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

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

Tardive dystonia (td), a rarer side effect after longer exposure to antipsychotics, is characterized by local or general, sustained, involuntary contraction of a muscle or muscle group, with twisting movements, generally slow, which may affect the limbs, trunk, neck, or face . Td has been shown to develop in about 3% of patients who have had long - term exposure to antipsychotics . . The low risk of td for atypical antipsychotics is thought to result from their weak affinity for dopamine receptors . Compared with typical, atypical antipsychotic agents have a greater affinity for serotonin 5-ht2a than dopamine d2 receptors, with a low propensity to induce td . Among this olanzapine is thought to have preferential action at mesolimbic over nigrostriatal dopaminergic pathways and is, therefore, associated with a very low incidence of extrapyramidal symptom (eps). Furthermore, a retrospective analysis of controlled multicentric trials suggested that olanzapine also improves preexisting symptoms of tardive movements . We report a case of 20-year - old male, belonging to lower socioeconomic class, educated up to 2 standard, presented with severe unilateral dystonic left sided neck movements [figure 1]. Careful history exploration revealed he was taking risperidone 2 mg irregularly for 2 months and then olanzapine 5 mg for another 4 months . Picture of neck dystonia of patient at 19 years, the patient presented with occasional anger outbursts, getting provoked on small matters and beating family members, running away from home, screaming episodes occasionally, fearfulness, sleep disturbance for 2 days; which was precipitated after fever . According to the mother, one friend might have threatened / made fun of him actually and after that patient stopped going out of house, and displayed above mentioned symptoms . This was interpreted as psychosis with persecutory ideas, and he was treated with risperidone 2 mg / day for 2 months and then with olanzapine 5 mg / day for 4 months . In last two follow - ups patient did not present himself, and mother reported unusual neck movements, which were taken as a part of his overall psychopathology and not taken seriously, slight intermittent neck movements reported were missed as part of adolescent behavior problems mimicking some hero in movies . As neck dystonia increased, the patient had a severe disability as patient had to keep his hands behind his head for the support . The movement would decrease when the patient was lying down and was absent during sleep . He even stopped taking food due to severe neck movements making chewing and swallowing difficult . His birth and early developmental milestones were normal . During 210 years of age patient was inattentive and mildly hyperactive . Other siblings were educated with master's degree, and patient was also sent to school, but due to inattention and restlessness, he did not pass 2 standard after three attempts . He left the schooling . With average executive functioning and life skills, he worked as an unskilled laborer in the neighborhood shops as a helping hand ., he was found to be getting over familiar, cheerful, moody, and short tempered . Sometimes, the patient had inappropriate social judgment; for which his friends made fun of him, and teased him . On mental status assessment, routine investigations, thyroid function tests, electroencephalogram, fundus examination, cervical x - ray, magnetic resonance imaging brain were normal . After consulting neurophysician, wilson's disease and other secondary causes of dystonia were ruled out . The patient was treated with clonazepam 1 mg total dissolved solid (tds), tetrabenazine 25 mg tds, trihexiphenidyl 2 mg bipolar disorder (bd). After 2 months, there was some improvement of around 30% . Baclofen 10 mg was added; increased up to 20 mg, trihexyphenidyl reduced to 2 mg . With little improvement after 4 months of treatment for dystonia, levodopa + carbidopa (100 + 25) was added by neurophysician and increased up to tablet tds and baclofen omitted . After 12 months of treatment, patient has improved around 90% with tetrabenazine 75 mg, levodopa + carbidopa (100 + 25) - tablet bd, and clonazepam 1 mg bd . Earlier case reports reported td developing with high - dose atypical antipsychotics such as olanzapine 20 mg or aripiprazole 15 mg with longer duration of exposure of around 1215 months in established psychiatric illness like schizophrenia or any other psychotic illness . Eps in general and tardive dyskinesia, in particular, have been extensively studied in schizophrenia . Even though a number of studies suggest that bipolar patients experience higher rates of eps (parkinsonism, dystonia, akathisia) and td compared to patients with a diagnosis of schizophrenia, research within the bd population has been limited . The risk is found to be 3 to 5 times higher in elderly patients compared to young patients . In addition to age, the risk is directly proportional to: female gender, daily and total dose of the antipsychotic drug, presence of mood disorder, the use of anticholinergics with neuroleptics, previous physical therapies (electroconvulsive therapy), the presence of other physical illness such as diabetes or an organic disorder, younger age of exposure, and the presence of extrapyramidal symptoms early in treatment . This patient's severe dystonic neck movements developed within short period of 6 months of exposure to atypical antipsychotics risperidone 2 mg and then olanzapine 5 mg only, which can cause minimal extrapyramidal side effects . In this case, risk factors for developing serious disabling td were neuroleptic exposure, borderline intellectual functioning, externalizing behavior, probable misdiagnosis, and overlooking early indicators of side effects . This case highlights dangers of casually prescribing low dose second generation antipsychotics in patient with hyperthymic temperament and borderline intellectual functioning with vague short lasting presenting complaints; probably misdiagnosed as psychosis; leading to such severe adverse effects because patients with organic brain damage are more prone to develop adverse effects like td . Thus, judicious use of antipsychotics, with detailed and frequent assessments is important, and emergent stereotyped behavior or unexplained movements must be examined carefully and taken seriously . The authors certify that they have obtained all appropriate patient consent forms . In the form the patient(s) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed . The authors certify that they have obtained all appropriate patient consent forms . In the form the patient(s) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Lepidoptera include agricultural pests that, through feeding and other activities, negatively affect stored grains, food and fiber crops [2, 3]. Since a single lepidoptera adult can produce hundreds of eggs, and their primary food source is typically plant material, they can cause significant damage to agricultural crops . Although biological agents can help manage these insect pests, insecticides currently are essential for large - scale effective and economical pest control . These insecticides can also affect non - target organisms, including pollinators, and their application not only disrupts natural ecosystems but also reduces yields of crops that rely on pollination [5, 6]. The non - target effect of some pesticides is in part due to their effects on insect immunity, which is necessary for insect survival in natural environments . For example, currently used pesticides have been shown to affect cellular [710] and humoral [11, 12] immune responses and interfere with grooming behavior [13, 14]. These effects on immunity are likely non - specific and negatively impact the health of both the target pest and beneficial arthropods . Therefore, there is a need for novel target - specific approaches to control insect pests without affecting beneficial arthropods . Although immune pathways can be generally and non - specifically inhibited by pesticides, they also are a likely source of candidate molecules that could be inhibited for target - specific insect control since multiple classes of insect immunity genes, including signaling pathways, can be under strong selection for diversification . Fundamental mechanisms of innate immunity comprising cellular and humoral pathways are conserved throughout the animal kingdom and are controlled by signaling pathways activated by various stimuli [17, 18], including pathogen recognition by immune surveillance systems . Despite this overall conservation, aspects of immune systems are subject to strong selection to evolve in response to varying pathogen exposure and to pathogen evolution of virulence determinants that modulate immunity [15, 1921]. Such co - evolutionary dynamics can promote diversification of conserved elements of immunity as well as the recruitment of novel effectors . As such, the investigation of insect immune pathways and mechanisms of pathogen modulation can yield insights into components that may be susceptible to inhibition . For example, the insect pathogen xenorhabdus nematophila suppresses cellular and humoral immunity in the lepidopteran moths manduca sexta and spodoptera exigua [23, 24] but not in the dipteran fly drosophila melanogaster, suggesting the stage of immunity suppressed by x. nematophila may be absent from d. melanogaster, but present in lepidoptera . Since dipteran flies serve as pollinators [26, 27], decomposers, food sources for other animals, and pest control agents, capitalizing on the possible differences between dipteran and lepidopteran immune signaling cascades will help in the identification of targets for pest - specific inhibition . With this knowledge in hand, pest management can be achieved by developing small molecule inhibitors of these targets that will suppress pest insect immunity and lead to increased susceptibility to environmental pathogens . Indeed, many insecticides may contribute to insect (target and non - target) death by modulating aspects of immunity . The feasibility of targeted pest control via insect immune inhibition has been established for termites; a small molecule inhibitor of an immune surveillance protein led to faster termite death upon exposure to various pathogens . Much of our current knowledge of insect immune signaling pathways and receptor and effector function is based on the premiere model organism d. melanogaster, for which there are extensive genetic tools and several fully sequenced genomes . Well - established lepidopteran insect models such as the silkworm bombyx mori and the tobacco hornworm m. sexta also have been widely used to study insect immunity . These organisms have been particularly useful for investigating hemolymph proteins and hemocyte function because of their relatively large larval size and hemolymph volume . Many insects in the order lepidoptera are easy to rear in laboratory conditions, and new tools such as rna interference have been implemented successfully to study genetics of their immune systems [30, 31]. Also, their immune signaling pathways are gradually being revealed by genomic and transcriptomic data [3238]. Based on these model insect systems a fairly detailed picture of immunity, from pathogen detection to effector function, is emerging, though many gaps remain, particularly with regard to components that are unique to different insect orders . Here we review aspects of insect immunity with an emphasis on the similarities and distinctions between d. melanogaster and representative lepidoptera . In insects, the cellular immune response includes phagocytosis, nodulation and encapsulation [3942] and the humoral response involves the expression of antimicrobial peptides (amps) [43, 44] as well as the pro - phenol oxidase (propo) proteolytic cascade that results in formation of melanized nodules and toxic reactive compounds [45, 46]. Amps are small cationic peptides that insert into and disrupt microbial membranes, thereby killing and clearing pathogens . They are synthesized by hemocytes and to a greater extent in fat body from which they are released into the insect hemolymph rapidly after microbial infection [43, 47]. Amps are also expressed in extra - embryonic tissues of eggs, which may help protect the developing embryo from infection . Amps are a conserved component of immunity in plants and animals and while they have diverse structures most can be assigned to larger families such as cecropins, attacins, defensins and diptericins . Their diversity and immune effector function as well as their variant representation among insects (table 1) have made them a central focus in the study of invertebrate pathology [30, 52]. In d. melanogaster amp synthesis each of these pathways is activated by detection of microbial components via different pattern recognition receptors (prrs) that trigger, through complex regulatory cascades, nuclear factor kappa b (nf-b) dependent transcription of the genes encoding amps . After amps are translated in the cytoplasm they are released into the hemolymph where their high concentrations and broad activity are thought to enhance clearance of invading microorganisms from the insect . Bioinformatic and experimental data support the existence of the amp - inducing toll and imd pathways in lepidopterans, though not all components have been identified in model organisms such as m. sexta [32, 35]. The conserved presence of amps in immunity coupled with the possibility that certain elements of their induction pathways may vary among insects enhances the probability that microbially - induced amp expression could be inhibited in a pest - specific manner . As such, for the remainder of this review we focus on pathways leading to amp gene expression . In d. melanogaster, transcription of amp - encoding genes is activated by the nf-b family transcription factors in response to infection [6569] with distinct nf-b family transcription factors responding to the toll and immune deficiency (imd) signal transduction pathways . In response to toll pathway activation, the nf-b inhibitor cactus is phosphorylated and degraded allowing its targets, the nf-b factors dif and dorsal, to be translocated to the nucleus . Imd pathway activity culminates in the nf-b factor relish being activated by a stimulus - induced proteolytic cleavage . In the case of dif and dorsal, gram - positive bacterial and fungal infections primarily serve as the stimuli that induce degradation of cactus through the toll signaling pathway . In general, gram - negative bacterial infections of d. melanogaster stimulate the proteolytic cleavage of relish through the imd pathway . Once in the nucleus, these transcription factors drive the transcription of immune effectors, including amp genes whose promoters contain nf-b binding sites [70, 72]. Overall, nf-b proteins and their dna - binding specificities are conserved among organisms, including those lepidoptera studied to date [73, 74]. However, the nfb - binding regions for inhibitor of b (ib) proteins (e.g., cactus) are not conserved, suggesting diversification and co - adaptation between ib and nfb pairs . Also, recent work indicates that nf-b nuclear co - regulators may contribute to species - specific regulation of amp gene expression . Therefore, modulation of inhibitors and nuclear - co - regulators of nf-b - dependent transcription may be one avenue by which target - specific immune suppression could be achieved . In d. melanogaster, nf-b - dependent amp induction through the toll and imd pathways is activated by detection of microbial components via different pattern recognition receptors (prrs). Prrs are soluble or membrane - bound proteins that bind to specific microbe associated molecular patterns (mamps) such as lipopolysaccharide (lps), lipoteichoic acid (lta), peptidoglycan (pgn) or -1,3-glucan that are released from or are found on the cell surfaces of bacteria or fungi . Upon interaction with mamps, prrs can directly agglutinate pathogens or trigger proteolytic signaling cascades and cytokine release, which in turn lead to the activation of downstream cellular and humoral pathways, including pro - po activation and amp gene expression [16, 65, 76]. Pgn recognition proteins (pgrps) and -1,3-glucanase - related proteins (grps) were discovered in the lepidopteran silkworm (b. mori) by assaying for plasma components that activate the propo cascade . Pgrps were subsequently shown to be conserved across mammals and insects, and in d. melanogaster their role in the induction of amp gene expression through toll and imd pathways in response to pgn has been well documented [7983]. Similarly, grps have been shown to induce amp expression through toll pathway in response to fungal infections [79, 84]. In contrast, there is a dearth of literature linking specific pgrps or grps to amp induction in lepidoptera . Such a link is possible, since pgn and -1,3-glucan can activate amp gene expression in m. sexta and b. mori [8590] and multiple infection - induced pgrp- and grp - encoding genes have been identified in lepidoptera [32, 38, 54, 55, 9194]. However, there are numerous hints that lepidoptera and diptera may have evolved divergent mechanisms of linking pathogen detection to conserved toll and imd signal transduction cascades . First, a genome comparison between b. mori and d. melanogaster failed to identify 1:1 pgrp orthologs . Similarly, b. mori gram - negative binding protein (gnbp) and m. sexta microbe binding protein (mbp), members of the -1,3-glucanase - related protein superfamily [76, 95], appear to be distantly related to d. melanogaster gnbps, suggesting divergence of this group of proteins . M. sexta mbp expression is strongly up - regulated in fat body after immune challenge and shows specific binding to lta, lps, dap - pgn . Also, in contrast to the situation in d. melanogaster, highly purified lps and lta are inducers of amp gene expression in lepidoptera, though not as potently as crude lps (with contaminating pgn) or purified pgn [85, 90, 96, 97]. This raises the possibility that different mamps or combinations of mamps are most efficacious in eliciting amp gene expression in lepidoptera relative to diptera . Also, since purified lps can elicit amp expression in lepidoptera but not d. melanogaster, lepidoptera have either a distinct repertoire of prrs responsible for lps - dependent triggering of imd or toll pathways, or an as - yet undiscovered pathway that links lps to amp induction . Testing these ideas awaits the identification of the suite of prrs and signal transduction pathways responsible for transducing lps, lta, pgn, or combinatorial microbial signals to amp gene expression . One class of lepidopteran prr that may mediate infection - dependent induction of amps is the c - type lectins (ctls), ca - dependent, secreted proteins that have carbohydrate - binding capabilities . Similar to some ctls of d. melanogaster, several ctls of m. sexta and b. mori [54, 99] are reported to mediate induction of cellular responses and the propo cascade . Although the nomenclature quickly becomes confusing, ctls include lipopolysaccharide - binding protein (lbp). M. sexta iml-1 binds to gram - positive and gram - negative bacteria as well as yeast, iml-2 shows specific binding to lps, iml-3 and iml-4 show specific binding to lps and lta, and iml-3 can also bind laminarin, a -1,3-glucan [103, 104]. Diversity in ctl carbohydrate - binding specificities may result in lineage - specific pathogen recognition - signal transduction connections . Of particular relevance to the theme of this review are prrs present in lepidoptera but not diptera (table 1). In general, both orders of insects encode grps and pgrps . However, specific representatives of each class are restricted to lepidoptera (table 1). For example, the lepidopteran grp-2, which binds fungal cell wall -1,3 glucans and lta, is absent from diptera . Such derived grp and pgrps may contribute to lepidopteran - specific transduction of signals to downstream pathways . Other lepidoptera - specific prrs are hemolin and hemolymph proteinase-14 precursor (prohp14) (table 1). Like iml c - type lectins, hemolin is an lps- and lta - binding prr with roles in mediating cellular responses and as an opsonin to enhance phagocytosis . Hp14 has been shown to detect and bind a broad range of mamps, and may coordinate with grp1 or grp2 to activate propo [60, 106]. The potential role of the prrs discussed above in mediating the expression of amp genes remains to be determined, and further study of the lepidoptera - specific immune surveillance proteins and divergent activities of conserved prrs likely will yield novel avenues for pest - control . D. melanogaster has both mamp - dependent and mamp - independent routes to activate the toll pathway . In mamp - dependent toll induction, bacterial lys - pgn (typical of gram - positive bacteria) is detected by pgrp - sa or pgrp - sd (in the presence of gnbp-1), while yeast or fungal -1,3-glucan is detected by gnbp-3 [85, 108, 109] (figure 1). Mamp - independent stimuli are virulence determinants, such as proteases and chitinases, secreted by microbes and dubbed mamps and mamp - independent stimuli each trigger a distinct proteolytic cascade that both culminate in cleavage of the cytokine sptzle by the serine protease sptzle processing enzyme (spe). Interaction of active sptzle c - terminal domain (c-106) with the surface - localized toll receptor triggers an intracellular signal transduction terminating in induced expression of amps and cellular responses . Some of the basic components of the toll pathway are present in lepidoptera (figure 2). M. sexta hemocytes express an infection - induced toll - like receptor and the genome of b. mori encodes 14 genes predicted to encode toll - like receptors as well as homologs of each of the intracellular components of toll - dependent signaling [85, 114, 115]. Both m. sexta and b. mori encode homologs of the d. melanogaster toll - activating cytokine sptzle (figure 2). Also, for both m. sexta and b. mori there is experimental evidence linking the toll pathway with amp induction [116118]. In m. sexta, toll pathway results in expression of several antimicrobial peptides, including attacin-1, cecropin-6, moricin and lysozyme . In addition, the transcript level of hemolin, a pattern recognition protein exclusive to lepidopterans (table 1), is induced by injection of activated sptzle - c108 into larvae . Despite the conservation of certain aspects of the toll pathway, the extracellular cascades that lead to sptzle activation may have diverged between d. melanogaster and the two lepidoptera (figure 1). For example, in contrast to what is known in d. melanogaster, the m. sexta toll pathway is activated by gram - negative - associated mamps [115, 118]. Also, the genome of b. mori lacks 1:1 orthologs of grass, spirit and persephone, the d. melanogaster serine proteases responsible for mamp / prr - dependent and mamp - independent cleavage of spe (figure 1). Progress has been made in identifying a m. sexta proteolytic cascade that results in processing pro - sptzle into its active c - terminal domain (c-108). The direct cleavage is mediated by hemolymph proteinase (hp) 8 [11, 13], a homolog of d. melanogaster spe, in turn, hp8 is processed into its active form by hp6 . Hp6 is most similar to d. melanogaster persephone protease, which activates spe in response to mamp - independent stimuli [110, 113]. This hemolymph proteinase is activated in response to gram - positive or gram - negative bacteria and in response to -1,3-glucan . However, the prrs and proteolytic cascade that transduce mamp signals to amp induction are unknown (figure 1). The findings reviewed above demonstrate that while the overall architecture of the toll pathway is conserved among insects, the specific identities of proteolytic cascade members are distinct and many gaps remain in our understanding of toll activation in lepidoptera . Filling these gaps should reveal potential lineage - specific molecules that can serve as targets to hinder the activation of the toll pathway in agricultural pests . In d. melanogaster the imd pathway also contributes to amp gene induction and is triggered by direct interaction of dap - pgn, a mamp typical of gram - negative bacteria, with the transmembrane receptor pgrp - lc [82, 83, 125, 126]. For example, pgrp - le can act as an intracellular receptor for monomeric pgn and its truncated form can enhance pgrp - lc - mediated recognition . Dap - pgn / pgrp - lc interaction activates intracellular imd, which then recruits fas - associated death domain (fadd) and death - related ced-3/nedd2-like protein (dredd) to form a complex [129, 130]. Current evidence supports the idea that dredd, a caspase - like molecule, cleaves the nf-b transcription factor relish . Imd also appears to activate a phosphorelay: the transforming growth factor- (tgf)-activated kinase 1 (tak1) phosphorylates the ikb kinase (ikk) relish cleavage into its activated amino - terminal transcriptional regulator domain allows its translocation into the nucleus, where it activates amp gene expression . The translocation of relish into the nucleus is regulated by two recently discovered components of this pathway: inhibitor of apoptosis 2 (iap2) and transforming growth factor - activated kinase 1 (tak1)-binding protein 2 (tab2) [132, 133]. Both, iap2 and tab2 act upstream of relish and downstream of imd, while iap2 functions downstream of tak1 [132, 134]. Of particular importance to amp gene expression is iap2, the knockdown of which hampers the sustained expression of amp genes . While iap2 and tab2 are necessary for imd signal transduction, the gene product of pirk, a recently characterized gene, interacts directly with imd and pgrp - lc . Pirk overexpression analyses revealed that it acts as a negative regulator by reducing the expression of the amp genes attacin b, cecropin b, and diptericin b, which are all under the control of the imd pathway . Most of the information available about the imd pathway in lepidoptera comes from bioinformatics; orthologs of all intracellular components of the imd pathway have been found in b. mori [54, 137] and m. sexta . However, few experiments have been done to characterize the molecular mechanisms leading to activation of the imd pathway in these insects . In m. sexta several genes of the imd pathway, including those encoding imd, fadd, tak1, dredd and relish are up regulated in fat body of immune challenged 5th instar larvae and in the midgut of b. mori during the wandering stage . Genes encoding lysozyme, moricin and defensin amps also were up regulated in the midgut of b. mori in the wandering stage, consistent with the possibility that amp induction is imd - mediated . Finally, in the lepidopteran beet armyworm spodoptera exigua, rnai - mediated knockdown of relish expression resulted in loss of cecropin induction upon fungal infection, further strengthening the idea that the imd pathway may contribute to amp gene expression in lepidoptera, though perhaps it is triggered by distinct signals . Further study is needed to elucidate imd - mediated amp induction in lepidoptera and to reveal any differences there are in this pathway between diptera and lepidoptera . In d. melanogaster, transcription of amp - encoding genes is activated by the nf-b family transcription factors in response to infection [6569] with distinct nf-b family transcription factors responding to the toll and immune deficiency (imd) signal transduction pathways . In response to toll pathway activation, the nf-b inhibitor cactus is phosphorylated and degraded allowing its targets, the nf-b factors dif and dorsal, to be translocated to the nucleus . Imd pathway activity culminates in the nf-b factor relish being activated by a stimulus - induced proteolytic cleavage . In the case of dif and dorsal, gram - positive bacterial and fungal infections primarily serve as the stimuli that induce degradation of cactus through the toll signaling pathway . In general, gram - negative bacterial infections of d. melanogaster stimulate the proteolytic cleavage of relish through the imd pathway . Once in the nucleus, these transcription factors drive the transcription of immune effectors, including amp genes whose promoters contain nf-b binding sites [70, 72]. Overall, nf-b proteins and their dna - binding specificities are conserved among organisms, including those lepidoptera studied to date [73, 74]. However, the nfb - binding regions for inhibitor of b (ib) proteins (e.g., cactus) are not conserved, suggesting diversification and co - adaptation between ib and nfb pairs . Also, recent work indicates that nf-b nuclear co - regulators may contribute to species - specific regulation of amp gene expression . Therefore, modulation of inhibitors and nuclear - co - regulators of nf-b - dependent transcription may be one avenue by which target - specific immune suppression could be achieved . In d. melanogaster, nf-b - dependent amp induction through the toll and imd pathways is activated by detection of microbial components via different pattern recognition receptors (prrs). Prrs are soluble or membrane - bound proteins that bind to specific microbe associated molecular patterns (mamps) such as lipopolysaccharide (lps), lipoteichoic acid (lta), peptidoglycan (pgn) or -1,3-glucan that are released from or are found on the cell surfaces of bacteria or fungi . Upon interaction with mamps, prrs can directly agglutinate pathogens or trigger proteolytic signaling cascades and cytokine release, which in turn lead to the activation of downstream cellular and humoral pathways, including pro - po activation and amp gene expression [16, 65, 76]. Pgn recognition proteins (pgrps) and -1,3-glucanase - related proteins (grps) were discovered in the lepidopteran silkworm (b. mori) by assaying for plasma components that activate the propo cascade . Pgrps were subsequently shown to be conserved across mammals and insects, and in d. melanogaster their role in the induction of amp gene expression through toll and imd pathways in response to pgn has been well documented [7983]. Similarly, grps have been shown to induce amp expression through toll pathway in response to fungal infections [79, 84]. In contrast, there is a dearth of literature linking specific pgrps or grps to amp induction in lepidoptera . Such a link is possible, since pgn and -1,3-glucan can activate amp gene expression in m. sexta and b. mori [8590] and multiple infection - induced pgrp- and grp - encoding genes have been identified in lepidoptera [32, 38, 54, 55, 9194]. However, there are numerous hints that lepidoptera and diptera may have evolved divergent mechanisms of linking pathogen detection to conserved toll and imd signal transduction cascades . First, a genome comparison between b. mori and d. melanogaster failed to identify 1:1 pgrp orthologs . Similarly, b. mori gram - negative binding protein (gnbp) and m. sexta microbe binding protein (mbp), members of the -1,3-glucanase - related protein superfamily [76, 95], appear to be distantly related to d. melanogaster gnbps, suggesting divergence of this group of proteins . M. sexta mbp expression is strongly up - regulated in fat body after immune challenge and shows specific binding to lta, lps, dap - pgn . Also, in contrast to the situation in d. melanogaster, highly purified lps and lta are inducers of amp gene expression in lepidoptera, though not as potently as crude lps (with contaminating pgn) or purified pgn [85, 90, 96, 97]. This raises the possibility that different mamps or combinations of mamps are most efficacious in eliciting amp gene expression in lepidoptera relative to diptera . Also, since purified lps can elicit amp expression in lepidoptera but not d. melanogaster, lepidoptera have either a distinct repertoire of prrs responsible for lps - dependent triggering of imd or toll pathways, or an as - yet undiscovered pathway that links lps to amp induction . Testing these ideas awaits the identification of the suite of prrs and signal transduction pathways responsible for transducing lps, lta, pgn, or combinatorial microbial signals to amp gene expression . One class of lepidopteran prr that may mediate infection - dependent induction of amps is the c - type lectins (ctls), ca - dependent, secreted proteins that have carbohydrate - binding capabilities . Similar to some ctls of d. melanogaster, several ctls of m. sexta and b. mori [54, 99] are reported to mediate induction of cellular responses and the propo cascade . Although the nomenclature quickly becomes confusing, ctls include lipopolysaccharide - binding protein (lbp). M. sexta iml-1 binds to gram - positive and gram - negative bacteria as well as yeast, iml-2 shows specific binding to lps, iml-3 and iml-4 show specific binding to lps and lta, and iml-3 can also bind laminarin, a -1,3-glucan [103, 104]. Diversity in ctl carbohydrate - binding specificities may result in lineage - specific pathogen recognition - signal transduction connections . Of particular relevance to the theme of this review are prrs present in lepidoptera but not diptera (table 1). In general, both orders of insects encode grps and pgrps . However, specific representatives of each class are restricted to lepidoptera (table 1). For example, the lepidopteran grp-2, which binds fungal cell wall -1,3 glucans and lta, is absent from diptera . Such derived grp and pgrps may contribute to lepidopteran - specific transduction of signals to downstream pathways . Other lepidoptera - specific prrs are hemolin and hemolymph proteinase-14 precursor (prohp14) (table 1). Like iml c - type lectins, hemolin is an lps- and lta - binding prr with roles in mediating cellular responses and as an opsonin to enhance phagocytosis . Hp14 has been shown to detect and bind a broad range of mamps, and may coordinate with grp1 or grp2 to activate propo [60, 106]. The potential role of the prrs discussed above in mediating the expression of amp genes remains to be determined, and further study of the lepidoptera - specific immune surveillance proteins and divergent activities of conserved prrs likely will yield novel avenues for pest - control . D. melanogaster has both mamp - dependent and mamp - independent routes to activate the toll pathway . In mamp - dependent toll induction, bacterial lys - pgn (typical of gram - positive bacteria) is detected by pgrp - sa or pgrp - sd (in the presence of gnbp-1), while yeast or fungal -1,3-glucan is detected by gnbp-3 [85, 108, 109] (figure 1). Mamp - independent stimuli are virulence determinants, such as proteases and chitinases, secreted by microbes and dubbed mamps and mamp - independent stimuli each trigger a distinct proteolytic cascade that both culminate in cleavage of the cytokine sptzle by the serine protease sptzle processing enzyme (spe). Interaction of active sptzle c - terminal domain (c-106) with the surface - localized toll receptor triggers an intracellular signal transduction terminating in induced expression of amps and cellular responses . Some of the basic components of the toll pathway are present in lepidoptera (figure 2). M. sexta hemocytes express an infection - induced toll - like receptor and the genome of b. mori encodes 14 genes predicted to encode toll - like receptors as well as homologs of each of the intracellular components of toll - dependent signaling [85, 114, 115]. Both m. sexta and b. mori encode homologs of the d. melanogaster toll - activating cytokine sptzle (figure 2). Also, for both m. sexta and b. mori there is experimental evidence linking the toll pathway with amp induction [116118]. In m. sexta, toll pathway results in expression of several antimicrobial peptides, including attacin-1, cecropin-6, moricin and lysozyme . In addition, the transcript level of hemolin, a pattern recognition protein exclusive to lepidopterans (table 1), is induced by injection of activated sptzle - c108 into larvae . Despite the conservation of certain aspects of the toll pathway, the extracellular cascades that lead to sptzle activation may have diverged between d. melanogaster and the two lepidoptera (figure 1). For example, in contrast to what is known in d. melanogaster, the m. sexta toll pathway is activated by gram - negative - associated mamps [115, 118]. Also, the genome of b. mori lacks 1:1 orthologs of grass, spirit and persephone, the d. melanogaster serine proteases responsible for mamp / prr - dependent and mamp - independent cleavage of spe (figure 1). Progress has been made in identifying a m. sexta proteolytic cascade that results in processing pro - sptzle into its active c - terminal domain (c-108). The direct cleavage is mediated by hemolymph proteinase (hp) 8 [11, 13], a homolog of d. melanogaster spe, in turn, hp8 is processed into its active form by hp6 . Hp6 is most similar to d. melanogaster persephone protease, which activates spe in response to mamp - independent stimuli [110, 113]. This hemolymph proteinase is activated in response to gram - positive or gram - negative bacteria and in response to -1,3-glucan . However, the prrs and proteolytic cascade that transduce mamp signals to amp induction are unknown (figure 1). The findings reviewed above demonstrate that while the overall architecture of the toll pathway is conserved among insects, the specific identities of proteolytic cascade members are distinct and many gaps remain in our understanding of toll activation in lepidoptera . Filling these gaps should reveal potential lineage - specific molecules that can serve as targets to hinder the activation of the toll pathway in agricultural pests . In d. melanogaster the imd pathway also contributes to amp gene induction and is triggered by direct interaction of dap - pgn, a mamp typical of gram - negative bacteria, with the transmembrane receptor pgrp - lc [82, 83, 125, 126]. For example, pgrp - le can act as an intracellular receptor for monomeric pgn and its truncated form can enhance pgrp - lc - mediated recognition . Dap - pgn / pgrp - lc interaction activates intracellular imd, which then recruits fas - associated death domain (fadd) and death - related ced-3/nedd2-like protein (dredd) to form a complex [129, 130]. Current evidence supports the idea that dredd, a caspase - like molecule, cleaves the nf-b transcription factor relish . Imd also appears to activate a phosphorelay: the transforming growth factor- (tgf)-activated kinase 1 (tak1) phosphorylates the ikb kinase (ikk) relish cleavage into its activated amino - terminal transcriptional regulator domain allows its translocation into the nucleus, where it activates amp gene expression . The translocation of relish into the nucleus is regulated by two recently discovered components of this pathway: inhibitor of apoptosis 2 (iap2) and transforming growth factor - activated kinase 1 (tak1)-binding protein 2 (tab2) [132, 133]. Both, iap2 and tab2 act upstream of relish and downstream of imd, while iap2 functions downstream of tak1 [132, 134]. Of particular importance to amp gene expression is iap2, the knockdown of which hampers the sustained expression of amp genes . While iap2 and tab2 are necessary for imd signal transduction, the gene product of pirk, a recently characterized gene, interacts directly with imd and pgrp - lc . Pirk overexpression analyses revealed that it acts as a negative regulator by reducing the expression of the amp genes attacin b, cecropin b, and diptericin b, which are all under the control of the imd pathway . Most of the information available about the imd pathway in lepidoptera comes from bioinformatics; orthologs of all intracellular components of the imd pathway have been found in b. mori [54, 137] and m. sexta . However, few experiments have been done to characterize the molecular mechanisms leading to activation of the imd pathway in these insects . In m. sexta several genes of the imd pathway, including those encoding imd, fadd, tak1, dredd and relish are up regulated in fat body of immune challenged 5th instar larvae and in the midgut of b. mori during the wandering stage . Genes encoding lysozyme, moricin and defensin amps also were up regulated in the midgut of b. mori in the wandering stage, consistent with the possibility that amp induction is imd - mediated . Finally, in the lepidopteran beet armyworm spodoptera exigua, rnai - mediated knockdown of relish expression resulted in loss of cecropin induction upon fungal infection, further strengthening the idea that the imd pathway may contribute to amp gene expression in lepidoptera, though perhaps it is triggered by distinct signals . Further study is needed to elucidate imd - mediated amp induction in lepidoptera and to reveal any differences there are in this pathway between diptera and lepidoptera . Insecticides are necessary to guarantee effective insect pest management in agricultural settings . However, the cost and off - target effects of these insecticides directly and indirectly increase economic burden; the latter by affecting beneficial arthropods such as pollinators . The study of insect immunity can provide tools for the development of target - specific cost - effective approaches to control agricultural pests . Directed suppression of pest immune defenses is predicted to render them susceptible to environmental and applied biocontrol pathogens, as recently demonstrated in termites by bulmer and colleagues . The studies summarized above suggest that many aspects of insect immunity, including recognition factors and serine proteases, have diverged between d. melanogaster and lepidoptera . Continued comparative immunity of a broad array of species from diptera, lepidoptera, and other insect orders will reveal possible candidate immunity factors for target - specific approaches that will enable the effective control of insect pests . However, before such approaches can be realized, the details of lepidopteran immune signaling pathways must be elucidated . The relatively large sizes of last instar larvae of many lepidopteran species will facilitate biochemical approaches to such studies, while the establishment of immune - inducible lepidopteran cell lines such as the uga - cie1 cell line can enable the characterization of molecular mechanisms leading to imd pathway activation and its contribution to amp gene expression . Finally, ongoing investigations into the immune - modulatory mechanisms of entomopathogens will help identify key steps in immunity that are susceptible to manipulation, contributing to the development of natural, cost - effective, non - toxic alternatives to chemical insecticides currently used for pest management.

Syncope is caused by transient diffuse cerebral hypoperfusion and is characterized by transient loss of consciousness with a rapid onset followed by spontaneous and complete recovery . Clinical features of syncope may include myoclonic jerks which are often multifocal and asynchronous, convulsions, and urinary incontinence, making it difficult to differentiate from epileptic seizure by clinical features alone . Significant fluctuations in cerebral perfusion pressure are prevented by autoregulation of cerebral circulation, but there may be conditions where such mechanism may not compensate adequately . Cough syncope, a rare form of syncope, may be a result of transient failure of the cerebral autoregulatory mechanism to cope with sudden decrease in cerebral blood flow . We present an unusual case of recurrent cough syncope, which was initially diagnosed and treated as seizures, in the context of a left - sided glomus jugulare tumor, a benign paraganglioma . A 43-year - old right - handed woman with history of glomus jugulare tumor in the left jugular fossa with intracranial extension into the posterior cranial fossa was transferred from another hospital for recurrent seizure - like spells . She had a 90% surgical resection of the tumor done in 2011 followed by radiation therapy in september 2012 . Her episodes occurred multiple times a day (7 per day on average) during wakeful state . They were triggered by coughing (usually a bout of cough) and were characterized by staring and unresponsiveness as well as stiffening of the body with mild shaking of both upper extremities . She was diagnosed with epileptic seizures but continued to have episodes during treatment with the antiepileptic drugs (aeds) phenytoin, levetiracetam, and lamotrigine . Escalation of aed therapy made her increasingly drowsy, and she was on all three aforementioned aeds at the time of presentation . Her physical examination was remarkable for excessive drowsiness, mild dysarthria, right sixth cranial nerve palsy, mild hypertonia with hyperreflexia in the lower extremities (left more than right), and bilateral (left more than right) ankle clonus . She had a lumbar puncture done at the outside hospital, and the opening cerebrospinal fluid (csf) pressure was reported to be 25 cm . Blood work was also unremarkable except for mild anemia (hemoglobin: 9.4 g / dl), mild hyponatremia (132 meq / l), and mild hypokalemia (3.1 meq / l). Antiepileptic drug levels were within therapeutic range (free phenytoin: 1.3 g / ml, levetiracetam: 5.9 g / ml, and lamotrigine: 2.3 g / ml). All started with a bout of cough when the patient was lying in bed (in supine or in lateral position) which was followed by brief (less than a minute) distal upper extremity tremor and subtle proximal upper extremity myoclonic jerks and prolonged unresponsiveness for up to 10 min . All of these episodes were associated with hypotension (7278/3147 mm of hg as revealed by continuous arterial pressure monitoring) and bradycardia (5459 bpm). The eeg during the spells was characterized by generalized synchronous and asynchronous high amplitude 1- to 2-hz delta activity which progressed to generalized attenuation and then transitioned to generalized delta activity again with recovery (fig . 1). A head ct showed recurrence of the glomus jugulare tumor and communicating hydrocephalus . An external ventricular drain (evd) after placement of the evd, her drowsiness gradually started to improve, and episodes decreased in frequency to one per day . 3 showed an enhancing t2 hyperintense left skull base mass in the region of the left jugular foramen with extension into the posterior cranial fossa and below the base of the skull . Brain imaging showed evidence of hydrocephalus that had increased compared with her previous brain imaging done 2 months back . Her mental status continued to improve, and she had only one mild episode triggered by cough during the next two days before her discharge . Repeat surgical resection of the tumor was recommended by the otolaryngology team, which the patient declined . Based on the clinical features and eeg findings, the episodes observed in our patient are most consistent with cough syncope . The mechanism underlying cough syncope is not definitively established, but it is postulated that coughing increases intrathoracic and intraabdominal pressures leading to a transient increase in icp . Increased icp, in turn, causes a decrease in cerebral perfusion pressure which, if it drops below a critical level, may result in global cerebral hypoperfusion leading to syncope . Transient cerebral circulatory arrest has been demonstrated by transcranial doppler measurements during cough syncope . Our patient also had a drop in blood pressure and heart rate but probably not sufficient to cause syncope by itself . Cough syncope has been associated with posterior fossa mass lesions or tonsillar herniation and with hydrocephalus . It may be speculated that bouts of cough caused transient herniation of cerebellar tonsils obstructing csf flow that further contributed to the increase in icp during coughing . Decrease in frequency of events following placement of evd to relieve icp lends support to this notion . Paragangliomas are rare tumors of extraadrenal chromaffin cell origin that most commonly occur in the head and neck region . Catecholamine - hypersecreting paraganglionomas are uncommon in the head and neck region, and most patients (95%) with hypersecreting paraganglionomas have hypertension . Hypotension accompanying syncope observed in our patient was not orthostasis - related (the patient was always supine during spells) and was most likely related to cough . Identified a subset of patients with cough syncope who lacked a blood pressure overshoot (expected response) after the relief of straining during valsalva maneuver . The authors postulate that cough syncope in these patients might be the result of delayed recovery from hypotension that follows a paroxysm of cough, and this was likely contributing to global cerebral hypoperfusion in our patient . This case highlights the fact that cough syncope, a rare form of syncope, may be associated with intracranial mass lesions that indirectly exaggerate the increase in icp in response to cough . Glomus caroticum tumor presenting as recurrent unexplained syncope and posterior fossa meningioma presenting as recurrent cough syncope have been described . Recurrent cough syncope should trigger search for factors, including brain tumors, with the potential to cause transient elevation in icp . This case also illustrates an important role for ceeg monitoring with video in distinguishing syncope from seizures in cough syncope cases.

World - wide, infertility affects 1015% of couples who are trying to conceive, and about 15% of these cases are caused by male factors, which affect 1 out of 20 men in the general population . Most cases of male infertility are idiopathic, apart from several etiologies, such as obstruction of deferent duct, varicocele, sexual dysfunction, and cryptorchidism . Although assisted reproductive technology (art) has helped many sterile couples to conceive, non - obstructive azoospermia (noa), which accounts for a considerable proportion of male infertility, has a dramatically lower rate of sperm retrieval and clinical pregnancy . The etiological mechanism of noa is unknown, but factors such as oxidative stress were considered to have effects on spermatogenesis, and some antioxidants have been effective in protecting spermatogenesis . Therefore, it is helpful to explore the underlying pathogenesis of noa in these patients . Micrornas are a class of small rnas that do not code amino acid sequences, but they play fundamental roles in regulating gene expression after transcription . Lian et al . Found 154 down - regulated mirnas and 19 up - regulated mirnas in testes of noa patients compared to fertile males, by using microarray technologies . Furthermore, some of the mirnas have been shown to affect the proliferation, apoptosis, and dna damage in germ cells [911]. Mir-210 is one of the 19 up - regulated mirnas in testes of noa patients, located within the genomic loci of transcript ak123483 . It can be induced by hypoxia, and plays an essential role in cell adaptation to hypoxia . Mir-210 also affects regulation of diverse physiological processes, such as angiogenesis, cell survival, proliferation, cell cycle arrest, protein modification, and dna damage repair . Although mir-210 has been shown to be involved in regulation of physiological processes in various diseases and to be an up - regulated mirna in testes of noa patients, it remains unknown how mir-210 affects spermatogenesis . Hence, the aim of this study was to investigate the underlying mechanisms by which mir-210 is involved in the pathogenesis of spermatogenesis . We enrolled 25 patients (aged 1841 years) with azoospermia (proven by 3 semen analyses from testicular biopsies from the first affiliated hospital of anhui medical university). Pathological examinations were performed on each testicular specimen . Combined with clinical features, 4 patients were diagnosed as having sertoli - cell - only syndrome (scos), 7 patients were diagnosed as having maturation arrest (ma), 8 patients were diagnosed as having hypospermatogenesis, and the other 6 patients were diagnosed as having obstructive azoospermia (oa). All patients provided informed consent before their participation in this study . Our local medical ethics committee approved this study before it began . To examine the location of insulin - like growth factor ii (igf2) in human testicular tissues, we performed immunohistochemistry staining to detect the igf2 expression . Tissues were cut into sections for immunoperoxidase staining after being treated with 4% pfa and paraffin wax . After the specific treatment with standard - procedure immunohistochemistry staining as described as lian et al ., sections were incubated with igf2 antibody (abcam) overnight at 4c and biotinylated secondary antibody (abcam) for 2 h at room temperature . To detect expression of mir-210, rnas were extracted from nt-2 cells or tissues and subjected to real - time pcr as described as lian et al . . Briefly, rna extraction was performed following a standard trizol protocol, real - time pcr was carried out with the abi step one system (applied biosystems), and the sybr premix ex taq ii kit (takara bio, inc .) Was used . Primers for q - rt pcr were as follows: forward primer: 5-caataactgtgcgtgtgacagc-3 reverse primer: 5-tatggttttgacgactgtgtgat-3 forward primer: 5-cagcacatatactaaaattggaacg-3 reverse primer: 5-acgaatttgcgtgtcatcc-3 western blot analysis was carried out to detect protein expression of igf2 in the human testicular tissues in the 3 groups and in nt2 cells . Anti - igf2 (abcam) was used for western blot analysis, and we used -actin as a loading control to detect expression of igf2 . We supplemented the medium with 10% fetal bovine serum (life technology inc . ), 1% antibiotics (100 units / ml penicillin, and 100 ug / ml streptomycin, life technology inc . ). Cells were incubated at 37c in a humidified incubator with 5% co2 . To transfect oligonucleotides and plasmids into nt-2 cells, lipofectamine rnaimax (invitrogen) and fugene hd (roche) all processes were performed in accordance with the protocols supplied by manufacturers . In this study, all the experiments were performed independently at least 3 times . We enrolled 25 patients (aged 1841 years) with azoospermia (proven by 3 semen analyses from testicular biopsies from the first affiliated hospital of anhui medical university). Pathological examinations were performed on each testicular specimen . Combined with clinical features, 4 patients were diagnosed as having sertoli - cell - only syndrome (scos), 7 patients were diagnosed as having maturation arrest (ma), 8 patients were diagnosed as having hypospermatogenesis, and the other 6 patients were diagnosed as having obstructive azoospermia (oa). All patients provided informed consent before their participation in this study . To examine the location of insulin - like growth factor ii (igf2) in human testicular tissues, we performed immunohistochemistry staining to detect the igf2 expression . Tissues were cut into sections for immunoperoxidase staining after being treated with 4% pfa and paraffin wax . After the specific treatment with standard - procedure immunohistochemistry staining as described as lian et al ., sections were incubated with igf2 antibody (abcam) overnight at 4c and biotinylated secondary antibody (abcam) for 2 h at room temperature . Rnas were extracted from nt-2 cells or tissues and subjected to real - time pcr as described as lian et al . . Briefly, rna extraction was performed following a standard trizol protocol, real - time pcr was carried out with the abi step one system (applied biosystems), and the sybr premix ex taq ii kit (takara bio, inc .) Was used . Primers for q - rt pcr were as follows: forward primer: 5-caataactgtgcgtgtgacagc-3 reverse primer: 5-tatggttttgacgactgtgtgat-3 forward primer: 5-cagcacatatactaaaattggaacg-3 reverse primer: 5-acgaatttgcgtgtcatcc-3 western blot analysis was carried out to detect protein expression of igf2 in the human testicular tissues in the 3 groups and in nt2 cells . Anti - igf2 (abcam) was used for western blot analysis, and we used -actin as a loading control to detect expression of igf2 . We supplemented the medium with 10% fetal bovine serum (life technology inc . ), 1% antibiotics (100 units / ml penicillin, and 100 ug / ml streptomycin, life technology inc . ). Cells were incubated at 37c in a humidified incubator with 5% co2 . To transfect oligonucleotides and plasmids into nt-2 cells, lipofectamine rnaimax (invitrogen) and fugene hd (roche) the igf2 gene is part of a cluster of imprinted genes expressing the single polypeptide as igf2, which is only produced from the paternal allele . The maternal allele is transcriptionally silent . To clarify the location of igf2 in human testicular tissues, we found igf2 located in spermatocytes in the testes of patients with oa (figure 1). Because igf2 is located in spermatocytes of the testis, we detected the expression of igf2 in cases with ma, hypospermatogenesis, and oa, but not in the scos patients . We found that igf2 was down - regulated in patients with ma and hypospermatogenesis compared to oa patients, which was considered as the control group with normal spermatogenesis, although without a significant difference (figures 2, 3), possibly because there were fewer samples and longer preservation times of some samples . Quantitative real - time pcr was performed to examined mir-210 expression in the testis of patients with ma, hypospermatogenesis, and oa . We found that mir-210 was significantly up - regulated in the testis of ma and hypospermatogenesis patients compared to oa patients (figure 4). However, due to errors in the rna extraction in the preliminary experiment, 3 testis samples (1 each) from ma, hypospermatogenesis, and oa patients were damaged and were not tested . In the targetscan database, because the 3utr of the igf2-mrna has a putative mir-210-binding site, igf2 was predicted to be a potential target of mir-210 . To identify whether the igf2 gene was targeted by mir-210 directly, renilla luciferase reporters, which include the wild - type full - length 3utr forms of mir-210 seeding sites, figure 5 shows that there was a 60% decrease in luciferase activity after cotransfection of the mir-210 mimic and the renilla luciferase reporters into nt2 cells, and inhibiting mir-210 expression increased activity of the reporter renilla luciferase . Expression of igf2 protein was also significantly lower in the nt2 cells transfected with mir-210 mimics than in control cells, and knockdown of mir-210 with mir-210 inhibitor increased protein expression of igf2 (figures 6). The igf2 gene is part of a cluster of imprinted genes expressing the single polypeptide as igf2, which is only produced from the paternal allele . The maternal allele is transcriptionally silent . To clarify the location of igf2 in human testicular tissues, we found igf2 located in spermatocytes in the testes of patients with oa (figure 1). Because igf2 is located in spermatocytes of the testis, we detected the expression of igf2 in cases with ma, hypospermatogenesis, and oa, but not in the scos patients . We found that igf2 was down - regulated in patients with ma and hypospermatogenesis compared to oa patients, which was considered as the control group with normal spermatogenesis, although without a significant difference (figures 2, 3), possibly because there were fewer samples and longer preservation times of some samples . Quantitative real - time pcr was performed to examined mir-210 expression in the testis of patients with ma, hypospermatogenesis, and oa . We found that mir-210 was significantly up - regulated in the testis of ma and hypospermatogenesis patients compared to oa patients (figure 4). However, due to errors in the rna extraction in the preliminary experiment, 3 testis samples (1 each) from ma, hypospermatogenesis, and oa patients were damaged and were not tested . In the targetscan database, because the 3utr of the igf2-mrna has a putative mir-210-binding site, igf2 was predicted to be a potential target of mir-210 . To identify whether the igf2 gene was targeted by mir-210 directly, renilla luciferase reporters, which include the wild - type full - length 3utr forms of mir-210 seeding sites, were used . Figure 5 shows that there was a 60% decrease in luciferase activity after cotransfection of the mir-210 mimic and the renilla luciferase reporters into nt2 cells, and inhibiting mir-210 expression increased activity of the reporter renilla luciferase . Expression of igf2 protein was also significantly lower in the nt2 cells transfected with mir-210 mimics than in control cells, and knockdown of mir-210 with mir-210 inhibitor increased protein expression of igf2 (figures 6). During recent decades several studies have focused on the effects of mirnas on spermatogenesis in male infertility [911,17]. However, it was not understood how mir-210, which is one of the up - regulated mirnas in testes of patients with noa, was involved in spermatogenesis in male infertility . The transformation of diploid spermatogonia into mature haploid cells in spermatogenesis is a complex biological process in the testes of males . The insulin / igf system takes part in the processes of cell proliferation, cell growth, differentiation, and survival, which affects nearly every organ in the body . Also, insulin / igf plays an important role in the proper function of the testis in males . Igf2 binds to igf1r and insr - a with a high affinity and binds to insr - a / igf1r, insr - b / igf1r, but with lower affinity . Found that in inactivated insr and igf1r, there was a 79% reduction in daily sperm production in adult mouse testes by a conditional ko approach . Taken together, the aforementioned data suggest that igf2 might be involved in the process of spermatogenesis . To examine the specific mechanism by which mir-210 is associated with the process of spermatogenesis, quantitative real - time pcr was performed to detect mir-210 expression . We found that mir-210 was significantly up - regulated in the testes of subjects with ma and hypospermatogenesis patients compared to oa . These results agree with findings of lian et al . Using microarray technologies performed in noa and normal controls . Several studies have suggested that this mirna could be mediated by hypoxia and participate in various types of regulation of angiogenesis, cell survival, proliferation, cell cycle arrest, and protein modification [1214]. Furthermore, some researchers even found that mir-210 might be considered as one of the indicated markers in some diseases, such as clear cell renal cell carcinoma and acute myeloid leukemia . In the present study we found that igf2 was targeted by mir-210 directly in the in vitro experiment in nt2 cells, and mir-210 might be associated with spermatogenesis by targeting igf2 in male infertility . Firstly, as some errors occurred in the rna extraction in the preliminary experiment, mir-210 of 3 testes samples were damaged and not detected in the subsequent quantitative real - time pcr experiment, which might have affected our results . Secondly, we did not investigate the functions of mir-210 and igf2 in vitro or in vivo, and we plan to do this in future research . We demonstrated that mir-210 might be associated with spermatogenesis by targeting igf2 in male infertility . Future mechanistic studies on the role of mir-210/igf2 in the process of spermatogenesis in male infertility will provide new insights into the diagnosis and management of male infertility.

Midwife - led primary delivery care for low - risk pregnant women during labor has been reported to have various advantages, such as increased odds of high maternal satisfaction and a decrease of unnecessary medical interventions [18]. Although the maternity care system for low - risk pregnant women peculiar to one country cannot easily be compared with those in other countries, consumer demands for the humanization of obstetric care have arisen in various countries [18]. To date, we have found no evidence that midwife - led primary obstetric care is unsafe for low - risk pregnant women in comparison with obstetric care with the favorable cooperation of obstetricians and midwives in japan [912]. In addition, about 85% of low - risk pregnant women request that they give birth while receiving midwife - led primary delivery care . Therefore, safe midwife - led delivery care with the backup of obstetricians may also be required for low - risk pregnant women in japan . If complications occur or threaten to occur during the primary midwife - led delivery care, the midwives have to refer the woman to obstetricians at the same or a neighboring hospital or private obstetric clinic as soon as possible . This is because, in deliveries managed by independent midwives in japan, many intervention measures, such as oxytocin infusion, epidural anesthesia, episiotomy, suture, and instrumental delivery, are not available based on japanese legal restrictions . In our institute, one of the main tokyo city perinatal centers, there are 3 japanese systems of midwife - led delivery care, as follows: (1) those intending to give birth at home managed by midwives who do not belong to our hospital, (2) those planning to give birth on futons (i.e., japanese - style bedding) in japanese tatami mat delivery rooms in our hospital managed by the same midwives who do not belong to our hospital, and (3) those planning to give birth in japanese tatami mat delivery rooms managed by midwives who belong to our hospital . The objective of this study was to describe trends in transfers and perinatal outcomes among labors using these 3 japanese systems of midwife - led primary delivery care . The protocol for this analysis was approved by the ethics committee of the japanese red cross katsushika maternity hospital . In addition, informed consent for analysis from a retrospective database was obtained from each subject during their hospital visit . In our hospital, pregnant women who are initially considered low - risk at 3436 weeks of gestation can choose freely between the 3 systems of midwife - led care and obstetric shared care . In the midwife - led care units, midwives can practice autonomously and are fully accountable for their own practice, unsupervised by obstetricians . Factors used to exclude women from the low - risk group comprise the following [912]: (1) medical history: pregnancy - induced hypertension, chronic hypertension, diabetes mellitus, renal disease, idiopathic thrombocytopenia, and other systemic illnesses; (2) gynecological history: history of infertility therapies of in vitro fertilization, congenital uterine anomalies, uterine myomatosis, and adnexal anomaly; (3) obstetric history: narrowing of the pelvic outlet, cephalopelvic disproportion, previous cesarean section, previous anal sphincter injury, previous postpartum hemorrhage 1,000 ml with blood transfusion, previous manual removal of placenta, previous gestational diabetes, and history of severe preeclampsia; (4) complications during the present pregnancy: multiple pregnancy, nonvertex presentation, obesity (maternal body mass index before pregnancy 25 and/or during the third trimester 28), anemia (hemoglobin <9.0 g / dl), epilepsy with treatment, polyhydramnios, oligohydramnios, low - set placenta, placenta previa, fetal growth restriction, heavy for date fetus, gestational diabetes, and pregnancy - induced hypertension; when risk factors are present, those women are managed by obstetricians and midwives; (5) complications during labor: intrauterine infection, thick meconium staining, prolongation of labor such as active - phase dilation <1 cm / hour and duration of second stage of labor 2 hours, prolonged rupture of membranes (24 hours), uterine inertia, arrest of labor, and fetal heart rate abnormality such as a nonreassuring fetal status . When these factors are present, the women are transferred to be managed mainly by obstetricians (obstetric shared care) in a standard western - style delivery room or surgery room in our hospital . A retrospective study was performed to examine trends in transfers and perinatal outcomes among labors that started using the 3 systems of midwife - led primary delivery care . In this study, student's t - test was used for continuous variables and the test for categorical variables . Odds ratios (ors) and 95% confidence intervals (cis) were also calculated . Differences with p between 2009 and 2012, a total of 678 low - risk women were placed in the 3 forms of midwife - led primary delivery care at the onset of labor pains and/or rupture of membranes at 3741 weeks of gestation . Of these, 123 (18%) intended to give birth at home, 88 (13%) planned to give birth in the japanese tatami mat rooms in our hospital managed by midwives who do not belong to our hospital, and 467 (59%) planned to give birth managed by the midwives belonging to our hospital . Table 1 shows the clinical descriptions of the 678 pregnant women initially considered as low - risk for receiving our midwife - led primary delivery care systems . There were no significant differences in the maternal age or parity among the 3 groups . Table 2 shows the rate of transfers in the 3 groups of the midwife - led primary delivery care systems . The total rate of transfers in the system run by the midwives belonging to our hospital (56%) was higher than in the other 2 systems run by the independent midwives (31% in planned home birth: or 1.87, 95% ci 1.23.0, p <0.01; 38% in planned hospital birth: or 2.51, 95% ci 1.73.8, p <0.01). In addition, the timing of transfers in the system run by the midwives belonging to our hospital (before the second stage of labor: 52%) was earlier than those in the other 2 systems (21% in the planned home birth: or 4.12, 95% ci 2.66.6, p <0.01; 20% in planned hospital birth: or 4.29, 95% ci 2.57.4, p <0.01). However, if classified into nulliparous and parous women, there were no significant differences in the rate of transfers among the 3 groups, as shown in table 1 . In addition, among the 3 groups there were no significant differences in the rate of the main 2 indications for transfer: fetal heart rate abnormality and failure to progress . The main indications for transfer after delivery were maternal postpartum hemorrhage and neonatal respiratory distress associated with asphyxia . Table 3 shows the obstetric and neonatal outcomes in the pregnant women initially considered as low - risk for receiving our midwife - led primary delivery care systems . There were no significant differences in these outcomes among the 3 groups our obstetric care system involves the division of women in labor into low- and high - risk groups [912]. The women who are initially considered low - risk can choose freely between midwife - led care and obstetric shared care . If complications occur or risk factors arise during labor in the primary midwife - led care, they are transferred to obstetric shared care . This may be the first report concerning the differences in the timing of transfers from midwife - led care to obstetric shared care among the 3 systems of midwife - led primary delivery care in japan . In this study, there was no evidence that the primary midwife - led care is unsafe for low - risk pregnant women in any of these 3 midwife - led delivery care systems . However, there were no significant differences in the timing of referrals from midwife - led care to obstetric shared care between the system led by midwives who belong to our hospital (hospital midwifery system) and the systems led by the midwives who do not belong to our hospital . In the hospital midwifery system, the timing of transfers seemed to be the earliest due to the ease of transfer within the same hospital and administrator setting . On the other hand, the rate of transfers after delivery with the other 2 systems was higher than that in the hospital midwifery care . During the period, the main indications for transfers were maternal postpartum hemorrhage and/or neonatal respiratory distress associated with asphyxia . Fortunately, the difference was not associated with adverse obstetric or neonatal outcomes; however, unfortunately, they led to early mother - to - child separation, especially in cases of planned home birth because healthy puerperal women or newborns cannot be transferred from home to hospital according to japanese law . Although home birth might be very comfortable, those involved must be prepared for mother - to - child separation in cases of referrals after delivery . The major limitations of this study were the small sample size and lack of long - term follow - up of mothers and children to consider the potential of the findings based on our own context . There were no cases of fetal / neonatal death under the midwife - led delivery care . The most evaluated outcome under midwife - led delivery was the satisfaction of pregnant women with the development of mother - child relationships after delivery . In addition, there might be some bias related to the backgrounds in the selection of the systems because this was not a randomized trial study . Therefore, a further large prospective study with long - term follow - up may be needed . There were no significant differences in perinatal outcomes among the 3 systems; however, there were some differences in the status of the transfers to the obstetric shared care.

Diabetes decreases the overall life expectancy and cause a heavy burden on public health (1). Moreover, the asia - pacific region is considered to be on the verge of an emerging diabetes epidemic (2). The development of type 2 diabetes is affected by genetic and environmental determinants (3). Recently, one study investigated whether common variants of functional and positional candidate genes, including adrb3, pparg, enpp1 and capn10, were determinants of type 2 diabetes (4). Enpp1, also called k121q, has a glutamine substitution for lysine at codon 121 (5). Type 2 diabetes is characterized by insulin resistance (6), and enpp1 plays an important role in insulin resistance (7, 8). Enpp1 interacts with -subunit of the insulin receptor to interrupt signaling (9). In previous studies, the k121q polymorphism of the human pc-1 gene was strongly associated with insulin resistance (1, 3, 7, 10 - 12). However, there was no association between insulin resistance and the k121q variant (13, 14). In addition, there were discrepancies for the impact of enpp1 polymorphism on obesity between ethnic groups (5, 10, 13, 15 - 19). Obesity increases the concentration of insulin in plasma and is the major contributor of insulin resistance (20). Obesity appears to be an effect modifier of type 2 diabetes in d1057 carriers (21). The association of obesity with the genetic variant of the insulin receptor substrate was identified in other studies (21, 22). In the chinese han population, the pc-1 q121 allele was associated with insulin resistance . In women, carriers of the q allele had an increased risk for obesity development (3). In caucasians and african - americans, 121q carriers had an association with increased body mass index (bmi) (23), and the three - allele risk type haploid qdeltg with the q allele increased the risk for obesity (24) however, in the danish population, there were no differences in the distribution of frequencies of dominant types (kk wild type and kq / qq variant type) and alleles (19). The complexity of type 2 diabetes is related to factors such as genetic heterogeneity, interactions between genes, and the modulating role played by the environment (4). In spite of these limitations, studies of type 2 diabetes and genetic factors of obesity can predict the risks for development of both type 2 diabetes and obesity in order to assist primary prevention, and korea is an appropriate country for such studies because of the homogeneity of racial composition and lifestyle (25). Therefore, the aim of this study was to analyze the presence of the enpp1 polymorphism, not studied yet in korean population, to identify the association between genotypes and allele with type 2 diabetes and obesity . This company is an electric power company located at kori, yonggwang, ulchin, wolsung, and seoul in korea . There were 195 male workers (age 48.26.7 yr, bmi 24.672.64 kg / m) who were diagnosed as diabetics during medical examinations conducted from march 2004 to october . The 1,750 male workers (age 45.27.7 yr, bmi 24.772.64 kg / m) in the control group were selected randomly . Subjects were included if they met one of the criteria below and their onset age was older than 20 yr old to exclude type 1 diabetes: 1) blood - sugar level before a meal exceeded 126 mg / dl twice or more; 2) blood - sugar level before a meal exceeded 126 mg / dl once or more and blood - sugar level two hours after a meal exceeded 200 mg / dl; 3) those who reported that he had a history of diabetes in the questionnaire and being taken oral hypoglycemic agents . The workers included in the obesity group were those whose bmi was 25 kg / m or more . After collecting a blood sample from vein in fasting (8 hr) status, we measured the blood - sugar level, insulin, and lipid profile . We also measured height and weight to calculate bmi . If fasting glucose levels were greater than 126 mg / dl, we checked the 2 hr post - prandial plasma glucose level at each site within 1 month . Height and weight were measured by autoanalyzer (health guard, fanics, seoul, korea). The fasting blood level was analyzed by glucose - oxidase assay using an autochemistry analyzer . To determine the lipid profile, total cholesterol was analyzed by enzyme assay using cholesterol oxidase (cod), high density lipoprotein (hdl) cholesterol by glycerol phosphate oxidase assay, low density lipoprotein (ldl) cholesterol by direct surfactant assay . We carried out this study under the approval by the ethnics committee of the asan medical center, and obtained written consent from all subjects, providing subjects with sufficient explanation to obtain informed consent . We extracted genomic dna from buffy coats using the generall blood sv kit (general biosystem, seoul, korea) and following the instructions suggested by the manufacturer . The method of genotyping used to identify the k121q polymorphism in enpp1 exon 4 was polymerase chain reaction - restriction fragment length polymorphism (pcr - rflp), using dna treated with a restriction enzyme after pcr, based on the paper reported by abate et al . We carried out student's t - test to analyze the effects of genotypes on biochemical parameters using genotypes as factors . The hardy - weinberg equilibrium was computed based on the goodness - of - fit test . We also investigated the differences in frequencies of genotypes between type 2 diabetic and normal groups, and between obesity and normal groups by fisher's exact test . The spss 12.0 (for window) statistical software package was used for statistical analysis . This company is an electric power company located at kori, yonggwang, ulchin, wolsung, and seoul in korea . There were 195 male workers (age 48.26.7 yr, bmi 24.672.64 kg / m) who were diagnosed as diabetics during medical examinations conducted from march 2004 to october . The 1,750 male workers (age 45.27.7 yr, bmi 24.772.64 kg / m) in the control group were selected randomly . Subjects were included if they met one of the criteria below and their onset age was older than 20 yr old to exclude type 1 diabetes: 1) blood - sugar level before a meal exceeded 126 mg / dl twice or more; 2) blood - sugar level before a meal exceeded 126 mg / dl once or more and blood - sugar level two hours after a meal exceeded 200 mg / dl; 3) those who reported that he had a history of diabetes in the questionnaire and being taken oral hypoglycemic agents . The workers included in the obesity group were those whose bmi was 25 kg / m or more . After collecting a blood sample from vein in fasting (8 hr) status, we measured the blood - sugar level, insulin, and lipid profile . We also measured height and weight to calculate bmi . If fasting glucose levels were greater than 126 mg / dl, we checked the 2 hr post - prandial plasma glucose level at each site within 1 month . Height and weight were measured by autoanalyzer (health guard, fanics, seoul, korea). The fasting blood level was analyzed by glucose - oxidase assay using an autochemistry analyzer . To determine the lipid profile, total cholesterol was analyzed by enzyme assay using cholesterol oxidase (cod), high density lipoprotein (hdl) cholesterol by glycerol phosphate oxidase assay, low density lipoprotein (ldl) cholesterol by direct surfactant assay . We carried out this study under the approval by the ethnics committee of the asan medical center, and obtained written consent from all subjects, providing subjects with sufficient explanation to obtain informed consent . We extracted genomic dna from buffy coats using the generall blood sv kit (general biosystem, seoul, korea) and following the instructions suggested by the manufacturer . The method of genotyping used to identify the k121q polymorphism in enpp1 exon 4 was polymerase chain reaction - restriction fragment length polymorphism (pcr - rflp), using dna treated with a restriction enzyme after pcr, based on the paper reported by abate et al . We carried out student's t - test to analyze the effects of genotypes on biochemical parameters using genotypes as factors . The hardy - weinberg equilibrium was computed based on the goodness - of - fit test . We also investigated the differences in frequencies of genotypes between type 2 diabetic and normal groups, and between obesity and normal groups by fisher's exact test . The spss 12.0 (for window) statistical software package was used for statistical analysis . The frequencies of the kk type, kq type, and qq type in enpp1 k121q were 82.1%, 17% and 0.9%, respectively . The homozygous type of q carrier (qq type) was added to the heterozygous type (kq type) because the frequency of qq type was very low (0.9%). We investigated the differences in age, blood pressure, bmi, and results of clinical examinations according to genotypes of enpp1 k121q between the type 2 diabetic and non - diabetic groups (table 1). When type 2 diabetics and non - diabetics were pooled (n=1,945), there were no significant differences in bmi, systolic pressure, diastolic pressure, glucose value in fasting status, total cholesterol, ldl cholesterol, hdl cholesterol, triglyceride, c - reactive protein, and homa - ir between the kk type and kq+qq type . In addition, there were no significant differences in the same characteristics above between type 2 diabetic group and non - diabetic groups (table1), and between the obese group and non - obese groups (table2). The frequencies of genotypes were in accordance with the hardy - weinberg equilibrium (p=0.85). The odds ratio of having a kq+qq genotype was 0.85 for diabetics versus non - diabetics . The odds ratio of having a q allele was 0.91 for diabetics versus non - diabetics . However, there was no significant difference in the genotypic and allelic distribution between type 2 diabetics and non - diabetics (table3). The odds of a kq+qq genotype were 0.93 for obese versus non - obese subjects . Furthermore, the odds of having a q allele were 0.96 for obese versus non - obese subjects . However, there was no significant difference in the genotypic and allelic distribution between obese and non - obese (table4). The frequency of the kk type in enpp1 k121q genotypes was 82.1%, that of kq+qq type was 17.9% and that of q allele was 9.4% . There was no statistically significant difference in the distribution among these genotypes and alleles (p=0.81, p=0.89, respectively), although the 121q carrier and q allele in obese and/or diabetics seemed to differ slightly from those in the non - obese non - diabetics (reference group). In determining the prevalence of the q allele carriers (kq and qq subjects) and q allele, there were no significant differences in the genotypic and allelic distribution with the respect to any phenotypes (data not shown). After adjusting for the effects of obesity, the probability of type 2 diabetes in kq+qq type was 0.858 (data not shown) and that in q allele was 1.095, showing no significant difference (table 5). Moreover, after adjusting for the effects of type 2 diabetes, the probability of developing obesity in the kq+qq type was 0.936 (data not shown) and that in the q allele was 1.038, showing no significant difference (table 6). The results of studies of the association between enpp1 k121q variants and both type 2 diabetes and obesity in several races are disparate . We carried out this study to investigate the association of k121q variants with type 2 diabetes and obesity in korean male workers . Insulin resistance is a major component of the pathogenesis of type 2 diabetes (27), and insulin receptor kinase activity is impaired in muscle and other insulin - sensitive tissue of many type 2 diabetic patients (28), and then a potential inhibitor of the insulin receptor tyrosine kinase is identified as the plasma - cell membrane differentiation antigen-1 (pc-1) (29). Therefore, it is significant to analyze enpp1 (pc-1) polymorphism . In the previous studies of the association between type 2 diabetes and polymorphism in enpp1, the k121q missense mutation increased the odds ratio (or) for type 2 diabetes in dominican (10), south asian, caucasian (16), finnish (18), and french populations (24). Moreover, according to a meta - analysis of the association between enpp1 k121q variant and type 2 diabetes, the odds ratios were 1.30 (95% confidence interval [ci], 1.13 - 1.50) (16) and 1.17 (95% ci, 1.10 - 1.25) (19), showing significant association . In this study, 121q was not associated with type 2 diabetes, showing consistent results with those in the japanese population (5), danish caucasians (13), oji - cree population (17), finnish population (18), and danish white subjects (19). Most type 2 diabetes in koreans is characterized by non - obesity, thus the enpp1 k121q mutant relevant to insulin resistance possibly could be a candidate gene that is not appropriate to explain susceptibility to type 2 diabetes . This can be a possible explanation for the lack of association between enpp1 121q carrier and type 2 diabetes in this study . Obesity is a main risk factor for the development of type 2 diabetes (20) and there is linear association between obesity and type 2 diabetes (3). In previous studies of the association between obesity and polymorphism in enpp1, 121q carriers and/or q allele were associated with obesity in the chinese han population (bmi of obesity group 27 kg / m) (3), caucasians (bmi of obesity group> 90th percentile), african - american adults (bmi of obesity group> 80th percentile) (23), french population (bmi of obesity group 95th percentile) (24), and dominican population (bmi of obesity group 30 kg / m) (10). However, in this study (bmi of obesity group 25 kg / m), there was no difference in distribution between obesity and 121q carriers and presence of the q allele . This result was consistent with those from a study of 7,333 danes (19) and a spanish population (14) in which the bmi of the obesity group was 25 kg / m or higher . On the other hand, in matsuoka's study, the percentage of subjects whose bmi was 30 kg / m or higher was too low (2.5%) to investigate the effect of k121q genotype on obesity . The results of the present study showed that the frequencies of the q allele was 8.7% in the type 2 diabetic group and 9.2% in the obesity group, which was lower than those in finnish and swedish populations (12.9 - 15.1%) (11), danish caucasians (14 - 16%) (13), south asians in chennai (14%), caucasians in dallas (16%), south asians in dallas (19%) (16), the dominican population (54.2%) (10) and, black children (77%) (30). The frequencies of the q allele investigated in this study might have a smaller statistical power to explain any association with either type 2 diabetes or obesity with 121q carriers (kq+qq) and/or the q allele . In conclusion, the present study suggests that the enpp1 k121q polymorphism was not associated with type 2 diabetes and obesity . The results of negative associations in this study might be attributable to the low prevalence of obesity, relatively younger age, and low frequencies of the 121q carriers . Large and prospective studies are needed to confirm this preliminary observation in the korean population.

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

Agenesis of the inferior vena cava (ivc) as a cause of recurrent deep vein thrombosis (dvt) is uncommon . A 33-year - old male with no family history of thrombophilia, who had experienced multiple recurrent episodes of dvt over a 15-year period of unknown cause, was admitted into our hospital because of cellulitis in the right leg . Congenital absence of the ivc could be a rare risk factor for idiopathic dvt, especially in young individuals . Venous thromboembolism (vte), which includes deep vein thrombosis (dvt) and pulmonary embolism, has an incidence of 1 to 3 per 1000 individuals per year in western populations.1 congenital anomalies of the inferior vena cava (ivc) are uncommon, and have been associated with the development of venous thrombosis of the lower limbs.2 congenital anomalies of the ivc has been reported as a risk factor for dvt, especially in individuals <30 years old, and a concomitant thrombophilic disorder has been found in such individuals.3 we report a case of recurrent dvt in a 33-year - old man with agenesis of the ivc . The patient had experienced recurring episodes of idiopathic dvt in the right leg for 15 years . A 33-year - old man was admitted to the internal medicine department, holy family hospital, nazareth, israel, because of cellulitis in the right leg . One week prior to his admission, he complained about pain and increased local heat in the left ankle and thumb of the right leg . The patient had no history of previous trauma, surgery, insect bites, dysuria, or joint symptoms, and no family history of thrombophilia . He reported that he had (a) rheumatic fever without any complications when he was 19 years old, which was treated with penicillin, (b) been hospitalized when he was 23 years old because of infected skin ulcers on the right calf, for which he was treated by parenteral antibiotics, and (c) recurrent episodes of idiopathic dvt for the last 15 years . He also reported that he had not been treated with warfarin, but he had been on prophylactic enoxaparin therapy for dvt some years ago which has since been stopped and that he had been recently treated with allopurinol and colchicine for a presumed diagnosis of gout . He had been investigated several times for a primary hypercoagulability state, and the results were negative . On examination, the most outstanding clinical findings were swelling of ankles, mild edema, redness, and increased temperature of the right ankle and calf with trophic skin changes (skin discoloration with ulcers), and superficial varicose veins in the lower abdomen (figure 1). The clinical laboratory findings (erythrocyte sedimentation rate, leukocyte and platelet counts, and plasma hemoglobulin, plasma protein c, plasma protein s, fibrinogen, and antithrombin iii levels), the results of the kidney and liver function tests, and resistance to activated protein c were all normal . Polymorphisms of the genes that encode for methylenetetrahydrofolate reductase were not detected, and the factor v leiden and prothrombin mutations g20210a were absent . The results of the clinical immunological studies for complement c3 and c4 and rheumatoid factor were negative, and no circulating titers for antinuclear antibody, antineutrophil cytoplasmic antibody, and cardiolipin antibody were found . Cultures from the infected skin ulcers of the right leg were positive for methicillin - resistant staphylococcus aureus (mrsa). Ultrasound imaging of the leg veins showed a previous dvt in the right common femoral vein, and dilated superficial inguinal veins . Computer tomography with contrast of the abdomen showed agenesis of the infrarenal segment of the ivc (figure 2) with dilated azygos and hemiazygos veins (figure 3). There were also varicose veins in the abdominal wall and right groin, which were associated with dilated superficial and collateral veins (figure 4). Transthoracic echocardiography of the patient s heart revealed mild atrial enlargement and good systolic function of the left ventricle, and no pathological valvular flows . The patient was diagnosed as having agenesis of the infrarenal segment of the ivc and dvt of the right leg without concomitant risk factors for vte . Since we attributed the agenesis of the ivc to be the underlying cause of the recurrent episodes of the dvts, the patient was started on anticoagulant therapy (subcutaneous enoxaparin 160 mg / day) for dvt, antibiotic therapy (intravenous vancomycin 1.5 g / day for mrsa skin infection), and referred to a vascular surgeon specialist but the patient refused . At follow - up in the internal medicine clinic, the most outstanding clinical findings were swelling of left ankle, redness, with trophic skin changes, and a mild improvement of the skin ulcers . Despite several phone calls for follow - up the normal ivc is composed of 4 segments: hepatic, suprarenal, renal, and infrarenal . Since many transformations can occur during the formation of the ivc such anomalies occur in 0.3% of otherwise healthy individuals, and in 0.6% to 2% of patients with other cardiovascular anomalies.4 ruggeri et al reported 10 years ago 4 cases of congenital absence of the ivc in 75 young patients with idiopathic dvt over a 5-year period, and estimated that 5% of young patients with dvt had an anomaly of the ivc.5 venous thrombosis is caused by the presence of isolated or combined risk factors . Almost 150 years ago, the nineteenth century pathologist rudolf virchow described 3 critically important causes of venous thrombosis: venous damage, coagulation defect(s), and venous stasis.6 individuals with a congenital anomaly of the ivc are typically asymptomatic, and the anomaly is usually detected incidentally during radiological or abdominal procedures . Congenital absence of the ivc is infrequently associated with thromboembolic events.5 patients who suffer from congenital anomalies of the ivc usually develop a compensatory circulation through the azygos veins or collateral abdominal veins in order to keep the venous return near normal levels.7 most reported cases of congenital anomalies of ivc cases have been linked to thrombophilia disorders.3,5,7 however, the true prevalence of thrombophilia in congenital anomalies of the ivc is unknown because the screening for thrombophilia in patients with an ivc anomaly was usually incomplete.3 anticoagulants, but not thrombolytic therapy, are usually prescribed for venous thrombosis, but the duration of the anticoagulant therapy is not well established . Hence, anticoagulant therapy for an indefinite duration will probably be prescribed, unless vascular reconstructive surgery is done on the anomalous ivc . Such surgery has been rarely reported, and its long - term outcome is undetermined.8 congenital anomalies of the ivc may cause recurrent dvt, especially in young individuals.

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