Datasets:

xNoper

/

pubmed-sections-test

like 0

[ "the patient was a 41-week - gestational - age infant girl with a birth weight of 3300 g. after an uneventful pregnancy , the patient was delivered spontaneously and healthy until this episode . at 35 days of age , the patient was admitted to our hospital with a one - day history of anorexia , vomiting and recurrent diarrhea . on admission , conscious level was glasgow coma scale e2 v2 m2 , and blood pressure was 104/flat . physical examination revealed a distended and tender abdomen . laboratory values were significant for a c- reactive protein ( crp ) of 1.7 mg / dl ( normal range was less than 0.3 mg / dl ) . the patient was suspected intestinal obstruction due to enteritis , antibiotics were started ( abpc / mcipc and amk ) . 4 hours after admission , she was pale with a temperature of 39.2 c and 220 per minutes pulse . blood pressure was low , and the fevers , vomiting , and diarrhea persisted and worsened despite antibiotics . she failed to respond to medical managements and died 27 hours after admission due to multiple organ failures . the cyst was unilocular , contained watery fluid , did not communicate with the adjacent intestinal lumen ( fig . microscopic finding of the ileocecal duplication cyst had an undefined mucosal lining though it resembled pyrolic glands or duodenal glands .", "duplications of the alimentary tract can be located anywhere between the mouth and the anus.4 they are most commonly found in the ileum ( 30% ) , ileocecal valve ( 30% ) , duodenum ( 10% ) , stomach ( 8% ) , jejunum ( 8% ) , colon ( 7% ) and rectum ( 5% ) with the half of the all lesions may contain ectopic gastric mucosa.5,6 most alimentary tract duplications are cystic ( 80%90% ) , with the remainder being tubular.7 they have three common features , hollow structure that has a wall of smooth muscle often shared with the contiguous intestinal tract , lined by mucous membrane similar to some part of the alimentary canal , and usually attached to some part of the alimentary tube.8 the clinical symptoms are highly variable from minor digestive problems to intestinal obstruction , gastrointestinal bleeding , or perforation.9 most patients present before the age of 2 years with obstructive symptoms , pain , or an abdominal mass . the presence of gastric or pancreatic mucosa can lead to peptic ulceration , perforation , and hemorrhage . early diagnosis and treatment reduces the risk of dangerous complications , such as bowel perforation , bleeding , obstruction , and malignant alteration . resection of duplication alone is the treatment of choice , and in uncomplicated cases laparoscopic resection is advised . surgically treated intestinal duplications have good prognosis , however , such duplications can have a fatal consequence if not properly treated . possible complications like bowel perforation , bleeding , obstruction , and malignant alterations are the reason why all duplications should be surgically treated at the time of diagnosis.10 alimentary tract duplications can be easily mis - diagnosed as other disorders.5 pyloric and duodenal duplications can mimic hypertrophic pyloric stenosis or choledochal cyst.11,12 ovarian cyst should be considered in female patients , and adolescent patients can sometimes have a presumptive diagnosis of crohn s disease.5 yousefzadeh et al13 showed that duplication of the colon and rectum clinically presented as abdominal pain , vomiting and chronic constipation , a significant number of patients were thought to have hirschsprung s disease . in our fatal case , there are two reasons for this diagnostic difficulty : first , fevers , vomiting , and recurrent diarrhea persisted and worsened despite antibiotics . the patient was suspected intestinal obstruction due to enteritis , however , actually the ileocecal duplication cyst led to intestinal obstruction and necrotizing ileum ; second , the patient died in an instant due to multiple organ failures . if this patient was considered for exploratory laparotomy , she might be able to be alive . however , the patient was getting worse very quickly due to multiple organ failures and showed intractable psvt . exploratory laparotomy was impossible . it is demonstrated a high association of other anomalies in these patients including skeletal and urologic abnormalities,13,14 however , in this case , there were no other congenital anomalies . sudden unexpected death of infants associated with duplication cysts is extremely rare with only 4 cases reported in medical literature to date ( table 1 ) . puligandla ps et al5 and byard rw15 reported the patients presented with group b streptococcal sepsis and clostridium perfringens sepsis , respectively . kibayashi et al16 reported the patient died at home after being diagnosed as having gastroenteritis . in present case , though blood , stool and cyst cultures were negative , the patient had high fever and crp level elevated . infection is suspected to be a risk factor for sudden and unexpected death in infants with duplication cysts . in all cases , this potential diagnosis should be borne in mind for a patient who complains of abdominal symptoms with an unknown cause , and duplication cyst should be recognized as a fatal cause in infant ." ]

[ "the term presbyopia derives from greek for old eyes and refers to the age - related loss of natural accommodation and resulting reduction of baseline near vision around the age of 40 years . as people continue to work and stay active later in life than ever before , their need for quality vision at both near and distance vision is also growing . in fact , the presbyopic population worldwide is predicted to rise to 1.4 billion by 2020 and to 1.8 billion by 2050 . presbyopia can be compensated by glasses or contact lenses , but there is increasing interest in surgical options . since presbyopia is caused by progressive elasticity changes in the biological crystalline lens , presbyopic surgeries may either directly replace the lens through an intraocular approach or modify extraocular structures such as the cornea or sclera . this review will focus on corneal - based surgical strategies to treat presbyopia and in particular how these methods have been or may be used in pseudophakic patients . to improve uncorrected near vision in presbyopia , the two major techniques to alter the cornea generally utilize either an intracorneal inlay device or laser refractive surgery . corneal inlays are devices that are surgically placed within the corneal stroma of the nondominant eye to change the optical properties of the cornea . several different types of corneal inlays each take a distinct approach to minimizing presbyopia ( table 1 ) . the best studied inlay to date is the kamra inlay by acufocus , which is an opaque polymer ring that employs a pinhole concept to expand the depth of focus . the raindrop near vision inlay by revision optics is a clear hydrogel implant that increases the anterior corneal curvature to add optical power , with a refractive index approximating that of the cornea . inlays can also confer differing amounts of refractive power as in the flexivue microlens implant by presbia , which creates a multifocal effect via a central plano zone surrounded by circular rings of plus power . the icolens by neoptics ag is another corneal inlay with a bifocal design similar in concept to the flexivue . corneal inlays are intended to improve uncorrected near vision but may come at the cost of lowered distance vision or increased glare or haloes [ 7 , 8 ] or rarely infectious keratitis . however , inlays have been promoted as an additive , removable technology unlike laser refractive surgery which ablates corneal tissue ; patients usually return to within + /1.00 diopter of their preoperative refractive state after corneal inlay removal . it should be noted that intrastromal corneal ring segments ( icrs or intacs ) are another type of corneal implant but are indicated for treatment of keratoconus rather than presbyopia . laser refractive surgery on the cornea uses an excimer laser to remodel the corneal curvature in order to improve uncorrected vision and reduce dependency on eyeglasses or contact lenses . one of the most popular techniques , laser - assisted in situ keratomileusis ( lasik ) , removes corneal stromal tissue under an anterior flap . lasik can produce either monovision or multifocality , the latter of which has been nicknamed presbylasik when it is used to treat presbyopia . conventional monovision lasik corrects the dominant eye for distance vision and the nondominant eye for near vision . in central presbylasik , the central area is shaped hyperpositively for near vision , whereas the midperipheral cornea is adjusted for far vision . in peripheral presbylasik , the central area is shaped for far vision and the midperipheral corneal area for near vision . in the third approach , laser blended vision creates a combination of micromonovision and depth of field increase by inducing spherical aberration . there are concerns for the decreased contrast sensitivity , visual quality , and irreversibility of these laser ablation procedures . laser blended vision treatment seems to provide the best compromise in terms of safety and quality of vision .", "in contrast to the literature on corneal inlays in phakic patients , there are only a handful of published reports in pseudophakic individuals ( table 2 ) . these include only case reports and retrospective case series . the largest study of pseudophakic patients undergoing inlay implantation included 13 patients with monofocal intraocular lenses ( iols ) . four of these patients also underwent simultaneous lasik to optimize their underlying refractive error prior to insertion of a kamra pinhole inlay . the mean uncorrected near visual acuity ( unva ) improved 5 lines from j10 to j4 at 3 months postoperatively , without significant change in mean uncorrected or corrected distance visual acuity ( udva , cdva ) or corrected near visual acuity ( cnva ) . on a postoperative survey , 77% of the patients said they would opt to have the surgery again . in an earlier report by the same group , kamra inlays were inserted in the nondominant eye of 3 patients with phakic iol implants . these patients saw 25 lines of improvement in unva without change in udva at 3 months postoperatively . both of these studies had a short follow - up period of 3 months , at which point the authors assert that operative results would have stabilized . nonetheless , longer studies are definitely needed as the mean age of these patients was around 55 years and so the patients would be expected to live with the inlays for several decades . two case reports with slightly longer follow - up each described a pseudophakic patient who retained improvement of uncorrected near vision at 624 months after a corneal inlay procedure . one young patient at 32 years of age had received a monofocal iol on account of a traumatic cataract in the right eye , and a year later he developed headaches and asthenopia while reading with his right eye . given his requirement of a + 3.00 reading add in the right eye , he could not tolerate glasses due to anisometropia . after kamra inlay implantation , he reported improved symptoms but also slightly worse reading in dim light compared to bright light conditions . his unva improved from j17 to j3 in the operated eye at the 6-month follow - up . another pseudophakic patient with a monofocal iol saw a j3 to j1 improvement in unva after implantation of a flexivue microlens inlay 6 months after the cataract extraction . this recovery of uncorrected near vision continued to be maintained at a 2-year follow - up after inlay implantation . interestingly , this patient developed a symptomatic posterior capsule opacification in the operated eye at 2 years after the cataract surgery , underwent standard neodymium : yag ( nd : yag ) capsulotomy , and was reported to still be satisfied and spectacle free with unva of j1 6 months later . the authors asserted that the transparent design of this particular inlay enabled visualization for the nd : yag capsulotomy and also fundoscopy . the aforementioned studies demonstrate the efficacy of corneal inlays in presbyopes with a history of prior intraocular and/or refractive surgery . similar studies done in phakic patients suggest that the improved uncorrected near vision is achieved for at least 1 to 5 years after corneal inlay implantation . a mexican prospective study of 30 phakic patients undergoing inlay implantation ( raindrop near vision inlay ) and lasik demonstrated improvement of mean unva by 3 lines at one year , suggesting that the improved unva could also be stable at one year in pseudophakes . a larger retrospective study of 277 eyes in japan showed similar results at one year after simultaneous kamra inlay implantation and lasik , with mean unva improving from j8j10 to j2-j3 depending on patient age . the longest published follow - up of inlays involved an austrian prospective cohort of 32 emmetropic phakic patients who retained improved uncorrected near vision at 5 years after kamra inlay implantation . of note , the mean unva enhancement declined somewhat from j1 to j3 between the 3- and 5-year time points ; however , cdva did not change . it is worth mentioning that , by the 5-year follow - up , there were still no biocompatibility concerns and 84% of the patients said they would opt for the surgery again . several complications occurred , including 2 inlays needed to be recentered , 1 eye that required debridement for epithelial ingrowth , 18 eyes that developed iron deposits by year 3 , and 1 inlay that was removed at year 3 due to patient dissatisfaction . there are several case reports describing the opposite sequence of events , where patients with prior corneal inlay implantation subsequently undergo cataract extraction with intraocular lens placement , either with or without initially removing the inlay . these patients had previously received any one of the three major corneal inlay types , including the kamra inlay , presbia microlens inlay , and the raindrop near vision inlay . these anecdotes suggest that cataract surgery can still be successfully performed after inlay implantation , which will be important for those young presbyopes opting for surgical treatment of their presbyopia .", "an extensive review of the literature on laser refractive surgery for presbyopia revealed very few studies done in pseudophakic patients , although there are numerous published accounts in phakic patients . similar to the body of literature on corneal inlays , a history of prior intraocular surgery such as cataract extraction typically excluded such patients from studies on laser refractive surgery for presbyopia . nonetheless , laser refractive surgery has been performed successfully on pseudophakes to correct for ametropias [ 2225 ] , suggesting that laser refractive surgery to address presbyopia is likely to be equally successful in pseudophakic patients who have monofocal iols . clearly , the application of laser refractive surgery to presbyopia in pseudophakia merits more research . various studies examine the efficacy of laser refractive surgery on treating presbyopia in phakic patients . a prospective trial of central multifocal presbylasik on 50 hyperopic - presbyopic eyes resulted in spectacle independence at all distances for 72% of the patients after 6 months , although nearly a third lost 1 - 2 lines of cdva . this and similar studies have suggested that multifocal laser approaches to improving uncorrected near vision in presbyopia may compromise distance vision to some degree [ 2729 ] . another study utilizing peripheral presbylasik improved mean binocular udva and unva with high reported patient satisfaction rates but decreased contrast sensitivity . presbylasik treatment for presbyopia may be further modified in pseudophakic patients who are not satisfied with the outcome , as described in a recent case report using a wavefront - guided aspheric treatment to reverse the presbyopic treatment and eliminate dysphotopsia up to 6 months later . lasik and photorefractive keratectomy ( prk ) are known to be effective for fine - tuning residual ametropias after presbyopia - compensating iol implantation , which suggests that laser refractive surgery could similarly address presbyopia after iol implantation . two subsequent studies showed efficacy of lasik at up to 6 months in treating pseudophakic ametropia after multifocal iol implantation in 53 eyes and 85 eyes with mixed ametropias . these and other similar studies suggest that laser refractive surgery could also be used in pseudophakes to treat presbyopia . a general consensus is that lasik should be performed at least 612 weeks after intraocular surgery to reduce possible complications related to cataract incisions , postoperative corneal edema , and refractive and iol stability . while prk and lasik have both been performed safely in pseudophakic patients , it has been postulated that neither are as effective as primary refractive surgery . conductive keratoplasty ( ck ) , a corneal refractive surgical technique that uses radiofrequency energy to reshape the central cornea by shrinking peripheral collagen , has also been used to treat presbyopia . while again the majority of studies only include phakic patients , one chinese study reported that ck improved unva up to one year later in presbyopic pseudophakic patients with monofocal iols . studies have noted that myopes and hyperopes may express different levels of satisfaction with presbylasik as well as with other presbyopic treatments . although near acuity results tend to be better in myopes , the majority of hyperopes are satisfied whereas the majority of myopes are not . the decreasing visual quality after presbylasik in myopes who have experienced excellent uncorrected near visual acuity preoperatively can lead to dissatisfaction over unmet expectations .", "pseudophakic patients present a unique set of challenges and advantages for presbyopic surgeries as compared to the phakic population . some of the challenges stem from the prior intraocular surgery itself , such as navigating corneal scars and residual corneal irregularities from prior incisions . additionally , iol aberrations may alter laser refractive measurements and calculations normally used on phakic eyes . in general , the age difference of approximately two decades between pseudophakic patients and typical refractive patients also renders keratorefractive treatments less predictable and less effective . the older age of most pseudophakic patients correlates with increased prevalence of dry eye symptoms and slower healing rates . studies have suggested that the final uncorrected visual acuity after excimer laser or corneal inlay surgery is lower in pseudophakic patients than in typical refractive patients . on the other hand , older patients have reported similar or higher levels of satisfaction after presbyopic surgeries as compared with younger patients who may have had higher postoperative acuity expectations [ 17 , 36 ] . presbyopia may continue to progress for phakic individuals who undergo refractive or inlay procedures at a younger age , whereas this is not an issue for patients who have had cataract surgery . at the same time , the lack of residual natural accommodative power in pseudophakic patients gives little room for error in presbyopic surgeries . it is worth noting , however , that because the iol treats most of the spherical error in pseudophakic patients , there would be less keratorefractive - induced effect on the corneal prolate asphericity and quality of vision than in nonametropic phakic patients . in all patients , regardless of phakic status , there are certain considerations to optimize a satisfactory outcome from corneal - based presbyopic surgeries . the importance of a thorough preoperative evaluation can not be understated , and trial frames or contact lenses should be used in various lighting conditions to help develop realistic patient expectations . patients should be selected appropriately from baseline characteristics including tear film adequacy , normal corneal shape and thickness , and reasonable expectations . there need to be more studies and counseling of patients on possible negative outcomes of presbyopic surgeries , ranging from increased dry eye or glare symptoms to decreased distance and/or night vision and subsequent safety concerns . presbyopic surgery may not completely eliminate the need for reading glasses . given the necessity of fundus viewing for diagnosis and treatment of diseases such as age - related macular degeneration , diabetic retinopathy , or retinal detachments , it should be considered that corneal inlays may obstruct the view or hinder treatment unless they are first removed . although corneal inlays are promoted as removable , long - term follow - up on removed inlays is not available and presbylasik procedures are in general not reversible with the commonly available technology at present . as the first wave of refractive patients begins to require cataract surgery , we may be required to change not only the assessment and technique of cataract surgery for these patients , but also how we counsel these patients who have high expectations for visual acuity and spectacle independence .", "for patients suffering from presbyopia , there are now exciting surgical alternatives to glasses and contact lenses . pseudophakic patients who still desire better uncorrected near vision may choose corneal - based surgical therapies , such as corneal inlays or laser refractive surgery . nevertheless , presbyopic surgeries will not be ideal for all patients , and appropriately screening patients and managing patient expectations are both key to maximizing satisfactory outcomes . many studies on presbyopic surgeries excluded patients with prior ocular surgery , and the few published studies on pseudophakic patients are limited by short - term follow - up , small numbers , and limited lighting conditions . undoubtedly , there is a pressing need for more research on presbyopic surgeries in the pseudophakic population ." ]

[ "enteric duplications ( eds ) are uncommon anomalies that can occur at any point of the gastrointestinal tract . the small intestine is the most common location ; retroperitoneum is an extremely rare site . in general , diagnosed in the neonatal period or during infancy , they are increasingly diagnosed prenatally ; early prenatal detection is possible . , there have been seven reported cases of retroperitoneal ed cyst in the english literature .", "a female newborn , vaginally born at 39 weeks of gestation from a 32-year - old mother , gravid 3 , para 3 . prenatal ultrasound at 22 weeks of gestation objectified an abdominal cystic mass located in the left upper abdominal quadrant , associated with fetal pyelectasis . birth weight was 4000 g , length was 51 cm , and head circumference was 35 cm . postnatal ultrasound found a retroperitoneal para - aortic liquid - filled mass measuring 60 mm 33 mm 22 mm . magnetic resonance imaging ( mri ) confirmed the presence of a retroperitoneal cyst occupying the upper left retroperitoneal space ; with mass effect displacing the left kidney down [ figure 1 ] . peroperative finding was a retroperitoneal cyst above the left adrenal , displacing the left kidney down , measuring 70 mm 30 mm ; with no communication with any portion of the alimentary tract . histopathologic examination revealed an ed cyst lined by small intestinal epithelium , with no ectopic gastric mucosa . the postoperative period was uneventful ; the patient was discharged on the 5 postoperative day . magnetic resonance imaging showing retroperitoneal cyst occupying the upper left retroperitoneal space ; with mass effect displacing the left kidney", "intraabdominal duplications account for two - thirds of localization , among them , jejunoileal duplications account for 65% . eds occur early in intrauterine life ; their pathogenesis remains unclear ; several hypotheses have been proposed . reported 38 cases of ed cysts ; only one was retroperitoneal communicating with a nonfunctioning right kidney . eds are a part of fetal intraabdominal cysts which evoke several differential diagnoses including ovarian cysts , renal cysts , choledochal cysts , hepatic cysts , and mesenteric cysts . marchitelli et al . found high concordance between prenatal and postnatal findings in fetal intra - abdominal cystic lesions ( 90.4% ) . double - wall sign and peristaltism are suggestive of ed and help to differentiate it of differential diagnosis . postnatal ultrasound helps diagnosis showing an anechoic fluid - filled mass , rarely an echogenic mass is found due to complication ( hemorrhage , necrosis ) . more serious complications may occur : ulceration , perforation , severe hemorrhage , and malignant changes associated with the presence of ectopic gastric mucosa .", "", "", "" ]

[ "albert hoffa first described this fracture in 1904.1 these fractures usually involve the lateral femoral condyle . bicondylar hoffa fracture involving both the femoral condyles is a rare injury and has anecdotally been reported in the literature [ table 1].234567 most reported cases of bicondylar hoffa fracture have two separate fracture lines and the two condyles are separated from each other . we describe a rare case of conjoint bicondylar hoffa fracture where both the femoral condyles were joined by a bridge of intact bone adjacent to the intercondylar notch . to the best of our knowledge , only one case of such an injury has been reported in a child.7 previously published reports of bicondylar hoffa fractures", "a 17-year - old male labourer presented to orthopaedic emergency with the complaint of acute pain and swelling in his right knee following trauma . he had a fall from a 10-m - high ladder with direct impact on his semiflexed right knee . local examination revealed a painful swollen right knee with a 1 cm 1 cm lacerated wound over the anterior aspect of the knee [ figure 1 ] . plain radiographs revealed fracture distal end femur but were inadequate to define the exact fracture pattern [ figure 2 ] . noncontrast computed tomographic ( ct ) scan was performed which established the diagnosis of conjoined bicondylar hoffa fracture [ figure 3 ] . cm lacerated wound over the anterior aspect of the knee at the point of direct impact plain anteroposterior and lateral radiographs were inadequate to define the exact fracture pattern axial ct scan cuts showing a bicondylar hoffa fracture joined by a bridge of intact bone the patient was operated in supine position under tourniquet and regional anesthesia . the knee joint was then exposed by swashbuckler ( modified anterior ) approach.8 a lateral parapatellar arthrotomy was done . the vastus lateralis was retracted laterally after lifting it up from the lateral femoral side . the rest of the extensor mechanism along with the patella was retracted medially for unobstructed visualization of both femoral condyles . on exposing the knee , a tangential fracture involving both the femoral condyles was noted [ figure 4 ] . both the condyles were joined by a thin bridge of intact bone forming the roof of the intercondylar notch [ figure 4 ] . however , reduction was achieved and five 6.5 mm cannulated cancellous screws were passed from anterior to posterior direction through the nonarticular part under fluoroscopy control . post operatively above knee back splint with 30 of knee flexion was applied for 2 weeks . partial weight bearing was started at 6 weeks postoperatively and full weight bearing at 3 months when the fracture had united radiologically . at 18 months , patient had 0145 of range of movements without pain and deformity [ figure 5 ] . radiographs showed no signs of avascular necrosis , osteoarthritis , or implant breakage [ figure 6 ] . intraoperative photographs showing the swashbuckler approach ( a ) , pattern of fracture ( b ) , provision reduction ( c ) and fixation with cannulated cancellous screws ( d ) clinical photographs at 18 months showing range of motion followup radiographs anteroposterior ( a ) and lateral ( b ) views at 18 months showing radiological union , without any avascular necrosis , osteoarthritis or implant breakage", "hoffa fracture usually results from high - velocity trauma following road traffic accidents or fall from height . the specific mechanism of injury that produces hoffa fracture is not known . though a shearing force to the posterior femoral condyle has been postulated , both direct impact and vertical shear with twisting mechanisms have also been proposed and a single mechanism is not agreed upon.9 because of the physiological genu valgum , the lateral femoral condyle is more likely to sustain a direct shearing force , and hence is more likely to get fractured.9 this injury is usually caused when knee is hyperflexed at the time of impact , as during driving motorcycle.9 the exact mechanism of injury of a bicondylar hoffa fracture has also not been described . we feel that a bicondylar hoffa fracture occurs when the flexed knee is subjected to a posterior and upward directed force without any varus or valgus component and that the proximity of the fracture line and its obliquity depends upon the degree of knee flexion at the time of impact . the greater the degree of knee flexion , more is the distance of fracture line from the posterior femoral cortex [ figures 7 and 8 ] . our patient had sustained an injury following a fall from a 10-m - high ladder with direct impact on his semiflexed right knee , as evident by a small lacerated wound , probably without any varus or valgus component . therefore , the coronal shear force resulted in a bicondylar hoffa fracture where both the femoral condyles were joined by a bridge of intact bone adjacent to the intercondylar notch as the fracture line was anterior to the intercondylar notch . had the knee been flexed more , it would have resulted in a bicondylar hoffa fracture with two separate fragments with the fracture line being posterior to the intercondylar notch . the most widely used classification system developed by muller , updated by the ao group , and adopted by the orthopaedic trauma association ( ota ) classifies distal femoral fractures into three groups [ figure 9].10 we feel that b3.3 should be subclassified into two groups : type b3.3a- conjoint bicondylar hoffa fracture where the two condyles are joined by a bride of intact bone and occurs due to a posterior and upward directed force with a semiflexed knee without any varus or valgus [ figure 7 ] . type b3.3b- nonconjoint bicondylar hoffa fracture where the two condyles are separate from each other and occurs due to posterior and upward directed force with a hyperflexed knee without any varus or valgus [ figure 8 ] . however , this subclassification needs validation and further evaluation . in view of the rare occurrence of hoffa , further rarer occurrence of bicondylar hoffa , and unreported occurrence of conjoint bicondylar hoffa similarly , in view of limited information and followup , it is not possible to provide information about the prognosis of this fracture . a line diagram showing conjoint bicondylar hoffa fracture following a posterior and upward directed force ( f ) in a semiflexed knee a line diagram showing nonconjoint bicondylar hoffa fracture following a posterior and upward directed force ( f ) in a hyperflexed knee classification of distal femoral fractures the diagnosis of hoffa fracture on plain radiographs can present difficulties because the fracture is obscured in the anteroposterior view by the intact anterior part of the femoral condyle.5 if it is minimally displaced , the fracture may also be difficult to define in the lateral view . if the lateral view is not taken in a standard position , then it is further difficult to interpret whether it is the medial or the lateral condyle that is fractured even if displaced . this may result in the injury being missed on initial imaging.6 oblique radiographs have an important role both preoperatively and also intraoperatively for evaluation of the reduction , screw length , and condyle identification . however , a ct scan is most helpful not only in defining the fracture pattern but also in deciding the surgical approach . in our case also , the initial radiographs were inadequate to define the exact pattern of the injury . the ct scan demonstrated the bicondylar hoffa fracture with both fragments joined to each other by a bridge of bone forming the roof of intercondylar notch . it helped us not only in defining the exact nature of the injury but also in the surgical approach . therefore , like previous authors , we feel a ct scan with 3d reconstruction is the investigation of choice in such patients to define the exact pattern of the fracture and plan the surgical approach . nonoperative treatment in the form of plaster cast or skeletal traction leads to loss of extension , nonunion , instability , joint contracture , and deformity.239 therefore , anatomical reduction of articular surface , stable fixation , and early mobilization should be the aim of treatment.11 for open reduction of bicondylar hoffa fracture , most authors have used a combined medial and lateral approach . however , we used a swashbuckler ( modified anterior ) approach as advocated by dua et al.6 this allowed us to expose the back of femoral condyles on both the sides and facilitated unhindered anatomic reduction of the fracture fragments . the more anterior position of the skin incision as compared to the classical lateral approach allows unobstructed visualization of both the femoral condyles and obviates the need of two incisions . we believe that single incision would result in decreased breach of the quadriceps mechanism , lesser fibrosis , and earlier return of quadriceps strength and range of motion . lal et al.7 described arthroscopic assisted reduction and fixation for such injuries . however , we believe that it would be technically challenging in a case like ours where the fragment was large and displaced . although there is no consensus , there is some suggestion that posterior to anterior directed screws may be better.12 however , in our case , the unusual fracture pattern required that we use an approach by which both condyles could be exposed adequately . once the exposure was adequate , the best method was to fix the fractures from anterior to posterior direction under direct vision . thus , the direction of the screws was determined by the approach required for the fracture exposure . in conclusion , we described a rare case of a conjoint bicondylar hoffa fracture managed successfully by open reduction and internal fixation with good clinical outcome at 18 months of followup . we feel that a bicondylar hoffa fracture occurs when the flexed knee is subjected to a posterior and upward directed force without any varus or valgus component and that the proximity of the fracture line and its obliquity depends upon the degree of knee flexion at the time of impact . ct scan not only helps in defining the exact pattern of injury but also is invaluable in the surgical planning . the swashbukler ( modified anterior ) approach allows excellent exposure of both the condyles . anatomic reduction and rigid internal fixation allows early mobilization and excellent long term outcome ." ]

[ ", neither buccolingual width nor angulation can be properly visualized on the most traditional radiographs . in the following case report , an innovative simplified method without radiation is used to fabricate a three - dimensional model to assess the available bone for implant placement in the mandible . even a minor variation in comparison to ideal placement causes difficulties in fabrication of final prostheses . the surgical guide is essential to establish a logical continuity among diagnosis , prosthetic planning , and surgical phase .", "a patient of age 27 years reported to the department of prosthodontics for the replacement of missing left first molar . following steps were performed to achieve a three - dimensional model : \n intraoral impression was recorded with addition silicone putty and light body [ figure 1]fabrication of acrylic assembly for aligning both intraoral and extraoral impressiona rectangular block of acrylic was made to which impression tray was pressed to make indentations . after applying separating medium , the counter block of acrylic was made to which extraoral impression was attached [ figure 2 ] . in prototype , [ figures 24 ] plastic rod was used for supporting the extraoral impressionreplacing the plastic rod with metal plate and key system the plastic rod was replaced by a metal plate in the first generation [ figure 5 ] for better stability and better customization . a key system was incorporated to adjust the length and angulation according to each patient 's mandible . on the top of the metal plate , addition silicone putty placed on the acrylic plate can be customized each time to record the extraoral impression . the extraoral impression should record the lower border of the mandible to the medial extent as much as possible [ figure 6]fabrication of three - dimensional model the intraoral impression was poured first to get a cast . after the initial setting was over , the entire assembly was poured , and a three dimensional model of the mandible was fabricated [ figure 7 ] . \n intraoral impression was recorded with addition silicone putty and light body [ figure 1 ] fabrication of acrylic assembly for aligning both intraoral and extraoral impression a rectangular block of acrylic was made to which impression tray was pressed to make indentations . after applying separating medium , the counter block of acrylic was made to which extraoral impression was attached [ figure 2 ] . in prototype , [ figures 24 ] plastic rod was used for supporting the extraoral impression replacing the plastic rod with metal plate and key system the plastic rod was replaced by a metal plate in the first generation [ figure 5 ] for better stability and better customization . a key system was incorporated to adjust the length and angulation according to each patient 's mandible . on the top of the metal plate , acrylic addition silicone putty placed on the acrylic plate can be customized each time to record the extraoral impression . the extraoral impression should record the lower border of the mandible to the medial extent as much as possible [ figure 6 ] fabrication of three - dimensional model the intraoral impression was poured first to get a cast . after the initial setting was over , the entire assembly was poured , and a three dimensional model of the mandible was fabricated [ figure 7 ] . intraoral impression with acrylic assembly prototype ( extraoral impression ) prototype - extraoral and intraoral impression together with acrylic assembly first generation metal plate assembled metal frame three - dimensional model the accuracy of this method was verified with computed tomography ( ct ) scan . the cross section where the mandibular premolar teeth were disappearing from the ct image was taken ( 14 mm depth ) as a reference and measured to get the available bone width buccolingually ( 8.7 mm ) . this measurement was same when compared with the available bone in the sectioned cast at the premolar area , at a depth of 14 mm ( premolar root length ) . on the three - dimensional model , the surgical guide was fabricated [ figure 8 ] . this surgical template can dictate the implant body placement that offers the best combination of support for the repetitive forces of occlusion and esthetics . three - dimensional model with surgical guide this article had won the best table clinic award in 35 ips conference conducted in new delhi 2007 by army dental corps .", "", "" ]

[ "the use of ergotamines causing ischemia of peripheral vessels has been reported , particularly in patients with peripheral vascular disease . ischemic bowel induced by ergotamines is a much rarer event , with few documented cases in the literature . while colitis is always on the differential diagnosis of hospital patients with abdominal pain , the majority of cases are secondary to infectious colitis associated with antibiotic therapy . when suspected , non - occlusive mesenteric ischemia can be treated with anti - coagulation and blood pressure support with intravenous fluids . the predisposition for ischemia in patients with chronic constipation secondary to opioid use is amplified by concomitant use of vasoactive medications to control symptoms of migraine headache . while abdominal ct scanning is frequently used to assess colonic pathology , findings often lag behind those identified at the time of colonoscopy . patchy areas of ischemia are often managed non - surgically by discontinuing the offending medication . widespread necrosis , coupled with clinical deterioration , as in this case , mandated immediate surgical intervention to prevent irreversible septic shock .", "a 48-year - old woman with a long - standing history of intractable migraine headaches was admitted to our institution 's specialty headache unit for aggressive management . she had no known history of peripheral vascular or cardiac disease but has been admitted multiple times for treatment of her headaches since her initial diagnosis in 2003 . during the course of each of these hospitalizations , she had received one to two courses of dihydroergotamine mesylate ( dhe ) 45 . during this admission she received two courses of dhe 0.5 mg 1 , then 1 mg every 8 h for a total of eight doses , on days 13 and the second course of therapy on days 79 . several hours after the final dose of her second round she became obtunded , minimally responsive and hypotensive with a blood pressure of 80/45 mm hg . on physical examination her abdomen was moderately distended with few bowel sounds . mmol / l , white blood cell count was 18.0 ( with 17% bands ) , and stool was clostridium difficile negative . the patient was transferred to the intensive care unit , given intravenous fluid boluses , started on vasopressors , and given broad spectrum antibiotics . her chest radiograph was unremarkable , and her abdominal x - rays showed only mild prominence of the colon . over the next several hours she became progressively acidotic with a worsening bandemia . a bedside colonoscopy showed diffuse ischemic colitis with fecal impaction and no pseudomembranes ( fig . operative findings showed a peritoneal cavity filled with murky , foul - smelling fluid and gangrene of the descending colon was seen with necrosis in the area immediately distal to the splenic flexure to the sigmoid colon . final pathology on the surgical specimen showed 86 cm of patchy , dark green / black large bowel , consistent with ischemic necrosis . the final diagnosis was gangrenous large bowel , ischemic colitis with thrombi or emboli noted . a hypercoaguable panel was performed following the operation and the patient was negative for clotting disorders .", "the differential diagnosis of ischemic colitis includes arterial occlusion , caused by emboli or thrombus , venous thrombosis , and non - occlusive ischemia caused by systemic hypotension or , as is strongly suspected in this case , ergotamine - induced vasospasm . a diagnosis of ergotamine - induced vasospasm is a diagnosis of exclusion , made when all other etiologies of ischemia have been ruled out . in this case , an arterial occlusion is unlikely , because there was no palpable thrombus and there was no clear ischemic demarcation to suggest a major vessel distribution . the patient had no history of cardiac arrhythmias , such as atrial fibrillation , to predispose her to emboli . furthermore she was a non - smoker and had no other cardiac risk factors such as atherosclerosis or hyperlipidemia . emboli to inferior mesenteric artery ( i m a ) are exceedingly rare , and there are no reported cases of spontaneous emboli or thrombosis to i m a . all reported cases of i m a thrombosis are subsequent to trauma [ 1 , 2 ] . venous thrombosis as a cause of ischemia in this patient is equally unlikely as there were no signs of venous congestion or stasis at the time of surgery . the patient had no hypercoagulable disorder and on examination the colon was not edematous and no clot was identified in the vasculature . ischemia secondary to systemic hypotension alone would have resulted in a watershed - type distribution of gangrene . in this case the most probable cause of this event was non - occlusive mesenteric ischemia in the i m a distribution and more specifically the left colic artery due to intense vasoconstriction induced by high - dose ergotamine use . underlying bowel wall distention from the impacted stool in combination with vasoconstriction from ergotamine is the most likely etiology for this patient 's bowel ischemia . dhe is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes . its therapeutic activity in the treatment of migraine headaches is generally attributed to the agonist effect at 5-ht1d receptors . according to the neurovascular theory of migraine , it is hypothesized that activation of 5-ht1d receptors on intracranial blood vessels leads to vasoconstriction . the 5-ht1d receptors on sensory nerve endings of the trigeminal are also activated , causing inhibition of pro - inflammatory neuropeptide release . ergotamine and dhe cause vasoconstriction of both arteries and veins due to alpha - adrenergic agonistic action , and they may also have possible interaction with prostaglandins , calcium and serotonin . dhe was developed in 1943 for migraine prophylaxis and shown in four studies in 1987 and five studies in 2001 to have less effect on peripheral arteries than ergotamine . as indicated in this case a european consensus report in 2000 concluded that ergotamine is not a drug of first choice in the triptan era , but may be useful in longstanding migraine attacks with multiple recurrences . ergotamine is known to cause peripheral ischemia , as has been reported in several case studies , most commonly in the lower limbs [ 5 , 6 , 7 , 8 , 9 ] . a causal relationship has not however been clearly established and is still the subject of some debate . other reports of ergotamine causing ischemic bowel appear in the literature [ 13 , 14 , 15 ] . in previous reported cases of colitis , expectant management with this is the first reported cases of ischemia progressing to gangrene such that colon resection was required . it should be noted in this case that the patient 's dose of dhe was greater than the recommended amount . the recommended dosing of dhe 45 is 1 mg iv / im / sc , repeated once every 24 h for a total dose not to exceed 6 mg in 7 days . in this case , the patient received 17 mg of dhe over the course of 9 days . although ischemic colitis is considered a rare side effect of high - dose ergotamine use , it is a very real risk of which clinicians need to remain aware .", "this is the fourth reported case of ischemic colitis secondary to high - dose ergotamine use reported in the literature and the first to require colon resection . while dhe can be useful in patients with refractory migraines , patients should be informed of the risks of both peripheral and visceral ischemia before deciding on this treatment . finally , ischemic colitis should be considered in the differential diagnosis of all patients taking ergotamines who present with abdominal pain ." ]

[ "we analyzed all 140 mrsa isolates we obtained during a previous study ( 2 ) and 50 other isolates selected from our collection of nosocomial mrsa isolates obtained in 2003 . characteristics of these 190 isolates are shown in table 1 . * ni , nosocomial infection acquired at national taiwan university hospital ( ntuh ) ; nc , nosocomial colonization at ntuh ; ieoh , mrsa infection detected at ntuh within 48 h after transfer from another hospital . bl , blood ; ur , urine ; sp , sputum ; pu , pus ; wo , wound ; ns , nostril ; ct , catheter tip ; st , stool . pulsed - field gel electrophoresis patterns were interpreted according to procedures previously reported ( 7,8 ) . thirty - four isolates belonged to pulsotype a , 49 to pulsotype b , 69 to pulsotype c , 6 to pulsotype d , 2 to pulsotype e , 3 to pulsotype f , 11 to pulsotype k , 5 to pulsotype l , 8 to pulsotype m , and 3 ( all isolated in 2003 ) to 3 minor pulsotypes . all isolates were tested by sccmec element typing and multilocus sequence typing ( mlst ) ( 9 ) and were analyzed for the panton - valentine leukocidin ( pvl ) gene ( 10 ) and drug susceptibility to erythromycin , clindamycin , gentamicin , amikacin , ciprofloxacin , levofloxacin , tetracycline , trimethoprim - sulfamethoxazole , rifampin , and vancomycin by using the disk diffusion method ( 11 ) . isolates with pulsotype a are sequence type 254 ( st254 ) ; those with pulsotype b are st241 ; those with pulsotypes c , k , and l are st239 ; and those with pulsotypes d , e , f , and m are st59 , st 254 , st30 , and st5 , respectively . all mrsa isolates with pulsotypes a , d , e , and f have the type iv sccmec element . however , only isolates with pulsotypes d and f , as well as 2 isolates from 2003 with 2 minor pulsotypes , have the pvl gene . isolates with pulsotypes b and c have the type iii sccmec element , and isolates with pulsotype m have the type ii sccmec element . * p , pulsotype ; scc , staphylococcal cassette chromosome ; mlst , multilocus sequence typing ; pvl , panton - valentine leukocidin ; n , no ; y , yes . ox , oxacillin ; em , erythromycin ; cl , clinidamycin ; gm , gentamicin ; am , amikacin ; cp , ciprofloxacin ; lv , levofloxacin ; tc , tetracycline ; ts , trimethoprim - sulfamethoxazole ; rf , rifampin ; va , vancomycin . results of mlst and typing of sccmec elements of the 3 isolates with 3 minor pulsotypes obtained in 2003 are shown in table 2 . the correlation between sccmec element typing and mlst in this study corresponds to findings of previous reports ( 6,1214 ) . enright et al . identified st254-iv mrsa isolates in germany and the united kingdom ( 12 ) , and chongtrakool et al . identified st239-iii and st241-iii mrsa isolates in several asian countries ( 14 ) .", "we demonstrate that the predominant mrsa clone at ntuh in early 1990s had the type iv sccmec element . however , the predominant mrsa clones at ntuh from 1994 to 2003 had the type iii sccmec element . these findings differ from those of wisplinghoff et al . , who reported that that the sccmec element in predominant mrsa clones at their institute changed from type iii in 1984 to 1988 to type i in 1989 to 1998 ( 6 ) . mrsa isolates of pulsotypes b and c are more resistant than isolates of pulsotype a to certain antimicrobial drugs , especially fluoroquinolones and trimethoprim - sulfamethoxazole ; mrsa isolates with pulsotype c are more resistant to clindamycin but less resistant to rifampin than those with pulsotype b ( table 2 ) . from 1993 through 2000 , annual use of fluoroquinolones increased 3 at ntuh ; however , use of trimethoprim - sulfamethoxazole , clindamycin , and rifampin did not change ( 15 ) . therefore , the shift of predominant mrsa clones , which also led to the shift in types of sccmec elements at ntuh , might be caused by selective pressure from antimicrobial drugs , especially fluoroquinolones . the mrsa clone ( pulsotype a ) that predominated in 1992 and 1993 at ntuh has the type iv sccmec element . although the first study of mrsa with the type iv sccmec element reported that this element was found in community - acquired mrsa ( ca - mrsa ) ( 5 ) , some studies have reported mrsa isolates with this element in a hospital environment ( 12 ) . however , to our knowledge , these reports did not demonstrate that mrsa isolates with the type iv sccmec element became predominant among all mrsa isolates in an institution , especially before the mid-1990s . furthermore , 4 st59 mrsa isolates obtained in 1994 and 1996 and 3 st30 mrsa isolates obtained in 1992 and 1993 have the type iv sccmec element and pvl gene . recently , st59 mrsa isolates were found to cause ca - mrsa infection in taiwan ( 13 ) . among these st59 ca - mrsa isolates , some had the type iv sccmec element , and others had the type v sccmec element ( 13 ) . although the type iv sccmec element could be transferred to ca - mrsa clones with other genetic backgrounds , our finding supports the possibility that st59 mrsa isolates with the sccmec element type iv in taiwan may originate from hospital strains but transfer into ca - mrsa strains . recently reported the results of sccmec typing of 615 mrsa isolates obtained in 1998 and 1999 from 11 asian countries ( 14 ) . the st239-iii , st241-iii , st254-ii , and st5-ii mrsa isolates were prevalent in many asian countries . however , the st254-iv , st30-iv , and st59-iv mrsa isolates from our study were not found in other asian countries . in addition , st254-iv mrsa isolates have been found in germany and the united kingdom ( 12 ) . whether st254-iv mrsa isolates in our study were transmitted from those in germany or the united kingdom by international travel requires further study . the first mrsa isolate with the type iv sccmec element in our hospital appeared as early as 1992 . the sccmec element carried by predominant mrsa clones changed from type iv to type iii sccmec element during the period 19922003 at ntuh . because the major mrsa clones isolated in 19942003 are more resistant to antimicrobial drugs , especially fluoroquinolones and trimethoprim - sulfamethoxazole , than those obtained in 1992 and 1993 , this shift may be caused by selective pressure from indiscriminate use of antimicrobial drugs ." ]

[ "acute embolic limb ischemia is an urgent clinical condition in which sudden decrease or worsening in limb perfusion causes a potential threat to extremity viability and to life . thorough removal of all occlusive emboli in the arterial tree results in the best outcomes ; hence , some authors favored arteriography after embolectomy for lower limbs . \n angiography is traditionally performed with iodinated contrast material , but carbon dioxide ( co2 ) has been studied as an alternative intravascular contrast agent for patients with iodine allergy or renal function impairment . since it is not nephrotoxic , it was considered reasonable to utilize this contrast in a patient with borderline renal function who would be submitted to the noxious stimuli of the reperfused limb after revascularization . \n to the best of our knowledge , this was the first case assessing the intraoperative use of co2 as a substitute for iodine contrast in a patient with known chronic kidney disease and an acute ischemic limb .", "a 79-year - old woman presented to the emergency department with acute limb ischemia in her left leg with a 2-hour history . past medical history was positive for hypertension , atrial fibrillation and non - dialysis - dependent chronic renal failure . two years before , she had been operated on for acute aortic embolic occlusion , with bilateral femoral catheter embolectomy . upon discharge she presented pedal pulses , but no posterior tibial pulses on either limb . medication use was irregular , and her international normalized ratio ( inr ) of prothrombin time upon admission was 1.1 . her pulse was arrhythmic ; she was hypertensive ( 160x110mmhg ) and presented with normal femoral , popliteal and pedal pulses on her right leg . on palpation in the left lower limb only a weak femoral pulse was observed ; there were no distal pulses . she was classified as grade iib limb ischemia ( immediately threatened ) and was immediately referred for surgery . preoperative exams revealed a diminished creatinine clearance ( cockroft - gault of 12ml / min ) . arteriotomy was performed and a 4-fr embolectomy catheter was utilized ( edwards lifesciences corp , irvine , california , usa ) . the catheter progressed more than 60 cm on the superficial artery , but could not be felt neither on pedal artery topography nor on posterior tibial artery topography . back bleeding was not significant , and a decision was made to perform an angiography to better assess the infra - popliteal arterial tree . a homemade water seal co2 delivery system was used , similar to another previously described , but with one modification to prevent room - air contamination . bloomington , indianopolis , usa ) inserted in the arteriotomy while the arteries were clamped . \n figure 1 shows a patent popliteal artery , a patent fibular artery and an occlusion on the mid - third of the anterior tibial artery . we hypothesized that the embolectomy catheter reached the fibular artery on the first attempt , and thus could not be felt on physical exam . \n patent popliteal and fibular arteries , occlusion in the mid - third of the anterior tibial artery \n a new embolectomy was then performed . the catheter progressed to the foot , on the topography of the pedal artery ( i.e. , the catheter could be felt on the projection of the artery ) , and more thrombi were retrieved . control angiography ( figure 2 ) showed complete resolution of the anterior tibial artery occlusion , with contrast up to the foot ( figure 3 ) . a total of 28ml of co2 was used , and no iodine contrast was needed . \n the arteries were unclamped , and the popliteal and pedal pulses were noted to be present on the limb . ischemia signs ( e.g. , pallor , hypothermia ) were promptly resolved after arterial flow release . the patient remained in the intensive care unit ( icu ) until the 11 postoperative day . during this period , the patient did not receive any nephrotoxic agent , such as vancomycin or vasoactive drugs . after icu discharge she developed a urinary tract infection , as well as deteriorating renal function and uremia . the patient developed pneumonia , which progressed to septic shock on the 36 day of her admission . she required vasoactive drugs for 2 days at the icu and , unfortunately , her renal function was never fully recovered . she was discharged from hospital to a hospice care facility with a pedal pulse and no deficit on her limb , though requiring chronic dialysis .", "treatment of embolic arterial occlusion with severe limb ischemia is well defined and involves the use of an embolectomy catheter as the best alternative . \n co2 has been used electively in both diagnostic and therapeutic procedures in the femoropopliteal tree , and is reported to be safe and non - nephrotoxic . \n intraoperative angiography was beneficial because it allowed the diagnosis of the arterial tree occlusion after the initial embolectomy . additional removal of clots was performed and the result was documented as complete patency of the anterior tibial artery to the foot . our goal , when using co2 , was to decrease the need for postoperative dialysis . probably , in this case , the deleterious stimuli ( surgical stress , urinary tract infection and septic shock due to pneumonia ) contributed to renal failure and subsequent need for dialysis . the countermeasure ( such as the use of non - nephrotoxic contrast ) if we had used the iodinated medium , we might wonder if something could have been done differently to avoid dialysis . we consider co2 to be an alternative to iodine contrast when the decision to perform angiography is made in the acutely ischemic limb . to the best of our knowledge , this agent has never been described in this clinical setting ; it presents good quality imaging , is not nephrotoxic and does not increase the risk for the limb or the patient in acute arterial occlusions . this approach may prove to be fruitful in patients with borderline renal function , thereby reducing the risk of short or long - term need for dialysis .", "a isquemia aguda de membro de origem emblica uma situao clnica de carter urgente , em que ocorre uma diminuio ou piora sbita na perfuso de um membro , e configura um risco viabilidade da extremidade e vida . o tratamento consiste em revascularizao imediata com um cateter de embolectomia . a remoo completa de todos os mbolos oclusivos na rvore arterial leva aos melhores desfechos ; por isso , alguns autores defendem a arteriografia aps a embolectomia , para os membros inferiores . \n a angiografia tradicionalmente realizada com contraste iodado , mas o dixido de carbono ( co2 ) foi estudado como um agente de contraste intravascular alternativo para pacientes com alergia a iodo ou alterao na funo renal . como o co2 no nefrotxico , julgou - se razovel utilizar esse contraste em uma paciente com funo renal limtrofe ( borderline ) que seria submetida aos estmulos nocivos de reperfuso do membro , aps a revascularizao . \n em nosso entender , este foi o primeiro caso que avalia o uso intraoperatrio de co2 como um substituto de contraste iodado em um paciente com doena renal crnica conhecida e isquemia aguda de membro .", "paciente do sexo feminino , 79 anos , chegou ao pronto - socorro com isquemia aguda no membro inferior esquerdo , com durao de 2 horas . como antecedentes , apresentava hipertenso , fibrilao atrial e insuficincia renal crnica , no dependente de dilise . a paciente tinha sido operada 2 anos antes , por ocluso artica aguda de origem emblica , quando foi realizada embolectomia femoral bilateral com cateter . alta , os pulsos pediosos eram palpveis , mas os tibiais posteriores eram ausentes , bilateralmente . a paciente fazia uso irregular dos medicamentos , e o tempo de protrombina ( inr , sigla do ingls international normalized ratio ) era de 1,1 . o pulso estava arrtmico ; era hipertensa ( 160x110mmhg ) e apresentava pulsos femoral , poplteo e distal normais , na perna direita . palpao do membro inferior esquerdo , havia apenas um pulso femoral fraco ; os pulsos distais estavam ausentes . a paciente apresentava dor e dfice motor . ela foi considerada como portadora de isquemia de membro grau iib ( risco eminente ) e foi encaminhada imediatamente para cirurgia . o clearance de creatinina estava diminudo nos exames pr - operatrios ( cockroft - gault de 12ml / min ) . sob anestesia geral , foi realizado acesso femoral na cicatriz da inciso anterior do membro inferior esquerdo . as artrias femorais comum , superficial e profunda foram dissecadas e clampeadas . foi feita arteriotomia e uso de cateter de embolectomia de 4fr ( edwards lifesciences corp , irvine , califrnia , estados unidos ) . os trombos foram removidos das artrias femorais superficial e profunda . o cateter avanou mais de 60 cm na artria femoral superficial , mas no pde ser palpado . o fluxo retrgrado no foi significativo e decidiu - se realizar uma angiografia para avaliar melhor a rvore arterial infrapopltea . foi escolhido o co2 como substituto ao contraste iodado para a angiografia . utilizou - se um sistema home - made com fornecimento de co2 em selo dgua , semelhante a outro descrito anteriormente , mas com uma modificao para evitar a contaminao do ar ambiente . bloomington , indianpolis , estados unidos ) inserido na arteriotomia , quando as artrias foram pinadas . a figura 1 mostra uma artria popltea e uma fibular prvias , e uma ocluso no tero mdio da artria tibial anterior . levantamos a hiptese de o cateter de embolectomia ter alcanado a artria fibular na primeira tentativa , e por isso no ter sido palpvel ao exame fsico . \n artrias popltea e fibular prvias , ocluso no tero mdio da artria tibial anterior \n realizou - se , ento , nova embolectomia . o cateter avanou at o p , na topografia da artria pediosa ( isto , o cateter pde ser palpado na projeo da artria ) e mais trombos foram removidos . a angiografia de controle ( figura 2 ) mostrou resoluo completa da ocluso da artria tibial anterior , com contraste fluindo at o p ( figura 3 ) . foram usados 28ml de co2 , e no foi necessrio aplicar o contraste iodado . \n resoluo completa da ocluso da artria tibial anterior \n \n figura 3arteriografia com dixido de carbono . chegada de contraste na artria tibial anterior at o p \n foi realizada a arteriorrafia . as artrias foram desclampeadas , os sinais de isquemia ( palidez e hipotermia ) foram imediatamente resolvidos aps a liberao do fluxo arterial . a paciente no desenvolveu sinais de sndrome compartimental . a paciente permaneceu na unidade de terapia intensiva ( uti ) at o 11 dia ps - operatrio . durante esse perodo , no recebeu nenhum agente nefrotxico , como vancomicina ou drogas vasoativas . aps a alta da uti , desenvolveu infeco urinria , piora da funo renal e uremia . iniciou dilise no 18 dia ps - operatrio . a paciente teve pneumonia , que evoluiu para choque sptico no 36 dia de internao . necessitou de drogas vasoativas por 2 dias na uti e , infelizmente , nunca mais recuperou a funo renal . teve alta hospitalar e foi para instituio de cuidados terminais , com pulso distal sem dfice no membro inferior , mas em dilise crnica .", "o tratamento da ocluso arterial emblica com isquemia grave de membro est bem definido , sendo o uso de cateter de embolectomia a melhor alternativa . \n o co2 tem sido empregado de forma eletiva tanto nos procedimentos diagnsticos como nos teraputicos na rvore fmoro - popltea , sendo descrito como seguro e no nefrotxico . \n a angiografia intraoperatria foi benfica , j que permitiu o diagnstico de ocluso da rvore arterial aps a primeira embolectomia . mais cogulos foram removidos , e o resultado documentado foi a permeabilidade completa da artria tibial anterior at o p . nosso objetivo , ao utilizar co2 , foi o de diminuir a necessidade de dilise no ps - operatrio . neste caso , provavelmente , os estmulos prejudiciais ( estresse cirrgico , infeco do trato urinrio e choque sptico por pneumonia ) contriburam para a insuficincia renal e para consequente necessidade de dilise . a contramedida ( como o uso de contraste no nefrotxico ) poderia ter prevenido a insuficincia renal , se fosse esta uma situao nica . se tivssemos usado o contraste iodado , pensaramos se algo diferente poderia ter sido feito para evitar dilise . consideramos o co2 como uma alternativa ao contraste iodado quando necessria a angiografia para isquemia aguda de membro . em nosso entender , esse agente nunca foi descrito nessa situao clnica , proporcionando boa qualidade de imagem , no sendo nefrotxico , nem aumentado o risco do membro ou do paciente , em casos de ocluses arteriais agudas . essa abordagem pode se mostrar til em pacientes com funo renal limtrofe ( borderline ) , reduzindo , assim , o risco de precisar de dilise a curto ou longo prazo ." ]

[ "emphysematous gastritis , which was first described by fraenkel in 1889 ( 1 ) , is a rare disease characterized by the presence of air within the wall of the stomach and diffuse gastric wall inflammation by gas - forming bacteria , which may be also life - threatening due to systemic toxicity . predisposing factors include the ingestion of corrosives , alcohol abuse , recent abdominal surgery , diabetes , and immunocompromised conditions ( 1 - 3 ) . since 1889 , only 51 cases have been reported worldwide ( 1 - 8 ) . mucormycosis is a rare fungal infection that usually involves the nasopharynx ( 9 ) . among the several forms , gastrointestinal mucormycosis is very rare , and the manifestations range from colonization of peptic ulcers to infiltrative disease with vascular invasion and dissemination ( 9 ) . commonly associated conditions include diabetes mellitus , lymphoma , leukemia , renal disease , septicemia , malnutrition , and long - term treatment with steroids and antibiotics ( 10 ) . among the reported cases of emphysematous gastritis , fungal organisms such as candida species have been isolated rarely ( 4 , 11 - 15 ) . however , emphysematous gastritis associated with mucormycotic infection is extremely rare , and only one case has been reported in the english literature ( 15 ) . here we report a case of emphysematous gastritis , diagnosed by computed tomography ( ct ) and confirmed by histopathologic findings associated with invasive gastric mucormycosis that showed angioinvasion , necrosis , ultimately disseminated to the colon and liver , and was fatal despite medical and surgical treatment . to our knowledge , this is the first report of a patient with emphysematous gastritis associated with invasive gastric mucormycosis in korea .", "a 43-yr old man was admitted to the emergency room because of diffuse abdominal pain , indigestion , and poor oral intake for 4 days . he had had a 1-yr history of hypertension , there was also a history of excessive ingestion of alcohol and heavy smoking for 20 yr , but there was no history of peptic ulcer disease . his blood pressure was 160/100 mmhg , with a body temperature of 36.2 , pulse rate of 98/min , and respiration rate of 26/min . abdominal examination revealed decreased bowel sounds and severe tenderness in the epigastrium , with rigidity and rebound tenderness . hematological and biochemical examinations on admission showed hemoglobin 13.9 g / dl ( normal : 13 - 18 ) , white blood cell 11.7710/l ( 3.6 - 11 ) , platelet 21010/l ( 150 - 450 ) , blood sugar 816 mg / dl ( 70 - 110 ) , aspartate aminotransferase 148 iu / l ( 5 - 38 ) , alanine aminotransferase 76 iu / l ( 4 - 43 ) , lactate dehydrogenase 1,320 iu / l ( 180 - 460 ) , amylase 6 u / l ( 45 - 108 ) , blood urea nitrogen 37.7 mg / dl ( 8 - 23 ) , and creatinine 1.6 mg / dl ( 0.5 - 1.2 ) , and blood acetone - positive . chest radiography revealed collapse and consolidation in the basal part of the left lower lobe , suggesting pneumonia . abdominal ct scan revealed gastric wall thickening with a collection of dirty air bubbles and a small amount of pneumoperitoneum ( fig . operation findings showed nearly total necrosis of stomach wall with dark green colored pus collection around the stomach . grossly , the stomach had a large area of necrosis with black discoloration of the mucosa ( fig . the remaining viable stomach wall showed large numbers of neutrophilis in the edematous submucosa and muscle layer . there were several gas - filled bubbles in the submucosa and muscle layer associated with numerous scattered or colonies of gram - negative bacilli , consistent with emphysematous gastritis ( fig . 1 ) . at the same time , there were numerous broad - based , non - septate , right angular branched fungal hyphae , morphologically consistent with mucormycosis , detected on hematoxyline and eosin stain as well as silver stains throughout both necrotic and viable stomach wall ( fig . culture of pus in the peritoneum revealed klebsiella pneumonia , staphylococcus aureus , and pseudomonas aeruginosa . amphotericin b infusion was added after operation . on the fifth hospital day , there was pus discharge from the wound site . however , the patient remained to have non - toxic appearance with stable vital signs . on the seventh hospital day , he complained of diarrhea and vague abdominal discomfort . over the following 2 days , follow - up ct revealed an approximately 14.012.012.0 cm - sized , irregularly shaped air - containing fluid collection at the gastrectomy site , suggesting air - forming postoperative abscess and anastomotic site leakage . reoperation was performed , and the operative findings showed multiple perforations with necrosis in the transverse colon , necrotic change in the liver , hematoma with fluid collection in the peritoneal cavity , and leakage in the anastomotic site . rouxen - y esophagojejunostomy with cecocolostomy and segmental resection of the large intestine were performed . the submitted pathological specimen consisted of segments of colon , small intestine , and a portion of liver . the gross examination of the segment of colon showed multiple perforations , dirty serosa , and necrotic mucosa with greenish black exudates . microscopic examination of the colon and small intestine showed ischemic necrosis of mucosa with acute and chronic inflammation , and foreign body reaction . microscopic examination of the liver also showed totally necrotic parenchyma with many angioinvasive mucormycotic fungal hyphae . auscultation of the lungs revealed decreased breathing sounds with rale on both lung fields , and saturation of arterial blood gas analysis was decreased . he underwent intubation and ventilation . on the 21st - hospital day , the patient expired .", "clinically this condition is divided into gastric emphysema and emphysematous gastritis ( 3 , 5 , 12 ) . these two conditions should be differentiated because they are characterized by different clinical symptoms , possible etiology , radiologic findings , treatment , and prognosis ( 3 , 5 , 12 ) . in gastric emphysema , air enters the stomach wall from the lumen , from the peritoneal surface , or from its connections with the esophagus and duodenum , resulting from barotraumas in the absence of bacterial infection ( 12 ) . radiologically , in contrast to emphysematous gastritis , a more linear distribution of gas in the gastric wall is characteristic of gastric emphysema ( 3 ) . the symptom of acute abdomen as seen in patients with emphysematous gastritis is usually absent in patients with gastric emphysema ( 5 ) . in general , gastric emphysema is asymptomatic ; its course is usually benign and resolves spontaneously without treatment ( 3 , 5 , 12 ) . on the other hand , emphysematous gastritis , the gas formed in situ by gas - forming bacteria invading the gastric wall , results in a necrotizing inflammation of the gastric wall . in 1889 , fraenkel first reported a young man who died after several attacks of severe abdominal pain , blood vomitus , and diarrhea ( 1 ) . at autopsy , originally , the stomach wall is well protected from bacterial infection by the close connection between cells , acidic ph , and good blood supply ( 3 , 12 ) . the predisposing factors , leading to the breakdown of these defenses , are ingestion of corrosives , alcohol abuse , diabetes , recent abdominal surgery , gastroenteritis , immunocompromised conditions , and treatment with non - steroidal anti - inflammatory drugs ( 1 - 3 ) . in the present case , the patient had a history of alcohol abuse , which might have altered the unstirred mucous layer , and diabetes due to chronic pancreatitis , which might have led to a systemic predisposition to infection . patients with emphysematous gastritis typically develop acute abdominal pain , as was the case in our patient , usually developing 1 week after initiation , accompanied by diarrhea , nausea , vomiting , and occasionally hematemesis and melena ( 1 , 4 , 12 ) . physical examination of the abdomen reveals epigastric tenderness , distension , and decreased bowel sounds ( 4 , 12 ) . abdominal computed tomography , the best imaging modality to establish the diagnosis , reveals gastric wall thickening and intramural gas ( 1 , 3 , 12 ) . in contrast to gastric emphysema , the gas in the wall is in the form of irregular mottled bubbles or spots , especially around the fundus and the greater curvature , and remains in place despite the position of the body or absorption through the gastric tube ( 3 , 4 , 12 ) . organisms that have been cultured from stomach aspirates , blood , and peritoneal fluid include streptococci , e. coli , p. aeruginosa , clostridium . perfringens , and s. aureus ( 1 , 4 ) . among the previously reported cases , those associated with fungal infection were rare ( 4 , 11 - 15 ) . of these , most cases were candida species ( 4 , 11 , 12 , 15 ) . pathologically , the gas forming organisms in emphysematous gastritis have been shown to infiltrate the stomach wall diffusely and there are edematous stomach wall - containing gas bubbles ( 1 , 6 ) . the therapeutic approach for emphysematous gastritis included initial stabilization of the septic condition through vigorous fluid resuscitation and early empirical parenteral antibiotic therapy with a broad range of antibiotics covering gram - negative and anaerobic bacteria ( 2 , 3 , 12 , 14 ) . specific therapy should be modified according to the results of the gastric fluid culture and sensitivity testing of the isolated organism ( 12 ) . indication for emergency surgery include deterioration despite optimal medical management , involvement of a large portion of or the entire stomach , presence of gastric infarction , or perforation ( 3 , 4 ) . despite meticulous treatment , the mortality rate of emphysematous gastritis is about 60% , and the morbidity near 21% ( 2 ) . mucormycosis is a rare , opportunistic fungal infection that occurs almost exclusively in immunocompromised hosts such as patients with diabetes , leukemia , lymphoma , renal disease , septicemia , burns , malnutrition , and following long - term treatment with steroids and antibiotics ( 10 ) . clinical manifestations of mucormycosis can be categorized as rhinocerebral , pulmonary , disseminated , gastrointestinal , and cutaneous ( 9 ) . among these , rhinocerebral and pulmonary disease are the most common forms , and gastrointestinal involvement is very rare , accounting for only 7% of all cases ( 16 ) . other associated conditions are immunosuppressed conditions such as renal failure , hematological malignancies , cirrhosis , and solid organ transplantation ( 16 ) . it is believed that infection of the alimentary tract is acquired through direct ingestion of and invasion by fungal spores . the gastrointestinal organ most frequently involved is the stomach , followed by the colon , small intestine , and esophagus ( 16 ) . when they invade , the lesion extends and marked surrounding induration develops , with a shaggy , velvety discolored surface or large plaqe - like areas of green and blacked eschar ( 16 ) . they also invade blood vessels and thus tend to cause extensive thrombosis , necrosis , and , ultimately , dissemination ( 10 ) . association with emphysematous gastritis is an extremely rare , and only one such case has been reported ( 15 ) . mucormycosis is not gas - forming , therefore this infection is not a direct cause of emphysematous gastritis . gastric wall necrosis caused by bacterial infection may be predisposed to the invasion by mucormycosis . alternatively , it is possible that invasive mucormycosis with subsequent gastric wall necrosis led to secondary bacterial invasion and intramural gas production ( 15 ) . successful management of mucormycosis includes aggressive metabolic support , amphotericin b , and surgical debridement of all necrotic involved tissue ( 15 , 16 ) . as in emphysematous gastritis , the prognosis of gastrointestinal mucormycosis is poor . forty - two cases of gastric mucormycosis have been described in the literature thus for , with a mortality above 98% ( 15 ) . we report an extremely rare case of emphysematous gastritis associated with invasive gastric mucormycosis in a 43-yr - old man . heavy alcohol abuse and diabetes mellitus were the predisposing factors . ct is the diagnostic procedure of choice of emphysematous gastritis and helps in differentiating with gastric emphysema . moreover , the gastric mucormycosis showed angioinvasion , necrosis , and ultimately , disseminate to colon and liver . in the case of mucormycosis , biopsy of involved areas this patient also had a fatal outcome despite antibiotic and antifungal therapy and surgery . increased awareness of these disease entities may facilitate early diagnosis , prompt medical therapy , and appropriate surgical intervention , and ultimately improve survival rates ." ]

[ "in accordance with the 1997 documents of the world health organization ( who ) , amoebiasis is the infection by the protozoan parasite entamoeba histolytica with or without clinical manifestations . the only known natural host of e. histolytica is the human body with the large intestine as the major target organ . this parasite has a very simple life cycle in which the infective form is the cyst that is considered a resistant form of the parasite . the asymptomatic cyst passers and the intestinal amoebiasis patients are the natural transmitters ; they excrete cysts in their feces , which can contaminate food and water sources . the cysts are round structures around 1016 m in diameter . however , estimation of cyst diameter in entamoeba spp . in the old and recent literature the cyst has four visible nuclei when mature and only one when immature , and the nuclei are spherical with a membrane displaying small chromatin granules and a central karyosome . when in excystation , each cyst produces eight vegetative forms or trophozoites , which are the motile form of the parasite ; they are 2040 m in diameter . life cycle and the relevant structures of both forms of parasite are shown in figure 1 . cysts are resistant to desiccation in soil and can survive in humid environments and in water for several weeks . susceptible hosts exposed to the aforementioned infection sources ingest the cysts , which then undergo excystation during their pass through the gastrointestinal tract . amoebiasis is also considered a sexually transmitted disease , particularly in sexual relationships between men and in individuals with sexual anilingus practices . clinical and etiological diagnosis of intestinal and extra - intestinal amoebiasis is neither easy or simple in part because of the discovery of two species made from the previously known e. histolytica species , both indistinguishable under microscopy . e. histolytica sensu stricto is the potentially pathogenic species and e. dispar the commensal non - pathogenic entamoeba . d ) trophozoites of e. histolytica species with phagocyted erythrocytes ( dic 40 ) knowledge of both species with different pathogenic phenotypes comes from a large scientific debate during the second half of the twentieth century , which gave rise to the rapid development of diagnosis technology based on molecular and immunological strategies.[59 ] during the last 10 years , knowledge of the new epidemiology of amoebiasis in different geographic endemic and non - endemic areas has been obtained through the application of mostly molecular techniques.[1014 ] moreover , these molecular epidemiology studies have unveiled the extraordinary genetic variability[1315 ] of e. histolytica and e. dispar , allowing the discovery of other entamoeba species , such as e. moshkowskii , which can also infect the human intestine with a significant frequency . however , much of the epidemiology and its contribution to morbidity of entamoeba infections remain unknown . there are excellent recent reviews on the molecular epidemiology and intestinal and extra - intestinal characteristics of amoebiasis in the human host that can be consulted . nevertheless , the major purpose of the present work is to highlight the novelties in regard to human infection and the disease that can help the general physician from both endemic and non - endemic countries in their medical practice . this is especially critical given that emigration is undoubtedly a global phenomenon that is modifying the previous geography of infectious diseases worldwide .", "the speciation of entamoeba protozoa has been discussed since 1925 when emile brumpt proposed the existence of two distinct species that could infiltrate the human intestine : one associated with symptoms of diarrhea with or without dysentery and the other excreted with feces from asymptomatic individuals . while years of scientific discussions have left brump 's theory behind , no molecular technology prior to the 1990s allowed clear differentiation of the currently known e. histolytica and e. dispar species in terms of pathogenic or non - pathogenic phenotypes . both species are genetically diverse and this variability allowed for the beginning of studies on molecular epidemiology in different endemic areas . the new data on the epidemiology of amoebiasis based on frontier technology suggests that genetic variability could be an important tool in the study of geographic distribution of both species and particular strains of entamoeba , which may determine the morbidity rates of different forms of amoebic infection in different geographic areas . some e. histolytica genetic variants ( strains ) have been isolated from asymptomatic cyst passers , patients with invasive intestinal amoebiasis or from samples of amoebic liver abscess material . however , e. dispar has been mainly isolated in feces samples resulting from asymptomatic cyst passers and displays high genetic polymorphisms , even more than the e. histolytica species . we recently have obtained evidence that in at least two endemic countries ( brazil and mexico ) , e. dispar genetic variants have been detected in patients with invasive amoebiasis . in brazil , the icb - ado e. dispar strain was isolated from a non - dysenteric colitis patient maintained in culture with his own intestinal flora displaying a pathogenic behavior in experimental models of amoebic liver abscess . dna extracted from hepatic abscess material obtained from six patients in mexico also clearly showed the presence of e. dispar dna sequences . the third species of entamoeba , e. moshkowskii , has been considered a free - living organism since 1940s in contrast to e. histolytica and e. dispar , with a geographic distribution mainly in developing countries . e. moshkowskii has been frequently detected in individuals from developed and highly industrialized countries . particularly in regard to this species we are at the beginning of the study of its pathogenic potential and the context in which it is expressed and the epidemiologic significance of infection and its contribution to morbidity rates of diarrheic diseases .", "what doses of cysts are necessary for colonization of large bowel mucosa ? for the three entamoeba species this is not known with any certainty . moreover , we do not know which environmental characteristics are permissive for intestinal colonization , and this could be an interesting field for future research . finally , until today , the only species recognized as an etiologic agent of amoebic invasive disease is e. histolytica , which , once in the colon , undergoes excystation and the generation of trophozoites . trophozoites multiply by binary fusion and some of them may encyst and be excreted with stools . cyst viability under appropriate conditions of humidity may last as long as several weeks and thus they be available for a new susceptible host . we have to stress that more than 90% of infections have an asymptomatic course and are frequently auto - limited at different periods of time . after intestinal infection there is no evidence of induction of a long - lasting protective immune response , and in endemic areas , individuals may have several periods during the year of re - infection and clearance of infection . in relation to the susceptibility of hiv and aids patients to the invasive forms of infection , contradictory evidence exists ; however , morbidity seems to be more related to the particular prevalence of the e. histolytica strain with invasive phenotypes than to the specific immunological status of the patient.[2427 ] as for the invasive behavior of e. histolytica , some authors consider this trait not to be typical . on the contrary the natural history of invasive intestinal amoebiasis is an acute event , characterized by the presence of diarrhea that occurs days or weeks after exposure in our personal experience lasting no more than four to five weeks . although there are reports of occurrence years after exposure , in this case we presume the cause and effect relationship is extremely difficult to corroborate . intestinal amoebiasis is basically an acute disease in which the most frequent symptoms are abdominal pain ( colic ) and the presence of diarrhea with mucus and/or blood , or a clear dysenteric syndrome . however , fever and other systemic symptoms are infrequent . severe forms of invasive amoebiasis can be observed in young children ( < 5 years ) , pregnant woman , the elderly , and particular those with chronic diseases , such as diabetes mellitus , and in individuals being treated with immunosuppressants or those with immunodeficiency disorders . those severe forms of amoebiasis are colon ameboma , fulminant necrotizing colitis , and toxic mega colon . the appearance of symptoms , such as severe dysentery and pain with signs of peritoneal irritation ( rebound ) , intense tenesmus , fever ( > 38c ) , tachycardia , hypertension , nausea , and anorexia are suggestive of the previously mentioned severe forms of intestinal amoebiasis . the mortality rates of dysenteric syndrome due to e. histolytica are less than 1% , but mortality due to complications increases up to 75%.[2931 ] fortunately in the last few decades such complications are uncommon . the intestinal amoebiasis form known as chronic non - dysenteric colitis is the most frequent form of amoebiasis in people of all ages , characterized by non - specific symptoms . symptoms more relevant in this instance are periods of abdominal pain ( colic ) and auto - limited episodes of diarrhea alternating with constipation . however , both non - dysenteric amoebic colitis and irritable bowel syndrome are controversial themes in the clinical practice . where endoscopy examination is available , colonoscopy can be of great help in clinical diagnosis of invasive intestinal amoebiasis . this procedure allows for microscopic examination of samples taken directly from the characteristic flask - shaped ulcer produced by e. histolytica and from other sites of mucosal lesions . microscopic observations of this type of material are described in the diagnostics section and in figure 2 . on the other hand , colonoscopy detects the presence of lesions related to the mentioned severe forms of intestinal amoebiasis and allows for differential diagnosis of other pathologies , such as inflammatory bowel disease or colon carcinoma . d ) intestinal biopsy obtained from the edge of flask - shaped ulcer where large numbers of trophozoites ( he and pas stained , 60 ) are clearly visible . e ) biopsy obtained from the edge of amoebic liver abscess ( he and pas stained , 20 ) . notice the presence of trophozoites , hepatocytes , and the large number of inflammatory cells .", "what circumstances define the extra - intestinal invasive behavior of some e. histolytica strains ? this remains unknown today . for example , we do not know the frequency of extra - intestinal invasion after intestinal colonization with virulent e. histolytica . however , this seems to be an infrequent event as suggested by the low morbidity rates of amoebic liver abscess and other extra - intestinal forms of invasive amoebiasis compared with the prevalence rates of asymptomatic infections and intestinal disease . while amoebic liver abscess is a disease that can affect individuals of all ages , in some endemic areas the incidence rates are higher in both children under 5 years and young adults ( 2045 years ) . males are also more prone to developing amoebic hepatic abscess than females ( 1 female for 46 males ) . after exposure , 80% of patients display symptoms over a few days to 46 weeks . the most common symptoms suggestive of amoebic liver abscess are fever ( 38c ) , chills and diaphoresis , anorexia and abdominal pain in the right upper quadrant that increases during inspiration . pain also frequently radiates to shoulder and back . nausea has also been referenced but diarrhea is only occasionally mentioned ( 50% of cases ) . hepatomegaly can be detected during digital percussion of the hepatic area and is always related to the dimensions of the abscess ; patients can also display peritoneal signs ( abdominal guarding or rebound ) . absence of intestinal noises , jaundice , and pleural or pericardial rub are symptoms that should elicit alarm related to the rupture or imminence of rupture of the hepatic abscess . in general , the right hepatic lobule is the most frequently affected due to the portal circulatory system of the right colon . laboratory findings suggestive of amoebic liver abscess are the presence of leukocytosis , neutrophilia , increased globular sedimentation velocity , and high levels of alkaline phosphatase . thoracic x - ray data useful in the diagnosis of amoebic abscesses , as well as other types of hepatic abscesses , include elevation of the right hemidiaphragm , atelectasis , or pleural effusion [ figure 3a ] . ultrasound is the gold standard technique for diagnosis of amoebic liver abscess , as its positive predictive value ( ppv ) is around 95% ( 85100% depending on analyzed series ) . although contrast computed tomography ( ct scan ) [ figures 3d and 3e ] have a ppv up to 95% due to a higher definition capacity , ultrasound is considerably less expensive compared to ct scan technology , which is of tremendous importance to countries with limited medical and economic resources . ultrasound reveals hypoechoic areas that can be single or multiple with round edges [ figure 3b and 3c ] . several authors have mentioned the presence of a large single abscess as a frequent characteristic of a amoebic liver abscess . however , this characteristic is not a sine qua non of amoebic abscesses , and in our medical practice we have seen multiple abscesses more frequently than we had first assumed . early lesions due to amoebic invasion of hepatic parenchyma are multifocal in nature ( micro - abscesses ) as a consequence of tissue destruction and necrosis by proteases from e. histolytica and neutrophil recruitment to the site of infection . the advantage of ct scans and magnetic resonance is detection of small abscesses and the high definition of the images . moreover , other techniques not always available in endemic countries ( e.g. gallium scans ) can help differentiate between amoebic ( cold images ) and pyogenic abscesses ( hot images ) . thus , the difference is based on the absence ( amoebic ) or presence ( pyogenic ) of white blood cells in the abscess . additionally , we have to mention that in endemic countries the frequency of mixed abscesses ( pyogenic and amoebic ) is considerable ; in our practice this frequency is approximately 17% ( non - reported data ) . another important fact in medical practice is the coincidence of previous symptoms with the presence of high levels of serum anti - amoebic antibodies more than 90% of amoebic liver abscess patients develop this type of antibody response . however , in cases of fast development of amoebic abscess these antibodies may not be present . a ) thoracic x - ray of a patient with amoebic liver abscess showing the elevation of the right hemi - diaphragm . ultrasound images of : b ) single large amoebic abscess and c ) three amoebic hepatic abscesses . d ) contrasted computed tomography ( ct ) scan of a single abscess and e ) three clear amoebic liver abscesses", "etiological diagnosis of intestinal parasitic diseases has been mainly performed using direct or concentration techniques for microscopic examination of fecal specimens . while technically simple in approach , these techniques require the expertise of highly qualified technicians in the morphological identification of ova , cysts , and helminths to be feasible , and the sensitivity and specificity is no more than 80% . while this technique can not differentiate between the three entamoeba species already mentioned , in some endemic communities this is the only diagnostic technology available . on the other hand , during the last 10 years diagnostics in amoebiasis have changed dramatically , considerably improving sensitivity and specificity . some of the current techniques are based on immunological strategies , such as elisa and different modalities of polymerase chain reaction ( pcr ) , with clear advantages in bedside diagnosis and in clinical laboratories of health institutions . even though some of these diagnosis procedures are also suitable for large epidemiologic trials , it is mandatory to make a careful selection of the diagnosis test when the test has to be applied in the field . in particular , the election has to be directed to those procedures that do not need special conditions for sample preservation or pretreatment of specimens in the working field . in our experience , immunologically based diagnostics tests for detection of anti - amoebic secretory antibodies in feces or detection of intestinal amoebic antigens through polyclonal or monoclonal specific antibodies ( elisa ) are excellent tests in hospitals where fresh specimens ( feces ) can be obtained . results are reproducible and reliable . in contrast , in epidemiological trials , these techniques can be biased when samples are more than 18 hours old . tables 1 and 2 have a list of diagnostic tests that have proven to be useful in clinical and laboratory diagnosis of intestinal and extra - intestinal amoebiasis in first and second level health institutions . microscopy and immunoassays for e. histolytica detection pcr assays for e. histolytica and/or e. dispar detection", "the who / paho recommendations published in 1997 contain in detail the actions that who country members have to observe with regard to e. histolytica species infection . they highlight the characterization ( when possible ) of e. histolytica and e. dispar ( we now add e. moshkowskii ) to be treated properly . in accordance with the who recommendation only e. histolytica it is also important to remember that in some endemic countries , mixed infections ( e.g. e. histolytica and e. dispar ) are frequent , and that only those infected with e. dispar should be excluded for anti - amoebic treatment . table 3 shows treatment schedules that have proven to be highly effective in both intestinal and extra - intestinal invasive amoebiasis . in cases of large amoebic abscesses in which imminence of rupture or distances of less than 1 cm between the abscess wall and liver surface prevail , ultrasound - guided puncture is indicated . the procedure allows for the establishment of a differential diagnosis with other liver pathologies , especially pyogenic liver abscess , which is common in clinical practice . treatment of amoebiasis disease in our experience , patients with amoebic liver abscess may not excrete e. histolytica / e . however , some of these patients are asymptomatic cyst passers after treatment with systemic anti - amoebic drugs , such as metronidazole . in such cases , treatment has to include luminal anti - amoebic drugs . at present , evidence of low susceptibility or resistant strains of either e. histolytica or e. dispar species to metronidazole", "gastrointestinal infections are responsible for morbidity and mortality rates of children and young adults worldwide . in africa , diarrhea is responsible for 2575% of all childhood illnesses . infection and intestinal diseases with icd10 code a00-a09 are the second cause of disease in children under 10 years old in mexico , and intestinal amoebiasis ranks with some annual variations 5 and 6 in the list of the 20 major causes of disease in mexico ( http://www.dgepi.salud.gob.mx/anuario/index.html # ) . causes of diarrhea in endemic areas include a large variety of enteropathogens ( viruses , bacteria , and parasites ) . in mexico , parasitic intestinal infections are multiple infections that constitute approximately 40% of analyzed individuals in which it is possible to detect more than one pathogen together with commensal parasites that are an indicator of fecalism . prevalence of parasitic infection in three different communities in the state of morelos , mexico , are shown in \n table 4 , one of which is a strictly rural population ( amacuzac ) and two ( tlaltizapan and xoxocotla ) are suburban communities . the relevance of these results lies in the high frequency of mixed parasitic infections detected in the studied populations . a remarkable low prevalence of soil - transmitted helminthiasis was also observed and could be the consequence of a biannual anti - parasitic treatment of school children with albendazole . this policy was implemented by the health ministry since the 1990s . however , there are emerging parasites with an increasing prevalence in the last 10 years , including blastocystis hominis and in some areas cryptosporidium spp . in south africa intestinal mixed infection is present in 46% of patients with diarrhea and 33% in school children . furthermore , mixed intestinal infections due to bacteria , parasites , and viral pathogens are the major forms of intestinal infection in developing countries . however , cheun et al recently published a splendid study on diarrheal patients in hospitals in korea . the study documented the presence of enteropathogenic bacteria , parasites , and viruses in mixed infections , and highlighted the importance of diarrheal disease associated with protozoan infections . the major association of e. histolytica positive samples was with rotavirus type 1[10.3(6.114.6 ) positivity/100 infected individuals , 95% ci ] , astrovirus [ 9.3(5.213.4 ) positivity/100 infected individuals , 95% ci ] , pathogenic escherichia coli [ 7.2 ( 3610.0 ) positivity/100 infected individuals , 95% ci ] and clostridium perfringens [ 10.3(6.014.6 ) positivity/100 infected individuals , 95% ci ] . as the authors mentioned , the question is whether mixed infections with protozoa are more likely to induce serious diarrhea . prevalence rates of parasite intestinal infections in morelos , mexico efforts in the near future have to be directed on studies focusing the interactions of microorganism in the intestinal environment . this knowledge will have a positive impact in clinical and laboratory diagnosis of diarrheic syndrome , its treatment , and thereafter the implementation of more reliable control schedules ." ]

[ "engaging in high levels of physical activity is a key strategy for successful maintenance of weight loss . a study of nearly 4,000 participants in the national weight control registry ( nwcr ) , the largest longitudinal study of successful weight loss maintainers , indicated participants expend 2,621 2,252 kcal per week through physical activity , which is equivalent to approximately 60 minutes of moderate - intensity physical activity per day . additionally , long - term followup of participants in behavioral weight loss programs has shown that those who are most successful at maintaining their weight loss report activity levels similar to those of nwcr participants [ 3 , 4 ] . many individuals , particularly those who are obese , are insufficiently active , and increasing physical activity can be a challenge [ 5 , 6 ] . thus , strategies that assist individuals in adopting and sustaining high levels of physical activity to help facilitate a healthy body weight are needed . prior studies have identified multiple strategies for increasing physical activity adoption and maintenance , such as providing home or clinic - based exercise programs , increasing access to active behaviors ( e.g. , adding exercise equipment in the home ) , and reducing access to sedentary behaviors ( e.g. , limiting time to watch television ) , using pedometers to track activity and progress toward physical activity goals , and accumulating exercise throughout the day in multiple short bouts ( 10 min ) [ 11 , 12 ] . performing a variety of different types of activities may be another strategy to increase physical activity levels . the national health and nutrition examination survey ( nhanes ) showed that individuals who reported engaging in a variety of different activities ( i.e. , walking + other leisure - time activities ) were more likely to meet national physical activity recommendations compared to those who reported no variety ( i.e. , only walking ) . likewise , in an 18-month behavioral weight loss intervention , overweight participants who reported physical activity variety ( i.e. , 2 different activities ) at 6 months had higher self - reported activity - related energy expenditure and a lower body mass index ( bmi ) at 18 months than those who did not report physical activity variety ( i.e. , only 1 activity ) . thus , while the above findings suggest that physical activity variety may contribute to higher physical activity levels within the context of behavioral weight loss treatment , it is unclear whether physical activity variety is associated with higher physical activity in individuals who have achieved long - term success in controlling their body weight . in the current study , we examined the relationship between physical activity variety , defined as the number of different types of self - reported moderate - to - vigorous activities performed in one week , and minutes spent in objectively measured moderate - to - vigorous physical activity ( mvpa ) in two groups of individuals who have successfully maintained their body weight long - term : ( 1 ) weight loss maintainers with previous history of overweight / obesity and ( 2 ) normal - weight individuals without a history of overweight . normal - weight participants were included as a comparison group given that weight loss maintainers represent a unique group of individuals who report strict adherence to multiple behavioral strategies in order to maintain their body weight . due to their unique characteristics and history , it is possible that the association between physical activity variety and mvpa could be different for weight loss maintainers and normal - weight individuals . however , based on previous research showing a relationship between physical activity variety and higher physical activity levels across diverse groups and settings [ 14 , 15 ] , we predicted that engagement in a greater variety of moderate - to - vigorous activities would be associated with higher mvpa daily minutes in both the weight loss maintainer and normal - weight groups .", "participants were enrollees in the cross - sectional lite study that compared weight control behaviors of weight loss maintainers and normal - weight controls . a convenience sample of men and women was recruited through advertisements placed in national and local publications intended for a general audience . persons interested in participating were asked to either call a toll - free number or to visit a website . participants were recruited from across the united states , although most were from new england , california , and the washington , dc area . weight loss maintainers had a history of overweight or obesity ( bmi 25 ) but were currently normal weight ( bmi = 18.524.9 ) , having maintained a 10% loss of their lifetime maximum body weight for at least 5 years . normal - weight participants had a current bmi between 18.5 and 24.9 and no history of overweight or obesity . participants in both groups were weight stable ( 10 lb ) for at least 2 years prior to enrollment . of 813 individuals who responded to advertisements and a brief online screening tool , the study protocol was approved by the miriam hospital institutional review board , providence , ri , usa . participants reported information about age , gender , marital status , ethnicity / race , type of employment , and education . weight and weight history were assessed via self - report methods that have been previously validated . questions on the paffenbarger physical activity questionnaire regarding average number of city blocks walked per day , and weekly frequency and duration of sports and recreational activities performed were used to determine variety or number of different activities performed during the past 7 days . only activities that were performed at a moderate or vigorous intensity and for 10 minutes in duration were included given that engagement in these activities is considered necessary for improving health and achieving a healthy body weight [ 1 , 12 ] . the intensity of sports and recreational activities was determined using the paffenbarger coding scheme . for walking to be counted as an activity , participants had to report walking the equivalent of at least 12 blocks per day ( i.e. , 1 mile at a moderate intensity ) . treadmill walking reported as a sports and recreational activity was not distinguished as a separate activity from walking 12 blocks / day . climbing stair flights , walking < 12 blocks / day , and sports and recreational activities that were performed for < 10 minutes were not considered to contribute to variety . monrovia , ca , usa ) was used to objectively measure daily minutes spent in mvpa . this device converts accelerations or movements from vertical , horizontal , and anterior - posterior planes into counts , with greater magnitude or intensity of acceleration over a given time period generating a higher number of counts . participants were sent the device in a postage - paid envelope with instructions on how to activate the device and wear it on their waistband during all waking hours for 7 consecutive days , except while bathing or swimming . each device was programmed with the participant 's personal data ( sex , age , height , and weight ) and set to capture movements continuously in 1-minute intervals . the rt3 has shown to be a strong predictor of oxygen consumption during sedentary and treadmill activities [ 20 , 21 ] and a more precise measure of physical activity at the group level compared to its tri - trac predecessor . consistent with previously documented methods for analyzing rt3 data , a minimum of 4 days on which the device was worn for 10 hours each day was required for data to be considered valid [ 23 , 24 ] . rt3 nonwear times , defined as periods of 30 consecutive minutes of zero counts ( permitting intervals of up to 2 consecutive minutes registering 1100 counts / min ) , were deleted from analysis . the remaining time was partitioned according to intensity level . based on previous rt3 validation research and a recent study that used the rt3 to compare mvpa patterns in weight loss maintainers , normal - weight , and obese groups , we computed time spent in mvpa using a threshold of 984 counts / min . descriptive statistics are presented in tables as means sd for continuous measures and percentages for categorical responses . chi independent t - tests were conducted to assess differences between the groups on demographic characteristics , weight , accelerometer daily wear time , mvpa minutes / day , and reported variety / number of different types of moderate - to - vigorous activities performed . linear regression was used to examine the associations of physical activity variety and group status ( weight loss maintainers versus normal weight ) with objectively measured mvpa minutes / day , adjusting for age , gender , years of education , marital status , bmi , and accelerometer daily wear time . logistic regression was used to assess whether physical activity variety and group status were associated with achieving the 250 mvpa minutes / week recommendation for optimal long - term weight maintenance . for this analysis , mvpa minutes / week was calculated by multiplying average daily mvpa minutes by 7 ( days ) .", "of 413 participants who were sent an accelerometer and the ppaq , 394 ( 95% ) met valid accelerometer wear requirements and provided complete data on the ppaq . the characteristics of these 226 weight loss maintainers and 169 normal - weight participants are presented in table 1 . both groups were similar in age ( 48.8 12.9 years ) , gender ( 84% female ) , marital status ( 66% married ) , race / ethnicity ( 94% caucasian ) , employment status ( 82% employed ) , and job type ( 95% in professional or clerical positions ) . a greater proportion of normal - weight participants was college educated , compared to the weight loss maintainers . both groups were normal weight , although the weight loss maintainers had a slightly higher bmi . on average , weight loss maintainers had lost nearly 29 kg and maintained 10% weight loss for 13.7 9.6 years . there were no differences in accelerometer wear time between the groups , with the weight loss maintainers and normal - weight participants wearing the accelerometer for an average of 14.8 2.0 hours / day on 7.5 0.9 days . as reported previously , weight loss maintainers spent an average of 6 minutes more per day in mvpa , compared to normal - weight participants ( 58 versus 52 min / d ) . the variety / number of different activities performed by the weight loss maintainers and normal - weight participants was similar ( 1.8 1.2 versus 1.7 1.2 , p = 0.52 ) . additionally , when participants who reported no moderate - to - vigorous activities were excluded , the variety / number of activities performed by wlm ( n = 180 ) and nw ( n = 141 ) remained similar ( 2.2 1.0 versus 2.0 1.0 , p = 0.10 ) . we next examined the independent and joint associations of physical activity variety and group status with mvpa minutes per day . given that the physical activity variety group status interaction was not significant ( p = 0.73 ) , the results of the main effects linear regression model for mvpa minutes per day are shown ( table 2 ) . greater physical activity variety ( p < 0.001 ) and weight loss maintainer status ( p < 0.05 ) were independently related to greater daily time spent in mvpa , after adjustment for demographic characteristics ( age , gender , educational level , marital status , current bmi ) and daily accelerometer wear time . figure 1 presents estimated mvpa minutes per day in the weight loss maintainer and normal - weight groups by reported number of different moderate - to - vigorous activities performed . across both groups combined , the number of moderate - to - vigorous activities ranged from 0 to 4 , with 73 participants ( 18.5% ) reporting 0 activities , 105 reporting 1 activity ( 26.6% ) , 112 ( 28.4% ) reporting 2 activities , 74 reporting 3 activities ( 18.7% ) , and 30 ( 15.4% ) reporting 4 or more activities . each 1 unit increase in the number of different moderate - to - vigorous activities performed was associated with an additional 9.4 1.3 daily minutes spent in mvpa , representing an additional 56.2 8.3 kcal expended per day based on rt3-derived estimates . similarly , logistic regression analyses showed that greater physical activity variety ( or = 1.78 [ 1.372.30 ] , p < 0.001 ) , weight loss maintainer status ( or = 0.23 [ 0.080.69 ] , p = 0.002 ) , and lower bmi ( or = 0.81 [ 0.690.95 ] , p = 0.01 ) were independently associated with meeting the 250 mvpa minutes / week guideline for optimal weight maintenance . the physical activityvariety group status interaction was not significant ( p = 0.25 ) .", "given the continuing obesity epidemic and growing evidence that indicates greater amounts of physical activity are needed for successful long - term weight control , it is important to identify strategies that can assist individuals in adopting and maintaining high levels of physical activity . this study examined whether performing a greater variety of different types of moderate - to - vigorous physical activities was related to greater time spent in mvpa among weight loss maintainers and normal - weight individuals without a history of overweight / obesity . we found that , independent of group , greater variety was associated with higher daily mvpa minutes and meeting the 250 mvpa minutes per week recommendation for optimal long - term weight maintenance . these findings are consistent with previous studies of the general population and in overweight / obese individuals undergoing behavioral weight loss treatment . however , the present study is the first to show a relationship between greater physical activity variety and higher objectively measured mvpa duration and energy expenditure in two groups of individuals who have had long - term success in maintaining a normal body weight . we found that for each additional different type of moderate - to - vigorous activity performed , participants on average spent an additional 9 minutes in mvpa and expended 56 more kcal per day . thus , for example , participants who reported engaging in 3 different activities during the previous week spent on average an additional 18 minutes in mvpa and expended 112 more calories per day compared to participants who reported engaging in only 1 activity . while our findings do not imply causation , they do warrant additional longitudinal research to examine whether incorporating variety into a physical activity routine may be an efficacious strategy to achieve higher mvpa levels for enhanced weight control . the relationship between greater physical activity variety and engagement in higher mvpa levels may be potentially explained by a number of physiological and psychological factors . for example , alternating different physical activities that involve different muscle groups and energy systems ( aerobic , anaerobic ) might promote greater exercise consistency by affording more time for recovery and decreasing risk of overuse injuries [ 13 , 26 ] . participating in a variety of activities may also facilitate greater exercise adherence via increased enjoyment and decreased boredom [ 13 , 26 ] . greater access to a variety of activities may increase the likelihood that individuals will find an exercise activity or a combination of exercise activities that they like and will perform regularly . additionally , research based on the behavioral economics model suggests that motivation to exercise is enhanced when individuals can choose from a variety of physical activities versus only one physical activity [ 28 , 29 ] . consequently , adding a variety component to a physical activity prescription may aid individuals in achieving and maintaining high levels of physical activity . future research is needed to investigate potential mechanisms that underlie the relationship between variety and higher mvpa levels . whereas increased variety of healthy physical activities is associated with greater time spent in mvpa , it is also possible that decreased variety of unhealthy sedentary activities might contribute to lesser time spent being sedentary and higher overall physical activity levels . given that sedentary behaviors , independent of physical activity , have shown to be detrimentally associated with bmi and other cardiometabolic risk factors [ 30 , 31 ] , future studies that examine the association between variety and sedentary behaviors are needed . the cross - sectional nature of our study does not allow us to determine whether greater variety contributes to higher mvpa levels or alternatively whether individuals with higher mvpa levels naturally incorporate more variety into their physical activity routine . as variety in physical activity is rarely measured , the importance of factors such as the time frame for assessing variety ( i.e. , a week , month , year ) and frequency of occurrence of different activities within the time frame ( i.e. , once a week , twice a month ) are not known . while the use of an objective measure of physical activity is a strength of this investigation , it is important to note that hip - worn accelerometers like the rt3 used in this study may be limited in their ability to accurately estimate the intensity of activities not performed on flat surfaces . thus , it is possible that mvpa was underestimated in individuals who more frequently engaged in activities that involved an incline or greater upper body movement . additionally , the accelerometer count threshold we used to identify mvpa was determined in a leaner , younger male sample and thus may have affected validity in our older , largely female sample . given the homogeneity of our sample with respect to gender ( female ) and race ( white non - hispanic ) , our results may not be generalizable to men or other ethnic populations . similarly , participants in this study were all normal weight and had high physical activity levels on average . thus , future investigations should examine the potential importance of variety for increasing physical activity in overweight and inactive populations . finally , it is important to note that just as altering the variety of different types of activities performed could potentially increase mvpa duration and energy expenditure , so could altering the frequency , intensity , and duration of a single activity , independent of changes in physical activity variety . in summary , this study examined the relationship between physical activity variety and objectively measured mvpa levels in weight loss maintainers and normal - weight individuals who both had long - term success in maintaining their body weight . in both groups , physical activity variety was related to greater engagement in mvpa and likelihood of accumulating 250 mvpa minutes / week , consistent with physical activity guidelines for optimal long - term weight maintenance . future studies are needed to test whether incorporating variety or different types of activities ( e.g. , walking and cycling ) can facilitate engagement in higher levels of mvpa within interventions aimed at promoting and maintaining physical activity ." ]

[ "recently \n we reported on an analysis of the infrared spectrum of \n c2f4 . by observation \n of many combination and difference bands , including many from two c - containing isotopologues , and by comparison with mp2 and \n density - functional calculations , all 12 fundamentals could be assigned , \n although only five are ir active . the geometry \n was deduced from ro - vibrational analysis of strong ir active bands \n and by comparison with theoretical calculations . however , it is also \n instructive to correlate anharmonic constants with some peculiarities \n of the reactions of c2f4 . accordingly , in this \n work more anharmonic constants ( altogether 54 ) are derived from the \n spectra , and a complete set ( 78 ) is calculated . the earlier vibrational \n assignments of c2f4 were reported at a time \n when the unusual properties of this molecule were barely known . explained this property by positing that the electron attraction \n of fluorine leads to a preference of sp- over sp - type carbon : radical addition converts both \n c atoms from sp to sp hybridization , which \n stabilizes the primary product , lowers the transition state , and thus \n accelerates the reaction . alder reactions , for example , \n which was again explained by stabilization of radical intermediates . ( borden also presented an alternative but related description based \n on delocalization of unpaired radicalic electrons to accepting * \n orbitals of cf groups . ) the preference \n for carbon sp hybridization can also be expected to lower \n the force constants for the pyramidalization ( wagging ) vibrations \n ( 7 , 8 ) and/or increase their anharmonicity . \n furthermore , torsion ( 4 ) should be facilitated by \n rehybridization and in fact quantum chemistry confirmed this for a \n 90 twist . another spectacular property of c2f4 is how \n readily it can dissociate thermally to two cf2 molecules . a c = c bond energy of only 2.95 ev is derived , less than that of a typical c c single \n bond ( 4 ev ) . the low dissociation energy is caused by stabilization \n of the resulting two difluorocarbenes by back - bonding from nonbonding \n fluorine electrons to the empty carbon p - orbital . this also explains why cf2 has a singlet \n ground state which is more stable than the triplet ( by 2.458 ev , taken \n from the band origin of the phosphorescence spectrum ) . whereas in the previous work , only cc stretching is considered \n as the dissociation coordinate , it was argued in ref ( 16 ) that pyramidalization \n must also be involved . this idea is supported in the present work \n by the large value found for the anharmonic constant x18 coupling cc stretch with trans pyramidalization . the \n magnitude of x18 as compared to the much \n smaller x17 ( coupling cc stretch with \n cis pyramidalization ) also supports a valence - bond analysis of weak \n double bonds , which was reviewed in ref ( 19 ) .", "the samples in natural isotopic abundance were either taken from \n commercial c2f4 ( hoechst ) , that contained a \n trace of the cyclic dimer , or prepared from c2f4br2 + zn in a high - boiling \n alcohol ( diethylene glycol ) ; the comparison allowed for recognizing \n absorptions of impurities . a sample enriched in c to \n 50% was prepared from chclf2 by co2 laser isotope \n separation with enriched cf2 as the primary product . ir spectra of c2f4 in natural isotopic \n abundance \n and isotopically enriched were recorded between 370 and 4000 cm with 0.2 cm resolution by a perkinelmer \n ftir spectrometer in garching . at the \n synchrotron lab , the isotopically enriched sample was measured at \n moderate 0.1 cm resolution in the far ir region \n from 100 to 600 cm ( capturing the band at 210 \n cm ) , and at high resolution for the ir active \n cf stretch bands , see ref ( 1 ) . the present work focuses on anharmonic constants of c2f4 . only where the constants were \n expected to be different for ccf4 and c2f4 ( e.g. , in the case of \n fermi resonance ) theoretical values of the anharmonic constants xij were obtained from anharmonic \n vibrational \n frequency calculations performed using gaussian 03 revision c02 at the mp2 level using \n dunning - type correlation - consistent ( cc - pvtz ) orbitals . the molecular force field at this level of theory \n was shown in the previous study to reproduce the fundamental wavenumbers \n and the isotopic shifts of c2f4 very satisfactorily \n ( for details , see ref ( 1 ) ) , and hence was an appropriate choice for computing xij values . the calculations were performed for each of \n the c2f4 , ccf4 , and c2f4 isotopologues .", "the spectra were measured previously and the \n fundamentals extracted \n from them , using a limited number of anharmonic constants ( from combination \n and hot bands ) where necessary . for convenience \n table 1 lists the fundamentals again . in this \n work we derived a large set of experimental anharmonic constants from \n combination bands and in particular for the lower - wavenumber \n vibrations from hot bands , and report a complete set of theoretically \n computed values . symmetry types refer to a d2h molecule with z axis along the cc bond and the y axis perpendicular \n to the plane , as used in ref ( 1 ) for easier comparison with the c2v symmetric ccf4 ; the more conventional designation with x axis along the cc bond and z axis perpendicular \n to the plane is given in parentheses . revised value ( instead of 210 cm ) , based on a more definite \n assignment of a hot - band structure and x10,10 , see supporting information . band origins from high - resolution \n spectra ; low - resolution values are 1338.4 \n and 1187.0 . upright : \n experimental values . \n in parentheses : values calculated by mp2/pvtz . where two values or \n a range are given for the experimental data , it may indicate ( a ) a \n dependence of the effective xij on the involved levels due to perturbations ( fermi resonances , \n section 4.4 ) or ( b ) an uncertainty due to error \n limits ( e.g. , where broad bands are involved ) or an uncertain assignment . \n a preferred value is indicated by bold face . for further details on \n the derivation of each xij and some isotopic data , the anharmonic constants xij were calculated from observed \n combination and difference bands \n by assuming that anharmonic shifts are additive : for binary combination \n bands ( i j ) and for overtones \n we used1and2with obvious extensions for more complicated \n combinations . ( the xij values are mostly negative , as usual . ) the left - hand side of these \n equations should be read as wavenumber of ( name ) . for hot bands ( satellite transitions near i that originate from a thermally populated \n lower level j ) we used3again \n with obvious extensions . one can often \n observe sequences of equidistant q branches , corresponding to hot \n bands starting from higher levels mj , or combination of such sequences ( from mj + nk ) . equation 3 implies that the distance of a ( first ) hot band from the fundamental \n directly indicates the corresponding anharmonic constant . combination \n bands allow for a direct assignment , whereas hot bands must be identified \n by their intensity ( controlled by the boltzmann factor ) . in a number \n of cases the supporting information ( si ) compiles the sources for each xij in table s2 , whereas table s1 lists the observed \n bands ( with hot bands ) and their isotopic shifts . two examples of \n hot bands , whose shifts are dominated by the large x18 anharmonicity , are shown in figure 1 . absorbance spectra demonstrating the large x18 derived shifts for hot - bands originating in 8 . the spectra were recorded \n in the garching laboratory , with pressure and path length of 2 bar \n and 10 cm ( for the lower trace of each panel ) , and 140 mbar and 4 \n m ( upper trace ) , respectively . for levels involving more than two quanta of vibration , anharmonic \n shifts this helped to decide between different \n assignments of combination bands in a few cases where the harmonic \n sums were similar to each other . however , such additivity need not \n apply when the levels involved are subject to fermi resonance , producing \n shifts that depend on the separation of nearby interacting levels . \n we use eqs 13 to \n obtain the experimental values , and hence , table 2 reports phenomenological xij , some of which show a spread in the values suggestive of fermi \n resonances ( in particular x18 , x26 , and x77 ) . fermi \n resonances can also be recognized if the apparent xij or the hot - band structure depends \n on the isotopologue . for c2f4 , fermi resonances \n were identified ( see section 4.4 and si ) between:5 and 2+6 ( discussed already in ref ( 1)),1 and 5+6 ( indicated by the hot - band structure \n of 1-combinations , which are different in the mixed \n isotopologue),2 and 27 ( causing irregularities \n in overtone levels of 7 , also contributing to the \n large magnitude of x27 and x77).2 and 23 , identified from the \n mp2 calculations . 5 and 2+6 ( discussed already in ref ( 1 ) ) , 1 and 5+6 ( indicated by the hot - band structure \n of 1-combinations , which are different in the mixed \n isotopologue ) , 2 and 27 ( causing irregularities \n in overtone levels of 7 , also contributing to the \n large magnitude of x27 and x77 ) . 2 and 23 , identified from the \n mp2 calculations . the mp2/cc - pvtz calculations \n reproduced the observed wavenumbers \n and isotopic shifts very well . supporting \n the overall vibrational analysis exceptions are 15 ( x22 , x28 , x29 , x2,10 , x2,11 , x36 , x3,10 , x45 , x59 , x5,11 , x66 , x68 , x77 , x88 , x10,11 ) out of 54 cases where an observed value is available \n for comparison . some of these will be discussed below .", "as already \n described in the introduction , the peculiar \n reactions of c2f4 have to do \n with cc stretching and carbon pyramidalization . the discussion will \n focus on these coordinates ( sections 4.14.3 ) . for \n a planar geometry , \n cc dissociation correlates c2h4 and c2f4 with a pair of carbenes in their lowest triplet states ( figure 2a ) . because \n the energy of forming these products is practically the same for the \n two molecules , one could also expect that the potential energy curves \n coincide and the cc stretch force constants are equal . in fact , already \n early force - field calculations showed no substantial difference ( 889 \n n / m for c2f4 and \n 940 furthermore , \n the short cc distance ( 132 pm , which is 1 pm shorter than in ethylene ) and the high cc stretch wavenumber ( 1873.8 cm , compared to 1625.4 cm for ethylene ) do not point to a weakened bond . \n as early as 1965 , the low dissociation energy of c2f4 was attributed to switching over to a channel producing two \n singlet carbenes and to the stabilization ( by 2.458 ev , see introduction ) of singlet cf2 by back bonding , so that this channel is energetically favored by 4.9 ev . this path hence leads over an avoided \n crossing of potential surfaces ( figure 2a ) . \n if the avoidance is strong , one could expect an influence at least \n on the anharmonicity x11 ( 1 is dominated by cc stretching ) , even if not on the force \n constant at the bottom of the potential energy well . table 2 shows that the magnitude of x11 ( calculated 7.8 cm ) is not unusually \n large for such a high - frequency vibration , though noticeably larger \n than for ethylene ( x22 = 2.3 cm ) . that the increase \n in magnitude is only moderate can be taken as a sign that the avoidance \n along this coordinate is not very strong . hence , the back reaction \n ( recombination ) will have a high barrier in planar geometry . whereas \n the measured recombination barrier is not , in fact , zero , it is only \n minor ( 9 kj / mol = 0.09 ev ) . so , \n a lower - energy path must lead around the barrier , out of the drawing \n plane of figure 2a , that is , with distortion \n different from cc stretch . potentials for ground - state cc dissociation \n of c2f4 , leading over an avoided crossing to \n two singlet carbenes . \n in ( a ) it is assumed that the one - sided pyramidalization ( q7 + q8 ) begins only after overcoming the barrier , whereas \n ( b ) shows the preferred path , where this distortion is already fully \n developed on the barrier and is preceded by a trans pyramidalization \n ( q8 ) , while the cc distance is steadily increasing . it was argued in ref ( 16 ) that recombination of \n two cf2 molecules should \n be easiest if one of them points with its filled n orbital \n to the empty p orbital of the other . hence , the dissociation \n path will change from pure cc stretch to include also pyramidalization \n ( figure 2b ) , and the potential should be lowered \n in energy in the direction of q7 ( the coordinate of 7 ) and/or q8 . in turn in fact x18 has an unusually large magnitude , although x17 is in the normal range ( table 2 ) . ( the magnitude of x18 is not \n caused by secondary effects such as fermi resonance , as we shall see \n in section 4.4.3 . ) we can conclude that on \n stretching the cc bond the molecule first bends toward trans pyramidalization \n ( q8 ) ( figure 2b ) . the one - sided \n nonplanar bending ( figure 2 ) is a superposition \n of q7 and q8 . the reason why q8 is \n active earlier than q7 can be understood by a valence - bond \n model for weak double bonds . in this model several symmetric arrangements \n of carbenes ( a c \n of scheme 2 ) were considered : whereas with \n two triplet carbenes all arrangements ( a d ) lead to bonding \n interaction , with two singlet carbenes bonding occurs only in the \n trans - bent case ( c ) ; this corresponds to a double donor one can add that the cis - bent case with singlet carbenes would \n lead only to antibonding ( scheme 2d ) . malrieu \n and trinquier derived a criterion for trans - bending ( deriving even \n the angle ) by comparing the standard double - bond energy with the singlet their findings were confirmed by many examples , in particular with \n heavier - element homologues . we can apply \n this rule not only to the equilibrium geometry of c2f4 but also to its dissociation path , if we consider in the \n comparison the double - bond energy that is reduced on extension of \n this bond . the rule thus predicts that on cc extension c2f4 is distorted from planar geometry to a trans - bent structure , \n and this rationalizes the large magnitude of x18 . in the triplet case , the interaction \n can be bonding in all arrangements . in the singlet case , ( a ) is antibonding , \n ( b ) nonbonding , ( c ) bonding , ( d ) antibonding . more recently , borisov et al . found evidence \n for trans pyramidalization \n on extension of the cc bond also from molecular orbital calculation \n ( at high level : mller plesset perturbation theory of \n second , third and fourth order ) : the \n authors found that the onset is relatively sudden on cc extension \n to 142 pm and that the distortion lowers the energy appreciably . ( the \n large x18 anharmonicity is an indication \n that this pyramidalization already begins not far from the s0 minimum . in fact , a cc stretch by 10 pm from 132 to 142 pm is \n just about the vibrational amplitude in the 1 = \n 1 level . ) although borisov et al . did not find an energy minimum with \n such a distortion , they suggested that it plays a crucial role in \n the low - energy real intermediate found by buravtsev , kolbanovskii \n et al . in thermal reactions of c2f4 and recombination \n of cf2 ( see ref ( 31 ) and literature quoted therein and section 4.3 ) . one could suppose that in order to lower the activation \n energy \n for dissociation the only necessary deviation from simple cc stretching \n is distortion toward the 8 coordinate ( q8 ) . however , there is experimental \n evidence that the asymmetric pyramidalization ( corresponding to superposition \n of q7 and q8 as in figure 2b ) is already crucial in the transition state : the pre - exponential \n factor found in the rate of thermal c2f4 dissociation \n ( 2.8 10 s ) is clearly larger than would be typical for \n a simple bond splitting ( 10 s ) . this \n corresponds to a raised entropy of activation , such as that which \n happens if an additional degree of freedom is activated in the transition \n state . the most plausible candidate is free internal rotation , as \n it can be expected in the asymmetric structure with a single dative \n bond but not in symmetric geometry with double donor acceptor \n bond . this picture is also consistent with a stepwise cleavage of \n the double donator acceptor bond on c2f4 dissociation and its stepwise formation on cf2 recombination . it is worth noting that the molecule with one - sided pyramidalization \n has an electron distribution ( figure 2b ) that \n is zwitterionic and correlates in planar geometry with the 2ag state with two electrons excited to * , as \n already pointed out in ref ( 16 ) . a fully analogous dissociation path can also be \n expected for the \n other systems considered by malrieu and trinquier . in fact , according \n to ref ( 32 ) ground - state \n ( ir induced ) dissociation of diazomethane ( h2cnn ) follows \n a path with a pyramidalized methylene group to produce n2 + singlet ch2 ; the out - of - plane deformation was experimentally \n confirmed . in the backward reaction , n2 points with its \n n electron pair to the empty p orbital of the singlet \n methylene ( see refs ( 32 and 33 ) for a calculated potential in two dimensions , which would look similar \n for c2f4 ) . hence , \n the out - of - plane deformation on dissociation of c2f4 is not an isolated phenomenon . applying \n their energetic criterion to the equilibrium geometry of c2f4 , trinquier and malrieu found that this molecule is \n not far from the limit , where it would become nonplanar , and suggested \n that the 8 force constant may be significantly lower \n than that of ethylene . this is in fact \n confirmed in the following way : analytical expressions for a valence \n force field model for planar x2y4 were given \n by herzberg . besides the masses mx and my , bond lengths l1 ( for xx ) and l2 ( xy ) and the angle ( half of yxy ) , both 7 and 8 only depend on the force constant for pyramidalization \n ( k/l2 ) . with equilibrium distances and angles from ref ( 1 ) and i = ( 2ci ) one derives this force constant from \n 7 and 8 ( with identical results \n for c2f4 and c2f4):4both values should be identical \n in this valence - force field model . in fact for ethylene , the value \n is 22.9 n / m , whether derived from 7 or 8 . the pyramidalization force constant \n derived from 7 of c2f4 is \n slightly higher than in ethylene ( by 17% ) , but the same quantity derived \n from 8 is only 49% of the ethylene value . ( of course , \n these values are not quantitatively meaningful , as the discrepancy \n highlights that a pure valence - force field model is not sufficient \n for wagging of c2f4 . ) so in fact the restoring \n force for the 8 vibration is significantly smaller \n than in ethylene and than that expected on the basis of the same pyramidalization \n force constant as for 7 . this is consistent with \n the prediction of the valence - bond model favoring the trans - bent geometry . the slightly raised force constant for 7 could \n be due to repulsive nonbonding interaction in cis pyramidalization . \n such a geometry would be involved in the hypothetical transition state \n of the diels alder addition of c2f4 to \n butadiene , a reaction that has not been observed . it was argued that \n an increased energy associated with this distortion might contribute \n to inhibiting the reaction . however , an \n increase in the force constant of only 17% is hardly sufficient to \n support this explanation , and the other effects discussed in ref ( 7 ) , in particular the competing \n fast radical reactions , are probably more important . applying \n again the force - field formulas of herzberg , the force constant for torsion , k/l2 , is found to be 30.3 \n n / m for both ethylene and tetrafluoroethylene . that is , near the potential \n minimum the c = c bond in c2f4 behaves \n just like a normal double bond . consequently , the torsional barrier \n at a 90 twist ( which is a measure of the bond strength ) \n would be identical for both molecules ( 2.8 ev ) if the two c cf2 groups remained planar ; this was confirmed by a high - level \n calculation . however , pyramidalization \n lowers this barrier by 0.57 ev ( at mp2 level , consistent with ref ( 35 ) ) . if this stabilization is activated early along q4 , \n it could give rise to substantially negative values for x44 and especially for x47 and x48 . however , x44 and x47 are actually slightly positive \n ( 0.8 and 0.3 cm ) and x48 has no unusual magnitude ( 0.7 to 1.05 cm ) . evidently , the stabilizing effect of pyramidalization becomes \n effective only at high torsional angles . the corresponding values \n for ethylene are 2.4 , 8.9 , and 7.2 cm , respectively . the nondiagonal anharmonicities xi4 and x4j are \n generally smaller in magnitude than in ethylene . but this may simply \n have to do with the relative vibrational amplitudes , which are much \n larger for torsion of ch2 than of cf2 due to \n the relative masses . in the twisted - pyramidalized structure \n of c2f4 , the triplet ( t1 ) is only \n 0.013 ev lower than the singlet \n ( s0 ) . it \n can therefore act as a real intermediate and undergo radical - type \n reactions , further assisted by its low energy that is calculated at \n 2.1 ev . this has been a widespread interpretation \n of some peculiarities of c2f4 reactions ( see , \n for example ref ( 7 ) ) . however , buravtsev , kolbanovskii et al . found in shock - tube experiments \n ( with c2f4 diluted by ar and adiabatically compressed ) \n an intermediate at much lower energy ( 0.8 to 1 ev ) with uv and visible \n absorption ( 235 and 500 nm ) ( see refs ( 31,36 , and 37 ) and the \n literature quoted there ) . they supposed it to be a singlet diradicaloid \n of c2f4 with a geometry corresponding not to \n an energy minimum but to a point on a slope of the potential ( see , \n for example ref ( 31 ) ) . however , as these points are not stationary there are too many \n ( nearly ) isoenergetic locations with shifted electronic transitions , \n so that the electronic absorption would be smeared out . it was therefore \n suggested that the observed intermediate \n is another low - energy isomer , tetrafluoro - ethylidene cf3cf ( electronic absorption in an ar matrix : ) . however , its energy ( 1.9 ev ) seems to be nearly as high as that of the twisted - pyramidalized \n triplet . ( in one study the twisted - pyramidalized c2f4 triplet is calculated at 0.90 ev , but computational details are not given , and previous theoretical \n results are not discussed . ) some more anharmonicities of table 1 have unusually large magnitudes or show a range \n of values and/or deviate from prediction . in many of them fermi resonances \n play a role , as will be explained here . in section4.4.3 , however , it is shown that x18 is hardly influenced by such effects and its large magnitude mainly \n results from the overall shape of the potential energy surface . fermi resonances mix two nearby levels of the \n same symmetry , which differ by three units in the quantum numbers . \n the fermi - induced \n repulsion of the levels depends in a nonlinear way on both the magnitude \n of the fermi interaction parameter and on the original ( i.e. , unperturbed ) \n energetic distance of the levels . this separation will , in general , \n change ( a ) on isotopic substitution and ( b ) on adding a quantum of \n another vibration ( i.e. , in analogous combination bands ; similarly \n also in higher overtones , in which case a quantum number dependence \n must also be taken into account ) . another method of characterizing fermi resonance interactions relies \n on intensity borrowing caused by the mixing of levels . according \n to the mp2 calculations , the great majority of xij change by 1 cm on isotopic substitution the few exceptions are \n listed in table 3 and are compared to experimental \n values . identified ( fr13 ) and the interpretation in the line influenced by \n is based on the assumption that an xij is affected by such a resonance if at least one \n of the levels i and j is involved in the fermi interaction . the table shows that \n the calculated isotopic shift is sometimes \n much larger than in the experiment , for instance x26 , x27 . also x56 for c2f4 is probably \n too large , as the two observed bands 5+6+11 and 5+6+12 are close to their harmonic positions \n ( table s1 in si ) . it seems that at the \n present level of theory , the calculation does not reliably reproduce \n the fermi resonance induced shifts , at least the stronger ones . this \n is not surprising given the highly sensitive and nonlinear dependence \n of fermi shift on the unperturbed level separations . \n the same deficiency will also affect those xij connected with at least one level ( or a \n combination thereof ) involved in a resonance listed above ( examples \n in figure 3a ) . in fact , 10 of the 15 deviations \n listed at the end of section 3 can be attributed \n in this way to the resonances fr1 and fr2 with possible contributions \n of fr3 . the exceptions are x36 , x3,10 , x66 , x68 , and x88 . in \n all 42 other cases it is worthwhile to consider \n the two strongest fermi resonances , \n fr1 ( 2/27 ) and fr2 ( 5/2+6 ) , in c2f4 in some detail . the effect of these resonances \n is summarized in figure 3 . some levels involved \n in fermi resonances and observed transitions . \n solid arrows : ir , broken arrows : raman ; double arrows ( with interaction matrix element ) indicate repulsion \n between level pairs . the anharmonic shifts involving x77 are only nominal , because the fermi perturbation is \n strong : 6x77 = 18.1 is \n less than 3 times (= 8.2 ) and 4x77 is only \n 9.9 . ( but 2x77 + 4x77 = 6x77 , as is obvious from the level scheme , and the raman \n anharmonic shifts practically coincide with those from the ir spectra . ) \n ( b ) three - level fermi resonance 5/2+6/27+6 and \n their combinations with 9 for c2f4 and c2f4 . \n the indicated level energies are from the spectra except those in \n parentheses , which are calculated . the broken horizontal lines are \n the estimated unperturbed positions ( see the si ) , and the signed numbers are the calculated shifts . the 16.4 cm magnitude of the interaction term ( with its expected dependence \n on quantum numbers ) has been derived \n from band shifts and intensities for a series of levels built on 2/27 for all three isotopologues . bands for \n 27+x ( x = 9 , 11 ) borrow their entire intensity from 2+x . the detailed analysis \n is provided in si . it \n is also evident that x77 , x27 and x22 are affected by \n the fermi resonance ( and probably other x2i , if the level separations differ ) and that x77 is level dependent because of the varying \n separation . the fermi term is almost entirely responsible for the \n + 8.2 cm shift of 27 for c2f4 and those of the heavier isotopologues \n ( table 3 under fr1 ) . in the latter the fermi - induced \n shift is increased , because the levels 2 and 27 ( before perturbation ) are closer together than in c2f4 and are practically degenerate in c2f4 . the success of these calculations \n shows that the additional mixing of 2 with 23 ( fr3 ) is apparently a weak perturbation at most . the \n fermi resonance fr2 between 5 and 2+6 was qualitatively discussed in ref ( 1 ) . a more complete understanding \n of the resonance shifts and pattern of intensity borrowing requires \n the three - level scheme shown in figure 3b ; \n this figure also shows combinations with 9 , as they \n are all ir active and were directly observed . analysis based on this \n model has enabled the magnitude of the fermi term to be determined \n as 11 cm ; the fr1 term of 16.4 cm was used without change . significantly , the model predicts varying \n fr shifts that even differ in sign ( originating from the different \n repulsions in figure 3b ) and can thus account \n for the unusual isotopic shifts observed between c2f4 and c2f4 . \n it explains a substantial deviation of the observed isotopic shift \n 5 = 51.9 from the value of 5 = 43.1 \n expected from the teller redlich product rule , which is valid \n for harmonic oscillators . additionally \n the relative intensities of combination bands and their isotopic dependence \n are well predicted . it is also remarkable that according to the model \n the largest part of the anharmonicity x26 is due to fermi resonance . as described in ref ( 1 ) , the lower symmetry in ccf4 leads to strong mixing of 5 with 9 ( which are nearly degenerate in c2f4 ) . the two levels repel each other \n ( even in the harmonic approximation ) and give rise to two infrared - active \n transitions . it is sometimes difficult to disentangle them and their \n combination bands from the spectra . if the large magnitude of some \n anharmonicities is caused by fermi resonance , a crucial question is \n whether this might also be the case for x18 . if so , the conspicuous value of x18 could be largely a matter of the character of the resonance and \n less a consequence of global features of the potential for dissociation , \n which we considered in section 4.1 . in fact , \n weak perturbations of the 1 level and its combinations \n by the 1/5+6 fermi resonance are indicated by the slight x18 dependence on the level and on isotopic substitution and \n the change of the hot - band structure of 1 combinations \n in ccf4 , as explained in the si . a quantitative estimate of the strength \n of the 1/5+6 interaction can be deduced from the intensities of 5+6 combinations relative to those of the corresponding \n 1 combinations , assuming that the former borrow \n their full strength from the latter . the 5+6+12 band ( 2444.3 cm ) \n has 12% the strength of the 1+12 band ( 2428.7 cm ) , see figure 1a . similarly , the 5+6+11 shoulder ( 3072 cm ) is < 1% as intense as 1+11 ( 3056.2 cm ) and clearly visible only with longer \n path length than shown in figure 1b . from both \n observations , one can estimate a fermi term ( w ) of \n no more than 2.5 cm , causing a shift ( and \n consequent change in x18 ) of < 0.5 cm . this is actually an upper bound , because such weak \n bands can also be expected without intensity borrowing . hence , fermi \n resonance affects the magnitude of x18 only by a little ( by < 3% ) , and we can maintain the conclusions \n of section 4.1 on the shape of the potential .", "a large set of anharmonic \n constants of c2f4 was derived from spectroscopic \n data , and a complete set was calculated . \n most of the calculated and experimental values agree very well , and \n nearly all deviations can be attributed to fermi resonances . the values \n were used to interpret peculiarities of the potential and reactions \n of this molecule . the facile thermal cc dissociation of c2f4 is due to curve crossing of the ground state \n ( 1ag ) with \n the two - electron excited zwitterionic 2ag state . the crossing \n barely alters the properties of the potential curve ( cut purely as \n a function of cc stretch ) near the equilibrium geometry ; the force \n constant for cc stretching ( 1 in c2f4 , 2 in c2h4 ) is nearly \n identical for the two molecules . only a slightly larger magnitude \n of the anharmonicity x11 compared to the \n corresponding x22 of ethylene provides \n a hint of a weakly avoided crossing in planar geometry of c2f4 . however , the large magnitude of x18 leads us to conclude that the dissociation path bends \n early toward \n q8 , i.e. to trans pyramidalization of the two carbon atoms \n ( figure 2b ) . this is rationalized by a valence - bond \n model , which describes the stretched cc bond as a double donor acceptor \n bond ( scheme 2c ) . it is also consistent with \n the tendency of fluorine to induce sp hybridization at \n carbon , although this preference alone would also allow cis pyramidalization , \n q7 , which is not involved early in dissociation . on further \n cc stretching , one of the two donor acceptor bonds breaks , \n and the pyramidalization becomes fully one - sided already in the transition \n state ( figure 2b ) . in this way , free internal \n rotation of the cf2 groups becomes possible , providing \n an additional degree of freedom that rationalizes the high pre - exponential \n factor in the rate constant of dissociation . this structure with perpendicular \n arrangement of the two cf2 groups appears very plausible \n for the back reaction . thus , one cf2 group approaches with \n its filled n orbital the empty p orbital of the other \n cf2 group ( figure 2b ) . the easy \n trans pyramidalization on minor cc stretching is probably also the \n reason that the corresponding 8 force constant is \n lowered , although all other force constants are similar to those in \n ethylene . the preference of fluorine for sp hybridization \n at \n carbon has been invoked to explain not only the easy radical addition \n and other reactions , but also the low - lying , twisted - pyramidalized \n triplet , which is nearly isoenergetic with the singlet that has a \n saddle point there . this is indicated by x44 , x47 , and x48 , which have no unusual values . very recently , \n high - level theoretical studies investigated \n electronic ground and excited states of c2f4 and their dependence on some coordinates , mainly \n to discover the fate of this molecule after electronic excitation \n and make comparisons with a corresponding time - resolved experiment \n ( ref ( 16 ) ) . for the \n ground state , the stabilizing effect of pyramidalization in the twisted \n molecule was confirmed . interestingly , the excited molecule enters \n the s1/s0 conical intersection from the 2ag state , where the molecule has a large one - sided pyramidalization , \n a 90 cc twist and a cc bond length ( 1.51 ) similar to \n that of a single bond . in the present work , the transition state for \n s0 dissociation was said to result from avoided crossing \n of the 2ag and 1ag ( i.e. , s0 ) states , \n also with large one - sided pyramidalization but at longer cc distances \n and perhaps without twist . it would be interesting to check whether \n these geometrical differences are large enough to generate an excited - state \n barrier , because evidence was found in ref ( 16 ) that cc dissociation does not begin in the excited \n state ." ]

[ "cytomegalovirus ( cmv ) is one of the most common congenital viral infections in many regions . in the united states it occurs in 0.51% of live births , or approximately 40,000 infants annually . the manifestations of cmv infection cover a broad spectrum ranging from asymptomatic to severe systemic disease resulting in significant morbidity and mortality . 90% of infants with congenital cmv are asymptomatic at birth . despite being asymptomatic at birth , up to 7% of these children will develop sensorineural hearing loss ( snhl ) that can be unilateral or bilateral , fluctuating or progressive , and range from mild to profound [ 2 , 3 ] . approximately 10% of infants with congenital cmv are symptomatic at birth , and 40% of these patients will develop snhl [ 1 , 2 ] . hearing loss is the most common manifestation of congenital cmv infection making cmv a leading cause of nonhereditary congenital hearing loss . given the relatively large number of children potentially affected by cmv - related hearing loss and the wide range of manifestations of congenital cmv infection , it is difficult to predict how a child with symptomatic cmv will perform with a cochlear implant ( ci ) . previous studies suggest that children with symptomatic cmv derive auditory benefit from cis , albeit at a slower rate than other children . the degree to which these children benefit remains somewhat controversial as there is variation in the development of language skills after ci [ 59 ] . the objective of our study was to examine the relationships between intracranial radiographic abnormalities and preimplantation developmental assessment ( including head circumference ) with postimplant audiometric and language outcomes in children with symptomatic congenital cmv who have undergone cochlear implantation .", "this study was a retrospective review of children with a diagnosis of symptomatic congenital cmv who underwent cochlear implantation between 2004 and 2010 at a tertiary pediatric cochlear implant center . congenital cmv was diagnosed for most children via urine culture of the virus during the first two weeks of life . diagnosis was also made based on the identification of hearing loss coupled with brain image findings . medical charts of these patients were reviewed for pre- and postimplantation evaluations and central nervous system imaging findings . data regarding preimplantation developmental assessments included the diagnoses of developmental delay and/or other disabilities , nonverbal intelligence quotients or developmental quotients ( iq / dq ) , and head circumference ( hc ) at the preoperative visit . results from computed tomography ( ct ) and/or magnetic resonance imaging ( mri ) scans of the brain were reviewed , and the findings were classified by type and location of anomaly . postimplant audiometric behavioral testing , which was performed using validated and developmentally appropriate testing techniques , was collected . this data included frequency - specific thresholds and speech awareness or speech reception thresholds ( sat / srt ) . pure tone averages ( pta ) were calculated by an average of 4 frequencies ( 0.5 , 1.0 , 2.0 , and 4.0 khz ) . children 's developmental disability diagnoses were classified according to the areas of cognition , motor , vision , and language . cognitive disability was diagnosed using nonverbal cognitive measures such as the leiter international performance scale and supported by evaluating adaptive functioning with the vineland adaptive behavior scale . these evaluations were completed by psychologists with knowledge of testing deaf / hard of hearing children . if the nonverbal iq was not available , a nonverbal developmental quotient was used . this nonverbal or adaptive quotient was obtained from a developmental pediatrician with expertise in hearing loss as a part of the precochlear implant assessment . for this study , the diagnosis of cerebral palsy ( cp ) was made based on neurologic examination , patterns of persistent primitive reflexes , abnormalities in tone and reflexes , and presence of abnormalities on mri of the brain . the diagnosis of pervasive developmental disorder not otherwise specified was made by interdisciplinary evaluations with speech pathology and psychology using standardized measures to evaluate autism spectrum disorders . standardized language assessment scores , using the preschool language scale ( 4th edition ) were available on eight subjects who returned for speech therapy after implantation . this study was approved by the institutional review board at cincinnati children 's hospital medical center . data distributions were reported using medians with ranges ( for continuous data ) and frequencies with percentages ( for categorical data ) . characteristic differences between children with hc < 5th percentile and > 5th percentile were tested using wilcoxon rank sums test for continuous data and chi - square or fisher 's exact test for categorical data . biserial correlations were conducted to understand the association between presence and location of brain abnormalities with audiometric and language outcomes . the wilcoxon rank sums test was also used to explore statistical differences regarding factors ( e.g. , iq / dq ) that may be associated with presence and location of brain abnormalities . due to the small sample size , exact p values are reported .", "\n table 1 lists the fifteen cmv - positive children ( 9 females and 6 males ) who received a ci during the study timeframe . two additional subjects with cmv were excluded from this analysis : one subject had not returned for any postimplant visits and one child had normal cns imaging ( thought not to be symptomatic cmv ) . the median age at time of identification of hearing loss was 5 months ( range 162 months ) , and the median age at implantation was 28 months ( range 1296 months ) ( table 2 ) . the median iq / dq for the study population was 65 ( range 2390 ) ; 9 ( 60% ) children had an iq / dq < 70 . seventy - three percent ( n = 11 ) of children had a diagnosis of cognitive impairment and 13 children ( 87% ) had a motor delay or disability ; 9 had a diagnosis of cp . over half ( 60% , n = 9 ) of these children carried a diagnosis of more than one developmental disability and nearly half ( 47% , n = 7 ) had both a cognitive disability , and cp . seven children ( 47% ) had a head circumference ( hc ) less than the fifth percentile ( table 2 ) . children with a hc < 5th percentile had a significantly lower median iq / dq than children with a hc 5th percentile ( 42 versus 77 , p = 0.003 ) . all children with hc < 5th percentile had cognitive disabilities compared to only 50% of children with a hc 5th percentile . additionally , the children with a hc < 5th percentile had slightly poorer postimplant pta ( 38 db versus 27 db , p = 0.02 ) and sat / srt ( 30 db versus 23 db , p = 0.04 ) compared to children with larger heads . all children included in the study had central nervous system abnormalities present on imaging studies ( table 3 ) . twelve children had mri imaging ( all with identified abnormalities ) and 13 ct imaging of the brain with identified abnormalities . eighty percent ( n = 12 ) had calcifications , which occurred most frequently ( 53% ) in the periventricular region ( table 4 ) . additional imaging findings included ventriculomegaly in 53% , migrational abnormalities in 33% ( n = 5 ) , and encephalomalacia in 27% . all four children with encephalomalacia and all 3 children with cerebellar abnormalities had a diagnosis of cp . in addition to cp , 3 of the 4 children with encephalomalacia and all 3 children with cerebellar abnormalities also had a cognitive disability diagnosis . in fact , the children with cerebellar abnormalities had a lower nonverbal iq / dq than children without cerebellar abnormalities ( 35 ( range 2350 ) versus 68 ( range 2790 ) , p = 0.048 ) . calcifications in the temporal lobes were associated with poorer post - ci pta ( biserial correlation rb = 0.57 , p = 0.04 ) . the median ( range ) receptive language score was 21 ( 327 ) , and expressive language score was 28 ( 1777 ) . the iq / dq was highly correlated with both receptive ( spearman rho = 0.9 , p = 0.002 ) and expressive ( spearman rho = 0.86 , p = 0.007 ) , as having a head circumference < 5th percentile ( point biserial correlation rb = 0.75 and 0.68 resp . ) . periventricular calcifications were associated with lower receptive language ( rb = 0.75 , p = 0.03 ) and expressive language ( rb = 0.84 , p = 0.008 ) among children with post - ci assessments . because the iq / dq was associated with both periventricular calcifications ( rb = 0.53 , p = 0.04 ) and hc < 5th percentile ( rb = 0.73 , p = 0.002 ) , the relationship between these factors and language appears to be , at least in part , driven by iq / dq scores .", "one of the challenges in children with congenital cmv is predicting the sequelae they will develop and the extent of neurological and developmental deficits they will incur . previous studies have shown that brain imaging may be a good predictor of adverse neurodevelopmental outcomes . in one study of children with symptomatic congenital cmv , 90% of the children with an abnormal ct scan developed at least one sequela compared to 29% of those with a normal scan . greater than two - thirds of all children with congenital cmv had mri abnormalities and , of these , cortical malformations , ventriculomegaly and hippocampal dysplasia correlated highly with poor neurologic outcome . found that microcephaly was the most specific predictor , and abnormality on head ct was the most sensitive predictor of poor cognitive outcomes in this patient population . in a study of children with a diagnosis of snhl , 80% of the cmv positive children had abnormal brain mri scans compared with only 33% of cmv negative children . children with calcifications had a slightly poorer median post - ci pta compared to children without calcifications . interestingly , the location of the abnormalities also seemed to correlate with worse language outcomes . the parietal lobe processes sensory information and houses our language abilities , and the temporal lobe regulates emotion , hearing , language , and learning , which could explain why language outcomes are poorer in children with abnormalities in these regions . children with cerebellar anomalies also had lower receptive and expressive language levels than the other children . although the cerebellum has been largely thought to control balance , there may be other aspects of learning and development which depend on this entry point of sensory information to the higher cortical areas . the authors have implicated the cerebellum to be involved in temporal processing , language production and comprehension , spatial reasoning , and visual attention [ 1821 ] . in our 3 patients with cerebellar lesions , it is not clear if it is the location of the lesions in the cerebellum or the severe cognitive delay that resulted in worse outcomes . with only 3 patients , it is not possible to draw additional conclusions regarding cause and effect in this group . in addition to looking at the associations between cns imaging findings and post - ci outcomes , our study also looked for correlations between preimplantation developmental assessment and cochlear implant performance in these patients . although there is a relative paucity of relevant studies in the literature , previous studies have demonstrated that children with cognitive delay seem to derive benefit from ci , albeit at a slower rate than nondelayed children [ 22 , 23 ] . although children with cochlear implants who have more significant developmental delay have poorer outcomes than children with only mild delay , the biggest predictor of language development among children with implants and disabilities is a measure of nonverbal cognitive ability . unfortunately , when compared to appropriately matched developmentally delayed children without hearing impairment , children with cis had lower receptive and expressive language skills , which were not commensurate with their cognitive potential . although children with multiple handicaps may progress slower and to a lesser extent than typically developing children , these children still derive benefit from the auditory stimulation provided by a ci but may require additional post - ci intervention to optimize benefit [ 2729 ] . as we found in our study , the majority of children with symptomatic congenital cmv have associated developmental disabilities . the variability of neurocognitive deficits in these children warrants the examination of this group separately from other children with developmental disabilities . as with children with developmental disabilities , children with symptomatic congenital cmv appear to derive benefit from ci albeit at a slower rate . ramirez inscoe and nikolopoulos demonstrated mixed results for speech perception and intelligibility with 50% of children with congenital cmv performing more poorly than controls , 31% performing similarly , and 19% performing better than controls . these children did , however , derive auditory benefit from ci . in their study of 13 children with symptomatic congenital cmv , 73% of implanted children achieved closed - set word recognition , and 63% achieved open - set word recognition . children with congenital cmv have also demonstrated both improved pure - tone hearing thresholds and improved language perception and production as well as useful speech comprehension albeit lower than matched controls . another study of 11 children with congenital cmv found that 9 of the 11 carried a diagnosis of psycho - neurological disorders ( including attention deficit hyperactivity disorder , mental retardation , autism , and pervasive developmental disorder ) . although hearing thresholds were similar among children in this group , post - ci performance varied widely depending upon the concomitant diagnosis . our findings were consistent with these previous studies in that our patients did demonstrate overall improvement in post - ci thresholds . our results indicate that head size was significantly related to iq / dq and that children with microcephaly ( hc < 5th percentile ) were more likely to have cognitive disabilities than those without microcephaly . the microcephalic children also had significantly poorer post - ci pta and sat / srt as well as worse receptive language . these findings indicate that microcephalic children do not achieve the same degree of auditory benefit as the children with normal head size . the mean age at last audiometric followup did vary between the microcephalic and nonmicrocephalic groups ( 46 versus 59 months ) . this difference would not be expected to affect the results of audiometric testing as all testing was performed using developmentally appropriate behavioral methods that should account for the difference in age . given that the majority of the children ( 73% ) had developmental delay and nearly half were considered multiply handicapped , it is notable that head circumference was a better predictor of post - ci outcome than specific developmental delay diagnosis . this is not entirely surprising as head circumference relates to brain growth , which can impact developmental outcomes .", "although our study has limitations including its retrospective nature and small sample size , it provides data that may further efforts to identify factors which may help predict which children with congenital symptomatic cmv will benefit from ci . the presence of cerebellar anomalies or greater than one cns abnormality on imaging correlates with poorer outcomes after ci . the location of cns abnormalities , including calcifications , may play a role in audiometric and language outcomes after ci . early measurements such as brain imaging findings , head circumference , and iq / dq may allow for more accurate counseling of families regarding anticipated postimplantation performance in children with symptomatic congenital cmv ." ]

[ ". there have been significant achievements regarding to the millennium development goals ( mdgs ) as a global development target . the indicators showed reflection of these achievements , such as decreasing global poverty rate , increasing the number of children going to school , decreasing child death rate , increasing access to clean water , and also increasing malaria , hiv / aids , and tuberculosis control investment . mdgs were evaluated in the year 2015 , and there will be remaining new challenges to sustain the achievement at post-2015 era . numerous important issues have been raised by united nation ( un ) , which are poverty and hunger elimination , improving health and education , sustainable cities , combating climate changes , and also ocean and forest conservation . in mdgs , hiv / aids , malaria , and major diseases are clearly mentioned as global development goals . in this case , there will be plenty of diseases that are not a major concern of the world . questions were raised concerning neglected tropical disease ( ntd ) which is definitely out of the highlight . will these diseases be included in the ambitious post - mdgs sustainable development ? the new sustainable development goals ( sdgs ) , known also as the global goals , had been established after world leaders gathered on 25 september 2015 , at the united nations in new york to adopt the 2030 agenda for sustainable development and the broader and further agenda than the mdgs . mdg explicitly stated that hiv / aids , malaria , and tuberculosis will be efficiently controlled at the end of the year 2015 . the big three are the diseases that attract priority from sponsors , researchers , and policy makers [ 2 , 3 ] . this situation is not the same as ntd , which has not gained any priority from them and even worsened . the term of neglected in ntd referred to the fact that these tropical diseases are not being considered as important diseases . ntd result in long life 's deformities and handicaps , decrease productivity and economical status , and also end up many social consequences and stigmatization . though ntd is commonly found in tropical countries , it is not identical with tropical diseases . poverty as one of ntd determinants frequently occurs in rural area , slums , and marginalized populations living nearby the equator . ntd in this area are closely associated with poverty and limited resources , such as clean drinking water access , poor sanitation , and healthy housing . ntd may decrease child health , increase the health expenses and risk of ineffective treatment , decrease productivity , and result in education default . their potential to spread in developed countries is low , because ntd are closely related with local vector and intermediate host distribution which are specifically associated with geographic region . the technology and resource to control , prevent , and eliminate ntd are available , but not for the developing countries . who has included 17 diseases caused by bacteria , virus , and protozoa into ntd ( figure 1 ) . helminths caused diseases that dominated ntd : taeniasis , dracunculiasis , echinococcosis , trematodiasis , filariasis , onchocerciasis , schistosomiasis , and soil - transmitted helminthiasis . the ministry of health of indonesia reported only five ntd that can be found in indonesia , that is , leprosy , filariasis , schistosomiasis , soil - transmitted helminth , and yaws . however , this review describes more than those five diseases and aims to address the magnitude of the problem of ntd in indonesia .", "leprosy is an infectious disease is caused by mycobacterium leprae , a road shaped bacteria classified in the same genus as mycobacterium tuberculosis leprosy may be complicated with deformity and handicap , which may decrease the ability of the patient to work in daily life . leprosy was a serious problem in indonesia at 1980 , with 126,221 cases in 1985 . it was noted that the significant improvement in leprosy control was because of massive promotion of leprosy prevention and multidrug therapy ( mdt ) intervention in more than 5,600 primary health centers in indonesia . however , the new leprosy case finding in 2000 was not significantly different with year 2013 ( table 1 ) . fourteen provinces and 160 districts , which mostly are located in java island , reported prevalence of > 1 per 10,000 population in 2009 . leprosy epidemical indicators were significant , such as deformity grade 2 10.5% , leprosy cases in children 12.01% , and 82.43% multibacillary ( mb ) cases [ 10 , 1315 ] . the problems of leprosy in indonesia are summarized as follows : early detection.development of more effective treatment.development of more effective vaccine.understanding immunopathogenesis of peripheral nerve damage.management of chronic erythema nodosum leprosum ( enl).deformity and stigmatization.deformity and stigmatization are serious problems among leprosy patients in indonesia . survey conducted in subang district ( west java ) ; gresik and malang district ( east java ) ; bone and gowa district ( south sulawesi ) showed that deformity in leprosy patients occurred in 76.7% of patients . almost 60% respondents were experienced handicaps during their life , including participating to social activity . mdt has significant impact to decrease leprosy prevalence globally . however , there are various substantial operational and technical problems among countries and territory . resistance of m. leprae is a serious problem because of limited effective antimicrobes for leprosy . resistance against dapsone , that was applied as monotherapy , was initially reported in 1964 at malaysia . since then , resistance to dapsone and other drugs was reported . theoretically , combination of more than two drugs with different action mechanism will reduce the probability of resistant in mycobacteria . national surveillance of m. leprae resistance against mdt should be established to provide accurate data . sporadic and partial reports were not sufficient to measure the problems and establish the programs to reduce the prevalence and spread of resistance against mdt . phenotypic testing is the basic method for susceptibility testing of antimicrobial agents . even in the new proof of concept which combines the classical growth - based phenotypic test and dna based approach , pure culture of bacteria efforts were documented to culture m. leprae in artificial media and animal models [ 24 , 25 ] . mutations in the folp1 , rpob , and gyra genes are responsible for resistance to dapsone , rifampicin , and ofloxacin , respectively . to test the susceptibility of m. leprae against particular antibiotics , screening in north maluku and north sulawesi showed that resistance to dapsone occurs as 0.8% in new cases and 10% in relapse cases , while rifampicin occurs with 3.3% in new cases and 20% in relapse cases . there is higher prevalence of dapsone and rifampicin resistance among relapse cases comparing with new cases . it was noted that the incidence of resistance against dapsone and rifampicin in indonesia almost did not change between the time monotherapy was introduced and after mdt was recommended by who [ 29 , 30 ] .", "yaws is a treponema pallidum subspecies pertenue infection , which may develop as chronic and recurrent disease . yaws is nonsexually transmitted treponemal infection , which is latent and asymptomatic for years with positive serology result . small portion ( 10% ) of the patients will undergo bone destruction leading to deformities . diagnosis of yaws is commonly based on the clinical findings and serology [ 31 , 32 ] . confirmatory diagnosis of yaws is using serological test , which includes nontreponemal agglutination tests , such as rapid plasma reagin ( rpr ) and venereal disease research laboratory ( vdrl ) test , and also treponemal tests such as treponema pallidum hemagglutination assay ( tpha ) , treponema pallidum particle agglutination tppa , and fluorescent treponemal antibody - absorption ( fta - abs ) . the accuracy of yaws serological test is hampered in the area which syphilis , caused by t. pallidum subspecies pallidum , is endemically circulated . yaws was reported in 68 ( 14% ) of 497 districts in indonesia , mostly in the eastern part of indonesia . east nusa tenggara province reported 2,800 cases in 2012 , which is scattered at 566 small islands in this region . however , it gradually decreases to 5,319 cases in 2011 and 3,476 in 2012 [ 10 , 34 ] . there are several obstacles to eradicate yaws in indonesia : geographically the yaws patients are in a remote area including rural and small islands which are not easy to handle , difficulty to give benzathine penicillin for children , and also local political condition that is somehow counterproductive to the programs . who planned to eradicate yaws globally in 2020 with adoption of morges strategies . this program intends to introduce a mass treatment in the endemic regions by using azithromycin . however , benzathine penicillin can be used as back up in case of azithromycin is not indicated , treatment failure , or in places where azithromycin is not available . this treatment followed an active survey every six months to detect and treat the remaining cases [ 32 , 34 ] . the ministry of health launched yaws eradication program , aimed to eradicate yaws in 2013 , one year later than who target . there were several approaches conducted , such as active screening new cases and contacts , empowering community , improving the capacity of health worker to diagnose and manage yaws , and intersectoral collaboration approaches . access to health service is limited in the yaws endemic area , which obstacle the passive screening program . reported a survey among health workers in primary health center , elementary school teachers , and parents in muna , southeast sulawesi . they were asked about yaws to measure their knowledge about sign and symptoms , causative agent , and therapy for yaws . another report from southwest sumba showed clean water and healthy behavior is the risk factor for yaws . these reports showed that comprehensive intervention is needed to boost the community participation for yaws eradication . reporting system for yaws incidence is very important to support the best intervention for yaws eradication . learning the fact that their knowledge about yaws is remarkably low , it may diminish the validity of yaws reporting system . insufficiency of this sector may result in delay of yaws eradication and increasing yaws contact population . yaws eradication problem in indonesia is summarized as follows : early detection by health workers.geographical problem of endemic area.surveillances and reporting system.inadequate confirmatory laboratory test .", "dengue virus consists of four serotypes : denv1 , denv2 , denv3 , and denv4 . these viruses are responsible for infectious diseases with width spectrum of clinical manifestation : dengue fever ( df ) , dengue hemorrhagic fever ( dhf ) , and dengue shock syndrome ( dss ) [ 38 , 39 ] . dengue virus infection is an arbovirus disease , which in indonesia is primarily transmitted by aedes aegypti and aedes albopictus . the incidence of dhf significantly increased since reported initially in 1968 ( 0.05/100.000 ) to 3540/100,000 in 2013 . however , in 2010 , there was an extreme surge of dhf incidence to 86/100,000 . the significant increasing of dhf incidence was parallel with decreasing of case fatality rate ( cfr ) , which is 41% in 1968 to 0.73% in 2013 . however , it was noticed that from 1999 there was a trend of shifting to adults . dhf incidence described here is believed not to be able to draw a clear picture of all denv infections . . however , the proportion of those three clinical manifestations still becomes an enigma , although the awareness to the diseases , surveillance programs , diagnostic tools , and management of denv infection in indonesia have been significantly improved . it has been realized that controlling adult mosquitoes is prone to fail reducing denv transmission . the vector control approach should aim to interrupt the transmission cycle at an early phase through immature mosquito control , which is including larvae and pupae stages . immature mosquitoes control is believed to be more effective . the vector control approach is still considered effective while vaccine and prophylaxis remedies continuously develop . it seems that the socioecological approach is the best candidate to be implemented in an endemic country , such as indonesia . community and intersectoral approach are significantly important fundamentals of integrated public health strategies for dengue vector control [ 47 , 48 ] . as dengue infection has wide spectrum of clinical manifestation , the clinical diagnosis is confusing . there are guidelines issued by who to respond to the need of applicable tool for clinician : who classification system and dengue and control study ( denco ) revised clinical management . the study concerning the two guidelines showed that in surabaya , indonesia , the denco revised clinical management guideline superior in detection of severe dengue cases . however , in a study in semarang , indonesia , the denco guideline has failed to show its superiority . it is true that the denco guideline needs to be adjusted in terms of geographic and age - related variations issues . there are many factors that may be related with clinical manifestation of dengue virus infection , including human genetics involvement which is still controversially related with population , race , and geography [ 54 , 55 ] . several methods are available for laboratory test confirmation of denv infection : virus isolation , genome detection , antigen detection , and antibody detection . the first three methods are direct detection methods which were considered as more specific and able to confirm earlier onset of denv infection . the antibody detection is widely used in the field because they are easy to perform and less expensive , though it is not as powerful as direct detection especially in secondary infection [ 50 , 56 ] .", "rabies is an acute , progressive , incurable viral encephalitis disease that is transmitted from animal , mainly dogs , to human . it is caused by rabies virus ( rabv ) , a member of the family rhabdoviridae , genus lyssavirus . the highest incidence is concentrated in asia and africa . despite the fact that rabies is 100% vaccine - preventable infectious disease , it potentially threatens over 3 billion people in the world . however , poor surveillance , underreporting , frequent misdiagnosis , and poor coordination among sectors may lead to underestimation of the burden of the disease . ten countries of asean have been declared rabies - free asean by 2020 in the occasion of the thirty - fourth meeting of the asean ministers on agriculture and forestry ( 34th amaf ) , on september 2012 . rabies was reported in 24 provinces out of 34 provinces in indonesia . reported human rabies in indonesia is small ( 206 cases in 2010 and significantly decreased to 119 cases in 2013 ) compared to thousands of cases reported in other countries such as india , china , and other asian countries . to control rabies transmission , indonesian government uses one health approach which facilitates the multidisciplinary participation in management of zoonosis diseases . however , kalimantan and sulawesi , other islands of indonesia , are the most plausible hypothetical origin of the bali rabv strains . totally there were 133 reported human deaths because of rabies in bali from 2008 to september 2011 . this significantly decrease of rabid human death within 3 years is a good model of rabies control for other regions or countries . it was proposed that this success is mainly because of mass vaccination program for dogs , which is the primary ( 98% ) vector of rabies in bali . however , the number of reported humans bitten by dogs remained over 4,000 per month . the preparedness to human rabies should be maintained , as the threat of human rabies escalation is still high .", "lymphatic filariasis ( lf ) is caused by worms inhabiting the lymphatics [ 6365 ] . approximately 65% of total cases are found in the southeast asian region [ 6668 ] . lf cases were found in all provinces of indonesia . in 2009 , there were 11.914 lf cases reported . the number of total cases was steadily reported until 2013 . there were 11.912 cases registered in 2013 . lf prevalence in indonesia varied from 0.5 to 27.6% , in which the highest rates were found in maluku , papua , west papua , east nusa tenggara , and north maluku provinces . three lymphatic parasites are prevalently circulating in indonesia : wuchereria bancrofti , brugia malayi , and brugia timori [ 69 , 70 ] , which are transmitted by mosquitoes of five genera the site of adult - worm parasitism is within the lymphatic vessels , most commonly involving the extremities and male genitals [ 64 , 65 , 70 ] . the disease predominantly afflicts poor people in both urban and rural areas with limited resources condition , where mosquitoes as a vector might be found in high density [ 64 , 68 ] . who launched global program to eliminate lymphatic filariasis ( gpelf ) , which relies on mass drug administration ( mda ) approach [ 68 , 71 ] . the main goal of the program is to hamper transmission of disease between mosquitoes and human beings , mainly through mass drug distribution of diethylcarbamazine ( 6 mg / kg ) or ivermectin ( 150200 g / kg ) combined with albendazole ( 400 mg ) [ 68 , 71 ] . it is recommended that all people at risk are involved in this program , since patients with asymptomatic infection may have abnormal lymphatics , and that early treatment may prevent subsequent lymphatic damage [ 66 , 69 ] . the efficacy of six annual rounds of mda was studied in alor island , eastern part of indonesia . microfilaria rates of b. timori decreased significantly after mda intervention , from 26% to 0.17% . the prevalence of filarial - specific igg4 antibodies was significantly decreased from 80% to 6% . the lf national plan has implemented mda campaigns in 2002 . however , due to financial and human resource constraints , districts often provide only partial coverage of the at - risk population within the district . in 2009 , the challenge of mda implementation in indonesia is not the efficacy of the drugs which were given to the community . it seems that the infrastructure is the key of the implementation , which includes the availability of transportation and physical access to the target population , reliable data bases , and competence health workers . the other challenge was to gain the trust from the community member to boost the compliance of drug administration . currently , mda has been scaled up in a geographically scattered way to address high prevalence areas and political needs . medical professionals , donors , universities , and ngos have played a critical role in finding new cases , assessing disease burden and supporting trainings and mda campaigns . prevention of lf depends on mosquito vectors control , which has had limited success because development of mosquitoes resistance against insecticides . urbanization of vast areas of tropical asia , including indonesia , has resulted in a concomitant rise in the prevalence of both w. bancrofti and b. malayi varieties of filariasis , carried by mosquitoes that breed in nonsylvatic habitats [ 68 , 73 ] .", "schistosomiasis is a chronic water - borne infection caused by trematodes schistosoma , mainly found in developing countries in africa , south america , the caribbean , the middle east , and asia [ 69 , 74 , 75 ] . in indonesia it is found in three isolated areas of central sulawesi province , namely , lindu , napu , and bada valleys . except for schistosoma haematobium that is responsible for urinary tract disease , the human schistosomes primarily affect the intestine and liver . clinical manifestations of the disease are recognized as fever with dysenteric symptoms and loss of appetite , as well as physical growth and cognitive delay in children [ 69 , 77 , 78 ] . disease prevalence fluctuated between 0.3% and 4.8% in napu valley and between 0.8% and 3.6% in lindu valley . however , the prevalence of schistosomiasis in both areas tended to increase during the 20082011 period . the parasite transmission cycle involved domestic and wild animals as reservoir [ 76 , 79 ] . in 2012 , who approved the goal of eliminating schistosomiasis in endemic countries . it focused on improving sanitary conditions and large - scale distribution of the antiparasitic drug , praziquantel to high - risk target groups , such as school - age children , child bearing age women , and individuals involved in frequent contact with contaminated fresh water . praziquantel is well - tolerated , associated with few side effects , and has a very high therapeutic index . moreover , a single dose praziquantel administration is usually sufficient to kill all adult worms [ 69 , 78 ] . schistosomiasis control in indonesia has faced many difficulties even though the endemic areas are very limited [ 79 , 81 ] . the core strategy of mda should be coupled with education to the local community , rat and snail surveillance , and support to the environmental management programs including introduction of latrines and suitable water sources . in the future , there should be emphasis to understand the social dynamics and social change related to schistosomiasis , which may provide more information about concrete issues to control transmission of schistosomiasis . lack of intersectoral coordination and collaboration may have occurred , possibly leading to increase transmission and reinfection rates , and be prone to control failure .", "soil - transmitted helminthiasis ( sth ) is an infection with one or more intestinal parasitic worms : roundworms ( ascaris lumbricoides ) , whipworms ( trichuris trichiura ) , or hookworms ( necator americanus and ancylostoma duodenale ) . the tropical climate of indonesia is highly favourable to support the circulation of soil - transmitted helminths in the country . there are sporadic reports regarding the prevalence of the sth which come from scattered part of the country . the prevalence of sth was reported ranging from 40 to 70% in 80s to 90s . however , the estimated prevalence of sth was decreased in 2005 : ascaris ( 15.2% ) , trichuris ( 12.9% ) , and hookworms ( 8.4% ) . the survey conducted by ministry of health in elementary schools located in 33 provinces of indonesia showed prevalence of sth was 31.8% . india ( 64% ) and indonesia ( 16% ) together are contributing 80% of the regional 's burden . drugs used for deworming , albendazole , and mebendazole are effective and inexpensive to control sth transmission and reinfection . the mda programme for elimination of lf which is implemented by using combination of albendazole with ivermectin or diethylcarbamazine seems to have synergistic effect to decrease the prevalence of sth . the program targeted preschool and elementary school age . however , until this moment the country still struggles to combat sth . in conclusion , there were efforts and programs concerning ntd that were planed and implemented in indonesia . many factors may contribute to the rendering of ntd elimination in indonesia , such as high population , wide range geographic of the archipelago , and limited resources . by the end of 2015 ntd" ]

[ "walking is one of the recommended modes of exercise for obese individuals because of its \n merits in terms of safety , accessibility , and popularity , as well as proven efficacy in \n weight management1 , 2 . however , walking over a terrain of repetitive uphill and downhill \n inclines in activities such as mountain climbing can cause excessive fatigue and muscle \n damage3 . in particular , repetitive \n eccentric contractions of the lower limb muscles during downhill walking places sarcomeres \n under excessive tensile stress . this stress can destroy sarcomeres by extending them beyond \n their normal length , sometimes involving a local inflammatory reaction , and can thereby lead \n to delayed onset muscle soreness or exercise - induced muscle damage . the indexes reflecting \n such conditions are serum creatine kinase ( ck ) and lactate dehydrogenase ( ldh ) levels4 , 5 . it \n has been reported that the use of a pole during walking over an uneven terrain could improve \n gait stability and balance , and that its use during downhill terrain walking can reduce the \n load and stress on the lower limbs ( such as the ankle , knee , and hip joints)6,7,8 . however , previous studies on the effects of \n a pole during downhill walking have been limited to the kinetic aspects such as the \n reduction of knee joint forces or the load on the lower extremity joints . meanwhile , it has been suggested that increases in peripheral cartilage oligomeric matrix \n protein ( comp ) levels after exercise could serve as a biomarker of cartilage degradation and \n damage9 , and pruksakorn et al . in addition , according to a comparative study by \n andriacchi et al . that measured the maximum flexion of the lower extremity joints during \n various routine activities , the flexion of the knee joint was approximately 4 times greater \n during walking down stairs than during walking over level ground11 . taken together , such previous reports suggest that the \n use of a pole during downhill walking may alleviate the burden on lower extremity joint \n cartilages ; however , thus far , there has been no report examining this potential \n benefit . accordingly , this study aimed to investigate the effect of the use of a trekking pole on \n muscle and cartilage damage and fatigue during downhill walking . the study specifically \n examined obese women who had less muscle mass than men and whose heavy weights were likely \n to increase the burden on their lower limb muscles and joints during walking .", "eight obese women ( average age of 21.1 1.8 years , average height of 164.8 4.9 cm , \n average weight of 61.8 7.7 kg , average body fat percentage of 33.9 1.4% , and average \n resting heart rate of 69.6 3.7 beats / min ) with body fat percentages ranging from 30.0 to \n 36.1 volunteered as subjects for this study . the study conformed to the standards set by the \n latest revision of the declaration of helsinki , and all subjects read and signed a written \n informed consent statement consistent with the guidelines of the department of physical \n education at yonsei university . height and body composition were measured using a stadiometer ( seca213 ; seca , hamburg , \n germany ) and a bioimpedance analysis ( bia ) device ( inbody720 ; biospace , seoul , korea ) , \n respectively . resting heart rate was measured in a seated position using a heart rate \n monitor ( polar a5 ; polar , kempele , finland ) . each of the eight subjects participated in a total of two trials : one np trial ( walking \n without using a trekking pole ) , and one tp trial ( walking using a trekking pole ) . with the \n treadmill angle set to a decline of 15% based on a study by perrey and fabre12 , the participants were subjected to 30 \n minutes of walking at an exercise intensity of 50% of their heart rate reserve . the \n experiment used a crossover design to minimize the adaption from the repetitive exercise \n trials , and each trial was separated by 7 days to avoid any transient effects on the \n physiological and psychological conditions of the subjects . an adjustable - length trekking \n pole ( 6342011 ; leki , hamburg , germany ) was used , and the length was initially set at 70% of \n the user s height so that the elbow angle was maintained at 90 when the user was standing \n on level ground . when the pole was used for downhill walking , its length was increased by \n approximately 5 cm . using a 22-gauge needle , a serum separator tube ( becton dickinson , franklin lakes , nj , \n usa ) , and a ethylenediamine tetra - acetic acid tube ( becton dickinson ) , 7 ml of blood was \n collected from the antecubital vein of each subject at the pre - walking baseline ( pwb ) , \n immediately after walking ( iaw ) , and 2 hours post - walking ( 2hpw ) . collected blood samples \n were centrifuged for 15 minutes at 3,000 rpm and then stored at 80 c until analysis . the \n serum ck and ldh levels were determined using a clinical chemistry analyzer ( ektachem \n dtscii ; eastman kodak , rochester , ny , usa ) . the serum comp levels were determined with an \n enzyme - linked immunosorbent assay ( elisa ) using a commercially available human \n comp elisa kit ( anamar ab , lund , sweden ) . the absorbance was measured at \n 450 nm with a microplate reader ( molecular device , palo alto , ca , usa ) . the plasma lactate \n levels were determined using a clinical chemistry analyzer ( ektachem dt 60 ; eastman kodak , \n rochester , ny , usa ) . data are presented as the mean standard deviation ( sd ) unless otherwise stated . \n for identifying differences in normally distributed results , when significant group by time interactions occurred , simple \n main effects were assessed using one - way anova and independent t - tests .", "the biomarker levels measured are presented in table \n 1table 1.peripheral biomarkers after downhill walking with the use of trekking poles ( tp ) \n and without their use ( np)variabletrialpwbiaw2hpwck(u / l)np260.3 39.1349.1 37.9302.9 42.0tp256.1 42.0312.5 44.9270.9 34.5ldh(u / l)np351.5 77.8453.4 70.6377.0 84.0tp354.9 79.3385.1 71.2363.5 64.6comp(u / l)np9.6 2.013.6 3.812.0 2.8tp9.9 2.213.2 3.610.0 np : no trekking pole trial ; tp : trekking pole trial ; \n pwb : pre - walking baseline ; iaw : immediately after walking ; 2hpw : 2 hours post - walking ; \n * p<0.05 vs. pwb .. the serum ck , serum ldh , serum comp , and plasma lactate levels were \n significantly increased iaw when compared with those at the pwb in trials np and tp \n ( p<0.05 ) . in addition , in trial np , the serum ck , serum ldh , and serum comp levels were \n significantly increased at 2hpw when compared with those at the pwb ( p<0.05 ) . np : no trekking pole trial ; tp : trekking pole trial ; \n pwb : pre - walking baseline ; iaw : immediately after walking ; 2hpw : 2 hours post - walking ; \n * p<0.05 vs. pwb .", "exercise - induced muscle damage increases in situations involving eccentric muscle \n contractions , such as during downhill walking and/or running4 . this study \n measured the levels of serum ck , ldh , and comp to investigate the effect of the use of a \n trekking pole on muscle and cartilage damage during downhill walking . the results \n demonstrated that the levels of ck , ldh , and comp were significantly higher iaw and 2hpw \n than at the pwb in the case of the np trials . in the case of the tp trials , however , the \n levels 2hpw were significantly lower than those for the np trials and actually returned to \n their level at the pwb . the rationale could be that the use of a trekking pole alleviated \n the temporary muscle and cartilage damage induced after downhill walking . this result is in \n accordance with those of previous studies ; howatson et al . showed significantly lower serum \n ck levels at 24 hours after mountain climbing in an experimental group that used trekking \n poles than in the control group , suggesting that the use of trekking poles could alleviate \n muscle damage during recovery3 . in \n addition , exercise - induced increases in joint load have been shown to cause a temporary \n increase in serum comp levels after walking or running by promoting catabolism , in \n particular , in cartilages such as the articular cartilage in the knee9 , 13 . bohne and \n abendroth - smith suggested that the use of a trekking pole during downhill walking could be \n effective for reducing such loads on the lower extremity joints7 . according to the results of some previous studies , the use \n of a trekking pole could reduce lower limb joint forces by as much as 25% , enabling a 13 kg \n reduction of load per stride during downhill walking3 , \n 14 . however , as for the plasma lactate levels in this study , no significant difference was \n observed with the use of a trekking pole . the rationale is that although the use of a \n trekking pole reduced forces on the lower limbs , it increased the activity of the upper \n limbs and consequently maintained a similar fatigue level in the whole body . this \n interpretation is supported by the report that plasma lactate concentration was a biomarker \n reflecting peripheral muscle fatigue during exercise15 , as well as by the suggestion of fritschi et al . that , although the \n use of a pole during walking could reduce vertical knee joint forces , it could increase \n upper limb muscle activation16 . in conclusion , downhill walking can cause muscle and cartilage damage , and it is suggested \n that the use of a trekking pole can reduce temporary muscle and cartilage damage after \n downhill walking ." ]

[ "", "periampullary diverticula ( pad ) refer to extraluminal outpouchings of duodenal mucosa that develop within the radius of 2 to 3 cm from the ampulla of vater ( 1 ) . pad are largely asymptomatic but they sometimes can cause both pancreaticobiliary and non - pancreaticobiliary complications . rarely , obstructive jaundice can develop secondary to pad in the absence of choledocholithiasis or tumor and is termed lemmel 's syndrome ( 2 ) . recently , the authors experienced an unusual case of abdominal pain and obstructive jaundice due to extrinsic compression of mid common bile duct ( cbd ) by distended pad filled with pus - like material as a result of impacted intradiverticular enterolith at the pad orifice .", "an 81-yr - old woman presented to the emergency department on august 3 , 2012 with nausea , vomiting , fever ( 38.4 ) , and diffuse abdominal pain of 4 days ' duration . she had undergone subtotal gastrectomy with billroth ii anastomosis due to peptic ulcer perforation 10 yr ago . on physical examination , there was tenderness on her right upper quadrant but murphy 's sign was equivocal . her white blood count was increased to 11,170/l ( neutrophil 83.0% ) and crp was elevated to 2.392 mg / dl . the results of her liver function test were as follows : total bilirubin , 2.37 mg / dl ; aspartate aminotransferase , 88 iu / l ; alkaline phosphatase , 349 iu / l ; and -glutamyl transpeptidase , 571 iu / l . to evaluate the cause of diffuse abdominal pain with liver enzyme elevation in a cholestatic pattern , abdominal ct scan was taken . the axial images of the ct scan demonstrated distal cbd stone with upstream bile duct dilatation ( fig . however , on coronal reconstructed images , the stone was not located within the bile duct but inside the pad and the distended diverticulum was compressing the mid cbd ( fig . 1b , 1c ) . magnetic resonance cholangiopancreatography ( mrcp ) also revealed mid cbd compression and absence of choledocholithiasis ( fig . these findings were confirmed on endoscopic retrograde cholangiopancreatography ( ercp ) which showed normal biliary orifice ( fig . 2a ) with impacted dark brown pigment stone ( henceforth enterolith ) at the pad orifice ( fig . when the enterolith was pushed into the diverticulum by cannulation catheter and contrast dye was injected ( fig . 2c , 3a ) , old blood clots and pus - like fluid gushed out from the opening ( fig . biliary cannulation combined with endoscopic sphincterotomy ( est ) was also performed to explore the cbd for other possible causes of obstructive jaundice but no stone , stricture or obstruction by tumor could be found . on endoscopic nasobiliary drainage ( enbd ) tubogram , stenosis at mid cbd was also shown to be resolved , likely because the pad had been decompressed ( fig . 3b ) . after confirming that no other pathology was present , intradiverticular enterolith was crushed and removed by dormia basket on the following day ( fig . the patient no longer complained of abdominal pain , her liver enzyme was normalized , and she was discharged without any complication . she had been well until 6 months after enterolith removal , when the patient visited the outpatient clinic with vague abdominal discomfort . laboratory examination only revealed slightly increased total bilirubin to 1.96 mg / dl , but a large cbd stone was found on abdominal ct scan ( fig . when the cbd stone was removed by ercp , the stone proved to be brown pigment sludge stone that typically forms in the presence of ascending infection ( fig . follow - up ercp was performed again after 6 months but there was no recurrence of cbd stone or enterolith .", "diverticula of the gastrointestinal tract are outpouchings of all or part of the intestinal wall which can occur anywhere throughout the alimentary tract . the most common site of gastrointestinal diverticula is colon followed by duodenum , which was first described by chomel in 1710 ( 3 ) . the detection rate of duodenal diverticula ranges from 1% to 27% depending on the diagnostic modalities used and the average age at the time of diagnosis ( 1 ) . among duodenal diverticula , pad is the most common type comprising about 70% to 75% of all duodenal diverticula ( 1 ) . most pad are asymptomatic but complications can occur in about 5% of cases and they include bleeding , perforation , diverticulitis , pancreatitis , choledocholithiasis , cholangitis , jaundice , enterolith or bezoar formation , intestinal obstruction , etc . among these complications , hepatocholangiopancreatic disease can seldomly occur in the absence of choledocholithiasis and is termed lemmel 's syndrome ( 2 ) . first , diverticulitis or direct mechanical irritation of pad may cause chronic inflammation of ampulla and lead to chronic fibrosis of papilla ( papillitis chronica fibrosa ) ( 4 ) . third , distal cbd or ampulla can be directly compressed mechanically by pad that is usually filled with enterolith or bezoar ( 6 , 7 ) . in our case , enterolith that formed within the pad did not directly compress the distal cbd but it obstructed the pad orifice instead . this obstruction combined with inflammation of the diverticulum and collection of pus - like material within the obstructed pad seems to have expanded the pad with resultant extrinsic compression of mid cbd ( fig . therefore , the enterolith , bezoar , or food material within the pad is frequently evacuated and thus , the symptom could be intermittent . however , pad in our case had a narrow opening , likely due to repeated inflammation of the pad , and this seems to have hindered the clearance of entrapped enterolith out into the duodenal lumen . enterolith formation within the duodenal diverticula is known to be facilitated in the static environment such as a blind loop after gastrectomy or proximal portion of stricture formed by crohn 's disease or tuberculosis ( 8) . in our case , blind loop created by billroth ii anastomosis seems to have provided a static environment favoring enterolith formation within the pad . during enterolith removal , cbd was also explored to search for other possible source of obstructive jaundice such as cbd stone since primary biliary stone is known to occur more frequently in the presence of pad ( 9 , 10 ) . one possible mechanism behind increased occurrence of primary cbd stone in these patients involves colonization and overgrowth of -glucuronidase producing bacteria within the pad that spread into the bile duct , which in turn leads to deconjugation of bilirubin glucuronides and eventually results in precipitation of calcium bilirubinate gallstones ( 11 ) . although cbd was explored in our case , no other etiology of obstructive jaundice could be identified other than extrinsic compression by distended pad . however , primary bile duct stone newly developed on follow - up ercp performed 6 months later ( fig . the most plausible explanation is that est performed during cbd exploration at the time of enterolith removal has permitted the occurrence of ascending infection with resultant brown pigment stone formation . diagnosing lemmel 's syndrome could be challenging , but being aware of this condition is important to avoid mismanagement and it begins with identification of pad . scan and mrcp , pad appear as thin - walled cavitary lesions situated on the medial wall of the duodenum 2nd portion that typically contain gas . however , pad are sometimes filled with fluid and can frequently be mistaken for pancreatic pseudocyst , pancreatic abscess , cystic neoplasm in the pancreas head or even metastatic lymph node ( 12 , 13 ) . therefore , high index of suspicion is mandatory to arrive at a correct diagnosis in these patients . in our case , enterolith within the pad on axial images was at first mistaken for distal cbd stone due to its distal location combined with upstream dilatation of the bile duct ( fig . however , upon careful scrutinization of the coronal reconstructed images , it became evident that the stone was located within the pad ( fig . treatment is generally not recommended in asymptomatic patients or would be conservative management in pauci - symptomatic patients . nevertheless , since most patients with lemmel 's syndrome present with symptoms related to biliary obstruction ( i.e. jaundice , abdominal pain , and cholangitis ) as a result of extrinsic compression of cbd , some form of treatment is advocated . therapeutic options in this situation run the gamut from endoscopic extraction of entrapped material , extracorporeal shock wave lithotripsy to surgery ( diverticulectomy or biliodigestive anastomosis ) ( 7 , 14 , 15 ) . the patient in our case was also successfully treated endoscopically by fragmenting and removing enterolith using a dormia basket . it should be kept in mind that not all forms of lemmel 's syndrome are caused by extrinsic compression of cbd by bulging pad . if the underlying mechanism of lemmel 's syndrome is likely to be due to papillitis chronica fibrosa or sphincter of oddi dysfunction as mentioned above , the simplest and the most appropriate management would be to perform est ( 16 ) . in conclusion , lemmel 's syndrome is a rare cause of obstructive jaundice that should be included in the differential diagnosis of biliary obstruction when pad is present . maintaining a high index of suspicion is imperative to establish an accurate diagnosis since it can mimic other cystic or solid lesions around the pancreas head . symptomatic patient can be successfully managed endoscopically in many instances but recourse to surgical management would be necessary in selected cases ." ]

[ "body mass index is a simple index of weight for height that is frequently used in the assessment of nutritional status . a low bmi , or underweight status , is often associated with an increased risk of mortality in seriously ill or hospitalized older adults [ 1 , 2 ] . conversely , a high bmi , indicative of overweight or obesity , is associated with an exacerbation in age - related physical and cognitive decline [ 3 , 4 ] and with an increased prevalence or risk of many chronic health conditions common in older adults such as diabetes , hypertension , and cardiovascular disease [ 35 ] . such associations are typically determined across the entire spectrum of older adults ( aged 60 + ) , with no further demarcation within this age classification . our finding of a much higher prevalence of several nutritional deficiencies in centenarians as compared with octogenarians [ 6 , 7 ] , suggests that there is considerable heterogeneity in nutrient status in the older adult age group . likewise , there may also be considerable heterogeneity within the older adult age group with regard to chronic health conditions . thus , it is not known whether the associations between underweight or overweight / obesity and chronic health conditions as observed in previous studies of older adults extend to the very old . dietary intake patterns featuring a high intake of nutrient - dense foods such as cereals , fruits , vegetables , and low - fat meat and dairy products have been associated with a number of favorable health outcomes in adults including a decreased prevalence of obesity [ 8 , 9 ] , lower rates of weight gain over time , and better quality of life and improved survival . in contrast , low - nutrient dense dietary patterns with high intakes of sweets , desserts , and high - fat dairy products have been associated with higher rates of obesity and poor nutritional status in older adults . studies comparing energy intakes and dietary intake patterns of centenarians to younger older adult cohorts have generally observed lower energy and/or fat intake in the centenarians , while dietary preferences of centenarians are considerably more varied and dependent of the region of study likely reflecting cultural patterns and cohort differences rather than longevity - related differences per se ( reviewed ) . nonetheless , there can be considerable variation of body weight status within a given group of centenarians , though to our knowledge the extent to which this may be associated with potential differences in dietary intake patterns or selected health conditions has not been explored . thus , the objectives of this study were to explore associations ( 1 ) between bmi and dietary habits and ( 2 ) between underweight or overweight / obesity and health status in a population - based multiethnic sample of centenarians ( 98 years and above ) from northern georgia in the usa . it was hypothesized that overweight / obesity , but not underweight , would be associated with poorer dietary habits and that both overweight / obesity and underweight , as well as dietary habits , would be associated with specific health conditions in this population .", "this study was a secondary analysis of data collected by the georgia centenarian study , a population - based multidisciplinary study conducted in 44 counties in northern georgia ( usa ) from 2002 to 2005 . the original study included 244 centenarians ( defined as age 98 and older ) . the sampling procedures and data collection methods briefly , recruitment of participants from skilled nursing facilities was based on estimates of the institutionalized population of the area according to the 2000 u.s . census tabulations . the community dwelling participants resided in private residences and personal care homes and were recruited from voter registration lists . participants were recruited to match census figures for gender and race / ethnicity ( white or black ; all were non - hispanic ) and were interviewed by trained personnel in their place of residence . all questionnaires and procedures were approved by the university of georgia institutional review board on human subjects . information regarding age , gender , race / ethnicity , living arrangements , health conditions ( cardiovascular disease , diabetes , hypertension , etc . ) , and behaviors ( including tobacco and nutritional supplement use ) were obtained from each participant ( or his / her caregiver ) by self - report . questions regarding food intake , appetite , and weight change were adapted from the mini - nutritional assessment [ 15 , 16 ] and the response categories for food intake represented current frequency of consumption of food groups , including dairy products ( milk , yogurt , and cheese ) ; meat , fish , or poultry ; orange / yellow vegetables ; green vegetables ; citrus and noncitrus fruit and juice . the total food score , ranging from 0 to 5 , was based on comparisons with the dietary guidelines for americans 1,600-calorie meal pattern for sedentary older adults , as previously described . body weight and height were measured by interviewers , obtained from charts or via self - report . in addition , knee height was measured on the right leg , unless contraindicated , to the nearest 0.1 centimeter and used to predict stature as per the formulas of chumlea et al . . body mass index ( bmi ) was calculated as weight ( kg)/height ( meters ) . bmi calculated from observed / recorded height and weight was highly correlated with bmi calculated from predicted stature and observed / recorded weight ( r = 0.877 ; p < .0001 ) . bmi calculated from observed / recorded height and weight was used to form three bmi classifications based on the national institutes of health criteria for overweight / obesity and defined as underweight 20 kg / m , normal weight > 20 and < 25 kg / m , and overweight / obese 25 kg / m . triceps skinfold ( tsf ) was measured on the right arm , unless contraindicated , by caliper to the nearest 0.1 millimeter . mid - arm circumference ( mac ) was measured on the right arm , unless contraindicated , to the nearest 0.1 centimeter . , burlington , nc ) and anemia was defined as hemoglobin < 12 g / dl for females or < 13 g / dl for males . participants missing data for primary variables of interest were excluded from the present analyses . from the original sample of centenarians , 11 individuals were excluded due to missing data for bmi ( n = 7 ; includes one double - amputee ) , food intake patterns ( n = 1 ) , average grip strength ( n = 1 ) , and/or systolic / diastolic blood pressure ( n = 3 ) . overall characteristics of the 233 centenarians included in the study are given in table 1 . compared to the included centenarians ( n = 233 ) , the excluded centenarians tended to be older ( 102.6 3.6 versus 100.5 1.9 yrs ; p = .052 ) , but did not differ in gender ( 90.9% [ excluded ] versus 84.6% female ) , race / ethnicity ( 72.7% versus 79.0% white ) , or place of residence ( 36.4% versus 43.4% skilled nursing facility ) . means , standard deviations , medians , range of values , and/or frequencies were calculated . differences between participants with different bmi classifications were assessed with the wilcoxon rank sum test for continuous variables and chi square analysis for categorical variables . the level of significance was set at p < .05 . because the food groups provide calories , a series of logistic regression analyses were performed with bmi 20 or bmi 25 as the dependent variable and gender , race / ethnicity , living arrangements , and reported intake of specific food groups as the independent variables . in addition , because bmi can play a causative role as a risk factor for chronic disease , a second series of logistic regression analyses was performed with diabetes , anemia , or other chronic health conditions as the dependent variable and race , gender , residence , and bmi 20 or bmi > 25 as the independent variables ( model 1 ) . a final series of logistic regression analyses was performed with diabetes , anemia , or other chronic health conditions as the dependent variable and race , gender , residence , total fruit , and vegetable intake and bmi 20 or bmi > 25 as the independent variables ( model 2 ) . p - values are unadjusted for multiple comparisons , because all comparisons were preplanned . ", "approximately one - third ( 31.3% ) of the centenarians included in the final analytical sample had a bmi of 20 ( underweight ) , 43.8% were classified as being in the normal weight range , and 24.9% met the nih classification for overweight / obesity ( bmi 25 ) . triceps skin fold ( tsf ) and mid - arm circumference ( mac ) of centenarians in the lowest bmi classification averaged below the 5th percentile for females 80 + years in usa based on 20032006 nhanes data . both parameters increased with bmi classification in a stepwise manner ( data not shown ) and were highly correlated with bmi ( pearson correlation coefficient between bmi and tsf = 0.482 ; and between bmi and mac = 0.624 ; p < .0001 for both ) . chi - square analysis indicated that those with a bmi 20 were more likely to be women , live in a skilled nursing facility , eat a modified food diet , have experienced a weight change in the past three months , and have anemia as compared to centenarians classified as normal weight or overweight / obese ( table 2 ) . conversely , those with a bmi 25 were more likely to be black , diabetic , have a higher systolic blood pressure , and/or have a diastolic blood pressure 90 mm as compared to centenarians classified as underweight or normal weight . there were no differences according to bmi classification with regard to history of cvd , cancer , stroke , depression , or past or current tobacco use . bivariate analysis of diet intake patterns suggested that centenarians with bmi 20 had the highest total food scores and were more likely to report eating two or more servings of meat , fish , and poultry per day and three or more total servings of fruit per day as compared with centenarians in the other bmi classifications . in contrast , those with a bmi 25 were more likely to report eating less than one serving of citrus or noncitrus fruit per day , less than four servings of orange / yellow vegetables per week , or three total servings of fruit and vegetables per day ( table 2 ) . a series of logistic regression analyses indicated that when controlled for gender , race , and place of residence the odds of having a bmi 25 were about two to three times higher in centenarians with lower intakes of citrus and noncitrus fruit ( less than one serving per day ) , orange and yellow vegetables ( less than four servings per week ) , or total fruits and vegetables ( less than three servings per day ) , but were not related to intake of the meat group or dairy group ( table 3 ) . similar analyses with bmi 20 as the dependent variable , failed to show any significant association with dietary intake categories ( table 3 ) . finally , associations between bmi classifications and chronic health conditions were determined in a series of logistic regression analyses that included either bmi 20 or bmi 25 as an independent variable ( table 4 ) . when controlled for gender , race , and place of residence , the odds of having anemia , based on blood hemoglobin values , were over twofold higher in centenarians with bmi 20 versus those with bmi > 20 whereas the odds of self - reported cvd tended to be reduced in those in the underweight classification ( bmi 20 ; p = .053 ) . the latter finding became significant in regression models further controlled for total fruit and vegetable intake ( model 2 ; p = .048 ) . in analyses controlled for gender , race , and place of residence , the odds of having self - reported diabetes or systolic blood pressure 140 mmhg were approximately three- and twofold higher , respectively , in centenarians with bmi 25 versus those with bmi < 25 . being overweight / obese ( bmi 25 ) also tended to increase the odds of having diastolic blood pressure > 90 mmhg ( approximately three - fold ; p = .055 ) or cardiovascular disease ( approximately twofold ; p = .074 ) . further controlling for total fruit and vegetable intake ( model 2 ) strengthened the associations between bmi 25 and diabetes and systolic blood pressure > 140 mmhg , and resulted in a significant association between bmi 25 and diastolic blood pressure 90 mmhg . there were no associations between bmi 20 or bmi 25 and stroke , depression , or cancer in any of the regression models .", "to our knowledge , this is the first study to explore associations between dietary patterns and body weight status in the oldest old segment of the population . prevalence of overweight / obesity in this population - based study of centenarians was approximately 25% , which was considerably below the prevalence for these conditions in the overall population of older adults , aged 60 and above , in the usa at the time of data collection ( 69% ; ) . in analyses controlled for gender , race , and place of residence , several parameters indicative of a low frequency of fruit and vegetable intake were associated with overweight / obesity ( bmi 25 ) , whereas there were no associations between frequency of intake of meat , dairy , and fruits and vegetables and being underweight ( bmi 20 ) . other findings include strong associations of underweight with anemia and of overweight / obesity with diabetes and high blood pressure , extending knowledge of such associations to the very old . the present research was part of a large , multidisciplinary study across a range of cognitive , mental , physical , and health - associated domains exploring the role of various factors pertinent to the survival and functioning of centenarians . to decrease testing burden for participants , dietary intake data focused on frequency of intake of specific food groups selected based on the dietary guidelines for americans and age - related associations with nutritional deficiencies and chronic diseases [ 16 , 17 ] . notably , we observed that based on frequency of intake and regardless of bmi classification , a large percentage of centenarians were not meeting the dietary guidelines for many food groups , with the exception of green and orange / yellow vegetables . this later finding is consistent with an apparent preference for sweet potatoes and green vegetables reported for an earlier convenience sampling of georgia centenarians [ 23 , 24 ] . such preferences likely are reflective of the traditional diet of the southeastern usa , rather than longevity - related differences in dietary patterns , and may not be replicable in other regions and cultures . our initial analysis indicated a greater intake of meat and total fruits in the underweight centenarians , suggesting that they were eating better than those in the normal weight and overweight / obese classifications . the underweight centenarians also had the highest total food scores , suggesting that they were meeting more of the recommended servings for specific food groups . however , almost twice as many underweight centenarians lived in skilled nursing facilities as compared to the community , and there was no association between low bmi and dietary groups after controlling for race , residence , and gender . in a specific comparison between centenarians residing in skilled nursing facilities and in the community , johnson et al . reported that those in skilled nursing facilities were more likely to eat three or more meals a day and to have a higher frequency of intake of most food groups . they suggested that such differences may be due to ( 1 ) the requirement that skilled nursing facilities serve meals that meet dietary guidelines and other federal nutrition policies [ 25 , 26 ] , ( 2 ) the inability of the methodology used to distinguish between food that was served and food that was eaten , and ( 3 ) barriers faced by community dwelling centenarians or their caregivers in purchasing , preparing , or consuming appropriate food to meet their nutritional needs . thus , associations in centenarians between low bmi and dietary status may be quite complex and influenced considerably by place of residence . in the present study , there was an increase in the relative risk for being overweight / obese in centenarians reporting the lowest frequency of intake of some nutrient dense foods including orange / yellow vegetables and citrus and noncitrus fruits . these observations are consistent with previous studies finding associations between lower reported or inferred consumption of fruits and/or vegetables and increased prevalence of overweight / obesity in children and young to middle - age adults [ 5 , 2830 ] . interestingly , other studies in adults have indicated that increased consumption of fruits and vegetables may be an effective strategy for decreasing energy consumption and for increasing and maintaining weight loss [ 29 , 31 , 32 ] . in addition to potential beneficial effects on body weight , there is considerable evidence in other age groups that high consumption of fruits and vegetables may offer protective effects against and/or to reduce the relative risk of cardiovascular disease , hypertension , diabetes , and certain cancers [ 3340 ] . we observed that centenarians in the highest weight category ( bmi 25 ) reported eating lower amounts of certain types of fruits and vegetables than their nonoverweight / nonobese counterparts and also appeared to be at greater risk for diabetes , high blood pressure , and cardiovascular disease . this suggests that a high intake of fruits and vegetables may be beneficial for maintaining optimal weight , and perhaps decreasing risk of chronic disease , even at very advanced age . however , additional , ideally longitudinal , research collecting more detailed food intake data is needed to support this contention . in addition , as social isolation , missing teeth , digestion difficulties , poor self - reported health , cost and preparation issues have been identified as barriers to fruit and vegetable intake in older adults [ 4143 ] , research is needed to determine if and to what degree these or other potential barriers may be influencing the intake of fruit , vegetables , and other low energy , high nutrient dense foods in the very old . clinically defined anemia was present in greater than 60% of the centenarians in the lowest bmi grouping . after controlling for demographic covariates , a strong association remained between low bmi and anemia but not with other health conditions and indicators . accordingly , low bmi had been identified as an independent correlate or risk factor for anemia in some previous studies in older adults and clinical populations [ 4446 ] , but not in others . although older adults with a low bmi are considered to be at nutritional risk [ 47 , 48 ] , it can not be assumed that the anemia observed in underweight older adults is primarily of dietary or nutritional etiology . indeed , our previous studies indicate a similar prevalence of anemia in vitamin b12-deficient and vitamin b12-adequate in georgia centenarians and a high prevalence of inflammatory anemia , either alone or in combination with nutritional deficiencies , in this population . nonetheless , as anemia is associated with increased mortality in acute and chronic disease states , particularly in those underweight [ 50 , 51 ] , it is important to monitor and treat this condition , as appropriate , in the very old . in summary , this secondary analysis provides evidence of an inverse association between fruit and vegetable intake and body weight status in a population - based study of centenarians . in addition , both underweight and overweight emerged as potential risk factors for various chronic diseases , emphasizing the importance of monitoring weight and of maintaining a healthy weight , even at very advanced ages . a major strength of the study is the inclusion of a population - based sampling of centenarians with greater diversity in race , place of residence , and functional status than would be typically obtained with a convenience sample . limitations of the study include the relatively small sample size , lack of information regarding physical activity , and reliance on data of frequency of intake for only a few food groupings rather than the use of a more extensive food frequency questionnaire including individual foods and serving sizes as per our earlier convenience study of centenarians [ 23 , 24 ] . absence of intake data on key dietary components including grains / cereals and sweets / desserts necessitated the use a series of nonindependent binary logistic regression models instead of a more complex , single multinomial logistic regression to explore potential associations between bmi and dietary intake patterns . thus , specifically designed studies including more detailed information of dietary intake , physical activity data , and additional chronic disease indicators are needed to verify associations , or lack thereof , between dietary intake patterns , weight status , and chronic health conditions in the very old . furthermore , as dietary habits and other characteristics of this sample from georgia likely differ from those of centenarians from other countries and cultures , our findings need replication in other population groups ." ]

[ "environmental factors play a major role in the etiology of cancers , cardiovascular disease , and other chronic diseases . these factors are diverse in nature and include diet , drugs , cosmetics , household chemicals , pollutants , or infectious agents . exposures to these factors vary widely between populations , and between individuals within the same population . therefore , their measurement is essential to : ( i ) study associations in epidemiological studies with disease outcomes and assess their contribution to disease risk , ( ii ) monitor exposures to disease risk factors in population studies and ( iii ) assess subject compliance in clinical trials or large intervention studies ( 13 ) . exposure measurements have traditionally relied on the use of questionnaires and self - reporting . however , these methods are known to be error - prone and biased . molecular biomarkers , on the other hand , are more direct and objective indicators of exposure . indeed , biomarkers of exposure have been increasingly used since the early 1980s , thanks to rapid progress in analytical techniques and the establishment of large cohorts with extensive biospecimen collections . biomarkers of exposure can be compounds present in the environment and absorbed in the gut after ingestion , inhaled in lungs , or absorbed through the skin . they can also be metabolic end - products derived from environmental compounds that were metabolized by the liver and other tissues , and the microbiota . they may also be macromolecular indicators of environmental effects ( e.g. enzymes , proteins or rna transcripts related to the status of a nutrient or toxic agent ) . over the past 30 years several hundred biomarkers of exposure have been measured and reported in blood , urine and other biospecimens in various populations . however , this information is scattered over hundreds of publications under many diverse titles and subject headings . this makes the identification of these biomarkers along with their comparative performance , their field of application and their concentration ranges in different populations difficult . historically , most biomarkers of exposure have been measured individually using compound - specific assays . however , with the emergence of various omics technologies there is an increasing tendency to characterize exposures more comprehensively . indeed , modern mass spectrometry techniques now allow the measurement of thousands of compounds in blood , urine or other biospecimens in a single analytical run . these developments are leading , increasingly , to the reporting of data from multiple markers of exposure . modern omics technologies should also allow the translation into practice of the concept of the exposome ( the totality of exposures of a particular individual over lifetime ( 4,5 ) ) and the development of exposome - wide association studies ( ewas ) ( 2,68 ) . these newly emerging trends in exposure science , combined with the growing volume of comprehensive exposure data being published , make the establishment of a centralized , online database on biomarkers of exposure particularly critical . to date , relatively little effort has been directed to collecting and organizing data on biomarkers of exposure . the expocastdb database contains information on exposure to environmental chemicals such as pahs , pcbs , nonylphenols , or pesticides ( http://actor.epa.gov/actor/faces/expocastdb/home.jsp ) . expocastdb contains information on compound concentrations in various environmental matrices but very limited data in biospecimens . the comparative toxicogenomics database ( ctd ) is the only online database containing a large number of concentration values in blood , urine and other biospecimens extracted from the scientific literature ( 9 ) . the ctd contains about 35 000 concentration values in various biospecimens for 250 organic and inorganic compounds . while expocastdb and ctd are very useful and important databases it contains comprehensive information on almost 500 biomarkers of exposure with concentrations , correlations with exposure estimates and temporal reproducibility , as well as other details on study population and analytical methods . all data in exposome - explorer was acquired from a careful review and analysis of nearly 500 peer - reviewed publications , with a particular focus on dietary and pollution exposures .", "all data in exposome - explorer was compiled through extensive literature analysis along with manual curation and computer - assisted validation . literature searches were conducted using the web of science ( wos ) . only peer - reviewed publications describing original work with biomarker measurements in observational studies conducted in human populations publications on intervention studies , analytical method development , associations of biomarker with biological status or disease , biomarkers of biological status ( e.g. inflammation , oxidative stress , disease ) , or animal studies were not considered for this initial stage of development . articles not available online were omitted . for pollutants , general rather than occupational exposures were prioritized . exposure , biological monitoring ) and biospecimens ( blood , serum , plasma , adduct ) . for dietary biomarkers , data on the correlations between food or food compound intake and biomarker concentrations citations were searched for according to several intake synonyms ( intake , consumption , diet , recall , citations were searched for by common pollutant chemical group , such as polycyclic aromatic hydrocarbons ( pah ) , polychlorinated biphenyls ( pcb ) , polybrominated diphenyl ethers ( pbde ) , polybrominated biphenyls ( pbb ) , polychlorinated dibenzodioxins / furans ( pcdd / f ) , heterocyclic amines ( hca ) , phthalates and disinfection byproducts ( dbp ) . to search for biomarker reproducibility values , reliability , reproducibility , repeatability , intra - subject , inter - subject , within - subject , between - subject. full - record citations from the wos were downloaded in the bibtex format ( http://www.bibtex.org/ ) and handled with bibdesk , an open - source bibliography manager for bibtex libraries ( http://bibdesk.sourceforge.net/ ) . those rated as relevant were then manually described using a series of attributes ( tags ) related to exposures , study design , type of numerical data , populations , biospecimens , biomarkers and confounding variables to facilitate the selection of references for annotators . the bibdesk smart groups functionality and a combination of criteria based on the tags were used to dynamically generate a priority list of publications for further annotation . full - texts from these articles were then retrieved and submitted to annotators for detailed analysis and upload of the data to exposome - explorer using the annotation interface .", "a password protected annotation interface was used for the manual uploading of all data from scientific publications to exposome - explorer . , the annotator is guided through successive steps to ensure comprehensive capture of the following information : \n publication with its bibliographic details ( title , authors , year , journal , pubmed id).subject groups studied in the publication , and the populations to which they belong . each population is named with a short informative summary sentence ( e.g. cases and controls in a case - control study on breast cancer ) . all ) or several ( e.g. soy consumers and soy non - consumers ) subject groups according to different criteria ( e.g. by gender , by ethnicity , by smoking status ) . a reference to a cohort ( e.g. epic ) can also be indicated in this data field . age , height , weight , bmi , group size , gender , health condition , exclusion of supplement users , smoker proportion , country of origin and ethnicity are also specified when available.samples defined for each subject group . these describe number and time of collections ( e.g. baseline , 1 year ) of different biospecimens . biospecimens include urine , whole blood , serum , plasma , hair , nails , adipose tissue , breast milk , or fractions such as plasma phospholipids or red blood cell membranes.biomarkers . chemical information ( e.g. structure , chemical formula , average mass , monoisotopic mass ) is automatically generated by the structure server . identifiers and links to external databases such as cas , pubchem ( 10 ) , chebi ( 11 ) , hmdb ( 12 ) and foodb ( www.foodb.ca ) are provided.biomarker measurements . for each sample or biospecimen type , also included is the analytical method , the original measurement units as described in the publication , and specimen - specific concentration value adjustments ( e.g. normalizing to lipid for blood , or a list of regression variables ) . arithmetic or geometric mean , as well as median concentration values are compiled along with the minimum and maximum values , standard deviation , percentiles , confidence intervals , measurement size ( number of subjects from which the concentration value was calculated ) , as well as the proportion of subjects for which the biomarker was detected . information on the inclusion or exclusion of zero values in the calculated concentration is also given . this was mostly done for pollutant biomonitoring studies where a chemical is often detected only in a small proportion of the studied population . some authors used a threshold ( e.g. detected in at least 30% samples ) . below this threshold , the geometric mean was not calculated and the authors considered the compound to be not detected in the studied population . in certain cases , the compound used to express the concentration is given if it is different from the compound or compound class being measured ( e.g. polyphenols in urine expressed as gallic acid).correlations . to compile data on the correlations between specific biomarker measurements and food or dietary compound intake , information was collected on the intake of different foods , food groups or dietary compounds together with the method used for dietary assessment ( record or questionnaire , food composition database , food coverage and time period ) . food items in exposome - explorer are linked to the foodb database ( www.foodb.ca ) . for food groups , the list of individual foods considered to calculate the intake of that particular food group is indicated if described in the publication . for dietary compounds , the inclusion of dietary supplements in the calculation of their intake is indicated when mentioned in the publication . correlation coefficients ( pearson 's product moment or spearman 's rank - order ) are collated together with p - value , confidence intervals , statistical significance ( yes/no ) , and correlation size ( number of measurements from which the correlation coefficient was calculated ) . adjustment of intake or biomarker measurements prior to calculation of the correlation coefficient ( e.g. energy intake by residual method or creatinine ) as well as a list of regression variables included in the calculation ( e.g. age , smoking status , bmi , gender ) , and the use of measurement error de - attenuation are also indicated.temporal reproducibility of biomarker measurements in an individual is an important characteristic of the biomarker . a high reproducibility is required when only one sample per subject is available for biomarker measurement , as in most large cohort studies . reproducibility is usually measured on repeated samples collected in a small group of individuals over a given time interval ( generally weeks or months ) . reproducibility is principally described by the intraclass correlation coefficient ( icc ) , defined as the ratio of between - subject variance to the sum of within- and between - subject variance . the higher the icc value , the higher the reliability of the measurement . in some cases , within- and between - subject coefficient of variation ( cv ) , as well as within- and between - subject reproducibility size ( number of measurements from which the reproducibility value was calculated ) and the confidence interval are also indicated in the database . publication with its bibliographic details ( title , authors , year , journal , pubmed i d ) . each population is named with a short informative summary sentence ( e.g. cases and controls in a case - control study on breast cancer ) . all ) or several ( e.g. soy consumers and soy non - consumers ) subject groups according to different criteria ( e.g. by gender , by ethnicity , by smoking status ) . a reference to a cohort ( e.g. epic ) age , height , weight , bmi , group size , gender , health condition , exclusion of supplement users , smoker proportion , country of origin and ethnicity are also specified when available . these describe number and time of collections ( e.g. baseline , 1 year ) of different biospecimens . biospecimens include urine , whole blood , serum , plasma , hair , nails , adipose tissue , breast milk , or fractions such as plasma phospholipids or red blood cell membranes . biomarkers . chemical information ( e.g. structure , chemical formula , average mass , monoisotopic mass ) is automatically generated by the structure server . identifiers and links to external databases such as cas , pubchem ( 10 ) , chebi ( 11 ) , hmdb ( 12 ) and foodb ( www.foodb.ca ) are provided . also included is the analytical method , the original measurement units as described in the publication , and specimen - specific concentration value adjustments ( e.g. normalizing to lipid for blood , or a list of regression variables ) . arithmetic or geometric mean , as well as median concentration values are compiled along with the minimum and maximum values , standard deviation , percentiles , confidence intervals , measurement size ( number of subjects from which the concentration value was calculated ) , as well as the proportion of subjects for which the biomarker was detected . information on the inclusion or exclusion of zero values in the calculated concentration is also given . this was mostly done for pollutant biomonitoring studies where a chemical is often detected only in a small proportion of the studied population . some authors used a threshold ( e.g. detected in at least 30% samples ) . below this threshold , the geometric mean was not calculated and the authors considered the compound to be not detected in the studied population . in certain cases , the compound used to express the concentration is given if it is different from the compound or compound class being measured ( e.g. polyphenols in urine expressed as gallic acid ) . correlations . to compile data on the correlations between specific biomarker measurements and food or dietary compound intake , information was collected on the intake of different foods , food groups or dietary compounds together with the method used for dietary assessment ( record or questionnaire , food composition database , food coverage and time period ) . food items in exposome - explorer are linked to the foodb database ( www.foodb.ca ) . for food groups , the list of individual foods considered to calculate the intake of that particular food group is indicated if described in the publication . for dietary compounds , the inclusion of dietary supplements in the calculation of their intake is indicated when mentioned in the publication . correlation coefficients ( pearson 's product moment or spearman 's rank - order ) are collated together with p - value , confidence intervals , statistical significance ( yes/no ) , and correlation size ( number of measurements from which the correlation coefficient was calculated ) . adjustment of intake or biomarker measurements prior to calculation of the correlation coefficient ( e.g. energy intake by residual method or creatinine ) as well as a list of regression variables included in the calculation ( e.g. age , smoking status , bmi , gender ) , and the use of measurement error de - attenuation are also indicated . temporal reproducibility of biomarker measurements in an individual is an important characteristic of the biomarker . a high reproducibility is required when only one sample per subject is available for biomarker measurement , as in most large cohort studies . reproducibility is usually measured on repeated samples collected in a small group of individuals over a given time interval ( generally weeks or months ) . reproducibility is principally described by the intraclass correlation coefficient ( icc ) , defined as the ratio of between - subject variance to the sum of within- and between - subject variance . the higher the icc value , the higher the reliability of the measurement . in some cases , within- and between - subject coefficient of variation ( cv ) , as well as within- and between - subject variance ( var ) reproducibility size ( number of measurements from which the reproducibility value was calculated ) and the confidence interval are also indicated in the database . exposome - explorer 's annotation interface uses a number of features to help complex , heterogeneous , literature - derived data to be easily and systematically translated into organized electronic data . controlled vocabularies for compounds , foods , experimental methods , specimens , cohorts and units can be created and are fully documented in both the annotation interface and the database . this helps to avoid the inclusion of duplicate vocabulary items , such as different spellings or synonyms for a same item . hierarchical associations of populations , samples and measurements can be represented through the creation of parent - children relations . for instance , populations stratified into different sub - groups can be easily described , or the association of several samples taken at different collection times . all data uploaded to the database via the exposome - explorer annotation interface is automatically validated , thereby preventing the uploading of erroneous records . error checks include the usual database integrity verifications such as the presence of mandatory fields , checks on input text size , checks on allowable values or the uniqueness of specific values . the error checking utilities also include application - specific consistency verifications such as correlations can not be created between measurements of different subject groups or measurement size can not exceed subject group size. these checks ensure the highest consistency for data collected by different annotators . newly uploaded data is also manually and systematically checked by the database 's chief curator . repetitive insertion of similar data is facilitated via the support of record duplication and the ability to edit several records at once . error messages are displayed to guide annotators toward making correct data entries or fixing erroneous entries .", "exposome - explorer 's public user interface allows intuitive browsing and searching of almost any data type in the database ( figure 1 ) . data can be retrieved through the quick search functionality or through specific searches offered on the website 's different menu pages . distinct areas are shown : structure and chemical information ( a ) , concentrations ( b ) , correlations ( c ) and reproducibility ( d ) collated from several publications . biomarkers menu lists the biomarkers , biospecimens , analytical methods and cohorts documented in the database . each item has its own summary page with both general details ( name and classification ) and all data related to this item in the database . correlations menu lists the correlation values between different food or dietary compound intakes and the corresponding biomarker measurements . these correlations can be searched according to the food type , dietary compound , or biomarker . the data can be filtered according to a variety of parameters including the type of biospecimen or the method used to assess the dietary exposure . reproducibility menu lists the biomarker reproducibility values , which can also be filtered according to biomarker classification ( as well as other parameters ) and ranked in decreasing or increasing order . the data search menu lists all biomarker concentration values and allows searches over all data fields . searches by chemical structure are also possible , as well as browsing biomarker classes and subclasses . the the list can be filtered by title , authors , year or pubmed i d . full - text for these publications can be accessed via pubmed links or direct publisher urls . for every annotated publication , the totality of collected data including the bibliographic information , detailed subject descriptions , and biomarker data ( concentration values , dietary intake values , correlation values and reproducibility values ) is displayed in a single page . tables on exposome - explorer 's different webpages can be easily adjusted to suit user - specific needs . several hidden columns are available and can be shown in order to provide more details for the default display . every original value is listed with its corresponding bibliographic citation , making it possible to link each value back to its metadata . default conversions from highly diverse to standardized units are possible while original values are preserved . tables can be exported in different formats ( e.g. csv , tab ) and reused in other programs ( e.g. excel , r ) in order to conduct more specific analyses .", "ruby on rails is a web framework which employs the model - view - controller ( mvc ) design pattern . the exposome - explorer data is stored in a mysql relational database ( http://www.mysql.com/ ) . hierarchical associations of records ( trees ) are implemented as a nested set model inside a single database column of the tables using the rails gem ancestry ( https://github.com/stefankroes/ancestry ) . highly diverse units and their conversions are transparently handled with the phys - units library ( https://github.com/masa16/phys-units/ ) , which is a ruby implementation of the gnu units software ( http://www.gnu.org/software/units/ ) . website global search is implemented using the wishart 's unearth gem , which uses elasticsearch indexing ( https://www.elastic.co/ ) . the web interface is built with the bootstrap front - end framework ( http://getbootstrap.com/ ) .", "to date , data from a total of 480 publications have been entered into this first release of exposome - explorer . this includes 10 510 concentration values for 692 biomarker entries , among which 8,861 concentrations correspond to 488 single dietary and pollutant biomarkers . approximately one third of these biomarkers are dietary biomarkers ( table 1 ) . for dietary biomarkers , almost half of the concentrations are related to fatty acids , followed by carotenoids and polyphenols . with regard to pollutant biomarkers , about two thirds of the concentration data in exposome - explorer are related to pcbs and pbdes , followed by pahs , pcdd / fs and phthalates . some concentration data are also available for other biospecimens such as hair , nails , adipose tissue or breast milk .", "exposome - explorer currently contains the most complete and comprehensive information on exposure biomarkers ever compiled from peer - reviewed literature . it is also the first publicly available , web - enabled database specifically dedicated to exposure biomarkers . we believe it provides a good starting point for selecting markers of interest or for defining panels of biomarkers that can be used in exposome - wide association studies . through exposome - explorer , biomarker concentrations can be compared in different cohorts or population groups at different levels of exposure ( e.g. consumers and non - consumers of a particular food ) , or between different geographical areas . all of the database 's manually curated information is fully linked with other online databases and with the original publications . the high granularity of the data in the database should allow users to conduct very diverse and advanced analyses or comparisons across publications . looking both at the range of studied compounds and the number of corresponding studies , exposome - explorer also allows users to quickly identify poorly studied exposures or biomarkers that may require further work for validation . plans for future enhancements to exposome - explorer include its extension to other categories of exposures ( nutritional status , pesticides , occupational exposures ) , the addition of other types of biomarkers ( dna and protein adducts ) , and the inclusion of more information characterizing biomarkers such as their half - life and other pharmacokinetic parameters . plans are also being made to add putative or non - validated biomarkers identified in ( pre)clinical studies , but never measured in populations . overall , we believe exposome - explorer will help in the generation of hypotheses for discovery of new biomarkers to be tested in the laboratory . it should also help in evaluating the performance of existing biomarkers and integrating exposure data based on biomarkers with data collected with other technologies . exposome - explorer should contribute to the translation of the exposome into practice in epidemiological research .", "european commission : exposomics fp7-kbbe-2012 ; nutritech fp7-kbbe-2011 - 5 ; joint programming initiative foodball 201417 ." ]

[ "the aspergilli are filamentous fungi , which are multicellular eukaryotes with a relatively simple life cycle . many of them have long been used in food production , industrial fermentation , and agriculture . on the other hand , a few , such as a. fumigatus , a. flavus , a. niger , a. nidulans , and a. terreus , are opportunistic fungal pathogens , causing life - threatening invasive aspergillosis ( ia ) in immunosuppressed patients [ 1 , 2 ] , in which a. fumigatus is the predominant pathogen [ 35 ] . the crude mortality for ia is 6090% and remains around 2942% even when treatment is given . the main reasons for patient death are late diagnosis and the low efficiency of the drug therapies available to treat ia . it maintains cell shape and provides osmotic protection [ 7 , 8 ] and has therefore been recognized for a long time as an ideal drug target . indeed , several cell - wall - targeted drugs , such as echinocandins , caspofungin , micafungin , and anidulafungin , have been introduced as therapies . for example , echinocandins , which inhibit synthesis of -1,3-glucan , a crucial component of the cell wall are effective in the treatment of invasive fungal infections including ia . unfortunately , the echinocandins also trigger an increase of chitin [ 9 , 10 ] , which partially compensates for the loss of -1,3-glucan and reduces the efficiency of treatment due to the complicated mechanism of cell wall biogenesis in a. fumigatus . therefore , a more profound understanding of the mechanisms of cell wall biosynthesis in a. fumigatus would help to improve the efficiency of drug therapies , especially for drugs which target the cell wall . the cell wall of a. fumigatus is composed of a unique -1,3/1,4-glucan skeleton with chitin and galactomannan covalently linked to the nonreducing ends of -1,3-glucan . the cell wall is mainly coated with gpi proteins , which contain n- and o - glycans [ 11 , 12 ] . while there is no doubt that glycosylation is involved in cell wall organization , the functional importance of protein glycosylation in cell wall organization has , until recently , remained poorly understood . however , during the past few years , it has become increasingly evident that glycosylation is vital for cell wall synthesis and thus vital for growth and morphology of a. fumigatus . basically , all eukaryotes possess three types of protein glycosylation , n - glycosylation of asparagine residues , o - glycosylation of threonine and serine residues , and glycosylphosphatidylinositol - anchoring ( gpi - anchoring ) of the c - terminus of some proteins . humans lacking individual glycosyltransferases suffer from severe congenital diseases , known as carbohydrate - deficient glycoprotein syndromes ( cdgs ) [ 1214 ] . clearly , the sugar components of proteins play a major role in embryonic and postembryonic development of humans as well as of all higher eukaryotes . however , the molecular details leading to cdgs are only vaguely understood . during the past 20 years it is now known that carbohydrates play increasingly important roles in regulating the development of higher organisms . however , the mechanism by which carbohydrates play a role in development and disease is still unclear . our knowledge of protein glycosylation comes mainly from investigation of the model yeast s. cerevisiae and of mammalian cells . although investigation of the model yeast has been very useful in elucidating the biochemical features of protein glycosylation at the cellular level , they can not reveal the complicated functions of glycosylation in the development of multicellular eukaryotes . therefore , investigation of glycosylation in the multicellular fungus a. fumigatus not only helps understand the mechanism of cell wall synthesis in this species but also provides insights into the role of glycosylation in the development of multicellular eukaryotes . this paper concentrates on protein glycosylation in a. fumigatus , which will be discussed with respect to the enzymatic pathways involved and their functional importance . furthermore , the utility of a. fumigatus as a model for glycosylation during development of multicellular eukaryotes will be outlined .", "the cell wall of a. fumigatus is mainly composed of -1,3-glucans that are highly branched with -1,6 linkages . together they constitute a three - dimensional network with a large number of nonreducing ends , to which chitin , galactomannan , and -1,3/1,4-glucan are covalently anchored . the cell wall is mainly coated with gpi proteins , which contain n- and o - glycans derived primarily from the process of glycosylation [ 11 , 17 ] . deletion of gel2 leads to slower growth , abnormal conidiogenesis , an altered cell wall composition , and reduced virulence [ 18 , 19 ] . it has been proposed that gel2p is responsible for the elongation of -1,3-glucan side chains of -1,3/1,6 branched glucan to provide new nonreducing ends . ecm33p is also involved in maintaining proper cell wall architecture though its function is unknown . disruption of ecm33 results in morphogenetic aberrations such as defects in conidial separation , increase of chitin in conidial cell walls , rapid conidial germination , and increased virulence [ 20 , 21 ] . it is clear that glycoproteins are directly , as structural components of the cell wall , and indirectly , as enzymes required for cell wall synthesis , involved in maintaining proper cell wall architecture in a. fumigatus . increased chitin synthesis has been known as an important compensatory response to cell wall stress both in s. cerevisiae and filamentous fungi [ 2226 ] . in s. cerevisiae , the cell wall is required to maintain cell shape , which is essential for the formation of a bud and hence cell division . the yeast cell remodels its rigid structure to accommodate cell expansion during vegetative proliferation , mating pheromone - induced morphogenesis , and nutrient - driven filamentation through the cell wall integrity ( cwi ) signaling pathway . cell wall defects or damage induces the cells to activate the cwi pathway to survive , and the compensatory mechanism characterized by an increased chitin content is triggered . the cwi signaling pathway in s. cerevisiae is activated in response to low osmolarity , thermal stress , or mating pheromone and polarized growth . it is comprised of a family of cell surface sensors coupled to the small g - protein rho1p , which activates the cwi mapk cascade via protein kinase c ( pkc1p ) . this signaling cascade activates the expression of genes encoding for cell wall proteins that stabilize the cell wall . meanwhile , activated rho1p also activates a set of additional effectors such as bni1p and bnr1p formin proteins , skn7p transcription factor , and the sec3p exocyst component , which regulate a diverse set of processes including -glucan synthesis at the site of cell wall remodeling , gene expression related to cell wall biogenesis , organization of the actin cytoskeleton , and secretory vesicle targeting to the growth site . a family of cell surface sensors is responsible for detecting and transmitting the status of the cell wall to rho1p . these sensor molecules include wsc1p ( hcs77p / slg1p ) [ 2931 ] , wsc2p and wsc3p , and mid2p and mtl1p [ 32 , 33 ] . among these cell wall stress sensors , wsc1p and mid2p appear to be the most important and serve a partially overlapping role in cwi signaling . reduced o - mannosylation leads to incorrect proteolytic processing of these proteins , which in turn results in impaired activation of the pkc1 pathway and finally causes cell death in the absence of osmotic stabilization . more recently , n - glycan is found to be directly involved in mid2p sensing . it has been shown that both the extent of the n - linked glycan and its distance from the plasma membrane affect mid2p function . these observations demonstrate that n- and o - glycosylation are important for cwi sensing and thus important for cell wall biogenesis and polarized growth in yeast . the presence of a. fumigatus genes encoding for proteins homologous to the yeast rho1p , rho3p , and cdc42p suggests a similar mechanism for the cwi pathway . indeed , it has been recently shown that afcdc42/cdc42 , afrho1/rho1 , and afrho3/rho3 are highly expressed in the mutant devoid of cwh41p ( glucosidase i ) , which suggests an activation of these genes induced by cell wall damage . also , increased expression and activation of the a. fumigatus mpkap , an ortholog of the s. cerevisiae mpk1p , is also induced by cell wall damage [ 38 , 39 ] . it is becoming clear that , as in yeast , defects in cell wall integrity also trigger the cwi mapk cascade in a. fumigatus . on the other hand , in contrast to yeast , little is known about the cell wall stress sensors in a. fumigatus . in the last release of the a. fumigatus genomic database ( http://www.aspergillus.org.uk/indexhome.htm?secure/sequence_info/index.php~main ) , only one protein ( afua_5g09020 ) is annotated as a homologue of the wsc4p , which does not appear to contribute to cwi signaling in yeast . therefore , the a. fumigatus cell wall stress sensor molecule remains to be identified and investigated .", "the precursor of all mannose residues found in galactomannan , glycoprotein , and gpi anchor in a. fumigatus is gdp - mannose . the activation of mannose initiates from formation of mannose 6-phosphate ( man-6-p ) , which occurs by one of two routes : direct phosphorylation of mannose by hexokinase or interconversion from fructose 6-phosphate ( fru-6-p ) via phosphomannose isomerase ( pmi ) , and the latter pathway requires three enzymes : pmi , phosphomannomutase ( pmm ) , and gdp - mannose pyrophosphorylase ( gmpp ) . fru-6-p is converted to man-6-p by pmi , and then man-6-p is converted to mannose 1-phosphate ( man-1-p ) by pmm . subsequently , man-1-p is ligated with the guanosine 5-triphosphate molecule ( gtp ) to form gdp - mannose by man-1-p guanylyltransferase [ 4063 ] . the interconversion of man-6-p and fru-6-p catalysed by pmi is the first committed step in the synthesis of man - containing sugar chains and provides a link between glucose metabolism and mannosylation . pmi deficiency is the cause of carbohydrate - deficient glycoprotein syndrome type ib ( cdg - ib , omim 602579 ) in humans , but the clinical symptoms and aberrant glycosylation can be corrected with dietary mannose supplements . genes encoding for pmis have been investigated in several fungal species , such as s. cerevisiae , candida albicans , a. nidulans , and cryptococcus neoformans [ 4851 ] . the pmi mutant shows a significantly reduced growth rate at high concentrations of mannose . biochemical and genome - wide analysis reveals that excess mannose leads to an accumulation of man-6-p , which mainly inhibits the activity of phosphoglucose isomerase ( pgi ) and thus represses glycolysis , protein biosynthesis , and cell wall biogenesis . the a. nidulans mana1 mutant exhibits abnormal ballooning of hyphal tips and eventually ceases to grow . disrupted man1 mutant of c. neoformans leads to poor capsule formation , reduced polysaccharide secretion , morphological abnormalities , and attenuated virulence . in a. fumigatus , pmi activity is essential for viability and plays a central regulatory role in both glycosylation and energy production . deletion of the a. fumigatus pmi1 gene leads to uncoupling of the link between energy production and glycosylation and accumulation of man-6-p , which then results in defects in cell wall integrity , conidiation , and morphology . although extracellular mannose can rescue the growth of pmi deficient mutants in a. fumigatus , both lower and higher concentrations of mannose lead to a reduction in the levels of -glucan in the cell wall and an accumulation of man-6-p . the phenotypes associated with the mutant under mannose starvation are mainly due to an insufficient supply of gdp - man required for cell wall synthesis . the abnormal morphology associated with the pmi1 mutant under mannose - replete conditions is mainly ascribed to an accumulation of man-6-p , which can not efficiently enter glycolysis , instead becoming trapped in a cycle of dephosphorylation and rephosphorylation resulting in depletion of intracellular atp . it should be pointed out that the pmi in a. fumigatus mainly catalyzes the conversion of fru-6-p to man-6-p , and its binding affinity for man-6-p is similar to that of yeasts but different from the ones from bacteria or animals ( table 1 ) . this suggests that it may be possible to design a specific inhibitor for fungal pmis . several gmpps have been identified and characterized in different species [ 5559 ] . in s. cerevisiae and c. albicans , gmpp is essential [ 60 , 61 ] , while in leishmania mexicana gmpp is not required for viability . repression of gmpp in yeast leads to pleiotropic phenotypes including cell lysis , failure of cell separation , impaired budding and hyphal switching , clumping and flocculation , and cell wall defects . repression of expression of a. fumigatus gmpp srb1 , a homologue of yeast srb1/psa1/vig9 , leads to hyphal lysis , a defective cell wall , impaired polarity maintenance , and branching site selection , as well as rapid germination and reduced conidiation . in contrast to yeast , inducible repression of srb1 expression in a. fumigatus does affect the ability to direct polarity establishment and septation . these reports imply that mannose activation is specifically crucial for the synthesis and organization of the cell wall and thus essential for survival of fungal species . this further suggests that glycosylation is essential for the viability of pathogenic fungal species such as a. fumigates , and inhibitors that specifically block mannose activation in fungi may be potential drugs to treat fungal infections .", "n - glycosylated proteins contain oligosaccharides that are n - glycosidically linked to the -amido group of asparagine . this type of glycoprotein has been intensively studied in many model systems from yeast to human cells with respect to their structure , biosynthesis , and function . it has been shown that the formation of the highly variable n - linked oligosaccharides is initiated by the assembly of a lipid - linked oligosaccharide glc3man9glcnac2-pp - dol by a series of glycosyltransferases located on the cytoplasmic and luminal faces of the er membrane . the most complete understanding of biosynthesis of the lipid bound precursor has been obtained from s. cerevisiae and from mammals . as far as it is known , the corresponding reactions proceed almost identically in other eukaryotes . subsequently , the dol - pp - linked glc3man9glcnac2 is transferred as a whole to an asparagine residue within an n - x - t / s consensus sequence of a nascent peptide , which is catalyzed by the oligosaccharyltransferase ( ost ) , and then the n - glycosylated proteins are modified in a species - specific manner and transferred through the secretory pathway to the cell surface where they either get exported or anchored to the plasma membrane , to the extracellular matrix , or to the cell wall ( figure 1 ) . the ost complex consists of at least eight different subunits , including ost1p , ost2p , wbp1 , stt3p , swp1p , ost4p , ost5p , and ost3p / ost6p [ 6467 ] . although the function of each subunit is still unclear , stt3p is believed to be the catalytic subunit [ 6870 ] , and its homologues are found in almost all eukaryotes . it appears that the a. fumigatus stt3 is also essential as no viable knockout mutant has been recovered . repression of the stt3 gene in a. fumigatus leads to a severe retardation of growth and a slight defect in cell wall integrity . further analysis shows that repression of stt3 upregulates expression of the genes responsible for glucan and chitin synthesis , especially gel1 , gel2 , fska , chse , and chsg . indeed , an increase of cell wall mannoprotein and chitin was observed following repression of the stt3 gene . however , this upregulation of chitin is not accompanied by an activation of the mpka kinase . indeed , only the unfolded protein response ( upr ) is induced . as the upr has been shown to be involved in cwi signaling in a. fumigatus , it is likely that upr , instead of the mpka - dependent cwi signaling pathway , is the major compensatory mechanism induced by repression of the n - glycosylation in a. fumigatus . once glc3man9glcnac2 is transferred to proteins , the n - glycan is processed sequentially in the er and golgi . n - glycan processing is initiated by the removal of the glucose residues catalyzed by er glucosidase i and glucosidase ii . in mammalian cells , n - linked glycan plays a decisive role as a quality control ( qc ) of the folding of secretory proteins , which is composed of calnexin , calreticulin , udp - glucose : glycoprotein glucosyltransferase ( gt ) and glucosidase ii ( gii ) and is essential for cellular survival [ 7577 ] . n - glycans initially serve to increase the hydrophilicity of the as - yet - unstructured nascent polypeptides . subsequently , the two outermost glucose residues of the n - glycan are removed by the sequential action of glucosidase i ( gi ) and gii to the monoglucosylated form , which is recognized and bound by calnexin , a type i er membrane lectin , and calreticulin , its soluble relative . for many glycoproteins , the interaction with calnexin or calreticulin slows down the rate of folding but increases efficiency . gii - catalyzed removal of the third glucose residue follows the dissociation of folding substrates from calnexin and is required for release of native polypeptides from the er and transport to their final destination . the folding sensor gt adds back a terminal glucose to promote reassociation of nonnative polypeptides released from calnexin , thus prolonging their retention in the er folding environment . cycles of de-/reglucosylation might be protracted until the polypeptide released from calnexin fulfills quality control requirements . when correct folding is not achieved , an er - specific n - glycan - dependent pathway of degradation removes the misfolded proteins . when n - glycosylation is inhibited , the most commonly observed effect is the generation of misfolded , aggregated proteins that fail to reach a functional state [ 75 , 76 ] . before entering the qc system , the outermost glucose residue of the n - glycan is trimmed by er glucosidase i . a human inherited glucosidase i deficiency has been reported to result in neonatal birth with severe generalized hypotonia and dysmorphic features . unlike mammalian cells , s. cerevisiae lacks a calnexin cycle and gt and only has an effective mannosidase i - dependent erad system [ 80 , 81 ] . the yeast glucosidase i ( cwh1p ) is encoded by the cwh41 gene . mutational defects in the cwh41 gene cause severe and selective instability of glycoprotein kre6p , a putative golgi glucan synthase required for -l,6-glucan synthesis [ 23 , 83 , 84 ] . some filamentous fungi have been proposed to possess n - glycan - dependent qc of glycoprotein folding based on fungal genome sequence data . recently , evidence that filamentous fungi possess an n - glycan - dependent qc system has been reported in a. fumigatus [ 37 , 86 ] . indeed , calnexin ( aas68033 ) , glucosidase ii , and gt have been annotated in the last release of the a. fumigatus genomic database ( figure 2 ) . zhang et al . reported that deletion of the cwh41 gene in a. fumigatus results in defective n - glycan processing of the proteins secreted by a. fumigatus . although afcwh41 is not essential for hyphal growth and virulence , a severe reduction in conidial formation , abnormalities of polar growth and septation , and a temperature - sensitive deficiency of cell wall integrity were documented . also , the genes encoding rho - type gtpases ( rho - type gtpase / cdc42 ) were upregulated , which suggests that the cwi pathway was activated in the mutant . after processing by two er -glucosidases , the n - glycan is further processed by the action of various 1,2-mannosidases , which can remove one or more of the four 1,2-linked mannose residues . in mammalian cells , man9glcnac2 is converted to man5glcnac2 by the action of er and golgi -mannosidases , which is the precursor for complex , hybrid , and high - mannose n - glycans . in s. cerevisiae , a specific er 1,2-mannosidase converts man9glcnac2 into man8glcnac2 , which is elongated in the golgi to form an outer chain containing up to 200 residues of mannose [ 89 , 90 ] . a. saitoi and trichoderma reesei have been found to produce n - glycan structures containing five mannose units ( man5glcnac2 ) , suggesting further processing of the man9glcnac2 precursor [ 91 , 92 ] . the n - glycans on mature secreted glycoprotein produced by a. fumigatus are man6glcnac2 , man7glcnac2 , and man8glcnac2 , in which man6glcnac2 is the major glycoform . these observations demonstrate that n - glycan synthesis in filamentous fungi seems to differ from that in yeast and is similar to that in higher eukaryotes ( figure 3 ) . although small n - glycans are commonly found on glycoproteins of a. fumigatus , hex5 - 13hexnac2 glycans on the galactomannoproteins , and man5 - 9glcnac2 as well as galf1man5 - 7glcnac2 structures on other secreted glycoproteins have been identified in a. fumigatus [ 93 , 94 ] . the enzyme ( udp - galp mutase ) required to synthesize the requisite udp - galf donor has been shown to be an important factor in biosynthesis of the cell wall in a. fumigatus , while the gene / enzyme responsible for the transfer of galf has not been identified . recently , the a. fumigatus och1 , a key mannosyltransferase for synthesis of elaborated protein n - glycans in yeast , has been identified . deletion of the och1 gene results in a reduction of sporulation in the presence of high calcium concentrations . this evidence suggests that polymannosylated n - glycans exist in a. fumigatus and certain proteins engaged in sporulation require n - glycan outer chains to be fully functional . the -mannosidases have been classified into two groups : class i and class ii [ 102 , 120 , 121 ] . class i -mannosidases include er man9-mannosidase , endomannosidase , and golgi mannosidase i. class ii -mannosidases include the lysosomal mannosidases , golgi mannosidase ii , yeast vascular mannosidase [ 98 , 99 ] , and er -mannosidase ii [ 122 , 123 ] . several golgi -mannosidases have been cloned and characterized from penicillium citrinum [ 124 , 125 ] , a. saitoi , a. oryzae , t. reesei , and a. nidulans [ 102 , 129 ] . these enzymes are all monomeric with a molecular weight of 5060 kda and show the maximal activity in the semiacidic condition ( ph 46 ) . class i -mannosidase is known to play an important role in the processing of mannose - containing glycans . in drosophila melanogaster , deletion of the golgi mannosidase i ( mas-1 ) results in viable progeny , and the null organisms synthesize the same range of oligosaccharides as the wild - type ones , albeit at different ratios . in s. cerevisiae , disruption of the er -mannosidase gene does not prevent outer chain synthesis . in the last release of the tigr database ( http://www.aspergillus.org.uk/indexhome.htm?secure/sequence_info/index.php~main ) , nine a. fumigatus genes are annotated to encode -mannosidases , including xp_749038.1 , xp_754794.1 , xp_751252.1 , xp_751819.1 , xp_752444.1 , xp_752825.1 , xp_753592.1 , xp_751114.1 , and xp_750572.1 . among them , msdsp ( xp_752825.1 ) has been identified to encode a class i 1 , 2-mannosidase and acts on man8glcnac2 to produce man6glcnac2 . deletion of the msds gene leads to a defect in n - glycan processing , as well as a reduction of cell wall components ( including -glucan , -glucan , mannoprotein , and chitin ) and reduced conidiation . . in mammalian cells , free oligosaccharides ( fos ) are generated by ost - mediated hydrolysis of glc3man9glcnac2-pp - dolichol in the lumen of the er or peptide n - glycanase ( pngase)-mediated de - n - glycosylation of newly synthesized glycoproteins either in the er or the cytosol . fos that are liberated in the lumen of the er can be transported into the cytosol , where they are trimmed by an endo--d - n - acetylglucosamine h ( endo h)-like enzyme and the -mannosidase man2c1p in order to yield an oligosaccharide , man5glcnac , that can be imported directly into lysosomes to be degraded ( figure 4 ) [ 122 , 123 , 131135 ] . in humans and cattle [ 137139 ] , a deficiency in -mannosidase results in the lethal disease mannosidosis , a rare lysosomal storage disease with a collection of clinical symptoms including progressive mental retardation , impaired hearing , dysostosis multiplex , immune defects , elevation of serum and urinary oligosaccharide levels , and an enlargement of lysosomes in most cell types resulting from the accumulation of undegraded oligosaccharides . the rat man2c1p is involved in oligosaccharide catabolism of misfolded glycoproteins in the lumen of the er which have been retrotranslocated into the cytoplasm for proteolytic disposal [ 131133 ] . a proteolytically cleaved version of the rat man2c1p has been found in the lumen of the er where it is believed to be involved in the early stages of glycoprotein maturation ( also called er -mannosidase ii ) ( figure 4 ) [ 122 , 123 ] . the yeast cytosolic -mannosidase ams1p , a counterpart of man2c1p , is also involved in the processing of fos . since the yeast png1p is mainly localized to the cytosol , it is proposed that the png1p - generated fos may both be generated and processed in the cytosol . the role of the yeast ams1p is to aid in recycling macromolecular components of the cell under nutrient deprivation . interestingly , after its synthesis in the cytosol , the ams1p is translocated into the vacuole by the cytosol - to - vacuole targeting pathway , which suggests a common feature shared by the s. cerevisiae ams1p and its mammalian counterparts . however , the yeast ams1p only participates in recycling or utilizing of oligosaccharide but not in processing of n - glycan ( figure 4 ) . it should also be noted that no structural studies have been performed on the products that can be generated from man8glcnac2 by ams1p , and the ultimate fate of such products remains obscure . on the other hand , two png1p - independent fos pools , man3glcnac2 and man8glcnac2 , are also seen in s. cerevisiae . the pool comprising small fos ( man3glcnac2 ) appears to be disposed of by unknown enzymes in the vacuole . the pool containing mainly man8glcnac2 may be generated and disposed of along the secretory pathway . similarly , a. nidulans -mannosidase iic is also proposed to be involved in oligosaccharide catabolism . both a. nidulans-mannosidase iic and s. cerevisiae ams1p are not essential for normal cellular function since disruption of these genes has no visible effect on growth or morphology [ 98 , 99 , 102 ] . in contrast to its counterpart in yeast or a. nidulans , the a. fumigatus ams1p is required for normal cellular function . deletion of the a. fumigatus ams1 leads to a severe defect in conidial formation , especially at a higher temperature . these results show that the afams1 gene is required for morphogenesis and cellular function in a. fumigatus . the involvement of the afams1 gene in polarized growth demonstrates that the processes involved in fos regulation are important for a. fumigatus . it is likely that the ams1p is involved in cell wall synthesis and thus polarity through the cwi pathway . therefore , probably the afams1 mutant could serve as a simple model to investigate the mechanism of -mannosidosis . functional analyses of the genes required for n - glycosylation reveal that protein n - glycosylation is important for cell wall synthesis , morphogenesis , and polarized growth in a. fumigatus . 2-d gel analysis reveals that deletion of the cwh41 gene encoding glucosidase i in a. fumigatus leads to er stress , which induces overexpression of hsp70 and calnexin chaperone and activates the erad . meanwhile , the proteins required for actin rearrangement are found to be underexpressed or missing , which is consistent with the observation of random localization of actin fibers in the mutant . these observations , for the first time , clearly suggest that n - glycosylation contributes to proper folding and trafficking in a. fumigatus . it appears that proteins involved in cell wall biosynthesis in a. fumigatus are more dependent on the n - glycan - dependent folding system . as in yeast , cell wall defects also trigger the cwi signaling pathway in a. fumigatus , which activates downstream effectors that regulate cell wall biogenesis and polarized growth . zhang et al . [ 37 , 86 ] have proposed that the proteins required for cell wall synthesis or cell wall stress sensing are substrates of a. fumigatus cwh41p and require glucose trimming for their proper localization and function . misfolding of these proteins would cause cell wall defects , which then leads to activation of the erad and rho - type gtpases - mediated cwi pathway . moreover , activation of cdc42 in the cwi pathway also activates sepa , an upstream organizer of actin ring formation at septation sites , and thus causes abnormal polarized growth associated with the afcwh41 mutant ( figure 5 ) . although the phenotypes associated with different n - glycosylation mutants vary , the finding that all of these mutants exhibit phenotypes associated with cell wall defects , abnormal polarization , and morphological changes can all be explained by this proposed model . obviously , more investigations are needed to identify and characterize all of the proteins affected by n - glycosylation in a. fumigatus . this information would be key to understanding the complex compensatory mechanisms participating in cell wall biosynthesis in a. fumigatus , which would serve as a basis to develop new antifungal therapies , as well as help to elucidate the molecular mechanism of human diseases associated with defects in glycosylation .", "o - mannose glycosylated proteins were first discovered in yeast and filamentous fungi , and recently this type of glycoproteins has also been described in mammals . the o - mannosylation most likely occurs in all animals , with the exception of nematodes ( e.g. , caenorhabditis elegans ) ; it is also not detected in plants ( arabidopsis thaliana , oryza sativa ) . however , it has also been discovered in one bacterial species ( mycobacterium tuberculosis ) . in mammalian cells , the inner o - linked mannose is elongated with the first addition of a n - acetylglucosamine and then various sugars . in the case of yeast , the o - mannose type carbohydrate chain starts with a serine / threonine - linked mannose , which is extended to an oligomannose chain . in a. fumigatus , the o - linked glycans on cell wall mannoproteins are found to be glc1 , 6man , galf1 , 6man1 , 6man , galf1 , 5galf1 , 6man1 , 6man and galf1 , 5[galf1,5]3 galf1 , 6man , while only a single mannose residue was detected on secreted proteins . a further type of protein o - glycosylation , in which a single -o - linked glcnac residue is linked to serine and threonine occurs in animals , plants , and filamentous fungi , but not in s. cerevisiae . for this type of protein modification , protein o - mannosylation is initiated by a family of protein o - mannosyltransferases ( pmts ) that are evolutionarily conserved from yeast to human [ 145 , 146 ] . in s. cerevisiae a total of seven pmt family members ( scpmt17p ) are present [ 104 , 147 ] , which fall into three major groups of homology : ( i ) pmt1/5/7 , ( ii ) pmt2/3/6 , and ( iii ) pmt4 . genes with significant homology to pmts have been cloned in humans , mice , and drosophila [ 148150 ] . specific protein substrates that are o - mannosylated by scpmt1p , scpmt2p , or scpmt4p have been described in s. cerevisiae [ 151153 ] . in comparison with s. cerevisiae , the pmt family is less redundant in higher eukaryotes . in drosophila only two pmt family members are present ( rotated abdomen and twisted ) [ 149 , 150 ] . the same is true for mice and humans ( pomt1 and pomt2 ) [ 148 , 150 ] . mutations in human pomt1 , a homologue of the yeast pmt4 , cause walker - warburg syndrome ( wws ) , which is characterized by severe congenital muscular dystrophy , neuronal migration defects , and structural abnormalities of the eye . targeted deletion of pomt1 in mice results in embryonic lethality due to defects in the formation of the reichert 's membrane , the first basement membrane to form in the embryo . mutations of the drosophila pmt homologues alter muscle structures and the alignment of adult cuticle . the pmt family is crucial for viability , cell wall integrity , and morphogenesis in several fungal species , such as s. cerevisiae , s. pombe , c. albicans and c. neoformans , a. nidulans , and a. fumigatus [ 108 , 109 , 111115 , 145 , 156 ] . in s. cerevisiae , single pmt1 mutants fail to grow in anaerobic conditions on some media . the pmt1,2,3-triple mutants grow only in osmotically stabilized medium , whereas the pmt1,2,4- and pmt2,3,4-triple mutants are not viable in any conditions , indicating that pmt protein activity is essential in s. cerevisiae , although individual genes are dispensable . \n c. albicans contains five pmt genes . the pmt1 mutants are viable , but they are defective in undergoing cellular differentiation from yeast to a true hyphal growth form under some conditions . the virulence of the pmt1 null mutant is significantly attenuated , which is likely due to reduced o - glycosylation of the c. albicans adhesin als1p . the pmt phenotypes are closely linked to alterations in cell wall components , including cell wall mannoproteins and polysaccharides . in s. pombe only one member of each pmt subfamily is present , namely , oma1 , oma2 , and oma4 . deletion of oma2 , as well as simultaneous deletion of oma1 and oma4 is lethal . characterization of the viable s. pombe oma1d and oma4d single mutants shows that reduced o - mannosylation results in abnormal cell wall and septum formation , therefore severely affecting cell morphology and cell - cell separation . in c. neoformans , recently , willger et al . showed that pmt2 is an essential gene , and the double pmt1pmt4 deletion is lethal . filamentous fungi , such as a. fumigatus , a. nidulans , neurospora crassa , and fusarium gramineum , contain only three pmt genes that belong to the pmt1 , pmt2 , and pmt4 subfamilies , respectively [ 107 , 108 , 113 ] . all single pmt mutants in a. nidulans are viable but showed reduced growth at elevated temperatures and defects in morphogenesis [ 111 , 112 ] . the double deletion pmta / pmtc ( orthologues of the pmt2 and pmt4 ) and pmtb / pmtc ( orthologues of pmt1 and pmt4 ) are synthetically lethal . have shown that a single deletion of a. fumigatus pmt1 results in temperature - sensitive phenotypes . when the a. fumigatus pmt1 mutant was grown on solid complete medium at 37c , no difference was found between the mutant and the wild type . a strongly retarded growth , however , was observed when this mutant was grown at 42c and 50c . this temperature - sensitive phenotype could be complemented by the addition of 1 m sucrose in the media . further analysis shows that the mannoprotein , -glucan , and chitin in the cell wall of the mutant grown at 37c are increased , while -glucan is reduced . when the a. fumigatus pmt1 mutant was cultured at 42c , the -glucan was increased , while the -glucan was decreased , and the mannoprotein and chitin content remained unchanged . moreover , deficient conidiation and reduced germination have been documented at 42c . as compared with the s. cerevisiae pmt1 mutants , the a. fumigatus pmt1 mutant , as well as the c. albicans and s. pombe pmt1 mutants , shows more severe defects in cell wall integrity . this significant phenotype could be explained by the fewer members of pmt family presented in a. fumigatus , c. albicans , and s. pombe . however , in a recent study by mouyna et al . , the a. fumigatus pmt1 mutant does not show any visible phenotype . in the report by zhuo et al . , the pmt1 deletion mutant was constructed by replacement of the entire coding region of the pmt1 in a. fumigatus strain cea17 ( pyrg ) with a pyrg cassette . therefore , the genetic background of the pmt1 null mutant is pyrg pmt1 , while in the report by mouyna et al . , the pmt1 mutant was constructed by transformation of a. fumigatus strain ku80 with a deletion cassette containing the e. coli phleomycin phosphotransferase gene ( phle ) . therefore , the major differences may be due to the different genetic background of the strains used in these two reports . the single pmt2 or double pmt1pmt4 deletion(s ) are lethal [ 114 , 115 ] . fang et al . reported that reduced expression of pmt2 leads to retarded growth , cell wall defects , abnormal polarity , and reduced conidiation ; however , no temperature - sensitive growth was found . interestingly , this is the first time that pmt2p is revealed to be involved in polarized growth . these observations suggest that a. fumigatus pmt2p is required for cell wall synthesis and morphogenesis and its function is distinct from that of a. fumigatus pmt1p . disruption of a. fumigatus pmt4 leads to abnormal mycelial growth , poor conidiation , and abnormal polarity . although an increased sensitivity to echinocandin , a 1,3-glucan synthase inhibitor , was observed in the a. fumigatus pmt4 null mutant , glucan synthase activity and 1,3-glucan content were not affected . in contrast to its counterpart in c. albicans , a. fumigatus pmt4 is not required for full virulence . the different functions associated with different a. fumigatus pmts are likely due to their different substrate specificities . further investigation of the pmt mutants will be helpful for understanding their molecular mechanism , which will not only increase our understanding of the function of o - mannosylation in a. fumigatus , but also may deepen our understanding of the molecular basis of the human walker - warburg syndrome ( wws ) which features mutations in pomt1 , a homologue of a. fumigatus pmt4p , and results in a failure of polarized growth during neuronal migration .", "gpi anchoring is a conserved glycosylation process in eukaryotes , which enables many cell surface proteins such as cell surface enzymes , receptors , and adhesion molecules to be covalently anchored to the cell membrane . the core structure of the gpi anchor consists of a lipid group , myoinositol , glucosamine , several mannose residues , and a phosphoethanolamine group , which ultimately connects the gpi anchor to the protein via an amide bond . although the number of mannose groups and the position of side - chains on the gpi anchors vary widely between species , a common core structure of etnman3glcn - pi is conserved in all gpi - anchored proteins found in protozoa , yeast , plants , and mammals ( figure 6 ) . gpi anchoring is not essential in mammals at a cellular level as several gpi - deficient cell lines have been established . however , an acquired gpi - anchoring deficiency in haematopoietic stem cells causes paroxysmal nocturnal haemoglobinuria , a rare but serious human disease . also an overexpression of pig - p , a protein of unknown function required for gpi anchor synthesis , has been noted in fetal down syndrome brain . in contrast to mammals , gpi anchor synthesis is essential in s. cerevisiae . in s. cerevisiae , many gpi - anchored proteins are known to be involved in morphogenesis and cell wall organization . one type is the gpi - mannoproteins covalently linked to cell wall -1,6-glucan which play important biological functions in filamentation , mating , flocculation , or adhesion to the external matrix [ 161167 ] . the second type are the gpi proteins associated with the plasma membrane which possess enzymatic activities able to modify cell wall polymers and are involved in altering cell morphology , such as -glucanase and -glucosyltransferase [ 168170 ] . recent studies in a. fumigatus suggest that at least nine gpi - anchored proteins are common to filamentous fungi and yeast . five of them are homologues of putative gpi - anchored yeast proteins that have been shown to play a role in cell wall morphogenesis . the gpi anchor is assembled at the er in multiple steps catalyzed by the concerted actions of approximately 20 proteins . the first step of gpi anchor synthesis is initiated by the transfer of n - acetylglucosamine ( glcnac ) from udp - glcnac to phosphatidylinositol ( pi ) , which is catalyzed by the glycosylphosphatidylinositol - n - acetyl - glucosaminyltransferase ( gpi - gnt ) complex . the mammalian gpi - gnt complex consists of seven proteins , including pig - a , pig - h , pig - c , pig - p , gpi1 , pig - y , and dpm2 . all except dpm2 have structural and functional counterparts in s. cerevisiae , where they are known as gpi3p , gpi15p , gpi2p , gpi19p , gpi1p , and eri1p , respectively . pig - a / gpi3p is believed to possess the catalytic domain because gpi3p binds a photoactivatable udp - glcnac analog and is a member of glycosyltransferase family 4 of retaining glycosyltransferases . the roles of the other subunits in the gpi - gnt complex are as yet unclear , but they may mediate regulatory interactions . in yeast , gpi anchoring is essential for viability and plays an important role in the biosynthesis and organization of the cell wall . a gpi3 temperature - sensitive mutant is not viable at 37c [ 116 , 117 ] . , it is postulated that the introduction of mutations in gpi3/gpig-1 genes allows for minimal level of product function and survival when growing the mutant cells below the restrictive temperatures . however , the mechanism , by which the defect in gpi anchoring leads to a lethal phenotype in these two species , is poorly understood . it has been shown that a. fumigatus gpi anchors possess five mannose residues with a phosphoethanolamine linked on the first three residues [ 174 , 175 ] . the a. fumigatus pig - a gene , the homologue of the gpi3/pig - a gene in yeast , has been investigated . also , an increased content of -glucan and mannoprotein was observed in the mycelial cell wall of the afpig - a mutant . unlike the temperature - sensitive or conditional lethal phenotype seen in the yeast gpi3 mutant , afpig - a can survive at temperatures from 30c to 50c . completely blocking gpi anchor synthesis in a. fumigatus afpig - a leads to cell wall defects , abnormal hyphal growth , rapid conidial germination , and aberrant conidiation . in vivo assays therefore , the gpi anchor seems not essential for viability , but required for cell wall integrity , morphogenesis and virulence in a. fumigatus . indeed , this is the first report that a deficiency in gpi - anchor synthesis does not lead to a temperature - sensitive or conditional lethal phenotype in microbes , which provides an opportunity to identify the basic function of gpi anchoring in fungi .", "during the past 50 years , proteins and nucleic acids have dominated the field of biology . the enormous advances in the analysis of complex carbohydrates have enabled us to investigate the structure and function of carbohydrates , and the field has developed enormously . it is now known that carbohydrates play very important roles , especially in the regulation of development of higher organisms . however , the mechanisms by which carbohydrates play a role in development and diseases are still poorly understood . our knowledge of protein glycosylation comes mainly from the investigation of s. cerevisiae and mammalian cells . although investigations of the model yeast and mammalian cells have been very useful in elucidating the biochemical features of protein glycosylation , these investigations at the cellular level can not reflect the complicated functions of glycosylation in the development of multicellular eukaryotes . therefore , more model systems have been introduced , such as caenorhabditis elegans , drosophila melanogaster , and mice . however , these model systems are still too complex since deletion of individual glycosyltransferase genes in these systems sometimes leads to fetal death or nonvisible phenotypes . as compared with s. cerevisiae , c. elegans , d. melanogaster , or mice , a. fumigatus seems to be an ideal model for investigation of the function of glycosylation since a. fumigatus is a multicellular eukaryote with a relative simple life cycle , in which it undergoes a series of developmental events that require polarized growth . recent progress shows that a. fumigatus has evolved an intact n - glycan - dependent qc system , which is present in mammalian cells but not in yeast . disruption of either processing or degradation of n - glycan in a. fumigatus leads to phenotypes such as cell wall defects and abnormal polarity . based on investigations of s. cerevisiae and filamentous fungi , it is likely that glycosylation first evolved to ensure synthesis of the fungal cell wall and only later did the n - glycan - dependent qc system evolve to ensure precisely controlled cell wall synthesis and polarized growth which are important for multicellular development . however , this hypothesis is controversial . . showed that the n - glycan - dependent qc system is functional in entamoeba , trichomonas , cryptococcus , and s. pombe , but is not functional in some fungi such as giardia and plasmodium , theileria , encephalitozoon , toxoplasma , cryptosporidium , and tetrahymena . they proposed that the n - glycan - dependent qc system was likely present in the common ancestor of extant eukaryotes and was secondarily lost from some eukaryotes . for example , the s. cerevisiae kre5 is believed to be the gt ortholog that no longer glucosylates misfolded glycoproteins but is instead thought to be involved in -1,6-glucan synthesis . of course , the possibility that the s. cerevisiae kre5 is the ancestor of gt can not be excluded . it remains unclear where is the evolutionary origin of glycosylation , what is the basic function of glycosylation at the early stages of evolution , and how glycosylation is regulated . definitely , the answers to these questions will enable us to understand the basic function and regulation of glycosylation in the development of multicellular eukaryotes and help to understand more complex functions in higher eukaryotes . on the other hand , the investigation of a. fumigatus is also a key to understanding complex compensatory mechanisms of cell wall biosynthesis and may provide a new strategy for drug development . during the past few years , the framework of the biosynthetic pathways of glycosylation in a. fumigatus has been delineated . functional analyses of some of the genes in this pathway have shown that glycosylation is required for cell wall synthesis , polarity , morphogenesis , and cellular function in a. fumigatus ( figure 7 and table 2 ) . however , a detailed understanding of this pathway remains unknown , such as details regarding the synthesis of the n - glycan precursor , the precise molecular mechanism of n - glycan processing , qc of protein folding , and modification of the gpi anchor . moreover , the molecular mechanisms by which glycosylation plays a role in morphogenesis and development of a. fumigatus are vaguely understood . therefore , the future direction would be looking for those key proteins that are affected by glycosylation and identifying the signal transduction pathways that link glycosylation and development , through genetic , biochemical , cell biological , and proteomic studies ." ]

[ "in patients with hf , increased raas contributes to the pathogenesis , and ace inhibitors reduce the activity of the raas by inhibiting the production of angiotensin ii . two benchmark randomized controlled trials , namely the cooperative north scandinavian enalapril survival study7 and the studies of left ventricular dysfunction treatment trial,8 demonstrated that ace inhibitors reduce mortality and improved new york heart association class , exercise capacity and cardiac function in patients with hf with reduced ef . subsequently , the assessment of treatment with lisinopril and survival study5 investigated whether ace inhibitors had favourable effects on the outcome of patients with hf with reduced ef in a dosedependent manner . in this trial , an ace inhibitor , lisinopril , at high dose ( 32.535 mg daily ) significantly decreased death or hospitalization for any cause by 12% ( p = 0.002 ) compared with that at low dose ( 2.55 mg daily ) , but not significantly decreased death by 8% ( p = 0.128 ) . show that benazepril at supramaximal dose results in prolonged survival by 41% compared with that at low dose [ 95% confidence interval ( ci ) 0.360.98 , p = 0.042 ] . further research should reveal whether ace inhibitors at supramaximal dose reduce the mortality rate in patients with hf compared with those at high dose . common side effects of ace inhibitors are hyperkalaemia , hypotension , cough , and impaired renal function . according to the severity of these adverse events , it is crucial to manage when to stop uptitration , reduce dose , or discontinue treatment . five ace inhibitors , namely ramipril , enalapril , lisinopril , captopril , and trandolapril , are listed for the treatment of hf with reduced ef , and the starting dose and the target dose are also described in the current guidelines.3 however , it remains unclear which ace inhibitor should be administered or if there are differences between the drugs , because headtohead comparisons are still missing .", "angiotensin receptor blockers would be expected to exert beneficial effects on the treatment of hf through the stronger inhibition of angiotensin ii than ace inhibitors . the evaluation of losartan in the elderly study ii study9 showed that losartan was noninferior to captopril in reducing mortality in elderly patients with hf with reduced ef ( hazard ratio 1.13 , 95% ci 0.951.35 , p = 0.16 ) , and the candesartan in heart failureassessment of reduction in mortality and morbidityalternative trial10 showed that candesartan reduces the risk of cardiovascular death or hospital admission for hf in patients intolerant of ace inhibitors compared to placebo ( hazard ratio 0.70 , 95% ci 0.600.81 , p < 0.0001 ) . subsequently , the heart failure endpoint evaluation of angiotensin ii antagonist losartan study6 revealed that losartan at high dose ( 150 mg daily ) reduced death or hospitalization for hf in patients with hf with reduced ef , compared with losartan at low dose ( 50 mg daily ) ( hazard ratio 0.90 , 95% ci 0.820.99 ; p = 0.027 ) , indicating the doserelated therapeutic effect of arbs on the outcome of hf as well as ace inhibitors . in the swedish heart failure registry,11 the use of losartan was associated with significant increase in mortality in patients with hf compared with that of candesartan ( hazard ratio 1.43 , 95% ci 1.231.65 , p < 0.001 ) , suggesting the different clinical effects among arbs . common side effects of arbs are well known and include hyperkalaemia , hypotension , and impaired renal function , similar to ace inhibitors ; however , arbs are believed to be better tolerated than ace inhibitors . reports that 29 patients ( 29% ) at supramaximaldose benazepril withdrew from this study , as did 12 patients ( 12% ) at supramaximaldose valsartan . doserelated increase in the development of adverse events in patients receiving both benazepril and valsartan is observed , which is inconsistent with the findings of previous studies using very highdose arb.12 , 13 \n in view of these findings , arbs are considered second choice in patients with hf with reduced ef who are not tolerated to ace inhibitors or mineralocorticoid receptor antagonists in the current guidelines .", "because of the different mechanism of action of ace inhibitors and arbs in blocking the raas , combination therapy of an ace inhibitor and an arb was thought to be attractive for the treatment of hf as well as the monotherapy with an arb . in the valsartan heart failure trial,14 the addition of valsartan to conventional therapy for hf resulted in a significant decrease in cardiovascular events compared to placebo ( relative risk 0.87 , 97.5% ci 0.770.97 , p = 0.009 ) ; however , a post hoc analysis indicated increased mortality and complications in the subgroup taking an ace inhibitor , valsartan , and a betablocker . moreover , a recent metaanalysis15 suggested that combination therapy of an ace inhibitor with an arb should not be advocated in patients with hf , because the combination does not seem to reduce mortality or hospitalization and was associated with more adverse events . as described earlier , an ace inhibitor , lisinopril , or an arb , losartan , at high dose produced better clinical outcomes in patients with hf compared with each at low dose but did not decrease mortality significantly.5 , 6 on the other hand , he et al . reports that supramaximal dose of benazepril or valsartan improves not only cardiac function but also survival in patients with dcm compared with the low dose of each medication,16 which indicates that ace inhibitors or arbs at supramaximaldose might produce better outcomes in patients with ef compared with those at high dose ( target dose ) . these unique findings are derived from a singlecentre prospective , randomized , and controlled trial . the sample size is small , but the followup period is long enough to detect the statistical difference in the outcomes of hf among the treatment groups . they should be confirmed with doubleblind multicentre randomized controlled studies .", "recently , ivabradine17 and lcz696 , a combination of the new neprilysin inhibitor sacubitril ( ahu377 ) with valsartan,18 have attracted attention for the treatment of hf . if the efficacy and safety of supramaximaldose valsartan were well acknowledged in this field , it would be helpful to investigate the appropriate dose of lcz696 more precisely .", "" ]

[ "indian population representing one - sixth of the world population has been the global melting pot of human diversity . it has all the world s major linguistic groups and the populations have been shaped by different waves of migrations and admixture ( 1 , 2 ) . further , stringent mating patterns have led to the existence of several endogamous populations , which makes it an important resource for mapping genes ( 3 ) . the indian genome variation consortium ( igvc ) project , an initiative of the council for scientific and industrial research ( csir)was set up to develop a database of genomic variations in indian population for predictive marker discovery in complex diseases such as diabetes , asthma , neuropsychiatric , infectious and cardiovascular disorders , response to drugs , etc . the phase i of the project was conducted to determine the extent of genetic differentiation in india . toward this genotype data of 405 snps from 75 genes and 4.2 mb contiguous chromosome 22 regions were studied in 55 contrasting populations ( 4 , 5 ) . these populations were identified from 4 major linguistic groups namely , austro - asiatic ( aa ) , tibeto - burman ( tb ) , indo - european ( ie ) and dravidian(dr ) spanning 6 geographical regions of habitat ( n , north ; ne , north - east ; w , west ; e , east ; s , south ; c , central ) and different ethnic groups ( lp , large population , caste ; ip , isolated population , tribes ; sp , special population , religious groups ) . five genetically distinct clusters were identified and a set of 24 populations that represent these clusters were selected for the phase ii of the project . in the phase ii , 3824 snps from 834 candidate gene as well as 50 000 ( affy 50 k array ) genome wide neutral markers this initiative lays the foundation for the integration of global genotype - to - phenotype data ( 6 ) with indian population data and development of a federated database .", "to address the need for an online comprehensive resource that enables users to visualize igvc data with integrated information about snps from different resources we have developed igvbrowser as shown in figure 1 . \n distribution of markers in 2.41 mb region in human chromosome 1 from igvc data is displayed along with annotation data from different resources . distribution of markers in 2.41 mb region in human chromosome 1 from igvc data is displayed along with annotation data from different resources . the database includes ( i ) final validated dataset from 1871 samples in phase i comprising of 405 autosomal snps spanning over 75 genes including 90 snps from 5.2 mb region of chromosome 22 from 55 diverse endogamous indian populations ( 3 ) ; ( ii ) phase ii dataset for 3824 snps spanning from 834 genes in 545 samples from 24 igvdb populations and ( iii ) 50 000 ( affy 50k xbai array ) neutral markers in 26 populations . the phase ii populations are a subset of the populations genotyped in the phase i. web - based tool snpper ( http://snpper.chip.org/ ) was used to classify the 4229 markers in phase i and phase ii according to their location in genic regions ( figure 2 ) . similarly , david ( http://david.abcc.ncifcrf.gov/ ) was used to classify the genes containing these markers according to gene disease association class ( figure 3 ) and their mapping in various kegg pathways ( figure 4 ) . we report that a large fraction of genes are implicated in cardiovascular , metabolic , cancer and immune system - related diseases . thus , the igvc data provide a basal level variation data in indian population to study genetic diseases and pharmacology . \n more than 50% of the snps belong to intronic regions and 15% are in coding exons . \n figure 3.bar graph shows the functional annotation of candidate genes in igvc according to gene disease association . \n figure 4.bar graph shows the mapping of candidate genes in significant pathways ( after bonferroni correction ) of kegg pathway database . more than 50% of the snps belong to intronic regions and 15% are in coding exons . bar graph shows the mapping of candidate genes in significant pathways ( after bonferroni correction ) of kegg pathway database . igvbrowser also included hapmap snp genotype data from phases i + ii and iii of the hapmap project ( http://hapmap.ncbi.nlm.nih.gov/downloads/gbrowse/2009-02_phaseii+iii/gff/ ) based on ncbi b36 assembly , dbsnp b126 from 4 populations : yoruba from ibadan , nigeria ( yri ) ; japanese in tokyo , japan ( jpt ) ; han chinese in beijing , china ( chb ) ; and ceph ( utah residents with ancestry from northern and western europe ) ( ceu ) . additional annotation information including cytogenetic positions , link to pathway annotations in the reactome knowledgebase and mrna sequences were retrieved from hapmap in generic feature finding ( gff ) format . annotation data in tab - delimited format for non - coding rna genes and pseudogenes , omim - associated genes , mirbase and snornabase , simple repeats , database of genomic variants were downloaded from ucsc genome annotation database ( http://hgdownload.cse.ucsc.edu/goldenpath/hg18/database ) based on build hg18 . the browser implements one of the widely used platform - independent genome annotation viewer generic genome browser ( gbrowse v1.69 ) , developed by stein et al . ( 7 ) as a part of the generic model organism system database project ( http://www.gmod.org ) . gbrowse is a combination of database and interactive webpage for displaying genomic information along with providing data interoperability across systems running the same software . integrated annotation data from primary sources like ncbi , ucsc and hapmap have been linked with variation data from different ethnic populations in india . compiled data processed into gff format and complete human genome sequence as plain text files were loaded into mysql relational database management system using a script of gbrowse . a user can query chromosomal region of interest , reference snp i d , hgnc symbols , pathway name or any other unique feature recognized by database as a query . it allows researchers to upload their own data in gff format and view it along with data available in igvbrowser . in addition , the resource is facilitated with sequence analysis servers maintained by ncbi and ucsc . online data analysis plugins allows text dumps of visible features using a number of standard formats and also facilitates the download of sequence corresponding to selected region .", "the browser implements one of the widely used platform - independent genome annotation viewer generic genome browser ( gbrowse v1.69 ) , developed by stein et al . ( 7 ) as a part of the generic model organism system database project ( http://www.gmod.org ) . gbrowse is a combination of database and interactive webpage for displaying genomic information along with providing data interoperability across systems running the same software . integrated annotation data from primary sources like ncbi , ucsc and hapmap have been linked with variation data from different ethnic populations in india . compiled data processed into gff format and complete human genome sequence as plain text files were loaded into mysql relational database management system using a script of gbrowse . a user can query chromosomal region of interest , reference snp i d , hgnc symbols , pathway name or any other unique feature recognized by database as a query . it allows researchers to upload their own data in gff format and view it along with data available in igvbrowser in addition , the resource is facilitated with sequence analysis servers maintained by ncbi and ucsc . online data analysis plugins allows text dumps of visible features using a number of standard formats and also facilitates the download of sequence corresponding to selected region .", "indian genome variation data would be enormously useful for the dissection of common complex diseases and in pharmacogenomics studies . frequency profiles of markers on disease or drug - related genes that have been generated through the igvc are being used to identify at - risk chromosomes , founders , ld - based mapping , tracing history of diseases in pharmacogenetics as well as reference populations for mapping relatedness ( 3,4,5,819 ) . the interactive web browser , igvbrowser , has been created as a central repository for the current and future dataset on indian populations and is being made accessible in the public domain . a possible integration of igvbrowser with hgvbaseg2p ( 20 ) can enable researchers for cross study comparison among different populations of the world for disease gene association study .", "indian genome variation project was funded by the council for scientific and industrial research programme cmm0016 and sip0006 . funding for igvbrowser and open access charge is provided by european community 's seventh framework programme ( fp7/2007 - 2013 ) under grant agreement number 200754the gen2phen project ." ]

[ "coronary artery disease ( cad ) remains the principal cause of mortality and morbidity around the world [ 1 , 2 ] . although the mechanisms are still not entirely resolved , previous studies have demonstrated that an imbalance between t - helper 1- ( th1- ) mediated and th2-mediated immune functions contributes to the development of atherosclerosis . recently , th17 , which are a newly defined subset different from th1 and th2 , reactive to autoantigens are involved in the pathogenesis of several autoimmune diseases [ 4 , 5 ] . in addition to th1 , th2 , and th17 lineage , regulatory t cells ( tregs ) , a special subset of cd4 t cells , inhibit atherosclerosis development by attenuating activated t cell responses [ 6 , 7 ] . inspiringly , previous clinical and experimental studies from our laboratory have found that th17/tregs functional imbalance exists during atherogenesis , indicating that the imbalance of th17/tregs plays a critical role in cad [ 8 , 9 ] . hence , these findings have showed that cd4 t cell subpopulations play an important role in the initiation and progression of atherosclerosis . it is well known that cd4 t cells are divided into different subsets depending on the cytokines they produce . interferon- ( ifn- ) , the principal cytokine of th1 cells , is proinflammatory and exacerbates atherosclerotic disease , while the th2 cytokine such as interleukin- ( il- ) 4 is considered to be mainly atheroprotective and can neutralize th1 cytokine activity [ 1012 ] . moreover , hashmi and zeng have found that il-17 and il-17 induced cytokines ( il-6 and il-8 ) were significantly increased in acs patients . interestingly , tregs exert antiatherosclerosis partly by secretion of anti - inflammatory cytokine transforming growth factor ( tgf-1 ) , which can in turn induce the expression of forkhead box transcription factor p3 ( foxp3 ) and promote differentiation of tregs derived from cd4cd25 t cells [ 15 , 16 ] . therefore , these findings suggest that cytokines as those mentioned above are also essential for the formation and progression of the atherosclerotic plaque . the galectin family is characterized by conserved carbohydrate recognition domains ( crd ) that can bind glycosylated proteins . galectins are involved in a wide range of biologic processes such as cell adhesion and migration , proliferation and apoptosis , tumor biology , and regulation of the immune system . galectin- ( gal- ) 9 is a member of the galectin family of carbohydrate - binding proteins comprising two carbohydrate recognition domains connected by a linker peptide . gal-9 is mainly expressed by eosinophils , endothelial cells , macrophages , dcs , kupffer cells , vascular endothelial cells , intestinal epithelial cells , and in particular t lymphocytes . furthermore , gal-9 is believed to function predominantly as a multifaceted player in adaptive and innate immunity , especially in t cell development and homeostasis [ 2023 ] . accumulating evidence shows that gal-9 induces apoptosis in subsets of differentiated t cells , particularly in th1 and th17 cells , and stimulates the activity of tregs [ 19 , 2428 ] . indeed , treatment with recombinant gal-9 moderated the progression of experimental autoimmune encephalomyelitis ( eae ) , arthritis , and diabetes in animal models [ 19 , 2931 ] , by reducing the number of th1 and th17 cells and downregulating circulating ifn- levels . t cell immunoglobulin mucin- ( tim- ) 3 has been identified as a receptor for gal-9 . although gal-9 can function in a tim-3-independent fashion , the immune - regulatory effects of gal-9 are largely attributed to gal-9-tim-3 pathway [ 3235 ] . more recently , foks et al . demonstrated that anti - tim-3-ab administration promoted atherosclerotic plaque formation , which indicated that tim-3-gal-9 pathway may be concerned with the development of atherosclerosis . thus , it is reasonable to postulate that gal-9 may be involved in atherosclerosis based cad . in addition , several findings strongly support the original experimental observations that gal-3 plays an important role in the underlying heart failure ( hf ) processes and that elevation of gal-3 is associated with disease progression and poor outcome in hf [ 3739 ] . herein , we investigate serum gal-9 levels in chinese patients with cad , and the severity of coronary arteries stenosis was evaluated by gensini score . furthermore , ifn- , il-4 , il-17 , tgf-1 , high - sensitivity c - reactive protein ( hs - crp ) , and the classical atherosclerosis risk factors were evaluated . additionally , th1 , th2 , th17 , and cd4cd25foxp3 tregs differentiation were detected in pbmc cultures exposed to gal-9 .", "232 patients presenting at the department of cardiology of huazhong university of science and technology affiliated union hospital between jan . 2013 with suspected or established cad were recruited , including 149 males and 83 females . they were divided into four groups : ( 1 ) the control group , which consisted of 50 subjects with nca ( 28 men and 22 women , mean age 56.7 11.7 ) ; ( 2 ) sap group ( 25 men and 15 women , mean age 62.4 10.0 , inclusion criteria : typical chest discomfort that was associated with horizontal or downsloping st - segment depression > 1 mm in an exercise test ) ; ( 3 ) nsteacs group ( 60 men and 30 women , mean age 60.6 9.9 , which included unstable angina pectoris ( uap ) and non - st - segment elevation myocardial infarction ( nstemi ) , inclusion criteria : chest pain at rest with definite ischemic electrocardiographic changes , t - wave inversions and/or st - segment changes , or typical ischemic chest pain which persists for more than 20 min , elevated serum myocardial necrosis markers concentration and dynamic evolution , but not the typical st - elevation electrocardiogram ) ; ( 4 ) stemi group ( 36 men and 16 women , mean age 54.1 12.3 , inclusion criteria : myocardial infarction that was confirmed by a significant increase of serum creatine kinase mb , troponin i levels , and elevation of st - segment ) . furthermore , all participants underwent coronary angiography after admission and completed a standardized questionnaire about previous and present illness , medication history , and smoking status . cardiovascular - interrelated factors , such as age , body mass index ( bmi ) , gender , and ejection fraction ( ef ) were estimated via physical examination , ultrasonic cardiography ( ucg ) , and electrocardiogram ( ecg ) , respectively . patients with the following characteristics were excluded from study enrollment : valvular heart disease , thromboembolism , autoimmune diseases ( systemic lupus erythematosus , rheumatoid arthritis , etc . ) , collagen disease , disseminated intravascular coagulation , severe liver and kidney disease , symptomatic heart failure , trauma or surgery , or malignant disease . the study was approved by the ethics committee of tongji medical college of huazhong university of science and technology , and all participants were provided written informed consent prior to study entry . two experienced cardiologists , who were not aware of the patients ' clinical and biochemical results , visually examined angiographic images to assess the extent and severity of cad . cad diagnosis was made according to the presence of 50% stenosis in 1 main coronary artery . the stenosis severity of cad was assessed by gensini score as previously described . in the ami group , the blood was drawn with a 21-gauge needle for clean venipuncture of an antecubital vein and the samples were collected into sodium heparin vacutainers ( becton - dickinson ) . after centrifugation , the serum obtained was stored at 80c until further use to measure the concentration of gal-9 . the level of gal-9 was measured by elisa according to the manufacturer 's instructions ( r&d systems ) . in addition , the levels of ifn- , il-17 ( bolingkewei biotechnology , china ) , il-4 , hs - crp ( huijia biotechnology , china ) , and tgf-1 ( fumeng gene biotechnology , china ) were measured by elisa , following the manufacturer 's instructions . the minimal detectable concentrations were 28 pg / ml for gal-9 , 1.8 pg / ml for ifn- , 1.8 pg / ml for il-17 , 0.4 pg / ml for il-4 , 22 pg / ml for hs - crp , and 8 pg / ml for tgf-1 . the intra - assay and interassay coefficients of variation for all elisa were < 5% and < 10% , respectively . all the other biochemical measurements , including serum total cholesterol ( tc ) , triglyceride ( tg ) , low - density lipoprotein cholesterol ( ldl - c ) , high - density lipoprotein cholesterol ( hdl - c ) , apolipoprotein a - i ( apoa - i ) , apolipoprotein b ( apob ) , lipoprotein(a ) , creatinine , fasting plasma glucose ( fpg ) , uric acid , and cardiac troponin i ( ctni ) , were carried out by the biochemical laboratory of our cardiovascular institute using standard methods . peripheral blood mononuclear cells ( pbmcs ) from nca ( excluded from hypertension , diabetes , and dyslipidemia ) were isolated by ficoll - hypaque density gradient centrifugation ( pharmacia lkb technology , uppsala , sweden ) . cells from the interphase were collected and washed twice with dulbecco 's phosphate buffered saline ( d - pbs ) . remaining erythrocytes were removed using lysis buffer ( 4.14 g nh4cl , 0.5 g khco3 , and 18.6 mg na2edta in 500 ml water , ph = 7.4 and sterilized ) for 5 min on ice . pbmcs were resuspended in rpmi1640 ( lonza , verviers , belgium ) supplemented with 2.5% fcs , penicillin ( 100 u / ml)/streptomycin ( 100 u / ml ) , and sodium pyruvate ( 1 mm , sigma ) . pbmcs were stimulated with anti - human cd3 and anti - human cd28 antibodies ( both 2 g / ml , sanquin ) in the presence of recombinant gal-9 ( m ) ( 0.010.1 m , prospec - tany technogene ltd . , israel ) for 24 h. cells were allocated into tubes and washed once in phosphate buffered saline ( pbs ) . for tregs analysis , the cells were incubated with anti - cd4-fitc - hab and anti - cd25-apc - hab ( bd pharmingen ) . after the surface staining , the cells were stained with anti - foxp3-pe - hab ( bd pharmingen ) after fixation and permeabilization according to the manufacturer 's instructions . for analysis of th1 , th2 , and th17 cells , the cells were stimulated with phorbol myristate acetate ( pma , 20 ng / ml , alexis biochemicals , san diego , ca ) and ionomycin ( 1 g / ml , alexis biochemicals ) for 4 h in the presence of 2 mol / ml monensin ( alexis biochemicals ) . the incubator was set at 37c under a 5% co2 environment . after culture for 4 hours , the cells were collected for staining according to the instructions . fixation and permeabilization were necessary before staining with anti - ifn--pe- , anti - il-4-pe- , or anti - il-17-pe- hab ( bd pharmingen ) . continuous variables are summarized as mean standard deviation ( sd ) , and categorical data are presented as percentages . the shapiro - wilk test was used to assess the normality of distribution of continuous variables . in order to compare two groups , continuous variables were tested using the independent samples t - test for normally distributed data and the mann - whitney u test for nonnormally distributed data ; the chi - square test was used for categorical variables . when three or more groups were compared , one - way anova was used . if significance was found , newman - keuls test was performed for post hoc analysis to detect the difference among groups . multiple stepwise regression analysis was used to evaluate the influence of different variables on gal-9 and to adjust for covariates . independent factors were sex , age , ctni , and the metabolic - related variables including bmi , fpg , lipid profiles , and hs - crp . to determine the independent predictors for the presence and severity of cad , all the conventional risk factors associated with cad were tested in multiple stepwise regression analysis .", "the prevalence of smoking and the levels of tg , lipoprotein(a ) , fpg , creatinine , hs - crp , and ctni were significantly higher in patients with cad compared to patients with nca group ( all p < 0.05 ) . however , other biochemical results , including tc , hdl - c , ldl - c , and uric acid , were similar between nca and cad patients . compared with stemi group , patients in sap and nsteacs groups showed markedly higher hdl - c levels and age and lower levels of lipoprotein(a ) , fpg , hs - crp , and ctni ( all p < 0.01 ) . compared to patients with sap , the use of aspirin , -blockers , and statins was rare in patients with acs ( all p < 0.05 ) , whereas the levels of lipoprotein(a ) and hs - crp were markedly higher in patients with acs ( all p < 0.01 ) . a significant increase of creatinine levels was observed in patients with stemi compared with nsteacs group ( p < 0.05 ) and an obvious decrease of uric acid levels was found in patients with stemi compared to sap group ( p < 0.01 ) . unexpectedly , the distribution of hypertension , diabetes mellitus , dyslipidemia , and family history was similar among patients with acs and sap . among the total 232 study participants , serum gal-9 levels ranged from 1733.86 to 5259.39 pg / ml . compared with the nca group , patients with cad had significantly lower levels of gal-9 ( 3283.55 587.59 versus 3565.97 544.37 pg / ml , p < 0.05 ; figure 1(a ) ) . in addition , we found that serum gal-9 levels were significantly lower in the stemi ( 3126.36 637.7 pg / ml ) than those in the sap group ( 3607.91 541.35 pg / ml ) or the nca group ( stemi versus sap and nsteacs versus sap , all p < 0.01 ; stemi versus nca and nsteacs versus nca , all p < 0.01 ; figure 1(b ) ) . interestingly , serum gal-9 levels did not differ significantly between patients with nsteacs and stemi ( p > 0.05 ) , nor was there a difference between the sap and nca groups ( p > 0.05 ; figure 1(b ) ) . as shown in figure 2 , serum il-17 , il-4 , ifn- , and tgf-1 were detected in each group . the il-17 and ifn- concentrations in patients with stemi ( il-17 , 57.16 16.14 pg / ml ; ifn- , 13.43 5.29 pg / ml ) and nsteacs ( il-17 , 47.68 14.46 pg / ml ; ifn- , 11.28 4.23 pg / ml ) were significantly higher compared with those in patients with sap ( il-17 , 26.94 9.09 pg / ml ; ifn- , 6.05 2.41 pg / ml ) and nca groups ( il-17 , 24.00 10.14 pg / ml ; ifn- , 5.83 2.12 pg / ml ) ( all p < 0.01 ; figures 2(a ) and 2(c ) ) . il-4 concentrations showed no difference in any of the groups ( stemi , 7.25 3.82 pg / ml ; nsteacs , 7.22 3.87 pg / ml ; sap , 8.12 4.48 pg / ml ; nca , 6.83 3.25 tgf-1 concentrations in patients with stemi ( 4.08 2.13 ng / ml ) and nsteacs ( 4.73 2.71 ng / ml ) were significantly lower than those in patients with sap ( 8.03 3.88 ng / ml ) and nca ( 9.02 4.86 ng / ml ) ( all p < 0.01 ; figure 2(d ) ) . importantly , gal-9 levels were negatively correlated with il-17 ( r = 0.45 , p < 0.001 ; figure 3(a ) ) and ifn- ( r = 0.53 , p < 0.001 ; figure 3(c ) ) but positively associated with tgf-1 ( r = 0.58 , p < 0.001 ; figure 3(d ) ) . however , gal-9 levels showed no correlation with il-4 concentrations ( r = 0.04 , p = 0.528 ; figure 3(b ) ) . to detect the involvement of gal-9 in the induction of differentiation of human cd4 t cells gal-9 expanded the number of cd4cd25foxp3 tregs ( control , 6.99 1.61% ; gal-9 ( 0.01 m ) , 9.24 2.04% ; gal-9 ( 0.03 m ) , 10.27 3.04% ; gal-9 ( 0.1 m ) , 11.24 3.23% ) and decreased the development of th17 ( control , 0.628 0.239% ; gal-9 ( 0.01 m ) , 0.418 0.171% ; gal-9 ( 0.03 m ) , 0.214 0.064% ; gal-9 ( 0.1 m ) , 0.059 0.015% ) dose dependently ( figures 4(c ) and 4(d ) ) , with resulting increase in secretion of tgf-1 ( control , 165.3 48.6 pg / ml ; gal-9 ( 0.01 m ) , 227.8 72.4 pg / ml ; gal-9 ( 0.03 m ) , 312.9 81.7 pg / ml ; gal-9 ( 0.1 m ) , 528.1 97.4 pg / ml ) and suppressed il-17 production ( control , 132.4 23.6 pg / ml ; gal-9 ( 0.01 m ) , 110.3 25.7 pg / ml ; gal-9 ( 0.03 m ) , 81.9 18.0 pg / ml ; gal-9 ( 0.1 m ) , 56.6 13.8 however , the development of th1 and th2 cells and secretion of ifn- and il-4 in the supernatant were similar in the gal-9 untreated and treated pbmcs ( figures 4(a ) , 4(b ) , and 4(e ) ) . as we expected , gal-9 levels were found to be negatively correlated with hs - crp ( r = 0.37 , p < 0.001 ; figure 5(a ) ) , the gensini score ( r = 0.23 , p = 0.001 ; figure 5(b ) ) , fpg ( r = 0.15 , p = 0.027 ; figure 5(c ) ) , and lipoprotein(a ) ( r = 0.16 , p = 0.012 ; figure 5(d ) ) but positively associated with creatinine ( r = 0.21 , p = 0.002 ; figure 5(e ) ) and age ( r = 0.14 , p = 0.028 ; figure 5(f ) ) . to determine which variables were independently associated with gal-9 , multiple stepwise regression analysis using gal-9 as the dependent variable identified sex , age , bmi , fpg , tc , tg , hdl - c , ldl - c , hs - crp , lipoprotein(a ) , creatinine , uric acid , ctni , and therapeutic use of statins as independent variables . after adjustments , only hs - crp ( b = 72.158 , p < 0.001 ) , lipoprotein(a ) ( b = 8.333 , p = 0.045 ) , creatinine ( b = 5.228 , p < 0.001 ) , and use of therapeutic statins ( b = 362.29 , p < 0.001 ) retained significance for independently predicting gal-9 ( table 3 ) . in order to determine which variables gensini score was the dependent variable , and sex , age , bmi , fpg , lipid profiles , gal-9 , hs - crp , uric acid , traditional risk factors , and statins were independent variables . after adjustments , only gal-9 ( b = 0.145 , p = 0.011 ) , age ( b = 0.276 , p < 0.001 ) , and lipoprotein(a ) ( b = 0.280 , p <", "in the present study , we found that participants with cad had lower serum gal-9 levels compared with nca . furthermore , serum gal-9 levels in the acs group were significantly lower than those in the sap or nca group . moreover , gal-9 was found to be independently associated with hs - crp , lipoprotein(a ) , and creatinine . notably , gal-9 suppressed t - helper 17 ( th17 ) and expanded regulatory t cells ( tregs ) as analyzed within the activated cd4 t cell population , resulting in decreased il-17 production and increased secretion of tgf-1 . to the best of our knowledge , this is the first study to investigate the relation of serum gal-9 levels with the presence and the severity of coronary arteries stenosis . mor et al . have reported that cd4cd25 tregs deficiency enhanced atherosclerotic lesion development in ldlr mice , and adoptive transfer of cd4cd25 tregs attenuated the initiation and progression of atherosclerosis in apoe mice [ 42 , 43 ] . moreover , our laboratory has detected that th17/treg functional imbalance exists in patients with acs , suggesting a potential role for th17/treg imbalance in plaque destabilization and the onset of acs [ 8 , 9 ] . of note , gal-9 is a multifunctional modulator of t cell immunity with apoptotic effects on th17 cells and stimulatory activity on tregs in autoimmune diseases . in line with this publication , we found that gal-9 was able to induce cd4cd25foxp3 tregs development and inhibit th17 differentiation in activated pbmcs of nca . therefore , we speculated that gal-9 plays an immune - regulatory role in atherosclerosis via its effects on tregs and th17 cells . acs patients have significantly higher il-17 and il-17 induced cytokines ( il-6 and il-8 ) , while the pleiotropic cytokine ifn- is a proinflammatory regulator that is expressed at high levels in atherosclerotic lesions . in addition , it has been demonstrated that increased expression of tgf-1 is a stabilizing factor in human atherosclerotic plaques . in this study , we also found that il-17 and ifn- concentrations in patients with stemi and nsteacs were significantly higher compared with those in patients with sap and nca , while tgf-1 concentrations in patients with stemi and nsteacs were significantly lower than those in patients with sap and nca . these results again confirmed that inflammatory cytokines mentioned above have differential effects in atherosclerosis based cad . interestingly , gal-9 levels were showed to be negatively correlated with il-17 and ifn- but positively associated with tgf-1 . furthermore , we found that gal-9 was able to increase secretion of tgf-1 and decrease il-17 secretion in activated pbmcs . consequently , our data in vitro imply a protective role for gal-9 in atherosclerosis via expanding tgf-1 and suppressing il-17 secretion . however , the precise effect and mechanism of gal-9 in atherosclerosis are still to be elucidated in atherosclerosis animal models . surprisingly , we found that the development of th1 cells and secretion of ifn- in the supernatant were similar in gal-9 untreated and treated pbmcs , since zhu et al . reported that gal-9 induces apoptosis in th1 cells . this discrepancy may be ascribed to the diverse concentrations of gal-9 and different incubation periods . additionally , il-4 concentrations in the supernatant showed no difference in gal-9 untreated and treated pbmcs . this result further confirms that the effect of il-4 is still controversial [ 45 , 46 ] , reflecting its dual pro- and anti - inflammatory character . moreover , there are numerous publications showing that gal-9 has proinflammatory effects in addition to its immune - suppressive effects , especially through its actions on cells of the innate immune system like dc and nk cells [ 47 , 48 ] . thus , these results indicate that gal-9 has bidirectional effects like many immune - regulatory molecules . our data showed that cad patients had lower serum gal-9 levels than those without cad , and gal-9 was independently associated with the gensini score in patients with cad . these results suggest that low serum gal-9 levels are associated with the presence and the severity of coronary arteries stenosis . previous studies have elucidated that serum biomarkers are recognized as important tools for prediction , diagnosis , risk stratification , and therapeutic decision - marking for patients with cad . accumulating studies demonstrated that atherosclerotic lesion instability and rupture induced by inflammation are the major mechanisms of acs [ 50 , 51 ] . recently , a large number of clinical experiments have reported that hs - crp is not only a biomarker of inflammations and atherosclerosis , but also a marker of atheromatous plaque vulnerability [ 5254 ] . in our study , patients with acs had higher serum hs - crp levels compared to patients with sap . of note , gal-9 was found to be independently associated with hs - crp . hence , low serum concentrations of gal-9 may take part in the onset of acs and may act as a predictor of atheromatous plaque vulnerability . however , whether a causal relationship exists between the two processes is still to be studied . several lines of evidence indicate that lipoprotein(a ) is an independent risk factor for patients with cad [ 55 , 56 ] . all these findings together suggest that gal-9 might be a potential independent biomarker of cad . interestingly , our data showed that serum gal-9 levels were higher in patients of cad complicated with t2 dm than those of cad without t2 dm ( data not shown ) . 's study reporting that serum gal-9 levels are elevated in the patients with type 2 diabetes ( t2 dm ) and chronic kidney disease ( ckd ) . however , serum gal-9 levels were decreased in cad and elevated in the patients with t2 dm . this paradox could be attributed to the fact that atherosclerosis is highly multifactorial , tregs and gal-9 being only some factors among many others . the exact mechanism is still to be elucidated but different diseases may have divergent immune states . worth noting is the fact that the serum gal-9 level seems relatively higher in our study than in the previous studies [ 22 , 57 ] . the differences among these studies might be explained , at least partly , by different experimental designs , different number and characteristics of participants recruited , ethnical differences , medical treatments , lack of standardization of methods for the determination of serum gal-9 levels , and different ways in which samples were handled . nevertheless , several limitations of the present study should be considered . firstly , the number of study participants ( 232 ) was relatively small . secondly , given the cross - sectional design of the study , the causal relationship between gal-9 level and the severity of coronary artery stenosis can not be determined . thirdly , different methods of assessment of the coronary stenosis and the criterion for diagnosis of the diseased artery may lead to another result . finally , although we accounted for confounding of traditional cardiovascular risk factors , a potential for uncontrolled or residual confounding that could influence the relationship between gal-9 and cad would be plausible . in conclusion , we have shown that low serum gal-9 levels are associated with the presence and the severity of coronary arteries stenosis . importantly , gal-9 can expand cd4cd25foxp3 tregs and inhibit th17 development in activated pbmcs , leading to increased secretion of tgf-1 and decreased il-17 secretion . our observations provide evidence of the role of gal-9 in cad and that gal-9 is an independent negative predictor of acs , which may also at least partially explain the protection of gal-9 against coronary atherosclerotic plaque vulnerability . large - scale population - based clinical studies and further experimental studies are needed to elucidate the exact effect and potential biological mechanisms of gal-9 in the pathogenesis of cad and to evaluate whether gal-9 is a potential novel biomarker of cad ." ]

[ "sedation is often required in young children in order to obtain good diagnostic cross - sectional imaging like computed tomography scan ( ct scan ) and magnetic resonance imaging ( mri ) . sometimes sedation is also needed for older children with complex neurodevelopmental disorders , such as autism and attention deficit hyperactivity disorder . moderate sedation is unable to guarantee patient compliance ; therefore , a deeper level of sedation is required [ 1 , 2 ] . the success of sedation for mri has typically been measured by two factors : the safety of sedation procedure ( lack of adverse events ) and its effectiveness ( completion of diagnostic examination ) . it can be challenging to obtain the deep sedation level required to prevent the patient 's movement while maintaining respiratory and hemodynamic stability . therefore , it is very important to select the appropriate drugs and dosage to achieve those objectives . dexmedetomidine is a highly selective adrenoceptor agonist with a distribution half - life of six minutes and an elimination half - life of two hours . five prospective trials have evaluated the efficacy of dexmedetomidine for sedation during noninvasive radiologic imaging [ 812 ] . dexmedetomidine can be associated with side effects of hypotension , bradycardia , and transient hypertension with loading dose . dexmedetomidine has been used at our institution since 2006 for mri and other noninvasive radiologic procedures . the purpose of this retrospective study is to present our institutional experience with dexmedetomidine in relation to efficacy and related side effects .", "collection of quality assurance data includes patient demographics , adverse events , physiologic variables , drug dosages , the time required to sedate the patient , time needed to obtain the imaging study , and recovery time . after approval by the institutional review board , we conducted a retrospective analysis of all patients who received sedation for mri from july 2007 to december 2012 . institutional sedation policies are based on guidelines by the joint commission on accreditation of health care organization and american academy of pediatrics and were closely followed [ 13 , 14 ] . vital signs including pulse oximetry , heart rate , noninvasive blood pressure monitoring , and nasal capnography ( with concomitant oxygen delivery via the nasal cannula ) are continuously monitored and documented every five minutes throughout sedation . at the start of sedation , intravenous dexmedetomidine was bolused at 2 g / kg over 10 minutes followed by a continuous infusion of 1 g / kg / h . most of the patients were sedated by the end of the bolus ; if not , a second bolus of 2 g / kg was repeated over another 10 minutes prior to the start of the maintenance infusion . patients who continue to move after the second bolus or while the procedure is in progress , can compromise the quality of imaging and were given additional medications like midazolam or fentanyl as per physician discretion . mg / kg to a max of 2 mg and for fentanyl was 0.5 mcg / kg1 mcg / kg to a max of 50 mcg . the goal was to achieve a minimum ramsay sedation score ( rss ) of 4 as assessed by a sedation nurse . rss is a clinically derived sedation score generally accepted as a tool for assessing the depth of sedation . usually , a score of 4 - 5 is targeted to ensure appropriate sedation for diagnostic imaging studies [ 11 , 16 ] . peak onset of the sedation was defined as the time from the start of the loading dose to achievement of a ramsay score of 4 . procedure time was the time of achieving the required ramsay score to the end of the procedure ( stoppage of drug administration ) . discharge time was defined as time from the end of the procedure to actual time when the patient was discharged home . normal ranges for heart rates , blood pressure , and respiratory rates for data analysis were based on the published normal of fleming et al . [ 17 , 18 ] . a trained registered nurse provided continuous assessment and monitoring while the procedure was in progress under the direct supervision of a pediatric intensivist . monitoring was continued until the patient was awake with a minimum aldrete score of 9 points , and the patient has tolerated clear liquids prior to discharge [ 19 , 20 ] . all the parents were provided with written discharge instructions and a direct phone number for further assistance or to report any adverse effects . database records were analyzed using dedicated statistical software sas v9.3 ( sas institute , cary , nc ) . changes in the vital signs associated with the use of dexmedetomidine from the baseline were evaluated and compared using student 's t - test and mann - whitney rank - sum test , depending on the distribution of the data . the entire study cohort was divided into three groups depending on dexmedetomidine bolus and additional medications received . dexmedetomidine group a received one bolus ; dexmedetomidine group b received two boluses ; dexmedetomidine group c received one or two boluses and additional medications . three groups were compared with respect to age , weight , blood pressure , heart rate , procedure time , and discharge time using analysis of variance . incidences of bradycardia and hypotension were analyzed with fisher 's exact test , due to low cell counts . discharge time of bradycardia and hypotensive patients was compared with normal cohorts using the t - test .", "the most common indications included seizure disorder , developmental delay and behavioral disorder , autism , and neoplasia . 382 ( 70.2% ) of the total patients received one - time bolus , while two boluses were given to 162 patients ( 29.8% ) . in the population of 544 patients , additional medications ( fentanyl or midazolam ) were required in 117 ( 21.5% ) for spontaneous movements to avoid motion artifacts that can compromise mri quality ( 54 patients with one - time bolus and 43 patients with two boluses ) . dexmedetomidine - induced vital sign changes from baseline for the whole group are shown in figure 1 . hypotension ( systolic blood pressure 20% below the normal limits ) was observed in 100 patients ( 18.4% ) and transient hypertension ( systolic blood pressure > 20% above age - specific high limits ) was observed in 137 of the patients ( 25.2% ) . there were 210 ( 38.6% ) patients who had a significant decrease in respiratory rate , that is , > 20% from the baseline , but no desaturation , upper airway obstruction , or apnea events were observed and the decrease was minimal in 403 patients ( 74% ) . most of the patients received prophylactic supplemental oxygen to maintain oxygen saturation > 95% as per protocol , which makes it impossible to determine the actual incidence of desaturation at room air . patients were divided into three groups based on numbers of dexmedetomidine boluses and additional medications received . comparisons of blood pressure , heart rate , and other clinical measures between these groups of patients are shown in table 2 . procedure time was significantly shorter in dexmedetomidine group a ( 40.31 19.40 min , p < 0.0001 ) compared to the other two groups . oxygen , dose , maximum dbp , maximum respiration rate , and initial spo2 had statistically significant ( but clinically insignificant ) differences between groups . the occurrence of hypotension among all three groups did not reach a statistically significant value ( p = 0.82 ) . decrease in blood pressure from the baseline was frequently observed ; however , medical intervention was not needed to correct it . the incidence of hypotension was usually noticed to be towards the completion of procedure or after stopping the infusion , with a mean procedure time of 48.73 25.46 minutes . initial transient hypertension occurred in 137 patients approximately 20 minutes after the dexmedetomidine bolus and lasted for < 15 minutes . in the population of 544 patients , 165 children ( 30.9% ) had heart rates below the age - specific normal awake range during sedation ( based on the published normal of fleming et al . ) . only in 21 children ( 3.9% of total cohort ) did the lowest recorded heart rate fall > 20% below the given baseline average range . bradycardia ( hr < 60/min ) , as defined according to pediatric advance life support ( pals ) guidelines , was observed in 10 children ( 4.5% ) mostly in the age range of 13 years ( figure 2 ) . all the patients with bradycardia were continuously monitored and assessed by the supervising intensivist for normal blood pressure and oxygen saturation of 95% or above . no patient required treatment . the incidence of bradycardia was high in patients in the age range of 13 years compared with the rest of the cohort . the precise etiology of the bradycardia observed in this analysis can not be delineated as electrocardiogram monitoring is known to be significantly distorted by the magnetohydrodynamic ( mhd ) effect and is nondiagnostic within the bore of any mri magnet . time to discharge when dexmedetomidine was used alone was 92 25 versus 94 37 min when additional medications were used ( p = 0.46 ) . average discharge time among 165 children with bradycardia was longer and statistically significant compared to the other 372 children in the study population without bradycardia ( 99.08 32.57 min versus 89.74 25.54 min , p = 0.0012 , student 's t - test ) . gender was not associated with any change in discharge time ( p = 0.30 ) ( table 3 ) .", "the ideal drug would allow optimal imaging , while maintaining hemodynamic and respiratory stability . as reported in previous studies , this occurred more frequently in hyperactive , uncooperative , and older children [ 4 , 22 ] . dexmedetomidine , a selective alpha 2 adrenoceptor agonist , has a very safe therapeutic window with respect to respiratory depression . this quality offers a distinct advantage in procedural sedations , where the patient is not immediately accessible to the medical team . there are various studies demonstrating that dexmedetomidine is a good option for procedural sedation [ 10 , 12 ] . interestingly , the dose used varies greatly indicating an open debate regarding the best dosage . previous studies indicate that infusion of relatively low dose dexmedetomidine 0.10.7 /kg / h provides effective sedation [ 2327 ] . in a study conducted on eight healthy volunteers receiving dexmedetomidine infusion of 0.20.6 /kg / h , the visual analog sedation scores and bispectral index scores dropped by 3060% . however , this level of sedation will likely not be conducive to pediatric mri sedation , where higher doses of dexmedetomidine will be needed to accomplish the necessary sedation level . while dosing started low in initial reports , a recent one found that higher doses are required and have been well tolerated . a comparison of pentobarbital and chloral hydrate was performed by rooks et al . in 498 children for mri sedation . several clinical trials have compared dexmedetomidine to propofol for pediatric procedural sedation . in a trial of 60 children undergoing mri , onset , recovery , and discharge time were all significantly shorter in the propofol group . adverse effects such as lower blood pressure and heart rate and respiratory rate were also found more in the propofol group . dexmedetomidine safety and efficacy for sedation during noninvasive radiologic procedures have been evaluated in four prospective trials [ 1 , 810 ] . all of these studies reported that the use of high dose dexmedetomidine as a sole sedative resulted in high quality radiologic imaging with less use of additional rescue medicines . our study also demonstrated that the use of high dose dexmedetomidine as sole agent is effective for mri sedation . we used fentanyl and midazolam as rescue medicines in 117 ( 21.5% ) of our patients to avoid imaging artifacts , suggesting that these agents make a significant contribution to the sedation strategy for a sizeable minority of patients . in our study , the heart rate decreased significantly from baseline during sedation . this is an expected effect of anxiolysis and reflects higher baseline heart rate values from anxiety . other studies reported a decrease in heart rate < 20% from the baseline that was considered to be clinically insignificant in 86 ( 26% ) patients . to have a true comparison with previously published data , we use the same definition of bradycardia ; that is , the lowest recorded heart rate during sedation fell > 20% below the given baseline average range . using that definition , the incidence of bradycardia in our study was 3.9% ( 21 children ) in total cohort comparable to 4% as reported by mason et al . more importantly , during those periods of bradycardia , all patients maintained normal blood pressure and normal oxygen saturation ( 95% or higher ) . treating bradycardia in normotensive children with glycopyrrolate has been reported to be associated with hypertensive episode , which could be beneficial to children who are hypotensive and bradycardic at the same time . similar to our findings , previous investigators have also reported the occurrence of transient hypertension with bolus administration of dexmedetomidine . in our study , the occurrence of hypotension associated with high doses of dexmedetomidine was about 18% , observed immediately after stopping the infusion or towards the end of the procedure . none of the children needed any intervention , consistent with observation reported in other studies [ 12 , 31 ] . respiratory events make up a large proportion ( 5.5% ) of sedation complications in children . in some studies , rapid administration of large loading doses has been described to cause respiratory complications [ 3234 ] . a loading dose of dexmedetomidine given over 2 minutes has been reported to cause irregular respiration , apnea , slight hypoxemia , and hypercapnia . however , similar to ours , several other studies have reported trivial effect of dexmedetomidine on respiration [ 12 , 34 , 36 ] which is consistent with the notion that the risk of respiratory depression is minimal with careful dexmedetomidine sedation . despite these supporting lines of evidence , monitoring of respiratory function during the administration of dexmedetomidine in those receiving midazolam or fentanyl , which may depress respiratory function , appears warranted . our reported discharge time of 92 minutes with dexmedetomidine only and 94 minutes when additional medicines were used is comparable to the 90 minutes ' discharge time of heard et al . . observed a recovery time of 47 minutes and mason et al . reported recovery times ranging from 24.8 minutes to 35.2 minutes , depending on the dose of dexmedetomidine used . in some studies , recovery time is the time lapsed until the patient meets the discharge criteria , while in our study , like few others , discharged time is defined as the actual time of leaving the recovery room to go home . discharge time of children experiencing bradycardia was longer than that for those who did not . in our study , 165 children with bradycardia had a mean discharge time which was statistically significant and longer than the other 372 children in the study without bradycardia ( 99.08 minutes versus 89.74 minutes ; p = 0.0012 ) . this probably could be due to the prolonged monitoring of these patients until the bradycardia resolved . recovery time previously reported after sedation with propofol for mri has been 17 8 minutes , almost half of the recovery time when dexmedetomidine was used as a sole agent . in a second trial , forty children between the ages of 1 and 10 years were randomized to receive either a combination of midazolam + dexmedetomidine or propofol only for sedation during mri . the fast recovery times of propofol must be weighed against the fact that it induced deeper sedation with significant hypotension and oxygen desaturation . taking the results of these comparison trials as a whole , dexmedetomidine appears to provide a useful alternative to propofol for procedural sedation in children , with a longer time of recovery but a lower incidence of adverse effects . this is a good alternative to propofol for patients with soy and egg white allergy and also in institutions where use of propofol is strictly limited to be used by anesthesiologists . it could be asserted that the reported efficacy is due to the use of an intensivist based specialized sedation team rather than to dexmedetomidine itself . this is reasonably true to some extent as specialization and experience should increase both success and efficiency . in spite of that , this can be stated with confidence ; much of the reported success is specifically a function of dexmedetomidine . this is a descriptive study and few , if any , conclusions can be drawn about safety because the occurrence of serious sedation related side effects is fortunately rare . additional prospective studies of the sedation for mri in children using a greater number of patients are warranted to provide a true idea of safety . in summary , high dose dexmedetomidine is an attractive and effective medication in children for mri sedation . when using high dose dexmedetomidine as the only agent for pediatric mri , it is not unusual to observe heart rate and blood pressure outside the established awake normal values . in our experience , these changes were pretty benign and were not associated with any adverse event . we conclude and recommend that , from hemodynamics and respiratory perspective , higher dose dexmedetomidine was well tolerated and is effective to use for successful completion of mri , in the majority of pediatric patients ." ]

[ "exposure of ultraviolet ( uv ) irradiation to the skin causes acute and chronic detrimental cutaneous effects , which may result in photocarcinogenesis [ 17 ] . native human melanin includes eumelanin and pheomelanin that contains sulfur , and eumelanin has been found in almost every type of human skin [ 8 , 9 ] . in the skin , melanin synthesized in melanocytes located in the basal layer and hair bulbs transfers to keratinocytes . melanin in keratinocytes acts as a photoprotector through body coloration and scavenging reactive oxygen species [ 1015 ] . in spite of photoprotective role of melanin , there are many cosmetics developed to prevent melanin formation in the skin because of aesthetic satisfaction by whitening ability . of these , inhibitor of tyrosinase , which is a pivotal enzyme for melanin synthesis , has become major ingredient of cosmetics [ 1721 ] . tyrosinase is an enzyme which catalyzes the biological conversion of tyrosine to dopaquinone with dioxygen at the dinuclear copper active site under physiological conditions [ 2224 ] . other than oxidative catalysis of substrates by tyrosinase , a few studies on radical formation by tyrosinase have been reported . for instance , it was reported that tyrosinase - dependent activation of hydroxybenzenes formed reactive compounds including free radical , and some radicals were produced during the tyrosinase reaction and dopa - melanin formation . however , in these few studies , radical species have not been determined . we have studied the tyrosine - tyrosinase reaction in terms of melanin formation and ros scavenging ability of melanin . in a battery of studies , we found radical formation through the enzyme reaction , and discuss the formation mechanism in this paper .", "reagents were purchased from the following sources : l - tyrosine , phosphate buffer solution ( pb , ph 6.5 ) and catalase ( from bovine liver ) from wako pure chemicals ( osaka , japan ) ; tyrosinase ( from mushroom ) , and superoxide dismutase ( sod from bovine erythrocytes ) from sigma - aldrich corp . ( st . louis , mo ) ; 5,5-dimethyl-1-pyrroline - n - oxide ( dmpo ) from labotec ( tokyo , japan ) ; deuterium water ( d2o ) from tokyo chemical industry co. , ltd ( tokyo , japan ) . then 1 mm tyrosine solution was prepared by mixing 5 l of 200 mm tyrosine solution with 5 l of 1 m naoh and 990 l of 0.2 m pb . dmpo was dissolved in ultrapure water to be 4.5 m. the reaction mixture was prepared to contain different activity of tyrosinase , 20 l of 4.5 m dmpo , 60 l of 1 mm tyrosine and 0.2 m pb which was added to adjust a total volume of 200 l . immediately after mixing the mixture was transferred to an esr spectrometry cell , and the esr measurement was started after 45 s. the measurement conditions of esr ( jes - fa-100 , jeol , tokyo , japan ) were as follows : field sweep , 330.80340.80 mt ; field modulation frequency , 100 khz ; filed modulation width , 0.07 mt ; amplitude , 400 ; sweep time , 1 min ; time constant , 0.1 s ; microwave frequency , 9.430 ghz ; microwave power , 45 mw . then 1 mm tyrosine solution was prepared by mixing 5 l of 200 mm tyrosine solution with 5 l of 1 m naoh and 990 l of ultrapure water or d2o . tyrosinase was dissolved in ultrapure water to be 100 u/l . immediately before the measurement tyrosinase was diluted to be 10 u/l with ultrapure water or d2o . dmpo ( 8.9 m ) was diluted to be 4.5 m with ultrapure water or d2o . the reaction mixture was prepared to contain 100 l of d2o , 20 l of 10 u/l tyrosinase ( 90% d2o solution ) , 20 l of 4.5 m dmpo ( 50% d2o solution ) , and 60 l of 1 mm tyrosine ( 99% d2o solution ) . immediately after mixing the mixture was transferred to an esr spectrometry cell , and the esr measurement was started after 60 s. as a control , the reaction mixture was prepared to contain 100 l of h2o ( ultrapure water ) , 20 l of 10 u/l tyrosinase dissolved in h2o , 20 l of 4.5 m dmpo dissolved in h2o , and 60 l of 1 mm tyrosine dissolved in h2o , and was similarly subjected to esr measurement .", "reagents were purchased from the following sources : l - tyrosine , phosphate buffer solution ( pb , ph 6.5 ) and catalase ( from bovine liver ) from wako pure chemicals ( osaka , japan ) ; tyrosinase ( from mushroom ) , and superoxide dismutase ( sod from bovine erythrocytes ) from sigma - aldrich corp . ( st . louis , mo ) ; 5,5-dimethyl-1-pyrroline - n - oxide ( dmpo ) from labotec ( tokyo , japan ) ; deuterium water ( d2o ) from tokyo chemical industry co. , ltd ( tokyo , japan ) .", "then 1 mm tyrosine solution was prepared by mixing 5 l of 200 mm tyrosine solution with 5 l of 1 m naoh and 990 l of 0.2 m pb . dmpo was dissolved in ultrapure water to be 4.5 m. the reaction mixture was prepared to contain different activity of tyrosinase , 20 l of 4.5 m dmpo , 60 l of 1 mm tyrosine and 0.2 m pb which was added to adjust a total volume of 200 l . immediately after mixing the mixture was transferred to an esr spectrometry cell , and the esr measurement was started after 45 s. the measurement conditions of esr ( jes - fa-100 , jeol , tokyo , japan ) were as follows : field sweep , 330.80340.80 mt ; field modulation frequency , 100 khz ; filed modulation width , 0.07 mt ; amplitude , 400 ; sweep time , 1 min ; time constant , 0.1 s ; microwave frequency , 9.430 ghz ; microwave power , 45 mw .", "then 1 mm tyrosine solution was prepared by mixing 5 l of 200 mm tyrosine solution with 5 l of 1 m naoh and 990 l of ultrapure water or d2o . tyrosinase was dissolved in ultrapure water to be 100 u/l . immediately before the measurement tyrosinase was diluted to be 10 u/l with ultrapure water or d2o . dmpo ( 8.9 m ) was diluted to be 4.5 m with ultrapure water or d2o . the reaction mixture was prepared to contain 100 l of d2o , 20 l of 10 u/l tyrosinase ( 90% d2o solution ) , 20 l of 4.5 m dmpo ( 50% d2o solution ) , and 60 l of 1 mm tyrosine ( 99% d2o solution ) . immediately after mixing the mixture was transferred to an esr spectrometry cell , and the esr measurement was started after 60 s. as a control , the reaction mixture was prepared to contain 100 l of h2o ( ultrapure water ) , 20 l of 10 u/l tyrosinase dissolved in h2o , 20 l of 4.5 m dmpo dissolved in h2o , and 60 l of 1 mm tyrosine dissolved in h2o , and was similarly subjected to esr measurement .", "representative esr spectra obtained from tyrosine - tyrosinase reaction with different activity of tyrosinase are summarized in fig . 1 . each spectrum consists of quartet segments ( intensity ratio , 1:2:2:1 ) and triplet of triplet segments ( intensity ratio , 1:1:2:1:2:1:2:1:1 ) . the former segment was assigned to dmpo - oh , a spin adduct derived from oh ( hyperfine coupling constant , an = 1.49 ; ah = 1.49 mt ) . the latter segment was assigned to dmpo - h , a spin adduct derived from h ( hyperfine coupling constant , an = 1.63 ; ah = 2.25 mt ) as reported in a previous study . the ratio of dmpo - h and dmpo - oh generated in the tyrosine - tyrosinase reaction was approximately 1:2 . to examine if o2 and h2o2 are involved in a downstream of the generation process of h and oh , esr signals of dmpo - h and dmpo - oh generated by the tyrosine - tyrosinase reaction were analyzed in the presence of sod , a scavenger for o2 , and catalase , a cleaving enzyme for h2o2 . neither sod ( 1 u/l ) nor catalase ( 1 u/l ) affected the amounts of dmpo - h and dmpo - oh ( data not shown ) , suggesting that neither o2 nor h2o2 is involved in the generation process of h and oh . then to further examine if h2o is a source of h and oh , esr signals of dmpo - h and dmpo - oh generated by the tyrosine - tyrosinase reaction where d2o was used as a major solvent ( 94% d2o solution ) were compared with those where h2o was used as a solvent . as shown in fig . 2 , the amount of dmpo - h was reduced by 70% , suggesting that approximately 70% of h is derived from h2o . thus , we assume that the electron derived from the ligand of tyrosinase reacts with h2o or h to form h. that is , h2o + e oh + h or h + e h. on the other hand , the amount of dmpo - oh was not affected by the replacement of h2o to d2o , suggesting that oh was derived from the catalytic reaction of tyrosine to dopaquinone by tyrosinase . since catalase had no effect on the generation of two radicals as described above , fenton - like reaction in which h2o2 reacts with transient metal copper in the structures of tyrosinase and its intermediates is least likely involved in the generation mechanism of oh . as reported in the previous study on dinuclear copper complexes , a rather stable dicopper - peroxide intermediate in aqueous solution decays through an internal electron transfer from the ligand to produce oh . since tyrosinase is an enzyme which contains dinuclear copper ions at the active site , [ 2224 ] , dicopper - peroxide intermediates formed during the catalytic process of tyrosine to dopaquinone possibly decay to produce oh through an internal electron transfer from the ligand . the proposed mechanism by which h and oh are generated in tyrosine - tyrosinase reaction is illustrated in fig . although tyrosine - tyrosinase reaction is a key step of melanin formation as a photoprotection , it also produces not only h but oh which might be a causative factor of oxidative damage of the skin . since there are many cosmetics developed for whitening ability by inhibiting tyrosine - tyrosinase reaction , our study revealed that they also might contribute to alleviate the oxidative damage of the skin by inhibiting oh generation via the enzyme reaction ." ]

[ "bezoars are masses formed by the condensation of debris or stomach contents in the gastrointestinal tract . there are four major types of bezoars : a trichobezoar consists of hair , a phytobezoar of vegetable and fruit residues , a lactobezoar is formed from dairy products , a pharmacobezoar is caused by medications . a high - fiber diet , incomplete mastication , reduced gastric secretion , and decreased gastrointestinal motility from autonomic neuropathy can predispose patients to phytobezoar formation . it occurs more frequently in the small intestine , particularly in the terminal ileum and jejunum . the complications caused by bezoars are mechanical irritation , gastrointestinal obstruction , and , in severe cases , peritonitis caused by bowel perforation . bezoars are responsible for 0.44% of cases of mechanical intestinal obstruction , which occurs mainly in the stomach and small intestine . contrast - enhanced computed tomography ( ct ) is the method of choice to identify the location , severity , and etiology of intestinal obstruction . we describe our experience regarding a large - bowel obstruction caused by phytobezoar in a patient with a transplanted kidney .", "a 39-year - old man was admitted to our hospital for constipation , distension , and severe acute abdominal pain in the lower left quadrant . his medical history included alport syndrome resulting in progressive chronic kidney disease ( ckd ) , hypertension , and iron deficiency anemia under medical treatment . twelve years ago , he received a successful deceased - donor kidney transplant [ figure 1 ] . at the time of admission , vitals were stable , and he was afebrile . chest x - ray was normal and abdominal x - ray did not show signs of bowel obstruction . coronal computed tomography scan shows transplanted kidney in left iliac fossa ( ) non - contrast ct ( ncct ) of the abdomen was done ( toshiba aquilion 64-tsx-101a / hc ) as the patient had ckd ( serum creatinine level = 7.71 mg / dl ) . ct scan revealed a focal circumferential thickening of the sigmoid colon with an ovoid and encapsulated intraluminal mass measuring 4.7 3.6 cm [ figure 2 ] . dilatation of the proximal segment with abundant fecal material was seen [ figure 2 ] . based on the ct findings , particularly mottled gas pattern and encapsulated wall of the mass , we made the diagnosis of phytobezoar . hence , because of acute intestinal obstruction and to avoid peritonitis , the patient underwent urgent exploratory laparotomy . ( a ) coronal computed tomography scan shows an ovoid intraluminal mass containing mottled gas pattern with encapsulating wall and associated wall thickening ( arrows ) ; note some dilated bowel loops ( stars ) and an abundant fecal material ( arrowhead ) . ( b ) the mean attenuation value of the intraluminal mass is about 10.21 hu the obstructive intraluminal mass in the sigmoid colon was identified ( approximately 4 4 cm in size ) and manually broken down with evacuation of the obstructive material along with large amounts of liquid fecal material . the postoperative course was uneventful and the patient was discharged on the seventh postoperative day . at 3-month follow - up ,", "phytobezoars are concretions of poorly digested fruit and vegetable fibres that are found in the alimentary track and are mostly composed of indigestible cellulose , tannin , and lignin from ingested vegetables and fruits . normally , they are found in the stomach and may enter into the small bowel . the most important risk factors for phytobezoar formation are excessive consumption of fruits rich in fibers , poor dental health , insufficient mastication , diabetic gastroparesis , kidney failure , hypothyroidism , use of drugs which affect gastric motility , and previous gastrointestinal surgery . in our case , other symptoms include abdominal distension , vomiting , constipation , diarrhoea , anorexia , and weight loss . if treatment is delayed , colonic bezoars can be complicated by intestinal obstruction and perforation with consequent peritonitis . plain abdominal radiography and ct scan are used for radiological evaluation of the patients presenting with intestinal obstruction . simple abdominal x - ray may reveal air - fluid levels associated with mechanical obstruction , and occasionally it is possible to see the outline of bezoar , which is difficult to differentiate from abscess or feces within the colon . on abdominal ct , 89% of bezoars appear as spherically - shaped masses containing air - fluid levels . ct is also helpful in discriminating bezoars from other causes of bowel obstruction such as gastrointestinal malignancies , gallstone ileus , etc . in our case indeed , many authors have highlighted some ct features to allow easier differential diagnosis between these two entities . small bowel feces tends to be more amorphous and tubular in shape without evidence of an encapsulating wall , whereas phytobezoars have a well - defined ovoid shape and an encapsulating wall , such as in our case . chen et al . showed that a higher grade of obstruction is commonly associated with phytobezoar impaction without mesenteric fatty stranding and intraperitoneal fluid ; moreover , they found that a combination of the food debris length < 9.5 cm and the mean attenuation value < 11.75 hu of the obstructed bowel at the transition point was suggestive for phytobezoar , such as in our patient . although these features are typically found in the small bowel , they may also be considered very useful in the large bowel . conservative management is considered in uncomplicated cases of colonic bezoars and consist of digital evacuation , enemas and manual disimpaction . if conservative approach fails , a colonoscopy can be attempted for bezoar removal with contextual mechanical fragmentation and extraction using several instruments . although endoscopy has an acceptable success rate and fewer complications than surgery , surgical approach is mandatory in case of endoscopic treatment failure , sigmoid volvulus , hematochezia , intestinal obstructions , perforations , or peritonitis . when surgical approach is chosen , the first step is intestinal decompression and fluid - electrolyte replacement ; later , open or laparoscopic abdominal exploration may be performed . in our case , the patient underwent laparotomic surgery and phytobezoar was manually broken down with evacuation .", "bezoar is a rare disorder , however , it must be suspected in case of mechanical intestinal obstruction . our case underlined the importance of early detection and removal of a bezoar to prevent complications such as obstruction , perforation , or peritonitis .", "", "" ]

[ "mosquito samples were collected in vietnam in 2002 . each species was separated and pooled , and each mosquito pool was then homogenized and centrifuged . the supernatant was filtrated through a 0.22-m filter and then inoculated onto a monolayer c6/36 mosquito cell culture and subsequently incubated at 28c for 7 days . virus amplification in c6/36 cells was repeated twice , and the culture fluids were stored at 80c for further analysis . rna was extracted from the second cell culture fluid by trizol ls reagent ( invitrogen , carlsbad , ca , usa ) . reverse transcription was performed by using superscript iii reverse transcriptase ( invitrogen ) and random hexamers , after rna denaturation at a temperature of 95c for 5 minutes in the presence of 15% dimethyl sulfoxide . pcr was conducted by using takara la taq dna polymerase ( takara bio , inc . , otsu , japan ) with bav targeting primers ( for segment 5 , 5-cagctgcagtggttattgga-3 and 5accgtgcatcttaacccttg-3 ; for segment 8 , 5-ttgcagtcgctgagctttta-3 and 5-cgcatttgatcgtatgcttg-3 ) . these targeting primers were designed from sequences of bav strains from china and java ( genbank accession nos . af134519af134527 , ay549307ay549309 , af052024af052035 , ay568287ay568290 , nc_004211 , nc_004217-nc_004221 , nc_004200-nc_004204 , nc_004198 , and af052008af052013 ) . the amplified cdnas were sequenced in the 3100-avant genetic analyzer ( applied biosystems , foster city , ca , usa ) . the genomic sequences of all 12 genome segments for the 5 strains were determined ( genbank accession nos . the sequences were translated to protein sequences by using the transeq program of the emboss package ( 8) , version 5.00 . the protein sequences were aligned with the t - coffee program version 5.05 ( 9 ) with chinese and javanese bavs . nucleotide sequences were then aligned , on the basis of protein alignment , with the tranalign program of the emboss package . maximum likelihood phylogenetic trees were constructed from the protein - guided alignments of nucleotide sequences with dnaml software of the phylip package ( 10 ) , version 3.67 . five bav strains were isolated in ha tay and quang bing provinces ( figure 1 ) in vietnam from culex annulus and cx . phylogenetic analysis showed diversity within the phylogenetic clustering of each segment ( table 2 ) . segments 7 and 9 formed 5 independent clusters , segment 12 formed 3 clusters , and the remaining segments formed 4 clusters . phylogenetic trees for some representative segments ( segments 2 , 6 , 9 , and 12 ) are shown in figure 2 . javanese strains formed a single cluster for segments 1 , 2 , 6 , 8 , 10 , and 12 . for segments 7 , 9 , and 11 , however , they diverged into 2 clusters , i and ii ( figure 2 , panel c ) . segments 11 and 12 of the 2 vietnamese strains 02vn178b and 02vn018b were included in cluster iii with chinese bavs . segments 6 and 9 of isolate 02vn178b belonged to cluster v , although segments 1 , 2 , 3 , 4 , and 8 belonged to cluster iv . moreover , segments 5 and 7 of isolate 02vn178b and segments 8 and 11 of isolate 02vn009b showed a mixed electrogram pattern of clusters v and iv or iii . mosquito collection sites in vietnam . * length , length of each segment in the reference sequence of banna virus ( bav ) from refseq ( nc_004198 , nc_004200nc_004204 , nc_004211 , nc_004217nc_004221 ) ; aligned area , the fragment used to make the alignment and phylogenetic tree . the numbers are set following the sequences of strain jht-6423 , which is the reference strain in national center for biotechnology information reference sequences . i , the cluster including the javanese jkt-6423 strain ; ii , the cluster specific to the jkt-6969 and jkt-7043 strains ; iii , the cluster including chinese bavs ; iv , the cluster including the vietnamese 02vn018b strain ; v , the cluster including the vietnamese 02vn180b strain .", "we report isolation of bav in vietnam . the nucleotide sequences of the vietnamese isolates genomic rna segments diverged into 2 phylogenetically distant clusters . our data indicate that 2 bav populations exist in the country and that both evolved independently . two strains were clearly different from chinese and javanese bavs ( 02vn078b and 02vn180b ) . two other strains ( 02vn018b and 02vn178b ) were phylogenetically close to chinese bavs when 2 shorter segments , segments 11 and 12 , were analyzed but not when the remaining 10 , longer segments were considered . this finding implies that a recent reassortment event has occurred and that segments of chinese or vietnamese strains were replaced . in addition , although some vietnamese strains were phylogenetically distant , they could produce a viable progeny by reassortment of segments 5 , 6 , 7 , 8 , 9 , and 11 . this finding is clearly illustrated by the diversity in the phylogenetic clustering pattern and the mixed electrogram pattern of these segments ( table 2 ) . analysis of segment 12 showed that cluster iii ( table 2 ) contained 2 vietnamese strains ( 02vn178b and 02vn018b ) and the chinese strains af052030 and yn-6 ( isolated in yunnan province ) and bj95 - 75 ( isolated in beijing ) . this finding suggests the possibility of wide circulation of bavs containing segment 12 type iii not only in southeast asia but also in east asia . a regionwide genotype shift of japanese encephalitis virus ( jev ) , which is also carried by culex spp . mosquitoes , from genotype iii to genotype i , was witnessed in east asia during the 1990s ( 11,12 ) . these results and phylogenetic analysis of old jev strains in japan and southeast asia ( 11 ) strongly suggested that jev could be transferred frequently from southeast asia to east asia . similarly , bavs with segment 12 belonging to cluster type iii were also distributed in both southeast and east asia . therefore , we can speculate that bavs are actively circulating within the asian continent . to achieve a better understanding of the distribution dynamics of bavs in asia , more isolates are needed . in vietnam , a seasonal increase of viral encephalitis and meningitis cases is reported during the rainy season every year . among these cases , 50%70% are diagnosed as japanese encephalitis , while the rest of them remain idiopathic ( p.t . nga et al . , unpub . data ) . a clear association between bav and human diseases , as well as the prevalence of bav infection in humans , has not yet been established in vietnam . we also believe that bav is a good candidate for the differential diagnosis of viral encephalitis and meningitis cases of unknown origin in tropical and subtropical asia , where culex mosquitoes are abundant ." ]

[ "clozapine remains an ultimate option for patients with treatment resistant schizophrenia ( kane 2012 ) . efficacy of clozapine against positive symptoms of schizophrenia was confirmed in numerous studies and meta - analyses ( chakos et al . 2001 ) , including analysis published by the cochrane library ( asenjo lobos et al . however , treatment with clozapine is associated with very severe metabolic side - effects ( newcomer 2005 ) . clozapine - induced weight gain is very common ( wetterling 2001 ) , and so is impaired fasting plasma glucose levels . in patients with schizophrenia weight gain is associated with impaired physical functioning and negative body appraisal ( bachmann et al . 2012 ) , both of which affect quality of life . while treatment with clozapine may reduce mortality by reducing suicide rate , mortality due to clozapine - associated weight gain will diminish reduction in the suicide rate almost entirely over 10 years by the increased mortality associated with weight gain of 10 kg ( fontaine et al . also , obesity is linked with numerous secondary health problems ( pressure overload on lungs , joints and bones ) and is an important risk factor for life - threatening diseases , such as cardiovascular disease , type 2 diabetes and certain cancers . several mechanisms are considered as taking role in clozapine - induced weight gain , including antagonism at histamine h1 receptors ( kroeze et al . various receptors , including aforementioned 5-ht1b and 5-ht1c , regulate activity of the hypothalamic nuclei ( particularly the arcuate nucleus ( arc ) , which plays the key role in appetite regulation ) . activity of arc is also regulated by several hormones of anorexigenic properties : leptin , pancreatic polypeptide ( pp ) , cholecystokinin ( cck ) , glucagon - like peptide-1 ( glp-1 ) , oxyntomodulin ( oxm ) , peptide yy ( pyy ) and the first discovered orexigenic substance - ghrelin ( druce et al . 2004 ) . agouti - related peptide ( agrp ) is one of the hypothalamic hormones that works by increasing appetite and decreasing metabolism and energy expenditure , thus leading to weight gain . it was identified in 1997 based on its sequence similarity with agouti signaling peptide ( asip ) , a protein synthesized in the skin that controls coat color . compared with asip , agrp is physiologically expressed in the hypothalamus ( shutter et al . agrp is also expressed in the adrenal gland , testes , kidneys , and lungs . agrp induces obesity by antagonism of the melanocortin receptors ( mc3-r and mc4-r , subtypes implicated in weight regulation , via metabolism and appetite control ) ( ollmann et al . these neurons make peptides that potently stimulate food intake not only by increasing neuropeptide y ( npy ) signaling , but also by reducing melanocortin signaling via the release of agrp ( morton and schwartz 2001 ) . activity of the agrp / npy neurons is modulated by leptin , released from the adipose tissue , and insulin . the adiposity signals ( insulin and leptin ) are secreted in proportion to body fat content and act in the hypothalamus to inhibit anabolic and stimulate catabolic , effector pathways ( schwartz et al . the increase of food intake following a single central administration of agrp is sustained for up to a week ( hagan et al . 2000 ) , while the response to npy is sustained over hours , rather than days . this study was undertaken with the purpose to determine if patients with schizophrenia on clozapine monotherapy have higher fasting levels of agrp compared with healthy control . in order to provide more accurate measurements , biochemical and anthropometric measurements were combined with body composition determined using bioelectric impedance analysis ( bia ) , which provides accurate measurements of body fat , lean mass and body water ( bosy - westphal et al . this is the first study to investigate such combination of these parameters in subjects with schizophrenia treated with clozapine .", "data for 24 european caucasian adult hospitalized patients with paranoid schizophrenia ( 295.30 according to dsm - iv , f20.0 according to icd-10 ) was included into the study . these subjects were on clozapine monotherapy for at least two months prior the assessments with a minimum dose of 100 mg / day . most patients was in stable phase of the disease ( i.e. no acute psychosis ) . control group was 24 healthy subjects and was gender- and age - matched with patients in the clozapine group . health status of the control subjects was determined on the basis of basic physical examination , including vital signs and an interview . all patients and volunteers included in the study expressed their written informed consent for participation in this study . the blood samples for the chemistry panel were collected between 7 am and 8 am , after ensuring at least 8 h of overnight fasting . glucose , lipids , calcium and uric acid levels were measured using a dirui cs-400 analyzer ( dirui , china ) . homocysteine chemiluminescence assessments were performed using an immulite 2,000 analyzer ( siemens , germany ) , insulin immunochemistry assessments were performed using a cobas e411 analyzer ( roche diagnostics , switzerland ) and albumin levels were assessed using a cobas integra 800 analyzer ( roche diagnostics , switzerland ) . levels of agrp were measured in blood serum using elisa ( enzyme - linked immunosorbent assay ) method . prior to assays , serum samples were stored at 80 c for up to 6 months . elisa assays were performed using commercial kits ( intra - assay : cv < 10 % , inter - assay : cv < 12 % ) manufactured by raybiotech ( usa ) , according to protocol provided by its manufacturer ( all samples were 2-fold diluted ) . metabolic syndrome and abdominal obesity were defined according to international diabetes foundation ( idf ) criteria ( alberti et al . kg / m , 2530 kg / m and 30 kg / m were defined as normal weight , overweight and obesity , respectively . raised triglycerides ( tga ) level 150 mg / dl and/or total cholesterol ( tc ) 200 mg / dl and/or reduced hdl cholesterol level < 40 mg / dl for men and < 50 mg / dl for women and/or raised ldl cholesterol level 135 mg / dl were interpreted as dyslipidemia . corrected calcium was calculated using the formula : corrected calcium [ mg / dl ] = measured total calcium [ mg / dl ] + 0.8 ( 4.0 serum albumin [ g / dl ] ) . insulin resistance was estimated from fasting glucose and insulin results by homeostasis model assessment and quicki index , using the formula : homa1-ir = ( fasting plasma glucose [ mg / dl ] insulin [ mu / l])/405 . homa2-ir index was calculated using a calculator downloaded from http://www.dtu.ox.ac.uk . quicki index ( lower numbers reflect greater insulin resistance ) was calculated using the formula : 1/(log ( fasting insulin [ mu / l ] ) + log ( fasting plasma glucose [ mg / dl ] ) ) . height was measured with a wall - mounted height measure to the nearest 0.5 cm . weight was measured with a spring balance that was kept on a firm horizontal surface . subjects wore light clothing , stood upright without shoes and weight was recorded to the nearest 0.5 kg . body mass index ( bmi ) was calculated as body weight in kilogram divided by the height in meter squared ( kg / m ) . waist , abdominal and hip circumference was measured using a non - stretchable fiber measuring tape . waist - to - hip ratio ( whr ) was calculated as waist circumference divided by hip circumference . whr cut - off points were defined according to who recommendations ( 0.85 for women and 0.9 for men ) . fat mass index ( fmi ) was calculated as total body fat in kilogram divided by the height in meter squared ( kg / m ) . excess body fat according to fmi classification ranges were defined as fmi > 6 for men and fmi > 9 for women body composition was measured using a maltron bf-906 body fat analyzer ( maltron , uk ) , single frequency bioelectrical impedance analyzer to determine resistance and reactance at 50 hz . standard operating conditions were observed by a trained operator including preparation of the participant , electrode placement and operation . the measurement using bia was taken immediately prior to anthropometry measurements with participants lying supine , in a rested state . simple descriptive statistics ( means , standard deviations , 95 % confidence interval [ ci ] ) were generated for all continuous variables . for discrete variables number of patients and percentages are given . skewed variables were transformed to follow normal distribution using log , square root , inverse square root or square transformation . means , standard deviations , and confidence intervals are reported for non - transformed variables , results of tests are reported for transformed or non - transformed variables . if transformation resulted in normal distribution , two - tailed t - test was used to assess inter - group differences , otherwise variables were analyzed using mann associations were tested by pearson s ( for variables with normal distribution ) or spearman 's ( for other variables ) correlation coefficients . the significant level was set at p < 0.05 .", "for group of patients treated with clozapine the mean age was 38.812.6 and 39.912.3 for the control group ( p = 0.62 ) . in both groups there were 12 men and 12 women . in the clozapine group 12 subjects smoked cigarettes and 8 in the control group ( p = 0.38 ) . the mean duration of monotherapy with clozapine was 60.579.4 [ 95 % ci : 27.094.1 ] months and mean clozapine dose was 341.1148.6 [ 95 % ci : 278.4403.8 ] mg / day . detailed results for anthropometric measurements and laboratory tests are shown in table 1 . \n table 1results of anthropometric measurements and laboratory testsclozapine \n n = 24control \n n = 24weight [ kg]78.114.2(72.184.1)72.615.1(66.278.9 ) \n p = 0.08 \n t = 1.38bmi [ kg / m]27.13.6(25.528.6)24.83.5(23.326.2 ) \n p = 0.01 \n t = 2.25fmi [ kg / m]8.93.1(7.610.2)7.73.0(6.49.0 ) \n p = 0.09 \n t = 1.38abdominal circumference [ cm]96.59.4(92.5100.4)85.511.6(80.690.3 ) \n p < 0.001 \n z = 3.58waist circumference [ cm]91.112.1(86.096.2)82.410.6(77.886.8 ) \n p = 0.005 \n z = 2.66hip circumference [ cm]99.08.4(95.5102.5)95.97.1(92.998.9 ) \n p = 0.08 \n t = 1.39whr0.920.08(0.880.95)0.860.08(0.820.89 ) \n p = 0.005 \n z = 2.66sbp [ mm hg]121.713.6(115.9127.4)136.717.9(129.1144.2 ) \n p = 0.001 \n z = 3.26dbp [ mm hg]81.28.5(77.684.8)82.812.1(77.687.9 ) \n p = 0.30 \n t = 0.50uric acid [ mg / dl]4.51.4(3.95.1)4.31.3(3.74.8 ) \n t = 0.57homocysteine [ mol / l]14.5 4.4(12.616.4)13.6 5.0(11.515.7 ) \n p = 0.25 \n t = 0.67tc [ mg / dl]194.2 53.2(171.7216.6)216.6 65.3(189.0244.1 ) \n p = 0.06 \n t = 1.54hdl [ mg / dl]43.5 12.6(38.248.8)55.1 14.3(49.161.1 ) \n p 41.9(104.8140.3)128.3 39.7(111.5145.0 ) \n p = 0.29 \n t = 0.54tga [ mg / dl]140.3 120.4(89.4191.1)104.3 81.4(69.9138.6 ) \n p = 0.07 \n t = 1.50fpg [ mg / dl]103.5 31.7(90.1116.8)87.8 11.7(82.892.7 ) \n p = 0.03 \n t = 1.88insulin [ u / ml]11.8 8.2(8.3 - 15.3)7.7 3.2(6.3 - 9.1 ) \n p = 0.02 \n t = 2.08homa1-ir3.3 3.4(1.84.7)1.7 0.8(1.32.0 ) \n p = 0.009 \n t = 2.46homa2-ir1.6 1.1(1.12.1)1.0 0.4(0.81.2 ) \n p = 0.01 \n t = 2.26quicki0.15 0.01(0.140.15)0.16 0.01(0.150.16 ) \n p = 0.007 \n t = 2.52corrected calcium [ mg / dl]8.6 0.9(8.29.0)8.7 p = 0.37 \n t = 0.33data given as : mean standard deviation ( 95 % ci)bmi = body mass index ; fmi = fat mass index ; whr = waist - to - hip ratio ; sbp = systolic blood pressure ; dbp = diastolic blood pressure ; tc = total cholesterol ; hdl = high density lipoproteins ; ldl = low density lipoproteins ; tga = triglycerides ; fpg = fasting plasma glucose ; homa1-ir = homoeostasis model assessment of insulin resistance 1 ; homa2-ir = homoeostasis model assessment of insulin resistance 2 ; quicki = quantitative insulin sensitivity check index results of anthropometric measurements and laboratory tests data given as : mean standard deviation ( 95 % ci ) bmi = body mass index ; fmi = fat mass index ; whr = waist - to - hip ratio ; sbp = systolic blood pressure ; dbp = diastolic blood pressure ; tc = total cholesterol ; hdl = high density lipoproteins ; ldl = low density lipoproteins ; tga = triglycerides ; fpg = fasting plasma glucose ; homa1-ir = homoeostasis model assessment of insulin resistance 1 ; homa2-ir = homoeostasis model assessment of insulin resistance 2 ; quicki = quantitative insulin sensitivity check index we have found no inter - group differences for body composition analysis . detailed results for bia analysis are shown in table 2 . lean body mass was higher in men in the whole study sample ( 60.16.4 [ 95 % ci : 57.4 - 62.8 ] vs. 43.85.4 [ 95 % ci : 41.546.1 ] kg , t = 9.56 , p < 0.001 ) and in the clozapine group ( 59.65.7 [ 95 % ci : 56.063.3 ] vs. 45.37.0 [ 95 % ci : 40.9 - 49.8 ] kg , t = 5.48 , p < 0.001 ) . similarly , basal metabolic rate was higher in men in the whole study sample ( 1,707.7182.3 [ 95 % ci : 1,630.71,784.6 ] vs. 1,337.3138.4 [ 95 % ci : 1,278.8 - 1,395.7 ] kcal / day , t = 7.92 , p < 0.001 ) and in the clozapine group ( 1,701.2138.2 [ 95 % ci : 1,613.41,789.0 ] vs. 1,362.7173.0 [ 95 % ci : 1,252.71,472.5 ] kcal / day , t = 5.29 , p < 0.001 ) . \n n = 24control \n n = 24total body fat [ kg]25.6 8.8(21.829.2)22.4 8.7(18.726.1 ) \n p = 0.10 \n t = 1.25total body fat [ % ] 32.6 8.4(29.136.2)28.9 7.1(25.831.8 ) \n p = 0.06 \n t = 1.67lean body mass [ kg]52.5 9.6(48.456.5)51.4 10.8(46.855.9 ) \n p = 0.36 \n t = 0.36lean body weight [ % ] 67.6 8.1(64.271.0)71.1 7.1(68.174.1 ) \n p = 0.07 \n t = 1.61total body water [ l]38.4 7.0(35.441.3)37.7 7.9(34.340.9)p = 0.36 t = 0.35total body water [ % ] 49.9 5.4(47.652.1)52.1 5.2(49.854.2 ) \n p = 0.09 \n t = 1.42basal metabolic rate [ kcal / day]1,532.0 p = 0.39 \n t = 0.26data given as : mean standard deviation ( 95 % ci ) results of body composition analysis data given as : mean standard deviation ( 95 % ci ) there were no significant difference for fasting serum levels of agrp between the clozapine group and the control group ( 15.008.65 [ 95 % ci : 11.3418.65 ] vs. 15.336.82 [ 95 % ci : 12.4518.22 ] pg / ml , t = 0.32 , p = 0.37 ) , see fig . 1 . women had significantly lower levels of agrp in the whole study group ( 12.535.65 [ 95 % ci : 10.1414.92 ] vs. 17.808.66 [ 95 % ci : 14.1421.45 ] pg / ml , t = 2.47 , p = 0.009 ) and in the control group ( 12.905.77 [ 95 % ci : 9.2216.57 ] vs. 17.777.14 [ 95 % ci : 13.2322.31 ] pg / ml , t = 1.82 , p = 0.04 ) , but the difference was not significant for the clozapine group ( 12.175.75 [ 95 % ci : 8.5115.83 ] vs. 17.8210.28 [ 95 % ci : 11.28 - 24.36 ] pg / ml , t = 1.64 , p = 0.06).fig . 1mean fasting agrp serum levels [ pg / ml ] in subjects on clozapine and in the control group ( p = 0.37 ; horizontal bars indicate means ) . mean fasting agrp serum levels [ pg / ml ] in subjects on clozapine and in the control group ( p = 0.37 ; horizontal bars indicate means ) . for the whole study group significant correlations of agrp levels were found for total body fat [ % ] ( r = 0.34 , p = 0.02 ) , lean body mass [ kg ] ( r = 0.38 , p = 0.006 ) , lean body mass [ % ] ( r = 0.34 , p = 0.02 ) , body water [ l ] ( r = 0.38 , p = 0.006 ) , body water [ % ] ( r = 0.34 , p = 0.02 ) and homocysteine levels ( r = 0.29 , p = 0.04 ) . for the clozapine group significant correlations of agrp levels were found for total body fat [ % ] ( r = 0.48 , p = 0.02 ) , basal metabolic rate ( r = 0.42 , p = 0.04 ) , lean body mass [ % ] ( r = 0.49 , p = 0.01 ) , body water [ % ] ( r = 0.49 , p = 0.01 ) . for the control group significant correlations of agrp levels were found only for basal metabolic rate ( r = 0.42 , p = 0.04 ) . in the clozapine group there were no significant differences for agrp levels between subjects with or without excess body fat ( based on fmi value ) ( p = 0.59 ) , idf - defined metabolic syndrome ( p = 0.33 ) , smokers and non - smokers ( p = 0.15 ) , subjects with bmi < 25 kg / m and with bmi 25 kg / m ( p = 0.09 ) , subjects with and without impaired fasting glucose ( p = 0.16 ) , subjects with and without abdominal obesity ( p = 0.11 ) , subjects with and without dyslipidemia ( p = 0.09 ) , and subjects with and without homa-1ir defined insulin resistance ( p = 0.07 ) . in the control group there were no significant differences for agrp levels between subjects with or without excess body fat ( based on fmi value ) ( p = 0.20 ) , idf - defined metabolic syndrome ( p = 0.44 ) , smokers and non - smokers ( p = 0.35 ) , subjects with bmi < 25 kg / m and with bmi 25 kg / m ( p = 0.12 ) , subjects with and without impaired fasting glucose ( p = 0.36 ) , subjects with and without abdominal obesity ( p = 0.10 ) , subjects with and without dyslipidemia ( p = 0.37 ) , and subjects with and without homa-1ir defined insulin resistance ( p = 0.13 ) . in the whole study group there was no significant differences for agrp levels between subjects with or without excess body fat ( based on fmi value ) ( p = 0.30 ) , idf - defined metabolic syndrome ( p = 0.43 ) , smokers and non - smokers ( p = 0.29 ) , subjects with bmi < 25 kg / m and with bmi 25 kg / m ( p = 0.39 ) , subjects with and without impaired fasting glucose ( p = 0.29 ) , subjects with and without dyslipidemia ( p = 0.11 ) , and subjects with and without homa-1ir defined insulin resistance ( p = 0.33 ) . there was a significant difference for agrp levels between subjects with or without abdominal obesity ( 13.466.50 [ 95 % ci : 9.0917.83 ] vs. 16.926.93 [ 95 % ci : 12.7321.11 ] pg / ml , t = 1.80 , p = 0.04 ) .", "the main objective of the present study was to find out whether there is a significant difference in fasting serum levels of agrp peptide between patients with schizophrenia on clozapine monotherapy and age- and sex - matched healthy controls . we have found the difference was not significant ( clozapine : 15.008.65 , control : 15.336.82 pg / ml , p = 0.37 ) . we do not know pre - treatment values , so we can not determine whether and how this parameter changed during therapy with clozapine . to our knowledge , no data are available on the effect of clozapine on blood agrp concentrations in humans . limited data are available for olanzapine , which has clinical and pharmacological properties similar to clozapine . results of these studies show that treatment with olanzapine does not affect agrp levels ( basoglu et al . however , in animal study it was demonstrated that administration of olanzapine or clozapine upregulates npy and agrp and downregulates proopiomelanocortin in the arcuate nucleus of the hypothalamus ( ferno et al . we do not know studies demonstrating correlation between blood levels of agrp and levels in the hypothalamus , but since it was showed recently that agrp neurons are unique among hypothalamic neurons by being the predominant neuronal subtype situated outside the blood brain barrier ( olofsson et al . 2013 ) , we may assume that changes in hypothalamic expression are reflected in changes in blood levels . the finding that women had significantly lower levels of agrp in the whole study group ( 12.535.65 vs. 17.808.66 pg / ml , p = 0.009 ) and in the control group ( 12.905.77 vs. 17.777.14 pg / ml , p = 0.04 ) , but not in the clozapine group ( 12.175.75 vs. 17.8210.28 pg / ml , p = 0.057 ) , might indicate that the testes are important source of agrp , as shown previously ( shutter et al . however , several more recent studies showed no difference between men and ( gavrila et al . 2001 ) , therefore it may indicate that plasma agrp levels reflect central agrp concentrations . it was previously reported that total level of agrp is higher in obese subjects ( katsuki et al . 2001 ) , although in another study it has been demonstrated that agrp levels were lower in normal weight group compared with women with anorexia , probably due to increased leptin levels ( moriya et al . we did not measure levels of leptin or acylated ghrelin , but we found in the same group of patients that there were no differences for desacyl ghrelin levels between patients taking clozapine and control group ( wysokiski et al . while there was a significant difference in bmi values between the clozapine group and the control group , we found no differences between both groups for fmi values . compared with bmi , fmi is a better indicator of central obesity since it is much more sensitive to body fat content ( kelly et al . moreover , there were no differences for any of the bia results between both groups . these indicate that there was a substantial similarity between both groups in terms of body fat content , which is important considering that agrp levels may affect or result more from the amount of adipose tissue than from body weight per se . on the other hand , we have found negative correlations between agrp levels and total body fat ( r = 0.34 and 0.48 in the whole study group and clozapine group , respectively ) . these may indicate the effect of leptin on the expression of agrp , but require further studies . additionally , there were positive correlations with lean body mass ( r = 0.38 and 0.49 in the whole study group and clozapine group , respectively ) , body water ( which amount is negatively correlated with the amount of body fat : r = 0.96 , p < 0.001 ) ( r = 0.34 and 0.49 in the whole study group and clozapine group , respectively ) and basal metabolic rate ( r = 0.42 both in the clozapine group and control group ) , also being in line with the above - mentioned mechanism . in animal studies it has been found that high - fat diet leads to decreased expression of agrp in the hypothalamus , probably in the mechanism moderated by leptin ( staszkiewicz et al . we have no detailed data on diet patterns of our study subjects , but reports are consistent that patients with schizophrenia consume higher amounts of high - fat foods compared with healthy population ( dipasquale et al . . this might be one of the reasons why we have found no differences between our study groups . also , level of physical activity ( usually lower in hospitalized patients ) might affect mechanisms regulating agrp levels . finally , another important factor is the effect of treatment mediated by other anabolic or catabolic neuropeptides . here , two most important peptides are leptin ( which decreases agrp levels ) and ghrelin ( which has opposite effect ) and have also been studied most extensively ( sentissi et al . 2008 ) . since both leptin and ghrelin ( andrews 2011 ) may regulate activity of agrp / npy neurons in the arcuate nucleus , effects of antipsychotics on these neuropeptides must be taken into consideration . therefore , a study focused on interactions within this regulatory system would be very important for better understanding of this problem . based on our results however , the low number of study subjects limited the probability of finding inter - group differences due to lack of statistical power . due to the cross - sectional study design causal relationships can not be established and the effect of previous antipsychotic treatment can not be excluded . dual - energy x - ray absorptiometry ( dxa ) should be used to measure body composition and adipose tissue mass more accurately . due to complex structure of interactions between anabolic and catabolic neuropeptides , a longitudinal study comparing these interactions are crucial for understanding mechanisms of treatment - induced weight gain ." ]

[ "it is widely accepted that mutation is the main causal factor for diverse tumorigenesis [ 1 , 2 ] . the recent development of next - generation sequencing ( ngs ) technologies has revolutionized the speed and throughput of dna sequencing , which facilitates the discovery of new driver mutations . for example , the arid1a gene is mutated in 83% of gastric cancers with microsatellite instability and the sf3b1 gene is somatically mutated in 9.7% of chronic lymphocytic leukemia patients [ 4 , 5 ] . in colorectal cancers , although the majority of recurrent mutations have been previously known , some novel mutations , such as the mutations in the sox9 and fam123b genes , were also identified by ngs technology , which may have implications for colorectal tumorigenesis . in melanoma , approximately 40% was found to have causal mutations affecting b - raf function . along with the well - known driver mutations , the novel mutations identified by ngs will be useful for predicting the prognosis and molecular characterization of cancers [ 8 , 9 ] . recently , a number of mutation calling tools , such as varscan , genome analysis toolkit , and mutect , have been developed to detect single - nucleotide variants ( snvs ) or indels from ngs data . however , snv calling from a single cancer case is not the final step for defining clinically meaningful mutations . to define the pathogenic snvs in human cancers , a commonly used approach is to identify the phenotype - associated recurrent mutations in the study group . due to the data size burden of ngs output , profiling the mutations associated with a certain phenotype or prognosis in a study group by a researcher who does not have a bioinformatics background or facilities is very difficult . currently , there is no user - friendly tool supporting methods for the detection of recurrent or phenotype - specific mutations . in this study , in order to support the definition of recurrent mutations or phenotype - specific mutations from ngs data of a group of cancers with diverse phenotypes , we aimed to develop a user - friendly tool , named mutation arranger for defining phenotype - related snv ( map ) .", "map software was designed as a standalone program , compatible in microsoft windows environments with a user - friendly graphic interface , and compiled codes of map can be easily installed . both variant call format and its annotation files , such as annovar output , can be used as input files for map . when a user loads the input file , called sample descriptor file ( gsf ) , map software displays the sample set information and filter options ( fig . 1 ) . once data are loaded , the user can filter the data using the ' analysis options ' tab in map software based on annotation information . by using the sample set and analysis options summary metrics include the mutation status for each sample , total mutation frequency , p - values for differences between phenotype groups based on clinical information , genomic position , reference / observed sequence , and additional information , such as read depth by default . map software also displays more detailed information in summary metrics based on the user - selected ' analysis options . ' in the ' analysis result ' tab , map software provides the frequency- or p - value - based filter function . this functionality supports detection of the recurrent mutations in study subjects and identification of the phenotype - specific mutation that occurs significantly in a certain phenotypic subclass . then , map software represents the user - selected mutations graphically in the ' visualization ' tab . to sort the variants by genomic position , p - value , or frequency , users can use the sort function in the ' analysis result ' tab . details of the program download , installation , and analysis procedures are available in the user manual . the major steps of map are as follows . \n - generating mutation summary metrics in study subjects- determination of recurrent mutations by frequency- determination of phenotype - specific mutations by association test- graphical illustration of user - selected mutations \n - generating mutation summary metrics in study subjects - determination of recurrent mutations by frequency - determination of phenotype - specific mutations by association test - graphical illustration of user - selected mutations", "mutation calling files from genome analysis toolkit can be used directly as input files for ' sample descriptor . ' alternatively , manually prepared standard variant call format is also available . annotation information files , such as annovar outputs , can be used as input files for sample descriptor . gsf is a comma - separated values text file that describes the input files , such as gatk output files and annovar output files , and phenotype information .", "when users load the input file , map software displays the sample set information and filter options in the ' source ' tab . if any file is not prepared properly , map software informs the user in the ' sample set files ' tab . after data are loaded , the user can filter the data using the ' analysis option ' tab based on annotation information . based on user - selected filters in the ' analysis options ' tab , summary metrics represent additional annotation information , such as gene name , function , known variant , and amino acid change . the additional annotations can be hidden using the snp filter option in the ' analysis option ' tab . these mutation metrics are exported into a comma - separated values text file for further investigation .", "in the ' analysis result ' tab , map software defines the recurrent mutations in study subjects by frequency . the frequency threshold can be determined arbitrarily by the user in the ' frequency filter ' function . map also defines the phenotype - specific mutations using the mutation metrics and phenotype information . phenotype - specific mutations that occur more frequently in one of two clinical conditions ( e.g. , drug - responder vs. non - responder ) are determined by chi - square test under the user - defined significance level .", "the graphic user interface is implemented in the software for users to easily handle large - scale data or access the analysis result ( fig . 2b and 2c ) . the recurrent or phenotype - specific mutations can also be demonstrated visually in heat - map style . for example , the left and right of the heat - map represent the sample name and mutational spectrum , respectively . the bottom of the heat - map represents the gene name by color for mutational spectrum . frequency or p - value plots are represented on top of the heat - map ( fig . 2b and 2c ) .", "map is a user - friendly program with multiple functions that supports the determination of recurrent or phenotype - specific mutations and provides graphic illustration images to the users . its operation environment , microsoft windows , enables more researchers who can not operate linux to define clinically meaningful mutations with ngs data from cancer cohorts ." ]

[ "echocardiographic measurements were performed in 19992001 ( baseline ) and 20072009 ( follow - up ) examinations of the hoorn study . the hoorn study is a population - based cohort study on glucose metabolism and cardiovascular diseases , previously described in detail ( 10 ) . at baseline , 290 individuals with normal glucose metabolism ( ngm ) , 187 with impaired glucose metabolism ( igm ) , and 345 with type 2 diabetes participated . at follow - up , 167 ( 20% ) individuals were excluded a priori because of incomplete baseline data ( n = 26 ) , mental incompetence to participate ( n = 12 ) , or death ( n = 129 ) . of the remaining 655 individuals , 441 ( 67% ) participated . thirteen ( 3% ) of those were excluded in the present analyses because of missing echocardiography data at follow - up . to restrict the study population to individuals at risk of developing lv systolic and/or diastolic dysfunction , we also excluded 34 individuals ( 8% ) with an lv ejection fraction < 50% or an la volume index > 40 ml / m at baseline . the local ethics committee approved the study , and written informed consent was obtained from all participants . echocardiography was performed at baseline and follow - up with the use of an hp sonos 5500 echocardiography system ( 24 mhz transducer ) according to a standardized protocol consisting of two - dimensional , m - mode , and pulsed wave doppler assessments as previously described ( 13 ) . at follow - up , this protocol was expanded with tissue doppler assessments of mitral annular velocities . a set of three markers of lv diastolic dysfunction was determined : la volume index , lv mass indexed to height to the power of 2.7 ( 14 ) , and the ratio of early ( e ) mitral valve flow to early ( e ) diastolic lengthening velocity ( e / e ) using tissue and pulsed wave doppler assessments . incident heart failure was considered present if signs and symptoms were accompanied by lv systolic ( lv ejection fraction < 35% ) and/or diastolic dysfunction ( 15 ) . presence of incident lv diastolic dysfunction ( grade 2 or 3 ) was assessed according to international recommendations ( 16 ) . in the present analyses , we primarily focused on previously described ultrasound - derived distensibility coefficients of carotid , brachial , and femoral arteries to assess stiffness of the arterial wall ( 10 ) . additionally , systemic arterial compliance was determined according to the time - decay method and by calculating the ratio of stroke volume to aortic pulse pressure ( 17 ) . augmentation index was determined using applanation tonometry . in a subset of the study population , carotid - femoral pulse wave velocity was approached by measuring carotid - femoral transit time , adjusted for height in the statistical analyses . reproducibility of arterial ultrasound measurements at baseline was assessed by calculating intraobserver intersession coefficients of variation as previously described ( 10 ) . at follow - up , intraobserver intersession coefficients of variation in 10 individuals ( aged 70.3 3.6 years ) were comparable : 4.2 , 13.1 , 4.1 , and 6.1% for lv ejection fraction , la volume , lv mass , and e / e , respectively . for assessment of glucose status , all participants except those with previously diagnosed diabetes underwent a standard 75-g oral glucose tolerance test and were classified into ngm , igm ( impaired fasting glucose and/or impaired glucose tolerance ) , and type 2 diabetes groups according to the 1999 world health organization criteria ( 18 ) . health status , medical history , medication use , and smoking habits were assessed by questionnaires ( 10 ) . waist circumference , blood pressures ( systolic , mean arterial , and pulse pressures ) , and levels of cholesterol , insulin , hba1c , and c - reactive protein were determined as previously described ( 10 ) . descriptive statistics are presented as means sd or , in the case of a skewed distribution , as median ( interquartile range ) . the f test for anova in the case of continuous variables or tests in the case of proportions were performed to test for differences between groups of glucose status . in the case of skewed distributions , the above tests were done on log - transformed data . for every variable that had > 10% missing data , the number missing is presented in the legends of tables 13 . linear regression analyses , adjusted for age and sex , were performed to assess associations of glucose status and arterial stiffness with markers of lv systolic and diastolic dysfunction at follow - up . regression models with arterial stiffness as an independent variable were subsequently adjusted for mean arterial pressure to investigate to what extent these associations were explained by elevated blood pressure . for investigation of changes in markers , lv systolic and diastolic dysfunction according to glucose status or arterial stiffness , we adjusted all models for baseline values of these markers ( models assessing e / e adjusted for baseline la volume index ) . lv systolic and diastolic dysfunction in type 2 diabetes and arterial stiffness might partially be due to underlying factors , like overweight , hypertension , insulin resistance , or previous cardiovascular events ( 19 ) . therefore , we additionally analyzed which potentially underlying or mediating factors contribute to these associations and to what extent by adding these factors one by one or simultaneously to the models ( supplementary data ) . a secondary purpose of these analyses was to investigate potential residual confounding by these factors . product terms were entered to test for effect modification by sex or medication use at follow - up and for interactions of glucose status with arterial stiffness or prior cardiovascular disease . associations of arterial distensibility coefficients , systemic arterial compliance , and arterial compliance coefficients were shown per lower unit to reflect associations with greater arterial stiffness . additional analyses , adjusted for age and sex , were performed to investigate whether diabetes duration had an effect on markers of lv systolic and diastolic function . p values < 0.05 , or < 0.10 in case of interaction analyses , were considered statistically significant . statistical analyses were performed with spss for windows ( version 15.0 ; spss , chicago , il ) .", "echocardiography was performed at baseline and follow - up with the use of an hp sonos 5500 echocardiography system ( 24 mhz transducer ) according to a standardized protocol consisting of two - dimensional , m - mode , and pulsed wave doppler assessments as previously described ( 13 ) . at follow - up , this protocol was expanded with tissue doppler assessments of mitral annular velocities . a set of three markers of lv diastolic dysfunction was determined : la volume index , lv mass indexed to height to the power of 2.7 ( 14 ) , and the ratio of early ( e ) mitral valve flow to early ( e ) diastolic lengthening velocity ( e / e ) using tissue and pulsed wave doppler assessments . incident heart failure was considered present if signs and symptoms were accompanied by lv systolic ( lv ejection fraction < 35% ) and/or diastolic dysfunction ( 15 ) . presence of incident lv diastolic dysfunction ( grade 2 or 3 ) was assessed according to international recommendations ( 16 ) .", "in the present analyses , we primarily focused on previously described ultrasound - derived distensibility coefficients of carotid , brachial , and femoral arteries to assess stiffness of the arterial wall ( 10 ) . additionally , systemic arterial compliance was determined according to the time - decay method and by calculating the ratio of stroke volume to aortic pulse pressure ( 17 ) . augmentation index was determined using applanation tonometry . in a subset of the study population , carotid - femoral pulse wave velocity was approached by measuring carotid - femoral transit time , adjusted for height in the statistical analyses .", "reproducibility of arterial ultrasound measurements at baseline was assessed by calculating intraobserver intersession coefficients of variation as previously described ( 10 ) . at follow - up , intraobserver intersession coefficients of variation in 10 individuals ( aged 70.3 3.6 years ) were comparable : 4.2 , 13.1 , 4.1 , and 6.1% for lv ejection fraction , la volume , lv mass , and e / e , respectively .", "for assessment of glucose status , all participants except those with previously diagnosed diabetes underwent a standard 75-g oral glucose tolerance test and were classified into ngm , igm ( impaired fasting glucose and/or impaired glucose tolerance ) , and type 2 diabetes groups according to the 1999 world health organization criteria ( 18 ) . health status , medical history , medication use , and smoking habits were assessed by questionnaires ( 10 ) . waist circumference , blood pressures ( systolic , mean arterial , and pulse pressures ) , and levels of cholesterol , insulin , hba1c , and c - reactive protein were determined as previously described ( 10 ) .", "descriptive statistics are presented as means sd or , in the case of a skewed distribution , as median ( interquartile range ) . the f test for anova in the case of continuous variables or tests in the case of proportions were performed to test for differences between groups of glucose status . in the case of skewed distributions , the above tests were done on log - transformed data . for every variable that had > 10% missing data , the number missing is presented in the legends of tables 13 . linear regression analyses , adjusted for age and sex , were performed to assess associations of glucose status and arterial stiffness with markers of lv systolic and diastolic dysfunction at follow - up . regression models with arterial stiffness as an independent variable were subsequently adjusted for mean arterial pressure to investigate to what extent these associations were explained by elevated blood pressure . for investigation of changes in markers , lv systolic and diastolic dysfunction according to glucose status or arterial stiffness , we adjusted all models for baseline values of these markers ( models assessing e / e adjusted for baseline la volume index ) . lv systolic and diastolic dysfunction in type 2 diabetes and arterial stiffness might partially be due to underlying factors , like overweight , hypertension , insulin resistance , or previous cardiovascular events ( 19 ) . therefore , we additionally analyzed which potentially underlying or mediating factors contribute to these associations and to what extent by adding these factors one by one or simultaneously to the models ( supplementary data ) . a secondary purpose of these analyses was to investigate potential residual confounding by these factors . product terms were entered to test for effect modification by sex or medication use at follow - up and for interactions of glucose status with arterial stiffness or prior cardiovascular disease . associations of arterial distensibility coefficients , systemic arterial compliance , and arterial compliance coefficients were shown per lower unit to reflect associations with greater arterial stiffness . additional analyses , adjusted for age and sex , were performed to investigate whether diabetes duration had an effect on markers of lv systolic and diastolic function . p values < 0.05 , or < 0.10 in case of interaction analyses , were considered statistically significant . statistical analyses were performed with spss for windows ( version 15.0 ; spss , chicago , il ) .", "a total of 394 individuals in the age range of 5087 years were included in the present analyses , 87 ( 22% ) of whom had igm and 128 ( 32% ) of whom had type 2 diabetes . compared with individuals who were not included , these individuals were younger and less likely to have type 2 diabetes and had more favorable levels of arterial stiffness and lv systolic and diastolic dysfunction at baseline ( data not shown ) . individuals with type 2 diabetes were younger , had higher bmi and blood pressure , and had greater arterial stiffness and more severe lv systolic and diastolic dysfunction at baseline compared with individuals without type 2 diabetes ( table 1 ) . heart failure incidence was not significantly different : 23 ( 21% ) in type 2 diabetes versus 15 ( 19% ) in igm and 24 ( 15% ) in ngm . incidence of lv diastolic dysfunction grade 2 or 3 was higher with deteriorating glucose status : 88 ( 72% ) in type 2 diabetes versus 52 ( 61% ) in igm and 55 ( 31% ) in ngm . characteristics according to glucose status the presence of type 2 diabetes was associated with more severe levels of all markers of lv systolic and diastolic dysfunction : lv ejection fraction , la volume index , lv mass index , and e / e ( table 2 ) . after adjustment for age and sex , lv ejection fraction at follow - up was 2.98% lower in individuals with type 2 diabetes at baseline compared with that in subjects with ngm . individuals with type 2 diabetes had a 3.71 ml / m higher la volume index , 5.86 g / m higher lv mass index , and 1.64 higher e / e. these associations were attenuated after adjustment for baseline markers of lv systolic and diastolic dysfunction , but type 2 diabetes was still significantly associated with a higher lv mass index ( 3.41 g / m ) and e / e ( 1.43 ) . individuals with igm compared with those with ngm had a 2.93 g / m higher lv mass index , independent of baseline lv mass index . markers of lv systolic and diastolic dysfunction at follow - up according to baseline glucose status ( ngm = reference ) associations of type 2 diabetes with markers of lv systolic and diastolic dysfunction were largely independent of blood pressure , lipid levels , renal function , c - reactive protein , and coronary artery disease ( supplementary data table a ) . adjustment for hba1c levels or insulin resistance diminished the associations of type 2 diabetes with lv ejection fraction and la volume index . associations between type 2 diabetes and lv mass index were attenuated after adjustment for waist circumference . interaction analyses showed that type 2 diabetes was particularly associated with a lower lv ejection fraction in individuals with prior cvd . a longer diabetes duration ( per year ) was associated with a 0.59 ml / m higher la volume index at follow - up but not with other markers of lv systolic and diastolic function . greater stiffness of carotid , brachial , and femoral arteries , measured as lower distensibility coefficients , was associated with higher levels of la volume index , lv mass index , and e / e ( table 3 ) . after adjustment for age and sex , every 10 kpa lower carotid artery distensibility coefficient was associated with a 0.31 ml / m higher la volume index and a 0.58 g / m higher lv mass index . every 10 kpa lower brachial artery distensibility coefficient was associated with a 0.43 ml / m higher la volume index and a 0.09 higher e / e. every 10 kpa lower femoral artery distensibility coefficient was associated with a 0.80 ml / m higher la volume index , a 0.91 g / m higher lv mass index , and a 0.09 higher e / e. these associations were independent of mean arterial pressure , except for associations with e / e. after adjustment for baseline markers of lv diastolic dysfunction , 10 kpa lower distensibility coefficients of carotid , brachial , and femoral arteries remained significantly associated with a 0.29 , 0.38 , and 0.73 ml / m higher la volume index , respectively . markers of lv systolic and diastolic dysfunction at follow - up according to baseline arterial distensibility coefficients associations of femoral distensibility coefficients with markers of lv systolic and diastolic dysfunction were partly dependent on body weight and systolic blood pressure ( supplementary data table a ) . lower compliance coefficients of brachial and femoral arteries , as well as a higher young elastic modulus or pulse pressure , were similarly associated with more severe lv diastolic dysfunction ( supplementary data table b ) . a higher aortic augmentation index was the only marker of arterial stiffness that was significantly associated with lv systolic dysfunction : lv ejection fraction was 0.21% lower with every percentage point higher aortic augmentation index . carotid - femoral transit time was measured in a subset of 178 individuals , and lv ejection fraction was 0.14% lower with every second shorter carotid - femoral transit time , though not significantly ( p = 0.13 ) . there was no interaction between glucose status and arterial distensibility coefficients in their associations with lv systolic and diastolic dysfunction ( p values for interaction > 0.10 ) . figure 1 shows the associations of glucose status and sd scores of arterial stiffness ( measured as femoral artery distensibility coefficients ) with sd scores for all four markers of lv systolic and diastolic dysfunction , adjusted for age and sex . the right half of each histogram shows that values hardly changed if glucose status and arterial stiffness were combined in one model . for instance , the presence of type 2 diabetes was associated with a 0.26 sd lower lv ejection fraction after adjustment for age and sex . after subsequent adjustment for arterial stiffness , this value remained similar , despite a loss of statistical significance : 0.25 ( p = 0.08 ) . associations of glucose status with la volume index , lv mass index , and e / e hardly changed either after adjustment for arterial stiffness . furthermore , each sd higher arterial stiffness score was associated with a 0.14 sd higher la volume index after adjustment for age and sex . after subsequent adjustment for glucose status , this value was 0.12 ( p = 0.02 ) . associations of arterial stiffness with lv mass index and e / e did not change significantly either after adjustment for glucose status , despite a loss of statistical significance . standardized associations of impaired glucose metabolism ( black bars ) , type 2 diabetes ( light gray bars ) , and lower femoral artery distensibility coefficients ( dark gray bars ) with markers of lv systolic and diastolic dysfunction , adjusted for age and sex ( left half of each histogram ) and , additionally , for each other ( right half of each histogram ) . * there was no significant effect modification by sex , use of ace inhibitors , or lipid - lowering , glucose - lowering , or blood pressure lowering medication at follow - up on the associations of glucose status or arterial stiffness with markers of lv systolic and diastolic dysfunction ( p > 0.10 , data not shown ) .", "the presence of type 2 diabetes was associated with more severe levels of all markers of lv systolic and diastolic dysfunction : lv ejection fraction , la volume index , lv mass index , and e / e ( table 2 ) . after adjustment for age and sex , lv ejection fraction at follow - up was 2.98% lower in individuals with type 2 diabetes at baseline compared with that in subjects with ngm . individuals with type 2 diabetes had a 3.71 ml / m higher la volume index , 5.86 g / m higher lv mass index , and 1.64 higher e / e. these associations were attenuated after adjustment for baseline markers of lv systolic and diastolic dysfunction , but type 2 diabetes was still significantly associated with a higher lv mass index ( 3.41 g / m ) and e / e ( 1.43 ) . individuals with igm compared with those with ngm had a 2.93 g / m higher lv mass index , independent of baseline lv mass index . markers of lv systolic and diastolic dysfunction at follow - up according to baseline glucose status ( ngm = reference ) associations of type 2 diabetes with markers of lv systolic and diastolic dysfunction were largely independent of blood pressure , lipid levels , renal function , c - reactive protein , and coronary artery disease ( supplementary data table a ) . adjustment for hba1c levels or insulin resistance diminished the associations of type 2 diabetes with lv ejection fraction and la volume index . associations between type 2 diabetes and lv mass index were attenuated after adjustment for waist circumference . interaction analyses showed that type 2 diabetes was particularly associated with a lower lv ejection fraction in individuals with prior cvd . a longer diabetes duration ( per year ) was associated with a 0.59 ml / m higher la volume index at follow - up but not with other markers of lv systolic and diastolic function .", "greater stiffness of carotid , brachial , and femoral arteries , measured as lower distensibility coefficients , was associated with higher levels of la volume index , lv mass index , and e / e ( table 3 ) . after adjustment for age and sex , every 10 kpa lower carotid artery distensibility coefficient was associated with a 0.31 ml / m higher la volume index and a 0.58 g / m higher lv mass index . every 10 kpa lower brachial artery distensibility coefficient was associated with a 0.43 ml / m higher la volume index and a 0.09 higher e / e. every 10 kpa lower femoral artery distensibility coefficient was associated with a 0.80 ml / m higher la volume index , a 0.91 g / m higher lv mass index , and a 0.09 higher e / e. these associations were independent of mean arterial pressure , except for associations with e / e. after adjustment for baseline markers of lv diastolic dysfunction , 10 kpa lower distensibility coefficients of carotid , brachial , and femoral arteries remained significantly associated with a 0.29 , 0.38 , and 0.73 ml / m higher la volume index , respectively . markers of lv systolic and diastolic dysfunction at follow - up according to baseline arterial distensibility coefficients associations of femoral distensibility coefficients with markers of lv systolic and diastolic dysfunction were partly dependent on body weight and systolic blood pressure ( supplementary data table a ) . lower compliance coefficients of brachial and femoral arteries , as well as a higher young elastic modulus or pulse pressure , were similarly associated with more severe lv diastolic dysfunction ( supplementary data table b ) . a higher aortic augmentation index was the only marker of arterial stiffness that was significantly associated with lv systolic dysfunction : lv ejection fraction was 0.21% lower with every percentage point higher aortic augmentation index . carotid - femoral transit time was measured in a subset of 178 individuals , and lv ejection fraction was 0.14% lower with every second shorter carotid - femoral transit time , though not significantly ( p = 0.13 ) .", "there was no interaction between glucose status and arterial distensibility coefficients in their associations with lv systolic and diastolic dysfunction ( p values for interaction > 0.10 ) . figure 1 shows the associations of glucose status and sd scores of arterial stiffness ( measured as femoral artery distensibility coefficients ) with sd scores for all four markers of lv systolic and diastolic dysfunction , adjusted for age and sex . the right half of each histogram shows that values hardly changed if glucose status and arterial stiffness were combined in one model . for instance , the presence of type 2 diabetes was associated with a 0.26 sd lower lv ejection fraction after adjustment for age and sex . after subsequent adjustment for arterial stiffness , this value remained similar , despite a loss of statistical significance : 0.25 ( p = 0.08 ) . associations of glucose status with la volume index , lv mass index , and e / e hardly changed either after adjustment for arterial stiffness . furthermore , each sd higher arterial stiffness score was associated with a 0.14 sd higher la volume index after adjustment for age and sex . after subsequent adjustment for glucose status , this value was 0.12 ( p = 0.02 ) . associations of arterial stiffness with lv mass index and e / e did not change significantly either after adjustment for glucose status , despite a loss of statistical significance . standardized associations of impaired glucose metabolism ( black bars ) , type 2 diabetes ( light gray bars ) , and lower femoral artery distensibility coefficients ( dark gray bars ) with markers of lv systolic and diastolic dysfunction , adjusted for age and sex ( left half of each histogram ) and , additionally , for each other ( right half of each histogram ) . there was no significant effect modification by sex , use of ace inhibitors , or lipid - lowering , glucose - lowering , or blood pressure lowering medication at follow - up on the associations of glucose status or arterial stiffness with markers of lv systolic and diastolic dysfunction ( p > 0.10 , data not shown ) .", "this study shows that both glucose status and arterial distensibility coefficients were prospectively associated with more severe lv diastolic dysfunction . furthermore , associations of glucose status and arterial stiffness with lv diastolic dysfunction were largely independent of each other and indicated a deterioration of lv diastolic dysfunction compared with baseline . strengths include the population - based design and comprehensive assessment of glucose status , arterial stiffness , and lv systolic and diastolic dysfunction . these data provide a unique insight into many different aspects of arterial stiffness and their influence on lv systolic and diastolic dysfunction . lv diastolic dysfunction at baseline was therefore based on la volume index only , and this might have been subject to some misclassification . furthermore , differences between attendees and nonattendees suggest that a healthy cohort bias may have occurred in this study . we also had missing data for some echocardiographic markers , predominantly in individuals with high bmi . our findings that lv systolic and diastolic dysfunction was more severe in type 2 diabetic patients than in individuals with ngm are in line with previous data reporting associations between glucose metabolism and lv systolic and diastolic dysfunction ( 20,21 ) . the type 2 diabetes associated lv diastolic dysfunction at follow - up could not completely be explained by an already more severe lv diastolic dysfunction at baseline . these results imply that lv diastolic dysfunction deteriorates more in individuals with than in those without type 2 diabetes . there was a trend toward more severe lv systolic and diastolic dysfunction in individuals with igm as well , but this was not statistically significant . individuals with a longer duration of type 2 diabetes appeared to have a higher la volume index at follow - up . peripheral markers of arterial stiffness , like arterial distensibility and compliance coefficients , and brachial pulse pressure were most consistently associated with markers of lv diastolic dysfunction . associations of arterial distensibility coefficients with lv diastolic dysfunction were not due to elevated blood pressure , since adjustment for mean arterial pressure only resulted in a small reduction of the associations . associations of arterial distensibility coefficients with la volume index and e / e at follow - up were largely independent of baseline la volume index . this might imply that 1 ) arterial stiffness precedes deterioration of lv diastolic dysfunction or 2 ) stiffening of arteries and lv walls occurs simultaneously . the first might be due to arterial wave reflections that lead to an increased lv load and decreased coronary perfusion ( 6 ) . the second might be due to coinciding structural changes in arterial and lv walls ( 9 ) . in the current study , wave reflections seemed especially harmful to lv systolic function , since augmentation index was the only marker of arterial stiffness that was significantly associated with lv ejection fraction , followed by carotid - femoral transit time . lv diastolic dysfunction seemed to be more coherent to peripheral artery stiffening than to central artery stiffness . this might support the second theory : that stiffening of arteries and lv walls occurs simultaneously . type 2 diabetes and arterial stiffness were largely independently associated with lv systolic and diastolic dysfunction in the current study . more severe lv systolic and diastolic dysfunction in type 2 diabetes therefore can not be explained or can or just partly be explained by increased arterial stiffness . other mechanisms that might play a role in the development of lv systolic and diastolic dysfunction in type 2 diabetes include an altered cardiac metabolism or increased stiffening of the lv due to myocardial fibrosis or an elevated cardiomyocyte resting tension ( 11,2224 ) . this might be reflected by the lowered associations between type 2 diabetes and markers of lv systolic and diastolic dysfunction after adjustment for hba1c . overweight and obesity are known to be associated with a higher lv mass index , and indeed , waist circumference seemed to play a role in type 2 diabetes related higher lv mass index ( 25 ) . lv systolic function was particularly worsened in type 2 diabetic patients with prior cardiovascular disease . since individuals with type 2 diabetes already had a worse cardiovascular profile at baseline , the influence of changes in cardiovascular risk factors earlier in life on lv systolic and diastolic dysfunction may also be worth examining . to conclude , the presence of type 2 diabetes and the presence of arterial stiffness are both associated with deterioration of lv diastolic dysfunction . it is likely that type 2 diabetes and arterial stiffness relate to lv diastolic dysfunction through different pathways , since these associations were independent of each other . a better understanding of the mechanisms behind those different pathways in changes in lv diastolic dysfunction could help identify targets for prevention of heart failure .", "our findings that lv systolic and diastolic dysfunction was more severe in type 2 diabetic patients than in individuals with ngm are in line with previous data reporting associations between glucose metabolism and lv systolic and diastolic dysfunction ( 20,21 ) . the type 2 diabetes associated lv diastolic dysfunction at follow - up could not completely be explained by an already more severe lv diastolic dysfunction at baseline . these results imply that lv diastolic dysfunction deteriorates more in individuals with than in those without type 2 diabetes . there was a trend toward more severe lv systolic and diastolic dysfunction in individuals with igm as well , but this was not statistically significant . individuals with a longer duration of type 2 diabetes appeared to have a higher la volume index at follow - up .", "peripheral markers of arterial stiffness , like arterial distensibility and compliance coefficients , and brachial pulse pressure were most consistently associated with markers of lv diastolic dysfunction . associations of arterial distensibility coefficients with lv diastolic dysfunction were not due to elevated blood pressure , since adjustment for mean arterial pressure only resulted in a small reduction of the associations . associations of arterial distensibility coefficients with la volume index and e / e at follow - up were largely independent of baseline la volume index . this might imply that 1 ) arterial stiffness precedes deterioration of lv diastolic dysfunction or 2 ) stiffening of arteries and lv walls occurs simultaneously . the first might be due to arterial wave reflections that lead to an increased lv load and decreased coronary perfusion ( 6 ) . the second might be due to coinciding structural changes in arterial and lv walls ( 9 ) . in the current study , wave reflections seemed especially harmful to lv systolic function , since augmentation index was the only marker of arterial stiffness that was significantly associated with lv ejection fraction , followed by carotid - femoral transit time . lv diastolic dysfunction seemed to be more coherent to peripheral artery stiffening than to central artery stiffness . this might support the second theory : that stiffening of arteries and lv walls occurs simultaneously .", "type 2 diabetes and arterial stiffness were largely independently associated with lv systolic and diastolic dysfunction in the current study . more severe lv systolic and diastolic dysfunction in type 2 diabetes therefore can not be explained or can or just partly be explained by increased arterial stiffness . other mechanisms that might play a role in the development of lv systolic and diastolic dysfunction in type 2 diabetes include an altered cardiac metabolism or increased stiffening of the lv due to myocardial fibrosis or an elevated cardiomyocyte resting tension ( 11,2224 ) . this might be reflected by the lowered associations between type 2 diabetes and markers of lv systolic and diastolic dysfunction after adjustment for hba1c . overweight and obesity are known to be associated with a higher lv mass index , and indeed , waist circumference seemed to play a role in type 2 diabetes related higher lv mass index ( 25 ) . lv systolic function was particularly worsened in type 2 diabetic patients with prior cardiovascular disease . since individuals with type 2 diabetes already had a worse cardiovascular profile at baseline , the influence of changes in cardiovascular risk factors earlier in life on lv systolic and diastolic dysfunction may also be worth examining . to conclude , the presence of type 2 diabetes and the presence of arterial stiffness are both associated with deterioration of lv diastolic dysfunction . it is likely that type 2 diabetes and arterial stiffness relate to lv diastolic dysfunction through different pathways , since these associations were independent of each other . a better understanding of the mechanisms behind those different pathways in changes in lv diastolic dysfunction could help identify targets for prevention of heart failure ." ]

[ "primitive neuroectodermal tumor ( pnet ) , a highly aggressive tumor of the kidney is a rare malignancy with only few cases being reported in literature . boys and men are more likely to suffer rpnet ( renal pnet ) , and the sex ratio ( male : female ) is about 3:1 . it usually presents at an advanced stage , with distant metastasis and is associated with a poor prognosis . we report in this paper , a case of primary renal pnet in a young male .", "a 39-year - old male presented with complaints of hematuria and heaviness in the right flank since 15 days . physical examination revealed a soft lump in the right hypochondrium . ultrasound examination of the abdomen showed an irregular cystic structure in the right kidney at lower pole with few internal echoes . ct scan of the abdomen demonstrated a large significantly enhancing right renal lower polar mass with necrosis with thrombosis in right renal vein . on the basis of these clinico - radiological findings , diagnosis of right side renal cell cancer gross examination revealed a friable , grayish - white , lobulated mass ( 7 5 cm ) with multiple foci of hemorrhage and necrosis . the mass extended from mid to lower pole of the right kidney and infiltrated into the renal pelvis and was limited to the renal capsule the renal vein and ureter were free of the tumor . there was a thrombus inside the renal vein , which was not adherent to intima of renal vein . microscopically , the tumor was composed of monotonous sheets of round cells with scant cytoplasm , hyperchromatic vesicular nuclei , coarse chromatin and few conspicuous nucleoli , transverse by thin fibrous bands infiltrating and entrapping the renal glomeruli and tubules [ figure 1 ] . on immunohistochemistry , the tumor cells were positive for cd99 [ figure 2a ] , fli-1 [ figure 2b ] , nse [ figure 2c ] , and synaptophysin [ figure 2d ] , but negative for desmin , ck , ema , and lca . a diagnosis of pnet was made based on the above findings , and patient was started on vac ( vincristine , adriamycin , and cyclophosphamide ) alternating with ie ( ifosfamide and etoposide)-based adjuvant chemotherapy regimen which he tolerated well . after 6 cycles of chemotherapy , a pet scan showed absence of any metabolically active focal uptake in whole body . chemotherapy with vac ( vincristine , actinomycin d , and cyclophosphamide ) alternating with ie ( ifosfamide and etoposide ) for a year was planned . section showing malignant round cells arranged in pattern sheets infiltrating and entrapping the renal glomeruli and tubules { figure 1a : h&e ; 100 , figure 1b : h&e ; 200 } ( a ) the tumor cells express membranous expression of cd99 { dab ; 200 } ( b ) the tumor cells express nuclear positivity for fli-1{dab ; 200 } ( c ) the tumor cells express cytoplasmic positivity for neuron - specific enolase ( nse ) { dab ; 200 } ( d ) the tumor cells expressing cytoplasmic positivity for synaptophysin { dab ; 200 }", "the primitive neuroectodermal tumor ( pnet ) , was first recognized by arthur purdy stout in 1918 , and is a member of the family of small round - cell tumors . pnet arising in the kidney was first reported by mor in 1994 . primitive neuroectodermal tumors occurs preferentially in the soft - tissues of the paravertebral region and chest wall , less frequently in extremities , with a slight male predominance . rpnet appears to be an unique clinical entity that behaves more aggressively than pnet arising at other sites . the presenting symptoms and images of rpnet are non - specific and similar to other renal tumors . rpnet show a male predominance with 85% cases being diagnosed during the second to fourth decade . it is an aggressive tumor that tends to recur locally and to metastasize to lymph nodes , lung , liver , bone , and bone marrow , which entail a worse prognosis . the differential diagnosis of rpnet includes other small round cell tumors like neuroblastoma , adult nephroblastoma , malignant lymphoma , rhabdoid tumor , small cell carcinoma and monophasic , poorly differentiated , round cell variant of synovial sarcoma , carcinoid , rhabdomyosarcoma , clear cell sarcoma of the kidney , the small cell variant of osteosarcoma , and desmoplastic small round cell tumor . grossly , rpnet are typically very large tumors with about 65% measuring > 10 cm in diameter . they tend to be grayish in color , encapsulated , and contain focal areas of hemorrhage or necrosis . microscopically , the tumor is composed of sheets of round cells ; individual cells have a round nucleus with a distinct nuclear membrane , fine powdery chromatin , and 1 or 2 small nucleoli . the cytoplasm is ill - defined , scanty , usually pas - positive , and mitosis are variable . perivascular pseudo rosettes and homer - wright rosettes are common . to better address the diagnosis , immunohistochemical markers to be used to confirm diagnosis are cytokeratin ( for nephroblastoma , small cell carcinoma , and synovial sarcoma ) , lca ( for lymphoma ) , nse / chromogranin a ( for neuroblastoma ) , and cd-99 for pnet . cd99 ( the product of mic2 gene ) greatly aids in recognizing the es / pnet family of tumors . many pnet also stain for neural markers , including nse , leu-7 , s-100 protein , synaptophysin , and pgp9.5 . the most frequent translocation in pnet is t(11;22)(q24;q12 ) , detected in approximately 90% of cases , resulting in ews - fli fusion gene . the overall survival in patients who had localized rpent was longer than that in the patients who had rpent with regional nodes or distant metastases . the role of radiotherapy is not clear , but it may be advocated in locally advanced disease and involvement of gerota 's fascia . post - operative chemotherapy for rpent is usually used and can improve the prognosis of rpnet . the most commonly used chemotherapeutics are adriamycin , etoposide , dactinomycin , vincristine , cyclophosphamide , and ifosfamide . a multimodality management is recommended ." ]

[ "female sex workers ( fsws ) are at high risk of hiv infection and transmission . a systematic review conducted in over 25 countries with medium and high hiv prevalence indicated that 36.9% of sex workers in sub - saharan africa were hiv positive with some countries having hiv prevalence as high as 70.7% . despite this high burden of hiv infection , only 58% of sex workers have access to hiv prevention and care programmes and less than half of hiv positive sex workers are enrolled into hiv care . unaids reported that , in 2013 , art averted 6.3 million aids related deaths worldwide as a result of the increased number of people receiving art . in 2015 , who released revised guidelines for hiv treatment and recommended initiation of art among all hiv infected individuals irrespective of their cd4 count , for improved treatment outcomes and prevention of hiv transmission . sex workers are among the priority populations for expansion of hiv services including art . however , despite the existence of established targeted sex worker interventions , lots of challenges still exist that have hindered many from enrolling into care . several studies have highlighted barriers to linkage to care among female sex workers including discrimination by hospital staff [ 3 , 7 ] , delays at the health facility [ 8 , 9 ] , lack of money for transport and food , fear of drugs , stigma , use of drugs and alcohol , fear to be seen by clients , lack of knowledge about the treatment center [ 10 , 11 ] , and delays in accessing treatment among those who felt they were still healthy . however , while these barriers have been reported , there is still limited information on linkage to hiv care among sex workers in sub - saharan africa , particularly on effective linkage models to inform scale up of hiv interventions among sex workers . in 2012 , reach out mbuya hiv / aids initiative ( rom ) , a faith - based community non - government organization in uganda , introduced mobile outreach services to promote hiv testing and treatment among fsws and their clients . although the program has over 200 fsws enrolled in hiv care , some of the fsws who tested hiv positive did not enrol for treatment . we conducted a study to identify the facilitators and barriers to linkage to hiv care among the fsws who tested positive in order to design appropriate hiv interventions for this key population group .", "this was a cross - sectional qualitative study that involved in - depth and key informant interviews . this study was part of a larger study that explored the facilitators and barriers to linkage to hiv care among fsws in kampala and wakiso districts in central uganda . rom promotes hiv prevention through peer educators and provides hiv counselling and testing ( hct ) services through established outreach clinics that provide care and treatment for hiv positive fsws . mobile hct outreaches are conducted in locations surrounding mbuya parish in kampala and wakiso districts in central uganda . in - depth interview ( idi ) participants were selected from 301 hiv positive female sex workers who were registered in the hct registers at the different outreach points between may 2012 and december 2013 . of the 301 registered clients , 144 were traced and interviewed as part of the larger study where 28 of these were purposively selected to participate in the in - depth interviews . these included 14 fsws who were in hiv care and 14 who had not yet enrolled into care . the selected fsws were contacted by counsellors by phone to explain the study and to ask them to participate in the study . fsws with missing phone contact information or those who were unavailable after a minimum of three telephone attempts were tracked through their peer educators and friends . key informant interview ( kii ) participants were selected from peer educators who were trained by rom and were involved in following up fsws to encourage them to access hiv care . in addition , five rom staffs who were involved in the implementation of the outreach program were interviewed as key informants . rom provides static and bi - weekly outreach clinics for fsws using staff specifically trained on how to deal with key populations including fsws . at the time of the study , hiv testing and linkage to hiv care services were offered using bi - weekly mobile outreach clinics , brothel based testing , and nocturnal mobile vans at places where the fsws reside or conduct business . hiv testing was conducted following the national rapid testing algorithm and posttest counselling was provided to hiv infected women who were advised on the available health facilities for follow - up care . hiv infected women were advised to begin care immediately either at the static or mobile clinics operated by rom or other partners and were followed up with phone calls or by peer educators a week after testing and once every quarter thereafter , to ascertain linkage to care . those who were enrolled at the static clinic were subjected to a home assessment by the community art and tb treatment supporters ( catts ) to enable adequate follow - up . the information collected using the home assessment tool included the names and number of household members , water and sanitation , economic status , property owned , distance to the facility , and acceptable mode for communication . sex workers , who agreed to participate in the study , provided written informed consent and were interviewed in the language of their choice using unstructured , pretested questionnaires . the pretesting was conducted in the nearby project area two weeks before the commencement of the study . to ensure anonymity , data were collected on the facilitators and barriers to linkage to hiv care by trained research assistants with experience in handling fsws . data were collected on age , education , and linkage status to aid proper categorization of the study participants ( linked or not linked to care ) . we defined linkage to care as having registered within an hiv clinic . the interview themes ( i.e. , sociodemographic , socioeconomic , structural , and hiv - related factors ) were informed by theoretical constructs from the health belief model and the socio - ecological model and further informed by literature on barriers and facilitators to hiv service access among fsws . figure 1 presents a summary of the key variables and their interrelationships in informing linkage to hiv care among fsws . interviews were conducted at selected brothels , fsws homes , and static and outreach clinics . key informant interviews were conducted at the workplace or residence of the respondents , in english and luganda , using unstructured pretested questionnaires . the themes for the key informant interviews included hiv treatment seeking behaviour of the fsws , the challenges of enrolling into care , and the interventions to enhance linkage to hiv care in this population . additional data , including age , education , job category , residence , and the time allocated to working with fsws , was collected . the review of transcripts was guided by a priori themes pertaining to linkage to care , loss to follow - up , stopping treatment , and facilitators and barriers to linkage . issues that cut across the different themes which were captured by both authors were coded and categorized while those that were captured by one but not the other were subjected to further analysis until they were resolved and used to support the overriding themes or dropped . the study was approved by makerere university school of public health higher degrees research and ethics committee ( irb # : irb00011353 ) and the uganda national council of science and technology .", "of the 28 fsws interviewed , 14 ( 50% ) were enrolled in hiv care ( nine at rom ) , 8 had not yet enrolled , and 6 had previously enrolled but were either lost to follow - up or had stopped treatment . of the 28 women interviewed , 24 ( 85% ) were aged 2030 years while the rest where > 30 years . half ( 14 ) had at least secondary or higher education and the other half ( 14 ) had at least primary education . the fsws who were lost to follow - up or had stopped treatment were aged between 15 and 36 years with their education level ranging from none to secondary . the respondents included fsws who operate in bars ( 6 ) , on the streets ( 8) , at home ( 3 ) , and in brothels ( 11 ) ( table 1 ) . the findings have been grouped into two themes : ( a ) facilitators of linkage to hiv care and ( b ) barriers to linkage to hiv care among fsws , as presented below . the facilitators have been further grouped into two main themes : health system and social network factors ( table 2 ) . majority of the participants associated their linkage to care with the good quality of the services including good attitude and friendliness exhibited by the counsellors towards them . they noted that the counsellors talked to them with ease and were not judgmental : the counsellors are good , they talk to us very well and are almost like our parents . when i was told my results i got so scared as though i would die there and then . i failed to breath for 30 minutes ; the counsellor got me some cold water to drink and the care she showed me encouraged me to enrol for treatment . ( fsw , 29 years , enrolled in care ) the counsellors are good , they talk to us very well and are almost like our parents . when i was told my results i got so scared as though i would die there and then . i failed to breath for 30 minutes ; the counsellor got me some cold water to drink and the care she showed me encouraged me to enrol for treatment . ( fsw , 29 years , enrolled in care ) participants reported that the counsellors provided detailed information and encouragement to help them start treatment . the counsellors told them that testing hiv positive was not the end of life and that with medication they would be helped to stay healthy and live longer . in addition , participants appreciated the good follow - up support for those who tested positive . some said the counsellors called them and followed them up to their homes , which made them feel cared for : i started treatment due to counselor x 's advice , she was so caring and always followed me up , she could visit me ; otherwise on my own i had even disappeared but she was on my case . ( fsw , 24 years , enrolled in care ) i started treatment due to counselor x 's advice , she was so caring and always followed me up , she could visit me ; otherwise on my own i had even disappeared but she was on my case . ( fsw , 24 years , enrolled in care ) some participants acknowledged that it was easy for them to enrol in care because of the same - day results and immediate initiation of treatment . the peer educators and fellow sex workers enabled them to start treatment by encouraging them and helping to allay their fears regarding hiv treatment and occasionally escorting them to the clinics to start medication . some respondents said they would forget the clinic days because the clinic did not run every day but the peer educators reminded them . during the key informant interviews the peer educators mentioned how tirelessly they worked to follow up the hiv positive fsws ; they were sometimes abused by the sex workers but they never gave up on them : i feel it is my calling to help these people and even though i am not paid i make sure i have brought them to get medicine . ( peer educator , 29 years ) they come and tell me that on such and such a date i will be going to the clinic so remind me , i will note this in my diary and when the date approaches i go to them and tell them it is the day for the clinic . ( peer educator , 25 years ) i feel it is my calling to help these people and even though i am not paid i make sure i have brought them to get medicine . ( peer educator , 29 years ) they come and tell me that on such and such a date i will be going to the clinic so remind me , i will note this in my diary and when the date approaches i go to them and tell them it is the day for the clinic . ( peer educator , 25 years ) the proximity of the clinic to their residence was another enabling factor for linkage to care . some fsws did not want to move long distances for hiv care and others did not have transport so they thought that enrolling at rom would help reduce such burdens . across all interviews fsws who were enrolled in savings and they noted that the members of the support groups like village savings groups started by rom for sex workers only or mixed with other community members helped them to enrol into care . the members of the savings group reportedly advised them to start on treatment and live longer . being part of a savings group also created hope that money would be available for food and they would have capital to start their own business and live longer : i thought i was alone but when i realized we were many , i stopped fearing and also started medicine . my group members say that everyone is sick and so we should use our money well to care for ourselves and look nice to get customers and save much more . ( fsw , 25 years , enrolled in care ) i thought i was alone but when i realized we were many , i stopped fearing and also started medicine . my group members say that everyone is sick and so we should use our money well to care for ourselves and look nice to get customers and save much more . ( fsw , 25 years , enrolled in care ) across all the interviews the participants cited the need to remain healthy as one of their motivators for linkage to care . in order to continue doing their work , they wanted to start medication to remain healthy and not show any signs of opportunistic infections , which would scare away their customers . others wanted to remain healthy so as to live longer and take care of their children : it is because of my children ; i have to live for them because i am a widow , if i do n't take care of myself and die who will take care of them . ( fsw with 3 children , 24 years , in care ) it is because of my children ; i have to live for them because i am a widow , if i do n't take care of myself and die who will take care of them . ( fsw with 3 children , 24 years , in care ) several participants reported that seeing their colleagues improve after starting treatment motivated them to start on treatment while others did so because many of their friends were dying , which compelled them to start treatment so as to survive : i had a friend who stopped treatment and died , when we took her to the hospital the nurses said if only she continued with treatment she would be alive . when they ( providers ) came looking for sex workers to be enrolled into care i was the first on the list to go for treatment . ( fsw 20 years , enrolled in care ) i had a friend who stopped treatment and died , when we took her to the hospital the nurses said if only she continued with treatment she would be alive . when they ( providers ) came looking for sex workers to be enrolled into care i was the first on the list to go for treatment . ( fsw 20 years , enrolled in care ) barriers were similarly categorized into two themes : health systems and social network factors ( table 3 ) . the fsws enrolled at the government facilities mentioned discrimination from the health workers who openly exhibited a negative attitude towards sex workers . they said the health workers reacted differently after realizing that they were dealing with a sex worker and , upon telling their friends , those who had not yet registered for care feared to enrol : the counselor asked me what i do and i said sex work . she called four other counselors to ask me why i do that kind of work ; i wanted to ask them , what do you expect me to do ? ' but the counselor stood up and asked me rudely ; is that also work to mention among people ? ' that counselor annoyed me so much i walked off and never wanted to see her again . ( peer educator who is a fsw , 29 years ) the counselor asked me what i do and i said sex work . she called four other counselors to ask me why i do that kind of work ; i wanted to ask them , what do you expect me to do ? ' but the counselor stood up and asked me rudely ; is that also work to mention among people ? ' that counselor annoyed me so much i walked off and never wanted to see her again . ( peer educator who is a fsw , 29 years ) the four fsws who were enrolled at government facilities noted that they were discouraged by the requirement to present a treatment supporter coupled with the long procedures for enrolment that involved several visits to the facility : it was not easy to start arvs because i was told that unless i went with someone i would not be started on arvs and this person was always moving and too hard to get . may be i do not want someone else to know that i am positive . ( fsw , 29 years , enrolled in care ) it was not easy to start arvs because i was told that unless i went with someone i would not be started on arvs and this person was always moving and too hard to get . i felt this was not right because i must go for treatment by myself may be i do not want someone else to know that i am positive . ( fsw , 29 years , enrolled in care ) almost all the participants cited stigma as a major barrier to linkage to care . the majority feared to be seen by their clients at the clinic . although the close proximity of the clinic was mentioned as a motivator , for some fsws it was a hindrance . participants were afraid of being seen at the hiv clinic by customers , their friends , and other people in the village and were particularly concerned about rumours : i can not go to that clinic because everyone here goes there and they will see me which will spoil my business . right now the competition is much and the other girls will make me a topic because they want to take away my customers yet they are also sick . ( fsw 22 years , not enrolled ) i can not go to that clinic because everyone here goes there and they will see me which will spoil my business . right now the competition is much and the other girls will make me a topic because they want to take away my customers yet they are also sick . ( fsw 22 years , not enrolled ) due to lack of information , many participants had many myths about arvs ( e.g. , that they kill fast and need a lot of care ) . they avoided the arvs by not going to the clinic while some opted to wait until they got other jobs because of the perception that arvs could weaken them and disrupt their work . some respondents feared drugs and could not imagine swallowing them for life so they opted out . on the other hand , some participants feared death after testing and lost hope for living ; they did not see the need for starting on art : madam is n't there any danger with the arvs because friends tell me that when i start taking arvs they will burn my kidney and lungs ( fsw , 20 years , not in care and never went to school ) madam is n't there any danger with the arvs because friends tell me that when i start taking arvs they will burn my kidney and lungs ( fsw , 20 years , not in care and never went to school ) some fsws did not know what hiv is while others encountered difficulties in identifying an hiv clinic because they lacked proper information about the location of the clinics . this was mainly a challenge to the young girls ( aged between 20 and 25 years ) who lived in the brothels as indicated by the project staff : some were testing for the first time and others had ever tested but they were not even shocked when told that they were positive because they were just starting to understand what hiv is . ( key informant ) some were testing for the first time and others had ever tested but they were not even shocked when told that they were positive because they were just starting to understand what hiv is . ( key informant ) some fsws mentioned that they could not enrol in an hiv clinic since they did not believe their hiv results . some thought it was just a prick performed hurriedly in the night and wondered how it translated into an hiv positive result so they waited and retested many times : when i reached home , i started doubting the results and decided to go for another test in a different place . i continued living in denial but after some time i had to admit that i was hiv positive and started taking septrin . ( fsw 29 yrs , not enrolled in care ) when i reached home , i started doubting the results and decided to go for another test in a different place . i continued living in denial but after some time i had to admit that i was hiv positive and started taking septrin . ( fsw 29 yrs , not enrolled in care ) a third of the fsws mentioned that they were using herbs as a substitute for arvs and therefore saw no need of being registered in an hiv clinic . besides many of the fsws said they used local herbs from traditional healers to attract customers and did not have to line up for herbs like they did in the hiv clinic : no . i have not received treatment for hiv except local herbs which i prefer to take and i do not want to be forced to take medication [ meaning arvs ] . even with the herbs now am on medication ; i do take the local herbs and am fine with the treatment , i do n't want to be forced to take arvs . ( fsw , 24 yrs , not enrolled ) no . i have not received treatment for hiv except local herbs which i prefer to take and i do not want to be forced to take medication [ meaning arvs ] . even with the herbs now am on medication ; i do take the local herbs and am fine with the treatment , i do n't want to be forced to take arvs . ( fsw , 24 yrs , not enrolled ) some participants bought painkillers from general clinics instead of enrolling in an hiv clinic ( self - medication ) . even when the nurses in these clinics suspected that they were hiv infected , they did not tell them because they wanted business through treating their on and off sickness . because they are always travelling in different places looking for clients , fsws cited lack of time as one of the barriers to linkage to care : i am still very busy right now looking for rent and food . i can not lose any customer at this difficult moment but when i have raised some money to care for myself i will start medicine without any worries . ( fsw 23 years , not enrolled ) i am still very busy right now looking for rent and food . i can not lose any customer at this difficult moment but when i have raised some money to care for myself i will start medicine without any worries . ( fsw 23 years , not enrolled ) the kis felt that the street based sex workers had more challenges with linkage to hiv care compared to those in brothels because they were difficult to trace given that they only relied on phone numbers which were off most of the time : those on the streets do not want to access care . ( key informant ) those on the streets do not want to access care . ( key informant ) across all interviews , the fsws mentioned lack of finances as a major hindrance to linkage to care . they were concerned about requirements such as good food and frequent transport to the health facility : it 's the financial challenges and hunger because sometimes i go without food and my friends tell me that taking medication requires eating and drinking . ( fsw 22 years , not enrolled ) it 's the financial challenges and hunger because sometimes i go without food and my friends tell me that taking medication requires eating and drinking . ", "our study of facilitators and barriers to linkage to hiv care among female sex workers in kampala and wakiso districts in uganda shows that health system and social network factors are the major facilitators and barriers to linkage to hiv care . good quality health services ( especially polite and caring providers , strong follow - up structures using peer educators , and provider telephone calls ) and social network factors ( encouragement from peers and membership of savings group and the need to maintain good health ) were the primary facilitators of linkage to hiv care among fsws . on the other hand , perceived stigma , various forms of misinformation , and prohibitive clinic policies were major barriers to linkage to hiv care . contrary to the experience of fsws at rom , those who were registered in the public health facilities encountered negative staff attitudes , a major barrier that has been documented in several studies [ 8 , 16 , 17 ] . these findings suggest that efforts to improve linkage and retention in hiv care among fsws should focus on quality of services and improving social support networks . ensuring good quality services , particularly providers who can deliver services in a respectful and no - judgmental manner without undue delays and restrictions and adequate community education and mobilization as well as support structures for retention are key health system issues that can improve the quality of services . using peers to educate communities and follow - up of those who need treatment reduce the burden on health workers and strengthens community engagement . as reported elsewhere , the requirement of a treatment supporter before initiating care and treatment was a barrier to treatment that should no longer be strictly enforced . the training of providers and peer educators prior to implementation of this program could have contributed to delivery of quality services at rom and are a key intervention area . given the overriding concerns about being seen at hiv facilities , training for providers should emphasize the need for privacy and confidentiality . further , providing an integrated package of services for sex workers could reduce stigma around accessing hiv and other services . training should also emphasize flexibility with certain clinic policies that could hinder access to hiv services among sex workers . social network issues were also strong facilitators and barriers to linkage and require interventions particularly targeted at enhancing support by peers and reducing misinformation and stigma . enacted stigma , myths , and fears about arvs coupled with lack of correct information about hiv continue to be major barriers to linkage to hiv care . financial constraints were a prominent barrier to linkage to care . the savings groups were a good avenue for social support and financial stability and could be integrated into health programs for low - income sex workers [ 20 , 21 ] . collectively , these findings suggest that programs targeting fsws should integrate continuous sensitization and provision of tailor made services that address the individual level , community , and health system needs of fsw . this study is based on interviews with 14 fsws who were in hiv care and 14 others who were not . by all counts , the numbers are too small to represent the views of all fsws who are enrolled or not enrolled in hiv care . however , our study findings provide good insights into the facilitators and barriers to linkage that can inform interventions to improving linkage for fsws . future research is needed to further understand how the fsws can be maintained in care once they have been linked .", "our study shows that fsws ability to be linked to hiv care is largely influenced by good quality friendly services and community support systems especially from their peers . hiv programs for fsw should focus on enhancing these as well as dealing with the barriers that mainly stem from stigma , ignorance , and work - related challenges . these findings call for a need to design interventions that utilize a multichannel , multipronged approach to increase access to hiv services among fsws ." ]

[ "the acquired alexias may be categorized into posterior , anterior , central and deep alexias . analagous to semantic paraphasias , semantic paralexias constitute the substitution of content related words during reading . unlike the analogous subcortical aphasias such as thalamic aphasia , subcortical syndromes of alexia have rarely been described . this report depicts a patient with thalamic alexia with features of deep alexia ( or paralexia ) , the latter which has not been described after review of the english based literature .", "a 57 year old white , right handed , english speaking woman with 13 years of education , presented to our stroke center with mild right sided numbness and weakness ( graded + 4/5 medical research council grading scale ) with the family reporting transient confused conversation and speech difficulty . the clinical evaluation at our center encompasses a cognitive screening evaluation in all patients followed by psychometric assessment in selected patients described in detail elsewhere . no dysnomia was documented . specifically visual acuity and visual fields were normal and there was no object agnosia , dyschromatopsia , dyscalculia , finger agnosia , right left disorientation , or hemineglect syndrome . the substitution of semantically related words was documented with only mild slowing in her reading ( family corroboration ) . cerebrovascular risk factors included a significant smoking history and on investigation hyperhomocyteinemia ( 15.6 mmol / l ) . within 4 days , the reading difficulty had normalized but she remained with mild speech dysfluency , right hand ideomotor apraxia and developed a dejerine roussey or post stroke thalamic pain syndrome . multimodality magnetic resonance imaging investigations revealed a left lateral posterior thalamic infarct , well circumscribed on t2 weighted and diffusion weighted imaging without other brain parenchymal lesion ( figure 1 ) . magnetic resonance angiography revealed a left internal carotid artery stenosis graded 5074% and basilar artery fenestration . \n figure 1left thalamic infarct depicted on diffusion weighted and t2 weighted magnetic resonance scan ( arrows ) . \n left thalamic infarct depicted on diffusion weighted and t2 weighted magnetic resonance scan ( arrows ) . in view of the isolated reading impairment , additional psychometric examination was performed on day 3 after the stroke onset , with the boston diagnostic aphasia examination ( third edition - short form ) . in addition , the test for semantic paralexia prone words were tested with the standard version of the boston diagnostic aphasia examination ( version iii ) ( table 1 ) . in comparison to normative data , notable deficiencies were noted only in speech fluency , articulation , oral word and sentence reading , picture word matching and writing . \n table 1boston diagnostic aphasia test - version iii.subtests%fluency phrase length30 melodic line60 grammatical form70conversation expository speech100auditory comprehension basic word discrimination100 commands100 complex ideational material100articulation ( agility)70recitation ( automatized sequences)100repetition words60 sentences100naming responsive naming100 boston naming test100 special categories100paraphasia100reading matching case and scripts100 number matching100 picture word matching40 oral word reading40 oral sentence reading80 oral sentence comprehension100 sentence / paragraph100 comprehension100wiriting form20 letter choice40 motor facility40 \n", "a 57 year old white , right handed , english speaking woman with 13 years of education , presented to our stroke center with mild right sided numbness and weakness ( graded + 4/5 medical research council grading scale ) with the family reporting transient confused conversation and speech difficulty . the clinical evaluation at our center encompasses a cognitive screening evaluation in all patients followed by psychometric assessment in selected patients described in detail elsewhere . no dysnomia was documented . specifically visual acuity and visual fields were normal and there was no object agnosia , dyschromatopsia , dyscalculia , finger agnosia , right left disorientation , or hemineglect syndrome . the substitution of semantically related words was documented with only mild slowing in her reading ( family corroboration ) . cerebrovascular risk factors included a significant smoking history and on investigation hyperhomocyteinemia ( 15.6 mmol / l ) . within 4 days , the reading difficulty had normalized but she remained with mild speech dysfluency , right hand ideomotor apraxia and developed a dejerine roussey or post stroke thalamic pain syndrome .", "multimodality magnetic resonance imaging investigations revealed a left lateral posterior thalamic infarct , well circumscribed on t2 weighted and diffusion weighted imaging without other brain parenchymal lesion ( figure 1 ) . magnetic resonance angiography revealed a left internal carotid artery stenosis graded 5074% and basilar artery fenestration . \n figure 1left thalamic infarct depicted on diffusion weighted and t2 weighted magnetic resonance scan ( arrows ) . \n left thalamic infarct depicted on diffusion weighted and t2 weighted magnetic resonance scan ( arrows ) .", "in view of the isolated reading impairment , additional psychometric examination was performed on day 3 after the stroke onset , with the boston diagnostic aphasia examination ( third edition - short form ) . in addition , the test for semantic paralexia prone words were tested with the standard version of the boston diagnostic aphasia examination ( version iii ) ( table 1 ) . in comparison to normative data , notable deficiencies were noted only in speech fluency , articulation , oral word and sentence reading , picture word matching and writing . \n table 1boston diagnostic aphasia test - version iii.subtests%fluency phrase length30 melodic line60 grammatical form70conversation expository speech100auditory comprehension basic word discrimination100 commands100 complex ideational material100articulation ( agility)70recitation ( automatized sequences)100repetition words60 sentences100naming responsive naming100 boston naming test100 special categories100paraphasia100reading matching case and scripts100 number matching100 picture word matching40 oral word reading40 oral sentence reading80 oral sentence comprehension100 sentence / paragraph100 comprehension100wiriting form20 letter choice40 motor facility40 \n", "the commonly referred to syndromic classification of benson and geschwind of posterior alexia ( alexia without agraphia ) , central alexia ( alexia with agraphia ) , anterior alexia ( alexia in association with expressive dysphasia ) and deep dyslexia ( primarily semantic paralexia disorder ) aptly describes most acquired reading deficiencies . alexia secondary to isolated thalamic lesion has not been reported other than in combination with left occipital lesions , the latter lesions the usual focus . semantic paralexia due to thalamic lesions has not been reported previously with neuroanatomical lesions mostly referred to as large perisylvian and even right hemisphere lesions implicated . similar to subcortical aphasias , the subcortical ( thalamic ) alexia reported here is characterized by atypical alexia syndrome components . these include relatively mild deficit , transience , a mixture of syndromic components with rapid recovery . the lack of hemispheric lesions on magnetic resonance imaging using standard t2 weighted images diffusion weighted imaging for infarct exclusion , fluid attenuation inversion recovery sequences for covert white matter lesions and gradient echo sequences to exclude minor hemorrhagic lesions , implicated the thalamic lesion alone as the critical lesion in the syndrome described . although not a routine stroke investigative tool , functional magnetic imaging ( f - mri ) would have been an important additional neuroimaging modality to assess whether the right hemisphere had or had not played a role . however , the rapidity of recovery precluded functional magnetic imaging , that may have helped ascertain whether right hemisphere linguistic processing was operative , the contemporary hypothesis of semantic paralexia ." ]

[ "proliferative vitreoretinopathy ( pvr ) remains the major complication after retinal detachment surgery [ 13 ] . pvr was identified as an independent clinical entity in 1983 by the retina society terminology committee and a classification was created , based on the condition formerly named massive vitreous traction or massive periretinal proliferation [ 57 ] . this classification divided pvr into four stages , a , b , c , and d , apparently by increasing its severity , from minimal to massive pvr ( table 1 ) . nevertheless , this classification had numerous limitations . it did not consider the location of the vitreoretinal traction and the magnitude of the contraction . in addition , some of the stages provide a false idea of severity ; for instance , d4 caused by a localized epiretinal membrane could be more easily treated by surgery than a c1 caused by intraretinal changes [ 8 , 9 ] . in 1989 , the silicone study group introduced a new classification including some characteristics , such as the location , anterior or posterior , and the type of contraction ( table 2 ) . classification was then updated in 1991 according to modifications proposed by the silicone study group and also by other authors ( table 3 ) . this classification appears to be difficult to use in clinical practice and may not offer any special advantage for decision - making in relation to the treatment of the disease . moreover , the classifications might have prevented advances in the understanding of the disease pathogenesis . for instance , because the retina society committee defined pvr as a proliferative disease , many treatments based on the inhibition of cell proliferation were developed for more than 20 years , none of which appears to have produced a significant clinical advance . therefore , a review of both the classification and the pathogenesis of pvr appears to be appropriate to aid the development of new treatments . there is a clinical impression that over the last 15 years clinicians have abandoned current pvr classifications . thus , the purpose of this study has been to evaluate the current use of pvr classifications in papers dealing with clinical practice and therapy as an indirect measure of the degree of usefulness of existing classifications .", "a search in pubmed for papers published between january 2000 and january 2014 was undertaken by two independent researchers . inclusion criteria comprised human studies published in english , french , and spanish on pvr or retinal detachment with specific mention to pvr . prospective randomized and nonrandomized clinical studies , retrospective clinical studies , short series , and pilot studies were included . a manual search of related articles was also performed through references reported in each article . we also analyzed how the different authors interpreted the classifications , comparing the results they provided with the original description . therefore , we investigated if they used all the characteristics ( grade [ a , b , c ] , pvr localization , extension in hours , and type ) of the updated retina society classification or if they were used only partially . furthermore , it was also noted whether classifications were used both before and after an eventual pvr pharmacological or surgical treatment . data were extracted using a custom - made data sheet performed with agreement between authors .", "preliminary search identified a total of 219 publications , 81 of which were eliminated as they did not fulfill the inclusion criteria . 35 articles ( 25,4% ) did not undergo detailed analysis because there was no reference to the type of pvr classification used by the authors or because no classification was used ( generic terms such as initial or severe pvr or simply pvr were adopted , without using any grading system ) . 103 publications ( 74,6% ) used standardized pvr classifications and they were analyzed in detail . the most used classification was the updated retina society classification ( 58 cites ; 56,3% ) , followed by the first retina society classification ( 35 cites ; 33,9% ) . in addition , 3 authors ( 2,9% ) used modified or customized classifications [ 1315 ] . in 4 publications ( 3,8% ) , errors in the stated classification were identified [ 13 , 1618 ] : in two papers [ 16 , 18 ] , the authors cite the updated retina society ( 91 ) but in fact they used the first retina society classification ( 83 ) , koerner et al . , after citing the updated retina society classification used a customized one , and roldn - pallars et al . cite the two retina society classifications at the same time . among the papers using the updated retina society classification , the most documented was grade c pvr ( 48 articles , 83% ) , while grades b and a were less frequently documented ( 15 ( 26% ) and 7 ( 12% ) articles , resp . ) . of the publications documenting only c grade , the classification of subtypes was infrequently used . in 5 of 48 publications ( 10,4% ) , there was a full c grade description in terms of localization ( anterior or posterior ) , extension ( in clock hours ) , and type ( focal , diffuse , subretinal , circumferential , or anterior displacement ) . a similar finding was observed when authors used the first retina society classification ( 35 papers ) : only c and d grades were frequently reported ( 27 and 10 papers , resp . ) , while grades a and b were infrequently used ( 4 and 7 articles , resp . ) . when the silicone study classification was used , only grade c was mentioned ( in 2 out of 4 articles ) . finally , there were 2 publications ( 1,9% ) in which the standard classifications were used to assess changes in pvr status after any treatment , reporting pvr grade before and after it [ 19 , 20 ] . the remaining authors used the classifications only to describe pvr status , rather than using them to analyze the improvement or worsening of the previous stage after the applied treatment .", "classifications of pvr were developed to provide clinicians with a useful tool to compare results of treatments . they are , to date , purely descriptive and do not reflect the pathobiology of this complex vitreoretinal disease . the original classification of 1983 , which was relatively simple to use , induces errors in the estimating severity in some cases . as mentioned , d grades were based on the ophthalmoscopic appearance of the detached retina , and experience demonstrated that some of these cases could be relatively easily solved by peeling localized epiretinal membranes although , in some cases , classified as c , intraretinal severe changes prevent reattachment , unless complicated surgical techniques were used . subsequent classifications [ 10 , 11 ] were more detailed and therefore more complicated to use on a routine basis . they incorporated the anterior pvr forms , which add severity to the case , but until now no one has incorporated the intraretinal changes , observed in many surgical retinal samples [ 8 , 9 ] , which may prevent the anatomical reattachment of the retina and require retinectomy . another important limitation is that they do not provide information on the activity of the process , although it has been observed that pvr progresses through several stages [ 13 ] . this may be crucial in estimating the risk of reproliferation after surgery or when surgeons schedule removing silicone oil , and no data on the chronology of events is included in any classification . furthermore , current classifications are not prognostic and do not correlate with visual prognosis or anatomical success after surgical treatment . moreover , some of these classifications can be difficult to use in clinical practice , due to their complexity ( grade , localization , extension , type , etc . ) and because they may not provide useful information they have been largely abandoned by clinicians . our findings in this study demonstrate that , in clinical research , investigators are using them inconsistently and reporting limited observations of stages ( mostly grade c ) . some authors simply do not use any , preferring generic terms , such as minimal , moderate , and severe pvr [ 21 , 22 ] . furthermore , early stages of pvr ( named as grades a and b ) , which are common to all classifications , are not used , and most authors refer only to most advanced stages , basically grade c [ 20 , 23 ] . moreover , the presence of classification errors could indicate that there is confusion concerning their use [ 13 , 1618 ] . an important relevant finding is that only a limited number of clinicians appropriately and fully use the current updated classification of 1991 [ 2427 ] , while the majority of authors avoid using the added characteristics of localization , extension , and type , limiting the description to the grade . in addition , many colleagues still use the first reported classification , probably because although it presents many limitations , it is easier to use compared to the last version [ 23 , 28 ] . additionally , some authors decided to use alternative classification , probably to avoid problems evaluating pvr stages . the use of multiple classifications makes the efficient communication between clinicians and the comparison of different studies very problematic . as mentioned , one of the aims of this study was to evaluate the usefulness of these classifications for pvr management with surgery and other adjunctive treatments . unfortunately , many ophthalmologists did not use the normalized classifications for comparing the outcomes using non - clearly defined terms such as pvr recurrence [ 29 , 30 ] .", "our findings showed the inconsistent and limited use of the current pvr classifications suggesting that it may be of benefit to produce a revised classification incorporating , if possible , the new knowledge on pvr which has been published since 1991 , pointing out new potential targets for therapeutic agents distinct from those , mainly proliferative agents , targeted by the original description of this disease . thus , it is possible that we could reduce its prevalence after retinal detachment surgery and to improve the anatomical and functional results of this disease which resists the attempts of both basic researchers and clinicians for more than 30 years ." ]

[ "the number of total joint arthroplasties ( tjas ) performed has increased steadily in recent years , with projected numbers for the coming years rising further . consequently according to recent data , peri - prosthetic joint infection ( pji ) incidence constitutes between approximately 0.3% and 1.7% of all total hip arthroplasties ( tha ) , and between 0.8% and 1.9% of all total knee arthroplasties ( tka ) . pji can be classified in intra - operative , early post - operative , acute haematogenous and chronic infections , according to both timing and cause of infection . the risk factors potentially correlated with acute pji infection can be divided into pre - operative ( usually related to patient comorbidities ) , peri - operative and post - operative , which are mainly linked to the behaviours of the surgeon and the hospital staff . conversely , chronic infections are less influenced by the conduct of the surgeon , as they are most often related to haematogenous diffusion of bacteria . the aim of this paper is to review the recent literature , summarising the most relevant risk factors that the surgeon can modify in order to reduce the incidence of peri - prosthetic joint infection .", "several studies demonstrated that some comorbidity can be associated with an increased risk of pji . the american academy of orthopaedic surgeons ( aaos ) reported on the different risk factors for pji and developed a guideline for pji prevention and treatment . in 2013 consensus for definition , prevention and management of pji , as an update to the previous guidelines . potential risk factors for development of surgical site infection or peri - prosthetic joint infection after elective total joint arthroplasty , according to the international consensus on periprosthetic joint infection bmi , body mass index ; hba1c , glycated haemoglobin . although the majority of these conditions must be considered as non - modifiable factors , many preventive measures may be adopted to reduce their impact on the development of pji . table 2 summarises the modifiable and non - modifiable factors related to pji , including some preventive measures to manage reversible medical comorbidities , according to the existing literature . pre - operative modifiable and non - modifiable risk factors ; measures the surgeon can adopt to reduce impact of risk factors on development of pji pji , peri - prosthetic joint infections ; bmi , body mass index ; hba1c , glycated haemoglobin ; mrsa , methicillin - resistant staphylococcus aureus ; s. aureus , staphylococcus aureus other potential pre - operative risk factors are intra - articular corticosteroid injections and any infectious disease , particularly urinary tract infection ( uti ) and nasal colonisation with staphylococcus ( s. ) aureus . the relationship between steroid injections and post - operative pji was evaluated in several studies . papavasiliou et al reported an incidence of only 2% of infections in a series of 114 tkas , but all of the infected tkas had previously been treated with an intra - articular corticosteroid injection within the 11-month period prior to surgery . conversely , desai et al stated that the incidence of infection did not increase in patients with prior steroid injection treatment . the correlation between post - operative utis and pji has been demonstrated . however , the association between pre - operative bacteriuria and early deep infections remains uncertain . the presence of symptoms of a uti in association with urinary leukocyte counts greater than 1 10/ml and a bacterial count greater than 1 10/ml should be the only indication for surgical delay . conversely , in asymptomatic patients it is still possible to proceed with tja by treating those patients with urine colony counts greater than 1 10/ml . different authors confirmed that being a high - level nasal carrier of s. aureus is an important and significant independent risk factor for developing ssi with s. aureus . nasal application of mupirocin is widely accepted as treatment for nasal carriers of s. aureus . in a recent randomised controlled trial ( rct ) , mupirocin treatment resulted in a simple , safe and cost - effective intervention that can reduce the risk of ssi .", "different intra - operative components may play an important role as risk factors for developing pji ( table 3).the first six hours following surgery are the most important regarding infection , as during those hours the numbers of bacteria multiply exponentially . maintaining a low blood level of bacteria in this period is critical , and for this reason prophylactic antibiotics are infused to decrease bacterial multiplication and to extend this golden period . the pre - operative dose of antibiotics should be administered within one hour before the surgical incision ; this can be extended to two hours for vancomycin and fluoroquinolones . most authors agree that a single pre - operative prophylactic infusion of cefazolin ( 1 gr if < 80 kg ; 2 gr if > 80 kg ) is a good choice . however , recent studies have demonstrated that targeted use of vancomycin and cefazolin among patients undergoing revision tka significantly reduced the rate of overall infections , in particular of mrsa . surgeons should consider additional antibiotic administration if the surgery time is twice the length of the half - life of the antibiotic , or whenever the blood loss exceeds 2000 ml and fluid resuscitation is over 2000 ml . to reduce pji infection rate , some authors advocate using antibiotic - loaded bone cement ( albc ) for the cementation . however , it was demonstrated that routine use of albc does not change the pji rate , though it may be useful in the reduction of the pji rate in high - risk patients ( for example those with diabetes or immunosuppression ) . intra - operative factors potentially associated with pjis pji , peri - prosthetic joint infections surgical site preparation also plays a role in reducing pji rate . some authors have confirmed the reduction of pji in patients who underwent pre - admission surgical site preparation using chlorhexidine washing . different studies have evaluated the best solutions for surgical site preparation to reduce pji . in a rct conducted by darouiche et al , it was demonstrated that a chlorhexidine alcohol solution was more protective than povidone iodine against both superficial and deep infections . this is probably due to the more rapid action , persistent activity despite exposure to bodily fluids , and residual effect of chlorexidine compared with povidone . the preparation of the surgical site often includes using plastic adhesive drapes and sterile stockinette . however , a recent cochrane review showed no evidence that adhesive drapes reduce surgical site infection rates . the bactericidal action of incision drapes containing iodine is inferior to conventional skin preparation solutions , so using incision drapes as a substitute for conventional skin preparation is not recommended . furthermore , boekel et al concluded that the surgical field for tka can be contaminated by proximal microbial spread from the unprepared foot with the use of a sterile stockinette drape . the risk of pji is also directly correlated with the length of the surgery , which should be less than 2.5 hours as a reasonable cut - off point . zhu et al , in their meta - analysis , concluded that increased operative time is associated with a higher risk of pji development ( or = 2.18 , ci 95% 1.39 - 3.42 , p = 0.003 ) . however , these data may also be correlated with the high complexity of long procedures . furthermore , the surgeon s surgical volume may be directly associated with pji : surgeons with low volumes may have higher rates of infection . hand care is another crucial point in reducing pji infection ; hand surgical scrub recommendations were previously published by the centers for disease control and prevention . in particular , surgeons should remove debris from underneath the fingernails using a nail cleaner under running water , and either an antimicrobial soap or an alcohol - based hand rub should be used persistently for at least five minutes . different studies evaluated the number of glove changes necessary to reduce the risk of pji . of note , beldame et al recommended : renewing outer gloves after draping ( before placing a cutaneous adhesive ) ; opening the instrumentation secondarily , with a new glove change after handling instruments which may cause perforations ; renewing outer gloves after each surgical stage . no strong evidence is available in the literature regarding the appropriate number of glove changes . different authors recommended double gloving to reduce the risk of inner glove perforation , but no correlation with pji has been demonstrated . the role of the personal protection system ( pps ) in preventing pji is still debated . kearns et al demonstrated that the external surface of the pps can not be assumed to be sterile after removal from the original packaging , and they suggested the need to change gloves if the pps is touched or adjusted during the procedure . other authors agree with the consideration of pps as more a personal protection than equipment specifically to reduce pji . light handles can be a source of contamination , and surgeons must minimise their handling as far as possible . furthermore a limited number of portable devices such as mobile telephones and tablet computers in the operating room is recommended , although no evidence in the literature is able to link their use to increased risk . as airborne pathogens are a potential source of infection , the location and length of time that surgical instruments remain exposed for this reason , all instruments should be opened in operating rooms with clean air systems . these basins are repeatedly used during a surgical procedure and should therefore be considered a potential source of contamination . anto et al demonstrated that 23.8% of specimens from splash basins tested positive for bacterial contamination , and they suggested that surgeons should stop using them . a recent systematic review showed no conclusive results regarding the utility of laminar flow in reducing pji rate . other authors agree that , despite the number of previous studies demonstrating the efficacy of laminar flow , more recent research has failed to prove this efficacy . ultraviolet light seems to be more effective when compared with laminar flow in reducing pji ; however it is characterised by potentially unacceptable health costs to operative personnel . a level iii study showed that the number of door openings had a role in increased infection rate . surgeons may also play a role in reducing the rate of pji using power - pulsed lavage or wound lavage at surgery . in a level iv study ,", "different post - operative variables may also play a role as risk factors for pji development . antibiotic prophylaxis for other surgical procedures before and after tja , such as dental care or urological procedures , seems to play a role as a despite the lack of literature demonstrating the relationship between dental procedures and pji , the current recommendation of the aaos is to use antibiotic prophylaxis in patients with a tja who are undergoing dental procedures , as well as any other invasive procedure . furthermore , patients should be aware that any infection is a potential source of haematogenous dissemination . as previously reported by different authors , patients with tja who have an active infection anywhere in the body are at risk of developing a pji . for this reason , a prompt diagnosis and management of those infections is a mandatory prevention mechanism . there is still debate regarding the association between blood transfusion and pji . in a level ii study , pulido et al demonstrated that transfusion with allogenic blood is an independent risk factor for pji . patients receiving allogenic transfusions were 2.1 times more likely to develop pji compared with patients receiving no transfusion . in their study , innerhofer et al concluded that allogenic filtered transfusion is an independent variable for pji prediction ( or 23.65 ; ci 95% , 1.3 - 422.1 ; p = 0.01 ) . furthermore , the centers for disease control and prevention guidelines defined peri - operative allogeneic transfusion as a potential risk factor for developing pji , but concluded that the interpretation of the existing literature is difficult due to variations in assessment criteria . however , different measures can be adopted to reduce the need for blood transfusion , such as pre - operative screening for anaemia and its treatment , intra - operative accurate haemostasis , minimisation of surgical time and use of tranexamic acid . haematoma and persistent wound drainage were also related to an increased pji rate ; these conditions should be treated promptly with antibiotic prophylaxis , a decrease in anticoagulation dose , surgical evacuation of the haematoma , irrigation and debridement and modular component exchange . recently , more advanced surgical bandages such as hydrofibre absorbent dressings were proposed , with the aim of reducing the medication to allow for better wound healing and to prevent bacteria from entering the wound site from the external environment . in a level ii study , cai et al concluded that advanced surgical dressings such as hydrofibre may contribute to a reduction in the incidence of acute pji .", "infection represents a major challenge in tja , and is costly and demanding to manage for both surgeons and patients . the main risk factors involved in pji development are divided into pre - operative , intra - operative and post - operative factors . the surgeon can act to reduce the impact of some reversible comorbidities , for example controlling glycaemia in diabetic patients or improving malnutrition . various intra - operative risk factors such as operating theatre traffic , use of light handles , pulsed lavage or number of glove changes may also be related to infection . post - operative risk factors include transient bacteraemia related to dental procedures or other infections , wound care and blood transfusion as well as haematoma , and wound drainage should be controlled with care .", "no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article ." ]

[ "\n the use of sodium hypochlorite as toilet detergent is related to a red - brown urine discolouration in patients taking mesalamine.it seems that the red - brown discolouration relates to a harmless reaction.polymerisation of mesalamine and/or metabolites could be a theoretical mechanism of this discolouration . \n", "the exact working mechanism of mesalamine is not fully understood , but it appears to have anti - inflammatory properties . the drug blocks interleukin-1 and tumour necrosis factor-. mesalamine also inhibits the cyclo - oxygenase pathway , leading to inhibition of prostaglandin e2 in inflamed intestine . the most common adverse drug reactions ( adrs ) , as described in the summary of product characteristics ( smpc ) , are headache , rash and gastrointestinal symptoms , including diarrhoea , nausea , vomiting and abdominal pain . mesalamine is also associated with the renal adrs of renal failure , interstitial nephritis and haematuria [ 1 , 3 ] . in the period from august 2009 to april 2015 , the netherlands pharmacovigilance centre lareb received two case reports of red - brown urine discolouration in association with mesalamine . both cases were reported by patients and the urine discoloured after contact with the toilet bowl .", "this case concerned a 38-year - old male with a history of crohn s disease . the patient reported separate several episodes of a red - brown deposit in the toilet bowl after the start of mesalamine in 1999 ( pentasa slow - release 500 mg tablet ) . the latest episode occurred in april 2015 , 2 days after the use of mesalamine . the patient had a mild form of crohn s disease that had been stable for 68 years and only used mesalamine during episodes of exacerbations . due to an exacerbation in september 2014 , the daily dose of mesalamine was increased from 2 to 4 g. during this dose escalation , the patient recognised the same red - brown deposit that had occurred during previous use . in january 2015 , the mesalamine was tapered over a period of 2 months to 2 g once daily and he remained stable . he observed that the urine initially had a normal colour and developed the red - brown colour after contact with the water in the toilet bowl . most of the time the persistent deposit did not appear directly after contact with the toilet water but developed after a few days , despite flushing the toilet . of note , the deposit in the toilet bowl was more intense during the use of an increased dose of 4 g a day . the patient wondered whether the use of detergents could have caused this kind of discolouration and therefore he cleaned his toilet in the morning with a chlorine - containing detergent . in the evening a red - brown deposit had developed in the toilet bowl and on the seat and the water was unaffected . as the patient wanted more information on the possibility of the discolouration being the result of a reaction with the sodium hypochlorite detergent , he reported it to lareb . after the report had been assessed , the pharmacovigilance centre lareb asked the patient to collect his urine and to add household bleach as a test , to which he agreed ( fig . 1 ) . the urine ( 40 ml ) was mixed with 20 ml of sodium hypochlorite bleach and within a few minutes the discolouration developed . after shaking the mixture , 1 \n red brown discolouration after adding sodium hypochlorite bleach to normal - appearing urine ( left , right ) . agitation discoloured the urine completely ( right ) \n \n red brown discolouration after adding sodium hypochlorite bleach to normal - appearing urine ( left , right ) . agitation discoloured the urine completely ( right ) this case concerned a 36-year - old woman with ulcerative colitis , for which she is treated with 2 g of mesalamine ( pentasa sachet 2 g prolonged - release granules ) twice daily . since she started taking mesalamine in june 2009 , her urine appeared red - brown in the toilet bowl , but only when she had recently cleaned the toilet with sodium hypochlorite detergent . when the patient added a drop of sodium hypochlorite detergent to her normal - coloured urine in the toilet , the same red - brown discolouration occurred immediately . the patient is still taking mesalamine and the phenomenon is still present when cleaning the toilet .", "this case concerned a 38-year - old male with a history of crohn s disease . the patient reported separate several episodes of a red - brown deposit in the toilet bowl after the start of mesalamine in 1999 ( pentasa slow - release 500 mg tablet ) . the latest episode occurred in april 2015 , 2 days after the use of mesalamine . the patient had a mild form of crohn s disease that had been stable for 68 years and only used mesalamine during episodes of exacerbations . due to an exacerbation in september 2014 , the daily dose of mesalamine was increased from 2 to 4 g. during this dose escalation , the patient recognised the same red - brown deposit that had occurred during previous use . in january 2015 , the mesalamine was tapered over a period of 2 months to 2 g once daily and he remained stable . he observed that the urine initially had a normal colour and developed the red - brown colour after contact with the water in the toilet bowl . most of the time the persistent deposit did not appear directly after contact with the toilet water but developed after a few days , despite flushing the toilet . of note , the deposit in the toilet bowl was more intense during the use of an increased dose of 4 g a day . the patient wondered whether the use of detergents could have caused this kind of discolouration and therefore he cleaned his toilet in the morning with a chlorine - containing detergent . in the evening a red - brown deposit had developed in the toilet bowl and on the seat and the water was unaffected . as the patient wanted more information on the possibility of the discolouration being the result of a reaction with the sodium hypochlorite detergent , he reported it to lareb . after the report had been assessed , the pharmacovigilance centre lareb asked the patient to collect his urine and to add household bleach as a test , to which he agreed ( fig . 1 ) . the urine ( 40 ml ) was mixed with 20 ml of sodium hypochlorite bleach and within a few minutes the discolouration developed . after shaking the mixture , 1 \n red brown discolouration after adding sodium hypochlorite bleach to normal - appearing urine ( left , right ) . agitation discoloured the urine completely ( right ) \n \n red brown discolouration after adding sodium hypochlorite bleach to normal - appearing urine ( left , right ) .", "this case concerned a 36-year - old woman with ulcerative colitis , for which she is treated with 2 g of mesalamine ( pentasa sachet 2 g prolonged - release granules ) twice daily . since she started taking mesalamine in june 2009 , her urine appeared red - brown in the toilet bowl , but only when she had recently cleaned the toilet with sodium hypochlorite detergent . when the patient added a drop of sodium hypochlorite detergent to her normal - coloured urine in the toilet , the same red - brown discolouration occurred immediately . the patient is still taking mesalamine and the phenomenon is still present when cleaning the toilet .", "likewise , the disordered haem production in patients with porphyria can result in red - brown discolouration . a red - brown urine discolouration could be perceived as a sign of possible renal impairment or other diseases ; however , neither of the described patients are known to have an impaired renal function or physical abnormalities . furthermore , various drugs are associated with red and/or brown discolouration , e.g. rifampicin , doxorubicin , metronidazole , methyldopa , levodopa and sulfasalazine . a notable difference from the described mesalamine cases is that the urine of patients taking the above - mentioned drugs , such as sulfasalazine , is already discoloured at micturition . a pubmed search was conducted and it was found that two cases of red - brown urine associated with mesalamine have been reported previously by sacks and davis . both of the male adolescents in these reports experienced the same red - brown urine discolouration after contact with sodium hypochlorite bleach . a similar experiment was performed to that performed by patient a , and after adding sodium hypochlorite bleach to the collected urine the discolouration developed spontaneously . to our knowledge , there are no other published reports of this association after a chemical reaction with drugs structurally related to mesalamine ( sulfasalazine , olsalazine and 4-aminosalicylic acid ) . notably , there has been discussion regarding this phenomenon in several patient forums and blogs . case reports from altmann and mansell do , however , describe urine discolouration in patients using methyldopa or levodopa after contact with lavatory bleach and exposure to light . normal biotransformation of methyldopa produces a variety of metabolites ; presumably , these metabolites have properties that form melanin by spontaneous polymerisation , which results in darkening of the urine . melanins are polymers of phenolic compounds ( e.g. dopaquinone , benzothiazole ) that are formed by an extensive bio pathway . melanin is an aggregate of smaller component molecules such as pheomelanin and eumelanin ; both of these are initially formed by oxidation of tyrosine and then undergo cysteinylation and cyclisation , respectively . the end product is ultimately formed by polymerisation of several different derivatives . altmann and mansell found that urine samples that were made alkaline in patients treated with methyldopa or levodopa turned black on exposure to sunlight . mesalamine is acetylated by the enzyme n - acetyltransferase 1 ( nat1 ) in the liver and gut mucosal wall into the metabolite n - acetyl-5-aminosalicylic acid ( n - ac-5asa ) . evidence from the literature indicates that nat1 is polymorphic , but that these polymorphisms are associated with relatively minor effects on acetylation function . it is unknown whether the patients in our reports have a nat1 polymorphism , but if so we would expect no significant effect on the propensity of discolouring . furthermore , this acetylation is minimal when mesalamine and n - ac-5asa are both secreted back into the lumen by the drug efflux pump p - glycoprotein , excreted in the faeces , absorbed via the colon into the blood and , lastly , eliminated in the urine . the theory is that n - ac-5asa and/or mesalamine react with the sodium hypochlorite - containing bleach . sodium hypochlorite usually has a ph of 1113 and could therefore initiate the reaction as described by altmann and mansell . according to the cases reported by altmann and mansell , it is also possible that a similar polymerisation of mesalamine and/or n - ac-5asa could cause the discolouration of the urine . perhaps due to the alkaline environment , partial deprotonation of n - ac-5asa and mesalamine could also contribute to this reaction . since the introduction of the national spontaneous reporting system in 2003 to the general public , consumers have now become the largest group of reporters in the netherlands . the quality of consumer reports are generally good and these reports highlight via first - hand information the real - life experience of an adr . being unconstrained with regards to the probability of causality , consumers may report relevant adrs that healthcare professionals may not recognise initially or consider to be unlikely . patient b s gastroenterologist recognised the phenomenon , but it is conceivable that not every gastroenterologist will establish a direct relationship between urine discolouration , mesalamine therapy and the use of a specific detergent . the two reports received provide important information about a harmless reaction as this phenomenon probably concerns a lot of other patients using mesalamine .", "based on the described reports and the case reports in the literature , we suggest a causal relationship between red brown discolouration of urine after contact with sodium hypochlorite detergent and the use of mesalamine . the naranjo assessment scores for cases a and b were 9 and 6 , indicating a certain and probable relationship , respectively . this seems to be a harmless reaction as the patients experienced no physical complaints and in both the lareb cases and those described by sacks and davis , the patients were under the care of a gastroenterologist . in the differential diagnosis it is important to be aware that the use of sodium hypochlorite as a toilet detergent could be the cause of coloured deposits in and on the toilet bowl . the presence of sodium hypochlorite does not exclude the possibility of renal impairment ; therefore , it is important to distinguish already discoloured urine from normal - coloured urine that only discoloured after contacting the toilet bowl . thus , to inform and reassure patients , it might be helpful to mention red - brown discolouration in the patient leaflet for mesalamine .", "no financial support was received for the conduct of this study or preparation of this manuscript ." ]

[ "diabetic retinopathy ( dr ) is a leading cause of visual impairment and blindness in developed countries . the decrease in vision is due to diabetic macular edema ( dme ) and proliferative diabetic retinopathy ( pdr ) [ 1 , 2 ] . the control of the blood glucose level , vitreous surgery , and photocoagulation are the major treatments used to prevent dr from progressing to the pdr stage . currently , intravitreal injections of antivascular endothelium growth factor ( vegf ) or steroids have become the primary therapy for dme [ 35 ] . however , the use of a single therapeutic agent is not effective in all cases , and additional treatments or different agents are needed . the blood retinal barrier ( brb ) consists of two anatomical parts ; the inner brb is located within the endothelial cells of the retinal capillaries , and the outer brb is located between the retinal pigment epithelial ( rpe ) cells . an intact brb is required for an efficient and regulated control of fluids in the subretinal space and for the maintenance of healthy rpe and retinal cells . a breakdown of the outer brb results in an increase in the paracellular permeability between the rpe cells , and the leakage can cause retinal edema . the tight junctions ( tjs ) of the rpe cells are intercellular junctions located at the apical ends of the rpe cells , and they are integral structural components of the brb . tjs are made up of three tj related proteins , for example , the zonula occludens-1 ( zo-1 ) , occludin , and claudin . recent studies have shown that interactions between inflammatory cells and retinal cells are critical for the development of intraocular neovascularization [ 1012 ] . the results of these studies also demonstrated that , in eyes with pdr , an elevation of vegf was significantly correlated with the levels of several cytokines including interleukin- ( il- ) 6 , il-8 , and the monocyte chemoattractant protein-1 ( mcp-1 ) . another study showed that the levels of these cytokines were also strongly correlated with each other which suggest that there are common pathways involved in the inflammatory processes . in addition , various cytokines have been shown to be related to the maintenance of the conformation of the tj proteins . lecithin - bound iodine ( lbi , jolethin , daiichi pharmaceutical co. , tokyo , japan ) has been used clinically to reduce the antigen - induced immune responses in children with bronchial asthma . lbi acts on the peripheral blood mononuclear cells and downregulates the il-4-induced ige synthesis , which suggests that lbi have anti - inflammatory properties [ 15 , 16 ] . in patients with eye diseases , lbi has been used for the absorption of retinal or vitreous bleeding , vitreous opacities , and improvement of central serous choroidopathy . the purpose of this study was to determine whether lbi will alter the integrity of the tjs of arpe-19 cells in culture .", "lbi ( jolethin , daiichi pharmaceutical co. , tokyo , japan ) was dissolved in distilled water and diluted to the appropriate concentration for each experiment . an earlier study showed that lbi solutions contain 48.250.3% lecithin - iodine , approximately 10% free lecithin , and 40% phosphatidylinositol . rabbit polyclonal anti - zo-1 antibody ( sc-10804 ) was purchased from santa cruz biotechnology ( santa cruz , ca ) , and alexa 594 anti - rabbit igg was purchased from invitrogen ( molecular probs , eugene , or ) . rabbit anti - mcp-1 antibody ( # 2029 ) was purchased from cell signaling technology ( danvers , ma ) and rabbit anti - eotaxin ( ccl-11 ) antibody ( ab133604 ) was purchased from abcam ( cambridge , ma ) . cells from a human retinal pigment epithelium cell line , arpe-19 , were grown in dulbecco 's modified eagle 's medium / ham 's f-12 supplemented with 10% fetal bovine serum ( fbs , hyclone laboratories , inc . , logan , ut ) , 50 units / ml penicillin , and 50 g / ml streptomycin in an air-5% co2 atmosphere with constant humidity . prior to the experiments , cells were placed in serum - free media and pretreated with 50 g / ml of lbi or 250500 pg / ml of antibody ( anti - mcp-1 antibody and anti - chemokine ( c - c motif ) ligand-11 ( ccl-11 ) antibody ) for 24 h. to mimic hypoxic conditions , arpe-19 cells were incubated for 4 h with 100 m of cocl2 ( sigma , st . louis , mo ) , which is a chemical hypoxia - inducing agent . after the incubation , optimum concentration of lbi was defined as 50 g / ml because over 100 g / ml of lbi seems to be toxic ( data not shown ) . for the immunofluorescence studies , cells were grown to a density of 2 10 cells / ml on 12 mm cover slips and fixed in 10% tricarboxylic acid for 10 min at 4c . they were then treated with 0.5% triton x-100 for 15 min . to detect the presence of zo-1 , the cultured rpe cells were exposed to rabbit polyclonal anti - zo-1 antibody as the primary antibody and alexa 594 anti - rabbit igg as the secondary antibody . samples were examined and photographed with a fluorescence microscope ( bz-9000 ; keyence , osaka , japan , and eclipse 50i , nikon , tokyo , japan ) , and the intensity of fluorescence was quantified with a bz - ii analyzer ( keyence ) . the levels of the bioactive molecules in the conditioned medium were determined by human il-6 , il-8 , and mcp-1 elisa kits ( r&d systems , minneapolis , mn ) and ccl-11 elisa kit ( biosensis , thebarton , south australia , australia ) . all experiments were repeated at least three times and values are presented as the means standard deviations . data were analyzed by two - way nonrepeated analysis of variance ( anova ) followed by bonferroni post hoc tests for the comparison of the means .", "we first determined whether the lbi pretreatment affected the changes in the conformation of the tj proteins caused by the hypoxic stress induced by cocl2 . immunofluorescence microscopy showed that there appeared to be a disruption of tjs with cocl2 treatment ( figures 1(a ) and 1(b ) ) . when the arpe-19 cells were pretreated with lbi before the addition of cocl2 , the disruption of the tight junctions was not detected ( figures 1(c ) and 1(d ) ) . the signal intensity measurements showed that there was a significant decrease with the cocl2 addition compared to the control . but there was no significant change in the lbi pretreated group ( 29244.6 2981.2 in controls ; 5787.7 4126.4 with cocl2 ; and 27189.0 11231.1 with cocl2 after lbi pretreatment ; p < 0.05 , nonrepeated anova , n = 5 , figure 1(e ) ) . because disruption of tjs is detected as a decrease of signal intensity , these results indicate that lbi pretreatment can protect the tjs of the outer brb from hypoxic stress . because lbi pretreatment protected the conformation of the tj proteins from hypoxic stress , we hypothesized that lbi will block different inflammatory molecules that are secreted from cells during hypoxia . the results of the elisa measurements of the conditioned culture media ( n = 5 ) indicated that il-8 was not significantly changed after the addition of cocl2 or after pretreatment with lbi ( control , 6.9 0.1 ; with cocl2 , 6.8 0.1 ; and with cocl2 after lbi pretreatment , 6.9 0.1 pg / ml ; figure 2(a ) ) . although the level of il-6 was increased after addition of cocl2 which was decreased by lbi pretreatment , these changes were not significant ( control , 10.4 1.6 ; cocl2 addition , 15.0 6.7 ; and cocl2 addition after lbi pretreatment , 13.3 7.6 pg / ml ; figure 2(b ) ) . the level of mcp-1 increased significantly after the addition of cocl2 , and it was significantly decreased after the addition of cocl2 after lbi pretreatment ( control , 279.7 68.3 ; with cocl2 , 340.8 43.3 ; and with cocl2 after lbi pretreatment , 182.6 23.8 pg / ml , p < 0.05 ; nonrepeated anova ; figure 2(c ) ) . a similar tendency was observed for ccl-11 ( control , 12.5 6.1 ; with cocl2 , 15.2 12.9 ; and with cocl2 after lbi pretreatment , 5.46 1.9 pg / ml ; p < 0.05 ; nonrepeated anova ; figure 2(d ) ) . these results indicated that there is an increase of the mcp-1 and ccl-11 secretion under hypoxic stress , and all are suppressed by lbi pretreatment . to confirm that lbi effectiveness is related to suppression of mcp-1 or ccl-11 , cells were pretreated with anti - mcp-1 or anti - ccl-11 antibody for 24 hrs . the tj disruption from hypoxic stress was reduced with pretreatment ( figures 3(e ) and 3(f ) ) . these results indicated that both mcp-1 and ccl-11 were important to protect tjs from hypoxic stress and support the effectiveness of lbi . vegf is a major antigen factor and is biogenic permeability factor which can increase the vascular permeability endothelial cell - cell junctions . finally , to confirm that lbi pretreatment can protect tjs from direct vegf induced stress , after lbi pretreatment but after pretreatment of lbi , this disruption was decreased which indicates that lbi can also protect tjs from vegf induced damage .", "but there still remain patients who do not respond to the anti - vegf therapy and who had a reduction of their vision even after therapy . it must also be noted that the cost of anti - vegf therapy is quite high and continuous injections to control the dme can become an economic issue . combination therapies have also been proposed that can enhance the efficacy and may minimize the cost of anti - vegf therapies . for example , photocoagulation can extend the interval of anti - vegf injections resulting in a reduction in the number of injections [ 21 , 22 ] . if new drugs or treatments can be approved , this will make it easier and less expensive to use combination therapies . moreover , adjunctive therapies that include oral kallidinogenase could also be used for combined therapy [ 23 , 24 ] . our results showed that the hypoxic stress induced by exposure of arpe-19 cells to cocl2 caused a disruption of the tight junctions and that lbi pretreatment can protect the tjs from the hypoxic stress . hypoxic stress also enhanced the secretion of mcp-1 and ccl-11 , and this enhancement can be suppressed by lbi pretreatment . hypoxia has been reported to produce alterations in the tight junction proteins that are correlated with the vascular permeability increases . the integrity of the brb is dependent on tj - associated proteins such as occludin , claudin , and zo-1 . the function of zo-1 is to link the transmembrane protein , occludin , to the actin cytoskeleton . under hypoxic conditions , the phosphorylation of zo-1 is enhanced which is related to the damage of the tight junctions . mcp-1 is associated with a breakdown of the brb [ 3032 ] , and it also induces a disruption of the tjs by the caveolae that are dedicated to the internalization of the tj proteins , such as zo-1 . because mcp-1 is also increased in the vitreous of patients with dr , it probably plays an important role in the progression of dr and dme . in the photocoagulation - induced mouse model of retinal neovascularization , it was reported that an increase in mcp-1 contributes to the postischemic inflammation and dr progression [ 34 , 35 ] . mcp-1 has been recently postulated to have a direct effect on angiogenesis even though there is no link with macrophage recruitment . ccl-11 also promotes the recruitment of vascular endothelial cells and relates the conformation of the tight junctions . interestingly , there is also an increase of ccl-11 in the proliferative membranes obtained from eyes with pdr . so these cytokines relate to zo-1 and maintain tight junctions on diabetic retina . in the photocoagulation - induced retinal neovascularization or light - exposed mouse models , the levels of not only mcp-1 but also ccl-11 are increased in the rpe [ 3941 ] . these increases were related to the remodeling of f - actin that occurred after light damage and caused proinflammatory changes in the rpe cells . these findings support our results that showed that the hypoxia - induced stress affected the expression of cytokines especially mcp-1 and ccl-11 . the suppression of these cytokines by lbi leads to the protection of these cells from disruption of the tight junctions . steroids are also commonly used for dme therapy because their anti - inflammatory property helps to protect the tissues from neovascularization or vascular permeability increases . similarly , the effect of lbi on the suppression of the postischemic inflammation may be an additional contributor when used as either a primary or adjunctive dme therapy . mainly in japan and china , lbi has been approved for the treatment of various retinal diseases including central serous chorioretinopathy , vitreous hemorrhage , or vitreous opacity for a long time . in addition , both lecithin and iodine are commonly used in food materials indicating the safety of lbi . thus , the possibility exists that lbi can be even used as a safe adjunctive therapy with an anti - vegf drug to treat dme . further investigations into the use of lbi in conjunction with anti - vegf therapy need to be undertaken to determine the effectiveness of lbi in preventing the development or progression of dme . our findings showed that lbi pretreatment reduced the levels of mcp-1 and ccl-11 and blockage of them also results in protection of tjs . however , no significant changes were detected in the levels of il-6 and il-8 , which are the major cytokines related to neovascularization . in ischemic retinas , il-8 causes increases in the vegf and mcp-1 levels but it is dependent on tnf- . because il-8 has been shown to be secreted from either monocytes or macrophages and because our experiments were limited to arpe-19 cells in culture , there is the possibility that the results may not hold under in situ conditions . though we observed that vascular permeability improved after oral lbi administration for diabetic mice model ( data not shown ) , it is not clear whether this is the result of hypoxia improvement the same as we show here using arpe-19 . in addition , lbi pretreatment can also protect tjs from direct vegf induced damage which results in tj disruption . further investigations will need to be undertaken to definitively explain these phenomena . in conclusion , our data demonstrate the therapeutic potential of lbi for protecting the integrity of the tight junctions from hypoxia - induced stress . these data suggest a new aspect on the clinical use of lbi in the treatment of dme ." ]

[ "a 21-year - old caucasian woman presented to an outside facility with altered mental status after being found lethargic by family . on arrival to the emergency department , plasma glucose was 20 mg / dl . the patient was hospitalized and started on dextrose infusion , including 10% dextrose in water but remained hypoglycemic with capillary glucose ranging between 50 and 60 mg / dl . she was transferred to our facility on suspicion of an insulinoma as the patient was unable to recall her prior diagnosis . the patient reported repeated episodes of seizures , syncope , dizziness , headaches , palpitations , and sweating around age 12 ; however , symptoms were never formally investigated as she did not seek expert care . these symptoms were also reported to have been present since birth but had been intermittent and of varying severity . she remained seizure - free and without syncopal episodes until 17 when she experienced another syncopal episode . at that time , she underwent extensive inpatient hypoglycemia evaluation with the following results : blood glucose of 47 mg / dl after 2 h of fasting , proinsulin levels varying from 10.4 to 84.1 pmol / l ( normal range 010 pmol / l ) , c - peptide level 3.1 ng / ml ( normal range 1.14.4 ng / ml ) , negative insulin antibodies and sulfonylurea screen . magnetic resonance imaging of the abdomen showed no insulinoma , but genetic studies revealed val452 leu activating mutation of the gck gene . she was successfully treated with diazoxide and discharged home on oral diazoxide 250 mg daily , which she discontinued due to side effects of hirsutism and fluid retention . on current admission , her blood glucose level remained low in spite of a continuous infusion of 5% dextrose necessitating transfer to an intensive care unit . as review of her medication list did not show any implicating drugs , no additional work - up was pursued . she was then placed on octreotide 200 g subcutaneously twice daily and diazoxide suspension 100 mg three times a day on consultation with the pediatric endocrinologist . the patient 's hypoglycemia improved with capillary glucose of 55110 mg / dl by the time of discharge . importance of compliance with the treatment and follow - up with an endocrinologist was emphasized .", "when encountered in the inpatient setting , it is easily recognized as patients already have risk factors such as diabetes mellitus ( dm ) on treatment , sepsis , and end - organ failure . however , for patients presenting emergently with hypoglycemia alone , appropriate investigations are warranted to treat and prevent recurrence . after establishing a diagnosis of hypoglycemia by whipple 's triad ( low plasma glucose , hypoglycemic symptoms , and resolution of adrenergic / neuroglycopenic symptoms with correction of the blood sugar ) , interim treatment and search for risk / causative factors should ensue ( table 1 ) . ideally , treatment is only given after obtaining a plasma sample to ensure accuracy of diagnosis . medical history of ethanol use , surreptitious insulin ingestion , medication use and interaction , autoimmune disease , gastric bypass ( 4 ) , and subtle risk factors such as undiagnosed psychiatric disorder and polypharmacy should be excluded ( 5 ) . in seemingly well patients , the timing of hypoglycemic spells ( fasting / postabsorptive or postprandial / reactive ) is required to determine diagnostic studies . a mixed meal tolerance test under supervision is done for postprandial hypoglycemia while a 72-h fast should be done for fasting hypoglycemia . hepatic or renal disease , endocrine disorders of growth hormone , cortisol , adrenal insufficiency , and hypopituitarism should be excluded . plasma insulin , proinsulin , c - peptide , and beta - hydroxybutyrate levels should be assessed to exclude surreptitious use of insulin or insulin receptor antibodies . intravenous glucagon can be given to distinguish disorders of gluconeogenesis from glycogenolysis ( 5 ) . a 48-h supervised fast should be done to exclude insulinoma , with plasma insulin and proinsulin levels . pro - igf ii to igf ii ratio can be measured to look for non - beta - cell tumors ( 5 ) . negative findings suggest non - insulinoma pancreatogenous hypoglycemia syndrome ( niphs ) , which encompasses chi ( 4 , 6 ) . a selective pancreatic arterial calcium stimulation test ( spaci ) done at this time can detect hyperfunctioning of b - cells and confirm the diagnosis of niphs . causes of hypoglycemia in adults chi is uncommon in the pediatric population with an estimated incidence of 1 in 40,000 to 50,000 live births annually in europe ( 7 ) . gck mutations account for 7% of all causes of chi ( 8 , 9 ) ; gck facilitates phosphorylation of glucose to glucose-6-phosphate and is the main glucose sensor of the pancreatic beta cell and hepatocytes - controlling glucose - stimulated insulin secretion and glycogenesis ( 10 ) . activating mutations of the gck gene are typically inherited in an autosomal dominant pattern , showing variable phenotypic penetrance and expressivity ranging from asymptomatic to marked hypoglycemia ( 11 , 12 ) . inactivating forms of the mutation cause varying severity of persistent hyperglycemia depending on zygosity ( 13 ) . de novo gck mutations are very rare and exhibit marked variation in phenotypic expression ( 14 ) . over 600 heterozygous inactivating mutations have been reported , causing mild persistent hyperglycemia known as maturity onset diabetes of the young ( mody ) as opposed to only 13 known activating mutations of the gene ( 15 , 16 ) . activating mutations are usually clustered around the allosteric activator site of the enzyme and led to hyperinsulinemic hypoglycemia by lowering the glucose set point and threshold for glucose stimulated insulin release . the sheer numbers of existing mutations of the gck gene show it to be a highly mutable gene with varied disease outcomes depending on the type of activation . it is key to blood glucose homeostasis and has been identified as a potential target for anti - diabetic therapy . trials manipulating gck regulatory protein an allosteric switch for gck , which indirectly restores gck activity , are currently underway to evaluate its effect on blood glucose in patients with type 2 dm ( 17 , 18 ) . treatment of niphs involves lifelong dietary modification consisting of frequent , low carbohydrate meals ( 5 ) , which prevent surges in plasma glucose level , insulin level , and the consequent hypoglycemic spells . medications such as diazoxide , octreotide , glucagon , verapamil , and somatostatin , whose actions all involve inhibition of calcium channels , have been employed with varying degrees of success ( 7 ) . diazoxide binds to and activates the sulfonylurea receptor 1 subunit of the potassium adenosine triphosphate [ k(atp ) ] channel , causing calcium channel closure . response to diazoxide therefore varies with genetic mutations [ ineffective in mutations of the k(atp ) channel genes ] ( 8) and with pattern of inheritance ( 7 ) . octreotide , a somatostatin analogue ( secretin and insulin inhibitor ) , has been used in diazoxide unresponsive chi with improved blood glucose in these patients ; however , side effects such as gastrointestinal symptoms , dilated gallbladder , necrotizing enterocolitis , and qt prolongation sometimes limit its use ( 7 ) . long - term use of glucagon is effective in diazoxide - unresponsive cases or severe / diffuse chi but gastrointestinal side effects and crystallization in infusion tubing have been reported ( 19 ) . glucagon - like protein 1 receptor agonists such as exendin-4 are newer drugs that improve hypoglycemia in diazoxide - unresponsive patients by inhibiting insulin release ( 7 ) . partial pancreatectomy is indicated for medical treatment failure [ suggesting a k(atp ) defect ] and is only curative for focal lesions while extensive resection is reserved for diffuse chi to limit pancreatic burden ( 7 , 8 , 11 , 20 ) . affected patients can present in adulthood ; de novo mutations should be considered given the following:- positive family history of unremitting hypoglycemia- lifelong symptoms of low plasma glucose , even after eating- increased bmi- negative sulfonylurea and autoimmune work up- positive glycemic response to octreotide \n - positive family history of unremitting hypoglycemia - lifelong symptoms of low plasma glucose , even after eating - negative sulfonylurea and autoimmune work up - positive glycemic response to octreotide to our knowledge , only three families with affected adults have been reported . our case is unique because it expounds on genetic causes of hypoglycemia in adults . in addition , this case highlights the pediatric - to - adulthood transition for rare diseases and the key role that coordination and transition of care plays in timely management .", "after establishing a diagnosis of hypoglycemia by whipple 's triad ( low plasma glucose , hypoglycemic symptoms , and resolution of adrenergic / neuroglycopenic symptoms with correction of the blood sugar ) , interim treatment and search for risk / causative factors should ensue ( table 1 ) . ideally , treatment is only given after obtaining a plasma sample to ensure accuracy of diagnosis . medical history of ethanol use , surreptitious insulin ingestion , medication use and interaction , autoimmune disease , gastric bypass ( 4 ) , and subtle risk factors such as undiagnosed psychiatric disorder and polypharmacy should be excluded ( 5 ) . in seemingly well patients , the timing of hypoglycemic spells ( fasting / postabsorptive or postprandial / reactive ) is required to determine diagnostic studies . a mixed meal tolerance test under supervision is done for postprandial hypoglycemia while a 72-h fast should be done for fasting hypoglycemia . hepatic or renal disease , endocrine disorders of growth hormone , cortisol , adrenal insufficiency , and hypopituitarism should be excluded . plasma insulin , proinsulin , c - peptide , and beta - hydroxybutyrate levels should be assessed to exclude surreptitious use of insulin or insulin receptor antibodies . intravenous glucagon can be given to distinguish disorders of gluconeogenesis from glycogenolysis ( 5 ) . a 48-h supervised fast should be done to exclude insulinoma , with plasma insulin and proinsulin levels . pro - igf ii to igf ii ratio can be measured to look for non - beta - cell tumors ( 5 ) . negative findings suggest non - insulinoma pancreatogenous hypoglycemia syndrome ( niphs ) , which encompasses chi ( 4 , 6 ) . a selective pancreatic arterial calcium stimulation test ( spaci ) done at this time can detect hyperfunctioning of b - cells and confirm the diagnosis of niphs .", "chi is uncommon in the pediatric population with an estimated incidence of 1 in 40,000 to 50,000 live births annually in europe ( 7 ) . gck mutations account for 7% of all causes of chi ( 8 , 9 ) ; gck facilitates phosphorylation of glucose to glucose-6-phosphate and is the main glucose sensor of the pancreatic beta cell and hepatocytes - controlling glucose - stimulated insulin secretion and glycogenesis ( 10 ) . activating mutations of the gck gene are typically inherited in an autosomal dominant pattern , showing variable phenotypic penetrance and expressivity ranging from asymptomatic to marked hypoglycemia ( 11 , 12 ) . inactivating forms of the mutation cause varying severity of persistent hyperglycemia depending on zygosity ( 13 ) . de novo gck mutations are very rare and exhibit marked variation in phenotypic expression ( 14 ) . over 600 heterozygous inactivating mutations have been reported , causing mild persistent hyperglycemia known as maturity onset diabetes of the young ( mody ) as opposed to only 13 known activating mutations of the gene ( 15 , 16 ) . activating mutations are usually clustered around the allosteric activator site of the enzyme and led to hyperinsulinemic hypoglycemia by lowering the glucose set point and threshold for glucose stimulated insulin release . the sheer numbers of existing mutations of the gck gene show it to be a highly mutable gene with varied disease outcomes depending on the type of activation .", "it is key to blood glucose homeostasis and has been identified as a potential target for anti - diabetic therapy . trials manipulating gck regulatory protein an allosteric switch for gck , which indirectly restores gck activity , are currently underway to evaluate its effect on blood glucose in patients with type 2 dm ( 17 , 18 ) .", "treatment of niphs involves lifelong dietary modification consisting of frequent , low carbohydrate meals ( 5 ) , which prevent surges in plasma glucose level , insulin level , and the consequent hypoglycemic spells . medications such as diazoxide , octreotide , glucagon , verapamil , and somatostatin , whose actions all involve inhibition of calcium channels , have been employed with varying degrees of success ( 7 ) . diazoxide binds to and activates the sulfonylurea receptor 1 subunit of the potassium adenosine triphosphate [ k(atp ) ] channel , causing calcium channel closure . response to diazoxide therefore varies with genetic mutations [ ineffective in mutations of the k(atp ) channel genes ] ( 8) and with pattern of inheritance ( 7 ) . octreotide , a somatostatin analogue ( secretin and insulin inhibitor ) , has been used in diazoxide unresponsive chi with improved blood glucose in these patients ; however , side effects such as gastrointestinal symptoms , dilated gallbladder , necrotizing enterocolitis , and qt prolongation sometimes limit its use ( 7 ) . long - term use of glucagon is effective in diazoxide - unresponsive cases or severe / diffuse chi but gastrointestinal side effects and crystallization in infusion tubing have been reported ( 19 ) . glucagon - like protein 1 receptor agonists such as exendin-4 are newer drugs that improve hypoglycemia in diazoxide - unresponsive patients by inhibiting insulin release ( 7 ) . partial pancreatectomy is indicated for medical treatment failure [ suggesting a k(atp ) defect ] and is only curative for focal lesions while extensive resection is reserved for diffuse chi to limit pancreatic burden ( 7 , 8 , 11 , 20 ) .", "affected patients can present in adulthood ; de novo mutations should be considered given the following:- positive family history of unremitting hypoglycemia- lifelong symptoms of low plasma glucose , even after eating- increased bmi- negative sulfonylurea and autoimmune work up- positive glycemic response to octreotide \n - positive family history of unremitting hypoglycemia - lifelong symptoms of low plasma glucose , even after eating - negative sulfonylurea and autoimmune work up - positive glycemic response to octreotide to our knowledge , only three families with affected adults have been reported . in addition , this case highlights the pediatric - to - adulthood transition for rare diseases and the key role that coordination and transition of care plays in timely management .", "despite the congenital nature of gck mutations , some patients can go undiagnosed till early adulthood . future research into a cost - effective and prompt scheme of patient information dissemination is warranted for uncommon diseases .", "the authors have not received any funding or benefits from industry or elsewhere to conduct this study ." ]

[ "obstructive sleep apnea ( osa ) is a common public health problem worldwide and it has been shown to be associated with an increased incidence of cardiovascular complications such as death , stroke , or myocardial infarction . the 2014 american heart association / american stroke association guideline recommends that patients with stroke / transient ischemic disorder ( tia ) showed be worked up for osa . in this study , patients who had osa and stroke had an improved outcome with continuous positive airway pressure . extrapolating data from western population and implementing in the asian populations may not be possible as there are differences in genetic and anatomical factors . for example , the cutoff point for obesity based on body mass index ( bmi ) criterion for western population is 30 kg / m meanwhile the bmi for asian population is 25 kg / m . it is also evident that there are differences in anatomical factors between asian and caucasian population such as retrognathia and oropharyngeal width which are main risk factors for osa . alternatively , the stop - bang questionnaire developed by chung et al . has been widely used as a sensitive screening tool for osa . the stop - bang acronym stands for : snoring history , tired during the day , observed stop breathing while sleep , high blood pressure , bmi more than 35 kg / m , age more than 50 years , neck circumference more than 40 cm and male gender . the authors recommended that if a patient had 3 or more criteria mentioned above , it is strongly suggestive for osa . however , the cut - off values of this questionnaire are based on the data from caucasians , therefore we hypothesized that to use it in asian population , some adjustments are needed .", "we compared the clinical features in the stop - bang questionnaire between osa - induced hypertension patients and healthy control subjects . the study was conducted in the faculty of medicine , khon kaen university ( thailand ) . the study protocol was approved by the ethics committee for human research , khon kaen university . osa induced - hypertension patients were diagnosed by : i ) met the criteria of hypertension ; ii ) having average apnea - hypopnea index ( ahi ) by polysomnography more than or equal 5 times / hours and iii ) no evidence of other secondary hypertension . the control subjects filled up the modified berlin questionnaire and epworth sleepiness scale less than 10 and defined as low risk for osa with low scores . demographic data and clinical features of both osa - induced hypertension patients and healthy subjects were recorded and compared . the clinical features included age , gender , bmi , neck circumference , mallampati classification , torus palatinus , and torus mandibularis . the mallampati classification was defined by asking the subjects to protrude their tongue as much as possible and classified as class 1 to 4 . the sample size of the study population was calculated by using the proportion comparison between osa and healthy subjects using winpepi program . the proportion of osa was 0.35 and the healthy control was 0.07 with deviation of 5% , power of 90% , and missing data of 10% . the sample size was calculated to be 102 subjects ( osa 34 subjects and healthy control 68 subjects ) . due to the incompleteness of the database of medical students , 120 healthy controls were selected by systematic sampling from the database ( total of 1174 medical students ) . baseline and clinical characteristics of the participants in both groups were compared using descriptive statistics . univariate logistic regression analyses were applied to calculate the crude odds ratios of individual variables for having osa . all clinically significant variables or p<0.20 by the univariate analyses were included in subsequent multivariate logistic regression analyses . analytical results were presented as crude odds ratios ( or ) , adjusted or , and 95% confidence intervals ( ci ) . significant risk factors were calculated for the best cut - off points by the receiver operator characteristic curve ( roc curve ) . data analyses were performed with stata software ( college station , tx , usa ) and spss software ( chicago , il , usa ) .", "in this study , 42 osa - induced hypertension patients and 82 control subjects who had a complete set of clinical data were included . all clinical features of both groups the osa - induced hypertension patients were significantly older ( 59.5 vs 21.0 years ) , with higher proportion of males ( 64.3 vs 59.8% ) , more obese ( 78.6 vs 6.1% ) , higher incidence of mallampati class 3 or more ( 54.8 vs 24.4% ) , larger neck circumference ( 41.3 vs 32.0 cm ) , higher incidence of torus palatinus ( 26.6 vs 0% ) and of torus mandibularis ( 9.5 vs 0% ) . by multiple logistic regression analysis , only two factors bmi and neck circumference , the adjusted odds ratios for both factors were 1.49 ( 95% ci : 1.06 , 2.09 ) and 1.67 ( 95% ci : 1.11 , 2.51 ) , respectively . by the roc curve analyses , the best cut - off points for the bmi and the neck circumference were 24.5 kg / m ( figure 1a ) and 36 cm ( figure 1b ) . the sensitivity and the specificity for bmi cut - off point were 97.2% and 91.4% , whereas those for the neck circumference were 94.7% and 82.9% .", "the present results showed that the stop - bang questionnaire needed to adjust the cutoff values of the bmi and neck circumference suitable for thai population . subjects should referred for polysomnography if positive at least 3 questions : s , snoring history ; t , tired during the day ; o , observed stop breathing while sleep ; h , high blood pressure ; b , bmi more than 25 kg / m ; a , age more than 50 years ; n , neck circumference more than 36 cm ; g , male gender ( modified from chung et al . ) . for the criteria of obesity for asians , the cut - off of the bmi should lower from 35 kg / m to 24.5 or round up to 25 kg / m . the cut - off of the neck circumference also should be lowered from 40 cm to 36 cm for asians . proposed the cutoff points of 24.1 kg / m for the bmi and 35.5 cm for the neck circumference for japanese population . using stop - bang questionnaire is very suitable for thailand and other developing countries due to limited availability of polysomnography , the standard diagnostic tool for osa . this low cost tool can select appropriate patients for referral to sleep center for further polysomnography . healthy control subjects were not performed polysomnography to exclude osa . however , both the berlin questionnaire and the epworth sleepiness scale were used to exclude osa , which has a sensitivity and specificity of 0.86 , 0.95 and 0.49 , 0.80 , respectively . even though the age is a significant factor by univariate logistic regression , it was not included in the subsequent multivariate regression . this is because the difference of age group composition between the osa and the healthy control subjects . further studies , therefore , are needed to confirm the results of this study and to identify the appropriate cut - off point using the age- and sex - matched controls . also , to increase their sensitivity and specificity , osa patients with other complications than hypertension should be included and compared . whether simple measurement of the neck circumference and the bmi calculation are sufficient to identify osa patients in routine practice by primary health care personnel including physicians , nurses and volunteers should be examined in further study . osa has been proved to be a contributing factor for major cardiovascular diseases ; stroke , hypertension , sudden death , and also coronary artery disease . treatment of osa may reduce large economic burden from prevention of the morbidity and mortality from stroke and acute coronary syndrome . in conclusion , the appropriate cut - off points for the bmi and the neck circumference for stop - bang questionnaire were 25 kg / m and 36 cm for asian people . all hypertensive patients should have their bmi and neck circumference measured to detect the risk factors for osa . public health campaign for osa screening is also needed to reduce morbidity and mortality from osa complications ." ]

[ "triple - negative breast cancer ( tnbc ) is characterized by absence of expression of the estrogen ( er ) and progesterone receptors ( pr ) and no human epidermal growth factor receptor 2 ( her2)/neu gene amplification [ 1 , 2 ] . unlike hormone receptor - positive and her2-overexpressing breast cancers , tnbc is unresponsive to endocrine therapy and her2-targeted agents , respectively , thereby limiting available systemic treatment options to conventional cytotoxic chemotherapy [ 1 , 2 ] . patients with tnbc are more likely to have visceral or brain metastases and short relapse - free survival compared with those with other breast cancer subtypes [ 3 , 4 , 5 , 6 ] . while chemotherapies have been effective for treating early - stage disease , with pathologic complete response ( cr ) rates exceeding those of hormone receptor - positive subtypes , patients with metastatic disease have shorter disease - free survival progressing rapidly through several lines of chemotherapy . thus , response to chemotherapy has not translated to improvements in progression - free ( pfs ) or overall survival ( os ) in the metastatic setting , and the overall prognosis for tnbc remains poor [ 3 , 7 ] . the median os of patients with metastatic disease is relatively short , with reports between 9 and 13.3 months [ 3 , 4 , 5 , 6 ] . an unmet clinical need exists for more effective therapies for tnbc , particularly in the metastatic setting . taxane - based chemotherapy has demonstrated activity in patients with tnbc [ 1 , 2 ] . in the phase iii eastern cooperative oncology group 2100 trial in which 91% of the patients had her2-negative disease , 51% of the patients were pr negative and 37% were er negative , the addition of bevacizumab to solvent - based paclitaxel demonstrated significantly improved median pfs compared with solvent - based paclitaxel alone ( 11.8 vs. 5.9 months , respectively ) ; however , this did not translate into a significant improvement in median os for the combination arm . nab - paclitaxel , a novel formulation albumin - bound paclitaxel with a mean particle size of 130 nm , was initially designed with the intent to improve the therapeutic index of solvent - based taxanes [ 9 , 10 ] . currently , nab - paclitaxel is indicated for the treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant chemotherapy . a phase ii study examined the combination of nab - paclitaxel , bevacizumab , and gemcitabine as first - line therapy for patients with her2-negative metastatic breast cancer . in this small cohort of patients with stage iv tnbc , the clinical benefit rate as defined by cr , partial response , and stabilization of disease was 85% . additionally , in this study , there were no significant differences in pfs or os between triple - negative and hormone receptor - positive patients . this work reports on a patient with metastatic tnbc enrolled in this phase ii study of nab - paclitaxel , bevacizumab , and gemcitabine who experienced a long - term complete remission lasting just under 2 years and a pfs from diagnosis of nearly 3 years .", "in june 2007 , a 52-year - old woman was diagnosed with invasive ductal carcinoma . the patient initially presented with chest pain , and a subsequent breast examination revealed a mass in the left breast and a palpable sternal mass . a lumpectomy and axillary lymph node dissection were performed at an outside institution and results revealed a moderately differentiated , infiltrating ductal carcinoma , high nuclear grade , measuring 4 cm in maximal diameter , with metastases to 2 of 24 axillary nodes . further staging also revealed sternal and mediastinal metastases , and a computed tomography ( ct ) scan revealed bilateral pulmonary nodules ( fig . tumor samples were negative for er and pr , and positive ( + + ) for her2 by immunohistochemistry . however , fluorescent in situ hybridization results were negative for her2 gene amplification , and the patient was diagnosed with triple - negative primary metastatic / stage iv breast cancer . the patient was initially seen at the university of miami sylvester comprehensive cancer center and enrolled in the phase ii study of nab - paclitaxel , bevacizumab , and gemcitabine for her2-negative metastatic breast cancer . she was treated on study with gemcitabine 1,500 mg / m by 30-min infusion , followed by nab - paclitaxel 150 mg / m by 30-min infusion , then bevacizumab 10 mg / kg by 30-min infusion once every 2 weeks in a 4-week cycle . the patient experienced pain relief after 5 weeks on the study ( 2 infusions ) . serial ct scans , performed every 2 months , demonstrated progressive reduction in the size of all target lesions ( fig . she showed a complete clearance of lesions in all imaging studies , which was confirmed on at least 2 separate occasions approximately 2 months apart according to response evaluation criteria in solid tumors . one dose reduction , as required by the study protocol , occurred in november 2008 on cycle 12 , due to treatment - related fatigue . the dose of gemcitabine was reduced to 1,250 mg / m , nab - paclitaxel to 125 mg / m , with no modification of the bevacizumab dose , and treatment was continued once every 2 weeks on a 4 week cycle . throughout her treatment , she experienced no major side effects and continued to work uninterrupted except for visits for chemotherapy and evaluation , and her treatment - related fatigue was successfully managed with the dose reduction . the patient maintained her response and continued to receive treatment for just over 2 years . after 12 months on study , follow - up was performed every 3 months . in may 2010 , the patient had documented disease progression by ct scan . metastases were found in the lung , bone , and lymph nodes . as specified in the study protocol , the patient discontinued study treatment due to disease progression . she received her last dose of nab - paclitaxel , bevacizumab , and gemcitabine on may 28 , 2010 . three weeks after progressing , the patient received capecitabine at a dose of 2,000 mg / m orally twice a day for 2 weeks in 3-week cycles and showed minor response . however , therapy was stopped due to unacceptable toxicity , including diarrhea , dehydration , and severe palmar plantar erythrodysesthesia . after 2 months , she initiated therapy with ixabepilone , with a minor radiographic response . from august 2010 to december 2010 , she received 8 cycles of treatment with ixabepilone ( 30 mg / m ) administered intravenously every 3 weeks . in december 2010 , the patient requested a chemotherapy holiday . beginning in november 2011 , the patient was treated with eribulin 1.1 mg / m intravenously on days 1 and 8 of a 3-week cycle . treatment was discontinued in march 2012 due to rapid disease progression with development of central nervous system metastases . she was transferred to hospice care where she died a month later . throughout the course of her disease , she received zoledronic acid at 4 mg intravenously every 4 weeks beginning in november 2007 when she began the phase ii study . in may 2010 , she continued to receive denosumab throughout her chemotherapy holiday from december 2010 to november 2011 until discontinuing therapy in march 2012 after being transitioned to hospice care .", "patients with metastatic tnbc have a very poor prognosis . in a large analysis of 255 patients diagnosed with tnbc at the md anderson cancer center between 1985 and 2004 , the median os of patients with recurrent disease was only 1.0 year ( 95% ci , 0.81.2 years ) for tnbc patients , significantly shorter than the median os of 2.3 years ( 95% ci , 1.92.7 years ) for those with other breast cancer subtypes ( hr , 2.5 ; 95% ci , 1.83.5 ; p < 0.001 ) . other studies have reported median os times for patients with recurrent or metastatic tnbc between 9 and13.3 months [ 4 , 5 , 6 ] . while median os has not been specifically assessed in a large patient population initially presenting with metastatic tnbc , it is likely to be similarly poor . additionally , patients with metastatic tnbc exhibit progressively shorter response durations to successive lines of therapy . in a retrospective analysis of 111 patients with tnbc ( 14% of whom presented with metastatic disease at diagnosis ) , the median duration of response was only 12 weeks ( range , 073.1 weeks ) to first - line therapy , 9 weeks ( range , 0120.9 weeks ) to second - line chemotherapy , and 4 weeks ( range , 059 weeks ) to third - line chemotherapy . there is an unmet clinical need for effective therapies that prolong survival for patients with metastatic tnbc . in the absence of curative therapies for metastatic disease , the goal of therapy is primarily palliative in nature , leveraging systemic treatment with minimal toxicity to both prolong os and at the same time enhance quality of life by delaying the onset of cancer - related symptoms . numerous studies have shown that the combination of gemcitabine and a taxane is an effective regimen that is well tolerated with good response rates . the case described here is of a patient with metastatic tnbc treated with first - line combination chemotherapy consisting of nab - paclitaxel , bevacizumab , and gemcitabine every other week . after only 5 weeks and 2 infusions , the patient experienced significant symptom relief from her pain from bone metastases , including the sternum . following 7 months of treatment , she achieved a complete remission that , with continuous therapy , persisted for nearly 2 years for an overall progression - free period from initial diagnosis of 2 years and 7 months . following progression , subsequent lines of therapy were able to produce only limited efficacy in disease control . following her initial progression - free interval of almost 2 years in cr with nab - paclitaxel , bevacizumab , and gemcitabine therapy , subsequent treatment with capecitabine then ixabepilone resulted in short progression - free intervals of only 2 months and 4 months , respectively . while ixabepilone did provide a pfs benefit , it was very modest . from her initial diagnosis in june 2007 , the patient survived nearly 5 years , which is greatly improved compared to reported median survival of 913.3 months for stage 4 tnbc [ 3 , 4 , 5 , 6 ] . with the aim to enhance quality of life , systemic treatments with minimal toxicity while the patient did experience treatment - related fatigue while on nab - paclitaxel , bevacizumab , and gemcitabine combination therapy , this was easily managed with a dose reduction . in addition to a lengthy complete remission , the patient was able to work uninterrupted throughout her treatment period , a factor that may significantly elevate quality of life for many patients . this patient initially received treatment as a participant in a phase ii study of nab - paclitaxel , bevacizumab , and gemcitabine as first - line therapy for her2-negative metastatic breast cancer . a large proportion ( 13 of 29 ) of the patients enrolled in this study had triple - negative disease . overall , this subset of patients demonstrated promising outcomes , with 38% achieving a complete radiographic response and 85% experiencing clinical benefit . most notably , survival outcomes were almost identical between tnbc patients and those with hormone receptor - positive disease . additionally , severe adverse events appeared to be less frequent in the overall study population relative to results in other published chemotherapy studies in patients with metastatic breast cancer . this case study demonstrates the potential for triplet chemotherapy with nab - paclitaxel , bevacizumab , and gemcitabine to elicit prolonged responses , potentially prolong os , and improve quality of life for patients with metastatic tnbc . this combination shows promise for the treatment of tnbc and should be the subject of further investigation in larger randomized trials ." ]

[ "in humans , type i interferons are encoded by ~16 genes and individual genes encoding , , and . their gene products are highly structurally related and all bind to a single receptor ( ifnar ) consisting of heterodimeric r1 and r2 subunits . in contrast , ifn- consists of 3 genes , ifn-1 , 2 and 3 ( formally , il-29 , il-28a and il-28b ) that are more related to the il-10 family than to interferon . ifn- binds a receptor ( ifnlr ) composed of a unique ifnlr1 and a shared il-10r2 subunit . while stats 1 and 3 are promiscuously activated by a variety of other cytokines and growth factor receptors , stat2 is selectively recruited to the ifnar and ifnlr . stat2 recruitment and activation by both receptors involves tyrosine phosphorylation of stat2 by jak kinases and subsequent oligomerization with stat1 and irf-9 . although a fraction of stat1:stat2 heterodimers can translocate to the nucleus and bind atypical gamma activated sequence ( gas)-like elements , the canonical interferon - stimulated gene factor-3 ( isgf3 ) complex of stat2:stat1:irf-9 regulates a large fraction of the interferon pathway genes . thus , stat2 is central to the induction of these genes in response to both ifn-/ and ifn-. in some cases , type ii interferon , ifn- , can mobilize the antiviral response in a stat2-dependent manner . although there is no evidence for direct recruitment of stat2 to the ifn-r , ifn- signaling can drive the formation of an isgf3-like complex containing stat2 , inhibit viral replication and induce expression of ifn-/ target genes , perhaps through the pairing of phosphorylated stat1 with latent stat2 . regardless of its mode and route of activation , stat2 acts as the gatekeeper to the antiviral response , which is underscored by the severe susceptibility of stat2 knockout mice to viruses ranging from influenza to dengue . type i and iii interferon , while produced in different amounts by distinct cell populations , regulate the expression of an overlapping set of interferon stimulated genes ( isgs ) . some examples include 25-oligoadenylate synthase ( oas ) , which decorates viral rnas with branched polyadenosine , and rna endonuclease l , which promptly degrades rnas containing these polyadenosine modifications . most isgs , however , have not been well characterized , and some of these genes are so enigmatic that they do not contain any canonical secondary structures that could aid in predicting their function . over 300 isgs have been identified by microarray and genomic analysis , which is curious given the magnitude of antiviral activity exhibited by select individual isgs . for example , mxa potently inhibits the replication of a wide range of viruses and can do so in the absence of other isgs or interferon signaling if ectopically expressed . not all isgs exhibit such robust effects individually ; nonetheless , when combined with other isgs , the host can mount an impressive arsenal of anti - viral proteins that could conceptually block every step in the viral life cycle . however , like oas and mxa , most isg expression requires interferon signaling through stat2 . thus , while there are three major nodes to drive interferon secretion ( tlrs , rig - i and nlrs ) and two pathways available to drive stat2 activation ( ifn-/ and ifn- ) , there is only one stat2 . in addition to its role in interferon mediated antiviral effect , stat2 also confers anti - proliferative and apoptotic activities on a variety of cell types in response to both type i and iii interferon . this activity is perhaps one of the most fundamental actions of interferon to inhibit viral spread by blocking the replication of virally infected cells . however , much attention has been focused on the use of ifn-/ to inhibit cancer outgrowth and metastasis given its unique ability to inhibit proliferation of a variety of tumor cell types . stat2 is a critical signaling intermediate that regulates much of the apoptotic and anti - proliferative effects of ifn-/ and ifn-. further , mutations within stat2 that protract its ligand - mediated phosphorylation can drive cells down the apoptotic pathway . a variety of genetic mutations have been identified in humans that affect ifn-/ and ifn- production , including mutations in nemo , tyk2 and tlr3 . further , functional defects in the human unc93b1 gene , which controls signaling via tlr3 , 7 , 8 and 9 , results in dramatic reductions in ifn-/ and ifn- secretion in response to ligands that activate these receptors . however , these subjects are susceptible to only a few types of viral infections , mainly encephalitis caused by herpes simplex virus . this restriction in viral susceptibility may reflect the inherent redundancy in driving ifn-/ and ifn- production through alternative pathways such as rig - i and nlrs . in contrast , to date , no mutations have been found that block responsiveness to type i or iii interferons in humans , particularly within either the ifn-/ receptors or stat2 . yet , defects in a variety of genes that affect both ifn- production and responsiveness have been characterized including ifngr1 , ifngr2 , stat1 and il-12rb1 . thus , it is interesting to speculate that mutations that affect ifn- responsiveness , while debilitating , can be tolerated ; yet , mutations that cripple ifn-/ or ifn- responsiveness such as stat2 are perhaps lethal .", "a cascade of cytokines regulate processes of inflammation that drive both local and systemic activation of immune cells , and this process can be initiated by both pathogen sensing as well as sterile tissue injury . when discussing the role of stats in inflammation , it is perhaps more accurate to discuss their function in the context of distinct cytokine receptors , as most of the stat family members can be activated by multiple cytokines . for example , stat3 can be activated by both il-6 and il-10 , yet their biological activities are diametrically opposed and counterregulatory with il-6 contributing to inflammation and il-10 blocking inflammation . while ifn-/ can induce local inflammation under certain circumstances , it does not mediate the intense forms of inflammation seen with tnf- or il-1. initially , ifn-/ was thought to act similarly to il-12 in driving th1 development through the recruitment and activation of stat4 , thereby driving th1-mediated inflammation . indeed , stat2 was shown to be involved in recruiting stat4 to the human ifnar . however , our recent findings demonstrated that although stat4 is transiently activated by the human ifnar , it is not sufficient to promote th1 development . further , distinct ifn- subtypes can drive stat4 activation to the murine ifnar , which can occur in mouse cells even in the absence of stat2 , yet still does not promote either th1 or tc1 development compared with the effects of il-12 . nonetheless , ifn-/ may regulate some aspects of inflammation that play a more supportive rather than direct role . ifn-/ ( as well as ifn- ) is a potent regulator of the chemokine cxcl10 ( ip-10 ) , which recruits activated effector t and nk cells to sites of infection . thus , direct pathogen sensing by epithelial and endothelial cells can lead to recruitment of inflammatory cells via autocrine responses to ifn-/. ifn-/ also activates nk cells directly by driving lytic activity and ifn- secretion . further , recent studies by tracey and colleagues demonstrated that the ifn-/-induced kinase , pkr , regulates an alternative pathway for inflammasome activation . as a result , the induction of pkr by ifn-/ can lead to potent secretion of hmgb1 and other leaderless cytokines that are dependent upon inflammasome - mediated cleavage . although ifn-/ regulates these processes , a formal test for the direct role stat2 in driving these responses has not been performed in stat2 knockout mice . however , a recent study by gamero and colleagues demonstrated reduced skin and colonic chemokine and cytokine expression in stat2 knockout mice in two models of chemically induced carcinogenesis . these results suggest that stat2 may directly contribute to carcinogenesis by promoting expression of proinflammatory cytokines and chemokines . in summary , stat2 participates in some aspects of inflammation by autocrine responses to ifn-/ and downstream induction of inflammatory chemokines and cytokines .", "given the critical nature of the interferon pathway in viral defense , it is not surprising that viruses have evolved to antagonize the antiviral state induced by type i and type iii interferons . the different antagonistic mechanisms include inhibition of interferon production , interferon signaling and inhibition of interferon induced antiviral proteins . stat2 in particular is a target of many viral proteins , which in some cases determines viral host range . here we discuss the viruses that have particularly acquired the ability to subvert the interferon signaling pathway by targeting stat2 ( summarized in table 1 ) . viruses from a broad array of genera have developed unique ways to subvert the interferon response , and such examples include herpes simplex virus 2 ( hsv-2 ) , mouse cytomegalovirus ( mcmv ) and lymphocytic choreomeningitis virus ( lcmv ) . however , the paramyxoviridae family of viruses contains perhaps the most replete examples of how viruses have subverted the interferon response pathway by targeting stat2 . the henipavirus ( nipah and hendra virus ) are newly emerging zoonotic pathogens causing acute respiratory disease in both human and other animal populations . each of these viruses along with other members of the paramyxoviridae family express a v protein , which is encoded by a polycistronic gene segment ( p gene ) that utilizes unique overlapping reading frames . the v protein from measles , nipah and hendra viruses can bind to stat2 and prevent the interferon response via sequestration of stat2 in the cytoplasm . however , the modes of interaction of the v protein from measles mediate this interference by distinct mechanisms from that of henipahviruses . while the v proteins of these viruses contain a conserved c - terminal domain ( ctd ) , only the measles virus requires the ctd for binding and targeting stat2 as means of interference with interferon signaling . in contrast , the nipah virus v protein can also bind stat2 in a stat1 dependent manner through distinct regions of the v protein mapping outside the boundary of the ctd . these complexes are unable to translocate to the nucleus , thus sequestering stat2 to the cytoplasm and inhibiting efficient interferon signaling . the hendravirus v protein also operates in a similar manner to nipah virus , although the distinct interaction with stats have not been mapped . in addition , the nipah virus v protein has been shown to contain a nuclear export signal ( nes ) that enables the v protein to shuttle between the cytoplasm and nucleus . nonetheless , binding of stat1:stat2 complexes by nipah v protein is sufficient to prevent ifn-/ signaling even in the absence of the nes . therefore viruses belonging to the same family have evolved to target stat2 using diverse mechanisms in order to evade interferon response in the host . respiratory syncytial virus ( rsv ) is a member of the paramyxovirus family and causes severe flu and cold like symptoms in humans , particularly in children . rsv antagonizes the interferon - signaling pathway through two virally encoded nonstructural proteins , ns1 and ns2 . together , ns1/2 form a complex with stat2 and drive ubiquitin - mediated proteasomal degradation . binding of stat2 with this complex requires the c - terminus of ns2 , while ns1 acts as an e3 ligase that targets stat2 for degradation . in a similar manner to rsv , the rodent pathogen sendai virus ( sev ) encodes a c protein that antagonizes ifn-/ signaling at all phases of the infection process by interacting with stat1 and blocking activation of stat2 . finally , the human parainfluenza virus 2 ( hpiv2 ) is an rna virus of the paramyxoviridae family that causes upper and lower respiratory infections . in human , hpiv2 blocks type i interferon signaling by selectively inducing degradation of stat2 but not stat1 . the degradation of stat2 is independent of ifn-/ signaling , and like other members of this family of viruses , the v protein mediates the degradation of stat2 . post - translational degradation of stat2 protein by hpiv2 v protein was blocked by proteasome inhibitors indicating a role for proteasomal degradation . in contrast , the v protein of parainfluenza virus 5 [ piv5 , previously known as simian virus v ( sv5 ) ] , another member of the same family of viruses , preferentially induces stat1 degradation in a stat2-dependent manner in human . the c - terminal domain of this v protein is highly conserved across the members of rubulavirus genus of the paramyxoviridae family that includes both hpiv2 and piv5 . although piv5 can target human stat1 via stat2 , mouse stat2 does not interact with the piv5 v protein . thus , mouse stat2 restricts piv5 v protein interaction leaving the interferon response pathway intact . as such , piv5 is unable to efficiently replicate in mice due to an intact interferon response . transgenic mice expressing human stat2 restores the ability of piv5 v protein to mediated degradation of stat1 . likewise , expression of human stat2 in mouse embryonic fibroblasts permits antagonism of endogenous murine ifn-/ signaling by both piv5 and hpiv2 v proteins . thus , the requirement for stat2 interaction for antagonism of interferon response limits the host range of piv5 . dengue virus ( denv ) is another example of how host - pathogen co - evolution has become a host range - determining factor . dengue virus is a mosquito - borne rna virus that causes dengue fever , dengue hemorrhagic fever and dengue shock syndrome in humans . denv belongs to the genus flavivirus and has been shown to replicate efficiently in a variety of human immune cells including monocytes , macrophages , b cells and dendritic cells ( reviewed in ref . initial studies with denv replicons expressing all of the non - structural proteins demonstrated reduced ifn- stimulated genes concomitant with a reduction in endogenous stat2 protein levels . in later studies , denv ns5 was found to directly bind to and promote ubiquitin - mediated degradation of human , but not mouse stat2 . mouse stat2 expression in human cell lines restored the ifn - dependent block in virus production . ns5 interaction with human stat2 was mapped to the coiled - coil domain of human stat2 containing a species - specific sequence between residues 181301 . as ns5 failed to bind mouse stat2 , replacement of this region of mouse sequence with the human counterpart restored ns5 binding to the chimerized mouse molecule . in parallel studies , denv ns5 was found to specifically antagonize ifn- , but not ifn- signaling by binding to and inhibiting stat2 phosphorylation . recently , schoggins et al . have demonstrated that overexpression of stat2 in stat1-deficient fibroblast can limit denv replication without any significant isg expression . collectively these studies demonstrate that denv is able to establish infection in human due to its ability to surmount human antiviral response via stat2 degradation and blocking phosphorylation that may be circumvented in humans through augmented stat2 expression . however , murine stat2 has evolved to disengage this mechanism of stat2 antagonism by denv and thus restricting denv host range to humans .", "given the central role of stat2 in the induction of isgs , it is perhaps surprising that only a restricted subset of viruses have adapted their mechanism of innate subversion to target stat2 . for some viruses , stat2 determines the host range across species , and this is particularly evident with dengue virus , discussed above . however , closer examination of the stat2 gene and protein product reveals some important insights into how viruses shape the evolution of their hosts . in this section , we will explore how stat2 has emerged as a highly divergent member of the stat family while retaining its ability to exclusively regulate the interferon response in each species . the stat family can be traced as far back to rudimentary stat - like genes that exist in slime molds ( d. discoideum ) , thus suggesting that the current members that exist in mammals ( stats 1 , 2 , 3 , 4 5a , 5b and 6 ) arose from a common ancestral gene through duplication . in mammals , the seven stat family members are located as clusters in 3 genomic locations : in humans , stats 1 and 4 on chr . 17 and stats 2 and 6 on chr . 12 . considering their syntenic arrangement across species , how conserved are the various stat members in mammals ? within the ensemble database , there are seven species , including human , for which the full - length sequences are available for six of the seven stat family members . an alignment of these sequences reveals remarkable similarity ( > 95% for most pair - wise comparisons ) for each of the stat genes except stat2 ( fig . 1 ) . stat3 is the most highly conserved member , retaining > 98% sequence similarity comparing human with both mouse and rat . however , human stat2 , while being relatively well conserved with macaque and chimpanzee , diverges significantly when paired with mouse , rat , horse and elephant . a phylogenetic analysis further reveals the degree to which stat2 has diverged even within the non - human primate species when compared with the human counterpart ( fig . 2 ) . moreover , stat2 s dimerization partner stat1 displays roughly 5-fold greater sequence similarity than stat2 within primates ( based on sequence identity within the phylogenetic analysis in fig . the full length protein sequences of stats 1 , 2 , 3 , 4 , 5a and 6 were aligned against the human sequence for each of the species shown in the radar plot . the clustal alignment algorithm within macvector was used for the alignment , and the percent sequence similarity to human in pair - wise comparisons is plotted in the graph . the full length sequences of stat1 and stat2 for each species shown were aligned with the clustal algorithm within macvector . phylogenetic analysis was performed with this alignment , and the scale indicates the absolute numbers of sequence differences across the length of the dendrogram . within each stat family member , the sh2 domain is the most highly conserved segment of the gene across species , and stat2 is no exception to this ( fig . however , just beyond the sh2 domain , the c - terminal transactivation domain of stat2 diverges so significantly that only small segments of conservation are retained at the distal end of the protein . most striking is the disruption of the structure and insertion of a mini - satellite segment within the c - terminus of mouse stat2 that contains a repetitive element papqvlle . this element has no significant similarity to any other protein in the database , and mouse is the only species that harbors this sequence . the sequences of stat2 from the indicated species were aligned beginning with residue 651 of human stat2 . the sh2 and c - terminus of stat2 is indicated along with the conserved tyrosine residue ( y690 ) , which is phosphorylated in responses to ifn-/ signaling . the divergence in stat2 was first appreciated when mouse stat2 was cloned and sequenced over 12 years ago . at that time , it was known that stat2 interacted with other transcription factors to regulate expression of various isgs , and one of those factors was cbp . demonstrated that while the c - terminus of mouse was significantly different than human , cbp could still interact with the c - terminus of both mouse and human stat2 and functionally cooperate to regulate transcription . in addition , stat2 was also found to be required for recruitment of stat4 to the human , but not mouse ifnar . further , the human stat2 c - terminus was found to be required for this recruitment in human cells , and the significant divergence in this region partially explained the difference in signaling between the two species . however , the interaction was perhaps indirect as replacement of the mouse c - terminus with the human counterpart via knock - in failed to restore significant ifn-/-dependent stat4 activation in mouse t cells . nonetheless , these animals still responded normally to ifn-/ by activating isgf3 and by driving the expression of isgs . these types of domain - swapping experiments reveal some very interesting aspects of stat2 biology . despite drastic differences within the c - terminus , this domain still maintains a physical interaction with cbp and perhaps many other transcription factors whose evolution has remained relatively constant compared with stat2 . indeed , the c - terminus of stat2 is relatively unstructured compared with other domains within the protein . however , when bound to the transcriptional activator zinc binding ( taz ) domain of cbp , the human stat2 c - terminus undergoes dynamic folding to create a stable tertiary structure , thereby stabilizing its bound conformation to the taz domain . unfortunately , the structure of the c - terminus from other species such as mouse with the cbp taz domain has not been solved . nonetheless , stat2 displays remarkable plasticity in both its proximal receptor activation and downstream gene transactivation capabilities regardless of the remarkable structural differences that exist , particularly within the c - terminus . thus , even though stat2 has diverged at a much greater rate than other stat family members , the interactions that stat2 must maintain to mediate its function are still preserved and presumably contain enough inherent flexibility to accommodate large changes in stat2 s structure . considering the central role that stat2 plays in regulating the intracellular anti - viral response , it represents an important target for viral interference . while speculative , it is likely that lethal pandemic viruses drive stat2 evolution , in some cases , by targeting stat2 directly . perhaps the unique haplotypes that have been identified in stat2 among east asians and shared with neanderthal point to recent selection events in human evolution . regardless , the survival of each species , including humans , to viral assaults thus depends upon the flexibility of stat2 to maintain distinct physical interactions , which preserve its function in driving the interferon response ." ]

[ "for patients with operable breast cancer , the major prognostic determinant is whether there has or has not been spread to the axilla and the number of involved axillary nodes . initially it was suggested that breast cancer first spreads locoregionally via lymphatics to the axillary lymph nodes and then metastasises more distantly . in accordance with this concept , subsequently fisher postulated that the extent of micrometastases at diagnosis of breast cancer is an indicator of outcome , with biological behaviour of cancer predetermining the likelihood of progression of the disease . nowadays gene expression profiling arrays can delineate tumour types with different prognoses . the surgical approach for breast cancer treatment evolved from the extensive radical mastectomy and the patey modified radical mastectomy to breast conserving and minimally invasive techniques . traditionally the surgical management of breast cancer comprised wide local resection of the primary tumour and axillary lymph node dissection ( alnd ) . axillary status is the most important prognostic factor in breast cancer providing staging information and therefore largely defining treatment strategy . diagnostic imaging modalities such as ultrasound , magnetic resonance mammography , positron emission tomography , and 99 m technetium ( tc ) sestamibi scintimammography are not reliable for staging the axilla , particularly with lymph node metastases < 0.5 cm [ 8 , 9 ] . clinically palpable lymph nodes prove to be false positive in 2530% of patients and about 40% have positive results after ultrasound with or without fine - needle aspiration node negativity . studying 24,740 women with invasive breast cancer , carter et al . showed that approximately 80% with tumour size < 1 cm , 50% with up to 5 cm , and 30% with > 5% had negative axilla , a fact suggesting that metastases do not occur exclusively via the axillary lymph nodes , but rather lymph node status serves as an indicator of the tumour 's ability to spread . additionally , it has been recently shown that the molecular profile of the primary tumour is a more significant prognostic indicator in terms of disease - free survival ( dfs ) and overall survival ( os ) than lymph node metastases . the combination of the introduction of population - based mammographic screening for breast cancer , modern imaging methods , and increased public awareness resulted in patients being diagnosed more often with smaller - size tumours and less likelihood of axillary lymph node metastases . it is evident now that 6070% of patients with early breast cancer are node negative at the time of diagnosis and alnd puts them at significant risk of short- and long - term morbidities without benefit . alnd is associated with acute complication rates of 2030% including seroma formation , local swelling , numbness , impaired shoulder movement , neuropathy , infection , and chronic lymphoedema rates of 737% . in a prospective study by petrek et al . evaluating a cohort of 923 women with 20 years follow up , it was shown that breast - cancer - related lymphoedema following alnd occurred maximally in the first 3 years following surgery ; however , up to 23% of patients may still develop arm swelling during the rest of their lives . several randomised studies have established that sentinel node biopsy ( snb ) is a safe and accurate procedure for detecting tumour cells in sln and predicting the status of the other axillary nodes ( non - sln ) . although accuracy and appropriateness of snb were disputed by the finding of 510% false - negative cases when snb was followed by axillary dissection at high - risk patients for axillary nodal disease [ 13 , 18 ] , false - negative snb results seem to have decreased with the increasing experience of surgeons , and it is expected that the utilisation of snb in the future will be increased . a meta - analysis of seven prospective randomised controlled trials by kell et al . demonstrated that snb is equivalent to alnd for the detection of lymph node metastasis with the additional advantage of reduction of up to 75% in morbidity in patients with early stage breast cancer . furthermore , a trend towards an improved detection of ln metastases was shown when snb is used . patients undergoing snb have a 22% higher odds ratio of having a positive sln , due to the more intensive pathological examination which utilises multiple sections and immunohistochemistry ( ihc ) . in contrast , the false - negative cases seen after axillary dissection are probably due to the inability of the pathologist to perform serial sections and ihc on the 2030 lymph nodes found in a complete axillary clearance specimen . studies have shown that sln is the only positive lymph node in 3867% of patients when alnc followed . interestingly , it has been reported that only 48% of patients with negative alns have internal mammary lymph node involvement ( imn ) whereas 2550% of patients with affected alns have also imn metastases [ 23 , 24 ] . dissection of imn is not recommended because of the high morbidity and the uncertain benefit on survival . the recently published outcomes of nsabp b-32 trial established the efficacy of sln biopsy alone with no further alnd in 5611 breast cancer patients with clinically negative lymph nodes . women with invasive breast cancer who were randomly assigned to either sln resection plus alnd ( group 1 ) or to sln resection alone with alnd only if the slns were positive ( group 2 ) , after 8 years of followup , showed statistically equivalent overall survival , disease - free survival , and regional control . patient followup is still continuing for longer - term assessment of survival and regional control . moreover , a closer look into mature studies focused on axillary relapses and overall survival is in agreement with current findings favouring slb . the national surgical adjuvant breast and bowel project ( nsabp ) b04 randomised study compared breast cancer patients with clinically negative alns managed either by radical mastectomy , total mastectomy with axillary radiation , or total mastectomy alone . the results clearly defined that alnd decreases the risk of locoregional relaps ; however , no significant differences in survival were found among the treatment groups . this study has been criticised because of the variability of numbers of lymph nodes resected in the total mastectomy alone arm and the lack of statistical power to detect a small difference in outcome . indeed , a meta - analysis has suggested that inadequate axillary treatment may lead to not only an increased risk of local relapse but also a 5% reduction in survival . as a result of increasing detection of early breast cancer and the high rate of micrometastases and itcs ( itcs ) found in the detailed pathological examination of sln , a new debate has opened about the consequent necessity of alnd in these patients . this has arisen because of better understanding of breast cancer behaviour and improved efficacy of combined therapeutic modalities . in this paper we report the current guidelines concerning the management of the axilla after slnb and review the different aspects arising from recent studies on the role of micrometastases and itc clusters in sln on decision making .", "the american society of clinical oncology ( asco ) expert panel conducted a systematic review of the literature available through february 2004 on the use of snb in early - stage breast cancer in order to develop guidelines for the management of the axilla ( http://jop.ascopubs.org/content/1/4/134 ) , and these are similar to those of the national institute of health and clinical excellence ( nice ) recommendations in uk ( http://www.nice.org.uk/nicemedia/live/12132/43413/43413.pdf ) . alnd is the standard of care in those with a macrometastatic or micrometastatic positive sln to maximise local control . if the sln is negative , a calnd ( calnd ) is not necessary . itcs detected by ihc are of unknown clinical significance , and when identified , the sln is regarded as negative and no further alnd is required . although ihc is often used , it is not included in routine sln evaluation for breast cancer at this time . asco and nice recommendations for slnb , alnd alone and managing of the axilla after slnb are summarised in table 1 . in contrast the german guidelines do not recommend axillary clearance for 1 - 2 sln positive in patients with t1 and t2 tumours ( http://www.ago-online.de ) . it has been suggested that slnb should be carried out by an experienced team in order to minimise false negativity and improve the predictive value of the procedure . ", "the american joint committee on cancer ( ajcc ) in the sixth edition of the cancer staging manual defined a lymph node metastatic tumour with maximum diameter > 2 mm as macrometastasis ( pn1 ) , when the diameter of deposit is 0.22 mm as micrometastasis ( pnmi ) , and a lesion of single tumour cells or small cell clusters with diameter < 0.2 mm as itcs [ pn0(i+ ) ] . itcs are not distinguishable by h&e staining but detected only with immunohistochemistry ( ihc ) or molecular methods . moore et al . suggested that the presence of itcs was unrelated to known prognostic variables and partly the result of instrumentation and manipulation of the tumour . the management of patients with minimal sln involvement is problematic . in a meta - analysis of 25 studies of patients with sln micrometastases , in approximately 20% there was nonsentinel node disease falling to 9% when the sln involvement was detected by ihc . furthermore , the consequent effect on dfs and os remains controversial , so the biological relevance and clinical significance is a matter of debate . amaros investigates the benefit of a calnd in comparison to treatment with axillary radiotherapy ( art ) in patients with sln - positive breast cancer . a recently published substudy evaluated the identification rate and the nodal involvement of the first 2,000 patients between 2001 and 2005 who entered from 26 european institutions . the sentinel node identification rate was 97% which is high considering the relatively early days of this procedure . 34% were sln positive of whom 63% had macrometastases , 25% had micrometastases , and 12% had itcs . in the calnd arm non - sln involvement was identified in 41% of patients with macrometastases and in 18% of patients with either micrometastases or itcs . several studies have investigated the significance of occult metastases , such as micrometastases or small clusters of tumour cells in association with non - sln involvement and the impact of calnd on disease - free survival and overall survival , and the larger ones are summarised in table 2 [ 3743 ] . although the majority show no prognostic impact of itcs in the sentinel node , a large dutch investigation with 5-year followup indicated that women with itcs who received adjuvant chemotherapy had a significantly better event - free survival compared with untreated cases with itcs . furthermore , a finnish study showed a worse 5-year breast - cancer - specific survival for those with itc compared with node negative cases . in the largest published multicenter retrospective study of 187 sln - itcs patients undergoing calnd , houvenaeghel et al . reported an incidence of 16% non - sln involvement . the difference in the risk of non - sln involvement between sentinel nodes with itcs ( 16% ) and those with micrometastases ( 14% ) was not statistically significant . however it was not apparent whether the presence of non - sln metastases should affect the therapeutic decision in these patients . the authors proposed that calnd could be avoided in patients with tubular , colloid , or medullary small primary tumours ( pt1 ) with a risk of non - sln involvement approximately 5% . mirror is a large dutch cohort retrospective study which assesses the impact of sln - itcs and micrometastases on 5-year disease - free survival in patients with favourable primary tumour characteristics . according to recent published data , both patients with snb micrometastases and those with itcs who did not undergo calnd experienced a far higher 5-year axillary recurrence rate , 6% in comparison to 1% of snb - negative patients who did not undergo calnd . additionally , both patients with sln micrometastases and itcs had approximately 5-year disease - free survival improved by 10% with adjuvant systemic therapy . mirror findings support an aggressive treatment approach in patients with either sln micrometastases or itcs .", "many investigators have studied the incidence of non - sln involvement in patients with sln micrometastases to define which patients may need further axillary treatment . wada and imoto . collected 22 studies from 1999 until 2006 referring to the frequency of sln micrometastases in patients with breast cancer and the prevalence of non - sln involvement in those patients after alnd . the frequency of sln micrometastases was 38% with non - sln micrometastases ranging from 0 to 57% . additionally , a wide range of non - sln macrometastases was found ( 018% ) . because the prevalence of non - sln micrometastases was low , the prognostic impact was unclear . the wide range of results arose from the different numbers of patients involved , variations in number of pathological sections examined , and differences in tumour stage and grade . results of studies in which patients with micrometastases in snb and who were not treated by completion axillary node clearance are summarised in table 3 [ 38 , 4854 ] . most of the studies had small numbers and relatively short followup and tended to conclude that there was no benefit from completion axillary node clearance . the largest study ; however , found a significantly worse disease - free survival for women with micrometastases who did not undergo calnd . . de boer et al . conducted a systematic review of 58 studies conducted from 1977 to 2008 included 297,533 patients , aiming to define the prognostic relevance of micrometastases and itcs in patients with breast cancer . using random - effect meta - analysis they showed that the presence of aln metastases < 2 mm in diameter detected on single - section examination was associated with poorer overall survival . moreover the presence of occult metastases on retrospective examination of aln - negative patients by step sectioning and/or immunohistochemistry ( n = 7740 patients ) was associated with poorer 5-year disease - free and overall survival . outcomes from sentinel lymph node biopsy studies were not assessable due to small patient groups and short followup . the international breast cancer study group trial ibcsg-23 - 01 is a randomised multicentre study designed to determine the significance of minimal ln metastasis in patients with breast cancer . the trial was initiated in april 2001 , and it compares survival between patients with sln micrometastases who undergo slnb alone with those who receive calnd .", "it is known that the extent of macrometastases in sln is strongly correlated with non - sln involvement . the long - term effect of the residual axillary disease in the sentinel - lymph - node - positive patient on local and systemic recurrence has not been clearly defined for patients receiving modern radiotherapy and chemotherapy . older studies of patients with symptomatic breast cancers have shown that inadequate axillary surgery does lead to reduced overall survival [ 5760 ] . the study set out to randomise 1900 women with breast cancer and 15 involved snln to either calnd or observation . all had a lumpectomy and tangential breast irradiation , but systemic therapy was at the discretion of the treating centre . after a median followup of 6.3 years , the relapse - free survival for the alnd group was 82% compared with 84% for the observation group , and the overall survival was 92% in both groups . unfortunately the trial stopped accrual after 891 cases had been entered which makes it underpowered to detect a 5% difference in outcome . an additional aspect to be considered is that the guy 's wide excision studies showed no difference between the wide excision group and the radical mastectomy group at 10 years whereas after 25 years there was a significantly worse relapse - free and overall survival in the wide excision group with inadequately treated axillae . in a retrospective study , takei et al . confirmed the importance of calnd in sln - positive patients with high nuclear grade and hormone - negative breast cancer . it was noticed that of 459 patients with macrometastatic disease treated with calnd , after a median follow - up period of 34 months , the axillary recurrence rate was only 0.6% . bilimoria et al . studied a cohort of 403,167 patients with clinically node - negative breast cancer that underwent slnb from the us national cancer data base ( 19982005 ) . of the 97,314 ( 24% ) patients identified with nodal metastases , 28% had no further surgical intervention in the axilla and 72% underwent calnd . after a median followup of 63 months , it was found that in all patients and separately in those with macroscopic and microscopic nodal disease , the unadjusted axillary recurrence rate and overall survival were comparable . after adjustment for clinicopathological differences , there was a trend towards a lower risk of axillary recurrence and death in patients with macroscopic nodal involvement undergoing calnd . for those with micrometastases , recurrence rates were similar in those undergoing either slnb alone or calnd . of 26,986 patients with slnb - positive breast cancer from the seer database ( surveillance , epidemiology , and end results ) , 16% had no further axillary treatment and 84% had calnd . after a median followup of 50 months , although a higher rate of ipsilateral regional recurrence was noticed in patients who underwent slnb alone , no statistically significant differences in overall survival ( os ) between patients who underwent slnb alone versus complete alnd were found . the investigators suggested that in patients with small , low - grade primary tumours , positive er status , older age and who have received segmental mastectomy , calnd may be omitted . hwang et al . reviewed the outcome of 3,366 patients with invasive breast cancer who underwent slnb from 1993 to 2005 . of 750 sln - positive patients , 65% , 45.9% , and 34.2% were pn1 , pn1mi , and pn0 ( i+ ) , respectively . of these patients , 196 had no further axillary surgery due to clinician and patient preference . according to clinicopathological variables , adjuvant treatment was applied and locoregional and distant recurrence and survival were studied . after a median followup of 29.5 months , no patient had an axillary recurrence , one had supraclavicular lymph node recurrence , and three patients developed metastatic disease to the lung or bone . the median time to recurrence was 32 months . notably the patients with distant metastases had t3 grade iii invasive carcinoma . despite the low axillary recurrence rate , authors suggested that it is not possible from these results to conclude definitively that calnd should be abandoned for these patients .", "several factors correlated with the likelihood of additional non - sln metastasis have been investigated in an effort to distinguish which patients could avoid extensive axillary surgery . characteristics of the primary tumour , such as size [ 40 , 66 ] , grade , hormone receptor and her2 profile , tumour type , multifocality , mean proliferative fraction , and lymphovascular invasion [ 68 , 69 ] , have all been studied . additional features of the involved slns , such as size of metastases , number of positive slns , ratio of positive to resected slns , and the extracapsular spread have been also examined [ 21 , 61 , 7072 ] . particularly patients with minimal sln metastases are at a significantly lower risk to have further non - sln invasion than those with sln macrometastases ( 1324% versus 4579% ) . however , none of these characteristics individually can determine a subset of patients for whom alnd is unnecessary . molecular profiling of metastatic foci different from the primary tumour could be used as indicator for the selection of patients who might benefit of completion axillary dissection . the most important prognostic factors for the presence of non - sln metastases in patients with minimal sln involvement are presented in table 4 . several mathematical models have been developed to predict the risk of non - sln involvement in patients with sln - positive breast cancer . these include four nomograms : the memorial sloan - kettering cancer center ( mskcc ) , ( https://www.mskcc.org/mskcc/html/15938.cfm ) , mayo ( https://www.mayoclinic.org/breast-cancer/sentinelbiopsy.html ) , cambridge , and stanford ( https://www3-hrpdcc.stanford.edu/nsln-calculator/ ) . there are three scoring systems , the tenon , mda , and saidi , and two recursive partitioning ( rp ) tools developed by kohrt et al . . the institut curie studied 588 consecutive patients with positive slns who underwent alnd to compare the actual rate of non - sln metastases with those predicted by breast cancer nomogram of memorial sloan - kettering cancer center ( mskcc ) . while the predicted rate in non - sln macrometastases was relatively accurate , when the nomogram was applied to the 213 slns that contained only micrometastases , the predicted rate 59% was far away from the actual rate 44% of non - sln micrometastases detected by ihc . consequently , the authors concluded that a different predictive model should be created for patients with micrometastases . molecular tests based on technology such as oncotype dx ( genomic health , redwood city , calif , usa ) or other multigene arrays developed prognostic and predictive markers aiming to personalize surgical and adjuvant treatment of early breast cancer . an accurate , intraoperative sentinel lymph node test probably could help in avoidance of delayed axillary dissections . molecular tests may be proved more sensitive than current intraoperative tests but have not yet been validated .", "osna is an automated assay for the detection of cytokeratin message , ck19 mrna , present in approximately 98% of breast cancers . it provides an opportunity to make an intraoperative diagnosis of sentinel node involvement within 30 minutes , avoiding frozen section and allowing a one - stage procedure . larger verification studies in which half of the bisected sentinel node was sent for histology and the other half homogenised for osna are shown in table 5 [ 71 , 72 , 7981 ] . the usual reason for discordance between histopathology and osna was an uneven distribution of nodal metastases ( tissue allocation bias ) . the studies indicate a good concordance between results of histopathology and osna . indeed in a study conducted by osaka , comparing osna with frozen section , it is likely that in time osna will replace histopathological examination of sentinel lymph nodes because of its ease , accuracy , and potential for enabling almost all patients to have a one - stage operation for early breast cancer .", "recent studies aiming to determine if calnd is beneficial in patients with sln - positive breast cancer and even more in patients with minimal sln involvement have reached contrary conclusions . limitations in the published studies include the methods of pathological evaluation of lymph nodes and that the number of additional non - sln - positive nodes is usually not known thus lymph node step sectioning and ihc lead to increased identification of minimal metastases upstaging 9% to 25% of patients who initially were considered node negative [ 83 , 84 ] and did not have further axillary surgery . the different rates of recurrence may be due to the molecular type of cancers and so that patients with sln metastases may also have different risks of metastatic involvement . finally it is possible that not all minor tumour foci in axillary lymph nodes progress to local recurrences . according to al - hajj et al . , only a minority of cancer cells potentially give metastases and most itcs are not viable and do not have the ability to form new tumours . there may be two different breast cancer cell populations , true stem cells that have the capacity to develop metastases and the nonstem cells that never grow and are finally destroyed . at the level of everyday clinical practice , with both promising and disappointing results of the published studies , most breast surgeons will hardly ever take the risk of avoiding completion axillary dissection in breast cancer patients even with minimal sentinel lymph node metastases . many are seeking to find a balance between the needs of the majority to have minimal axillary surgery with minimal postoperative morbidity against the possibility that a minority will suffer relapse , morbidity , and possible increased mortality from undertreatment . results from ongoing phase iii trials will perhaps provide new guidelines for the treatment of patients with micrometastases or itcs . a predictive model which estimates accurately the likelihood of additional disease in the axilla might help tailor surgical therapy to the needs of the individual patient and identify those most likely to benefit from completion or alnd . genetic assays defining prognostic markers and new intraoperative tests detecting accurately sln involvement will help in early therapeutic decision making in the future . it is important that premature decisions to restrict axillary surgery are not made on a basis of early results from underpowered clinical trials ." ]

[ "labor wellbeing refers to all efforts of employers , trade unions , voluntary organizations , and governmental agencies , which help employees feel better and perform ( work ) better . it is a comprehensive term that refers to the physical , mental , moral , and emotional wellbeing of an individual including intra and extra mural facilities . although wellbeing includes a wide range of programs and services in organizations , the focus of this study is on the employee assistance programs and employee group services , which are provided by employers according to the real needs of the employees . hence , it is necessary for organizations to identify the real needs , as a base to provide a wellbeing package for their employees through wellbeing need assessment techniques . wellbeing need assessment is a systematic process of gathering information to determine and address the needs or gaps between the current conditions and the desired conditions . a need can be a desire to improve the current performance or to correct a deficiency . the wellbeing needs assessment includes two main targets ; exploring the effectiveness of the delivered services and exploring those wellbeing needs that are not fulfilled by an organization . davis and gibson emphasize on the importance of a comprehensive wellbeing needs assessment , both for obtaining the required information needed to design the appropriate interventions and also for providing the basic required information to evaluate the effectiveness of the wellbeing program . wellbeing assessments are vital for the determination of the economic and social needs of employees and for the best decisions to be taken in response to such needs . reviewing the human resources management literature showed an absence of attention given to the employee 's benefits . moreover , various expectations of employees in the field of wellbeing services caused organizations , especially the human resources ( hr ) offices , to face many challenges ( chen et al . ) . therefore , for keeping employees satisfied with the wellbeing services , all challenges had to be truly and effectively met ( hyde et al . ) . research indicated that satisfaction of the employees was not positively correlated with the benefits of the welfare package ( e.g. dreher , ash , and bretz ) . dencker , joshi , and martocchio argued that individual differences in benefit preferences emerged from particular employment relationships , with individuals having greater experience . the tehran university of medical sciences ( tums ) , including 69 research centers , 25 hospitals , 11 educational and health care centers , three health networks , and 10 faculties with more than 2020 faculty members and 19,000 students ( tums 2012 ) , requires an improved comprehensive system for delivering the wellbeing services ( financial , insurance , healthcare services , educational and training services , etc . ) . taking a look at the functions of the university 's wellbeing services system ; it uncovers a gap between the employees real needs and what is delivered to meet their needs . it is because of the lack of a participatory strategic wellbeing delivery plan that is based on prioritized wellbeing needs ( requirements ) . as the first step to make a strategic plan is identifying the needs , the main purpose of this study is to assess the wellbeing services of the staff working in tums first to see if they are satisfactory enough or they need to be changed , and second , to help decision - makers develop services that are essential to improve the well - being of employees , as also the quality and effectiveness of the tums 's wellbeing delivery system . what are the services used and to what extent they have been satisfactory? this question aims to explore the reasons why they are not delivered . the second question is , what type of services are essential to be provided by the university? with respect to the main purpose of this research , the wellbeing delivery system of tums is assessed with a thorough answering of the questions mentioned above .", "the research design was a cross - sectional survey ( 2008 - 2009 ) using a structured non - disguised questionnaire . the sample size was 98 with a 95% level of confidence and absolute error of 0/01 . cluster sampling based on the occupational scope as the main variable , was used as the sampling method , with regard to the existence of different occupational scopes . data was collected from 98 officers working at different departments of central organizations of tums ( tehran university of medical sciences ) including logistics , education , research and technology , student and cultural affairs departments . the research participants were assured of the confidentiality of their personal information at the beginning of the questionnaire . the questionnaire included 45 questions ( 43 close - ended questions and 2 open - ended questions1 ) organized into two separate parts ( cranach alpha = 0.85 ) : according to table 1 , within the first part , the respondents were supposed to mark the wellbeing services if they had ever used any of them . those who used the services were supposed to show their level of satisfaction by choosing from almost satisfied , almost dissatisfied, and full dissatisfied , and those who had never used the services , were supposed to express their reasons by choosing from poor announcement , unwillingness to receive the service , undesirability of the service, and undesirability of the receiving process of the service. main parts and the main purpose of asking questions for each part in the second part , the respondents were provided with a list of not delivered wellbeing services to choose which of them is essential , neither essential nor non - essential or non - essential. for making sure if the questionnaire was valid content - wise , first a comprehensive collection of wellbeing services delivered both in tums and in other organizations was identified according to the comprehensive definition of wellbeing services . next , according to the main purpose of the research , they were put into classified groups to form the research tool . furthermore , to make sure about the appropriateness and transparency of each question and also the whole tool , in addition to its comprehensiveness , the questionnaire was sent to five professionals and experts in the relevant field . the reliability of the questionnaire was determined after thoroughly calculating the cronbach alpha , which was reported to be around 0.85 . subsequently , after improving and clarifying the instrument , the participants of sample group were asked to fill in the questionnaire . the data was gathered by means of filled questionnaires , and were analyzed with the excel software and spss , by calculating the frequency rate of the staff that used the welfare services and those who did not use the services . in addition , the t - test was used to calculate the satisfaction score for each service used by the staff .", "among all the 98 respondents , almost 46 employees with a mean satisfactory score of 48.46 used the existing services , for which the satisfactory rate was distributed as shown in table 2 . satisfactory scores of categorized wellbeing services the result shows that financial services , including loans for buying a car , emergency loan , loan for buying commodities , awards for staffs children , and two other kinds of non - profit loans in comparison with other categories is considered as the most satisfactory service ( average t = 61.83 ) . among respondents who did not use the categorized services ( 52 persons on an average ) , as shown in the table 3 , the most frequents reasons for not receiving services was , staff 's unwillingness to receive the service ( 38.75 in average ) and poor announcement ( unawareness on the wellbeing services ) ( 37.6 in average ) . frequency rate of reasons for not receiving welfare services table 4 presents the frequency of wellbeing services and necessity ( delivered by other public / private organizations ) , which were asked to be judged by respondents ( to be added or replaced by the delivered wellbeing services list ) , as follows : frequency distribution of wellbeing services necessity educational subvention for children of the staff , who were under their patronage is the only non - financial service , with the highest frequency ( 92.85 ) , identified as the most necessary wellbeing service among all . among other services that were mentioned by respondents ( 61 persons of the sample group ) , the provision of discount cards for using other organizations services ( frequency = 12 ) , providing employees with free health care services ( frequency = 7 ) , and contracting with adult higher education institutions ( frequency = 6 ) had the most frequency among other items .", "as mentioned , the objectives of the study were to measure the staff 's satisfaction with the wellbeing services received , identify the reasons for not receiving the existing wellbeing services , identify the wellbeing services that were not delivered , but were essential as per the staff , and then ask the staff about other wellbeing services that were possible to be delivered and sort them according to their priority . with regard to the first purpose , the results showed that almost half of the respondents used the wellbeing services provided by the wellbeing office of the university , among which almost half of them were satisfied with the services . the results suggested that not only were most of the staff not interested in using the provided services , but also more than half of those respondents who used them were not really happy . with regard to the second purpose , the results showed that among those who did not use the services , most of them decided not to use it by themselves . this was recommended to be surveyed in a separate study in the future . as was evident , it can be concluded that the functional desirability of the wellbeing service delivery system of tums was not evaluated as satisfactory enough , because of the almost high dissatisfaction level of services that were used . with regard to the third purpose , the results indicated a big gap between the required wellbeing services ( by employees ) and what was provided by the office , as almost all the respondents agreed with the necessity of services such as health , education , and safety . the existing gap can result from lack of managerial attention to differences in the demographical characteristics and expectations of employees . consistent with the arguments of boudreau and ramstad , dencker et al . argued that market segmentation of employees ( offering market segments have different benefits ) may strengthen the benefits return - on - investment. one of the most significant reasons for the dissatisfaction and unwillingness of employees to use the services refers to the different priorities and type of services they prefer to include , according to their individual differences . need assessment as a useful technique can help planners to pay more attention to employee 's priority differences in wellbeing services and what they really need to include , by designing the appropriate interventions , as davis and gibson emphasized . considering the employees as the most important organizational stakeholders makes them to participate in the wellbeing decision - making process , such as , asking them to add what services they prefer to be included within the wellbeing package . although the wellbeing service delivery system of tums has not been effective enough to meet the real needs of the staff by delivering the appropriate services , the most prioritized service type preference of most respondents can be identified . as in the first place the satisfactory score of educational and training services among those who used them was rather high , and second , the most necessary identified services were related to educational services , and of course , among the identified wellbeing service priorities , provision of educational opportunity was one of the preferences with high frequency , therefore , it was clear that educational and training opportunities were important for a majority of the respondents . the findings show that the functional desirability of tums wellbeing services is not satisfactory enough by the staff 's view point .", "the following conclusions can be drawn from the present study ; the first major finding is the existence of a big gap between the required wellbeing services ( by employees ) and what is provided by the wellbeing office of tums . the second and the most obvious finding of this study is the importance of the educational and training opportunities from the point of view of the staff , which has not been paid attention to by the wellbeing service provider in tums . although we tried to assess the overall quality and functional desirability of the wellbeing service delivery system of tums , some further studies are required in the researcher 's view . it is recommended that the factors that cause dissatisfaction and unwillingness to use services in employees be identified , and also the real needs and wellbeing requirements ( based on employees preferences , job categories , genders , age , and other considerable individual and social factors ) as a strategic basis for redesigning the current wellbeing service delivery system that appears not to be desirable enough in the employees view , be determined ." ]

[ "the clinical manifestation is typical and it is characterized by abduction of the affected arm , flexion of the elbow and pronation of the forearm . bilateral luxatio erecta represents an extremely rare condition , and just a few cases were reported in medical literature . because of a high incidence of related complications such as neurovascular damages early recognition and treatment of this type of dislocation is required by physicians . in this article we describe a case of a bilateral luxatio erecta that was successfully treated without long - term complications .", "a 70-year - old female was accepted in our emergency department because of a bilateral shoulder pain that onsets after a sudden fall happened in her house . the anamnestic research showed that the patient tumbled downstairs ; while clinging to both lateral banisters , she slipped down banging her face and chest to the ground . at physical examination both shoulders were abducted and elevated approximately 90100 from the horizontal plane , with flexed elbows and with hands below the head . the patient was unable to adduct and lower the arms , and there was immediate pain when attempting passive movements . no vascular deficit was found , and the patient complained of slight paresthesias on both arms , with superficial and deep sensation deficit on both arms . an x - ray examination was performed showing a bilateral inferior dislocation of humeral heads in relation with the glenoid fossa ; no fracture was associated ( fig . 1 ) . 1bilateral luxatio erecta bilateral luxatio erecta close reduction under sedation was achieved without difficulty by pushing the humeral head superiorly with an axial traction - countertraction maneuver on both shoulders . x - ray control revealed a correct anatomic reduction of dislocations and after the reduction no vascular damage were found while paresthesias were still present on the left arm ( fig . 2 ) . both arms were immobilized with bilateral slings in total adduction , intrarotation with the supinated arms . 2post - reduction x - ray the progressive mobilization of the shoulders started after 2 weeks with passive movements and pendulum codman s exercises . after 3 weeks the patient gave up complaining paresthesias on the left arm and active movements were allowed . after 8 weeks she recovered the complete function of both shoulders and after a one - year follow - up treatment the patient showed a complete range of motion of both arms .", "inferior dislocations are rare ( 0.5% of all shoulder dislocations ) and bilateral inferior shoulder dislocations are exceptional : only 10 cases have been described so far in the literature . according to the literature , luxatio erecta is due to an indirect mechanism such as a violent abduction force on abducted limb resulting in impingement of the proximal shaft of the humerus against acromion . direct axial loading from superior direction is another different mechanism , though less common . in our case the first mechanism has to be taken into consideration ; in fact , while the patient was sliding in a sitting position downstairs , her hands were holding onto both banisters and the arms were abduced . when she reached the ground floor the hands were blocked around the end of the banisters and her head and body were thrown forward by gravity . the clinical presentation of an inferior shoulder dislocation is typical : the extremities are held over the head or abduced in a fixed position with the elbow flexed . any passive movement is possible , and the humeral head is palpable on the chest wall . x - ray shows the humeral head located below the rim of the glenoid and the humeral shaft is parallel to the scapular spine . in order to reduce inferior glenohumeral dislocation , it is recommended a traction counter - traction maneuver under sedation followed by immobilization in a desault bandage for at least 2 weeks . there is a high incidence of associate tears of the rotator cuff ( 12% of patients ) and a slap lesion has been described by schai and hintermann after a post - reduction arthroscopic assessment view . fracture of the acromion , clavicle , inferior glenoid fossa and greater tuberosity represent a complication that should need a surgical treatment . neurovascular damages are also commonly associated with inferior shoulder dislocation [ 5 , 7 ] ; garcia et al . described a case of bilateral luxatio erecta complicated by an axillary vein thrombosis . in general , neurologic injuries ( 60% of cases ) of brachial plexus , axillar , radial and ulnar nerves are more common than vascular injuries but they tend to resolve after reduction with an excellent prognosis , suggesting the neuropraxia as the main mechanism of the injury [ 5 , 9 , 10 ] ." ]

[ "a biloma is a rare abnormal accumulation of intrahepatic or extrahepatic bile caused by traumatic or spontaneous rupture of the biliary tree1 , 2 ) . it is most commonly caused by surgery , percutaneous transhepatic cholangiography ( ptc ) , percutaneous transhepatic biliary drainage ( ptbd ) , and abdominal trauma11 , 12 ) . we report here a patient who complained of chills , fever and right upper quadrant abdominal discomfort .", "a 78-year - old woman presented to the emergency room with her guardian , with acute fever and chills that developed the day before admission . the patient was diagnosed with diabetes a few years previously , but this was not being treated . on admission to the emergency room , the vital signs were as follows : blood pressure 70/40 mmhg , heart rate 118/min , respiratory rate 30/min and temperature 40.3. the patient appeared to be in acute distress ; she was lethargic , the sclerae were slightly yellow and the conjunctivae were pale . the abdominal examination revealed slight tenderness in the right upper quadrant , but there was no palpable mass . the laboratory studies were as follows : wbc 52,400/mm , hb 12.3 g / dl , platelets 90,000/mm , ast 153 iu / l , alt 135 iu / l , alkaline phosphatase 255 iu / l , total bilirubin 2.07 mg / dl , total protein 5.9 g / dl , albumin 3.0 g / dl , bun / cr 25/1.9 mg / dl , esr 25 mm / hr , and crp 20.4 mg / dl . the serum electrolyte levels were normal except for an elevated potassium 7.0 mmol / l . the abga data were as follows : ph 7.24 , pao271 mmhg , paco2 19 mmhg , hco3 15.1 the hepatitis viral marker tests , including hbsag , anti - hbs ab and anti - hcv , were all negative . standard x - rays on the day of admission revealed lung infiltrates and no specific findings in the abdomen . the abdominal computed tomography ( ct ) revealed a 9.58.5 cm subcapsular cyst with a clear boundary in the left hepatic lobe and enlargement of the intrahepatic bile duct around the cyst . although the left hepatic lobe had some atrophic findings , there were no significant signs of an enlarged bile duct or abnormal gallbladder ( figure 1 ) . on the day of admission after the computed tomography , the abga revealed a ph 7.05 , pco2 64.8 mmhg , po2 73.3 mmhg , hco3 the patient was intubated and put on a respirator ; she was treated with antibiotics and vasopressors . on the second day of admission , percutaneous drainage with an 8.5 fr pigtail catheter , under the guidance of an abdominal ultrasound was performed for diagnosis and treatment . we removed 565 ml of fluid that was dark brown in color . for a diagnosis , biochemical tests were carried out on the bile , and these tests revealed a total bilirubin of 22.3 mg / dl and a direct bilirubin of 18.9 mg / dl . the leukocyte count was 4,560/mm , and gram staining showed a gram negative bacillus . on the third day of admission , her vital signs were as follows : blood pressure 100/65 mmhg , heart rate 110/min and temperature 37.2. there was 200 ml of drained bile , the s - fibrinogen was 894 mg / dl ( 200 - 415 ) , the d - dimer was 9,040 ng / ml ( 0 - 255 ) , and the fdp was elevated up to 97 ug / ml ( normal range : 0 - 5 ) . on the eighth day of admission , the patient 's mental status improved , the vital signs were stable and voluntary respirations recovered . on the thirteenth day of admission , pancreatico - biliary magnetic resonance imaging ( mri ) revealed a biloma that was connected to the intrahepatic bile duct ( figure 2 ) . on the sixteenth day of admission , the biloma that was connected to the intrahepatic duct and common bile duct was noted again via a tubogram performed with a catheter . over time , the amount of bile drainage decreased . on the twentieth day of admission , 64 ml of bile was drained , the leukocyte count was 340/mm and there were no signs of bacteria on culture or gram staining of the bile . the follow - up ct showed that the size of the cyst had decreased to 5.44.6 cm and the density around the cyst had increased . the amount of drainage did not decrease afterward , and the connection between the biloma and the bile duct was still noted . on the 25th day of admission , the drainage tube was blocked and follow - up of the bilirubin in blood and the size of the biloma were assessed . on the 29th day of admission , follow - up ct showed a marked decrease in the size of the cyst ( figure 3 ) , and the serum bilirubin was normal ( 0.22 mg / dl ) . on the 34th day of admission , the drainage tube was removed after evaluating the size and connection of the biloma via a catheter tubogram ( figure 4 ) .", "they reported a case with extrahepatic bile leakage after trauma to the upper right quadrant of the abdomen ; the bile did not cause peritonitis , but it accumulated in an encapsulated form . this concept was later applied to all cases with biliary tract lacerations caused by bile leaks that formed a capsule inside or outside of the liver1 ) . the mechanism of encapsulation is explained by a large amount of bile leaking at a fast pace that causes biliary peritonitis , or a small amount of bile leaking at a slow pace that causes mild inflammation . this leaked fluid is simultaneously trapped by the greater omentum and mesentery , where it becomes encapsulated2 ) . although the amount of bile leaked may be minor , the occurrence of an inflammatory reaction contributes to the appearance of a growth in size of the biloma3 ) . as diagnostic techniques continue to develop , more cases of biloma are being reported , but cases of spontaneous biloma and biloma accompanied by other diseases have rarely been reported to date . from 1979 to 1997 , 25 cases of spontaneous biloma were analyzed by fujiwara ; the underlying causes included choledocholithiasis ( 16 cases ) , cholangiocarcinoma ( 2 cases ) , acute cholecystitis ( 1 case ) , liver infarction ( 1 case ) , hepatic abscess ( 1 case ) , nephrotic syndrome ( 1 case ) , obstructive jaundice ( 1 case ) , sickle cell anemia ( 1 case ) , and tuberculosis ( 1 case)4 ) . in korea , there have been two cases of choledocholithiasis accompanied by a biloma , and they were treated by nonsurgical methods5 , 6 ) . there is one report of a case of biloma after trauma7 ) , and 1 case of a biloma after endoscopic retrograde cholangiopancreatography ( ercp)8 ) . one of the patients with a choledocholithiasis who suffered a nontraumatic intrahepatic rupture of the bile duct , had a surgical repair9 ) . the causes of biloma include trauma to the liver , which is the most common cause , abdominal surgery , endoscopic surgery and percutaneous catheter drainage10 - 13 ) . currently , the term biloma is generally used to describe intrahepatic or intraperitoneal focal biliary stasis14 ) . the clinical symptoms of a biloma are nonspecific , and they can range from no symptoms to abdominal pain and distention , jaundice and fever ; leukocytosis can also be present15 ) . in the case there were complaints of sudden chills , fever , upper abdominal discomfort and sensations of abdominal distention . physical examinations showed tenderness in the upper right area of the abdomen , slight jaundice , hypotension , leukocytosis and fever over 40. the size and location of the biloma are determined by the cause of the rupture of the bile duct , the location and speed of bile leakage and the rate the bile is reabsorbed by the peritoneum2 ) . fujiwara reported that the locations for bile leakage included the left hepatobiliary duct ( 8 cases ) , the gallbladder ( 5 cases ) , the right hepatobiliary tract ( 2 cases ) , the common bile duct ( 1 case ) , and unknown ( 9 cases ) ; the locations where the bilomas formed were the left lobe ( 11 cases ) , the right lobe ( 10 cases ) , and the upper abdomen ( 4 cases ) . vazquez analyzed 21 cases of biloma and found that 16 cases occurred in the upper abdominal area near the liver and five in the left upper abdominal area4 ) . the diagnosis of a biloma can be assisted by surgery , a history of trauma with abdominal ultrasonography , abdominal ct and mri . a definite diagnosis can be made by a 99mtc - disida scan , percutaneous aspiration or by ercp1 , 2 ) . abdominal ultrasonography shows a mass of low echogenicity with a clear border in the liver , and the follow up tests show changes in size16 ) . the abdominal ct will give a more accurate view of the location of the biloma and show its relationship to the surrounding organs . a standard ct view will show a low - density mass in the liver at a ct number lower than 20 . ultrasonography and abdominal ct are sometimes unable to differentiate bilomas from seromas , lymphoceles and angiomas . mris or hepatobiliary scans can be useful when continuous bile leakage is present , but they are not diagnostic when continuous leakage is not present7 , 17 ) . radiological image - guided aspiration tests , when testing for bilirubin , can be diagnostic18 ) . when the aspirated substance is a clear yellow liquid , then microbiological tests must be done to rule out an infection . ercp can be used to determine the location and severity of an active bile leak . however , the presence of small biliary cysts or bilomas , located in the lower areas of the liver that can be hidden by gastrointestinal shadows , can be difficult to diagnosis19 ) . we were able to identify a cystic lesion by abdominal ct ; a tubogram and magnetic resonance cholangiopancreatography ( mrcp ) were used to confirm a bile leak from the common bile duct . the fluid obtained by the transabdominal ultrasonography assisted percutaneous cyst drainage containing 22.3 mg / dl of total bilirubin and 18.9 mg / dl of direct bilirubin ; these findings confirmed the diagnosis of a biloma . treatment for bilomas that have a diameter of only a few centimeters is not always necessary ; these lesions can be watched . however , most bilomas require treatment . in the past , surgery was the main approach to treatment . currently , there are a much wider variety of options such as percutaneous catheter drainage , endoscopic sphincterotomy ( est ) , endoscopic nasobiliary drainage ( enbd ) and endoscopic drainage4 , 6 , 15 , 19 , 20 ) . surgery is now performed only in cases with a persistent bile leak or for treatment of underlying disease . in this case , a spontaneous biloma with bacterial infection was found after the patient presented in septic shock . after percutaneous drainage was performed , the amount of bile excreted did not decrease to lower than 64 ml per day . as there was no difficulty in flow through the common bile duct , the biochemical tests performed after removal of the drainage catheter showed no increase in total bilirubin or any increase in the size of the biloma , thus demonstrating a rare case of recovery ." ]

[ "the construct of unintended pregnancies ( ups ) is multifactorial and broadly encompasses pregnancies that are either unwanted or mistimed.1 in many instances , ups are likely to end by induced abortion ; worldwide estimates suggest that 50% will be voluntarily terminated.2 in 2008 , it was estimated that 43.8 million abortions occurred worldwide , of which 86% occurred in low-/middle - income countries.3 furthermore , between 2003 and 2008 , the number of induced abortions was found to have decreased in high - income countries but to have increased in low-/middle - income countries . during this same period of time , the proportion of unsafe abortions increased and they were believed to account for 13% of maternal deaths , with the majority of these concentrated in countries with restrictive laws on abortion.4 elective abortion in brazil is considered non - legal , unless the pregnancy resulted from a rape , would cause a life - threatening condition to the mother , or the fetus has anencephaly or any other malformation that is incompatible with the extrauterine life . as a result , data on prevalence and associated costs of abortion are limited and remain a challenge to collect . however , it is recognized worldwide that direct health costs of up and resulting abortions can significantly impact local health services and the families affected.5 health system and societal costs can also arise from ups that do not end in abortion and are carried to parturition . in the united states , the public health costs attributed to unintended births in a single year cost taxpayers $ 11.1 billion ( 2006).6 furthermore , previous studies have reported that ups are more likely to result in preterm births and low - birth - weight babies , which would increase health costs for neonatal care and costs associated with long - term disabilities.7 this is particularly relevant for ups in adolescence , which are more likely to result in low - birth - weight births , which can increase health costs.8 over the past few decades , brazil , like many fast - emerging economies , has experienced a fertility transition noted by a dramatic reduction in the total fertility rate , which currently sits at 1.8 births per woman.9,10 furthermore , during the fertility transition , the rate of contraception has also increased.11 despite increased contraception use , the cumulative rate of spontaneous and induced abortion changed very little between 1996 and 2006 , for which population survey estimates are available.12,13 furthermore , a survey of more than 1,000 women aged 1024 years in a single postnatal unit in brazil reported that more than 50% of all births were unintended , suggesting that possibly significant unmet contraception need still exists.8 similarly , for the whole country , the data from the last demographic and health survey ( dhs ) performed in 2006 indicates that 55% of all births were unintended.14 prevention of up using publicly funded programs in high - income countries has proven to generate significant cost savings for health services and public services.15 previous economic studies evaluating the consequences of up have mostly been performed in high - income countries where publicly funded fertility services and abortion legislation are different from those in low-/middle - income countries.15 the aim of this study was to evaluate the cost consequences of up in brazil , an emerging economy with vastly different fertility planning services than most advanced economies and with restrictive abortion laws . to the best of our knowledge , this is the first published study that describes the economics of up , and it is believed that this work can aid decision makers regarding access to contraceptives .", "a model was developed to evaluate the humanistic burden and financial impact of ups in brazil . the analysis factored in costs and outcomes for 1 year post - delivery of ups . possible birth outcomes of up included induced abortion , miscarriage , and ongoing pregnancy resulting in birth . all birth deliveries were assumed to have taken place in a hospital within the brazil public health system as reported by datasus , the data system for the ministry of health in brazil . available data was further separated into vaginal ( 61.0% ) and cesarean section ( c - section ) deliveries ( 38.4%).16,17 outcomes and resulting costs for infants were also followed . these included stillbirths and infant survival and complications from term and preterm deliveries . complications included admission to a neonatal intensive care unit ( icu ) , hospitalization during the first year , and cerebral palsy . data from datasus were used when possible to populate the model to reflect the reality of the public health care system . however , for parameters not identified in datasus , other relevant sources were used . a decision tree model was constructed in microsoft excel ( microsoft corporation , redmond , wa , usa ) from the perspective of the brazilian public health system ( figure 1 ) . the total annual number of pregnancies was estimated using the reported number of live births for the year 2010 and adjusted with estimated percentages of induced abortion and miscarriage.18 the percentages of induced abortions and miscarriage were derived from the population - based 2006 dhs and found to be 1.5% and 8.9% , respectively.19 all induced abortions in the model were assumed to be from unintended pregnancies resulting in an adjusted abortion rate of 2.7% . the up rate was estimated to represent 55% of all pregnancies.20 maternal mortality rates of 20 , ten , and 30 deaths per 100,000 births were used for miscarriage , vaginal delivery , and c - section delivery , respectively.2123 in addition , a case fatality rate of 100 deaths per 100,000 abortions was assumed.24 for both delivery methods , it was estimated that 7.8% of all deliveries were preterm births and 0.85% were stillbirths.25 the remainder of the deliveries was assumed to be term births . differential infant mortality rates were used for term and preterm births , with 8.5 per 1,000 live births for the former and 68 per 1,000 live births for the latter.25,26 the model assessed infant complications , including admissions to neonatal icu , hospitalization during the first year , and cerebral palsy . all preterm birth infants were assumed to require neonatal intensive care , compared to 7.6% of term birth infants.27 for preterm infants , the average number of hospitalizations during the first year was 1.7 , mostly from respiratory issues.28 for term birth infants , hospitalization was calculated as a relative risk reduction.29 cerebral palsy occurred in 0.1% and 1.7% of term and preterm births , respectively.30 resource use and unit costs were identified from published sources and the dhs in brazil . in brazil the public national health system ( sus ) pays for around 70%75% of all reproductive procedures . however , in this model , it is assumed that the costs are those from the public system , although , in approximately one - quarter of ups , the costs are probably higher when related to women s care covered by insurance or privately . costs of elective abortion were not included in the analysis because these procedures rarely meet the legal requirements and would not be covered by the public health system . costs of miscarriage were related to the following procedures : pelvic exam , blood test , ultrasound , and dilation and curettage . the cost components for each method included antenatal care and labor and delivery.31,32 unit cost for hospitalization readmission during the first year was r$2,794.33 this unit cost was also assumed for neonatal care admission , while cerebral palsy was estimated to be r$19,854.33 cost parameters are summarized in table 1 .", "a model was developed to evaluate the humanistic burden and financial impact of ups in brazil . the analysis factored in costs and outcomes for 1 year post - delivery of ups . possible birth outcomes of up included induced abortion , miscarriage , and ongoing pregnancy resulting in birth . all birth deliveries were assumed to have taken place in a hospital within the brazil public health system as reported by datasus , the data system for the ministry of health in brazil . available data was further separated into vaginal ( 61.0% ) and cesarean section ( c - section ) deliveries ( 38.4%).16,17 outcomes and resulting costs for infants were also followed . these included stillbirths and infant survival and complications from term and preterm deliveries . complications included admission to a neonatal intensive care unit ( icu ) , hospitalization during the first year , and cerebral palsy . data from datasus were used when possible to populate the model to reflect the reality of the public health care system . however , for parameters not identified in datasus , other relevant sources were used . a decision tree model was constructed in microsoft excel ( microsoft corporation , redmond , wa , usa ) from the perspective of the brazilian public health system ( figure 1 ) .", "the total annual number of pregnancies was estimated using the reported number of live births for the year 2010 and adjusted with estimated percentages of induced abortion and miscarriage.18 the percentages of induced abortions and miscarriage were derived from the population - based 2006 dhs and found to be 1.5% and 8.9% , respectively.19 all induced abortions in the model were assumed to be from unintended pregnancies resulting in an adjusted abortion rate of 2.7% . the up rate was estimated to represent 55% of all pregnancies.20 maternal mortality rates of 20 , ten , and 30 deaths per 100,000 births were used for miscarriage , vaginal delivery , and c - section delivery , respectively.2123 in addition , a case fatality rate of 100 deaths per 100,000 abortions was assumed.24 for both delivery methods , it was estimated that 7.8% of all deliveries were preterm births and 0.85% were stillbirths.25 the remainder of the deliveries was assumed to be term births . differential infant mortality rates were used for term and preterm births , with 8.5 per 1,000 live births for the former and 68 per 1,000 live births for the latter.25,26 the model assessed infant complications , including admissions to neonatal icu , hospitalization during the first year , and cerebral palsy . all preterm birth infants were assumed to require neonatal intensive care , compared to 7.6% of term birth infants.27 for preterm infants , the average number of hospitalizations during the first year was 1.7 , mostly from respiratory issues.28 for term birth infants , hospitalization was calculated as a relative risk reduction.29 cerebral palsy occurred in 0.1% and 1.7% of term and preterm births , respectively.30", "resource use and unit costs were identified from published sources and the dhs in brazil . in brazil the public national health system ( sus ) pays for around 70%75% of all reproductive procedures . however , in this model , it is assumed that the costs are those from the public system , although , in approximately one - quarter of ups , the costs are probably higher when related to women s care covered by insurance or privately . costs of elective abortion were not included in the analysis because these procedures rarely meet the legal requirements and would not be covered by the public health system . costs of miscarriage were related to the following procedures : pelvic exam , blood test , ultrasound , and dilation and curettage . the cost components for each method included antenatal care and labor and delivery.31,32 unit cost for hospitalization readmission during the first year was r$2,794.33 this unit cost was also assumed for neonatal care admission , while cerebral palsy was estimated to be r$19,854.33 cost parameters are summarized in table 1 .", "based on the modeled parameters we estimate 1.79 million annual ups and 1.47 million annual planned pregnancies . we estimate annual maternal deaths of 351 , of which 49 ( 14% ) are attributed to abortions and 302 to complications from miscarriages and deliveries . the number of infant deaths within the 12 months following birth was estimated at 32,864 . the number of estimated neonatal admissions for the year 2010 associated with up was 224,631 which included all preterm deliveries and 7.6% of all term deliveries . the disaggregated values for different pregnancy outcomes attributed to up are described in table 2 . costs of abortions are not reimbursed in the public health system and are not included in the analysis . the total costs attributed to up are estimated to be r$4.1 billion annually , of which approximately r$32.9 million ( 0.8% ) was attributed to miscarriage and r$4.07 billion ( 99.2% ) to births and resulting complications . from the direct birth - related costs , antenatal care accounted for approximately r$233 million ( 5.7% ) of birth costs , with labor and delivery costs responsible for r$988 million ( 24.3% ) . the remainder of birth costs were attributed to infant complications , estimated to be r$2.8 billion ( 70.0% ) , with neonatal costs accountable for approximately r$628 million ( 15.4% ) and hospital readmission in the first year costs of r$2.1 billion ( 52.9% ) of all birth costs annually . based on the national cost estimates and the number of annual ups", "our analysis estimates the costs and outcomes associated with unintended pregnancies to derive a cost per up of r$2,293 . the cost per up factors in a range of health - related costs attributed to those resulting in abortion and resulting live births for those carried to parturition . this figure is broadly aligned with previous analyses in the united states of $ 1,609 per up after factoring in the purchasing power parity between the two countries.35 it is also worth noting that the estimates provided here are likely an underestimate of all costs . for example , the analysis described here focused on the costs that occur within the public health systems . consequently , costs of elective abortions paid for by individuals are not represented in this analysis . furthermore , because elective abortion is illegal in brazil except in extreme and rare cases , hidden costs from elective abortions may filter into the public health system . for instance , costs associated with post - abortive care are likely to be classified as miscarriages when reported to national authorities . additionally , the long - term societal costs that arise from up and reduced educational attainment and lost productivity of young mothers has not been accounted for in our analysis.3639 our analysis highlights that considerable cost savings can be achieved by reducing up , which are thought to represent 55% of all pregnancies in brazil.20 the analysis accounted for both untimed and unwanted births to estimate the up rate and associated costs , in which live births resulting from unwanted pregnancies represented the largest share of health costs , representing 99% of all costs . this is also attributed to the fact that abortion is a relatively inexpensive procedure that is paid for outside of the health service . because a substantial proportion of pregnancies are attributed to mistimed pregnancies , ie , pregnancies that would have occurred at some point in the future , but occurred sooner due to mistimed pregnancy , the actual cost savings to be realized by reducing up is less than described here and would mostly be associated with averting those pregnancies considered to be unwanted . to put the potential cost savings into perspective , an analysis conducted for the state of california , usa estimated that preventing many up in a single year will offer savings of $ 1.1 billion up to 2 years of age of the child , and that every dollar spent on averting up offers $ 2.76 of saving in 2 years and $ 5.33 at 5 years post - delivery.15 a national - level analysis that focused on the federally financed medicaid program in the united states noted that taxpayer savings of $ 4.7$6.2 billion could be achieved by reducing unintended pregnancies.40 based on the cost savings attributed to up , it is anticipated that future health researchers can build on the research described here to better understand the cost savings that may be achieved through improved contraceptive use . the analysis sought to incorporate a broad range of costs associated with up to illustrate that costs extend beyond the point of delivery . for instance , ups often occur in adolescent and young adults and can be predictive of low birth weight , preterm birth , and neonatal admission.8,4143 the precise mechanism by which up influences preterm birth is likely to be multifactorial . however , some studies have observed that women with ups are less likely to receive adequate prenatal care44 and are also more likely to smoke and drink alcohol during pregnancy , which contributes to adverse outcomes.44,45 it is important to highlight these costs because it suggests that ups place unnecessary demand on health services that are often stretched to capacity . since up , for the most part , can be avoided , this illustrates the health service benefits and health service capacity that could be released by reducing up . much of the humanistic burden attributed to up relates to maternal mortality and morbidity of women who pursue unsafe abortions . in our analysis , we estimate 49 annual deaths from abortions representing 13% of the estimated maternal deaths . it has been suggested that access to improved contraceptive services could prevent maternal mortality by 25%35%.46 furthermore , estimates from the world health organization reported that unsafe abortion disables approximately 5 million women each year , suggesting reductions in morbidity could also be achieved through improved contraception use.4 empirical evidence and clinical guidelines agree that the most effective approach to preventing up is through education and contraceptive use , of which long - acting contraceptive ( larc ) methods are the most effective intervention.4751 in particular , among adolescents , prevailing evidence suggests that education and contraception are the main interventions for reducing up.49 in advanced economies , the percentage of women using larc methods has been steadily increasing . a recent study noted that the proportion of women using larc methods has increased from 2.4% of women aged 1544 years since 2002 to 8.5% of women in 2009.52 in the united states , the american college of obstetricians and gynecologists ( acog ) advocates use of intrauterine contraceptives ( both copper - intrauterine device and the levonorgestrel - releasing intrauterine system ) and implants as first - line therapy for adolescent women because they contribute to reduce the number of ups.48 larc has also proven to be cost - saving compared with combined oral contraceptives in the united kingdom . investigators reported that this finding was influenced almost entirely by the lower failure rates associated with larc.50,53 an analysis conducted in the united states also noted that cost savings could be achieved by switching women from oral contraceptives to larcs , and approximately 50% of costs of up were attributed to contraceptive adherence.54 despite the positive benefits of larc , use in brazil lags behind that of other countries . a survey conducted in 2008 in northern brazil reported that only 1% of women attending a post - abortion clinic elected for an intrauterine device , despite 93% of women having knowledge of the product.55 several barriers have been identified , which often limit uptake of larc methods.56 these include health care provider lack of knowledge of risks , myths , misconceptions , and lack of training for insertion of the various devices . also , misinformation and fear of pain at insertion among women can limit demand for larc methods . furthermore , larc can often involve considerable up - front expense , although evidence does suggest that these methods are cost - effective compared with alternative contraceptive methods . because of the expense , reimbursement can influence the rate of uptake . even recognizing the importance of abortion , and especially induced and unsafe abortion , for maternal mortality and morbidity in brazil , there are no reliable and available data confirming a pandemic of such conditions as commonly reported by media and gray literature . data extracted from the 2006 brazilian dhs indicated that only 1.5% self - reported induced abortions among all pregnancies for the whole period of the survey.14,19 a probable contribution for this scenario is the high prevalence of and easy access to contraceptive use among women in reproductive age in the country during the last 2 decades . although all induced abortions are technically classified as unsafe , this is not the impression of the majority of obstetricians working in the field . there is a general belief that complications due to unsafe induced abortions are less and less frequent and that there was recently a marked drop in their occurrence . with no direct information to confirm this , one indirect point of evidence is the decrease in the proportional contribution of abortion as cause of maternal mortality in the country . in fact , official brazilian data confirm that it was 16.4% in 1990 ( representing the third cause of maternal mortality ) , while only 8.9% in 2000 and 9.0% in 2010 ( the fifth cause , behind even the indirect obstetric causes).20 in the meantime , there was a spread of the use of misoprostol as an agent for inducing abortion , not only in health facilities for situations where abortion is allowed , but mainly for situations not legally permitted , wherein the women obtain misoprostol in the black market and self - administer it vaginally . this is believed to be the current most common way of inducing medical abortion and also to be associated with the low rates of severe complications due to abortion , especially infection and hemorrhage , in brazil . there are also at least two possible limitations for the external validity of the current cost estimates . the first refers to the assumption that all miscarriages are really diagnosed and treated with dilation and curettage . however , it is possible that a proportion of individuals will never reach health facilities and receive no intervention . currently , in brazil , the majority of medical abortions are performed by the woman through self - administration of misoprostol acquired off - label or in the black market . with these procedures , the rate of complications due to medical abortions has dropped significantly during the last decade , with some of these cases arriving at hospitals already as complete abortions that need no complementary procedures . although insufficient data are available to support this scenario , this would probably impact strongly on the estimates of post - abortion care , taking into account the correspondent reduced morbidity and mortality . the cost consequences of live births attributed to up in adolescents can extend beyond the observed costs of increased prenatal care , preterm births , and abortions . studies have noted that adolescent women are more likely to dropout from school following pregnancy . furthermore , others have suggested that future generations will follow the reproductive pattern of their parents , which could perpetuate the likelihood of up in the offspring of these mothers.57 as reported , education has been shown to break the association of adolescent fertility across generations , suggesting the longer - term benefits to be achieved by reducing up .", "our analysis illustrates the cost consequences associated with up in brazil . in the past 2 decades , brazil has made considerable progress toward reducing abortion rates , but , despite these efforts , the humanistic and direct economic costs associated with up remain high.58 to achieve economic savings from reducing the up rate will require education , training of providers , and improved access to effective contraceptive measures . it is believed that the research described herein can inform the burden of up and the benefits of improved fertility planning . the cost consequences associated with up in brazil could be investigated in other settings using the same methodology used in this report . it is important to estimate the cost associated to up to initiate actions to reduce the high rate observed in many countries .", "the cost consequences associated with up in brazil could be investigated in other settings using the same methodology used in this report . it is important to estimate the cost associated to up to initiate actions to reduce the high rate observed in many countries ." ]

[ "pmds is a rare form of male pseudo - hermaphroditism characterized by the presence of mullerian duct structures in an otherwise phenotypically , as well as genotypically , normal man . it is characterized by the persistence of the uterus , fallopian tubes and upper vagina in otherwise normally virilized boys . despite the normal male genotype ( 46 xy ) and the subsequent normal development of fetal testes , mllerian structures do not regress either due to absence of mllerian inhibiting substance ( mis ) or lack of response to it . the persistence of a large uterus - like paramesonephric duct in a man is in itself clinically unusual , but when it forms a part of the contents of a hernial sac , it must be considered a rarity . we report the case of a 70 year old man with unilateral cryptorchidism on the right side and left obstructed inguinal hernia containing uterus and fallopian tube ( that is , hernia uteri inguinalis ; type i male form of pmds ) coincidentally detected during an operation for an obstructed left inguinal hernia with right cryptorchidism .", "a 70 year old man presented to our hospital with a painful left - sided inguinal swelling of one day duration . the patient gave history of asymptomatic left inguinal swelling from past 20 years and absence of the right testis since birth . he had been married for fifty years and was having 4 children , the youngest one being 38 year old female . general physical examination revealed a man of sub - average built with well developed secondary sexual characters . his urethra and penis were fully developed with a poorly developed right hemi - scrotum and no palpable right testis in the scrotum or inguinal canal . there was a non - reducible , tender swelling measuring approximately 10 8 cm in the left inguinal region with absent cough impulse . exploration of the inguinal canal revealed an indirect inguinal hernia containing a globular structure resembling uterus , fallopian tubes with an atrophic right testis embedded in the broad ligament and attached to pelvis with a thick fibrous band [ figs . 1 and 2 ] . total excision of the uterus with fallopian tubes and atrophic right testis was performed and the operation was completed with left inguinal hernioplasty [ figs . 3 and 4 ] . grossly , the specimens removed were identified as a uterus with patent endometrial and endocervical linings and two fallopian tubes . the right testis measuring 2 1 1 cm , was atrophic and embedded in the right broad ligament . the specimen was sent for histopathological examination which revealed uterine muscular tissue with its cavity lined by endometrial tissue and congested fallopian tubes .", "male pseudo - hermaphroditism is a condition in which the gonads are testes but the internal genitalia are not completely virilized . pmds is a rare form of internal male pseudo - hermaphroditism in which mullerian duct derivatives are seen in men . the exact cause of pmds is not known , however it is thought to result from a defect of the synthesis or release of mif , or from defects in the mif receptor . defects in the mif gene lead to the persistence of a uterus and fallopian tube in males . it is likely that remnant mullerian structures lead to cryptorchidism by hindering the normal testicular descent mechanism . patients with pmds usually have normal development of external genitalia and secondary sexual characteristics . the typical patient with pmds has unilateral or bilateral cryptorchidism and is assigned to the male sex at birth without hesitation , as they have normal male genotypes and phenotypes . the male form is encountered in 8090% of cases , characterized by unilateral cryptorchidism with contralateral inguinal hernia , and can be one of the two types : the first type is hernia uteri inguinalis , which is characterized by one descended testis and herniation of the ipsilateral corner of uterus and fallopian tube into the inguinal canal . the second type is crossed testicular ectopia , which is characterized by herniation of both testes and the entire uterus with both fallopian tubes . clinically , the persistence of a uterus and fallopian tubes leads to either cryptorchidism or inguinal hernia depending on whether or not mullerian derivatives can be mobilized during testicular descent . if the uterus and fallopian tube are mobile , they may descend into the inguinal canal during testicular descent . pmds is usually coincidently detected during surgical operation , as in our patient 's case . however pre - operative ultrasonography , computerized tomography and mri allow possible pre - operative diagnosis . an element of deciding on intervention is largely based on reducing risk of malignancy , while maintaining maximum reproductive function . in pmds patients with undescended testes , the rate of testicular cancer is about 12% which is comparable to the rate seen in undescended testes not associated with pmds . several authors have asserted that the mullerian structures should not be removed as there is minimal risk associated with their retention , and excision of the mullerian structures risks damaging primary blood supply to the pmds testis via the internal spermatic and deferential arteries . however most recent reports have demonstrated rare malignancies including adenocarcinomas of the mullerian duct associated with retained mullerian structures .", "pmds is a rare form of male pseudo - hermaphroditism characterized by the presence of mullerian duct structures in an otherwise phenotypically , as well as genotypically , normal man . since patients are phenotypically male , the diagnosis is usually not suspected until surgery is performed for cryptorchidism or hernia repair . hernia uteri inguinalis is type i of the male form of pmds , characterized by one descended testis and the herniation of the ipsilateral corner of the uterus and fallopian tube into the inguinal canal . in order to prevent further complications such as infertility and malignant change , the surgeon should be aware of pmds while dealing with patients who present with unilateral or bilateral cryptorchidism . in summary , in cases of unilateral or bilateral cryptorchidism associated with hernia , as in our patient 's case ,", "", "", "a written informed consent was obtained from the patient for publication of the case report and various images which may be used with the same . the patient being a major gave a written consent of the same after assuring him that name and hospital mrd no of the patient will not appear in the case report .", "all the authors have contributed either as being part of surgical and anaesthesia team or helping in the photography , paper writing , submission etc . afak yusuf sherwani , abdul qayoom shah , abdul majeed wani , farooq ahmad sofi and ashfaq amin wani were in the surgical team . bashir a chalkoo , bashir a khan and ab hamid sherwani in the anaesthesia team . wasim lone , mehmood a sheikh and raj reshi sharma did photography and paper writing ." ]

[ "spider nevus ( also known as spider angioma or vascular spider ) is a common benign vascular anomaly that may appear as solitary or multiple lesions . spider nevi are represented by telangiectases that consist of a large arteriole from which radiate numerous small vessels that resemble spider 's legs . they are found in the distribution of the superior vena cava , that is , on the face , neck , arms , and upper trunk . spider nevi are usually < 2 cm in diameter and rarely grow to assume large size more than 2 cm . we hereby report a case of very large spider nevus in a patient with hepatitis c virus ( hcv ) related liver cirrhosis .", "a 48-year - old - female presented with a history of abdominal distension and jaundice of 3-month duration . physical examination revealed pallor , icterus , pedal edema , hepatospleenomegaly and tense ascites . she had multiple classical spider nevi over the chest . also , she had a large spider nevi situated on the forehead , measuring 8 cm in largest dimension with palpable dilated vessels and venous hum [ figure 1 ] . deep compression on the central area of the lesion produced complete disappearance with blanching and when released refilling of vessels occurred . laboratory tests revealed a hemoglobin level of 9.8 g / dl , a white - cell count of 4240/mm , and a platelet count of 77,000/mm . anti - hcv antibody for hcv was positive with hcv rna of 1.6 10 iu / ml . an ultrasound abdomen was suggestive of liver cirrhosis with portal hypertension ( portal vein diameter of 14 mm ) , ascites and splenomegaly . thus , a diagnosis of cirrhosis liver with portal hypertension was made ( ctp-9 , class b , and meld 11 ) . she was put on diuretics for the control of ascites but developed hepatic encephalopathy and renal dysfunction . diuretics were stopped and in view of refractory tense ascites , she was taken up for a transjugular intrahepatic portosystemic shunt . however , during the procedure she had massive intrahepatic bleed and in spite of intensive resuscitative measures she died 48 hours later .", "spider nevi can be seen in pregnancy , in patients with thyrotoxicosis , rheumatoid arthritis , oral contraceptive use and most commonly , liver cirrhosis . these frequently appear in alcoholic cirrhotic or when liver function deteriorates in patients of the chronic liver disease . found elevated levels of vascular endothelial growth factor and basic fibroblast growth factor in patients with liver cirrhosis , especially in those with spider nevi . in patients with nonalcoholic cirrhosis , the levels of substance p are elevated which may play an important role in the pathogenesis of spider nevi by causing vasodilatation . most remain small in size and rarely do they assume the size as seen in our patient . the present case is unique because of its very large size , rare presentation over the forehead and palpable mass like vascular lesion in a patient with nonalcoholic cirrhosis . electrodesiccation and laser treatments under local anesthesia are effective therapeutic procedures for facial spider nevi . spider nevi , however , usually do not require any treatment in cirrhotic patients due to a high risk of bleeding from these vascular lesions ." ]

[ "primary hyperhidrosis is a common disease that is characterized by excessive sweating of face , palms , or axilla , occurring in 0.6 - 3% of a population ( 1 , 2 ) . since kux performed endoscopic thoracic sympathetic surgery ( 3 ) , it has been popular during the past few decades as the surgical treatment of choice for facial , palmar , and axillary hyperhidrosis ( 4 - 6 ) . although endoscopic thoracic sympathetic surgery offers permanent cure for hyperhidrosis , it is often accompanied by serious complications , such as compensatory hyperhidrosis . in order to decrease compensatory hyperhidrosis , endoscopic thoracic sympathetic surgery has attempted to reduce the extent of resection of the sympathetic nerve , but these procedures did not significantly decrease the occurrence of compensatory hyperhidrosis ( 7 ) . we performed sympathetic nerve reconstruction surgery using intercostal nerve in 19 patients with severe compensatory hyperhidrosis after endoscopic thoracic sympathetic surgery and evaluated the results of the procedure .", "from february 2004 to august 2007 , we performed endoscopic thoracic sympathetic surgery in 184 patients with primary hyperhidrosis . among theses patients , reconstruction surgery of sympathetic nerve using intercostal nerve was performed in 19 patients with severe compensatory hyperhidrosis after endoscopic thoracic sympathetic surgery . fourteen patients were male and 5 were female ( median age : 28 yr , range : 19 - 61 ) . this study was approved by the institutional review board of our hospital ( irb no : 3 - 20080021 ) . all procedures of reconstruction surgery were performed under general anesthesia with a single lumen endotracheal tube . the patients were in a semi - fowler position with their arms extended . in 18 patients except for one patient with severe pleural adhesion , starting on the left side , two separate skin incisions were made along the previous thoracoscopic scars and thoracoscopic ports were placed . after co2 gas insufflation into the thoracic cavity with less than 10 mmhg of pressure to deflate the lung , the pleural space was inspected with 5-mm thoracoscope . the intercostal neurovascular bundle was dissected in lengths of 5 - 7 cm and the distal part was resected . after the proximal and distal part of previously operated sympathetic nerve was exposed , the nerve sheaths of proximal and distal part of exposed sympathetic nerve and harvested intercostal nerve end were removed with an electro - surgical tip cleaner ( surgisite , ethicon , gargrave , skipton , uk ) . the intercostal nerve end was placed between the proximal and distal part of the exposed sympathetic nerve and the fibrin glue was applied to contact surface of the sympathetic and intercostal nerve ( fig . the same procedure was repeated on the right side . in cases of sympathetic nerve clipping , this procedure was performed after clip removal . in one patient with severe pleural adhesion we reviewed the clinical charts of all patients who underwent sympathetic nerve reconstruction surgery using the intercostal nerve . patients were followed by telephone questionnaire on the effects of the surgery and postoperative complications . the degree of improvement of compensatory hyperhidrosis was graded as \" definite \" , \" mild \" , or \" absent \" . \" definite \" means that patients felt fully satisfied after the reconstruction surgery , \" mild \" means that patients felt satisfied to a certain extent , and \" absent \" means that patients felt no improvement . median interval between the sympathetic nerve reconstruction surgery and questionnaire was 22 ( range : 1 - 45 ) months . in one patient ( patient number 17 in table 1 ) , digital infrared thermographic imaging was performed preoperatively and postoperatively .", "primary hyperhidrosis patients were composed of 9 facial , 8 palmar , and 1 axillary , and one patient had both facial and palmar hyperhidrosis . initial endoscopic thoracic sympathetic surgery for primary hyperhidrosis was t3 sympathicotomy in 5 patients ; t2 sympathicotomy in 8 ; t2 , 3 sympathicotomy in 1 ; t2 , 3 , 4 sympathicotomy in 1 ; t2 clipping in 2 ; t2 , 3 clipping in 1 ; and t2 clipping with t3 sympathicotomy in 1 patient . the median interval between the first endoscopic thoracic sympathetic surgery for primary hyperhidrosis and sympathetic nerve reconstruction surgery was 47 ( range , 4 - 111 ) months . r3 intercostal nerve was used for sympathetic nerve reconstruction surgery in 15 patients , r4 intercostal nerve in 2 , r2 intercostal nerve in 1 , and r3 with r5 intercostal nerve in 1 patient . three patients replied that the effects of reconstruction were \" definite \" , 6 responded with \" mild \" , and 8 said \" absent \" . postoperative complications were numbness of the chest wall in 2 patients , chest wall pain in 2 patients , and temporary ptosis in 1 patient in whom ptosis spontaneously resolved after 3 months . preoperative and postoperative digital infrared thermographic imagings performed in one patient showed the thermal change in chest and back .", "since kux advocated thoracoscopic sympathetic surgery ( 3 ) , recent developments in thoracoscopy and specialized instruments have facilitated the procedure . and , it became the treatment of choice for hyperhidrosis because of its low morbidity , short hospital stay , and excellent cosmetic results ( 6 ) . although it has many advantages , some patients suffer from compensatory hyperhidrosis , which is by far the most common and disagreeable complication after endoscopic thoracic sympathetic surgery . according to the previous reports , compensatory hyperhidrosis occurs in 59.8 - 90% of patients after sympathetic surgery ( 8 - 10 ) . the mechanism of compensatory hyperhidrosis is not clear , but it seems to be associated with compensation for thermoregulatory function ( 11 , 12 ) . because the incidence and degree of compensatory hyperhidrosis appear to be related to the extent of resection of the sympathetic chain , some clinicians have suggested that the extent of resection should be limited ( 13 ) . for these reasons , many treatment methods , such as different level sympathectomy or sympathicotomy , ramicotomy , and clipping , have been attempted to reduce the extent of resection ( 14 - 18 ) , although the effects of these methods remain controversial . in mild compensatory symptoms , antiperspirants including aluminum - based compounds , iontophoresis , and systemic or topical anticholinergic drugs can be used . however , if the symptoms are severe , the management is more difficult and results are unsatisfactory . since philipeaux and vulpian reported the first experimental nerve graft in 1870 , many successful nerve grafts were reported in the field of orthopedic surgery . in the field of thoracic surgery , schoeller et al . ( 19 ) reported successful phrenic nerve reconstruction using sural nerve in patient with mediastinal tumor resection . telaranta reported that reconstruction of the sympathetic chain using sural nerve graft diminished compensatory sweating in a male patient who underwent sympathicotomy for palmar hyperhidrosis ( 20 ) . miura et al . ( 21 ) reported that sympathetic nerve reconstruction surgery using the intercostal nerve was useful after resection of the sympathetic nerve involved by tumor . although the sural nerve is the most commonly used for nerve graft , the intercostal nerve has several advantages over the sural nerve . first , the intercostal nerve has more sympathetic nerve fibers than the sural nerve , hence the intercostal nerve is more appropriate for sympathetic nerve reconstruction surgery . second , the sural nerve can be used only as free graft but the intercostal nerve can be used as pedicled graft and harvested as a neurovascular bundle . therefore , a sufficient blood supply in the graft can be maintained . so , an additional incision is not needed and donor site morbidity decreases . in our experience , thoracoscopic intercostal nerve could be harvested in all patients except 1 patient with severe pleural adhesion , leading us to believe that the intercostal nerve is a useful graft for sympathetic nerve reconstruction surgery . epineural and fascicular sutures are the most used for nerve anastomosis , but the foreign body reaction caused by suture material to nerve is another possible problem ( 22 , 23 ) . some reports demonstrated the successful nerve anastomosis using fibrin sealant without suture technique ( 24 , 25 ) . if microscopic suture technique is used in sympathetic nerve reconstruction surgery , it inevitably needs thoracotomy . the type of anastomosis performed in this procedure is the modification of end - to - side neurorrhaphy where axonal sprouting occurs ( 26 ) . the nerve is generally anastomosed in the original direction , but the free graft should be prepared to be anastomosed in the original direction in this operation . some reports revealed the anastomosis in reverse orientation did not influence the nerve conduction ( 27 , 28 ) . in the questionnaire on the effects of sympathetic nerve reconstruction surgery , nine patients replied \" definite \" or \" mild \" . in 3 patients who replied that the results were \" definite \" , compensatory sweating decreased and anhidrosis of the affected areas after endoscopic thoracic sympathetic surgery improved . patients , who replied mild improvement , complained still uncomfortable compensatory hyperhidrosis , although amount and frequency of perspiration decreased . these results of the reconstruction surgery were not different between variables such as age , sex , affected area , and interval from endoscopic thoracic sympathetic surgery due to the small number of cases in this study . the digital infrared thermographic imaging is a useful tool in evaluation of body temperature distribution . in the image , before and after sympathetic nerve reconstruction , we performed the digital infrared thermographic imagings in 22 yr - old man complaining of compensatory hyperhidrosis in chest after t3 sympathicotomy . after the reconstruction surgery , trunk temperature has increased , and this result corresponded with patient 's symptom . even though the number of patients is not sufficient for data analysis , outcome of the reconstruction surgery did not correlate with the interval between the sympathetic surgery and reconstructive surgery . to evaluate the exact effects of sympathetic nerve reconstruction , more cases and longer postoperative complications of the reconstruction surgery were seen in 5 patients ; prolonged chest wall pain which was tolerable in 2 patients , and numbness of chest wall in 2 patients . in addition , because compensatory hyperhidrosis depends on climate and season , the timing of a questionnaire survey is important . in this study , the questionnaire was performed on october when it is relatively cool and dry in korea . , our results suggest that sympathetic nerve reconstruction with intercostal nerve may be one of the useful surgical methods in severe compensatory hyperhidrosis patients . the reconstruction surgery must be decided very carefully in highly selected patients with severe compensatory hyperhidrosis ." ]

[ "endometrial cancer ( ec ) is one of the most common gynecologic malignancies , occupying the sixth place in malignant tumor throughout the world with an increasing trend . the initial treatment of ec is comprehensive staging surgery , which consists of total hysterectomy , bilateral salpingo - oophorectomy , pelvic and para - aortic lymphadenectomy and peritoneal cytology . laparotomy is the traditional approach , but laparoscopic surgery is widely proposed recent years since it was first reported using for the treatment of ec in 1992 by childers and surwit . in lots of retrospective and prospective studies , laparoscopy has been showed with many advantages compared to laparotomy , such as smaller incision , less pain , and faster recovery . it seems that laparoscopic surgery for ec also has similar recurrence rate and survival outcome with laparotomy procedure . however , most of these studies have focused on patients with early stage or low - risk disease and few specifically on patients with advanced stage or high risk . what 's more , data of long - term survival outcomes about laparoscopic surgery remain limited . willis et al have published an article about laparoscopic hysterectomy in a high - risk series of patients with ec , showed that laparoscopy provide all the benefits inherent in minimal access surgery with no compromise in terms of outcomes , but there was no laparotomy data as control . therefore , to compare the long - term safety and efficacy between laparoscopic surgery and laparotomy in patients with high - risk ec , we conducted a retrospective analysis based on our decade of clinical data using propensity score matching ( psm ) in this research .", "a total of about 400 medical case notes of patients with histologically confirmed ec who has been received surgical treatment in beijing chao - yang hospital affiliated capital medical university from 2000 to april 2014 were reviewed . we selected subjects according to the following criteria : high - risk ( grade 2 , histologic nonendometrioid , myometrial invasion 1/2 , positive pelvic or para - aortic nodes or stages ii iv ) patients who had undergone comprehensive surgical staging in the form of peritoneal cytology , total hysterectomy , bilateral salpingo - oophorectomy , pelvic lymphadenectomy and para - aortic lymphadenectomy or sampling , + / cytoreductive surgery by the same experienced surgical team via laparotomy ( total abdominal hysterectomy , tah ) or laparoscopy ( total laparoscopic hysterectomy , tlh ) . para - aortic lymphadenectomy was performed when para - aortic lymph nodes sampled positive and nonendometrioid carcinomas . patients who were enrolled ( excepted staged i ag2 with histologic endometrioid ) received postoperative adjuvant therapy including 3 to 6 cycles of chemotherapy ( paclitaxel , 175 mg / m + carboplatin , area under the concentration time curve [ auc ] 5 or adriamycin , 45 mg / m + cisplatin , 50 mg / m + paclitaxel , 160 mg / m ) and vaginal cuff brachytherapy or pelvic irradiation ( 45 gy over 5 weeks ) . patients had antibiotic prophylaxis ( cephalosporins or quinolones ) half an hour before operation and venous thrombosis prophylaxis after operation by using molecular weight enoxaparin ( 0.4 ml every day for 45 days ) and lower extremity sequential compression device or graduated compression stocking . patients associated with severe cardiopulmonary disease ( myocardial infarction , heart failure , or cerebral infarction ) , other malignancies or a bulky uterus 12 weeks of gestation were excluded . because our data source was case notes and the missing data were few , we deleted the individuals with missing data . the collected data of patients included age , body mass index ( bmi ) , the scope of operation , operating time , blood loss , intraoperative and postoperative complications , first flatus time , postoperative hospital stay , surgical stage , histologic type and grade , number of lymph nodes dissection , and clinical outcome . the staging of patients was done according to the international federation of gynecology and obstetrics ( figo ) 2009 staging classification . intraoperative complications included injuries to bladder , ureter , intestine or large vessels , bleeding requiring blood transfusion , conversion from laparoscopy to laparotomy and transferred to intensive care unit ( icu ) for any unintended reasons . postoperative complications included fever ( > 38c ) after 24 hours postoperatively , wound infection or dehiscence , deep - vein thrombosis ( dvt ) , and pulmonary embolism ( pe ) within 30 days after operation . the overall survival ( os ) was defined as the period from the date of surgery to death or the date of last contact for living people . follow - up is completed by telephone , e - mail , or outpatient service . all procedures were approved by the ethics committee for human experiments of the capital medical university . because parts of the baseline characteristics were statistical different between patients received laparoscopic surgery and laparotomy eight covariates entered in the propensity model , including age , bmi , the scope of operation , myometrial invasion , pathologic type and grade , lymph node metastasis , and surgical stage . propensity scores were calculated using a nonparsimonious multivariable logistic regression model to estimate the conditional probability of a patient receiving a surgery approach . then a 1:1 match between the laparoscopy and laparotomy groups was performed by using the nearest available neighbor matching . after matching , data of patient baseline characteristics , operation outcome and incidence of intraoperative and postoperative complication were compared using t test , chi - square test , or fisher exact test . survival data were estimated using kaplan meier curves and compared between groups by log - rank statistics . the 5- and 10-year survival rate and os were reported . all of the statistical analysis was completed by spss 19.0 ( spss version 19.0 ; spss , inc . , chicago , il ) . statistical significance was defined as p < 0.05 .", "three hundred eighty - two case notes were reviewed including 255 patients with high - risk ec . among these 225 patients , 31 individuals with severe cardiopulmonary disease , other malignancies or uterus 12 weeks of gestation were excluded ; 4 individuals with missing surgical or pathological data were deleted . finally , a total of 220 patients with high - risk ec met the study criteria , 107 were treated by laparotomy and 113 by laparoscopy . table 1 provides details of patient characteristics across the laparotomy and laparoscopy group pre- and postpropensity score matching . before matching , significant differences were not found in age , myometrial invasion , pathological type , and grade and lymph node metastasis between 2 groups but in bmi , scope of operation , and figo stage which could be the confounding factors . after matching , 81 pairs of patients were matched successfully . in the matched cohorts baseline patient characteristics pre- and postpropensity score matching the mean operative time was similar between 2 groups , 253 minutes in laparoscopy group and 258 minutes in laparotomy group . the mean blood loss were significant less in laparoscopy group ( 107 ml ) than laparotomy group ( 414 ml ) ( p < 0.01 ) . the laparoscopy cohort also has significant shorter first flatus time ( 2.0 days vs. 2.4 days , p < 0.01 ) and postoperative hospital stay ( 14.7 days vs. 17.7 days , p = 0.02 ) than laparotomy which meant that patients received laparoscopic surgery had more rapid recovery than that received laparotomy . the mean numbers of pelvic lymph nodes dissected by laparoscopy were 16.6 compared 21.9 by laparotomy with significant difference ( p < 0.01 ) . however , the mean numbers of para - aortic lymph nodes were comparable between 2 groups ( p = 0.11 ) ( table 2 ) . comparison of operation outcome intraoperative complications were significant different between the 2 groups ( 6.2% for laparoscopy and 25.9% for laparotomy , p < 0.01 ) . the patients received transfusion during surgery in laparotomy group was statistically more than that in laparoscopy ( p < 0.01 ) . for the incidence of transferred to icu on account of poor cardiopulmonary resuscitation , it was also statistically higher in patients treated by laparotomy than by laparoscopy . moreover , no injury to bladder , ureter , or large vessels occurred in both 2 groups , only 1 patient in laparotomy group had the intestine injury because of heavy pelvic adhesion that had been received intestinal repair . there was no significant difference in postoperative complications between the 2 groups ( 19.8% for laparoscopy and 29.6% for laparotomy , p = 0.14 ) . dvt occurred more often in laparotomy patients than laparoscopy patients , 14.8% versus 3.7% ( p = 0.01 ) . six patients developed pe in laparotomy group compared 1 in laparoscopy with no statistically difference ( table 3 ) . comparison of intraoperative and postoperative complications clinical outcome of 2 groups was shown in table 4 . the median follow - up was 45 months ( rang 5176 ) . during the follow - up time , there were 16 ( 9.9% ) recurrences which were similar between the 2 treatment cohorts , 7 ( 8.6% ) were observed in laparotomy group at peritoneal , liver , lung , vaginal , and abdominal incision versus 9 ( 11.1% ) in laparoscopy group at peritoneal , liver , lung , and vaginal . twenty patients died , 11 in the laparotomy group and 9 in the laparoscopy group . the kaplan meier estimate for survival rate in laparotomy and laparoscopy at 5 years was 89.2% , 85.3% and at 10 years was 75.8% , 85.3% , respectively . no statistically significant difference was found between the 2 groups when os was compared ( p = 0.97 ) ( figure 1 ) . it showed that no significant difference between laparotomy and laparoscopy cohorts ( 75.8% vs. 85.3% , p = 0.97 ) .", "three hundred eighty - two case notes were reviewed including 255 patients with high - risk ec . among these 225 patients , 31 individuals with severe cardiopulmonary disease , other malignancies or uterus 12 weeks of gestation were excluded ; 4 individuals with missing surgical or pathological data were deleted . finally , a total of 220 patients with high - risk ec met the study criteria , 107 were treated by laparotomy and 113 by laparoscopy . table 1 provides details of patient characteristics across the laparotomy and laparoscopy group pre- and postpropensity score matching . before matching , significant differences were not found in age , myometrial invasion , pathological type , and grade and lymph node metastasis between 2 groups but in bmi , scope of operation , and figo stage which could be the confounding factors . after matching , 81 pairs of patients were matched successfully . in the matched cohorts", "the mean operative time was similar between 2 groups , 253 minutes in laparoscopy group and 258 minutes in laparotomy group . the mean blood loss were significant less in laparoscopy group ( 107 ml ) than laparotomy group ( 414 ml ) ( p < 0.01 ) . the laparoscopy cohort also has significant shorter first flatus time ( 2.0 days vs. 2.4 days , p < 0.01 ) and postoperative hospital stay ( 14.7 days vs. 17.7 days , p = 0.02 ) than laparotomy which meant that patients received laparoscopic surgery had more rapid recovery than that received laparotomy . the mean numbers of pelvic lymph nodes dissected by laparoscopy were 16.6 compared 21.9 by laparotomy with significant difference ( p < 0.01 ) . however , the mean numbers of para - aortic lymph nodes were comparable between 2 groups ( p = 0.11 ) ( table 2 ) .", "intraoperative complications were significant different between the 2 groups ( 6.2% for laparoscopy and 25.9% for laparotomy , p < 0.01 ) . none of the laparoscopic cases was converted into open procedures . the patients received transfusion during surgery in laparotomy group was statistically more than that in laparoscopy ( p < 0.01 ) . for the incidence of transferred to icu on account of poor cardiopulmonary resuscitation , it was also statistically higher in patients treated by laparotomy than by laparoscopy . moreover , no injury to bladder , ureter , or large vessels occurred in both 2 groups , only 1 patient in laparotomy group had the intestine injury because of heavy pelvic adhesion that had been received intestinal repair . there was no significant difference in postoperative complications between the 2 groups ( 19.8% for laparoscopy and 29.6% for laparotomy , p = 0.14 ) . dvt occurred more often in laparotomy patients than laparoscopy patients , 14.8% versus 3.7% ( p = 0.01 ) . six patients developed pe in laparotomy group compared 1 in laparoscopy with no statistically difference ( table 3 ) .", "the median follow - up was 45 months ( rang 5176 ) . during the follow - up time , there were 16 ( 9.9% ) recurrences which were similar between the 2 treatment cohorts , 7 ( 8.6% ) were observed in laparotomy group at peritoneal , liver , lung , vaginal , and abdominal incision versus 9 ( 11.1% ) in laparoscopy group at peritoneal , liver , lung , and vaginal . twenty patients died , 11 in the laparotomy group and 9 in the laparoscopy group . the kaplan meier estimate for survival rate in laparotomy and laparoscopy at 5 years was 89.2% , 85.3% and at 10 years was 75.8% , 85.3% , respectively . no statistically significant difference was found between the 2 groups when os was compared ( p = 0.97 ) ( figure 1 ) . it showed that no significant difference between laparotomy and laparoscopy cohorts ( 75.8% vs. 85.3% , p = 0.97 ) .", "for accurately estimating the effect of intervention , randomized controlled trial ( rct ) is considered the optimal approach but often limited by ethic and other problems . psm can eliminate the imbalance between groups and reduce the effects of confounding to achieve a random effect in observational studies . in the present study , the patient baseline characteristics of laparotomy and laparoscopy group were adequately balanced after matching , and then , the surgery outcomes achieved comparability . this retrospective study demonstrated that laparoscopic technique is effective and even safer compared with laparotomy for patients with high - risk ec . in 2009 , gynecologic oncology group ( gog ) compared laparoscopy and laparotomy for comprehensive surgical staging of ec in a randomized multicenter trial which involved 2616 patients and reported that laparoscopic surgery resulted in fewer complications and shorter hospital stay but longer operation time . in another large randomized trial published in 2010 , laparoscopic surgery was associated with a shorter hospital stay and less amount of blood loss , but no beneficial effect was observed in terms of major complications and operation time . however , our data showed evidence of less blood loss , lower proportion of major complications and shorter hospital stay with laparoscopy versus laparotomy and a similar operation time . operation time is much related to the experience of the surgical team and learning curve . as the improvement of surgical technique , it is a trend that laparoscopic operation time becomes shorter . moreover , our study indicated that the first flatus time was shorter in laparoscopy group than in laparotomy . patients treated with laparoscopic surgery had smaller incision and less pain compared to those treated with laparotomy . laparoscopy can also bring out an earlier resumption of bowel function and shorter hospital stays . we found that the postoperative hospital stays in our data were longer than that reported in most of the previously studies and just similar to kong 's study in korea . kong reported a mean hospitalization of 16.4 days for laparoscopy and 23.3 days for laparotomy . but in gog study , the median hospital stays was 3 days for laparoscopy and 4 days for laparotomy . patients in china are accustomed to a longer hospitalization , which is mainly decided by the social factors . in chinese traditional opinion , patients are willing to discharge from hospital only when they have complete recovery ( after removing drainage tube and urinary catheter or taking out stitches ) , what 's more , they need not worry about the medical expense because of the coverage of insurance . so , some patients even have been in hospital until the end of the first chemotherapy . in the present study , intraoperative complications were significantly lower in the laparoscopy group and no injuries to bladder , ureter , or large vessels occurred . the incidence of major complications can be highly reduced when the procedure was performed by experience surgeon . however , it seems that laparoscopy had no benefit in the incidence of postoperative complications . but we found dvt occurred significantly often in patients treated by laparotomy than those treated by laparoscopy . in gog study , there was no significant difference in incidence of venous thromboembolism ( vte ) and pe between different approaches . in contrast , fader 's study showed that the laparoscopy cohort had significantly fewer episodes of vte . lots of studies indicate that the combination of underlying malignancy and pelvic surgery is the risk for developing a vte . in a japanese large research about risk factors for vte , the age ( 50 or 55 years ) , a diagnosis of cancer , operating time ( 4 hours ) , blood loss ( 1000 ml ) , and blood transfusion ( 2000 ml ) were reported significantly related to postoperative vte . it may account for the difference of dvt incidence between the 2 groups that laparotomy had longer operating time and more blood loss in our study . what 's more , trendelenburg position during laparoscopic surgery may play a role in preventing vte . most of the previous studies demonstrate that the pelvic or para - aotic lymph nodes count removed by laparoscopy approach were similar to those dissected by laparotomy . laparoscopy has been proven to be even more efficient in lymphadenectomy because of its clearer vision . however , obermair and kalogiannidis reported lower number of lymph node dissections in the laparoscopy group . in the present study , the mean number of dissected para - aotic lymph nodes was comparable between the 2 groups , but the pelvic lymph nodes were significant fewer in laparoscopy cohort than laparotomy . two large rcts reported by benedett and kitchener showed no evidence that lymphadenectomy could decrease the risk of recurrence or mortality rate in patients with early ec . conversely , another retrospective research gave a result that lymphadenectomy improved the survival of patients with high - risk ec and stage i b to stage iv . moreover , an article published in lancet in 2010 reported that para - aotic had a significantly benefit in terms of os for patients with ec at mediate or high risk . it seems that the difference of pelvic lymph nodes count between the laparoscopy and laparotomy groups had not influenced the os in our study . lots of previous studies have proven that laparoscopy surgery was similar to laparotomy in short - term survival . a meta - analysis reported in 2012 based on 8 rcts showed that there was no significant difference in disease - free survival , cancer - related survival , or os . cho et al reported a similar 5-year os and progression - free survival between laparoscopy and laparotomy groups based on 10-year experience . in 2012 , the gog published the survival data of their large rct in 2009 that the 5-year os was almost identical in both laparoscopy and laparotomy cohorts at 89.8% . between 2000 and 2010 , we conducted a randomized trial and reported that the 5-year os rates were 91% of laparotomy and 96% of laparoscopy with no significantly difference . in another retrospective study focus on high - grade ec in 2012 , progression - free and os were not significantly different between the surgical cohorts at 44-month median follow - up . in the present study , parts of patients were follow - up more than 10 years . with a median follow - up time of 45 months , the 5- and 10-year survival rate for the laparotomy were 89.2% and 75.8% compared with 85.3% and 85.3% for the laparoscopy . there was no significant difference in os between 2 cohorts and also the recurrence rate . although the patients enrolled were not assigned to different approaches randomly which was a limitation of our study , we performed a psm and successfully to control a certain confounding factors yet . when randomized trial was limited by the objective conditions , psm might be a feasible alternative to reduce selection bias . in conclusion , it seems that laparoscopic surgery is as effective as laparotomy in the long term and can be safely carried out in patients with high - risk ec for surgery treatment . furthermore , other long - term follow - up data on high - risk ec of randomized trials is still needed to confirm these results ." ]

[ "syringomyelia is the development of a fluid - filled cavity within the spinal cord . despite different etiologies that cause syringomyelia , it is largely agreed that the alteration of cerebrospinal fluid ( csf ) flow dynamics plays an important role in the development of a syrinx . known causes of syringomyelia include chiari 1 malformation and basal arachnoiditis [ postinfectious , inflammatory , postirradiation , blood in subarachnoid space ( sas ) amongst others ] . primary spinal syringomyelia refers to syrinx formation due to a spinal pathology , e.g. , spinal cord tumor , spinal infection , trauma , and surgery . the term idiopathic syringomyelia has been used to describe syrinx formation in cases where causative mechanism remains undetermined after clinical and routine radiological work - up . the term does not imply the absence of a cause but just the absence of a cause that can be detected using standard diagnostic methods . there are very few reports in the literature describing arachnoid bands / webs as causes of idiopathic syringomyelia . we present our experience in the management of cases of syringomyelia due to dorsal spinal arachnoid bands and review the current available evidence of the diagnostic work - up and management of this etiology .", "a 43-year - old male was referred with a 2-year history of progressive dissociative sensory loss in his lower limbs with myoclonic twitches . this was associated with neck and low back pain in addition to left - sided radiating leg pain . there was no history of previous trauma , central nervous system ( cns ) infection , or spinal surgery . on examination , there was non - dermatomal numbness in left lower limb but normal power in all four limbs . he had been investigated previously in another neurosurgical center and the magnetic resonance imaging ( mri ) scan revealed a cervicothoracic syrinx but in the absence of any apparent cause ; the patient was managed conservatively for 2 years till he was eventually referred to our center for a second opinion . mri scan [ figure 1 ] showed twin syrinx cavities in the cervical and upper thoracic regions with an unusual distribution and no apparent etiology . the patient underwent a computed tomography ( ct ) myelogram [ figure 2 ] that showed csf block at t1/t2 suggestive of arachnoid pathology . during the ct myelogram , a small air bubble was inadvertently introduced that ascended superiorly and was trapped at the level of the csf block . he was now experiencing increasing dysesthetic pain down both arms along with left flank numbness and gait disturbance . in view of progressive deterioration , he underwent a t1/t2 thoracic laminectomy for intradural exploration that revealed a thickened dorsal band of arachnoid . preoperative ( top row ) and postoperative ( bottom row ) mri for case 1 showing cervical significant syrinx prior to surgery and collapsed down following surgery . the postoperative scan was done 6 months after the surgery preoperative ct myelogram and axial mri for case 1 . the abrupt change in cord caliber / displacement demonstrated by the myelogram was not evident on mri studies . note inadvertent bubble of air that ascended superiorly to the level of arachnoid web , which was useful in confirming the presence and level of the web postoperatively , the patient recovered well from the operation and there was gradual improvement in his symptoms with normal gait and return of normal function of hands . six months after the surgery , the patient reported complete symptom resolution and follow - up mri scan [ figure 1 ] showed significant reduction in the size of the syrinx . a 45-year - old male was referred following an episode of legs giving way that was followed by paraparesis for a few hours that recovered fully . on examination mri scan [ figure 3 ] revealed a lower thoracic syrinx with some signal change in spinal cord . follow - up imaging after 18 months showed no change . however , 4 months later the patient reported increasing discomfort and numbness in both the arms with subjective lower limb weakness and gait disturbance . a ct myelogram [ figure 4 ] was performed that revealed displacement of the spinal cord at t3 to t5 and compression to the left likely secondary to either arachnoid band or cyst . pre- ( top row ) and postoperative ( bottom row ) mri for case 2 showing significant syrinx prior to surgery and collapsed down following surgery . the postoperative scan was done 12 months after the surgery preoperative ct myelogram for case 2 demonstrating the cord displacement and change in caliber by now , the patient had developed right lower limb spastic weakness along with left radiating leg pain . on examination he had brisk reflexes , positive hoffmann 's sign bilaterally , positive ankle clonus , reduced sensation in the right leg , and upgoing plantars . intradurally , we found a dorsal arachnoid band that was excised and histology confirmed arachnoid tissue . postoperatively , the patient recovered well from the operation with improvement in right leg strength and the left leg pain . at 6-month follow - up , he reported complete symptomatic resolution , and neurological examination was normal . his follow - up mri [ figure 3 ] at 6 months postoperatively revealed significant reduction in the syrinx size .", "a 43-year - old male was referred with a 2-year history of progressive dissociative sensory loss in his lower limbs with myoclonic twitches . this was associated with neck and low back pain in addition to left - sided radiating leg pain . there was no history of previous trauma , central nervous system ( cns ) infection , or spinal surgery . on examination , there was non - dermatomal numbness in left lower limb but normal power in all four limbs . he had been investigated previously in another neurosurgical center and the magnetic resonance imaging ( mri ) scan revealed a cervicothoracic syrinx but in the absence of any apparent cause ; the patient was managed conservatively for 2 years till he was eventually referred to our center for a second opinion . mri scan [ figure 1 ] showed twin syrinx cavities in the cervical and upper thoracic regions with an unusual distribution and no apparent etiology . the patient underwent a computed tomography ( ct ) myelogram [ figure 2 ] that showed csf block at t1/t2 suggestive of arachnoid pathology . during the ct myelogram , a small air bubble was inadvertently introduced that ascended superiorly and was trapped at the level of the csf block . he was now experiencing increasing dysesthetic pain down both arms along with left flank numbness and gait disturbance . in view of progressive deterioration , he underwent a t1/t2 thoracic laminectomy for intradural exploration that revealed a thickened dorsal band of arachnoid . preoperative ( top row ) and postoperative ( bottom row ) mri for case 1 showing cervical significant syrinx prior to surgery and collapsed down following surgery . the postoperative scan was done 6 months after the surgery preoperative ct myelogram and axial mri for case 1 . the abrupt change in cord caliber / displacement demonstrated by the myelogram was not evident on mri studies . note inadvertent bubble of air that ascended superiorly to the level of arachnoid web , which was useful in confirming the presence and level of the web postoperatively , the patient recovered well from the operation and there was gradual improvement in his symptoms with normal gait and return of normal function of hands . six months after the surgery , the patient reported complete symptom resolution and follow - up mri scan [ figure 1 ] showed significant reduction in the size of the syrinx .", "a 45-year - old male was referred following an episode of legs giving way that was followed by paraparesis for a few hours that recovered fully . on examination mri scan [ figure 3 ] revealed a lower thoracic syrinx with some signal change in spinal cord . follow - up imaging after 18 months showed no change . however , 4 months later the patient reported increasing discomfort and numbness in both the arms with subjective lower limb weakness and gait disturbance . a ct myelogram [ figure 4 ] was performed that revealed displacement of the spinal cord at t3 to t5 and compression to the left likely secondary to either arachnoid band or cyst . pre- ( top row ) and postoperative ( bottom row ) mri for case 2 showing significant syrinx prior to surgery and collapsed down following surgery . the postoperative scan was done 12 months after the surgery preoperative ct myelogram for case 2 demonstrating the cord displacement and change in caliber by now , the patient had developed right lower limb spastic weakness along with left radiating leg pain . on examination he had brisk reflexes , positive hoffmann 's sign bilaterally , positive ankle clonus , reduced sensation in the right leg , and upgoing plantars . intradurally , we found a dorsal arachnoid band that was excised and histology confirmed arachnoid tissue . postoperatively , the patient recovered well from the operation with improvement in right leg strength and the left leg pain . at 6-month follow - up , he reported complete symptomatic resolution , and neurological examination was normal . his follow - up mri [ figure 3 ] at 6 months postoperatively revealed significant reduction in the syrinx size .", "we report a very uncommon and hence under - recognized cause of symptomatic syringomyelia . whilst arachnoid bands / webs have previously been reported as the etiologic factor for idiopathic syringomyelia first reported the importance of recognizing occult arachnoid webs , pouches , and cysts in idiopathic syringomyelia . in a large series of 28 patients with thoracic arachnoid pathology , 6 cases of ventral or dorsal arachnoid bands were reported . however , there is uncertainty not only regarding the pathophysiology of syrinx formation with arachnoid webs but also regarding the ideal radiological investigations . arachnoid adhesions due to trauma / infection / previous surgery are well - recognized causes of syringomyelia . idiopathic arachnoid bands have been hypothesized to develop from the septum posticum , the membrane dividing the midline dorsal arachnoid space of the cervicothoracic spinal canal . it is however equally possible that they represent localized arachnoiditis due to factors that are not always elicited in the history . frequently cited theories in syrinx formation are those of gardner , williams , and oldfield . greitz proposed that increased intramedullary pulse pressure in the spinal cord relative to the nearby sas is the distending force in the production of syringomyelia and that syrinx consists of extracellular fluid accumulated in the distended spinal cord . directly addressed the pathophysiology of primary spinal syringomyelia in their prospective study of 36 patients . their findings were consistent with their theory that a spinal subarachnoid block increases subarachnoid pulse pressure above the block , producing a pressure differential across the obstructed segment of the sas , which results in syrinx formation and progression . they reported that their findings were similar to that of their previous studies , which examined the pathophysiology of syringomyelia associated with obstruction of sas at the foramen magnum , inferring a common mechanism for both . three - dimensional computational models of the spinal sas have been used to study csf flow either in unobstructed sas or with sas obstructed by a porous region simulating dorsal and circumferential arachnoiditis . the findings suggest that syrinx formation may be related to a change of temporal csf pulse pressure dynamics . consequently , it would appear that restoring csf flow across the arachnoid webs / bands should result in syrinx resolution . alternatively , syrinx formation may occur due to resonance in a mechanical system with a pathology - induced nodal point . however , the recognition of a secondary imaging finding the scalpel sign can suggest the presence of an arachnoid web . this is a focal indentation of the thoracic spinal cord , resembling a scalpel on sagittal mri images with the scalpel blade pointing posteriorly . however , none of our patients had any clear evidence suggesting an arachnoid web on conventional mri . in all the early reported series of arachnoid webs , ct myelography was the investigation of choice . indeed , it has been reported that cardiac gated mri techniques were less successful in studying csf flow in the spine than at the craniovertebral junction . however , in a large series of 125 patients with idiopathic syringomyelia , mauer et al . performed cardiac gated phase contrast mri of csf flow in the median sagittal plane in the spine and reported that these were more reliable compared to myelography . cardiac gated phase contrast cine - mode mri in multiple axial planes has also been used to quantitatively analyze csf flow in those planes for the diagnosis of arachnoid webs . whilst in these papers , arachnoid webs were indirectly diagnosed using flow studies ; direct visualization of arachnoid membranes has been reported with high resolution using retrospectively cardiac gated cine steady - state free precession mri . however , all these mri techniques are susceptible to movement artifacts and also require a 3tesla mri that may not always be available . arachnoid webs may be missed even with mri csf flow sequences , hence ct myelography remains useful . it is worth noting that the inadvertent air bubble introduced during the ct myelogram of our first patient provided an excellent clue about the location of the csf block . the location of the syrinx is not a reliable clue regarding the level of arachnoid web / csf block . the arachnoid web was just caudal to the syrinx in our first patient and at the cranial end of the syrinx in the second patient . we recognize that myelography is an invasive procedure with potential morbidity and with recent significant advancements in mr technology , it may be prudent to investigate symptomatic idiopathic syringomyelia with mri csf flow studies in the first instance and failing that , to proceed to myelography . we believe that restoring csf flow by excision of the arachnoid band and thereby improving sas compliance offers the best possible outcome in these symptomatic cases . in the earliest reported series , all patients treated by web excision improved whereas both patients treated with syringo - pleural shunts worsened . mixed result were obtained with shunting in other series but excision of the webs was almost always associated with successful outcome . shunting syrinxes is associated with high rates of recurrence , poor long - term outcomes , and sometimes worsening of neurological status . in fact , most patients with any short segment arachnoid pathology causing primary spinal syringomyelia , generally have good outcomes after surgical decompression / detethering procedures . it is the patient group with long segment pathology that often requires multiple surgeries , frequently for csf diversion . this was corroborated in a recent systematic review , which suggested that arachnolysis rather than shunting was the only initial surgical treatment that is likely to have a statistically significant effect on lowering recurrence rates . this once again highlights the importance of exhaustively looking for a rectifiable surgical targets , such as arachnoid webs and cysts in the presumed idiopathic syrinxes , which would otherwise have be treated with shunts .", "arachnoid webs / bands are a rare and hence often underdiagnosed cause of idiopathic syringomyelia , leading to delayed diagnosis and treatment . in symptomatic / deteriorating patients with idiopathic syringomyelia , imaging studies should be closely inspected for the presence of a transverse arachnoid web . conventional mri should always be augmented with mri csf flow studies in the sagittal plane and if needed in multiple axial planes to aid in the diagnosis . ct myelography should be performed if these studies do not yield answers or also if the surgeon feels further information is needed prior to definitive treatment , especially as myelography provides more robust localization of the level of block . focussed surgical decompression and excision of the offending arachnoid tissue usually leads to good clinical and radiological outcomes .", "", "" ]

[ "osteoporosis is a systemic disease leading to progressive decrease in bone mineral density , decreased bone strength , and increased risk of skeletal fractures . approximately 30% of women have sustained at least 1 vertebral fracture by the age of 75 . these fractures are an important and common cause of morbidity in osteoporotic patients ; moreover , fractures evidenced both clinically and at radiographic examination are associated with an increased mortality rate . back pain owing to vertebral fractures has a significant affect on osteoporotic patients [ 46 ] , and the number and severity of these fractures also increases the risk of developing chronic back pain . this has a marked negative impact on the quality of life ( qol ) and functional impairment of the affected patients . conventional treatments for osteoporosis including bisphosphonates , selective estrogen receptor modulators ( serms ) , and estrogen have been shown to reduce the rate of bone resorption and to preserve bone mass . another therapeutic option includes rhpth , an agent that has been shown to increase both bone mass and bone strength . when injected , teriparatide ( rdna origin ) , the amino - terminal fragment of human pth ( rhpth 134 ) , is a potent bone formation agent for the treatment of severe osteoporosis . it increases osteoblast production / growth and prevents osteoblast apoptosis ; at the same time , it enhances absorption of calcium from the intestine , renal reabsorption of calcium , while decreasing the excretion of phosphates in the kidney [ 1114 ] . when administered once daily by subcutaneous injection , rhpth increases bone density and improves trabecular architecture , cortical geometry , and strength . not only does rhpth increase trabecular bone density by stimulating bone formation , but it also stimulates osteoclastic bone resorption [ 1719 ] . in several studies , rhpth has been shown to increase bone mineral density in postmenopausal osteoporosis , in senile osteoporosis in men , and in glucocorticoid - induced osteoporosis . teriparatide acts via the pth-1 receptor on osteoblasts and bone marrow stromal cells to induce osteoblastic bone formation , that is , osteoid synthesis and accelerated mineralization . this , in turn , results in reductions in skeletal fractures to levels equivalent to , or over , those obtained by using antiresorptive agents . the increase in bone mineral density induced by rhpth is substantial , ranging 10% to 15% over 2 to 3 years in most studies [ 10,2024 ] . moreover , rhpth can cause demonstrable increases in bone mineral density and changes in markers of bone turnover within 3 months since the start of treatment . quality of life ( qol ) can be measured to compare the effect of different treatments for osteoporosis . measuring pain scores only for these patients would be inadequate , because apart from acute and chronic back pain , patients with vertebral fractures also experience anxiety , constant fear of falling , or suffering another fracture while their daily living activities are impaired . most information has been collected thanks to the efforts made by some researchers to develop specific instruments to test the physical and emotional disability generated by the disease . generic tools available for measuring qol are useful to evaluate general health but they lack disease specificity . more recently , some specific instruments have been developed to measure the qol in osteoporosis more accurately . the most widely used are the osteoporosis quality of life questionnaire ( oqlq ) , the osteoporosis assessment questionnaire ( opaq ) , the osteoporosis - targeted quality of life questionnaire ( optqol ) , and the quality of life questionnaire of the european foundation for osteoporosis ( qualeffo-41 ) . one of the first ones was qualeffo-41 , which has been translated and validated in different languages including italian . this questionnaire has proved to be repeatable , coherent , and able to discriminate between patients and controls . in the last few years , other specific questionnaires have been developed , but not all of them have been as extensively used and validated in different countries as qualeffo-41 . the goal of this study was firstly to assess the validity of rhpth treatment in a cohort of postmenopausal women with severe osteoporosis ; secondly , to evaluate the improvement in qol and pain symptoms after several months of rhpth therapy . a follow - up qualeffo-41 questionnaire was used to quantify the patient s pain and the affect on qol after rhpth therapy .", "the study was a 18 months , randomized prospective cohort study conducted at department of molecular and clinical endocrinology and oncology , university of naples federico ii , naples , italy . inclusion criteria for this study consisted of back pain , postmenopausal osteoporosis ( t - score 2.5 at lumbar spine or femoral neck ) , the presence of 2 osteoporotic vertebral fractures , previous treatment for osteoporosis . the exclusion criteria were : an increased risk of osteosarcoma ( ie , patients with paget disease bone , previous skeletal exposure to external beam radiotherapy , or previous malignant neoplasm involving the skeleton ) , hypercalcemia , malignant neoplasms , impaired renal function , liver disease , history of diseases other than postmenopausal osteoporosis that affect bone metabolism , nephrolithiasis , alcohol or drug abuse . secondary osteoporosis was excluded in order to avoid the interference of the primitive disease with the patient s quality of life . informed consent was obtained from all subjects and the study protocol was approved by the hospital / science s ethical committee . eighty - one postmenopausal women were enrolled and divided in two groups with no statistically significant differences in any of the considered variables : group a forty - two women ( mean age 659 yrs ; mean body mass index bmi 24.52.6 kg / m ) , with severe postmenopausal osteoporosis ( mean lumbar bmd 3.880.70 , mean femoral neck bmd 3.070.60 and with 2 vertebral atraumatic fractures ) , persistent back pain and previous treatment with biphosphonates for osteoporosis ; group b thirty - nine women matched for age ( 6014.4 yrs ) , bmi ( 22.88.8 kg / m ) , menopausal status , affected by back pain , severe postmenopausal osteoporosis ( lumbar spine bmd 3.900.73 , mean femoral neck bmd 3.020.61 and with 2 vertebral atraumatic fractures ) previously treated for osteoporosis with biphosphonates . bmi , age at menopause , lifestyle habits ( i.e. , smoking , drinking , nutrition style ) , nutrition anamnesis ( calcium intake ) , history of diseases other than osteoporosis , family history of osteoporosis were considered . groups were randomized to daily treatment with 20 g s.c . of recombinant human parathyroid hormone ( rhpth 134 ) , self - administered injections ( group a ) or 70 mg per os of alendronate every week ( group b ) . all women received 1,000 mg elemental calcium daily and 800 iu of vitamin d daily for 18 months . biochemical markers of bone turnover were dosed in all the selected female patients : alkaline phosphatase ( alp : 35104 u / l ) , n - terminal propeptide of type i procollagen ( pinp : 19102 g / l ) , n - telopeptide crosslinks ( ntx : 565 nmol / mmol crea ) were assessed at baseline , 3 , 12 and 18 months ( t0 , t3 , t12 , t18 ) . the bmd of the lumbar spine and the proximal femur was measured by dual - energy x - ray absorptiometry ( dual - energy x - ray absorptiometry qdr 1000 ; hologic , waltham , ma , usa ) at baseline and at 18 months ( t0 , t18 ) . all women underwent anteroposterior and lateral radiography of thoracic and lumbar spine at t0 and t18 . the qol questionnaire of the european foundation for osteoporosis ( qualeffo ) was administered at baseline and at the end of the study to evaluate the impact of rhpth on health - related qol . originally , the questionnaire consisted of 48 questions and 6 visual analogue scales . in the qualeffo validation study , this resulted in the qualeffo-41 , which consisted of 41 questions in 5 domains : pain , physical function , social function , general health perception , and mental function . all answers were recorded so that all items range from 1 to 5 , and all answers were standardized so that 1 represents the best and 5 the worst qol , with the exception of questions e23 - 25 ( questions with 3 answer options ) , questions e24 - 26 - 27 - 28 ( 4 answer options ) , and questions g33 - 34 - 35 - 37 - 39 - 40 ( answer with reverse scores : 1 is the worst while 5 is the best ) . domain scores are calculated by averaging the answers of 1 domain and transforming the scores to a score from 0 to 100 . data are expressed as mean sd or percentage ; moreover , to assess the affect of teriparatide treatment on markers of bone turnover , bone mineral density , and on health - related qol , pearson correlation coefficients were computed in the 2 study groups . therefore , percentage changes of biomarkers , bone mineral density , and qualeffo results were calculated .", "there was no significant difference in these characteristics between the 2 groups . in the group a , 39 ( 93% ) out of the 42 recruited women completed the study : 2 patients discontinued the drug therapy because of lack of compliance with the study treatment ; 1 patient discontinued because of a new vertebral atraumatic fracture . the aim of this study was to evaluate percentage changes from baseline in biochemical markers of bone turnover , values of bone mineral density ( measured at lumbar spine and proximal femur ) , and measurements of qol . follow - up checks , where we also evaluated clinical conditions , adverse events , compliance to treatment and use of non - steroid anti - inflammatory drugs , were carried out at 3 , 12 and 18 months since the beginning of treatment . in group a serum levels of pinp increased of 90% , 145% and 127% at t3 , t12 , t18 , respectively ; bone alp levels increased of 57% , 79% and 65% ; ntx levels increased of 53% at t3 , of 100% at t12 , of 110% at t18 . in group b percentage changes from baseline of serum levels of pinp were 50% , 70% and 74% at t3 , t12 , t18 , respectively ; bone alp levels decreased of 30% , 48% and 41% ; ntx levels were reduced by 55% at t3 , of 69% at t12 , of 72% at t18 . mean percentage changes from baseline are shown over time for all 3 biochemical markers in figures 1 and 2 . mean pinp values were 426 g / l at t0 , 8012 g / l at t3 , 10334 g / l at t12 , 9526 g / l at t18 in group a ( t0 vs t3 r : 0.81 , p<0.001 ; t0 vs t12 r : 0.88 , p<0.001 ; t0 vs t18 r : 0.86 , p<0.001 ) and 7816 g / l , 395 g / l , 2313 g / l , 208 g / l at t0 , t3 , t12 , t18 respectively ( t0 vs t3 r : 0.67 , p<0.001 ; t0 vs t12 r : 0.76 , p<0.001 ; t0 vs t18 r : 0.82 , p<0.001 ) . in group u / l , 10720 u / l at t3 , 12245 u / l at t12 and 11235 u / l at t18 ( t0 vs t3 r : 0.72 , p<0.001 ; t0 vs t12 r : 0.46 , p<0.01 ; t0 vs t18 r : 0.85 , p<0.001 ) ; instead , in group b mean alp was 72 15 u / l at baseline , 5015 after 3 months , 3717 u / l at t12 and 427 u / l at the end of the study ( t0 vs t3 r : 0.91 , p<0.001 ; t0 vs t12 r : 0.53 , p<0.001 ; t0 vs t18 r : 0.65 , p<0.001 ) . ntx mean values in group a were 317 nmol / mmol crea , 4721 nmol / mmol crea , 6211 nmol / mmol crea , 6523 nmol / mmol crea at t0 , t3 , t12 and t18 respectively ( t0 vs t3 r : 0.22 , p>0.1 ; t0 vs t12 r : 0.57 , p<0.001 ; t0 vs t18 r : 0.49 , p<0.01 ) while in group b ntx mean values were 534 nmol / mmol crea at t0 , 29 11 nmol / mmol crea at t3 , 2013 nmol / mmol crea at t12 and 158 nmol / mmol crea at t18 ( t0 vs t3 r : 0.74 , p<0.001 ; t0 vs t12 r : 0.58 , p<0.001 ; t0 vs t18 r : 0.69 , p<0.001 ) . by the end of the study period , the bmd values expressed in terms of t - score in our total pool displayed important changes ( figure 3 ) . at month 18 , lumbar spine bmd increased by 12.4% in group a compared with group b in which it increased by 3.85% . specifically , in group a mean t - score at t0 was 3.870.71 and mean t - score at t18 was 3.390.72 ( r : 0.88 ; p<0.001 ) ; instead , in group b , mean t - score at t0 was 3.900.73 and mean t - score at t18 : 3.750.72 ( r : 0.98 ; p<0.001 ) . the bmd in the femur increased from baseline at month 18 , in group a , by 5.2% and by 1.99% in group b. in group a , mean femoral neck t - score was 3.070.60 at baseline and mean t - score at t18 was 2.910.63 at the end of the study ( r : 0.87 ; p<0.001 ) ; in group b , mean femoral t - score was 3.020.61 at t0 and 2.960.64 at t18 ( r : 0.99 ; p<0.001 ) . at t0 , patients treated with teriparatide were more protected against new fractures , compared with patients treated with bisphosphonates ; in fact , only 1 new vertebral fracture occurred in group a ( 2.4% ) at study endpoint ( t18 ) vs 6 new vertebral fractures that occurred in group b ( 15.7% ) at t18 . the most - common reported adverse effects were back pain worsened in the first month of treatment that was reported by 14% of women ; nausea , reported by 10% ; headache and dizziness that were reported by only 1 and 2 women . the reported adverse effects were abdominal pain in 9 patients , arthralgia in 4 patients , and dyspepsia in 1 patient . we evaluated the teriparatide impact on several aspects of qol by administering the patients qualeffo-41 test at t0 and t18 ( figure 4 ) . first domain ( domain a ) result indicated a serious reduction in pain ( 22% ) after treatment with rhpth : mean scores measured was 729.2 at start and 5614 after 18 months ( r : 0.61 ; p<.001 ) compared with group b ( 9.7% ; 718.7 at t0 and 6511 at t18 ; r : 0.53 ; p<.001 ) . for everyday activities ( domain b ) , an average of 5513.6 was measured at t0 and of 4022.9 at t18 ( r : 0.44 ; p<.01 ) in group a which had a total improvement of 27.3% , while the improvement was of 11% in group b ( 61.118 at t0 and 54.315.7 at t18 ; r : 0.68 ; p<.001 ) . the performed domestic job domain ( domain c ) showed an improvement of 29% in group a ( 6010.7 at t0 ; 42.613.3 at t18 ; r : 0.68 ; p<.001 ) and of 2.9% in group b ( 62.113.3 at t0 ; 60.313.7 at t18 ; r : 0.88 ; p<.001 ) . the mean score of domain d ( locomotor function ) was of 48.410 at baseline and 30.214.3 at the end of the study that indicates a percentage change of 37.8% in group a compared to group b where the change was of 11.5% ( 46.88.6 at t0 ; 41.410.05 at t18 ; r : 0.69 ; p<.001 ) . the quality of free time and of the social activities ( domain e ) at the 2 time points they were 36.28.6 and 25.98.6 , indicating a percentage change of 28.4% in group a ( r : 0.50 ; p<.01 ) ; the values of group b were 38.214 at t0 and 34.214.3 at t18 reaching a percentage change of 10.5% only ( r : 0.87 ; p<.001 ) . patients taking teriparatide showed also an improvement of 33.9% in the self - perception of their health ( domain f ) ( 5925 at t0 ; 3916.7 at t18 ; r : 0.84 ; p<.001 ) versus 12.8% improvement of group b ( 63.228.2 at t0 ; 55.124.8 at t18 ; r : 0.90 ; p<.001 ) . in the mood domain ( domain g ) , the qualeffo - test revealed a mean value of 20.67.2 at t0 and 29.39.7 at t18 in group a ( r : 0.71 ; p<.001 ) . these data demonstrated a considerable improvement ( 29.7% ) compared with group b ( 1.8% ; 32.59.8 at t0 ; 33.19.9 at t18 ; r : 0.18 ; p>.1 ) . as a consequence of pain relief , the consumption of nonsteroidal anti - inflammatory drugs also decreased in 29 women of group a , while it did not decrease in group b.", "in group a serum levels of pinp increased of 90% , 145% and 127% at t3 , t12 , t18 , respectively ; bone alp levels increased of 57% , 79% and 65% ; ntx levels increased of 53% at t3 , of 100% at t12 , of 110% at t18 . in group b percentage changes from baseline of serum levels of pinp were 50% , 70% and 74% at t3 , t12 , t18 , respectively ; bone alp levels decreased of 30% , 48% and 41% ; ntx levels were reduced by 55% at t3 , of 69% at t12 , of 72% at t18 . mean percentage changes from baseline are shown over time for all 3 biochemical markers in figures 1 and 2 . mean pinp values were 426 g / l at t0 , 8012 g / l at t3 , 10334 g / l at t12 , 9526 g / l at t18 in group a ( t0 vs t3 r : 0.81 , p<0.001 ; t0 vs t12 r : 0.88 , p<0.001 ; t0 vs t18 r : 0.86 , p<0.001 ) and 7816 g / l , 395 g / l , 2313 g / l , 208 g / l at t0 , t3 , t12 , t18 respectively ( t0 vs t3 r : 0.67 , p<0.001 ; t0 vs t12 r : 0.76 , p<0.001 ; t0 vs t18 r : 0.82 , p<0.001 ) . u / l , 10720 u / l at t3 , 12245 u / l at t12 and 11235 u / l at t18 ( t0 vs t3 r : 0.72 , p<0.001 ; t0 vs t12 r : 0.46 , p<0.01 ; t0 vs t18 r : 0.85 , p<0.001 ) ; instead , in group b mean alp was 72 15 u / l at baseline , 5015 after 3 months , 3717 u / l at t12 and 427 u / l at the end of the study ( t0 vs t3 r : 0.91 , p<0.001 ; t0 vs t12 r : 0.53 , p<0.001 ; t0 vs t18 r : 0.65 , p<0.001 ) . ntx mean values in group a were 317 nmol / mmol crea , 4721 nmol / mmol crea , 6211 nmol / mmol crea , 6523 nmol / mmol crea at t0 , t3 , t12 and t18 respectively ( t0 vs t3 r : 0.22 , p>0.1 ; t0 vs t12 r : 0.57 , p<0.001 ; t0 vs t18 r : 0.49 , p<0.01 ) while in group b ntx mean values were 534 nmol / mmol crea at t0 , 29 11 nmol / mmol crea at t3 , 2013 nmol / mmol crea at t12 and 158 nmol / mmol crea at t18 ( t0 vs t3 r : 0.74 , p<0.001 ; t0 vs t12 r : 0.58 , p<0.001 ; t0 vs t18 r : 0.69 , p<0.001 ) .", "by the end of the study period , the bmd values expressed in terms of t - score in our total pool displayed important changes ( figure 3 ) . at month 18 , lumbar spine bmd increased by 12.4% in group a compared with group b in which it increased by 3.85% . specifically , in group a mean t - score at t0 was 3.870.71 and mean t - score at t18 was 3.390.72 ( r : 0.88 ; p<0.001 ) ; instead , in group b , mean t - score at t0 was 3.900.73 and mean t - score at t18 : 3.750.72 ( r : 0.98 ; p<0.001 ) . the bmd in the femur increased from baseline at month 18 , in group a , by 5.2% and by 1.99% in group b. in group a , mean femoral neck t - score was 3.070.60 at baseline and mean t - score at t18 was 2.910.63 at the end of the study ( r : 0.87 ; p<0.001 ) ; in group b , mean femoral t - score was 3.020.61 at t0 and 2.960.64 at t18 ( r : 0.99 ; p<0.001 ) .", "at t0 , all patients of groups a and b showed baseline vertebral fractures . patients treated with teriparatide were more protected against new fractures , compared with patients treated with bisphosphonates ; in fact , only 1 new vertebral fracture occurred in group a ( 2.4% ) at study endpoint ( t18 ) vs 6 new vertebral fractures that occurred in group b ( 15.7% ) at t18 .", "the most - common reported adverse effects were back pain worsened in the first month of treatment that was reported by 14% of women ; nausea , reported by 10% ; headache and dizziness that were reported by only 1 and 2 women . the reported adverse effects were abdominal pain in 9 patients , arthralgia in 4 patients , and dyspepsia in 1 patient .", "we evaluated the teriparatide impact on several aspects of qol by administering the patients qualeffo-41 test at t0 and t18 ( figure 4 ) . first domain ( domain a ) result indicated a serious reduction in pain ( 22% ) after treatment with rhpth : mean scores measured was 729.2 at start and 5614 after 18 months ( r : 0.61 ; p<.001 ) compared with group b ( 9.7% ; 718.7 at t0 and 6511 at t18 ; r : 0.53 ; p<.001 ) . for everyday activities ( domain b ) , an average of 5513.6 was measured at t0 and of 4022.9 at t18 ( r : 0.44 ; p<.01 ) in group a which had a total improvement of 27.3% , while the improvement was of 11% in group b ( 61.118 at t0 and 54.315.7 at t18 ; r : 0.68 ; p<.001 ) . the performed domestic job domain ( domain c ) showed an improvement of 29% in group a ( 6010.7 at t0 ; 42.613.3 at t18 ; r : 0.68 ; p<.001 ) and of 2.9% in group b ( 62.113.3 at t0 ; 60.313.7 at t18 ; r : 0.88 ; p<.001 ) . the mean score of domain d ( locomotor function ) was of 48.410 at baseline and 30.214.3 at the end of the study that indicates a percentage change of 37.8% in group a compared to group b where the change was of 11.5% ( 46.88.6 at t0 ; 41.410.05 at t18 ; r : 0.69 ; p<.001 ) . the quality of free time and of the social activities ( domain e ) at the 2 time points they were 36.28.6 and 25.98.6 , indicating a percentage change of 28.4% in group a ( r : 0.50 ; p<.01 ) ; the values of group b were 38.214 at t0 and 34.214.3 at t18 reaching a percentage change of 10.5% only ( r : 0.87 ; p<.001 ) . patients taking teriparatide showed also an improvement of 33.9% in the self - perception of their health ( domain f ) ( 5925 at t0 ; 3916.7 at t18 ; r : 0.84 ; p<.001 ) versus 12.8% improvement of group b ( 63.228.2 at t0 ; 55.124.8 at t18 ; r : 0.90 ; p<.001 ) . in the mood domain ( domain g ) , the qualeffo - test revealed a mean value of 20.67.2 at t0 and 29.39.7 at t18 in group a ( r : 0.71 ; p<.001 ) . these data demonstrated a considerable improvement ( 29.7% ) compared with group b ( 1.8% ; 32.59.8 at t0 ; 33.19.9 at t18 ; r : 0.18 ; p>.1 ) . as a consequence of pain relief , the consumption of nonsteroidal anti - inflammatory drugs also decreased in 29 women of group a , while it did not decrease in group b.", "our results demonstrate that daily injections of rhpth for 18 months are an efficacious and generally well - tolerated therapy in postmenopausal women with severe osteoporosis . more importantly , in our experience rhpth therapy results in decreased fractures and pain symptoms in patients with osteoporosis , and teriparatide is a bone - forming agent and its effect is demonstrated by increases in biochemical markers of bone turnover over the study period : bone formation markers showed more rapid and higher increases than resorption ones , suggesting an early imbalance of bone turnover in favor of formation ; these data are in agreement with previous studies . treatment with teriparatide resulted in a greater increase in bone mineral density ( bmd ) . after 18 months of therapy with rhpth , bone mineral density in the lumbar spine and of the proximal femur increased by 12.4% and 5.2% ; these reported percentage increases are consistent with results of other studies . at month 18 in patients treated with bisphosphonates , instead , lumbar spine increased only by 3.85% and the bone mineral density in the femur increased by 1.99% . the differences in the percentage increases between the 2 groups of patients can be explained with substantial differences between antiresorptive and anabolic therapeutic effects on bone mass and architecture as well as on bone mineral density . moreover , rhpth increases trabecular connectivity , whereas the majority of bone mineral density increases observed with bisphosphonate treatment are a result of increased mineralization of existing bone matrix . teriparatide has been referred to be an efficacious treatment against new fractures , making a significant change in the course of severe osteoporosis , which can lead rapidly not only to varying degrees of disability , the loss of self - sufficiency , and to institutionalization , but also to death [ 3436 ] . in this study , we have confirmed that patients with osteoporosis treated with teriparatide experience improvements in pain symptoms . in addition , use of teriparatide caused a considerable decrease of pain , accompanied by a consequent reduction of the need for nonsteroidal anti - inflammatory drugs by the patients ; this was the main factor that assured an absolute compliance of the patients . in severe osteoporosis vertebral fractures are an important cause of back pain owing to muscle weakness and altered posture , resulting in serious acute and chronic pain that contributes to further disabilities ; in fact , vertebral fractures are the top health condition accounting for length of hospitalization , and added significantly to the length of hospitalization in patients admitted for other medical problems . apart from the physical disabilities had by these patients in fact , patients with vertebral fractures often experience impaired physical functions , limited activities of daily living , limited leisure and recreational activities , and significant emotional distress with loss of self - esteem and depression [ 3436 ] . in this study , we have confirmed that patients with osteoporosis treated with teriparatide experience improvements in pain symptoms . to analyze all these variables and to measure the values of qol at baseline and at the end of the study , we used the qualeffo - test , developed by lips and associates in 1997 . specifically , we used qualeffo-41 , that represents a qol questionnaire which is brief , easy to administer , and with adequate preliminary psychometric properties . we preferred this test to the generic ones ( such as nhp , sip , sf-36 , eq - sd ) because of its specificity in the evaluation of qol in people affected by osteoporosis with vertebral deformities ; in fact , disadvantages of generic instruments are that they usually include irrelevant questions and that these questionnaires are less able to investigate those aspects that mostly influence qol of osteoporotic patients [ 2628 ] . this makes the qualeffo-41 potentially useful during routine clinical practice and research for the treatment and the follow - up of postmenopausal women with severe osteoporosis . by using this test , our study evidences that the use of rhpth influences all considered domains of qol ; in fact , pain , physical and social functions , mood significantly improved in nearly all patients treated with rhpth at the end of the study . thus , the reduction of back pain observed from baseline of active treatment through posttreatment follow - up is consistent with the reduction of new vertebral painful fractures , that means improved qol for this kind of patients . our data clearly demonstrate that rhpth is more effective than bisphosphonates in acting on back pain and all the domains of qol . adverse events ( back pain , headache , nausea , dizziness ) in our patients receiving rhpth were mild and transient , with a percentage lower than in previous studies . the adverse effects attributed to teriparatide did not stop the patients from continuing with the treatment .", "our results demonstrate that rhpth increases bone mineral density considerably , reduces the occurrence of new fractures , and the need for analgesic therapy . therefore , this study evidences that this anabolic agent represents a valid therapeutic option in severe postmenopausal osteoporosis ; moreover , patients after this treatment experience , improvements not only in pain relief , but also in certain aspects of emotional functioning , activities of daily living , and leisure activities , improve qol considerably ." ]

[ "a 22 years old female patient was admitted to our outpatient clinic with a complaint of dyspnea for the previous three years . a right bundle branch block was detected on her electrocardiogram . in the transthorasic echocardiography ( tte ) , a 22 mm secundum type atrial septal defect ( asd ) , right heart dilatation and pulmonary arterial hypertension ( pap 45 mmhg ) were detected . transesophageal echocardiography ( tee ) showed that the defect was 25 mm , the superior rim was 16 mm and the aortic rim was 8 mm in size . the defect was closed through a right femoral route with a 30 mm asd occluder after balloon sizing with tte . in the cineangiography and tte early after the procedure , the device was observed to be in the correct position ( fig . the tte revealed that the device was not in the defect and it had embolized to the pulmonary artery . the patient was referred to the cardiovascular surgery unit and underwent surgery promptly . under general anaesthesia the pulmonary artery was incised along its vertical axis and the occluder device was removed ( fig . the right atrium was opened and the defect was then closed with a pericardial patch .", "secundum asd is the most common type , which accounts for 50% to 70% of all asds and located in the fossa ovalis . sinus venosus type asd is located at the upper portion of the interatrial septum where the vena cava superior opens . a shunt between atria leads to chronic right ventricular volume overload , which in turn causes lower filling rates of left ventricle . surgical or percutaneous closure in asymptomatic patients is indicated in the case of right ventricular volume overload and if the pulmonary to systemic flow ratio increases beyond 1.5 . in adult patients , the defect should be repaired as soon as possible after it is detected because patients who undergo repair after 25 years of age have a shorter life span than a control population . the most important factor for success in percutaneous closure is the correct patient selection . in patients with secundum asd , percutaneous closure can be performed safely with careful evaluation of anatomical factors like defect size and sufficiency of the rims . in a previous report , it was shown that atrial defects up to 43 mm in diameter can be closed percutaneously . a sufficient anterior rim is not necessary to bring the device into a stable position . conversely , deploying the device in patients with deficient cranial rims can be difficult and may lead to an unstable position of the device and increased risk of device embolization . the most common type of complications in percutaneous closure is device embolization , with a rate of 0.5% to 1 % . in a study with 450 patients , seven cases of device embolization into pulmonary artery in the first 12 hours one hour after intervention we detected device embolization into the pulmonary artery after performing echocardiography since the patient had dyspnea . after that , emergency surgery was performed within one hour with a median sternotomy and under cardiopulmonary bypass . , snares can be used to take out the device , but most of the time , surgical extraction of the device and asd patch closure is needed . percutaneous asd closure is a widely used and has been performed successfully throughout the world in recent years . however , it should be kept in mind that improper patient and device selection may result in deadly complications like device embolization , cardiac perforation and tamponade ." ]

[ "extracellular vesicles ( evs ) are a heterogeneous group of vesicles that can be subdivided based on their size , biogenesis , and molecular composition . using the biogenesis as a classification tool , evs can be divided into three major groups , namely , exosomes , microvesicles ( mvs ) , and apoptotic bodies [ 13 ] . even though the molecular composition of these three subsets of evs is different , several markers overlap . so far , identification of a specific marker that with certainty can distinguish or identify the particular ev subset still awaits . it can be expected that the different ev subsets may cover different biological roles , but the function of evs has also been described to depend both on the cellular source and on the recipient tissue / cell . nevertheless , it is now recognized that evs are involved in numerous physiological processes , including intercellular communication and delivery of proteins , lipids , and genetic material to recipient cells [ 2 , 3 , 57 ] . in addition , evs have been associated with the development and progression of different pathological conditions , including cancer and infectious diseases [ 815 ] . the immunological effects of evs comprise a broad range of mechanisms , including immune activation , immune suppression , and modulation of immune surveillance . cells from both the innate and the adaptive immune system have been shown to release evs , such as t and b cells , dendritic cells ( dcs ) , macrophages , mast cells , and natural killer ( nk ) cells [ 1624 ] . the effect of evs is directly related to their molecular composition and several studies have ascribed an immunostimulatory effect of evs to the presence of a very specific molecular content [ 20 , 23 , 2531 ] ; for instance , cd56-positive and perforin - containing evs from nk cells can mediate ev - induced cytotoxicity . several immunosuppressive effects of evs have also been reported [ 21 , 32 , 33 ] ; for instance , fas ligand ( fas - l ) evs released from regulatory t cells are able to inhibit dc - induced cytotoxic t - lymphocyte ( ctl ) responses . furthermore , inhibitory roles of evs derived from immature dcs have been observed in relation to transplant tolerance [ 3436 ] . thus , identification of a specific molecular signature of evs released by immune cells can provide knowledge that can lead to the use of evs in a therapeutic setting . numerous studies have investigated the effects of evs released from different leukocytes , leading to an incipient understanding of the physiological functions of these evs . nevertheless , several basic questions concerning specific characteristics , like the protein composition of the different types of leukocyte - derived evs , remain unclear . the present study investigated the expression of selected immunological lineage - specific markers and selected vesicle - related markers on five major leukocyte subpopulations , namely , cd4 t cells , cd8 t cells , nk cells , b cells , and monocytes . the expression was determined for leukocytes present in freshly isolated whole blood and on cultured isolated leukocyte subpopulations and compared to the presentation of these markers on the corresponding leukocyte - derived evs . the ev array , used for phenotyping of evs , is optimized for detection of small evs with a size below 150 nm that present cd9 , cd63 , and/or cd81 , such as exosomes and exosome - like vesicles . however , as these markers may be present on several types of evs and as the intracellular origin of the characterized evs was not determined , the ev subset investigated in the current study was denoted by small evs ( sevs ) .", "blood samples were obtained from ten healthy volunteers at the department of clinical immunology , aalborg university hospital . from each donor two blood samples were collected , one tube containing edta ( k3edta , vacuette , greiner bio - one , austria ) for immediate analysis of noncultured leukocytes and one tube containing cpda ( vacuette , greiner bio - one , austria ) for the vesicle analysis ( plasma ) . plasma was isolated by centrifugation at 1800 g for 6 min at room temperature ( rt ) , after which the plasma supernatant was aliquoted and stored at 40c until analysis . buffy coats were obtained from three healthy donors at the department of clinical immunology , aalborg university hospital , and used for isolation of peripheral blood mononuclear cells ( pbmcs ) . buffy coats were diluted ( 1 : 4 ) in sterile pbs ( spbs ) and pbmcs were isolated by density gradient centrifugation using lymphoprep ( axis - shield , oslo , norway ) . pbmcs were subsequently washed twice in growth medium ( rpmi1640 ( gibco , life technologies , carlsbad , ca , usa ) , 10% heat - inactivated fetal calf serum ( fsc ) ( gibco ) , 100 u / ml penicillin , and 10 g / ml streptomycin ( amplicon , odense , denmark ) ) and counted in trypan blue and resuspended in isolation buffer ( ca- and mg - free pbs , 2 mm edta , and 0.1% bovine serum albumin ( bsa ) ) . magnetic dynabeads were used for isolation of human cd4 and cd8 t cells according to the manufacturer 's instructions ( dynabeads cd4 positive isolation kit and dynabeads cd8 positive isolation kit , life technologies ) . briefly , 1 10 cells / ml were mixed with washed beads and incubated for 20 min at 4c with gentle rotation . the cell suspension was subsequently placed in a magnet for 3 - 4 min . the supernatant was removed and the bead - bound cells were incubated with detachabeads for 45 min at rt with gentle rotation . the cell suspension was placed in a magnet for 3 - 4 min and the supernatant containing the detached cells was collected . the detached cells were washed once in growth medium and adjusted to 3 10 cells / ml . from the cd4 depleted pbmcs , b cells were isolated using the dynabeads untouched human b cells kit ( life technologies ) according to the manufacturer 's instructions . from the cd8 depleted pbmcs , monocytes were isolated using the dynabeads untouched human monocytes kit ( life technologies ) according to the manufacturer 's instructions . human nk cells were isolated from pbmcs by negative selection according to the manufacturer 's instructions ( dynabeads untouched human nk cells kit , life technologies ) . briefly , 1 10 cells / ml were mixed with the antibody cocktail and incubated for 20 min at 4c followed by washing and incubation with dynabeads for 15 min at 4c while rotating . the cell suspension was subsequently placed in a magnet for 3 - 4 min . the supernatant , containing the cells of interest , was removed and centrifuged at 500 g , for 5 min at rt . the pellet was washed once in growth medium and adjusted to 3 10 cells / ml . for each isolation , the purity of the cells was determined by flow cytometry . isolated leukocytes were adjusted to 3 10 cells / ml and cultured in either 12-well ( 3 10 cells / well , 1.5 ml / well ) or 24-well plates ( 1.5 10 cells / well , 1 ml / well ) ( nunc , thermo scientific , carlsbad , ca , usa ) for 4448 hours at 37c and 5% co2 . following incubation , the plates were centrifuged at 600 g for 10 min at rt and the supernatants containing the cell - derived evs were harvested from the plates . complete protease inhibitor , edta - free ( roche , de , usa ) , was added to the ev - rich supernatants , which were subsequently upconcentrated using amicon ultra 100k spin columns according to the manufacturer 's instructions . briefly , pbs was added to the harvested supernatants ( total volume of 5 ml ) and the supernatants were subsequently centrifuged at 600 g for 7 min at rt . the supernatants were transferred to 50 ml spin columns and centrifuged at 3200 g for 10 min at rt . prior to adding the supernatants , the spin columns were washed once in 5 ml pbs ( 3200 g , 10 min , rt ) . following the first centrifugation of the supernatant , 5 ml of pbs was added to the retention volume and centrifuged again . the retention volume , containing the upconcentrated supernatants , was harvested and the filter unit was washed in 50100 l pbs . due to varying cell counts between the subpopulations and across the experiments , every supernatant was adjusted to a volume corresponding to 5.5 10 cells / ml . no further purification of the evs was performed and the upconcentrated supernatants were aliquoted and stored at 40c until analysis by the ev array . the cells were harvested in pbs , washed , and resuspended in pbs with 0.5% bsa and 0.09% nan3 , followed by a subsequent surface marker staining . for the ev array , the following antibodies were used for capturing : cd11a ( hi111 ) from ab biotech ( san diego , ca , usa ) ; flotillin-1 and tsg101 ( 5b7 ) from abcam ( cambridge , ma , usa ) ; cd3 ( hit3a ) , cd14 ( m5e2 ) , cd16 ( 3g8 ) , cd28 ( l293 ) , cd49d ( l25 ) , and cd56 ( 3g8 ) from bd biosciences ( mountain view , ca , usa ) ; cd41 ( hip8 ) , cd63 ( mem-259 ) , hla - abc ( w6/32 ) , and alix ( 3a9 ) from biolegend ( san diego , ca , usa ) ; icam-1 ( r6.5 ) from ebiosciences ( san diego , ca , usa ) ; cd9 , cd42a , cd81 , and ctla-4 ( anc152.2/8h5 ) from lifespan biosciences ( seattle , wa , usa ) ; annexin v ( af399 ) , cd4 ( 34930 ) , cd8 ( 37006 ) , cd19 ( 4g7 - 2e3 ) , cd37 ( 424925 ) , cd45 ( 2d1 ) , cd80 ( 37711 ) , cd82 ( 423524 ) , cd83 ( hb15e ) , mic a / b ( 159207 ) , tnf ri , and tnf rii from r&d systems ( minneapolis , mn , usa ) ; tlr3 ( 3.7 ) from santa cruz biotechnologies ( dallas , tx , usa ) ; hla - dr / dp / dq ( hb-145 ) from loke diagnostics ( aarhus , denmark ) ; fas ligand ( 10f2 ) from serotec ( oxford , uk ) ; and pd - l1 from sino biological ( beijing , china ) . the following antibodies were used for detection ( biotinylated ) : cd9 , cd63 , and cd81 from lifespan biosciences . for flow cytometry the following antibodies were used : cd45 apc ( t29/33 ) , cd45 fitc ( t29/33 ) , and cd3 fitc ( ucht1 ) from dakocytomation ( glostrup , denmark ) ; cd3 apc ( ucht1 ) , cd4 fitc ( rpa - t4 ) , cd4 apc - h7 ( sk3 ) , cd8 apc - h7 ( sk1 ) , cd9 percp - cy5.5 ( m - l13 ) , cd14 fitc ( m5e2 ) , cd16 fitc ( 3g8 ) , cd16 pe - cy7 ( 3g8 ) , cd19 apc ( hib19 ) , cd56 apc ( b159 ) , and cd56 pe - cy7 ( b159 ) from bd biosciences ( mountain view , ca , usa ) ; cd63 pe - cy7 ( h5c6 ) from ebiosciences ; and cd81 pe from lifespan biosciences . in addition , isotype- and fluorophore - matched control antibodies were included . for analysis of noncultured leukocytes , 100 l of freshly drawn whole blood was labeled with fluorescence - conjugated antibodies for 30 min at rt , red blood cells were lysed , and the remaining leukocytes were washed and resuspended in bd facsflow sheath fluid ( bd biosciences ) with 1% paraformaldehyde . the cultured leukocytes were labeled with fluorescence - conjugated antibodies for 30 min at rt . the leukocytes were washed twice in pbs with 0.5% bsa and 0.09% nan3 and resuspended in bd facsflow sheath fluid ( bd biosciences ) with 1% paraformaldehyde . cells were analyzed on a facscanto ii flow cytometer ( bd biosciences ) using the bd facsdiva software version 6.1.3 ( bd biosciences ) . the acquired data files were analyzed by flowjo vx.0.7 ( treestar , ashland , usa ) , first by adding a leukocyte - gate based on morphologic characteristics ( fsc / ssc ) and subsequently by the use of the lineage - specific markers ; cd3 and cd4 for cd4 t cells ; cd3 and cd8 for cd8 t cells ; cd16 and cd56 for nk cells ; cd19 for b cells ; and cd14 for monocytes . for the production of the protein microarray , microarray printing was performed on a spotbot extreme protein edition microarray printer with a 946mp4 pin ( arrayit , sunnyvale , ca , usa ) . epoxy coated slides ( 75.6 mm 25.0 mm ; schott nexterion , jena , germany ) were used as microarray basis . the antibodies listed above were diluted in pbs containing 5% glycerol and printed at a concentration of 180200 g / ml . as a positive control , 100 g / ml of biotinylated human igg in pbs with 5% glycerol was printed . as a negative control , for catching , visualization , and data analysis , the procedures were performed as previously described . in short , the slides were incubated with 100 l plasma , prediluted 1 : 10 , or 100 l upconcentrated cell culture supernatant , prediluted 1 : 2 in wash buffer ( pbs with 0.05% tween-20 ) . after overnight sample incubation and a subsequent wash , the slides were incubated with a cocktail of biotinylated detection antibodies ( anti - human cd9 , cd63 , and cd81 ) , diluted 1 : 1500 in wash buffer . after incubation , cy5-labeled streptavidin ( invitrogen , frederick , md , usa ) diluted 1 : 1500 was used for detection . prior to scanning , the slides were washed and dried using a microarray high - speed centrifuge ( arrayit ) . briefly , the intensity of the antibody signal was calculated by subtracting the mean of the background ( without sample / blank ) from the mean of the triplicate antibody spots . this signal was then divided by the signal from the mean of the triplicate negative spots ( without capture antibody , with sample ) .", "leukocytes can be subdivided based on morphological characteristics upon staining into polymorphonuclear cells ( the granulocytes ) and mononuclear cells ( the lymphocytes and the monocytes ) . the present study investigated the sevs produced by the different subpopulations of mononuclear cells found in peripheral blood and compared the vesicular phenotype to the cellular phenotype . in addition , sevs present in plasma were phenotyped for the same panel of markers . the purity of the different subpopulations throughout the three individual experiments was 9799.5% for the cd4 and the cd8 t cells , 8295% for the b cells , 6894% for the monocytes , and 8597% for the nk cells . the isolated subpopulations of leukocytes were cultured for 4448 hours and the supernatants , containing the leukocyte - produced evs , were investigated for the presence of a panel of selected immunological and ev - related markers using the ev array ( table 1 ) . it was investigated whether sevs from isolated leukocyte subpopulations presented the lineage - specific markers that define the parent cells . the results demonstrated that not all lineage - specific markers could be observed on the corresponding sev subpopulations ( figure 1(a ) ) . for instance , cd19 , which is a well - defined lineage marker for b cells , could not be detected on sevs in supernatant from cultured b cells . likewise , cd14 , cd16 , cd56 , and cd3 could not be detected on sevs from cultured monocytes , nk cells , and t cells , respectively ( figure 1(a ) ) . in contrast , cd4 and cd8 , which are lineage markers for two different populations of t cells , were detected on sevs from the supernatants of these two t cell subpopulations . in addition , sevs from cultured pbmcs presented cd8 , but none of the other markers . aside from the parental lineage - specific markers , likewise , cd45 and cd16 could be detected in one of the experiments with sevs from cd4 t cells . a panel of ev - related markers was assayed on the different subsets of the leukocyte - derived evs ( figure 1(b ) ) . cd9 was detected on all sev subsets , though at very low levels on sevs from t cells and nk cells . similarly , cd81 was detected on all sevs but at very low levels on sevs from b cells and nk cells . cd82 was detected at high levels on sevs from monocytes and pbmcs and at very low levels on sevs from b cells and t cells but was absent on sevs from nk cells . furthermore , alix was detected at very low levels on sevs from the cultured cd8 t cells . in contrast , annexin v , tsg101 , and flotillin-1 could not be detected on the leukocyte - derived sevs . furthermore , the presence of more general immunological markers was investigated on the different sev populations . a total of 18 markers were chosen based on their relevance for the function of leukocytes ( table 1 ) . the majority of markers could not be detected on the sev subpopulations using the ev array ( figure 1(c ) ) . however , cd49d was found on sevs from all the different leukocyte subpopulations and cd41 was detected on sevs from all subpopulations besides sevs from nk cells . additionally , sevs from cultured cd4 and cd8 t cells presented several of the immunological markers , including cd11a , tlr3 , cd28 , ctla-4 , and the fas - l . the data presented in the heat maps were from three individual experiments and illustrated a degree of variation between the individuals . the presence of a natural variation in the phenotype of sevs between healthy individuals was also observed upon phenotyping of the sevs present in plasma from 10 healthy individuals ( figure 2 ) . plasma sevs presented several of the markers that were detected on the leukocyte - derived sevs . in addition , plasma sevs presented some lineage - specific markers , including cd3 , cd14 , and cd19 that were not detected on sevs from cultured leukocytes . furthermore , tnf ri , tlr3 , cd42a , cd80 , and cd83 as well as annexin v , flotillin-1 , and alix were detected on the majority of the plasma sevs . the cellular expression pattern of cd9 , cd63 , and cd81 was determined for all the leukocyte subpopulations by flow cytometry ( figure 3 ) . the expression of these vesicle - related markers was investigated for leukocytes present in freshly drawn whole blood ( n = 10 ) as well as for isolated subpopulations of leukocytes following two days of culture ( n = 3 ) . figures 3(a ) and 3(b ) demonstrate the expression levels in histograms from two representative donors . none of the leukocyte subsets from whole blood presented cd9 on their surface ( figure 3(a ) ) . in contrast , both cd63 and cd81 were expressed on all leukocytes , but the expression pattern varied between the different subsets . the lymphocytes , including the cd4 t cells , the cd8 t cells , the b cells , and the nk cells , expressed cd81 at high levels , while they all expressed cd63 at low - to - intermediate levels . the opposite situation was observed for the monocytes that presented high levels of cd63 on their surface , but only low - to - intermediate levels of cd81 . regarding the cultured leukocytes , each subpopulation was isolated from three different donors and cultured for 4448 hours ( figure 3(b ) ) . the results showed that , in contrast to the freshly isolated leukocytes , the cultured leukocytes presented cd9 on their surface . for the lymphocyte populations , the expression of cd9 was low , while the monocyte population expressed intermediate levels of cd9 . all cultured lymphocyte subpopulations expressed cd63 and cd81 at low - to - intermediate levels , while the monocytes expressed high levels of both markers . even though the levels varied , the expression patterns of cd63 and cd81 on the cultured leukocyte subpopulations were similar to the patterns observed on leukocytes present in freshly isolated blood . based on the obtained minimum and maximum mfi values , it was clear that the expression level of the three markers varied between the individuals illustrating a natural variation . in order to investigate the phenotypic homogeneity between the sevs and the parent cells , the cellular expression patterns of selected lineage - specific and vesicle - related markers were compared to the vesicular presentation of these markers ( figure 4 ) . in relation to the selected lineage - specific markers , cd3 , cd14 , cd16 , and cd19 could not be detected on sevs from cultured t cells , monocytes , nk cells , and b cells , respectively , indicating that not all cell surface molecules are transferred to the sev surface . for cd9 , cd63 , and cd81 , the majority of the subpopulations presented vesicular levels that overall correlated with the cellular expression . exceptions were observed with cd63 , in which case the cellular expression on monocytes was high , but the vesicular presentation was low . similarly , the cellular expression of cd63 was intermediate or low for both nk cells and b cells , but no cd63 could be detected on the corresponding sevs .", "several studies have reported that evs are released from different leukocyte subsets ; however , a thorough simultaneous investigation of the major leukocyte subsets with focus on lineage - specific markers has not yet been described . in the current study the phenotype of five different subsets of leukocyte - derived sevs was determined and related to both the phenotype of sevs present in plasma and the cellular phenotype of the leukocyte subpopulations . the ev array , used for the investigation of the phenotype of sevs , is a protein microarray technique that provides the opportunity to detect and characterize sevs for up to 60 markers in a high - throughput manner and with high sensitivity [ 37 , 38 ] . one major advantage of the ev array is the ability to phenotype sevs from unpurified material without a requirement for preanalytical purification . isolation of specific ev subsets is in many cases highly warranted , but for phenotyping of evs using the ev array , crude plasma or cell - free supernatants are applicable . in order to investigate whether lineage - specific proteins present on leukocytes could be detected on the corresponding sevs , leukocytes were phenotyped for selected lineage - specific markers using flow cytometry , while the sevs were phenotyped using the ev array . the results showed that none of the included lineage - specific markers could be detected on the sevs released from b cells , nk cells , and monocytes in monocultures ( cd19 , cd56 , and cd14 , resp . ) . in contrast , sevs from monocultures of cd4 and cd8 t cells did present cd4 and cd45 or cd8 and cd45 , respectively . none of the t cell - derived sevs presented cd3 . a study by kornek et al . investigated evs from jurkat t cells activated with phytohemagglutinin ( pha ) and observed that the fraction of large evs ( sedimented at 10.000 g ) only presented low levels of cd3 , while the fraction of sevs ( sedimented at 100.000 g ) presented high levels of cd3 . regarding cd19 , a study by admyre and coworkers from 2007 showed that evs from a b cell line presented cd19 , which differs from the observations obtained in the study at hand . similarly , another study has described that evs from resting nk cells present typical nk cell markers like cd56 and fas - l , but not cd16 . in terms of cd14 , a study by aharon et al . observed this marker on large evs ( mvs ) released from a monocytic cell line . the discrepancy between some of the results may be due to investigations of different preparations of evs and/or may be explained by the fact that the ev - producing cells were different , for example , cells isolated from peripheral blood versus cell lines . in addition , differences in the activation state of the ev - producing cells are of importance for the outcome . upon stimulation , cells change their phenotype and this phenotypic change depends on the specific stimulus given to the cells [ 28 , 42 ] . in the present study , leukocyte subpopulations were isolated and cultured without any activation signal , while several of the other studies investigated the phenotype of the evs released upon adding a stimulus to the cells . the presented results obtained with sevs released from cultured pbmcs support this phenomenon as these sevs apparently displayed fewer markers than sevs from monocultures . overall , these data indicate that the phenotype of the vesicle subset is context - dependent . however , during the current conditions , several of the leukocyte - derived sevs did not present the lineage - specific markers found on the parent cell type ( figure 1(a ) ) . variations in the molecular content between cells and evs were also observed in a study by hunter et al . that reported significant differences in the presence of mirnas between plasma evs and pbmcs . for comparison , the presentation of lineage - specific markers on plasma sevs was determined . in contrast to the leukocyte - derived sevs , plasma sevs presented several lineage - specific markers , including cd3 , cd14 , and cd19 . compared to the evs present in cell supernatants , evs in plasma are a mixture of evs produced by many different cell types . thus , plasma can act as a liquid biopsy and will present a very heterogeneous ev phenotype that provides information about numerous cellular processes . the detection of cd3 , cd14 , and cd19 on plasma sevs , but not on sevs from cultured leukocyte subpopulations , emphasizes that the biological context has a great impact on the phenotype of the released evs . interestingly , some of the sev subsets presented other markers , for example , sevs from cd8 t cells presenting cd16 . several studies have described the expression of cd16 on a small portion of different types of t cells and even shown a functional role of cd16 on t cells [ 44 , 45 ] . thus , the observations of cd16 on sevs released from cultured t cells combined with the fact that functional molecules , such as perforin and lytic granules , can be stored inside evs may indicate a specific functionality of these evs , for example , surrogates or extensions of the effector cell in antibody - dependent , cell - mediated cytotoxicity . apart from the selected lineage - specific markers , the sevs were phenotyped for the presence of 26 different immunological or vesicle - related markers . regarding the leukocyte - derived sevs , cd49d was the only marker detected on all sev subsets ( figure 1(c ) ) . cd49d is an 4 integrin that is expressed as a heterodimer on t , b , and nk cells and monocytes as well as on other immune cells . together with cd29 , cd49d forms the very late antigen-4 ( vla-4 ) that is involved in leukocyte trafficking , adhesion , and extravasation [ 46 , 47 ] . so far , two studies have reported on the presence of cd49d / vla-4 on evs from b cells [ 48 , 49 ] , and these results can be confirmed by the present study . in terms of plasma sevs , surprisingly , cd41 was observed on sevs from t cells , b cells , monocytes , and pbmcs as well as on plasma sevs from half of the healthy donors ( figure 1(c ) ) . however , according to the protein atlas , cd41 is expressed by pbmcs and even though the function is unclear , the presence of cd41 on sevs released from these cells , either in monocultures or as pbmcs , is possible . in addition , sevs from cultured t cells presented an array of other immunological markers , ranging from more general markers , like cd45 , to specific markers like cd28 , and the tlr3 . moreover , sevs from cd8 t cells presented ctla-4 and the fas - l . even though the mechanisms are quite different , both of these molecules play a role in downregulation of an immune response , either by transmitting an inhibitory signal in activated t cells or by inducing activation - induced cell death , respectively . the presence of such regulatory molecules on evs suggests that t cell - derived evs can be involved in immune regulation . the presence of fas - l on evs from t cells has also been observed in other studies [ 5254 ] , but to the best of our knowledge , studies observing ctla-4 on evs from leukocytes have not previously been published . upon evaluating the presence of markers on evs , it is important to consider the natural variation in the molecular composition of the ev pool that exists between healthy individuals as visualized by the ten plasma samples . thus , the present results are a snapshot providing insight about the current vesicular presentation of selected markers . the sevs investigated in this study were identified by the presence of cd9 , cd63 , and/or cd81 . thus , in order to investigate the similarity of the leukocytes and the corresponding sevs , the cellular expression patterns of cd9 , cd63 , and cd81 were determined . the expression pattern was determined for both leukocytes present in whole blood and cultured leukocyte subpopulations . the results demonstrated a lack of cd9 on the surface of leukocytes present in freshly drawn whole blood ( figure 3(a ) ) . in contrast , cd9 was present on every leukocyte subpopulation following two days of culture . in accordance with the present results , a recently published study also observed cd9 on the surface of isolated populations of cd3 , cd14 , and cd19 cells . the expression patterns of cd63 and cd81 were quite similar between the two cell preparations but with minor differences in the expressions levels . overall , these findings are in agreement with previously described results [ 5661 ] . when looking at both the cellular and the vesicular presentation of these markers , it is clear that , for the majority of the cultured subpopulations , the presentation of these markers was comparable . however , for the nk cells , the b cells , and the monocytes , the cellular expression of cd63 was very different from the presentation observed on sevs . a comparison between the presentation of cd9 , cd63 , and cd81 on whole blood leukocytes and plasma evs is a more complex procedure that needs to take into account that plasma evs are a very heterogeneous group of evs that emanate from multiple cell types . the tetraspanin signals observed on the plasma sevs represent all tetraspanin - positive sevs irrespective of their origin . thus , the presentation of tetraspanins on plasma sevs can not be expected to correlate with the expression of tetraspanin on leukocytes . nevertheless , it is clear that the cd63 signals in plasma generally were low , while the cellular expression of cd63 for several of the leukocyte subpopulations is medium to high , indicating that the presentation of cd63 is different from sevs to cells . overall , the vesicular signal intensities for cd63 were much lower than the intensities observed for cd9 and cd81 , suggesting that cd63 might be a poor marker for sevs in general , which has also been observed in other studies [ 38 , 6264 ] . the results underline the importance of detecting evs with a cocktail of antibodies against tetraspanins , as detection with a single marker may overlook some subsets of evs .", "surface molecules on evs are responsible for the biodistribution and the ligation to target cells . thus , the protein composition is related to the functionality of evs , why phenotyping of evs can be used to gain knowledge about the functionality . in summary , the presented data regarding the lineage - specific markers and the tetraspanins support the accumulating observations suggesting that the transfer of molecular cargo into evs is tightly controlled . a tightly regulated sampling of molecules to evs would match with the fact that evs play an important role as systemic regulators , traveling through tissues providing key intercellular communication as well as transfer of biologically active components ." ]

[ "in march 2014 , an unprecedented \n outbreak of ebola virus disease \n ( evd ) began in western africa that as of july 2015 is ongoing and \n has claimed more than 11000 lives . the \n current outbreak is caused by viruses belonging to the species of \n the zaire ebolavirus , a member of the filoviridae family . filoviridae are enveloped , filamentous viruses with lengths that \n may reach > 1000 nm . ebola virus \n can be excreted in bodily fluids , including vomit , stool , blood , saliva , \n semen , and breast milk . ebola virus loads of up to 10 genome \n copies ml have been reported in blood , 10 genome copies ml in stool , and 10 genome copies ml in urine ; however , the conversion between genome copies \n and infectious units is unknown . once infected , individuals may produce up to 9 l of liquid waste \n per day , primarily watery diarrhea . ebola virus is considered a potential bioterrorism \n agent . in response to the evd epidemic , both \n the world health organization \n ( who ) and the u.s . centers for disease control and prevention advised \n direct disposal of ebola - contaminated liquid waste into sewage systems \n ( wastewater collection and treatment systems ) and latrines without \n disinfection . initial recommendations \n were made on the basis of an expected limited persistence of ebola \n virus in the environment , as ebola virus is an enveloped virus , and \n a lack of strong evidence for a waterborne transmission route . as \n stated by a who guidance document , ebola virus is likely to \n inactivate significantly faster in the environment than enteric viruses \n with known waterborne transmission ( e.g. , norovirus , hepatitis a virus ) . however , as has been noted in a recent review , \n the persistence of enveloped viruses in the water environment varies \n by > 2 orders of magnitude . recommendations \n for ebola virus - contaminated wastewater disposal were met with debate \n ( e.g. , refs ( 1618 ) ) because of uncertainty \n about ebola virus persistence within wastewater matrices and the lack \n of a risk - based analysis for waste handling . wastewater handling recommendations \n have since been revised to recognize uncertainty in this area and \n to recommend disinfection of latrines and holding of wastewater prior \n to handling to allow ebola virus inactivation . additionally , \n some facilities have opted to provide additional disinfection prior \n to disposal of liquid waste into sewer systems . recent research found both ethanol and hypochlorite to \n be effective disinfectants for ebola virus dried on surfaces ; however , the disinfection kinetics of ebola \n virus within liquid matrices remains unknown . various wastewater disinfection \n approaches have been recently suggested for pathogen control in an \n outbreak setting . currently , no \n data on ebola virus persistence in wastewater exist , \n hindering risk estimation and examination of potential environmental \n exposure routes . the necessity of evaluating ebola virus persistence \n in wastewater matrices has previously been highlighted , as wastewater \n in ebola virus outbreak settings may be temporarily held in open containers \n or disposed of in open sewers . historically , \n the transmission of ebola virus via environmental routes ( droplets , \n aerosols , or fomites ) has been thought to be unlikely due to epidemiological \n evidence and environmental sampling . the \n primary ebola virus transmission route is via direct contact with \n bodily fluids . transmission has previously \n occurred without known direct contact with infected individuals , providing supporting evidence that ebola virus \n transmission may be possible via large droplets . the potential for transmission of ebola virus via wastewater \n is currently unknown . to address uncertainties regarding ebola \n virus persistence in wastewater , \n we have conducted an initial evaluation of ebola virus persistence \n within wastewater to address uncertainty and inform ongoing risk assessments . \n a current ebola virus outbreak strain from guinea ( makona - wpgc07 ) \n was spiked to two end concentrations ( 10 and 10 tcid50 ml ) into a domestic wastewater \n ( untreated sewage ) sample . the ebola virus - containing wastewater was \n sampled for 8 days , and the viability of ebola virus was determined \n in these samples . study results are presented , and study limitations \n and implications are discussed , as well as recommendations for an \n ongoing research agenda .", "untreated wastewater was \n collected from an anonymous regional wastewater \n treatment facility in western pennsylvania that receives wastewater \n from seven communities ( combined population of approximately 60000 ) . \n the total raw wastewater flow to the treatment facility is < 10 \n mgd ( million gallons per day ) . the wastewater \n was frozen at 80 c to minimize compositional changes \n prior to analysis . wastewater characteristics ( table 1 ) were determined at an epa - certified analysis \n facility ( microbac laboratories , marietta , oh ) . the region from which \n the sample was collected uses a combined sewer system that experiences \n significant infiltration , and the determined composition is typical \n for the region . ebola virus cultivation experiments \n were conducted at rocky mountain \n laboratories under bsl4 conditions . wastewater samples were shipped \n to rocky mountain laboratories overnight on ice . upon receipt , samples \n were sterilized with 5 mrad of -irradiation . sterilization \n was performed to limit cell culture death due to wastewater microbial \n activity leading to a false positive . stock virus ( ebola virus guinea \n makona - wpgc07 , 10 tcid50 ml ) was handled as described previously . ebola virus was diluted in wastewater to achieve \n two separate virus titers ( 10 and 10 tcid50 ml ) , and both experiments were completed \n in triplicate . the ebola virus concentration in sewage has not been \n previously measured or estimated ; thus , two separate concentrations \n were utilized to cover possible concentration scenarios . tcid50 is an end point dilution series that is used to determine \n at what dilution 50% of the infected wells produce cell death . an approximation of focus - forming \n units ( ffus ) can be made from a poisson distribution utilizing the \n formula tcid50 0.69 , assuming each ffu is formed \n from a single virus . spiked wastewater was then distributed into three \n labeled vials for each concentration , and samples were taken daily \n for 8 days . tests were conducted at 20 c and 40% relative humidity . \n at each time point , including the time zero measurement , 50 l \n of wastewater from the bulk wastewater vial was added into 450 l \n of dulbecco s modified eagle s medium ( dmem , sigma ) \n supplemented with heat - inactivated fetal bovine serum ( fbs , gibco ) \n to a final concentration of 2% , pen / strep ( gibco ) to a final concentration \n of 50 units / ml penicillin and 50 g / ml streptomycin , and l - glutamine ( gibco ) to a final concentration of 2 mm in an appropriately \n labeled 2 ml screw top vial and frozen at 80 c . negative \n controls were 50 l of nonspiked wastewater in 450 l \n of dmem . to perform the titrations , a 96-well 1.1 ml well dilution \n plate ( axygen , corning , ny ) was prepared . the thawed sample ( 400 l ) \n was placed in the top row of the plate and a 10-fold dilution conducted \n by passing 40 l of sample into 360 l of dmem . next , \n 100 l from each well of the dilution plate was transferred \n to a 96-well cell culture plate seeded with vero cells . the cells \n were incubated with virus dilutions for 1 h ; then the medium was removed \n from the two highest concentrations and rinsed two times with pbs , \n and 200 l of fresh culture medium was added . fresh culture \n medium ( 100 l ) was also added to the remaining wells in the \n plate . the plates were incubated at 37 c for 7 days , inspected \n for the cytopathic effect ( cpe ) , and scored . the natural \n logarithm of c / co tcid50 was plotted and fit with a linear trendline for estimation \n of the inactivation constant ( k ) . a literature review \n was then performed to compare observed inactivation to other environmental \n matrices .", "ebola virus was \n spiked into wastewater at two concentrations and assayed for 8 days \n to determine persistence in a wastewater matrix . the time zero time \n point was measured immediately following addition of ebola virus to \n the wastewater . no viable ebola virus was recovered from samples spiked \n with 10 ebola virus tcid50 ml after the initial time zero sampling . virus \n viabilities from the initial 10 ebola virus tcid50 ml concentration are shown in figure 1 and detailed in table s1 . ebola virus titer was rapidly reduced ( approximately \n 99% ) within the first day of the test , consistent with an inability \n to identify infectious ebola virus from the initial sample with 10 ebola virus tcid50 ml on day \n 1 . persistence of an initial ebola virus concentration of 10 tcid50 ml in domestic wastewater \n ( untreated sewage ) ( a ) including the time zero time point and ( b ) \n excluding the time zero time point to mitigate potential aggregation \n effects . fit inactivation constants ( k ) were determined to be 1.08 when including time \n zero and 0.35 when excluding time zero . error bars are 1 \n standard deviation . there was a rapid decrease \n ( approximately 99% ) in ebola virus titer \n within the first day of the test . in addition to inactivation , viral \n particle aggregation or adsorption to wastewater particles may play \n a role in the apparent rapid viral decrease and enhanced viral persistence . \n in this case first , aggregated \n particles would not be detected as multiple infectious units , resulting \n in an apparent rapid decrease . second , it has been previously recognized \n that aggregation increases viral persistence and resistance to inactivation \n stressors . similarly , viral association with particles \n has been recognized to provide protection from inactivation , including association of viral particles with \n wastewater solids . mechanistically , particle \n association is believed to protect viral particles from inactivation \n by shielding them from environmental stressors and is dependent on \n the organism and particle type . utilizing the current assay , it can not be determined if the initial \n rapid decrease in viral titer was due to viral inactivation or aggregation . \n aggregation would result in an apparent viral titer decrease as each \n viral aggregate would function as an infectious unit in the cell culture \n assay . to address this uncertainty , we plotted two inactivation curves , \n both including ( figure 1a ) and excluding the measured time zero point ( figure 1b ) . a linear trendline , as has been previously \n suggested for viral and ebola virus persistence , showed a lower fit ( r = 0.59 including the time zero time point , and r = 0.67 excluding the time zero time point ) \n than that previously observed for ebola virus in deionized water ( r > 0.91 ) , but a fit better than that previously \n observed for ebola virus in human blood ( r < 0.29 ) . the inactivation constant ( k ) was determined \n to be 1.08 when including the time zero time point and 0.35 \n when excluding the time zero time point . on the basis of the model \n fit , the t90 ( time for 90% inactivation ) \n would be 2.1 days including the time zero time point and 6.6 days \n excluding the time zero time point . the observed ebola virus inactivation \n in wastewater was slower than that observed for deionized water , which \n required 1.8 days for 90% inactivation at 21 c . the observed ebola virus inactivation in wastewater was \n more rapid than that reported for human blood , which required 20 days \n for a 90% inactivation , and results are \n consistent with recent studies that identified viable ebola virus \n to persist in infected macaque blood for > 8 days . in general , ebola virus was found to be less persistent \n in wastewater than model enteric viruses . while the t90 for ebola virus in wastewater was found to be < 1 \n day , the t90 for hepatitis a is greater \n than 17 days and the t90 for enteric adenovirus is 33 days ; however , the t90 for poliovirus \n is 5 days , which is between the observed t90 values including or excluding the time zero \n time point . the results demonstrate a more rapid initial viral titer \n decrease but overall enhanced persistence of ebola virus in wastewater \n compared to the proposed enveloped surrogate bacteriophage phi6 . this \n study has two primary limitations \n that may alter the persistence of ebola virus compared to what may \n be observed in the field . first , the tested wastewater was more dilute \n than would be expected in typical latrine waste . in general , interaction with constituents within the wastewater \n ( e.g. , ammonia ) would be expected to contribute to more rapid inactivation \n of viruses ; however , the true effect \n of these constituents on ebola virus persistence is unknown . second , \n the wastewater was frozen to minimize compositional changes and disinfected \n ( -irradiation ) prior to utilization to limit microbial activity \n resulting in false positive viral cell culture . microbial activity \n within wastewater matrices would be expected to contribute to more \n rapid inactivation of infectious viral particles ; however , the true effect of microbial activity on ebola virus persistence \n is unknown . microbial activity reduces viral persistence through both \n the production of metabolites detrimental to viral persistence and \n direct usage of the viral particles as a nutrient source . additionally , the influence of other environmental \n characteristics ( e.g. , temperature , ph , and mixing ) on ebola virus \n persistence is unknown and may contribute to altered environmental \n behavior . as such , we believe these results to be an upper bound for \n ebola virus persistence in wastewater matrices . subsequently , we caution \n extrapolation of these results without a holistic assessment of all \n factors , including wastewater composition , dilution , and potential \n exposure routes . the results of this \n study suggest a potential \n exposure route to infectious ebola virus via wastewater ; however , \n any assessment of potential exposure routes must consider the effects \n of wastewater composition , dilution of contaminated wastewater , and \n inactivation of ebola virus during treatment and holding . additionally , \n the possibility for ebola virus transmission via wastewater and subsequent \n infection remains unknown . the who updated guidelines in january 2015 \n to recommend holding of latrine waste for 1 week prior to further \n handling or transport . the objective \n of this holding period is to allow ebola virus die - off . on the basis \n of these results , it would be reasonable to approximate a three - log \n ( i.e. , 99.9% ) removal of ebola virus due to this holding period . the \n resulting risk would ultimately depend upon the initial ebola virus \n concentration in wastewater , potential for exposure , and susceptibility \n to infection via wastewater exposure . the wastewater travel times \n for wastewater via a sewer system to a centralized sewage treatment \n works would typically be < 1 day , depending on system dynamics . further assessment is necessary to determine \n ebola inactivation and dilution within this period and potential human \n exposure routes , including workers within the sewer system and ebola \n virus persistence within wastewater sludges . the greatest exposure \n risk would be expected for persons in contact with contaminated wastewater \n prior to significant dilution , treatment , or holding . these \n results demonstrate a persistence of ebola virus in wastewater greater \n than what has previously been suggested and the potential of a wastewater \n exposure route to infectious ebola virus . while ebola virus was found \n to be generally less persistent than enteric viruses in wastewater , \n the identified survival period suggests value in a nuanced evaluation \n of wastewater exposure risks during an epidemic response . specifically , \n these findings highlight the value of a precautionary approach to \n wastewater handling within an outbreak scenario , in response to both \n ebola virus and other emerging viruses ." ]

[ "pulmonary nodules and lung tumours move substantially during respiration with significant differences according to the tumour localization . respiratory tumour motion is a big challenge for radiotherapy , especially for high precision techniques . an additional target dose escalation which is deemed necessary for a curative approach of lung cancer is limited as so far as tumour motion is not sufficiently quantified and integrated into modern treatment planning . thus , the risk of side effects within the surrounding normal tissue is unacceptably high . radiation pneumonitis and the development of lung fibrosis are the physiological reactions of the lung which are not acceptable in severely ill patients . thus modern techniques of adaptive radiotherapy will greatly benefit from devices which take lung and tumour motion into account in radiotherapy planning . the final objective is an additional increase in the radiation dose within the tumour volume together with maximum protection of the adjacent normal lung parenchyma . a basic requirement is the accurate measurement and quantification of the mobility of pulmonary tumours . but also for follow - up examinations of patients with pulmonary tumours , a confident registration of the respiratory level is important in order to achieve easy identification and valid measurements . integration of the knowledge about lung and lung tumour motion is essential for planning of high precision radiotherapy . four - dimensional imaging using computed tomography ( 4d - ct ) is under development for optimization of radiotherapy by integration of motion [ 24 ] . these developments also include online imaging with a linac - integrated cone beam ct . the particular advantages of magnetic resonance imaging ( mri ) are the high soft - tissue contrast , differentiation of tumour and atelectasis , the possibility to choose the optimal plane for motion quantification and the possibility to integrate further dynamic parameters , e.g. lung perfusion or o 2 \n quantification , into one imaging session . the temporal resolution is already reasonably high for monitoring lung tumour motion in real - time . \n", "novel mri techniques allow for non - invasive acquisition of the motion of lung and pulmonary tumours during the respiratory cycle with high spatial and temporal resolution [ 8 , 9 ] . continuous improvements and new developments in mr scanner technology , such as high performance gradient systems and pulse sequences , have made this possible and address the inherent challenges of mri of the chest , such as low proton density with an unfavourable signal to noise ratio and short t2 relaxation times with \n substantial susceptibility artefacts . parallel imaging techniques make use of the different spatial sensitivities for the receiver coils in order to employ them for the simultaneous acquisition of image data , significantly reduce the phase encoding steps and achieve a marked improvement in spatial and temporal resolution . thus , important requirements were met to measure the respiratory movement of the lung quantitatively . fast - low - angle - shot ( flash ) sequences with a temporal resolution of one image per second demonstrate chest wall motion per se and postoperative changes of respiratory motion , i.e. changes of the cranio - caudal distance before and after lung volume reduction surgery . modified true - fast - imaging - with - steady - state - precession ( truefisp ) sequences , widely used in cardiac mri , were successfully applied in volunteers ( fig . 1 ) . by adding a mathematical model , a continuous quantitative measurement of lung volume was achieved , which again showed a high correlation with spirometry . \n\n", "after successful tests in volunteers , dynamic mri was transferred to patients with solitary pulmonary tumours in order to visualise lung tumour motion by mri in two dimensions ( fig . quantification was performed by measuring the cranio - caudal distance and the diaphragmatic length over time . again , the results showed good correlations with the forced expiratory capacity in 1 s . the diaphragmatic length was particularly useful in the assessment of respiratory mechanics and the respective effects of pulmonary tumours . in such studies the truefisp sequence was superior to a flash sequence due to its higher t2 signal . the respiratory motion of patients with a pulmonary tumour showed a significant difference between the tumour bearing and the non - tumour bearing hemithorax . in addition , the location of the nodule had a marked effect on the regional mobility of the lung . thus , mri is capable of providing important complementary quantitative regional information , which might be especially useful during follow - up . depending on size and location of the tumour , differences in motion were observed in the three axes ( x- , \n y - and \n z - direction ) . for this assessment pulmonary nodules were grouped as cranial , middle and caudal according to giraud et al . \n especially , the cranio - caudal motion ( y -direction ) showed a significant dependence on tumour size and location . small tumours in the caudal lung area can \n move up to 5 cm during maximum respiration . but also during shallow breathing , nodules in the lower lung zone exhibited a mean dislocation of 9.5 mm in the cranio - caudal direction and 6.6 mm in the anterior posterior direction ( fig . theoretical calculations for 20 patients with pulmonary nodules demonstrated that this information for treatment planning might already lead to a marked increase of the target dose . a sufficient safety margin might not be larger than 3.4 mm for the upper , 4.5 mm for the middle , and 7.2 mm for the lower lung zone . this is substantially smaller than the conventional safety margin of 5 or 10 mm , respectively , and might allow for an additional dose escalation especially in the upper lung zone . but it has to be mentioned that an individual quantification of the tumour motion is recommended as the interindividual differences in tumour motion are high . simultaneous application of markers on the external chest wall demonstrated correlation and influencing factors between internal and external motion . further developments in parallel imaging technology , especially view sharing techniques , have resulted in a further improvement in temporal resolution . this advantage can be applied to establish a three - dimensional flash sequence for a continuous volumetric visualisation of respiratory motion of lung and tumours . in \n fig . 4 , the 3d - flash sequence is compared to the 2d - truefisp sequence . a 3d - flash data set contains 52 slices with isotropic 3 mm voxels and a temporal resolution of one data set per second . motion of pulmonary nodules can be visualised and quantified in all three axes in order to be transferred in potential treatment concepts . segmentation of such data sets , however , is still demanding and time - consuming and can not be recommended for clinical use , yet . \n besides the mere information about tumour motion , three - dimensional techniques also allow for quantification of changes in tumour volume during the respiratory cycle . changes in tumour volume are associated with deformations and changes of the main rotation axes of the nodules . although this is not real rotation , the rotation of the axes can add up to 30 and impressively \n reflects the degree of deformation . however , this information seems to be highly important , e.g. for further improvements in position and adaptation of collimators in radiotherapy . in addition , the knowledge about deformation of nodules and changes in volume during the respiratory cycle has substantial impact on the accuracy of volume measurement during the follow - up of pulmonary nodules and attempts to calculate nodule doubling times . \n", "radiotherapy very quickly leads to a significant , often temporary reduction of motion of the treated hemithorax when compared to the situation prior to radiotherapy . this ipsilateral reduction is compensated for by an increased motion range of the contralateral lung . obviously , such changes between right and left lung can not be detected by global lung function tests . further studies are warranted to demonstrate which patients might benefit from preventive treatment , e.g. to prevent clinical aggravation . \n", "additional split lung analysis is feasible revealing important insights into differences between right and left lungs undetectable by global pulmonary function tests . motion of pulmonary tumours can be measured in two or three dimensions , effects of respiration on volume and shape can be calculated . however , presently the evaluation of such data sets is extremely time - consuming . \n", "substantial portions of this paper and the figures were originally published in plathow c , meinzer hp , kauczor h - u .", "respiratory cycle from maximum expiration to maximum inspiration within 1 s. top row shows a healthy volunteer with synchronous movement of both lungs . bottom row shows a patient with lung cancer on the left and subsequently reduced motion range of the left lung . \n lung motion is reflected by measuring the distance from the apex to the top of the diaphragm ( l ) . cranio - caudal lung tumour motion is measured with regard to the intervertebral space t 6/7 ( 1 ) ; antero - posterior motion with regard central anterior margin of the spine ( 2 ) ; and medio - lateral motion with regard to the centre line of the spinal processus ( 3 ) . \n maximum lung tumour motion ( mm ) during shallow breathing in cranio - caudal ( cc ) , medio - lateral ( ml ) and antero - posterior ( ap ) direction depending on tumour localization in the upper , middle or lower lung zone . \n top row , 2d - truefisp sequence ; middle row , 3d - flash sequence with a temporal resolution of one volume data set per second ; bottom row , volume segmentation of lung and tumour from the 3d - flash data set . \n" ]

[ "a 21-month - old male patient , 75 cm in height and 10 kg in weight , experienced tricuspid valve regurgitation ( tvr ) and was scheduled to undergo tricuspid valve plasty . the tvr was discovered in a follow - up test 1 year after he had undergone ventricular septal defect repair surgery . before tricuspid valve plasty , a tee was performed , which showed a level 3 - 4 tvr and severe right ventricular hypertrophy . atropine , thiopental sodium , and vecuronium were administered to induce anesthesia and muscle relaxation . a catheter was placed at the left radial artery to measure the constant blood pressure and analyze the abga ( table 1 ) . there were complications due to the adhesion of the svc and ivc near the surgical site . therefore , a 20 fr and 22 fr cannula was placed on them , respectively . 2 u of packed red blood cells ( prc ) , albumin , and mannitol was used as the priming solution . immediately after activating the cardiopulmonary bypass , the measured hematocrit level was 27.5% . the acid - base balance management mid - surgery was performed with an -stat . during extracorporeal circulation , the body temperature was aimed at a moderately low degree of 25. the perfusion rate was kept at 0.5 - 1.0 l / min . after tricuspid valve surgery , the patient was weaned from the cardiopulmonary bypass by reducing the perfusion rate of the machine and starting mechanical ventilation . the total anesthesia , surgery and extracorporeal circulation time was 510 minutes , 420 minutes and 180 minutes , respectively . the amount of blood loss was estimated to be 800 ml . during surgery , 600 ml of a crystalloid solution , 3 u prc and 2 u platelets were administered . however the patient 's eyes could not focus , and his upper and lower limbs experienced intermittent convulsions . brain computed tomography revealed findings indicative of a cerebral infarction in the occipital lobe ( fig . eeg was performed , which showed no abnormal findings of alpha rhythm loss , which is customary in cortical blindness . phenobarbital was administered until 19 days after surgery under the suspicion of a connection between the ocular deviation and the convulsions . the convulsions did not return , but the reaction to light or objects in front of the eyes did not trigger an avoidance response from the patient . there were no hopeful clinical signs of a visual recovery but fundoscopy showed normal findings . on the postoperative day 28 , when the flash visual evoked potential ( fvep ) and mri had been planned , the patient 's eyes refocused . he was able to recognize the objects in front of his eyes , could walk and avoid things in his path , and was able to recognize his guardians .", "post surgery visual loss or reduction can be caused by a variety of factors , and occurs 0.1% to 1% of cases . visual loss is caused by damage to any connecting striate area between the cornea and occipital cortex . direct pressure on the eyeball , indirect increase in ocular tension due to improper positioning and blood vessel damage can cause central retinal artery occlusion or ischemic optic nerve damage , which can lead to visual loss . in addition , a severe decrease in blood pressure , emboli , and thrombus mid- or post - surgery can cause an infarction in the occipital cortex , which can lead to cortical blindness . visual loss after a cpb might be caused primarily due to emboli , severe low blood pressure , acute anemia , hypoxia or a combination of these factors . in the present case twenty seven cases were cortical blindness , of which 22 cases occurred after cardiac surgery ( 81% ) . aldrich et al . reported a retrospective study of 25 patients , where the causes of cortical blindness were natural ischemic stroke in 8 patients ( 32% ) , cardiac surgery in 5 patients ( 20% ) , cerebral angiography in 3 patients ( 12% ) , non - surgery in 4 patients ( 16% ) , seizure in 2 patients ( 8% ) , and other factors , such as damage to the head and peritoneal dialysis , in 3 patients ( 12% ) . there were also cases of temporary cortical blindness reported after post - cardiac surgery angiography . in the case of children , the early indicators of brain damage after surgery are age , the complexity of surgery , metabolic acidosis , increase in lactate , and artery acidosis . diagnosing cortical blindness is simple when the patient makes a complaint but as in our case , a pediatric patient has limited ability to communicate . therefore , conducting an eeg , fvep , angiography , and funduscopy can assist in making a diagnosis . in this case , the eeg did not show the abnormal finding of a loss in alpha rhythm . however , computed laminography revealed an infarction in the occipital cortex we checked for visual loss with light and objects to test the patient 's avoidance response but he did not respond properly . however , microemboli caused by extracorporeal circulation can obstruct the blood flow in the cerebral vessels , particularly in the watershed area . braekken et al . reported that cardiac surgery using extracorporeal circulation causes microemboli in most cases . in addition , in patients with neural damage , there are more cases of transcranial doppler detection of microembolic signals in the right middle cerebral artery than in patients without . microemboli mid - surgery occurs most often when blocking the aorta ( 18% ) and unblocking the aorta ( 13% ) . rodriguez and belway stated that in pediatric cardiac surgery , the likelihood of microemboli can increase with increasing time of extracorporeal circulation depending on the oxygenator , circuit , adnexa parts , and components . the surgery in this case was not complicated , but may have increased the likelihood of microembolization due to the long extracorporeal circulation time . however , we should have been more careful in the selecting the -stat and ph - stat method . nevertheless , the strength of the ph - stat should have been considered regarding neural sequelae . the cpb priming solution in pediatric patients , unlike adults , can cause blood thinning , which can lead to possible ischemic organ failure . aldrich et al . reported that conditions , such as the age below 40 , no diabetes or high blood pressure , and no impairment in cognitive skills , language skills or memory , indicate a good prognosis for visual recovery . in addition , eeg tests can assist in a diagnosis but are not helpful in accurately predicting the prognosis . in this study , two weeks after the surgery , he recovered his speech and cognitive skills , so we did expected a good prognosis . the patient 's vision recovered rapidly from postoperative day 28 and he could be discharged . other tests such as a fvep were not performed , so the precise extent of the recovery rate is unknown . considerable effort is required to reduce neural sequelae after pediatric cardiac surgery , such as visual loss . the cpb machine 's circuit components and type choice should be made on what can best prevent the likelihood of emboli . a pediatric transesophageal scan and cerebral oxymeter can help in the early identification of neural side - effects . a transesophageal scan plays an important role in eliminating emboli , so it should be prepared for all suitable pediatric patients . the pathological difference between an adult and pediatric cardiopulmonary bypass should be recognized , and proper measures should be followed . when cortical blindness is suspected , the ophthalmologist and neurologist should perform a combined examination , being cautious of permanent sequelae . in conclusion , with the reported visual loss in our pediatric patient , surgeons should consider the possibility of visual loss and cerebrovascular injury after a cardiac surgery using cardiopulmonary bypass ." ]

[ "neonatal period ( the first 28 days after birth ) , which is the period of various physiological adaptations to the extrauterine life , is a vulnerable time . more than 10 million children die before the age of 5 years , 8 million of whom die before the age of 1 year and more than half of these deaths occur in the first 4 weeks after birth . about 98% of the neonatal deaths occur in developing countries . according to the world health organization ( who ) , the rate of deaths is 30 times more in the countries with the highest rate compared to the countries with the lowest rate . according to the reports of ministry of health and medical education , the index of neonatal death in iran is 16 - 20 deaths out of 1000 survived births , which is higher than that in developed countries . who has urged iran to halve its neonatal death rate by 2015 . risk factors in studying neonatal death are categorized into three groups : prenatal , intrapartum , and postnatal factors . all over the world , infection , preterm delivery , and birth asphyxia contribute to about 87% of neonatal deaths . in most societies , congenital malformations and premature birth babies with low birth weight ( lbw ) and extremely lbw account for 6 - 7% and 1% of babies death , respectively . these causes , however , are the second and third reasons , respectively , which are responsible for one half of the neonatal deaths . prematurity is responsible for about 60 - 80% of neonatal deaths all over the world in babies without congenital anomalies . in many cases , neonatal diseases are caused by respiratory problems , of which hyaline membrane disease ( hmd ) can be mentioned as the foremost . about 1.3% of all neonatal deaths are caused by hmd or its complications in premature newborns . have mentioned five main causes of neonatal death , including prematurity , internal bleeding , septicemia , respiratory distress syndrome , and congenital anomalies , while gheibi et al . have reported prematurity ( 68% ) , hmds ( 51% ) , asphyxia ( 13% ) , sepsis ( 13% ) , and congenital cardiac malformations ( 8% ) as the most important causes of neonatal death . the baby 's gender has also been considered as an important factor in his or her death . one of the most important issues in babies death is suitable management and timely referral of newborn babies with high - risk levels and being hospitalized in neonatal intensive care unit ( nicu ) . nicu is a critical section in a hospital , dealing with infections ( e.g. septicemia , pneumonia , surgical infections , and other infections ) that are difficult to control . in the usa , management , appropriate care , and supportive cares are the important factors in preventing babies death . rostami et al . have reported that the rescue chances of the babies who have received preventive nasal continuous positive airflow pressure ( ncpap ) are three times higher than the other babies . considering that an analytical and comprehensive study has not been done about the role of neonatal risk factors and the therapy given for hospitalized neonatal death in west azerbaijan ,", "the study is case control study , wherein the case group included 250 died babies who were hospitalized in the nicu during 2007 - 2009 . the control group also included 250 newborn babies who were hospitalized in the same unit and were discharged alive and healthy after they were given appropriate treatment . only the newborn babies from shahid motahhari therapy - training center were selected in order to homogenize the sample and eliminate some threatening factors ( factors involved in referral , death , etc . ) . data collection was carried out through a researcher - designed questionnaire which was designed based on other studies and scholars points of view . inclusion criteria included the babies complete profiles , and the criteria for exclusion included their incomplete profiles . the questionnaire contained six sections ( mother 's and baby 's demographic information , causes of hospitalization , during - treatment complications , therapeutic actions , and causes of death ) for alive babies and five sections for dead ones . chi - square test , odds ratio ( or ) , and logistic regression were applied to analyze how the variables were related .", "based on single - variable analysis , neonatal risk factors affecting the newborn babies hospitalized in the nicu are as follows : 51.6% of case babies and 18.3% of control babies had first - minute apgar score of less than 6 , which proved to have a significant correlation with babies death ( p < 0.001 ) . about 9.6% of babies of case group and 2.4% of babies in the control group had during - birth asphyxia which proved to have a significant correlation with neonatal death ( p = 0.001 ) [ table 1 ] . the distribution of independent variables by independent variables ; p value based on chi - square test in this study , one of the factors causing death of babies hospitalized in the nicu was hmd ; 77.6% of case babies and 44.8% of control babies suffered from this disease ( p < 0.001 ) . fourteen percent of case babies and 2% of control babies had sepsis which showed a significant relation with babies death ( p < 0.001 ) . moreover , 58.8% of case babies and 71.5% of control babies were born through cesarean section which also proved to have a significant effect ( p < 0.001 ) [ table 1 ] . congenital anomalies have been recognized as one of the significant risk factors of death of babies hospitalized in the nicu . eight percent of case babies and 2.8% of control babies were reported to have congenital anomalies ( p < 0.001 ) [ table 1 ] . regarding therapeutic actions , the results of the study also showed that having ncpap played a significant role in decreasing death of babies hospitalized in the nicu ( p < 0.001 ) . there was also a significant relation between supportive cares and neonatal death ( p < 0.001 ) . increased number of pregnancies also had a significant effect on neonatal death ( p < 0.001 ) [ table 1 ] . variables like lbw , baby 's gender , blood group , history of preterm labor , and consanguinity had no significant role in the death of neonates hospitalized in the nicu . in order to gauge the key effects of the mentioned factors , the adjusted or calculated from advanced logistic regression model was measured through advance selection method . the results showed that the or of neonatal death was 4.02 times greater for neonates with first - minute apgar score of less than 6 compared to those with first - minute apgar score of 6 and more , for asphyxia , the or was 6.16 , for hmd it was 4.08 , and for sepsis it was 6.42 . applying ncpap and multiparity led to a decrease in the death of neonates hospitalized in the nicu [ table 1 ] .", "in the present study , the most important neonatal risk factors affecting neonatal death were found to be sepsis , birth asphyxia , hmd , first - minute apgar score of less than 6 , congenital anomalies , and delivery method . in our study , the most common risk factor for neonatal deaths was sepsis which raised the risk of death by infection to 6.42 times more than the other causes . , sepsis and its complications were reported to be the first cause of death , but in the investigations of nayeri et al . and amin et al . , sepsis had higher ratings . this may be due to the factor that premature babies are prone to infection , but it should be more investigated because of the high number of deaths resulting from it . this spread of sepsis has been reported to be in 1 - 10 cases out of 1000 live births , but 10 - 50% of deaths occur because of it . the second risk factor in the present study was at birth asphyxia , which is in line with tariq and kundi 's study which mentioned sepsis and neonatal asphyxia as the main causes of death , but in the studies carried out by sereshtedari et al . , it was the cause of the 16% deaths in 18 provinces of the country , in bangladesh approximately 26% of neonatal deaths are caused by asphyxia . the other serious clinical problem is respiratory difficulty , and in this study , it manifested as respiratory distress and hmd . in our study , it was the third risk factor of infant death . the study of abdul in malaysia showed that this problem with sepsis is the most important cause of infants death . there is also a second leading cause of infant death in tariq and kundi 's study , and respiratory distress syndrome which were studied by kumar et al . in india , jehan et al . in pakistan , naghavi in 18 provinces of iran , javanmardi et al . in isfahan , amani et al . in ardebil , and in the studies of nayeri et al . in tehran and sereshtedari one of the causes of infant death , low apgar score at birth , is increasingly mentioned in many studies to be a risk factor . low apgar score at birth could be correlated to factors such as neonatal infections , birth asphyxia , meconium aspiration , respiratory distress syndrome , and other causes which may result in infant mortality . in our study , ncpap was applied in the control group two times more than in the case group , which resulted in a decrease of babies death by 0.43 . in their study , rostami et al . also reported that applying preventive ncpap to newborn babies will increase their survival chances by three times . congenital anomalies was found to be in the second position in the studies of sharifi , hematyar and yarjo , javanmardi et al . in esfahan , and naghavi 's study in 18 provinces . it was mentioned as the second and first cause in the studies of sareshtedati et al . and 's study , congenital anomalies and infection were mentioned as the leading factors of infant death . the rate of abnormalities in our study compared with other studies , which shows that it is a less important factor in the incidence of neonatal death . this may be due to high morbidity and mortality caused by other factors such as immaturity , lack of attention and careful examination at the time of birth , lack of screening for neonatal abnormalities , and not performing autopsy in dead neonates . death rate in babies with lbw is about 40 times higher than in babies with normal weight . unlike these studies this finding is in correlation with that of nayeri et al . in the present study , normal vaginal delivery was higher in the case group than that in the control group . this finding shows that cesarean section can be better when there is an emergency case or prematurity . although emergency cesarean section is performed to save the lives of the mother and baby , the selection is not always uncomplicated . in a study , it has been reported that two - third of babies who died were born through cesarean section . in our study , despite the high level of infant mortality in males , there was no significant relation between gender and the cause of death . an important risk factor that was investigated in this study was the number of pregnancies . the results of this investigation showed that death rate decreased as the number of pregnancies increased . number of births higher than 5 , pregnancy number above 3 , and high rate of birth were mentioned as effective factors causing babies death in studies conducted by shirvani and khosravi , chaman et al . , and titaley et al . , respectively . appropriately carrying out care and supportive cares can be effective factors in preventing babies death . in our study , 51.6% of case babies and 2.3% of control babies had received supportive care from birth . higher death rate in case babies can be due to bad physical conditions and other threatening factors . the results of the study show that incorrect methods of transfer can increase the death rate . in this study , special attention was devoted to increasing the care standards in order to decrease the death rate . according to the results of the study that took into consideration factors such as age , occupation , consanguinity , blood group , preterm delivery background , and sex in two groups with equal distribution , it can be concluded that factors related to accompanying diseases and care during delivery play a significant role in neonatal death . therefore , regarding the fourth goal of millennium development , decreasing babies death to two - fourths by 2015 in countries with high rate of mortality , it seems to be better to spot pregnancies with high risk of babies death through pre - delivery care and to transfer mothers who are likely to bear premature or sick babies to centers that have nicus . in cases where it is impossible to specify whether a delivery is risky before birth , the subsequent hospitalization problems can be prevented by providing appropriate conditions of transfer and therapeutic actions in intensive care units .", "the major risk factors in this study ( sepsis , asphyxia during birth , hmd , congenital anomaly , and apgar score less than 6 in the first minute of birth ) are considered as the major complications of preterm labor and preterm infants . so , strict preventive programs should be undertaken for premature preterm labor and preterm infants ; taking care of the infants in four stages ( before conception , during pregnancy , during delivery , and thereafter ) can be highly effective as well ." ]

[ "lung cancer remains the leading type of cancer worldwide and in latin america [ 1 , 2 ] . the disease burden is significantly high , with around 2.5 million new cases per year and 1.5 million deaths worldwide . the two main histological subtypes of lung cancer are small - cell lung cancer ( sclc ) , which comprises 15% of cases , and non - small - cell lung cancer ( nsclc ) accounting for 85% of cases which include adenocarcinoma , squamous cell carcinoma , and large cell carcinoma . among all newly diagnosed nsclc cases , adenocarcinomas are the most frequent subgroup following by squamous cell carcinomas [ 6 , 7 ] . cigarette smoking is the major risk factor for lung cancer but around 1020% of cases are found in never smokers ; also wood - smoke is a major risk factor in countries like mexico [ 811 ] . surgery is the selected treatment for early stage nsclc with the greatest probability of long - term survival in such patients . in advanced nsclc , conventional therapies are based on chemotherapy and radiotherapy but with low efficacy . over the last decade , there have been advances in the study of molecular pathways underlying tumor development leading to the development of targeted therapies such as tyrosine kinase inhibitors ( tkis ) and antibodies directed against the two main actionable genes in nsclc up to now : mutations in the epidermal growth factor receptor ( egfr ) gene targeted by tkis like gefitinib [ 13 , 14 ] , erlotinib [ 9 , 15 , 16 ] , and afatinib [ 1719 ] and translocations involving the anaplastic lymphoma kinase ( alk ) gene treated with the tki crizotinib , alectinib , and ceritinib . benefits have been shown in a subset of 1520% of patients harboring egfr mutations which correlate with definite clinical characteristics : adenocarcinoma histology , female sex , asian ethnicity , and nonsmokers [ 2325 ] . despite these improvements in therapeutic strategies , early diagnosis is very difficult ; most cases are diagnosed at an advanced stage and cancer metastasis is very frequent ; therefore , there is still an exceedingly low 5-year survival rate of 1124% [ 2628 ] . the immunotherapy approach has opened new therapeutic options in advanced nsclc with the advent of antibodies against immune checkpoints [ 29 , 30 ] . recently , the anti - programmed death-1 ( pd-1 ) antibodies nivolumab and pembrolizumab have been approved in the treatment of advanced metastatic nsclc based on results from clinical trials after prior chemotherapy [ 31 , 32 ] . both antibodies block signaling through pd-1 and may restore antitumor immunity with benefits in overall survival [ 33 , 34 ] . for example , nivolumab , a fully human monoclonal antibody , has recently shown greater overall survival than docetaxel . these antibodies exhibit a reasonable toxicity profile but they should be administered in selected patient populations based on biomarkers such as pd - l1 expression to avoid serious immune - mediated adverse effects . although these checkpoint inhibitors have proven efficacy in patients , their mechanism of action implies side effects as the onset of autoimmune diseases and a series of endocrine disorders [ 37 , 38 ] . this is the rationale for further research into other molecular and cellular factors of the immune system that could be effectively targeted to develop novel therapeutic strategies for the management of advanced nsclc . recent findings indicate that inflammation plays a key role in tumor progression and survival across several cancer types . cancer related inflammation affects many aspects of malignancy including proliferation , survival , angiogenesis , and tumor metastasis . inflammatory components in the development of the neoplasm include diverse leukocytes populations , like macrophages and neutrophils , which respond immediately to inflammatory stimulus . immunoregulatory cytokines secreted in a proinflammatory environment also contribute to tumor growth and metastases and identify patient subsets in advanced nsclc with differential prognosis . both macrophages and neutrophils are increased in patients with lung cancer ; this is associated with poor clinical outcomes , suggesting that these cells might have important tumor - promoting activities [ 43 , 44 ] . tumors escape phagocytosis and immune response through overexpressing cd47 that interacts with the signal regulatory protein alpha ( sirp ) preventing engulfment .", "macrophages within the tumor microenvironment are called tumor - associated macrophages ( tams ) . tams have a complex relationship with tumor cells ; at an early stage they attack tumor cells avoiding tumor spread ; however , over time they begin producing reciprocal growth factors and establish a symbiotic relationship with tumor cells . macrophages are polarized into two functionally distinct forms m1 and m2 , mirroring the th1 and th2 nomenclature of t cells . differentiation of the m1 macrophages is induced by interferon- , lipopolysaccharides , tumor necrosis factor ( tnf ) , and granulocyte - monocyte colony - stimulating factor . the m1 macrophages produce high levels of interleukin- ( il- ) 12 , il-23 , tnf , il-1 , il-6 , cxc ligand 10 ( cxcl10 ) , inducible nitric oxide synthase ( inos ) , human leukocyte antigen- ( hla- ) dr , and reactive oxygen and nitrogen intermediates [ 47 , 48 ] . differentiation of the m2 macrophages is induced by il-4 , il-10 , il-13 , il-21 , activin a , immune complexes , and glucocorticoid . the m2 macrophages express high levels of il-10 , il-1 receptor antagonist , cc ligand 22 ( ccl22 ) , scavenger , mannose receptor , galactose receptor , arginase i , and cd163 antigen , reduce the expression of inos , and inhibit antigen presentation and t cell proliferation [ 47 , 49 ] . factors that shift tams towards a m2 phenotype include the location of tams within the tumor microenvironment , tumor stage , and type of cancer . nevertheless , it is still not fully defined whether the diversity within the tam population is due to the maturation of unique monocytic precursors or due to various factors within the local tumor microenvironment . the m2 macrophages have been found to encourage the growth of various tumour cells in vitro and to increase tumor cell survival [ 51 , 52 ] . studies suggest that in solid tumors established and progressively growing tams are reprogrammed to induce immune suppression in situ in the host through cytokines , prostanoids , and other humoral mediators [ 54 , 55 ] . il-1 and il-6 expression in tams differs in ovarian cancer compared to peripheral blood monocytes . tams in the ovary produce low levels of il1 and increase the release of il-6 , which contributes to elevated acute phase proteins and increased malignancy . there is an association between the number of macrophages and prognosis in a variety of human tumors . tam infiltration increased in carcinomas of breast , cervix , and bladder and correlates with a poor prognosis . however , in prostate , lung , and brain , increasing tams is associated with regression of tumors . tams can regulate the development of new blood vessels within tumors . in hypoxic sites , they stimulate the production of enzymes and extracellular matrix molecules that regulate endothelial cell activity by stimulating factors such as vascular endothelial growth factor ( vegf ) , basic fibroblast growth factor ( bfgf ) , tumor necrosis factor- ( tnf- ) , transforming growth factors- and ( tgf- , ) , interferons , thrombospondin , il-8 , and epidermal growth factor ( egf ) .", "innate immunity in lung involves alveolar macrophages ( ams ) which act as a barrier avoiding penetration of pathogens . conversely , macrophages contribute in part to the pathogenesis of lung disease due to toxic particles ingestion , releasing lysosomal enzymes that can kill the macrophage itself , or contribute to the recruitment of new macrophages inducing chronic inflammation . clinical evidence has indicated that the activation of alveolar macrophages by sio2 produces rapid and sustained inflammation characterized by the generation of monocyte chemotactic protein 1 , which , in turn , induces fibrosis . exposure to cigarette smoke activates nf - e2-related factor 2 ( nrf2 ) in macrophages and reduces neutrophil recruitment , reduces ams phagocytic ability and expression of several important recognition molecules , and impairs clearance of apoptotic cells through oxidant - dependent activation of rhoa [ 60 , 61 ] . in current smokers , the exposure to cigarette smoke affects several important recognition molecules on ams and downregulates cd31 , cd91 , cd44 , and cd71 on these cells . ams with defective phagocytosis lead to chronic inflammation and significantly increase the likelihood of developing chronic obstructive pulmonary disease , lung injury , and cancer ( figure 1 ) . the infiltration of alveolar macrophages promotes the death of tumor cells in those sites of primary tumor growth and/or metastasis in lung . the antitumor activity of alveolar macrophages from lung cancer patients decreases with increased metastasis , tumor size , and development of pleural invasion . the onset of malignant disease triggers the immune response recruiting tams into the tumor site . high numbers of intratumor tams have been linked with invasion , angiogenesis , hypoxia , and early occurrence of metastasis in different tumor types including lung cancer [ 48 , 50 ] ( figure 2 ) . in patients with nsclc , the m1 macrophage phenotype has been associated with the expression of il-1 , il-12 , tumor necrosis factor- ( tnf- ) , and inos and also has been correlated with extended survival time . in a study , m1 tams were identified using cd68 and inos markers in tumor compared to nontumor tissue in nsclc patients . results indicate that inos expression is lower in tissues from patients with adenocarcinoma and squamous cell carcinoma compared to nontumor tissues but surprisingly this was not the case in large cell lung carcinomas . the classically activated m1 macrophages produce effector molecules such as reactive oxygen intermediates , reactive nitrogen intermediates , and tnf , to limit tumor growth . overall there is an association of m1 tams with better lung cancer prognosis . at the other end are the alternatively activated m2 macrophages which have been correlated with tumor initiation , progression , metastases , by secretion of matrix - degrading enzymes , angiogenic factors , and immunosuppressive cytokines chemokines , inhibiting inflammation [ 65 , 67 , 68 ] . m2 macrophages polarized by cigarette smoke lead to proliferation , migration , and invasion of alveolar basal epithelial cells , and exposition to these cigarette smoke - induced m2 macrophages also significantly increased the cell population in g2/m phase causing proliferation in lung cancer cells . in nsclc , the concentration of macrophages m2 was 70% in comparison with 30% m1 . density of macrophages m1 in the tumor islets , stroma , or islets and stroma was positively associated with patient 's survival time . also ,", "neutrophils are also polarized into n1/n2 subgroups , n1 being proinflammatory , while n2 is anti - inflammatory . n1 and n2 represent a dichotomy in neutrophil subpopulations present in patients and animal models with cancer where they play distinctive roles in the pathogenesis of disease . they displayed an activated phenotype that included chemokine receptors as ccr5 , ccr7 , cxcr3 , and cxcr4 . also , tans produced proinflammatory factors mcp-1 , il-8 , mip-1 , and il-6 , as well as the anti - inflammatory il-1r antagonist . also , tans exhibit high activated phenotype compared with peripheral neutrophils . in cancer patients , tans could drive antitumoral immunity through regulating cytotoxic t lymphocytes . in early stages of lung cancer disease , tans increased t cell ifn- production and activation and increase t cell proliferation . the blockage of tgf- is able to polarize n2 tans to n1 tans in murine models of mesothelioma and lung cancer . if apoptotic neutrophils within the tissues are not removed in an efficient and timely manner , they will become necrotic and release cytotoxic granule proteins that may perpetuate host tissue damage . thus , neutrophils apoptosis and clearance is a critical limiting factor for the successful resolution of inflammation . in colon adenocarcinoma cell line , so far , the possible mechanisms by which neutrophils are increased in nsclc patients have not been described ; despite this , these cells are dysfunctional ; increased levels of il-8 could explain this accumulation ; however , the mechanisms by which this occurs are not known .", "neutrophils are recruited to tumor sites through transendothelial migration involving the cd47:sirp recognition ( signal regulatory protein alpha ) creating an inflammatory environment . malignant cells escape phagocytosis displaying high levels of cd47 on their surface which binds to sirp in macrophages and dendritic cells . after binding to sirp , cd47 induces a dephosphorylation cascade preventing phagocytosis through impaired synaptic myosin accumulation . in this way , cd47 can regulate the function of cells in the monocyte / macrophage lineage [ 8082 ] . cd47 is a ubiquitous cell - surface molecule from the immunoglobulin ( ig ) superfamily that interacts with sirp , thrombospondins , and integrins . cd47 was first isolated in association with integrin in neutrophil granulocytes and was later shown to regulate integrin function [ 84 , 85 ] . it plays a role in cellular processes like proliferation , apoptosis , adhesion , and migration and in immunological processes such as inflammatory response , immune response , and tumor immunity [ 87 , 88 ] . this receptor is recognized as a marker of self highly expressed by circulating hematopoietic stem cells , red blood cells , macrophages , macrophages neutrophils , and many cancer types . cd47 has also been identified as a tumor marker , and its dysregulation contributes to cancer progression and evasion of antitumor immunity [ 9194 ] . cd47 is expressed ubiquitously whereas its counter - receptor sirp is more abundant in myeloid - lineage cells such as macrophages , neutrophils , and dendritic cells . several processes are regulated through the cd47:sirp signaling system of macrophages , including phagocytosis mature red blood cells ( rbcs ) in the spleen , phagocytosis of senescent cells and apoptotic bodies , rejection of transplants of hematopoietic stem cells ( hscs ) , and immunosurveillance thereby preserving tissue integrity and function [ 9699 ] . remarkably , there are many factors positively regulating phagocytosis while sirp-cd47 is the only negative regulator preventing self - phagocytosis . cd47 is critical for transepithelial and transendothelial migration of neutrophils or polymorphonuclear leukocytes ( pmn ) facilitating diapedesis through endothelial cells while targeted cd47 deletion decreases neutrophil extravasation [ 100 , 101 ] . the sirp-cd47 interaction initially recruits pmns to tumor sites or sites of injury but later negatively regulates these cells to end the inflammatory response . however , in a postacute stage of inflammation , neutrophils experience cleavage of the cytoplasmic signaling domains of sirp , correlating with increased recruitment and neutrophil - associated damage . truncated sirp acts like a decoy , able to bind cd47 but not signaling intracellularly therefore maintaining the inflammatory microenvironment and being a caveat for cd47 targeted therapies [ 102105 ] . additionally , sirp binding to cd47 in vitro downregulates cd18 as marker of neutrophil activation thus playing a role in the inflammatory activation state of pmns [ 106 , 107 ] . the dual role of cd47 in promoting inflammation through neutrophil migration and recognition of self through blocking phagocytosis in macrophages plays a role in the development of cancer and later in tumor immune evasion . loss of cd47 induces phagocytosis by macrophages in vitro and blocks tumor development and metastasis in vivo . this receptor is strongly overexpressed in several cancer types including both hematological and solid tumors [ 80 , 91 , 109 , 110 ] . a high cd47 expression has been a poor prognostic factor for patients with these diseases [ 80 , 111 , 112 ] . cd47 is also highly expressed in tumor initiating cells ( tics ) or cancer stem cells ( csc ) where it is a marker of more aggressive tumor cells , with higher metastatic potential , and less sensitive to engulfment by macrophages , thereby escaping from immune surveillance while increasing cell proliferation through activation of the pi3k / akt pathway [ 92 , 113116 ] . therefore , cd47 becomes an attractive target for therapeutic approaches with both antitumor and anti - inflammatory properties and anti - cd47 antibodies are being tested with positive results in preclinical and clinical settings [ 80 , 111 , 112 , 117 ] . in lung cancer and in several types of cancers including breast , bladder , colon , pancreatic , and hematological cancers , blocking cd47 in tumor cells the cd47:sirp interaction is involved in the pathogenesis of lung cancer and other cancer types when tumors release cytokines promoting tumor growth and stimulating the conversion of macrophages from m1 to m2 phenotype . systemic administration of nanoparticles with anti - cd47 sirna showed efficient inhibition of lung metastasis to about 30% of controls . in patients with lung metastasis , the number of circulating tumor cells ( ctc ) with the phenotype epcam(+)cd44(+)cd47(+)met(+ ) were associated with poor overall survival and increased metastasis and cd47 was a marker associated with the fraction of metastasis - initiating cells within the pool of ctcs . antisense suppression of cd47 in squamous lung tumors prior to irradiation showed benefit obtaining a 71% tumor size reduction . this protection could possibly be exerted through thrombospondin-1 signaling to recover from radiation stress , revealing a strategy to protect normal tissues from radiation damage using anti - cd47 antibodies which could be useful in the application of combined radiation with targeted therapies in lung cancer . there is a close relationship between macrophage , neutrophil infiltration , and upregulation or cd47 with poor prognosis and lack response to treatment . nowadays , therapies are developed to block the interaction of tumor cells with macrophages through cd47 , thereby offering an opportunity to turn tams against nsclc cells by allowing the phagocytic behavior of resident macrophages . also , anti - cd47 could regulate the recruitment of neutrophils into tumor and diminish the chronic inflammation figure 3 .", "inhibition of csf-1 receptor , which is essential for macrophage differentiation significantly increased survival and suppressed established tumors , accompanied by decreased m2-like tam . treatment with metformin is able to reduce the metastases in vivo , through blocked matrix metalloproteinase-9 and expression of mmp-2 , maintaining the components of the extracellular matrix , avoiding the separation of tumor cells , inhibiting the growth and metastasis of tumors . also , metformin prevented m2-polarization of macrophages regulated ampk1 and , besides , inhibited il-1 induced release of the proinflammatory cytokines il-6 and il-8 in macrophages [ 124 , 125 ] . glycodelin ( gene name paep ) is a proliferation suppressor and apoptosis inducer of t cells , monocytes , b cells , nk , and regulated pulmonary immune response in asthmatic inflammation . however , atypical expression is observed in squamous cell carcinomas and adenocarcinomas of nsclc . in vitro , silencing by sirna - transfection of paep in two nsclc cell lines resulted in significant upregulation of immune system modulatory factors such as pdl1 , cxcl5 , cxcl16 , mica / b , and cd83 as well as proliferation stimulators edn1 and hbegf . this kind of therapy provides a mechanism to overcome tumor immunosurveillance . as mentioned above , currently the only fda - approved immunotherapies for the treatment of nsclc are nivolumab and pembrolizumab . these antibodies inhibit checkpoint molecules such as ctl-4 and pdl-1 , improving the survival and response to treatment . ctla-4 is thought to regulate t cell proliferation early in an immune response , primarily in lymph nodes , whereas pd-1 is upregulated in current smokers and suppresses t cells . these antibodies switch on immune system cells mediated by t cells , increasing their ability to recognize and destroy cancer cells [ 128 , 130 ] . monoclonal antibodies specific for tumor cell antigens , coupled with appropriate cytokines , may provide rational basis for designing trials to employ the neutrophil cytotoxic potential as adjuvant therapy in cancer patients .", "chronic inflammation seems to play a major role in the onset and development of cancer . understanding the interaction between the cellular and molecular factors that mediate inflammation in nsclc , including the rather unexplored components of innate immunity such as macrophages and neutrophils , can elucidate novel targets affecting key oncogenic pathways in this malignancy and allow preventing cancer cell proliferation , angiogenesis , and metastasis . inhibiting cd47 as promoter of neutrophil extravasation and migration may reduce inflammation thereby preventing cancer , and blocking the antiphagocytic signal of cd47 on the surface of tumor cells can overcome immune suppression , harnessing the immune system to target malignant cells more effectively . on the other hand , the potential side effects should be addressed by careful selection of patient populations based on biomarkers such as tumor cd47 overexpression ." ]

[ "gastroenteropancreatic neuroendocrine tumors ( gepnets ) are rare malignant neoplasm with an incidence ranging from two to five cases/100,000/yr . because it originates from the enterochromaffin serotonin - producing cell , it has a unique feature of hormone secretion and expression of distinctive differentiation markers [ 1 - 6 ] . some patients remain asymptomatic for several years , or complain of episodic flushing , abdominal pain , nausea , vomiting , and diarrhea . in most cases , due to the vagueness of symptoms , a diagnosis is delayed ( 3 - 10 years on average ) , with an increased risk of developing metastases . the ability of the imaging method to localize primary or metastatic site of gep - net also has some limitations . most gep - nets are highly vascular , thus could easily be detected by a contrast enhanced computed tomography ( ct ) ; however , approximately 6% to 20% are hypovascular and often difficult to be evaluated by a ct scan or other imaging methods . gep - nets originating from jejunum and ileum are also often difficult to identify on an image due to their small size . therefore , non - invasive parameters , indicating gep - pet , are needed for diagnosis , following - ups and prognosis . chromogranin a ( cga ) , a glycoprotein contained in secretion granules of neuroendocrine cells , is the most abundant granin in gep - nets and widely used as a circulating tumor marker , but only few studies have been published on the role of cga in patients with gep - pet , and the range of sensitivity were variously reported [ 8 - 10 ] . we investigated to evaluate whether biochemical response using serial plasma cga is reliable in concordance with the tumor response based on response evaluation criteria in solid tumors ( recist ) criteria in gep - nets irrespective of chemotherapeutic agents .", "a total of 27 cases in 18 patients , who were pathologically diagnosed in gep - nets , were analysed between march 2011 and september 2013 . for all cases , non - functioning was defined to the absence of clinical syndromes of hormonal hypersecretion , such as hypoglycemia , peptic ulcer , diarrhea , steatorrhea , acromegaly , cushing s syndrome , and gallstone . the following clinicopathological characteristics of all 18 patients were collected : age , sex , primary site , tumor grade in accordance to the 2010 world health organization ( who ) classification , liver metastasis , number of metastatic site , site of metastasis , and information of chemotherapy . systemic chemotherapies for gep - net included octreotide , vip ( vincristine , ifosfamide , cisplatin ) , xelox ( capecitabine , oxaliplatin ) , ep ( etoposide , cisplatin ) , pazopanib , sunitinib , everolimus , and xeliri ( capecitabine , irinotecan ) . biochemical efficacy was estimated according to the criteria proposed by the italian trials in medical oncology ( itmo ) group for evaluating markers ( biochemical response ) . partial response ( pr ) was defined as 50% decrease in plasma cga compared to the baseline cga ; stable disease ( sd ) was defined as a decrease < 50% or as an increase < 25% ; and progressive disease ( pd ) was defined as an increase 25% . the level of cga was determined from venous blood samples drawn into edta - containing tube after overnight fasting and collected before systemic treatment . the plasma cga level was measured by cga - ria ( chromoa assay , cis bio international , saclay , france ) with a normal range of 27 - 94 ng / ml . chromoa is based on sandwich enzyme - linked immunosorbent assay , using two monoclonal antibodies ( the same antibodies as cga - riact ) directed against the central domain of the molecule ( 145 - 245 ) , which is less sensitive to proteolysis . the tumor size was measured by using a ct or magnetic resonance imaging by recist criteria ver . 1.1 . group comparisons were performed using a nonparametric test of mann - whitney or kruskal - wallis , followed by a dunn multiple comparison test , as appropriate . comparisons of paired values were performed using a nonparametric test of wilcoxon . the chi - square test and the fisher exact test ( for value less than 5 ) were employed to compare the sensitivity and rate of concordance in different groups . in all statistical tests , progression - free survival ( pfs ) was measured as the time from the date of chemotherapy to the date of first documented disease progression or death . the pfs were estimated using the kaplan - meier method with log - rank analysis .", "a total of 27 cases in 18 patients , who were pathologically diagnosed in gep - nets , were analysed between march 2011 and september 2013 . for all cases , non - functioning was defined to the absence of clinical syndromes of hormonal hypersecretion , such as hypoglycemia , peptic ulcer , diarrhea , steatorrhea , acromegaly , cushing s syndrome , and gallstone . the following clinicopathological characteristics of all 18 patients were collected : age , sex , primary site , tumor grade in accordance to the 2010 world health organization ( who ) classification , liver metastasis , number of metastatic site , site of metastasis , and information of chemotherapy . systemic chemotherapies for gep - net included octreotide , vip ( vincristine , ifosfamide , cisplatin ) , xelox ( capecitabine , oxaliplatin ) , ep ( etoposide , cisplatin ) , pazopanib , sunitinib , everolimus , and xeliri ( capecitabine , irinotecan ) .", "biochemical efficacy was estimated according to the criteria proposed by the italian trials in medical oncology ( itmo ) group for evaluating markers ( biochemical response ) . partial response ( pr ) was defined as 50% decrease in plasma cga compared to the baseline cga ; stable disease ( sd ) was defined as a decrease < 50% or as an increase < 25% ; and progressive disease ( pd ) was defined as an increase 25% . the level of cga was determined from venous blood samples drawn into edta - containing tube after overnight fasting and collected before systemic treatment . the plasma cga level was measured by cga - ria ( chromoa assay , cis bio international , saclay , france ) with a normal range of 27 - 94 ng / ml . chromoa is based on sandwich enzyme - linked immunosorbent assay , using two monoclonal antibodies ( the same antibodies as cga - riact ) directed against the central domain of the molecule ( 145 - 245 ) , which is less sensitive to proteolysis . the tumor size was measured by using a ct or magnetic resonance imaging by recist criteria ver .", "group comparisons were performed using a nonparametric test of mann - whitney or kruskal - wallis , followed by a dunn multiple comparison test , as appropriate . comparisons of paired values were performed using a nonparametric test of wilcoxon . the chi - square test and the fisher exact test ( for value less than 5 ) were employed to compare the sensitivity and rate of concordance in different groups . in all statistical tests , progression - free survival ( pfs ) was measured as the time from the date of chemotherapy to the date of first documented disease progression or death . the pfs were estimated using the kaplan - meier method with log - rank analysis .", "the rectum was the second most common site of gep - net ( 22.2% ) in this study . according to who classification , ten of the 27 cases ( 37% ) were grade 3 neuroendocrine carcinoma . grades 1 and 2 nets were nine ( 33.3% ) and eight ( 29.6% ) , respectively . measurable lesions were found on ct images in 18 out of the 27 cases . among the 27 cases included in this study , no difference in the basal cga level was observed in terms of gender , primary tumor site , tumor grade ( who classification ) , liver metastasis , number of metastatic site , and line of chemotherapy with serial cga monitoring . the plasma cga level ranged from 33.18 to 895 ng / ml ( table 1 ) . the overall response rate ( rr ) by recist criteria was six out of the 27 cases ( 22.2% ) and eight out of the 27 cases ( 29.6% ) for biochemical rr . the concordance of response between recist criteria and biochemical criteria were 74% ( table 3 ) . compared with the baseline values , a decrease of 50% in the cga level were observed in three out of six cases ( 50% ) with pr by recist criteria ( figs . 1a , 2 ) . in only grades 1 and 2 gep - nets cases ( n=17 ) , the concordance of disease control between recist criteria and biochemical criteria were 94.1% ( fig . there was a significant difference for pfs between responders and non - responders ( 35.73 months vs. 5.93 months , p=0.05 ) based on the biochemical criteria ( fig . 3 ) . a subgroup analysis of pfs between responders and non - responders , in accordance to recist response , tumor grade , and primary site , were not statistically significant , but showed longer pfs in the biochemical responder group ( fig .", "the rectum was the second most common site of gep - net ( 22.2% ) in this study . according to who classification , ten of the 27 cases ( 37% ) were grade 3 neuroendocrine carcinoma . grades 1 and 2 nets were nine ( 33.3% ) and eight ( 29.6% ) , respectively .", "among the 27 cases included in this study , no difference in the basal cga level was observed in terms of gender , primary tumor site , tumor grade ( who classification ) , liver metastasis , number of metastatic site , and line of chemotherapy with serial cga monitoring . the plasma cga level ranged from 33.18 to 895 ng / ml ( table 1 ) .", "the overall response rate ( rr ) by recist criteria was six out of the 27 cases ( 22.2% ) and eight out of the 27 cases ( 29.6% ) for biochemical rr . the concordance of response between recist criteria and biochemical criteria were 74% ( table 3 ) . compared with the baseline values , a decrease of 50% in the cga level were observed in three out of six cases ( 50% ) with pr by recist criteria ( figs . 1a , 2 ) . in only grades 1 and 2 gep - nets cases ( n=17 ) , the concordance of disease control between recist criteria and biochemical criteria were 94.1% ( fig . there was a significant difference for pfs between responders and non - responders ( 35.73 months vs. 5.93 months , p=0.05 ) based on the biochemical criteria ( fig . 3 ) . a subgroup analysis of pfs between responders and non - responders , in accordance to recist response , tumor grade , and primary site , were not statistically significant , but showed longer pfs in the biochemical responder group ( fig .", "cga is the most abundant granin in gep - nets and represents the best general marker in the tissue and blood . cga expression generally correlates with the number of dense core granules in the neuroendocrine cells . thus , cga monitoring may be helpful in assessing the response to the different therapeutic options . in some studies , however , it is still controversial whether serial cga changes reflect tumor response for treatment . this study showed that the change of the cga level was correlated with tumor response in nonfunctioning gepnets . additionally , biochemical response based on serial cga may be a predictive marker for pfs in gep - nets . changes in circulating cga have been reported to represent tumor burden and treatment response . to our knowledge , there were no definite measuring criteria of plasma cga for tumor response and conflicting result of sensitivity and specificity in accordance to treatment response were reported in the literature . previous studies [ 2 - 10,18 ] showed acceptable sensitivity ( 54%-78% ) and specificity ( 60%-86% ) for regression and sd ; jensen et al . also reported that plasma cga concentration is important to disclose tumor progression with specificity and sensitivity , 86% and 86% , respectively . in our study , the concordance of response between recist criteria and biochemical criteria was 74% . compared with the baseline values , a decrease of 25% in the cga level was observed in four out of six patients ( 66.7% ) with pr based on recist criteria and an increased cga levels was shown in all 4 patients with pd ( 100% ) . among 11 patients available for serial cga levels , all five patients with sd or partial remission had a more than 20% decrease in the cga levels compared to the baseline value . all six patients with pd showed a less than 20% decrease or increase in the cga levels . several other studies also showed the possibility of cga as a biochemical marker of treatment response ( table 4 ) . high - baseline cga value has been considered to be an independent poor prognostic marker for gep - nets in previous studies [ 21 - 25 ] . however , whether changes of the cga levels compared to the baseline values could predict the prognosis has not been established . in this study , there was a significant difference for pfs between the responders and non - responders for biochemical criteria ( p=0.05 ) . it suggested that a decrease in the cga levels from the baseline levels may be an important predictive marker for survival in gep - nets . this study was a retrospective analysis with small sample size , and heterogeneous patient population . a recognized international standard for cga assay is not available and variations in assay types may influence results . nevertheless , this analysis identified the usefulness of serial cga monitoring as a biomarker that predicts treatment response and survival .", "this study revealed that the changes of the plasma cga levels were associated with tumour response . additionally , biochemical response based on serial cga may be a predictive marker for pfs in gep - nets ." ]

[ "subjective cognitive complaints ( scc ) are quite prevalent among older adults , with some estimates suggesting that between 25% and 50% of all older adults have self - perceived memory impairment [ 1 , 2 ] . in clinical practice , it is often difficult to assess the veracity and severity of subjective cognitive complaints , primarily because such complaints vary widely from individual to individual . as a result , clinicians and caregivers perhaps do not consider subjective complaints to have the same weight as objective findings . however , studies have shown that subjective complaints may be valid indicators of current and future cognitive impairment . a recent study by amariglio and colleagues showed that certain subjective complaints , such as i have trouble finding my way around familiar streets , are correlated with impairment in delayed recall , naming , and semantic fluency . a review conducted by jonker and colleagues showed that memory complaints may be predictive of dementia or alzheimer 's disease onset within two to four years , especially in individuals with a diagnosis of mild cognitive impairment ( mci ) . subjective cognitive complaints also have clinical implications that are outside the realm of cognitive function . a review by mol and colleagues found that scc correlated with depression , anxiety [ 4 , 5 ] , and low level of well - being , even in the absence of objective cognitive impairment . scc and objective cognitive function in older patients with and without major depression and found no changes in objective cognitive function between the two groups , but significantly more scc in the depressed group . scc have also been correlated with decreased functional ability , even when depression is controlled for . although the direction of causality between many of these variables remains unclear , scc should be considered in a clinical setting because of their associations with objective impairment , dementia , depression , low quality of life , and functional ability . previous research in the area of scc has largely focused on memory complaints [ 13 , 7 , 8 ] . in the current study , we have broadened the scope of scc in order to examine other areas of cognition that have shown impairment following complaints . the most common method appears to be a single , dichotomous , yes or no assessment of complaints ( e.g. , do you find that you have trouble with your memory ? ) [ 713 ] , or a combination of similar yes or no questions [ 3 , 14 , 15 ] . furthermore , most of the existing literature on scc examines community - dwelling , healthy , and older populations [ 3 , 7 , 9 , 12 , 16 ] . subjective cognitive complaints , in addition to predicting the onset of a neurodegenerative process , may yield important information about areas of impairment , specifically in patients with mild disease . two such disorders are mild cognitive impairment ( mci ) and its vascular equivalent , vascular mild cognitive impairment ( vamci ) . differences in functional impairment between individuals with mci and those with vamci , which may be overlooked by objective cognitive testing , may be predicted by an analysis of significance of scc . in the current study , we compared the profile of scc in individuals with a diagnosis of mci to those with vamci using the neuropsychological impairment scale ( nis ) . the nis is a comprehensive scale - based questionnaire , which may elicit differences in presence and severity of scc between the two groups . we hypothesized that the severity of subjective cognitive complaints would not differ between the two groups , because objective cognitive functioning is similar . however , we hypothesized that the specific types of scc might differ between mci and vamci , due to the differing pathologies of these two disorders .", "twenty patients with mci and twenty patients with vamci matched on demographic characteristics ( age , education ) were recruited from the memory disorders clinic at st . patients are referred to the clinic by their primary or secondary care physicians , for assessment and diagnosis of cognitive impairment . patients typically undergo a standardized history and a standardized cognitive exam as part of the workup . in addition , routine blood work including tsh , b12 , and rbc folate is done to rule out reversible causes of dementia . as well , most patients receive structural imaging ( either computed tomography ( ct ) or magnetic resonance imaging ( mri ) ) and in some cases functional imaging ( single photon emission computed tomography ( spect ) ) . for this study , only patients clinically diagnosed with either mci or vamci were recruited . the diagnostic criteria for mci describe cognitive impairment which is more severe than normal aging but less severe than dementia and typically not associated with serious impairment in everyday functions . vamci is described as the vascular equivalent of mci , thereby indicating a similar level of objective cognitive performance despite possible differences in mechanism and etiology . currently , there are no specific neuroimaging or vascular criteria that are necessary for a diagnosis of vamci . some patients underwent mri scans instead of ct scans as part of their clinical visit . as we used different imaging modalities we could not compare degree of white matter disease across study subjects in a quantifiable manner . rather , patients were assigned to the vamci group if scans showed evidence of white matter lesions , lacunar infarcts , and/or moderate to severe microangiopathic change . cognitive testing and data intake occurred during the patients ' initial visits to the clinic . follow - up visits to the memory disorders clinic were not considered for this cross - sectional analysis . subjective cognitive complaints were assessed using the neuropsychological impairment scale ( nis ) [ 20 , 21 ] . the nis is a questionnaire consisting of 95 complaints , such as i am forgetful and i am easily distracted . subjects rated these statements on a five - point likert scale according to applicability and intensity . when scored , the nis divides complaints into seven domains : critical items ( e.g. , head injury , stroke , and dizziness ) , cognitive efficiency ( e.g. , confusion , mental slowness ) , and attention , memory , frustration tolerance , verbal learning , and academic skills ( e.g. , counting change , learning new tasks ) . the nis also includes three scores that give a general , comprehensive picture of complaints : the global measure of impairment ( gmi ) score is a simple sum of all domain subscores ; the total items circled ( tic ) score indicates how many complaints are reported ; and the symptom intensity measure ( sim ) score indicates the average intensity of complaints . the nis also includes three validity checks : defensiveness , inconsistency , and affective disturbance . thus , the nis can detect if subjects are overly defensive or inconsistent ; and the affective disturbance validity check controls for levels of depression and other emotional disturbances . the mini - mental state examination ( mmse ) was used to measure cognitive performance from a general perspective . the bna consists of five subcategories : memory , attention , naming , visuospatial function , and executive function . functional ability was objectively assessed using the older american resources and services ( oars ) activities of daily living questionnaire . this questionnaire assesses fourteen activities of daily living ( adls ) : seven basic adls ( eating , dressing and undressing , grooming , walking , getting in and out of bed , bathing , and going to the bathroom ) and seven instrumental adls ( using the telephone , traveling , shopping , preparing meals , doing housework , taking medications , and handling money ) . subjects were asked about their own ability to perform the above adls ; where possible , informants who knew the subjects well were asked to supplement and verify responses . mean scores for each group ( mci and vamci ) were compared via an independent samples t - test . age , education , and other demographic factors were also compared between the two groups .", "the mci and vamci groups were matched on demographic measures such as age , years of education , and hollingshead two - factor index of social position ( table 1 ) . functional ability , as measured by the oars questionnaire , was also similar between the two groups ( p = 0.919 ) ( table 2 ) . objective cognition function was measured by the mmse and the bna ( table 2 ) . mmse scores were similar between the two groups ( p = 0.330 ) , which implies similar levels of general cognitive function . overall bna scores were also similar between the mci and vamci groups ( p = 0.177 ) . scores from subcategories of the bna were also compared between groups to look for specific areas of cognitive impairment ( table 2 ) . performance on all subcategories of the bna ( attention , memory , naming , visuospatial function , and executive function ) was similar between mci and vamci groups . performance on the individual tasks which comprise the above five subcategories was also similar between groups , with the exception of the explaining proverbs task ( p = 0.034 ) . on this task , which falls into the subcategory of executive function , mci subjects averaged a better score than vamci subjects ( 3.15 compared to 2.30 ) . despite similar performance on objective functional and cognitive measures ( oars , mmse , and bna ) , the mci and vamci groups achieved markedly different results when subjective cognitive complaints were assessed by the nis . in general , vamci subjects had significantly higher scores on the nis than mci subjects ( table 3 ) ; higher scores indicate greater scc . the nis global measure of impairment ( gmi ) score gives a broad , comprehensive view of complaints . the vamci group averaged a gmi score of 117.0 , compared to just 79.3 for the mci group ( p = 0.050 ) . a qualitative analysis of the total items circled ( tic ) scores shows that vamci subjects had a greater number of complaints than mci subjects ( 52.8 compared to 44.2 ) ; however this difference was not statistically significant ( p = 0.136 ) . the symptom intensity measure ( sim ) scores reveal that vamci subjects ' complaints were greater in severity than those of mci subjects ( 2.0 compared to 1.7 ) ; however , again , this difference was not statistically significant ( p = 0.065 ) . thus , we can not attribute the difference in gmi scores to just one cause . rather , it is likely that difference in gmi scores stems from differences in both complaint quantity and complaint severity . quantitatively , the vamci group had higher scores in all seven domains of the nis ( table 3 ) . four of these domains yielded differences in scores that were statistically significant : critical items ( p = 0.017 ) , cognitive efficiency ( p = 0.043 ) , memory ( p = 0.046 ) , and verbal learning ( p = 0.027 ) . the nis also includes three validity checks to test for defensiveness , affective disturbance , and inconsistency . in our sample of subjects , there was no statistical difference in any of the above variables between the mci and vamci groups ( table 3 ) , confirming that the complaints were valid . although vamci subjects had qualitatively higher scores on the three validity measures , their scores were not significantly different from those of the mci group .", "mci and vamci are clinical conditions that precede the development of neurodegenerative disorders including alzheimer 's disease and vascular dementia , respectively . apart from differences on neuroimaging there has been very little study of how these two clinical conditions differ in terms of their subjective and objective clinical profiles . taken altogether , our findings from the mmse , bna , oars , and nis show that despite similar levels of functional ability and objective cognitive function , vamci subjects have significantly more scc than mci subjects . our findings support the existing view of mci and vamci as disorders with similar presentations with regard to objective function , but ultimately different etiologies . as previously discussed , mci and vamci subjects were matched on age , education , and social status and achieved statistically similar scores on the mmse and bna . the one component of the bna that differed between the two groups was the explaining proverbs task ; however , this seeming disparity may have resulted from differences in cultural background . in our sample of patients from the diverse city of toronto , 17 out of 40 subjects ( unfamiliarity with english proverbs certainly confounded this result and may explain this difference observed on the bna . leaving aside this single anomaly , our findings show that mci and vamci subjects had comparable levels of objective cognitive function . however , our findings from the nis questionnaire show that vamci subjects had more subjective cognitive complaints than their mci counterparts . this discrepancy suggests that vamci patients are exhibiting particular cognitive deficits , which are not identified by the bna , or that vamci patients are more sensitive to and aware of mild deficits in these particular areas . the nature of vamci - specific deficits may be determined from the domains in which vamci patients report greater complaints : critical items , cognitive efficiency , memory , and verbal learning . the critical items domain references events in a patient 's history that are evident predictors of cognitive difficulty : dizziness , concussion , head trauma , stroke , and so forth . vamci subjects reported greater complaints in this domain than mci subjects ; this finding may be explained by simply considering the diagnostic criteria of vamci compared to those of mci . as mentioned above , history of clinical stroke can differentiate vamci from mci . a vamci patient is more likely than an mci patient to have experienced stroke or stroke - like symptoms , so he / she is more likely to have complaints in the critical items domain . vamci subjects ' greater complaints in the memory , verbal learning , and cognitive efficiency domains may be explained by examining the pathology of vamci , which differs from that of mci upon neuroimaging . a study by vannorsdall et al . found that white matter hyperintensities in both periventricular and subcortical regions correlated with poorer working memory . found that deep white matter hyperintensities correlated with decreased performance on verbal fluency tasks , while periventricular hyperintensities were not associated with any particular domain . white matter lesions have also been correlated with slowed information processing [ 25 , 27 ] . recent research has demonstrated that this decrease in processing speed may be specific to white matter lesions in the anterior thalamic radiation . our analysis may be hampered by the limitations of our cognitive testing methods . in this study , the mmse and bna may have suffered from ceiling effects , which would have masked any differences in cognitive function between the mci and vamci groups . however , the advantages of the mmse and bna are numerous and informed our decision to use these tests . in addition , more sensitive cognitive testing would not have been possible at the study facility , given the amount of time allotted for a clinical visit . the differences we have found in scc between mci and vamci groups may suggest a need for alternate cognitive testing methods , which , unlike the mmse or bna , would elicit different results between the two groups and would not suffer from ceiling effects . our study has demonstrated that vamci patients may be exhibiting particular cognitive deficits in memory , verbal learning , and cognitive efficiency , separate from those exhibited by mci patients . these deficits may be explained by the greater white matter burden in vamci patients , as compared to age - matched mci patients . further research should be done to elaborate on the nature of vamci - specific deficits , particularly in the domains we have identified in this study . as well , vamci - specific deficits should be related to neuroimaging findings , in order to associate deficits with particular locations and severities of white matter disease . finally , tools for more sensitive cognitive testing must be developed , so that we may identify vamci - specific cognitive deficits ." ]

[ "the 42 participating spanish hospitals were selected according to earss criteria ( 1,7 ) . the total catchment population was 9 million people , or 22.5% of the spanish population . the first blood e. coli isolates obtained from each patient between 2003 and 2006 were included . each laboratory identified the strains and tested their susceptibilities according to standard microbiologic procedures ; all used commercial microdilution systems . susceptibility data were interpreted according to clinical laboratory standards institute criteria ( 8) . for epidemiologic purposes , intermediate susceptibility to amc was considered as resistance . multidrug resistance was defined as resistance to > 3 of the following antimicrobial agents : ciprofloxacin , gentamicin , cotrimoxazole , and cefotaxime . to assess the comparability of susceptibility test results , an external quality assurance exercise ( uk national external quality assessment scheme ) was performed yearly . hospital - acquired infections were defined as infections acquired at least 48 hours after hospital admission . outpatient consumption of penicillin/-lactamase inhibitors ( world health organization code j01cr02 ) for the period 20022006 was assessed from the especialidades consumo de medicamentos database , which showed retail pharmacy sales of all medicines acquired with national health system prescriptions and covered nearly 100% of the spanish population ( 5 ) . the information was tabulated , and the number of units was converted into defined daily doses ( ddd ) of active drug ingredients according to who methodology ( 9 ) . the number of ddd per 1,000 inhabitants per day ( dids ) was calculated for each active drug ingredient . differences in the antimicrobial resistance prevalence between different groups were assessed by fisher exact test . association was determined by calculation of the odds ratio ( or ) with 95% confidence intervals ( ci ) . statistical analyses were performed by using graphpad prism version 3.02 software ( graphpad software , inc . participating hospitals reported data on 9,090 cases of e. coli bacteremia during the study period , corresponding to the same number of patients ; 4,526 ( 49.8% ) were male patients and 4,564 ( 50.2% ) were female patients . a total of 1,531 cases ( 16.8% ) were diagnosed in 2003 ; 2,526 ( 27.8% ) in 2004 ; 2,438 ( 26.8% ) in 2005 ; and 2,597 ( 28.6% ) in 2006 . of the total number of isolates , 328 ( 3.6% ) were obtained from children < 14 years of age ; 2,857 ( 31.4% ) were obtained from patients > 15 and < 64 years of age ; and 5,909 ( 65% ) were obtained from patients > 64 years of age . there were 3,384 ( 37.9% ) isolates implicated in hospital - acquired infections and 5,540 ( 62.1% ) in community - acquired infections ; information was missing for 166 cases . of the 9,090 e. coli isolates tested , 1,136 ( 12.5% ) were nonsusceptible to amc , 5.1% were resistant , and 7.4% were intermediate . the prevalence of amoxicillin / clavulanic acid nonsusceptibility in relation to gender , age , infection origin , and resistance to other antibimicrobial drugs is detailed in the table . * the most prevalent phenotypes included multidrug resistance to ciprofloxacin , cotrimoxazole , and gentamicin , which was detected in 73 nonsusceptible amc isolates ( 36.9% of multiresistant isolates and 6.4% of isolates overall ) , and resistance to ciprofloxacin , cotrimoxazole , and cefotaxime was detected in 55 isolates ( 27.8% of multiresistant isolates ; 4.9% of isolates overall ) . multidrug resistance was more prevalent in nosocomial ( 23.5% ) than in community - acquired isolates ( 15.1% ; or 1.99 , 95% ci 1.462.72 ; p<0.0001 ) . among nonsusceptible amc isolates , susceptibility to other antimicrobial drugs , including ciprofloxacin , gentamicin , cefotaxime , and cotrimoxazole , was more frequent in community- ( 28.7% ) than in hospital - acquired isolates ( 13.3% ; or 1.68 , 95% ci 1.272.22 ; p = 0.0003 ) . the overall rate of invasive e. coli nonsusceptibility to amc increased from 9.3% ( 2003 ) to 15.4% ( 2006 ) ( test for trend 36.51 ; p<0.0001 ) ( figure 1 ) ; this increase was observed in 64.3% of the participant hospitals . this increase was also detected in both intermediate and resistant isolates , with annual distributions of 5.6% and 3.8% , respectively , in 2003 ; 6.8% and 4.8% in 2004 ; 7.5% and 5.4% in 2005 ; and 9.4% and 6% in 2006 . evolution of amoxicillin - clavulanic acid nonsusceptibility of escherichia coli from blood isolates , spain , 20032006 . amc nonsusceptibility according to age groups increased over the study period as follows : children < 14 years of age ( 10.6% in 2003 , 14.6% in 2004 , 14.3% in 2005 , and 16.3% in 2006 ) ; patients > 15 and < 64 years 9.6% in 2003 , 11.2% in 2004 , 11.7% in 2005 , and 13.3% in 2006 ) ; patients > 64 years ( 8.8% in 2002 , 11.3% in 2004 , 15.9% in 2005 , and 16.3% in 2006 ) . the prevalence of amc nonsusceptibility in community - acquired infections increased from 8.9% ( 2003 ) to 15.6% ( 2006 ) ( test for trend 29.43 ; p<0.0001 ) . amc nonsusceptibility in nosocomial infections increased from 9.2% ( 2003 ) to 15.2% ( 2006 ) ( test for trend 11.94 ; p = 0.0006 ) . in the final 2 years of the study period ( 20052006 ) this increase was due to community - acquired e. coli isolates only ; the nonsusceptible proportion varied from 11.5% ( 2005 ) to 15.6% ( 2006 ) ( or 1.42 , 95% ci 1.161.74 ; p = 0.0009 ) in community - acquired isolates compared with 15.4% ( 2005 ) to 15.2% ( 2006 ) in hospital - acquired isolates ( figure 1 ) . community - acquired infection probably included healthcare - associated infections , a recently described epidemiologic category distinct from both community - acquired and nosocomial status . in this study , the number of blood isolates of e. coli producing extended - spectrum -lactamase ( esbl ) was 614 ( 6.7% ) ; 188 of them ( 30.6% ) were nonsusceptible to amc . when esbl - producing e. coli isolates were excluded from analysis , amc nonsusceptibility increased from 8.4% ( 2003 ) to 14.3% ( 2006 ) ( test for trend 34.39 ; p<0.0001 ) in total isolates ; from 8.2% ( 2003 ) to 14.5% ( 2006 ) ( test or trend 25.23 ; p<0.0001 ) in community - acquired isolates ; and from 8.9% ( 2003 ) to 13.3% ( 2006 ) ( test for trend 6.35 ; p = 0.012 ) in hospital - acquired isolates ( figure 1 ) . the proportion of isolates highly susceptible to amc ( mic < 4 mg / l ) steadily decreased over the study period as follows : 70.2% ( 2003 ) , 70% ( 2004 ) , 64.8% ( 2005 ) , and 57.4% ( 2006 ) ( test for trend 99.36 ; p<0.0001 ) . community consumption of penicillin/-lactamase inhibitors , predominantly amc , increased 34.7% from 2000 to 2006 ( figure 2 ) , whereas total antimicrobial drug consumption remained relatively constant ( 19.6 dids in 2000 compared with 19.1 dids in 2006 ) . after amc , the most used -lactam antimicrobial agents in the community in spain were amoxicillin , cefuroxime , and cefixime ; their consumption did not vary or slightly decreased from 2002 through 2005 ( 6 ) . evolution of consumption of outpatient penicillin/-lactamase inhibitors ( world health organization code j01cr02 ) , spain , 20002006 .", "the increased amc resistance of e. coli isolates from blood observed in this study is of serious concern from clinical and epidemiologic standpoints because amc is the first - choice antimicrobial treatment for many invasive e. coli infections . increased amc resistance coincided with growing amc consumption at the community level . in urinary infections , previous treatment with amc is a risk factor for the development of amc resistance ( 10 ) . amc resistance mechanisms ( -lactamase overproduction , ampc cephalosporinase hyperproduction , and inhibitor - resistant penicillinases ) ( 11 ) might be favored by strong amc consumption ." ]

[ "a 51-year - old caucasian female was referred to our institution because of an abnormal nodule detected in her right lung . this had at first been detected four months earlier when she underwent an urgent hartmann procedure due to refractory adenocarcinoma of the sigmoid colon ( pt4n1 stage ) . due to the urgency of the surgery , the patient was not staged prior to the surgery but was initially staged after the operation . the only pathologic finding in the computed tomography ( ct ) of the lung was a nodule in the lower right lobe of 2.5 cm at its longest dimension ( fig . she received 4 cycles of chemotherapy for the sigmoid adenocarcinoma before she was referred to us for excision of what was believed to be a single metastatic nodule . although the radiologic findings supported a benign tumor , neither positron emission tomography - ct nor any other procedure to attempt to diagnose the nodule was performed due to the patient 's willingness to undergo complete removal of the mass even if it were benign . the patient underwent video - assisted thoracoscopic ( vats ) wedge excision of the tumor . the specimen of the resected lung contained a firm intrapulmonary white - colored well - defined mass with dimensions of 2.52.32.2 cm . microscopically , the tumor had a \" patternless pattern , \" with proliferation of bland spindle cells in alternating hypocellular and hypercellular areas , accompanied by a collagenous stroma ( fig . the tumor had no evidence of increased mitotic activity ( 0 to 1 mitoses per 10 high power fields using an olympus bh-2 microscope , with a 40 field , 0.5 mm diameter , and area of 0.196 mm ) , any significant atypia , or necrosis . immunohistocemically , the tumor cells were positive for vimentin , cd34 ( fig . 2c ) , and bcl-2 . the index of cellular proliferation with the antibody ki-67 is low and estimated at < 1% of the cellular population . immunohistochemistry staining of the tumor cells was negative for alfa - smooth muscle actin ( sma ) , muscle specific actin ( hhf-35 ) , h - caldesmon , cd117 ( c - kit ) , s-100 protein , epithelial antigens ( wide spectrum cytokeratins [ ae1/ae3 ] and epithelial membrane antigen ) , and thyroid transcription factor-1 .", "solitary fibrous tumors ( sfts ) were first pathologically described by klemperer and rabin in 1931 . to the present , sft is the preferred term for an uncommon , but histomorphologically distinctive spindle cell neoplasm , that was identified in the past as fibrous mesothelioma , localized fibrous mesothelioma , localized fibrous tumor , localized mesothelioma , pleural fibroma , solitary fibrous mesothelioma , or submesothelial fibroma . there are reports of sfts arising either from mediastinal , diaphragmatic , or parietal pleura , or from within a lung fissure and in various extrapleural locations , such as the retroperitoneum , mediastinum , thyroid gland , nasal cavities , meninges , or parietal surfaces of the intra - abdominal viscera . less than 20 cases of intraparenchymal sfts have been reported in the english literature [ 1 - 5 ] . to prove and establish the fact that these lesions are indeed of pulmonary origin , it is important to consider the clinical , radiologic , and pathologic findings to demonstrate the lack of continuity with the visceral pleura and to exclude an endophytic growth in a pleural - based lesion . hypoglycemia and seizures can be encountered in some cases due to secretion of insulin - like growth factor ii by the tumor [ 1 - 3,5 ] . hemoptysis due to sft as well as hypertrophic osteoarthropathy secondary to sft of the lung has also been reported . there is no association with smoking or asbestos exposure . due to its non - specific symptoms , it can potentially mimic solitary pulmonary metastasis , as was the case with our patient . on gross examination , histologically , it is associated with variable patterns , the most common being the \" patternless pattern . \" the cytologic features consist of cellular areas composed of spindled to ovoid cells with scanty cytoplasm , occurring either solely or in groups . immunohistochemistry plays a substantial role in supporting the diagnosis made by morphologic features and is also helpful in differentiating these tumors from mesothelioma , neurofibroma , and other spindle - cell lesions . a differential diagnosis of intrapulmonary sft includes , among other lesions , pulmonary adenofibroma , benign neural neoplasms , leiomyoma and leiomyosarcoma , synovial sarcoma , spindle cell thymoma , spindle cell carcinoid tumor , nerve sheath tumor , fibrosarcoma , sarcomatoid carcinoma , and sarcomatoid mesothelioma . the morphologic features and immunohistochemical profile of sft are sufficiently distinct to allow separation from such conditions in the majority of the cases . several studies have reported positivity of tumor cells with cd34 antibody in almost 100% of cases , and with cd99 antibody in 70% of cases , whereas bcl-2 , sma , and epithelial membrane antigen are positive in 20% to 35% of the cases . the histologic criteria for classifying the malignant variants of sft of the lung and pleura were described by england et al . in 1989 and vallat - decouvelaere et al . in 1998 . they established the following features suggestive of malignancy : 1 ) more than 4 mitoses per 10 high - power fields , 2 ) presence of necrosis , 3 ) hemorrhage , 4 ) hypercellularity as detected by nuclear crowding and overlapping , 5 ) nuclear atypia , 6 ) pleomorphism , 7 ) stromal or vascular invasion , and 8) size exceeding 10 cm . . the absence of these characteristics does not exclude malignant behavior . on the other hand , encapsulation , pedunculated and resectability with free surgical margins are considered to be favorable prognostic factors even in histologically malignant variants . positive margins are associated with an aggressive clinical course and high rates of local recurrence and metastasis . resection with free margins is considered to be the treatment for sft located either in the lung or on the pleura . wedge resection may be accomplished by vats or standard thoracotomy , according to the anatomic position and size of the lesion and the experience of the surgeon . adjuvant therapy may have a place in recurrent or systemic disease , but its benefit is undefined . in general , sfts have an unpredictable course , depending on their potential for malignancy . in large series , the recurrence rate of benign sfts is reported to be low ( 1.4% ) , while the recurrence rate of malignant variants is reported to be higher ( range , 9% to 19% ) . a staging system based on pedunculated versus sessile attachment and malignant versus benign histology that predicts recurrence has been proposed by perrot et al . ( table 1 ) . due to the possibility of local recurrence and/or distal metastasis after surgical removal of the primary sft , long - term follow - up is recommended . local recurrence detected early is amenable to reoperation and resection , with good long - term results . the long - term survival rate for both benign and malignant variants is reported to be more than 90% [ 1 - 3,6 ] . in conclusion , sfts are neoplasms that usually arise from the pleura . an intraparenchymal or endobronchial location is a rare occurrence . resection with clear margins is curative and final diagnosis and prognosis can be defined only after surgical resection . the prognosis of patients with rare sfts of the lung depends on the completeness of the tumor resection . variants of sfts of the lung that are malignant or suspected to be malignant should be managed as lung cancer with regard to the surgical resection of the tumor and follow - up strategy ." ]

[ "synthesis of metal nanoparticles with the help of plant extracts is an emerging field of nanotechnology , due to their novel properties , terrific applications in biomedicine and its eco - friendly nature . in recent past great efforts were made for synthesis of environment benign and eco - friendly nanoparticle from plants such as iron oxide nanoparticles from medicago sativa , copper nanoparticles from magnolia kobus , calcium nanoparticles from boswellia ovalifoliolata , gold nanoparticles from avena sativa , zinc oxide nanoparticles from catharanthus roseus , and silver nanoparticles ( agnps ) from syzygium alternifolium . silver is one among the metal nanoparticles focused much interest due to its wide variety of applications . it has different biological activities such as antimicrobial , anthelmintic , antilarvicidic , antioxidant , anticancer , anti - inflammatory , hepatoprotective , and wound healing activity . conventional methods for synthesizing agnps are mainly by chemical , physical , and microbe - mediated synthesis . in these chemical and physical methods , usage of hazardous chemicals , high energy requirements , difficult and wasteful materials generate potential and biological hazards to the environment . whereas in the case of microbe - mediated synthesis . therefore biological synthesis of agnps by using plant materials is easy , efficient , and eco - friendliness in comparison to chemical mediated or microbe - mediated synthesis and they possess secondary metabolites having the redox capacity to reduce metal nanoparticles in an easiest way . adansonia digitata l. belongs to the family malvaceae is a large tree indigenous to africa and found in many countries also . traditionally , the fruit pulp dissolved in water or milk is used as a drink or sauce for food in africa . fruit pulp and powdered seeds are used for the treatment of diarrhea and dysentery in india . the high content of vitamin c in fruit pulp is recommended to pregnant women s for daily intake . in recent times , different scientists prove different activities of pulp such as hepatoprotective , antimicrobial , antiviral , antioxidant , antidiarrheal , hypoglycemic , anti - inflammatory , and antioxidant activities . due to high medicinal values and mythological significance of this plant is known as kalpavriksha ( a tree which fulfill all desires ) in india . in our previous studies , synthesis of agnps from stem bark and leaf extract of a. digitata acts as excellent reducing agents and show potential antimicrobial activity against different microorganisms . however , the potentiality of fruit pulp mediated synthesis of agnps is not carried out so far . hence , the present study is aimed to synthesize agnps from a. digitata fruit pulp extract , characterize and to know the potentiality of agnps against different microbial pathogens .", "2 to 4 kg weight mature fruits possess a great amount of pulp is collected from acharya ranga agricultural university , tirupati and cross checked by herbarium ( voucher no : svu362 ) deposited in department of botany , sri venkateswara university , tirupati . cut open the fruit and separate the seeds adhesive to pulp . grounded the collected pulp with the help of mortar and pestle , sieved the content for the synthesis of nanoparticles . for synthesis , 25 g of fruit pulp is extracted with 100 ml of distilled water on boiling water bath for 30 min , filter the content with whatman no . 1 filter paper and stored at room temperature . from this , 5 ml of the extract is taken into 250 ml of erlenmeyer conical flask and titrated against with the solution of 1 mm agno3 at a 60 - 80c temperature . the contents are cooled and centrifuged at 10,000 rpm for 20 min to avoid the presence of any biological impurities , and it is used for further characterization and antimicrobial studies . confirmation of synthesized nanoparticles is agnps by ultraviolet ( uv)-vis spectrophotometry absorption spectra using a spectro uv 2080 double beam , between the wavelength scan range of 190 - 700 nm , 1200 l / mm spectrophotometer , analytical technologies , india . to know the possible bio - molecules responsible for reduction and stabilization of agnps by fourier transform infra - red ( ftir ) spectra in the scan range of 4,000 to 500 cm transmittance with an alpha interferometer , bruker , ettlingen , karlsruhe , germany by kbr pellet method . x - ray diffraction of synthesized nanoparticles is examined by an x - ray diffractometer ( xrd ) ( shimadzu , xrd-6000 ) equipped with cu ka radiation source using ni as a filter at a setting of 30 kv/30 ma to know the crystalline nature of agnps . purity of agnps was analyzed by fei quanta 200 feg high resolution ( hr)-scanning electron microscopy ( sem ) machine equipped with edax instrument . to know the size , shape , agglomeration pattern , and dispersed nature of the nanoparticles are done by atomic force microscopy ( afm ) by nova nt - mdt solver next , russia . transmission electron microscopy ( tem ) using hf-3300 advanced 300 kv tem / stem from hitachi . the antimicrobial activity of biologically synthesized nanoparticles are analyzed on seven pathogenic bacteria such as bacillus subtilis atcc 6633 , staphylococcus aureus atcc 6538 ( gram - positive ) , escherichia coli atcc 25922 , klebsiella pneumonia atcc 43816 , proteus vulgaris atcc 13315 , pseudomonas aeruginosa atcc 15442 , salmonella typhimurium atcc 14028 ( gram - negative ) , and five fungal pathogens such as alternaria solani atcc 32904 , aspergillus flavus atcc 9643 , aspergillus niger atcc 16404 , penicillium chrysogenum atcc 11709 , and trichoderma harzianum atcc 20476 procured from department of microbiology , sri venkateswara university , tirupati . disc diffusion method was followed for testing antimicrobial activity against biologically synthesized agnps , and comparative studies were made with plant pulp extract , 1 mm agno3 as negative controls and streptomycin or fluconazole as a standard for bacteria and fungi , respectively . 1 filter paper and 20 l of plant extract , 1 mm agno3 solutions , and 10 g / disc streptomycin / fluconazole are loaded on separate discs and allowed to air dry for 1 h at sterile conditions . apart from these , a 5 , 10 , 20 , 40 , 60 , 80 g / ml concentrations of synthesized agnps are tested separately to know the minimum inhibitory concentration . 20 and 40 g / ml concentration of agnps show minimum inhibitory effect and 80 g / ml concentrations of agnps show maximum inhibitory concentration . due to this , we prefer 80 g / ml concentrations of agnps to check the antimicrobial activity on different microbial organisms . freshly prepared nutrient agar media for bacteria and potato dextrose agar media for fungi are poured into sterile petri plates , allowed to 30 min for solidification . the plates are swabbed with 100 l of microbial cultures and placed the previously prepared discs ; the experiment is carried out in triplicates . the plates are incubated at 37c for 24 - 48 h , and then the zone of inhibition is measured with the help of a scale and tabulated the results .", "2 to 4 kg weight mature fruits possess a great amount of pulp is collected from acharya ranga agricultural university , tirupati and cross checked by herbarium ( voucher no : svu362 ) deposited in department of botany , sri venkateswara university , tirupati . cut open the fruit and separate the seeds adhesive to pulp . grounded the collected pulp with the help of mortar and pestle , sieved the content for the synthesis of nanoparticles", "for synthesis , 25 g of fruit pulp is extracted with 100 ml of distilled water on boiling water bath for 30 min , filter the content with whatman no . 1 filter paper and stored at room temperature . from this , 5 ml of the extract is taken into 250 ml of erlenmeyer conical flask and titrated against with the solution of 1 mm agno3 at a 60 - 80c temperature . the contents are cooled and centrifuged at 10,000 rpm for 20 min to avoid the presence of any biological impurities , and it is used for further characterization and antimicrobial studies .", "confirmation of synthesized nanoparticles is agnps by ultraviolet ( uv)-vis spectrophotometry absorption spectra using a spectro uv 2080 double beam , between the wavelength scan range of 190 - 700 nm , 1200 l / mm spectrophotometer , analytical technologies , india . to know the possible bio - molecules responsible for reduction and stabilization of agnps by fourier transform infra - red ( ftir ) spectra in the scan range of 4,000 to 500 cm transmittance with an alpha interferometer , bruker , ettlingen , karlsruhe , germany by kbr pellet method . x - ray diffraction of synthesized nanoparticles is examined by an x - ray diffractometer ( xrd ) ( shimadzu , xrd-6000 ) equipped with cu ka radiation source using ni as a filter at a setting of 30 kv/30 ma to know the crystalline nature of agnps . purity of agnps was analyzed by fei quanta 200 feg high resolution ( hr)-scanning electron microscopy ( sem ) machine equipped with edax instrument . to know the size , shape , agglomeration pattern , and dispersed nature of the nanoparticles are done by atomic force microscopy ( afm ) by nova nt - mdt solver next , russia . transmission electron microscopy ( tem ) using hf-3300 advanced 300 kv tem / stem from hitachi .", "the antimicrobial activity of biologically synthesized nanoparticles are analyzed on seven pathogenic bacteria such as bacillus subtilis atcc 6633 , staphylococcus aureus atcc 6538 ( gram - positive ) , escherichia coli atcc 25922 , klebsiella pneumonia atcc 43816 , proteus vulgaris atcc 13315 , pseudomonas aeruginosa atcc 15442 , salmonella typhimurium atcc 14028 ( gram - negative ) , and five fungal pathogens such as alternaria solani atcc 32904 , aspergillus flavus atcc 9643 , aspergillus niger atcc 16404 , penicillium chrysogenum atcc 11709 , and trichoderma harzianum atcc 20476 procured from department of microbiology , sri venkateswara university , tirupati . disc diffusion method was followed for testing antimicrobial activity against biologically synthesized agnps , and comparative studies were made with plant pulp extract , 1 mm agno3 as negative controls and streptomycin or fluconazole as a standard for bacteria and fungi , respectively . 7 mm sterile discs are prepared from whatman no . 1 filter paper and 20 l of plant extract , 1 mm agno3 solutions , and 10 g / disc streptomycin / fluconazole are loaded on separate discs and allowed to air dry for 1 h at sterile conditions . apart from these , a 5 , 10 , 20 , 40 , 60 , 80 g / ml concentrations of synthesized agnps are tested separately to know the minimum inhibitory concentration . 20 and 40 g / ml concentration of agnps show minimum inhibitory effect and 80 g / ml concentrations of agnps show maximum inhibitory concentration . due to this , we prefer 80 g / ml concentrations of agnps to check the antimicrobial activity on different microbial organisms . freshly prepared nutrient agar media for bacteria and potato dextrose agar media for fungi the plates are swabbed with 100 l of microbial cultures and placed the previously prepared discs ; the experiment is carried out in triplicates . the plates are incubated at 37c for 24 - 48 h , and then the zone of inhibition is measured with the help of a scale and tabulated the results .", "reduction of ag into ag nanoparticles was observed visually by means of a color change pattern of the reaction medium . a. digitata fruit pulp having thick cream color , upon synthesis the color change from creamy to light yellow indicates the formation of nanoparticles . this color changed nanoparticles solution was analyzed by uv - vis spectrophotometry shows a broad absorption peak at 434 nm further confirms the formation of nanoparticles are agnps [ figure 1 ] . ftir spectroscopic studies of these synthesized nanoparticles show broad transmittance peaks at 3322 cm assigned for an o - h bond of phenols and 1636 cm assigned for an n - h bond of primary amines [ figure 2 ] . xrd spectrum of synthesized agnps shows the crystalline nature of agnps and gives four intensive peaks at 38.1 , 46.2 , 64.5 , and 77.3 of 2 degrees of x - axis corresponds to 111 , 200 , 220 , and 311 bragg reflections of y - axis [ figure 3 ] . the mean particle diameter of synthesized agnps is 44 nm , calculated according to debye - scherrer equation ( d = k/ cos ) and it coincides with powder diffraction file of joint committee on powder diffraction standards file no . the full width at half maximum values , i.e. k = 0.44 was derived from 38 , 46 , 64 , and 77 bragg reflections of the x - axis . 2 m resolution studies of biologically synthesized agnps with afm reveal the particles are polydispersed , spherical in shape , having the size range from 25 to 57 nm , and there is no agglomeration observed between the particles [ figure 4a ] . raw data obtained from this afm microscope is treated with a specially designed image processing software ( nova - tx ) to further exploit the three - dimensional ( 3d ) image of nanoparticles [ figure 4b ] . 500 nm resolution studies with 20 kv electron energy passing through the nanoparticles coated thin films on a clean glass slide reveals the nanoparticles are spherical in shape , polydispersed and having the size range from 18 to 32 nm [ figure 5a ] . the same sample was analyzed with the help of edax instrument shows 33.28% presence of ag in the sample [ figure 5b ] along with 05.29% of carbon , 03.28% of nitrogen , 31.80% of oxygen , 08.37% of sodium , 02.57% of magnesium , 01.01% of aluminum , 00.78% of silicon , 07.87% of aurum , and 05.74% of calcium [ table 1 ] . crystalline nature of synthesized agnps was analyzed using selected area electron diffraction ( saed ) by directing the electron beam perpendicular to nanoparticles . the saed pattern of synthesized agnps shows the spots had been corresponding to 111 , 200 , 220 , and 311 of the crystallographic nature of face - centered cubic structures [ figure 6a ] . 20 nm resolution studies with 300 kv electron energy passing through nanoparticles coated thin films on copper grid show the nanoparticles are polydispersed , spherical in shape and size range from 3 to 7 nm [ figure 6b ] . to know the antimicrobial potency of biologically synthesized agnps from fruit pulp of a. digitata was analyzed against two gram - positive , five gram - negative , and five fungal pathogens by disc diffusion method . among the bacterial pathogens , the highest inhibition zones were observed in p. vulgaris followed by k. pneumoniae , p. aeruginosa , s. typhimurium , e. coli , b. subtilis , and s. aureus . whereas in the case of fungi , the highest inhibition zones were observed in t. harzianum , followed by a. niger , a. flavus , p. chrysogenum , and a. solani . ultraviolet - vis spectrum of synthesized silver nanoparticles shows broad peak at 434 , 280 , and 247 nm of narrow peaks is due interference of phytoconstituents in the medium . inset figure shows color change pattern from cream to light yellow fourier transform infra - red spectrum of synthesized silver nanoparticles shows broad peaks at 3322 cm and 1636 cm x - ray diffractometer pattern of synthesized silver nanoparticles shows four intensive peaks atomic force microscopy micrograph of synthesized silver nanoparticles ( agnps ) , ( a ) 2 m resolution studies 25 - 57 nm size , spherical shaped , polydispersed particles , ( b ) three - dimensional image of agnps analyzed by nova - tx software scanning electron microscopy micrograph of synthesized silver nanoparticles ( agnps ) ( a ) 500 nm resolution studies shows 18 - 32 nm size , spherical shaped particles , ( b ) edax spectrum of synthesized agnps shows 33.28 weight percent of ag metal in the sample metal analysis by edax spectrum shows different weight percentages of sample transmission electron microscopy micrograph of synthesized silver nanoparticles ( agnps ) , ( a ) selected area electron diffraction pattern shows characteristic crystal spots of elemental silver , ( b ) 20 nm resolution studies of agnps shows 3 - 7 nm size , spherical shaped nanoparticles antimicrobial studies of biologically synthesized silver nanoparticles ( agnps ) from adansonia digitata pulp extract , ( a ) bacillus subtilis , ( b ) staphylococcus aureus , ( c ) escherichia coli , ( d ) klebsiella pneumoniae , ( e ) proteus vulgaris , ( f ) pseudomonas aeruginosa , ( g ) salmonella typhimurium , ( h ) alternaria solani , ( i ) aspergillus flavus , ( j ) aspergillus niger , ( k ) penicillium chrysogenum , ( l ) trichoderma harzianum , ( 1 ) plant extract , ( 2 ) agno3 , ( 3 ) agnps , ( 4 ) streptomycin / fluconazole zone of inhibition ( mm ) of agnps on microbial pathogens and comparative studies with different controls", "when the addition of agno3 solution to the plant extract the color of the plant extract is changed gradually according to the quantitative addition of agno3 solution . this color change is due to the reduction of nanoparticles with the help of electrons present in the fruit pulp extract coming from nad and ascorbic acid as electron donors present in the plant extracts . significantly higher amount of ascorbic acid , i.e. , > 300 mg/100 g was reported in fruit pulp of a. digitata . this solution was subjected to uv - vis spectrophotometry between the scan ranges of 190 - 750 nm , a broad peak is obtained at 434 nm . the same type of results was observed in leaf extract mediated synthesis of agnps from couroupita guianensis . the color change pattern and broad peak obtained in uv - vis spectrophotometry are due to surface plasmon resonance nature of agnps present in the medium . these nanoparticles absorb light at different wavelengths and excited due to charge density at the interface between conductor and insulator to give a respective peak on uv - vis spectrophotometry . ft - ir is a sensitive tool to analyze functional groups present in the biological samples . it relies on the light absorbance between 4000 cm to 500 cm of the electromagnetic , infrared region . in our case , the same type of results was observed in myristica fragrans seed extract mediated synthesis of agnps . from this ftir study , clearly reveals hydroxyl groups of phenols and amide groups of proteins from plant extract forming a layer to the nanoparticles and acting as a capping agent to prevent agglomeration and providing stability in the medium . based on these ftir studies , we suggest that the bio - molecules present in plant extracts play dual role in formation and stabilization to agnps . afm is a primary tool for analyzing size , shape , agglomeration pattern and also offers visualizations of 3d views of the nanoparticles , unlike the electron microscopes . it has an advantage over combination of hr , samples do not have to be conductive and does not require the high - pressure vacuum conditions . better resolution and percentage presence of nanoparticles were demonstrated by sem with edax instrument provides reliable characterization and morphology of the particles when compare to afm . the four intensive bragg reflections are appear in xrd pattern [ figure 3 ] is correlated with saed pattern [ figure 6a ] of agnps , clearly indicates the nanoparticles are crystalline in nature . higher resolution studies with tem analysis shows size , shape , and agglomeration pattern of nanoparticles . it achieves better resolution than sem due to electron energies higher than 20 kv used in sem . finally , all the microscopic studies reveal the biologically synthesized agnps are spherical in shape , having the size range from 3 to 57 nm polydispersed and no agglomerations were found between the particles . to test the inhibitory effect of biologically synthesized nanoparticles on different microorganisms bacterial species show the highest inhibitory activity when compare to fungi because the cell walls of fungi are made up of chitin is more rigid when compare to bacterial cell walls containing peptidoglycans . among the bacteria , gram - negative species show the highest inhibitory zones when to compare to gram - positive species , because the gram - negative species containing a less amount of peptidoglycans . silver is a precious metal used as an effective antimicrobial agent before the advent of agnps . due to overuse of silver products , decreased the efficiency of silver agents as antibiotic . in recent times with the advancement of nanotechnology , the interest in the use of agnps as antibacterial agents had been rekindled . small sized nanoparticles have higher antimicrobial activity than larger particles because they have large surface area to interact bacteria efficiently . in recent times , the scientists produce 30 to 40 nm size , spherical shaped agnps from fruit extract of vitis vinifera shows excellent antimicrobial activity against b. subtilis and k. planticola . 10 to 70 nm size , spherical shaped agnps synthesized from emblica officinalis fruit extract shows potential antimicrobial activity against s. aureus , b. subtilis , e. coli , and k. pneumoniae . euphorbia hirta leaf mediated synthesis of agnps having a spherical shape with 40 - 45 nm size shows good antifungal efficacy . in our studies also 3 - 57 nm size , spherical shaped agnps produced from a. digitata pulp extract confirmed by hr microscopic studies with afm , sem , and tem proved these agnps are eco - friendly antimicrobial agents against different microorganisms .", "in the present study , we report an eco - friendly , non - toxic , cost - effective method for synthesis of agnps from a. digitata pulp extract as reducing agent . in this method , naturally occurring materials are acts as reducing agents such as bio - molecules such as phenols and proteins present in plant extract as a simple and alternative to complex physical or chemical synthetic procedures . 3 to 57 nm size , spherical shaped , polydispersed nanoparticles are produced from a. digitata pulp extract confirmed by afm , sem , and tem prove this plant extract as an effective reducing agent for the production of narrow range of nanoparticles by industrial scale . further antimicrobial studies reveal that small size , spherical shaped particles have immense activity against different microbial pathogens and acts as eco - friendly antimicrobial agents ." ]

[ "malakoplakia is a rare chronic inflammatory disease that occurs most commonly in the genitourinary tract , especially the urinary bladder . most patients have associated conditions characterized by some degree of immunosuppression , as seen in solid - organ transplants , autoimmune diseases requiring steroid use , chemotherapy , chronic systemic diseases , alcohol abuse and poorly controlled diabetes.1 ) despite some characteristic histological features including the presence of large histiocytes with clusters of michaelis - gutmann ( mg ) bodies , malakoplakia of the kidney is difficult to diagnose because of its rarity and varying histological pictures.2 ) to our knowledge , there have been no case reports of malakoplakia of the kidney in a secondary adrenal insufficiency from korea . here , we report an unusual case of renal malakoplakia involving the perirenal space and extending to the descending colon in a 65-year - old korean woman with secondary adrenal insufficiency and diabetes mellitus .", "in march 2010 , a 65-year - old woman was transferred from the national police hospital ( nph ) to our facility , shinchon severance hospital ( seoul , korea ) via the emergency room ( er ) , presenting with a decreased level of consciousness . according to her medical history , she had hypertension , diabetes mellitus for 10 years , recurrent cystitis , and degenerative arthritis . she had been taking dexamethasone ( 5 mg , once a day ) for the degenerative arthritis for approximately five years up to the time of admission . three weeks before the admission , she had been hospitalized at nph due to drowsy mentality for 3 or 4 hours . on the day of admission at nph , she presented with a fever ( 38.8 ) and dyspnea . the patient was given antibiotics ( ceftriaxone and azithromycin ) for 14 days , on suspicion of community - acquired pneumonia . thereafter , her presenting symptoms were improved , but she complained of consistent pain in the left lower quadrant of the abdomen . abdomen - pelvis computed tomography ( ct ) scan was performed , which showed the mass - like lesion in the left renal area suspecting abscess . while being treated with ciprofloxacin , she developed a decreased level of consciousness . upon physical examination on the day of the admission to our hospital , her initial vital signs were as follows : blood pressure 134/71 mm hg , pulse rate 95 bits per minute , body temperature 36.4 , and respiration rate 18 breaths per minute . her breathing sound was clear , and her heart sound was normal without any murmurs . laboratory studies had the following results ( reference values ) : low sodium ( na ) levels of 112 mmol / l ( 135.0 - 145.0 ) , potassium ( k ) 3.4 mmol / l ( 3.5 - 5.5 ) , chloride ( cl ) 77.0 mmol / l ( 98 - 110 ) , total co2 21.0 mmol / l ( 24 - 30 ) , low serum osmolality 240.0 mosm ( 289.0 - 308.0 ) , and normal urine osmolality 315.0 ( 50.0 - 1200 ) . initial urinalysis results showed 3 - 5 white blood cells / high - power field and yeast - like organisms . in the radiological examination , there was no acute ischemic lesion in the brain magnetic re sonance imaging and angiography with neck angiography ( 3d ) , and no specific finding on the chest x - ray . sodium replacement therapy for hypotonic euvolemic hyponatremia had been started from the day of admission . at that stage , secondary adrenal insufficiency due to exogenous steroid was suspected . a low dose adrenocorticotropic hormone ( 1 g cosynthropin ) stimulation test was conducted to diagnose the secondary adrenal insufficiency . the stimulation test showed that there was adrenal insufficiency ; basal level of cortisol 8.56 g / dl , peak level during the hour - long test 13.94 g / dl ( table 2 ) . steroid hormone ( hydrocortisone sodium succinate ; solucortef ) was replaced . on the third day after admission , her general condition including clear consciousness was improved , with a normal level of serum sodium ( 136 mmol / l ) , and her steroid hormone dosage had been gradually tapered down and was maintained at 7.5 mg ( 5 mg , 2.5 mg two times a day ) of prednisolone acetate . however , the patient complained of myalgia , which was accompanied with leukocytosis ( white blood cell count 13,650 g / l [ neutrophil 84.9 % ] ) . radiological reading of the abdomen - pelvic ct conducted on the second day after admission showed that there was an ill - defined inflammatory lesion with multifocal abscess pockets in the left perirenal space , which was suspected of actinomycosis of the descending colon , extended to the left kidney ( figure 1a ) . compared to the abdomen - pelvic ct finding performed outside , the lesion seemed to have decreased slightly in size . urinalysis was repeated and showed many white blood cells per high - power field and yeast - like organisms , which was confirmed as yeast in the urine culture . considering the laboratory and radiologic findings , intravenous antibiotic treatment was started ( ubacillin 1,500 mg a day ) for suspected actinomycosis . no specific lesion was found at the colonoscopy performed to confirm the diagnosis of actinomycosis . on the 12th day after admission the histology of the lesion showed a collection of foamy histiocytes also known as von hansemann cells with von - kossa stain positive spheres ( michelis - gutmann body ) ( figure 2 ) . the patient presented dysuria and urgency , and antibiotic treatment was changed to oral ciprofloxacin ( 500 mg a day ) . on the 15th day after admission , she was discharged , as her presenting symptoms and laboratory findings were improved . about 4 months after discharge , the patient was readmitted presenting with general weakness for one month . the findings of the abdomen - pelvic ct conducted upon readmission ( figure 1b ) showed that the extent of the malakoplakia in the perirenal space had decreased since 9 week prior , as she had been taking the oral antibiotics . she has had follow - up in our outpatient clinic ever since , taking oral trimethoprim - sulfamethoxazole .", "malakoplakia is an uncommon but distinctive type of chronic granulomatous inflammation . upon microscopic examination , malakoplakia is characterized by the presence of sheets of histiocytes with granular cytoplasm ( von hansemann cells ) and the formation of intracellular bacterial inclusions called michaelis - gutmann bodies.3 - 7 ) the pathogenesis is poorly understood , but it is thought to result from acquired bactericidal defects in macrophages occurring mostly in patients with chronic debility or immunosuppression , a kidney transplant requiring steroids , or azathioprine.8,9 ) these observations suggest that an altered immune response may play a role in the pathogenesis of the disease . individuals with diabetes mellitus have a greater frequency and severity of infection . from the earliest reports on studies of adrenocortical function , there has been impressive evidence that adrenocortical hormone , and more specifically cortisol , is essential for normal immunity . otherwise , prednisone , triamcinolone , dexamethasone and similar commercially popular steroids have the dangerous side - effect of lowering resistance to infection , which is common to all known glucocorticoids.10 ) according to previous studies , gram - negative bacteria , particularly escherichia coli , have been isolated from involved sites of genitourinary malakoplakia in more than two - thirds of patients.11 ) bacteria other than yeast were not isolated in the urine culture in the present case with cystitis because the patient was on antibiotic therapy before admission to our hospital . although we did not carry out a detailed investigation of the patient 's immunity , we believe that unilateral renal malakoplakia extending to the perirenal space and the descending colon , as observed in the present case , may result from an interaction between various factors such as bacterial infection , impaired host immune response and diminished leukocyte function under the influence of a systemic illness such as secondary adrenal insufficiency and diabetes mellitus . the common presenting features of malakoplakia of the kidney are high fever , loin tenderness , and a palpable mass with a history of urinary tract infection.8 ) based on the reported studies , the degree of decreased kidney function varies up to acute renal failure.12,13 ) ultrasound and ct features are variable and only briefly mentioned in many reviews . features include enlarged kidneys,14 ) focal hypoechoic renal masses that simulate abscesses15 ) and heterogeneous masses that calcify , show central areas of necrosis and are mistaken for tumors.16 ) the imaging appearance of malakoplakia is therefore non - specific , and malignant renal tumor is a common misdiagnosis . the final diagnosis of malakoplakia is usually attained only upon histopathologic examination of the excised specimen . there is no established treatment for patients with malakoplakia . however , there are treatment options for malakoplakia that include antibiotics , surgical excision , or a combination of both , depending on the site and extent of involvement . some researchers have suggested that such antibiotics as trimethoprim - sulfamethoxazole and ciprofloxacin were beneficial because of their ability to penetrate intracellularly.8,17 - 20 ) we started the treatment with ciprofloxacin . during follow - up in the outpatient clinic , we changed the antibiotic treatment to trimethoprim - sulfamethoxazole due to the patient 's continued complaint of cystitis symptoms . in conclusion , renal malakoplakia should be taken into account in the differential diagnosis of a patient who presents with urinary tract infection , fever , abdominal pain , and abscess - like lesion in ultrasonography or ct , especially if the patient concerned has diabetes mellitus and a long history of use of exogenous steroids . it is considered that family physicians ' early diagnosis would enable prompt treatment and regular monitoring , leading to avoidance of long - term morbidity and mortality ." ]

[ "ghrelin , a 28-amino - acide peptide , is a potent stimulator of growth hormone release that \n has been implicated in the control of food intake and energy homeostasis in \n human begins and rodents \n [ 15 ] . ghrelin is not secreted into the gastrointestinal tract like digestive enzymes but into blood vessels to circulate throughout the body . ghrelin causes weight gain by increasing food intake and reducing fat use [ 7 , 8 ] . ghrelin has effects on nutrient intake and growth hormone ( gh ) release , subsequently on physical development and growth . tumor necrosis factor ( tnf- ) and interleukin-6 ( il-6 ) are pleiotropic cytokines with numerous immunologic and metabolic actions [ 10 , 11 ] . il-6 is generally considered to be an important cytokine in the network of cytokines that regulate immune reactions and acute phase responses . the relationship between congenital heart disease ( chd ) , malnutrition , and growth \n retardation is well documented . infants with congenital heart disease are prone to malnutrition for several reasons including decreased energy intake , \n increased energy requirements , or both . different types of cardiac malformations can affect nutrition and growth to varying degrees . although \n nutritional and growth status were investigated in children with cyanotic and acyanotic heart disease , serum ghrelin levels have not been established . the objective of this study is to investigate and compare the functional role of ghrelin on the regulation of energy balance in children with cyanotic and acyanotic congenital heart disease and the association of ghrelin with tnf- , il-6 , that were not entirely confirmed in literature by now .", "the study was conducted on 47 children with acyanotic chd , 21 children \n with cyanotic chd , and 25 healthy children . all patients ' cardiac diagnoses were \n made on the basis of clinical and laboratory examinations . body mass index ( bmi ) \n was calculated as the ratio of body weight ( kg ) and squared height ( m ) . all blood samples were drawn at 08 - 09 am and stored 20c \n until the procedure . serum ghrelin , tnf- , and il-6 levels were analyzed with \n elisa kits ( tnf- , il-6 kit was purchased from bio - source international inc . ( camarillo , calif , usa ) ; ghrelin kit from phoenix international , inc , usa ) . the given data were compared between groups using one - way anova , followed by post - hoc ; bonferroni test .", "in 47 acyanotic patients , mean age was 30.518.4 months , in 21 cyanotic patients was 28.415.6 months and in 25 control subjects was 31.115.1 months . age and anthropometric data of the patients and the control subjects are shown in table 1 . there was no significant difference between groups ( the acyanotic patients , the cyanotic patients ) in terms of mean age , weight , height , bmi . serum ghrelin levels were significantly higher than in acyanotic and cyanotic groups compared to in the control group ( p<.0001 ) ( table 3 ) . \n serum ghrelin levels in the acyanotic patients were significantly higher than in the cyanotic patients \n ( p<.0001 ) . \n tnf- \n levels were significantly higher \n than in cyanotic and acyanotic patients with chd compared to in the control groups ( p<.001 , p<.0001 , resp . ) . serum tnf- values were higher in the acyanotic patients compared to the cyanotic patients with chd ( p<.001 ) . serum il-6 levels were higher than in cyanotic and acyanotic patients with chd compared to in the control groups ( p<.0001 , p<.001 , resp . ) . in both acyanotic and cyanotic groups , serum ghrelin levels were negatively \n correlated with bmi ( r=.549 , p<.05 and r=.688 , p<.01 , resp . ) \n\t\t\t\t tnf- levels were not related \n to bmi in the acyanotic and cyanotic patients with chd . ghrelin levels were also correlated with tnf- in the acyanotic and cyanotic groups ( r=.485 , p<.05 and r=.573 , p<.01 , resp . ) ghrelin levels were not related to il-6 in the acyanotic and cyanotic patients with chd ( r=.263 , p>.05 and r=.398 , p>.05 , resp . ) .", "inadequate caloric intake , \n malabsorption , and increased energy requirements caused by increased metabolism \n may all contribute . however , inadequate caloric intake appears to be the most \n important cause of growth failure in chd [ 13 , 15 , 16 ] . patients with acyanotic \n heart disease had a greater growth deficit in weight , and those with cyanotic \n heart disease had a greater growth deficit in stature as demonstrated by both \n decreased height and weight . although growth impairment is most pronounced in \n infants with cyanotic chd , growth failure does not correlate well with the \n degree of hypoxia . in this study , the cyanotic patients had a more pronounced \n retardation in both height and weight than in the acyanotic patients [ 13 , 17 ] . ghrelin is accepted as a good marker of the nutritional state , mainly in situations of \n malnutrition , like anorexia nervosa , owing its fast recovery after weight gain . the inverse correlation between ghrelin levels and bmi we observed the mentioned correlation , both in children with cyanotic heart disease and in children with acyanotic heart disease . although the cyanotic patients had a more pronounced retardation in both height and \n weight than in the acyanotic patients , we found that serum ghrelin levels \n significantly elevated in the acyanotic patients than in the cyanotic patients \n ( p<.0001 ) . growth failure in cyanotic children has not been shown \n to be proportional to the severity of cyanosis , suggesting that multiple \n factors are involved in the pathogenesis of their growth disturbance . alteration of endocrine mediators of growth has been implicated as a possible \n mechanism of growth failure in cyanotic patients . cyanotic newborn lambs have \n decreased levels of serum insulin - like growth factor i without a corresponding \n decrease in growth hormone or hepatic growth factor receptors . weintraub et al . reported that while insulin - like growth factor i levels were linearly related to height and weight in patients with cyanotic lesions , no \n such correlation was found in their cyanotic patients . these studies suggest \n that chronic tissue hypoxia may have independent role in growth failure . we found that serum tnf- significantly increased in the cyanotic patients and in \n the acyanotic patients . similarly , serum il-6 was increased in both groups but the change was more distinctive in the cyanotic patients . tnf- and il-6 appear to be important cachectic process mediators , although this association is not completely established [ 23 , 24 ] . cachexia results in decreased muscle \n strength and function and compromised immune function [ 25 , 26 ] . this syndrome is likely to occur in children who have chronic congestive heart failure , chronic shunt hypoxemia . in addition to inadequate calorie and protein intake , there is evidence that this syndrome may be caused by circulating tumor necrosis factor , which stimulates catabolism . in the present study , ghrelin correlated to positively with tnf- , in acyanotic patients and cyanotic patients with chd . the relation of ghrelin with tnf- raises the possibility \n of the direct effect of tnf- upon ghrelin or the impact of heart failure \n severity upon both ghrelin and tnf-. nagaya et al . have shown that plasma ghrelin level is increased in cachectic patients with congestive heart \n failure as a compensatory mechanism in response to anabolic - catabolic \n imbalance . in conclusion , serum ghrelin level is elevated in cyanotic and acyanotic patients \n with chd . increased ghrelin levels additionally , the relation of ghrelin with cytokines \n may be explained by the possible effect of chronic congestive heart failure and chronic shunt \n hypoxemia ." ]

[ "enteric viruses are major etiologic agents of acute gastroenteritis among infants and young children worldwide . rotavirus , norovirus , adenovirus , and astrovirus are the recognized viral causes of pediatric gastroenteritis . the world health organization ( who ) data showed that each child practically has viral diarrhea irrespective of race and socioeconomic status within the first 5 years of life and this has great economic burden for the system of public health services and all society [ 2 , 3 ] . viral intestinal infections are the most common cause of acute infectious diarrhea in the pediatric group and accounted for approximately 70% of episodes of acute infectious diarrhea in children . there is paucity of information as regards viral enteropathogens of diarrhea in many developing countries including nigeria . the reason(s ) attributed to this may be as a result of the poor health care system in the country where important health issues are taken for granted such as the aforementioned case . thus , as a result of the nonperformance of viral tests for diarrheal patients , information on viral enteropathogens is lost and thus measures to implement control strategies become difficult . against this background , this study was carried out to ascertain the prevalence of rotavirus , adenovirus , and norovirus infection in young children with diarrhea in two primary health centers in edo state , nigeria . it also aimed at assessing the coinfection rates of the viral agents , age , seasonal distribution of infection , and the association between clinical symptoms and viral diarrhea .", "this study was carried out in two primary health centers located in ikpoba - okha local government area of edo state , nigeria . the health centers attend to the primary health needs of the people within and around the locality . cases attended to include malaria , diarrhea , immunization of infants and children , antenatal and postnatal cases , and other minor health issues within the scope of the health personnel . the two primary health centers are aduwawa and evbomodu primary health centers and they are neighboring communities with a fast growing population made up of indigenes with new residents from the main city alongside other inhabitants from other parts of the country . a total of two hundred and eighty - two ( 282 ) stool specimens comprising 223 diarrhea and 59 nondiarrhea stool specimens were collected from children aged between 0 and 36 months attending two primary health centers . as regards children with diarrhea , males were 121 while females were 102 . verbal informed consent was obtained from patients or guardian of the children prior to sample collection . the samples were collected from patients at the time of clinic visit as well as other times when the child defecates . sterile wide mouth specimen containers were used for specimen collection and they were processed within 6 hours of collection . rotavirus , adenovirus , and norovirus were detected by the immunochromatographic technique ( ict ) . rotavirus and adenovirus were detected using vikia rota - adeno rapid test device manufactured by biomerieux , france . briefly , 2 drops of liquid stool specimen was added to the specimen dilution buffer and shaken vigorously to homogenize . two drops of the diluted sample was transferred to the sample well of the test device ( cassette ) and was timed for 10 minutes . similarly , norovirus was detected using rida quick norovirus ( ni403 ) test device manufactured by r - biopharm ag , germany . briefly , 1 ml of sample dilution buffer ( diluent ) was placed in a separate labeled test tube and 100 ml of liquid stool was added to it and shaken vigorously to homogenize . this was allowed to settle for 2 minutes and 250 l of the supernatant was placed in a clean labeled test tube . six drops of conjugate 1 was added to the test tube and was shaken vigorously to homogenize . the mixture was emptied into the sample well of the test device and incubated for 10 minutes at room temperature . four drops of conjugate 2 was added to the reaction window of the test device and incubated for 1 minute at room temperature . 10 drops of wash buffer was added to the reaction window and was allowed to stay until the buffer was completely absorbed . six drops of substrate was added to the reaction window and timed for 3 minutes . statistical analysis was carried out using odd ratio and chi - square ( ) tests .", "a total of 223 children with diarrhea were tested for three viral agents ( rotavirus , adenovirus , and norovirus ) . a total of 95 ( 42.6% ) were positive for at least one viral agent while none of the 59 children without diarrhea was positive for any viral agent . the overall result showed that rotavirus had a prevalence of 63 ( 28.3% ) ( table 1 ) . the sex distribution of enteric viruses showed that males had 54 ( 44.6% ) positive cases while females had 41 ( 40.2% ) , and this was not statistically significant ( p = 0.60 ) . age group distribution of infection showed that 712 months had the highest infection rate with 48 ( 58.5% ) and was closely followed by 06 months which had 32 ( 50.8% ) . there was a statistical significance between age group and infection ( p < 0.0001 ) ( table 2 ) . the pattern of coinfecting viruses showed rotavirus - adenovirus mixed infection as the most prevalent with 12 ( 5.4% ) ( table 3 ) . the seasonal pattern of enteric viruses showed that rainy season had 60 ( 46.9% ) while dry season had 35 ( 36.8% ) , and this was not statistically significant ( p = 0.17 ) . the distribution of enteric viruses according to health centers was not statistically significant ( p = 0.89 ) ( table 4 ) . the distribution of viral agents with respect to clinical symptoms is showed in table 5 . the prevalence of rotavirus , adenovirus , and norovirus infections was investigated among children with diarrhea . the results of this study when compared to other studies carried out in nigeria and other parts of the world showed that the incidence of viral agents varied from one locality to another . the 28.3% of rotavirus in this study is lower than 55.9% in ilorin , nigeria , 35% in jos , nigeria , 33.3% in two districts in nigeria , and 39% in ghana . it is higher than 27% in zaria , nigeria , 28.1% in edo state , nigeria , 9.2% in botswana , and 16.9% in korea . the 19.3% of adenovirus in this study is lower than 22.3% in northwestern nigeria and 23.0% in tanzania . it is higher than 6.7% in nigeria , 3.0% in south africa , and 7.8% in botswana . the 3.6% of norovirus in this study is lower than 37.3% in nigeria , 16.4% in ghana , 39% in brazil , 11.6% in korea , and 15% in ghana . the differences among studies reporting viral infections in different countries might be explained by the different age group , seasonal variations , and viral detection methods used . there was a statistical significance between infection and age group ( p < 0.0001 ) . age group of 712 months had the highest prevalence of viral diarrhea with 48 ( 58.8% ) . this is consistent with the report of moyo et al . , who also found 712 months as the group with the highest infection . the reason for this may be due to the fact that it is the period of activities for many children . crawling and walking stages are at this period and in the process , children could pick harmful materials into their mouth especially in unhygienic conditions . it was observed in this study that , within the first year of life , viral infection rate was 84.2% and in the second year , it was 97.9% . this is in accordance with other studies where infection was most prevalent in children within the first 2 years of life [ 11 , 16 , 19 , 20 ] . the relatively low prevalence of viruses among older children could be partly due to immunity acquired through previous exposures . in this study , coinfection rate was 7.6% , and rotavirus - adenovirus coinfection was the highest with 12 ( 5.4% ) . this , however , did not agree with the reports of chung et al . and koh et al . , who had rotavirus - norovirus mixed infection as the most prevalent . the seasonal pattern of viral infection was not statistically significant ( p = 0.17 ) , though infection was more during the rainy season ( 46.9% ) than in the dry season ( 36.8% ) . reports from nigeria have showed that viral diarrhea occurs throughout the year but with variations with respect to seasons [ 8 , 13 , 16 ] . viral diarrhea with respect to the two primary health centers did not show statistical significance ( p = 0.89 ) , as infection rates for evbomodu and aduwawa health centers were 43.0% and 42.1% , respectively . the most commonly associated clinical symptom observed in this study with rotavirus , adenovirus , and norovirus positive cases was vomiting with 55.6% , 55.8% , and 75.0% , respectively . this finding is similar to other studies [ 2325 ] where vomiting was the most commonly associated symptom with viral diarrhea . rotavirus positive patients with respect to clinical symptoms such as fever , dehydration , and abdominal pain were low in this study compared to other studies [ 23 , 26 , 27 ] which reported high percentage of clinical symptoms . similarly , for adenovirus positive patients , fever , dehydration , and abdominal pain were low compared to other studies with moderate symptoms [ 13 , 24 , 28 , 29 ] . however , as regards norovirus positive patients , fever , dehydration , and abdominal pain were also low , but other studies with norovirus showed moderate to high clinical symptoms [ 25 , 30 , 31 ] . thus , the differences in clinical symptoms with viral diarrhea as seen from the different studies may be attributed to seasonal variations , geographical location , nutritional status of the patients , and type of viral pathogens causing the infection .", "coinfection of viral agents was found to be 7.6% and the most common clinical symptom was vomiting . this is worrisome considering the burden of these viruses on the young children in this locality . the fact that viral diagnostic tests are not routinely done or rarely done in any of the hospitals in this locality means that such vital information on viral diarrhea is missed out due to the poor attention given to health care in the country . thus , there is need to test stool specimens of clinically confirmed diarrheal patients for enteric viruses as this will go a long way in reducing the wasteful use of antibiotics which are used as blind treatment for persistent diarrhea that may be of viral origin . finally , the primary health care centers should be provided with all the necessary diagnostic test materials to address cases of viral diarrhea ." ]

[ "alpha ( )2-adrenoceptor agonists have been used as adjuvant to anesthetic agents in peri - operative period for its several beneficial actions . these drugs improve hemodynamic stability during endotracheal intubation and surgical stress by its central sympatholytic action , and thus reduce anesthetic and opioids requirements . dexmedetomidine , the pharmacologically active d - isomer of medetomidine , is highly selective and specific 2-adrenoceptor agonist . the analgesic effect of dexmedetomidine is qualitatively different as compared to opioids and can be used as an alternative to opioids in general anesthesia . the anesthetic sparing effect of dexmedetomidine demonstrated in earlier studies is confounded by the use of opioids . opioids , when used as analgesic in general anesthesia , are known to decrease mac value of sevoflurane . inhalation agents were titrated based on either hemodynamic criteria and/or bispectral index values in studies done earlier , and none of them demonstrated the effect of dexmedetomidine alone on requirement of sevoflurane with the use of entropy as a measure of depth of anesthesia . the primary objective of our study was to evaluate the effect of continuous infusion of dexmedetomidine alone , without use of opioids , on sevoflurane requirement during general anesthesia with continuous monitoring of depth of anesthesia by entropy analysis .", "the study protocol was approved by ethical committee of the institute , and written informed consent was obtained from all patients included in the study . the study population comprised of 60 patients , aged 18 - 55 years , with american society of anesthesiologists ( asa ) status of 1 and 2 , undergoing major elective surgical procedures . we excluded patients older than 55 years , those with a history of psychiatric / neurological illness , cardiovascular disease , hypertensive patients , morbid obese patients , pregnant and nursing women , with known allergic reaction to any of the study medication , recent use of sedatives or analgesics , and with significant laboratory abnormalities . the consenting patients were randomly allocated into one of the two anesthetic groups based on the simple randomization table generated : group a ( control group ) : sevoflurane - fentanyl and group b ( test group ) : sevoflurane - dexmedetomidine . after arrival in the operating room , glycopyrrolate 0.004 mg / kg and ondansetron 0.15 mg / kg intravenous ( iv ) were given as pre - medication in both the groups . the patients in group b received dexmedetomidine(2 ml diluted in 48 ml of saline ) iv in a dose of 1 mcg / kg over10 minutes through infusion pump prior to induction . monitoring consisted of continuous electrokardiogram ( ekg ) , non - invasive blood pressure ( nibp ) , pulse oximetry ( spo2 ) , co2 expired fraction ( etco2 ) , sevoflurane inspired fraction ( fisevo ) , sevoflurane expired fraction ( etsevo ) , and electroencephalograph ( eeg ) analysis by entropy ( response and state entropy ) . after the start of drug infusion , heart rate ( hr ) , blood pressure ( bp ) , respiratory rate ( rr ) , spo2 , and entropy were measured at 5 and 10 minute . patients in group a received fentanyl 2 g / kg intravenous slowly , 2 minutes prior to induction . after pre - oxygenation for 10 minutes , general anesthesia was induced with thiopentone sodium 5 mg / kg iv slowly . , dexmedetomidine infusion was continued between 0.2 and 0.8 mcg / kg / h depending on hr , bp , and entropy value changes . anesthesia was maintained with sevoflurane to a maximum of 2.5% end tidal to maintain heart rate and blood pressure within 20% of baseline value and entropy value between 40 and 60 . the anesthesiologist was permitted to treat hemodynamic events , defined as heart rate and blood pressure more than 20% of baseline , in spite of increasing sevoflurane concentration to 2.5% and dexmedetomidine infusion to 0.8 mg / kg with supplemental analgesia in the form of fentanyl 1 mcg / kg . if rise in heart rate and blood pressure persisted further after supplementation with fentanyl , anesthesiologist was permitted to administer incremental doses of metoprolol 2 - 5 mg . ephedrine 5 mg iv was given for fall in heart rate and blood pressure more than 20% of baseline . in the group b , dexmedetomidine was stopped approximately 15 - 20 minutes before completion of surgery , diclofenac sodium aqueous 1 mg / kg was given iv in both groups at the time of skin closure . reversal of neuromuscular blockade was achieved with neostigmine 0.05 mg / kg and glycopyrrolate 0.008 mg / kg iv slowly . tracheal extubation was done when respiration was satisfactory and adequate muscle tone was achieved . \n hr and bp were recorded before induction , at the time of induction , intubation , and then at 5 , 10 , 15 , 30 , 45 , and 60 minute after intubation and at extubation.depth of anesthesia was evaluated by entropy ( state entropy , response entropy ) analysis ( datex - ohmeda s/5 avance workstation , ge healthcare , helsinki , finland ) at 5 , 10 , 15 , 30 , 45 , and 60 minute after intubation and at extubation.end tidal concentration of sevoflurane was assessed with anesthesia gas assessment module e - caiovx at same interval as entropy analysis . \n hr and bp were recorded before induction , at the time of induction , intubation , and then at 5 , 10 , 15 , 30 , 45 , and 60 minute after intubation and at extubation . depth of anesthesia was evaluated by entropy ( state entropy , response entropy ) analysis ( datex - ohmeda s/5 avance workstation , ge healthcare , helsinki , finland ) at 5 , 10 , 15 , 30 , 45 , and 60 minute after intubation and at extubation . end tidal concentration of sevoflurane was assessed with anesthesia gas assessment module e - caiovx at same interval as entropy analysis . statistical analysis was conducted with epi info software ( version 3.5.3 , 2011 , centers for disease control and prevention , atlanta , ga , usa ) for windows statistical package using unpaired t - test for continuous variables with normal distribution . the non - parametric kruskal - wallis test was used for variables not normally distributed . for categorical variables , chi - square test was used .", "the two groups were similar regarding age , sex , weight , and asa physical status [ table 1 ] . pre - induction heart rate , systolic and diastolic blood pressures were similar between two groups ( p > 0.05 ) . the depth of anesthesia as assessed by response entropy ( re ) and state entropy ( se ) was comparable between two groups at all time points during maintenance period ( p > 0.05 ) . the re and se was maintained between 40 and 60 during the period of observation . the fisevo concentration was significantly less in group b as compared to the group a at all time points ( p < 0.05 ) [ figure 1 ] . the average etsevo concentration during anesthetic maintenance was 1.35% and 1.72% in the group b and a , respectively . a significant decrease of 13% to 33% of etsevo concentration was seen with group b from 5 min to 60 minutes post - intubation ( p < 0.05 ) during surgery [ figure 2 ] . fraction of inspired sevoflurane at different time interval ( pi - post - intubation , fi - fraction of inspired ) end tidal sevoflurane at different time intervals ( pi - post - intubation ) during anesthesia maintenance , group b showed a statistical significant decrease in heart rate , systolic and diastolic blood pressure from baseline at all time points as compared to the group a ( p < 0.05 ) . an average 6.5% fall in heart rate from baseline in group b as compared to 3.7% rise in the group a , 8% fall in systolic blood pressure from baseline as compared to 3.6% rise in the group a , and 8.16% fall in diastolic blood pressure from baseline as compared to 3.3% rise in the group a was observed [ figures 3 and 4 ] . changes in sbp and dbp at various time points post - intubation ( pi - post - intubation , sbp - systolic blood pressure , dbp - diastolic blood pressure ) changes in hr at various time points post - intubation ( pi - post intubation , hr - heart rate ) in our study , none of the patients in either group required supplemental analgesia or anti - hypertensive drugs intra - operatively . bradycardia was observed in 2 patients in group b within 10 mins post - extubation , which promptly responded to atropine 0.6 mg iv .", "the major observation in our study was that dexmedetomidine infusion as an adjuvant in general anesthesia causes decreased requirement of sevoflurane without compromising adequate depth of anesthesia , thus it has anesthetic - sparing property . a study done on patients undergoing hysterectomy showed a 30% reduction of maintenance concentration of isoflurane . similarly , a reduction in 35% to 50% in isoflurane concentration with low or high dose of dexmedetomidine was found in a study on healthy human volunteers . this larger reduction in isoflurane requirement seen as compared to our study might be due to difference in study population ( healthy human volunteers vs. patients posted for elective surgery ) and the type of stimulus ( tetanus nerve stimulus vs. surgical stimulus ) . the results of our study results are consistent with that of the study done by fragen , et al . in elderly patients , which showed a 17% reduction . dexmedetomidine by its sympatholytic action decreases heart rate and blood pressure , thus assessing the depth of anesthesia by hemodynamic parameters would be unreliable in evaluating its effect on requirement of inhalational agent . several electroencephalogram - dependent indices such as bispectral index and entropy have been used to measure the depth of anesthesia . entropy is a useful monitor for measuring the electroencephalographic effects of increasing and decreasing sevoflurane concentration and assessing the depth of anesthesia . analogous to the bispectral index , entropy displays a high degree of specificity and sensitivity in assessing consciousness during anesthesia . using bispectral index to assess the depth of anesthesia , magalhes et al . showed decreased requirement of sevoflurane with continuous infusion of dexmedetomidine during general anesthesia . in our study , we used entropy to measure the depth of anesthesia , thereby eliminating the bias of evaluation by hemodynamic parameters as in earlier studies . use of dexmedetomidine produces intra - operative and post - operative opioids - sparing effect . dexmedetomidine by its sympatholytic action attenuates symapthoadrenal response to tracheal intubation . in patients undergoing laparoscopic tubal ligation , a 33% decrease in morphine use post - operatively was observed when dexmedetomidine was used at a dose of 0.4 mcg / kg . dexmedetomidine when administered as infusion at a dose of 0.5 mcg / kg / h has specific analgesic effect and provides visceral pain relief . in morbidly obese , dexmedetomidine produces a greater decrease in sympathovagal balance intra - operatively than fentanyl along with better post - operative analgesia . dexmedetomidine , when used as sole substitute for remifentanil in ambulatory gynecologic laparoscopic surgery , provides better peri - operative hemodynamic stability and post - operative analgesia . dexmedetomidine provides similar intra - operative hemodynamic response and better post - operative analgesia compared to remifentanil in patients undergoing supratentorial craniotomy . use of opioids along with dexmedetomidine would confound its effect on requirement of inhalation agent . hence , in our study , fentanyl was not administered in dexmedetomidine group b , and we found a 21.5% decrease in the etsevo , in contrast to 33.12% decrease in study done by magalhes e et al . where fentanyl was used . one limitation of our study was that we included both laparoscopic as well as open surgeries . to conclude , the continuous infusion of dexmedetomidine , as adjuvant in general anesthesia , significantly decreases the requirement of sevoflurane for maintaining adequate depth of anesthesia . studies measuring plasma concentration of dexmedetomidine should be undertaken to establish the precise correlation between its dose and inhalational agent 's requirements ." ]

[ "", "rkshv.219 virus is latently infected in islk.rkshv219 cell line , derived from islk cell line , as previously described by . rkshv.219 cells were seeded at 5 10 cells into 150-mm dish ( one day prior to induction ) . for induction of kshv reactivation , the previous medium is replaced with 1% fbs dmem media containing a final concentration of 0.2 g / ml doxycycline . kshv reactivation was induced at 0 , 6 , 12 , 24 , and 48 h. the 0 h sample was treated identically to other timepoints , however doxycycline was not added . two independent biological replicates for each timepoint in islk.rkshv219 cell lines were processed and behaved similar for the nucleosome distribution assay . following doxycycline induction of kshv reactivation , islk.rkshv219 cells were harvested at 0 , 6 , 12 , 24 , and 48 h at 2.5 10 cells . media was aspirated and then 1% formaldehyde in pbs was incubated with the cells for 10 min at room temperature , to cross - link the chromatin structure . 125 mm glycine was then added to stop the formaldehyde cross - linking reaction . nucleus isolation buffer , 0.3 m sucrose , 2 mm mgoac2 , 1 mm cacl2 , 1% nonidet p-40 , 10 mm hepes , and ph 7.8 were then added to islk.rkshv219 cross - linked cells . the cells were scraped and placed within a 50 ml conical tube , and the nuclei were isolated by centrifugation at 1000 g for 5 min at 4 c . micrococcal nuclease , mnase , is a internucleosomal cleavage reagent , which does not cleave the dna protected by a nucleosome . islk.rkshv219 nuclei were digested with a titration of mnase : 4 u / ml , 2 u / ml , 1 u / ml , and 0.5 u / ml ( worthington biochemical corp . ) in mnase cleavage buffer ( 5 mm kcl , 4 mm mgcl2 , 1 mm cacl2 , 12.5% glycerol , and 50 mm tris cl ( ph 7.4 ) ) . a titration of mnase concentrations was utilized to ensure nucleosomes that are more and less readily cleaved are equally represented . the nuclei , following mnase digestion , were treated with 0.2 g/l proteinase k and 1% sodium dodecyl sulfate . mnase digested dna for all samples was resolved on a 2% agarose gel , and mononucleosomally protected dna , ~ 150 bp , was isolated by gel excision . following gel excision , the mononucleosomally protected dna was purified by electroelution , and for each sample 's mnase titration the mononucleosomally protected dna was combined . the mononucleosomally protected dna was further purified with phenol chloroform extraction and precipitated with alcohol . islk.rkshv219 cells were resuspended in 0.2-g/l proteinase k and 1% sds solution and incubated at 55 c overnight for bare genomic dna isolation . we utilized a high - resolution dna microarray , which we customized to contain 1 kb upstream and downstream of the transcription start sites of 462 immunity - related genes . nimblegen 's 12-plex and hd2 design were utilized for the custom dna microarray 100319_hg19_immunity_jd_cgh array . sequences were repeat - masked around the tsss , and only probes containing unique sequences for both the forward and reverse dna strands were printed on the microarray . oligonucleotide probes , sized at 60 bp , were tiled on each subarray with a mean spacing of 47 bp overlap . approximately 180 probes of spacing of 12.5 bp were printed on the microarray for each locus . the samples were fluorescently labeled : nucleosomally protected dna with cy3 and bare genomic dna ( reference ) with cy5 . samples were hybridized to the dna microarray according to nimblegen 's instructions ( http://www.nimblegen.com/technology/index.html ) . the resulting .tiff files were used for microarray data feature extraction , primary data analysis and generation of initial data files using the nimblegen deva software version 1.2 cgh workflow . specifically , loess spatial correction was applied to the raw data ; background correction was used to determine and adjust the signal data for noise using specifically designed background control probes ; and qspline normalization was applied to compensate for inherent differences in cy3 and cy5 signal . the ratio between nucleosomal ( cy3 ) and bare genomic cy5 signals was then calculated and stored as a general feature format , .gff subsequent analysis was performed using a software developed in our laboratory dennislab.r , which runs in the r environment for statistical computing . dennislab.r was used to generate summary statistics on the range of nucleosome distribution values for each individual chromosome . finally , we analyzed the nucleosome distribution changes at the 24 hour timepoint on a per chromosome basis , by calculating the t - statistic and p - value ( assuming unequal variance ) for the pairwise comparison of the range of values between all chromosomes . in our previous work we demonstrated that nucleosome redistributions are widespread , transient , and dna - directed , . we next wanted to determine if nucleosome redistributions showed chromosome specific changes in a time dependent manner . we first calculated the range of nucleosome occupancy values for all loci studied on a per chromosome basis for each post - kshv reactivation timepoint ( fig . these results comport with our previous observation that the greatest positioning occurs at the 24 hour timepoint , however do not indicate chromosome specificity with respect to increased positioning . we next wanted to investigate if the nucleosome redistribution changes at the 24 hour timepoint reflected increased or decreased nucleosomal occupancy . we calculated the median nucleosome occupancy values on each chromosome for all of the loci measured . we discovered that nucleosome occupancy values change in a chromosome specific manner ( fig . chromosomes 18 , 19 , and 22 show the greatest median nucleosome occupancy values at the 24 hour timepoint . conversely , chromosomes 1 , 2 , 9 , 10 , 12 , 15 , and 17 show the lower median nucleosome occupancy values at the 24 hour timepoint . we were next interested in calculating the statistical significance of the chromosome specific nucleosome occupancy changes that we had identified at the 24 hour timepoint . most of the ranges of nucleosome occupancy values are not statistically significantly different from one another ( fig . 1c , yellow highlights ) . these two chromosomes show clear increases in the nucleosome occupancy relative to the other chromosomes . at the other end of the scale , chromosomes these results demonstrate that while nucleosomal positioning remains relatively constant between chromosomes at each timepoint , nucleosomal occupancy changes in a chromosome specific manner .", "rkshv.219 virus is latently infected in islk.rkshv219 cell line , derived from islk cell line , as previously described by . rkshv.219 cells were seeded at 5 10 cells into 150-mm dish ( one day prior to induction ) . for induction of kshv reactivation , the previous medium is replaced with 1% fbs dmem media containing a final concentration of 0.2 g / ml doxycycline . kshv reactivation was induced at 0 , 6 , 12 , 24 , and 48 h. the 0 h sample was treated identically to other timepoints , however doxycycline was not added . two independent biological replicates for each timepoint in islk.rkshv219 cell lines were processed and behaved similar for the nucleosome distribution assay .", "following doxycycline induction of kshv reactivation , islk.rkshv219 cells were harvested at 0 , 6 , 12 , 24 , and 48 h at 2.5 10 cells . media was aspirated and then 1% formaldehyde in pbs was incubated with the cells for 10 min at room temperature , to cross - link the chromatin structure . 125 mm glycine was then added to stop the formaldehyde cross - linking reaction . nucleus isolation buffer , 0.3 m sucrose , 2 mm mgoac2 , 1 mm cacl2 , 1% nonidet p-40 , 10 mm hepes , and ph 7.8 were then added to islk.rkshv219 cross - linked cells . the cells were scraped and placed within a 50 ml conical tube , and the nuclei were isolated by centrifugation at 1000 g for 5 min at 4 c .", "micrococcal nuclease , mnase , is a internucleosomal cleavage reagent , which does not cleave the dna protected by a nucleosome . islk.rkshv219 nuclei were digested with a titration of mnase : 4 u / ml , 2 u / ml , 1 u / ml , and 0.5 u / ml ( worthington biochemical corp . ) in mnase cleavage buffer ( 5 mm kcl , 4 mm mgcl2 , 1 mm cacl2 , 12.5% glycerol , and 50 mm tris cl ( ph 7.4 ) ) . a titration of mnase concentrations was utilized to ensure nucleosomes that are more and less readily cleaved are equally represented . the nuclei , following mnase digestion , were treated with 0.2 g/l proteinase k and 1% sodium dodecyl sulfate . mnase digested dna for all samples was resolved on a 2% agarose gel , and mononucleosomally protected dna , ~ 150 bp , was isolated by gel excision . following gel excision , the mononucleosomally protected dna was purified by electroelution , and for each sample 's mnase titration the mononucleosomally protected dna was combined . the mononucleosomally protected dna was further purified with phenol chloroform extraction and precipitated with alcohol . islk.rkshv219 cells were resuspended in 0.2-g/l proteinase k and 1% sds solution and incubated at 55 c overnight for bare genomic dna isolation .", "we utilized a high - resolution dna microarray , which we customized to contain 1 kb upstream and downstream of the transcription start sites of 462 immunity - related genes . nimblegen 's 12-plex and hd2 design were utilized for the custom dna microarray 100319_hg19_immunity_jd_cgh array . sequences were repeat - masked around the tsss , and only probes containing unique sequences for both the forward and reverse dna strands were printed on the microarray . oligonucleotide probes , sized at 60 bp , were tiled on each subarray with a mean spacing of 47 bp overlap . approximately 180 probes of spacing of 12.5 bp were printed on the microarray for each locus . the samples were fluorescently labeled : nucleosomally protected dna with cy3 and bare genomic dna ( reference ) with cy5 . samples were hybridized to the dna microarray according to nimblegen 's instructions ( http://www.nimblegen.com/technology/index.html ) .", "the resulting .tiff files were used for microarray data feature extraction , primary data analysis and generation of initial data files using the nimblegen deva software version 1.2 cgh workflow . specifically , loess spatial correction was applied to the raw data ; background correction was used to determine and adjust the signal data for noise using specifically designed background control probes ; and qspline normalization was applied to compensate for inherent differences in cy3 and cy5 signal . the ratio between nucleosomal ( cy3 ) and bare genomic cy5 signals was then calculated and stored as a general feature format , .gff subsequent analysis was performed using a software developed in our laboratory dennislab.r , which runs in the r environment for statistical computing . dennislab.r was used to generate summary statistics on the range of nucleosome distribution values for each individual chromosome . finally , we analyzed the nucleosome distribution changes at the 24 hour timepoint on a per chromosome basis , by calculating the t - statistic and p - value ( assuming unequal variance ) for the pairwise comparison of the range of values between all chromosomes .", "in our previous work we demonstrated that nucleosome redistributions are widespread , transient , and dna - directed , . we next wanted to determine if nucleosome redistributions showed chromosome specific changes in a time dependent manner . we first calculated the range of nucleosome occupancy values for all loci studied on a per chromosome basis for each post - kshv reactivation timepoint ( fig . these results comport with our previous observation that the greatest positioning occurs at the 24 hour timepoint , however do not indicate chromosome specificity with respect to increased positioning . we next wanted to investigate if the nucleosome redistribution changes at the 24 hour timepoint reflected increased or decreased nucleosomal occupancy . we calculated the median nucleosome occupancy values on each chromosome for all of the loci measured . we discovered that nucleosome occupancy values change in a chromosome specific manner ( fig . chromosomes 18 , 19 , and 22 show the greatest median nucleosome occupancy values at the 24 hour timepoint . conversely , chromosomes 1 , 2 , 9 , 10 , 12 , 15 , and 17 show the lower median nucleosome occupancy values at the 24 hour timepoint . we were next interested in calculating the statistical significance of the chromosome specific nucleosome occupancy changes that we had identified at the 24 hour timepoint . most of the ranges of nucleosome occupancy values are not statistically significantly different from one another ( fig . 1c , yellow highlights ) . these two chromosomes show clear increases in the nucleosome occupancy relative to the other chromosomes . at the other end of the scale , chromosomes 1 and 12 are statistically indistinguishable , yet different from all other chromosomes . these results demonstrate that while nucleosomal positioning remains relatively constant between chromosomes at each timepoint , nucleosomal occupancy changes in a chromosome specific manner ." ]

[ "primary pleuropulmonary synovial sarcoma ( ppss ) is a rare soft tissue malignancy representing only 0.1% - 0.5% of all primary lung malignancies . the frequency of cardiac metastasis from soft tissue sarcomas ranges from 3.5% to 35% with only two cases of metastatic synovial sarcoma of the heart reported : one involving the right ventricle and the other the left ventricle . both cases had a primary tumor in the extremities rather than in the lungs without focusing on the imaging findings of these rare lesions ( 2 - 4 ) . we report a case of ppss that eventually metastasized to the heart in a 17-year - old female .", "a 17-year - old female presented with dull pain in the left upper chest alternating with brief periods of chest discomfort lasting a few months . she had no serious medical or surgical history and grew up in normal residential and social environments . all laboratory data including blood tests , standard biochemical tests , and urinalysis were within normal limits . chest radiographs ( figure 1a and b ) revealed a well - defined round mass in the left upper hemithorax . the mass was at an obtuse angle to the chest wall and was approximately 8 cm long . chest ct ( figure 1c - e ) confirmed a well - defined oval - shaped mass with heterogeneous enhancement in the left upper hemithorax abutting the pleura . in the pre - contrast image , the lesion showed homogeneous soft tissue attenuation and a lack of calcification , but a small amount of high - attenuation fluid was present in the left pleural space , suggestive of hemothorax . after contrast enhancement , the mass showed heterogeneous enhancement , with attenuation similar to that of the back muscles , and contained subtle low densities suggestive of necrosis or hemorrhage . the mediastinal and hilar lymph nodes were not enlarged . in the scanned portion of the abdomen f-18 fluorodeoxyglucose positron emission tomography - ct ( 18f fdg pet / ct ) revealed increased fdg uptake in the mass , with a maximum standardized uptake value of 31.7 ( figure 1f ) . from these imaging findings , the diagnoses of a localized fibrous tumor of the pleura , malignant mesothelioma , metastatic pleural malignancy , and rare primary pulmonary sarcoma ( e.g. , pleuropulmonary synovial sarcoma , fibrosarcoma , leimyosarcoma , sarcomatoid carcinoma , malignant nerve sheath tumor , hemangiopericytoma , and malignant fibrous histiocytoma ) were considered . these diagnoses were based on the tumor s appearance as a sharply marginated , heterogeneously enhanced mass with low attenuation foci and no involvement of the bone or calcifications . ct - guided core needle biopsy of the mass yielded two samples of yellowish gelatinous material . microscopic examination showed relatively uniform spindle - shaped cells with occasional mitoses arranged in tight fascicles . the tumor cells were immunoreactive to vimentin and cd99 and were focally positive for epithelial membrane antigen ( ema ) , suggesting a monophasic synovial sarcoma . medical and surgical oncologists agreed to treat the tumor with surgical resection and to initiate a combination chemotherapy regimen consisting of five cycles of vincristine , doxorubicin , and cyclophosphamide , alternating with four cycles of ifosfamide and etoposide . a thoracotomy was performed , and the mass was found to arise from the visceral pleura and to adhere to the left first to third intercostal spaces , with invasion into the left first intercostal muscle with adjacent hemothorax . the surgical specimen consisted of an 8.0 6.5 5.5 cm well - circumscribed but unencapsulated tumor . the tumor was whitish - yellow , soft , and fleshy with cystic degenerative changes and hemorrhage . histologically , the tumor was composed of densely packed , cellular sheets of spindle cells , and some of the tumor cells were arranged in intersecting fascicles in a herringbone pattern , suggesting fibrosarcoma - like changes ( figure 1 g - h ) . the tumor cells were relatively uniform with ovoid nuclei , scant cytoplasm , and occasional mitotic figures . immunohistochemical staining revealed immunoreactivity of the tumor cells to cytokeratin , ema , and cd99 but not to cd34 or desmin ( figure 1i - j ) . a final diagnosis of a monophasic synovial sarcoma from the visceral pleura was made based on the histological and immunohistochemical findings . she was discharged after surgical resection without complications , after which she underwent adjuvant chemotherapy and radiotherapy . the patient remained stable for 28 months until follow - up contrast - enhanced chest ct revealed a 1.6 cm low attenuation nodule with poor enhancement in the left pericardial area and a small amount of left pericardial and pleural fluid ( figure 2a ) . subsequent 18f fdg pet / ct showed slightly increased fdg uptake in the developing nodule with suspected metastasis . five months after discovery , follow up contrast - enhanced chest ct demonstrated a well - circumscribed polycyclic marginated mass with heterogeneous enhancement in the left pericardial region that had enlarged from 1.6 cm to 5.1 cm ( figure 2b ) . although mri is the most accurate technique for demonstrating cardiac mass , oncologists found the following mri might be ineffective for choosing further treatment for the pericardial mass due to high cost . they had no choice but to do surgery for the mass whether to perform mri or not . therefore , they agreed to operate surgical resection to treat pericardial mass without obtaining cardiac mri . the tumor specimen was a 6.0 5.0 2.0 cm well - circumscribed , whitish - yellowish , fleshy to rubbery mass with zones of necrosis and hemorrhage . the tumor was lateral to the left ventricular wall with invasion into the pericardium , myoendocardium , and endocardium of the left ventricle . microscopically , the tumor contained tight clusters and fascicles of spindle cells with scant cytoplasm , identical to the ppss , confirming a metastatic synovial sarcoma with left pericardial , myoendocardial , and endocardial involvement . after metastatectomy , the patient received adjuvant chemotherapy and radiotherapy . the patient s postoperative period was complicated by recurrent pneumonia .", "ppss is a rare mesenchymal spindle cell malignancy representing a type of pulmonary sarcoma that comprises 0.1% - 0.5% of all primary lung malignancies . typically , it arises from the chest wall , lung parenchyma , pleura , or mediastinum , but rarely at the level of the bronchial tree , and during the fifth decade of the patient s life ( 1 ) . the 5-year survival rate varies from 36% to 76% ( 6 ) . a small but increasing number of cases of ppss have been reported over the past decades ( 5 ) , but very few of these cases have involved cardiac metastasis . cardiac metastasis from soft tissue sarcomas varies from 3.5% to 35% , with only two cases of metastatic synovial sarcoma of the heart reported : one involving the right ventricle and the other the left ventricle . both of those cases had a primary tumor in the extremities but not in the lung without focusing on the imaging findings of these rare lesions ( 2 - 4 ) . additionally , a literature review of soft tissue sarcomas included only 105 cases of cardiac metastasis . in that review , the predominant histological type was leiomyosarcoma ( 22% ) followed by rhabdomyosarcoma ( 19% ) , and liposarcoma ( 9% ) ; 27% of the cases were unspecified . that report suggested that the clinical manifestation of cardiac metastasis can be subtle , as one - third presented with congestive cardiac failure , which led to other complications such as embolism , tumor thrombus , cardiac tamponade , and arrhythmia ( 2 ) . in our case , the patient was initially asymptomatic except for dull chest pains with only pericardial effusion on follow - up chest ct . symptoms frequently associated with these tumors are chest pain , dyspnea , and cough ; up to 40% of patients are asymptomatic ( 7 ) . the radiological features of ppss are summarized as follows : chest radiographs typically demonstrate a well - defined pleural - based or parenchymal mass - like lesion occasionally associated with ipsilateral pleural effusion . generally , the contralateral lung is not involved . ct and magnetic resonance imaging ( mri ) are relatively useful tools for evaluating ppss , although the findings are nonspecific . the most common ct finding of ppss is a well - defined , heterogeneously enhancing mass often with combined ipsilateral pleural effusion . the inner low - density area often contains necrosis , hemorrhage , or fibrous components . associated lymphadenopathy as well as calcifications , cortical bone destruction , or tumor infiltration of the chest wall and musculature are infrequent . ppss often exhibits heterogeneous high signal intensity on t2-weighted images and iso- or low signal intensity on t1-weighted images . after administering gadolinium differential diagnoses for ppss include metastasis from the extrapulmonary synovial sarcoma , a primary tumor such as a pleural fibroma or mesothelioma , or other primary sarcomatous or sarcomatoid neoplasms . the typical clinical and radiologic features can help narrow down the differential diagnosis of ppss . a history of asbestos exposure and the presence of pleural plaques are indicative of malignant mesothelioma . metastatic disease rarely manifests as a large solitary pulmonary lesion , although many other rare primary sarcomatous or sarcomatoid neoplasms can not be distinguished reliably from ppss based on clinical and radiologic features alone ( 5 ) . monophasic synovial sarcomas are much more common , representing 94% of ppss , and are composed of uniform spindle cells . the surrounding plump spindle cells have hyperchromatic nuclei with scant cytoplasm resembling the tumor cells of monophasic synovial sarcoma . immunohistochemically , most synovial sarcomas show focal expression of cytokeratin and ema . furthermore , 30% are protein s-100 positive , 60% - 70% cd99 positive , and 75% - 100% bcl-2 positive ( 8) . the prognosis of ppss remains uncertain but is usually poor . the 5-year survival rate varies from 36% to 76% depending on the patient s age , tumor size , and tumor resectability ( 6 ) . there is no recommended treatment for ppss , but the mainstay of treatment for all soft tissue sarcomas is surgical resection . aggressive surgery can reduce the tumor size before or after chemotherapy , and complete surgical excision seems to improve the survival of patients with ppss . combination chemotherapy consisting of doxorubicin and ifosfamide has been associated with higher rates of survival in patients with synovial sarcoma ( 6 ) . in summary , ppss is a very rare , aggressive malignancy that must be considered in the differential diagnosis of lung and pleural malignancies . the imaging findings of ppss are nonspecific , and ppss is difficult to confirm based on imaging ; detailed immunohistochemical staining is required for definitive diagnosis . ppss with cardiac metastasis is also extremely rare , and only two such cases have been reported . however , cardiac metastasis of ppss can lead to immediate or delayed death ; therefore , early detection and appropriate management are very important to extend survival ." ]

[ "", "the work is self - sponsored by the first author who conceptualized and designed and wrote the manuscript . the second author assisted in the surgery provided some literature review and made necessary correction which lead to the final manuscript .", "the ethical committee of first choice specialist hospital where the authors carried out the procedure approved the work .", "he understood that part of his images will be published and also understood that due to the rarity of the case , that it is worthwhile publishing it for education and for health care delivery .", "the second author assisted during the surgery , provided immediate care , provided some literature review and made necessary correction which lead to the final manuscript .", "" ]

[ "a number of skin disorders have been described in patients with acquired immunodeficiency syndrome ( aids ) . among them , secondary infections are common , but their incidence has decreased considerably following the introduction of combined therapies targeted to the human immunodeficiency virus ( hiv ) . some clinical presentations may be puzzling , particularly in secondary syphilis exhibiting lesions showing a marked tendency to polymorphism .", "a 29-year - old woman with a three - year history of aids presented with polymorphic papules on the face and abdomen . the skin lesions were asymptomatic but the patient complained of discrete malaise , stiff neck , myalgia headache , and mild fever . a biopsy specimen was taken from a papule on the abdomen . a series of 5-m thick sections were cut from the formalin - fixed paraffin - embedded biopsy . an immunohistochemical assessment was performed using a rabbit polyclonal antibody directed to treponema pallidum ( 1:200 biocare medical , walnut creek , ca , usa ) . the envision ( dakopatts , glostrup , denmark ) polymer - based revelation system and fast red ( dakopatts ) staining were used . negative immunohistochemical controls were performed by omitting or substituting the primary and the secondary antibodies in the laboratory procedure .", "the dermoepidermal junction contained a band - like infiltrate composed mostly of lymphocytes , histiocytes , and plasma cells . a deeper cell infiltrate of similar composition extended along the microvasculature , hair follicles , and sweat glands . the typical spiral , corkscrew , and threadlike spirochetes were highlighted by the red chromogen , and the contrast with the clear background was striking ( figure 1a , b , c ) . their presence inside the lichenoid infiltrate was associated with a dense superficial and deep perivascular cuff of spirochetes . the latter slender spirochetes were clustered in the dermal stroma ( figure 1a ) and in rims confined to the perivascular areas ( figure 1b , c ) . in addition , some t. pallidum were evident in the cytoplasm of cells , particularly endothelial cells ( figure 1c ) . dermal homing of t. pallidum on immunohistochemistry : ( a ) multiple interstitial clumps of spirochetes ( 200 ) ; ( b ) vascular trapping of spirochetes ( 400 ) ; ( c ) prominent accumulation of spirochetes in the microvasculature wall ( 400 ) . early syphilis . dermal homing of t. pallidum on immunohistochemistry : ( a ) multiple interstitial clumps of spirochetes ( 200 ) ; ( b ) vascular trapping of spirochetes ( 400 ) ; ( c ) prominent accumulation of spirochetes in the microvasculature wall ( 400 ) .", "in the present case , skin immunohistochemistry shed some light on the diagnosis of syphilis in an aids patient and showed the dermal homing and the microvascular tropism of t. pallidum . it is acknowledged that during a five - year period after inoculation , t. pallidum spreads to every organ . a long time later , it commonly re - emerges as a chronic and deadly illness . at any stage in its evolution , syphilis may mimic a number of other unrelated diseases . during the past decade , a sizable proportion of the population with syphilis corresponded to gay men coinfected with hiv . when the clinical diagnosis of syphilis is not established , a skin biopsy sometimes is submitted to the dermatopathologist without any relevant information . at the conventional histological examination , the diagnostic clues for syphilis are not always obvious because the disease presentation depends on both the host immunological response to the infection and the diverse angioinvasive propensity of the t. pallidum strains indeed , the histochemical silver stain may be difficult to interpret owing to heavy background staining . immunohistochemistry using an antibody directed to t. pallidum was reported to improve the histological diagnostic accuracy of syphilis . the present finding was assumed to illustrate the migration of t. pallidum toward the microvasculature during early syphilis . in summary , t. pallidum were abundant and heavily clustered in some specific portions of the skin . the peculiar homing of t. pallidum in the skin appears quite specific as it has not been reported for any other infectious microorganism ." ]

[ "hadrontherapy is an innovative form of radiotherapy , based on high - technology equipment using proton or carbon ions beams to destroy tumours [ 1 , 2 ] . this treatment method enables significantly higher ballistic precision to be achieved , compared to photons ( x - rays ) with , as expected therapeutic benefit , an improvement of quality of life and chances of recovery . carbon ions are also specifically characterised by superior biological efficacy ( relative biological effectiveness from 1.5 to 3 ) , overcoming the radiation resistance of certain cancers to photons and even protons . indeed , carbon ion beams when compared to x - rays represent a distinct advantage for the treatment of highly radiation - resistant tumours . an initial study assessing recruitment potential for proton therapy was conducted in 1998 in italy , showing an incidence of 10 825 cases / year . one year later , a second study was carried out in the context of the medaustron project for the construction of a carbon ions therapy centre in austria . considering patients living in austria and neighbouring countries , the patient recruitment potential ( proton and carbon ) was estimated with an incidence of 13 145 cases / year . in france , in 2002 , a third study was conducted in the context of the etoile medical project . this study revealed an annual incidence of approximately 5320 cases / year for carbon ions . concomitantly , a fourth study was conducted , again in the context of the medaustron project , estimating the incidence of cases eligible for hadrontherapy in austria at 2044 cases / year . finally , again in 2002 , in the context of the project for the construction of the cnao centre in italy , an epidemiological study was conducted , estimating the incidence of cases eligible for carbon therapy at 3694 cases / year and proton therapy at 1885 cases / year . . since 2004 , no other epidemiological studies have been published for hadrontherapy . in 2011 , however , the japanese team from the national institute for radiological sciences ( nirs ) , pioneer in carbon therapy , published the results of its 1994 to 2011 clinical activity . patients were included in clinical trials and the number of patients receiving carbon therapy was 6157 . this value is the incidence of treated cases , over 17 years without any notion of recruitment potential and with a rather slow ramp up of the activity . a list of priority indications that can be treated by hadrontherapy ( table 1 ) was drawn up by the gcs etoile medical group , in collaboration with national and international experts , based on published data ranked using an evidence - based medicine this literature review was based on provided or expected medical service criteria ( survival and quality of life ) . according to the classification used by the european survey group of rare diseases , the eligible tumours that can be treated by hadrontherapy conform to the criteria of rare diseases based on the following thresholds of epidemiological indicators : prevalence 50 cases/100 000 persons within a given population and incidence 6 cases/100 000 persons / year . indeed , for all tumor types identified during the previous hadrontherapy epidemiological studies [ 58 ] , the calculated and cumulative incidences are all below these thresholds ( table 2 ) . amongst the hadrontherapy indications , 25 are tumours listed in the orphanet international database of rare diseases ( cf . the exact incidence of each disease eligible for hadrontherapy is difficult to determine from the available resources . indeed , the published data [ 513 ] pertain to series of patients for which the aim was not to assess the level of demand for treatment . these were rather series of patients who had received the therapy , but whose recruitment had not been accounted for in tumour registries . considering the scarcity and specific nature of the tumours concerned by hadrontherapy , it is difficult to extrapolate and assess the treatment demand from these results . hadrontherapy indications are defined according to anatomical location of the tumours , clinical stage , pathology , therapeutic alternatives ( e.g. , surgical contraindications ) , and patient characteristics ( general condition and comorbidities ) . french cancer registries record data required to estimate cancer incidence but fail to provide sufficient detail of the tumour stage or of therapeutic data . moreover , the registries cover only approximately 15% of the french population and mainly for the most frequent cancers . therefore , these registries do not allow the incidence of these tumours to be estimated . this regional study will provide us with more detailed figures concerning the potential number of new cases eligible for hadrontherapy , allowing us to better adapt the future care offer delivered by the national hadrontherapy centre . this survey should also provide us with information on certain medical indicators to assist in the design of future hadrontherapy clinical trials ( detailed incidence data , patient population characteristics , tumour stages , recruitment pools , etc . ) . finally , this epidemiological field study is also eventually intended to be used to organise a network of highly specialised cares . according to the first epidemiological study carried out in france , in association with ( i ) the results of the literature review that defined the list of hadrontherapy indications and ( ii ) the indications chosen for proton therapy in france , the number of cases in the rhne - alpes region eligible for hadrontherapy is estimated at 200 per year ( the rhne - alpes region is home to 10% of the french population ) .", "the main goal is to asses , within the rhne - alpes region , the incidence of cancers with hadrontherapy indication . the secondary goals are ( 1 ) to characterise the affected population , ( 2 ) to describe the characteristics of the observed cancers , and ( 3 ) to describe the characteristics of the treatments implemented when hadrontherapy is unavailable .", "this is a prospective , multicentre incidence study , lasting 24 months , conducted with the rcp ( runion de concertation pluridisciplinaire multidisciplinary tumor board ) groups of the rhne - alpes region in france , that offer a therapeutic strategy for cancers for which hadrontherapy is an alternative . \n this study required the involvement of a part - time consultant epidemiology engineer , who totalled one woman - year of work to provide ( 1 ) phone canvassing to identify and involve regional cancer research players ; ( 2 ) the protocol construction and testing phase , along with the data collection tools ; ( 3 ) meetings with 3c ( cancer coordination centres ) coordinators and rcps ; ( 4 ) investigator centres inclusion meetings . these included year of birth ; gender ; patient 's department of residence ; world health organization ( who ) performance status , patient 's therapeutic status : initial stage or recurrence ; initial staging ( uicc tnm classification : international union against cancer ) ; treatments received before recurrence ; time to recurrence ; staging at time of current tumour management ; icd-10 ( international classification of diseases ) ; icdo ( international classification of diseases for oncology ) histological type ; site of surgery and margin quality ; postsurgical histopathological stage ( ptnm stage ) ; prior radiotherapy ; proposed treatment . \n the criteria included adults and children , no age limit , and patients presenting with hadrontherapy indications listed in table 1 , whose medical files have been discussed by experts during an rcp . compatible general and psychological condition refers to patients not suffering from life - threatening comorbidities ( no acute or chronic diseases whose short - term lethal risk is dominant relative to the cancer ) , capable of adhering to a disease monitoring protocol and of understanding and accepting a complex treatment requiring close cooperation and staying for several days away from home . \n tumour inclusion criteria . these include unresectable tumour , belonging to a known radiation - resistant pathological group , mainly in a locoregional development stage , recurrent or local relapse , with low metastatic potential or m+ dissemination ( presence of one or more remote metastases at the time of diagnosis ) presenting a low threat ( slow development and/or metastases that can be readily treated ) . these inclusion criteria are the results of a consensus synthesis of a systematic literature review performed during 8 years , pathology by pathology with the participation of about one hundred of european medical , surgical , and radiation oncologists , managed by physicians trained in hadrontherapy ( mainly protontherapy ) . the review was carried out by an academic laboratory specialized in clinical trial setup and analysis and was made according to the evidence - based medicine definition of tumour inclusion criteria \n\n radiation resistance : tumour which estimated local dose required for local control that is higher that the maximum acceptable dose equivalent ( mpde ) for surrounding organs necessarily irradiated under applicable technical conditions , assessed by a radiation oncologist ( guide des procdures de radiothrapie externe 2007 ( guidelines for external radiotherapy procedures ) ; joint effort by the french society for oncology radiotherapy ( socit franaise de radiothrapie oncologique sfro ) , and the french society for medical physics ( socit franaise de physique mdicale sfpm ) , conducted in collaboration with the representatives of the french association of electroradiology paramedical workers ( association franaise du personnel paramdical d'electroradiologie afppe ) ) . \n unresectable : tumour which local or locoregional expansion stage renders excision either is technically impossible ( opinion of an experienced surgical team ) or surgically unacceptable due to the irreparable damage that would be necessary ( cancer : principles & practice of oncology 2005 ; devita , v. general articles on treatment strategies in cancer ) . \n locoregional : it refers to the tumour expansion state corresponding to the anatomical diffusion region of the primary tumour by contiguous expansion ( t of tnm ) and/or by lymphatic diffusion , maintaining a rank of n in tnm staging , in other words , any tumour at stage m0 ( latest edition of the tumour tnm classification published by the ( uicc ) international union against cancer or the ( ajc ) american joint committee for cancer staging ) . \n low metastatic potential : m0 situations whose medium - term ( 5-year ) metastatic risk is considered to be sufficiently low to justify curative locoregional treatment involving significant means . this threshold is difficult to determine ; a level greater than 50% seems unreasonable . as an example , nonthreatening m+ dissemination or controlled by medical treatments : this means the presence of one or more remote metastases at the time of diagnosis , presenting no immediate threat as displaying slow development and/or accessible to effective treatment ( typical case of some low - grade sarcomas lung metastases ) . these situations are indicative of locoregional disease treatment using complex and expensive techniques such as hadrontherapy . \n local relapse or local recurrence ( these two terms are synonymous ) : it means the redevelopment , at the same site as initially , of a previously effectively treated tumour ( dictionary of medical terms , garnier - delamare ) . \n \n radiation resistance : tumour which estimated local dose required for local control that is higher that the maximum acceptable dose equivalent ( mpde ) for surrounding organs necessarily irradiated under applicable technical conditions , assessed by a radiation oncologist ( guide des procdures de radiothrapie externe 2007 ( guidelines for external radiotherapy procedures ) ; joint effort by the french society for oncology radiotherapy ( socit franaise de radiothrapie oncologique sfro ) , and the french society for medical physics ( socit franaise de physique mdicale sfpm ) , conducted in collaboration with the representatives of the french association of electroradiology paramedical workers ( association franaise du personnel paramdical d'electroradiologie afppe ) ) . \n unresectable : tumour which local or locoregional expansion stage renders excision either is technically impossible ( opinion of an experienced surgical team ) or surgically unacceptable due to the irreparable damage that would be necessary ( cancer : principles & practice of oncology 2005 ; devita , v. general articles on treatment strategies in cancer ) . \n locoregional : it refers to the tumour expansion state corresponding to the anatomical diffusion region of the primary tumour by contiguous expansion ( t of tnm ) and/or by lymphatic diffusion , maintaining a rank of n in tnm staging , in other words , any tumour at stage m0 ( latest edition of the tumour tnm classification published by the ( uicc ) international union against cancer or the ( ajc ) american joint committee for cancer staging ) . \n low metastatic potential : m0 situations whose medium - term ( 5-year ) metastatic risk is considered to be sufficiently low to justify curative locoregional treatment involving significant means . this threshold is difficult to determine ; a level greater than 50% seems unreasonable . as an example , nonthreatening m+ dissemination or controlled by medical treatments : this means the presence of one or more remote metastases at the time of diagnosis , presenting no immediate threat as displaying slow development and/or accessible to effective treatment ( typical case of some low - grade sarcomas lung metastases ) . these situations are indicative of locoregional disease treatment using complex and expensive techniques such as hadrontherapy . \n local relapse or local recurrence ( these two terms are synonymous ) : it means the redevelopment , at the same site as initially , of a previously effectively treated tumour ( dictionary of medical terms , garnier - delamare ) . \n they are the description of the tumours and population characteristics , along with the treatments proposed and implemented by the rcps . \n those were healthcare establishments ( private and public ) in the rhne - alpes region hosting rcp groups and having radiotherapy departments . \n they consisted of groups of oncology specialists with expertise in the following diseases : musculoskeletal sarcomas and tumours , head and neck ( h and n ) , gastroenterology , paediatrics , dermatology , endocrine and central nervous system tumours . \n case screening is performed continuously by the physicians and clinical research technician in light of the list of indications ( table 1 ) , during each rcp . \n the questionnaire , along with the organisation of the investigation , was assessed beforehand by a sample population of investigators ( 3c coordinators and cras ) via a semiguided telephone interview . for the questionnaire , the evaluation focused on general understanding , the form and length of the questionnaire , time required for completion , amount of data to collect , and the relevance of the selected criteria . the evaluation of the investigation method pertained to the choice of individuals involved in data collection organisation , the data recording method , the organisation for data recording , and the identification source for clinical cases . \n variables are encoded in a uniform and standard manner in an investigator 's guide book , which contains detailed information concerning the definitions of each indicator to collect . dual computer data input is performed , along with checks for missing or improbable data ( encoding errors , date inconsistencies ) . \n statistical methods . the incidence of cancers is expressed as the number of cases reported from the demographic figures of the rhne - alpes region over the studied period and expressed per 100,000 inhabitants .", " the study involves 13 clinical research technicians , 50 rcp coordinating physicians and 12 cancer coordination centres ( see table 3 ) . the study mobilises 27 rhne - alpes region healthcare centres , of which 8 university hospitals , 1 regional cancer centre , 1 public - private cancer institute , 12 general hospitals , the lyon paediatric oncology hospital institute , and 4 private clinics . this led to a sense of ownership and motivation on the part of the centres . as a whole , the study covered the region 's 11 hospital areas and involved 52 groups , out of some sixty listed , of cancer specialists with expertise in the diseases that were to identify . during the study , mean patient age was 43 years [ 289 ] , and men were more numerous ( or = 1.52 ) . the highest number of cases ( 39.6% ) was in the 218 years age group . the number of patients with recurrence was slightly lower ( 45.3% ) than the number of patients receiving initial care ( 54.7% ) . carcinomas , sarcomas ( table 4 ) , and paediatric tumours ( table 5 ) were the most frequently identified diseases , and their locations are varied . during the rcp , radiotherapy , chemotherapy , and surgery were prescribed , respectively , in 58% , 57% , and 57% of cases . previous treatments were chemotherapy , surgery , or conventional radiotherapy in 62.5% , 58.3% , and 58.3% of cases , respectively . the number of cases identified during the study was approximately four times lower than the potential estimate . ( i.e. , 2.5 cases / rcp ) , and the rhne department identified 56.6% ( i.e. , 1.2 cases / rcp ) . isre identified twice as many cases as rhne , even though it only has nine expert groups , that is , 2.6 times less than in rhne , which has 24 . the geographic areas not covered by the study correspond to the location of 15 private healthcare centres and to the medical activity of six general and four specialist rcp groups . the first six groups had no recruitment potential according to the statement of their coordinators . this preliminary data collection , conducted over a one - year period , reported 53 cases of hadrontherapy indications , compared to the estimated cap of 200 cases . the estimated incidence of cancers eligible for hadrontherapy in the rhne - alpes region in 2010 , regardless of disease , is of 8.5/100,000 inhabitants .", "the diseases to identify in this study are little known , their distribution has not been studied , and we are unaware of any epidemic outbreaks . moreover , considering that the cancers to identify are rare , it is likely that the number of cases to identify per investigator centre will be very low ( estimated incidence of at the most 1 to 5 cases / year ) . finally , the primary goal of the rcp groups is to provide an immediate therapeutic solution . case identification for an observational study is thus unusual in the context of an rcp . because of this , sustaining team vigilance and motivation for case identification is difficult to obtain and requires regular refreshing throughout the study . this step also served to circulate hadrontherapy information and to facilitate adhesion , ownership , and mobilisation around the project . the individuals involved in study organisation were in charge of systematically directing each cancer patient to the elective experts . patients suffering from diseases eligible for hadrontherapy were frequently in relapse condition and rather at the end of their therapeutic options . this is due to the fact that these diseases have usually a slow and long evolution ; therefore , this study had more chance to catch them somewhere in an advanced stage than at the beginning . it can also be considered that the lack of satisfactory treatment means as hadrontherapy makes these populations have more chance to show more advanced disease than it will be expected to be seen in the future . the identification and decision to include a patient in the study were made by the rcp groups including these experts . under these conditions , we have confidence in the case orientation and identification system . selection criterion is one of the criteria used to identify patients eligible for hadrontherapy . in our current state of knowledge this can be explained in part by the fact that it is easier to create multidisciplinary expert groups in public hospitals and to set up clinical research . due to their structure , these establishments benefit from human resources with more varied medical specialities than in private radiotherapy practices . in all likelihood , cases eligible for hadrontherapy could have been treated by these private centres during the study and ignored . one should be very cautious when comparing the results of this study with those of published incidence studies . the methodologies employed in these previous studies are heterogeneous , and/or their flow is insufficiently documented . moreover , their goal was to estimate a recruitment potential based on the extrapolation of the results . the methodologies used were not intended to provide information concerning an exhaustive incidence , as proposed by our study . finally , the published studies were conducted in attractive institutions , specialising in cancer care and selected for this reason ; this may bias the assessment of prevalence . under these conditions , it is easy to confuse incidence and prevalence . these elements could , in part , explain the observed difference between the preliminary results obtained in our study and the estimate calculated from the epidemiological results published in the literature . only the publication of results obtained from other exhaustive epidemiological studies conducted in the same areas could support this hypothesis . it is unlikely that the lack of case recording associated with the medical activity of the four groups not involved in this data collection could alone explain the observed difference between the calculated incidence estimates and the preliminary results obtained . for several clinicians involved in the study , the prognosis and risk of metastatic development were difficult to estimate considering the lack of knowledge for these rare diseases . moreover , the novelty of hadrontherapy , which can potentially modify usual treatment strategies , could have led to the omission of this indication in some cases , in particular conditions unusually treated by radiotherapy as hepatic and biliary tumours . these difficulties , along with the more sustained vigilance effort made by some groups relative to others , could account for the nonhomogeneous data collection and the observed difference between predictions and obtained results , despite the high motivation of the investigators . furthermore , the reorganisations ( case of two major rcp clusters ) , changes of persons involved and the low frequency of cases to report , lead to a constant erosion of vigilance , requiring continuous action by the organiser . however , some important institutions with their own recruitment targets did not wish to participate , which reduces the scope of our results . about the detailed conditions of the recruited cases , there are a large proportion of recurrent diseases as explained above , and some metastatic diseases have also been included according to defined characteristics : ( i ) the number of metastasis was limited ( 1 to 3 metastasis ) ; ( ii ) their very slow growing speed was not immediately threatening ; ( iii ) the possibility of effective treatment of these pauci - metastatic conditions , essentially by ablative procedures . actually , the principle to treat , with curative intend , patients in such situation is more and more accepted by expert oncologists . the estimated incidence of cancers , irrespective of type and location , eligible for treatment by hadrontherapy , for the study , that is , 8.5/100,000 individuals , is mildly higher than the reference incidence threshold of 6 cases/100,000 individuals , as defined in the orphanet international database of rare diseases . this figure can be obviously explained by the fact that the incidence was calculated by adding the five major cancer categories and 34 different locations . if one was to calculate the incidence for each of the disease types , their respective incidence would be significantly below the reference threshold of 6 cases/100,000 . indeed , for our study , the minimum number of cases listed per disease is of 1 case and the maximum is of 7 cases . table 4 . considering all of the difficulties and limitations of this preliminary phase of the study , the yield of approximately 25% notification , compared to the expected maximum , appears satisfactory . in the perspective of a ( necessary ) ramp up of a future hadrontherapy centre , there is thus a sufficient population to initiate operation and to progressively establish recruitment for this centre , without immediately generating an insufficient offer effect .", "future epidemiological studies will benefit from focusing on the characterisation of the metastatic development of diseases eligible for hadrontherapy . all cancers have their own development pattern , and , in this respect , the literature provides few elements concerning diseases eligible for hadrontherapy . this information should serve both to improve diagnosis procedures , medical care , and the surveillance of these rare diseases . this study of hadrontherapy healthcare decision networks in the rhne - alpes region , able to identify areas not properly covered by rcps , should enable us to analyse the potential effect of this lack on the outcome of the patients of these areas . they shed no light on posttreatment medical activity : follow - up visits , medical imaging , and other care beyond the irradiated activity per se . one of the most valuable outcomes of this study has been to make the existence of some particularly rare diseases known and to provide information concerning an innovative treatment : hadrontherapy , whose existence will doubtless have a favourable effect on the very knowledge of these diseases . an additional benefit of this approach has been to open the way for a new treatment system in a region of france that is home to approximately 10% of the country 's population . at last , these elective indications will have to be validated by health authorities to register them as part of the good professional practices of oncology and give an equal chance to each patient to receive hadrontherapy through the well - established decision process of the rcps ." ]

[ "type 2 diabetes continues to present a public health burden across the world , and asia is considered to be at the epicenter of this diabetes epidemic , with 60% of the disease burden borne by this region1 . the increase in diabetes prevalence across asia has been rapid , fuelled by increasing obesity , aging populations and urbanization , which in turn have been driven by rapid economic development , a sedentary lifestyle and increased consumption of refined foods3 . these socioeconomic changes have been particularly significant in countries across southeast asia4 , and reflected by dramatic rises in type 2 diabetes prevalence over the past decade ( figure 1 ) . indeed , indonesia and the philippines are projected to be among the top 10 countries in the world with the highest number of estimated cases by 20301 . another issue curtailing the type 2 diabetes rise in asia is the high number of undiagnosed individuals . for instance , in hong kong and taiwan it was reported that almost 53% of diabetic patients remain undiagnosed5 . furthermore , the prevalence of prediabetes ( impaired glucose tolerance ) further adds to the already burgeoning burden of overt diabetes and its consequences in this region ( figure 1 ) . comparative prevalence of diabetes in countries across southeast asia in 2011 ( calculated by assuming that every country and region has the same age profile ) . these data are based on figures compiled by the international diabetes federation in the international diabetes atlas , 2011 ( available at : http://www.idf.org/atlasmap/atlasmap ) . it is widely recognized that diabetes is a major source of morbidity , mortality and economic burden6 . prolonged and poor glucose control increases the risk of developing macrovascular ( coronary artery disease , stroke ) and microvascular ( nephropathy , retinopathy and neuropathy ) complications7 , which can greatly reduce life expectancy and quality of life8 . in fact , the risk of allcause mortality ( cardiovascular and noncardiovascular ) is higher in diabetic than nondiabetic patients9 . consequently , the rapidly growing prevalence of diabetes in asia is likely to result in large increases in diabetesassociated mortality10 . from an economic perspective , the impact of diabetes on healthcare resources and personal expenditure , as well as the financial implications associated with loss in productivity and disability , is enormous11 . in taiwan , the direct healthcare cost associated with diabetes was 11.5% of the total national healthcare cost and was 4.3fold higher than the care of nondiabetic individuals12 . in hong kong , the annual total cost of type 2 diabetes equated to usd 1,725 2,044 per patient . furthermore , complications increased treatment costs associated with inpatient hospital stay by between 6 and 300% compared with treatment of type 2 diabetes patients without complications14 . of note is the considerable heterogeneity in healthcare spending for diabetes between countries across southeast asia . the international diabetes federation estimated that , in 2010 , treatment of diabetes accounted for 5 and 7% of the total healthcare expenditure in vietnam and indonesia , respectively , compared with 15 and 16% in singapore and malaysia , respectively11 . taken together , it is clear that early diagnosis and disease control are important healthcare initiatives to improve the lives , outcomes and economies of these atrisk countries . in determining the optimal management approach , recognizing the differences in clinical characteristics and risk of diabetes between asian and caucasian populations is important to understand . for instance in asians , diabetes develops over a shorter time , in younger people and in those with a lower body mass index ( bmi)15 . furthermore , asians have a higher proportion of body fat and abdominal obesity , putting them at a higher risk of developing insulin resistance16 . reports that asians show early cell dysfunction might further explain their increased susceptibility to type 2 diabetes16 . the thrifty gene and thrifty phenotype hypotheses have been proposed as plausible explanations for the increasing diabetes epidemic seen across asia18 . although considered protective during periods of famine or food shortage , thrifty genes have rendered individuals highly predisposed to obesity in times of plenty . alternatively , the thrifty phenotype relates to the impact of an unfavorable intrauterine environment ( e.g. undernutrition ) and low birth weight on the subsequent development of diabetes and metabolic syndrome in adults18 . several diabetesassociated genes have been implicated to account for the heightened predilection in asians , especially asian indians , and include polymorphisms of the peroxisome proliferatoractivated receptor coactivator1 alpha ( pgc1 alpha ) gene , plasma cell glycoprotein ( pc1 ) gene and insulin receptor substrate ( irs2 ) gene ( reviewed in radha and mohan)19 . given the increased prevalence of diabetes among younger populations in asia and early exposure to hyperglycemia , it has been suggested that they are also at a high risk of endorgan damage and are likely to have to live with complications for longer20 . indeed , the asia pacific cohort studies collaboration ( apcsc ) , which assessed the impact of diabetes on cardiovascular outcomes and mortality , found a greater risk of fatal coronary heart disease , hemorrhagic and ischemic stroke among younger compared with older individuals21 . apcsc also showed an association between diabetes and increased risk of death as a result of renal disease , cancer , respiratory infections , and other infective and inflammatory causes21 . although optimal blood glucose control has been shown to reduce the risk of both macrovascular and microvascular complications6 , the marked prevalence of renal dysfunction in asia reflects , in part , the continuing challenge in achieving this goal22 . the aim of the present article was to review the barriers to achieving optimal blood glucose control in asian patients with type 2 diabetes who have declining renal function and to discuss the treatment modalities that might be appropriate for the management of these special patient populations .", "of the diabetesassociated complications , the most debilitating is chronic kidney disease ( ckd ) and its pathogenic progression to endstage renal disease ( esrd ) that requires dialysis or transplantation23 . defining and diagnosing ckd in clinical practice has evolved since its first classification by the national foundation kidney disease outcomes quality initiative ( nkfkdoqi ) in 200224 . in these guidelines , ckd was categorized into five stages according to the severity of disease as defined by decreasing glomerular filtration rates ( gfr ) alone24 . in the more recent update , the assessment criteria have been modified to encompass both gfr and albuminuria measures as correlates of a patient 's prognosis . in addition , a subdivision of the previously described gfr stage 3 has been proposed to help further define the severity of kidney dysfunction in patients with ckd25 . risk factors for the development of reduced kidney function in southeast asian populations have been identified and include the presence of diabetes , systolic hypertension ( > 159 mmhg ) , hyperuricemia ( > 6.29 mg / dl ) , elevated bmi ( > 24.9 kg / m ) and hypercholesterolemia ( > 248.3 mg / dl)26 . microalbuminuria is the earliest clinical manifestation of ckd in type 2 diabetes and persistent microalbuminuria represents an early clinical marker for the development of diabetic nephropathy ( dn)27 . although the number of studies exploring the epidemiology of microalbuminuria across asia has been limited , the microalbuminuria prevalence study ( maps ) of 6,800 hypertensive diabetic patients from 10 countries in the region reported an overall prevalence rate of 39.8% ( 95% confidence interval [ ci ] 39.240.5)22 . these data show how a high proportion of hypertensive , type 2 diabetes asian patients are showing early signs of declining renal function , and further support a need for early intervention so as to reduce accelerated progression of cardiorenal complications and the associated healthcare burden28 . with the exception of taiwan ( chiang sc et al . jcma 2011 ; 74 : 310 ) , these data are based on subanalyses of the microalbuminuria prevalence study of 6,800 hypertensive diabetic patients from 10 countries across asia ( wu ay et al . 2005 ; 48 : 1726 . ) in recognition of the utility of measuring microalbuminuria , guidelines recommend annual screening of this clinical marker for identifying atrisk populations32 . patients identified with microalbuminuria early in the course of disease might require stricter glycemic and blood pressure control targets . indeed , several prospective studies have shown the importance of tight glycemic control alone and combined with blood pressure lowering in the prevention of microvascular complications . for instance , the uk prospective diabetes study compared the effects of intensive bloodglucose control with either sulfonylureas or insulin and conventional treatment ( including diet ) on the risk of microvascular and macrovascular complications in type 2 diabetes patients . intensive glucose control with sulfonylureas or insulin resulted in a 33% relative risk reduction in the development of microalbuminuria . furthermore , this reduction in risk was sustained in the 10year followup study during which longterm benefits on cardiovascular disease ( cvd ) risk also emerged33 . in the kumamoto study , the frequency and severity of diabetic microvascular complications were assessed in japanese type 2 diabetes patients after treatment with either intensive glucose control ( multiple insulin injections of three or more ) or conventional therapy ( insulin injections administered once or twice daily ) . there was a significant reduction in the progression of nephropathy and other microvascular complications ( retinopathy ) after intensive insulin therapy ( p < 0.05)35 . the effect of an intensive , stepwise multifactorial intervention , targeting hyperglycemia , hypertension , dyslipidemia and microalbuminuria , on the initiation and progression of microvascular complications in type 2 diabetes patients with microalbuminuria was assessed in the steno2 study . type 2 diabetes patients receiving early intensive diabetes management including tight glucose control and angiotensin converting enzyme inhibitors ( acei ) to reduce blood pressure were significantly less likely to develop nephropathy than patients receiving standard therapy ( odds ratio 0.27 ; 95% ci 0.100.75 ) . this reduction in risk was maintained in an observational follow up of 5.5 years36 . in the most recent analysis of the action in diabetes and vascular disease : preterax and diamicronmodified release controlled evaluation ( advance ) trial , which included a large number of asian type 2 diabetes patients , further support for the benefits of combining bloodpressure lowering with intensive blood glucose control was provided38 . patients received either intensive glucose control ( target glycated hemoglobin [ hba1c ] 6.5% ) or standard glucose control ( defined by local guidelines ) with placebo or acei plus indapamide therapy . a combination of intensive glucose control plus acei plus indapamide therapy led to a significant percentage in risk reduction in new or worsening nephropathy ( 95% ci 1250% ; p = 0.005 ) ; a 54% reduction in the development of newonset macroalbuminuria ( 95% ci 3568% ; p < 0.001 ) , and a 25% reduction in the risk of newonset microalbuminuria ( 95% ci 1633% ; p < 0.001 ) . furthermore , the effects of blood pressure lowering and intensive glucose control were independent of each other , so that on combining these agents , additive benefits were observed , particularly on renal outcomes38 . indeed , the benefits of early and tight target control strategies on the prevention of dn in chinese type 2 diabetes patients have been observed . in this asian cohort with normoalbuminuria , achievement of american diabetes association ( ada)recommended targets of hba1c ( < 7% ) , systolic blood pressure ( < 130 mmhg ) , diastolic blood pressure ( < 80 mmhg ) and lipid profiles ( lowdensity lipoprotein [ ldl ] < 100 mg / dl ; triglycerides < 150 mg / dl ; highdensity lipoprotein > 4050 mg / dl ) reduced the risk of developing newonset microalbuminuria compared with those who were unable to attain these targets39 . interestingly , in a separate study of taiwanese type 2 diabetes patients with microalbuminuria , almost 36% of patients achieved remission to normoalbuminuria following a tight , multifactorial target control approach40 . worldwide , rates of ckd have been increasing , and have accompanied the increasing prevalence of type 2 diabetes , hypertension and cvd . for instance , in the usa , it is estimated that 30% of patients with type 2 diabetes will develop some form of kidney disease as reflected by protein leakage , microalbuminuria , macroalbuminuria or a decline in the glomerular filtration rate ( gfr)41 . nephropathy is a common complication of asians with type 2 diabetes , as reflected by the accelerating prevalence and incidence rates of observed ckd23 . indeed , incidence rates of esrd across asia have shown increases over a 6year period ( 20032008 ) of 15.8% in hong kong , 22% in malaysia and thailand , 24% in singapore , and up to 31% in the philippines43 . although incidence rates of esrd appear to have declined in taiwan since 2005 , this country has the third highest rate of esrd in the world , with an incidence rate of 384 per million population ( pmp ) , highlighting the disparity between the rate of kidney disease and a country 's economic status42 . furthermore , it has become apparent that a high proportion of esrd cases are as a result of diabetes , ranging from 41% to 62% in individual countries across southeast asia ( figure 2)43 . incidence of endstage renal disease ( esrd ) as a result of diabetes in selected countries across southeast asia in 2008 . these data are based on figures compiled by the us renal disease system ( figure adapted from 2010 us renal disease system annual report chapter 12 international comparisons ; volume 2 ; pages 383396 ) . for singapore , the 2008 data have been extracted from the national registry of diseases office , released 1 march 2011 ( inp111 ) . the presence of ckd is also associated with a high cvd risk , which is further exacerbated by the presence of diabetes and hypertension45 . indeed , cvd remains the main cause of death in patients with ckd rather than kidney failure , and it is estimated that cvdassociated mortality is 1030fold higher in patients with advanced ckd receiving dialysis than the general population46 . given that the prevalence of hypertension in asia is increasing , and that diabetes and hypertension commonly coexist ( type 2 diabetes patients are twice as likely to have elevated blood pressure than nontype 2 diabetes patients ) , screening these highrisk patients for ckd early might help slow the course of renal function decline and reduce the greater cardiovascular mortality risk observed in such individuals47 .", "microalbuminuria is the earliest clinical manifestation of ckd in type 2 diabetes and persistent microalbuminuria represents an early clinical marker for the development of diabetic nephropathy ( dn)27 . although the number of studies exploring the epidemiology of microalbuminuria across asia has been limited , the microalbuminuria prevalence study ( maps ) of 6,800 hypertensive diabetic patients from 10 countries in the region reported an overall prevalence rate of 39.8% ( 95% confidence interval [ ci ] 39.240.5)22 . these data show how a high proportion of hypertensive , type 2 diabetes asian patients are showing early signs of declining renal function , and further support a need for early intervention so as to reduce accelerated progression of cardiorenal complications and the associated healthcare burden28 . with the exception of taiwan ( chiang sc et al . jcma 2011 ; 74 : 310 ) , these data are based on subanalyses of the microalbuminuria prevalence study of 6,800 hypertensive diabetic patients from 10 countries across asia ( wu ay et al . diabetologia . 2005 ; 48 : 1726 . ) in recognition of the utility of measuring microalbuminuria , guidelines recommend annual screening of this clinical marker for identifying atrisk populations32 . patients identified with microalbuminuria early in the course of disease might require stricter glycemic and blood pressure control targets . indeed , several prospective studies have shown the importance of tight glycemic control alone and combined with blood pressure lowering in the prevention of microvascular complications . for instance , the uk prospective diabetes study compared the effects of intensive bloodglucose control with either sulfonylureas or insulin and conventional treatment ( including diet ) on the risk of microvascular and macrovascular complications in type 2 diabetes patients . intensive glucose control with sulfonylureas or insulin resulted in a 33% relative risk reduction in the development of microalbuminuria . furthermore , this reduction in risk was sustained in the 10year followup study during which longterm benefits on cardiovascular disease ( cvd ) risk also emerged33 . in the kumamoto study , the frequency and severity of diabetic microvascular complications were assessed in japanese type 2 diabetes patients after treatment with either intensive glucose control ( multiple insulin injections of three or more ) or conventional therapy ( insulin injections administered once or twice daily ) . there was a significant reduction in the progression of nephropathy and other microvascular complications ( retinopathy ) after intensive insulin therapy ( p < 0.05)35 . the effect of an intensive , stepwise multifactorial intervention , targeting hyperglycemia , hypertension , dyslipidemia and microalbuminuria , on the initiation and progression of microvascular complications in type 2 diabetes patients with microalbuminuria was assessed in the steno2 study . type 2 diabetes patients receiving early intensive diabetes management including tight glucose control and angiotensin converting enzyme inhibitors ( acei ) to reduce blood pressure were significantly less likely to develop nephropathy than patients receiving standard therapy ( odds ratio 0.27 ; 95% ci 0.100.75 ) . this reduction in risk was maintained in an observational follow up of 5.5 years36 . in the most recent analysis of the action in diabetes and vascular disease : preterax and diamicronmodified release controlled evaluation ( advance ) trial , which included a large number of asian type 2 diabetes patients , further support for the benefits of combining bloodpressure lowering with intensive blood glucose control was provided38 . patients received either intensive glucose control ( target glycated hemoglobin [ hba1c ] 6.5% ) or standard glucose control ( defined by local guidelines ) with placebo or acei plus indapamide therapy . a combination of intensive glucose control plus acei plus indapamide therapy led to a significant percentage in risk reduction in new or worsening nephropathy ( 95% ci 1250% ; p = 0.005 ) ; a 54% reduction in the development of newonset macroalbuminuria ( 95% ci 3568% ; p < 0.001 ) , and a 25% reduction in the risk of newonset microalbuminuria ( 95% ci 1633% ; p < 0.001 ) . furthermore , the effects of blood pressure lowering and intensive glucose control were independent of each other , so that on combining these agents , additive benefits were observed , particularly on renal outcomes38 . indeed , the benefits of early and tight target control strategies on the prevention of dn in chinese type 2 diabetes patients have been observed . in this asian cohort with normoalbuminuria , achievement of american diabetes association ( ada)recommended targets of hba1c ( < 7% ) , systolic blood pressure ( < 130 mmhg ) , diastolic blood pressure ( < 80 mmhg ) and lipid profiles ( lowdensity lipoprotein [ ldl ] < 100 mg / dl ; triglycerides < 150 mg / dl ; highdensity lipoprotein > 4050 mg / dl ) reduced the risk of developing newonset microalbuminuria compared with those who were unable to attain these targets39 . interestingly , in a separate study of taiwanese type 2 diabetes patients with microalbuminuria , almost 36% of patients achieved remission to normoalbuminuria following a tight , multifactorial target control approach40 .", "worldwide , rates of ckd have been increasing , and have accompanied the increasing prevalence of type 2 diabetes , hypertension and cvd . for instance , in the usa , it is estimated that 30% of patients with type 2 diabetes will develop some form of kidney disease as reflected by protein leakage , microalbuminuria , macroalbuminuria or a decline in the glomerular filtration rate ( gfr)41 . nephropathy is a common complication of asians with type 2 diabetes , as reflected by the accelerating prevalence and incidence rates of observed ckd23 . indeed , incidence rates of esrd across asia have shown increases over a 6year period ( 20032008 ) of 15.8% in hong kong , 22% in malaysia and thailand , 24% in singapore , and up to 31% in the philippines43 . although incidence rates of esrd appear to have declined in taiwan since 2005 , this country has the third highest rate of esrd in the world , with an incidence rate of 384 per million population ( pmp ) , highlighting the disparity between the rate of kidney disease and a country 's economic status42 . furthermore , it has become apparent that a high proportion of esrd cases are as a result of diabetes , ranging from 41% to 62% in individual countries across southeast asia ( figure 2)43 . incidence of endstage renal disease ( esrd ) as a result of diabetes in selected countries across southeast asia in 2008 . these data are based on figures compiled by the us renal disease system ( figure adapted from 2010 us renal disease system annual report chapter 12 international comparisons ; volume 2 ; pages 383396 ) . for singapore , the 2008 data have been extracted from the national registry of diseases office , released 1 march 2011 ( inp111 ) . the presence of ckd is also associated with a high cvd risk , which is further exacerbated by the presence of diabetes and hypertension45 . indeed , cvd remains the main cause of death in patients with ckd rather than kidney failure , and it is estimated that cvdassociated mortality is 1030fold higher in patients with advanced ckd receiving dialysis than the general population46 . given that the prevalence of hypertension in asia is increasing , and that diabetes and hypertension commonly coexist ( type 2 diabetes patients are twice as likely to have elevated blood pressure than nontype 2 diabetes patients ) , screening these highrisk patients for ckd early might help slow the course of renal function decline and reduce the greater cardiovascular mortality risk observed in such individuals47 .", "despite the advent and availability of a range of antidiabetic and blood pressure lowering agents , many patients in asia remain suboptimally controlled and therefore at risk of developing complications . in the maps study , just 10.6% of type 2 diabetes asian patients with microalbuminuria achieved blood pressure targets below 130/80 mmhg and mean hba1c levels of 7.9%22 . similarly , in a crosssectional survey in china , the majority of type 2 diabetes patients with nephropathy ( 66.9% ) had a mean hba1c level of > 7.5% , indicating poor glycemic control in patients with complications50 . these data are supported by the recent international diabetes management practice study ( idmps ) that explored the barriers to achieving optimal glycemic control across asia , latin america and eastern europe51 . in asia , of the 5,372 type 2 diabetes patients assessed , 35.8% had microalbuminuria and just 37.3% achieved the hba1c target of < 7.0% ; 21.8% achieved the blood pressure target of < 130/80 mmhg ; and 37% achieved the ldl cholesterol target of < 100 mg / dl . another significant and worrying finding was that just 4.7% of patients in asia attained all three treatment targets51 . factors that might be contributing to such low control rates have been reported to include : difficult medical access by patients in some developing countries , physician perception of target levels , prescribing habits , as well as knowledge of guidelines an aging population provides additional challenges in managing type 2 diabetes , as aging itself is associated with changes in kidney structure and function , and these agerelated renal changes can be accelerated by the presence of comorbid conditions52 . furthermore , a study of the hong kong diabetes registry revealed how long disease duration and complexity of treatment regimens might also play a role in suboptimal glycemic control54 . poor control might also result in type 2 diabetes patients who present and commence treatment when their renal function is normal , but subsequently go on to develop kidney disease . without appropriate monitoring of gfr levels and diagnosis of kidney disease or its progression , the need for dose adjustments or reevaluation of prescribed therapies might be missed and , consequently , adverse sideeffects might arise55 . hypoglycemia is a particular challenge in the management of type 2 diabetes , especially in patients with a decline in renal function . for instance , diabetic patients with ckd are twice as likely to experience hypoglycemic events than those without kidney disease56 . this might be a result of reduced insulin clearance , reduced gluconeogenesis by the kidney and increased accumulation of drugs excreted by the kidney57 . the reduction in drug clearance results in prolonged exposure to the drug itself or its metabolites , which can lead to adverse sideeffects . this is a major issue in moderate to severe ckd ( stages 35 ) when renal dysfunction is particularly pronounced55 .", "the american diabetes association guidelines recommend target hba1c levels of < 8% for patients with more advanced microvascular complications and increased risk of hypoglycemia , such as those with more advanced ckd . however , in practice , the use of antidiabetic medications in achieving these glycemic targets is often challenging58 . there are now an array of antihyperglycemic agents available that include both injectable , such as insulin and the incretin mimetics glp1 analogs ( exenatide , liraglutide ) , and oral antidiabetics ( oads ) . among the oads are biguanides ( metformin ) , second generation sulfonylureas ( glimepiride , glipizide , glicazide ) , meglitinides ( nateglinide , repaglinide ) glucosidase inhibitors ( acarbose ) , thiazolidinediones ( tzd ; pioglitazone ) and incretinbased therapies that include dipeptidylpeptidase iv ( dpp4 ) inhibitors ( linagliptin , sitagliptin , vildagliptin , saxagliptin ) . in addition , oral sodiumglucose transporter 2 ( inhibitors are currently in development ( empagliflozin , dapagliflozin ) . despite the range of medications available for the treatment of type 2 diabetes and its complications , many of these require dose modification or avoidance and close monitoring55 . this poses a particular challenge in more advanced disease ( ckd stages 35 ) , where contraindications or the increased risk of hypoglycemia serve to limit the number of treatment options ( table 2)55 . as all these agents differ in their mechanism of action , efficacy , sideeffects and costs , the choice of therapy should be guided by several factors . patient demographics , presence of comorbid conditions , risk or severity of renal function decline , tolerability , and risk of developing adverse events , such as hypoglycemia , weight gain and edema , should help in the treatment decision process57 . with most of the oads currently available for the treatment of type 2 diabetes , their use in patients with kidney dysfunction is compromised55 . however , sulfonylureas and their metabolites are affected by kidney function by increasing in potency as renal function declines . furthermore , in type 2 diabetes patients with esrd receiving dialysis , treatment with sulfonylureas might lead to severe and prolonged episodes of hypoglycemia61 . however , secondgeneration sulfonylureas , such as gliclazide and glipizide , which have inactive metabolites , carry less risk of hypoglycemia than the firstgeneration sulfonylureas and might therefore be used in type 2 diabetes patients with declining renal function , but with caution . similarly , the meglitinide , nateglinide , undergoes hepatic metabolism that gives rise to weakly active metabolites that are excreted predominantly through the kidneys . furthermore , 15% of the drug is excreted unchanged in urine . given the reduced clearance in ckd and the likelihood of hypoglycemic episodes , cautious use in these special populations , particularly in more advanced stages of ckd , is warranted . in contrast , repaglinide appears to have a lower risk of hypoglycemia and might be of use in ckd stages 3 and 4 , but requires low initial dosing and careful dose titration in these patients62 . the use of metformin , the standard firstline therapy of type 2 diabetes , also poses a risk for diabetic patients with ckd as a result of lactic acidosis , and is therefore contraindicated in patients with advanced renal dysfunction57 . whether this medication provides an additional risk to the underlying comorbidity or acts directly to bring about lactic acidosis requires further investigation63 . treatment with glycosidase inhibitors in type 2 diabetes patients with ckd ( stage 35 ) is also not recommended , because of the potential risk of hepatic damage as a result of cumulated dose effects57 . in contrast , a few small , shortterm studies have implicated a renoprotective role for tzd , as it resulted in greater reductions in albuminuria than metformin or sulfonylureas . whether this translates into direct prevention of renal function decline , however , requires further study64 . nevertheless , tzd undergo hepatic metabolism and have a low risk of hypoglycemia , making them appropriate for use in ckd . of note , fluid retention is a known sideeffect of tzd , and in ckd patients this outcome could be exacerbated . dpp4 inhibitors are the most recent addition to the type 2 diabetes treatment paradigm and have been developed in recognition of the multifactorial nature of type 2 diabetes pathology . this drug class mediates its antihyperglycemic effects by preventing the degradation of the incretin hormones these hormones are released in the intestine after a meal , and target the pancreas by increasing glucosedependent insulin secretion and suppressing glucagon secretion , which subsequently improves both fasting plasma glucose ( fpg ) and postprandial glucose ( ppg ) levels . dpp4 inhibitors are therefore important in regulating glucose homeostasis67 . furthermore , beneficial effects on pancreatic cells have also been reported with this drug class and therefore it might play a role in preventing or slowing the progression of cell dysfunction68 . there are currently five dpp4 inhibitors approved for type 2 diabetes : sitagliptin , vildagliptin , saxagliptin , alogliptin ( japan ) and linagliptin ; and their efficacy and tolerability have been studied in several clinical trials72 . although there are limited direct headtohead studies between dpp4 inhibitors that have been carried out to date , observations across studies suggest that all five agents have comparable efficacy as reflected in their levels of hba1c reduction . when compared with other antihyperglycemic agents , headtohead studies showed dpp4 inhibitors to have similar efficacy to metformin , sulfonylureas , tzd and glycosidase inhibitors73 . in terms of tolerability , all five dpp4 inhibitors have been shown to be well tolerated with low rates of adverse effects and , in general , comparable with placebo or comparator72 . furthermore , the issues of hypoglycemia and weight gain frequently seen with the more traditional antihyperglycemic therapies are not readily observed with dpp4 inhibitors . although there is little to differentiate between these agents in terms of observed efficacy , each differs in their chemistry and pharmacokinetic profile , which might translate into differences in their clinical applicability79 . indeed , dpp4 inhibitors differ in their halflives : sitagliptin , alogliptin and linagliptin have longhalf lives , allowing for oncedaily administration ; vildagliptin has a short halflife and twicedaily dosing is recommended . saxagliptin has a short halflife , but given its active metabolite , oncedaily dosing is adequate79 . furthermore , on examining their metabolism and excretion profiles , differences between the dpp4 inhibitors have emerged . sitagliptin , vildagliptin , alogliptin and saxagliptin are predominantly excreted through the kidneys72 . despite the renal excretion profiles of these agents , their favorable tolerability in patients with various severity of renal dysfunction still permits their use in such patients , although dose modifications are recommended in line with increasing kidney dysfunction ( table 2 ) . in contrast , linagliptin is excreted through the bile and with approximately 5% being renally excreted80 . furthermore , recent data suggest that dose modifications of linagliptin are not required irrespective of the severity of renal dysfunction ( table 2)81 . linagliptin might therefore represent an important addition to the currently limited therapeutic armamentarium for achieving glycemic control in type 2 diabetes patients with declining renal function . in recognition of the favorable clinical profile of dpp4 inhibitors , recent international guidelines recommend dpp4 inhibitors as an option in both firstline ( when fpg and ppg levels are elevated ) and combination therapy82 . thus , type 2 diabetes patients , particularly special populations like those who are renally impaired , benefit from the emergence and evolution of newer antidiabetic agents , such as the dpp4 inhibitors , that address the limitations of older therapies , and allow for a more tailored and effective approach to disease control . longterm studies to assess the impact of dpp4 inhibitors on reducing the risk of diabetes complications are awaited .", "dpp4 inhibitors represent a good choice of oad for patients with type 2 diabetes . within this drug class , linagliptin , a novel dpp4 inhibitor , possesses favorable and comparable profiles in terms of both efficacy and adverse events , and is indicated for use in all patients with type 2 diabetes . furthermore , linagliptin is the only dpp4 inhibitor that is not predominantly dependent on renal metabolism . many antidiabetic therapies are often of little use in renallyimpaired type 2 diabetes patients because of contraindications or increased risk of hypoglycemia . the favorable pharmacokinetic profile of linagliptin has advantageous implications given the importance of addressing the decline in renal function in asian patients with type 2 diabetes early . in addition , the lack of dose modification requirements and ease of dosing ( one dose , once daily ) further support the suitability of linagliptin in these difficulttotreat populations ." ]

[ "pott 's disease accounts for 50% of the cases of skeletal tuberculosis ( tb ) , 15% of the cases of extrapulmonary tuberculosis ( eptb ) and 2% of all cases of tb.1 the diagnosis of pott 's disease is mostly based on clinicoradiological observations substantiated by staining and culture methods to detect the causative organism . the typical tubercular lesions of the spine can be diagnosed by radiological methods as their sensitivity is increased by the advent of newer imaging techniques like computed tomography and magnetic resonance imaging ( ct and mri ) . these techniques give sufficient information about lesions in the bone and tissues ; although the definite diagnosis is based on tissue / pus examination.2 the conventional bacteriological examination includes ziehl - neelsen ( zn ) microscopy and culture for acid fast bacilli ( afb ) . zn microscopy method is a popular technique routinely used in the clinical laboratories worldwide , due to its simplicity , cost effectiveness and rapidity , but it suffers with low sensitivity and requires 10 to 10 bacilli / ml in the clinical specimens to be positive.34 the culture of mycobacterium tuberculosis ( m. tuberculosis ) is a gold standard method for diagnosis but it also has limitations like that required 6 to 8 weeks due to the slow growth of m. tuberculosis and is often negative , it still needs 10 -10 bacilli / ml ( live bacilli ) in clinical specimens for culture recovery and also stringent test conditions that is difficult to implement at primary or secondary clinical laboratories.56 moreover , histopathological examination plays a valuable role in the diagnosis of pott 's disease but sometime it may be inconclusive and in addition need high expertise and the final reporting also takes more than 1 week.6 recently , the molecular biology technique , polymerase chain reaction ( pcr ) represents a major advance in the diagnosis of tb.6 with the use of amplification systems , nucleic acid sequences unique to m. tuberculosis can be detected directly in clinical specimens , offering better accuracy than zn microscopy and greater speed than culture . the pcr has shown very promising results for early and rapid diagnosis of the disease due to its detection limit of one to 10 bacilli in various clinical specimens.6 the present study was undertaken to evaluate the efficiency and effectiveness of different laboratory diagnostic modalities along with the role of pcr in the diagnosis of clinicoradiological suspected cases of pott 's disease .", "62 clinicoradiological suspected cases of pott 's disease with neurological complications [ table 1 ] were prospectively enrolled in this study , from 2008 to 2011 in the department of neurosurgery , at a tertiary care hospital , india . the specimens of these patients such as pus and tissue were obtained either during surgery or under ct guidance . clinicoradiological evidence of suspected pott 's disease we included clinicoradiological suspected cases of pott 's spine who underwent either open biopsy or ct guided aspiration at our institute . we excluded those subjects who did not give consent for biopsy or ct guided aspiration or biopsy showed neoplastic pathology . the specimens were examined by following methods : \n histopathology - the tissues stained with hematoxylin and eosin and zn stain were analyzed under the microscope for epithelioid cell granulomas with or without the presence of langerhans giant cell and afb.7periodic acid - schiff ( pas ) stain - fungal examination was performed by pas stain according to standard laboratory procedure.7zn microscopy - smears were stained using the zn method and examination for afb were done under light microscopy.8bactec 12b culture - bactec vials were incubated and interpreted as per becton dickinson ( bd , sparks , md , usa ) manual instructions.9p - nitro--acetylamino--hydroxy propiophenone ( nap ) test - the nap was done for identification and differentiation of mycobacterium tuberculosis complex ( mtbc ) and nontubercular mycobacterium from culture isolates.9molecular diagnosis - pcr for tb was done using a mtbc specific sequence is6110 ( 123 base pairs [ bp ] ) primer . \n histopathology - the tissues stained with hematoxylin and eosin and zn stain were analyzed under the microscope for epithelioid cell granulomas with or without the presence of langerhans giant cell and afb.7 periodic acid - schiff ( pas ) stain - fungal examination was performed by pas stain according to standard laboratory procedure.7 zn microscopy - smears were stained using the zn method and examination for afb were done under light microscopy.8 bactec 12b culture - bactec vials were incubated and interpreted as per becton dickinson ( bd , sparks , md , usa ) manual instructions.9 p - nitro--acetylamino--hydroxy propiophenone ( nap ) test - the nap was done for identification and differentiation of mycobacterium tuberculosis complex ( mtbc ) and nontubercular mycobacterium from culture isolates.9 molecular diagnosis - pcr for tb was done using a mtbc specific sequence is6110 ( 123 base pairs [ bp ] ) primer . dna extractions from tissues were done with hipura genomic dna extraction kit according to the manufacturer protocol3 . mb505 bacterial and yeast genomic dna miniprep purification spin kit , hi - media laboratories private limited mumbai , india . the reaction mixture contained 10 l pyrostart fast pcr master mix 2x ( dntp , taq polymerase with mgcl2 , fermentas , india ) , 1 l ( 10 pmole ) of each primer , 3 l water ( nuclease free ) and 5 l of extracted dna . the oligonucleotide primers11 were used forward and reverse sequence : cct gcg agc gta ggc gtc gg and ctc gtc cag cgc cgc ttc gg respectively ( sbs gene tech co. ltd . ) . these primers amplified a target fragment of 123 bp from the insertion like sequence element is6110 of mtbc . it was performed in a programmable thermal cycler ( mj research , ptc-100 , gmi , inc . each cycle comprised denaturation at 94c for 2 min , annealing at 68c for 2 min and primer extension at 72c for 1 min . after the 40 cycles , the additional extension for 10 min at 72c was carried out . the amplified products were separated on 2% agarose gel , visualized on an ultraviolet - transilluminator ( bangalore genei , bangalore , india ) . the presence of 123 bp fragment indicated as a positive test for mtbc [ figure 1 ] . the positive controls included the dna of h37rv strain and negative control included pcr grade water . polymerase chain reaction is6110 gene for detection of mycobacterium tuberculosis complex at 2% agarose gel . lane 1 ( l1 ) and l9 ladder 100 base pairs , l2 positive and l3 negative control , l4 , 5 , 6 , 8 showed positive and l7 showed negative specimens a definite treatment either by surgery ( 46 cases ) or by only anti tubercular treatment ( att ) ( 9 cases ) was offered . we followed the following major indications for surgical intervention in our setup : ( 1 ) advanced cases of neurological involvement such as marked sensory or sphincter disturbances , flaccid paralysis or severe flexor spasms . ( 2 ) prevertebral cervical abscess with difficulty in respiration and deglutition , seemingly difficult resolution on chemotherapy during conservative treatment . ( 3 ) worsening of already present neurological complications during the treatment . ( 5 ) no improvement in neurological complications / morbidity even after 4 - 6 weeks of att . a four drug regimen chemotherapy consisting of isoniazid , rifampicin , pyrazinamide and ethambutol ( hrze ) were given to all patients in their appropriate doses according to the weight of patients as per departmental protocol , following or along with surgery . four - drug regimen for at least 4 - 6 weeks to gauge the response was given ( 8 - 12 mg / kg / day rifampicin , 4 - 6 mg / kg / day isoniazid and 15 - 20 mg / kg / day ethambutol in a single daily dose ; and pyrazinamide 15 - 20 mg / kg / day in two divided doses ) , if not contraindicated the drug therapy was continued for 18 months12 . in cases of no improvements or hepatotoxicity , the patients were switched to modified att with the addition of ofloxacin and streptomycin and modification in doses of isoniazid and rifampicin or discontinuation of them . the therapeutic response was observed by clinical improvement in the form of healing sign that is an improvement in motor power / spasticity , sensory loss of limbs , autonomic dysfunctions and constitutional symptoms [ table 2 ] . the liver function test was done as per protocol to rule out the subclinical hepatotoxcity . the radiological assessment was done by using followup mri , the first at the end of 6 months of the commencement of the att and was compared with pretreatment images by the same senior radiologist of our institute . criteria for clinical improvement : ( first ( pain ) is mandatory and any other two improved symptoms / sign ) this study was approved by 41 institutional ethics committee ( a-04 pgi / imp / ec/41/28/2/2008 ) . the final diagnosis was established by using the collective results of zn microscopy , bactec culture , histopathological findings and response to att . the efficiency of test tools was calculated as ( total positive cases / total number of cases ) 100 . the positive concordance between traditional tools and pcr were assessed using the kappa coefficient ( > 0.75 , excellent agreement ; < 0.4 , poor agreement ; 0.4 and 0.75 , good to a fair agreement)13 and significance difference was analyzed by the chi square ( 2 ) test with the help of the spss 15.1 version . the cases were labeled as definite tb if at least one performed test ( zn microscopy / bactec culture / or histopathology ) was found positive .", "the specimens were examined by following methods : \n histopathology - the tissues stained with hematoxylin and eosin and zn stain were analyzed under the microscope for epithelioid cell granulomas with or without the presence of langerhans giant cell and afb.7periodic acid - schiff ( pas ) stain - fungal examination was performed by pas stain according to standard laboratory procedure.7zn microscopy - smears were stained using the zn method and examination for afb were done under light microscopy.8bactec 12b culture - bactec vials were incubated and interpreted as per becton dickinson ( bd , sparks , md , usa ) manual instructions.9p - nitro--acetylamino--hydroxy propiophenone ( nap ) test - the nap was done for identification and differentiation of mycobacterium tuberculosis complex ( mtbc ) and nontubercular mycobacterium from culture isolates.9molecular diagnosis - pcr for tb was done using a mtbc specific sequence is6110 ( 123 base pairs [ bp ] ) primer . \n histopathology - the tissues stained with hematoxylin and eosin and zn stain were analyzed under the microscope for epithelioid cell granulomas with or without the presence of langerhans giant cell and afb.7 periodic acid - schiff ( pas ) stain - fungal examination was performed by pas stain according to standard laboratory procedure.7 zn microscopy - smears were stained using the zn method and examination for afb were done under light microscopy.8 bactec 12b culture - bactec vials were incubated and interpreted as per becton dickinson ( bd , sparks , md , usa ) manual instructions.9 p - nitro--acetylamino--hydroxy propiophenone ( nap ) test - the nap was done for identification and differentiation of mycobacterium tuberculosis complex ( mtbc ) and nontubercular mycobacterium from culture isolates.9 molecular diagnosis - pcr for tb was done using a mtbc specific sequence is6110 ( 123 base pairs [ bp ] ) primer . dna extractions from tissues were done with hipura genomic dna extraction kit according to the manufacturer protocol3 . mb505 bacterial and yeast genomic dna miniprep purification spin kit , hi - media laboratories private limited mumbai , india . the reaction mixture contained 10 l pyrostart fast pcr master mix 2x ( dntp , taq polymerase with mgcl2 , fermentas , india ) , 1 l ( 10 pmole ) of each primer , 3 l water ( nuclease free ) and 5 l of extracted dna . the oligonucleotide primers11 were used forward and reverse sequence : cct gcg agc gta ggc gtc gg and ctc gtc cag cgc cgc ttc gg respectively ( sbs gene tech co. ltd . ) . these primers amplified a target fragment of 123 bp from the insertion like sequence element is6110 of mtbc . it was performed in a programmable thermal cycler ( mj research , ptc-100 , gmi , inc . each cycle comprised denaturation at 94c for 2 min , annealing at 68c for 2 min and primer extension at 72c for 1 min . after the 40 cycles , the additional extension for 10 min at 72c was carried out . the amplified products were separated on 2% agarose gel , visualized on an ultraviolet - transilluminator ( bangalore genei , bangalore , india ) . the presence of 123 bp fragment indicated as a positive test for mtbc [ figure 1 ] . the positive controls included the dna of h37rv strain and negative control included pcr grade water . polymerase chain reaction is6110 gene for detection of mycobacterium tuberculosis complex at 2% agarose gel . lane 1 ( l1 ) and l9 ladder 100 base pairs , l2 positive and l3 negative control , l4 , 5 , 6 , 8 showed positive and l7 showed negative specimens a definite treatment either by surgery ( 46 cases ) or by only anti tubercular treatment ( att ) ( 9 cases ) was offered . we followed the following major indications for surgical intervention in our setup : ( 1 ) advanced cases of neurological involvement such as marked sensory or sphincter disturbances , flaccid paralysis or severe flexor spasms . ( 2 ) prevertebral cervical abscess with difficulty in respiration and deglutition , seemingly difficult resolution on chemotherapy during conservative treatment . ( 3 ) worsening of already present neurological complications during the treatment . ( 5 ) no improvement in neurological complications / morbidity even after 4 - 6 weeks of att . a four drug regimen chemotherapy consisting of isoniazid , rifampicin , pyrazinamide and ethambutol ( hrze ) were given to all patients in their appropriate doses according to the weight of patients as per departmental protocol , following or along with surgery . four - drug regimen for at least 4 - 6 weeks to gauge the response was given ( 8 - 12 mg / kg / day rifampicin , 4 - 6 mg / kg / day isoniazid and 15 - 20 mg / kg / day ethambutol in a single daily dose ; and pyrazinamide 15 - 20 mg / kg / day in two divided doses ) , if not contraindicated the drug therapy was continued for 18 months12 . in cases of no improvements or hepatotoxicity , the patients were switched to modified att with the addition of ofloxacin and streptomycin and modification in doses of isoniazid and rifampicin or discontinuation of them . the therapeutic response was observed by clinical improvement in the form of healing sign that is an improvement in motor power / spasticity , sensory loss of limbs , autonomic dysfunctions and constitutional symptoms [ table 2 ] . the liver function test was done as per protocol to rule out the subclinical hepatotoxcity . the radiological assessment was done by using followup mri , the first at the end of 6 months of the commencement of the att and was compared with pretreatment images by the same senior radiologist of our institute . criteria for clinical improvement : ( first ( pain ) is mandatory and any other two improved symptoms / sign ) this study was approved by 41 institutional ethics committee ( a-04 pgi / imp / ec/41/28/2/2008 ) .", "the final diagnosis was established by using the collective results of zn microscopy , bactec culture , histopathological findings and response to att . the efficiency of test tools was calculated as ( total positive cases / total number of cases ) 100 . the positive concordance between traditional tools and pcr were assessed using the kappa coefficient ( > 0.75 , excellent agreement ; < 0.4 , poor agreement ; 0.4 and 0.75 , good to a fair agreement)13 and significance difference was analyzed by the chi square ( 2 ) test with the help of the spss 15.1 version . the cases were labeled as definite tb if at least one performed test ( zn microscopy / bactec culture / or histopathology ) was found positive .", "the study group consisted of 62 specimens from suspected pott 's spine individuals . on the basis of histopathological examination , 7 cases ( 5 specimens from open biopsy and 2 from fine needle aspiration [ fna ] ) were excluded from the study as they were diagnosed to be neoplastic . out of rest 55 cases , 46 specimens were obtained through open biopsy during surgery and 9 were ct guided fna . further , in all ( 46 ) open biopsy specimens , 7 were positive for epithelioid cell granulomas with afb , 27 revealed granulomatous lesions suggestive of tb with or without the presence of the langerhans giant cell . however , the histological diagnosis could not be reached in 12 specimens because of either suspicious granulomatous lesions or on account of inconclusive histology . five of nine ct guided fna specimens were diagnosed as tubercular and 4 specimens showed no granulomatous / no malignant lesions . the received specimens included 31 ( 56.4% ) pus and 15 ( 27.3% ) tissues through open biopsy along with 6 ( 11% ) pus and 3 ( 0.54% ) tissues were obtained through ct guided fna . the overall collected specimens were consisted 37 pus and 18 tissue specimens ( either open biopsy or by ct fna ) were analyzed . the zn microscopy was positive in total 20 ( 36.4% ) of 55 cases ( 18/37 cases in pus and 2/18 cases in tissue specimens ) . the bactec culture was positive 27 ( 49% ) of 55 cases ( 22/37 in pus and 5/18 in tissue specimens ) . the desired amplification of pcr is6110 was positive in 37 ( 67.5% ) of 55 cases ( 30/37 cases in pus and 7/18 in tissue specimens ) [ table 3 ] . the kappa coefficient of pcr with zn microscopy ( = 0.37 , [ p = 0.001 ] ) showed poor agreement and with the bactec culture ( = 0.57 , [ p < 0.001 ] ) it showed a good agreement [ figure 2 ] . result of laboratory findings bar diagram showing kappa coefficient concordance between pcr and traditional tools . ( znm = zn microscopy , bc = bactec culture and hp = histopathology ) on histopathological results ; 39 ( 71% ) cases were positive and 16 ( 29% ) were negative for tb . out of 39 positive cases , 31 ( 56.4% ) were positive on pcr also . thus , the false negative and positive of pcr was found to be 8 ( 14.4% ) and 6 ( 11% ) respectively . therefore , the kappa coefficient of pcr with histopathology was ( = 0.4 [ p = 0 . 004 ] ) slightly good [ figure 2 ] . in 55 cases , it was possible to reach a final diagnosis through the combined result of all performed tests ( without consideration of pcr results ) and with att response . hence , among all 55 cases , 45 ( 82% ) cases were tb positive test and 10 ( 18% ) were negative by all tests carried out ( zn microscopy , bactec culture and histopathology ) . although pcr showed 67.3% ( 37/55 ) sensitivity at the final diagnosis , while pcr showed 37/45 positive and no any false positive out of 10 negative cases by all traditional tests . therefore , the kappa coefficient of pcr with the combined results of all traditional tests ( = 0.63 [ p < 0.001 ] ) ultimately reached to a fair positive agreement [ figure 2 ] . the present study , the combination of ( a ) zn microscopy with bactec , the total 31 positive cases due to only 20 cases positive on zn microscopy and an additional 11 cases were positive on bactec culture . ( b ) zn microscopy with histopathology , the total positivity showed 43 cases due to 23 cases more positive on histopathology against zn microscopy . ( c ) bactec culture with histopathology , the total 45 cases to be positive due to 39 cases positive on histopathology and an additional 6 cases were positive on bactec culture , where the histopathology was negative . ( d ) the total 45 cases were positive in combination of zn microscopy + bactec culture + histopathology . ( e ) zn microscopy with pcr , the total positivity was 38 cases , in which 18 more cases were positive on pcr method . ( f ) bactec culture with pcr , the total 38 positive cases due to only 27 cases positive on bactec culture and additional 11 cases were positive on pcr . ( g ) histopathology with pcr , the total 45 cases positive on this possible battery due to 39 cases positive on histopathology and an additional 6 cases were positive on pcr . ( h ) the battery of zn microscopy + bactec culture + histopathology + pcr showed ultimately 45 cases were positive because pcr could not give any more positive against the mentioned battery d and g [ table 4 ] .", "the received specimens included 31 ( 56.4% ) pus and 15 ( 27.3% ) tissues through open biopsy along with 6 ( 11% ) pus and 3 ( 0.54% ) tissues were obtained through ct guided fna . the overall collected specimens were consisted 37 pus and 18 tissue specimens ( either open biopsy or by ct fna ) were analyzed . the zn microscopy was positive in total 20 ( 36.4% ) of 55 cases ( 18/37 cases in pus and 2/18 cases in tissue specimens ) . the bactec culture was positive 27 ( 49% ) of 55 cases ( 22/37 in pus and 5/18 in tissue specimens ) . the desired amplification of pcr is6110 was positive in 37 ( 67.5% ) of 55 cases ( 30/37 cases in pus and 7/18 in tissue specimens ) [ table 3 ] . the kappa coefficient of pcr with zn microscopy ( = 0.37 , [ p = 0.001 ] ) showed poor agreement and with the bactec culture ( = 0.57 , [ p < 0.001 ] ) it showed a good agreement [ figure 2 ] . result of laboratory findings bar diagram showing kappa coefficient concordance between pcr and traditional tools .", "on histopathological results ; 39 ( 71% ) cases were positive and 16 ( 29% ) were negative for tb . out of 39 positive cases , 31 ( 56.4% ) were positive on pcr also . thus , the false negative and positive of pcr was found to be 8 ( 14.4% ) and 6 ( 11% ) respectively . therefore , the kappa coefficient of pcr with histopathology was ( = 0.4 [ p = 0 . 004 ] ) slightly good [ figure 2 ] .", "in 55 cases , it was possible to reach a final diagnosis through the combined result of all performed tests ( without consideration of pcr results ) and with att response . hence , among all 55 cases , 45 ( 82% ) cases were tb positive test and 10 ( 18% ) were negative by all tests carried out ( zn microscopy , bactec culture and histopathology ) . although pcr showed 67.3% ( 37/55 ) sensitivity at the final diagnosis , while pcr showed 37/45 positive and no any false positive out of 10 negative cases by all traditional tests . therefore , the kappa coefficient of pcr with the combined results of all traditional tests ( = 0.63 [ p < 0.001 ] ) ultimately reached to a fair positive agreement [ figure 2 ] .", "the present study , the combination of ( a ) zn microscopy with bactec , the total 31 positive cases due to only 20 cases positive on zn microscopy and an additional 11 cases were positive on bactec culture . ( b ) zn microscopy with histopathology , the total positivity showed 43 cases due to 23 cases more positive on histopathology against zn microscopy . ( c ) bactec culture with histopathology , the total 45 cases to be positive due to 39 cases positive on histopathology and an additional 6 cases were positive on bactec culture , where the histopathology was negative . ( d ) the total 45 cases were positive in combination of zn microscopy + bactec culture + histopathology . ( e ) zn microscopy with pcr , the total positivity was 38 cases , in which 18 more cases were positive on pcr method . ( f ) bactec culture with pcr , the total 38 positive cases due to only 27 cases positive on bactec culture and additional 11 cases were positive on pcr . ( g ) histopathology with pcr , the total 45 cases positive on this possible battery due to 39 cases positive on histopathology and an additional 6 cases were positive on pcr . ( h ) the battery of zn microscopy + bactec culture + histopathology + pcr showed ultimately 45 cases were positive because pcr could not give any more positive against the mentioned battery d and g [ table 4 ] .", "pott 's disease , accounts for 2% of all tb infections.1 the diagnosis of pott 's disease is principally based on classical clinical manifestations of spinal infection supplemented by modern imaging like ct and mri.1415 the ct and mri in particular can detect the subtle changes in the spine , from initial changes in the intensity pattern of the vertebrae to the extreme changes like deformity of the spine including soft tissue shadow , granulation tissue and pus etc.16 however , the various pathologies including neoplastic and other inflammatory conditions simulate with pott 's diseases on imaging . the current study excluded 7 of 62 cases ; they were diagnosed to be neoplastic by the histopathological examination . it signifies that even strong clinicoradiological diagnosis based on classical or nonclassical radiological and clinical findings can be wrong on histopathological evaluation . the remaining 55 cases , 20 ( 36.3% ) were tested positive with zn microscopy and 27 ( 49% ) with bactec culture . an earlier report by jain et al.17 found 14.8% positivity on zn microscopy and 11.11% positivity on culture method in cases of spinal tb . the zn microscopy and bactec culture reports revealed higher positivity in relation to the earlier published series . our higher detection rate was because of the fact that we used the liquid culture medium bactec 12b medium . it is the rapid , sensitive and efficient method for the isolation of mycobacterium in a clinical laboratory as compared to solid medium lowenstein jensen.19 moreover , it is established today that all the traditional tests need to have a minimum concentration of bacilli for yielding positive results as mentioned in the introduction . hence , if the specimens , which are naturally having more concentration of bacilli , like sputum and pus it may become easy to detect m. tuberculosis.20 similarly , in our study the pus specimens had higher recognition of tubercular bacilli on zn microscopy and bactec culture methods [ table 3 ] . the study quoted the detection rate of eptb including pott 's spine varying from 53% to 81%.182122 the histopathological diagnosis could be reached in 71% ( 39 out of 55 ) of the cases which were either confirmed by the presence of afb in 12.7% or strongly suggestive of tubercular pathology . in our series , we found 16 cases were negative on histology . among these negative cases , 10 out of 16 cases had been under anti tubercular therapy for more than 6 months and another reason of histology negative might be a possible sampling error during the collection of the representative tissues for processing . the positivity of fna specimens seems to higher than surgical specimens , however , we require a long sample size for definite conclusion . molecular diagnostic tool , such as pcr has been shown to have higher efficiency in the diagnosis of pulmonary tb as well as eptb.4 it has been studied on clinical specimens of sputum , cerebrospinal fluid , edta - blood , pleural fluid , fluid from fistulae and pus from wounds.2324 in an attempt to increase diagnostic precision , we performed pcr is6110 , which was detected in 37/55 ( 67.3% ) cases . various studies documented the increased positivity by pcr targeting is6110 in specimens of eptb i.e. , sekar et al.25 found 63% positivity , negi et al.26 73% and tiwari et al.27 62% positivity among clinical specimens of eptb . the overall positive agreement shows a fair agreement ( = 0.63 ) between pcr and definite tb . the false negative results were observed in 14.5% cases out of 45 cases diagnosed by all performed traditional tests . the reasons of false negative results of pcr may be on account of insufficient specimens , irregular distribution of mycobacterium bacilli in specimens , the presence of extensive necrosis and presence of inhibitors.28 the limitation of our study are a low positive correlation ( = 0.4 ) of pcr with histopathological findings . this can be explained up to some extent by the specimen variation as that is different specimens ( such as pus , tissue ) from the same subjects . surgeons prefer to send tissue specimens for histology and pus for zn microscopy , bactec culture and pcr . in this study histology was done on tissue specimens ( all 55 cases ) , while zn microscopy , bactec culture and pcr were done in 37 pus and 18 tissue specimens . in our diagnostic battery , all performed traditional tests were diagnosed 45/55 cases and pcr was alone detected 37/55 cases . thus , positive results of pcr with the clinicoradiological assumption it would be possible to make a decision in suspected pott 's disease to start early treatment to prevent irreversible complications . in the present study , it is observed that no single diagnostic modality is having a good positivity rate . hence , a combination of diagnostic battery is required for rapid diagnosis and better results . the combination of bactec culture and histopathology has detected a maximum of 45 cases . while the combination of pcr and histopathology has also detected same number of cases table 4 . as culture takes long incubation time for results , the combination of pcr and histopathology can be applied for rapid detection of pott 's disease . to conclude , for diagnosis of pott 's disease , the combined results of zn microscopy , bactec culture and histopathology are most appropriate . however , for rapid diagnosis the combination of pcr amplification and histopathology offer a better prospect ." ]

[ "such proteins perform many basic functions including cell signalling , transcription regulation , energy conservation and transformation , and ion exchange . membrane proteins are difficult to study , since they are inserted into lipid bilayers and expose to the polar outer and inner environments portions of different sizes . it is therefore difficult to purify them in the native , functional form and even more difficult to crystallize them . for such technical reasons , only a small fraction of the protein data bank structures are membrane proteins ( < 1% of the total number of structures and far less than their estimated abundance in cells ) ( 1 ) . there are a number of computational methods available to predict the topology of membrane proteins , which consists of two basic features : ( i ) the location of transmembrane domains along the protein chain and ( ii ) the location of the n- and c - termini with respect to the lipid membrane . topological models are sufficient in many instances to design simple experiments in order to prove the location of the n- and c - protein termini , that of the inner and outer loops with respect to the membrane plane , and concomitantly the number of transmembrane segments in the chain . however , the best - performing methods are offered at different servers and are endowed with different graphical interfaces . this hampers the direct comparison of predictions , especially for experimentalists interested in comparing their results with computational methods . currently , two other web servers of which we are aware ( 2,3 ) are available and separately comprise two of the predictors that we implement tmhmm2.0 ( 4 ) and memsat ( 5 ) . the novelty of our web server is to include in the same framework ensemble ( 6 ) and prodiv ( 7 ) , two powerful methods that became available only recently . furthermore the available web servers render only the consensus prediction , without allowing a critical discrimination among different predictions that may be useful , considering that different predictors may highlight different properties , depending on the different implementation . automatic topology annotation for membrane proteins has been included among the efforts of the biosapiens european network of excellence ( ) with the specific aim of taking into consideration different predictors for annotating membrane proteins in the human genome . the common platform for these efforts is the biosapiens distributed annotation servers ( das ) ( ) . in this context , the pongo - das server ( ) provides topology annotation for the all - alpha membrane proteins of the human genome . this is done using the das protocol ( ) to answer at das queries that can be seen using specific visualizers such as dasty ( 8) or ensembl ( 9 ) . in order to allow users to browse directly the pre - computed transmembrane annotations the annotation is carried out using four selected predictors , namely ensemble1.0 ( 6 ) and prodiv ( 7 ) , in order to allow a direct comparison of the topology prediction for the sequence at hand . the server has also been set up to make it possible to predict the topology of any putative membrane proteins of interest regardless of provenance . the topological models computed by the different predictors can be directly obtained simply by pasting in a box the sequence of interest and looking at the results . recently developed web technologies ( e.g. ajax ) are used to improve the user interface .", "the website implements the following predictors : memsat is a new version of the memsat predictor of transmembrane helices in proteins ( 4 ) . tmhmm2.0 which is a predictor of transmembrane helices in proteins based on hidden markov models ( 5 ) . it has been shown that it performs quite well taking into account that it uses only single sequence information . ensemble1.0 is an ensemble of two hidden markov models and one neural network ( 6 ) . ensemble takes also advantage of the evolutionary information derived by multiple sequence alignment , both for the neural network and the hidden markov model systems . prodiv_tmhmm_0.91 is a recent predictor of transmembrane helices in proteins ( 7 ) which uses a hidden markov model similar to tmhmm , but exploits the evolutionary information derived by multiple sequence alignment . spep is a signal peptide predictor based on combination of neural networks ( 10 ) . this predictor has performance similar to the most widely used signalp ( 11 ) , and it has been included since it is quite common that signal peptides are mispredicted as transmembrane helices . in the context of the biosapiens project , we downloaded the uniprot dataset ( september 22 , 2004 ) which consists of 33 135 human protein sequences , and for future use also the ipi dataset ( august 5 , 2004 ) which consists of 46 782 human proteins . the union of the two datasets comprises 50 600 sequences from the human genome . it is worth noticing that these 50 600 sequences do not include the known splice variants , since those variants are not presently included as unique uniprot codes . the choice of annotating uniprot sequences is well justified from the fact that ensembl gene products ( in contrast to the uniprot entries ) are not stable ; for instance , only 60% of the sequences are common ( and conserved ) between the ensembl releases 34 and 35 , respectively . we then use four state - of - the - art predictors already described in the literature in order to identify the most probable integral membrane proteins . in this way the union of the predictions obtained with the four methods gives a set of likely membrane proteins , while the intersection contains those chains on whose annotation as membrane proteins all the predictors agree upon . the pre - computed annotations are filtered with spep before being processed by the transmembrane predictors . this is done since it is quite common that signal peptides are mispredicted as transmembrane helices by all the predictors implemented in our web server . in the case of a positive spep answer , the system cuts the corresponding predicted segment and processes the remaining part of the sequence with the four transmembrane predictors .", "the website implements the following predictors : memsat is a new version of the memsat predictor of transmembrane helices in proteins ( 4 ) . tmhmm2.0 which is a predictor of transmembrane helices in proteins based on hidden markov models ( 5 ) . it has been shown that it performs quite well taking into account that it uses only single sequence information . ensemble1.0 is an ensemble of two hidden markov models and one neural network ( 6 ) . ensemble takes also advantage of the evolutionary information derived by multiple sequence alignment , both for the neural network and the hidden markov model systems . prodiv_tmhmm_0.91 is a recent predictor of transmembrane helices in proteins ( 7 ) which uses a hidden markov model similar to tmhmm , but exploits the evolutionary information derived by multiple sequence alignment . spep is a signal peptide predictor based on combination of neural networks ( 10 ) . this predictor has performance similar to the most widely used signalp ( 11 ) , and it has been included since it is quite common that signal peptides are mispredicted as transmembrane helices .", "in the context of the biosapiens project , we downloaded the uniprot dataset ( september 22 , 2004 ) which consists of 33 135 human protein sequences , and for future use also the ipi dataset ( august 5 , 2004 ) which consists of 46 782 human proteins . the union of the two datasets comprises 50 600 sequences from the human genome . it is worth noticing that these 50 600 sequences do not include the known splice variants , since those variants are not presently included as unique uniprot codes . the choice of annotating uniprot sequences is well justified from the fact that ensembl gene products ( in contrast to the uniprot entries ) are not stable ; for instance , only 60% of the sequences are common ( and conserved ) between the ensembl releases 34 and 35 , respectively . we then use four state - of - the - art predictors already described in the literature in order to identify the most probable integral membrane proteins . in this way the union of the predictions obtained with the four methods gives a set of likely membrane proteins , while the intersection contains those chains on whose annotation as membrane proteins all the predictors agree upon . the pre - computed annotations are filtered with spep before being processed by the transmembrane predictors . this is done since it is quite common that signal peptides are mispredicted as transmembrane helices by all the predictors implemented in our web server . in the case of a positive spep answer , the system cuts the corresponding predicted segment and processes the remaining part of the sequence with the four transmembrane predictors .", "pongo has two different usage options : \n pongo - das accessing the pre - computed annotations using keywords or das queries;pongo - pred that is an enhanced and modern version of a standard through - the - web server application . pongo - das accessing the pre - computed annotations using keywords or das queries ; pongo - pred that is an enhanced and modern version of a standard through - the - web server application . in the case of pongo - das we implemented two types of result visualization : \n by means of a das , which is a client server system in which a single client integrates information from multiple servers . it allows a single machine to gather up genome annotation information from multiple distant web sites , collate the information , and display it to the user in a single view . little coordination is needed among the various information providers , anda user - friendly interface that allows the search for a specific prediction.through the das protocol a web client like ensembl can obtain the list of the annotations for each human protein using its uniprot code as requested for the das queries ( ) ; in order to check this url the client needs a das client such as the one that will be embedded in ensembl pages at ebi and a uniprot code for the sequence . a user can directly query the database , without using the das infrastructure , using the web interface available at ( figure 1 ) the user can then use a crc64 ( the sequence hash code ) , or the sequence uniprot or ipi code to get the predictions in a graphical view . an example of a sequence filtered with the different predictors is presented together with the detailed sequence annotation ( figure 2 ) . a colour code is used to quickly identify the transmembrane segments . by means of a das , which is a client server system in which a single client integrates information from multiple servers . it allows a single machine to gather up genome annotation information from multiple distant web sites , collate the information , and display it to the user in a single view . little coordination is needed among the various information providers , and a user - friendly interface that allows the search for a specific prediction . conversely , pongo - pred provides the user with a unique framework for membrane protein topology and signal peptide predictions . another interesting feature of pongo - pred is the javascript - enabled portlet that in real time refreshes the queue status ( without reloading of the submission page and with very lightweight xml http requests ) . in particular , on the left - side of the page the user can realise whether her / his submission is a new call , whether it is running ( in this case the starting date and an absolute link is provided for bookmarking ) , or whether it has been processed .", "the pongo homepage . on the left - side it is possible to follow the status of the different queries and the starting of a new action ." ]

[ "the epstein barr virus ( ebv ) infects b cells . in most cases , ebv - positive patients develop a severe form of infectious mononucleosis which typically manifests with fever , tonsillopharyngitis , lymphadenopathy and hepatosplenomegaly . deficiencies may be characterized by abnormal activity of lymphocyte function leading to hemophagocytosis and multi - organ failure . although ebv - associated hlh carries a high mortality rate , quick diagnosis and appropriate treatment can subside the disease . we describe here a patient who developed hepatosplenomegaly and pancytopenia at 2 years of age but achieved automatic recovery . , there was a clinical suspicion of ebv - induced hlh and the patient was given the option of treatment with rituximab .", "she received antibiotic treatment due to fever and chills . during the hospitalization period , the patient recovered and developed hemophagocytosis with pancytopenia as well as sores on the lip . the patient underwent bma and nothing abnormal was found . in spite of treatment , the disease did not subside and she developed fever , abdominal distention and edema in her lower extremities . physical examination showed that the patient had decreased deep - tendon reflexes ( dtr ) and was unable to walk . clindamycin , ceftazidime , dexamethasone , ivig ( intravenous immunoglobulin ) and g - csf were administered . since the patient did not achieve full recovery , she was transferred to our center . based on clinical symptoms and lab tests ( table 1 ) , bma was performed once again and the result raised suspicion of ebv - induced secondary hlh . rituximab was injected once and the patient developed a blood ebv load of zero within one week . in order to control abnormal stimulation of the immune system , the patient was investigated for mutations in il-2-inducible t cell kinase ( itk ) and negative test results were received . ( the patient was negative for mutations in il-2-inducible t cell kinase ( itk ) ) . she is now considered to be an acceptable candidate for transplantation from an hla matched sibling donor . \n ", "hlh can be divided into two subgroups : primary or familial hlh and secondary hlh . the primary form is an inflammatory disease which is similar to secondary one on the basis of symptoms . primary hlh usually arises in young children less than one year old ( 70% cases ) ; however , in rare cases it can also occur in adults ( perforin gene mutations have been identified in patients with primary hlh ) . for example , type 2 is caused by mutations in genes 21 - 22 and type 5 is due to mutations in the munc18 - 20 that may be accompanied by hypogammaglobulinemia . hypogammaglobulinemia was not confirmed in the patient because it was not possible to check mutation ( the related tests were sent to germany to examine the type 5 disease ) . ebv may also be accompanied by hypogammaglobulinemia for a certain period secondary hlh is associated with immunologic stimulation caused by malignancies and bacterial or congenital infections . the most common causes of secondary hlh are viral infections by ebv , cmv , prob19 and hiv . however , it may also be seen in patients with immune system defects . , 4 secondary hlh is a known complication of ebv infection , particularly in patients with x - linked lymphoproliferative disease . the incidence of x - linked lymphoproliferative syndrome is 1 in 1,000,000 male infants . \n diagnostic criteria for hlh disease diagnosis of hlh requires the presence of all 5 major criteria . if the patient meets only 4criteria but the clinical suspicion for hlh is high , one should initiate treatment , because delays may be fatal . alternative criteria 1 or a combination of 2 and 3 may substitute for 1 major criterion . adapted from henter ji , elinder g , ost a.semin oncol . 1991 ; 18:29 - 33 . it means that ebv - infected b cells stimulate cytotoxic t lymphocytes leading to hypercytokinemia and stimulation of histolytic cells . more recently , it has been found that chronic stimulation by ebv may cause chronic hlh in the patient . on the other hand , ebv causes stimulation , generation and uncontrolled secretion of t - and nk- cells , as well as generation of il2 , infa and il6 . there is another mechanism by which ebv stimulates membrane protein ( lmp-1 ) in cells . similar to xlp , lmp-1 may cause acquired immune deficiency , leading to hlh accordingly . \n treatment follows two goals : first , to suppress immune response using ivig , steroid and hlh protocol . second , to inhibit undesirable influence of immune response and cytokine - stimulated cell activation using immunochemotherapy . in cases with neurological symptoms the level of viral dna which is measured by quantitative pcr may be useful to demonstrate treatment response predicting mortality . the dna level reached zero in our patient . using ivig prior to start of protocol 2004 it has also been recommended in the treatment of ebv - induced secondary hlh monthly . \n decrease of b cells , which have been contaminated by ebv , actually causes decrease of viruses , as it may be useful for our patient as well . finally , treatment - refractory patients , transplant candidates , patients with familial type of hlh , or recurrent disease undergo chemotherapy for 8 weeks . patients who respond favorably to treatment do not undergo transplantation but those who experience relapse and exhibit neurological symptoms are considered for transplantation .", "severe infection of ebv is not associated with life - threatening condition , but our case study needs urgent treatment . in patients with long - term ebv infection , pancytopenia , coagulopathy and hepatosplenomegaly , bma will be performed and the serum ferritin level will be measured as well . for patients with secondary hlh , rituximab can be used when hlh is associated with ebv to inhibit the immune response . thus , the main aim of treatment is to reduce the rate of mortality in patients with hlh ." ]

[ "we used data from the hoorn study , a population - based cohort study on glucose metabolism and other cardiovascular risk factors in a general caucasian population , which has been described in detail previously ( 12 ) . in brief , men and women aged 5075 years were randomly selected from the population register of the town of hoorn , the netherlands ; 2,484 subjects participated ( response rate 71% ) . all subjects had a 75-g oral glucose tolerance test , except those in whom type 2 diabetes had previously been diagnosed . an extensive metabolic and cardiovascular investigation was performed in an age- , sex- , and glucose tolerance stratified , random subsample of 631 participants ( 89% of those invited ) , which is used in the present study ( 12 ) . participants without representative urine samples available ( n = 45 ) and/or who did not complete at least 7 of the 10 autonomic function tests ( n = 31 ) , had a history of neurological disease ( n = 5 ) , and were using ace inhibitors ( n = 33 ) and/or drugs known to influence autonomic nerve function ( namely antiparkinson drugs , phenytoin , antihistamines , or parasympatholytic , parasympathomimetic , and sympathomimetic drugs ) ( n = 49 ) were excluded from the analyses . the present study , therefore , consisted of 490 individuals : 305 with normal glucose metabolism , 71 with igm ( including those with impaired fasting glucose and/or impaired glucose tolerance ) , and 114 with type 2 diabetes . the hoorn study was approved by the ethical review committee of vu university medical centre , amsterdam , the netherlands . urinary albumin concentration was measured in a first voided sample by rate nephelometry ( array protein system , beckman coulter , galway , ireland ) with a detection threshold of 6.2 mg / l ( intra- and interassay coefficients of variation of 5 and 8% , respectively ) . microalbuminuria was present if the albumin - to - creatinine ratio ( acr ) was in the range of 2.030 mg / mmol ( 5 ) . the average value of the acr was used if two representative samples ( n = 154 ) were available . excluding subjects with an acr > 30 mg / mmol ( i.e. , macroalbuminuria , n = 4 ) did not materially affect any of the results , which are therefore presented for the entire group . cardiovascular autonomic function tests were performed as described in detail elsewhere ( 9 ) . in brief , participants were asked to refrain from smoking and drinking coffee for at least 2 h before the assessments . tests took place between 8:30 a.m. and 4:00 p.m. in a quiet location with room temperature of 1922c after a resting period of at least 10 min . ten parameters of cardiac autonomic function were derived from the r - r interval and finger systolic blood pressure ( sbp ) continuous recordings by a computerized data analyses system developed locally by the department of medical physics , vu university , amsterdam , the netherlands ( 13 ) . tests were performed under three conditions : during spontaneous breathing over 3 min in the supine position ( mean of all normal to normal r - r intervals [ meannn ] , sd of all normal to normal r - r intervals [ sdnn ] , low - frequency [ lf ] power , high - frequency [ hf ] power , and lf/(lf + hf ) ) , during six deep breaths over 1 min in the supine position ( expiration - inspiration [ ei ] difference and baroreflex sensitivity [ brs ] ) , and during an active change from lying to standing ( sbp difference , r - r interval maximum [ rrmax ] , and r - r interval maximum divided by minimum [ rrmax / min ] ) ( for further explanation of measurements , see supplementary table a1 , available in an online appendix at http://care.diabetesjournals.org/cgi/content/full/dc08-1544/dc1 ) . we thus obtained results in four tests that reflect heart rate or blood pressure changes due to certain maneuvers , in this case deep breathing or standing up ( i.e. , ei difference , rrmax , rrmax / min , and sbp difference ) ( 14 ) , five tests of spectral analyses of heart rate variability ( hrv ) [ i.e. , meannn , sdnn , lf power , hf power , and lf/(lf + hf ) ] ( 15 ) , and one brs measurement ( 16 ) . in addition , these tests were grouped into those representing predominantly parasympathetic ( i.e. , ei difference , rrmax , and hf power ) , sympathetic ( i.e. , sbp difference ) , or both functions ( i.e. , mean - nn , sdnn , lf power , lf/(lf + hf ) , brs , and rrmax / min ) ( 15,16 ) . bmi , waist - to - hip ratio ( whr ) , sbp and diastolic blood pressure ( dbp ) , levels of fasting plasma glucose ; a1c ; insulin ; total , hdl , and ldl cholesterol ; triglycerides ; creatinine ; and smoking status were measured as described elsewhere ( 5,9,12 ) . glomerular filtration rate was estimated by the short modification of diet in renal disease equation . hypertension was defined as sbp 140 mmhg and/or dbp 90 mmhg and/or the use of antihypertensive drugs . prior cardiovascular disease ( cvd ) was defined when individuals had ( any of the following ) : a history of myocardial infarction , abnormalities on a resting electrocardiogram ( minnesota codes 1.11.3 , 4.14.3 , 5.15.3 , or 7.1 ) , previous coronary bypass surgery or angioplasty , peripheral arterial bypass , or nontraumatic amputation , or an ankle - brachial index of < 0.9 in either leg . data on the participants ' vital status up to 1 january 2005 were collected from the mortality register of the municipality of hoorn . information on cause of death was extracted from the medical records of the general practitioners and the local hospital and coded according to the icd-9 . cardiovascular mortality , including sudden death , was defined by icd-9 codes 390459 and 798 . information on cause of death could not be obtained for 20 of the deceased individuals . all subjects were followed until death or end of follow - up , at which time they were censored . baseline characteristics between survivors and nonsurvivors were compared with the use of student 's t or tests . we computed z scores ( [ individual 's observed value population mean]/sd ) for each of the 10 measurements of c - ad . all z scores ( except sbp difference ) were inverted and averaged into a total score ( c - ad total score ) , so that higher values reflect greater c - ad . the association between microalbuminuria and c - ad total score was investigated with multiple linear regression analyses . kaplan - meier survival curves were plotted for cardiovascular mortality among individuals with normoalbuminuria versus microalbuminuria and similarly across tertiles of the c - ad total score , and differences between groups were tested with a log - rank test . cox proportional hazards regression models were used to calculate the crude and adjusted relative risks ( rrs ) and respective 95% ci of microalbuminuria ( versus normoalbuminuria ) and of the c - ad total score ( per sd [ = 0.605 ] increase ) for cardiovascular and all - cause mortality .", "urinary albumin concentration was measured in a first voided sample by rate nephelometry ( array protein system , beckman coulter , galway , ireland ) with a detection threshold of 6.2 mg / l ( intra- and interassay coefficients of variation of 5 and 8% , respectively ) . microalbuminuria was present if the albumin - to - creatinine ratio ( acr ) was in the range of 2.030 mg / mmol ( 5 ) . the average value of the acr was used if two representative samples ( n = 154 ) were available . excluding subjects with an acr > 30 mg / mmol ( i.e. , macroalbuminuria , n = 4 ) did not materially affect any of the results , which are therefore presented for the entire group . cardiovascular autonomic function tests were performed as described in detail elsewhere ( 9 ) . in brief , participants were asked to refrain from smoking and drinking coffee for at least 2 h before the assessments . a light meal > 1 h before the measurements was allowed . tests took place between 8:30 a.m. and 4:00 p.m. in a quiet location with room temperature of 1922c after a resting period of at least 10 min . ten parameters of cardiac autonomic function were derived from the r - r interval and finger systolic blood pressure ( sbp ) continuous recordings by a computerized data analyses system developed locally by the department of medical physics , vu university , amsterdam , the netherlands ( 13 ) . tests were performed under three conditions : during spontaneous breathing over 3 min in the supine position ( mean of all normal to normal r - r intervals [ meannn ] , sd of all normal to normal r - r intervals [ sdnn ] , low - frequency [ lf ] power , high - frequency [ hf ] power , and lf/(lf + hf ) ) , during six deep breaths over 1 min in the supine position ( expiration - inspiration [ ei ] difference and baroreflex sensitivity [ brs ] ) , and during an active change from lying to standing ( sbp difference , r - r interval maximum [ rrmax ] , and r - r interval maximum divided by minimum [ rrmax / min ] ) ( for further explanation of measurements , see supplementary table a1 , available in an online appendix at http://care.diabetesjournals.org/cgi/content/full/dc08-1544/dc1 ) . we thus obtained results in four tests that reflect heart rate or blood pressure changes due to certain maneuvers , in this case deep breathing or standing up ( i.e. , ei difference , rrmax , rrmax / min , and sbp difference ) ( 14 ) , five tests of spectral analyses of heart rate variability ( hrv ) [ i.e. , meannn , sdnn , lf power , hf power , and lf/(lf + hf ) ] ( 15 ) , and one brs measurement ( 16 ) . in addition , these tests were grouped into those representing predominantly parasympathetic ( i.e. , ei difference , rrmax , and hf power ) , sympathetic ( i.e. , sbp difference ) , or both functions ( i.e. , mean - nn , sdnn , lf power , lf/(lf + hf ) , brs , and rrmax / min ) ( 15,16 ) . bmi , waist - to - hip ratio ( whr ) , sbp and diastolic blood pressure ( dbp ) , levels of fasting plasma glucose ; a1c ; insulin ; total , hdl , and ldl cholesterol ; triglycerides ; creatinine ; and smoking status were measured as described elsewhere ( 5,9,12 ) . glomerular filtration rate was estimated by the short modification of diet in renal disease equation . hypertension was defined as sbp 140 mmhg and/or dbp 90 mmhg and/or the use of antihypertensive drugs . prior cardiovascular disease ( cvd ) was defined when individuals had ( any of the following ) : a history of myocardial infarction , abnormalities on a resting electrocardiogram ( minnesota codes 1.11.3 , 4.14.3 , 5.15.3 , or 7.1 ) , previous coronary bypass surgery or angioplasty , peripheral arterial bypass , or nontraumatic amputation , or an ankle - brachial index of < 0.9 in either leg .", "data on the participants ' vital status up to 1 january 2005 were collected from the mortality register of the municipality of hoorn . information on cause of death was extracted from the medical records of the general practitioners and the local hospital and coded according to the icd-9 . cardiovascular mortality , including sudden death , was defined by icd-9 codes 390459 and 798 . information on cause of death could not be obtained for 20 of the deceased individuals . all subjects were followed until death or end of follow - up , at which time they were censored .", "baseline characteristics between survivors and nonsurvivors were compared with the use of student 's t or tests . we computed z scores ( [ individual 's observed value population mean]/sd ) for each of the 10 measurements of c - ad . all z scores ( except sbp difference ) were inverted and averaged into a total score ( c - ad total score ) , so that higher values reflect greater c - ad . the association between microalbuminuria and c - ad total score was investigated with multiple linear regression analyses . kaplan - meier survival curves were plotted for cardiovascular mortality among individuals with normoalbuminuria versus microalbuminuria and similarly across tertiles of the c - ad total score , and differences between groups were tested with a log - rank test . cox proportional hazards regression models were used to calculate the crude and adjusted relative risks ( rrs ) and respective 95% ci of microalbuminuria ( versus normoalbuminuria ) and of the c - ad total score ( per sd [ = 0.605 ] increase ) for cardiovascular and all - cause mortality .", "subjects excluded from the analyses ( n = 141 ) were older , more often had type 2 diabetes , and had a worse risk profile than the subjects included ( n = 490 ) ( data not shown ) . median duration of the follow - up was 13.6 ( range 0.5215.19 ) years . during the follow - up period , 141 ( 28.8% ) participants died , of whom 53 ( 37.6% ) died of cvd . at baseline , individuals who died had a worse c - ad total score , more often had microalbuminuria and were older , more often were men and had type 2 diabetes and hypertension , and had a higher a1c and whr as compared with the survivors ( table 1 ) . baseline characteristics of survivors versus nonsurvivors data are presented as frequencies ( % ) , means sd , or medians ( interquartile range ) . for a detailed explanation of autonomic function tests , these include diuretics , -blockers , -blockers , calcium channel blockers , and other blood pressure lowering drugs but exclude ace inhibitors ( because subjects using these drugs were excluded from the analyses ) . c - ad total score was associated with microalbuminuria ( = 0.33 [ 95% ci 0.160.51 ] ) ( table 2 , model 1 ) . after adjustment for potential confounding factors , c - ad total score was still borderline associated with microalbuminuria ( 0.16 [ 0.01 to 0.33 ] ) ( table 2 , model 3 ) . comparable results were obtained when tests were combined on the basis of their methodology or on the part of the autonomic nervous system they predominately represent . all individual c - ad tests , except lf/(lf + hf ) , were positively associated with microalbuminuria ( although not all statistically significantly so ) ( data not shown ) . association between microalbuminuria and c - ad * model 1 : univariate analysis ; model 2 : adjusted for sex , age , and gts ; model 3 : model 2 plus adjustments for hypertension , whr , estimated glomerular filtration rate , ldl , hdl , triglycerides , smoking , and prior cvd . indicates the difference in c - ad score between individuals with microalbuminuria vs. normoalbuminuria . both microalbuminuria ( rr 3.49 [ 95% ci 1.876.53 ] ) and c - ad total score ( 2.54 [ 1.604.04 ] ) these associations were attenuated after adjustment for age , sex , and glucose tolerance status ( gts ) ( 2.23 [ 1.164.29 ] and 1.81 [ 1.112.94 ] , respectively ; model 2 ) . further adjustment for other cardiovascular risk factors only slightly further attenuated these rrs ( model 3 ) , and when the c - ad total score or microalbuminuria was added to these models , the rr attributable to microalbuminuria remained practically unchanged and both microalbuminuria ( 2.13 [ 1.094.17 ] ) and c - ad total score ( 1.76 [ 1.052.94 ] ) were independently associated with cardiovascular mortality ( model 4 ) . association of microalbuminuria or c - ad with cardiovascular and all - cause mortality * model 1 : univariate analysis ; model 2 : adjusted for sex , age , and gts ; model 3 : model 2 plus adjustments for hypertension , whr , estimated glomerular filtration rate , ldl , hdl , triglycerides , smoking and prior cvd ; model 4 : model 3 , with additional adjustment for , respectively , c - ad or microalbuminuria . rr of microalbuminuria vs. normoalbuminuria or per sd ( = 0.605 ) increase in c - ad total score . kaplan - meier survival plots for cardiovascular mortality . among individuals with normo- versus microalbuminuria ( a ) and across tertiles of c - ad total score ( b ) . both microalbuminuria and c - ad total score were also associated with all - cause mortality ( table 3 , model 1 ) . however , after adjustment for age , sex , gts , and other cardiovascular risk factors , microalbuminuria ( rr 1.33 [ 95% ci 0.832.13 ] ) , in contrast to c - ad total score ( 1.52 [ 1.112.09 ] ) , was not independently associated with all - cause mortality ( model 3 ) . the associations described above were also investigated by examining autonomic function tests combined on the basis of their methodology or on the part of the autonomic nervous system they predominantly represent ( supplementary table a2 , available in an online appendix ) . these additional analyses showed that overall all different groups of tests were associated with increased mortality risk , that these associations were attenuated when further adjusted for age , sex , gts , and other risk factors ; and that none of the specific group of tests explained the association between microalbuminuria and mortality . the associations reported in table 3 did not materially change after additional adjustment for use of lipid- or blood pressure lowering drugs and the presence of leukocytes in urine ( tested by microscopy and scored as positive whenever there were more than five leukocytes per high - power field ) or when the dichotomous variable hypertension used in those models was replaced by either sbp or pulse pressure ( a marker of arterial stiffness ) or when analyses were adjusted for prior coronary heart disease instead of prior cvd ( data not shown ) . finally , we found no evidence of effect modification by gts in the association between cardiovascular mortality and c - ad total score or microalbuminuria ( pinteraction > 0.4 in both cases ) .", "c - ad total score was associated with microalbuminuria ( = 0.33 [ 95% ci 0.160.51 ] ) ( table 2 , model 1 ) . after adjustment for potential confounding factors , c - ad total score was still borderline associated with microalbuminuria ( 0.16 [ 0.01 to 0.33 ] ) ( table 2 , model 3 ) . comparable results were obtained when tests were combined on the basis of their methodology or on the part of the autonomic nervous system they predominately represent . all individual c - ad tests , except lf/(lf + hf ) , were positively associated with microalbuminuria ( although not all statistically significantly so ) ( data not shown ) . association between microalbuminuria and c - ad * model 1 : univariate analysis ; model 2 : adjusted for sex , age , and gts ; model 3 : model 2 plus adjustments for hypertension , whr , estimated glomerular filtration rate , ldl , hdl , triglycerides , smoking , and prior cvd . indicates the difference in c - ad score between individuals with microalbuminuria vs. normoalbuminuria .", "both microalbuminuria ( rr 3.49 [ 95% ci 1.876.53 ] ) and c - ad total score ( 2.54 [ 1.604.04 ] ) were associated with cardiovascular mortality ( table 3 , model 1 ; fig . these associations were attenuated after adjustment for age , sex , and glucose tolerance status ( gts ) ( 2.23 [ 1.164.29 ] and 1.81 [ 1.112.94 ] , respectively ; model 2 ) . further adjustment for other cardiovascular risk factors only slightly further attenuated these rrs ( model 3 ) , and when the c - ad total score or microalbuminuria was added to these models , the rr attributable to microalbuminuria remained practically unchanged and both microalbuminuria ( 2.13 [ 1.094.17 ] ) and c - ad total score ( 1.76 [ 1.052.94 ] ) were independently associated with cardiovascular mortality ( model 4 ) . association of microalbuminuria or c - ad with cardiovascular and all - cause mortality * model 1 : univariate analysis ; model 2 : adjusted for sex , age , and gts ; model 3 : model 2 plus adjustments for hypertension , whr , estimated glomerular filtration rate , ldl , hdl , triglycerides , smoking and prior cvd ; model 4 : model 3 , with additional adjustment for , respectively , c - ad or microalbuminuria . rr of microalbuminuria vs. normoalbuminuria or per sd ( = 0.605 ) increase in c - ad total score . kaplan - meier survival plots for cardiovascular mortality . among individuals with normo- versus microalbuminuria ( a ) and across tertiles of c - ad total score ( b ) . both microalbuminuria and c - ad total score were also associated with all - cause mortality ( table 3 , model 1 ) . however , after adjustment for age , sex , gts , and other cardiovascular risk factors , microalbuminuria ( rr 1.33 [ 95% ci 0.832.13 ] ) , in contrast to c - ad total score ( 1.52 [ 1.112.09 ] ) , was not independently associated with all - cause mortality ( model 3 ) .", "the associations described above were also investigated by examining autonomic function tests combined on the basis of their methodology or on the part of the autonomic nervous system they predominantly represent ( supplementary table a2 , available in an online appendix ) . these additional analyses showed that overall all different groups of tests were associated with increased mortality risk , that these associations were attenuated when further adjusted for age , sex , gts , and other risk factors ; and that none of the specific group of tests explained the association between microalbuminuria and mortality . the associations reported in table 3 did not materially change after additional adjustment for use of lipid- or blood pressure lowering drugs and the presence of leukocytes in urine ( tested by microscopy and scored as positive whenever there were more than five leukocytes per high - power field ) or when the dichotomous variable hypertension used in those models was replaced by either sbp or pulse pressure ( a marker of arterial stiffness ) or when analyses were adjusted for prior coronary heart disease instead of prior cvd ( data not shown ) . finally , we found no evidence of effect modification by gts in the association between cardiovascular mortality and c - ad total score or microalbuminuria ( pinteraction > 0.4 in both cases ) .", "in this prospective study we found that both microalbuminuria and c - ad ( estimated from the mean of 10 standardized tests ) were independently associated with cardiovascular mortality in a cohort of elderly , caucasian subjects with and without diabetes . therefore , c - ad does not explain why microalbuminuria is related to cardiovascular mortality in either the general population or in diabetic subjects . recently , hrv was found not to predict the decline of gfr but was independently associated with cardiovascular mortality in middle - aged type 1 diabetic subjects with overt nephropathy ( 17 ) . in another study , investigating the independent predictive role of gfr , microalbuminuria , and cardiovascular autonomic neuropathy showed the latter to also be associated with all - cause and cardiovascular mortality in subjects with diabetes ( 18 ) . hitherto , no other prospective studies examining the relation of microalbuminuria and c - ad with cardiovascular mortality have been reported . the independent association of both microalbuminuria and c - ad with cardiovascular mortality reported herein indicates that they are linked to cardiovascular mortality by different biological pathways . several mechanisms linking c - ad to cardiovascular mortality have been proposed ( e.g. , qt interval prolongation and silent myocardial ischemia ) ( 19 ) . microalbuminuria may be linked to cvd by a common pathophysiological process ( such as endothelial dysfunction or chronic low - grade inflammation ) ( 3 ) . however , the possibility that microalbuminuria reflects the presence of a set of undiscovered factors that are causally related to cvd remains to be further elucidated . furthermore , aggressive treatment of microalbuminuria by inhibiting the renin - angiotensin - aldosterone system has been shown to decrease renal and cardiovascular risk in individuals with diabetes ( 20 ) . there is some evidence that c - ad is also a useful risk indicator for cvd , especially in subjects at high risk ( type 2 diabetes , hypertension , or prior cvd ) ( 9,21 ) , and this study reinforces that observation . however , whether the improvement in c - ad , e.g. , with exercise training or blood pressure or lipid - lowering drugs ( 2224 ) , leads to a better prognosis is unknown . in our study , additional adjustment for use of -blockers or lipid - lowering drugs had no effect on the associations reported . therefore , the clinical relevance of treating c - ad in the general population remains unclear and needs to be further examined . the strengths of our study are the relatively large , truly population - based and prospective design with a long follow - up period . in addition , we characterized subjects ' c - ad as comprehensively as possible by conducting 10 autonomic function tests , which are thought to reflect all aspects of cardiovascular autonomic function . previous cross - sectional studies evaluating the relationship between microalbuminuria and c - ad used less extensive autonomic function tests ( 4,6 ) . because we included all three groups of gts , we were able to analyze possible effect modification of gts in the relationship between the main determinants , c - ad and microalbuminuria and cardiovascular mortality ( but found none ) . first , each of the test parameters of autonomic function was measured with moderate levels of reproducibility ( reliability coefficient 50% ) ( 13 ) . therefore , the results were combined into a c - ad total score , which enabled us to circumvent , at least partially , this problem . specifically , the results herein reported with the c - ad total score were more powerful than results obtained on the basis of each individual test ( separately ) , because these results would be more strongly affected by misclassification ( likely to be random ) , causing an underestimation of the strength of the associations . indeed , the associations between each individual test result with cardiovascular mortality were in accordance , although with lower strength , with those as reported herein with the c - ad total score ( data not shown ) . in addition , this approach had the advantage of circumventing the problem of multiple testing ( type i errors ) that would have occurred when the associations with each test were analyzed separately . however , because each test may represent different parts of autonomic function , some overlapping but others complementary , our c - ad total score does not allow the distinction of potential different contributions of sympathetic and parasympathetic functions to cardiovascular mortality . therefore , we examined the autonomic function tests combined on the basis of their methodology or on the part of the autonomic nervous system they predominantly represent in the additional analyses . the results of these alternative combinations of autonomic function tests were comparable to those of the c - ad total score ( supplementary table a2 ) , but we acknowledge that these analyses may not have been specific enough , as most authors agree that a clear distinction between parasympathetic or sympathetic dysfunction can not be made on the basis of these tests . altogether , we feel that the advantages ( i.e. , reduced misclassification and avoidance of type i errors without impairment of etiological validity ) of the approach used by us outweigh the disadvantages . measurement of hrv during a longer period may be more reliable , although measurements obtained in time periods as short as 2 min correlate highly with 24-h measurements ( 25 ) . third , evaluation of subjects ' c - ad was conducted at baseline only , and , therefore , we were not able to evaluate deterioration of autonomic function during follow - up . fourth , for most participants microalbuminuria was defined on an acr measured in one urine sample only . because microalbuminuria is quite variable from day to day we can not fully exclude the possibility that some subjects were misclassified . however , we tried to avoid this problem by collecting urine overnight and expressing albumin excretion as acr . in addition , analyses in the 154 participants for whom two samples were available yielded essentially similar results ( data not shown ) . finally , we studied an elderly , caucasian population , and it is not known whether our results can be generalized to other ethnic groups or to younger individuals . in summary , we have shown that both microalbuminuria and c - ad are independently associated with cardiovascular mortality in an elderly , caucasian population of individuals with normal glucose metabolism , igm , and diabetes . these results suggest that microalbuminuria and c - ad are related to cardiovascular mortality by different biological pathways . therefore , it may be useful to treat not only microalbuminuria but also c - ad in populations at high risk of cardiovascular mortality .", "" ]

[ "cervical cancer is the third most common cancer after breast and colorectal cancer and the fourth leading cause of death among women in malaysia(1 - 3 ) . it remains to be one of the major cancers that burden worldwide particularly in under - developed and developing countries ( cervical cancer incidence rate increased with age after 30 years and has its peak at ages 65 - 69 years . according to ethnicity in malaysia , women of indian ethnic group have the highest incidence for cervical cancer followed by chinese and malay ( 3 ) . majority malays are muslims , thus lower incidence of this cancer was observed . in iran , there are almost no extramarital sexual relations and they depend strongly on family - based traditions ( 7 ) the five - year survival exceeded 70% in korea ( 810 ) , 55% in turkey ( 11 ) and it can be as low as 17% which was in uganda ( 12 ) . there were various prognostic factors established in many studies such as stage , age , lymph node involvement and tumor size ( 1316 ) . in kentucky , between january 2001 and may 2010 , a study of 381 cervical cancer patients who were referred to tertiary care centre found that stage of disease was a significant prognostic factor for overall survival ( 17 ) . meanwhile , a study of 44,182 patients diagnosed with cervical cancer between 1993 and 2002 in korea , found that both stage and histological type of cervical cancer were important factors for survival ( 18 ) . to our knowledge , the analysis from published studies was often limited to the frequently used cox proportional hazard regression model when examining the relationship of the survival distribution to covariates ( 17 , 1921 ) . this is perhaps due to the fact that although baseline hazard is not specified in cox model , the parameter can still be estimated . the objective of this study was to determine the effects of explanatory variables on the survival of cervical cancer patients using parametric regression model . in some cases , parametric models are more informative than the cox model such as the baseline hazard and survival estimates are known ( can be estimated ) . several examples of parametric models can be found in the following studies ( 2227 ) . zhu et al . have compared the cox and weibull model in modeling the gastric cancer data and found that the weibull model gave more a precise results in than the cox model ( 28 ) . the weibull model has gained popularity in modeling survival data due to its flexibility in the shape parameter that can accommodate a decreasing , constant and increasing hazard . furthermore , the suitability of the weibull model can be easily assessed using a log - cumulative hazard plot . in this study , a stratified weibull model was used since there was a time - dependent covariate that caused the proportional hazard assumption vio - lated .", "the study design was retrospective in nature in which patients records were reviewed retrospectively to obtain the data . the husm , located in kubang kerian , kelantan has been long regarded as the referral centre for the east coast region of malaysia . the inclusion criteria were histopathologically and clinically diagnosed with cancer of cervix between 1 july 1995 and 30 june 2007 , and received at least one treatment related to cervical cancer in husm . patients who were died due to other competing causes of death ( not cervical cancer ) , or with incomplete data were excluded from this study . ethical clearance was obtained from research and ethics committee of university sains malaysia ( reference number : usmkk / ppp / jepem [ 205.4 ( 2.4 ) ] ) . the variable of interest was time ( in months ) which was measured from the patient was diagnosed with cervical cancer up to the time of death . factors that were considered in the analysis were ethnicity ( non malay , malay ) , lymph node involvement ( negative , positive ) , metastasis ( with metastasis , without metastasis ) , histology ( squamous cell carcinoma , adeno cell carcinoma ) , primary treatment ( surgery , radiotherapy and/or chemotherapy ) , age at diagnosis ( < 40 , 40 59 , 60 ) and stage ( stage i & ii , stage iii & iv ) . international federation of gynecology and obstetrics ( figo ) system was used in staging patients with cervical cancer . data analysis was performed using the statistical package tibco spotfire s - plus version 8.1 . the suitability of the weibull model for the data was assessed using a plot of the log of the negative log of the estimated survivor function against log time or log - cumulative hazard plot . univariate analysis was conducted using the simple weibull regression analysis to identify the possible prognostic factors individually . significant factors from the univariate analysis were further analyzed by the weibull multivariate analysis to model the prognostic factors . model selection procedure was based on the forward variable selection method with statistical significance set at = 0.10 . the proportionality of the hazards was assessed using the test based on schoenfeld ( 29 ) . as the proportional hazard assumption was not satisfied , a stratified model was used instead ( 30 ) and in measuring the goodness of fit of the model , deviance residuals were used . 1 shows a study flow diagram which summarizes the steps of the statistical analysis performed . the study flow diagram", "the log - cumulative hazard plotshows a straight line which suggests that the distribution of survival time considered follows weibull distribution ( fig . patients characteristics and the incidence rate ratio were tabulated in table 1 . about 74% of total patients the ratio of the risk of death for patients who were diagnosed in stage iii & iv compared to the risk of death for patients in group stage i & ii was 1.44 . meanwhile , the risk of dying of patients in with metastasis group was 1.55 , greater than patients who had no metastasis . the results from the univariate analysis are presented in table 2 . from this analysis , based on the forward selection procedure in multivariate analysis , two variables namely stage and metastasis was found to be significant factors ( table 3 ) . however , it was noted that metastasis ( p=0.032 ) did not satisfy the proportional hazard assumption and a stratified model was then considered . it is worthwhile to note that while the stratification allows separate baseline hazard function to each metastasis group , the coefficient of the predictor variables are assumed to be the same within each metastasis group ( 29 ) . the first stratum consists of patients without metastasis and the second stratum were patients who do have metastasis . parameter estimates of the stratified model were performed and the output is given in table 4 . the log - cumulative hazard plot characteristics of patients treated in husm ( n=120 ) univariate analysis of weibull model with prognostic factors multivariate analysis of weibull model with prognostic factors output of weibull model under stratification the hazard ratio for variable stage stratified on metastasis the estimated scale parameters ( ) for the first and second stratum were 1 = 1.11 and 2 = 0.733 respectively . the risks of death for cervical cancer patients were estimated by finding the regression coefficient ( j ) \n j=j , \n and the hazard ratio ( j ) \n j = exp(j ) where j = 1,2 denotes the stratum . for the first stratum , patients who were diagnosed at stage iii & iv are at 2.30 times the risk of death as those in stage i & ii . meanwhile , for the second stratum , patients in stage iii & iv group were more likely to die ( 3.53 times ) than patients in stage i & ii . the index plot of deviance residuals ( rdi ) was performed to identify the presence of subjects who was poorly predicted by the model ( 31 ) . 3 shows that the residuals are roughly symmetrically distributed around zero and most of the residuals are between -2 to 2 . outliers and influential observations are not observed in the plot thus implying a good fit of the model .", "in this study , the weibull model was used instead of the cox model because the log - cumulative hazard plot has confirmed that the survival time followed the weibull distribution . multivariate analysis through forward selection method found that the most feasible model to describe the survival of cervical cancer patients was dependent upon the covariates namely , stage and metastasis . as the metastasis variable did not meet the proportional hazard assumption , the stratified weibull model was applied . this study found that patients who were diagnosed at stage iii & iv have greater risk of death compared to those who were diagnosed at early stage , stage i & ii for both stratum , with and without metastasis . it is worthwhile to note that a study of 515 cervical cancer patients by dueas - gonzlez et al . showed a significant result for advance stage iii & iv with adjusted hazard ratio of 1.54 ( 95% ci= 1.11- 2.14 ) ( 16 ) , indicating that patients with advanced stage of disease had a 54% higher risk of progression or death at any time than earlier stage patients .", "after applying the stratified model , this study found that the prognosis of cervical cancer patients was dependent upon the stage at diagnosis . these findings provide useful knowledge on the understanding of the survival of cervical cancer patients . besides , this study also demonstrates the solution to time - dependent covariates problem , or when the proportional hazards assumption is violated . cervical cancer dataset that comprise of the national data may be obtained to give a more general prognosis and a better description of the survival pattern of all cervical cancer patients in malaysia .", "ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc ) have been completely observed by the authors ." ]

[ "according to the european society of endodontology ( 1994 ) , the assessment of endodontic treatment requires clinical as well as radiological follow - ups at regular intervals . the radiographic evidence of success is the presence of a normal periodontal ligament space around the root . if radiographs reveal that a lesion has remained the same or has only diminished in size , the treatment is not considered a success.1,2 it is generally accepted that the outcome of endodontic treatment is positively correlated with the technical quality of the root filling , expected to provide an hermetic seal against bacterial ingress.3,4 however , it has been suggested that the quality of the coronal restoration may also have an impact on the periapical health of root - filled teeth;5,6 when the restoration quality is good , this may allow for a favorable outcome even when the root filling quality is poor.7 attention has been focused on the prevalence and the technical quality of root fillings through the evaluation of intraoral810 or panoramic radiographs.2,11,12 epidemiologic studies have been performed on the root canal morphology in turkish populations.13,14 information about the prevalence and technical standard of root - canal treatment , and the occurence of periapical lesions in turkey are scarce.12,15 moreover , there is only one investigation about quality of root fillings and coronal restorations in turkish population.16 the aim of the present study was to relate the quality of root canal treatment and coronal restorations to the periapical status of root filled teeth in adult turkish population based on radiographic examination .", "the sample consisted of 400 subjects , aged 38.7013.80 years , 138 males ( 34.5% ) and 262 females ( 65.5% ) , presenting consecutively as new patients seeking routine dental care in department of oral diagnosis and radiology , faculty of dentistry , marmara university , istanbul , turkey , between 2005 and 2006 . the criteria for inclusion in the study were that the patients should be attending for the first time . patients younger than 20 years and patients having less than eight remaining teeth were excluded . all the patients gave written informed consent for the study . all participants underwent a panoramic radiograph and additional periapical radiographs of endodontically treated teeth were processed . all panoramic and periapical radiographs were taken with a veraviewpocs hi - sped ( j. morita mfg . kyoto , japan ) and evolution x 3000 - 2c x - ray unit ( new life radiology srl , italy ) , respectively . two radiographers using the long - cone paralleling technique , setting of 70 kv , 10 ma , a film - focus distance of 30 cm took all periapical radiographs . , kg , bissingen , germany ) , kodak medical x - ray processor ( eastman kodak company , rochester , ny , usa ) , general rapid medical developer and fixer ( general a. . , the viewing conditions were standardized , using a view - box with fixed light intensity . the incidence of root fillings was recorded along with the periapical status of all teeth with the exception of third molars . adequate if the root filling was 2 mm or less from the radiographic apex , when it was more than 2 mm from the apex , it was considered as an underfilling and when excess filling was beyond the radiographic apex , it was categorized as an adequate if the radiodensity of fill was uniform and appeared to be radiographically adapted to the root - canal walls periapical index ( pai ) score ( orstavik et al18 ) , recorded for each one of the roots . pai scores 1 and 2 signified a nondiseased apical periodontium , and pai scores 3 , 4 , and 5 signified the presence of an apical radiolucency . the worst score of all roots was taken to represent pai score for multirooted teeth . in case of a root filling was present , the type of coronal restoration ( crown or filling ) was recorded . the quality of the restoration was assessed radiographically and classified as inadequate if the restoration was absent or if open margins , overhangs or secondary caries were detectable . evaluation of the periapical status and the quality of root filling in the present study was made independently by two examiners ( fnp , bg ) using the same examination procedure after a calibration session . for calibration 20 radiographs were used and not included in main study . the cohen s kappa value for inter - examiner agreement of pai - values for all scored teeth was 0.81 . the inter - examiner agreement scores gave cohen s kappa of 0.68 for quality of filling and crown restoration , 0.83 for adaptation of fillings to canal walls , and 0.86 for length of root fillings . the data were analyzed with spss ( statistical package for social sciences ) for windows 10.0 statistical package software . descriptive statistical methods ( mean and standard deviation ) were used for the evaluation of the data . p values of less than .05 were interpreted as significant , and the level in confidence intervals was 95% .", "the sample consisted of 400 subjects , aged 38.7013.80 years , 138 males ( 34.5% ) and 262 females ( 65.5% ) , presenting consecutively as new patients seeking routine dental care in department of oral diagnosis and radiology , faculty of dentistry , marmara university , istanbul , turkey , between 2005 and 2006 . the criteria for inclusion in the study were that the patients should be attending for the first time . patients younger than 20 years and patients having less than eight remaining teeth were excluded . all the patients gave written informed consent for the study .", "all participants underwent a panoramic radiograph and additional periapical radiographs of endodontically treated teeth were processed . all panoramic and periapical radiographs were taken with a veraviewpocs hi - sped ( j. morita mfg . kyoto , japan ) and evolution x 3000 - 2c x - ray unit ( new life radiology srl , italy ) , respectively . two radiographers using the long - cone paralleling technique , setting of 70 kv , 10 ma , a film - focus distance of 30 cm took all periapical radiographs . , kg , bissingen , germany ) , kodak medical x - ray processor ( eastman kodak company , rochester , ny , usa ) , general rapid medical developer and fixer ( general a. . , istanbul , turkey ) ) were used in this study .", "the viewing conditions were standardized , using a view - box with fixed light intensity . the incidence of root fillings was recorded along with the periapical status of all teeth with the exception of third molars . adequate if the root filling was 2 mm or less from the radiographic apex , when it was more than 2 mm from the apex , it was considered as an underfilling and when excess filling was beyond the radiographic apex , it was categorized as an adequate if the radiodensity of fill was uniform and appeared to be radiographically adapted to the root - canal walls . periapical index ( pai ) score ( orstavik et al18 ) , recorded for each one of the roots . pai scores 1 and 2 signified a nondiseased apical periodontium , and pai scores 3 , 4 , and 5 signified the presence of an apical radiolucency . the worst score of all roots was taken to represent pai score for multirooted teeth . in case of a root filling was present , the type of coronal restoration ( crown or filling ) was recorded . the quality of the restoration was assessed radiographically and classified as inadequate if the restoration was absent or if open margins , overhangs or secondary caries were detectable . evaluation of the periapical status and the quality of root filling in the present study was made independently by two examiners ( fnp , bg ) using the same examination procedure after a calibration session . for calibration 20 the cohen s kappa value for inter - examiner agreement of pai - values for all scored teeth was 0.81 . the inter - examiner agreement scores gave cohen s kappa of 0.68 for quality of filling and crown restoration , 0.83 for adaptation of fillings to canal walls , and 0.86 for length of root fillings .", "the data were analyzed with spss ( statistical package for social sciences ) for windows 10.0 statistical package software . descriptive statistical methods ( mean and standard deviation ) were used for the evaluation of the data . p values of less than .05 were interpreted as significant , and the level in confidence intervals was 95% .", "a total of 9460 teeth were examined , an average number of 23.634.35 remaining teeth per subject . the total number of root - filled teeth was 890 ( 9.39% ) ; of which 658 ( 73.9% ) teeth had ap . apical periodontitis was found in 75.5% of teeth with adequate length of root filling , whereas if the filling was too short or long , periapical lesions were present in 72.8% and 96.2% of teeth , respectively . there was a significant correlation between the presence of periapical pathology and inadequate root canal fillings ( p<.05 ) . the relationship between the adaptation of root filling to canal walls and periapical status is shown table 2 . root filled teeth without voids had ap in 72.9% of cases , whereas if voids were detected , ap was present in 74.7% of the teeth ( p : 0.54 , odds ratio : 1.09 , ci : 0.811.48 ) . the relationship between the quality of the prosthetic restoration and periapical status is presented in table 3 . 75.9% of the teeth with adequate coronal restorations had ap , whereas if the coronal restoration was inadequate , ap was present in 74.2% of the teeth ( p : 0.70 , odds ratio : 0.91 , ci : 0.581.45 ) . the relationship between the quality of the filling restoration and periapical status is presented in table 4 . 72.8% of the teeth with adequate filling restoration had ap , whereas if the filling restoration was inadequate , ap was present in 72.3% of the teeth ( p : 0.92 , odds ratio : 0.97 , ci : 0.621.54 ) .", "the subjects included in this study were adult patients attending for general dental treatment for the first time . the recruitment of subjects was the same as those used by others.8,11,17,19,20 there is no information available for this patient population , which makes it difficult to extrapolate the data obtained into the turkish population . however , the dental faculty attracts a patient population from numerous parts of the city and its surroundings , which eliminates the risk of only including patients previously treated by a limited number of practitioners . some patients sought care because of the expense of prosthetic treatment , which in general is less at the dental faculty than in the private sector in turkey . in addition , extraction of teeth due to low socio - economic status gives rise to a limited number of root filled teeth epidemiologically . patients with eight or fewer remaining teeth were excluded because they often had periodontal disease and it was impossible to determine the role played by the endodontic treatment in the occurrence of a radiographic periapical lesion.17 although studies comparing panoramic and periapical radiographs for detecting periapical lesions indicate similar overall diagnostic accuracy,21,22 panoramic radiographs are claimed to show lower sensitivity when detecting periapical lesions of the anterior teeth and mandibular molars compared with periapical radiographs.23 therefore , there is a possibility for loss of information when endodontic conditions are recorded based on panoramic radiographs only in some studies.2,11,17,2426 however , other epidemiological studies have used a combination of panoramic and periapical radiographs.4,8,9,27 as panoramic radiographs do not reveal details and inter - observer variability is greater with panoramic radiographs.28 in this investigation , therefore , all participants underwent a panoramic and additional periapical radiographs of affected teeth were processed . criteria for ap vary among studies.2,10,29,30 in recent years , most of the studies on the prevalence of ap have used this index scoring to assess periapical status , so the results of this study can be more appropriately compared with them.4,18,25 therefore , in the present study , the pai was used to assess the periapical status . the reproducibility of the observer ( cohen s kappa=0.81 ) was acceptable , probably because of prior calibration . a total of 890 teeth had root fillings , accounting for 9.39% of all teeth . the prevalence of root - filled teeth in the turkish population was found lower than previously done other studies about different countries ( 34%87%).4,5,9,10,19,27,29 this phenomenon can be explained by the fact that first , the survey population was not representative of the whole country , and secondly , the differences in health care services and socioeconomical factors in the various countries could account for these discrepancies . in contrast , other studies found the prevalence of root - filled teeth to range between 1.3% and 4.8% , similar to that found in this study.8,17,3032 the quality of endodontic treatment was disappointing . root filling length was found to be adequate in 24.5% of the teeth and the adaptation of fillings to the canal walls in 27.1% of the teeth . in this respect , the data confirm the findings of several other investigators showing poor quality of root canal treatment.8,17,19 apical periodontitis was found in 75.5% of teeth with adequate length of root filling , whereas if the filling was too short or long , periapical lesions were present in 72.8% and 96.2% of teeth , respectively . tsuneishi et al29 observed apical radiolucency most often in overfilled teeth ( 79.8% ) , followed by adequately filled teeth ( 41.6% ) and then underfilled teeth ( 34.5% ) . siquera et al33 indicated that poor outcome in case of overfillings is usually associated with concurrent endodontic infection , or as a result of previous overinstrumentation of an infected root canal that propelled infected dentin chips to the periradicular tissues or can be due to a lack of apical seal that allows the traffic of tissue fluids into the canal and of microorganisms and their products towards the periradicular tissues . in contrast , sunay et al12 reported 90.8% of root - filled teeth with apical periodontitis had inadequate root canal fillings , the majority of them being short of the radiographic apex . dugas et al4 reported the prevalence of apical periodontitis close to 60% when the root filling was inadequate , regardless of whether the filling was too short or too long consistent with the observations in other studies.17,19,27 in the present study , the relationship between the type of coronal restoration within root filled teeth and the presence of apical periodontitis were investigated . it is indicated that the technical quality of the coronal restoration may be more important for periapical health than the technical quality of the root filling.34 although some researchers found a significant correlation between the radiographic quality of the coronal restoration and the periapical status of root filled teeth.4,5 on the other hand , hommez et al35 reported that the quality of the coronal restoration did not have a significant influence on the periradicular status when it was combined with the quality of endodontic treatment . the results of the present study revealed that the quality of the restoration did not significantly affect the treatment outcome .", "in the present study , the frequency of endodontically treated teeth was found lower than other studies . the technical quality of root fillings and restoration in a turkish subpopulation was poor and was consistent with a high prevalence of apical periodontitis ." ]

[ "the neighborhood has emerged as a prominent level of analysis in studies of contextual influences on health and wellbeing in human development . this owes to the social organization of life within neighborhoods , and to the availability of data at neighborhood - like levels of analysis ( i.e. , census tracts ) . neighborhood context has also received greater attention due to ecological psychology 's conceptualization of human development as the product of a dynamic interaction between the individual and multiple nested environments , of which the neighborhood is one of the most immediate environments . contemporary scholarship on neighborhood factors has also highlighted the importance of understanding whether neighborhood variables add explanatory variance above and beyond individual differences . neighborhood socioeconomic status ( ses ) is the most consistently reported neighborhood - level predictor of cognitive outcomes certainly in childhood , and potentially across the life span . ses is also the strongest and most consistently reported neighborhood - level predictor of health outcomes among older adults a relationship which may have a cumulative effect across the life span . the association of neighborhood - level ses with health is in fact stronger among adults aged 6069 than among young and middle - aged adults , and during these years its association with health is comparable to or stronger than the relationship of individual ses to health . in addition to predicting poorer physical health , lower neighborhood ses is also associated with reduced rates of physical activity , increased incidence of depression and psychosocial stress , and less neighborhood - based social support and social engagement . many of these outcomes have also been identified as correlates of late life cognition , yet few studies to date have specifically investigated the role of the neighborhood in cognitive aging . while neighborhood effects on late life cognition have received less attention , neighborhood effects on early - life cognitive development are relatively well documented . neighborhood ses is positively correlated with cognitive development across the entire spectrum of child development , from the prenatal stages ( in the form of reduced rates of congenital anomalies and neural tube defects among higher - ses neighborhoods , presumably due to reduced risk of exposure to environmental toxins ; [ 6 , 7 ] ) and preschool years [ 8 , 9 ] to academic achievement in the school age [ 10 , 11 ] adolescent , and young adulthood years ( e.g. , high school graduation rates and college attendance ) . four recent studies explored relationships between late life cognition and the neighborhood context on a broad scale . wight and colleagues found that after controlling for individual - level education and area - level median household income , elders living in areas with low neighborhood - level educational attainment ( defined by census tract area ) achieved lower cognitive status scores compared to elders living in areas with high neighborhood - level educational attainment ( as assessed using the mini - mental state examination or mmse ) . a united kingdom study reported a clear and significant downward trend in cognitive performance on the mmse and tests of verbal fluency and memory for older individuals living in neighborhoods with greater deprivation , after controlling for individual - level wealth , income , and education , across all age and gender groups . these effects were also robust after adjusting for the effects of individual systolic blood pressure , history of stroke , and duration of residence in the current neighborhood . sheffield and peek moved beyond cross - sectional analysis to examine how neighborhood ses and ethnic composition ( proportion mexican american ) predicted 5-year change in mmse score in a us national sample . independent of individual - level risk factors , odds and rate of incident cognitive decline increased as a function of lower neighborhood ses and decreased with the proportion of mexican american neighborhood residents . finally , recent findings from the baltimore memory study suggest that the relationship between neighborhood and late life cognition may also depend on genotype . however , apolipoprotein e4 genotype was found to interact with high neighborhood psychosocial hazards , resulting in poorer cognitive performance on measures of processing speed and executive functioning after controlling for individual - level covariates . this suggests evidence of a gene - environment interaction in neighborhood 's relation to late life cognition . the existing studies focused on broad differences in late life cognitive status ( i.e. , mmse score ) , but did not investigate the effect of neighborhood on different cognitive domains ( see recommendations by cullum et al . ) . furthermore , the use of the mmse in these studies was not an ideal measure of cognition , as they targeted samples of initially healthy , independent elders . the mmse is not sensitive to differences among healthy older adults , having been designed to screen for dementia . cognitive aging research has instead focused increasingly on the use of confirmatory factor analysis ( cfa ) and structural equation modeling ( sem ) to explore whether differences in late life cognitive performance are related to general or specific processes . it has also been noted that conceptualizing late life cognition using a single general factor ( g ) is a simplistic approach to a complex and dynamic cognitive system . this suggests neighborhood influences should be investigated at both general and domain - specific levels . neighborhood effects may support some dimensions of cognition more strongly than others , in addition to influencing general cognitive status . the present study aimed to identify whether neighborhood effects on cognition were global , or specifically related to particular cognitive domains such as memory , reasoning , processing speed , everyday cognition , or vocabulary . another innovation of the present study is the capacity to address whether neighborhood effects might also influence the magnitude of potential benefit from cognitive intervention . no study , in part because of a lack of data availability , has examined this question . elucidating both the specificity of neighborhood effects on particular domains of cognition and the extent to which neighborhood affects cognitive training response may provide additional hints toward potential mechanisms by which the neighborhood exerts influence . for example , effects on the fluid cognitive abilities such as processing speed , memory , and reasoning ( and their response to cognitive training ) would suggest a more biologically mediated influence given their sensitivity to brain integrity . in contrast , effects on measures of crystallized cognitive abilities , especially vocabulary , might hint toward a more socioculturally mediated , and possibly lifespan accumulative influence , as crystallized cognitive abilities are developed with the accumulation of verbal knowledge , developed over a lifetime of experience in engaging with culture . as this lifelong accumulation is strongly influenced during childhood , adolescence , and young adulthood , effects of current neighborhood sep on crystallized abilities may also reflect , in part , effects of early - life neighborhood sep . the advanced cognitive training for independent and vital elderly ( active ) study was a randomized , controlled clinical trial examining the effects of three cognitive interventions for community - dwelling older adults . in active , older adults from six us catchment areas ( baltimore / coastal maryland ; the metropolitan areas of birmingham , boston , detroit , and indianapolis ; central pennsylvania ) completed a baseline assessment including multiple cognitive measures . participants were then randomized to one of three ten - session cognitive intervention programs or a no - contact control condition . the present study sought to examine whether neighborhood socioeconomic position ( sep ) shows bivariate relationships with baseline cognitive level and immediate response to cognitive training , beyond individual - level predictors of cognition . if so , we aimed to discern whether neighborhood effects were significant for general cognitive ability ( g ) , and whether effects were differential for specific cognitive abilities ( memory , reasoning , speed , everyday cognition , and vocabulary ) . we hypothesized that the potential effect of neighborhood sep may most likely occur by way of sociocultural processes , and therefore would have significant positive associations with general cognitive ability and with crystallized cognitive domains , including vocabulary . neighborhood sep was hypothesized to have relatively weaker , if detectable , associations with fluid cognitive domains , including memory , reasoning , speed , and everyday cognition .", "the primary objective of active was to test the effectiveness and durability of three cognitive interventions . the initial trial randomized individuals to one of three 10-session cognitive interventions designed to improve memory , reasoning , or processing speed performance or to a no - contact control condition . following training there was an immediate posttest and follow - up assessments at 1- , 2- , 3- , and 5-years after intervention . the current study sought to examine only the immediate pretest - posttest data , focusing on the proximal outcome measures used . information on potential covariates was collected , including demographic variables , mmse , recent depressive symptoms , and general health . testers at all six sites were trained in standardized assessment protocols and quality control by both study investigators , and the coordinating center ensured fidelity to testing procedures . the initial sample of 2,802 participants was recruited through on - site presentations , letters to interested persons , newspaper advertisements , introductory letters , and follow - up telephone calls . participants were cognitively healthy , community - dwelling older adults aged 65 to 94 years ( mean age = 73.6 years , mean years of education = 13.5 , mean mmse = 27 , 75.8% female , 72% caucasian , 26% african american , and 2% other minority groups ) . the majority of participants ( 64% ) were not married , and most reported good to excellent health ( 84.3% ) . efforts were aimed at recruiting older adults independent of care at enrollment , as well as recruiting a diverse sample especially inclusive of african americans , who were previously under - represented in most cognitive training research . exclusion criteria included ( a ) being under age 65 at the start of the study , ( b ) significant functional and/or cognitive decline at enrollment ( e.g. , impaired activities of daily living , mmse < 23 , and diagnosis of alzheimer 's disease ) , ( c ) having a medical condition disposing the participant to imminent cognitive decline or to mortality within the next 2 years , ( d ) severe sensory or communicative difficulties precluding participation in assessments and training , ( e ) having had cognitive training , or ( f ) planning to be unavailable during the testing and training periods of the study . active included multiple assessments of participants , but the present paper restricted itself to baseline cognitive performance and the immediate post - test . neighborhood - level socioeconomic data from publicly available geographic datasets were then merged with active data at the individual level . active did not aim a priori to include multiple measures of individual - level socioeconomic position . education ( highest level achieved ) was assessed for all participants , but other person - level socioeconomic indices ( e.g. , income , occupation ) were not collected at baseline ; occupational status was collected at the second annual follow - up occasion . the cognitive domains measured in actve included memory , inductive reasoning , processing speed , everyday cognition , and vocabulary ; descriptive statistics on the sample performance for measures within each domain are illustrated in table 1 . memory was measured using the hopkins verbal learning test ( hvlt , ) , a 12-word list memory task assessing immediate and delayed recall over 3 learning trials , the rey auditory verbal learning test ( avlt , ) , a 15-word list memory task assessing immediate and delayed recall over 5 consecutive learning trials , and the rivermead behavioral memory test , a paragraph recall task assessing immediate verbal episodic memory . reasoning was measured using letter series , a task requiring accurate identification of the next logical letter group in a series of letters ( e.g. , a m b a n b a o b ) , letter sets , an inductive reasoning task requiring participants to identify which of 4 sets of letters is unrelated to the others ( e.g. , eef hhi llm ysy ) , and word series , a task requiring accurate identification of the next logical word in a series . processing speed was measured using the useful field of view test ( ufov , ) , a computer - administered task measuring visual sustained , selective , and divided attention through four subtasks , and the complex reaction time test , a computer - administered task measuring the time taken to perform various motor behaviors and to complete each task . everyday cognition was measured using the everyday problems test , a performance - based test of ability to solve everyday problems including medications , nutrition , phone use , shopping , and management of finances and household , the observed tasks of daily living ( otdl ) , a timed task of problem solving in medication use , telephone use , and financial management , and the timed instrumental activities of daily living ( tiadl ) , a timed test of ability to complete daily living tasks ( e.g , find telephone number , make change , find and read ingredients on a can , find food items on a shelf , read instructions on medicine bottle ) . vocabulary was measured using a multiple - choice measure of vocabulary attainment in which the participant is presented with a word and must choose one of four possible synonyms . geocoding is a process by which a location ( e.g. , street address ) is assigned cartesian mathematical coordinates , allowing for other levels of geographic information to be linked with that location . geolytics , a commercial provider of geocoding services and census demographic data , ( 1 ) geocoded the active participant addresses , and ( 2 ) appended to these addresses data from the 2000 u.s . census and 2002 economic census , creating a dataset that could be used to characterize the neighborhood environment . neighborhood research , active participant addresses were geocoded and linked with their associated census tract numbers , which allowed for census tract - level data from the 2000 u.s . census to be appended to the individual - level active data . participants receiving mail by post office boxes were excluded as such addresses can not be verified to represent the participant 's actual place of residence . addresses with invalid house numbers , street names , and zip codes were flagged for followup ; invalid addresses or poorly matched addresses were dropped from the analysis ( 93% of the active addresses accurately matched to a us geological survey ( usgs ) geocode ; final sample size = 2,521 ) . census tracts are subdivisions of a county , with an average size of approximately 4,000 residents designed to capture collectively agreed - upon areas approximating neighborhoods . that is , the boundaries of census tracts were agreed upon by local officials knowledgeable of the area and were intended to be homogenous with respect to population characteristics , economic status , and living conditions . smaller measurement units of area - level ses ( e.g. , block group ) have been shown to correlate highly with census - level measures of ses , and variability in ses among block groups is small relative to variability within their census tract . the association of area - level ses with the cognitive measures was tested at three different levels of area measurement ( block group , census tract , and zip code ) , with no significant difference in the strength of associations across levels . because the census tract has traditionally been the most frequently used and most strongly recommended unit of measurement for area - level effects in health research , especially in terms of sep [ 3 , 35 ] , and because it differed very little in model fit or regression coefficients from the other geographic levels , the census tract level of aggregation was selected for all final analyses involving sep . neighborhood socioeconomic position was measured by creating a socioeconomic position ( sep ) index . because ses variables such as income , education , and occupation are often strongly correlated and have been found to load onto a common factor at the census level , census - level data on these variables were combined into a weighted factor score to create a neighborhood sep index that parsimoniously represented multiple socioeconomic variables . the analytical framework for the study involved exploratory and confirmatory factor analysis , structural equation modeling , and repeated measures mixed effects modeling . in keeping with best practice in conducting neighborhood research , individual- and area - level effects would ideally have been examined using a multi - level modeling ( mlm ) approach , with samples of individuals clustered in neighborhoods allowing formal assessment of random variation within neighborhoods . however because active was not originally designed to sample data stratified by neighborhood but sampled widely across each region , the insufficient sample size within each neighborhood measured precluded the use of mlm . in keeping with recent scholarship , the current study can instead be classified as ecologic , in which neighborhood variables are measured for each person . statistical package for the social sciences ( spss ) 18.0 and analysis of moment structures ( amos ) 18.0 were used to conduct all statistical analyses . prior to analysis , all variables were inspected for consistency with the assumption of multivariate normality ( to permit maximum likelihood estimation ) . where that assumption was not met , blom transformations were applied to those variables to improve the normality of their distributions . while no data were missing for any neighborhood - level variables , in a few instances data were missing from the active dataset 's cognitive variables ( e.g. , due to failure to complete a task or attrition between the baseline and posttraining testing occasions ) . models were estimated using full information maximum likelihood ( fiml ) , which uses all available data ( thereby not eliminating participants with incomplete data ) . preparatory to examining the relationship of neighborhood sep to active cognitive outcomes , factor analytic constructs representing neighborhood sep and baseline cognition were developed . criteria for acceptable model fit indices included root mean square error of approximation ( rmsea ) < 0.06 , comparative fit index ( cfi ) > 0.95 , normed fit index ( nfi ) > 0.95 , and tucker - lewis index ( tli ) > 0.95 . exploratory factor analyses were first conducted on the neighborhood sep variables , using promax rotation to allow optimal fit to the data . a weighted composite measure of sep was then estimated and optimized in amos based on a common factor identified in the exploratory factor analysis . the cognitive measurement model for the present study dimensionalized cognition into several domains , for which the active dataset was well designed , having captured at least three measures each of specific cognitive domains including memory , reasoning , processing speed , and everyday cognition , or measures of cognition related to everyday abilities . as stated in the introduction , cognitive aging research has increasingly emphasized conceptualization of cognition as both a general ability ( g ) , and a multifaceted system of specific cognitive domains which may respond differently to neighborhood effects . therefore the model also estimated effects on each of the above cognitive domains , as well as effects on a higher - order factor representing general cognition or g , which captures the shared variance among the five cognitive domains in the measurement model . the sep and cognition factor models were combined in a structural equation model estimating regression paths from sep to the each of the cognitive factors . model covariates included age , quadratic age , years of education , gender , and race ( white , african american ) . measures of individual wealth and duration of residence in neighborhood were not collected in active , and could not be included as covariates . neighborhood sep as a predictor of training gains was estimated as repeated - measures mixed effects models rather than as structural equation models because this provided a more flexible interface for the analysis of training gains , which was operationalized as a two - occasion difference score ( and thus would not significantly benefit from a latent variable approach ) while still permitting fiml estimation for maximum power in the presence of missing data ( i.e. , using all available cases ) . separate models were estimated for each domain trained ( memory , reasoning , or speed ) to examine the gains of each training group relative to other participants who did not receive that training ( i.e. , the other two training groups and the no - contact controls ) . each model tested sep as a continuous predictor and occasion ( baseline , posttest ) and training group ( received training on the ability being examined or not ) each as class variables . each model also tested all possible two - way interactions and the three - way interaction of sep , occasion , and group . interactions were estimated as residualized interaction terms to correct for collinearity with the model 's main effects .", "neighborhood sep was initially developed using exploratory factor analysis ( efa ) to combine 8 indicators of area - level ses : median household income , % households with income $150,000 , % persons in poverty , % with 9th grade education , % with high school education , % with bachelor 's degree , % unemployed , and % working in management or higher . the efa indicated all 8 variables loaded strongly onto one factor ( eigenvalue = 5.97 ) , explaining 71% of the variance ( factor loadings ranged from 0.71 0.94 ) . all indicators were then included in a confirmatory factor analysis , where modification indices ( mi ) suggested high intercorrelations of error variances among variables ( e.g. , ranging up to mi = 1325.42 ) . to derive an optimally - fit , parsimonious set of variables capturing the shared variance of characteristics on which sep is typically based ( e.g. , income , education , and occupational attainment ) , redundant variables were progressively removed from the model . the final sep factor model ( figure 1 ) consisted of four variables measuring socioeconomic advantage in income , education , and occupation ( median household income , % with income $ 150,000 , % with bachelor 's degree , and % in management or higher ) . as two indices of area - level income would be expected to correlate , a correlation path was estimated between the error variances of median household income and % income $ 150,000 and was retained in all subsequent models . model fit was good ( cfi = 0.999 , nfi = 0.999 , tli = 0.996 , /df ratio = 8.23 ( p = 0.004 ) , and rmsea = 0.05 ( p = 0.36 ) ) . notably , the variables loading on the latent sep factor are all indicators of neighborhood affluence or advantage rather than disadvantage ; prior neighborhood research has suggested that measures of social advantage , compared to social disadvantage , may be especially important protective factors in neighborhood influences on development . mean sep factor scores were found to differ across active catchment sites ( f(5,2515 ) = 184.30 , p < .001 ; table 2 ) . reestimating the models with catchment site as an additional covariate did not alter the pattern of effects , but reduced the fit of the model to an unacceptable extent . thus , active catchment site was tested but not retained in the study models as a covariate . the present paper sought to characterize both general and specific domains of late life cognition . the measured variables ( figure 2 ) related to memory were combined to represent a memory factor ; measures of reasoning combined to form a reasoning factor ; guided by preliminary exploratory analyses , measures of processing speed optimally first combined into separate factors based on test , which were then combined to form a speed factor , and individual measures of everyday cognition combined on a factor representing everyday cognition . because these cognitive domains were represented by latent factors ( making them purer representations of their domains ) , the vocabulary measure was also represented as a factor by using odd and even scores as indicators loading on a single vocabulary factor ; this effectively transforms that factor into a construct representing the odd - even split half reliable variance of the measure . model covariates included linear age , the quadratic effect of age , years of education , gender , and race . the error variances of the ufov 2 and 4 subtests , and the everyday problems test and vocabulary were also allowed to correlate in the process of optimizing model fit ( table 3 ) . as the first - order cognitive factors all correlated with one another ( p < 0.001 ) , and as discussed earlier g , capturing the variance shared by the cognitive factors ( table 4 ) . model fit was acceptable ( cfi = 0.98 , nfi = 0.97 , rfi = 0.96 , tli = 0.97 , rmsea = 0.046 , ( p = 1.00 ) , /df ratio = 6.40 , and ( p < 0.001 ) ) . the sep and cognitive measurement models were combined in a structural equation model ( figure 2 ) estimating regression paths from neighborhood - level sep to the cognitive constructs of g , reasoning , speed , everyday cognition , and vocabulary ( a path could not be estimated for sep or any covariates to memory ) . model covariates included linear age , the quadratic effect of age , years of education , gender , and race . model fit was adequate ( cfi = 0.96 , nfi = 0.96 , tli = 0.95 , /df ratio = 6.52 , ( p < 0.001 ) , and rmsea = 0.05 ( p = 0.99 ) ) . after controlling for individual - level predictors , sep remained a significant predictor of vocabulary alone ( p < 0.01 ; table 5 ) . repeated - measures mixed effects analyses of variance were used to estimate whether neighborhood sep predicted differences in training - related gains , beyond practice - related gains , on posttraining measures of memory , reasoning , and speed . three separate models examined the gains of each training group relative to all other participants ( control group plus members of other training groups ) who did not receive that particular training ( i.e. , for the reasoning outcome , the reasoning training group was compared to the control plus memory plus speed training groups ) . each model tested sep as a continuous predictor and occasion ( baseline , posttest ) and training group ( received training on the ability being examined or not ) , all possible two - way interactions , and the three - way interaction of sep , occasion , and group . significant effects for occasion , training group , and their interaction were observed as previously reported in the parent study . a main effect was found for sep , but for sep to predict differences in response to active training the three - way interaction would have to be significant ; this was not found for any of the trained abilities ( memory : f(1 , 4594 ) = 0.66 , p = 0.42 ; reasoning : f(1 , 4847 ) = 0.001 , p = 0.98 ; speed : f(1 , 4793 ) = 0.001 , p = 0.97 ) .", "the present study sought to examine the relationship between current neighborhood - level socioeconomic position ( sep ) and cognitive level , including several specific cognitive domains in the active study , and response to cognitive training . the findings demonstrated that , after controlling for individual - level demographic predictors , census - defined neighborhood socioeconomic position independently predicted differences in late life vocabulary as measured in active , but not differences in general cognition ( g ) , reasoning , everyday cognition , or speed . these findings differed from the similar prior study by brandt , which found neighborhood ses effects on a composite cognitive measure capturing cognitive status , verbal fluency , verbal learning , and prospective memory . the results also demonstrated that neighborhood sep does not predict individual differences in the immediate response to cognitive training in memory , reasoning , or processing speed . the lack of effect for neighborhood sep on any fluid cognitive ability ( memory , reasoning , speed , and everyday cognition ) or on cognitive plasticity ( i.e. , response to training ) is somewhat surprising given the extensive research documenting neighborhood effects on factors affecting brain health , such as cardiovascular fitness and chronic diseases ( e.g. , [ 43 , 44 ] ) . it would be reasonable to hypothesize that neighborhood could indirectly affect fluid cognitive abilities and training gains , which are more sensitive to compromised brain health than vocabulary , through differences in access to health care , nutrition , and opportunities for exercise ; however , results suggest that if these indirect effects are present they may be relatively weak . given the relatively good health of this cohort at baseline testing , the majority of respondents reported good or health , and all were independent of care , there also may not have been sufficient variability in baseline fluid cognition scores for neighborhood effects to be detectable . the specific association of neighborhood sep with vocabulary suggests neighborhood influences cognition more through sociocultural mechanisms , as vocabulary captures crystallized cognitive abilities , the dimension of cognition related to stored verbal knowledge , developed over a lifetime of engaging with culture . crystallized knowledge is also the only domain that continues to improve in the presence of advancing age , compared to fluid cognitive abilities which become less efficient with age . a review of vocabulary in aging reported increasing vocabulary scores with advancing age , as well as with higher education ( although in the present study neighborhood sep predicted vocabulary independent of education ) . vocabulary measures like the one used in this study , requiring multiple - choice word recognition rather than production of word meanings , are especially robust to the effects of aging . neighborhood may influence vocabulary by facilitating or constraining one 's capacity for , and influencing the results of , sociocultural engagement in the community . it may do so by providing resources or facilities encouraging cultural interaction or by encouraging acculturation through modeling and social comparisons . that is , high - sep neighborhoods may support vocabulary because more neighbors with high educational and occupational attainment provide more social models of high achievement . this modeling may foster upward social comparisons [ 48 , 49 ] , pressuring or evoking desire in an individual to be more like his or her neighbors , resulting in greater engagement in activities enhancing cognitive skills and abilities . certainly , other researchers have hinted toward social processes ( i.e. , social norms , interactions and ties , and collective efficacy ) as the mechanism linking neighborhoods with developmental outcomes [ 2 , 47 ] . while vocabulary is related to current neighborhood sep , it is important to consider that vocabulary is also highly correlated with childhood cognitive level . vocabulary often reflects both cognitive reserve and premorbid ability level , as it is most robust to not only aging but physical insults to the brain , including head trauma , medical conditions , and exposure to neurotoxins . expressed differently , when cognition is measured in late life , vocabulary is the strongest index of early life cognitive ability therefore , the current neighborhood - vocabulary association found in this study may reflect both historical and current relationships between neighborhood context and cognition ; the well - established relationship between neighborhood and cognition in childhood supports this hypothesis . thus , a part of the late life neighborhood effects on cognition observed here may represent an berkman and glymour found that the county of residence during primary schooling , by way of the laws guiding educational requirements in that county , predicted individual differences in both educational attainment and late life cognitive performance . similarly , wilson and colleagues reported that parental education during childhood independently predicted cognitive activity across the lifespan and into old age . therefore , it is likely that childhood sep , had it been collected in active , may be associated with both late life vocabulary and late life neighborhood sep . finally , it was reported in the results that there were catchment site - level differences in mean sep . clearly , an individual 's neighborhood sep is also part of the general sep of the region in which that individual lived ; the interaction between neighborhood and regional sep may influence how a neighborhood 's sep relates to cognition . normal to live in a lower - sep neighborhood ; this experience might differ from the experience of living in a low - sep neighborhood within a high - sep region , and might differently affect cognition . such issues have been explored on the level of individual ses - to - neighborhood ses interactions ( e.g. , low individual education predicts worse cognition for those living in low - education neighborhoods versus high - education neighborhoods , ) , but neighborhood - region sep interactions affecting cognition have not been described to our knowledge . this study was limited in several ways due to its nature as a secondary analysis . several covariates would ideally have been included had they been collected in the parent study , including individual - level income and occupation ( although this may later be examined in for the subset present at the 2nd - annual followup ) and the length of time lived at current residence . as a consequence , this is an important limitation , as the observed neighborhood association may be attributable , partially or completely , to unmeasured differences in individual - level socioeconomic status . the possibility that the relationship between vocabulary and neighborhood sep can be explained by childhood neighborhood sep must also remain speculation , as this data was not originally collected in active . this study therefore was unable to examine measures of childhood socioeconomic status ( e.g. , mother 's or father 's education and income , neighborhood sep in childhood ) . it is likely that childhood sep is associated with both vocabulary and late life sep , in which case vocabulary 's relationship with current neighborhood sep would be expected to diminish or disappear if childhood sep was accounted for in the study . the cross - sectional nature of effects also limits discussion to relationships among variables at a particular time rather than to causal or temporal relationships between variables . longitudinal assessment of these relationships is an important next step that will be attempted in future studies . at the time this study was conducted , active collected its 10th annual follow - up testing occasion , allowing examination of the interaction between 2000 neighborhood and cognition with 2010 neighborhood and cognition . future studies will also attempt to examine ( a ) neighborhood effects on change trajectories , and ( b ) whether there were neighborhood moves for participants , and whether such moves were associated with functional changes . furthermore , at this follow - up data was collected documenting participant 's county of primary schooling . national historical data will allow investigators to use county information to explore whether and how distal environmental influences ( i.e. , county - level sep and educational laws during primary schooling years ) might predict contextual neighborhood characteristics and cognitive outcomes later in life .", "this paper adds to the body of research examining neighborhood - cognition associations in late life , and extends previous findings by looking beyond general cognition or cognitive status to examine effects of neighborhood across specific cognitive domains . the finding that neighborhood sep predicts crystallized cognitive abilities ( specifically , vocabulary ) suggests that neighborhood effects may be most related to sociocultural influences on cognitive development . there was a lack of association between neighborhood sep and fluid cognitive abilities , as well as between neighborhood sep and immediate cognitive change following training . as discussed above , future research should investigate how associations between early life neighborhood context and cognitive development may influence cognitive function and neighborhood selection in late life ." ]

[ "cocaine and other amphetamine - like psychostimulants have been a significant part of the human pharmacopoeia for thousands of years . however , the appearance of these substances in western societies has been relatively recent , cocaine having debuted as both a local anesthetic and a psychostimulant in the 19th century . over the course of the next century , it became increasingly clear that the amphetamine - like psychostimulants carried serious abuse liability , as well as producing a prominent paranoia - like syndrome among many individuals who chronically used this class of drugs . the abuse liability of these drugs has resulted in sociological use patterns that have been described as epidemics , such as the methamphetamine epidemic in japan in the 1950s , the cocaine epidemic in the united states in the 1980s , and the crack cocaine epidemic of the 1990s . \n the high abuse liability of this class of drugs relies on both pharmacological properties and the sociological characteristics of how the drugs are introduced into various societies around the world . this article will not significantly address the sociology of psychostimulant abuse , which involves diverse events ranging from the use of amphetamines by japanese soldiers in world war ii , to the formulation of crack as a less expensive version of cocaine in the united states , to the introduction of prescription formulations to regulate eating habits or to treat attention deficit - hyperactivity disorder . rather , we will review the basic pharmacology of amphetamine - like drugs , integrate these molecular mechanisms into the brain circuitry of reward , and describe how these drugs are thought to create pathological changes in reward and learning circuitry finally , this knowledge will be amalgamated into a vision of future pharmacotherapies for treating psychostimulant addiction .", "the defining mechanism of action of amphetamine4ike psychostimulants as a class of drugs with high abuse liability is the ability to bind to dopamine transporters ( dat ) . dopamine transporters are a member of a class of proteins that eliminate monoamines , including dopamine , from the synaptic cleft after neuronal release . this protein has a high affinity for dopamine relative to other monoamines , such as norepinephrine or serotonin , and while all the readily abused psychostimulants bind to dat , they may also bind to the other monoamine transporters with greater or lesser affinity . to some extent , the relative profile of binding by individual drugs to the different transporter proteins explains different characteristics of the drugs . most striking , for example , is 3,4-methylenedioxymethamphetamine ( mdma ) which has a relatively higher affinity for serotonin transporters , and is thereby a mild hallucinogen and neurotoxic to serotonin axon terminals , while methamphetamine binds more avidly to dat , which explains its greater toxicity at dopamine terminals , as well as its propensity to induce paranoid psychosis - like symptoms . while the binding to other monoamine transporters contributes to the antidepressant and hallucinogenic characteristics of some psychostimulants , it is the binding to dat that provides the major influence on abuse liability , which is the focus of this review . there are two major categories of interaction by ampetamine - like psychostimulants with dat , but in all cases the end result is to inhibit the elimination of dopamine from the synapse and thereby increase the quantity and half - life of synaptic and extrasynaptic dopamine levels . the first mechanism is typified by cocaine and methylphenidate that bind to dat , but are not transported into the presynaptic terminal as surrogate dopamine . therefore , when these drugs bind to dat the increase in extracellular dopamine relies primarily on normal synaptic release , which is more amenable to physiological feedback regulation . the second mechanism is typified by amphetamines , and involves not only binding to dat , but also translocation into the cell in place of dopamine . in addition , these drugs enter dopamine synaptic vesicles , where the fact that these compounds are basically charged degrades the ph gradient necessary to sequester dopamine into the vesicle . this in turn results in a large buildup of dopamine in the cytosol , thereby reversing the direction of dat to release dopamine into the extracellular space rather than facilitating its removal regardless of the precise interaction with dat by individual amphetamine - like psychostimulants , this class of drugs dramatically elevates extracellular dopamine , and this action is thought to be the initiating molecular event that reinforces drugseeking behaviors , ultimately culminating in addiction . \n", "thus , when an organism encounters a novel stimulus , whether a positive stimulus such as a food reward or a negative stimulus such as a stressor , the activity of dopamine cells in the ventral tegmental area , and dopamine release in axon terminal fields in the prefrontal cortex , nucleus accumbens , and/or amygdale , are altered . an important characteristic of this brain - environment interaction is that the ability of a given stimulus to increase dopamine cell firing and release decreases with repeated presentation of the stimulus . however , it can be shown that if a motivationally neutral stimulus ( such as a light or tone ) is associated with the motivational event in such a manner that the neutral stimulus predicts arrival of the motivational event , the ability of the motivational stimulus to release dopamine is transferred to the neutral stimulus . thus , the neutral stimulus now causes dopamine release in a manner predicting arrival of a motivationally relevant event . based upon these data , the role for dopamine release in the mesocorticolimbic brain regions is twofold : ( i ) to cue the organism that a novel motivationally relevant event is occurring and that adaptive behavioral responses need to be engaged ( eg , approach a reward or avoid a stress ) ; ( ii ) once the behavioral response is established , dopamine release is antecedent to the appearance of the motivationally relevant event and is triggered by environmental associations that the organism has made with the event as part of learning the adaptive behavioral response . in this way , dopamine serves to alert and thereby prepare the organism for an impending important event . the primary differences between psychostimulant - induced dopamine release and release associated with normal learning about important environmental events such as rewards and stressors is : ( i ) since psychostimulants block the elimination of dopamine through dat , the level of dopamine achieved far exceeds what is possible from a biological stimulus ; ( ii ) in contrast to biological stimuli that cease to release dopamine once an approach or avoidance response to that stimulus has been learned , psychostimulants continue to release large amounts of dopamine upon every administration ( with the possible exception of extended binging that can temporarily deplete dopamine stores ) . thus , with psychostimulants , each administration releases dopamine into mesocorticolimbic regions , causing further associations to be made between the drug experience and the environment . in this way , it is thought that the more a psychostimulant is administered , the more learned associations are made with the environment and the more effective the environment becomes at triggering craving and drug - seeking . it is this overlearning of drugseeking behaviors by progressive associations formed between repeated drug - induced dopamine release and the environment that is thought to lead to increased vulnerability to relapse .", "as outlined above , psychostimulant - induced dopamine release is responsible for reinforcing behaviors designed to seek and administer the drugs . the dopamine projections involved in this process are outlined in figure 1a , and as indicated , the most critical projection in this regard is the projection from the ventral tegmental area dopamine cells to the nucleus accumbens . for example , if psychostimulant - induced release of dopamine in the nucleus accumbens is impaired , this affects the acquisition of drug - seeking behaviors , and can markedly influence the amount of drug taken in a well - trained subject . thus , the learning of a task to obtain the drug and the amount of drug taken in a given session is strongly regulated by dopamine release in the accumbens . however , when an animal has been withdrawn from repeated psychostimulant use , and drug - seeking is initiated by an environmental stimulus such as a cue previously paired with drug delivery , or a novel stressor , it is dopamine release in the prefrontal cortex and amygdala , respectively , that mediates the reinstatement of drug - seeking . thus , relapse can be induced by dopamine release in prefrontal and allocortical brain regions , and reflects the aforementioned physiological role of dopamine release as a predictive antecendent to stimulus ( drug ) delivery . what this implies is that chronic release of dopamine by repeated psychostimulant administration may be modifying cortical and allocortical regulation of behavior . \n figure 1b shows that the cortical and allocortical regulation of behavior is primarily mediated by glutamatergic projections . these projections are to subcortical structures , such as the nucleus accumbens and dopamine cells in the ventral tegmental area , as well as between the cortical and allocortical regions . thus , when dopamine is released into the prefrontal cortex or amygdala by a drug - associated cue or stressor , this is thought to stimulate glutamatergic projections between the prefrontal cortex and amygdala , as well as glutamatergic outputs to the accumbens and ventral tegmental area . a variety of studies have linked this activation of corticofugal glutamate transmission with craving in psychostimulant addicts or drug - seeking in animal models of addiction . the neuroimaging literature clearly shows metabolic activation of regions of the prefrontal cortex , including portions of the anterior cingulate and ventral orbital cortices , and the amygdala during cue - induced craving for amphetamine - like psychostimulants . interestingly , while a cue or low dose of psychostimlant markedly increases metabolic activity in the prefrontal cortex and amygdala , in the absence of a learned drug association the prefrontal cortex is hypoactive . the reduction in basal metabolic activity is taken to indicate a potential deficit in cognitive ability to regulate relapse , and recent cognitive testing in psychostimulant addicts confirms the presence of certain cognitive dysfunctions related to impulse control and switching behaviors in an adaptive manner to changing environmental circumstances . a strong role for activation of both the prefrontal cortex and amygdala thus , pharmacological inhibition of either of these regions prevents the reinstatement of drug - seeking in animals withdrawn from drugs that have undergone extinction training . moreover , a marked release of glutamate is measured in the nucleus accumbens of animals initiating drug - seeking in response to a stressor , and this glutamate is derived from increased activity in the projection from the prefrontal cortex to the nucleus accumbens . one final set of studies to be considered regarding cortical glutamate is the recent evidence that as drug - seeking becomes more compulsive there is a gradual shift to greater reliance on corticostriatal habit circuitry , and less involvement of prefrontal to accumbens circuitry . this possibility is supported by animal models in two ways : ( i ) if animals that have been trained to self - administer cocaine are left in abstinence for an extended period , drug - seeking is augmented , and in this case inhibition of the prefrontal cortex or amygdala no longer inhibits drug - seeking induced by drug - associated stimuli . however , inhibition of the dorsolateral striatum is still effective at blocking drug - seeking ; ( ii ) as training of an animal in drug - seeking paradigms progresses it is possible to show a gradual increase in dopamine released into the caudate in favor of release into the nucleus accumbens . this is illustrated in figure 1a , showing that dopamine release into the caudate can regulate habitual behaviors . on one hand , these data point to the possibility that in treating compulsive relapse we should be focusing on regulation of corticostriatal habit circuitry , including glutamate input to the caudate from sensorymotor cortex and dopamine input from the substantia nigra . however , these studies have been conducted in rats in whom the frontal cortex is poorly evolved , and given the marked activation produced in the prefrontal cortex and amygdala by drug - associated stimuli in psychostimulant addicts , the conclusion that compulsive relapse is entirely derived from corticostriatal habit circuitry may be an oversimplification . indeed , it has been argued that a primary role for therapy in treating addiction is to strengthen prefrontal regulation of drug - seeking behaviors , whether through psychosocial interventions or pharmacotherapy . \n", "given the apparent critical role played by glutamatergic affrents to the nucleus accumbens in initiating drugseeking or craving , recent studies have identified a number of enduring cellular changes in glutamate transmission that may be critical pathological neuroadaptations to psychostimulant use , and may serve as targets for pharmcotherapeutic intervention . in general the neuroplasticity can be categorized as postsynaptic , presynaptic and nonsynaptic ( ie , residing predominantly in glia ) . however , since these processes are intimately related to each other , it is perhaps best to consider all the adaptations as changes in glutamate homeostasis , the end result of which is a psychostimulant - induced enduring change in the fidelity of communication between the prefrontal cortex and the nucleus accumbens , and the regulation by this projection of corticostriatal habit circuitry . it has been proposed that this loss of fidelity results in a weakening or loss in the capacity of psychostimulant addicts to cognitively intervene in habitual behaviors , thereby making drug - seeking more difficult to control and increasing the vulnerability to relapse . \n as mentioned above , drug - seeking is associated with a large release of prefrontal glutamate into the nucleus accumbens . the large release of glutamate during drugseeking is all the more remarkable because it was discovered using microdialysis . which is not a very sensitive measure of glutamate transmission . indeed , when animals are trained to seek a biological reward , such as food , microdialysis can not measure glutamate release . thus , the large psychostimulant - induced release of glutamate has been hypothesized to be a pathological and perhaps critical mediator of relapse . this hypothesis is supported by the fact that treatments interrupting synaptic glutamate release also inhibit drug - seeking . this includes a variety of pharmacological treatments that have the potential to be developed into pharmacotherapeutic agents , as outlined below . perhaps in part a consequence of the massive synaptic glutamate release occurring during psychostimulantseeking behavior , a number of marked changes in postsynaptic glutamate transmission have been measured in animals withdrawn from chronic cocaine or amphetamine administration . perhaps among the most dramatic importantly , this appears to be accompanied by an increase in the insertion of a - amino3-hydroxy-5-methylisoxazole-4-propionic acid ( ampa ) glutamate receptors into the membrane of spiny neurons in the accumbens , and is associated with an increase in electrophysiological sensitivity to ampa receptor stimulation ( as measured by the ampa : n - methyl d - aspartate [ nmda ] ratio ) . moreover , a number of other proteins regulating the fidelity of postsynaptic glutamate transmission are altered after chronic cocaine use , including proteins that regulate the structure and function of the protein scaffolding in which the glutamate receptors are embedded , including postsynaptic density ( psd)-95 and homer proteins , among others . also , in addition to ampa ionotropic glutamate receptors , signaling through metabotropic glutamate receptors is downregulated . finally , this psychostimulant - induced postsynaptic neuroplasticity is associated with changes in the biochemical machinery regulating spine formation , notably an increase in actin cycling and formation of factin ( a primary structural protein regulating spine morphology and the insertion of proteins into and out of the membrane ) . taken together , these findings indicate that significant changes have been produced by psychostimulants in the way that synaptically released glutamate will be interpreted by postsynaptic cells . thus , there remain many apparent contradictions in the literature regarding changes in specific proteins , and in the overall direction of synaptic grading ( ie , is postsynaptic glutamate transmission augmented or inhibited by chronic psychostimulant administration ) . therefore , for now it is probably not prudent to speculate on the type of drug development that may arise from this particular direction of research into psychostimulant - induced changes in glutamate signaling .", "as outlined above , given our current state of knowledge it is more likely that pharmacotherapeutic restoration of normal glutamate release may be a more successful approach than manipulating postsynaptic proteins responsible for and/or associated with changes in the fidelity of postsynaptic glutamate transmission . in part , this is due to the relatively contradictory status of the emerging literature on postsynaptic plasticity . moreover , it has been hypothesized that the adaptations in presynaptic glutamate release may be at least partly causal in the postsynaptic adaptations , posing the possibility that if the pathological release of glutamate can be successfully ameliorated , postsynaptic normalization may follow . \n pharmacotherapeutic targets for regulating the pathological synaptic glutamate release seen in the accumbens of psychostimulant - seeking animals can be placed into two categories : ( i ) targets based upon psychostimulant induced changes in proteins regulating synaptic glutamate release ; ( ii ) proteins that produce a general decrease in excitatory transmission . compounds in the first category are likely to be the most specific for psychostimulant addiction , and perhaps carry the least number of unwanted side effects , while the latter category may be less selective not only regarding effects on other addictive drugs , but also in terms of unwanted side effects . neuroplasticity produced by chronic cocaine administration that could potentially contribute to pathological glutamate release includes downregulation of cystine - glutamate exchange , downregulation of glial glutamate transporters , and downregulation of release - regulating presynaptic metabotropic glutamate receptors ( mglur2/3 ) . importantly , these three changes are interrelated due to the cystine - glutamate exchanger and glutamate transporter regulating extrasynaptic glutamate tone on release regulating mglur2/3 . drugs have been examined in animal models of psychostimulant addiction , and to a lesser extent in clinical trials with cocaine addicts that regulate one or more of these processes . for example , n - acetylcysteine upregulates cystine glutamate exchange , and has been shown in animal models to prevent synaptic glutamate release associated with drug - seeking , restore inhibitory tone on synaptic release through activation of mglur2/3 , and to inhibit the desire for cocaine in a double - blind cue - reactivity trial in non - treatment - seeking cocaine addicts . also , mglur2/3 agonists have proven effective at inhibiting cocaine seeking in animal models ; however , unlike nacetylcysteine , food - seeking was inhibited at only a 3- to 10-fold increase in dose relative to inhibiting cocaineseeking . although no studies have yet evaluated regulating glutamate transport in drug - seeking models of psychostimulant addiction , recent reports of the use of -lactam antibiotics to increase glutamate transporter membrane insertion poses an interesting possibility for pharmacologically overcoming the cocaine - induced downregulation of glutamate transporters . finally , while the mechanism is not clear , modafinil has been reported to increase extracellular glutamate levels , which would restore tone on release inhibiting mglur2/3 . notably , modafinil has been found to successfully decrease cocaine relapse in a number of clinical trials . \n the primary drugs in the category of nonspecific inhibitors of synaptic glutamate release include a variety of -aminobutyric acid ( gaba)-mimetic compounds . these range from relatively specific agonists at gabab receptors , such as baclofen , which inhibit synaptic glutamate release to a host of less selective compounds known to increase gaba transmission via interactions with synthetic or elimination mechanisms , such as topiramate or vigabatrin . for all of these compounds there is preclinical and clinical data to support some potential efficacy . however , as predicted , especially for the nonselective gabamimetics untoward side effects , such as sedation , are reported .", "this review has endeavored to transport the reader from the initiating molecular actions of amphetamine - like psychostimulants on dopamine systems in the brain to enduring neuroplasticity produced in glutamate transmission responsible for communicating from prefrontal and allocortical brain regions through the nucleus accumbens to motor regulatory systems . moreover , by examining molecular neuroplasticity produced in excitatory synapses by chronic psychostimulant administration , it is possible to make some deductions about potential pharmacotherapeutic interventions . indeed , there already exists an emerging literature supporting this approach in developing potential pharmacotherapies for treating psychostimulant addiction . importantly , this is a nascent and emerging science , and while much has been discovered , the cutting edge of discovery into the neuroplasticity produced by psychostimulants is understandably contradictory . as further discoveries are made that allow us to understand the nature of these contradictions , it should follow that additional targets will emerge to provide potential novel pharmacotherapies for treating psychostimulant addiction ." ]

[ "the roots of zapoteca portricensis is a common remedy in the treatment gastrointestinal disorders used by tradomedical practitioners in eastern nigeria .", "this study was aimed at evaluating the possible antiulcer activity of the root of this plant in experimental rats .", "different groups of albino rats of male sex were given three doses ( 50 , 100 , 200 mg / kg ) of the extract .", "the ethanol model produced an average ulceration in rats with reduction of ulcer ( 50% , 75% and 90% ) seen in all the extract treatment . a dose dependent inhibition of ulcer was seen in all doses of the extract with doses 100 and 200 mg / kg produced a significant reduction compared with control . in the indomethacin model , inhibition of ulcer ( 57.1% , 65.7% and 80.0% ) was seen in the treatments with the extracts in a dose dependent manner .", "this study has shown that roots of this plant ( zapoteca portoricensis ) possess potent antiulcer activity ." ]

[ "the online version of this article ( doi:10.1007/s10815 - 012 - 9815-x ) contains supplementary material , which is available to authorized users .", "the development of assisted reproductive technology ( art ) has recently enabled the direct observation of human oocytes , revealing various mysterious phenomena involving the beginning of life . however , it is undeniable that frequent microscopic examinations of human early embryos may have negative effects on them , making it difficult to obtain reliable detailed information of human embryonic development from still images . we therefore developed an in vitro culture system for time - lapse cinematography ( tlc ) , based on payne et al . this system enables non - invasive and continuous imaging of human oocyte fertilization and embryonic development . our previous dynamic analyses of the fertilization process in human oocytes and of human embryonic development using the in vitro tlc system confirmed for the first time the detailed time course of sequential events during embryonic development and revealed novel phenomena [ fertilization cone , cytoplasmic strand , and splitting of the inner cell mass ( icm ) ] under culture conditions in vitro [ supplementary movie 1 ( online resource 1 ) ] . our further observation of the movie revealed another novel phenomenon that is likely to be involved in the mechanism of polyspermy block , wherein once the leading sperm has penetrated the zona pellucida ( zp ) and attached to the oocyte membrane , any following sperm within the zp stop penetrating immediately . to date , two types of polyspermy block were thought to exist in marine animals and mammals , including human ( oocyte membrane block and zona reaction ) . in addition , the oocyte membrane block occurs in seconds , while an oocyte membrane depolarization block has not been detected in studies of mammalian oocytes . we therefore consider that the phenomenon described herein differs from previously proposed mechanisms for polyspermy block , prompting us to re - analyze all of our tlc data covering the fertilization process . herein , we provide the results of this second detailed tlc analysis , which we believe confirms the existence of a novel mechanism for the prevention of polyspermy .", "the in vitro culture system for tlc has been described in detail elsewhere . in brief , we used an inverted microscope ( ix-71 ; olympus , tokyo , japan ) with nomarski differential interference contrast optics ( olympus ) and a micromanipulator ( narishige , japan ) , which was covered by a handcrafted acrylic chamber . our system also contained a small acrylic chamber surrounded by a small waterbath on the stage of the microscope , into which a glass petri dish containing a microdrop of culture medium ( 5 l ) was placed . the volume of flowing co2 and temperature within the chamber were adjusted to give the optimal values ( temperature , 37.0 0.3 c ; ph , 7.37 0.03 ) . the inverted microscope was equipped with a ccd digital camera ( roper scientific photometrics , tucson , az ) connected to the computer and display by metamorph ( universal imaging co , downingtown , pa ) ( fig . the upper two images are from the tlc system , and the lower two tables indicate imaging and culture conditions of the tlc time - lapse cinematography ( tlc ) . the upper two images are from the tlc system , and the lower two tables indicate imaging and culture conditions of the tlc digital images of the cultured embryos were acquired for approximately 40 h by using an exposure time of 50 s . in total , approximately 2,0002,800 frames were taken during the observation period . we displayed movies at 30 frames per second to analyze the fertilization process and elucidate the mechanism of polyspermy block . before the commencement of tlc observation , we mechanically and gently removed the cumulus cells from around the oocytes , so as not to damage the tails of the sperm that penetrated into the zp , at 1 h after the in vitro insemination ( approximately 50 10 sperm per oocyte ) . images were acquired at 10-s intervals for the first 2 h , and thereafter at 2-min intervals , based on our preliminary study that showed most of the sperm penetrating the zp within 3 h after the in vitro insemination . oocytes were collected from 122 couples after receiving informed consent , from july 2004 to december 2011 . one oocyte was randomly selected from each couple and 122 oocytes were tested . in the tlc images obtained from these oocytes , penetration of the leading sperm into the zp and attachment to the oocyte membrane was confirmed in the 22 oocytes . among these , only three oocytes showed both the leading and following sperms within the zp in the same frame , and these tlc data were therefore used to evaluate the dynamic changes in both sperms until the leading sperm attached to the oocyte membrane during the fertilization process . the ethics committee of the japanese institution for standardizing art ( jisart ) approved our study protocol .", "of the 22 imaged oocytes , in which penetration into the zp and attachment to the oocyte membrane of the leading sperm were confirmed , the leading sperm attached to the oocyte membrane within an average of 96 min after insemination , and the sperm head disappeared an average of 37 min after attachment of the sperm to the oocyte membrane . there was no difference in the time course of the fertilization process between the three oocytes subsequently chosen to analyze the mechanism for prevention of polyspermy and the remaining 19 oocytes . figure 2 shows the results of analyzing each tlc frame of the selected oocytes ( oocyte 1 , 2 and 3 ) , in which the following sperm penetrated the zp together with the leading sperm . penetration of the following sperm into the zp was arrested within 10 s after the leading sperm attached to the oocyte membrane , even though the tail of the following sperm was still actively moving in all three oocytes ( fig . 2 ) . additional data are given in supplementary movies 2 to 4 ( online resource 2 to 4).fig . the sperm fertilizing the oocyte ( leading sperm ) is indicated by a blue circle , while the sperm following the fertilizing sperm ( following sperm ) is indicated by a red circle among three oocytes ( a ) . sections of the images containing both leading and following sperms were magnified to facilitate observation of the process ( b , c , d ) . the images were acquired in 10-s intervals . with regard to oocyte 1 shown in the upper panel , both the leading and following sperm penetrated into the zona pellucida from the beginning of imaging to shortly prior to the attachment of the leading sperm to the oocyte membrane ( a , b ) . the leading sperm attached to the oocyte membrane 1,850 s ( 30.8 min ) after the beginning of imaging ( c ) , and the penetration of the following sperm was inhibited at 1,860 s ( d ) , which is within 10 s after the attachment of the leading sperm to the oocyte membrane . with regard to oocyte 2 shown in the middle panel and oocyte 3 shown in the lower panel , the penetration of the following sperm was also inhibited within 10 s after the attachment of the leading sperm to the oocyte membrane ( c , d ) dynamics of the leading sperm and following sperm . the sperm fertilizing the oocyte ( leading sperm ) is indicated by a blue circle , while the sperm following the fertilizing sperm ( following sperm ) is indicated by a red circle among three oocytes ( a ) . sections of the images containing both leading and following sperms were magnified to facilitate observation of the process ( b , c , d ) . the images were acquired in 10-s intervals . with regard to oocyte 1 shown in the upper panel , both the leading and following sperm penetrated into the zona pellucida from the beginning of imaging to shortly prior to the attachment of the leading sperm to the oocyte membrane ( a , b ) . the leading sperm attached to the oocyte membrane 1,850 s ( 30.8 min ) after the beginning of imaging ( c ) , and the penetration of the following sperm was inhibited at 1,860 s ( d ) , which is within 10 s after the attachment of the leading sperm to the oocyte membrane . with regard to oocyte 2 shown in the middle panel and oocyte 3 shown in the lower panel , the penetration of the following sperm was also inhibited within 10 s after the attachment of the leading sperm to the oocyte membrane ( c , d ) next , we analyzed the time course of the distance that the leading and following sperms traveled in the zp ( fig . 3 ) . the following sperm traveled at a similar velocity to the leading sperm , until the leading sperm attached to the oocyte membrane after penetrating the zp . however , once the leading sperm reached the oocyte membrane across the perivitelline space , the following sperm immediately ceased further penetration , within 10 s. the behaviors of the leading and following sperm were identical among the three oocytes.fig . 3change in the distance between the surface of the zona pellucida and leading or following sperm . the time course of the change in zona pellucida penetration distance of the leading sperm ( blue line ) and the following sperm ( red line ) shows that the zona pellucida penetration of the following sperm was inhibited when the leading sperm attached to the oocyte membrane ( indicated by the arrow ) after zona pellucida penetration in all oocytes ( oocyte 1 , 2 and 3 ) used in this analysis change in the distance between the surface of the zona pellucida and leading or following sperm . the time course of the change in zona pellucida penetration distance of the leading sperm ( blue line ) and the following sperm ( red line ) shows that the zona pellucida penetration of the following sperm was inhibited when the leading sperm attached to the oocyte membrane ( indicated by the arrow ) after zona pellucida penetration in all oocytes ( oocyte 1 , 2 and 3 ) used in this analysis", "we revealed a novel phenomenon that is likely to be associated with the polyspermy block in human oocytes . this new mechanism involved cessation of the following sperm penetrating the zp within 10 s of the leading sperm penetrating the zp and attaching to the oocyte membrane . this was despite the following sperm retaining active tail movement and both sperm traveling at a similar velocity within the zp before penetration . the behaviors of the leading and following sperm were identical among the three oocytes imaged and analyzed . the difficulty in obtaining tlc images in which both the leading and following sperm within the zp were clearly identified precluded analysis of their respective behaviors in more than three oocytes . achieving normal fertilization of a single egg by a single sperm is core to life in many sexually reproducing animals , including humans . in most mammalian reproduction processes , huge numbers of sperm are ejaculated into the female reproductive tract ( ratio of sperm to oocyte is approximately 10:1 ) ; however , the vast majority of sperm are rapidly eliminated from the female tract . it is thought that polyspermy is usually prevented by a decreased number of sperm reaching the fallopian tube and a block mechanism in the fertilized oocyte . in this context , it is also thought that in vitro fertilization ( ivf ) involves different mechanisms from the normal in vivo process in mammals . in particular , successful fertilization in vitro of a single oocyte requires a large number of motile sperms , and thus there is always the possibility that more than one sperm could penetrate the zp and reach the oocyte . however , between a healthy mature ovum and a healthy sperm , normal fertilization of a single egg by a single sperm occurs at a relatively high rate , which can also be confirmed easily in the environment of ivf . there are also many clinical cases of polyspermy that are attributable to the penetration of excess sperm after ivf . hundreds of articles have been published on the process of fertilization and polyspermy block in marine animals and mammals including human [ 24 ] . two types of mechanisms for polyspermy block have been reported : the oocyte membrane block to sperm penetration and the zona reaction . the former involves a depolarization of the oocyte membrane caused by the influx of na , which changes the potential of the oocyte membrane from negative to positive . this change in potential prevents any following sperm from attaching to the oocyte membrane , transiently contributing to polyspermy block . the oocyte membrane block or so - called fast block to polyspermy occurs in seconds [ 68 ] ; however , it was unlikely to be involved in fast block to polyspermy in the fertilization process in mammals . the second proposed mechanism involves a ca oscillation event activated by attachment of the sperm to the oocyte membrane . the subsequent increase in intracellular ca concentration triggers the exocytosis of cortical granules ( approximately 1 m in diameter ) from just below the oocyte membrane into the perivitelline space . enzymes such as hydrolase , proteinase , and peroxidase , which are contained in the cortical granules , prevent the penetration of following sperm by modifying the structure of the sperm receptors such as zp2 and zp3 ( slow block to polyspermy ) and by hardening the zp . this slow block occurs within approximately 5 to 8 min of oocyte activation and is considered the main mechanism of polyspermy block in humans ; however , the mechanistic details of this process remain largely unclear in human . the entire fertilization process is extremely delicate and precise , and there is no doubt that multiple layers of safety mechanisms exist to ensure the achievement of normal fertilization . a failure of this safety mechanism is believed to instantly trigger abnormal fertilization , such as polyspermy . however , because it is so difficult to establish laboratory models of the human in vivo fertilization process and few such studies have been conducted , fertilization safety mechanisms operating in human oocytes remain unclear . in addition , dynamic morphological tactics such as tlc have not been applied to analyze the possible mechanisms of polyspermy block . it is true that the tlc analysis presented here still does not exactly represent the in vivo situation . nevertheless , we believe that these morphological data reveal a novel system for polyspermy block that could occur in human oocytes , and that the images analyzed represent the true dynamic physiology of the human fertilization process . we believe that a novel mechanism of polyspermy block takes place in the zp , which differs from both the oocyte membrane block to sperm penetration ( fast block to polyspermy ) and the zona reaction ( slow block to polyspermy ) ( fig . 4a proposed mechanism for a fast zona - block to polyspermy during the human fertilization process . the findings of our tlc analysis indicate the existence of a novel mechanism of polyspermy block , which takes place in the zona pellucida and differs from the oocyte membrane block to sperm penetration ( fast block to polyspermy ) and the zona reaction ( slow block to polyspermy ) a proposed mechanism for a fast zona - block to polyspermy during the human fertilization process . the findings of our tlc analysis indicate the existence of a novel mechanism of polyspermy block , which takes place in the zona pellucida and differs from the oocyte membrane block to sperm penetration ( fast block to polyspermy ) and the zona reaction ( slow block to polyspermy ) we are planning to elucidate the details of this novel mechanism by further observing the fertilization process of human oocytes using our tlc system .", "by use of our original tlc system , we have succeeded in demonstrating the possible existence of a novel mechanism of polyspermy block in human oocytes . however , the details of this mechanism of polyspermy block are not yet fully understood , and the mechanism we have revealed in this study may be a small part of a highly complicated system . we will continue to analyze the fertilization process of human oocytes by use of the tlc system to reveal the details of this novel mechanism of polyspermy block in human oocytes .", "movie 1this is the first movie to successfully demonstrate the dynamic process of fertilization in human oocytes in vitro whereby once the leading sperm was attached to the oocyte membrane , the following sperm stopped further penetration within the zp . this phenomenon prompted our hypothesis that a novel mechanism could exist for the polyspermy block in the human fertilization process . ( mpg 12897 kb ) this is the first movie to successfully demonstrate the dynamic process of fertilization in human oocytes in vitro whereby once the leading sperm was attached to the oocyte membrane , the following sperm stopped further penetration within the zp . this phenomenon prompted our hypothesis that a novel mechanism could exist for the polyspermy block in the human fertilization process . ( mpg 12897 kb ) movie 2this movie represents the same tlc imaging used to make movie 1 . while the leading sperm ( blue circle ) traveled within the zp and moved across the perivitelline space , the following sperm ( red circle ) was also steadily penetrating within the zp . however , once the leading sperm was attached to the oocyte membrane , the following sperm stopped penetrating within the zp even though the following sperm was far away from the leading sperm attachment site . ( mpg 2680 kb ) this movie represents the same tlc imaging used to make movie 1 . while the leading sperm ( blue circle ) traveled within the zp and moved across the perivitelline space , the following sperm ( red circle ) was also steadily penetrating within the zp . however , once the leading sperm was attached to the oocyte membrane , the following sperm stopped penetrating within the zp even though the following sperm was far away from the leading sperm attachment site . ( mpg 2680 kb ) movie 3the penetration of the following sperm in this case was also inhibited within 10 s after the attachment of the leading sperm to the oocyte . ( mpg 2243 kb ) the penetration of the following sperm in this case was also inhibited within 10 s after the attachment of the leading sperm to the oocyte . ( mpg 2243 kb ) movie 4this movie represents the same tlc imaging data used to make movies 2 and 3 . it shows that even though the tail of the following sperm was still moving actively , the sperm did not penetrate further . ( mpg 2680 kb ) this movie represents the same tlc imaging data used to make movies 2 and 3 . it shows that even though the tail of the following sperm was still moving actively , the sperm did not penetrate further .", "this article is distributed under the terms of the creative commons attribution license which permits any use , distribution , and reproduction in any medium , provided the original author(s ) and the source are credited ." ]

[ "primary human schlemm 's canal cell lines were grown to confluence in six - well plates ( bd falcon , franklin lakes , nj , usa ) containing dulbecco 's modified eagle 's medium ( dmem ; life technologies , grand island , ny , usa ) ; 10% fetal bovine serum ( mediatech , manassas , va , usa ) ; and 1% penicillin / streptomycin ( life technologies ) in 5% co2 at 37c . confluent cells were washed twice with phosphate - buffered saline and incubated in serum - free dmem for 24 hours to synchronize the growth potential of the cells . cells were incubated with latanoprost ( de - esterified free - acid form at 100 nm final concentration ; cayman chemical , ann arbor , mi , usa ) or vehicle ( ethanol , final dilution 1:1000 ) in dmem containing 1% penicillin / streptomycin . primary schlemm 's canal cells were grown to confluence , treated with 100 nm latanoprost for 6 hours , and harvested . total rna was extracted using an rna isolation kit ( rneasy total rna isolation kit ; qiagen , hilden , germany ) . approximately 250 ng of total rna was reverse transcribed into cdna using a synthesis kit ( iscript cdna ; bio - rad laboratories , inc . , hercules , ca , usa ) . quantitative real - time polymerase chain ( qpcr ) reaction using stc-1 ( forward , 5-aggcggagcagaatgactc-3 ; reverse , 5-gttgaggcaacgaaccactt-3 ) and glyceraldehyde 3-phosphate dehydrogenase ( gapdh : forward , 5-cctctgacttcaacagc-3 ; reverse , 5-gctgtagccaaattcgt-3 ) primers were performed on a pcr system using a master mix ( roche light cycler 480 with sybr green i ; roche , indianapolis , in , usa ) . we performed qpcr amplification with a predenaturation step at 95c followed by 45 cycles of denaturation at 95c , annealing at 63c , and extension at 72c . primary schlemm 's canal cells were grown to confluence , treated with 100 nm latanoprost for 15 minutes , 1 , 2 , 4 , or 6 hours , and harvested . schlemm 's canal cell pellets were suspended in ice - cold lysis buffer ( 50 mm tris ph 8.0 , 0.5% sodium dodecyl sulfate , 0.5% triton x-100 , 137 mm nacl , 3 mm kcl , 8 mm na2hpo4 - 7h2o , 1 mm kh2po4 , protease inhibitors ; roche ) and passed repeatedly through a 21-gauge needle for homogenization . lysate was centrifuged at 13,000 g for 10 minutes , and total protein was quantified by the bradford assay . cell lysates containing 20 g total protein were mixed with reducing lane marker sample buffer ( thermo fisher scientific , waltham , ma , usa ) containing 15% 2-mercaptoethanol ( sigma - aldrich corp . , st . louis , mo , usa ) , heated and separated on a 4% to 15% sds - page gradient gel ( bio - rad laboratories , inc . ) . proteins were transferred to polyvinylidene difluoride membrane ( millipore corp . , billerica , ma , usa ) in 1x transfer buffer ( 50 mm tris , 384 mm glycine , 0.01% sds , 20% methanol ) . membranes were blocked in 20 mm tris ( ph 7.5 ) , 150 mm nacl , 0.05% tween-20 , and 2% instant nonfat dry milk . blots were probed with rabbit monoclonal anti - human stc-1 ( novus biologicals , littleton , co , usa ) and mouse monoclonal anti - human gapdh ( novus biologicals ) . secondary antibodies used were horseradish peroxidase linked anti - rabbit or anti - mouse , respectively ( ge healthcare , piscataway , nj , usa ) . antibody / antigen complexes were detected using ecl western blot signal detection reagent ( ge healthcare ) . chemiluminescence film ( biomax xar ; eastman kodak , rochester , ny , usa ) was used to visualize protein signals . each film was digitized with a photographic scanner ( epson perfection 2400 ; epson america , inc . , long beach , ca , usa ) . the band intensities for western blot analysis were quantified using imagej software ( http://rsb.info.nih.gov/ij/index.html in the public domain by the national institutes of health , bethesda , md , usa ) and normalized to gapdh . all animal studies and treatment protocols were approved by the mayo clinic ( rochester , mn , usa ) institutional animal care and use committee and adhered to the arvo statement for the use of animals in ophthalmic and vision research . we obtained stc-1 and littermate wild - type mice from the sheikh - hamad laboratory , baylor college of medicine , and bred at mayo clinic . a handheld rebound tonometer ( icare tonolab ; colonial medical supply , franconia , nh , usa ) was used to measure iop in conscious mice . for iop measurements , the tonometer was held perpendicular to the cornea according to the manufacturer 's instructions . the tonometer records six readings from the same eye , discards the highest and lowest values , and shows the average of the remaining four values as a single iop reading . three independent measurements were obtained daily at similar time points and were averaged to obtain the daily iop value for each eye . after 1 week of baseline iop measurements , stc-1 mice were treated with latanoprost ( n = 10 ) or rho kinase inhibitor y27632 ( enzo life sciences , farmingdale , ny ; n = 10 ) . congenic wild - type controls were treated with latanoprost ( n = 8) or y27632 ( n = 10 ) . treatments were daily in one eye for 7 consecutive days with 5 l of latanoprost - free acid ( 100 m dissolved in 1:1000 dmso in pbs ) or 10 mm y27632 ( dissolved in phosphate - buffered saline ) . in the contralateral eye , vehicle was added daily in the same proportion as the treated eye for 7 consecutive days . additionally , wild - type mice ( n = 7 ; charles rivers laboratories , wilmington , ma , usa ) were treated with 5 l of topically administered recombinant human stc-1 ( 0.5 mg / ml ; biovendor research & diagnostic products , asheville , nc , usa ) or vehicle ( phosphate - buffered saline ) daily for 7 days to examine the effect of stc-1 on iop . in all animals , the right eye served as the vehicle control eye while the left eye received study drug ( latanoprost , y27632 , or stc-1 ) . we recorded iop in both eyes three times daily at 1 , 4 , and 23 hours following treatment . anterior segments from human donor eyes ( age 75.5 17.5 years , range : 51 to 98 years ; n = 8) were perfused in culture with dmem within 10.2 4.4 hours of death as previously described . after achieving a stable baseline pressure , one anterior segment from each pair received recombinant human stc-1 at concentrations of 5 , 50 , or 500 ng / ml ( dissolved in h2o ) , while the fellow eye received vehicle and served as the control . we added stc-1 and vehicle using a gravity - driven constant pressure method of anterior chamber exchange followed by continuous perfusion . hourly pressure readings were obtained from the average of 60 , one - minute pressure measurements using a custom - designed software program . the experimental eye was typically the right eye and the control was the left eye . for human anterior segments , selected wedges of tissue 180 apart that included the trabecular meshwork and schlemm 's canal were isolated and fixed with 4% paraformaldehyde in 0.1 m phosphate buffer ( ph 7.2 ) . tissue wedges were dehydrated in a series of ascending ethanol concentrations , cleared with 100% acetone , infiltrated and embedded in epon araldite , and sectioned at 0.5 m . eye tissue sections were stained with toluidine blue and examined using a light microscope ( nikon corp . , additional tissue wedges were sectioned at 100 nm , placed on copper film grids , and stained with uranyl acetate and lead citrate . tissue sections on copper film grids were examined using a transmission electron microscope ( jeol-1400 ; jeol usa , inc . , peabody , ma , usa ) . for mouse eye histopathology eyes were placed in 4% paraformaldehyde in 0.1 m phosphate buffer ( ph 7.2 ) overnight , and processed for light microscopy as described above for human anterior segment wedges . additional 100-nm sections were placed on copper film grids , and stained with uranyl acetate and lead citrate . processed sections were obtained following examination under a light microscope ( nikon corp . ) and a transmission electron microscope ( jeol usa , inc . ) . prior to initiation of statistical analysis , all data sets were evaluated for distribution assessment using the shapiro - wilk test . for animal studies , significance of iop change was assessed between experimental and vehicle - treated control eyes using student 's paired t - test for data sets with normal distribution and wilcoxon sign - rank test for nonparametric data sets . variations in daily iop are graphically presented as the mean daily iop of the vehicle and treated eyes . statistical calculations were performed using a statistical software package ( jmp ; sas institute , inc . , cary , nc , usa ) . for human anterior segment studies , the effect of latanoprost was expressed as the change in outflow facility ( c ) for each anterior segment . results from each pair of anterior segments were combined into a group mean for each drug , and statistical significance was analyzed using a student 's 2-tailed paired t test .", "primary human schlemm 's canal cell lines were grown to confluence in six - well plates ( bd falcon , franklin lakes , nj , usa ) containing dulbecco 's modified eagle 's medium ( dmem ; life technologies , grand island , ny , usa ) ; 10% fetal bovine serum ( mediatech , manassas , va , usa ) ; and 1% penicillin / streptomycin ( life technologies ) in 5% co2 at 37c . confluent cells were washed twice with phosphate - buffered saline and incubated in serum - free dmem for 24 hours to synchronize the growth potential of the cells . cells were incubated with latanoprost ( de - esterified free - acid form at 100 nm final concentration ; cayman chemical , ann arbor , mi , usa ) or vehicle ( ethanol , final dilution 1:1000 ) in dmem containing 1% penicillin / streptomycin . primary schlemm 's canal cells were grown to confluence , treated with 100 nm latanoprost for 6 hours , and harvested . total rna was extracted using an rna isolation kit ( rneasy total rna isolation kit ; qiagen , hilden , germany ) . approximately 250 ng of total rna was reverse transcribed into cdna using a synthesis kit ( iscript cdna ; bio - rad laboratories , inc . , hercules , ca , usa ) . quantitative real - time polymerase chain ( qpcr ) reaction using stc-1 ( forward , 5-aggcggagcagaatgactc-3 ; reverse , 5-gttgaggcaacgaaccactt-3 ) and glyceraldehyde 3-phosphate dehydrogenase ( gapdh : forward , 5-cctctgacttcaacagc-3 ; reverse , 5-gctgtagccaaattcgt-3 ) primers were performed on a pcr system using a master mix ( roche light cycler 480 with sybr green i ; roche , indianapolis , in , usa ) . we performed qpcr amplification with a predenaturation step at 95c followed by 45 cycles of denaturation at 95c , annealing at 63c , and extension at 72c . primary schlemm 's canal cells were grown to confluence , treated with 100 nm latanoprost for 15 minutes , 1 , 2 , 4 , or 6 hours , and harvested . schlemm 's canal cell pellets were suspended in ice - cold lysis buffer ( 50 mm tris ph 8.0 , 0.5% sodium dodecyl sulfate , 0.5% triton x-100 , 137 mm nacl , 3 mm kcl , 8 mm na2hpo4 - 7h2o , 1 mm kh2po4 , protease inhibitors ; roche ) and passed repeatedly through a 21-gauge needle for homogenization . lysate was centrifuged at 13,000 g for 10 minutes , and total protein was quantified by the bradford assay . cell lysates containing 20 g total protein were mixed with reducing lane marker sample buffer ( thermo fisher scientific , waltham , ma , usa ) containing 15% 2-mercaptoethanol ( sigma - aldrich corp . , st . louis , mo , usa ) , heated and separated on a 4% to 15% sds - page gradient gel ( bio - rad laboratories , inc . ) . proteins were transferred to polyvinylidene difluoride membrane ( millipore corp . , billerica , ma , usa ) in 1x transfer buffer ( 50 mm tris , 384 mm glycine , 0.01% sds , 20% methanol ) . membranes were blocked in 20 mm tris ( ph 7.5 ) , 150 mm nacl , 0.05% tween-20 , and 2% instant nonfat dry milk . blots were probed with rabbit monoclonal anti - human stc-1 ( novus biologicals , littleton , co , usa ) and mouse monoclonal anti - human gapdh ( novus biologicals ) . secondary antibodies used were horseradish peroxidase linked anti - rabbit or anti - mouse , respectively ( ge healthcare , piscataway , nj , usa ) . antibody / antigen complexes were detected using ecl western blot signal detection reagent ( ge healthcare ) . chemiluminescence film ( biomax xar ; eastman kodak , rochester , ny , usa ) was used to visualize protein signals . each film was digitized with a photographic scanner ( epson perfection 2400 ; epson america , inc . , long beach , ca , usa ) . the band intensities for western blot analysis were quantified using imagej software ( http://rsb.info.nih.gov/ij/index.html in the public domain by the national institutes of health , bethesda , md , usa ) and normalized to gapdh .", "primary human schlemm 's canal cell lines were grown to confluence in six - well plates ( bd falcon , franklin lakes , nj , usa ) containing dulbecco 's modified eagle 's medium ( dmem ; life technologies , grand island , ny , usa ) ; 10% fetal bovine serum ( mediatech , manassas , va , usa ) ; and 1% penicillin / streptomycin ( life technologies ) in 5% co2 at 37c . confluent cells were washed twice with phosphate - buffered saline and incubated in serum - free dmem for 24 hours to synchronize the growth potential of the cells . cells were incubated with latanoprost ( de - esterified free - acid form at 100 nm final concentration ; cayman chemical , ann arbor , mi , usa ) or vehicle ( ethanol , final dilution 1:1000 ) in dmem containing 1% penicillin / streptomycin .", "primary schlemm 's canal cells were grown to confluence , treated with 100 nm latanoprost for 6 hours , and harvested . total rna was extracted using an rna isolation kit ( rneasy total rna isolation kit ; qiagen , hilden , germany ) . approximately 250 ng of total rna was reverse transcribed into cdna using a synthesis kit ( iscript cdna ; bio - rad laboratories , inc . , hercules , ca , usa ) . quantitative real - time polymerase chain ( qpcr ) reaction using stc-1 ( forward , 5-aggcggagcagaatgactc-3 ; reverse , 5-gttgaggcaacgaaccactt-3 ) and glyceraldehyde 3-phosphate dehydrogenase ( gapdh : forward , 5-cctctgacttcaacagc-3 ; reverse , 5-gctgtagccaaattcgt-3 ) primers were performed on a pcr system using a master mix ( roche light cycler 480 with sybr green i ; roche , indianapolis , in , usa ) . we performed qpcr amplification with a predenaturation step at 95c followed by 45 cycles of denaturation at 95c , annealing at 63c , and extension at 72c .", "primary schlemm 's canal cells were grown to confluence , treated with 100 nm latanoprost for 15 minutes , 1 , 2 , 4 , or 6 hours , and harvested . schlemm 's canal cell pellets were suspended in ice - cold lysis buffer ( 50 mm tris ph 8.0 , 0.5% sodium dodecyl sulfate , 0.5% triton x-100 , 137 mm nacl , 3 mm kcl , 8 mm na2hpo4 - 7h2o , 1 mm kh2po4 , protease inhibitors ; roche ) and passed repeatedly through a 21-gauge needle for homogenization . lysate was centrifuged at 13,000 g for 10 minutes , and total protein was quantified by the bradford assay . cell lysates containing 20 g total protein were mixed with reducing lane marker sample buffer ( thermo fisher scientific , waltham , ma , usa ) containing 15% 2-mercaptoethanol ( sigma - aldrich corp . st . louis , mo , usa ) , heated and separated on a 4% to 15% sds - page gradient gel ( bio - rad laboratories , inc . ) . proteins were transferred to polyvinylidene difluoride membrane ( millipore corp . , billerica , ma , usa ) in 1x transfer buffer ( 50 mm tris , 384 mm glycine , 0.01% sds , 20% methanol ) . membranes were blocked in 20 mm tris ( ph 7.5 ) , 150 mm nacl , 0.05% tween-20 , and 2% instant nonfat dry milk . blots were probed with rabbit monoclonal anti - human stc-1 ( novus biologicals , littleton , co , usa ) and mouse monoclonal anti - human gapdh ( novus biologicals ) . secondary antibodies used were horseradish peroxidase linked anti - rabbit or anti - mouse , respectively ( ge healthcare , piscataway , nj , usa ) . antibody / antigen complexes were detected using ecl western blot signal detection reagent ( ge healthcare ) . chemiluminescence film ( biomax xar ; eastman kodak , rochester , ny , usa ) was used to visualize protein signals . each film was digitized with a photographic scanner ( epson perfection 2400 ; epson america , inc . the band intensities for western blot analysis were quantified using imagej software ( http://rsb.info.nih.gov/ij/index.html in the public domain by the national institutes of health , bethesda , md , usa ) and normalized to gapdh .", "all animal studies and treatment protocols were approved by the mayo clinic ( rochester , mn , usa ) institutional animal care and use committee and adhered to the arvo statement for the use of animals in ophthalmic and vision research . we obtained stc-1 and littermate wild - type mice from the sheikh - hamad laboratory , baylor college of medicine , and bred at mayo clinic . mice , aged 5 to 8 months , were utilized in the experiments . a handheld rebound tonometer ( icare tonolab ; colonial medical supply , franconia , nh , usa ) was used to measure iop in conscious mice . for iop measurements , . the tonometer records six readings from the same eye , discards the highest and lowest values , and shows the average of the remaining four values as a single iop reading . three independent measurements were obtained daily at similar time points and were averaged to obtain the daily iop value for each eye . after 1 week of baseline iop measurements , stc-1 mice were treated with latanoprost ( n = 10 ) or rho kinase inhibitor y27632 ( enzo life sciences , farmingdale , ny ; n = 10 ) . congenic wild - type controls were treated with latanoprost ( n = 8) or y27632 ( n = 10 ) . treatments were daily in one eye for 7 consecutive days with 5 l of latanoprost - free acid ( 100 m dissolved in 1:1000 dmso in pbs ) or 10 mm y27632 ( dissolved in phosphate - buffered saline ) . in the contralateral eye , vehicle was added daily in the same proportion as the treated eye for 7 consecutive days . additionally , wild - type mice ( n = 7 ; charles rivers laboratories , wilmington , ma , usa ) were treated with 5 l of topically administered recombinant human stc-1 ( 0.5 mg / ml ; biovendor research & diagnostic products , asheville , nc , usa ) or vehicle ( phosphate - buffered saline ) daily for 7 days to examine the effect of stc-1 on iop . in all animals , the right eye served as the vehicle control eye while the left eye received study drug ( latanoprost , y27632 , or stc-1 ) . we recorded iop in both eyes three times daily at 1 , 4 , and 23 hours following treatment .", "anterior segments from human donor eyes ( age 75.5 17.5 years , range : 51 to 98 years ; n = 8) were perfused in culture with dmem within 10.2 4.4 hours of death as previously described . after achieving a stable baseline pressure , one anterior segment from each pair received recombinant human stc-1 at concentrations of 5 , 50 , or 500 ng / ml ( dissolved in h2o ) , while the fellow eye received vehicle and served as the control . we added stc-1 and vehicle using a gravity - driven constant pressure method of anterior chamber exchange followed by continuous perfusion . hourly pressure readings were obtained from the average of 60 , one - minute pressure measurements using a custom - designed software program . the experimental eye was typically the right eye and the control was the left eye .", "for human anterior segments , selected wedges of tissue 180 apart that included the trabecular meshwork and schlemm 's canal were isolated and fixed with 4% paraformaldehyde in 0.1 m phosphate buffer ( ph 7.2 ) . tissue wedges were dehydrated in a series of ascending ethanol concentrations , cleared with 100% acetone , infiltrated and embedded in epon araldite , and sectioned at 0.5 m . eye tissue sections were stained with toluidine blue and examined using a light microscope ( nikon corp . , additional tissue wedges were sectioned at 100 nm , placed on copper film grids , and stained with uranyl acetate and lead citrate . tissue sections on copper film grids were examined using a transmission electron microscope ( jeol-1400 ; jeol usa , inc . , peabody , ma , usa ) . for mouse eye histopathology , whole eyes were enucleated from euthanized mice following termination of the experiment . eyes were placed in 4% paraformaldehyde in 0.1 m phosphate buffer ( ph 7.2 ) overnight , and processed for light microscopy as described above for human anterior segment wedges . additional 100-nm sections were placed on copper film grids , and stained with uranyl acetate and lead citrate . processed sections were obtained following examination under a light microscope ( nikon corp . ) and a transmission electron microscope ( jeol usa , inc . ) .", "prior to initiation of statistical analysis , all data sets were evaluated for distribution assessment using the shapiro - wilk test . for animal studies , significance of iop change was assessed between experimental and vehicle - treated control eyes using student 's paired t - test for data sets with normal distribution and wilcoxon sign - rank test for nonparametric data sets . variations in daily iop are graphically presented as the mean daily iop of the vehicle and treated eyes . statistical calculations were performed using a statistical software package ( jmp ; sas institute , inc . , cary , nc , usa ) . for human anterior segment studies , the effect of latanoprost was expressed as the change in outflow facility ( c ) for each anterior segment . results from each pair of anterior segments were combined into a group mean for each drug , and statistical significance was analyzed using a student 's 2-tailed paired t test .", "preliminary findings from confluent primary human schlemm 's canal cell lines treated with latanoprost identified stc-1 , a secreted phosphoglycoprotein hormone with multiple functions , as a gene consistently upregulated following latanoprost treatment . quantitative pcr studies in human schlemm 's canal cells showed an 18.1 4.3-fold ( n = 3 ) induction . cell lysates isolated from latanoprost - treated primary human schlemm 's canal cells at various time points showed an increase of stc-1 protein expression of 1.9-fold at 2 hours and approximately 5.0-fold at 4 and 6 hours , correlating with increased mrna expression levels identified by qpcr ( fig . 1 ) . induction of stc-1 in schlemm 's canal cells following treatment with latanoprost . because of its multifunctional properties and ability to act in an autocrine and paracrine fashion similar to prostaglandin analogs , we examined the role of stc-1 in downstream signaling following latanoprost treatment in vivo using stc-1 mice and congenic wild - type controls . assessment of baseline iops for 6 days showed no significant difference between stc-1 mice ( 16.6 0.5 , n = 10 ) and wild - type controls ( 16.2 0.3 , n = 8 ; p = 0.1 ) . histologic examination of stc-1 mice by light and transmission electron microscopy showed a normal - appearing ocular anatomy , an open angle with appropriate trabecula within the trabecular meshwork , and intact inner and outer walls of schlemm 's canal , all similar to wild - type controls ( fig . , we proceeded to assess the effect of latanoprost treatment on iop in these mice . topical eye treatment with latanoprost ( 100 nm ) reduced iop in wild - type controls by 3.8 mm hg ( p < 0.001 , n = 8) , which correlated to a 22.0% 1.9% decrease in iop when compared to the fellow contralateral eyes treated with vehicle alone ( fig . consistent iop change was identified throughout the once daily dose as determined by iop pressure monitoring at 1 , 4 , and 23 hours after treatment ( table ) . in contrast , stc-1 mice did not show any significant reduction in iop after topical latanoprost treatment ( 0.5% 0.7% , p = 0.34 , n = 10 ) at any time point throughout the 7-day treatment regime . to determine if this was unique to latanoprost , we treated stc-1 with y27632 , a rho kinase inhibitor that increases outflow through both the uveoscleral and the conventional outflow pathway . treatment of either wild - type ( n = 10 ) or stc-1 ( n = 10 ) mice with y27632 resulted in significant reductions of iop , 12.5% 1.2% and 13.1% 2.8% , respectively ( p < 0.0001 , n = 10 ; fig . 4 ; table ) . these data suggest that stc-1 has a unique and key role in latanoprost signaling mediated iop reduction . top : light microscopy images of whole eye sections from wild - type and stc-1 mice . wild - type and stc-1 mice have similar - sized lens with both wild - type and stc-1 mice showing similar retinal morphology . middle : light microscopy images of wild - type and stc-1 mice showing conventional outflow pathway with open angles and similar number of trabecula , trabecular meshwork ( tm ) cells , and schlemm 's canal ( sc ) volume . bottom : transmission electron micrographs of wild - type and stc-1 mice showing similar appearing trabecular meshwork and intact schlemm 's canal inner walls ( iw ) and outer walls ( ow ) . the daily iop was recorded as the average of iop measurements at 1 , 4 , and 23 hours following latanoprost treatment . while congenic control mice show iop reduction with latanoprost , stc-1 do not , suggesting stc-1 is an important effector molecule for latanoprost - induced iop reduction . intraocular pressure in wild - type and stc-1 mice following treatment with latanoprost and rho kinase inhibitor rho kinase inhibitor y27632 reduces iop in stc-1 mice . n = 10 ) and congenic controls ( n = 10 ) were treated once daily with 10 mm y27632 . the daily iop was recorded as the average of iop measurements at 1 , 4 , and 23 hours following y27632 treatment . both stc-1 mice and congenic controls showed iop reduction following treatment with y27632 . to determine if stc-1 would influence iop reduction by itself , we perfused human anterior segments with several concentrations of recombinant stc-1 for 24 hours . perfusion with either 5 ng / ml ( 0.15 0.04 to 0.15 0.04 l / min / mm hg , n = 2 , p = 0.20 ) or 50 ng / ml ( 0.14 0.05 to 0.18 0.07 l / min / mm hg , n = 4 , p = 0.20 ) had no significant effect on outflow facility . however , all anterior segments perfused with stc-1 at 500 ng / ml had decreased pressure and increased outflow facility ( 0.15 0.03 to 0.27 0.09 l / min / mm hg , n = 5 , p = 0.02 ) compared to baseline ( fig . 5 ) . paired controls treated with vehicle showed no change in outflow facility from their baseline values . to determine whether the changes in pressure could be secondary to morphologic changes morphologic analysis showed viable and healthy cells in the trabecular meshwork and schlemm 's canal of control and treated eyes ( fig . no major disruptions of the juxtacanalicular tissue or the basement membrane of schlemm 's canal inner and outer walls were observed . these results indicate that stc-1 may be a molecule within the latanoprost signaling pathway that can be therapeutically targeted to lower iop . ( a ) outflow facility of human anterior segments ( n = 8) following perfusion with 5 , 50 , or 500 ng / ml of recombinant human stc-1 . ( b ) representative graph of an eye pair perfused with 500 ng / ml stc-1 . ( a , b ) representative sections ( 3 m ) of recombinant stc-1 and vehicle - treated eyes that were stained with toluidine blue . ( c , d ) transmission electron micrographs showing ultrastructure of recombinant stc-1 and vehicle - treated eyes . recombinant human stc-1 and vehicle - treated eyes had similar morphology and ultrastructural appearance suggesting no apparent detrimental side effects of recombinant stc-1 treatment . ac , anterior chamber ; jct , juxtacanalicular region ; tm , trabecular meshwork ; sc , schlemm 's canal . to determine if stc-1 has ocular hypotensive activity in vivo , wild - type c57bl/6 mice were treated with recombinant stc-1 ( 0.5 mg / ml ) or vehicle daily for 7 days ( fig . stanniocalcin-1 reduced iop by 15.2% 3.0% when compared to vehicle - treated contralateral eyes ( range of iop reduction from 5.1% 5.2% these results suggest that stc-1 has iop - lowering properties when used as a standalone agent . wild - type mice ( n = 10 ) were treated topically with recombinant stc-1 ( 0.5 mg / ml ) or vehicle ( phosphate buffered saline ) . the daily iop was recorded as the average of iop measurements at 1 , 4 , and 23 hours following stc-1 treatment .", "preliminary findings from confluent primary human schlemm 's canal cell lines treated with latanoprost identified stc-1 , a secreted phosphoglycoprotein hormone with multiple functions , as a gene consistently upregulated following latanoprost treatment . quantitative pcr studies in human schlemm 's canal cells showed an 18.1 4.3-fold ( n = 3 ) induction . cell lysates isolated from latanoprost - treated primary human schlemm 's canal cells at various time points showed an increase of stc-1 protein expression of 1.9-fold at 2 hours and approximately 5.0-fold at 4 and 6 hours , correlating with increased mrna expression levels identified by qpcr ( fig . 1 ) . induction of stc-1 in schlemm 's canal cells following treatment with latanoprost .", "because of its multifunctional properties and ability to act in an autocrine and paracrine fashion similar to prostaglandin analogs , we examined the role of stc-1 in downstream signaling following latanoprost treatment in vivo using stc-1 mice and congenic wild - type controls . assessment of baseline iops for 6 days showed no significant difference between stc-1 mice ( 16.6 0.5 , n = 10 ) and wild - type controls ( 16.2 0.3 , n = 8 ; p = 0.1 ) . histologic examination of stc-1 mice by light and transmission electron microscopy showed a normal - appearing ocular anatomy , an open angle with appropriate trabecula within the trabecular meshwork , and intact inner and outer walls of schlemm 's canal , all similar to wild - type controls ( fig . , we proceeded to assess the effect of latanoprost treatment on iop in these mice . topical eye treatment with latanoprost ( 100 nm ) reduced iop in wild - type controls by 3.8 mm hg ( p < 0.001 , n = 8) , which correlated to a 22.0% 1.9% decrease in iop when compared to the fellow contralateral eyes treated with vehicle alone ( fig . consistent iop change was identified throughout the once daily dose as determined by iop pressure monitoring at 1 , 4 , and 23 hours after treatment ( table ) . in contrast , stc-1 mice did not show any significant reduction in iop after topical latanoprost treatment ( 0.5% 0.7% , p = 0.34 , n = 10 ) at any time point throughout the 7-day treatment regime . to determine if this was unique to latanoprost , we treated stc-1 with y27632 , a rho kinase inhibitor that increases outflow through both the uveoscleral and the conventional outflow pathway . treatment of either wild - type ( n = 10 ) or stc-1 ( n = 10 ) mice with y27632 resulted in significant reductions of iop , 12.5% 1.2% and 13.1% 2.8% , respectively ( p < 0.0001 , n = 10 ; fig . 4 ; table ) . these data suggest that stc-1 has a unique and key role in latanoprost signaling mediated iop reduction . top : light microscopy images of whole eye sections from wild - type and stc-1 mice . wild - type and stc-1 mice have similar - sized lens with both wild - type and stc-1 mice showing similar retinal morphology . middle : light microscopy images of wild - type and stc-1 mice showing conventional outflow pathway with open angles and similar number of trabecula , trabecular meshwork ( tm ) cells , and schlemm 's canal ( sc ) volume . bottom : transmission electron micrographs of wild - type and stc-1 mice showing similar appearing trabecular meshwork and intact schlemm 's canal inner walls ( iw ) and outer walls ( ow ) . the daily iop was recorded as the average of iop measurements at 1 , 4 , and 23 hours following latanoprost treatment . while congenic control mice show iop reduction with latanoprost , stc-1 do not , suggesting stc-1 is an important effector molecule for latanoprost - induced iop reduction . intraocular pressure in wild - type and stc-1 mice following treatment with latanoprost and rho kinase inhibitor rho kinase inhibitor y27632 reduces iop in stc-1 mice . stc-1 mice ( n = 10 ) and congenic controls ( n = 10 ) were treated once daily with 10 mm y27632 . the daily iop was recorded as the average of iop measurements at 1 , 4 , and 23 hours following y27632 treatment .", "to determine if stc-1 would influence iop reduction by itself , we perfused human anterior segments with several concentrations of recombinant stc-1 for 24 hours . perfusion with either 5 ng / ml ( 0.15 0.04 to 0.15 0.04 l / min / mm hg , n = 2 , p = 0.20 ) or 50 ng / ml ( 0.14 0.05 to 0.18 0.07 l / min / mm hg , n = 4 , p = 0.20 ) had no significant effect on outflow facility . however , all anterior segments perfused with stc-1 at 500 ng / ml had decreased pressure and increased outflow facility ( 0.15 0.03 to 0.27 0.09 l / min / mm hg , n = 5 , p = 0.02 ) compared to baseline ( fig . 5 ) . paired controls treated with vehicle showed no change in outflow facility from their baseline values . to determine whether the changes in pressure could be secondary to morphologic changes morphologic analysis showed viable and healthy cells in the trabecular meshwork and schlemm 's canal of control and treated eyes ( fig . 6 ) . no major disruptions of the juxtacanalicular tissue or the basement membrane of schlemm 's canal inner and outer walls were observed . these results indicate that stc-1 may be a molecule within the latanoprost signaling pathway that can be therapeutically targeted to lower iop . ( a ) outflow facility of human anterior segments ( n = 8) following perfusion with 5 , 50 , or 500 ng / ml of recombinant human stc-1 . ( b ) representative graph of an eye pair perfused with 500 ng / ml stc-1 . p 0.05 . histologic analysis of human anterior segment ocular tissue following treatment with recombinant stc-1 . ( a , b ) representative sections ( 3 m ) of recombinant stc-1 and vehicle - treated eyes that were stained with toluidine blue . ( c , d ) transmission electron micrographs showing ultrastructure of recombinant stc-1 and vehicle - treated eyes . recombinant human stc-1 and vehicle - treated eyes had similar morphology and ultrastructural appearance suggesting no apparent detrimental side effects of recombinant stc-1 treatment . ac , anterior chamber ; jct , juxtacanalicular region ; tm , trabecular meshwork ; sc , schlemm 's canal .", "to determine if stc-1 has ocular hypotensive activity in vivo , wild - type c57bl/6 mice were treated with recombinant stc-1 ( 0.5 mg / ml ) or vehicle daily for 7 days ( fig . stanniocalcin-1 reduced iop by 15.2% 3.0% when compared to vehicle - treated contralateral eyes ( range of iop reduction from 5.1% 5.2% [ day 1 ] to 21.4% 5.3% these results suggest that stc-1 has iop - lowering properties when used as a standalone agent . wild - type mice ( n = 10 ) were treated topically with recombinant stc-1 ( 0.5 mg / ml ) or vehicle ( phosphate buffered saline ) . the daily iop was recorded as the average of iop measurements at 1 , 4 , and 23 hours following stc-1 treatment .", "prostaglandin analogs like latanoprost are a first - line medical therapy for iop reduction due to their once daily dosing , greater response rates , and greater amount of iop reduction compared to other classes of pressure - lowering medications . identifying the critical effector molecules in the signaling pathway of latanoprost will provide insights into additional molecules to target for iop reduction , potentially with fewer side effects . in the current study , we identified stc-1 as a transcript and protein that is highly induced following treatment of human schlemm 's canal cells with latanoprost . topical latanoprost significantly reduced iop in wild - type controls while stc-1 mice demonstrated no iop reduction to topical latanoprost . in contrast , rho kinase inhibitor y27632 demonstrated iop reduction in both wild - type and stc-1 mice , indicating that stc-1 is a unique and important downstream signaling molecule necessary for the ocular hypotensive properties of latanoprost . additionally , recombinant stc-1 by itself also increased outflow facility in human anterior segments and reduced iop in vivo in wild - type mice . together , these results suggest that stc-1 is a critical and unique effector molecule for the latanoprost signaling pathway that is necessary for latanoprost - induced iop reduction and that stc-1 by itself can act as an ocular hypotensive agent . stanniocalcin was first described in fish as a 50-kda homodimeric glycoprotein that is secreted from the corpuscles of stannius into the bloodstream in the setting of hypercalcemia to regulate calcium excretion at the gills and gut . in mammals , two homologues of stc stc-1 is the most studied of the two mammalian forms , having a 50% amino acid homology with its fish counterpart . stc-1 is a secreted , homodimeric phosphoglycoprotein that has preserved protein structure similarity between mammals and fish including the conservation of 11 cysteine residues . it is expressed in a wide variety of tissues most notably bone , skeletal muscle , heart , thymus , and spleen . functionally , stc-1 has been associated with calcium uptake , hypoxic preconditioning , and antioxidative stress properties through suppression of reactive oxygen species . additionally , stc-1 has also been shown to be neuroprotective for neurons , photoreceptors , and retinal ganglion cells , and has been linked to anti - inflammatory effects by inhibiting macrophage chemotaxis , modulating transendothelial migration of leukocytes and reducing t cell infiltration . in treating wild - type mice with topical latanoprost , we observed a reduction in iop by approximately 22.0% 1.9% , consistent with previous reports , while the stc-1 mice showed no response ( 0.55% 0.7% ) . mice that were stc-1 were responsive to rho kinase inhibitor y27632 , which confirmed that stc-1 mice have normal functioning outflow pathways , but that elimination of stc-1 expression in these mice renders topical latanoprost ineffective . the current study adds schlemm 's canal cells to the list of cells that express stc-1 and shows that its expression is highly influenced by latanoprost . this is an important finding as little is known about the molecular events that connect latanoprost treatment with iop reduction . latanoprost has been shown to phosphorylate myosin light chain kinase in the iris , indicating a role for latanoprost in cell relaxation . however , stc-1 is the first individual molecule that has been identified as a key downstream effector of latanoprost signaling . in addition to its variety of functional activities , our results also suggest that stc-1 has ocular hypotensive properties , since addition of recombinant stc-1 to human anterior segment cultures decreased pressure and increased outflow facility , and when applied topically to wild - type mice reduced iop in vivo . despite the benefits of latanoprost in lowering iop , long - term treatment with latanoprost can often cause significant side effects , which can be contraindicative for its prolonged usage . identification of stc-1 as a downstream signaling molecule through which latanoprost executes its iop - lowering effects , and the fact that recombinant stc-1 shows ocular hypotensive properties , makes this an attractive therapeutic target . utilization of a specific downstream molecule such as stc-1 within the latanoprost signaling cascade may eliminate some of the major side effects while providing a specialized therapeutic strategy . in summary , additionally , stc-1 demonstrates ocular hypotensive properties when used by itself , mimicking the effect of latanoprost . given its novel role in latanoprost - mediated iop reduction , stc-1 may be considered a promising candidate molecule for devising future therapeutic regiments to reduce iop ." ]

[ "single - crystalline kinked nanowires were synthesized by the nanocluster - catalyzed vls method described previously18,19 in quartz tube connected to gas manifold and vacuum pump and heated by a temperature controlled tube furnace . monodisperse gold nanoparticles ( ted pella ) were dispersed on sio2/si or sapphire growth substrates ( au surface coverage : 0.010.1 particles/m ) , which were placed within the central region of the quartz tube reactor . the silicon ( si ) nanowires were synthesized at 450460 c using silane ( sih4 ) as the silicon reactant source , hydrogen ( h2 ) as the carrier gas , and phosphine ( ph3 , 1,000 p.p.m . in h2 ) and diborane ( b2h6,100 p.p.m . in h2 ) as the n- and p - type dopants . in a typical synthesis of uniform n - type , 80 nm kinked silicon nanowires , the flow rates of sih4 , ph3 and h2 were 12 , 210 and 60 standard cubic centimetres per minute , respectively , and the total pressure was 40 torr and purge duration was 15 s ; the minimum pressure during the purge cycle was ca . 3 10 torr . the dopant feed - in ratios ( silicon : boron / phosphorus ) in kinked p - n silicon nanowires were 500:1 for both p - and n - type segments . in n - kink - n - kink-(n - n ) dopant modulated silicon nanowires , the silicon - phosphorus feed - in ratios were 200:1 and 10000:1 for n- and n - type segments , respectively , and the n- segment was grown for 30 s. germanium nanowires were synthesized at 270290 c , 40 torr , with germane ( geh4 , 10 % in h2 ) and h2 as the reactant and carrier gas , respectively . cadmium sulphide nanowires were grown in a three - zone furnace by evaporating cds power at 650720 c , with nanowire growth by gold nanocluster catalyzed vls method at 550 - 500 c . the purge cycle used to form kinks in the germanium and cadmium sulphide nanowires was typically 15 s. zeiss ultra55/supra55vp field - emission sems and jeol 2010 field emission tem were used to carry out sem and tem analyses , respectively . for sample preparation , kinked nanowires were gently sonicated in isopropyl alcohol and dispersed onto heavily doped silicon substrates ( 100 nm oxide/200 nm nitride , 110 cm resistivity , nova electronic materials , carrollton , tx ) or lacey carbon grids ( ted pella ) . devices were fabricated on silicon substrates ( nova electronic materials , n - type 0.005 cm ) with 100 nm thermal oxide and 200 nm silicon nitride at the surface . devices were defined by electron - beam lithography followed by ti / pd ( 1.5 nm/100 nm ) contact deposition in a thermal evaporator . current - voltage ( i v ) data were recorded using an agilent semiconductor parameter analyzer ( model 4156c ) with contacts to devices made using a probe station ( desert cryogenics , model ttp4 ) . electrostatic force microscopy and scanned gate microscopy measurements were carried out with a digital instruments nanoscope iiia multimode afm and metal coated tips ( nanosensors , ppp - nchpt ) . the electrostatic force microscopy surface potential maps and scanned gate microscopy conductance maps were acquired in lift mode with lift heights of 40 and 20 nm , respectively . in the surface potential measurements , the p - n diode was reverse - biased at 5 v and the tip voltage was modulated by 3v at the resonance frequency . in scanned gate measurements , the tip functions as a local gate vtip = 10 v , and the conductance versus position provides a measure of local accumulation or depletion of carriers in the device .", "single - crystalline kinked nanowires were synthesized by the nanocluster - catalyzed vls method described previously18,19 in quartz tube connected to gas manifold and vacuum pump and heated by a temperature controlled tube furnace . monodisperse gold nanoparticles ( ted pella ) were dispersed on sio2/si or sapphire growth substrates ( au surface coverage : 0.010.1 particles/m ) , which were placed within the central region of the quartz tube reactor . the silicon ( si ) nanowires were synthesized at 450460 c using silane ( sih4 ) as the silicon reactant source , hydrogen ( h2 ) as the carrier gas , and phosphine ( ph3 , 1,000 p.p.m . in h2 ) and diborane ( b2h6,100 p.p.m . in h2 ) as the n- and p - type dopants . in a typical synthesis of uniform n - type , 80 nm kinked silicon nanowires , the flow rates of sih4 , ph3 and h2 were 12 , 210 and 60 standard cubic centimetres per minute , respectively , and the total pressure was 40 torr and purge duration was 15 s ; the minimum pressure during the purge cycle was ca . 3 10 torr . the dopant feed - in ratios ( silicon : boron / phosphorus ) in kinked p - n silicon nanowires were 500:1 for both p - and n - type segments . in n - kink - n - kink-(n - n ) dopant modulated silicon nanowires , the silicon - phosphorus feed - in ratios were 200:1 and 10000:1 for n- and n - type segments , respectively , and the n- segment was grown for 30 s. germanium nanowires were synthesized at 270290 c , 40 torr , with germane ( geh4 , 10 % in h2 ) and h2 as the reactant and carrier gas , respectively . cadmium sulphide nanowires were grown in a three - zone furnace by evaporating cds power at 650720 c , with nanowire growth by gold nanocluster catalyzed vls method at 550 - 500 c . the purge cycle used to form kinks in the germanium and cadmium sulphide nanowires was typically 15 s.", "zeiss ultra55/supra55vp field - emission sems and jeol 2010 field emission tem were used to carry out sem and tem analyses , respectively . for sample preparation , kinked nanowires were gently sonicated in isopropyl alcohol and dispersed onto heavily doped silicon substrates ( 100 nm oxide/200 nm nitride , 110 cm resistivity , nova electronic materials , carrollton , tx ) or lacey carbon grids ( ted pella ) .", "devices were fabricated on silicon substrates ( nova electronic materials , n - type 0.005 cm ) with 100 nm thermal oxide and 200 nm silicon nitride at the surface . devices were defined by electron - beam lithography followed by ti / pd ( 1.5 nm/100 nm ) contact deposition in a thermal evaporator . current - voltage ( i v ) data were recorded using an agilent semiconductor parameter analyzer ( model 4156c ) with contacts to devices made using a probe station ( desert cryogenics , model ttp4 ) . electrostatic force microscopy and scanned gate microscopy measurements were carried out with a digital instruments nanoscope iiia multimode afm and metal coated tips ( nanosensors , ppp - nchpt ) . the electrostatic force microscopy surface potential maps and scanned gate microscopy conductance maps were acquired in lift mode with lift heights of 40 and 20 nm , respectively . in the surface potential measurements , the p - n diode was reverse - biased at 5 v and the tip voltage was modulated by 3v at the resonance frequency . in scanned gate measurements , the tip functions as a local gate vtip = 10 v , and the conductance versus position provides a measure of local accumulation or depletion of carriers in the device .", "" ]

[ "arachnoid cysts are benign , non - neoplastic and extra - axial lesions ; most of them are clinically silent and unchanged in size . in previous studies112131524 ) , the incidence of arachnoid cysts has been estimated to range between 0.3% to 1.7% . however , the advanced neuroimaging techniques have facilitated the diagnosis of arachnoid cysts , which , in turn , has led to an increase in the number of patients2121415 ) . in some cases , an arachnoid cyst arouses symptoms and its clinical presentations vary according to the size and location of the cyst . the most frequent symptom is headache , which is caused by the local mass effect , increased intracranial pressure ( icp ) , and/or hydrocephalus15 ) . above this , seizures , cognitive dysfunction , developmental delay , and intracranial hemorrhage can be also presented . in this report , we describe a case where a patient with a posterior fossa arachnoid cyst complained of visual field defect , visual disturbance , and mild headache ; no ataxia and unsteady gait were reported . the patient 's visual symptoms rapidly deteriorated in a week and , consequently , the patient 's vision got worse .", "a 39-year - old male patient presented at our emergency room after a traffic accident and the brain computed tomography ( ct ) scan indicated an incidental arachnoid cyst on posterior fossa . at that time , the patient complained only of facial abrasions and the left knee pain , but not of headache or visual disturbance . in eight months , however , he revisited our department of ophthalmology to check the decreased visual acuity , visual field defect , and headache . on the ophthalmologic examination , bilateral papilledema ( fig . 2a ) were found . after the transfer to the department of neurosurgery , we rechecked brain ct scans ( fig . the diameter of the patient 's arachnoid cyst did not change compared to the previous ct scans ; however , the slightly enlarged third ventricle was compressing the optic chiasm and the suprasellar area . since visual complications were expected , we recommended an emergency operation . one week later , he came back to the hospital with nearly complete visual loss . his right eye was completely blind , whereas his left eye recognized only light ( fig . a conventional suboccipital craniectomy was performed on the patient lying on the operating table in the prone position . after the dural incision , the arachnoid cyst was exposed and cystic fluid was expelled . arachnoid membrane was carefully dissected and the arachnoid cyst was fenestrated to cisterna magna for connecting with the cerebrospinal fluid ( csf ) flows . arachnoid membrane which covering the foramen of magendie was also fenestrated and the csf flows was running properly ( fig . 4 ) . excluding the brain tumor , the collected membrane was sent to the pathologic laboratory . in high power field microscopy under the hematoxylin and eosin stain , the cystic membrane was composed by membranous fibrocollagenous tissues without tumor cells . one week afterwards , we checked the brain ct scans and the removal of the cyst and the decreased ventricle size were confirmed . on the ophthalmologic examination , the papilledema and visual field were slightly improved ; however , the patient 's visual acuity did not improve . upon the tenth day after the operation , the patient was discharged and , during the next one month , he was subject to the steroid therapy . in five months after the operation , papilledema ( fig . nevertheless , visual acuity and visual field improved slowly and slightly ( fig . 2c ) . the blind right eye improved to recognize the light and the blurred left eye improved to acknowledge the silhouette of an object ; thus , it did not fully recovered to the prior , normal condition .", "their prevalence has been reported to amount to approximately 1% of all intracranial mass lesions112152430 ) ; however , advanced neuroimaging techniques and the widespread use of ct and mri imaging have led to an even higher incidence of report of these lesions1249121619203031 ) . one recent study , al - holou et al.1 ) , reviewed 48417 brain images and identified 661 ( 1.4% ) arachnoid cysts . this report found that the prevalence of arachnoid cyst in children was 2.6% , slightly higher than in adults , and men ( 1.8% ) have a high prevalence than women ( 1.1% ) . the most common locations were middle fossa ( 34% ) , retrocerebellar ( 33% ) , and cerebral convexity ( 14%)124 ) . despite the increased identification of arachnoid cysts , the natural history and mechanism of enlargement has not been well defined1131524 ) . nevertheless , when arachnoid cysts give rise to any symptom , headache is the most common complaint . in addition to headache , gait imbalance , seizure , and visual changes can also be presented according to the location and size of the arachnoid cyst . various operation techniques , such as cyst excision1517 ) , stereotactic aspiration1825 ) , endoscopic cyst fenestration512 ) , ventriculocystostomy26 ) , and cystoperitoneal shunt810152728 ) , have been introduced and the main purpose of such operations is similar , namely , a direct decompression of the arachnoid cyst or making the connection between the cyst and the csf flows for spontaneous resolution . generally , visual symptoms occur in the patients with suprasellar arachnoid cysts , because the arachnoid cyst is adjacent to the optic nerves7 ) . the patients with posterior fossa arachnoid cysts usually do not complain of visual symptoms , as the cyst is not adjacent to the optic nerves . however , a posterior fossa arachnoid cyst can indirectly disrupt the csf flows and , in turn , the disruption increases the whole ventricle size and the icp . in our case , the enlarged third ventricle was compressing the optic chiasm with cephalocaudal direction on the ct scan ( fig . the compressed superior part of optic chiasm led to the defect of inferior visual field ( fig . , visual acuity was affected by the papilledema , which was caused by the increased icp . consequently , both visual acuity and visual field were influenced by the posterior fossa arachnoid cyst . when the patient first visited our department of ophthalmology , his visual symptoms and headache were not severe and the patient could walk and drive . besides , the brain ct scan showed no changes as compared to previous ct scans , so we could not predict a risk of rapid deterioration . the patient 's refusal to have an operation and the surgeon 's wrong prediction delayed the appropriate on - time treatment ; ultimately , the patient 's vision was severely damaged during the critical seven days . after the operation , the patient 's visual acuity , visual field , and papilledema were slightly improved ; however , we regard that the patient 's vision will unfortunately not fully recover .", "unlike gait disturbance and ataxia , visual symptoms do not frequently occur in the patients with posterior fossa arachnoid cysts ; this is so because the cyst is located away from the optic nerves . however , the disruption of csf flows can indirectly induce visual symptoms and these symptoms can rapidly deteriorate . considering the results of our case , it should be emphasized that the patients with posterior fossa arachnoid cysts could develop a rapid neurologic deterioration . therefore , in the event of the development of symptoms , an early intervention or close observation are crucial ." ]

[ "these techniques include closed reduction , percutaneous pin reduction , intramedullary pin reduction with elastic stable intramedullary nailing or kirschner - wires ( k - wires ) , and open reduction with or without internal fixation . our goals for treatment are to avoid incision , reduce the fracture adequately with no reduction loss , and achieve good postoperative function . we performed a closed reduction with a percutaneous leverage technique and internal fixation method with k - wires to treat angulated radial neck fractures in children .", "from january 2011 to april 2013 , we treated 16 cases of angulated radial neck fractures in 12 boys and 4 girls . the types of fractures categorized by the obrien classification as follows : type i angulation < 30 ; type ii angulation > 60. among our patients , 5 had type ii and 11 had type iii fractures . the left side was affected in 9 cases , right side was affected in 7 cases . complications with ulnar olecranon fracture and medial epicondyle fracture were present in 3 cases and 2 cases , respectively . no blood vessel or nerve trauma was evident . the shortest time from trauma to surgery was 4 hours and the longest time was 6 days . a 1.6- or 2.0-mm k - wire was inserted from distal to proximal of the elbow percutaneously . in this procedure , the k - wire was inserted into the fracture site . the k - wire was used to lever the fracture and to orient the proximal part horizontally with the lateral condyle plane . was attained , two 1.2 mm k - wires were percutaneously inserted from the articular surface through the fracture site to the opposite cortex for fixation ( fig . the 3 cases with ulnar olecranon fractures were not treated because there was no obvious displacement . our research was approved by the biomedical research ethics committee of hong hui hospital , xian jiaotong university college of medicine . ( a ) the kirschner wire ( k - wire ) was inserted percutaneously into the fracture site . ( b ) the inserted k - wire was used as a lever to reduce the fracture . ( c ) one 1.2 mm k - wires was percutaneously inserted from the articular surface passing through the fracture site to the opposite cortex . typical case : femail , 12 years old , and right side . a long - arm cast or brace was used for 3 to 4 weeks after the procedures , with the elbow in 90 of flexion and the forearm in supination .", "a 1.6- or 2.0-mm k - wire was inserted from distal to proximal of the elbow percutaneously . in this procedure , the k - wire was inserted into the fracture site . the k - wire was used to lever the fracture and to orient the proximal part horizontally with the lateral condyle plane . was attained , two 1.2 mm k - wires were percutaneously inserted from the articular surface through the fracture site to the opposite cortex for fixation ( fig . the 3 cases with ulnar olecranon fractures were not treated because there was no obvious displacement . our research was approved by the biomedical research ethics committee of hong hui hospital , xian jiaotong university college of medicine . ( a ) the kirschner wire ( k - wire ) was inserted percutaneously into the fracture site . ( b ) the inserted k - wire was used as a lever to reduce the fracture . ( c ) one 1.2 mm k - wires was percutaneously inserted from the articular surface passing through the fracture site to the opposite cortex . typical case : femail , 12 years old , and right side . a long - arm cast or brace was used for 3 to 4 weeks after the procedures , with the elbow in 90 of flexion and the forearm in supination .", "cases were followed up for an average of 3 years 7 months ( range 2 years 6 months to 4 years 10 months ) . the postoperative reduction was assessed by roentgenograph within 1 week after surgery . no infection or nerve damage occurred in the short - term follow - up . no radial head necrosis or synostosis of the proximal ulna and radius was seen in the long - term follow - up . there was no disclosure of the epiphysis or valgus of the elbow during the follow - up . according to the metaizeau reduction classification , 12 cases were excellent , and 4 cases were good . according to the metaizeau clinical classification , 14 cases were excellent , and 2 cases were good . ( a ) the preoperative x - ray showed the severe tilt and displacement of radial neck . ( c ) the 2 years later follow - up x - ray picture showed the radial head normal .", "most authors agree that fractures with slight angulation should be treated conservatively , but severely angulated fractures ( > 60 ) require further treatment with different methods . the complications of these fractures reported in children include avascular necrosis , early physeal closure , elbow stiffness , periarticular ossification , and overgrowth of the radius head . the prognosis was not only related with the angulation of the radial neck fracture , but also with the age of the patient and extent of trauma . metaizeau suggested that a residual tilt above 10 to 15 at 10 to 12 years of age or 20 to 30 at a younger age could not be remodeled by growth . additionally , bernstein found that the determination of what constituted a significant angulation vari with the child 's age , with greater angulation degrees acceptable for younger children . the compression and impaction extends to the lateral side of radial neck upon radial neck fracture . the redisplacement will be accomplished easily only if it is immobilized by cast as there is no support from the lateral portion of the radial neck for the radius head after reduction . steinberg reported that 22 cases which occurred redisplacement in whole 28 cases which were immobilized by cast after reduction . one method uses an elastic stable intramedullary nailing to indirectly reduce and fix the fracture site . the other method uses an intramedullary k - wire to perform indirect reduction and internal fixation . the 3rd method uses a percutaneous k - wire to perform direct reduction and internal fixation . in comparing the 3 different methods , some authors recommended closed reduction and elastic intramedullary fixation to treat a fracture of the radius in children . however , we found that it was difficult to reduce the displaced radius head through rotating the distal part of the elastic intramedullary nail . this reduction approach usually requires an assistant to manipulate the percutaneous k - wire . it is challenging to fix the radial head with elastic intramedullary nail after a good reduction . the radial head was easily separated from the fracture site when penetrating with and rotating the nail . the functional lever arm was too long when the elastic intramedullary nail or intramedullary pin was used to fix the radial head . it was challenging to maintain a good position . there was no disclosure of the epiphysis or valgus of the elbow during the follow - up . trauma was minor and there was no interference with the blood supply of the radial head . there was no postoperative scarring and the patients and their parents were satisfied with outcome . the insertion site should be carefully selected to avoid damage to the deep branch of the radial nerve . the k - wires should be appropriately sized , with a diameter no greater than 1.5 mm . we usually choose 1.2 mm k - wires to prevent damage to the epiphysis .", "we recommend the percutaneous leverage technique during closed reduction and internal fixation using k - wires for the treatment of angulated radial neck fractures in children . this is a simple method with little trauma to the patient and a satisfactory clinical outcome ." ]

[ "cities around the world can look very different if you compare the living conditions for the residents . however , it is not only different cities that can have completely diverse standards of infrastructure and social security . living in the slums compared to more wealthy neighbourhoods , will expose the inhabitants to different risks . traditionally cities can offer many advantages compared to rural settings , but under certain circumstances they can rather be a health hazard . the rapid migrations of people to cities can lead to overcrowding , which can generate slums or shanty towns . these slums are characterized by poor housing , lack of fresh water , and bad sanitation facilities ( 2 ) . all of these shortages can be a threat to the residents health and be a possible breeding ground for infectious diseases . the location of slums are often outside of the city centres , in more hazardous locations and the population feels a lack of social and economic opportunities compared with other residents . in sub - saharan africa , 62% of the urban population in 2012 lived in shanty towns ( 2 ) . for example , in 2009 , 96% of the urban population in central african republic lived in these slums ( 6 ) . in kenya 's capital nairobi , 60% of the population lives in slums , and child mortality there is 2.5 times greater than other parts of the city ( 9 ) . the community and health care services have great challenges to provide the entire population with equal and adequate service . the collected parties need to be aware of the differences in threats with respect to infectious diseases , both at the local and governmental levels . infections have been linked to slums in dar es salaam , tanzania , with high population density and low income ( 10 ) . in several other countries , cholera incidence is the highest in urban regions with high population density ( 11 , 12 ) . differences in prevalence of asymptomatic carriers of antimicrobial drug - resistant diarrhoeagenic escherichia coli have also been found in brazil between slum settlements and more wealthy parts of the community 13 ) . the poor infrastructure in the slum can be a barrier for improvement , but at the same time targeted interventions for safer water and better sanitation facilities could potentially have a profound effect of the overall health . overcrowded housing in high - density populations in the slums can be a breeding ground for infectious diseases such as tuberculosis . the rate of tuberculosis has traditionally been higher in urban centres compared to rural ( 14 , 15 ) . studies in slum settlements in dhaka city , bangladesh , indicate a high prevalence of tuberculosis , which was almost twice as high compared to the overall national average and four times higher than the overall urban levels ( 16 . however , different patterns can be seen in different countries ; for example , in poland the rates of tuberculosis have shown only slightly lower incidence in rural population compared to urban , 21.9 per 100,000 versus 22.4 per 100,000 respectively ( 17 ) . tuberculosis in the united states has declined in the twentieth century , and several factors such as improved nutrition status , socioeconomic status , overall public health , and new drug regimens have been thought to play a major role . however , in the mid-1980s a resurgence occurred which reached its peak in 1992 , especially in urban areas among the homeless and incarcerated population ( 18 ) . the knowledge regarding symptoms , transmission , and prevention has been shown to be greater among the urban population in pakistan 's punjab province compared to the rural population . health - seeking behaviour was also better among the urban population , in the aspect of when to seek medical advice for early diagnosis and potential treatment ( 19 ) . information about infectious diseases and how they spread in the community can help the individuals to protect themselves , but knowledge about the slums and the infectious diseases panorama is also crucial for local physicians . they need to know how to look for the correct diagnosis , even if their diagnostic tools might be limited .", "the rapid influx of migrants can lead to overcrowding and local governments might not be able to provide safe housing , drinking water , and adequate sewage facilities , all of which are potential health hazards and must be taken into account for safe city planning . today more than half of the world 's population , almost 4 billion people , have access to piped water connected to their homes . since 1990 , well over 2 billion people have gained improved drinking water facilities , and almost 2 billion people have access to improved sanitation . however , more than 700 million people still lack access to improved sources of safe drinking water , and in sub - saharan africa half of the population lack such facilities . globally however , 1 billion people in the world still practice open defecation . in this group , 90% live in rural areas , but the actual amount of residents from urban settings is gradually increasing . between 1990 and 2012 , the group in urban settings which lacked sanitation actually significantly increased from 215 million to 756 million , which could be explained by population growth ( 20 ) . much of the hard work to improve sanitation facilities has benefited large population groups , but the rapid influx of new urban residents shows that there is still much hard work to be done . residents who are subject to overcrowding and who lack access to safe drinking water or proper sanitation can be more susceptible to soil - transmitted helminths ( 21 ) . these infections are among the most important causes of physical and intellectual growth retardation in the world and have a major impact on public health ( 22 ) . good hygiene practices and good sanitary conditions have lowered the prevalent levels of contamination . in the brazilian city of salvador , with a population of 2.5 million , an improvement of sewerage coverage from 26 to 80% of the households led to an estimated overall reduction of diarrhoeal diseases of 22% ( 23 ) . neglected tropical diseases can cause substantial health problems in developing countries , and some of these diseases have a faecal - oral transmission pathway . examples of such diseases could be schistosomiasis , trachoma , and soil - transmitted helminthiases . in many countries , however , the focus is on treatment by medication and not improved sanitation . the reason could be that it would be much more expensive to carry out the necessary infrastructural improvements ( 24 ) . safe drinking water and proper sanitary facilities must be taken into account in city planning . factors like this can potentially have a profound positive effect in lowering infectious diseases with a faecal oral route . one example of this is for chagas disease , which is a parasitic infection caused by the protozoan trypanosoma cruzi . an important mode of transmission is vectorial infected bites of triatomine bugs . living in close contact to domestic animals and poor hygienic habits chagas disease affects an estimated 8 million people every year , and is an important health challenge in latin america . in recent decades , progress has been made to reduce the burden of disease , by vector control , screening blood donors , improved housing , and epidemiological surveillance . chagas disease is a growing health problem in non - endemic areas because of population movements ( 26 ) . it is estimated that 300,000 individuals in the united states are infected ( 27 ) and the most affected country in europe , spain , is thought to have 45,00067,000 cases ( 28 ) . the example of chagas disease shows that physicians who practice in countries where the disease is not present must be aware of the travel history of the patient to connect the potential symptoms to the correct diagnosis . the environment in urban cities has proven to be favourable for the rat population ( rattus spp . ) and close encounters between rats and humans can lead to transmission of zoonotic infectious diseases . , rickettsia typhi , streptobacillus moniliformis , bartonella spp . , seoul hantavirus , and angiostrogylus cantonensis \n ( 29 ) . new york city has one of the largest populations of rats in the united states . it has been shown that encounters between rats and humans have been linked to proximity to open public spaces and subway lines , the presence of vacant housing units , and low education of the population ( 30 ) . information like this can be useful for health officials when they launch specific control initiatives . the changes in human population with increased urbanization and urban poverty has also altered our perception of some zoonoses linked to the rat population . leptospirosis has traditionally been perceived as a primarily rural disease , but the incidence in urban centres is increasing ( 31 , 32 ) . in chinese cities , the incidence of seoul hantavirus haemorrhagic fever with renal syndrome has been linked to urban growth , growing rat population , and increase rat human contact ( 33 ) . large megacities all over the world have large rat populations , but the surveillance and local knowledge seem to be inadequate . a better understanding of how to prevent uncontrolled growth in rat population can potentially lead to a decline of these zoonotic diseases .", "the growing trend of urbanization around the world has shifted some infectious diseases , which have traditionally been perceived as rural , to urban settings . the world health organization ( who ) has published a list of 17 neglected tropical diseases . several of them have now become a reality in the urban environment , these diseases are something the practicing physicians in these areas have to be aware of ( 34 ) . many of the diseases on the list are present in the developing world , which sometimes lack the opportunity to solve these problems by themselves . one of the neglected infectious diseases is lymphatic filariasis ( lf ) with 2 billion people at risk , and 394.5 million in urban areas . one of the main reasons is the lack of proper sanitation facilities ( 35 ) . lf still has its major impact in rural settings , but the increasing urbanization in the developing world has made lf an infectious disease that also has to be considered elsewhere . one of the parasite species wuchereria bancrofti has been located in many urban areas and has the potential for transmission in this environment . moreover , one of the vectors for the parasite is the mosquito culex quinquefasciatus , which thrives in these surroundings , especially in overcrowded areas with poor sanitary and draining facilities . however , within one city the transmission can vary substantially depending on the standard of the sanitary conditions . the mosquito vector culex spp can be found in large parts of central and south america , east africa , and asia ( 36 ) . another vector which has adapted to urban surroundings is the mosquito aedes aegypti , which is a key component for dengue transmission . dengue is on who 's list of neglected tropical diseases , and is on the rise worldwide . the number of infections has drastically increased in the tropical regions of the world in the last 40 years . recent studies have estimated 390 million cases each year , and the burden is the highest in india with one - third of all the new infections ( 37 ) . several factors have played a big role in the escalation , such as urbanization , globalization , and lack of mosquito control . aedes aegypti lay their eggs in artificial water containers made by humans , which is a key component in the urban transmission cycle . the adaption of dengue through its vector has made dengue an infectious disease on the clear rise ( 38 ) . thailand is a country with all four serotypes of dengue virus , and the epidemics of dengue haemorrhagic fever have shown a possible correlation to originate from the urban capital of bangkok and then spread geographically in an outward manner to more rural settlements and provinces . a model to understand this mechanism could lead to more effective use of the health systems in the affected areas ( 39 ) . dengue has become a global problem and is no longer restricted to the developing world . despite better knowledge , it seems tough to control the vector , which has adapted to the urban environment and living close to people . an efficient vaccine is not yet commercially available , but could be a powerful factor in the fight against the global dengue epidemic . often several different factors need to be favourable for a vector - borne disease to adapt to the conditions in an urban environment . for example , west nile virus ( wnv ) infection is an infectious disease which has become a reality in the urban environment . the primary vector is the mosquito culex pipens , which lay their eggs in water resources which are often man - made . however , for a successful transmission cycle wnv also need the american robin ( turdus migratorius ) , which has several broods per season and hatchlings are more susceptible to wnv infection than adult birds ( 40 ) . the county of dallas , texas , experienced an epidemic of wnv infections in 2012 . surveillance reports revealed 25% of the cases in the united states were found in dallas county ( 41 ) . it shows for a vector - borne disease to have a successful transmission cycle several different factors need to be in place to affect the human population . \n leishmaniasis is a disease caused by the protozoa leishmania , which affects 12 million and threatens 350 million people in 88 different countries . when rural migrants bring their domesticated animals to urban settings , often slums , they create favourable conditions for an urban transmission ( 43 ) . it has been shown that it is a growing health problem and the ongoing urbanization has contributed to the increase ( 44 ) . if the different vectors can adapt to the urban environment and man - made resources , the potential health implications can be of major concern . control programs and adequate surveillance is of importance , but in rapidly growing cities and slums it can be tough to implement such measures . emerging infectious diseases can also make the jump to stable transmission in the urban surroundings and surveillance of these can potentially prevent major health concerns and high cost for the health care services . who can play a major role in the fight for better control and knowledge . many of the countries in the developing world do not have the proper resources and the problem is not concentrated to one region , but is a global concern . numerous of the neglected tropical diseases play a major role in the developing world , which is currently experiencing a much faster pace of urbanization compared to the developed world . the who 's call for help is important and , for example , dengue is now turning into a global crisis . safe and targeted assistance can be a huge factor for overall health ; such assistance could be an effective vaccine or safe and easy vector control programs .", "the basis of large population groups in a restricted area can provide the perfect conditions for different epidemics . international travel has connected the world in the last century , and this mobility creates a potential threat of many emerging diseases . international tourist arrivals have shown an exceptional growth from 25 million in 1950 to 1,087 million in 2013 . according to the latest forecast from the world tourism organization , international tourism arrivals will continue to increase , and in 2030 the figure is expected to be 1.8 billion ( 45 ) . with the pace of modern travel , highly contagious infectious diseases can be a potential threat in a completely different setting compared to the original outbreak . urban population and the density of residents can meet the criteria for a new epidemic and create a public health disaster , if not taken seriously . international trade and travel can potentially also contribute to the occurrence of a worldwide pandemic . sars is thought to originate from the sars - like coronavirus ( scov ) of bats and reached the human host in china due to hunting and trading of bats for food ( 46 ) . investigations have found this scov from the himalayan palm civets in live - animal markets in the region . the first cases of sars reportedly occurred in individuals who handled these animals to prepare exotic food , and the virus is thought to have crossed over to their human host ( 47 ) . it spread in urban dwellings in large cities and in well - equipped city hospitals . public fear of travelling led to considerable economic losses that affected entire countries ( 48 ) . the example of sars shows that food markets in southern china can be the origin of a worldwide health crisis . travel routes around the world have connected the urban world and large megacities like never before . accordingly it is important to take necessary preventive measures before the epidemic gets out of control , and here big organizations like who , but also governments , play an important role . early action is of utmost importance , and functional surveillance programs needs to be in place . the zoonotic disease dengue is endemic in most tropical and subtropical regions , which often are also popular tourist destinations . the burden of disease is on the rise , and estimations are that in returning travellers from southeast asia , dengue is now a more frequent cause of febrile illness compared to malaria ( 49 ) . dengue is now an urban health problem , which is one of the major reasons why the rise is exceptional . the worldwide spread of certain antibiotic resistant staphylococcus aureus has been linked to tourism , which shows the potential impact on international health ( 50 , 51 ) . faecal colonization with esbl - producing enterobacteriaceae has also been linked to international travellers in several studies ( 5254 ) . the physician needs to take into account the recent travel activities of the patient to better evaluate the current condition and need for potential treatment and care . global travel shows no signs of decline and the interconnected megacities around the world make global surveillance even more important when it comes to contagious infectious diseases . measurements to stop the spread need to be taken at the original location , but knowledge about the specific disease needs to be passed on to the global community and local health workers in other parts of the world . this global surveillance and alert system needs to be fast and efficient to , if possible , reduce the impact . the expected rise of travel makes it critical for the future global health and the possibility to react in time for possible threats .", "rapid and sometimes uncontrolled urbanization can , in certain circumstances , lead to closer encounters with wildlife . human influence on the ecosystems creates meeting points for new and potential zoonotic diseases , which could have a profound impact for both local and global health . new housing in the outskirts of big cities can potentially be meeting points for new and already known zoonotic diseases . of 335 emerging infectious diseases , which have been recognized between 1940 and 2004 , more than 60% have been zoonotic diseases ( 55 ) . living in close contact to domesticated animals and hunt for bush - meat can also be risk factors for an infectious disease to make the jump from the animal host to humans . major deforestation creates closer contact between humans and bats and even primates , who can potentially be host for new viruses . a better understanding , surveillance , and prevention of zoonotic diseases would be of great value , to both prevent and manage this upcoming threat for global health . hot spots for this transmission have been found and they often correlate where the process of urbanization is on the clear rise ( 56 ) . even if it is not always the urban population who is at the front of new encounters with wildlife , it can still have an effect on urban health . the trend of people moving to cities are at the highest , where many of these new encounters with ecosystems take place , and infectious diseases can be introduced to these growing urban environments . the sometimes uncontrolled growth of cities pushes residents to untouched ecosystems when new housing expands . ebola virus disease ( evd ) has had a profound impact on the world in 2014 . since the spring of 2014 , the hub of the epidemic has been the three countries in western africa : sierra leone , liberia , and guinea . it all began in december 2013 in guinea , in the providence of guckdou , in the eastern rainforest region . the disease transmission in the capital of conakry is thought to be the first major urban setting for evd ( 57 ) . who was first notified of the evd outbreak in march 2014 , and on august 8 , the who declared the current situation as evd outbreaks in central africa had been limited in size and geographical spread to a few hundred persons , mostly in remote areas and not large urban settings ( 59 ) . the centre of the epidemic ( guinea , liberia , and sierra leone ) has , as many of their neighbouring countries , a large population living in rural settings ; only 36 , 49 , and 40% of their population live in urban centres ( 6062 ) . the population is , however , highly interconnected in these countries with travel and cross - border traffic , with good road access between rural and urban settings . these communications have made the magnitude of the evd epidemic possible . despite cases of evd in nigeria and lagos , a megacity with 20 million inhabitants , the transmission has been limited , which proves that implementation of control measures can limit the transmission ( 63 ) . the mortality rate has been high in previous outbreaks , up to 90% ( 64 ) . the fatality rate in the west africa epidemic has been estimated to around 70% for guinea , liberia , and sierra leone when data for patients with recorded definitive clinical outcomes ( 63 ) . this unprecedented epidemic points out the importance of better surveillance , understanding , and preventions measures for this potentially deadly virus . ebola virus ( ebov ) is thought to be a zoonotic disease , and fruit bats are under investigation to be the natural reservoir . ebov sequences have been found in these animals near the human outbreaks which implies where the virus might originate from ( 65 , 66 ) . closer contact with humans and fruit bats are thus risks for a new global health crisis and the severity of an ebola epidemic has already been witnessed . the high costs , both from an economic and overall health perspective , have affected entire countries and have even cost lives on the other side of the earth .", "different factors , such as education , direct primary care services , and the governments capacity for rapid response to upcoming health threats , can contribute to the opportunities in a city . however , in many cities the poor can find it difficult to access proper health care , due to the cost of such services . in more rural areas , the problem can instead be the distance to the nearest clinic , which in reality makes it impossible for prompt and efficient treatment ( 2 ) . malaria has historically been and is still a major health concern in large parts of the world . who estimates 198 million cases ( 124283 million ) of malaria and 584,000 deaths ( 367,000755,000 ) in 2013 . the highest mortality rates have been shown to be closely linked to poor countries with a low gross national income ( gni ) per capita ( 67 ) . estimations have been made that nearly 25% of the total african population , 200 million , currently live in urban settings where malaria transmission is a reality . the annual incidence is estimated at 24.8103.2 million cases of clinical malaria among the urban population in africa ( 68 ) . the relationship between the malaria mosquito vector and the human host determines the burden of morbidity and mortality . this interface is dependent on many different factors and the degree of urbanization is an important one . increased urbanization and decreased transmission have correlated in several different studies ( 69 ) . however , whether it was the increased urbanization that led to a reduction in transmission or the malaria reduction that led to development that promoted urbanization of societies is a challenge to determine ( 70 ) . a clear connection has been shown between reduced transmission of plasmodium falciparum and urbanization ; however , for plasmodium vivax it is less obvious . for p. vivax , a connection has been found globally and in asia and africa ; inconsistent results , however , were found in the americas . several possibilities could explain these incoherent results , such as more widespread transmission of p. vivax , lower transmission intensity , the wide distribution in asia , and high prevalence of duffy negativity in africa , which protects against p. vivax \n ( 71 ) . the overall decrease of the burden of malaria has been a positive effect of urbanization , but the exact mechanisms are not yet known . coverage of measles vaccination in indonesia have shown to be 68.5% in rural areas , compared with 80.1% in urban regions ( 72 ) . studies in nigeria have shown that sometimes the coverage can actually be better in more rural areas , and it might be explained by better mobilization and participation in the delivery of immunization services ( 73 ) . in a study in uganda , 58% of the urban group compared to 53% in the rural areas were fully immunized , but polio vaccine was given to 51% in the urban group and 52% in the rural group ( 74 ) . immunization coverage can also vary considerably among different settings , not only between rural and urban surroundings , but also between urban , rural , and slum settlements . in changdigarh , a union territory of india , full immunization of children at the age of 2 was 30% in slums , 74% in urban , and 62.5% in rural settings ( 75 ) . it shows that there can be a wide variety of reasons for immunization status among the population in different regions and countries of the world . high coverage can prevent epidemics in large cities and save many lives ; however , immunization needs to be available both for the rural and urban population to achieve the greatest benefit . a study in tanzania has compared the knowledge about certain zoonotic diseases among general practitioners in urban and rural areas . the rural practitioners had poor knowledge of how sleeping sickness is transmitted and clinical features of anthrax and rabies . laboratories in rural areas are often poorly equipped and can not always diagnose certain zoonotic diseases , which could limit the doctors capability for correct diagnosis and treatment ( 76 ) . the knowledge about sexually transmitted diseases ( stis ) among bangladeshi adolescents was higher among people in urban areas compared to rural , both in general and hiv and aids ( 77 ) . the same results about hiv and aids have been found among a canadian population ( 78 ) . studies in chengdu and shanghai , china , have shown risk perception about stis and hiv and aids is profoundly changed in rural - to - urban migrants ( 79 , 80 ) . the same result has been shown in a study among rural - to - urban migrants in ethiopia 81 ) . the rapid influx of migrants moving to cities makes it hard to get adequate information to all the different groups in the society . to educate the public is one of the many challenges for local governments and health officials . campaigns to improve the public knowledge are useful to fight the threat of infectious diseases . residents need to be aware of symptoms of infectious diseases to gain knowledge about when to seek health care and when it is safe to treat yourself . knowledge about food storage , waste management , vector control , and sanitary facilities are all aspects that can lower the burden of communicable diseases . these campaigns can sometimes be easier in the urban environment because of the density of the population .", "urbanization is an ongoing process in the world at the moment , but the pace of the process is not universal . the developed countries , which have traditionally been thought of as high - income countries , are already urbanized , and it is in the developing world that the rapid rise is taking place . infectious diseases still have a big impact on the global health , and urbanization is now altering the characteristics of these diseases . living conditions in cities are overall better in urban environments compared to rural settings ; better housing , sanitation , ventilation , and social services all play an important role in this improvement . certain pathogens can , however , adapt to the different conditions and thus create a new challenge for both local governments and the global community . the capacity for surveillance , control programs , prevention , and public knowledge programs is far better in cities . but some countries do not have the resources and because these diseases can be of global concern , it is also the international community 's responsibility to help and support with knowledge and resources . the rapid urbanization has also interfered in previously untouched ecosystems . these new settlements create new and closer encounters with wildlife , which can be a potential source of zoonotic diseases . these can be both previously known or new pathogens , which make the shift from their animal host to generate infections in humans . surveillance is of primary importance to monitor the burden of disease and will give both local authorities and the global community a chance for a quick response to public health threats .", "the author have not received any funding or benefits from industry or elsewhere to conduct this study ." ]

[ "inadequate blood flow to the brain , termed cerebral ischemia , will produce brain injury and a progression of pathophysiological responses associated with energy depletion that include cell swelling , cytotoxic edema , vasogenic edema and if sufficiently severe or prolonged , neuronal cell death . when brain regions are directly damaged by ischemia this can lead to secondary injury or degeneration in associated axonal connections such as the corticospinal tracts . detection of such changes on early subacute diffusion mri have been described as early or such early signs of wallerian degenerative injury are predictive of specific functional outcomes and may improve prognostication , guide rehabilitation , and could represent both a selection criteria and potential novel target for clinical trials . in particular , if there is diagnostic evidence for early degenerative injury , such as increases in the intensity of the corticospinal tract in diffusion weighted magnetic resonance ( mr ) images , then prognosis for a good recovery in such infants has consistently been poor ( domi et al . , 2009 ; understanding better the cellular responses that evolve with axonal degeneration following stroke are important considering both their potential contributions to diagnosis and the potential for providing novel targets for therapeutic intervention . currently , the tissue alterations underlying these mr biomarkers are unknown and speculative because histopathology , if available , is usually performed at single and relatively chronic time points many weeks to months after an ischemic insult . studies of the evolution of ischemic brain damage or infarction at subacute and chronic times has been assessed using standard mr imaging sequences such as t2 or diffusion weighted imaging ( latchaw et al . , 2009 ) . we recently demonstrated that following neonatal hypoxia with unilateral transient ischemia there is evidence for early wallerian degeneration visible as either decreases in the apparent diffusion coefficient ( adc ) and magnetization transfer ratio or increases in dw or t2 ( lama et al . the early corticospinal axonal changes ( e.g. in the cerebral peduncle ) reflected several cellular alterations such as a reduced staining for phosphorylated neurofilament h and increased vacuolation in hematoxylin and eosin stained sections . dti holds additional promise for detecting specific degenerative responses because of its potential sensitivity to certain ultrastructural cellular changes depending on the measured dti parameter i.e. fractional anisotropy , mean diffusivity and parallel or radial diffusivity . of the extensive cellular responses produced by ischemia , those considered most likely to affect the diffusion properties of water are those that involve morphological tissue changes such as necrosis , astrogliosis , loss of myelin , loss of axonal neurofilaments or cellular inflammation ( i.e. microglial / macrophage activation ) ( nucifora et al . , 2007 ; zhang et al . , 2012 ) . our group and others have shown that corticospinal tract dti alterations are strongly correlated with motor outcome in children with perinatal stroke ( hodge , 2013 ; roze et al . however the progression of dti changes and whether there are differences between the evolution of cellular responses in direct ischemically injured brain versus associated connected tracts is not known . differences are expected considering the different cellular compositions , for example neuronal rich cerebral cortex compared to axonal bundles within the descending corticospinal tract . a differential timing of dti alterations is also expected considering direct ischemic injury is thought to be followed by a delayed wallerian degeneration ( lama et al . , 2011 ; tuor et al . , 2013 ) . in order to better understand the unique cellular and dti imaging alterations associated with secondary wallerian degeneration relative to the onset and progression of direct ischemically damaged brain , it is necessary to compare their progression directly at multiple time points . in the current study we hypothesized that dti imaging would provide measures of progressive tissue changes within axonal tracts distal to the ischemic injury distinct from those in directly injured brain ( e.g. cerebral cortex ) and these differences would correspond with specific tissue morphological alterations in response to ischemia this was investigated by using a neonatal rat model of unilateral transient cerebral hypoxia ischemia and measuring dti changes in the parietal cerebral cortex compared with its associated descending corticospinal tract axon fibers within the cerebral peduncle . dti measurements were made at acute , subacute and chronic times after hypoxia ischemia along with processing of brains at each of these time points to assess immunohistochemically potential contributions of morphological modifications . we focused on using markers for detecting cell death in neurons , loss of myelin and loss of neurofilaments in axons , and , activation of astrocytes and microglia / macrophages .", "fifty one pups delivered from 9 different pregnant wistar female rats ( charles river laboratories , montreal , canada ) were used in the study . experiments followed the canadian council on animal care guidelines and were approved by a university of calgary animal care committee . a moderate unilateral ischemic lesion with hypoxia ( vannucci and vannucci , 2005 ) was produced as described previously ( lama et al . briefly , pups ( n = 38 ) on their 7th day of life had their right common carotid artery ligated under isoflurane anesthesia followed by a 60 minute exposure to hypoxia in a chamber containing 8% o2 and 92% n2 at 35.5 c . sham control animals ( n = 13 ) experienced a similar surgical procedure without carotid artery ligation and hypoxia exposure . the vannucci model of neonatal cerebral hypoxia ischemia ( vannucci and vannucci , 2005 ) produces ischemic damage and infarction within the distribution of the middle cerebral artery territory . thus , the parietal cortex was selected as a representative brain region of direct hypoxic ischemic damage or infarction . the posterior cerebral peduncle supplied by the posterior circulation was selected as a region of secondary injury remote to the hypoxia brain near the aqueduct in the posterior pons was selected as a control region generally unaffected by the hypoxia ischemia . sham animals or animals subjected to cerebral hypoxia ischemia were anesthetized ( 1.52% isoflurane ) and dti images in addition to anatomical scans were acquired at 3 h , 1 d , 2 d , 1 w or 4 w post - insult . anatomical images were also acquired at 1 d post insult in the chronic animals ( 1 or 4 w ) to confirm the extent of ischemic damage . mr images were acquired using a 9.4 t bruker biospin mr imaging system and paravision 5.1 software . throughout the scanning , respiration was monitored and maintained by adjustments in anesthesia and body temperature was maintained using a feedback heated air system ( small instruments inc . , stony brook , ny ) . images were acquired using a 3.5 cm diameter quadrature volume coil for radiofrequency transmission and reception . the head and body was restrained using custom designed swaddling and a head band or ear pins . depending on the age of the animal , each mr imaging scan consisted of 2530 slices of 0.50.55 mm thick covering the cerebrum and medulla , a 2 2 cm or 2.5 2.5 cm field of view and a data matrix size of 128 128 . anatomical t2 maps were first generated using a t2 imaging sequence consisting of a set of t2 weighted spin echo images with 32 echoes , repetition time of 10 s and echo time of 10 ms between echoes . for dti , a four - shot echo - planar imaging sequence was used to acquire four averages of sets of diffusion weighted images . these were acquired with b values of 0 ( 5 images ) and 1000 s / mm ( 30 images in non - collinear directions ) using a repetition time of 6500 ms and an echo time of 35 ms . artifacts associated with imperfections in the radio frequency pulse , gradient stability , and gradient echo currents were removed using a navigator - echo phase correction . nyquist ghost artifacts were suppressed in the image reconstruction using information acquired during the initial automatic receiver gain adjustment . dti image acquisition time was approximately 1 h. t2 weighted images were visualized using local mr analysis software ( marevisi , national research council of canada , winnipeg , canada ) . these images were used to assess the extent of ischemic damage and measure brain volumes ( atrophy ) . inspection of t2 images was also used to exclude from further analysis animals with no cortical t2 lesions or very large hyperintense lesions extending into the pons . they were also used to identify anatomical landmarks for selection of the regions of interest in subsequent dti analysis and histological analysis as identified using a rat brain atlas ( paxinos and watson , 1998 ) . these regions of interest were manually defined in the mr images and histological sections and included the cerebral peduncle ( 0.30.4 mm ) , pons ( within the central gray and mesencephalic trigeminal nucleus regions , 0.60.9 mm ) and parietal cortex ( 0.71.0 mm ) for areas both ipsilateral and contralateral to the lesion containing hemisphere . once the ischemic infarct had progressed towards cavitation and cyst formation ( i.e. 1 and 4 w post - hypoxia ischemia ) , homologous measures of cortical tissue were not possible and therefore were taken adjacent to the cyst a peri - cyst cortical region ( 0.40.6 mm ) . sizes and shapes were adjusted using the contralateral region ( e.g. cerebral peduncle ) as a guide and areas of interest were adjusted if there was atrophy in order to minimize partial volume effects . diffusion tensor images were imported into dti studio ( jiang et al . , 2006 ) through the dti mapping function as philips rec files . entire scans were excluded if less than eighteen artifact free images were available per slice . the minimum of eighteen directions was selected empirically as the cut - off following an analysis of 12 test data sets with repeatedly fewer b directions ( e.g. 25 , 22 , 20 , 18 , 16 and 15 compared to 30 ) which demonstrated no significant effect of a reduction in the number of b directions except for fa and l3 ; and , those were altered only once the number of directions was 16 or less ( p < 0.05 , repeated anova ) . for each image slice the dti program calculated the over - determined matrix , the adc vector and the pseudo - inverse of the matrix using singular value decomposition in order to compute the tensor for each pixel ( jiang et al . , 2006 ) . imaging maps were then calculated for the mean diffusivity ( adc ; ( 1 + 2 + 3 ) / 3 ) , the parallel diffusivity ( 1 ) , the radial diffusivity ( ( 2 + 3 ) / 2 ) and the fractional anisotropy ( fa ) . measures of the dti variables were obtained within regions of interest manually drawn ipsilateral and contralateral ( non - ischemic damaged side ) of the brain slice . following their last mr scan , subgroups of animals were perfused transcardially with 10% formalin under deep pentobarbital anesthesia and their brains were embedded in paraffin . brains from 44 rats were processed and stained for 5 different cellular or injury markers within sections containing the parietal cortex , posterior cerebral peduncle and central gray region of the pons . thirteen of these animals were sham controls and 31 were animals subjected to hypoxia ischemia and euthanized at the 5 different times post hypoxia ischemia ( n = 47/group ) . sections ( 6 m thick ) were cut at the level of the posterior cerebral peduncle and parietal cortex using the brain atlas and anatomical landmarks to match sections to the mr slices and measure staining changes in equivalent regions of interest to those for the mr images . sections from each region were stained for a marker of cell death or degenerating neurons using fluorojade b ( schmued and hopkins , 2000 ) according to the manufacturer 's instructions ( millipore , billerica , ma , usa ) . briefly , deparaffinized sections were exposed to 0.06% potassium permanganate for 15 min washed in distilled water and then stained with 0.0004% fluorojade solution . sections at each level were also processed immunohistochemically to stain for the following : neurofilaments using a pan - axonal neurofilament marker ( monoclonal smi312 ) , reactive astrocytes using anti - glial fibrillary acidic protein ( gfap ) , activated microglia / macrophages using anti - cd68/ed1 , and , myelin using an antibody against myelin basic protein ( mbp ) . sections were deparaffinized and processed for antigen retrieval by boiling in sodium citrate ( ph = 6.0 , 90 c ) for 10 min then washed in pbs . slides were subsequently blocked with 1% h2o2 in methanol for 5 min followed by 10% goat serum in 0.1 m pbs and then a pbs wash . slides were then incubated for 1 h at room temperature with one of 4 different primary antibodies : smi312 antibody ( 1:1000 in bsa , covance , berkeley , ca , usa ) , polyclonal rabbit anti - gfap ( 1:500 in bsa , diagnostics canada inc . , on , canada ) , mouse anti - rat cd68/ed1 ( 1:500 in bsa , abd serotec , raleigh , nc , usa ) or rabbit anti - mbp ( 1:500 in bsa , chemicon international , ca , usa ) . following a pbs wash , slides were incubated overnight at 4 c with the appropriate secondary antibody , either biotinylated goat anti - rabbit igg or biotinylated goat anti - mouse igg ( 1:400 in bsa , jackson immunoresearch lab inc . this was followed by incubation for half an hour with horseradish peroxidase - streptavidin ( 1:400 in pbs , diagnostics canada inc . , on , canada ) . finally , positive cells were visualized following an application of 3,3-diaminobenzidine ( sigma aldrich , mo , usa ) dissolved in 0.3% h2o2 in distilled water for approximately 3 min . the histological sections were assessed semi - quantitatively for changes in staining within the regions of interest either by measuring optical density or by quantifying numbers of positively stained cells per field of view . for optical density measures , sections stained with either smi312 , gfap or mbp were first captured digitally using a scanner ( nikon scan , version 4 , nikon inc . ) . these images were converted to gray images and mean gray levels ( imagej , nih ) were measured within the same regions of interest as those drawn for the mr brain slices . regions with less intense staining had higher mean gray values . the ipsilateral versus contralateral differences in gray levels were converted to a percentage of the contralateral value . the cd68/ed1 and fluorojade stained sections were analyzed using digitized microscopy ( microbrightfield , olympus , 40 magnification ) . the numbers of positively stained cells per field of view were estimated within regions corresponding to those selected from mr images . three different fields of view were counted for positive staining cells by an investigator ( m.s . ) all group data is reported as mean sd and statistical comparisons were considered significant at p < 0.05 . measured values within different brain regions a two way repeated analysis was used to determine significant region and time interactions and these were followed by a holm statistical tests were performed using sigmaplot ( systat software inc , san jose , ca ) . to convey clearly the differences for the cerebral peduncle , we noted in the graphs only the significant differences for this region . the correlation between histological changes and dti parameters was assessed using a pearson product correlation analysis within each time point or all time points with a bonferroni adjustment for multiple comparisons .", "despite intensive investigation of dti 's ability to detect brain injury , the interpretation of alterations in dti measures is usually speculative because of a lack of direct documentation of the corresponding histological changes . in the present study we report detailed differences in the progression and magnitude of dti and histological changes that provide a reference for identifying the potential contribution of various cellular responses to fa and axial , radial and mean diffusivity . the results are first to characterize the correspondence of the progression of cellular and dti changes within the cerebral peduncle of the descending corticospinal tract following hypoxic ischemic damage to the cortex . novel is the demonstration of the differing progression of dti alterations in a directly damaged ischemic region such as parietal cortex versus that in associated subcortical tracts . dti changes were less severe or delayed in the cerebral peduncle of the corticospinal tract and this in general corresponded to less severe and delayed cellular responses consistent with early wallerian degeneration . as discussed in more detail , the tissue alterations following ischemia and axonal degeneration had a complex relationship with changes in fa , parallel diffusivity and radial diffusivity . regarding our assessment of progressive changes in the dti parameters , it is important to realize that superimposed on the effects of hi injury are well recognized developmental changes in the dti parameters that occur during development and aging ( dubois et al . , 2013 ) . indeed , the contralateral hemisphere was similar to those in sham animals but developmental changes may have been differentially affected in the left and right hemispheres by the ischemic insult . right differences needs to include an awareness that these can be accounted for by an injury modulation of cellular maturation processes in white matter , which we assessed in our histological sections . the region of cerebral peduncle measured was approx 0.30.4 mm consisting of approx 10 pixels of sizes 0.024 mm in the neonatal scans and 0.038 mm in 5 wk old animals . partial volume effects could be greater in neonatal brain than older brain . however , because we compared left and right differences in values , we expect that there were similar ipsilateral and contralateral partial volume effects in the cerebral peduncle at each time point . right differences but this did not appear to be an issue considering that many of our measures had the maximal changes in our neonates ( e.g. 1 d post insult ) . there have been numerous studies regarding the evolution of adc or mean diffusivity following transient cerebral ischemia in regions of stroke . adc alterations reported previously are comparable to those observed presently ( e.g. lama et al . , 2011 ; liu et al . , 2007 ) . notably , there were striking similarities between the adc and parallel diffusivity changes suggesting that both reflect similar cellular responses to injury . very early adc and parallel diffusivity changes in ischemic cortex are likely due to a greater restriction of water diffusion as a result of cytotoxic edema , reduced extracellular space and increased tortuosity which in the present study was also accompanied by decreased neurofilament staining and increased neuronal cell death . as vasogenic edema and damage to cellular membranes proceeded , which histologically corresponded to a continuing cell death and microglial / macrophage activation and astrogliosis , the reductions in adc and parallel diffusivity normalized and this process occurred over several days . by 14 w , phagocytosis produced cysts in the infarct region and such cystic regions had an extremely large adc in all directions whereas peri - infarct regions generally had normalized adc and normalized parallel diffusivity despite the presence of inflammatory cells . in contrast , in the cerebral peduncle with indirect ischemic injury , by the first 3 h there were modest but significant adc and parallel diffusivity reductions . the hyperacute changes in adc and parallel diffusivity correspond to our previous observation of a reduction in smi31 , demonstrating a decrease in phosphorylated heavy neurofilament subunits already hours after insult . subsequently , the adc and parallel diffusivity reductions increased in magnitude and were maximal in the first few days . this corresponded well with the diminished staining observed for the pan - axonal ( heavy , medium and light ) neurofilament marker smi312 used presently . loss of phosphorylation of neurofilaments promotes their disassembly and this corresponded to a decreased radial diffusivity as well as a decreased parallel and mean diffusivity of water . at chronic time points post - insult ( 14 w ) , a similar greater sensitivity for parallel diffusivity than adc in detecting wallerian degenerative changes in the corticospinal tract has been reported after an excision lesion of the feline cortex ( qin et al . , 2012 ) . microglial / macrophage cell activation likely did not contribute greatly to the parallel diffusivity alterations observed , considering the rather modest positive ed1/cd68 staining observed in the cerebral peduncle . the occurrence of astrogliosis coincided with normalization of adc potentially contributing to some extent to these changes . however , as discussed below , there were also ipsilateral increases in radial diffusivity that likely contributed to the adc normalization . reductions in radial diffusivity have been proposed to reflect well increases in myelin whereas elevations in radial diffusivity have been found to be associated with a loss of myelin ( song et al . , 2002 , 2004 ; the current study provides some support for this if one examines only chronic recovery times i.e. times when the axons in the contralateral cerebral peduncle have become well myelinated . at 1 w and beyond , myelin within the cerebral peduncle ipsilaterally was reduced reflecting less ontogenic myelination of fewer axons following their degeneration and atrophy . this coincided with relative increases in radial diffusivity ipsilaterally and is consistent with increases in radial diffusivity reported in the corticospinal or pyramidal tracts at relatively chronic times ( e.g. 1 w to 3 y ) following an ischemic insult in children or adults ( roze et al . , 2012 ; yu et al . , 2009 ; zanier et al . , 2013 ) . at acute times post - insult we observed ipsilateral reductions in radial diffusivity within the cerebral peduncle indicating that in the absence of effects on myelination , early axonal injury such as that detected by decreases in phosphorylated neurofilaments were also associated with reduced radial diffusivity it is noteworthy that the neurophysiological correlates of alterations in parallel and radial diffusivity are potentially more complex in humans than rodents . a diffusion tensor analysis has an implicit assumption that the white matter fibers are cylindrical and when fibers have complicated microstructures or crossing fibers as occurs in human developing brain ( dubois et al . , 2013 ; 2013 ) then in particular the directions of orientation for tractography require careful interpretation . despite crossing fibers potentially complicating the interpretation of parallel diffusivity changes , transverse or radial diffusivity appears to consistently decrease with all maturational processes within white matter , including myelination ( dubois et al . , 2013 ) . furthermore , emerging imaging methods exploring diffusion parameters beyond the tensor model may provide more in depth assessments to facilitate translation from animals to humans ( dubois et al . the fa measures provided a sensitive measure of direct ischemic injury . in the cortex at hyperacute times , there was an increase in fa , as has been observed previously in rats and non - human primates , however , usually soon after permanent rather than transient occlusion ( kim et al . , 2013 ; liu et al . , 2007 ; yang et al . , 1999 ) . this suggests that the very early cortical ischemic changes were relatively severe and similar to those with permanent ischemia . cellular changes likely involve previously established hyperacute cytotoxic cell swelling and reductions in extracellular space leading to cell death considering our histological evidence for hyperacute neuronal cell death in the cortex . by the first day post - insult , the fa increase became a decrease that persisted at subacute and chronic time points , confirming previous reports of a reduced fa commonly observed in damaged brain post - stroke ( e.g. kim et al . , 2013 ; liu et al . , 2007 ; yang et al . , 1999 ) . this decrease in fa , reflecting diminished preferential diffusivity , is likely associated with a loss of membrane integrity and intracellular structure due to necrosis as supported histologically by continuing cell death and loss of neurofilament staining . the increase in astrogliosis between 3 and 1 d appears rather isotropic considering that there is a decline in fa between these times . the fa also provided a rather robust measure of degenerative changes in the cerebral peduncle . in contrast to ischemic cortex , fa in cerebral peduncle was decreased at all time points . indeed , fa appeared to be the most sensitive dti parameter for detecting axonal degenerative changes in the cerebral peduncle independent of time post - insult and this corresponded well to the persistent decreases in axonal neurofilament staining . similar reductions in fa have been reported at various select times in the corticospinal tract following neonatal stroke ( ludeman et al . , 2008 ; puig et al . , 2013 ; tusor et al . , 2012 ) . it is currently clear that at chronic times , fa is superior to adc or other standard imaging methods such as t2 imaging because lesions detected with these other sequences tended to pseudo - normalize at times post - insult ( lama et al . , 2011 ; tuor et al . , the results demonstrate that in general , diffusivity changes and histological responses within directly damaged ischemic brain precede and are often larger in magnitude than corresponding alterations in a region of secondary axonal degeneration , such as the cerebral peduncle . with the progression of damage over one or more weeks , dti components such as fa and radial diffusivity are better than mean adc for detecting ischemia associated axonal injury indicative of wallerian degeneration . also , differences in radial diffusivity in brain injured perinatally are likely related to a lack of ontogenic myelination on the injured side . thus , the specific progression of dti alterations following an ischemic insult not only depends on the maturity of the subject but also appears dependent on other factors such as the type of insult ( e.g. spinal cord injury or brain resection ) ( brennan et al . , 2013 ; liu et al . , 2013 ; qin et al . , 2012 ) . the inflammatory response investigated ( microglial or astroglial activation ) appears to have modest contributions to the evolution of axonal changes in diffusion tensor parameters . thus , this systematic study is informative regarding the optimal dti mr imaging parameters to probe axonal injury following hypoxic / ischemic brain damage in developing brain in addition to aiding our interpretation of dti parameters for detecting various stages of wallerian degeneration ." ]

[ "the effect of family on workforce is an important though often overlooked issue for work organizations , with implications for the morale , stability and productivity of the workforce . presumably men and women do not shed their family roles , relationships and experiences the moment they don their work clothes . indeed , the logic underlying many corporations ' decisions to offer employer - based family support , such as child care and flexible working schedules , may be that such benefits will enhance employees ' abilities to handle family matters and in so doing will enhance their work performance , commitment and satisfaction . this line of reasoning views the relationship between work and family as a reciprocal process in which work and family influence each other in a circular or feedback fashion . indian families are undergoing change , which in turn influences the environment in the basic unit . the family environment has been bombarded with new expectations , the media , high cost of living and a striving for better quality of life . although not much literature is available on the aspect of how family stress has influenced the productivity of the indian workforce , the author is of the opinion that absenteeism , alcoholism , gambling , heavy debts among employees are a reflection of bruised familial systems . the dual - earning couple is a new prototype that reflects the increasing educational and career aspirations of women . a significant proportion of these women in the workforce comprises of wives and mothers whose employment status demands a radical change in their pattern , activities , commitments and responsibilities , requiring a reassessment of the family environment . in india the proportion of women in the workforce in 1981 was 19.67% and it rose to 22.73% in 1991 , further rising to 25.68% in 2001 . on the flipside , psychosocial studies have shown that dual - earning couples in india have a poorer quality of marital life compared to single - earning couples,[46 ] in their study found that work - family conflict was expressed in 63% of thematic appreciation test ( tat ) stories written by women , whereas men 's stories did not reflect this conflict . sources of stress in the lives of working women emerged from a lack of time to attend to multiple roles , presence of young children ( 6 - 12 years ) in the family and additional responsibility at work in the form of promotions . the most common outcome of stress for the working woman was found to be poor mental and physical health resulting in depression , anxiety , asthma and colitis.[911 ] rajadhyaksha[79 ] studied dual - career as opposed to dual - earning couples in two metropolitan cities in india and found that in a dual - career family where husbands and wives were presumably matched in terms of their career involvement , work - family role conflict and organizational role stress were not significantly different among husbands and wives . for instance , women experienced more conflict between their job and home roles , while men experienced more conflict between their job and spousal roles . in the present day , the young indian adult is exposed to an entirely new pattern of living and a new set of mores , values and standards that are being widely accepted but which stand in contrast to those which were promoted by their parents and grandparents . the ambiguous values children and adolescents observe today in india , coupled with the increasing gap between aspirations and possible achievement , have led to a greater sense of ' alienation . ' parents too appear ill - prepared to cope with rapid social change , having grown up in hierarchically structured and interdependent social groups that included the extended family and kinship network , as well as caste groups that provided stability and solidarity . parents who seem modern in their child - rearing practices get anxious when their offspring breach established social codes . inter - generation conflicts related to marriage , career choice or separate living arrangements result in the tendency to fall back on tradition . subtle changes in family patterns , especially with regard to the use of authority within the family , as well as an increased focus on individual autonomy,[1617 ] are also likely to influence members ' expectations with regard to marriage and their choice of a spouse . educated middle class families are now more hesitant to make decisions for their offspring with regard to marriage , education and employment . changes have also been noticed with regard to a greater focus on the husband - wife relationship rather than the parent - child relationship . with an increased onus of responsibility falling on the individual rather than on the entire family , gore calls ' choice anxiety' increased autonomy and increased choice that have led to increased anxiety . ambiguity with regard to issues like respect for elders , role of the eldest son , love marriages , working wives , etc . , is an inevitable fallout of the changes within the indian family . relationship - focused education for young adults in the workforce has not been on top of the agenda for india 's policy makers . india 's policies on family and child welfare have been focused more in terms of health care , nutrition , reproductive health , sexuality and venereal disease . however , one can not forget that young adults of marriageable age from ' first - generation urban - educated families ' are facing relationship - based problems due to changing dynamics within the indian family . these include shifts in loyalty from filial obligations to lean more towards conjugal ties and issues of power and gender role allocations . marriage is traditionally seen as means for procreation , but there are slow changes in perception among adolescents towards viewing it as a means of companionship . with couples migrating to cities for better job prospects , there is a decreased availability of the informal support provided by the extended family in the past , resulting in young couples having to develop greater problem - solving and coping skills on their own . this in turn weighs heavily on an employee 's ability to focus completely on tasks at work . it is essential to bridge the gap between what their families of origin considered as an ideal or happy marriage and what they now desire from a spouse and family life .", "the author conducted individual interviews with family - intervention experts in bangalore city in order to better understand the changing family patterns that they were observing . among the professionals , there were two clinical psychologists , two psychiatric social workers , two psychiatrists and one divorce lawyer . the key person interview ( kpi ) cue statements to initiate discussions with the experts were as follows [ table 1 ] : description of key person interview participants \n changes that you are seeing in the nature of problems that families are coming to you with in comparison to the nature of problems brought up a decade agoname some culture - specific areas that need to be kept in mind while preparing the family life education programsome areas that you feel need to be essentially covered by a family life education program for single young adults . \n changes that you are seeing in the nature of problems that families are coming to you with in comparison to the nature of problems brought up a decade ago name some culture - specific areas that need to be kept in mind while preparing the family life education program some areas that you feel need to be essentially covered by a family life education program for single young adults .", "it is interesting to note that among the changes noticed by family experts in relation to the aspect of family issues , is the ability to recognize issues early on in the marriage and to seek help for the same . another important change noticed by the experts was that a larger number of young couples who were either engaged or in a relationship were now seeking professional help in order to help them make the right choice of a partner or to resolve issues that they were afraid would snowball into a larger issue post - marriage . an interesting perspective put forward by the legal expert in family law was that he was seeing an increasing number of divorces that were occurring as early as the third or sixth month of marriage , with both partners willing to go in for a divorce by mutual consent . this , he said , was in stark contrast to what he encountered some 10 years ago , when most couples would go through a long - drawn - out battle with much mud - slinging or would want to keep trying to make things work . the recognition of sexual dissatisfaction by , and the unwillingness to stay in a marriage on the part of , the female spouse was also another prominent change that experts were noticing . a long - distance relationship , with spouses staying in different cities and meeting on the weekends , was also another trend that was being noticed . themes from key person interview with family experts leadership and decision - making issues in the joint family largely arose due to the inability to face up to , or communicate with , authority figures within the family , thus leading to frustration and passive aggression . talking about one 's sexual needs was another cultural peculiarity that often created rifts within couples or forced couples to try and work things out . it is also interesting to note that the family experts were able to clearly point out the need for any family life education program to be sensitive to indian culture in terms of how it viewed the role of the joint family . experts also pointed out the program had to be careful about how it portrayed communication within the family and had to keep in mind the factor of ' respect ' that indian families often prescribe to . the third column clearly gives the areas that these family experts felt a family life education program should cover . the experts felt that adaptability was an important skill that the new indian spouse was quickly losing . gender sensitivity in terms of acceptance of changing work and family roles of the female spouse by the male spouse was another important area that the experts talked about . discussions with these family - intervention experts brought out the following areas as possible aspects to be included in family life education program for the younger - generation workforce : \n gender sensitivityparenting skillsconflict resolution skillsadaptability to changebalancing work and the familycommunication skillssocialization and social supportmoney managementchoosing a life partnersexuality and intimacydealing with violence and addiction \n conflict resolution skills adaptability to change balancing work and the family socialization and social support choosing a life partner sexuality and intimacy dealing with violence and addiction the experts definitely seemed to sense the need for some form of education or training for the young indian adult who is either contemplating family life or is a new entrant into marriage or parenthood .", "family issues that eat into employees ' ability to perform or affect his cognitive and emotional state of being need to be addressed . a promotive and preventive strategy rather than a curative one would have to be adopted for this purpose . relationship - focused family life education programs for the target group of employees at the workplace may actually serve to fulfill this purpose , whereby employees , through group interaction and experiential learning , can be taught skills to deftly handle family - life conflicts either by themselves or through the support of mental health professionals . thus a mental health professional need not be there merely to diffuse a difficult situation arising out of deviance of an employee . he or she may act as a preventive agent of avoiding such deviance from arising , by tackling the problem at the root by pre - equipping the family with the necessary psychoeducation and skills ." ]

[ "macroscopically , renal cell carcinomas ( rccs ) generally present as either solid or cystic mass . among cystic rccs , multilocular cystic rcc represents a rare entity that was recognized in 1982 , with a reported incidence of 1 - 4% of all rccs . renal leiomyomas are benign tumors of the kidney originating from smooth muscle cells of the renal capsule , pelvis , calices , or blood vessels . although small renal leiomyomas can be found in about 5% of autopsy specimens , clinical incidence of these lesions is much lower . in this report , we discuss the first case of simultaneous occurrence of a multilocular cystic rcc and a leiomyoma in the same kidney .", "a 38-year - old man was referred for treatment of a right renal cystic mass found incidentally . physical examination on admission revealed no palpable mass , and laboratory data were negative . computed tomography of the abdomen showed a about 5.4 4.6 cm poorly enhancing cystic mass with enhancing septa in the polar area of the right kidney ( fig . since multilocular cystic rcc could not be excluded , the patient underwent right laparoscopic radical nephrectomy . macroscopically , in the mid pole , a well - circumscribed mass showing a multicystic feature with thin fibrous septa and without expansile tumor nodules was noted .", "rccs show cystic changes on imaging studies in 4 - 15% of cases [ 4 , 5 ] . since it is often difficult to differentiate cystic rccs from benign cystic lesions , a definite diagnosis can in most cases only be established by histopathologic examination . these include : ( 1 ) intrinsic multiloculated growth ; ( 2 ) intrinsic unilocular growth ; ( 3 ) cystic necrosis , and ( 4 ) origin from the epithelial lining in a pre - existing cyst . because multilocular cystic rcc are more likely to be discovered incidentally , this feature may contribute to their excellent prognosis compared to that of conventional rccs . since the majority of rccs originate from the proximal tubules , the characteristics and/or environment of the proximal tubules are considered to play an important role in the pathogenesis of rcc . recently , imura et al . carried out a detailed immunohistochemical analysis of multilocular cystic rcc cases . they found that in a high proportion of cases , multilocular cystic rcc reacted strongly with the distal nephron markers , but none reacted preferentially with proximal nephron markers . these results illustrate that multilocular cystic rcc originates from the distal nephron , although the precise pathogenesis of cystic formation in multilocular cystic rcc has not been elucidated clearly . renal leiomyomas are benign tumors arising from the mesenchymal ( or connective ) tissue of the kidney . tumors may be subcapsular ( 53% ) , capsular ( 37% ) , or located in the renal pelvis ( 10% ) . a variety of structural patterns have been described at imaging : solid , cystic , and both cystic and solid [ 9 , 10 ] . in 1990 , steiner et al . the first group comprises small cortical or subcortical neoplasms that are usually asymptomatic , less than 2 cm in size , and are often detected incidentally during autopsy or surgery . the second group consists of larger neoplasms that arise from the renal capsule or blood vessels and may be symptomatic . unfortunately , it is almost impossible to clinically distinguish renal leiomyomas from their malignant counterparts . because of their small size ( usually less than 2 cm ) , these smooth muscle - containing tumors are commonly diagnosed during autopsy , and clinical manifestations become apparent only when they grow larger , hemorrhage , or undergo cystic or sarcomatous degeneration . since the finding of primary synchronous renal neoplasms is very uncommon , especially when they have a different histogenesis , up to now , only a few primary , synchronous rccs with different histotypes have been reported . the coexistence of multilocular cystic rcc and leiomyoma has not been documented . this present case is the first report of synchronous renal neoplasms with different histogenesis ( multilocular cystic rcc and leiomyoma ) in a patient without any symptoms . the significance of the relationship between multilocular cystic rccs and leiomyomas is not well understood and needs further exploration ." ]

[ "the ganoderma strains listed in table 1 were obtained from the korean collection for type culture ( ktct , jeongeup , korea ) , the american type culture collection ( atcc , rockville , md , usa ) , the korean agricultural culture collection ( kacc , suwon , korea ) , the mushroom division of the rural development administration ( eumseong , korea ) , the centraalbureau voor schimmelcultures ( cbs , utrecht , netherlands ) , incheon university ( incheon , korea ) , and konkuk university ( seoul , korea ) . ganoderma species were cultured on potato dextrose broth ( difco , detroit , mi , usa ) and incubated at 30 for 2 wk . cultured mycelia , filtered through 2 layers of miracloth ( calbiochem , la jolla , ca , usa ) , were ground in liquid nitrogen , and genomic dna was extracted using the cetyltrimethylammonium bromide method . pcrs were performed using a premixed polymerase kit ( taq premix ; tnt research , anyang , korea ) in a 20 l reaction mixture containing 1 l of dna . amplification of the its region was carried out using a thermal cycler ( takara , tokyo , japan ) at the following conditions : 5 min at 94 for initial denaturation , followed by 30 cycles of 30 sec at 94 for denaturation , 30 sec at 56 for primer annealing , and 1 min at 72 for extension , and 10 min at 72 for a final extension . pcr products were detected by electrophoresis on 1.2% agarose gels in 0.5 tris - acetate ethylenediaminetetraacetic acid buffer . pcr products were ligated into the pgem - t easy vector ( promega , madison , wi , usa ) according to the manufacturer 's instructions . ligation products were transformed into the escherichia coli dh5 competent cell ( rbc , taiwan ) by heat shock . plasmid dnas were extracted using the dna hybrid - qtm plasmid mini dna isolation kit ( geneall , seoul , korea ) . recombinant clones were identified , and the presence of inserts was confirmed by ecori restriction enzyme digestion and sequencing ( using the sp6 and t7 promoters ; genotech , daejeon , korea ) . nucleotide sequences were deposited in the national center for biotechnology information genbank database ( table 1 ) . the sequences of the its rdna were aligned for phylogenetic analysis using the program bioedit ( http://www.mbio.ncsu.edu/bioedit/bioedit.html ) . the phylogenetic trees were constructed by using the mega5 program and the neighbor - joining method . confidence levels for individual branches of the resulting tree were assessed using the bootstrap test in which 1,000 replicate trees were generated from resampled data . the size of basidiospores from the korean cultivated yeongji strains was determined using a fluorescence microscope ( axio observer a1 ; carl zeiss , jena , germany ) and a 5% koh solution as a mounting medium . the size of each spore was calculated , and the mean value was used in the description .", "the ganoderma strains listed in table 1 were obtained from the korean collection for type culture ( ktct , jeongeup , korea ) , the american type culture collection ( atcc , rockville , md , usa ) , the korean agricultural culture collection ( kacc , suwon , korea ) , the mushroom division of the rural development administration ( eumseong , korea ) , the centraalbureau voor schimmelcultures ( cbs , utrecht , netherlands ) , incheon university ( incheon , korea ) , and konkuk university ( seoul , korea ) . ganoderma species were cultured on potato dextrose broth ( difco , detroit , mi , usa ) and incubated at 30 for 2 wk .", "cultured mycelia , filtered through 2 layers of miracloth ( calbiochem , la jolla , ca , usa ) , were ground in liquid nitrogen , and genomic dna was extracted using the cetyltrimethylammonium bromide method . pcrs were performed using a premixed polymerase kit ( taq premix ; tnt research , anyang , korea ) in a 20 l reaction mixture containing 1 l of dna . amplification of the its region was carried out using a thermal cycler ( takara , tokyo , japan ) at the following conditions : 5 min at 94 for initial denaturation , followed by 30 cycles of 30 sec at 94 for denaturation , 30 sec at 56 for primer annealing , and 1 min at 72 for extension , and 10 min at 72 for a final extension . pcr products were detected by electrophoresis on 1.2% agarose gels in 0.5 tris - acetate ethylenediaminetetraacetic acid buffer .", "pcr products were ligated into the pgem - t easy vector ( promega , madison , wi , usa ) according to the manufacturer 's instructions . ligation products were transformed into the escherichia coli dh5 competent cell ( rbc , taiwan ) by heat shock . plasmid dnas were extracted using the dna hybrid - qtm plasmid mini dna isolation kit ( geneall , seoul , korea ) . recombinant clones were identified , and the presence of inserts was confirmed by ecori restriction enzyme digestion and sequencing ( using the sp6 and t7 promoters ; genotech , daejeon , korea ) .", "nucleotide sequences were deposited in the national center for biotechnology information genbank database ( table 1 ) . the sequences of the its rdna were aligned for phylogenetic analysis using the program bioedit ( http://www.mbio.ncsu.edu/bioedit/bioedit.html ) . the phylogenetic trees were constructed by using the mega5 program and the neighbor - joining method . confidence levels for individual branches of the resulting tree were assessed using the bootstrap test in which 1,000 replicate trees were generated from resampled data .", "the size of basidiospores from the korean cultivated yeongji strains was determined using a fluorescence microscope ( axio observer a1 ; carl zeiss , jena , germany ) and a 5% koh solution as a mounting medium . the size of each spore was calculated , and the mean value was used in the description .", "the phylogenetic analysis of ganoderma species in this study was generally consistent with the findings reported by the group from china . the 62 ganoderma strains were divided into 7 groups , a to g ( fig . in addition , ganoderma lucidum were largely divided into two groups ( groups a and g ) . group a included all the korean g. lucidum strains , as well as the g. lucidum strains from bangladesh and japan , and chinese g. sichuanense and g. lingzhi . g. meredithae ( usa and unknown sources ) in group b was closely related to g. lucidum in group a as evidenced by a high bootstrap value of 98% . g. multipileum ( china and taiwan ) was grouped within group c and g. tropicum ( china and taiwan ) within group d , with 96% and 99% bootstrap support , respectively . group e includes three strains of g. resinaceum from the czech republic and uk ( two strains ) , and was supported by very high bootstrap values of 99% . strains of g. weberianum ( australia , china , and philippines ) and two other chinese g. sichuanense strains ( cui 7691 and hmas 86597 ; holotype ) were grouped within group f with 99% bootstrap support . groups e and f were closely related with bootstrap values of 96% . it is worth noting that other g. lucidum strains from europe ( france , finland , italy , sweden , and uk ) and canada could be clustered into group g with g. tsugae strains from north america ( canada and usa ) , supported by a very high bootstrap value of 99% . the findings of the current study are consistent with those of park et al . who reported that g. lucidum strains from europe and north america could be clustered into one group together with g. tsugae based on both analyses of the its rdna gene and partial -tubulin gene sequences . interestingly , korean g. lucidum strains could be clustered into a group together with g. sichuanense and g. lingzhi strains from china . reported that g. lucidum is incorrectly recorded in china , as well as in other countries , and suggested that the name ' g. lucidum ' as used for the chinese species should be corrected as g. sichuanense . however , they did not obtain sequences from type specimens of g. sichuanense ( the holotype ; hmas 42798 ) . reported that korean g. lucidum ( asi-7004 ) could be clustered into one group together with chinese g. lucidum and g. lingzhi based on the its2 sequences and rna secondary structures . furthermore , cao et al . reported that g. sichuanense ( included the holotype ; hmas 42798 ) was distantly phylogenetically related to g. lingzhi ( included the holotype ; wu 1006 - 38 ) , but it was closely related to g. resinaceum . with regard to the morphological characteristics , it has been reported that chinese g. lucidum ( g. lingzhi ) has a yellow pore surface , european g. lucidum has a white pore surface , and korean g. lucidum has pale brownish thread - like tissues in the middle of the context . cao et al . found that the morphological characteristics of ' g. lucidum ' from east asia were consistent with those of g. lingzhi . thus , they concluded that g. sichuanense was a distinct species since they display obvious morphological differences from g. lingzhi and suggested that the name ' g. lucidum ' should be corrected as g. lingzhi not g. sichuanense . it is commonly called \" yeongji \" in korea , \" lingzhi \" in china , and \" reishi \" or \" mannentake \" in japan . however , the ganoderma species from various countries including africa , oceania , america , asia ( china , korea , and japan ) , and europe have been incorrectly reported as g. lucidum . in addition , moncalvo et al . classified g. lucidum collections from different regions ( asia and europe ) into different species based on its and partial nuclear large subunit ribosomal dna sequences . this is similar to the results of our its nucleotide sequence analysis of g. lucidum . likewise , hong and jung reported that the g. lucidum from korea and japan were monophyletic , and were distinguished from the g. lucidum from europe and north america based on sequence analysis of mitochondrial small - subunit ribosomal dna . as described above , the taxonomy of g. lucidum has been reported by many researchers . nevertheless , the name g. lucidum has been misapplied to various species around the world . the results of this study also reveal that korean g. lucidum was clustered into one group together with chinese g. sichuanense and chinese g. lingzhi ( both formerly g. lucidum ) , and it was clearly separated from g. lucidum from europe and north america . in addition , g. sichuanense were divided into two groups ( groups a and f ) . g. sichuanense strains ( cui 7691 and hmas 86597 ; holotype ) , including the holotype , could be clustered into group f together with g. weberianum , and it was closely related to g. resinaceum . cao et al . also reported that the size of basidiospores of g. lingzhi [ ( 9.85 0.85 ) ( 6.4 0.6 ) m ] differs from that of g. sichuanense [ ( 8.3 0.9 ) ( 5.8 0.8 ) m ] . interestingly , the average size of the basidiospores from the korean cultivated yeongji strains [ ( 10.65 0.65 ) ( 6.6 0.6 ) m for asi-7004 , ( 10 1 ) ( 6.4 0.3 ) m for asi-7071 ] were similar to that of g. lingzhi ( fig . the comparison of the its rdna sequences and the estimation of the basidiospores size presented in this study confirm previous findings and contribute additional evidence that suggests the naming korean cultivated yeongji strains of ' g. lucidum ' should be renamed as g. lingzhi ." ]

[ "successfully conducted the first simultaneous liver - kidney transplant ( slkt ) in 1983 on a patient with chronic kidney allograft rejection and liver cirrhosis , this procedure has become the most effective method for the treatment of combined end - stage liver disease and renal failure . the number of patients with end - stage liver disease and renal insufficiency receiving slkt has increased remarkably , particularly since the introduction of the model for end - stage liver disease ( meld ) scoring system by the united network for organ sharing ( unos ) in 2002 . statistics showed that the number of slkt recipients in the united states has quadrupled from 1998 to 2006 . in addition , the survival rate of slkt recipients has significantly increased following the adoption of meld . the primary causes of end - stage liver disease are cirrhosis caused by viral hepatitis , alcoholic cirrhosis , liver cancer , and congenital liver diseases . while hepatitis c is the leading cause in western countries , hepatitis b is the most prevalent type in china . epidemiological studies have shown that more than 800 million people have been infected with hepatitis b in china . up to 10.31% of the chinese population is hepatitis b surface antigen ( hbsag)-positive . in china , up to 80% of patients with liver failure requiring liver transplant are due to hepatitis b - associated causes . relapse of hepatitis b after liver transplant can reduce the patient s probability of survival by inducing graft dysfunction , recurrence of liver cancer , and lymphatic proliferation . a previous study reported that slkt for hepatitis c , non - alcoholic steatosis and hepatocellular cancer could be associated with worst outcomes compared with other slkt indications . however , few studies have reported the effectiveness of slkt and hepatitis b recurrence in hepatitis b carriers receiving slkt . previous studies have compared the outcome of slkt mainly to outcomes of liver transplant ( lt ) patients with normal renal function as controls [ 1216 ] , while comparison to lt patients with renal insufficiency has been largely ignored . a comparison between slkt recipients with hepatitis b infection and lt recipients with renal insufficiency and hepatitis b infection could provide a more objective assessment of the outcome of slkt associated with hepatitis b. in addition , which indicators can predict the long - term outcomes of liver transplant patients still need to be assessed . therefore , this comparative study analyzed rates of postoperative infection , rejection , long - term survival , and relapse of hepatitis b in hepatitis b carriers receiving slkt at the organ transplant center of the shanghai first people s hospital .", "this was a retrospective analyses in 21 patients ( male : 19 , female : 2 ) who underwent slkt at the organ transplant center of shanghai first people s hospital , shanghai jiaotong university , between january 2001 and may 2005 . recipients of slkt were selected based on the following criteria : 1 ) irreversibly compromised renal function confirmed by preoperative examination , including serum creatinine levels > 133 mol / l lasting for 1 month continuously ; 2 ) high - risk factors for kidney diseases , such as diabetes and hypertension ; and 3 ) massive proteinuria and/or requiring renal replacement therapy for more than 3 weeks . liver and kidney allografts for the same patient came from the same donor , whom was not necessarily a relative . panel reactive antibody ( pra ) class i of recipients was 028% , and class ii was 017% . the study period also included 25 patients who underwent lt alone with renal insufficiency ( preoperative serum creatinine levels > 133 mol / l ) . twenty - five recipients developed renal insufficiency due to hepatorenal syndrome without acute tubular necrosis and renal parenchymal disease . this study was approved by the ethical committee of the shanghai first people s hospital , and written informed consent was obtained from each patient . written consent has been obtained from all donors at the time of their donation . criteria for slkt : 1 ) end - stage liver disease and irreversible kidney failure ; 2 ) congenital diseases involving the liver and kidney ; 3 ) liver failure and chronic kidney disease ( ckd ) with gfr 30 ml / min ; 4 ) acute kidney injury ( aki ) with creatinine levels 176.8 mol / l and dialysis 8 weeks ; or 5 ) liver failure and ckd and biopsy demonstrating > 30% glomerulosclerosis or fibrosis . if there was no evidence to prove irreversible renal damage , liver transplantation alone was preferred . whether patients with hepatorenal syndrome should undergo slkt was controversial , and each patient was discussed . when patients with hepatorenal syndrome were on dialysis for < 4 weeks , liver transplant alone was performed . biochemical indicators ( including serum creatinine , total bilirubin , and aspartate aminotransferase ( ast ) levels ) were followed up for 5 years in all transplant recipients . lt patients were stratified according to the severity of aki as described by the risk , injury , failure , loss and endstage kidney disease ( rifle ) classification : risk , injury or failure . early- and late - stage postoperative complications , postoperative infections , rejection , and long - term survival were also recorded . the diagnosis of acute renal allograft rejection was primarily based on recipients clinical presentation , biochemical indicators ( a 25% increase of serum creatinine levels or more ) , and histopathological biopsy . the diagnosis of acute hepatic allograft rejection required increases in serum ast levels and/or in total bile acids , and was confirmed by liver biopsy . treatment of acute allograft rejection mainly relied on methylprednisolone sodium succinate pulse therapy , an increase in the dose of immunosuppressants , and/or change of types of immunosuppressive agent . the induction regimen of anti - cd25 monoclonal antibody ( daclizumab or basiliximab ) was prescribed to all patients . slkt recipients received a triple maintenance therapy of calcineurin inhibitor ( cni ; cyclosporine and tacrolimus ) , mycophenolate mofetil ( mmf ) and prednisolone ( pred ) , while lt recipients received the steroid - free regimen of cni + mmf . nucleoside analogues coupled with low - dose hepatitis b immunoglobulin ( hbig ) were given to prevent hepatitis b relapse . preoperative nucleoside analogue therapy was followed by intraoperative hbig 2000 u. postoperative combined therapy was administered with maintenance hbig twice per week . within 6 months of transplantation , survival rates of recipients and allografts were analyzed using the kaplan - meier and log - rank methods . continuous data were analyzed using the student s t - test , and categorical variables using the chi - square test .", "this was a retrospective analyses in 21 patients ( male : 19 , female : 2 ) who underwent slkt at the organ transplant center of shanghai first people s hospital , shanghai jiaotong university , between january 2001 and may 2005 . recipients of slkt were selected based on the following criteria : 1 ) irreversibly compromised renal function confirmed by preoperative examination , including serum creatinine levels > 133 mol / l lasting for 1 month continuously ; 2 ) high - risk factors for kidney diseases , such as diabetes and hypertension ; and 3 ) massive proteinuria and/or requiring renal replacement therapy for more than 3 weeks . liver and kidney allografts for the same patient came from the same donor , whom was not necessarily a relative . panel reactive antibody ( pra ) class i of recipients was 028% , and class ii was 017% . the study period also included 25 patients who underwent lt alone with renal insufficiency ( preoperative serum creatinine levels > 133 mol / l ) . twenty - five recipients developed renal insufficiency due to hepatorenal syndrome without acute tubular necrosis and renal parenchymal disease . this study was approved by the ethical committee of the shanghai first people s hospital , and written informed consent was obtained from each patient . written consent has been obtained from all donors at the time of their donation .", "criteria for slkt : 1 ) end - stage liver disease and irreversible kidney failure ; 2 ) congenital diseases involving the liver and kidney ; 3 ) liver failure and chronic kidney disease ( ckd ) with gfr 30 ml / min ; 4 ) acute kidney injury ( aki ) with creatinine levels 176.8 mol / l and dialysis 8 weeks ; or 5 ) liver failure and ckd and biopsy demonstrating > 30% glomerulosclerosis or fibrosis . if there was no evidence to prove irreversible renal damage , liver transplantation alone was preferred . whether patients with hepatorenal syndrome should undergo slkt was controversial , and each patient was discussed . when patients with hepatorenal syndrome were on dialysis for < 4 weeks , liver transplant alone was performed .", "biochemical indicators ( including serum creatinine , total bilirubin , and aspartate aminotransferase ( ast ) levels ) were followed up for 5 years in all transplant recipients . lt patients were stratified according to the severity of aki as described by the risk , injury , failure , loss and endstage kidney disease ( rifle ) classification : risk , injury or failure . early- and late - stage postoperative complications , postoperative infections , rejection , and long - term survival were also recorded .", "the diagnosis of acute renal allograft rejection was primarily based on recipients clinical presentation , biochemical indicators ( a 25% increase of serum creatinine levels or more ) , and histopathological biopsy . the diagnosis of acute hepatic allograft rejection required increases in serum ast levels and/or in total bile acids , and was confirmed by liver biopsy . treatment of acute allograft rejection mainly relied on methylprednisolone sodium succinate pulse therapy , an increase in the dose of immunosuppressants , and/or change of types of immunosuppressive agent .", "the induction regimen of anti - cd25 monoclonal antibody ( daclizumab or basiliximab ) was prescribed to all patients . slkt recipients received a triple maintenance therapy of calcineurin inhibitor ( cni ; cyclosporine and tacrolimus ) , mycophenolate mofetil ( mmf ) and prednisolone ( pred ) , while lt recipients received the steroid - free regimen of cni + mmf . nucleoside analogues coupled with low - dose hepatitis b immunoglobulin ( hbig ) were given to prevent hepatitis b relapse . preoperative nucleoside analogue therapy was followed by intraoperative hbig 2000 u. postoperative combined therapy was administered with maintenance hbig twice per week . within 6 months of transplantation ,", "survival rates of recipients and allografts were analyzed using the kaplan - meier and log - rank methods . continuous data were analyzed using the student s t - test , and categorical variables using the chi - square test .", "meld scores , child - pugh scores , and incidence of preoperative dialysis were not significantly different between slkt and lt recipients . however , slkt recipients had lower egfr ( p=0.003 ) and higher preoperative serum creatinine levels ( p=0.004 ) , lower serum ast levels , and lower total serum bilirubin levels than lt recipients ( table 2 ) . four slkt recipients died : 2 died due to hepatitis b relapse and graft - versus - host disease within 2 months of surgery ; 1 discontinued lamivudine against medical advice and died due to hepatitis b relapse and subsequent acute liver failure 14 months after surgery ; and 1 died due to systemic infection 24 months after surgery . recipients had a 1-year survival rate of 90.5% , a 3-year survival rate of 81.0% , and a 5-year survival rate of 81.0% ( table 2 ) . eleven recipients died ( table 3 ) : 6 died due to fulminant hepatic failure and subsequent renal failure within 1 month of surgery , which is defined as a clinical syndrome developing as a result of massive necrosis of liver cells or following any other cause of sudden and severe impairment of hepatic function occurring in patients without pre - existing or at least well - compensated liver disease ; 1 died due to primary graft dysfunction ; 1 died due to portal vein thrombosis ; and 1 died due to bleeding of an inferior vena cava aneurysm . another 2 patients died due to tumor recurrence during long - term follow - up . recipients had a 1-year survival rate of 60.0% , a 3-year survival rate of 56.0% , and a 5-year survival rate of 56.0% ( table 2 ) . kaplan - meier survival analysis showed that slkt recipients had a higher survival rate than that of lt recipients ( p=0.025 ) , particularly at 1 year post - transplant ( figure 1 ) . seven cases of hepatic allograft rejection occurred among the slkt recipients ; 4 developed rejection within 1 month of surgery , and the others developed rejection at 12 months , 18 months , and 37 months after surgery , respectively . four lt recipients developed allograft rejection ( table 2 ) : 2 cases of allograft rejection occurred within 1 month of surgery , while the other 2 cases occurred at 6 months and 12 months of surgery , respectively . univariate analyses revealed that slkt recipients had a higher but insignificant incidence of infection at an early postoperative stage , compared with lt recipients . slkt recipients had significantly longer stay in the intensive care unit ( icu ) and longer total length of hospital stay , compared with lt recipients . on the other hand , lt recipients demonstrated higher incidence of renal failure and higher mortality at an early postoperative stage compared to slkt recipients ( p=0.005 ) ( table 2 ) . slkt recipients and lt recipients demonstrated sero - clearance of hbsag within 3 months after surgery . however , slkt recipients experienced a significantly higher rate of hepatitis b relapse ( 38.1% , p=0.007 ) compared with lt recipients . steroid therapy for other subjects was discontinued , and nucleoside analogues coupled with high - dose hbig ( hbig 20 000 u / d14d ) were given . following the treatment , the patients had serologic hepatitis b virus ( hbv ) dna test results that showed undetectable levels of hbv ( table 4 ) . risk factors for high mortality ( 32% ) at an early stage after lt were analyzed using univariate and multivariate analyses . according to univariate analyses ( table 5 ) , patients who died at an early stage after surgery had significantly higher preoperative serum creatinine levels ( 239.5107.7 mol / l ) than survivors ( 146.021.6 mol / l ) , and had significantly lower egfr levels ( 30.812.7 ml / min/1.73 m ) than survivors ( 47.18.7 ml / min/1.73 m ) . the early death recipients after lt had higher rifle stage than survivors ( 75% vs. 11.8 , p=0.004 ) . compared with survivors , patients who died during the study had significantly higher preoperative meld scores and child - pugh scores . in addition , a higher incidence rate of postoperative renal failure ( 24% ) was associated with mortality compared with that of survivors ( 4% , p=0.001 ) . multivariate analysis revealed that postoperative renal failure ( p=0.003 ; or 48 ; 95%ci : 3.65631.76 ) and higher rifle stage ( p=0.012 , or 8 ; 95%ci : 1.5638.22 ) were independent risk factors for mortality after liver transplant ( table 6 ) .", "meld scores , child - pugh scores , and incidence of preoperative dialysis were not significantly different between slkt and lt recipients . however , slkt recipients had lower egfr ( p=0.003 ) and higher preoperative serum creatinine levels ( p=0.004 ) , lower serum ast levels , and lower total serum bilirubin levels than lt recipients ( table 2 ) .", "four slkt recipients died : 2 died due to hepatitis b relapse and graft - versus - host disease within 2 months of surgery ; 1 discontinued lamivudine against medical advice and died due to hepatitis b relapse and subsequent acute liver failure 14 months after surgery ; and 1 died due to systemic infection 24 months after surgery . recipients had a 1-year survival rate of 90.5% , a 3-year survival rate of 81.0% , and a 5-year survival rate of 81.0% ( table 2 ) . eleven recipients died ( table 3 ) : 6 died due to fulminant hepatic failure and subsequent renal failure within 1 month of surgery , which is defined as a clinical syndrome developing as a result of massive necrosis of liver cells or following any other cause of sudden and severe impairment of hepatic function occurring in patients without pre - existing or at least well - compensated liver disease ; 1 died due to primary graft dysfunction ; 1 died due to portal vein thrombosis ; and 1 died due to bleeding of an inferior vena cava aneurysm . another 2 patients died due to tumor recurrence during long - term follow - up . recipients had a 1-year survival rate of 60.0% , a 3-year survival rate of 56.0% , and a 5-year survival rate of 56.0% ( table 2 ) . kaplan - meier survival analysis showed that slkt recipients had a higher survival rate than that of lt recipients ( p=0.025 ) , particularly at 1 year post - transplant ( figure 1 ) .", "seven cases of hepatic allograft rejection occurred among the slkt recipients ; 4 developed rejection within 1 month of surgery , and the others developed rejection at 12 months , 18 months , and 37 months after surgery , respectively . four lt recipients developed allograft rejection ( table 2 ) : 2 cases of allograft rejection occurred within 1 month of surgery , while the other 2 cases occurred at 6 months and 12 months of surgery , respectively . univariate analyses revealed that slkt recipients had a higher but insignificant incidence of infection at an early postoperative stage , compared with lt recipients . slkt recipients had significantly longer stay in the intensive care unit ( icu ) and longer total length of hospital stay , compared with lt recipients . on the other hand , lt recipients demonstrated higher incidence of renal failure and higher mortality at an early postoperative stage compared to slkt recipients ( p=0.005 ) ( table 2 ) .", "slkt recipients and lt recipients demonstrated sero - clearance of hbsag within 3 months after surgery . however , slkt recipients experienced a significantly higher rate of hepatitis b relapse ( 38.1% , p=0.007 ) compared with lt recipients . steroid therapy for other subjects was discontinued , and nucleoside analogues coupled with high - dose hbig ( hbig 20 000 u / d14d ) were given . following the treatment , the patients had serologic hepatitis b virus ( hbv ) dna test results that showed undetectable levels of hbv ( table 4 ) .", "risk factors for high mortality ( 32% ) at an early stage after lt were analyzed using univariate and multivariate analyses . according to univariate analyses ( table 5 ) , patients who died at an early stage after surgery had significantly higher preoperative serum creatinine levels ( 239.5107.7 mol / l ) than survivors ( 146.021.6 mol / l ) , and had significantly lower egfr levels ( 30.812.7 ml / min/1.73 m ) than survivors ( 47.18.7 ml / min/1.73 m ) . the early death recipients after lt had higher rifle stage than survivors ( 75% vs. 11.8 , p=0.004 ) . compared with survivors , patients who died during the study had significantly higher preoperative meld scores and child - pugh scores . in addition , a higher incidence rate of postoperative renal failure ( 24% ) was associated with mortality compared with that of survivors ( 4% , p=0.001 ) . multivariate analysis revealed that postoperative renal failure ( p=0.003 ; or 48 ; 95%ci : 3.65631.76 ) and higher rifle stage ( p=0.012 , or 8 ; 95%ci : 1.5638.22 ) were independent risk factors for mortality after liver transplant ( table 6 ) .", "the effectiveness of slkt in patients with hepatitis viral infection had not been thoroughly examined previously . in western countries , hepatitis c virus is the primary cause of end - stage liver disease and subsequently renal impairment . hepatitis c carriers who received slkt have demonstrated a 5-year survival rate of 68% . however , in asian countries , including china , most liver transplant recipients are hepatitis b virus carriers , in whom the outcome of slkt is less understood . this study reported the largest number of hepatitis b patients receiving slkt , in which the 1- , 3- , and 5-year survival rates were 90.5% , 81.0% , and 81.0% , respectively . singal et al . have reported that slkt for hepatitis c , non - alcoholic steatosis and hepatocellular cancer could be associated with worst outcomes compared with other slkt indications ; however , they did not include patients with hepatitis b , which is the most common indication for liver transplantation due to liver failure in china . slkt recipients had significantly higher 1-year survival rate ( 90.5% ) , compared with lt recipients with hepatitis b infection and renal failure . this finding suggested that slkt was effective in improving the survival rate of transplant recipients with renal insufficiency . compared with lt alone , slkt was associated with significantly longer icu stay , longer total hospital stay , and higher incidence of postoperative early - stage infection ( 38.1% vs. 20% ) , which might be related to the greater surgical trauma and higher incidence of complications . in addition , the healthcare system in china requires that the patients are completely symptom - free at discharge , which could explain , at least in part , this longer hospital stay . the incidence of acute allograft rejection between slkt recipients ( 33.3% ) and lt recipients ( 16% ) did not reach statistical significance , suggesting that slkt failed to decrease the incidence of acute hepatic allograft rejection . these results are comparable with previous studies , but this comparison should be made with caution since these previous studies evaluated patients without hepatitis b virus infection [ 12,1416 ] . high mortality was observed in the lt group , which could be attributable to the fact that these patients were with kidney dysfunction , as shown by the multivariate analysis . in addition , even if the meld score was similar between the 2 groups , creatinine and bilirubin levels were higher in the lt group , which could be another part of the reason for the high mortality observed in this group . in addition , some other articles have reported a mortality rate from fulminant hepatic failure as high as 90% after transplantation . a number of factors may also be associated with death after liver transplantation , including infections and rejection . a previous study showed that primary liver graft dysfunction could predict kidney failure , but the present study was not designed to address this relationship . our study revealed that slkt was associated with a higher rate of hepatitis b recurrence than lt ( 38.1% vs. 4% ) . this finding might be due to the stronger and longer immunosuppressive therapy , particularly long - term steroids , administered to slkt recipients compared with steroid - free treatment for lt recipients . the use of steroids has been reported as a risk factor for hepatitis b relapse and for poor survival and hepatitis c relapse . glucocorticoids can directly stimulate an enhancer region and a glucocorticoid response element in hepatitis b virus dna , thereby inducing viral transcription . glucocorticoid administration also suppresses the immune response by reducing the hbv - specific cytotoxic t cell response , and therefore hbv - dna titer increases during glucocorticoid treatment . alternatively , slkt recipients higher hepatitis b relapse rate might be related to the effect of double transplantation on recipients immune function . several previous studies have indicated that hbv can influence the survival of hepatic and renal allografts and lead to fulminant hepatic failure and renal allograft dysfunction . however , 2 subjects in our study died due to hepatic failure ; they discontinued anti - hbv medicine against medical advice and died due to fulminant hepatic failure . for the 6 slkt recipients with hepatitis b relapse , hormone therapy was discontinued and replaced by nucleoside analogues and high - dose hbig ( 20 000 u / d14d ) immediately after the relapse . therefore , slkt recipients with hbv infection should be advised of the risks for hepatitis b relapse . reasonable treatment can achieve hbv - dna sero - clearance in patients with hepatitis b relapse without affecting long - term survival . criteria for slkt for potential lt recipients with renal insufficiency are still unclear . according to the study by hanish et al . on transplant recipients with dialysis history , slkt generates better outcome than single kidney transplantation , liver transplantation followed by dialysis , or staged liver and kidney transplantation . reached similar conclusions . in the present study , lt recipients with renal insufficiency had higher mortality at an early stage after surgery than slkt recipients ( lt vs. slkt : 32% vs. 0% ) . risk factors for death in lt recipients included lower egfr and higher rifle stage , preoperative serum creatinine levels , meld score , child - pugh score , and postoperative renal failure . although gfr is considered the best estimate of renal function than serum creatinine levels , gfr was not an independent risk factor for postoperative deaths . therefore , a gfr less than 30 ml / min is not enough to qualify for slkt . postoperative renal failure ( or=48 ) and rifle stage ( or=8 ) among lt recipients were an independent risk factor for postoperative deaths . it is reported that rifle criteria has been shown to predict clinical outcomes with a progressive increase in mortality with worsening rifle class . therefore , patients who might inevitably develop postoperative renal failure or be in need of dialysis should opt for slkt when possible . it is essential that patients with liver failure with worsening rifle class should be considered for slkt . indeed , this was a retrospective study that suffers from all the limitations inherent to this type of study . furthermore , these patients were from a single center , and the sample size was relatively small . the small number of death events in the slkt group ( 4/21 ) prevented a multivariate analysis in this group .", "despite longer hospital stay and higher infection rate at an early stage after surgery , slkt demonstrated satisfactory long - term survival rates in patients with hepatitis b infection . despite a higher rate of hepatitis b relapse following slkt , timely and reasonable treatments were able to prevent hepatitis b relapse from affecting long - term prognosis . therefore , slkt can achieve good long - term outcomes in patients with hepatitis b , end - stage liver disease , and renal insufficiency . for lt recipients with renal failure , postoperative renal failure and rifle stage were independent risk factors for postoperative deaths ." ]

[ "although dinoflagellates are best known as the notorious cause of toxic red tides , they are also important contributors to the ocean 's primary production . photosynthesis in these organisms is typically carried out in plastids surrounded by three membranes ( 1 ) , an evolutionary footprint reflecting their origin through secondary endosymbiosis ( 2 ) . the evolutionary ancestor of the peridinin - containing plastids is suggested from molecular phylogenetic reconstructions using plastid - encoded genes to be a red alga ( 3,4 ) , a conclusion supported by phylogeny of nuclear - encoded plastid - directed genes ( 5 ) . in general , these findings are also consistent with phylogenetic reconstructions of the host cells as determined from non - plastid - directed genes ( 6,7 ) . despite widespread acceptance of a red - algal origin for the peridinin - containing plastid , these organelles display a number of peculiar characteristics that share no homology with any known extant plastids . for example , the carotenoid peridinin itself ( 8) and the unusual light harvesting peridinin - chlorophyll a - protein to which it binds ( 9 ) are found in no other organisms . furthermore , the rubisco in peridinin - containing plastids , an unusual form ii enzyme , is dissimilar from the form i protein employed by all other plastids ( 10 ) . the evolutionary provenance of these proteins is thus unknown , and as they are derived from nuclear - encoded genes , it seems possible that their history may be distinct from that the plastid itself . an additional issue having bearing on plastid evolution , and one more likely to reflect the plastids themselves , is the number and arrangement of the genes within the genome . genome architecture may be different from the phylogeny of the plastid genes themselves , and in the case of the dinoflagellates , quite remarkably so . indeed , the only known plastid genes so far identified have been located on generally unigenic plasmid - like minicircles . these minicircles have been found in at least five genera of peridinin - containing dinoflagellates including amphidinium ( 11 ) , ceratium ( 12 ) , heterocapsa ( 13 ) , protoceratium ( 14 ) and symbiodinium ( 15 ) . each minicircle has regions conserved within a species , and extensive pcr amplification of the genes located between these conserved regions has been performed in several species . taken together , these studies have led to the conclusion that the known minicircle gene complement has reached saturation ( 16 ) with a total of sixteen protein encoding genes ( atpa - b ; petb and petd ; psaa - b ; psba - e and psbi ; ycf16 and ycf24 ; rpl28 and rpl33 ) in addition to the large ( 23s ) and small ( 16s ) ribosomal rna . the identification of this highly reduced set of plastid genes as comprising the plastid genome is also supported by recent results demonstrating that at least some of the missing genes ( i.e. ones normally found in plastids ) are instead nuclear - encoded in several species ( 1719 ) . these experiments suggest that dinoflagellates do not obey for the rules normally governing plastid gene transfer to the nucleus ( 20 ) . however , it is still a formal possibility that additional genes may be encoded in the plastid in a form different from the minicircle format found so far . one method potentially applicable to the characterization of the plastid genome is to determine the spectrum of genes expressed , as gene expression should be independent from the form in which the genes are found . however , it is generally difficult to discriminate between organelle- and nuclear - encoded transcripts , as both can be modified by addition of a poly(a ) tail at their 3 termini ( 21 ) . we have found that , unlike other transcripts in the dinoflagellates , those encoded by known minicircle genes carry a homogenous polyuridine tract at their 3 termini . we have taken advantage of this unusual feature to characterize the dinoflagellate plastid transcriptome , and find that our analysis fully supports a highly reduced plastid genome for the peridinin - containing dinoflagellates . furthermore , as it seems likely that polyuridylylation may be common in dinoflagellate plastids , it may be possible to rapidly characterize the transcriptome of many different species using the method described here .", "amphidinium carterae ( ccmp 1314 ) and lingulodinium polyedrum ( ccmp 1936 , formerly gonyaulax polyedra ) were obtained from the provasoli guillard culture center for marine phytoplancton ( boothbay harbor , maine ) and cultured as described ( 22 ) . poly(a ) rna was purified from lingulodinium and amphidinium using oligo(dt ) chromatography ( 23 ) and hybridized to a psba and 23s probes as described ( 22 ) . the 16s probe was prepared against an est sequence from our library ( see below ) , while the atpb probe was prepared using previously described amino acid microsequence data ( 22 ) to design two degenerate oligonucleotides 5-ttyticargciggiwsigargt-3 and 5-acytcigciacraaraaiggytg-3 ; the 500 bp pcr product was confirmed as atpb by sequence analysis . the 3 end sequences of atpb and psba transcripts were obtained from cdna synthesized from poly(a ) rna tailed in vitro with rgtp by poly(a ) polymerase . specific sequences were amplified using a d(c)10 oligonucleotide and 5-tatccaattggacaaggaag-3 ( lingulodinium psba ) 5-gtgtagcacaagatgtaagc-3 ( lingulodinium atpb ) , 5-gtattcggtcaagaggatg-3 ( amphidinium psba ) and 5-ctatctcagccgttctttg-3 ( amphidinium atpb ) . the genomic psba sequences from lingulodinium were obtained using tail - pcr ( 24 ) using three nested internal psba oligonucleotides ( 5-gctgcttggccagttattggtatctg-3 ; 5-tctggtttacagcacttggtgttag-3 ; 5-gtccataattgattcatcaggtcatc-3 ) to amplify a fragment from at - rich dna purified by bisbenzimide - cscl gradients . to obtain the 3 end of genomic sequences from amphidinium , minicircle dna was amplified by inverse pcr using outwardly directed oligonucleotides 5-gtattcggtcaagaggatg-3 and 5-caggagcaaggaagaaag-3 ( psba ) or 5-gtggtcgtaagattgagagg-3 and 5-gatgagagcgttggcatac-3 ( atpb ) . for cdna preparation , 10 g poly(a)-enriched rna was used as a template for first strand synthesis using a commercial kit ( stratagene ) but replacing the usual oligo(dt ) primer with 5-(ga)10actagtctcgag(a)18 - 3. sequences were identified using the blast algorithm ( ) and have been deposited in genbank under the accession nos . dq264844 through dq264867 . all sequence alignments and analyses were performed using macvector ( accelrys ) except for rna secondary predictions that were made using a web server ( ) . statistical analysis using rarefaction ( 25 ) to determine the likelihood that our sample size was sufficient to detect all different cdnas in the library was made on a web server ( ) .", "we began our analysis of the dinoflagellate plastid transcriptome by fractionation of rna into poly(a)-enriched and depleted fractions by oligo(dt ) chromatography . the plastid - encoded psba ( 22 ) in rna extracted from the dinoflagellates lingulodinium ( figure 1a ) and amphidinium ( figure 1b ) , was found enriched by 10-fold in poly(a ) fractions , while 23s rrna remained in the poly(a ) fraction . the small size of the 23s rrna signal is suggestive of processing and has been previously observed in dinoflagellates ( 13 ) . the 16s rna was similarly processed , but the full - length form was found to a greater extent in the polyadenylated fraction than was the 23s rna . the abundance of these transcripts in a poly(a ) rich fraction was unexpected , as usually only a small fraction of plastid messages are polyadenylated ( 21 ) . furthermore , it seemed at odds with the lack of minicircle genes found in dinoflagellate est libraries ( 1719 ) . we originally thought that the tails might be heterogeneous , similar to the 3 termini in chloroplasts and cyanobacteria rna formed by polynucleotide phosphorylase ( pnp ) ( 21 ) , since the presence of nucleotides other than adenine in the 3 tails might inhibit cdna synthesis more than oligo(dt ) chromatography . to test this , we guanylated our poly(a)-enriched rna using poly(a ) polymerase , and performed rt pcr with a primer pair allowing specific amplification of the psba 3 end ( figure 2a ) . fourteen different psba clones were sequenced , and all contained a homogeneous 3 terminal stretch of thymidine residues . at least five of the sequences obtained were independent clones based on differences in tail length , which varied between 25 and 40 thymidine residues ( figure 2b ) . a comparison to the genomic dna sequence , obtained by thermal asymmetric interlaced ( tail ) pcr ( 24 ) , shows that these residues are added post - transcriptionally , and all appeared to have been added at the same site ( between arrows , figure 2b ) . poly(t ) tracts of similar length were found on the 3 termini of atpb transcripts from lingulodinium ( data not shown ) and on atpb transcripts from the dinoflagellate amphidinium ( figure 2c ) . we propose that binding of these polyuridylylated mrnas to the longer and more prevalent poly(a ) tails of nuclear transcripts is responsible for their presence in poly(a)-enriched rna fractions obtained by oligo(dt ) cellulose chromatography . the unusual 3 terminal polyuridylylation , if a common feature of dinoflagellate plastid transcripts , suggested that analysis of cdna synthesized using an oligo(da ) instead of the usual oligo(dt ) primer would provide a straightforward method to catalog the plastid gene complement . roughly 60 ng of cdna was synthesized from 10 g poly(a)-enriched rna , a yield 30-fold less than that obtained with an oligo(dt ) primer in similar experiments . polyuridylylated transcripts are thus a small but significant proportion of cellular rna . to characterize the library , several hundred clones were selected at random and sequenced . some gc - rich and unidentified sequences were found , but none were polyuridylylated and were presumably derived from hairpin priming of the predominant gc - rich nuclear - encoded transcripts . in contrast , all polyuridylylated sequences were at - rich and were identified as transcripts from the minicircle genes found in other dinoflagellates ( 16 ) ( table 1 ) . the majority of the transcripts correspond to photosystem ii components ( psba - d ) and 16s rna . this latter may appear more frequently in our oligo(da)-primed library than the 23s rna because the full - length16s rna appears more abundant in a poly(a ) enriched sample ( figure 1a ) . to assess the likelihood that other low abundance polyuridylylated transcripts might be present in the library , we performed rarefaction analysis ( 25 ) . originally developed to compare species richness in biodiversity collections of different sizes , this technique estimates the number of different cdnas that would be obtained if smaller sample sizes were taken . the analysis of the data in table 1 indicates that the identification of twelve different sequences could have been possible with only 120 random clones sequenced ; the three hundred clones reported here represent a significant excess of this minimum value . the calculations can also be used to illustrate the progression in the number of random sequences required to reveal each additional sequence : while 10 different cdnas are expected in 65 random sequences , almost twice as many sequences are required to uncover the eleventh sequence , and roughly six times more sequences to yield the twelfth cdna ( figure 3 inset ) . this analysis suggests that to recover a potential new plastid transcript , well over a thousand random clones would have to be sequenced . to further test the contention the twelve genes recovered are likely to represent saturation coverage of the oligo(da ) , roughly a thousand different cdna clones were randomly selected and streaked on a new petri plate in a grid configuration . colony lifts were then hybridized with a probe prepared against a mixture of psba - d or 16s sequences . from this , 50 cdnas that hybridized weakly or not at were selected and sequenced . only 14 sequences among the 50 sequenced were at - rich and polyuridylylated , and these included two atpa , four 23s rna , a petb , three psbb , three psbc and a psbd . these later three photosystem ii components may have been recovered following the virtual subtraction because of poor bacterial growth or poor transfer to the membrane . more importantly , no new polyuridylylated genes were identified , again suggesting that our coverage of the library had reached saturation . as it seems unlikely that alternative 3 modifications might be found within the same organelle , we conclude that the genome of this photosynthetically active chloroplast is likely to encode only the transcripts identified here . to address the mechanism underlying site selection for poly(u ) addition secondary structure is the principal determinant of polyadenylation site selection in prokaryotes ( 27 ) . however , computer generated secondary structure predictions from rna complementary to the genomic sequence surrounding the polyuridylylation site of either lingulodinium psba or amphidinium atpb did not show any reasonably stable stem loop structures ( data not shown ) . however , two loosely conserved primary structure motifs are located within 50 bp of the modification site in all twelve transcripts ( figure 4 ) . these motifs ( agaaa and aauua ) might thus constitute primary structure elements signalling the polyuridylylation site in a manner similar to the use of aauaaa in determining polyadenylation sites in nuclear encoded transcripts ( 28 ) . we were also curious about the identity of the enzyme that might be used to catalyze the polyuridylylation reaction . as polyuridylylation of protein coding transcripts has been observed in organelles undergoing extensive uridine insertion editing ( 29,30 ) , we thus checked for uridine insertion in comparisons of genomic and cdna sequences using lingulodinium psba , petb and 16s rna ( 2.5 kb total sequence ) . our data reveals no evidence for uridine insertion although numerous examples of substitutional editing in dinoflagellate plastid transcripts ( principally a to g ) were observed ( table 2 , supplementary figures s1 and s2 ) . these results agree with a previous report of substitutional editing in the dinoflagellate ceratium ( 31 ) .", "we have found that the plastid transcripts in two species of peridinin - containing dinoflagellates are characterized by an unusual 3 polyuridylylation . this modification differs dramatically from the poly(a ) tails of nuclear - encoded transcripts , and so provides a facile method for cataloging the plastid transcriptome . we report here that an oligo(da)-primed cdna library has a remarkably low complexity , with only 12 different clones identified in 300 randomly selected polyuridylylated sequences ( table 1 ) . interestingly , all the sequences identified from the library were previously identified as minicircle genes in other dinoflagellate species . this concordance between two independent methods ( characterization of the minicircular genome and the transcriptome analysis reported here ) suggests that the minicircular gene format is likely to be the only genome architecture in the plastid . our results thus strongly support the contention that the dinoflagellate genome is the smallest of any functional chloroplast . furthermore , since the dinoflagellate amphidinium also contains polyuridylylated transcripts , it is possible that the technique described here could be used to catalog the plastid transcriptome from a range of other species . is it likely that the transcriptome contains other low abundance transcripts that were undetected in our relatively small sample size ? the chance of finding a specific transcript in a single random sample is a function of its relative proportion , or frequency of occurrence within the bank . however , if many other sequences were present , then the chance of finding any other sequence would also depend on the number of additional sequences present and on their relative proportions within the library . to estimate our coverage of the library , we used rarefaction analysis to determine if smaller sample sizes would also have recovered the same twelve genes . our analysis suggests that it is likely the same twelve genes would have been recovered using a smaller sample size , indicating that the number of clones sequence was in excess of that required . furthermore , the progression in the number of clones sequenced as a function of the number of different clones identified ( figure 3 ) suggests that well over a thousand random clones would have to be sequenced to find an additional clone if it were indeed present in the library . taken together with the virtual subtraction of psba - d and 16s rna sequences , these results strongly suggest that coverage of the library has reached saturation . the selective forces that serve to maintain genes in the chloroplast are hotly debated , and thought to reflect either difficulties in targeting or transport of proteins that are extremely hydrophobic or a relationship between control of gene expression and the redox state of the organelle ( 32 ) . with respect to the former , the twelve protein encoding genes found in our library are not the most hydrophobic of known thylakoid proteins . indeed , a better explanation for the retention of this particular gene set in the plastid may lie in the length of the protein rather than hydrophobicity . as recently shown by analysis of arabidopsis thylakoid proteins ( 33 ) , the proteins encoded by the dinoflagellate plastid genes are generally the longest of the thylakoid proteins . however , even a combination of length and hydrophobicity is insufficient to explain transfer of some genes to the nucleus , such as the shorter yet relatively hydrophobic protein encoded by the atpi gene recently reported in an oligo(dt ) primed est bank from the dinoflagellate alexandrium . if instead of hydrophobicity , the redox control of gene expression were the determining factor , this would suggest the set of proteins encoded by the dinoflagellate plastids are most sensitive to changes in redox potential . the proposal that it is genes requiring editing may that are conserved in plastids ( 34 ) is supported by analysis of the petb gene of lingulodinium , as editing removes a stop codon in the middle of the derived protein sequence ( supplementary figure s2 ) . with respect to the unusual nature of the modification itself , there is precedent for polyuridylylation in organelles experiencing extensive editing , such as the mitochondria of trypanosomes or myxomycetes . in some cases , 3 polyuridine tails have been observed not only for the guide rnas used to determine the site of uridine insertion but for rrna and mrna as well ( 29,30 ) . however , a comparison of 2.5 kb genomic and cdna sequences showed only substitutional editing ( table 2 ) . our experiments thus provide the first example of extensive polyuridylylation occurring in the absence of rna editing . it is tempting to speculate that the poly(u ) tracts may result from a terminal uridylyltransferase ( tut ) ( 35 ) acting in the absence of guide rna to define a site for uridine insertion . however , an alternative possibility is that the plastids may contain a type poly(a ) polymerase with specificity for uridine residues instead of adenine . recently , it has also been shown that microrna - directed cleavage can result in addition of non - encoded oligonucleotides ( mostly uridine ) to 3 termini ( 36 ) . however , in this case the polyuridylylated transcripts are intermediates in an rna degradation pathway . it seems unlikely that the extensive polyuridylylation of the plastid transcripts is used as a signal for rna turnover , since the majority of psba transcripts appear modified as judged by their co - purification on oligo(dt ) chromatography . in contrast to the full - length protein coding transcripts , the small fragments hybridizing to 16s and 23s rna on northern analyses appear unmodified by these criteria ( figure 1 ) . interestingly , the apparent stability of the polyuridylylated plastid transcripts thus suggests that this particular 3 end modification has a different function from that in either cyanobacteria or the plastids of higher plants , where transcripts are marked for degradation by 3 end polyadenylation ( 21 ) . despite extensive molecular phylogenetic studies pointing to a common evolutionary origin for both host cells ( 7 ) and plastids ( 37 ) of the chromalveolates , no other plastids or cyanobacteria thus the mechanism and function of the dinoflagellate plastid transcript 3 end modification are as unique as their form ii rubisco ( 10 ) and peridinin chlorophyll a - protein ( 9 ) . the major challenge for plastid phylogeny underscored by our results is to reconcile the many unique features of the dinoflagellate plastids with their phylogenetic relationships to red algae . in addition , given the concurrence of several lines of evidence supporting the highly reduced nature of the dinoflagellate plastid genome , it will be of interest to reinvestigate the nature of the selective forces maintaining the current plastid genome size in higher plants .", "", "", "dinoflagellate plastid messages are located in poly(a)-enriched rna . total rna samples ( t ) from the dinoflagellates lingulodinium ( a ) and amphidinium ( b ) were resolved into fractions enriched ( a+ ) and depleted ( a ) for poly(a ) rna by chromatography on oligo(dt ) cellulose . rna blots were challenged with gene probes for either psba , 23s rna or 16s . ( a ) lingulodinium rna samples enriched for poly(a ) rna were tailed with guanine residues , and transcript 3 end sequences amplified using a specific internal oligonucleotide and an oligo(dc ) oligonucleotide . ( b ) sequences of the 3 end of fourteen psba cdnas yielded five clones with different numbers of thymidine residues . the polyuridylylation site is defined to the stretch of thymidine residues encoded by the genomic sequence ( arrows ) . ( c ) amphidinium rna samples were treated similarly except that atpb specific primers were used in the amplification . estimates of the number of different sequences expected for different numbers of random clones sequenced were made by rarefaction analysis of the data in table 1 . the estimated number of different cdna sequences expected with smaller sample sizes shows a statistical possibility that the twelve different clones could have been identified with only 120 different sequences . the progression of the number of random sequences as a function of the number of different clones ( inset ) suggests over a thousand sequences would be required to identify any potentially new clone in the library . all different polyuridylylated 3 terminal sequences corresponding to sequences identified in the library were aligned at the site of the poly(u ) modification and at each of two potential conserved sequences ( underlined ) . only transcripts from known minicircle genes are polyuridylylated in lingulodinium various patterns of substitutional editing are found in dinoflagellate plastid transcripts" ]

[ "several prospective , randomized , controlled clinical trials regarding cervical artificial disc replacement ( c - adr ) have been published . however , the number of c - adr patients with long - term follow - up for more than 4 years is still sparse . the purpose of this systematic review is to provide a summary of the available literature reporting long - term follow - up of c - adr and to elucidate whether the favorable outcomes seen in the short - term continue after 4 to 5 years .", "does single - level unconstrained , semiconstrained , or fully constrained c - adr improve health outcomes compared with single - level acdf in the long - term ? search : pubmed , cochrane collaboration database , and national guideline clearinghouse databases ; bibliographies of key articles . inclusion criteria : ( 1 ) fda trials comparing c - adr with anterior cervical discectomy and fusion ( acdf ) ; ( 2 ) follow - up 4 years . exclusion criteria : ( 1 ) non - fda trials comparing c - adr with acdf ; ( 2 ) follow - up < 4 years . outcomes : neck disability index ( ndi ) , pain in the neck and arm ( visual analog scale [ vas ] ) , quality of life ( sf-36 physical component score [ pcs ] ) , adjacent segment disease ( asd ) , neurological success , subsequent surgeries , and complications .", "study design : systematic review . search : pubmed , cochrane collaboration database , and national guideline clearinghouse databases ; bibliographies of key articles . inclusion criteria : ( 1 ) fda trials comparing c - adr with anterior cervical discectomy and fusion ( acdf ) ; ( 2 ) follow - up 4 years . exclusion criteria : ( 1 ) non - fda trials comparing c - adr with acdf ; ( 2 ) follow - up < 4 years . outcomes : neck disability index ( ndi ) , pain in the neck and arm ( visual analog scale [ vas ] ) , quality of life ( sf-36 physical component score [ pcs ] ) , adjacent segment disease ( asd ) , neurological success , subsequent surgeries , and complications .", "two randomized , multicenter fda trials comparing outcomes following c - adr and acdf with follow - up > 48 months were found ( fig . 1 ) . inclusion and exclusion criteria and demographic information for each study are listed in table 1 . overall , a total of 1004 adult patients ( 47% male ) with a mean age of 44 years were included . all patients were diagnosed with single - level degenerative disc disease between c3 and c7 and had failed a minimum of 6 weeks conservative treatment . function , pain , and health - related quality of life ( table 2 ) at 48 months in the bryan trial , patients in the c - adr group showed significantly greater mean improvement in ndi , vas neck and arm pain , and sf-36 pcs measured at 48 months compared with patients in the acdf group . at 60 months in the prestige trial , only mean improvement in ndi scores was significantly greater in the c - adr group ( 38.4 vs 34.1 , p = .022 ) ; however , for the remaining three outcomes , mean improvements were slighter greater following c - adr versus fusion . success , asd , and return to work ( table 3 ) at 48 months in the bryan trial , overall success and ndi success , were achieved in a significantly greater proportion of c - adr patients compared with acdf patients ( p = .004 and .003 , respectively ) . at both 48 months in the bryan trial and 60 months in the prestige trial , more patients achieved overall neurological success ( maintenance or improvement ) and were working following c - adr compared with acdf , although these differences were not significant . the rate of asd at 48 months in the bryan trial was identical between groups ( 4.1% ) ; at 60 months in the prestige trial the rate was 2.9% in the c - adr group versus 4.9% in the acdf group , however these differences were not statistically significant . both studies reported preserved segmental range of motion in the cervical spine following c - adr compared with acdf : 8.5 versus 1.1 ( 48 months , bryan ) and 6.5 versus 0.4 ( 60 months , prestige ) . subsequent operations ( table 4 ) no significant differences between groups were reported for rates of revisions , hardware removal , supplemental fixation , use of bone growth stimulators , or reoperation at 48 months postoperatively in the bryan trial . at 60 months , a significant difference was seen between the prestige c - adr and acdf groups , respectively , in revisions ( 0% vs 1.9% ; p = .028 ) , supplemental fixation ( 0% vs 1.9% ; p = .028 ) , and the use of external bone growth stimulator ( 0% vs 2.6% ; p = .007 ) . the bryan study only reported more severe who grade 3 or 4 events that occurred after 24 months and up to 48 months follow - up in the c - adr and acdf groups , respectively : any , 24.3% vs 26.1% ; severe arm and neck pain , 1.7% vs 3.6% ; and new neurological deficits , 0% vs 1.4% . in patients with complete radiographic follow - up at 60 months in the prestige trial , subsidence ( loss of > than 2 mm in functional spinal unit height ) was seen in 2.8% and 1.4% of patients in the c - adr and acdf groups , respectively ; bridging bone was reported in 3.2% of the c - adr patients . one guideline was found , published by the north american spine society ( nass ) in 2010 , entitled diagnosis and treatment of cervical radiculopathy from degenerative disorders . among the major recommendations listed were the following statements relevant to the topic of this review : acdf and total disc arthroplasty ( tda ) are suggested as comparable treatments , resulting in similarly successful short term outcomes , for single level degenerative cervical radiculopathy . ( grade : b ; fair evidence level ii or iii studies ) surgery is an option for the treatment of single level degenerative cervical radiculopathy to produce and maintain favourable long term ( > 4 years ) outcomes . ( grade c ; poor quality evidence level iv or v studies ) results of literature search . adults > 18 years of age single - level symptomatic ddd between c3 - 7 intractable radiculopathy , myelopathy or both vas neck pain scores 20 preserved motion at the symptomatic level found in all included patients unresponsive to 6 weeks conservative treatment or progressive neurological worsening despite conservative treatment no previous procedures at the operative level negative for several radiographic findings , medications , and diagnoses multilevel symptomatic ddd or evidence of cervical instability sagittal plane translation of > 3.5 mm or sagittal plane angulation of > 20 at a single level symptomatic c2-c3 or c7-t1 disc disease previous surgery at the involved level severe facet joint disease at the involved level medical condition that required long - term use of medication , such as steroid or nonsteroidal antiinflammatory drugs that could affect bone quality and fusion rates ddd at single level between c3 and c7 disc herniation with radiculopathy , spondylotic radiculopathy , disc herniation with myelopathy , or spondylotic myelopathy 6 weeks minimum unsuccessful conservative unless myelopathy requiring immediate treatment ct , myelography and ct , and/or mri demonstration of need for surgical treatment preoperative ndi 30 and minimum one clinical sign associated with level to be treated willing to sign informed consent and comply with protocol significant cervical anatomical deformity moderate to advanced spondylosis any combination of bridging osteophytes , marked reduction , or absence of motion collapse of intervertebral disc space of > 50% normal height , radiographic signs of subluxation > 3.5 mm , angulation of disc space > 11 greater than adjacent segments , significant kyphotic deformity or reversal or lordosis axial neck pain as solitary symptom previous cervical spine surgery metabolic bone disease active systemic infection or infection at operative site known allergy to components of titanium , polyurethane , ethylene oxide residuals concomitant conditions requiring steroid treatment daily insulin management medical condition which may interfere with postoperative management program or may result in death before study completion current or recent alcohol and/or drug abuser signs of being geographically unstable fda indicates us food and drug administration ; ddd , degenerative disc disease ; ndi , neck disability index ; vas , visual analog scale ; ct , computed tomography ; and mri , magnetic resonance scan . c - adr indicates cervical artificial disc replacement ; fda , us food and drug administration ; ndi , neck disability index ; sf-36 , short - form 36 questionnaire ; and pcs , physical component score . p values compare the mean improvement in scores from baseline to each follow - up time - point between c - adr and fusion . asd indicates adjacent segment disease ; c - adr , cervical artificial disc replacement ; fda , us food and drug administration ; ndi , neck disability index ; and ns , not statistically significant . composite measure in which patients had to achieve all the following : an improvement of 15 points on ndi , neurological improvement , no serious ( who grade 3 or 4 ) adverse events related to the implant or surgical implantation procedure , and no subsequent surgery or intervention that would be classified as treatment failure . improvement of 15 points in ndi from baseline . defined as maintenance or improvement of all three neurological parameters ( motor and sensory function , and reflexes ) . c - adr indicates cervical artificial disc replacement ; fda , us food and drug administration ; and ns , not statistically significant .", "a 43-year - old woman presented with cervical myelo - radiculopathy that did not respond to medical treatment for 6 weeks . the magnetic resonance images demonstrated a large herniated disc at the level of c5/6 , eccentric to the right side ( fig . her symptoms improved significantly after surgery and x - rays taken 2 years postoperatively demonstrated very good range of motion at the index level ( fig . her vas arm pain score improved from a preoperative score of 8 to a postoperative score of 1 at 2-year follow - up . preoperative axial ( a ) and sagittal ( b ) magnetic resonance images of a 43-year - old woman with myeloradiculopathy due to a c5/6 disc herniation . postoperative flexion ( a ) and extension ( b ) x - rays of the patient 24 months after surgery .", "limitations : a small number of studies with long - term data comparing c - adr with cervical acdf were available . in both prospective studies , the c - adr cohort maintained statistical improvement in validated clinical outcome measurements at 48 and 60 months and preserved segmental motion at the operated level . rates of revision and supplemental fixation surgeries were lower in the c - adr group . these studies demonstrate the durability of the c - adr procedure ; however , it may still be too early to detect implant - related failures . future studies should examine issues such as wear - related failures , device fatigue , or delayed spinal instability . the follow - up rates were 68.7% ( 318/463 ) in the bryan disc study at 4 years and 50.1% ( 271/541 ) in the prestige st study at 5 years . these high rates of lost to follow - up may alter the study results if those patients lost to follow - up had late - onset clinical or radiographic issues .", "significantly greater mean improvement from baseline in all outcomes in the bryan c - adr group compared with the acdf group at 48 months . only the ndi showed greater mean improvement from baseline in the prestige c - adr group compared with the acdf group at 60 months . overall success and ndi success , which were only reported by the bryan trial , were achieved in a significantly greater proportion of c - adr patients compared with acdf patients at 48 months . at both 48 ( bryan ) and 60 months ( prestige ) the rates of asd at 48 ( bryan ) and 60 months ( prestige ) were not statistically different between treatment groups . at both 48 ( bryan ) and 60 months ( prestige ) , more patients were working following c - adr compared with acdf . significantly fewer revisions , supplemental fixations , and use of external bone growth stimulators were reported in the prestige c - adr compared with the acdf group at 60 months . rates of who grade 3 or 4 adverse events were similar between groups at 48 months in the bryan trial .", "cervical arthroplasty is a viable treatment option for cervical herniated disc / spondylosis with radiculopathy . the inclusion / exclusion criteria of us fda trials should be followed . c - adr achieves neural decompression and preserves normal segmental motion at the operated level at 4 to 5 years follow - up . adjacent level degeneration may be decreased with arthroplasty versus acdf , but further study is warranted on this topic ." ]

[ "zeolite is a natural porous mineral described as hydrated aluminosilicates containing exchangeable alkali and earth alkaline cations ( na , k , ca , or mg ) and could be synthesised from the aluminium silicate materials as clay minerals and pumice by alkali attack [ 13 ] . zeolites have a large surface area , microporous structure , and high affinity for metal ions , providing an efficient scavenging pathway for heavy metals in toxic systems [ 4 , 5 ] . some of the attractive applications of natural zeolites are listed by taffarel and rubio and babel and kurniawan . most of these research efforts are undertaken on laboratory scale and are at early stages of investigations to develop the synthesis methods . synthetic zeolites are carried out in many industrialized countries in europe , east asia , and north america . na - p1 zeolite is one of the synthetic zeolites which are a class of highly porous materials . the unique structural features of these crystalline microporous solids that contain pores and cavities in the order of molecular dimensions ( 310 ) are the main reason for their application in the realms of catalysis , separation , purification , ion exchange , and radioactive waste clean - up . more novel applications for na - p1 zeolites are expected in electrochemistry , photochemistry , pharmaceutical , engineering , membrane science , and nanotechnology as their structures are expanded and more suitably engineered in a foreseeable future . it is well established that these materials that are equivalently called molecular sieves are mainly hydrated aluminosilicates . zeolite na - p1 contains two - dimensional pore system with two intersecting 8-ring channels . a synthetic zeolite na - p1 has similar pore structure to the natural zeolite phillipsite . na - p1 zeolite is classified as high silica zeolites where it has si / al ratio equal to or greater than about 3 . it is considered as a hydrated sodium aluminosilicate zeolite that could be synthesised from the naturally occurring alkaline volcano with naoh attack of varying concentrations at different volcanic temperatures . pumice is a natural rock of volcanic origin , formed by gases released during the solidification of acidic lava . the vesicular structure of pumice is formed during the eruption of gases contained in the molten viscous lava on cooling . in egypt , pumice occasionally occurs in few locations , at the northern coast of the mediterranean sea at el - arish , north sinai . the heavy metals contamination of water by the discharge of industrial wastewater of electroplating , metallurgy , chemical manufacturing , mining , and battery manufacturing is a worldwide environmental problem . adsorption process provides an attractive alternative treatment to other removal techniques because it is more economical and readily available [ 1012 ] . a good number of adsorbents have been used for cd(ii ) , fe(ii ) , cu(ii ) , and co(ii ) removal from water . the adsorption of cd(ii ) on red mud fitted langmuir isotherm model having a maximum adsorption capacity of 10.57 mg g . wang used maize cobs for adsorption of fe(iii ) from aqueous solution with the langmuir adsorption capacity and the freundlich adsorption capacity being 2.53 mg g and 0.104 l g , respectively . the maximum adsorption capacity for cu(ii ) on red mud gupta et al . used spirogyra species for removal of cu(ii ) with the maximum adsorption capacity of 133.3 mg g. use of adsorbents like mg pellets has also been reported for co(ii ) removal from water and the adsorption capacity has been found to be 15.8 mg g. the aim of this work is to study the best condition of temperature , sodium hydroxide concentration , and time required for synthesis of na - p1 zeolite from the local pumice raw material and utilize the synthetic zeolite as an adsorbent for removing ( cd , fe , cu , and co ) ions from synthetic solutions in a batch laboratory system . also , the effect of experimental conditions such as contact time and initial zeolite dose was described .", "the main material used in this work is pumice grains received from el - nile mining company from the mediterranean sea coast at el - arish province , north sinai , egypt . in addition , commercial naoh is used for alkaline hydrothermal attack for synthesis of zeolite from pumice . hydrated chloride salts of cu , co , fe , and cd of analytical grade ( ar ) supplied by merck as analytical - grade reagents and deionized water are used . all adsorption experiments were carried out using an aqueous solution of cucl22h2o , cocl26h2o , fecl2 , and cdcl2h2o . the stock solution was prepared by dissolving accurately weighted salt in distilled water to the concentration of 500 mg / l . the initial concentrations of solution were done by diluting the stock solutions in appropriate proportions to different initial concentrations . na - p1 has been prepared from pumice , which is naturally occurring alkaline volcanic rock with naoh attack . a series of experiments were conducted to synthesis na - p1 zeolite from locally produced pumice raw material at temperatures ( 80 to 120c ) , naoh solution concentrations ( 13 molar ) , and crystallization periods ( 12 h , one week , and up to one month . pumice powder was mixed with naoh solution in a well - sealed teflon cylindrical vessel , heated , and stirred for 12 hours at 80c , and then the vessel was kept in the dryer at 8090c for one week . the produced gel was filtered and washed well till becoming free from sodium hydroxide ; the wet powder was dried for 24 h in the dryer at 110c . the optimum conditions required for synthesis of na - p1 zeolite from locally produced pumice raw material are one molar naoh concentration , temperature at 80c , and one week as a crystallization time . several investigations for the adsorption of the heavy metal were carried out , including effect of contact zeolite dose , effect of time , and effect of metals concentration . the physical and chemical characteristics of prepared adsorbents such as slurry ph , point of zero charge ( phpzc ) , bulk density , and moisture were performed to determine the capability of prepared adsorbents in removing the metals co , cu , fe , and cd from an aqueous media . for ph determination , 0.2 g of the dry , grinded adsorbent was mixed with 25 ml of distilled water and allowed to boil for 30 min in stoppered glass bottle . after cooling , the ph of the adsorbent was measured using a digital ph meter ( hanna , model ph20 ) , allowing 5 min for the ph probe to equilibrate . also , the point of zero charge ( pzc ) for the samples was determined by the following procedure : 200 ml of deionized water was added to an erlenmeyer flask , which was then capped with stoppered glass . the deionized water was heated until boiling for 20 min to eliminate the co2 dissolved in the water . the co2-free water was cooled down as soon as possible and the flask was immediately capped . on the other hand , 0.5 g of each sample was weighed and placed in a 25 ml erlenmeyer flask to which 20 ml of co2-free water was added . the flask was sealed with a rubber stopper and left in continuous agitation for 72 h at 25c . then the solution ph was measured and this value is the point of zero charge . the bulk density was estimated by a standard procedure by weighing a known volume of gently tapped adsorbent granules . the apparent density was calculated from the volume of the graduated cylinder closely packed with the powdered sample and from the sample weight in triplicate . for moisture measurement , about 0.5 g of powdered air - dried adsorbent sample is weighed and taken in a crucible . the crucible is placed inside an electric hot - air oven and heated at 150c for 3 hours . it is then taken out , cooled in a desiccator , and weighed . from this , the percentage of moisture can be calculated as follows : percentage of moisture = ( loss in weight of adsorbent / weight of air - dried adsorbent taken ) 100 . surface characteristics of prepared zeolite sample were characterized by scanning electron microscope ( sem ) using sem model philips xl 30 attached with edx unit , with accelerating voltage 30 k.v . , magnification 10x up to 400.000x , and resolution for w. ( 3.5 nm ) . x - ray powder diffractograms , xrd , of the samples were recorded using a bruker diffractometer ( bruker d8 advance target ) and the scan rate was fixed at 8 in 2 min for phase identification . the patterns were run with cu k and secondly with monochromator ( = 0.1545 nm ) at 40 kv and 40 ma . mineralogical and chemical study of the pumice were done by using x - ray fluorescence spectrometer ( xrf ) to identify the chemical composition . xrf , a spectrometer with wavelength dispersion pw 2400 philips , and centrifuge hermle were used . xrf shows that quartz , cristobalite , and albite are the main constituents in the pumice ( figure 2 ) . sio2 , al2o3 , and na2o are the main oxides in the pumice under investigation ( 93.69% ) confirming the mineralogical constituents , whereas tio2 , mno , mgo , fe2o3 , and cao analyzed in the pumice under are calculated as 3.88% ( table 1 ) . the concentrations of heavy metals in all samples were determined according to apha using atomic absorption spectrometer unicam model 939 with graphite furnace accessory , equipped with deuterium arc background corrector . precision of the metal measurement was determined by analyzing ( in triplicate ) the metal concentration of all samples and for each series of measurements an absorption calibration curve was constructed , composed of a blank and three or more standards . accuracy and precision of the metals measurement were confirmed using external reference standards from merck . the adsorption isotherm shows the equilibrium relationship of concentration in the adsorbate - adsorbent system at constant temperature . such adsorption isotherms may be used for scaling up batch type processes with moderate success . the shape of the equilibrium adsorption isotherm provides us with information about the adsorbent surface whether it is homogeneous or heterogeneous . also , its study is helpful in evaluating the maximum adsorption capacity of adsorbate for the given adsorbent . for adsorption isotherms models they differ in their assumption , shape of the isotherm , and nature of the adsorbent surface . langmuir ( 1918 ) model assumes that uptake of metal ion occurs on a homogeneous surface by monolayer adsorption without any interaction between adsorbed ions . the model is also based on the assumption that all the sorption sites are energetically identical and sorption occurs on a structurally homogeneous sorbent . thus , a linear plot of ce / qe versus ce confirms the validity of the langmuir giving correlation coefficients ( r ) close to unity , and kl is a constant related to the free energy of adsorption as expressed ( kle ) . deviations from the basic assumption of the langmuir model do limit interpretation of the values for qm and kl in terms of absolute surface areas and sorption free energies . the free energy of adsorption , g , can also be evaluated from the parameter kl according to the expression g = rtlnkl . values of qm and kl are obtained from slope and intercept of ce / qe versus ce plot , respectively . a further analysis of the langmuir equation can be made on the basis of a dimensionless equilibrium parameter , rl ( known as the separation factor which is considered as a more reliable indicator of adsorptions ) . this parameter ( rl ) can be expressed by weber and chakkravorti ( 1974 ) : \n ( 2)rl=11+bci , \n where ci is the initial concentration metal ion ( mg / l ) and b ( l mg ) is the langmuir constant described above . also , the influence of the isotherm shape on whether the adsorption is unfavorable at highest initial concentration of the dye , co , can be described by a term rl , a dimensionless constant separation factor in equation ; calculated value for rl indicates the nature of adsorption process as given : irreversible ( rl = 0 ) , favorable ( 0 < rl < 1 ) , linear ( rl = 1 ) , and favorable ( rl > 1 ) . freundlich isotherm is an empirical equation that can be described as the reversible adsorption onto heterogeneous surface at sites with different energy of adsorption and is not restricted to the formation of the monolayer of adsorbate . the nonlinear form of this model is expressed as \n ( 3)qe = kfce1/n , \n where kf is the freundlich constant ( mg / g)/(l / mg)1/n and also referred to as adsorption capacity , while n is the heterogeneity factor and related to adsorption intensity . the parameter n gives an indication of the adsorption type whether is linear ( n = 1 ) or a physical process ( n > 1 ) is favorable , or a chemical process ( n < 1 ) . on the other hand , the value of 1/n < 1 or 1/n > 1 indicates a normal langmuir isotherm and cooperative adsorption , respectively . freundlich model can be represented by linear form as follows : \n ( 4)lnqe = lnkf+1nlnce . a plot of lnqe versus lnce gives a straight line , where the values of kf and 1/n are determined from the intercept and the slope , respectively . the kinetic tests were carried out following the same procedure used for the equilibrium tests . aqueous samples were taken at different intervals of time and the concentrations of adsorbent were measured at the same intervals . the amount of absorbed onto the developed adsorbents at time t ( min ) , qt ( mg / g ) was calculated by means of the expression below : \n ( 5)qe=(c0ct)vm , \n where co and ct are the liquid - phase concentrations at an initial and predetermined time t ( mg / l ) , respectively , v is the volume of solution ( l ) , and m is the dry weight of the added adsorbent ( g ) . the kinetic data were then carried out for the pseudo - first - order and pseudo - second - order . the rate constant of adsorption was determined from the pseudo - first - order equation : \n ( 6)logqeqt = logqek1t2.303 , \n where qe and qt ( mg / g ) are the amounts of adsorbed ( mg / g ) at equilibrium and at time t ( min ) , respectively , and kt is the adsorption rate constant ( min ) . the pseudo - second - order equation based on the equilibrium adsorption is expressed as \n ( 7)tqt=1k2qe2+tqe , where k2 ( g / mgmin ) is the rate constant of second - order adsorption .", "some physical and chemical features of pumice and na - zeolite p1 are listed in table 2 . it is evident that the treatment with naoh has a significant efficiency on the physicochemical properties of synthesized adsorbent na - zeolite p1 . the ph of the aqueous slurry and phpzc of adsorbents may give a good indication about the surface oxygen complexes and the electronic surface charges of adsorbents . the complexes on adsorbent surface are generally classified as acidic , basic , or neutral . based on the slurry ph , the nature of surface oxygen groups on the support and the dominant complexes can be deduced . from table 2 , it is clear that the ph is higher than the phpzc ; the surface of the adsorbent is negatively charged , favoring the adsorption of cationic species ( co , cu , fe , and cd ) . bulk density of the pumice and na - zeolite p1 decreased from 0.85 to 0.50 mg / g and the moisture is 0% . this finding is due to the generation of porous structure and the increase in binding sites after chemical modification . chemical and phase composition as well as microstructure of the pumice raw material have been studied . the data obtained from the xrf and xrd are discussed before . table 1 illustrates that sio2 is the major component ( ~71.0% ) with about 14.20% al2o3 as well as a total of about 12.4% fluxing oxides . xrd pattern in figure 1 confirms the glassy phase in addition to minor crystalline quartz phase , which is the only phase . the amorphous nature of the silicate pumice as well as the high content of the pore size with variable distributions is ensured by the sem in figure 3(b ) . phase composition and microstructure of the synthetic zeolite studied by xrd ( figure 2 ) and sem reveal that the zeolite p1 is the only phase formed during these conditions of alkali treatment during the alkaline hydrothermal attack of locally produced pumice raw material at the optimum condition of synthesis . the micrograph of synthetic zeolite shows very fine agglomerated crystalline grains ( gray ) figure 3(a ) . xrd analysis was used to prove the formation of na - zeolite p1 before and after treatment with naoh . the x - ray diffractogram of pumice shows that it was considered a glass because it has no crystal structure . pumice is an unusually light rock due to the many bubbles inside it , figure 3(b ) . pumice varies in density according to the thickness of the solid material between the bubbles ; many samples float in water . it is formed by volcanic eruptions when molten lava is shot in the air with many bubbles of gas in it . the treatment with naoh leads to the formation of na - zeolite p1 which has higher degree of crystallinity , figure 3(a ) . xrd analysis was used to prove the formation of na - zeolite p1 before and after treatment with naoh . adsorption isotherm and kinetics of co , cu , fe , and cd on the synthetic zeolite were investigated using batch experiments . equilibrium and kinetic studies were carried out on the removal of co , cu , fe , and cd from aqueous solution using synthetic zeolite p1 . adsorption test on prepared adsorbent was studied using a batch process . for this purpose , the effects of adsorbents dose ( 0.11 g ) , contact time ( 18 min ) , and metal concentration ( 300700 mg / l ) on the adsorption of co , cu , fe , and cd ( 25 ml of 100 for all the above - mentioned equilibrium and kinetic studies , the mixture of adsorbent and solution was magnetically stirred at 150 rpm for 30 min as determined from kinetic tests . batch adsorption experiments were conducted by mixing 50 cm solutions of 500 ppm containing one metal of co , cu , fe , and cd with a constant dose of na - zeolite p1 ( 0.1 g , 0.25 g , 0.5 g , 0.75 g , or 1 g ) in 100 cm pyrex erlenmeyer flasks with cap . flasks were shaken ( 150 rpm ) at 25 1c using a brunswick scientific g25kc incubator orbital shaker . it is observed that the percentage adsorption for co , cu , fe , and cd ions increases with increasing zeolite weight in aqueous solutions as illustrated in figure 4 . the maximal exchange levels attained were as follows : cd > fe > cu > co. the heavy metal uptake may be attributed to different mechanisms of ion - exchange processes as well as to the adsorption process [ 1820 ] . during the ion - exchange process , metal ions had to move not only through the pores of the na - zeolite p1 mass , but also through channels of the lattice , and they had to replace exchangeable cations ( mainly sodium ) . diffusion was faster through the pores and was retarded when the ions moved through the smaller diameter channels . in this case the metal ion uptake 6 could mainly be attributed to ion - exchange reactions in the microporous minerals of the na - zeolite p1 samples . by varying the contact time ( 1 , 2 , 4 , 6 , and 8 min ) while keeping all other parameters constant with respect to ph , temperature , and dose of na - zeolite p1 , 0.25 gm , the influence of contact time on the zeolite capacity for different metal ions is shown in figure 5 . removal efficiency increases for cadmium from 95 to 98% , for copper from 71 to 76% , for iron from 64 to 76% , and for cobalt from 58 to 61% as the time increases from 1 to 8 min . figure 6 represents the variation in metal ion adsorption with time ; however the adsorption rate becomes slower with passage of time up to 4 min . the initial faster rate of removal of each metal ion may be due to the availability of the uncovered surface area of the adsorbents . the slight increase in the percentage of adsorption of each metal adsorbent is cd > fe > cu > co. this may be attributed to the difference in nature between metal ions with respect to na - zeolite p1 surface . that may be attributed to different mechanisms of ion - exchange processes as well as the adsorption process [ 1820 ] . the uptake of cd(ii ) , cu(ii ) , ni(ii ) , pb(ii ) , and zn(ii ) onto na - zeolite p1 as a function of their concentrations was studied at 25 0.1c by varying the metal concentrations 300 , 400 , 500 , and 700 mg / l while keeping all other parameters constant with respect to dose and time . for adsorption isotherms models were used in this work , langmuir and freundlich isotherms . they differ in their assumption , shape of the isotherm , and nature of the adsorbent surface . langmuir ( 1918 ) isotherm which models the monolayer coverage of the sorbent surface assumes that sorption occurs at specific homogeneous sorption site . the model is also based on the assumption that all the sorption sites are energetically identical and sorption occurs on a structurally homogeneous sorbent [ 1820 ] . figure 7 shows that the langmuir model effectively and significantly described the sorption data with all r values 0.96 . table 3 shows the relation between the ionic radius , electronegativity , and langmuir constant . the maximum sorption capacity ( kl ) represents monolayer coverage of sorbent ; according to the kl ( mg / g ) parameter , monolayer capacities of zeolite are arranged in the following sequence : cd > fe > cu > co. these metals seem to reach saturation , which means that the metal had clogged possible available sites in zeolite and further adsorption could take place only at new surfaces . the sequence of adsorption of several heavy metals are not correlated either with the sequence of ionic radii or with the sequence of electronegativity . there is , however , a parallel relation between the adsorption sequence and the hydrolysis properties of the heavy metal cations , as pointed out by several investigators [ 2224 ] . this isotherm developed by freundlich ( 1926 ) describes the equilibrium on heterogeneous surfaces and does not assume monolayer capacity . this isotherm gives an expression encompassing the surface heterogeneity and the exponential distribution of active sites and their energies . a linear plot is obtained when log ce is plotted against log qe over the entire concentration range of metal ions investigated and the values of kf ( mg / g ) and n can be calculated from the intercept and the slope of this straight line , respectively ( figure 8) . the arrangement of heavy metals according to dose required for the reduction of metal concentrations in freundlich equation is cd > fe > cu > co. the adsorption isotherm data were fitted well to the langmuir model from langmuir model equations . in order to investigate the adsorption kinetics of heavy metals on the prepared zeolite adsorbent the calculated parameters from pseudo - first - order and pseudo - second - order models ( figures 9 and 10 ) are summarized in table 4 . according to the pseudo - first - order model , the values of k1 and qe were calculated from the slope and intercept from the plots of log ( qe qt ) versus t. it was found that the experimental values were not adequate with the calculated ones ( table 4 ) , indicating that the first - order model does not reproduce the adsorption kinetic of heavy metals on the prepared adsorbents . in case of the pseudo - second - order model , the calculated values of kinetic studies showed that the zeolite is a good potential as adsorbent for ( co , cu , fe , and cd ) ions follows the pseudo - second - order , and , hence , this model is more likely to predict the behavior over the whole experimental range of h m adsorption more than pseudo - first - order model . also , the values of correlation coefficients ( 2 ) are close to unity for pseudo - second - order model rather than the pseudo - first - order one ; that is , the kinetic removal of h m is quite described by pseudo - second - order model .", "the alkaline treatment of very cheap local pumice leads to the formation of na - zeolite p1 which has the high degree of crystallinity , the ph is higher than the phpzc , and the surface of the adsorbent is negatively charged , favoring the adsorption of cationic species ( co , cu , fe , and cd ) . the adsorption kinetics study of the heavy metals followed a pseudo - second - order model . both the langmuir and freundlich models fit equilibrium data well implying the existence of a monolayer adsorption and a heterogeneous surface existence in na - zeolite p1 , showing a strong adsorption capacity for ( co , cu , fe , and cd ) ions reaching a maximum capacity for cd . heavy metal ions uptake is the result of a combination of several interfacial reactions , namely , ion exchange , chemisorption , and adsorption as potential determining ions . results found showed that the modified zeolite shows a good potential as adsorbent for ( co , cu , fe , and cd ) ions ." ]

[ "surgical resection of tumors is a common therapeutic procedure , especially for early - stage localized , and potentially curative , disease . while surgery can ultimately cure many patients , such as those with early - stage disease , distant macroscopic metastasis can emerge in others months to years later ( demicheli et al . it has been reported that 25%30% of colorectal cancer patients who have no visible metastasis at the time of diagnosis will develop distant metastases within 5 years after primary tumor resection , which in some cases may be related to the effects of the surgery ( van der bij et al . , 2009 ) . similarly , high risk of recurrence for early - stage breast cancer patients following mastectomy has been reported in an analysis of 1,173 patients who underwent mastectomy with no subsequent adjuvant systemic therapy ( demicheli et al . , 1996 ) . mechanisms to explain distant metastasis following primary tumor resection include ( 1 ) the presence of residual tumor cells or tissue at the resected site ( ando et al . , 2003 , minsky et al . , 1988 ) , ( 2 ) the recruitment of inflammatory cells and platelets to the resected site that promote wound healing and cell proliferation ( ceelen et al . , 2014 , hofer et al . , 1999 , retsky et al . , 2012 ) , and ( 3 ) increased local and systemic effects that can induce an angiogenic switch in remote dormant tumors ( bono et al . , 2010 , retsky et al . , 2012 , takemoto et al . , 2012 ) . previous studies have revealed that hypoxic tumor cells stimulate angiogenic - related factors via hif1- , leading to increased tumor invasion ( paraskeva et al . , 2006 , hif1- expression in tumors can also upregulate lysyl oxidase ( lox ) ( erler et al . , 2006 ) , a member of the secreted copper - dependent amine oxidases known to covalently crosslink collagens and elastin in the extracellular matrix ( ecm ) ( barker et al . , 2012 ) . lox is expressed by different cell types , including tumor cells and stromal cells within the tumor microenvironment ( decitre et al . , 1998 ) . it has been shown that increased lox expression in tumors accounts for the recruitment of cd11b bone - marrow - derived cells ( bmdcs ) at distant organs , contributing to the formation of a niche and facilitating a pre - metastatic microenvironment for tumor cell seeding ( erler et al . , 2009 ) . however , the contribution of lox to tumor cell seeding and subsequently to metastasis soon after surgery is unknown . the host response to anti - cancer therapy and its contribution to tumor ( re)growth and metastasis has been evaluated following chemotherapy ( daenen et al . , 2011 , gingis - velitski et al . , 2011 ) , radiotherapy ( barcellos - hoff et al . , 2005 , 2015 ) , and various molecularly targeted drugs ( beyar - katz et al . , 2016 ) ( for a review , see shaked , 2016 ) . here , we evaluated remote ( pulmonary ) changes in lox expression and activity in response to surgery and their contribution to tumor cell seeding and metastasis .", "increased metastases after localized tumor resection in some cases could be due to systemic changes that affect various host tissues in response to surgery . previous clinical studies indicated that both systemic and local angiogenesis are induced in response to surgery when compared to laparoscopy ( bono et al . , 2010 ) . to test whether our surgical mouse model induces angiogenesis , we performed a surgical procedure in non - tumor - bearing mice involving a 1 cm incision in the peritoneum followed by suturing . thereafter , we evaluated the levels of circulating bone - marrow - derived proangiogenic cells over time and the extent of local angiogenesis following surgery . a significant increase in the number of viable circulating endothelial cells ( cecs ) and endothelial progenitor cells ( ceps ) likewise , increases in microvessel density in matrigel plugs , in vitro human umbilical vein endothelial cell ( huvec ) microvessel tube formation , and microvessel sprouting from murine aortic rings were observed in the presence of plasma obtained from post - surgery mice compared to control ( figure s1b the surgical procedure in our mouse model mimics host angiogenic effects reported in certain clinical circumstances . we next evaluated the host - derived effects of surgery on tumor cell seeding and growth in metastatic sites . we employed an experimental lung metastasis assay using the murine emt/6-gfp+ breast cancer cell line . control mice and mice that previously underwent surgery were intravenously injected with tumor cells , which subsequently seeded in the lungs . mortality rates were increased in post - surgery mice compared to controls ( figure 1a ) . similarly , recipient mice injected with 100 l plasma from donor mice that had undergone surgery exhibited an increased mortality rate in comparison to mice injected with control plasma ( figure 1b ) , indicating that a host effect , expressed within the plasma , in response to surgery rather than the actual surgical procedure is responsible for the observed effects . to directly assess tumor cell seeding in the lungs , regardless of any host responses that may affect tumor cells per se while seeding and proliferating at the metastatic sites , a pulmonary metastatic assay ( puma ) was performed using the emt/6-gfp+ cell line . in this assay , the potential of tumor cell seeding is solely dependent on tumor cells binding to the lungs and not systemic effects that could affect tumor cell proliferation . the number of gfp+ tumor cells present in the lungs of mice that underwent surgery was substantially elevated in comparison to control mice ( figures 1c and 1d ) . taken together , our results suggest that enhanced tumor cell seeding is a result of remote changes occurring , in part , in the pre - metastatic ( lung ) tissue in response to surgery . ecm remodeling is one of the main factors that can facilitate tumor cell seeding ; lox mediates collagen crosslinking and therefore is a key regulator of ecm remodeling ( barker et al . , 2012 ) . recent studies have shown that lox is expressed by tumor cells , and serves as a key enzyme promoting metastasis by contributing to a pre - metastatic niche ( cox et al . , 2015 , erler et al . , 2006 , erler et al . , 2009 ) . in our model , we found that lox expression and activity were significantly upregulated at the hypoxic surgical site in the wounded peritoneum in comparison to control peritoneum ( figures 2a2c ) . specifically , high - magnification images of the surgical site revealed intracellular lox expression of peritoneal myofibers ( figure s2a ) . furthermore , lox expression and activity , quantity of newly synthesized collagen , and fibrillar collagen expression were all significantly higher in the lungs of mice that underwent surgery than in the lungs of control mice ( figures 2d2i ) . notably , high lox extracellular staining was located mainly in the lung stroma surrounding the bronchioles in post - surgery lungs when compared to control lungs ( figure 2j ) . however , high - magnification images detected intracellular lox expression in different cell types , with no noticeable differences in expression pattern between control and post - surgery lungs , suggesting that the major source of lox in the lungs of post - surgery mice is from the remote surgical site ( figure s2b ) . in addition , a significant decrease in lox expression and activity was found in the liver of mice that underwent surgery compared to control mice , whereas no significant changes were observed in the spleen ( figures s2c and s2d ) . importantly , 24 hr after surgery , the percentage of cd11b cells in the pre - metastatic lungs of post - surgery mice was comparable to that in control mice ( figures s2e and s2f ) , ruling out the possibility of the formation of a reported pre - metastatic niche at this early time point ( erler et al . , 2009 , kaplan et al . , 2005 , these results indicate that the immediate effects of surgery are primarily associated with ecm remodeling . in order to strengthen the hypothesis that lox is a major contributor to metastatic seeding in the lungs within hours of surgery , a puma , which measures cell seeding in the lungs , was carried out on mice 24 hr after they were injected with recombinant lox , the function of which was evaluated by a lox activity assay ( figure s2 g ) . an increased number of metastatic cells was found in the lungs of mice injected with recombinant lox compared to control mice injected with pbs ( figures 2k and 2l ) . the seeding of cells in collagen and ecm is regulated in part by integrin signaling pathways ( larsen et al . , 2006 ) . one of the major readouts of integrin signaling is paxillin , a scaffold protein connecting focal adhesion kinase to the actin cytoskeleton ( turner et al . , 1990 , zaidel - bar et al . , 2007 ) . we therefore sought to determine the level of phospho - paxillin ( p - pax ) in mcf-7 breast carcinoma cells , a cell line with minimal lox expression ( kraft - sheleg et al . , 2016 ) , in response to plasma from control or post - surgery mice . mcf-7 cells were seeded on collagen , laminin , or fibronectin , all of which are ligands of integrins ( heino and kpyl , 2009 ) , in the presence or absence of plasma from control or post - surgery mice . increased expression of p - pax was observed with all three ligands in the presence of plasma from post - surgery mice compared to control , with laminin producing the weakest effect ( figures 3a and 3b ) . in addition , when the same experiment was performed using plasma from post - surgery mice depleted of lox , the expression of p - pax was found to be lower than the post - surgery non - depleted plasma group ( figures 3c and 3d ) , suggesting that lox expression mediates focal adhesion signaling . furthermore , expression of p - pax was higher in the lungs of mice that underwent surgery than in control mice , an effect that could be inhibited by treating the mice with -aminoproprionitrile ( bapn ) , an irreversible competitive inhibitor of all lox family members ( bondareva et al . , 2009 ) it should be noted that all three ligands are substrates of lox as assessed by the oxidation assay , whereas laminin was the least effective substrate , in line with the results shown in figures 3a3d ( figure s3a ) . taken together , increased lox activity in the lungs soon after the mice undergo surgery contributes to tumor cell seeding via focal adhesion signaling , suggesting interactions between integrins and lox ligands in the remodeled ecm . as lox contributes to the seeding of tumor cells in the lungs , we next studied the effects of lox inhibition in mice using bapn . plasma from control mice or mice that underwent surgery was injected into recipient naive mice . after 24 hr , the recipient mice were injected with emt/6-gfp+ cells to obtain the experimental lung colonization metastasis assay described above . bapn monotherapy did not affect the percentage of gfp+ cells in the lungs of control mice . in contrast , the increase in percentage of gfp+ cells in the lungs of mice injected with plasma obtained from the post - surgery mice was completely abolished by the bapn therapy ( figures 4a and 4b ) , and their mortality rate was reduced , as assessed in a parallel experiment ( figure 4c ) . no significant changes in mortality rate and percentage of gfp+ cells in the lungs of control mice treated with bapn or pbs control were found ( figures 4b and 4c ) . importantly , escalating doses of bapn in a range of 010 mg / ml did not contribute to tumor cell apoptosis ( figure s3b ) , suggesting that the therapeutic effect of bapn is related to the inhibition of lox activity . furthermore , inhibiting lox using specific anti - lox activity - inhibiting antibodies similarly reduced tumor cell seeding in the lungs of mice injected with plasma from post - surgery mice , indicating that the effect is largely regulated by lox . of note , it is not clear why blocking lox in control mice increased metastatic cell seeding ( figures 4d4f ) . it is possible that other bypass pathways may play a role similar to mmp9 inhibition in control mice as previously described ( gingis - velitski et al . , 2011 , moreover , fibrillar collagen and newly synthesized collagen quantities in the lungs of mice 3 days after localized peritoneal surgery were significantly increased when compared to lungs obtained from post - surgery mice treated with bapn or anti - lox antibodies ( figures 4g4i ) . of note , both anti - lox and bapn reduced lox activity in the lungs , while control rabbit immunoglobulin g ( igg ) had no effect ( figures s3c and s4 , respectively ) . to further strengthen our results , we wished to rule out the possibility that inflammation - induced pulmonary vessel permeability mediates the increased tumor cell seeding in the lungs at this early time point . evans blue assay performed on mice 24 hr after they underwent surgery revealed that pulmonary vessel permeability was not significantly different in post - surgery mice compared to control mice ( figure s5a ) , suggesting that tumor cell seeding was not affected by inflammation . additionally , the number and percentage of tumor cells ( emt/6-gfp+ ) seeded in the lungs 20 min after tail vein injection of 2 10 cells ( 10-fold higher than the number of cells injected in the puma ) were significantly higher in post - surgery mice than in control mice . this effect was dramatically reduced when the mice were also treated with bapn as assessed by microscopic imaging of lung specimens and flow cytometry of single - cell suspensions from dissociated lungs ( figures s5b and s5c ) . taken together , lox - induced ecm remodeling accounts for tumor cell seeding in the lungs of post - surgery mice . the fact that plasma derived from post - surgery mice had the same effect on tumor cell seeding as surgery itself suggested it entails the factor mediating this activity . therefore , lox levels were evaluated in the plasma of control and post - surgery mice . the plasma of post - surgery mice exhibited significantly elevated lox levels compared to plasma from control mice , suggesting that lox upregulation in the plasma may affect tumor cell seeding in the lungs ( figure 5a ) . to test this possibility , we depleted lox from plasma of control mice and mice that underwent surgery and assessed tumor cell seeding using puma in recipient mice injected with the different plasma samples . whereas lox depletion did not affect tumor cell seeding in the control group , it significantly decreased tumor cell seeding in the surgery group ( figures 5b and 5c ) . in a parallel experiment , plasma was obtained from untreated wild - type mice or bapn - treated lox heterozygous mice ( mki et al . , the plasma was then injected into mice , and survival was assessed in an experimental lung metastasis assay . however , in the surgery group , survival times were increased when lox was inhibited ( figures 5d and 5e ; statistical significance [ p = 0.043 ] was reached when comparing surgery with surgery + lox depletion groups ) . collectively , our results suggest that lox in the plasma from post - surgery mice promotes tumor cell seeding , and its depletion inhibits collagen synthesis and ecm remodeling . to bolster the possibility that our results may be clinically relevant , we employed two different experimental approaches . in the first , we used a more clinically relevant tumor mouse model of metastasis , in which spontaneous metastases appear in the lungs after resection of a primary orthotopic 4t1 murine breast cancer . to inhibit lox , bapn - treated mice exhibited significantly extended survival and reduced lung metastasis in comparison to mice that did not receive treatment after surgery ( figures 6a6d ) . in the second approach , plasma was drawn from colorectal cancer patients at baseline and 24 hr after they underwent abdominal surgery ( n = 6 ) . the plasma was injected into mice , and metastases were evaluated using emt/6-gfp+ cells in an experimental lung metastasis assay . in five out of six cases , the post - surgery plasma induced higher numbers of lung metastases in comparison to baseline plasma ( figures 6e and 6f ) . such post - surgical plasma also induced ecm remodeling and increased fibrillar collagen expression as well as lox activity in the lungs in a manner similar to that found in mice that underwent abdominal surgery ( figures 6 g , s6a , and s6b ) . importantly , pooled plasma obtained from patients that underwent surgery that was depleted of lox did not increase metastatic seeding in the lungs as assessed by puma ( figures 6h and s6c ) .", "the notion that tumor cells remaining at the site of a surgical resection can re - grow and sometimes even spread may contribute to inferior outcomes in both clinical and preclinical scenarios ( coffey et al . , 2003 , delisser et al . we find that the host , in response to surgery , conditions potential metastatic sites to facilitate tumor cell seeding . we demonstrate that mice that undergo abdominal surgery and are subsequently injected with tumor cells via the tail vein succumb to extensive metastatic lesions earlier than controls . these mice exhibit structural changes in the ecm at the site of metastasis due to an increase in newly synthesized collagen . lox activity and expression are substantially enhanced in the lungs of mice following surgery , as well as in mice pre - conditioned with plasma from donor mice that underwent surgery . accordingly , we find that the surgery is associated with release of lox to the circulation from the hypoxic wounded site , which in turn induces the formation of the pre - metastatic sites . such pro - metastatic effects are abolished following lox inhibition ( e.g. , using bapn , neutralizing antibodies for lox , or lox depletion from plasma ) . notably , antibodies only neutralize extracellular lox and therefore act primarily on the ecm rather than on lox intracellular targets . lox has been implicated as a key enzyme contributing to the pre - metastatic niche promoting the recruitment of cd11b cells to future metastatic sites measured within weeks after primary tumor cell implantation ( erler et al . , 2009 ) . furthermore , increased activity of lox and collagen crosslinking have been shown to promote fibrosis and subsequent metastasis ( cox et al . , 2013 ) . in our study , we focused on the immediate contribution of lox to metastasis by means of ecm remodeling , which promotes the seeding of tumor cells in the lungs within hours following surgery . at this time point , no changes in cd11b cells colonizing the pre - metastatic sites were observed , and there was no significant difference in pulmonary permeability , suggesting that inflammation at this early time point did not contribute to tumor cell seeding . however , it should be noted that clinically , the use of ketorolac ( an analgesic drug with non - steroidal anti - inflammatory properties ) in surgery resulted in superior disease - free survival of breast cancer patients who underwent mastectomy compared to patients who underwent mastectomy but were not treated with ketorolac ( retsky et al . , 2012 ) . have demonstrated that lox is a key regulator of metastasis that is induced by hypoxia . lox expression in hypoxic tumors correlates with increased incidence of metastasis in patients with breast and head and neck cancers . accordingly , the blockade of lox in mice bearing orthotopic breast cancers results in decreased tumor cell invasiveness and metastasis ( erler et al . , 2006 ) . in addition , bone metastasis of triple negative breast cancer cells is associated with hypoxia and lox activity ( cox et al . , 2015 ) . family members promote endothelial cell activity and angiogenesis in tumors and support ecm remodeling ( baker et al . therefore , antiangiogenic therapy , which induces hypoxia in tumors ( blagosklonny , 2001 ) , may lead to increased lox expression . as a result , alterations in ecm may take place in distant sites ( e.g. , lungs or liver ) that can decrease the therapeutic response to therapy . these effects may also explain why , at least pre - clinically , antiangiogenic drugs sometimes promote metastasis ( ebos et al . , 2009 , pez - ribes et al . , 2009 , the question remains why lox has a significant effect on ecm remodeling in the lungs while its expression and activity in other organs are reduced or do not change in post - surgery mice when compared to control mice . it is possible that the high oxygen concentration in lung tissue contributes to lox enzymatic activity . abundant microvessel networks in the lungs contribute to increased oxygen availability , which in turn promotes lox enzymatic activity ( barker et al . this may explain the increased lox enzymatic activity in the lungs compared to other organs . thus , the level of ecm remodeling could be higher in lung stroma than in other tissues . mice bearing tumors that spontaneously metastasize exhibit a reduced mortality rate when lox is inhibited following surgery . additionally , mice preconditioned with plasma from post - surgery colorectal cancer patients exhibit an increased number of metastatic cells in the lungs compared to mice injected with the same plasma that was depleted of lox or plasma at baseline ( before surgery ) . taken together , in addition to the known metastatic effects of lox ( barker et al . , 2012 ) , our study reveals that lox induction contributes to the rapid formation of a permissive niche for metastatic cell seeding in response to surgery .", "murine lewis lung carcinoma ( llc ) , emt/6 and 4t1 mammary adenocarcinoma , and human mcf7 breast carcinoma cell lines were purchased from the american type culture collection ( atcc ) . all cells were grown in dmem , supplemented with 10% fetal calf serum , 1% l - glutamine , 1% sodium pyruvate , and 1% streptomycin , penicillin , and neomycin in solution ( 10 mg / ml , biological industries ) . some of the cell lines ( as indicated below ) were stably transfected with gfp or mcherry vectors ( clontech laboratories , 632379 and 631985 , respectively ) . the cells were passaged in culture for no more than 4 months after being thawed from authentic stocks and were regularly tested and found to be mycoplasma - free . the use of animals and experimental protocols were approved by the animal care and use committee of the technion . balb / c female mice ( harlan ) , 810 weeks of age , were orthotopically injected with 0.5 10 mcherry - expressing 4t1 ( 4t1-mcherry+ ) to the mammary fat pad . tumor size was assessed regularly with vernier calipers using the formula , width length 0.5 . an experimental pulmonary metastatic model was obtained using female balb / c or c57bl/6 mice , 810 weeks of age , intravenously injected through the tail vein with 2.5 10 gfp - expressing emt/6 ( emt/6-gfp+ ) or gfp - expressing llc ( llc - gfp+ ) cells , respectively . mice were not randomized after surgery except in the case of the clinically relevant tumor model ( 4t1 mouse model ) . the experiments were not blinded to the investigator ; however , they were blinded to the mouse health care attendant who carried out daily health checks and reported on mice at endpoint . 10-week - old female lox c57bl/6 heterozygous mice described previously ( mki et al . , 2002 ) were used in some experiments . mice were anesthetized using an induction of 4% isoflurane , followed by maintenance anesthesia with 1.5% isoflurane . a 11.5 cm incision in the peritoneum was then performed , followed by suturing with silk . for resection of primary 4t1 tumors , when tumors reached 150200 mm , . of note , all mice ( control and surgery groups ) received anesthesia and analgesic buprenorphine at a concentration of 0.04 mg / kg for three sequential days according to the institutional ethical protocols . 8- to 10-week - old balb / c or c57bl lox mice underwent the surgical procedure ( as above ) or left as control . after 24 hr , blood was drawn by cardiac puncture using citrate tubes , and plasma was separated . plasma was injected intraperitoneally into recipient mice at a volume of 100 l / mouse . in some experiments , bapn ( sigma - aldrich ) was injected intraperitoneally at a dose of 100 mg / kg daily for seven consecutive days , or as indicated in the text , as previously described ( bondareva et al . , 2009 ) . the antibodies were intraperitoneally injected at a dose of 20 mg / kg as previously described ( erler et al . , 2006 ) . control rabbit igg antibodies ( jackson immunoresearch laboratories ) were injected intraperitoneally at a dose of 20 mg / kg . recombinant lox ( origene ) was injected intraperitoneally at a dose of 25 g / kg , as previously described ( cox et al . , 2015 ) . the human study was approved by the ethic committee at the european institute of oncology ( eio ) , milan , italy , and all patients signed an informed consent . plasma from colorectal cancer patients , who underwent open abdominal surgery , was provided by the department of pathology at the eio . blood from the patients ( n = 6 ) was collected at baseline ( before surgery ) and 24 hr after surgery . blood was drawn from anaesthetized mice by cardiac puncture and collected in edta tubes , and red blood cells were lysed . lung samples or matrigel plugs were prepared as single cell suspensions as previously described ( adini et al . , 2009 , gingis - velitski et al . , 2011 ) . cecs , ceps , emt/6-gfp , and 4t1-mcherry+ were analyzed by flow cytometry as previously described ( shaked et al . , 2005 ) . frozen lung sections or matrigel plugs were immunostained as previously described ( gingis - velitski et al . , 2011 ) . plates coated with collagen ( 20 g / ml ) , fibronectin ( 20 g / ml ) , or laminin ( 20 g / ml ) were incubated with plasma from control , post - surgery mice or plasma from post - surgery mice depleted of lox . after 4 hr , the plasma was washed and mcf7 cells ( 7 10/well ) were seeded and cultured for 24 hr . mcf7 cells were then removed , and lysates were prepared to evaluate paxillin and p - pax expression by western blotting . the assay was performed as previously described ( mendoza et al . , 2010 ) . collagen production in lung lysates was quantified using the sircol collagen assay kit ( biocolor ) in accordance with the manufacturer s instructions . details are provided in supplemental experimental procedures . to visualize ecm and collagen , a two - photon microscopy and a second harmonics generation system lungs from the different groups as indicated in the text were frozen in optimal cutting temperature ( oct ) and sliced at a thickness of 150 m in pbs . the slices were imaged using a two - photon microscope 2pm : zeiss lsm 510 meta nlo , equipped with a broadband mai tai - hp - femtosecond single box tunable ti - sapphire oscillator , with automated broadband wavelength tuning 7001,020 nm from spectraphysics , for two - photon excitation . for second harmonic imaging ( shg ) to detect collagen , a wavelength of 800 nm was used ( detection at 400 nm ) . data were collected ( n = 3 mice / group ) . for quantification measurements , images were analyzed using imagej 1.41k . to avoid edge effects ( attenuation of the shg signal at the top and bottom of the section ) , only the central image of each z mean gray value limited to threshold of each image was calculated for each image and averaged over a set of at least five fields of view . lox activity was evaluated as previously described ( siegel , 1974 , siegel et al . , 1970 ) . briefly , a reaction solution containing 50 mm sodium borate ( ph = 8.2 ) and 4 u / ml horseradish peroxidase was mixed with lung extracts to obtain a protein concentration of 250 g / ml . the lysate extracts were obtained from mice treated with bapn , anti - lox , recombinant lox , or rabbit polyclonal antibody using the same concentrations as above . furthermore , lysate extracts of lungs or peritoneum obtained from control mice or mice that underwent surgery were treated with bapn , anti - lox antibodies , recombinant lox , or rabbit polyclonal antibody and used as controls for the lox activity assay . the enzymatic reaction was started by adding substrate mixture containing 50 mm sodium borate ( ph = 8.2 ) , 100 mm n - acetyl-3,7-dihydroxyphenoxazine ( amplex red ; molecular probes , invitrogen ) , and 20 mm 1,5-diaminopentane . in some experiments , 500 m bapn was added to the mixture as a negative inhibitory control . the production of h2o2 by lox results in fluorescent resorfurin production , which can be measured ( excitation at 540 nm and emission at 580 nm wavelengths ) . the fluorescent reaction was measured every 5 min for 1.5 hr at 37c using a fluorimeter ( fluo star galaxy ) . lox expression in plasma and organ lysates ( 50 g protein ) was evaluated by elisa ( cloud - clone - corp . sec580mu ) in accordance with the manufacturer s instructions . to analyze the activity of lox on different substrates , the oxidation assay was performed as previously described ( kraft - sheleg et al . , 2016 , zaffryar - eilot et al . , 2013 ) . briefly , the lox activity assay was performed as above using lung lysates from control mice at a concentration of 200 g / ml . the only modification is that the substrate ( 1,5-diaminopentane ) used in the lox activity assay was replaced with collagen ( 1 mg / ml ) , fibronectin ( 1 mg / ml ) , or laminin ( 1 mg / ml ) . the fluorescent reaction was measured every 5 min for 1.5 hr at 37c using a fluorimeter ( fluo star galaxy ) . a representative plot out statistical significance of the in vitro experiments was determined by either two - tailed student s t test for a comparison between two groups or one - way anova for multiple groups followed by tukey ad hoc statistical test using graphpad prism 5.0 . for the lox activity assay and human experiment results , a comparison between control / baseline and the related group was calculated based on paired student s t test . the number of replicates for each experiment is provided in supplemental information and/or figure legends . in the in vitro experiments , estimate of variance was performed and parameters for the statistical test were adjusted accordingly . in the in vivo / ex vivo studies , n = 37 mice / group ( as specified in the figures ) was used to reach statistical significance . the sample size for each experiment was designed to have 80% power at a two - sided of 0.05 . for the calculation of mouse survival , a kaplan - meier survival curve statistical analysis was performed in which the uncertainty of the fractional survival of 95% confidence intervals was calculated .", "c.r .- t . , p.h . , and y.s . conceived and designed all experiments ." ]

[ "these conditions may be life - threatening ( e.g. oral cancers ) or not , progressing ( caries , periodontitis , etc . ) or not , dealing with aesthetics ( staining in anterior teeth such as molar incisor hypomineralisation ( mih ) ) or pain ( pulpitis , mih in posterior teeth , etc . ) . ohrqol is highly subjective and has to be assessed within the framework of patients conditions , sociocultural environments and own experiences and states of mind : because ohrqol is related to daily life and is unique to each individual , even patients with severe conditions can report having good quality of life . furthermore , quality of life is by itself multi - faceted , showing variation over time for each individual . ohrqol should therefore be assessed longitudinally to take into account changes over time , using versatile tools .", "this means having relevant questions with well - defined items and being able to analyse answers in a good way . many limitations can be found to the current validation testing , including relevance of the questions , validity and sensitivity to change , risk of misinterpretations ( role of the ethnocultural environment ) , problems of translation of english questionnaires and difficulty to interpret the significance of a psychometric measurement when reported simply as a numerical score or a mean [ 1 , 2 ] . this latter point is of importance since the same score can be obtained from people answering in a different way to a majority of questions . finally , patient - based outcome measures ( as named by fitzpatrick et al . ) should provide the opportunity to measure the extent or intensity of the changes in ohrqol . various psychometric instruments have also been used to measure ohrqol ( tables 1 and 2 ) [ 1 , 4 ] . these are based on different criteria that enable them to be more or less patient- or expert - centred . some are generic ( ohip1 - 49 , ohip-14 , oidp , oh - qol , sf-362 ) and can be considered as core indicators ; others are adapted to specific conditions / domains ( orthognathic qol questionnaire , sooq for orthodontic surgery , ohip - aesthetic,3 ohrqol for dental hygiene ) or populations ( cohqol and child - oidp for children , gohai for elderly people , etc.).table 1conceptual and structural basis of psychometric instruments used in dentistry ( adapted from brondani and mcentee ) instrumentsacronymstructural originsempirically basedconnotation of questionsnumber of questionssocial impacts of dental diseasesiddsipyesn14oral health impact profileohipicidhyesn49geriatric ( generic ) oral health assessment indexgohaiicidh and sipyesn and p12oral health - related qol instrumentohrqlmultiplenon36oral impact on daily performancesoidpicidhnon8dental impact on daily livingdidlsipyesn and nt and p36dental impact profiledipsipyesn and nt and p25oral health - related quality of life measureohqolmultiplenon3oral health quality of life inventoryoh - qolsipunclearp15rand dental questionnaireunspecifiedsipnon3oral health questionnaireunspecifiedicidhunclearn and nt and p70oral health quality of life ukohqol - ukicidh2yesn and p16subjective oral health status indicatorssohsimultiplenon and nt34liverpool oral rehabilitation questionnairelorqunclearnon40self - rated oral healthsrohicidhnon and p3dentaldentalunclearnon15dental health status quality of life questionnaireds - qolgeneric qol instrumentnon and punclearn 1/4 negative , nt neutral , p positive , sip sickness impact profile , icidh international classification of impairments , disabilities and handicapsinformation derived from open - ended interviewssome indicators present shorter or extended forms other than the original versionhealth - related models : natural history of disease model and sipdeveloped from existing measures ( rand , oral facial pain index , etc.).table 2oral health outcome measures developed before 2007 ( adapted from locker and allen ) pre-1997 ( presented at the 1997 conference ) social impacts of dental diseasegeneral ( geriatric ) oral health assessment index ( gohai)dental impact profile ( dip)oral health impact profile ( ohip)oral impacts on daily performances ( oidp)subjective oral health status indicators ( sohsi)oral health - related quality of life measuredental impact on daily living ( didls)oral health quality of life inventoryrand dental questionspost-1997ohqol - ukchild oral health quality of life questionnaire ( cohqol)child oidpohrqol for dental hygieneorthognathic qol questionnairesurgical orthodontic outcome questionnaire ( sooq ) conceptual and structural basis of psychometric instruments used in dentistry ( adapted from brondani and mcentee ) n 1/4 negative , nt neutral , p positive , sip sickness impact profile , icidh international classification of impairments , disabilities and handicaps information derived from open - ended interviews some indicators present shorter or extended forms other than the original version health - related models : natural history of disease model and sip developed from existing measures ( rand , oral facial pain index , etc . ) . oral health outcome measures developed before 2007 ( adapted from locker and allen ) the ohip , also called ohip-49 , is the most widely used , and this has enabled investigators to modify forms that can be subsequently adapted to populations or conditions . the initial 49-question form was constructed to assess the social impact of oral disorders . each of the set of 49 statements represented one of seven domains : it is mainly expert - centred and constructed to select items according to their fit with a conceptual framework rather than on the basis of their importance to the patients from whom they were derived . a shorter version of ohip restricted to 14 items ( ohip-14 ) was later proposed . one major question is to know if we need to use either a generic questionnaire , an adapted form of a generic questionnaire or to construct a new questionnaire specific to the population or condition to be studied . constructing or using one of these specific questionnaires may lead to many questions , for example , ( 1 ) is it made specifically for the purpose of research or for clinical practice ? or ( 2 ) how to adapt each questionnaire to local languages and cultures ? this may subsequently lead us to consider the impact of dentin hypersensitivity ( dhs ) or exposed cervical dentin ( ecd ) on ohrqol of those individuals being assessed .", "very few studies have been devoted to this aspect of dhs / ecd as recently shown , with only two papers written in english specifically dedicated to the evaluation of ohqol in dhs / ecd patients . one paper provided results using a generic questionnaire and the second paper constructed a specific questionnaire to evaluate ohqol in dhs / ecd patients but provided no epidemiological results . these studies are more extensively described in an accompanying paper . in the future , studies using validated questionnaires specifically constructed to evaluate the impact of the condition on ohqol should be employed . these questionnaires should be patient - centred and derived from interviews with patients who are expected to complete the questionnaire [ 4 , 10 ] . furthermore , if these studies also attempt to evaluate the efficacy of desensitising agents in reducing dhs / ecd and its subsequent impact on ohqol , then it is imperative that the condition should be clearly diagnosed by trained and calibrated dentists experienced in conducting clinical studies using recognised and accepted clinical criteria for the evaluation of dhs / ecd . due to the cultural and language differences between countries , there is also a need of norm or reference value(s ) for each population to be studied . for example , when constructing a questionnaire for a non - english - speaking population , the questionnaire should be initially written in english , then translated by two people of the designated native ( foreign ) language and subsequently translated back into english by two native english - speaking people to identify any potential issues that may have arisen from the translation . finally , as indicated above , any future study attempting to evaluate the efficacy of a desensitising agent in reducing dhs / ecd and its subsequent impact on ohqol should be conducted by experienced and calibrated examiners using established guidelines for conducting dhs / ecd clinical studies . such studies should also be based on a randomised clinical study design and include both placebo or control groups .", "patients suffering from dhs / ecd have been reported to have a significantly impaired ohrqol ; this may however be improved following treatment with a desensitising agent as reported by several authors . it is therefore of the upmost importance that the use of the ohrqol as a quality control tool in the dental office be established in robust clinical studies . furthermore , because of its ability to reflect a patient s satisfaction with any proposed treatment , it may prove to be a valuable asset for practitioners when assessing their patients quality of life before , during and after treatment of various clinical conditions such as dhs / ecd .", "" ]

[ "male sprague - dawley rats ( n = 24 ) weighing approximately 250 g were used for the study . permission for the experimental work was obtained from the institutional animal ethics committee ( 767/iaec/13 dated 1 - 1 - 2014 ) . rats were divided into 4 equal groups and injected physiological saline ( twice daily subcutaneously in morning and evening ; group i ) , morphine sulfate ( 10 mg / kg twice daily subcutaneously ; group ii ) , fosaprepitant ( 30 mg / kg once by intraperitoneal route ; group iii ) , and finally , the last group was co - administered both morphine and fosaprepitant ( group iv ) in the same doses as in group ii and iii , respectively , for a week . in the last group , fosaprepitant was injected 30 min before the morphine injection . the dose of fosaprepitant ( 30 mg / kg ) was higher than that used in an earlier study ( 25 mg / kg ) . the rationale for selecting a higher dose was the rapid conversion of fosaprepitant to aprepitant ( half - life ~30 min ) in the rat compared to dogs and humans . hot plate latency or the thermal escape behaviour was determined in the morning , 40 min after saline ( group i ) , fosaprepitant ( group iii ) , or morphine injection ( group ii and iv ) . the hot plate test is commonly employed for screening the putative antinociceptive property of drugs . the advantages of this test are the brief nature of the nociceptive stimulus , which does not produce any tissue damage and that multiple testing can be done in the same animal . the predictability of this test to clinical situations is high for morphine and related opioid substances . testing was done in a quiet room with the ambient temperature between 22c and 25c . on the day of the experiment , the testing platform of the hot plate apparatus ( stoelting , usa ) was set at a constant temperature of 52.5c . the rats were placed on the hot plate , and the behavioral end points were either licking of the hindpaw or jumping . the test was repeated thrice at 57 min intervals and the average of these values was the latency period ( sec ) . a 40 s , cut - off was fixed to prevent damage to the completely analgesic paw after morphine injection . transformation of these values was done by calculating the percent maximum possible effect ( % mpe ) as follows : ( [ drug induced latency basal response time]/[40 s basal response time ] ) 100 on day 8 ( morning ) , rats were anesthetized by pentobarbital injection ( 100 mg / kg intraperitoneal ) . this was followed by intracardiac perfusion with 4% paraformaldehyde solution in 0.1 m phosphate buffer saline . transverse sections of the spinal cord ( 20 m thick ) were obtained in a cryostat and processed for immunohistochemical localization of sp and cgrp using specific antibodies ( anti - sp antibody , abcam , uk ; anti - cgrp antibody , calbiochem , usa ; 1:500 titer ) using the avidin - biotin complex method ( vector labs , usa ) . representative sections ( 3/rat ; systematic random sampling ) were later viewed under a microscope and the images captured . the expression of sp and cgrp in the superficial laminae ( rexed 's laminae i - ii ) of the gray matter was quantitated by image j software ( nih , usa ) . specific expression was obtained after deducting background staining in the white matter ( lateral funiculus ) from the total value obtained from the superficial laminae . some of the cryostat sections were stained with 0.5% cresyl violet for localization of neurons in the dorsal horn . statistical evaluation of data was done by graphpad prism version 5 ( graphpad software , la jolla , san diego , usa ) . values of latency period of the different groups of animals were independently analyzed at each time point by one - way analysis of variance followed by bonferroni multiple comparison test .", "the various groups of rats had different baseline values , which affected the subsequent comparison of the antinociceptive effect of the drugs [ figure 1a ] . hence , normalization of the data was done by calculating the % mpe [ figure 1b ] . the % mpe values of control and the fosaprepitant - treated groups did not show any statistically significant change during the experiment . morphine injection produced significantly higher antinociceptive effect on day 1 ( p < 0.001 ) and to a lesser extent day 4 ( p < 0.05 ) compared to the control group . the sharp decrease in the antinociceptive effect from day 2 in the morphine treated group indicated the development of tolerance . morphine + fosaprepitant combination delayed the onset of tolerance in comparison to morphine treated group on days 1 ( p < 0.01 ) and 3 ( p < 0.001 ) . compared to control , antinociception was higher between days 1 and 4 ( p < 0.001 ) for this group . ( a ) please note the variability of basal latency period and hence these values were not considered in the experimental results ( b ) % maximum possible effect shows rapid development of tolerance after morphine treatment . however , co - administration of fosaprepitant with morphine increased the antinociceptive effect of morphine ( days 14 ) and also attenuated tolerance ( days 1 and 3 ) . values are represented as mean standard error of mean p < 0.05 , * * p < 0.01 , * * * , ,p < 0.001 cresyl violet staining showed the dorsal horn neurons arranged in various laminae [ figure 2 ] . immunohistochemical study revealed the expression of sp and cgrp over the superficial laminae ( laminae i - ii ) of the dorsal horn [ figure 2 ] . quantitative image analysis revealed increased sp expression in the morphine + fosaprepitant treated group compared to others [ figure 3 ] . statistically significant difference was present between morphine and morphine + fosaprepitant co - treatment groups ( p < 0.001 ) . cresyl violet staining showed the different laminae of the gray matter of the cervical region of the spinal cord ( top panel ) . location of the box showed the area of interest ( laminae i - ii ) . expression of both substance p and calcitonin gene - related peptide was noted over the superficial laminae ( i - ii ) . each group had 6 animals quantitative image analysis of the expression of substance p and calcitonin gene - related peptide ( cgrp ) shows that morphine + fosaprepitant treatment led to higher substance p expression compared to all other groups including the morphine treated group . p", "the a and c groups of nerve fibers carry pain from the periphery to the spinal cord . the peptidergic subgroup of these nerve fibers contains neuropeptides such as sp and cgrp , which are released into the synaptic cleft following noxious stimulation . these neuropeptides diffuse to the postsynaptic terminal , where they bind to the corresponding receptors . morphine - induced antinociception is linked to decreased release of glutamate , sp , cgrp , etc . , from presynaptic terminals and greater postsynaptic hyperpolarization due to the activation of inwardly rectifying potassium channels . co - administration of fosaprepitant possibly interfered with the binding of sp to the nk1rs expressed by postsynaptic neurons in the spinal cord . the results of this study show that combining morphine with fosaprepitant ( group iv ) delayed the development of morphine tolerance and concurrently increased the antinociceptive effect compared to the control group . as mentioned earlier , this could be due to decreased binding of sp to the nk1r . evidence from electrophysiological experiments indicates that noxious stimuli produce slow and prolonged excitatory potentials in postsynaptic dorsal horn neurons , which are inhibited by nk1r antagonist . since fosaprepitant treatment ( group iii ) alone did not result in an antinociceptive effect , the interaction between morphine and fosaprepitant is likely synergistic in nature . previously , injection of a bifunctional peptide having both -opioid receptor agonist and nk1r antagonist properties relieved pain in neuropathic rats without producing tolerance . in a different study , tumati et al . reported that intrathecal administration of both morphine and a nk1r antagonist reduced subsequent opioid withdrawal - induced hyperalgesia . pharmacokinetic interaction between fosaprepitant / aprepitant and morphine could also contribute to the enhanced antinociceptive effect . hence , morphine concentration in the nervous system could be increased by concurrent administration of these drugs . significant alterations in the expression of sp and cgrp were not observed except in the group treated with morphine + fosaprepitant combination ( group iv ) . this was unexpected because prevailing evidence suggests that nk1r does not regulate the release of sp in the spinal cord . however , contrary to this , nk1r has been recently reported to be crucial for release of sp from dorsal root ganglion neurons . moreover , it has been speculated that there could be sp autoreceptors on presynaptic terminals , which can modulate sp release . but , fosaprepitant treatment alone did not increase sp immunoreactivity in the present work . as noted earlier , morphine inhibits the release of sp under acute conditions but rats chronically treated with morphine in our study did not show a statistically significant increase in sp expression . presumably , both nk1 autoreceptors as well as morphine - induced inhibition of sp release might have contributed to the increased sp expression in group iv [ figure 4 ] . a limitation of this study was that the expression of sp and cgrp was evaluated at the end of the observation period and not between days 1 and 4 , when the antinociceptive effect was maximum . another limitation was the use of a fixed - dose combination of morphine and fosaprepitant . diagrammatic representation of the dorsal horn of the spinal cord ( a ) primary sensory afferents carrying nociceptive sensation ends in the dorsal horn of the spinal cord . ( b ) the presynaptic terminals of the primary sensory afferents contain excess substance p following morphine + fosaprepitant treatment ( red ) . - receptor is present on both the presynaptic and postsynaptic terminals the antinociceptive effect of morphine decreased rapidly following daily administration , indicating development of tolerance . the antinociceptive effect of morphine is likely due to decreased release of pronociceptive neurotransmitters such as glutamate and neuropeptides such as sp from presynaptic nerve terminals which could be lost during tolerance . one of the factors responsible for tolerance could be counter - adapting processes , which maintains the status quo in the spinal cord . similarly , the potentiation of the antinociceptive effect of morphine by fosaprepitant is also lost on continued administration ( day 5 onward ) . identical result was reported with a chimera possessing both opioid agonist and nk1r antagonist properties . moreover , the factors can differ depending upon the specific -opioid receptor agonist used for producing the tolerance .", "the results indicate that addition of fosaprepitant to morphine can delay morphine tolerance for a limited period of time . to the best of our knowledge , this is the first report on the novel antinociceptive effect of morphine + fosaprepitant combination . further studies are required to further elucidate this novel antinociceptive effect of morphine + fosaprepitant combination .", "", "" ]

[ "the direct conversion \n of solar energy to a chemical fuel is an \n essential part of future sustainable energy systems that are independent \n of fossil reserves . hydrogen is an environmentally \n benign energy carrier of high - energy density and can be produced by \n photocatalytic water reduction . platinum \n and other noble metals can serve as heterogeneous hydrogen evolution \n catalysts ; however , their limited earth abundance and cost precludes \n further development and/or large - scale applications . on the other hand , organometallic compounds are attractive catalysts \n for this transformation considering the variety of complexes that \n can be prepared , the synthetic ease with which electronic properties \n ( and hence catalyst activity ) can be modulated , and the ability to \n study their mechanisms in detail . in nature , hydrogenase enzymes , \n especially those containing fe2 active sites , efficiently \n catalyze proton reduction to molecular dihydrogen . models \n of the [ fefe]-hydrogenases can act as biomimetic hydrogen evolution \n catalysts , although they often suffer \n from limited stability , especially when catalysis is driven photochemically \n in conjunction with photosensitizers . the \n necessity of an external matrix to stabilize the catalyst is thus \n evident . metal organic frameworks ( mofs ) , also referred \n to as porous \n coordination polymers , have emerged as an intriguing class of microporous \n crystalline materials due to their intrinsic topology and porosity and have been studied for a range of applications \n in gas storage / separation , chemical sensing , drug delivery , and \n catalysis . unlike other porous materials \n such as zeolites , the organic ligand component of mofs allows for \n functionalization of internal channels and/or cavities either through \n direct solvothermal synthesis or by postsynthetic \n modification reactions that include the metathesis of metal ions and \n organic linkers under relatively mild conditions . hupp , cohen , and others have reported on this postsynthetic exchange \n ( pse ) phenomenon ( also termed solvent - assisted linker exchange , sale ) , \n including in highly robust mofs , such as the materials of the institute \n lavoisier , zeolitic imidaozolate framework , and university of oslo \n ( uio ) materials . all of these materials are considered to be inert \n with exceptionally high thermal and chemical stability , and can provide \n a robust platform for the incorporation of potentially labile molecular \n catalysts . incorporation of catalytic sites into mofs has resulted \n in heterogeneous \n catalysts that promote a wide range of organic reactions . the heterogeneous \n nature of mof catalysts allows for their easy separation , reusability , \n and enhanced stability . in the context of light - to - fuel \n conversion schemes , homogeneous photosensitizers such as ir polypyridine \n complexes and porphyrins have been incorporated in mofs and were shown to drive \n photochemical hydrogen production catalyzed by pt nanoparticles . organometallic ir and re catalysts have been \n incorporated as the ligand linker part of the mof and were shown to \n catalyze ce - promoted water oxidation and photochemical co2 reduction , respectively . although excellent proof - of - concept studies , \n in both cases , resource - limited \n precious metal catalytic sites were used . moreover , the scope of these \n reports is somewhat limited , as the solvothermal procedures that were \n used for the synthesis of the mofs require organometallic units that \n are thermally robust . herein , we describe the incorporation of an \n organometallic fe2 complex that bears structural resemblance \n to the active site of [ fefe ] h2ases into a mof . [ fefe](bdt)(co)6 ( 2 ) ( bdt = benzenedithiolate ) has previously \n been shown to be an effective proton reduction catalyst in electro- \n and photochemical schemes . decoration of complex 2 at the bdt ligand with two carboxylates results in complex 1 which can be introduced into mofs by pse of 1,4-benzenedicarboxylate \n ( bdc ) ligands , which is a common ligand linker in many mofs ( figure 1 ) . pse thus allowed for the introduction of a thermally \n unstable [ fefe](bdt)(co)6 moiety into the thermally stable \n zr(iv)-based uio-66 mof ( figure 2 ) . x - ray absorption \n spectroscopy ( xas ) was used to confirm the coordination environment \n of the fe2 site in the mof . importantly , uio-66-[fefe](dcbdt)(co)6 was found to be a highly active hydrogen production catalyst \n in photochemical arrays with [ ru(bpy)3 ] as \n a photosensitizer and ascorbate as an electron donor . the catalytic \n performance of the mof exceeds that of an analogous homogeneous reference \n system . [ fefe ] hydrogenase active site model complexes [ fefe](dcbdt)(co)61 and [ fefe](bdt)(co)62 and the bdc ligand", "2,3-dimercaptoterephthalic \n acid was prepared from benzene-1,2-dithiole \n via lithiation and carboxylation and directly \n converted to complex 1 ( [ fefe](dcbdt)(co)6 , dcbdt = 1,4-dicarboxylbenzene-2,3-ditiolate ) by combining the ligand \n with fe3(co)12 in thf . single crystal x - ray \n analysis of complex 1 shows the usual distorted octahedral \n coordination sphere around the fe ions , with the dcbdt ligand perpendicular \n to the fe fe bond vector ( see also esi ) . the uio-66 framework , \n consisting of zr(iv)-based secondary building \n units ( sbus ) and bdc ligand ( zr6o4(oh)4(bdc)6 ) , was chosen for the incorporation of complex 1 because of its exceptionally high structural stability with \n respect to water and weak acids . highly crystalline uio-66 was synthesized \n under solvothermal conditions using zrcl4 , bdc , and benzoic \n acid ( as a crystal growth modulator ) in dmf for 24 h , followed by \n washing with meoh and activation under vacuum . field - emission scanning \n electron microscopy ( fe - sem ) shows an octahedral morphology of the \n resultant uio-66 crystals with a particle size ranging from 200 \n to 500 nm ( figure 3 ) . fe - sem image of ( a ) uio-66 \n and ( b ) uio-66-[fefe](dcbdt)(co)6 . scale bar is 1 m . attempts to directly include 1 during solvothermal \n synthesis ( > 50 c ) resulted in decomposition of the cluster , \n presumably due to the labile bonds between the fe centers and the \n highly electron - deficient dcbdt ligand . taking advantage of the structural \n homology of the bdc and dcbdt ligands in complex 1 ( figure 1 ) , we employed pse as a mild functionalization approach \n to introduce complex 1 into uio-66 ( figure 2 ) . optimization of the pse conditions revealed that the use \n of deoxygenated , ultrapure water ( room temperature for 24 organic solvents , including meoh , dmf , \n and chcl3 , gave lower incorporation , consistent with previous \n observations on the solvent dependence of pse . as expected from the attempted solvothermal syntheses , \n pse at elevated temperatures ( > 50 c ) gave results that also \n suggested partial decomposition of 1 . interestingly , \n it was found that pse was facilitated by using a highly microcrystalline \n form of uio-66 that was synthesized in the presence of a benzoic acid \n modulator . in contrast , conventionally synthesized uio-66 ( without \n modulator ) resulted in a less crystalline material and a less efficient \n exchange process . the linker - exchanged material , uio-66-[fefe](dcbdt)(co)6 , was isolated as an orange microcrystalline powder after \n washing \n thoroughly with fresh meoh and activation under vacuum . g / cm , measured \n with nitrogen at 77 k. this value is close to the bet surface area \n of pristine uio-66 ( 1475 89 g / cm ) , suggesting \n a true pse process between 1 and the framework , and not \n simple trapping of the iron complex in the mof pores ( which would \n be expected to produce a much lower surface area ) . n2 absorption / desorption \n isotherms of uio-66 and uio-66-[fefe]dcbdt(co)6 do indicate \n a modest decrease in pore size distribution ( figure \n s1 ) . uio-66 is known to possess two pore types , tetrahedral \n and octahedral cages , with pore widths of 8 and 11 \n , respectively ( figure s2 ) . pristine uio-66 gave a median pore width of 11.8 , \n while after incorporation of 1 , a reduction in the median \n pore width to 10.9 was observed , consistent with incorporation \n of the [ fe2s2 ] functionality in uio-66-[fefe]dcbdt(co)6 . powder x - ray diffraction ( pxrd ) patterns before and after \n pse confirmed the retention of the crystalline uio-66 framework ( figure 4a ) . fe - sem showed that uio-66-[fefe](dcbdt)(co)6 possesses a nearly identical particle size and octahedral \n particle morphology compared to uio-66 , again indicative of a pse \n mechanism ( figure 3 ) . asterisks \n indicate remaining benzoic acid ( modulator ) and the black square indicates \n dcbdt . the degree of pse was characterized \n by energy - dispersed x - ray spectroscopy \n ( edx ) , elemental analysis ( ea ) , thermogravimetric analysis ( tga ) , \n and proton nuclear magnetic resonance spectroscopy ( h \n nmr ) . the ratio of heavy elements in uio-66-[fefe](dcbdt)(co)6 was determined to be 3.52:1:1.01 ( zr : fe : s , normalized to \n fe ) via edx , which suggests that 14% of bdc in uio-66 was \n exchanged for [ fefe](dcbdt)(co)6 ( figure \n s3 ) . the expected 1:1 fe / s ratio determined by edx also further \n supports that the cluster is intact within the mof . treatment of uio-66-[fefe](dcbdt)(co)6 with dilute hf / d - dmso was used to digest the mof but also decomposed [ fefe](dcbdt)(co)6 to dcbdt . integration of the proton resonances for bdc and \n dcbdt in the h nmr confirmed the degree of pse at 14% \n ( figure 4 ) , giving an overall formula for uio-66-[fefe](dcbdt)(co)6 as zr6o4(oh)4(bdc)5.1([fefe](dcbdt)(co)6)0.92ch3oh . based on this given formula , c / h / n / s elemental analysis also \n confirmed the degree of functionalization [ c(% ) : 32.75 ( obs ) , 32.80 \n ( calcd ) ; h(% ) : 1.75 ( obs ) , 1.68 ( calcd ) ; n(% ) : 0.00 ( obs ) , 0.00 ( calcd ) ; \n s(% ) : 2.97 ( obs ) , 2.84 ( calcd ) ] . unlike pristine uio-66 , which displays \n only one major decomposition step at 400 c , the tga \n trace of uio-66-[fefe](dcbdt)(co)6 exhibits two decomposition \n steps at 80200 and 350400 c , \n respectively ( figure 4 ) . the first mass loss \n is likely due to partial thermal liberation of the carbonyl ligands \n attached to fe centers ( obs : 7% ; calcd : 7.2% ) . both bdc and [ fefe](dcbdt)(co)6 start to decompose at 350 c , leading to a combination \n of zro2 and fe2o phases ( obs : 46.3% ; calcd : \n 43.6% , percent weight residual mass ) . to confirm that compound 1 was being incorporated \n into the framework lattice to give uio-66-[fefe]dcbdt(co)6 , additional experiments were performed to exclude the possibility \n that compound 1 was merely trapped in the pores of the \n mof . in one experiment , compound 2 ( figure 1 ) contains the same cluster core but lacks the coordinating \n carboxylate ligands required for mof formation and hence pse . incubation \n of uio-66 with compound 2 showed no evidence of substantial \n incorporation into the mof as shown by a lack of color change ( figure s4 ) and a low iron content in the edx \n analysis ( figure s5 ) . in a second experiment , \n pse between uio-66 and 1 was performed in d2o , and the presence of bdc was observed in the reaction solution , \n as determined by h nmr ( figure s6 ) , indicative of displacement of bdc by 1 . importantly , \n uio-66 in d2o in the absence of 1 does not \n show release of free bdc into solution . these nmr observations are \n also indicative of a ligand metathesis process and argue against simple \n inclusion of 1 into the pores of the mof . finally , as \n stated above , performing pse between uio-66 and 1 in \n other solvents ( meoh , dmf , and chcl3 ) was not efficient , \n achieving negligible incorporation ( < 2% ) , consistent with the known \n solvent dependence of pse processes . if \n complex 1 was only being included into uio-66 via sorption \n into the pores , then inclusion would not be expected to be strongly \n solvent dependent . taken together , these experiments provide strong \n evidence , consistent with reported pse studies , that the iron cluster \n is becoming part of the uio-66 framework via a ligand pse process \n and that the data do not support simple inclusion of the cluster into \n the pores of the mof . in order to further demonstrate the incorporation \n of the intact \n fe2s2 dinuclear cluster into the mof , we employed \n fourier - transformed infrared spectroscopy ( ftir ) and diffuse reflectance \n uv vis spectroscopy . ftir of uio-66-[fefe](dcbdt)(co)6 exhibited three prominent co stretching vibration bands at 2078 , \n 2038 , and 2001 cm , while no such absorption bands \n were observed for pristine uio-66 material between 2100 and 2000 cm ( figure 4 ) . moreover , the \n relative intensity of these three characteristic bands was identical \n to that of free 1 , suggesting the dinuclear cluster is \n intact in the mof . solid - state uv vis spectroscopy of uio-66-[fefe](dcbdt)(co)6 also showed a characteristic absorption at 350 nm , \n which is consistent with the spectral features of 1 ( figure s7 ) . due to the potentially labile \n nature of [ fefe](dcbdt)(co)6 , we sought to provide data \n to confirm the coordination environment \n of fe2s2 core in the mof . fe k - edge extended \n x - ray absorption fine structure spectroscopy ( exafs ) was performed \n on both 1 and uio-66-[fefe](dcbdt)(co)6 . as \n shown in figure 5 , fourier - transformed exafs \n in r space revealed nearly identical coordination environments of \n the fe centers in [ fefe](dcbdt)(co)6 before and after pse \n into the uio-66 framework . both sets of data were best fit using the \n first and second neighboring atoms of fe from the single - crystal x - ray \n structure obtained for [ fefe](dcbdt)(co)6 , where fe centers \n occupy a distorted octahedral geometry ( see esi ) . exafs of uio-66-[fefe](dcbdt)(co)6 suggests three carbon atoms from carbonyl groups and two \n sulfur atoms bridging the dinuclear fe2 center at distances \n of 1.7961.814 and 2.2832.285 , \n respectively ( table 1 ) . importantly , these \n bond lengths are in good agreement with the crystallographic data \n of 1 ( see esi ) , showing 1.7971.811 \n ( fe c ) and 2.2552.257 ( fe s ) \n . in addition , x - ray absorption near - edge structure indicates a common \n fe(i ) oxidation state of the cluster within the framework and in 1 ( figure s8 ) . fe k - edge exafs fourier \n transforms and exafs spectra ( inset ) for \n ( a ) 1 and ( b ) uio-66-[fefe](dcbdt)(co)6 . solid \n black lines show the experimental data , dashed red lines show the \n fits based on crystallographic data of 1 , and dotted \n gray lines show the fitting \n window . fitting \n data having observed that pse could be used to incorporate \n complex 1 into a robust mof , we explored the suitability \n of this material \n as a catalyst in photochemical hydrogen production schemes . thus , \n uio-66-[fefe](dcbdt)(co)6 was suspended in a 1.0 m acetate \n buffer solution of [ ru(bpy)3 ] photosensitizer \n ( 0.5 mm ) , and ascorbate electron donor ( 100 mm ) at ph 5 . as depicted \n in figure 6 , the projected sequence for photocatalytic \n proton reduction by uio-66-[fefe](dcbdt)(co)6 commences \n with the reductive quenching of photoexcited [ ru(bpy)3 ] by the electron donor ascorbate with a rate constant of \n 1 10 m s. following the analysis of schmehl \n et al . , 14% of * [ ru(bpy)3 ] excited states can be expected to form the [ ru(bpy)2(bpy ) ] reductant \n ( [ ascorbate ] = 0.1 m ; (*[ru(bpy)3 ] ) \n = 500 ns ) . charge recombination between photogenerated [ ru(bpy)3 ] and oxidized ascorbate can be expected to occur \n close to the diffusion limit and will \n compete with the productive heterogeneous electron transfer ( et ) between \n [ ru(bpy)3 ] and uio-66-[fefe](dcbdt)(co)6 . the driving force for the et can be estimated at 300 \n mv from the electrochemically obtained reduction potentials , assuming \n that the reduction potential of the fe2 site in uio-66-[fefe](dcbdt)(co)6 is similar to that obtained for complex 1 in \n solution . from solution studies , it is well established that the electrochemical \n reduction of 1 , and its bdt derivative 2 , is a two - electron process due to inverted electrochemical potentials . \n assuming that the fe2 complex in uio-66-[fefe](dcbdt)(co)6 shows similar reductive chemistry as complex 2 in solution , the driving force for electron transfer from a second \n photogenerated [ ru(bpy)3 ] to the previously \n produced monoreduced fe2 site in the mof will be even > 300 \n mv . the dianionic fe2 site 1 a second plausible \n pathway to 1 is through disproportionation \n of two singly reduced 1 in the mof . \n this disproportionation is thermodynamically feasible as evidenced \n by the inverted electrochemical potentials of the 1/1 and 1/1 couples . reaction scheme for the \n photocatalytic reduction of protons . as demonstrated in figure 7 , uio-66-[fefe](dcbdt)(co)6 is indeed a proton reduction catalyst . under the reaction \n conditions described above , hydrogen production is observed and can \n be quantified with a hydrogen specific solid - state sensor ( see esi \n for details ) . it is thus clear that heterogeneous electron transfer \n between photogenerated [ ru(bpy)3 ] and uio-66-[fefe](dcbdt)(co)6 can compete with homogeneous charge recombination with oxidized \n ascorbate . the fe2 sites within the mof can be reduced \n in a light - driven reaction and are themselves catalysts for the reduction \n of protons to molecular hydrogen . as the rate of electron transfer \n from photogenerated [ ru(bpy)3 ] decreases exponentially \n with distance , it can be assumed that only fe2 sites that \n reside within a few nm from the surface of the mof particles will \n be viable acceptor sites . the de facto concentration of operating \n catalysts in the mof may thus be substantially smaller than the total \n concentration of 1 in the mof . comparing the activity \n of uio-66-[fefe](dcbdt)(co)6 with that of a homogeneous \n reference system that contains complex 1 at concentrations \n similar to the total amount of fe2 complex in uio-66-[fefe](dcbdt)(co)6 shows that the activity of the former is not only preserved \n but actually exceeds that of the latter , both in terms of initial \n rate as well as overall amount of produced hydrogen . control experiments without uio-66-[fefe](dcbdt)(co)6 or with unmodified uio-66 ( which does not contain [ fefe](dcbdt)(co)6 ) do not show meaningful amounts of hydrogen generation ( figure 7 ) . photocatalytic hydrogen production in the presence of \n uio-66-[fefe](dcbdt)(co)6 ( blue trace , 5 mg mof , 0.59 \n mol catalyst ) , \n complex 1 ( red , 0.59 mol ) , uio-66 ( black , \n 5 mg mof ) , and background ( gray ) . conditions : 1 m acetate buffer ph \n 5 , 100 mm ascorbic acid , 0.5 mm [ ru(bpy)3 ] . quantitative comparison between the homogeneous and heterogeneous \n hydrogen production systems must be done with great care , as hydrogen \n production in both systems is not limited by an intrinsic step of \n the catalytic cycle but by insufficient photoproduction of the [ ru(bpy)2(bpy ) ] reductant . nevertheless , figure 7 clearly shows that the heterogeneous system outperforms \n the homogeneous one both in overall hydrogen production as well as \n initial rate . as shown in a recent study , the photoproduction of [ ru(bpy)2(bpy ) ] is not strongly influenced by homogeneous complex 2(39 ) and probably also not by uio-66-[fefe](dcbdt)(co)6 . the amount of available reductant can thus considered to \n be comparable in both systems . also , the heterogeneous et rate constant ket , het in figure 6 is \n presumably not higher than the corresponding ket , hom in the homogeneous reference system . therefore , the \n reasons for the superior catalytic performance of uio-66-[fefe](dcbdt)(co)6 compared to that of the homogeneous reference system must \n be due to differences in the catalyst . a trivial but nevertheless \n important rationale for the increased hydrogen production yield in \n the mof is the stabilization of the catalyst when inside the framework . \n supporting this notion , it was found that uio-66-[fefe](dcbdt)(co)6 recovered after 1 h of photocatalysis still shows the characteristic \n co bands in the ir spectrum ( figure s10 ) . in contrast , and in accordance with published work , complex 1 decomposes under identical \n photocatalysis conditions , as evidenced by the lack of any ir signals \n in the typical co region . as for all photochemical reduction \n schemes based on [ ru(bpy)3 ] , one - electron \n photochemistry needs to be coupled \n to a two - electron catalytic process . with the limited availability \n of reductant , most productive et events will produce singly reduced \n fe2 sites ( 1 ) , while dianionic \n fe2 species ( 1 ) are unlikely \n to be formed by an encounter with a second equivalent of [ ru(bpy)2(bpy ) ] due \n to the low concentrations of both species . as discussed above , it \n is thermodynamically feasible that two 1 sites disproportionate to form the catalytically active 1 site that reacts with two protons to form hydrogen . \n disproportionation as well as protonation needs to occur before the \n reduced species recombine with oxidized ascorbate . here , the fe2 site in uio-66-[fefe](dcbdt)(co)6 has an undisputable \n advantage over the homogeneous system , as its incorporation into the \n mof spatially protects from unproductive charge recombination . moreover , \n the presence of many fe2 sites within the mof may promote \n disproportionation as soon as two monoreduced sites are present . it \n is these kinetic advantages that explain the higher initial hydrogen \n production rates in uio-66-[fefe](dcbdt)(co)6 .", "we employed pse as an efficient and mild approach to obtain the \n first mof that contains a multinuclear , organometallic , nonprecious - metal - based \n proton reduction catalyst . the resulting uio-66-[fefe](dcbdt)(co)6 is a hybrid material that combines the advantages of molecular \n catalysts with a highly ordered and stable inorganic support . [ fefe](dcbdt)(co)6 ( 1 ) is among the most complex structure that \n has ever been introduced into a mof , and its presence and molecular \n integrity within the uio-66 framework could be confirmed by exafs , \n ftir , and other methods . uio-66-[fefe](dcbdt)(co)6 exhibits \n high efficiency for photochemical hydrogen evolution , exceeding that \n of the homogeneous reference system in terms of rate and total hydrogen \n production yield . incorporation of the fe2 complex in uio-66-[fefe](dcbdt)(co)6 results in a higher stability under the photocatalysis conditions , \n protects reduced species from nonproductive charge recombination , \n and may promote disproportionation reactions to produce catalytically \n active dianion 1 ." ]