia inducing proinflammatory molecules tnf- il-1 il-6 via map kinase kinase mek phosphatidylinositol 3-kinase pi3k pathways activation rage leaded nf-b mapk mediated signaling propagate perpetuate inflammation status rage also mediates transport peripheral brain across blood brain barrier bbb cd200rcd200 transmembrane glycoprotein expressed many different cell types including neurons endothelial cells lymphocytes dendritic cells the receptor cd200 cd200r expression predominant myeloid cells macrophages microglia 84 85 case sirp-cd47 cd200 exerts inhibitory effect cd200r cd200-cd200r interaction downregulate activity microglia retina shown activation cd200r microglia show direct effect migration cd200-cd200r signaling restores lps ifn-induced loss migration cd200 knockout leads expansion myeloid population several tissues increased expression activation markers microglia including signaling adaptor protein dnax activating protein 12 kda dap12 cd11b cd45 cd68 inducible synthase inos these observations suggest cd200-cd200r signaling leads anti inflammatory state protection neurotoxic stimuli cd200 cd200r expression levels neurons microglia resp ) are decreased ad hippocampus inferior temporal gyrus indicating inhibition cd200-cd200r axis contributes ad pathology cd200 transmembrane glycoprotein expressed many different cell types including neurons endothelial cells lymphocytes dendritic cells the receptor cd200 cd200r expression predominant myeloid cells macrophages microglia 84 85 case sirp-cd47 cd200 exerts inhibitory effect cd200r cd200-cd200r interaction downregulate activity microglia retina shown activation cd200r microglia show direct effect migration cd200-cd200r signaling restores lps ifn-induced loss migration cd200 knockout leads expansion myeloid population several tissues increased expression activation markers microglia including signaling adaptor protein dnax activating protein 12 kda dap12 cd11b cd45 cd68 inducible synthase inos these observations suggest cd200-cd200r signaling leads anti inflammatory state protection neurotoxic stimuli cd200 cd200r expression levels neurons microglia resp ) are decreased ad hippocampus inferior temporal gyrus indicating inhibition cd200-cd200r axis contributes ad pathology trem2trem2 recently identified innate immune receptor adaptor protein dap12 expressed microglia cortical neurons hippocampal neurons astrocytes oligodendrocytes their expression correlates clearance apoptotic neurons microglia without inflammation 9092 however endogenous ligand specific agonist trem2 identified recently heat shock protein 60 hsp60 mitochondrial chaperone interacts trem2 directly hsp60-induced phagocytosis found microglia robust expression trem2 ad model mouse trem2 expression highest outer zone plaques expression level correlated size plaque forced expression trem2 positively regulated microglial phagocytosis ability microglia stimulate cd4 cell proliferation tnf- ccl2 production ifn production trem2 recently identified innate immune receptor adaptor protein dap12 expressed microglia cortical neurons hippocampal neurons astrocytes oligodendrocytes their expression correlates clearance apoptotic neurons microglia without inflammation 9092 however endogenous ligand specific agonist trem2 identified recently heat shock protein 60 hsp60 mitochondrial chaperone interacts trem2 directly hsp60-induced phagocytosis found microglia robust expression trem2 ad model mouse trem2 expression highest outer zone plaques expression level correlated size plaque forced expression trem2 positively regulated microglial phagocytosis ability microglia stimulate cd4 cell proliferation tnf- ccl2 production ifn production tlrs class pattern recognition receptors innate immune system induce inflammatory responses 13 tlrs identified human mouse date except tlr10 expressed human 95 96 cd11b marker macrophages microglia shown interact tlr signaling cd11b knockout mouse exhibited enhanced tlr mediated responses subsequent susceptibility endotoxin shock among tlrs lps receptor tlr4 potently activates microglia various aspects phagocytosis proinflammatory molecules production 98 99 activation tlr1 tlr2 tlr3 tlr9 selective agonist also increased phagocytosis several cytokines chemokine production 98 100 the response microglia fibrillar mediated via cd14 act together tlr4 tlr2 bind fibrillar induced microglial activation p38 mapk deficiency cd200 induces expression tlr2 tlr4 glial cells proliferation cd11b mhcii cd40 activated microglia these mice show memory impairment suggesting dual activation tlr2 tlr4 may induce inflammatory phenotype microglia negatively regulate synaptic plasticity ad model a triggers inflammatory status microglia via heterodimer tlr4 tlr6 regulated cd36 therefore cd14-tlr2-tlr4 cd36-tlr4-tlr6 signaling crucial a-induced inflammatory response also microglial phagocytosis bacterial dna containing motifs unmethylated cpg dinucleotides cpg dna ligand tlr9 initially identified activate microglia strongly induces tnf- il-12 production however shown cpg activated microglia produce neuroprotective molecule hemeoxygenase-1 ho-1 matrix metalloproteinase 9 mmp-9 without producing neurotoxic molecules tnf- glutamate nitric oxide enhanced clearance protect memory disturbance vivo there discrepancies cpg effect aforementioned two reports despite using origin cells mouse primary microglia ) may due concentrations tlr9 ligand used higher concentration 10 former report whereas lower concentrations 1 100 nm latter report moreover latter report revealed difference neuroprotective effect cpg among synthetic oligodeoxynucleotides odns classes c class cpg activate microglia classes b c cpgs increased microglial neuroprotective effect induction clearance production neuroprotectant cpg increased chemokine ccl9 receptor ccr1 expression macrophages microglia via tlr9/myd88 signaling involving erk p38 mapk pi3k pathways phagocytotic cells recognize apoptotic cells several mechanisms including recognition ps expressed cells the receptors ps psrs clarified long time uncovered recent years these include mfg e8 lactadherin homolog humans cell immunoglobulin mucin domain 4 tim4 107 108 these act bridge ps expressing apoptotic cells psr expressing phagocytes trigger engulfment cellular debris mfg e8 expressed various macrophage subsets periphery microglia cns recently shown cx3cl1 induces mfg e8 expression primary mouse microglia lead microglial clearance degenerated neuronal debris others also reported induction mfg e8 cx3cl1 macrophages rat microglia 109 110 mfg e8 bridges ps integrins v 3 v 5 surface phagocytes 107 111 high mobility group box 1 protein hmgb1 intracellular protein activates transcriptional factors including p53 nf-b hmgb1 reportedly suppresses interaction mfg e8 v 3 integrin macrophage inhibits phagocytosis apoptotic cells erk mediated signaling pathway mfg e8 may also involved phagocytosis since expression reduced ad therefore mfg e8 may possibly lead targeted clearance unwanted molecules without inflammation the well studied psr tim4 expressed mac-1 cells various mouse tissues including spleen lymph nodes fetal liver among tim family members tim1 neither tim2 tim3 also specifically binds ps it shown recently rage also recognizes ps induces apoptotic cell clearance however mentioned previously rage guided intracellular signaling pathway induces prolonged inflammatory status -secretase protein complex four essential membrane proteins aph-1 pen-2 nicastrin presenilin a recent study suggests presenilin increases microglial phagocytosis -secretase dual role ad pathogenesis one cleavage amyloid precursor protein app produce pathologic reduction microglial phagocytosis -secretase inhibitor vertebrates two presenilin genes psen1 located chromosome 14 humans encoded presenilin 1 psen2 located chromosome 1 encoded presenilin 2 there report presenilin 2 identified predominant -secretase mouse microglia presenilin 1 repressed microglial activation via function -secretase expression increased inflammatory stimuli ifn- order explore detailed mechanism -secretase regulates microglial activity studies needed since -secretase therapeutic target ad traumatic injury brain presenilin nicastrin expressions -secretase mainly cleaves app lead accumulation 1 42 results aggregation protein worsen ad pathology microglia express wide array receptors characteristic immune cell cd molecules integrins chemokine receptors psr figure 1 chemokine receptors induce migration microglia also contribute directly ad pathogenesis regulation phagocytosis neuroprotective activity ps acts eat signal psr mediated phagocytosis far regarded inducing anti inflammatory responses however according recent reports rage interacts psr facilitates phagocytosis robust inflammation status 80 120 therefore phagocytosis related receptors including tlrs interact psr microglia would activated outbreak excessive phagocytosis robust inflammation microglia old app ps1 mouse younger ones show reduction sra cd36 rage a-degrading enzymes including insulysin neprilysin mmp9 thus important consider microglial status depending disease stage treat ad effectively as shown figure 2 fkn il-34 may intrinsic neuroprotectant damaged still surviving neurons activation microglia

microglia are multifunctional immune cells in the central nervous system ( cns ) . in the neurodegenerative diseases such as alzheimer 's disease ( ad ) , accumulation of glial cells , gliosis , occurs in the lesions . the role of accumulated microglia in the pathophysiology of ad is still controversial . when neuronal damage occurs , microglia exert diversified functions , including migration , phagocytosis , and production of various cytokines and chemokines . among these , microglial phagocytosis of unwanted neuronal debris is critical to maintain the healthy neuronal networks . microglia express many surface receptors implicated in phagocytosis . it has been suggested that the lack of microglial phagocytosis worsens pathology of ad and induces memory impairment . the present paper summarizes recent evidences on implication of microglial chemotaxis and phagocytosis in ad pathology and discusses the mechanisms related to chemotaxis toward injured neurons and phagocytosis of unnecessary debris .

conducted qualitative study september november 2006 peri urban community outskirts cape town south africa this township emerged last two decades rapid migration today permanent fixture formal informal dwellings many younger generation born township still maintain strong bonds rural areas family origin generally people living poor conditions high unemployment rates well high levels crime alcohol drug use 23 24 this qualitative study undertaken conjunction larger quantitative survey among men high risk hiv quantitative survey employed respondent driven sampling rds recruit participants 25 rds chain referral method requires pre determined number initial contacts subsequent recruits enlist maximum three new participants social network the inclusion criteria quantitative survey men older 18 years one female sexual partner past 3 months least one sexual partners younger 24 years 3 years younger participant close 56% high school education 17.2% unemployed majority 94.7% ) purposive sampling identify individuals willing participate depth individual interviews used among participants quantitative study twenty participants selected asked participate qualitative component waiting complete quantitative survey interviews conducted weekends difficult attract men participate week however screening participants interviews necessary ensure influence narcotics alcohol common problem weekends study setting each interview took approximately one half hours conducted first author ar a trained local interpreter present interviews translated conversations english and/or isixhosa necessary all interviews audiotaped transcribed verbatim cross checked initial recordings ensure quality transcription participants given cellular telephone voucher worth 30 rand approximately us$4 token appreciation a thematic question guide tqg open ended questions used interviews the tqg provided structure interviews simultaneously allowing interviewer freely explore probe ask questions would expand clarify particular topics the tqg themes included sexual behaviours social sexual networks masculinity risk reduction strategies the transcripts analysed according latent content analysis suggested graneheim lundman 26 descriptive explicit areas content little attempt interpretation extracted first examined underlying meaning situated sub themes cut across categories sub themes grouped overarching themes expressed latent content transcripts data discussed detail research team identify different themes analysis facilitate uncovering aspects underlying meaning contributed increased validity analysis ethical clearance obtained health sciences faculty research ethics committee university cape town this research funded swedish research council swedish international development agency sida)/sarec national research foundation nrf south africa self perceived social identities among hard reach men study informal urban context suggested dominant masculine ideals ways legitimise specific behaviours created high risk environment sexually transmitted hiv one common category among study participants described reasons multiple female sexual partners themes emerged promoted power imbalances sexual relationships lack trust women disempowerment biological determinism the predominant ideal male identity conceptualised one word player characterised two symbols status wealth women thus player incorporated symbols believed important make hegemonic masculinity clearly helped men position community money material goods could visualised crucial seemed override status symbols education societal position.it guys lot money afford things yes money king.you must well dressed must look brand new everyday even clothes new must always money asks something sometime must able take care it guys lot money afford things yes money king must well dressed must look brand new everyday even clothes new must always money asks something sometime must able take care symbols cellular telephones sunglasses trendy clothes important overtly portraying economic status used position men relation men study context manner new fashionable items became important communication men key forming hierarchical systems incorporated specific forms ideal masculinities these symbols material wealth also played important role men strategies access sexual networks sexual partners besides displays overt economic status player would expected show could afford handle several women time having multiple often young female sexual partners enhanced men social position women served marker sexual financial power.i make example eight girlfriends it style wear clothes money money.yes say guys looked upon even ladies see like girls lot girls friends girls bring girls even know many girls already it style wear clothes money money i say guys looked upon even ladies see like girls lot girls friends girls they bring girls even know many girls already seemingly women responded strategies aided socialisation men sexual identities new gender power dynamics contrary many previous norms traditional initiation schools furthermore strong peer pressure many concurrent young sexual partners played important part creation masculine ideal within male social groups manifesting large sexual networks.i take lot pressure boys they tease make funny jokes tell one girlfriend one all.other people think game multiple girlfriends they tease make funny jokes tell one girlfriend one other people think game multiple girlfriends the pressure live set norms reinforced meaning status player if man adopted alternative form masculine ideal would risk emasculated thought takes real man according prevalent norms specific context group men it would seem masculinity norms evolved study context making use new symbols express power facilitate redefinition men relation men thereby reinforcing risky sexual behaviours the attributes suggested successful man also indicate representations man like player exist integrated new urban form masculinity explore forms identities underlying associated reasons different levels needed explain certain types masculinity evolve two themes closely associated player biological determinism frustration self perceived disempowerment construction player involved manifestation material wealth multiple girlfriends also offered set underlying reasons gender related power structures irrespective whether women long term concurrent temporary sexual encounters strong negative views revealed a woman crossed strict boundaries existed gender relations often labelled bitch term also sometimes used describe women general.they get negative label called bitches lose respect dignity.they look funny way they call bitches girl always sleeping different partners girl always sex girl use they get negative label called bitches lose respect dignity they call bitches girl always sleeping different partners girl always sex girl use assessing women behaviour perceived unacceptable men automatically felt certain rights legitimised negative power play men women applying restrictive social norms certain female behaviours way define men masculinity promote power imbalances women also considered physically vulnerable engaging sexual intercourse especially several sexual partners biological determinism legitimised sexual risk taking among men men greater need several sexual partners built sexual encounters.the thing lots girls finish girls girl many boys stupid one finished.it different sexual orientation guys deposit ladies receive vagina looks like rubbish throw everything it.because girl body destroyed pretty easy lot men guy body deteriorate easy many girlfriends the thing lots girls finish girls girl many boys stupid one finished it different sexual orientation guys deposit ladies receive vagina looks like rubbish throw everything because girl body destroyed pretty easy lot men guy body deteriorate easy many girlfriends these biological explanations reinforced strong negative perceptions women female sexuality helped polarise men interpretation gender constructions the fact women often challenged predominant gender stereotypes engaging perceived normative male sexual behaviour used excuse degrading attitudes behaviours towards women this could explain rubbish metaphor used vagina men association women destroyed thus behaviours biology women themes helped men structure relations women also promoted high risk sexual behaviours form multiple concurrent sexual relations another theme occurred underlying frustration among men also reflected position society large bitches women passive victims rather active agents strategically played cards thus certain ambivalence revealed men views women opposition sexes.they players like us think play playing also cards playing us also.they women got much power we got less power women rights much they players like us think play playing also cards playing us also we got less power women rights much underlying distress insecurity among men can seen sign situation traditional hegemonic masculinity contested allowing new forms evolve maintain certain power im)balance the urban context characterised lack money men self perceived disempowerment relation women society general created situation manhood constantly questioned many men believed women actively engaged concurrent transactional relationships economic benefits this interpretation women active agents relationships created deeply rooted insecurity among men alienated women the commonly expressed negative perceptions women thus multilayered reflected intricate power play included lack control distrust towards women.according they keep one partner anymore n't trust going around.they also players thing unemployment rate organized get jobs maybe start lives if give money go next person according they keep one partner anymore n't trust going around they also players thing unemployment rate organized get jobs maybe start lives men distrust perceived disempowerment relation women supported formation large sexual networks characterised unequal power dynamics sexual relationships within networks often based direct economic reciprocity common urban peri urban townships people struggle meet basic needs the predominant ideal male identity conceptualised one word player characterised two symbols status wealth women thus player incorporated symbols believed important make hegemonic masculinity clearly helped men position community money material goods could visualised crucial seemed override status symbols education societal position.it guys lot money afford things yes money king.you must well dressed must look brand new everyday even clothes new must always money asks something sometime must able take care it guys lot money afford things yes money king must well dressed must look brand new everyday even clothes new must always money asks something sometime must able take care symbols cellular telephones sunglasses trendy clothes important overtly portraying economic status used position men relation men study context manner new fashionable items became important communication men key forming hierarchical systems incorporated specific forms ideal masculinities these symbols material wealth also played important role men strategies access sexual networks sexual partners besides displays overt economic status player would expected show could afford handle several women time having multiple often young female sexual partners enhanced men social position women served marker sexual financial power.i make example eight girlfriends it style wear clothes money money.yes say guys looked upon even ladies see like girls lot girls friends girls bring girls even know many girls already it style wear clothes money money i say guys looked upon even ladies see like girls lot girls friends girls they bring girls even know many girls already seemingly women responded strategies aided socialisation men sexual identities new gender power dynamics contrary many previous norms traditional initiation schools furthermore strong peer pressure many concurrent young sexual partners played important part creation masculine ideal within male social groups manifesting large sexual networks.i take lot pressure boys they tease make funny jokes tell one girlfriend one all.other people think game multiple girlfriends they tease make funny jokes tell one girlfriend one other people think game multiple girlfriends the pressure live set norms reinforced meaning status player if man adopted alternative form masculine ideal would risk emasculated thought takes real man according prevalent norms specific context group men it would seem masculinity norms evolved study context making use new symbols express power facilitate redefinition men relation men thereby reinforcing risky sexual behaviours the attributes suggested successful man also indicate representations man like player exist integrated new urban form masculinity explore forms identities underlying associated reasons different levels needed explain certain types masculinity evolve two themes closely associated player biological determinism frustration self perceived disempowerment the construction player involved manifestation material wealth multiple girlfriends also offered set underlying reasons gender related power structures irrespective whether women long term concurrent temporary sexual encounters strong negative views revealed a woman crossed strict boundaries existed gender relations often labelled bitch term also sometimes used describe women general.they get negative label called bitches lose respect dignity.they look funny way they call bitches girl always sleeping different partners girl always sex girl use they get negative label called bitches lose respect dignity they call bitches girl always sleeping different partners girl always sex girl use assessing women behaviour perceived unacceptable men automatically felt certain rights legitimised negative power play men women applying restrictive social norms certain female behaviours was way define men masculinity promote power imbalances women also considered physically vulnerable engaging sexual intercourse especially several sexual partners biological determinism legitimised sexual risk taking among men men greater need several sexual partners built sexual encounters.the thing lots girls finish girls girl many boys stupid one finished.it different sexual orientation guys deposit ladies receive vagina looks like rubbish throw everything it.because girl body destroyed pretty easy lot men guy body deteriorate easy many girlfriends the thing lots girls finish girls girl many boys stupid one finished it different sexual orientation guys deposit ladies receive vagina looks like rubbish throw everything girl body destroyed pretty easy lot men guy body deteriorate easy many girlfriends these biological explanations reinforced strong negative perceptions women female sexuality helped polarise men interpretation gender constructions the fact women often challenged predominant gender stereotypes engaging perceived normative male sexual behaviour used excuse degrading attitudes behaviours towards women this could explain rubbish metaphor used vagina men association women destroyed thus behaviours biology women themes helped men structure relations women also promoted high risk sexual behaviours form multiple concurrent sexual relations another theme occurred underlying frustration among men also reflected position society large the informants view bitches women passive victims rather active agents strategically played cards thus certain ambivalence revealed men views women opposition sexes.they players like us think play playing also cards playing us also.they women got much power we got less power women rights much they players like us think play playing also cards playing us also we got less power women rights much underlying distress insecurity among men can seen sign situation traditional hegemonic masculinity contested allowing new forms evolve maintain certain power im)balance urban context characterised lack money and men self perceived disempowerment relation women society general created situation manhood constantly questioned many men believed women actively engaged concurrent transactional relationships economic benefits this interpretation women active agents relationships created deeply rooted insecurity among men alienated women the commonly expressed negative perceptions women thus multilayered reflected intricate power play included lack control distrust towards women.according they keep one partner anymore n't trust going around.they also players thing unemployment rate organized get jobs maybe start lives if give money go next person according they keep one partner anymore n't trust going around they also players thing unemployment rate organized get jobs maybe start lives if give money go next person men distrust perceived disempowerment relation women supported formation large sexual networks characterised unequal power dynamics sexual relationships within networks often based direct economic reciprocity common urban peri urban townships people struggle meet basic needs we found challenges hiv prevention among men living urban south african township urgently need addressed the dominant masculine ideal player thrived money multiple concurrent sexual relations casual sex strong social pressure within male core groups pursue maintain concurrent sexual relationships temporary sexual encounters existed helped legitimise specific behaviours player represented the common use derogatory words attributed women genitals bitch rubbish dehumanised women restricted female sexuality order retain instances reclaim male superiority women perceived empowered could trusted making men feel alienated lacking control sexual relationships the lack trust women fidelity stated important reason engaging concurrent sexual relationships well casual sexual encounters known key driver hiv transmission 10 our findings thus support previous research showing dominant masculinities characterised large sexual networks means express manhood response societal changes unemployment poverty low self esteem perceived disempowerment 27 the representation man associated attributes evolved shaped new sets meanings traditional social expectations conservative restrained sexuality largely changed particular context ways manhood defined clearly put men women increased risk sexually transmitted hiv gender structures profoundly influence men sexual identity sexuality used manifest power least men an urban modern way sexual socialisation incorporates ideal masculinity player poses clear risk needs addressed one potential way risk could addressed traditional initiation rituals key sexual socialisation boys men the practice continues important part many young men transition adulthood thus revisited potential integrating gender related hiv prevention previous research designed interventions show weak support scaling traditional male circumcision biomedical intervention 28 medical circumcision together traditional initiation could promising 29 global debate potential benefits circumcision relation hiv infection largely biomedical focus thereby ignoring important core traditions context stipulated taking account traditional importance rites passage power successful intervention might solely removal foreskin rather development structures boys sexually gender socialised responsible men the potential bridging traditional systems medical interventions shown promising results currently recommended 30 however research required examine effectiveness bridging medical traditional interventions well assess potential harm reduction associated example circumcision 28 traditional structures could one entry point important give meaning people this research based selected group men high risk sexually transmitted hiv one specific urban environment south africa self reported data fully explore underlying structures social norms however depth interviews gave interviewees opportunity describe quality social sexual relationships shed light normative systems legitimise behaviours peri urban settlement these norms represent masculine ideal supported males accepted society large this unique study terms high risk context conducted believe managed reach males normally difficult research whose behaviours key explaining extremely high hiv prevalence south african townships although findings might representative group men believe unique opportunity reach men harsh urban setting provides important new knowledge contemporary masculine ideals affect gender dynamics need addressed hiv prevention our results highlight need firmly address sexuality gender dynamics among men growing informal urban areas strikingly high hiv prevalence south africa an understanding dominant urban masculinity key characteristics masculinity affect hiv transmission well innovative interventions help endorse alternative norms behaviours urgently needed traditional new structures might potentially serve focal entry points future preventive actions prevention efforts focus changing underlying masculine ideals gender relations promote maintain concurrent temporary sexual relationships well high risk behaviours future research try explore potential using traditional structures intervention strategies testing innovative intervention models the authors received funding benefits industry conduct study

backgroundthe perspectives of heterosexual males who have large sexual networks comprising concurrent sexual partners and who engage in high - risk sexual behaviours are scarcely documented . yet these perspectives are crucial to understanding the high hiv prevalence in south africa where domestic violence , sexual assault and rape are alarmingly high , suggesting problematic gender dynamics.objectiveto explore the construction of masculinities and men 's perceptions of women and their sexual relationships , among men with large sexual networks and concurrent partners.designthis qualitative study was conducted in conjunction with a larger quantitative survey among men at high risk of hiv , using respondent - driven sampling to recruit participants , where long referral chains allowed us to reach far into social networks . twenty in - depth , open - ended interviews with south african men who had multiple and concurrent sexual partners were conducted . a latent content analysis was used to explore the characteristics and dynamics of social and sexual relationships.resultswe found dominant masculine ideals characterised by overt economic power and multiple sexual partners . reasons for large concurrent sexual networks were the perception that women were too empowered , could not be trusted , and lack of control over women . existing masculine norms encourage concurrent sexual networks , ignoring the high risk of hiv transmission . biological explanations and determinism further reinforced strong and negative perceptions of women and female sexuality , which helped polarise men 's interpretation of gender constructions.conclusionsour results highlight the need to address sexuality and gender dynamics among men in growing , informal urban areas where hiv prevalence is strikingly high . traditional structures that could work as focal entry points should be explored for effective hiv prevention aimed at normative change among hard - to - reach men in high - risk urban and largely informal contexts .

previous issue critical care chase coworkers reported implementation clinical practice evaluation specialized relative insulin nutrition table sprint this improved protocol form wheel based system control blood glucose levels nutritional intakes intensive care patients developed years ago blood glucose become key biological parameter critical care since publication study conducted van den berghe colleagues demonstrated decreased mortality surgical intensive care patients association tight glycaemic control tgc based intensive insulin therapy however two negative studies recently reported interrupted early high rates severe hypoglycaemia namely visep study yet unpublished glucontrol trial hence currently much debate regarding actual benefits strategy intensive care patients terms outcomes it also uncertain whether results ongoing multicentre open label randomized controlled trial nice sugar effects blood glucose management 90-day cause mortality heterogeneous population intensive care unit icu patients resolve remaining concerns tgc icu included among concerns key issue appropriate algorithm achieve desired blood glucose range the major focus study conducted chase colleagues method achieve predetermined blood glucose range modulating insulin infusion rate nutritional inputs as reported studies comparing protocols efficacy evaluated comparison historical control patients however although study reported chase coworkers conducted great care rigour another case control retrospective comparative study nevertheless clear need introduce efficient tools help clinicians nursing staff control blood glucose levels icu patients hyperglycaemia superior 10 mmol studies required provide clinicians recommendations evaluation comparison various protocols currently use soon become available benchmarking tgc protocols must take account dimensions efficiency performance risk severe hypoglycaemia practical aspects ease use training time required materials prior implementation error rate integrated continuous monitoring nursing workload evaluated mean time controls furthermore best way compare performance controversial time glucose within common target range hyperglycaemia index recently described glycaemic penalty index variability would associated outcome ? this raises question whether efficacy results instructions regarding nutritional intake allowing insulin infusion rates limited level lower usual intrinsic quality algorithm used based glucose insulin regulatory system model capturing insulin utilization rate insulin losses saturation dynamics also sprint apparently associated severe hypoglycemia events contrasts high rate severe hypoglycaemic episodes reported second leuven study finally sprint relatively simple implement numerous icus paper based protocol presented original form using wheel without need computational resources weaknesses sprint rest inability monitor parameters related quality glucose control sprint paper based protocol importantly despite favourable subjective opinions care givers sprint may reduce workload requires measurements every hour 2 hours ultimately evaluation tgc protocol must also include assessment ability implemented easily safely another icu participate development the monocentric study chase coworkers may ensure exportability tgc protocol the debate continues real benefits tgc numerous questions asked optimal target range patients benefit icu stay tgc applied derive benefits best method control glucose level intensive insulin therapy and/or limitation nutritional intakes acute phase and/or antidiabetic drugs ? however competition develop ideal tool control blood glucose levels icu perhaps throughout hospital stay begun involving multidisciplinary teams physicians engineers specialized control systems feedback control model predictive control icu intensive care unit sprint specialized relative insulin nutrition table tgc tight glycaemic control pk declares holds shares lk2 saint avertin france

the report by chase and coworkers in the previous issue of critical care describes the implementation into clinical practice of the specialized relative insulin nutrition table ( sprint ) for tight glycaemic control in critically ill patients . sprint is a simple , wheel - based system that modulates both insulin rate and nutritional inputs . it achieved a better glycaemic control in a severely ill critical cohort than their previous method for glycaemic control in a matched historical cohort . reductions in mortality were also observed .

foot mouth disease fmd one highly contagious diseases domestic animals caused foot mouth disease virus fmdv member family picornaviridae colossal global impact due huge number animals affected the fmd endemic countries collectively contain three quarters world population robinson et al 2011 indicating global economic significance disease national level india annual total economic loss due fmd ranges rs 12,000 crore rs 14,000 crore singh et al 2013 in spite control measures taken fmd continues economically important disease india due poor surveillance inadequate control programs understanding mechanism foot mouth disease virus fmdv infection replication virus important control worldwide menace alexandersen et al 2003 longjam et al 2011 a vital question yet addressed concerns role viral receptors pathogenesis fmd integrins biologically important set proteins used cells bind respond extracellular matrix belong large family integral membrane receptors required cell adhesion functionally active integrins consist two noncovalently bound transmembrane glycoprotein subunits viz alpha beta springer 2002 evidence suggested virus binding infection integrin 6 itgb6 transfected cells mediated rgd dependent interaction baxt becker 1990 jackson et al 2000 mason et al 1994 considering role host itgb6 receptor gene the aim present study screen genetic variation within snp rs136500299 exon 14 region among different indigenous cattle the polymorphism c located position 2145 reference itgb6 mrna produces missense change phe ser position 667 polypeptide previously polymorphism reported least ten times ss250661448 ss263658018 ss415630763 ss420604742 ss422472086 ss679762826 ss752601716 ss828200981 ss907724252 ss942564461 study describe accurate method basis competitive polymerase chain reaction pcr called tetraplex arms pcr identification snp among different animals for analyzing scenario targeted snp among different zebu cattle total 148 animals different indigenous breeds cattle sahiwal 51 kankrej 48 ongole 38 gir 11 different agricultural zones used study blood samples collected animals jugular vein puncture using sodium heparin 10 iu ml anticoagulant immediately collection blood samples stored portable refrigerator 4 c transported laboratory stored 80 c dna extraction chloroform extraction method sambrook russell 2001 purity genomic dna assessed spectrophotometrically tetra primer pcr procedure ye et al 2001 ) was used genotyping snp rs136500299 exon 14 region itgb6 receptor gene the method employs four primers amplify fragment dna containing snp amplicons representing two allelic forms primers designed amplify fragments differing sizes allele band order easily resolved using agarose gel electrophoresis details primer used present study amplicon size different genotypes shown table 1 pcr performed total volume 25 l containing approximately 50 ng dna 2.5 l 10x buffer 2.0 mm mgcl2 0.2 mm dntps 5 pmol outer primers 10 pmol inner primers 1 u taq polymerase sigma aldrich usa the polymerase chain reaction pcr protocol 94 c 5 min followed 35 cycles 94 c 30 annealing 55 c 30 72 c 30 final extension 72 c 10 min the pcr products separated 1.0% agarose gel sigma aldrich usa including 0.5 g ml ethidium bromide photographed gel documentation system alpha imager ep validation three different genotypes analyzed cloning sequencing 433 bp pcr products genotype gene allele genotype frequencies itgb6 receptor gene calculated direct counting method the four populations tested hardy weinberg equilibrium using proc allele sas inst cary nc chi square test used find difference genotype frequencies different breeds the present study aimed develop single tube tetraplex pcr based genotyping assay snp rs13650029 exonic region bovine itgb6 receptor gene snp genotyping techniques depend amplification target dna using pcr technique differ means discerning different alleles involves significant post amplification manipulations for instance restriction fragment length polymorphism typing method based digestion amplified pcr products suitable restriction endonuclease another extensively used snp typing technique allele specific oligonucleotide aso melting involves lengthy blotting hybridization techniques tetra primer arms pcr method described present context circumvents limitations earlier mentioned techniques the technique used present study involves single step pcr protocol two sets primers detect different banding pattern without downstream processing like digestion hybridization the primers designed way amplify fragments differing sizes allele order resolve differentially agarose gel electrophoresis the method described present study simple swift cost effective method snp genotyping large number individuals ye et al 2001 correspondence arms pcr sequencing confirmed three genotype pattern targeted snp exon 14 region bovine itgb6 gene among different zebu cattle breeds fig 1 genotyping revealed genotype tt widely distributed among targeted zebu cattle breeds the study revealed frequency allele higher indigenous populations compared c allele this trend mostly seen breeds except sahiwal heterozygotic frequency comparatively higher even though difference statistically significant table 2 the test hw equilibrium among different populations showed breeds equilibrium respect itgb6 receptor gene indicating absence aggressive selection i.e. selection primarily based gene p 0.05 the frequency animals cc genotype lowest four breeds order study variation genotype frequencies among different indigenous breeds cattle the result showed table 3 indicates genotype frequencies statistically different 7.900 p 0.2455 among breeds indicating populations similar genetic constitution regard itgb6 receptor gene the snp rs136500299 c located position 2145 reference itgb6 mrna produces missense change phe ser serine polar amino acid smaller size whereas phenylalanine aromatic amino acid complex structure thus may presumed changes amino acid may alter conformational changes itgb6 receptor coding polypeptide however needs confirmed studies the results present study suggest allele widely distributed among indigenous breeds cattle associated resistance fmd virus susceptibility fmd virus lower tauras breeds however studies larger sample sets wide range cattle breeds still needed confirm exact genetic distribution pattern snp

the present study was aimed to screen genetic variation within a snp ( rs136500299 ) located at exon 14 region of bovine itgb6 gene among different zebu cattle breeds . the genotyping method describe in the present study is a tetraplex arms pcr , which offers extremely fast , economical , and simple detection tool . the distribution of the itgb6 genotypes among the different breeds studied suggested that the populations were under hardy weinberg equilibrium . our findings revealed that tt genotypes are widely distributed among different zebu cattle breeds , which can be associated with the resistance to fmd virus , as the bos indicus are more resistant to fmd virus in comparison to bos taurus .

huntington disease hd progressive autosomal dominantly inherited neurodegenerative disorder characterized impaired motor control cognitive decline occasional psychiatric illness hd results expansion cag repeat exon 1 huntingtin htt gene yielding protein polyglutamine polyq expansion tract near amino terminus this polyq expanded huntingtin protein propensity misfold making resistant proteasomal autophagy mediated degradation earlier age disease onset rapid disease progression correlate increasing cag repeat length hd manifesting patients carrying 40 cag repeats hd common polyq repeat disease prevalence least 1 10,000 usa europe hd polyq expanded huntingtin protein expressed throughout brain severe degeneration occurring striatal medium spiny neurons cortical projection neurons extend striatum currently hd research conducted rodent models rodent primary neurons non neural human cell lines questions whether systems yield findings truly relevant mechanistic basis human hd pathogenesis about six years ago takahashi yamanaka developed method reprogramming human somatic cells entered pluripotent state allowing differentiation cell types including neurons this induced pluripotent stem cell ipsc approach ushered new era human neurodegenerative disease modeling two recent publications one hd ipsc consortium another et al respectively reported generation characterization ipsc derived models hd genetic correction disease causing cag repeat expansion mutation ipscs individuals hd together two studies provide important insights utility limitations ipsc modeling neurodegenerative disease one greatest challenges facing ipsc modeling field enormous variability different ipsc lines neurons derived generation characterization ipsc lines can laborious costly one obvious solution assure validity ipsc disease models create research teams work together particular disorder sharing ipsc lines derived neurons this strategy applied hd ipsc consortium study eight different groups produced ipscs three individuals hd three control individuals used assay wide range phenotypes these included gene expression cell adhesion bioenergetics glutamate toxicity cell death calcium flux trophic factor withdrawal these phenotypes assessed neural stem cells nscs grown spherical aggregates defined growth factor conditions well differentiated striatal like neurons obtained using long short differentiation protocols differed growth factors added this comprehensive inventory cellular molecular assays revealed certain phenotypes correlate hd disease cag repeat length whereas phenotypes the common results recapitulated across various laboratories highlight integrity developed ipsc lines making hd ipsc consortium study impressive blueprint worthy emulation the study et al quite different goal perform genetic correction hd ipsc line thereby creating isogenic revertant ipsc line would carry two normal length htt alleles these corrected controls genetic background identical uncorrected ipsc line phenotypic expression differences two could solely attributed cag expansion the corrected line created successfully using standard recombination approach allowing comparison number cellular molecular characteristics mutant progenitor line normalized derivative line this study also demonstrated genetically corrected hd ipsc line could used produce nscs using protocol described previously group furthermore nscs could successfully transplanted striatum hd mice able populate crucial brain region underwent proper differentiation neurons glia thus stage set potential future application strategy therapeutic intervention hd in tandem papers catalogue variety phenotypes observed hd ipsc derived neural progenitors medium spiny neurons groups performed gene expression analysis compare hd ipscs neuronal derivatives hd ipsc consortium findings implicated genes involved cell signaling cell cycling axon guidance neuronal development dysregulated nscs figure 1 importantly medium cag repeat expansions longer cag repeat expansions expressed genes differently co workers performed transcript expression analysis although ipscs rather ipsc derived nscs observed comparison corrected controls hd ipscs showed increased expression genes involved tgf- signaling decreased expression genes involved cadherin signaling figure 1 notably expression differences hd ipscs corrected hd ipscs order magnitude less non related control ipscs hd ipscs hd ipscs corrected ipscs ipsc derived neurons reveal key disease associated phenotypes an et al also generated corrected hd ipscs homologous recombination showed compared corrected hd ipscs hd ipscs increased expression genes induced tgf- signaling pathway decreased expression cadherin pathway genes hd ipsc lines developed hd ipsc consortium differentiated form npcs darpp-32-positive striatal like neurons these npcs yielded evidence altered expression hd genes involved cell signaling cell cycling axon guidance neurodevelopmental pathways delineated here future studies might compare two datasets thus could evaluate expression target genes transcription factors known interact huntingtin examine mitochondrial dysfunction hd investigate exact identity dying cells hd npc neural progenitor cell ros reactive oxygen species tf transcription factor comparison two studies also highlights shared relevance certain cellular molecular phenotypes cell death mitochondrial dysfunction figure 1 initial studies previously indicated hd ipsc derived nscs display increased caspase activity hd ipscs derived neurons exhibit increased lysosomal activity an important finding shared two groups relates defects energy metabolism mitochondrial dysfunction resulting impaired cellular bioenergetics emerging hallmark hd the hd ipsc consortium reported decreased intracellular atp levels hd neural progenitor cells npcs et al both phenotypes revealed defects energy metabolism hd models importance mitochondrial dysfunction requires investigation another hd associated phenotype observed groups increased cell death the hd ipsc consortium used variety assays including longitudinal survival tracking nuclear condensation assays caspase 3/7 activation detect increased cell death hd nscs striatal like derivatives colleagues also observed cag repeat length dependent cell death similar assays both groups demonstrated severe cell death phenotype upon withdrawal brain derived neurotrophic factor bdnf adding mounting evidence support role bdnf associated toxicity hd bdnf secreted neurotrophin undergoes transcriptional repression certain hd models indications expression bdnf ameliorate hd phenotype cell death striatum cortex hallmarks hd hence shared observation significant recapitulates vitro seen vivo an et al taken initial step toward application corrected hd ipsc derived neurons cell replacement therapy they showed differentiated striatal like neurons survive transplantation mouse brain report whether transplanted r6/2 mice exhibited recovery phenotype despite uncertainty quite clear newly derived hd ipsc models hold great potential use drug screening illustrated figure 1 future studies examine effects htt interactor target genes compare results obtained data sets two studies observations studies regarding gene expression mitochondrial dysfunction support findings generated models the huntingtin protein known interact number transcription factors co activators including creb binding protein cbp sp1 tafii130 ppar co activator 1 pgc-1 follow analysis expression target genes encode already implicated transcription factors might worthwhile figure 1 diminished pgc-1 function appears major contributor hd pathogenesis hd ipsc model could used evaluate mitochondrial phenotypes seen hd mice including decreased mitochondrial complex activities decreased mitochondrial number increased oxidative stress pgc-1 overexpression rescue hd associated phenotypes mice inducing transcription factor eb tfeb master regulator autophagy validation role pgc-1 tfeb dysfunction hd ipsc models would worthwhile could facilitate development new therapies finally missing piece puzzle exact identity dying cells hd the hd ipsc consortium used method tracking live cells longitudinal studies allowed identify dying cells morphologically similar neurons although specific neural type unspecified as hd patients longer cag repeats suffer widespread neuron cell death important determine vulnerability ipsc derived neurons differs neural cell types figure 1 amelioration cell death relevant ipsc derived neural lineage could useful indicator potential drug efficacy once hd field homes viable lead compounds hd ipsc models could serve invaluable tools validation accelerate therapeutic development bdnf brain derived neurotrophic factor hd huntington disease htt huntingtin gene ipsc induced pluripotent stem cell nsc neural stem cell the authors acknowledge funding support nih r01 ns065874 huntington disease research

deconstructing the mechanistic basis of neurodegenerative disorders , such as huntington 's disease ( hd ) , has been a particularly challenging undertaking , relying mostly on post - mortem tissue samples , non - neural cell lines from affected individuals , and model organisms . two articles recently published in cell stem cell report first the generation and characterization of induced pluripotent stem cell ( ipsc)-derived models for hd , and second , the genetic correction of a disease - causing cag expansion mutation in ipscs from individuals with hd . taken together , these two studies provide a framework for the production and validation of ipsc materials for human neurodegenerative disease research and yield crucial tools for investigating future therapies .

early december 2013 zikv outbreak 44-year old man tahiti symptoms zikv infection asthenia low grade fever temperature 37.5c 38c arthralgia eight weeks later described second episode symptoms compatible zikv infection temperature 37.5c 38c headache days 13 wrist arthralgia days 57 the patient seek treatment thus biological samples collected first 2 periods illness the patient fully recovered second episode 2 weeks later noted signs hematospermia sought treatment patient experienced symptoms zikv infection weeks referred laboratory institut louis malard papeete tahiti zikv infection diagnostic testing the medical questionnaire revealed signs urinary tract infection prostatitis urethritis cystitis patient stated recent physical contact persons acute zikv infection we extracted rna using nuclisens easymag system biomrieux marcy letoile france 200 l blood 500 l semen urine eluted 50 l elution buffer we tested blood semen rna extracts using real time reverse transcription pcr rrt pcr described using 2 primers probe amplification sets specific zikv 3 the rrt pcr results positive zikv semen negative blood confirmed sequencing genomic position 8581138 encompassing prm e protein coding regions zikv generated sequence genbank accession km014700 identical previously reported beginning zikv outbreak 3 three days later collected urine sample second set blood semen samples semen urine second collection found contain traces blood direct macroscopic examinations rrt pcr detected zikv rna semen urine blood sample we quantified zikv rna loads using rna synthetic transcript standard covers region targeted 2 primers probe sets rna loads 2.9 10 copies ml 1.1 10 copies ml first second semen samples respectively 3.8 10 copies ml urine sample we cultured semen urine described dengue virus cultured urine 6 briefly 200 l sample diluted 200 l 1% fetal calf serum fcs minimum essential medium mem inoculated onto vero cells incubated 1 h 37c inoculum removed replaced 1 ml culture medium we also inoculated negative control 200 l 1% fcs mem positive control 5 l zikv positive serum diluted 200 l 1% fcs mem the presence zikv culture fluids detected rrt pcr described replicative zikv particles found 2 semen samples none detected urine sample ( 7 perinatal transmission 8) potential risk transfusion transmitted zikv infections also demonstrated 9 ( 10 described patient infected zikv southeastern senegal 2008 returning home colorado united states experienced common symptoms zikv infection symptoms prostatitis four days later observed signs hematospermia day wife symptoms zikv infection wife patient traveled united states previous year sexual intercourse 1 day returned home transmission semen suggested zikv infection patient wife confirmed serologic testing presence zikv semen patient investigated infectious organisms especially sexually transmitted microorganisms including viruses human papillomavirus herpes simplex virus known etiologic agents hematospermia 11 knowledge report foy et al ( 10 study arbovirus infections humans reported associated hematospermia arboviruses isolated human semen we detected high zikv rna load replicative zikv semen samples zikv remained undetectable rrt pcr blood sample collected time these results suggest viral replication may occurred genital tract know replication started long lasted fact patient common symptoms zikv acute infection concomitantly hematospermia suggests viremic phase occurred upstream probably first second episode mild fever headache arthralgia the detection zikv urine semen consistent results obtained study effects japanese encephalitis virus another flavivirus boars the virus isolated urine semen experimentally infected animals viremia developed female boars artificially inseminated infectious semen 12 flaviviruses also detected urine persons infected west nile virus wnv wnv rna detected urine longer time higher rna load plasma 13 wnv antigens detected renal tubular epithelial cells vascular endothelial cells macrophages kidneys infected hamsters 14 suggesting persistent shedding wnv urine caused viral replication renal tissue dengue virus denv ) rna denv nonstructural protein 1 antigen also detected urine samples longer time blood infectious denv isolated culture concluded detection denv rrt pcr useful confirm denv infections viremic phase 6 also yellow fever virus rna isolated urine vaccinated persons 15 saint louis encephalitis viral antigens infective virus detected urine samples infected patients 10 furthermore observation zikv rna detectable urine viremia clearance blood suggests found denv wnv infections urine samples yield evidence ofzikv late diagnosis investigation needed

in december 2013 , during a zika virus ( zikv ) outbreak in french polynesia , a patient in tahiti sought treatment for hematospermia , and zikv was isolated from his semen . zikv transmission by sexual intercourse has been previously suspected . this observation supports the possibility that zikv could be transmitted sexually .

irritable bowel syndrome ibs common gastrointestinal disorder affecting approximately 1015% people western world the patient group heterogeneous characterized abdominal pain discomfort abnormal bowel habits the pathophysiology ibs unknown would appear due heterogeneous patient material multiple explanations symptom development currently patients subdivided according main symptom proposed called rome criteria ibs diarrhea ibs ibs constipation ibs c ibs mixed bowel habits ibs no single unifying cause ibs reported several factors associated disease etiology including genetic predisposition anxiety depression well female gender moreover strong evidence indicating changes intestinal microbiota function could one contributing factors development ibs several studies reported differences intestinal microbiota composition ibs patients healthy controls however results show little overlap study study this likely caused different methodological approaches analysis steps well heterogeneity ibs patients regardless lack coherent changes microbial composition clear evidence role microbiota pathogenesis ibs for one patients report improved symptoms consuming agents targeted modify intestinal microbiota including probiotics antibiotics changing diet avoidance fodmap carbohydrates moreover strongest predictor ibs prior gastroenteritic episode increase risk developing ibs 7-fold it estimated 10% ibs cases begin episode gastroenteritis causing post infectious pi ibs indicating cause effect relationship this line previously proposed model event infection affects intestinal microbiota generates alternative stable state recently number bistable microbial groups i.e. microbes two stable homeostatic states identified could act tipping points well known ecological process associated resilience recent study jalanka colleagues the differences microbial composition pi ibs patients addressed analyzing faecal microbiota study subjects previously validated benchmarked phylogenetic microarray detecting abundance 1000 bacterial phylotypes found human intestine studied cohort consisted 57 british subjects divided 5 study groups patients pi ibs diagnosis group 1 rome ii patients 6 months gastroenteritic episode persisting bowel dysfunction however qualify ibs pi bd group 2 experience bowel dysfunction anymore pi nonbd group 3 the results benchmarked ibs patients group 4 rome ii healthy controls group 5 our aim determine microbial compositional differences address associations faecal microbiota clinical features ibs patients varying degree symptoms as development ibs multifactorial hypothesized observed symptoms development pi ibs may arise interplay faecal microbiota host immune response psychological factors therefore analyzed parallel detailed records participants psychological well intestinal symptoms systemic immunological markers well levels host gene expression rectal mucosa integrated approach addressing associations clinical phenotype faecal microbiota allowed us address complex relationships host microbiota pathogenesis ibs pi ibs since intestinal microbiota heterogeneous subject specific hypothesized instead limiting comparative microbiota analysis individual taxa would relevant search microbial signature potentially differs patients healthy controls by using novel bioinformatic approach bootstrap aggregated rda method baggedrda identified combination 27 genus like bacterial groups significantly separated healthy controls patients ibs symptoms moreover found microbial profile pi ibs pi bd groups resembled suffering ibs the major difference patients microbiota 12-fold increase bacteroidetes phylum 35-fold decrease uncultured clostridiales belonging firmicutes phylum furthermore participants ranked according abundance discriminating bacterial taxa specific ordering obtained called index microbial dysbiosis imd rank ordering reflected patient health status correlated increase several immunological markers intestinal complaints associations observed subdividing patients according clinical status interestingly significant correlations imd psychological symptoms often associated ibs our results corroborate previous reports microbial composition could used stratify ibs patients thus complement clinical subgroupings recent study it estimated circa 33% ibs patients exhibit anxiety 13% suffer depression in addition found somatisation significantly increased ibs patients compared controls gastrointestinal symptoms without ibs although intestinal microbiota patients studied light recent evidence could hypothesized etiology disease patients psychological symptoms differs microbial aberrations taken together results suggest discriminant microbial profile could used objective measure disturbed bowel functions therefore potential novel way stratifying heterogeneous patient material future studies clinical practise verify findings larger patient material we combined microbiota data form british subjects swedish pi ibs cohort reported recently sundin colleagues both studies conducted identical analysis pipeline including well established mechanical lysis extraction faecal dna hitchip phylogenetic microarray platform normalization analysis software suite the combined data aimed determine whether pi ibs patients 2 countries share similarities microbiota compared healthy controls the swedish cohort introduced new subjects healthy controls n=16 pi ibs patients n=13 rome iii therefore doubling sample size total 51 subjects remarkably significant difference microbiota profiles healthy pi ibs patients replicated p 0.05 fig 1 the strongest difference observed significant increase bacteroides ssp decrease members uncultured clostridiales pi ibs patients interestingly bacteroides fragilis uncultured clostridiales identified bistable microbial groups predicted act tipping points gut ecosystem opposite ways however imd taxa reported original study appeared significantly different patients controls new taxa significantly increased combined pi ibs patient group one dialister recently identified bistable i.e. either abundant nearly absent contrast bacteria show gradual abundance distribution this highlights need conducting future research large cohorts order verify separating species pi ibs healthy controls figure 1.intestinal microbiota pi ibs patients significantly different form healthy controls hc difference measured baggedrda used identify microbial signature separates hc pi ibs patients two study cohorts abundance discriminating taxa creates called index microbial dysbiosis imd intestinal microbiota pi ibs patients significantly different form healthy controls hc the difference measured baggedrda used identify microbial signature separates hc pi ibs patients two study cohorts abundance discriminating taxa creates called index microbial dysbiosis imd the role bacteroides spp pathophysiology ibs controversial probably reflecting heterogeneity patients well genus bacteroides previous studies reported opposing results regarding relevance bacteroides genera ibs evidence increased well decreased abundance patients interestingly elevated levels bacteroides spp among microbiota changes associated susceptibility enteric pathogens mice it suggested susceptibility infections could increase due imbalanced microbial composition since complex interactions microbiota host immune system might reduce resistance episodes gastroenteritis recently similar observations made humans dicksved colleagues followed abattoir workers high risk contracting c. jejuni infection the participants donated faecal samples start employment regularly followed the subjects became c. jejuni infected increased levels bacteroides species prior infection opposed individuals contract disease follow period similar findings recently shown subjects contracting gastroenteritis increased levels bacteroides spp decreased levels firmicutes immediately infection although infectious agents study diverse differences microbiota profile similar found altogether data several studies allow hypothesize subjects microbial profile resembling imd could susceptible contracting gastrointestinal infection later developing pi ibs more studies patients gastroenteritis required verify hypothesis moreover recent experiments mice indicated innate mucosal immune system play deterministic role shaping gut microbiota hence observed imd may reflection activity host immune system while alternative explanation may offer new insight etiology ibs confirms significance application potential imd stratifying ibs subjects to analyze crosstalk host microbiota concentrated 27 bacterial taxa imd separately studied associations bacterial abundance host gene expression mucosal surface rectum last part large intestine we mapped microarray derived gene expression data rectal biopsies known biological functions using gene set analysis gsa there numerous statistically significant associations abundance ibs type microbiota level expressed host genes suggested association discriminant microbiota physical barrier integrity host the prominent negative correlation observed 7 bacteroides ssp expression glycine serine threonine metabolism pathway general glycine serine threonine are known important maintenance gut integrity structure mucin layer for example majority dietary threonine utilized synthesising secretory mucin dietary restriction results impaired gut barrier moreover mucus structure extent glycosylation shape microbiota composition similar compositional changes also previously associated barrier function abnormalities fucosyltransferase-2 involved formation abo blood groups activity also creates adhesion receptor several microbes therefore interesting fut2 deficient mice fut2 shown display similar differences microbiota composition found study i.e. increased amounts several bacteroides species decreased levels clostridiales in addition alterations mucosal barrier genes identified several pathways including regulate cell junctions inflammatory responses associated imd bacterial taxa the results led us hypothesize physical immunological gut barrier subjects ibs type microbiota compromised resulting low grade inflammation feature ibs patients changes inflammatory response barrier function microbiota composition could therefore lead changes host parameters gut brain axis receiving signals systems moreover observed imd correlated ibs symptoms clinical features whereas scores anxiety depression correlate imd indicating patients psychological basis disease rather undisturbed microbiota this line previous findings great significance allows proposing model subjects relatively healthy microbiota report ibs symptoms others microbiota resembling ibs patients complaints compensating factors overcome microbial component hence scored healthy fig 2 the pi ibs patients stratified according imd generally microbial composition ibs like microbiota red composition resembling healthy individuals turquoise objective measurements low grade inflammation altered gene expression correlated imd psychological aspects depression anxiety correlate imd patients though diagnosed ibs show healthy like microbiota profile the correlations host response microbiota aberration identified study indicated bold proposed model microbial aberrations could explain disease etiology ibs the pi ibs patients stratified according imd generally microbial composition ibs like microbiota red composition resembling healthy individuals turquoise objective measurements low grade inflammation altered gene expression correlated imd psychological aspects depression anxiety correlate imd patients though diagnosed ibs show healthy like microbiota profile the correlations host response microbiota aberration identified study indicated bold ibs heavy impact health care system currently patient diagnosis based subjective symptoms exclusion gastrointestinal diseases results study well others suggest diagnosis based symptoms alone optimal accompanied objective markers microbiota composition we introduced index microbial dysbiosis imd potentially used objectively stratify patients smaller groups patients psychological basis syndrome could separated peripheral gut abnormality using relatively small carefully phenotyped cohort identified several associations imd taxa hosts gene expression clinical markers suggesting impairment intestinal barrier may underlie immunological microbiological deviations often associated pi ibs here we show microbial signatures observed british pi ibs cohort reproduced independent swedish pi ibs cohort fig 1 this testifies robustness signatures different cohorts countries well used microbial analysis pipeline the main observed microbial aberration included increased level bacteroides spp decreased level uncultured clostridiales recently identified contrasting tipping point taxa reflect alternative stable states gut ecosystem recently similar bacterial signatures also detected subjects prior gastroenteritis suggesting perhaps microbial composition already time initial infection predisposes certain subjects pi ibs this significance allows diagnose subjects also may provide basis treatment dietary corrections represent major approach managing ibs symptoms expected efficacy depends individual gut microbiota microbial activity food metabolism directly indirectly contributes many ibs symptoms this hypothesis supported pilot study among pediatric ibs patients us note those children whose symptoms decreased test diet lower abundance bacteroides dialister spp found typify pi ibs microbiota stressing relevance organisms ibs we believe proposed model fig 2 built microbiota based patient stratification give insight observed microbiota heterogeneity among ibs patients well partial overlap healthy controls also represents concrete step toward improved diagnostics novel treatment options improved efficacy we grateful collaborators notably prof robin spiller md prof robert jan brummer md helpful discussions this work partly supported finland academy sciences grants 137389 141140 1272870 unrestricted spinoza netherlands organization scientific research

irritable bowel syndrome ( ibs ) is a multifactorial and heterogeneous disorder estimated to affect over 10% of the western population . a subset of the patients reports the start of the disease after an episode of gastroenteritis . the alterations in the intestinal microbiota of the post - infectious ibs ( pi - ibs ) patients were recently investigated in a british cohort and shown to differentiate from the healthy controls and resemble that of diarrhea - predominant ibs ( ibs - d ) patients . the altered 27 genus - like groups created a microbial signature , which could be used to objectively stratify patients and healthy controls . in this addendum , we combine the microbiota data derived from the british cohort with that of a recently reported swedish pi - ibs cohort . remarkably , robust and reproducible microbiota signatures were observed in these pi - ibs patients . we discuss these results with attention on the emerging role of microbiota in the classification , development and treatment of pi - ibs .

intracranial dural arteriovenous fistula davf abnormal arteriovenous shunts occur within leaflets dura mater comprised 10 15% intracranial arteriovenous malformation8 meta analysis 377 patients davf reported 1989 tentorial davf 8% 32/ 377 intracranial davf tentorial davf aggressive neurological behavior 97% 31/32 causing hemorrhage progressive focal neurological deficits110 unlike less aggressive davfs lateral cavernous sinuses drain venous sinuses tentorial davf drains pial veins11 ct mr imaging revealed acute hemorrhage left tectum mid brain fourth ventricle fig cerebral angiography showed davf around torcular fed meningeal branch ascending pharyngeal artery transosseus branch right occipital artery drained cortical vein left occiput basal vein rosenthal fig an intravenous bolus 3000 iu heparin administered placement 6-fr guiding sheath right femoral artery a 6-fr guiding catheter envoy cordis endovascular miami lakes fl usa placed external carotid artery we planned superselective catheterization meningeal branch ascending pharyngeal artery failed due tortous curve cranial base we could access fistula point transosseus branch occipital artery using microcatheter apollo ev3 inc the volume 0.7 ml onyx-18 ethyl vinyl alcohol ev3 inc irvine post embolization angiogram demonstrated onyx occupying retrograde drainage cortical vein obliteration davf fig the patient discharged 7 days later postoperative course uneventful 74-year old man presented progressive headache dementia symptom several months seven years ago spontaneous hemorrhage 4th ventricular treated davf transarterial embolization using n butyl cyanoacrylate nbca both middle meningeal arteries using 33 50% glue transosseus branch left occipital artery using 20% glue selected embolization although arteriovenous shunting flow completely abolished retrograde cortical flow remarkably decreased he refused treatment seek hospital since time visit well ct mr image showed prominent tortous vascular structure around medial tentorium multiple fine vessels engorgements thalamic putamen areas fig angiogram demonstrated recanalization recruitment middle meningeal arteries posterior choroidal arterial supply vertebral artery the retrograde leptomeningeal drain infratentorial vermian vein showed dilated saccular change fig we embolized davf right middle meningeal artery inject onyx-18 1.0 mg described korea mini mental state examination k mmse score improved 14 28 ct mr imaging revealed acute hemorrhage left tectum mid brain fourth ventricle fig cerebral angiography showed davf around torcular fed meningeal branch ascending pharyngeal artery transosseus branch right occipital artery drained cortical vein left occiput basal vein rosenthal fig an intravenous bolus 3000 iu heparin administered placement 6-fr guiding sheath right femoral artery a 6-fr guiding catheter envoy cordis endovascular miami lakes fl usa placed external carotid artery we planned superselective catheterization meningeal branch ascending pharyngeal artery failed due tortous curve cranial base we could access fistula point transosseus branch occipital artery using microcatheter apollo ev3 inc the volume 0.7 ml onyx-18 ethyl vinyl alcohol ev3 inc irvine post embolization angiogram demonstrated onyx occupying retrograde drainage cortical vein obliteration davf fig a 74-year old man presented progressive headache dementia symptom several months seven years ago spontaneous hemorrhage 4th ventricular treated davf transarterial embolization using n butyl cyanoacrylate nbca middle meningeal arteries ( using 33 50% glue transosseus branch left occipital artery using 20% glue selected embolization although arteriovenous shunting flow completely abolished retrograde cortical flow remarkably decreased he refused treatment seek hospital since time visit well ct mr image showed prominent tortous vascular structure around medial tentorium multiple fine vessels engorgements thalamic putamen areas fig angiogram demonstrated recanalization recruitment middle meningeal arteries posterior choroidal arterial supply vertebral artery the retrograde leptomeningeal drain infratentorial vermian vein showed dilated saccular change fig we embolized davf right middle meningeal artery inject onyx-18 1.0 mg described korea mini mental state examination k mmse score improved 14 28 davf associated retrograde leptomeningeal venous drainage exhibit high incidence aggressive behavior3912 leptomeningeal venous drainage classified type iii borden et al.2 in tentorial davf patients 22/22 cases 100%)14 26/31 cases 84%)10 13/14 cases 93%)6 classified borden type iii needed prompt treatment the tentorial davf rare type dvaf treated even though without remarkable clinical symptoms natural history disappointing knowledge tentorial davf located tentorial dura mater fed primarily branches meningohypophyseal trunk middle meningeal arteries occipital artery the multitude small dural arteries variety venous pathways high flow may prevent spontaneous closure11 davf usually multiple fistula points multiple feeding arteries drains single vein the aim davf treatment retrograde leptomeningeal venous drainage complete permanent obliteration arterial supply occlusion proximal draining vein therapeutic options treating davf include transvenous and/or transarterial embolization surgical excision davf nidus ligation draining vein usually transvenous embolization preferred venous anatomic features open tortuous catheterization draining vein fistula13 these combinations transvenous transarterial embolization results high obliteration rates davf tentorial davf somewhat different more importantly tentorial davf often drain exclusively subarachnoid veins rather associated sinus borden type iii prevents transvenous access261011 huang et al.6 reported complete cure tentorial davf 78.6% 11/14 transarterial embolization using onyx case partial obliteration arterial supply patients borden type ii iii lesions considered surgery may experience temporary palliation symptoms provide protection risk hemorrhage progression effects venous hypertension414 hwang et al.7 lawton et al.10 recommended surgical option incomplete embolization tentorial davf simple interruption draining vein surgical interruption simple venous drainage analogous transarterial and/or tranvenous embolization outlet nidus without effect normal venous drainage the surgical interruption proximal venous drain could considered according types tentorial davf location drain vein the tentorial sinuses drain supra- infratentorial veins well deep veins brain stem lasjaunias et al.9 divided tentorial davf torcular basal tentorium marginal tentorium location draining veins lesions marginal tentorium drain tentorial vein vein rosenthal mesencephalic veins picard et al.12 divided tentorial davf 3 groups draining veins medial lateral marginal tentorial sinus group lesions medial tentorial sinus group situated adjacent torcular drain lateral straight sinus they primarily receive venous drainage cerebellar hemispheres vermis infratentorial drainage lesions lateral tentorial sinus group lie adjacent lateral sinus receive supratentorial drainage lateral inferior surfaces temporal occipital lobes lesions marginal tentorial sinus group lie along free edge tentorium receive venous drainage basilar lateral mesencephalic veins fistulae location may infra- supratentorial drainage drain spinal veins case 1 torcular type lasjaunias et al.9 lawton et al.10 marginal tentorial sinus group picard et al.12 located around tocular area drained supratentorial cotical vein basal vein rosenthal causes brain stem hemorrhage case 2 medial tentorial sinus group picard et al.12 straight sinus type lawton et al.10 located around midline torcular drained infratentorial vermian vein causes venous hypertension various embolic agents used including particles platinum coils nbca onyx arterial approach case nbca solidification time material should matched local flow velocity angioarchitectural features lesion although nbca usually considered permanent embolic agent may result recanalization case delayed fashion5 furthemore posterior choroidal artery could selected embolization complete angiographic cure nbca recently due superior ability penetration controllability onyx used treatment choice transarterial embolic agent davf effective obliteration multiple fistula point proximal draining vein single transarterial access contrast nbca case 2 onyx could penetrate deeper venous sac reach posterior choroidal arterial supply middle meningeal artery results complete angiographic cure tentorial davf treated aggressively transarterial embolization onyx prior option transvenous access difficult transarterial approach using onyx also applied delayed recanalization embolization nbca if partially treated tentorial davf embolization procedure simple surgical interruption proximal draining vein considered according location drain veins

tentorial dural arteriovenous fistula ( davf ) is a rare vascular disease , which has high risk of intracranial hemorrhage . we present two cases of tentorial davf which were successfully treated with single trial of transarterial embolization using onyx . we briefly reviewed the types of the tentorial davf and strategies of treatment .

last 3 decades population based studies aiming determine true burden neurological disorders increasingly acknowledged nevertheless developing countries limited access neurologists rural areas logistic economic limitations perform neuroepidemiological studies significantly complicated implementation.1 however series epidemiological studies conducted upper egypt last 2 decades epidemiologic research progressed egypt particularly last 6 years two major projects evaluate incidence prevalence different neurological disorders al kharga district new valley al quseir city red sea governorate upper egypt this project aimed evaluate incidence prevalence epilepsy stroke incidence bell palsy prevalence dementia chorea athetosis dystonia parkinson disease cerebellar ataxia multiple sclerosis migraine trigeminal neuralgia cerebral palsy spinal cord disorders the project designed assess major neurological disorders al quseir city representative coastal city lying red sea al quseir city long history dating pharaonic era named thagho time batlamic romanic eras named leukos limen poptus albus respectively its population representative native inhabitants immigrants different governorates reside participate tourist activities fishing mining.2 eligible inhabitants living al quseir city least 6 months time interview included survey the study duration extended july 1 2009 june 31 2012 different stages data collection preparatory stage screening data entry statistical manipulation tabulation all households n 33,285 7497 families sexes 49.4% males n 16,428 50.6% females n 16,857 screened three neurologists addition 15 female social workers sociodemographic data collection via door door survey a standardized questionnaire sensitivity specificity 96% 93.2% respectively,3 applied three neurologists every member family children elderly questioned caregivers a total population 31,754 95.4% free neurological disorder versus 1531 4.6% sexes 3.9% n 647 males 5.2% n 884 females different neurological disorders full history data examinations general systemic neurological carried three neurologists collaboration nine senior staff members neurology departments assiut al azhar sohag qena universities all neurological disorders finally diagnosed evaluation three neurologists separately well specific investigatory tools diagnoses different neurological disorders based accepted definition diagnostic criteria given world health organization.4,5 definition incidence rate prevalence lifetime prevalence study according provided abramson.6 ethical approval study obtained research ethics committee assiut university ministry health carry project al quseir city red sea governorate each participant provided written informed consent children illiterate disabled individuals consented responsible person family caregivers data management carried two specialists data entry three medical statisticians using spss software v 16 ibm corporation armonk ny usa excel microsoft corporation redmond wa usa epicalc 2000 microsoft corporation the project designed assess major neurological disorders al quseir city representative coastal city lying red sea al quseir city long history dating pharaonic era named thagho time batlamic romanic eras named leukos limen poptus albus respectively its population representative native inhabitants immigrants different governorates reside participate tourist activities fishing mining.2 eligible inhabitants living al quseir city least 6 months time interview included survey the study duration extended july 1 2009 june 31 2012 different stages data collection preparatory stage screening data entry statistical manipulation tabulation all households n 33,285 7497 families sexes 49.4% males n 16,428 50.6% females n 16,857 screened three neurologists addition 15 female social workers sociodemographic data collection via door door survey a standardized questionnaire sensitivity specificity 96% 93.2% respectively,3 applied three neurologists every member family children elderly questioned caregivers a total population 31,754 95.4% free neurological disorder versus 1531 4.6% sexes 3.9% n 647 males 5.2% n 884 females different neurological disorders full history data examinations general systemic neurological carried three neurologists collaboration nine senior staff members neurology departments assiut al azhar sohag qena universities all neurological disorders finally diagnosed evaluation three neurologists separately well specific investigatory tools diagnoses different neurological disorders based accepted definition diagnostic criteria given world health organization.4,5 definition incidence rate prevalence lifetime prevalence study according provided abramson.6 ethical approval study obtained research ethics committee assiut university ministry health carry project al quseir city red sea governorate each participant provided written informed consent children illiterate disabled individuals consented responsible person family caregivers data management carried two specialists data entry three medical statisticians using spss software v 16 ibm corporation armonk ny usa excel microsoft corporation redmond wa usa epicalc 2000 microsoft corporation the incidence rates epilepsy stroke bell palsy compared worldwide rates illustrated table 1 the prevalence neurological disorders studied al quseir city illustrated tables 24 table 5 shows record prevalence different neurological disorders studied al quseir city worldwide the increase number different major projects study neurological disorders worldwide last 3 decades help us construct map neurological disorders throughout world clarify burden neurological disorder among different countries this study new one series large epidemiological studies carried country assess burden neurological disorders different localities egypt screening carried door door survey including every household using standardized questionnaire,7 subsequent clinical evaluation suspected cases neurologists three specialists well nine senior staff members al quseir general hospital assiut university hospital the limitations study include stigma neurological disorders eg view epilepsy evil attack dementia normal aging process necessitates extraneous effort project team clarify nature disorders suitability treat noncompliance patients prescribed treatments due scarce financial resources lack health care systems suited long term needs chronic neurological disorders these limitations required extra effort project team encourage participation inhabitants detailed explanations project goals members project team responsible authorities defined area study recruitment well known key persons well female social workers among native inhabitants accompanied screening team facilitate family interviews encourage participation capture recapture method present homes first visit the incidence rate epilepsy 48/100,000 per year al quseir city within international rate lower recorded sub saharan africa10 northern tanzania.11 meanwhile incidence rate epilepsy 48/100,000 study higher recorded new york ny usa 16/100,000)12 netherlands 29/100,000).13 although incidence rate stroke al quseir city lower recorded france14 areas egypt al kharga district new valley),7 similar recorded sohag upper egypt.15 incidence rate bell palsy al quseir city higher recorded worldwide.7,1618 great variation incidence rate epilepsy stroke bell palsy al quseir city comparison incidence rates worldwide could attributed different genetic characteristics population al quseir city population contains mixture native inhabitants immigrants different adjacent governorates thus variable distinct genetic predisposition various neurological disorders study age specific prevalence neurological disorders al quseir city revealed dementia 3.83% aged 60 years frequent followed migraine 2.8% stroke 6.2/1000 epilepsy 5.5/1000 parkinson disease 452.1/100,000 cerebral palsy 3.6/1000 however less frequent neurological disorders spinal cord injury 63.0/100,000 dystonia 39.1/100,000 cerebellar ataxia 30.0/100,000 trigeminal neuralgia 28/100,000 chorea 21.0/100,000 athetosis 15.0/100,000 multiple sclerosis 13.7/100,000 macdonald et al uk study found stroke frequent neurological disorder followed epilepsy parkinson disease finally multiple sclerosis.9 hand mexican rural community 2011 quet et al found headache frequent neurological disorder followed epilepsy stroke parkinson disease cerebellar ataxia.19 al kharga district order frequency prevalence neurological disorders studied follows dementia epilepsy stroke parkinson disease cerebral palsy cerebellar ataxia chorea dystonia athetosis.7 variable results different epidemiological studies might attributed differences methodology types neurological disorders studied impact different environmental factors diverse geographic areas different genetic compositions studied populations the prevalence multiple sclerosis 13.7/100,000 spinal cord disorders 63/100,000 18/100,000 traumatic 45/100,000 nontraumatic causes al quseir city first results community based epidemiological study egypt while radhakrishnan et al recorded lower prevalence multiple sclerosis libya 5.9/100,000)20 recorded study macdonald et al recorded much higher prevalence 200/100,000 uk.9 hand intermediate figure 33.9/100,000 prevalence multiple sclerosis recorded elik et al metropolitan area edrine city turkey.21 wide variation prevalence multiple sclerosis worldwide could attributed differences climate race immigration emigration well varied genetic predispositions studied sample frame this study clarified important issues regarding epidemiology studied neurological disorders summarized follows high prevalence parkinson disease 452.1/100,000 comparison worldwide studies localities egypt could attributed environmental pollution heavy metals manganese lead phosphorus area the higher prevalence cerebral palsy 3.6/1000 worldwide records previously recorded data al kharga district egypt could explained lack antenatal perinatal postnatal care al quseir city lower prevalence chorea al quseir city 21.03/100,000 comparison two studies conducted country al kharga district 31.96/100,000;7 assiut 62.00/100,00022 rheumatic chorea could attributed governmental efforts eradication rheumatic activities last years door door surveys direct personal interviews health seeking non health seeking individuals gives better chance diagnosing rare neurological disorders it remains gold standard method epidemiological studies especially absence existing coded data due lack medical registry systems health insurance coverage this study aim evaluating prevalence trigeminal neuralgia multiple sclerosis spinal cord disorders first time egypt the study shows high prevalence parkinson disease cerebral palsy stroke al quseir city compared cities worldwide study shows marked decline prevalence chorea egypt compared previous study.22

a door - to - door survey , including every household , was conducted for all inhabitants of al quseir city ( 33,283 ) , red sea governorate , egypt by three specialists of neurology as well as nine senior staff members of neurology and 15 female social workers to assess the epidemiology of major neurological disorders . over six phases , from july 1 , 2009 to january 31 , 2012 , screening of all eligible people in the population was carried out , by which case ascertainment of all major neurological disorders included in the study was done according to the accepted definitions and diagnostic criteria of the world health organization . the order of frequency of prevalence of the studied neurological disorders was dementia ( 3.83% for those aged > 60 years ) , migraine ( 2.8% for those aged > 8 years ) , stroke ( 6.2/1000 for those aged > 20 years ) , epilepsy ( 5.5/1000 ) , parkinson s disease ( 452.1/100,000 for those aged > 40 years ) , cerebral palsy ( 3.6/1000 among children < 18 years ) , spinal cord disorders ( 63/100,000 ) dystonia ( 39.11/100,000 ) , cerebellar ataxia ( 30.01/100,000 ) , trigeminal neuralgia ( 28/100,000 for those aged > 37 years ) , chorea ( 21.03/100,000 ) , athetosis ( 15/100,000 ) , and multiple sclerosis ( 13.74/100,000 ) . the incidence rates of stroke , epilepsy , and bell s palsy were 181/100,000 , 48/100,000 , and 98.9/100,000 per year , respectively .

group included patients arm ru fistula undergone posterior sagittal anorectoplasty psarp without closure ru fistula february 2006 january 2010 the rest psarp procedure conventionally done difference close ru fistula separating rectum we separated rectum urethra left urethral fistula without closing group b included 34 previous successive patients undergone psarp january 2006 ru fistula closed using interrupted sutures all patients groups undergone staged repair arm primary psarp micturating cystourethrogram mcu distal colostogram done patients prior psarp all patients evaluated follow clinically investigations like mcu cystoscopy the patients studied parameters like urinary stream urinary dribbling urinary tract infections recurrent ru fistula moreover patients undergone urethrocystoscopy three months psarp check status urethra bladder patients sacral agenesis excluded study group congenital sacral defects lead neurogenic bladder the following observations group immediate postoperative period urinary leakage urinary retention complication thus patients uneventful recovery ( b urinary stream normal evidence urinary dribbling retention urinary tract infection recurrent rectourinary fistula follow mcu showed normal urethra without evidence stenosis stricture urethro ejaculatory duct vasal reflux diverticulum cases however group b complications like urethral stenosis urethral diverticulum neurogenic dysfunction seen a comparative analysis two groups done overall complications listed table 1 during psarp urological injuries male patients known complications.[13 excessive traction urethra dissection leads transection injury urethra it extremely important surgeon bear mind arm ru fistula rectum intimately attached urethra meticulous dissection separation necessary urethral stenosis occur due traction ru fistula indirect traction urethra separation closure fistula urethral stenosis avoided applying less traction fistula separation avoiding closure fistula seen series urethral stenosis seen cases group ru fistula closed closing another point note separate rectum urethra near urethral wall use interrupted sutures closure also increases chances urethral stenosis urethral stenosis due ligation closure ru fistula may result recurrent epididymo orchitis urethral diverticulum result segment rectum left attached urethra separated end closed such patients usually present recurrent urinary tract infections stone formations diverticulum leading dysuria urinary tract infections this complication avoided separating rectum away urethra without leaving segment rectum attached leaving fistula without closing nothing like pouch diverticulum formed neurogenic dysfunction psarp reported form neurogenic bladder impotence loss ejaculation postoperatively neurogenic bladder may reflect poor surgical technique denervation bladder bladder neck repair avoiding closure ru fistula avoid excessive traction fistula hence urethra also prevent excessive dissection fistula closure minimize chance neurogenic dysfunction damage external vesical sphincter also reported ligation closure fistula thus avoiding closure fistula avoid complication also hence neurovesical dysfunction thus seen something closing ru fistula psarp avoid many complications something preferable

aim : to study the effect of nonclosure of rectourethral ( ru ) fistula and to do a comparative analysis of the complications with and without nonclosure of ru fistula during posterior sagittal anorectoplasty ( psarp ) in anorectal malformation cases ( arm).materials and methods : a total of 68 cases of arm were included in the study group , of which 34 cases were those in whom ru fistula was not closed ( group a ) during psarp . another 34 successive cases were included in study group b in whom the ru fistula was closed as is conventionally done by using interrupted sutures.results:comparatively , group a had none or minimum urological complications as compared to group b.conclusion:ru fistula closure is not mandatory during psarp and nonclosure avoids urological complications . it especially avoids urethral complications , which are 100% preventable .

pathogenesis middle ear cholesteatoma debated century four basic theories invagination basal cell hyperplasia epithelial ingrowth squamous metaplasia last century etiopathogenicity middle ear cholesteatoma raised many controversies still unanimous concept n't exist histological point view pathological tissue the interaction cellular components essential major histopathological features cholesteatoma hyperproliferation bone destruction 1964 american anatomist gray referred middle ear cholesteatoma skin wrong place 1 this simplified misdefinition stuck literature cited profusely many scientific papers metaplasia theory 2 existence called congenital cholesteatoma put question skin origin middle ear cholesteatoma gave etiopathogenetical evidences simplified definition skin wrong place the list histological differences includes absence cutaneous adnexa specialized dermal structures neither hypodermal structures blood vessels nerve endings ever described cholesteatoma the similarity left presence multistratified squamous epithelium cholesteatoma epithelium hyperproliferative properties experimental models critical studying pathogenesis middle ear cholesteatoma vivo models tried establish chemical injection middle ear 3 ligation external auditory canal 4 transplantation skin 5 keratinocytes middle ear cholesteatoma cultured tissue culture 6 passaged subculture 7 air liquid interface system 8) however stable experimental models middle ear cholesteatoma established our study aimed create adequate vitro model based cell cell interaction keratinocytes fibroblasts assess grade homogeneity cholesteatoma skin keratinocytes focusing cytokeratin profile enzymatic disaggregation protocol simultaneous isolation primary keratinocytes fibroblasts cholesteatoma tissue developed the biopsy samples harvested patients undergoing surgical treatment department otolaryngology ajou university hospital korea informed consent form approved institutional review board ajou university hospital cholesteatoma keratinocytes cultured defined keratinocytes serum free medium gibco brl gaithersburg md usa supplied growth supplement 5 mg ml gentamicin gibco brl according manufacture instructions cholesteatoma primary fibroblasts successfully cultured dulbeco modified eagle medium gibco brl supplemented 10% fetal bovine serum fbs clonetics walkersville md usa 1% penicillin streptomycin mixture gibco brl primary keratinocytes passage 1 fibroblasts passages 1 5 used establishment co cultured system hacat cell line kindly provided department dermatology ajou university hospital feeder layer cholesteatoma fibroblasts louis mo usa concentration 0.25 g ml fibroblasts incubated overnight 37 5% co2 humidified atmosphere next day the feeder layer subsequently trypsinized substrate transferred polyester membrane transwell costar cambridge usa system develop subconfluent feeder layer cholesteatoma keratinocytes hacat cells seeded density 210 cells ml feeder layer co cultured 3 5 days air exposed period 14 days transwell membranes fixed 4% formaldehyde overnight 4 dehydrated graded alcohols cleared histoclear national diagnostics atlanta georgia embedded paraffin six thick sections prepared subjected routine hematoxylin eosin staining polyacrylamide gel electrophoresis used protein separation staining coomassie blue performed compare protein profile cholesteatoma keratinocytes hacat cells blocking nonspecific staining accomplished membrane incubation 5% non fat skim milk 1 hr room temperature rt membranes incubated primary mouse monoclonal anti cytokeratin antibody clone k 8.12 sigma immunospecific cytokeratin 13 ck 13 cytokeratin 16 ck 16 dilution factor 1:100 1 hr rt after washing membranes incubated goat anti mouse horseradish peroxidase conjugate zymed san francisco ca usa the positive reaction visualized ecl western blotting detection system amersham bucks uk the localization cytokeratin 13 16 middle ear cholesteatoma tissue accomplished ihc study described 9 five middle ear cholesteatoma samples compared corresponding retroauricular skin samples obtained surgery six thick formalin fixed paraffin embedded tissue sections processed abc method primary mouse monoclonal anticytokeratin antibody sigma concentration 1:20 incubated overnight rt vectorlab elite abc kit vector laboratories burlingame ca usa used detection positive reaction using diaminobenzidine substrate enzymatic disaggregation protocol simultaneous isolation primary keratinocytes fibroblasts cholesteatoma tissue developed the biopsy samples harvested patients undergoing surgical treatment department otolaryngology ajou university hospital korea informed consent form approved institutional review board ajou university hospital cholesteatoma keratinocytes cultured defined keratinocytes serum free medium gibco brl gaithersburg md usa supplied growth supplement 5 mg ml gentamicin gibco brl according manufacture instructions cholesteatoma primary fibroblasts successfully cultured dulbeco modified eagle medium gibco brl supplemented 10% fetal bovine serum fbs clonetics walkersville md usa 1% penicillin streptomycin mixture gibco brl primary keratinocytes passage 1 fibroblasts passages 1 5 used establishment co cultured system hacat cell line kindly provided department dermatology ajou university hospital feeder layer cholesteatoma fibroblasts louis mo usa concentration 0.25 g ml fibroblasts incubated overnight 37 5% co2 humidified atmosphere next day the feeder layer subsequently trypsinized substrate transferred polyester membrane transwell costar cambridge usa system develop subconfluent feeder layer cholesteatoma keratinocytes hacat cells seeded density 210 cells ml feeder layer co cultured 3 5 days air exposed period 14 days transwell membranes fixed 4% formaldehyde overnight 4 dehydrated graded alcohols cleared histoclear national diagnostics atlanta georgia embedded paraffin six thick sections prepared subjected routine hematoxylin eosin staining polyacrylamide gel electrophoresis used protein separation staining coomassie blue performed compare protein profile cholesteatoma keratinocytes hacat cells blocking nonspecific staining accomplished membrane incubation 5% non fat skim milk 1 hr room temperature rt membranes incubated primary mouse monoclonal anti cytokeratin antibody clone k 8.12 sigma immunospecific cytokeratin 13 ck 13 cytokeratin 16 ck 16 dilution factor 1:100 1 hr rt after washing membranes incubated goat anti mouse horseradish peroxidase conjugate zymed san francisco ca usa the positive reaction visualized ecl western blotting detection system amersham bucks uk the localization cytokeratin 13 16 middle ear cholesteatoma tissue accomplished ihc study described 9 five middle ear cholesteatoma samples compared corresponding retroauricular skin samples obtained surgery six thick formalin fixed paraffin embedded tissue sections processed abc method primary mouse monoclonal anticytokeratin antibody sigma concentration 1:20 incubated overnight rt vectorlab elite abc kit vector laboratories burlingame ca usa used detection positive reaction using diaminobenzidine substrate the low selectivity potential damages cells case prolonged incubation major disadvantages procedure as inflammatory tissue cholesteatoma posed difficulties isolation primary keratinocytes attendant inflammation possible contamination requires adequate decontamination the first primary keratinocytes appeared usually 7 10 days trypsinization generally within next 10 days keratinocytes reached confluence the individual variations proliferative activity cholesteatoma keratinocytes related cholesteatoma localization sex patient for instance attic cholesteatoma frequently resulted isolation primary keratinocytes bigger proliferative ability another interesting correlation fact cholesteatoma samples obtained young female patients characterized higher proliferative activity vitro primary cholesteatoma keratinocytes uniform shape arranged typical monolayer pattern fig in passage 2 abrupt deceleration proliferation established accompanied morphological alterations enlargement flattening cells well vacuolization cytoplasm passage 3 primary cholesteatoma fibroblasts steadily maintained without significant changes doubling time passage 10 bigger stratification proliferation observed proposed 3d vitro system primary cholesteatoma keratinocytes co cultured presence fibroblasts fig 3b comparison control group without fibroblasts fig 3a 4a disrupted differentiation suprabasal layers revealed cholesteatoma keratinocytes air exposed presence fibroblasts mimicking parakeratosis state typical pathological tissue vivo fig coomassie blue staining protein extracts primary cholesteatoma keratinocytes hacat cells revealed significantly different protein profiles fig stronger expression ck 16 48 kda ck 13 51 kda established cholesteatoma keratinocytes comparison hacat cells fig 5b using mouse monoclonal antibody clone k 8.12 tissue localization ck 13 ck 16 the intensity ck 13 16-positive staining varied different areas cholesteatoma sample the positive control revealed specific expression ck 13 16 confined islands neoplastic squamous cells laryngeal carcinoma specimens the low selectivity potential damages cells case prolonged incubation major disadvantages procedure as inflammatory tissue cholesteatoma posed difficulties isolation primary keratinocytes attendant inflammation possible contamination requires adequate decontamination the first primary keratinocytes appeared usually 7 10 days trypsinization generally within next 10 days keratinocytes reached confluence the individual variations proliferative activity cholesteatoma keratinocytes related cholesteatoma localization sex patient for instance attic cholesteatoma frequently resulted isolation primary keratinocytes bigger proliferative ability another interesting correlation fact cholesteatoma samples obtained young female patients characterized higher proliferative activity vitro primary cholesteatoma keratinocytes uniform shape arranged typical monolayer pattern fig in passage 2 abrupt deceleration proliferation established accompanied morphological alterations enlargement flattening cells well vacuolization cytoplasm passage 3 primary cholesteatoma fibroblasts steadily maintained without significant changes doubling time passage 10 bigger stratification proliferation observed proposed 3d vitro system primary cholesteatoma keratinocytes co cultured presence fibroblasts fig 3b comparison control group without fibroblasts fig 3a 4a disrupted differentiation suprabasal layers revealed cholesteatoma keratinocytes air exposed presence fibroblasts mimicking parakeratosis state typical pathological tissue vivo fig coomassie blue staining protein extracts primary cholesteatoma keratinocytes hacat cells revealed significantly different protein profiles fig ck 13 51 kda established cholesteatoma keratinocytes comparison hacat cells fig using mouse monoclonal antibody clone k 8.12 tissue localization ck 13 ck 16 verified basal suprabasal layers cholesteatoma fig the intensity ck 13 16-positive staining varied different areas cholesteatoma sample the positive control revealed specific expression ck 13 16 confined islands neoplastic squamous cells laryngeal carcinoma specimens the putative interactions major cellular components cholesteatoma tissue extensively studied literatures we demonstrate summarized schematic model possible intercellular cross talking epithelial mesenchymal components cholesteatoma fig pro inflammatory cytokines interleukin-1 interleukin-1 il-1 il-1 released matrix keratinocytes stimulate keratinocytes growth factor kgf expression turn induced proliferation cholesteatoma keratinocytes 10 granulocyte macrophage colony stimulating factor gm csf another fibroblasts derived growth factor induced il-1 acknowledged stimulating effects proliferation terminal differentiation keratinocytes 11 keratinocytes derived parathyroid hormone related protein pthrp induces expression kgf kgf released perimatrix fibroblasts accelerates proliferative response matrix keratinocytes a possible connection pthrp bone destructive lesions also reported 12 transforming growth factor alpha tgf- ) is constitutively expressed keratinocytes regulates keratinocyte proliferation differentiation autocrine manner 13 hand possible synergism tgf- epidermal growth factor egf ) was proposed possible effect keratinocytes proliferation epidermal growth factor receptor egf r indicating existence alternative paracrine regulatory mechanism 14 transforming growth factor beta tgf- expressed hyperproliferative epithelium granulation tissue 15 influences epithelial morphogenesis autocrine paracrine fashion the statements cellular interactions taken consideration creating adequate vitro middle ear cholesteatoma model mentioned before proliferative capacity primary cholesteatoma keratinocytes vitro limited expires within 2 passages improve plating efficiency survival rate low density 3t3-mouse embryo fibroblasts used routinely cell culture practice display different morphological patterns cobble stone morphology differs vivo state complicates result interpretation feeder layer secretes nutrients growth factors matrix constituents positive control study we choose hacat cell line order avoid donor donor site site variations proliferative capacity normal skin keratinocytes hacat cells spontaneously immortalized human adult skin keratinocytes raised reduced calcium level elevated temperature conditions 16 hacat found extensive application tissue engineering development artificial skin equivalents 17 the proposed organotypic vitro model revealed stronger proliferation bigger stratification hacat cells co cultured fibroblasts comparison control group without fibroblasts histopathological diagnosis cholesteatoma includes unrestrained proliferation uncoordinated differentiation migration invasion 18 consistent mentioned observation proposed 3d model disclosed disrupted differentiation presence nucleated cells upper layers cholesteatoma ali fibroblasts squamous metaplasia middle ear epithelium considered adaptive tissue response towards persistent pathological stimuli chronic inflammation possible etiopathogenetical mechanism middle ear cholesteatoma an experiment reported confirmation possible transformation differentiated middle ear epithelium towards functionally inferior multilayered squamous epithelium 19 epithelial cells characterized presence specific set intermediate protein filaments named cytokeratins specific different epithelial types one primary objectives assess grade homogeneity hacat cells cholesteatoma keratinocyte ck 16 suggested literature proliferation marker ck 13 considered marker differentiation 20 immunohistochemical investigation study disclosed non uniform patterns expression ck 13 ck 16 middle ear cholesteatoma tissue variation intensity positively stained areas different cholesteatoma samples well different areas sample probably related different proliferative capacity cholesteatoma the expression nonepidermal cytokeratins middle ear cholesteatoma tissue gives arguments probable skin origin mech keratinocytes protein separation coomassie blue staining revealed significantly different protein profile cholesteatoma hacat cells precised western blotting analysis demonstrated comparatively stronger expression ck 13 16 cholesteatoma keratinocytes regard hacat cell line the different protein cytokeratin profiles established cholesteatoma keratinocytes hacat cells favors metaplasia possible cause development mech the proposed vitro model underlines importance fibroblasts major component 3d vitro system our results emphasize integrity cholesteatoma separated pathological tissue composed two closely related functional structural parts matrix perimatrix

objectivesexperimental models are of importance to study the pathogenesis of middle ear cholesteatoma , however , they were not established until now . we aimed to develop in vitro model of middle ear cholesteatoma using primary keratinocytes and fibroblasts isolated from cholesteatoma tissue . hacat cell line was used as a " skin equivalent " and to compare the grade of homogeneity between cholesteatoma keratinocytes and hacat cells.methodsprimary keratinocytes were isolated from cholesteatoma tissue , co - cultured with preliminary prepared feeder layer from cholesteatoma fibroblasts and subsequently air - exposed . the protein profile of cholesteatoma keratinocytes and hacat cells was evaluated by means of immunoblot using monoclonal antibody against cytokeratin ( ck ) 13 and 16 . tissue localization of ck 13 and 16 was accomplished with immunohistochemistry.resultsdifferent protein profile and stronger expression of ck 13 and 16 were demonstrated in cholesteatoma keratinocytes in comparison with hacat cells . bigger stratification was observed in the 3d - in vitro systems when both cholesteatoma keratinocytes and hacat cells were respectively co - cultured with fibroblasts in comparison with the corresponding control groups without fibroblasts.conclusion3d-model demonstrates the significance of intercellular interaction between components of cholesteatoma tissue .

dynamic biomolecules often undergo large scale structural changes visit distinct conformational states biological function it great biological pharmaceutical interest characterize structures conformational transition pathways ideally detailed free energy landscapes sought understand functional mechanisms biomolecules quantitative manner however due large energy barriers conformational transitions biomolecules usually take place time scales milliseconds even longer this presented grand challenge computational molecular dynamics md simulations limited typically hundreds nanoseconds tens microseconds address challenge biasing simulation methods found useful enhanced sampling free energy calculation biomolecules these methods include umbrella sampling conformational flooding metadynamics adaptive biasing force abf calculations orthogonal space sampling etc simulations potential force bias is applied along certain reaction coordinates collective variables facilitate biomolecular conformational transitions across high energy barriers typical reaction coordinates include atom distances torsional dihedrals root mean square deviation rmsd relative reference configuration eigenvectors generated principal component analysis the definition reaction coordinates however often requires expert knowledge studied systems furthermore predefined reaction coordinates largely place constraints pathway conformational space sampled biasing simulations it often leads slow convergence simulations important reaction coordinates missed simulation setup accelerated molecular dynamics amd enhanced sampling technique works often adding non negative boost potential smoothen biomolecular potential energy surface the boost potential v decreases energy barriers thus accelerates transitions different low energy states this amd able sample distinct biomolecular conformations rare barrier crossing events accessible conventional md cmd simulations unlike previously mentioned biasing simulation methods amd require predefined reaction coordinate(s advantageous exploring biomolecular conformational space without priori knowledge restraints amd successfully applied number biological systems 10 hundreds nanosecond amd simulations shown capture millisecond time scale events globular membrane proteins amd demonstrated greatly enhance conformational sampling biomolecules suffers large energetic noise reweighting the boost potential applied amd simulations typically order tens hundreds kilocalories per mole much greater magnitude wider distribution biasing simulation methods make use predefined reaction coordinates e.g. several kilocalories per mole it long standing problem accurately reweight amd simulations recover original free energy landscapes especially large proteins our recent studies showed boost potential follows near gaussian distribution cumulant expansion second order provides improved reweighting amd simulations compared previously used exponential average maclaurin series expansion reweighting methods the reweighted free energy profiles good agreement long time scale cmd simulations demonstrated alanine dipeptide fast folding proteins however improvement limited rather small systems e.g. proteins less 35 amino acid residues simulations larger systems boost potential exhibits significantly wider distribution and gaussian accelerated molecular dynamics gamd approach presented reduce energetic noise simultaneous unstrained enhanced sampling free energy calculation biomolecules even large proteins gamd makes use harmonic functions construct boost potential adaptively added biomolecular potential energy surface a minimal set simulation parameters dynamically adjusted control magnitude distribution width boost potential such resulting boost potential follows gaussian distribution allows accurate reweighting simulations using cumulant expansion second order study gamd demonstrated unconstrained simulations alanine dipeptide chignolin folding ligand binding t4-lysozyme gaussian accelerated molecular dynamics enhances conformational sampling biomolecules adding harmonic boost potential smoothen system potential energy surface figure 1 consider system n atoms positions 1, ... ,n when system potential v lower threshold energy e boost potential added as1where k harmonic force constant the modified system potential v v v given by2otherwise system potential threshold energy i.e. v e boost potential set zero v v when threshold energy set maximum potential e vmax system potential energy surface smoothened adding harmonic boost potential follows gaussian distribution the coefficient k0 range 01 determines magnitude applied boost potential greater k0 higher boost potential added original energy surface conventional molecular dynamics cmd provides enhanced sampling biomolecules across decreased energy barriers order smoothen potential energy surface enhanced sampling first two arbitrary potential values v1 v2 found original energy surface v1 v2 v monotonic function change relative order biased potential values i.e. v1 v2 replacing v eq 2 isolating e obtain3second v1 v2 potential difference observed smoothened energy surface smaller original i.e. v2 v1 v2 v1 similarly replacing v eq 2 derive4with vmin v1 v2 vmax need set threshold energy e following range combining eqs 3 4:5where vmin vmax system minimum maximum potential energies ensure eq 5 valid vmax vmin 1/k k satisfy following:6we define k k0(1/(vmax vmin 0 k0 1 illustrated figure 1 k0 determines magnitude applied boost potential greater k0 higher boost potential added potential energy surface provides enhanced sampling biomolecules across decreased energy barriers third standard deviation v needs small enough i.e. narrow distribution ensure accurate reweighting using cumulant expansion second order:7where vav v average standard deviation system potential energies v standard deviation v 0 user specified upper limit e.g. 10kbt accurate reweighting provided eq 5 gives range threshold energy e e set lower bound e vmax plug e k obtain8we define right hand side eq 8 k0 0/v)((vmax vmin)/(vmax vav efficient enhanced sampling highest possible acceleration k0 set upper bound as9the greater v obtained original potential energy surface particularly large biomolecules smaller k0 may applicable allow accurate reweighting alternatively when threshold energy e set upper bound e vmin 1/k according eq 5 plug e k eq 7 obtain10we define right hand side eq 10 k0 1 0/v vmax vmin)/(vav vmin when k0 0 v 0 k0 theoretically set value zero 1 although k0 1 applied case current implementation gamd see appendix note smaller k0 give higher threshold energy e smaller force constant k. 0 k0 1 k0 set either k0 highest threshold energy e upper bound 1.0 greatest force constant k. case k0 k0 applied current gamd implementation k0 > 1 lower threshold energy e ensure 0 k0 1 e.g. e vmax default k0 1 given e k0 calculate boost potential as11similar amd gamd provides options add total potential boost vp dihedral potential boost vd dual potential boost vp vd the dual boost simulation generally provides higher acceleration two types simulations enhanced sampling the simulation parameters comprise threshold energy values effective harmonic force constants k0p k0d total dihedral potential boost respectively characterize extent v follows gaussian distribution its distribution anharmonicity calculated done previously:12where v dimensionless divided kbt kb boltzmann constant system temperature respectively smax 1/2 ln(2ev2 maximum entropy v reweighting approximating exponential average term cumulant expansion second order able accurately recover original free energy landscape appendix b as increases v distribution becomes less harmonic reweighted free energy profile obtained cumulant expansion second order deviates original demonstrated alanine dipeptide chignolin t4-lysozyme study gaussian distribution boost potential normally achieved gamd simulations the anharmonicity v distribution serves indicator enhanced sampling convergence accuracy reweighted free energy gamd currently implemented gpu version amber 12 see appendix implementation details simulations alanine dipeptide chignolin t4-lysozyme performed using amber ff99sb force field gpus ligand benzene removed x ray crystal structure leu99ala mutant protein data bank pdb 181l another four benzene molecules placed bulk solvent least 40 away ligand binding site starting configuration solvating structures tip3p water box extends 810 solute surface alanine dipeptide system contained 630 water molecules 2,211 waters chignolin 9,011 waters t4-lysozyme the total number atoms three systems 1,912 6,773 29,692 alanine dipeptide chignolin t4-lysozyme respectively table 1 bonds containing hydrogen atoms restrained shake algorithm 2 fs time step used weak coupling external temperature pressure bath used control temperature pressure the electrostatic interactions calculated using pme particle mesh ewald summation cutoff 8.0 long range interactions the three systems initially minimized 2,000 steps using conjugate gradient minimization algorithm solvent equilibrated 50 ps isothermal isobaric npt ensemble solute atoms fixed another minimization performed atoms free systems slowly heated 300 k 500 ps final system equilibration achieved 200 ps isothermal isovolumetric nvt 400 ps npt run ensure water box simulated systems reached appropriate density in present study system threshold energy set e vmax gamd simulations the maximum minimum average standard deviation values system potential vmax vmin vav v obtained initial 2 ns nvt simulation boost potential optimal acceleration greatest 0 k0 were determined short testing simulations e.g. 2 ns increasing 0 either k0 calculated using eq 9 reaches 1.0 highest acceleration level v reaches 10kbt upper limit v distribution width accurate reweighting each gamd simulation proceeds 2 ns equilibration run followed production simulations dihedral potential boost identify optimal 0 k0 acceleration parameters supporting information tables s1s3 long time dual boost gamd simulations obtained analysis including three independent 30 ns simulations alanine dipeptide three independent 300 ns simulations chignolin complete binding benzene target ligand binding site observed one five simulations even simulation extended 1,800 ns time courses dihedral angles rmsd radius gyration rg residue distances amber simulation trajectories analyzed using cpptraj tool particularly backbone dihedral angles calculated alanine dipeptide figure 2a for chignolin rg rmsd simulation frames relative pdb native structure figure 3a calculated protein c atoms terminal residues gly1 gly10 excluded ligand binding t4-lysozyme figure 5a ) symmetry corrected rmsd benzene obtained generating six symmetrically imaged reference benzene configurations 181l crystal structure calculating rmsds diffusing benzene molecules frame aligning protein c terminal domain residues 80160 extracting minimum value calculated rmsds moreover number protein atoms found within 5 benzene ncontact heavy atoms considered calculated using pbwithin vmd accounts periodic boundary conditions the pyreweighting toolkit used reweight gamd simulations calculating pmf profiles examine boost potential distributions two dimensional 2d pmf profiles computed backbone dihedrals alanine dipeptide bin size 6 selected balance reducing anharmonicity increasing bin resolution discussed earlier two dimensional pmf profiles also constructed using rmsd rg chignolin bin size 1.0 1.0 benzene binding t4-lysozyme 2d pmf constructed using ligand rmsd ncontact bin size 1.0 5 number simulation frames within bin lower certain limit i.e. cutoff bin sufficiently sampled thus excluded reweighting the cutoff determined iteratively increasing minimum position pmf profile change the final cutoff set 10 50 1000 reweighting gamd simulations alanine dipeptide chignolin t4-lysozyme respectively gamd provides enhanced sampling conformational transitions alanine dipeptide chignolin folding ligand binding t4-lysozyme furthermore boost potential applied present gamd simulations follows gaussian distribution allows accurate reweighting using cumulant expansion second order recovery original biomolecular free energy landscapes even proteins large t4-lysozyme notably hundreds nanoseconds gamd simulations able capture complete folding chignolin ligand binding benzene t4-lysozyme take place significantly longer time scales order balance achieving highest acceleration large v ensuring accurate reweighting small enough standard deviation v short gamd simulations 2 ns tested alanine dipeptide search optimal acceleration parameters for total potential boost 0p adjusted 1.0 2.0 resulting k0p calculated using eq 9 increased 0.21 1.0 accompanied increases vp standard deviation 1.03 1.75 kcal mol vp average 2.36 3.85 kcal mol see supporting information table s1a k0p reached maximum 1.0 slight changes observed 0p increased 2.0 3.0 dihedral potential boost the calculated k0d reached 1.0 0d increased 3.0 supporting information table s1b therefore 0p,0d set 3.0 3.0 production dual boost gamd simulations alanine dipeptide enables highest acceleration well accurate reweighting k0p k0d equal 1.0 supporting information table s1c as shown figure 2b boost potential v applied gamd simulation alanine dipeptide follows gaussian distribution the average standard deviation v 10.9 2.9 kcal mol respectively table 1 figure 2c plots 2d pmf backbone dihedrals obtained reweighting three 30 ns gamd simulations combined using cumulant expansion second order the reweighted pmf able recover five energy minimum wells centered around 162 12 72 12 right handed helix r 48 18 left handed helix l 156 162 -sheet 66 156 polyproline ii pii conformation the corresponding minimum free energies estimated 0 1.40 1.07 2.94 4.27 kcal mol respectively this good agreement pmf results exceptionally long 1000 ns cmd simulation presented earlier additionally distribution anharmonicity vof frames clustered bin 2d pmf exhibits values smaller 0.10 low energy regions figure 2d suggests sufficient sampling reweighting using cumulant expansion second order greater anharmonicity is found high energy regions especially energy barriers low boost potential applied less sampling normally achieved therefore anharmonicity v distribution appears good indicator sufficiency enhanced sampling accuracy reweighted free energy ( scheme representation backbone dihedrals alanine dipeptide ( c 2d potential mean force pmf backbone dihedrals calculated three 30 ns gamd simulations combined using cumulant expansion second order the low energy wells labeled corresponding right handed helix r left handed helix l -sheet polyproline ii pii conformations ( distribution anharmonicity v frames found bin pmf profile chignolin short 2 ns testing gamd simulations showed k0p reached 1.0 maximum highest total potential boost 0p increased 3.0 supporting information table s2a for dihedral potential boost simulation crashed 0d increased 0.9 stable simulation achieved 0d increased 0.6 supporting information table s2b thus 0p,0d set 3.0 0.6 production dual boost gamd simulations chignolin supporting information table s2c the resulting boost potential follows gaussian distribution calculated 9.22 10 figure 3b the average standard deviation v 9.8 2.4 kcal mol respectively table 1 folding chignolin captured gamd simulations comparison simulation folded chignolin blue pdb 1uao native structure red exhibits 0.2 rmsd b distribution boost potential v c 2d rmsd rg pmf calculated reweighting three 300 ns gamd simulations combined distribution anharmonicity v frames found bin pmf profile started extended conformation gamd simulations able capture complete folding chignolin native structure supporting information movie s1 the rmsd obtained simulation folded chignolin nmr experimental native structure pdb 1uao reaches minimum 0.2 figure 3a using protein rmsd relative pdb native structure rg 2d pmf profile calculated reweighting three 300 ns gamd simulations combined figure 3c the reweighted pmf allows us identify three distinct low energy conformational states folded f unfolded u intermediate the folded state corresponds global energy minimum 1.0 4.0 unfolded state 3.68 kcal mol higher local energy well centered 6.0 7.0 intermediate 3.06 kcal mol free energy well centered 4.0 5.5 the energy barrier chignolin folding unfolded folded states 4.0 kcal mol 3.5 kcal mol transitions intermediate folded states figure 3c comparison three 300 ns gamd simulations analyzed separately reweighted pmf profiles exhibit significant differences supporting information figure s2 whereas three folded intermediate unfolded low energy states captured sim2 unfolded intermediate states sufficiently sampled converged low energy wells sim1 sim3 respectively figure 3d plots distribution anharmonicity v frames found bin 2d pmf shown figure 3c the anharmonicity exhibits values smaller 0.05 simulation sampled conformational space suggesting v achieves sufficient sampling reweighting using cumulant expansion second order compared native structure unfolded chignolin exhibits extended conformation without proper secondary structure formed protein backbone shown figure 4a the intermediate conformation observed folding chignolin characterized hydrophobic interactions pro4 trp9 residue side chains turn thr8 such conformation also observed previous microsecond time scale cmd simulations simulation derived folded state protein residue side chains exhibit closely similar conformations nmr native structure figure 4c residues tyr2 pro4 form hydrophobic interactions side chains hydrophilic residues asp3 glu5 thr6 thr8 expose side chains solvent structures chignolin observed gamd simulations corresponding unfolded u b intermediate c folded f states blue aligned pdb native structure red residues including tyr2 asp3 pro4 glu5 thr6 thr8 trp9 represented sticks finally 2d free energy profile chignolin calculated using rmsd protein c atoms relative native pdb structure backbone dihedral residue gly7 supporting information figure s3 this allows identification misfolded low energy state addition f u states observed figure 3c the conformation chignolin shows 180 rotation c terminal strand long axis relative native pdb structure the free energy misfolded chignolin found 1.89 kcal mol greater folded state this consistent previous findings misfolded chignolin observed higher probability simulations amber ff99sb force field used present study short testing gamd simulations t4-lysozyme showed k0p reached 1.0 maximum highest total potential boost 0p increased 3.0 supporting information table s3a for dihedral potential boost simulation crashed 0d increased 5.0 supporting information table s3b stable simulation achieved 0d increased 4.0 calculated k0d 0.35 testing stable dual boost gamd simulation 0p,0d set 3.0 4.0 final production simulations t4-lysozyme supporting information table s3c gamd captured complete binding benzene deeply buried ligand binding cavity leu99ala t4-lysozyme within 100 ns one five independent 800 ns simulations supporting information movie s2 benzene remained bound ligand binding site even simulation extended 1,800 ns aligning c terminal domain residues 80160 t4-lysozyme rmsd diffusing benzene molecules relative bound pose 181l x ray crystal structure reaches minimum 0.1 figure 5a the boost potential applied 1,800 ns gamd simulation follows gaussian distribution 1.39 10 figure 5b the average standard deviation v 36.5 4.7 kcal mol respectively table 1 although v average values exhibit variations five independent simulations v standard deviations closely similar provided 0p,0d set 3.0 4.0 supporting information table s3c using rmsd benzene relative bound pose number protein heavy atoms within 5 benzene ncontact a 2d pmf profile calculated reweighting 1,800 ns gamd simulation figure 5c the reweighted pmf allows us identify three distinct low energy states unbound u intermediate bound b states the bound state corresponds global energy minimum located (0 30 unbound state local energy well centered (33 0 intermediate centered (11 20 it important note since complete binding benzene target ligand binding site observed calculated binding free energy bound unbound states subject error limited sampling nevertheless benzene visits intermediate site many times 1800 ns gamd simulation ligand rmsd decreased 11 supporting information figure s2a repeated sampling intermediate state observed four 800 ns gamd simulations well supporting information figure s2 local energy well appears around 11.0 20 2d pmf profiles supporting information figure s3 the relative free energy intermediate unbound states estimated 0.53 0.46 kcal mol pmf profiles five gamd simulations furthermore benzene observed bind another intermediate 2 i2 site located pocket formed hinge c helix b helix n terminal domain supporting information figure s2 a corresponding local energy well i2 state appears calculated 2d pmf profiles figure 5d plots v distribution anharmonicity frames found bin 2d pmf it exhibits relatively large values high energy regions less sampling notably energy barrier intermediate bound states ligand entry intermediate bound state is thus suggested rate limiting step benzene binding comparison exhibits values smaller 0.01 energy well regions suggesting v achieves sufficient sampling reweighting using cumulant expansion second order binding benzene leu99ala t4-lysozyme simulated via gamd comparison simulation derived complex structure captures benzene binding blue 0.1 ligand rmsd relative 181l pdb structure red b distribution boost potential v c 2d ligand rmsd ncontact pmf calculated reweighting 1,800 ns gamd simulation distribution anharmonicity v frames found bin free energy profile a complete binding pathway benzene observed gamd simulation shown figure 6a benzene diffuses bulk solvent protein surface formed g helices target ligand binding site protein c terminal domain figure 6b depicts unbound pose benzene molecule located far away ligand binding site 181l x ray crystal structure intermediate state benzene interacts residues lys83 pro86 val87 helix thr115 thr119 gln122 residues g helix figure 6c bound pose benzene superimposable ligand cocrystallized 181l crystal structure it forms hydrophobic interactions residues ile78 leu84 tyr88 val87 leu91 val111 leu118 leu121 deeply buried protein cavity figure 6d supporting information figure s5 shows transient snapshot observed benzene binding intermediate bound poses benzene appears slide ligand binding cavity interacting residues gln81 lys83 leu84 val111 phe114 thr115 leu118 f g helices pathway benzene binding t4-lysozyme observed gamd simulation ( b b unbound u c intermediate bound b poses protein ligand complex blue protein c terminal domain residues 80160 aligned pdb native structure red the protein benzene represented ribbons spheres respectively colored blue simulation structure red pdb native structure except simulated benzene represented lines colored simulation time bwr color scale residues heavy atoms found within 3 benzene represented sticks by adaptively adding harmonic boost potential smoothen system energy surface gamd provides unconstrained enhanced sampling free energy calculation biomolecules important statistical properties system potential average maximum minimum standard deviation values used calculate simulation acceleration parameters particularly threshold energy e force constant k0 alanine dipeptide k0p k0d increased 1.0 maximum greatest possible boost total dihedral potential energies the resulting standard deviation v follows gaussian distribution 2.9 kcal mol allows accurate reweighting using cumulant expansion second order notably high energy regions gamd sampled free energy surface especially energy barriers exhibit increased anharmonicity compared low energy wells figure 2d thus free energy barriers appear unconverged still suffer insufficient sampling three short 30 ns gamd simulations nevertheless gamd reweighted pmf profile able recover low energy states system good agreement observed 1000 ns cmd simulation furthermore gamd able fold chignolin extended conformation nmr native structure three independent 300 ns simulations while k0p increased 1.0 greatest total potential boost k0d reach 0.150.17 stable simulation nevertheless seems provide sufficient sampling chignolin folding process among three independent simulations although folded intermediate unfolded low energy states captured sim2 unfolded intermediate states sufficiently sampled sim1 sim3 respectively supporting information figure s2 all three folded intermediate unfolded states identified resulting reweighted free energy profiles particularly intermediate conformation also observed earlier microsecond time scale cmd simulations gamd appears achieve better convergence previous amd simulations able distinguish intermediate unfolded states within simulation time finally gamd captured complete binding benzene ligand binding site t4-lysozyme one five independent simulations benzene diffused deeply buried ligand binding cavity within 100 ns remained bound even when similar chignolin k0p increased 1.0 maximum greatest total potential boost t4-lysozyme simulations k0d reach 0.330.35 greatest dihedral boost the resulting v standard deviation 4.7 kcal mol final dual boost gamd simulations such narrow distribution v ensures accurate reweighting using cumulant expansion second order distinct low energy unbound intermediate bound states identified reweighted pmf profiles the atomistic gamd simulation also elucidates highly detailed binding pathway benzene diffuses bulk solvent intermediate site located protein surface formed g helices slides target ligand binding cavity channel formed f g helices the free energy difference intermediate unbound states found small 0.53 0.46 kcal mol estimated five independent gamd simulations benzene repeatedly visits intermediate site protein surface comparison ligand entry protein surface deeply buried protein cavity appears rate limiting step complete benzene binding it important note complete ligand binding observed four 800 ns gamd simulations suggesting present gamd simulations still suffer insufficient sampling ligand entry process reweighted free energy profiles remain unconverged figure 5c supporting information figure s5 this also indicated increased anharmonicity corresponding free energy barrier intermediate bound states shown figure 5d nevertheless gamd simulation captured binding pathway benzene t4-lysozyme the ligand entry site indeed adjacent mobile f helix residues 108113 suggested earlier based finding f helix exhibits increased b factors leu99ala complex structures compared apo structures here gamd compared original amd particularly performance smoothening potential energy surface energetic reweighting supporting information table s4 summarizes statistical properties boost potential original modified potential energies obtained amd gamd simulations alanine dipeptide chignolin t4-lysozyme reference cmd simulations specifically dual boost amd simulations alanine dipeptide chignolin obtained previous study used comparison t4-lysozyme restarting initial configuration gamd simulations 200 ns dual boost amd simulation performed using following acceleration parameters edihed vdihed_av 4nres dihed 4nres/5 etotal vtotal_av 0.2natoms total 0.2natoms vdihed_av vtotal_av average dihedral total potential energies calculated short 10 ns cmd simulation shown supporting information table s4 although higher average boost potentials applied gamd simulations three systems amd simulations boost potentials exhibit smaller standard deviations i.e. narrower distribution gamd simulations except alanine dipeptide furthermore anharmonicity boost potential distribution significantly reduced gamd simulations relative cmd amd gamd simulations mostly exhibit smaller standard deviations modified dihedral total potential energies notably t4-lysozyme standard deviations modified potential energies significantly smaller gamd simulations amd thus potential energy surfaces appear smoothened gamd enhanced sampling t4-lysozyme provided narrower distribution lower anharmonicity boost potential supporting information table s4 gamd allows accurate approximation exponential average reweighting factor using cumulant expansion second order thus improved free energy calculation especially t4-lysozyme present simulations ligand binding t4-lysozyme complete binding benzene observed largely target ligand binding site deeply buried protein however benzene binding intermediate site protein surface formed g helices captured many times provides better statistics free energy calculation it suggested pmf based approach appropriate calculate binding free energy ligands especially charged bind protein surface systems type future applications gamd might include binding benzamidine trypsin allosteric modulators protein surface g protein coupled receptors comparison many enhanced sampling methods umbrella sampling conformational flooding metadynamics abf calculations orthogonal space sampling gamd advantage need set predefined reaction coordinates metadynamics particular another potential biasing technique widely used map free energy landscapes biomolecules protein conformational changes protein ligand binding monitoring energy surface biomolecules simulation metadynamics keeps adding small gaussians potential energies low energy regions this eventually fill low energy wells achieve uniform sampling free energy surface along selected reaction coordinates the usage predefined coordinates greatly reduces complexity biomolecular simulation problems facilitates free energy calculations e.g. significantly lower energetic noise compared amd simulations however key select proper reaction coordinates often requires expert knowledge studied systems construction biomolecular reaction coordinates collective variables thus one main objectives metadynamics studies when important reaction coordinates missed simulation setup metadynamics simulations may suffer slow convergence problems discussed earlier furthermore predefined reaction coordinates tend place constraints sampled space pathways it seems difficult identify certain intermediate states protein folding ligand binding pathways e.g. intermediate 2 observed binding benzene t4-lysozyme comparison amd simulations constrained reaction coordinates also leads much higher energetic noise presents grand challenge accurate reweighting recover original free energy landscapes biomolecules although cumulant expansion second order shown improve amd reweighting boost potential follows near gaussian distribution improved reweighting still limited small systems protein 35 residues constructing boost potential using harmonic function follows gaussian distribution gamd enables rigorous energetic reweighting cumulant expansion second order even simulations larger proteins e.g. t4-lysozyme this first present gamd simulations seem provide sufficient sampling low energy regions appear remain unconverged sampling high energy barriers this particularly true ligand entry step gamd simulation benzene binding t4-lysozyme it worth recalling threshold energy adding boost potential set lower bound present gamd simulations it subject future investigation whether using upper bound threshold energy facilitate sampling high energy barriers gamd simulations second based potential biasing approach gamd mainly accelerates transitions across enthalpic energy barriers improvement application systems high entropic barriers still need this regard gamd potentially combined parallel tempering replica exchange algorithms enhanced sampling particularly combination parallel tempering metadynamics pt metad shown facilitate enhanced sampling biomolecules entropic barriers summary without need set predefined reaction coordinates gamd generally applicable wide range biomolecular systems demonstrated protein folding ligand binding study systems increasing size upper limit v standard deviation 0 adjusted dynamically ensure distribution width applied boost potential narrow enough accurate energetic reweighting using cumulant expansion second order therefore gamd provides unconstrained enhanced sampling free energy calculation biomolecular simulations

a gaussian accelerated molecular dynamics ( gamd ) approach for simultaneous enhanced sampling and free energy calculation of biomolecules is presented . by constructing a boost potential that follows gaussian distribution , accurate reweighting of the gamd simulations is achieved using cumulant expansion to the second order . here , gamd is demonstrated on three biomolecular model systems : alanine dipeptide , chignolin folding , and ligand binding to the t4-lysozyme . without the need to set predefined reaction coordinates , gamd enables unconstrained enhanced sampling of these biomolecules . furthermore , the free energy profiles obtained from reweighting of the gamd simulations allow us to identify distinct low - energy states of the biomolecules and characterize the protein - folding and ligand - binding pathways quantitatively .

40-year old previously healthy man presented left hemiparesis left facial weakness developed four hours admission struck right side neck edge door ct mri brain revealed acute infarction vascular territory right middle cerebral artery intravenous heparinization initiated thus maintaining twice normal activated partial thromboplastin time aptt angiography performed admission revealed near complete occlusion suprabulbar portion right internal carotid artery complete occlusion ipsilateral proximal middle cerebral artery suggesting dissection vessel subsequent arterial thromboembolism figs following admission patient mental status deteriorated suddenly ct revealed large intracerebral hemorrhage within territory infarcted right middle cerebral artery follow angiography day 20 revealed partial restoration luminal patency lumen however largely compromised presence thick intimal flap fig because risk continuing anticoagulation therapy endovascular treatment dissection planned two days angioplasty performed day 35 daily doses aspirin 100 mg ticlopidine 250 mg initiated continued thereafter a heparin bolus 5000 iu injected intravenously order maintain aptt 1.5 2 times normal continued one day atropine 1 mg injected intravenously stent placement primary stenting dissected segment self expandable uncovered metallic stent 30 mm length 8 mm diameter easy wallstent boston scientific corporation watertown mass u.s.a used fig 1d postdilatation 6-mm diameter angioplasty catheter ultra thin boston scientific corporation watertown mass u.s.a low inflation pressure employed intermittent neurological examinations conducted throughout procedure stenting focal residual dissected false lumen posterior portion artery observed fig interestingly symptom left side weakness showed slight improvement two days stent placement motor power increased grade 2 3 thirty six days procedure follow axial ct scanning 2d reconstruction images showed complete reconstitution arterial lumen disappearance false lumen ticlopidine discontinued 39-year old man presented multiple fractures lower extremities fractured left zygoma skull base motor vehicle accident brain ct performed immediately arrival emergency room showed significant abnormality orthopedic management initiated fourth day following admission however patient showed mild weakness right extremities brain ct revealed cortical areas low density left frontal occipital lobes angiography performed following day focal significant stenosis associated dissecting aneurysm observed subpetrosal portion left internal carotid artery fig because patient fit condition sustained anticoagulation therapy percutaneous angioplasty aimed reestablishing vessel lumen performed session a 7-fr guiding catheter introduced proximal portion internal carotid artery prevent thromboembolic complications heparin bolus 5000 iu administered intravenously primary stenting affected portion vessel premounted balloon expandable uncovered stent nir primo boston scientific scimed inc maple grove minn this 16 mm length dilated 4.2 mm balloon pressure 10 atm fig a postangioplastic angiogram showed improved luminal patency reduction aneurysmal sac fig 2c aspirin 100 mg day ticlopidine 250 mg day subsequently administered maintain aptt 1.5 2 times normal jw2]heparinization continued five days stenting although filled aneurysmal sac significantly smaller focal filling part noted fig the patient symptom improved gradually procedure motor power affected extremities returned normal time follow angiography a 40-year old previously healthy man presented left hemiparesis left facial weakness developed four hours admission struck right side neck edge door ct mri brain revealed acute infarction vascular territory right middle cerebral artery intravenous heparinization initiated thus maintaining twice normal activated partial thromboplastin time aptt angiography performed admission revealed near complete occlusion suprabulbar portion right internal carotid artery complete occlusion ipsilateral proximal middle cerebral artery suggesting dissection vessel subsequent arterial thromboembolism figs following admission patient mental status deteriorated suddenly ct revealed large intracerebral hemorrhage within territory infarcted right middle cerebral artery follow angiography day 20 revealed partial restoration luminal patency lumen however largely compromised presence thick intimal flap fig because risk continuing anticoagulation therapy endovascular treatment dissection planned two days angioplasty performed day 35 daily doses aspirin 100 mg ticlopidine 250 mg initiated continued thereafter a heparin bolus 5000 iu injected intravenously order maintain aptt 1.5 2 times normal continued one day atropine 1 mg injected intravenously stent placement primary stenting dissected segment self expandable uncovered metallic stent 30 mm length 8 mm diameter easy wallstent boston scientific corporation watertown mass u.s.a used fig 1d postdilatation 6-mm diameter angioplasty catheter ultra thin boston scientific corporation watertown mass u.s.a low inflation pressure employed intermittent neurological examinations conducted throughout procedure stenting focal residual dissected false lumen posterior portion artery observed fig interestingly symptom left side weakness showed slight improvement two days stent placement motor power increased grade 2 3 thirty six days procedure follow axial ct scanning 2d reconstruction images showed complete reconstitution arterial lumen disappearance false lumen a 39-year old man presented multiple fractures lower extremities fractured left zygoma skull base motor vehicle accident brain ct performed immediately arrival emergency room showed significant abnormality orthopedic management initiated fourth day following admission however patient showed mild weakness right extremities brain ct revealed cortical areas low density left frontal occipital lobes angiography performed following day focal significant stenosis associated dissecting aneurysm observed subpetrosal portion left internal carotid artery fig because patient fit condition sustained anticoagulation therapy percutaneous angioplasty aimed reestablishing vessel lumen performed session a 7-fr guiding catheter introduced proximal portion internal carotid artery prevent thromboembolic complications heparin bolus 5000 iu administered intravenously primary stenting affected portion vessel premounted balloon expandable uncovered stent nir primo boston scientific scimed inc maple grove minn this 16 mm length dilated 4.2 mm balloon pressure 10 atm fig a postangioplastic angiogram showed improved luminal patency reduction aneurysmal sac fig 2c aspirin 100 mg day ticlopidine 250 mg day subsequently administered maintain aptt 1.5 2 times normal jw2]heparinization continued five days stenting follow angiography performed 65 days stent placement showed good luminal patency although filled aneurysmal sac significantly smaller focal filling part noted fig the patient symptom improved gradually procedure motor power affected extremities returned normal time follow angiography carotid dissection initiated hemorrhage medial layer artery due various causes where dissection primarily involves subintima stenosis occlusion artery usually results angiography reveals called string sign subadventitia principally involved pouching sac dissecting aneurysm form outponihing sae usually arises luminal stenosis cause distal ischemia leading stroke transient ischemic attacks subintimal subadventitial dissections the resulting exposure basement membrane leads platelet aggregation serves embolic source 1 it suggested ischemic symptoms often secondary embolic phenomena hypoperfusion caused stenosis 2 because many cases escape diagnosis patients receive form therapy natural history carotid dissection remains somewhat unclear although clinical course may benign 1 overall mortality rates consistently reported 20 40% 3 in addition recent study time course symptoms extracranial carotid artery dissection authors observed ischemic events 82.5% afflicted patients complete stroke two thirds 12 these results imply time course carotid dissection benign authors emphasized need early preventive measures avoid ischemic complications 12 the management goal cases extracranial carotid dissection prevent development worsening neurologic deficits preventing thrombosis embolization 3 options include observation anticoagulation therapy surgery endovascular treatment fabian et al suggested anticoagulative measures used non occlusive arterial dissections without contraindications regardless degree luminal narrowing 13 anticoagulation often initially achieved heparin 1 3 weeks maintained warfarin continued 6 months surgical repair reserved management symptomatic patients lesions accessible location 3 technique preservation artery technically demanding time consuming many years endovascular occlusion affected artery involved use detachable balloons coils alternative surgery the advent stenting techniques carotid artery angioplasty however led exploitation preservation arterial patency the techniques much easier safer surgical repair published case reports described successful application 4 11 various stents used restoration luminal patency occlusion sac dissecting aneurysm authors insisted covered stent especially useful 11 though stents without fabric covering also used purpose successful results cases obliterate dissecting aneurysms guglielmi detachable coils along stents also used 10 suprabulbar internal carotid artery dissection applied self expandable stent subpetrosal internal carotid artery dissection balloon expandable type cases results successful emphasized superiority self expandable stents balloon expandable type terms radial expansile force longitudinal flexibility 5 they surmised first two factors helpful effectively sealing dissecting aneurysm case involving use balloon expandable stent aneurysm sac also effectively disappeared the balloon expandable stent used also flexible feature allowed us place angled portion vessel follow showed softness stent compromise luminal patency vessel selection stent must individualized basis factors include characteristics location lesion diameter geometry vessel management case 1 delayed stent placement infarction patient right middle cerebral artery territory due embolic occlusion overt parenchymal infarction patient for stabilization already infarcted parenchyma anticoagulative measures applied wait three four weeks recommended though case 1 unexpected hemorrhagic transformation infarction flow patent anterior communication artery good management could involved occlusion dissected ica relative ease safety endovascular recanalization methods available however destructive method kind considered case 2 the cause left cerebral cortical infarction clear dissecting aneurysm already known potential embolic source dissected segment recanalized initial angiography without evaluating significance stenosis angiography appeared indicate narrow enough cause watershed infarction due hemodynamic insufficiency stenting stenotic segment could recanalize stenosis well seal aneurysmal sac follow angiography however revealed focal residual sac suggesting dissection opened cases endovascular stent placement safe effective method management patients extracranial carotid artery dissections without associated aneurysm

extracranial carotid artery dissection may manifest as arterial stenosis or occlusion , or as dissecting aneurysm formation . anticoagulation and/or antiplatelet therapy is the first - line treatment , but because it is effective and less invasive than other procedures , endovascular treatment of carotid artery dissection has recently attracted interest . we encountered two consecutive cases of trauma - related extracranial internal carotid artery dissection , one in the suprabulbar portion and one in the subpetrosal portion . we managed the patient with suprabulbar dissection using a self - expandable metallic stent and managed the patient with subpetrosal dissection using a balloon - expandable metallic stent . in both patients the dissecting aneurysm disappeared , and at follow - up improved luminal patency was observed .

techniques for isolation and culture of fetal type ii alveolar epithelial cells , as well as the morphologic and biochemical characteristics of these histotypic cultures , are described . type ii alveolar epithelial cells can be isolated from fetal rat lungs and grown in an organotypic culture system as described in this review . the fetal type ii cells resemble differentiated rat type ii cells in morphology , biochemistry , and karyotype as they grow in culture for up to 5 weeks . the cells of the mature organotypic cultures form alveolarlike structures while growing on a gelatin sponge matrix . the type ii cells also synthesize and secrete pulmonary surfactant similar in biochemical composition to that produced in vivo . this system has been used to study the effects of hormones on surfactant production and composition . the organotypic model has many potential applications to the study of pulmonary toxicology.imagesfigure 1.figure 2 .

defining alterations in signalling pathways in normal and malignant cells is becoming a major field in proteomics . a number of different approaches have been established to isolate , identify and quantify phosphorylated proteins and peptides . in the current report , a comparison between scx prefractionation versus an antibody based approach , both coupled to tio2 enrichment and applied to tmt labelled cellular lysates , is described . the antibody strategy was more complete for enriching phosphopeptides and allowed the identification of a large set of proteins known to be phosphorylated ( 715 protein groups ) with a minimum number of not previously known phosphorylated proteins ( 2 ) .

allogeneic bone marrow transplantation bmt widely used treatment various hematologic disorders leukemia aplastic anemia major complication bmt graft versus host disease gvhd we discuss whether autologous melanocyte transplantation appropriate way treatment vitiligo allogeneic bmt report we describe patient hodgkin lymphoma developed universal vitiligo allogeneic bmt sister he underwent four times melanocyte keratinocyte transplantation mkt treatment vitiligo treated depigmented patches significant repigmentation an 18-year old patient diagnosed epstein barr virus related hodgkin like lymphoma 2003 antivirotic used control lymphoma treatment ineffective march 2009 received histocompatibility leukocyte antigen hla)-matched allogeneic bmt sister cyclosporine methotrexate used prophylaxis strategy prevent gvhd 6 months allogeneic bmt 6-month recovering period the patient developed small erythematous rash consistent clinical features graft versus host disease gvhd skin no external agents used rash dissipated short period time small depigmented macules started appear cheek 11 months allogeneic bmt february 2010 followed rapid progression whole body face hands within 1 month we indicated typical universal vitiligo reason depigmentation macules chalky white appearance wood light moreover leukotrichia appeared time associated vitiligo affecting back arms figure 1 the patient extensive vitiligo back arms depigmentation macules expanded received whole body nb uvb therapy twice week 2 months simultaneously following doctor advice 0.1% tacrolimus used traditional chinese medicine orally taken the patient underwent therapies mentioned 8 months total poor repigmentation then discontinued medical therapies performed non cultured mkt january 17 2011 including left forehead temple figure 2 almost complete repigmentation shown 8 months since first transplantation figure 3a then received mkt right face september 29 2011 8 months second mkt 28 months first time transplantation transplanted areas almost completely repigmented color repigmented area matched normal surrounding skin excellently figure 3c then patient underwent third fourth mkt procedure right left side neck respectively may 28 2012 january 22 2013 figure 4a significant improvement shown area around left side neck also majority repigmentation right side figure 4b c no hyperpigmentation scar infection adverse effects recipient donor sites noticed leukasmus involving face symmetrical around nose eyes mouth repigmentation vitiligo mkt face ( c 28 months first time transplantation significant repigmentation obtained normal skin achieved mkt performed neck ( b 12 months surgery right neck showing nearly 100% repigmentation vitiligo common depigmentation disorder affects 0.5 2.0% world population the etiology vitiligo remains obscure prevalent hypothesis today considers vitiligo autoimmune disease focuses melanocyte specific cytotoxic cell immune reaction destruction melanocytes supported perhaps four explanations development vitiligo bmt destruction melanocytes stimulated pretransplantation chemotherapy radiotherapy chronic gvhd infusion larger number lymphocytes adoptive passive transfer donor recipient case patient vitiligo might result immune response directed melanocyte destruction initiated gvhd reported cases allogeneic posted bmt vitiligo but pre bmt diagnosis chronic myelogenous leukemia none diagnosed hodgkin lymphoma report terms treatment cases partial accepted therapies none performed transplantation bmt context extensive relentless vitiligo progression indicated aggressive alloimmune process destruction melanocyte alloimmune nature there report make discriminate melanocyte destruction alloimmune autoimmune au et al proposed success melanocyte autografts autoimmune vitiligo could used alloimmune setting therefore came idea vitiligo melanocyte transplantation treatment invalid patient melanocyte grafting technique include cultured autologous melanocyte suspension transplantation autologous noncultured melanocyte keratinocyte report patient obtained universal vitiligo allogeneic bone marrow transplantation hodgkin lymphoma in the condition vitiligo failed respond non surgical treatment patient underwent four times mkt 2 years the largest area treated lesions 50 cm repigmentation rate achieved 95% transplantation without adverse effects koebner phenomenon the pattern repigmentation uniform first three times mkt diffuse last one whatever follow time needed future 2 years follow graft sites still repigmented obviously color similar surrounding normal skin illustrated mkt treat allogeneic vitiligo successfully this first time report treating vitiligo allogeneic bone marrow transplantation mkt we suggest autotransplantation especially autologous grafting noncultured melanocyte simple safe inexpensive remedying loss melanocyte bmt case depigmented macules stable whether melanocyte transplantation used alloimmune vitiligo effective autoimmune need follow ups this first time report treating vitiligo allogeneic bone marrow transplantation hodgkin lymphoma non cultured melanocyte keratinocyte transplantation without koebner phenomenon adverse effects successful it probably suggests therapy transplantation used treatment vitiligo allogeneic bone marrow transplantation

the treatment of vitiligo is derisory since the pathogenesis of vitiligo is not clear at present . most conservative treatments are difficult to approach satisfactory therapy . so transplantation is the only way left when the disease becomes insensitive to those conservative treatments . here we describe an 18-year - old patient who developed vitiligo , which was triggered by graft - versus - host disease after a allogeneic bone marrow transplantation for the treatment of hodgkin 's lymphoma from his sister . in the following treatment to vitiligo , the patient successfully performed the transplantation of autologous uncultured melanocyte on the premise of poor reaction to other conservative methods . we infer that transplantation can be a treatment of the vitiligo after allogeneic bone marrow transplantation .

spondylolisthesis defined anterior migration vertebral body relation vertebra located immediately caudal 1930 junghanns first describe anterior translation lumbar vertebra without defect neural arch following term degenerative spondylolisthesis ds introduced newman 1955 five types spondylolisthesis described including dysplastic isthmic traumatic pathologic degenerative there many predisposing factors like sagittally placed facet joint high iliac crest 4 6 etc ds characterized intact vertebral ring presumed result degeneration facet joints intervertebral discs aging thus traditionally considered represent instability vertebral segment a 66-year old gentleman farmer occupation came complaints lower backache 2 years insidious onset gradually progressive non radiating he also complained acute retention urine since 15 days catheterized he also history neurogenic claudication distance 100 m. history trauma a detailed systemic neurological examination revealed power flexor hallucis longus(fhl flexor digitalis longus(fdl 4/5 ankle jerks absent sensory deficits s1-s2 dermatome per rectal examination revealed decreased perianal sensations anal tone absent anal wink plain radiographs lumbo sacral spine revealed spondylolisthesis s1-s2 meyerding grade 1 fig.1 magnetic resonance imaging computed tomography scan spine revealed lumbarization s1 spondylolisthesis s1 s2 facetal hypertrophy l5-s1 canal stenosis s1-s2 figs 2 3 anteroposterior lateral b radiographs showing grade 1 spondylolisthesis ats1-s2b the patient underwent posterior spine surgery decompression done laminotomy s1 bilaterally pedicular screw fixation done bilaterally l5 s1 s2 fig.4 s1 and post operative radiographs anteroposterior lateral b view the bladder symptoms disappeared 3 weeks power fhl fdl improved 4/5 5/5 the patient underwent posterior spine surgery decompression done laminotomy s1 bilaterally pedicular screw fixation done bilaterally l5 s1 s2 fig.4 s1 and post operative radiographs anteroposterior lateral b view the bladder symptoms disappeared 3 weeks power fhl fdl improved 4/5 5/5 the patient underwent posterior spine surgery decompression done laminotomy s1 bilaterally pedicular screw fixation done bilaterally l5 s1 s2 fig.4 s1 and post operative radiographs anteroposterior lateral b view the bladder symptoms disappeared 3 weeks power fhl fdl improved 4/5 5/5 the deformity occurs l4 5 6 times often lumbar levels four times often sacralized l5 the lumbosacral junction middle lumbar spine often involved lesion also found cervical rarely thoracic vertebra best knowledge ds sacral vertebrae reported available english literature till the prevalence complete lumbarization 1.8% get spondylolisthesis even rarer there many publications literature mentioning incidence spondylolisthesis sacralization hardly spondylolisthesis lumbarization further case series longitudinal studies cases may help understand better pathomechanics related spondylolisthesis level ds s1-s2 rare entity case reports help us explore biomechanics level

introduction : degenerative spondylolisthesis ( ds ) is usually seen at l4-l5 level and less frequently at l5-s1 level . this is a rare case report of spondylolisthesis of s1 over s2 with lumbarization of s1 . lumbarization of s1 is seen in just 1 - 2% of the population and to have spondylolisthesis in this segment is even rarer . the purpose is to report a rare case of ds at s1-s2 level.case report : this is a single case report of a 66-year - old gentleman who presented with complains of lower backache for 2 years and acute retention of urine to the emergency department . detailed clinical and radiological evaluation of the spine was done which revealed lumbarization of s1 with spondylolisthesis at s1-s2 and facetal hypertrophy at l5 , s1 , and s2 . he underwent decompression and stabilization at l5 , s1 , and s2 along with placement of autologous bone graft . the bladder symptoms disappeared after 3 weeks . at 1-year follow - up , patient s clinical symptoms were relieved , and he improved clinically.conclusion:to the best of our knowledge , this is probably the first case of ds of sacral vertebrae to be reported in english literature . the prevalence of complete lumbarization is around 1.8% and to get spondylolisthesis in this segment is even rarer , hence the lack of literature in this regard . since this is the first of its kind of case , further case series or longitudinal studies of such cases may help understand better the pathomechanics related to spondylolisthesis at this level .

research protocol approved institutional review board oregon health science university ohsu performed accordance tenets declaration helsinki written informed consent obtained participant explanation nature possible consequences study participants recruited casey eye institute ohsu according aig study protocol the ohsu ancillary site followed eligibility endpoint protocol aig study used advanced swept source oct prototype system instead commercially available oct instruments briefly normal control participants met following criteria eyes iop less 21 mm hg eyes normal humphrey visual field hvf achromatic standard automated perimetry swedish interactive threshold algorithm 24 2 testing hfa ii carl zeiss meditec inc dublin ca usa mean deviation md glaucoma hemifield test ght pattern standard deviation psd within normal limits in addition normal subjects normal appearing optic nerve head onh nfl ophthalmoscopic examination open angle gonioscopy glaucoma participants required glaucomatous onh rim nfl thinning ophthalmoscopic examination glaucomatous eyes classified pg subgroup visual field vf psd ght outside normal limits p 0.05 p 1% respectively consistent pattern two qualifying vf exams exclusion criteria groups included visual acuity less 20/40 age 40 79 years enrollment ocular surgery uncomplicated cataract extraction diseases might cause vf onh abnormality factors might preclude participant performing study procedures completing study a prototype high speed swept source fourier domain oct system used study the device operated axial scan speed 100 khz using swept source cavity laser operating 1050 nm tuning range 100 nm a resolution 5.3 axially 18 laterally imaging depth 2.9 mm tissue achieved the ocular light power exposure 1.9 mw within american national standards institute ansi safety limit participants scanned using high density 8 8 mm raster scan pattern centered onh fast transverse scan direction the time acquire 3d volumetric scan 4.3 seconds scan protocol one eye participant scanned 4 scans consisting 2 horizontal 2 vertical scans an orthogonal registration algorithm applied register merge 4 scans reduce eye motion concentric cylindrical cross sectional oct images varying radii resampled volume scan fig we selected rings radii 1.5 1.7 2 2.5 3 3.5 mm analysis the disc center decided manually one us matching disc boundary ellipse en face view fig ( en face view average projection log reflectance intensity 8 8 mm volumetric cube scan onh region glaucomatous eye 3-mm radius circle centered onh ( b 3-mm radius cylindrical cross section resampled cube scan the ilm contour white dashed line measured circular cross section ( c en face oct showing resampling circles radii 1.5 1.7 2.0 2.5 3.0 3.5 mm the ilm detected inner boundary retina cylindrical cross section images an automated algorithm developed follow vessel bumps avoid artifacts points vitreous macular adhesion ilm elevation profile contour ) one us inspected cross sectional images ilm contour overlay performed manual correction contour necessary the ilm elevation profile transformed spatial frequency domain using fast fourier transform fig the spatial frequency components lowest frequencies removed simply relate average axial position tilt oct scan beam relative onh plane the highest frequency components also nondiagnostic high noise little anatomic information the middle frequency band optimized detection retinal vessel relief nfl bundle defects determined empirically based difference average normal glaucoma ilm spatial frequency spectrum fig the rscv defined average log value within middle spatial frequency band fourier transform elevation profile inner retinal surface ( spatial frequency spectrum ilm elevation showing averages glaucoma eyes normal eyes derived 3.0-mm oct cylindrical sections ( b shows difference spectrum glaucoma normal optimize frequency band dotted lines used compute rscv optimized passbands rscv calculation different radii cylindrical cross sectional oct image radius 1.7 mm the wilcoxon rank sum test performed determine statistical significance study groups the area receiver operating characteristic curve aroc calculated diagnostic accuracy pearson correlation used determine correlations rscv axial length nflt visual field test md coefficient variance cv ) the first one compares rscv value r 2.8 mm r 3.0 mm the second test compares results graded independently two authors ot all image processes statistical analyses done using matlab mathworks natick usa the research protocol approved institutional review board oregon health science university ohsu performed accordance tenets declaration helsinki written informed consent obtained participant explanation nature possible consequences study participants recruited casey eye institute ohsu according aig study protocol the ohsu ancillary site followed eligibility endpoint protocol aig study used advanced swept source oct prototype system instead commercially available oct instruments briefly normal control participants met following criteria eyes iop less 21 mm hg eyes normal humphrey visual field hvf achromatic standard automated perimetry swedish interactive threshold algorithm 24 2 testing hfa ii carl zeiss meditec inc dublin ca usa mean deviation md glaucoma hemifield test ght pattern standard deviation psd within normal limits in addition normal subjects normal appearing optic nerve head onh nfl ophthalmoscopic examination open angle gonioscopy glaucoma participants required glaucomatous onh rim nfl thinning ophthalmoscopic examination glaucomatous eyes classified pg subgroup visual field vf psd ght outside normal limits p 0.05 p 1% respectively consistent pattern two qualifying vf exams exclusion criteria groups included visual acuity less 20/40 age 40 79 years enrollment ocular surgery uncomplicated cataract extraction diseases might cause vf onh abnormality factors might preclude participant performing study procedures completing study a prototype high speed swept source fourier domain oct system used study device operated axial scan speed 100 khz using swept source cavity laser operating 1050 nm tuning range 100 nm a resolution 5.3 axially 18 laterally imaging depth 2.9 mm tissue achieved the ocular light power exposure 1.9 mw within american national standards institute ansi safety limit participants scanned using high density 8 8 mm raster scan pattern centered onh fast transverse scan direction the time acquire 3d volumetric scan 4.3 seconds scan protocol one eye participant scanned 4 scans consisting 2 horizontal 2 vertical scans an orthogonal registration algorithm applied register merge 4 scans reduce eye motion concentric cylindrical cross sectional oct images varying radii resampled volume scan fig we selected rings radii 1.5 1.7 2 2.5 3 3.5 mm analysis the disc center decided manually one us matching disc boundary ellipse en face view fig ( en face view average projection log reflectance intensity 8 8 mm volumetric cube scan onh region glaucomatous eye 3-mm radius circle centered onh ( b 3-mm radius cylindrical cross section resampled cube scan the ilm contour white dashed line measured circular cross section ( c en face oct showing resampling circles radii 1.5 1.7 2.0 2.5 3.0 3.5 mm the ilm detected inner boundary retina cylindrical cross section images an automated algorithm developed follow vessel bumps avoid artifacts points vitreous macular adhesion ilm elevation profile contour ) one us inspected cross sectional images ilm contour overlay performed manual correction contour necessary the ilm elevation profile transformed spatial frequency domain using fast fourier transform fig 3a spatial frequency components lowest frequencies removed simply relate average axial position tilt oct scan beam relative onh plane the highest frequency components also nondiagnostic high noise little anatomic information the middle frequency band optimized detection retinal vessel relief nfl bundle defects determined empirically based difference average normal glaucoma ilm spatial frequency spectrum fig the rscv defined average log value within middle spatial frequency band fourier transform elevation profile inner retinal surface ( spatial frequency spectrum ilm elevation showing averages glaucoma eyes normal eyes derived 3.0-mm oct cylindrical sections ( b shows difference spectrum glaucoma normal optimize frequency band dotted lines used compute rscv on cylindrical cross sectional oct image radius 1.7 mm lower nfl boundary also detected using method described previously the wilcoxon rank sum test performed determine statistical significance study groups the area receiver operating characteristic curve aroc calculated diagnostic accuracy pearson correlation used determine correlations rscv axial length nflt visual field test md coefficient variance cv ) the first one compares rscv value r 2.8 mm r 3.0 mm the second test compares results graded independently two authors ot all image processes statistical analyses done using matlab mathworks natick usa of 17 participants glaucoma group 8 pg 9 ppg subgroups 15 early vf damage md 6 db 2 severe vf damage we enrolled 25 participants normal control group due younger average age 17 oldest control participants used present analysis the age matching exact control participants still averaged 9 years younger table 1 as expected glaucoma group significantly worse vf md thinner nfl overall area superior inferior quadrants the image quality normal group significantly higher glaucoma group based signal strength index participant characteristics spatial frequency transforms ilm profile averaged normal glaucoma groups fig optimized bands detected frequency components glaucoma group significantly larger normal group fig we averaged rscvs optimized bands circle rscv distribution normal glaucoma groups illustrated figure 5 the rscv significantly higher sampling radii glaucoma group compared normal control group table 2 distribution rscv values normal n glaucoma g groups sampling radii 1.5 3.5 mm retinal surface contour variability diagnostic accuracy nfl rscv assessed using aroc values sampling radius table 3 the diagnostic accuracy rscv improved larger radii highest aroc value 0.90 found radius 3.5 mm this higher nflt parameters significantly temporal nasal quadrants 0.01 we examined averages rscv various ranges radii found average 2.5 3.5 mm highest aroc 0.91 the combination marginally higher aroc 0.91 nfl p 0.08 diagnostic accuracy comparison venn diagram analysis fig 6 showed rscv higher sensitivity glaucoma diagnosis 53% nflt 29% it also notable abnormal eyes detected nflt also detected rscv however difference sensitivity statistically significant p 0.13 the threshold rscv set 2.33 sd mean normal group 99 percentile cutoff assuming normal distribution threshold nfl 2.33 sd mean normal group normal group all eyes within cutoff parameters indicating 100% specificity glaucoma groups rscv detected abnormality nine participants including five detected nfl the correlations averaged rscv nflt averaged rscv vf md estimated glaucomatous participants significant correlations found rscv nfl r 0.54 p 0.03 md r 0.32 p 0.21 a significant correlation also found nfl md r 0.68 p 0.002 we also evaluated correlation rscv nfl normal participants significant r 0.10 p 0.70 we tested whether rscv sensitive transverse magnification changes i.e. axial eye length variation comparing values evaluated sampling radii r 2.8 3 mm no significant difference found two radii either glaucoma normal group p 0.26 1.3% glaucoma eyes also tested grader ot reproducibility rscv onh boundary center defined manually the reproducibility cv 1.6% normal eyes 1.1% glaucoma eyes we find significant correlation axial length rscv parameter r 3.5 mm normal r 0.06 p 0.83 glaucoma r 0.42 p 0.09 groups we also find significant correlation axial length rscv parameters radius normal group p 0.32 in pilot study reported knowledge first use spatial frequency analysis detect small scale retinal surface contour change glaucoma the rscv measured peripapillary area significantly larger glaucoma eyes the diagnostic accuracy rscv least good nflt although larger study would needed see significant advantage in early glaucoma nflt limited diagnostic sensitivity literature values 33.3% 67.4% fixed specificity 99% this surprising relatively wide range population variation average nflt reported 9.0% 10.0% sd rscv measures small scale focal changes unlikely due inborn variation nflt may able better detect glaucoma earlier stages nfl damage small variable location study nflt abnormally 99% specificity cutoff thin 5 17 participants glaucoma group rscv abnormally elevated 9 17 glaucoma participants while advantage statistically significant shows promising trend deserves study nflt rscv measure different aspects nfl damage while previously developed another parameter measure focal peripapillary nfl macular ganglion cell complex gcc thinning called focal loss volume flv algorithm optimized detect relatively larger areas 500 superpixels focal damage contrast the rscv spatial frequency analysis detects changes 2 100 radians mm corresponds spatial features small 60 diameter small arteriole thus believe three parameters synergistic based fact measure glaucoma damage different spatial scales we found rscv appeared higher diagnostic accuracy circles large radii 2.53.5 mm small radii 1.52 mm firstly observed normal eye larger retinal vessels submerge retina disc margin thus inner retinal surface smoother rscv lower disc this observation also might due fact glaucoma damages axon bundles nonuniformly within onh laminar pores forth bundle losses may detectable within nfl bundles spread another assumption thinner nfl away disc going less likely mask blood vessels loss axon bundles may reveal blood vessels readily regions the second observation population variances tighter larger radii table 2 we suspected simply due larger number scans sampling circles larger radii thus maximizing oct scan density 2.5- 3.5-mm radius annulus around optic disc may improve rscv evaluation an additional advantage rscv nflt rscv value relatively insensitive magnification variation decentration relative optic disc center scan radii 2.5 3.5 mm mean rscv values varied less 2% normal glaucoma groups intergrader variation disc boundary identification also affected rscv less 2% comparison furthermore nfl quadrant thickness averages known exquisitely sensitive decentration sampling circle relative optic disc therefore rscv may robust diagnostic parameter relatively resistant introduction bias due patients oct operators graders in previous studies contour variability accessed heidelberg retinal tomography hrt considerably inferior ability diagnose glaucoma progression compared nfl measured oct we believe two reasons contour variability hrt considerably inferior diagnostic power thus difficult hrt catch small changes contour variability caused protrusions retinal vessels found contour variability less sensitive location near disc edge one limitations study relatively small number participants especially advanced glaucoma vf 6db a power calculation shows sample size 17 normal 17 glaucoma subjects able detect difference aroc 0.67 compared aroc rscv 0.90 probability 0.80 significance threshold p 0.05 however rscv significantly affected sex control group p 0.62 second glaucoma group also 9 years older normal group consequence oct image quality normal however ssi good normal 60 9 glaucoma 50 12 groups the rscv parameters sensitive ssi image quality good enough accurate ilm boundary detection we also tested correlation ssi rscv find significance normal glaucoma groups p 0.38 furthermore rscv correlated age normal group p 0.43 retinal surface contour variability also may sensitive focal nfl loss caused optic neuropathies anterior ischemic optic neuropathy aion optic neuritis since rscv nonspecific detector nfl loss small spatial scale specific diagnosis particular conditions would require physician consider clinical presentation well patterns nfl gcc optic disc topography vf changes summary since rscv detects small scale focal damage average nflt measures global damage provide different diagnostic information may synergistic

purposewe investigated the feasibility of glaucoma detection by measuring retinal surface contour variability ( rscv ) using optical coherence tomography ( oct).methodsthe peripapillary region in one eye of each participant was scanned over an 8 8 mm area with a swept source oct prototype . the retinal surface contour was sampled at approximately 1.5- to 3.5-mm radius circles centered on the optic nerve head . the rscv is defined as the average log value within a middle spatial frequency band of the fourier transform to the elevation profile of the inner retinal surface . the spatial frequency band was optimized to distinguish glaucoma from normal . nerve fiber layer thickness ( nflt ) was sampled around a 1.7-mm radius circle . glaucoma severity was assessed by automated static perimetry.resultswe enrolled 17 glaucomatous eyes and 17 healthy eyes . a great majority of the glaucoma group were in the early stage ( visual field mean deviation average 2.48 3.73 db ) . significant differences were found for rscv between glaucoma and control eyes ( p < 0.003 ) at all radii . the area under the receiver operating characteristic curve ( aroc = 0.90 ) of rscv was best at the 3.5-mm radius . this was not significantly better than nflt ( aroc = 0.84 ) . with the 99% specificity , the glaucoma detection sensitivity was 53% for rscv and 29% for nflt ( p = 0.13).conclusionsretinal surface contour variability was significantly increased in glaucoma patients . the diagnostic accuracy of rscv was equal to nflt in early glaucoma . since the rscv detects small - scale focal damage and the average nflt measures global damage , they provide different diagnostic information that may be synergistic .

organic foreign bodies generally associated severe inflammatory reaction infection nature reaction elicited inorganic foreign bodies depends material foreign body graphite major constituent pencil lead reported remain inert eye long time however also reported cause severe endophthalmitis like reaction eye we report rare case retained graphite pencil tip anterior chamber six year old girl a six year old girl presented us history mild pain left eye two days duration the child mother gave history trauma graphite lead pencil four months ago school accidentally poked left eye another child the child examined ophthalmologist incident apparently asymptomatic time examination the best corrected visual acuity 20/20 right eye 20/40 left eye there full thickness corneal scar figure 1 left eye a small area iris atrophy sphincter tear noted edge pupil 6 clock position black foreign body resembling graphite pencil lead tip measuring 1.5 mm size iris 7 clock position figure 1 ocular ultrasonography left eye reveal abnormality posterior segment figure 1slit lamp photograph left eye showing corneal scar graphite pencil lead tip iris slit lamp photograph left eye showing corneal scar graphite pencil lead tip iris a corneal incision made 5 clock position 2.8 mm keratome the anterior chamber filled 2% methyl cellulose foreign body figure 2 removed toto bechert mcpherson forceps the remaining graphite particles aspirated simcoe cortex aspiration cannula using anterior chamber maintainer post operatively patient put tapering doses topical steroids cycloplegics on follow one month later best corrected visual acuity left eye 20/40 there inflammation lens clear fundus normal the reaction eye retained intraocular foreign body varies depending composition foreign bodies comprised materials like gold silver platinum reported remain inert intraocular environment there reports ocular trauma retention graphite pencil lead eye retained graphite described conjunctiva cornea angle anterior chamber posterior segment case pencil tip injury orbit retained graphite foreign body associated delayed orbital infection also described however potential toxicity constituents pencil lead like animal fats clay clearly known there report severe endophthalmitis like reaction incited retained graphite foreign bodies vitreous case unclear whether reaction induced constituents pencil lead like aluminium kaolinite associated infection case decided surgically remove intraocular foreign body spite fact obviously remained eye time evidenced healed corneal scar presence iris atrophy without inciting inflammatory response causing much damage intraocular structures there distinct possibility causing damage lens inciting inflammatory reaction surgical removal foreign body this risk weighed damage foreign body might cause left eye there chance foreign body would get dislodged angle later stage cause progressive damage angle structures cornea case reported han et al honda et al reported case five year old child graphite foreign body lodged peripheral retina followed six years serial electroretinograms fundus photographs fundus fluorescein angiography there evidence damage eye caused foreign body end follow however case meticulous follow would quite impossible child family belonged poor socio economic background parents would able afford cost repeated hospital visits investigations our case also differed honda et al.s case foreign body anterior segment therefore accessible site there higher chance removal foreign body without causing damage intraocular structures case conclusion graphite foreign bodies may retained eye without causing inflammation damage intraocular structures hand also possibility progressive damage intraocular structures foreign bodies due various mechanisms therefore decision surgical removal foreign body made individual basis taking multiple factors consideration estimating risk benefit ratio patient

retained intraocular graphite foreign bodies are uncommon . although they are generally inert , they have been reported to cause severe inflammatory reaction and progressive damage to intraocular structures . we report a case of a six - year - old girl with a retained intraocular graphite pencil lead foreign body in the anterior chamber of the eye and discuss the various considerations in the management of such cases .

polyacrylonitrile pan commercially important used precursor high performance carbon fiber fiber applications pan dissolved suitable solvent spin fibers wet dry spinning process the extensively used solvents aqueous sodium sulfocyanate nascn n ndimethylformamide dmf n n dimethylacetamide dmac n n dimethyl sulfone dmso unfortunately solvents mentioned unfriendly environment meet requirements green chemistry scientists searching green solvent alternative solvents in recent years room temperature ionic liquids rtils received lot attention potential green designable solvents although ionic liquids studied since 1950s handled inert atmosphere these part studies kinds water stable air stable ionic liquids found bmim]cl extremely low volatility rtils promising environment friendly solvents instead volatile organic solvents range science technology applications media organic inorganic reactions materials processing electrochemistry chemical separation copolymerization mma rtils research group find rtils good solvents pan copolymer pan copolymer could precipitated rtils solutions addition water therefore rtils promising green solvents pan understanding rheological properties solution convenient effective way gain fundamental knowledge spinnability structure property relationships spinning solution thus paper investigates rheological properties pan copolymer bmimcl concentrated solutions detail the pan copolymer chlorobutane 1-methylimidazole ethyl acetate acetone used supplied firstly pan powder swollen bmim]cl room temperature give white little viscous pulp secondly pulp heated 90c homogeneous transparent solution formed the pan/[bmim]cl solution 5 wt% 22 wt% concentration obtained within 5 hours 90c figure 1 shows process dissolution pan ionic liquids bmim]cl 90c concentration 10 wt% steady state rheological measurements performed haake rs150l rotational rheometer using 35 mm 1 cone plate the apparent viscosity shown function shear rate pan two different solvents bmim]cl dmf see figure 2 experimental range the pan dmf solution newtonian fluid pan/[bmim]cl solution pseudoplastic apparent viscosity decreases increasing shear rate according called power law equation k n constants pseudoplastic liquids viscosity decrease nearly linearly shear rate log log plot value n less one however surprising find data pan/[bmim]cl solution considered two linear stages see figure 2 the value n first stage less 1 according shear thinning rheological behavior while second stage apparent viscosity decreases dramatically even value n negative it known n used indicate non newtonian property fluids the value n deviates 1 non newtonian fluids would usually value n pan traditional organic solvents solutions 0 1 therefore could postulated would much stronger interaction pan new solvent bmim]cl discussed following text the data figure 3 shows viscosity shear rate curves pan/[bmim]cl solutions different concentrations these curves show solutions lower concentration remain newtonian behavior high shear rates concentrated solutions high concentration the rheological behavior pan/[bmim]cl solutions acts like liquid crystalline polymers lcp the solvent bmim]cl reduces number entanglements reducing number entanglements given shear rate since orientation macromolecular major cause non newtonian behavior increasing shear rate would make non newtonian behavior noticeable besides could found figure 3 high shear rate viscosity high concentration solutions lower low concentration example viscosity 22wt% solution lowest among solutions shear rate close 1000 1/s as known liquid crystalline polymers usually rigid chain segment aromatic polyamide aromatic polyester flexibility c c bond pan main chain smaller c bond c - n bond decrease strong polarity cn comparing liquid crystalline polymers pan chain segment oriented lack strong rigid chain segment case high concentration means entanglements indicates low shear rates would needed orient macromolecules and the amount entanglements large enough time much difficulties slip disengage increasing shear rate number oriented segments increases viscosity high concentration pan/[bmim]cl solution decreases greatly commonly viscosity follows andrade arrhenius equation good approximation equation constant e activation energy the slope straight line plotted ln versus 1/t e r the value energy activation depends strongly whether viscosities various temperatures evaluated constant shear stress constant shear rate here since low molecular weight polymers fewer entanglements high molecular weight ones surprising deviations newtonian behavior start higher shear rates low molecular weight solutions however figure 5 shear rate 210 1/s viscosity high molecular weight pan/[bmim]cl solution lower one the viscoelasticity polymer usually characterized dynamic rheological experiment sample subjected sinusoidal strain infinitesimal amplitude fixed angular frequency the term g called storage modulus phase component modulus represents energy stored recovered per cycle correspondingly term g called loss modulus phase component modulus represents energy dissipated heat per cycle deformation figure 6 shows modulus angular frequency curves pan/[bmim]cl solutions different concentrations(90c)(a temperature(14wt%)(b the data shows loss modulus g much higher storage modulus g. either module increases concentration increases temperature decreases the storage modulus g increases faster loss modulus g elasticity solution increases data fig 7 shows complex viscosity angular frequency curves pan/[bmim]cl solutions different concentrations(90c)(a temperature(14wt%)(b complex viscosity solution increases concentration increases temperature decreases this non newtonian behavior tremendous practical importance processing fabrication polymer material first decreased viscosity makes polymer solution easier process squirt small channels spinning second decrease viscosity associated development elasticity polymer solution this elasticity produces phenomena die swell puff extruded strands the possible dissolution mechanism pan ionic liquid bmim]cl shown figure 8 it proved miscibility ionic liquid polymer function structural characteristic we focus polar group pan strong interaction ionic liquid electronegativity nitrogen atom nitrile grouping strong when electron density large nitrogen atom nitrile grouping donate electrons carbon atom nitrile grouping attract electrons result strong interaction cation nitrogen atom nitrile grouping similarly strong interaction anion carbon atom nitrile grouping the pan copolymer chlorobutane 1-methylimidazole ethyl acetate acetone used supplied firstly pan powder swollen bmim]cl room temperature give white little viscous pulp secondly pulp heated 90c homogeneous transparent solution formed the pan/[bmim]cl solution 5 wt% 22 wt% concentration obtained within 5 hours 90c figure 1 shows process dissolution pan ionic liquids bmim]cl 90c concentration 10 wt% steady state rheological measurements performed haake rs150l rotational rheometer using 35 mm 1 cone plate the apparent viscosity shown function shear rate pan two different solvents bmim]cl dmf see figure 2 experimental range the pan dmf solution newtonian fluid pan/[bmim]cl solution pseudoplastic apparent viscosity decreases increasing shear rate according called power law equation k n constants pseudoplastic liquids viscosity decrease nearly linearly shear rate log log plot value n less one however surprising find data pan/[bmim]cl solution considered two linear stages see figure 2 the value n first stage less 1 according shear thinning rheological behavior second stage apparent viscosity decreases dramatically even value n negative it known n used indicate non newtonian property fluids the value n deviates 1 non newtonian fluids would usually value n pan traditional organic solvents solutions 0 1 therefore could postulated would much stronger interaction pan new solvent bmim]cl discussed following text the data figure 3 shows viscosity shear rate curves pan/[bmim]cl solutions different concentrations these curves show solutions lower concentration remain newtonian behavior high shear rates concentrated solutions high concentration the rheological behavior pan/[bmim]cl solutions acts like liquid crystalline polymers lcp the solvent bmim]cl reduces number entanglements reducing number entanglements given shear rate reduces amount orientation macromolecular since orientation macromolecular major cause non newtonian behavior increasing shear rate would make non newtonian behavior noticeable besides could found figure 3 high shear rate viscosity high concentration solutions lower low concentration example viscosity 22wt% solution lowest among solutions shear rate close 1000 1/s as known liquid crystalline polymers usually rigid chain segment aromatic polyamide aromatic polyester flexibility c c bond pan main chain smaller c bond c - n bond decrease strong polarity cn comparing liquid crystalline polymers pan chain segment oriented lack strong rigid chain segment case high concentration means entanglements indicates low shear rates would needed orient macromolecules and the amount entanglements large enough time much difficulties slip disengage increasing shear rate number oriented segments increases viscosity high concentration pan/[bmim]cl solution decreases greatly commonly viscosity follows andrade arrhenius equation good approximation equation constant e activation energy slope straight line plotted ln versus 1/t e r the value energy activation depends strongly whether viscosities various temperatures evaluated constant shear stress constant shear rate here the two molecular weights high enough become entangled since low molecular weight polymers fewer entanglements high molecular weight ones surprising deviations newtonian behavior start higher shear rates low molecular weight solutions however figure 5 shear rate 210 1/s viscosity high molecular weight pan/[bmim]cl solution lower one the viscoelasticity polymer usually characterized dynamic rheological experiment sample subjected sinusoidal strain infinitesimal amplitude fixed angular frequency the term g called storage modulus phase component modulus represents energy stored recovered per cycle correspondingly term g called loss modulus phase component modulus represents energy dissipated heat per cycle deformation figure 6 shows modulus angular frequency curves pan/[bmim]cl solutions different concentrations(90c)(a temperature(14wt%)(b the data shows loss modulus g much higher storage modulus g. either module increases concentration increases temperature decreases the storage modulus g increases faster loss modulus g elasticity solution increases data fig 7 shows complex viscosity angular frequency curves pan/[bmim]cl solutions different concentrations(90c)(a temperature(14wt%)(b the complex viscosity solution increases concentration increases temperature decreases this non newtonian behavior tremendous practical importance processing fabrication polymer material first decreased viscosity makes polymer solution easier process squirt small channels spinning second decrease viscosity associated development elasticity polymer solution this elasticity produces phenomena die swell puff extruded strands the possible dissolution mechanism pan ionic liquid bmim]cl shown figure 8 it proved miscibility ionic liquid polymer function structural characteristic we focus polar group pan strong interaction ionic liquid electronegativity nitrogen atom nitrile grouping strong when electron density large nitrogen atom nitrile grouping donate electrons carbon atom nitrile grouping attract electrons result strong interaction cation nitrogen atom nitrile grouping similarly strong interaction anion carbon atom nitrile grouping within limits experimental techniques accessible us results obtained pan/[bmim]cl solutions show pseudoplastic similar pan traditional organic solvents solutions the dependence concentration molecular weight shows entanglements play important role rheological behaviors pan/[bmim]cl concentrated solutions the dynamic rheological measurement indicates elasticity solution increases concentration increasing temperature decreasing the rheological behaviors concentrated solution high share rate directive spinning pan fiber

one of the room temperature ionic liquids ( rtils ) , 1-butyl-3-methylimidazolium chloride ( [ bmim]cl ) was chosen to prepare the concentrated solutions of polyacrylonitrile ( pan ) . the rheological behaviors of the solutions were measured with rotational rheometry under different conditions , including temperatures , concentration , and molecular weight of pan . the solutions exhibited shear - thinning behaviors , similar to that of pan / dmf solutions . the viscosities decreased with the increasing of shear rates . however , the viscosity decreased sharply at high shear rates when the concentration was up to 16wt% . the dependence of the viscosity on temperature was analyzed through the determination of the apparent activation energy . unusually , the viscosity of solutions of higher concentration is lower than that of lower concentration . similarly , the viscosity of low molecular weight pan was higher than high molecular weight pan at high shear rates . the dynamic rheological measurement indicates the loss modulus is much higher than storage modulus . the trend of complex viscosity is similar with the result of static rheological measurement . the interaction between pan and ionic liquid [ bmim]cl was discussed .

fistulae upper respiratory gastrointestinal tracts uncommon adults whereas developmental anomaly commonest cause infancy childhood etiology adults frequently secondary esophageal malignancy we report two cases esophagobronchial fistulae one secondary chronic chest tuberculosis secondary squamous cell carcinoma upper esophagus diagnosed multi detector computed tomography mdct traditionally fluoroscopy oral contrast swallow examination mainstay radiological investigation diagnosis fistulae however inconvenient study need multiple projections adequately demonstrate fistula course also luminal study cause fistula adequately evaluated use various post processing features like thick maximum intensity projections mips volume rendering techniques vrts enables better detection depiction fistulae use virtual endoscopy also guides clinician conventional endoscopy would needed biopsy treatment a 15-year old male presented cough mucopurulent expectoration dyspnea since 3 months this finding swallow cough sequence referred ono sign a chest radiograph revealed complete opacification right hemithorax volume loss suggesting complete collapse right lung mediastinal shift right figure 1 a plain intravenous contrast enhanced ct study oral contrast swallow performed 128-slice mdct scanner siemens somatom definition erlangen germany the study revealed complete collapse right lung irregular dilated ectatic bronchi right lower lobe figure 2 there stenosis diffuse narrowing right mainstem bronchus nodularity mucosa seen best virtual bronchoscopy figure 3 an air filled tract noted extending one right lower lobar bronchi toward posterior mediastinum ill defined soft tissue around the possibility esophagobronchial fistula suspected ct oral contrast swallow study detect oral contrast swallow study performed patient right decubitus position using diluted non ionic iodinated contrast medium 1:20 dilution iohexol normal saline it depicted site fistula tract right lateral wall esophagus one ectactic bronchi right lower lobe lung thick mip images vrt processing demonstrated fistula site tract figures 4 5 these imaging findings led us conclude changes likely sequelae chronic tuberculosis histology lung specimen revealed distorted bronchioles diffuse focal dense infiltration mononuclear cells giant cells frontal chest radiograph reveals severe volume loss complete opacifi cation right hemithorax ipsilateral tracheal mediastinal shift branching tubular radiolucencies are noted right lower zone representing bronchiectasis encircled area axial coronal b ct chest lung window shows complete collapse right lung shift heart mediastinum right dilated irregular fluid bronchi seen right lower lobe thin black arrows air fluid levels within thick black arrow coronal ct chest lung window demonstrates narrowing right mainstem bronchus thick black arrow virtual bronchoscopy images b revealing stenotic orifice right mainstem bronchus mucosal nodularity near carina thick maximum intensity projection mip image ct contrast swallow study demonstrating esophagus pulled right opacification oral contrast fistula tract esophagus dilated right lower lobe bronchi volume rendering technique vrt images- frontal lateral b projections derived post processing contrast swallow examination demonstrating fistula arrowheads right lateral aspect pulled esophagus right lower lobar bronchus opacifi cation bronchial tree 65-year old male presented progressive dysphagia solids past 2 months an ultrasound neck revealed enlarged lymph nodes fine needle aspiration fna revealed neoplastic squamous cells a plain intravenous contrast enhanced ct study ct oral contrast swallow performed there loss fat plane esophagus carina left mainstem bronchus aorta a defect seen posterior wall proximal left mainstem bronchus suggesting formation fistula esophagus figure 6 ct oral contrast swallow study performed prone position diluted non ionic contrast 1:20 dilution iohexol normal saline revealed small fistula tract esophagus proximal left mainstem bronchus distal carina figure 7 post processing contrast swallow study volume rendering depicted fistulous communication 3d figure 8 axial contrast enhanced ct level beyond carina demonstrates defect posterior wall proximal left mainstem bronchus thick white arrow a virtual bronchoscopy image b shows site fistula opening thin white arrow oral contrast ct swallow- axial ct performed patient prone position shows fistula tract white arrow opacifi ed diluted oral contrast volume rendering technique vrt images- frontal lateral b projections derived post processing contrast swallow examination show fistula tract esophagus proximal left mainstem bronchus a 15-year old male presented cough mucopurulent expectoration dyspnea since 3 months this finding swallow cough sequence referred ono sign a chest radiograph revealed complete opacification right hemithorax volume loss suggesting complete collapse right lung mediastinal shift right figure 1 a plain intravenous contrast enhanced ct study oral contrast swallow performed 128-slice mdct scanner siemens somatom definition erlangen germany the study revealed complete collapse right lung irregular dilated ectatic bronchi right lower lobe figure 2 there stenosis diffuse narrowing right mainstem bronchus nodularity mucosa seen best virtual bronchoscopy figure 3 an air filled tract noted extending one right lower lobar bronchi toward posterior mediastinum ill defined soft tissue around the possibility esophagobronchial fistula suspected ct oral contrast swallow study detect oral contrast swallow study performed patient right decubitus position using diluted non ionic iodinated contrast medium 1:20 dilution iohexol normal saline it depicted site fistula tract right lateral wall esophagus one ectactic bronchi right lower lobe lung thick mip images vrt processing demonstrated fistula site tract figures 4 5 these imaging findings led us conclude changes likely sequelae chronic tuberculosis histology lung specimen revealed distorted bronchioles diffuse focal dense infiltration mononuclear cells giant cells frontal chest radiograph reveals severe volume loss complete opacifi cation right hemithorax ipsilateral tracheal mediastinal shift branching tubular radiolucencies are noted right lower zone representing bronchiectasis encircled area axial coronal b ct chest lung window shows complete collapse right lung shift heart mediastinum right dilated irregular fluid bronchi seen right lower lobe thin black arrows air fluid levels within thick black arrow coronal ct chest lung window demonstrates narrowing right mainstem bronchus thick black arrow virtual bronchoscopy images b revealing stenotic orifice right mainstem bronchus mucosal nodularity near carina thick maximum intensity projection mip image ct contrast swallow study demonstrating esophagus pulled right opacification oral contrast fistula tract esophagus dilated right lower lobe bronchi volume rendering technique vrt images- frontal lateral b projections derived post processing contrast swallow examination demonstrating fistula arrowheads right lateral aspect pulled esophagus right lower lobar bronchus opacifi cation bronchial tree a 65-year old male presented progressive dysphagia solids past 2 months an ultrasound neck revealed enlarged lymph nodes fine needle aspiration fna revealed neoplastic squamous cells a plain intravenous contrast enhanced ct study ct oral contrast swallow performed there loss fat plane esophagus carina left mainstem bronchus aorta a defect seen posterior wall proximal left mainstem bronchus suggesting formation fistula esophagus figure 6 ct oral contrast swallow study performed prone position diluted non ionic contrast 1:20 dilution iohexol normal saline revealed small fistula tract esophagus proximal left mainstem bronchus distal carina figure 7 post processing contrast swallow study volume rendering depicted fistulous communication 3d figure 8 axial contrast enhanced ct level beyond carina demonstrates defect posterior wall proximal left mainstem bronchus thick white arrow a virtual bronchoscopy image b shows site fistula opening thin white arrow oral contrast ct swallow- axial ct performed patient prone position shows fistula tract white arrow opacifi ed diluted oral contrast volume rendering technique vrt images- frontal lateral b projections derived post processing contrast swallow examination show fistula tract esophagus proximal left mainstem bronchus esophagobronchial fistulae uncommon difficult diagnose elderly frequently seen intrathoracic malignancy commonly associated malignancy esophagus large case series subsequent ulceration necrosis malignant tissue leads tissue breakdown fistula formation non malignant causes infrequent include trauma blunt penetrating iatrogenic chronic inflammation chronic infections like tuberculosis histoplasmosis crohn disease late presentation congenital fistula rarely poisoning years iatrogenic trauma become commoner cause fistulae compared infections tuberculosis cause fistulae infrequently reported western literature however indian subcontinent incidence tuberculosis high chest tuberculosis high list differentials non malignant fistula encountered in nonmalignant conditions traumatic bronchial tracheal wall necrosis necrotizing inflammation responsible fistulization fluoroscopic oral contrast swallow examination barium initial investigation choice evaluation dysphagia suspected fistulae even though endoscopy needed definite evaluation if esophageal perforation suspected iodinated contrast medium used barium extravasation lead mediastinitis if frank leak seen barium given produces better radiographic quality higher density iodine if respiratory fistula suspected barium still may used small quantity barium tracheobronchial tree harmless however ionic iodinated contrast medium used cause chemical pneumonitis non ionic iodinated contrast medium used cases best initial agent use scenarios perforation fistula non ionic iodinated contrast agent fluoroscopy allows dynamic evaluation esophageal motility well evaluation lumen even though barium swallow fluoroscopy examination advantage real time study fistula tracts may always detected if detected depiction three dimensional course fistula may difficult spite use multiple projections also luminal study would fail show changes wall esophagus mediastinum shown accurately ct no large case series published efficacy adult fistulae case reports highlighted role the patient given mouthful bolus preparation asked swallow promptly instruction since oral pharyngeal phases deglutition take 2 seconds acquisition triggered immediately instruction patient swallow given the patient position may changed better opacify fistula tract used prone right decubitus positions cases better opacify fistula tracts a recent study demonstrated ct contrast swallow better tolerated sensitive fluoroscopy detecting post esophagectomy anastomotic leaks post processing studies maximum intensity projection volume rendering allows three dimensional evaluation fistula tract supplementing oral contrast swallow chest ct protocol cases fistulae suspected improve diagnostic ability ct also better demonstrate fistulae

we report two cases of esophagobronchial fistulae diagnosed by multi - detector computed tomography ( mdct ) oral contrast swallow examination . it is helpful to supplement the ct study with an oral contrast swallow as it aids in confirmation of a suspected fistula and also demonstrates the fistula tract better . we present the clinical details and the imaging findings on mdct of two cases of esophagobronchial fistulae one secondary to chronic chest tuberculosis and the other secondary to a squamous cell carcinoma of the upper esophagus followed by discussion of the etiology , pathogenesis , and imaging of these fistulae .

individual consumer researcher wants buy refrigerator appliances sorts people regard best practice decision making consulting trustworthy comparison websites magazines ones go beyond expressing opinions recording likes numerically rate alternative products set attributes criteria they want decision support tools give ratings trusted produced free conflict interest biases the consumer know want know refrigerator given 4*/80% rating reliability 3*/60% rating environmental impact another one opposite ratings feeling justified assuming common sense lay understanding terms reliability environmental impact neither time motivation find concepts mean terms mechanical functioning refrigerator quality components emissions produces whatever else contributes ratings made expert assessors some may wish establish whether consumers made informed decision seeing well score test refrigerator knowledge giving considerable fixed weight knowledge measures decision quality consumers decisions might regarded poor quality knowledge sub score low in contrast consumers may regard made good decisions indeed best possible decisions could make given time cognitive effort willing devote research decision making process including accessing accumulating knowledge deemed important even essential others but surely health care decisions different buying refrigerators choosing surgery medical options newly diagnosed cancer pain management chronic osteoarthritis like buying household appliance ? in fact nothing really changes individual conceptualize researcher conducting continuing informal n of-1 study health the affective emotional differences two situations may well produce differences decision making process patient accepts necessarily enhance quality decision defines patients may become interested finding medical condition would refrigerators actually but unless leads change performance rating available option one criteria especially bean criterion weigh heavily additional information possess decision neutral people researchers may feel better informed sense realize necessarily position make better decision therefore ended decisionally empowered they may even simply become anxious regretful opportunity costs acquiring information form foregone benefits activities could engaged informed decision according us absolutely since consulted transparent set option performance ratings relevant criteria originating source decided trustworthy their decision quality score may well low according instrument weights highly knowledge assumed others need make the growing number condition specific decision quality instruments developed notably karen sepucha colleagues give heavy weight knowledge subcomponent there could clearer confirmation issue stake title one background papers projects feeling informed relate informed? trust crucial either shared unshared decision making trust relates inputs decision making since left behind notion agency relationship previously dominant conceptualising medical practice trust always matter degree rather binary nothing whether relates beans provided clinician decision support tool even one dubious source trustworthy unless person rates estimates trustworthy best source since so envisage individual regarding respected consumer magazine beans refrigerators trustworthy relation purchase decision people task health care decisions given restricted willingness devote time energy processing information assess trustworthiness available sources beans outcomes criteria important they would expect clinician team developing ratings decision aid highly trustworthy provided evidence especially case aid the key information person researcher requires labelling ensures get says tin open aid meta information make informed choice tins size open the major problem imposed information requirement condemns many continuum health literacy especially health numeracy receiving little help we fully support attempts reduce health illiteracy innumeracy especially decision focused forms however much expect decision support tool clinician overcome limitations previous education socialization respects moreover important accept even aid users able register report relative numbers sad smiley faces frequency diagrams repeat back 1 x statements considerable doubt way ensure meaningfully incorporate numerical probabilities correctly registered say 10% .05% 1 10 1 2000 decisions this say decision aid contain help respect including guidance person best avail offers information bases offering it suggest much provided opt basis nothing said intended imply community entitled apply community level criteria weights provides allows provided conditions cost pursuit goals efficiency equity justice formal laws regulations including informed consent clinician liability resource allocation policies including reimbursement decisions context individual decision made frequently conflict individual sees best given personal criteria weights external consequences others may trump individuals preferences case infectious diseases trickier issues social responsibility morality dealt formally apart issues environmental social impact arising hormonal treatments opioids arise resource constrained interdependent systems simply result constraints interdependencies cases say two things first function individual decision support tools mandate inclusion exclusion social criteria individual set concern others health insist given specific weights second order regarded made high quality decision individual required informed social criteria select processed beans available trustworthy source normative checklists decision support tools constructed accordance guidelines ipdasi collaboration clearly intended promote person patient empowerment but most decision aids comply guidelines designed use within context shared decision making person assigned status patient many cases the support accessed within clinical encounter provider permission they perpetuate idea decision informed particular way particular extent good decision we need concept informed decision good better best possible decision none these will definition multi dimensional therefore preference sensitive there one answer patient person patient

most guidelines for clinical practice , and especially those for the construction of decision support tools , assume that the individual person ( the patient ) needs to be in possession of information of particular sorts and amount in order to qualify as having made an informed decision. this often implicitly segues into the patient having made a good decision. in person - centred health care , whether , in what form , and with what weight , information is included as a criterion of decision quality is a matter for the person involved , to decide in the light of their own values , preferences , and time and resource constraints .

pancreatic intraepithelial neoplasia panin nomenclature microscopic proliferative epithelial lesions pancreas proposed 2001 hruban et al panin assumed precursor lesion invasive ductal carcinoma idc precursor lesions idc also include intraductal papillary mucinous neoplasm ipmn mucinous cystic neoplasm panin divided three grades panin-1 -2 -3 according cytological architectural atypia panin-1 subdivided flat panin-1a papillary types panin-1b this hypothesis arisen observation resected specimens synchronous metachronous occurrence panin idc seen panin reported common pancreas idc without 2 3 it also reported idc occurred remnant pancreas several years partial pancreatectomy high grade panin performed 4 5 several studies demonstrated higher frequencies genetic alterations k ras mutation dpc4 inactivation higher grade panin lesions 6 7 8 9 thus hypothesized pancreatic ductal lesions may progress histologically normal duct flat lesion panin-1a papillary lesion panin-1b atypical lesion panin-2 severely atypical lesion panin-3 panin-3 likely develop eventually idc panin-3 idc share critical genetic abnormalities however histological evidence panin-3 invades beyond basement membrane pancreatic ductal epithelium moment panin-3 becomes idc captured yet defined consensus guideline panin microscopic papillary flat non invasive epithelial neoplasia usually 5 mm diameter panin-3 obstructed several branch pancreatic ducts subsequently caused pancreatitis developed clinical symptom detectable pancreatic mass imaging studies since pancreatic cancer suspected examinations performed histological examination resected specimens showed panin-3 slightly invading beyond basement membrane ductal epithelia accompanied fibrotic changes caused occlusion branch ducts a 65-year old woman admitted former hospital acute pancreatitis recurred 2 months thereafter she referred center examination pancreas second pancreatitis relieved she slightly thin showing body mass index 20.2 neither smoking drinking habits laboratory data showed abnormalities including serum levels amylase tumor markers related pancreatic diseases abdominal ultrasound revealed low echoic mass 13 mm diameter pancreatic body without upstream dilatation main pancreatic duct mpd fig endoscopic ultrasound showed low echoic mass 20 mm diameter pancreatic body fig since pancreatic cancer suspected pancreatic body underwent endoscopic retrograde pancreatography showed strictured segment 2 mm length mpd pancreatic body fig cytological examination pancreatic juice obtained endoscopic retrograde pancreatography revealed adenocarcinoma fig 1 g patient diagnosed pancreatic body cancer without obvious vascular involvement t3 n0 m0 stage iia according uicc classification underwent distal pancreatectomy the resected specimens fixed formalin cut slice thickness 5 mm shown fig histological examination revealed papillary growth intraductal epithelia significant nuclear atypia classified panin-3 according definition consensus guideline mainly branch ducts fig panin-3s located separately branch ducts normal epithelia mpd fig 2b h indicating originated different sites branch ducts histologically case diagnosed idc pancreatic body t1 n0 m0 stage high grade panin panin-3 recognized best defined precursor lesion idc based genetic well histological observations panin-3 reported share genetic alterations idc 6 7 8 9 found usually pancreas idc 2 3 4 5 however direct evidence moment panin-3 invades beyond basement membrane become idc captured yet this first case report microinvasion panin-3 histologically confirmed resected pancreatic specimens considerable ambiguities existed distinction panin ipmn therefore definitions two lesions revised consensus meeting held johns hopkins hospital 2003 according revised definitions panin microscopic papillary flat epithelial neoplasm arising pancreatic duct differs ipmn defined grossly visible mucin producing predominantly papillary epithelial neoplasm case pancreatic epithelial neoplasm identified radiological examinations mucin production evident pancreatic ductal epithelia microscopic observation a reports suggested minimally invasive carcinoma distinguished invasive ipmn subgroup ipmn showed apparently better prognosis 11 12 13 however precise definition minimally invasive carcinoma established 14 15 recently proposed studies 16 17 case patient alive without signs recurrence 3 years since concept minimally invasive panin date case classified idc spite excellent outcome new notion minimally invasive panin should distinguished idc might widely accepted future case panin-3 lesions located separately several branch ducts without involving epithelia main duct this fact indicates panin arise one small portion pancreatic ductal epithelium spread creeping along epithelia arises multicentric it well known ipmn another precursor lesion idc occurs multicentric whole pancreas may involved genetic alteration related carcinogenesis difficult understand panin occurs independently different sites pancreas several cases dealing multiple occurrence idc reported rare clinical manifestation 18 19 this observation could explain rapid growth pancreatic ductal carcinoma follows microinvasion initially occurs several pancreatic ducts invasion independently progresses eventually makes fusion mass this observation could also explain multiple occurrence idc microinvasions occur independently distinct unlike ipmn panin-3 hardly detected clinical practice panin-3 visible imaging examination case panin-3 successfully detected due pancreatitis caused intraductal growth panin-3 subsequent occlusion pancreatic ducts pancreatitis might candidate diagnostic clues early detection pancreatic ductal carcinoma within preinvasive stage there known diagnostic clues early detection pancreatic cysts dilatation mpd case however neither pancreatic cyst dilatation mpd observed the detection pancreatic ductal carcinoma preinvasive stage promising way improving patient survival we hope report contribute understanding early development pancreatic ductal carcinoma

high - grade pancreatic intraepithelial neoplasia ( panin-3 ) is recognized as a precursor lesion of invasive ductal carcinoma ( idc ) . however , histological evidence that panin-3 invades beyond the basement membrane of pancreatic ductal epithelium , that is , the moment panin-3 becomes idc , has not been captured yet . this may be because panins which are microscopic papillary or flat lesion rarely develop clinical symptoms and are not detectable on imaging examination . on the other hand , most idcs were found in the advanced stage with massive invasion . in this report , panin-3 obstructed several branch pancreatic ducts and subsequently caused pancreatitis which developed clinical symptom and was detectable as a pancreatic mass in imaging studies . a 65-year - old woman was referred to our institution for further examination of her repeated pancreatitis . abdominal ultrasound revealed a low echoic mass of 13 mm in diameter in the pancreatic body without upstream dilatation of the main pancreatic duct ( mpd ) . endoscopic retrograde pancreatography showed a strictured segment of 2 mm in length in the mpd at the pancreatic body . cytological examination of pancreatic juice revealed adenocarcinoma and distal pancreatectomy was performed . a resected specimen revealed a whitish mass of 15 mm in diameter in the pancreatic body , which was identified as pancreatitis by histological examination . papillary growth of panin-3 was seen mainly in the branch ducts . each panin-3 was located separately in the branch ducts with normal epithelia in the mpd between them . in three adjacent branch ducts , panin-3 was observed to be invading microscopically beyond the basement membrane .

ductal adenocarcinoma prostate first reported melicow pachter 1967 endometrial carcinoma prostatic utricle since then ductal adenocarcinoma prostate found account 0.27.5% prostate carcinomas a 73-year old man referred hospital due elevated prostate specific antigen psa level 23.4 ng ml remarkable medical history the hematological biochemical data showed abnormal findings aside elevated psa levels february 2016 prostate needle biopsy detected gleason score 4 4 adenocarcinoma left prostate computed tomography ct and magnetic resonance imaging mri showed higher density left peripheral zone fig 1a b may 2016 radical prostatectomy lymph node resection histologically many large clear edged cells cancer cells low differentiation forming circular shape based findings ductal adenocarcinoma gleason score 4 4 8 acinar adenocarcinoma positive surgical margin diagnosed the patient experienced recurrence biochemical recurrence 10 months since radical prostatectomy histologically many large clear edged cells cancer cells low differentiation forming circular shape based findings ductal adenocarcinoma gleason score 4 4 8 acinar adenocarcinoma positive surgical margin diagnosed no adverse perioperative events observed patient experienced recurrence biochemical recurrence 10 months since radical prostatectomy ductal adenocarcinoma prostate first reported endometrial carcinoma prostatic utricle 1967 recent studies suggested ductal adenocarcinoma prostate developed ductal epithelium based findings immunohistochemical electron microscope analyses histologically ductal adenocarcinoma prostate characterized high cylindrical epithelium collate papillary etat cribriform the histological differences ductal adenocarcinoma acinar adenocarcinoma thought clear case although prostate needle biopsy showed acinar adenocarcinoma surgical specimens showed ductal adenocarcinoma the first mixed type acinar adenocarcinoma accounts 75% ductal prostate specimens mixed type ductal prostate adenocarcinomas account 5.06.6% prostate cancer cases pure type ductal prostate adenocarcinomas account 0.40.8% prostate cancer cases because ductal carcinomas account 90% prostatic carcinoma cases case assumed pure type extension toward urethra tumor palpable digital rectal examination showed low psa level ductal adenocarcinoma prostate usually extends toward urethra shows macrohematuria urinary symptoms early stage reported ductal adenocarcinoma prostate showed significantly poorer prognosis acinar prostate adenocarcinoma nonmetastatic cases however metastatic cases prognostic differences 2 groups other reports found marked differences 5-year survival rate ductal adenocarcinoma gleason score 810 acinar adenocarcinoma reported therapies ductal adenocarcinoma prostate also acinar adenocarcinoma including radical prostatectomy androgen deprivation therapy radiation therapy combination therapies reported pure ductal adenocarcinoma tended extend submucosal urethra pure ductal adenocarcinoma carries higher risk positive surgical margin urethra although performing adjuvant therapy patient present careful observation including ct mri positron emission tomography ct performed psa always accurately represent cancer progression

ductal adenocarcinoma is an unusual variant of adenocarcinoma of the prostate . a 73-year - old male was referred to our hospital for the further examination of an elevated prostate - specific antigen level of 23.4 ng / ml . radical prostatectomy ( rp ) was performed based on the diagnosis obtained by a prostate needle biopsy . the rp specimen revealed ductal adenocarcinoma of the prostate with positive capsular penetration . we herein report a rare case of ductal adenocarcinoma of the prostate .

patients treated salvage chemotherapy response rate 9% median time tumor progression ttp 9 weeks although bevacizumab offer significantly higher response rate 55% period clinical stabilization median ttp 26 weeks tumor remains brain continues proliferate despite clinical radiological appearances improvement result bevacizumab questionable impact overall survival patients 3 4 therefore new novel treatments needed patients recurrent glioblastoma failed initial treatment radiotherapy temozolomide the novottf-100a device new treatment approved united states food drug administration fda recurrent glioblastoma the device emits alternating tumor treating electric fields ttfields via 2 pairs transducer arrays placed orthogonally scalp the ttfields work interrupting tumor cells mitosis resulting violent blebbing cytokinesis asymmetric chromosome segregation aneuploidy 5 6 these cell biology effects ultimately result apoptosis slippage g0 state tumor cell simultaneously making susceptible immunogenic cell death pivotal phase iii clinical trial novottf-100a device similar efficacy compared salvage chemotherapy without toxicities associated systemic chemotherapies 7 8 here report patient failed bevacizumab therapy recurrent cystic glioblastoma time bevacizumab continuation received add ttfields therapy using novottf-100a device this treatment combination eventually resulted disappearance cystic enhancement together marked reduction cyst size cerebral edema surrounding brain the patient 76-year old right handed woman came brain tumor center evaluation recurrent glioblastoma bevacizumab failure her initial neurological problems occurred 9 months prior presentation consisted mental confusion comprehension problems manifesting fluent aphasia a gadolinium enhanced head mri outside hospital showed cystic enhancing mass left temporal lobe brain she received 6 weeks external beam fractionated radiotherapy 6,000 cgy 200 cgy 30 fractions concomitant daily temozolomide 75 mg followed adjuvant temozolomide 200 mg 5 days monthly basis after 5 cycles adjuvant temozolomide new cystic enhancement discovered performing head mri fig 1a b placed 4 mg dexamethasone 4 times day bevacizumab subsequently started dose 10 mg kg every 2 weeks after 2 cycles bevacizumab partial decrease gadolinium enhancement size cystic tumor fig additional pathology testing revealed negative idh1 immunohistochemical labeling positive olig2 egfr amplification methylated mgmt promotor status ttfields interrupt tumor cells mitosis appreciable overlapping toxicity bevacizumab proceeded add bevacizumab treatment ttfields therapy using novottf-100a device the treatment compliance recorded sensors embedded within transducer arrays downloaded computer review clinic visits after total 6 cycles bevacizumab plus ttfields therapy respective mean median compliance 17.6 hours 73% day 18.4 hours 77% day range 3.6 22.8 h near complete resolution gadolinium enhancement 65% reduction size cystic tumor fig 1e f however also recurrent tumors detected left internal capsule medial left frontal brain fig 2a b located outside prior radiation treatment fields therefore recurrent tumors treated fractionated cyberknife radiosurgery 2,100 cgy 700 cgy 3 fractions despite radiosurgery intervention patient continued deteriorate neurologically deterioration likely caused microscopic invasive glioblastoma she eventually died 15 months first recurrence 22 months initial diagnosis the addition novottf-100a bevacizumab therapy patient appears safe may provide added efficacy initial incomplete response bevacizumab alone rationales combine ttfields therapy bevacizumab threefold first overlapping side effect therefore combination appear cause synergistic additive toxicities patients glioblastoma we retrospectively analyzed 20 patients treated combination found instance intracranial hemorrhage other treatment side effects minor severity include expected scalp rash electric shock sensation poorly applied transducer arrays vivid dreams resolved upon application corticosteroid cream adjustment arrays second ttfields therapy mimics effects chemotherapy interference tumor cell mitosis conventional side effects chemotherapy 5 7 when first approved fda bevacizumab combined various cytotoxic agents including carboplatin irinotecan carboplatin etoposide well lomustine carmustine side effects warrant routine clinical use bevacizumab combined cytotoxic chemotherapy third bevacizumab novottf-100a listed national comprehensive cancer network practice guideline recurrent glioblastoma therefore appear strong rationales combine novottf-100a bevacizumab recurrent glioblastoma the resolution patient cystic tumor notable response novottf-100a bevacizumab initial bevacizumab failure although response assessment neuro oncology criteria deem nonmeasurable cystic tumors measured traditional bidimensional fashion response assessment unless associated solid nodule measuring 10 mm greater diameter however disappearance enhancement cystic tumor still remarkable retrospective series 51 recurrent high grade gliomas treated bevacizumab irinotecan zuniga et al reported 8% patients complete response majority either partial response 63% response 29% similarly bevacizumab used single agent kreisl et al friedman et al these data indicate bevacizumab alone rarely results complete radiographic response partial response seen majority patients suggests probably multiple proangiogenic pathways activated glioblastoma a prior post hoc analysis response characteristics pivotal phase iii trial indicates secondary glioblastomas well low dexamethasone usage potentially important predictors response patients treated novottf-100a device alone 7 17 first secondary glioblastomas may different genetic composition makes tumor cells susceptible ttfields indeed verhaak et al shown secondary glioblastomas fall proneural genotype amplification pdgfra olig2 well mutations idh1 tp53 although patient tumor appears primary glioblastoma lack idh1 immunohistochemical labeling could still unidentified genetic mutations make tumor susceptible ttfields therapy indeed 9 14 responders phase iii trial prior low grade histologies could genetic mutations epigenetic alterations make susceptible novottf-100a monotherapy second slower growth rate patient tumor may helped allow sufficient time ttfields effect treatment response this median time response ttfields therapy longer chemotherapies 8.4 versus 5.8 months respectively noted prior post hoc response analysis last patient dexamethasone completely discontinued 2 months initiation combination ttfields bevacizumab therapy near complete resolution gadolinium enhancement significant reduction cystic tumor detectable 6 months treatment consistent observation inverse relationship response dexamethasone dosage probably consequence removing immunosuppressive effect dexamethasone would allow better control glioblastoma patient immune system therefore allowing sufficient treatment time removing dexamethasone key parameters maximize probability response ttfields the pattern relapse combination ttfields bevacizumab therapy unknown time tumor recurrence this type distant recurrence glioblastoma could consequence progressive development invasive phenotype intracranial inhomogeneity ttfields incomplete coverage certain parts brain ttfields these hypothesis generating observations would important future studies correlate location relapsed disease distribution electric fields within brain

the novottf-100a device emits alternating tumor treating electric fields ( ttfields ) that interfere with cytokinesis and chromosome segregation during mitosis . because it has a similar efficacy to cytotoxic chemotherapy , the device has been approved by the united states food and drug administration for the treatment of recurrent glioblastoma . although bevacizumab has been in use for recurrent glioblastoma , patients who experience incomplete or no response to bevacizumab may be predisposed to early bevacizumab treatment failure . however , the addition of ttfields therapy may augment the efficacy from bevacizumab . we report a patient with recurrent cystic glioblastoma who received add - on ttfields therapy due to an incomplete response to single - agent bevacizumab . after 6 cycles of therapy , a resolution of cystic enhancement was noted , together with reduction of the tumor cyst and resolution of most of the cerebral edema in the surrounding brain . however , the patient also suffered from relapsed disease at locations distant from the original glioblastoma and the corresponding radiation fields received at initial diagnosis . we conclude that combination ttfields and bevacizumab therapy is safe and may be efficacious for patients with recurrent glioblastoma . a further study would be needed to determine the relapse pattern and the distribution of the electric fields in the brain .

plaque induced gingivitis one frequent periodontal diseases affecting 90% population regardless age sex race20 brazilian epidemiologic studies show high prevalence gingival inflammation ranging 74% 100% although mean individual percentage gingival bleeding varies 28% 35%5 however inability normal adult population perform adequate toothbrushing led search chemotherapeutic agents order improve plaque control12 these chemicals mainly triclosan chlorhexidine used mouthrinses added dentifrices avoid plaque formation development gingivitis10,12,14,22 as substances may undesirable side effects tooth staining taste alteration phytotherapic agents antimicrobial antiinflammatory properties investigated7,16,17 the use natural products prevention treatment oral conditions increased recently could benefit low socioeconomic level urban rural communities4 among various currently available herbal agents aloe vera popularly known babosa plant commonly found northeast brazil its foliage extract resin present antimicrobial antiinflammatory healing properties indicated hepatic stomach diseases9 the antimicrobial effect dentifrice containing aloe vera demonstrated vitro study phytotherapic agent inhibited growth diverse oral microorganisms s. mutans s. sanguis a. viscosus c. albicans 7 the study available evaluating clinical effects aloe vera showed significant reduction gingivitis plaque accumulation use mouthrinse containing natural product20 present date reported controlled trial evaluating efficacy dentifrice containing aloe vera control plaque gingivitis therefore purpose present study assess antiplaque antigingivitis effects phytotherapic agent compared fluoridated dentifrice thirty adult subjects university fortaleza brazil 15 male 15 female aged 35 43 years enrolled double blind parallel controlled clinical trial all randomly screened participants informed nature study signed informed consent form compliance guidelines brazilian national health council the protocol approved institutional ethics committee report cotica unifor 407/ 2006 the subjects entered study gingival bleeding index gbi)1 40% presence least 20 natural teeth absence supragingival calculus plaque retentive factors subjects medical disorders probing depth 3 mm individuals antimicrobial therapy least 1 month prior study using mouthrinses dentifrices containing substances antiinflammatory properties well smokers pregnant women excluded trial the participants assigned either test group n=15 control group n=15 random permutation three the test group used herbal dentifrice containing aloe vera forever bright forever living products tempe az usa control group used fluoridated dentifrice sorriso dentes brancos kolynos brasil paulo sp brazil antiinflammatory properties color taste similar test dentifrice a single previously calibrated examiner3 scored gingival bleeding index gbi)1 plaque index pi)19 recorded buccal mesial distal lingual surfaces teeth values 4 sites tooth averaged determine gbi pi subject in addition examination hard soft oral tissues visually inspected presence adverse reaction examiner after initial examination teeth subject polished pumice flossed eliminate plaque remnants personal kit containing new toothbrush leader facilit odontolgica e perfumaria ltda rio de janeiro rj brazil test control dentifrice given participants they instructed brush teeth 1 min three times day using bass technique refrain oral hygiene procedures throughout period clinical trial verbal written instructions correct use dentifrice given subjects well the tubes containing dentifrices previously coded warrant neither examiner volunteers knew content revealed completion study the subjects asked return dentifrice tubes weighted digital balance filizola modelo bp6 indstrias filizola s.a paulo sp brazil previously trial compliance could indirectly evaluated student test used evaluate statistical differences weights dentifrice tubes days 0 30 =0.01 mann whitney test performed evaluate statistical differences control test groups days 0 30 =0.01 group the mean scores gbi pi compared baseline end trial wilcoxon test =0.01 the test dentifrice good acceptance show adverse effects formation abscess ulcerations allergic reactions only one subject test group reported unpleasant taste drop clinical trial significant reduction dentifrice tube weights days 0 30 groups p<0.001 indirectly indicated volunteers actually used dentifrices table 1 day 0 statistically significant difference control test groups respect gbi p=0.8774 pi p=0.0477 means these results indicated groups well balanced baseline tables 2 3 30th day plaque p=0.2801 gingival bleeding p=0.9346 present groups difference significant statistically tables 2 3 comparing means baseline day 30 group there statistically significant difference gbi p=0.002 control group p=0.001 test group pi indexes p=0.002 control group p=0.001 test group tables 2 3 aloe vera natural product contained herbal dentifrices commercial appeal control plaque gingivitis despite free commercial use phytotherapic agent sufficient data support antigingivitis antiplaque claims21 to best knowledge present study first report effect dentifrice containing aloe vera gingivitis the results showed toothpastes efficient plaque reduction 23% test group 19% control group this percent difference significant end trial spite of a reported vitro inhibitory effect aloe vera microorganisms supragingival biofilm7 vivo antiplaque effect present study satisfactory it interesting note previous study7 evaluated dentifrice also contained antiplaque agents probably masked effect aloe vera the test control dentifrices reduced gingivitis significantly although fluoridated dentifrice presented higher percent reduction bleeding areas 56% versus 53% the gbi generally used dichotomous index evaluate gingivitis access severity gingival inflammation studies evaluating reduction gingivitis grading index could interesting complement results gingival index uses scale color changes gingival tissues precede bleeding probing however parameter necessarily accurate indicator gingivitis18 the findings present study agreement villalobos et al.20 2001 observed significant reduction plaque gingivitis 30-day use mouthrinses containing aloe vera associated toothbrushing this study20 also showed additional antiplaque antigingivitis effect phytotherapic agent observed present clinical trial villalobos et al.20 2001 used higher concentration aloe vera 50% could explain better effect phytotherapic agent compared findings although manufacturer inform concentration aloe vera product used present study percentage therapeutic agent dentifrice usually range 0.4% 1.0% total formulation6 probably concentration used study could explain results furthermore villalobos et al.20 2001 used mouthrinse containing aloe vera active agent favoring action without interference components the test dentifrice used present trial contains agents promote moderate antiplaque effect menthol sodium lauryl sulfate12,21 since last two components also present control dentifrice considering difference found groups the antagonism diverse substances similar effects product considered well this fact highlighted wua savitt21 2002 confirmed clinical trials comparing fluoridated herbal dentifrices11,15 home use dentifrice studies often influenced number factors mask superiority test agent controls participants clinical trials may experience improvement associated specifically therapeutic properties test agent rather related behavior change hawthorne effect15 subjects enrolled oral hygiene studies usually improve toothbrushing irrespective product receive11,13,15 although volunteers present study aware dentifrice using another important factor novelty effect motivation oral hygiene practice use new substance on the hand lack compliance correct use dentifrice occur well15 order minimize occurrence the participants asked bring dentifrice tubes end trial weighed could evaluate indirectly subject compliance significant difference weights groups study indicates participants used products confirm used correctly however may sufficient show superiority test dentifrice control toothpaste15 further long term studies must performed evaluate antigingivitis effect herbal dentifrice if real benefit confirmed use aloe vera advantageous cases patients little motor skills toothbrushing compromised within limits clinical study may concluded dentifrice containing aloe vera show additional effect plaque gingivitis control compared fluoridated dentifrice

the effect of aloe vera on the reduction of plaque and gingivitis was evaluated in a randomized , parallel and double - blind clinical trial . subjects were randomly allocated to the test group ( n=15 ) dentifrice containing aloe vera - or the control group ( n=15 ) fluoridated dentifrice . plaque index ( pi ) and gingival bleeding index ( gbi ) were assessed at days 0 and 30 . subjects were asked to brush their teeth with the control or test dentifrice , three times a day , during a 30-day period . there was a significant reduction on plaque and gingivitis in both groups , but no statistically significant difference was observed among them ( p>0.01 ) . the dentifrice containing aloe vera did not show any additional effect on plaque and gingivitis control compared to the fluoridated dentifrice .

sporadic cases reported since first described lennox et al 1952 we report additional case pmc skin 70-year old male presenting swelling lateral canthal region left eye review pertinent literature a 70-year old male noticed swelling near left canthus since one half years a raised freely mobile firm skin mass approximately 3.0 2.5 cm present lateral canthal region left eye gross examination revealed well circumscribed spherical soft tissue mass partially skin covered measuring 2 cm diameter the cut surface tumor gray brown gelatinous appearance figure 1 microscopically sections revealed tumor dermis composed tumor cells arranged nests glands cribriform patterns figure 2 the cells seen floating large pools mucin separated thin fibrovascular septa figure 3 figure 4 investigations including colonoscopy ultrasonographic examination abdomen computerized tomography ct scans chest abdomen pelvis found normal thus lesion skin reported pmc skin gross specimen revealing spherical well circumscribed tumor gelatinous cut surface tumor dermis composed cells arranged nests glands cribriform patterns floating mucin lakes h e 20 small nests adenocarcinoma lying pools extracellular mucin separated fibrocollagenous septae h e 40 photomicrograph showing pools pas positive diastase resistant mucin tumor nests pas stain 20 ) primary mucinous carcinoma skin pmcs rare adnexal neoplasm sweat gland differentiation this tumor first described lennox et al 1952 later designated mendoza helwig 1971 recently studied approximately 200 cases pmcs documented literature found mean annual age standardized incidence pmcs period 1978 2003 0.07 per million person years although debate exists apocrine eccrine origin tumor authors favor eccrine differentiation based evidence obtained immunohistochemical studies electron microscopic ultra structural analysis it suggested pmcs may develop progression abnormal apocrine eccrine ducts analogous progression seen mucinous carcinoma breast a ductal situ component occasionally seen ranging ductal hyperplasia frank carcinoma situ rosai originally suggested ductal proliferation continues overproduction mucin results islands tumor cells breaking floating mucinous pools primary mucinous carcinoma skin slightly common men women typically affects people age range 50 70 years the large majority specimens pmcs arise face especially eyelids scalp the primary lesion mesenchymal chondrosarcoma mcs often solitary history often small cutaneous lesion grows slowly many months years suddenly enlarges time it first brought medical attention neoplasm nodule varies diameter 0.7 8.0 cm mucinous carcinoma rarely originates skin majority examples skin actually metastatic common sites origin mucinous carcinomas breast gastrointestinal tract salivary glands lacrimal glands nose paranasal sinuses bronchi renal pelvis ovary metastatic lesions breast colon likely mimic mucinous carcinoma skin differentiating primary mucinous carcinoma metastatic tumors particularly sites the absence expression ck20 immunohistochemical staining may exclude diagnosis metastatic colorectal mucinous carcinoma it important recognize however likelihood mucinous carcinoma breast metastasizing skin much less face eyelid exceedingly low cases pmcs found estrogen receptor progesterone receptor gcdfp-15 positive qureshi et al suggest finding situ component tumor stains myoepithelial cells positive stains p63 ck5/6 among others help exclude metastatic mucinous breast carcinoma the distinction mcs mucinous carcinoma metastatic skin important prognosis mucinous carcinoma metastatic skin poorer mcs primary lesions differentiated metastatic lesions organized epithelial cells less hyperchromasia fewer mitoses individual cells in addition case metastatic carcinoma tumor cells invade collagen bundles margin nodule due difficulty distinguishing histologically thorough workup metastatic lesions no primary tumor detected breast digestive tract salivary glands lacrimal glands paranasal sinuses lungs kidneys primary mucinous carcinoma skin slow growing benign tumor high local recurrence rate treatment mucinous carcinoma entails local excision account high rate recurrence adequate excision generous margins other treatments chemotherapy radiation generally employed management tumors patients counseled importance frequent follow ups evaluation local tumor recurrence development regional lymphadenopathy

primary mucinous carcinoma of the skin is a rare adnexal tumor of sweat gland origin . a case report is presented of a 70-year - old male , who presented with a slow growing mass near the lateral canthus of his left eye . the case was clinically diagnosed as a fibroma . an excisional biopsy of the lesion revealed mucinous carcinoma of the skin . investigations excluded the possibility of metastatic mucinous carcinoma . thus , the lesion in the lateral canthus region was diagnosed as primary mucinous carcinoma of the skin , a rare site of occurrence .

incidental detection small renal masses increasing led increase biopsy small renal masses proportion which needle biopsy small renal masses controversial owing risk seeding malignant cells along needle tract needle tract seeding rare event incidence estimated less 1 10,000 cases biopsies eight cases needle tract seeding renal mass biopsy described medical literature two recently 2013 table 1 we report experience man renal cell carcinoma rcc seeding along biopsy tract compare circumstances biopsy techniques reported cases literature a 66-year old man incidentally found 32-mm right lower pole renal mass computed tomography ct scan fig two samples obtained use 16-gauge temno core biopsy needle carefusion san diego ca usa 22-gauge francine needle histopathology revealed well circumscribed 30-mm clear cell rcc predominantly fuhrman grade 2 focal areas grade 3 there area capsule interrupted corresponded hemorrhagic area cortical surface fig a tumor deposit also noted perinephric fat features suggested tumor deposit fat likely due tumor seeding rather metastasis tumor seeding could resulted needle biopsy his tnm staging pt3a nx mx least stage 3 disease american joint committee cancer 7th edition 2010 leibovich score 5 intermediate risk six months operation radiological evidence tumour recurrence ct scan aside potential false negative results key risk renal mass biopsy seeding biopsy tract malignant cells several factors theory could affect risk biopsy tract seeding needle size number needle passes use coaxial needle biopsy tract seeding reported renal mass biopsies using needles fine 23-gauge large 14-gauge theoretically larger bore needle would increase risk seeding owing increased area defect surface tumor increased circumference surface area needle however scarcity cases difficult stage accurately determine relationship needle size risk seeding it also difficult underreporting associate risk needle tract seeding number needle passes tumor use coaxial needle allows multiple passes renal mass one pass surrounding normal tissue this theoretically reduces risk needle tract seeding normal tissue potentially reduces patient discomfort well although interesting note coaxial needle used currently reported cases needle tract seeding renal mass biopsy table 1 cases establish firm relationship risk biopsy tract seeding use coaxial needle visualization larger coaxial needles ultrasound ct may easier smaller biopsy needles may improve accuracy histological evidence biopsy tract seeding may always found definitive surgery remove renal mass seeding excised perinephric tissues found soon surgery seeding surrounding muscle fascia skin may apparent months even years surgery seen case biopsy needle traversed skin subcutaneous tissue multiple muscle fascia layers perinephric fat reaching renal lesion fig thus tumor could theoretically seed one tissues seeding superficial subcutaneous tissue reported table 1 this delayed presentation may increase risk adverse outcomes metastasis poorer prognosis time presentation diagnosis tumor seeding renal mass biopsy ranged 24 days 84 months previously reported cases tumor seeding found initial histopathological analysis table 1 conclusion a common feature reported cases needle tract seeding renal mass biopsy coaxial needle used however paucity cases currently satisfactory association risk needle tract seeding needle size number needle passes it important consider histopathological evidence needle tract seeding may apparent cases especially seeding occurred beyond excised tissues

a 66-year - old man underwent computed tomography - guided needle biopsy of a suspicious renal mass . two months later he underwent partial nephrectomy . histology revealed a 30-mm clear cell renal cell carcinoma , up to fuhrman grade 3 . an area of the capsule was interrupted , which corresponded to a hemorrhagic area on the cortical surface . under microscopy , this area showed a tongue of tumor tissue protruding through the renal capsule . a tumor deposit was found in the perinephric fat . these features suggest that tumor seeding may have occurred during the needle biopsy .

despite ubiquity cell membranes little quantitative information effects small mole fractions cholesterol phase diagrams molecular organization surface viscosity mixtures phospholipids cholesterol understanding cholesterol effects altering local molecular organization rheology lipid monolayers may give clues mechanisms stabilize nanometer scale rafts complex lipid cholesterol mixtures raft hypothesis emerged recent years general organizing principle structure eukaryotic cell membranes rafts hypothesized result nanometer scale phase separation ordered viscous domains cholesterol saturated lipids membrane proteins preferentially accumulate surrounded sea less viscous unsaturated lipids greater protein diffusivity however fundamental physics underlying raft formation still developed especially interactions saturated phospholipids cholesterol determine membrane phase behavior viscosity diffusivity the interactions cholesterol saturated phospholipids also play important poorly understood role properties human lung surfactant ls lipid protein monolayer necessary reduce surface tension lung alveoli present even existence cholesterol native ls questioned lung lavage required harvest ls inevitably causes blood cell debris coextracted potentially contaminating ls cholesterol this lack consensus reflected composition replacement lung surfactants used treat neonatal respiratory distress syndrome nrds occurs 20 00030 000 premature infants year u.s survanta curosurf two clinically approved animal extract replacement surfactants treatment nrds cholesterol removed harvesting infasurf third clinically approved surfactant retains 4 5 wt cholesterol resolving this controversy difficult little information effects small cholesterol fractions organization dynamics phospholipid monolayers our previous work shown surface viscosity dipalmitoylphosphatidylcholine dppc monolayers decreases order magnitude per wt cholesterol 3 wt suggesting cholesterol containing infasurf would significantly different monolayer dynamics cholesterol free survanta curosurf interfacial viscosity believed significant effect monolayer collapse surfactant spreading breathing transport type ii epithelial cells surfactant produced alveolar air water interface interfacial viscosity may also important instillation replacement surfactant reopening bronchial airways however origin dramatic effect cholesterol dppc viscosity yet known cholesterol may also play role lung surfactant inactivation acute lung injury ali acute respiratory distress syndrome ards ards occurs rapid onset respiratory failure affects 150 000 people per year u.s mortality rate 3040% the pathogenesis ards fully understood ali ards surfactant inactivated primary pathogenesis lung inflammation trauma pulmonary infection near drowning etc the cholesterol content ards patients shows increase cholesterol content vitro cholesterol levels greater 10 mol increase minimum surface tension monolayer collapse may exacerbate lung damage grazing incidence x ray diffraction gixd shows 7 mol added cholesterol change basic alkane packing dppc decrease extent ordering coherence area suggesting increased number lattice defects we postulate free area available diffusive transport two dimensional analog classic cohen turnbull free volume model viscosity inversely proportional number molecules coherence area using relationship surface viscosity data surface pressures cholesterol fractions collapses simple logarithmic relation adjustable parameters this suggests decreased molecular ordering caused incompatibility cholesterol alkane chain lattice origin orders magnitude decrease surface viscosity 1,2-dipalmitoyl sn glycero-3-phosphocholine dppc r enantiomer dihydrocholesterol avanti alabaster al 0.1 wt texas red dhpe n-(texas red sulfonyl)-1,2-dihexadecanoyl sn glycero-3-phosphoethanolamine invitrogen grand island ny mixed appropriate ratios diluted 0.2 mg ml hplc grade chloroform fisher scientific st dihydrocholesterol chol used instead cholesterol minimize oxidation little impact phase behavior surface pressure area isotherms recorded 25 c using teflon trough nima coventry england custom designed stainless steel ribbons reduce film leakage high surface pressures a filter paper wilhelmy plate riegler kirstein gmbh potsdam germany used measure surface pressure the open area trough used 125 cm complete compression expansion cycle took 8 min 0.42 cm for fluorescence imaging langmuir trough mounted nikon optiphot optical microscope custom designed stage equipped long working distance objectives designed fluorescent light a dichroic mirror barrier filter assembly directed excitation light onto monolayer films normal angle incidence filtered emitted light images detected silicon intensified ccd camera videos monolayer film recorded compression expansion cycle directly onto computer using pinnacle studio capture software the continuous fluid lipid phase appears bright due preferential segregation texas red dye better ordered domains exclude dye molecules appear dark two dimensional gixd experiments carried chemmatcars station beamline 15-id advanced photon source argonne national laboratory dppc chol appropriate ratios dissolved chloroform solution 1 mg ml spread dropwise onto air deionized water interface custom langmuir trough temperature controlled 22 c. waiting 30 min solvent evaporation monolayers compressed desired surface pressure 20 30 40 mn annealed additional 30 min the trough enclosed helium filled chamber oxygen level constantly monitored exposure x ray beam the analysis gixd data two dimensional films air water interface follows kaganer et al well established bragg peaks correspond ordering within alkane chains lipid tailgroups organization headgroups inferred changes tailgroup lattice response changes surface pressure cholesterol fraction circular ferromagnetic probes microbuttons diameter 20 thickness 1 button holes diameter 3.5 fabricated photolithography uniform magnetic field magnitude b orientation generated output two independent pairs electromagnets controlled custom labview code exert controlled torque l microbutton moment orientation measure frequency dependent linear viscoelastic response sinusoidal magnetic field applied generate time varying applied torque the microbutton orientation determined bright field images holes microbuttons function applied torque determine rotational resistance rotational resistance linear viscoelastic surface moduli obtained solution hydrodynamic problem rotating cylinder within viscoelastic monolayer atop viscous subphase terms measured experimental properties surface loss modulus g phase component rotational resistance surface storage modulus g phase component conventional 3-d rheology figure 6b surface viscosity newtonian response observed frequency range 0.110 hz g/ 1 hz frequency used figure 6 g/2. exponential dependence surface viscosity surface pressure obtained using 100 probe showing continuum values elasticity viscosity measured the 100 probe order magnitude larger domain sizes seen figures 5 6 recent results using macroscopic wire rings 10 cm diameter ring 0.7 mm diameter wires showed identical trends surface pressure good agreement similar monolayers maximum surface viscosity could measure our rheometer 100 pams surface viscosity pure dppc 40 mn greater measured freshly cleaved mica substrates s&j trading inc glen oaks ny connected computer controlled dipping mechanism commercial circular nima l b trough biolin scientific inc linthicum heights md pulled monolayer 5 mm min constant surface pressure 20 mn transfer ratios determined recording interfacial area change trough transfer comparing surface area mica substrate transfer ratio 1 means areas equal films transfer ratios 1 examined the mica substrates glued stainless steel discs affixed magnetic holder mmafm-2 afm digital instruments santa barbara ca cantilever tip asylum research ac160ts santa barbara ca designed tapping mode operation two dimensional gixd carried chemmatcars sector 15-id advanced photon source argonne national laboratory dppc monolayers various mole fractions dihydrocholesterol chol figure 1 shows gixd intensity maps pure dppc 20 mn b 6.4 mol chol dppc monolayers 40 mn figure 2 shows qz integrated intensity profiles arbitrary units dppc chol monolayers 20 30 40 mn 0 7 mol chol spectra offset 1000 two dimensional x ray maps pure dppc 20 mn b 6.4 mol chol dppc 40 mn two bragg reflections visible degenerate reflection positive qz lower qxy higher qxy qz 0 indicating nearest neighbor tilt the peak remains location cholesterol surface pressures dotted lines the basic motif dppc lattice unchanged cholesterol although tilt reduced increasing cholesterol cholesterol broadens peaks consistent decrease size correlated areas monolayer we assign bragg peak figure 1 lower qxy positive qz due degenerate 11 11 reflections distorted hexagonal packing second peak higher qxy qz 0 due nondegenerate 02 reflection as 11 reflection located qz 0 02 reflection centered qz 0 alkane chains tilted nearest neighbor nn direction regardless composition surface pressure ordered areas monolayers distorted hexagonal packing nn tilt figure 3b inset ( d11 b d02 function cholesterol surface pressure d11 decreases increasing surface pressure cholesterol fraction this consistent decrease tilt decreases d11 alkane chain packing normal chain axis hence d02 remains one gray one white circle two alkane chains rectangular unit cell dimensions b. translation pair gray white circles and/or b generates lattice the spacing dotted lines corresponds spacings table 2 b. qz integrated intensity profiles figure 2 show 11 bragg peak broadens moves higher qxy increasing cholesterol content dotted lines surface pressures 02 peak also broadens increasing cholesterol content remains constant qxy qij values table 1 the real space lattice dimensions dij 2/qij table 2 figure 3 the tilt angle nearest neighbor tilt given tan qz[q112 q02/2 the coherence length determined full width half maximum fwhmij peak correction instrumental resolution lij 0.92)/(fwhmij table 2 q02 q11 lattice parameters fourier space two strong reflections qz averaged data all spacings referenced two molecule rectangular unit cell d10 d112 2d02 b 2d02= d01 see inset figure 3b the error larger b 11 reflection much broader 02 reflection see figure 2 tilt angle alkane chains degrees respect water surface tan qz[q112 (q02/2 table 1 see inset figure 3b the chain area cross sectional area chains direction perpendicular chains ab cos )/2 l02 l11 coherence lengths 02 11 directions lij 0.92)/(fwhmij figure 3a shows fixed surface pressure adding chol decreases d11 figure 3b shows d02 remains constant pure dppc d11 decreases 4.79 4.58 surface pressure increases 20 40 mn d02 constant 4.30 table 1 cholesterol surface pressure influence lattice similar way linear relationship d11 tilt angle holds range surface pressures cholesterol fractions examined figure 4 decreases increasing surface pressure scatter increasing cholesterol fraction 35 pure dppc 20 mn 18 7 mol chol 40 mn this change tilt causes decrease area per dppc molecule air water interface 49.9 1 43.9 1 molecular tilt angle measured monolayer normal decreases manner increasing cholesterol fraction increasing surface pressure range sin tilt tilt convert degrees tilt 180(tilt/ black symbols 20 mn surface pressure open symbols 30 mn gray symbols 40 mn scatter tilt decreases increasing cholesterol fraction this linear relationship d11 changes cholesterol fraction surface pressure suggests local alkane packing dppc change added cholesterol surface pressure cholesterol act decrease mismatch lipid headgroup tailgroup area way values table 2 determine rectangular two molecule unit cell dimensions d10 d112 2d02 b 2d02 d01 figure 3b inset decreasing 5.8 0.1 20 mn 5.4 0.1 40 mn b remains constant 8.6 0.05 these unit cell dimensions consistent hexagonal packing alkane chains tilted accommodate mismatch projected area dppc headgroup close packed chains as case lipids accommodation larger dppc headgroup area occurs dilation alkane chain area via increase tilt angle tilt costs little favorable alkane chain contact energy tilt occurs without changing distances alkane chains tilt nn direction causes measured plane monolayer increase however b remains constant spacing change tilt alkane chains retain close packed configuration increasing surface pressure provides uniform compression dppc headgroup results decrease headgroup chain incompatibility hence tilt without altering alkane chain packing the area per alkane chain perpendicular alkane chains 20.5 0.3 ab cos )/2 constant within experimental error surface pressures also cholesterol fractions pure chol untilted hexagonal lattice spacing 5.7 area per molecule 35 much larger 20.5 area per alkane chain measure the invariance d02 b linear relationship d11 consistent bulk chol intercalating uniformly dppc lattice higher mole fractions separating primarily second phase figure 5 shows afm images dppc chol monolayers transferred mica substrates 20 mn showing two distinct morphologies 0.8 mol chol dark gray 10100 nm circular areas dispersed extended light gray domains the dark gray nanodomains localize preferentially boundaries light gray domains arrows increasing chol fraction causes circular nanodomains percolate linear structures 3.7 mol although width linear structures remains 10100 nm linear structures eventually break light gray domains 5 mol afm force spectroscopy showed nanodomains compliant easier deform dppc domains suggesting nanodomains disordered contribute gixd signature monolayer the alkane chains dppc prefer untilted maximize van der waals contact chains frustrated conflicting cross sectional area requirements phosphocholine headgroup this mismatch requires tailgroup lattice dilate responds lower energy tilt deformation order fill space efficiently however chol complementary shape dppc relatively small alcohol headgroup relatively large sterol ring tailgroup hence shape complementarity suggests chol relieve packing frustration dppc making mismatch headgroups alkane chains palmitic acid pa hexadecanol hd also complementary shapes dppc also lead decreased tilt given surface pressure show nanodomains afm images hd c16 alkane chain dppc allows pa hd incorporated dppc lattice pa hd increase correlation length mixed crystal surface viscosity tapping mode afm images dppc cholesterol monolayers transferred langmuir blodgett deposition mica substrates 20 mn for 0.8 mol cholesterol dispersed circular 10100 nanodomains appear darker gray indicates compliant relative lighter gray background phase preferentially locate boundaries light gray domains arrows 3.7 mol chol the circular nanodomains condensed linear features begin break light gray domains light gray domains remain continuous 5.0 mol % chol nanodomains make cocontinuous network separating light gray domains decreasing size light gray domains 100200 nm fluorescence images dppc monolayers 0.0 0.2 0.4 mol cholesterol coexistence disordered le light ordered lc dark phases 10 mn contrast due doping monolayer 0.1 wt fluorescent n-(texas red sulfonyl)-1,2-dihexadecanoyl sn glycero-3-phosphoethanolamine invitrogen segregates fluid le phase the domain width decreases increasing cholesterol indicative decrease line tension although shape cholesterol relieve frustration area headgroup alkane chains dppc sterol rings efficiently pack alkane chain lattice this leads second type frustration decrease tilt due accommodation area mismatch results disrupting alkane chain lattice likely higher energy decreasing tilt the combination sterol rings chol disordered dppc chains gives nanodomain phase excess tailgroup area may relieve part packing frustration headgroups adjacent ordered dppc domains albeit longer range cholesterol intercalated within dppc lattice the size domains typical phase separated monolayers governed competition line tension leads larger domains entropy electrostatic interactions favor smaller domains fluorescence images figure 6 coexistence surface pressure 910 mn show increasing chol leads dramatic decrease width domains means large decrease decrease may sufficient stabilize nanodomains coalescence an additional factor stabilizing nanodomains may energy reducing tilt adjacent dppc domains the time diffusive mixing nanodomains bulk order seconds 100 nm length scales nanodomains even electrostatic interactions slowing bulk coalescence molecular diffusion eliminate nanodomains minutes structure stable this stability may also indication seeing example recently proposed 2-d analogs 3-d microemulsions compositional variations within single phase due coupling monolayer curvature i.e. incompatible area requirements headgroups tails composition evolution structure discrete circular nanodomains analogous spherical micelles 3-d extended linear structures rod like micelles interconnected network bicontinuous microemulsion suggests possibility figure 7a shows coherence length l02 untilted direction pure dppc 70 lattice repeats 300 five times tilted direction l11 60 12 lattice repeats table 2 20 30 mn m l02 decreases monotonically increasing cholesterol fraction 20 lattice repeats l11 decreases 10 lattice repeats 40 mn l02 monotonically decrease cholesterol fraction scatter l02 much greater lower surface pressures l02 always less expected results lower surface pressures this likely due decrease film stability caused combination leakage trough barriers slow monolayer collapse 3 5 h required gixd the afm images figure 5 show average dppc light gray domain size decreases microns 100200 nm cholesterol even decreasing domain size positional ordering given coherence lengths orders magnitude smaller domain size given cholesterol fraction however orientational order extends tens microns shown spiral domain textures figure 6 dppc chol monolayers nanometer range positional order micron range orientational order similar tilted smectic c liquid crystals langmuir films classified hexatics ( coherence lengths l11 11 tilt direction l02 02 untilted direction normalized respective lattice constants d11 d02 l02 decreases significantly cholesterol fraction less affected surface pressure l02 40 mn scatter nonmonotonic cholesterol fraction likely result film instabilities due trough leakage monolayer collapse higher surface pressure ( b surface viscosity dppc chol monolayers measured microbutton magnetic rheometer decreases exponentially cholesterol fraction given surface pressure small mole fractions cholesterol plateaus fashion l02 ( surface viscosity pure dppc 40 mn high viscometer measure c free area model dppc chol monolayers eqs 6 8 provides excellent correlation surface viscosity number correlated molecules l02l11)/ab entire range cholesterol fraction the lines linear regression fits eq 7 data p 0.01 ( normalizing reference state taken pure dppc 20 30 mn 0.4% chol 40 mn surface pressures collapses data onto single universal curve relating surface viscosity molecular organization the line linear regression fit eq 8 data p .001 showing data well described free area model figure 7b shows surface viscosity dppc chol monolayers decreases exponentially increasing cholesterol fraction given surface pressure previous work found exponential dependence surface viscosity surface pressure well correlated free area the free volume model developed explain divergence viscosity liquid glass transition the premise underlying model order diffuse molecule liquid condensed phase sufficient free volume , volume occupied molecules order escape cage formed neighboring molecules each molecule minimum van der waals volume v0 moves randomly thermal velocity u within confining cages diameter d0 defined nearest neighbors cohen turnbull calculated probability fluctuations free volume relative average free volume v. local fluctuation free volume exceeds v0 hole created confining cage sufficiently large allow diffusional jump solute molecule hole diffusion occurs another molecule fills hole left solute molecule original molecule returns starting position the probability p(v0 free volume vf rearranges give void volume v0 large enough molecule diffuse constant energy given by1thus giving diffusivity2 g geometric factor the parameter b eqs 1 2 take account overlaps free volume cohen turnbull suggest range 1/2 b 1 three dimensions diffusivity related bulk viscosity via generalized stokes einstein relationship kt f for spherical particles friction factor f given stokes drag sphere diameter f 3a this leads free volume model viscosity:3 applications model free volume difference measured volume per molecule v v0 vf v v0 applications model v0 fitting parameter theoretically v0 related volume per molecule glass transition viscosity diverges 2-dimensional film constant thickness l:4 analogy free volume af( ) a0 a( area per molecule determined surface pressure surface pressure area isotherm a0 taken fitting parameter 2-dimensions diffusivity free area related surface viscosity via saffmann delbrck model cylinder diffusing within viscous monolayer surrounded viscous subphase give equation analogous eq 3 terms free area:5from fitting dppc viscosity data found a0 40 roughly equal ab cos molecular area dppc molecule close packed untilted lattice table 2 however cohen turnbull speculate molecular origins af(19 modeling unstructured liquid however semicrystalline monolayers postulate free area proportional number defects lattice inversely proportional number correlated molecules composition surface pressure:6 lattice defects dislocations vacancies grain boundaries decorrelate lattice creates free area pathways diffusion we define free area number defects times area per defect per number correlated molecules take constant independent concentration combining eqs 5 and 6:7 ba0/. linear regression eq 7 figure 7c shows 20 30 40 mn slopes 0.0134 0.0007 0.0131 0.002 0.0196 0.007 within experimental error s0( 20 mn 0.09 0.02 s0( 30 mn 0.37 0.2 s0( 40 mn 0.6 0.5 pms although physical significance surface pressure variation s0 given model pearson correlation coefficient r three lines 0.99 0.95 0.81 respectively giving statistically significant fit eq 7 data p 0.001 0.001 0.05 respectively better compare data different surface pressures surface viscosity correlated area normalized relative reference composition xref :8ref(xref, surface viscosity l02l11)/ab)ref number molecules coherence area xref taken pure dppc 20 30 mn 0.4% chol 40 mn linear regression eq 8 gives 0.0133 0.007 fits eq 7 the pearson correlation coefficient 0.91 giving p 0.001 showing eq 8 gives statistically significant representation surface viscosity almost three orders magnitude change surface viscosity figure 7b for a0 40 1500 b 1/2 3000 b 1 pure dppc l02l11)/ab 450 giving af 36 eq 6 consistent variation area per molecule a(x, a0 af(x, measured dppc isotherms adding cholesterol decreases l02l11)/ab 100 thereby increasing free area per molecule 1530 resulting dramatic decrease surface viscosity these values af agreement assumptions behind cohen turnbull free volume theory postulates vf v0 hence af a0 in summary gixd shows increasing chol fraction constant surface pressure increasing surface pressure constant chol fraction decreases tilt dppc lattice leaving alkane chains close packed invariant area per molecule normal alkane chain direction this confirms afm images show cholesterol intercalate homogeneously dppc lattice expelled disordered nanodomains break dppc domains the nanodomains evolve isolated circular 10100 nm diameter domains 1050 nm wide linear nanodomain aggregates interconnected network structure increasing cholesterol however monolayer homogeneous micron scale optical images macroscopic phase separation occur lower surface pressure figure 6 hence dppc cholesterol monolayer better described nanostructured single phase monolayer rather mixture two distinct phases similar recently proposed two dimensional microemulsions system analogous 3-d nanostructured surfactant oil water bicontinuous microemulsions copolymer systems separate nanometer scale regions enriched one monomer considered single phase adding cholesterol change local hexagonal dppc chain packing reduce molecular tilt suggesting cholesterol relieves packing frustration dppc headgroup tailgroups most important monolayer dynamics extent order number correlated molecules decreases increasing cholesterol fraction surface pressures suggesting increased number lattice defects create free area visco diffusive transport cholesterol fractions the positional order much shorter ranged orientational order consistent overall hexatic organization we show simple model proposes free area available visco diffusive transport inversely proportional number correlated molecules collapses surface viscosity data surface pressures cholesterol fractions onto single universal curve molecular defects associated decrease domain size caused incompatibility cholesterol packing alkane chain lattice enhance visco diffusive transport monolayers model data show extent molecular correlations excellent predictor effects cholesterol surface viscosity model lung surfactant monolayers

adding small fractions of cholesterol decreases the interfacial viscosity of dipalmitoylphosphatidylcholine ( dppc ) monolayers by an order of magnitude per wt % . grazing incidence x - ray diffraction shows that cholesterol at these small fractions does not mix ideally with dppc but rather induces nanophase separated structures of an ordered , primarily dppc phase bordered by a line - active , disordered , mixed dppc - cholesterol phase . we propose that the free area in the classic cohen and turnbull model of viscosity is inversely proportional to the number of molecules in the coherence area , or product of the two coherence lengths . cholesterol significantly reduces the coherence area of the crystals as well as the interfacial viscosity . using this free area collapses the surface viscosity data for all surface pressures and cholesterol fractions to a universal logarithmic relation . the extent of molecular coherence appears to be a fundamental factor in determining surface viscosity in ordered monolayers .

pollution predicated tiny particles air produced due human natural activities 1 since centralization human activities is associated metabolic human interactions urban areas different pollutants enter air easily cause urban environment vulnerable 2 it world health organization 1992 addressed air pollution serious problem 3 improper use fuel inappropriate topography tehran caused air pollution due entrance approximately 1.5 million tons pollutants annually hence combination natural artificial factorscauses tehran one polluted cities inthe world standing mexico city beijing cairo sao paulo shanghai jakarta bangkok 4 air pollution also caused painful events around world pollution event meuse 1930 63 people experienced respiratory problems death 400 people london due contaminated thick smog 1952 two examples irrecoverable events 1 accor ding environmental program united nations 48 premature deaths due exposure particulate matter outdoor indoor environments potentially 500000 excess deaths annually due particulate matter outdoor situations 5 likewise air quality control agency report indicates 4500 people dying every year tehran due air pollution 6 important sources air pollution divided four key groups including overcrowding 7 economic growth 8) natural factors exp geographical situation topography temperature inversion etc.)(9 mobile stationary sources exp non standards poor fuel consumption motor vehicles industries around city home heating cooling systems 1 10 depending type sources pollutants metropolises around world took different measures control air pollution among developing countries south africa benefited collection best legal solutions order reduce air pollution among objective standard setting status quo assessment priority area delineation control strategy preparation implementation 11 china developed country also taken effective measures control air pollution including integrated monitoring program acidification chinese terrestrial systems impacts permanent control vehicles emissions increasing quality fuels taking advantage new technologies developing transportation systems providing five year plans understand causes sources pollution current status effects control acid rain 1216 italy special measures taken energy management industry transportation systems domestic systems 17 economic industry growth plus overcrowding india caused city planners take serious measures including banning polluting vehicles developing roads escalating standards regulations enforcement etc just successful decline air pollution others failed effectively efficiently control air pollution south africa despite numerous plans policies controlling air pollution failed due major challenges lack relationship district local municipalities lack relationship provincial local authorities plan integration public roles technical capabilities programs extending partial focus polluter sources lack systemic approach air pollution planning plans climate change management shortage funding etc.(11 improper prioritization environmental intervention lack funding unwillingness countries plan systemic approach lack enforcement poor communication public private sectors principal factors causing failure successfully control air pollution 1821 1334 lots case cross sectional plans programs projects developed individually part national document control air pollution tehran they including first five year development plan 19881993 clean air plan 1995 transportation emission reduction project 1997 comprehensive plan tehran combating air pollution 1997 second five year development plan 19962000 third five year development plan 20012005 20 year visionary plan 2005 forth five year development plan 20062010 tehran master plan 2007 fifth five year development plan 20112015 master plan metropolises combating air pollution 2011 22 despite fact plans precisely codified present evidence implies expected results based reducing air pollution met due lack integrated stewardship responsible regulating coordinating monitoring process gained results air pollution control plans 23 hence necessary analyze air pollution controlling plans pathologic approach identify set practical solutions tehran this paper bears twofold purpose first pathologically analyze air pollution control plans tehran viewpoint experts secondly offer appropriate effective solutions controlling air pollution a descriptive case study method used 2012 pathologic analysis air pollution control plans order offer solutions tehran metropolis capital city iran the research team provided semi comprehensive review literature contained 70 articles different metropolises around world developing initial conceptual framework springboard developing interview questions the scope review limited developed developing metropolises china italy india south africa faced air pollution difficulties tehran developing framework a qualitative content analysis drawn identify manifest latent contents relating different air pollutants plans control the key contents around interview questions organized consists 1 causes sources air pollution 2 challenges obstacles towards effective performance air pollution control plans 3 effective controlling solutions air pollution metropolitan areas a semi structured face face interview done survey tehran air pollution control plans aspects mentioned the participants chosen snow balling sampling according context work practicing professionals tehran tarbiyat modarres shahid beheshti university professors the interviews continued saturation data information gathered interviewing 80% data repeated experts 14 experts professors managers interviews practical applied data analysis the context interview consists extent air pollution control plans iran appropriate ways cope air pollutants different sectors industry transportation systems domestic system regard metropolises experience field in addition asked provide information relevant issues possible as interview sessions precede quality relevancy comprehensiveness questions developed simultaneously all opinions meaning units reviewed condensed labeled code back forth movement whole part interview texts then codes meaning grouped together higher order heading create categories 27 sub categories 8 categories way group codes dealt specific issue content area next primitive title content categories sub categories discussed article research team finally underlying meanings latent contents categories formulated four main themes the analysis results 14 viewpoints practicing professionals categorized four main themes the first theme demonstrated table 1 causes sources air pollution tehran metropolis depicted table vital sources air pollution corresponds process policy making lack attention environmental changes topogherafic status tehran pollutant due mobile stationary sources matter improper energy management the second theme demonstrated table 2 challenges obstacles towards effective performance air pollution control plans tehran metropolis causes sources air pollution tehran metropolis challenges obstacles towards effective performance air pollution control plans tehran metropolis shown important challenges tehran air pollution management focused nine areas abstracted two wider categories including firstly air pollution stewardship challenges secondly environmental political economic social technical challenges some factors lack information evidence base decision making poor vertical horizontal coordination among urban developmental goals plans improper funding follo wing unfit pattern mores categorized stewardship challenges hand political intervention plans provision performance sanctions iran unaffordability families exchange non standard cars new ones identified environmental challenges presented table 2 detail order demonstrate challenges importance amount repetitions accounted shown table 3 percentage third theme demonstrated table 4 effective controlling solutions air pollution metropolitan areas regard fact air pollution one national planning priorities metropolitan areas the effective controlling solutions air pollution world forth theme demonstrated table 5 effective controlling alternatives air pollution tehran metropolis broken two main categories first technical infrastructural factors managerial administrative factors planning based reliable evidences involving responsible key stakeholders planning process developing parks green sites monitoring amount type different pollutant air help new technology fair distribution facilities development non individual based planning considering implementation monitoring capacities contemporary planning improving mutual understanding communication among authorities citizens considering revision loops plan developing environmental standards mores categorized technical infrastructural factors furthermore improving cooperative mutual communications among education deputy tehran municipality authorities forculturalization informing developing public participation capacities categorized managerial administrative factors tables 5 alternatives suites tehran status mentioned interviewees order estimate alternatives importance amount repetitions accounted shown table 6 percentage the effective controlling alternatives air pollution tehran metropolis priorities effective controlling alternatives air pollution tehran metropolis our findings confirm tehran air pollution due five major reasons including improper policy making attention pollutants changes geographical situation mobile stationary sources nonstandard energy production paying inadequate incoherent attention sources pollution caused authorities face important challenges including could due unique organized stewardship course challenges could due environmental changes controllable air pollution management authorities metropolises confront challenges authorities implement different plans order manage air pollution some best effective controlling solutions focused culturalization infrastructural development public transportation 16 applying economical control levers china 13 utilizing participatory capacities strategic planning south africa 11 applying solar battery produce clean energy italy 24 identifying emission limits automobiles industry india 3 iran metropolises several plans prepared implemented unfortunately thanks challenges mentioned failed control tehran air pollution expected achieved plans solve challenges improve quality effectiveness controlling air pollution plans should name paying attention matter stewardship field air pollution management cultural infrastructural development focusing effective management system systematic studies planning words systematizing plan preparation process standardization fuel energy production consumption enhancing public participation capacity developing appropriate coordination controlling mechanism realization social justice capacity evaluation regional scope standardizing utilizing new technologies professional experts stopping manufacture low quality automobiles reducing import tariff high quality ones applying economical control levers making transparency deaths statistic due air pollution providing environment organization box centralize polluting industries penalties legitimizing air pollution control plans enhance implementation guarantee 22 our findings air pollution control plans challenges replicate finding survey controlling air pollution plans south africa conducted niaiker et al ( 11 viewpoint niaiker poor standards regulations support plans implementation poor cooperation among stakeholders key authorities planners policymakers citizens etc poor resource generation poor attention type source pollution important challenges caused failure control plans also asadollah 23 mentions poor disorganized stewardship key factor leads failure tehran air pollution control plan furthermore finding controlling alternatives tehran air pollution similar findings survey subject metropolis 19 he believed developing appropriate evaluation monitoring mechanism enforce different responsible authorities evaluate performance realization social justice improving participation capacities success factors plan implementation these finding help tehran authorities look plan preparation process new approach would practical every developing large cities confronting problems words authorities positively benefit viewpoints practicing professionals consider plan deficiencies unlike aspects diverse levels initials advanced studies requirements plan preparation plans implementation we considered important challenges tehran air pollution control plans order offer effective controlling solutions further researches done determine priority offered solutions accordance tehran facilities requirements controlling air pollution tehran needs serious attention policymakers make effectual enforcement applying systemic cycle preparation revising effective comprehensive plans implementing enforcement evaluating environmental impact plans involving stakeholders ethical issues including plagiarism informed consent misconduct data fabrication and/or falsification double publication and/or submission redundancy etc completely observed authors

abstractbackgroundthe centralization of human activities is associated with different pollutants which enter into environment easily and cause the urban environment more vulnerable . regarding the importance of air pollution issue for tehran metropolis , many plans and regulations have been developed . however , most of them failed to decline the pollution . the purpose of this study was to pathologically analyze air - pollution control plans to offer effective solutions for tehran metropolis.methodsa qualitative content analysis in addition to a semi - structured interview with 14 practicing professional were used to identify 1 ) key sources of tehran s air pollution , 2 ) recognize challenges towards effective performance of pertinent plans and 3 ) , offer effective solutions.resultsrelated challenges to air - pollution control plans can be divided into two major categories including lack of integrated and organized stewardship and pest challenges.conclusionfor controlling the air pollution of tehran effectively , various controlling alternatives were identified as systematization of plan preparation process , standardization and utilization of new technologies & experts , infrastructural development , realization of social justice , developing coordination mechanisms , improving citizens participatory capacity and focusing on effective management of fuel and energy.controlling air pollution in tehran needs a serious attention of policymakers to make enforcements through applying a systemic cycle of preparation comprehensive plans . further , implement the enforcements and evaluate the environmental impact of the plans through involving all stakeholders .

syndrome named french neurosurgeon octave crouzon described rare genetic disorder first time 1912 although encountered rarely crouzon syndrome constitutes almost 5% craniosynostoses approximate birth prevalance 1/25,000 1/50,000 the syndrome characterized abnormal head shape midfacial hypoplasia maxillary hypoplasia mandibular prognathism ocular hypertelorism proptosis airway obstruction due premature fusion multiple calvarial skull base sutures within first year life however clinical picture may vary greatly mild severe midfacial orbital anomalies the relationship craniosynostosis chiari malformation type cm well documented cm tendency accompany syndromic craniosynostosis commonly sporadic synostosis the incidence cm crouzon syndrome 70% herein present 16-year old boy admitted symptoms related cm underwent suboccipital decompression however physical examination cruzonoid features drawed attention a 16-year old formerly healthy boy admitted outpatient clinic occasional headache neck pain physical examination it remarked characteristic features syndromic craniosynostoses hypertelorism proptosis midfacial hypoplasia abnormal head shape figures 1a b however patient family admit hospital reason despite prominent cruzonoid features the patients neurological examination revealed abnormalities including pinprick touch pain temperature sensations upper extremities anteroposterior ap lateral plain radiographs head cranial computed tomography ct demonstrated midfacial orbital hypoplasia fusion bilateral coronal lambdoid sutures sagittal suture alongside increase ap diameter head figures 2a b cranial spinal magnetic resonance imaging mri studies obtained showed 18 mm cerebellar tonsil herniation foramen magnum accompanying syringomyelia th 4 th 7 figure 3 surgery planned order decompress posterior cranial fossa using median incision the dura opened form arachnoid dissection duraplasty performed there significant events postoperative course patient discharged hospital neurological deficits the patient referred genetics department evaluation craniosynostosis phenotypical features like typical dismorphic facies ocular proptozis hypertelorism parrot like nose frontal bossing alongside patients mothers history four recurrent intrauterine fetal losses supported diagnosis crouzon syndrome patient regular follow examinations scheduled observation orbital deformities vision control mri showed complete resolution tonsillar herniation significant reducement syringomyelia length thickness figures 4a b four years operation patient still well neurological ocular deficits relief symptoms admission b photographs show characteristic features syndromic craniosynostoses patient hypertelorism proptosis midfacial hypoplasia abnormal head shape ( published permission informed consent patient anteroposterior ap lateral plain radiographs head shows increase ap diameter head midfacial orbital hypoplasia fusion multiple calvarial sutures also remerkable b axial cranial computed tomography scan demonstrated abnormal head shape fusion bilateral coronal lambdoid sutures alongside sagittal suture sagittal t2-weighted magnetic resonance imaging shows 18 mm cerebellar tonsil herniation foramen magnum accompanying syringomyelia th 4 th 7 largest thickness 11 mm sagittal t2-weighted mri craniocervical junction showed complete resolution 18 mm cerebellar tonsil herniation b sagittal t2-weighted thoracal mri showed relative resolution accompanying syringomyelia th 4 th 7 largest thickness 7 mm the premature fusion cerebral sutures postulated mechanism leading development cm patients syndromic craniosynostosis especially premature fusion lambdoid suture accepted crucial developmental anomaly results relatively small posterior fossa cinalli et al reported cm present 70% patients crouzon syndrome contrary they proposed relationship due earlier closure sagittal lambdoid sutures crouzon syndrome compared apert syndrome hydrocephalus jugular venous stenosis leads venous hypertension associated brain malformations postulated mechanisms leading cm development mutations three four fibroblast growth factor receptor fgfr genes demonstrated responsible various types syndromic craniosynostoses including crouzon syndrome fujisawa et al demonstrated missense mutation fgfr2 gene tyr281cys responsible development cm patients crouzon syndrome patient family never attempted seek professional medical help the syndrome diagnosed patient admitted department symptoms cm strahle et al presented series patients cm associated craniosynostosis series 29 patients however mean age whole patient group 1.8 years range 2 months-9 years this data shows craniosynostosis craniosynostosis related cm expected diagnosed early childhood cm could diagnosed craniosynostosis instances age patient diagnosis 16 knowledge case report indicating late adolescent diagnosis crouzon syndrome clinical symptoms associated cm i surgical approach craniosynostosis related cm may include cranial vault remodeling adequate posterior fossa decompression however neurosurgeons agree conservative follow patients cm unless symptomatic associated spinal syringomyelia strahle et al reported patients cm resolved regressed cranial vault remodeling without posterior fossa decompression consider cranial vault remodeling option instead applied classical posterior fossa decompression cm strahle et al underlined risk venous bleeding due abnormal venous sinuses increased venous hypertension therefore suggested posterior fossa decompression without dural opening c1 arcusectomy we encounter venous bleeding surgery opened dura performed duraplasty pediatric patients cm carefully examined clinical signs features crouzon syndrome syndromic craniosynostosis mild clinical forms case late diagnosis posterior fossa decompression without cranial remodeling kept mind treatment option

chiari malformation type i ( cm - i ) related to syndromic craniosynostosis in pediatric patients has been well - studied . the surgical management consists of cranial vault remodeling with or without posterior fossa decompression . there were also cases , in whom cm - i was diagnosed prior to the craniosynostosis in early childhood . we present a 16-year - old boy who admitted with symptoms related to cm - i . with careful examination and further genetic investigations , a diagnosis of crouzon syndrome was made , of which the patient and his family was unaware before . the patient underwent surgery for posterior fossa decompression and followed - up for crouzon 's syndrome . to our knowledge , this is the only case report indicating a late adolescent diagnosis of crouzon syndrome through clinical symptoms of an associated cm - i .

permanent postoperative hypoparathyroidism results unintentional removal injury parathyroid glands thyroid parathyroid surgery permanent hypoparathyroidism defined persistent hypocalcemia requiring calcium vitamin supplementation 6 months surgery the risk nominal minimally invasive parathyroidectomy single adenoma greatest subtotal total parathyroidectomy thyroid resection nodal dissection large extensive thyroid cancers reoperative neck operations even though risk transient hypocalcemia high extensive neck dissection permanent hypoparathyroidism rate typically around 1% hands experienced endocrine surgeons high volume centers the accidental onset permanent hypoparathyroidism agonizing patient clinician alike patient negative impact includes reduced quality life expensive lifelong medication supplementation frequent laboratory testing potential frequent hospital admissions in addition persistent absence parathyroid hormone pth long term systemic effects body development osteoporosis due decreased function osteocytes premature cataracts cardiac dysfunction neurologic dysfunction 1 2 late 1960s 1970s several new techniques introduced attempt prevent detrimental health social consequences permanent hypoparathyroidism for example intraoperative autotransplantation parathyroid tissue sternocleidomastoid muscle brachioradialis muscle recommended however patients risk permanent hypoparathyroidism actually develop patients require immediate autotransplant in fact unnecessary autotransplant performed parathyroid surgery could result persistent hyperparathyroidism additionally autograft could become autonomously hyperfunctional posing diagnostic treatment dilemma future wells et al overcame limitation transformed approach prevent hypoparathyroidism introducing autotransplantation cryopreserved parathyroid tissue cryopreservation permits parathyroid tissue stored potential reimplantation thereby avoiding risk needlessly implanting parathyroid tissue initial surgery the clinician able accurately determine whether residual parathyroid tissue recover function whether delayed autotransplant needed the disadvantages cryopreservation parathyroid tissue include potential graft failure risk graft dependent hypercalcemia this paper provides date comprehensive review cryopreservation parathyroid tissue current role thyroid parathyroid surgery the clear indication autotransplant cryopreserved parathyroid tissue permanent postoperative hypoparathyroidism hands experienced endocrine surgeons the risk particularly low patients sporadic primary hyperparathyroidism phpt single parathyroid adenoma nonetheless certain patients higher risk developing permanent hypoparathyroidism initial neck surgery table 1 most commonly risk patients multigland parathyroid hyperplasia especially familial primary hyperparathyroidism such patients may undergo either subtotal 3.5-gland parathyroidectomy total parathyroidectomy immediate autotransplant both subtotal parathyroidectomy total parathyroidectomy result aparathyroidism cryopreservation parathyroid tissue recommended time initial surgery addition reported use intraoperative parathyroid hormone iopth monitoring parathyroid surgery accurately predict patients risk developing postoperative hypocalcemia a drop 80% iopth 10 minutes significant factor postoperative hypocalcemia therefore cryopreservation parathyroid tissue considered parathyroid surgery iopth drop 80% patients end stage renal disease high risk developing secondary shpt tertiary thpt hyperparathyroidism such patients persistent stimulation parathyroid glands secondary abnormalities metabolism calcium phosphorus vitamin resulting multigland parathyroid hyperplasia they inherently high risk disease recurrence subtotal parathyroidectomy performed high risk permanent hypoparathyroidism total parathyroidectomy immediate autotransplant performed moreover patients may require multiple operations prevent aparathyroidism consequence initial subsequent operations cryopreservation parathyroid tissue recommended the risk aparathyroidism nominal thyroidectomy increases extensive surgical resections routine central neck dissections thyroid cancer complication rate permanent hypoparathyroidism 14% given risks role prophylactic central neck dissections papillary thyroid cancer continues debated an immediate intraoperative autotransplant preferred neck dissection thyroid cancer yet cryopreservation parathyroid tissue fragments also warranted given multiple operations may required future subsequent operations increase risk permanent aparathyroidism outcome cryopreservation parathyroid tissue may prevent in contrast initial neck operations risk permanent hypocalcemia redo neck operation minuscule rather high 30% 6 10 risk aparathyroidism higher redo neck operation viability remaining parathyroid glands adequately determined initial surgery parathyroid glands left situ may unknowingly devascularized damaged redo neck operation removal inadvertent injury remaining functional gland this scenario particularly problematic patients develop hyperparathyroidism previously undergoing thyroidectomy redo neck operation parathyroid gland removed must assumed last viable parathyroid gland autotransplanted immediately optimize transplantation success a fragment parathyroid tissue may cryopreserved possible delayed autotransplantation future neck reoperations result aparathyroidism other common reasons parathyroid reoperations include persistent hyperparathyroidism hypercalcemia 6 months initial surgery recurrent hyperparathyroidism hypercalcemia 6 months initial surgery operative success redo parathyroid surgery 90% fraught 18% rate causing permanent hypoparathyroidism immediate autotransplantation parathyroid tissue prevent hypoparathyroidism impedes determination surgical outcome unpredictable redo parathyroid surgery accurately assessing number parathyroid glands previously resected viability remaining parathyroid glands difficult cryopreservation parathyroid tissue rather immediate autotransplant allows surgeon appropriately predict surgical outcome functionality remaining parathyroid tissue need delayed parathyroid autotransplant operative failure disease recurrence infrequent patients sporadic phpt reoperations commonly needed shpt thpt up 15% patients shpt thpt tend four parathyroid glands increasing risk operative failure cryopreservation parathyroid tissue especially important long term renal effect prolonged shpt thpt predisposes patients transient hypocalcemia bone hunger parathyroid autotransplant critical differentiate transient permanent hypoparathyroidism similarly patients thyroid cancer require repeating operations risk hypoparathyroidism remaining parathyroid gland function properly assessed furthermore if parathyroid glands immediately autotransplanted neck muscles initial thyroid surgery function glands properly evaluated reoperations thyroid cancer a portion inadvertently removed devascularized parathyroid glands sent cryopreservation immediate autotransplant patients develop aparathyroidism subsequent operations might later benefit delayed autotransplant cryopreserved parathyroid remnant is dissected 30 40 pieces 1 1 1 mm the supernatant decanted 10 tissue fragments transferred sterile freezing vial resuspended freezing media several media proposed literature since initial report wells et al the typical freezing medium contains roswell park memorial institute rpmi 1640 solution 2 4 6 10 1316 most institutions use 80% rpmi 1640 solution 2 4 10 13 use either 60% rpmi solution 1640 rpmi 1640 solution addition authors recommend supplementing rpmi 1640 solution 2 mm glutamine 11 16 5 g ml penicillin streptomycin 50 g ml gentamicin dimethyl sulfoxide dmso 10% concentration added cytoplasmic stabilizer 2 4 10 11 15 other reported concentrations dmso range 7.5% 20% 16 18 the last component storage medium either 10% 30% autologous serum 2 10 11 15 16 10% 20% fetal bovine serum 4 11 when rpmi 1640 solution excluded 90% fetal bovine serum used the goal freezing process preserve cellular function maintaining cellular integrity temperature change accomplish goal a cooling technique developed mayo clinic entails placing vials ice chest filled dry ice prechilled 55c 60c 1 hour allow cooling 1c per minute other authors recommend placing vials 60c ethyl alcohol bath either 70c 80c freezer overnight the vials also placed programmable freezer cooled 1c per minute temperature 80c reached once vials cooled transferred liquid nitrogen freezer stored several recommended temperatures 170c 15 16 180c 4 17 190c 196c the vials containing parathyroid tissue designated delayed autotransplantation removed liquid nitrogen freezer placed warm water bath the vials shaken 37c 11 17 42c parathyroid tissue fragments thawed the fragments washed rpmi 1640 solution 37c three times 10 11 other authors recommend rinsing fragments five times 1 ml rpmi 1640 solution 20% autologous serum the rpmi wash performed rinse dmso toxic cells room temperature the patient nondominant forearm chosen parathyroid tissue reimplantation local anesthesia dissection continued flexor muscle preferably brachioradialis muscle exposed one three parathyroid graft fragments transplanted separate muscle pockets maximize chances graft function care must taken cause intramuscular hematoma compromise graft function functionality determined clinically also biochemically sampling blood grafted nongrafted antecubital veins determine pth level sites the parathyroid graft reported fully functional partially functional nonfunctional table 2 clinically graft considered fully functional patient remains eucalcemic asymptomatic calcium vitamin supplementation discontinued a graft also considered fully functional pth ratio grafted nongrafted arms greater 1.5again calcium vitamin supplementation discontinued the graft considered partially functional patient continues require calcium supplementation without vitamin supplementation pth ratio greater 1.5 the graft considered nonfunctional patient hypocalcemic requires calcium supplementation without vitamin supplementation pth ratio less 1.5 renal patients the functionality parathyroid graft determined pth levels independent calcium vitamin supplementation since renal patients require supplementation table 2 the potential benefits cryopreservation limited reduced functionality cryopreserved grafts compared immediately autotransplanted grafts cryopreserved grafts retain functionality 70% patients fresh autografts 90% 2 15 the cryopreservation process may induce cellular necrosis impair cellular viability ultimately cellular function earlier studies found difference cell viability secretory capacity fresh cryopreserved parathyroid tissue grafts 6 19 yet studies demonstrated even though percentage viable cells necessarily differ fresh cryopreserved tissue cryopreservation decreased total number live cells 70% that effect live cell yield whether parathyroid tissue frozen tissue fragments dispersed cells recently authors reported cryopreservation process decreased total cell viability decreased cell viability associated increased storage time both viability function drastically reduced storage time 22 months 15 17 counterbalance effects cellular necrosis authors routinely perform histologic examination cryopreserved tissue autotransplant parathyroid tissue according percentage necrotic cells in addition cryopreserved parathyroid tissue utilized soon deemed necessary since longer storage time limits delayed autotransplant success the devastating effect permanent aparathyroidism part ameliorated parathyroid gland cryopreservation delayed autotransplants an immediate autotransplant preferred thyroid surgery yet cryopreservation portion parathyroid tissue also greatly help patients high risk undergoing surgery cryopreservation allows clinician make appropriate decisions regarding status remaining parathyroid glands such enhanced decision making important patients undergoing parathyroid thyroid surgery experience transient hypocalcemia differentiating transient permanent hypocalcemia critical especially parathyroidectomy hypocalcemia may result bone hunger rather insufficiency pth cryopreservation facilitates appropriate surgical clinical decisions prevents unnecessary immediate parathyroid autotransplants offers chance cure aparathyroidism

the risk of permanent hypoparathyroidism following thyroid and parathyroid surgery is around 1% in the hands of experienced endocrine surgeons . although this complication is rare , rendering a patient permanently aparathyroid has significant consequences on the health and quality of life of the patient . immediate autotransplantation of parathyroid glands that are injured or unintentionally removed offers the best possibility of graft viability and functionality . however , since the majority of cases of hypoparathyroidism are transient , immediate autotransplantation can complicate postoperative surveillance in certain patients , especially those with primary hyperparathyroidism . cryopreservation of parathyroid tissue is an alternate technique that was developed to treat patients with permanent hypoparathyroidism . this method allows for parathyroid tissue to be stored and then autotransplanted in a delayed fashion once permanent hypoparathyroidism is confirmed . this article provides a contemporary review on cryopreservation of parathyroid tissue and its current role in thyroid and parathyroid surgery .

major feature movement toward hospital cost containment last decade replacement expensive inpatient care less costly outpatient care most discussions increasing reliance outpatient care focus utilization revenue measures a important issue hospital payment policy however actual costs affected shift inpatient outpatient services trends relative cost changes easily identified hospital accounting systems easily disaggregate total cost inpatient outpatient components cost finding methodologies complex allowing hospitals considerable discretion cost allocation patterns furthermore incentive created prospective payment system pps allocate costs centers incurring outpatient charges medicare pays fixed amount per inpatient discharge continues pay outpatients basis reasonable cost changes relative costs important implications current environment changing methods payment hospital outpatient services concern increases medicare outpatient expenditures led congressional legislation 1986 mandated implementation pps outpatient care an understanding true cost increases critical adoption plan accurately reflects outpatient costs article provide methodology disaggregating total cost inpatient outpatient components examine relative changes this accomplished estimation multiple output total cost function sample acute care hospitals years 1984 88 the adoption pps medicare 1983 changed payment basis hospital inpatient care hospital specific costs diagnosis related groups drgs pps hospital payments made according prices determined averaging historic costs specific groups diagnoses across hospitals the force behind change federal government largest third party payer inpatient care an intended consequence pps substitution less expensive outpatient care inpatient care without compromise quality the change medicare system impetus behind increased emphasis outpatient care hospitals also influenced third party payers also trying contain costs managed care options expanded use copayments deductibles many plans including majority blue cross blue shield plans adopted fee schedules similar pps new techniques cataract extraction cardiac catheterization example made possible people undergo procedures without overnight stay the magnitude increase outpatient utilization period study dramatic the annual number outpatient visits reported community hospitals rose approximately 210 million 270 million 1984 1988 the surge occurred number hospitals offering services well types services performed 1984 49 percent community hospitals reported organized outpatient department the proportion hospitals reporting performance ambulatory surgery increased 91 95 percent period the substantial shift inpatient outpatient activity also reflected changes inpatient outpatient revenue components whereas total revenues community hospitals increased 44 percent 1984 1988 156 billion 224 billion outpatient revenues doubled period 22 46 billion program payments hospital outpatient services increased 2.2 billion 1984 1987 average annual growth rate 18 percent mounting medicare payments outpatient care led call development prospective payment method care 1986 congress passed omnibus budget reconciliation act directed secretary health human services develop prospective payment plan types hospital outpatient care implementation law requires system outpatient classification one grouping method currently consideration discussed later ambulatory patient groups apgs lion et al this scheme similar drgs rely charge data calibration payment weights if discrepancy true cost outpatient visits charges made visits distortion could occur establishment payment rates in section describe procedure disaggregating total costs inpatient outpatient components includes estimable multiple output cost function to identify outpatient costs employ concept incremental costs described baumol panzar willig 1988 outpatient costs incremental costs incurred result outpatient activity oc represents outpatient costs tc represents total costs dis opv represent number discharges outpatient visits respectively x vector exogenous variables therefore assuming total costs sum outpatient costs inpatient costs inpatient costs specifically cost function evaluated actual level outpatient visits zero outpatient visits given breakdown total costs hospital specific cost components obtained the discussion turns multiple output cost function used determine disaggregated costs described equations 1 2 one type estimates average cost per patient per patient day function various regressors considered affect costs this widely used set behavioral cost functions often accused ad hoc lacking foundation assumptions usual production theory another group models following work mcfadden 1978 employs flexible functional forms regress total cost output levels input prices hence consistent characteristics standard economic theory production the advantage models better suited calculation scale scope economy measures developed multiple output production however models criticized large numbers parameters must estimated excluding many factors known significant explaining variation costs complex modern hospitals some recent work estimates hybrid cost functions incorporate number desirable features existing types models grannemann brown pauly 1986 vita 1990 hadley zuckerman 1990 expand literature dynamic model designed capture process adjustment pps however consensus reached appropriate form hospital cost function major objective disaggregate total costs inpatient outpatient components function estimated total cost function focus scale scope economies substitution inputs chose form although derived particular production technology incorporates many factors likely important explaining hospital cost variation our approach draws work grannemann brown pauly 1986 evidence hospitals longrun equilibrium our expression shortrun total costs geographic input price variation major determinant cost variation the input price measure available index local area wage rates produced health care financing administration hcfa use determining prospective payments hospitals impose assumption linear homogeneity input prices the dependent variable used equation logarithm total cost minus logarithm wage index variation cost hospital energy food may partially reflected wage rates must compensate workers higher costs living the second- third order terms variables number inpatient discharges outpatient visits consistent cost function exhibits u shaped average marginal cost curves there two aspects inpatient care number patients patient length stay these may entered separately discharge average length stay variables combined one total days care variable we chose former approach although latter would likely yield similar result use functional form allows outpatient levels take value zero case outpatient visits hospitals calculation incremental cost outpatient activity also requires cost function evaluated level zero outpatient visits hospital the vector remaining variables described later section chosen based results previous studies we make assumption output exogenous commonly done studies conrad strauss 1983 grannemann brown pauly 1986 friedman shortell 1988 hadley swartz 1989 hadley zuckerman 1990 the majority data used analysis comes two independent sources american hospital association 1984 88 aha annual survey hospitals hcfa hospital cost reporting information system hcris data files the hcris files cycles one five 1984 88 pps supplemented tax equity fiscal responsibility act tefra data set used complete pps data 1984 the sample represents hospitals aha pps data available eliminating specialty hospitals inclusive rate payers hospitals fewer 100 beds the data bases 68 hospitals subject payer systems payment comparable larger group group small hospitals exhibits cost structures distinctly different hospitals 100 beds this latter point verified using chow test structural difference sample included sample excluded small hospitals ( 3,961 n 2,235 respectively unique data set consists 2,235 hospitals non profit proprietary total fixed assets drawn hcris data used measure fixed capital estimating shortrun cost function assumed capital stock exogenous test assumption i.e. supply evidence whether hospitals longrun equilibrium performed hausman 1978 specification test exogeneity capital variable year 1988 capital exogenous uncorrelated error term cost function null hypothesis misspecification correlation error term tested comparing two sets parameter estimates cost function one using total fixed assets one using instrumental variable correlated fixed assets uncorrelated error term the specification test based statistic 1 m1 parameter estimates covariance matrix estimation using instrumental variable 2 m2 similar estimates model using total fixed assets the statistic (k distribution k number unknown parameters because value 2.29 critical value 1-percent level 40.29 fail reject null hypothesis therefore incorporate actual value total fixed assets cost function the cost discharge variables described obtained hcris data set outpatient visits obtained aha data in addition cost output capital variables additional explanatory variables appear cost function case mix measured using medicare drg case mix index included control output variation among inpatients captured discharge length stay variables this estimate costliness particular hospital medicare patient load unavailable prior adoption pps medicare although still imperfect improves many earlier cost studies relied cruder case mix measures the implications market concentration hospital costs addressed number recent works many studies found evidence various forms non price competition example quality range service offerings general conclusion greater market competition associated higher costs joskow 1980 robinson luft 1985 white 1987 hadley swartz 1989 zwanziger melnick 1988 demonstrate effect changing california hospitals this constructed using county market number discharges measure output determine market shares ( 1987 found county acceptable alternative uniform geographic area defining markets scope range services measured precisely cost functions often interaction terms various outputs examined attempt establish presence economies diseconomies scope we incorporate scope services index calculated cluster analysis verified using guttman scale statistics follows methodology developed klastorin watts 1982 also henderson defiore stefos 1990 we grouped hospitals ranked scale 0 18 hospitals higher index offer services three categories service availability ranging lowest highest basic community offering full range services our service index approach economies scope differs grannemann brown pauly 1986 include interaction terms output pairs finally dummy variables included teaching status population size ownership the level teaching activity classified three groups major teaching affiliation medical school membership council teaching hospitals minor teaching medical school affiliation non teaching neither affiliation council teaching hospitals membership population hospital surrounding community coded collapsing metropolitan statistical area msa size one three groups large urban 1 million small urban 100,000 1 million rural ownership categorized non profit profit government city county state facility the teaching population variables obtained aha data set ownership dummy defined hcris data this allows comparison relative costs time literature cost functions a potential hazard estimation total costs cross sectional data presence heteroscedasticity associated output levels a useful procedure detecting violation ols assumptions case multiple output cost function park glejser test see vitaliano 1987 another application test hospital cost function glejser 1969 generalizes test allow case heteroscedasticity error term proportional one explanatory variables in addition testing failure assumption constant error term variance test supplies estimate covariance matrix disturbance term u inverse diagonal matrix contains weights used weighted least squares wls regression the park glejser test indicated presence heteroscedasticity years 1984 86 1988 consequently wls regressions performed years ols applied 1987 the belsley kuh welsch 1980 diagnostics applied problems due multicollinearity detected the coefficients discharge outpatient visit los variables exhibit highly significant pattern positive negative positive quantity quantity squared quantity cubed respectively the sign herfindahl index negative supportive theory non price competition small rural markets tend lower input prices included input price wage index possible herfindahl measure could incorporating effect omitted input price measures major teaching hospitals located large urban areas expensive shown previous empirical work previous authors grannemann brown pauly 1986 vita 1990 failed find evidence complementarities among specific measured outputs the signs coefficients scope service dummy variables also fail indicate presence economies scope however results suggestive topic one need investigation the results estimated cost functions used disaggregate total costs inpatient outpatient components equations 1 2 evaluated hospital using estimated cost function determine hospital specific values particular hospital means inpatient outpatient costs listed year various hospital categories table 3 seen final column inpatient costs grew average annual rate 6.6 percent outpatient costs rate 7.4 percent this result contrasts starkly relative change inpatient outpatient revenues already discussed revenues outpatient services rose much rapidly costs 5 years following introduction pps the results cost function disaggregation procedure indicate growth rate outpatient costs differ substantially inpatient costs despite considerable differences relative utilization patterns revenue components explore finding useful consider relationship total cost output levels unit costs the ratio two components cost may represented ratio costs equal product ratio output ratio unit costs because ratio outpatient inpatient costs remained relatively steady ratio outpatient visits discharges rose follows ratio average incremental cost outpatient visit average cost discharge fell table 4 lists outpatient visit discharge unit costs hospital strata 1984 overall average incremental cost outpatient visit 2.3 percent average inpatient cost 1988 percentage fallen 1.7 the decline outpatient inpatient unit cost ratio offset increase ratio outpatient visits inpatient discharges trend unit costs outpatient services finding analysis unanticipated interpretation result order ( mean outpatient unit costs 1988 57 1984 dollars 11 percent lower 1984 unit cost economic effect could partially account economies scale the output volume change outpatient activity 1984 1988 considerable average number visits rose 58,000 74,000 28 percent additional econometric evidence economies scale appears study determinants 1987 medicare hospital outpatient department costs miller 1992 one change accounts increase use outpatient services rise number ambulatory surgical procedures performed hospitals because operations relatively costly might expected would drive average cost hospital outpatient visit despite focus growth ambulatory surgery noted surgery comprises relatively small portion total outpatient volume 1988 less 4 percent outpatient visits reported community hospitals surgical procedures american hospital association 1990 91 the percentage hospitals reporting ambulatory surgery rose 91 95 period study number freestanding ambulatory surgical centers ascs rose 670 percent 1983 1990 prospective payment assessment commission 1992 medicare changed incentives utilization facilities beginning 1988 bringing hospital outpatient surgery payments line lower rates already established ascs the increase number outpatient visits sample hospitals study large the figures table 1 indicate average hospital reported 16,000 outpatient visits 1988 1984 the question arises whether increase result unbundling part hospitals some states instituted non medicare cost containment regulations permit rate increases allow volume adjustments it suggested hospitals split services multiple billable pieces order increase payments this practice could reflected aha number visits measure appearance outpatient one unit hospital counted visit pre admission testing outpatient basis another response hospitals fixed payments per discharge this unbundling practice way increasing payment workload extent increase number visits 1984 1988 partially result overreporting changes way visits are counted unit costs outpatient component later years would underestimated ( variation total costs resulting outpatient activity spread larger number visits ) although estimated equation variable cost function excludes capital expenditures questionable whether remaining non capital element measured costs fixed relation number discharges number outpatient visits could significant similarly incremental cost approach properly allocate costs vary jointly inpatients outpatients considerable amount joint costs assigned inpatients methodology measure outpatient costs biased downward however trends observed 4-year period study would hold assuming nature fixed joint costs stable time another approach disaggregation cost components taken aha method representing multiple hospital outputs single measure discharges adjusted multiplied adjustment factor adjusted discharges refer number discharges hospital could serve offering outpatient non inpatient services the desired adjustment factor ratio total cost inpatient cost converts non inpatient services discharge equivalents ( aha adjusts inpatient days adjustment factor assuming total costs sum inpatient costs outpatient costs desired adjustment factor may expressed adjusted discharges calculated latter algebraically equivalent dividing inpatient cost unadjusted discharges ic dis however aha uses ratio total revenue inpatient revenue proxy ratio total cost inpatient cost hence aha adjustment process revenue based approach calculation unit costs table 5 lists aha costs per adjusted discharge along implied outpatient unit costs oc opv this revenue based approximation changes unit costs substantially overestimates outpatient costs cost increases underestimates inpatient costs observed comparing results listed table 5 table 4 finally adjustment factors calculated using cost function approach disaggregation inpatient outpatient components listed aha adjustment factors table 6 the discrepancy cost- revenue based unit costs adjustment factors serious among hospitals smaller less urban non teaching seen comparing results listed tables 4 5 well results table 6 the growth rate hospital outpatient costs implications perspective policy research regarding policy current effort government private insurers control hospital payments outpatient services the results research indicate hospital outpatient costs rising nearly rapidly outpatient revenues attempts bringing payments line actual cost increases serious impact hospitals largest discrepancies costs revenues these tend smaller rural non teaching facilities sample this system similar drgs relies charge data calibration payment weights the appropriateness using charge rather cost data annual recalibration drg weights subject debate work cotterill bobula connerton 1986 using 1981 data showed little difference use cost charge data the results study rogowski byrne 1990 showed 1984 cost- charge data based drg weights less congruent however authors counsel use charge data addition timeliness charge data even best cost data partially based charge data many biases work either case price 1989 updated issue study using 1986 data showed much larger differences cost- charge based weights previously found results present work indicate discrepancy outpatient costs revenues significant grew period 1984 88 if historical charge data used weighting outpatient payment groups system could seriously distorted favor procedures charges set well costs if outpatient rates general biased upward inpatient rates downward smaller hospitals would particularly vulnerable relatively smaller outpatient departments cost allocation patterns also research implications particularly results studies rely aha revenue ratio adjusted output measures if relatively high outpatient revenues reflective true costs adjusted output measures overstate true output levels examination changes unit costs demonstrates extent trends variables misrepresented revenue adjusted measures table 4 seen cost function measure discharge unit cost rose 43 percent 1984 1988 revenue ratio measure variable table 5 declined 29 percent measures hospital labor productivity also understated based aha adjusted output measures although trends difficult gauge tracking measures labor inputs time confounded number factors ( it noted results much empirical research dependent reliability aha adjusted cost output measures numerous studies used aha cost per adjusted unit output dependent variable estimations average cost functions researchers aware changing patterns cost allocation use revenue charge data proxy costs may affect conclusions improvements hospital accounting data would beneficial future research well construction drg apg weights payment levels

in this article , the authors estimate a multiple - output cost function for a sample of 2,235 hospitals during the period 1984 - 88 to disaggregate total costs into inpatient and outpatient components . the results suggest that outpatient cost growth is roughly proportional to that of inpatient cost , despite much higher relative growth in revenues and utilization on the outpatient side . the stability in the outpatient / inpatient cost ratio implies that the increase in the outpatient - to - inpatient utilization ratio was offset by a decline in their relative unit costs .

wilms tumor wt also known nephroblastoma frequent renal tumor occurring children aged 0 15 years especially among younger 6 years wt accounts roughly 6% childhood cancers 5% bilateral involvement 1% family history thanks prospective clinical trials performed international society pediatric oncology renal tumor study group siop rtsg europe children oncology group cog formerly nwtsg north america patients 85% affected wt successfully cured however studies released surveys reporting still children may poor prognosis relapse current therapies 50% die despite intensive treatment it proven genetic variants strongly associated development wt mutations wt1 epigenetic defects chromosome 11p15 contribute major genetic susceptibility locus previous studies reported several non wt1 loci smaller effects genetic predisposition wt including p53 gene insulin like growth factor ii gene ctnnb1 gene h19 however less half wt cases attributable known genes associated wt risk therefore exact pathogenesis wt cases remains unknown identification novel genetic loci urgently needed the reversion inducing cysteine rich protein kazal motifs reck gene known transformation suppressor gene restrain tumor invasion metastasis suppression matrix metalloproteinases mmps including mmp-4 mmp-9 mmps proteolytically degrade extracellular matrix proteins critical tumor metastasis invasion reck expressed number normal tissues appears regulated several types cancers including esophageal cancer breast cancer lung cancer colorectal cancer osteosarcoma gastric carcinoma prostatic cancer oral cancer pancreatic cancer cholangiocarcinoma moreover clinical investigations demonstrated high expression reck tumor tissues usually contributes increasing survival rates reducing tumor invasion moreover hawthorm et al analyzed wt using single nucleotide polymorphism snp mapping array based comparative genomic hybridization found chromosomal deletion 9q reck gene locates 9q13-p12 although well documented reck impact metastasis prognosis human cancers reck gene snps wt susceptibility clinical features remains poorly characterized obtain adequate power assessing potential association chose snps minor allele frequencies 5% furthermore rs10972727 rs11788747 snps previously identified potentially associated several types human cancers including oral cancer non small cell lung cancer hepatocellular carcinoma therefore purpose study determine whether 2 snps rs10972727 rs11788747 reck gene associated susceptibility wt chinese children this case control study received approval human research ethics board jinan children hospital a total 291study participants 97 wt children 194 healthy controls based age sex matched pair 1 2 ratio identified jinan children hospital all participants han chinese written informed consent obtained parents participant inclusion study there 41 male 56 female patients mean age time surgery 3.3 years the patients histopathological types cancer grading determined according classification renal tumor childhood defined siop rtsg accordingly 43 44.3% 97 cases characterized wt stage 35 36.1% stage ii 12 12.4% stage iii 7 7.2% stage iv according prognostic group moreover case bilateral wt according histologic type 26 cases blastemal type wt 8 diffuse anaplasia 9 focal anaplasia 17 epithelial 37 mixed genomic dna extracted qiaamp dna blood mini kits qiagen valencia ca according instructions manufacturer reck genotype polymorphisms rs10972727 rs11788747 determined polymerase chain reaction restriction fragment length polymorphism pcr rflp method pcr carried reaction mixture 10 l containing 58 l dna template 0.5 u taq biocatalysts 1.8 mmol l mg2 2.4 l dntps promega madison wi 200 nm primer the 2 snps genotyped according methods described chung et al primers rs10972727 5-gtagaagaagtgactgatcc-3 5-atctgactccgaagataacc-3. primers rs11788747 5-ttctatcaggtcatggaaca-3 5-tgcggttaagactggagaag-3. pcr cycling conditions initial denaturation 94c 5 min followed 35 cycles 1 min 94c 60c 30 72c 1min final extension 72c 10 min verify results pcr ctpp approximately 10% sample analysis duplication genotype determined dna sequence analysis hardy weinberg equilibrium analyzed compare observed expected genotype frequencies using standard test fisher exact test the differences distributions genotypes alleles cases controls assessed tests the estimated genotype specific risks presented odds ratios ors cases this case control study received approval human research ethics board jinan children hospital a total 291study participants 97 wt children 194 healthy controls based age sex matched pair 1 2 ratio identified jinan children hospital all participants han chinese written informed consent obtained parents participant inclusion study there 41 male 56 female patients mean age time surgery 3.3 years the patients histopathological types cancer grading determined according classification renal tumor childhood defined siop rtsg accordingly 43 44.3% 97 cases characterized wt stage 35 36.1% stage ii 12 12.4% stage iii 7 7.2% stage iv according prognostic group moreover case bilateral wt according histologic type 26 cases blastemal type wt 8 diffuse anaplasia 9 focal anaplasia 17 epithelial 37 mixed genomic dna extracted qiaamp dna blood mini kits qiagen valencia ca according instructions manufacturer reck genotype polymorphisms rs10972727 rs11788747 determined polymerase chain reaction restriction fragment length polymorphism pcr rflp method pcr carried reaction mixture 10 l containing 58 l dna template 0.5 u taq biocatalysts 1.8 mmol l mg2 2.4 l dntps promega madison wi 200 nm primer the 2 snps genotyped according methods described chung et al primers rs10972727 5-gtagaagaagtgactgatcc-3 5-atctgactccgaagataacc-3. primers rs11788747 5-ttctatcaggtcatggaaca-3 5-tgcggttaagactggagaag-3. pcr cycling conditions initial denaturation 94c 5 min followed 35 cycles 1 min 94c 60c 30 72c 1min final extension 72c 10 min verify results pcr ctpp approximately 10% sample analysis duplication genotype determined dna sequence analysis hardy weinberg equilibrium analyzed compare observed expected genotype frequencies using standard test fisher exact test the differences distributions genotypes alleles cases controls assessed tests the estimated genotype specific risks presented odds ratios ors cases five 97 cases family history wt 6 cases relapse 16 metastasis present study distributions genotypes cases controls agreement hardy weinberg equilibrium rs10972727 p=0.349 p=0.121 rs11788747 p=0.519 p=0.123 respectively table 2 shows genotype allele frequencies 2 snps rs10972727 rs11788747 reck gene no significant difference cases controls observed distribution rs10972727 genotype rs11788747 genotype rs11788747 allele however found allele g rs11788747 snp significantly associated increased risk wt or=0.7 95%ci 0.450.99 p=0.042 moreover although taking aa genotype reference found ag gg genotype statistically significantly associated risk wt pronounced trend carriers 1 variant combined genotype increasing risk wt or=0.6 95%ci 0.381.03 p=0.065 further analysis conducted investigate associations distribution genotype allele rs11788747 polymorphisms clinicopathological features wt patients shown table 3 although significant difference distribution genotype allele g carriers advanced tumor stage p=0.026 increased risk wt metastasis p=0.002 table 2 shows genotype allele frequencies 2 snps rs10972727 rs11788747 reck gene no significant difference cases controls observed distribution rs10972727 genotype rs11788747 genotype rs11788747 allele however found allele g rs11788747 snp significantly associated increased risk wt or=0.7 95%ci 0.450.99 p=0.042 moreover although taking aa genotype reference found ag gg genotype statistically significantly associated risk wt pronounced trend carriers 1 variant combined genotype increasing risk wt or=0.6 95%ci 0.381.03 p=0.065 further analysis conducted investigate associations distribution genotype allele rs11788747 polymorphisms clinicopathological features wt patients shown table 3 although significant difference distribution genotype allele g carriers advanced tumor stage p=0.026 increased risk wt metastasis p=0.002 the findings novel study provide evidence effects snps reck wt susceptibility clinicopathologic status association various lines evidence found tumor stage metastasis risk factors development wt current study explored association reck gene wt risk subsequently analyzed effects combinations functionally related polymorphisms clinicopathological features wt patients to best knowledge first study examining association reck gene polymorphism wt risk although several previous studies reported association several types human cancers frequent renal tumor occurring children although wt high survival rate 25% wt children may poor prognosis relapse current therapies 50% die despite intensive treatment therefore urgent us identify novel genetic loci might associated wt risk it proven igf pathway plays role development wt the igf pathway complex signaling system stimulated insulin like growth factors igfs produced almost tissue body important effect growth development survival many different cell types overexpression igf2 activating insulin signaling pathway results disorder protein synthesis cell cycle cell growth blocks apoptosis furthermore yamamoto et al indicated reduced reck could increase igf2 expression the interaction reck gene igf gene might potential influence susceptibility wt a study huang et al demonstrated regulation reck gene expression patients wt therefore conducted study determine whether reck gene associated wt risk current study findings suggest mutant rs10972727 reck impact increasing wt risk in addition allele g carriers advanced tumor stage involving metastasis increasing risk wt advanced tumor stage metastasis responsible patient mortality tumors 3739 found level reck expression determined prognosis pancreatic cancer tumors overexpression reck significantly decreasing invasiveness compared reck negative tumors revealing potential value reck prognostic molecular marker pancreatic cancer zhang et al reported silenced reck gene associated poor survival hepatocellular carcinoma showed carried rs10814325 least 1 c allele higher risk hepatocellular carcinoma follow salivary adenoid cystic carcinoma patients revealed expression reck mmp-2 gene correlated tumor progression study found correlation rs10972727 reck tumor stage metastasis however exact physiological mechanism reck influences progression wt remains unclear firstly primary weakness study small sample size may affect power statistical analysis secondly results replicated additional individuals might contribute potential false positive errors moreover method used select potentially functional snps targets using web based tool might led positive negative errors finally perform functional study reveal mechanism genetic polymorphisms reck affect wt risk data present data indicate rs10972727 reck gene associated wt risk chinese children association mutant g rs11788747 reck wt risk shown g carriers advanced tumor stage metastasis might increased risk wt therefore research necessary reveal mechanism genetic polymorphisms reck affect wt risk

backgroundwilms tumor ( wt ) is the most common malignant renal tumor in children . previous studies suggested the reversion - inducing , cysteine - rich protein with kazal motifs ( reck ) down - regulation might have a role in numerous human cancers . the current study was done to investigate the associations of reck single - nucleotide polymorphisms ( snps ) with the wt susceptibility in chinese children.material/methodswe analyzed 2 snps ( rs10972727and rs11788747 ) in a total of 97 wt children and 194 healthy matched controls ( 1:2 ratio ) by real - time pcr and pcr - rflp genotyping analysis.resultswe found that the g allele of rs11788747 in the reck gene was significantly associated with wt in chinese children ( or=0.7 , 95% ci : 0.450.99 ; p=0.042 ) ; as with another snp rs10972727 , however , no statistically significant difference was detected . further analysis showed there was also a statistically significant difference in genotype frequencies between terminal tumor stage ( p=0.026 ) and metastatic groups ( p=0.002).conclusionsthe present data indicate that there is a significant association between mutant g of rs11788747 in reck and wt risk . g carriers with advanced tumor stage or with metastasis might have an increased risk of wt .