Circumdata, the section Nigri (=Aspergillus niger group) is reviewed relative to their production of mycotoxins and their effects on plants as pathogens. Molecular methods have revealed more than 18 cryptic species, of which several have been characterized as potential mycotoxin producers. Others are defined as benign relative to their ability to produce mycotoxins. However, these characterizations are based on in vitro culture and toxins production. Several can produce the ochratoxins that are toxic to livestock, poultry, and humans. The black aspergilli produce rots of grapes, maize, and numerous other fruits and grain and they are generally viewed as post-harvest pathogens. Data are review to suggest that black aspergilli, as so many others, are symptomless endophytes. These fungi and their mycotoxins contaminate several major grains, foodstuffs, and products made from them such as wine, and coffee. Evidence is presented that the black aspergilli are producers of other classes of mycotoxins such as the fumonisins, which are known carcinogenic and known prior investigations as being produced by the Fusarium species. Three species are identified in U.S. maize and peanuts as symptomless endophytes, which suggests the potential for concern as pathogens and as food safety hazards. The black spored fungi of the subgenera  Aspergillus have a long history of associations with humankind. The genus was first described by Micheli in 1729 [A. glaucus by Link [Aspergillus and are in general toxic to livestock, poultry, fish, and humans. Fungi of the genus Aspergillus as causes of animal toxicities, mainly poultry [A. flavus and A. parasiticus [et al. [Aspergillus ochraceus Whilh, and Penicillium verrucosum. One of the first reports for the natural occurrences of ochratoxicosis was in poultry, which consisted of five independent episodes including about 970,000 turkeys, two episodes of about 70,000 laying hens, and two episodes in about 12,000,000 broilers [Aspergillus sections Circumdati (A. ochraceus group), and by Eurotium herbariorum, a member of the Aspergillus section (A. glaucus group). Recently, the black species of Aspergillus have been shown able to produce the ochratoxins [Early attention was devoted to species of  poultry . Immediaasiticus . Subsequasiticus , which i [et al.  as the mratoxins , which eAspergillus species are associated with grapes, onions, maize, and peanuts, where they are cited as pathogens causing such diseases as peanut and maize seedling blight, and maize kernel rot. However, there are numerous examples of fungi associated with plants as symptomless endophytes, and there is evidence that this life habit may be practiced by the Aspergillus species as well. In association with several hosts, these symptomless endophytes have the capacity to either develop as pathogens or as saprophytes, and in either state become producers of mycotoxins. Symptomless expressions of several black aspergilli are indicated in the literature but nothing is indicated about their ability to produce mycotoxins and any associated pathology. Further, the black species of Aspergillus associated with any plant pathological problem was indicated in early publications as A. niger, the black species. In this review, we refer to A. niger sensu strictu, i.e., A. niger var. niger, to designate or distinguish the present day discription from the older published accounts, which in most instances were applied sensu lato and will be referred to here as simply A. niger. While several cryptic species within this subgenus have been delineated, this recent taxonomic revision creates a large gap of knowledge of black Aspergillus species that are presently defined, and which is important to food safety and plant pathology. This review focuses on identifying the species of the subgenera Circumdati, the section Nigri (=A. niger group) (The black aspergilli are commonly found as soil organisms decomposing dead plant residues  and theyr group)  encounteAspergillus species, and these can be conveniently separated into several distinct morphospecies, and several of these are based on colors according to the earlier classification of Raper and Fennell [Aspergillus genus into eight subgenera [Circumdati, the sections Circumdati (=Aspergillus ochraceus group) and Nigri (A. niger group). There are no known teleomorphic species of group Nigri. In recent years, members of the Aspergillus section Nigri have undergone an extensive taxonomic revision resulting in several new taxa, such as A. niger var. niger, A. melleus, A. sulphureus, A. brasilensis, A. ostianus, A. petrakii, A. scletotium, A. carbonarius, A. aculeatus, A. japonicus, A. tubingensis, A. ibericus and Eurotium herbariorum [There are well over 190 number of  Fennell . Howeverubgenera . Followibariorum ,13,14  have now been isolated from maize and peanuts  and other Fusarium species [Fusarium verticillioides-contaminated maize is correlated with human esophageal cancer, and the fumonisins are highly toxic to horses, pigs, and poultry [2 is more cytotoxic than B1. The most commonly isolated fumonisin is the B1 homologue, while B2 is isolated less frequently. Only strains of A. niger var. niger have currently been shown to produce the fumonisins including B4 and the new B6 homologue [A. niger var. niger from grapes have been reported as producers of the fumonisins. A survey of black aspergilli isolated from raisins indicated that 77% of A. niger from grapes produced fumonisin B2 and B4, and interestingly none of these strains produced the ochratoxins [6, was isolated from A. niger, with in general the frequencies of production of fumonisins in this species so far are 100% FB2, 10–25% FB4, and 5–10% FB6[F. verticillioides from maize and peanuts suggesting that the source of fumonisin accumulation on these substrates might be derived from either fungus. However, the production of strains of A. niger var. niger from maize has not been demonstrated. Since the black aspergilli, especially A. niger var. niger, are used in so many biotechnological processes for food use, the production of the fumonisins by the commonly occurrence of this species increases the concern for food safety.Additional toxic substances are presented in  species . Fusariu poultry . The fumomologue ,37,44. Sratoxins ,44, suggα –henenoic acid) is particularly produced by most of the golden colored species of section Circumdati (=A. ochraceus group), and is oftentimes co-produced with ochratoxin A by strains of A. ochraceus [A. ochraceus group, penicillic acid is also produced by numerous other species of Aspergillus and Penicillium [The black aspergilli have produced a variety of biologically active compounds , some ofchraceus ,45.Besidicillium ,47, whicicillium ,49,50, aicillium ,52. Whilicillium , its proAspergillus species. Since the biological activities described for penicillic acid above are important from several control measures, its production by the black aspergilli should be investigated.Penicillic acid is also inhibitory with microorganisms, particularly Gram-negative bacteria , and mayBlack aspergilli are reported as pre- and post-harvest pathogens in maize, other cereal grain, bunch grapes, onions, garlic, soya beans, apples, mangoes, and peanuts ,59,60,61Aspergillus carbonarius SRRC 2131 and A. niger var. niger SRRC 13 were transformed with a yellow fluorescent protein vector that was used to measure colonization of maize seedlings [A. niger from surface disinfected plant materials of onions by Hayden and Maude [An investigation of the endophytic nature of maize seedling was investigated. eedlings ,65. The eedlings . The infnd Maude . The infnd Maude . Aspergillus rot in grapes is caused by the black species, A. niger, var. niger, A. carbonarius and A. aculeatus [A. niger is known to cause kernel rot of maize (Fusarium verticillioides, and F. graminearum. However, black aspergilli are isolated from surface disinfected kernels of maize (A. niger var. niger can develop into a postharvest disease, but perhaps due to injury to the bulbs or unsuited storage conditions [A. flavus. Nevertheless, endophytic infections do occur as demonstrated from isolations from surface disinfected kernels, and these endophytic infections can colonize plant tissue. Therefore, some black aspergilli are capable of a biotrophic endophytic existence with maize and onion. Since these two plants are widely separated taxonomically, it is possible that endophytic infection by the black aspergilli exist in numerous plant taxa.In grapes, another situation is described. culeatus . These bof maize , which iof maize . Symptomnditions ,66. In tF. verticillioides, can exclude the Aspergillus species such as A. niger var. niger, from colonizing maize, but this depended on optimum temperature and specific water activity levels [Since ochratoxin A is present in maize, and other cereal grain under field conditions , there iy levels ,68. The A. niger, resulting in a great deal of confusions concerning the actual species observed. Recent molecular analysis of the black aspergilli indicated several cryptic species, which now should be aligned with recent phytopathological and toxicological concerns. To prevent this confusion, the older A. niger has been replaced by A. niger, var. niger in order to exclude the prior confusion in discussions of both the earlier and recent discriptions. The subgenus Circumdati section Nigri consists of at least 19 species of black spore species of which A. niger var. niger is probably the most dominant species in the US where it is found in most soil types and on dozens of fruits and cereal grains. Of major concern is the relationship of the black aspergilli with maize and peanuts, two plants of major economic concern in the US Strains of A. niger var. niger, along with others, can produce the ochratoxins and the fumonisin B1 mycotoxins. In addition to the effect of the mycotoxins on animals and humans, these toxins are interactive with other secondary metabolites to produce synergistic effects. Others are also phytotoxic [A. niger. Certain species have been characterized as producing specific toxins and associated pathology. This indicates the need for reexamination of taxa associated with specific food crops. Additionally, detailed studies of their host relationship are also indicated, as some species are associated with crops as symptomless endophytes. There are also reports on the co-occurrence of both ochratoxin A with the fumonisins in maize [F. verticillioides. Further, evidence of co-infection of A. niger with A. ochraceus in maize is observed also a concern as this presents difficulty in identifying the correct offending mycotoxic species. The black aspergilli are known pathogens in peanut culture where major problems are indicated from the seedling stage or during peanut set late in matured plants. The result is poor quality nuts that are rated too low for human consumption. Thus, pathogenic expressions in maize, cotton, grapes, peanuts and other plants, the production of the ochratoxins and fumonisins on these products, and the unknown species associated with specific pathological expressions on these important crop plants underlines the need for further studies of the black aspergilli. Finally, the prediction of rising global temperatures should influence the population patterns and shifts of species within the A. niger group to more northern latitudes that should increase the number of additional crops, adding to the mycotoxigenic potential globally for all species of the subgenera Circumdata.In the past most descriptions and concerns relative to the black aspergilli have been referred to as ytotoxic , suggestin maize ,71, whic


Dirofilaria, which are transmitted by a plethora of mosquito species. The principal agent of canine dirofilariosis in the Americas is Dirofilaria immitis, which may also occasionally infest humans, resulting in pulmonary nodules that may be confounded with malignant lung tumours. Because human cases of dirofilariosis by D. immitis are relatively frequent in the Americas and rare in Europe and other eastern countries, where Dirofilaria repens is the main causative agent, the existence of a more virulent strain of D. immitis in the Americas has been speculated. Recently, a case of human ocular infestation by Dirofilaria sp. was diagnosed in Pará State, northern Brazil, where canine heartworm dirofilariosis is endemic. The nematode was shown to be morphologically and phylogenetically related to D. immitis but it was genetically distinct from reference sequences, including those of D. immitis infesting dogs in the same geographical area. This finding raised questions regarding the aetiology of human dirofilariosis in the Americas, since information on the genetic makeup of filarioids infesting dogs and humans is meagre. Further studies would be needed to better characterize filarioids infesting dogs, wild animals, and humans in the Americas and to assess the existence of a more virulent D. immitis strain in this continent. Finally, the competence of different culicid species/strains from Europe and the Americas as vectors of Dirofilaria species should be investigated. Such studies would help us to understand possible variations in transmission patterns and even to predict possible scenarios that may emerge in the future, with the introduction of non-endemic Dirofilaria species/strains in free areas through importation of infested animals, vectors, or both.Dirofilarioses are widespread diseases caused by filarioid nematodes (superfamily Filarioidea) of the genus  Dirofilaria of the family Onchocercidae. These nematodes may infest wild and domestic mammals of several orders, such as Artiodactyla, Carnivora, Edentata, Lagomorpha, Perissodactyla, Primates, and Rodentia [Dirofilaria immitis, also known as heartworm, can present with respiratory distress, epistaxis, haemoptysis, ascites, exercise intolerance, and anorexia [D. immitis can be expensive and often associated with life-threatening complications, particularly in patients with moderate to severe heartworm disease [Dirofilariosis is a worldwide-distributed disease caused by nematodes of the genus Rodentia ,2. Most anorexia ,4. Impor disease .Dirofilaria infestations in dogs are still of major veterinary and public health concern, considering that canine and human dirofilariosis continue to be diagnosed in several tropical, subtropical and temperate regions of the world [Even if canine dirofilariosis is still widespread and highly prevalent worldwide, the availability of preventatives, improved diagnostic tools and different treatment options ,4 have ghe world ,7.Dirofilaria repens, whereas in the New World pulmonary dirofilariosis by D. immitis predominates [D. immitis or to a species other than D. repens in the Old World put in doubt the pathogenic role of the former species in humans in this region [D. immitis in Europe has been ascertained [D. repens[D. immitis prevails [Dirofilaria species is well recognized, the control and prevention of Dirofilaria infestations in reservoir hosts is often neglected.Human cases of dirofilariosis have been reported worldwide. In the Old World, most cases refer to subcutaneous infestations by ominates ,4. Nonets region . Indeed,ertained ,10, the prevails . AlthougD. immitis but genetically distinct from reference sequences, including those of D. immitis infesting dogs in the same geographical area [Dirofilaria species infesting wild and domestic animals in South America, as well on the aetiology of human pulmonary and subcutaneous dirofilariosis in the same region. Within this context, the present review focuses on some aspects related to the dirofilariosis and Dirofilaria parasites in the Americas, with an emphasis on South America, and lists future research needs on this neglected field of human parasitology.Information on the aetiology and, thus, eco-epidemiology of animal and human dirofilariosis in the Americas is fragmentary, particularly in South America. For instance, a recent human case of dirofilariosis from northern Brazil was attributed to a nematode morphologically and phylogenetically close to cal area . These fDirofilaria consists of 27 apparently valid species (Table Dirofilaria have been replaced into other genera [Candidatus Dirofilaria hongkongensis”) [Dirofilaria based on robust morphological and genetic data would be needed before the description of any new species.Dirofilariae are spirurid nematodes, which localize, with a few exceptions, in subcutaneous tissues of mammalian hosts  and are transmitted predominately by mosquitoes ,2,13-25.gensis”) , but congensis”)  any descDirofilaria species have been reported from wild and domestic mammals. In Brazil alone, eight Dirofilaria species – i.e., D. acutiuscula, D. freitasi, D. incrassata, D. immitis, D. magalhaesi, D. repens, D. spectans, and D. striata – have been reported so far [D. magalhaesi) has been questioned [D. repens in this country, and in the Americas as a whole, remains doubtful [In the Americas, several d so far , even ifestioned . Moreovedoubtful .D. repens in the Americas has been first reported in a dog from São Paulo, south-eastern Brazil [D. repens were detected in dogs from a semi-rural district near Santiago (Chile), but these microfilariae were larger and genetically distinct from D. repens[Dirofilaria species in the Americas needs to be further investigated, also to determine whether cases of D. repens in dogs are being actually misdiagnosed as D. immitis based on the retrieval of blood circulating microfilariae.The presence of n Brazil . RecentlD. repens. In any Dirofilaria species infesting wild and domestic animals in the Americas as well as the scant number of surveys on the mosquito species acting as potential vectors, the diversity of culicids transmitting Dirofilaria species in this region is currently underestimated. Indeed, little is known regarding the mosquito vectors of wildlife-associated Dirofilaria species, even considering that some of them  are of zoonotic concern [D. immitis in naturally caught mosquitoes [Given the fragmentary data on  concern . On the squitoes -31 or insquitoes -36.Dirofilaria immitis can be transmitted by mosquitoes belonging to different genera, such as Aedes (Ae.), Anopheles (An.), Culex (Cx.), and Ochlerotatus (Oc.). For instance, a study conducted in Rio de Janeiro State, south-eastern Brazil, using canine, feline and human baits, reported Oc. taeniorhynchus, Cx. quinquefasciatus, Oc. scapularis, Cx. declarator, and Cx. nigripalpus as the most likely vectors of D. immitis in this region [D. immitis developmental stages were found in Oc. scapularis, Oc. taeniorhynchus, Cx. quinquefasciatus, Cx. declarator, Cx. saltanensis and Wyeomyia bourrouli, with L3 being found only in the first three species [Cx. quinquefasciatus[Cx. quinquefasciatus supports the development of D. immitis to the L3 [D. immitis were found in Cx. pipiens and Stegomyia aegypti and they have been regarded as putative vectors of this nematode in Argentina [St. aegypti to D. immitis[D. immitis, including St. aegypti, Stegomyia albopicta, Oc. canadensis, Jarnellius sierrensis, Oc. trivittatus, Aedimorphus vexans, An. punctipennis, An. quadrimaculatus, and Cx. quinquefasciatus[D. immitis throughout the American continent, as it occurs in the Old World [s region . Indeed, species . In anotfasciatus. Indeed,o the L3 . Similarrgentina . As a co. immitis. Meanwhifasciatus,39-41. Ald World .Dirofilaria transmission is D. ursi, which infests American black bears (Ursus americanus) and is vectored by black flies (Simuliidae) [Worth mentioning, an interesting exception regarding uliidae) .D. immitis and other filarial nematodes in the Americas remains fragmentary. Some mosquito species may present high specificity for city regions  and landscape elements within these regions  [St. aegypti with high-density housing in urban areas, of Cx. quinquefasciatus with low-density housing in suburbs, and of Gymnometopa mediovittata and other native mosquitoes  with less disturbed habitats  [D. immitis may vary according to city region and landscape type. Indeed, studies indicate that the prevalence of heartworm infestation in dogs is usually higher in some coastal regions [D. immitis are widespread and may be present throughout the entire year. For example, an entomological survey carried out in Rio de Janeiro, south-eastern Brazil revealed that St. aegypti and C. quinquefasciatus were present the year-round [D. immitis infestation at the individual and population level.The American continent is extremely variegated in terms of topography, hydrography and climate. As such, the transmission patterns of different vector-borne pathogens may vary widely throughout this vast land territory. Still, the knowledge on the transmission patterns of density) . For inshousing) . Therefo regions . Becausear-round . AccordiD. immitis vectors may be restricted to particular months of the year. For instance, mathematical models suggested that D. immitis transmission in Argentina is markedly seasonal (with peaks in January and February) and that no region of this country would support transmission throughout the year [D. immitis infestation in dogs, especially during high-risk months. The elaboration of optimized control strategies is particularly important in developing countries, where dog owners cannot always afford the costs of preventative chemoprophylactic measures.In temperate regions, the presence of the year . UndoubtD. acutiuscula, D. immitis, D. repens, and D. striata in dogs [D. immitis is the most important causative agent of canine dirofilariosis [In the Americas, there are reports of infestation by  in dogs ,45,48,49lariosis ,45, beinlariosis . In Centlariosis ,45,51,52D. acutiuscula in a dog from Argentina [, D. striata in a dog from the United States [D. repens in a dog from Brazil [D. repens European sequence (GenBank accession number: AM779775), suggesting that the parasite found in Chile [D. repens. Another study conducted in Marajó Island, northern Brazil, revealed some level of intra-specific difference in 5.8S and ITS2 regions [The reports of rgentina , D. strid States , and D. m Brazil  and in dm Brazil  are doubin Chile  may not  regions . In geneD. immitis in cats may vary regardless of the prevalence of infestation in dogs from the same area.In the Americas, feline dirofilariosis has been reported in the United States, Canada, Brazil, and Venezuela . In a stD. immitis, other species may also infest and cause disease in humans in this region  has been reported once in the orbit of a 6-year-old boy living in North Carolina [Dirofilaria have been reported only once in humans, these case reports suggest that the number of potentially zoonotic dirofilariae in the American continent may be currently underestimated.While most cases of human pulmonary dirofilariosis in the Americas have been attributed to n Figure . For exa in Ref. ), which  in Ref. . Dirofil Janeiro . SimilarCarolina . Even coDirofilaria species  in humans is reputed to be higher in areas where there is a high incidence of these worms in their natural hosts [Dirofilaria species as a consequence of the fact that these nematodes may adapt to new animal hosts and arthropod vectors. At some specific occasions, such as in the case of hurricane Katrina in the United States, dogs infected by D. immitis were relocated from the areas stricken by the hurricane  to other states of North America, resulting in the introduction of this filarioid into previously non-endemic areas [Little is known regarding the epidemiology and risk factors of human dirofilariosis in the Americas. The risk of infestation by some al hosts . Importaal hosts , and thuic areas .D. repens[D. immitis and D. repens may co-infest the same reservoir hosts [D. immitis. For instance, over 100 cases have been detected in the United States, most of which coming from south-eastern regions where D. immitis infestation in dogs is highly prevalent [D. immitis in dogs in São Paulo is low [Most human cases of dirofilariosis reported in the international literature refer to subcutaneous/ocular dirofilariosis cases caused by D. repens. The greir hosts . In the revalent ,50,61. Crevalent ,62,63 anrevalent ,64-66. Rrevalent , one of o is low , the appo is low .D. tenuis, D. ursi and D. immitis (a single case) in North America [D. repens in dogs from Chile [Dirofilaria species in Chile and suggests a late introduction of this parasite in this country, which until recently was considered as a Dirofilaria-free area [D. immitis. However, high nucleotide differences  was found by comparing sequences from the nematode recovered from the patient’s eye with sequences obtained from dogs living in the same area and/or from other countries available in GenBank [Dirofilaria, which is close to D. immitis, might be circulating in Brazil and in the western hemisphere as a whole.Subcutaneous/ocular dirofilariosis in the Americas have been attributed to different species, such as  America ,61. In a America  and Braz America , respectom Chile . This reree area ,45,70. Free area . The parD. immitis in the Old World concluded that there is no proof demonstrating that Old World D. immitis plays a pathogenic role in humans [D. repens, even if D. immitis is more prevalent than D. repens in both dogs and vectors in some areas [D. immits genotypes in the New and Old Worlds, with varying infective capacities for dogs and humans. Alternatively, some unidentified factor, probably related to the vector, could modify the infective capacity of the parasite to humans in the Old World. Although both hypotheses are plausible and deserve to be investigated more in-depth, there is no evidence indicating the existence of a more virulent D. immitis strain in the Americas.A critical analysis of human dirofilariosis cases attributed to n humans . Indeed,me areas . Based ome areas . First, Even if some individuals can present with cough, chest pain, haemoptysis, and dyspnoea ,63,67,71D. immitis infestation in human hosts, most cases of pulmonary dirofilariosis will likely remain without a definitive diagnosis. As a consequence, the actual number of pulmonary dirofilariosis in the Americas is likely to be grossly underestimated at present. Nonetheless, the existence of a more virulent strain of D. immitis in the Americas remains uncertain. So far, available data do not support this hypothesis, mainly considering that most human patients present no apparent clinical signs.Considering the usually benign nature of bona fide information about the species of filarioids infesting dogs and humans in this region is meagre. Further studies are needed to better characterize filarioids circulating among different domestic and wild animals in the American continent. Certainly, the use of an integrated genetic  and morphological approach could be beneficial for the identification of filarioids [There are several lacunae in our knowledge regarding different aspects of animal and human dirofilarioses in the Americas. For example, larioids .Dirofilaria species is currently lacking. Similarly, scientific knowledge on the biology of Dirofilaria species infestation in humans is limited for obvious ethical reasons and several aspects of the host-parasite interactions  remain unknown. Certainly, studies on bacterial endosymbionts associated with Dirofilaria nematodes may provide further data on their biology and evolution [Wolbachia pipientis in Dirofilaria species has been associated with the immuno-pathology of dirofilariosis [Wolbachia surface protein and the participation of this bacterium in inflammatory processes occurring during dirofilariosis has been intensively investigated in recent years [Wolbachia endosymbionts of filariae were useful in damaging or even killing D. immitis adult worms [D. immitis, eventually reducing the risk of thromboembolism [D. repens[The high diversity of potential zoonotic dirofilariae in the Americas is undisputed, but information on the biology of most wildlife-associated volution , also colariosis ,74. In plt worms . Therefoembolism . A similD. repens,78.Dirofilaria species should be better investigated. Such studies would help us to understand possible variations in transmission patterns and even to predict possible scenarios that may emerge in the future, with the introduction of non-endemic species/strains in free areas through importation of infested animals, vectors, or both. In this context, mathematical models and distribution maps are extremely important for predicting the presence/absence and abundance of mosquito vectors in different regions.The competence of different culicid species/strains in the Americas as vectors of Finally, it is crucial to increase awareness among veterinary practitioners and medical physicians regarding the zoonotic significance of filarial nematodes of domestic and wild animals in the Americas. This is particularly important in remote areas, such as the Amazon region, where a different range of zoonotic, yet unknown filariae  is likelThe authors declare there are no conflicts of interest.FD-T wrote the manuscript and DO reviewed critically it. Both authors approved the final version of the manuscript.


Hemiscorpius lepturus (Scorpionida: Hemiscorpioiidae) and Androctonus crassicauda (Buthidae) are present. Ramhormoz is in southwestern Iran and is one of the most important foci of the scorpion sting problem. The current study was carried out to gain both epidemiological and medical information about scorpion stings in and around the city of Ramhormoz. In total, 179 people who were admitted to the Emergency Department of Ramhormoz Imam Khomeini Hospital during 2008 and 2009 after being stung by scorpions were monitored. Epidemiological and medical parameters including sex of the victim; the part of the body stung; the month when stung; the biochemical parameters comprising blood sugar (BS), blood urea nitrogen (BUN), and creatinine (CR); hematological parameters including white blood cells (WBC), count blood cells (CBC), red blood cells (RBC), hemoglobin (Hb), hematocrit (HCT), platelet (PLT); and urine analysis including hemoglobinuria were recorded. The current study showed that most of the victims were stung by H. lepturus, while very few were stung by A. crassicaud, but in over half of the cases the species was not known. Stings were most common from May to Aguust. 73% of the victims were female. The limbs were the part of the body most likely to be stung. Hemogobinuria was very common in H. lepturus victims.Scorpion stings are a common and important health problem in Iran, particularly in south and southwestern Iran, including the province of Khuzestan. In the area of Khuzestan near the city of Ramhormoz,  Scorpion stings are a common and important health problem in Iran, particularly in south and southwestern Iran. From 2001 to 2005, 192,351 cases were reported, in which 104 cases resulted in death . Most ofHemiscorpius lepturus, belongs to the Hemiscorpiidae family, and is the most medically important scorpion in Iran (The Iranian scorpion (Scorpionida) fauna consists of over 44 named species from 23 genera in two families, Buthidae and Scorpionidae. However,  in Iran .Hemiscorpius lepturus, Androctonus crassicauda (Buthidae), and Mesobuthus eupeus are the main species responsible for stings in this area .In the current study, the data of scorpion stings were studied from the points of epidemiological and medical lab parameters. The data included: the sex of the scorpion-stung victim; the body part stung; the month of the scorpion sting; the biochemical parameters blood sugar (BS), blood urea nitrogen (BUN), and creatinine (CR); the hematological parameters white blood cells (WBC), count blood cells (CBC), red blood cells (RBC), hemoglobin (Hb), hematocrit (HCT), and platelet (PLT); and urinalysis hemoglobinuria.t-test was used to compare the results. A p-value of < 0.05 was used for the level of significance.The frequencies of the epidemiological and medical lab parameters were converted to the percentage rank. A H. lepturus or A. crassicauda . The scorpion species responsible for the remaining cases were unknown. 131 of the patients were female (73 %)  .H. lepturus and A. crassicauda, respectively. These results came from 179 patients.H. lepturus and 140 ± 63 mg/dL, 13 ± 3mg/dL, and 0.6 ± 0.1 mg/dL for A. crassicauda. The other data belong to unidentified species.Biochemical blood test results are shown in the The results of hematological parameters, including WBC, RBC, HB, HCT, PLT, PTT, and PT, are shown in H. lepturus, which constituted 7% of this group and 4% of the total.The results of the hemoglobinuria test, which are presented in H. lepturus and A. crassicauda, in terms of the percentages of scorpion stings. There is very little specific data regarding the other species, except that M. eupeus is counted as the third most important scorpion in Khuzestan in terms of percentage of stings.Scorpionism studies in Iran have been restricted to Khuzestan province. Data on scorpion stings in Ramhormorz, in the eastern region of Khuzestan, showed that the two most important scorpion species in this area are The results of the present study showed that most of the patients with scorpion stings were female (73%). This rate is in accordance with the results of Vazirianzadeh and Samie  for KhuzA. crassicauda and 98% of H. lepturus stings. Both species are non-drilling scorpions, and can hide themselves everywhere. Most scorpion sting cases are reported from the Ramhormoz region. This region has the most scorpions in the province (http://pezeshkan.ir/view.asp.2008),therefore the local people are at high risk of being stung by a scorpion.Vazirianzadeh et al.  reportedH. lepturus and A. crassicauda, targeted the limbs with frequencies of 72% and 67%, respectively, compared to the other parts of the body. This result agrees with studies of Al-Sadoon and Jarrar , and A. crassicauda was most active in August (33%). These results are confirmed by the results of Vazirianzadeh and Samie (H. lepturus was most active in May (8%), and A. crassicauda was most active in August (10%). Therefore, the more important scorpionism in the mild temperate seasons is due to H. lepturus, and to A. crassicauda during warmer seasons. These results, however, are not in accordance with the results of Pipelzadeh et al. . This result is in accordance with the studies of Chitnis et al. , Vaziriand Samie , who reph et al.  regardinIn the current study, biochemical results including rates of BS, BUN, and CR in the stung people were in the normal rates, and there was not any significant difference between those rates and normal values . Therefore, the levels of BS and BUN of the blood may be used as factors signifying scorpionism by H. lepturus in Ramhormorz. In the case of A. crassicauda stings, only BS level can be used as a factor signifying scorpionism in Ramhormorz. However, the alteration in levels of BS in the blood tests must be interpreted before treatment with dextrose injection to the patients, which is a common treatment in the terms of scorpion sting in Khuzestan, especially for H. lepturus stings.All the above comparative issues were discussed on the basis of the means of the biochemical parameters. The maximum levels of BS in the cases of A. crassicauda and H. lepturus, respectively . However, this result is not in accordance with the results obtained by Chitnis et al.  counts were in the normal range in all scorpion-victim cases. This normalcy shows that these factors were not important indices in scorpion sting cases. This result is not in agreement with the results obtained by Emam et al. (9/L) counts were considered as important indices in H. lepturus victims.PTT, PT, and PLT (× 10m et al.  and Murtm et al. . They reH. lepturus victims with greater than +1; however, this rate also occurred in 17% of A. crassicauda victims. This difference occurred because erythrocyte hemolysis was more severe in the victims of H. lepturus in Ramhormoz. The hemogobinuria decreased with time. Therefore, monitoring hemogobinuria is considered as an essential parameter in the recovery period of H. lepturus victims compared to A. crassicauda victims. This conclusion is in accordance with other researchers (H. lepturus and A. crassicauda victims, the majority of which were H. lepturus stung victims. Afzali and Pezeshki (H. lepturus sting is a secondary phenomenon, and the venom of this species is not nephrotoxic. They have also explained that hemoglobinuria is the most important sign of a H. lepturus sting, and can be followed by renal failure. This conclusion is in agreememnt with the results of the present study.The results of the present study showed that there was severe hemogobinuria in 95% of earchers . Howeverearchers , b, 1998earchers , and Emaearchers  reportedH. lepturus sting, leading to a diagnosis of hemolytic uremic syndrome.All the mentioned lab results regarding the hematological and urine data should be analyzed and interpreted together as multifactorial data. The reduction of RBC, hemogobinuria, and produced anemia must be considered as parallel and accompanied together. Valavi and Alamzadeh Ansari  explaineFinally, there are valuable reasons to further study and interpret the differences between our results and the results of other similar studies regarding hematological and biochemical data. The most important reasons for these differences are related to using different geographical areas and methods of studies.Hemiscorpius or subspecies of H lepturus is raised up by the authors of the present study. Similar hypotheses may be considered regarding A. crassicauda based on Farzanpey (A. amorexi is present in the field of Khuzestan.The difference in geographical area is considered to be the major reason why the present study obtained different results than the Emam et al.  study inarzanpey , Vaziriaarzanpey  and Mirsarzanpey  studies.The reason the results of the present study differed from the results of the Emam et al  study isH. lepturus, and antivenom treatments to reduce neurotoxic effects of A. crassicauda venom (H. lepturus, A. crassicauda, Mesobuthus eupeus, Odonthobothus doriae, Hottentotta saulcyi, and Hottentotta schach. It is made at the Razi Research Vaccine and Serum Institute, Iran.The authors of the present study suggest the application of alkaline diuresis to regulate alkalosis of the urine as a medical approach against renal failure due to the hemolysis effects of da venom . This anH. lepturus and A. crassicauda, with an emphasis on paraclinical data. Thedifference between the results of the current study and the other similar studies, especially regarding H. lepturus, is due to the possibility of the existence of different subspecies of H. lepturus and A. crassicauda, or different species of Hemiscorpius and Androctonus genera in Khuzestan (The present study was carried out in one area, including both huzestan . These dH. lepturus stings are more dangerous than A. crassicauda stings, identification of the species involved is very helpful. Gathering these paraclinical data should be considered in the warmer months for A. crassicauda victims and in the temperate months of spring for H. lepturus victims.Urine analysis data are considered to be the most important in the follow-up of scorpion victims and during their recovery period. Because


Dr. Dario Barbone was not included in the author byline. He should be listed as the sixth author and affiliated with Lung Biology Centre, SFGH, UCSF, San Francisco, CA, USA. The contributions of this author are as follows: Dr Barbone critically reviewed the paper together with Prof. Courtney Broaddus. He also participated in scientifically relevant discussion of the experiments.Dr. Luciano Mutti was not included in the author byline. He should be listed as the seventh author and affiliated with Department of General Medicine, Vercelli and Borgosesia Hospitals, Vercelli, Italy. The contributions of this author are as follows: Dr Mutti actively and critically reviewed the paper.


In many countries, the need for physical therapists to use standardised measures has been recognised and is recommended in clinical practice guidelines. Research has shown a lack of clinimetric knowledge and clinical application of measurement instruments in daily practice may hamper implementation of these guidelines.The aims of our study were a) to investigate the current use of measurement instruments by Dutch physical therapists; b) to investigate the facilitators and barriers in using measurement instruments.To get a complete and valid overview of relevant barriers and facilitators, different methods of data collection were used. We conducted a literature search, semi-structured interviews with 20 physical therapists and an online survey.Facilitators are the fact that most therapists indicated a positive attitude and were convinced of the advantages of the use of measurement instruments. The most important barriers to the use of measurement instruments included physical therapists' competence and problems in changing behaviour, practice organisation  and the unavailability and feasibility of measurement instruments. Furthermore, physical therapists indicated the need to have a core set of measurement instruments with a short user's instruction on application, scoring and interpretation.The main barriers are on the level of the physical therapist  and organisation .There seems to be a disparity between what physical therapists say and what they do. The majority of participating physical therapists indicated a positive attitude and were convinced of the advantages of the use of measurement instruments. However, the main problem for physical therapists is when to use which instrument for what patient (lack of knowledge). Furthermore, physical therapists indicated a need to compile a core set of measurement instruments with instructions concerning application, scoring and interpretation. Based on the identified factors, a number of strategies will be developed and evaluated in future studies. In almost every disease, condition or ailment that receives attention in modern medicine, methods have been developed for describing or rating the observed clinical phenomena. Clinimetrics is the practice of assessing or describing symptoms, signs and laboratory findings by means of scales, indices, and other quantitative instruments . Clinimehttp://www.wcpt.org/node/29447). Not only do we need to evaluate physiotherapy treatment outcomes as an integral part of professional accountability, we need to make sure our diagnostic process is transparent, and that we are able to give our patients some sense of their prognosis with treatment. As a result, clinical practice guidelines often incorporate specific recommendations for the use of standardised measurements and measurement tools.The need for physical therapists to use standardised (outcome) measures has been recognised worldwide and has been articulated in a number of policy statements, including the Core Standards of Physiotherapy Practice of the World Confederation for Physical Therapy . This has resulted in the development and publication of 18 (mono-disciplinary) Clinical Practice Guidelines (CPGs). Many Dutch CPGs are translated into English. They can be downloaded at As well as in guidelines developed in other countries, in these guidelines, the use of standardised measurement instruments is recommended in order to support the process of clinical reasoning. However, considerable variation in guideline adherence exists among therapists ,6. ReseaMeasurement in clinical practice' in cooperation with two research centres in Utrecht and Heerlen. The final goal of the project was to improve the use of standardised measures in physical therapy daily practice.Much research has been done on implementation methods of clinical practice guidelines in health care , but untThe project group adopted the model of systematic implementation by Grol & Wensing , comprisGrol et al emphasise that the innovations to be implemented must be of good quality, fit in with the needs of the target group, be useable end easily available and be attractively designed .This analysis concerns the characteristics of the target group, the factors that stimulate and hamper change and the aspects of performance that show the greatest deviation from the proposed behaviour. Factors that determine whether the implementation is successful or not may be connected to the setting in which the change is to be implemented, the relationship between individuals within the setting, the goals of the implementation, the professionals and the involved patients and the organisational or structural conditions.The literature gives a great number of different strategies that can be used for the implementation of changes. Usually, a mix of strategies is selected, but the problem is that the most optimal choice is not only dependent on the strategy but also on the target group and its context.When making an implementation plan, attention has to be paid to effective dissemination, both to encourage its acceptance and to promote the actual implementation and integration in normal working routines.This step is crucial to be sure of the effectiveness of implementation. To find out whether the goals have been reached they must be made measurable. That means that outcome measures must be defined clearly to put into operation.The project group followed steps 1 and 2 of the implementation model: a) investigating the current use of measurement instruments and b) investigating the facilitators and barriers in the use of measurement instruments. The project focused in particular on physical therapists working in two different settings: private practices and nursing homes. The reason to focus on the former group is that the majority of physical therapists in the Netherlands work in private practices. Physical therapists working in nursing homes were chosen because of the expected contrast in the kind of measurement tools used by private practice physical therapists. We also expected that the two different settings would require different implementation strategies. In this paper we describe the first two steps of the implementation model  and current use of measurement instruments (familiarity with instruments in practice).- Attitude and individual readiness about the usefulness of measurement instruments in practice and their actual use.- Participants' opinions on the most important barriers and facilitators for implementation in daily practice as well as participants' thoughts on how best to overcome barriers for the implementation of a standardised set of instruments.- The conditions needed for successful implementation.In the interviews we also focused on underlying thoughts and possible solutions. The facilitators and barriers mentioned in the interviews were classified into four categories: 1) Physical therapist (competence and attitude), for example lack of knowledge; 2) Organisation (practice and colleagues), for example lack of time; 3) Patients, for example patients unaccustomed to the use of questionnaires and 4) Measurement instruments, for example overly extensive instruments. This classification is based on findings from another study where barriers to the use of standardised outcome measures were investigated . The ratTo compose the questionnaire for the survey we added relevant topics from the semi-structured interviews to the Barriers and Facilitators Questionnaire  (BFQ) (sThis study was funded by the Dutch Scientific College of Physiotherapy (WCF) of the Royal Dutch Society for Physical Therapy (KNGF), with the final goal to perform a national structural implementation of the use of standardised measures in practice.Many publications exist on implementation in general or implementation of guidelines in health care. Specifically, Cochrane et al.  identifiThese findings mirror the seven categories of barriers as defined by Cochrane et al.  except fOn the implementation of standardised measures, fewer studies were available ,11,21,22The semi-structured interviews were conducted with ten private practice physical therapists and ten nursing home physical therapists. No new information was gleaned in the last two interviews, indicating that the sample size was sufficient to saturate the topics.There appeared to be minor differences between physical therapists working in nursing homes versus private practice , but the great majority of factors were comparable. These are summarised in Table Most therapists indicated that the application of measurement instruments in daily practice is difficult and not yet integrated in the process of clinical reasoning.During the interviews, the therapists were honest and admitted that they did not use the instruments as often as they would like to do. In particular, the semi-structured interviews indicated that application of measurement instruments is certainly not part of daily clinical practice.which measurement instrument for which patient and information on the interpretation of the scores. Furthermore, the interviewed therapists indicated a need for a toolkit of short and feasible measurement tools and, additionally, a short description of how to apply and interpret these instruments.In the interviews, physical therapists indicated needing a core set of measurement instruments with a short user's instruction on application, scoring and interpretation, as well as a need for small-scale tailor-made education and frequent feedback in order to facilitate their use of measurement instruments. The tailor-made education should in particular focus on knowledge of measurement instruments, integration in daily routine, and guidelines on when to use Completed questionnaires were received from 468 physical therapists; a response rate of 16%. Three hundred ninety four (394) out of these 468 (84%) were private practice physical therapists; 74 (16%) were nursing home physical therapists. The mean age of respondents was 41.6 years (SD = 10). The details of the determinants of respondents are reflected in Table The most dominant facilitators are that the majority of physical therapists indicated having a positive attitude towards the use of standardised measures and being convinced of the benefits of the use of measurement instruments. However, both groups of therapists indicated having difficulty in changing their daily routine. In private practice, 72% of respondents indicated using standardised measures, and 97% of physical therapists working in nursing home indicated using measures. Eighteen different measures could be listed from the group of physical therapists working in nursing homes. Only 5% of these measurement instruments was mentioned once. In contrast, 144 different measures could be listed from the private practice physical therapists, of which 58% were mentioned only once . These results indicated a higher percentage of measurement use in PTs working in nursing homes. Table There proved to be a difference in the most frequently used outcome measures. Table The survey also investigated the most frequently reported facilitators and barriers to the use of measurement instruments, which are summarised in Table In summarising Table The aim of this study was to investigate the current use of measurement instruments, and related barriers and facilitators in the use of measurement instruments in clinical physical therapy practice. Comparing the results of this study with other studies in the literature, the same problems prove to exist in different countries regarding the use of measurement instruments ,20,25-27A way to classify measurement instruments is the International Classification of Function, Disability and Health Problems (ICF) . Using tGoniometry and VAS are listed as two of the five standardised measures used by private practice physical therapists, yet they are in the ICF body structure/function category. The five most frequently used measures listed by nursing home physical therapists were in the "activity"-category, but none were in the "participation" category. Physical therapists, particularly in orthopaedic practice, have traditionally focused on the measurement of impairments such as pain, range of motion and muscle strength, but have not utilised standardised measures of activity and participation. Based on our findings, the assessment of activity and participation is clearly not routine in private practice. Perhaps private practice physical therapists deal with more orthopaedic problems which warrant more direct focus on impairments (cure) whereas nursing home physical therapists are focused primarily on functional training (care). In general, the results from Table A very small number of short and feasible measurement instruments was used by physical therapists working in private practices, where, conversely, a large number of instruments were being used by physical therapists working in nursing homes. This is comparable with the results of the study by Haigh et al.  who publMore than 70% of the respondents indicated the use of measurement instruments. More than forty percent of private practice responders indicated using one or two outcome measures and one third indicated using three to five outcome measures in clinical practice. This is comparable with the results of a New Zealand study  . In both the interviews and the survey, therapists indicated a need for small scale education, feedback on the use of measurement tools and guidance on which measurement tools to choose. This is consistent with the comparable study for American physical therapists  as well Earlier studies used mainly written inquiries (questionnaires) to identify barriers and facilitators for the use of measurement instruments in physical therapy ,12,13. IThe results revealed that the application of measurement instruments is only partially implemented in the process of clinical reasoning in daily practice. The same has been reported by a number of authors across different countries. One reason for this might be that physical therapists have difficulty interpreting measurement scores, as indicated in the interviews, and therefore do not integrate these scores into the process of clinical reasoning. Interpreting scores remains a difficult issue as there are often no normative data available. The use of measurement instruments should not be a goal, but a tool that supports the clinical decision making process. It is therefore, essential to incorporate the use of measurement instruments in the structure of clinical reasoning and daily routine instead of using it as a separate trick. The project group adopted the model for systematic implementation by Grol & Wensing  and focuOne limitation of this study is the fact that the literature study was not a systematic review of the literature. Another limiting point is the relatively small response rate to the electronic survey, which could jeopardise the validity of the reported findings.• A very small number of measurement instruments is used by physical therapists working in private practices, where conversely a large number of instruments are being used by physical therapists working in nursing homes.• The reported use is probably an overestimation of reality in clinical practice.• The most important barriers could be detected at the level of the physical therapists (lack of knowledge and insufficient integration in daily practice) and on the level of organisation (lack of time and no instruments available in practice).• In nursing homes, an important barrier is the lack of support from management.• There is a need for tailor-made education focusing on implementation in clinical reasoning and organisation structure• There is a need for a toolkit of short and easily applicable instruments and user descriptionsOutcome measureMeasurementInstrumentAssessmentTestQuestionnaireClinimetricsIndexScaleReliabilityValiditySensitivityResponsivenessPhysiotherapyPhysical therapyRehabilitationand combination of these keywordsBarriers and Facilitators Questionnaire*this questionnaire has not been validated in English.The purpose of this questionnaire is to get your opinion on the use of measurement instruments in clinical physiotherapy care during evaluation and treatment. By measurement instruments we mean, for instance, a visual analogue scale (VAS), a goniometer, walking tests, but also questionnaires. Some statements refer to "the project". By this, we mean the Royal Dutch Society of Physiotherapy project on measurement in clinical care.Below follow a number of statements on the use of measurement instruments. Please indicate whether you completely disagree, disagree, disagree nor agree, agree or completely agree.I have been using measurement instruments before this projectI have sufficient knowledge to use measurement instrumentsI have sufficient skills to apply measurement instrumentsChanging my routine is difficult for meIn general, I resist using measurement instrumentsI have a positive attitude towards the use of measurement instrumentsUsing measurement instruments gives me enough room to include patient preferencesUsing measurement instruments during treatment is too time consumingPatients value the use of measurement instruments to gain insight into their functioningPatients find the use of measurement instruments too time consumingCo-workers (physiotherapists) support the use of measurement instrumentsMy supervisor supports the use of measurement instrumentsPatients support the use of measurement instrumentsThe use of measurement instruments fits my way of working in the clinic wellI find using measurement instruments a problem because I do not have  space in my practiceI find using measurement instruments a problem because I have had no training in using themI would like to know more about the use of measurement instruments before I decide to use themUsing measurement instruments requires additional financial compensationThe use of measurement instruments leaves enough room for me to make my own clinical decisionsAre there reasons, other than the above statements that are barriers for you to the use of measurement instruments? (open question)Are there reasons, other than the above statements that are facilitators for you for the use of measurement instruments? (open question)I miss the routine of using measurement instruments in daily clinical practiceIn evaluating patients I primarily focus on impairmentsOur professional body overloads me with too many guidelines and rulesThere are so many different questionnaires; I do not know which one to use.I am convinced of the usefulness of measurement instrumentsIn my daily clinical practice sufficient measurement instruments are availableThe use of measurement instruments is part of the organisational goals of our practiceThe kinds of patients I treat are unsuitable for the use of measurement instrumentsThe use of measurement instruments is always an integral part of my treatmentI am convinced the use of measurement instruments improves the quality of my treatmentPatients want to evaluate treatment results objectivelyReferrers want to evaluate treatment results objectivelyUsing measurement instruments might strengthen negotiations with insurersI use measurement instruments primarily for diagnostic purposesI use measurement instruments primarily for prognostic purposesI use measurement instruments primarily for evaluative purposesWhat would your preferred measurement be?• Impairments in body functions and structures, e.g. Range of motionPainMuscle strengthSwellingSensibilityMental functions (depression etc).......................................• Limitations in activities; e.g. Activities of Daily LifeStanding/sittingMobility Arm/hand .................................• Participation restrictions, e.g. WorkSportSocial activities.................................• Personal factors, e.g. ChronicityPatient's cognition and attributesFear of movementCoping..........................................• Environmental factors, e.g. Problems in home environmentWork conflictsFinancial factorsSick leaveStress-provoking factorsWork stress.......................................For the evaluation and treatment of patients I use about........different instruments:- 0 - 2 instruments- 3 - 5 instruments- 6 - 10 instruments- 11-20 instruments- ≥ 21 instrumentsI use measurement instruments during evaluation and treatment in:- 1 of each 5 patients ( 20%)- 2 of each 5 patients ( 40%)- 3 of each 5 patients ( 60%)- 4 of each 5 patients ( 80%)- 5 of each 5 patients (100%)Please indicate your top 5 measurement instruments and for each measurement instrument how often you use this instrument? (example: Roland Morris Questionnaire: 2 out of 19 patients)Instrument number............of number of patients per week1...........................................................................2...........................................................................3...........................................................................4...........................................................................5...........................................................................Finally, some questions about you and your work environment:Gender: male/femaleCurrent work environment - Hospital- Rehabilitation Centre- Nursing Home- Private Practice- Other,How many hours a week do you work as a physiotherapist?- 0 - 8 hours- 9 - 16 hours- 17 - 24 hours- 25 - 32 hours- More than 33 hoursHow many patients a week do you treat on average?- 1-5 patients- 6-10 patients- 11-15 patients- 16- 20 patients- 21-25 patients- > 25 patientsHow many years of experience do you have as a physiotherapist?..................years.BarriersLevel topicsPhysiotherapistExpertiseLack of routine in using measurement instruments in evaluation and treatmentLack of knowledge in using measurement instrumentsLack of education in measurement (instruments)Diagnostic process mainly directed at impairmentsInsufficient experience in using measurement instrumentsAttitude/personalityLack of autonomy, Dutch Royal Society of Physiotherapists directs (what to do and how to do it)Overwhelmed by evidence based practiceOverwhelmed by quantity of guidelines, rules and informationHabit of determining for oneself what best practice is without outside directionInsufficiently convinced by need to use measurement instruments and whether this leads to better quality care.Physiotherapist decides in a different manner whether treatment is successfulInsufficiently prepared to change clinical practiceResistant to changeLack of confidence in own (measurement) skillsOrganisationAvailability of measurement instruments, guidelines and suchLack of timeSingle person private practice, no feedback colleaguesMonodisciplinary workUse of measurement instruments not included in organisational policyFinancesCosts of measurement instrumentsLack of time, time is moneyNo  reimbursementColleaguesInsufficient feedback from, consultation with colleaguesTeam not very innovative, 'late adopters'People break their engagementKey-persons disagree with the use of measurement instrumentsPatientExpectation patient; does not want measurement, just treatmentPatient category unsuitable for the use of measurement instrumentsPatient pressurises physiotherapistSocial contextOverall negative attitude, not ready yet to use measurement instrumentsProblems with referrersFacilitatorsLevel topicsPhysiotherapistExpertiseRoutine in using measurement instruments in evaluation and treatmentSufficient education in measurement (instruments) and ongoing continuing educationKnowledge of measurement instrumentsAttitude/personality'Readiness to change'Being convinced of the positive contribution of the use of measurement instruments to the quality of (physiotherapy) careUnderstanding the advantages of using measurement instrumentsPositive attitude towards the use of measurement instrumentsOrganisationWorking with (multiple) physiotherapy colleaguesRegular feedback/consultation colleaguesAvailability measurement instruments .Use of measurement instruments is part of organisational policyColleaguesteam is innovative, 'early adopters'Sufficient support from physiotherapy colleaguesPatientPatient want objective instruments to evaluate the treatment processSocial contextPositive attitude towards using measurement instrumentsReferrers want objective findings/evaluation of treatmentThe authors declare that they have no competing interests.RS participated in part of the semi-structured interviews and wrote the core text of the manuscript. RvP participated in part of the semi-structured interviews, did the literature search and developed the topic list. HW was responsible for the online survey and data analysis and updated the literature search. JC Conceived of the study and participated in the design and coordination of the study. SB Conceived of the study and participated in the design and coordination of the study and corrected and improved the text of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/106/prepub


Retraction to: British Journal of Cancer (2011) 104, 68–74. doi: 10.1038/sj.bjc.6605972BJC.After a thorough review, the corresponding author, Dr Antonio Gualberto, has concluded that the key results reported in this manuscript are incorrect and cannot be reproduced. As there are no remaining samples that would allow a new analysis, he has therefore recommended the retraction of the manuscript to the Editor-in-Chief of The co-authors have been informed of this decision.BJC.Dr Gualberto sincerely apologises for any inconvenience this may have caused the readers of the


This special issue is dedicated to the study of microbial enzymes and their applications in various industries. The biocatalytic uses for enzymes have grown immensely in recent years since they are ecologically correct, have a high specificity, present chemo-regio-enantio selectivity, and have a wide diversity of reactions. Moreover, the conditions to obtain and optimize the production of enzymes in terms of nutrients, pH, temperature, and aeration are easily controlled in bioreactors. Microorganisms can also be manipulated genetically to improve the desirable characteristics of a biocatalyzer. Additionally, the substrates used in the cultural medium are sustainable and industrial residuals can be used to produce value-added products. All these characteristics together have encouraged the ever-growing search for biocatalytic processes. The main industries that apply microbial enzymes are the food, textile, leather, pharmaceutical, cosmetics, fine chemicals, energy, biomaterials, paper, cellulose and detergent industries. Immobilization processes allow the reuse of these enzymes and increase stability. The enzymes and the microorganisms themselves have also been much used for bioremediation processes. In this issue, the paper by B. Joseph et al. is about the production of cold-active lipases by semisolid fermentation and the paper by A. L. Willerding et al. is a study about lipases obtained from microorganisms isolated from soils in the Amazon. Studies with lipases immobilized for the synthesis of isopropyl acetate and isopropyl ferulate are presented in the papers by M. Lal Verma et al., A. Kumar and S. S. Kanwar, respectively.Bambusa bambos are presented in the papers by D. Deka et al. and A. Kuila et al. The paper by R. C. Kuhad et al. is a review of the innumerous industrial applications of the cellulases.The results of cellulase production optimization studies with cellulosic substrates and delignified “Bioconversion of agricultural waste to ethanol by SSF using recombinant cellulase from clostridium thermocellum,” “Petroleum-degrading enzymes: bioremediation and new prospects,” and “Assessment of the morphological, biochemical, and kinetic properties for Candida rugosa lipase  The papers entitled immobilized on hydrous niobium oxide to be used in the biodiesel synthesis” are about enzymes and biofuels: the use of a recombinant cellulase from Clostridium thermocellum for the production of ethanol from agro-industrial residues, a brief review on the role of enzymes that degrade oil, the use and description of the properties of a Candida rugosa lipase immobilized for the production of biodiesel.Laccase: microbial sources, production, purification, and potential biotechnological applications” is a review of the industrial applications of laccases, while the “Isolation, purification, and characterization of fungal laccase from Pleurotus sp.” and “Application of asymetrical and Hoke designs for optimization of laccase production by the white-rot fungus Fomes fomentarius in solid-state fermentation” are studies on laccases from fungi and production optimization. The paper by A. Arsenault et al. shows that a laccase from Coriolopsis polyzona was insolubilized as cross-linked enzyme aggregates (CLEAs) for the first time with chitosan as the cross-linking agent. Also, within the laccase theme, the paper entitled “β-estradiol using immobilized laccase from Trametes versicolorVoEnzyme-catalyzed oxidation of 17” is about the oxidation of 17β-estradiol using immobilized laccase from Trametes versicolor. The paper by M. Neifar et al. is about the decolorization of Solophenyl red 3BL (SR), a polyazo dye extensively used in the textile industry using a laccase-mediator system. The last article about laccase, entitled “Improved laccase production by Trametes pubescens MB 89 in distillery wastewaters,” is a study of its production by Trametes pubescens using distillery wastewaters. The paper entitled “Cryptococcus flavus fungus expressed in the yeast Saccharomyces cerevisiae. The paper by I. Akpan et al. demonstrated the use of activated Charcoal in order to recovery glucoamylase. The paper by A. S. Galdino et al. describes the characterization of amylases of the S. cerevisiae using optimization statistics. The paper by E. F. Ries and G. A. Macedo reports on the improvement of phytase activity of a new strain of Aspergillus niger tannase, and, in the paper by L. V. Rodríguez-Durán et al., novel strategies for upstream and downstream processing of tannin acyl hydrolase are described. The paper by A. Flores-Maltos et al. describes the catalytical properties of free and immobilized Aspergillus japonicus 586 in the food industry. The use of proteases with potential in the food and animal feed industry are focused on in two articles: the one by B. Tchorbanov et al. describes the use of Lactobacillus LBL-4 proteases to remove the bitter taste of proteinic hydrolysates, and the paper by A. M. Mazotto et al. describes how strains of Bacillus sp. were used to ferment feather flour so that it could be transformed into more easily absorbed hydrolysates. And within the same theme, the paper by F. C. Lopes et al. shows that a strain of Aspergillus niger was able to grow in feather meal producing proteases and keratinases.The paper by M. F. S. Teixeira et al. shows the improvements that occur in cupuacu juice after treatment with crude enzyme extract produced by Bacillus licheniformis NCIM 2042 and the effect of different culture media on Bacillus sp. isolated from soil sample of Lavizan Jungle Park are focused on in the papers by B. Bhunia and A. Dey; L. Jabalameli and A. A. Sepahy, respectively.Optimization of the proteases from Bacillus mojavensis AG137 with agricultural residues. The xylanase enzymes are described in the paper by A. A. Sepahy et al. that reports on the cost effective production and optimization of this enzyme  using indigenous Stereum ostrea, isolated from wood logs, are described.In the paper by K. Praveen et al., the lignolytic enzymes of the mushroom α-l-rhamnosidase and β-D-glucosidase activities of naringinase is described in the paper by H. Vila-Real et al.Naringinase (NGase) is an enzyme complex with high potential for the pharmaceutical and food industries. The paper by M. H. L. Ribeiro and M. Rabaça describes the process of enzyme immobilization with cross-linked enzyme aggregates (CLEAs). The enzymatic synthesis of the flavone glucosides, prunin and isoquercetin, and the aglycones, naringenin, and quercetin, with selective β-glucosidase was screened.In the paper by J. de A. Figueira et al., a set of supports  based matrices (Lentikats), and sol-gel) for the immobilization of a partially purified extract of Aspergillus niger by solid-state fermentation using different substrates, and the paper by S. Shukla and A. Goyal identifies the hyperproductive strains of glucan.The paper by S. Ou et al. describes the production of feruloyl esterase from Microbial Enzyme: Applications in Industry and in Bioremediation” offers an important contribution to microbial enzyme studies, encompassing their production and optimization, immobilization techniques and, industrial applications. We would like to thank the collaboration of all the authors and the reviewers for their analyses of the papers. We believe that this special issue that gathers together updated studies under the theme “Alane Beatriz VermelhoAlane Beatriz VermelhoClaudiu T. SupuranClaudiu T. SupuranJose M. GuisanJose M. Guisan


This article provides an overview on the application of metallic ions in the fields of regenerative medicine and tissue engineering, focusing on their therapeutic applications and the need to design strategies for controlling the release of loaded ions from biomaterial scaffolds. A detailed summary of relevant metallic ions with potential use in tissue engineering approaches is presented. Remaining challenges in the field and directions for future research efforts with focus on the key variables needed to be taken into account when considering the controlled release of metallic ions in tissue engineering therapeutics are also highlighted. Severdelivery –13. In adelivery . Furtherdelivery ,15. In tdelivery . From a delivery . There adelivery . It is tdelivery . These adelivery . In addidelivery ). This a2.et al. [In the body, various metallic ions act as cofactors of enzymes and stimulate a chain of reactions associated with cell signalling pathways towards tissue equilibrium . These pet al.  demonstret al. –40. Moreet al. –45. By cet al. –48. The et al. ,50.3.in vitro or in vivo [in vivo when no longer needed [in vivo  [The interest in the application of MITA in the field of regenerative medicine and TE scaffold development is growing owing to the fact that MITA may offer therapeutic opportunities coupled with high flexibility to be incorporated in engineered biomaterial scaffolds by a broad range of processing methods. Moreover, MITA have lower cost, higher stability and potentially greater safety than recombinant proteins or genetic engineering approaches . Table 1 in vivo ,32. For  in vivo  is used  in vivo ,91–101.  in vivo ,95,102.  in vivo . It is,  in vivo . A compr in vivo . Novel sr needed . In thisr needed . There ar needed ,106–113.r needed ,114–118.r needed ,246. Furexample) ,141. In 4.in vivo evidence confirming that metallic ions can be released locally from scaffolds without systemic toxicity and carcinogenic effects is bound to follow [Metallic ions are of interest in the fields of regenerative medicine and tissue engineering owing to the possibility of exploiting their unique advantages for therapeutic applications: reduced cost, increased stability and, in terms of safety, potentially lesser risk than techniques of recombinant proteins or genetic engineering. Several biomaterial-based strategies are being designed for the controlled-localized delivery of metallic ions and the field is continuously expanding. However, many challenges remain. First, there is a need to acquire a deep understanding of the roles of specific metals in cellular regulation and cell–cell signalling in both healthy and diseased tissue when they are released locally from scaffolds, implants or other releasing devices. Second, more o follow . In addi


To the Editor: To the list of zoonotic infections with wildlife sources reported by Kruse et al. , but also has been found in wild mammals, birds, and arthropods. The transmission of Q fever to humans from wild rabbits was documented in the 1980s (Rattus norvegicus) in Oxfordshire, which suggests that they are a possible reservoir for C. burnetii in the United Kingdom. The study also speculated why cats, as frequent predators of rats, are important in maintaining the transmission cycle of the disease (e et al. , I woulderrorism . C. burnhe 1980s . More re disease .A case-control study published in 2001  attempte


Candida albicans (C.a) and Candida tropicalis (C.t) were treated with Streptococcus sanguinis bacteriocin (S.s bacteriocin), respectively; the bacteriostatic dynamics of S.s bacteriocin, their effects on cell surface hydrophobicity, leakage of inorganic phosphorus and macromolecular substance, cytosolic calcium concentration, and ultrastructure changes of Candida thallus were detected and analyzed. The results showed that inhibitory effect of S.s bacteriocin on C.a and C.t reached peak level at 24 h, the cell-surface hydrophobicity decreased significantly (P < 0.05) after S.s bacteriocin treatment, and there was leakage of cytoplasmic inorganic phosphorus and macromolecular substance from C.a and C.t; cytosolic calcium concentration decreased greatly. After 24 h treatment by S.s bacteriocin, depressive deformity and defect could be found in the cell surface of C.a and C.t; the thallus displayed irregular forms: C.a was shrunken, there was unclear margins abutting upon cell wall and cell membrane, nucleus disappeared, and cytoplasm was inhomogeneous; likewise, C.t was first plasmolysis, and then the cytoplasm was shrunk, the ultrastructure of cell wall and cell membrane was continuously damaged, and the nucleus was karyolysis. It was illustrated that S.s bacteriocin had similar antifungal effect on C.a and C.t; their cell surface hydrophobicity, membrane permeability, and ultrastructure were changed significantly on exposure to S.s bacteriocin. Candida is the main pathogen causing deep fungal infection in clinic; the highest rate of infection occurred at 5 fungi strains: Candida albicans (C.a), Candida glabrata (C.g), Candida tropicalis (C.t), Candida parapsilosis (C.p), and Candida krusei (C.k)  = (F0 − F)/F0 × 100%; F represented fluorescence intensity after S.s bacteriocin treatment; F0 represented fluorescence intensity of control group. The result showed that cytosolic calcium concentration and Ca2+i were decreased significantly in the test group  is the dominant bacteria in a healthy oral cavity and it is generally accepted that an antibacterial substance generated by S. sanguinis has an inhibitory effect on putative periodontal pathogens; in our previous studies, it was found that there were significant inhibitory effects of the intracellular proteins extracted from S. sanguinis on pathogenic bacteria , fungi , and the biofilms formed by them; the growth curves and morphology of C. albicans and C. tropicalis were altered following treatment with the intracellular proteins, resulting in disc-like depressions in the surfaces of the fungal spores and mycelia [ Streptococcus sanguinis by being ultracentrifuged at low temperature, ultrasonication, and so on. Fungistatic dynamics study showed that antifungal dynamics of S.s bacteriocin for C.a and C.t reached the climax at 24 h, and characteristics of fungistatic dynamics of S.s bacteriocin were quite similar between C.t and C.a.Bacteriocins are generated by ribosome synthesis mechanism in metabolic processes of some bacteria; they are a kind of proteins, polypeptides, or precursor polypeptides . Strepto mycelia . In this Candida to oral epithelium; the stronger the surface hydrophobicity the Candida had, the stronger the adhesion it had [The effects of S.s bacteriocin on cell surface hydrophobicity of C.a and C.t showed that S.s bacteriocin could result in the hydrophobicity decrease of C.a and C.t. It was reported that cell surface hydrophobicity played an important role in the initial adhesion ofn it had . Cell su Candida surface could bind to hydrophobic groups; the formation ability of Candida biomembrane had a positive correlation with cell surface hydrophobicity [ Candida and host histiocyte was cut off, the formation of Candida biomembrane was hampered, and the pathogenicity of Candida was decreased.There were some macromolecules with relative molecular mass of 190 kD in hydrophobic cell; they were called surface proteantigen, and they were found in the bacterial cell walls; without these proteins, the hydrophobicity was decreased . It was hobicity . In this2+; in the third way, micromolecule with less polarity could penetrate the cell membrane by physical diffusion, for example, O2, hydrone [In the process of cellular metabolism, there were different materials that went into/out of the cell, including some ions, micromolecules, macromolecules, and particulate matters. In normal cases, the penetration to cell membrane of these materials could be divided to 3 ways: in the first way, water-solubility micromolecule could penetrate the cell membrane by the mediation of membrane protein, for example, inorganic phosphorus and amine acid; in the second way, macromolecule and some particulate matters proceeded the transmembrane transport through a particular way, for example, protein, Ca hydrone . In this2+i were decreased significantly in the test group.UV-absorbing substance permeability of C.a and C.t was increasing slowly in the first 6 h after S.s bacteriocin treatment; with the time extending, the permeability increased greatly, while, without S.s bacteriocin treatment, UV-absorbing substance permeability was little. Fluo-3 AM was hydrolyzed to free acid by intracellular hydrolase after entering cells; their conjugates with calcium ion could generate specific fluorescence under excitation light, and the intensity of fluorescence signals was changed following the concentration of calcium ion; the result showed that cytosolic calcium concentration and CaIt could be found that there were leakages of inorganic phosphorus, UV-absorbing substance, and decrease of intracellular calcium ion. In normal cases, the micromolecule and macromolecule could not penetrate the cell membrane, but when the cell membrane permeability was changed, there might be the leakages of cell contents. Candida. (2) The main structure of cell membrane was constituted by phospholipid bilayer; S.s bacteriocin could bind to some specific compositions in the bilayer; integrity of cell membrane was broken, so the cell membrane permeability was changed; the transport of micromolecule and macromolecule in thallus of Candida became abnormal. (3) Ergosterol was an important component of fungal cell membrane; it could stabilize the structure of cell membrane and decrease their fluidity [The roles of S.s bacteriocin could be the following. (1) The cell membrane structures might be destroyed by S.s bacteriocin, resulting in the formation of channels in the cell membrane, so the cell membrane permeability was changed; the micromolecule and macromolecule could be released from thallus offluidity ; with th Candida was changed by the effect of S.s bacteriocin; many of them were accumulated in the thallus of Candida and combined specifically to molecules with cell wall synthesis function, so the cell wall synthesis of Candida was affected and resulted in deformation and collapse of cell wall, with various depressions appearing.In the present, the main mechanism of antifungal agents was as follows: the destruction of fungal cell wall, interference on fungal cell membrane, inhibition of protein synthesis, and influence on mitochondria ATP synthetase . In this Candida thallus and then affect the synthesis and expression of protein and DNA in Candida, finally resulting in transfer interruption of material, energy, and information, and the cell turned to death. Besides, S.s bacteriocin could attach to the surface of Candida cell wall by electrostatic attraction; the enzyme synthesis of cell wall was inhibited and the cell wall structure was destroyed, so depression, defect, and fracture could be found in the surface of cell wall.There were cytoplasm pycnosis, plasmolysis, nucleus destruction, disappearance, and vacuolization in C.a and C.t after 24 h treatment of S.s bacteriocin. It could be speculated that S.s bacteriocin could cause the organelle damage of Candida thallus. The results could provide references for fungistatic mechanisms studies.In conclusion, S.s bacteriocin could not only cause the same fungistatic dynamics of C.a and C.t, but also result in the decrease of hydrophobicity in the cell surface, the cell membrane permeability, and ultrastructure changes of


Rheum palmatum complex comprises all taxa within section Palmata in the genus Rheum, including R. officinale, R. palmatum, R. tanguticum, R. tanguticum var. liupanshanense and R. laciniatum. The identification of the taxa in section Palmata is based primarily on the degree of leaf blade dissection and the shape of the lobes; however, difficulties in species identification may arise from their significant variation. The aim of this study is to analyze the patterns of variation in leaf blade characteristics within and among populations through population-based sampling covering the entire distribution range of R. palmatum complex.Samples were taken from 2340 leaves from 780 individuals and 44 populations representing the four species, and the degree of leaf blade dissection and the shape of the lobe were measured to yield a set of quantitative data. Furthermore, those data were statistically analyzed.Palmata should be considered as one species. Based on the research on the R. palmatum complex, we considered that the quantitative characteristics were greatly influenced by the environment. Therefore, it is not reliable to delimitate the species according to the continuously quantitative vegetative characteristics.The statistical analysis showed that the degree of leaf blade dissection is continuous from lobed to parted, and the shape of the lobe is also continuous from broadly triangular to lanceolate both within and between populations. We suggested that taxa in section  Species are fundamental units of systematic, ecological and evolutionary studies, and species delimitation has long been the focus of biologists' attention. The discovery and description of species is a major endeavor in the field of systematics. However, most species continue to be circumscribed based on morphological comparisons of museum specimens Rheum palmatum complex comprises all taxa  within Rheum Sect. Palmata. These taxa differ from other members of genus Rheum in the possession of palmately lobed leaf blades R. officinale and R. palmatum are lobed; the lobes of R. officinale are broadly triangular, and those of R. palmatum are narrowly triangular. The blades of R. tanguticum and R. laciniatum are parted, and the lobes are narrow and triangular-lanceolate. The difference between R. tanguticum and R. laciniatum is that the lobelets of the former are narrowly lanceolate, and those of the latter are linear. However, the transitional morphologies between species are often observed in both the herbarium specimens and the field individuals. Previous DNA-based studies have drawn conflicting conclusions, and the interspecific relationships remain to be resolved. Using AFLP (amplified fragment length polymorphism) markers, Suo et al. R. officinale and R. palmatum are mutually sisters and are together sisters with R. tanguticum based on samples from Sichuan and Gansu provinces. Using DNA sequences from the chloroplast gene matK, Yang et al. R. officinale and R. tanguticum are mutually sisters and are together sisters with R. palmatum based on samples from Qinghai, Sichuan, and Gansu provinces. Based on chloroplast DNA trnL-F sequences from samples from Chongqing and Qinghai provinces, Wang et al. R. palmatum, R. officinale, and R. tanguticum are nested one with one another on the phylogenetic tree. Based on the nuclear ITS  sequences from eight samples from Qinghai and Gansu provinces, Li et al. R. officinale in their study is sister with their seven samples of R. palmatum and R. tanguticum. According to our previous study, R. palmatum is the most widely distributed among the distribution of the species complex; the distribution of R. tanguticum overlaps with that of R. palmatum in northwestern distribution of the species complex, the distribution of R. officinale overlaps with that of R. palmatum in southeastern distribution of the species complex, and the distribution of R. officinale also overlaps with that of R. tanguticumR. laciniatum only inhabits the northern Sichuan province and embeds in the distribution areas of the other three species Palmata might not be truly distinct species R. palmatum complex.For some genera of Chinese flora, microspecies were published by several authors based on the limited specimens collected from various localities by different collectors. Chinese botanists have devoted attention to some species complexes in recent decades Palmata is not on the list of state-protected plant species http://www.people.com.cn/item/faguiku/zrzyf/U1020.html). Thus, no specific permits were required for the described field studies, and no harm was caused to the plants and their habitats.According to regulations of the People's Republic of China on the protection of wild plants, permits are required only for the species included on the list of state-protected plant species at the time of collection. Sect. R. palmatum complex, i.e., R. officinale, R. palmatum, R. tanguticum, R. tanguticum var. liupanshanense, and R. laciniatum, from the entire distribution range of Sect. Palmata  to CD, to represent the length of the central lobe .To intuitively indicate the changes in the leaf lobe width and the leaf cleft depth, the above lines  were linked to form two triangles, ABC and BCE. In triangle ABC, if the length of the central vein (AB) is regarded as a unit of length, then the values of AC/AB vary with the depth of the leaf cleft. A smaller AC/AB value indicates that the leaf cleft is deeper , whereas a larger AC/AB value shows that the leaf cleft is shallower . Likewise, if BE, the height of triangle BCD, is regarded as a unit of length, then the values of CD/BE vary with the width of the leaf lobe. A smaller CD/BE value indicates that the leaf lobe is narrower , whereas a larger CD/BE value shows that the leaf lobe is wider . Therefore, the analyses of inter-population and intra-population variations were conducted at the individual and population levels based on the values of AC/AB and CD/BE. Variation among the populations can be observed from the scatter diagram comparing the two indices of leaf lobes and from the histogram indicating the number of individuals in different ranges of leaf cleft indices. Variation within the populations can be obtained from the histogram indicating the range of variation of leaf cleft indices in different individuals.R. palmatum complex, the differences between the maximum and minimum values of AC/AB or CD/BE were divided into three equal intervals, and each interval corresponded theoretically to a morphological variation range of leaf blade. Thus, each morphological variation range of leaf blade was obtained. All measurements were obtained using a rule precise to 0.1 cm. The correlation analysis among the morphological parameters and the correlation analysis of these morphological parameters with environmental factors were performed with the statistical software SPSS 17.0 .Using the parameters measured in the field, the maximum and minimum values of AC/AB and CD/BE were obtained at the individual and population levels, and the difference between the maximum and minimum values for each parameter were then assessed. Because the scatter diagram showed that the AC/AB and CD/BE values among different populations were continuous within taxa of r = 0.949, P<0.01)  . If a le P<0.01)  showed aE values  differedE values . Most inR. palmatum complex, and the difference between the maximum and minimum values is 0.7515  and R. laciniatum. For the maximum and the moderate variation ranges, Pop1-Pop6 and Pop10-Pop13 were included in the maximum variation range that corresponded with R. officinale both for the AC/AB value and for the CD/BE value, but Pop7 and Pop8 were exceptions; seventeen populations, i.e., Pop 15-Pop19, Pop21-Pop24, Pop26-Pop28, Pop30 and Pop33-Pop36, were within the moderate variation range, which corresponded to R. palmatum. However, six populations, Pop9, Pop14, Pop20, Pop25, Pop29 and Pop31, were within the moderate variation range based on the AC/AB value but belonged to the maximum variation range for the CD/BE value. Pop7 and Pop8 differed from the above populations, residing within the maximum variation range of the AC/AB value; however, these two populations were within the moderate variation range and the maximum variation range of CD/BE values, respectively. These results indicate that these eight populations, Pop7, Pop8, Pop9, Pop14, Pop20, Pop25, Pop29 and Pop31, are the transitional forms between R. officinale and R. palmatum.The AC/AB values ranged from 0.1658 to 0.7271 at the population level in the  complex , and theon level , and theThe two indices of the leaf blade cleft also differed greatly among the different individuals within populations, and the differences between populations were also not identical ; Fig. 3.P<0.01and P<0.05, respectively). With higher latitudes and/or altitudes, the blade divisions became deeper, and the blade lobes became narrower, especially on a single mountain, such as the four populations on the north slope of Mt. Taibai, Shaanxi province. The indices of leaf division showed no significant correlation with the longitudes or with the different longitudes at approximately the same latitudes.Correlation analysis revealed that the AC/AB and DC/BE values were both significantly correlated with latitudes and altitudes , leaves tend to be flat and thin. Therefore, leaves become the organ with the largest contact area with the environment, and they are thus heavily influenced by the environment. Many quantitative characteristics in plants, including size, weight and number, are controlled by polygenes R. palmatum complex was indeed based on unreliable morphological characteristics. Morphological characteristics based on the degree of leaf blade dissection and the lobe shape are continuous among and within the studied populations. Yang and Zhang published a new species, R. qinlingense, which was later treated as a synonym of R. palmatumR. qinlingense actually represents the intermediate type of R. officinale and R. palmatum. Wu et al. R. officinale and R. palmatum as recorded in Flora TsinlingensisR. officinale and R. palmatum can be found within a single population, such as Pop14 . This phenomenon can also be found in R. palmatum and R. tanguticum, such as Pop38 . As described in Flora of China R. laciniatum differs from R. tanguticum only in the shape of the lobelets. R. laciniatum is distributed in the northern Sichuan Province; unfortunately, we failed to find a specimen of R. laciniatum in any of the herbaria in China. According to the scatter diagram or the histogram, it is clear that R. laciniatum is not a separate entity but an extreme form of R. tanguticum. Likewise, R. tanguticum var. liupanshanense also represents an extreme form of R. tanguticum var. tanguticum. Similar findings also exist for other taxa, e.g., Gallego et al. R. officinale, R. tanguticum or R. laciniatum as independent species. It appears more reasonable to recognize these species as synonyms of R. palmatum.Leaves are photosynthetic organs. To absorb sufficient light energy, leaves must be as wide as possible. Meanwhile, to facilitate gas exchange . With the latitude rising, the growth environment of R. palmatum complex becomes increasingly dry. While the leaves of R. palmatum complex are relatively large, so in order to reduce transpiration area, the leaf lobes of R. palmatum complex become deeper and narrower. The change of the altitude is similar with that of the latitude.To date, many reports have dealt with the relationships among R. officinale, R. tanguticum, and R. palmatum at the molecular level as described in the introduction. It should be noted that these studies Palmata and to examine the interspecific relationships proposed in this study. A molecular study is currently underway to gain further insight into this issue.AC/AB and DC/BE values were found to be significantly correlated with each other, indicating that the degree of leaf blade dissection and the shape of the lobes were not meaningful for identifying the species in ngitudes . ContinuR. laciniatum, its difference from R. tanguticum lies only in the shape of the lobelets, which are linear and lanceolate for R. laciniatum and R. tanguticum, respectively. Although the terminal lobes were not analyzed in the present study, leaf lobe types, which varied from no secondary lobes to trilobate lobes, differ greatly among different populations, among different individuals within the same population, and even among different blades of the same individual. Whether secondary lobes or trilobate lobes, their shape also varied from triangular to narrowly lanceolate.As for R. palmatum complex be considered as a single species. Rheum officinale, R. tanguticum (including var. liupanshanense) and R. laciniatum are synonyms of R. palmatum. However, our hypothesis has yet to be confirmed by further studies, possibly using various molecular markers.In summary, we suggest that


Recently we read with great interest the paper by Wang et al. . The autP value for Hardy-Weinberg equilibrium (HWE) in control groups. According to the original data  as 0.06 and 0.19. However, using the same program, we obtained much different results; the P values were equal to 0.005 and 0.02, respectively. These results significantly deviated from Hardy-Weinberg equilibrium (P < 0.05), and thus publication bias may be present, distorting the meta-analysis. To avoid this, the authors should reject these studies in this analysis.First, the authors made some mistakes about counting the i et al.  and Hongi et al.  for GG/GSecond, the racial categories of the original studies were not always clear in this paper . The authors pegged the Egyptians of the original study by Wang et al. as Caucasian . After cFinally, there are some problems of the method of stratified analyses. The authors simply categorized types into the same cancer with all races and the same race with all types of cancer . It is worth considering that the R521K SNP exhibits differences in allele frequencies between ethnic groups under normal conditions. Therefore, this kind of classification method only based on cancer types and ignoring differences between populations is not reliable.In conclusion, the results of the study by Wang et al.  should b