Alcohol misuse is a significant public health problem with major health, social and economic consequences. Systematic reviews have reported that brief advice interventions delivered in various health service settings can reduce harmful drinking. Although the links between alcohol and oral health are well established and dentists come into contact with large numbers of otherwise healthy patients regularly, no studies have been conducted in the UK to test the feasibility of delivering brief advice about alcohol in general dental settings.The Dental Alcohol Reduction Trial (DART) aims to assess the feasibility and acceptability of screening for alcohol misuse and delivering brief advice in patients attending National Health Service (NHS) general dental practices in North London. DART is a cluster randomised control feasibility trial and uses a mixed methods approach throughout the development, design, delivery and evaluation of the intervention. It will be conducted in 12 NHS general dental practices across North London and will include dental patients who drink above the recommended guidance, as measured by the Alcohol Use Disorders Identification Test (AUDIT-C) screening tool. The intervention involves 5 min of tailored brief advice delivered by dental practitioners during the patient's appointment. Feasibility and acceptability measures as well as suitability of proposed primary outcomes of alcohol consumption will be assessed. Initial economic evaluation will be undertaken. Recruitment and retention rates as well as acceptability of the study procedures from screening to follow-up will be measured.Ethical approval was obtained from the Camden and Islington Research Ethics Committee. Study outputs will be disseminated via scientific publications, newsletters, reports and conference presentations to a range of professional and patient groups and stakeholders. Based on the results of the trial, recommendations will be made on the conduct of a definitive randomised controlled trial.ISRCTN81193263. The brief alcohol advice intervention has been modified and applied for the first time to the setting of a National Health Service (NHS) general dental practice.The training programme was designed after extensive consultation with key stakeholders and was tailored to address the needs and circumstances of NHS dental professionals and their patients.This feasibility study will inform the design of a future definitive evaluative study.Alcohol misuse is a significant public health problem with major health, social and economic consequences. Findings from the latest Health Survey for England show that approximately 24% of men and 18% of women exceed the current Department of Health alcohol consumption guidelines.2The identification of people who are drinking above the recommended guidelines and the provision of brief advice by NHS primary care professionals are important components of an alcohol control strategy. National Institute of Health and Care Excellence (NICE) guidelines recommend that primary care professionals should screen all patients for alcohol misuse.5The links between alcohol and oral health are well established. Most importantly these include increased risk for oral cancers, with and without the synergistic effect of smoking,A limited body of research has been conducted on the use of certain screening tools to assess the prevalence of high-risk drinking among dental patients. Two clinical audits assessing the completion of an alcohol consumption question  in a standard medical history form used in the emergency clinic at the university dental hospital in Cardiff, found that the question was either completed incorrectly, or not used at all. In the second audit, the M-SASQ question  was answered more often and resulted in more patients receiving alcohol advice compared to the standard question.A limited number of randomised controlled trials have investigated the effectiveness of brief advice interventions in clinical dental settings, using dental care professionals rather than dentists. A randomised controlled trial in Cardiff used a nurse-led brief intervention utilising motivational interviewing with young males who were treated at an oral and maxillofacial surgery outpatient clinic for alcohol related facial injury and demonstrated a significant reduction in alcohol consumption in the intervention group compared to the controls at 12 months follow-up.Exploratory work has, however, revealed that general dental practitioners are reluctant to engage with patients about alcohol due to lack of confidence in discussing the subject and concerns that this may adversely affect the practitioner–patient relationship.The Dental Alcohol Reduction Trial (DART) study aimed to assess the feasibility and acceptability of screening for alcohol misuse and delivering brief advice to patients attending NHS general dental practices in North London.To explore the views of dental professionals and dental patients on the relevance and importance of alcohol misuse to oral health, as well as the acceptability of screening and providing brief alcohol advice in general dental settings.To develop and evaluate a brief alcohol advice intervention tailored for use in NHS general dental practices and to assess through a process evaluation the feasibility and acceptability of the intervention to patients and dental professionals.To assess the feasibility of the main trial methodology including the use of a screening tool, subject recruitment and retention, and data collection procedures including economic evaluation to inform the future design of a definitive randomised controlled trial.The study objectives were:The developmental phase which involved separate focus groups with dental professionals and dental patients. This phase informed the development of the training programme and intervention for the main phase of the trial.The feasibility trial which involved: (A) engagement and recruitment of dentists, (B) training dental teams on research governance (control and intervention arms) and on how to deliver alcohol brief advice (intervention arm), (C) participant recruitment, (D) data collection (baseline and 6 months follow-up data), (E) process evaluation including assessment of intervention fidelity, acceptability to participants and dental professionals and feasibility of cost-effectiveness evaluation.The DART study comprises of two phases:The study is registered as a primary clinical trial (ISRCTN number: 81193263).The DART study is a cluster randomised control feasibility trial and uses a mixed methods approach throughout the development, design, delivery and evaluation of the intervention. The trial took place in general dental practices across North London . The study timeline is presented in The developmental phase of the study involved the completion of five focus groups; two with dental professionals and three with dental patients. Recruitment for the developmental phase started in December 2013. The discussions explored dental teams’ understanding and views of the importance of alcohol misuse in relation to oral health; perceived extent of alcohol misuse among patients; dental professionals’ attitudes towards screening, providing advice, and referral when necessary; acceptability and barriers of engaging in alcohol screening and advice; best ways of delivery; and also perceived training and support needs.Similarly, discussions with dental patients explored their views on the relevance of alcohol to oral health and dentistry, acceptability of dental teams enquiring about alcohol intake and offering advice, views on the best ways for dental teams to approach the subject and provide advice and support, and on suitable information for participants in the group not receiving the intervention. The information gathered during these discussions was used to design the intervention.NHS dental practices were recruited into the study through a number of complementary ways. The principal investigator along with the research team had already established excellent links with a number of dental practices across North London, which had participated in previous research studies and had expressed interest in being involved in future research. In addition a mail was sent out to all NHS dental practices in the selected areas of North London and interested practices then visited by the principal investigator. Finally, a snowballing recruitment method was also used with dental professionals already engaged in the study recommending other colleagues who might be interested in participating in the research.To avoid risk of contamination, dental practices were randomised to intervention and controls. Lists of all the dental practices which expressed interest in participating in the trial were compiled and equal numbers allocated to each arm of the trial using simple randomisation. A member of staff not involved in data collection or delivering the intervention was responsible for allocating dental practices to groups. The researchers collecting the 6-month follow-up data will be masked to the practices’ allocation status.All members of the dental teams who participated in the study  at each practice were trained in research governance issues. This included how to introduce the study to potential participants, recruitment strategies, obtaining verbal and written consent, data collection procedures, confidentiality and data storing/handling.All dentists from the intervention practices attended a 6 h training course over 2 days . The traThe first session provided the participants with essential theoretical knowledge on issues around alcohol, including its epidemiology, public health burden and links to oral health. Key terminology was defined , followed by an introduction to raising the issue of alcohol and using the AUDIT-C screening tool. Exercises included estimating alcohol units in various popular alcoholic drinks and determining patients’ AUDIT-C score using real-life scenarios. During the second session, dental professionals were introduced to a specifically modified version of the brief advice tool tailored to oral health. Using role-plays of increasing complexity, dentists learnt how to raise the issue of alcohol with their patients, go through the AUDIT-C tool, provide feedback based on the AUDIT-C score and then proceed with delivering brief advice. Concerns and barriers to delivering the intervention were explored and addressed. Area specific information on local alcohol services for referral was also provided to each practice. The training programme was evaluated using a pretraining and post-training questionnaire which assessed participants’ knowledge, skills and attitudes towards screening for alcohol misuse and providing preventive advice.Different patient recruitment approaches were used by the dental professionals in the participating practices. Some practices used a targeted approach based on their knowledge of their patients, and others approached all patients attending for treatment during the recruitment period. Recruitment for the main trial phase began in May 2014. Dental staff at each participating dental practice were trained and briefed on effective ways of approaching potential participants.Patients were eligible to take part in the study if they consumed alcohol above the current recommendationsIn addition, participants were excluded if they were already involved in a research study conducted in the dental practice and if they were already seeking or receiving help for alcohol dependence.From our exploratory work, it was ascertained that compared to the M-SASQ and FAST alcohol screening questionnaires, the AUDIT-C questionnairePatients who expressed an interest in participating in the study completed the screening questionnaire, which was then given to the dentist in order to ascertain eligibility for the study. A score of 5 or above in the AUDIT-C questions indicates drinking levels above the current recommendations and therefore eligibility to enter the study.Consent to participate was obtained in a two-stage process. Dental staff obtained verbal consent to screen participants using the AUDIT–C measure. Patients who obtained a positive AUDIT-C score were invited into the trial. Information sheets explained the details of the study and any queries were addressed at this point. If the participants were happy to continue, written consent was obtained at this point by the dental professional.All eligible and consenting participants were asked to complete a short baseline questionnaire which comprised of basic demographic questions  and the EuroQoL five dimensions questionnaire (EQ-5D).Six months after the completion of baseline measures, all participants will be contacted via telephone by a researcher masked to the participant's allocation status. The full AUDIT tool will be administered.Eligible participants attending the intervention practices were given up to 5 min of simple, structured, brief advice using a modified version of the brief advice tool ‘Brief advice about alcohol risk’ which was developed for the Screening and Intervention Programme for Sensible drinking (SIPS) studyIn the control practices, eligible participants received standard oral healthcare and were initially given an oral cancer prevention leaflet which included brief guidance on reducing alcohol intake and stopping smoking. After all the follow-up data are collected, they will then also be offered the 5 min brief advice and given a copy of the Change for Life leaflet. A summary flow chart of the study process in control and intervention practices can be found in We will measure recruitment and retention rates as well as practicality of engagement with dental practices, fidelity of delivery of the intervention and general acceptability of the study procedures from screening to follow-up. In addition, we will also assess if outcome measures proposed for the main trial could successfully be collected. The proposed primary outcome of the full trial is the score on the full AUDIT questionnaire, with a cut-off of 8 or more as used in the SIPS programme.For feasibility studies a detailed sample size calculation is neither appropriate nor necessary. The primary aim of conducting feasibility trials is to provide data to inform power calculations for a future larger scale trial.30Based on pragmatic considerations it was estimated that 12 dental practices were required with a sample of 240 participants at baseline—20 participants per practice. Assuming a 30% drop out rate this would give a sample of 168 participants at the 6 months follow-up. This figure was deemed to be reasonable as the average dental practice has approximately 1500 adult patients of whom approximately 25% were drinking at higher risk levelsNo published studies have reported the effect of brief advice provided in general dental practice. The variance in the proposed primary outcome for the definitive trial (AUDIT score at 6 months) will be used in conjunction with recruitment and follow-up rates as well as an estimate of the intraclass correlation coefficient (and 95% CIs) in order to calculate the sample size for the definitive trial.To ensure that the study was relevant and informed by patient experience, a dental patient research forum was established in one of the dental practices involved in the study. The principal dentist invited a diverse mix of dental patients to join the forum. Semistructured discussions took place with the forum members. These discussions were facilitated by the patient and public involvement co-investigator (CG) and members of the study team. The forum was consulted on a variety of practical aspects of the study, such as the design of recruitment materials and data collection questionnaires, the best ways to introduce the study to potential participants, suggestions on retention of the study sample and effective follow-up methods. The group also assisted with piloting the data collection questionnaires once they were finalised.The research team developed a comprehensive monitoring system with monthly visits to the dental practices to collect the screening and baseline questionnaires and to ascertain if recruitment and data collection were going well. Visit checklists were designed and completed at each visit and feedback emails were sent when deemed useful for the practitioners.The process evaluation will consist of a mixed methodology using both qualitative and quantitative methods. This will include an assessment of the recruitment procedures, satisfaction among participating dental patients and dental teams, and intervention fidelity.All dentists at the intervention practices were asked to complete a fidelity form for each patient who received the brief intervention to ensure that the intervention was delivered consistently. The form was based on a checklist used in a previous trial,Face to face individual interviews will be held in the intervention and control dental practices to gain an understanding of the dental professionals’ experience and views of the study. Dentists and reception staff who were directly involved with the recruitment and data collection process will be interviewed by the research team on an individual basis. The discussions with the intervention practices will assess views on the recruitment procedures, value and relevance of the alcohol brief advice training, the appropriateness of delivering advice on alcohol in the dental practice and overall perceptions surrounding participation in research. In the control practices, the discussions will focus on the study protocol procedures namely the challenges and facilitators in recruiting dental patients for the study and the data collection process. In addition, dentists in the control arm will be asked if they would find the training for delivering alcohol advice relevant and useful to them.The experience of participants will also be evaluated through individual telephone interviews and will focus on their experiences of the study  and general perceptions around participating in research. Members of the research team will also be interviewed one-to-one by an external interviewer, discussions surrounding recruitment of dental practices, training of dental teams and general perceptions of the organisation of the study will be carried out.We will assess key feasibility parameters, such as recruitment and retention rates, number of participants screened in order to assess eligibility, the practicalities of screening and delivering the intervention in dental settings, in order to inform the acceptability of the study procedures in both patients and dental professionals. The study instruments will be evaluated in terms of ease of administration as well as acceptability by participants in order to inform their suitability for the main trial. Descriptive analysis of the proposed main outcome measure (AUDIT score) will provide a SD which will be subsequently used in the sample size calculation for the definitive trial.The process evaluation interviews with dentists, dental teams, dental patients and members of the research team involved in the study will be transcribed and coded, classified and organised into main themes using thematic analysis.A decision to process to the full scale study will be based on recruitment of at least 85% of the planned sample within the allocated time, completion of primary outcome follow-up interviews with no less than 75% of participants and receipt of brief advice by at least 60% of those randomised to the intervention arm.Alcohol misuse remains a major health and social problem in the UK affecting a significant proportion of the population. Excessive alcohol consumption adversely affects oral health in a variety of ways, but currently most dentists do not ask their patients about their alcohol intake or provide any advice to those that require support. Indeed, many health professionals lack the necessary knowledge and confidence to discuss alcohol misuse with their patients.This paper has described the study methodology and intervention design for an alcohol screening and brief advice intervention delivered in NHS dental practices in North London. The comprehensive feasibility study will provide detailed insights into the development, implementation and evaluation of the alcohol intervention which will inform the design of a future definitive trial. Findings from the initial exploratory phase of the study will help ensure that the intervention training programme and resources are tailored to the needs and circumstances of NHS dental professionals.Furthermore, the feasibility trial will explore the logistics and practicality of delivering brief advice to dental patients in a NHS dental setting. The planned process evaluation will determine the acceptability of the intervention to dental professionals and patients. These implementation and feasibility issues will be explored in depth as they will likely influence uptake of this approach in primary dental care. The comprehensive methodology of this study will provide useful data on this important and under researched topic and provide evidence which will inform primary dental care practice in and outside of the UK.


Nursing education is a key component to the delivery of safe epidural analgesia in the post-operative critical care setting .An audit of our practice revealed a significant failure rate in epidural analgesia in elective major abdominal surgery patients and a high proportion of missing documentation in cases where epidural analgesia had failed.To devise and deliver an interdisciplinary education program to enhance nursing knowledge and management of epidural analgesia in critical care patients.To improve patient safety through earlier recognition of adverse events by encouraging improved monitoring of epidural analgesia.We developed a teaching program for nursing staff on the care of patients receiving epidural analgesia.The program consisted of a lecture course and interactive teaching session with a pre course questionnaire to assess existing knowledge of the benefits and complications of epidural analgesia and management of common side effects. We repeated the questionnaire after the course without the participants having prior knowledge that this would occur.The group of 36 nurses who participated had been qualified for a median of 5 years IQR, they had worked in a critical care environment for a median of 2.5 years IQR and 25% of them had some experience of managing epidural analgesia in an environment outside of critical care.Following the education program there was 56% increase in the number of nurses who could identify at least two advantages of epidural analgesia for patients who had undergone major abdominal surgery.There was a 26% improvement in the number of nurses able to identify signs of high sensory level blockade, 47% improvement in the number of nurses able to name methods for improving an inadequate block and a 67% improvement in the number of nursing staff being able to identify signs of a potential epidural haematoma.Baseline nursing knowledge of clinical assessment and recognition of associated complications of epidural analgesia was limited despite a pre-existing trust-wide education program.Interdisciplinary training is beneficial to the acquisition of short-term knowledge with regard to optimising effective pain relief and identifying common side effects.The post course short answer exam highlights a significant increase in nursing awareness of potential serious complications of epidural analgesia.We expect that increased nursing knowledge of the benefits of epidural analgesia and its potential problems will lead to comprehensive monitoring, superior post-operative analgesia and a reduction in adverse events.


The perception of unpleasant stimuli enhances whereas the perception of pleasant stimuli decreases pain perception. In contrast, the effects of pain on the processing of emotional stimuli are much less known. Especially given the recent interest in facial expressions of pain as a special category of emotional stimuli, a main topic in this research line is the mutual influence of pain and facial expression processing. Therefore, in this mini-review we selectively summarize research on the effects of emotional stimuli on pain, but more extensively turn to the opposite direction namely how pain influences concurrent processing of affective stimuli such as facial expressions. Based on the motivational priming theory one may hypothesize that the perception of pain enhances the processing of unpleasant stimuli and decreases the processing of pleasant stimuli. This review reveals that the literature is only partly consistent with this assumption: pain reduces the processing of pleasant pictures and happy facial expressions, but does not – or only partly – affect processing of unpleasant pictures. However, it was demonstrated that pain selectively enhances the processing of facial expressions if these are pain-related . Extending a mere affective modulation theory, the latter results suggest pain-specific effects which may be explained by the perception-action model of empathy. Together, these results underscore the important mutual influence of pain and emotional face processing. Emotions possess immense power to alter pain perception. The influence of experimentally induced emotions on experimental pain has been investigated with various affective stimuli like affective pictures e.g., , 2008, pA theoretical framework for the explanation of the emotional modulation of pain is the motivational priming hypothesis , which aAs mentioned above and also common in emotion research, most of the studies investigating emotional modulation of pain used affective pictures e.g., , 2008 orA possible theoretical explanation for the interaction of viewing others’ facial expression of pain and the own sensation of pain is offered by the perception-action model (PAM) of empathy . The PAMThe aim of this mini-review is to selectively summarize research on the influence of visual affective stimuli on pain perception, but mainly on the opposite effect of pain on the processing of affective stimuli such as facial expressions. Given the growing interest in pain modulation by facial expressions of pain and the lack of studies which used other affective stimuli, we focus on studies on facial expressions. In addition we seek to extend the viewpoint of a mere affective modulation of pain with regards to the theory of vicarious pain and include a recent experiment from our lab which aimed at investigating the mutual effects of the perception of facial expressions of pain and pain perception. This review is far from exhaustive; it only summarizes the literature relevant for our work within the research group “Emotion and Behavior” at the University of Würzburg, Germany. We are fully aware that much more research is available on the topics of emotional modulation of pain and vicarious pain, and we direct the attention of the interested reader to the excellent reviews by As mentioned above, the effect of pain on emotion processing has been investigated much less, although from a clinical perspective the high prevalence of mood disorders in chronic pain suggests effects in this direction . One stuIn a further study, we then investigated the effect of tonic pressure pain on the electrocortical correlates of processing of facial expressions . Here, fWe conclude that on the one hand there is some evidence that experimental pain alters perception and processing of positive affective stimuli (scenes and faces), although most effects were observed with regards to attentional mechanisms. On the other hand, little is known about how pain alters processing of facial displays of pain and vice versa. Given the match between observed and experienced pain, one may argue that selective enhancement and mutual influences have to be expected. Before we report an experiment in which these mutual influences were investigated, we will briefly summarize why facial expressions of pain may be special compared to other facial expressions.The sensation of pain is accompanied by distinct albeit not uniform facial expressions e.g., . Pain exFigure 1).Compared to neutral facial expressions, facial expressions of pain receive prioritized processing and elicit enhanced initial orienting . SimilarCorroborating our findings, Since emotional stimuli have a great impact on pain perception as summarized above, one may assume that a highly salient signal such as the facial expression of pain should also modulate pain perception. This assumption is further strengthened by the fact that the cortical regions involved in the decoding of pain  and emotThe interaction of facial expressions of pain and perception of pain is rarely investigated. In one study, volunteers viewed videos showing different levels of pain expression before noxious electric shocks were delivered. Viewing stronger pain expressions generally increased pain unpleasantness ratings, the amplitude of the nociceptive flexion reflex, and corrugator responses to the noxious stimulation . In anotBesides the lack of information of the pain-specificity of these effects, little is known to date about the mutual effects of the perception of facial expressions of pain in others and the own pain sensations. Given the observations from functional neuroimaging that seeing others facial expression of pain leads to activations in pain-related areas in the brain of the observer, one may assume strong interactions between seeing pain of others and feeling pain. A number of studies using methods such as functional magnetic resonance imaging and electrophysiological recordings have provided support for this view by showing increased activity in pain-related brain regions during perception of pain in others  includinFigures 2A,B, the selective enhancement of arousal ratings of pain faces by pain in Figure 2C.In a recent study we aimed at investigating both the effects of facial expressions of pain on the actual perception of pain, and vice versa the influence of pain sensation on the affective ratings of facial expressions of pain . To thisThese findings demonstrate that the relation between pain and emotion is bidirectional with pain faces showing selectively mutual influences. This study provides further experimental evidence that processing painful stimulation and the facial expressions of pain in others are highly interconnected. Extending previous findings it also shows pain-specific modulations of pain perception such that highest pain ratings of painful thermal stimuli were obtained while participants watched faces of pain compared to other facial expressions. Importantly, this effect was also larger for pain compared to fear faces, suggesting that the facial expressions of pain enhance self-pain perception not only due to its negative valence but due to its pain relevance. In addition to the predictions from the motivational priming theory, these results support the notion that not only the valence of a facial expressions enhances pain perception, but that the expressed pain itself primes the sensorimotor system, which might drive a potentiating pro-algesic mechanism . AdditioAnother potential mechanism of pain modification in addition to the affective priming hypotheses has been put forward as the PAM of empathy . This moThis mini-review featured recent work on the emotional modulation of pain perception by affective stimuli such as facial expressions, but more importantly on the reverse impact of pain on emotional face processing. The presented studies also further underscore the special relevance of facial expressions of pain. The functional significance of pain faces for human social interaction, however, is still under debate, therefore future work needs to clarify whether they elicit predominantly approach or avoidance behavior in the observer . This woThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A middle-aged woman was undergoing elective rhytidectomy by the senior author using a high superficial musculoaponeurotic (high-SMAS) approach deep plane facelift. After horizontal SMAS division and elevation over the zygomatic arch, the temporal division of the facial nerve was seen crossing the zygomatic arch approximately 1 cm anterior to the tragus with an initial vertical trajectory before coursing anteriorly . The facInjury to the temporal branch of the facial nerve is one of the most undesirable surgical outcomes in the temporal region. Its course is most commonly described as running along Pitanguy's line, although deviations from this trajectory are seldom discussed among clinicians. Moreover, conflicting data have been written about its fascial relationships over the years. Given its vulnerability during extended aging face procedures, as well as surgical approaches to the temporomandibular joint, maxillofacial trauma, or temporal artery biopsy, a thorough understanding of the temporal branch anatomy in terms of trajectory and fascial planes is essential to avoid iatrogenic injury.What is the classic trajectory of the temporal division of the facial nerve?In what instances is this trajectory defined as abnormal?What are the fascial relationships of the temporal branch in the temporal region?What are the clinical correlates of these relationships?-Several anatomical studies have described the trajectory of the temporal division of the facial nerve after its emergence from the parotid.1To understand the normal anatomical variations in its trajectory, multiple dissection studies have dissected the temporal branch of the facial nerve. We have reported a select group of landmark studies in 5Much has been written on the fascial relationships of the temporal branch of the facial nerve in the temporal region. The most recent high-quality evidence has consistently shown that the temporal branch travels deep and transitions into a sub-SMAS plane before entering the muscles in the frontal region.The mastery of these relationships is essential to surgeons performing common procedures such as temporal artery biopsy, facelift, temporomandibular join surgery, maxillofacial trauma, or pterional neurosurgical approaches, among others. Understanding the normal and abnormal anatomy of the temporal branch of the facial nerve in terms of trajectory and facial layers is essential for the surgeon operating in the temporal region to avoid iatrogenic nerve injury.


The mechanical pressure difference across the bacterial cellulose membrane located in a horizontal plane causes asymmetry of voltage measured between electrodes immersed in KCl solutions symmetrically on both sides of the membrane. For all measurements, KCl solution with lower concentration was above the membrane. In configuration of the analyzed membrane system, the concentration boundary layers (CBLs) are created only by molecular diffusion. The voltages measured in the membrane system in concentration polarization conditions were compared with suitable voltages obtained from the model of diffusion through CBLs and ion transport through the membrane. An increase of difference of mechanical pressure across the membrane directed as a difference of osmotic pressure always causes a decrease of voltage between the electrodes in the membrane system. In turn, for mechanical pressure difference across the membrane directed in an opposite direction to the difference of osmotic pressure, a peak in the voltage as a function of mechanical pressure difference is observed. An increase of osmotic pressure difference across the membrane at the initial moment causes an increase of the maximal value of the observed peak and a shift of this peak position in the direction of higher values of the mechanical pressure differences across the membrane. P) across the membrane and volume flux (Jv) through the membrane cause changes in thickness of the CBLs  and areP)max is smaller for all Ch/Cl max) are higher for electrodes located at a greater distance from the membrane  is oriented with difference of osmotic pressure (greater activity of K+ ions for greater ΔP). In turn, fixing of mechanical pressure difference across the membrane directed in an opposite direction to osmotic pressure difference causes smaller activities of K+ ions to be observed . The above statements are also valid when the activity of K+ ions is measured at points at nonzero distances from the membrane. Changes in time of activities of K+ ions are lower when the points are more distant from the membrane. Such changes in the activity of K+ ions in the vicinity of the membrane are due to a disturbance of reconstruction of CBLs by mechanical pressure difference across the membrane.As results from analysis of changes in time of activity of Kane Fig.  applicatThe characteristic feature of voltage between electrodes in steady-states of the membrane system in concentration polarization conditions as a function of applied difference of mechanical pressure is the occurrence of a maximum. This maximum is observed in the range of difference of mechanical pressure directed in an opposite direction to difference of osmotic pressure . An increase of difference of osmotic pressure across the membrane at initial moment causes a shift of observed peak toward higher (more negative) values of differences of mechanical pressure and an increase in the value of maximum. Furthermore, as results from Fig.


In 1986, only 7 of the 50 states in the US had obesity rates above 10%; whereas in 2010 all 50 states had obesity rates above 10% and 13 states had obesity rates above 30%  involved in the regulation of several hypothalamic and extra-hypothalamic cell populations involved in energy expenditure as well as glucose sensing/metabolism. The author also summarizes current data describing the role of neurotransmitters (gabaergic and glutamatergic inotropic neurotransmission) in the regulation of hypothalamic and hindbrain neuron activity.The review from Sohn  discusseVanevski et al. (Vanevski and Xu, Khan , presentThe final review by Udit and Gautron  focuses The aforementioned articles highlight that over the past century prevalent models of energy and glucose homeostasis have been developed from a better understanding of the neural circuits that, when perturbed, lead to the development of obesity and diabetes. Furthermore, these data also demonstrate how the neuronal processes involved in energy and glucose homeostasis also impinge on numerous CNS functions, including the regulation of autonomic outflow and other behaviors. Undoubtedly, utilizing combinatorial research strategies highlighted in these articles will be key to understanding and uncovering potential therapeutics in the treatment of endocrine disorders including obesity and diabetes.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The increase in paediatric patients suffering from chronic disease, often involves the transfer between different care sectors. The transition from the protected hospital environment to the patient’s home is often faced with difficulties and discomfort. Therefore it is essential to ensure proper management of the course of treatment and care of the child and his family, from admission to return to home, as a single longitudinal and transverse episode. The transition phase invests heavily on empowerment of the patient and the family, as a necessary condition for safe care in self-management.The early assessment of care needs in the early hours of admission allows signalling through a standardized form (within 48 hours of admission) to the territory of residence / domicile post-discharge care needs. The immediate activation of the territory allows you to organize the take-over without solutions of continuity. The preparation in particularly complex cases of a joint multi-professional assessment Hospital / Territory before discharge ensures total care of both patient and family. The investment in empowerment of patients and their families through a card intended to guide the informative / educational activities and assessment of learning outcomes ensures a safe discharge as well as a competent share of the care pathway for the patient and family.All children requiring home care have been taken into care before discharge and the first access at home was made within 2 days of discharge. Patients and family members have continued training activity even at home until reaching complete autonomy.The detection of user satisfaction reported in 80% of cases who returned the questionnaire a good satisfaction.The focus in 2014 will be placed primarily in the reporting of at least 90% of the cases that require territorial continuity of care within 48 hours of admission and the onset of training already at this stage. It should be also developed a greater integration between hospital school and schools of the area of residence of the child for activation when needed to address the educational activity.


The paper by Jargin  addresseIt also seems very likely that illegally distilled, counterfeit, and surrogate alcohol poses a risk to human health, playing an important role in the high level of alcohol-related deaths in Russia. It was found that home-made spirits contained the toxic alcohols that could cause damage to the liver . The finHistorically, government policies designed to raise prices and restrict availability of commercial alcohol beverages in Russia have driven black market growth. Surrogates consumption increased markedly following the prohibition of vodka sales in July 1914 as Russia mobilized for war .The development of events on the Russian alcohol scene in recent years shows how complex and multifaceted the problem of undocumented alcohol consumption is. In 2006, amendments were introduced to the Federal Law “On State Regulation of the Production of Ethyl Alcohol, Alcohol and Alcohol-Containing Products” number 171, which seriously impacted the alcohol situation in the country . FirstlyMaking vodka less affordable through differential taxation was an essential element of the Russian alcohol policy in the most recent years . The govAccording to experts' estimates, the market of surrogate alcohol over the past six years has been up from 500 million liters to 800 million liters . Many ofThe major problem is that the informal alcohol market is largely immune to regulation and effective policymaking. The Russian government should consider a number of potentially effective approaches to addressing the problem of noncommercial alcohol, including raising public awareness of the risks of surrogates drinking and creating an alternative to strong alcoholic drinks by preferences to low alcoholic beverages.


Unfortunately, the original version of this article  containeAs Dr. Ugra Singh is no longer at the University of South Carolina, the corresponding author has been changed to Dr Donald J DiPette  in the author details above.


As neuronal pathologies cause only minor morphological alterations, molecular imaging techniques are a prerequisite for the study of diseases of the brain. The development of molecular probes that specifically bind biochemical markers and the advances of instrumentation have revolutionized the possibilities to gain insight into the human brain organization and beyond this—visualize structure-function and brain-behavior relationships. The review describes the development and current applications of functional brain imaging techniques with a focus on applications in psychiatry. A historical overview of the development of functional imaging is followed by the portrayal of the principles and applications of positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), two key molecular imaging techniques that have revolutionized the ability to image molecular processes in the brain. We conclude that the juxtaposition of PET and fMRI in hybrid PET/MRI scanners enhances the significance of both modalities for research in neurology and psychiatry and might pave the way for a new area of personalized medicine. Traditionally, diagnostic imaging was restricted to the visualization of aberrations in morphological structures. However, neurological pathologies generally do not cause significant correlates to macroscopically or microscopically visible changes in cell morphology. Since the contrast obtained for the differentiation of pathophysiological abnormality defines the performance of an imaging modality, highly sensitive methods for imaging alterations in brain functioning had to be developed. In general, any kind of radiation that penetrates the human body can be used as signal source for diagnostic imaging. Hence, the diversity of imaging modalities reflects the variety of the capabilities of the different kinds of radiation used in clinical practice. The aim of this short review is to introduce the principles of the most common and most promising molecular imaging techniques for the investigation of alterations in brain functioning: positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) and to deduce their limitations and prospects.The contemporary imaging methods: computer tomography (CT), magnetic resonance imaging (MRI), PET, and ultrasound (US) can be traced back to the German physicist Wilhelm Conrad Röntgen. In 1895 Röntgen recognized that X-rays penetrate solid mater. He further discovered that the attenuation of X-rays depends on the characteristics of the object penetrated. When he subsequently deduced the technique of X-ray imaging a great invention took place: the visualization of structures inside the body without using surgery!Since then the imaging with X-rays has been shown to provide images of excellent anatomic resolution. The development of CT, the corresponding tomographic modality, has further enhanced X-ray imaging and up to the present billions of scans have been carried out. The specific strength of CT imaging is its high anatomic resolution. The imaging is straightforward as long as bony materials or calcified tissue is investigated. In soft tissues the differences of X-ray attenuation are marginal and contrast agents are used to provide the known high-quality CT images in the major areas of the body i.e., the vascular system, the lungs and the kidneys. Inclusion of elements of high atomic number is pivotal for the efficacy of CT contrast agents as the X-ray absorbency is almost directly proportional to the third power of an elements atomic number. However, unfortunately, most elements of high atomic number are not biocompatible and iodine containing contrast agents dominate the choice of contrast agents in clinical use. High doses of up to 42 g of the contrast agent are required to induce sufficient contrast  passive agents that modulate an external signal i.e., in CT and US; and (b) probes that either produce a signal autonomously i.e., radiotracers and bioluminescent dyes, or transformations of an external signal, such as with MRI contrast agents or fluorescent probes. As passive contrast agents only enhance the body’s signal, relatively high doses are required to delineate their endogenous contrast. While very high concentrations of CT contrast agents are required, the signal of radiolabeled tracers can be measured at an exceptionally high sensitivity. As the radioactive signal is exclusively emitted by the endogenous tracer it can be definitively traced back to the imaging agent. The short lived positron emitters Selective radioligands are often derived from psychoactive drugs and gain their specificity by mimicking neurotransmitters. The visualization of their specific binding to a target such as a receptor, a transporter or an enzyme allows revealing various pathologic conditions. In the following, PET tracers will be reviewed that target receptors, proteins or neurotransmitter, or glucose consumption.11C]raclopride and [18F]fallypride for dopamine D2/D3 receptors for differential diagnosis of movement disorders and for assessment of receptor occupancy by neuroleptics drugs in schizophrenia  receptors and the 5-HT transporter. These transporters are dysregulated in affective disorders and shall be valuable structures for the assessment of activity of antidepressants. In the midbrain and amygdala of patients with major depressive disorder lower 5-HT transporter binding can be assessed with tracers such as [11C]McN5652 , the working horse of modern molecular imaging  and 18F (108 min) very small amounts of the tracer are required to obtain the appropriate signal intensity and the total radiation exposure is comparable to the one obtained by whole body CT scans. The short half lives in turn entail the on demand synthesis of the radiotracers ideally with a cyclotron in close proximity to the PET imaging facility. The effective doses are continuously reduced by using tracers with short physical and biological half-lives, by minimizing the activity injected and by the ongoing enhancement of the sensitivity of PET scanners.The study of tracers that map the regional differences of blood flow represents a different approach to visualize pathological changes and to gain function information of the brain. While PET imaging allows the assessment of neurotransmitter concentrations in the brain, it is not suitable to reveal micro- and macroscopic structural aberrations in the white and gray matter. In addition, PET cannot be used to detect rapid changes in brain activation. Moreover, despite the enormous achievement of PET imaging there is always a concern about the radiation risks involved in this modality. Magnetic resonance spectroscopy (MRS) represents an alternative as endogenous compounds involved in the biochemistry of the brain are detected. The resonance frequency of protons depends on their chemical structure and MRS measures the concentration of marker molecules such as methionine or lipids  are working indirectly by affecting the relaxation of water molecules in their coordination sphere. Due to the high exchange rate of water in the sphere of gadolinium complexes a large number of water molecules are relaxed within one scan . As a result, an apparent several thousand fold amplification of the effect is observed. Consequently, a huge variety of MRI contrast agents have been developed  and gadolinium contrast agents had been described -effect can be traced back to neural activity (rather than spiking of neurons), probably mainly due to increased uptake of glutamate in astrocytes  its clinical convenience—fMRI is performed with the standard MRI scanners and does not require the injection of contrast agents, but is achieved due to the measurement of an endogenous contrast agent that is present at high concentration in the brain; (b) the fact that the contrast agent is functional and responsible to stimuli; (c) the fact that fMRI it is not associated with the use of radioactive probes provides a high ease of repeatability and therefore makes longitudinal studies of subjects possible; and (d) the possibility to study not only alterations in brain morphology that affect activation of a certain region, but also its connectivity to other brain regions.Nowadays, MRI scans of the brain are standard in clinical care in neurologic and psychiatric hospitals. Neurological, as well as vascular diseases of the brain can be easily detected and help guiding diagnostics and appropriate therapies. In addition, fMRIs can be acquired prior to brain surgeries to allow the surgeon an individualized anatomical mapping of visual and motoric functions of the patient.Moreover, fMRI has a prominent role in neurologic and psychiatric brain imaging research. For the sake of brevity, the following illustration of MRI and fMRI for psychiatric research will be exemplarily illustrated for schizophrenia. MRI studies on schizophrenia show a volume loss of brain tissue, specially an enlargement of the ventricles, replicating earlier CT studies, making it one of the most robust findings in MRI research  and in fMRI the development of the instrumentation , as well as the analysis methods .However, improvements of the specificity of molecular imaging probes invariably go along with the loss of effectual resolution as the orientation guide—the accumulation in the non-target tissue is decreased. Hence, bimodal imaging techniques that combine the outstanding molecular imaging probabilities of PET with imaging techniques with a better spatial resolution were developed. PET/CT is the prime example for such a bimodal imaging technique as the anatomical information gained at high resolution by CT synergistically matches the functional information of PET imaging. Due to the lack of tissue that provides significant attenuation of X-rays in the brain, PET/CT images of the brain do not significantly benefit from the CT-portion of the fused images. Since MRI has excellent soft tissue contrast, MRI should be perfect to navigate the PET information in the brain and high hopes are placed into the clinical outcome of the PET/MRI scanners that currently emerge. Hence, despite the exceptional technical challenges that had to be mastered  for PET provide the basis not only for a better understanding of molecular processes in the brain, but also for the stratification procedures essential for the safe development of individualized therapies. The directly combined application of BOLD fMRI measuring brain function with PET radiolabeled reporters that map the distribution and function of receptors synergistic will form the basis of a new area in today’s rapidly increasing insight into brain function.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the current context of high fatality rates associated with American visceral leishmaniasis (VL), the appropriate use of prognostic factors to identify patients at higher risk of unfavorable outcomes represents a potential tool for clinical practice. This systematic review brings together information reported in studies conducted in Latin America, on the potential predictors of adverse prognosis  and death from VL. The limitations of the existing knowledge, the advances achieved and the approaches to be used in future research are presented.The full texts of 14 studies conforming to the inclusion criteria were analyzed and their methodological quality examined by means of a tool developed in the light of current research tools. Information regarding prognostic variables was synthesized using meta-analysis. Variables were grouped according to the strength of evidence considering summary measures, patterns and heterogeneity of effect-sizes, and the results of multivariate analyses. The strongest predictors identified in this review were jaundice, thrombocytopenia, hemorrhage, HIV coinfection, diarrhea, age <5 and age >40–50 years, severe neutropenia, dyspnoea and bacterial infections. Edema and low hemoglobin concentration were also associated with unfavorable outcomes. The main limitation identified was the absence of validation procedures for the few prognostic models developed so far.Integration of the results from different investigations conducted over the last 10 years enabled the identification of consistent prognostic variables that could be useful in recognizing and handling VL patients at higher risk of unfavorable outcomes. The development of externally validated prognostic models must be prioritized in future investigations. In contrast to other clinical presentations of leishmaniasis in Latin America, American visceral leishmaniasis (VL) can lead to death in 5-10% of patients under treatment. The fatality rates associated with this disease have remained stable at a high level over the years in Brazil and are neither recorded in under-treatment patients from endemic countries of the Old World nor from non-endemic countries where such cases are imported. Since VL-induced lethality can occur even after the implementation of recommended therapy, the understanding of individual, clinical and laboratory factors that predispose to an unfavorable outcome might represent an important feature for informing better practice in the clinical management of cases. The present systematic review with meta-analysis brings together information on various prognostic variables associated with the severity of VL. Potential predictors identified in the studies surveyed were grouped according to the strength of evidence available, and 13 were considered to be of significant relevance. The gaps in the existing knowledge and the need for the development of externally validated prognostic models were also discussed. The results presented herein could be useful in identifying patients at higher risk of unfavorable evolution or death from VL, and might provide an aid in decision-making regarding the clinical management of VL cases. Visceral leishmaniasis (VL) constitutes a serious public health problem in endemic regions, especially in the Indian sub-continent, in North and East Africa, and in South America. However, VL is one of the most neglected diseases in the world Lutzomyia, which hosts the promastigote form of Leishmania infantumIn the Americas, the transmission of VL to humans occurs through the bite of female phlebotomine sandflies of the genus Treatment options for VL in Brazil are pentavalent antimonial compounds and formulations of amphotericin B The lack of reduction in the fatality rates of VL in Brazil can be explained not only by the limitations in therapy applied and the delay in diagnosis Generally, prognostic factors have received less research attention than etiological factors and therapeutics Considering the relevance of predictors of clinical evolution in reducing the number of VL-induced deaths, and the need for reliable prognostic models , the present systematic review with meta-analysis seeks to bring together information reported in studies of the potential predictors of death and other adverse outcomes of American VL. In addition, based on the analysis of the limitations of the published studies and of existing knowledge we propose possible improvements that might be incorporated into future research.Independent literature searches were conducted between March and September 2011 by two of the authors (VSB and DSB) using the databanks and keywords listed in P values or crude data that made possible the calculation of effect sizes (provided such information had not been obtained directly from the authors); (v) studies containing confusing text or incomprehensible analyses; (vi) studies exhibiting bias or inconsistencies that invalidated the results; and (vii) studies of prognostic factors related to genetic features or to quantification of cytokines.The systematic review encompassed epidemiological studies containing data that allowed us to estimate measures of association relating to predictors of death or of adverse prognosis independent of the occurrence of death  in individuals diagnosed with VL. No restrictions were made regarding the age or gender of the patients or of the language of the publication. The exclusion criteria proposed were (i) studies performed outside Latin America; (ii) reports published as proceedings of symposiums or conferences; (iii) studies restricted to the description of signs and symptoms observed in VL-infected individuals without comparisons regarding the evolution of the disease; (iv) studies that simply described the existence of statistically significant (or not) associations without reporting at least the calculated The extraction of data from the publications was performed by one of the authors (VSB) and verified by the co-authors. Attempts were made to contact the authors of original reports when further information was required in order to calculate measures of association for possible inclusion in the meta-analysis. Data pertaining to individual patients were not requested.P-values using the Stouffer method, weighted proportionally to the inverse of the study squared standard error P-values was carried out as for the first group. For both groups of studies, we conducted theoretical discussions about variables that could not be submitted to meta-analysis, either because of the small number of studies involved or because of the non-uniform manner in which the data were presented or analyzed among the primary studies.The selected studies were separated into two main groups according to the outcomes, namely: (i) adverse evolution of the disease independent of death (as defined in the last section), (ii) evolution of the disease resulting in death. The first group of studies encompassed various possible outcomes and the information concerning each of the clinical or laboratory predictors identified was, if considered plausible , combined through meta-analysis of one sized 2I test, which describes the percentage of total variation across studies associated with real dispersion in effect-sizes (inter-study variation) rather than random error (intra-study variation). For each prognostic factor, the studies were separated according to the ages of the participants (adults and children) and evaluations were performed separately for each group. When the measures of association were similar in the two groups the data were combined, otherwise the combination of data was performed only within the specific group.Measures of association were combined using the random effects model, except when the number of studies was less than four in which case the fixed effects model was employed P-values, while CMA software version 2.0.057 was used for all other meta-analyses.Meta-P software was employed for the meta-analysis of The relative strength of each of the clinical and laboratory variables as a predictor of the severity of VL was evaluated according to defined criteria which were, in decreasing order of weight: (i) force of summary measure obtained through meta-analysis; (ii) pattern of data (direction of association and heterogeneity in studies where the outcome was death); (iii) number of statistically significant studies in which the control for confounding variables had been performed; and (iv) pattern of associations in studies where the outcome was unfavorable clinical evolution independent of death.There is no universally accepted or standardized tool for the identification of limitations or potential risks of bias in the analysis and/or presentation of data in studies relating to prognostic factors. Thus, in order to analyze the quality of studies reviewed we opted to use five publications Sistema de Informação de Agravos de Notificação; SINAN; 1/14) as shown in Of the 2945 studies identified and screened as part of the comprehensive survey, only 14 prognostic studies Each of the 14 studies reviewed employed appropriate criteria for selecting the study populations and defining the cases, and all except one All predictors of adverse evolution of VL and/or related mortality for which it was possible to perform meta-analysis  are presApart from hepatomegaly, splenomegaly and weight loss, which were considered weak predictors, there was a predominance of statistically significant summary measures that showed, however, no significance in the majority of multivariate analyses  and adults above 40 years  are more likely to have an adverse evolution. The distribution of lethality with peaks among children and older adults suggests that different factors may be involved in the acquisition of infections and complications at different ages Together with the strong prognostic factors of groups I and II , it is wLeishmania replication by the adaptive immunosystem, particularly by Th1 cells, of undernourished patients could explain the lack of association between undernutrition and mortality risk The reduced strength of some relationships may be attributed to the specific therapeutic measures employed in some cases. For instance, individuals presenting hemoglobin levels below 7 g/dL would have received transfusions of packed red cells, as recommended by the Ministry of Health of Brazil Several potentially relevant variables could not be included in the categories of evidence proposed herein because of the scarcity of studies. Among these are factors that can be readily assessed in clinical practice with minimal cost and must be better evaluated in future research, for example, mean cell volume, eosinophil count, serum creatinine, inappetence, weakness or asthenia, dehydration, lymphadenopathy and occurrence of comorbidities such as diabetes, tuberculosis, heart or renal diseases and dengue fever. In this context, it is noteworthy that the influence of helminthiasis on the clinical evolution of VL was not investigated in any of the reviewed studies even though infection by intestinal parasitic worms is highly prevalent in urban and rural areas of Brazil The present review provides a reliable source of information for the identification of risk factors of adverse prognosis and mortality in VL and should be used as an aid in decision-making in clinical practice. It is important to emphasize, however, that the results presented herein do not directly allow the creation and validation of prognostic scores based on the signs and symptoms presented by patients. Thus, studies should be carried out with the specific purpose of developing such scores and performing external validation of prognostic models already proposed, along with the incorporation of prognostic factors or additional biomarkers as recommended by Pencina et al. Concerning other limitations in the analyzed studies, the procedures adopted to deal with the problem of missing information from medical records were generally unclear. According to Little and Rubin The majority of studies considered in the present review failed to define the criteria adopted for the stratification of continuous variables. The quality of studies could be improved by adoption of credible and unequivocal clinical and analytical stratification criteria Although the majority of the reviewed studies can be considered acceptable with respect to the adequacy of case definitions, statistical methods and multivariate analyses adopted, there were limitations in the models in cases where no interaction or multi-colinearity tests between the predictor variables were performed. In most of the studies, various prognostic factors were analyzed and many of them could be correlated, thereby producing the same explanation of variability in outcome Considering the limitations of the present review, none of the studies conducted in other parts of the world were analyzed since those studies would reflect specific clinical, social and epidemiological characteristics distinct from those of VL in the Americas. Other relevant issues included the problem of combining data acquired from distinct populations (in terms of areas and characteristics) as well as the inability to explore the causes of heterogeneity of effect sizes between studies, and the impracticality of determining the existence of publication bias. Most studies described the results for all of the variables analyzed, but four articles did not provide data regarding some associations, particularly for non-significant variables, and this may have modified the true effect of some of the calculated summary measures. The force of these measures may also have been overestimated because of the use of odds ratio as a proxy for the relative risk This is the first systematic review with meta-analysis on the prognosis factors relating to VL severity. The integration of information from different investigations conducted in Brazil in the last 10 years led to the identification of consistent predictor variables that might be useful in clinical practice for designing distinct therapies for patients at risk of an unfavorable outcome of the disease. The analysis of the quality of the published studies may be of assistance in future research, since positive features have been highlighted while logical criticism of the flaws, mainly relating to the external validation of multivariate prognostic models, has been offered. Similar assessments in different regions of the globe would be highly relevant since lethality of VL and the impact of this disease on our society can only be diminished by using consistent evidence-based medical approaches.Table S1Main characteristics of the studies included in the systematic review on prognostic factors relating to visceral leishmaniasis (VL) severity.(DOC)Click here for additional data file.Table S2Predictors, classified according to strength, of unfavorable clinical evolution independent of death and mortality for American visceral leishmaniasis identified in this systematic review.(DOC)Click here for additional data file.Text S1Forest plots for the variables submitted to meta-analysis.(DOCX)Click here for additional data file.Text S2PRISMA checklist (DOC)Click here for additional data file.


Orthopoxvirus and is endemic to Central and Western African countries. Previous work has identified two geographically disjuct clades of monkeypox virus based on the analysis of a few genomes coupled with epidemiological and clinical analyses; however, environmental and geographic causes of this differentiation have not been explored. Here, we expand previous phylogenetic studies by analyzing a larger set of monkeypox virus genomes originating throughout Sub-Saharan Africa to identify possible biogeographic barriers associated with genetic differentiation; and projected ecological niche models onto environmental conditions at three periods in the past to explore the potential role of climate oscillations in the evolution of the two primary clades. Analyses supported the separation of the Congo Basin and West Africa clades; the Congo Basin clade shows much shorter branches, which likely indicate a more recent diversification of isolates within this clade. The area between the Sanaga and Cross Rivers divides the two clades and the Dahomey Gap seems to have also served as a barrier within the West African clade. Contraction of areas with suitable environments for monkeypox virus during the Last Glacial Maximum, suggests that the Congo Basin clade of monkeypox virus experienced a severe bottleneck and has since expanded its geographic range.Monkeypox is a zoonotic disease caused by a virus member of the genus  Orthopoxvirus genus, which includes other viruses pathogenic to humans , and produces mild to severe rash illness in infected individuals. The first human case of monkeypox was identified in the Democratic Republic of the Congo (DRC) in 1971  p < 0.001). The two Nigerian isolates group together in spite of having high genetic differentiation between them and are from a group that is sister to the one formed by the remaining isolates of the clade; in addition, all isolates obtained from captive animals form a single monophyletic group.Results of the phylogenetic analysis are shown in Within the CB clade, five monophyletic groups were formed after the phylogenetic analysis: group I includes the two western most isolates from this clade: Cameroon 1989 and Gabon 1987; group II contains 11 isolates, five from Sankuru District , one from South Sudan (Sudan 2005), one from the Republic of the Congo (Impfondo 2003), and four from other parts of DRC ; group III is the closest sister group to group II, twelve of the thirteen isolates in this group are from Sankuru District , the remaining one is from Yambuku; six of the seven isolates in group IV are from Sankuru District , the remaining one is Ikubi; group V only has one isolate from Sankuru District (JX878417). The groups are indicated in ENM projections into present day environmental conditions are similar to models presented in previous works ,39 and iGARP model projections onto climatic conditions during the Mid-Holocene show more connection between areas with suitable environments for MPXV in West Africa and also between those suitable areas in Nigeria and Central Africa; the most evident discontinuity of suitable areas separates such areas in costal Nigeria from the rest of West Africa and is located in Benin C. MaxentFinally, ENM projections onto environmental conditions during the LIG identified a larger and more continuous area of model agreement for both algorithms than that for the LGM located in central Africa with a few small patches along the coast in West Africa for GARP and Gabon for Maxent G,H.Pan [Praomys [Our phylogenetic analysis separates the MPXV isolates into two major groups that correspond to the previously identified WA and CB clades. The eastern most isolate of the WA clade  is between the Niger River (west) and the Cross River (east); while the western most isolate of the CB clade  is south of the Sanaga River B. These Pan , flying Pan , and mic[Praomys . The twoThe Cameroon Highlands are also located between the Cross and Sanaga Rivers; they are recognized as a high biodiversity ecoregion where the dominant vegetation types are tropical and subtropical moist broadleaf forest , represeThe Dahomey Gap is a savanna corridor that interrupts the West African rain forest in Togo, Benin, and Eastern Ghana , which hConsistent with the Pleistocene refuge theory ,75, ecolIn the present study, we first identified potential biogeographic barriers for MPXV that could be related to the CB-WA split. Further studies are necessary to determine whether the presence of a river, change in elevation, or change in the dominant vegetation cover is involved in the genetic differentiation of MPXV. The addition of MPXV isolates from the area between the Sanaga and Cross rivers would be ideal; however, cases of human or wildlife MPX have not been reported from this area. Second, we propose that the CB clade is a group with very recent diversification, possibly explained by the colonization of a bigger area with suitable conditions (refuge theory); however, dating the times of differentiation between and within clades is not possible with our current dataset. Tying MPXV cladogenesis to geologic or climatic events is a subject of future efforts. Additional field studies that result in the isolation of MPXV or the finding of serological evidence of infection with this virus in wildlife could be key to better understanding its natural history and biogeography.


In this article recent progress on the elucidation of the dynamic composition and structure of plastid nucleoids is reviewed from a structural perspective. Plastid nucleoids are compact structures of multiple copies of different forms of ptDNA, RNA, enzymes for replication and gene expression as well as DNA binding proteins. Although early electron microscopy suggested that plastid DNA is almost free of proteins, it is now well established that the DNA in nucleoids similarly as in the nuclear chromatin is associated with basic proteins playing key roles in organization of the DNA architecture and in regulation of DNA associated enzymatic activities involved in transcription, replication, and recombination. This group of DNA binding proteins has been named plastid nucleoid associated proteins (ptNAPs). Plastid nucleoids are unique with respect to their variable number, genome copy content and dynamic distribution within different types of plastids. The mechanisms underlying the shaping and reorganization of plastid nucleoids during chloroplast development and in response to environmental conditions involve posttranslational modifications of ptNAPs, similarly to those changes known for histones in the eukaryotic chromatin, as well as changes in the repertoire of ptNAPs, as known for nucleoids of bacteria. Attachment of plastid nucleoids to membranes is proposed to be important not only for regulation of DNA availability for replication and transcription, but also for the coordination of photosynthesis and plastid gene expression. Plastids are the characteristic organelles of photosynthetic eukaryotes. They are the sites of photosynthesis, and their biosynthetic pathways supply the plant cell with many essential compounds. Chloroplasts evolved from a cyanobacterial ancestor after a single endosymbiotic event, that was followed by an extensive reduction of the plastid genome size  together with RNA and proteins are organized in structures that are similar to bacterial nucleoids. The compact structure of DNA in such nucleoids has been compared with the chromatin in the nucleus of eukaryotic cells . Interestingly, transcription by RNA polymerase II requires dynamic changes in the chromatin structures of the templates  proteins Grasser,  also plaPackaging of DNA by histones into nucleosomes is not a distinguishing feature of eukaryotes, but also occurs in some groups of archaebacteria which might have participated in the origin of eukaryotes   were shown to be organized as rosettes with a compact central core from which supercoiled DNA loops with an average size of 10 kbp were observed to radiate  The large single copy region (LSC) which in Arabidopsis comprises as much as 54% of the genome, (2) the small single copy region (SSC) making up 12% of the plastid genome in Arabidopsis, and (3) the two inverted repeats, IRs Green, . This doin situ hybridization showed that besides circular chromosomes, linear forms occur in plastids that were proposed to be the major forms in chloroplasts where many small nucleoids are attached to thylakoids  and a stand-alone SWIB domain protein, the only type of SWIB proteins found in bacteria. Chlamydiae are a group of bacteria living as endosymbionts and parasites in other bacteria or in eukaryotic cells. Phylogenetic analyses suggested that an ancestral member of the group of Chlamydiae facilitated the establishment of the primary endosymbiosis between cyanobacteria and an early eukaryote  and WHIRLY3 (pTAC11) that have been found in the proteome of transcriptionally active chromosomes (TAC) isolated from Arabidopsis chloroplasts  and SVR4-like (MRL7-like), was found  and SVR4-like proteins, which were originally identified as important proteins for chloroplast development in Arabidopsis  and CHLI (Mg chelatase subunit I) genes. These mutants possess thylakoids but lack grana stacks and are devoid of the photosynthetic complexes resulting in compromised photosynthesis  -dependent genes increases, whereas at the same time the expression of NEP (nuclear encoded polymerase) -dependent genes decreases , as well as with the two nucleoid associated superoxide dismutases FSD2 and FSD3 (Qiao et al., Of particular importance for the activity of nucleoids is their association with the thylakoid membranes where the photosynthetic machinery undergoes changes in composition in response to environmental conditions. A prerequisite for remodeling of the photosynthetic apparatus is the regulation of plastid gene transcription in response to light-dependent changes in the redox state of the photosynthetic apparatus (Pfannschmidt et al., In this context, proteins found to be located at the interface between nucleoids and the thylakoid membrane are of particular interest. MFP1 was proposed to anchor nucleoids to thylakoids in chloroplasts (Jeong et al., Transgenic plants with different levels of nucleoid/thylakoid associated proteins might help to elucidate the roles of these proteins in linking the activity of the photosynthetic machinery to organization and expression of plastid genes as well as the expression of nuclear genes.In the nucleus the availability of DNA for transcription is regulated mainly by posttranslational modifications, whereas in bacteria regulation of transcription involves the exchange of DNA binding proteins (Luijsterburg et al., It remains to be shown whether the different packaging of DNA in different regions of the nucleoid changes during development and in response to environmental cues. Whether, however, the central body of nucleoids with dense packaging (Sakai et al., The comparison of DNA organization in plastids, nucleus and bacteria shows that the shaping and organization of plastid nucleoids involves novel organelle specific mechanisms resembling those acting on eukaryotic chromatin besides mechanisms described for eubacterial nucleoids. During evolution of plants, the architectural proteins of bacterial nucleoids have been lost and replaced by new proteins. Some of these are enzymes that have acquired an additional function as DNA binding proteins. Others might have been contributed by Chlamydiae which facilitated establishment of the primary endosymbiosis between an early eukaryote and the cyanobacterial ancestor of plastids. These proteins do not exhibit sequence or structural conservation with the eukaryotic histones, but similar to the histones they might be regulated by posttranslational modifications.In comparison to eukaryotic chromatin, nucleoids of plastids have as those of bacteria a more open structure, that allows easy access for DNA transaction enzymes. The enrichment of enzymes involved in RNA processing and translation in the nucleoid fraction suggests that transcription, RNA processing and translation are tightly connected with each other.Similarly to bacteria, also in plastids, membranes seem to play a key role in the organization and maintenance of nucleoids. In chloroplasts, the proximity of nucleoids and photosynthetic machinery as well as the presence of several redox active proteins in nucleoids, allows for a tight coordination of photosynthesis and nucleoid function, i.e., replication and gene expression. It is striking that not only particular enzymes involved in gene expression but also architectural proteins are controlled by redox signals. Thereby these proteins might have a tremendous impact on the different enzymatic activities associated with nucleoids; in particular replication, transcription and DNA repair.The architectural organization of the plastid genetic machinery is not well understood. Since principles underlying the dynamic shaping of genomes are uniform in all forms of life, the knowledge about DNA organization in bacteria and eukaryotes can be used in future studies on the dynamic architecture of chloroplast nucleoids.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Automated analysis of premature electroencephalogram (EEG) for diagnosis is a crucial step to reduce the workload of neurologists. The grade of discontinuity gives important information about the maturation . For norIn conclusion, this research adds another valuable feature for the automated analysis of premature background EEG, which would improve the overall assessment in the NICU for EEG diagnosis


In this study, the Spectral Relaxation Method (SRM) is used to solve the coupled highly nonlinear system of partial differential equations due to an unsteady flow over a stretching surface in an incompressible rotating viscous fluid in presence of binary chemical reaction and Arrhenius activation energy. The velocity, temperature and concentration distributions as well as the skin-friction, heat and mass transfer coefficients have been obtained and discussed for various physical parametric values. The numerical results obtained by (SRM) are then presented graphically and discussed to highlight the physical implications of the simulations. The study of boundary layer flow and heat transfer inducted by stretching surface has attracted considerable interest due to its wide applications in industrial processes such as the cooling of an infinite metallic plate in a cooling bath, the aerodynamic extrusion of plastic sheets, boundary layer along the material handling conveyers, the boundary layer along a liquid film and condensation processes. The quality of the final product depends on the skin friction coefficient and the rate of heat transfer. One of the earliest studies of the boundary layer flow problem was conducted by Sakiadis Unsteady flows in rotating fluid have numerous uses or potential applications in chemical and geophysical fluid dynamics and mechanical nuclear engineering. Using the Fourier series analysis, Soundalgekar et al. Many chemically reacting systems involve the species chemical reactions with finite Arrhenius activation energy, with examples occurring in geothermal and oil reservoir engineering. The interactions between mass transport and chemical reactions are generally very complex, and can be observed in the production and consumption of reactant species at different rates both within the fluid and the mass transfer. One of the earliest studies involving the binary chemical reaction in boundary layer flow was published by Bestman This work deals with the effects of chemical reactions with finite Arrhenius activation energy on unsteady rotating fluid flow due to a stretching surface with Binary chemical reaction and activation energy. The governing partial differential equations are solved using the spectral relaxation method (SRM). The SRM is based on simple decoupling and rearrangement of the governing nonlinear equations in a Gauss-Seidel manner. The resulting sequence of equations are integrated using the Chebyshev spectral collocation method. The SRM was introduced in Consider the three-dimensional, unsteady flow due to a stretching surface in a rotating fluid. The motion in the fluid is three dimensional. At time The following non-dimensional variables are introduced,The governing The non-dimensional skin friction in both In this section, the spectral relaxation method (SRM) is applied to solve the governing nonlinear PDEs (10 – 13). For the implementation of the spectral collocation method, at a later stage, it is convenient to reduce the order of The spectral relaxation method algorithm uses the idea of the Gauss-Seidel method to decouple the governing systems of The initial approximation for solving Starting from given initial approximations (27 – 28), the iteration schemes 19 – 26) can be solved iteratively for  can be sThus, applying the spectral collocation method and finite difference approximation on the SRM scheme (19 – 26) gives35)(36)subject tIn order to determine the evolution of the boundary layer flow properties, numerical solutions of the set of governing systems of partial differential In this investigation, we considered the spectral relaxation method approach to solving an coupled non-linear partial differential equation system that governs the unsteady flow with binary chemical reaction and activation energy due to a stretching surface in a rotating fluid. The effects of the governing parameters namely the rotation rate parameter, the Schmidt number, the non-dimensional activation energy, the Prandtl number, the chemical reaction rate constant, the temperature relative parameter and on the flow characteristics as well as the local skin friction, heat and mass transfer coefficients have been studied. Small values the rotation rate parameter


In a retrospective study of 113 patients presenting to a Brisbane general practitioner with eating disorders, 14 patients gave a history of anaphylaxis, whilst another 7 reported significant food allergies. This is significantly higher than population estimates of anaphylaxis of 1 in 1700.This high incidence leads one to ponder the origins of the issues - whether the fear of anaphylaxis contributes to a fear of food in general  or whether the two conditions may share underlying immunological and/or genetic risk factors.Of particular note is the recent treatment of anaphylaxis in children using probiotics, the known association of PANDAS, recent discoveries linking the micro biome to mental health and the increased rate of asthma in mothers with depression.


Improving outcomes for women with epithelial ovarian cancer is a major health issue worldwide as 5-year survival has not improved significantly over the last two decades.CLASP1, a regulator of microtubule dynamics essential for mitotic cell cycling was positively associated with survival, either overall or disease free (The urgent need to increase our understanding of high-grade serous ovarian cancer (HG-SOC) led to it being chosen for the pilot project of The Cancer Genome Atlas (TCGA) and the genomes of over 400 HG-SOC samples are now freely accessible for interrogation. These data are being used for the discovery of biomarkers as well as the generation of hypotheses to understand the natural history of this malignancy and develop effective targeted therapies. In this Research Topic, Lisowaska and colleagues used gene expression profiling to identify that reduced expression of in silico resource now available via TCGA and other web-based portals, research in HG-SOC is hampered on a number of fronts. Comparison of results from cancerous or cancer-associated stromal cells with each non-cancerous  equivalent is a fundamental research question, but what to use for normal cells is unclear. Recent evidence suggests that HG-SOC has its origins in the secretory cells located in the fimbrial end of the fallopian tube. This is contrary to the prevailing notion that HG-SOC arises from the epithelium lining the ovary and inclusion cysts. The contribution of each site to serous ovarian carcinogenesis is currently under debate. Jones and Drapkin recount the evolution of evidence for each site of origin and review the use and limitations of primary cell culture model systems developed from each site  culture conditions. 3D culture systems feature in several articles in this Research Topic indicating the enthusiasm for this culture type and recognition of the deficiencies of the monolayer systems , 5, 6. Iin vitro development of treatment resistance  and serous tubal intraepithelial carcinomas (STICs) all in the fallopian tubal epithelium, implicating this tissue as a site of origin for HG-SOC. George and Shaw provide a critical review of the literature related to these findings, noting that P53 signatures are found with similar frequencies in BRCA-mutation carriers and non-carriers, and that STILs and STICS are uncommon and identified with poor reproducibility  as a background strain for breeding with relevant genetically engineered changes  models was aimed at overcoming two of these deficiencies by using pieces of patient tumors that had never been cultured in vitro and that retained the microenvironment of the original tumor. PDX models are aimed primarily at testing drug responses. The site of implantation of PDXs can alter the rate of engraftment as well as the characteristics of the model. The advantages and disadvantages of the different sites of implantation are discussed by Scott and colleagues as part of their review of PDX model systems that have been trialed for EOC (Xenografts are the most utilized  for EOC . They an for EOC , 14, 16.The rapid acceptance of PDXs as preclinical models underscores the increasing awareness of the contribution of the microenvironment to the pathogenesis and progression of cancer. An overview of the different components of the microenvironment such as proteases and extracellular matrix and their roles in promoting invasion and metastasis in EOC is presented by Davidson and colleagues . Dissemiin vivo models.In summary, this Research Topic showcases our current understanding of a number of key areas in EOC. It has a strong focus on model systems given the critical importance of having accurate systems and the particular difficulties and dilemmas faced especially in the development of The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Severe soft tissue defects as a result of lye contamination remain a huge challenge in the interdisciplinary approach of trauma surgeons and plastic surgeons. Free tissue transfer is a suitable surgical option for successful reconstruction of form and function of defects in the distal parts of the lower extremities. We report the successful two-stage reconstruction of a full thickness lye contamination at the dorsum of the foot with a free temporoparietal fascia flap covered with a split-thickness skin graft from the thigh. The described method is a suitable operative alternative to anterolateral thigh flaps or other thin fascia flaps regarding flap harvest and donor site morbidity and should be considered in the portfolio of the plastic surgeon.  Soft tissue defects of the foot and ankle region are usually the result from mechanical, chemical or thermal trauma or are a consequence of systemic disorders with reduced perfusion, trophic dysfunction and soft tissue infections . The sucThe 24-year-old male was referred from an external hospital after a job-related chemical injury to the dorsum of his left foot. He accidentally poured an unknown amount of caustic soda solution over his foot. The emergency treatment was performed in a general hospital near to the patient’s place of residence. He was admitted to our Burns Unit the following day. Patient examination showed extensive necroses from the ankle region until the distal third of the dorsum of his left foot and the metatarsals. Planta pedis, heel and toe region remained intact Figure 1 . Due to th day after admittance in a healthy condition with good scarring. The initial care was performed by our outpatient unit with weekly follow-up visits and short-term visits after 9 weeks  based on perforators of the descending branch of the lateral femoral circumflex artery or the free serratus fascia flap , 6], , . They coDue to the extensive defect of our young but overweight patient we did not chose local flap options. Patient factors such as weight and postoperative weight bearing requirements as a very young patient led us to perform surgery with the microvascular free temporoparietal fascial flap with end-to-side anastomosis to the tibal dorsal artery. With this option we achieved an optimal consensus of form and function of the foot on the one hand and the aesthetic outcome on the other hand. The short-term follow-up of our patient shows a good and plane scarring, optimal donor site outcome and a very good postoperative function. Our results are in conformity with the experiences of Duteille et al., who showed similar results on twelve consecutive patients . All patThe complexity of soft tissue reconstruction of the foot arises with a relative high incidence of flap failure and secondary major amputations of the foot or distal lower leg in a lot of patients. One reason leading to amputation may be limited capacity for plastic reconstructive surgery and therefore limited surgical expertise in smaller health centers. A grave reason may also be a high complication rate of chronically ill patients with a lot of comorbidities leading care-givers to more definite options such as amputations. Ligh et al. from Duke University recently compared a group of patients which received free flaps to a group of patients which received local flaps . AccordiConsistent with the findings of Duteille et al. we deem the microvascular free temporoparietal fascial flap for a good operative option in patients with profound defects of the dorsum of the foot. It may expand the portfolio of the plastic surgeon in reconstructive surgery in this body region. The authors declare that they have no competing interests.


The up regulation of central BDNF gene expression has been suggested in the treatment of major depression. Chronic administration of dopaminergic agents activates the function of CREB which results into the up regulation of the BDNF gene expression. Statin therapy is associated with a reduced risk of depression and could be of therapeutic potential for major depression.We have examined a possible link amongst simvastatin, bromocriptine, haloperidol and levodopa in accordance with BDNF exon II gene expression using RT-PCR method in mice treated with standard paradigm of chronic mild stress procedure for 14 days. We specifically determined if the oral administration of simvastatin would affect the efficacy of bromocriptine, haloperidol or levodopa in mediating the regulation of the BDNF exon II gene expression.The results of RT-PCR method revealed the differential expression patterns for the expression of BDNF exon II gene in brain of mouse by indicating the three different bands, as evidenced previously to be the three different exon II transcript variants in mouse namely BDNF IIA, BDNF IIB and BDNF IIC. Mice treated with bromocriptine or levodopa in combination with simvastatin for 14 days could synergize the up regulation of for the expression of specific BDNF exon II transcript as compared to simvastatin alone whereas the mice treated with haloperidol in combination with simvastatin for 14 days could abolish the for the expression of up regulation of specific BDNF exon II transcript compared to simvastatin alone.2 like receptor and differential expression patterns for the expression of BDNF exon II gene in brain of mouse which further strengthen the emerging hypothesis, suggesting the ability of neuronal systems to exhibit the appropriate adaptive plasticity could contribute to the treatment of depression. Further, the dopaminergic agents in accordance with the cholesterol lowering drug as adjuncts may reduce the depressive like behavior more significantly and facilitation of antidepressant action of dopaminergic agents may be correlated with HMGR or cholesterol or mevalonate pathway.The results of the above study suggests linkage between the function of dopamine or dopamine D