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american visceral leishmaniasis ( avl ) is a serious public health problem in brazil and presents a new epidemiological profile associated with domestic environments and , in this context , lutzomyia ( lutzomyia ) longipalpis is important considering its capacity to adapt to a wide range of impacted habitats , in addition to its sylvatic origin [ 13 ] .
the enzyme immunoassay ( elisa ) has been used to identify the feeding habits of l. ( l. ) longipalpis [ 46 ] . in light of this , studies related to feeding habits of sand fly vector l. ( l. ) longipalpis could contribute to a better understanding of eco - epidemiology of avl , discussing its close association with leishmania ( leishmania ) infantum chagasi reservoirs .
currently , northeastern brazil accounts for about 47% of human cases for avl exhibiting both epidemiological profiles , rural and urban , with highest incidences of the disease according to the brazilian national leishmaniases program ( nlp ) .
the aim of this study was to identify potential blood meal sources for l. ( l. ) longipalpis from some northeastern brazil endemic municipalities .
sand flies were collected from the municipalities of jequi ( state of bahia , ba ) , sobral and massap ( state of cear , ce ) , and teresina ( state of piau , pi ) .
these municipalities were selected based on their levels and profiles of avl transmission according to nlp : teresina , urban and intense transmission ; sobral , rural and intense transmission ; jequi , rural and moderate transmission , and massap , rural and sporadic transmission .
sand flies were collected from march 2006 to september 2007 during months of high frequency of sand flies .
sand flies were collected using unbaited modified cdc light traps , hp model , between 6:00 pm and 6:00 am for each location ( municipality ) , the same number of site collections was selected ( four houses with human cases of avl and with environmental characteristics adequate for breeding sand flies ) .
collections were done in the peridomicile ; two traps were randomly placed at a minimum distance of 50 meters from the residence and from each other .
the collected sand flies were screened in a cold chamber ( cryolyzer ) , and females were stored in plastic microtubes and placed in a 20c freezer for future analysis .
l. ( l. ) longipalpis engorged females or those with some residual blood meal were tested by elisa , following the method of burkot et al .
modified by duarte using bird , dog , goat , opossum , equine , feline , human , sheep , and rodent antisera ; male specimens of l. ( l. ) longipalpis were used as a control ; they were treated in the same manner as the overfed female samples .
the males for the negative control were chosen because they do not feed on blood and were used to pinpoint false positives in the samples of female sand flies .
the l. ( l. ) longipalpis specimens were identified according to diagnostic morphological features ( cibarium and spermatheca ) . to the analysis , the abdomen of the frozen female specimens , as well as the controls ( males ) ,
were macerated in pbs ( ph 7.2 , 0.001 m ) and kept at 20c until processing .
samples were diluted 1 : 20 in carbonate bicarbonate buffer ( ph 9.6 ; 0.05 m , sigma ) and applied to 96-well polystyrene microplate ( nuncc , 442404 , maxisorp , dermark ) .
after incubation ( at 37c for 2 h ) , plates were washed in pbs / tween 200.05% ( sigma chemicals co - st .
the next steps involved adding antiserum ( pbs / tween 20 plus 1% skim milk
molico - nestl , brazil ) into the wells and incubating the microplate at 37c for 30 min ( goat anti - rabbit serum peroxidase conjugate
sigma chemical usa ) . should be washed , the diluted conjugate , at 1 : 20,000 was added , and after another incubation and wash , the developing buffer ( citrate / phosphate ph 5.00.05 m hydrogen peroxide ( h2o2 ) 30 vol .
the reaction was stopped after 15 min by adding 50 l of sulfuric acid solution 1 n and read on an elisa plate reader ( wi , usa ) using 490 nm operational and 630 nm reference filters . in every plate ,
positive controls were used consisting of homologous sera diluted in carbonate bicarbonate buffer ( ph 9.6 , 0.05 m , sigma ) 200 times . for validation ,
amounts over 1.0 were expected . in order to estimate the positivity of the samples ,
a calculation was made based on the average of the absorbance obtained from the reactions observed in heterologous serums plus two standard deviations ( cutoff point ) .
this procedure was adopted to exclude the results of possible crossover reactions and to increase the specificity of the assay .
the antisera used were obtained from the immunodiagnostics laboratory , department of biological science , escola nacional de sade pblica srgio arouca , fiocruz ; because there are no antibodies to all food sources , we used anti - total protein , which can increase the sensitivity of the method , since the insect feeds on blood .
the assay sensibility is estimated ( 96% ) in the standard operational procedure described in the laboratory where the analyses were performed and described in the reference duarte .
a total of 609 sand fly females were analyzed and a general reactivity index of 60% was obtained ; specimens from massap displayed the greatest diversity in feeding sources , 19 antisera or combinations of antisera unlike the population from jequi , which was reactive to only six .
the percentages of positivity to the antisera tested in four populations of l. ( l. ) longipalpis are presented in table 1 .
bird , dog , and equine antisera were positive for all l. ( l. ) longipalpis populations , with highest positivity observed in blood of birds ( jequi , 36.0% , teresina , 67.6% , sobral , 29.9% , massap , 51.0% ) followed by blood of dogs ( jequi , 16.0% , teresina 9.5% , sobral 14.3% , massap 2.3% ) .
equine antisera were reactive in all populations ( jequi , 16.0% , teresina 2.7% , sobral 15.6% , massap 8.5% ) .
blood from opossum was detected in l. ( l. ) longipalpis females from three populations ( jequi , 8.0% , sobral , 2.6% , and massap , 2.3% ) , and blood of sheep has also been identified in three populations ( teresina 2.7% , sobral 9.1% , and massap 10.8% ) .
human antiserum was reactive in l. ( l. ) longipalpis females from jequi ( 20% ) and massap ( 0.8% ) .
feline and goat antisera showed positivity for females from sobral and massap , respectively . and rodent antisera were reactive only in massap species .
females that had fed on more than one blood meal source for all l. ( l. ) longipalpis populations were detected ; especially those from sobral and massap , specimens were found that had fed on at least three distinct sources . from the 17 blood combinations detected , dog + bird , dog + sheep , dog + equine , dog + opossum ,
previous reports based on field studies have suggested that l. ( l. ) longipalpis has a varied diet , feeding on a wide range of animals , including dogs , pigs , horses , cattle , and chickens [ 3 , 1214 ] . along with favorable environmental conditions ,
it has been suggested that population growth of this sand fly vector is determined by the abundance of food sources , which facilitates its adaptation to human dwellings , especially in rural areas .
the data from the present study show that specimens from the four analyzed populations fed mainly on birds , based on the significant percentage of positivity compared to other feeding sources .
the strong attraction to birds has already been observed in many other studies in brazilian states such as maranho ( ma ) [ 1517 ] and mato grosso do sul ( ms ) .
it is known that when chicken coops are in a peridomicile , they attract sand flies and can act as breeding sites .
this proximity increases contact between vectors and humans , suggesting that chicken coops play an important epidemiological role .although chickens may be refractory to leishmania infection ; they serve as a feeding source for sand flies and attract potential reservoirs of l. ( l. ) i. chagasi , allowing the establishment and maintenance of avl transmission in rural areas . in argentina , a study on the spatial distribution of l. ( l. ) longipalpis found a positive association between the vector and the presence of chicken coops and could contribute to the design of control strategies , defining priority areas for prevention and control .
the positivity to dog blood was confirmed for the l. ( l. ) longipalpis populations analyzed . since the pioneering studies on epidemiology of avl in brazil ( sobral / ce ) , the attraction to dogs was evident . in most avl transmission areas , there is epidemiological evidence implicating dogs as domestic reservoirs .
studies have been suggesting that dogs are an important blood source for l. ( l. ) longipalpis in teresina ( pi ) and araatuba ( sp ) , both areas for high incidence of avl [ 21 , 22 ] .
however , studies conducted in campo grande ( ms ) , an area with high prevalence of avl human cases and where the presence of dogs was observed in all domestic sites , showed a low reactivity for dog blood . in this way ,
sand fly populations may present different feeding preferences in different ecotypes . a low positive reaction to feline antiserum was only found in l. ( l. ) longipalpis females from sobral and massap . in fact , there is no evidence for a role of felines in the avl epidemiology , although recently the experimental infection of l. ( l. ) longipalpis by l. infantum (= l. infantum chagasi ) was described after xenodiagnosis on a naturally infected cat from an endemic area in belo horizonte ( mg ) . in the present study , even with low indices of positivity , opossum blood in specimens from three populations was detected : sobral , massap , and jequi .
this is the first report of an association between l. ( l. ) longipalpis and opossums in brazil . in colombia ,
these data should be analyzed carefully since the opossum ( didelphis albiventris ) has been suggested as a possible secondary reservoir host for l. ( l. ) i. chagasi ; based on studies conducted in jacobina / ba , only 2 of 84 animals were positive , a result that for some authors has no significant epidemiological importance [ 25 , 26 ] .
, possibly l. ( l. ) i. chagasi , arguing the role of these mammals as potential avl reservoirs [ 27 , 28 ] . in light of the evidence for natural infection in opossums and the finding that these animals are feeding sources for l. ( l. ) longipalpis , the possibility that this synanthropic mammal participates in the transmission cycle of avl in some regions should be considered , especially those that have been undergoing environmental alterations , which facilitates contact of these animals with human habitation . the anthropophily of l. ( l. ) longipalpis has been observed in fieldworks [ 13 , 12 , 19 ] , which is one essential criteria in implicating sand fly species as vector .
otherwise , studies evaluating the blood meal of this sand fly conducted in maraj island ( state of par ) and in campo grande ( ms ) demonstrated its high anthropophily [ 4 , 5 ] .
only two l. ( l. ) longipalpis populations ( jequi and massap ) in this study contained human blood in low percentage .
similar results obtained in araatuba suggested low anthropophily of l. ( l. ) longipalpis , which was also observed in studies conducted in colombia .
the abundance of feeding sources ( birds and dogs ) surrounding houses should be considered , as observed at the collection sites in teresina and sobral , it can be a determining factor in the choice of the insect 's feeding source , corroborating the opportunistic behavior of this sand fly .
the finding of more than one blood source in some females , mainly in massap ( up to three ) , is a strong evidence of the eclectic diet of l. ( l. ) longipalpis .
this behavior is common in sand flies , which is to try out different hosts until completing their blood meal .
the adaptation of l. ( l. ) longipalpis to different habitats , even its urbanization , remains a great challenge for avl control .
clearly , the results of this study indicate the eclecticism of l. ( l. ) longipalpis with regard to blood feeding . in light of entomological surveillance of leishmaniases ,
information about the biology of the vector , and especially its interaction with reservoir hosts in association with environmental factors , can indicate changes in the transmission profile of avl and the process of geographical expansion . in this context
, the ability to feed frequently on domestic animals such as birds ( chickens ) , dogs and even synanthropic mammals ( opossums ) is an important attribute that allows l. ( l. ) longipalpis to maintain avl transmission in rural environments and the expansion of the disease to urban areas , contributing to the maintenance of two transmission profiles currently found in brazil .
this paper was supported by instituto oswaldo cruz and escola nacional de sade pblica sergio arouca - fiocruz ; conselho nacional de desewnvolvimento cientfico e tecnolgico , decit - cnpq/2006 ( # 410503/2006 - 1 ) . | the aim of this study was to identify potential blood feeding sources of l. ( l. ) longipalpis specimens from populations in northeastern brazil , endemic areas of american visceral leishmaniasis ( avl ) and its correlation with the transmission of l. ( l. ) i. chagasi .
the elisa technique was applied using bird , dog , goat , opossum , equine , feline , human , sheep , and rodent antisera to analyze 609 females , resulting in an overall positivity of 60% . in all municipalities ,
females showed higher positivity for bird followed by dog antiserum and sand fly specimens were also positive for equine , feline , human , sheep , goat , opossum , and rodent antisera .
the finding for 17 combinations of two or three types of blood in some females corroborates the opportunistic habit of this sand fly species .
the results demonstrating the association between l. ( l. ) longipalpis and opossum suggest the need for further evaluation of the real role of this synanthropic mammal in the eco - epidemiology of avl . |
a
curative therapy has not been established for pd , and a combination of drug therapy ,
surgical treatment , and physical therapy is recognized as the standard treatment1 , 2 . the estimated incidence of pd in japan is 50 per 100,000 in the overall population and 200
per 100,000 in the population aged 64 or older3 .
the number of patients with pd is expected to additionally increase
with the aging of the population in the future4 .
rates of discharge to home in patients with pd are high despite
heavy dependence on medical treatment5 ,
and 85.4% of all patients are under care at home2 .
accordingly , any support system or intervention to maintain
physical function in home care patients is important . in japan
, the nursing care insurance
service seems to play a major role under the current social security system in regard to
health insurance and nursing care insurance .
one survey of outpatients with pd revealed that
75% of pd have been certified as being in need of care , and that the use of ambulatory care
and ambulatory rehabilitation services by pd patients has increased by 38% and 23% ,
respectively , compared with a survey conducted 8 years previously6 .
the number of users of nursing care insurance is also
increasing , although the service contents do not satisfy their needs7 ; tailored intervention is necessary because of great
variations in symptoms and severity among patients2 ,
8 .
in addition , in our study of exercise
therapy in home care patients with pd7 , we
found that a demand existed for intervention tailored to symptoms and their severity ,
because the rehabilitation service provided by nursing care insurance is centered on group
exercise and exercise therapy using machines .
intervention by guidance or by personal or group exercise therapy in patients with pd has
been reported in several studies to improve activities of daily living ( adls)9 , increase exercise capacity and improve
gait10 , 11 , extend range of motion12 , and improve balance13 .
however , few reports are available on the effectiveness of home
visit guidance on home exercise performed voluntarily by home care patients with pd . in
addition
, it is not known how interventions in which home visit guidance is provided affect
aspects of daily living in home care patients with pd , a disease that is characterized by
daily fluctuations such as the on - off phenomenon and wearing - off phenomenon .
our aim was to clarify the effect of home exercise consisting of daily self - administered
exercise by patients ( self - exercise ) and weekly home visit exercise therapy guided by a
physical therapist ( home visit exercise ) on physical function , adls , and postural status in
home care patients with pd .
this cohort study design was based on the performance of a 2-month home exercise
intervention in home care patients with pd and a comparison of physical function and
physical activity between before and after the intervention .
fourteen home care patients
with pd who belonged to the miyagi branch of the japan parkinson disease association
participated in the study .
the inclusion criteria for the pd group were as follows : patients
with no change in antiparkinsonian drugs for 2 months who were in stage ii or iii of the
hoehn and yahr severity scale and were capable of independent locomotion and participation
in the intervention program .
the study was divided into three periods to take account of
seasonal affects on conditions : the first period was from january to february and included
two patients , the second was from february to march and included seven patients , and the
third was from may to june and included five patients .
one patient in the second period and
three patients in the third period withdrew from the study because of hospitalization during
the intervention period , difficulty in conducting the home exercise because of aggravation
of low back pain , or other reasons ; a total of four patients were thus excluded from the
study .
accordingly , the final analysis set included 10 patients ( two male and eight female
patients ) . in the pd group ,
the mean duration of disease was 12.6 years ( sd , 5.6 ) and the
mean number of oral antiparkinsonian drugs being taken was 3.9 ( sd , 1.2 ) .
the home exercise consisted of daily self - exercise by patients and weekly home visit
exercise guided by a physical therapist ( the first author ) ; the intervention period was 2
months .
self - exercise was composed of the following five types of exercises : 1 . stretching ;
2 .
balancing in a four - points - kneeling position , with muscle strengthening ; and 3 .
postural
change movements from sitting for a long time to a four - points - kneeling position . at the
beginning of the intervention ,
the physical therapist ( the first author ) provided guidance
on practice of self - exercise in the form of a self - made booklet with photographs , and the
patients were challenged to perform self - exercise at least three a week .
we asked the
patients to keep a record of their daily training and falls on a calendar to confirm that
they had done the exercise and monitor any falling events during the intervention period . in
order to improve the motivation for self - exercise , guidance of self - exercise by the physical
therapist
was provided to the patients during a visit in the presence of their family . in
addition , the status of implementation of self - exercise was checked weekly .
balancing in a standing position , and 5 . stepping in a
standing position . the physical therapist ( the first author )
patients performed self - exercise with no fixed schedule ,
and the home visit exercise was conducted 1 to 2 h after treatment with antiparkinsonian
drugs .
the
study was planned in accordance with the declaration of helsinki and was conducted with the
approval of the ethics committee of the graduate school of health sciences , hirosaki
university .
prior written informed consent was obtained from the patients , and an encoding
process was used during the analyses to avoid identifying individuals .
an interview and assessment of physical function and physical activity were conducted
before and after the intervention .
the assessment of physical function was always conducted
1 to 2 h after treatment with antiparkinsonian drugs .
we interviewed patients regarding basic issues , including current medical history and
medications , and the following items : implementation of self - exercise : before the intervention , we interviewed patients regarding
their self - exercise habits and the average number of times they had exercised during the
week preceding the study . after the intervention , the number of self - exercise sessions and
the daily average duration of self - exercise ( in min ) were calculated from the written
records of the patients .
chief complaints regarding aspects of daily living : the number of chief complaints
regarding 37 aspects of daily living in relation to the symptoms and signs of pd , adls , and
instrumental adls ( iadls ; see below ) was surveyed in a multiple - answer manner , in accordance
with previous studies14,15,16,17,18 .
falls : patients were asked to state the number of times they had fallen in the past month
and to assess their fear of falling during that time .
the modified falls efficacy scale
( mfes ; scores ) developed by hill et al.19
was used to measure fear of falling .
the mfes scores 14 activities on a 0 ( not confident ) to
10 ( completely confident ) scale .
the maximum total score is 140 points , and higher scores
indicate greater self - efficacy in falling incidents .
parkinson s disease rating scale ( pdrs ) : the pdrs is a scale developed by webster20 that is used to score the severity of
symptoms in patients with pd .
it consists of 10 items , including rigidity , postural
regulation impairment , tremor , and self - care activities .
the maximum total score is 30 points , and a higher score indicates a greater level of
severity .
instrumental activities of daily living ( iadls ) : the tokyo metropolitan institute of
gerontology index of competence ( tmig index of competence21 ) was used as an indicator of the performance of iadls , which are
non - fundamental adls , such as shopping , laundering , telephoning , and medication management ,
that enable an individual to live independently in the community .
the following seven items were selected as indicators of physical function : range of motion : the ranges of motion of shoulder flexion , trunk extension , and trunk
rotation ( shoulder flexion angle , trunk extension angle , and trunk rotation angle ,
respectively , in degrees ) were measured according to criteria established by the japanese
orthopedic association and the japanese association of rehabilitation medicine .
muscle strength : the isometric maximum muscle strengths of the hip flexors and knee
extensors were measured with a handheld dynamometer ( tas f-1 ; anima corporation , tokyo ,
japan ) ; a sensor of the handheld dynamometer was held in the hand to impose manual
resistance in accordance with the posture required for measurement in daniel s &
worthington s muscle testing ( hislop22 ) .
measurements were taken three times , including practice runs , and the maximum value ( n ) was
used in the analysis . because no statistical difference between the sides of the body was
observed in the results , measurements from the dominant leg ( the right foot in all patients )
were used as representative values .
activities of daily living ( adls ) : the functional independence measure23 ( fim ) was used as an indicator of the ability to perform
basic adls such as feeding , going to the toilet , putting on clothes , grooming , and bathing .
the fim consists of 13 physical items and five cognitive items , totaling 18 items .
gait : the time and number of steps required to walk 5 m at an optimum speed were measured ,
and the walking speed ( m / min ) and cadence ( steps / min ) were calculated .
patients walked in
the principal walking style normally they used at home ( with or without a cane ) .
all
patients could walk without a cane . timed up and go ( tug ) test : in the tug test , the time required for an individual to stand
up from a seated position in a chair , walk toward a mark 3 m ahead at their optimum walking
speed , make either a clockwise or counterclockwise turn around the mark , walk back at their
optimum walking speed , and sit down was measured twice , and the mean value was used in the
analysis .
functional reach test ( frt ) : with the patient standing in a comfortable position with the
legs spread approximately shoulder - width apart and with the shoulder on the side of the
dominant arm flexed 90 degrees and the elbow joint completely extended , the distance moved
by the third metacarpal bone from its original position to when the individual reached
forward as far as possible was measured twice , and the mean value was used in the
analysis . functional balance scale ( fbs ) : for the fbs , the berg balance scale24 , a 14-item scale with a total score of 56 points , was used
for assessment .
in addition , a 20-cm stool was used to test movement requiring a foot to be
placed on a stool .
the assessment was conducted in the order of movements listed on the test
sheet . as indicators of daily physical activity status , we measured the amount of physical
activity on the basis of the movements of a site near the center of the body .
we also
recorded the changes in postural state , including the percentages of time spent per 24 h
lying down , sitting , standing , and walking and the number of postural changes .
a high - capacity triaxial accelerometer ( mvp - a3 - 05a - sd ; microstone corporation , nagano ,
japan ) , which had the capacity to record continuously for up to 30 h , was used to measure
the amount of physical activity .
the accelerometer was set with a sampling time of 200 ms
and a low - pass filter of 35 hz . considering the impact of rhythmic segmentation of the head ,
limbs , and other body parts , the device was placed at the middle of the abdomen near the
center of the body to quantitatively assess movement ability in terms of full body motion .
according to the methods proposed by iwashita25 , the resultant acceleration was calculated from the left - right ( x
axis ) , front - back ( y axis ) , and up - down ( z axis ) acceleration .
furthermore , the sum of all
impulse values for a 24-h period was obtained through integration with respect to time
( total impulse , kg m / h ) and used as an indicator of the amount of physical activity . a behavior recorder ( a - mes ; solid brains co. , ltd .
, kumamoto , japan ) consisting of two
3-dimensional position and acceleration sensors ( sampling time : 200 ms ) attached to the
chest and thigh was used to measure the percentages of time spent per 24 h in the four
movements of lying down , sitting , standing , and walking and the numbers of postural changes .
in addition , the time spent lying down was further categorized into the percentages of time
spent per 24 h in a supine , side - lying , or prone position .
the high - capacity triaxial
accelerometer and behavior recorder were attached together to give measurements for 24 h for
2 consecutive weekdays , when average levels of activity were expected .
the wilcoxon signed - rank
test was used to compare data from before and after the intervention , and the statistical
significance level was set at 5% .
of the 10 study patients , four had been engaged in self - exercise before the intervention ;
the remaining majority had not .
two patients had neither been engaged in self - exercise nor used
ambulatory services .
changes between before and after the 2-month self - exercise and home visit exercise
intervention are shown in table 1table 1.results of surveys and measurements before and after the intervention ( n =
10)unitsbefore interventionafter interventionmean(sd)mean(sd)interview itemnumber of self - exercise sessions(times)2.0(2.7)4.7(1.9)*duration of self - exercise sessions(min)8.5(12.0)20.0(9.4)*number of chief complaints(none)18.1(7.7)15.7(6.9)*number of falls(times)0.9(0.9)0.8(1.6)mfes(points)119.0(16.4)127.4(14.2)*pdrs(points)17.0(7.1)16.2(6.8)tmig index of competence(points)10.2(2.3)11.2(2.3)range of motionshoulder flexion(degrees)158.5(11.8)165.0(8.5)*trunk extension(degrees)15.5(6.9)19.5(5.5)*trunk rotation(degrees)44.5(1.6)45.0(0.0)muscle strengthhip flexors(n)115.8(28.7)151.5(24.1)**knee extensors(n)151.7(48.9)191.3(45.3)*activities of daily livingfim(points)118.2(10.0)119.6(10.1)gaitwalking speed(m / min)50.3(8.6)49.5(6.8)cadence(steps / min)136.6(16.2)136.5(14.9)tug(s)10.8(1.8)10.1(1.8)balancefrt(cm)25.4(8.7)28.9(8.7)fbs(points)53.6(3.2)55.6(1.0)amount of physical activitytotal impulse(kg m / h)509.9(103.4)523.2(113.6)postural change statuslying / day(%)36.7(4.8)29.3(10.5)*sitting / day(%)24.0(8.6)31.9(10.9)*standing / day(%)17.7(8.6)14.8(7.7)walking / day(%)21.6(5.2)21.0(6.2)number of postural changes / day(times)477.4(208.8)624.9(499.6)supine / lying(%)79.7(17.3)74.0(20.9)side lying / lying(%)20.2(17.4)25.9(20.9)prone / lying(%)0.1(0.2)0.1(0.1)*p < 0.05 ;
* * p < 0.01 .
* p < 0.05 ;
* * p < 0.01 in the interview survey , a significant change was observed after the intervention compared
with before in the number and duration of self - exercise sessions ; significant increases were
seen in these items after the intervention . in addition
, there was a significant decrease in
the number of chief complaints and a significant improvement in the mfes after the
intervention . however , there was no significant change in the pdrs ( which indicates the
severity of pd symptoms ) or the tmig index of competence , an indicator of iadl . in the physical function tests ,
a significant difference was observed in shoulder flexion
angle , trunk extension angle , hip flexion muscle strength , and knee extensor muscle strength
between before and after the intervention .
no significant changes were observed in fim ,
walking speed , cadence , tug , frt , or fbs . in the physical activity status testing ,
a significant change was seen only in the
percentages of time spent lying down ( percentage time decreased ) and sitting ( percentage
time increased ) .
no significant change was observed in total impulse ( an indicator of the
amount of physical activity ) , number of postural changes , or other parameters .
four of the 10 patients had been engaged in self - exercise on a regular basis ; their main
exercises were stretching and walking .
significant increases in the number and duration of
self - exercise sessions per week were observed after the intervention compared with before .
it seemed that this was due to the effects of guidance in self - exercise and of management of
its implementation by using a self - exercise record book .
these results are the same as those
reported by montgomery et al.26 , who
found an increase in the number of exercise hours after the provision of daily living and
exercise guidance .
in addition , our data on the number and duration of self - exercises before
the intervention highlight a problem : the duration of self - exercise each day in home care
patients with pd is insufficient , even if they are in the habit of performing self - exercise ;
patients may not have the chance to exercise , except when they use ambulatory services
. meanwhile , the number and duration of self - exercise sessions were increased by the
intervention .
accordingly , it seems that guidance and management to promote habitual
self - exercise in home care patients with pd are effective and are needed . in the interview surveys ,
no marked changes were observed between before and after the
intervention in terms of the number of falls , the pdrs , or the tmig index of competence . in
other words , the intervention seemed less effective at treating the number of falls in the
month before the survey , less effective at reducing the severity symptoms of pd , or the
performance of iadls .
however , a decrease in the number of falls13 in the absence of improvement in primary functional
impairment27 , 28 in response to exercise therapy has also been reported . in this
respect , further discussion of the content and duration of our home exercise intervention is
needed .
in contrast , the number of chief complaints and the mfes scores were significantly
improved . in the chief complaint survey , patients were interviewed about how many items were
true of their pd symptoms and made their adl difficult ; the numbers of items decreased after
the intervention .
it seemed that this was because the patients awareness of the effects of
guidance on exercise led to subjective changes29 .
this appeared to result from the patients increased awareness of the
effectiveness of exercise guidance29 and
from the improvement in fall risk scores because of the exercise intervention30 . in the physical function testing ,
shoulder flexion angle , trunk extension angle , hip
flexion muscle strength , and knee extensor muscle strength significantly increased after the
intervention .
the trunk rotation angles in
our patients were close to the normal reference range of motion , even before the
intervention .
this is apparently the reason why no significant difference in this parameter
was observed between before and after the intervention . in relation to adl , gait , and balance ,
no significant difference was observed between
before and after the intervention in fim , an indicator of adl .
some previous studies have
found an improvement in adl after an intervention consisting of exercise therapy11 , 31 , whereas others have reported otherwise32 . opinions are thus not unified .
the following factors were
considered to be the reasons why the results of this study showed no significant differences
in fim before and after the intervention : most of the study patients performed adl
independently ; the intervention period of two months was too short and insufficient ; and the
program of the intervention focused on stretching , muscle strengthening , and postural
change .
interventional effects using
treadmills or external cues such as visual and auditory stimulation during gait33,34,35,36,37 have been reported .
however , it seems that
we observed no significant differences in these parameters because neither a treadmill nor
external cues were used concurrently in the self - exercise and home visit exercises .
moreover , our patients had relatively good walking ability and could walk at an optimum
speed of 50 m / min .
the tug , frt , and fbs reflect walking ability38 . because no change was observed in the indicators of
walking ability between before and after the intervention , no significant changes were
apparent in the tug , frt , or fbs either.in the tests of physical activity status ,
significant differences between before and after the intervention were found only in the
percentages of time spent sitting and lying down .
no significant change was observed in
total impulse as an indicator of the amount of physical activity or in the number of
postural changes . the significant decrease in the percentage of time spent lying down and
the increase in the percentage of time spent sitting were likely a result of the guidance in
self - exercise and the home visit exercise .
the decreased time spent lying down is
particularly suggestive of the effectiveness of the intervention in improving physical
activity status .
because pd patients have reduced opportunities for walking owing to their
increased risk of falling39 , these
patients are prone to sedentary living40 ,
and their decreased activity can contribute to disuse syndrome40 .
furthermore , because many patients with pd experience
difficulty in rolling over with progression of the disease29 , bed rest in a supine position tends to be prolonged .
our
intervention of personal guidance in exercise therapy and self - exercise attempted to solve
these problems .
however , significant improvements in amount of activity or the number of
postural changes were not obtained .
our study focused on the average daily physical activity status of home care patients with
pd .
however , our consideration of the patient s family and the social environment , which can
influence activity status , was not sufficient and is a limitation on our study .
furthermore ,
the individual attention we provided was inadequate as guidance on exercise therapy was
conducted only once a week by a single physical therapist ; this is another limitation of our
study .
in addition to these points , tasks such increasing the number of patients to enable
us to consider disease severity in our investigation , as well as introducing exercise
guidance strategies proposed in previous studies and collaborating with other health
professionals , should be considered in a future study . a 2-month home exercise intervention consisting of self - exercises and home visit exercises
was conducted in home care patients with pd . physical function , adl , and posture status
change were used as indicators .
the intervention had favorable effects on self - exercise
frequency and duration and on self - recognition in terms of a reduction in the number of
chief complaints due to pd symptoms and a reduction in fear of falling .
furthermore , the
intervention was effective in improving flexibility and muscle strength and decreasing bed
rest time .
however , the intervention did not increase the amount of activity or the number
of postural changes and thus did not reduce the overall sedentary nature of the patients
lifestyles .
further improvement of the intervention method , for example by adding group
exercise therapy or collaborating with other health professionals , will be needed to achieve
improvements in physical function and activity that reflect improvements in daily
living . | [ purpose ] the aim of this study was to clarify the effects of guidance in home exercise
on physical function and the amount of activity in home care patients with parkinson s
disease ( pd ) . [ subjects and methods ] a 2-month home exercise intervention consisting of
self - administered exercise by patients ( self - exercise ) and home visit exercise therapy
guided by a physical therapist ( home visit exercise ) was conducted in 10 home care
patients with pd to compare changes in physical function , activities of daily living , and
postural status between before and after the intervention .
[ results ] a decreased number of
chief complaints and alleviation of fear of falling were observed after the intervention .
in terms of physical function , a significant increase in flexibility and muscle strength
were observed , although no significant changes were found in activities of daily living ,
gait , and balance .
although there was no significant change in the total amount of daily
physical activity , the analysis of daily posture changes revealed a significant reduction
in the percentage of time spent lying down and a significant increase in the percentage of
time spent sitting after the intervention .
[ conclusion ] guidance in home exercise in home
care patients with pd can be effective in making self - exercise a habit , improving range of
motion and muscle strength , and reducing the time spent in a supine position . |
oral lichen planus ( olp ) is a chronic inflammatory disease affecting 1 - 2% of general adult population .
andreasen s classical classification was modified by other authors who sub classified olp to reticular , atrophic , and erosive forms . in the erosive form
one theory is that in olp , autocytotoxic cd t - cells initiate the programmed cell death of oral epithelial cells .
other etiologies include stress , several drugs , genetic background , infectious agents , certain dental materials , or an association with autoimmune disorders .
the role of angiogenesis in the development of chronic inflammatory diseases is of considerable concern .
angiogenesis is the development of new blood vessels from existing ones and is an imperious feature in the new tissue formation , and healing of the tissues .
the adult vasculature is mostly quiescent , and angiogenesis does not happen under normal conditions .
therefore , this process has a role in physiological conditions such as embryonic development and wound healing , and in pathological conditions such as growth of cancer , and the development of chronic inflammatory diseases such as rheumatoid arthritis and psoriasis .
vascular endothelial growth factor ( vegf ) is a key regulator of vasculogenesis and angiogenesis .
different cells such as endothelial cells , macrophages , fibroblasts , and smooth muscle cells produce vegf .
it is a chimerical glycoprotein with a molecular weight of 34 - 45 kda , consisting of two subunits .
different physiological and pathological conditions accompanied by hypoperfusion and/or hypoxia can cause upregulation of vegf .
elevated levels of vegf have been reported in the serum of patients with rheumatoid arthritis , polymyositis / dermatomyositis , and active systemic lupus erythematosus .
scardina and colleagues reported that 64.2% of olp samples show vegf expression and they found that a considerable neoangiogenesis occuring in olp .
tao and co - workers assessed the microvessel density and expression of vegf in patients with olp and found that angiogenesis and vegf expression were closely correlated to the different clinical forms of olp lesions .
however , there is no data on the correlation between serum vegf levels and different clinical forms of olp .
therefore , we aimed to evaluate the serum vegf level in patients with olp and to investigate its clinical significance .
in this case - control study , 36 serum samples from patients diagnosed with olp ( 14 men , 22 women , mean [ sd ] age : 38.8 [ 6.07 ] years ) and 23 serum samples from healthy individuals ( 9 men , 14 women , mean [ sd ] age : 38.7 [ 4.9 ] years ) were collected .
the patients were admitted to the oral medicine department at the school of dentistry , shiraz university of medical sciences and were diagnosed with olp both clinically and histopathologically .
the ethics committee of shiraz university of medical sciences approved the study . written informed consent
the types of olp were subclassified into two clinical forms ; reticular ( n=22 ) and erosive / atrophic lesions ( n=14 ) . exclusion criteria for both groups were the presence of any systemic disease , existence of periodontal disease , use of corticosteroid or non - steroid anti - inflammatory medications at least 3 months prior to the study , or a history of malignancy of any type .
serum samples were drawn from clotted blood following centrifugation at 4c and stored at -80c until analysis .
vegf concentrations were measured by sandwich enzyme - linked immunosorbent assay ( elisa ) , according to the manufacturer s instructions ( bms bender med system gmbh , germany ) ( 8) as follows : 1 coating microtiter plate wells with 100 l of the appropriate coating antibody , at a concentration between 1 - 10 g / ml in coating buffer and then cover the plate and incubate overnight at 4c . 2 add 150 l of blocking solution to each well and incubate for 60 minutes at 37c . 3
add 100 l of suitably diluted samples to the relevant wells and incubate for 90 minutes at 37c or overnight at 4c. 4 add 100 l of biotin - conjugated detection antibody ( appropriately diluted in wash buffer ) to each well and incubate them for 1 hour at 37c .
5 add 100 l of enzyme - conjugated streptavidin ( appropriately diluted in wash buffer ) to each well and incubate them for 60 minutes at 37c .
6 add 100 l of the appropriate substrate solution to each well and incubate at room temperature for 30 minutes , or until desired color change is attained .
to determine under curve area and suggestion for diagnostic test , receiver operating characteristics curve ( roc ) was used .
22 ( 61.1% ) women and 14 ( 38.9% ) men were diagnosed as having olp in our study .
the mean [ sd ] serum vegf level was higher in patients with olp compared with the healthy controls ( 112.97 [ 63.2 ] vs. 66.21 [ 56.2 ] ngr / ml , p<0.001 ) . a cut - off point of 71 ngr / ml was found to differentiate the patients with olp from the controls ( sensitivity : 77.8% , specificity : 82.6% , c index : 0.791 , roc analysis ) .
the mean ( sd ) serum vegf level was significantly higher in patients with erosive olp compared with the patients who had the reticular form ( 178 [ 51.62 ] vs. 71.59 [ 20.19 ] ngr / ml , p<0.001 ) .
however , we found no statistically significant difference in serum vegf levels between the men and women ( p=0.885 ) .
moreover , there was no significant correlation between serum vegf levels and the patients age .
recently , many studies have focused on the role of angiogenesis and microvascular endothelial injury in the pathogenesis of different diseases .
furthermore , angiogenesis is correlated with disease activity of some chronic inflammatory diseases such as rheumatoid arthritis , psoriasis , and osteoarthritis .
vegf expression may be induced by numerous inflammatory mediators including il6 , il1 , and il8 and regulated by the oxygen concentration of the tissue , with hypoxia stimulating its expression . as an autoimmune disease with an inflammatory origin and chronic progression , ding and
colleagues found that oral mucosa in patients with olp is under a hypoxic condition ; under which increased angiogenesis and vegf levels can be expected .
another study showed that a series of pro - angiogenic cytokines , including tumor necrosis factor- ( tnf- ) , il-1 , il-6 , and il-8 substantially increased in the tissue of lesions and different oral fluids in patients with olp .
these factors can upregulate the expression of vegf and lead to increased serum vegf levels .
the significantly increased serum vegf level in our patients , may point out that angiogenesis in olp is a systemically driven process .
moreover , because of its high sensitivity ( 77.8% ) and specificity ( 82.6% ) , measuring serum vegf levels can be used as a diagnostic tool .
vegf is expressed in olp tissues within keratinocytes , fibroblasts , inflammatory cells and endothelial cells ; thus , the spill over of vegf from different cells can be the source of elevated serum vegf concentration . in our study ,
the serum vegf level was altered in different clinical subtypes of olp with the erosive / atrophic form showing a particularly increased level .
this finding was consistent with another study showing that angiogenesis and vegf expression were strongly correlated to different clinical form of olp lesions .
the serum vegf level is associated with disease activity in a large number of autoimmune diseases including rheumatoid arthritis , psoriasis and osteoarthritis .
increased level of vegf in the atrophic erosive group implies that angiogenesis can be an implicit indicator of disease activity of olp .
previous immunohistochemical studies have revealed that angiogenetic phenomenon is present in the malignant transformation of many precancerous lesions of the oral epithelium , including olp .
thus , greater tendency for malignant transformation reported in erosive olp lesions , may be related to the increased angiogenesis .
considering the expression of the inducing factors of angiogenesis , new therapeutic modalities based on the use of anti - angiogenic medicine should be considered .
these medications are already used in other pathologies with chronic inflammatory pathogenesis and are yielding good results .
many studies have shown that anti - angiogenic treatment , can decrease disease severity and delay the progression of chronic inflammation in some autoimmune and inflammatory diseases through the specific inhibition of vegf .
considering the poor response to routine immunosuppressive or anti - inflammatory treatment in some patients with olp , and regarding the role of angiogenesis and vegf expression in olp , angiogenesis can be used as an efficient target for therapeutic strategies .
one of the limitations of our study was that we did not have the post treatment serum samples of the patients and therefore , we could not compare vegf levels before and after treatment .
the analysis of serum vegf may serve as a useful and convenient marker to scrutinize the activity of olp .
however , further studies are recommended to measure serum vegf level after therapeutic intervention using anti - angiogenic strategies to evaluate the role of vegf in the treatment of olp .
| background : oral lichen planus is a chronic inflammatory disease with a poorly understood etiology . the role of angiogenesis in the development of different chronic inflammatory diseases is of great concern . vascular endothelial growth factor ( vegf ) is an important regulator of angiogenesis .
we aimed to evaluate the serum level of vegf in patients with oral lichen planus compared with normal individuals and consider its clinical significance .
methods : in this case - control study , 36 serum samples from patients diagnosed with oral lichen planus admitted to the oral medicine department of the school of dentistry at shiraz university of medical sciences ( 14 men , 22 women , mean [ sd ] age : 38.8 [ 6.07 ] years ) and 23 serum samples from healthy individuals ( 9 men , 14 women , mean [ sd ] age : 38.7 [ 4.9 ] years ) were collected .
vegf concentration was measured using the elisa method .
the mann - whitney test was used for statistical analysis .
results : the serum vegf level was significantly higher in patients with oral lichen planus compared with the healthy controls ( 112.97 [ 63.2 ] vs. 66.21 [ 56.2 ] ngr / ml , p<0.001 ) . a similar difference was also observed between the two types of oral lichen planus , being more pronounced in the erosive form ( p<0.001 ) .
conclusion : serum vegf can be used as a useful and suitable marker to scrutinize the disease activity . |
posttraumatic stress disorder ( ptsd ) is an anxiety disorder that can develop following exposure to traumatic life events .
central clinical features of ptsd include a persistent , heightened experience of alarm and distress , as well as a failure of extinction processes to diminish the emotional impact of traumatic memories .
investigation of the neural mechanisms that underlie fear acquisition , consolidation , and extinction may thus enhance our understanding of the neurobiological basis of ptsd , and open opportunities for mechanism - based drug discovery and development of the next - generation pharmacotherapies for this disabling disorder .
the process by which emotionally - aversive memories become consolidated is recognized to be an interaction between glucocorticoid hormones and norepinephrine , both of which are released in response to stress .
the primary component of this response appears to be a noradrenergic signal that is necessary for encoding emotionally salient information .
the hyperconsolidation of traumatic memories in ptsd is driven by a glucocorticoid - hormone - facilitated potentiation of norepinephrine inputs to the basolateral amygdala ( bla ) .
recent work has revealed that this glucocorticoid action is mediated by cannabinoid type-1 ( cb1 ) receptors , a mechanism that is critical for the consolidation of aversive memories and thus implicates cb1 receptors in the etiology of ptsd .
moreover , there is an emerging body of evidence demonstrating an important role for cb1 receptor - mediated endocannabinoid signaling in the extinction of aversive memories . augmenting levels of anandamide in the amygdala modulates short - term fear extinction , thereby resulting in long - term reduction in fear and highlighting the endocannabinoid system as a candidate system for developing novel pharmacotherapies for ptsd .
cb1 receptors are the most abundant g - protein - coupled receptors in the central nervous system , and are found in high concentrations within an amygdala - hippocampal - cortico - striatal circuit responsible for processing and storing fear - related memories and coordinating fear - related behaviors .
animal studies have shown that chronic stress is associated with decreased brain levels of the endocannabinoid anandamide and cb1 receptor adaptations , which in turn give rise to an anxious / depressive phenotype . however , it is not clear whether these animal findings apply to ptsd in humans .
the development of a cb1 receptor selective radiotracer[c]omar now makes it possible for the first time to conduct a quantitative assessment of in vivo cb1 receptor availability using positron emission tomography ( pet ) . in the current study
, we hypothesized that , relative to healthy non - trauma - exposed ( hc ) and trauma - exposed controls ( tc ) , individuals with ptsd would have increased cb1 receptor availability . in light of data from animal studies
, we further predicted more pronounced cb1 receptor elevations in women than men with ptsd .
a tc group free of lifetime ptsd or other psychiatric illness was recruited in order to assess the relation between trauma exposure alone and cb1 receptor availability .
we also assessed peripheral levels of the endocannabinoids anandamide and 2-arachidonoylglycerol ( 2-ag ) ; levels of the fatty acid ethanolamides oleoylethanolamide ( oea ) and palmitoylethanolamide ( pea ) ; and cortisol .
we expected to find lower anandamide and cortisol levels in the ptsd group relative to the hc and tc groups .
finally , psychiatrically relevant biomarkers for ptsd are important yet elusive contributors towards accurate diagnosis and improved clinical care for trauma survivors .
we predicted that measures of cb1 receptor availability , anandamide and cortisol would accurately categorize a majority of participants with regard to ptsd diagnostic status relative to healthy and trauma - exposed controls .
participants were recruited via public advertisements seeking individuals with non - combat trauma histories and healthy control participants with and without lifetime histories of trauma .
the protocol was approved by the new york university institutional review board , the yale university school of medicine human investigation committee , the yale university magnetic resonance research center , and the yale new haven hospital radiation safety committee . after providing written informed consent
, participants underwent a thorough medical and psychiatric evaluation that included physical examination , electrocardiogram , standard blood chemistry and hematology laboratory tests , urine analysis and toxicology , followed by a magnetic resonance ( mr ) imaging scan and a resting pet scan with the cb1 receptor antagonist radiotracer [ c]omar .
psychiatric diagnoses were made using diagnostic and statistical manual of mental disorders , fourth edition
text revision ( dsm - iv - tr ) criteria and the structured clinical interview for dsm - iv ( scid ) , which was administered by an experienced psychiatric clinician .
ptsd symptom severity was assessed using the clinician - administered ptsd scale for dsm - iv ( caps ) and trauma history was assessed using the traumatic life events questionnaire ( tleq ) . only traumatic events meeting dsm - iv - tr ptsd criterion a1 for severe trauma exposure , as well as criterion a2 , which confirms the emotional response to the trauma ( i.e. , response involved intense fear , horror , or helplessness ) , were counted towards participants ' trauma history in this study .
additional assessments included the hamilton rating scale for anxiety ( ham - a ) , the montgomery - sberg depression rating scale ( madrs ) , the alcohol module of the addiction severity index and the fagerstrm test for nicotine dependence ( ftnd ) .
to meet tc inclusion criteria , individuals must have been exposed to at least one potentially traumatic event that met dsm - iv - tr ptsd criteria a1 and a2 , but have no lifetime ptsd or other axis i diagnosis .
participants with significant medical or neurological conditions , substance abuse within 12 months of the pet scan , a lifetime history of substance dependence ( including cannabis ) , or history of head injury with loss of consciousness were excluded from the study .
the absence of substance use ( including cannabis ) was determined by self - report and confirmed by urine toxicology and breathalyzer test at screening , and on the days of mr and pet imaging .
participants were asked to abstain from food , nicotine , and caffeinated beverages after midnight on the day prior to the imaging study until after completion of the scan .
blood samples were collected at the time of tracer injection and processed immediately after collection in the laboratory , which is adjacent to the scan room and frozen at 80celsius until analyzed , as previously described .
[ c]omar was prepared in high specific activity ( 10974 mbq / nmol at end of synthesis ) .
the radiotracer ( injected dose : 589122 mbq , injected mass : 0.050.03 g / kg ) was infused over 1 minute through the antecubital vein . the radioactivity concentration in blood from the radial artery
was measured continuously using an automated system ( pbs101 , veenstra instruments , joure , the netherlands ) for the first 7 min after radiotracer administration and manually drawn and counted thereafter .
discrete samples were acquired at selected times and measured on a gamma counter ( wizard 1480 , perkin - elmer , waltham , massachusetts , united states ) to determine radioactivity concentration in whole blood and plasma .
five discrete blood samples ( 5 , 15 , 30 , 60 , 90 minutes ) were analyzed for the fraction of unchanged [ c]omar and its radiometabolites using a column - switching high pressure liquid chromatography method .
listmode emission data were collected for 120 minutes after radiotracer administration using the high resolution research tomograph ( hrrt ; siemens medical systems , knoxville , tennessee , united states ) , a dedicated brain pet scanner with spatial resolution better than 3 mm .
head motion was measured using the polaris vicra optical tracking system ( northern digital inc . , waterloo , ontario , canada ) and incorporated into pet image reconstruction with all corrections ..
the pet images were registered to subject - specific t1-weighted magnetic resonance images ( 256 256 176 grid of 1 mm isotropic voxels ) acquired on a 3 tesla trio imaging system ( siemens medical systems , erlangen , germany ) .
anatomical mr images were in turn nonlinearly registered to an mr template where regions of interest ( rois ) were defined . regional time activity curves ( tacs )
were extracted from the dynamic pet data and analyzed using the multilinear analysis method with metabolite - corrected arterial input functions and cutoff time t*=30 minutes . the kinetic analysis yielded regional estimates of total volume of distribution ( vt ) , the equilibrium ratio of radioligand concentration in tissue relative to arterial plasma , which is directly proportional to cb1 receptor availability .
shapiro - wilk tests were conducted to assess data distributions of all study variables for normality .
non - normally distributed variables ( e.g. , [ c]omar vt values , cortisol levels ) were transformed using logarithmic - base-10 prior to analysis .
analyses of variance ( anova ) were then used to compare continuously - distributed demographic and clinical variables of the hc , tc , and ptsd groups ; tests were used to compare categorical variables . because [ c]omar vt values across brain regions were highly correlated ( r values=.73 to .96 ) , mean composite [ c]omar vt values were computed by averaging [ c]omar vt values across all brain regions for each individual . a series of analyses of covariance ( ancova )
were then conducted to test for group differences in mean composite [ c]omar vt values , as well as in regions that comprise the amygdala - hippocampal - cortico - striatal circuit implicated in ptsd . in these analyses ,
group ( hc , tc , and ptsd ) and sex were entered as independent variables , age as a covariate , and [ c]omar vt values as the dependent variable .
least - squares difference tests were computed to compare [ c]omar vt values in each of the three groups , with p<.01 used to indicate significant group differences .
effect sizes of differences in [ c]omar vt values in the tc and ptsd groups relative to the hc group were expressed using percent difference and cohen 's d ( ( mgroup1-mgroup2)/sdpooled ) .
similar ancovas were conducted for anandamide , 2-ag , oea , and pea and cortisol values . to examine the relation between [ c]omar vt values , anandamide , and cortisol biomarkers , and ptsd group membership ,
a series of binary logistic regression analyses were conducted , with main effects and all combinations of these variables entered as explanatory variables in separate analyses , and ptsd ( coded 1 ) vs. tc+hc group ( coded 0 ) entered as the dependent variable .
participants were recruited via public advertisements seeking individuals with non - combat trauma histories and healthy control participants with and without lifetime histories of trauma .
the protocol was approved by the new york university institutional review board , the yale university school of medicine human investigation committee , the yale university magnetic resonance research center , and the yale new haven hospital radiation safety committee . after providing written informed consent
, participants underwent a thorough medical and psychiatric evaluation that included physical examination , electrocardiogram , standard blood chemistry and hematology laboratory tests , urine analysis and toxicology , followed by a magnetic resonance ( mr ) imaging scan and a resting pet scan with the cb1 receptor antagonist radiotracer [ c]omar .
psychiatric diagnoses were made using diagnostic and statistical manual of mental disorders , fourth edition
text revision ( dsm - iv - tr ) criteria and the structured clinical interview for dsm - iv ( scid ) , which was administered by an experienced psychiatric clinician .
ptsd symptom severity was assessed using the clinician - administered ptsd scale for dsm - iv ( caps ) and trauma history was assessed using the traumatic life events questionnaire ( tleq ) . only traumatic events meeting dsm - iv - tr ptsd criterion a1 for severe trauma exposure , as well as criterion a2 , which confirms the emotional response to the trauma ( i.e. , response involved intense fear , horror , or helplessness ) , were counted towards participants ' trauma history in this study .
additional assessments included the hamilton rating scale for anxiety ( ham - a ) , the montgomery - sberg depression rating scale ( madrs ) , the alcohol module of the addiction severity index and the fagerstrm test for nicotine dependence ( ftnd ) .
to meet tc inclusion criteria , individuals must have been exposed to at least one potentially traumatic event that met dsm - iv - tr ptsd criteria a1 and a2 , but have no lifetime ptsd or other axis i diagnosis .
participants with significant medical or neurological conditions , substance abuse within 12 months of the pet scan , a lifetime history of substance dependence ( including cannabis ) , or history of head injury with loss of consciousness were excluded from the study .
the absence of substance use ( including cannabis ) was determined by self - report and confirmed by urine toxicology and breathalyzer test at screening , and on the days of mr and pet imaging .
participants were asked to abstain from food , nicotine , and caffeinated beverages after midnight on the day prior to the imaging study until after completion of the scan .
blood samples were collected at the time of tracer injection and processed immediately after collection in the laboratory , which is adjacent to the scan room and frozen at 80celsius until analyzed , as previously described .
[ c]omar was prepared in high specific activity ( 10974 mbq / nmol at end of synthesis ) .
the radiotracer ( injected dose : 589122 mbq , injected mass : 0.050.03 g / kg ) was infused over 1 minute through the antecubital vein . the radioactivity concentration in blood from the radial artery
was measured continuously using an automated system ( pbs101 , veenstra instruments , joure , the netherlands ) for the first 7 min after radiotracer administration and manually drawn and counted thereafter .
discrete samples were acquired at selected times and measured on a gamma counter ( wizard 1480 , perkin - elmer , waltham , massachusetts , united states ) to determine radioactivity concentration in whole blood and plasma .
five discrete blood samples ( 5 , 15 , 30 , 60 , 90 minutes ) were analyzed for the fraction of unchanged [ c]omar and its radiometabolites using a column - switching high pressure liquid chromatography method .
listmode emission data were collected for 120 minutes after radiotracer administration using the high resolution research tomograph ( hrrt ; siemens medical systems , knoxville , tennessee , united states ) , a dedicated brain pet scanner with spatial resolution better than 3 mm .
head motion was measured using the polaris vicra optical tracking system ( northern digital inc . , waterloo , ontario , canada ) and incorporated into pet image reconstruction with all corrections ..
the pet images were registered to subject - specific t1-weighted magnetic resonance images ( 256 256 176 grid of 1 mm isotropic voxels ) acquired on a 3 tesla trio imaging system ( siemens medical systems , erlangen , germany ) .
anatomical mr images were in turn nonlinearly registered to an mr template where regions of interest ( rois ) were defined .
regional time activity curves ( tacs ) were extracted from the dynamic pet data and analyzed using the multilinear analysis method with metabolite - corrected arterial input functions and cutoff time t*=30 minutes . the kinetic analysis yielded regional estimates of total volume of distribution ( vt ) , the equilibrium ratio of radioligand concentration in tissue relative to arterial plasma , which is directly proportional to cb1 receptor availability .
shapiro - wilk tests were conducted to assess data distributions of all study variables for normality .
non - normally distributed variables ( e.g. , [ c]omar vt values , cortisol levels ) were transformed using logarithmic - base-10 prior to analysis .
analyses of variance ( anova ) were then used to compare continuously - distributed demographic and clinical variables of the hc , tc , and ptsd groups ; tests were used to compare categorical variables . because [ c]omar vt values across brain regions were highly correlated ( r values=.73 to .96 ) ,
mean composite [ c]omar vt values were computed by averaging [ c]omar vt values across all brain regions for each individual . a series of analyses of covariance ( ancova ) were then conducted to test for group differences in mean composite [ c]omar vt values , as well as in regions that comprise the amygdala - hippocampal - cortico - striatal circuit implicated in ptsd . in these analyses ,
group ( hc , tc , and ptsd ) and sex were entered as independent variables , age as a covariate , and [ c]omar vt values as the dependent variable . pairwise comparisons
least - squares difference tests were computed to compare [ c]omar vt values in each of the three groups , with p<.01 used to indicate significant group differences .
effect sizes of differences in [ c]omar vt values in the tc and ptsd groups relative to the hc group were expressed using percent difference and cohen 's d ( ( mgroup1-mgroup2)/sdpooled ) .
similar ancovas were conducted for anandamide , 2-ag , oea , and pea and cortisol values . to examine the relation between [ c]omar vt values , anandamide , and cortisol biomarkers , and ptsd group membership ,
a series of binary logistic regression analyses were conducted , with main effects and all combinations of these variables entered as explanatory variables in separate analyses , and ptsd ( coded 1 ) vs. tc+hc group ( coded 0 ) entered as the dependent variable .
reasons for exclusion were previous medication exposure ( n=9 ) and medical reasons that would interfere with correct interpretation of the collected data ( n=4 ) .
table 1 shows demographic , trauma , and clinical characteristics of the hc , tc , and ptsd groups whose data were used for analyses .
[ c]omar injection parameters , age , sex , education , nature of trauma histories , and body mass index did not differ among the groups ; there was a greater proportion of white individuals in the hc than tc and ptsd groups .
the ptsd group was significantly more likely than the hc and tc groups to currently smoke cigarettes , and to have a lifetime history of mood or anxiety disorder , and alcohol or drug abuse , but the groups did not differ with respect to lifetime and current alcohol use and nicotine dependence .
the ptsd group scored higher on the madrs and ham - a relative to both control groups , and on the caps relative to the tc group .
bivariate correlations revealed that composite [ c]omar vt values correlated negatively with age ( r= .34 , p=.007 ) and positively with female sex ( r= .39 , p=.002 ) .
composite [ c]omar vt values also correlated negatively with anandamide levels ( r= .27 , p=.038 ) , but not cortisol levels ( r= .06 , p=.67 ) ; and the correlation between anandamide and cortisol levels was also not significant ( r= .02 , p=.88 ) .
other demographic variables , bmi , lifetime and current alcohol use , current cigarette smoking status and nicotine dependence , and trauma - related variables and lifetime history of mood or anxiety disorders , and alcohol or drug abuse were not associated with [ c]omar vt values ( all r values<|.22| , all p values>.10 ) .
an ancova examining mean composite [ c]omar vt values in the hc , tc , and ptsd groups revealed significant main effects of group ( f(2,53)=7.96 , p=.001 ) , sex ( f(1,53)=5.52 , p=.023 ) , and age ( f(1,53=11.95 , p=.001 ) ; there was a trend towards a significant group - by - sex interaction ( f(2,53)=2.75 , p=.073 ) .
women in the full sample had higher mean composite [ c]omar vt values than men ( m=1.233 , se=.040 vs. m=1.369 , se=.042 , cohen 's d=.61 ) .
as shown in table 2 , mean composite [ c]omar vt values differed by group , such that ptsd group vt was higher than the tc and hc groups , which did not differ .
this same general pattern was also observed in brain regions that comprise the amygdala - hippocampal - cortico - striatal neural circuit implicated in ptsd . as shown in figure 1 , effect sizes for the differences between the ptsd group and hc and
differences between the tc and hc groups were generally small in magnitude . analyses of [ c]omar vt values in brain regions outside of the amygdala - hippocampal - cortico - striatal neural circuit implicated in ptsd revealed this same pattern of results , with the ptsd group having significantly greater [ c]omar vt values than both the hc and tc groups ( all f 's for group effect>4.91 , all p's<.01 ; all p 's for pairwise comparisons<.01 ) .
figure 2 shows mean [ c]omar vt values for the ptsd , and hc and tc groups by sex .
pairwise comparisons revealed that mean [ c]omar vt values were significantly higher among women in the hc ( p=.009 ; d=1.26 ) and ptsd ( p=.011 ; d=1.16 ) groups , but not in the tc group ( p=.65 ; d=.32 ) .
an ancova examining anandamide levels in the hc , tc , and ptsd groups revealed significant main effects of group ( f(2,53)=9.75 , p<.001 ) and sex ( f(1,53)=4.23 , p=.045 ) , but age ( f(1,53)=1.00 , p=.32 ) and the interaction of group - by - sex ( f(2,53)=1.47 , p=.24 ) were not significant .
pairwise comparisons revealed that the ptsd group had lower anandamide levels than both the hc ( p=.001 ; cohen 's d=1.10 ) and tc ( p=.001 ; cohen 's d=1.36 ) groups ; anandamide levels did not differ between the hc and tc groups ( p=.51 ; cohen 's d=.26 ) .
women had lower levels than men ( m=2.44 , se=.24 vs. m=1.76 , se=.23 ; cohen 's d=.54 ) .
oea levels also differed by group , with the hc group having significantly higher oea levels than the tc and ptsd groups ; age ( f(1,45)=2.91 , p=.095 ) , sex ( f(1,45)=.55 , p=.46 ) , and the interaction of group sex ( f(2,45)=.02 , p=.98 ) were not significant .
an ancova examining cortisol levels in the hc , tc , and ptsd groups revealed a significant main effect of group ( f(2,52)=12.69 , p<.001 ) , but sex ( f(1,52)=.05 , p=.82 ) , age ( f(1,52)=1.84 , p=.18 ) , and the interaction of group - by - sex were not significant ( f(2,52)=.33 , p=.72 ) .
pairwise comparisons revealed that the hc group had higher cortisol levels than both the tc ( p<.001 ; cohen 's d=1.59 ) and ptsd ( p<.001 ; cohen 's d=1.22 ) groups ; cortisol levels did not differ between the tc and ptsd groups ( p=.35 ; cohen 's d=.34 ) .
table 3 shows results of binary logistic regression analyses that examined how each of the biomarkers ( [ c]omar vt values , anandamide , and cortisol ) independently and in various combinations related to ptsd vs. hc / tc group membership .
results revealed that the classification accuracy increased as additional biomarkers were added to the model , with the highest classification accuracy observed when [ c]omar vt values , anandamide , and cortisol were entered simultaneously .
we found that ptsd is associated with a ubiquitously expressed large magnitude elevation ( ~20% ) in [ c]omar vt values , which quantitatively reflects cb1 receptor availability .
notably , this elevation was found in an amygdala - hippocampal - cortico - striatal neural circuit implicated in ptsd , as well as in brain regions outside this circuit .
these results suggest greater brain - wide cb1 receptor availability in individuals with ptsd relative to control participants with and without histories of trauma exposure . reduced peripheral anandamide levels in ptsd complemented the brain [ c]omar vt results , suggesting that the elevated cb1 receptor availability in ptsd may result from a combination of both receptor up - regulation and low receptor occupancy by anandamide .
the lack of displacement of cb1 radioligands by agonists which has been attributed to a large receptor reserve suggests that increased [ c]omar vt values are explained to the most part by receptor up - regulation in response to low anandamide levels rather than low receptor occupancy by anandamide .
this idea is substantiated by data showing that cb1 receptor up - regulation in response to low stress - induced synaptic anandamide availability was prevented by enhanced anandamide signaling .
oea levels were higher in hc relative to tc and ptsd participants in the current study , but groups did not differ with respect to 2-ag and pea levels . taken together , these data suggest that abnormal cb1 receptor - mediated anandamide signaling is implicated in the etiology of ptsd .
the sex - related results of the current study accord with animal data demonstrating sex differences in cb1 receptor regulation , with stress - related up - regulation of cb1 receptors observed predominantly in female animals .
another key contribution of the current study is the finding that collective consideration of all three of the biomarkers examined omar vt , anandamide , and cortisol was highly accurate in classifying ptsd , with nearly 85% of ptsd cases correctly classified and overall classification accuracy approaching 90% .
results of this study advance the extant literature in three important ways : ( 1 ) they contribute to extant knowledge regarding the etiology of ptsd ; ( 2 ) they identify candidate biomarkers that may be used to support clinical decision - making regarding diagnostic classification of ptsd ; and ( 3 ) they provide a promising neurobiological rationale to develop novel , evidence - based pharmacotherapies for ptsd .
our results of reduced peripheral anandamide levels together with a compensatory up - regulation of cb1 receptors in ptsd suggest lower anandamide tone in ptsd .
notably , elevated rates of cannabis abuse / dependence among individuals with ptsd have been reported .
such findings substantiate , at least in part , emerging evidence that synthetic cannabinoid receptor agonists or plant - derived cannabinoids such as marijuana may possess some benefits in individuals with ptsd by helping relieve haunting nightmares and other symptoms of ptsd .
however , such data do not allow the conclusion that self - medication with cannabis with its primary psychoactive constituent tetrahydrocannabinol should be recommended for the treatment of ptsd , as direct activation of cb1 receptors with plant - derived cannabinoids over an extended period of time leads to down - regulation of cb1 receptors , which may in turn result in a depression - like phenotype in certain individuals and increase risk of addiction .
another important finding in this study is the sex differences in anandamide levels and [ c]omar vt values in both the hc and ptsd groups .
animal data showing higher cb1 receptor levels in male relative to female animals and receptor fluctuations during the estrous cycle together with changes in affinity of agonist binding highlight the importance of careful considerations of gender and menstrual cycle phase in assessments of cb1 receptor availability in imaging studies .
in addition , we believe , that a conclusive interpretation of the cb1 receptor profile in males and females requires a broad and dynamic perspective rather than a single observation in a cross - sectional study with a single time point .
our results are largely in agreement with a previous study that used the cb1 pet tracer [ f]mk-9470 to investigate the effects of age and gender .
that report found greater plasma parent fraction and higher normalized brain uptake ( suv ) in men , which is consistent with our findings .
however , because of the nearly irreversible uptake kinetics of the radiotracer and the lack of significant gender differences in the metabolite - corrected input function in the initial cohort that underwent arterial blood sampling , the [ f]mk-9470 study used brain suv as the final outcome metric of tracer binding .
we performed kinetic analysis of [ c]omar data using metabolite - corrected arterial input functions in all participants .
this methodology provided estimates of vt , which in contrast to suv , which was greater in men than women was reduced in men compared to women .
thus , our measurements are compatible with those of the previously reported [ f]mk-9470 data and the discrepant interpretations appear to be accounted for by different endpoints centered on our use of arterial input functions in kinetic analyses rather than the simplified outcome of normalized brain concentration . if , as our results suggest , women show higher cb1 receptor availability than men already under basal , non - stress conditions , then they may be at increased risk for ptsd when exposed to trauma .
this finding may thus provide a neurobiological explanation for why women are at greater risk for developing ptsd following exposure to various types of trauma than men even when sexual trauma which is more common in women is excluded . to date
, drug development in ptsd has been opportunistic , building almost entirely on empirical observations with drugs approved for other indications .
the data reported herein are the first of which we are aware of to demonstrate the critical role of cb1 receptors and endocannabinoids in the etiology of ptsd in humans . as such ,
they provide a foundation upon which to develop and validate informative biomarkers of ptsd vulnerability , as well as to guide the rational development of the next generation of evidence - based treatments for ptsd . blocking anandamide deactivation or re - uptake , both
of which will increase synaptic anandamide availability , may lead to a more circumscribed and beneficial spectrum of biological responses than those produced by direct cb1 receptor activation .
this is of particular interest for the development of mechanism - based novel pharmacotherapies for ptsd , as emerging data have revealed that enhanced anandamide signaling can curb the effects of chronic stress , possibly by maintaining normal amygdala function via extinction - driven reductions in fear resulting in improved stress - reactivity in humans . | endocannabinoids and their attending cannabinoid type 1 receptor ( cb1 ) have been implicated in animal models of posttraumatic stress disorder ( ptsd ) . however , their specific role has not been studied in people with ptsd .
herein , we present an in vivo imaging study using positron emission tomography ( pet ) and the cb1-selective radioligand [ 11c]omar in individuals with ptsd , and healthy controls with lifetime histories of trauma ( trauma controls [ tc ] ) and those without such histories ( healthy controls [ hc ] ) .
untreated individuals with ptsd ( n=25 ) with non - combat trauma histories , and tc ( n=12 ) and hc ( n=23 ) participated in a magnetic resonance ( mr ) imaging scan and a resting pet scan with the cb1 receptor antagonist radiotracer [ 11c]omar , which measures volume of distribution ( vt ) linearly related to cb1 receptor availability .
peripheral levels of anandamide , 2-arachidonoylglycerol ( 2-ag ) , oleoylethanolamide ( oea ) , palmitoylethanolamide ( pea ) , and cortisol were also assessed . in the ptsd group ,
relative to the hc and tc groups , we found elevated brain - wide [ 11c]omar vt values ( f(2,53)=7.96 , p=.001 ; 19.5% and 14.5% higher , respectively ) which were most pronounced in women ( f(1,53)=5.52 , p=.023 ) .
anandamide concentrations were reduced in the ptsd relative to the tc ( 53.1% lower ) and hc ( 58.2% lower ) groups .
cortisol levels were lower in the ptsd and tc groups relative to the hc group .
three biomarkers examined collectively omar vt , anandamide , and cortisol correctly classified nearly 85% of ptsd cases .
these results suggest that abnormal cb1 receptor - mediated anandamide signaling is implicated in the etiology of ptsd , and provide a promising neurobiological model to develop novel , evidence - based pharmacotherapies for this disorder . |
wide disparities in health outcomes have been described for racial and ethnic minorities in the united states .
the institute of medicine , charged with examining disparate health outcomes , found that a large body of research supports inequities in health care as possible contributors to inequities in health .
though disparities in obstetrical outcomes have been well documented [ 24 ] , differential obstetrical care by maternal race / ethnicity has been less well studied .
the prevention of early onset group b streptococcal ( gbs ) infection in neonates has become a major public health effort .
the 1990s saw a significant decline in cases of early gbs disease , from 2 to 3 cases per 1,000 live births to 0.5 cases per 1,000 live births , thought largely due to more widespread use of intrapartum antibiotic prophylaxis ( iap ) [ 6 , 7 ] . in 1996 , the centers for disease control and prevention ( cdc ) issued guidelines for the prevention of perinatal gbs disease , and allowed obstetrical providers to choose between two strategies for maternal risk stratification . in one (
risk factor - based ) , women presenting in labor were evaluated for risk factors for early onset gbs disease ( preterm gestation , fever in labor , prolonged rupture of membranes , for example ) and treated if criteria for risk were met . in the other strategy ( screening - based ) , recto - vaginal cultures for gbs were collected between 35 and 37 weeks gestation , and women with positive cultures were treated with iap in labor . in 2002 ,
the cdc released new guidelines , reflective of surveillance data collected since the 1996 release , which compared the effectiveness of the two screening strategies .
the new recommendations included guidelines for universal gbs screening , with the risk - factor based approach deemed to be a substandard strategy .
the demonstration of racial / ethnic disparities in rates of gbs screening would provide evidence of inconsistencies in the quality of care delivered to obstetrical patients and would serve as a concrete area for quality improvement efforts on the part of health care providers and systems .
the documentation of such inequities generally provides a first step towards ameliorating them . to date , few metrics of quality of obstetric care have been identified and used to assess quality , equality or adequacy of care .
the finding of disparities in a process of care measure such as gbs screening may be causally related to disparities in neonatal outcomes . in the current study
, we sought to test our hypothesis that racial and ethnic minority women , in particular , black women , would be less likely to be screened for gbs than white women , both during the time period in which screening or risk - factor based strategies were endorsed by cdc ( 19962002 ) , as well as during the period of recommendation for universal screening ( 2002 and beyond ) .
we also tested the hypothesis that disparities by race / ethnicity would exist irrespective of insurance status ( i.e. , publicly vs. privately insured ) , and that among those women screened , rates of gbs carriage were higher among black women , in particular .
we conducted a retrospective cohort study of women delivering at the university of california , san francisco ( ucsf ) between 1996 and 2008 .
the primary outcome for this study was availability of a recto - vaginal gbs culture result at delivery as a measure of having had screening for gbs performed ; the primary predictor was self - reported maternal race / ethnicity .
in addition , data on maternal socio - demographic and clinical characteristics were evaluated as covariates .
the ucsf department of obstetrics , gynecology & reproductive sciences maintains a perinatal database of all deliveries occurring at ucsf moffitt - long hospital .
each woman s prenatal and inpatient medical record is abstracted by trained research personnel and entered into this database .
women who delivered at or beyond 37 completed weeks of gestation were included in these analyses , as recommendations for the screening strategy call for cultures to be conducted between 35 and 37 weeks of pregnancy .
women transported to our institution for delivery were excluded from analyses , as were women with no information on maternal race / ethnicity .
we conducted bivariate analyses , using chi - squared tests , t - tests and logistic regression to assess the association between availability of gbs culture and each maternal race / ethnicity category , as well as for several other potential confounding factors such as maternal age , parity , number of prenatal care visits , history of a preterm delivery and insurance status .
those variables that were found to be statistically significantly associated ( at the p < 0.10 level ) with availability of gbs culture were retained in multivariable logistic regression models which predicted gbs culture availability as a function of maternal race / ethnicity .
we stratified analyses by time period ( 19962001 and 20022008 ) , and also included a test for trend by year of delivery .
we tested our hypothesis that disparities in gbs screening are not modified by maternal insurance status by testing an interaction between race / ethnicity and insurance status . to demonstrate consistency with findings in other populations
, we sought to confirm that rates of gbs carriage are higher among racial and ethnic minorities in our population by creating multivariable logistic models of gbs carriage among women for whom culture data were available .
all analyses were conducted using the stata 9 statistical package ( statacorp , college station , tx ) .
this study received institutional approval from the committee on human research at the university of california , san francisco .
after exclusion of 603 women with missing data on race / ethnicity , there were 16,333 women who met study inclusion criteria .
this varied greatly by year of delivery : for those women delivering between 1996 and 2001 ( before the cdc recommendation for universal screening ) , the proportion of available cultures was 26.9% . between 2002 and 2008 , the proportion of available culture data was 86.2% . in 2008 , the proportion was 98.5% .
characteristics of the study population are shown in table 1 . in unadjusted analyses , asian ( odds ratio ( or )
0.86 [ 95% ci 0.80 , 0.94 ] ) and black women or 0.73 [ 0.66 , 0.80 ] were less likely to have gbs results available than were white women .
known gbs status at delivery was also associated with older maternal age and private insurance . in multivariable regression modeling , also presented in table 1 , black race remained an independent predictor of absence of a gbs result at delivery ( adjusted odd ratio ( aor ) 0.80 [ 0.69 , 0.94 ] ) .
models were adjusted for parity , public vs. private insurance , number of prenatal visits , gestational age , prior preterm delivery , and year of delivery.table 1socio - demographic and clinical characteristics of the study population , n = 16,333% population or ( mean sd)% with available gbs culture or ( mean sd)prace / ethnicity<0.001 asian17.358.9 black12.854.8 latina11.462.1 white45.962.4 other12.659.0age(30.2 6.2)(30.7 6.1)<0.001parity0.07 nulliparous54.961.0 multiparous45.159.6insurance<0.001 private75.662.0 public24.455.3number of visits(7.9 3.2)(7.5 3.2)<0.001previous preterm delivery2.150.3<0.001year of delivery<0.001 1996200143.526.9 2002200856.586.2 socio - demographic and clinical characteristics of the study population , n = 16,333 when we stratified the population by year of delivery ( 19962001 vs. 20022008 ; table 2 ) , black women remained statistically significantly at lower odds of having gbs culture data available at delivery in the earlier time period ( aor 0.79 [ 0.65 , 0.97 ] ) but this lower odds did not reach statistical significance in the later time period ( aor 0.85 [ 0.65 , 1.12 ] ) . during 19962001 , asian women were also less likely to have known gbs status ( aor 0.75 [ 0.63 , 0.88 ] ) , but not during 20022008 . in the earlier time period public health insurance coverage was associated with a lower odds of gbs status availability ( aor 0.83 [ 0.71 , 0.98 ] ) , but not in the later time period .
no significant interactions were noted between race / ethnicity and insurance status during either time period.table 2unadjusted and adjusted odds of available gbs culture , in all years and stratified by year of deliveryunadjusted or for available gbs culture ( 95% ci ) : all yearsadjusted or for available gbs culture ( 95% ci ) : all yearsunadjusted or for available gbs culture ( 95% ci ) : 19962001adjusted or for available gbs culture ( 95% ci ) : 19962001unadjusted or for available gbs culture ( 95% ci ) : 20022008adjusted or for available gbs culture ( 95% ci ) : 20022008race / ethnicity asian0.86 ( 0.80,0.94)0.89 ( 0.78 , 1.01)0.79 ( 0.68 , 0.92)0.75 ( 0.63 0.88)1.09 ( 0.92 , 1.30)1.18 ( 0.95 , 1.47 ) black0.73 ( 0.66,0.80)0.81 ( 0.69 , 0.95)0.77 ( 0.65 , 0.91)0.79 ( 0.65 , 0.97)0.86 ( 0.72 , 1.04)0.85 ( 0.65 , 1.12 ) latina0.98 ( 0.89,1.09)0.92 ( 0.78 , 1.08)1.01 ( 0.85 , 1.21)1.01 ( 0.83 , 1.22)1.10 ( 0.92 , 1.30)0.80 ( 0.61 1.03 ) white1.001.001.001.001.001.00 other0.86 ( 0.78,0.95)0.88 ( 0.76 , 1.02)0.84 ( 0.71 , 1.00)0.80 ( 0.66 , 0.96)1.16 ( 0.95 , 1.42)1.05 ( 0.81 , 1.36)age1.03 ( 1.02,1.03)1.00 ( 0.99 , 1.01)1.01 ( 1.00 , 1.01)1.00 ( 0.99 , 1.01)1.01 ( 1.00 , 1.02)0.99 ( 0.98 , 1.00)parity nulliparous1.06 ( 1.00,1.12)see footnote0.95 ( 0.86 , 1.06)see footnote1.28 ( 1.14 , 1.44)see footnote multiparous1.001.001.00insurance private1.001.001.001.001.001.00 public0.75 ( 0.71,0.82)0.87 ( 0.77 , 0.99)0.86 ( 0.77 , 0.97)0.83 ( 0.71 , 0.98)0.93 ( 0.81 , 1.08)0.92 ( 0.74 , 1.13)number of visits0.91 ( 0.90,0.92)see footnote0.98 ( 0.97 , 1.00)see footnote1.04 ( 1.02 , 1.06)see footnoteprevious preterm delivery0.69 ( 0.53,0.82)1.45 ( 1.09 , 1.94)1.44 ( 1.09 , 1.92)1.50 ( 1.10 , 2.04)0.62 ( 0.40 , 0.98)0.72 ( 0.40 , 1.30)year of delivery 199620011.00see footnote 2002200816.9 ( 15.6,18.3)adjusted for other covariates presented , in addition to parity ( as a continuous variable ) , gestational age , number of prenatal visits ( as a categorical variable ) and year of deliveryvalues in italics have p < 0.05 unadjusted and adjusted odds of available gbs culture , in all years and stratified by year of delivery adjusted for other covariates presented , in addition to parity ( as a continuous variable ) , gestational age , number of prenatal visits ( as a categorical variable ) and year of delivery values in italics have p < 0.05 a test for trend shows a significant increase in the odds of available gbs data at delivery in more recent years ( p < 0.001 ) .
relative to the year 2002 , the odds of having a gbs culture available in 1996 was 0.61 [ 0.51 , 0.73 ] , and was 140.3 [ 76.2 , 258.5 ] in 2008 .
figure 1 demonstrates the proportion of women with available gbs data by race / ethnicity and year of delivery . prior to 2002 ,
women of racial / ethnic minorities were less likely , on average , to have gbs screening completed by delivery , while after 2002 , the differences are less pronounced.fig .
1proportion of women with available gbs culture data , by year of delivery and maternal race / ethnicity proportion of women with available gbs culture data , by year of delivery and maternal race / ethnicity when we explored the rates of gbs - positive culture among women with culture data available at delivery , women of all minority groups were more likely to have gbs detected on rectovaginal culture than were white women ( aor for asians 1.22 [ 1.07 , 1.40 ] , blacks 1.98 [ 1.68 , 2.35 ] , latinas 1.32 [ 1.13 , 1.55 ] and other 1.31 [ 1.12 , 1.53 ] ; table 3).table 3risk of presence of gbs on rectovaginal culture by race / ethnicity , among women with known gbs statusrace / ethnicitygbs+/number screened ( % ) adjusted orasian415/1,733 ( 24.1)1.22 ( 1.07 , 1.40)black432/1,192 ( 36.2)1.98 ( 1.68 , 2.35)latina321/1,201 ( 26.7)1.32 ( 1.13 , 1.55)white990/4,836 ( 20.5)1.00other311/1,255 ( 24.8)1.31 ( 1.12 , 1.53)adjusted for maternal age , parity , gestational age , number of prenatal visits , insurance , year of delivery and prior preterm deliveryvalues in italics have p < 0.05 risk of presence of gbs on rectovaginal culture by race / ethnicity , among women with known gbs status adjusted for maternal age , parity , gestational age , number of prenatal visits , insurance , year of delivery and prior preterm delivery values in italics have p < 0.05
in our population of women with term deliveries , black women were significantly less likely to be screened for gbs than were white women .
these findings were most significant during the time period when the cdc allowed for a risk - factor based or screening - based approach to the reduction of early - onset gbs disease ( eod ) .
following their 2002 recommendations for universal screening for gbs , rates of screening were similar for women of different race / ethnicities . during the same time period , there was a dramatic increase in overall screening rates for gbs , as has been documented elsewhere .
disparities in recommended screening for gbs are of concern , especially in light of the recent release of surveillance data for eod in the united states between 2000 and 2006 .
it is well known that black race is a risk factor for eod [ 6 , 11 , 12 ] .
the most recent data demonstrate that the sole group in which the incidence of eod is on the rise is black term infants , a group which saw an increase in incidence from 0.33 cases per 1,000 live births to 0.70 cases per 1,000 live births from 2003 to 2006 .
a prior study in north carolina in 20022003 showed that hispanic women and women receiving care in a hospital clinic or health department were less likely to be screened for gbs .
this study relied on maternal self - report ; our study has as a strength our ability to have objective evidence of gbs status availability .
another investigation of predictors of screening for perinatal infections in 20002001 revealed no differences by race / ethnicity or insurance status with regards to universally - recommended screenings for infections such as hepatitis b , syphilis and rubella , but did show some variation by both race / ethnicity and insurance for infections in which recommendations at the time were based on risk factors , such as gbs , hepatitis c and varicella .
the authors suggest that the systems of care in which minority and poor women may be enrolled may have different practice standards , reflective of provider and patient awareness , as well as reimbursement rates of insurers .
our finding that race / ethnicity and insurance predicted gbs screening in the era prior to the recommendation for universal screening , but not after , would support this notion .
the institution of uniform practice standards and the reduction in permissive variability in care may be effective strategies to reduce disparities in health care and outcomes .
we also confirm a higher risk among black women of carriage of gbs among those women who were screened during pregnancy , consistent with other reports [ 16 , 17 ] , and reiterating the need for adherence to best practices for screening in all populations .
our study benefits from its conduct in a single delivery center and from inclusion only of patients with term deliveries , not transported to our institution from other centers .
we therefore believe that our ascertainment of availability of gbs data is quite good , though we are not able to validate the accuracy of the perinatal database using primary microbiology laboratory records . while there is a possibility of differential documentation of gbs status in the medical chart by race / ethnicity or practice
our ability to capture deliveries from the entire period from the 1996 cdc recommendations for screening vs. risk factor based protocols , through their mandate for universal screening and into the present day also represents a strength .
we do not believe the association between race / ethnicity and availability of gbs results to be confounded by the natures of the practices in which patients are seen ; in our institution , insurance status is a close proxy for obstetrical practice , and we have adjusted for the former in our analyses .
our outcome is derived from review of the medical record , and not from laboratory data .
while in some ways this limits our ability to comment on true availability of culture data , our outcome definition lies closest to the information available to the providers at the time prenatal and intrapartum care was rendered .
other studies have documented that , despite high rates of overall screening since 2002 , screening may not occur at the appropriate time ( e.g. , prior to 35 weeks , then not repeated ) [ 18 , 19 ] ; we did not look specifically at this phenomenon .
we are also unable to comment on rates on intrapartum antibiotic prophylaxis among women with risk factors or positive screens for gbs in this population ; this rate represents another potential measure of obstetrical care quality . and
lastly , while it is likely that black women in this population were somewhat more likely to have had gbs bacteriuria or a prior neonate affected by invasive gbs disease , and thus appropriately not screened by recto - vaginal culture in the index pregnancy , we do not believe that the magnitude of the racial / ethnic differences in these conditions explains the extent of the absolute difference in screening rates that we witnessed in the early period .
racial and ethnic minorities are less likely to receive recommended immunizations , less likely to be screened for colorectal cancer and less likely to receive weight management counseling if obese .
it is therefore not surprising that disparities in quality of obstetrical care exist as well . in our field , however , we have relatively few agreed - upon metrics of quality care .
screening for gbs , while not a measure used by groups such as the agency for healthcare research and quality when reporting quality of care , is clearly a key component of antenatal care , with relevance to neonatal outcomes .
disparities in this procedure should raise a warning that similar disparities likely exist in other areas of obstetric care that allow for similar variability in management styles as seen in the pre-2002 era of gbs screening .
while other process measures are perhaps less easily measured , they may be no less important to maternal and infant outcomes .
clinical , research and health policy endeavors should have as a goal ensuring that patients , providers and systems of care all contribute positively to equitable processes of care and health outcomes . | the objective of this article is to determine whether racial / ethnic disparities exist in screening for group b streptococcus ( gbs ) colonization among pregnant women .
a retrospective cohort study of deliveries at a single institution was conducted .
the primary outcome was the availability of gbs culture data at the time of delivery ; the primary predictor was maternal race / ethnicity .
analyses were stratified by the time periods before and after the cdc recommendations for universal screening for gbs . among 16,333 deliveries ,
60.4% of the population was screened for gbs but screening rates varied markedly by year of delivery .
black women had a lower odds of having available gbs data ( aor 0.81 [ 0.69 , 0.95 ] ) but this disparity was limited to the period of time before universal screening was recommended .
prior to the recommendation for universal screening for gbs , racial / ethnic disparities existed in rates of screening among pregnant women delivering at term .
these differences were reduced after 2002 , suggesting that uniform policies regarding obstetrical care may be effective in eliminating disparities in obstetrical care and outcomes . |
surveys on skin diseases of dogs demonstrate that neoplastic tumors of the skin are common [ 13 ] .
several studies report that in dogs the skin is the most commonly affected organ for both neoplastic and nonneoplastic tumors [ 47 ] . in one study ,
it has long been recognized among human populations that incidence rates and relative frequencies for several types of neoplasms differ markedly by geographic region .
although studies on cutaneous neoplasms of dogs from different geographic regions report similarities , differences in tumor types and relative frequencies have also been reported .
such studies include those from the united kingdom ; greece ; united states of america ; australia ; korea ; thailand ; brazil ; zimbabwe ; india ; zambia .
for example , cutaneous histiocytoma was the most frequently reported neoplasm in dogs in india and zambia [ 16 , 17 ] ; lipoma was the most common skin tumor in dogs in korea , and mast cell tumor ranked first in studies on dogs from the united states , thailand , the united kingdom , greece , brazil , and zimbabwe [ 6 , 7 , 10 , 11 , 14 , 15 ] .
transmissible venereal tumor in the skin was only reported in studies from korea and brazil [ 13 , 14 ] .
studies on canine nonneoplastic skin tumors have also reported differences in types and in frequency of these tumors .
for example , studies from korea , thailand , and brazil report that epidermal and follicular cysts are the most common nonneoplastic tumors affecting the skin of dogs followed by sebaceous hyperplasia , whereas a study from serbia reports only the occurrence of dermoid cysts [ 7 , 8 , 13 , 14 ] .
although geographic differences for the types and frequencies of canine cutaneous neoplastic and nonneoplastic tumors are recognized , the reasons for these differences are not well understood .
for some types of cutaneous tumors it is likely that both climate and the breeds of dogs in respective locations play a role .
ultraviolet radiation from sunlight has been implicated as a risk factor for canine cutaneous hemangiosarcoma , hemangioma , and squamous cell carcinoma [ 18 , 19 ] .
importantly , none of the studies on the frequencies of canine skin tumors to date reflect data from tropical island communities such as exist in the caribbean .
we hypothesize that in grenada , a small island state in the caribbean with a warm , humid climate ( mean temperature of 28c/82f ) and a relatively confined , interbreeding mongrel dog population that the types and relative frequencies of canine skin tumors are different from that reported elsewhere . to our knowledge , this study is the first survey of canine skin tumors in a small tropical island setting . the objectives of this retrospective study were to identify the most common histologic types of cutaneous neoplastic and nonneoplastic canine tumors , determine the relative frequency of each tumor type , and compare the results with published findings from different geographic regions .
the island of grenada is bordered by the caribbean sea to the west and the atlantic ocean to the east .
the island has equable temperatures varying slightly with altitude and averaging 82f ( 28c ) .
canine skin biopsies and samples from necropsy cases with skin masses suspected to be neoplastic processes and submitted to the diagnostic pathology laboratory from 2002 to 2007 were included in this study .
samples were submitted from the small animal hospital , the grenada society for prevention of cruelty to animals and from private clinics .
samples were submitted fixed in 10% buffered formalin , processed , sectioned at 3 m , stained with hematoxylin and eosin , and examined microscopically .
tumors were diagnosed and classified according to the current world health organization ( who ) classification of animal tumors [ 2123 ] . where possible , history relating to sex , breed , age , and site of the tumor on the body was obtained along with the submission .
location of the tumor on the body was categorized into 4 groups : head and neck , trunk , limbs , and multiple sites . in this study , masses were grouped according to neoplastic , nonneoplastic , and inflammatory .
we defined nonneoplastic tumors as neoplastic - like lesions without an inflammatory component whereas masses with inflammatory infiltrates with / or without an intralesional etiologic agent were defined as inflammatory lesions .
in addition , published studies on skin tumors of dogs from other geographic regions were evaluated and compared with the results of our study .
two hundred and twenty five canine skin masses from 207 dogs comprising 89 females and 118 males were examined . among these skin masses ,
the prevalence of neoplasms was 72% ( 95% confidence interval , 66.13% to 77.87% ) ( 162/225 ) .
thirty - five ( 15.6% ) ( 95% ci , 10.82% to 20.3% ) were diagnosed as nonneoplastic tumors , and 28 ( 12.4% ) ( 95% ci , 8.13% to 16.75% ) were inflammatory conditions .
inflammatory conditions included pyogranulomatous dermatitis ( 50% ) ; nodular and diffuse chronic dermatitis ( 25% ) ; deep and superficial pyoderma ( 10.7% ) ; sterile granuloma ( 10.7% ) , and allergic dermatitis ( 3.6% ) .
more than half of the samples ( 58% ) were from the mixed local breed of dog referred to as the grenadian pothound .
pothounds are the most common type of dog in grenada . they are often owned but generally allowed to wander at will .
other breeds represented in this study in descending order of frequency were german shepherd dog , rottweiler , boston terrier , jack russell terrier , scottish terrier , pompek , rhodesian ridgeback , labrador retriever , boxer , golden retriever , shih tzu , dachshund , doberman pinscher , bulldog , pit bull terrier , bouvier , and anatolian shepherd dog .
the frequency , mean age in years , and male - to - female ratio of each neoplastic and nonneoplastic tumor type are as shown in table 1 . among the 162 neoplastic skin masses examined ,
the 10 most common neoplasms were hemangiosarcomas 31 ( 19.1% ) , histiocytomas 14 ( 8.6% ) , melanocytomas 13 ( 8% ) , mast cell tumors 11 ( 6.8% ) , lipomas 11 ( 6.8% ) , hemangiopericytomas 10 ( 6.2% ) , papillomas 9 ( 5.6% ) , fibrosarcomas 9 ( 5.6% ) , hemangiomas 8 ( 4.9% ) , and squamous cell carcinomas 7 ( 4.3% ) . among the 10 most common neoplasms ,
the type of neoplasm and prevalence in each of the two breed categories ( local mixed breeds and other breeds ) is as shown in table 2 .
there were 10 types of nonneoplastic tumors including sebaceous hyperplasia 9 ( 25.7% ) , fibroepithelial polyps 8 ( 22.9% ) , collagenous hamartomas 4 ( 11.45% ) , infundibular cysts 4 ( 11.45% ) , fibroadnexal hamartomas 3 ( 8.6% ) , scrotal vascular hamartomas 2 ( 5.7% ) , isthmus cysts 2 ( 5.7% ) , sebaceous hamartomas 1 ( 2.8% ) , dermoid cysts 1 ( 2.8% ) , and fibropruritic nodules 1 ( 2.8% ) . among the neoplastic tumors , 62 ( 38.3% ) were malignant whereas 100 ( 61.7% ) were benign .
generally , neoplasms occurred in relatively older dogs with a mean age of 7.6 years .
neoplastic tumors were most frequently located on the trunk followed in descending order by limbs , head and neck , and multiple sites . among nonneoplastic tumors limbs were the most frequently affected site followed by trunk , head and neck , and multiple sites .
of the 4 cases of cutaneous transmissible venereal tumor ( tvt ) in this study , 3 were diagnosed in castrated males and one was diagnosed in an intact female .
it was not clear from the records if the dogs were castrated prior to presentation or at the time of tumor removal .
hepatoid ( perianal ) gland tumors were diagnosed in 2 male dogs of unknown neuter status and in 1 spayed female .
results from our study confirm that the types of skin tumors affecting dogs in grenada are consistent with previous reports from other geographic areas but the relative frequency of skin tumor types differ . in our study
neoplastic tumors represented 72% ( 95% ci 66.13% to 77.87% ) of all skin masses ( neoplastic , nonneoplastic , and inflammatory ) .
this is within the range of other published studies conducted in zimbabwe , brazil , and india where neoplastic tumors represented 60% , 88% , and 95% , respectively of all skin tumors [ 1416 ] .
however , when the frequency of neoplastic tumor types is compared , important differences are noted ( table 3 ) . in our study hemangiosarcoma was the most commonly reported canine skin neoplasm . in other studies
the most commonly reported skin neoplasm was the mast cell tumor except for korea where lipoma was more frequently reported and india and zambia where histiocytoma was the most commonly reported skin neoplasm [ 16 , 17 ] .
our study is the first to report hemangiosarcoma as the most commonly diagnosed canine skin neoplasm , comprising 19.1% of all cutaneous neoplasms evaluated .
adhering to the 1998 who classification of tumors of vascular tissue , a diagnosis of hemangioma was restricted to well - circumscribed tumors consisting of vascular channels lined by well - differentiated cells .
this differs from the approach taken by hargis et al . where greater emphasis was placed on the presence of mitotic activity such that even locally infiltrative lesions were classified as hemangiomas . in dogs
it is now generally accepted that solar radiation is a contributing factor in the development of several skin neoplasms including hemangiomas and hemangiosarcomas [ 1821 ] . indeed , gross et al .
recognize a subset of vascular tumors as solar - induced dermal hemangiomas ; they note the difficulties in distinguishing benign tumors from malignant and suggest that there is a continuum from vascular ectasia to benign and malignant neoplasia . in our study
the majority of the vascular growths were located on sparsely haired areas such as the ventral abdomen , inguinal areas , and limbs .
this lends support to a role of sun exposure in the pathogenesis of these skin neoplasms , as sparsely haired skin is more exposed to the harmful effects of solar radiation than haired areas . additionally , in the adjacent nonneoplastic areas of some of these neoplasms we noted other changes that may be associated with solar radiation , including vascular ectasia ( 18 dogs ) , mild superficial dermal fibrosis ( 11 dogs ) , collagen degeneration or solar elastosis ( 4 dogs ) , pigmentary incontinence ( 3 dogs ) , and hyperkeratosis ( 2 dogs ) .
importantly , there is abundant sunshine in grenada year around , and most dogs in grenada live outdoors their entire lives .
this is in direct contrast with the situation in the greek study where 2.9% of 174 neoplasms were hemangiosarcomas and 3.4% were hemangiomas ; the authors noted that the majority of dogs in their area spent most of their time indoors .
genetics should also be considered as a possible risk factor for these vascular skin tumors in dogs , as inherited forms of cutaneous angiomatosis in humans have been documented , and in dogs there is a breed predisposition for scrotal vascular hamartomas .
although not in the top 10 most common skin neoplasms , the frequency of cutaneous tvt was high in our study compared to other studies , comprising 2.5% of all skin neoplasms .
the majority of the published studies reviewed did not report any tvt in the skin of dogs .
only studies from brazil and korea reported cutaneous tvt and in both of these studies cutaneous tvt represented less than 0.6% of skin neoplasms out of over 600 cutaneous neoplasms evaluated in each study [ 13 , 14 ] .
the higher frequency of cutaneous tvt in dogs in grenada may reflect uncontrolled breeding as a result of unrestricted movement of unneutered dogs .
it is also possible that the pothound , the predominant dog type in grenada , is at increased risk for cutaneous tvt , as was suggested in a previous report .
all but one of the studies evaluated for comparison to our results had mast cell tumors ranked first in relative frequency for skin neoplasms ( table 3 ) . in our study mast cell tumors were ranked 4th .
it has been reported that certain breeds of dogs , including boxers , labradors , and terriers , are at increased risk for mast cell tumors [ 10 , 20 ] .
the lower ranking for frequency of mast cell tumors in our study is likely due to few pure breed dogs known to be at increased risk for this tumor type in our study population .
most histiocytomas ( 6080% ) occur in dogs less than 5 years of age , though they can be found throughout life . in our study age
of these 12 dogs 7 were under 5 years of age with 4 of these being under 2 years of age .
a few older dogs in our small sample size for this tumor type resulted in a mean age of 4.7 yrs .
several other studies also report a mean age similar to our observation . in a study from australia
the mean age was 3.9 years ( range 5 months to 13 years ) ; in a study from zimbabwe the mean age was 5.45 years ( range 0.6 to 12 years ) ; in a study from thailand the mean age was 5.13 years ( range 3 months to 15 years ) [ 7 , 12 , 15 ] .
it is possible that the age distribution in our study reflects a delay in diagnosis due to the fact that routine and preventive veterinary care for dogs is not the norm in grenada . to our knowledge
this is the first study detailing the types and frequencies of neoplastic and nonneoplastic skin tumors in dogs from grenada .
one limitation of this study is that it does not include samples from dogs which were not evaluated by a veterinarian . nor does it include samples from dogs seen by veterinarians who did not request histologic evaluation of skin masses .
thus , comparison of relative frequencies of the tumor types in this study to other studies has merit and helps to shed light on possible risk factors for specific tumors . in our study
the grenadian pothound is the most frequently represented type of dog diagnosed with skin tumors , reflecting that the vast majority of dogs in grenada are pothounds .
it is possible that the differences we observed in the grenada dog population for relative frequencies on skin neoplasms compared to other published reports is due to pothounds being genetically more susceptible to some tumors and more resistant to others .
it is also possible that environmental factors may account for and/or contribute to the differences we observed .
grenada represents a geographic area with a set of environmental conditions distinct from locations of other published reports of skin tumors in dogs .
possible environmental risk factors for skin tumors in grenada include abundant solar radiation , year around warm , humid climate , and heavy ectoparasite loads and associated dermatitis in many dogs .
our results provide valuable information on specific tumor types observed at increased frequency within this unique tropical climate .
this information on cutaneous tumors in dogs may serve as a reference for future comparative studies in grenada and the caribbean region . because dogs are the one domestic animal that most closely shares the human environment , determining environmental risk factors for canine tumors may contribute to identification and understanding of such risk factors for similar tumors in humans . | this retrospective survey was undertaken between 2002 and 2007 on samples from dogs residing in grenada .
the objectives of the study were to identify the most common histologic types of canine cutaneous tumors , determine the relative frequency of each tumor type , and compare results to reports from other regions . in a series of 225 skin masses examined , the proportion of neoplasms was 72% whereas nonneoplastic tumors accounted for 15.6% , and inflammatory conditions constituted 12.4% .
there were 10 types of nonneoplastic tumors with hamartomas being the most common ( 28.5% ) , followed by sebaceous hyperplasia ( 25.7% ) and fibroepithelial polyps ( 22.8% ) .
the 10 most common cutaneous neoplasms were hemangiosarcomas ( 19.1% ) , histiocytomas ( 8.6% ) , melanocytomas ( 8% ) , mast cell tumors ( 6.8% ) , lipomas ( 6.8% ) , hemangiopericytomas ( 6.2% ) , papillomas ( 5.6% ) , fibrosarcomas ( 5.6% ) , hemangiomas ( 4.9% ) , and squamous cell carcinomas ( 4.3% ) .
tumors of vascular origin and transmissible venereal tumors were more common in dogs in our study than reported from other regions . |
lower extremity amputation remains a definitive therapy for the management of ischemic disease that fails revascularization . despite recent advances in revascularization techniques and broadening of indications ,
each year 55,000 to 65,000 major lower extremity amputations are performed in the usa , making lower extremity amputation one of the most common vascular surgery procedures .
major lower extremity amputation , either below- or above - knee amputation , is associated with significant morbidity and mortality .
patients with advanced age or coronary artery disease have poor outcomes . in the framingham heart study ,
the prevalence of metabolic syndrome doubled during a 10-year period and was associated with a three - fold increased risk in death .
patients with metabolic syndrome undergoing peripheral vascular interventions have been shown to have unfavorable perioperative outcomes .
patients who undergo above - knee amputation ( aka ) have worse functional and survival outcomes compared to patients who undergo below - knee amputation ( bka ) .
the aim of our study is to identify whether comorbid diseases such as metabolic syndrome are associated with either peri - operative or long - term adverse events in patients undergoing major lower extremity amputation for ischemic disease .
we have previously shown that veterans with vascular disease have more comorbid disease than non - veterans with similar diagnoses , and that these veterans form a high - risk population .
we hypothesized that these high - risk patients would have extensive comorbid diseases such as metabolic syndrome , and that peri - operative and long - term survival would be related to the presence of these risk factors .
therefore , we examined the peri - operative and long - term outcomes of veterans undergoing major lower extremity amputation .
the electronic records of all patients who underwent a major lower extremity amputation for ischemic disease at our institution between july 2005 and june 2010 were reviewed .
major lower extremity amputation was defined as amputation below the hip and above the ankle and further categorized as aka or bka .
pre - operative , intra - operative , and post - operative data were collected .
criteria for diagnosis of metabolic syndrome were met when three or more of the following criteria were met : fasting blood glucose > 110 mg / dl or previously diagnosed diabetes mellitus , bmi > 30 kg / m , sbp / dbp > 140/90 mmhg or treatment of previously diagnosed hypertension , hdl < 40 mg / dl in males or < 50 mg / dl in females or specific treatment for this lipid abnormality , and fasting triglycerides > 150 mg / dl or specific treatment for this lipid abnormality . chronic kidney disease ( ckd ) was defined as stage 3 or worse , corresponding to an estimated glomerular filtration rate of less than 60 ml / min/1.73 m using the modification of diet in renal disease ( mdrd ) study equation and includes patients with end - stage renal disease ( esrd ) on dialysis
early postoperative outcomes include morbidity and mortality within 30 days of surgery or the duration of the post - operative hospitalization if the patient remained in the hospital longer than 30 days .
these outcomes included 30-day mortality , revision for wound failure , conversion from bka to aka , myocardial infarction and stroke .
late postoperative outcomes were recorded through the end of the study period and consisted of death , development of congestive heart failure , fatal , and non - fatal myocardial infarction , stroke , and progression to esrd .
jmp 9.0.0 software ( sas institute , cary , nc ) was used for data analysis .
categorical variables were compared with chi - square analysis and continuous variables were compared with the t - test .
kaplan - meier analysis was used for survival analysis , with comparison of groups using the log rank test .
all tests were double tailed with a type i error risk ( alpha ) equal to 5% .
jmp 9.0.0 software ( sas institute , cary , nc ) was used for data analysis .
categorical variables were compared with chi - square analysis and continuous variables were compared with the t - test .
kaplan - meier analysis was used for survival analysis , with comparison of groups using the log rank test .
all tests were double tailed with a type i error risk ( alpha ) equal to 5% .
all patients were male ; the mean age was 65.9 years . sixty percent ( n = 36 ) underwent bka and 40% ( n = 24 ) underwent aka .
eighteen percent had a prior contralateral amputation and 65% had a previous vascular intervention ( endovascular , open or both ) .
all the above - mentioned characteristics were not statistically different when compared between the bka and aka groups [ table 1 ] . demographics and comorbidities the prevalence of comorbid conditions was extremely high in this population and is shown in table 1 .
the most prevalent conditions were arterial hypertension ( 90% ) , diabetes mellitus ( 78% ) , metabolic syndrome ( 68% ) , history of myocardial infarction ( mi , 63% ) , dyslipidemia ( 62% ) , chronic kidney disease ( ckd , 40% ) , and congestive heart failure ( chf , 30% ) .
thirty - eight percent were dependent in their performance of activities of daily life prior to surgery .
however , the prevalence of comorbidities was not statistically different between the aka and bka groups except that the bka group had more patients with ckd who were dialysis - dependent than the aka group ( 25% vs 4% , p = 0.03 ) [ table 1 ] .
forty - six percent of the amputations were performed in an urgent or semi - urgent setting for treatment of life - threatening limb disease .
forty percent were staged interventions requiring one or more additional procedure before the creation of the final amputation stump .
amputations were equally distributed between both lower extremities ; one patient required bilateral amputation during the same hospitalization as a result of worsening ischemia from multiple organ system failure following endovascular repair of aortic aneurysm .
however , there was a trend toward a higher rate of staged procedures in the bka group ( 50% vs 35% , p = 0.05 ) [ table 2 ] .
peri - operative mortality was 7% ( bka 8% , aka 4% , p = 0.53 ) .
the rate of revision for wound failure was 10% ( bka 8% , aka 12% , p = 0.60 ) and conversion from bka to aka occurred in one patient ( 2.7% ) .
one of these patients ( 1.7% ) had an additional non - fatal post - operative mi after bka .
all operative outcomes were not statistically different between the bka and aka groups [ table 3 ] .
peri - operative and long - term outcomes long - term outcomes are shown in table 3 .
through the course of the study , 50% of the patients died ( bka 56% , aka 42% , p = 0.26 ) .
thirty - eight percent of all patients developed a new mi , stroke , chf or esrd , the rates of which were comparable between aka and bka groups [ table 3 ] .
kaplan - meier analysis showed the 1-year survival to be 73% , 3-year survival to be 61% and 5-year survival to be 54% in the whole cohort [ figure 1 ] .
survival was independent of level of amputation ( p = 0.24 ) or urgency of the procedure ( p = 0.51 ) .
survival was significantly decreased by the presence of underlying chronic kidney disease ( p = 0.04 ) but not by other comorbidities ( history of mi , p = 0.79 ; metabolic syndrome , p = 0.64 ; diabetes mellitus , p = 0.56 ) [ figure 1 ] .
the only variable that was a statistically significant predictor of mortality was ckd ( risk ratio 2.27 ; 95% confidence interval 1.02 - 5.06 ; p = 0.0425 ; table 4 ) . survival analysis .
( a ) survival of entire cohort ; ( b ) survival stratified by presence or absence of chronic kidney disease ; ( c ) survival stratified by presence or absence of metabolic syndrome ; ( d ) survival stratified by level of amputation ; ( e ) survival stratified by presence or absence of history of myocardial infarction cox proportional hazards model
we report a perioperative mortality of 7% after lower extremity amputation , with comparable results between the aka and bka groups . in this high - risk group of patients with extensive comorbid disease ,
the presence of metabolic syndrome , history of myocardial infarction , level of amputation , or urgency of the procedure did not affect late survival .
however , the presence of ckd prior to the amputation was associated with worse late survival [ table 4 ] .
multiple studies have evaluated specific comorbid diseases associated with reduced survival after major lower extremity amputation . frequently , more than one comorbid condition have been identified , including congestive heart failure , renal disease , cerebrovascular disease , chronic obstructive pulmonary disease , preoperative pneumonia , diabetes mellitus , age > 75 , and admission through the emergency department .
in addition , aka was previously found to be associated with worse survival compared to bka .
metabolic syndrome has a high prevalence in our patient population ( 68% ) similar to the one reported in patients with peripheral artery disease .
it is a pro - inflammatory and pro - thrombotic state accompanied by an increased risk for cardiovascular disease and type 2 diabetes mellitus . at the endothelial level , it is associated with altered intima - media thickness and impaired myocardial perfusion which are independent predictors of adverse cardiovascular outcomes .
two of the components of the metabolic syndrome , elevated fasting plasma glucose and microalbuminuria , are predictors of peripheral vascular disease . in patients undergoing hemodialysis access placement , metabolic syndrome
however , we did not find an association between metabolic syndrome and long - term mortality after major lower extremity amputation [ table 4 ] .
the lack of association of metabolic syndrome with outcome after amputation may be related to several factors .
first , patients with metabolic syndrome may be treated for their condition , including multiple medications that address the glucose as well as the lipid abnormalities .
second , metabolic syndrome may not be a statistically significant factor compared to others , such as ckd or cardiac disease that have significant effects on perioperative mortality .
reported significantly decreased survival among patients with diabetes mellitus , serum creatinine > 2 mg / dl or esrd .
interestingly , patients with elevated creatinine without esrd had decreased survival similarly to those with esrd .
. reported on a large series from a veteran population and found that patients with renal disease have worse survival during the first year after amputation .
other predictors of worse mortality were proximal level of amputation , cerebrovascular disease and congestive heart failure .
multiple preoperative comorbidities were associated with worse perioperative and late survival including bun > 40 mg / dl and esrd .
reported a hospital mortality of 24% , a 1-year survival of 38% and a 2-year survival of 20% among patients with esrd , advocating for aggressive foot care and patient education to prevent amputation .
one study reported an association between preoperative ckd and postoperative malnutrition in patients undergoing open vascular surgery .
it might be of value to examine the nutritional status of this subgroup of patients and determine whether malnutrition is a common underlying factor .
our peri - operative mortality of 7% is consistent with previously reported data ranging from 4 to 17% .
peri - operative mortality was similar between the aka and bka groups , in contrast to previous reports of higher peri - operative mortality after aka .
we report a rate of wound revision and conversion that is lower than the rates reported in larger series where wound revision ranged between 13.2% and 15.4% and conversion ranged between 9% and 20% . also , we did not find a higher rate of local wound complications in the bka group compared to the aka group , which is different from previous reports . the lower rate of local wound complications could be explained by the relatively high rate of staged procedures in our series ( 40% ) , since 46% of the procedures were performed in the setting of limb - threatening wet gangrene ; two - stage amputation has fewer wound complications than one - stage amputation performed for wet gangrene .
our analysis is limited by the relatively small size of the population and retrospective nature of the study .
it includes only veterans and lacks female patients who may have health characteristics different from the general population . due to the population size
, we could not determine whether the observed decreased survival in patients with ckd is related to the subgroup of patients with esrd .
in addition , it is not known how the medical management of comorbid conditions evolved during the study period .
further studies are required to determine if better control of specific comorbid disease improves outcomes after lower extremity amputation . in conclusion ,
major lower extremity amputation for ischemic disease is characterized by substantial perioperative mortality and morbidity .
metabolic syndrome is not associated with increased risk of adverse outcomes after lower extremity amputation .
however , patients with chronic kidney disease constitute a sub - group of patients at higher risk of postoperative long - term mortality and may be a group to target for intervention to improve outcomes . | background : despite low peri - operative mortality after major lower extremity amputation , long - term mortality remains substantial .
metabolic syndrome is increasing in incidence and prevalence at an alarming rate in the usa.aim:this study was to determine whether metabolic syndrome predicts outcome after major lower extremity amputation.patients and methods : a retrospective review of charts between july 2005 and june 2010.results:fifty-four patients underwent a total of 60 major lower extremity amputations .
sixty percent underwent below - knee amputation and 40% underwent above - knee amputation .
the 30-day mortality was 7% with no difference in level ( below - knee amputation , 8% ; above - knee amputation , 4% ; p = 0.53 ) .
the mean follow - up time was 39.7 months .
the 5-year survival was 54% in the whole group , and was independent of level of amputation ( p = 0.24 ) or urgency of the procedure ( p = 0.51 ) .
survival was significantly decreased by the presence of underlying chronic kidney disease ( p = 0.04 ) but not by other comorbidities ( history of myocardial infarction , p = 0.79 ; metabolic syndrome , p = 0.64 ; diabetes mellitus , p = 0.56).conclusion : metabolic syndrome is not associated with increased risk of adverse outcomes after lower extremity amputation .
however , patients with chronic kidney disease constitute a sub - group of patients at higher risk of postoperative long - term mortality and may be a group to target for intervention . |
. early detection of a supraspinatus tear using an accurate physical examination is essential to avoiding expensive and invasive additional tests .
unfortunately , only a few physical examinations that can detect isolated lesions of the supraspinatus alone are available in the clinical setting . the empty can ( ec ) test , also known as jobe 's test or the supraspinatus test , was first described in 1982 and aimed at isolating supraspinatus activity to some degree
. the full can ( fc ) test , developed in 1996 , was found to activate the supraspinatus to a level similar to that in the ec test . however , these tests provided insufficient data to support the isolation of supraspinatus activity and were subsequently found to be confounded by other synergistic muscles ( such as the deltoid , infraspinatus , subscapularis , and serratus anterior ) on the basis of electromyographic ( emg ) and biomechanical studies . furthermore , many clinical studies questioned the validity of the ec and fc tests as diagnostic tools to understand supraspinatus pathology owing to their poor to moderate specificity and accuracy .
the neer sign and the hawkins - kennedy sign , commonly used to diagnose subacromial impingement , have a high sensitivity of 7588% for supraspinatus tears .
however , these signs are characterized by a lack of specificity ( < 40% ) .
the transdeltoid palpation test , first described by codman in 1934 , has been used to diagnose full - thickness rotator cuff tears and yields a high sensitivity of 8295.7% . however , for all types of supraspinatus tears , the sensitivity of the transdeltoid palpation test decreased to 6367% .
furthermore , small , nonretracted defects and partial tears with predominantly articular surface involvement are more difficult to detect with this test , and it requires some experience to be utilized reliably .
overall , the currently available commonly used physical tests for supraspinatus tears are poor diagnostic indicators with a wide range of sensitivity and specificity values .
therefore , a more accurate physical test is needed for use in a clinical setting .
previous studies have shown that the emg activity of the supraspinatus increased during the lift - off test , belly - press test , and bear - hug test .
reported all the patients with false - positive results on the bear - hug test had a supraspinatus tear .
they believed that by increasing the forward elevation of the shoulder to maximize the anterior positioning of the elbow , the supraspinatus fibers might be activated to a greater degree with the bear - hug test than with the belly - press test . on the basis of these previous studies
, one would assume that recruitment and firing of the supraspinatus muscle fibers would be increased while the elbow is held as anterior as possible to the body .
therefore , we developed a new test , the hug - up test , wherein elevation is resisted as the palm is held on the opposite shoulder with the elbow held in maximal anterior translation .
the purpose of this study was to describe the hug - up test and compare it with other conventional tests used for diagnosing supraspinatus tears .
we expected a greater increase in supraspinatus activation owing to the anterior position of the elbow in comparison to the ec test and fc test , which would allow for a more sensitive detection of supraspinatus tears , especially small tears .
our hypothesis was that the hug - up test would be more accurate than other diagnostic tests for supraspinatus tears .
herein , 200 consecutive patients scheduled to undergo an arthroscopic procedure for a diagnosis related to shoulder pain and/or weakness or dislocation by one of the senior authors from november 2012 to january 2014 were enrolled .
patients with a history of shoulder surgery , upper extremity fractures , and bilateral shoulder diseases were excluded from the study group .
the study was carried out in accordance with the ethical standards described by the local ethics committee of the national health commission and was approved by the ethics committee of peking university third hospital .
the results of 5 physical tests used to detect supraspinatus tears , including the hug - up test , ec test , fc test , neer impingement sign , and hawkins - kennedy impingement sign were prospectively evaluated .
pain experienced during the neer impingement and hawkins - kennedy impingement tests and weakness during the ec test and the fc test were considered positive results .
all the tests were independently conducted by two authors blinded to the magnetic resonance imaging ( mri ) findings for the supraspinatus .
the initial tests were performed during outpatient evaluation by the senior author , and the other tests were performed on the day of admission for surgery by another trained author .
the hug - up test was performed with the patient 's palm of the involved side placed on the opposite shoulder , and the elbow positioned anterior to the body [ figure 1 ] .
the examiner then pushed the patient 's elbow downward with an inferiorly directed force applied perpendicular to the elbow while asking the patient to resist the pressure [ figure 2 ] .
the test was considered to have shown a positive result if the weakness , upon resisting the force , was > 20% compared with that in the opposite side . if the strength was comparable to that of the opposite side , without any pain , the result was negative .
a painful hug - up test without weakness was recorded as a separate category but was presumed to be negative .
the palm of the involved side was placed on the opposite shoulder with the elbow positioned anterior to the body .
the examiner pushed the patient 's elbow downward with an inferiorly directed force applied perpendicular to the elbow while asking the patient to resist the pressure .
shoulder strength was measured for the ec test , fc test and hug - up test using an electronic digital tensiometer ( gt-300 , og giken , japan ) .
resistance was applied to the wrist or elbow , perpendicular to the plane of the forearm , using a padded sling attached to the tensiometer .
the patient was asked to maintain maximal resistance against the tensiometer for 5 s to obtain a static result [ figure 3 ] . the hug - up test performed with an electronic digital tensiometer .
resistance was applied to the elbow , perpendicular to the plane of the forearm , using a padded sling attached to the tensiometer .
strength was measured while asking the patient to maintain maximal resistance against the tensiometer for 5 s to obtain a static result ( force was measured in newtons ) .
supraspinatus tears were categorized as full - thickness tears ( ftts ) , which were classified as small ( 1 cm ) , moderate ( 3 cm ) , large ( 5 cm ) , and massive ( > 5 cm ) , on the basis of the largest dimension , and partial - thickness tears ( ptts ) , which were classified as bursal - sided , articular - sided , and intra - tendinous .
other combined diseases including acromioclavicular joint derangement , infraspinatus lesions , subscapularis lesions , superior labrum anterior and posterior ( slap ) lesions , biceps disorders , and bankart lesions were recorded as well to assess the specificity of the tests .
the accuracy of the tests was assessed by using the sensitivity , specificity , accuracy , positive predictive value ( ppv ) , negative predictive value ( npv ) , positive likelihood ratio ( plr ) , and negative likelihood ratio ( nlr ) , calculated from 2 2 tables .
the reproducibility of the hug - up test was assessed with the kappa coefficient , which determined the interobserver variation .
receiver operating characteristic curve was plotted and the area under the curve ( auc ) was calculated .
chi - square test or fisher 's exact test was performed to compare the sensitivity , specificity , and detection rate of the hug - up test with the arthroscopic examination conducted in different patterns , and z - test was used to compare the auc of different tests .
comparisons of strength between involved and opposite sides were performed using paired t - tests .
comparisons of the mean difference of strength for the involved and opposite sides between patients with tears and without tears were performed using independent sample t - test .
the statistical analyses were performed with the spss 21.0 software package ( spss inc . ,
the mean age of the 200 patients was 46.8 15.8 years old ( range , 1477 years old ) .
there were 119 male and 81 female patients with 125 right and 75 left affected shoulders .
, we detected 153 ( 76.5% ) cases of supraspinatus tears , including 53 combined subscapularis tears and 18 infraspinatus tears , 45 bankart lesions , 27 slap lesions , 44 pathologic biceps , 3 acromioclavicular joint arthritis , and 1 kim lesion .
the sensitivity , specificity , accuracy , ppv , npv , plr , nlr , and auc for the five physical tests are listed in table 1 .
the sensitivity of the hug - up test was significantly greater than that of the ec test ( = 7.642 , p = 0.009 ) , fc test ( = 15.896 , p < 0.001 ) , neer impingement sign ( = 44.509 , p < 0.001 ) , and hawkins - kennedy sign ( = 113.832 , p < 0.001 )
. the specificity of the hug - up test did not significantly differ from that of the other four tests ( = 0.058 , p > 0.999 , = 0.254 , p = 0.802 , = 2.712 , p = 0.169 , and = 1.795 , p = 0.284 , respectively ) .
the auc of the hug - up test was not significantly different from that of the ec ( z = 1.438 , p = 0.075 ) and fc tests ( z = 1.498 , p = 0.067 ) , but was significantly greater than that of the neer impingement sign ( z = 2.466 , p = 0.007 ) and hawkins - kennedy impingement sign ( z = 5.322 , p < 0.001 ) .
the diagnostic values of the five tests for detecting a torn supraspinatus tendon * the sensitivity of the hug - up test was significantly greater than that of the ec test ( = 7.642 , p = 0.009 ) , fc test ( = 15.896 , p<0.001 ) , neer impingement sign ( = 44.509 , p<0.001 ) , and hawkins - kennedy sign ( = 113.832 , p<0.001 ) ; the auc of the hug - up test was not significantly different from that of the ec ( z = 1.438 , p = 0.075 ) and fc tests ( z = 1.498 , p = 0.067 ) , but was significantly greater than that of the neer impingement sign ( z = 2.466 , p = 0.007 ) and hawkins - kennedy impingement sign ( z = 5.322 , p<0.001 ) .
ec : empty can ; fc : full can ; ppv : positive predictive value ; npv : negative predictive value ; plr : positive likelihood ratio ; nlr : negative likelihood ratio ; auc : area under the curve ; se : standard error .
the senior author reported 148 positive hug - up tests and the second examiner reported 155 .
statistical analysis of the interobserver reliability of the hug - up test the kappa value of cross - tabulation between examiner i and ii was 0.823 .
the results for shoulder strength measured with the tensiometer for the hug - up test , ec test , and fc test are summarized in table 3 .
the mean strength of the involved side was significantly lower than that of the opposite side in the patients with tears for the hug - up test ( t = 24.362 , p < 0.001 ) , ec test ( t = 15.349 , p < 0.001 ) , and fc test ( t = 14.77 , p < 0.001 ) and patients without tears for the hug - up test ( t = 3.309 , p = 0.002 ) , ec test ( t = 4.086 , p < 0.001 ) , and fc test ( t = 4.277 , p < 0.001 ) .
the mean difference in strength for the involved and opposite sides was significantly greater in patients with tears compared with those without tears for the hug - up test ( t = 12.183 , p < 0.001 ) , ec test ( t = 7.592 , p < 0.001 ) , and fc test ( t = 7.803 , p < 0.001 ) . strength measured with a tensiometer for the hug - up test , empty can test , and full can test the values are expressed as means sd .
the mean strength of the involved side was significantly lower than that of the opposite side in patients with and without tears for the hug - up test , ec test , and fc test .
n : newton ; ec : empty can ; fc : full can ; sd : standard deviation .
the results for the hug - up test and arthroscopic examination for different tear patterns are listed in table 4 .
the hug - up test showed no statistical difference in terms of detecting different tear patterns for ffts ( fisher 's exact test , p > 0.999 ) and ptts ( = 0.578 , p = 0.898 ) compared with arthroscopic examination .
results of the hug - up test and arthroscopic examination for different tear patterns ftt : full - thickness tears ; ptt : partial - thickness tears .
at present , the diagnostic accuracy of the conventional clinical tests for detecting isolated lesions of the supraspinatus remain highly variable , and a more accurate physical test for supraspinatus tears is needed in clinical practice . in our clinical practice , we developed a new test , the hug - up test , to more accurately detect supraspinatus tears .
the results of the present prospective study demonstrated that the newly proposed test can accurately detect supraspinatus tears with a high sensitivity , comparable specificity , and low nlr compared with the other 4 conventional tests mentioned above
. the favorable testing profile may be useful in alerting the surgeon to a possible supraspinatus tear .
in general , a diagnostic test is considered good when the auc is above 0.8 . in our study , the hug - up test yielded an auc of 0.854 , with no statistically significant difference compared with that of the ec test and the fc test in terms of diagnosing supraspinatus tears .
therefore , we can conclude that the discriminative ability of the hug - up test was at least similar to that of the conventional physical tests .
furthermore , the sensitivity of the hug - up test was higher ( 94.1% ) than that of the conventional tests . owing to its advantage of high sensitivity , the hug - up test could be uniquely valuable in alerting the surgeon to the specific pathology .
moreover , in terms of the most important clinical measures of accuracy by far , the ppv and npvs of the hug - up test was very high in the 5 physical examinations , which also indicated that it is an accurate testing tool for detecting supraspinatus tears . additionally , the specificity ( 76.6% ) observed for the hug - up test was relatively lower than the sensitivity .
thus , we should consider the possibility of false - positive results before coming to a final diagnosis .
however , the specificity of the hug - up test was acceptable in comparison with the other 4 conventional tests .
the likelihood ratios are also good summaries of diagnostic accuracy . in the present study ,
the nlr of the hug - up test was the lowest ( 0.08 ) among the five tests and the plr was high ( 4.02 ) , which indicates that the accuracy of the hug - up test is not significantly influenced by the prevalence of a disease .
thus , understanding the favorable testing profile with likelihood ratios of the hug - up test is useful to a clinician .
the reliability of a diagnostic test depends on not only the accuracy but also the reproducibility of the test results . in our study ,
the kappa coefficient of 0.823 indicated that the hug - up test had almost perfect agreement .
one is , in our experience , that the test is very simple to conduct and perform .
the other one is the strict criterion of weakness , rather than pain , for indicating a positive result , which is relatively objective .
one may argue that the position used during the hug - up test is similar to that during yocum 's test , which is typically used for detecting tendinopathy and subacromial impingement .
, the patient actively elevates the arm while his or her hand is placed on the opposite shoulder .
although the position of the arm is the same as that in yocum 's test , the hug - up test requires the patient to gently elevate the arm with resistance rather than active elevation as in the yocum 's test .
moreover , the positional pain provocation caused by the possible subacromial impingement might affect muscle strength and reduce the specificity of the hug - up test .
firstly , we asked the patients to elevate the arm gently and stop immediately after they experienced pain .
we assumed that the painless position would avoid further impingement when muscle strength with resistance was being evaluated .
secondly , we set the positive standard as weakness , upon resisting the force , that was > 20% compared with that in the opposite side . in other words , the influence of slight weakness caused by the impingement positional pain on interpreting the result as positive was expected to be as little as possible .
thirdly , pain without weakness during the hug - up test was not considered a positive result .
we believe the strict criterion for interpreting the result as positive may have improved the specificity of the hug - up test as much as possible .
moreover , the position of the shoulder upon elevation and adduction during the hug - up test may also place a load on the acromioclavicular joint , which may have been the source of the pain . because pain at the acromioclavicular joint can be easily detected by the patients and diagnosed on the basis of tenderness or plain radiography findings
, we recommend that acromioclavicular conditions are ruled out when using the hug - up test to improve the specificity .
however , further investigation is needed to identify the exact correlations between the hug - up test and subacromial impingement or the presence of acromioclavicular disease .
objective strength measurement with the tensiometer showed significantly greater differences between the involved side and the opposite side in patients with tears compared with patients without tears . diagnosing a disease according to the presence of muscle weakness
a result was interpreted as positive if the weakness upon resisting the force was > 20% compared with that in the opposite side .
we believe this criterion would allow for more objective and reliable results when determining muscle strength against resistance . however , it is not always practical to perform a physical examination with a specific device in the clinical setting .
recognized both the fc and ec tests as pure manual muscle tests ( mmt ) and determined muscle strength by mmt using a scale of 0 - 5 .
we recommend the same method to interpret the results of the hug - up test .
however , it is not clear at present which mmt grade should be used to define muscle weakness .
we further compared the detection rate of the hug - up test with the arthroscopic examination according to the tear pattern and found no statistical differences .
this indicates that the diagnostic value of the hug - up test for detecting supraspinatus tears in different positions and of different sizes was comparable to that of arthroscopic examination .
however , because the number of patients with large ( n = 12 ) or massive tears ( n = 4 ) in our series was too small , we could not confirm whether the hug - up test was accurate for detecting larger tears .
on the basis of the available literature , many classic clinical tests or signs can be used to diagnose larger tears with satisfactory sensitivity and specificity , however , the diagnostic value of these tests for detecting small or partial - thickness supraspinatus tears is limited .
the results of the present study may suggest the potential advantage of the hug - up test in this aspect .
the strengths of this study include its large sample size , prospective design , exact measurement of muscle strength with the tensiometer , and the reliable gold standard ( arthroscopic examination ) .
firstly , the patients in the study were managed in the surgical department , and their characteristics would not be representative of the population seen in general or in medical practice . however , the shoulder lesions were confirmed using arthroscopic surgery , which is the gold standard and more reliable than any other modalities including mri and ultrasound .
in addition , we studied the accuracy of not only the hug - up test but also the conventional tests and compared them . thus , the result is relatively reliable .
secondly , the study might have involved detection bias because one of the examiners who conducted the physical examination also conducted the surgical evaluation .
we attempted to minimize this source of bias by creating a standardized protocol for the arthroscopy procedure such that all structures are investigated carefully and reported on in a standardized fashion .
thirdly , we did not include the transdeltoid palpation test for comparison in the study because its diagnostic value for all types of supraspinatus tears was reported to be limited and because it requires experience to be utilized reliably . finally , although the reliability of the hug - up test demonstrated in the present study seems to be related to the more efficient activation of the supraspinatus , emg and biomechanical evidence is lacking and needs to be investigated in further research .
however , we do agree with somerville 's and longo 's opinion in that , because of the close relationship of the structures in the shoulder , no test can selectively detect a lesion in any one of the rotator cuff tendons , and any result from muscle tests might implicate a number of structures .
what we can do is to explore a test relatively accurate for one tendon . in conclusion
, the present prospective study demonstrated that the newly proposed test , the hug - up test , can accurately detect supraspinatus tears with a high sensitivity , comparable specificity , and low nlr compared with conventional clinical tests and might improve the diagnosis of supraspinatus tears in clinical settings .
further emg and biomechanical investigations are necessary to analyze the supraspinatus activity when the hug - up test is performed .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
this work was supported by a grant from the specialized research fund for the doctoral program of higher education of china ( no .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
this work was supported by a grant from the specialized research fund for the doctoral program of higher education of china ( no .
| background : the supraspinatus tendon is the most commonly affected tendon in rotator cuff tears . early detection of a supraspinatus tear using an accurate physical examination is , therefore , important .
however , the currently used physical tests for detecting supraspinatus tears are poor diagnostic indicators and involve a wide range of sensitivity and specificity values .
therefore , the aim of this study was to establish a new physical test for the diagnosis of supraspinatus tears and evaluate its accuracy in comparison with conventional tests.methods:between november 2012 and january 2014 , 200 consecutive patients undergoing shoulder arthroscopy were prospectively evaluated preoperatively .
the hug - up test , empty can ( ec ) test , full can ( fc ) test , neer impingement sign , and hawkins - kennedy impingement sign were used and compared statistically for their accuracy in terms of supraspinatus tears , with arthroscopic findings as the gold standard . muscle strength was precisely quantified using an electronic digital tensiometer.results:the prevalence of supraspinatus tears was 76.5% .
the hug - up test demonstrated the highest sensitivity ( 94.1% ) , with a low negative likelihood ratio ( nlr , 0.08 ) and comparable specificity ( 76.6% ) compared with the other four tests .
the area under the receiver operating characteristic curve for the hug - up test was 0.854 , with no statistical difference compared with the ec test ( z = 1.438 , p = 0.075 ) or the fc test ( z = 1.498 , p = 0.067 ) .
the hug - up test showed no statistical difference in terms of detecting different tear patterns according to the position ( 2 = 0.578 , p = 0.898 ) and size ( fisher 's exact test , p > 0.999 ) compared with the arthroscopic examination .
the interobserver reproducibility of the hug - up test was high , with a kappa coefficient of 0.823.conclusions:the hug - up test can accurately detect supraspinatus tears with a high sensitivity , comparable specificity , and low nlr compared with the conventional clinical tests and could , therefore , improve the diagnosis of supraspinatus tears in clinical settings . |
it usually presents at , or soon after birth with hyperkeratotic verrucous dark - brown ridges . porcupine men and systematized epidermal naevus have also been used to describe these lesions .
based on the pattern of distribution , five clinical variants namely brocq type , lambert type , curth - macklin type , rheydt type and bfverstedt type have been described .
we report a case of curth - macklin variant of ichthyosis hystrix with the absence of family history .
it has been described to run in families as an autosomal dominant trait , very few sporadic cases of the entity have been described in the literature .
an 11-year - old male child presented with asymptomatic , dark - brown , spiny , hyperkeratotic , verrucous scales and ridges all over body since birth .
the patient gave history that scales shed after scrubbing and reappear in 5 - 7 days .
there was no history of parental consanguinity , collodion presentation at birth , blistering or erythroderma .
the affected skin showed symmetrically distributed , generalized , thickened , verrucous , dark - brown cobblestone - like lesions [ figure 1a ] .
there was sparing of scalp and central part of face with involvement of ear [ figure 1b ] .
axillary region , dorsum of hand , popliteal fossa and antecubital fossa were less markedly affected [ figures 1a and 2a ] .
( a ) generalized dark - brown , spiny , hyperkeratotic , verrucous scales and ridges .
( b ) involvement of ear with sparing of central part of face ( a ) spiny scales with relative sparing of dorsum of hand .
nails are normal ( b ) keratoderma and fissuring of sole skin biopsy ( h and e staining ) showed hyperkeratosis , acanthosis and papillomatosis with thick granular layer [ figure 3a ] .
perinuclear vacuolization and coarse keratohyaline granules were seen in upper spinous layers [ figure 3b ] .
( a ) h and e staining , 40 showing hyperkeratosis , acanthosis and papillomatosis with thick granular layer ( b ) h and e staining , 100 showing hyperkeratosis with perinuclear vacuolization and coarse keratohyaline granules seen in an upper spinous layer
ichthyosis hystrix is a poorly defined entity which encompasses disorders displaying striking hyperkeratotic verrucous brown ridges .
it is an extremely rare disorder , reported in only a few families and sporadic cases .
five clinical variants have been described : brocq type , lambert type , curth - macklin type , rheydt type and bfverstedt type .
the distinctive distribution of lesions , associated abnormalities and inheritance patterns help to differentiate between these forms . in brocq
bfverstedt type was described in a single case which had striking follicular hyperkeratosis and mildly affected palms .
lambert type , seen in the lambert family with 11 affected members across four generations , has no blistering with sparing of face , palms and soles .
two large families with autosomal dominant inheritance and very few sporadic cases have been reported since its first description in 1954 .
it results from heterozygous frameshift mutation in keratin 1 gene ( krt1 ) , and a new mutation for this disease has recently been reported .
recently , it has been suggested to rename the entity as ichthyosis curth - macklin and group it under keratinopathic ichthyoses , along with epidermolytic ichthyosis and superficial epidermolytic ichthyosis .
there is wide variability in its time of onset and clinical presentation , which varies even within families .
it is characterized by massive palmo - plantar keratoderma leading to deep , bleeding , and painful fissures .
there is development of hyperkeratotic , ridged or cobblestoned plaques over the large joints and/or hyperkeratotic papules on trunk and extremities .
histopathological features include hyperkeratosis , acanthosis , and papillomatosis , along with the characteristic findings of perinuclear vacuolization and binucleate keratinocytes .
the clinical and histopathologic findings in our patient were consistent with those of ichthyosis curth - macklin .
this can be further confirmed by electron microscopy which also reveals keratin intermediate filaments aggregated into continuous , peripheral shells , without keratin clumping typical for epidermolytic hyperkeratosis .
the same could not be performed in our patient due to lack of such facilities .
however , it was ruled out by absence of history of blistering at birth and presence of very thick palmoplantar hyperkeratotic scales .
our case , with severe palmoplantar keratoderma , generalized involvement with relative sparing of face and scalp , along with absence of blistering , erythroderma and deafness , and no family history of ichthyosiform disease , are suggestive of sporadic type of ichthyosis curth - macklin which is a very rare entity . | ichthyosis hystrix is a rare autosomal dominant genodermatosis , characterized by persistent spiny hyperkeratotic scales which cover a significant part of the skin surface .
based on the pattern of distribution , five clinical variants namely brocq type , lambert type , curth - macklin type , rheydt type and bfverstedt type have been described .
we report the case of an 11-year - old male child with spiny , hyperkeratotic scales all over the body since birth with sparing of scalp and central part of the face .
palmoplantar keratoderma was also present .
these clinical features are suggestive of ichthyosis curth macklin , which has been typically described in families . however , family history was negative in our patient .
the case is being reported on account of rarity of the disease , that too with a very rare sporadic presentation . |
( caesalpiniaceae ) has great therapeutic implication in indian system of medicine and exerts an antipyretic , analgesic , antiinflammatory , and hypoglycemic effects [ 1 , 2 ] . over the past few years
, there has been an exponential growth in study of pharmacological properties of this plant [ 35 ] .
antioxidant components are microconstituents that inhibit lipid oxidation by inhibiting the initiation or propagation of oxidizing chain reactions , and are also involved in scavenging of free radicals .
clinical approaches of antioxidants increased multifold during the recent time for the management and therapeutic implication of neurodegenerative disorders , aging , and chronic degenerative diseases . in view of the above
, we designed the study to evaluate the antioxidant potential and phenolic content in cassia fistula .
all the chemicals and solvents were of analytical grade and obtained from merck and himedia , mumbai , india .
the fresh ripe fruits of cassia fistula were collected in june from the campus of delhi college of pharmaceutical science and research ( dipsar ) , new delhi , india , and properly authenticated .
a voucher of specimen ( pm 21 ) was stored in the laboratory for further reference .
it was extracted with the hexane for 72 hrs and the same materials were reextracted with methanol for 72 hrs in soxhlet apparatus .
hence , we obtained hexane extract of seed ( he s ) , hexane extract of pulp ( hep ) , methanolic extract of seed ( mes ) , and methanolic extract of pulp ( mep ) .
the total phenol content was estimated in the methanolic extracts of seed and pulp using folin - ciocalteu reagent ( fcr ) according to the procedure reported by singleton et al . , using standard gallic acid ( y = 1.8478x + 0.0702 , r = 0.9971 ) and tannic acid ( y = 1.388x + 0.0472 , r = 0.9958 ) , curve standardized in the lab for the calculation of gallic acid equivalent ( gae ) and tannic acid equivalent ( tae ) per gram of extracts , respectively .
the blue complex was formed by the reduction of reagent by phenolic compounds in extract .
briefly , aliquot of 400 l of extract was added to 1.6 ml of sodium carbonate ( 7.5% in deionised water ) and 2 ml of folin - ciocalteu reagent ( diluted 10-fold in deionised water ) .
after incubation of 1 hr at room temperature , absorbance was measured at 525 nm using labomed inc .
total phenolic content was expressed in mg gae and tae per gram of extracts , using calibration curve .
total flavonoids contents were estimated both in methanolic extracts of pulp and seed by method of zhishen et al . , using quercetin standard .
briefly , 0.5 ml of aliquot of extract was added to 75 l of 5% nano2 solution .
after 6 minutes , 150 l of a 10% alcl3 6h2o solution was added and the mixture was allowed to stand another 5 minutes .
then , 0.5 ml of 1 mol / l naoh and 2.5 ml of distilled water was added .
the solutions were mixed and absorbance was measured at 510 nm using labomed inc .
total flavonoid content was calculated as mgqe / g , using the following equation based on the calibration curve :
( 1)y=2.234x+0.992 , r2=0.9927 ,
where x was the absorbance and y was the mgqe / g .
dpph radicals scavenging of cassia fistula extracts was estimated according to the method of miliauskas [ 8 , 9 ] .
dpph radicals absorbed maximum at 515 nm , which disappears with reduction by an antioxidant compound ( s ) .
three milliliter ( 3 ml ) dpph solution in methanol ( 0.1 mm ) was mixed with 100 l of extracts ( mg / ml ) . in control 100 l methanol ( without extracts ) mixed with dpph solution .
the samples were incubated in a water bath for 20 min at 37c , and the decrease in absorbance at 515 nm was measured .
radical scavenging activity was calculated using the following formula :
( 2)% inhibition=[(ac ae)ab]100 ,
where ac = absorbance of the control and ae = absorbance of tested samples .
ferric reducing power of cassia fistula extracts were determined using frap assay [ 10 , 11 ] .
this method is based on the reduction of colourless ferric complex ( fe tripyridyltriazine ) to blue - colored ferrous complex ( fe tripyridyltriazine ) by the action of electron donating antioxidants at low ph .
the working frap reagent was prepared by mixing 10 volumes of 300 mm acetate buffer , ph 3.6 , with 1 volume of 10 mm tptz ( 2,4,6-tri(2-pyridyl)-s - triazine ) in 40 mm hcl and with 1 volume of 20 mm ferric chloride .
100 l of samples ( mg / ml ) were added to 3 ml of prepared frap reagent .
the reaction mixture was incubated in a water bath for 30 min at 37c .
the difference between absorbance of sample and the absorbance of blank was calculated and used to calculate the frap value .
frap value was expressed in terms of mmol fe / g of sample using ferric chloride standard curve y = 1.7057x 0.2211 , r = 0.9904 .
the scavenging activity for hydroxyl radicals was measured with fenton reaction [ 12 , 13 ] .
reaction mixture contained 60 l of 1.0 mm fecl3 , 90 l of 1 mm 1,10-phenanthroline , 2.4 ml of 0.2 m phosphate buffer ( ph 7.8 ) , 150 l of 0.17 m h2o2 , and 1.5 ml of extract at various concentrations .
after incubation at room temperature for 5 min , the absorbance of reaction mixture was noted at 560 nm .
the hydroxyl radicals scavenging activity was calculated according to the following equation and compared with ascorbic acid as standard :
( 3)% inhibition=((abae)ab100 ) ,
where ab was the absorbance of blank ( without extract ) and ae was the absorbance of tested samples .
the fe reducing power of extracts was determined by the method of oyaizu [ 9 , 11 , 14 ] .
the extract ( 0.75 ml ) of various concentrations was mixed with 0.75 ml of phosphate buffer ( 0.2 m , ph 6.6 ) and 0.75 ml of potassium hexacyanoferrate ( k3fe(cn)6 ) ( 1% , w / v ) , followed by incubation at 50c in a water bath for 20 min .
the reaction was stopped by adding 0.75 ml of trichloroacetic acid ( tca ) solution ( 10% ) and mixture centrifuged at 800 g for 10 min .
1.5 ml of the obtained supernatant was mixed with 1.5 ml of distilled water and 0.1 ml of ferric chloride ( fecl3 ) solution ( 0.1% , w / v ) for 10 min .
statistical significance was evaluated employing t - test and p < 0.05 which were considered to be significant .
dpph ( 1,1-diphenyl-2-picrylhydrazyl ) analysis is one of the best - known , accurate , and frequently employed methods for evaluating antioxidant activity .
it is a stable free radical because of its spare electron delocalization over the whole molecule .
the donation of h to the dpph radicals made a corresponding change from violet colour to pale yellow in the solution .
the dpph scavenging also made a proportionate decrease in its absorbance at 517 nm ( see scheme 1 ) .
the order of dpph scavenging against cassia fistula extract was found to be in the order of mep > mes > hep > he s .
antioxidant activity of the methanol extracts of pulp and seed was also compared to total phenolic content and it was further found that radical scavenging effects of extracts were directly proportional to the phenolic content present in extracts ( table 1 ) .
hence , methanol extract of pulp and seed showed the significant radical scavenging as the concentration increased , whereas hexane extract of pulp and seed showed low scavenging effect up to 1 mg / ml ; thereafter , dpph scavenging increased with the concentration of extract .
the positive control , ascorbic acid showed maximum scavenging effect at very low concentration ( figure 1 ) .
a significant correlation coefficient ( r , 0.978 ) was found between the antioxidant activity of the methanolic extract of pulp and seed .
the proton radical scavenging action is known to be one of the important mechanisms for measuring antioxidant activity .
this assay determines the scavenging of stable radical species dpph by antioxidants compounds present in the extracts .
the results showed the greater rate of dpph scavenging activity of both the methanolic extracts as compared to thehexane extracts probably due to the presence of high content of phenolic compounds .
ec50 value was determined from the plotted graph of scavenging activity against various concentrations of extracts , which is defined as the efficient concentration of antioxidant necessary to decrease the initial dpph radicals concentration by 50% ( table 2 ) .
the lowest ec50 indicates the strongest ability of the extracts to act as dpph radicals scavengers . out of the all extracts ,
methanolic extract of pulp and seed showed the lowest ec50 , 0.915 and 1.088 mg / ml , whereas hexane extracts of pulp and seed showed 1.865 and 2.239 mg / ml , respectively ( table 2 ) .
ascorbic acid showed highest dpph radicals scavenging with ec50 of 0.102 mg / ml . sun and ho reported a significant correlation between total phenolics and scavenging ability of buckwheat extracts on dpph radicals .
our study clearly indicated that the methanol extracts of pulp and seed of cassia fistula exhibited high content of phenolic compounds which was significantly correlated with the dpph radical scavenging activity ( p < 0.005 ) .
the hydroxyl radicals are extremely reactive oxygen species that can react with every possible molecule in living organisms , especially with proteins , dna , and lipids .
hydroxyl radicals are capable of rapid initiation of the lipid peroxidation process by extracting hydrogen atoms from unsaturated fatty acids .
the electron or proton donation capacities of cassia fistula extracts were further confirmed by the fenton reaction system . under in vitro , condition very reactive oh radicals were formed through the fenton reaction .
the reversible reaction between fe and 1,10-phenathroline formed fe(phen)2 , which react with h2o2 and formed oh free radicals [ 19 , 20 ] :
( 4)fe(phen)32+fe(phen)22++phen , fe(phen)22++h2o2fe(phen)23++oh+oh. among the reactive oxygen species ( ros ) , h2o2 is the most reactive and predominant radical generating molecule endogenously during aerobic metabolism .
the results showed that methanolic extracts of pulp and seed of cassia fistula have scavenging ability of oh free radicals in a dose - dependent manner ( figure 2 ) .
the highest activity was noted for the pulp extract of methanol followed by methanolic extract of seed at all concentrations .
oh free radical scavenging potential of all the extracts was found to be lower than that of the reference compound ascorbic acid .
the ec50 values of mep , mes , he s , hep , and ascorbic acid were 0.889 , 1.058 , 2.075 , 1.723 , and 0.105
the trend obtained in oh free radical scavenging behaviour was similar to the dpph free radical scavenging nature ( figure 2 ) .
the result of oh free radical scavenging activity was significantly correlated with the dpph free radical scavenging ( p , 0.05 ) .
the reducing power assay is often used to evaluate the ability of an antioxidant to donate an electron . in this assay ,
the presence of antioxidants in the extracts resulted into reduction of the ferric cyanide complex ( fe ) to the ferrous cyanide form ( fe ) .
in reducing power assay , antioxidants cause the reduction of the fe into fe , thereby changing the solution into various shades from green to blue , depending on the reducing power of the compounds .
strong reducing agents , however , formed perl 's prussian blue colour and absorbed at 700 nm .
figure 3 showed the reducing activities of various extracts of cassia fistula in comparison with ascorbic acid as standard .
the higher the absorbance of the reaction mixture , the higher would be the reducing power .
hexane extract of seed and pulp showed less degree of fe reduction than the methanolic extracts .
the reducing power was found to be in order of mep > mes > hep > he s .
interestingly , the rate of reducing power of methanolic extracts of both pulp and seed ( mep and mes ) first increased rapidly with concentration but later it decreased .
the reducing power of reference compound ( ascorbic acid ) was found to be higher than all the tested extracts .
it has been reported that the reducing power of substances is probably because of their hydrogen - donating ability .
methanolic extracts of pulp and seed might , therefore , contain high amount of reductones than hexane extracts of pulp and seed .
hence , methanolic extracts of fruit pulp and seed may act as electron donors and could react with free radicals to convert them into more stable products and then terminate the free radical chain reactions .
they reported that the hydroalcoholic extract of flower demonstrated significant radical scavenging activity in ferric reducing power and dpph assays .
it was also correlated with the total phenols which could be responsible for the antioxidant activity .
the reducing power assay is often used to evaluate the ability of an antioxidant to donate an electron which is an important mechanism of phenolic antioxidant action .
many reports have revealed that there is a direct correlation between antioxidant activities and reducing power of certain plant extracts [ 26 , 27 ] .
frap assay measures the reducing potential of an antioxidant reacting with a ferric tripyridyltriazine ( fe - tptz ) complex and producing a coloured ferrous tripyridyltriazine ( fe - tptz ) .
the reducing properties associated with the presence of compounds exert their action by breaking the free radical chain through donating a hydrogen atom [ 29 , 30 ] .
frap assay showed positive correlation between reducing power and phenolic content in cassia fistula extracts ( table 2 ) . here also , methanolic extracts of pulp showed greater frap value as 136.05 equivalent mmol of fe / g sample .
the other extracts mes , hep , and he s showed frap value 112.02 , 75.09 , and 69.02 equivalent mmol of fe / g samples , respectively .
the result was similar with benzie and szeto , who found a strong correlation between total phenolic content and frap assay .
rice - evans et al . reported that phenolic compounds have redox properties , which allow them to act as reducing agents , hydrogen donators , and singlet oxygen quenchers .
the redox potential of phenolic compounds played an important role in determining the antioxidant potential .
antioxidant potential of cassia fistula extract demonstrated the highest reducing power in the methanolic extract of pulp and seed .
it was concluded that the antioxidant activity of these extracts was directly proportional to the phenolic contents .
the hexane extracts of seed and pulp , however , did not significantly reduce the free radicals under in vitro study . | antioxidant potential of various extracts of cassia fistula was determined by the dpph , frap , fe3 + reducing power , and hydrogen peroxide scavenging assay .
methanolic extracts of cassia fistula showed the highest amount of phenolic and flavonoid content and reducing capacity , whereas hexane extracts exhibited the lowest level of reducing capacity .
the order of antioxidant activity in cassia fistula extracts displayed from higher to lower level as methanolic extracts of pulp , methanolic extracts of seed , hexane extracts of pulp , and hexane extracts of seed .
the antioxidant potential of cassia fistula extracts significantly correlated ( p < 0.02 ) with the phenolic content of the methanolic extracts .
ascorbic acid taken as control showed highest antioxidant power in the present study . |
betathalassemia major is one of the commonest hereditary hemoglobinopathies , characterized by reduced or absent betaglobin chain synthesis 1 .
management is based on regular blood transfusions to suppress ineffective erythropoiesis , with the goal to maintain pretransfusion hemoglobin concentration above 90 g / l 2 . repeated transfusions may lead to iron overload toxicity affecting the liver , spleen , heart , and endocrine system .
endocrine complications from repeated transfusion include secondary hypogonadism ( prevalence of 3555% ) 3 , short stature ( 3135% ) , diabetes mellitus ( 610% ) , primary hypothyroidism ( 311% ) , and hypoparathyroidism ( 17% ) 3 , 4 .
iron deposition cardiomyopathy is the leading cause of morbidity and mortality in patients with thalassemia with consequent congestive cardiac failure accounting for up to 70% of deaths in patients with thalassemia 3 .
the coexistence of diabetes in patients with thalassemia leads to an increased risk for myocardial fibrosis 5 , while diabetes and hypogonadism are independently associated with myocardial iron loading 6 . in conditions such as hypertrophic and dilated cardiomyopathy
, fibrosis increases the risk of dysrhythmias and heart failure . in thalassemia , although the cardiac burden is principally driven by iron loading per se , fibrosis might further increase the risk of cardiac dysfunction .
this case report describes the congruence of multiorgan dysfunction in an individual who had ceased chelation therapy after a history of repeated redcell transfusions .
a 37yearold man of indian origin presented with 3 weeks of deteriorating exertional dyspnea and dry cough .
he had a history of betathalassemia major and had been receiving regular transfusion therapy ( averaging four units of packed red cells per month ) from 3 months of age .
, he was diagnosed with insulindeficient ( type 3 c ) diabetes and commenced continuous subcutaneous insulin therapy ( csii ) , 30 units over 24 h , with stable control .
he had recently switched to multidose injection therapy due to subcutaneous edema and coughing resulting in persistent pump giving set failure .
his insulin dose on admission was 60 units / day ( 15 units basal insulin and 15 units prandial insulin with each meal ) . on examination , blood pressure was 95/55 mmhg , pulse 100/min ( regular rhythm ) .
body weight was 53 kg and height 1.52 m ( bmi 22.9 kg / m ) .
his jugular venous pressure was 7 cm above the sternal angle , and he had pitting ankle edema .
abdominal ultrasound scan confirmed hepatosplenomegaly plus evidence of increased reflectivity of the liver parenchyma , in keeping with fatty change .
a transthoracic echocardiogram showed a severely reduced left ventricular systolic function and mildly reduced right ventricular systolic function .
cardiac mri demonstrated severe myocardial iron loading with evidence of severe myocardial fibrosis and t2 of 4.5 msec plus bilateral pleural effusions ( fig .
1 ) . liver mri revealed moderatetosevere iron loading with an average liver iron concentration above 43.0 mg / g dry tissue ( normal range 0.171.8 mg / g ) ( fig .
he commenced furosemide 80 mg bd , plus iron chelation with continuous deferoxamine infusion 2200 mg over 24 h , and oral deferiprone 1500 mg tds until repeat cardiac mri and ferriscan .
biochemical and hematological variables in admission alp , alkaline phosphatase ; alt , alanine aminotransferase ; ast , aspartate aminotransferase ; gt , gammaglutamyl transferase ; pth , parathyroid hormone ; tibc , total iron binding capacity ; tsh , thyroid stimulating hormone .
a continuous subcutaneous infusion ( csii ) of insulin was commenced , and on discharge , his insulin dose was 30 units / day via csii , with greatly improved control .
subsequent testing has shown cpeptide 69 pmol / l ( ref 2982350 ) with concomitant plasma glucose 9.9 mmol / l , demonstrating insulin deficiency .
the cardiac mri indicated severe residual iron loading with cardiac t2 at 5.8 msec but the left ventricular function was remarkably improved and now within normal limits .
a decrease was noted in average liver iron concentration with a level of 39.2 mg / g dry tissue ( normal range 0.171.8 ) on liver mri .
the patient 's presentation of lethargy and dyspnoea was considered the cumulative result of cardiac failure , anemia , hypogonadism , and hypothyroidism .
his clinical deterioration was compounded by dysglycemia with escalating insulin doses representative of insulin resistance and reduced exercise capacity .
cardiac siderosis and associated heart failure account for the majority of deaths in betathalassemia major even on optimal treatment and chelation therapy 7 .
this differs from thalassemia intermedia in which left ventricular function is usually preserved ( although pulmonary hypertension is a recognized complication ) 8 . in this case report , the patient 's clinical condition rapidly deteriorated due to left ventricular failure as a result of noncompliance with chelation therapy .
myocardial relaxation time on t2 images is used for the quantitative assessment of iron deposition .
optimal values are > 20 msec , and severe impairment is considered when < 10 msec because the rate of heart failure has been shown to increase dramatically below this value . in this case , the t2 was 4.5 msec and therefore represents severe iron overload of the myocardium 9 , 10 , 11 .
labile plasma iron ( lpi ) is a component of nontransferrin bound iron that is capable of participating in redox reactions and may be transported into extrahepatic tissues .
lpi exposure increases with liver iron concentration 13 meaning that patients with higher liver iron stores are likely to have a worse cardiac outcome following noncompliance with chelation ( as with this case ) .
data from the uk thalassemia register 14 , 15 show that the mortality from betathalassemia has fallen in the past two decades , mainly due to a reduction in deaths from cardiac iron overload .
similarly , the frequency of cardiac siderosis in patients with betathalassemia major from north american and uk registries has fallen to 1726% , down from 60% over 10 years ago 16 , 17 .
serum ferritin and liver iron concentration are poor surrogates of iron loading in the heart , and the improvement in mortality has been attributed , in part , to the introduction of cardiovascular magnetic resonance ( cmr ) to identify myocardial siderosis and the optimization of iron chelation regimes 18 .
currently , there are three available iron chelators : deferoxamine , deferiprone , and deferasirox .
deferiprone has been shown to clear cardiac iron at nearly double the rate of deferoxamine , with improvement in cardiac performance 19 .
there appears to be a synergistic effect between deferiprone and deferoxamine : a randomized controlled trial of 65 patients over 12 months showed that defepromine reduced myocardial iron and improved ejection fraction with mild moderate iron overload , when compared to deferoxamine alone 20 .
the 2013 american heart association ( aha ) guidelines state that patients in acute heart failure should be immediately commenced on continuous ( uninterrupted ) intravenous iron chelation treatment with deferoxamine 50 mg / kg / day .
deferiprone should be introduced as soon as possible at a dose of 75 mg / kg / day ( the total dose given in three divided doses ) 2 , 20 , 21 , 22 . at the present time
caution is advised with diuretic treatment during the acute presentation because of the importance of maintaining preload , as patients are at risk of a restrictive ventricular defect 23 .
after resolution of decompensated heart failure , treatment may need to continue for several years to remove cardiac iron in thalassemia 10 .
patients with thalassemia may have insulin sensitivity reduced by 40% , with a close correlation ( r = 0.70 ) with iron status 24 .
the betacell is particularly sensitive to oxygen radicals and this may explain insulinopenia in many patients with betathalassemia
. in studies ( of limited numbers of patients ) , iron chelation with deferoxamine may improve glucose handling 25 , 26 .
hypogonadotropic hypogonadism is the most frequent endocrine complication in patients with iron overload and thalassemia 3 .
there is a close association between insulin resistance ( ir ) and testosterone deficiency 27 .
free and total testosterone levels are inversely correlated with indices of ir such as insulin levels and homeostatic model assessment of insulin resistance ( homair ) 28 , 29 , 30 . in this case report
, the patient 's suboptimal testosterone replacement may have further contributed to poor glycemic control 31 and cardiac performance 32 .
if hypothyroidism is diagnosed early , intensification of chelation therapy may improve thyroid function even without thyroid hormone replacement 34 . in conclusion , interruptions to chelation therapy may lead to the rapid development of complications , particularly if hepatic iron content is high .
| key clinical messagepatients with higher liver iron stores are likely to have a worse cardiac outcome following noncompliance with chelation .
cardiovascular magnetic resonance identifies myocardial siderosis allowing optimization of iron chelation regimes .
diabetes puts thalassemic patients at increased risk of myocardial fibrosis .
dual chelation therapy with deferoxamine and deferiprone offers improved cardiac outcomes . |
spontaneous central vein thrombosis is a rare but potentially serious condition as it can present with a fatal pulmonary embolism .
activated protein c resistance ( apc - r ) due to homozygous factor v leiden mutation is an exceptional cause of spontaneous central venous thrombosis . we describe here a right - sided internal jugular vein ( ijv ) and subclavian vein ( scv ) thrombosis in a patient due to apc - r and homozygous factor v leiden mutation .
the relationship with dengue viral infection and apc - r with central vein thrombus has been explored .
a 21-year - old non - obese female patient with no co - morbid illness was referred to our intensive care unit ( icu ) from a private hospital with history of high grade fever with chills 8 days back with respiratory distress for 6 days and altered sensorium for 2 days .
she was intubated for altered sensorium and had already received mechanical ventilation for 48 hours .
she was referred to us in a state of shock with vasopressors infusions on flow ( dopamine through peripheral line ) . additionally , she had edematous peripheries ( right upper limb swelling was more as compared to the left ) .
she had leukocytopenia ( 2,400/cmm ) , thrombocytopenia ( 20,000/cmm ) , and normal prothrombin time , activated partial thromboplastin , and thrombin times and fibrinogen levels .
neck ultrasonography ( usg ) prior to an attempt of right ijv cannulation revealed a non - compressible right ijv along with absence of venous flow in color doppler strongly suggestive of right ijv thrombus .
her left ijv and scv were compressible ( checked by using linear ultrasound probe supraclavicularly ) and patent , hence we inserted the central line in the left scv for hemodynamic monitoring , fluid resuscitation and vasopressor use .
echocardiography showed mild tricuspid regurgitation with ejection fraction < 55% with mild dilatation of main pulmonary arteries .
urgent thoracic computed tomography ( ct ) angiography revealed left distal pulmonary artery thrombosis [ figure 1 ] .
we immediately started unfractionated heparin ( loading dose : 80 u / kg followed by continuous infusion @ 20 u / kg / hr . ) to achieve a target activated partial thromboplastin time ( aptt ) of 2 - 2.5 times the normal .
further investigations demonstrated apc - r using the test kit sta -staclot apc - r ( diagnostica stago , asnieres , france ) and genetic markers for thrombosis using polymerase chain reaction showed homozygous to factor v leiden mutation . after achieving the target aptt , oral vitamin k anticoagulants ( ovka ) in the form of warfarin 5 mg
was started along with the heparin to aim international normalized ratio ( inr ) of 2 - 2.5 .
her other supportive management included fluids , sedation , vasopressors , broad spectrum antibiotics , enteral nutrition , and mechanical ventilation . in the meantime , dengue igm
enzyme - linked immunosorbent assay ( elisa ) ( dengue igm capture elisa , panbio , australia ) was also found to be positive . within the next week
after the shock recovered , we did thrombophilia testing of this patient [ table 1 ] .
but , her right ijv and scv thrombus persisted with partial recanalization in follow up usg [ figure 2 ] .
importantly , her father , mother , and younger sister underwent factor 5 leiden mutation test which was tested negative . computer tomography angiography scan of thorax coronal view showing pulmonary artery thrombus ( arrowed ) usg scan of right ijv ( 1 ) showing presence of partial thickness thrombus ( 2 ) and right carotid artery ( 3 ) ( follow up pictures ) thrombosis screening in our patient
apc - r is an autosomal dominant abnormality leading to thrombophilia due to point mutation ( position 1691 ) in the factor v gene . with this mutation ,
factor v becomes unresponsive to proteolytic action of activated protein c. thus protein c resistance occurs and resulting in uninhibited coagulation and intravascular thrombosis .
the clinical picture is of spontaneous intravascular thrombosis at an early age ( > 45 years ) in an unusual venous site or pulmonary embolism or recurrence . hence after radiological confirmation of right ijv thrombus and thoracic ct angiography , thrombophilia testing was initiated .
age of the patient and unusual venous site thrombus with distal pulmonary artery thrombus prompted us to send thrombophilia testing for secondary prevention .. additionally , we did testing for homocysteine levels which were very low in our patient .
epidemiological studies have proved that increased homocysteine level is a risk for venous thrombosis , but the recent evidence has also challenged this concept . antibodies against dengue antigen nonstructural protein 1 ( ns1 ) can cross - react with endothelial cells , leading to endothelial activation and expression of more cytokine , chemokines , and adhesion molecules , resulting in widespread endothelial cell damage . dengue virus
infected endothelial cells can inhibit prostacyclin release and intensify von willebrand factor release from endothelial cells .
similar intravascular thrombosis is also known with sepsis of any cause . in our case , we believe that central venous thrombosis was due to dengue infection mediated endothelial injury or dengue virus sepsis syndrome induced .
venous thromboembolism in patients with factor v leiden mutation related heritable thrombophilias is managed with anticoagulants .
ovka , like warfarin , are preferred with a target inr of 2.5 ( range 2.0 - 3.0 ) .
the duration of anticoagulant therapy ( 3 - 6 months ) is based on the risk factors , no of events , recurrence , and area of involvement .
after a first episode , like in this case , the british committee recommends anticoagulation for 6 months .
this case report elaborates about a rare incidence of spontaneous central vein thrombosis in a patient of acp - r .
the relation between dengue infections and dengue viral sepsis with spontaneous thrombosis in a predisposed patient was also explored .
this case report also emphasizes the significance of usg as fortuitous detection of central vein thrombosis during usg for venous access . | spontaneous central vein thrombosis is a rare and potentially fatal condition in critical care setting .
activated protein c resistance due to homozygous factor v leiden mutation is an exceptional cause of central venous thrombosis .
we recently treated a healthy female student who presented with acute febrile illness , septic shock , and encephalopathy .
neck ultrasonography ( usg ) prior to an attempt of right internal jugular vein ( ijv ) cannulation revealed non compressibility of the vein along with absence of venous blood flow .
right ijv and subclavian vein thrombus was confirmed subsequently in usg doppler by radiologist .
radiological evidence of distal pulmonary artery embolism in pulmonary angiography was also evident .
further investigations demonstrated homozygous factor v leiden mutation and activated factor c resistance and dengue igm positivity in our patient .
intravenous heparin followed by oral vitamin k anticoagulants ( ovka ) aided in her recovery .
spontaneous intravascular thrombosis with activated protein c resistance and the relationship of acute dengue infection were explored in our report . |
sarcomatoid carcinomas of the lung are very uncommon tumors , comprising between 0.3 and 3% of all non - small lung carcinomas .
it is a heterogeneous group of poorly differentiated carcinomas with two cell types : sarcomatoid or sarcomatous morphology with giant and/or spindle cells .
their clinical presentation is not specific ; however , this type of neoplasm is very aggressive , with an overall 5-year survival rate of approximately 20% .
few studies have examined these tumors but chemoresistance appears to be responsible for their bad prognosis . to define the types of sarcomatoid carcinomas ,
clarify their immunohistochemical phenotype , and examine their therapeutic features , we herein describe two cases treated at the national institute of oncology in rabat .
a 53-year - old female presented in january 2010 with a cervical mass of gradually increasing volume that was associated with dyspnea and dry cough .
chest computed tomography ( ct ) scan revealed a cervico - mediastino - pulmonary lesional process of 120/80 , 70/70 , and 50 mm sheathing cervical and intrathoracic vascular axes and displacing the mediastinum .
a biopsy was performed and the histological examination revealed diffuse cellular water with large cells and hypertrophic irregular macro - nucleoli and macro - nuclei .
however , they were negative for thyroid transcription factor-1 ( ttf-1 ) , epithelial membrane antigen ( ema ) , muscle actin ( hhf35 ) , cytokeratins 7 , 20 , and 5/6 , ps100 , actin , and calretinin .
the tumor was classified as stage iv ( t4n0m1 ) and the patient received the following chemotherapy - based platinum salts : navelbine ( 25 mg / m j1 , j8 ) and cisplatin ( 80 mg / m j1 ) .
chest ct scan showing a right cervicothoracic mass with vascular sheathing after 18 months with the stable disease , the patient clinically progressed with the onset of chest pain .
a chest ct examination showed increased tumor volume ( from 120 to 160 mm ) .
evaluation after the third and sixth courses showed significant clinical benefit with radiographic disease stabilization .
the condition of the patient remained stable for 4 months and is currently being monitored routinely . in february 2013 , a 46-year - old male with a history of cigarette smoking for 20 years ( 30 cigarettes per day ) presented with dyspnea stage ii of the new york heart association classification , ( nyha ) , chest pain , and anorexia .
symptomatology evolved in a context of progressive deterioration of the general state and poor general condition . upon physical examination
, he appeared weak ( stage ii of who score ) , with a body temperature of 36.2c .
chest ct scans showed a large mass in the right lower lobe with spiculated contours that measured 110 mm .
the mass was associated with latero - tracheal , anterior mediastinal , and right hilar lymphadenopathy .
further staging showed multiple lesions of the spine ( d8 ) , right sacroiliac joint , 4 right odds .
using a scan - guided biopsy , histological and immunohistochemical evidences supported a sarcomatoid carcinoma , with carcinomatous proliferation of pleomorphic spindle and globoid cells [ figure 2a ] .
tumor cells were positive for vimentin [ figure 2b ] , cytokeratin , and ttf1 [ figure 2c ] .
the patient received cisplatin and navelbine , with a partial response after the third cycle ( 70 mm versus 110 mm ) .
we decided to continue the same chemotherapy after the good clinical and radiological response ; however , the patient presented with an acute kidney injury after the fourth cycle , with an estimated clearance of 25 ml / min according to the cockroft - gault formula .
the decision was made to switch to carboplatin ( auc 5 ) and paclitaxel ( 175 mg / m ) .
chest ct was performed again and showed the appearance of a lesion process in the right posterior of 7.5 cm , associated with two left hilar lymphadenopathies ( 20 mm and 26 mm , respectively ) .
therefore , we moved to a second - line therapy of docetaxel ( 75 mg / m ) .
the patient received 3 courses , and the period between these cycles of chemotherapy was marked by neuropathy grade i. a chest thoracic scan showed an increase in the size of the right posterior parietal lesion process , measuring 105/77 , 5 mm vs. 75.5/36 mm .
the process extended behind the 4 , 5 , and 6 dimensions , with invasion of the erector spinae muscles , trapezius invasion , and root canal .
( a ) h&e staining g 200 carcinomatous proliferation of pleomorphic spindle and globoid cells ( b ) h&e staining g 400 : tumor cells expressing the vimentin antibody ( clone v9 , immunotec ) ( c ) h&e staining g 400 : tumor cells expressing the ck ( clone ae1/ae3 , dako ) ( + ) and thyroid transcription factor-1 ( ttf1 ) ( clone 8g7g3 / 1 dako ( flex ) .
a 53-year - old female presented in january 2010 with a cervical mass of gradually increasing volume that was associated with dyspnea and dry cough .
chest computed tomography ( ct ) scan revealed a cervico - mediastino - pulmonary lesional process of 120/80 , 70/70 , and 50 mm sheathing cervical and intrathoracic vascular axes and displacing the mediastinum .
a biopsy was performed and the histological examination revealed diffuse cellular water with large cells and hypertrophic irregular macro - nucleoli and macro - nuclei .
however , they were negative for thyroid transcription factor-1 ( ttf-1 ) , epithelial membrane antigen ( ema ) , muscle actin ( hhf35 ) , cytokeratins 7 , 20 , and 5/6 , ps100 , actin , and calretinin .
the tumor was classified as stage iv ( t4n0m1 ) and the patient received the following chemotherapy - based platinum salts : navelbine ( 25 mg / m j1 , j8 ) and cisplatin ( 80 mg / m j1 ) .
chest ct scan showing a right cervicothoracic mass with vascular sheathing after 18 months with the stable disease , the patient clinically progressed with the onset of chest pain .
a chest ct examination showed increased tumor volume ( from 120 to 160 mm ) .
evaluation after the third and sixth courses showed significant clinical benefit with radiographic disease stabilization .
the condition of the patient remained stable for 4 months and is currently being monitored routinely .
in february 2013 , a 46-year - old male with a history of cigarette smoking for 20 years ( 30 cigarettes per day ) presented with dyspnea stage ii of the new york heart association classification , ( nyha ) , chest pain , and anorexia .
symptomatology evolved in a context of progressive deterioration of the general state and poor general condition . upon physical examination
, he appeared weak ( stage ii of who score ) , with a body temperature of 36.2c .
chest ct scans showed a large mass in the right lower lobe with spiculated contours that measured 110 mm .
the mass was associated with latero - tracheal , anterior mediastinal , and right hilar lymphadenopathy .
further staging showed multiple lesions of the spine ( d8 ) , right sacroiliac joint , 4 right odds .
using a scan - guided biopsy , histological and immunohistochemical evidences supported a sarcomatoid carcinoma , with carcinomatous proliferation of pleomorphic spindle and globoid cells [ figure 2a ] .
tumor cells were positive for vimentin [ figure 2b ] , cytokeratin , and ttf1 [ figure 2c ]
the patient received cisplatin and navelbine , with a partial response after the third cycle ( 70 mm versus 110 mm ) .
we decided to continue the same chemotherapy after the good clinical and radiological response ; however , the patient presented with an acute kidney injury after the fourth cycle , with an estimated clearance of 25 ml / min according to the cockroft - gault formula .
the decision was made to switch to carboplatin ( auc 5 ) and paclitaxel ( 175 mg / m ) .
chest ct was performed again and showed the appearance of a lesion process in the right posterior of 7.5 cm , associated with two left hilar lymphadenopathies ( 20 mm and 26 mm , respectively ) .
therefore , we moved to a second - line therapy of docetaxel ( 75 mg / m ) .
the patient received 3 courses , and the period between these cycles of chemotherapy was marked by neuropathy grade i. a chest thoracic scan showed an increase in the size of the right posterior parietal lesion process , measuring 105/77 , 5 mm vs. 75.5/36 mm .
the process extended behind the 4 , 5 , and 6 dimensions , with invasion of the erector spinae muscles , trapezius invasion , and root canal .
( a ) h&e staining g 200 carcinomatous proliferation of pleomorphic spindle and globoid cells ( b ) h&e staining g 400 : tumor cells expressing the vimentin antibody ( clone v9 , immunotec ) ( c ) h&e staining g 400 : tumor cells expressing the ck ( clone ae1/ae3 , dako ) ( + ) and thyroid transcription factor-1 ( ttf1 ) ( clone 8g7g3 / 1 dako ( flex ) .
thus , there could be a direct mechanism between toxicity and emergence of a sarcomatoid component .
dyspnea and cough were the first symptoms to appear in our patients , which were followed by generally rapid physical deterioration .
other symptoms may occur including weakness , shortness of breath , and fever . for proximal tumors ,
hemoptysis is present in 50% of cases , whereas for peripheral tumors , chest pain is frequently described .
radiologically , sarcomatoid carcinoma is usually a single lesion , with a large diameter ( from 40 to 180 mm ) , and central or peripheral location in the upper lobes .
the tumor is usually and locally advanced at the time of diagnosis with a large proportion of pleural invasion , either vascular or parietal ( 40 - 70% of cases ) .
our patients had large tumors ( 160 and 110 mm , respectively ) with vascular and nervous axis invasion ( case 1 ) .
they are defined in the world health organization classification as poorly differentiated non - small cell lung carcinomas ( nsclcs ) containing a sarcoma - like element ( malignant spindle or giant cells ) or sarcomatous component .
we can define five types of carcinomas based on specific histological criteria : giant cell carcinoma , pleomorphic carcinoma , carcinosarcoma , spindle cell carcinoma , and pulmonary blastoma .
pleomorphic carcinoma is formed by malignant giant and/or spindle cells plus epithelial components , such as squamous cells . the spindle and/or giant cells appear as cohesive aggregates of the tumor cell , without glandular or squamous differentiation .
the neoplastic spindle cells are isolated or in loose clusters , and are usually very polymorphic and elongated .
additionally , the nuclear - cytoplasmic ratio is high . in some cases , multiple keratin antibodies and ema
the tumor cells often co - express cytokeratin , vimentin , carcinoembryonic antigen , and smooth muscle markers .
the differential diagnosis for pleomorphic carcinoma consists of other tumors as both primary and metastatic sarcomas .
epidermal growth factor receptor ( egfr ) is a membrane of tyrosine kinase receptor that becomes oncogenic by acquiring a mutation within its catalytic domain .
indeed , in 22 surgically treated patients , egfr expression was analyzed and egfr gene mutations were observed .
egfr overexpression was found in all cases , with mutation analyses for egfr exons 18 , 19 , 20 , and 21 were obtained in 19 cases .
no results could be obtained in three cases , but no egfr mutations were detected .
recently , chang et al . , reported results that confirm the existence of carcinomas with pleomorphic egfr mutations in a taiwanese population .
pelosi et al . , reported 22% of patients had k - ras mutations at codon 12 .
for localized tumors , surgery remains adequate for treatment and appears to provide adequate local control .
however , for metastatic disease , no data are currently available and sarcomatoid carcinomas are usually treated as non - small cell lung cancer ( nsclcs ) .
cytotoxic agents used for the treatment of sarcomatoid carcinomas are the same used as those used for nsclcs . in the series of vieira et al . ,
study 97 patients with metastatic disease were included , of which 73% of them received chemotherapy - based platinum salts .
the difference in progression - free survival ( pfs ) was not statistically significant between patients receiving or not a platinum - based chemotherapy , no statistically significant difference in overall survival was observed ( 7months with platinum versus 5.3 months without , p = 0.096 ) .
our two patients received platinum - based doublets for first - line therapy but their responses varied between stabilization and progression , but these elements remain insufficient to conclude that platinum salts possess an activity on this type of tumor or not .
other protocols have been used , such as cav ( cyclophosphamide , adriamycin , and vincristine ) , to target the epithelial and sarcomatous component .
one study evaluated the short - term outcomes of using doxorubicin and ifosfamide in the treatment of metastatic sarcomatoid carcinoma . among 15 patients , 50% showed partial responses to short - term chemotherapy with doxorubicin and ifosfamide .
however , all patients experienced disease progression and died despite continuous treatment . for targeted therapies ,
the study by italiano showed that patients with lung sarcomatoid carcinoma did not benefit from anti - egfr treatment .
the histological and immunohistochemical characteristics of this tumor type are specific and very different from non - small cell lung carcinoma , resulting in an aggressive entity .
conventional chemotherapy did not show satisfactory results , and future studies are needed to explore the molecular profile of these tumors in order to determine the best therapeutic approach . | context : lung tumors are very heterogeneous histological entities .
pulmonary sarcomatoid carcinoma is a subset of tumors characterized by specific histological features .
their poor prognosis compared to other lung tumors is due to limited responses to different types of chemotherapy.case report : we report two patients with sarcomatoid tumors : a 53-year - old woman and a 46-year - old man who presented respiratory symptoms : dyspnea , cough , associated with a deterioration of general condition.conclusion:pulmonary sarcomatoid carcinomas remained an unexplored entity , despite their poor prognosis .
based on these cases , we will discuss the histological and immunohistochemical features of these tumors , as well as report their responses to different chemotherapy regimens used in the course of treatment . |
patients with schizophrenia have a two- to threefold higher risk of premature death than those without schizophrenia .
this increased mortality is accounted for by a combination of factors , such as lifestyle factors , high suicide rates ( especially in young male patients soon after diagnosis ) , premature development of cardiovascular disease , a high prevalence of metabolic syndrome , carbohydrate and lipid metabolic disorders , and , equally important but not often mentioned , sudden unexpected death.13 the exact pathophysiological cause of sudden unexpected death in patients with schizophrenia is unknown , but it is likely that cardiac arrhythmias play a role.4,5 it has been established that people with schizophrenia are at a high risk of developing cardiovascular disease and that some atypical antipsychotics may be associated with adverse cardiovascular events ( e.g. , qt interval prolongation ) . together , these risk factors may lead to torsades de pointes or sudden cardiac death.4 , 6,7 moreover , an important issue that has not yet been explored is the possible existence of a
. studies of the pathophysiology of sudden unexpected death in epilepsy ( sudep ) have revealed that cardiac bradyarrhythmias that are triggered by epileptic activity in the left amygdala , anterior hippocampus , orbitofrontal cortex , and insular cortex can occur and lead to adverse cardiovascular outcomes.810 through their connections with the hypothalamus and pons as well as nuclei in the medulla and spinal cord , these regions can initiate integrated cardiovascular responses related to emotion and motivated behavior that may be inappropriately activated during a seizure.10 the thalamus receives projections from the insular cortex and amygdala and projects to the anterior cingulate cortex , which is the executive region involved in exerting emotional control .
this region , in turn , projects to the hypothalamus , periaqueductal grey matter , and the nucleus ambiguus , which control the parasympathetic and sympathetic cardiac ganglia and the atrioventricular node of the heart10 .
heart rate , cardiac contractility , and atrioventricular ( a - v ) conduction may therefore be controlled independently by both these brain structures and the thalamus.11 thalamic pathology and reduced thalamic volumes have been implicated in the pathophysiology of temporal lobe epilepsy , largely due to the important connection that the thalamus has with the temporal lobe , especially the hippocampus.12 in patients with schizophrenia , thalamic pathology has been described and may be associated with the occurrence of sudden cardiac death . the aim of our paper is to discuss the possible association of sudden cardiac death in schizophrenia with abnormalities in the thalamic complex .
the presence of anatomical abnormalities in the brains of patients with schizophrenia has been well established , especially since the introduction of several imaging modalities that can be used to perform structural and functional brain imaging.13 the structural findings in the brains of patients with schizophrenia include dilatation and enlargement of the ventricles,14 volume reductions in the frontal grey matter,15,16 bilateral reductions in hippocampal volume,17 and a reduction in thalamic volumes .
these findings have all been obtained via structural magnetic resonance imaging ( mri ) studies.18,19 because the thalamus is heterogeneous , schizophrenia - related changes would likely occur in specific thalamic subregions ( figure 1 ) .
this brain structure is composed of various subnuclei that have received special attention in schizophrenia research due to to their unique locations and neuronal connectivity.13,2023 the thalamus acts as a central relay station that transfers peripheral sensory input to the cortex , thereby playing a critical role in filtering sensory information , regulating cognitive input to the cortex , and mediating corticocortical connections between areas that have been especially implicated in schizophrenia , such as the frontal and temporal cortices.21,24 recently , lang and colleagues25 demonstrated the presence of a bilateral reduction in thalamic volume in a cohort of drug - naive or minimally treated patients experiencing initial episodes of psychosis , suggesting that such abnormalities are present very early in the course of the disease . the existence of some structural alterations in the brains of schizophrenic patients is supported by data from functional studies that have shown the presence of abnormal thalamic glucose metabolism in these patients.26,27 in patients with schizophrenia , positron emission tomography ( pet ) studies have shown evidence of dysfunction of the cortico - cerebellar - thalamic - cortical neuronal circuit .
this dysfunction contributes to the presence of cognitive dysmetria , i.e. , impaired cognition , as well as other symptoms of the disease.28,29 similarly , reduced levels of metabolic activity in the thalamus as measured by pet and single - photon emission computed tomography ( spect ) studies of cerebral perfusion
have been linked to cognitive deficits and an increased severity of both positive and negative symptoms in schizophrenic patients30 .
functional mri studies have shown that these patients have sensory processing and attention deficits that involve thalamic hypofunction.3135
on the cellular level , the density of the parvalbumin - immunoreactive varicosities in the middle layer of the prefrontal cortex has been shown to be lower in schizophrenic patients , suggesting that these patients have fewer neuronal projections from the thalamus to the prefrontal cortex.36 post - mortem findings of reduced thalamic volume , neuronal number , and overall thalamic size37 as well as reductions in the size of the mediodorsal nucleus , pulvinar nucleus , and ventral posterior thalamic nucleus3842 support the hypothesis that thalamic function and the connections between various thalamic nuclei and different brain structures in patients with schizophrenia are disturbed . in recent h - mrsi ( proton magnetic resonance spectroscopy imaging )
studies , reduced n - acetyl - aspartate ( naa ) levels have been noted to be present in the entire thalamus as well as the anterior and mediodorsal nuclei of the thalamus in patients with schizophrenia.4345 reductions in naa levels indicate a loss of the functional and structural integrity of neurons .
however , a correlation between naa levels and structural parameters has not been demonstrated.4248 therefore , alterations of naa may be related to the dysfunction of neurons with altered glutamatergic neurotransmission.49,50 the glutamate hypothesis of schizophrenia is based on the observation that phencyclidine and ketamine , both of which block the ion channel of the glutamatergic n - methyl - d - aspartate ( nmda ) receptor , initiate nmda receptor hypofunction and precipitate psychosis,51,52 resulting in a final hypoglutamatergic state in the corticostriatal projections.53,54 in the striato - thalamo - cortical loop , this hypoglutamatergic state may lead to a dysfunction of the gamma - amino - butyric acid ( gaba)ergic striatothalamic projections with consecutive thalamic disinhibition and glutamatergic overflow to the cortex.24,55 accordingly , in a 4.0-tesla mri spectroscopy study , higher levels of glutamine resulting from glutamate breakdown in glial cells ) have been reported to be found in the thalami of unmedicated and chronic schizophrenic patients.56,57 these results correspond to an increased expression of glutamine synthetase and glutaminase .
the upregulation of these enzymes suggests an increased rate of glutamate turnover.58 consistent with these findings , the gene expression of the glial glutamate transporters [ excitatory amino acid transporters 1 and 2 ( eaat1 and eaat2 ) ] that remove glutamate from the synaptic cleft as well as the expression of a vesicular glutamate transporter ( vglut2 ) have been shown to be increased in patients with schizophrenia.59,60 on the one hand , this increased expression may occur as a result of transcriptional regulation due to an increased glutamate concentration in the synapse . on the other hand ,
the increased expression of these transporters may induce a hypoglutamatergic state by decreasing the amount of glutamate that is present in the synaptic cleft .
the mrna expression of the nmda receptor subunits nr1 , nr2b and nr2c , the ionotropic glutamatergic ampa receptor subunits glur1 and glur3 , the kainate receptor subunit ka2 , and the polyamine and glycine binding sites of the nmda receptor has been shown to be decreased in the mediodorsal and central medial nuclei of the thalamus in schizophrenic patients.61,62 these changes suggest a diminished glutamatergic activity or abnormal glutamatergic innervation of afferent or efferent cortical or limbic ( hippocampal ) structures . in contrast , clinton et al.63 reported the presence of increased protein levels of the nr2b subunit and its associated protein psd95 ( which targets glutamate receptors to the synaptic membrane , modulates receptor activity , and coordinates glutamate receptor - related signal transduction ) in the thalami of patents with schizophrenia .
these conflicting results are not surprising , since changes in the mrna levels of a gene transcript may not always reflect alterations in protein levels . altered naa levels may also be related to the decrease in neuropil ( dendrites and axons ) content that is present in patients with schizophrenia . in concordance with this hypothesis , in a post - mortem study the levels of the synaptic protein rab3a were found to be reduced in the left thalamus of schizophrenic patients.64 alterations in the neuropil content of specific brain regions may also reflect a reduction in the presence of components of cell membranes , i.e. , phospholipids . in a p - mrsi ( phosphorus magnetic resonance spectroscopy imaging ) study , a decrease in the levels of the membrane breakdown product glycerophosphoethanolamine has been observed in the left thalamus of patients with schizophrenia .
this change has been viewed as indicative of altered phospholipid metabolism in that region.65 accordingly , in a post - mortem study , we showed that there was a decrease in the levels of the main membrane phospholipid ( phosphatidylcholine ) and the major myelin membrane components ( sphingomyelin and galactocerebrosides 1 and 2 ) in schizophrenic patients .
in contrast , phosphatidylserine levels were increased in these patients , supporting the concept that there is an increased breakdown of phospholipids in schizophrenic patients .
since these phospholipds are mainly present in the myelin sheath of oligodendrocytes , his finding was thought to be indicative of oligodendrocyte dysfunction and decreased myelination in the thalami of these patients.66
in light of the findings mentioned above , the question arises as to whether sudden cardiac death in schizophrenia could be related to functional or anatomical changes in the thalami of these patients .
it has long been recognized that , in the healthy brain , stimulation of ( or the presence of lesions in ) certain central nervous system structures can lead to morphological and functional cardiovascular alterations . because it has been documented
that disorders of the central nervous system ( cns ) can alter cardiovascular function,8 we believe that this issue should be deeply explored in schizophrenia research . before these studies are undertaken , it is prudent for us to clarify our research background . in a previous study ,
our research group found that the thalamus plays an interesting and important role in the cerebral circuits of rats with epilepsy67,68 .
interestingly , in studies of epilepsy , which is the most prevalent serious neurological condition worldwide , clinical data suggest that these patients are at a two- to threefold higher risk of dying prematurely than those without epilepsy .
the most common epilepsy - related cause of death is sudep.69 following this reasoning , we proposed a new line of thinking : because several morphological and/or functional changes of the thalamus have been reported to occur in patients with epilepsy , it is possible that this brain region might also be involved in the occurrence of cardiovascular abnormalities and hence sudep . to answer this question
, we initially based our hypothesis on the elegant study performed by boyko and colleagues.70 the authors showed that bilateral injections of kainic acid into the thalamus of adult rats led to myocardial necrosis .
this effect was particularly marked in the lateral posterior thalamic nuclei , suggesting that this specific thalamic nucleus has a direct relationship with the cardiovascular system .
first , in 2005 , we evaluated the heart rate of rats with epilepsy , both in vivo ( via electrocardiography ) and in an isolated ex vivo preparation ( via langendorff preparation).71 our results from the in vivo experiment showed that there were significant differences in the mean heart rate of the two groups ( control animals : 3079 bpm ; animals with epilepsy : 3467 bpm ) .
in contrast , we did not find these differences in the isolated ex vivo experiment ( control animals : 1757 bpm ; animals with epilepsy : 1766 bpm ) .
these findings suggest that some part of the central nervous system ( e.g. , the thalamic nuclei ) has the potential to modulate cardiovascular function , which could explain the pathophysiology underlying sudep . in a more recent study ,
our group ( scorza and colleagues , unpublished data ) evaluated the heart rate ( in vivo and isolated ex vivo ) of rats with epilepsy before and after bilateral lesioning of the lateral posterior nuclei of the thalamus .
the results showed significant differences in the mean heart rate before and after thalamic injury in the in vivo experiment .
surprisingly , no differences in heart rate could be observed before and after thalamic injury in the isolated ex vivo experiment .
these observations seem to indicate the existence of a specific thalamic modulation of cardiac functioning that could support our hypothesis that sudep occurs due to cardiovascular dysfunction secondary to thalamic dysfunction . finally , based on these results
, we raised the possibility that the presence of thalamic nuclear lesions in people with temporal lobe epilepsy could be responsible for some of the processes that culminate in sudep , and that cardiovascular dysfunction could play a significant role in this condition.72 taking all of these data together , the important question arises as to how to use our growing understanding of thalamic abnormalities and cardiovascular dysfunction in epilepsy patients to guide our examination of the possible role that abnormalities in thalamic nuclei play in the development of cardiovascular abnormalities in schizophrenic patients73 .
however , from post - mortem studies , it is unclear whether thalamic abnormalities or antipsychotic treatment contribute to sudden cardiac death , since most of the patients in these studies are treated with typical and atypical antipsychotics for several decades . in schizophrenic patients , treatment with antipsychotics not only induces qt interval prolongation , but also influences thalamic volume and activity .
the first study on this topic found that both typical and atypical antipsychotic treatment increased thalamic volumes in schizophrenic patients.20 a recent mri study also found that the use of atypical antipsychotics is associated with an enlargement of the thalamus.74 however , in another study , the authors found that after patients switched from typical neuroleptics to the atypical antipsychotic olanzapine , their thalamic volume decreased to a normal size as compared to healthy controls.75 another study found that patients who were taking atypical antipsychotics had decreased thalamic volumes , whereas patients treated with typical neuroleptics did not.76 the atypical antipsychotic risperidone has been shown to increase levels of the neuronal marker naa in the thalamus.77 accordingly , pet studies have shown an increased regional cerebral blood flow in the thalamus after treatment with the typical neuroleptic haloperidol , whereas olanzapine reduced blood flow in this region.78 in animal studies , the typical antipsychotic haloperidol as well as the atypical drugs clozapine and olanzapine have been shown to induce c - fos expression in the thalamus , which is related to activation of gene expression in cells in which its expression is induced.79 hyperactivity of the dopamine d2 neurotransmitter system has also been implicated in schizophrenia .
this increased dopaminergic signaling may result in disinhibition of the thalamus.80 in a pet study , haloperidol was found to downregulate the activity of dopa decarboxylase in the thalami of schizophrenic patients , suggesting that haloperidol leads to a decrease in the dopamine synthesis capacity of the thalamus.81 additionally , the occurrence of akathisia ( as a side effect of olanzapine treatment ) reduced the level of metabolic activity that was present in the thalamus of affected patients.82 mri spectroscopy studies have indicated that high glutamine levels in the thalamus are reduced after atypical antipsychotic treatment is initiated.56,57 animal models of antipsychotic treatment have demonstrated an activation of inhibitory gabaergic neurons , a decreased gabaa receptor binding , and an altered expression of proteins that interact with glutamate transporters.8385 in summary , the inhibition of thalamic activity may be a mode of action of at least atypical antipsychotics and may influence patients sensitivity to cardiac events . where do we go from here ? a priority of ours is to raise the possibility that the presence of lesions in the thalamic nuclei of patients with schizophrenia could represent the underlying mechanism of some processes that culminate in sudden cardiac death in these patients .
we also feel it is important to raise the possibility that heart failure may play a significant role in this mechanism .
it is clear that more animal model and clinical research needs to be done on this topic .
however , in a similar manner to what our group has reported about the relationship between heart issues and epilepsy , we believe that a clear relationship exists between schizophrenia , thalamic dysfunction , heart failure , and sudden cardiac death . | patients with schizophrenia have a two- to three - fold increased risk of premature death as compared to patients without this disease .
it has been established that patients with schizophrenia are at a high risk of developing cardiovascular disease . moreover ,
an important issue that has not yet been explored is a possible existence of a
cerebral focus that could trigger sudden cardiac death in patients with schizophrenia . along these lines ,
several structural and functional alterations in the thalamic complex are evident in patients with schizophrenia and have been correlated with the symptoms manifested by these patients . with regard to abnormalities on the cellular and molecular level
, previous studies have shown that schizophrenic patients have fewer neuronal projections from the thalamus to the prefrontal cortex as well as a reduced number of neurons , a reduced volume of either the entire thalamus or its subnuclei , and abnormal glutamate signaling . according to the glutamate hypothesis of schizophrenia , hypofunctional corticostriatal and striatothalamic projections are directly involved in the pathophysiology of the disease .
animal and post - mortem studies have provided a large amount of evidence that links the sudden unexpected death in epilepsy ( sudep ) that occurs in patients with schizophrenia and epilepsy to thalamic changes . based on the results of these prior studies ,
it is clear that further research regarding the relationship between the thalamus and sudden cardiac death is of vital importance . |
though the most common presentation of obstructive uropathy is urosepsis , this disorder may be associated with hyponatremia and loss of salt in the urine .
the present case posed a diagnostic challenge because despite the presence of an obstructive salt losing uropathy , the urinary salt concentration was paradoxically low .
this previously unreported paradox was due to the entrapment of a high concentration of salt within the obstructed upper moiety of a duplex system , the contents of which were not mixing with urine in the bladder .
an afebrile 6-month - old female was transferred to our institution with lethargy , vomiting , and diarrhea .
laboratory evaluation was remarkable for metabolic acidosis , hyponatremia ( 133 meq / l ) , and hypokalemia ( 3.4 meq / l ) . since the patient promptly improved and laboratory values , including urinary sodium concentration , corrected with intravenous hydration , the patient was discharged with the diagnosis of dehydration without a proper work - up for obstructive uropathy .
admission laboratory work revealed metabolic acidosis , hyponatremia ( 123 meq / l ) , hyperkalemia ( 6.0
meq / l ) , and decreased serum osmolality ( 270 mosm / kg ) .
the urine sodium and osmolality were also decreased , 10 meq / l and 101 mosm / kg , respectively .
plasma renin was > 1800 mcu / ml ( normal 664 mcu / ml ) and aldosterone was 1621 ng / dl ( normal 799 ng / dl ) , both markedly elevated .
there was no history of significant vomiting or diarrhea and the cause of the electrolyte abnormalities could not be explained .
renal sonography demonstrated a duplex left collecting system ( figure 1 ) and dilation of the upper pole moiety terminating as a large ectopic ureterocele at the bladder base .
the echogenicity of the trapped urine was homogeneously increased suggesting a higher concentration of debris or minerals ( figure 2 ) .
voiding cystourethrography confirmed the presence of a ureterocele and was otherwise normal ( figure 3 ) .
the sonographic findings and discordance between urine and serum sodium concentration suggested that the enclosed upper pole collecting system had entrapped a higher sodium concentration , not reflected in the urinalysis .
prior to repair , aspirates of the bladder and ureterocele revealed discordant sodium concentration , 22 meq / l and 118 meq / l , respectively .
ectopic ureterocele is associated with ureteral duplication and obstructive dilation of the ureter and its calices .
though the most common presentation is urinary tract infection , some children have a more insidious course with intermittent abdominal pain or failure to thrive . rarely , the infants have salt losing obstructive uropathies .
salt losing nephropathy associated with obstructive uropathy has been called pseudohypoaldosteronism and is thought to reflect tubular unresponsiveness to aldosterone . though the combination of renal tubule immaturity , obstructive uropathy , and urinary tract infection are predisposing factors , pseudohypoaldosteronism has been described with pyelonephritis independent of obstruction and with obstruction independent of infection .
because of these associations , urine culture and renal sonography have been advocated in any infant with an electrolyte disturbance .
ordinarily the salt concentration in a urine sample correlates with the degree of renal salt excretion .
however , our case demonstrates that anomalies resulting in entrapment or diversion of the urine with high salt concentration away from the bladder create exceptions to this principle . the paradox exemplified here
need not be limited to cases associated with an obstructed ectopic ureterocele terminating at the bladder base . if the ectopic ureter of an obstructed moiety enters anywhere else than the bladder , such as the seminal vesicles , vagina , or urethra , similar clinical challenges may be encountered .
though the observation of echogenic fluid within a ureterocele has been made before , it is usually attributed to nonspecific debris or pus related to urinary tract infection . in our case , which was not associated with urosepsis , sonography helped explain the unusual laboratory results . normal or decreased urinary sodium concentration and hyponatremia do not exclude salt losing obstructive uropathies in patients with hyponatremia .
the excess salt can be entrapped in an obstructed system resulting in a false - negative urinalysis and diversion of attention away from this surgically correctible group of disorders . | a 6-month - old hyponatremic female with failure to thrive had low urinary sodium concentration .
renal sonography revealed a duplex left collecting system with obstruction of the upper moiety as a blind - ended ectopic ureterocele extending to the bladder base .
the echogenicity of the urine within the upper pole system was greater than the bladder contents .
we believed that low urinary sodium concentration represented a false negative test and the salt loss by the obstructed left kidney was entrapped in the upper pole collecting system . prior to ureterocele repair
, intraoperative bladder and ureterocele aspirates revealed discordant sodium concentration supporting the sonographic conclusion . |
secondary brain stem injury is associated with transtentorial herniation , and manifests as duret hemorrhages .
such an injury has been considered a terminal brain stem event with a high morbidity and mortality , sometimes discouraging continuation of care . however , there have been rare instances where patients have had reasonable recovery .
we report another case , emphasizing that such an injury by itself should not deter aggressive measures , as good outcomes remain a possibility .
a 37-year - old male sustained a right subdural hematoma after a mechanical fall while intoxicated .
three days later , he exhibited acute neurological deterioration to glasgow coma scale 4 , requiring intubation and mannitol .
repeat scan demonstrated enlarging right subdural hematoma with worsening shift ; brain stem hemorrhage was noted at pontomesencephalic junction .
he had a short stay for inpatient rehabilitation and underwent autologous cranioplasty at 3 months . on examination ,
he was awake , alert , and oriented to self , time , and location ; he exhibited dysarthric speech , right ptosis , but followed commands in all four extremities with no focal motor weakness .
in contrast to the common belief , patients suffering from a duret hemorrhage can still have a good outcome .
the finding from this paper suggests the finding of duret hemorrhages on imaging should not deter aggressive measures especially in patients with lesions causing significant mass effects .
secondary brain stem injury is associated with herniation syndromes , and manifests as duret
such an injury has been regarded as a fatal brain stem event with a high morbidity and mortality , sometimes discouraging continuation of care.26 however , there have been rare instances where patients have had reasonable recovery.1,2,712 we report another case , emphasizing that such an injury by itself should not deter aggressive measures , as good outcomes remain a real possibility .
patient is a 37-year - old male , history of hypertension , who sustained a mechanical fall while intoxicated .
a computed tomography head demonstrated a right frontal contusion and right subdural hematoma ( 5 mm thickness , 5 mm midline shift ) .
three days later , patient exhibited acute neurological deterioration ; on examination , patient did not open eyes to pain ; left pupil was 3 mm , nonreactive ; right pupil was 2 mm , sluggish ; patient exhibited extensor posturing in all four extremities .
repeat scan demonstrated enlarging right subdural hematoma ( 6 mm thickness ) with worsening shift ( 7.3 mm ) ; brain stem hemorrhage was noted at pontomesencephalic junction ( figure 1 ) ; the latter was not evident during initial imaging .
on postoperative day 1 , patient was able to sluggishly follow commands in all four extremities .
he was awake , alert , and oriented to self , time , and location ; he exhibited dysarthric speech , right ptosis , but followed commands in all four extremities with no focal motor weakness .
traumatic brain stem hemorrhages may be grouped based on primary or secondary etiologies.12 primary etiologies are commonly associated with the traumatic event , accompanied by diffuse supratentorial lesions , and frequently identified on initial imaging .
mechanisms include diffuse axonal injury from acceleration / deceleration , inertial injury at the midbrain due to the tentorium or clivus , and hyperextension of the cervical spine that contuses the lower brain stem.2,12 on the other hand , secondary etiologies are related to transtentorial herniation due to intractable intracranial hypertension , manifesting as duret hemorrhages .
there is a predisposition for involvement at the midline of the rostral pons and the ventral tegmentum of the midbrain.4 other findings related to herniation are possible , including lesions in the contralateral cerebral peduncle and infarction along the distribution of the posterior cerebral artery.8 differentiation between primary and secondary brain stem hemorrhage may be challenging since duret hemorrhages may transpire within a half - hour after the initial trauma.8 the reported incidence of duret hemorrhages is 5%10% of all brain stem hemorrhages in prior radiological studies.4,8 the pathogenesis of duret hemorrhages has been debated .
when the brain stem is displaced inferiorly , the basilar artery and its paramedian pontine perforating vessels remain relatively fixed ; this may cause the latter to shear and lead to hemorrhage.1,13 on the other hand , since veins are more compressible than arteries , herniation may lead to venous congestion and subsequent infarction at the rostal brain stem draining veins , followed by hemorrhagic conversion.1,13 interestingly , an element of hemorrhage may be linked to reperfusion injury , as there have been reports of brain stem hemorrhages after surgical decompression.7,9 duret hemorrhage has been considered a fatal , irreversible brain stem event with high morbidity and mortality , sometimes discouraging continuation of care.26 however , early withdrawal of care eludes a true assessment of outcomes for such lesions .
several authors believed that timely surgical decompression and/or early diagnosis may improve chances for good recovery.2,8,10,11 ishizaka et al1 suggested that the overall , primary parenchymal injury may have a more significant influence on prognosis than duret hemorrhages , where patients with duret hemorrhages but relatively less primary injury may be salvageable.1,12 in addition , beier and dirks2 believed that a younger age ( with inherent plasticity ) could also be a factor for favorable prognosis .
duret hemorrhage ; the finding was not evident during the initial imaging , where the patient had a good clinical examination after his traumatic event . once the hematoma expanded and the shift worsened , the patient exhibited an acutely worsening neurological examination to gcs 4 t , consistent with a herniation syndrome that likely led to the duret hemorrhage . based on the brain trauma foundation guidelines , an acute subdural hematoma with midline shift greater than 5 mm prompts recommendation for surgical evacuation regardless of gcs .
though not as young as the pediatric patients reported by beier and dirks,2 the patient was relatively young .
an acute subdural hematoma that requires surgical evacuation is associated with many general neurocognitive morbidities .
moreover , the frontal lobe injury may also affect higher functions such as motivation , judgment , planning , and social behavior .
in addition , the duret hemorrhage may reflect injury at the reticular activating system , which also influences levels of consciousness .
given the favorable outcome , surgical interventions should remain an option for patients presenting with
hemorrhages and surgical lesions , such as a subdural hematoma , producing significant mass effect .
in contrast to the common belief , patients suffering from a duret hemorrhage can still have good outcomes .
the finding from this paper suggests that the finding of duret hemorrhages on imaging should not deter aggressive measures especially in patients with lesions causing significant mass effects . | backgroundsecondary brain stem injury is associated with transtentorial herniation , and manifests as duret hemorrhages .
such an injury has been considered a terminal brain stem event with a high morbidity and mortality , sometimes discouraging continuation of care . however , there have been rare instances where patients have had reasonable recovery .
we report another case , emphasizing that such an injury by itself should not deter aggressive measures , as good outcomes remain a possibility.case presentationa 37-year - old male sustained a right subdural hematoma after a mechanical fall while intoxicated .
he presented initially with a glasgow coma scale 15 .
three days later , he exhibited acute neurological deterioration to glasgow coma scale 4 , requiring intubation and mannitol .
repeat scan demonstrated enlarging right subdural hematoma with worsening shift ; brain stem hemorrhage was noted at pontomesencephalic junction .
patient was immediately taken for subdural hematoma evacuation .
the following day , patient was able to sluggishly follow commands in all four extremities .
he had a short stay for inpatient rehabilitation and underwent autologous cranioplasty at 3 months . on examination ,
he was awake , alert , and oriented to self , time , and location ; he exhibited dysarthric speech , right ptosis , but followed commands in all four extremities with no focal motor weakness.conclusionin contrast to the common belief , patients suffering from a duret hemorrhage can still have a good outcome .
duret hemorrhages may not represent a fatal injury .
the finding from this paper suggests the finding of duret hemorrhages on imaging should not deter aggressive measures especially in patients with lesions causing significant mass effects .
overall clinical status should drive surgical options and clinical course . |
rhinitis sicca or generally speaking dry nose is a rather frequent problem involving many people .
many symptoms during dry nose could be encountered ranging from subjective sensation of the dry nose and itching up to mild burning , nasal obstruction , crusting associated with unpleasant smell , epistaxis , and diminished sense of smell .
rhinitis sicca anterior means a chronic inflammation in the region of the anterior part of the nose , affecting the anterior and caudal septum and/or the corresponding lateral nasal vestibule .
the treatment of rhinitis sicca involves mainly elimination of promoting factors , moistening , sufficient daily drinking amount , cleansing of the crusts , care of the mucosa and inhibition of possible infections , or in rare cases the elimination of overlarge endonasal space .
the main treatment for rhinitis sicca consists of humidification of the nose , especially the mucus , focusing in a real wash - out of possible inflammatory triggers and application of a protective layer on the mucus .
the market offers a huge number of different devices involving saline , oils , moisturizers , sprays , and ointments for this purpose .
nasal irrigation and nasal saline sprays wash out inflammatory triggers directly [ 2 , 3 ] and achieve an improvement of mucociliary clearance by improving the ciliary beat frequency [ 4 , 5 ] .
nasal ointments mostly including glycerol develop a protective moistening effect and protect the nose from water loss .
low concentrated oils also have beneficial effects on nasal ciliary beat frequency . the efficacy of dexpanthenol , the alcohol analog of pantothenic acid , in the treatment of rhinitis sicca is widely spread in the otc use and has been shown clinically .
in addition , use of dexpanthenol has a strong tradition in the treatment of various skin diseases in which dexpanthenol is used as humidifier / moisturizer . also , use in wound healing has been reported .
besides these different options , patients ask for alternative treatments as the current treatments often leave patients unsatisfied and a demand for other nonpharmacological treatment options exists .
ectoine is an extremolyte , a compatible solute which is produced by microorganism living under extreme environmental conditions such as extreme salinity or dryness . in those microorganisms
different in vitro , ex vivo , and in vivo studies have shown that ectoine can be used to protect epithelial tissues and moisturize and reduce inflammations [ 1315 ] .
membranes and lipids are protected indirectly : as ectoine is expelled from the surface of proteins and lipids , those are protected by a water shell , thereby increasing the fluidity of membranes and resulting in the preferential formation of the native conformation of proteins .
this might stabilize mucous membranes such as lining epithelia of the nose , thereby protecting those cells from invading allergens or pathogens .
recent developments have demonstrated that these cell protective attributes could be transferred into medical devices including ectoine containing creams , nasal sprays , or eye drops which can be used for human use , for example , the treatment of atopic dermatitis , allergic rhinitis , and rhinosinusitis [ 1720 ] .
the use of ectoine in a saline based nasal spray could be a useful therapeutic approach for patients suffering from dry nose syndrome .
additionally a combinatory approach could be applied , for example , of ectoine and dexpanthenol .
the combined effects of ectoine and/or dexpanthenol are already used in the field of dermatology and promise a useful combination effect for the treatment of rhinitis sicca . by using an ectoine and dexpanthenol nasal spray ,
the moisturizing and regeneration supporting effects of both compounds could assist a possible healing of ulcers and prevent nasal obstruction in addition to the reduction of primary symptoms .
the current paper describes two prospective , open - label , noninterventional trials ( studies 1 and 2 ) .
restricted inclusion of patients study based on the diagnosis of rhinitis sicca and strict adherence to the principle of nonintervention allowed data to be collected for a very unselective patient population . as study designs for both studies were very similar , data are summarized and differences are only outlined where applicable .
patients in study 1 were treated with an ectoine containing nasal spray with 0.5% ectoine and further ingredients were sodium chloride , sodium - di - hydrogen - phosphate dihydrate , di - sodium - hydrogen - phosphate , and water .
patients in study 2 used a 0.5% ectoine nasal spray which contained 1.0% dexpanthenol , sodium chloride , sodium - di - hydrogen - phosphate dihydrate , di - sodium - hydrogen - phosphate , and water .
both studies were open for all patients from 18 years on , who were identified by ent specialist with symptoms of dry nose .
following confirmation of the diagnosis of rhinitis sicca , patients were asked by the ent specialist whether they were interested to participate in the current trials . upon signing a patient information and consent form , patients had to attend two more site visits : v2 on day 7 2 and v3 on day 14 2 . during the entire treatment period of 2 weeks
clinical symptoms were assessed on a 12-point scale ranging from 0 ( no symptoms ) to 12 ( very severe symptoms ) . during the visits ,
the physician assessed the main symptoms of nasal obstruction and crusting of the nose as well as the following secondary symptoms : endonasal blood deposits , concomitant pharyngitis , cacosmia , rhinorrhea , exudate viscosity , and turbinate hyperplasia . on days 3 , 6 , 9 , and 12 after start of the study
, patients were asked to document the severity of the following symptoms in a patient diary : nasal obstruction , dryness of the nose , nose bleeding , sore throat , cacosmia , and exudate from the nose .
in addition , patients were asked to describe the consistency of exudate on a 12-point scale from 0 ( fluid ) to 12 ( crusted ) .
both efficacy and tolerability were assessed by physicians ( during v2 and v3 ) and by the patients ( days 3 , 6 , 9 , and 12 ) on a scale from 0 ( very good ) to 12 ( none / bad ) .
the statistical analysis was carried out with spss version 15 ( study 1 ) or 17 ( study 2 ) , respectively .
further analysis was carried out with the mann - whitney u test , wilcoxon test , or friedman test .
both studies were conducted in accordance with the declaration of helsinki . all investigations were carried out with informed consent of all participants .
study 1 was a noninterventional trial taking place from april to july 2008 ; study 2 took place from march to april 2009 .
both studies were carried out at a german ear nose throat ( ent ) practice .
distribution and demographics of patients are shown in figures 1 and 2 . in both studies ,
the investigators assessment revealed that the symptom nasal obstruction decreased significantly from v1 to v2 as well as further to v3 . in study 1 , symptom scores decreased from baseline values 4.60 2.23 at v1 to 2.74 1.95 at v2 and then to 1.54 1.52 at v3 .
values in study 2 decreased comparably from 5.43 1.46 at v1 to 2.23 2.05 at v2 and further to 1.73 1.89 at v3 ( figures 3 and 4 ) .
decreases of the symptom nasal obstruction were similar and in accordance with the patients ' assessments .
the symptom nasal crust formation decreased significantly from v1 to v2 and further to v3 in both studies in the investigators assessment .
values in study 1 decreased from baseline values of 6.20 1.99 to 2.16 2.26 at v2 and further to 1.52 1.85 at v3 .
values in study 2 decreased comparably from baseline values of 6.43 2.08 to 2.40 1.81 at v2 and to 1.30 1.24 at v3 .
patients evaluated the decrease of the symptom dry nose in a similar way to the physician 's assessments as listed in table 2 .
the symptom nasal dryness decreased significantly from day 3 to day 12 in both studies .
in addition to the symptoms nasal obstruction and crust formation / nasal dryness , further symptoms were assessed by both investigators and patients . as depicted in figures 7 and 8
, there was a similarity between the results of both studies in the investigators assessment .
the symptoms blood deposits , pharyngitis , turbinate hyperplasia , and exudate viscosity improved significantly from baseline values at v1 to the final visit v3 .
the symptom rhinorrhea only improved significantly in study 2 , whereas decreases in this symptom were nonsignificant in study 1 .
as only very few patients complained about the symptom cacosmia ( n = 2 in study 1 and n = 5 in study 2 ) , decreases in this symptom were negligible .
patients ' scores of secondary symptom evaluation are listed in tables 3 and 4 . in study 1 , the symptom rhinorrhea improved significantly from d3 to d12 . in study 2 , nose bleeding , rhinorrhea , cacosmia , and exudate viscosity
the physician judged both efficacy and tolerability of treatment after 7 days ( v2 ) and after 14 days ( v3 ) .
as shown in figures 9 and 10 , ectoine nasal spray treatment was considered to be both efficient and well tolerable .
mean values for efficacy at v3 were 3.5 2.06 ( study 1 ) and 1.83 1.39 ( study 2 ) meaning good to very good efficacy .
mean values for tolerability were 2.08 1.21 ( study 1 ) and 0.57 0.97 ( study 2 ) , which also means good to very good tolerability .
patients ' assessments of tolerability and efficacy of treatment are depicted in figures 11 and 12 .
mean efficacy values were 3.12 3.08 at day 12 of treatment in study 1 and 2.43 2.24 in study 2 corresponding to good efficacy .
tolerability was judged as very good in both studies with mean values on day 12 of 1.40 1.80 in study 1 and 1.17 1.21 in study 2 . in study 1 , no ae occurred . in study 2 , 1 ae occurred ( acute rhinitis ) .
the aim of these observational studies was to gain insight into the tolerability and the extent to which the treatments influenced the severity of the patients ' symptoms .
an ectoine nasal spray ( study 1 ) or an ectoine and dexpanthenol nasal spray ( study 2 ) was tested in patients with rhinitis sicca under practical conditions . a total of 80 patients ( 50 patients in study 1 , 30 patients in study 2 ) with a wide variety of disease severities participated in this postmarketing surveillance study
. however , the potential flaw of these studies is their noncontrolled character , the missing randomization , or placebo control .
therefore the evidence grade of the results needs to be reduced at least to iib .
the studies showed a significant decrease of the main symptoms nasal obstruction and crust formation from v1 to v2 as well as further to v3 .
the decrease of nasal obstructions assessed by the physicians was confirmed by patients in both studies , with a stronger decrease of symptoms assessed by the physicians .
this is likely to be due to the timing of the patient 's diary , as this was started at day three of treatment , when the first positive effect of the respective treatments had occurred already .
apart from main symptoms , the secondary symptom scores also decreased similarly in both studies . in the investigators assessment , the symptoms blood deposits , pharyngitis , turbinate hyperplasia , and exudate viscosity improved significantly from starting values at v1 to the final visit v3 .
treatment with the nasal spray with ectoine only did not lead to a significant improvement of rhinorrhea , whereas the improvement in with the ectoine nasal spray alone was not statistically significant .
the degree of symptom reduction in the main parameter nasal obstruction seemed to be reduced more efficiently in the study with the combined nasal spray , as the score started with a higher value and dropped faster and to a higher degree as in the study with the ectoine nasal spray . in the patient assessment of study 2
symptom improvement was significant for nose bleeding , exudate viscosity , rhinorrhea , and cacosmia , whereas the patient assessment in study 1 showed only a significant reduction of the symptoms in nose bleeding .
it can be mentioned that only a few patients in both studies suffered from cacosmia and the decreases in these symptoms were negligible for both of them . as a summary , the ectoine nasal spray achieved in study 1 treatment success similar to that of the combination of ectoine and dexpanthenol in study 2 with respect to the main symptom scores of both studies , crust formation and nasal obstruction .
differences in treatment effect between both nasal sprays and studies were observable in the secondary parameters , both in physicians and in patients assessment , tending towards an additional effect if ectoine and dexpanthenol are combined in one product compared to ectoine alone .
both natural nonpharmacological nasal sprays showed efficacy in treatment of rhinitis sicca , which is comparable to the reported outcome for other products .
data from preclinical studies also support the combination of ectoine and dexpanthenol ( data not shown ) .
the mode of action and subsequent effect in treatment of rhinitis sicca of dexpanthenol is understood from the literature .
the treatment effects of the ectoine nasal spray can be attributed to its physical action . by increasing the fluidity of the nasal epithelia ,
the barrier function of this membrane is increased , therefore inhibiting the potential loss of water .
experiments with ectoine on biological and artificial membranes support this thesis further , including the reduction of mechanical stress induced membrane damage [ 1517 ] .
the additional hydrating effect of ectoine is well described in the literature [ 15 , 23 , 24 ] as well as the capacity of reduction of inflammation in skin and respiratory epithelium [ 14 , 17 , 18 , 25 ] . taken together , rhinitis sicca anterior or dry nose could be successfully treated with an ectoine containing nasal spray .
therefore an interesting option of a new and safe nonpharmacological treatment of rhinitis sicca will be available in the future .
the addition of the well - known and accepted dexpanthenol did not enhance the treatment regarding the major symptoms scores .
the decrease of symptom over the 14-day treatment period was more pronounced for the combination of ectoine and dexpanthenol , but this difference was not significant .
slightly better improvement in different secondary symptoms revealed synergistic characteristics of the two substances in combination when compared to the ectoine nasal spray alone .
therefore additional controlled trials are suggested to further prove the efficacy of ectoine nasal spray with or without dexpanthenol . | objectives . the safety and efficacy of ectoine nasal spray and ectoine nasal spray with dexpanthenol in the treatment of rhinitis sicca were evaluated in two studies .
design and methods .
two noninterventional observational studies were performed to evaluate the efficacy and safety of a nasal spray containing ectoine ( study 1 ) and ectoine / dexpanthenol ( study 2 ) over a period of two weeks including comparable numbers of patients suffering from rhinitis sicca anterior .
patients and physicians were asked to rate the efficacy in reducing symptoms and the tolerability over the treatment phase .
results .
the treatment in both studies resulted in a clinical and statistical significant reduction of the main diagnosis parameters , nasal airway obstruction , and crust formation .
there was also a significant reduction in the secondary diagnosis parameters in both studies .
importantly , the tolerability was very good . during the whole observational study ,
neither patients nor doctors stopped the medication due to unwanted effects .
conclusion .
rhinitis sicca could be successfully treated with a nasal spray containing ectoine and a nasal spray combining ectoine with dexpanthenol .
the combination of both substances led to slight advantages . |
breast cancer remains a significant public health challenge both in the united states and worldwide .
while breast cancer is potentially curable when detected at an early stage , it remains incurable in the metastatic setting .
hence , there has been a major effort to detect breast cancer early , optimize the management of early - stage disease to prevent or delay distant recurrence , and improve the treatment of metastases .
each subtype is characterized by varied risk factors , clinicopathologic and molecular features , responses to therapy , patterns of recurrence , and clinical outcomes .
as our understanding of the underlying biologic diversity of breast cancer has evolved , this knowledge has prompted investigators and clinicians alike to abandon a
this review highlights the advances made in the screening and treatment of breast cancer and explores how our increased insight into the underlying biology of breast cancer has influenced our diagnostic and therapeutic approach in the era of precision medicine .
screening mammography for the early detection of breast cancer in women went into widespread use in the 1970s and 1980s , and randomized controlled trials ( rcts ) have shown a significant reduction in mortality . while supplementary screening techniques and computer - aided diagnosis ( cad ) are being used more widely , equally effective digital or screen - film 2d mammography remains the mainstay of breast cancer screening , detecting 24 cancers per 1000 average - risk women screened .
however , current guidelines from the american college of radiology ( acr ) , american society of clinical oncology ( asco ) , society of breast imaging ( sbi ) and united states preventive services task force ( uspstf ) all recommend yearly mammographic screening beginning at age 40 for the general population .
furthermore , the breast imaging - reporting and data system ( birads ) optimizes our standardized lexicon terminology and assessment , facilitating global communication .
digital breast tomosynthesis ( dbt ) is a new 3d method of screening approved by the united states food and drug administration ( fda ) that captures images of the compressed breast from multiple angles and combines them to generate a 3d rendering of the breast .
dbt can depict cancers not visible on the standard mammogram , improving sensitivity and specificity in all breasts while also decreasing recall rates .
furthermore , it is associated with only a minimal increase in low dose radiation and no significant screening time difference , when compared to 2d mammography .
dbt is rapidly being incorporated into clinical practice , and the future may see it completely replace 2d mammography .
a current topic of interest for many ( including individual women , radiologists and the government ) is breast density .
breast density refers to the proportions of fat and fibroglandular tissue in a breast , which varies between women and over time .
breast tissue can be categorized as : predominantly fatty , scattered fibroglandular , heterogeneous or extremely dense . increased breast density ( heterogeneous or extremely dense )
is an independent risk factor for breast cancer and can decrease sensitivity of cancer detection on mammogram due to the superimposition of fibroglandular tissue .
approximately half of all states in the us have either drafted or enacted breast density notification legislature requiring a radiologist to notify patients if they are found to have dense breasts . in response ,
utilization of supplemental screening techniques ( including screening bilateral breast ultrasound or magnetic resonance imaging [ mri ] ) in women with dense breasts has increased .
the addition of screening ultrasound to mammography has been shown to detect an additional 34 cancers per 1000 high - risk women screened .
ultrasound elastography is an adjunct tool to gray scale and color doppler , which dynamically assesses the mechanical stiffness of tissue , increasing the specificity for characterizing masses .
three - dimensional automated breast ultrasound has been developed to eliminate inter - performer variability and also to optimize workflow , since the exams are time consuming .
contrast enhanced ultrasound is currently being investigated to potentially assist in increasing sensitivity and specificity .
screening recommendations for women at high - risk ( e.g. > 20% lifetime risk of breast cancer ) , determined by risk assessment models that are predominantly based on family history ( e.g. tyrer - cuzick , claus , brcapro , and boadicea ) , include a yearly screening mammogram and bilateral breast mri .
the stratification of risk continues to evolve as more emphasis is placed on patient characteristics , such as age and co - morbidities .
studies are also currently evaluating the role of supplementary screening in intermediate - risk women .
mri computer - aided detection is being investigated as a possible means for improving detection sensitivity and diagnostic accuracy . due to the high cost
, mri is less widely used as a supplemental screening tool in the general population .
however , shorter mri screening protocols are being developed , which cost approximately the same as a screening ultrasound .
the heterogeneous nature of breast cancer defined by different genotypes and phenotypes has fueled the field of radiogenomics .
radiogenomics involves correlating radiologic imaging with genetic information . in parallel with the goal of optimizing personalized medicine
sentinel lymph node biopsy ( slnb ) has revolutionized the surgical management for clinically node - negative breast cancer patients .
studies performed in the late 1990s and early 2000s established the slnb procedure alone as standard axillary staging for pathologically node - negative disease , and reported rates of axillary recurrence of < 1% , substantially lower than the percentage of disease left in situ given the 7% slnb false - negative rate .
the knowledge that not all microscopic axillary disease becomes clinically apparent , and that rates of regional recurrence have been declining with increased utilization of adjuvant therapy , has led to the investigation of slnb for the management of node - positive patients as well .
two rcts compared slnb alone to completion axillary lymph node dissection ( alnd ) for patients with micrometastatic axillary sentinel lymph node ( sln ) disease , defined as < 2 mm of tumor burden .
the international breast cancer study group ( ibcsg ) 23 - 01 trial enrolled women with a primary breast tumor 5 cm from 27 institutions , from 20012010 . at a median follow - up of 5 years ,
disease - free survival ( dfs ) and overall survival ( os ) were also similar among the slnb and alnd groups ( dfs 88% vs 84% , respectively , log - rank p = 0.16 ; os 98% vs 98% , respectively , log - rank p = 0.73 ) . similarly , a multicenter rct from spain randomized 233 women with a tumor < 3.5 cm and an sln with micrometastatic disease to slnb alone or alnd . at a median follow - up of 5.2 years , only four cases of any disease recurrence were reported .
there were two axillary recurrences in the slnb group and one axillary soft tissue recurrence in the alnd group .
dfs and os were similar between the surgical arms ( log - rank , p = 0.33 ) .
slns were evaluated with serial sectioning followed by pathological evaluation with both hematoxylin and eosin ( h&e ) staining and cytokeratin immunohistochemistry , which resulted in an increased detection of micrometastatic axillary disease .
acosog z0010 evaluated the prevalence and significance of immunohistochemistry - detected micrometastasis among patients with t1-t2 clinically node - negative disease .
immunohistochemistry was then performed on h&e - negative slns and 10.5% were found to contain immunohistochemistry - detected occult metastases . at a median follow - up of 6.3 years
, there was no significant difference in recurrence or death between women with or without immunohistochemistry - detected disease ( 5-year dfs , 92% immunohistochemistry - negative sln vs 90% immunohistochemistry - positive sln , p = 0.82 ) .
nsabp b32 also examined the prognostic significance of immunohistochemistry - positive slns and , at 10 years of follow - up , reported no significant difference in overall survival between patients with immunohistochemistry - positive or immunohistochemistry - negative disease . because immunohistochemistry - detected micrometastatic disease does not impact recurrence or overall survival , the use of routine immunohistochemistry for sln evaluation is not warranted .
these trials established the safety of slnb alone for micrometastatic disease , and led to guideline changes omitting the routine use of immunohistochemistry for sln evaluation . given that the definition of micrometastatic disease is an arbitrary cutoff of 2 mm , studies next investigated the use of slnb for women with sln macrometastatic ( > 2 mm ) disease burden .
acosog z0011 randomized women with clinical t1 - 2n0m0 breast cancer who were found to have 12 positive slns detected by h&e alone to slnb or to completion alnd .
all women were treated with lumpectomy and whole breast radiation therapy , and 97% received systemic therapy . of the alnd group ,
27% had additional positive lymph nodes , so it is assumed that a similar percentage in the slnb group had residual diseased tissue . at a median follow - up of 6.3 years
, regional recurrences occurred in < 1% of each group ( 0.9% slnb vs 0.5% alnd , p = 0.11 ) .
treated with multimodality therapy , the morbidity of alnd can safely be avoided by staging the axilla with slnb alone .
in addition to axillary management , recent advances regarding margins in breast - conserving surgery have been reported .
controversy has existed amongst surgeons and radiation oncologists regarding the adequate negative margin width in a lumpectomy specimen , and approximately 25% of all patients undergoing breast - conserving surgery undergo re - excision for close or positive margins . a multidisciplinary consensus panel recently met and reviewed an updated meta - analysis of margin width and local recurrence for women undergoing lumpectomy with whole breast radiotherapy for invasive carcinoma , reporting on over 28,000 patients .
positive margins , defined as ink on tumor , are associated with an increase in local recurrence , and therefore re - excision is appropriate .
however , margins more widely negative than no ink on tumor are not associated with a significant reduction in local recurrence , and routine re - excision to obtain more widely negative margins is not recommended .
having a unified definition of negative margins as no ink on tumor has the potential to reduce unnecessary re - excisions , which will have significant impact on cosmesis and healthcare costs .
radiation therapy is an effective treatment for microscopic residual disease after the surgical management of breast cancer , and thereby reduces the incidence of locoregional failure .
meta - analyses have established that the improvements in local and regional control that result from radiotherapy are also associated with reductions in distant metastases and breast cancer - specific mortality .
the utilization of adjuvant radiotherapy has enabled breast - conserving therapy to become the standard approach for most women who present with early - stage breast cancer .
additionally , higher - risk patients in the post - mastectomy setting also benefit from radiotherapy to the chest wall and regional lymph nodes , with significant reductions observed in local - regional failure , distant metastases , and increased os [ 28,3133 ] .
the excellent local control rates of luminal a breast cancer after breast - conserving therapy has led to the question of whether adjuvant radiotherapy may be omitted in certain low - risk breast cancer patient subsets .
there are 5 rcts that have evaluated the need for postoperative radiotherapy in early stage , estrogen receptor positive ( er+ ) breast cancer , undergoing breast - conserving surgery in the setting of adjuvant hormonal therapy [ 3539 ] .
all of these studies demonstrated an effect of radiotherapy in preventing local recurrence that was statistically superior to the local control benefit of hormonal therapy alone .
however , the absolute reduction in local recurrence by radiotherapy , particularly among elderly patients with er+ breast cancer , was significantly less than had been previously observed for unselected breast cancer patients .
for this reason , the routine use of adjuvant radiotherapy for older women with ct1 - 2n0 er+ breast cancer who undergo breast - conserving surgery and adjuvant hormonal therapy is no longer considered a standard of care . a potential alternative to conventional whole - breast radiotherapy in low - risk , early - stage breast cancer patients that is currently under investigation
is accelerated partial breast irradiation ( apbi ) , which has the additional advantage of being delivered over a shorter time interval .
there are large , prospective randomized clinical trials ( nsabp b-39/rtog 0413 and the canadian rapid ) that are currently ongoing .
results are eagerly awaited for both toxicity and local control outcomes relative to whole breast irradiation , which should establish the appropriate indications for apbi utilization .
the interim report of increased rates of adverse cosmesis and late radiation toxicity with 3d - crt apbi in the rapid trial is a reason for caution in using this approach outside of a clinical trial .
radiotherapy is increasingly recognized as an equally effective and less morbid alternative to alnd in ct1 - 2n0 patients who have 12 positive slns identified at the time of surgery .
acosog z0011 was the first trial to demonstrate that an alnd was not required in such patients , and adjuvant treatment with tangential field whole breast radiotherapy ( which frequently includes the inferior axillary lymph nodes ) results in excellent regional control .
the eortc amaros trial also investigated ct1 - 2n0 patients with a positive slnb , with randomization either to alnd or axillary radiotherapy .
this trial was notable for including patients who underwent mastectomy as well as those who underwent breast - conserving surgery .
the interim results of this trial have revealed very low 5-year axillary recurrence rates in both treatment arms , with significantly less lymphedema in the axillary radiotherapy arm relative to the alnd arm ( 5-year incidence 14% vs 28% , respectively ) .
neoadjuvant chemotherapy is an established approach for the management of locally advanced breast cancer that is either unresectable or potentially cytoreduced to enable breast - conserving surgery .
however , there is also a growing appreciation that the pathological response to neoadjuvant chemotherapy has prognostic significance for the likelihood of distant metastases and os .
retrospective analysis of the nsabp b18 and b27 trials also identified a correlation between pathological complete response to neoadjuvant chemotherapy and reduced likelihood of both local and regional failure .
whether a patient with locally advanced breast cancer who achieves a pathological complete response to neoadjuvant chemotherapy can forgo post - mastectomy radiation therapy ( pmrt ) remains an open and unanswered question .
retrospective data suggests that withholding pmrt in such patients may be associated with increased rates of local - regional failure , although these studies may be highly subject to selection bias .
prospective randomized trials to address the utility of pmrt in the neoadjuvant chemotherapy setting are sorely needed , and will hopefully begin accruing patients in the near future .
outcomes for patients diagnosed with metastatic breast cancer continue to improve , as our understanding of the drivers of cancer growth continue to evolve hand in hand with the development of novel targeted therapies .
nowhere is this advancement more evident than in the treatment of patients with human epidermal growth factor receptor 2 ( her2)-positive breast cancer . in the last two years
, the fda has approved two new agents for the management of this subtype of breast cancer .
pertuzumab is a humanized monoclonal antibody that binds to her2 at a distinct epitope from trastuzumab on the extracellular domain , and inhibits the heterodimerization of her2 and other her - family receptors , preventing downstream signaling through the pi3k pathway and consequent tumor growth .
the cleopatra trial randomized 808 patients with her2-positive metastatic breast cancer to receive trastuzumab and docetaxel in combination with either placebo ( control ) or pertuzumab .
based on improvement in median progression - free survival ( 18.5 vs 12.4 months ; hazard ratio ( hr ) = 0.62 ; 95% confidence interval ( ci ) , 0.51 to 0.75 ; p < 0.001 ) and overall survival ( hr = 0.66 ; 95% ci , 0.52 to 0.84 ; p = 0.0008 ) between the group receiving pertuzumab as compared to the control group , this drug was approved in june 2012 as first - line treatment for her2 + metastatic breast cancer .
this agent also recently ( september 2013 ) became the first drug approved for the neoadjuvant treatment of breast cancer under the fdas accelerated approval program .
ado - trastuzumab emtansine ( tdm-1 ) is a novel antibody - drug conjugate that links the monoclonal antibody trastuzumab to the cytotoxic agent dm-1 , a derivative of maytansine with microtubule inhibitory properties . between february 2009 and october 2011 the emilia trial , a large multicenter phase iii trial ,
randomized 991 patients with her2 + locally advanced or metastatic breast cancer to receive either the combination of capecitabine 1000 mg / m oral twice daily ( days 114 ) and lapatinib 1250 mg oral daily or tdm-1 3.6 mg / m every 21 days . treatment with tdm-1 , as compared to lapatinib and capecitabine , resulted in a statistically significantly improvement in both median progression - free survival ( 9.6 vs 6.4 months ; hr = 0.65 ; 95% ci , 0.55 to 0.77 ; p < 0.001 ) and os ( 30.9 vs 25.1 months ; hr = 0.68 ; 95% ci , 0.55 to 0.85 ; p < 0.001 ) .
tmd-1 was well - tolerated , with a toxicity profile which differed from that commonly reported with a combination of lapatinib plus capecitabine ( primarily diarrhea , nausea , vomiting and palmar - plantar erythrodysesthesia ) .
based on this trial , this agent was fda approved in february 2013 for the treatment of patients with metastatic her2-positive breast cancer who previously received treatment with a taxane and/or trastuzumab in the metastatic setting , or whose disease recurred during or within six months of completing their adjuvant therapy .
unfortunately some patients will develop disease recurrence despite adjuvant therapy , and many patients with metastatic disease do not respond to therapy , or develop refractory disease .
endocrine therapy is an integral part of both adjuvant and metastatic management of hormone receptor - positive breast cancer .
the activation of the mammalian target of rapamycin ( mtor ) signaling pathway has been associated with the development of resistance to endocrine therapy in patients with er+ breast cancer . based on this finding , it was hypothesized that the addition of everolimus , an mtor inhibitor to exemestane ( an aromatase inhibitor ) , may overcome resistance to this fundamental therapy .
bolero-2 , a multi - institutional randomized phase iii trial , randomly assigned 724 patients in a 2:1 ratio to receive either the combination of everolimus and exemestane or exemestane and placebo .
the combination of everolimus and exemestane improved median progression - free survival , in comparison to single agent exemestane , when assessed by both local investigators ( 6.9 vs 2.8 months ; hr = 0.43 ; p < 0.001 ) , and centrally ( 10.6 vs 4.1 months ; hr = 0.36 ; p < 0.001 ) .
this trial supports the use of this regimen to extend the benefit of endocrine therapy at relapse or disease progression .
several additional combination therapies targeting cellular signaling pathways , associated with breast cancer progression ( e.g. the pi3k / akt survival pathway ) and the development of resistance , are currently being investigated .
as screening and the surgical and medical management of breast cancer continue to evolve , so too will the role for radiotherapy .
novel molecular markers of biological behavior will be identified and validated , and there may be greater opportunities for risk - adaptive management .
furthermore , as clinical outcomes for breast cancer patients continue to improve , there is a growing appreciation that minimizing the long - term morbidities of therapy such as cardiac toxicity , pneumonitis , fibrosis , lymphedema , and the risk of secondary malignancy are also important and clinically relevant goals .
novel technologies and medical interventions that reduce the risk of such toxicities must be rigorously evaluated to determine the best way to improve clinical outcomes for breast cancer patients .
| although substantial progress has been made in the screening and management of breast cancer , globally it remains the most common cause of cancer and cancer death in women .
while breast cancer is potentially curable when detected at an early stage , it remains incurable in the metastatic setting .
thus , given its high prevalence , improved prevention and treatment of metastases remains a clinically meaningful unmet need .
we review here the advances made in the last several years in the screening and treatment of breast cancer and explore how our increased insight into the underlying biology of breast cancer has influenced our efforts to individualize patient care . |
world - wide , at least 2.8 million people die each year as a result of being overweight or obese and an estimated 35.8 million ( 2.3% ) of global dalys are caused by overweight or obesity .
overweight and obesity lead to adverse metabolic effects on blood pressure , cholesterol , triglycerides ( tg ) and insulin resistance .
some natural products have been considered to play a good role as an alternative to synthetic chemicals in this clinical condition .
a wide variety of plants has been reported to have lipid lowering activity . among such plants nigella sativa ( n. sativa ) ( black seed ) in several studies has been investigated for its lipid lowering effects on animals .
the seeds of the plant have been used in the southeast asia , middle and far east as a natural remedy to treat many diseases , including anti - microbial , anti - oxidant , anti - inflammatory , antitumor , hematologica , anti - hypertensive , anti - hypertensive , anti - diabetic , antilipidemic , hypophagic and anti - obesity effects and respiratory health .
in fact , this plant has occupied a special place for its wide range of medicinal value in the islamic civilizations . due to the sayings of the holy prophet ,
mohammad ( peace be upon him ) that in the black seed there is healing for every illness except death .
anwar and tayyab reported that n. sativa in the diet has a favorable effect on the lipid profile by lowering the tg , total cholesterol ( tc ) and low - density lipoprotein ( ldl)-cholesterol and increasing the high density lipoprotein ( hdl)-cholesterol in rats .
exercise is most important for every living being ; in other words , we can also say that physical inactivity results in several types of diseases in the body .
a sedentary life - style is associated with an increased risk for an acute myocardial infarction and death from coronary heart disease ( chd ) .
the findings are consistent and show that sedentary people have about twice the risk of developing or dying from chd , compared to active people .
physical inactivity is now recognized by the american heart association as an independent risk factor , comparable to the other established risk factors for chd .
it is well - established that habitual physical activity improves physical fitness in middle - aged men and women .
yar et al . had monitored the effect of n. sativa supplementation on cardiac reserve in rats .
their results suggest that n. sativa generated homogenous cardiac hypertrophy similar to that provoked by exercise training . despite the aforementioned beneficial effects of exercise and n. sativa ,
thus , the purpose of this randomized , double blind , controlled trial was to investigate whether 8 weeks of aerobic training combined with n. sativa supplementation could improve lipid profile and maximal oxygen consumption ( vo2 max ) in sedentary overweight females .
a total of 20 adult females with a mean age of 34.31 7.9 years , body mass index ( bmi ) 25 kg / m and sedentary life - style for at least 2 years participated in this study voluntarily .
the main criterion for entry of adult females was a tc concentration more than 200 mg / dl .
subjects taking lipid - altering medication within 8 weeks prior to the study were excluded .
other exclusion criteria were pregnant , current smoking , lactation , having diabetes mellitus , cardiovascular disease ( cvd ) , renal or liver disease , thyroid dysfunction and myopathy .
physical characteristics of the study participants * according to the subject 's profiles number and the random figures tables , they were randomized to receive either n. sativa capsules ( ns group ) or placebo ( pla group ) .
each black seed capsule contained 500 10 mg n. sativa crushed seeds and subjects had to take 2 g of n. sativa per day for 8 weeks .
they were instructed to take two capsules before breakfast and two capsule in the afternoon prior their food .
subjects were also asked not to change their usual daily diet and physical activity during the study .
subjects in two groups performed slow running ( 10 min ) , stretching muscles and loosening joints ( 10 min ) , aerobic training program ( 30 min ) and cool down ( 10 min ) .
the intensity of training was 60 - 70% of target pulse rate calculated by karvonen et al .
target heart rate ( hr ) zone = ( [ hr maximum hr rest ] { 60 - 70% } + hr rest ) hr maximum = 220 age .
if the subjects are not able to take a measurement first thing in the morning , make sure subjects lie down for at least 10 min before taking a measurement . measurement was taken from the radial artery with forefinger and the middle finger of the right hand placed horizontally across the subject 's wrist while sitting on the chair .
after that , the number of pulse beats multiplied by two to give the 1 min hr .
cardio - respiratory fitness was determined by 1609 m ( 1 mi ) walk test using rockport fitness test . after a brief warm up , the subject walked as briskly as possible for 1609 m ( 1 mi ) with a hr monitor .
the formula used to calculate vo2 max was : 132.853 ( 0.0349 mass [ kg ] ) ( 0.3877 age [ year ] ) + ( 6.315 gender ) ( 3.2649 time [ min ] ) ( 0.1565 hr [ bpm ] ) .
the validity of the test was nearly high r = 0.88 and standard error of the test was 5 ml / kg / min .
cardio - respiratory measurement was taken before and after 8 weeks of aerobic training program and supplementation .
a total volume of 20 ml blood was drawn from the subjects in their forearm vein after a 12 h overnight fast immediately before and after 8 weeks of aerobic training program and supplementation in the sitting position after a 20-min rest between 8:00 and 9:00 a.m. plasma was separated by centrifugation and samples were stored at 10c until assays were determined ( within 48 h ) in all samples .
the statistical analysis was initially performed using the changes in the one - sample kolmogorov - smirnov test .
data was analyzed using paired t - test for within group 's comparison and unpaired t - test for between - groups comparison .
a total of 20 adult females with a mean age of 34.31 7.9 years , body mass index ( bmi ) 25 kg / m and sedentary life - style for at least 2 years participated in this study voluntarily .
the main criterion for entry of adult females was a tc concentration more than 200 mg / dl .
subjects taking lipid - altering medication within 8 weeks prior to the study were excluded .
other exclusion criteria were pregnant , current smoking , lactation , having diabetes mellitus , cardiovascular disease ( cvd ) , renal or liver disease , thyroid dysfunction and myopathy .
according to the subject 's profiles number and the random figures tables , they were randomized to receive either n. sativa capsules ( ns group ) or placebo ( pla group ) . each black seed capsule contained 500 10 mg n. sativa crushed seeds and subjects had to take 2 g of n. sativa per day for 8 weeks .
they were instructed to take two capsules before breakfast and two capsule in the afternoon prior their food .
subjects were also asked not to change their usual daily diet and physical activity during the study .
subjects in two groups performed slow running ( 10 min ) , stretching muscles and loosening joints ( 10 min ) , aerobic training program ( 30 min ) and cool down ( 10 min ) .
the intensity of training was 60 - 70% of target pulse rate calculated by karvonen et al .
target heart rate ( hr ) zone = ( [ hr maximum hr rest ] { 60 - 70% } + hr rest ) hr maximum = 220 age .
resting hr was measured in the morning immediately after the participants were awake . if the subjects are not able to take a measurement first thing in the morning , make sure subjects lie down for at least 10 min before taking a measurement .
measurement was taken from the radial artery with forefinger and the middle finger of the right hand placed horizontally across the subject 's wrist while sitting on the chair .
after that , the number of pulse beats multiplied by two to give the 1 min hr .
cardio - respiratory fitness was determined by 1609 m ( 1 mi ) walk test using rockport fitness test . after a brief warm up , the subject walked as briskly as possible for 1609 m ( 1 mi ) with a hr monitor .
the formula used to calculate vo2 max was : 132.853 ( 0.0349 mass [ kg ] ) ( 0.3877 age [ year ] ) + ( 6.315 gender ) ( 3.2649 time [ min ] ) ( 0.1565 hr [ bpm ] ) .
the validity of the test was nearly high r = 0.88 and standard error of the test was 5 ml / kg / min .
cardio - respiratory measurement was taken before and after 8 weeks of aerobic training program and supplementation .
a total volume of 20 ml blood was drawn from the subjects in their forearm vein after a 12 h overnight fast immediately before and after 8 weeks of aerobic training program and supplementation in the sitting position after a 20-min rest between 8:00 and 9:00 a.m. plasma was separated by centrifugation and samples were stored at 10c until assays were determined ( within 48 h ) in all samples .
cardio - respiratory fitness was determined by 1609 m ( 1 mi ) walk test using rockport fitness test . after a brief warm up , the subject walked as briskly as possible for 1609 m ( 1 mi ) with a hr monitor .
the formula used to calculate vo2 max was : 132.853 ( 0.0349 mass [ kg ] ) ( 0.3877 age [ year ] ) + ( 6.315 gender ) ( 3.2649 time [ min ] ) ( 0.1565 hr [ bpm ] ) .
the validity of the test was nearly high r = 0.88 and standard error of the test was 5 ml / kg / min .
cardio - respiratory measurement was taken before and after 8 weeks of aerobic training program and supplementation .
a total volume of 20 ml blood was drawn from the subjects in their forearm vein after a 12 h overnight fast immediately before and after 8 weeks of aerobic training program and supplementation in the sitting position after a 20-min rest between 8:00 and 9:00 a.m. plasma was separated by centrifugation and samples were stored at 10c until assays were determined ( within 48 h ) in all samples .
the statistical analysis was initially performed using the changes in the one - sample kolmogorov - smirnov test . all variables presented normal distribution .
data was analyzed using paired t - test for within group 's comparison and unpaired t - test for between - groups comparison . statistical significance was accepted as p 0.05 .
numbers of four subjects were excluded during the study , because of altering their usual aerobic training program and being irregular in taking capsules , so we did our statistical analysis on 16 subjects ( 8 subjects in ns group and 8 subjects in pla group ) who fully completed the study [ figure 1 ] .
there were no differences among groups for age , bodyweight , height and bmi [ table 1 ] .
changes of lipid profiles after 8 weeks for two groups are shown in table 2 . tc ( p < 0.001 ) and ldl - cholesterol ( p < 0.01 ) were reduced in pla group and vo2 max ( p < 0.01 ) increased .
however , these changes were not statistically significant for tg , bmi and hdl - cholesterol ( p > 0.05 ) .
the schematic diagram of the study changes in the health related physical fitness parameters and blood lipids in pla and ns group in the ns group tc ( p < 0.01 ) , tg ( p < 0.001 ) and ldl - cholesterol ( p < 0.001 ) levels were decreased by 4.79% , 7.97% and 5.02% respectively and bmi ( p < 0.01 ) was significantly reduced by 2.76% and hdl - cholesterol ( p < 0.01 ) and vo2 max ( p < 0.01 ) significantly increased by 5.76% and 2.53% respectively .
furthermore , there were significant differences between the ns and pla groups for ldl - cholesterol ( p < 0.05 ) and hdl - cholesterol ( p < 0.05 ) values [ table 2 ] .
the relationship between ldl - cholesterol and chd risk is continuous over a broad range of ldl - cholesterol levels : the higher the ldl - cholesterol level , the greater the chd risk .
the increased permeability of the endothelium in the presence of elevated concentration of ldl promotes accumulation of ldl particles in the intima .
these particles undergo oxidative modification , which may lead to inflammatory reactions and initiate atherosclerosis process .
therefore , lowering ldl - concentration and improving antioxidant defense of the body are two important ways to prevent atheriovascular disease .
the relationship between the dietary fats and cvd , especially chd , has been extensively investigated , with strong and consistent associations emerging from a wide body of evidence accrued from animal experiments , as well as observational studies , clinical trials and metabolic studies conducted in diverse human populations .
the evidence shows that intake of saturated fatty acids is directly related to cardiovascular risk and raise total and ldl - cholesterol . when substituted for saturated fatty acids in metabolic studies with unsaturated fatty acids lower plasma total and ldl - cholesterol concentrations ; polyunsaturated fatty acids are somewhat more effective in this respect , especially linoleic acid .
this double - blind , randomized placebo - control study examined the long - term n. sativa supplementation and aerobic training on lipid profile and vo2 max in sedentary overweight females .
the main finding of this study was that 8 weeks of aerobic training with n. sativa supplementation improved hdl - cholesterol and impaired ldl - cholesterol .
results of the present study are in consistent with other previous studies that found improvements in health related parameters of overweight and obesity females participants as a result of aerobic exercise program also n. sativa for the treatment of hyperlipidemia .
since , we asked all subjects not to change their usual daily diet , it seems that this changes may be due to the result of consuming black seeds and regular aerobic training .
furthermore , these results are also in agreement with the results obtained by anwar and tayyab who observed that polyunsaturated fat have hypotriglyceridemic effect .
the choleretic function of n. sativa is either by reducing the synthesis of cholesterol by hepatocytes or by decreasing its fractional reabsorption from the small intestine .
furthermore , it has been proved that volatile oil of n. sativa has two main constituents , i.e. nigellone and thymoquinone which play a key role in heart disease prevention .
n. sativa is a rich source of unsaturated fatty acids , mainly linoleic acid ( 50 - 60% ) , oleic acid ( 20% ) , eicosadienoic acid ( 3% ) and dihomo linolenic acid ( 10% ) that cholesterol lowering effect of n. sativa may be attributed to the presence of phytosterols like beta - sitosterol , polyunsaturated fatty acids and its antioxidant activity
. n. sativa may be able to reduce synthesis of cholesterol by hepatocytes and lower its absorption from the small intestine .
it may also activate ldl - receptor by decreasing intracellular cholesterol , which leads to rapid clearance of ldl - cholesterol from blood circulation .
the effect of n. sativa on increasing cholesterol secretion in the bile is another probable mechanisms , which can enhance its cholesterol lowering properties .
furthermore , physical exercises performed regularly have effects on obesity , cardiovascular system , physical fitness and healthy life of the middle - aged individuals .
exercise may promote reverse cholesterol transport by increasing pre- hdl - cholesterol recycling from hdl - cholesterol substrates that have been induced by exercise itself .
this mechanism can explain the greater cholesterol efflux from cultured human fibroblasts when exposed to serum of activity people 's versus sedentary controls .
several studies have confirmed this belief and the results of the present study are in agreement with the above statement .
results of the present study is consistent with arazi et al . in pla group that applied at the end of 8-week of regular aerobic exercises on middle - aged sedentary women ,
found that decreased in ldl - cholesterol and increased in the hdl - cholesterol levels .
in addition , bemelmans et al . applied at the end of 12-day of walking exercises on middle - aged sedentary men and women , found in their study that decreased in the ldl - cholesterol and tc levels and increased in the hdl - cholesterol levels .
in addition , aerobic exercise training increases the percentage of skeletal slow - twitch fibers , which have a higher capacity to metabolize fatty acids liberated by lipoprotein lipase from tg - rich lipoproteins .
also , exercise decreases the presence of small , dense ldl - cholesterol and increases that of larger , more buoyant ldl - cholesterol particles , in a relationship that appears dose - dependent with the amount and intensity of exercise . because over the last 10 years , there have been a growing number of studies that show the benefits of moderate intensity physical activity for cardiovascular health so in our study intensity of training was 60 - 70% of target pulse rate . despite the aforementioned results , n. sativa supplementation may facilitate additional lipid profile improvements in exercise by hypotriglyceridaemic effect and increasing cholesterol secretion in the bile .
our results suggest that 2 g / day of n. sativa combined with an aerobic exercise program provides significant improvements in ldl - cholesterol and hdl - cholesterol that are known to influence cvd risk in sedentary overweight females .
however , further studies with a larger sample size and diet assessment are still needed . | background : regular moderate intensity physical activity and lipid lowering effects of nigella sativa ( n. sativa ) supplementation may be appropriate management for sedentary overweight females . therefore , the aim of the present study was to examine the effects of long - term n. sativa supplementation and aerobic training on lipid profile and maximal oxygen consumption ( vo2 max ) in sedentary overweight females.methods:in this randomized , double - blind , controlled trial , which was conducted in kerman city ( iran ) , 20 sedentary overweight females were divided into two groups and assigned to n. sativa supplementation ( n. sativa capsules ) or a placebo for the 8 weeks , both groups participated in an aerobic training program ( 3 times / week ) . each n. sativa capsule contained 500 10 mg n. sativa crushed seeds and subjects had to take 2 g n. sativa per day for 8 weeks .
blood lipids and vo2 max were determined at baseline and at the end of 8 weeks.results:n .
sativa supplementation lowered total cholesterol ( tc ) ( p < 0.01 ) , triglyceride ( p < 0.001 ) , low - density lipoprotein ( ldl ) ( p < 0.001 ) and body mass index ( p < 0.01 ) and increased high density lipoprotein ( hdl ) and vo2 max ( p < 0.01 ) . aerobic training program lowered tc ( p <
0.001 ) and ldl ( p < 0.01 ) and increased vo2 max ( p < 0.01 ) .
furthermore , we observed a significant effect of aerobic training program and n. sativa supplementation lowered ldl and hdl ( p < 0.05).conclusions : the present study demonstrates that 8-week aerobic training plus n. sativa supplementation have a synergistic effect in improve profile lipid parameters . |
gene fusion leading to the formation of multidomain proteins is one of the major routes of protein evolution .
gene fusions characteristically bring together proteins that function in a concerted manner , such as successive enzymes in metabolic pathways , enzymes and the domains involved in their regulation , or dna - binding domains and ligand - binding domains in prokaryotic transcriptional regulators .
the selective advantage of domain fusion lies in the increased efficiency of coupling of the corresponding biochemical reaction or signal transduction step and in the tight co - regulation of expression of the fused domains . in signal transduction systems , such as prokaryotic two - component regulators and sugar phosphotransferase ( pts ) systems , or eukaryotic receptor kinases ,
furthermore , accretion of multiple domains appears to be one of the important routes for increasing functional complexity in the evolution of multicellular eukaryotes .
pairs of distinct genes that are fused in at least one genome have been termed fusion - linked .
a gene fusion is presumably fixed during evolution only when the partners cooperate functionally and , by inference , a functional link can be predicted to exist between fusion - linked genes .
recently , this simple concept has been used by several groups as a means of systematic prediction of the functions of uncharacterized genes .
in addition to their utility for functional prediction , analysis of gene fusions may help in addressing fundamental evolutionary issues .
gene fusions often show scattered phyletic patterns , appearing in several species from different lineages . by investigating the phylogenies of each of the two fusion - linked genes
a recent study provided evidence that the fission of fused genes occurred during evolution at a rate comparable to that of fusion . here
, we address another central aspect of the evolution of gene fusions , namely , do fusions of the same domains in different phylogenetic lineages reflect vertical descent , possibly accompanied by multiple lineage - specific fission events , or independent fusion events , or horizontal transfer of the fused gene ?
in other words , is a fusion of a given pair of genes extremely rare and , once formed , is it spread by horizontal gene transfer ( hgt ) perhaps also followed by fissions in some lineages ?
alternatively , are independent fusions of the same gene pair in distinct lineages relatively common during evolution ? among fusions that are found in at least two of the three primary kingdoms of life ( bacteria , archaea and eukaryota ) , we detected both modes of evolution , but horizontal transfer of a fused gene appeared to be more common than independent fusion events or vertical inheritance with multiple fissions .
to distinguish between a single fusion event followed by hgt and/or fission of the fused gene and multiple , independent fusion events in distinct organisms , we analyzed phylogenetic trees that were constructed separately for each of the fusion - linked domains ( proteins ) .
the fusion was split into the individual component domains and phylogenetic trees were built for each of the corresponding orthologous sets from 32 complete microbial genomes ( figure 1 , and see materials and methods ) , including both fusion components and products of stand - alone genes .
the topologies of the resulting trees were compared to each other and to the topology of a phylogenetic tree constructed on the basis of a concatenated alignment of ribosomal proteins , which was chosen as the ( hypothetical ) species tree of the organisms involved .
if the fusion events either occurred independently of each other or were vertically inherited , perhaps followed by fission in some lineages , the distribution of the fusion components in the phylogenetic trees for the orthologous clusters to which they belong is expected to mimic the distribution of the species carrying the fusion in the species tree .
in contrast , if the fusion gene has been disseminated by hgt , fusion components will form odd clusters different from those in the species tree .
this could be a straightforward approach to reconstructing the evolutionary history of gene fusions , if only the topology of the species trees was well resolved .
however , this is not necessarily the case for bacteria or archaea , where relationships between major lineages remain uncertain , although a recent detailed analysis suggested some higher - level evolutionary affinities .
because the distinction between the three primary kingdoms is widely recognized and is clear in the trees for most protein families , trans - kingdom horizontal transfers of fused genes can be more reliably detected with the proposed approach .
therefore , we concentrated on the evolutionary histories of gene fusions that are shared by at least two of the three primary kingdoms .
as the framework for this analysis , we used the database of clusters of orthologous groups ( cogs ) of proteins , which contains sets of orthologous proteins and domains from complete microbial genomes ( 32 genomes at the time of this analysis ; see materials and methods ) .
domain fusions represented in some genomes by stand - alone versions of the fusion components are split in the cog database so that each fusion component can be assigned to a different cog .
whenever distinct domains of a fusion protein belong to separate cogs , the corresponding cogs are said to be fusion - linked .
the vast majority ( 87% ) of fusion links include fusion present in only one primary kingdom ( table 1 ) .
only 52 pairs of fusion - linked cogs included fusions represented in two or three kingdoms ( table 1 ) , and for reasons discussed above , we chose these pairs of cogs for an evolutionary analysis of gene fusions .
figure 1 shows a genome - cog matrix that reveals the phyletic ( phylogenetic ) patterns of the presence or absence of the orthologs across the spectrum of the sequenced genomes for each of the 52 pairs of fusion - linked cogs containing cross - kingdom fusions . when assessed against the topology of the tentative species tree based on the concatenated alignments of ribosomal proteins , fusions showed a scattered distribution in phyletic patterns ( depicted by columns in figure 1 ) .
for example , the fusion between cog1788 and cog2057 ( and subunits of acyl - coa : acetate coa transferase ) is seen in the bacteria escherichia coli , deinococcus radiodurans and bacillus halodurans , and in the archaea aeropyrum pernix , thermophilus acidophilum and halobacterium sp .
similarly , the fusion between cog1683 and cog3272 ( uncharacterized , conserved domains ) was found in the bacteria pseudomonas aeruginosa and vibrio cholerae , and in the archaeon methanobacterium thermoautotrophicum . in each of these cases , with the species tree used as a reference , the bacteria involved are phylogenetically distant from each other and more so from the archaea , and non - fused versions of the two domains exist within the same bacterial lineages and in archaea ( figure 1 ) .
these observations emphasize the central question of this work : are the fusions between the same pair of domains in different species independent or are they best explained by hgt ?
figure 2 shows the pair of phylogenetic trees for the fusion - linked cogs 1788 and 2057 . in both trees , the fusion components from e. coli and b. halodurans ( ydif and bh3898 , respectively ) confidently group with the archaeal fusion components , to the exclusion of the non - fused orthologs .
this position of the e. coli and b. halodurans fusion components is unexpected and is in contrast to the placement of the orthologs from other gamma - proteobacteria and gram - positive bacteria , as well as non - fused paralogs from the same species ( atoa / d and bh2258/2259 , respectively ) within the bacterial cluster .
these observations strongly suggest that the gene for fused subunits of acyl - coa : acetate coa transferase was disseminated horizontally between e. coli , b. halodurans , and archaea .
the presence of non - fused paralogs in both these bacterial species appears to be best compatible with gene transfer from archaea to bacteria .
in contrast , the fusion of the pair of domains from the same cogs seen in d. radiodurans seems to be an independent event because , in both trees , the d. radiodurans branch is in the middle of the bacterial cluster ( figure 2a,2b ) .
thus , the history of this pair of fusion - linked cogs appears to involve horizontal transfer of the fused gene between bacteria and archaea ( and possibly also within kingdoms ) , as well as at least one additional , independent fusion event in bacteria .
figure 3 shows the phylogenetic trees for the two domains of phosphoribosylformylglycinamidine ( fgam ) synthase , a purine biosynthesis enzyme .
the components of this fusion , which is found in proteobacteria and eukaryotes , form a tight cluster separated by a long internal branch from the non - fused bacterial and archaeal orthologs .
this tree topology suggests hgt between bacteria and eukaryotes , possibly a relocation of the fused gene from the pro - mitochondrion to the eukaryotic nuclear genome or , alternatively , gene transfer from eukaryotes to proteobacteria .
an additional aspect of the evolution of this gene is the apparent acceleration of evolution upon gene fusion , which is manifest in the long branch that separates the proteobacterial - eukaryotic cluster from the rest of the bacterial and archaeal species ( figure 3a,3b ) .
the fusion - linked cogs 1605 and 0077 ( chorismate mutase and prephenate dehydratase , respectively ) show a more complicated history , with distinct fusion events resulting in different domain architectures ( see legend to figure 4 ) .
the presence , in both trees , of two distinct clusters of fusion components and the isolated fusion in campylobacter jejuni suggest at least three independent fusion events , two of which apparently were followed by horizontal dissemination of the fused gene ( figure 4a,4b ) .
the single archaeal fusion , the arachaeoglobus fulgidus protein af0227 , belongs to one of these clusters and shows a strongly supported affinity with the ortholog from the hyperthermophilic bacterium thermotoga maritima .
the broad distribution of this fusion in bacteria , horizontal transfer of the bacterial fused gene to archaea is the most likely scenario .
the pair of fusion - linked cogs 0777 and 0825 ( and subunits of acetyl - coa carboxylase , respectively ) shows unequivocal clustering of the fusion components from numerous archaeal and bacterial species , which indicates a prevalent role for hgt in the evolution of this fusion ( figure 5a,5b ) .
it could be argued that , in cases like those in figure 5 , where there is a sharp separation ( a long , strongly supported internal branch in each of the trees ) between the fusion components and stand - alone proteins , the cogs involved needed to be reorganized , to form one cog consisting of fusion proteins only and two separate cogs consisting of stand - alone proteins .
formally , this would eliminate the need for hgt as an explanation of the tree topology for any of these new cogs .
however , this solution ( even if attractive from the point of view of classification ) does not seem to be correct in light of the principle of orthology that underlies the cog system : it appears that , in both of the cogs involved , the fusion components and stand - alone proteins are bona fide orthologs , as judged by the high level of sequence conservation and by the fact that , in the majority of species involved , they are the only versions of this key enzyme
. the results of phylogenetic analyses of the 51 cross - kingdom fusion links are summarized in tables 2 and 3 and the additional data . in 31 of the 51 links ,
an inter - kingdom horizontal transfer of the fused gene appeared to be the evolutionary mechanism by which the fusion entered one of the kingdoms .
in contrast , only 14 fusion - linked pairs of cogs show evidence of independent fusion in two kingdoms , and in just two cases , the fusion seems to have been inherited from the last universal common ancestor .
the latter two scenarios were distinguished on the basis of the parsimony principle , that is , by counting the number of evolutionary events ( fusions or fissions ) that were required to produce the observed distribution of fusion components and stand - alone versions of the domains involved across the tree branches .
accordingly , it needs to be emphasized that we can only infer the most likely scenario under the assumption that the probabilities of fusion and fission are comparable .
it can not be ruled out that some of the scenarios we classify as independent fusions in reality reflect the existence of an ancestral fused gene and subsequent multiple , independent fissions .
the detection of ancestral domain fusions may call for the unification of the respective cog pairs in a single cog , with the species in which fission occurred represented by two distinct proteins .
examination of the genomic context of the genes that encode stand - alone counterparts of the fusion components showed that , in 25 of the 51 cases , these genes were juxtaposed in some , and in certain cases , many prokaryotic genomes ( table 2 ) .
this suggests that evolution of gene fusions often , if not always , passes through an intermediate stage of juxtaposed and co - regulated , but still distinct , genes within known or predicted operons .
in addition , some of the juxtaposed gene pairs might have evolved by fission of a fused gene .
the results of the present analysis point to hgt as a major route of cross - kingdom dissemination of fused genes .
horizontal transfer might be even more prominent in the evolution of fused genes within the bacterial and archaeal kingdoms .
this notion is supported by the topologies of some of the phylogenetic trees analyzed , which show unexpected clustering of bacterial species from different lineages ( note , for example , the grouping of d. radiodurans with p. aeruginosa in figure 5 ) .
massive hgt between archaea and bacteria , particularly hyperthermophiles , has been suggested by genome comparisons .
however , proving hgt in each individual case is difficult , and the significance of cross - kingdom hgt has been disputed . with gene fusions , the existence of a derived shared character ( fusion ) supporting
the clades formed by fusion components and the concordance of the independently built trees for each of the fusion components make a solid case for hgt .
the apparent independent fusion of the same pair of genes ( or , more precisely , members of the same two cogs ) on multiple occasions during evolution might seem unlikely .
however , we found that one - fourth to one - third of the gene fusions shared by at least two kingdoms might have evolved through such independent events , and probable additional independent fusions were noted among bacteria .
this could be due to the extensive genome rearrangement characteristic of the evolution of prokaryotes , and to the selective value of these particular fusions , which tend to get fixed once they emerge .
the version of the cog database used in this study included the following complete prokaryotic genomes .
bacteria : aae , aquifex aeolicus ; bap , buchnera aphidicola ; bbu , borrelia burgdorferi ; bsu , bacillus subtilis ; bhal , bacillus halodurans ; cje , campylobacter jejuni ; cpn , chlamydophila pneumoniae ; ctr , chlamydia trachomatis ; dra , deinococcus radiodurans ; eco , escherichia coli ; hin , haemophilus influenzae ; hpy , helicobacter pylori ; mge , mycoplasma genitalium ; mpn , mycoplasma pneumoniae ; mtu , mycobacterium tuberculosis ; nme , neisseria meningitidis ; pae , pseudomonas aeruginosa ; rpr , rickettsia prowazekii ; syn , synechocystis sp . ; tma , thermotoga maritima ; tpa , treponema pallidum ; vch , vibrio cholerae ; xfa , xylella fastidiosa .
archaea : ape , aeropyrum pernix ; afu , archaeoglobus fulgidus ; hbs , halobacterium sp . ; mja , methanococcus jannaschii ; mth , methanobacterium thermoautotrophicum ; pho , pyrococcus horikoshii ; pab , pyrococcus abyssi ; tac , thermoplasma acidophilum .
cogs containing fusion components from at least two of the three primary kingdoms , were selected for phylogenetic analysis .
cogs containing 60 or more members were excluded because of potential uncertainty of orthologous relationship between members of such large groups .
phylogenetic trees were constructed by first generating a distance matrix using the protdist program and the dayhoff pam model for amino - acid substitutions and employing this matrix for minimum evolution ( least - square ) tree building using the fitch program .
the tree topology was then optimized by local rearrangements using protml , a maximum likelihood tree - building program , included in the molphy package .
local bootstrap probability was estimated for each internal branch by using the resampling of estimated log - likelihoods ( rell ) method with 10,000 bootstrap replications .
the gene order in prokaryotic genomes was examined using the ' genomic context ' feature of the cog database .
phylogenetic trees for 84 individual cogs presented as 52 pairs of trans - kingdom fusion - linked cogs are available .
archaeal proteins are designated by black squares , bacterial proteins by gray squares and eukaryotic proteins by empty squares .
fusion components are denoted by _ 1 , _ 2 , _ 3 , etc .
pylogenetic trees are avaliabel as pdf files for the following individual cogs : see table 2 for more details of individual cogs
click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file click here for additional data file cdf2psc : converts a .cdf file into a .psc file .
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we thank charles delisi , adnan derti , i. king jordan , kira makarova , igor rogozin , and fyodor kondrashov for critical reading of the manuscript and helpful discussions .
the dark - gray rectangles indicate fusions , the light - gray rectangles indicate that the fusion components are represented by stand - alone genes in the given genomes , and the white rectangles indicate that there is no representative of the given cog in the given genome . where one rectangle in a double column is light gray and the other is white , the genome in question has a representative of only one of the pair of fusion - linked cogs .
phylogenetic trees for fusion - linked cogs : and subunits of acyl - coa : acetate coa transferase .
fusion components are denoted by shading and by a number after an underline ( _ 1 for the amino - terminal domain and _ 2 for the carboxy - terminal domain ) .
( a ) subunit ( domain ) ( cog1788 ) ; ( b ) subunit ( domain ) ( cog2057 ) .
the proteins are designated using the corresponding systematic gene names followed ( after the underline ) by the abbreviated species names .
( a ) synthetase domain ( subunit ) ( cog0046 ) ; ( b ) glutamine amidotransferase domain ( subunit ) ( cog0047 ) .
( a ) chorismate mutase ( cog1605 ) ; ( b ) prephenate dehydratase ( cog0077 ) .
the protein af0227 contains a prephenate dehydrogenase domain in addition to the chorismate mutase and prephenate dehydratase domains .
phylogenetic trees for fusion - linked cogs : and subunits of acetyl - coa carboxylase .
( a ) subunit ( domain ) ( cog0777 ) ; ( b ) subunit ( domain ) ( cog0825 ) .
the proteins dra0310 and pa1400 , in addition to the domains corresponding to the and subunits of acetyl - coa carboxylase , contain a biotin carboxylase domain and a biotin carboxyl carrier protein domain .
the clustering of these proteins in phylogenetic trees almost certainly reflects hgt between the respective bacterial lineages .
phyletic patterns of gene fusions a , archaea ; b , bacteria ; e , eukaryota .
evolutionary history of trans - kingdom gene fusions abbreviations : a , archaea , b , bacteria , e , eukaryotes ; a dash indicates that the given kingdom is not represented in at least one of the fusion - linked cogs .
af , ancestral fusion , hgt , horizontal gene transfer , ife , independent fusion events .
in several cases , the indicated genes are separated by one to three genes or their order is switched compared to that of the fusion components .
paby , pyrococcus abyssi , an archaeal genome not included in the master set of genomes analyzed in this study .
llac , lactococcus lactis , a bacterial genome not included in the master set of genomes analyzed in this study .
ccre , caulobacter crescentus , a bacterial genome not included in the master set of genomes analyzed in this study .
, an archaeal genome not included in the master set of genomes analyzed in this study .
summary of evolutionary scenarios for cross - kingdom gene fusions as indicated in table 2 , the evolutionary scenarios for some of the analyzed cogs included both cross - kingdom horizontal transfer and apparent independent gene fusion within one of the kingdoms . | backgroundgene fusions can be used as tools for functional prediction and also as evolutionary markers .
fused genes often show a scattered phyletic distribution , which suggests a role for processes other than vertical inheritance in their evolution.resultsthe evolutionary history of gene fusions was studied by phylogenetic analysis of the domains in the fused proteins and the orthologous domains that form stand - alone proteins .
clustering of fusion components from phylogenetically distant species was construed as evidence of dissemination of the fused genes by horizontal transfer .
of the 51 examined gene fusions that are represented in at least two of the three primary kingdoms ( bacteria , archaea and eukaryota ) , 31 were most probably disseminated by cross - kingdom horizontal gene transfer , whereas 14 appeared to have evolved independently in different kingdoms and two were probably inherited from the common ancestor of modern life forms . on many occasions ,
the evolutionary scenario also involves one or more secondary fissions of the fusion gene . for approximately half of the fusions ,
stand - alone forms of the fusion components are encoded by juxtaposed genes , which are known or predicted to belong to the same operon in some of the prokaryotic genomes .
this indicates that evolution of gene fusions often , if not always , involves an intermediate stage , during which the future fusion components exist as juxtaposed and co - regulated , but still distinct , genes within operons.conclusionthese findings suggest a major role for horizontal transfer of gene fusions in the evolution of protein - domain architectures , but also indicate that independent fusions of the same pair of domains in distant species is not uncommon , which suggests positive selection for the multidomain architectures . |
the medial entorhinal cortex ( mec ) is a major center for spatial navigation and memory .
we demonstrate that cannabinoid type-1 receptor - expressing gabaergic basket cells selectively innervate principal cells in layer ii of the rat mec that project outside the hippocampus , but avoid neighboring cells giving rise to the perforant pathway to the dentate gyrus .
these results show that the organization of gabaergic microcircuits reflects the long - distance axonal targets of principal neurons . | |
influenza a virus ( iav ) is a common infectious pathogen in humans , which occasionally causes influenza - associated encephalopathy ( iae ) .
iae is characterized by severe neurological complications , such as convulsive seizures , loss of consciousness , and abnormal behaviors.1,2
oseltamivir phosphate ( op ) is a selective neuraminidase inhibitor that prevents influenza virus replication .
it is prescribed for seasonal influenza and was the recommended drug for treating the anticipated pandemic of swine influenza ( h1n1 ) in 2009.35 op works effectively in humans when used within 48 hours following the first appearance of symptoms ( fever).6 however , case reports have associated op intake with sudden abnormal behaviors.79 recent studies have shown that op and its metabolite , op carboxylate ( oc ) , cross the blood - brain barrier.10,11 they have been shown to induce neuronal excitability and synchrony in hippocampal slices and slice cultures.7,12 moreover , op increases dopamine levels in the medial prefrontal cortex of rats.13 most animal model studies of the action of op on the brain have been conducted in normal rather than iav - infected rats or mice , and the animals functioned at the normal core temperature . until now , there has been no information describing the effect of op on intact brain hippocampal activity of iav - infected animals during hyperthermia . despite the efficacy of op in clinics , the putative side effects associated with op have made the use of this drug controversial . in clinics , iae patients electroencephalograms ( eeg ) are characterized by abnormal high - voltage eeg activity with spikes and theta oscillations during high fever.1416 these clinical abnormal eeg activities ( high - voltage amplitudes , increased eeg spikes , and theta oscillations ) were reproduced in the rat model of iae under hyperthermia ( 39.9c41c).17 rats and mice do not normally develop fever after iav infection.17,18 in a previous study,17 abnormal eeg activities were not observed in non - anesthetized iav - infected rats at the normal core temperature ( 37c38c ) .
thus , hyperthermia was a precondition to observe abnormal eeg activities and was induced using a heating system , as previously reported.17 in the present study , we examined the effect of op on abnormal eeg activities in the hippocampus of isoflurane - anesthetized rats during hyperthermia , using the rat model of iae.17
this study was performed in accordance with the guidelines for animal care and use approved by the animal care committee of the university of tokushima . since our goal was to model iae in children , male wistar rats aged 3 to 4 weeks were used because rats in this range correspond roughly to the human age range of 2.5 to 3 years.19 for viral infection , the rats were anesthetized with ketamine - xylazine ( 62.6 mg / kg12.4 mg / kg ) . influenza a / wsn/33 strain was stocked ( frozen ) at 82c and diluted to obtain the dose ( 1 10 plaque forming unit in pbs , 60 l ) , which was then applied intranasally to the rats , as previously reported.17 the rooms for virus stockage , viral infection , and handling of the infected animals were designed in accordance with the guidelines for animal care and use of the university of tokushima .
eeg activity in isoflurane anesthetized animals is characterized by slow bursting activity followed by a burst suppression period.17,20 the rats were first anesthetized by low - dose of ether , then fitted to a stereotaxic frame ( model sn-6n , narishige , tokyo ) .
the animals were gas - anaesthetized with 1.51.7 minimum alveolar concentration ( mac ) of isoflurane mixed with 30% o2 and 70% n2 , which allowed spontaneous respiration . during the eeg recordings , a heating pad system ( model 21051 - 00 ; fine science tools
inc , foster city , ca ) with a feedback control probe was inserted rectally .
the body temperature of rats placed on the heating pad gradually increased from 37c to 41c in a period of 20 minutes , as previously reported.17 eeg activity was recorded using enamel - coated tungsten wire electrodes with an uncoated diameter of 120 m ( mt giken co , tokyo , japan ) .
craniotomy was performed without damaging the underlying dura using a standard miniature drill equipped with 0.5 mm diameter drill bit .
the electrodes were inserted based on the rat brain in stereotaxic coordinates of paxinos and watson.21 to record the hippocampal activity , an electrode was lowered into the ca1-ca3 area ( left hemisphere ) at 2.8 to 3.0 mm posterior to the bregma , 2.7 to 2.9 mm lateral from midline , and 2.6 to 3.0 mm below the dura .
signals were recorded using a dual microprobe system ( wp manufacturing , inc , longmont , co ) , and a homemade amplifier ( 1000 ) .
the baseline was adjusted to zero - level with a slow voltage clamp system with a time constant of 2.2 seconds .
the signal was low - pass filtered at 0.5 to 3 khz , sampled at 1 khz , and recorded using axopatch software ( axon instruments , palo alto , ca ) . to verify the electrode position , the electrode tip was coated with a lipophilic tracer dissolved in dimethylsulfoxide at a concentration of 1 mg / ml to 2.5 mg / ml before insertion into the brain .
after removal of the electrodes , the rats were anesthetized with ketamine - xylazine ( 62.6 mg / kg12.4 mg / kg ) and were transcardially perfused with saline , followed by fixation ( 4% paraformaldehyde ) .
the brain was removed and immediately put in sucrose and kept in a 4c room .
red traces of the dye left by the electrodes were observed under the microscope and photographed .
the electrophysiology eeg data analysis was performed using igor pro 4 ( wavemetrics , inc , lake oswego , or ) and the fast fourier transformation ( fft ) of eeg activity was computed for 30-second periods .
slow and distinctive eeg waves were monitored continuously during the experiments to ensure that the rat was well anesthetized and without pain . at the end of experiments ,
the rats were given a lethal dose of pentobarbital ( 50 mg / kg ) . in order to examine the efficacy of op on abnormal eeg activities during hyperthermia
, we focused particularly on the following observed after iav infection in the rats during hyperthermia:17 abnormal high - voltage eeg activity , enhanced low - amplitude fluctuation ( laf ) during burst suppressed periods , increased eeg spikes , and theta oscillations .
the eeg activity was recorded in the hippocampus of the iav - infected rats at 8 to 12 hours , 26 to 30 hours , and 50 to 56 hours , corresponding to the periods during which the peak abnormal eeg activities are observed in the rat model of iae.17 the eeg amplitude was measured by quantifying the number of bursts ( n = 15 bursts average / point ) and the eeg spike was identified as a sharp wave that usually sprouts randomly within the burst and during the burst suppressed periods , as previously described.17 theta oscillations amplitude was determined by measuring theta wave amplitude ( from the positive to the peak , n = 15 waves average / points ) .
op was not administered ( control ) to some of the rats , but was administered to the remaining rats .
tamiflu capsules ( 75 mg ) were purchased commercially from chugai pharmaceutical co. ( tokyo , japan ) , and the op in the contents of the capsules was dissolved in water . op mixture with stabilizing additives from the capsules or recrystallized op was orally administered to the rats and they were monitored ( for 1 hour postadministration ) in a cage prior to the eeg recording . op was administered to the rats in a single dose or in two doses per day ( figure 2a ) .
atropine ( 30 mg / kg ; nacarai , kyoto , japan ) , an machr agonist , was dissolved in saline ( 0.9% nacl ) and was given via intraperitoneal ( ip ) injection .
p value was obtained by student s paired t - test ( using sigmaplot 10 ; systat software inc , san jose , ca ) , and p < 0.05 was considered statistically significant .
this study was performed in accordance with the guidelines for animal care and use approved by the animal care committee of the university of tokushima . since our goal was to model iae in children , male wistar rats aged 3 to 4 weeks were used because rats in this range correspond roughly to the human age range of 2.5 to 3 years.19 for viral infection , the rats were anesthetized with ketamine - xylazine ( 62.6 mg / kg12.4 mg / kg ) . influenza a / wsn/33 strain was stocked ( frozen ) at 82c and diluted to obtain the dose ( 1 10 plaque forming unit in pbs , 60 l ) , which was then applied intranasally to the rats , as previously reported.17 the rooms for virus stockage , viral infection , and handling of the infected animals were designed in accordance with the guidelines for animal care and use of the university of tokushima .
eeg activity in isoflurane anesthetized animals is characterized by slow bursting activity followed by a burst suppression period.17,20 the rats were first anesthetized by low - dose of ether , then fitted to a stereotaxic frame ( model sn-6n , narishige , tokyo ) .
the animals were gas - anaesthetized with 1.51.7 minimum alveolar concentration ( mac ) of isoflurane mixed with 30% o2 and 70% n2 , which allowed spontaneous respiration . during the eeg recordings , a heating pad system ( model 21051 - 00 ; fine science tools
inc , foster city , ca ) with a feedback control probe was inserted rectally .
the body temperature of rats placed on the heating pad gradually increased from 37c to 41c in a period of 20 minutes , as previously reported.17
eeg activity was recorded using enamel - coated tungsten wire electrodes with an uncoated diameter of 120 m ( mt giken co , tokyo , japan ) .
craniotomy was performed without damaging the underlying dura using a standard miniature drill equipped with 0.5 mm diameter drill bit .
the electrodes were inserted based on the rat brain in stereotaxic coordinates of paxinos and watson.21 to record the hippocampal activity , an electrode was lowered into the ca1-ca3 area ( left hemisphere ) at 2.8 to 3.0 mm posterior to the bregma , 2.7 to 2.9 mm lateral from midline , and 2.6 to 3.0 mm below the dura .
signals were recorded using a dual microprobe system ( wp manufacturing , inc , longmont , co ) , and a homemade amplifier ( 1000 ) .
the baseline was adjusted to zero - level with a slow voltage clamp system with a time constant of 2.2 seconds .
the signal was low - pass filtered at 0.5 to 3 khz , sampled at 1 khz , and recorded using axopatch software ( axon instruments , palo alto , ca ) . to verify the electrode position , the electrode tip was coated with a lipophilic tracer dissolved in dimethylsulfoxide at a concentration of 1 mg / ml to 2.5 mg / ml before insertion into the brain .
after removal of the electrodes , the rats were anesthetized with ketamine - xylazine ( 62.6 mg / kg12.4 mg / kg ) and were transcardially perfused with saline , followed by fixation ( 4% paraformaldehyde ) .
the brain was removed and immediately put in sucrose and kept in a 4c room .
red traces of the dye left by the electrodes were observed under the microscope and photographed .
the electrophysiology eeg data analysis was performed using igor pro 4 ( wavemetrics , inc , lake oswego , or ) and the fast fourier transformation ( fft ) of eeg activity was computed for 30-second periods .
slow and distinctive eeg waves were monitored continuously during the experiments to ensure that the rat was well anesthetized and without pain . at the end of experiments ,
the rats were given a lethal dose of pentobarbital ( 50 mg / kg ) .
in order to examine the efficacy of op on abnormal eeg activities during hyperthermia , we focused particularly on the following observed after iav infection in the rats during hyperthermia:17 abnormal high - voltage eeg activity , enhanced low - amplitude fluctuation ( laf ) during burst suppressed periods , increased eeg spikes , and theta oscillations .
the eeg activity was recorded in the hippocampus of the iav - infected rats at 8 to 12 hours , 26 to 30 hours , and 50 to 56 hours , corresponding to the periods during which the peak abnormal eeg activities are observed in the rat model of iae.17 the eeg amplitude was measured by quantifying the number of bursts ( n = 15 bursts average / point ) and the eeg spike was identified as a sharp wave that usually sprouts randomly within the burst and during the burst suppressed periods , as previously described.17 theta oscillations amplitude was determined by measuring theta wave amplitude ( from the positive to the peak , n = 15 waves average / points ) .
op was not administered ( control ) to some of the rats , but was administered to the remaining rats .
tamiflu capsules ( 75 mg ) were purchased commercially from chugai pharmaceutical co. ( tokyo , japan ) , and the op in the contents of the capsules was dissolved in water . op mixture with stabilizing additives from the capsules or recrystallized op was orally administered to the rats and they were monitored ( for 1 hour postadministration ) in a cage prior to the eeg recording . op was administered to the rats in a single dose or in two doses per day ( figure 2a ) .
atropine ( 30 mg / kg ; nacarai , kyoto , japan ) , an machr agonist , was dissolved in saline ( 0.9% nacl ) and was given via intraperitoneal ( ip ) injection .
p value was obtained by student s paired t - test ( using sigmaplot 10 ; systat software inc , san jose , ca ) , and p < 0.05 was considered statistically significant .
p value was obtained by student s paired t - test ( using sigmaplot 10 ; systat software inc , san jose , ca ) , and p < 0.05 was considered statistically significant .
in single dose cases , op was administered 3 hours after infection ( n = 5 ) and eeg was recorded at 8 hours to 12 hours after infection . in the control rats ( iav - infected rats not given op ) , the eeg showed slow oscillations at 38c core temperature ; the corresponding slow component ( < 1 hz ) is depicted in the fft plot ( figure 1b , top left ) . at 40c core temperature ,
the eeg showed high - voltage slow eeg activity ( or theta - like oscillations in two of the five rats ) with increased spikes ( arrowheads in the eeg traces ) and enhanced amplitudes of the laf , as shown in the expanded trace ( segment 1 ) ( figure 1b , left bottom ) . in this study and a previous study,17 theta - like oscillations in the control rats
in contrast , in the op - administered rats , the eeg displayed theta - like oscillations at the normal core temperature ( 38c ) in two out of the five rats ( figure 1b , top right ) .
the fft plot shows the corresponding theta frequency distributions ( figure 1b , bottom right ) . at 40c ,
the eeg amplitude was reduced and the rhythmic activity of the laf was disrupted while the amplitude of the laf was reduced , as shown in the expanded trace ( segment 2 ) shown in figure 1b .
there was a significant difference ( n = 3 , p < 0.001 ) between the amplitude of laf values of the op - administered rats ( 0.14 0.05 mv ) and that of the control rats ( 0.39 0.06 mv ) .
the quantified abnormal eeg amplitudes ( left ) and eeg spikes ( right ) were reduced in the op - administered rats compared with the control rats ( figure 1b , bottom ) .
abnormal eeg amplitudes in op - administered rats were reduced ( n = 5 , supplementary figures 1 ) , but the reduction was not significant . however , the amplitude of laf values ( 0.26 0.04 ) was significantly ( n = 3 , p < 0.05 ) reduced in the op - administered rats compared to the control rats ( 0.14 0.04 ) , and the eeg spikes were significantly ( p < 0.001 ) reduced in op - administered rats .
this suggests that the efficiency of the single - dose op administration may be weakened after 26 hours of infection .
when two doses of op were administered per day , abnormal eeg amplitudes ( p < 0.05 ) and eeg spikes ( p < 0.001 ) recorded at 26 to 30 hours after infection were more significantly reduced compared with the control rats ( n = 3 ; figure 2b , top ) .
those at 50 to 60 hours after infection were also reduced in comparison with the control rats ( n = 3 , figure 2b , bottom ) .
this finding suggests that two doses of op administered per day were more efficient than a single dose in reducing abnormal eeg activities in iav - infected rats .
two types of theta are known : atropine sensitive ( a muscarinic receptor blocker ) and atropine resistant.22,23 we studied the effect of atropine on the op - induced theta oscillations in iav - infected rats .
then , maintaining this temperature , a saline ip solution was injected , and 30 minutes after the saline injection , atropine ( 30 mg / kg , ip ) was administered . as can be seen in figure 3 , atropine blocked the theta oscillation in all the rats examined ( n = 3 ) , revealing that the op - induced theta oscillation is atropine sensitive .
the present work is the first study to report the effect of op on rats infected with iav under hyperthermia in vivo .
we found that one or two orally administered doses of op were efficient when given soon ( ~3 hours ) after iav infection .
op efficiently reduced the abnormal eeg activities ( ie , enhanced amplitude of the laf , high - voltage eeg amplitudes , increased eeg spike ) in the iav - infected rats .
however , we also observed theta oscillations at 38c core temperature in the op - administered rats .
although the mechanisms by which op reduces abnormal eeg activity are not clear , we presume at least that the n - methyl - d - aspartate ( nmda ) receptor and the blockage of the virus spread from the host cells could play important roles in reducing the high - voltage amplitudes and eeg spikes , as explained below .
our recent study also found that in uninfected rats the activation of nmda receptors peaked at 2 hours after op administration and declined at 4 hours after op administration ( data not shown ) .
this suggests the inactivation of the nmda receptors at 4 hours after op administration , and this inactivation may prevent calcium influx into the neurons .
it is also known that op is a sialic acid analogue , which inhibits the influenza neuraminidase enzyme and prevents the release and spread of the virus from infected host cells during budding.4,6 op treatment ( 1 hour after infection at daily base ) significantly reduces the infection rate in multiple cell types and reduces the progression of the virus in mice.24 these previous findings suggest that the early administration of op after iav infection within a period before the virus proliferates , in addition to the inactivation of the nmda receptors at a later time ( > 4 hours ) after op administration , could be possible factors in explaining how op works to reduce the abnormal eeg activities .
the observation of theta oscillations at 38c in op - administered rats is an important finding for confirming the possible action of op on muscarinic acetylcholine ( mach ) receptors .
we have observed a similar finding in normal uninfected rats ; the op administered to these rats induced theta oscillations ( 2 hz to 6 hz ) at 38c core temperature ( data not shown ) .
theta oscillations were atropine sensitive and prevented fast hippocampal activity , which resulted in a slow eeg activity ( figure 3 ) .
this result is in full agreement with a previously reported in vitro study in which op was found to activate mach receptors.12 the activation of mach receptors may suggest the stimulation of acetylcholine containing cholinergic neurons , which have been known to play important roles in cortical activation and in regulating states of consciousness.25,26 ach is a major excitatory neurotransmitter in the central nervous system .
it plays key roles during synaptic transmission , and constitutes a system with other neurotransmitter / modulators to regulate brain states of vigilance .
25 because the eeg recording from the hippocampus in nonanesthetized rats was not possible , the effect of anesthesia could be an issue to consider during the interpretation of the data .
it reduces excitatory synaptic transmission in the hippocampus,2729 and it enhances inhibitory synaptic potentials at concentrations above 0.5 mac ( 1%).29 isoflurane alters the ach release in a dose - related manner , and that at 1.5 mac , it significantly decreases ach release in the cortex and striatum of rats.30,31 with such concentrations , eeg activity is generally characterized by slow ( bursting ) activity followed by burst - suppressed periods.17,20 in the present and previous studies,17 1.51.7 mac isoflurane was used .
the physiological significance of high - voltage slow and theta oscillations in influenza patients in the clinic is not well documented . however , in the rat model of iae , we speculated that the alternation between these two oscillations may lead to brain instability , and that this may explain the abnormal behaviors observed in some patients.17 in the present study , the op - induced theta oscillations were similar to those observed during hyperthermia in the iav - infected rats not given op .
. excessive release of ach may affect synaptic transmission and oscillation patterns in the brain , which may lead to abnormal behavior in influenza patients .
under such conditions , atropine may play a therapeutic role in stabilizing the brain states from fast ( 26 hz ) to slow ( < 1 hz ) oscillations .
in the present study , because hyperthermia was a precondition for observing eeg abnormalities in the control rats , the effect of op on core temperature before and during eeg recording was not investigated . however , recent studies showed that op induces hypothermia in mice32 and op administered in ethanol - injected rats significantly augmented the hypothermia effect.7 hypothermia has also been reported after op ingestion in clinics.33
our data show that op , when administered in the early phase of an infection , can efficiently reduce abnormal eeg activities in iav - infected rats .
however , op administration may stimulate ach release in rats at the normal core temperature .
future studies should investigate the biomolecular basis of nmda and machrs expression levels and measure ach release in op - administered rats , especially in the cortex and the hippocampus .
such an investigation could improve our understanding of protecting the brain during the early phase of iav infection against neuronal excitability and neurological complications , and thus prevent abnormal behaviors ( which can lead to fatal accidents ) in influenza patients with high fever .
note a decrease of eeg amplitude in the op - administered rats compared with the control rats .
in contrast , a significant decrease in the number of spikes was observed in the op - administered rats . | backgroundoseltamivir phosphate ( op , tamiflu ) is a widely used drug in the treatment of influenza with fever .
however , case reports have associated op intake with sudden abnormal behaviors . in rats infected by the influenza a virus ( iav ) , the electroencephalogram ( eeg ) displayed abnormal high - voltage amplitudes with spikes and theta oscillations at a core temperature of 39.9c to 41c .
until now , there has been no information describing the effect of op on intact brain hippocampal activity of iav - infected animals during hyperthermia.objectivethe aim of the present study was to examine the effect of op on abnormal eeg activities in the hippocampus using the rat model of influenza - associated encephalopathy.methodsmale wistar rats aged 3 to 4 weeks were used for the study .
influenza a / wsn/33 strain ( 1 105 plaque forming unit in pbs , 60 l ) was applied intranasally to the rats . to characterize op effects on the iav - infected rats ,
eeg activity was studied more particularly in isoflurane - anesthetized iav - infected rats during hyperthermia.resultswe found that the hippocampal eeg of the op - administered ( 10 mg / kg ) iav - infected rats showed significant reduction of the high - voltage amplitudes and spikes , but the theta oscillations , which had been observed only at > 40c in op non - administered rats , appeared at 38c core temperature .
atropine ( 30 mg / kg ) blocked the theta oscillations.conclusionour data suggest that op efficiently reduces the abnormal eeg activities after iav infection during hyperthermia .
however , op administration may stimulate ach release in rats at normal core temperature . |
due to their collective significance in mediating the host response against pathogens , the genes of the interferon response have been an area of particular focus in the field of antiviral defense .
understanding the biology of interferon - stimulated genes is challenging because of the diversity in their specificity and breadth of action against pathogens . among them , and of considerable interest in the field of hiv research , are the paradigmatic retroviral restriction factors trim5 , apobec3 g , and bst2/tetherin , as well as newly identified factors such as samhd1 and slfn11 .
a second challenge in studying interferon - stimulated gene biology is understanding the apparent lack of efficacy against hiv infection . during chronic infection ,
what 's more , persistent production of interferon during chronic infection is thought to be deleterious [ 5 - 7 ] .
this stands in contrast with the efficacy of exogenous administration of interferon that contributes to active control of hiv infection in vivo .
adding to the challenge , antiviral responses can also be triggered by interferon - independent paths .
understanding the protective and deleterious contribution of the innate cellular response to hiv needs a more complete understanding of the components of such defense machinery . in this report , we highlight approaches from genomics that can help in these endeavors .
the emphasis is on the components of intracellular defense ; thus , we do not discuss non - cell autonomous systems that are typically considered to be within the innate framework ( e.g. nk cells , macrophages , dendritic cells , etc . ) .
the gene ontology project ( http://www.geneontology.org/ ) includes the term innate immunity response ( go:0045087 ) ; innatedb ( http://www.innatedb.ca ) identifies curated genes , experimentally verified protein interactions , and signaling pathways involved in innate immunity ; and the interferon - stimulated gene database identifies interferon - stimulated genes through expression analyses .
additionally , recent work compiled a list of interferon - stimulated genes that were used for extensive functional analyses in the context of viral infection , including hiv .
however , the overlap across these various lists is limited : of 1492 genes included in one or more of the above databases , only 25 are common to all four sets ( figure 1 ) .
the reasons for this lack of consensus are many fold : diversity of biology ( innate immunity refers to activities spanning many molecular and cellular functions ) , methodological approaches for gene identification ( e.g. microarray , functional assays ) , experimental setups ( e.g. different cell lines , stimuli , pathogens ) , and diverse levels of confidence in annotation .
more recently , a number of initiatives have aimed at defining restricted sub - fields , such as that of the intrinsic cellular defense and of cell - autonomous immunity .
clearly , an effort of convergence is needed as experts agree that the function of the several hundred genes has been comprehensively summarized to only limited extents .
a number of recent papers have advanced evolutionary genomics , human genetic approaches , and large scale functional genomic screens that dissect components of innate immunity .
venn diagram representing four sets of innate immunity human genes : i ) in purple , 649 genes associated to go term innate immune response
( go:0045087 ) ; ii ) in green , 927 manually annotated genes from innatedb ; iii ) in blue , 369 interferon - stimulated genes in the interferon - stimulated gene database ; iv ) in yellow , 424 interferon - stimulated genes genes compiled by schoggins et al . .
it is well accepted that genes and cellular pathways enriched for signals of positive selective pressure are frequently involved in the immune response .
the underlying concept is that evasion from , and co - evolution with , pathogens is one of the strongest evolutionary pressures , resulting in signals identifiable through comparative genomics .
it is expected that genes with such characteristics have an effector role , and that the signals will be most pronounced at domains of direct interaction with a pathogen .
indeed , signatures of positive selection are enriched in the various sets of innate immunity genes ( figure 2a ) .
the hiv restriction factors trim5 apobec3 g , bst2 and samhd1 are relevant examples of genes that have undergone positive selection .
panel
( a ) in grey , the genome - wide distribution ( density ) of dn / ds values a measure of positive selection - for 19252 protein coding genes in primates .
lines depict the distribution of dn / ds values for genes associated with the various innate immunity sets discussed in fig 1 .
panel
( b ) distribution of duplication events occurring during the evolutionary history of a gene across the various innate immunity gene sets .
the histogram depicts the proportion of genes that have none , one or more duplications in the human genome .
dotted lines represent the duplication events for genes associated with the innate immunity gene sets .
the values of those measurements for the prototypical innate immunity genes samhd1 , bst2 , trim5 and apobec3 g are indicated . gene expansion ( figure 2b ) and ,
in particular in primates , segmental duplications are prominent features of innate immunity genes .
the resulting gene duplications may lead to increased gene dosage , and neo- or sub - functionalization .
the current state of functional annotation suggests that characterization of duplicated innate immunity genes is largely incomplete .
for example , 83% of the 927 genes in innatedb have paralogs ( genes emerging from duplication events ) .
however , most of these paralogs have not themselves been annotated as part of innate immunity , despite many of them showing high levels of sequence similarity .
therefore , estimates of positive selection and patterns of duplication can help establish categories within innate immunity genes . as a corollary
, these metrics could serve to annotate genes that have not been previously considered part of innate immunity .
exome and whole - genome sequencing in thousands of individuals have revealed large numbers of variants that change amino acid sequences .
increasing numbers of non - synonymous variants are a feature of genes under positive selection , and of genes of innate immunity ( figure 3 ) . in some instances , variants code for nonsense mutations that , when homozygous , may result in natural knock - outs .
we estimate , on the basis of 1092 exome sequences from the 1000 genomes project , that around 10% of innate immunity genes carry a homozygous stop codon or frameshift variant that may lead to a loss of function . as a correlate to the discussion on gene expansion in the evolution of genomes
, there is also interest in the presence of copy number variation and , in particular , deletions also enriched in human genes involved in innate immunity and the inflammatory response .
the interpretation of these data includes the possibility that greater genetic diversity provides a benefit to the species , i.e. through balancing selection .
however , the high frequency of functional variation in innate immune genes could also represent the substrate of human susceptibility to infection including the possibility of selective immunodeficiency .
exome and whole - genome sequencing to understand rare human variation in the setting of hiv is an important research avenue that will complement the various genome - wide association studies that have been published in the field .
( a ) non - synonymous coding variants in 14213 human genes in the 1000 genome project are plotted according to estimates of positive selection in primates .
the x - axis distributes genes from the most conserved ( lower decile intervals ) to the genes under positive selection ( higher decile intervals ) . in red , innate immunity genes ( n=1143 ) : the greater the signal of positive selection , the more frequent the identification of non - synonymous variants . in grey , the rest of human genes .
there is significant room for characterization of innate immune genes through the iterative combination of genomic and functional assays .
some commonly applied tools include silencing rna and gain - of - function screens , large - scale co - immunoprecipitation of interacting host and pathogen proteins in cell lines , and phosphoproteome studies .
however , it is broadly acknowledged that the interferon response is deficient in many laboratory cell lines which explains their utility in pathogen research .
this observation notwithstanding , the underlying integrity of the cellular innate immune system is rarely considered .
for example , rna sequencing of supt1 or 293 t cells , highly permissive cell lines used in hiv research , shows that they are poorly equipped to respond to the incoming virus .
between 25 and 50% of innate immunity genes are downregulated or not expressed in these cell lines , which stands in contrast with their level of expression in primary cd4 + t cells .
thus , analysis of expression in multiple cellular systems generates a checkerboard of innate immunity genes that are absent in one or more susceptible cell types , but present in cell lines or primary cells that do not support pathogen replication .
thus , genes of innate immunity that are missing in susceptible cell lines , and present in primary cells , can be considered as candidates for further investigation .
it is well accepted that genes and cellular pathways enriched for signals of positive selective pressure are frequently involved in the immune response .
the underlying concept is that evasion from , and co - evolution with , pathogens is one of the strongest evolutionary pressures , resulting in signals identifiable through comparative genomics .
it is expected that genes with such characteristics have an effector role , and that the signals will be most pronounced at domains of direct interaction with a pathogen .
indeed , signatures of positive selection are enriched in the various sets of innate immunity genes ( figure 2a ) .
the hiv restriction factors trim5 apobec3 g , bst2 and samhd1 are relevant examples of genes that have undergone positive selection .
panel
( a ) in grey , the genome - wide distribution ( density ) of dn / ds values a measure of positive selection - for 19252 protein coding genes in primates .
lines depict the distribution of dn / ds values for genes associated with the various innate immunity sets discussed in fig 1 .
panel
( b ) distribution of duplication events occurring during the evolutionary history of a gene across the various innate immunity gene sets .
the histogram depicts the proportion of genes that have none , one or more duplications in the human genome .
dotted lines represent the duplication events for genes associated with the innate immunity gene sets .
the values of those measurements for the prototypical innate immunity genes samhd1 , bst2 , trim5 and apobec3 g are indicated .
gene expansion ( figure 2b ) and , in particular in primates , segmental duplications are prominent features of innate immunity genes .
the resulting gene duplications may lead to increased gene dosage , and neo- or sub - functionalization .
the current state of functional annotation suggests that characterization of duplicated innate immunity genes is largely incomplete .
for example , 83% of the 927 genes in innatedb have paralogs ( genes emerging from duplication events ) .
however , most of these paralogs have not themselves been annotated as part of innate immunity , despite many of them showing high levels of sequence similarity .
therefore , estimates of positive selection and patterns of duplication can help establish categories within innate immunity genes . as a corollary
, these metrics could serve to annotate genes that have not been previously considered part of innate immunity .
exome and whole - genome sequencing in thousands of individuals have revealed large numbers of variants that change amino acid sequences .
increasing numbers of non - synonymous variants are a feature of genes under positive selection , and of genes of innate immunity ( figure 3 ) . in some instances , variants code for nonsense mutations that , when homozygous , may result in natural knock - outs .
we estimate , on the basis of 1092 exome sequences from the 1000 genomes project , that around 10% of innate immunity genes carry a homozygous stop codon or frameshift variant that may lead to a loss of function . as a correlate to the discussion on gene expansion in the evolution of genomes
, there is also interest in the presence of copy number variation and , in particular , deletions also enriched in human genes involved in innate immunity and the inflammatory response .
the interpretation of these data includes the possibility that greater genetic diversity provides a benefit to the species , i.e. through balancing selection .
however , the high frequency of functional variation in innate immune genes could also represent the substrate of human susceptibility to infection including the possibility of selective immunodeficiency .
exome and whole - genome sequencing to understand rare human variation in the setting of hiv is an important research avenue that will complement the various genome - wide association studies that have been published in the field .
( a ) non - synonymous coding variants in 14213 human genes in the 1000 genome project are plotted according to estimates of positive selection in primates .
the x - axis distributes genes from the most conserved ( lower decile intervals ) to the genes under positive selection ( higher decile intervals ) . in red , innate immunity genes ( n=1143 ) : the greater the signal of positive selection , the more frequent the identification of non - synonymous variants . in grey , the rest of human genes .
there is significant room for characterization of innate immune genes through the iterative combination of genomic and functional assays .
some commonly applied tools include silencing rna and gain - of - function screens , large - scale co - immunoprecipitation of interacting host and pathogen proteins in cell lines , and phosphoproteome studies .
however , it is broadly acknowledged that the interferon response is deficient in many laboratory cell lines which explains their utility in pathogen research .
this observation notwithstanding , the underlying integrity of the cellular innate immune system is rarely considered .
for example , rna sequencing of supt1 or 293 t cells , highly permissive cell lines used in hiv research , shows that they are poorly equipped to respond to the incoming virus .
between 25 and 50% of innate immunity genes are downregulated or not expressed in these cell lines , which stands in contrast with their level of expression in primary cd4 + t cells .
thus , analysis of expression in multiple cellular systems generates a checkerboard of innate immunity genes that are absent in one or more susceptible cell types , but present in cell lines or primary cells that do not support pathogen replication .
thus , genes of innate immunity that are missing in susceptible cell lines , and present in primary cells , can be considered as candidates for further investigation .
from a genomic perspective , a number of approaches are useful to characterize innate immunity and thus important to characterize the first barrier of defense against hiv .
positive selection , gene duplication , human genetic diversity , and differential expression across cell lines and primary cells are quantifiable features that point to a differential genomic landscape of effector genes participating in protection against hiv and other pathogens .
| innate immunity is a theme of increasing interest for hiv research .
however , the term is overstretched to cover biological barriers , cellular systems , soluble factors , signaling pathways , and effectors and is inconsistently applied
. a clearer semantic classification of the components of innate immunity is needed , which will have direct relevance to the interpretation of human genome variation . here
, we discuss genomic approaches that can assist in re - defining the perimeter of innate immunity .
we place particular emphasis on the characteristics of effectors of the intracellular defense against hiv and other pathogens . |
the term haemorrhagic disease of the newborn ( hdn ) was coined by charles townsend in 1894 to describe an acquired bleeding disorder in the newborn due to vitamin k deficiency .
nowadays , the term hdn is replaced by vitamin k deficiency bleeding ( vkdb ) , as neonatal bleeding is often not due to vitamin k deficiency and vkdb often occurs after the 4-week neonatal period .
vkdb can be classified according to the time of presentation after birth into early ( 024 h ) , classical ( 17 days ) and late ( 212 weeks ) vkdb . late vkdb occurs primarily in exclusively breastfed infants who have received no or inadequate vitamin k prophylaxis .
in addition , intestinal malabsorption defects ( cholestatic jaundice , cystic fibrosis , -1-antitrypsin deficiency etc . ) are a well known frequent cause of late vkdb . in some children , warning bleeds such as mild bruises , nose bleeds or umbilical oozing are the first manifestation of vkdb . in about 50% of the cases in late vkdb ,
the efficacy of neonatal vitamin k prophylaxis ( oral or parenteral ) in the prevention of classic vkdb is firmly established .
it has been the standard of care since the committee on nutrition of the american academy of paediatrics recommended to administer vitamin k prophylaxis to all newborn infants in 1961 . since then , many countries adopted this recommendation , although controversies concerning the best dose , route and frequency of administration still exist . in 1990 , the dutch paediatric association recommended the administration of a single oral dose of 1 mg of vitamin k1 at birth to all healthy infants .
parenteral administration of vitamin k1 at birth was recommended for newborns especially at risk ( preterm babies , babies born with instrumental help or caesarean section , asphyxia or if maternal medication was interfering with coagulation ) . for infants who are largely or fully breastfed ,
a daily dose of 25 g of vitamin k1 orally was recommended from 1 to 13 weeks of age . in case of additional risk factors like a known malabsorption , this dose
after the introduction of this guideline , the incidence of late vkdb , which was studied by a nationwide active surveillance performed by the netherlands paediatric surveillance unit ( nsck ) in 1992 to 1994 , decreased from about 7.0 to 1.1/100,000 live births .
however , still , some cases of late vkdb have been reported in the netherlands , merely due to an underlying cholestatic liver disease [ 7 , 10 , 11 ] .
therefore , a one - year surveillance was started again to study the current incidence and the aetiology of late vkdb in the netherlands .
discussion will rise about the efficacy of the current guideline in order to completely prevent late vkdb .
from 1 january to 31 december 2005 , an active surveillance programme for vkdb was in operation in the netherlands , using methods developed by the british paediatric association surveillance unit .
surveillance was based on monthly report cards sent to paediatricians responsible for in- and outpatient care in all hospitals by the nsck .
the paediatricians were asked to report all infants in whom bleeding may have resulted from vkdb .
the reported cases were validated with a questionnaire asking for information about the infant , type of feeding , clinical presentation , dose of vitamin k prophylaxis , route of vitamin k prophylaxis , associated diseases and laboratory data .
for all reported cases , we asked for an anonymous hospital discharge letter to verify the diagnosis of late - onset vkdb .
the case definition of late - onset vkdb was as internationally defined : any infant between 8 days to 26 weeks of age , with spontaneous bruising , bleeding or intracranial haemorrhage associated with a grossly prolonged prothrombin assay , not due to an inherited coagulopathy or disseminated intravascular coagulation .
confirmed vkdb was diagnosed when the prothrombin assay results were grossly abnormal compared with the standards for age : international normalized ratio ( inr ) 4 control value , prothrombin time ( pt ) 4 control value and at least one of the following was present :
platelet count normal or raised and normal fibrinogenprothrombin assay returned to normal after vitamin k administrationconcentration of proteins induced by vitamin k absence ( pivka ) exceeded normal controls platelet count normal or raised and normal fibrinogen prothrombin assay returned to normal after vitamin k administration concentration of proteins induced by vitamin k absence ( pivka ) exceeded normal controls pivka is a sensitive indicator of vitamin k status , allowing the detection of subclinical deficiency states which would not be detected by conventional coagulation assays .
idiopathic cases were defined as cases in whom no factor predisposing to vitamin k deficiency was identified .
secondary cases were those in whom an underlying condition such as cholestasis or other causes of malabsorption of vitamin k could be identified .
vitamin k prophylaxis was considered to be as recommended if the dutch guideline was followed at the time of bleeding : 1 mg of vitamin k1 ( oral , intravenous , intramuscular ) directly after birth , followed by a daily dose of 25 g of vitamin k1 from 1 to 13 weeks of age for all breastfed babies .
the konakion mixed micellar preparate ( phytomenadion 10 mg / ml , hoffmann - la roche , basel , switzerland ) , which can be used for both oral , intramuscular and intravenous administration , an oral preparate called davitamon k ( marketed by chefaro , rotterdam , the netherlands , 25 g/5gtt ) and an oral preparate , phytomenadion , which is made by the dutch pharmacist mixtura ( phytomenadion 10 mg / ml fna ) were the only vitamin k preparations licensed in the netherlands .
the 95% confidence intervals ( ci ) were calculated according to a binomial distribution and the chi - squared test was used for the comparison of incidences between different periods , with a value of p < 0.05 being considered as significant .
the response rate to the surveillance amounted to 93.4% and the response to our questionnaires was 100% . in total , seven cases of late vkdb were reported : four reports from academic paediatric centres and three from general district hospitals . a hospital discharge letter
one case did not fulfil the criteria of the case definition because there were no clinical signs of bleeding , only biochemical clotting disorders due to a vitamin k deficiency .
six cases fulfilled the criteria of the case definition and could be validated as late vkdb .
the mean age of presentation was 5 weeks and 2 days , and all of the cases were exclusively breastfed . in all cases ,
the pt time or inr was at least four times greater than normal and vitamin k deficiency was confirmed by a documented pt or inr normalisation after the administration of vitamin k. five of the cases also received fresh frozen plasma .
table 1confirmed cases of late vitamin k deficiency bleeding ( vkdb ) in the netherlands from 1 january to 31 december 2005patient ; sex ; age ( weeks)presentationfeedingvitamin k prophylaxisprothrombin assay ( after vitamin k administration ) additional morbidityoutcome of bleedinga ; female ; 5 + 1/7intracranial bleedingbreastfeedingbirth : 1 mg p.o.25 g / daypt>120 s ( 13.3 ) ; aptt>120 s ( 37)nodiedb ; female ; 6 + 6/7intracranial bleedingbreastfeedingbirth : 1 mg p.o.25 g / dayinr>8 ( inr<2 ) ; aptt>240 s ( 49)biliary atresiahemipareses rightc ; male ; 4 + 4/7intracranial bleedingbreastfeedingbirth : 1 mg p.o.25 g / daypt>90 s ( 30 ) ; aptt>120 s ( 38 ) ; vitamin k : 0.1 nmol / lbiliary atresiahemipareses rightd ; male ; 5 + 2/7nasal bleedingbreastfeedingbirth : 1 mg p.o.25 g / daypt>75 s ( normal ) ; aptt : 118 s ( normal)biliary atresiano sequelaee ; male ; 6 + 2/7nasal bleedingbreastfeedingbirth : 1 mg p.o.25 g / daypt>165 s ( normal ) ; aptt>240 s ( normal)biliary atresiano sequelaef ; male ; 3 + 6/7nasal bleedingbreastfeedingbirth : 1 mg p.o.25 g / daypt>71 s ( 12.7 ) ; aptt : 128 s ( 39.1)cholestasisno sequelae confirmed cases of late vitamin k deficiency bleeding ( vkdb ) in the netherlands from 1 january to 31 december 2005 concerning the cause of vkdb , there was one case of idiopathic vkdb , who presented with signs of bleeding at the age of 5 weeks .
unfortunately , no post - mortem obduction was performed but , biochemically , there were no signs of cholestasis .
the age of presentation in this group was between 3 and 7 weeks of age .
all of these bleedings were due to an underlying cholestasis which was diagnosed after the first presentation of bleeding . in two cases ,
all infants had been exclusively breastfed and all had received exactly the recommended prophylaxis . in the study period ,
therefore , the total incidence of late vkdb and idiopathic late vkdb was calculated to be 3.2 ( 95% ci : 1.26.9 ) and 0.5 ( 95% ci : 02.9 ) per 100,000 live births , respectively .
data from the united kingdom , germany and switzerland prove that intramuscular vitamin k1 prophylaxis ( 1 mg ) is highly effective in the prevention of late vkdb .
this is supported by data from australia , which demonstrate a higher incidence of late vkdb in babies who received oral vitamin k compared to those with parenteral vitamin k at birth . however , most of these failures of oral vitamin k were in cases reported with an underlying cholestatic liver disease [ 3 , 12 , 14 , 25 , 32 , 33 ] . in 1992 , golding et al
. reported an increased risk of developing childhood cancer after parenteral vitamin k1 prophylaxis .
recent studies , however , show that solid tumours are no commoner in children who had parenteral vitamin k. although no convincing evidence between parenteral vitamin k and childhood leukaemia was found in these studies , it can not be fully excluded that there is no risk [ 4 , 18 ] . since the report of golding et al . , there has been an increasing trend towards oral vitamin k administration and many oral prophylaxis regimes have been developed . in 1997
, we summarised the results of surveillance studies of over 2 million infants in four different countries using different multiple oral dose schedules and parenteral administration of vitamin k. a daily low oral dose of 25 g of vitamin k1 following an initial oral dose of 1 mg vitamin k1 directly after birth for exclusively breastfed infants , as was used in the netherlands since 1990 , seemed to be as effective as parenteral vitamin k1 prophylaxis .
the present surveillance study shows that the current dutch guideline still seems quite effective in preventing idiopathic late vkdb , but it is insufficient against secondary late vkdb . in our surveillance , the incidence of all late vkdb and idiopathic late vkdb was 3.2 ( 95% ci : 1.26.9 ) and 0.5 ( 95% ci : 02.9 ) per 100,000 live births , respectively .
the incidence of the latter is comparable to 0.5 ( 95% ci : 0.11.6 ) per 100,000 live births reported in our surveillance study performed by the same netherlands paediatric surveillance unit ( nsck ) in 19921994 .
the incidence of late vkdb secondary to an underlying cholestatic liver disease is , however , significantly higher ( p < 0.05 ) ; 2.7 ( 95% ci : 0.96.2 ) compared to 0.7 ( 95% ci : 0.12.0 ) in 19921994
. a higher incidence of cholestatic liver diseases in general or a delayed recognition of symptoms can be explanations for this difference .
unfortunately , data about the incidence or recognition of cholestatic liver diseases in the netherlands are not available . in this surveillance
this can be explained by the assumption of the higher efficacy of parenteral vitamin k1 or the low use of intramuscular and intravenous vitamin k1 these days . since 1994
this mixed micellar formulation is prepared with the phospholipids lecithin and the bile salt glycocholic acid , and it was presumed that this preparate would reduce the incidence of late vkdb due to a better absorption of oral vitamin k. however , a recent randomised controlled trial shows that the mixed micellar vitamin k gives unreliable and still severely impaired intestinal absorption in infants with cholestasis .
furthermore , von kries et al . reported no significant reduction in the incidence of late vkdb in healthy infants and infants with an underlying cholestatic liver disease with this preparate compared to the use of the original konakion ( cremophor el ) and kanavit ( polysorbat 80 ) . in view of the fact that vitamin k has limited tissue reserves and
is rapidly catabolised , with 6070% of a single dose being excreted via the urine and bile in about 3 days , it seems reasonable that repeated doses rather than a higher single dose is more effective in preventing late vkdb .
an important study from denmark has established that 1 mg of oral vitamin k1 given weekly during the first 3 months of life , following an initial oral dose of 2 mg of vitamin k1 directly after birth , is as effective as 1 mg of vitamin k1 given intramuscularly at birth .
therefore , we hypothesise that the dosage of 25 g of vitamin k1 daily is not enough to prevent the secondary cases of late vkdb , as we encountered in this study . in most co - operative studies ,
the upper age limit for inclusion was set arbitrarily at the end of 12 weeks of age . in our study
, we included infants presenting with vkdb up to the age of 26 weeks of age , as suggested by tripp et al .
the mean age of all infants with late vkdb was 5 weeks , which is comparable to other reports .
in our study , the boy : girl ratio was 2.5:1 . why late vkdb occurs more in boys than girls is unknown , but this is consistent with other european reports [ 22 , 24 ] .
first , this surveillance was based on one data source only : the netherlands paediatric surveillance unit . in spite of the high return rate of the report cards ( 93.4% ) ,
it is plausible that dramatic conditions , such as intracranial bleedings , are more likely to be reported , as also noted by von kries et al . .
for this reason , our data could give an under - reporting of the true incidence of late vkdb in the netherlands .
however , the fact that 50% of late vkdb cases were intracranial bleedings is comparable to other , larger reports [ 3 , 13 , 14 , 19 , 22 , 30 , 31 , 33 ] .
, the confidence interval would be smaller when the length of the surveillance was prolonged .
third , the proportion of infants that is breastfed is unknown , and , additionally , we lack data about compliance to the prophylaxis .
it is likely , however , that less than 100% of the eligible cases received the recommended prophylaxis .
prophylaxis failure , therefore , is likely to be underestimated due to a greater denominator than the true numbers exposed .
we would suggest to double the daily dose of vitamin k1 to 50 g for all breastfed babies from 1 to 13 weeks of age to prevent bleedings in infants with an underlying cholestatic liver disease as well .
this amount is comparable to the ingested dose of vitamin k1 by formula - feeding .
formula is supplemented with vitamin k1 to a minimal concentration of 50 g / l .
vkdb are not reported in formula - fed babies and there is no evidence that they are at an increased risk of childhood cancer .
studies with such a concentration of vitamin k1 have never been performed and further research is necessary to study the efficacy of this prophylaxis in infants with underlying cholestatic liver disease . due to the low incidence of late vkdb , it would be difficult to perform a randomised trial of 25 g versus 50 g of vitamin k1 daily .
alternatively , a new surveillance for 1 or 2 years after implementing 50 g of vitamin k1 as the prophylaxis could give an indication of the efficacy of this dose . furthermore , an earlier recognition of symptoms associated with cholestatic liver disease and immediate investigation and treatment of warning bleeds helps to prevent the severe consequences of secondary late vkdb . in conclusion , with the current guideline of vitamin k prophylaxis in the netherlands , idiopathic late vkdb is rare , but late vkdb secondary to an underlying cholestatic liver disease still occurs . we suggest to double the daily maintenance dose of vitamin k1 to 50 g per day for all breastfed infants from 1 to 13 weeks of age in order to prevent bleedings in children with an underlying cholestatic liver disease as well . | vitamin k prophylaxis is recommended to prevent the hazard of haemorrhage caused by vitamin k deficiency in newborns .
the present dutch guideline recommends 1 mg of vitamin k1 orally at birth , followed by a daily dose of 25 g of vitamin k1 from 1 to 13 weeks of age for breastfed infants . since the introduction of this prophylaxis , the incidence of vitamin k deficiency bleeding ( vkdb ) has decreased
; however , late vkdb is still reported . from 1 january to 31 december 2005 , a nationwide active surveillance was performed by the netherlands paediatric surveillance unit ( nsck ) to study the current incidence and aetiology of late vkdb in infants .
six cases could be validated as late vkdb : all were breastfed , one fatal idiopathic intracranial haemorrhage at the age of 5 weeks and five bleedings secondary to an underlying cholestatic liver disease between the age of 3 and 7 weeks .
the total incidence of late vkdb and idiopathic late vkdb was calculated to be 3.2 ( 95% ci : 1.26.9 ) and 0.5 ( 95% ci : 02.9 ) per 100,000 live births , respectively . with the current dutch guideline ,
idiopathic late vkdb is rare but late vkdb secondary to cholestasis still occurs in breastfed infants .
doubling the daily dose of vitamin k1 to 50 g , as is comparable to formula - feeding , may possibly prevent vkdb in this group .
further research , however , is needed to prove this hypothesis . |
during the past decade , the patterns of diseases generated by shiga toxin - producing escherichia coli ( stec ) strains have changed from a clinical novelty to a global public health problem .
this group of e. coli strains can cause a spectrum of human diseases , ranging from symptom - free carriage to severe bloody diarrhea and even life - threatening disorders , such as hemolytic - uremic syndrome ( hus ) and hemorrhagic colitis ( hc ) ( 1 - 4 ) .
the infections caused by the stec strains have been reported from over 30 countries where e. coli
o157:h7 strain has been the most common serogroup .
furthermore , the prevalence of foodborne diseases due to consumption of contaminated foods and/or water has increased worldwide ( 5 , 6 ) . among the contaminated foods , fresh fruits and vegetables
have been increasingly recognized as a source of foodborne outbreaks in many regions of the world ( 6 - 8 ) .
although , the outbreaks of the diseases attributable to stec strains have been associated with consumption of raw vegetables ; the epidemiological investigations implicated lettuce as the most likely source of the outbreak ( 9 - 11 ) . as examples , large stec - related outbreaks due to consumption of lettuce were observed in sweden and spain , where association was found between outbreaks caused by e. coli
o157:h7 strain and the consumption of lettuce ( 10 , 11 ) . among the reservoirs of these pathogenic e. coli strains ,
cattle may be considered as a principal source , because the studies on the prevalence of e. coli
o157:h7 in cattle feces have shown a wide variety of positive cases in different countries ( 12 - 14 ) .
the way by which these groups of pathogens can spread over the farm lands may be the ubiquitous employment of bovine manure in the agriculture ( 15 ) .
fresh vegetables can be contaminated by these strains through bovine manure , irrigation with contaminated or waste water , and further contact with infected animals and/or humans ( 16 , 17 ) .
we have previously shown the importance of stec in diarrheal diseases of both iranian children and adults ( 18 ) .
the main purpose of this study was to detect the presence of stec in lettuce samples collected from tehran , iran and to evaluate the antibiotic resistance patterns of the isolates . the extensive use of lettuce as a raw vegetable in homemade meals and restaurants served as a prime motivator for inspection of the prevalence and the genotype distribution of stec in the lettuce samples .
one hundred lettuce samples were collected weekly from various farm lands in tehran between june and september 2011 .
every sample was packed in a separate stomacher bag ( interscience , france ) and transported ( in ice ) to the laboratory , where they were immediately processed by a stomacher instrument ( bag mixer400 vw , interscience , france ) .
enrichment and processing of the samples were carried out according to previously described protocols ( 7 ) .
briefly , 25 g of each sample was homogenized by the stomacher in its bag containing 225 ml e. coli broth ( ec ) medium ( merck , germany ) , supplemented with 0.05 mg / l cefixime ( daana pharmaceutical co. , iran ) .
, a portion of the mixture was spread over a macconkey agar plate ( merck , germany ) and was further incubated at 37c overnight .
a sweep from the semi - confluent area of the plate was used for dna extraction for polymerase chain reaction ( pcr ) detection of stec .
the stec - positive samples were subjected to further isolation processes of stec , further pcr and antibiotic susceptibility tests .
prior to detection of the strains by pcr , the dna was extracted from the bacteria on the culture plates according to the previously described protocol with some modification ( 18 ) .
briefly , one heterogenic loopful of the grown bacteria from the first area of the macconkey agar plate was taken and homogenized in 25 l distilled water in a 1.5-ml microtube . the resulting suspension was placed in a boiling water bath at 100c for 10 minutes and centrifuged at 15000 rpm for five minutes in a microcentrifuge ( peqlab , germany ) .
the supernatant containing bacterial dna was transferred to a new tube and processed for pcr detection of the stx1 , stx2 and eaea genes .
the information related to the oligonucleotide primers ( faza biotech , iran ) are shown in table 1 .
the pcr was performed in a reaction volume containing 5 l of the extracted dna , 2.5 l pcr buffer ( 10x ) , 0.5 l deoxynucleoside 5-triphosphate , 0.5 l of each primer , 0.25 l taq dna polymerase 500 u ( 5 u/l ) , and 1.5 l mgcl2 ( 20 mm ) ( cinnagen co. , iran ) , adjusted to a total volume of 25 l with sterile deionized water .
the reaction was carried out by an amplification thermal cycler ( peqlab , germany ) . the procedure consisted of initial denaturation at 96c for minutes , followed by 32 cycles of template denaturation at 94c for 20 seconds .
the final cycle was followed by incubation of the reaction mixture at 72c for six minutes .
the results were compared with those of atcc standard strains of e. coli atcc 43890 ( stx1 ) , e. coli atcc 43889 ( stx2 ) and e. coli atcc 43887 ( eaea ) .
after reculturing the pcr - positive samples , the single lactose positive colonies grown on the fourth area of the macconkey agar plates , suspected to be e. coli , were subjected to another culture on macconkey agar plates .
the pure cultures were further processed for dna preparation and screening by pcr ; so , they were isolated as the final colonies containing stx1 , stx2 and/or eaea .
all the pcr - positive strains were subjected to biochemical tests including triple sugar iron agar ( tsi ) , sulfide indole motility ( sim ) , citrate agar , and methyl red and voges - proskauer ( mrvp ) to confirm the identification of e. coli strains .
finally , the possible presence of o157:h7 in the isolated strains was investigated through pcr for the presence of rbfo157 and flich7 genes .
in addition to assessment of genotype diversity , a phenotypic analysis was implemented . for this purpose ,
the isolated strains were tested against seven groups of antibiotics ( himedia laboratories co. , india ) including amino - penicillin ( ampicillin ) , carbapenem ( imipenem ) , the first through fourth generations of cephalosporins ( cephalothin , ceftazidime , ceftriaxone , and cefepime ) , tetracycline , aminosides / aminoglycosides ( gentamicin , amikacin , kanamycin , streptomycin ) , phenicol ( chloramphenicol ) , and quinolones ( ciprofloxacin , norfloxacin ) , using the standard disk diffusion method ( 24 ) .
abbreviations : am , ampicillin ; an , amikacin ; c , chloramphenicol ; caz , ceftazidime ; cf , cephalothin ; cp , ciprofloxacin ; cro , ceftriaxone ; fep , cefepime ; gm , gentamicin ; imp , imipenem ; k , kanamycin ; nor , norfloxacin ; st , streptomycin ; tet , tetracyclin .
one hundred lettuce samples were collected weekly from various farm lands in tehran between june and september 2011 .
every sample was packed in a separate stomacher bag ( interscience , france ) and transported ( in ice ) to the laboratory , where they were immediately processed by a stomacher instrument ( bag mixer400 vw , interscience , france ) .
enrichment and processing of the samples were carried out according to previously described protocols ( 7 ) .
briefly , 25 g of each sample was homogenized by the stomacher in its bag containing 225 ml e. coli broth ( ec ) medium ( merck , germany ) , supplemented with 0.05 mg / l cefixime ( daana pharmaceutical co. , iran ) .
, a portion of the mixture was spread over a macconkey agar plate ( merck , germany ) and was further incubated at 37c overnight .
a sweep from the semi - confluent area of the plate was used for dna extraction for polymerase chain reaction ( pcr ) detection of stec .
the stec - positive samples were subjected to further isolation processes of stec , further pcr and antibiotic susceptibility tests .
prior to detection of the strains by pcr , the dna was extracted from the bacteria on the culture plates according to the previously described protocol with some modification ( 18 ) .
briefly , one heterogenic loopful of the grown bacteria from the first area of the macconkey agar plate was taken and homogenized in 25 l distilled water in a 1.5-ml microtube . the resulting suspension was placed in a boiling water bath at 100c for 10 minutes and centrifuged at 15000 rpm for five minutes in a microcentrifuge ( peqlab , germany ) .
the supernatant containing bacterial dna was transferred to a new tube and processed for pcr detection of the stx1 , stx2 and eaea genes .
the information related to the oligonucleotide primers ( faza biotech , iran ) are shown in table 1 .
the pcr was performed in a reaction volume containing 5 l of the extracted dna , 2.5 l pcr buffer ( 10x ) , 0.5 l deoxynucleoside 5-triphosphate , 0.5 l of each primer , 0.25 l taq dna polymerase 500 u ( 5 u/l ) , and 1.5 l mgcl2 ( 20 mm ) ( cinnagen co. , iran ) , adjusted to a total volume of 25 l with sterile deionized water .
the reaction was carried out by an amplification thermal cycler ( peqlab , germany ) . the procedure consisted of initial denaturation at 96c for minutes , followed by 32 cycles of template denaturation at 94c for 20 seconds .
the final cycle was followed by incubation of the reaction mixture at 72c for six minutes .
the results were compared with those of atcc standard strains of e. coli atcc 43890 ( stx1 ) , e. coli atcc 43889 ( stx2 ) and e. coli atcc 43887 ( eaea ) .
after reculturing the pcr - positive samples , the single lactose positive colonies grown on the fourth area of the macconkey agar plates , suspected to be e. coli , were subjected to another culture on macconkey agar plates .
the pure cultures were further processed for dna preparation and screening by pcr ; so , they were isolated as the final colonies containing stx1 , stx2 and/or eaea .
all the pcr - positive strains were subjected to biochemical tests including triple sugar iron agar ( tsi ) , sulfide indole motility ( sim ) , citrate agar , and methyl red and voges - proskauer ( mrvp ) to confirm the identification of e. coli strains .
finally , the possible presence of o157:h7 in the isolated strains was investigated through pcr for the presence of rbfo157 and flich7 genes .
in addition to assessment of genotype diversity , a phenotypic analysis was implemented . for this purpose ,
the isolated strains were tested against seven groups of antibiotics ( himedia laboratories co. , india ) including amino - penicillin ( ampicillin ) , carbapenem ( imipenem ) , the first through fourth generations of cephalosporins ( cephalothin , ceftazidime , ceftriaxone , and cefepime ) , tetracycline , aminosides / aminoglycosides ( gentamicin , amikacin , kanamycin , streptomycin ) , phenicol ( chloramphenicol ) , and quinolones ( ciprofloxacin , norfloxacin ) , using the standard disk diffusion method ( 24 ) .
abbreviations : am , ampicillin ; an , amikacin ; c , chloramphenicol ; caz , ceftazidime ; cf , cephalothin ; cp , ciprofloxacin ; cro , ceftriaxone ; fep , cefepime ; gm , gentamicin ; imp , imipenem ; k , kanamycin ; nor , norfloxacin ; st , streptomycin ; tet , tetracyclin .
among the 100 lettuce samples investigated , 8 ( 8% ) were positive for presence of the stx1 and stx2 genes and were defined as stec . of the eight stec strains , three specimens contained stx1 and five
contained stx2 , of which , one sample was positive for the presence of both rbfo157 and flich7 .
all the positive samples were isolated from the samples collected from the southern farm lands in the warmer ( the second ) half of summer .
the pcr screening analyses for detection of the eaea gene were negative for these stec strains .
the agarose gel images of the pcr products for stx1 , stx2 , rbfo157 and flich7 are shown in figures 1 , 2 , 3 and 4 . 1 , standard ; 2 and 3 , positive samples for the stx1 gene ( 130 bp ) ; 4 , dna ladder ( 100 bp ) . 1 , standard ; 2 and 3 , positive samples for the stx2 ( 294 bp ) gene ; 4 , dna leader ( 100 bp ) .
1 , positive sample for the flich7 gene ( 654 bp ) ; 2 , positive sample for the rbfo157 gene ( 497 bp ) ; 3 , positive sample for the eaea gene ( 890 bp ) ; 4 , dna ladder ( 100 bp ) .
2 , stx1 ( 130 bp ) ; 3 , stx2 ( 294 bp ) ; 4 , rbfo157 ( 497 bp ) ; 5 , flich7 ( 645 bp ) ; 1 and 6 , dna ladder ( 100 bp ) .
the two independent susceptibility tests implemented revealed that the isolates were susceptible to all the antibiotics except for tetracycline and ampicillin .
abbreviations : am , ampicillin ; an : amikacin ; c , chloramphenicol ; caz , ceftazidime ; cf , cephalothin ; cp , ciprofloxacin ; cro , ceftriaxone ; fep , cefepime ; gm , gentamicin ; imp , imipenem ; k , kanamycin ; nor , norfloxacin ; st , streptomycin ; tet , tetracyclin .
among the 100 lettuce samples investigated , 8 ( 8% ) were positive for presence of the stx1 and stx2 genes and were defined as stec . of the eight stec strains , three specimens contained stx1 and five
contained stx2 , of which , one sample was positive for the presence of both rbfo157 and flich7 .
all the positive samples were isolated from the samples collected from the southern farm lands in the warmer ( the second ) half of summer .
the pcr screening analyses for detection of the eaea gene were negative for these stec strains .
the agarose gel images of the pcr products for stx1 , stx2 , rbfo157 and flich7 are shown in figures 1 , 2 , 3 and 4 . 1 , standard ; 2 and 3 , positive samples for the stx1 gene ( 130 bp ) ; 4 , dna ladder ( 100 bp ) . 1 , standard ; 2 and 3 , positive samples for the stx2 ( 294 bp ) gene ; 4 , dna leader ( 100 bp ) .
1 , positive sample for the flich7 gene ( 654 bp ) ; 2 , positive sample for the rbfo157 gene ( 497 bp ) ; 3 , positive sample for the eaea gene ( 890 bp ) ; 4 , dna ladder ( 100 bp ) .
2 , stx1 ( 130 bp ) ; 3 , stx2 ( 294 bp ) ; 4 , rbfo157 ( 497 bp ) ; 5 , flich7 ( 645 bp ) ; 1 and 6 , dna ladder ( 100 bp ) .
the two independent susceptibility tests implemented revealed that the isolates were susceptible to all the antibiotics except for tetracycline and ampicillin .
abbreviations : am , ampicillin ; an : amikacin ; c , chloramphenicol ; caz , ceftazidime ; cf , cephalothin ; cp , ciprofloxacin ; cro , ceftriaxone ; fep , cefepime ; gm , gentamicin ; imp , imipenem ; k , kanamycin ; nor , norfloxacin ; st , streptomycin ; tet , tetracyclin .
as the highest prevalence of e. coli bacteria can be observed in summer , all the samples were collected during this season .
assessment of the 100 lettuce samples purchased from the farm lands in tehran indicated that 8% of the samples were contaminated with stec strains .
this was the first study providing an evidence for contamination of lettuce samples by stec strains in tehran , the capital of iran .
the samples were put in e. coli broth medium supplemented with cefixime and then incubated at 37c for 24 hours for proliferation of the pertinent bacteria .
this enrichment is critical as the bacteria are stressed under sampling and transformation conditions . besides
, the use of cefixime and the favored environment of the broth allow the growth of particular types of bacteria .
isolation of the strains of interest was made by pcr as a fast , convenient , and highly precise method .
moreover , it was a proper choice because several types of bacteria were present in these samples .
detection of both stx1 and stx2 genes along with one o157:h7 strain confirmed the effectiveness of the pcr analysis protocol used in this study .
the advantage of this pcr screening method was its remarkable potential for detection of stec strains in a complex mixture before any purification and obtaining of the isolated colonies .
the applied colony screening enabled a reliable assessment of antibiotic resistance and sensitivity because all the impurities and interactions caused by unwanted strains can be excluded by this procedure .
several investigators have assessed the epidemiology of stec strains in both developed and developing countries ( 20 , 21 , 23 - 30 ) .
the results obtained in those studies have revealed that overall , consumption of some raw vegetables and food such as hamburger and apple juice could be the plausible sources of stec strains . in most of the cases ,
however , the consumption of raw vegetables such as lettuce has been indicated as the principal source of stec strains ( 24 , 25 ) .
we have previously studied the frequency of stec strains in parsley and leek samples collected from tehran , where we found that 25% of the samples contained stec strains , of which 1% was o157:h7 ( 31 ) .
the isolation rate of stec in the lettuce samples in the present study was lower than that of the parsley and leek .
this low isolation rate may be ascribed to the presence of a higher number of other microbial species or e. coli strains in the lettuce samples in addition to stec strains .
it may also be due to the sampling mode , as higher rates of stec could be obtained if more than one geographical area was used for sampling .
indeed , the relatively low rates of stec strains in these samples could be ascribed to the official health protection policies enforced in this area , regarding the prohibitive legislations and monitoring on the utilization of municipal or industrial waste waters as well as urging the use of chemical fertilizers instead of natural fertilizers .
in addition , our positive samples were originated from the farm lands where a wider use of bovine manure was applied for soil nourishment and use of sewages was also applied for watering in some cases .
the isolation of one o157:h7
e. coli strain in the present study ( 1% of all the samples ) suggested that this strain survived well in the unfavorable natural conditions of the lettuce samples along with a mixture of other microbial species .
similar studies , conducted in ireland and norway , have shown no positive results on detection of o157:h7 strain in local lettuce samples ( 15 - 17 ) . using a pcr primer conceived for the eae gene detection ( 21 ) ,
the presence of various eae genes among stec strains encoding the intimin types and subtypes have been demonstrated earlier ( 26 , 27 ) .
hence , the negative result of this work upon analysis for this strain while testing only one pair of primers may also be related to the variability of the eae genes among e. coli strains .
stec strains isolated in this investigation were all resistant to tetracycline and ampicillin , a finding in accordance with earlier studies performed in iran ( 28 , 29 ) .
for example , fazeli and salehi reported that 85.6% of their isolates showed resistance to tetracycline ( 28 ) .
jafari et al . also noted a high rate of resistance to amoxicillin and tetracycline among stec strains with an observed 5% multi - resistance to more than six antibiotics ( 29 ) . in other areas such as romania and india , resistance to ampicillin and both ampicillin and tetracycline has also been reported ( 30 , 32 ) .
the presence of multi - resistance among the stec strains isolated from lettuce may be important from the standpoint of transferring the resistant genes to the human microflora , because multidrug resistance may easily be transferred via the mobile genetic elements of e. coli strains ( 33 ) . as a conclusion , the results of this investigation indicated the possible role of lettuce samples in transmission of stec strains .
it also suggested the presence and/or increase of antibiotic resistance genes among stec strains isolated in iran . | background : during the last decade , the prevalence of foodborne diseases due to contaminated food as well as the outbreaks of diseases due to shiga toxin - producing escherichia
coli ( stec ) strains has increased.objectives:the aim of this study was to evaluate the prevalence and antibiotic resistance pattern of stec strains in lettuce samples .
since lettuce is used as a raw vegetable in salads , the rates of infections caused by this vegetable are high.materials and methods : a total of 100 samples collected from tehran , iran , were transported to the laboratory , homogenized by a stomacher in e. coli broth containing cefixime , and cultured on macconkey agar medium .
their dna was extracted by boiling method and polymerase chain reaction ( pcr ) was performed , using five primers targeting the stx1 , stx2 , flich7 , rbfo157 , and eaea genes .
susceptibility testing against ampicillin , imipenem , cephalosporin , tetracycline , aminoglycosides , chloramphenicol and quinolones was performed using disk diffusion method.results:eight samples were positive for presence of stec strains , three contained stx1 , five contained stx2 , and one sample was positive for presence of both rbfo157 and flich7 . they were susceptible to all the antibiotics except for ampicillin and tetracycline.conclusions:this study indicated the contamination of lettuce by stec strains and its possible role as the source of infection
. resistance to both tetracycline and ampicillin may be considered as an emergency alarm for a multidrug resistance of stec strains . |
solubility of a drug is an important property that mainly influences the extent of oral bioavailability .
enhancement of oral bioavailability of poorly water soluble drugs is the most challenging aspect of drug development .
most of the new chemical entities suffer from low bioavailability due to their low aqueous solubility and dissolution .
therefore , it is very important to find appropriate formulation approaches to improve aqueous solubility and bioavailability of poorly aqueous soluble drugs .
raloxifene ( marketed as evista by eli lilly and company ) is an oral second generation selective estrogen receptor modulator ( serm ) used to prevent osteoporosis in postmenopausal women .
it is 2-(4-hydroxyphenyl)-3-({4-[2-(piperidin-1-yl ) ethoxy ] phenyl } carbonyl)-1-benzothiophen-6-ol that has estrogenic actions on bone and antiestrogenic actions on the uterus and breast .
it belongs to class ii drug according to biopharmaceutical classification system ( bcs ) , that is , low solubility and high permeability .
but raloxifene has very less bioavailability , only 2% , and it would be advantageous to increase the solubility of such molecule .
the drug is poorly absorbed from the gastrointestinal ( gi ) tract therefore ; it is important to enhance aqueous solubility and dissolution rate which may lead to enhancement of bioavailability from its oral solid dosage forms . in this study ,
the first one is complexation of drugs with cyclodextrin , and the second one is cogrinding with natural polymers .
cyclodextrins ( cds ) are cyclic macromolecules , obtained by the degradation of starch by -1,4-glucan - glycosyl transferase .
they have also been used to improve drug stability , bioavailability , or toxicity profiles . moreover , chemically modified cyclodextrins have been extensively used . among the chemically modified cyclodextrins
, 2-hydroxypropyl--cyclodextrin ( hp--cd ) deserves special attention due to its favorable physicochemical and biological properties .
kneading method was employed for the preparation of raloxifene hcl with hpcd , and the effect of complexation on the solubility and dissolution rate of raloxifene was evaluated . in the second approach , cogrinding of raloxifene hcl with modified guar gum was done .
guar gum ( gg ) is a gum obtained from the ground endosperms of cyamopsis tetragonolobus ( leguminosae family ) .
the natural polymers have surfactant activity that enhances the solubility and dissolution rate of drug , but high viscosity of these polymers is a limitation for them to be used as carriers for dissolution enhancement ; this problem is overcome by heating of the polymers at particular time and temperature condition which reduces the viscosity .
the present study was carried out to investigate the inclusion complex of raloxifene hcl and hpcd in the solid state and the rlx - mgg cogrind mixture using x - ray diffractometry ( xrd ) differential scanning calorimetry ( dsc ) , fourier transform infrared spectroscopy ( ftir ) , and scanning electron microscopy ( sem ) .
the objective of this study was to enhance solubility and dissolution rate of rlx which may lead to enhancement of bioavailability of this drug [ 1 , 8 , 9 ] .
raloxifene ( rlx ) was obtained as a gift sample from zydus cadila healthcare ltd . ,
hpcd was gifted by roquette pharma , france and , guar gum ( gg ) was gifted by lucid colloids ltd . ,
raloxifene hcl is practically insoluble in water , an inclusion complex of the antiosteoporotic raloxifene hcl ( rlx ) in hydroxypropyl--cyclodextrin ( hpcd ) was prepared and characterized .
the mixture of rlx and hpcd in 1 : 1 molar ratio was triturated in a mortar with a small volume of water - methanol ( 1 : 2 v / v ) solution .
the thick slurry formed was kneaded for 45 min and then dried at 45c .
powdered gum was taken in a porcelain bowl and kept in hot air oven at different temperatures and different time intervals .
the viscosity and swelling index were studied , which reveals that viscosity decreases as the time and temperature of heating increases but swelling index remains unaffected .
it was observed that guar gum produced colour change on heating above 130c and 120c more than 2 hrs respectively .
characterization of polymers
swelling index ( si ) [ 1 , 9 , 11 ] . about 1 gm of gg and mgg were accurately weighed and transferred to 100 ml measuring cylinder .
the initial volume of powder in measuring cylinder was noted which is denoted as x0 .
distilled water was added in measuring cylinder up to 100 ml mark , shaken gently , and cylinder was kept aside for 24 hrs . the final volume occupied by polymers
swelling index was calculated according to the following equation :
( 1)si = xtx0x0 100 .
1% ( w / v ) solution was prepared in distilled water and used for measuring the viscosity .
cogrind mixtures of drug and modified gum were prepared in different ratio such as 1 : 1 to 1 : 9 .
the ratio was optimized by using solubility data . the sample of drug and gum in 1 : 1 w / w ratio was cogrinded for 25 min , in ceramic mortar and sieved through mesh no
the cogrind mixture of rlx with mgg and gg denoted as rlx - mgg and rlx - gg , respectively .
samples were placed in 10 ml solvent ( ph 7 phosphate buffer ) in teflon facing screw capped vial and kept at equilibrium for a period of 24 hrs on orbital shaking incubator ( remi instruments ltd . ) at 37 0.5c and 50 rpm .
the contents of vials were filtered through 0.2 micron filter and analyzed by uv - visible spectrophotometer ( uv 1601 , shimadzu ) at 287 nm .
as shown in table 3 , the solubility increases as the gum concentration increases , the optimized ratio was found to be 1 : 8 w / w as further increase in ratio to 1 : 9 w / w showed no significant increase in solubility of drug .
cogrinding mixtures of rlx with mgg and gg were prepared in 1 : 8 w / w ratio .
dsc studies of raloxifene hcl , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were performed using differential scanning calorimeter ( mettler toledo dsc 1 star system , zurich , switzerland ) at heating rate of 10c / min from 40 to 340c in nitrogen atmosphere .
powder xrd patterns of raloxifene hcl , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were recorded using diffractogram ( bruker axs , d8 advance , germany ) and cu - k radiation .
diffractogram was run at a scanning speed of 2/min and a chart speed of 2/2 cm per 2.
fourier transform infrared spectroscopy ( ft - ir ) .
raloxifene hcl , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were mixed separately with ir grade kbr in the ratio of 1 : 100 , and corresponding pellets were prepared by applying 10 metric ton of pressure in hydraulic press .
the pellets were then scanned over a wave range of 4000400 cm in ftir instrument ( 8400 s shimadzu ) .
the sem photographs of raloxifene hcl , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were obtained by scanning electron microscope ( jsm 6390lv , jeol model , japan ) with 10 kv accelerating voltage .
dsc studies of raloxifene hcl , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were performed using differential scanning calorimeter ( mettler toledo dsc 1 star system , zurich , switzerland ) at heating rate of 10c / min from 40 to 340c in nitrogen atmosphere .
powder xrd patterns of raloxifene hcl , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were recorded using diffractogram ( bruker axs , d8 advance , germany ) and cu - k radiation .
diffractogram was run at a scanning speed of 2/min and a chart speed of 2/2 cm per 2.
fourier transform infrared spectroscopy ( ft - ir ) .
raloxifene hcl , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were mixed separately with ir grade kbr in the ratio of 1 : 100 , and corresponding pellets were prepared by applying 10 metric ton of pressure in hydraulic press .
the pellets were then scanned over a wave range of 4000400 cm in ftir instrument ( 8400 s shimadzu ) .
the sem photographs of raloxifene hcl , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were obtained by scanning electron microscope ( jsm 6390lv , jeol model , japan ) with 10 kv accelerating voltage .
the phase solubility technique permits the evaluation of the affinity between hpcd and raloxifene in water .
phase solubility studies were performed according to the method reported by higuchi and connors . as given in table 1 ,
raloxifene was taken into vials in an excess amount , and 20 ml of distilled water was added , containing various concentration of hpcd ( 1040 mmol ) .
these vials were sealed and shaken at 20c for 4 days . this period was considered sufficient to reach equilibrium .
subsequently , the aliquots were withdrawn , using a syringe , and samples were filtered through 0.2 micron filter and appropriately diluted .
a portion of the sample was analyzed by uv spectrophotometer ( uv 1601 , shimadzu ) at 287 nm against blank prepared in the same concentration of hpcd in water so as to cancel any absorbance that may be exhibited by the hpcd .
the apparent stability constant ( kc ) of complexes was calculated from the phase solubility diagram using the following equation :
( 2)kc = slopes0(1slope ) .
the slope obtained from the initial straight line portion of the plot of raloxifene concentration against hpcd concentration , and s0 is the equilibrium solubility of raloxifene in water .
the solubility of rlx , rlx - gg and rlx - mgg were determined in distilled water , 1.2 ph hcl buffer , and 7.0 ph buffer .
the solubility of drug and cogrinding mixtures were determined by taking an excess amount 30 mg of drug and the cogrind mixture equivalent to 30 mg of drug , was added in 10 ml of the previous solvents , in teflon facing screw capped vials .
the samples were kept at equilibrium for a period of 48 hrs on orbital shaking incubator at 37 0.5c and 50 rpm .
the contents of vials were filtered through 0.2 micron filter and analyzed by uv - visible spectrophotometer ( uv 1601 , shimadzu ) at 287 nm .
dissolution rates from rlx , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture were determined in 900 ml of ph 6.8 phosphate buffer at 37 0.5c with a stirrer rotation speed of 75 rpm using the usp dissolution test apparatus type ii ( paddle type ) ( tdt 08l - electrolab , mumbai , india ) .
rlx - hpcd inclusion complex and rlx - mgg cogrind mixture were taken equivalent to 100 mg of rlx .
an aliquot of 5 ml of sample was withdrawn at 5 , 10 , 15 , 30 , 45 , 60 , 90 , 105 , and 120 min with a pipette .
the samples were filtered through 0.2 micron filter , suitably diluted and assayed spectrophotometrically at 287 nm .
each dissolution rate test was repeated three times . as a model independent approach , dissolution efficiency ( de )
de is defined as the area under the dissolution curve up to the time t , expressed as a percentage of the area of the rectangle described by 100% dissolution in the same time .
differences between the two related parameters were considered statistically significant for p values for less than 0.05 .
drug to polymer optimization ratio , solubility determination , and dissolution efficiency results were analyzed by applying one way anova test .
cyclodextrin ( cd ) has a hydrophobic central cavity and hydrophilic outer surface and can encapsulate model substrates to form host - guest complexes or supramolecular species .
this usually enhances drug solubility in aqueous solution and affects the chemical characteristics of the encapsulated drug .
hpcd is a hydroxyalkylated--cyclodextrin derivative that combines relatively high water solubility with low toxicity and satisfactory inclusion ability .
the binding behavior of hydroxypropyl--cyclodextrin with rlx and the solubilization effect of hpcd toward rlx may provide a useful approach to produce a novel rlx formulation with improved bioavailability .
the natural polymers are mainly evaluated in industry for their new applications . due to the less toxic effect and low production cost , these polymers mainly used as drug carrier in pharmaceutical industry .
guar gum has surfactant activity , which reduces the contact angle and increases wetting of drug particles , thus enhances solubilization and dissolution of drug particles .
these polymers produce gel layer on the hydrated surfaces which prevents the drug release during drug dissolution and reduced the dissolution .
it is reported that the swelling of polymers influences improvement of dissolution rate of poorly aqueous soluble drugs .
therefore , it is useful to modify the gum in such a way that its swelling ability remains the same and decreases the viscosity .
the result indicates that the viscosity of mgg is lower than that of the gg , and swelling index of mgg was not reduced significantly than the gg .
because of swelling nature of the carrier , the extensive surface was increased during the dissolution and thus dissolution rate of drug was enhanced . as shown in figure 1 , the thermograms of the rlx , hpcd , and mgg showed respective endothermic peaks at 266.44c , 97.46c and 64.95c corresponding to their melting points .
in the thermogram of rlx - hpcd complex , the peak of drug disappeared indicating the complexation of rlx with cyclodextrin , whereas in dsc spectra of rlx - mgg cogrind mixture , the peak of drug was observed , but the intensity was reduced suggesting the conversion of raloxifene hydrochloride from crystalline form to amorphous form . as shown in figure 2 ,
the x - ray diffraction patterns were recorded for pure rlx , hpcd , mgg , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture .
pxrd studies were performed in conjunction with dsc to verify the reduction of crystallinity of rlx .
diffraction spectrum of drug sample showed distinct peaks at 2 of 12.812 , 14.47 , 15.784 , 19.153 , 22.682 , and 25.876. all these peaks , though of relatively lesser intensity , were observed to be in rlx - hpcd complex and rlx - mgg cogrind mixture .
as shown in figure 3 , ft - ir spectra of rlx exhibited characteristic peaks at 1,642.44 ( c = o stretching ) , 1,596.15 ( c o
c stretching ) , 1,466.91 ( s benzothiofuran ) , and 905.61 cm ( benzene ring ) .
they were well preserved in the rlx - hpcd complex and rlx - mgg cogrind mixture .
as shown in figure 4 , the scanning electron microscopy photomicrographs of rlx shown in figure 4 show the longer crystals with very specific morphology , whereas for rlx - hpcd complex and rlx - mgg cogrind mixture , a decrease in crystallinity due to formation of drug - cyclodextrin complex and molecular dispersion of rlx in the polymer matrix ( mgg ) was observed , respectively .
the phase solubility diagram for the complex formation between rlx and hpcd is shown in figure 5 .
the aqueous solubility of rlx increased linearly with a slope 0.3083 ( r = 0.9926 ) as a function of hpcd concentration .
the apparent solubility constant kc , obtained from the slope of the linear phase solubility diagram was found to be 4.5949 mol .
solubility data for rlx , rlx - gg and rlx - mgg in different solvents are given in table 4 .
anova ( p < 0.05 ) performed on solubility parameter demonstrated significant difference between solubility of rlx , rlx - gg and rlx - mgg cogrinding mixtures .
cogrinding mixture of rlx - mgg showed slight better results than rlx - gg ; therefore rlx - mgg was selected for further studies .
but there was significant difference between solubility of rlx - hpcd inclusion complex and cogrinding mixtures .
figure 6 represents in vitro dissolution profiles of rlx , rlx - hpcd inclusion complex , and rlx - mgg cogrind mixture .
table 5 summarizes % drug release from the rlx - hpcd inclusion complex and rlx - mgg cogrind mixture at 60 and 120 min . from table 5
, we can conclude that maximum enhancement in dissolution rate up to 84.47% 0.84% is shown by rlx - hpcd inclusion complex as compared to that of 51.30 0.57% by rlx - mgg cogrind mixture at 120 min .
the results of the statistical analysis ( anova ) suggest significant enhancement of dissolution rate of rlx from rlx - hpcd inclusion complex at all the time points ( p < 0.05 ) when compared with plain rlx and rlx - mgg cogrind mixture .
the molecular structure of cyclodextrin creates a bucket - like cavity that can function to complex with drug or functional groups on drug .
the investigation suggests from phase solubility study and dissolution rate profile of the inclusion complex that the solubility and dissolution rate of raloxifene increases significantly due to hpcd .
whereas , the cogrinding method enhances the solubility of rlx by converting it to amorphous form , reducing the particle size and increasing wettability .
the optimum ratio for cogrinding mixture was found to be 1 : 8 which shows higher solubility . moreover , this natural polymer like guar gum has advantage over other synthetic polymers as these polymers are biocompatible , biodegradable , and having low cost .
hence , from practical point of view , cogrinding method appeared easier and was considered as the most convenient method .
but when both these techniques were compared the inclusion complex method showed better results as compared to those of the other methods and thus was found to be more effective than cogrinding method . | the objective of the present work was to enhance the solubility and dissolution of practically water - insoluble drug raloxifene hcl ( rlx ) , for the same two approaches that were used .
in the first approach , drug was kneaded with hydroxypropyl--cyclodextrin ( hpcd ) , and in the second one drug was cogrinded with modified guar gum ( mgg ) .
the drug - cyclodextrin complex and drug - mgg cogrind mixtures were characterized by differential scanning calorimetry , x - ray diffraction studies , scanning electron microscopy , and fourier transform infrared spectroscopy . the solubility and dissolution study reveals that solubility and dissolution rate of rlx remarkably increased in both methods .
it was concluded that the prepared inclusion complex showed a remarkable increase in solubility and dissolution of poorly water - soluble drug raloxifene . in the cogrinding mixture
, a natural modified gum is used as a surfactant and enhances the solubility and dissolution of rlx without requiring addition of organic solvent or high temperature for its preparation ; thus , process is less cumbersome and cost effective .
but when both methods were compared ; hpcd complexation method showed significant enhancement of drug solubility . |
trauma is still one of the leading causes of death among people aged 45 and younger .
the annual economic burden of direct and indirect costs in germany alone is estimated to be around 40 billion euros annually . due to the heterogeneity of trauma , complex injury patterns , and broad variability of therapeutic options ,
it is an enormous challenge to collect valid data in prospective or retrospective studies concerning posttraumatic pathophysiological changes and possible treatment options . of all polytraumatized patients 86%
sustain an injury to the extremities , 69% to the head , and 62% to the chest . in this regard ,
the effects of a combined injury on the patient are not comparable to that after isolated trauma .
indicated that mortality rises from 7% to 18% when an additional trauma to the chest is present .
musculoskeletal trauma induces the systemic release of diverse danger molecules damps ( danger - associated molecular patterns ) which lead to a pronounced early immunological and inflammatory response .
the release of these damps is a tremendous challenge for the immune system in severe trauma as explained by the danger model of the immune system ( danger sensing , transmission , response , elimination ) [ 3 , 5 ] . as a consequence of the injury severity and the immune status of the patients
, the posttraumatic inflammatory response often results in an overindulging and uncontrolled activation of the complement system with an increased release of proinflammatory mediators often resulting in multiple organ dysfunction and death . in this
regard , il-6 has been shown to be elevated at the scene of injury and a positive correlation between these il-6 levels , the severity of the injury and the increased rate of complications including enhanced mortality has been demonstrated [ 7 , 8 ] .
in addition , increased systemic levels of the anaphylatoxins c3a and c5a in severe polytraumatized patients seem to be correlated with a higher risk of sepsis and a poor clinical outcome [ 6 , 9 ] .
however , up to date , little is still known about the immune response after severe polytrauma on a cellular and molecular basis . in particular , it is still unclear whether the early immune response is qualitatively or quantitatively different after severe polytrauma compared to an isolated injury .
furthermore , there is a lack of pathophysiology - based therapeutic remedies for polytrauma patients to prevent posttraumatic immunosuppression .
therefore , highly standardized experimental polytrauma models are required to define the early complex pathophysiology of severe combined trauma and to examine novel surgical or immunomodulatory treatment options . in this study
, we describe a new polytrauma model in rats and characterize the early systemic and local inflammatory response accompanied by a rapid activation of the complement system similar to that seen in humans .
the study protocol was approved by the university animal care committee and the federal authorities for animal research , tuebingen , germany .
the experiments were performed in adherence to the national institutes of health guidelines for the use of laboratory animals including a total of 352 male wistar rats ( 250 g , 1012 weeks , jackson laboratories , bar harbour ) .
anaesthesia was applied i.p . using 75 mg / kg ketamin ( ketavet , pfizer pharma , karlsruhe , germany ) and 0.4 mg / kg kg medetomidine i.p .
animals which underwent blunt chest trauma were anesthetized with a mixture of 4% sevoflurane ( sevorane abbott , wiesbaden , germany ) and 96% oxygen under a continuous flow of 2 l / min and received the aforementioned i.p anesthesia after the chest trauma .
the rats were randomly assigned to the different trauma groups ( each n = 610 ) .
narcotized rats underwent either a sham operation ( sham ) , a blunt bilateral chest trauma ( cht ) , a blunt bilateral chest trauma and a lower leg ( tibia / fibula ) fracture with a contra - lateral soft tissue trauma ( cht + fx + stt ) , a closed head injury ( chi ) , a bilateral blunt chest trauma and a head injury ( cht + chi ) , or a combination of chest trauma , head trauma , fracture , and soft tissue trauma referred to as polytrauma ( pt ) .
sham animals were anesthetized rats with an incision and surgical closure of the aponeurotic galea .
all animals were placed on a heating pad after undergoing the surgical procedures . continuous reflex status and vital signs of all animals were checked .
animals subjected to the blunt bilateral chest trauma were narcotized and fixed in a supine position .
the trauma was induced by a single blast wave as previously described [ 1012 ] .
the traumatic brain injury was induced by a weight drop device inducing a focused blunt injury over an intact skull after 1.5 cm incision of the aponeurotic galea as described in detail elsewhere [ 13 , 14 ] .
after trauma , the incision was closed by a monofil suture . for the right side tibia / fibula fracture a weight drop device
( 650 g , 13 cm ) induced a reproducible closed transverse fracture of the lower leg , as reported in the past . on the contra - lateral gastrocnemic region a soft tissue injury was applied using a weight drop device ( 170 g , 180 cm ) as previously described .
waking the animals after trauma was strictly avoided and anaesthesia was deepened with repeated i.p .
after 2 hrs or 4 hrs , respectively , all rats were sacrificed and the blood and organs harvested .
whole blood was spun at 500 g at 4c for 10 min , the serum stored at 80c until final analysis .
after death the trachea was dissected and cannulated , the left lung clamped , and the right lung flushed 3 times with 5 ml pbs including 1 : 1000 broad spectrum protease inhibitor ( sigma - aldrich , st .
the bal fluids were then centrifuged 450 g at ( 4c ) for 10 min and stored at ( 80c ) until analysis . left lung tissue was filled with formalin after bal was taken and immediately stored in 10% formalin until evaluation .
interleukin ( il)-6 , tumor necrosis factor ( tnf)- , complement anaphylatoxin 3a ( c3a ) , monocyte chemoattractant protein ( mcp)-1 ( all bd opteia elisa set , bd pharmingen , san diego , ca ) , and cytokine - induced neutrophil chemoattractant ( cinc ) ( r&d , minneapolis , mn , usa ) concentrations of bal - fluids were determined by sandwich - enzyme - linked immunosorbent assay technique ( elisa ) according to the manufacturer 's recommendation . in serum , il-6 , tnf- , and cinc were detected .
a dilution series of the samples was made ( 1/201/480 ) using tris - buffered saline ( tbs ) and the diluted samples were incubated for 60 min at 37c with sheep erythrocytes ( colorado serum company , denver , co , usa ) . the hemolytic complement system reaction was stopped using ice - cold tbs and centrifugation at 700 g for 5 min .
edta whole blood ( 100 l ) was incubated with indicated fitc- or pe - labelled fluorochrome - conjugated monoclonal antibodies at room temperature for 20 min in the dark .
immediately after the incubation period , 2 ml of facs lysing solution ( bd biosciences ) was added to each tube , followed by incubation for 10 min at room temperature in the dark .
after centrifugation , the supernatant was removed , and 2 ml of dulbecco phosphate - buffered saline ( dpbs ) per tube was added , followed by an additional centrifugation step . after a second washing step , the cell pellet was resuspended in 100 l of cellfix solution ( bd biosciences ) for final flow cytometric analysis .
leukocyte populations ( neutrophils , monocytes , and lymphocytes ) were discriminated by forward / sideward scatter and additional cd45 staining . for each measurement
for quantification of c3ar and cregs ( cd35 , cd55 , and cd59 ) expression , mean fluorescence intensity ( mfi ) emitted by the fitc- or pe - conjugated antibodies was calculated by subtracting the corresponding isotype control .
formalin - fixed lung tissue was dehydrated using ethanol , dissolved with xylol and embedded in paraffin .
sections of 1 m were prepared followed by h&e staining . following that a semiquantitative analysis of the sections including a cell count was performed .
polymorphonuclear neutrophils ( pmns ) were isolated using ficoll - paque ( pharmacia biotech , stockholm , sweden ) gradient centrifugation ( 340 g , 30 min , room temperature ) .
the use of this technique may be responsible for some artificial activation of cells in vivo . for neutrophil isolation , red blood cells ( rbcs )
neutrophils were resuspended in dpbs and finally diluted at 2 mio cells per ml .
1 ml aliquots of pmns were centrifuged at 800 g for 5 min , supernatants were removed , and cells were resuspended in 100 l of pharmigen cell lysis buffer ( bd biosciences ) .
after 30 min of incubation on ice , samples were pelleted ( 16000 g , 5 min , 4c ) and supernatants were frozen at 80c .
a one - way analysis of variance ( anova ) followed by the student - newman - keuls test as a post hoc test for multiple comparisons was performed to determine significant differences between experimental means .
the blood gas analysis ( 2 and 4 hrs after injury ) was indicative of stable hemoglobin ( hb ) and hematocrit ( hct ) values in this polytrauma model .
the hb values did not significantly differ in sham and pt animals ( sham 2 h 16.5 0.4 g / dl versus pt 2 h 16.2 0.4 g / dl sham 4 h 16.5 0.32 g / dl versus pt 4 h 15.4 0.4 g / dl ; data not shown ) .
the po2 levels stated no hypoxic state in the anaesthetized animals ( sham 4 h 87.7 2.0 mmhg versus pt 4 h 90.0 3.6 mmhg , data not shown ) . as early as 2 hrs after injury , systemic il-6 levels
however , 4 hrs after polytrauma there was a significant increase in the il-6 concentrations ( figure 1(a ) ) .
similarly , cinc serum concentrations were significantly enhanced in cht + fx + stt , cht + chi , and pt groups compared to the sham group 4 hrs after injury ( figure 1(b ) ) .
systemic tnf- levels were rather unchanged in all groups up to 4 hr after injury ( figure 1(c ) ) .
in addition to the systemic inflammatory response , the local inflammatory changes were investigated with focus on the lungs .
the local concentrations of il-6 in the bal fluids were increased in pt , cht + chi and cht rats 4 hrs after injury compared to sham - treated rats ( figure 2(a ) ) .
four hours after trauma , the local tnf- levels were increased in all trauma groups except chi alone ( figure 2(b ) ) .
cinc and mcp-1 levels in bal - fluids were significantly increased in all groups compared to sham and chi animals 4 hrs after injury ( figures 2(c ) and 2(d ) ) .
early morphological changes were assessed on h&e stained lung tissue sections analyzed with 20x magnification .
lung sections of the control animals showed physiological lung parenchyma identical to the morphology seen in the traumatic brain injury ( chi ) group .
after bilateral blunt chest trauma plentiful erythrocytes could be found intra - alveolar , intra - bronchial and sub - pleural .
in addition an increased number of alveolar macrophages , some damage to the alveolar wall and tissue edema were found .
similar qualitative morphological changes could be detected in pt - animals but all in a markedly aggravated intensity ( figure 3 ) .
the trauma - induced changes of the complement system were first screened by ch50 testing ( figure 4(a ) ) .
after 2 hrs there was a minimum decrease in ch50 values in the pt - group compared to the sham group , but after 4 hrs this difference reached statistically significance , indicating systemic complement activation . focusing on the central complement activation product c3a , bal - fluid levels of c3a were significantly increased in pt animals compared to sham animals 4 hrs after trauma ( figure 4(b ) ) .
the related c3ar revealed a significant loss of surface expression on neutrophils isolated 4 hrs after polytrauma , whereas the c3ar profile remained rather unchanged on monocytes and lymphocytes ( figure 4(c ) ) .
protectin , also known as cd59 , exhibited no difference in the expression on neutrophils after trauma ( figure 5 ) .
in contrast , complement receptor 1 ( cd35 ) was significantly decreased in pt animals versus sham rats ( figure 5 ) . a slight but insignificant decrease in expression of cd55
the clinical and molecular danger management after polytrauma is rather complex and often associated with fatal complications .
the aim of this study was to establish a highly standardized and reproducible rodent polytrauma model capable of closely mimicking the posttraumatic inflammatory response found in humans .
patients at the scene are dying mostly based on severe brain injury or massive blood loss following an injury to a large blood vessel . in contrast , mortality of patients in the hospital several days after major trauma is often associated with a severe systemic inflammatory response ( sirs ) and resulting systemic changes such as coagulopathy and complementopathy , breakdown of physiological barriers , impairment of the immune defense , and finally organ dysfunction and failure . the proinflammatory cytokines ( e.g. , il-6 , il-8 , etc . ) and
complement anaphylatoxins ( e.g. , c3a , c5a ) were experimentally and clinically proposed to be crucially involved in the early damage response after severe trauma and somehow indicative of the degree of tissue damage and clinical outcome [ 6 , 9 ] . in the cecal ligation and
puncture ( clp ) sepsis model in rodents , the complement activation product c5a has been shown to contribute significantly to the development and progression of the systemic inflammatory response .
furthermore , blockade of the c5a - c5ar interaction was associated with improved function on a molecular , cellular , and organ - level and finally resulted in a beneficial outcome [ 1820 ] .
however , it is rather unclear if a similar immune modulation would provide some advantageous effects in the setting of multiple injuries .
this needs to be investigated further using this new polytrauma model . in the context of the complexity of the polytrauma danger response and the lack of effective therapeutics in the early posttraumatic phase , it is somehow surprising , that despite highly effective anaesthesia protocols there is a worldwide lack of valid rodent models closely simulating multiple injuries of humans .
the single traumata used has been well established and are highly standardized and reproducible in rodents [ 1113 , 15 , 21 , 22 ] . upon adjustment to the combined injury application , this model provides the unique opportunity to study the impact of an individual trauma and different trauma combinations on the following immune response .
a lethality of up to 20% could be detected in this model which reflects the lethality of polytraumatized humans ( annual report of the german trauma register 2009 ) .
care has been taken to first design a hemodynamically stable polytrauma model to rule out hemorrhagic shock effects on the inflammatory response . according to sauaia
however , hemorrhage / shock as well as abdominal trauma certainly represents certainly a major trigger of the inflammatory response .
thus , pressure - controlled hemorrhage or clp may be included in this model in future studies to discriminate their contribution to the inflammatory response as well . the early systemic inflammatory response in the present multiple injury model
was reflected by enhanced serum levels of il-6 and cinc which are also enhanced in polytrauma patients [ 25 , 26 ] and somehow associated with the injury severity and predictive of the clinical outcome . in comparison to sham - treated animals ,
the systemic tnf- levels of pt littermates were rather unchanged in the early posttraumatic phase .
in contrast , tnf- levels in multiply injured patients were found to be increased early after trauma but rather irrelevant for the prediction of injury severity or outcome . in ex vivo experiments ,
even a decrease in tnf- levels in stimulated whole - blood samples from polytraumatized patients 24 hrs after trauma was reported in relation to healthy donor samples .
the local inflammatory polytrauma response with focus on the lungs as the engine of multi - organ dysfunction was reflected by increased concentrations in bal fluids of cytokines and chemokines early after trauma .
similar chemokine profiles have been reported for blunt chest trauma alone by our group . in the clinical setting of blunt chest trauma ,
there is a lack of data in bal - fluids but a distinct increase of these cytokines in whole blood with an overall correlation with lung injury severity [ 8 , 26 ] .
present histological analysis of polytraumatized rats revealed severe intra - alveolar , intrabronchial , and subpleural hemorrhage as well as the presence of interstitial oedema , atelectasis , and an increased amount of alveolar macrophages .
these changes have been described in experimental blunt chest trauma alone , but in pt animals an aggravation of the histological alterations is evident .
the pathophysiological reasons for this enhanced lung injury are rather speculative and might be due to the accompanied brain injury with subsequent disturbances of the neurohormonal - stress - inflammation axis or due to a specific mediator release by the fracture .
described that polytraumatized patients with systemically increased plasma levels of tnf- , il-8 , or il-10 are more likely to develop ards .
the complement response globally screened by ch50 changes was unaltered early after polytrauma . however , 4 hrs after multiple injuries , a decent but significant decrease in ch50 was observed .
it is noteworthy that already a reduction in ch50 by 10% can be considered as evidence of significant systemic complement activation .
these findings are supported by recent reports showing complement activation after major trauma in humans .
complement regulation after severe tissue trauma has been recently addressed by our group , describing a specific leukocyte expression profile of the complement regulatory proteins ( cregs ) cd55 , cd59 , and cd35 early after polytrauma . whereas cd59 and cd55 were rather unchanged , cd35 expression on neutrophils in the pt versus
the dynamic of creg expression beyond the 4 hr observational period remains to be seen .
however , based on the extremely heterogenous patient groups and the complexity of the pathophysiological reaction , the apoptotic response has been reported rather controversially in polytrauma patients [ 33 , 34 ] .
described during sepsis induced by clp a c5a - induced decrease of the neutrophil apoptosis rate along with increased levels of bcl - xl and decreased levels of bim . addressing the posttraumatic regulation of the reduced neutrophil apoptosis rate further mechanistic studies need to be performed in the present novel polytrauma model .
, 4 hrs maximum according to the animal care committee protocol , after injury the organisms may be incapable to building up the full inflammatory response especially in the absence of shock symptoms .
in addition , the applied traumata and early posttrauma phase occurred in deep anaesthesia , which certainly exclude an additional stress - load seen in reality . on a technical level , although performed within 7 min , the traumata could not be applied simultaneously as it usually occurs in reality .
the role of each single trauma on the pathophysiology of polytrauma leading to sirs , sepsis , and mof is still unknown .
the patient 's prognosis and the outcome mainly depends on the presence of the traumatic brain injury and the associated secondary brain damage . in summary , this study is to our knowledge the first to demonstrate very early inflammatory changes in a highly standardized , reproducible , hemodynamically stable polytrauma rodent model , mimicking most important injuries of polytraumatized patients excluding hemorrhagic shock .
the present polytrauma model may therefore represent the basis for further investigation of the pathophysiology of polytrauma and the evaluation of early therapeutic interventions . | background .
the molecular mechanisms of the immune response after polytrauma are highly complex and far from fully understood . in this paper , we characterize a new standardized polytrauma model in rats based on the early molecular inflammatory and apoptotic response . methods .
male wistar rats ( 250 g , 610/group ) were anesthetized and exposed to chest trauma ( cht ) , closed head injury ( chi ) , or tib / fib fracture including a soft tissue trauma ( fx + stt ) or to the following combination of injuries : ( 1 ) cht ; ( 2 ) cht + fx + stt ; ( 3 ) cht + chi ; ( 4 ) chi ; ( 5 ) polytrauma ( pt = cht + chi + fx + stt ) .
sham - operated rats served as negative controls .
the inflammatory response was quantified at 2 hours and 4 hours after trauma by analysis of key inflammatory mediators , including selected cytokines and complement components , in serum and bronchoalveolar ( bal ) fluid samples .
results .
polytraumatized ( pt ) rats showed a significant systemic and intrapulmonary release of cytokines , chemokines , and complement anaphylatoxins , compared to rats with isolated injuries or selected combinations of injuries .
conclusion .
this new rat model appears to closely mimic the early immunological response of polytrauma observed in humans and may provide a valid basis for evaluation of the complex pathophysiology and future therapeutic immune modulatory approaches in experimental polytrauma . |
emergency medical services ( ems ) providers constantly deal with situations associated with high stress and anxiety ( 1 ) . given the serious nature of burn injuries , dealing with burn emergencies
pre - hospital emergency teams and hospital staff face various problems , particularly in times of major burn emergencies , when victims are severely and extensively injured ( 3 ) . many pre - hospital emergency personnel describe missions of caring for burned patients a time of great anxiety ( 4 ) .
job stress can lead to significant physical and emotional issues for medical care providers ( 1 ) ; consequently , they may be easily affected by post - traumatic stress disorder ( 1 , 5 , 6 ) . as previous studies suggested , nearly 22% of medical emergency staff show symptoms of post - traumatic stress disorder ( 7 ) .
negative stressors affect the health of ems providers and compromise their ability to provide care for victims ( 8) . exceedingly high levels of anxiety may gradually result in job burnout ( 9 ) .
studies show that approximately 6.8% of emergency technicians are at risk of job burnout ( 10 ) .
one of the suitable strategies for improving mental health of ems staff is resilience ( 11 ) .
argue that resilience may reduce anxiety and depression and help individuals overcome the adverse effects of physical and emotional exhaustion ; moreover , it can help staff maintain their mental health ( 12 )
. therefore , resilience , as a coping strategy , can help ems personnel to deal with occupational challenges ( 13 ) .
considering lack of sufficient information about resilience of ems staff in face of burn injuries , the present study aimed to qualitatively assess resilience and its contributing factors among pre - hospital care providers , based on their perceptions and experiences of burn emergencies .
in the present study , a qualitative approach using latent content analysis was used to provide a condensed but comprehensive description of ems staff experiences ; the outcome was an overview of concepts and categories , describing the staff experiences .
data was collected with no a priori hypothesis and focused on obtaining interviewee s point of view .
afterwards , they were conceptually ordered considering their properties and dimensions ( 14 , 15 ) .
tehran , the capital and largest city of iran , has a population of 13 million ( 16 ) and is equipped with a large number of ems vehicles dispatched from a call center . in this study ,
18 interviews were conducted with experts and authorities in pre - hospital emergency system , ( including 12 emergency technicians , 1 emergency care support worker and 1 anesthesiology assistant and 4 nurses ) .
they were recruited by purposeful sampling method and included if had previous experience with burn injury patients .
diversity was observed by selecting subjects of various age groups with different education levels , working experiences and organizational roles .
the interview guide included general as well as more specific questions to direct the interview .
some examples of the questions are please talk about your experience of burn care
, what problems do you face during burn injury care ? and what do you do in face of burn accidents ? .
each interview lasted 40 - 60 minutes and conducted by the same interviewer ( in persian ) ; the interviews were transcribed verbatim and then translated into english .
all interviews were performed by the first author and audiotaped with the medical emergency staff consent .
the interviewer was an expert in qualitative research , trained in qualitative courses and workshops and had the experience of working in emergency burn units ( 18 years ) .
data collection , data analysis and participants selection continued until data saturation occurred and a rich description of medical emergency staff experiences was obtained . to analyze data ,
framework is an analytical process , which involves a number of distinct though highly interconnected stages ( 17 ) . in the first stage or familiarization stage , we transcribed data verbatim and read each interview several times to gain a sense of content . the second stage or identifying a thematic framework , involved dividing the text into meaning units .
the condensed meaning units were abstracted and labeled with a code , which constitute the manifest content . in the third stage or indexing , we compared various codes based on differences and similarities and sorted them into subcategories and categories and collated all the relevant codes into data extracts within the identified categories . in the fourth stage or charting , we read all the collated extracts for each category and considered whether they appeared to form a coherent pattern .
then , we considered the validity of individual categories in relation to the dataset and whether our candidate categories accurately reflected the meaning evident in the dataset as a whole .
two researchers independently examined data for categories . in the fifth stage or mapping and interpretation , we defined and further refined the categories .
the simultaneous analysis of the interviews was performed using the lundmen and grancheim content analysis method in five stages ( 18 ) .
we acquired four criteria of creditability , transferability , dependability and conformability to provide the validity and reliability of the results ( 19 ) .
prolonged engagement in the field from september 2012 to march 2013 helped us to establish some trust and support the participants , providing an opportunity to collect data . to ensure that the analysis reveals the ems experiences ,
member checking was performed during the data collection , and where needed , some changes were made . for the creditability of the findings
, we tried to present the quotes of participants with fidelity , so that the readers had a better judgment over the study results . to confirm dependability and conformability of data , the interviews , and the results of the analyses , like the initial codes and subcategories
we implemented the external check method using two authors ( the first and second authors ) expert in pre - hospital care and then peer - checked by two phd students who had previous experience in pre - hospital care ( 20 ) . furthermore ,
this project was approved in the ethics committee of university of social welfare and rehabilitation sciences under the code 3113/2/a/ 801/91 july , 2012 with consideration of the above - mentioned guidelines .
in the present study , a qualitative approach using latent content analysis was used to provide a condensed but comprehensive description of ems staff experiences ; the outcome was an overview of concepts and categories , describing the staff experiences .
data was collected with no a priori hypothesis and focused on obtaining interviewee s point of view .
afterwards , they were conceptually ordered considering their properties and dimensions ( 14 , 15 ) .
tehran , the capital and largest city of iran , has a population of 13 million ( 16 ) and is equipped with a large number of ems vehicles dispatched from a call center . in this study ,
18 interviews were conducted with experts and authorities in pre - hospital emergency system , ( including 12 emergency technicians , 1 emergency care support worker and 1 anesthesiology assistant and 4 nurses ) .
they were recruited by purposeful sampling method and included if had previous experience with burn injury patients .
diversity was observed by selecting subjects of various age groups with different education levels , working experiences and organizational roles .
the interview guide included general as well as more specific questions to direct the interview .
some examples of the questions are please talk about your experience of burn care
, what problems do you face during burn injury care ? and what do you do in face of burn accidents ? .
each interview lasted 40 - 60 minutes and conducted by the same interviewer ( in persian ) ; the interviews were transcribed verbatim and then translated into english .
all interviews were performed by the first author and audiotaped with the medical emergency staff consent .
the interviewer was an expert in qualitative research , trained in qualitative courses and workshops and had the experience of working in emergency burn units ( 18 years ) .
data collection , data analysis and participants selection continued until data saturation occurred and a rich description of medical emergency staff experiences was obtained . to analyze data ,
framework is an analytical process , which involves a number of distinct though highly interconnected stages ( 17 ) . in the first stage or familiarization stage , we transcribed data verbatim and read each interview several times to gain a sense of content . the second stage or identifying a thematic framework , involved dividing the text into meaning units .
the condensed meaning units were abstracted and labeled with a code , which constitute the manifest content . in the third stage or indexing , we compared various codes based on differences and similarities and sorted them into subcategories and categories and collated all the relevant codes into data extracts within the identified categories . in the fourth stage or charting
, we read all the collated extracts for each category and considered whether they appeared to form a coherent pattern .
then , we considered the validity of individual categories in relation to the dataset and whether our candidate categories accurately reflected the meaning evident in the dataset as a whole .
two researchers independently examined data for categories . in the fifth stage or mapping and interpretation
the simultaneous analysis of the interviews was performed using the lundmen and grancheim content analysis method in five stages ( 18 ) .
we acquired four criteria of creditability , transferability , dependability and conformability to provide the validity and reliability of the results ( 19 ) .
prolonged engagement in the field from september 2012 to march 2013 helped us to establish some trust and support the participants , providing an opportunity to collect data . to ensure that the analysis reveals the ems experiences ,
member checking was performed during the data collection , and where needed , some changes were made .
for the creditability of the findings , we tried to present the quotes of participants with fidelity , so that the readers had a better judgment over the study results . to confirm dependability and conformability of data , the interviews , and the results of the analyses , like the initial codes and subcategories
we implemented the external check method using two authors ( the first and second authors ) expert in pre - hospital care and then peer - checked by two phd students who had previous experience in pre - hospital care ( 20 ) . furthermore ,
this project was approved in the ethics committee of university of social welfare and rehabilitation sciences under the code 3113/2/a/ 801/91 july , 2012 with consideration of the above - mentioned guidelines .
the subjects were within the age range of 26 - 43 years , with a mean age of 34.28 4.8 years and a mean working experience of 11.28 3.4 years ( table 1 ) .
all participants had more than five years of experience in dealing with burn injuries and performing pre - hospital emergency care .
from the deep and rich explanations of the participants , 456 initial codes were derived .
after several reviewing and summarizing and based on similarities and differences , 21 codes were derived . regarding the development of resilience , four main contributing concepts were formed through the content analysis method including : 1 ) scene safety / security , 2 ) effective clinical decision making , 3 ) self - efficacy and 4 ) religious support ( table 2 ) . the first derived concept , scene safety / security included two subcategories : ( a ) management of the burn scene and ( b ) sensible approach . in this
regard , p9 said : ... we make sacrifices during our missions , especially during burn emergencies ... we have no protection ... in an electric shock accident , the anxious and angry father of the victim got in a fight with me
... he did not understand that i had to wait for the rescue team to come and secure the location
i was forced to act at the scene ... the second subcategory , sensible approach to challenges at the burn scene deals with the strategies used by personnel when they do not feel secure at the scene .
examples of this approach include encouraging the aggressor to calm down , showing empathy with victims and their companions , involuntary submission and self - defense . as a reaction to verbal violence
, some ems staff tried to calm down the aggressor . as p8 said : ... the accident scene was overcrowded ...
i mean i acted in a way that the unrest calmed down ... in other words , i offered them reassurance ... the victim and his companions trusted us because of our approach . regarding empathy with victims and their families , p6 said :
when i got into the house , i tried to put myself in the victim s shoes ; in fact , i consider the victim as part of my family .
after all , we put ourselves out there during missions . due to the particular nature of emergency care , most personnel involved in the process experience physical and psychological problems . provision of emergency care , especially in burn emergencies , is associated with many difficulties and abnormal behaviors , including violent and aggressive manners .
submission , albeit involuntarily , to the requests of the aggressor is another approach used by ems workers when dealing with a violent situation . in this
what are you doing? ... come on take him to a hospital ... damn it , he is dying ... one of his companions attacked me ... because of the anxiety at the accident site , we transferred the victim to the ambulance ... we could have got ourselves beaten up .
threat and violence at the scene have negative impacts on the mental health of ems staff . in relation to self - defense in face of violence
, p11 said : we are humans just like you , we unconsciously act in self - defense you see , on one hand , the high number of missions is devastating , and on the other hand , victims should be immobilized ... but they ( the companions ) do not let us do our work
the second emerged concept was effective clinical decision making , which included two subcategories : ( a ) patient monitoring / exchange of experience and ( b ) selection of a medical center .
participants believed that clinical decision making as well as clinical skills is of critical importance . according to participants ' experiences , due to factors such as special conditions of burn scenes , limited burn care experiences , and lack of coherent protocols ,
pre - hospital care providers make clinical decisions based on careful monitoring of victims and exchange of experiences . in this
regard , p5 added : the kid was trapped in a car full of smoke ... i checked his airway ... he could talk ...
i controlled his breathing regularly the kid had problems breathing on our way to motahari burn hospital
i talked to my experienced partner and we decided to intubate the kid ... we stopped the ambulance and managed to intubate the kid .
the current study includes only one specialized hospital with limited equipment for specific emergency situations such as burn traumas .
therefore , ems personnel choose a medical center , based on the needs of victim .
as p2 said : the burn victim was unconscious due to the explosion ... he needed a ct scan and a neurologist consultation .
choosing the right hospital for transferring the victim is a serious issue since equipment and facilities of motahari hospital are limited we may have trouble hospitalizing the victim . the third concept , self - efficacy ,
is categorized as ( a ) knowledge / competence improvement , ( b ) increased self - control , ( c ) acquisition of clinical skills and ( d ) social support / encouragement . through formal training , interaction with hospital staff and tracking the effects of emergency care on burn victims , the competence and self - efficacy of the personnel improve .
p17 made the following remark about informal training of staff : during a mission , a novice partner accompanied me on our way to the accident scene , we discussed scene management , venipuncture and control of breathing in airway burns .
ems providers are in contact with hospital staff at emergency departments to verify clinical appropriateness of emergency interventions for burn victims . as p18 remarked : we even sometimes bet on the type and degree of burn injuries we were happy to see that we made the right diagnosis ; actually , we want to prove our skills and expertise . ems personnel seek to enhance their clinical practice through tracking the outcomes of emergency medical interventions for burn victims . as p10 said
unfortunately , due to inhalation burn and restlessness , the victim was intubated and transferred to icu ... i had some time to myself and reviewed the victim s symptoms and clinical measures ... participants acknowledged that preparation strategies such as mental preparation ( related to mental picture formed by previous experiences of burn scenes ) and task - driven approaches would lead to resilience improvement . in relation to mental preparedness , p3 said : while we were on our way to the scene , i described a mental image of the scene for my novice colleague so that he could get a grip on the situation since i had previous experience of burn accidents ... we reviewed all the measures and described our duties .
participants , to control their emotions , manage the burn scene and provide proper clinical care for burn victims , try to focus on the sites of burn injuries and use a task - driven approach . as p4 said :
i tried to just look at the burn injuries ... in fact , i only thought about what i had to do at that moment ... unfortunately , i did not have any eye contact with the victim .
due to limited skills of ems staff in clinical care provision for burn victims , they try to acquire essential skills . in this
regard , p13 said : the best learning opportunity for me was when i was at the burn scene ...
i tried to review the situation and performed triage with the help of my supervisor ...
social support / encouragement , one of the strongest predictors of mental health , comprises the support provided by experienced colleagues , families and society .
as the participants stated , higher social support is associated with higher levels of mental health . in this
regard , p 14 said : as the emergency dispatcher declared a burn accident , i thanked god that a skilled technician , who was actually my teammate , accompanied me during the mission ... well , he is experienced ... i trust him ... he sends good vibes given the stressful nature of working in ems and caring for burned individuals , ems personnel try to avoid discussing their experiences with their family members to prevent tension ; this ultimately deprives staff of emotional support of their own families . in this respect , p7 said :
i try my best to leave everything behind as i enter home , but i can not , it is out of my hands ... i keep telling my wife that if i had done this or that , the victim might have survived she gets nervous when i go to work religious support significantly affected participants ' lives and modified the situation in a way that they could enjoy a stress - free lifestyle .
religious support takes many forms among ems personnel such as trust in god and intercession ( seek nearness to god and imams ) . as p16 remarked : as i saw the victim , who was burned from tip to toe , i put my trust in god ; he helped me control myself
the first derived concept , scene safety / security included two subcategories : ( a ) management of the burn scene and ( b ) sensible approach . in this regard , p9 said : ... we make sacrifices during our missions , especially during burn emergencies ... we have no protection ... in an electric shock accident , the anxious and angry father of the victim got in a fight with me
... he did not understand that i had to wait for the rescue team to come and secure the location
i was forced to act at the scene ... the second subcategory , sensible approach to challenges at the burn scene deals with the strategies used by personnel when they do not feel secure at the scene .
examples of this approach include encouraging the aggressor to calm down , showing empathy with victims and their companions , involuntary submission and self - defense . as a reaction to verbal violence
, some ems staff tried to calm down the aggressor . as p8 said : ... the accident scene was overcrowded ...
i mean i acted in a way that the unrest calmed down ... in other words , i offered them reassurance ... the victim and his companions trusted us because of our approach .
regarding empathy with victims and their families , p6 said : when i got into the house , i tried to put myself in the victim s shoes ; in fact , i consider the victim as part of my family .
after all , we put ourselves out there during missions . due to the particular nature of emergency care , most personnel involved in the process experience physical and psychological problems
. provision of emergency care , especially in burn emergencies , is associated with many difficulties and abnormal behaviors , including violent and aggressive manners .
submission , albeit involuntarily , to the requests of the aggressor is another approach used by ems workers when dealing with a violent situation . in this
what are you doing? ... come on take him to a hospital ... damn it , he is dying ... one of his companions attacked me ... because of the anxiety at the accident site , we transferred the victim to the ambulance ... we could have got ourselves beaten up .
threat and violence at the scene have negative impacts on the mental health of ems staff . in relation to self - defense in face of violence
, p11 said : we are humans just like you , we unconsciously act in self - defense you see , on one hand , the high number of missions is devastating , and on the other hand , victims should be immobilized ... but they ( the companions ) do not let us do our work they attack us
the second emerged concept was effective clinical decision making , which included two subcategories : ( a ) patient monitoring / exchange of experience and ( b ) selection of a medical center .
participants believed that clinical decision making as well as clinical skills is of critical importance . according to participants ' experiences , due to factors such as special conditions of burn scenes , limited burn care experiences , and lack of coherent protocols ,
pre - hospital care providers make clinical decisions based on careful monitoring of victims and exchange of experiences . in this
regard , p5 added : the kid was trapped in a car full of smoke ... i checked his airway ... he could talk ... he was crying ... but it was all temporary ... i controlled his breathing regularly the kid had problems breathing on our way to motahari burn hospital
i talked to my experienced partner and we decided to intubate the kid ... we stopped the ambulance and managed to intubate the kid . the current study includes only one specialized hospital with limited equipment for specific emergency situations such as burn traumas .
therefore , ems personnel choose a medical center , based on the needs of victim .
as p2 said : the burn victim was unconscious due to the explosion ... he needed a ct scan and a neurologist consultation .
choosing the right hospital for transferring the victim is a serious issue since equipment and facilities of motahari hospital are limited we may have trouble hospitalizing the victim .
the third concept , self - efficacy , is categorized as ( a ) knowledge / competence improvement , ( b ) increased self - control , ( c ) acquisition of clinical skills and ( d ) social support / encouragement . through formal training ,
interaction with hospital staff and tracking the effects of emergency care on burn victims , the competence and self - efficacy of the personnel improve .
p17 made the following remark about informal training of staff : during a mission , a novice partner accompanied me on our way to the accident scene , we discussed scene management , venipuncture and control of breathing in airway burns
. ems providers are in contact with hospital staff at emergency departments to verify clinical appropriateness of emergency interventions for burn victims . as p18 remarked : we even sometimes bet on the type and degree of burn injuries we were happy to see that we made the right diagnosis ; actually , we want to prove our skills and expertise .
ems personnel seek to enhance their clinical practice through tracking the outcomes of emergency medical interventions for burn victims .
unfortunately , due to inhalation burn and restlessness , the victim was intubated and transferred to icu ... i had some time to myself and reviewed the victim s symptoms and clinical measures ... participants acknowledged that preparation strategies such as mental preparation ( related to mental picture formed by previous experiences of burn scenes ) and task - driven approaches would lead to resilience improvement . in relation to mental preparedness , p3 said : while we were on our way to the scene , i described a mental image of the scene for my novice colleague so that he could get a grip on the situation since i had previous experience of burn accidents ... we reviewed all the measures and described our duties .
participants , to control their emotions , manage the burn scene and provide proper clinical care for burn victims , try to focus on the sites of burn injuries and use a task - driven approach . as p4 said :
i tried to just look at the burn injuries ... in fact , i only thought about what i had to do at that moment ... unfortunately , i did not have any eye contact with the victim .
due to limited skills of ems staff in clinical care provision for burn victims , they try to acquire essential skills . in this
regard , p13 said : the best learning opportunity for me was when i was at the burn scene ...
i tried to review the situation and performed triage with the help of my supervisor ...
social support / encouragement , one of the strongest predictors of mental health , comprises the support provided by experienced colleagues , families and society .
as the participants stated , higher social support is associated with higher levels of mental health . in this
regard , p 14 said : as the emergency dispatcher declared a burn accident , i thanked god that a skilled technician , who was actually my teammate , accompanied me during the mission ... well , he is experienced ... i trust him ... he sends good vibes given the stressful nature of working in ems and caring for burned individuals , ems personnel try to avoid discussing their experiences with their family members to prevent tension ; this ultimately deprives staff of emotional support of their own families . in this respect , p7 said :
i try my best to leave everything behind as i enter home , but i can not , it is out of my hands ... i keep telling my wife that if i had done this or that , the victim might have survived she gets nervous when i go to work
religious support significantly affected participants ' lives and modified the situation in a way that they could enjoy a stress - free lifestyle .
religious support takes many forms among ems personnel such as trust in god and intercession ( seek nearness to god and imams ) . as p16 remarked : as i saw the victim , who was burned from tip to toe , i put my trust in god ; he helped me control myself
the four key concepts derived in this study were scene security / safety , effective clinical decision making , self - efficacy and religious support ( figure 1 ) . scene security / safety : the security / safety of the ems staff , before entering the burn scene , is the most important matter in pre - hospital emergency care .
as the participants stated , lack of required safety equipment and insufficient training were among their negative experiences .
in fact , they were compelled to risk their own lives to ensure the safety and security of area .
a recent national study showed that 89% of ems personnel reported behaviors which endangered their own safety ( 21 ) . regarding the sensible approach subcategory of scene security / safety , due to the nature of burn injuries , ems personnel are more prone to workplace violence , which in turn interrupts the flow of patient care .
suserud stated that many ambulance personnel are at risk of being attacked and being beaten up and are threatened by victims companions ( 20 ) . in another study
, he suggests to use appropriate strategies to mitigate threats and violence at the scene ( 22 ) .
given the complexity of situation , ems personnel approach to control violence varies and might involve asking the aggressor to calm down , empathize with victim and cooperate with personnel .
moreover , ems personnel frequently use strategies of submission and self - defense in face of threats .
unfortunately , iran s healthcare system has not paid enough attention to physical violence and very few studies investigated physical violence against medical staff ( 23 , 24 ) .
studies in other countries indicate a high level of workplace violence against pre - hospital emergency personnel ( 22 , 25 ) , which confirms the hypothesis that violence against healthcare workers is a global issue , affecting all countries .
effective clinical decision making : due to the changing conditions of victims and uncertain clinical environments , ems personnel must constantly make decisions of uncertain consequences .
participants consider clinical decision making , particularly during burn emergencies , as the most critical part of their profession .
participants considered protocol - based treatments to be useful and necessary ; however , considering pre - hospital clinical environment , existing trainings and protocols for emergency care of burn victims are not sufficient . due to
the limited facilities and equipment of hospitals , experienced personnel can be of high value , because other team members can benefit from their experiences .
therefore , through gaining a comprehensive understanding of victims clinical status , ems providers can make a proper clinical decision .
white ( 26 ) argue that clinical decision making is the main responsibility of nurses .
therefore , they should acquire essential skills for clinical decision making , given its high impact on the quality of care .
self - efficacy : the third derived concept , self - efficacy , included four subcategories : knowledge / competence improvement , self - control , acquisition of clinical skills and social support / encouragement .
gillespie et al . included self - efficacy as one of the components of resilience , which includes the ability to perform a specific task in a specific situation ( 27 ) .
acquisition of new skills and improvement of the learned ones can significantly contribute to the quality of care provided .
following up patient s status to evaluate shortcomings of performed approaches , is of critical value in this regard .
harrahill and gunnels suggested that ambulance nurses are often not adequately trained and tracking patient s health status can help increase their knowledge ( 28 ) .
these factors may have physical , emotional , cognitive and behavioral consequences , which may eventually affect the personnel s performance . through the use of mental images and task - driven approaches
, they are also able to deal with the situation objectively and not let their emotions stand in the way .
chang et al . stated that through self - control , individuals learn how to face traumas and keep their feelings to themselves ( 29 ) .
based on the study findings , acquisition of clinical skills is one of the subcategories of self - efficacy .
participants believed that due to their inadequate education and training , burn scenes serve as the only opportunity where they can enhance their skills .
spencer argues that clinical environments provide the opportunity for focused learning in a professional context . in these environments ,
students become motivated through active participation ; they also acquire various skills such as history taking , physical examination , clinical reasoning , decision - making , empathy and commitment , in an integrated manner ( 30 ) .
social support , the fourth subcategory of self - efficacy , can substantially decrease the stress of personnel and act as a buffer against stressful conditions .
tusaie and dyer found that social support is an essential element of resilience ( 31 ) .
moreover , another studies found that social support has a positive impact on personal and organizational objectives .
it is believed that when ems personnel are supported by their colleagues , their mental health is positively affected ( 32 , 33 ) . based on our findings , many young and inexperienced personnel
are not adequately supported by their partners ; however , experienced colleagues , working in a team , have positive feelings , interact with each other and benefit from each other s company .
religious support : many participants considered spirituality , faith , belief and trust in god as highly effective strategies for coping with stress and dealing with burn emergencies . therefore , it can be inferred that religious beliefs contribute to the development of resilience and intrapersonal aspects of mental health and positively influence mental health .
shaker et al . stated that religious beliefs are associated with reduced psychological stress ( 34 ) .
the present study showed that major themes contributing to resilience of the ems workforce in caring for burned patients are scene security / safety , effective decision making , self - efficacy and religious support .
these contributing factors , if used in the right direction , help ems personnel cope with environmental stressors , have positive effects on their mental health and protect them from burnout . by recognizing the importance of resilience in ems care and enforcing its contributing factors , healthcare system , ems personnel and patient would all benefit .
future studies are needed to address the question whether the findings of the present study can be generalized to ems workers with different cultural backgrounds , work experience and education / training levels .
this was the first qualitative study on the experiences of pre - hospital emergency personnel dealing with resilience in the event of burn in tehran , iran .
this study was able to provide valuable information about experiences of pre - hospital emergency personnel in the event of burn injuries .
however , since data was collected through semi - structured interviews , the results were more comprehensive and subjective .
considering the fact that the process of providing pre - hospital emergency care for the burn victims is not yet well - established , a grand theory approach is recommended for further investigations . | background : medical emergency staff complete understanding of the nature of resiliency in burn events is a prerequisite for improving the quality of clinical service delivery in pre - hospital burn events.objectives:the present study aimed to describe resiliency in view of medical emergency staff in burn events.materials and methods : the present qualitative study was performed using a content analysis method . in total , 18 iranian emergency care personnel participated in the study .
a purposeful sampling method was applied until reaching data saturation .
data was collected using semi - structured interviews and field observations .
afterwards , data was analyzed by face content analysis.results:by analyzing 456 primary codes , four main concepts including : 1 ) scene safety / security , 2 ) effective clinical decision making , 3 ) self - efficacy and 4 ) religious support were extracted through content analysis from experiences of pre - hospital emergency personnel during burn care.conclusions:different factors affect resiliency improvements in medical emergency staff and consequently the quality of pre - hospital burn care .
this study showed that various factors such as scene security / safety , effective decision making , self - efficacy and religious support are effective in the improvement of resiliency and the quality of pre - hospital emergency care . |
all the chemicals used were of analytical grade and purified by standard methods prior to use .
the melting points were measured using a stuart scientific melting point apparatus smp3 ( uk ) and are uncorrected .
the nmr spectra were taken using bruker dpx 300 mhz instrument at organic chemistry institute , bonn , germany .
dmso - d6 was used as solvent and the chemical shifts are given in ( ppm ) values .
the chemical shifts of the remaining protons of the deuterated solvent served as internal standard : h : 2.49 ppm , c : 39.7 ppm .
the ei - ms was obtained using ei- finnigan mat 95xl ( thermo finnigan , bremen ) and fab - ms was obtained using concept 1h ( kratos , hofheim ) , with m - nitrobenzyl alcohol as matrix .
2-(4-hydroxyphenylthio)acetic acid , 2-(3,4-dihydro-2,4-dioxopyrimdin-1(h)-yl)acetic acid and 2-(3,4-dihydro-5-methyl-2,4-dioxopyrimdin-1-(h)-yl)acetic acid were prepared as described according to the reported procedure .
synthetic route of the final compounds 43 - 58 . to a solution of acid chloride derivative
( 1 , 17a - e ) ( 37,84 mmol ) in acetone ( 60 ml ) , potassium thiocyanate ( 3.68 g , 37.84 mmol , 1.0 eq . ) under efficient stirring .
the reaction mixture was refluxed at 60 for 60 - 120 min and monitored using tlc until the start is completely disappeared .
ethanol or methanol ( 94.60 mmol , 2.5 eq . ) was added drop wise and the reaction mixture was refluxed for 4 - 7 h and then cooled , filtered , washed with acetone ( 15 ml ) .
the filtrate was evaporated and the residue was purified either by silica gel chromatography if it is oil or by crystallization if it is solid to afford the desired product .
the molecular characteristics of o - methyl - n-(benzoyl)thiocarbamate 19 as representative example for this series are as follow , ( 300 mhz , cdcl3 ) : 9.16 ( br , 1h ) , 7.75 ( m , 2h ) , 7.51 ( m , 1h ) , 7.42 ( m , 2h ) , 4.13 ( s , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 190.38 , 162.51 , 133.27 , 132.83 , 129.06 , 127.73 , 59.62 .
ei - hrms ( m / z ) : calcd . for c9h9no2s 195.0354 , found 195.0359 [ m ] . yield : 68% , mp 102 - 104. o - methyl - n - acyl - thiocarbamate or o - ethyl - n - acyl - thiocarbamate derivative 3 , 19 - 26 ( 28.01 mmol , 1 eq . ) and p - nitrophenyl - hydrazine ( 4.29 g ; 28.01 mmol , 1 eq . ) were suspended in ethanol ( 30.0 ml ) in a round - bottom flask equipped with a reflux condenser and a bubbler .
the reaction mixture was refluxed for 12 - 20 h. during the course of the reaction h2s evolution was observed .
the reaction mixture was cooled and the precipitated product was filtered off followed by thorough washing cycles with cold ethanol .
the residue was purified using silica gel column or crystallized from ethanol to afford the nitro - triazole derivatives 4 , 26 - 32 as yellow solid . the molecular characteristics of 3-methoxy-1-(4-nitrophenyl)-5-phenyl-1h-1,2,4-triazole 27 as representitve example for this series are as follow , h - nmr ( 400 mhz , dmso ) : 8.31 ( d , j=9.19 hz , 2h ) , 7.61 ( d , j=9.19 hz , 2h ) , 7.47 ( m , 5h ) , 3.98 ( s , 3h ) .
c - nmr ( 100 mhz , dmso ) : 168.63 , 154.21 , 146.96 , 142.86 , 131.09 , 129.32 , 129.29 , 127.64 , 126.25 , 125.30 , 57.23 . ei - hrms ( m / z ) : calcd . for c15h12n4o3 296.0909 , found 296.0908 [ m ] .
yield : 80% , mp 142 - 44. as per method a , nitrotriazole derivative 4 , 27 - 34 ( 0.63 g , 1.85 mmol , 1 eq . ) , ammonium chloride ( 0.30 g , 5.61 mmol , 3.0 eq . ) and fe powder ( 0.52 g , 9.31 mmol , 5 eq . ) were suspended in 1:1 solution of methanol and water ( 20 ml ) . concentrated hcl ( 0.25 ml )
was added to the above reaction mixture and was heated at 65 for 3 h. the reaction mixture was filtered when hot and was washed several times with hot methanol ( 815 ml ) .
the filtrate was evaporated to remove methanol and the precipitated product was filtered and washed with cold water .
the crude product was purified by silica gel chromatography to afford the product as pale white solid .
in the method b , to a suspension of the nitro derivative 4 , 27 - 34 ( 7.61 mmol ) in ethanol ( 70 ml ) , ( pd / c10% 2.87 g ) was added portion wise after washing with argon gas three times .
the reaction mixture was transferred into autoclave under h2 atmosphere and 20 bar pressure and stirred overnight .
the reaction mixture was filtered through celite pad and was washed with ethanol ( 120 ml ) and then hot methanol ( 5120 ml ) .
the solvent was concentrated and the rest was cooled in the refrigerator to afford the amine product ( 5 , 35 - 42 ) as white crystals .
the molecular characteristics of 4-(3-methoxy-5-phenyl-1h-1,2,4-triazol-1-yl)phenyl amine 35 as representative example of this series are as follows , h - nmr ( 300 mhz , dmso ) : 7.33 - 7.45 ( m , 5h ) , 6.99 ( d , j=8.5 hz , 2h ) , 6.57 ( d , j=8.5 hz , 2h ) , 5.49 ( br s , 2h ) , 3.91 ( s , 3h ) .
c - nmr ( 75 mhz , dmso ) : 167.80 , 152.73 , 149.97 , 130.20 , 128.88 , 128.69 , 128.17 , 127.41 , 126.56 , 114.04 , 56.77 .
ei - hrms ( m / z ) : calcd . for c19h22n4o 322.1794 , found 322.1790 [ m ] .
yield obtained was 76% with an mp 198 - 200. n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)2-(phenylthio)-acetamide 6 was synthesized by adding to a solution of 5 ( 1.277 g , 4.12 mmol , 1 eq . ) and triethyl amine ( 1.14 ml , 8.22 mmol , 2 eq . ) in dichloroethane ( 20 ml ) and phenylthioacetyl chloride ( 0.61 ml , 4.11 mmol , 1 eq . ) .
the reaction mixture was stirred overnight at room temperature ( rt ) and was diluted with dichloromethane ( 100 ml ) .
the reaction mixture was washed with 5% aqueous na2co3 solution ( 25 ml ) and water ( 250 ml ) , respectively .
the crude product was purified by silica gel chromatography using ethylactate / cyclohexane ( 1:1 ) as eluent system to give the product as pale white foam .
yield obtained was 67% , mp 202 - 204. h - nmr ( 400 mhz , cdcl3 ) : 8.60 ( br , 1h ) , 7.48 ( d , j=8.84 hz , 2h ) , 7.30 - 7.18 ( m , 7h ) , 6.90 ( dd , j=8.08 hz , j=1.64 hz , 1h ) , 6.87 ( d , j=1.64 hz , 1h ) , 6.66 ( d , j=8.08 hz , 1h ) , 5.90 ( s , 2h ) , 3.97 ( s , 3h ) , 3.71 ( s , 2h ) ; c - nmr ( 100 mhz , d6-dmso ) : 167.48 , 167.16 , 152.45 , 148.67 , 147.23 , 139.19 , 135.66 , 132.90 , 128.99 , 128.15 , 126.44 , 126.05 , 123.18 , 120.99 , 119.52 , 108.40 , 108.36 , 101.63 , 56.41 , 37.52 ; fab ( m / z ) : 461.1 [ m + 1 ] .
2-(4-hydroxyphenylthio)-n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl ) acetamide 7 was synthesised by adding under argon atmosphere , to a solution of 4-hydroxyphenylthioacetic acid ( 0.42 g , 2.26 mmol ) , edc ( 0.44 g , 2.26 mmol ) and dmap ( 0.09 g , 0.74 mmol ) in dcm ( 10 ml ) and dmf ( 6 ml ) , the triazole amine derivative 5 ( 0.7 g , 2.26 mmol ) .
after the reaction mixture was stirred at rt overnight , the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using ( cyclohexane / ethylacetate 1:1 ) as eluent system to give the product as white powder .
yield obtained was 0.32 g , ( 31% ) and the mp was 212 - 214. h - nmr ( 400 mhz , d6-dmso ) : 10.27 ( br s , 1h ) , 9.59 ( br s , 1h ) , 7.63 ( d , j=8.5 hz , 2h ) , 7.28 - 7.32 ( m , 4h ) , 6.88 - 6.91 ( m , 3h ) , 6.72 ( d , j=8.5 hz , 2h ) , 6.05 ( s , 2h ) , 3.92 ( s , 3h ) , 3.65 ( s , 2h ) .
c - nmr ( 100 mhz , d6-dmso ) : 168.03 , 157.65 , 152.92 , 149.93 , 149.16 , 147.71 , 139.76 , 133.69 , 126.91 , 123.65 , 123.38 , 121.46 , 119.97 , 116.52 , 108.89 , 108.85 , 102.13 , 56.89 , 40.68 .
ei - hrms ( m / z ) : calcd . for c24h20n4o5s 476.1154 , found 476.1156 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(phenyl - sulfonyl)acetamide 8 was prepared by adding to a stirred solution of 6 ( 117 mg , 0.254 mmol ) in dcm ( 5 ml ) , a solution of peracetic acid ( 39% in acoh , 175 mg , 1.07 mmol ) .
the reaction mixture was stirred for 7 h before being extracted with dcm ( 30 ml ) and water ( 30 ml ) .
the organic phase was washed with water ( 225 ml ) and the combined aqueous phases were extracted with dcm ( 50 ml ) .
the combined organic phases were dried over mgso4 and evaporated in vacuo to yield the product as white powder , which purified by column chromatography using ethylactate / cyclohexane ( 1:1 ) as eluent system .
yield obtained was 0.105 mg ( 84% ) with an mp of 217 - 219. h - nmr ( 300 mhz , cdcl3 ) : 8.65 ( br s , 1h ) , 7.85 ( d , j=8.85 hz , 2h ) , 7.62 - 7.68 ( m , 1h ) , 7.49 - 7.55 ( m , 4h ) , 7.25 ( d , j=8.85 hz , 2h ) , 6.87 - 6.93 ( m , 2h ) 6.67 ( d , j=8.05 hz , 1h ) , 5.92 ( s , 2h ) , 4.11 ( s , 2h ) , 3.98 ( s , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.32 , 158.57 , 153.09 , 149.27 , 147.80 , 137.87 , 137.23 , 134.87 , 134.80 , 129.74 , 128.12 , 126.28 , 123.67 , 121.28 , 120.65 , 109.09 , 108.53 , 101.60 , 62.84 , 56.89 . ei - hrms ( m / z ) : calcd . for c24h20n4o6s 492.1104 , found 492.1105 [ m ] .
to a solution of ( 2-pyridylthio)acetic acid ( 0.55 g , 3.2 mmol ) , edc ( 0.617 g , 3.2 mmol ) and dmap ( 0.12 g , 0.99 mmol ) in dcm ( 10 ml ) and dmf ( 5 ml ) under argon atmosphere , the amine 5 ( 1.0 g , 3.2 mmol ) was added .
the reaction mixture was stirred at rt overnight and the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using 3 - 7% meoh / dcm to give the desired product with an yield of 51 % ( 0.76 g ) and mp 176 - 178. h - nmr ( 300 mhz , cdcl3 ) : 10.40 ( br s , 1h ) , 8.46 - 8.49 ( m , 1h ) , 7.47 - 7.50 ( m , 3h ) , 7.18 - 7.28 ( m , 3h ) , 7.07 - 7.11 ( m , 1h ) , 6.86 - 6.90 ( m , 2h ) , 6.64 ( dd , j=8.40 hz , j=1.00 hz , 1h ) , 5.90 ( s , 2h ) , 3.96 ( s , 3h ) , 3.81(s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.50 , 158.12 , 152.93 , 148.91 , 147.70 , 138.85 , 137.10 , 133.64 , 126.19 , 123.59 , 122.99 , 121.47 , 120.86 , 119.83 , 109.09 , 108.43 , 101.52 , 56.83 , 35.37 .
ei - hrms ( m / z ) : calcd . for c23h19n5o2s 461.1158 , found 461.1160 [ m ] .
yield ( 0.77 g , 52 % ) , mp 198 - 200. h - nmr ( 300 mhz , cdcl3 ) : 8.67 ( br s , 1h ) , 8.39 ( d , j=5.85 hz , 2h ) , 7.47 ( d , j=8.88 hz , 2h ) , 7.21 ( d , j=8.88 hz , 2h ) , 7.11 ( d , j=5.85 hz , 2h ) , 7.30 - 7.18 ( m , 7h ) , 6.90 ( dd , j=8.08 hz , j=1.64 hz , 1h ) , 6.87 ( d , j=1.64 hz , 1h ) , 6.65 ( d , j=7.93 hz , 1h ) , 5.90 ( s , 2h ) , 3.96 ( s , 3h ) , 3.78 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.27 , 165.35 , 153.04 , 149.84 , 149.26 , 147.77 , 146.26 , 137.41 , 134.54 , 126.15 , 123.64 , 121.23 , 120.47 , 109.02 , 108.52 , 101.61 , 56.90 , 35.62 .
ei - hrms ( m / z ) : calcd . for c23h19n5o2s 461.1158 , found 461.1152 [ m ] .
thymine-1-acetic acid ( 0.30 g , 1.61 mmol , edc ( 0.31 g , 1.61mmol ) and dmap ( 0.037 g , 0.31 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture the amine 5 ( 0.5 g , 1.61 mmol ) in dcm ( 10 ml )
was added and the reaction was further stirred overnight at rt the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using dcm / meoh ( 9:1 ) as eluent system to give the product as white powder .
yield obtained was ( 25 g ) 32.5 % , with a mp of 197 - 199. h - nmr ( 300 mhz , dmso ) : 11.34 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.68 ( d , j=8.6 hz , 2h ) , 7.51 ( s , 1h ) , 7.34 ( d , j=8.6 hz , 2h ) , 6.87 - 6.94 ( m , 3h ) , 6.05 ( s , 2h ) , 4.52 ( s , 2h ) , 3.92 ( s , 3h ) , 1.77 ( s , 3 h ) .
c - nmr ( 75 mhz , dmso ) : 167.96 , 166.58 , 164.85 , 152.94 , 151.54 , 149.15 , 147.71 , 142.77 , 139.48 , 133.36 , 127.07 , 123.63 , 121.43 , 119.90 , 108.88 , 188.83 , 108.51 , 102.13 , 56.90 , 50.49 , 12.33 .
ei - hrms ( m / z ) : calcd . for c23h20n6o6 476.1444 , found 476.1448 [ m ] .
to a solution of 3-thiopheneacetic acid ( 0.23 g , 1.6 mmol , edc ( 0.309 g , 1.6 mmol ) and dmap ( 0.06 g , 0.50 mmol ) in dcm ( 10 ml ) and dmf ( 3 ml ) under argon atmosphere , the amine 5 ( 0.5 g , 1.6 mmol ) was added .
the reaction mixture was stirred at rt overnight and then the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using cyclohexane / ethylacetate ( 1:2 ) as eluent to give the product as white crystals .
yield was 0.22 g ( 31.4% ) and mp was 213 - 215. h - nmr ( 300 mhz , cdcl3 ) : 10.05 ( br s , 1h ) , 7.78 ( d , j=8.80 hz , 2h ) , 7.38 ( dd , j=2.83 hz , j=2.08 hz , 1h ) , 7.29 - 7.32 ( m , 3h ) , 7.18 ( dd , j=3.78 hz , j=1.13 hz , 1h ) , 7.01 ( dd , j=6.42 hz , j=1.69 hz , 1h ) , 6.96 ( d , j=1.51 hz , 1h ) , 6.80 ( d , j=8.12 hz , 1h ) , 6.05 ( s , 2h ) , 4.06 ( s , 3h ) , 3.78 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 174.18 , 172.79 , 157.50 , 153.86 , 152.44 , 144.45 , 139.99 , 137.93 , 133.38 , 130.72 , 128.20 , 127.27 , 126.10 , 124.78 , 113.61 , 113.16 , 106.39 , 61.46 , 43.49 .
ei - hrms ( m / z ) : calcd . for c22h18n4o4s 434.1049 , found 434.1042 [ m ] .
( 0.39 g , 2.26 mmol , edc ( 0.44 g , 2.26 mmol ) , tea ( 0.6 ml , 4.54 mmol ) and dmap ( 0.09 g , 0.74 mmol ) in dcm ( 20 ml ) under argon atmosphere , the amine 5 ( 7.0 g , 2.26 mmol ) was added .
the reaction mixture was stirred at rt overnight and then the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using dcm / meoh ( 3 - 6% ) as eluent to give the product as white crystals .
yield was 0.61 g ( 62% ) and the mp was 180 - 182. h - nmr ( 400 mhz , cdcl3 ) : 10.20 ( br s , 1h ) , 8.56 ( d , j=4.90 hz , 1h ) , 7.63 - 7.67 ( m , 1h ) , 7.57 ( d , j=8.31 hz , 2h ) , 7.19 - 7.24 ( m , 4h ) , 6.86 - 6.90 ( m , 2h ) , 6.64 ( d , j=8.18 hz , 1h ) , 5.89 ( s , 2h ) , 3.96 ( s , 3h ) , 3.82 ( s , 2h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.27 , 167.23 , 155.12 , 152.97 , 148.94 , 147.70 , 138.59 , 137.69 , 133.97 , 126.19 , 124.45 , 123.61 , 122.48 , 121.48 , 120.18 , 109.10 , 108.42 , 101.53 , 56.84 , 45.52 .
ei - hrms ( m / z ) : calcd . for c23h19n5o4 429.1437 , found 429.1432 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(pyridin-4-yl)acetamide 14 was prepared using the same procedure of 13 using instead 4-pyridylacetic acid hydrochloride to afford 14 as a white powder .
yield was 0.76 g ( 78.4% ) and the mp was 214 - 216. h - nmr ( 300 mhz , d6-dmso ) : 10.48 ( br s , 1h ) , 8.51 ( d , j=5.30 hz , 2h ) , 7.69 ( d , j=8.85 hz , 2h ) , 7.31 - 7.36 ( m , 4h ) , 6.87 - 6.91 ( m , 3h ) , 6.86 - 6.90 ( m , 2h ) , 6.05 ( s , 2h ) , 3.92 ( s , 3h ) , 3.74 ( s , 2h ) .
c - nmr ( 75 mhz , d6-dmso ) : 168.61 , 167.94 , 152.91 , 149.93 , 149.15 , 147.70 , 144.83 , 139.83 , 133.27 , 126.93 , 125.13 , 123.66 , 121.46 , 119.99 , 108.88 , 108.83 , 102.12 , 56.89 , 42.78 .
ei - hrms ( m / z ) : calcd . for c23h19n5o4 429.1437 , found 429.1446 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(1h - imidazol-4-yl)acetamide 15 was prepared in the following manner . to a solution of imidazole-4-acetic acid hydrochloride ( 0.185 g , 1.13 mmol , edc ( 0.22 g , 1.13 mmol ) and dmap ( 0.045 g , 0.37 mmol ) in dcm ( 5 ml ) and dmf ( 10 ml ) under argon atmosphere , the amine 5 ( 0.35 g , 1.13 mmol ) was added .
the reaction mixture was stirred overnight at rt and the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using meoh / dcm ( 5 - 8% ) to give the desired product .
yield obtained was 0.15 g ( 28% ) and the mp was 196 - 198. h - nmr ( 400 mhz , d6-dmso ) : 11.91 ( br s , 1h ) , 10.34 ( br s , 1h ) , 7.70 ( d , j=8.5 hz , 2h ) , 7.56 ( s , 1h ) , 7.31 ( d , j=8.5 hz , 2h ) , 6.94 ( s , 1h ) , 6.87 - 6.94 ( m , 3h ) , 6.05 ( s , 2h ) , 3.91 ( s , 3h ) , 3.33 ( s , 2h ) .
c - nmr ( 100 mhz , d6-dmso ) : 167.92 , 152.90 , 149.13 , 147.69 , 140.15 , 135.32 , 133.02 , 126.91 , 123.61 , 123.38 , 121.47 , 119.82 , 108.87 , 108.81 , 102.11 , 56.88 , 49.01 .
ei - hrms ( m / z ) : calcd . for c21h18n6o4 418.1390 , found 418.1391 [ m ] .
uracil-1-acetic acid ( 0.274 g , 1.61 mmol , edc ( 0.31 g , 1.61 mmol ) and dmap ( 0.037 g , 0.31 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 5 ( 0.5 g , 1.61 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography dcm / meoh ( 9:1 ) as eluent system to give the product as white crystals with an yield of 0.24 g ( 32% ) and mp of 252 - 254. h - nmr ( 300 mhz , dmso ) : 11.35 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.61 - 7.69 ( m , 3h ) , 7.35 ( d , j=8.31 hz , 2h ) , 6.87 - 6.94 ( m , 3h ) , 6.05 ( s , 2h ) , 5.60 ( d , j=8.12 hz , 1h ) , 4.57 ( s , 2h ) , 3.92 ( s , 3h ) .
c - nmr ( 75 mhz , dmso ) : 167.96 , 166.48 , 164.28 , 152.94 , 151.56 , 149.15 , 147.71 , 147.02 , 139.45 , 133.39 , 127.09 , 123.63 , 121.42 , 119.90 , 108.88 , 102.13 , 101.07 , 56.90 , 50.66 .
ei - hrms ( m / z ) : calcd . for c22h18n6o6 462.1288 , found 462.1289 [ m ] .
n-(4-(3-methoxy-5-phenyl-1h-1,2,4-triazol-1-yl)phenyl)-2-(phenylthio)-acetamide 43 . to a solution of amine 35 ( 0.546 g , 2.05 mmol , 1 eq . ) and triethyl amine ( 0.57 ml
, 4.10 mmol , 2 eq . ) in dcm ( 15 ml ) was added phenylthioacetyl chloride ( 0.3 ml , 2.06 mmol , 1 eq . ) .
phenylthioacetyl chloride ( 0.1 ml , 0.67 mmol ) was added and then reaction was refluxed for 3 h. the reaction mixture was diluted with dichloromethane ( 50 ml ) and the reaction mixture was washed with 5% aq .
the crude product was purified by silica gel chromatography using cyclohexane : etoac ( 3:2 ) as eluent to give the product as white crystals .
yield , ( 0.38 g , 44 % ) , mp 120 - 122. h - nmr ( 300 mhz , cdcl3 ) : 8.65 ( br s , 1h ) , 7.46 ( d , j=8.5 hz , 2h ) , 7.38 ( d , j=8.5 hz , 2h ) , 7.11 - 7.30 ( m , 10h ) , 3.98 ( s , 3h ) , 3.70 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.50 , 166.29 , 153.29 , 137.59 , 134.39 , 133.96 , 130.14 , 129.60 , 128.87 , 128.61 , 128.59 , 127.69 , 127.27 , 126.14 , 120.28 , 56.91 , 38.55 .
ei - hrms ( m / z ) : calcd . for c23h20n4o2s 416.1307 , found 416.1307 [ m ] .
thymine-1-acetic acid ( 0.28 g , 1.5 mmol , edc ( 0.29 g , 1.5 mmol ) and dmap ( 0.030 g , 0.25 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 35 ( 0.4 g , 1.5 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography dcm / meoh ( 9:1 ) to give the product as white crystals of an yield of 0.2 g ( 30.77% ) and mp of 199 - 201. h - nmr ( 300 mhz , dmso ) : 11.34 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.67 ( d , j=8.5 hz , 2h ) , 7.51 ( s , 1h ) , 7.39 - 7.41 ( m , 5h ) , 7.34 ( d , j=8.5 hz , 2h ) , 4.52 ( s , 2h ) , 3.94 ( s , 3h ) , 1.77 ( s , 3 h ) .
c - nmr ( 75 mhz , dmso ) : 168.16 , 166.58 , 164.85 , 153.17 , 151.54 , 142.78 , 139.53 , 133.31 , 130.52 , 129.04 , 127.84 , 127.02 , 119.88 , 114.04 , 108.52 , 56.95 , 50.50 , 12.33 .
ei - hrms ( m / z ) : calcd . for c22h20n8o4 432.1546 , found 432.1546 [ m ] .
n-(4-(5-(2-fluorophenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(phenylthio)-acetamide 45 . to a solution of amine 36 ( 0.285 g , 1.01 mmol , 1 eq . ) and triethyl amine ( 0.28 ml , 2.01 mmol , 2 eq . ) in dcm ( 10 ml ) was added phenylthioacetyl chloride ( 0.15 ml , 1.01 mmol , 1 eq . ) .
the reaction mixture was stirred overnight at room temperature , 0.15 ml of phenylthioacetyl chloride was added and then the reaction was stirred at 55 for 3 h. the reaction mixture was diluted with dichloromethane ( 70 ml ) .
the reaction mixture was washed with 5% aquous na2co3 solution ( 15 ml ) and water ( 225 ml ) , respectively .
the crude product was purified by silica gel chromatography to give the product as pale white foam like crystals with a yield of 0.2 g ( 46% ) and mp of 122 - 124. h - nmr ( 400 mhz , cdcl3 ) : 8.60 ( br s , 1h ) , 7.45 - 7.49 ( m , 1h ) , 7.40 ( d , j=8.5 hz , 2h ) , 7.33 - 7.36 ( m , 1h ) , 7.23 - 7.28 ( m , 3h ) 7.11 - 7.19 ( m , 5h ) , 6.91 - 6.96 ( m , 1h ) , 3.99 ( s , 3h ) , 3.68 ( s , 2h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.74 , 166.19 , 160.76 , 158.25 , 148.68 , 137.22 , 134.26 , 133.96 , 132.57 , 132.48 , 131.52 , 131.50 , 129.58 , 128.55 , 127.25 , 124.43 , 120.04 , 116.87 , 116.46 , 116.25 , 56.98 , 38.52 .
ei - hrms ( m / z ) : calcd . for c23h19fn4o2s 434.1213 , found 434.1213[m ] .
thymine-1-acetic acid ( 0.32 g , 1.76 mmol , edc ( 0.33 g , 1.76 mmol ) and dmap ( 0.050 g , 0.42 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 36 ( 0.5 g , 1.76 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography with dcm / meoh ( 9:1 ) as eluent system and then crystallized from ethanol to give the product as white crystals .
yield was 0.42 g ( 53% ) and mp was 200 - 202. h - nmr ( 300 mhz , dmso ) : 11.33 ( br s , 1h ) , 10.45 ( br s , 1h ) , 7.56 - 7.60 ( m , 4h ) , 7.50 ( s , 1h ) , 7.23 - 7.35 ( m , 4h ) , 4.49 ( s , 2h ) , 3.96 ( s , 3h ) , 1.76 ( s , 3 h ) .
c - nmr ( 75 mhz , dmso ) : 168.49 , 166.51 , 164.85 , 160.91 , 157.60 , 151.52 , 148.65 , 142.76 , 139.07 , 133.38 , 132.98 , 132.16 , 132.13 , 125.14 , 119.74 , 116.71 , 116.45 , 116.43 , 108.49 , 57.09 , 50.44 , 12.33 . ei - hrms ( m / z ) : calcd . for c22h19fn6o4 450.1452 , found 450.1452 [ m ] .
n-(4-(5-(2-fluorophenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(3,4-dihydro-2 - 4-dioxo - pyrimidin-1(2h)-yl))acetamide 47 was synthesized by the same procedure of 46 using uracil-1-acetic acid instead of thymine-1-acetic acid to give the product as white crystals .
yield was 0.27 g ( 35.1% ) and mp was 238 - 240. h - nmr ( 300 mhz , dmso ) : 11.34 ( br s , 1h ) , 10.47 ( br s , 1h ) , 7.52 - 7.62 ( m , 5h ) , 7.29 - 7.35 ( m , 1h ) , 7.23 - 6.27 ( m , 3h ) , 6.05 ( s , 2h ) , 5.59 ( dd , j=6.12 hz , j=2.26 hz , 1h ) , 4.53 ( s , 2h ) , 3.96 ( s , 3h ) .
c - nmr ( 75 mhz , dmso ) : 168.49 , 166.40 , 164.27 , 160.91 , 157.60 , 151.54 , 148.64 , 147.01 , 139.06 , 133.48 , 133.27 , 132.99 , 132.16 , 125.16 , 119.74 , 116.70 , 116.45 , 116.43 , 101.05 , 57.09 , 50.62 .
ei - hrms ( m / z ) : calcd . for c21h17fn6o4 436.1295 , found 436.1292 [ m ] .
yield , ( 0.48 g , 53% ) , mp 126 - 128. h - nmr ( 300 mhz , cdcl3 ) : 8.60 ( br s , 1h ) , 7.44 ( d , j=8.5 hz , 2h ) , 7.15 - 7.27 ( m , 8h ) , 7.01 - 7.09 ( m , 1h ) , 6.86 - 6.94 ( m , 1h ) 3.99 ( s , 3h ) , 3.69 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.76 , 166.21 , 160.10 , 160.05 , 157.11 , 156.79 , 153.85 , 153.79 , 147.51 , 137.46 , 133.91 , 129.59 , 128.56 , 127.27 , 124.46 , 120.09 , 119.36 , 118.93 , 117.71 , 57.04 , 38.53 .
ei - hrms ( m / z ) : calcd . for c23h18f2n4o2s 452.1119 , found 452.1118 [ m ] .
yield , ( 0.97 g , 54% ) , mp 150 - 152. h - nmr ( 300 mhz , cdcl3 ) : 8.59 ( br s , 1h ) , 7.45 - 7.49 ( m , 1h ) , 7.32 - 7.41 ( m , 3h ) , 7.23 - 7.27 ( m , 3h ) 7.11 - 7.19 ( m , 4h ) , 6.91 - 6.95 ( m , 1h ) , 4.35 ( q , j=7.00 hz , 2h ) , 3.68 ( s , 2h ) , 1,38 ( t , j=7.10 hz , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.15 , 166.17 , 160.75 , 158.24 , 148.48 , 137.14 , 133.97 , 132.51 , 132.42 , 131.52 , 131.51 , 129.58 , 128.53 , 127.23 , 124.38 , 120.04 , 116.87 , 116.46 , 116.25 , 65.70 , 38.51 , 14.78 . ei - hrms ( m / z ) : calcd . for c24h21fn4o2s 448.1369 , found 448.1367 [ m ] .
thymine-1-acetic acid ( 0.31 g , 1.68 mmol , edc ( 0.32 g , 1.68 mmol ) and dmap ( 0.050 g , 0.42 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 39 ( 0.5 g , 1.68 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at room temperature .
the crude product was purified by silica gel chromatography ( dcm / meoh , 9:1 ) as eluent system and then crystallized from ethanol to give the product as white powder with a yield of 0.41 g ( 52% ) and mp of 241 - 243. h - nmr ( 300 mhz , dmso ) : 11.33 ( br s , 1h ) , 10.44 ( br s , 1h ) , 7.53 - 7.60 ( m , 4h ) , 7.49 ( s , 1h ) , 7.21 - 7.35 ( m , 4h ) , 4.49 ( s , 2h ) , 4.33 ( q , j=7.4 hz , 2h ) , 1.76 ( s , 3 h ) , 1.37 ( t , j=7.4 hz , 3h ) .
c - nmr ( 75 mhz , dmso ) : 167.84 , 166.50 , 164.85 , 160.91 , 157.60 , 151.52 , 148.43 , 142.76 , 139.03 , 133.44 , 132.99 , 132.16 , 132.13 , 125.09 , 119.74 , 116.70 , 108.49 , 65.54 , 50.44 , 15.01 , 12.33 .
ei - hrms ( m / z ) : calcd . for c23h21fn6o4 464.1608 , found 464.1614 [ m ] .
yield : ( 0.39 g , 42.4% ) , mp 156 - 158. h - nmr ( 400 mhz , cdcl3 ) : 8.60 ( br s , 1h ) , 7.40 ( d , j=8.5 hz , 2h ) , 7.17 - 7.26 ( m , 6h ) , 7.15 ( d , j=8.5 hz , 2h ) , 7.02 - 7.07 ( m , 1h ) , 6.87 - 6.93 ( m , 1h ) , 4.34 ( q , j=7.20 hz , 2h ) , 3.69 ( s , 2h ) , 4.34 ( t , j=7.20 hz , 3h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.18 , 166.20 , 159.70 , 157.25 , 157.20 , 156.70 , 154.21 , 147.31 , 137.38 , 133.92 , 129.60 , 128.54 , 127.27 , 124.41 , 120.09 , 119.02 , 118.05 , 118.02 , 117.85 , 117.81 , 117.77 , 65.81 , 38.52 , 14.75 .
ei - hrms ( m / z ) : calcd . for c24h20f2n4o2s 466.1275 , found 466.1269 [ m ] .
n-(4-(5-(4-tert - butylphenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(phenylthio)-acetamide 52 was prepared by the same method of 45 using amine 41 .
yield : ( 0.41 g , 42.3% ) , mp 167 - 169. h - nmr ( 300 mhz , cdcl3 ) : 8.68 ( br s , 1h ) , 7.48 ( d , j=8.5 hz , 2h ) , 7.19 - 7.33 ( m , 11h ) , 3.97 ( s , 3h ) , 3.70 ( s , 2h ) , 1.21 ( s , 9 h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.43 , 166.32 , 153.48 , 153.37 , 137.57 , 134.59 , 134.02 , 129.58 , 128.49 , 128.59 , 127.24 , 126.26 , 125.57 , 124.69 , 120.28 , 56.85 , 38.57 , 34.86 , 31.14 .
ei - hrms ( m / z ) : calcd . for c27h28n4o2s 472.1933 , found 472.1926 [ m ] .
thymine-1-acetic acid ( 0.29 g , 1.55 mmol , edc ( 0.30 g , 1.55 mmol ) and dmap ( 0.037 g , 0.31 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 41 ( 0.5 g , 1.55 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography ( dcm / meoh , 9:1 ) as eluent system to give the product as white powder .
yield , ( 0.24 g , 32% ) , mp 225 - 227. h - nmr ( 300 mhz , dmso ) : 11.35 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.66 ( d , j=8.6 hz , 2h ) , 7.51 ( s , 1h ) , 7.31 -7.42 ( m , 6h ) , 4.53 ( s , 2h ) , 3.93 ( s , 3h ) , 1.77 ( s , 3 h ) , 1.24 ( s , 9h ) . 13c - nmr ( 75 mhz , dmso ) : 168.11 , 166.60 , 164.85 , 153.28 , 151.55 , 142.77 , 139.57 , 133.51 , 128.53 , 127.23 , 125.88 , 124.98 , 119.92 , 108.52 , 56.90 , 50.52 , 34.99 , 31.27 , 12.34 . ei - hrms ( m / z ) : calcd . for c26h28n6o4 488.2172 , found 488.2169 [ m ] .
yield ( 71 mg , 86.6% ) , mp 204 - 206. h - nmr ( 400 mhz , cdcl3 ) : 8.68 ( br s , 1h ) , 7.61 - 7.65 ( m , 2h ) , 7.47 - 7.52 ( m , 3h ) , 7.35 - 7.41 ( m , 3h ) 7.13 - 7.19 ( m , 3h ) , 6.93 - 6.97 ( m , 1h ) , 4.36 ( q , j=7.00 hz , 2h ) , 4.11 ( s , 2h ) , 1,39 ( t , j=7.10 hz , 3h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.15 , 166.74 , 158.63 , 148.54 , 137.97 , 136.90 , 134.79 , 132.60 , 132.52 , 131.53 , 131.52 , 129.67 , 128.16 , 127.72 , 124.68 , 124.44 , 120.45 , 116.48 , 116.27 , 65.77 , 62.87 , 14.77 .
ei - hrms ( m / z ) : calcd . for c24h21fn4o4s 480.1268 , found 408.1061 [ m ] .
to a solution of amine 42 ( 0.265 g , 0.84 mmol , 1 eq . ) and triethyl amine ( 0.24 ml , 1.68 mmol , 2 eq . ) in dcm ( 15 ml ) was added thiophene-2-acetylchloride ( 0.135 g , 0.105 ml , 0.84 mmol , 1 eq . ) .
the reaction mixture was diluted with dichloromethane ( 40 ml ) , washed with 5% aq .
the crude product was purified by silica gel chromatography using cyclohexane : etoac ( 1:1 ) and then repurified using another eluent system of cyclohexane : etoac ( 2:3 ) to afford the pure target product with a yield of 0.1 g ( 23% ) and mp 153 - 155. h - nmr ( 300 mhz , cdcl3 ) : 7.57 ( br s , 1h ) , 7.46 ( d , j=8.6 hz , 2h ) , 7.11 - 7.25 ( m , 6h ) , 6.97 - 7.01 ( m , 3h ) , 3.98 ( s , 3h ) , 3.89 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.37 , 168.07 , 163.68 , 161.22 , 151.94 , 151.91 , 138.20 , 135.23 , 133.78 , 129.46 , 127.71 , 126.19 , 124.57 , 124.53 , 120.33 , 117.36 , 117.15 , 116.08 , 115.84 , 57.01 , 38.55 .
ei - hrms ( m / z ) : calcd . for c21h17 fn4o2s 408.1056 , found 408.1061[m ] .
yield ( 0.250 g , 35.7% ) , mp 214 - 216. h - nmr ( 300 mhz , cdcl3 ) : 7.59 ( br s , 1h ) , 7.45 ( d , j=8.6 hz , 2h ) , 7.10 - 7.25 ( m , 6h ) , 6.96 - 7.03 ( m , 3h ) , 4.35 ( q , j=7.00 hz , 2h ) , 3.88 ( s , 2h ) , 1.38 ( t , j=7.10 hz , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.06 , 167.86 , 164.07 , 160.79 , 151.79 , 151.75 , 138.12 , 135.24 , 133.87 , 130.33 , 130.22 , 127.69 , 126.16 , 124.52 , 124.47 , 120.32 , 117.01 , 116.08 , 115.76 , 65.69 , 38.53 , 14.75 .
ei - hrms ( m / z ) : calcd . for c22h19fn4o2s 422.1213 , found 422.1216 [ m ] .
n-(4-(5-(2,5-difluorophenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(thiophen-2-yl)-acetamide 57 . to a solution of amine 37 ( 0.61 g , 2.01 mmol , 1 eq . ) and triethyl amine ( 0.56 ml
, 4.02 mmol , 2 eq . ) in dichloromethane ( 15 ml ) was added thiophene-2-acetylchloride ( 0.323 g , 0.25 ml , 2.01 mmol , 1 eq . ) .
the reaction mixture was diluted with dichloromethane ( 40 ml ) , washed with 5% aq .
the crude product was purified by silica gel chromatography ( cyclohexane : etoac , 1:1 ) two times to give the pure product .
yield : ( 0.26 g , 30% ) , mp 172 - 174. h - nmr ( 300 mhz , cdcl3 ) : 7.47 ( br s , 1h ) , 7.39 ( d , j=8.5 hz , 2h ) , 7.17 - 7.24 ( m , 2h ) , 7.14 ( d , j=8.5 hz , 2h ) , 6.97 - 7.08 ( m , 1h ) , 6.85 - 6.95 ( m , 3h ) , 3.99 ( s , 3h ) , 3.86 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.75 , 167.96 , 160.09 , 160.03 , 156.77 , 153.78 , 147.53 , 137.70 , 135.23 , 133.81 , 127.93 , 127.70 , 126.24 , 124.42 , 120.08 , 119.36 , 118.92 , 117.90 , 57.04 , 38.52 .
ei - hrms ( m / z ) : calcd . for c21h16f2n4o2s 426.0962 , found 426.0964 [ m ] .
yield ( 0.27 g , 30% ) , mp 208 - 210. h - nmr ( 300 mhz , cdcl3 ) : 7.43 ( br s , 1h ) , 7.39 ( d , j=8.5 hz , 2h ) , 7.19 - 7.25 ( m , 2h ) , 7.13 ( d , j=8.5 hz , 2h ) , 7.01 - 7.07 ( m , 1h ) , 6.95 - 6.98 ( m , 2h ) , 6.85 - 6.93 ( m , 1h ) , 4.34 ( q , j=7.2 hz , 2h ) , 3.87 ( s , 2h ) , 1.39 ( t , j=7.2 hz , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 167.93 , 160.09 , 160.03 , 156.82 , 153.83 , 147.31 , 137.62 , 135.23 , 133.88 , 127.95 , 127.71 , 126.26 , 124.38 , 120.06 , 118.87 , 118.08 , 117.71 , 65.82 , 38.53 , 14.74 .
ei - hrms ( m / z ) : calcd . for c22h18f2n4o2s 440.1119 , found 440.1113 [ m ] . [ 17]arf1 and arno - sec-7 were subcloned into pet15 vectors ( novagen ) as described previously .
n - terminal truncated [ 17]arf1 ( amino acids 18 - 181 ) , lacking the first 17 amino acids and cytohesin-1-sec-7 were expressed in escherichia coli and purified by ni - nta chromatography ( ni - nta agarose , quiagen ) .
gdp / gtp exchange was measured on [ 17]arf1 by tryptophan fluorescence because a large increase in intrinsic fluorescence of arf occurs upon exchange of gdp for gtp .
all measurements were performed in pbs ph 7.4 , 3 mm mgcl2 at 37. [ 17]arf1 ( 1 m ) in pbs without mgcl2 was preincubated with gdp ( 80 m ) in the presence of edta ( 2 mm ) for 15 min .
the bound gdp was stabilized by addition of mgcl2 ( final concentration 3 mm ) and incubation for 5 min . for each exchange reaction 250 nm [
17]arf1 was mixed with 10 nm arno - sec-7 ( total volume 200 l ) in the absence or presence of inhibitor .
the tryptophan fluorescence was measured at an excitation and emission wavelength of 280 and 340 nm , respectively .
all fluorescent measurements were performed with a varioskan microplate reader ( thermo scientific ) , in 96-well plates . for analysis
hepg2 cells ( ecacc ) 10 were seeded in 12 well plates and cultured for 24 h in emem ( cambrex ) containing 10% fcs .
cells were then serum starved in emem for 24 h and stimulated for 12 h with 10 nm insulin in the presence of the inhibitor secinh3 or control , with 0.8% final concentration of dmso .
total mrna was prepared using the absolutely rna kit ( stratagene ) and cdna for qpcr was generated from 1 g rna with the high capacity cdna archive kit ( applied biosystems ) .
qpcr was performed in a 10 l scale on an iq5-cycler ( biorad ) using a taqman gene expression assay for igfbp1 ( applied biosystems ) .
to a solution of acid chloride derivative ( 1 , 17a - e ) ( 37,84 mmol ) in acetone ( 60 ml ) , potassium thiocyanate ( 3.68 g , 37.84 mmol , 1.0 eq . ) under efficient stirring .
the reaction mixture was refluxed at 60 for 60 - 120 min and monitored using tlc until the start is completely disappeared .
ethanol or methanol ( 94.60 mmol , 2.5 eq . ) was added drop wise and the reaction mixture was refluxed for 4 - 7 h and then cooled , filtered , washed with acetone ( 15 ml ) .
the filtrate was evaporated and the residue was purified either by silica gel chromatography if it is oil or by crystallization if it is solid to afford the desired product .
the molecular characteristics of o - methyl - n-(benzoyl)thiocarbamate 19 as representative example for this series are as follow , ( 300 mhz , cdcl3 ) : 9.16 ( br , 1h ) , 7.75 ( m , 2h ) , 7.51 ( m , 1h ) , 7.42 ( m , 2h ) , 4.13 ( s , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 190.38 , 162.51 , 133.27 , 132.83 , 129.06 , 127.73 , 59.62 .
ei - hrms ( m / z ) : calcd . for c9h9no2s 195.0354 , found 195.0359 [ m ] .
o - methyl - n - acyl - thiocarbamate or o - ethyl - n - acyl - thiocarbamate derivative 3 , 19 - 26 ( 28.01 mmol , 1 eq . ) and p - nitrophenyl - hydrazine ( 4.29 g ; 28.01 mmol , 1 eq . ) were suspended in ethanol ( 30.0 ml ) in a round - bottom flask equipped with a reflux condenser and a bubbler .
the reaction mixture was refluxed for 12 - 20 h. during the course of the reaction h2s evolution was observed .
the reaction mixture was cooled and the precipitated product was filtered off followed by thorough washing cycles with cold ethanol .
the residue was purified using silica gel column or crystallized from ethanol to afford the nitro - triazole derivatives 4 , 26 - 32 as yellow solid . the molecular characteristics of 3-methoxy-1-(4-nitrophenyl)-5-phenyl-1h-1,2,4-triazole 27 as representitve example for this series are as follow , h - nmr ( 400 mhz , dmso ) : 8.31 ( d , j=9.19 hz , 2h ) , 7.61 ( d , j=9.19 hz , 2h ) , 7.47 ( m , 5h ) , 3.98 ( s , 3h ) .
c - nmr ( 100 mhz , dmso ) : 168.63 , 154.21 , 146.96 , 142.86 , 131.09 , 129.32 , 129.29 , 127.64 , 126.25 , 125.30 , 57.23 .
ei - hrms ( m / z ) : calcd . for c15h12n4o3 296.0909 , found 296.0908 [ m ] .
as per method a , nitrotriazole derivative 4 , 27 - 34 ( 0.63 g , 1.85 mmol , 1 eq . ) , ammonium chloride ( 0.30 g , 5.61 mmol , 3.0 eq . ) and fe powder ( 0.52 g , 9.31 mmol , 5 eq . ) were suspended in 1:1 solution of methanol and water ( 20 ml ) .
concentrated hcl ( 0.25 ml ) was added to the above reaction mixture and was heated at 65 for 3 h. the reaction mixture was filtered when hot and was washed several times with hot methanol ( 815 ml ) .
the filtrate was evaporated to remove methanol and the precipitated product was filtered and washed with cold water .
the crude product was purified by silica gel chromatography to afford the product as pale white solid .
b , to a suspension of the nitro derivative 4 , 27 - 34 ( 7.61 mmol ) in ethanol ( 70 ml ) , ( pd / c10% 2.87 g ) was added portion wise after washing with argon gas three times .
the reaction mixture was transferred into autoclave under h2 atmosphere and 20 bar pressure and stirred overnight .
the reaction mixture was filtered through celite pad and was washed with ethanol ( 120 ml ) and then hot methanol ( 5120 ml ) .
the solvent was concentrated and the rest was cooled in the refrigerator to afford the amine product ( 5 , 35 - 42 ) as white crystals .
the molecular characteristics of 4-(3-methoxy-5-phenyl-1h-1,2,4-triazol-1-yl)phenyl amine 35 as representative example of this series are as follows , h - nmr ( 300 mhz , dmso ) : 7.33 - 7.45 ( m , 5h ) , 6.99 ( d , j=8.5 hz , 2h ) , 6.57 ( d , j=8.5 hz , 2h ) , 5.49 ( br s , 2h ) , 3.91 ( s , 3h ) .
c - nmr ( 75 mhz , dmso ) : 167.80 , 152.73 , 149.97 , 130.20 , 128.88 , 128.69 , 128.17 , 127.41 , 126.56 , 114.04 , 56.77 .
ei - hrms ( m / z ) : calcd . for c19h22n4o 322.1794 , found 322.1790 [ m ] .
yield obtained was 76% with an mp 198 - 200. n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)2-(phenylthio)-acetamide 6 was synthesized by adding to a solution of 5 ( 1.277 g , 4.12 mmol , 1 eq . ) and triethyl amine ( 1.14 ml , 8.22 mmol , 2 eq . ) in dichloroethane ( 20 ml ) and phenylthioacetyl chloride ( 0.61 ml , 4.11 mmol , 1 eq . ) .
the reaction mixture was stirred overnight at room temperature ( rt ) and was diluted with dichloromethane ( 100 ml ) .
the reaction mixture was washed with 5% aqueous na2co3 solution ( 25 ml ) and water ( 250 ml ) , respectively .
the crude product was purified by silica gel chromatography using ethylactate / cyclohexane ( 1:1 ) as eluent system to give the product as pale white foam .
yield obtained was 67% , mp 202 - 204. h - nmr ( 400 mhz , cdcl3 ) : 8.60 ( br , 1h ) , 7.48 ( d , j=8.84 hz , 2h ) , 7.30 - 7.18 ( m , 7h ) , 6.90 ( dd , j=8.08 hz , j=1.64 hz , 1h ) , 6.87 ( d , j=1.64 hz , 1h ) , 6.66 ( d , j=8.08 hz , 1h ) , 5.90 ( s , 2h ) , 3.97 ( s , 3h ) , 3.71 ( s , 2h ) ; c - nmr ( 100 mhz , d6-dmso ) : 167.48 , 167.16 , 152.45 , 148.67 , 147.23 , 139.19 , 135.66 , 132.90 , 128.99 , 128.15 , 126.44 , 126.05 , 123.18 , 120.99 , 119.52 , 108.40 , 108.36 , 101.63 , 56.41 , 37.52 ; fab ( m / z ) : 461.1 [ m + 1 ] .
2-(4-hydroxyphenylthio)-n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl ) acetamide 7 was synthesised by adding under argon atmosphere , to a solution of 4-hydroxyphenylthioacetic acid ( 0.42 g , 2.26 mmol ) , edc ( 0.44 g , 2.26 mmol ) and dmap ( 0.09 g , 0.74 mmol ) in dcm ( 10 ml ) and dmf ( 6 ml ) , the triazole amine derivative 5 ( 0.7 g , 2.26 mmol ) .
after the reaction mixture was stirred at rt overnight , the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using ( cyclohexane / ethylacetate 1:1 ) as eluent system to give the product as white powder .
yield obtained was 0.32 g , ( 31% ) and the mp was 212 - 214. h - nmr ( 400 mhz , d6-dmso ) : 10.27 ( br s , 1h ) , 9.59 ( br s , 1h ) , 7.63 ( d , j=8.5 hz , 2h ) , 7.28 - 7.32 ( m , 4h ) , 6.88 - 6.91 ( m , 3h ) , 6.72 ( d , j=8.5 hz , 2h ) , 6.05 ( s , 2h ) , 3.92 ( s , 3h ) , 3.65 ( s , 2h ) .
c - nmr ( 100 mhz , d6-dmso ) : 168.03 , 157.65 , 152.92 , 149.93 , 149.16 , 147.71 , 139.76 , 133.69 , 126.91 , 123.65 , 123.38 , 121.46 , 119.97 , 116.52 , 108.89 , 108.85 , 102.13 , 56.89 , 40.68 .
ei - hrms ( m / z ) : calcd . for c24h20n4o5s 476.1154 , found 476.1156 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(phenyl - sulfonyl)acetamide 8 was prepared by adding to a stirred solution of 6 ( 117 mg , 0.254 mmol ) in dcm ( 5 ml ) , a solution of peracetic acid ( 39% in acoh , 175 mg , 1.07 mmol ) .
the reaction mixture was stirred for 7 h before being extracted with dcm ( 30 ml ) and water ( 30 ml ) .
the organic phase was washed with water ( 225 ml ) and the combined aqueous phases were extracted with dcm ( 50 ml ) .
the combined organic phases were dried over mgso4 and evaporated in vacuo to yield the product as white powder , which purified by column chromatography using ethylactate / cyclohexane ( 1:1 ) as eluent system .
yield obtained was 0.105 mg ( 84% ) with an mp of 217 - 219. h - nmr ( 300 mhz , cdcl3 ) : 8.65 ( br s , 1h ) , 7.85 ( d , j=8.85 hz , 2h ) , 7.62 - 7.68 ( m , 1h ) , 7.49 - 7.55 ( m , 4h ) , 7.25 ( d , j=8.85 hz , 2h ) , 6.87 - 6.93 ( m , 2h ) 6.67 ( d , j=8.05 hz , 1h ) , 5.92 ( s , 2h ) , 4.11 ( s , 2h ) , 3.98 ( s , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.32 , 158.57 , 153.09 , 149.27 , 147.80 , 137.87 , 137.23 , 134.87 , 134.80 , 129.74 , 128.12 , 126.28 , 123.67 , 121.28 , 120.65 , 109.09 , 108.53 , 101.60 , 62.84 , 56.89 .
ei - hrms ( m / z ) : calcd . for c24h20n4o6s 492.1104 , found 492.1105 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(pyridin-2-ylthio)acetamide 9 was sythesised as follows . to a solution of ( 2-pyridylthio)acetic acid ( 0.55 g , 3.2 mmol ) , edc ( 0.617 g , 3.2 mmol ) and dmap ( 0.12 g , 0.99 mmol ) in dcm ( 10 ml ) and dmf ( 5 ml ) under argon atmosphere ,
the reaction mixture was stirred at rt overnight and the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using 3 - 7% meoh / dcm to give the desired product with an yield of 51 % ( 0.76 g ) and mp 176 - 178. h - nmr ( 300 mhz , cdcl3 ) : 10.40 ( br s , 1h ) , 8.46 - 8.49 ( m , 1h ) , 7.47 - 7.50 ( m , 3h ) , 7.18 - 7.28 ( m , 3h ) , 7.07 - 7.11 ( m , 1h ) , 6.86 - 6.90 ( m , 2h ) , 6.64 ( dd , j=8.40 hz , j=1.00 hz , 1h ) , 5.90 ( s , 2h ) , 3.96 ( s , 3h ) , 3.81(s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.50 , 158.12 , 152.93 , 148.91 , 147.70 , 138.85 , 137.10 , 133.64 , 126.19 , 123.59 , 122.99 , 121.47 , 120.86 , 119.83 , 109.09 , 108.43 , 101.52 , 56.83 , 35.37 .
ei - hrms ( m / z ) : calcd . for c23h19n5o2s 461.1158 , found 461.1160 [ m ] .
yield ( 0.77 g , 52 % ) , mp 198 - 200. h - nmr ( 300 mhz , cdcl3 ) : 8.67 ( br s , 1h ) , 8.39 ( d , j=5.85 hz , 2h ) , 7.47 ( d , j=8.88 hz , 2h ) , 7.21 ( d , j=8.88 hz , 2h ) , 7.11 ( d , j=5.85 hz , 2h ) , 7.30 - 7.18 ( m , 7h ) , 6.90 ( dd , j=8.08 hz , j=1.64 hz , 1h ) , 6.87 ( d , j=1.64 hz , 1h ) , 6.65 ( d , j=7.93 hz , 1h ) , 5.90 ( s , 2h ) , 3.96 ( s , 3h ) , 3.78 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.27 , 165.35 , 153.04 , 149.84 , 149.26 , 147.77 , 146.26 , 137.41 , 134.54 , 126.15 , 123.64 , 121.23 , 120.47 , 109.02 , 108.52 , 101.61 , 56.90 , 35.62 .
ei - hrms ( m / z ) : calcd . for c23h19n5o2s 461.1158 , found 461.1152 [ m ] .
thymine-1-acetic acid ( 0.30 g , 1.61 mmol , edc ( 0.31 g , 1.61mmol ) and dmap ( 0.037 g , 0.31 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 5 ( 0.5 g , 1.61 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using dcm / meoh ( 9:1 ) as eluent system to give the product as white powder .
yield obtained was ( 25 g ) 32.5 % , with a mp of 197 - 199. h - nmr ( 300 mhz , dmso ) : 11.34 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.68 ( d , j=8.6 hz , 2h ) , 7.51 ( s , 1h ) , 7.34 ( d , j=8.6 hz , 2h ) , 6.87 - 6.94 ( m , 3h ) , 6.05 ( s , 2h ) , 4.52 ( s , 2h ) , 3.92 ( s , 3h ) , 1.77 ( s , 3 h ) .
c - nmr ( 75 mhz , dmso ) : 167.96 , 166.58 , 164.85 , 152.94 , 151.54 , 149.15 , 147.71 , 142.77 , 139.48 , 133.36 , 127.07 , 123.63 , 121.43 , 119.90 , 108.88 , 188.83 , 108.51 , 102.13 , 56.90 , 50.49 , 12.33 . ei - hrms ( m / z ) : calcd . for c23h20n6o6 476.1444 , found 476.1448 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(thiophen-3-yl)acetamide 12 was prepared . to a solution of 3-thiopheneacetic acid ( 0.23 g , 1.6 mmol , edc ( 0.309 g , 1.6 mmol ) and dmap ( 0.06 g , 0.50 mmol ) in dcm ( 10 ml ) and dmf ( 3 ml ) under argon atmosphere , the amine 5 ( 0.5 g , 1.6 mmol ) was added .
the reaction mixture was stirred at rt overnight and then the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using cyclohexane / ethylacetate ( 1:2 ) as eluent to give the product as white crystals .
yield was 0.22 g ( 31.4% ) and mp was 213 - 215. h - nmr ( 300 mhz , cdcl3 ) : 10.05 ( br s , 1h ) , 7.78 ( d , j=8.80 hz , 2h ) , 7.38 ( dd , j=2.83 hz , j=2.08 hz , 1h ) , 7.29 - 7.32 ( m , 3h ) , 7.18 ( dd , j=3.78 hz , j=1.13 hz , 1h ) , 7.01 ( dd , j=6.42 hz , j=1.69 hz , 1h ) , 6.96 ( d , j=1.51 hz , 1h ) , 6.80 ( d , j=8.12 hz , 1h ) , 6.05 ( s , 2h ) , 4.06 ( s , 3h ) , 3.78 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 174.18 , 172.79 , 157.50 , 153.86 , 152.44 , 144.45 , 139.99 , 137.93 , 133.38 , 130.72 , 128.20 , 127.27 , 126.10 , 124.78 , 113.61 , 113.16 , 106.39 , 61.46 , 43.49 .
ei - hrms ( m / z ) : calcd . for c22h18n4o4s 434.1049 , found 434.1042 [ m ] .
( 0.39 g , 2.26 mmol , edc ( 0.44 g , 2.26 mmol ) , tea ( 0.6 ml , 4.54 mmol ) and dmap ( 0.09 g , 0.74 mmol ) in dcm ( 20 ml ) under argon atmosphere , the amine 5 ( 7.0 g , 2.26 mmol ) was added .
the reaction mixture was stirred at rt overnight and then the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using dcm / meoh ( 3 - 6% ) as eluent to give the product as white crystals .
yield was 0.61 g ( 62% ) and the mp was 180 - 182. h - nmr ( 400 mhz , cdcl3 ) : 10.20 ( br s , 1h ) , 8.56 ( d , j=4.90 hz , 1h ) , 7.63 - 7.67 ( m , 1h ) , 7.57 ( d , j=8.31 hz , 2h ) , 7.19 - 7.24 ( m , 4h ) , 6.86 - 6.90 ( m , 2h ) , 6.64 ( d , j=8.18 hz , 1h ) , 5.89 ( s , 2h ) , 3.96 ( s , 3h ) , 3.82 ( s , 2h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.27 , 167.23 , 155.12 , 152.97 , 148.94 , 147.70 , 138.59 , 137.69 , 133.97 , 126.19 , 124.45 , 123.61 , 122.48 , 121.48 , 120.18 , 109.10 , 108.42 , 101.53 , 56.84 , 45.52 .
ei - hrms ( m / z ) : calcd . for c23h19n5o4 429.1437 , found 429.1432 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(pyridin-4-yl)acetamide 14 was prepared using the same procedure of 13 using instead 4-pyridylacetic acid hydrochloride to afford 14 as a white powder .
yield was 0.76 g ( 78.4% ) and the mp was 214 - 216. h - nmr ( 300 mhz , d6-dmso ) : 10.48 ( br s , 1h ) , 8.51 ( d , j=5.30 hz , 2h ) , 7.69 ( d , j=8.85 hz , 2h ) , 7.31 - 7.36 ( m , 4h ) , 6.87 - 6.91 ( m , 3h ) , 6.86 - 6.90 ( m , 2h ) , 6.05 ( s , 2h ) , 3.92 ( s , 3h ) , 3.74 ( s , 2h ) .
c - nmr ( 75 mhz , d6-dmso ) : 168.61 , 167.94 , 152.91 , 149.93 , 149.15 , 147.70 , 144.83 , 139.83 , 133.27 , 126.93 , 125.13 , 123.66 , 121.46 , 119.99 , 108.88 , 108.83 , 102.12 , 56.89 , 42.78 .
ei - hrms ( m / z ) : calcd . for c23h19n5o4 429.1437 , found 429.1446 [ m ] .
n-(4-(5-(benzo[d]dioxol-5-yl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl-2-(1h - imidazol-4-yl)acetamide 15 was prepared in the following manner . to a solution of imidazole-4-acetic acid hydrochloride
( 0.185 g , 1.13 mmol , edc ( 0.22 g , 1.13 mmol ) and dmap ( 0.045 g , 0.37 mmol ) in dcm ( 5 ml ) and dmf ( 10 ml ) under argon atmosphere , the amine 5 ( 0.35 g , 1.13 mmol ) was added .
the reaction mixture was stirred overnight at rt and the solvent was evaporated under reduced pressure .
the crude product was purified by silica gel chromatography using meoh / dcm ( 5 - 8% ) to give the desired product .
yield obtained was 0.15 g ( 28% ) and the mp was 196 - 198. h - nmr ( 400 mhz , d6-dmso ) : 11.91 ( br s , 1h ) , 10.34 ( br s , 1h ) , 7.70 ( d , j=8.5 hz , 2h ) , 7.56 ( s , 1h ) , 7.31 ( d , j=8.5 hz , 2h ) , 6.94 ( s , 1h ) , 6.87 - 6.94 ( m , 3h ) , 6.05 ( s , 2h ) , 3.91 ( s , 3h ) , 3.33 ( s , 2h ) .
c - nmr ( 100 mhz , d6-dmso ) : 167.92 , 152.90 , 149.13 , 147.69 , 140.15 , 135.32 , 133.02 , 126.91 , 123.61 , 123.38 , 121.47 , 119.82 , 108.87 , 108.81 , 102.11 , 56.88 , 49.01 .
ei - hrms ( m / z ) : calcd . for c21h18n6o4 418.1390 , found 418.1391 [ m ] .
uracil-1-acetic acid ( 0.274 g , 1.61 mmol , edc ( 0.31 g , 1.61 mmol ) and dmap ( 0.037 g , 0.31 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 5 ( 0.5 g , 1.61 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography dcm / meoh ( 9:1 ) as eluent system to give the product as white crystals with an yield of 0.24 g ( 32% ) and mp of 252 - 254. h - nmr ( 300 mhz , dmso ) : 11.35 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.61 - 7.69 ( m , 3h ) , 7.35 ( d , j=8.31 hz , 2h ) , 6.87 - 6.94 ( m , 3h ) , 6.05 ( s , 2h ) , 5.60 ( d , j=8.12 hz , 1h ) , 4.57 ( s , 2h ) , 3.92 ( s , 3h ) .
c - nmr ( 75 mhz , dmso ) : 167.96 , 166.48 , 164.28 , 152.94 , 151.56 , 149.15 , 147.71 , 147.02 , 139.45 , 133.39 , 127.09 , 123.63 , 121.42 , 119.90 , 108.88 , 102.13 , 101.07 , 56.90 , 50.66 .
ei - hrms ( m / z ) : calcd . for c22h18n6o6 462.1288 , found 462.1289 [ m ] .
n-(4-(3-methoxy-5-phenyl-1h-1,2,4-triazol-1-yl)phenyl)-2-(phenylthio)-acetamide 43 . to a solution of amine 35 ( 0.546 g , 2.05 mmol , 1 eq . ) and triethyl amine ( 0.57 ml
, 4.10 mmol , 2 eq . ) in dcm ( 15 ml ) was added phenylthioacetyl chloride ( 0.3 ml , 2.06 mmol , 1 eq . ) .
phenylthioacetyl chloride ( 0.1 ml , 0.67 mmol ) was added and then reaction was refluxed for 3 h. the reaction mixture was diluted with dichloromethane ( 50 ml ) and the reaction mixture was washed with 5% aq .
the crude product was purified by silica gel chromatography using cyclohexane : etoac ( 3:2 ) as eluent to give the product as white crystals .
yield , ( 0.38 g , 44 % ) , mp 120 - 122. h - nmr ( 300 mhz , cdcl3 ) : 8.65 ( br s , 1h ) , 7.46 ( d , j=8.5 hz , 2h ) , 7.38 ( d , j=8.5 hz , 2h ) , 7.11 - 7.30 ( m , 10h ) , 3.98 ( s , 3h ) , 3.70 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.50 , 166.29 , 153.29 , 137.59 , 134.39 , 133.96 , 130.14 , 129.60 , 128.87 , 128.61 , 128.59 , 127.69 , 127.27 , 126.14 , 120.28 , 56.91 , 38.55 .
ei - hrms ( m / z ) : calcd . for c23h20n4o2s 416.1307 , found 416.1307 [ m ] .
thymine-1-acetic acid ( 0.28 g , 1.5 mmol , edc ( 0.29 g , 1.5 mmol ) and dmap ( 0.030 g , 0.25 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 35 ( 0.4 g , 1.5 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography dcm / meoh ( 9:1 ) to give the product as white crystals of an yield of 0.2 g ( 30.77% ) and mp of 199 - 201. h - nmr ( 300 mhz , dmso ) : 11.34 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.67 ( d , j=8.5 hz , 2h ) , 7.51 ( s , 1h ) , 7.39 - 7.41 ( m , 5h ) , 7.34 ( d , j=8.5 hz , 2h ) , 4.52 ( s , 2h ) , 3.94 ( s , 3h ) , 1.77 ( s , 3 h ) .
c - nmr ( 75 mhz , dmso ) : 168.16 , 166.58 , 164.85 , 153.17 , 151.54 , 142.78 , 139.53 , 133.31 , 130.52 , 129.04 , 127.84 , 127.02 , 119.88 , 114.04 , 108.52 , 56.95 , 50.50 , 12.33 . ei - hrms ( m / z ) : calcd . for c22h20n8o4 432.1546 , found 432.1546 [ m ] .
, 1.01 mmol , 1 eq . ) and triethyl amine ( 0.28 ml , 2.01 mmol , 2 eq . ) in dcm ( 10 ml ) was added phenylthioacetyl chloride ( 0.15 ml , 1.01 mmol , 1 eq . ) .
the reaction mixture was stirred overnight at room temperature , 0.15 ml of phenylthioacetyl chloride was added and then the reaction was stirred at 55 for 3 h. the reaction mixture was diluted with dichloromethane ( 70 ml ) .
the reaction mixture was washed with 5% aquous na2co3 solution ( 15 ml ) and water ( 225 ml ) , respectively .
the crude product was purified by silica gel chromatography to give the product as pale white foam like crystals with a yield of 0.2 g ( 46% ) and mp of 122 - 124. h - nmr ( 400 mhz , cdcl3 ) : 8.60 ( br s , 1h ) , 7.45 - 7.49 ( m , 1h ) , 7.40 ( d , j=8.5 hz , 2h ) , 7.33 - 7.36 ( m , 1h ) , 7.23 - 7.28 ( m , 3h ) 7.11 - 7.19 ( m , 5h ) , 6.91 - 6.96 ( m , 1h ) , 3.99 ( s , 3h ) , 3.68 ( s , 2h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.74 , 166.19 , 160.76 , 158.25 , 148.68 , 137.22 , 134.26 , 133.96 , 132.57 , 132.48 , 131.52 , 131.50 , 129.58 , 128.55 , 127.25 , 124.43 , 120.04 , 116.87 , 116.46 , 116.25 , 56.98 , 38.52 .
ei - hrms ( m / z ) : calcd . for c23h19fn4o2s 434.1213 , found 434.1213[m ] .
thymine-1-acetic acid ( 0.32 g , 1.76 mmol , edc ( 0.33 g , 1.76 mmol ) and dmap ( 0.050 g , 0.42 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 36 ( 0.5 g , 1.76 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography with dcm / meoh ( 9:1 ) as eluent system and then crystallized from ethanol to give the product as white crystals .
yield was 0.42 g ( 53% ) and mp was 200 - 202. h - nmr ( 300 mhz , dmso ) : 11.33 ( br s , 1h ) , 10.45 ( br s , 1h ) , 7.56 - 7.60 ( m , 4h ) , 7.50 ( s , 1h ) , 7.23 - 7.35 ( m , 4h ) , 4.49 ( s , 2h ) , 3.96 ( s , 3h ) , 1.76 ( s , 3 h ) .
c - nmr ( 75 mhz , dmso ) : 168.49 , 166.51 , 164.85 , 160.91 , 157.60 , 151.52 , 148.65 , 142.76 , 139.07 , 133.38 , 132.98 , 132.16 , 132.13 , 125.14 , 119.74 , 116.71 , 116.45 , 116.43 , 108.49 , 57.09 , 50.44 , 12.33 . ei - hrms ( m / z ) : calcd . for c22h19fn6o4 450.1452 , found 450.1452 [ m ] .
n-(4-(5-(2-fluorophenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(3,4-dihydro-2 - 4-dioxo - pyrimidin-1(2h)-yl))acetamide 47 was synthesized by the same procedure of 46 using uracil-1-acetic acid instead of thymine-1-acetic acid to give the product as white crystals .
yield was 0.27 g ( 35.1% ) and mp was 238 - 240. h - nmr ( 300 mhz , dmso ) : 11.34 ( br s , 1h ) , 10.47 ( br s , 1h ) , 7.52 - 7.62 ( m , 5h ) , 7.29 - 7.35 ( m , 1h ) , 7.23 - 6.27 ( m , 3h ) , 6.05 ( s , 2h ) , 5.59 ( dd , j=6.12 hz , j=2.26 hz , 1h ) , 4.53 ( s , 2h ) , 3.96 ( s , 3h ) .
c - nmr ( 75 mhz , dmso ) : 168.49 , 166.40 , 164.27 , 160.91 , 157.60 , 151.54 , 148.64 , 147.01 , 139.06 , 133.48 , 133.27 , 132.99 , 132.16 , 125.16 , 119.74 , 116.70 , 116.45 , 116.43 , 101.05 , 57.09 , 50.62 .
ei - hrms ( m / z ) : calcd . for c21h17fn6o4 436.1295 , found 436.1292 [ m ] .
yield , ( 0.48 g , 53% ) , mp 126 - 128. h - nmr ( 300 mhz , cdcl3 ) : 8.60 ( br s , 1h ) , 7.44 ( d , j=8.5 hz , 2h ) , 7.15 - 7.27 ( m , 8h ) , 7.01 - 7.09 ( m , 1h ) , 6.86 - 6.94 ( m , 1h ) 3.99 ( s , 3h ) , 3.69 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.76 , 166.21 , 160.10 , 160.05 , 157.11 , 156.79 , 153.85 , 153.79 , 147.51 , 137.46 , 133.91 , 129.59 , 128.56 , 127.27 , 124.46 , 120.09 , 119.36 , 118.93 , 117.71 , 57.04 , 38.53 .
ei - hrms ( m / z ) : calcd . for c23h18f2n4o2s 452.1119 , found 452.1118 [ m ] .
yield , ( 0.97 g , 54% ) , mp 150 - 152. h - nmr ( 300 mhz , cdcl3 ) : 8.59 ( br s , 1h ) , 7.45 - 7.49 ( m , 1h ) , 7.32 - 7.41 ( m , 3h ) , 7.23 - 7.27 ( m , 3h ) 7.11 - 7.19 ( m , 4h ) , 6.91 - 6.95 ( m , 1h ) , 4.35 ( q , j=7.00 hz , 2h ) , 3.68 ( s , 2h ) , 1,38 ( t , j=7.10 hz , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.15 , 166.17 , 160.75 , 158.24 , 148.48 , 137.14 , 133.97 , 132.51 , 132.42 , 131.52 , 131.51 , 129.58 , 128.53 , 127.23 , 124.38 , 120.04 , 116.87 , 116.46 , 116.25 , 65.70 , 38.51 , 14.78 .
ei - hrms ( m / z ) : calcd . for c24h21fn4o2s 448.1369 , found 448.1367 [ m ] .
thymine-1-acetic acid ( 0.31 g , 1.68 mmol , edc ( 0.32 g , 1.68 mmol ) and dmap ( 0.050 g , 0.42 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 39 ( 0.5 g , 1.68 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at room temperature .
the crude product was purified by silica gel chromatography ( dcm / meoh , 9:1 ) as eluent system and then crystallized from ethanol to give the product as white powder with a yield of 0.41 g ( 52% ) and mp of 241 - 243. h - nmr ( 300 mhz , dmso ) : 11.33 ( br s , 1h ) , 10.44 ( br s , 1h ) , 7.53 - 7.60 ( m , 4h ) , 7.49 ( s , 1h ) , 7.21 - 7.35 ( m , 4h ) , 4.49 ( s , 2h ) , 4.33 ( q , j=7.4 hz , 2h ) , 1.76 ( s , 3 h ) , 1.37 ( t , j=7.4 hz , 3h ) .
c - nmr ( 75 mhz , dmso ) : 167.84 , 166.50 , 164.85 , 160.91 , 157.60 , 151.52 , 148.43 , 142.76 , 139.03 , 133.44 , 132.99 , 132.16 , 132.13 , 125.09 , 119.74 , 116.70 , 108.49 , 65.54 , 50.44 , 15.01 , 12.33 . ei - hrms ( m / z ) : calcd . for c23h21fn6o4 464.1608 , found 464.1614 [ m ] .
yield : ( 0.39 g , 42.4% ) , mp 156 - 158. h - nmr ( 400 mhz , cdcl3 ) : 8.60 ( br s , 1h ) , 7.40 ( d , j=8.5 hz , 2h ) , 7.17 - 7.26 ( m , 6h ) , 7.15 ( d , j=8.5 hz , 2h ) , 7.02 - 7.07 ( m , 1h ) , 6.87 - 6.93 ( m , 1h ) , 4.34 ( q , j=7.20 hz , 2h ) , 3.69 ( s , 2h ) , 4.34 ( t , j=7.20 hz , 3h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.18 , 166.20 , 159.70 , 157.25 , 157.20 , 156.70 , 154.21 , 147.31 , 137.38 , 133.92 , 129.60 , 128.54 , 127.27 , 124.41 , 120.09 , 119.02 , 118.05 , 118.02 , 117.85 , 117.81 , 117.77 , 65.81 , 38.52 , 14.75 .
ei - hrms ( m / z ) : calcd . for c24h20f2n4o2s 466.1275 , found 466.1269 [ m ] .
n-(4-(5-(4-tert - butylphenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(phenylthio)-acetamide 52 was prepared by the same method of 45 using amine 41 .
yield : ( 0.41 g , 42.3% ) , mp 167 - 169. h - nmr ( 300 mhz , cdcl3 ) : 8.68 ( br s , 1h ) , 7.48 ( d , j=8.5 hz , 2h ) , 7.19 - 7.33 ( m , 11h ) , 3.97 ( s , 3h ) , 3.70 ( s , 2h ) , 1.21 ( s , 9 h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.43 , 166.32 , 153.48 , 153.37 , 137.57 , 134.59 , 134.02 , 129.58 , 128.49 , 128.59 , 127.24 , 126.26 , 125.57 , 124.69 , 120.28 , 56.85 , 38.57 , 34.86 , 31.14 .
ei - hrms ( m / z ) : calcd . for c27h28n4o2s 472.1933 , found 472.1926 [ m ] .
thymine-1-acetic acid ( 0.29 g , 1.55 mmol , edc ( 0.30 g , 1.55 mmol ) and dmap ( 0.037 g , 0.31 mmol ) were dissolved in 10 ml dmf under argon atmosphere . to the reaction mixture
the amine 41 ( 0.5 g , 1.55 mmol ) in dcm ( 10 ml ) was added and the reaction was further stirred overnight at rt .
the crude product was purified by silica gel chromatography ( dcm / meoh , 9:1 ) as eluent system to give the product as white powder .
yield , ( 0.24 g , 32% ) , mp 225 - 227. h - nmr ( 300 mhz , dmso ) : 11.35 ( br s , 1h ) , 10.53 ( br s , 1h ) , 7.66 ( d , j=8.6 hz , 2h ) , 7.51 ( s , 1h ) , 7.31 -7.42 ( m , 6h ) , 4.53 ( s , 2h ) , 3.93 ( s , 3h ) , 1.77 ( s , 3 h ) , 1.24 ( s , 9h ) . 13c - nmr ( 75 mhz , dmso ) : 168.11 , 166.60 , 164.85 , 153.28 , 151.55 , 142.77 , 139.57 , 133.51 , 128.53 , 127.23 , 125.88 , 124.98 , 119.92 , 108.52 , 56.90 , 50.52 , 34.99 , 31.27 , 12.34 . ei - hrms ( m / z ) : calcd . for c26h28n6o4 488.2172 , found 488.2169 [ m ] .
yield ( 71 mg , 86.6% ) , mp 204 - 206. h - nmr ( 400 mhz , cdcl3 ) : 8.68 ( br s , 1h ) , 7.61 - 7.65 ( m , 2h ) , 7.47 - 7.52 ( m , 3h ) , 7.35 - 7.41 ( m , 3h ) 7.13 - 7.19 ( m , 3h ) , 6.93 - 6.97 ( m , 1h ) , 4.36 ( q , j=7.00 hz , 2h ) , 4.11 ( s , 2h ) , 1,39 ( t , j=7.10 hz , 3h ) .
c - nmr ( 100 mhz , cdcl3 ) : 168.15 , 166.74 , 158.63 , 148.54 , 137.97 , 136.90 , 134.79 , 132.60 , 132.52 , 131.53 , 131.52 , 129.67 , 128.16 , 127.72 , 124.68 , 124.44 , 120.45 , 116.48 , 116.27 , 65.77 , 62.87 , 14.77 .
ei - hrms ( m / z ) : calcd . for c24h21fn4o4s 480.1268 , found 408.1061 [ m ] .
to a solution of amine 42 ( 0.265 g , 0.84 mmol , 1 eq . ) and triethyl amine ( 0.24 ml , 1.68 mmol , 2 eq . ) in dcm ( 15 ml ) was added thiophene-2-acetylchloride ( 0.135 g , 0.105 ml , 0.84 mmol , 1 eq . ) .
the reaction mixture was diluted with dichloromethane ( 40 ml ) , washed with 5% aq .
the crude product was purified by silica gel chromatography using cyclohexane : etoac ( 1:1 ) and then repurified using another eluent system of cyclohexane : etoac ( 2:3 ) to afford the pure target product with a yield of 0.1 g ( 23% ) and mp 153 - 155. h - nmr ( 300 mhz , cdcl3 ) : 7.57 ( br s , 1h ) , 7.46 ( d , j=8.6 hz , 2h ) , 7.11 - 7.25 ( m , 6h ) , 6.97 - 7.01 ( m , 3h ) , 3.98 ( s , 3h ) , 3.89 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.37 , 168.07 , 163.68 , 161.22 , 151.94 , 151.91 , 138.20 , 135.23 , 133.78 , 129.46 , 127.71 , 126.19 , 124.57 , 124.53 , 120.33 , 117.36 , 117.15 , 116.08 , 115.84 , 57.01 , 38.55 .
ei - hrms ( m / z ) : calcd . for c21h17 fn4o2s 408.1056 , found 408.1061[m ] .
yield ( 0.250 g , 35.7% ) , mp 214 - 216. h - nmr ( 300 mhz , cdcl3 ) : 7.59 ( br s , 1h ) , 7.45 ( d , j=8.6 hz , 2h ) , 7.10 - 7.25 ( m , 6h ) , 6.96 - 7.03 ( m , 3h ) , 4.35 ( q , j=7.00 hz , 2h ) , 3.88 ( s , 2h ) , 1.38 ( t , j=7.10 hz , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.06 , 167.86 , 164.07 , 160.79 , 151.79 , 151.75 , 138.12 , 135.24 , 133.87 , 130.33 , 130.22 , 127.69 , 126.16 , 124.52 , 124.47 , 120.32 , 117.01 , 116.08 , 115.76 , 65.69 , 38.53 , 14.75 .
ei - hrms ( m / z ) : calcd . for c22h19fn4o2s 422.1213 , found 422.1216 [ m ] .
n-(4-(5-(2,5-difluorophenyl)-3-methoxy-1h-1,2,4-triazol-1-yl)phenyl)-2-(thiophen-2-yl)-acetamide 57 . to a solution of amine 37 ( 0.61 g , 2.01 mmol , 1 eq . ) and triethyl amine ( 0.56 ml
, 4.02 mmol , 2 eq . ) in dichloromethane ( 15 ml ) was added thiophene-2-acetylchloride ( 0.323 g , 0.25 ml , 2.01 mmol , 1 eq . ) .
the reaction mixture was diluted with dichloromethane ( 40 ml ) , washed with 5% aq .
the crude product was purified by silica gel chromatography ( cyclohexane : etoac , 1:1 ) two times to give the pure product .
yield : ( 0.26 g , 30% ) , mp 172 - 174. h - nmr ( 300 mhz , cdcl3 ) : 7.47 ( br s , 1h ) , 7.39 ( d , j=8.5 hz , 2h ) , 7.17 - 7.24 ( m , 2h ) , 7.14 ( d , j=8.5 hz , 2h ) , 6.97 - 7.08 ( m , 1h ) , 6.85 - 6.95 ( m , 3h ) , 3.99 ( s , 3h ) , 3.86 ( s , 2h ) .
c - nmr ( 75 mhz , cdcl3 ) : 168.75 , 167.96 , 160.09 , 160.03 , 156.77 , 153.78 , 147.53 , 137.70 , 135.23 , 133.81 , 127.93 , 127.70 , 126.24 , 124.42 , 120.08 , 119.36 , 118.92 , 117.90 , 57.04 , 38.52 .
ei - hrms ( m / z ) : calcd . for c21h16f2n4o2s 426.0962 , found 426.0964 [ m ] .
yield ( 0.27 g , 30% ) , mp 208 - 210. h - nmr ( 300 mhz , cdcl3 ) : 7.43 ( br s , 1h ) , 7.39 ( d , j=8.5 hz , 2h ) , 7.19 - 7.25 ( m , 2h ) , 7.13 ( d , j=8.5 hz , 2h ) , 7.01 - 7.07 ( m , 1h ) , 6.95 - 6.98 ( m , 2h ) , 6.85 - 6.93 ( m , 1h ) , 4.34 ( q , j=7.2 hz , 2h ) , 3.87 ( s , 2h ) , 1.39 ( t , j=7.2 hz , 3h ) .
c - nmr ( 75 mhz , cdcl3 ) : 167.93 , 160.09 , 160.03 , 156.82 , 153.83 , 147.31 , 137.62 , 135.23 , 133.88 , 127.95 , 127.71 , 126.26 , 124.38 , 120.06 , 118.87 , 118.08 , 117.71 , 65.82 , 38.53 , 14.74 . ei - hrms ( m / z ) : calcd . for c22h18f2n4o2s 440.1119 , found 440.1113 [ m ] .
[ 17]arf1 and arno - sec-7 were subcloned into pet15 vectors ( novagen ) as described previously .
n - terminal truncated [ 17]arf1 ( amino acids 18 - 181 ) , lacking the first 17 amino acids and cytohesin-1-sec-7 were expressed in escherichia coli and purified by ni - nta chromatography ( ni - nta agarose , quiagen ) .
gdp / gtp exchange was measured on [ 17]arf1 by tryptophan fluorescence because a large increase in intrinsic fluorescence of arf occurs upon exchange of gdp for gtp .
all measurements were performed in pbs ph 7.4 , 3 mm mgcl2 at 37. [ 17]arf1 ( 1 m ) in pbs without mgcl2 was preincubated with gdp ( 80 m ) in the presence of edta ( 2 mm ) for 15 min .
the bound gdp was stabilized by addition of mgcl2 ( final concentration 3 mm ) and incubation for 5 min . for each exchange reaction 250 nm [
17]arf1 was mixed with 10 nm arno - sec-7 ( total volume 200 l ) in the absence or presence of inhibitor .
the tryptophan fluorescence was measured at an excitation and emission wavelength of 280 and 340 nm , respectively .
all fluorescent measurements were performed with a varioskan microplate reader ( thermo scientific ) , in 96-well plates . for analysis
hepg2 cells ( ecacc ) 10 were seeded in 12 well plates and cultured for 24 h in emem ( cambrex ) containing 10% fcs .
cells were then serum starved in emem for 24 h and stimulated for 12 h with 10 nm insulin in the presence of the inhibitor secinh3 or control , with 0.8% final concentration of dmso .
total mrna was prepared using the absolutely rna kit ( stratagene ) and cdna for qpcr was generated from 1 g rna with the high capacity cdna archive kit ( applied biosystems ) .
qpcr was performed in a 10 l scale on an iq5-cycler ( biorad ) using a taqman gene expression assay for igfbp1 ( applied biosystems ) .
the design and synthesis of the new secinh3 derivatives 6 - 15 and 43 - 58 is based on the change of the substitutions at three points as illustrated in fig .
these derivatives were synthesized as illustrated in schemes 1 and 2 . in this group of compounds in scheme 1 the blue part of secinh3 was changed ( fig .
firstly p - oh was introduced to the phenyl moiety in compound 8 and 54 to increase the polarity and consequently the water solubility and for the same reason sulfur was oxidized the to sulfonyl group in compound 8 and 54 .
trials to investigate if the phenyl group could be changed by other heterocyclic rings such as imidazole , pyridine , thiophene , uracil and thymine as aromatic bioisoester groups with retained activity of secinh3 .
finally , the sulfur bridge was also changed to investigate if it must be exocyclic or could be included in heterocyclic rings or not essential at all . from these changes the structure activity relationship ( sar ) of secinh3 could be studied .
the second group of compounds scheme 2 represents the change and study of structure activity relationship ( sar ) of secinh3 by changing both red part and green parts .
the green part was modified within 2 - 3 carbons according our pervious study that small substituents such as methyl , ethyl and propyl could be tolerated at this position .
the third point of design is the change of pipronyloyl moiety ( red part ) by phenyl group carrying electron attracting groups at different positions of the ring to investigate the effect of these groups on the biologicall activity of the secinh3 .
the intermediates , 2-(4-hydroxyphenylthio)acetic acid , 2-(3,4-dihydro-2,4-dioxopyrimdin-1(h)-yl)acetic acid and 2-(3,4-dihydro-5-methyl-2,4-dioxopyrimdin-1-(h)-yl)acetic acid were prepared as described according to the reported procedure .
the compounds 3 and 19 - 26 were prepared by reaction of acid chloride derivatives 1 and 17a - e with kscn and the respective alcohols as illustrated in schemes 12 .
these derivatives were confirmed using h - nmr , c - nmr , fab - ms , ei - ms and hrms ( see exp .
their h - nmr spectra were characterized by appearance of amidic nh around 9 - 9.6 ppm and the introduced methyl , ethyl or isopropyl moities and c - nmr spetra showed c = o group ranged from 180 to 189 ppm and c = s group ranged from 160 to 164 ppm .
these derivatives 3 and 19 - 26 were reacted with p - nitrophenylhydrazine in ethanol to afford the 3-alkyl-5-(3-(un)substitiutedphenyl)-1-(4-nitrophenyl)-1h-1,2,4-triazol derivatives 4 , 27 - 34 .
the products were characterized by disappearance of amidic nh in h - nmr and appearance of introduced p - phenyl moiety .
their c - nmr spectra showed disappearance of both signals corresponding to c = o and c = s groups and this evidence for cyclization and formation of triazole nucleus .
also , their structures were further confirmed by hrms , for example compound 32 shwoed m / z : 346.0877 [ m ] for calcd .
4-(5-(un)substituted phenyl)-3-alkyl-1h-1,2,4-triazol-1-yl)phenyl amine derivatives 5 , 35 - 42 were prepared by reduction of nitro derivatives 4 , 27 - 34 , respectively .
the reduction process was achieved using two methods of reduction : i. chemical reduction using ammonium chloride and iron in methanol and water , followed by purification using silica gel chromatography to afford the product as pale white solid .
the problems of this method are the low yield ( 40 - 50% ) and its awful efforts in purification .
ii . catalytic reduction method using palladium as catalyst under hydrogen atmosphere and 20 bar pressure using autoclave .
the advantages of the second method are higher yield ( 70 - 80% ) , easier purification and more convenient procedure .
the latter method enables us to make multigram scaling synthesis of final derivatives especially compound 6 for further biological investigations .
these amine derivatives 5 , 35 - 42 were proved by different spectral data h - nmr , c - nmr and hrms .
compound 5 for example was characterized by appearance of broad singlet ( 2h ) at 5.39 ppm corresponding to nh2 group and further confirmed by hrms ( m / z ) : calcd . for c16h14n4o3 310.1066 , found 310.1069 [ m ] .
the final compounds 6 - 15 and 43 - 58 were synthesized either by condensation of amine derivatives with the respected acid chloride in dichloromethane and triethylamine as catalyst under argon atmosphere or with the respected carboxylic acid derivative in presence of condensing agent such as edc and dmap in dimethylformamide under argon atmosphere .
h - nmr spectra of these derivatives were characterized by disappearance of the signal corresponding to nh2 and appearance of downfield signal ( 1h ) corresponding to amidic nh and signals corresponding to introduced moiety .
in addition , c - nmr spectra showed amidic c = o signal around 167 - 168 ppm and new signals corresponding to introduced moiety if compared to parent amine .
the compound 6 was required for further biological animal experiments so it was synthesized in multi gram amounts .
it was synthesized many times after optimization of synthetic method including the reduction step and the final coupling in different conditions and in each time was confirmed by spectral data in addition to hrms ( m / z ) : calcd . for c24h20n4o4s 460.1205 , found 460.1215 [ m ] ( first batch ) , found 460.1203 [ m ] ( 2 batch ) found and 460.1203 [ m ] ( 3 batch ) .
sulfonyl compounds 8 and 54 were prepared by oxidation of compounds 6 and 49 , respectively using peracetic acid ( 39% in acoh ) and then purified by column chromatography .
the h - nmr spetra of these derivatives showed downfieldshift of ch2-so2- if compared to ch2-s- and further conformed by hrms for example compound 8 ( m / z ) : calcd . for c24h20n4o6s 492.1104 , found 492.1105 [ m ] .
preliminary biological screening of the target compounds indictaed that some of the new synthesized secinh3 derivatives showed higher potency and promising activity more than secinh3 itself ( detalied study is still in progress ) .
for example compund 9 and 10 were approximate equal to secinh3 activity as cytohesin antagonist activity .
detailed biological screening and study of the structure activity relationship ( sar ) of secinh3 new derivatives is in progress . in conclusion , rational design , synthesis of novel secinh3 derivatives as potential cytohesin inhibitors
final compounds were synthesized as shown in schemes 12 starting with benzodioxole-5-carbonyl - chloride or different benzoyl chloride derivatives and potassium - isothiocyanate ( kncs ) .
the 1,2,4-triazol ring was readily assembled from benzodioxole-5-carbonyl - isothiocyanate in two steps , using ( 4-nithrophenyl)-hydrazine as previously described and then further elaborated after reduction using the appropriate substituted acetic acid derivative to yield the desired compounds in the presence of hbtu in dmf . | cytohesins are small guanine nucleotide exchange factors that stimulate adp ribosylation factors , ras - like gtpases , which control various cellular regulatory networks ranging from vesicle trafficking to integrin activation . a small molecule secinh3 ( 1,2,4-triazole derivative ) in an aptamer displacement assay as a pan - cytohesin sec7-domain inhibitor
was previously identified . here a series of different secinh3-analogues was designed and synthesised as potential cytohesin sec7-domain inhibitors .
all final synthesized compounds 6 - 8 , 43 - 58 and their intermediates were confirmed by 1h nmr , 13c nmr and high resolution mass .
preliminary biological screening of target compounds indictaed that some of the new synthesized secinh3 derivatives showed higher potency and promising activity more than secinh3 itself ( unpublished results ) .
compund 9 and 10 were approximate equal to secinh3 activity as cytohesin antagonist activity .
furthermore compound 52 showed twice inhibition potency if compared to secinh3 . |
lyme disease ( ld ) is an increasing health burden on the australian community requiring wider diagnostic recognition.1
borrelia burgdorferi sensu lato ( bbsl ) are closely related spirochetal species that are the causative agents of ld in humans.2 the author has previously reported the endemic presence of ld in australia by positive serological and molecular testing of blood samples taken from symptomatic patients who have never been abroad , supporting the preliminary observations of others.1,3,4 in the current study , the presence of ld in australia is confirmed by the detection of borrelia species ( spp . ) using polymerase chain reaction ( pcr ) analysis of biopsy tissue taken from patients with a clinical presentation of erythema migrans ( em ) .
the use of central biopsy to replace leading - edge biopsy is explored , with indications it is more reliable in detecting borrelia spp .. positive findings led to analysis of the sequences deducing preliminary information on australian genotypes consistent with both b. burgdorferi sensu stricto ( bbss ) and bbsl , an important factor in accurate future identification and diagnosis of native infection .
skin punch biopsies were taken from the bite sites of four patients presenting with em , each at a time interval between 1 and 6 days from bite to biopsy .
two biopsies were taken from patient a , one from the central bite site and the other from the leading edge of the lesion .
see figure 1 at day 3 , the day of biopsy and commencement of treatment , and figure 2 at day 6 .
the sample from the central biopsy of patient a was positive and the leading - edge sample was negative . prior to this , the author had always been sampling from the leading edge of em lesions , with consistently negative results . the result on patient a encouraged subsequent sampling using central biopsy only on b , c , and d , which yielded the results in this study .
case a is the index case on a timeline of 1 year in this series .
it is of note that all prior leading - edge biopsies taken before the day of patient a s presentation were analyzed with the same primers about to be discussed for patients a , b , and c. the patients will be referred to as patients a , b , c , and d in this discussion , and biopsies taken from them referred to as biopsies a , b , c , and d respectively .
a , b , and c , primers for borrelial rna polymerase gene ( rpoc ) were employed for amplification using a set of one forward and one reverse .
it was analyzed differently as part of a process of attempting to improve borrelial detection by that laboratory .
positive borrelia dna product was then submitted to australian genome research facility ( agrf ) in sydney for confirmatory testing .
agrf is a national association of testing authorities ( nata ) accredited laboratory and is australia s largest provider of genomics services and solutions.5 all four sequence results from agrf were then submitted for basic local alignment search tool ( blast ) inquiry.6 the technique follows in the discussion section .
then under alignments ( third grouping using blast ) tree analysis using neighbor joining was performed on the results.6 there were unnamed leaves .
pathosystems resource integration center ( patric ) was then used to examine the sequences , revealing additional findings.7 patric was also used to construct a cladogram of all known borrelia spp .
the author selected the following blast parameters : nucleotide blast > copy the biopsy s sequence into the enter accession number box > database set and choose others
> program selection and choose megablast for highly similar sequences > blast button at the bottom of the page .
results on a , b and c show detection of borrelia dna consistent with bbss ( see figure 3 ) .
in particular , results demonstrate strains n40 , zs7 , and b31 as equal top alignments with the best match .
this group of results shows a maximum identification ( max ident ) percentage between 97 and 99 and an extremely low expected value ( e ) .
medical science places much emphasis on probability ( p ) when interpreting results . examining p in the blast output above ,
the mathematic constant e is 2.7 to one decimal place , and e is raised to that negative power .
the distribution of a sequence analysis of this type is a poisson distribution.8 it is currently believed that with high letter count submissions in these types of sequences that the e value is thought to approximate probability.8 the e value is the expected number of high scoring pairs for a certain nominated score when comparing the alignment of local pairs.8 algorithms find all segment pairs whose scores can not be improved by extension or trimming.8 analysis of the alignments using neighbor joining shows patient a and b samples to be lying identically between bb zs7 and bb b31 ( see figure 4).6 two unnamed nodes lay between those results which are further analyzed below using patric . for patient c , however , the picture is very different .
the result on phylogenetic tree analysis appears in the neighborhood of , but distinct from , bissettii dn127 , in spite of initial indications suggesting similarity to a and b ( see figure 5).6 blast comparison alignment using bl2seq ( this is a selection on the blast site for aligning any two sequences ) demonstrated that samples a and b are identical ( see table 4 ) . a further paired alignment between samples a and c shows it is very similar in equality but not quite as strong ( see table 5 ) .
results for blast analysis of cloned product from patient d returns no significant similarity found . then using blastn ( comparison for similar sequences ) instead of choosing megablast for highly similar sequences , a b. valaisiana - like species is demonstrated.6 attempts with
it was produced using patric by choosing organisms > bacteria > phylogeny then selecting order spirochaetales and cladogram.7 the result was trimmed to borrelia spp .
the findings from nihc blast were then superimposed in figure 3 to demonstrate their position .
the sequence data was then analyzed at patric producing rather different results.7 for each specimen , the output is some 1400 lines in a spreadsheet .
results are summarized here and show that a , b , and c had identical matches with max ident of 99% and e value of 9 10 to all of the following borrelia spp . equally
: zs7 , w191 - 23 , n40 , ca-11.2a , bol126 , b31 , 94a , 72a , 64b , 29805 , 156a , and 118a .
after several more borrelia genotypes are listed at much lower max ident and e values , one finds the first non - borrelial bacterium is fusobacterium with an e of just 0.029 , and then listeria and campylobacter .
specimen d had a much lower confidence band , with six of the above genotypes at an e of 2 10 .
the first non - borrelial listings were three clostridium species with an e of 0.16 .
bl2seq from ncbi of the sequences was then used in an attempt to further analyze the specimens using deposited sequences for known borrelia spp . from genomic sequencing center for infectious diseases , university of maryland , usa ,
this time demonstrating the 64b serotype.6 the accession number used for whole genome shotgun sequencing and resulting match was bb 64b abka02000001.1 .
the author proposes detection of borrelia is more likely to be successful when the specimen is taken from the central bite site than when taken from the leading edge in early lesions .
this contradicts convention , the standard long - held practice of biopsy from the leading edge for which there is no published data on pubmed searching on february 10 , 2012 using the headings erythema migrans tissue biopsy . adding the term peripheral finds a paper examining central versus peripheral biopsy by jurca et al , where the authors conclude that detection from peripheral and central sites was equivalent.9 it has been thought that borrelia dna detection from em rashes at the leading edge is successful in 80% of cases.10 this statement by sydney university is not itself referenced .
the current study suggests that employing central site of biopsy may reliably provide detectable spirochetal dna evidence up to 6 days after tick attachment , even after tick removal .
all patients received their tick bite within 10 kilometers of the eastern coastline in the state of new south wales .
a and b were only 12 km apart but with a time gap of 1 year .
patient d was some 80 km north of patients a and b. patient d had presented multiple times with em over a 1-year period .
he had protracted chronic ld , and lesion edge biopsies were negative prior to this attempt to determine whether a b. burgdorferi spp .
there has been considerable debate concerning the existence of ld on the continent of australia .
there are two longstanding published reports of both em and locally acquired human b. burgdorferi infection and one contrary.3,4,11 at the time of the mccrossin study in 1986 , only serological diagnostic tests were available.3 so sequencing was not possible for confirmation of those results .
the russell et al study in 1994 examined the midgut content of over 12,000 mostly unfed ticks with no spirochetes found.11 however , it is now known that spirochetes within flat , or unfed , nymphs exist in low numbers and in a poorly understood metabolic state that enables them to endure prolonged periods of nutrient deprivation . in this state ,
the transcription regulators rrp2rpon rpos and the hybrid histidine hk1rrp1 pathways are inactive , as are mammalian - phase genes , while tick - phase genes are maximally expressed.2 at the commencement of feeding , this status is reversed with rapid replication.2 then , under the heading within the mammalian host a clear model of salivary hypostome spirochete movement from tick to skin is described.2 the russell study s negative findings may no longer be appropriate .
the hudson study in 1998 described a cultured isolate of borrelia identified by molecular testing from one patient who had travelled overseas but due to the length of time since overseas travel ( 17 months ) it was believed the patient acquired their infection in australia .
sequencing results suggest similarity to a european strain of b. garinii , rather than the b. garinii species typically described in asia.4 in a 2011study , the current author published serological and molecular evidence of endemic lyme borreliosis in australia , reporting positive ld test results of whole blood and serum taken from patients who had never left the country.1 the current study provides further proof of endemicity of borrelia infection in australian patients using molecular detection of borrelia dna from biopsy material .
further investigation is required to determine if there are novel borrelia genotypes in that a b. bisettii - like organism and a b. valaisiana - like organism are suggested from the data of patients c and d respectively .
further genotyping studies should be done to confirm or disprove the serotype 64b nature of specimens a and b. in the expanding universe of b. burgdorferi , in addition to small mammals , transhemispheric bird migration is responsible for spirochete dissemination.2,12 although australia has approximately 75 tick species , it is generally accepted that ixodes spp . , and ixodes holocyclus ( ih ) in particular , are the main contenders in transmitting human tick - borne diseases.13,14 the eastern coastline is habitat to ih , which is known to vector human disease , including rickettsial infection and tick paralysis.1,1316 the ih tick is colloquially named paralysis tick.10 it may also be called grass tick , shell back tick , and several others .
it thrives in humid coastal conditions , mainly in flatlands , from the north of the continent just above cooktown in queensland to lakes entrance in victoria at the very south of the continent.10 this region contains a very high proportion of australia s human population .
the ih tick has larval , nymph , and adult stages all of which require a blood meal.10 larvae typically feed upon small animal hosts , whilst the nymph and adult will also feed upon larger animals.2,10 humans are incidental hosts to all three forms , but the nymph is primarily responsible for 90% of human tick - borne disease.2 the tick may stay attached for up to 56 days before detaching if not found .
many tick bites are not observed or reported.1 in australia , the majority of bites will come to nothing more than an erythematous macule ( nonelevated ) on the skin , of up to 2 cm diameter , resolving completely over a few days , providing the tick is removed promptly .
some lesions grow at the bite site to form a 23 cm papule by the second day , showing a black central eschar.17 such a presentation at the bite site is the typical appearance of queensland tick typhus , a rickettsial infection , and if untreated , this can be followed by a spotted rash of widespread distribution known as rickettsial spotted fever , a febrile illness whose erythematous macules are typically 45 mm in diameter.15,16 em is a local clinical manifestation of bbsl infection.2,18,19 the incubation period is 332 days.2,20 at this stage , the term early ld is also used , and this terminology includes early systemic manifestations such as meningitis , cranial nerve neuropathy , or carditis .
an em documented on an individual after being in a known endemic area is considered sufficient for a clinical diagnosis of ld ; however , the single primary lesion must reach more than 5 cm in size to be classified as diagnostic and to be considered pathognomonic.21 the em is often described as an initial 1 cm macular erythematous lesion , that at day 25 or even later , grows in diameter and thickens , lasting for up to 14 days or more if left untreated .
spirochetes are deposited into the skin during initial attachment.2 in the northern hemisphere , infection is rare in the first 24 hours after tick bite but most likely after 48 hours.2 australia does not have enough data to confirm whether this is true locally .
ld is a protean multisystem illness that develops after a tick bite transmitting human pathogenic borrelia spirochete when the initial local reaction is not treated or is under treated.22 nomenclature of the disease includes the use of the terminology early disseminated ld and late disseminated ld.23 the international lyme and associated diseases society uses the terminology chronic ld for infection lasting more than 12 months.22 in north america , a principal symptom of the disease is an arthritic illness that may cause severe pain and swelling , especially in large joints , and can be associated with marked general fatigue and other somatic features.22 the centers for disease control and prevention website states that in the musculoskeletal system , ld produces recurrent attacks of arthritis with objective joint swelling in one or a few joints , sometimes followed by chronic arthritis.23 ld in north america may also be present as a neurological disease , which is generally accepted to be the principal manifestation throughout europe and asia.24 the author has presented similar findings of neurological manifestation with locally acquired ld in australia with no arthropathy.1 current thought is that borrelia spp .
are found along the eastern coastline of australia and transmitted to humans by ih.1 this study is implicating the same vector for transmission .
patients a and b received their tick at the same latitude but with a time gap of 1 year . clinically , both patients reported painful itchy swellings of their em . from a clinical standpoint ,
the two bbss genotypes caused an infection characterized by an intensely painful itchy eruption , one without significant systemic event .
on the contrary , in patient c , the em eruption was not particularly sore or itchy .
this infection , with the possible b. bissettii - like genotype , in addition to producing local reaction , produced a profound systemic meningitic illness that lasted many weeks .
there is conflict in the findings for patient c with one method of analysis , suggesting bbss 64b and the other ( neighbor joining tree ) a similarity to b. bissettii .
this distinction needs further research and clarification , and in particular , note should be taken that clinical manifestation was different .
it is of clinical significance that this infection could not be controlled quickly with the amoxycillin clavulanate combination taken orally , and is an indicator of possible coinfection of babesiosis or bartonellosis .
the author has already presented the independent incidence rate of these as 31% and 21% in australia in associated tick - born diseases.1 patient d had symptoms of protracted neurological ld on first presentation and had leading edge skin biopsies of em done by the author , which returned negative as discussed above .
central biopsy on this occasion was positive and showed the b. valaisiana - like organism .
this being the first human report of such a species in australia warrants further research .
there are no published reports of a lymelike illness in australia using a pubmed search with the term lyme - like australia on january 24 , 2012 .
the term lymelike illness on this continent could now be considered , as the study presents some identity pointer to the wider borrelia spp .
it is used appropriately to describe clinical infection by borrelia that fall outside the sensu lato group , particularly in europe and the usa where there are an increasingly growing number of genospecies of borrelia being identified .
it is being wrongly interpreted by media and australian compensation insurance companies as a possible lyme illness , lacking serological proof of borrelial infection .
the identity of the genotype in patient d would appear to fit this appellation of lyme - like illness . although the sample size is small , the relationship between the clinical presentations , the genotype involved , and geographical distribution demonstrated here may all be relevant to the development of local testing modalities , successful diagnosis of ld , and the subsequent clinical severity of disease .
firstly , the results provide objective evidence confirming endemic ld in australia by detecting and characterizing borrelia genotypes of the bbss group from biopsies of em .
possible identity to a lyme - like illness in australia is suggested as a valaisiana - like genotype .
the author s findings indicate that during the first week of em eruption , tissue biopsy at the bite site is preferable to that at the leading edge .
thirdly , the evidence provided suggests that further research is needed to elucidate the genetic diversity of borrelia spp . and b. burgdorferi genotypes causing ld on the continent of australia .
at least two and possibly three distinct genotypes are suggested , one characteristic of bbss genetically lying between strains b31 and zs7 and looking like 64b , one possibly related to , but discrete from , b. bissettii dn127 , and finally a b. valaisiana - like genotype .
the genetic diversity of borrelia spp . associated with ld has diagnostic laboratory and clinical significance to the medical profession and has implications for assessment of public health risk . | backgroundlyme disease ( ld ) is an emerging infectious disease in australia .
there has been controversy regarding endemic lyme disease in the country for over 20 years .
borrelia burgdorferi sensu stricto ( bbss ) and sensu lato ( bbsl ) are closely related spirochetal species that are the causative agents of ld in humans .
clinical transmission of this tick - borne disease is marked by a characteristic rash known as erythema migrans ( em ) .
this study employed molecular techniques to demonstrate the spirochetal agent of lyme disease isolated from em biopsies of patients in australia and then investigate their genetic diversity.methodsfour patients who presented to the author s practice over a one - year period from mid 2010 to mid 2011 returned positive results on central tissue biopsy of em lesions using polymerase chain reaction ( pcr ) analysis .
the findings were confirmed by dna sequencing , and basic local alignment search tool ( blast ) analysis was then used to genetically characterize the causative organisms.resultsthree isolates were identified as bbss that lay genotypically between strains b31 and zs7 and were then characterized as strain 64b .
one of the three isolates though may have similarity to b. bissettii a bbsl .
the fourth isolate was more appropriately placed in the sensu lato group and appeared to be similar , but not identical to , a b. valaisiana - type isolate . in this study , a central biopsy taken within 6 days of infection was used instead of conventional sampling at the leading edge , and the merits of this are discussed.conclusionthese patients acquired infection in australia , further proving endemic ld on the continent .
central biopsy site of em is a useful tool for pcr evaluation .
blast searches suggest a genetic diversity of b. burgdorferi , which has implications concerning the diagnosis , clinical severity , and testing of ld in australia . |
tinnitus , defined as the perception of sound that results exclusively from activity within the nervous system without any corresponding mechanical , vibratory activity within the cochlea , and not related to external stimulation of any kind
it is argued that approximately one third of the population experiences tinnitus at least once per lifetime , and approximately 15% develop serious psychosocial complications .
tinnitus may be perceived in one or both ears or within the head and is experienced as continuous or intermittent .
the sound varies from simple sounds , such as whistling , to complex sounds , such as music .
tinnitus - related activity in the nervous system ( tra ) is hypothesized to be present in every human being .
multifunctional connections between the auditory system , the limbic system , and the autonomic nervous system seem to be crucial in the development of tinnitus and tinnitus annoyance .
a close association between tinnitus and comorbid psychological disorders has been demonstrated [ 611 ] , and a high prevalence of anxiety and depression has been reported in tinnitus sufferers [ 1216 ] . it is also argued that tinnitus patients score lower on self - esteem and well - being assessments .
a screening or assessment for psychological distress in tinnitus sufferers is recommended to give the patients adequate treatment .
researchers state that the consequences of chronic pain and tinnitus are similar : emotional effects , reduced involvement in work - related activities , interpersonal problems , and decreased opportunities to engage in previously enjoyable activities [ 15 , 17 , 18 ] .
it is argued that tinnitus patients with no hearing loss tend to have more diagnoses per patient and more anxiety disorders than those with hearing loss [ 3 , 19 ] .
jastreboff and hazell argue that for most people , tinnitus perception is far from indicating any medical problem and is , in fact , a natural and benign experience that can be easily habituated . only in rare cases
is tinnitus caused by a medical problem ( e.g. , a vestibular schwannoma or acoustic tumor ) that requires examination .
nevertheless , for a considerable number of individuals , tinnitus is experienced as an annoying condition and a pressing reason for seeking professional help .
an increasing number of patients have , over the last two decades , received treatment based on the neurophysiological model of understanding the process that leads to tinnitus and tinnitus annoyance .
the model is customarily labeled the neurophysiological model of tinnitus to distinguish it from other models involving neuroscience . as a crucial part of this model , it was proposed that inappropriate activation of the limbic and sympathetic part of the autonomic nervous systems by the tinnitus signal is responsible for behaviorally observed reactions to tinnitus , such as anxiety , problems with concentration , panic attacks , and suppression of the ability to enjoy activities in life .
annoyance does not depend on the strength of the tinnitus - related activity but on the strength of the connection between the cerebral cortex , the auditory system , and the limbic and autonomic nervous system .
the strength of this connection produces sufferers as opposed to nonsufferers . the same type of reaction
is observed after overstimulation of the limbic and autonomic nervous systems by many other factors , such as sleep deprivation , chronic pain , or sensory stimulation , which we can not control .
a considerable number of tinnitus sufferers relate their first awareness of tinnitus to changes in their life , whether small or substantial .
these changes could include such events as divorce , being laid off , sickness in the family , accidents , surgery , or even having had their ears syringed .
such events can produce a change in the arousal of the brain or its homeostasis , resulting in a state of heightened brain arousal during which the tinnitus signal is registered cortically .
it is also likely that such events can weaken the normal mechanisms of defense against anxiety and other emotional reactions
. based on the neurophysiological model presented by jastreboff and hazell , also denoted retraining therapy , habituation therapy , the three vital components in the therapeutic program are ( 1 ) cognitive aspects , such as belaboring fear and anxiety , ( 2 ) relaxation , and ( 3 ) sound therapy .
the main goal of this therapy is to decrease the strength of the tinnitus signal within the brain ( enhancing environmental sounds to effectively decrease the strength of the tinnitus signal and reduce activation of the limbic and autonomic nervous systems ) .
this neurophysiological - based therapy means that the tinnitus - related neuronal activity is blocked from reaching the limbic and autonomic nervous systems , and , consequently , there are no negative reactions to tinnitus ( habituation of reaction ) . moreover , the auditory system is capable of blocking this tinnitus - related neuronal activity , preventing it from reaching higher cortical areas and thus being perceived ( habituation of perception ) .
jastreboff and hazell underline the importance of including all three components in a therapeutic program .
the concept cognitive - behavioral treatment when used in connection with the neurophysiological approach to tinnitus sometimes encompasses all three components mentioned above [ 8 , 24 , 25 ] .
the theoretical background for the neurophysiological model is confirmed by herraiz , who argues that progress in neuroscience research has given birth to new theories for tinnitus generation .
from the point of view in which cochlear dysfunctions would be considered the origin and maintenance mechanisms , the concept of the importance of compensation systems from the central auditory pathways has been introduced .
these systems could act as the most relevant factor for chronic persistent tinnitus after peripheral aggression .
several studies report positive long - term outcomes from treatments built on the neurophysiological model [ 4 , 2732 ] .
the described results of these studies include cognitive and emotional aspects , such as anxiety and depression , as well as annoyance and influence on life quality .
however , most of these studies are based on a follow - up assessment no longer than two years after completion of treatment .
only one research project is found to report a longer follow - up study of cognitive behavioral therapy , reporting stable improvements of the tinnitus parameters and stable additional symptoms 15 years after the completion of therapy .
that annoying tinnitus can cause several symptoms in tinnitus sufferers calls for a multidisciplinary approach to treatment .
the neurophysiological model with its three components requires knowledge derived from the audiological field , the psychological field , and the field of relaxation therapy .
practitioners from the audiological field experience a need for more tinnitus knowledge among therapists representing other scientific fields .
the purpose of this paper is to describe the results of a long - term follow - up effect study that was performed five years after a completed tinnitus habituation therapy program based on jastreboff and hazell 's neurophysiological model
eighty - three individuals participated in a one - year treatment program and completed a survey , the hospital depression and anxiety scale ( hads ) , both before and immediately after treatment .
out of these individuals , 68 ( 82% ) completed the survey at the 5-year follow - up assessment .
of these 68 , 32 ( 47% ) were women and 36 were ( 53% ) men .
the age distribution for the group at the 5-year follow - up was 3382 years with a mean age of 58.49 .
the results of the effect analyses were based on the assessment carried out immediately after the treatment ended were published in 2003 . before treatment , 19% of the participants had experienced tinnitus for less than one year , 10.3% had 1 to 2 years of experience , 20.6 had 25 years , 17.6 had 510 years and the largest group of 32.4% had experienced tinnitus annoyance for more than 10 years .
the multidisciplinary team consisted of two medical doctors , two educational audiologists , a physiotherapist , and a psychologist . due to the limitation of resources
each patient was invited to participate in eight so - called main group sessions .
three of these sessions were in the form of lectures with all participants present where a physician described the current knowledge of tinnitus generation , the process of hearing , and the aim and structure of rehabilitation .
the fitting of a white noise generator or hearing aid was , however , carried out individually .
a total of 20.6% of the participants were users of hearing aids , whereas 55% were daily users of a white noise generator ( viennatone am / ti or viennatone silent star ) .
the cognitive inputs and instructions to enable the participants to examine themselves were given systematically in the groups .
most of the patients participated in every session . to take account of individual needs ,
the treatment program carried out after a medical investigation included three main components : ( 1 ) systematic structured retraining aimed at making the tinnitus signal insignificant by taking away tinnitus - related misconceptions and emotions , such as fear and anger .
this retraining was aimed at breaking the vicious circle of tinnitus perception at different levels .
( 2 ) stress management training , including relaxation techniques , with the goal of understanding and reducing oversensitive reactions to perceived threats .
this goal may be achieved by enhancing dormant central resources ( e.g. , improving general physical health ) , drawing on past skills and experiences , modifying attitudes and beliefs , considering emotional make - up , accepting appropriate social support , and improving the ability to relax .
the goal of this component of the therapy is to adjust more readily and effectively to routine and major incidental life demands or changes .
( 3 ) the avoidance of silence by sound enrichment and sound therapy aimed at reducing the contrast between silence and tinnitus , for example , by using hearing instruments , white noise generators , or environmental sounds as appropriate in each individual case .
the important notion here is that the patient habituates to these sounds of known origin , while at the same time reducing the awareness of the tinnitus signals , as they do not stand out in contrast to silence .
this study employs a longitudinal survey design assessing the long - term effect of a tinnitus habituation program 5 years after the treatment ended .
the participants were recruited from the norwegian association of the hard of hearing ( hlf ) and their school and resource center in briskeby .
the program was carried out at the university of oslo , department of special needs education in cooperation with briskeby .
the follow - up investigation of the results was carried out at the university of oslo .
the collected data were based on the hospital anxiety and depression scale ( hads ) .
the questionnaire was developed for use in general hospital outpatient departments as a screening test for emotional disorders , such as anxiety and depression .
to assess the reliability of the indexes , we used cronbach 's alpha scale where 1.0 represents perfect reliability .
i get a sort of frightened feeling as if something awful is about to happen ,
i get a sort of frightened feeling like butterflies in my stomach ,
i feel restless , as if i have to be on the move , and i get sudden feelings of panic .
i still enjoy the things i used to enjoy , i can laugh and see the funny side of things ,
i look forward with enjoyment to things , and i can enjoy a good book , listening to the radio or watching tv .
an analysis of factors that may explain the informants ' experience of anxiety and depression was performed incrementally .
first , all of the relevant background variables were analyzed to reveal those that correlated significantly with either anxiety or depression .
these selected variables were subsequently included in a multiple regression analysis with anxiety and depression as the dependent variables .
the independent variables that did not contribute to an improved explanation of anxiety or depression in the multiple regression model were removed , and the model was recalculated .
the level of significance was set to a p value of 0.05 or less ( without correction for multiple testing ) .
the regional committee for medical research ethics ( rek ) and the norwegian social science data services approved this project .
the results obtained from the present study of the long - term effects five years after treatment ended show that the positive and significant effects on anxiety and depression , which were achieved immediately after tinnitus habituation therapy , were maintained .
in fact , a considerable number of patients continued to improve . no significant difference in outcome
was shown between the participants who had experienced tinnitus annoyance for more than 10 years and those who had experienced the annoyance for a shorter period of time .
table 2 shows that the reduction of anxiety as reported immediately after treatment was 0.18 points ( from 1.10 to 0.92 ) with a further slight reduction from posttreatment to five years after treatment assessment ( from 0.92 to 0.87 ) .
the total reduction from pretreatment to five years after treatment assessment was 0.23 and , therefore , strongly significant ( p = 0.002 ) .
table 3 shows the results form a simple bivariate correlation between the explored variables that correlated significantly with the degree of anxiety . for both posttreatment and at the 5-year follow - up , the strongest correlation was found between the participants ' positive experience of the lecture given in the treatment and a better outcome of the treatment ( 0.463 , p = 0.000 , 0.353 , p = 0.004 , resp . ) .
in addition , the self - reported pretreatment health condition correlated significantly both immediately after treatment and at the five - year follow - up .
the results from the multiple regression analysis on experienced anxiety are presented in table 4 .
the analysis gave a coefficient of determination r of .227 , indicating that the included variables were associated with 22.7% of the total variance in the experienced anxiety of people with tinnitus .
those who experienced decreased anxiety in relation to tinnitus were those who stated post - treatment that they were most satisfied with the lectures in the treatment and those who had the best self - reported health condition before treatment started .
the size of each standardized regression coefficient showed that the experienced effect of the lectures explained most of the variation in anxiety , when the other variable was kept constant .
table 2 shows a reduction of depression immediately after treatment of 0.15 points ( from 0.77 to 0.62 ) . the depression score
five years after treatment shows a further slight reduction of 0.07 points ( from 0.62 to 0.55 ) .
the maximum score possible for depression was 3 . from the pretest to the assessment five years after treatment , the reduction was 0.22 points ( p = 0.000 ) .
table 5 shows the results form a simple bivariate correlation between the explored variables that correlated significantly with the degree of depression . for both post - treatment and at the 5-year follow - up
, the strongest correlation was found between the participants ' self - reported pre - treatment health condition and improved outcomes of the treatment ( 0.378 , p = 0.002 , 0.411 , p = 0.001 , resp . ) .
the analysis shows that the same variables that were of significant importance right after the treatment were also significant at the 5-year follow - up time point .
the results from the multiple regression analysis over the variation in experienced depression are presented in table 6 .
the analysis gave an r of 0.349 , indicating that the included variables were associated with 34.9% of the total variance in the experienced anxiety ( the radj was 0.305 ) .
reduced depression in relation to tinnitus was associated with the feeling of being in good health pre - treatment , the absence of hyperacusis , and high satisfaction with the lectures given as part of the intervention .
the size of each standardized regression coefficient shows that the pre - treatment health condition and the absence of hyperacusis equally explained most of the variation in depression , when the other variable was kept constant .
in line with the results of other studies [ 4 , 6 , 11 ] , we found a higher prevalence of anxiety than depression .
the participants further reported that they experienced significantly less anxiety and depression five years after neurophysiologically based tinnitus treatment than before treatment , indicating a long - term effect of such therapy .
the findings confirm results from other studies based on shorter follow - up times [ 4 , 2732 ] , suggesting that modified tinnitus retraining therapy may lead to subjective improvements in tinnitus - related symptoms , such as emotional and cognitive distress and intrusiveness .
the results are also in line with those of goebel et al . , who , in a 15-year prospective comparable follow - up study , reported improvements of the tinnitus parameters and additional symptoms .
this result indicates that the positive findings in the present study , which were based on a five - year follow - up study , will also be maintained at a later point in time .
our findings show a strong effect of the treatment related to the positive experience of the treatment lectures .
the significant correlation between the participants ' positive experience of the educational , medical , psychological , and physiotherapeutic lectures indicate that all of these aspects are of importance in the treatment offered .
this result indicates the crucial importance of information that helps the patients understand the neurophysiological model of tinnitus and the importance of motivation for practicing the advice given to them during the treatment period .
self - reported good health was shown to be a positive indicator for outcome , which could indicate that individuals reporting good health before treatment are more likely to benefit more from this kind of treatment than individuals reporting a poor health condition .
further data indicate that the patients who suffer from both tinnitus and hyperacusis are those with the lowest therapy outcome .
our finding may support the suggestion of jastreboff and hazell that in these individuals , one must start treating hyperacusis first .
the post - treatment results show that the habituation treatment outcome regarding anxiety was higher in the individuals with pre - treatment hearing impairment compared with those with no hearing loss .
other studies suggest that subjective discomfort is more present in tinnitus patients with normal hearing than in those with hearing impairment .
our findings obtained five years after treatment , however , did not show a significant effect of pre - treatment hearing status and the degree of anxiety .
fifty - two percent of the participants in our study reported their first awareness of tinnitus to be related to a change in their life .
being aware of this common experience and the possible consequences for tinnitus annoyance can be a crucial step in the habituation process .
the documentation of a close relationship between tinnitus and comorbid psychological disorders must also be taken into account in the initial phase of treatment .
stress this point by recommending screening or assessment for psychological distress in tinnitus sufferers such that patients can be adequately treated .
the placebo effect , defined as a temporary ( two to three months ) improvement of symptoms not related to the effect of the treatment with tinnitus ranges around 40% .
therefore , the potential impact of a placebo effect on the results should be examined carefully .
however , jastreboff and hazell argue that a sustained result over 624 months can not be a placebo effect .
habituation therapy in the present study shows a significant long - term effect of 5 years , and the importance of the placebo effect can thus be reduced or eliminated .
a control group for the current study would have been desirable ; such a group was , however , not applicable for several reasons , mainly ethical aspects .
it was not ethically acceptable to allow a group of patients to be let out of treatment for a period of five years .
neurophysiologically based management treatment showed a longitudinal positive effect on anxiety and depression in tinnitus suffers five years after completed treatment .
the results indicate that the participants have learned how to cope with their tinnitus annoyance and how to continue their improvement after completing therapy without becoming dependent on professionals . | treatment programs based on a neurophysiological model have shown a positive effect on anxiety and depression in tinnitus patients .
the aim of this paper was to assess the long - term effect of tinnitus habituation therapy .
sixty - eight individuals were treated with a comprehensive therapy program .
the degree of anxiety and depression was assessed before , after , and five years after intervention using the hospital anxiety and depression scale .
the positive and significant changes achieved after habituation therapy ( pre = 1.10 , post = 0.92 for anxiety and pre = 0.77 , post = 0.62 for depression ) were maintained five years after treatment ended ( 0.87 for anxiety and 0.52 for depression ) .
a regression analysis revealed that individual evaluation of the treatment lectures , self - reported health condition , individual experiences of hyperacusis , and hearing loss could explain 44.3% of the variation in anxiety and 30.5% of the variation in depression posttreatment .
five years after , individual evaluation of the treatment lectures and self - reported health condition explained 22.2% of the variation in anxiety . these factors and individual experiences of hyperacusis
could further explain 34.9% of the variation in depression .
the effect of a neurophysiologic - based management treatment was maintained five years after treatment ended , indicating that the patients continued the improvement process without becoming dependent on professionals . |
primary classical hodgkin 's lymphoma ( hl ) of the gastrointestinal tract ( git ) are rare lymphoproliferative neoplasm representing less than 5% of git lymphomas , predominantly confined to the small intestine .
diagnosis of the primary lesion requires the lack of peripheral or mediastinal lymphadenopathy , normal white blood cell ( wbc ) count and differential on peripheral blood smear .
the most common site of extranodal lymphoma is the git with the majority of cases in the ileum due to the abundant lymphoid follicles .
pulmonary system , thyroid , skin , genitourinary and central nervous system being the other sites .
more recent criteria for classification of primary gastrointestinal lymphoma includes cases where bulk of tumor involves git .
the blocks of an intestinal mass operated at a peripheral hospital were received at our institute for histomorphological and immunohistochemistry ( ihc ) confirmation .
a 30-year - old male presented to the surgical out - patient department of a peripheral hospital , with a recent history of abdominal distension , constant pain in the right lower quadrant along with nausea and vomiting .
he was a known case of abdominal tuberculosis and had received a full course of anti - tubercular treatment . however , at the time of presentation , no relevant history of fever , night sweats , weight loss or bleeding per rectum was recorded .
hematological findings showed a total leucocyte count of 8900/mm and a differential count of neutrophils 68% , lymphocytes 26% , eosinophil 4% , monocytes 2% , and a hemoglobin of 11.3 g / dl .
computerized tomographic scan revealed a mass at the terminal ileum along with right sided pericolic infiltrate and mesenteric lymphadenitis .
exploratory laparotomy was done to relieve patient symptoms and establish the diagnosis . surgical intervention comprised of right hemicolectomy and ileocolic anastomoses .
microscopic examination of the lesion revealed multiple nodules of cellular infiltrates extending from intestinal mucosa up to the serosa .
cellular infiltrates comprised of mixed population of lymphocytes , plasma cells histiocytes , neutrophils , eosinophil , reed - sternberg ( rs ) cells and its variants [ figure 1 ] .
ihc staining showed that the rs cells and its variants were positive for cd30 antigen [ figure 2 ] and weakly positive for cd15 and negative for cd45 [ figure 3 ] .
stain for cd3 and cd20 showed normal pattern . on the basis of histomorphological features and ihc , a definitive diagnosis of hl ,
a full work - up of patient to identify the presence of the disease anywhere else in the body was done .
all investigations were within the normal limits hence a diagnosis of primary hl of the git was made .
photomicrograph of the lesion showing reed - sternberg cells in a polymorphous background ( h and e , 40 ) photomicrograph showing reed - sternberg cells and its variants with cd30 positivity ( immunohistochemistry , 40 ) photomicrograph showing cd45 negative reed - sternberg cells and its variants ( immunohistochemistry , 40 )
primary classical hl are well - established neoplasms of the lymphnode ; however , the primary extranodal forms are rare and account for less than 1% , git being the most common site . in view of its rare occurrence
, diagnosis has to be made in accordance with histological as well as other clinical and radiological criteria .
these can be outlined as : ( a ) no superficial lymphadenopathy should be present at the time of diagnosis ( b ) no involvement of mediastinal lymph node on chest imaging ( c ) complete blood count and wbc differential should be within normal limits ( d ) predominance of git lesion with or without positive adjacent lymph node ( e ) liver and spleen should be disease free at the time of diagnosis .
the present case fulfilled all the criteria and was thus categorized as primary gastrointestinal hl .
a case has been reported to be associated with cholelithiasis and ileocaecal intussusception , ileum being the most common site .
it has been well - documented that ileum is rich in lymphoid follicles hence , neoplastic transformation due to changes in immune response can occur . because it is rare for hl to localize to the small intestine , any diagnosis of the small bowel hl should prompt a thorough search for additional disease at the other site .
hl presenting with primary bowel involvement is a unique clinical entity , despite the frequent inclusion of hl in various series of malignant lymphoma , reports on primary lesion of the small intestine are rare .
a series of literature revealed only seven cases of intestinal hl out of 778 git lymphomas . in a case series , out of 24 cases of lymphoma of the git five cases of hl were reported .
however , only two cases of primary hl were encountered out of a total of 117 patients who presented with gastrointestinal lymphoma .
only 11 individual patients with small intestine hl were recorded since 1967 . however , their diagnosis was in doubt due to lack of ihc staining .
many of these patients were thought to resemble hl histologically such as anaplastic large cell lymphoma shows atypical cells resembling rs cells , similarly a highly differentiated carcinoma or multiple myeloma could also mimic hl with large rs like cells in a background of inflammatory cells . in the present case ,
the large atypical cells were negative for activin receptor - like kinase-1 ruling out anaplastic large cell lymphoma .
emphasis has to be laid on the importance of ihc . with currently available ihc techniques
these histologically similar tumors can be readily differentiated from hl . in the present case ,
to conclude , since it is rare for hl to localize in the small intestine without involvement of regional or distant lymph nodes , any diagnosis of small bowel hl should prompt a thorough search for additional disease at other sites .
histological confirmation by ihc technique supports the diagnosis of small intestinal hl to be valid .
all the criteria for inclusion should be adhered to for a conclusive diagnosis of a primary hl of the intestine . | primary intestinal lymphoma is a rare lymphoproliferative neoplasm of the small intestine .
the primary nature is established on the basis of lack of evidence of lymphoma on chest x - ray , computerized tomographic scan , peripheral blood or bone marrow puncture .
tumor involvement is limited to the gastrointestinal tract , the criteria for inclusion are that the symptoms related to the small intestine are predominant or the only symptoms at the time of laparotomy .
hodgkin 's lymphoma ( hl ) primarily in the small intestine is a rare entity and an uncommon presentation of the disease .
ileum is the more common site of infliction than the jejunum because of its abundant lymphoid follicles .
here , we present a case of primary intestinal hl , in a 30-year - old male . |
gastrointestinal stromal tumors ( gists ) are mesenchymal tumors that may develop anywhere within the gastrointestinal tract .
they are defined as cd117-(c - kit ) or cd34-positive spindle cell tumors and are derived from interstitial cells of cajal .
the most common site of growth is the stomach , accounting for 6070% of the entire gastrointestinal tract , followed by the small intestine , large intestine , and esophagus . in the stomach ,
developmental morphology is classified as exogastric ( 3040% ) , intramural ( 2944% ) , endogastric ( 1822% ) , and mixed type ( 1622% ) based on the skandalakis classification for leiomyomas .
the gist treatment guidelines show risk classifications combining tumor diameter and karyokinesis count , which is an index of cell proliferation potential .
tumors with a diameter of 5 cm and karyokinesis count of 5/hpf are classified into the high - risk group .
other factors that increase recurrence risk in malignant cases include hematogenous metastasis , invasion of surrounding tissue , peritoneal metastasis , and tumor rupture .
we treated a patient with a giant submucosal tumor of the stomach with extramural growth that was pathologically diagnosed as a classical gist postoperatively .
a 76-year - old man presented to our hospital with a feeling of abdominal fullness and poor appetite for approximately 1 month ; he had lost 7 kg , a 10% weight loss relative to his initial weight . of note , he had a medical history of myocardial infarction . during a regular checkup at the cardiovascular medicine department at our hospital ,
a computed tomography ( ct ) scan of the abdominal region revealed a giant , solid mass occupying the epigastrium .
an irregular - shaped solid mass with elastic hardness , of the size of an infant 's head , was palpated in the epigastrium .
blood test results after admission indicated mild normocytic and normochromic anemia ( hemoglobin , 11.3 g / dl ) and elevated inflammatory response ( c - reactive protein , 10 mg / dl ; table 1 ) .
contrast - enhanced abdominal ct revealed a giant , solid mass with a diameter of 23 cm occupying the epigastrium , and the gastric corpus was markedly displaced to the left . in the arterial phase
gallstones were detected ; otherwise , no obvious metastatic lesions in other organs were seen .
abdominal contrast magnetic resonance imaging showed an irregularly shaped tumor with hypoechoic signals on t1 images , and mixed areas of high and low intensity were noted on t2 images in the epigastrium .
the tumor had dominant borders , with a poorly enhanced area in the center , indicating internal necrosis .
much of the tumor was in contact with the liver , which was being excluded .
however , it was clearly demarcated , with regular borders and no apparent invasion ( fig .
extramural growth from the posterior wall of the middle stomach to the pyloric region was seen during esophagogastroduodenoscopy ( egd ) .
the diagnosis of a giant gastric submucosal tumor with extramural growth was established . despite blood transfusions , anemia progressed .
surgical findings indicated that a tumor had developed from the lesser curvature side of the stomach .
it adhered to the transverse mesocolon , liver , and gallbladder ; however , no invasion and metastatic lesions were detected .
macroscopic findings of the resected specimen showed a giant tumor of 23 20 13 cm on the gastric serosal side .
most of the tumor was covered in a capsule , but the capsule had broken in some places and parenchyma was disintegrating .
histopathological findings indicated that tumor cells were spindle shaped and oval nuclei exhibited tight , intricate hyperplasia in bundles below muscularis propria of the stomach .
on immunohistochemistry , the tumor cells were indicated to be cd117 ( c - kit)(+ ) , cd34(+ ) , s-100( ) , -sma ( -smooth muscle actin)( ) , and desmin( ) ( fig .
thus , a diagnosis of classical gist was made , and the tumor was classified into the high - risk group due to the high karyokinesis count and larger diameter .
imatinib ( 300 mg / day ) was initiated as adjuvant therapy on post - operative day 84 .
we performed a literature search on the american medical abstracts society for articles published from 2006 through 2015 using the keywords gastric gist and giant and excluded meeting minutes .
we found only 7 reports of lesions with a maximum diameter of 20 cm or greater over 10 years .
five of these ( 71% ) were in males and most patients ( six patients , 86% ) were 5060 years old .
the most common complaint was a feeling of fullness in the abdominal region ( four patients , 57% ) , followed by abdominal pain ( two patients , 29% ) ( table 2 ) [ 4 , 5 , 6 , 7 , 8 , 9 , 10 ] . because gist of the stomach developed extramurally , there were few clinical symptoms until it grew large , and it was difficult to detect . when tumors become exceedingly large , they displace surrounding organs and it can be difficult to identify the primary onset site and perform differential diagnosis . based on frequency ,
malignant tumors of the abdominal region requiring differentiation include gists , leiomyosarcomas , liposarcomas , desmoid tumors , and malignant fibrous histiocytomas .
gists more than 4 cm often involve necrosis , which is observed as a non - contrasted area on enhanced ct , and we made similar observations in our case . in our case , crp level was elevated up to 10 mg / dl ; however , it normalized after surgical resection .
thus , it appeared that necrosis in the gist was causing the stimulated inflammatory response .
the utility of imaging modalities such as ct in definitive preoperative diagnosis of gists is limited . in many cases , tumor biopsy with endoscopic ultrasound - guided fine needle aspiration
however , we did not perform this procedure on our patient in consideration of the risk of hemorrhage , as we had noted the formation of an aneurysm within the tumor .
it has been reported that in gists of 10 cm or larger , the surface is nodular due to countless large vessels and the tissue weakens , making it prone to hemorrhage .
therefore , in cases of giant tumors , eligibility for tumor biopsy for the purpose of preoperative diagnosis should be carefully considered taking into account the risk of hemorrhage and metastasis .
there were no clinically malignant findings in our patient but the tumor was classified into the high - risk group based on the diameter and karyokinesis count .
surgery should be performed taking into account the possibility of invasion of and adhesion to organs surrounding the tumor that can not be identified on preoperative diagnostic imaging and the need for extended surgery .
if a definitive diagnosis can be established based on histopathological findings , preoperative chemotherapy may also be considered as an option .
preoperative chemotherapy is performed to improve the complete resection rate , preserve organ function , and improve surgical safety .
however , it has also been reported that sudden reductions in tumor size may lead to adverse events such as tumor hemorrhage and tumor penetration .
postoperatively , it is recommended that adjuvant therapy with imatinib be administered for moderate and high - risk group tumors . according to a recent placebo - controlled randomized trial , adjuvant therapy for initial - onset gists ( c - kit - positive , 3 cm or larger ) involving 400 mg / day of imatinib for one year
thus , the recurrence - free survival rate was statistically significantly higher in the imatinib group .
it has been reported that in the high - risk group , a postoperative recurrence rate of approximately 60% is observed but that adjuvant therapy is effective .
the recent randomized trial that comparatively investigated groups administered imatinib for 1 year and 3 years found that the recurrence - free survival period and overall survival period were better in the 3-year - administration group .
| a 76-year - old man presented to our hospital with abdominal distention and loss of appetite .
the 10% of weight lost relative to this patient in 1 month .
abdominal computed tomography and magnetic resonance imaging revealed a giant mass , with a major axis of 23 cm , containing solid components , not involving the upper abdominal organs .
esophagogastroduodenoscopy showed extramural compression from the middle gastric body to the antrum , as well as a normal mucosal surface .
these findings were suggestive of a gastrointestinal stromal tumor attached to the anterior wall of the stomach without metastasis or invasion .
partial gastrectomy was performed for tumor resection , and the patient was subsequently treated with adjuvant imatinib .
we report a rare case of a large extramural gastrointestinal stromal tumor of the stomach that was larger than 20 cm in diameter and present a pertinent literature review . |
live intact tissues can be imaged using two - photon laser scanning microscopy ( tplsm ) either intravitally with the animal anesthetized or by isolating and imaging tissue explants maintained in oxygen - supplemented media at controlled temperature ( 15 ) . using a femtosecond pulsed - emission laser and near infrared light for excitation , optical slices are acquired at descending depths ( along the z axis ) of up to several hundred microns into the tissue generating a stack of images .
these z stacks are acquired in quick succession at regular time intervals . with the aid of computer software ,
the z stacks are rendered into three - dimensional images , which are then displayed as a contiguous stream in fast succession .
the results provide high resolution time - lapse video of cellular behaviors deep inside living tissue .
similar time - lapse images of live cells can be obtained using other types of imaging such as epifluorescence microscopy ( combined with deconvolution ) and confocal microscopy technologies that do not , however , allow in - depth imaging of tissue ( 6 ) .
images captured by epifluorescence and confocal microscopy provided our first glimpses into the process of immune recognition ( 711 ) and gave rise to today 's intense investigation of the formation , structure , and function of the immunological synapse ( 12 ) .
in addition to revealing new behavior at the tissue and cellular level , recent improvements in imaging technology are allowing scientists to visualize processes with nanoscale resolution , revealing intracellular activity which has never before been imagined , much less seen .
recent work by kindzelskii and petty using epifluorescence microscopy captured time - lapse images of intracellular calcium flux in neutrophils upon stimulation ( 13 ) .
these vivid , patterned waves of calcium could only be visualized by acquiring images at submicrosecond resolution .
there is no doubt that the ability to visualize events at the level of individual cells with this kind of spatiotemporal resolution will have a radical impact on the study of signal transduction , which until now has been dominated by biochemical study of isolated cell populations rather than direct observation of single cells .
be it on a molecular scale or at the tissue level , being able to visualize events in real time reveals new information concerning the spatial distribution and the dynamics of cellular events that simply can not be gleaned from conventional experimental approaches . but with such huge strides in technological development come new challenges .
although advanced imaging technology can indeed produce stunning images , the data sets provide far more than entertainment for the scientific community .
there is a wealth of information contained in visual data that reflect mechanisms underlying the function of biological systems .
the challenge we face now is to develop the means to extract mechanistic understanding from the data and thereby take full advantage of the powerful capabilities afforded by today 's new age of scientific imaging .
we believe that two approaches will be the keys to mining the wealth of information in data obtained from imaging experiments .
the second is to develop models that can be simulated on a computer and can be used to test hypotheses for mechanisms underlying the observed behavior . properly done , quantitative analysis of data can provide a precise description of visual information that can not be conveyed by subjective language .
t cells move faster than b cells when migrating through the lymph node is unsatisfying , leaving open questions such as , how much faster ? and do t cells move faster all the time or only during certain time intervals ? with the recent release of specialized computer software , imaris , developed by bitplane , it is now possible to track fluorescently labeled objects , either cells or particles , moving in three dimensions through time ( fig . 1 ;
reference 14 ) . with this new capability comes the means to make quantitative and time - resolved measurements that can precisely characterize motility in terms of velocities ( speed and direction of movement ) , acceleration , and deceleration .
importantly , this software is user friendly , and bitplane offers both personalized and web - based training sessions . tracking cell migration in four dimensions .
a still photo taken from a time - lapse video of gfp - labeled thymocytes moving in three dimensions through an intact thymic lobe acquired by tplsm . the image ( left )
was reconstructed from a single z stack and is shown along the x and y axes with selected migratory tracks highlighted .
tracks were generated using imaris computer software by bitplane , and are color coded to indicate the passage of time from blue ( beginning of imaging ) to yellow ( end of imaging ) .
the x , y , and z coordinates of the tracked object are determined at each time point throughout tracking .
coordinate data is then imported into microsoft excel and can be used to extract a number of measurements related to three - dimensional movement .
the ability to assess differences and similarities with precision provides the necessary objectivity to unambiguously interpret experimental results .
for example , cells migrating through tissue exhibit a characteristic degree of pausing ( fig .
quantitative information about cell movement can sometimes be used to test predictions as to what would happen to this behavior if the system were manipulated ( for example , the loss of a critical adhesion factor involved in thymocyte - stromal cell synapse formation ) .
we can predict that under these conditions the frequency and/or duration of migratory pausing will decrease and we can experimentally determine the developmental consequences of such a change .
moreover , the significance of observed differences can be evaluated using statistical methods that can establish confidence limits on the data and its interpretation .
a still photo taken from time - lapse video acquired by tplsm shows the migratory path taken by a single gfp - labeled thymocyte as it moved through an intact thymic lobe .
the red arrow indicates the point at which cell displacement ceased and the green arrow indicates the time at which the cell resumed its displacement .
this behavior can be measured to determine the incidence and the average duration of pausing calculated from thousands of migratory events ( unpublished data ) .
quantitating visual data removes the subjectivity that can sometimes taint interpretation of qualitative observations . when viewing time - lapse video , one 's attention can easily be drawn to a behavior that catches the eye , possibly leading to the erroneous conclusion that the behavior is representative or otherwise significant .
computing the frequency of such a behavior may reveal that it is extraordinarily rare and , despite the eye 's tendency to focus on it , may not be biologically meaningful .
conversely , it is also possible that rare events that direct biologically important phenomena can be masked by the dominant and uninteresting dynamic events .
quantitative measurements can also lead to totally new mechanistic insights that would simply not have been revealed without the precise data .
davis and coworkers have developed single molecule - counting methods where individual agonist peptide mhc molecules can be fluorescently tagged , and their numbers at the junction between a t cell and an apc can be precisely determined .
this enabled them to show that cd4 t cells undergo transient calcium signaling upon stimulation by a single agonist peptide mhc molecule , and that sustained calcium signaling and immunological synapse formation can be induced by as few as 10 agonist peptide mhc molecules in a sea of endogenous peptide mhc molecules ( 30,000 ) in the contact zone ( 15 ) .
these observations are in contrast to the previous supposition that cd4 t cell responsiveness required on the order of 60400 agonist peptide mhc molecules ( 1619 ) .
this previous estimate had been derived from biochemical methods that calculated the average number of agonist peptide
quantitation of the direct visualization of molecular events in the contact zone provided a precise value for the minimum number of agonist peptide mhc molecules required for stimulating t cell signaling .
this finding of an unexpected sensitivity and selectivity of t cell response to antigen raised many important mechanistic questions such as : how is the extraordinary sensitivity with which t cells detect self from
this question , motivated by precise quantitation of direct visualization experiments , led to synergies between mathematical models and biochemical and imaging experiments that have suggested striking new models for early activation events in cd4 t cells ( 7 , 15 , 20 ) .
in particular , the suggestion ( 15 , 20 ) that the formation of dimers of self and agonist peptide mhc molecules and the spatial localization of a kinase ( lck ) play key roles in amplifying the sensitivity and selectivity with which t cells detect antigen provides a framework for future experimentation .
quantitating some types of visual data can be straightforward , as in the case of measuring migratory speed with computer software assistance .
quantifying more complex phenomena , such as the dynamics of changes in cell shape , is more challenging and will require collaborations between immunologists and physical scientists and applied mathematicians .
intracellular signaling and effector functions resulting from receptor - ligand binding are emergent properties that involve cooperative events and many cellular components .
the migratory behavior of cells in the thymus or lymph nodes is also influenced by many events occurring in concert .
direct visualization experiments are providing vivid images of the consequences of these cooperative dynamic phenomena .
the inherently cooperative nature of dynamic processes in cell biology , however , can confound our ability to understand mechanism based on observations of just a few experimental reporters .
statistical physics is a discipline that has been focused on understanding collective dynamic processes in synthetic systems .
as we focus on developing a mechanistic understanding of cooperative dynamic processes in immunology and cell biology , it seems that the time is ripe for synergies between statistical mechanical model building and genetic , biochemical , and imaging experiments .
recent studies have shown that such a marriage between in silico , in vitro , and in vivo studies can be fruitful in developing mechanistic insights ( 2023 ) .
counterintuitive ideas regarding the signaling function of the immunological synapse , the importance of spatial organization of receptors , ligands , and kinases for the extraordinary sensitivity of t cells to antigen , mechanisms underlying tcr down - regulation , and signaling by the fc receptor are just some examples of insights that have emerged from such synergies between methods rooted in the physical and biological sciences .
mathematics is well appreciated as being the language of physics , elegantly and concisely describing physical phenomena over a wide spectrum of length and time scales .
understandably , the disciplines of physics and mathematics have often developed in concert , leap - frogging over one another as an achievement in one field led to the advancement of the other .
indeed , the development of one of the most influential branches of mathematics , calculus , was partly driven by the physicist 's desire to explain planetary motion ( 24 ) . with some notable exceptions ( 25 ) , the histories of biology and the physical sciences have been far less intertwined .
but the strict boundary between these disciplines , so clearly delineated in the past , has become blurred in recent years . in the last half century , biology has branched into numerous subdisciplines , many of which rely heavily on mathematics and physical and computer sciences . for example , a student of modern neuroscience is heavily immersed in the principles of physics and is well advised to acquire computational expertise .
increasing numbers of universities now offer degree programs in the fields of theoretical and computational biology . despite some notable exceptions ( 26 ) , computational and experimental studies in immunology
this is perhaps partly due to an almost stereotypical math phobia that afflicts many biologists ( including immunologists ) but is largely because , until now , the value and benefits of such a marriage may not have been immediately obvious .
images of collective dynamic phenomena and the difficulties associated with intuitively discriminating between the consequences of different mechanistic hypotheses regarding the cooperative events is changing this situation rapidly .
the invention of the telescope gave us the ability to see what could never have been seen before .
out of this capability arose the need for ways to extract , interpret , and exploit the fruits of this powerful new technology of visualization .
the result was classical mechanics ( 24 ) . in a very literal sense , biology
today is in a similar situation , where new imaging technologies are revealing worlds that have never been seen before , from the in vivo setting to the subcellular .
the development of methods to quantitate visual data in immunology and understand it at a mechanistic level will allow us to take steps toward developing predictive algorithms and protocols for intervention when things go awry .
achieving this lofty goal will require a multidisciplinary approach , involving the fields of biology , mathematics , physics , chemistry , and computer science .
an unprecedented level of outreach by biologists , physical scientists , and engineers is required to forge such collaborations .
a blending of disciplines has not been business as usual in mainstream immunology , but such synergies appear to be necessary if we are to move beyond the stunning images and reap the full benefits of advanced imaging technology .
properly done , quantitative analysis of data can provide a precise description of visual information that can not be conveyed by subjective language .
t cells move faster than b cells when migrating through the lymph node is unsatisfying , leaving open questions such as , how much faster ? and do t cells move faster all the time or only during certain time intervals ? with the recent release of specialized computer software , imaris , developed by bitplane , it is now possible to track fluorescently labeled objects , either cells or particles , moving in three dimensions through time ( fig . 1 ; reference 14 ) .
with this new capability comes the means to make quantitative and time - resolved measurements that can precisely characterize motility in terms of velocities ( speed and direction of movement ) , acceleration , and deceleration .
importantly , this software is user friendly , and bitplane offers both personalized and web - based training sessions . tracking cell migration in four dimensions .
a still photo taken from a time - lapse video of gfp - labeled thymocytes moving in three dimensions through an intact thymic lobe acquired by tplsm . the image ( left )
was reconstructed from a single z stack and is shown along the x and y axes with selected migratory tracks highlighted .
tracks were generated using imaris computer software by bitplane , and are color coded to indicate the passage of time from blue ( beginning of imaging ) to yellow ( end of imaging ) .
the x , y , and z coordinates of the tracked object are determined at each time point throughout tracking .
coordinate data is then imported into microsoft excel and can be used to extract a number of measurements related to three - dimensional movement .
the ability to assess differences and similarities with precision provides the necessary objectivity to unambiguously interpret experimental results .
for example , cells migrating through tissue exhibit a characteristic degree of pausing ( fig .
quantitative information about cell movement can sometimes be used to test predictions as to what would happen to this behavior if the system were manipulated ( for example , the loss of a critical adhesion factor involved in thymocyte - stromal cell synapse formation ) .
we can predict that under these conditions the frequency and/or duration of migratory pausing will decrease and we can experimentally determine the developmental consequences of such a change .
moreover , the significance of observed differences can be evaluated using statistical methods that can establish confidence limits on the data and its interpretation .
a still photo taken from time - lapse video acquired by tplsm shows the migratory path taken by a single gfp - labeled thymocyte as it moved through an intact thymic lobe .
the red arrow indicates the point at which cell displacement ceased and the green arrow indicates the time at which the cell resumed its displacement .
this behavior can be measured to determine the incidence and the average duration of pausing calculated from thousands of migratory events ( unpublished data ) .
quantitating visual data removes the subjectivity that can sometimes taint interpretation of qualitative observations . when viewing time - lapse video , one 's attention can easily be drawn to a behavior that catches the eye , possibly leading to the erroneous conclusion that the behavior is representative or otherwise significant .
computing the frequency of such a behavior may reveal that it is extraordinarily rare and , despite the eye 's tendency to focus on it , may not be biologically meaningful .
conversely , it is also possible that rare events that direct biologically important phenomena can be masked by the dominant and uninteresting dynamic events .
quantitative measurements can also lead to totally new mechanistic insights that would simply not have been revealed without the precise data .
davis and coworkers have developed single molecule - counting methods where individual agonist peptide mhc molecules can be fluorescently tagged , and their numbers at the junction between a t cell and an apc can be precisely determined .
this enabled them to show that cd4 t cells undergo transient calcium signaling upon stimulation by a single agonist peptide mhc molecule , and that sustained calcium signaling and immunological synapse formation can be induced by as few as 10 agonist peptide mhc molecules in a sea of endogenous peptide mhc molecules ( 30,000 ) in the contact zone ( 15 ) .
these observations are in contrast to the previous supposition that cd4 t cell responsiveness required on the order of 60400 agonist peptide mhc molecules ( 1619 ) .
this previous estimate had been derived from biochemical methods that calculated the average number of agonist peptide
quantitation of the direct visualization of molecular events in the contact zone provided a precise value for the minimum number of agonist peptide mhc molecules required for stimulating t cell signaling .
this finding of an unexpected sensitivity and selectivity of t cell response to antigen raised many important mechanistic questions such as : how is the extraordinary sensitivity with which t cells detect self from
this question , motivated by precise quantitation of direct visualization experiments , led to synergies between mathematical models and biochemical and imaging experiments that have suggested striking new models for early activation events in cd4 t cells ( 7 , 15 , 20 ) .
in particular , the suggestion ( 15 , 20 ) that the formation of dimers of self and agonist peptide mhc molecules and the spatial localization of a kinase ( lck ) play key roles in amplifying the sensitivity and selectivity with which t cells detect antigen provides a framework for future experimentation .
quantitating some types of visual data can be straightforward , as in the case of measuring migratory speed with computer software assistance .
quantifying more complex phenomena , such as the dynamics of changes in cell shape , is more challenging and will require collaborations between immunologists and physical scientists and applied mathematicians .
intracellular signaling and effector functions resulting from receptor - ligand binding are emergent properties that involve cooperative events and many cellular components . the migratory behavior of cells in the thymus or lymph nodes is also influenced by many events occurring in concert .
direct visualization experiments are providing vivid images of the consequences of these cooperative dynamic phenomena .
the inherently cooperative nature of dynamic processes in cell biology , however , can confound our ability to understand mechanism based on observations of just a few experimental reporters .
statistical physics is a discipline that has been focused on understanding collective dynamic processes in synthetic systems .
as we focus on developing a mechanistic understanding of cooperative dynamic processes in immunology and cell biology , it seems that the time is ripe for synergies between statistical mechanical model building and genetic , biochemical , and imaging experiments .
recent studies have shown that such a marriage between in silico , in vitro , and in vivo studies can be fruitful in developing mechanistic insights ( 2023 ) .
counterintuitive ideas regarding the signaling function of the immunological synapse , the importance of spatial organization of receptors , ligands , and kinases for the extraordinary sensitivity of t cells to antigen , mechanisms underlying tcr down - regulation , and signaling by the fc receptor are just some examples of insights that have emerged from such synergies between methods rooted in the physical and biological sciences .
mathematics is well appreciated as being the language of physics , elegantly and concisely describing physical phenomena over a wide spectrum of length and time scales .
understandably , the disciplines of physics and mathematics have often developed in concert , leap - frogging over one another as an achievement in one field led to the advancement of the other .
indeed , the development of one of the most influential branches of mathematics , calculus , was partly driven by the physicist 's desire to explain planetary motion ( 24 ) . with some notable exceptions ( 25 ) , the histories of biology and the physical sciences have been far less intertwined .
but the strict boundary between these disciplines , so clearly delineated in the past , has become blurred in recent years . in the last half century , biology has branched into numerous subdisciplines , many of which rely heavily on mathematics and physical and computer sciences . for example , a student of modern neuroscience is heavily immersed in the principles of physics and is well advised to acquire computational expertise . increasing numbers of universities now offer degree programs in the fields of theoretical and computational biology . despite some notable exceptions ( 26 ) , computational and experimental studies in immunology have largely followed parallel tracks .
this is perhaps partly due to an almost stereotypical math phobia that afflicts many biologists ( including immunologists ) but is largely because , until now , the value and benefits of such a marriage may not have been immediately obvious
. images of collective dynamic phenomena and the difficulties associated with intuitively discriminating between the consequences of different mechanistic hypotheses regarding the cooperative events is changing this situation rapidly .
the invention of the telescope gave us the ability to see what could never have been seen before .
out of this capability arose the need for ways to extract , interpret , and exploit the fruits of this powerful new technology of visualization .
the result was classical mechanics ( 24 ) . in a very literal sense , biology today is in a similar situation , where new imaging technologies are revealing worlds that have never been seen before , from the in vivo setting to the subcellular .
the development of methods to quantitate visual data in immunology and understand it at a mechanistic level will allow us to take steps toward developing predictive algorithms and protocols for intervention when things go awry . achieving this lofty goal will require a multidisciplinary approach , involving the fields of biology , mathematics , physics , chemistry , and computer science .
an unprecedented level of outreach by biologists , physical scientists , and engineers is required to forge such collaborations .
a blending of disciplines has not been business as usual in mainstream immunology , but such synergies appear to be necessary if we are to move beyond the stunning images and reap the full benefits of advanced imaging technology . | immunological phenomena that were once deduced from genetic , biochemical , and in situ approaches are now being witnessed in living color , in three dimensions , and in real time .
the information in time - lapse imaging can provide valuable mechanistic insight into a host of processes , from cell migration to signal transduction .
what we need now are methods to quantitate these new visual data and to exploit computational resources and statistical mechanical methods to develop mechanistic models . |
japan is one of the world s fastest aging societies , and the increase in the elderly
disabled requiring long - term care is becoming a social problem .
according to the long - term
care insurance report 2012 issued by the ministry of health , labour and welfare ( mhlw ) ,
5,306,000 people , including the bedridden elderly , now have a certification of long - term
care need1 , and the figure is expected to
continue to increase . according to the mhlw report of basic research on japanese life 2010 , cerebrovascular
diseases ( strokes ) are the most common cause for disabilities that require care , accounting
for 21.5% .
the percentage increases as the care - need level increases . for people with the
highest care - need , which is level v ,
since japan is rapidly aging , people suffering from strokes are expected
to increase . taking appropriate measures for the bedridden elderly
in addition , strokes often cause
aftereffects . under the government policy that reduces medical spending and encourages
elderly people to be treated at home , discharging them from institutions as soon as
possible ,
services for homebound elderly hemiparetic stroke patients that consider their
quality of life ( qol ) are required for them to live securely and stably at home .
this study looked at homebound elderly hemiparetic stroke patients , researched their
physical conditions and qol , and analyzed and examined factors that affect the qol to
discover how these patients can maintain their qol at home after being discharged from
institutions .
a questionnaire was administered to 21 homebound elderly hemiparetic stroke patients who
were 65 years old or over , used home - visit care services , did not suffer from obvious
dementia , and were able to answer the questionnaire ( 12 males and 9 females , average age :
79.3 8.4 years old ) .
we visited their homes and researched their physical functions and
qol . in term of ethical considerations , details of the study
were explained to subjects verbally
and in writing , and signed consent forms were received from subjects .
the research items were subject age , gender , daily life independence level of the elderly
disabled persons ( bedridden degree ) , care - need level , activities of daily living ( adl ) , and
qol .
this measure consists of 13 mobility items
and 5 communication and social cognition items .
a full score is 126 points in total , meaning fully - independent , and the
lowest possible score is 18 points , meaning total assistance is required .
the mos 36-item short - form health survey ( sf-36 , japanese - version 1.2 ) was used for the qol
assessment5 .
this measure is a
comprehensive health - related qol scale , and is commonly used for assessment with subjective
outcome measures .
the subscales consist of 8 sections : physical functions ( pf ) , role
physical ( rp ) , body pain ( bp ) , general health ( gh ) , vitality ( vt ) , social functions ( sf ) ,
role emotional ( re ) , and mental health ( mh ) .
nationwide standard
scores for each gender and age are available , and can be easily compared with the scores of
the subject group .
this is an advantage of this measure . to examine the correlations between the qol and adl and the burden felt by caregivers ,
, we used stat soft s statistical analysis software ,
statistica . a significance level of 5% was considered statistically significant .
for the adl independence of the homebound elderly hemiparetic stroke patients , the
subjects total fim scores ranged from 24 to 123 points ( average : 72.7 34.1 ) , indicating
that some required total assistance and some were nearly fully - independent . for the
bedridden degree , only 1 subject ( 4.8% ) was nearly independent and able to go out alone .
eight subjects ( 38.1% ) were independent at home but required assistance for going out , and
12 subjects ( 57.1% ) required assistance both at home and when going out .
regarding their
care - need levels , 2 subjects were at the assistance - need level , 5 subjects were at care - need
level i , 3 subjects were at care - need level iii , 6 subjects were at care - need level iv , and
5 subjects were at care - need level v. the average qol of the homebound elderly hemiparetic stroke patients was lower in six
subscales , excluding rp and re , and was particularly lower for the pf and mh subscales , than
the deviation score of 50 of the nationwide standard scores for the same age group ( table 1table 1 .
comparison between disabled elderly person s qol and the national standard
deviation value ( 50)deviation valuesf-36mean sdphysical function29.311.4role physical55.8 6.2body pain49.8 9.6general health47.913.8vitality45.810.8social function47.114.5role emotional 52.07.8mental health 43.17.8 ) .
no correlations were observed between the qol and age and gender . for the correlations between the qol and total fim scores of the homebound elderly
hemiparetic stroke patients , the pf and vt subscales for qol were significantly high when
adl independence was high . as for the correlations between the qol and fim items , the
physical functions and vitality
significantly correlated with all mobility items . when adl
independence was high , the pf and vt subscales for qol were also high ( r=0.710.84 ,
p<0.001 ) .
the sf subscales were significantly correlated with the independence of
transfer ( from bed to chair , wheelchair to toilet seat , etc . ) and movement ( from a
room / place to another room / place ) .
when patients are more capable in
transfer and movement , their spheres of activity become
broader and the sf scores also become higher .
the bp subscale showed significant negative
correlations with transfer ( 0.55 , p<0.05 ) and movement ( r=0.71 , p<0.01 ) , suggesting
that patients complain more about body pain when they are more capable in transfer and
movement and their spheres of activity are broader ( table 2table 2 .
correlation coefficient of disabled elderly person s qol ( sf-36 ) and
independence in adl , bedridden degree , and care - need levelsf-36adl and otherspfrpbpghvtsfremhfimmovement itemself - care0.77 * * 0.50 0.47 0.02 0.61 * * 0.25 0.08 0.35 excretion control0.71 * * 0.49 0.42 0.17 0.52 * 0.29 0.05 0.34 transfer0.78 * * 0.42 0.55 * 0.05 0.51 * 0.51 * 0.19 0.08 locomotion0.84 * * 0.50 0.71 * * 0.01 0.55 * 0.52 * 0.29 0.11 cognition itemcommunication0.17 0.16 0.22 0.13 0.21 0.10 0.16 0.10 social cognition0.30 0.19 0.25 0.26 0.30 0.46 0.05 0.05 total0.78 * * 0.46 0.53 * 0.05 0.53 * 0.47 0.01 0.29 bedridden level 0.74 * * 0.45 0.61 * 0.21 0.61 * 0.26 0.13 0.20 care - need level0.50 * 0.20 0.55 * 0.31 0.10 0.37 0.43 0.08 * * p<0.01 , * p<0.05 .
pf : physical function , rp : role physical , bp : body pain , gh :
general health , vt : vitality , sf : social function , re : role emotional , mh : mental
health ) . *
pf : physical function , rp : role physical , bp : body pain , gh :
general health , vt : vitality , sf : social function , re : role emotional , mh : mental
health for the correlations between the qol and bedridden degree , subjects with a higher bedridden
degree showed significantly lower pf ( r=0.74 , p<0.01 ) and vt scores ( r=0.61 , p<0.05 )
and complained less about body pain ( r=0.55 , p<0.05 ) . for the correlations between the
qol and care - need level , subjects with a higher care - need level showed significantly lower
pf scores ( r=0.50 , p<0.05 ) and complained less about body pain ( r=0.55 , p<0.05 )
( table 2 ) .
although the stroke mortality rate is decreasing in japan , more and more people are
suffering from strokes . strokes often cause aftereffects , leaving patients with
disabilities . since shortening the duration of hospital / institution stays is encouraged
today , services for homebound elderly hemiparetic stroke patients that consider their qol
are required for them to live securely and stably at home after discharge from hospitals or
institutions .
this study looked at homebound elderly hemiparetic stroke patients and their
qol , and analyzed and examined factors that affect qol . the results indicated that patient
age or gender does not directly affect qol .
the results , however , showed that their qol was
affected by the bedridden degree , care - need level , and adl independence .
the results showed that the qol of the homebound elderly hemiparetic stroke patients was
lower in six subscales , excluding rp and re , than the deviation score of the same age group .
their physical activity and spheres of activity are limited , and they have less social
interaction .
our results
suggested that homebound elderly hemiparetic stroke patients are more anxious about their
future health and are depressed .
as for the correlations between the adl and qol of ordinary elderly people , sugisawa6 reported that their qol correlates with
their adl independence .
sasuga8 noted that extended adl ( 8 adl items and 12 iadl items ) are a factor
that affects the qol of the homebound disabled .
our results also indicated that the adl
independence of homebound elderly hemiparetic stroke patients correlates with their qol ,
such as their physical functions and vitality , verifying the results of the above - mentioned
researchers .
the qol of homebound elderly hemiparetic stroke patients also significantly
correlated with the bedridden degree and care - need level , which indicate mobility and amount
of assistance required .
when patient bedridden degree and care - need level were higher , the
qol was lower .
therefore , our results suggested that improving the adl independence and
lowering the bedridden degree and care - need level are required to improve the qol of
homebound elderly hemiparetic stroke patients . regarding the correlations between the qol and fim items , the pf and
vt subscales were
significantly correlated with independence in the mobility items . when transfer and movement
ability are higher , individuals have broader spheres of activity and higher social
functions .
therefore , in order to improve the qol , such as physical functions , vitality and
social functions , of people requiring long - term care , improving adl independence is , of
course , important .
it is , however , particularly important to assure their movement ability ,
as fukuya9 has noted .
patients with higher
transfer and movement ability also tended to have broader spheres of activity and to
complain more about body pain . with the development or worsening of such body pain ,
this
contradicts the improved social functions with broader spheres of activity . when patients
have more opportunities to engage in activity , the physical burden imposed on their bodies
increases , and they have more risk of suffering from body pain .
the risk of developing new body pain
must be assessed and addressed appropriately in order to improve qol , particularly the
individual s social functions and body pain .
the results of this study suggested that , in order to improve the qol of homebound elderly
hemiparetic stroke patients , continuous rehabilitation to maintain and improve patient adl
ability and assess and relieve the pain that patients feel when they move their bodies is
required . | [ purpose ] this study examined the quality of life ( qol ) of homebound elderly hemiparetic
stroke patients and factors that affect it . [ subjects ] the subjects of the study were 21
homebound elderly hemiparetic stroke patients who were 65 years old or over and required
care for daily living ( 12 males and 9 females , average age : 79.3 8.4 years old ) .
their
physical and psychological conditions , qol , and other characteristics were researched .
[ methods ] the functional independence measure ( fim ) was used for the activities of daily
living ( adl ) assessment , and the mos 36-item short - form health survey ( sf-36 , japanese
version 1.2 ) was used for the qol assessment .
[ results ] no correlations were observed
between the qol of homebound elderly hemiparetic stroke patients and their age and gender .
however , the results showed that their qol was affected by their independence in adl ,
bedridden degree , and care - need level .
[ conclusion ] these results suggest that in order to
improve the qol of homebound elderly hemiparetic stroke patients , ongoing rehabilitation
to improve independence in adl and lower the bedridden degree and care - need level is
required . |
spontaneous bacterial peritonitis ( sbp ) is defined as an infection of ascetic fluid without a proven intra - abdominal source ( 1 , 2 ) .
sbp is a common and severe complication in cirrhotic patients ( 3 ) , and is the major cause of mortality and morbidity among them ( 4 ) .
bacterial infection due to complications such as hepatic encephalopathy or hepatic failure , disruption of homeostasis , and renal insufficiency are common causes of the increased morbidity and mortality rates in cirrhotic patients ( 5 , 6 ) .
one of the required measures for sbp patients is rapid diagnosis of peritonitis for empirical antibiotic treatment ( 7 , 8) .
diagnosis of sbp is based on the number of ascetic fluid cells as polymorphonuclear cell count ( pmn ) 250/mm in ascetic fluid . also , only 50 to 70% of a patient s positive cultures for ascetic fluid
are generally reported ( 9 - 11 ) . due to limitations such as the time - consuming process for the diagnosis of peritonitis ascetic fluid and the lack of access to appropriate laboratory facilities , reports of negative cultures
could be delayed ( 12 , 13 ) . given these circumstances , numerous studies have been done on the available assessment techniques and rapid diagnosis of peritonitis .
it seems that some inflammatory cytokines can be used to determine the presence and severity of an inflammatory response and organ failure ( 14 - 16 ) .
the c - reactive protein is an acute phase protein that is produced predominantly by liver hepatocytes after stimulus by many cytokines and conditions such as infection or inflammation ( 17 - 20 ) .
the marker is one of the most common clinical and inflammatory indicators that can be measured in any laboratory ( 21 , 22 ) .
a few studies have shown increased levels of this marker in cirrhotic patients ( 1 , 2 , 23 ) .
for instance , in the study by preto - zamperlini et al . , increased serum levels of crp in children with sbp were demonstrated ( 24 ) .
we investigated the accuracy , sensitivity , and specificity of crp compared to the pmn count of cultured ascetic fluid for the diagnosis of sbp in children .
this prospective study was conducted as a single - center cross - sectional cohort study during july 2013 to august 2014 in the department of pediatric gastroenterology in nemazee teaching hospital , which is affiliated with shiraz university of medical sciences , the major referral center in southern iran .
this study was approved by the ethics committee of shiraz university of medical sciences , and all parents were asked to provide informed consent .
all patients aged two months to 18 years , regardless of gender , who were admitted for liver disease and ascites were candidates for the sample for our study , and underwent abdominal paracentesis procedures for clinical suspicion of sbp .
the exclusion criteria were as follows : 1 , receiving antibiotics during the past week or outside the hospital for any reason ; 2 , history of abdominal surgery in the past month ; 3 , renal dysfunction ; 4 , secondary bacterial peritonitis ; 5 , peritonitis carcinomatosis ; 6 , pancreatic peritonitis ; 7 , malignancy , or 8 , tuberculosis .
children with other sources of infection were also not included , along with children with evidence of nephritic syndrome or heart failure . based on the exclusion and inclusion criteria , 150 children with liver disease
samples were sent to a specialized laboratory and subjected to laboratory , cytology , and bacteriology culture evaluation .
wbc counts ( sysmex , usa ) , erythrocyte sedimentation rate ( esr ) , crp levels , prothrombin time ( pt ) , international normalized ratio ( inr ) , serum total protein levels , serum albumin levels ( sigma aldrich , st .
louis , usa ) , alanine transaminase ( alt ) levels , and aspartate transaminase ( ast ) levels ( sigma aldrich , st .
diagnosis of sbp was based on pmn cell count 250/mm in ascetic fluid ( 25 ) . in this study
, serum was obtained from patients within the first hours of admission for measurement of crp .
quantitative crp was measured by the immunoturbidimetry method ( biorex , antrim , uk ) .
data were expressed as means sd for quantitative variables , and as frequencies for qualitative variables .
the normality was continuously assessed with a kolmogorov - smirnov test . for the crp marker compared to the pmn count by means of a positive culture test , sensitivity , specificity ,
positive predictive value ( ppv ) , and negative predictive value ( npv ) were calculated according to a standard formula .
also , the area under the curve ( auc ) of the receiver operating characteristic ( roc ) curves was applied to assess the predictive power of crp .
the data were assessed by simple linear regression analysis to determine the correlations between crp values and other markers related to liver function , such as albumin , protein , pt , and bilirubin levels .
statistical analysis of the data was performed using the spss 19 ) spss inc . , il , chicago , usa ) software package .
this study was approved by the ethical committee of shiraz university of medical sciences ( no .
information about 150 patients with cirrhosis of the liver was investigated ; 72.7% of the patients presented without sbp , and 27.3% of patients were diagnosed with sbp .
the most common symptoms in patients without spb were abdominal pain ( 67.9% ) and abdominal distension ( 66.05 % ) . in patients with sbp , the most common clinical symptoms were also abdominal pain ( 70.7% ) and abdominal distension ( 58.5% ) .
the etiology of cirrhosis revealed that the most common causes of cirrhosis were biliary atresia ( 29.3% ) , neonatal hepatitis ( 19.26% ) , and wilson s disease ( 17.9% ) in patients without sbp . in patients with spb ,
the most common causes of cirrhosis were also biliary atresia ( 31.7% ) , neonatal hepatitis ( 24.4% ) , and wilson s disease ( 17.7% ) . among the 150 cases , 17 cases had positive cultures for the following : e. coli ( n=7 ) ; acinetobacter ( n = 2 ) ; klebsiella ( n = 2 ) ; streptococcus pneumoniae ( n = 2 ) ; and enterococcus ( n = 3 ) .
the different results of the laboratory findings of cirrhotic patients without sbp and those with sbp are shown in table 2 .
evaluation of ascites fluid showed that the mean sd of total cell counts in patients with sbp ( 1986.54 234.54 ) was significantly higher compared to the counts for patients without sbp ( 725.46 134.35)(p < 0.0001 ) .
the means sd of white blood cell ( wbc ) count and polymorph nuclear cell ( pmn ) count in patients with sbp were significantly higher than the counts for patients without sbp ( p < 0.0001 ) ( table 2 ) .
abbreviations : alp , alkaline phosphates ; alt , alanine aminotransferase ; ast , aspartate aminotransferase ; crp , c - reactive protein ; esr , estimated sedimentation rate ; inr : international normalization rate ; ldh : lactate dehydrogenate ; pt : prothrombin time ; pmn : polymorphonuclear cell ; wbc : white blood cell . the means and standard deviations of protein and albumin levels in patients with sbp were higher than the corresponding rates in patients without sbp ( p < 0.0001 ) .
similar to the case with the other markers mentioned , the mean sd of ldh in patients with sbp was higher than the corresponding rate in patients without sbp ( p < 0.0001 ) .
the means sd of both wbc and pmn counts were higher in patients with sbp ( 13587.6 240.4 vs. 8029.4 332.3 , p = 0.005 , and 3024.5 265.4 vs. 1766.54 435.3 , p = 0.345 , respectively ) .
the means sd of inflammatory markers such as crp and esr were significantly higher in patients with sbp in contrast to the rates for patients without sbp ( p < 0.05 ) ( table 2 ) .
table 3 and figure 1 show the area under the curve and the predictive values of crp for the diagnosis of sbp in children with liver disease .
the percentages for sensitivity and specificity of the crp marker for sbp in cirrhotic patients according to the pmn count of ascetic fluid were 69% and 90.25% , respectively ( table 3 ) .
abbreviations : auc , area under curve ; npv , negative predictive value ; ppv , positive predictive value ; sen , sensitivity ; spe , specificity .
figure 2 shows the relationship between the levels of crp and total protein based on the presence ( positive ) or absence ( negative ) of sbp in cirrhotic patients .
as shown in figure 2 , in both patients with and without sbp , the increased crp levels were associated with increased total protein . however , this increase in patients with sbp showed higher severity than the increase in patients without sbp .
our results showed a significant correlation between total protein and crp levels in children with and without sbp ( p = 0.029 , p = 0.006 , respectively ) .
figure 3 shows the relationship between albumin levels and crp levels in patients with and without sbp .
the results showed that in patients with sbp , increased levels of crp were associated with increased albumin levels , which was significant ( p = 0.002 ) .
however , this result was not observed in patients without sbp ; the levels of crp albumin in patients without sbp decreased significantly ( p = 0.013 ) .
the same results were revealed for bilirubin ( figure 4 ) , in that with increased crp in patients with sbp , bilirubin levels increased significantly ( p = 0.003 ) , while in patients without sbp with increased levels of crp , bilirubin levels decreased ( p = 0.011 ) .
the relationship between the crp levels with pt among the patients is shown in figure 5 .
increased protein level was associated with significantly increased pt ( p = 0.006 ) . however , in patients with sbp , pt did not change significantly according to the level of crp changes ( p = 0.697 ) .
sbp is a frequent and serious complication in cirrhotic patients that is associated with high in - hospital mortality rates of 20% - 30% , poor prognosis , and recurrence of over 70% in the first year of life .
early antibiotic treatment can reduce the mortality and morbidity of sbp , which requires performance and rapid diagnostic tests ( 26 ) .
although extensive studies have been conducted for laboratory testing efficiency and various markers for the diagnosis of sbp ( 24 , 26 ) , the first report on the highly significant correlation between crp and sbp was only published recently ( 24 ) . in the study by preto - zamperlini
streptococcus pneumoniae was the most cultured organism ( 24 ) . in our study , e. coli was the most frequently cultured organism .
the serum wbc counts were significantly higher in the sbp group compared to the counts for patients without sbp .
this finding was similar to the results of preto - zamperlini et al.s study ( 24 ) .
measurement of crp in cirrhotic patients determined that serum crp levels were significantly higher in patients with sbp compared to patients without sbp . in the study by preto - zamperlini
, the crp level was significantly higher in cases with sbp than in cases without sbp ( 24 ) . in the study by yuan et al .
, it was concluded that crp is a better marker than wbc count for diagnosis of patients with chronic hepatitis b and spb ( 27 ) .
esr was significantly higher in patients with sbp compared to patients without sbp . in another study by viallon et al .
, the authors reported that crp is significantly higher in adult cirrhotic patients with sbp compared to those that had sterile ascites fluid ( 28 ) .
the serum total bilirubin levels were not significantly different between children with sbp and those without sbp .
this finding was similar to those of other studies ( 24 , 29 ) . in our study ,
albumin levels were significantly higher in the sbp group compared to the non - sbp group . in contrast to our study , albumin levels were significantly higher in the non - sbp group compared to sbp group in the study by preto - zamperlini et al .
et al.s study , no significant difference was found between sbp patients and those with non - sbp ascites ( 30 ) .
this difference may be due to the difference in sample size or the histories of albumin infusion . in our study , no significant difference was found between the two groups in terms of pt and inr .
this result is similar to the study by vieira et al . , who reported that these markers in patients with and without sbp were not significantly different ( 30 ) .
in contrast to the above study , a significant difference was found in the study by preto - zamperlini et al .
crp was a significant indicator of infection in hospitalized children with cirrhosis ( 31 ) .
the difference between the severity of liver disease in these studies may be the cause of these differences .
the results of our study showed no significant difference regarding the age and sex of the patients with and without sbp .
as mentioned above , serum wbc count , esr , and crp may be good indicators of sbp in children with liver disease .
however , further studies are required in this field because most of the available studies have been conducted on adult patients .
another limitation is the lack of serial measurement of crp and the lack of finding a correlation between crp and prognosis and recurrence of sbp .
another limitation is the lack of serial measurement of crp and the lack of finding a correlation between crp and prognosis and recurrence of sbp . | backgroundthe diagnosis of peritonitis as a complication of cirrhosis is an important clinical problem.objectivesthe aim of this study was to evaluate serum c - reactive protein levels as a diagnostic factor for spontaneous bacterial peritonitis ( sbp ) in child patients with liver disease.methodsin this study , 150 children diagnosed with liver disease and ascites upon admission to nemazee teaching hospital ( shiraz , iran ) were examined .
patients were divided into spontaneous bacterial peritonitis and sterile ascetic fluid groups according to the pmn count 250/mm3 in the ascetic fluids .
routine laboratory tests were conducted and quantitative c - reactive protein ( crp ) levels were measured for all of the patients .
accuracy , sensitivity , and specificity of crp was evaluated for diagnosis of sbp.resultsof 150 cirrhotic patients , 109 patients presented without sbp ( 52.29% male , mean age : 5.02 4.49 years ) and 41 patients presented with sbp ( 51.21% male , mean age : 4.71 years ) .
cell counts , protein levels , albumin levels , and lactate dehydrogenize ( ldh ) levels of the ascetic fluid and serum samples in the sbp group were higher than the rates for those without sbp ( p < 0.05 ( .
the mean sd of crp in the sbp group ( 36.89 23.43 ) increased significantly compared to the rate among those without sbp ( 21.59 15.43 , p = 0.001 ) .
the percentages for sensitivity and specificity of crp , the diagnosis of sbp based on the pmn count 250/mm3 , and cultured ascites were 69.23% , 90.25% , 88.43% , and 84.32% , respectively .
the areas under the curve of crp for sbp based on the pmn count 250/mm3 and cultured ascites was 0.94 ( ci 95% : 0.90 to 0.96 ) and 0.85 ( ci 95% : 0.84 to 0.92 ) , respectively ( p < 0.001).conclusionsour study showed that crp is a marker with high sensitivity and specificity for the diagnosis of sbp in cirrhotic children . |
attempted suicide is self injury with a desire to end one 's life but does not lead to death .
large amounts of undesirable behavior results in suicidal behavior that is an expression of a specific form of vulnerability .
patients with hopelessness systematically misconstrue experiences in a negative manner and tend to anticipate dire consequences for their problems .
the present study was carried out with the objective of evaluating stressful life events , hopelessness , suicidal intent along with sociodemographic characteristics of patients presenting with attempted suicide to a tertiary referral centre .
ethics : the study protocol was approved by the institutional ethics committee and written , informed consent was taken from all patients .
design and sample size : a cross sectional study in 50 consecutive patients with suicide attempts admitted either to the internal medicine ward or medical intensive care unit .
instruments : the presumptive stressful life events scale [ psles ] , beck 's hopelessness scale [ bhs ] and beck 's suicidal intent scale [ bsis ] were used .
presumptive stressful life events scale ( psles ) : this scale is based on the social readjustment rating questionnaire ( srrq ) of holmes and rahe ( 1967 ) .
it is a list of 51 life events relevant to the indian setting given a score based on the mean score of general population standardized for two time frames past 1 year and lifetime .
beck 's hopelessness scale ( bhs ) : it is a 20-item self - report instrument that assesses the positive and negative attitudes about the future during the past week as perceived by the patients . the total score ranges from 0 to 20 ( 0 - 3 : minimal , 4 - 8 : mild , 9 - 14 : moderate , and 15 - 20 : severe )
beck 's suicidal intent scale : this is an interviewer administered measure of seriousness of the intent to commit suicide among suicide attempters .
score is calculated from first 15 items , ranging from 0 to 30 ( 15 - 19 : low intent , 20 - 28 : medium intent , and 29 or more : high intent ) .
the internal reliability of the scale is 0.95 while inter - rater reliability ranges from 0.81 to 0.95 .
scores were assessed for normality using the kolmogorov smirnov test and non normal scores between men and women analyzed using the mann whitney u test .
correlation between bhs , bsis and psles with the stressful life event was done using sperman 's rho .
all analyses were carried out using spss version 11.0 and a p value of 5% was considered significant .
scores were assessed for normality using the kolmogorov smirnov test and non normal scores between men and women analyzed using the mann whitney u test .
correlation between bhs , bsis and psles with the stressful life event was done using sperman 's rho .
all analyses were carried out using spss version 11.0 and a p value of 5% was considered significant .
the demographics mean age of the participants was 25.94 ( 7.85 ) years with 72% less than 30 years of age .
majority of the participants ( 66% ) had stressful life event score between 101 and 200 , while 24% had scores less than or equal to 100 and only 10% patients had score more than 200 . the mean stressful life event score for
most of the participants had mild ( 34% ) and moderate ( 40% ) degrees of hopelessness and few had minimal ( 10% ) or severe ( 16% ) degree of hopelessness .
majority had medium suicidal intent ( 70% ) , 26% had high suicidal intent , and a very few had low suicidal intent ( 4% ) .
hopelessness and suicidal intent had significant positive correlation ( spearman 's rho : 0.540 , p-<0.000 * ) ; however , stressful life event had no significant correlation with either hopelessness ( spearman 's rho : 0.142 , p -0.326 ) or suicidal intent ( spearman 's rho : 0.080 , p -0.581 ) .
majority of the participants in this study were females . though females attempt suicide approximately three times as often as males , indian data suggest the ratio as 1:1 .
the possible explanation can be as follows : those with higher stress levels might have already sought help and prevented the event or might have adopted more lethal and planned measures so that they never reached the hospital . the participants with
lesser stressful event score might have eventually coped with the situation rather than taking escape by attempting suicide .
the patients who believed they need psychiatric help had significantly higher mean stressful life event score [ table 1 ] .
this finding supports the hypothesis that those with higher stressful event score may seek help to come out of it rather than attempt suicide .
different coping mechanisms , support system , and several other factors of the individuals result in different response and level of stress for each individual .
literature suggests that recent adverse life events contribute to the increased risk of suicide and vulnerability for suicidal behavior . though stressful life events ca nt be directly correlated to the occurrence of suicide attempt or suicide ; social and situational factors appear to play a significant role in self - harm behavior and suicide .
comparison of stressful life event score , hopelessness , and suicidal intent there were fewer patients with severe hopelessness in this study than those with mild and moderate hopelessness .
participants who had expected themselves to die after the suicide attempt had significantly more hopelessness than those who thought they will survive after the attempt of suicide .
hopelessness prevents a person to think about future positively resulting in expecting the worse outcome and also predicts the ultimate suicide .
hopelessness rather than depression per se is a determinant of suicidal intent and serves as the link between depression and suicide .
the patients perceiving suicide attempt and reasons behind it as major problem had significantly higher mean suicidal intent score .
this indicates that worse the perception of the situation at hand disastrous can be the consequences .
stressful life event ca nt predict suicide but is associated with more help - seeking behavior .
this study implies that suicide attempters should be specifically looked for hopelessness and their coping styles so as to plan appropriate psychiatric therapy to prevent future suicide attempt .
| background : suicide is a psychiatric emergency .
stressors in life and social variables ( like marital status , family , and social support ) are among the determinants of suicide .
hopelessness and suicidal intent are among the psychological variables that have shown promise in the prediction of suicide.aims and objectives : to assess stressful life events , hopelessness , suicidal intent , and sociodemographic variables in patients of attempted suicide.materials and methods : fifty consecutive patients admitted with attempted suicide were interviewed .
presumptive stressful life event scale , beck hopelessness scale , and beck suicidal intent scale were used along with a semistructured pro forma for interview .
data were analyzed with statistical tests.results:sixty-six percent of the participants were females , 72% were less than 30 years of age .
sixty - six percent of the patients had stressful life event score between 101 and 200 with the mean score of 127 .
the stressful life event score in those who considered they are in need of psychiatric help was significantly high .
most of the patients had mild ( 34% ) and moderate ( 40% ) degrees of hopelessness , and the mean score was 9.64 .
the mean suicidal intent in the participants was 25.14 , when correlated with hopelessness score significant positive correlation was found.conclusion:lethality of the attempt increases with the increase in hopelessness . |
in recent years , increasing attention has been devoted to the synthesis of various nanostructured batio3 , such as nanoparticles , nanocubes , nanorods , nanowires , and nanotubes , because of the dependence of their ferroelectric and piezoelectric properties on the dimension and size , which is essential for realizing nanoscale devices for a wide range of applications , including memory , transducers , sensors , energy - harvesting devices,[1 - 6 ] .
for instance , batio3 nanoparticles transformed from tetragonal to cubic phase at room temperature with the critical crystallite size of approximately 40 nm due to the size effect .
one - dimensional , stable ferroelectric monodomain was found in an 80 nm diameter single - crystalline batio3 nanowire . and
periodic voltage was generated from the batio3 nanowire by applying periodically varying tensile mechanical strain .
furthermore , fu and bellaiche reported that the local dipoles in small batio3 dots prefer to form a vortex - like pattern rather than the traditional viewed structures as arrayed in straight lines in neat rectangular rows and columns based on a first - principles approach . following their research , wang et al . and prosandeev et al .
also reported that , in sufficient small nanoscale ferroelectric objects ( nanoparticles or nanodots ) , conventional domain structures should be replaced by vortex domain states based on atomistic simulation modeling .
[ 14 - 16 ] tried to experimentally verifying the existence of vortex domains , they pointed out that magnetic vortex domains can be stabilized through the physical removal of the vortex
core , ferroelectrics with hollow structure should offer the greatest opportunity for experimentally creating polarization vortices in ferroelectrics .
periodic arrays of pzt nanorings were fabricated using a self - assembly technique namely the nanosphere lithography ( nsl ) method .
pzt nanorings were synthesized through solution deposition inside of an anodized aluminum oxide nanopores thin film . however , these kinds of polarization vortices have not yet been experimentally observed in these pzt nanorings . based on these points ,
the synthesis of hollow single - crystalline batio3 will also offer the opportunity for experimental observation of such vortices domain .
but comparatively little work has been performed on the fabrication of batio3 with hollow structure . only , nakano et al . and buscaglia et al .
reported the synthesis of hollow poly - crystalline batio3 structures by a layer - by - layer colloidal templating method and a two - step process combining colloidal chemistry and solid - state reaction , respectively .
all these features make the synthesis of hollow single - crystalline batio3 of great significance .
hydrothermal method has been considered as one of the most promising routes to synthesize oxide powders with controlled morphology , high crystallinity in a one - step process .
this method has been widely used for the synthesis of batio3 powders , nanotabulars and nanowires [ 21 - 23 ] .
but there is no literature available about the synthesis of bowl - like batio3 particles based on hydrothermal method . in this study , we report the novel single - crystalline batio3 nanoparticles with bowl - like structure via hydrothermal method .
piezoresponse force microscope measurement has been employed to characterize the properties of the batio3 nanoparticles .
typical synthesis procedure : 0.0102 mol of ba(oh)28h2o and 0.006 mol of tio2 were mixed in 80 ml distilled water .
the mixture was transferred into a teflon - lined stainless steel autoclave ( inner volume of 100 ml ) and heated at 180c for 72 h under autogenous pressure .
the resulting batio3 powders were filtered , washed with 0.1 m formic acid and deionized water several times , and finally dried at 80c for 12 h in an oven . in our synthesis , after titania was added with ba(oh)2 in solution , tio2 would interact with the oh and h2o to form titanium hydroxyl species ( probably htio3 ) . then , htio3 reacted with ba ions to form batio3 particles .
x - ray powder diffraction patterns ( xrd ) of the products were obtained on an x - ray diffractometer ( philips pw3050/60 , mpss ) using cu k radiation .
raman spectroscopy was performed at room temperature in a raman spectrometer ( renishaw rm-1000 ) , employing an ar+ laser for excitation ( = 514 nm ) .
scanning electron microscope ( sem ) images were obtained by a scanning electron microscope ( jeol , jsm-5610lv ) .
transmission electron microscope ( tem ) images and high - resolution electron microscope ( hrem ) images were recorded on a transmission electron microscope ( jeol , jem-2100f ) . for tem observations ,
the nanoparticles were ultrasonically dispersed in ethanol and then dropped onto carbon - coated copper grids .
the local polarization switching behaviors of the nanoparticles were characterized using high sensitivity piezoresponse force microscopy ( pfm ) .
a silicon tip coated with ru ( micro cantilever , si - df3-r ) was used .
the spring constant of the cantilever was 1.6 n / m , and the free resonance frequency was 27 khz . for sample preparation , batio3 nanoparticles dispersed in water were drop - coated directly onto a highly oriented pyrolytic graphite ( hopg ) substrate .
the purity and crystallinity of the synthesized samples were examined by the powder xrd technique . the xrd pattern of the prepared batio3 samples is shown in fig .
01 - 075 - 0583 ) with a lattice parameters a = b = 3.9950 , c = 4.0340 .
1 . dash lines are positions of each profile of 200 and 002 peaks obtained by the best fit to a mixed gaussian
this result suggests that batio3 samples prepared by the hydrothermal method can be assigned to tetragonal symmetry ( space group p4 mm ) .
the inset shows the reflection around 45 2 ( 200)/(002 ) peak ( filled circle measured , thine line fitted , thick line calculated . )
the raman shift peaks located at around 261 , 304 , 517 and 715 cm match well with the typical raman peaks of batio3 .
the bands around 261 and 517 cm are assigned to the transverse optical ( to ) modes of a1 symmetry .
the peak at 304 cm is assigned to the b1 mode indicating asymmetry within the tio6 octahedra of batio3 on a local scale .
the peak at 715 cm is related to the highest frequency longitudinal optical mode ( lo ) with a1 symmetry . the intense band at 304 cm indicates the presence of tetragonal phase .
raman spectrum of the synthesized batio3 product figure 3 shows the representative sem micrographs of the as - prepared bowl - like batio3 nanoparticles . the low magnification sem image ( fig .
3a ) illustrates that the batio3 product mainly consisted of well - defined bowl - like nanoparticles with a uniform size about 100200 nm in diameter . a closer examination of these batio3 nanoparticles in fig .
sem micrographs of the synthesized batio3 nanoparticles tem and hrtem provide further insight into the microstructural details of the bowl - like nanoparticles .
figure 4a4b is the tem images of typical bowl - like batio3 nanoparticle with a concave in the center .
the distances of 4.03 and 3.99 of lattice fringes can be indexed to the ( 001 ) plane and ( 010 ) plane of tetragonal batio3 , respectively . and the corresponding selected - area electron diffraction pattern ( saed ) pattern shown in fig .
4d can be indexed to the reflection of a tetragonal batio3 crystal recorded from the zone axis .
the same lattice fringes are observed in the four hrtem images of figure c. it well proves that the whole bowl - like nanoparticle is a single - crystalline batio3 .
different with the hollow poly - crystalline batio3 spheres reported by nakano and buscaglia , this novel single - crystalline bowl - like nanoparticle is good candidate for experimental observation of polarization vortices in ferroelectrics . a , b tem images of typical bowl - like batio3 nanoparticles with a concave in the center . c hrtem images of the corresponding portions ( a ) , ( b ) , ( c ) , ( d ) in ( b ) .
d the corresponding fast fourier transformation ( fft ) pattern of portion ( a ) the local polarization switching behavior and effective piezoelectric coefficients of the bowl - like batio3 nanoparticles were characterized using pfm .
figure 5a gives the scheme of the test and the topography of a typical nanoparticle with a diameter about 150 nm .
figure 5b shows the local piezoelectric displacement - voltage loops and piezoelectric hysteresis loops at particle edge ( ) and the center concave ( ) area marked by arrows in fig .
the measurement was achieved by keeping the pfm tip fixed above the nanoparticle and applying a dc voltage from 9 to 9 v while recording the piezoresponse signal . as shown in fig . 5b , typical well - shaped butterfly
loops are observed in both area and . the maximum displacements of the two areas are 0.19 and 0.21 nm , which appear at 8.1 and 8.3 v , respectively .
the maximum effective values are estimated to be about 23 and 28 pm / v for area and area , respectively , comparable to the reported value ( ~22 pm / v ) on 20 nm batio3 ceramics based on the same measure method .
b local piezoelectric displacement - voltage loops and effective piezoelectric coefficient of the bowl - like particle at edge ( ) and the center concave ( ) area ferroelectrics with hollow structure should offer the greatest opportunity for experimentally creating polarization vortices domain . but till now , similar with the forerunners research about the pzt nanorings , detailed resolution of polarization behavior in hollow batio3 particles has not been found to be achievable due to the lack of characterization technique , the vortices domains also can not be measured .
but the research of ferroelectric domain state in the unusual way should be a fertile area for further theory and experiment .
the unique bowl - like single - crystalline batio3 nanoparticles shown in the present study will provide an ideal candidate to investigate the polarization vortices in ferroelectric nanostructures . and this is clearly an objective for our future research .
in summary , bowl - like single - crystalline batio3 nanoparticles have been synthesized through a hydrothermal method using ba(oh)28h2o and tio2 as starting materials .
piezoresponse force microscope measurements indicate that the local polarization of the batio3 nanoparticle is switchable at room temperature .
the local effective piezoelectric coefficient is approximately 28 pm / v , which is comparable to the reported value ( ~22 pm / v ) of the batio3 ceramics .
these unique batio3 nanoparticles will provide an ideal candidate for fundamental studies of the ferroelectricity and piezoelectricity , which may prove useful in fabricating a variety of nanoscale functional devices .
this work was supported by the national natural science foundation of china ( no . 50672072 , 50972115 , 50932004 , a3 foresight program-50821140308 ) and the ph.d .
this article is distributed under the terms of the creative commons attribution noncommercial license which permits any noncommercial use , distribution , and reproduction in any medium , provided the original author(s ) and source are credited .
this article is distributed under the terms of the creative commons attribution noncommercial license which permits any noncommercial use , distribution , and reproduction in any medium , provided the original author(s ) and source are credited . | novel bowl - like single - crystalline batio3 nanoparticles were synthesized by a simple hydrothermal method using ba(oh)28h2o and tio2 as precursors .
the as - prepared products were characterized by xrd , raman spectroscopy , sem and tem .
the results show that the bowl - like batio3 nanoparticles are single - crystalline and have a size about 100200 nm in diameter .
local piezoresponse force measurements indicate that the batio3 nanoparticles have switchable polarization at room temperature .
the local effective piezoelectric coefficient is approximately 28 pm / v . |
one of the major reasons for patients presenting at a primary care practice is pain ; according to surveys , around 40% of patients consult their family doctor mainly owing to pain , and 2040% of those have been suffering from pain for more than 6 months [ 1 , 2 ] .
high prevalence rates for chronic pain have been reported in many countries [ 310 ] ; for example , 20% of the european population are suffering from moderate - to - severe chronic pain ( 1-month prevalence , excluding cancer pain ) . in the majority of cases ( 70% )
the most frequent indications associated with chronic pain in the family practice are of musculoskeletal origin , primarily affecting the back and joints ( figures 1 and 2 ) [ 1 , 4 ] .
chronic pain affects quality of life and personal relationships and is often accompanied by depression , sleep disorders , and also low self - esteem .
in addition to the immense burden to the patient , it presents a substantial challenge and burden to society in terms of direct ( healthcare resource utilization ) and indirect costs ( e.g. , social compensations , retirement pensions , loss of productivity , and skills [ 4 , 12 ] ) . for many indications ,
chronic pain management is basically a balancing act between the obvious goal of pain reduction and the goals of safety and quality of life of the affected patients .
whereas a number of medications are suitable for the short - term treatment of acute pain , patients with chronic pain require long - term , sometimes life - long treatment , and finding effective , safe , and tolerable pain treatments may become a challenge .
in addition , many affected patients are elderly [ 7 , 13 , 14 ] , which is not surprising as age - related degenerative diseases such as osteoarthritis are frequently associated with chronic pain .
thus , comorbidities and possible ensuing drug - drug interactions owing to polypharmacy and the adverse event profile of a given medication must all be taken into account in an individual patient 's tailored treatment approach .
a consensus meeting of pain specialists from different fields was held in november 2010 in paris , france , in order to review and discuss the management of moderate - to - severe chronic pain with special emphasis on the use of paracetamol , nsaids , and tramadol / paracetamol as an example for fixed - dose combination analgesics .
discussions about available treatment options for chronic pain management and current guidelines and treatment recommendations for various conditions and patient populations were continued after the meeting ; the final consensus on pain management options for pain indications frequently seen by a family practitioner is presented in this paper .
chronic pain can be categorized as nociceptive pain ( caused by tissue damage or disease ) , neuropathic pain ( caused by damage or disease of the peripheral or central nervous system ) , or mixed pain with both nociceptive and neuropathic components .
in addition , the location of pain may differ from the site of origin of pain , as is the case with referred pain and radicular pain .
successful pain management initially requires a thorough diagnostic work - up , through patient history , physical examination , and diagnostic tests in order to identifythe location and cause of pain;the frequency with which the pain occurs and potential exacerbating and relieving factors;previous treatment received by patient , and its efficacy ; the severity of pain , and its quality ( e.g. , dull , aching , stabbing , lancinating , burning , etc.);the chronification stage of pain;the impact of pain on the patient ( e.g. , quality of life , loss of productivity ) , his / her family or caregivers . the location and cause of pain ; the frequency with which the pain occurs and potential exacerbating and relieving factors ; previous treatment received by patient , and its efficacy ; the severity of pain , and its quality ( e.g. , dull , aching , stabbing , lancinating , burning , etc . ) ; the chronification stage of pain ; the impact of pain on the patient ( e.g. , quality of life , loss of productivity ) , his / her family or caregivers .
initial pain assessment should also include documentation of pain frequency ( continuous , intermittent , or continuous with intermittent flares ) , of presence or absence of triggers , and of presence or absence of somatosensory abnormalities such as increased or decreased perception of stimuli ( e.g. , hypo- or hyperalgesia , allodynia , or numbness ) .
simple scores should be used to assess pain intensity in order to monitor the progression / improvement of pain with a time - saving method during the family practitioner visit .
pain intensity is usually assessed using 11-point rating scales with 0 indicating no pain and 10 indicating worst imaginable pain or along a 100 mm horizontal line , with ratings measured from the left edge ( table 1 ) .
visual analogue ( vas ) and numerical ( nrs ) and verbal ( vrs ) rating scales are available both for the assessment at the family practice and for patients ' self - assessments .
in addition , wong - baker faces scales ( figure 3 ) are used for children and adults who are unable to communicate their pain such as patients with cognitive impairment .
pain intensity assessments are widely used as efficacy parameters for a given medication , both in clinical trials and in clinical practice . for a comprehensive diagnosis of chronic pain ,
a determination of pain type is also necessary and should include the use of neuropathic pain assessment tools such as pain detect , dn4 ( douleur neuropathique en 4 questions , table 2 ) , or lanss ( leeds assessment of neuropathic symptoms and signs ) , which have been validated in several languages . the assessment of neuropathic pain in primary care has recently been extensively reviewed .
one way of defining pain as chronic has been on the basis of its duration , that is , if it lasts for more than 3 or 6 months [ 22 , 23 ] ; however , a standard , internationally accepted definition for chronic pain is not available . in germany ,
chronicity staging with the validated mainz pain staging system is part of the german pain questionnaire , a standardized and validated tool for chronic pain therapy .
the three stages i ( at risk of chronification ) , ii ( chronification ) , and iii ( marked chronification)indicate the progression of the disease .
currently , attempts are underway to include psychological and behavioral factors in a definition of chronic pain , with the objective of including all aspects of a patient 's pain in an integrated pain management strategy .
the assessment of chronicity is important in order to assess the risk of future chronic pain in a given patient and to rapidly initiate adequate pain management .
initial and follow - up pain intensity assessments are essential but not sole indicators for successful or unsuccessful treatment .
other factors such as improved mobility or independence of the patient , working ability , improved coping and psychological status , and overall quality of life might be equally important to the patient ( see the following ) .
chronic pain has an enormous impact on quality of life and daily activities of the patient .
it affects sleep in the majority of patients , impairs physical activities , the ability to attend to household chores , and employed work , and restricts many patients in terms of relationships and social activities . additional burden arises for the patient through pain - related comorbidities such as depression and anxiety .
according to a recent survey among chronic pain patients with moderate - to - severe pain ( defined as pain 5 on an 11-point scale for six months or more ) in the european union , 21% had been diagnosed with pain - related depression . whereas pain treatment in the past primarily targeted the reduction of pain intensity , maintaining or improving quality of life of the patients is increasingly being recognized as an equally important goal .
thus , in addition to the diagnosis of pain , quality of life parameters and pain - related comorbidities ought to be assessed and taken into consideration in treatment decisions .
some examples for commonly used assessment tools are given in table 1 ; many international tools have been translated and validated in various languages .
in addition to overall quality of life questionnaires such as the sf-36-health survey , scales determining depression , anxiety , and stress [ 29 , 30 ] , and disease - specific tools such as the western ontario and mcmaster universities ( womac ) osteoarthritis index [ 31 , 32 ] have been developed .
recently , the change pain scale was introduced , a simple tool easy to use in primary practice , which can initially be used to record pain intensity and define individual treatment goals but can subsequently determine patient - centered perceptions of change .
given primary practice reality with a short - time frame available for each individual patient , many physicians may shy away from the extra time spent in completing and evaluating additional questionnaires .
however , these tools may enable a more efficient and thus in the long - term time - saving approach .
in particular , focusing on the patient 's individual needs may reduce a substantial burden for the patient and avoid long periods of unnecessary suffering owing to unsuitable treatment approaches .
the family practitioner plays an important role in the prevention , diagnosis , and early management of chronic pain .
he / she is usually the physician who is most familiar with the patient and his / her medical history , keeps an overview on the various therapies prescribed by him-/herself and other specialists , and is likely to be the first to be alerted in the case of inadequate pain control or if safety issues owing to comorbidities or comedications arise .
since the family practitioner usually also builds a trusting relationship with the patient , the patient is most likely to disclose concerns , potential side effects of medications , effects of the treatments / pain on his / her daily life and social network , and so forth .
the family practitioner might be able to identify unmet needs of the patient , requirements for patient information , and education and potential requirements to involve the family / partners in the overall treatment plan and care .
for many indications , in particular musculoskeletal diseases , a multimodal treatment approach combining both nonpharmacological and pharmacological treatments will likely lead to the best outcome in terms of pain relief and improvement of quality of life .
the family practitioner should be at the core of a multidisciplinary team for pain management including , for example , pain specialists , physiotherapists , and others .
nonpharmacological treatments may include changes in diet , weight loss , changes in lifestyle , exercise , or massage that can be easily accessible to primary care physicians .
other options like acupuncture , thermotherapy , transcutaneous electrical nerve stimulation ( tens ) , surgery , and many others are beyond the scope of this paper .
paracetamol ( also known as acetaminophen or apap ) is a very popular medication , which is available over - the - counter as well as in prescription medications .
it has analgesic and antipyretic but , unlike nonsteroidal anti - inflammatory drugs , no confirmed anti - inflammatory properties , although there have been studies pointing to some anti - inflammatory effects [ 38 , 39 ] .
its exact mode of action is still poorly understood and several mechanisms have been proposed , which seem to point to a largely central effect . in healthy individuals , a daily maximum dose of 4 g
however , certain conditions such as chronic alcohol abuse , malnutrition , existing liver disease , and concurrent use of drugs , which induce cytochrome p450 enzymes , can lead to hepatotoxicity even at therapeutic dosages . in europe and north america ,
paracetamol overdoses are often unintentional and likely occur because many patients are unaware of the fact that their harmless
patients therefore need to be properly educated if paracetamol - containing medications are prescribed .
nsaids are very effective drugs with antipyretic , anti - inflammatory , and analgesic efficacy rendering them useful for many acute pain conditions .
they are widely used over - the - counter and prescription products and are contained in many combination formulations .
nsaids are associated with gastrointestinal , cardiovascular , and renal side effects and mortality with an estimated 3500 to 16,500 deaths per year due to nsaid - related gastrointestinal bleeding in usa .
in addition , nsaids also interact with many other medicinal products [ 4548 ] , and special caution and close monitoring are recommended for patients with conditions such as gastrointestinal disorders , renal , cardiac , or hepatic impairment , and hypertension and patients with a history of asthma and seasonal allergic rhinitis ( since they act as bronchoconstrictors ) . following the discovery of cyclooxygenase ( cox)-2 and in an attempt to overcome the gastrointestinal side effects of nsaids , cox-2-selective nsaids were developed .
5 years later because of cardiovascular risks , shortly followed by warnings and dose restrictions for all nsaids . owing to these safety issues ,
all nsaids should be used for the shortest possible duration at the lowest effective dose . in the elderly in particular ,
nsaids should be used rarely and with extreme caution in highly selected individuals . in general , nsaids are not suitable for long - term treatment of chronic pain conditions .
opium has been used since antiquity for treating pain . in modern times , synthetic opioids
some of the side effects and special issues related to opioids might restrict their long - term use , at least in some patients .
in addition , respiratory depression is likely to cause problems in special patient groups , such as asthmatics and cardiovascular patients with impaired lung function .
tolerance describes the state in which a patient requires increasingly higher doses of the opioid to achieve the same level of pain relief . in some cases ,
tolerance is a normal response to opioid therapy ; it can sometimes be managed by opioid rotation , that is , switching to other opioids .
manifestations of opioid - induced hyperalgesia mimic tolerance . a patient with opioid - induced hyperalgesia
should , however , be tapered off opioids , whereas a patient with tolerance may require a judicious and supervised increase of the opioid dose .
dependence occurs when discontinuation of the substance results in withdrawal symptoms ; dependence is a normal and expected result of long - term opioid therapy and is typically managed by tapering the drug rather than abruptly stopping it .
addiction has been defined as the continuing use of a substance ( or behaviour ) despite adverse consequences to the user .
opioid - addicted patients are dependent , but not all opioid - dependent patients are addicted . a newer term in use is inappropriate use of opioid , a continuum of behaviors involving the intentional or inadvertent misuse of opioids , particularly prescribed opioids .
a variety of opioid analgesic products have been designed in abuse - deterrent or abuse - resistant formulations , aimed at making it more difficult to tamper with the products [ 57 , 58 ] . however
, these dangers are frequently overestimated , and opioids are often the only choice for severe pain and can be a good choice for special patient groups such as the elderly .
the transdermal formulations of fentanyl and buprenorphine in particular appear to be effective with low toxicity and good tolerability profiles , especially at low doses .
tramadol has been on the market since 1977 and is considered a type of opioid . however , it is different from most other opioids because of its multiple mechanism of analgesic action ( binding to -opioid receptors and inhibition of neuronal reuptake of norepinephrine and serotonin ) [ 60 , 61 ] .
tramadol has been shown to be effective in different acute and chronic pain states [ 62 , 63 ] ; its extended - release formulations are thought to be particularly suitable for long - term treatment of multimechanistic pain conditions such as osteoarthritis , low back pain , and neuropathic pain .
side effects include nausea , vomiting , dizziness , drowsiness , sweating , and dry mouth ; reports of drug dependence and abuse are rare .
isolated cases of serotonin syndrome have been reported during concomitant use of tramadol in combination with other serotoninergic medicinal products such as selective serotonin reuptake inhibitors ( ssris ) or with mao inhibitors .
unlike other opioids , tramadol has no clinically relevant effects on respiratory or cardiovascular parameters at recommended doses . for chronic pain , 50 mg or 100 mg tramadol
is administered every 4 to 6 h , with a total daily dose not in excess of 400 mg ; the dosage interval should be extended in elderly patients and patients with renal or hepatic impairment .
overall , this group is efficacious with a good safety profile . due to reduced or no systemic action , the risk of systemic side effects is markedly reduced which might increase patient compliance , safety , and quality of life .
most topical analgesics are available as patches , ointments , or creams , many as over - the - counter products .
examples are the 5% lidocaine medicated plaster , topical nsaids , and the 8% capsaicin patch . the clearest evidence for the efficacy of anticonvulsants in pain relief was found in patients suffering from neuropathic pain .
several mechanisms of action have been reported for anticonvulsants , among them the blockage of voltage - gated calcium channels ( gabapentin , pregabalin , etc . ) and the blockage of voltage - gated sodium channels ( carbamazepine , oxcarbazepine , lamotrigine , lacosamide , etc . ) .
dose - related side effects occur with all anticonvulsants ; the majority are cns related ( i.e. , somnolence , dizziness , ataxia , and headache ) .
there are also specific , sometimes significant adverse reactions depending on the prescribed anticonvulsant such as hyponatremia , leukopenia , thrombocytopenia and hepatotoxicity for carbamazepine and weight gain , and blurred vision and edema for gabapentin and pregabalin .
there is evidence of antidepressant analgesia independent of their effect on depression or other psychiatric disorders .
tricyclic antidepressants ( tcas ) provide pain relief in a variety of conditions but are associated with side effects such as sedation , dizziness , blurred vision , constipation , and dry mouth , which can be treatment limiting .
cardiac toxicity is a concern , and it is recommended to prescribe tcas with caution in patients with ischemic cardiac disease or ventricular conduction abnormalities .
amitriptyline and other tertiary tcas are listed on the recently revised beers list of potentially inappropriate medication use in older adults with a strong recommendation to avoid their use because they are highly anticholinergic , sedating and cause orthostatic hypotension .
the selective serotonin norepinephrine reuptake inhibitors ( snris ) , duloxetine and venlafaxine , are first - line treatments for neuropathic pain , and duloxetine and milnacipran are recommended for fibromyalgia treatment .
overall , they are better tolerated than tcas with nausea as the main side - effect .
glucocorticoids have clinically important anti - inflammatory and immunosuppressive effects which are , among others , used in the treatment of rheumatic diseases .
safety concerns for higher doses or long - term treatment include amongst others glucocorticoids - induced osteoporosis and risk of fracture , immunosuppression , increased risk of infections , weight gain , leg edema , thinning skin , cushing 's syndrome , hypertension , glaucoma , cataracts , shortness of breath , and sleep disturbances , and the onset or worsening of diabetes .
patients with established rheumatoid arthritis should be made aware of long - term complications with glucocorticoids and all other treatment options should be offered before glucocorticoid treatment is maintained in the long - term . since most pain conditions involve more than one underlying pain generating process and pain is transmitted via a large number of different pathways , a practical treatment approach is using drugs or drug combinations with different mechanisms of action and thus different targets .
however , not all combinations are ideal because a combination of two or more individual compounds may lead to additive or even synergistic analgesic effects but might also lead to a higher than anticipated side - effect rate .
thorough testing of combinations and determining the right dose ratio of the individual components are therefore required . a recent
fixed - dose combination analgesic products reduce the pill burden and may require lower dosages than the individual compounds .
they are , however , inflexible , and doses may not be ideal for particular patients .
many fixed - dose combination analgesics contain paracetamol , and patients may exceed the recommended daily paracetamol intake of 4 g for healthy adults .
fixed - dose combinations with an opioid include codeine / paracetamol , oxycodone / paracetamol , tramadol / paracetamol , and others
. these products may be opioid sparing , because they provide effective analgesia at lower opioid doses than opioids taken in monotherapy .
this was shown in two studies comparing tramadol / paracetamol with tramadol monotherapy in the management of subacute low back pain and pain following ambulatory hand surgery with iv regional anesthesia .
fixed - dose combination treatment reduced tramadol consumption by 24% in both studies and resulted in significantly fewer side effects than with tramadol monotherapy .
analgesic synergy of fixed - dose combination products for pain relief in humans has , to our knowledge , so far only been demonstrated for tramadol / paracetamol .
this section lists the most common chronic pain indications encountered by the family practitioner and available treatment guidelines / recommendations for the individual indications .
a summary of the studies investigating treatment with tramadol / paracetamol for a given indication is included .
three studies assessed tramadol / paracetamol for musculoskeletal pain of different origins and are discussed here [ 8587 ] .
the two latter studies are of particular interest to the family physician because they observed pain management in the clinical practice setting .
the efficacy and tolerability of tramadol / paracetamol were compared to codeine / paracetamol in adult patients with chronic nonmalignant low back pain , osteoarthritis pain , or both . at baseline , three - quarters of patients in both treatment groups
pain relief was comparable between treatments and associated with a similar incidence of overall adverse events except for somnolence ( 24% versus 17% ; p = 0.05 ) and constipation ( 21% versus 11% ; p < 0.01 ) , which was more common for codeine / paracetamol treatment . patients completing this study could participate in an 23-month open - label extension study .
they received a mean daily tramadol / paracetamol dose of 157 mg/1363 mg .
overall treatment efficacy was rated very good or excellent by 39% of the patients and 40% of the physicians .
the elza study assessed efficacy and safety of tramadol / paracetamol in 5495 patients aged over 12 years who presented with moderate - to - severe pain ( for more than 3 months in 15.6% of the patients ) to general practitioners in france .
the most common origin of pain was musculoskeletal ( 24.9% osteoarthritis , 20.1% low back pain , and 13.9% spinal nerve root compression ) .
treatment reduced the mean pain intensity at baseline from 6.3 1.7 ( 11-point nrs scale ) to 2.3 1.9 at final assessment ( p < 0.001 ) .
a total of 4.2% of the patients reported adverse events , most commonly gastrointestinal disorders .
the salza study assessed the clinical benefits of tramadol / paracetamol in 2663 patients aged 65 years with moderate - to - severe pain in french general practices .
the most common origin of pain was musculoskeletal ( 59.1% arthrosis , 33% low back pain , 16.9% spinal nerve root compression , and 15.8% other rheumatological pathologies ) .
the mean pain intensity at baseline of 6.1 1.6 ( 11-point nrs scale ) was reduced by 3.1 points ; 64.8% experienced complete pain relief , and the majority ( 90.5% ) were satisfied with the treatment .
discontinuation of treatment due to insufficient efficacy or adverse events occurred in 1.5% and 2.5% of all patients , respectively .
adverse events were reported by 4.5% of the patients , mainly gastrointestinal disorders ( 4.1% ) .
these studies show the efficacy of fixed - dose tramadol / paracetamol with a good safety profile in the treatment of chronic musculoskeletal pain both under randomized study conditions and , more importantly , in clinical practice .
the clinical benefits in the elderly in particular are noteworthy and suggest tramadol / paracetamol as an alternative to conventional analgesics such as nsaids , which should be considered rarely with extreme caution in this population .
prevalence of osteoarthritis ( oa ) increases with advancing age ; the greatest disease burden is attributable to the involvement of the hip or knee joints .
complex underlying pain mechanisms might require the administration of pain medications from different medication classes to achieve sufficient analgesia .
oa management is focused on symptom control , prevention of disease progression , minimization of disability , and improvement of quality of life and requires a combination of nonpharmacological and pharmacological measures .
recommendations for initial analgesic treatment include paracetamol and topical nsaids ( for hand and knee ) ahead of oral nsaids including cox-2 inhibitors [ 9395 ] .
the latter should be used at the lowest effective dose , and long - term use should be avoided .
weak opioids and topical capsaicin and intra - articular corticosteroid injections as an adjunct can also be considered .
however , stronger opioids should only be used for severe pain in exceptional circumstances or in symptomatic knee or hip oa following insufficient response to both nonpharmacological and pharmacological treatments and where patients are not suitable for total joint arthroplasty .
oa pain management using tramadol / paracetamol fixed - dose combination as an add - on treatment to nsaids or cox-2 inhibitors or as monotherapy was investigated in four studies [ 9699 ] . adding the fixed - dose combination to the treatment regimen of patients with oa flare pain ( hip or knee ) significantly reduced mean baseline pain intensity scores from 2.4 0.5 to 1.3 at the final visit compared to placebo ( p < 0.001 ) on a 4-point scale ( from 0 = none to 3 = severe ) .
treatment - related adverse events occurred in 24.4% patients receiving tramadol / paracetamol and in 8.1% of placebo patients ; withdrawal due to adverse events was reported for 12.7% patients on fixed - dose combination and 5.4% of placebo patients .
tramadol / paracetamol also provided significantly superior pain relief compared to placebo ( p = 0.019 ) in the subgroup of 113 elderly patients .
patients with knee or hip oa and with at least moderate pain ( > 69 mm in a 100 mm vas scale ) despite treatment with stable doses of celecoxib or rofecoxib received tramadol / paracetamol or placebo as add - on therapy for 3 months .
pain intensity scores following combination treatment were significantly lower than those for placebo ( 41.5 26 versus 48.3 26.6 , p = 0.025 ) .
improvement in womac physical function was also significantly better than that in the placebo group ( p = 0.049 ) .
withdrawal due to adverse events occurred in 13.1% tramadol / paracetamol and 3.9% placebo patients .
korean patients with knee oa and moderate pain despite stable doses of meloxicam or aceclofenac received add - on treatment with tramadol / paracetamol for 4 weeks . all patients with reduced pain ( < 4 on the nrs ) were then randomized to monotherapy of either tramadol / paracetamol or nsaid treatment for a further 8 weeks .
the 97 patients with significant pain reduction and significant improvements of the womac oa index score ( both p < 0.0005 ) following the 4-week add - on therapy maintained their pain - improved state with either agent for the next 8 weeks .
a second korean study investigated the effect of tramadol / paracetamol titration on the development of adverse events in patients with knee oa on stable nsaid therapy .
patients were randomized to either one 37.5 mg tramadol/325 mg paracetamol tablet tid for 2 weeks or titration to this dose over 7 days .
the discontinuation rate due to adverse events was significantly lower in the titration group ( 10.5% versus 26.2% for nontitration , p < 0.001 ) . in all studies ,
the most common treatment - related adverse events were nausea , vomiting , constipation , dizziness , and somnolence .
these adverse effects can be avoided in the majority of patients with a thorough titration of tramadol / paracetamol .
these studies suggest the effectiveness of tramadol / paracetamol as an add - on option to nsaids in the management of oa pain .
however , in light of today 's knowledge about nsaids , long - term treatment with nsaids can not be considered safe any longer and maintenance treatment with tramadol / paracetamol with nsaids for flares is likely the safer option .
it can arise from many different causes and can comprise both nociceptive and neuropathic mechanisms . a multimodal and individualized treatment approach is therefore required .
both the acpc / aps and nice guidelines recommend physical activity and exercise , manual therapy ( including spine manipulation ) , acupuncture , and cognitive - behavioral therapy as nonpharmacological options [ 104 , 105 ] . according to the nice guidelines ,
pharmacological treatment should start with paracetamol followed by nsaids ( combined with a proton pump inhibitor in persons > 45 years ) and/or weak opioids ( which seem to include fixed - dose combinations ) .
paracetamol and nsaids provide pain relief for nociceptive pain but are largely ineffective in neuropathic pain . a combination of treatments is therefore often required to manage both components of chronic low back pain .
the efficacy of tramadol / paracetamol for the treatment of chronic low back pain was assessed in two studies [ 106 , 107 ] .
both were double - blind , randomized studies in patients with at least moderate chronic lower back pain receiving either fixed - dose combination treatment or placebo over a 3-month period .
in the first study , patients had a mean baseline pain score ( 100 mm vas pain scale ) of 71.1 mm ( tramadol / paracetamol group ) and 68.8 mm ( placebo group ) .
combination treatment significantly improved pain scores ( to 44.4 mm versus 52.3 mm for placebo , p = 0.015 ) compared to placebo and provided better pain relief ( p < 0.001 ) and improved scores on measures of functioning and quality of life .
cumulative incidence of discontinuation due to insufficient pain relief was significantly lower for the combination product ( 22.1% versus 41% for placebo , p < 0.001 ) .
treatment - related adverse events were reported for 23.6% of tramadol / paracetamol and 3.8% placebo patients with discontinuation rates due to adverse events more frequently observed for the active agent ( 18.6% versus 5.7% ) .
the mean baseline pain score of the patients included in the second study was 68 mm .
tramadol / paracetamol treatment reduced pain more effectively than placebo ( final pain scores 47 mm versus 63 mm , p < 0.001 ) and improved quality of life and emotional and mental health .
the withdrawal rate due to adverse events was 28.1% for tramadol / paracetamol and 7.6% for placebo .
main treatment - related adverse events in the combination group were nausea ( 12% ) , dizziness ( 10.8% ) , and constipation ( 10.2% ) . in summary ,
the two studies show moderate benefits of tramadol / paracetamol treatment compared to placebo for patients with chronic low back pain over a 3-month period .
rheumatoid arthritis ( ra ) is a common inflammatory disease characterized by persistent synovitis , systemic inflammation , and autoantibodies .
the etiology is multifactorial ; prevalence rises with age and is highest in elderly women . besides the destruction of cartilage and underlying bone
disease - modifying antirheumatic drugs are the mainstay of ra treatment but analgesics are commonly required from the very beginning to control pain .
nsaids are recommended for pain management in early arthritis after careful evaluation of gastrointestinal , renal , and cardiovascular status and in a stepped approach coprescribed with a proton pump inhibitor in the short term but are not appropriate for long - term disease control [ 81 , 112 , 113 ] .
analgesics such as paracetamol , codeine , or fixed - dose combinations are recommended to potentially reduce the need for long - term nsaid or cox-2 inhibitor treatment .
patients with ra pain inadequately controlled by nsaids and disease - modifying antirheumatic drugs received one tramadol / paracetamol tablet tid or matching placebo for one week as add - on to their treatment regimen .
mean pain intensity ( 100 mm vas scale ) at baseline was 60.2 14.5 mm for the combination and 61.3 17.6 mm for placebo and improved significantly more in the tramadol / paracetamol group ( 47.2 20 mm versus 53.8 16.6 mm for placebo ; p = 0.018 ) .
mean daily pain relief scores were also significantly greater ( p = 0.037 ) but physical function did not differ between the groups . adverse events ( 57.6% versus 22.4% for placebo ) and discontinuations due to adverse events ( 19% versus 3% ) were significantly more common in the active group ( p < 0.001 ) .
this study indicates some short - term efficacy of tramadol / paracetamol in ra pain management . in light of the long - term safety problems with nsaids , alternative long - term maintenance treatment with tramadol / paracetamol accompanied by
6% of type 1 and 18% of type 2 diabetic patients , this condition is associated with neuropathic pain which has a profound impact on quality of life .
traditional analgesics such as paracetamol and nsaids are largely ineffective in all types of neuropathic pain .
there are a number of guidelines available , and the ones published in the last two years were recently summarized and compared . according to this paper ,
all guidelines recommend tcas and duloxetine as first - line agents except for the american academy of neurology ( aan ) guidelines which recommend only pregabalin .
additional first - line medications according to the european federation of neurological societies ( efns ) guidelines are gabapentin , pregabalin , and venlafaxine .
two studies have assessed the efficacy of tramadol / paracetamol for painful dpn [ 109 , 110 ] . in the first study ,
diabetic patients ( 94% type 2 ) with daily painful dpn in the lower extremities for the past 3 months received tramadol / paracetamol or placebo for 66 days .
patients presented with average daily pain scores of 7.1 1.4 and 7.1 1.3 , respectively ( 11-point nrs scale ) .
supplemental paracetamol use was permitted during the treatment phase but could not exceed 4 g daily from all sources .
treatment with tramadol / paracetamol reduced the average daily pain more effectively than placebo ( 2.71 versus 1.83 , p = 0.001 ) with a greater number of treatment responders ( 50% pain reduction : 37.5% versus 21.9% , p = 0.003 ) .
significantly greater improvements than placebo were also observed for further pain measures , sleep interference , global impression , and several quality of life measures and mood .
the adverse event rate was similar for both groups with nausea ( 11.9% versus 3.3% ) , dizziness , and somnolence ( both 6.3% versus 1.3% ) more common under combination treatment .
the second study compared the efficacy of tramadol / paracetamol and gabapentin in type 2 diabetes with painful symmetric neuropathy in the lower limbs .
mean pain intensity was reduced with no significant difference between treatments ( p = 0.744 ) .
improvements in further pain measures , sleep interference , and quality of life were comparable between groups .
the incidence of adverse events was not significantly different between treatments except for nausea / vomiting ( 8.9% tramadol / paracetamol , 1.2% gabapentin , p = 0.03 ) , and similar withdrawal rates due to adverse events were reported ( 13.9% versus 13.1% ) .
overall , the two studies suggest that fixed - dose tramadol / paracetamol is well tolerated and leads to pronounced pain relief in the treatment of painful dpn .
most elderly patients ( 85% ) experience moderate or severe pain ; for a third of them this pain is continuous .
pain is often underrecognized and undertreated with significant consequences for mobility , mood , restrictions in daily activities , and social activities which can all greatly affect quality of life .
elderly patients often suffer from comorbidities and require various medications , which could increase the risk of drug - drug interactions and limit the range of drugs appropriate for treatment .
pharmacokinetic and metabolic changes with advancing age resulting in different drug sensitivities compared to younger patients also need to be considered when prescribing medication .
the recently updated beers criteria for potentially inappropriate medication use in older adults provide the family practitioner with information and recommendations for different medication classes including pain medication .
caution is advised when prescribing nsaids ; the american geriatrics society recommends to consider nsaids rarely , with extreme caution , in highly selected individuals and to avoid their use in patients 75 years of age .
the efficacy and safety of tramadol / paracetamol fixed - dose combination were assessed in a subset of patients 65 years of age with oa flare pain in a placebo - controlled , randomized study and in elderly patients with predominantly musculoskeletal pain participating in the larger - scale noninterventional , observational salza study .
both studies were described previously ; both showed that tramadol / paracetamol was efficacious with a good safety profile for the elderly participants .
older patients ( 75 years old ) in the observational elza study also showed significantly reduced pain intensity following treatment with the fixed - dose combination ; 65.1% reported important or complete pain relief .
for patients aged over 75 years , the minimum interval between doses should be not less than 6 hours , due to the presence of tramadol .
pain is one of the major reasons for patients to consult their family practitioner .
the family practitioner plays an important role in the prevention , diagnosis , and early management of chronic pain and should be at the core of the multidisciplinary team for pain management .
the diagnostic work - up of pain should include quality of life parameters and an evaluation of the specific situation of the patient.the goal of pain management is not only pain relief , but also should include improvements in restrictions of daily activities and social life and in quality of life to increase the overall well - being of the patient.long-term treatment of chronic pain is often associated with safety and tolerability issues and must be individualized for each patient .
nsaids are useful short - term analgesics but are associated with gastrointestinal , cardiovascular , and renal side effects and mortality .
their long - term use in the management of chronic pain needs to be carefully weighted against potential side effects.pain is often multimechanistic .
fixed - dose combination analgesics combine compounds with different mechanisms of action and might thereby be useful in the treatment of multimechanistic pain
. they might provide a broader analgesic spectrum , potentially synergistic analgesic efficacy , and an improved benefit / risk ratio .
the combination was effective in a variety of different pain conditions frequently encountered by the family practitioner and showed good tolerability.tramadol/paracetamol might be considered in particular in elderly patients as an alternative to conventional analgesics such as nsaids , which should be used rarely with extreme caution in this population.however , studies are required to investigate the long - term use of fixed - dose combinations .
pain is one of the major reasons for patients to consult their family practitioner .
the family practitioner plays an important role in the prevention , diagnosis , and early management of chronic pain and should be at the core of the multidisciplinary team for pain management
. the diagnostic work - up of pain should include quality of life parameters and an evaluation of the specific situation of the patient .
the goal of pain management is not only pain relief , but also should include improvements in restrictions of daily activities and social life and in quality of life to increase the overall well - being of the patient .
long - term treatment of chronic pain is often associated with safety and tolerability issues and must be individualized for each patient .
nsaids are useful short - term analgesics but are associated with gastrointestinal , cardiovascular , and renal side effects and mortality .
their long - term use in the management of chronic pain needs to be carefully weighted against potential side effects .
fixed - dose combination analgesics combine compounds with different mechanisms of action and might thereby be useful in the treatment of multimechanistic pain .
they might provide a broader analgesic spectrum , potentially synergistic analgesic efficacy , and an improved benefit / risk ratio .
the combination was effective in a variety of different pain conditions frequently encountered by the family practitioner and showed good tolerability .
tramadol / paracetamol might be considered in particular in elderly patients as an alternative to conventional analgesics such as nsaids , which should be used rarely with extreme caution in this population .
however , studies are required to investigate the long - term use of fixed - dose combinations . | the family practitioner plays an important role in the prevention , diagnosis , and early management of chronic pain . he / she is generally the first to be consulted , the one most familiar with the patients and their medical history , and is likely the first to be alerted in case of inadequate pain control or safety and tolerability issues
. the family practitioner should therefore be at the center of the multidisciplinary team involved in a patient 's pain management .
the most frequent indications associated with chronic pain in family practice are of musculoskeletal origin , and the pain is often multimechanistic .
fixed - dose combination analgesics combine compounds with different mechanisms of action ; their broader analgesic spectrum and potentially synergistic analgesic efficacy and improved benefit / risk ratio might thus be useful .
a pain specialist meeting held in november 2010 agreed that the fixed - dose combination tramadol / paracetamol might be a useful pharmacological option for chronic pain management in family practice .
the combination is effective in a variety of pain conditions with generally good tolerability . particularly in elderly patients ,
it might be considered as an alternative to conventional analgesics such as nsaids , which should be used rarely with caution in this population . |
asthma is one of the most prevalent diseases in children and adolescents worldwide and the leading reason for inability in children .
the prevalence of asthma has been reported variously in iran ( 4 - 7% ) and worldwide ( 8 - 12% ) . also , the prevalence in children is so growing worldwide that it has increased by 50% in different countries .
as shown , asthma accounts for approximately 1.6 million emergency visits , over two million hospitalizations , and about 1.1 million days of school absence , major activity limitation , and unsatisfactory performance in children . te incidence of asthma in adolescence
not only brings about numerous challenges for adolescents , but also increases the likelihood of symptoms exacerbation and asthma attacks , because significant physical , psychological , emotional , sexual , and social variations occur in adolescence . therefore ,
psychological and mental problems in adolescence are more prevalent than other life periods ; for example , the incidence rate of such problems in 14 years of age increases by 10 times as compared to 10 years of age . as a result ,
acquisition of any disease , particularly chronic ones such as asthma , could intensify the crises of adolescence and lead to various complications , including psychological , because of the nature of chronic diseases which cause many limitations , and affect the adolescents life greatly and hence their group activities as well as psychosocial functioning .
more clearly , incidence of chronic diseases such as asthma in adolescence results in some lack of balance and peace for adolescents due to difficulties including repeated hospitalizations , side effects of treatment , school absence , and decline in academic performance culminating in stress . in this regard
, the findings of a study demonstrated that stress and depression were highly prevalent among the adolescents with asthma .
moreover , the results of another study indicated that the incidence of asthma symptoms and attacks in the asthmatic adolescents suffering higher stress was more than those with lower levels of stress .
accordingly , the experience of stress in asthmatic adolescents increases the likelihood of asthmatic attacks .
therefore , prevention of attacks and control of stress and anxiety in the adolescents with asthma is an important concern of healthcare teams .
as the nurses spend the greatest amount of time with patients , they are often in the best position to detect symptoms and prevent complications in these patients .
training is a significant way to promote the adolescents health through implementing various projects with reliance on the patients active participation in various health behaviors . by relevance
, self - care pattern is an important training pattern which is based on the individual abilities and needs .
for example , orem s self - care model is a self - care pattern which is an appropriate clinical guideline to plan for and implement self - care principles and could be applied as a conceptual framework to design self - care programs .
the orem self care model is developed in three types of care systems with reference to the patient s needs and health problems and the role of the nurse , namely wholly compensatory nursing system , partly compensatory nursing system , and supportive - educative nursing system . in this model ,
when the patient is going to learn and perform the behavior of interest but is not able to do it without assistance , the supportive - educative nursing system is applied . here
this system is conducive to decision making , behavior management , and acquisition of knowledge and skills . in this study ,
findings of a study investigating the effect of orem s model on self - care in adolescents with asthma demonstrated that five domains of self - care including appropriate drug taking , use of exercise techniques , use of functional programs for asthma control , careful adherence to diet , and protection against environmental stimuli of asthma attacks in the treatment group were significantly different from the controls compared with prior to the intervention . also , the results of another study demonstrated the effect of supportive - educative program , based on the orem s theory , on knowledge , asthmatic control and self - care behaviors in the adolescents with asthma , showing that the control of self - care behaviors enhanced after the intervention .
a study of training program and asthma control in adolescents showed that attending training classes by the adolescents with asthma led to a decrease in and mitigation of asthma attacks ; hence , the incidence of stress became less likely in them .
therefore in view of sensitive period of adolescence , adverse psychological and mental effects of asthma on adolescents as well as insufficient number of investigations on the orem - based self - care model , this study aimed to investigate the effect of the orem s self - care model on perceived stress in adolescents with asthma .
this semi - experimental study was conducted from april 2013 to february 2014 ( throughout 11 months ) .
the sample size was calculated as 32 in each group based on the data of similar studies : ( d=0.7s , =0.05 , =0.2 ) . for ethical considerations ,
ethical approval was issued by research and technology deputy of isfahan university of medical sciences ( 291302 ) and relevant authorities for this study .
the patients were enrolled by simple random sampling so that the first referring individual with inclusion criteria was assigned to the intervention group and the second to control and it continued till the desired number of participants were included in the two groups .
( by definition , chronic diseases take three months to interfere in daily activities and affect the patient s quality of life ) , ability to answer questions and debate in training classes , full consciousness , the age of 11 - 21 years , and no previous participation in similar training .
the exclusion criteria were absence in two consecutive and/or one fourth of all the sessions , no other chronic disease , mental health and no mental retardation ( by medical file and the physician ) , no history of taking drugs with mental effects ( by medical file and the physician ) , no emergency conditions throughout the study , no stressful incidence , for example bereavement during the study ( based on the patients statement before and during the study as they were already informed of the participation in this study ) in both groups , and withdrawal from the study .
a physician confirmed that the patients in the two groups were matched for the severity of asthma and the type of the drug(s ) taken .
the patients training based on the orem s model were considered as independent variable and perceived stress as dependent variable .
gender , age , disease duration , and parental education level and occupation were considered as the underlying variables in this study .
the researcher completed the pre - test questionnaires after she described the research purposes for the participants and obtained their written consent forms .
the participants over 18 years of age needed no parents permission and hence independently signed the letter of consent to participate in the study . for younger participants , the parents did it on behalf of their children . to examine the training needs of each participant before the intervention
, a questionnaire was developed based on the orem s model to investigate and detect some domains such as respiratory conditions , mood function , social function , and physical activity .
therefore , the researcher initially administered this questionnaire to the patients , and then planning for the intervention in the intervention group started with reference to the frequency of self - care needs in any domains . among self - care needs ,
the highest frequency was derived for social function followed by mood function and physical function .
after needs generation , the training materials were judged as appropriate . to develop the training materials , we derived the content by reviewing the relevant literature , and then offered to and confirmed by some university teachers who previously investigated such patients and a subspecialist .
the training materials consisted of : asthma and methods of controlling its symptoms , effective breathing types ( diaphragmatic and lip - bud ) , proper application of spray , and ways to relieve stress and anxiety based on the orem s self - care model were instructed within eight 2-h sessions .
training was implemented by the researcher as a group , individually , and face - to - face through speech , brainstorming and educational aids including powerpoint , movie and educational replica at clinical skills training workshop of shariati hospital with a pulmonologist s help .
it is noteworthy that all sessions were held in group , but when the parents and/or adolescents did not understand a subject and/or raised any questions regarding the disease and how to care for , they were individually trained by the researcher or a subspecialist . in addition , the researcher s phone number was given to the patients for further advice and support if necessary during the follow - up .
therefore , the patients could call the researcher if they had any queries . for follow - up , all the patients in the intervention group were called after the educational intervention on an ongoing basis once a week ( for two months ) , and the content was taught to them and care practices were evaluated .
two months after the intervention , the patients of both groups were requested to complete the questionnaire of perceived stress .
the training in the control group was run as routine , so that the patients only received recommendations from physician in visits .
notably , the researcher trained the patients of both groups similarly for observance of research ethics .
cohen perceived stress scale has three versions , 4 , 10 , and 14-item , administered to measure the overall perceived stress .
this scale measures thoughts , stress - causing incidence , control , overcoming , coping with psychological pressure and experienced stresses .
the items are scored on a 5-point likert scale as never ( 0 ) , almost
never ( 1 ) , sometimes ( 2 ) , often ( 3 ) , and many times ( 4 ) . the items 4 - 13 are scored inversely ranging from never ( 4 ) too many times ( 0 ) .
it should be noted that for positive statements ( 4 - 10 , and 13 ) , the scores were calculated inversely .
this scale , which was psychometrically investigated by ghorbani et al . in 2002 , assesses perceived typical stress over the past month .
reported cronbach s alpha at 0.84 and 0.86 for this scale . in the study done by ghorbani et al .
, cronbach s alpha in an american sample was 0.86 and in an iranian sample it was calculated as 0.81 .
in addition , its validity was approved in the study performed by khushabi et al . in iran .
this questionnaire has been already used in the studies on students and its validity and reliability ( cronbach s alpha : 80% ) had been confirmed for this population . to investigate the questionnaire s validity , concurrent validity with the scales of positive and negative emotions , happiness , and depression was used .
the positive emotion was significantly correlated with positive ( r=0.73 ) and negative ( r=0.53 ) perceived stress , negative emotion was significantly correlated with positive ( r=0.68 ) and negative ( r=0.68 ) perceived stress , happiness was significantly correlated with positive ( r=0.68 ) and negative ( r=0.43 ) perceived stress , and depression was significantly correlated with positive ( r=0.57 ) and negative ( r=0.49 ) perceived stress .
further , the association between this scale and validity criteria is not affected by age and gender .
the data were analyzed using descriptive and analytical statistics consisting of paired t - test , independent t - test , chi - square and mann - whitney tests in spss 20 .
the results of independent t - test , analysis of variance , and mann - whitney revealed that there was no significant difference in age , duration of asthma , gender , fathers and mothers education , and fathers and mothers occupation between the two groups .
demographic characteristics of asthma patients in the two groups independent t - test indicated a significant difference in the mean score of perceived stress after the intervention in both studied groups ( p=0.01 ( , while no statistically significant difference was obtained prior to the intervention in the two groups ( p=0.79 ) .
furthermore , paired t - test indicated a significant difference in the mean score of perceived stress between before and after the intervention in the intervention group ( p=0.01 ) , but no statistically significant difference was derived in the control group ( p=0.68 ) .
( table 2 ) comparison of meansd score of perceived stress in the intervention and control groups before and after training moreover , independent t - test indicated that the mean differences in perceived stress score between the intervention and control groups were significant before and after training ( p=0.04 ) ( table 3 ) .
difference in mean perceived stress between the two groups of the study before and after training
this study was conducted to investigate the effect of the orem s self - care model on perceived stress in adolescents with asthma . as to the participants demographics in the present study ,
most adolescents of intervention and control groups were male . in another studym the mean age of asthmatic children in treatment and control groups
the present study indicated that although there was no significant difference in the mean score of perceived stress prior to the training in both intervention and control groups , the difference were significant between the two groups after the training .
this means that the intervention implemented in this study reduced perceived stress in patients with asthma in the intervention group , while the perceived stress was not significantly different between the two groups before the intervention .
holding sessions in the hospital s clinical skills centre , use of educational aids such as models , powerpoint and movie , a variety of methods including speech and brainstorming and above all presence of parents at sessions could contribute to the intervention efficacy .
the important purpose of training is to develop appropriate and stable behaviors , and if self - care activities are performed through active training methods and recognition of patients attitudes and beliefs and also provision of an environment laden with confidence and comfort for clients , then they may contribute sufficiently to promotion of the desired healthy behaviors .
on the other hand , presentation of materials in an understandable manner , based on individual needs , and by group training , along with questions and answers can lead to better results , and above all help to continue appropriate caring behaviors . since self - care as practiced by the adolescents could stimulate regressive and forgotten abilities and use them to eliminate inabilities , implementation of self - care programs could reinforce motivation and self - esteem in the patients with asthma , so that they improve their deficits and inabilities through assuming responsibility for self - care and use the self - care to remove these difficulties .
similarly , a study of peer - centred training and health outcomes in the adolescents with asthma in jordan demonstrated that the participants in the intervention group , as compared with controls , exhibited a significant improvement of health - related quality of life , resistance to smoking , and knowledge of asthma self - management .
moreover , a study of the orem s self - care model in adolescents with asthma indicated that self - care skills including use of drugs and a codified program , adherence to a daily follow - up program , and protection against disease - initiating factors such as stress significantly increased in the intervention group , but they did not cause a change in the controls . also , the number of adolescents who accomplished self - care increased in the intervention group , who were less dependent on parents for self - care .
another study of self - management of asthma in adolescents indicated that the students who underwent self - care intervention had a higher level of self - esteem for management of their disease and took more measures to prevent symptoms compared to the control group .
moreover , use of appropriate coping skills , decrease in school absence due to asthma , improvement of quality of life , and decrease in hospitalization turns were reported . a study on the effect of interactive teaching of children and their families on the control of disease symptoms after one - year follow - up indicated that the number of children s referral to the emergency ward decreased .
in addition , the present study obtained a significant difference in perceived stress score in the intervention group between before and after the training . in view of the great contribution of psychological factors including stress to incidence and/or exacerbation of asthma conditions , training of coping strategies to the participants by the researcher and their physician led to their active participation in self - care and hence decline of stress in them .
therefore , the orem s self - care model - based training caused a decrease in perceived stress in asthmatic adolescents .
because this model aimed to prepare the patients for and assist them in self - care , then we must let them be actively involved in decision making and planning for self - care . in this regard ,
a study of a program of stress management in the adolescents with asthma demonstrated that the intervention developed to control stress and improve coping with the disease in the intervention group resulted in promotion of physical health ( lung function ) and alleviation of perceived stress and depression .
another study of the effect of asthma - related training on health outcomes in asthmatic children hospitalized in emergency ward of the hospital indicated that the training caused a significant decrease in hospitalization - associated stress in children , parents , and/or both compared to the controls .
the distinctive point of the present study is investigation of self - care needs by the patients needs assessment , because development and implementation of a program without consideration of the patients needs yields no positive outcomes .
implementation of self - care program could reinforce motivation and self - esteem in these clients , so that they are able to improve the disease - derived inabilities and utilize self - care capability to remove the associated problems by self - care .
since in the present study , because of time limitations , the effect of the orem self - care programs has not been evaluated within an extensive length of time , it is recommended that its effect should be investigated more longitudinally ( about four to six months after the intervention ) to determine the reliability of the intervention .
as the present study indicated , self - care training could be addressed as a significant factor contributing to the decrease in perceived stress .
therefore , the use of the models capable of inviting the clients and involving them in self - care could provide a valuable model which could be used to identify and evaluate the healthcare system for these patients .
then , it is recommended that this program should be considered as a part of treatment program for these patients . | background : incidence of asthma in adolescents leads to variations in family status , roles and interaction with peers for them , which could be a source of stress and psychological tensions in them .
therefore , the present study was conducted to investigate the effect of orem s self - care model on perceived stress in adolescents with asthma.methods:in this semi - experimental study conducted from april 2013 to february 2014 , 64 asthmatic adolescents referring shariati hospital , isfahan were enrolled by simple random sampling and the patients were assigned to two groups of control and intervention .
then , orem s self - care model - based training was implemented throughout eight sessions of two hours each and the cohen perceived stress scale was administered to both groups prior to and two months after the completion of the training .
the data were analyzed by descriptive and analytical statistics consisting of paired t - test , independent t - test , chi - square and mann - whitney using spss version 20.results:mean age of the participants was 14.153.12 years in the intervention group and 15.213.09 years in the control groups .
68.8% and 59.4% of the participants were male in the intervention and control groups , respectively .
independent t - test indicated a significant difference in the mean scores of perceived stress in the intervention ( 25.465.31 ) and control groups ( 28.905.27 ) after the training .
also , the result of paired t - test indicated a significant difference in the mean score of perceived stress between before ( 29.185.27 ) and after ( 25.465.31 ) training.conclusion:as the training based on orem s model had a positive effect on declining perceived stress in asthmatic adolescents , continuation of using these training interventions could contribute to ultimately achieving positive outcomes in health functions of these patients . |
after colostomy , the nonfunctioning intestinal segment presents inflammatory alterations comprising a nosological entity known as diversion colitis ( dc).1 the preferred treatment for dc is intestinal transit reconstruction which , in most cases , resolves the inflammatory process.2 ma et al.3 analyzed 21 cases of dc and concluded that moderate chronic inflammation with lymphoplasmocytary infiltrate in the lamina propria , vascular congestion , minimal alterations in crypt architecture and a slight decline in their number were the main histopathologic alterations found in the disease . additionally , these changes were accompanied by the presence of prominent lymphoid nodules with or without hyperplasia of the germinal centers .
haque et al.4 observed the presence of eosinophilic polymorphonuclear cells ( epns ) in the lamina propria and colonic lumen of children with dc .
pinto et al.5 reported that the onset of significant atrophy in the colonic mucosa of wistar rats coincides with the 40 day after surgical exclusion of the colon .
grove et al.6 demonstrated the relationship between diet and the presence of short chain fatty acids ( scfas ) in the colonic lumen .
roediger showed that around 70% of colonocyte energy requirements originate in the scfas and , further , that 90% of these scfas are formed by acetic , npropionic and nbutyric acid , the latter of which serves as the main energy source for colonocytes.7 the scfas exert trophic effects on the large bowel through direct contact of the acids with the colonic mucosa.8 colonic trophism mechanisms occur as a result of increased energetic oxygenation , stimulated flow of blood microcirculation caused by dilated resistance arteries , enterotrophic hormone production and stimulation of the enteric nervous system .
this trophism occurs transmurally and is not restricted to the mucosa.8,9 in addition to stimulating collagen maturation , these aforementioned functions are fundamental in colonic physiology and contribute to decreased bacterial translocation , intestinal adaptation in short bowel syndrome , stimulation of healing and increased anastomosis resistance.8 - 10 some authors have postulated that the use of scfas in the nonfunctioning segment reverses the alteration of dc.2,11 other studies were not as successful , however , and their authors question this form of treatment.12,13 the present study aimed to assess the use of scfas in the nonfunctioning colonic stump of wistar rats in order to demonstrate microscopically the existence ( or lack thereof ) of a prophylactic or therapeutic role .
forty male wistar rats weighing between 220 g and 230 g were housed in a room under standard conditions of temperature , light , humidity , water and diet ( labinapurina , so paulo , brazil ) according to specifications described by reeves et al.14 the animals were supplied by the vivarium of the center for experimental surgery , department of surgery of the ccs ( centro de cincias da sade ) ( health science center ) of ufrn ( universidade federal do rio grande do norte ) ( federal university of rio grande do norte ) .
the animals were treated according to the use of nonhuman animals in research : a guide for scientists.15 the surgery was performed in the laboratory of the operatory technique discipline ( ufrn ) with the collaboration of the department of pathology ( ufrn ) and the postgraduate program in health sciences ( ppgcsa ( programa de psgraduao do centro de cincias da sade ) , ufrn ) .
all of the animals were submitted to a 12hour fast with the exclusive use of water . immediately before surgery , a retrograde intestinal wash was performed with physiological saline to remove all fecal matter.5 all surgical procedures were conducted under aseptic conditions .
anesthesia was obtained using pentobarbital ( 20 mg / kg intraperitoneally ) and ketamine ( 50 mg / kg intramuscularly ) .
they were fixed in dorsal decubitus , and trichotomy and asepsis using povidoneiodine were performed.16 the abdominal cavity was opened by a median laparotomy of around 5 cm to identify the cecum and proximal colon , which was divided 5 cm from the ileocecal valve .
the proximal segment was colostomized and exteriorized through the abdominal wall left of the median incision .
a singlebarreled end colostomy was performed along with fixation of the stoma to the abdominal wall ( primary maturation ) with a 60 polypropylene thread .
1).5 four groups of ten adult wistar rats submitted to colostomy underwent additional interventions .
the protocol distributed the animals into groups a ( a1 and a2 ) and b ( b1 and b2 ) .
two control groups ( a1 and b1 ) received infusions of physiological saline administered rectally , whereas the two experimental groups ( a2 and b2 ) received shortchain fattyacids rectally .
the a groups were prophylactically treated ( 5th to 40th postoperative days , twice a week ) , whereas the b groups were therapeutically treated ( after postoperative day 40 , for seven days ) .
the scfa solution was developed in the biochemistry laboratory of the bioscience center at ufrn and was composed of : 75 mmol / l of sodium acetate ; 35 mmol / l of sodium propionate ; 20 mmol / l of butyricn acid ; 2.5 mmol / l of calcium chloride ; 7.5 mmol / l of magnesium chloride ; 10 mmol of potassium chloride.17 the solutions were elaborated in an isoosmolar ( 280
mosm / l ) , and the ph was adjusted to seven by using appropriate amounts of naoh or hci .
the mean of four microscopic measures of mucosal thickness in the rats of each subgroup was measured using a nikon lobophot 10 microscope ( nikon , tokyo , japan ) .
this equipment expresses the mean thickness in millimeters by multiplying the value obtained by the standard correction factor indicated for the lens ( 0.0078 ) as a function of its amplification and diameter .
the measures were obtained for each of the transversal and longitudinal histological sections of the colonic wall using the final mean for each animal from the values found.5 different cell type counts were performed to assess neutrophilic polymorphonuclear cells ( npns ) , lymphocytes , and epns .
the lymphoid follicle size of the mucous associated lymphoid tissue ( malt ) was assessed in the lamina propria of the mucosa as well as in the colonic wall .
the intensity of alterations was graduated on a 6point scale ranging from 0 to 5 .
these values were later converted into whole numbers using our modified version of myers ' index,18 which is based on variables appropriate to the study of dc .
a variable was stipulated for each type of variable analyzed , depending on whether it was favorable for dc diagnosis .
this value was multiplied by the intensity of the alterations observed in the histologic sections . in quantitative assessment ,
statistical analysis compared the measures obtained in the two paired groups ( a1 and a2 ) and ( b1 and b2 ) using analysis of variance procedures ( student 's ttest ) . for qualitative assessment ,
exploratory analysis was performed by building tables and then comparing the mean intensity of the cells observed in each group according to cell type . to determine the existence of significant differences in cellularity between groups ( a1 and a2 ) and ( b1 and b2 ) , the nonparametric mannwhitney test was applied .
a significance level of 5% ( pvalue 0.05 ) was set for all of the results assessed .
forty male wistar rats weighing between 220 g and 230 g were housed in a room under standard conditions of temperature , light , humidity , water and diet ( labinapurina , so paulo , brazil ) according to specifications described by reeves et al.14 the animals were supplied by the vivarium of the center for experimental surgery , department of surgery of the ccs ( centro de cincias da sade ) ( health science center ) of ufrn ( universidade federal do rio grande do norte ) ( federal university of rio grande do norte ) .
the animals were treated according to the use of nonhuman animals in research : a guide for scientists.15 the surgery was performed in the laboratory of the operatory technique discipline ( ufrn ) with the collaboration of the department of pathology ( ufrn ) and the postgraduate program in health sciences ( ppgcsa ( programa de psgraduao do centro de cincias da sade ) , ufrn ) .
all of the animals were submitted to a 12hour fast with the exclusive use of water . immediately before surgery , a retrograde intestinal wash was performed with physiological saline to remove all fecal matter.5 all surgical procedures were conducted under aseptic conditions .
anesthesia was obtained using pentobarbital ( 20 mg / kg intraperitoneally ) and ketamine ( 50 mg / kg intramuscularly ) .
they were fixed in dorsal decubitus , and trichotomy and asepsis using povidoneiodine were performed.16 the abdominal cavity was opened by a median laparotomy of around 5 cm to identify the cecum and proximal colon , which was divided 5 cm from the ileocecal valve .
the proximal segment was colostomized and exteriorized through the abdominal wall left of the median incision .
a singlebarreled end colostomy was performed along with fixation of the stoma to the abdominal wall ( primary maturation ) with a 60 polypropylene thread .
the protocol distributed the animals into groups a ( a1 and a2 ) and b ( b1 and b2 ) .
two control groups ( a1 and b1 ) received infusions of physiological saline administered rectally , whereas the two experimental groups ( a2 and b2 ) received shortchain fattyacids rectally .
the a groups were prophylactically treated ( 5th to 40th postoperative days , twice a week ) , whereas the b groups were therapeutically treated ( after postoperative day 40 , for seven days ) .
the scfa solution was developed in the biochemistry laboratory of the bioscience center at ufrn and was composed of : 75 mmol / l of sodium acetate ; 35 mmol / l of sodium propionate ; 20 mmol / l of butyricn acid ; 2.5 mmol / l of calcium chloride ; 7.5 mmol / l of magnesium chloride ; 10 mmol of potassium chloride.17 the solutions were elaborated in an isoosmolar ( 280 mosm / l ) , and the ph was adjusted to seven by using appropriate amounts of naoh or hci .
the mean of four microscopic measures of mucosal thickness in the rats of each subgroup was measured using a nikon lobophot 10 microscope ( nikon , tokyo , japan ) .
this equipment expresses the mean thickness in millimeters by multiplying the value obtained by the standard correction factor indicated for the lens ( 0.0078 ) as a function of its amplification and diameter .
the measures were obtained for each of the transversal and longitudinal histological sections of the colonic wall using the final mean for each animal from the values found.5
different cell type counts were performed to assess neutrophilic polymorphonuclear cells ( npns ) , lymphocytes , and epns .
the lymphoid follicle size of the mucous associated lymphoid tissue ( malt ) was assessed in the lamina propria of the mucosa as well as in the colonic wall .
the intensity of alterations was graduated on a 6point scale ranging from 0 to 5 .
these values were later converted into whole numbers using our modified version of myers ' index,18 which is based on variables appropriate to the study of dc .
a variable was stipulated for each type of variable analyzed , depending on whether it was favorable for dc diagnosis .
this value was multiplied by the intensity of the alterations observed in the histologic sections .
in quantitative assessment , statistical analysis compared the measures obtained in the two paired groups ( a1 and a2 ) and ( b1 and b2 ) using analysis of variance procedures ( student 's ttest ) . for qualitative assessment ,
exploratory analysis was performed by building tables and then comparing the mean intensity of the cells observed in each group according to cell type . to determine the existence of significant differences in cellularity between groups ( a1 and a2 ) and ( b1 and b2 ) , the nonparametric mannwhitney test was applied .
a significance level of 5% ( pvalue 0.05 ) was set for all of the results assessed .
no significance difference was found between the control ( a1 ) and prophylactic ( a2 ) groups in the prevention of dc in terms of mucosal atrophy ( p = 0.1680 ) . however , there was a significant difference between the control group ( b1 ) and treatment group ( b2 ) , p = 0.0001 .
table 2 shows the different cell types , including the presence and size of malt lymphoid follicles ( lfs ) , with values expressed in accordance with myers ' modified score .
the highest indices observed were the presence of lfs ( 5 ) , mainly large size ( 3 ) , and number of epns ( 3 ) in the colonic lumen ; these findings favored the diagnosis of dc . the histologic sections from group a1 ( control ) exhibiting mucosal atrophy are shown in figure 3(a ) .
figure 3(b ) shows sections from group a2 ( prophylactic ) exhibiting mucosal atrophy and slight malt hyperplasia , and figure 3(c ) shows sections from group b1 ( control ) exhibiting mucosal atrophy and malt hyperplasia .
figure 3(d ) shows sections from group b2 ( treatment ) exhibiting normal mucosal thickness and malt hyperplasia .
the assessment of histologic scores by cell type and lymphoid follicles of malt , which are represented by the sum of the median values in the control ( a1 ) and prophylactic ( a2 ) groups , is shown in table 3 .
the results obtained in the qualitative analysis of the samples revealed a significant numerical increase in lymphocytes ( p = 0.006 ) and epns in the lamina propria of the colonic mucosa ( p = 0.0022 ) in the prophylactic group ( a2 ) compared to the control group ( a1 ) .
the prophylactic use of scfas ( group a2 ) did not significantly reduce malt hyperplasia compared to the control group ( a1 ) ( p = 0.0670 ) . with respect to total cellularity
, there were no significant differences between groups a1 and a2 ( p = 0.2233 ) .
table 4 shows a significant reduction in epns in the lamina propria of the treatment group ( b2 ) compared to the control group ( b1 ) ( p = 0.0126 ) , and a reduction was also observed in the intestinal lumen ( p = 0.0256 ) .
we also found that the therapeutic use of scfas had little effect on the inhibition of malt hyperplasia when comparing groups b2 and b1 ( p = 0.5514 ) .
total cellularity showed no significant difference between groups b1 and b2 ( p = 0.0781 ) .
no significance difference was found between the control ( a1 ) and prophylactic ( a2 ) groups in the prevention of dc in terms of mucosal atrophy ( p = 0.1680 ) . however , there was a significant difference between the control group ( b1 ) and treatment group ( b2 ) , p = 0.0001 .
table 2 shows the different cell types , including the presence and size of malt lymphoid follicles ( lfs ) , with values expressed in accordance with myers ' modified score .
the highest indices observed were the presence of lfs ( 5 ) , mainly large size ( 3 ) , and number of epns ( 3 ) in the colonic lumen ; these findings favored the diagnosis of dc .
the histologic sections from group a1 ( control ) exhibiting mucosal atrophy are shown in figure 3(a ) .
figure 3(b ) shows sections from group a2 ( prophylactic ) exhibiting mucosal atrophy and slight malt hyperplasia , and figure 3(c ) shows sections from group b1 ( control ) exhibiting mucosal atrophy and malt hyperplasia .
figure 3(d ) shows sections from group b2 ( treatment ) exhibiting normal mucosal thickness and malt hyperplasia .
the assessment of histologic scores by cell type and lymphoid follicles of malt , which are represented by the sum of the median values in the control ( a1 ) and prophylactic ( a2 ) groups , is shown in table 3 .
the results obtained in the qualitative analysis of the samples revealed a significant numerical increase in lymphocytes ( p = 0.006 ) and epns in the lamina propria of the colonic mucosa ( p = 0.0022 ) in the prophylactic group ( a2 ) compared to the control group ( a1 ) .
the prophylactic use of scfas ( group a2 ) did not significantly reduce malt hyperplasia compared to the control group ( a1 ) ( p = 0.0670 ) . with respect to total cellularity
, there were no significant differences between groups a1 and a2 ( p = 0.2233 ) .
table 4 shows a significant reduction in epns in the lamina propria of the treatment group ( b2 ) compared to the control group ( b1 ) ( p = 0.0126 ) , and a reduction was also observed in the intestinal lumen ( p = 0.0256 ) .
we also found that the therapeutic use of scfas had little effect on the inhibition of malt hyperplasia when comparing groups b2 and b1 ( p = 0.5514 ) .
total cellularity showed no significant difference between groups b1 and b2 ( p = 0.0781 ) .
in clinical practice , the objective assessment of dc is made according to three main criteria : ( 1 ) analysis of mucosal thickness ; ( 2 ) study of the role of inflammatory cells of the lamina propria and malt and ; ( 3 ) investigation of surface colonocyte alterations .
the latter parameter is therefore more reliable than the others , as it can be easily measured.19 the relevant results obtained in the present study show that scfas are effective for the treatment of dc as they reverse colonic mucosal atrophy .
therapeutic use of scfas has also been shown to reduce the number of epns in the lamina propria of the mucosa and colonic lumen , thereby decreasing the inflammatory process .
in contrast , therapeutic scfa use did not benefit the nonfunctioning colonic tissue by reversing lymphoid follicular hyperplasia in malt.20 scfas were ineffective when used as dc prophylaxis , as shown by the fact that they did not impede mucosal atrophy on the 40 day postoperatively .
harig et al.,2 for example , observed clinical , endoscopic , and histopathologic reversal in four patients with dc who underwent scfa treatment in the excluded segment .
worsening resulted with treatment interruption or when the infusion solution was replaced by physiological saline . with the exclusive use of topically
infused scfas , kiely et al.11 observed symptom remission and significant improvement in the endoscopic and histopathologic dc findings in three out of five patients studied .
these authors observed that the topical use of butyrate favored increased cellularity in the colonic crypt , elevated mitoses , and consequent cell proliferation and atrophy reversal .
the authors also observed that the effect of butyrate was dosedependent and that its action was of short duration . oliveiraneto and aguilarnascimento22 assessed the infusion effect of a solution containing fibers on the nonfunctioning colonic stump of 11 patients .
these authors observed a significant decrease in the degree of dc , as well as a significant increase in crypt depth after infusion .
given that scfas are a result of fiber degradation caused by anaerobic bacteria in the colonic lumen , these findings suggested that scfas were directly responsible for dc remission .
some researchers , however , found no relevance in the use of scfas as an active agent in dc remission .
published a doubleblind study with thirteen patients.12 these authors observed no significant endoscopic or histopathologic differences in dc reversal between the scfas and physiological saline infusion groups .
schauber et al.13 examined 9 patients in a doubleblind study and only 7 of these completed the protocol .
the study showed no significant endoscopic or bacteriologic differences between the control and scfa groups .
the disparity in results between these authors and those who observed data favoring the use of scfas may be explained by the differences in clinical indications for colostomy .
recent studies have revealed the inhibitory action of butyrate metabolism in patients with idiopathic ulcerative colitis.23 the trophic action of scfas on the large intestine , which occurs through its direct contact with the colonic mucosa , is important in the clinical control of dc.8 this action reduces the signs and symptoms associated with the condition itself ( e.g. mucous discharge and transrectal bleeding ) .
further , scfas also prevent the emergence of complications related to mucosal atrophy and colonic epithelium lesion , as well as complications inherent to reestablishing intestinal transit .
neut et al.20 reported that the colonic mucosal atrophy with loss of integrity seen in dc could predispose patients to bacterial translocation by interfering with local immunity and modifying native bacterial flora , both quantitatively and qualitatively .
the present study found that the use of scfas for a short period of time not only reversed atrophy but also reduced the risk of losing mucosal integrity .
the fact that this latter finding has not been reported in the literature makes it scientifically relevant .
these results , therefore , favor the preservation of local immunity while avoiding the modification of native bacterial flora . furthermore , bacterial translocation was not observed in the results reported by pinto jr .
lim et al.25 raised the hypothesis that dc is a factor predisposing patients to the emergence of idiopathic ulcerative rectocolitis .
this occurs through the sensitization of leukocytes in the nonfunctioning colon and subsequent leukocyte aggression toward the endothelium of the functional colon as a result of the emergence of anticolonic selfantibodies .
the therapeutic action of scfas observed in this study would reduce the possibility of disease evolution .
owing to their high morbidity and mortality rates , intestinal anastomosis fistulae remain the greatest threat to gastrointestinal tract surgeons .
pearce et al.26 observed higher reanastomosis dehiscence indices when the interval for transit reconstruction was more than six months , which is sufficient time for atrophy of the nonfunctioning colon wall to occur .
scfa enemas facilitated the healing process of colonic anastomosis in rats.10 possible mechanisms that might mediate this effect include an increase in cell proliferation of the colonic mucosa and the acceleration of collagen maturation.27 the first mechanism accelerates reepithelization and increases blood flow , with a consequent rise in oxygen supply .
the topical use of scfas twice daily for 7 days ( the therapeutic methodology used in this study ) reversed colonic mucosal atrophy .
this therapy would reduce the potential risk of fistula formation in patients undergoing intestinal transit reconstruction .
the use of scfas is important for proper nutrition of the nonfunctioning colonocyte , because scfas reverse colonocyte atrophy and therefore minimize symptoms in some patients
. this treatment may be particularly valuable for those patients undergoing intestinal transit reconstruction , however , because the aim of atrophy reversal is to prevent complications inherent to the surgery .
in conclusion , the prophylactic action of scfas on dc in terms of colonic mucosal trophism was not confirmed .
this study demonstrates the therapeutic use of scfas in experimental dc by showing the significant effects of scfas on atrophy regression and epn reduction in the intestinal lumen and lamina propria of the colonic mucosa , despite their lack of interference with the intensity of malt hyperplasia .
thus , the therapeutic application of scfas may be of great significance in clinical practice , especially in patients without associated inflammatory disease
. scfas may shorten hospitalization and favor better postoperative management in colostomized patients by reducing complications .
| objectives : to study the effect of shortchain fattyacids on atrophy and inflammation of excluded colonic segments before and after the development of diversion colitis.introduction:diversion colitis is a chronic inflammatory process affecting the dysfunctional colon , possibly evolving with mucous and blood discharge .
the most favored hypotheses to explain its development is shortchain fattyacid deficiency in the colon lumen.methods:wistar rats were submitted to colostomy with distal colon exclusion .
two control groups ( a1 and b1 ) received rectally administered physiological saline , whereas two experimental groups ( a2 and b2 ) received rectally administered shortchain fattyacids .
the a groups were prophylactically treated ( 5th to 40th days postoperatively ) , whereas the b groups were therapeutically treated ( after postoperative day 40 ) .
the mucosal thickness of the excluded colon was measured histologically .
the inflammatory reaction of the mucosal lamina propria and the lymphoid tissue response were quantified through established scores.results:there was a significant thickness recovery of the colonic mucosa in group b2 animals ( p = 0.0001 ) , which also exhibited a significant reduction in the number of eosinophilic polymorphonuclear cells in the lamina propria ( p = 0.0126 ) and in the intestinal lumen ( p = 0.0256 ) .
group a2 showed no mucosal thickness recovery and significant increases in the numbers of lymphocytes ( p = 0.0006 ) and eosinophilic polymorphonuclear cells in the lamina propria of the mucosa ( p = 0.0022).conclusion : therapeutic use of shortchain fattyacids significantly reduced eosinophilic polymorphonuclear cell numbers in the intestinal wall and in the colonic lumen ; it also reversed the atrophy of the colonic mucosa .
prophylactic use did not impede the development of mucosal atrophy . |
zfin ( http://zfin.org ) is a curated database of zebrafish genetic and genomic data including genes , mutants , transgenic lines and constructs , genotypes , phenotypes , gene expression , anatomical structures , orthology , nucleotide and protein sequences and reagents such as morpholinos and antibodies .
a table illustrating growth of these data at zfin since 1998 can be accessed on the zfin web site at http://zfin.org/zf_info/zfin_stats.html .
it is apparent from these data that mutant and transgenic lines and transgenic constructs are the most rapidly growing data types in zfin ( figure 1 ) .
as technology has evolved , it has become possible for laboratories to generate large numbers of mutant and transgenic lines at lower cost . to maximize utilization of these resources by the zebrafish research community
, it is increasingly important for zfin to load , store and retrieve information about large numbers of mutants and transgenics . to meet this need , zfin has increased support for storing , searching and displaying information about transgenic constructs and lines , and we have increased the expressivity of our phenotype curation syntax .
figure 1.in the past 2 years , mutant and transgenic features ( genetic features ) as well as transgenic constructs have been among the most rapidly growing data types at zfin . * 2012 data through 8 august 2012 .
table 1.summary of data content at zfin as of 8 august 2012data type2012genes gene records32 893 genes on assembly19 332 transcripts31 913 ests / cdnas34 865 full - length cdna clones ( zgc)17 191genetics genetic features22 738 transgenic insertions16 922 transgenic constructs1562 transgenic genotypes10 787 genotypes19 237functional annotation genes with any go annotation18 051 genes with iea go annotation14 569 genes with non - iea go8898 total go annotations139 639reagents morpholinos5035 antibodies916expression and phenotypes gene expression patterns59 829 images83 538 anatomical structures2760genomics mapped markers38 434 links to other databases648 395community information publications16 671 researchers6130 laboratories782 companies148orthology genes with curated human orthology12 601 genes with curated mouse orthology9724a full table showing growth of these data on an annual basis since 1998 can be found by using the
est : expressed sequence tag ; iea : inferred from electronic annotation . in the past 2 years , mutant and transgenic features ( genetic features ) as well as transgenic constructs have been among the most rapidly growing data types at zfin . * 2012 data through 8 august 2012 .
summary of data content at zfin as of 8 august 2012 a full table showing growth of these data on an annual basis since 1998 can be found by using the
zebrafish have become one of the pre - eminent model organisms for studies of gene function aimed at understanding human development and disease .
one reason for this is the growing ease with which large numbers of zebrafish mutants and transgenics can be created and analyzed .
zfin has recently developed collaborations with the laboratories of shawn burgess and shuo lin , steve ekker and derek stemple ( the zebrafish mutation project , zmp , hosted at the sanger institute ) to load data from their large - scale mutant / transgenic fish resources ( 14 ) . to make these resources widely accessible to the zebrafish research community ,
thier data has been annotated and loaded into the zfin database , while the fish are made available to the research community by the zebrafish international resource center .
each mutant or transgenic integration site is given an official genomic feature designation ( allele number ) and is annotated with the affected gene , the construct utilized , the type of mutation , the protocol used , the laboratory of origin , mapping information , associated genbank accession numbers , current sources and genotypes in which the genomic feature can be found . for transgenic fish ,
the construct utilized is curated to include details about the promoters , expressed genes and distinctive features such as loxp sites , etc .
genomic features can be searched from the mutants / morphants / transgenics search form and the annotated data can be accessed on the genomic feature page ( figure 2 ) .
in addition , transgenic insertions for which we have integration site sequence information have a dedicated track in the zfin genome browser , gbrowse ( figure 3 ) . the gbrowse view for transgenic insertions is important because it provides a simple graphical view of where a transgenic insertion is located within a gene s structure .
the closer an insertion is to the start site of a gene , the more likely it is to produce a mutant phenotype , information that can be critical in helping researchers select transgenic insertions of interest . to date , zfin has loaded 13 192 viral insertions and 4435 genotypes from the burgess and lin project , 63 genomic features and 96 genotypes from the ekker laboratory project , and 881 genomic features and 881 genotypes from the two most recent zmp data submissions ( table 3 ) . in 2010 ,
the sanger institute provided zfin with phenotype and image data for 102 of 249 mutants that had been added to zfin in earlier loads ( 58 ) .
the sanger institute will continue to provide zfin with phenotype and image data from the ongoing zmp project .
this is an example of a viral insertion feature including affected gene , previous name , associated construct , type of mutation , protocol used , laboratory of origin , mapping information , associated genbank accessions , current sources and genotypes .
like other items shown in gbrowse , transgenic insertions shown on this track are linked to their feature records in zfin .
table 2.ontologies used to describe zebrafish phenotypeontologyid prefixexample termsphenotypic qualitypatoyellow , dorsalized , increased rate , fused with , absentzebrafish anatomy and developmentzfa , zfsposterior lateral line , rohon - beard neuron , pancreas , segmentation : 1013 somites , larval : day 4gene ontologygobrain morphogenesis , transferase activity , ciliummouse pathology ( neoplasm branch)mpathcarcinoma , hepatoblastoma , spermatocytic seminomaspatial ontologybspoanterior / posterior axis , left side , dorsal regionrelation ontologyrois_a , part_of , develops_fromontology files can be downloaded from the open biological and biomedical ontologies foundry ; http://obofoundry.org . the genomic feature page provides detailed information about the genomic feature .
this is an example of a viral insertion feature including affected gene , previous name , associated construct , type of mutation , protocol used , laboratory of origin , mapping information , associated genbank accessions , current sources and genotypes .
, transgenic insertions shown on this track are linked to their feature records in zfin .
ontologies used to describe zebrafish phenotype ontology files can be downloaded from the open biological and biomedical ontologies foundry ; http://obofoundry.org .
basic search functionality for transgenic constructs is available using the zfin genes / markers / clones search .
, we plan to provide increased support for transgenic constructs , including construct images and a dedicated transgenic construct search that supports queries for specific promoters , expressed genes and distinctive features such as loxp sites and reporter expression patterns .
recognizing the importance of searches for the rapidly increasing volume of mutant , morphant and transgenic fish , we released a new version of mutant / morphant / transgenic search in may 2012 .
changes to the mutant / morphant / transgenic search interface include the ability to search using more than one term , the ability to use gene ontology ( go ) terms for phenotype , and improved search filters .
in addition , the speed of the search has improved significantly by using a backend data mart .
searching for multiple terms is a web standard , and we are working hard to bring this ability to zfin users .
the first step in this process was to provide a search for multiple genes and/or alleles at the same time .
this is critical when searching for double mutants , a mutant injected with a morpholino , or a transgenic fish expressing gfp under the control of regulatory sequences from specific genes ( e.g. pax2a ) .
lucene text indexes are now embedded in our database to support multi - term searching and to increase the speed of the search . transforming curated data into a data mart utilizing lucene text indexes de -
normalizes the data so that sorting happens on demand , result lists can be broken down by feature and affected gene without extra queries and figure counts can be displayed without real - time computation .
although zfin has supported searches for mutants with phenotypes affecting specific anatomical structures ( ao ) for some time , go biological process ( gobp ) terms used in phenotype annotations were not searchable until recently .
gobp terms are an integral part of curated mutant phenotypes at zfin , and it is now possible to choose from both gobp and ao terms in the auto - complete phenotype search box when searching for mutant phenotypes .
additionally , we updated the search filters to allow results to include exclusively or exclude specifically fish that use morpholinos or are transgenic .
noticeable improvements to the search results include faster results return and improved default ordering of results , column sorting options , a display of constructs for transgenic fish and a link to gene expression data for each fish .
best match is calculated by looking first for exact text matches of the search string , and then ordering results based on a biologically defined set of criteria including number of mutations in a particular fish and the mutation type .
for example , simple mutants ( ones with single point mutations ) are returned with greater priority than mutants with multiple genes affected . as zfin s
if results are more interesting when sorted by affected gene , then results can be sorted alphabetically by mutated / morpholino - affected gene . likewise ,
if results are more useful when ordered by allele designation or morpholino , results can be sorted by line designation / morpholino name . finding information for specific transgenic fish is also easier now with the addition of the construct column .
not only is it obvious which constructs were used in each fish but also information about the constructs is one click away on the construct page
. finally , gene expression data for the fish are available directly from the search results . to determine
which genes have been recorded as expressed , or not expressed in mutant , morphant or transgenic fish , click on the summarized
in addition to capturing data from publications , collaborations with research laboratories result in direct submission of phenotype data to the database .
we use biological ontologies ( controlled vocabularies ) to construct phenotype statements ( table 2 ) .
this method improves consistency , facilitates searches and allows computation across disparate data sets both within zfin as well as across model organisms . at zfin
, phenotypes are represented using the eq syntax to create phenotype statements , where e represents the entity ( an anatomical structure or gobp ) and q is the phenotypic quality from the phenotypic quality ontology , pato ( e.g. increased size ; pato:0000586 , decreased rate ; pato:0000911 ) ( 9 ) . in addition , a phenotype statement also includes an abnormal / normal tag or modifier .
the normal or recovered tag is used when the annotation of a normal phenotype is notable or when the annotation represents a recovered normal phenotype , such as that resulting from the addition of a morpholino to a mutant or the creation of a complex mutant genotype .
when a more detailed entity description is needed and a representative term is not available from one of the ontologies , ontology terms can be combined to post - compose a more specific term .
for instance , the eq statement trabecula communis chondrocyte disorganized , abnormal combines two anatomy terms , trabecula communis ( superterm ) and chondrocyte ( subterm ) , to create a more specific entity representing a chondrocyte that is part of the trabecula communis .
phenotype statements are displayed to enhance user readability but have underlying relationships that define the syntax of the annotations .
for instance , an eq statement uses the relationship inheres_in and translates as the quality type , which inheres_in the entity. for post - composition , an inferred part_of relationship exists between the subterm and superterm .
enu : n - ethyl - n - nitrosourealaboratorynumber of genomic features in zfinnumber of genotypes in zfins . burgess and s. lin13 192 viral insertions4435s .
ekker63 gene breaking transposon insertions96zebrafish mutation resource881 enu - induced point mutations881 number of genomic features and genotypes loaded into zfin in ongoing collaborations .
enu : n - ethyl - n - nitrosourea we have introduced several enhancements to zebrafish phenotype annotation during the past year . to increase the detail of phenotype annotations ,
we now use two additional ontologies for post - composition with zebrafish anatomy terms : the spatial ontology and the neoplasm branch of the mouse pathology ontology ( mpath ) ( 10 ) .
the spatial ontology supports representation of phenotypes for refined sub - regions of anatomical structures ( dorsal spinal cord for example ) , and mpath neoplasm terms are used to describe cancer phenotypes .
another new addition to zfin is the ability to compose and display phenotype statements using relational quality terms from pato .
a relational quality is a type of quality that requires an additional entity , i.e. those expressed in an eqe statement .
fused with used to describe cyclopia with the eqe statement eye fused with eye , abnormal. with post - composed entities and the use of a relational quality , a complex phenotype statement can be constructed that expresses a high degree of detail , e.g. midbrain posterior region has fewer parts of type dopaminergic neuron axon. when viewing a phenotype statement at zfin , you can find more information about the component ontology terms by clicking the icon at the end of the statement that opens a pop - up window ( figure 4 ) .
you can click again to close the pop - up , or you can click a hyperlinked term name to go to a term detail page where you can explore the ontology .
the zebrafish anatomy term detail pages include expression and phenotype data associated with the structure , as well as images when available .
links to phenotype data are located on a number of zfin pages , including gene , genomic feature and mutant / morphant / tg search result pages ; complete phenotype statements are displayed on figure , genotype , anatomy details , phenotype summary and phenotype statement pages .
access to the full set of phenotype data is available for download from the zfin data reports page ( http://zfin.org/downloads ) , which has recently been updated .
figure 4.example of a figure page at zfin with phenotype summary statements . clicking the complete hyperlinked phenotype statement opens a phenotype statement summary page ( not shown ) .
clicking the icon at the end of the statement ( red arrow ) opens a pop - up window with additional ontology term information as shown .
click on a hyperlinked term name from the pop - up to redirect to the term detail page for additional information and the ability to navigate the ontology .
represented are examples of a normal or recovered phenotype statement , the use of a relational quality ( boxed phenotype statement ) and post - composition , which is displayed in the pop - up where the ao term retinal rod cell is post - composed with the go cellular component term photoreceptor outer segment .
clicking the complete hyperlinked phenotype statement opens a phenotype statement summary page ( not shown ) . clicking
the icon at the end of the statement ( red arrow ) opens a pop - up window with additional ontology term information as shown .
click on a hyperlinked term name from the pop - up to redirect to the term detail page for additional information and the ability to navigate the ontology .
represented are examples of a normal or recovered phenotype statement , the use of a relational quality ( boxed phenotype statement ) and post - composition , which is displayed in the pop - up where the ao term retinal rod cell is post - composed with the go cellular component term photoreceptor outer segment .
in addition to those who access data at zfin through the zfin.org web site , a growing segment of the research community needs direct access to downloads of full data sets with which they can perform more comprehensive bioinformatic analyses .
the majority of data in the zfin database are freely available from the downloads page ( https://zfin.org/downloads ) that is accessed from a link on the zfin home page .
the downloads are grouped into a section of files available directly from zfin and a section of files provided by external sources .
files are listed in a table with a file description , including the file size and the number of records .
alternatively , a download can be started immediately by clicking a button with the file format indicated .
an additional link provides a header with details that describe each column in the file .
most files are tab - delimited with the exception of the gbrowse data files that use gff3 file format , a slightly extended tab - delimited standard format for exchanging genomic coordinate data . to support access to the growing number of mutants in our database , we added two new files to the downloads collection , files for all genomic features and genomic features and their affected genes. the all genomic features file provides details about every allele and transgenic insertion recorded in zfin .
the genomic features and their affected genes file lists all the gene alleles for each feature , as well as
the common use of downloaded data in large - scale bioinformatics analyses has made it increasingly important to support access to snapshots of data versioned through time in addition to providing downloads of the most up - to - date data .
we strongly encourage users of any downloaded data sets to record and report the version and/or date stamp for the data and software they use . without this information ,
reproducibility of results becomes virtually impossible due to changes in data and software over time .
the zebrafish has emerged in recent years as a pre - eminent vertebrate model organism for studies aimed at understanding gene function and human disease .
zfin is dedicated to supporting the research community in this ongoing effort . among the most rapidly growing data types are mutants and transgenic lines . recognizing this , zfin has begun collaborations with laboratories that produce large numbers of mutants and transgenics to ensure that core aspects of these important data are centrally located at zfin
. we will continue to seek and support such collaborations in the future . to help researchers find mutants and transgenics , the mutant / morphant / transgenic search interface was recently updated and backed with data mart infrastructure .
phenotype data associated with mutants and transgenics must be detailed and well structured to support mining human disease knowledge from the model organism annotation sets .
we have increased the detail of our phenotype annotation methods , providing more expressive phenotype statements that will play an integral role in our ability to integrate phenotype data with data at other resources . in the future
, we plan to expand our use of data marts to increase the speed and utility of all of our searches .
national human genome research institute ( nhgri ) [ hg002659 , hg004838 and hg004834 ] ; national institutes of health ( nih ) . funding for open access charge : nhgri
hg002659 ; nih ( to m.w . ) . | zfin , the zebrafish model organism database ( http://zfin.org ) , is the central resource for zebrafish genetic , genomic , phenotypic and developmental data .
zfin curators manually curate and integrate comprehensive data involving zebrafish genes , mutants , transgenics , phenotypes , genotypes , gene expressions , morpholinos , antibodies , anatomical structures and publications .
integrated views of these data , as well as data gathered through collaborations and data exchanges , are provided through a wide selection of web - based search forms . among the vertebrate model organisms , zebrafish are uniquely well suited for rapid and targeted generation of mutant lines .
the recent rapid production of mutants and transgenic zebrafish is making management of data associated with these resources particularly important to the research community . here
, we describe recent enhancements to zfin aimed at improving our support for mutant and transgenic lines , including ( i ) enhanced mutant / transgenic search functionality ; ( ii ) more expressive phenotype curation methods ; ( iii ) new downloads files and archival data access ; ( iv ) incorporation of new data loads from laboratories undertaking large - scale generation of mutant or transgenic lines and ( v ) new gbrowse tracks for transgenic insertions , genes with antibodies and morpholinos . |
the use of 18-fluorodeoxyglucose positron emission tomography - computed tomography ( 18-fdg pet / ct ) in the field of oncology is well - established ; however , 18f - fdg is not tumor specific . aside from physiological uptake fdg
knowledge of these fdg - avid non - malignant lesions is essential for accurate pet interpretation .
also this non - specificity of fdg uptake is being successfully used in evaluating infective , inflammatory diseases and pyrexia of unknown origin .
we describe use of fdg pet / ct for evaluation xanthogranulomatous pyelonephritis ( xgnp ) , a benign , chronic suppurative renal inflammation .
a 60-year - old indian man underwent 18-fdg pet / ct for evaluation of pyrexia and weight loss of 9 kg in 2 months . his blood examination revealed anemia , leukocytosis , and high erythrocyte sedimentation rate .
patient 's serum creatinine was found to be raised ( 1.9 mg% , normal up to 1.4 mg% ) .
he was found to have multiple calculi in left kidney on ultrasonography ( usg ) .
usg also demonstrated multiple hypo echoic masses ; thinned out parenchyma ; and a dilated collecting system suggesting a chronically obstructed kidney .
suspicion of pyelonephritis was raised in the usg report and rest of the abdominal organs were unremarkable .
antibiotic therapy was instituted for treatment of the urinary tract infection . even after extensive antibiotic therapy , the fever remained unresolved and weight loss continued . before invasive diagnosis
, patient was referred for a whole body 18-fdg pet / ct to confirm kidney as the sole site of active disease and rule out any extra - renal pathology as the cause of symptoms . for pet / ct
, 10 mci of fdg was injected intravenously to patient after 6 h of fasting .
whole body ct scan was obtained as part of pet / ct protocol on a multi - slice ct with 3.5 mm slice thickness without contrast injection .
standardized uptake value ( suv ) of fdg was normalized to body weight obtained over lesions .
the maximum intensity projection ( mip ) image [ figures 1a and b , arrows ] revealed intense fdg uptake in cortex of grossly enlarged hydronephrotic left kidney .
multiple calculi were seen in pelviureteric junction and in pelvi - calyceal system [ figure 1c red arrows ] .
extensive perinephric fat stranding and mild fdg uptake in perinephric , retroperitoneal lymph nodes was seen with suv max of 4.1 [ figure 1c and d white arrows ] .
in addition to these findings diffuse fdg uptake was seen in bone marrow [ black arrow in figure 1a ] .
post - nephrectomy , patient 's fever resolved and he reported gradual weight gain over last 4 months .
the maximum intensity projection image [ figure 1a and b , arrows ] revealed intense fluorodeoxyglucose ( fdg ) uptake in cortex of grossly enlarged , hydronephrotic left kidney . standardized uptake value ( suv ) max of uptake was 14.1 .
multiple calculi were seen in pelviureteric junction and in pelvi - calyceal system [ figure 1c red arrows ] .
extensive perinephric fat stranding and mild fdg uptake in perinephric , retroperitoneal lymph nodes was seen with suv max of 4.1 [ figure 1c and d white arrows ] .
the findings were reported as possible xanthogranulomatous pyelonephritis . this diagnosis was confirmed post - nephrectomy
xgnp is an uncommon condition characterized by chronic suppurative renal inflammation that leads to progressive parenchymal destruction .
the disease process is characterized by the destruction and replacement of renal parenchyma by lipid - laden macrophages ( xanthoma cells ) .
the patients present with recurrent urinary tract infections , flank pain , hematuria , and occasionally sepsis and weight loss .
the main predisposing factor appears to be obstruction , and an obstructing renal calculus is present in up to 75% of cases .
it is postulated that renal obstruction promotes recurrent renal tract infections that lead to an abnormal immune response causing parenchymal destruction . whereas the first - line treatment of choice for both , localized and diffuse xgnps , is conservative ( appropriate antibiotic treatment )
, the approach to surgical treatment is different : nephron - sparing surgery is warranted in focal xgnp , but diffuse xgnp will require nephrectomy with resection of all other involved tissue in most cases .
early diagnosis and prompt treatment play a crucial role in minimizing the morbidity and mortality rates of xgnp .
multiple areas of low attenuation are visualized within the kidney , representing dilated renal calyces and pus - filled cavities replacing destroyed renal parenchyma .
ct is also very useful in determining the extent of the inflammatory process in perirenal tissues including the iliopsoas muscle , abdominal wall , diaphragm , skin , and bowel .
though xgnp can be suspected on ct findings alone , with rising use of pet / ct in evaluation of pyrexic states , added knowledge of pet findings can be advantageous to add certainty to the diagnosis .
scarce data is available on fdg pet / ct findings in xgnp , in form of case reports .
ct findings characteristic of xgnp along with diffuse fdg uptake in kidney and mild fdg uptake in retroperitoneal lymph nodes is seen in the diffuse xgnp .
mild fdg uptake in retroperitoneal lymph nodes and extensive perinephric fat stranding are suggestive of benign inflammatory pathology in such cases .
however it should be kept in mind that focal xgnp can mimic pathologies such as pyelonephritis , tuberculosis , renal abscess , renal cell carcinoma , and renal metastasis on pet / ct .
thorough clinical history , and correlation with anatomical imaging are essential components to arrive at diagnosis of xgnp . to conclude , we present fdg pet / ct findings in xgnp . because , use of fdg pet / ct for evaluation of infective and inflammatory conditions is on the rise and such condition can co - exist in patients with known malignancy , this possible diagnosis should be kept in mind , when similar uptake pattern and ct findings are encountered in practice . | xanthogranulomatous pyelonephritis ( xgnp ) is an uncommon condition characterized by chronic suppurative renal inflammation that leads to progressive parenchymal destruction .
this condition can clinically present as recurrent urinary tract infections , flank pain , hematuria , and occasionally sepsis , and weight loss .
this condition is usually associated with obstructing renal calculus .
we present 18-fluorodeoxyglucose positron emission tomography - computed tomography ( 18-fdg pet / ct ) findings in an elderly male suffering from pyrexia and weight loss and suspected urinary tract infection .
pet / ct findings in this case lead to diagnosis of xgnp .
this diagnosis should be kept in mind while evaluating similar symptoms and pet / ct scan findings . |
the ciliate diploplastron affine is a common species of rumen fauna in the domesticated ruminants ( dogiel 1927 ) . to date , the fibrolytic properties of this protozoan were studied by coleman ( 1985 ) whereas its ability to digest and utilize starch is not well known .
the objectives of the reported studies were to examine the ability of d. affine to digest starch and to use this polysaccharide to cover the requirement for energy .
the ciliates were isolated from the rumen fluid of sheep . the cell extract for enzymatic studies
was obtained by homogenization of purified protozoa and removal of the particulate matter by centrifugation . to restrict the bacteria ,
the ciliates were incubated overnight with ampicillin , streptomycin and chloramphenicol prior to the homogenization .
the amylolytic activity of the ciliates was examined by quantification of products released during incubation of the cell extract with appropriate substrates .
fractionation of the crude enzyme preparation was performed by molecular filtration using a glass column packed with sephadex g-150 .
enzymes were identified by a zymography technique following separation of protein on polyacrylamide gel ( gabriel and wang 1969 ) .
volatile fatty acids ( vfa ) were measured chromatographically during the incubation of the protozoa with starch and antibiotics .
protozoal cell extract prepared from ciliates incubated with antibiotics released reducing sugars from starch , dextrin , maltose and isomaltose ( fig . 1 , table 1 ) .
on the other hand , pullulanase activity was not found ( table 1 ) .
similar results were obtained earlier when amylolytic activity of eudiplodinium maggii was studied ( beecki et al .
the ciliate d. affine ingested and fermented starch , releasing about 45 pmol vfa per protozoan per h. the control cultures produced only about 20 pmol vfa per protozoan per h ( table 2 ) .
this indicates that the products of starch degradation were utilized to cover the requirement of ciliates for energy . the determination of amylase activity after the separation of protozoal protein by molecular filtration revealed that this activity formed two distinct peaks ( fig . 2 ) .
( 2007 ) found only a single peak of amylolytic activity when the crude enzyme preparation of e. maggii was fractionated by ion exchange chromatography . on the other hand ,
three starch - degrading enzymes were identified by a zymographic technique following the separation of d. affine protein by native polyacrylamide gel electrophoresis ( fig .
, four such enzymes were found in e. maggii crude enzyme preparation ( beecki et al .
ciliate d. affine belongs to the rumen microorganisms which are able to digest starch and to utilize the obtained products as a carbon source in energy - yielding processes.fig .
1thin layer chromatography of the products of starch degradation by crude enzyme preparation and its two fractions .
lanes 14 standards of glucose , maltose , maltotriose and maltooligosaccharides , respectively ; lanes 57 products of starch degradation by ciliate cell extract and its fractions 21 and 30 ( see also fig . 2)table 1the digestion characteristics of starch , dextrin , maltose and isomaltose by cell extract of d. affine
degraded substrate
degradation rateoptimum phoptimum temperaturestarch2.42 0.475.550dextrin1.25
0.255.545maltose0.05 0.017.040isomaltose0.025 0.015.550digestion characteristics : rate ( in millimoles per litre of released glucose per milligram protein per minute ) , optimum ph and temperature ( in degrees celsius ) of hydrolysis of particular substrates ; means sd of triplicates
pullulan was not detectedtable 2the production rate of vfa ( in picomoles per protozoon per hour ) and proportion of particular acids in a total of vfa ( moles / mole)acidciliate
ciliate + starch
acetic70.5 0.3767.9 0.49propionic10.2 0.5910.3 0.34butyric19.2 0.8121.8 0.83total vfa19.9
3.2844.9 11.46
all values are means sd of triplicatesfig .
2distribution of amylase and maltase activity over the fractions of crude enzyme preparation separated by molecular filtration method on sephadex g-150fig .
3amylolytic enzymes ( 1 , 2 , 3 ) identified by zymogram technique in combination with non - denaturating polyacrylamide gel electrophoresis of cell extract protein of d. affine protein .
the activities were visualized by staining with 2,3,5-triphenyltetrazolium chloride thin layer chromatography of the products of starch degradation by crude enzyme preparation and its two fractions .
lanes 14 standards of glucose , maltose , maltotriose and maltooligosaccharides , respectively ; lanes 57 products of starch degradation by ciliate cell extract and its fractions 21 and 30 ( see also fig .
2 ) the digestion characteristics of starch , dextrin , maltose and isomaltose by cell extract of d. affine
digestion characteristics : rate ( in millimoles per litre of released glucose per milligram protein per minute ) , optimum ph and temperature ( in degrees celsius ) of hydrolysis of particular substrates ; means sd of triplicates
pullulan was not detected the production rate of vfa ( in picomoles per protozoon per hour ) and proportion of particular acids in a total of vfa ( moles / mole )
all values are means sd of triplicates distribution of amylase and maltase activity over the fractions of crude enzyme preparation separated by molecular filtration method on sephadex g-150 amylolytic enzymes ( 1 , 2 , 3 ) identified by zymogram technique in combination with non - denaturating polyacrylamide gel electrophoresis of cell extract protein of d. affine protein . | the ciliate diploplastron affine is known as a common species of the rumen fauna in cattle and sheep .
this protozoon is able to digest cellulose , whereas its amylolytic activity is not well known .
the objective of the reported studies was to examine the ability of d. affine to digest starch and to use this polysaccharide to cover the requirement for energy .
the enzymatic studies showed that the protozoal cell extract degraded starch to reducing products with the rate being equivalent to 2.4 0.47 mol
/ l glucose per mg protein per min .
maltose , maltotriose and a small quantity of glucose were the end products of starch degradation .
the degradation rate of maltose was only 0.05 mol
/ l glucose per mg protein per min .
two peaks in -amylase and a single peak in maltase activity were found following molecular filtration of ciliate cell extract , whereas three starch - degrading enzymes were identified by a zymographic technique .
incubation of the bacteria - free ciliates with starch in the presence of antibiotics resulted in a release of volatile fatty acids with the net rate of 25 pmol per protozoan per h. acetic acid followed by butyric acid was the main product of starch fermentation .
the results confirmed the ability of d. affine to utilize starch in energy - yielding processes . |
wild - type ( c57bl/6j ) and sod1 ( b6.cg-tg(sod1*g93a)1gur/j , stock # 004435 ) mice were obtained from jackson laboratories ( bar harbor , me , usa ) .
intraocular pressure elevation was induced by anterior chamber microbead injections as originally described by sappington et al .
however , we applied a recently described modification , in which microbead injections are followed by injection of a viscoelastic substance to thereby push the beads into the anterior chamber angle and prevent the bead reflux when the injection cannula is removed .
briefly , a 50-m glass cannula connected by tubing to a hamilton syringe ( hamilton company reno , nv , usa ) .
was first filled with a viscoelastic solution ( 10 mg / ml sodium hyaluronate ) , then 0.05 l air , and finally microbeads ( 3 10 beads per l ) .
we injected 4 l of the two - bead mixture ( equal volumes of 6 m and 1 m diameter beads ) , then 1 l of viscoelastic , as this protocol provides higher and more consistent iop elevation and greater axon loss .
intraocular pressure was measured immediately before and after injection , and twice weekly thereafter using a tonolab rebound tonometer ( tiolat , helsinki , finland ) .
the iop - time integral was used to determine the cumulative iop exposure for each mouse by calculating the area under the pressure - time curve in the ocular hypertensive eye , then subtracting this iop - time integral from that in the normotensive fellow eye ( expressed in units of mm hg - days ) . to minimize the influence of iop variability among animals , all data were analyzed in mouse eyes matched for the cumulative iop exposure between 200 and 400 mm hg - days ( corresponds to up to 50% neuron loss ) .
ocular hypertension was induced in c57bl/6j and sod1 mice after 5 months of age , and the animal age was less than 32 weeks at the end of the experimental period .
all animals were handled according to the regulations of the institutional animal care and use committee , and all procedures adhered to the tenets of the arvo statement for the use of animals in ophthalmic and vision research .
mice with unilaterally induced iop elevation received antioxidant treatment , or vehicle ( saline ) alone , over a period of 6 weeks .
tempol ( 4-hydroxytetramethylpiperidine-1-oxyl ; enzo life sciences , farmingdale , ny , usa ) , a superoxide dismutase mimetic and peroxynitrite - derived free radical scavenger that also reduces the formation of hydroxyl radicals was used for antioxidant treatment .
this multifunctional antioxidant is blood - brain barrier permeable and can readily access the intracellular compartment .
tempol ( 200 mg / kg / d ) was given by subcutaneously implanted osmotic mini - pumps ( model 2006 ; alzet , cupertino , ca , usa ) for drug delivery by constant infusion .
the mini - pumps that were used to deliver solution at a rate of 0.15 l / h and provide constant infusion for 6 weeks .
the treatment dose was chosen based on previously published studies of other disease models , our earlier in vitro study of rgcs , and in vivo dose / response experiments to provide optimum antioxidant capacity but avoid toxicity .
the selected dose is far lower than the toxic or lethal doses of tempol ( ld50 = 2 mmol / kg given by intravenous or intraperitoneal injection ) .
all animals well tolerated the antioxidant treatment with no noticeable adverse effects on systemic health status .
osmotic mini - pumps were implanted at the time of microbead injection . before implantation , pumps were primed in sterile saline at 37c .
we measured the residual volume in the pumps explanted at the end of the treatment period .
the protein lysates that were obtained from retina and optic nerve samples ( including the optic nerve head and a 2-mm segment of the optic nerve proximal to the globe ) were quantitatively analyzed for carbonyl and 4-hydroxynonenal ( hne ) levels using specific competitive elisa kits ( oxiselect protein carbonyl and hne - his adduct elisa kits ; cell biolabs , san diego , ca , usa ) , as we previously described . for the assay of protein carbonyls , protein samples adsorbed to wells of a 96-well plate react with 2,4-dinitrophenylhydrazine ( dnph ) in similar technical principal we previously used for analysis of retinal protein oxidation . for hne assay , hne - protein adducts present in the sample are probed with an anti - hne - his antibody , followed by an horseradish peroxidase conjugated secondary antibody .
a multiplexed assay kit similarly based on a standard elisa protocol ( qiagen , valencia , ca , usa ) was used to analyze retina cytokine profiles .
these multi - analyte elisarray kits allow simultaneous profiling of 12 proteins ( cytokines and chemokines ) .
a specific elisa kit was also used to analyze the dna binding activity of nf-b ( abcam , cambridge , ma , usa ) . within this assay kit
, a specific double - stranded dna sequence containing the nf-b response element is immobilized onto the wells of a 96-well plate , and binding of the nf-b in nuclear extracts can be detected by specific p65 antibody labeling .
nuclear proteins were extracted with a specific buffer containing protease and phosphatase inhibitors ( abcam ) .
detection sensitivity for the kits were low pg / ml to less than 10 g / ml . all analyses included triplicated wells and negative controls .
retina and proximal optic nerve protein samples were analyzed by quantitative western blotting that followed a methodology similar to previously described .
briefly , protein samples were separated on denaturing polyacrylamide gels ( bio - rad , hercules , ca , usa ) and transferred to pvdf membranes ( bio - rad ) . following a blocking step , membranes were probed with a phosphorylation site specific primary antibody to nf-b subunit , p65 ( phospho - ser536 ) ( 1:500 ; abcam ) .
after a second blocking step , membranes were incubated with a secondary antibody conjugated with horseradish peroxidase ( 1:2000 ; sigma - aldrich corp . , st .
immunoreactive bands were visualized by enhanced chemiluminescence using commercial reagents ( ge healthcare , pittsburgh , pa , usa ) . a beta - actin antibody ( 1:1000 ; sigma - aldrich corp . )
histological sections of the mouse retina were analyzed after specific immunofluorescence labeling with a monoclonal antibody to tnf- ( 1:500 ; abcam ) , as previously described .
in addition , specific antibodies against glial fibrillary acidic protein ( gfap ) or iba1 ( 1:500 ; santa cruz , ca , usa ) were used to identify astroglia and microglia , respectively .
a mixture of alexa fluor 488- or 568-conjugated iggs ( 1:500 ; thermo fisher scientific , waltham , ma , usa ) was used for the secondary antibody incubation .
the 4,6-diamidino-2-phenylindole , dihydrochloride ( dapi ; thermo fisher scientific ) was used for nuclear counterstaining .
slides were examined by fluorescence microscopy and images were recorded by digital photomicrography ( carl zeiss , thornwood , ny , usa ) .
negative controls were performed by replacing the primary antibody with serum or using an inappropriate secondary antibody to determine species specificity .
1 m - thick plastic cross - sections of the optic nerve ( more distal to the segment sampled for protein analysis ) were used for imaging - based axon quantification in a masked fashion as previously described .
briefly , the optic nerves excised from enucleated eye balls were fixed and then embedded in epoxy resin .
stained sections were imaged in their entirety as nonoverlapping tile images , and the captured images were analyzed for axon counts using the zeiss / zen imaging software ( carl zeiss ) .
this methodology allows axon counts representing the entire surface area of optic nerve cross - sections .
nerve outlines were manually traced on mosaics of images , and the size and shape parameters were determined to exclude intervening glia , myelin debris , and highly degenerated axons to ensure accurate counts . after image processing and axon counting , the axon loss was expressed as a ratio of axon counts in ocular hypertensive to fellow control eye .
retinal ganglion cell counting followed a similar imaging - based methodology representing the entire whole - mounted area .
whole - mounted retinas were immunolabeled for -iii - tubulin , a neuronal lineage marker that preferentially stains tubulin - rich rgcs ( 1:1000 ; abcam ) .
retinas were also double immunolabeled with an antibody to syntaxin , a marker for amacrine cells ( 1:1000 ; abcam ) . after secondary antibody incubation
, images were obtained at the focal plane of the rgc layer in whole - mounts , and these images were used to count -iii - tubulin+/syntaxin neurons in a masked fashion .
most of the syntaxin+ amacrine cells that exhibited only weak to moderate labeling for -iii - tubulin were lying the outside of the immediate focal plane and were not subject to the counting process .
an additional criterion for counting rgcs included a minimal somal size of 10 m to also eliminate dying or phagocytized rgcs .
retinal ganglion cell loss was expressed as a ratio of counts in ocular hypertensive to fellow control eye .
wild - type ( c57bl/6j ) and sod1 ( b6.cg-tg(sod1*g93a)1gur/j , stock # 004435 ) mice were obtained from jackson laboratories ( bar harbor , me , usa ) .
intraocular pressure elevation was induced by anterior chamber microbead injections as originally described by sappington et al .
however , we applied a recently described modification , in which microbead injections are followed by injection of a viscoelastic substance to thereby push the beads into the anterior chamber angle and prevent the bead reflux when the injection cannula is removed .
briefly , a 50-m glass cannula connected by tubing to a hamilton syringe ( hamilton company reno , nv , usa ) .
was first filled with a viscoelastic solution ( 10 mg / ml sodium hyaluronate ) , then 0.05 l air , and finally microbeads ( 3 10 beads per l ) .
we injected 4 l of the two - bead mixture ( equal volumes of 6 m and 1 m diameter beads ) , then 1 l of viscoelastic , as this protocol provides higher and more consistent iop elevation and greater axon loss .
intraocular pressure was measured immediately before and after injection , and twice weekly thereafter using a tonolab rebound tonometer ( tiolat , helsinki , finland ) .
the iop - time integral was used to determine the cumulative iop exposure for each mouse by calculating the area under the pressure - time curve in the ocular hypertensive eye , then subtracting this iop - time integral from that in the normotensive fellow eye ( expressed in units of mm hg - days ) . to minimize the influence of iop variability among animals , all data were analyzed in mouse eyes matched for the cumulative iop exposure between 200 and 400 mm hg - days ( corresponds to up to 50% neuron loss ) .
ocular hypertension was induced in c57bl/6j and sod1 mice after 5 months of age , and the animal age was less than 32 weeks at the end of the experimental period .
all animals were handled according to the regulations of the institutional animal care and use committee , and all procedures adhered to the tenets of the arvo statement for the use of animals in ophthalmic and vision research .
mice with unilaterally induced iop elevation received antioxidant treatment , or vehicle ( saline ) alone , over a period of 6 weeks .
tempol ( 4-hydroxytetramethylpiperidine-1-oxyl ; enzo life sciences , farmingdale , ny , usa ) , a superoxide dismutase mimetic and peroxynitrite - derived free radical scavenger that also reduces the formation of hydroxyl radicals was used for antioxidant treatment .
this multifunctional antioxidant is blood - brain barrier permeable and can readily access the intracellular compartment .
tempol ( 200 mg / kg / d ) was given by subcutaneously implanted osmotic mini - pumps ( model 2006 ; alzet , cupertino , ca , usa ) for drug delivery by constant infusion .
the mini - pumps that were used to deliver solution at a rate of 0.15 l / h and provide constant infusion for 6 weeks .
the treatment dose was chosen based on previously published studies of other disease models , our earlier in vitro study of rgcs , and in vivo dose / response experiments to provide optimum antioxidant capacity but avoid toxicity .
the selected dose is far lower than the toxic or lethal doses of tempol ( ld50 = 2 mmol / kg given by intravenous or intraperitoneal injection ) .
all animals well tolerated the antioxidant treatment with no noticeable adverse effects on systemic health status .
osmotic mini - pumps were implanted at the time of microbead injection . before implantation , pumps were primed in sterile saline at 37c .
we measured the residual volume in the pumps explanted at the end of the treatment period .
the protein lysates that were obtained from retina and optic nerve samples ( including the optic nerve head and a 2-mm segment of the optic nerve proximal to the globe ) were quantitatively analyzed for carbonyl and 4-hydroxynonenal ( hne ) levels using specific competitive elisa kits ( oxiselect protein carbonyl and hne - his adduct elisa kits ; cell biolabs , san diego , ca , usa ) , as we previously described . for the assay of protein carbonyls , protein samples adsorbed to wells of a 96-well plate react with 2,4-dinitrophenylhydrazine ( dnph ) in similar technical principal we previously used for analysis of retinal protein oxidation . for hne assay ,
hne - protein adducts present in the sample are probed with an anti - hne - his antibody , followed by an horseradish peroxidase conjugated secondary antibody . a multiplexed assay kit similarly based on a standard elisa protocol (
qiagen , valencia , ca , usa ) was used to analyze retina cytokine profiles .
these multi - analyte elisarray kits allow simultaneous profiling of 12 proteins ( cytokines and chemokines ) .
a specific elisa kit was also used to analyze the dna binding activity of nf-b ( abcam , cambridge , ma , usa ) . within this assay kit ,
a specific double - stranded dna sequence containing the nf-b response element is immobilized onto the wells of a 96-well plate , and binding of the nf-b in nuclear extracts can be detected by specific p65 antibody labeling .
nuclear proteins were extracted with a specific buffer containing protease and phosphatase inhibitors ( abcam ) .
detection sensitivity for the kits were low pg / ml to less than 10 g / ml . all analyses included triplicated wells and negative controls .
retina and proximal optic nerve protein samples were analyzed by quantitative western blotting that followed a methodology similar to previously described .
briefly , protein samples were separated on denaturing polyacrylamide gels ( bio - rad , hercules , ca , usa ) and transferred to pvdf membranes ( bio - rad ) . following a blocking step , membranes were probed with a phosphorylation site specific primary antibody to nf-b subunit , p65 ( phospho - ser536 ) ( 1:500 ; abcam ) .
after a second blocking step , membranes were incubated with a secondary antibody conjugated with horseradish peroxidase ( 1:2000 ; sigma - aldrich corp . , st .
immunoreactive bands were visualized by enhanced chemiluminescence using commercial reagents ( ge healthcare , pittsburgh , pa , usa ) . a beta - actin antibody ( 1:1000 ; sigma - aldrich corp . )
histological sections of the mouse retina were analyzed after specific immunofluorescence labeling with a monoclonal antibody to tnf- ( 1:500 ; abcam ) , as previously described .
in addition , specific antibodies against glial fibrillary acidic protein ( gfap ) or iba1 ( 1:500 ; santa cruz , ca , usa ) were used to identify astroglia and microglia , respectively .
a mixture of alexa fluor 488- or 568-conjugated iggs ( 1:500 ; thermo fisher scientific , waltham , ma , usa ) was used for the secondary antibody incubation .
the 4,6-diamidino-2-phenylindole , dihydrochloride ( dapi ; thermo fisher scientific ) was used for nuclear counterstaining .
slides were examined by fluorescence microscopy and images were recorded by digital photomicrography ( carl zeiss , thornwood , ny , usa ) .
negative controls were performed by replacing the primary antibody with serum or using an inappropriate secondary antibody to determine species specificity .
1 m - thick plastic cross - sections of the optic nerve ( more distal to the segment sampled for protein analysis ) were used for imaging - based axon quantification in a masked fashion as previously described .
briefly , the optic nerves excised from enucleated eye balls were fixed and then embedded in epoxy resin .
stained sections were imaged in their entirety as nonoverlapping tile images , and the captured images were analyzed for axon counts using the zeiss / zen imaging software ( carl zeiss ) .
this methodology allows axon counts representing the entire surface area of optic nerve cross - sections .
nerve outlines were manually traced on mosaics of images , and the size and shape parameters were determined to exclude intervening glia , myelin debris , and highly degenerated axons to ensure accurate counts . after image processing and axon counting , the axon loss was expressed as a ratio of axon counts in ocular hypertensive to fellow control eye .
retinal ganglion cell counting followed a similar imaging - based methodology representing the entire whole - mounted area .
whole - mounted retinas were immunolabeled for -iii - tubulin , a neuronal lineage marker that preferentially stains tubulin - rich rgcs ( 1:1000 ; abcam ) .
retinas were also double immunolabeled with an antibody to syntaxin , a marker for amacrine cells ( 1:1000 ; abcam ) . after secondary antibody incubation ,
images were obtained at the focal plane of the rgc layer in whole - mounts , and these images were used to count -iii - tubulin+/syntaxin neurons in a masked fashion .
most of the syntaxin+ amacrine cells that exhibited only weak to moderate labeling for -iii - tubulin were lying the outside of the immediate focal plane and were not subject to the counting process .
an additional criterion for counting rgcs included a minimal somal size of 10 m to also eliminate dying or phagocytized rgcs .
retinal ganglion cell loss was expressed as a ratio of counts in ocular hypertensive to fellow control eye .
antioxidant treatment with tempol was started at the time of anterior chamber microbead / viscoelastic injections to induce iop elevation in c57bl/6j mice .
another group of ocular hypertensive c57bl/6j mice received the equivalent volume of the vehicle ( saline ) alone .
additional groups included sod1 and wt ( c57bl/6j ) mice with similarly induced ocular hypertension .
as shown in figure 1 , tempol treatment , or sod1 , did not affect the level of iop increase or the duration of ocular hypertension over an experimental period of 6 weeks ( mann - whitney u test , p > 0.05 ) .
control groups of c57bl/6j wt or sod1 mice that received physiologic saline injection into the anterior chamber had a steady level of iop that was maintained at an average value of 10.8 1.2 mm hg through the experimental period
. however , the microbead / viscoelastic - injected mice , including both wt and sod1 animals , exhibited a transient course of ocular hypertension . also shown are the treatment groups including the wt ocular hypertensive mice that received either antioxidant tempol or the saline vehicle alone ( n = 12/group ) .
data are presented as mean sd . at the end of the 6-week treatment period , we measured the antioxidant capacity in retina and optic nerve samples by a specific assay and detected a significant increase in tempol - treated ocular hypertensive samples relative to ocular hypertensive controls that were given the vehicle alone ( p < 0.01 ) .
parallel to the increased antioxidant capacity , protein carbonyls and hne adducts exhibited a significant decrease in ocular hypertensive samples treated with tempol ( p < 0.01 ) .
figure 2 presents our data ( mean sd ) , expressed as fold - change with antioxidant treatment in ocular hypertensive mice relative to ocular hypertensive mice that received only the vehicle .
in contrast , ocular hypertensive retina and optic nerve exhibited decreased antioxidant capacity and increased protein oxidation in sod1 mice relative to wt ocular hypertensive controls ( also shown in fig .
the mouse retina ( a ) and optic nerve ( b ) protein samples were analyzed for antioxidant capacity , protein carbonyls , and hne adducts by specific assays . presented is the fold - change ( mean sd ) in tempol - treated versus vehicle - treated groups , or sod1 versus wt controls ( c57bl/6j ) .
the antioxidant capacity was increased and the oxidative stress end products were decreased after tempol treatment of ocular hypertensive mice relative to ocular hypertensive controls that received only the vehicle ( mann - whitney u test ; p < 0.01 ) . in contrast , ocular hypertensive sod1 mice exhibited decreased antioxidant capacity and increased protein oxidation compared with ocular hypertensive wt controls ( p < 0.01 ) .
we next tested the neuroinflammatory and neurodegenerative outcomes of mouse glaucoma in the study groups with decreased or increased oxidative stress .
as detailed below , tempol treatment limiting the oxidative stress resulted in a prominent decrease in neuroinflammation and neurodegeneration in ocular hypertensive mice ( relative to ocular hypertensive mice that received the saline vehicle alone ) .
however , ocular hypertension induced neuroinflammatory and neurodegenerative responses were increased in sod1 mice with defective antioxidant response ( relative to wt ocular hypertensive controls ) .
it should be clarified that although fold alterations are presented in the same graphs , tempol - treated or sod1 groups represent different experimental paradigms , having their specific controls ( vehicle - treated , or wt , ocular hypertensive groups , respectively ) .
comparison of the magnitude of effects between tempol treatment or sod1 groups would not be suitable , because tempol is a broad - spectrum antioxidant with dose - dependent outcomes , whereas the mice knockout for a specific antioxidant enzyme ( sod1 ) may potentially exhibit compensatory changes of other superoxide dismutases or other antioxidant enzymes . to determine the inflammatory status of the retina and optic nerve , we measured the cytokine / chemokine titers . among a range of cytokines measured in retina samples , proinflammatory cytokines , il-1b ( mann - whitney u test , p = 0.03 ) , il-2 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.006 ) , exhibited over 2-fold decreased titers in tempol - treated ocular hypertensive samples compared with the ocular hypertensive controls given the vehicle alone .
optic nerve samples from tempol - treated samples presented a similar decrease in proinflammatory cytokine production .
the optic nerve cytokines exhibiting over 2-fold decreased titers with tempol treatment , relative to the vehicle group , included il-1a ( p = 0.03 ) , il-2 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.005 ) .
in addition , some cytokines that may act as either proinflammatory or anti - inflammatory , including il-13 ( p = 0.006 ) in the retina , and il-4 ( p = 0.01 ) , il-6 ( p = 0.006 ) , and il-13 ( p = 0.03 ) in the optic nerve , exhibited decreased titers with tempol treatment .
in contrast to a prominent decrease in cytokine response to ocular hypertension with antioxidant treatment , the retina and optic nerve samples collected from ocular hypertensive sod1 mice exhibited a significant increase in cytokine production . compared with ocular hypertensive wt controls , ocular hypertensive sod1 retina exhibited an over 2-fold increase in il-6 ( p = 0.03 ) , il-12 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.009 ) .
the most significantly increased cytokines in the optic nerve samples from ocular hypertensive sod1 mice included il-1a ( p = 0.03 ) , il-2 ( p = 0.005 ) , il-6 ( p = 0.005 ) , il-12 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.006 ) .
bar graphs in figure 3 show the fold - change ( mean sd ) in ocular hypertension
induced cytokine production in the retina or optic nerve with antioxidant treatment ( relative to vehicle ) or sod1 ( relative to wt ) .
retina and optic nerve inflammation in ocular hypertensive mice . to determine the inflammatory status of the retina and optic nerve ,
the bar graphs show the fold - change ( mean sd ) in ocular hypertension
( a ) fold decrease in retina cytokine titers in tempol - treated ocular hypertensive mice compared with ocular hypertensive controls that received only the saline vehicle .
( b ) fold increase in retina cytokine titers in sod1 mice with ocular hypertension compared with wt ( c57bl/6j ) ocular hypertensive mice .
( c ) fold decrease in optic nerve cytokine titers in tempol - treated versus vehicle groups of ocular hypertensive mice .
( d ) fold increase in optic nerve cytokine titers in sod1 versus wt ocular hypertensive mice .
presented data represent at least six mice per group . * p < 0.05 ; * * p < 0.01 ( mann - whitney u test ) .
antioxidant treatment also resulted in a prominent decrease in ocular hypertension - induced activation of nf-b , a redox - sensitive master regulator of inflammatory mediators .
based on western blot analysis using a phosphorylation site - specific antibody to nf-b subunit ( p65 ) , and the nf-b dna binding activity assay , tempol - treated samples of the ocular hypertensive retina and optic nerve exhibited over 3-fold decreased activation of nf-b ( relative to ocular hypertensive controls that received the vehicle alone ) .
however , nf-b activation was increased 3-fold in ocular hypertensive sod1 mice relative to ocular hypertensive wt controls ( fig .
4 ) . presented data from protein analysis represent at least six mice per group .
activity of nf - kb , a transcriptional regulator of inflammation , in experimental mouse glaucoma .
( a ) for western blot analysis of protein expression , retina and optic nerve protein samples were probed with a phosphorylation site - specific antibody to nf-b subunit , p65 ( p - p65 ) .
this analysis indicated that tempol treatment of the ocular hypertensive mice ( relative to ocular hypertensive controls that received the saline vehicle alone ) resulted in a prominent decrease in p - p65 expression .
however , sod1 mice ( relative to c57bl/6j wt controls ) exhibited a prominent increase in ocular hypertension induced p - p65 expression .
( b ) nuclear factorb dna binding activity assay similarly indicated over 3-fold decreased activity of nf-b in tempol - treated ocular hypertensive samples relative to ocular hypertensive controls that received only the vehicle ( mean sd ) .
however , nf-b activity was significantly increased in ocular hypertensive sod1 mice relative to ocular hypertensive wt controls . presented
we also analyzed the extent and cellular localization of cytokine production by immunolabeling of the retina sections for an important proinflammatory cytokine , tnf-. we detected increased immunolabeling of the ocular hypertensive retina for tnf- that was localized to gfap+ astroglia and iba1 + microglia .
the ocular hypertension - induced increase in glial tnf- immunolabeling was prominently decreased after tempol treatment compared with ocular hypertensive controls that received only the vehicle .
in contrast , glial immunolabeling for tnf- was greater in the ocular hypertensive sod1 retina than wt ocular hypertensive control ( fig . 5 ) .
specific antibodies to astroglia ( gfap ) or microglia ( iba1 ) markers were used to determine the retinal localization of tnf- , an important proinflammatory cytokine .
presented include retina images from c57bl/6j wt mice with or without induced ocular hypertension , wt ocular hypertensive mice treated with tempol , and sod1 mice with induced ocular hypertension . compared with the normotensive retina ( thin arrows ) , hypertrophic astrocytes in the ocular hypertensive retina exhibited increased immunolabeling for gfap ( red ) . as seen in the image from sod1 mice , the ocular hypertension
induced glial response also included gfap immunolabeling of the mller glia located in the inner nuclear layer ( arrowheads ) . besides astroglia , the glial activation response to ocular hypertension included the microglia .
the weakly labeled microglia for iba1 in the normotensive control retina ( thin arrows ) were mainly localized around the blood vessels in the ganglion cell ( gcl ) or inner nuclear ( inl ) layers . however , ocular hypertensive retinas exhibited increased number and iba1 immunolabeling ( red ) of the microglia that were distributed throughout the inner retina .
tumor necrosis factor- immunolabeling was not detectable in the normotensive retina ; however , ocular hypertensive retinas were prominently immunolabeled for this proinflammatory cytokine ( green ) , which was remarkably decreased after tempol treatment .
the glia in the ocular hypertensive sod1 mice presented the most prominent immunolabeling for tnf- ( thick arrows ) .
the increased tnf- immunolabeling in the glaucomatous retina was localized to gfap+ astroglia and iba1 + microglia .
data represent three different samples for each group ( scale bar : 100 m ) .
we counted optic nerve axons and rgcs in tempol - treated versus vehicle - treated groups , and sod1 versus wt groups .
induced axon loss ( mann - whitney u test , p = 0.04 ) and 29% decrease in ocular hypertension induced rgc loss ( p = 0.01 ) in tempol - treated animals relative to ocular hypertensive controls that received the vehicle alone . however , in ocular hypertensive sod1 mice , axon loss increased by 34% ( p = 0.008 ) and rgc loss increased by 36% compared with ocular hypertensive wt controls ( p = 0.02 ) .
presented data ( mean sd ) represent 12 mice per group for axon counts and at least 3 mice per group for rgc counts .
( a ) analysis of optic nerve cross - sections and whole - mounted retinas indicated prominent injury to rgc somas and axons with experimentally induced glaucoma in mice .
compared with c57bl/6j wt mice , ocular hypertension induced greater injury to neurons in sod1 mice .
the red arrow indicates degenerating axons and myelin debris ; blue asterisk indicates the areas of prominent axon loss .
optic nerve axons were counted in cross - sections , and rgcs were counted in whole - mounted retinas after -iii - tubulin immunolabeling . to estimate the neuron loss in each mouse
, axon and rgc counts in the ocular hypertensive eye were adjusted to the normotensive fellow eye .
bar graphs in ( b ) and ( c ) indicate the percentage of axon or rgc loss in ( 1 ) wt ocular hypertensive mice ( relative to wt normotensive controls ) ; ( 2 ) tempol - treated wt ocular hypertensive mice ( relative to wt ocular hypertensive controls that received only the saline vehicle ) ; and ( 3 ) ocular hypertensive sod1 mice ( relative to ocular hypertensive wt controls ) .
presented data ( mean sd ) represent 12 mice per group for axon counts and at least 3 mice per group for rgc counts .
antioxidant treatment with tempol was started at the time of anterior chamber microbead / viscoelastic injections to induce iop elevation in c57bl/6j mice .
another group of ocular hypertensive c57bl/6j mice received the equivalent volume of the vehicle ( saline ) alone .
additional groups included sod1 and wt ( c57bl/6j ) mice with similarly induced ocular hypertension .
as shown in figure 1 , tempol treatment , or sod1 , did not affect the level of iop increase or the duration of ocular hypertension over an experimental period of 6 weeks ( mann - whitney u test , p > 0.05 ) .
control groups of c57bl/6j wt or sod1 mice that received physiologic saline injection into the anterior chamber had a steady level of iop that was maintained at an average value of 10.8 1.2 mm hg through the experimental period
. however , the microbead / viscoelastic - injected mice , including both wt and sod1 animals , exhibited a transient course of ocular hypertension . also shown are the treatment groups including the wt ocular hypertensive mice that received either antioxidant tempol or the saline vehicle alone ( n = 12/group ) .
data are presented as mean sd . at the end of the 6-week treatment period , we measured the antioxidant capacity in retina and optic nerve samples by a specific assay and detected a significant increase in tempol - treated ocular hypertensive samples relative to ocular hypertensive controls that were given the vehicle alone ( p < 0.01 ) .
parallel to the increased antioxidant capacity , protein carbonyls and hne adducts exhibited a significant decrease in ocular hypertensive samples treated with tempol ( p < 0.01 ) .
figure 2 presents our data ( mean sd ) , expressed as fold - change with antioxidant treatment in ocular hypertensive mice relative to ocular hypertensive mice that received only the vehicle .
in contrast , ocular hypertensive retina and optic nerve exhibited decreased antioxidant capacity and increased protein oxidation in sod1 mice relative to wt ocular hypertensive controls ( also shown in fig .
the mouse retina ( a ) and optic nerve ( b ) protein samples were analyzed for antioxidant capacity , protein carbonyls , and hne adducts by specific assays . presented is the fold - change ( mean sd ) in tempol - treated versus vehicle - treated groups , or sod1 versus wt controls ( c57bl/6j ) .
the antioxidant capacity was increased and the oxidative stress end products were decreased after tempol treatment of ocular hypertensive mice relative to ocular hypertensive controls that received only the vehicle ( mann - whitney u test ; p < 0.01 ) . in contrast , ocular hypertensive sod1 mice exhibited decreased antioxidant capacity and increased protein oxidation compared with ocular hypertensive wt controls ( p < 0.01 ) .
we next tested the neuroinflammatory and neurodegenerative outcomes of mouse glaucoma in the study groups with decreased or increased oxidative stress .
as detailed below , tempol treatment limiting the oxidative stress resulted in a prominent decrease in neuroinflammation and neurodegeneration in ocular hypertensive mice ( relative to ocular hypertensive mice that received the saline vehicle alone ) .
however , ocular hypertension induced neuroinflammatory and neurodegenerative responses were increased in sod1 mice with defective antioxidant response ( relative to wt ocular hypertensive controls ) .
it should be clarified that although fold alterations are presented in the same graphs , tempol - treated or sod1 groups represent different experimental paradigms , having their specific controls ( vehicle - treated , or wt , ocular hypertensive groups , respectively ) .
comparison of the magnitude of effects between tempol treatment or sod1 groups would not be suitable , because tempol is a broad - spectrum antioxidant with dose - dependent outcomes , whereas the mice knockout for a specific antioxidant enzyme ( sod1 ) may potentially exhibit compensatory changes of other superoxide dismutases or other antioxidant enzymes .
to determine the inflammatory status of the retina and optic nerve , we measured the cytokine / chemokine titers . among a range of cytokines measured in retina samples , proinflammatory cytokines , il-1b ( mann - whitney u test , p = 0.03 ) , il-2 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.006 ) , exhibited over 2-fold decreased titers in tempol - treated ocular hypertensive samples compared with the ocular hypertensive controls given the vehicle alone .
optic nerve samples from tempol - treated samples presented a similar decrease in proinflammatory cytokine production .
the optic nerve cytokines exhibiting over 2-fold decreased titers with tempol treatment , relative to the vehicle group , included il-1a ( p = 0.03 ) , il-2 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.005 ) .
in addition , some cytokines that may act as either proinflammatory or anti - inflammatory , including il-13 ( p = 0.006 ) in the retina , and il-4 ( p = 0.01 ) , il-6 ( p = 0.006 ) , and il-13 ( p = 0.03 ) in the optic nerve , exhibited decreased titers with tempol treatment .
in contrast to a prominent decrease in cytokine response to ocular hypertension with antioxidant treatment , the retina and optic nerve samples collected from ocular hypertensive sod1 mice exhibited a significant increase in cytokine production . compared with ocular hypertensive wt controls ,
ocular hypertensive sod1 retina exhibited an over 2-fold increase in il-6 ( p = 0.03 ) , il-12 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.009 ) .
the most significantly increased cytokines in the optic nerve samples from ocular hypertensive sod1 mice included il-1a ( p = 0.03 ) , il-2 ( p = 0.005 ) , il-6 ( p = 0.005 ) , il-12 ( p = 0.005 ) , ifn- ( p = 0.005 ) , and tnf- ( p = 0.006 ) .
bar graphs in figure 3 show the fold - change ( mean sd ) in ocular hypertension
induced cytokine production in the retina or optic nerve with antioxidant treatment ( relative to vehicle ) or sod1 ( relative to wt ) .
retina and optic nerve inflammation in ocular hypertensive mice . to determine the inflammatory status of the retina and optic nerve ,
the bar graphs show the fold - change ( mean sd ) in ocular hypertension
( a ) fold decrease in retina cytokine titers in tempol - treated ocular hypertensive mice compared with ocular hypertensive controls that received only the saline vehicle .
( b ) fold increase in retina cytokine titers in sod1 mice with ocular hypertension compared with wt ( c57bl/6j ) ocular hypertensive mice .
( c ) fold decrease in optic nerve cytokine titers in tempol - treated versus vehicle groups of ocular hypertensive mice .
( d ) fold increase in optic nerve cytokine titers in sod1 versus wt ocular hypertensive mice .
presented data represent at least six mice per group . * p < 0.05 ; * * p < 0.01 ( mann - whitney u test ) .
antioxidant treatment also resulted in a prominent decrease in ocular hypertension - induced activation of nf-b , a redox - sensitive master regulator of inflammatory mediators .
based on western blot analysis using a phosphorylation site - specific antibody to nf-b subunit ( p65 ) , and the nf-b dna binding activity assay , tempol - treated samples of the ocular hypertensive retina and optic nerve exhibited over 3-fold decreased activation of nf-b ( relative to ocular hypertensive controls that received the vehicle alone ) .
however , nf-b activation was increased 3-fold in ocular hypertensive sod1 mice relative to ocular hypertensive wt controls ( fig .
4 ) . presented data from protein analysis represent at least six mice per group .
activity of nf - kb , a transcriptional regulator of inflammation , in experimental mouse glaucoma .
( a ) for western blot analysis of protein expression , retina and optic nerve protein samples were probed with a phosphorylation site - specific antibody to nf-b subunit , p65 ( p - p65 ) .
this analysis indicated that tempol treatment of the ocular hypertensive mice ( relative to ocular hypertensive controls that received the saline vehicle alone ) resulted in a prominent decrease in p - p65 expression .
however , sod1 mice ( relative to c57bl/6j wt controls ) exhibited a prominent increase in ocular hypertension induced p - p65 expression .
( b ) nuclear factorb dna binding activity assay similarly indicated over 3-fold decreased activity of nf-b in tempol - treated ocular hypertensive samples relative to ocular hypertensive controls that received only the vehicle ( mean sd ) .
however , nf-b activity was significantly increased in ocular hypertensive sod1 mice relative to ocular hypertensive wt controls . presented
we also analyzed the extent and cellular localization of cytokine production by immunolabeling of the retina sections for an important proinflammatory cytokine , tnf-. we detected increased immunolabeling of the ocular hypertensive retina for tnf- that was localized to gfap+ astroglia and iba1 + microglia .
the ocular hypertension - induced increase in glial tnf- immunolabeling was prominently decreased after tempol treatment compared with ocular hypertensive controls that received only the vehicle .
in contrast , glial immunolabeling for tnf- was greater in the ocular hypertensive sod1 retina than wt ocular hypertensive control ( fig . 5 ) .
specific antibodies to astroglia ( gfap ) or microglia ( iba1 ) markers were used to determine the retinal localization of tnf- , an important proinflammatory cytokine . presented
include retina images from c57bl/6j wt mice with or without induced ocular hypertension , wt ocular hypertensive mice treated with tempol , and sod1 mice with induced ocular hypertension .
compared with the normotensive retina ( thin arrows ) , hypertrophic astrocytes in the ocular hypertensive retina exhibited increased immunolabeling for gfap ( red ) . as seen in the image from sod1 mice , the ocular hypertension
induced glial response also included gfap immunolabeling of the mller glia located in the inner nuclear layer ( arrowheads ) .
besides astroglia , the glial activation response to ocular hypertension included the microglia . the weakly labeled microglia for iba1 in the normotensive control retina ( thin arrows
) were mainly localized around the blood vessels in the ganglion cell ( gcl ) or inner nuclear ( inl ) layers . however , ocular hypertensive retinas exhibited increased number and iba1 immunolabeling ( red ) of the microglia that were distributed throughout the inner retina .
tumor necrosis factor- immunolabeling was not detectable in the normotensive retina ; however , ocular hypertensive retinas were prominently immunolabeled for this proinflammatory cytokine ( green ) , which was remarkably decreased after tempol treatment .
the glia in the ocular hypertensive sod1 mice presented the most prominent immunolabeling for tnf- ( thick arrows ) .
the increased tnf- immunolabeling in the glaucomatous retina was localized to gfap+ astroglia and iba1 + microglia .
data represent three different samples for each group ( scale bar : 100 m ) .
we counted optic nerve axons and rgcs in tempol - treated versus vehicle - treated groups , and sod1 versus wt groups .
induced axon loss ( mann - whitney u test , p = 0.04 ) and 29% decrease in ocular hypertension induced rgc loss ( p = 0.01 ) in tempol - treated animals relative to ocular hypertensive controls that received the vehicle alone . however , in ocular hypertensive sod1 mice , axon loss increased by 34% ( p = 0.008 ) and rgc loss increased by 36% compared with ocular hypertensive wt controls ( p = 0.02 ) .
presented data ( mean sd ) represent 12 mice per group for axon counts and at least 3 mice per group for rgc counts .
( a ) analysis of optic nerve cross - sections and whole - mounted retinas indicated prominent injury to rgc somas and axons with experimentally induced glaucoma in mice . compared with c57bl/6j wt mice ,
the red arrow indicates degenerating axons and myelin debris ; blue asterisk indicates the areas of prominent axon loss .
optic nerve axons were counted in cross - sections , and rgcs were counted in whole - mounted retinas after -iii - tubulin immunolabeling . to estimate the neuron loss in each mouse , axon and rgc counts in the ocular hypertensive eye
bar graphs in ( b ) and ( c ) indicate the percentage of axon or rgc loss in ( 1 ) wt ocular hypertensive mice ( relative to wt normotensive controls ) ; ( 2 ) tempol - treated wt ocular hypertensive mice ( relative to wt ocular hypertensive controls that received only the saline vehicle ) ; and ( 3 ) ocular hypertensive sod1 mice ( relative to ocular hypertensive wt controls ) .
presented data ( mean sd ) represent 12 mice per group for axon counts and at least 3 mice per group for rgc counts .
glaucomatous neurodegeneration has been recognized as having an inflammatory component , and resident astroglia and microglia in the retina and optic nerve play key roles in the phenotype that drives innate and adaptive immune responses with neurodestructive consequences . based on multiple evidence , oxidative stress may signal for neuroinflammation in human glaucoma and animal models .
findings of this study support the oxidative stress induced mechanisms that contribute to neuroinflammatory and neurodegenerative outcomes of glaucoma .
presented findings also point to the immunomodulatory potential of antioxidant treatment for protecting neurons from inflammatory injury during glaucomatous neurodegeneration . to determine the importance of oxidative stress for neurodegenerative inflammation in glaucoma
, this study analyzed the neuroinflammatory and neurodegenerative outcomes of mouse glaucoma using two experimental paradigms of decreased or increased oxidative stress ( by pharmacological antioxidant treatment , or sod1 , respectively ) . in the first paradigm ,
c57bl/6j mice with experimentally induced glaucoma received an antioxidant , tempol . by providing protection against multiple oxidants , including superoxide , peroxynitrite , and hydroxyl radicals , tempol treatment has the advantage of multitarget combination strategies .
our previous in vitro studies with primary cultures of isolated rgcs have also used tempol and detected its treatment effect on rgc protection against glaucoma - related stimuli .
this multifunctional antioxidant has been successfully used in various in vivo models of oxidative stress , prolonged the life span of normal mice , provided neuroprotection in brain injury models , and protected rgcs against optic nerve crush injury and light - induced retinal injury in rats .
evidently , one of the mechanisms by which oxidative stress stimulates neuroinflammation is the redox - sensitive transcriptional activation of inflammatory mediators by glial nf-b . opposing its critical roles in regulation of the neuronal survival programs , nf-b activation is known to trigger inflammation and secondary neurodegenerative processes through the transcriptional activation of pro - interleukins that are later processed into active cytokines by the inflammasome .
this redox - sensitive transcriptional program is a common regulator of the cytokine signaling , tlr signaling , and inflammasome that comediate the glia - driven proinflammatory processes during neurodegeneration in human glaucoma and experimental models . in the present study
, we detected that antioxidant treatment of ocular hypertensive mice with tempol , in comparison with the controls given the vehicle alone , resulted in decreased activation of nf-b and decreased production of cytokines in the retina and optic nerve .
the proinflammatory cytokines exhibiting a significant decrease in tempol - treated ocular hypertensive tissues included the transcriptional targets of nf-b , such as tnf- and ifn-. among the proinflammatory cytokines , tnf- has been the most studied in the field of glaucomatous neurodegeneration .
increased glial production of tnf- in the glaucomatous human retina and optic nerve has been shown to trigger pro - apoptotic caspase cascade in rgcs and induce neuroinflammatory responses during glaucomatous neurodegeneration . besides tnf- and ifn- , other proinflammatory cytokines also exhibited significant decrease after tempol treatment of ocular hypertensive mice , which included il-1b and il-2 in the retina , and il-1a and il-2 in the optic nerve .
in addition , tempol treatment affected some cytokines that may act either proinflammatory or anti - inflammatory , including il-13 in the retina , and il-4 , il-6 , and il-13 in the optic nerve .
it is important to note that cytokine / chemokine profiles ( and different sets of receptors ) determine the status of an inflammatory activation , in which dynamics of anti - inflammatory versus proinflammatory cytokines are critical for the outcome function that spans from tissue cleaning and repair to neurodegenerative inflammation .
our findings supporting the oxidative stress related proinflammatory activation in this study stimulate more focused studies to illuminate the individual contribution ( and interrelationship ) of different cytokines in inflammatory injury to glaucomatous retina and optic nerve . although the pharmacological antioxidant treatment was used to study the effects of decreased oxidative stress in mouse glaucoma , a complementary experimental strategy aimed to model increased oxidative stress .
therefore , we also studied sod1 mice to determine whether overloaded oxidative stress ( as evident by aging ) promotes neuroinflammation and neurodegeneration in experimental glaucoma .
the sod family is a major antioxidant system , and sod1 deficiency in mice results in a phenotype that resembles accelerated aging .
for example , sod1 mice , compared with wt mice , have showed a greater injury to neurons in oxidative stress
a progressive degeneration of retinal neurons in these animals has been documented by morphological and physiological criteria . despite normal iop
, sod1 deficiency has also resulted in decreased rgc counts and decreased perg amplitude along with the elevated superoxide anions in the rgc layer .
regarding glaucoma , this major antioxidant enzyme has been found to be upregulated in ocular hypertensive animal models . in the present study of sod1 mice
, we detected a stronger inflammatory response to ocular hypertension ( relative to wt ocular hypertensive controls ) that resulted in increased injury to rgcs and optic nerve axons .
compared with wt mice , neuron counts were lower in sod1 mice before iop elevation ; however , the neuron loss ratio that reflects the injury in the ocular hypertensive eye adjusted to the normotensive fellow eye supported the adverse effect of overloaded oxidative stress on ocular hypertension induced inflammatory and neurodegenerative outcomes in sod1 mice . thus ,
if there is a deficiency in the endogenous antioxidant response , as in sod1 ( or if the generated oxidative stress overwhelms the endogenous antioxidant response ) , proinflammatory activation can not be repressed and the stimulated inflammation may contribute to neurodegeneration .
the increased neuroinflammation and neurodegeneration in sod1 mice with experimental glaucoma support the involvement of sod1 in oxidative stress induced damaging outcomes .
these observations warrant additional studies to expand the information ; however , due to a wide spectrum of injuries detected in sod1 ( which may affect both neuronal and non - neuronal tissues ) , these mice do not present an informative model for further analysis . likewise ,
the sod1 group did not receive antioxidant treatment , because treatment of sod1 mice ( that may exhibit compensatory changes of other superoxide dismutases or other antioxidant enzymes ) with tempol ( that is a multifunctional antioxidant against different reactive oxygen species ) would not provide any specific information .
we hope that prospective studies using tissue / cell - targeted inducible transgenic lines or locally delivered treatments ( with rgc or glia - targeting vectors ) should help gain detailed information about the immunomodulatory potential of different antioxidants ( and the inflammatory role of different reactive oxygen species ) in glaucoma .
the accumulating evidence of oxidative stress in human glaucoma includes a decreased antioxidant potential in aqueous humor and blood samples of patients with glaucoma .
the blood samples collected from these patients also exhibit elevated levels of oxidative stress end products .
furthermore , recent proteome analysis in the glaucomatous human donor retina has indicated oxidative stress inducing cellular events and increased generation of oxidation - related end products .
more recent proteomics analysis of the ocular hypertensive human retina has also pointed to oxidative stress as a molecular risk factor distressing the physiological equilibrium toward glaucoma development .
similar to clinical or postmortem studies of human glaucoma , experimental glaucoma models exhibit a prominent oxidative stress in the retina and optic nerve , as evidenced by increased free radical production , decreased antioxidant levels , and accumulation of protein oxidation and lipid peroxidation end products .
given the neurodegenerative and neuroinflammatory consequences of oxidative stress in glaucoma , the oxidative stress
, a number of previous studies have indicated that antioxidant treatment can decrease oxidative stress and improve neuron survival in glaucoma .
for example , -luminol treatment has prevented the age - related decreases in glutamate , glutathione , and glutamine synthetase ; -lipoic acid treatment has limited the rgc death and dysfunction ; and coenzyme q10 treatment has inhibited the oxidative stress mediated mitochondrial alterations in dba/2j mice with hereditary glaucoma . in rat glaucoma , treatment with the ginkgo biloba extract ( a nitric oxide scavenger ) , or overexpression of thioredoxins , has protected rgcs , whereas the dietary deficiency of antioxidants predispose to increased rgc loss .
regarding human glaucoma , there are similar reports supporting the protective effects of ginkgo biloba extract in some patients with glaucoma .
a prospective population - based study has also revealed a protective effect of the dietary intake of antioxidant nutrients on human glaucoma . despite the studies focusing on antioxidant treatment effects on neuron survival , only one previous study of glaucoma
has examined the antioxidant treatment responses on inflammatory outcomes , which merely focused on the in vitro analysis of pig trabecular meshwork cells . in primary cultures of trabecular meshwork cells subjected to chronic oxidative stress , chronic administration of the dietary supplement of resveratrol
has prevented the increased production of reactive oxygen species and resulted in a decrease in inflammatory markers , including il-1a , il-6 , il-8 , and elam-1 . in addition , inhibition of oxidative stress by coenzyme q10 has improved the bioenergetic function of cultured optic nerve head astrocytes . as far as we are aware ,
the presented herein is the first study testing the antioxidant treatment effects on inflammatory outcomes of experimental glaucoma .
findings of this study encourage further research to value oxidative stress as an immunomodulatory treatment target to restrain neurodegenerative inflammation , as well as primarily improving the neuron survival .
respecting the widespread aspects of oxidative stress and inflammation through different neuronal compartments in glaucoma , antioxidants can provide a widely useful treatment strategy to protect rgcs and their axons , and also manipulate the inflammatory responses of neighboring glia . | purposebesides primary neurotoxicity , oxidative stress may compromise the glial immune regulation and shift the immune homeostasis toward neurodegenerative inflammation in glaucoma .
we tested this hypothesis through the analysis of neuroinflammatory and neurodegenerative outcomes in mouse glaucoma using two experimental paradigms of decreased or increased oxidative stress.methodsthe first experimental paradigm tested the effects of tempol , a multifunctional antioxidant , given through osmotic mini - pumps for drug delivery by constant infusion . following a 6-week treatment period after microbead / viscoelastic injection - induced ocular hypertension , retina and optic nerve samples were analyzed for markers of oxidative stress and cytokine profiles using specific bioassays .
we also analyzed a redox - sensitive transcriptional regulator of neuroinflammation , namely nf-b .
the second paradigm included a similar analysis of the effects of overloaded oxidative stress on retina and optic nerve inflammation in mice knockout for a major antioxidant enzyme ( sod1/).resultsincreased antioxidant capacity and decreased protein carbonyls and hne adducts with tempol treatment verified the drug delivery and biological function . among a range of cytokines measured , proinflammatory cytokines , including il-1 , il-2 , ifn- , and tnf- , exhibited
more than 2-fold decreased titers in tempol - treated ocular hypertensive eyes .
antioxidant treatment also resulted in a prominent decrease in nf-b activation in the ocular hypertensive retina and optic nerve .
although pharmacological treatment limiting the oxidative stress resulted in decreased neuroinflammation , ocular hypertension
induced neuroinflammatory responses were increased in sod1/ mice with defective antioxidant response.conclusionsthese findings support the oxidative stress related mechanisms of neuroinflammation and the potential of antioxidant treatment as an immunomodulation strategy for neuroprotection in glaucoma . |
anaphylaxis is a medical emergency that is manifested by a broad spectrum of signs and symptoms that can be similar to those of other diseases .
vascular collapse and bronchospasm are hallmarks of this condition , but neither is universally present .
other findings , such as flushing or urticaria , are easily overlooked in surgical patients .
numerous agents have been identified as triggers of intraoperative anaphylaxis , the most common being neuromuscular blocking drugs ( nmbds ) and latex .
this report describes an unusual case of intraoperative anaphylaxis during a routine gynecologic procedure that was ultimately ascribed to intravenous fentanyl citrate .
a 31-year - old , 50-kg , g2p1 apprehensive woman with a history of abdominal ache from appendicitis from the previous 4 days along with 101f off and on fever was admitted in the hospital .
past surgical and anesthetic history included diagnostic hysteroscopy under conscious or moderate sedation ( with propofol , midazolam , and fentanyl citrate ) , which was uneventful except the significant intraoperative nausea during diagnostic hysteroscopy which was treated with ondansetron and metoclopramide .
vital signs were bp = 104/60 mmhg , pr = 108/min , rr = 22/min , spo2= 94% on room air .
laboratory studies including a complete blood count , electrolytes , glucose , and serum creatinine were also all within normal limits except the raised white blood cell counts .
after preoxygenation by using a face mask , anesthesia was induced intravenously with propofol 80 mg , lidocaine ( preservative - free ) 40 mg , fentanyl citrate 100 g , and midazolam 0.5 mg .
after confirmation of the tube placement , the patient was maintained on isoflurane < 1.0% in 50% oxygen , 50% nitrogen .
a latex - containing foley catheter was then inserted into the bladder . due to her past medical history of nausea and vomiting , metoclopramide
she had one shot of antibiotics intravenously after skin sensitivity in the preoperative ward 30 min before coming to the operation theater ( ot ) room .
approximately 10 min after induction but before skin incision , the electrocardiogram ( ecg ) showed brief episodes of supraventricular tachycardia ( 510 beats per episode ) .
the anesthetic was deepened and a total of 20 mg of esmolol was given intravenously in incremental doses . over the next few minutes , the heart rhythm became sinus tachycardia at 140 beats / min .
the patient 's blood pressure decreased precipitously from a baseline of 104/60 to 60/30 mmhg .
intravenous fluids were opened to gravity and ephedrine 12 ( 6 + 6 ) mg was given intravenously without effect .
phenylephrine 200 g was then given intravenously , which increased blood pressure only slightly to 70/50 mmhg .
at this point , an ascending slope was noted on the capnogram , and the peak airway pressure was 30 cm h2o , up from a baseline of 20 cm h2o .
chest auscultation revealed bilateral wheezing , and the patient 's oxyhemoglobin saturation ( spo2 ) decreased from 100 to 90% .
an anaphylactic or anaphylactoid reaction was suspected , and epinephrine 20 g was given intravenously in intermittent incremental doses . the patient 's blood pressure improved with epinephrine ( 110/80 mmhg ) , although peak airway pressures remained near 35 cm h2o .
an examination of accessible skin revealed flushing of the neck and upper torso , but no other signs .
her blood pressure plummeted again , and copious frothy secretions were noted emerging from the endotracheal tube .
a positive end - expiratory pressure of 7.5 cm h2o was applied in an effort to maintain alveolar recruitment .
additional epinephrine was given , a radial arterial catheter was inserted , and arrangements were made to transfer the patient to our intensive care unit ( icu ) . the latex - containing foley catheter was replaced with a polyvinyl chloride substitute .
arterial blood gases on an fractional inspired oxygen concentration ( fio2 ) of 1.0 demonstrated metabolic acidosis and relative hypoxemia : ph 7.26 , pco2= 42 mmhg , po2= 83 mmhg , with bicarbonate of 18.2 meq / l ( normal 22 - 26
an epinephrine infusion was started and titrated to maintain systolic blood pressure greater than 90 mmhg .
hydrocortisone 200 mg , diphenhydramine 50 mg , and ranitidine 20 mg were given intravenously .
intravenous fluids given up to this point consisted of approximately 3 l of ringer 's lactate solution .
the patient continued to require epinephrine for blood pressure support . in light of the significant pulmonary edema ,
a central venous catheter was inserted to follow filling pressures as a guide for fluid management .
serial troponin i values were abnormal , with a peak value of 1.33 ng / ml at 8 h ( normal < 0.05 ng / ml ) .
an allergist was consulted , who concurred with the diagnosis of anaphylactic or anaphylactoid reaction .
a serum tryptase concentration was ordered but not obtained . over the next two days , the patient 's oxygenation improved and the fio2 was reduced .
the epinephrine infusion was tapered off after about 24 h. after 48 h of mechanical ventilation , the patient was conscious , hemodynamically stable , and well oxygenated .
her trachea was extubated , and the patient was continued on face - mask oxygen .
she remained in the hospital for another 24 h and was discharged home without apparent sequelae .
scratch and intradermal tests were negative for midazolam , propofol , rocuronium , and cisatracurium .
positive reactions ( wheal and flare ) were noted with both fentanyl citrate and succinylcholine .
the allergist advised the patient to avoid fentanyl citrate and all paralytic agents , if possible .
she was also seen by the consulting cardiologist and underwent an exercise stress echocardiogram , which was normal .
she returned 1 month after the initial event for her hysterectomy . with intravenous premedication with midazolam 1.0 mg , a spinal anesthetic containing 2 ml of 0.5% hyperbaric bupivacaine along with clonidine 15 g was given at the l2 - 3 level .
antiemetic prophylaxis was given intravenously , including dexamethasone 4 mg , metoclopramide 10 mg , and ondansetron 4 mg .
moderate sedation with dexmedetomidine ( 0.2 g / kg / h ) was continued throughout the case .
following surgery , the patient awakened readily and was transferred to the postanesthesia care unit without incident .
she had an uneventful hospital course and was discharged home on the second postoperative day . a 26-year - old male patient with intertrochanteric fracture of left leg with history of road traffic accident 1 day before planned for open reduction and internal fixation . on preanesthetic checkup ,
his past medical and surgical history was nonsignificant except for the incision and drainage done for right gluteal abscess under local anesthesia .
, he was found to have a small laceration wound on forehead for which suturing and aseptic dressing were applied without any history of nausea , vomiting , ear , nose , throat ( ent ) bleed , or loss of consciousness at the time of accident .
after taking the patient 's written informed consent and nil per orally ( npo ) history , his surgery was planned under a subarachnoid block .
after applying local anesthesia topically at the site of l3 - 4 vertebral bodies , spinal anesthesia was performed in the sitting position with the help of the 26-gauage quincke needle after confirming free cerebrospinal fluid outflow 3 ml of 0.5% hyperbaric bupivacaine with clonidine 15 g as adjuvant was introduced in the subarachnoid space .
the patient was sedated with the injection of midazolam 1 mg and fentanyl citrate 50 g intravenously after repositioning the patient according to surgeon 's perspective and demand in the left lateral position .
after 5 min of the administration of sedatives , the patient was found to have desaturated progressively with initial 98% spo2 to 70% along with the rise in his pulse rate and bp from the baseline 86 to 130 per min and from 126/86 to 150/100 mmhg , respectively .
he was found agitated , restless , and tachypnoic at 40 breaths / min , with cyanosed coloration of lips and face .
pruritic rashes were seen on his arms and face after 10 min of spinal anesthesia and 5 min after administering fentanyl citrate intravenously . the patient was not allowed to undergo surgery at that moment of time and managed conservatively with 100% o2 via a tight mask on intermittent positive pressure ventilation ( ippv ) manually in the 15 propped up position , injecting diphenhydramine 20 mg , dexamethasone 8 mg , hydrocortisone 100 mg , and betaprolol 5 mg intravenously every 10 min in incremental doses till vital parameters settled down to within normal limits . after 30 min of these conservative measures , he was found to be stable but still tachypnoic at 28 breaths / min .
his arterial blood gas analysis ( abg ) showed ph = 7.28 , pao2 = 56 mmhg , paco2 = 28 mmhg , hco3 = 30 mmhg .
surgery was postponed on the same day as the patient shifted to icu for further monitoring and close observation for motor and sensory blockade in lower limbs .
he was kept on bilevel positive airway pressure noninvasive ventilation via mask electively for 2 h. he was later found to be conscious , oriented , and comfortable having vital parameters ( pr , bp , spo2 , ecg , rr , and pattern ) and abg within normal limits ( ph = 7.38 , pao2 = 86 mmhg , paco2 = 32 mmhg , hco3 = 28 mmhg , and diminishing of rashes overnight when in icu ) . the same surgery was planned for the next day under general anesthesia , avoiding fentanyl citrate as analgesic .
the patient was premedicated with an intravenous injection of ranitidine 50 mg and glycopyrrolate 0.2 mg .
after preoxygenating for 5 min , he was induced intravenously with morphine 5 mg , propofol 100 mg , and vecuronium 6 mg .
anesthesia was maintained on 02:n20 ( 40:60 ) and isoflurane 1% and vecuronium 1 mg intermittently . on completion of surgery and
after adequate spontaneous respiration , he was reversed normally by injecting neostigmine 2.5 mg and glycopyrrolate 0.4 mg intravenously . at the end of anesthesia , he was fully conscious to obey the verbal commands .
a 31-year - old , 50-kg , g2p1 apprehensive woman with a history of abdominal ache from appendicitis from the previous 4 days along with 101f off and on fever was admitted in the hospital .
past surgical and anesthetic history included diagnostic hysteroscopy under conscious or moderate sedation ( with propofol , midazolam , and fentanyl citrate ) , which was uneventful except the significant intraoperative nausea during diagnostic hysteroscopy which was treated with ondansetron and metoclopramide .
vital signs were bp = 104/60 mmhg , pr = 108/min , rr = 22/min , spo2= 94% on room air .
laboratory studies including a complete blood count , electrolytes , glucose , and serum creatinine were also all within normal limits except the raised white blood cell counts .
after preoxygenation by using a face mask , anesthesia was induced intravenously with propofol 80 mg , lidocaine ( preservative - free ) 40 mg , fentanyl citrate 100 g , and midazolam 0.5 mg .
after confirmation of the tube placement , the patient was maintained on isoflurane < 1.0% in 50% oxygen , 50% nitrogen .
a latex - containing foley catheter was then inserted into the bladder . due to her past medical history of nausea and vomiting , metoclopramide
she had one shot of antibiotics intravenously after skin sensitivity in the preoperative ward 30 min before coming to the operation theater ( ot ) room .
approximately 10 min after induction but before skin incision , the electrocardiogram ( ecg ) showed brief episodes of supraventricular tachycardia ( 510 beats per episode ) .
the anesthetic was deepened and a total of 20 mg of esmolol was given intravenously in incremental doses . over the next few minutes , the heart rhythm became sinus tachycardia at 140 beats / min .
the patient 's blood pressure decreased precipitously from a baseline of 104/60 to 60/30 mmhg .
intravenous fluids were opened to gravity and ephedrine 12 ( 6 + 6 ) mg was given intravenously without effect .
phenylephrine 200 g was then given intravenously , which increased blood pressure only slightly to 70/50 mmhg .
at this point , an ascending slope was noted on the capnogram , and the peak airway pressure was 30 cm h2o , up from a baseline of 20 cm h2o .
chest auscultation revealed bilateral wheezing , and the patient 's oxyhemoglobin saturation ( spo2 ) decreased from 100 to 90% .
an anaphylactic or anaphylactoid reaction was suspected , and epinephrine 20 g was given intravenously in intermittent incremental doses . the patient 's blood pressure improved with epinephrine ( 110/80 mmhg ) , although peak airway pressures remained near 35 cm h2o .
an examination of accessible skin revealed flushing of the neck and upper torso , but no other signs .
her blood pressure plummeted again , and copious frothy secretions were noted emerging from the endotracheal tube .
a positive end - expiratory pressure of 7.5 cm h2o was applied in an effort to maintain alveolar recruitment .
additional epinephrine was given , a radial arterial catheter was inserted , and arrangements were made to transfer the patient to our intensive care unit ( icu ) . the latex - containing foley catheter was replaced with a polyvinyl chloride substitute .
arterial blood gases on an fractional inspired oxygen concentration ( fio2 ) of 1.0 demonstrated metabolic acidosis and relative hypoxemia : ph 7.26 , pco2= 42 mmhg , po2= 83 mmhg , with bicarbonate of 18.2 meq / l ( normal 22 - 26
an epinephrine infusion was started and titrated to maintain systolic blood pressure greater than 90 mmhg .
hydrocortisone 200 mg , diphenhydramine 50 mg , and ranitidine 20 mg were given intravenously .
intravenous fluids given up to this point consisted of approximately 3 l of ringer 's lactate solution .
the patient continued to require epinephrine for blood pressure support . in light of the significant pulmonary edema ,
a central venous catheter was inserted to follow filling pressures as a guide for fluid management .
serial troponin i values were abnormal , with a peak value of 1.33 ng / ml at 8 h ( normal < 0.05 ng / ml ) .
an allergist was consulted , who concurred with the diagnosis of anaphylactic or anaphylactoid reaction .
a serum tryptase concentration was ordered but not obtained . over the next two days , the patient 's oxygenation improved and the fio2 was reduced .
the epinephrine infusion was tapered off after about 24 h. after 48 h of mechanical ventilation , the patient was conscious , hemodynamically stable , and well oxygenated .
her trachea was extubated , and the patient was continued on face - mask oxygen .
she remained in the hospital for another 24 h and was discharged home without apparent sequelae .
scratch and intradermal tests were negative for midazolam , propofol , rocuronium , and cisatracurium .
positive reactions ( wheal and flare ) were noted with both fentanyl citrate and succinylcholine .
the allergist advised the patient to avoid fentanyl citrate and all paralytic agents , if possible .
she was also seen by the consulting cardiologist and underwent an exercise stress echocardiogram , which was normal .
she returned 1 month after the initial event for her hysterectomy . with intravenous premedication with midazolam 1.0 mg , a spinal anesthetic containing 2 ml of 0.5% hyperbaric bupivacaine along with clonidine 15 g was given at the l2 - 3 level .
antiemetic prophylaxis was given intravenously , including dexamethasone 4 mg , metoclopramide 10 mg , and ondansetron 4 mg .
moderate sedation with dexmedetomidine ( 0.2 g / kg / h ) was continued throughout the case .
following surgery , the patient awakened readily and was transferred to the postanesthesia care unit without incident .
she had an uneventful hospital course and was discharged home on the second postoperative day .
a 26-year - old male patient with intertrochanteric fracture of left leg with history of road traffic accident 1 day before planned for open reduction and internal fixation . on preanesthetic checkup ,
his past medical and surgical history was nonsignificant except for the incision and drainage done for right gluteal abscess under local anesthesia .
, he was found to have a small laceration wound on forehead for which suturing and aseptic dressing were applied without any history of nausea , vomiting , ear , nose , throat ( ent ) bleed , or loss of consciousness at the time of accident .
after taking the patient 's written informed consent and nil per orally ( npo ) history , his surgery was planned under a subarachnoid block .
he was found to be quite apprehensive on the day of surgery . after applying local anesthesia topically at the site of l3 - 4 vertebral bodies ,
spinal anesthesia was performed in the sitting position with the help of the 26-gauage quincke needle after confirming free cerebrospinal fluid outflow 3 ml of 0.5% hyperbaric bupivacaine with clonidine 15 g as adjuvant was introduced in the subarachnoid space .
the patient was sedated with the injection of midazolam 1 mg and fentanyl citrate 50 g intravenously after repositioning the patient according to surgeon 's perspective and demand in the left lateral position .
after 5 min of the administration of sedatives , the patient was found to have desaturated progressively with initial 98% spo2 to 70% along with the rise in his pulse rate and bp from the baseline 86 to 130 per min and from 126/86 to 150/100 mmhg , respectively .
he was found agitated , restless , and tachypnoic at 40 breaths / min , with cyanosed coloration of lips and face .
pruritic rashes were seen on his arms and face after 10 min of spinal anesthesia and 5 min after administering fentanyl citrate intravenously .
the patient was not allowed to undergo surgery at that moment of time and managed conservatively with 100% o2 via a tight mask on intermittent positive pressure ventilation ( ippv ) manually in the 15 propped up position , injecting diphenhydramine 20 mg , dexamethasone 8 mg , hydrocortisone 100 mg , and betaprolol 5 mg intravenously every 10 min in incremental doses till vital parameters settled down to within normal limits .
after 30 min of these conservative measures , he was found to be stable but still tachypnoic at 28 breaths / min .
his arterial blood gas analysis ( abg ) showed ph = 7.28 , pao2 = 56 mmhg , paco2 = 28 mmhg , hco3 = 30 mmhg .
surgery was postponed on the same day as the patient shifted to icu for further monitoring and close observation for motor and sensory blockade in lower limbs .
he was kept on bilevel positive airway pressure noninvasive ventilation via mask electively for 2 h. he was later found to be conscious , oriented , and comfortable having vital parameters ( pr , bp , spo2 , ecg , rr , and pattern ) and abg within normal limits ( ph = 7.38 , pao2 = 86 mmhg , paco2 = 32 mmhg , hco3 = 28 mmhg , and diminishing of rashes overnight when in icu ) .
the same surgery was planned for the next day under general anesthesia , avoiding fentanyl citrate as analgesic .
the patient was premedicated with an intravenous injection of ranitidine 50 mg and glycopyrrolate 0.2 mg .
after preoxygenating for 5 min , he was induced intravenously with morphine 5 mg , propofol 100 mg , and vecuronium 6 mg .
anesthesia was maintained on 02:n20 ( 40:60 ) and isoflurane 1% and vecuronium 1 mg intermittently . on completion of surgery and after adequate spontaneous respiration
, he was reversed normally by injecting neostigmine 2.5 mg and glycopyrrolate 0.4 mg intravenously . at the end of anesthesia , he was fully conscious to obey the verbal commands .
anaphylaxis is a fulminant , unexpected ige - mediated allergic reaction that can be triggered by multiple agents .
a clinically indistinguishable syndrome , anaphylactoid reaction , can only be differentiated with later testing and is treated identically .
the incidence of intraoperative anaphylaxis has ranged from 1 in 3500 to 1 in 20,000 anesthetics .
the most common system involved is cardiovascular ( hypotension , arrhythmia , myocardial depression , cardiovascular collapse ) , followed by cutaneous ( flushing , urticaria ) and respiratory ( bronchospasm , laryngeal edema ) manifestations . the intraoperative period , however , poses numerous challenges to diagnosing anaphylaxis .
patients receive multiple drugs in close succession , are often unconscious and unable to relate symptoms , and are usually surgically draped , delaying recognition of cutaneous signs .
the pathophysiology of anaphylaxis begins with the binding of an allergen to ige on the surface of mast cells and basophils with the cross - linking of receptors and subsequent cell activation leads to the resultant massive release of mediators such as histamine , leukotrienes , kinins , and eosinophil .
a recent survey found that nmbds , most commonly rocuronium and succinylcholine , accounted for 58.2% of perioperative events .
these were followed by latex ( 16.7% ) , antibiotics ( 15.1% ) , colloids ( 4.0% ) , hypnotics ( 3.4% ) , and opioids ( 1.3% ) . outside the perioperative period ,
insect stings and certain foods ( peanuts , shellfish , and tree nuts ) are also common triggers .
individuals may be sensitized without prior exposure to nmbds , because quaternary ammonium moieties are present in many products including over - the - counter drugs , food products , and cosmetics .
latex fluid contains several proteins that are believed to be the immunologic triggers of anaphylactic reactions .
increasing awareness of bloodborne pathogens and use of barrier precautions has exposed more individuals to this agent .
opioid - induced anaphylaxis , however , is rare . to date , there have been three reported cases of fentanyl citrate - induced anaphylaxis,[57 ] one of which was subsequently retracted due to an undiagnosed latex allergy . in each of these cases ,
the treatment of perioperative anaphylaxis begins with removing the likely trigger and aborting the procedure , if possible .
epinephrine should be administered intravenously , both for its 2 effects ( bronchodilation ) and for its 1 effects ( increased vascular resistance ) .
in addition , the -agonist effect of epinephrine can inhibit further mediator release from mast cells and basophils .
invasive monitoring such as arterial blood pressure and central venous pressure measurements can help with hemodynamic management
regardless of the monitors used , admission to an icu is warranted due to the possibility of airway edema or recurrent symptoms .
tryptase , a protease released from activated mast cells , can be used as a marker of immune activation . an elevated serum tryptase concentration in blood drawn within several hours after the event can be helpful , although it can not differentiate between anaphylaxis and an anaphylactoid reaction . a normal result
subsequent outpatient skin testing may also be useful but suffers from variations in methodology and both false - positive and false - negative results . if utilized , skin testing should include both prick and intradermal tests , as each has its weaknesses : prick tests suffer from concentration dependence of the antigen and a lack of standardization , while intradermal tests are more prone to false - positive results .
a positive skin test ( wheal and flare ) to a suspected agent suggests the presence of relevant ige antibodies . in the first case , pulmonary edema is rarely associated with anaphylaxis , but is not without precedent .
its rapid presentation in a relatively young woman with no cardiac disease , a normal echocardiogram , and normal central venous pressures suggests a noncardiac etiology .
since the patient was tracheally intubated and paralyzed , negative - pressure pulmonary edema from airway obstruction seems improbable . without any increased risk for aspiration or a witnessed event
it is thus reasonable to suspect that anaphylaxis itself was the cause of pulmonary edema , especially as increased capillary permeability is a hallmark of the disorder .
elevated lactic acid levels usually imply tissue ischemia . in the setting of profound vasodilation requiring epinephrine infusion ,
a lack of wall motion abnormalities on the postoperative echocardiogram and a subsequent negative stress test suggests that transient ischemia caused subendocardial myocardial injury .
severe vasodilation with insufficient coronary blood flow in the setting of aggressive epinephrine use may have created a significant energy supply demand imbalance in the myocardium .
subsequent skin testing ( performed according to the recommendations of mertes et al . ) revealed positive reactions to both fentanyl citrate and succinylcholine .
given that the patient did not receive succinylcholine , fentanyl citrate seems the likely cause .
if all skin test results were negative , the diagnosis of anaphylactoid reaction would be more appropriate .
the patient was not tested for the antiemetic drugs she received , but her uneventful reexposure to these same drugs argues against their triggering her anaphylaxis .
the reaction to succinylcholine may also have been spurious , as there is a 9.3% prevalence of positive skin test results to nmbds in the general population , without clinically apparent allergic reactions .
although the skin test results suggest she could safely receive rocuronium or cisatracurium , the allergist instructed the patient to avoid nmbds in the future , if possible . consequently , neuraxial anesthesia was chosen for appendicectomy in the first case . in the second case , the development of cyanosis with generalized pruritic rashes after intravenously administering fentanyl citrate warrants further investigation related to anaphylaxis . the initial rise in vitals parameters ( pr
, bp , rr ) might be suggestive of counter sympathetic stimulation of body immune defense system in response to progressively decreasing spo2 .
since the patient received fentanyl citrate as sedative analgesic during the subarachnoid block , it was better decided to have total amnesia intraoperatively so the need of general anesthesia ( ga ) in place of regional anesthesia ( ra ) was advisable next time inside ot , along with morphine as analgesic in place of fentanyl citrate .
in brief , these cases describe otherwise healthy patients who experienced intraoperative anaphylaxis most likely due to fentanyl citrate allergy .
anesthesiologists should remain vigilant of the risk of intraoperative anaphylaxis as well as its treatment .
we advocate the skin sensitivity test of the opioids ( fentanyl ) prior to their intravenous administration on routine basis for the patients posted for various surgeries . | anaphylaxis is a fulminant , unexpected , immunoglobulin e - mediated allergic reaction that can be triggered by multiple agents .
common causative agents include neuromuscular blocking drugs , latex , antibiotics , colloids , hypnotics , and opioids .
fentanyl citrate , however , is an extremely unusual cause of anaphylaxis .
pulmonary edema , although uncommon in anaphylaxis , can be a prominent feature , as was in one of the patient .
an adverse drug reaction is a noxious or unintended reaction to a drug that is administered in standard doses by the proper route for the purpose of prophylaxis , diagnosis , or treatment .
reactions are classified into two major subtypes : type a , which are dose dependent and predictable ; and type b , which are not dose dependent and unpredictable .
unpredictable reactions include immune ( allergic ) or no immune drug hypersensitivity reactions and are related to genetic susceptibilities or undefined mechanisms ( formally called idiosyncratic and intolerance reactions ) . a drug allergy is always associated with an immune mechanism for which evidence of drug - specific antibodies or activated t lymphocytes can be shown . in the last few years , many novel drugs have entered clinical practice ( i.e. , biologic agents ) generating novel patterns of drug hypersensitivity reactions . as old drugs continue to be used ,
new clinical and biologic techniques enable improvement in the diagnosis of these reactions . |
issues pertaining to biology and therapy of malignancies occurring amongst adolescent and young adults ( aya ) have largely remained neglected till last few years when data emerging from epidemiology and outcome registries suggested the need for active research in this field . over the years , improvements in the understanding of biology and survival rates in this age group have lagged behind than those in pediatric and adult malignancies .
the same story holds true for lymphomas which constitute 13% of all cancer diagnoses in aya .
aya non - hodgkin lymphomas ( nhl ) have become a reason of concern among oncologists due to their rising incidence without a commensurate improvements in survival .
the major reasons for the above observation are remarkable heterogeneity in the management of aya nhl and lack of prospective trial for this subset of patients .
diagnosis , staging , risk stratification and treatment protocols are largely dependent on whether the patient is referred to a pediatric or adult medical oncologist .
these diversities in management make it difficult to compare the results from different protocols and identify the optimal therapy for this subgroup .
several retrospective analyses have suggested that pediatric protocol based treatment improves the event free and overall survival of aya acute lymphoblastic leukemia .
considering aya patients as older children and treating them with pediatric protocols might not be helpful in improving outcomes due to differences in toxicity patterns , drug pharmacokinetics , and disease biology . to compound this further , aya nhls neither features prominently in the clinical trials done in pediatric or adult nhls nor any specific trials
these pertinent issues can only be resolved by the retrospective analysis of existing data from various centers and then designing appropriate prospective studies .
unfortunately , due to lack of data , most of the studies in oncology fail to incorporate the perspective of developing world in terms of disease nature and treatment outcomes .
the present retrospective analysis provides information on clinical presentation , histology patterns , and outcome results of aya nhl treated with both adult and pediatric protocols at a tertiary cancer in india .
records of all consecutive patients with confirmed diagnosis of de - novo non - hodgkin lymphoma ( nhl ) registered in lymphoma joint clinic at our hospital from january 2007 to july 2010 were reviewed in this audit .
for this audit , we considered any patient between 15 - 25 years of age as aya .
electronic medical records and hospital records were retrospectively reviewed and demographic details , duration of symptoms , presence or absence of b symptoms at diagnosis , clinical features , treatment regimen , and follow up information were collected .
evaluated parameters and initial staging procedures included physical examination , performance status as per eastern cooperative oncology group ( ecog ) scale , complete blood count with differential , serum chemistry panel , ldh levels , chest radiography , ct scan of the thorax , abdomen and pelvis or pet - ct and bone marrow biopsy .
patients were assigned to one of four prognostic scores according to the international prognostic index ( ipi ) that takes into account the presence or absence of prognostic factors ( serum ldh level , age , stage , performance status , and number of extranodal sites ) .
histopathological diagnosis in all cases was reviewed and reported by the expert hematopathologists as per who 2008 classification for hematolymphoid neoplasms .
only patients with aggressive nhl like burkitt 's lymphoma ( bl ) , lymphomas intermediated between burkitt 's and diffuse large b - cell ( burkitt's - like ) , diffuse large b - cell lymphoma ( dlbl ) , t - cell rich b - cell lymphoma , lymphoblastic lymphoma ( ll ) , anaplastic large - cell lymphoma ( alcl ) ( alk - positive and alk - negative ) and other aggressive t - cell lymphomas were included in the analysis .
treatment was done according to the lymphoma joint clinic decision . various chemotherapy protocol used were-
mcp-842 protocol is used at our centre for treatment of pediatric large - cell lymphomas and burkitt 's lymphomas .
it is a short course , intensive , alternating cycle multiagent chemotherapy regimen based on cyclophosphamide , cytarabine , adriamycin , vincristine , etoposide , ifosfamide , and methotrexate .
response assessment was done as per the standards at our centre and it included clinical and radiological evaluation .
bone marrow biopsies were done at the end of therapy if it was involved at the baseline .
incidence and severity of toxicities were recorded in form of number of episodes of febrile neutropenia , duration of hospitalization for management of febrile neutropenia , use of antifungals , use of inotropes , and intensive care support and organ toxicities .
follow - up was done with clinical evaluation every 3 months for first 2 years and then every 6 months for the following 2 years .
descriptive statistical analysis was done for demographic variables , clinical features , serum ldh levels , serum albumin , stage , ipi score , histopathologic subtype , type of chemotherapy received , response rates , relapse , progression , and toxicities .
overall survival was calculated from date of registration to the date of death due to disease or any other cause or last date of follow up .
progression - free survival was calculated from the date of registration to the time of relapse , disease progression , death due to disease or treatment related complications or last follow up .
records of all consecutive patients with confirmed diagnosis of de - novo non - hodgkin lymphoma ( nhl ) registered in lymphoma joint clinic at our hospital from january 2007 to july 2010 were reviewed in this audit .
for this audit , we considered any patient between 15 - 25 years of age as aya .
electronic medical records and hospital records were retrospectively reviewed and demographic details , duration of symptoms , presence or absence of b symptoms at diagnosis , clinical features , treatment regimen , and follow up information were collected .
evaluated parameters and initial staging procedures included physical examination , performance status as per eastern cooperative oncology group ( ecog ) scale , complete blood count with differential , serum chemistry panel , ldh levels , chest radiography , ct scan of the thorax , abdomen and pelvis or pet - ct and bone marrow biopsy .
patients were assigned to one of four prognostic scores according to the international prognostic index ( ipi ) that takes into account the presence or absence of prognostic factors ( serum ldh level , age , stage , performance status , and number of extranodal sites ) .
histopathological diagnosis in all cases was reviewed and reported by the expert hematopathologists as per who 2008 classification for hematolymphoid neoplasms .
only patients with aggressive nhl like burkitt 's lymphoma ( bl ) , lymphomas intermediated between burkitt 's and diffuse large b - cell ( burkitt's - like ) , diffuse large b - cell lymphoma ( dlbl ) , t - cell rich b - cell lymphoma , lymphoblastic lymphoma ( ll ) , anaplastic large - cell lymphoma ( alcl ) ( alk - positive and alk - negative ) and other aggressive t - cell lymphomas were included in the analysis .
treatment was done according to the lymphoma joint clinic decision . various chemotherapy protocol used were- chop with or without rituximab , bfm-90 , mcp-842 , and mcp-841 .
mcp-842 protocol is used at our centre for treatment of pediatric large - cell lymphomas and burkitt 's lymphomas .
it is a short course , intensive , alternating cycle multiagent chemotherapy regimen based on cyclophosphamide , cytarabine , adriamycin , vincristine , etoposide , ifosfamide , and methotrexate .
response assessment was done as per the standards at our centre and it included clinical and radiological evaluation .
bone marrow biopsies were done at the end of therapy if it was involved at the baseline .
incidence and severity of toxicities were recorded in form of number of episodes of febrile neutropenia , duration of hospitalization for management of febrile neutropenia , use of antifungals , use of inotropes , and intensive care support and organ toxicities .
follow - up was done with clinical evaluation every 3 months for first 2 years and then every 6 months for the following 2 years .
descriptive statistical analysis was done for demographic variables , clinical features , serum ldh levels , serum albumin , stage , ipi score , histopathologic subtype , type of chemotherapy received , response rates , relapse , progression , and toxicities .
overall survival was calculated from date of registration to the date of death due to disease or any other cause or last date of follow up .
progression - free survival was calculated from the date of registration to the time of relapse , disease progression , death due to disease or treatment related complications or last follow up .
a total of 2745 patients with confirmed diagnosis of nhl were registered in lymphoma joint clinic at our centre from january 2007 to july 2010 .
one hundred and fourteen patients were between 1525 years of age and had aggressive nhl .
the demography , clinical features , distribution of histopathologic subtypes , stage at diagnosis and ipi scores in the group with complete information were similar to the whole group of 114 patients .
the remaining patients did not complete staging work up ( ten patients ) or were not treated at our centre subsequently ( four patients ) .
a significant proportion of patients had b symptoms ( 53% ) and bulky disease ( 58% ) at presentation .
extranodal disease involving bones , gastrointestinal tract , paranasal sinuses and ovaries was seen in 43% of patients .
seventy - eight percent patients had raised serum ldh levels . low serum albumin ( < 3.5 g/ dl ) level was found in 32% patients [ table 1 ] .
baseline characteristics of aya nhl distribution of histopathologic subtypes in order of their frequency was as follows .
diffuse large b - cell : 42% , t - lymphoblastic lymphomas : 18% , burkitt 's lymphoma : 11% , anaplastic large - cell lymphomas - alk - positive : 9% , lymphomas intermediate between dlbl and burkitt 's : 8% , anaplastic large - cell lymphoma - alk- negative : 6% , others ( mantle cell lymphoma , peripheral t - cell lymphoma- nos , t / nk cell lymphoma , hepatosplenic gamma- delta t - cell lymphoma ) 6%
patients with dlbl ( 40 patients ) and lymphoma intermediate between dlbl and burkitt 's were treated with chop , r - chop or mcp-842 protocol as per the decision in lymphoma clinic .
two patients in dlbl category had primary cns lymphoma and received treatment as per de - angelis regimen .
chemotherapy regimens used for lymphoblastic lymphoma were very variable ( bfm-90 , mcp-841 , continuous chop , and lsa2l2 ) and were decided based on the socioeconomic status of the patients .
distribution of chemotherapy regimen among various histopathological subtypes complete response rates at the completion of treatment amongst different histological subtypes ( irrespective of the chemotherapy used ) were dlbl : 67.5% , bl : 63% , lymphoma intermediate between dlbl and burkitt 's : 100% , alcl - alk positive : 100% , alcl- alk negative : 100% , ll- 44% [ table 3 ] .
two patients with primary cns dlbl were in complete remission at the end of treatment .
responses to various chemotherapeutic regimens in individual histopathological subtype among patients with systemic dlbl complete remission was seen in 61.5% , 63% , and 87.5% patients treated with mcp-842 , chop , and r - chop regimen , respectively .
one patient each in mcp-842 regimen and chop was on therapy at the time of this analysis thus nonevaluable for the response .
median duration of hospitalization was 3 days ( range 0 - 52 days ) . among patients requiring hospitalization
requirement of inotropic support , care at intensive care unit , and antifungal therapy was seen in 2% , 4% , and 7% , respectively .
table 4 describes the details of toxicity differences among different chemotherapeutic regimen in dlbl patients .
there was one treatment related death in mcp-842 regimen due to bleeding secondary to grade-4 thrombocytopenia .
details of toxicities in patients with diffuse large b - cell lymphoma treated with different chemotherapy regimen the 2-year progression - free survival ( pfs ) for various histopathologic subtypes was as follows dlbl : 64% , bl : 56% , lymphoma intermediate between dlbl and burkitt 's : 70% , alcl - alk positive : 85.7% , alcl - alk negative : 66.7% , and ll : 33.2% [ figure 1 ] .
progression free survival for different subtypes of non - hodgkin lymphoma two - year overall survival ( os ) rates were dlbl : 76.9% , burkitt 's lymphoma : 56% , lymphoma intermediate between dlbl and burkitt 's : 80% , alcl- alk positive and alk - negative : 100% , and ll : 44% [ figure 2 ] .
overall survival for different subtypes of non - hodgkin lymphoma among 42 patients of dlbl subgroup the 2-year pfs and os according to different chemotherapy regimens were following .
mcp-842 51% and 69.2% , chop : 65% and 80% , r - chop : 83.3% , and 88.7% [ figures 3 and 4 ] .
progression free survival for diffuse large b - cell lymphoma according to type of chemotherapy overall survival for diffuse large b - cell lymphoma according to type of chemotherapy
this single centre retrospective analysis highlights few relevant features of aya nhls in our country . in this study ,
increased propensity of males to develop nhl as reported in seer data could not reasonably explain the striking disproportionate male to female ratio of 4.9:1 .
gender bias in seeking medical care is a more likely reason as seen for other diseases in our country .
clinical features associated with adverse outcomes like b symptoms , bulky disease , raised ldh , and advanced stage at presentation figured prominently in our patient population .
this observation differs from literature where in more than 50% of adult patients are reported to have stage i or ii disease at diagnosis .
delay in seeking medical care can not be the sole reason for the high frequency of poor prognostic clinical correlates as the median duration of symptoms were only 2 months
. it would be pertinent to study the underlying biology to answer these clinical differences .
the distribution of histological subtypes has few similarities and differences in comparison to the reported literature .
dlbl was the most frequent subtype in our study followed by lymphoblastic lymphomas - t cell .
there is a conspicuous lack of data on frequency distribution of lymphomas intermediate between burkitt 's and dlbl and alk - negative anaplastic large cell lymphomas in literature that constituted approximately 9% of aya nhl in our analysis .
based on the referral , these patients are treated with chemotherapy regimens used in either adults or pediatric patients .
treatment of adult patients with chop based regimen has resulted in 5-year os of only 30 - 40% .
subsequent studies demonstrated that addition of rituximab lead to significant improvement in 2-year event - free survival ( efs ) to 57% from 38% and 2 year os to 70% from 57% .
in contrast to adults , children with dlbl are treated with burkitt 's lymphoma like regimen with 5-year event - free survival of 8997% .
the impressive survival rates in pediatric dlbl population with burkitt 's lymphoma like regimen makes the oncologist feel that aya nhl should be treated with intensive regimens as they are older children .
however , due to lack of retrospective or prospective comparisons it remains unclear whether increase toxicities and toxic deaths on intensive regimens can offset the benefit .
our analysis failed to show any remarkable difference in outcomes with the use of burkitt 's lymphoma like regimen in patients dlbl .
potential explanations for this lack of benefit are smaller number of patients , inclination to use intensive regimens in patients with poor risk disease , higher toxicity leading to treatment delays . the best results in our patients were obtained with r - chop ( 2-year pfs : 83.3% , 2 year os : 85.7% ) ; however , the number of patients in this subgroup were few
. there has not been much literature on the incidence and optimal management of lymphomas intermediate between dlbl and burkitt 's as it has come in to existence after who 2008 classification .
the limited information available on its therapy suggests the use of burkitt 's lymphoma like regimens . at our centre
, we have treated these patients with both mcp-842 regimen and chop chemotherapy with 2-year pfs and os of 70% and 80% , respectively .
currently practiced regimen in pediatric population like lmb- 96 and bfm-90 protocols achieve 4-year efs of 92% .
two - year efs of 92% have been obtained in adult patients too with protocols like codox - m / ivac and hyper - cvad.[1012 ] in this analysis , patients with burkitt 's lymphoma have shown relatively inferior results ( complete response rate of 63% with 2-year pfs of 56% ) as compared to the results reported in the literature for pediatric and adult population ( complete remission rates of 97% and efs of 92% at 2 years ) .
this may be due to poor tolerance of therapy , poor risk features like advanced stage at presentation and delay in starting therapy due to financial constraints .
the outcome of lymphoblastic lymphoma is inferior in this analysis with 2-year pfs and os rates of 33.2% and 44% , respectively .
the treatment outcomes with various regimens have been in excess of 70% for patients in age group of 15 - 50 years .
use of multiple regimens , advanced stage of disease was the potential reasons for this inferior outcome .
alk - negative alcl is seen more frequently in older adults and alk - positive alcl is the predominantly the disease of children and young adults . in our study ,
the frequency of both subtypes of alcl was similar . in pediatric population strategy of intensive therapy
is efficacious and it results in overall survival of 65% at 5 years for patients with alk+ alcl.[1517 ] alk - negative alcl has relatively poor outcome with 5 year os of 49% .
, patients with both alk - negative and positive alcl received treatment with mcp-842 regimen predominantly .
the 2-year pfs rates in alk - negative and alk - positive groups were 66.7% and 85.7% , respectively .
this study is the only study reporting the disease patterns and treatment outcome results for aya nhl from the developing country . as for developed world ,
differences in biology and uniqueness of this disease will hold true in developing countries too .
however , there are several other important issues relevant to the developing world which needs to be addressed for improving the treatment results .
these include poor compliance , lack of financial help for treatment and higher toxicities due to poor nutritional status of the host .
this is a very small and retrospective study of aya nhl and thus it has several limitations in terms of applicability of the results .
however , it does give an insight on the various aspects of clinical presentation and treatment outcome in this subgroup . | background : the uniqueness of adolescent and young adult ( aya ) non - hodgkin lymphomas ( nhl ) with respect to biology and treatment have largely remained unanswered due to marked heterogeneity in treatment , paucity of prospective , or retrospective studies and poor representation of aya in clinical trials .
this audit attempts to put forward the clinicopathological attributes and treatment outcomes of aya nhl treated with both pediatric and adult protocols from a single centre in a developing country.patients and methods : hospital records of all consecutive nhl patients registered in lymphoma clinic from january 2007 to may 2010 were reviewed for information on demography , clinical features , histology subtype , staging , treatment regimen , response rates , toxicities , and follow up .
two - year progression - free ( pfs ) and overall survival ( os ) were calculated with kaplan - meier method.results:aya nhl constituted 4% of all lymphomas .
diffuse large b - cell ( dlbl ) was the most frequent subtype .
following were the 2-year pfs and os - dlbl 64% , 76.9% , burkitt 's lymphoma : 56% , 56% , lymphoblastic lymphoma : 33.2% , 44% .
our results did not show any improvement in outcome of dlbl with the use of burkitt 's lymphoma like regimen.conclusions:this study highlights some of the key features of aya nhl occurring in developing world . |
surfactant - like peptides
( slps ) have a remarkable ability to self - assemble
into different nanostructures , primarily due to their amphiphilic
nature .
for example , they can aggregate into high aspect ratio structures
while displaying bioactive peptides .
slps are a class of amphiphilic
peptide comprising a headgroup which is a short sequence of charged
residues attached to a tailgroup of neutral residues .
pioneering work on slps has been conducted by the zhang group including
a6d , v6d , v6d2 and l6d2 .
we have recently investigated
the self - assembly of a cationic peptide which consists of six consecutive
hydrophobic alanine residues as a tailgroup with a cationic arginine
headgroup .
we reported that this slp can
self - assemble into ultrathin sheets at low concentrations and at higher
concentrations the sheets wrap around to form nanotubes and helical
ribbons .
an example includes the transcription activating peptide , tat [ transactivator
of transcription ] from hiv-1 , which has been reported to have antimicrobial
properties .
the tat peptide is 11 amino acids
long , and it is highly basic as it contains six arginine and two lysine
residues .
it was found that substitution of any of the basic residues
with a neutral amino acid causes a reduction of antimicrobial activity ,
which arises from its ability to bind to cell membranes .
arginine contains a guanidinium group which adopts
a planar y - shape , which can delocalize the cationic charge . as a result
arginine can form bidentate hydrogen bonds with phosphates in lipid
headgroups as well as electrostatic interactions .
as arginine interacts
with cell membranes , this can lead to negative curvature and subsequently
to cell leakage giving rise to antimicrobial properties .
our group previously investigated
the self - assembly of a peptide
amphiphile ( pa ) hexadecyl--alanine - histidine ( c16-ah ) along with mixtures of multilamellar dppc vesicles .
we observed that the pa self - assembles into
nanotapes based on lamellae , that is , stacked bilayers .
mixing the
pa with dppc caused a transition from multilamellar to unilamellar
vesicles .
moshe et al . have studied the interactions of a designer
cell - penetrating peptide ( cpp ) with phospholipids including dopc and
dope .
the peptide consisted of an arginine
residue with two short hydrophobic moieties either side to create
hydrophobic and electrostatic interactions . at low concentrations ,
below the critical aggregation concentration
, the peptide was reported
to insert in the lipid bilayers and cause a reduction in the membrane
thickness .
the cpp was found to change the charge of the dopc membrane
and even cause a phase transition in dope from an inverted hexagonal
to a multilamellar phase .
these observations were ascribed to a change
in the delicate balance of the hydrophobic , electrostatic interactions
and steric effects .
examined the effect of both
anionic ( a6d ) and cationic ( a6k ) slp s
on the bicontinuous
cubic phase ( pn3m ) of mono - olein . at low concentrations of a6d
, a bicontinuous
cubic structure is retained , and only at high concentrations of the
peptide a phase transition to an inverted hexagonal phase occurs .
the addition of a6k to mono - olein had no effect on the
phase transition .
these observations were attributed to the ability
of a6d to fully penetrate the membrane interface in contrast
to a6k which essentially does not penetrate the membrane
due to electrostatic repulsion .
as a6d is inserted , destabilization
of the lipid bilayer occurs , leading to negative curvature in the
membrane interface .
previously , our group studied the influence of
anionic and nonionic surfactants ( sodium dodecyl sulfate and pluronic p123 , respectively ) on the self - assembly of a collagen stimulating pa ,
c16-kttks .
both surfactants
influenced the self - assembly of c16-kttks since morphological
transitions from nanotapes to fibrils were observed .
then we
attempt to understand by investigating the effect of the
cationic peptide a6r on the structure of model zwitterionic
lipid ( dppc ) vesicles using a combination of microscopic , spectroscopic ,
and scattering techniques .
dppc vesicles were selected as a model
system , building on previous work in our group on lipopeptide / vesicle
interactions . actually , dppc is a suitable
model for mammalian cell membranes , but not bacterial membranes .
bacterial membranes are typically rich in anionic lipids such as
popg ( oleoyl-1-palmitoyl - sn - glycero-3-phosphoglycerol )
or dppg ( 1,2-dipalmitoyl - sn - glycero-3-phosphoglycerol ) .
it is therefore of practical as well as fundamental interest
to characterize the peptide lipid interactions to further enhance
our understanding of the mechanism of binding and to improve the development
of antimicrobial applications for the future .
peptide nh2-aaaaaar - cooh , referred
to as a6r , was custom synthesized by cs bio company ( menlo
park , ca ) and was received as the tfa salt variant .
the purity was
97.01% by hplc in water / acetonitrile ( 0.1% tfa ) .
electrospray - ionization
mass spectroscopy ( esi - ms ) indicated a molar mass 600.87 g mol ( 600.69 g mol , expected ) .
esi - ms indicated
a molar mass 559.33 g mol ( 559.59 g mol , expected ) .
the phospholipid , 1,2-dipalmitoyl - sn - glycero-3-phosphocholine ,
dppc , was purchased from sigma aldrich , and has a molecular weight
of 734.05 g mol .
escherichia
coli o157 strain bw25113 , the parent strain of the
keio collection , was kindly provided by professor h. mori , keio university ,
japan .
staphylococcus aureus ncdo 949
was originally from the collection of the national institute for research
in dairying , now listed as ncimb 13062 .
strains were maintained as
frozen stocks at 70 c on cryobeads ( prolab diagnostics ,
neston , u.k . ) , which were plated onto nutrient agar ( na , oxoid ) and
incubated at 37 c overnight ( 1618 h ) to obtain single
colonies before storage at 4 c .
experimental cultures were prepared
by inoculating a single colony into 10 ml of tryptone soy broth ( tsb )
supplemented with 0.3% ( w / v ) yeast extract ( tsby ) , and incubating
statically for 6 h at 37 c .
this culture was then subcultured
into a fresh broth of tsb and incubated with shaking at 180 rev min overnight at 37 c before use .
viability was
assessed by diluting samples in maximum recovery diluent ( mrd , oxoid ) ,
and plating 0.02 ml volumes onto nutrient agar .
plates were incubated
at 37 c , and colonies were counted after 48 h. colony counts
were calculated by colony forming units ( cfu ) equal to number of colonies
times dilution factor times volume ( cfu = n
dilution factor v ) .
cells were harvested
by centrifugation at 1300 rpm , 5 c , for 5 min .
the pellet was
resuspended in 1.5 ml of ice - cold phosphate - buffered saline ( pbs ,
ph 7.0 , sigma - aldrich ) , and 20 l of this solution was diluted
into 200 l of peptide solution ( 5 , 2.5 , 1 , 0.5 mg / ml ) to give
approximately 10 cells ml .
these solutions were vortexed for 3 s and left for set time intervals
( 10 , 20 , 30 , 40 , 50 , 60 min ) before diluting with mrd and plating .
plates were then incubated at 37 c overnight for 1824
h , followed by a cell count ( cfu calculation ) .
dppc vesicles were prepared by
the thin layer hydration method to ensure the formation of multilayered
vesicles . a measured quantity of dppc
was dissolved in ethanol and placed into a 100 ml round - bottom flask .
the solvent was evaporated by using a rotary evaporator , which formed
a thin dppc film at the bottom of the flask .
a measured quantity of
water was added to the flask to make up the defined concentration .
the flask was returned to the rotary evaporator , which was rotated
while at 50 c by submerging it under a water bath .
solutions of 0.5 , 1 , and
2 wt % dppc vesicles were first prepared followed by the addition
of 1 wt % a6r .
a measured quantity of a6r powder
was added to a solution of dppc vesicles to make up the three different
solutions with different proportions of dppc .
the mixture was left
to sonicate for 30 min at 50 c to dissolve a6r .
then
the solution was left to equilibrate at room temperature for a few
days before any measurements .
imaging was carried out using
a field emission cryo - electron microscope
( jeol jem-3200fsc ) , operating at 200 kv .
images were taken in bright
field mode and using zero loss energy filtering ( omega type ) with
a slit width of 20 ev .
vitrified specimens were prepared using
an automated fei vitrobot device using quantifoil 3.5/1 holey carbon
copper grids with a hole size of 3.5 m . just prior to use ,
grids
were plasma cleaned using a gatan solarus 9500 plasma cleaner
and then transferred into an environmental chamber of a fei vitrobot
at room temperature and 100% humidity . thereafter , 3 ml of sample
solution was applied on the grid and it was blotted twice for 5 s
and then vitrified in a 1/1 mixture of liquid ethane and propane at
temperature of 180 c .
the grids with vitrified sample
solution were maintained at liquid nitrogen temperature and then cryo - transferred
to the microscope .
measurements
were performed
on stalks prepared by drying filaments of solutions containing 1 wt
% a6r mixed with 0.5 , 1 , and 2 wt % dppc .
solutions of
the mixtures were suspended between the ends of wax - coated capillaries
and dried .
the stalks were mounted ( vertically ) onto the four axis
goniometer of a raxis iv++ x - ray diffractometer ( rigaku ) equipped
with a rotating anode generator .
the wavenumber scale ( q = 4 sin / , where 2 is the scattering
angle ) was geometrically calculated using the size of each pixel in
the detector screen ( 0.0898 mm ) and the sample detector distance .
solution saxs
data was performed on the biosaxs beamline bm29 at the esrf , grenoble ,
france .
solutions containing 1 wt % a6r and 1 wt % a6r mixed with 0.5 , 1 , and 2 wt % dppc were loaded in pcr tubes
in an automated sample changer .
cd was
performed on solution mixtures containing dppc vesicles with a6r added later , with a 0.5 nm step , 1 nm bandwidth and 1 s
collection time per step at 20 c .
the working cell was filled with 200 l of 0.1
wt % dppc solution ( dissolved in water ) and the reference cell was
filled with deionized water .
the itc experiment was programmed
to run 20 injections of 2 l volume of the titrant solution
( 1 wt % a6r ) into the working cell ( 0.1 wt % dppc ) with
300 s lag between each injection to ensure return to the baseline .
the syringe was stirred throughout the experiment at 500 rpm and the
working cell was set at 25 c .
the data was analyzed using origin
7 ( microcal ) by fitting the curve using the one set of sites model .
since many antimicrobial peptides contain arginine
residues , it is of interest to investigate the antimicrobial
activity of model
arginine - containing peptides such as a6r .
the antibacterial
activity of this peptide was assayed against gram positive s. aureus and gram negative e. coli . against s. aureus in particular
,
peptide a6r shows a significant time - dependent reduction
in the number of colony - forming units as shown in figure 1 , in contrast to the control ( culture medium only ) .
at the highest peptide concentration used (
5 mg / ml ) , a reduction in
the number of colony - forming bacteria to approximately 1525%
of their initial number was observed after 1 h , with the reduction
being larger the higher the peptide concentration . at the higher peptide
concentration ,
the reduction is also greater for s.
aureus than for e. coli ( data shown in supporting information ( si ) figure 1a ) . as an additional control ,
the same protocol was
followed but using peptide a6d . despite having an anionic
( aspartic acid ) headgroup rather than a cationic one ,
this peptide
does exhibit some antibacterial activity ( si figure 1b , c ) , although greatly reduced compared to a6r .
the antibacterial activity of a6r is larger than the
reported 35- 45% reduction in number of bacteria ( e.
coli or s. aureus )
for a6k to 5565% surviving bacteria , although this
peptide was studied only at lower concentration ( up to 0.2 mg / ml ) .
peptide a9k showed better activity ,
in particular a reduction by 80% in numbers of e. coli and 70% of s. aureus after 1 h for
an 0.1 mg / ml sample .
antimicrobial testing
results for a6r with s. aureus . dose and time dependence of colony
having established the antimicrobial
properties of a6r , we set out to examine the origin of
this effect in terms of interactions
between the peptide and model lipid membranes , using dppc vesicles .
to investigate the binding interactions of a6r with dppc ,
figure 2 presents cd spectra for 1
wt % a6r on its own and with mixtures of 0.5 , 1 , and 2
wt % dppc .
the spectra show that a6r adopts a -sheet
structure as a minimum at approximately 220 nm is observed .
this is consistent with our previous fiber xrd
data , which revealed a -sheet spacing .
mixing of dppc vesicles with a6r leads to a spectrum
indicative of a polyproline ii ( ppii ) helix .
the presence of a broad
maximum band at 220 nm due to 0
* ( parallel electronic transition ) and a minimum between 190
and 200 nm arising from the 0 *
( perpendicular electronic transition ) is characteristic of a ppii
helix .
detailed modeling of the change
in peptide conformation on binding to the dppc bilayer is beyond the
scope of the present article ; however , it may be mentioned that many
surface - active peptides undergo conformational changes upon binding
to lipid membranes , for example , as well as antimicrobial peptides , this has been very well studied for the amyloid
peptide .
it is clear that the
cd spectrum from the mixture is completely different from that of
a6r on its own and can not be expressed as a superposition
of the spectra from the species in the mixture , which indicates interactions
between the peptide and lipid vesicles .
cd spectra of solutions
of 1 wt % a6r mixed with varying
concentrations of dppc compared with 1 wt % a6r on its
own .
cryo - tem images from solutions
of 0.5 , 1 , and 2 wt % dppc vesicles
are shown in figure 3a c , respectively .
the size
of the vesicles varies greatly from approximately 150 nm to 2 m
or more .
sheets of dppc not forming vesicles were also observed
in the 0.5 wt % dppc sample .
as the concentration of dppc increases
from 0.5 to 1 wt % , a reduction in the number of sheets not forming
vesicles was noted as well as a decrease in the fraction of larger
vesicles .
upon addition of a6r to a solution of dppc , the
multiwall vesicle structure is retained as shown in figure 3d f . for low dppc concentration , the overall
size of the vesicles largely remains the same as those of dppc vesicles
in the absence of a6r ; however , the size distribution of
vesicles shifted toward smaller particles for 1 wt % a6r + 2 wt % dppc .
notably , the addition of a6r does not
cause membrane disruption and break up of vesicles .
cryo - tem images of dppc
vesicles of varying concentrations containing
( a ) 0.5 wt % , ( b ) 1 wt % , and ( c ) 2 wt % .
images of 1 wt % a6r solution mixed with ( d ) 0.5 wt % dppc , ( e ) 1 wt % dppc , and ( f )
2 wt % dppc .
microscopy can provide
valuable information ; however , to provide
nonlocal information on the average nanostructure , saxs was employed
to compliment the cryo - tem images and to further elucidate the influence
of a6r on the structure of the dppc walls .
saxs intensity
profiles for a6r / dppc mixtures are plotted along with their
individual components for comparison as shown in figure 4 . the data for 1 wt% a6r has been presented before
and reveals the self - assembly of the peptide into flat sheet - like
nanostructures .
the dppc phospholipid
vesicles were prepared by using the rehydration method to ensure the
development of multilamellar vesicles .
saxs
one - dimensional profiles comparing the different ratio mixtures
of 1 wt % a6r with dppc vesicles and its individual components .
the saxs curves for 0.5 wt % ,
1 wt % and 2 wt % dppc contain of
structure factor peaks , which are due to a stacking arrangement within
the multilamellar walls .
a periodicity of 64.8 was obtained
from the highest order of diffraction for both 0.5 wt % and 1 wt %
dppc , which is in good agreement with previous literature .
a contribution of a bilayer form factor as well as structure factor
due to the stacking arrangement of the dppc walls is present and therefore
was taken into consideration when fitting the saxs intensity profile
for dppc using the modeling software , sasfit .
a fit to a model comprising a gaussian bilayer form factor along
with a modified caill structure factor ( described in our previous
work ) for 1 wt % dppc is presented in
figure 5a , and the fitting parameters are listed
in table 1 .
a fit to the saxs profile for 0.5
wt % dppc is shown in si figure 2 .
the
saxs curves for the mixtures are well fitted to a gaussian bilayer
form factor excluding the modified caill structure factor
since the structure factor peaks are no longer present .
saxs profiles
for ( a ) 1 wt % dppc fitted to a gaussian bilayer
form factor along with a modified caill structure factor and
( b ) 1 wt % a6r + 1 wt % dppc fitted to a gaussian bilayer
form factor .
saxs confirms a multilamellar
architecture for dppc in the vesicle
walls with a period of 64.8 .
this value is too small to observe
the stacking arrangement within the vesicle walls using cryo - tem .
as a6r is inserted in the bilayers , cryo - tem suggests the
retention of multilamellar vesicles , which are noticeable in figure 3 .
however , the saxs structure factor peaks are lost
( figure 5b and si figure 2b ) .
this indicates that the local multilamellar order is
disrupted , possibly due to swelling effects ( cryo - tem shows multilayer
vesicles with a vesicle wall spacing much larger than 6.5 nm ) .
the
profound change in saxs intensity profiles , suggests that a6r has inserted in the lipid bilayers .
since dppc is zwitterionic
it is likely that a6r interacts with the negative charge
on the phosphate group favoring insertion into the bilayer .
fiber xrd stalks dried from solution were employed to obtain further
structural detail in the wider angle regions .
equatorial and
meridional xrd intensity profiles for 1 wt % dppc and 1 wt % a6r mixed with 1 wt % dppc are shown in figure 6 . the one - dimensional intensity profile for 1 wt % dppc exhibits
several peaks corresponding to second , third and fourth order reflections
associated with the multilayer structure of dppc , which can be observed
especially for a 2 wt % sample as shown in si figure 4c . in addition , a peak with a d - spacing
of 4.2 can also be observed .
this peak has been previously
reported for dppc , and was ascribed to the hexagonal packing of the
fatty acid side chains of phospholipid .
the 4.2
lipid chain spacing is still present upon the addition of a6r to dppc in 1:1 ( figure 6 ) , 1:0.5 and 1:2
( si figure 4 ) mixtures . an additional 5.42
reflection
recently we
reported a 5.5 spacing for dilute concentrations ( 0.5% - 4% )
of a6r , which was assigned to the polyalanine -sheet
spacing .
this suggests that some -sheet
like ordering is retained , possibly due to the presence of a population
of dppc - free a6r sheets or due to the presence of rafts
of ordered a6r within the dppc vesicle walls .
however ,
circular dichroism spectroscopy ( figure 1 )
indicates the absence of a significant -sheet content globally
in the system under the same conditions .
xrd one - dimensional radial
profiles ( equatorial and meridional
radial averages ) for 1 wt % dppc and 1 wt % a6r + 1 wt
% dppc with indicated d - spacings .
line colors :
1% dppc , black = equatorial and red = meridional ; 1% a6r + 1% dppc , green = equatorial and blue = meridional . to further probe the possible interactions between
a6r and dppc we employed isothermal titration calorimetry .
itc is a
well - known technique to enable investigation of the molecular interactions
of biological samples , in this case a peptide - lipid interaction .
a
solution of 1 wt % a6r was injected into 0.1 wt % dppc
since a6r is the ligand and dppc acts as the receptor .
a low concentration of dppc was selected for itc to reduce the total
number of binding sites to ensure saturation of a6r binding
to dppc was reached . the itc profile for the titration of a6r into dppc
is presented in figure 7 , which
exhibits a series of negative peaks , indicating an exothermic reaction .
the integration and normalization of the exothermic peaks produced
a sigmoidal curve relative to the moles of ligand added , which was
then appropriately fitted to a one set of sites model .
the one set
of sites model was used for the peptide / lipid system as it is assumed
that each binding site has the same binding affinity .
a binding constant k = 1.25 10 m was
determined from the fitting parameters .
other parameters including
the number of binding sites n = 0.3 , enthalpy h = 3817 j mol and entropy s = 4.84 j mol k were also obtained from the fit .
itc profile for 1 wt % a6r
solution injected into a
solution of 0.1 wt % dppc .
investigated the binding of an 18 amino acid long
antimicrobial peptide interacting with charged large unilamellar vesicles
( luvs ) .
they reported that the binding
of the peptide to luvs is mainly an exothermic process .
the binding
of a cationic pentapeptide composed of analogs of lysine resides to
negatively charged phospholipid , dppg was investigated .
a binding constant , k = 5.4
10 m , was determined , which
is a similar value to the one we obtained .
the vogel group also investigated
the binding of an antimicrobial peptide , ac - frwwhr - nh2 to
popg vesicles , which reveal an exothermic reaction and a binding constant , k = 3.13 10 m. the mentioned examples are in good agreement
with our observations that an exothermic process occurs during binding
and the binding constant values are similar to those we obtained .
in summary , a6r interacts with
dppc vesicles leading
to changes in the vesicle wall layer spacing such that the saxs structure
factor peaks present for dppc vesicles are eliminated and only the
form factor of isolated bilayers is observed . this is similar to what
is observed for the interaction of the peptide amphiphile c16-ah ( ah : -alanine - histidine dipeptide , known
as l - carnosine ) with dppc .
x - ray diffraction
indicates the presence of a fraction of tightly packed alanine - rich
-sheet structures in the a6r / dppc mixtures , although
circular dichroism spectroscopy shows the suppression of global -sheet
ordering of a6r in the presence of dppc .
some a6r may form separate -sheet assemblies or rafts
of ordered a6r may be present in the vesicle walls . discriminating
between these possibilies is a challenge for future work . interestingly
,
a6r does not seem to permeabilize dppc
vesicles despite its insertion into the vesicle walls ( as inferred
from dramatic changes in the saxs intensity profiles ) .
this is the
opposite of the behavior observed by moshe et al . for their gffwg
( f : d - phenylalanine ) peptide interacting with model cell
membranes ( dops , dopc , dope mixture ) since a series of bragg reflections
were observed in the presence of the peptide , but only form factor
( similar to that shown in our figure 4b ) features
were observed for the membrane / lipid mixture .
reported that short basic pentapeptides such
as
k5 insert into lipid ( dppg ) membranes , in contrast to the findings of ben - tal et al .
however , in neither of these studies was imaging
of vesicles or permeabilization measurements performed .
the hexapeptide
frwwhr , identified by combinatorial screening methods to have strong
antimicrobial activity , does not cause substantial leakage from vesicles ,
and rezansoff et al .
suggested that the bactericidal action of the
peptide may involve translocation across the membrane .
however , blondelle et al . did observe lysis
of model dppc - containing membranes in the presence of lysine - rich
18-mer peptides .
natural antimicrobial
peptides such as magainin and gomesin permeabilize membranes and lead to lysis .
some
cationic peptides are known to cause fusion of cell membranes and
have been studied in particular in the context of viral infection
where they mediate fusion of the host cell membrane and the enveloped
virus .
the fusogenic tat protein transduction domain has been used
to deliver a wide range of biologically active cargo ( dna , proteins ,
liposomes , and others ) .
the initial model
for cellular uptake involves direct penetration across the lipid membrane ,
however it has been shown that tat - fusion proteins are rapidly internalized
by lipid - raft dependent macropinocytosis ( pinocytosis is nonspecific endocytosis within vesicles ) . as mentioned
above , substitution of any of the basic residues in the tat peptide
with a neutral amino acid causes a reduction of antimicrobial activity ,
reflecting the influence of charge and hydrophobicity .
thus , prior work indicates that membrane permeabilization
can occur
for peptides with more than one cationic residue , but this alone is
not sufficient .
the sequence and length of the peptide is also important ,
as is the nature and composition of the lipid membrane .
this was highlighted
by chen et al . in their comparison of the antibacterial properties
of a3k , a6k , and a9k .
they found that the latter , which has the longest
hydrophobic alanine block and the strongest aggregation tendency ,
has the highest antimicrobial activity .
this peptide also did not
significantly disrupt dppc vesicles , although dppg membranes were
broken up .
as
discussed in the introduction , models for
bacterial cell membranes should consist of anionic lipids although
as discussed above many studies have used dppc as model membranes .
we have shown that a6r is a model antimicrobial cationic
peptide containing a single arginine residue attached to a hydrophobic
hexa - alanine sequence to drive self - assembly .
it also introduces
the concept of addition of slps to modulate the structure of lipid
vesicles . | we investigate the properties of
an antimicrobial surfactant - like
peptide ( ala)6(arg ) , a6r , containing a cationic
headgroup .
the interaction of this peptide with zwitterionic ( dppc )
lipid vesicles is investigated using a range of microscopic , x - ray
scattering , spectroscopic , and calorimetric methods .
the -sheet
structure adopted by a6r is disrupted in the presence of
dppc .
a strong effect on the small - angle x - ray scattering profile
is observed : the bragg peaks from the dppc bilayers in the vesicle
walls are eliminated in the presence of a6r and only bilayer
form factor peaks are observed .
all of these observations point to
the interaction of a6r with dppc bilayers .
these studies
provide insight into interactions between a model cationic peptide
and vesicles , relevant to understanding the action of antimicrobial
peptides on lipid membranes .
notably , peptide a6r exhibits
antimicrobial activity without membrane lysis . |
in the mid 1960s , brinley
presented a novel plotting
method to consider the
relationship between response times in young and older
adults across a variety
of tasks with varying levels of cognitive difficulty
.
the average response times
for both the young and older groups of adults on each task was
placed on a
scatter - plot , and a regression line was then fitted to the
data using the
operation of y = mx+b .
in doing so ,
a relationship was
realized between the
behavior in young adults and its ability to predict behavior
on the same task
in older adults .
the power of this method of data analysis is
that it can be
used across task types to pool data from multiple studies .
here we harvest the
powerful aspects of the brinley analysis method and apply
them to functional
magnetic resonance imaging ( fmri ) data .
meta - analyses of
fmri data are
typically hindered by differences in the types of tasks
used across studies .
the use of the brinley method allows for a
meta - analysis of fmri data that
actually takes advantage of multiple cognitive tasks .
the history of brinley plots is rife with
debate and discussion on what the plot is measuring
and what it means .
feelings in opposing camps can
even be so strong as to
elicit t - shirts emblazoned with the no symbol over
the word brinley .
later
researchers inferred that aspects of brinley plots
could provide information on
general cognitive functioning in older adults since
brinley 's data contained
both task switching and nonswitching data subsets
[ 27 ] .
for example , if the slope
for the fitted line of a group of tasks is 1 , then there is
equal change between tasks for younger and older adults .
however , when the slope of the
fitted line deviates and is greater than 1 , there is
an increased slowing in
older adults associated with more cognitively demanding tasks
( i.e. , a general cognitive slowing deficit is evident in
older adults regardless of task [ e.g. ,
] ) .
other researchers have
disagreed with this brinley plot interpretation and suggest
that the plot
reflects a difference in response variability
between the age groups rather
than processing speed , per se
.
finally , current work in how
aging affects processing speed questions the degree
to which general cognitive
slowing can be summarized with one linear
function across all types of tasks
[ 5 , 9 , 10 ] .
in addition to describing the behavioral appearance
of cognitive slowing , research
has pursued localizing the phenomenon within the
aging brain .
generalized
cognitive slowing has been thought to
result from pervasive slowing of all
cognitive brain functions in older adults .
with this in mind , some researchers
have proposed that the locus of general
cognitive slowing occurs where sensory
impulses transfer to a common site of motor
generation for the response and
that this sensorimotor dysregulation intensifies
with more difficult tasks [ 1113 ] .
yordanova and colleagues
found evidence to support this hypothesis using event - related
potentials , which
are able to evaluate the timing and strength
of cognitive processing in
response to external stimuli
.
however , when considering
task - specific slowing impact , other researchers point to
additional slowing in
specific cognitive areas such as working memory ,
visual search and mental
rotation [ 10 ,
14 ] ,
which may occur in addition to
or instead of the sensorimotor slowing . after reviewing the body of research literature
on general cognitive slowing in
aging , we adopted the early brinley method
for plotting reaction times and
applied it to the blood - oxygen level dependent ( bold )
signal from multiple fmri
studies . in doing so ,
an attempt is made to localize
brain areas responsible
for the deviant slope in the response time brinley plot .
unlike reaction times
,
the bold signal has a
legitimate negative value
( i.e. , deactivations ) that occurs when contrasting activity
during two different events .
for example ,
certain brain areas are more active during
baseline than during any particular task .
these areas prominently include
posterior cingulate cortex and inferior parietal lobe
areas and are known as
the default network .
in applying brinley 's
plotting method on the bold signal ,
we are able to construct
novel peiffer
plots , a meta - analysis of fmri data that is not limited to
site locations of
activation maxima and thus not skewed to evaluate only areas
identified as
statistically different within a study
[ see discussion in ] .
typical meta - analyses of
fmri data use location - centered approaches
where the focus of peak activity is
evaluated [ 1620 ] .
this can underestimate
between - task differences because subthreshold
activity differences are
overlooked [ see discussion in ] .
further , differences in task
parameters and paradigm domain limit the tasks
compared in many fmri
meta - analyses to a single type of task
( e.g. , stroop interference task
[ 16 ,
21 ] ) .
with the novel method
proposed here , a plot can be made across a
variety of fmri studies to evaluate
two different population groups to identify areas
showing between - task
differences that may not necessarily be identified as
deviant within an
individual study comparison .
lastly , in using this method to
compare young and
older adults , we may be able to show localization of the areas
that may in fact
identify differences in age - related information
processing that characterize
general cognitive slowing .
bold data and behavioral response times were obtained from 4 simple
detection tasks ( 3 visual and 1 auditory ) . in order to plot a bold signal value
for young and older adults in each study ,
the fmri data center ( http://www.fmridc.org ) contributed a complete dataset from buckner and colleagues
( accession no .
2 - 2000 - 1118w ) for 2 points in
the analysis ( young = 14 ; older adults = 14 )
.
these bold signal
measurements related to responses associated with the
presentation of a single
or double flashing checkerboard .
the other 2 points were
from studies performed
in our laboratory ( young = 20 ; older adults = 20 )
.
these bold signal
measurements were related to block activity during an
auditory task where
subjects needed to respond when they heard a target tone or
in a visual task
where they responded to the blurring of a flashing checkerboard .
for all points
in the meta - analysis , all fmri comparisons were between
task and baseline
( i.e. , fixation cross ) and were preprocessed with global
signal correction .
further ,
during the preprocessing of the data ,
it is spatially normalized to mni
template space .
normalized task specific
con images reflecting the
task - related bold activity change from baseline
were computed with spm99 for
all individuals in each dataset .
these individual
con images were then
averaged within age group for each study resulting in a
total of 8 average bold
activity maps ( 2 age groups over 4 tasks ) .
this process emulated the
construction of a traditional brinley plot which averaged
the response times
for each task within each age group .
within the bold average signal maps ,
each
voxel contains a value representing the age
group 's average bold activity for
that task at that standardized mni x , y , z
coordinate . using the 4 average young maps
as observed x - values and
the corresponding 4 average older adult maps as observed
y - values , a linear
regression analysis ( y = mx+b ) was calculated
within each voxel that contained
at least 3 x , y data points ( see figure 1 for
a representative voxel ) .
individual 3d maps were computed that contained
voxels with individual
regression parameters of interest ( e.g. , slope , b - intercept ,
r - square , predicted y - value , etc . ) .
since the null hypothesis h0 in question was whether or
not there was equivalent change between young and older
adults across tasks ,
the slope value for h0 was 1 .
to evaluate
h0 : m=1 , the
absolute residual values were calculated at each data point in
spm2 ( =|yy^| where y^=mx+b and =|xx^| where x^=(yb)/m ) .
the resulting 8 residual maps ( 2
age groups over 4 tasks ) were then statistically compared
using a t - test in
spm .
when the n is large enough , theoretically ,
it would be more statistically
correct to analyze the difference between these residuals with
a paired t - test .
if the null hypothesis was true ,
then the absolute residual values would be
equal and not statistically different from each other
( = ) .
if the slope was not equal to 1 , then the
voxel 's t - test would be significant
( ) .
multiple comparisons were controlled for by using fwe of
p < 0.05 and an
extent threshold of at least 3 consecutive voxels
.
the sign ( + or ) and value of
the slope could then be assessed to determine how
the two groups deviated in
their bold signals across the tasks plotted in the analysis
( e.g. , one group activates an area more across tasks then the other group ) .
as graciously pointed out by an anonymous reviewer ,
slopes of 1 should not be considered as
part of the null hypothesis , since the direction of
activity across tasks for
the age groups would actually be opposite
( i.e. , young adults activating across
tasks while older adults deactivate ) .
therefore , it is also important to
investigate areas where the slope is significantly negative ,
since the above
residual analysis would not just eliminate slopes
of + 1 but also slopes which
were not significantly different from 1 .
an example of this can be seen in the
plotted data of figure 1
in which this particular voxel would not be significant
in the above residual analysis , but still
represents an interesting result .
significant
voxels with a slope of 1 can be identified using the
p - value
of the regression
used to fit the peiffer plot
( i.e. , p < .05 for the slope to be different from
zero ) .
three contiguous voxels with a significant regression
p - value
and a negative slope will be
considered a cluster of interest as well . to evaluate a significant voxel 's b - intercept ,
if this interval
contained zero , the voxel 's b - intercept was considered
not to deviate from
zero .
again , b - intercept clusters were considered
significant if they contained
at lest 3 contiguous voxels with significantly nonzero
b - intercepts .
the traditional brinley plot using average response times
across the 4 tasks included in the fmri meta - analysis showed the established
differences between young and older adults
( see figure 2 ) .
the slope of 1.4 supports general
cognitive slowing within the dataset even though
relatively simple response
time tasks were used , and although uninterpretable
for response time data , the
negative b - intercept is also typical . with a slope
greater than one , older
adults had greater differences between
tasks in response time than younger
adults . for the fmri meta - analysis
the location of these clusters
is summarized visually
in figure 3 and details
are given in table 1
.
clusters of interest to competing
theories of general cognitive slowing were
found within the left pre- and
postcentral gyrus areas as well as within the right
medial frontal gyrus .
all
clusters identified in the analysis had , on average ,
a slope that was
significantly less than one yet significantly greater
than negative one ( see figure 4 ) .
this slope indicates that between these 4 tasks , younger
adults had greater bold signal change than older adults
in these brain areas .
notably ,
there is a lack of difference in between - task bold activity
within primary
sensory areas such as vision between older and younger adults ,
even though several studies have reported older adults
having less activity than younger
adults in sensory areas
[ 2426 ] .
when the peiffer plot was explored for 3 contiguous
voxels with significantly negative slopes less than zero ,
19 total clusters were identified .
nine of these
clusters ( 47% ) were located within the right
middle and superior frontal gyri and included a total of
68 voxels ( see figure 5 ) .
across these clusters
older adults showed bold deactivation on
tasks when younger adults tended to slightly activate and
older adults had bold activation
when younger adults were deactivating on a task
( average slope 1.89 + / 0.21 ) .
these areas appear to be activating in opposition between
the age groups and
are contiguous to the right middle frontal gyrus area
( cluster no .
other clusters , showing similar activity
differences were seen within left medial frontal gyrus
( 2 clusters ; 6 voxels ) ;
left inferior parietal lobule ( 3 clusters ; 10 voxels ) ;
cingulate gyrus ( 2 clusters ; 7 voxels ) ;
and single clusters within the basal ganglia ( 5 voxels ) ,
midbrain ( 3 voxels ) , and the left posterior
lobe of the cerebellum ( 7 voxels ) .
it is important to note , however , that these findings ,
unlike those from the residual
analysis above , have not been stringently controlled for
multiple comparisons
aside from retaining the requirement for 3 contiguous voxels . to assess whether these slope findings were dependent
on age and not an epiphenomenon of the
datasets , a randomization of the age groups was
performed within each dataset .
individuals were randomized in two groups so that the average
age of both
groups was roughly equal ( 51 years of age ) .
when the peiffer plot was
constructed for these new groups , no significant clusters were
identified where
the null hypothesis ( h0 : m=1 )
was false .
these findings thus support the
claim that the results of the original plot
were not due to the dataset
composition ( i.e. , scanner , site , or paradigm )
but were dependent on separating
the study populations by age .
assessment of
the b - intercept indicated that the lack of significant
slopes within the
primary sensory areas may be due to a baseline shift in activity
between the
age groups ( see figure 6 ) .
for example , within visual cortex , several areas were
identified that had negative b - intercepts which
indicated that across the tasks
older adults tended to start from a lower bold
activity level than young adults
( if x=0 , then
y = a negative bold signal ) .
this result is a continual within - task
difference , which is also seen in the published literature
[ 2327 ] ; however , since this reduced
bold signal in older adults is constant across several tasks ,
it does not have
a slope which deviates significantly from 1 .
in addition , an area within right
motor cortex shows a positive b - intercept and thus greater
activity in older
adults relative to younger adults .
as graciously pointed out by an anonymous
reviewer , this result is consistent with the model hypothesis
of hemispheric asymmetry
in older adults ( harold ) .
the harold model states that there is reduced
lateralization of brain activity in older adults
relative to younger adults ,
which results from changes in neural architecture
and not cognitive strategy
[ 28 ,
29 ] . due to
the small number of
data points used to construct these plots ,
the area included within the 95% confidence
interval of the b - intercept is relatively large .
therefore , these early
findings may underestimate the amount of brain activity
which could be
described as being affected by an age - related
dc - shift and is thus an
age - related bold signal difference that is independent of task .
finally , an epiphenomenon of the method was
revealed when evaluating the goodness of fit ,
as measured by the r - squared value .
areas where the slope was similar to one
showed very high r - squared values ( > 0.8 )
suggesting a high predictability
for older adults ' bold signal in several
brain regions ; however , within the
clusters identified as significantly deviant
from one , r - squared values were
lower and ranged between 0.10.46 .
here we report the preliminary use of a
novel meta - analysis technique in studies on
aging , which localizes one factor of general
cognitive slowing to the
sensorimotor transfer .
these findings lend support to
existing data from
event - related potential work indicating that
slowing occurs predominately
during the time for generation of the response in older
adults and not when evaluating
incoming sensory material
[ 11 ,
13 ] .
deviant slopes could be
found in between - task bold activity values where younger
adults have greater
bold activity change than older adults in the
sensorimotor transfer area in the
left hemisphere .
additionally , right frontal
areas were identified with slopes
near 1 , indicating that older and younger
adults were activating these
attentional areas in opposite directions across the tasks .
not surprisingly ,
more attentionally demanding tasks have shown
that older adults have
differential patterns of activation within the
frontal cortex in response to the
task when compared to younger participants
[ 30 ,
31 ] .
an important caveat exists , however ,
since datasets within this analysis were obtained from
relatively noncognitively demanding tasks .
in other words , more brain areas
may be involved as loci of general cognitive
slowing and would emerge as more
cognitively demanding datasets become available for assessment .
comparing our
current datasets to the existing literature on brinley plots of
reaction times ,
simple discrimination tasks
show the least amount of response
time slowing ;
therefore , these bold signal findings presumably will only
become stronger with
the addition of datasets containing more cognitively demanding
conditions
( e.g. , working memory ) .
in addition , with more tasks requiring
greater attentional demand , the negative slope found within right
frontal cortex may
steepen and be found within the residual analysis which
can control for the
multiple comparisons inherent within imaging data .
power analyses of these
preliminary results suggest that roughly 9 datasets are needed to
perform a meta - analysis with a paired t - test to achieve a
power - level of 80% .
interestingly , all
significant clusters identified as deviant within the
meta - analysis were
separate from peak activity differences reported in any of the
individual tasks
used within the datasets .
if traditional meta - analysis techniques were used
[ 1620 ] , none of these areas would
have been found . utilizing this novel meta - analysis technique ,
it is possible
to assess between - task differences in bold activity between
groups regardless
of paradigm design , task parameters , and location of the scan .
while global
signal correction was used to normalize
the datasets within this study , the
assessment method could also be performed using
average group z - maps that would
allow datasets from multiple fmri processing software
packages to be analyzed
collectively .
additionally , this method may yield
interesting findings in a
variety of study groups where a clear normal
group can be identified and used
on the x - axis
( e.g. , schizophrenics versus normals ;
dyslexics versus normals ; ad versus
normal older adults ) .
it is important to keep in mind that
the use of this
method is to determine between - task differences among
two populations and not
to differentiate the two groups within any one paradigm
of the analysis .
thus ,
differences in whether or not an area is
identified as deviant come from how
the bold signal responds across a wide array of tasks .
an existing disadvantage of this meta - analysis technique
is that it requires access to raw
fmri data to obtain subjects ' normalized contrast
weighted bold activity maps
( task - baseline ) from multiple tasks . with the
continued increase of complete data sets maintained in
accessible repositories
like the fmri data center ,
overall as a meta - analysis method in the fmri field ,
this plotting addresses several
limitations of existing analysis methods .
specifically , it allows the
assessment of between - task differences regardless of a
task 's paradigm domain
or baseline condition .
further , it can identify
areas of subthreshold effects
in addition to the suprathreshold
within - task differences that are identified
by performing a meta - analysis on voxel quadrants
identified in individual
studies as the local maxima .
lastly , this method
provides imaging researchers
the ability to localize between - task differences
in bold signal and apply that
knowledge to existing behavioral evidence not only in aging but
in other complex conditions
( e.g. , dyslexia , schizophrenia , alzheimer 's disease , etc . )
as well . | by plotting response times of young and older adults across a variety of tasks , brinley spurred investigation and debate into the theory of general cognitive slowing
. though controversial , brinley plots can assess between - task differences , the impact of increasing task demand , and the relationship between responses in two groups of subjects . since a relationship exists between response times and the blood - oxygen level dependent ( bold ) signal of functional mri ( fmri ) , brinley 's plotting method could be applied as a meta - analysis tool in fmri studies of aging . here , fledgling
peiffer plots are discussed for their potential impact on understanding general cognitive brain activity in aging .
preliminary results suggest that general cognitive slowing may be localized at the sensorimotor transformation in the precentral gyrus .
although this meta - analysis method is naturally used with imaging studies of aging , theoretically it may be applied to other study pairs ( e.g. , schizophrenic versus normal ) or imaging datasets ( e.g. , pet ) . |
some cyclists use the bicycle as a means of transportation , others ride for recreation , and some are competitive cyclists .
the repetitive movements of cycling put cyclists at a risk of overuse injuries , particularly to the leg joints ( knee and ankle ) . during 1985 ,
about 8.36% of causalities seen in the emergency room of king fahd hospital of the university were sports related , and knee injuries accounted for 24% of those injuries . in a cross - sectional study of 224 recreational cyclists in california in1995 using mailed surveys ,
85% of the cyclists reported one or more overuse injuries , 36% of which required medical attention .
miles / week , lower number of gears , and low level of experience were associated with increased prevalence .
the study by zwingenberger et al . also suggested that low experience level was associated with increased prevalence of injury . in a study by silberman in new jersey in professional road cyclists ,
94% of them had experienced at least one overuse injury in the preceding 12 months ; knee was the most common site .
many injuries were mild , resulting in limited time off the bike . in another study by clarsen et al . among seven professional teams in the usa , involving 109 professional cyclists ,
the prevalence of knee overuse injury was 23% and most likely resulted in time loss .
vleck and garbutt studied the prevalence of knee injury among elite triathletes in the uk .
nearly 75% of them had overuse injury , and knee injuries accounted for 14.2%-21.9% of the injuries .
almost 62.1% of the knee injuries occurred during running and 34.5% occurred during cycling . in a study conducted in london on military personnel undergoing a fitness test , it was found that obesity was associated with the increased incidence of musculoskeletal injury .
many studies suggest that the bike fit and alignment , lack of training , and inappropriate equipment are major contributory factors and that efforts should be made to control these factors to reduce the prevalence of overuse injuries and reduce time off training .
the outcome of a randomized controlled trial ( rct ) was favorable with respect to strengthening and stretching exercises in preventing anterior knee pain ( akp ) .
however , a systematic review showed a marked reduction ( 50% ) in overuse injury by means of strengthening exercises , but , stretching exercises did not show any benefit . despite the increasing popularity of cycling , to the best of our knowledge
, there have been no published epidemiological studies in saudi arabia , and indeed , few studies have been published worldwide that describe the prevalence of knee problems of cyclists and the associated risk factors .
this study was conducted to assess the prevalence and the magnitude of knee pain and other knee problems of active cyclists in the eastern province and to determine the factors associated with knee pain in the study population .
a cross - sectional study was conducted to assess the prevalence , magnitude , and associated factors of knee pain of active cyclists in the eastern province , saudi arabia , in 2015 .
the study population included all active cyclists who were members of a recognized professional or amateur cycling club in the eastern province of saudi arabia .
an online link to the questionnaire was sent to 513 cyclists , 311 of whom completed the questionnaire , giving a response rate of 60.62% .
the following inclusion criteria were then used : ( 1 ) minimum age of 18 years ; ( 2 ) should have been bicycling for 6 months ; ( 3 ) and should ride the bicycle at least once per week .
the data were collected using a structured , self - administered questionnaire which had been designed by the researchers after reviewing the literature and similar questionnaires based on the objectives of the study .
the questionnaire consisted of seven parts : ( 1 ) sociodemographic data : age , gender , nationality , level of education , marital status , and club name ; ( 2 ) chronic medical illnesses that may affect the sport or predispose to knee symptoms , smoking , height and weight ; ( 3 ) participation in sport : goal , experience , frequency , duration , warm up , stretching exercises , strengthening exercises , and rest days ; ( 4 ) type of bicycle used , bicycle fitting , and clip - less pedal ; ( 5 ) current knee pain and pain in the past 12 months , frequency , precipitating event , site , and associated symptoms and management . a frequency scale comprising always ,
we tested six types of bicycles : road bicycle ( a bicycle built for traveling at speed on paved roads , time trial bicycle ( a racing bicycle designed for use by an individual or team time trials on roads ) , mountain bicycle ( a bicycle created for off - road cycling ) , hybrid bicycle ( a blend of characteristics of a road bicycle and a mountain bicycle ) , and the recumbent bicycle ( a bicycle on which the rider is in a laid - back position ) .
the questionnaire was designed by the researchers , validated by four faculty , and piloted on forty cyclists ( different from the target group ) .
the study was approved by the ethical committee of postgraduate saudi board program , eastern province .
all participants were sent an invitation explaining the purpose of the study , reassuring them of confidentiality and a web link to the survey in october 2015 .
sms , whatsapp application , and e - mail were used to deliver the invitations to the participants .
completion and return of the questionnaire was considered as assent to participation in the study .
returned questionnaire that did not meet the inclusion criteria were excluded , giving a total of 283 valid questionnaires .
the data were coded , entered , and analyzed using statistical package for social sciences ( spss ) version 20.0 ( released in 2011 by ibm corp . ,
cyclists were classified into two groups : professional ( competitive cyclists who are registered in the saudi cycling federation ) and amateur ( unpaid cyclists not under the umbrella of the saudi cycling federation ) .
the term bicycle fitting was used for a process whereby an expert adjusts the bicycle dimensions to suit those of the cyclist 's body .
the term clip - less pedal was a system comprising special pedals and cleats , devices on the pedals that attach to the soles of clip - less cycling shoes . the term triathlon is used for a multiple - stage competition involving swimming , cycling , and running in immediate succession over various distances .
body mass index ( bmi ) was classified into six categories according to the world health organization classification : < 18.5 as underweight , 18.524.9 as normal weight , 2529.9 as overweight , 3034.9 as obesity class i , 3539.9 as obesity class ii , and 40 as obesity class iii . the numeric rating scale ( 11 ) was used to categorize pain : mild ( 13 ) , moderate ( 46 ) , and severe ( 710 ) .
age was classified into four groups : teenage ( 1819.99 ) , young adult ( 2039.99 ) , middle aged ( 4064.99 ) , and elderly ( 65 ) .
data were presented using descriptive statistics in the form of frequencies and percentages for categorical variables and mean and standard deviation for quantitative variables .
mann - whitney test was used to compare median ranks between different pain category groups .
out of 513 , a total of 311 cyclists responded to the survey ( 60.6% response rate ) .
majority of the participants were male ( 95.1% ) , and young adults ( 63.3% ) .
teenagers constituted 45.4% of the professional teams and 2% of the amateur teams ( p = 0.0001 ) .
almost two - thirds ( 69.3% ) were saudi , 12% were asians , while the remainder were of various other nationalities .
half of them had a bachelor 's degree or higher , and about three - fourths ( 72.7% ) were married .
concerning smoking , 13.6% of the participants smoked tobacco products , 21.1% had quit , and 65.2% had never smoked .
amateur cyclists had higher smoking rates ( 15.7% ) compared to professional cyclists ( 2.3% ) ( p = 0.001 ) [ table 1 ] .
distribution of active cyclists according to sociodemographic characteristics , eastern province , saudi arabia , 2015 .
the overall prevalence of knee pain was 25.8% . the second most common symptom in relation to the knee joint was popping ( 6.7% ) followed by swelling of the knee ( 5.0% ) .
the 12-month prevalence of knee pain was higher in amateur cyclists ( 27.6% ) compared to professional cyclists ( 15.9% ) , but that was not statistically significant [ figure 1 ] .
distribution of knee symptoms among active cyclists by club type , eastern province , saudi arabia , 2015 the distribution did not statistically vary among the different studied sociodemographic categories or smoking status .
as regards cyclists with knee pain , 39.7% of the cyclists seldom experienced knee pain , 39.7% experienced it sometimes , while almost 18.5% often or always experienced knee pain .
knee pain occurred spontaneously with no obvious cause in 32.8% of cases , for 25% , it was precipitated by running , and for 17.2% , it was precipitated by cycling .
anterior aspect of the knee was the most common location of the pain , accounting for 58.1% ; 21% were above the patella , 27.4% were below the patella , and 9.7% were behind the patella [ table 2 ] .
characteristics of the knee pain among active cyclists , eastern province , saudi arabia , 2015 .
( n=75 ) the average duration of knee pain was 12 months that was higher than other knee symptoms such as swelling , locking , popping , and giving way .
the average days - off training because of the knee problems was 2 days . swelling and
the presence of a lump were associated with a higher average of days - off training .
more than half ( 61.6% ) of knee pain was mild , 28.7% was moderate , and 9.5% was severe pain [ table 2 ] . of cyclists with knee pain ,
about half of those with knee pain ( 49.2% ) used medications for their pain , 28.6% underwent physiotherapy , and 12.7% underwent knee surgery . only two cases ( 3.17% )
the highest prevalence of knee pain was found in road racers ( 50% ) followed by cyclists who rode for fitness and weight loss ( 29.2% ) .
the lowest prevalence of knee pain was found in those who used cycling as a mean of transportation ( 16.7% ) ( p = 0.020 ) [ table 3 ] .
frequency distribution of various cycling and other sports - related factors among active cyclists by knee pain , eastern province , saudi arabia , 2015 .
the distribution was much higher among cyclists who used to ride mountain bikes off road ( 80% ) , followed by those who used to ride time trial bikes ( 45.5% ) and cyclists who rode mountain bikes on road ( 34.8% ) .
the lowest prevalence of knee pain was found in those who rode recumbent bikes ( 14.3% ) ( p = 0.042 ) [ table 3 ] .
the prevalence was higher in underweight cyclists ( 62.5% ) and surprisingly lower in obese cyclists ( 23% ) , but this was not statistically significant ( p = 0.137 ) .
the prevalence was higher in cyclists who participated in football games ( 40% ) compared to cyclists who did not ( 26.6% ) ( p = 0.368 ) [ table 3 ] .
the average jogging hours was higher among cyclists with knee pain ( 2 h ) compared to cyclists who had no knee pain ( 1 h ) ( p = 0.007 ) .
moreover , the average of swimming hours among cyclists with knee pain was higher as well ( 1 h ) ( p = 0.019 ) [ table 3 ] .
when preventive measures were tested , there were no statistically significant differences between cyclists with knee pain and cyclists with no knee pain .
the measures included a professional bike fit , coach supervision , clip - less pedal usage , warm up , strength training , and stretching exercises [ table 3 ] .
there was no statistically significant difference in the average of years of cycling , cycling hours per week , riding frequency per week , kilometers ridden per week , and rest days between cyclists who had knee pain and cyclists who had no knee pain [ table 3 ] .
knee pain , common in active cyclists in the eastern province of saudi arabia , has an overall 12-month prevalence of 25.8% .
professional cyclists had a lower prevalence of knee pain than the amateur cyclists , suggesting that experience is protective . however , the results show no difference in the average years of the experience . professional cyclists undergo a high - quality bike fitting on a regular basis and get trained under direct coach supervision , in which an emphasis is put on the correct technique necessary in preventing injuries .
berkovich et al . also posited the importance of coaching techniques in preventing knee injuries in cyclists .
many researchers have also suggested that the appropriate bicycle configuration and saddle height are protective .
however , the results of this study did not show any difference in the prevalence of injury between cyclists who had a professional bike fit and cyclists who did not .
the 12-month prevalence in amateur cyclists of this study was higher than the 18-month prevalence in the uk adventure racing cyclists ( 21.9% ) .
this is probably because the cyclists in the uk were more physically fit and experienced , based on years of cycling .
the 12-month prevalence was higher in japanese triathletes ( 33.0% ) , but lower than what was found in recreational cyclists in california ( 41.7% ) .
the prevalence of knee pain in this study was higher than the prevalence in the residents of al - qassim , the ksa , with clinical knee osteoarthritis ( 13% ) , but close to the prevalence of knee pain for non - hispanic and mexican - american males aged 6074 years ( 26.1% ) .
most cyclists attributed their knee pain to causes other than bicycling itself ; only 17.2% thought that their pain was due to cycling .
this is close to the conclusion drawn by deakon , which imputed 20% of injuries during triathlon to cycling .
a large percentage of injuries occurred spontaneously ( 32.8% ) , suggesting insidious causes of knee pain rather than acute injuries .
this conclusion is supported by the fact that the average running time was double in cyclists with knee pain .
vleck and garbutt concluded that injuries that occur during running were almost twice than those of injuries that occur during the bicycling part of the triathlon events .
akp affected 14.9% of cyclists in this study compared to 36% of the usa professional cyclists as described by clarsen et al .
this suggests that patellofemoral pain syndrome , patellar tendenopathy , patella chondromalacia , fat pad impingement , or patellar bursitis are the possible etiologies of the knee pain in the studied population . by the same token ,
the average duration was 12 months , suggesting that the most likely causes were chronic .
most knee pains were mild or moderate ( 62.1% and 28.8% ; respectively ) and were not frequent ; more serious injuries were most likely to be associated with more severe and frequent pain .
needed surgery or an intra - articular injection ( 12.7% and 3.2% , respectively ) .
the highest prevalence of knee pain ( 50.0% ) was in road racers , but the lowest was in commuters ( 16.7% ) , suggesting that the volume and intensity of training are the important risk factors for knee pain .
however , there were no differences in the average bicycling hours per week , kilometers ridden per week , riding times per week , or rest days per week , which means that high - intensity training was a key factor .
, there is a positive correlation between the hours spent cycling per week and rest days per week and the number of injuries .
moreover , there was a relatively higher prevalence in cyclists who rode for fitness and weight loss .
this may be explained by the low fitness level and high bmi of this group of cyclists as suggested by taanila et al . in this study , warm up , strength training , and stretching exercises
however , an rct by coppack et al . showed that strength and stretching exercises reduced the incidence of akp by 75% .
a systematic review by herman et al . also showed that proper neuromuscular warm - up strategies decreased the risk of injury .
prevalence in underweight cyclists ( 62.5% ) was higher than obese and normal weight cyclists .
this confirms the finding that being underweight was a risk factor of musculoskeletal overuse injuries .
the rate of greater knee pain was not higher in the obese than in those with normal weight .
smoking rate among amateur cyclists ( 15.7% ) was higher than what prevailed in the general population of saudi arabia ( 12.2% ) .
though it was not associated with higher rate of knee pain in this study , it is well documented that smoking increased the risk for musculoskeletal injuries .
we recommend clinical trials to evaluate the effect of the above - mentioned preventive measures on performance and injuries .
there should be an annual survey to assess injury patterns , especially among professional cyclists .
clinicians should be involved in increasing the awareness of the importance of bike fit , proper cycling and running techniques , and the right fit of footwear .
emphasis should also be put on the importance of cessation of smoking , the maintenance of ideal body weight , and the avoidance of over training .
the data were collected using a self - administered questionnaire , which may have been subject to recall bias . there may have been nonresponse bias as response rate was low ( 60.6% ) .
a simple short survey was used for preventive measures , but a prospective study is necessary for a better assessment .
. nevertheless , this first study of the population surveyed has highlighted the problem of knee pain in cyclists in saudi arabia and emphasized the need for health education about this problem and ways to prevent injuries .
running , football participation , and being underweight were associated with higher rates of knee pain .
the rate of knee pain in road racers and mountain cyclists was higher , probably because their knees were susceptible to overuse .
there was no association with bicycle fitting , coaching , using clip - less pedals , warming up average years of cycling , average distance ridden in a week , resistance training , strength training , and average rest days in a week .
the study underpins the importance of ensuring that athletes use the appropriate technique in cycling , running , and swimming , use appropriate footwear , and ensure that the increase in the training load is gradual in trial to prevent knee pain in cyclists , especially amateur cyclists .
| introduction : bicycling is one of the most enjoyable aerobic exercises recommended for the promotion of an individual 's health
. the eastern province of saudi arabia has seen a huge increase in the number of people who cycle .
people have different goals for bicycling , but the injuries they sustain are common .
most of them relate to overuse , particularly of lower body joints .
this study was conducted to determine the prevalence of knee problems and factors associated with knee pain in cyclists.materials and methods : a cross - sectional study was conducted in october 2015 , using an online self - administered questionnaire .
the questionnaire was based on pertinent literature , was piloted , and validated .
a web link was sent to 513 cyclists ( professional and amateur ) using e - mail , whatsapp application , or sms .
three hundred and eleven responses were received , 283 of which were included in the analysis.results:the overall prevalence of knee pain was 25.8% ; 27.6% for amateur cyclists and 15.9% for professional cyclists .
only 17.2% knee pain was attributed to cycling , whereas in 32.8% it happened spontaneously and in 25% of cases it occurred while running .
majority of the cyclists reported pain as mild ( 61.6% ) or moderate ( 28.7% ) ; anterior knee pain accounted for 58.1% knee pain .
different goals of cycling and different bicycle types had statistically significant difference on the rate of knee pain . of underweight cyclists , 62.2% reported knee pain .
cyclists who run more or participated in football had a higher rate of pain.conclusion:knee injuries are common with cyclists .
factors such as the type of the bicycle , the goal of bicycling , club type , body mass index , and participation in other sports play a significant role in the rate of knee pain . |
our patient was a 76-year - old man with a coronary artery bypass graft due to unstable angina . during the postoperative period ,
a blood gas analysis showed a paco2 concentration of 45 mmhg , pao2 concentration of 63 mmhg , and a ph of 7.40 during intermittent mandatory ventilation at a rate of 12 breaths per minute , a tidal volume of 500 ml , a positive end expiratory pressure of 10-cm h2o , and fio2 of 100% .
the neck was prepared with povidone iodine , surgical drapes were placed , and tracheostomy was started .
after neck incision , subcutaneous tissue and pretracheal fascia dissections were performed using a monopolar electrocautery device to secure hemostasis . after the identification of tracheal rings , the second and the third rings
were incised vertically along the midline by using a scalpel , and to control minor bleeding in the paratracheal area , an electrocautery device was used . however , during its use , a loud pop was heard and a flame erupted from the surgical site .
initially , we attempted to control the fire by applying manual pressure with a surgical towel but were unsuccessful because of the pure - oxygen spillage through the cuff and the use of positive end - expiratory pressure .
we quickly disconnected the ventilator , removed the endotracheal tube , and extinguished the flame in the surgical field by using a saline spray .
a tracheostomy tube was then inserted uneventfully . the skin at the peri - tracheostomy site was deeply burnt ( fig .
unfortunately , the follow - up chest x - ray showed progressive pulmonary infiltration , and the patient subsequently succumbed to a multiorgan failure after unsuccessful recovery efforts .
surgical field fires are dangerous to patients and surgeons , but unfortunately , many patients undergoing tracheostomy do not tolerate low fio2 .
all fires require the following three elements : an oxidizing agent , an ignition source , and fuel . during tracheostomy ,
the oxidizing agent is supplemental oxygen , the ignition source is the electrocautery device , and the fuel is the endotracheal tube .
smith and roy reported that all 18 of the reported tracheostomy fires were started by the electrosurgical unit and that the fuel was the endotracheal tube in 7 cases ( 39% ) and the patient s drape in 4 cases ( 22% ) .
some case reports have described airway fires occurring when monopolar electrosurgical devices were used during tracheostomy , although this type of injury has been reported during bronchial sleeve resection , otolaryngeal surgery , and bronchoesophageal fistula repair . during tracheostomy ,
when an open trachea is present , the surgical field may become oxygen - enriched .
furthermore , when an airway fire occurs during tracheostomy with an endotracheal tube located just proximal to the tracheostomy opening , a flame is often seen venting from the tracheostomy opening , and this venting can cause an extensive burn injury to the distal aspect of the tracheobronchial tree . to minimize the risk of fire during tracheostomy , surgeons must maintain fio2 at the lowest possible level .
on the other hand , when fio2 levels are higher than 50% , an electrosurgical device should never be used to enter the trachea . in a previous study
, it was shown that endotracheal tubes can be ignited in a 25% oxygen atmosphere .
bailey et al . recommended that the following minimal precautions be taken to prevent fires during elective tracheostomy : 1 ) oxygen air and/or helium mixtures ( as permitted by patient condition ) be used to reduce combustibility ; 2 ) electrocautery devices be used sparingly , and if used , the voltage be set at a low level , particularly when the trachea is exposed during surgical resection ; 3 ) a bipolar rather than a unipolar electrocautery device be used to prevent / minimize current leakage ; and 4 ) saline or water be used instead of air to inflate the endotracheal tube cuff .
ho et al . reported that co2 flooding of the surgical field reduces the risk of fire in patients who can not tolerate ventilation interruption or require high inspired o2 concentrations .
surgeons should be aware of the possibility of airway fire and the means of preventing its occurrence during tracheostomy .
our experience cautions that electrocautery be approached carefully in patients requiring high - oxygen therapy . | tracheostomy is a relatively common surgical procedure that is performed easily in an operating room or intensive care unit .
open tracheostomy is needed in patients requiring prolonged ventilation when percutaneous tracheostomy is inappropriate .
sometimes , it is difficult to achieve bleeding control in the peritracheal soft tissue , and in such cases , we usually use diathermy .
however , the possibility of an electrocautery - ignited surgical field fire can be overlooked during the procedure .
this case report serves as a reminder that the risk of a surgical field fire during tracheostomy is real , particularly in patients requiring high - oxygen therapy . |
over the past two decades , numerous studies have provided evidence that sleep enhances memory consolidation .
it has been initially shown that consolidation of declarative / episodic memories is enhanced by early sws - rich periods of sleep whereas procedural memory rather benefits from late sleep during which rem sleep prevails ( e.g. , plihal and born , 1997 ) . other authors have pointed out the relevance of the succession of nrem rem sleep cycles for memory consolidation regardless of the memory system the trace belongs to ( giuditta et al . , 1995 ) , potentially reflecting different processes operating on memory traces . thus , gais et al . ( 2000 ) showed that performance on a procedural visual discrimination task requires rem sleep but also a certain amount of preceding sws .
we also showed a complementary role of rem sleep and sws in the consolidation of truly episodic memories .
whereas early sws favors consolidation of the temporal aspects of episodic memories , rem sleep rather supports the consolidation of the spatial characteristics of these memories ( i.e. , location of words on a paper sheet ) and the richness of contextual details ( rauchs et al . , 2004 ) .
consolidation of emotionally laden material also depends on rem sleep ( wagner et al . , 2001 ) .
more recently , studies have tried to unravel the electrophysiological substrates that mediate the beneficial effect of sleep on memory consolidation .
three main mechanisms may participate in this complex process of reorganization of memory traces during sleep : hippocampal reactivations , neocortical slow oscillations , and thalamo - cortical sleep spindles .
using hippocampus - dependent spatial learning tasks in rodents , studies have reported that hippocampal place cells , activated during training , were reactivated in the same sequential order during subsequent periods of sleep ( wilson and mcnaughton , 1994 ) .
such neuronal reactivations were mainly observed during sws ( skaggs and mcnaughton , 1996 ; kudrimoti et al . , 1999 ) and more rarely during rem sleep ( louie and wilson , 2001 ) .
these re - expressions are not limited to the hippocampus but also occur in the striatum and thalamus ( ribeiro et al . , 2004 ) and in various neocortical areas ( qin et al . , 1997 ; ji and wilson , 2007 ; peyrache et al . , 2009
2004 ) showed that the hippocampus , activated during a spatial learning task , was reactivated during post - learning sws .
interestingly , the amount of hippocampal activity during sws was positively correlated with the overnight improvement of memory performance .
( 2007 ) showed that reinstating during sws an odor that was used as a contextual cue during learning , significantly enhanced episodic memory performance .
this improvement was mediated by the hippocampus as odor re - exposure during sws induced hippocampal activation that was even greater than during wakefulness .
brain oscillations also participate actively in memory consolidation . spindle density , spindle activity ( index reflecting the activity or intensity of the spindle process ) , and the frequency of hippocampal ripples are increased during post - learning sleep ( fogel and smith , 2011 ; girardeau and zugaro , 2011 for reviews ) .
learning experience increases the amplitude and slope of slow oscillations as well as slow wave activity during subsequent sleep ( diekelmann and born , 2010 for review ) .
these increases are associated to enhanced memory performance ( e.g. , huber et al . , 2004 ) .
in addition , inducing slow oscillation - like potential fields during post - learning sleep with transcranial direct current stimulation increases time spent in sws , enhances eeg power in the slow oscillation frequency band and in the slow spindle band , and improves retention on an episodic memory task ( marshall et al . , 2006 ) .
the different findings cited above are summarized in a model of sleep - dependent consolidation of declarative / episodic memories termed the hippocampo - neocortical dialogue ( buzski , 1996 ; figure 1a ) .
briefly , during wakefulness , freshly learned information is temporarily encoded into neocortical and hippocampal networks . during sws ,
they are driven by slow oscillations which synchronize reactivations with the occurrence of thalamo - cortical spindles to drive the transfer of memory traces toward neocortical sites where they will be stored durably .
low levels of cortisol and acetylcholine are required to allow the replay and transfer of information ( diekelmann and born , 2010 ) .
the existence of this process has been demonstrated in rodents ( bontempi et al . , 1999 ) and
it occurs more so in subjects who slept after learning than in subjects who were sleep - deprived ( gais et al . , 2007 ) .
with time , the ventromedial prefrontal cortex plays an important role in the retrieval of consolidated memories .
schematic representation of the possible alteration of sleep - dependent consolidation of declarative memories in older adults .
( a ) during wakefulness , information is encoded in neocortical and hippocampal networks ( black arrow ) . during sws , recently acquired information is repeatedly reactivated within hippocampal networks .
reactivations are associated with sharp waves - ripples and are driven by slow oscillations which also synchronize hippocampal memory reactivations with the occurrence of sleep spindles .
these reactivations stimulate the transfer of memory traces toward neocortical sites for long term storage ( red arrow ) .
( b ) with age , the decrease in sws and slow oscillations combined with anatomical and functional changes in memory - related brain areas and neurochemical changes ( acetylcholine , cortisol ) are likely to explain that sleep - dependent memory consolidation is impaired in older adults . adapted from
for procedural memories , the mechanism could be very similar , involving however different brain areas such as the striatum and cortico - cerebellar networks ( doyon and benali , 2005 ) .
besides this active system consolidation hypothesis , an alternative mechanism has been proposed as the synaptic homeostasis hypothesis ( tononi and cirelli , 2006 ) . during wakefulness ,
such a state is not sustainable in terms of energy and tissue volume demands , and saturates the capacity of synapses for new learning .
sleep , and more precisely slow oscillations , would serve to downscale synaptic strength to a baseline level , keeping nevertheless a difference between synapses that were potentiated during prior waking and those that were not .
this hypothesis has found experimental support in animals ( vyazovskiy et al . , 2008 ; bushey et al . , 2011 ) and in humans ( huber et al . , 2004 ; van der werf et al . , 2009 ) .
older adults complain of early awakening in the morning and of difficulties to maintain continuous sleep .
these difficulties are attested by an increase in the number of arousals during the night leading to sleep fragmentation .
total sleep time decreases , whereas time spent awake during the night or wake after sleep onset increase , thereby decreasing sleep efficiency ( i.e. , proportion of sleep time compared to time spent in bed ) .
sleep efficiency declines progressively with age , from approximately 86% at ages 3754 to 79% over age 70 ( bliwise , 2005 ) .
in contrast , the frequency of daytime naps increases with age ( humm , 2001 ) , potentially worsening the disruption of nocturnal sleep .
the most striking change in sleep architecture is the dramatic decrease in time spent in sws across the adult lifespan .
this decline is further accompanied by a reduction in the number and amplitude of slow oscillations ( petit et al . , 2004 ) .
to a lesser extent , changes of phasic events in stage 2 , such as k - complexes and sleep spindles are also observed ( crowley et al . , 2002 ) .
thus , while the duration of rem sleep episodes increases through the night , it remains constant in older adults ( van cauter et al . , 2000 ) , and the density of rems is reduced ( darchia et al . , 2003 ) .
aging is further characterized by alterations of circadian rhythms ( bliwise , 2005 ) and reduced melatonin secretion ( pandi - perumal et al . , 2005 ) .
indeed , there is a circadian control of rem , but not of nrem sleep ( dijk and czeisler , 1995 ; dijk et al . , 2000 ) .
melatonin is also intimately connected to memory consolidation as melatonin secretion is low during rem sleep ( birkeland , 1982 ) and high levels of this neurohormone inhibit memory formation during night ( rawashdeh et al . , 2007 ) .
, older adults complain of memory impairment concerning mainly episodic memory . as mentioned above , consolidation of episodic memories relies upon sws , which is also significantly reduced in older adults .
furthermore , with age some memory - related areas such as the frontal cortex undergo substantial structural and functional alterations ( kalpouzos et al . , 2009 ) .
this may be explained by the fact that the effects of age are not homogeneous within the hippocampus but rather concern its posterior part ( kalpouzos et al . , 2009 ) . more precisely , mueller and weiner ( 2009 ) reported a significant volume loss of ca3 ( mueller and weiner , 2009 ) .
( 2010 ) who reported a strong effect of age on the volume of the subiculum only ) , this point is of particular interest since during sws , freshly encoded memories are reactivated in the ca3 subfield and then spread back into ca1 and cortical areas for effective consolidation ( hasselmo , 1999 ) .
evidence of impaired hippocampal reactivations after spatial learning has been provided in aged rats compared to young animals ( gerrard et al . , 2008 ) .
in addition , frontal white - matter tracts are also affected by age and may lead to impaired interactions between the prefrontal cortex and the hippocampus ( salat et al . , 2005 ) .
age - related changes in some neuroendocrine and neuromodulatory systems may likewise have an impact on sleep quality and architecture , and therefore on memory consolidation .
thus , aging is accompanied by a cholinergic hypofunction ( schliebs and arendt , 2006 ) .
classically , acetylcholine levels are high at the waking state allowing encoding of new information and reach a minimum during sws .
the nadir of acetylcholine during early sleep allows the reactivation of memory traces within hippocampal networks and their transfer toward neocortical areas ( hasselmo , 1999 ; gais and born , 2004 ) .
age - related cholinergic hypofunction may not have consequences on sws - dependent consolidation of declarative memories but could have repercussions on consolidation of procedural memories during rem sleep , during which acetylcholine levels are high .
indeed , cholinergic activation during rem sleep appears to be a critical factor mediating the beneficial effect of sleep on procedural memories ( rasch et al . , 2009 ) .
finally , aging is also accompanied by changes in the hypothalamo - pituitary adrenal axis schematically leading to increases in evening cortisol levels ( buckley and schatzberg , 2005 ) . as memory consolidation requires low cortisol levels during early sleep ( plihal and born , 1999 ) and since the hippocampus contains a high density of cortisol receptors ( roozendaal et al . , 2009 )
, elevated glucocorticoid levels may impair hippocampal functioning and impede the hippocampo - neocortical transfer .
all the points mentioned above seem closely interlinked and underline the complexity to assess sleep - dependent memory consolidation in older adults ( figure 1b ) .
a handful of studies have been conducted in recent years and have provided mixed results ( see also pace - schott and spencer , 2011 for review ) .
the first studies conducted in healthy older adults ( without depressive disorder or dementia ) have mainly focused on rem sleep , due to the potential pharmacological modulations by cholinergic agents .
thus , schredl et al . ( 2001 ) revealed positive correlations between overnight improvements on a word - pair recall task and rem sleep augmentation following administration of the cholinesterase inhibitor donepezil before bedtime during six consecutive nights .
more recently , hornung et al . ( 2007 ) assessed the effect of various rem sleep manipulations ( increase or decrease in time spent in rem sleep ) on episodic and procedural memory consolidation .
rem sleep augmentation was performed either physiologically through rem sleep rebound after a selective rem sleep deprivation or pharmacologically by administration of donepezil .
in contrast , only pharmacological rem sleep augmentation had positive effects on procedural memory consolidation , suggesting that cholinergic activation , more than rem sleep per se , is a crucial component of rem sleep memory consolidation in elderly people .
other studies tried to relate memory performance with sleep stages in healthy older adults , without administration of cholinergic medication .
thus , mazzoni et al . ( 1999 ) reported correlations between recall performance on a word - pair learning task and the mean duration of nrem / rem sleep cycles and the proportion of time spent in cycles , indicating that sleep structure and the cyclic succession of nrem rem sleep are important for sleep - dependent memory consolidation in older adults .
more recently , backhaus et al . ( 2007 ) reported a decline of sleep - dependent consolidation of semantically related word - pairs , associated with a decrease of early nocturnal sws in 50 years old subjects .
retention of word - pairs after sleep was also positively correlated with the amount of sws .
these results were not replicated with lists of unrelated word - pairs ( wilson et al .
finally , aly and moscovitch ( 2010 ) showed that memory of stories and personal events in older adults benefited from a night of sleep as much as in young adults .
the personal relevance of the material is therefore a crucial factor favoring sleep - dependent memory consolidation . concerning procedural memory , spencer et al .
( 2007 ) have proposed to young and older adults a serial reaction time task .
however , performance of older adults did not improve following sleep , indicating that sleep - dependent consolidation is impaired with age .
these results were replicated and extended to middle - aged subjects who showed , compared to young adults , a reduced sleep - dependent change in performance ( wilson et al .
( 2008 ) compared young and older healthy participants on a simple pursuit rotor task .
both age groups exhibited significant improvements after a 1-week delay but the magnitude of this improvement was lower in the older group .
interestingly , spindle density significantly increased after learning in young but not in old subjects .
2011 ) were the only ones to observe , using a motor sequence task ( finger - tapping ) , similar improvements after sleep in young and older adults , although full expression of these improvements was seen later during the retest session in older participants .
( 2008 ) , no correlation between overnight improvement and sleep architecture or spindle density was observed in the elderly group .
overall , studies conducted in older adults have provided mixed results , especially for declarative memory . while one may logically expect an impaired consolidation of declarative memories during early sleep , due to the dramatic decrease in sws , this result was not consistently found .
further studies are needed to better understand the effects of age . as for procedural memory
, studies report that sleep - dependent consolidation is impaired , or that the magnitude of overnight changes in performance is reduced or that the behavioral expression of consolidation is delayed compared to young adults .
the reduction of cholinergic activation during rem sleep during aging is one of the mechanisms likely to account for these quantitative or qualitative changes in memory performance .
over the past 20 years , a plethora of studies have shown that sleep benefits memory consolidation in young healthy subjects . in older adults , several factors
closely interlinked ( decrease in sws and slow oscillations , hypofunctioning and atrophy of frontal areas , reduction of the cholinergic tone , etc . ) appear to hamper memory consolidation during sleep .
even if this field of research has sparked renewed interest during the last 5 years , some questions remain unanswered . in particular ,
studies combining sleep recordings , memory consolidation assessment , and functional neuroimaging acquisitions are needed to determine which brain areas will subserve the reorganization of memory traces during sleep and compensate for the frontal dysfunction .
studies in healthy older adults are also a prerequisite to understand how sleep - dependent memory consolidation is disrupted in neurological diseases such as alzheimer s disease .
indeed , we observed in patients with mild alzheimer s disease a specific decrease in the number and intensity of fast spindles ( rauchs et al . , 2008 ) as well as a faster mean theta frequency during sws ( hot et al . , 2011 ) .
both parameters were positively correlated with episodic memory performance confirming the deleterious impact of sleep changes on memory function and the existence of compensatory mechanisms in the early stages of the disease to maintain , albeit inefficiently , memory performance .
the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest . | memories are not stored as they were initially encoded but rather undergo a gradual reorganization process , termed memory consolidation .
numerous data indicate that sleep plays a major role in this process , notably due to the specific neurochemical environment and the electrophysiological activity observed during the night .
two putative , probably not exclusive , models ( hippocampo - neocortical dialogue and synaptic homeostasis hypothesis ) have been proposed to explain the beneficial effect of sleep on memory processes .
however , all data gathered until now emerged from studies conducted in young subjects .
the investigation of the relationships between sleep and memory in older adults has sparked off little interest until recently . though , aging is characterized by memory impairment , changes in sleep architecture , as well as brain and neurochemical alterations .
all these elements suggest that sleep - dependent memory consolidation may be impaired or occurs differently in older adults .
this review outlines the mechanisms governing sleep - dependent memory consolidation , and the crucial points of this complex process that may dysfunction and result in impaired memory consolidation in aging . |
type 2 diabetes mellitus affects about 5% of the german population.1 eighty percent of patients with type 2 diabetes are treated with diet or oral antiglycemic drugs ( oads).2 for successful treatment of patients with diabetes , we have different therapy options , such as modification of eating behavior and physical exercise , oads , and insulin
. a necessary prerequisite of successful treatment is the active involvement of the patients in their treatment .
continuous adjustment of nutrition , exercise , and medication according to the patient s insulin secretion and/or insulin resistance is necessary for the treatment of diabetes mellitus .
diabetes education contributes to better metabolic control or to preservation of good control.3,4 however , some reviews on the effectiveness of education in type 2 diabetes have also reported positive effects on patient knowledge , self- care behavior , and psychological outcomes.57 the duration of effective diabetes education programs is controversial .
the trials evaluating the majority of these treatment and teaching programs have only a relatively short follow - up period of 612 months.3,4,8 another controversial topic is whether blood glucose self - monitoring ( bgsm ) has advantages over urine glucose self - monitoring ( ugsm ) in patients not requiring insulin therapy.912 a structured diabetes treatment and teaching program ( dttp ) for patients with type 2 diabetes not on insulin therapy was implemented in the german health care system several years ago .
the first evaluation of this dttp in germany with a follow - up of 12 months was published 20 years ago.3 another evaluation from austria published in 1995 had a follow - up of 6 months.4 however , longer follow - up periods have hitherto not been studied .
a total of 126 patients with type 2 diabetes mellitus not requiring insulin therapy took part in the dttp in 20042005 in the outpatient department for endocrinology and metabolic diseases of the university hospital in jena , germany .
all patients with newly diagnosed type 2 diabetes or problems with metabolic control were enrolled in the dttp .
medication , type and frequency of self - monitoring , severe hypoglycemia , hemoglobin a1c ( hba1c ) , weight , and blood pressure were recorded before the dttp and then at every visit , usually quarterly .
data were obtained from the electronic patient record emil ( v4.3.9.79 ; marburg , germany ) were collected from general practitioners files .
data are described at baseline ( before dttp ) and at 6 months , 12 months , and 24 months after participation in the dttp .
hba1c was adjusted to dcct standards with an evaluated standardization procedure using local reference ranges.13 the dttp consists of four sessions once a week of 90120 minutes , including interactive training .
the topics of the dttp are basic information about diabetes , postprandial self - monitoring of urine glucose , physiology and pathophysiology , hypocaloric nutrition , withdrawal of insulinotropic oral agents when unnecessary , foot care , hypoglycemia , and exercise ( for details , see table 1 ) .
patients were trained to achieve glucose - free urine 2 hours postprandially and to tailor the type and amount of their food accordingly . if postprandial glucosuria - free tests correlated with the desired level of metabolic control , this inexpensive testing was considered to be sufficient .
the main teaching part of the dttp was performed by diabetes educators ( ie , nurses and dieticians with special postgraduate training ) .
primary outcomes are changes in hba1c , weight , and oads 24 months after training in the dttp .
a secondary outcome is the difference in hba1c between self - monitoring of urine glucose and blood glucose .
statistical analysis was performed with spss 14.0 ( spss , inc , chicago , il ) .
normally distributed values were registered as mean standard deviation and non - normally distributed values as median and range .
differences were statistically evaluated by t - test , mann - whitney u test , or test .
the dttp consists of four sessions once a week of 90120 minutes , including interactive training .
the topics of the dttp are basic information about diabetes , postprandial self - monitoring of urine glucose , physiology and pathophysiology , hypocaloric nutrition , withdrawal of insulinotropic oral agents when unnecessary , foot care , hypoglycemia , and exercise ( for details , see table 1 ) .
patients were trained to achieve glucose - free urine 2 hours postprandially and to tailor the type and amount of their food accordingly . if postprandial glucosuria - free tests correlated with the desired level of metabolic control , this inexpensive testing was considered to be sufficient .
the main teaching part of the dttp was performed by diabetes educators ( ie , nurses and dieticians with special postgraduate training ) .
primary outcomes are changes in hba1c , weight , and oads 24 months after training in the dttp .
a secondary outcome is the difference in hba1c between self - monitoring of urine glucose and blood glucose .
statistical analysis was performed with spss 14.0 ( spss , inc , chicago , il ) .
normally distributed values were registered as mean standard deviation and non - normally distributed values as median and range .
differences were statistically evaluated by t - test , mann - whitney u test , or test .
from the initial 126 trained patients we were able to re - evaluate 119 ( 94% ) after 24 months . at baseline , age was 61.5 years ( 10.29 years ) , time since diagnosis of diabetes was 5.57 years ( 6.53 years ) , body weight was 89.89 kg ( 15.88 kg ) , body mass index was 32.23 kg / m ( 5.74 kg / m ) , and blood pressure was 159/88 mmhg ( 24.69/12.18 mmhg ) .
of the patients , 39.4% ( n = 47 ) were newly diagnosed with type 2 diabetes , and 59.7% ( n = 71 ) were still cared for in the university outpatient department .
hba1c decreased significantly 6 months after education from 7.33% ( 1.59% ) to 6.89% ( 0.98% ; p = 0.001 versus baseline ) and was maintained for up to 12 months ( 7.02 1.07% ; p = 0.017 versus baseline ) , as well as up to 24 months ( 6.96 1.06% ; p = 0.005 versus baseline ) .
patients still attending our university outpatient department had a higher baseline hba1c than patients of general practitioners ( 7.61% versus 6.94% ; p = 0.024 ) and also a higher hba1c 12 months ( 7.23% versus 6.69% ; p = 0.008 ) and 24 months after education ( 7.18% versus 6.65% ; p = 0.007 ) .
hba1c decreased in both groups , but the change was significant only in patients cared for at the university hospital ( p = 0.027 ) . at baseline , 49.6% of patients had an hba1c of 7% and 10.1% > 9% .
twelve months after participation in the dttp , the number of patients with an hba1c 7% increased to 60.0% ( p = 0.001 ) , whereas the number with an hba1c > 9% decreased to 3.5% ( p = 0.069 ) .
these results were maintained after 24 months , with 58.8% having an hba1c 7% and 5% > 9% ( p = 0.112 versus baseline ) .
body weight decreased significantly from 89.9 kg at baseline to 87.8 kg after 6 months ( p = 0.001 ) , increased to 88.9 kg at 12 months ( p = 0.001 versus baseline ) , and was 88.5 kg 24 months later ( 1.4 kg compared with baseline ; p = 0.001 ) .
blood pressure decreased from 159/87 mmhg to 140/81 mmhg ( p = 0.001 ) 24 months after participation in the dttp .
changes in hba1c and body weight are shown in table 2 , changes in hba1c according to diabetes therapy at baseline and at 24 months are shown in figure 1 , and changes in body weight according to therapy are depicted in figure 2 . at baseline ,
31.1% of the patients were not on antidiabetic medication ( hba1c 6.75% ) , and 68.9% were on oads ( hba1c 7.60% ) .
twenty - four months after the dttp , 19.3% were still not on antidiabetic medication .
the baseline hba1c of this subgroup was 6.42% and remained constant ( 6.49% at 24 months ; not significant ) .
the body weight of this group decreased significantly from 92.5 kg at baseline to 90.3 kg at 24 months ( p = 0.014 ) .
the hba1c values of patients taking oads at 24 months ( 52.1% ) decreased slightly ( 7.14% at baseline ; 6.88% at 24 months ; not significant ) , whereas body weight decreased significantly from 87.4 kg at baseline to 85.1 kg at 24 months ( p = 0.001 ) .
hba1c of patients with insulin treatment at 24 months ( 28.6% ) decreased significantly from 8.33% at baseline to 7.43% ( p = 0.011 ) , but body weight increased from 92.7 kg to 93.7 kg ( p = 0.088 ) .
patients attending the university outpatient department were more often on insulin therapy at 24 months than patients in the care of a general practitioner ( 43.7% versus 6.3% , p = 0.001 )
. the methods of self - monitoring according to diabetes therapy are shown in table 3 .
only 53.8% of the patients performed self - monitoring at baseline , compared with 75.6% at 24 months .
both methods , ugsm and bgsm , were used at baseline by 4.2% and at 24 months by 5.0% . of those patients not on insulin therapy at 24 months , more preferred ugsm ( 36.5% versus 23.5% , p = 0.048 ) . there were differences concerning the self - monitoring method applied between those patients who were exclusively treated by a general practitioner and those who also attended the university outpatient department .
all patients treated in the university outpatient department used one kind of self monitoring ( ugsm or bgsm ) , but only 39.6% of patients treated by their general practitioner performed self monitoring ( p = 0.001 ) . at 24 months
, most patients not requiring insulin therapy and treated in the university outpatient department performed ugsm ( ugsm 65% ; bgsm 22.5% ) .
this compares with those patients who were treated by their general practitioner with most of them performing bgsm ( ugsm 11.1% ; bgsm 24.4% ) . comparing the hba1c of those patients not requiring insulin therapy applying ugsm or bgsm ,
no difference was found either at baseline ( 7.23% versus 7.04% ; p = 0.597 ) or at 24 months ( 6.91% versus 6.87% ; p = 0.855 ; figure 3 ) .
changes in hba1c and body weight are shown in table 2 , changes in hba1c according to diabetes therapy at baseline and at 24 months are shown in figure 1 , and changes in body weight according to therapy are depicted in figure 2 . at baseline ,
31.1% of the patients were not on antidiabetic medication ( hba1c 6.75% ) , and 68.9% were on oads ( hba1c 7.60% ) .
twenty - four months after the dttp , 19.3% were still not on antidiabetic medication .
the baseline hba1c of this subgroup was 6.42% and remained constant ( 6.49% at 24 months ; not significant ) .
the body weight of this group decreased significantly from 92.5 kg at baseline to 90.3 kg at 24 months ( p = 0.014 ) .
the hba1c values of patients taking oads at 24 months ( 52.1% ) decreased slightly ( 7.14% at baseline ; 6.88% at 24 months ; not significant ) , whereas body weight decreased significantly from 87.4 kg at baseline to 85.1 kg at 24 months ( p = 0.001 ) .
hba1c of patients with insulin treatment at 24 months ( 28.6% ) decreased significantly from 8.33% at baseline to 7.43% ( p = 0.011 ) , but body weight increased from 92.7 kg to 93.7 kg ( p = 0.088 ) .
patients attending the university outpatient department were more often on insulin therapy at 24 months than patients in the care of a general practitioner ( 43.7% versus 6.3% , p = 0.001 ) .
the methods of self - monitoring according to diabetes therapy are shown in table 3 .
only 53.8% of the patients performed self - monitoring at baseline , compared with 75.6% at 24 months .
both methods , ugsm and bgsm , were used at baseline by 4.2% and at 24 months by 5.0% . of those patients
not on insulin therapy at 24 months , more preferred ugsm ( 36.5% versus 23.5% , p = 0.048 ) .
there were differences concerning the self - monitoring method applied between those patients who were exclusively treated by a general practitioner and those who also attended the university outpatient department .
all patients treated in the university outpatient department used one kind of self monitoring ( ugsm or bgsm ) , but only 39.6% of patients treated by their general practitioner performed self monitoring ( p = 0.001 ) . at 24 months , most patients not requiring insulin therapy and treated in the university outpatient department performed ugsm ( ugsm 65% ; bgsm 22.5% ) .
this compares with those patients who were treated by their general practitioner with most of them performing bgsm ( ugsm 11.1% ; bgsm 24.4% ) . comparing the hba1c of those patients not requiring insulin therapy applying ugsm or bgsm ,
no difference was found either at baseline ( 7.23% versus 7.04% ; p = 0.597 ) or at 24 months ( 6.91% versus 6.87% ; p = 0.855 ; figure 3 ) .
the first evaluation of dttp for patients with type 2 diabetes not requiring insulin therapy was published in 1988.3 the program was primarily developed for general practitioners to improve care for diabetic patients .
patients had a significant reduction in bodyweight of 2 kg and the already good hba1c at study entry did not deteriorate in spite of 30% less oads used and none of the patients switching to insulin .
the following evaluations of this dttp in austria and latin america showed reductions in hba1c ranging from 0.4% to 1.1% after a follow - up of 612 months,4,1618 and a body weight reduction of 2.5 kg .
these favorable results are also shown in our study but with a considerably longer follow - up of 24 months .
the recently published desmond ( diabetes education and self management for ongoing and newly diagnosed ) study in the uk evaluated the effectiveness of another group education program in people with newly diagnosed type 2 diabetes mellitus19 and found that 12 months after education there was a greater weight reduction for those patients than for patients in the control group ( 2.98 kg versus 1.86 kg ) , without there being a difference in hba1c .
it is well known that a reduction in body weight reduces insulin resistance in patients with type 2 diabetes , which results in better metabolic control.3,8,14,18 in contrast to these results , patients in the uk prospective diabetes study assigned to diet therapy only had weight gain and the worst hba1c .
the different results might be caused by the dttp initiating behavior modification by the participating patients and the possibility of continuous feedback by self - monitoring .
a further reason for encouraging results is the absence of a diet plan in the curriculum used in our study . except for drinks with sugar and instant food ,
type and amount of food corresponds to the endogenous insulin present and to the person s individual insulin resistance if postprandial urine glucose tests are negative .
lifestyle interventions are effective , particularly in obese type 2 diabetes patients , but , in the long term , insulin treatment will become necessary in many people with type 2 diabetes .
initially , these patients had the worst baseline hba1c but the greatest improvement in metabolic control .
before starting insulin therapy these patients took part in another dttp conceived for patients with insulin therapy .
all those patients switched to insulin after the first evaluation of this program after 12 months.3 in the evaluation from pieber et al,4 no patient was on insulin therapy 6 months after education .
however , the hba1c value 6 months after education was 8.11% and considerably higher than in the study presented .
not surprisingly , patients on insulin therapy gained weight , as was reported in other studies starting with insulin treatment.15 however , weight gain was only 1 kg after 2 years . the number of sessions recommended in dttps is debatable .
the outcome of the dttp with only four sessions is not worse compared with a program with eight or twelve sessions.8 this program decreased hba1c from 8.1% to 7.4% and weight from 87.8 kg to 85.3 kg .
the highest decrease of hba1c was in patients on insulin , so the significant total hba1c reduction mainly derives from the reduction in hba1c of patients on insulin therapy .
it was not the target of the dttp to reduce the good hba1c , which was already at baseline in the target .
the aim for these patients was to maintain good hba1c for longer , and this aim was achieved .
it is likely that it is not the number of sessions that is important but the delivery of the program by the team who is responsible for the permanent care of the patient .
presented and evaluated , all patients not requiring insulin therapy are trained to perform postprandial urine tests for glucose . if postprandial urine is glucose free and matches the desired level of metabolic control after 36 months
nevertheless , some subgroups may require bgsm ( eg , patients with elevated or reduced renal threshold for glucose ) . whether bgsm has any advantages in patients not requiring insulin therapy treatment has been repeatedly evaluated and discussed . in a retrospective study from germany ,
martin et al10 showed a decreased diabetes - related morbidity and all - cause mortality in type 2 diabetes patients who received a prescription of bgsm material in spite of higher hba1c , compared with those not using bgsm , and this association was also present in a subgroup of patients not receiving insulin therapy . in the fremantle study from australia ,
davis et al11 did not find any difference in hba1c in bgsm users or nonusers , but bgsm was associated with a 79% increased risk of cardiovascular mortality in patients not treated with insulin.20 in addition , a large survey from austria and germany did not show any association between hba1c and the frequency of bgsm in type 2 diabetic patients not requiring insulin therapy.21 in the randomized controlled trials by miles et al9 and the recently published desmond study , bgsm was not superior to ugsm in respect of no self - control in patients with newly diagnosed type 2 diabetes.12 the results of our study support those findings that ugsm is not inferior to bgsm in well - trained patients , considering that most patients not requiring insulin therapy performed ugsm and that no difference in hba1c after 2 years was found .
the strongest limitation of our study is the lack of a control group . for ethical reasons , it is not possible to refuse patients participation in the dttp over 2 years .
furthermore , there are already controlled trials that have shown the effectiveness of the dttp but over a shorter period.3,4 another limitation is the possibility of a negative selection of patients , because we are a specialist university outpatient department
, the results of our study showed that a treatment and teaching program consisting of four sessions once a week effectively reduces hba1c and weight over 2 years , irrespective of the method of self - monitoring applied .
hba1c of patients without oads still met the target after 24 months . in patients on oads ,
twenty - nine percent of patients were on insulin therapy 24 months after the dttp .
glucose control ( hba1c ) was similar with ugsm ( 7.03% ) and bgsm ( 6.97% ; p = 0.807 ) at 24 months .
these findings suggest that postprandial urine testing is effective , as well as blood glucose control . more research is required to assess whether there is a difference in effectiveness between these types of self - monitoring .
patient education should be an integral part of the diabetes treatment , and all patients should have the opportunity to participate in the dttp . | objectivelong - term outcomes after participation in a structured diabetes treatment and teaching program ( dttp ) for patients with diabetes without insulin use , primarily based upon postprandial urine glucose self - monitoring ( ugsm).methodsa total of 126 patients took part in the dttp in a university outpatient department in 20042005 .
we re - evaluated 119 ( 94.4% ) at baseline and at 6 months , 12 months , and 24 months . hemoglobin a1c ( hba1c ) was dcct adjusted.resultshba1c decreased significantly 6 months after education from 7.33% ( 1.59% ) to 6.89% ( 0.98% ; p = 0.001 versus baseline ) and was maintained for up to 12 months ( 7.02% 1.07% ; p = 0.017 versus baseline ) as well as up to 24 months
( 6.96% 1.06% ; p = 0.005 versus baseline ) .
weight decreased from 92.5 kg at baseline to 90.3 kg at 24 months ( p = 0.014 ) .
a total of 36.5% of patients not on insulin therapy preferred ugsm , whereas 23.5% preferred blood glucose monitoring , at 24 months .
glucose control was similar in both groups at 24 months ( hba1c ugsm 7.03 versus blood glucose monitoring 6.97% ; p = 0.807).conclusionparticipation in the dttp resulted in long - term behavior modification .
hba1c of patients without insulin met the target 24 months after the dttp , irrespective of the type of glucose self - monitoring . |
as indicated in a recent systematic review relating to canada 's physical activity guidelines for older adults , exercise interventions ( comprised of aerobic and strength training ) in older adults can maintain or improve functional abilities .
less is known about the role of flexibility in the maintenance or improvement of functional abilities . while joint flexibility may decrease with age , with the potential to affect normal daily function
the 2009 american college of sports medicine ( acsm ) position statement exercise and physical activity for older adults
noted there is a lack of studies of the effects of range of motion exercises on flexibility outcomes in older populations and a lack of consensus regarding the prescription of stretching exercises for older adults . despite the lack of a synthesis of the literature to support the recommendation of the inclusion of a flexibility component to older adult exercise programs , many older adult activity programs place a considerable emphasis on flexibility . stretching exercises are used extensively in the rehabilitation context wherein injury or disease
may have resulted in a restricted range of motion specific to given joints , and the goal is to regain normal range of motion .
however , the present paper is focused not on stretching exercise for rehabilitation purposes but for the role of flexibility in general exercise prescription for older adults . in light of the significant benefits of an exercise program for an aging population , it is important to provide evidence - based prescription for older adult exercise programs and highlight areas of research requiring further investigation in order to maximize these benefits .
the goal of a flexibility program is to improve range of motion in the major muscle - tendon groups in accordance with individualized goals . for the majority of the aging population
, the goals may not be related to athletic performance , but rather performance of functional abilities in activities of daily living .
nevertheless , there is relatively little research on the potential benefits of flexibility - specific training interventions for this population in that context . despite the lack of research and
no known health benefits , again , there is still a tendency in the literature to mention flexibility training as a presumed component of fitness and beneficial adjunct to other forms of exercise .
therefore , the purpose of this systematic review is to investigate the functional outcomes of flexibility specific training in older adults .
a search strategy was developed , where all reasonable expressions of the concepts of aging , flexibility , functional outcomes , and training interventions were considered ( see appendix for a sample search strategy ) .
a comprehensive electronic literature search was conducted on five online databases : pubmed ( ncbi ; 1950- ) , embase ( ovid ; 1974- ) , cinahl ( ovid & ebsco ; 1982- ) , scopus ( 1823- ) , and sportdiscus ( ebsco ; 1800- ) .
the final inclusion criteria for this paper were ( 1 ) an original research article , ( 2 ) human subjects , ( 3 ) an intervention study , ( 4 ) flexibility training was an independent intervention or was used as a control , ( 5 ) aged population ( mean age 65 years ) , and ( 6 ) the population was healthy but allowing for arthritis , osteoarthritis , and those residing in assisted living ( based on age and risk , not diseases or other medical conditions ) . for this paper , healthy
was operationally defined as community - dwelling and assisted living with the health and function and cognitive ability to participate in light physical activity interventions and complete physical function measures .
interventions targeting specific chronic conditions ( aside from arthritis and osteoarthritis ) were excluded from review . despite their use in flexibility training , tai chi- and yoga - based studies were excluded from this paper because by nature they include strength components .
the citations and applicable electronic versions of the article ( where available ) were downloaded to an online research management system ( refworks , bethesda , md , usa ) .
two reviewers independently ( rl , ls ) evaluated the articles for relevance using standard systematic review methodology leading to further consideration of 22 articles .
level 1 screening was based on article titles , level 2 was based on the title and abstract , and level 3 was a full text screening .
the articles that progressed through to level 3 were retrieved electronically or manually via the canadian interlibrary system and were printed from electronic copy .
any cross - referenced articles from the reference section of level 3 articles were hand - screened .
data from the included studies were extracted ( table 1 ) and organized by the target muscle groups of the flexibility interventions .
one reviewer performed the data extraction for each paper assigned to them and the extraction was verified by another reviewer .
the reviewers were not blinded to the journal or the author names when extracting information from the articles .
the approach used to establish the level and grade of evidence was consistent with lau et al . which provide
thus , the strength of the evidence was assessed for flexibility interventions and functional outcomes in older adults with respect to general recommendations and appropriate dose .
the downs and black scale was selected to assess the quality of each study as it is appropriate to evaluate nonrandomized investigations , and it contained the highest number of relevant items for the needs of this paper .
however , as not all items were relevant to the various study types included in this paper , a modified version of the checklist was employed for each of rcts ( randomized control trials ) , and non - rcts study types .
thus , the quality of each study was also established similar to the method of gorber et al . to include the most relevant components of the scoring tool .
therefore , a modified version of the downs and black checklist was used with the final checklist consisting of 22 items with a maximum score of 24 points for the studies of a rct design ; 22 items for non - rct designs with a maximum score of 23 ; experimental single group interventions had a maximum score of 18 from 18 items ; experimental single - group and single - session studies were based on 14 items for a maximum score of 14 .
due to the heterogeneity across study populations , methods used , and outcomes assessed , we conducted a narrative synthesis of the results .
twenty - two articles were ultimately included after meeting level 3 inclusion criteria ( figure 1 ) . of the final 22 articles ,
quality assessment indicated that the rct studies ( n = 13 ) were of good quality with an average score of 18 out of 24 .
the non - rct studies ( n = 6 ) had an average score of 14 out 23 .
an average score of 12 out of 18 was assessed for the experimental single - group studies ( n = 3 ) .
fourteen articles were conducted in the united states [ 1012 , 14 , 15 , 17 , 18 , 20 , 22 , 2529 ] , while the remainder of the studies were from japan , brazil [ 23 , 24 ] , turkey , australia [ 9 , 16 ] , taiwan , and canada .
the mean sample age was 74.1 years , ranging from 64 years to 88.8 years .
seven studies included populations that were 80 years of age [ 10 , 11 , 13 , 14 , 18 , 25 , 27 ] .
the number of participants in the articles of this paper ranged from 7 to 132 .
there were a total of 1127 participants , 841 of whom were female ( 75% ) , while 286 were male .
twenty studies were based on community - dwelling populations , and two studies involved individuals residing in assisted - living facilities [ 10 , 13 ] .
one study also used brain imaging for the purposes of identifying changes in hippocampal volume with training .
a common outcome measure was simply whether there was a change in range of motion usually assessed by goniometry [ 15 , 17 , 20 , 2428 , 30 ] .
the inclusion of these studies in the review ( although they reported no functional outcome ) was to provide the data for the purpose of determining whether older adults would , in fact , improve range of motion about different joints with various flexibility exercise programs .
functional outcomes were operationally defined as tests or measures designed to reflect abilities for various levels of daily activities and potentially related to maintenance of independence of older adults . in general , these tests assessed ability in a function that involved more than a single fitness component ( e.g. , not just a strength measure of a weight that could be lifted , but rather a performance that may involve strength and power as well as balance and agility ) . the most commonly used tests of functional outcome were gait and various walking speeds [ 11 , 13 , 14 , 19 , 21 , 22 , 26 ] , the sit - and - reach test [ 10 , 1214 , 19 , 29 ] , the sit - to - stand test [ 9 , 12 , 14 , 16 , 18 , 19 ] , functional reach test [ 9 , 10 , 21 , 26 ] , step test [ 9 , 16 ] , timed up - and - go ( tug ) [ 10 , 13 , 14 , 16 , 19 , 24 , 26 ] , and romberg test [ 11 , 21 ] .
other functional outcome measures were berg balance scale , questionnaires [ 9 , 12 ] , peg board , red - light - green - light , lequesne 's index of disability , the physical performance test ( ppt ) , and the gallon jug shelf test . gait and walking speed proved to be more positively affected by flexibility training than other outcome measures [ 14 , 19 , 21 , 22 , 26 ] , although this was not entirely consistent [ 11 , 13 ] .
several studies showed increases in flexibility - related outcomes , but lacked significant changes in other more applicable and generic measures of functionality .
this study found that knee torque and timed up - and - go showed improvements compared to the control group , which persisted for four weeks after intervention . in the sub - group containing eight studies of the very old ( 80 years ) ,
frail , and assisted - living populations [ 10 , 11 , 13 , 14 , 18 , 21 , 25 , 27 ] , there were significant improvements seen in functional reach , sit - to - stand [ 10 , 14 ] and 30 m walk times , but no changes in the ppt and mixed results for flexibility , strength , balance , and tug tests .
as compared to studies on less aged independently - living populations , the outcomes results of this sub - group were similar , except that the more aged / dependent group had less consistent flexibility outcomes ; there were some neutral outcomes and some negative changes following flexibility training .
six out of the 22 studies included several functional outcome measures and were considered most relevant to this paper [ 1114 , 16 , 19 ] , and are individually reviewed herein .
four of the six conducted randomized control trials ( rct ) [ 1114 ] , and only two studies reported sample sizes less than 68 participants .
brown et al . conducted a 12-week rct ( n = 87 ) , wherein the flexibility trained group demonstrated only flexibility measure improvements and no change in functional outcomes .
the measures included were very practical and included the chair stand , picking up a penny , putting on and taking off a coat , and the romberg balance test .
however , it should be noted that this study also showed minor strength and balance losses . in a one year rct ,
king et al . , similarly , showed no change in most functional outcomes in the flexibility trained group .
functional measures included lift - and - reach , sit - to - stand , sit - and - reach , self - rated physical performance , self - efficacy for physical performance scale , and perceived functioning and well - being .
there were only significant increases for the sit - and - reach test in men only ( 10.4 to 11.9 inches ) and decreases in self - rated daily bodily pain scores ( by 7.3% for women and 9.4% for men ) .
timed up - and - go increased ( worsened ) from 27 to 33 seconds , and no changes were seen in any other functional measures or in the sit - and - reach test .
additional functional measures included strength tests , berg balance scale , self - paced and fast - paced walk tests , stair - climbing , and the functional independence measure for functional capacity .
stanziano et al . employed an 8-week rct ( n = 17 ) , where the experimental flexibility group significantly improved in every measure : chair stand repetitions ( 11 to 13 ) , modified ramp power ( 69 w to 86 w ) , arm curl repetitions ( 12.9 to 18.8 ) , gallon jug shelf test ( 13.4 to 11.5 seconds ) , 8 foot timed up - and - go ( 8.7 to 7.6 seconds ) , and 50 foot gait speed ( 13.9 to 12.3 seconds ) .
the study by bird et al . was a 32-week randomized cross - over design ( n = 32 ) with 16 weeks spent in the flexibility group .
four functional outcomes improved significantly for the flexibility group : tug ( 7.6 to 6.6 seconds ) , sit - to - stand ( 22.6 to 18.0 seconds ) , step test ( 13.5 to 17.6 steps ) , and mediolateral sway range ( eyes open : 4.16 to 2.97 cm ; eyes closed : 6.87 to 5.64 cm ) .
strength was also tested , with no improvement by the flexibility group . in a 12-week non - rct ( n = 117 ) , takeshima et al .
reported no improvements for the flexibility trained group in the 12-minute walk , arm curls , chair stand , tug , functional reach , back scratch , and sit - and - reach .
these six studies exemplify the mixed results of the functional outcome measures in this paper .
they serve as a strong representation of the lack of consistency of functional outcomes in the literature and therefore , any specific recommendation regarding type or frequency of stretching exercises is premature .
overall , seven of 22 studies demonstrated mostly positive functional outcomes [ 9 , 10 , 14 , 16 , 21 , 23 , 29 ] , while six reported mostly negative functional results , that is , no improvement in variables [ 1113 , 18 , 19 , 22 ] .
ten studies showed no functional outcome measures [ 15 , 17 , 20 , 2430 ] and only reported changes in flexibility and rom ( although they purported to relate flexibility to function , and were included for their results related to the ability of older adults to improve flexibility ) .
there were no obvious differences between the characteristics of the studies with positive , negative , or no functional outcomes .
twelve studies used flexibility training as the sole intervention [ 10 , 11 , 14 , 17 , 2127 , 29 ] , four studies used flexibility training as a significant part of an intervention protocol [ 15 , 16 , 19 , 30 ] , five studies used flexibility as a control group to compare with various other exercise interventions [ 9 , 1113 , 18 , 20 ] , and four studies utilized flexibility exercises along with strength or aerobic exercise in the intervention protocol but in the control group , the entire exercise protocol was flexibility exercises [ 9 , 11 , 13 , 20 ] . the types of flexibility training methods varied from simple static stretches ( 19 studies ) to different proprioceptive neuromuscular facilitation ( pnf ) techniques ( 1 study ) .
passive static stretching was the most common method used [ 9 , 1113 , 16 , 1829 ] , while passive static stretching with added weights was used once , active - assisted ( aa ) was used twice [ 14 , 30 ] , active and passive were used in conjunction once , contract - relax ( cr ) pnf was used once , contract - relax - agonist contract ( crac ) pnf was used once , and hold - relax - agonist contract ( hrac ) pnf was used once as well .
active - assisted stretching had positive and sometimes significant improvements in several outcome measures as compared to the inactive control group , but less significant than the improvements seen with the pnf techniques .
weighted flexibility exercises were similar to nonweighted exercises in one study , but significantly better than nonweighted exercises in another .
thirteen studies involved whole body flexibility training [ 921 ] , two focused on hips and calves [ 22 , 23 ] , one focused on hamstrings , three focused on calves [ 2527 ] , one focused on hip flexors , one focused on the trunk , and one study focused on the quadriceps muscles .
whole body flexibility training showed some minor to significant increases in outcomes ; however , most increases were seen in rom and flexibility measures , per se , and not in other functional outcome measures .
these results were consistent with the overall effects of specific isolated stretching interventions on outcome measures for the related specific body parts .
the mean length of the included studies was 14.2 weeks , ranging from 4 weeks to one year [ 12 , 20 ] .
in the three studies of at least 25 weeks in duration [ 12 , 15 , 20 ] , no functional outcome measures were improved other than flexibility and rom . in the four studies with durations of 6 weeks or less [ 2325 , 27 ] tug improved from 8.4 to 7.2 seconds ,
walking velocity increased 1.07 to 1.22 m / s , and flexibility and rom were improved overall .
the mean frequency was 4-exercise sessions per week , ranging from the lowest frequency of twice per week [ 9 , 10 , 12 , 22 , 24 ] to 14x / week [ 27 , 28 ] .
two studies did not report exercise frequency [ 20 , 22 ] . some results from these studies include a tug time decrease from 8.4 to 7.2 seconds and a no - change , sit - to - stand time decreased from 10.2 to 9.2 seconds and 9.3 to 7.9 seconds and a no - change , a step test increased in reps from 16.5 to 20.2 , and an increase in freely chosen gait speed from 1.23 to 1.30 m / s .
the 5x / week and 14x / week studies did not include functional outcomes similar to the twice weekly studies .
the 3x / week studies included results such as an improved tug time from 7.6 to 6.6 seconds and a worsening time from 26.8 to 33.0 seconds , a functional reach improvement of 16.0 to 19.6 cm and two no - changes [ 19 , 26 ] , a sit - to - stand improvement of 22.6 to 18.0 seconds , a step test improvement of 13.5 to 17.6 repetitions , a 10 m walk time improvement from 6.44 to 5.99 seconds , and a 30 m walk time improvement from 28.1 to 20.0 seconds .
although limited in number , these results show that the frequency of the flexibility training interventions had no noticeable differences compare with 2 and 3 times per week .
the mean flexibility exercise session time was 32 minutes , ranging from 30 seconds to 85 minutes .
there are currently scientific discussions regarding the utility of stretching exercises which are regularly recommended and conducted as a part of preexercise protocols to reduce injury and increase performance .
earlier reviews of stretching and flexibility have questioned their value in terms of injury prevention , delayed onset of muscle soreness , and improvement of performance [ 31 , 32 ] . in fact , what occurs physiologically with stretching remains unknown .
due to equivocal evidence thus far , the current american college of sports medicine 's guidelines for exercise testing and prescription recommended the removal of static stretching as part of a warm - up routine for strength and power activities . additionally , based on available evidence ,
the 2011 acsm position statement for guidance on prescribing exercise suggests performing flexibility after cardiorespiratory endurance or resistance exercise for general fitness programs .
this position stand highlighted the need for further research to ascertain the effects of various flexibility prescriptions for various activities and performance goals .
from the present review , there is not enough consistent evidence to make recommendations for any specific prescriptions of type , frequency , duration , or length of program related to flexibility training ; particularly no specific recommendations can be made regarding the program or dose response of flexibility training to the focus of the present study , the transfer of flexibility gains to functions of daily life , or ability to live independently . a recent systematic review of 106 articles relating the effects of pre - exercise acute - passive static stretching on maximal muscle performance provided 74 methodologically sound studies providing 104 findings .
this paper showed that 50% of the 104 findings reported significant reductions in task performances , and the authors concluded that static muscle stretches totaling less than 45 s can be used in pre - exercise protocols without significant decrement to strength , power or speed type tasks ; thus a conclusion was to recommend stretches held for at maximum 45 s to avoid loss of strength .
shrier had also previously reported the potential negative acute effects of stretching on performance , but additionally reviewed the literature regarding regular stretching on performance which indicates that regular stretching improves force , jump height , and speed performance .
both reviews recommend further synthesis of the literature with respect to the effects of other forms of stretching on various performance measures .
the difficulties of the ability of this paper to provide a consensus on flexibility training prescription for healthy older adults include the lack of well - conducted studies focused on flexibility in older adults and the lack of consistency in the flexibility protocols employed , functional outcomes measured , and functional results observed . as such , according to the criteria used to assess level of evidence , to recommend stretching / flexibility exercises as a routine component of an exercise program for older adults to enhance health or functional abilities is level 4 , grade c. the more influential studies in this paper ( based on focused flexibility protocols with clear functional outcomes and relatively large sample sizes ) [ 1114 , 16 , 19 ] showed very comparable effects to the overall outcomes of the 26 studies , namely , an ambivalence in the value of flexibility training on functional outcomes that may be related to maintenance of independence in daily activities of older adults .
of these six studies , 5 were rcts with an average quality assessment score of 18 out of 24 .
only two of the six showed improvement in flexibility and functional outcomes ( 16/24 ; 19/24 ) . in the sub - group ( 80 years ) ,
frail , and assisted - living populations there were significant improvements seen in functional reach , sit - to - stand , and 30 m walk times , but no changes in the ppt , and mixed results were observed for flexibility , strength , balance , and tug tests .
this sub - group was similarly ambivalent in the role of flexibility training with functional outcomes to the rest of the study populations , although this group had less consistency in the flexibility - related outcome measures .
when different muscle groups were targeted , the flexibility outcomes were expectedly fairly body - part specific . regarding the different flexibility training methods , active - assisted ( aa ) stretching had positive and sometimes significant improvements in several outcome measures as compared to the inactive control group , but less significant than the improvements seen with the pnf techniques .
weighted flexibility exercises were similar to nonweighted exercises in one study , but significantly better than nonweighted exercises in another .
one study showed acr - pnf to be much more effective than cr - pnf and static stretching for both rom and emg activity .
the overall results point to pnf stretching being more effective than non - pnf techniques for improving flexibility outcomes , but not necessarily functional outcome measures . while flexibility training interventions synthesized in the present paper have been shown to increase flexibility and joint rom , no consistent increases in functional outcomes have been observed .
therefore , future studies should consider the relationship that increased flexibility and joint rom have with functional outcomes to determine if the increased flexibility is beneficial and worthwhile in terms of maintaining or increasing functional capacity for healthy older adults .
more research is also needed regarding the relationships between outcome variables ( i.e. , how one variable such as functional reach would relate to another variable such as the timed up - and - go ) and on the relationships between outcome measures and quality of life through self - reported functioning / quality of life questionnaires to best determine the applicability of the outcome measures .
older adults are less concerned with high performance benefits from increased flexibility and more focused on being safely active and safely performing activities of daily living .
injury and fall prevention are also common motives for recommending flexibility programs to older adults .
the 2011 acsm position statement notes that flexibility training may enhance postural stability and balance when combined with resistance training ; however , no consistent link has been shown between regular flexibility exercise and a reduction of musculoskeletal injuries or delayed onset of muscle soreness .
however , despite the growing literature describing the relationship of flexibility to injury risk in younger populations , there is little research regarding older adults .
this paper found that flexibility training interventions in older adults are often effective at increasing joint range of motion in various joints , and various functional outcomes can be improved .
however , due to the wide range of intervention protocols , body parts studied , and functional measurements , conclusive recommendations regarding flexibility training and functional outcomes for older adults remain ungrounded . as such , a specific prescription of
how long to hold a stretch , how many repetitions of each stretch to conduct , and the type of stretches to do , is not determinable at this point . because there is conflicting information regarding both the relationship between flexibility training interventions and functional outcomes , and the relationship between improved flexibility and daily functioning and health benefits
have not been established , future research studies should attempt to address these issues . while there is a lack of evidence to recommend stretching routines outside of a rehabilitative context
, there is no additional health or functional risk of including flexibility exercises . as such , in light of increases in functional outcomes achieved by other exercise modes ( balance , aerobic exercise , and strengthening exercises ) , stretching exercises can be included as an adjunct to the above , but the current literature would indicate it would add little to the functional benefits of the other exercise modes . of note , the evidence - based and expert consensus statements of physical activity guidelines for older adults of the us , the uk , canada , and the world health organization ( global recommendations ) have not included flexibility as a component in the recommendations . | background . as indicated in a recent systematic review relating to canada 's physical activity guidelines for older adults , exercise interventions in older adults can maintain or improve functional abilities .
less is known about the role of flexibility in the maintenance or improvement of functional abilities , and there currently does not exist a synthesis of the literature supporting a consensus on flexibility training prescription .
purpose . to systematically review the effects of flexibility - specific training interventions on measures of functional outcomes in healthy older adults over the age of 65 years
. methods .
five electronic databases were searched for intervention studies involving concepts related to aging , flexibility , functional outcomes , and training interventions . after evaluating the articles for relevance , 22 studies were considered .
results .
the results suggested that while flexibility - specific interventions may have effects on range of motion ( rom ) outcomes , there is conflicting information regarding both the relationship between flexibility interventions and functional outcomes or daily functioning .
conclusions . due to the wide range of intervention protocols , body parts studied , and functional measurements , conclusive recommendations regarding flexibility training for older adults or the validity of flexibility training interventions as supplements to other forms of exercise , or as significant positive influences on functional ability , require further investigation . |
in each country , the government and health system are responsible for providing sufficient and cost - effective health and curative care . moreover , increasing the accessibility and utilization of health services are critical for improving health systems .
primary health care is largely financed and delivered by public sector while the secondary and tertiary level care are provided by both public and private in iran . despite increasing the insurance coverage in iran , 10 - 20% of population
is not covered by any insurance and according to the who report , over 58% of health expenditure is out - of - pocket in 2001 . protecting households from the risk of impoverishment due to out - of - pocket expenses for health care
it is because out - of - pocket payments can make some of families face with catastrophic costs and pay an important proportion of income for health care .
sometimes , low cost payment for common illnesses can financially affect the poor households with no insurance to cover catastrophic costs .
household health expenditure is defined catastrophic when the ratio of the household 's out - of - pocket health expenditure and its disposable income goes from 30% or 40% of capacity to pay , or if it reaches 10% of total expenditures .
therefore , in developed countries protecting household and people from catastrophic spending by social institutions such as social insurance is established as an ideal goal in health policy .
the out - of - pocket health expenditure varies among countries according to their health policies and insurance coverage from 1.6% of total health expenditure in niue to 80% in vietnam , 82.9% in guinea , and 90% to cambodia according to the reports .
based on who report , the out - of - pocket cost for health expenditure was 58% in 2001 .
furthermore , the out - of - pocket costs can even have a preventive effect for seeking and obtaining health care due to financial burden .
as such , the aim of this study is to evaluate some specified time and cost expenditure for inpatient and outpatient care as well as assess the predictors of catastrophic costs for inpatient care in markazi province of iran .
this study was a cross - sectional one in which 760 households was selected by multistage sampling method in markazi province of iran . in the first stage ,
then , in each stratum random cluster sampling was used to select the eligible cluster . in the final phase ,
the study included those households of which all members were volunteers and if one member was not so , that household was excluded .
data were collected by a standard questionnaire that had been used previously in health utilization care survey in 2002 .
the interview was conducted with all family members , excluding those subjects who were under 15 years old or unable to respond to the questions .
their mothers or nurses were interviewed . if one of the family members did not fulfill the interview , that household was excluded from sampling . beside some demographic factors such as age , gender , having insurance and socio - economic variables , the usage of inpatients and outpatient care was asked in the interview sessions .
moreover , data of time spending and cost for receiving care were included in the interview .
catastrophic cost was evaluated in a scale that varied from 0 to 100 . in this scale ,
the financial sources for paying inpatient care were assessed as 0 = no cost , 25 = over 50% of household month income , 50 = all household month income , 75 = using saved money or borrowing inside of all income , 100 = selling out all wealth .
catastrophic costs were defined as payment over 40% of total household financial sources for taking inpatient care .
however , catastrophic cost has been defined in recent studies as households with over 40% of capacity to pay out - of - pocket for health . in the current study , patients who paid over 20% of household financial sources or 40% of month income were regarded as being exposed to catastrophic costs since data of income and food expenditures were not collected due to poor validity in our study population as is the case in other developing countries .
the results of the current study were calculated for 802 and 284 subjects who were reported to need outpatient and inpatient care , respectively .
wealth index was created by principle component analysis ( pca ) on 12 asset variables including vehicle , refrigerator , liquid - crystal - display television , indoor and healthy toilet and bathroom , washing and dishwasher machine , microwave oven , mobile , private computer , access to internet , and house ownership .
robust estimator in negative binomial method was used for removing the clustering effect of household and modeling of most important predictors of catastrophic costs , respectively . all data analysis conducted in spss chicago inc ( version 16 ) software and p value considered at 0.05 .
wealth index was created by principle component analysis ( pca ) on 12 asset variables including vehicle , refrigerator , liquid - crystal - display television , indoor and healthy toilet and bathroom , washing and dishwasher machine , microwave oven , mobile , private computer , access to internet , and house ownership .
robust estimator in negative binomial method was used for removing the clustering effect of household and modeling of most important predictors of catastrophic costs , respectively . all data analysis conducted in spss chicago inc ( version 16 ) software and p value considered at 0.05 .
out of all 760 target household , 758 household were interviewed correctly and 2711 subjects answered the questions ( response rate 99.74% ) . of all participated households 28.5% ( 216 households ) were reported to have inpatient need for health care at least for one of the family members in the previous year .
overall , 10.5% ( 284 subjects ) of all studied participants had reported in patient need care in the year prior to the interview .
50.7% ( 144 subjects ) of the households with inpatient need were residing in urban areas and 87.3% ( 248 subjects ) were insured .
in addition , 35.1% of participants ( 952 subjects ) were reported to have outpatient need for care in the last 2 weeks before the interview .
seeking care for inpatient and outpatient care was 91.5% and 67.4% , respectively . using care after seeking it for inpatient and outpatient care was 97.6% and 97.7% , respectively for all subjects .
the most important causes of not attempting to seek care were lack of money 31.4% , self - treatment 20.9% and lack of time 18.6% for outpatient care and lack of money and family problems for inpatient care .
the mean of time expenditure for receiving outpatient care is presented in table 1 on subjects who were seeking it . according to the results of table 1 , patients who needed outpatient care reached care in 13 min , but the time spent for outpatients care was equal to 105 h approximately . as shown in table 2 ,
the mean cost expenditure for each outpatient and inpatient care was 10.5 $ and 326 $ , respectively .
the highest out - of - pocket cost was related to drugs and medical equipment in the first rank and commuting to / from the clinic for outpatient care while the one related to the hospital treatment costs was the most important cause for out - of - pocket cost in inpatient care .
time expenditure for receiving outpatient care in subjects whom seeking them cost expenditure for receiving outpatient and inpatient care in dollar according to the results , 42.6% ( 121/284 ) of hospitalized subjects encountered with catastrophic costs .
in addition , 11.2% ( 85/758 ) households faced catastrophic costs among all participated households and 39.3% ( 85/216 ) were reported to need inpatient need care .
negative binomial model results [ table 3 ] showed that the age range 40 - 59 years is one of the predictors of facing catastrophic costs ( p < 0.05 ) .
furthermore , based on the results only being in the richest level of wealth index did not show a significant relationship with facing catastrophic costs while the other levels of wealth index showed significant association .
on the other hand , being in the first to fourth quintile of wealth index was the highest predictor of facing catastrophic costs ( p < 0.05 ) . moreover , being insured , complementary insurance , sex , job type , and educational level did not show any significant association with catastrophic costs ( p > 0.05 ) .
predictors of exposing to catastrophic costs in subjects with inpatient need according to negative binomial model
the prevalence of un - using care after seeking it in our study was low and less than 5% for in- and out - patient care .
our results showed that nearly 10% of subjects with inpatient need and 35% of subjects with outpatient need did not seek them due to the lack of money and time .
this finding is in accordance with results of another study that has been conducted in iran . in hosseinpoor
however , another study showed that around 40% of the population did not seek care from medical providers after the need .
11.2% of all participated households and 39.3% of households with hospitalized patients encountered with catastrophic costs . in another study by kavosi et al
the proportion of household with catastrophic cost was calculated based on xu method and it was shown to be 11.8% and 12.6% for 2003 and 2007 , in tehran , respectively .
another study in ghazvin showed that 24% of households experienced catastrophic cost , but only 3% of it was due to hospitalization costs .
furthermore , gotsadze et al . showed that in georgia the proportion of catastrophic cost was 11.7% in 2007 .
these result showed that paying out over 20% of household financial sources or 40% of month income can be defined for catastrophic costs , if data of food expenditure do not exist .
another advantage of using total expenditure is in removing the recall bias during the study for data collection of disposable incomes , since the validity and reliability of these data were not assessed in developing countries .
however , another study in iran estimated that in 2007 only 2.5% of households were exposed to catastrophic cost that was lower than that in other studies .
it is a considerable estimate , but the method for calculating this result is different with the above - mentioned studies . according to binomial negative model , the age range of 40 - 59 years old was as an important factor for facing catastrophic costs .
however , some studies also showed household members with low age range ( younger than 12 years old ) can be related to financial health expenditure .
moreover , based on regression results , being in the richest level of wealth index can prevent household from encountering catastrophic costs .
the rate of facing catastrophic costs in uganda was higher in poor people than the nonpoor .
another interesting finding in our data was the increasing trend of odds ratio by decreasing the level of wealth index .
however , being in the poorest level of wealth index increases the chance of facing catastrophic health expenditure up to 48% while being in the second , third , or fourth level increases this chance up to 36% . according to the results
, it is concluded that poor people are more susceptible to poverty from catastrophic health expenditure .
furthermore , the most important factors determining the financial catastrophe health expenditures in our study are hospitalization due to inpatient care need ; household members aged 40 - 59 years old especially with chronic diseases and nonrich status of the household .
however , our results showed that only 8.5% of subjects with inpatient need did not seek it ; however , it is considerable that the most important factor for un - seeking care was reported to be lack of money .
therefore , in our study and other studies evaluating hospitalized patients , the ratio of households with catastrophic health expenditure was underestimated . household capacity to pay
is not considered as its total effective income , but as defined as effective income after providing subsistence needs .
since the data of income in developing countries is not reliable and valid , expenditure cost is suggested as a surrogate variable .
however , in the current study , we have not subsistence expenditure to calculate the average food expenditure for the 45 and 55 percentile households that were suggested by cavagnero et al . moreover , the monitoring and tracing the change in out - of - pocket health expenditure and catastrophic cost is very difficult and limited due to cultural and methodological issues .
however , this study could reflect some health expenditure for inpatient and outpatient care in iran based on a national survey data .
in addition , the amount of expenditure costs for in- and out - patient care is determined regarding each service , separately .
furthermore , based on these results , the lack of money was the most important factor for un - seeking care and the most of out - of - pocket cost was related to drugs and medical equipment .
hence , the government and ministry of health should enforce the insurance companies to increase the financial coverage of drugs and medical equipment .
this policy helps people increase health care utilization and decrease the out - of - pocket cost .
however , we could not determine the costs for outpatient care due to lack of data . and because gathering data from all provinces was inaccessible ,
the most important causes of un - seeking care are lack of money and time , self - treatment and family problems .
the rate of patients with catastrophic health expenditure is higher than that in the developed countries .
hospitalization due to inpatient care needs , household members aged 40 - 59 years old especially with chronic diseases and nonrich status of the household are the strong predictors of facing catastrophic costs . | background : protecting households from risk of impoverishment due to out - of - pocket costs in health care is a major challenge for health systems .
therefore , this study aimed at evaluating some health expenditure of inpatient and outpatient care as well as assessing the predictors of catastrophic costs for inpatient care in one of central provinces of iran.methods:in this cross - sectional study , 760 household were selected by multistage sampling method in markazi province of iran and interviewed in order to complete a standard questionnaire .
catastrophic costs were evaluated in a scale that varied from 0 ( no money for care ) to 100 ( spending all income and wealth ) .
patients who were paid over 20% of household financial sources or 40% of month income were regarded as being exposed to catastrophic costs .
negative binomial model with robust estimator logit function was used for prediction of catastrophic costs.results:based on data analysis , 42.6% of hospitalized subjects encountered catastrophic costs . moreover ,
11.2% households faced catastrophic cost among all participated households and 39.3% were reported to need inpatient need care .
multivariate regression model showed that age range 40 - 59 years and being in the lower levels of wealth index were significant predictors of facing catastrophic costs ( p < 0.05).conclusions : lack of money is the most important cause of un - seeking care .
hospitalizations due to inpatient care needs , household members aged 40 - 59 years old , especially with chronic diseases and nonrich status of the household were the highest predictors of facing catastrophic costs . reducing out - of - pocket costs can increase health care utilization . |
recent technological advances in endoscopy have supported a flood of new diagnostic methods , collectively reported as consensus terminology .
the narrow band imaging ( nbi ) used in this study fits into the well - studied image - enhancing endoscopy ( iee ) category [ 225 ] as autofluorescence imaging ( afi ) [ 2124 ] , as distinct from standard imaging with white light .
there is almost uniform agreement that magnifying endoscopy combined with crystal violet ( cv ) staining is useful for pit pattern delineation [ 2642 ] .
however , this diagnostic imaging technique is not widely used because it is troublesome and time - consuming , and because mucus on the lesion surface may obstruct image acquisition .
magnifying endoscopy with nbi observation ( me - nbi ) , by contrast , does not involve a complicated technique and provides vascular information in a simple way .
me - nbi provides a simple and fast alternative for vascular imaging that is widely used to examine tumors in the upper gastric tract including the esophagus and stomach for diagnostic purposes [ 27 ] .
nbi has also been used successfully for endoscopic examination of the lower gastrointestinal tract [ 825 ] . in japan ; however , the capillary network classification using me - nbi is not popular due to its complication and each medical institution tends to adopt their own classification [ 1114 ] .
an important point with nbi observation is establishing early in the diagnosis whether the cancer is best resected endoscopically or surgically .
if this point can be resolved , me - nbi has great potential as an additional tool in the diagnosis and treatment of colon cancer .
this study histopathologically evaluated submucosal invasive cancer ( sm cancer ) by me - nbi examination in comparison to the images obtained by confocal laser - scanning microscopy , as a simple and useful means of selecting the appropriate therapeutic intervention .
the study analyzed 515 colon tumors in patients who underwent endoscopic or surgical resection at the jikei university hospital from september 2005 to march 2010 .
these lesions were preoperatively performed with examination by using me - nbi and magnifying observation cv staining by two experienced specialists ( s.s .
cf - h260azi and cf - fh260azi endoscopes were used in this study ( olympus medical systems co. , ltd tokyo , japan ) .
figure 1 depicts the capillary - pattern classification into four groups used in this study ; pattern 1 capillaries followed an unrecognized course ; pattern 2 capillaries were slightly dilated ; pattern 3 capillaries were markedly dilated ; pattern 4 was characterized by sparse capillaries not following an obvious vascular course in the lesion .
pattern 3 was further divided into 2 subtypes , whereby one subtype of capillaries assumed a regular course , while the other featured irregularities such as capillary tortuousness , abrupt caliber change , and heterogeneity in shape .
since the type iv pit pattern is observed indirectly in the former subtype , along with a villous component , capillaries of this type were classified as a 3-villous pattern ( pattern 3v ) .
sm cancer was classified as slight ( sm - s ) if the depth of invasion was 1000 m or massive ( sm - m ) cancer if the depth of invasion exceeded 1000 m according to the general rules for clinical and pathological studies on cancer of the colon , rectum and anus .
cancers were measured as recommended by the japanese society for cancer of the colon and rectum .
pathological examinations were performed on he stain by a single pathologist ( m.i . ) , with extensive experience in gastrointestinal tract histopathology without prior knowledge of the endoscopic findings . for immunofluorescent microscopy ,
cells were fixed with 1% paraformaldehyde in a 0.1 m phosphate buffer for 30 min each at 4c .
the specimens fixed in this way were washed in phosphate - buffers saline ( pbs ) and treated with 0.5% triton x-100 in pbs for 5 min at 4c .
after incubation for 30 min at room temperature with a blocking solution containing 1% normal goat serum in pbs , the specimens were incubated in a blocking solution containing mouse monoclonal antihuman endothelium antibody ( cd34 ; novocastra laboratories , ltd .
newcastle , united kingdom ) for 60 min at room temperature , and then placed at 4c after extensive washing in pbs , the cells were labeled with fluorescein isothiocyanate-(fitc- ) conjugated goat anti - mouse igg ( molecular probes , inc . , eugene , oregon , usa ) in the blocking solution for 60 min at room temperature . after washing in pbs ,
the specimens were examined using confocal laser - scanning microscopy ( lsm 510 ; carl zeiss co , jena , germany ) .
excitation fluorescein was achieved with an argon laser at a wavelength of 488 nm .
an image analysis processing software lsm 5 image browser ( carl zeiss ) was used for 3d reconstruction of the immunostained microvessel .
the proportions of histological findings and constructions of lesions within the capillary pattern groups were compared by using the x test as statistical analysis . to determine differences in the mean distance of invasion into sm layer , comparisons between the capillary pattern groups were performed by one - way analysis of variance ( anova ) , followed by multiple comparison testing using the bonferroni - dunn method .
capillaries in the normal colon mucosa , tubular adenoma , intramucosal cancer , and sm cancer were examined for course and caliber .
a honeycomb - like network was formed by minute vessels of approximately 10 m in diameter in the normal colon mucosa ( figures 2(a ) and 2(b ) ) .
vascular dilation to about 12.11 m in diameter was observed by lsm ( figure 3(c ) ) in tubular adenomas . in the tubular adenoma
, vascular dilation was brought into view by me - nbi ( figure 3(b ) ) , and at the sites of notable dilation ( figure 4(b ) ) thin vessels were found arranged in bundle form on an enlarged view , and vessels were as thin as 3 to 4 m individually but formed bundles which observed like dilated vessels 40 to 50 m in diameter ( figure 4(c ) ) . at sites where no apparent capillary course was seen by me - nbi , only a few minute vessels could be observed travelling from the superficial layer of the lesions to deeper into the submucosa ( figure 4(d ) ) , but their caliber could not be measured . in the capillary pattern 1 group ,
large hyperplastic polyps ( hp ; 15 mm or larger ) accounted for 82.4% of lesions , with serrated adenomas ( sa ) 14.9% , and tubular adenomas ( ta ) 2.7% . in the group of capillary pattern 2 lesions showing slight dilation
, hp and sa accounted for only about less than 3.0% , with 60.0% of the patterns observed in ta , and remaining 5 lesions ( 2.8% ) being sm cancers . in the group of 3v capillary pattern lesions ( villous component showing notable dilation ) ,
sa accounted for 4.3% of lesions , ta 19.4% , and intramucosal cancers for the remaining 62.6% .
the frequency of atypical lesions was higher in the pattern 3v than pattern 2 lesions group .
furthermore , 13.7% of study lesions were identified as sm cancer and 7.9% as sm - m cancer . in the group of subtype 3i lesions ( irregular vascular course ) ,
on the other hand , intramucosal lesions decreased to 18.2% , with sm - s and sm - m cancers representing 22.7% and 56.1% , respectively . in the group of pattern 3i lesions , about 50% were indicated for surgical resection . in the type 4 lesions ( untraceable capillary course ) , intramucosal lesion accounted for 1.6% of the total number and this case was diagnosed as moderately differentiated adenocarcinoma .
the remaining 98.4% of lesions were sm cancer , with 96.8% of these being , sm - m cancer .
the characteristics of histological invasive findings in sm cancers ( n = 133 ) were classified into three types : type a showed an intramucosal lesion across the entire area of tumor ; type b showed a ruptured muscular mucosa permitting the invading sm end to be exposed to the superficial layer , but no accompanying desmoplastic reaction ; type c showed a desmoplastic reaction and were thus analyzed with respect capillary pattern .
all lesions in the group with capillary pattern 2 lesions were of type a , while only 47.1% of lesions in the pattern 3i group were type a , with type b accounting for 47.1% of lesions , and type c 5.8% . in the capillary pattern 4 group ,
type b accounted for 24.1% of lesions with the reminder ( 75.9% ) classified as type c. the rate of accurate diagnosis was determined prospectively based on the findings of vascular dilation between the pit and the capillary patterns in 291 lesions of early colon cancer at the preoperative examination . when the highly irregular type v irregular ( vi ) pit pattern or type v nonstructure ( vn ) pit pattern was selected as pit pattern - related indicators of sm - m , sensitivity and specificity were 94.5% and 86.2% , respectively , with no appreciable difference between vi and vn pits .
in contrast , sensitivity and specificity were 95.6% and 77.3% , respectively , when patterns 3i and 4 were selected as the indicators of sm - m .
accuracy rate as an indicator was not significantly different from pit pattern ( 91.4% ) and capillary pattern ( 88.7% ) .
an appropriate therapeutic modality for the resection of colon cancer is selected according to criteria established by the japanese society for cancer of the colon and rectum in japan .
these criteria consider cancer of the colon and rectum an indication for endoscopic resection if the depth of invasion into the sm layer is 1000 m and no vessels are involved [ 4245 ] .
preoperative diagnosis is of overriding importance from both a clinical and economic standpoint as it may avoid unnecessary treatment .
as part of this , a thorough endoscopic examination is considered necessary for selecting the appropriate therapeutic modality .
examination by magnifying endoscopy with cv staining is one such modality , although time limitations can preclude this technique in some cases .
endoscopic equipment has improved markedly with respect to resolution in recent years such that pit pattern can be clearly visualized . as a result , magnifying observation is rarely needed to distinguish sm cancer from hp or ta .
me - nbi differs from magnifying observation with cv staining in that images are easily interchangeable with the former technique .
me - nbi is also extremely useful for examining capillaries for dilation to differentiate , which is particularly valuable for differentiating a tumor from a nontumorous lesion . to this end ,
sano et al . [ 8 , 9 , 11 ] proposed a classification into 3 types for capillary pattern observed by me - nbi , based on the initial degree of microcapillary dilatation at the mucosal surface .
in contrast , another study proposed that assessing the degree of the dilatation of the capillary vessel dilatation should include the pit pattern , which is indirectly observed by me - nbi , to distinguish between sm - s and sm - m cancer .
based on the present study , we alternatively propose that classifications of capillary pattern , including ours , are difficult to use without experience , because they are complicated patterns and the estimation is quite subjective of endoscopists .
hence a simpler means of endoscopic examination by me - nbi is needed to enable meaningful selection of the appropriate treatment . in the present case ,
the tumorous lesions included traditional serrated adenomas and also seemed to include sessile serrated polyps / adenomas [ 47 , 48 ] .
given that the concept of sessile serrated polyps / adenoma remains to be fully accepted by japanese pathologists , further investigation and consideration are warranted .
the distance of the capillary pattern observed by me - nbi from the mucosal surface remains unclear .
thus , we used lsm to accurately resecte the specimen by endoscopic forceps [ 2 , 5 ] , and the lsm images were comparable to those by me - nbi .
therefore , it seemed that the observation by me - nbi does represent the surface histological architecture of the mucosa .
lesions were classified as pattern 3 or 4 according to the vascular - course details .
this is an important point of difference that will help beginners to interpret findings obtained by me - nbi .
for that reason , we classified lesions without a recognizable vascular course into a separate category called pattern 4 .
lsm imaging confirmed that these lesions were virtually without microcapillary vessels , further indicating that the desmoplastic reaction occurs on the surface of the tumor due to the invasion into the sm layer .
lesions of pattern 3 were also divided into patterns 3v and 3i , with the former predominately intramucosal and thus clearly indicated for endoscopic resection . on the other hand , 50% or less pattern
3i lesions were also indicated for endoscopic resection even if they had an irregular vascular course and intramucosal or sm invasion depth within 1000 m .
these lesions showed limited desmoplastic reaction and were left with neoplastic glands leading to the surface layer of the tumor . in lesions of pattern 4 ,
the vascular course is already devastated and surgical resection should be selected without hesitation when such findings are obtained .
the selection of an appropriate therapeutic modality would therefore rest with the presence or absence of a vascular course . in the case of pattern
3i lesions , however , more than 50% were from cases of sm - m cancer .
in such cases where selecting an appropriate modality remains difficult , magnifying observation of the pit pattern with conventional cv staining and endoscopic ultrasound examination should be combined with due discretion . as discussed above
, microcapillary patterns do not directly reflect the depth of cancer invasion , and me - nbi observation can accordingly be considered a useful aid to pit pattern diagnosis .
endoscopic resection may be selected as a temporary measure for the treatment of pattern 3i lesions that are suspected of invasion by sm - m cancer if patients have a tumor in the lower part of the rectum or serious complications in the cardiovascular or respiratory systems . | introduction . this study examined whether magnifying endoscopy with nbi observation ( me - nbi ) could be useful selecting the appropriate treatment for submucosal invasive cancer ( sm cancer ) .
patients and methods .
we analyzed 515 cases of colon tumors excised endoscopically or surgically .
we classified capillary network pattern into four types according to the degree of dilatation , irregularity , and distribution of microcapillary features .
results . the comparison of capillary pattern and histological features revealed microcapillary networks by using confocal laser - scanning microscopy and me - nbi in intramucosal lesion or sm cancer with remnant neoplastic glands at the superficial layer .
in contrast , the network was absent in sm cancer with desmoplastic reactions , which invaded deeper into the submucosal layer .
conclusions .
the remaining microcapillary network is designed to maintain the architecture of neoplastic glands .
consequently , loss of this network could correlate with depth of tumor invasion and desmoplastic reaction .
therefore , we can decide the appropriate treatment by using me - nbi method . |
immunosuppressive agents are the major therapy in focal segmental glomerulosclerosis ( fsgs ) and in aplastic anemia , and therefore it generally believed that immunological mechanisms contribute to both diseases .
the pathogenesis of fsgs is unknown but appears to be the result of a lymphokine or cytokine , which leads to glomerular epithelial cell injury resulting in segmental scar formation and finally glomerular destruction ( 1 , 2 ) .
aplastic anemia is manifested as a reduction in the number of pluripotent hematopoietic stem cells , but , why this occurs is still uncertain .
some of the causes include abnormalities of the hematopoietic stem cells , abnormalities in the hematopoietic microenvironment , and immunologically mediated damage to the hematopoietic stem cells ( 3 , 4 ) .
although immune pathophysiology might influence on each disease mechanism , a medline review of the literature notices there is no previous description involving fsgs with aplastic anemia . here
, we report a case of fsgs associated with aplastic anemia , and summarize the literature in this setting .
a 30-yr - old woman was admitted to this hospital with symptoms of general weakness and generalized edema lasting for 3 weeks . she had no previous history of drug , chemical exposure , radiation , or infection .
the physical findings included pale conjunctiva , marked pretibial edema , and a blood pressure of 130/80 mmhg .
a peripheral blood count showed hemoglobin 7.2 g / dl , hematocrit 20.7% , corrected reticulocyte count 0.8% , white blood count of 4,200/l ( 39% polymorphonuclear cells , 45% lymphocytes , 12% monocytes ) , and platelet count 70,900/l . in blood smear ,
normochromic , normocytic anemia without polychromatophilia was found , no schistocytes were present , and white cells and platelets were decreased without abnormal cells .
proteinuria ( 2 + , 3.6 g / day ) and microscopic hematuria were detected by urinalysis .
blood urea nitrogen ( bun ) was 25 mg / dl , creatinine 0.8 mg / dl , serum cholesterol 292 mg / dl and serum protein 7.0 g / dl with albumin 3.2 g / dl .
kidney biopsy revealed obliteration of the glomerular capillary lumen in segmental parts of some of the glomeruli ( 12% ) , establishing the diagnosis of fsgs ( fig .
tubules exhibited focal moderate to severe atrophy or loss with interstitial fibrosis and mononuclear cell infiltration .
electron microscopy showed marked foot process fusions of the podocytes in a microscopically normal glomerulus .
biopsy confirmed severe hypocellular bm ( 10% ) , with increased fatty areas and a few hematopoietic cells with normal appearance , and negative cytogenetic studies ( fig .
in addition , we excluded any other secondary causes of fsgs and aplastic anemia . no clinical or serological evidence for parvovirus b19 , ebstein barr virus , cytomegalovirus , hepatitis b or c infection and human immunodeficiency virus ( hiv ) was obtained .
other immunological tests showed c3 112 mg / dl ( normal 62 - 99 mg / dl ) , c4 32.5 mg / dl ( normal 19 - 36 mg / dl ) and antinuclear antibody or ra factor within the normal range .
she was treated with immunosuppressive therapy of prednisone 60 mg / day orally for 8 weeks and oral cyclosporine 15 mg / kg / day . additionally , supportive therapy including ace inhibitor and protein restriction ( <
after 2 months , she responded with gradually improving her clinical manifestation and increasing peripheral blood cell counts .
prednisone was maintained at the adequate doses with tapering after 8 weeks but cyclosporine was given sufficient to achieve trough serum levels of 100 - 200 ng / ml . no cyclosporine - associated toxicity occurred . at review ten
month after diagnosis and initial therapy , the patient was feeling well and her blood cell counts increased to near normal ( hb 9.5 g / dl , hct 32% , wbc 8,300/l , platelet 123,000/l ) and renal function maintained stable ( bun 22 mg / dl , creatinine 1.0 mg / dl ) with normal range proteinuria ( 0.25 g / day ) .
fsgs is a clinicopathological disease defined by the presence of proteinuria and by segmental glomerular scars involving some glomeruli .
primary fsgs accounts for 7 - 20% of glomerular lesions in patients presenting with nephrotic syndrome ( 5 , 6 ) .
since the pathogenesis and treatment for primary and secondary fsgs may differ significantly , secondary causes associated with fsgs such as infection with hiv , heroin abuse and reflux nephropathy must be excluded before making the diagnosis of primary fsgs ( 2 ) .
aplastic anemia is manifested as a marked reduction in the number of pluripotent hematopoietic stem cells , but why this occurs is still uncertain .
some of the proposed pathogenic mechanisms include intrinsic defects of hematopoietic stem cells , defects in the marrow microenvironment , and abnormal humoral or cellular immune control of hematopoiesis ( 3 , 4 , 7 ) .
aplastic anemia is occasionally associated with renal diseases such as , chronic renal failure , chronic glomerulonephritis or nephrotic syndrome .
glomerular involvement is mainly caused by parvovirus b19 with or without renal allograft , organic solvent exposure or autoimmune diseases ( 8 , 9 ) . in particular , in aplastic anemia combined with an autoimmune disease , some reports showed that eosinophilic fasciitis , glomerulonephritis , thymoma or systemic lupus erythematosus ( sle ) were associated with aplastic anemia ( 10 ) .
though the association between glomerulonephritis and aplastic anemia has yet not been well established , immunosuppressive agents are often effective in treating fsgs and aplastic anemia .
thus , it is now believed that immunological mechanisms contribute to the disease , with active destruction of blood - forming cells by lymphocytes .
cases have been reported in which cytotoxic t cell clones that damage the autologous hematopoietic precursor cells are present and some have suggested that t cell dysfunction may play a role in the pathogenesis of the glomerular lesion ( 11 ) .
other proposed mechanisms include the production of circulatory ' permeability ' factor ( s ) , possibly cytokines or lymphokine ( ifn- , tnf ) or related substances that could suppress hematopoietic cell proliferation and increase glomerular membrane permeability , resulting in epithelial cell injury , segmental scar formation and ultimately glomerular obsolescence .
the aberrant immune response may be triggered by environmental exposure to chemicals , drugs or viral infections , and perhaps , to endogenous antigens generated by genetically altered bm cells ( 2 , 12 ) . in the case
described here , the clinical and pathological features led to a diagnosis of fsgs coexistent with aplastic anemia . in this case of both fsgs and aplastic anemia , each disorder is occasionally associated with autoimmune disease , such as sle or rheumatoid arthritis ( 10 ) . also ,
although a renal biopsy was not performed , a case was reported by park et al . that aplastic anemia and nephrotic syndrome was simultaneously diagnosed in sle ( 13 ) . in our opinion , this case is suggested that direct immune mechanism , i.e. , involving cytotoxic t cells and cytokines , influences both diseases and there was no trigger factor , such as drug and chemical exposure or viral infection .
the treatment of fsgs and aplastic anemia are controversial issues , mostly immunosuppressive therapies and conservative treatments have been used ( 3 , 8 , 14 ) .
response to immunosuppressive therapy would suggest a causative or perpetuating role for autoimmunity in the development of these diseases .
in aplastic anemia , treatment with immune suppression ( cyclosporine aanti - lymphocyte globulin ) and bm transplantation has improved the response rates and survival of patients ( 3 , 8) .
in fact , various immunosuppressive agents such as corticosteroid , cyclophosphamide , azathioprine , or cyclosporine a have been used in the treatment of fsgs . however , among them , only cyclosporine a is an effective immunosuppressive drug in aplastic anemia .
so , in our case , we decided to use high - dose corticosteroids and cyclosporine a and added ace inhibitors combined with diet therapy for anti - proteinuric effect . at the present time , she is in the ten month of follow - up and her blood cell count increases near to normal and serum creatinine remains stable with near normal proteinuria . in summary , we describe a rare report showing an association between fsgs and aplastic anemia .
our observations suggest that immune mechanism including t lymphocytes and cytokines could play a role in the development of fsgs and aplastic anemia . | the pathogenic mechanism of focal segmental glomerulosclerosis ( fsgs ) and aplastic anemia are associated with immunologic events which lead to glomerular cell injury or hematopoietic cell destruction .
we present an extremely rare case of fsgs with aplastic anemia in a 30-yr - old woman .
the laboratory examination show - ed hemoglobin 7.2 g / dl , white blood count of 4,200/l , platelet count 70,900/l .
proteinuria ( 2 + , 3.6 g / day ) and microscopic hematuria were detected in urinalysis .
the diagnosis of fsgs and aplastic anemia were confirmed by renal and bone marrow biopsy .
she was treated with immunosuppressive therapy of prednisone 60 mg / day orally for 8 weeks and cyclosporine a 15 mg / kg / day orally .
she responded with gradually improving her clinical manifestation and increasing peripheral blood cell counts .
prednisone was maintained at the adequate doses with tapering after 8 weeks and cyclosporine was given to achieve trough serum levels of 100 - 200 ng / ml .
at review ten month after diagnosis and initial therapy , the patient was feeling well and her blood cell counts increased to near normal ( hb 9.5 g / dl , hct 32% , wbc 8,300/l , platelet 123,000/l ) and renal function maintains stable with normal range proteinuria ( 0.25 g / day ) . |
the increasing incidence of complex percutaneous coronary intervention ( pci ) is accompanied by risks of device fracture or dislodgement .
guide wire fractures during pci are very rare , but in such cases , life - threatening complications such as embolization , thrombus formation and perforation may occur . although , in most cases , percutaneous retrieval techniques of fractured guide wires are recommended , there have been several reports of fragments being left in place without complications.1 - 4 ) we present the case of a 78-year - old female patient who was diagnosed with non - st segment elevation myocardial infarction ( nstemi ) and treated with pci .
the patient had remnant guide wire filaments in the left anterior descending artery ( lad ) and aorta but did not experience any serious complications during a one - year follow up period .
a diagnostic coronary angiogram showed diffuse significant stenosis from the proximal to middle lad and first diagonal branch ( d1 ) ( fig .
we initially treated the patient with a single paclitaxel - eluting stent ( 2.7532 mm taxus , boston scientific , natick , ma , usa ) .
four days later , two coronary angioplasty 0.014 guide wires were inserted { one hi - torque balance middleweight ( bmw ) universal coronary guide wire ( abott vascular , santa clara , ca , usa ) into the lad , and one high - torque whisper coronary guide wire ( abott vascular ) into the d1}. an intravascular ultrasound after predilatation with a 2.520 mm voyager balloon ( abott vascular ) revealed a large plaque burden at both the lad and the d1 .
we deployed two overlapped sirolimus - eluting stents at the proximal and middle lad : a 2.7533 mm cypher at the middle lad and a 2.7518 mm cypher at the proximal lad ( cordis corporation , miami lakes , fl , usa ) . when we exchanged the guide wires to perform kissing balloon angioplasty , a fracture occurred at the distal tip of the bmw guide wire ( fig .
1 ) . another guide wire was inserted to perform a beaded wire rotation , and distal balloon inflation retrieval was attempted , in order to remove the fractured guide wires .
finally , we used a goose neck loop - snare ( microvena corporation , st .
multiple forward and backward movements of the snare , combined with distal balloon inflation retrieval , successfully removed most of the fractured guide wires ( fig .
2 ) but we later observed retained filaments during echocardiography ( figs . 3 and 4 ) .
the patient declined surgical intervention for removal of these stray filaments and was discharged from our hospital , with triple anti - platelet medication and no complications .
the patient did not experience any thrombotic or embolic events and did not suffer from any subjective symptoms over the one year of clinical follow up .
guide wire fractures during pci are very rare , occurring in approximately 0.1 - 0.2% of cases.5 ) guide wire remnants could lead to life threatening complications such as thrombosis , emboli , and perforation .
therefore , in the event of failed percutaneous retrieval and persistent signs of ischemia , patients should be urgently referred for surgical intervention .
there are several methods recommended for the management of fractured guide wires , including emergent surgery , loop snare removal , two- or three - wire rotation , stenting over the retained wire , and conservative treatment.6 - 8 ) surgical extraction is strongly recommended in cases of protrusion of the guide wire into the ascending aorta.9 - 11 ) however , guide wire segments retained within the coronary circulation may remain benign for a long time , particularly if they are entrapped within a distal part of the vessel and do not have accompanying total coronary occlusions.3 ) vascular endothelial cell covering over the guide wire fragments may render them immobile and non - thrombogenic .
hi - torque bmw guide wires consist of a distal core and a stainless proximal shaft , facilitating treatment of multiple lesions and tortuous vessels .
however , guide wire fractures may occur if the distal core and stainless proximal shaft are separated by either the trapping of the distal tip or by vascular resistance .
because the fracture in the lad developed after stent deployment at the main branch , we could not determine the mechanism of fracture in this particular case . however , trapping of the distal tip of the bmw wire , or stent deployment over a severely angulated guide wire are two possible explanations . in conclusion
, even though the most ideal management option for remnant guide wires is their removal , conservative treatment with the fragments left in situ may be successful in cases in which patients remain asymptomatic and hemodynamically stable .
however , life - long administration of intensive anti - platelet medications and close observation are recommended for these patients . | guide wire fractures during percutaneous coronary intervention ( pci ) are very rare , but when they do occur they may lead to life - threatening complications , such as embolization , thrombus formation and perforation . in cases when percutaneous retrieval has failed , surgical extraction of the remnant fragments is recommended .
we present a case of remnant guide wire filaments that remained in place without complications , over a one - year clinical follow up period . |
in china , hepatocellular carcinoma ( hcc ) is the fifth most common malignant cancer and the third leading cause of cancer - related mortality . about 90% of patients with hcc also have various levels level of liver cirrhosis , mainly caused by chronic liver disease after hepatitis b and c , especially in patients associated with hypersplenism caused by cirrhotic portal hypertension .
patients with concurrent cirrhosis and portal hypertension often have liver malfunction and coagulation disorders . over the past few decades
, liver resection was regarded as a contraindication for patients with both hcc and portal hypertension , and some patients with child - pugh class a cirrhosis even developed postoperative decompensation in liver function .
perioperative liver dysfunction and difficult bleeding control are the major problems associated with hepatectomy in patients who have hcc with portal hypertension .
splenectomy has proved to be a feasible strategy to overcome these problems . in 2000 , shimada et al reported that hepatectomy after laparoscopic splenectomy is a solution for patients with cirrhotic hypersplenism with hcc .
synchronous open splenectomy and hepatectomy ( osh ) is also a safe treatment strategy that may solve hypersplenism and prolong disease - free survival , without an increased perioperative risk for patients with cirrhotic hypersplenism and hcc .
minimally invasive surgical procedures that contribute to rapid recovery are desired by doctors . in the present study ,
we investigated whether simultaneous laparoscopic splenectomy and hepatectomy ( lsh ) is a feasible and safe surgical treatment for cirrhotic hypersplenism with hcc .
from january 2012 through december 2015 , 23 patients were identified in our department as having hcc and secondary hypersplenism due to liver cirrhosis . of those ,
simultaneous lsh was introduced in our department in january 2015 , and 12 patients have undergone the procedure ( lsh group ) .
inclusion criteria were age 1875 years , cirrhosis of any etiology , child pugh class a or b liver function , platelet count < 5.0 10/mm , tumor size less than 5 cm , and tumor location in the peripheral right lobe or left lobe .
it was approved by the ethics committee of the clinical medical college of yangzhou university . before the operation , all patients were notified that , compared with typical osh , minimally invasive lsh is in the experimental stage .
each patient selected his or her preferred type of surgical procedure , and signed an informed consent .
clinical data were collected as follows : patient sex , age , etiology of cirrhosis , child
pugh class , acute physiology and chronic health evaluation ( apache ) ii score , tumor size , length of the spleen , duration of operation , blood loss , and blood transfusion .
other data were estimated as follows : postoperative visual analog scale ( vas ) pain score ; times to first oral intake , passage of flatus , and off - bed activity ; postoperative duration of hospitalization ; number of days of postoperative temperature > 38.0c ; perioperative complications ; and white blood cell ( wbc ) count and absence of fever on postoperative days 1 and 7 .
blood analyses were as follows : white blood cell ( wbc ) count , platelet count , and level of aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , blood urea nitrogen ( bun ) , and creatinine ( cre ) , determined before and 1 and 7 d after surgery .
a 5-port ( figure 1 ) or 5 + 1-port ( figure 2 ) method was used for lsh .
a 10-mm trocar ( a ) was inserted through an umbilical incision for the laparoscope .
trocar b was located in the right midclavicular line halfway between the costal margin and the umbilicus .
trocar d was located in the left midclavicular line halfway between the costal margin and the umbilicus .
trocar e was located in the left anterior axillary line below the border of the spleen .
trocar f was located in the right anterior axillary line just below the costal margin .
trocars b e were used for laparoscopic splenectomy and for laparoscopic left partial hepatectomy .
first , the device for the modified pringle maneuver , prepared as described elsewhere , could be used to block the inflow of blood into the entire liver if necessary .
if the tumor was located in the right lobe , trocar e was commonly used for the device .
if the tumor appeared in the left lobe , trocar f was prepared for the device , when needed . with increasing experience with laparoscopy , trocar f was omitted in the laparoscopic left hemihepatectomy or laparoscopic hepatic left lateral lobectomy .
if the laparoscopic approach was a wedge hepatectomy , ultrasonography was used to assess the relationship between the tumor and the major vascular structures and the boundaries of the tumor . a 1-cm hepatic resection line beyond the margin of the tumor
the entire spleen was removed through trocar d with an electromechanical morcellator ( tscs , hangzhou , china ) ; spleen samples had a cylindrical appearance ( figure 3 ) .
the tumor specimen was loaded into a specimen bag and removed though the enlarged umbilical incision , usually < 5 cm , which was extended to a proper length along the linea alba , according to the size of the tumor . at the end of the operation ,
2 surgical drainage tubes were placed at the epiploic foramen and under the left diaphragm .
liver specimen and cylindrical spleen tissue . for tumors in the left liver , a midline laparotomy was selected .
for those in the right liver , a large inverse l - shaped incision was selected .
data are presented as the mean sd , median ( range ) , or percentage .
student 's t test was used to compare parametric data , the mann - whitney u test was used to compare nonparametric data , and fisher 's exact test was used to compare percentages .
spss version 16.0 software ( spss , chicago , illinois , usa ) was used for statistical analysis .
from january 2012 through december 2015 , 23 patients were identified in our department as having hcc and secondary hypersplenism due to liver cirrhosis . of those ,
simultaneous lsh was introduced in our department in january 2015 , and 12 patients have undergone the procedure ( lsh group ) .
inclusion criteria were age 1875 years , cirrhosis of any etiology , child pugh class a or b liver function , platelet count < 5.0 10/mm , tumor size less than 5 cm , and tumor location in the peripheral right lobe or left lobe .
it was approved by the ethics committee of the clinical medical college of yangzhou university . before the operation , all patients were notified that , compared with typical osh , minimally invasive lsh is in the experimental stage .
each patient selected his or her preferred type of surgical procedure , and signed an informed consent .
clinical data were collected as follows : patient sex , age , etiology of cirrhosis , child
pugh class , acute physiology and chronic health evaluation ( apache ) ii score , tumor size , length of the spleen , duration of operation , blood loss , and blood transfusion .
other data were estimated as follows : postoperative visual analog scale ( vas ) pain score ; times to first oral intake , passage of flatus , and off - bed activity ; postoperative duration of hospitalization ; number of days of postoperative temperature > 38.0c ; perioperative complications ; and white blood cell ( wbc ) count and absence of fever on postoperative days 1 and 7 .
blood analyses were as follows : white blood cell ( wbc ) count , platelet count , and level of aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , blood urea nitrogen ( bun ) , and creatinine ( cre ) , determined before and 1 and 7 d after surgery .
a 5-port ( figure 1 ) or 5 + 1-port ( figure 2 ) method was used for lsh .
a 10-mm trocar ( a ) was inserted through an umbilical incision for the laparoscope .
trocar b was located in the right midclavicular line halfway between the costal margin and the umbilicus .
trocar d was located in the left midclavicular line halfway between the costal margin and the umbilicus .
trocar e was located in the left anterior axillary line below the border of the spleen .
trocar f was located in the right anterior axillary line just below the costal margin .
trocars b e were used for laparoscopic splenectomy and for laparoscopic left partial hepatectomy .
first , the device for the modified pringle maneuver , prepared as described elsewhere , could be used to block the inflow of blood into the entire liver if necessary .
if the tumor was located in the right lobe , trocar e was commonly used for the device .
if the tumor appeared in the left lobe , trocar f was prepared for the device , when needed . with increasing experience with laparoscopy ,
trocar f was omitted in the laparoscopic left hemihepatectomy or laparoscopic hepatic left lateral lobectomy .
if the laparoscopic approach was a wedge hepatectomy , ultrasonography was used to assess the relationship between the tumor and the major vascular structures and the boundaries of the tumor . a 1-cm hepatic resection line beyond the margin of the tumor
the entire spleen was removed through trocar d with an electromechanical morcellator ( tscs , hangzhou , china ) ; spleen samples had a cylindrical appearance ( figure 3 ) .
the tumor specimen was loaded into a specimen bag and removed though the enlarged umbilical incision , usually < 5 cm , which was extended to a proper length along the linea alba , according to the size of the tumor . at the end of the operation ,
2 surgical drainage tubes were placed at the epiploic foramen and under the left diaphragm . liver specimen and cylindrical spleen tissue .
a 5-port ( figure 1 ) or 5 + 1-port ( figure 2 ) method was used for lsh .
a 10-mm trocar ( a ) was inserted through an umbilical incision for the laparoscope .
trocar b was located in the right midclavicular line halfway between the costal margin and the umbilicus .
trocar d was located in the left midclavicular line halfway between the costal margin and the umbilicus .
trocar e was located in the left anterior axillary line below the border of the spleen .
trocar f was located in the right anterior axillary line just below the costal margin .
trocars b e were used for laparoscopic splenectomy and for laparoscopic left partial hepatectomy .
first , the device for the modified pringle maneuver , prepared as described elsewhere , could be used to block the inflow of blood into the entire liver if necessary .
if the tumor was located in the right lobe , trocar e was commonly used for the device .
if the tumor appeared in the left lobe , trocar f was prepared for the device , when needed . with increasing experience with laparoscopy ,
trocar f was omitted in the laparoscopic left hemihepatectomy or laparoscopic hepatic left lateral lobectomy .
if the laparoscopic approach was a wedge hepatectomy , ultrasonography was used to assess the relationship between the tumor and the major vascular structures and the boundaries of the tumor . a 1-cm hepatic resection line beyond the margin of the tumor
the entire spleen was removed through trocar d with an electromechanical morcellator ( tscs , hangzhou , china ) ; spleen samples had a cylindrical appearance ( figure 3 ) .
the tumor specimen was loaded into a specimen bag and removed though the enlarged umbilical incision , usually < 5 cm , which was extended to a proper length along the linea alba , according to the size of the tumor . at the end of the operation ,
2 surgical drainage tubes were placed at the epiploic foramen and under the left diaphragm . liver specimen and cylindrical spleen tissue .
for tumors in the left liver , a midline laparotomy was selected . for those in the right liver , a large inverse
data are presented as the mean sd , median ( range ) , or percentage .
student 's t test was used to compare parametric data , the mann - whitney u test was used to compare nonparametric data , and fisher 's exact test was used to compare percentages .
spss version 16.0 software ( spss , chicago , illinois , usa ) was used for statistical analysis .
eleven patients who had cirrhotic hypersplenism with hcc underwent osh , and 12 underwent lsh .
the osh and lsh groups were similar in sex , age , etiology of cirrhosis , apache ii score , child - pugh class , tumor size , length of the spleen , preoperative wbc and platelet counts , and preoperative ast , alt , bun , and cre levels ( table 1 ) .
baseline demographic and clinical characteristics of the osh and lsh groups data are mean sd , median ( range ) values , or number of patients , as indicated .
hbv , hepatitis b virus ; hcv , hepatitis c virus ; plt , platelet duration of the operation and the volume of intraoperative estimated blood loss and blood transfused were similar in the 2 groups ( p > .05 each ; table 2 ) .
intraoperative and postoperative characteristics of the osh and lsh groups data are the mean sd or number of patients .
the lsh group exhibited a lower visual analog ( vas ) pain score on the first day after surgery , and shorter times to first oral intake , flatus , off - bed activity , and hospital stay ( all p < .05 ; table 2 ) .
all 11 patients in the osh group and 7 of 12 in the lsh group had postoperative complications ( p < .05 ) .
the 11 complications in the osh group were as follows : 2 patients with incision complications , 2 with pneumonia , 1 with an emergency operation for bleeding , 1 with pancreatic fistula , and 5 with asymptomatic portal vein thrombosis .
of the 7 patients who had complications in the lsh group , 1 had pneumonia , 1 had an incision complication , and 5 had asymptomatic portal vein thrombosis .
there was no fever in either group before surgery . compared with the osh group , the lsh group had fewer days of postoperative temperature > 38.0c ( p < .01 ; table 3 ) .
postoperative fever was absent in only 2 patients in the lsh group and in none in the osh group , and there was nonsignificant similarity between the groups ( p > .05 ) . although the wbc counts of the groups were similar at admission ( p > .05 ) , mean wbc counts on postoperative days 1 ( p < .01 ) and 7 ( p <
.01 ) were significantly lower after lsh than after osh . compared with the osh group ,
the percentage of patients with normal wbc counts on postoperative day 7 was significantly higher in the lsh group ( p < .05 ) .
postoperative fever and wbc counts of the osh and lsh groups data are mean sd or number of patients .
postoperative fever , the number of days of postoperative body temperature > 38.0c ; d 1 , postoperative day 1 ; d 7 , postoperative day 7 .
although the ast level was similar on postoperative day 1 ( p > .05 ) , median ast on postoperative day 7 ( p < .001 ) was significantly lower in the lsh group than in the osh group ( table 4 ) . moreover , although the alt level on postoperative day 1 was not significantly different in the 2 groups , median alt was significantly lower in the lsh group than in the osh group on postoperative day 7 ( p < .05 ) .
postoperative liver and renal functions of the osh and lsh groups data are mean sd or median ( range ) values .
there were also similarities between the groups in preoperative bun and cre levels ( table 1 ) . compared with the osh group ,
the lsh group had significantly lower mean bun levels on postoperative days 1 ( p < .001 ) and 7 ( p = .001 ) ( table 4 ) .
similarly , the lsh group has lower mean cre levels on postoperative days 1 ( p < .001 ) and 7 ( p = .001 ) .
the median observation period was 9 months ( range , 514 ) for the lsh group and 33 months ( range , 1652 ) for the osh group .
two patients had hcc recurrence and no patients died in the lsh group , whereas in the osh group , 4 patients had hcc recurrence and 2 patients died of cancer - related causes and liver failure .
duration of the operation and the volume of intraoperative estimated blood loss and blood transfused were similar in the 2 groups ( p > .05 each ; table 2 ) .
intraoperative and postoperative characteristics of the osh and lsh groups data are the mean sd or number of patients .
compared with the osh group , the lsh group exhibited a lower visual analog ( vas ) pain score on the first day after surgery , and shorter times to first oral intake , flatus , off - bed activity , and hospital stay ( all p < .05 ; table 2 ) .
all 11 patients in the osh group and 7 of 12 in the lsh group had postoperative complications ( p < .05 ) .
the 11 complications in the osh group were as follows : 2 patients with incision complications , 2 with pneumonia , 1 with an emergency operation for bleeding , 1 with pancreatic fistula , and 5 with asymptomatic portal vein thrombosis .
of the 7 patients who had complications in the lsh group , 1 had pneumonia , 1 had an incision complication , and 5 had asymptomatic portal vein thrombosis .
there was no fever in either group before surgery . compared with the osh group , the lsh group had fewer days of postoperative temperature > 38.0c ( p < .01 ; table 3 ) .
postoperative fever was absent in only 2 patients in the lsh group and in none in the osh group , and there was nonsignificant similarity between the groups ( p > .05 ) . although the wbc counts of the groups were similar at admission ( p > .05 ) , mean wbc counts on postoperative days 1 ( p < .01 ) and 7 ( p <
.01 ) were significantly lower after lsh than after osh . compared with the osh group ,
the percentage of patients with normal wbc counts on postoperative day 7 was significantly higher in the lsh group ( p < .05 ) .
postoperative fever and wbc counts of the osh and lsh groups data are mean sd or number of patients .
postoperative fever , the number of days of postoperative body temperature > 38.0c ; d 1 , postoperative day 1 ; d 7 , postoperative day 7 .
although the ast level was similar on postoperative day 1 ( p > .05 ) , median ast on postoperative day 7 ( p < .001 ) was significantly lower in the lsh group than in the osh group ( table 4 ) .
moreover , although the alt level on postoperative day 1 was not significantly different in the 2 groups , median alt was significantly lower in the lsh group than in the osh group on postoperative day 7 ( p < .05 ) .
postoperative liver and renal functions of the osh and lsh groups data are mean sd or median ( range ) values .
there were also similarities between the groups in preoperative bun and cre levels ( table 1 ) . compared with the osh group , the lsh group had significantly lower mean bun levels on postoperative days 1 ( p < .001 ) and 7 ( p = .001 ) ( table 4 ) .
similarly , the lsh group has lower mean cre levels on postoperative days 1 ( p < .001 ) and 7 ( p = .001 ) . the median observation period was 9 months ( range , 514 ) for the lsh group and 33 months ( range , 1652 ) for the osh group .
two patients had hcc recurrence and no patients died in the lsh group , whereas in the osh group , 4 patients had hcc recurrence and 2 patients died of cancer - related causes and liver failure .
however , it is often accompanied with hypersplenism caused by cirrhotic portal hypertension , resulting in low wbc and platelet counts . because of poor liver function and coagulation disorders , hepatectomy has been controversial in patients with both hcc and portal hypertension .
studies have shown that the advantages of splenectomy are that it may improve coagulation and liver function , nutritional metabolism , and child - pugh scores for patients with cirrhotic hypersplenism .
one is open splenectomy followed by hepatectomy , and the other is laparoscopic splenectomy followed by open hepatectomy .
however , these 2-stage operations may result in more complications and delay timely surgical treatment for hcc that may grow or metastasize during the waiting time for the second operation .
a previous study and a meta - analysis all reported that , compared with open hepatectomy group , laparoscopic hepatectomy group is associated with fewer complications , more rapid recovery , and lower morbidity .
a meta - analysis suggested that simultaneous osh does not increase postoperative complications or perioperative mortality and can solve hypersplenism , improve the functions of coagulation and immunity , and decrease the incidence of postoperative bleeding .
some studies reported that , compared with open hepatectomy alone , simultaneous osh is associated with improved 5-year tumor - free survival in patients who have hcc with hypersplenism . with the rapid development of minimally invasive laparoscopic techniques
, lsh was devised and successfully performed by surgeons with excellent laparoscopic skills . in 2009 ,
hand - assisted lsh was first described to be safe in a case report . in 2013 ,
another case report described uneventful simultaneous lsh without hand assistance . in comparison to osh ,
miyoshi et al demonstrated that lsh is safe and useful in the treatment of hcc with hypersplenism within limited criteria .
we think the surgeon and surgical assistants should possess skillful laparoscopy techniques and have abundant experience with laparoscopic splenectomy and laparoscopic hepatectomy .
before performing the new operation , we had performed 200 laparoscopy splenectomies and 80 laparoscopic hepatectomies . in this study , patients who underwent conventional osh complained of pain associated with the large incision , usually 3045 cm , that was held open by retractors .
in contrast , the total length of all incisions with lsh was 10 cm without muscle injury caused by the retractors , and postoperative abdominal pain was rare .
furthermore , minimally invasive lsh had more rapid recovery and lesser postoperative complication rates , owing to the small incisions required .
for example , the absence of pain may improve appetite and shorten postoperative time to oral intake .
reduced pain may also shorten the time to first off - bed activity and flatus .
in addition , a small incision with reduced pain may decrease patients ' psychological trauma and increase their confidence in overcoming their concerns . compared with osh
, lsh also significantly shortened the number of days after surgery that patients had a body temperature > 38.0c .
although preadmission wbc count was similar in the 2 groups , compared with osh , lsh had significantly lower wbc count on postoperative day 7 ( p < .01 ) .
these findings were consistent with each other , because high wbc count is associated with high body temperature . compared with the osh group ,
we also found that bun and cre concentrations on postoperative days 1 and 7 were lower in the lsh group , providing further evidence of the benefits of lsh .
these findings also demonstrated a difference between 2 groups of the recovery of the liver and kidneys due to surgical trauma .
we are in the initial developmental stages of lsh , and patients with hcc who elect to undergo the procedure should meet the following indications : tumor size < 5 cm , tumor location in the peripheral right or left lobe of the liver , and child - pugh class a or b.
with appropriate indications , synchronous lsh is a safe , feasible , and effective surgical procedure with satisfactory recovery , and it allows for optimal minimally invasive treatment for patients with cirrhotic hypersplenism and hcc .
this study was limited by its small sample size ; therefore , prospective studies with a larger cohort , including randomized comparisons with open surgery , should be performed . | background and objectives : patients undergoing synchronous open splenectomy and hepatectomy ( osh ) for concurrent hepatocellular carcinoma ( hcc ) and hypersplenism usually have major surgical trauma caused by the long abdominal incision .
surgical procedures that contribute to rapid recovery with the least possible impairment are desired by both surgeons and patients .
the objective of this study was to explore outcomes in patients treated with simultaneous laparoscopic or open splenectomy and hepatectomy for hepatocellular carcinoma ( hcc ) with hypersplenism.methods:we retrospectively evaluated the treatment outcomes in 23 patients with cirrhosis , hcc , and hypersplenism , who underwent simultaneous laparoscopic splenectomy and hepatectomy ( lsh ; n = 12 ) or open splenectomy and hepatectomy ( osh ; n = 11 ) from january 2012 through december 2015 .
their perioperative variables were compared.results:lsh was successful in all patients .
there were nonsignificant similarities between the 2 groups in duration of operation , estimated blood loss , and volume of blood transfused ( p > .05 each ) . compared with osh
, lsh had a significantly shorter postoperative visual analog scale pain score ( p < .001 ) ; shorter time to first oral intake ( p < .001 ) , passage of flatus ( p < .05 ) and off - bed activity ( p < .001 ) ; shorter postoperative duration of hospitalization ( p < .001 ) ; fewer days of postoperative temperature >
38.0c ( p < .01 ) ; fewer postoperative complications ( p < .05 ) ; and better liver and renal function on postoperative days 7 ( p < .05 each).conclusions : simultaneous lsh is safe for selected patients with hcc and hypersplenism associated with liver cirrhosis . |
osteomas are the most common benign tumors of the nose and paranasal sinuses , with an incidence that ranges between 0.43 - 1% ( 1 , 2 ) .
they occur most commonly within the frontal sinus ( 52% ) , followed by the ethmoid ( 22.0% ) , the maxillary sinus ( 5.1% ) , and the sphenoid ( 1.7% ) ( 1 ) .
it is very rare for an osteoma to arise in the nasal cavity or turbinates .
only four middle turbinate ( 2 - 5 ) , one superior turbinate ( 6 ) and one inferior turbinate osteoma cases ( 7 ) have been reported in the literature to date .
we report an unusual case of middle turbinate osteoma associated with left - side nasal obstruction , epiphora and post nasal discharge in a patient managed successfully by endoscopic surgery ( es ) .
a 41-year - old woman was referred to the department of otorhinolaryngology at the rasool akram hospital with a two - month history of progressive left nasal obstruction , epithora , and post nasal discharge .
endoscopic examination revealed a mass completely blocking the left nasal cavity of bony hard consistency . computed tomography ( ct )
scan showed a circumscribed bony mass integrated laterally to the left middle turbinate that exerts pressure on the medial maxillary wall .
the osteoma was totally extirpated subsequently without damaging the surrounding structures by es under general anesthesia .
the mass was released gently from its attachment to the middle turbinate using a sickle knife .
although the mass measured 3.02.7 cm in diameter , it passed through the left nostril without the need for further incision ( fig .
2 ) . examination of the histologic sections revealed a dense , mature , predominantly lamellar bone , consistent with osteoma ( figs . 3 and 4 ) .
while it is a common tumor of paranasal sinuses that is found more frequently in the maxillary , ethmoidal and frontal sinuses ( 1 ) , it is very rare in the nasal cavity . beside the turbinates , the nasal septum can also be the origin of nasal osteoma ( 1 ) . reported cases of turbinate osteoma in the literature
the etiology of osteomas arising from the paranasal sinuses can be embryological , traumatic or infective .
osteomas can also be a part of gardner 's syndrome , an autosomal dominant disease characterized by intestinal polyposis , osteomas , cutaneous and soft tissue tumors . in affected individuals , the risk of developing colon cancer approaches 100% . on average ,
osteomas are detected 17 years before colon polyps begin to appear ( 8 , 9 ) . in turbinate osteomas ,
no associated history of facial trauma or nasal surgery had been reported , and paranasal sinus infection appears to be the result of sinus meatal obstruction due to mass effect of the tumor ( 3 ) .
paranasal sinus osteomas may occur at any age , but usually present between the second and fourth decade , with a slight male predominance ( 3 ) . however , in the seven reported turbinate osteomas cases , including this ,
six cases were found in women and only one case in man ( table 1 ) .
the majority of osteomas are asymptomatic in the early stages and are diagnosed incidentally during radiological examination for the other conditions . in symptomatic cases , the most common symptoms are progressive headache and chronic inflammation of the adjacent mucosal membranes ( 10 ) .
the most common symptom in turbinate osteomas is nasal obstruction . in this case , the patient presented with nasal obstruction , epithora and post nasal discharge .
however , it does not give detailed information of the lesion and it is not conducive for surgical interventions .
although ct scan is an effective modality for the evaluation of osteomas , capable of detecting the extent of osteoma and invasion of the adjacent structures , namely the anterior cranial fossa , cribriform plate , and the orbit that may improve surgical decision making ( 6 ) . in osteoma arising from the paranasal sinuses ,
surgical removal is indicated if it extends beyond the boundaries of the sinus , continues to enlarge , localizes in the region adjacent to the naso - frontal duct , or if signs of chronic sinusitis are present , regardless of size in symptomatic tumors ( 6 - 8 ) .
surgical approaches are classified into external , endoscopic drill - out , and combined endoscopic and external procedures ( 10 ) .
although endoscopic removal is the preferred modality , the open approach should be considered to manage tumor involvement of the cribriform plate and frontal sinus . in osteoma arising from the turbinates ,
the tumor is more accessible and endoscopic removal carries less risk , and is easier compared to sinus osteomas .
it is therefore important to diagnose nasal osteoma when it is small in size , follow it up and resect it when it is of a size that can be resected successfully by es , as in the present case .
based on the fact that es carries low risk in the management of nasal osteoma , except when the cribriform plate is involved , and it is technically easier compared to endoscopic removal of sinus osteomas and smaller tumors and leads to better cosmetic outcomes , it appears clinically relevant to remove nasal osteomas at the time of diagnosis . | osteoma is the most common benign tumor of the paranasal sinuses .
turbinate osteomas are very rare and only four middle turbinate , one superior turbinate and one inferior turbinate osteoma cases have been reported .
we present a rare case of osteoma of the left middle turbinate in a patient presented with unilateral nasal obstruction and epiphora that was removed endoscopically , and conduct a literature review on turbinate osteomas arising from different turbinates , their symptoms and management . |
systemic sclerosis ( ssc ) , or scleroderma , is a chronic multisystem disorder of small vessels and connective tissues characterized by diffuse fibrosis of the skin and internal organs , most frequently the lungs and gastrointestinal tract .
the disease has a 3:1 female predilection and typically occurs in the third to fifth decades of life .
up to 80% of patients have limited cutaneous disease , which typically has an insidious onset and skin changes confined to the face and extremities , whereas 20% with diffuse involvement may have more severe and rapidly progressive skin , lung , cardiac , and gastrointestinal disease .
patients with interstitial lung disease ( ild ) and pulmonary vascular disease may be severely symptomatic due to restrictive lung physiology and low diffusing capacity .
esophageal dysmotility occurs in almost all ssc patients , and gastroesophageal reflux may mimic or overlap with ild .
cardiac involvement , to include right heart dysfunction due to pulmonary hypertension ( ph ) , myocardial fibrosis , and pericardial involvement , may further compound pulmonary symptoms .
ild and ph are the most common cardiopulmonary findings in ssc [ 2 , 3 ] .
about two thirds of patients suffering from ssc develop scleroderma ild ( sild ) [ 46 ] .
ph is present in about 20% of ssc patients and is typically associated with severe pulmonary disease , although it may be an isolated manifestation of ssc .
currently , sild is the leading cause of death in ssc patients , due to pulmonary fibrosis with or without ph .
the mortality rate from sild is about 40% within 10 years after the onset of the disease [ 79 ] .
there are four key roles of imaging in ild related to ssc : 1 ) detection of lung involvement , 2 ) identification of patients likely to respond to treatment , 3 ) assessment of treatment efficacy , and 4 ) exclusion of other significant diseases to include ph and cardiac and esophageal abnormalities .
chest radiography is highly insensitive in detecting and assessing the extent of lung involvement in ssc patients .
in fact , patients with pulmonary symptoms and early lung involvement may have a normal chest radiograph .
radiographic findings of sild are observed in up to two thirds of symptomatic patients , whereas pulmonary fibrosis is detected in only 25% to 44% .
sild typically manifests as low lung volume and predominantly increased ground glass opacity ( ggo ) and reticular interstitial thickening that is greatest in the lung bases .
however , some patients with pulmonary fibrosis may have subtle radiographic findings [ 10 , 11 ] .
high - resolution ct ( hrct ) has been shown to be more accurate than chest radiography in detecting and characterizing diffuse lung diseases , and abnormalities on ct correlate more closely with pulmonary function test ( pft ) abnormalities [ 1214 ] .
hrct is now well - established as a sensitive and noninvasive means of detecting and characterizing sild [ 1519 ] .
ct features of fibrosis are present in 55% to 65% of all patients with ssc and in up to 96% of those with abnormal pft results [ 5 , 11 , 13 , 14 , 17 , 19 , 20 ] . as a result
classically , the disease affects juxtapleural , posterior , and basilar portions of the lungs , with initially subtle alterations of increased ggo , defined as increased lung attenuation in the absence of architectural distortion , as well as accentuated reticular markings that may progress to pulmonary fibrosis , defined as architectural distortion with reticular intralobular interstitial thickening , traction bronchiectasis and bronchiolectasis , and honeycomb cystic change ( figs . 1 and 2 ) .
these hallmark ct features of sild are similar to those of idiopathic , nonspecific interstitial pneumonitis ( nsip ) .
a similar association has been reported in radiologic - pathologic correlations of surgical lung biopsy specimens of patients with ssc [ 2023 ] .
1coronal and sagittal chest ct reconstructions ( lung window ) demonstrate the classic appearance of early lung involvement in scleroderma interstitial lung disease .
initially subtle alterations of increased ground glass opacity and accentuated reticular markings ( a and b ) that affect the peripheral , posterior , and basilar portions of the lungsfig .
2coronal and sagittal chest ct reconstructions ( lung window ) demonstrate the classic appearance of scleroderma interstitial lung disease in patients with progressive disease , showing extensive architectural distortion due to progressive pulmonary fibrosis ( a and b ) coronal and sagittal chest ct reconstructions ( lung window ) demonstrate the classic appearance of early lung involvement in scleroderma interstitial lung disease
. initially subtle alterations of increased ground glass opacity and accentuated reticular markings ( a and b ) that affect the peripheral , posterior , and basilar portions of the lungs coronal and sagittal chest ct reconstructions ( lung window ) demonstrate the classic appearance of scleroderma interstitial lung disease in patients with progressive disease , showing extensive architectural distortion due to progressive pulmonary fibrosis ( a and b ) sild typically manifests on ct as predominantly ggo with an admixture of pulmonary fibrosis consistent with the nsip pattern .
this is unlike other patients with nsip , who have little or no cystic change [ 2325 ] . as honeycomb cystic change is typically a marker for usual interstitial pneumonia ( uip ) and pulmonary fibrosis
, these findings suggest that patients with sild disease may have a mixture ( or overlap ) of uip and nsip patterns .
this is consistent with the findings of desai et al . and other autopsy studies , in which typical histopathologic findings of sild included marked pulmonary fibrosis and honeycomb cystic change [ 24 , 27 , 28 ] .
it has been incorrectly assumed that sild is more common and severe in patients with diffuse cutaneous systemic sclerosis ( dcssc ) .
in several recent studies , about 40% of patients with pulmonary involvement have demonstrated cutaneous systemic sclerosis ( lcssc ) [ 8 , 9 , 29 , 30 ] . in the recent scleroderma lung study , lcssc and dcssc
patients were indistinguishable with regard to their baseline pulmonary functions , but lcssc patients presented with more extensive pulmonary fibrosis , possibly reflecting a delay in diagnosis and progression of lung disease prior to study entry [ 30 ] .
the rate of progression of sild is similar in lcssc and dcssc patients after adjustment for baseline differences in the degree of pulmonary fibrosis . given that baseline forced vital capacity and pulmonary fibrosis scores were the most important independent predictors of the decline in pulmonary function over time in scleroderma lung study patients , all ssc patients should be evaluated carefully for lung involvement irrespective of disease extent .
criteria have been developed for scoring the severity and extent of sild disease based on disease distribution , relative proportions of reticulations and ggo , and presence of fibrosis on ct scans at one or more levels throughout the chest .
visual scoring systems typically divide each lung into three zones ( lung apex to aortic arch , aortic arch to inferior pulmonary veins , inferior pulmonary veins to lung bases ) , and the extent of lung abnormality in each zone is scored on a scale of 04 ( 0 = absent ; 1 = 1%25% ; 2 = 26%50% ; 3 = 51%75% ; 4 = 76%100% ) .
more recently , a simplified scoring system based on whether more or less than 25% of the lung is affected has been suggested [ 32 ] .
computer - based approaches also have been investigated and are based on measurement of the density or texture features of each pixel and assignment of a measure of the amount of abnormal lung tissue present .
computer - based models correlate well with visual scoring techniques for the detection of fibrosis ( area under the curve = 0.86 ) and with the assessment of extent of disease ( area under the curve = 0.96 for estimating lung involvement > 25% ) without the intrareader variation encountered with visual scoring .
hrct scanning has been used to predict outcome in addition to characterizing the nature and extent of sild [ 3436 ] .
the absence of lung disease at an initial ct evaluation is a superior predictor of excellent long - term prognosis with regard to sild . in a serial hrct study of 90 ssc patients ,
40 had no evidence of pulmonary fibrosis on an initial scan ; of these 40 , 35 ( 88% ) continued to have a normal hrct scan at follow - up for an average of 5 years .
because many ssc patients have limited pulmonary fibrosis that may not necessarily progress , the decision to start treatment is often a clinical challenge .
the estimation of disease extent ( using hrct ) and severity ( using pft ) is pivotal .
careful prognostic evaluation , including the staging of disease severity and the definition of longitudinal disease behavior ( by serial imaging and pft ) , is central to the formulation of a logical management plan .
it is now well - established that ggo is not indicative of active inflammation and likely represents microscopic pulmonary fibrosis that is below the resolution of ct .
previously , the presence of ggo in the absence of associated architectural distortion was thought to represent underlying inflammation , or
alveolitis , and to predict a high likelihood of reversible lung disease in ssc , based on studies in other diffuse lung diseases .
recent studies have shown that at best , a weak relationship between ggo and abnormal bronchoalveolar lavage evidence for active lung inflammation .
furthermore , the limitations of ggo as a predictive marker of active or reversible inflammation have been reinforced by longitudinal studies of ct change with and without treatment .
when reticular interstitial abnormalities are present , as in most ssc cases , regression of disease on ct occurs in only a minority of patients in the short term . in the long term
, ggo usually progresses to overt fibrosis . in a recent serial study of 41 ssc patients , ggo that occurred in two thirds of the cases regressed in only 5% during the following 2 years and
thus , the postulated relationship between ggo and active inflammation / alveolitis in sild has been largely discredited .
more recently , the findings of fibrosis on hrct scans of patients with sild have been shown to be a useful predictor of the progression of fibrosis when untreated and of a favorable response to treatment with cyclophosphamide compared with placebo .
the extent of pulmonary fibrosis on ct also has played a key role in determining the prognosis of patients with ssc [ 32 ] . in a study of 215 patients , those with more extensive disease on hrct ( i.e. , abnormalities involving > 20% of the lung volume ) had strikingly higher mortality and rapid decline of lung function , whereas patients with less than 20% abnormality had no increase in long - term mortality compared with ssc patients with a normal hrct [ 32 ] . to overcome the difficulties in formally scoring disease extent on hrct in routine practice , the authors proposed a simple semiquantitative staging system of limited and extensive disease ,
experience is limited with the use of hrct as an outcome measure in therapeutic trials .
hrct scanning has been used only infrequently in a prospective , systematic manner as an outcome parameter for assessing therapeutic responses in patients with sild [ 3943 ] .
the validity of serial ct studies is also compromised by the difficulty in achieving exact anatomic comparability between initial and follow - up ct scans , which is due to inherent differences in hrct slice acquisitions .
low - dose volume ( spiral ) acquisition ct techniques may overcome this problem , and several studies are under way . in contrast , when anatomic comparability is achieved , it may be difficult to ascertain the clinical significance of minor ct changes that are confined to limited lung regions .
the recent serial study of launay et al . was limited by their definition of change in lung involvement by more or less than 50% of the lung volume .
this system may fail to identify significant change in many cases in which the arbitrary threshold of 50% is not crossed . in a more recent study ,
when readers graded sild on serial hrct as worsened , unchanged , or improved , there was an excellent correlation among ct changes , patient outcome , and treatment efficacy that was only marginal as suggested by conventional pulmonary function criteria .
ph , defined as pulmonary artery pressure greater than 35 mm hg as estimated by transesophageal echocardiography , affects about 20% ( range , 6%60% ) of patients with ssc [ 2 , 3 ] and is a major cause of ssc - related death [ 44 ] .
when complicated by ph , systemic sclerosis has a very poor prognosis . about half of patients with
ph develop the disease within 5 years of the ssc diagnosis [ 44 ] .
primary cardiac involvement from ssc may smolder for years before manifesting as overt cardiomyopathy , pericardial disease , or conduction abnormalities .
ssc heart disease has a poor prognosis and may be related to excessive deposition of abnormal collagen that impairs myocardial contractility , and to ischemia from coronary vasculopathy .
scleroderma involves the gastrointestinal tract in up to 90% of patients , and fibrosis and atrophy may result in motility disorders .
a dilated esophagus containing fluid , gas , and/or debris in the setting of ssc reflects esophageal involvement and may help differentiate ild due to connective tissue disease from other etiologies ( fig .
gastroesophageal reflux may play a role in the development and/or progression of sild [ 48 , 49 ] .
early detection and treatment of esophageal involvement may forestall complications , which include chronic reflux , aspiration pneumonia , barrett s esophagus , and esophageal stricture and malignancy .
3esophageal dilatation with retained debris is an early and frequent manifestation of scleroderma and may help differentiate interstitial lung disease due to connective tissue disease from that of other etiologies esophageal dilatation with retained debris is an early and frequent manifestation of scleroderma and may help differentiate interstitial lung disease due to connective tissue disease from that of other etiologies the presence of mediastinal lymph node enlargement in patients with sild is relatively higher than other causes of ild and has been reported in up to 60% of cases .
scleroderma is a systemic disorder of connective tissues and vasculopathy that involves multiple organ systems , typically the skin , esophagus , and lungs .
symptoms of ild may frequently overlap with those of ph , aspiration pneumonia , and cardiomyopathy . as patients with limited and diffuse cutaneous scleroderma may exhibit progressive and extensive pulmonary fibrosis , all scleroderma patients should be evaluated for lung involvement .
hrct , in conjunction with pft results , plays a critical role in the detection and treatment of sild and in the prediction of outcomes . visual scoring and computer - based hrct techniques
, sild typically manifests as ggo and accentuated reticulations that may progress to pulmonary fibrosis . | interstitial lung disease and pulmonary hypertension ( ph ) are the most common cardiopulmonary findings in patients with systemic sclerosis ( ssc ) .
about two thirds of patients suffering from ssc develop scleroderma interstitial lung disease .
ph is present in about 20% of ssc patients and is typically associated with severe lung disease , although it may be an isolated manifestation of ssc .
high - resolution ct scanning is a key method for evaluating chest involvement .
there are four roles of imaging in scleroderma interstitial lung disease : 1 ) detection of lung involvement , 2 ) identification of patients likely to respond to treatment , 3 ) assessment of treatment efficacy , and 4 ) exclusion of other significant diseases to include ph and cardiac and esophageal abnormalities . |
the movement of organelle dna to the nucleus has been , and remains , a driving force in fashioning eukaryotic genomes ( timmis et al . 2004 ; kleine et al .
early on in both mitochondrial and plastid evolution , there was a massive migration of organelle genes to the nuclear genome ( gray et al .
2009 ) ; thus , present - day nuclear dna is a mosaic of endosymbiont - derived organelle genes and host genes ; and contemporary mitochondrial and plastid dnas ( mtdnas and ptdnas ) are significantly more reduced than the endosymbiotic genomes from which they evolved ( gray et al .
1999 ; archibald 2009 ) . aside from adding to the gene repertoire of nuclear genomes ,
organelle - to - nucleus dna transfer events have generated , and continue to generate , forms of noncoding nuclear dna ( and occasionally exonic nuclear dna , noutsos et al .
2007 ) that share sequence identity with the coexisting organelle dnas ; these types of sequences are referred to as nuclear mitochondrial dnas ( numts ) and nuclear plastid dnas ( nupts ) ( lopez et al .
although the nuclear genomes from at least 85 eukaryotic species have been analyzed for numts ( hazkani - covo et al .
this is because , until recently , there were only a small number of published nuclear genome sequences from plastid - harboring eukaryotes .
nonetheless , an intriguing observation has come from the nupt data that are available : species with one plastid per cell ( monoplastidic ) have fewer nupts than those with many plastids per cell ( polyplastidic ) ( lister et al .
for example , the monoplastidic protists chlamydomonas reinhardtii and plasmodium falciparum have < 2.5 kb of nupts ( richly and leister 2004b ; matsuo et al .
2005 ) , whereas rice , which contains upwards of 100 plastids per cell , has around 900 kb of nupts ( guo et al .
a possible explanation for these observations is that in monoplastidic species , the transfer of ptdna to the nucleus is greatly reduced as compared with polyplastidic taxa because 1 ) there are fewer plastids to donate ptdna to the nucleus and 2 ) lysis of the plastid would almost certainly result in death to the cell , unlike the case for polyplastidic species ( lister et al .
( barbrook et al . 2006 ) . when presenting this hypothesis , barbrook et al . ( 2006 ) predicted that
the sequencing of the nuclear genomes of organisms containing a single plastid should always reveal a low abundance of nupts . but a lack of nuclear dna sequence data from monoplastidic species and from plastid - harboring taxa in general has made this prediction difficult to test . in this study , we take advantage of newly available genomic sequence data from a series of diverse mono- and polyplastidic species to formally investigate the limited transfer window hypothesis . altogether , we calculate the number and accumulative length of nupts in the nuclear dnas of 11 polyplastidic and 19 monoplastidic ( or effectively monoplastidic ) eukaryotes .
when possible , we also analyze these same genomes for numts and compare these data with the corresponding nupt statistics .
to assess a genome for nupts , at least two things are required : complete nuclear dna and ptdna sequence data .
we found 30 species for which both these statistics are available , including 13 land plants , 7 green algae , 5 apicomplexans , 3 stramenopiles , 1 haptophyte , and 1 red alga ( table 1 ) .
the sources for these genome sequence data are listed in supplementary tables s1 and s2 ( supplementary material online ) . to the best of our knowledge ,
detailed nupt statistics for the majority of the above - mentioned taxa have not been published elsewhere . for 20 of these species , complete mtdna sequence data
although most of these taxa have already been explored for numts ( hazkani - covo et al .
2010 , and references therein ) , we performed our own numt investigations because in the past differences in search parameters among studies have led to discrepancies in nupt / numt tabulations .
we did try , however , to use similar search constraints as those employed in previous reports : blastn with an expectation value of 0.0001 .
another source of discrepancy in nupt / numt assessments among earlier studies ( hazkani - covo et al .
2010 ) were instances where one segment of nuclear dna matched to multiple sections of organelle dna . in our analyses
, multiple organelle dna hits to the same nuclear dna regions were counted only once .
because many of the nuclear genomes that we scanned are only in their draft assembly stage , the nupt / numt data presented here should be treated as approximations of the true values .
as these genome sequences become more polished , the nupt / numt estimates will change , but the major trends that we observed among the different groups should arguably remain the same .
number and total amount ( in kilobases ) of nupts and numts in the available nuclear genome sequences from plastid - harboring eukaryotes note. na data not available ( i.e. , mitochondrial genome has not been sequenced ; thus , we were unable to search the nuclear dna for numts ) .
blast parameters were as follows : blastn ( version 2.2.23 ) with an expectation value of 0.0001 ; a word size of 11 ; match and mismatch scores of 2 and 3 , respectively ; and gap cost values of 5 ( existence ) and 2 ( extension ) .
regions of nuclear dna that contained tight clusters of nupts / numts ( i.e. , sections of organelle - like dna interrupted by genomic sequence that did not show sequence identity to organelle dna ) were not counted as a single nupt / numt but as separate hits .
see supplementary table s3 ( supplementary material online ) for references and notes on the number of organelles per cell .
s. moellendorffii and p. patens both contain cells that are polyplastidic , but for the purpose of this study , they are considered
effectively monoplastidic because mitosis and meiosis only occurs in cells that contain a single plastid ( brown and lemmon 1990 ) .
of the 30 species we investigated , 11 are polyplastidic and 19 are either monoplastidic or effectively so .
thirteen of the monoplastidic species are also monomitochondrial ( i.e. , they have one mitochondrion per cell ) . the number of organelles per cell for each species and the references used to determine these statistics are listed in table 1 and supplementary table s3 ( supplementary material online ) , respectively .
when possible , the decision to categorize a species as having one or multiple organelles per cell was based on published ultrastructural data .
two caveats should be noted : the haptophyte emiliania huxleyi and the stramenopile thalassiosira pseudonana can have up to two plastids per cell but , for simplicity , were treated here as monoplastidic ( badger et al .
2008 , and references therein ) ; and the lycophyte selaginella moellendorffii and the moss physcomitrella patens both contain cells that are polyplastidic , but for the purpose of this study , they were considered
effectively monoplastidic because mitosis and meiosis only occur in cells that contain a single plastid ( brown and lemmon 1990 ) .
complete nupt and , when attainable , numt statistics for the various plastid - bearing species that we investigated are shown in table 1 .
overall , we found the difference in nupt content between mono- and polyplastidic species to be highly significant ( fig .
1 ) . species with multiple plastids per cell had on average 80 times more nupts than those with one plastid per cell .
the mean nupt content for polyplastidic species was 460 kb as compared with only 6 kb for monoplastidic taxa .
moreover , the average number of nupts ( based on blast hits , not accumulative length ) for polyplastidic individuals was 20 times greater than that of monoplastidic species ( 1,540 vs. 79 hits ) . in species with only a single plastid , the nupt content ranged from undetectable levels in the protists aureococcus anophagefferens , babesia bovis , ostreococcus sp .
rcc809 , and theileria parva to 65 kb for the multicellular green alga volvox carteri , whereas in polyplastidic species , it spanned from 50 kb for arabidopsis thaliana to > 800 kb for glycine max , vitis vinifera , and oryza sativa .
there is a clear separation in nupt content between mono- and polyplastidic species , with the members of the latter group having considerably more nupts than the former ( figs . 1 and 2 ) .
2 ) ; the reasons for this may be linked to their capacity ( or deficiency ) for purging bulk nuclear dna ( discussed further below ) .
it is also noteworthy that of the 13 land plants that were explored the 2 that are effectively monoplastidic ( s. moellendorffii and p. patens ) had about 60 times fewer nupts than those that are polyplastidic ( figs . 1 and 2 ) .
beanplot depicting the difference in nupt / numt content between mono- and polyplastidic ( and polymitochondrial ) species .
plot was generated using the beanplot package ( kampstra 2008 ) from r v. 2.1.1 .
the dashed line in the middle of each of the two plots is the overall average of the continuous variable ( total nupt or numt content in kilobases ) .
the thick black line in the middle of each category ( mono or poly ) is the median of each continuous variable ( nupt or numt content ) with respect to the categorical variable ( mono- or polyplastidic / polymitochondrial ) .
the colored curved beanpod surrounding the observations beans is the theoretical probability density distribution of these observations .
if there were multiple observations with the same number ( e.g. , nupts content of 4 kb for two different taxa ) , then the line gets longer respective to the other measurements in the beanplot .
a wilcoxon signed rank test ( nonparametric ) was performed in r on all data because errors were not normally distributed .
note , the p values shown are approximations the exact values could not be computed due to ties in the data . for polyorganellar species ,
however , to avoid clutter , only the highest points are labeled for mono - organellar species .
c-169 ; os , oryza sativa ; ts , thalassiosira pseudonana ; and vc , volvox carteri .
log - scale bar graph showing the number and accumulative length of nupts ( right side ) and numts ( left side ) for various plastid - harboring eukaryotes .
see table 1 and supplementary table s3 ( supplementary material online ) for references and notes on the number of organelles per cell .
selaginella moellendorffii and physcomitrella patens are effectively monoplastidic mitosis and meiosis only occurs in cells that contain a single plastid ( brown and lemmon 1990 ) .
species with only a single mitochondrion per cell had significantly fewer numts than those with many mitochondria per cell ( figs . 1 and 2 ) .
the average numt content for monomitochondrial species ( 1.1 kb ) was 300 times less than that of polymitochondrial taxa ( 380 kb ) .
these data are consistent with earlier observations on numts ( hazkani - covo et al .
2010 ) and support the belief that organelle number influences both nupt and numt content .
it was recently shown that numt content scales positively with nuclear genome size ( hazkani - covo et al .
2010 ) . here , we found that this is true for nupts as well : bloated nuclear genomes tend to have more nupts than those that are compact ( fig .
3)based on the 30 species investigated here , we found a reasonably strong relationship between nuclear genome size and nupt content ( r = 0.57 , p = 8.6 10 ) .
we expected to find this relationship because nupts are a type of excess dna , and it is well established that all types of excess dna mutually expand as the number of nucleotides in a genome increases ( lynch and conery 2003 ) .
ultimately , this suggests that the forces governing the expansion and contraction of noncoding nuclear dna impact the accumulative length of nupts in a nuclear genome .
although the nature of these forces is hotly debated , there is evidence that the tendency for excess dna to accumulate depends on the combined effects of the mutation rate ( ) and the effective genetic population size ( ne ; lynch and conery 2003 ) . according to this hypothesis
, one may expect species with a low ne to have more nupts than those with a high ne. although there are very few reliable data on this fundamental population genetic parameter , a recent study indicates that v. carteri has a very small ne , especially relative to other protists ( smith and lee 2010 ) .
this could help explain why of all the monoplastidic species that we studied , v. carteri had the largest nupt content .
being monoplastidic , one would expect the transfer of ptdna to the nuclear genome to be rare in v. carteri , but having a low ne implies that it has a reduced ability to detect and eradicate excess dna ( smith and lee 2010 ) so that the few nupts that do arise avoid deletion and therefore can accumulate to reasonably high levels over time .
2008 ) ; thus , one explanation for why a. thaliana , which is polyplastidic , had fewer nupts than the monoplastidic v. carteri could be that it is reasonably efficient at perceiving and purging noncoding nuclear dna .
it is worth mentioning that the v. carteri ptdna , at 525 kb , is the largest plastid genome sequenced to date ( smith and lee 2010 ) , being > 300 kb larger than any other ptdna employed in our data set .
and although we did not find an association between plastid genome size and nupt content ( supplementary fig .
s1 , supplementary material online ) , there is still the possibility that the prodigious ptdna of v. carteri is in some way contributing to its elevated nupt content .
log - log plot of nupt ( top ) and numt ( bottom ) content versus nuclear genome size .
polyplastidic and polymitochondrial species are shaded gray on the top and bottom plots , respectively .
nuclear genome size data came from genbank s entrez eukaryotic genome project database ( http://www.ncbi.nlm.nih.gov/genomes/leuks.cgi ) .
the data presented here provide support for the limited transfer window hypothesis and the notion that the number of plastids per cell in a eukaryotic species governs the amount of nupts found in its nuclear genome .
we argue that the evolution of nupts is a give and take process where plastid number determines the potential for ptdna to be donated ( i.e. , given ) to the nuclear genome , and the probability that these ptdna sequences will be accepted ( i.e. , taken ) by the nuclear genome and persist as nuclear dna is determined by a species ability ( or lack thereof ) to detect and eliminate excess dna . in this study , being monoplastidic versus polyplastidic was used to define the number of plastids per cell in a species , and nuclear genome size was used as of a proxy for defining a species , ability to eradicate noncoding nuclear dna .
again , it must be stressed that many of the nuclear dna sequences that we used to calculate nupt / numt abundance were in their draft assembly stage .
as these genome assemblies improve , their nupt / numt statistics may change , but we believe that the major trends reported here will be borne out by future investigations .
finally , given the wide diversity of eukaryotic species that we explored , there are certainly factors in addition to a limited transfer window and susceptibility to bulk dna that are influencing nupt and numt content ; however , we argue these additional factors ( whatever they may be ) will turn out to be secondary to the forces outlined here .
the sources and references for the nuclear genome sequences employed in this study , as well the genbank accession numbers , when available , are shown in supplementary table s1 ( supplementary material online ) .
all nuclear dna data came from publicly available sources . the organelle dna sequences ( including their lengths , genbank accession numbers , and noncoding dna contents ) used as queries for blastn searches against nuclear genomes are listed in supplementary table s2 ( supplementary material online ) .
some of the organelle dna sequences that were used in this study are not deposited in genbank but are available for download online from the given genome project web site ( supplementary table s2 , supplementary material online ) .
nuclear genomes were scanned for nupts and numts with blastn ( version 2.2.23 ) ( altschul et al . 1990 ) using the following parameters : an expectation value of 0.0001 ; a word size of 11 ; match and mismatch scores of 2 and 3 , respectively ; and gap - cost values of 5 ( existence ) and 2 ( extension ) .
hits under 30 nt and showing < 70% sequence identity to the query were ignored .
spurious hits , such as those where organelle genes matched to homologous genes in the nuclear genome ( e.g. , organelle ribosomal dna [ rdna ] matching to nuclear rdna ) were ignored .
instances where one segment of nuclear dna matched to multiple sections of organelle dna ( i.e. , duplicate blast hits ) were reduced to a single blast hit ; in other words , nupts and numts matching to multiple organelle genomic regions , such as repetitive elements , were counted only once
. regions of nuclear dna that contained tight clusters of nupts or numts ( i.e. , sections of organelle - like dna interrupted by genomic sequence that did not show sequence identity to organelle dna ) were not counted as a single nupt or numt but as separate hits .
data and sources used to calculate the number of organelles per cell are shown in supplementary table s3 ( supplementary material online ) .
supplementary tables s1s3 and figure s1 are available at genome biology and evolution online ( http://www.gbe.oxfordjournals.org/ ) . | the abundance of nuclear plastid dna - like sequences ( nupts ) in nuclear genomes can vary immensely ; however , the forces responsible for this variation are poorly understood .
the limited transfer window hypothesis predicts that species with only one plastid per cell will have fewer nupts than those with many plastids per cell , but a lack of genome sequence data from monoplastidic species has made this hypothesis difficult to test . here ,
by analyzing newly available genome sequences from diverse mono- and polyplastidic taxa , we show that the hypothesis holds . on average ,
the polyplastidic species we studied had 80 times more nupts than those that were monoplastidic .
moreover , nupt content was positively related to nuclear genome size , indicating that in addition to plastid number , nupts are influenced by the forces controlling the expansion and contraction of noncoding nuclear dna .
these findings are consistent with data on nuclear dnas of mitochondrial origin ( numts ) , suggesting that similar processes govern the abundance of both nupts and numts . |
statins are used to lower serum cholesterol concentrations in the primary and secondary prevention of cardiovascular disease ( 1 ) . in randomized trials ,
the use of statins has demonstrated 30% reductions in atherosclerotic end points without serious morbidity .
the pleiotropic effects of statins , indirectly related to cholesterol - lowering activities ( 2 ) , have also been assessed , making these drugs more widely accepted in various clinical settings .
fluvastatin , available as both fluvastatin sodium and fluvastatin extended - release , is the first synthetic 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitor . because fluvastatin is well tolerated and lacks clinically significant drug - drug interactions , it is regarded as one of the safest statins , especially in patients receiving multiple medications ( 3 ) .
even patients with renal disease , renal transplantation recipients and patients who have undergone pci can be safely treated with fluvastatin ( 4 ) .
this includes a broad clinical spectrum of disorders , from mild and non - specific muscle aches or weakness , through asymptomatic and symptomatic elevation of serum creatine kinase levels , to life - threatening rhabdomyolysis . to date
, few cases of fatal rhabdomyolysis associated with the use of statins have been reported ; these include 19 patients taking lovastatin , 3 taking pravastatin , 14 taking simvastatin , 6 taking atorvastatin , and 31 taking cerivastatin , the latter which was withdrawn worldwide ( 5 ) .
there have been no reports to date of fatal rhabdomyolysis associated with the use of fluvastatin .
we report a case of fluvastatin - induced fatal rhabdomyolysis in a patient with liver cirrhosis ; this patient had been switched from simvastatin to fluvastatin 10 days earlier and died due to severe rhabdomyolysis complicated by hepatic failure .
a 56-yr - old man with liver cirrhosis caused by the hepatitis b virus visited our hospital on december 30 , 2008 for evaluation of weakness in his lower legs of 1-week duration .
he first experienced discomfort and myalgia in his lower legs , which worsened over time and made him unable to walk .
he had undergone a percutaneous coronary intervention 10 yr previously at the local hospital and had taken simvastatin ( 20 mg / day ) regularly since then .
he was diagnosed with child - pugh c cirrhosis due to hepatitis b virus a year ago and followed - up at the same hospital with stable liver function in a compensated state .
ten days before visiting our hospital , he was switched from simvastatin to fluvastatin ( 20 mg / day ) by his doctor , as the patient was concerned about his liver disease .
in addition to fluvastatin ( 20 mg / day ) , his medications included aspirin ( 100 mg / day ) , betaxolol ( 10 mg / day ) , candesartan ( 16 mg / day ) , lactulose ( 30 ml / day ) , and entecavir ( 0.5 mg / day ) without diuretics or fibrates .
his medical history was significant for no alcohol use and 10 pack - years of smoking , but he had quit smoking 10 yr previously .
the patient 's blood pressure was 122/76 mmhg , his temperature was 36.8 , his pulse was 63 beats / min , weight was 98 kg , and his body mass index was 29.8 kg / m .
laboratory findings included sodium 125 mm / l , potassium 5.1 mm / l , chloride 97 mm / l , phosphorus 3.1 mg / dl , co2 24.4 mm / l , serum creatinine 1.0 mg / dl , blood urea nitrogen 21 mg / dl , glucose 176 mg / dl , calcium 8.3 mg / dl , phosphorus 3.1 mg / dl , aspartate transaminase 1,303 iu / l ( normal < 40 ) , alanine transaminase 354 iu / l ( normal < 40 ) , alkaline phosphatase 145 iu / l ( normal 40 to 120 ) , total bilirubin 4.6 mg / dl , direct bilirubin 1.4 mg / dl , protein 8.0 g / dl , albumin 2.7 g / dl , and uric acid 3.5 mg / dl .
his hematocrit was 38.5% , platelet count was 80,000/l , and white blood cell count was 11,100/l , with 18.5% lymphocytes , 69.7% polymorphonuclear leukocytes , 10.% monocytes , 1.4% eosinophils , and 0.2% basophils .
his prothrombin time ( pt ) was 1.78 inr ( 40.7% ) and activated partial thromboplastin time ( aptt ) was 36.5 seconds .
his total serum creatine kinase ( ck ) was 36,804 iu / l ( normal 50 to 250 iu / l ) and his ck - mb was 157.0 ng / ml ( normal < 5 ng / ml ) .
urinalysis revealed no red or white blood cells , positive dipsticks for protein , occult blood , bilirubin and urobilinogen , but negative for glucose .
a tc - diphosphonate scintigram bone scan showed increased uptake over all extremities and muscles of the thorax and abdomen ( fig .
treatment with fluvastatin , betaxolol and candesartan was discontinued , and he received massive hydration and urine alkalization .
he was treated with intravenous sodium bicarbonate ( 100 meq in 1,000 ml of half - normal saline at a rate of up to 500 ml / h or 50 meq / h ) titrated to a urine ph > 6.5 .
he was administered a 20 - 80 mg dose of intravenous furosemide to maintain diuresis .
his ck concentration was increased to 166,160 iu / l , and renal failure occurred .
he underwent continuous renal replacement therapy on day 7 , but his renal function did not recover and hepatic function worsened , with pt prolonged to 3.8 inr ( 18% ) and total bilirubin increased to 24.5 mg / dl ( fig .
fluvastatin is one of the statins shown to reduce the incidence of vascular events and slow the angiographically demonstrated progression of atherosclerotic disease ( 4 ) . since its approval in 1993 , fluvastatin has been administered for more than 21 million patient - years worldwide . among the statins ,
although there was a report of fatal rhabdomyolysis induced by fluvastatin - gemfibrozil combination therapy ( 6 ) , to our knowledge , fluvastatin alone has not been reported to induce fatal rhabdomyolysis .
our patient had both chronic liver disease and established coronary artery disease , making it difficult to choose the most appropriate type and dose of statin , or even whether to treat with statin .
the benefits of statins in lowering cholesterol and preventing heart disease outweigh the potential risks of hepatotoxicity , even in patients with chronic liver disease ( 7 ) . the national lipid association ( nla ) expert liver panel has stated that patients with chronic liver disease , nonalcoholic fatty liver disease and nonalcoholic steatohepatitis may safely receive statin therapy , supporting no scientific evidence to contraindicate statin use in patients with compensated cirrhosis ( 8) .
literature has also indicated that use of statins in patients with hepatitis c infection and primary biliary cirrhosis is safe .
statins have not been shown to worsen the outcome in persons with chronically increased transaminase levels due to hepatitis b or c viruses ( 9 ) . however , the incidence of discontinuations from statins due to hepatotoxicity was significantly higher in hbsag - positive than in hbsab - negative patients with coronary heart disease ( 10 ) .
statins are contraindicated in patients with active liver disease or unexplained , persistent increases in liver function tests . except for cerivastatin
, all statins have a very low systemic bioavailability owing to their extensive first - pass extraction by the liver .
all statins , except for pravastatin , undergo microsomal metabolism by the cytochrome p450 ( cyp ) isoenzyme systems .
inhibition of cyp450 isoenzymes by concomitantly interacting drugs can lead to increased plasma concentrations of statins , resulting in myositis and rhabdomyolysis .
fibrates , warfarin , digoxin and mibefradil have been reported in patients with statin - associated rhabdomyolysis ( 11 ) .
advanced age , diabetes , chronic renal insufficiency , and multiple medications are also associated with increased risks of statin - associated myopathy ( 9 ) .
our patient , however , was not taking any drugs that interact with statins , nor was he ingesting alcohol .
he did not have any other factors including hypokalemia , hypophosphatemia , hypo- or hyperthyroidism , and diuretics that could predispose him to the development of myopathy .
no clinically important interactions have been observed between statins and other drugs used in cardiovascular diseases , such as propranolol , angiotensin - converting enzyme inhibitors , and thiazide diuretics ( 12 ) . about half of all statins currently available in clinical practice
fluvastatin , unlike other statins , is metabolized primarily by the cyp2c9 enzyme in the liver , with cyp3a4 and cyp2c8 contributing to a lesser extent , and is therefore less subject to interactions than other statins ( 13 ) .
as fluvastatin has the shortest elimination half - life of inactive metabolites among the statins and higher liver extraction , however , it results in high liver and peripheral tissue concentration , minimizing the systemic burden , instead potentiating hepatocellular injury in serious liver disease ( 6 ) . in a population
based cohort study ( 14 ) , the highest risk of serious liver dysfunction among statins was associated with fluvastatin ( hazard ratio 2.53 , 95% confidence interval 1.84 - 3.47 ) , which was significantly higher than that with simvastatin ( hazard ratio 1.52 , 95% confidence interval 1.38 to 1.66 ) . with regard to this ,
candesartan is primarily excreted as unchanged drug ( 75% ) in the urine and feces with a smaller proportion ( 20%-25% ) inactivated by cyp2c9 .
entecavir and lactulose are not substrates for and do not inhibit or induce cyp isoenzymes .
however , the major enzymes involved in glucuronidation and hydroxylation of nsaids are cyp2c9 ( 16 ) .
therefore , we could not exclude the possibility that cyp2c9 enzyme in our patient was partially saturated with candesartan and aspirin or he had genetic variants in cyp2c9 , which we could not identify unfortunately .
/ d , simvastatin and fluvastatin can reduce low - density lipoprotein by 30%-40% and 10%-20% , respectively .
lipophilic statins , including lovastatin , simvastatin , and cerivastatin , also have a greater potential for muscle toxicity than do hydrophilic statins including fluvastatin , atorvastatin , and pravastatin owing to their enhanced ability to penetrate myocytes . in our patient
it could be preliminarily explained in addition from a report that hepatic reactions associated with fluvastatin might be more common and more serious than those caused by other statins ( 17 ) , especially in patients with hepatic dysfunction . in one third of severe hepatotoxicity associated with fluvastatin
fluvastatin is an established treatment for hypercholesterolemia ; its efficacy and safety have been documented in several clinical trials .
rhabdomyolysis associated with fluvastatin is very rare , with the adverse event reporting system of the u.s .
food and drug administration showing that only 1.7% of the incidents of statin - associated rhabdomyolysis were related to fluvastatin administration .
however , our findings indicate that fluvastatin should be used with caution in patients with liver cirrhosis , especially with other medications metabolized with cyp2c9 . | hmg - coa reductase inhibitors ( statins ) are widely used to treat hypercholesterolemia . among the adverse effects associated with these drugs
are statin - associated myopathies , ranging from asymptomatic elevation of serum creatine kinase to fatal rhabdomyolysis .
fluvastatin - induced fatal rhabdomyolysis has not been previously reported .
we describe here a patient with liver cirrhosis who experienced fluvastatin - induced fatal rhabdomyolysis .
this patient had been treated with simvastatin ( 20 mg / day ) for coronary artery disease and was switched to fluvastatin ( 20 mg / day ) 10 days before admission .
he was also taking aspirin , betaxolol , candesartan , lactulose , and entecavir .
rhabdomyolysis was complicated and continued to progress .
he was treated with massive hydration , urine alkalization , intravenous furosemide , and continuous renal replacement therapy for acute renal failure , but eventually died due to rhabdomyolysis complicated by hepatic failure . in conclusion
, fluvastatin should be used with caution in patients with liver cirrhosis , especially with other medications metabolized with cyp2c9 . |
it refers to abnormal hearing of sound heard during metabolism and not from an external sound source .
the most common cause of vibratory tinnitus is intracranial vascular disease , such as aneurysm and arteriovenous malformation.1 ) the authors performed excisional biopsy on pulsatile lip masses of 46 year old male .
a 46 year old male patient experienced vibratory tinnitus on the right side for 10 years .
he had pulsatile mass on the right side of his lip and did not undergo any treatment . since 1 month before diagnosis , the level of tinnitus increased along with the size of the mass .
upon physical examination , there were no symptoms of tenderness , but 2 pulsatile masses were found on the right upper and right lateral side lip .
the size of the former mass was 11 cm and the latter was 1.51.0 cm ( fig .
1 ) . there were no other special abnormalities in the oral cavity , oropharynx and the other head and neck area .
the tinnitus decreased when pressure was applied to the left tympanic membrane area and increased when leaning forward .
the tympanic membrane was in sound condition and hearing tests revealed both ears to be normal .
the frequency was 2 khz , and loudness was between 60 and 70 decibels and there were no residual inhibitions .
arteriovenous malformation from the right facial artery was found resulting from computed tomography of the facial bone ( fig .
2 ) . ct with angiography was not conducted due to hypotension and tachycardia after the injection of the contrast media .
it was diagnosed as resulting from an abnormality in vessel and excisional biopsy was conducted through oral access after general anesthesia ( fig .
operation revealed the superior labial artery and facial artery after incising the oral mucosa in the mass and the area showing evidence of vascular malformation was ligated .
the patient did not complain of any tinnitus symptoms after the operation and shows no sign of recurrence up until now , 1 year after the operation .
tinnitus can be classified as objective or subjective tinnitus , depending on whether the examiner can hear the sound that the patient is complaining about . from a radiologic point of view
non - vascular causes include the abnormal patency of the eustachian tube , temporomandibular joint disorder , arteriovenous anastomosis , myoclonus of the oropharyngeal , stapedius , and tensor tympani muscles.2 ) depending on the type of condition , pulsatile tinnitus shows varying levels of strength , duration and the size of the tinnitus , all of which are characteristically in line with the regular rhythm of the patient 's heart beat . sometimes true pulsatile and pseudo - pulsatile tinnitus is categorized by whether the tinnitus is in line with the rhythmic beating of the heart .
patients diagnosed with objective tinnitus mostly show vascular disease representing a 7.6% of all tinnitus patients.3 ) finding the cause of the tinnitus raises the possibility of cure , and tinnitus can sometimes be the tell - tale sign of a more serious condition .
clinical symptoms differ depending on the location of the lesion and the structure of the anatomy
. if the lesion is close to the skull base or scalp vessel , symptoms such as pulsatile mass , palpable thrill or murmur may show and pulsatile tinnitus.4,5 ) the possible venous cause for pulsatile tinnitus is benign intracranial hypertension and intracranial venous malformation .
benign intracranial hypertension usually shows in young obese females , and symptoms include pulsatile tinnitus , headaches , blurred vision among other non - characteristic symptoms .
otologic symptoms , such as earfullness , low frequency hearing difficulty and dizziness may also follow .
symptoms worsen during situations where the cranial blood pressure increases , such as coughing and leaning forwards and thus , are at its peak during the morning .
pulsatile tinnitus arising from venous malformation can be due to sigmoid sinus diverticulum , jugular bulb diverticulum , dehiscent high jugular bulb , dehiscent sigmoid sinus and abnormal emissary vein .
patients with pulsatile tinnitus must be examined thoroughly , including neurological and radiological examination , along with physical examination and past history . in cases with vessel malformation
other neoplasms include middle ear adenoma , hemangioma , hemangiopericytoma , plasmacytoma , giant cell tumor , neuroendocrine carcinoma , and etc . in this example , the location of the lesion was relatively easier to access , and due to the abnormal reaction , the ct - angiography was not conducted . for a radiological examination of pulsatile tinnitus , enhanced temporal bone - hrct , enhanced brain ct , ct angiography ,
mr angiography / venography , four - vessel angiography and the contrast enhancement are used to observe the head and neck vessel in detail .
this is because the diagnostic sensitivity and the specificity of each method differ , and as there is no specified standard in determining the level of the finding to be considered abnormal .
however , to propose some rules to the method of examination , firstly , a method utilizing the contrast enhancement must be used , and secondly , a method checking the abnormalities in angiography in the cervical and head , not just in the temporal bone , must be used .
thirdly , if there are past history in the head trauma and there is a possibility of an arterial malformation and no abnormalities are found upon initial exam , four - vessel angiography must be considered.6 ) external and internal access was considered before the surgery , however due to the young age of the patient and for cosmetic reasons , the area was accessed through the mouth .
it is considered that this instance of tinnitus arising from the facial vessel is very abnormal .
the authors successfully cured tinnitus after removal of arteriovenous malformation near the lips and have compiled the findings in this thesis . | tinnitus is one of the most common symptoms in an audiologic field .
it can be classified as either as subjective or objective ; former referring to the sensation heard by both patient and examiner .
pulsatile tinnitus is perceived as sounds that vary in frequency , intensity and duration .
the cause of pulsatile tinnitus include high jugular bulb , benign intracranial hypertension , glomus tumors , carotid artery stenosis , vascular lesions of the temporal bone , arteriovenous malformation , aneurysms , and arnold - chiari malformation .
vascular tinnitus is most common ( 7.6% ) .
recently , the authors experienced one case of the pulsatile tinnitus caused by atherosclerosis and atheroma in superior labial artery & facial artery .
after surgery , the symptom had disappeared .
we report a unique case regarding the objective tinnitus with the literature review . |
falls in adults pose a major health concern , are a well - known public health problem,1 and are the main cause of injury , hospitalization , disability , poor quality of life , depression , and mortality in older adults.2,3 about 30%40% of adults in the usa report falling at least once per year,4 but less than half discuss their falls with their health care provider.5 one of the most common biological risk factors for falls is sarcopenia , which is observed in knee osteoarthritis ( oa).6 knee oa is an important risk factor for falls , particularly in women.7 in the usa , about 40% of adults with knee oa reported their health as poor or fair , and more than 50% of those with knee oa reported falling in the previous year.8 as the number of older adults increases , it is expected that the prevalence of falls and knee oa will increase.8,9 in 2010 , the overall rate of falls and fall - related injury was 43 per 1,000 population.9 an estimated 42.7 million americans ( 15% of the population ) had knee oa in 1995 , and , because of the increasing average age of the population , this figure is projected to rise to 59.4 million ( 18.2% ) by 2020.10 because of this growing epidemic , it is important to understand and monitor the impact of falls and knee oa on physical and mental health .
one health outcome of particular interest in patients with falls and knee oa is health - related quality of life ( hrqol).11 assessment of hrqol has received considerable attention in recent decades.12 a key reason for serial measurement of hrqol is to reflect the changes that occur in an individual s health state in response to disease progression , various therapies , and recovery.12 there are a variety of generic and knee - specific instruments available to assess hrqol in people with oa.13 the knee injury and osteoarthritis outcome score ( koos ) is a knee - specific instrument , while the short form-12 ( sf-12 ) is a generic measure developed to assess hrqol in persons who have had falls during the previous 12 months .
the objective of this study was to examine the relationship between self - reported falls , doctor - diagnosed knee oa , and hrqol using both disease - specific and generic measures .
we selected the koos - qol subscale as a disease - specific measure and the sf-12 as a generic measure because they are widely used to assess hrqol and have been validated for the subpopulation of patients with self - reported falls and doctor - diagnosed knee oa .
the osteoarthritis initiative is a publicly and privately funded , ongoing , longitudinal multicenter study of the onset and progression of knee oa.14 adults aged 4579 years at enrollment who had or were at high risk of knee oa were recruited between february 2004 and may 2006 from four clinical sites in the usa , ie , baltimore , md ; pittsburgh , pa ; pawtucket , ri ; and columbus , oh . details regarding the osteoarthritis initiative , including study overview , objectives , collaboration worldwide , funding , resources , visit schedule , and assessments are described elsewhere.15 the study protocol was approved by the institutional review board at the center coordinating the osteoarthritis initiative at the university of california , san francisco , ca , usa.14 the data used for the present study were obtained from the study documentation and data publically available in the online osteoarthritis initiative database.14 the specific dataset used was version 0.2.2 ( n=4,796 , november 2008 ) .
we considered three subpopulations according to self - reported history of falling and doctor - diagnosed knee oa status as follows : those had neither a self - reported history of falling nor doctor - diagnosed knee oa ; those who had either a self - reported history of falling or doctor - diagnosed knee oa ; and those who had both a self - reported history of falling and doctor - diagnosed knee oa .
subjects were included if they were aged 4579 years , regardless of sex or ethnicity ( figure 1 ) .
we excluded individuals who did not know , were not sure , or refused to answer ( < 6.5% of the 4,312 respondents)14 from the analysis ( figure 1 ) .
history of self - reported falling and doctor - diagnosed knee oa had been assessed using the following questions : have you fallen and landed on the floor or ground in the past 12 months?16 and has the doctor said you have osteoarthritis / degenerative arthritis of the knee?17 respondents were defined as having neither a self - reported history of falling nor knee oa if they had answered no to both the above questions , and to have either a self - reported history of falling or knee oa if they answered no to only one of the above questions .
hrqol was assessed using both disease - specific and generic measures.18 the koos - qol18 was used as the knee - specific measure and the sf-1219 as the generic measure .
the koos consists of five subscales , ie , pain , other symptoms , ability to perform activities of daily living , function in sports and recreation .
the koos - qol subscale was used in this study and consists of four items , ie , knee problems , knee activity , knee troubles , and knee difficulty .
each subscale score ranges from 0 ( no problems ) to 4 ( extreme problems ) , and was calculated as the sum of the above four items .
the scores are transformed using a 0100 scale , with zero representing extreme problems and 100 representing no problems.20 responses of do nt know and refused were treated as missing data .
the sf-12 scale , a shorter version of the sf-36 scale , uses 12 questions to measure the following eight dimensions of health : physical function , role limitations related to physical problems , pain , general health perception , vitality , social functioning , role limitations due to emotional problems , and mental health . these dimensions can be categorized into a physical component scale ( pcs ) and a mental component scale ( mcs ) .
these health concepts are described by norm - based scores , with a mean of 50 in the general population and higher scores indicating better heath.21 the demographic and socioeconomic variables included were age ( years ) , race ( white versus non - white ) , sex ( female versus male ) , education ( high school / less versus some college / graduation ) , marital status ( married versus unmarried ) , employment ( employed versus unemployed ) , annual income ( < us$50,000 versus us$50,000 ) , household composition ( single versus living with others ) , smoking status ( never versus current ) , and weekly alcoholic consumption ( never versus current ) .
validated general health measures of comorbidity and depression ( high versus low ) were used .
the carlson cormorbidity index was used to measure comorbidity.19 a score 16 on the center for epidemiological studies depression scale was taken to indicate severe depressive symptoms.22 the sample characteristics were described using the mean and standard deviation for continuous variables and the frequency ( number and percentage ) for categoric variables .
we used analysis of variance for continuous covariates and the chi - square test for categoric covariates to examine differences in sample characteristics and covariates according to self - reported history of falling and doctor - diagnosed knee oa status .
multiple regression analyses were used to examine the relationship between falls and knee oa status on the koos - qol and sf-12 ( pcs and mcs ) .
model 1 examined the unadjusted relationship between falls and knee oa status on the koos - qol and sf-12 ( pcs and mcs ) .
model 2 investigated whether the relationship between falls and knee oa status on the koos - qol and sf-12 ( pcs and mcs ) was affected by sociodemographic , lifestyle , and clinical characteristics ( ie , sex , race , education , marital status , employment , household composition , annual income , health care coverage , smoking status , alcohol consumption , comorbidity , and depressive symptoms ) .
the data used for the present study were obtained from the study documentation and data publically available in the online osteoarthritis initiative database.14 the specific dataset used was version 0.2.2 ( n=4,796 , november 2008 ) .
we considered three subpopulations according to self - reported history of falling and doctor - diagnosed knee oa status as follows : those had neither a self - reported history of falling nor doctor - diagnosed knee oa ; those who had either a self - reported history of falling or doctor - diagnosed knee oa ; and those who had both a self - reported history of falling and doctor - diagnosed knee oa .
subjects were included if they were aged 4579 years , regardless of sex or ethnicity ( figure 1 ) .
we excluded individuals who did not know , were not sure , or refused to answer ( < 6.5% of the 4,312 respondents)14 from the analysis ( figure 1 ) .
history of self - reported falling and doctor - diagnosed knee oa had been assessed using the following questions : have you fallen and landed on the floor or ground in the past 12 months?16 and has the doctor said you have osteoarthritis / degenerative arthritis of the knee?17 respondents were defined as having neither a self - reported history of falling nor knee oa if they had answered no to both the above questions , and to have either a self - reported history of falling or knee oa if they answered no to only one of the above questions .
hrqol was assessed using both disease - specific and generic measures.18 the koos - qol18 was used as the knee - specific measure and the sf-1219 as the generic measure .
the koos consists of five subscales , ie , pain , other symptoms , ability to perform activities of daily living , function in sports and recreation .
the koos - qol subscale was used in this study and consists of four items , ie , knee problems , knee activity , knee troubles , and knee difficulty .
each subscale score ranges from 0 ( no problems ) to 4 ( extreme problems ) , and was calculated as the sum of the above four items .
the scores are transformed using a 0100 scale , with zero representing extreme problems and 100 representing no problems.20 responses of do nt know and refused were treated as missing data .
the sf-12 scale , a shorter version of the sf-36 scale , uses 12 questions to measure the following eight dimensions of health : physical function , role limitations related to physical problems , pain , general health perception , vitality , social functioning , role limitations due to emotional problems , and mental health . these dimensions can be categorized into a physical component scale ( pcs ) and a mental component scale ( mcs ) .
these health concepts are described by norm - based scores , with a mean of 50 in the general population and higher scores indicating better heath.21 the demographic and socioeconomic variables included were age ( years ) , race ( white versus non - white ) , sex ( female versus male ) , education ( high school / less versus some college / graduation ) , marital status ( married versus unmarried ) , employment ( employed versus unemployed ) , annual income ( < us$50,000 versus us$50,000 ) , household composition ( single versus living with others ) , smoking status ( never versus current ) , and weekly alcoholic consumption ( never versus current ) . validated general health measures of comorbidity and depression ( high versus low ) were used .
the carlson cormorbidity index was used to measure comorbidity.19 a score 16 on the center for epidemiological studies depression scale was taken to indicate severe depressive symptoms.22
the sample characteristics were described using the mean and standard deviation for continuous variables and the frequency ( number and percentage ) for categoric variables .
we used analysis of variance for continuous covariates and the chi - square test for categoric covariates to examine differences in sample characteristics and covariates according to self - reported history of falling and doctor - diagnosed knee oa status .
multiple regression analyses were used to examine the relationship between falls and knee oa status on the koos - qol and sf-12 ( pcs and mcs ) .
model 1 examined the unadjusted relationship between falls and knee oa status on the koos - qol and sf-12 ( pcs and mcs ) .
model 2 investigated whether the relationship between falls and knee oa status on the koos - qol and sf-12 ( pcs and mcs ) was affected by sociodemographic , lifestyle , and clinical characteristics ( ie , sex , race , education , marital status , employment , household composition , annual income , health care coverage , smoking status , alcohol consumption , comorbidity , and depressive symptoms ) .
of the 4,484 participants , 2,297 ( 51.23% ) had neither a self - reported history of falling nor doctor - diagnosed knee oa , 1,815 ( 40.48% ) had either a history of falling or knee oa , and 372 ( 8.30% ) had both a history of falling and knee oa ( table 1 ) .
those who had both a history of falling and knee oa were significantly more likely to be women , have a lower income , report more depressive symptoms , partake in less physical activity , and have a lower hrqol score than the other two groups .
table 2 shows the regression analysis for self - reported history of falling and doctor - diagnosed knee oa status according to the koos - qol . in model 1 ( unadjusted ) , either a history of falling or knee oa was significantly associated with koos - qol score ( = 19.7 , standard error 1.35 , p<0.0001 ) compared with no history of falling or knee oa . having both a history of falling and knee
oa was more strongly associated with koos - qol score ( = 39.5 , standard error 2.38 , p<0.0001 ) compared with neither a history of falling or knee oa and either a history of falling or knee oa ( table 2 ) . in model 2 , when sociodemographic , lifestyle , and clinical characteristics ( sex , race , education , marital status , employment , household composition , annual income , health care coverage , smoking status , alcohol consumption , comorbidity , and depressive symptoms ) were added , the negative association with koos - qol score was statistically significant ( = 18.5 , standard error 1.29 , p<0.0001 ) in persons with either a history of falling or knee oa compared with persons who had no history of falling or knee oa . having both a history of falling and knee oa was more strongly associated with koos - qol score ( = 34.4 , standard error 2.27 , p<0.0001 ) compared with no history of falling or knee oa and compared with either a history of falling or knee oa .
other variables significantly associated with koos - qol scores in model 2 were age , sex , race , education , employment , income , smoking , depression , and comorbidity ( see table 2 ) .
the regression analysis of history of falling and doctor - diagnosed knee oa status on the pcs and mcs of the sf-12 is shown in tables 3 and 4 , respectively . in model 1 ( unadjusted ) , either a history of falling or knee oa were significantly associated with pcs and mcs scores ( = 6.1 , standard error 0.55 , p<0.0001 , and = 1.1 , standard error 0.50 , p=0.030 , respectively ) than neither a history of falling nor knee oa . having both a history of falling and knee
oa was more strongly associated with pcs and mcs scores ( = 11.4 , standard error 0.98 , p<0.0001 , and = 4.20 , standard error 0.88 , p<0.0001 , respectively ) than neither a history of falling nor knee oa or either a history of falling or knee oa ( see tables 3 and 4 ) . in model 2 ,
when sociodemographic , lifestyle , and clinical characteristics ( sex , race , education , marital status , employment , household composition , annual income , health care coverage , smoking status , alcohol consumption , comorbidity , and depressive symptoms ) were added , there was a statistically significant negative relationship with pcs score ( = 5.56 , standard error 0.50 , p<0.0001 ) in persons with either a history of falling or knee oa compared with persons who had no history of falling or knee oa .
having both a history of falling and knee oa was more strongly associated with pcs score ( = 9.44 , standard error 0.90 , p<0.0001 ) compared with no history of falling or knee oa and compared with either a history of falling or knee oa ( see table 3 ) .
however , no statistically significant relationship was found with mcs score ( see table 4 ) .
other variables that were significantly associated with pcs scores in model 2 were race , education , employment , income , smoking status , alcohol consumption , depression , and comorbidity ( see table 3 ) .
variables significantly associated with mcs scores in model 2 were age , race , marital status , income , smoking , and depression ( see table 4 ) .
the aim of the current study was to examine the relationship between self - reported history of falling , doctor - diagnosed knee oa , and hrqol .
we found that self - reported history of falling and doctor - diagnosed knee oa were significantly associated with poorer quality of life according to the koos - qol subscale and the pcs of the sf-12 , after controlling for all covariates .
we used both disease - specific ( koos - qol subscale ) and generic ( sf-12 ) hrqol measures to capture different aspects of the health status of the study population.23 although a history of falling and knee oa were associated with poorer hrqol , the pcs domain of the sf-12 and the qol domain of the koos - qol subscale showed significantly lower score in persons with both conditions ( fall and knee oa ) compared with persons who had no history of falling or knee oa and persons with either a history of falling or knee oa .
the lower scores on the pcs and hrqol domains indicate a significant determinant worthy of further evaluation over a longer follow - up duration .
we had expected to find low psc scores on the sf-12 and on the koos - qol subscale when investigating how a history of falling and having knee oa affects these constructs at baseline . according to our data , individuals who had experienced falls and had knee oa showed lower mcs scores even after adjustment for sociodemographic , lifestyle , and clinical characteristics , compared to persons who had no history of falling or knee oa and persons with either a history of falling or knee oa .
previous research has identified adverse effects of falling and knee oa across different dimensions of hrqol , including mental health.24 for example , chen et al25 found that persons with a history of falling and knee oa had more comorbid mental health conditions and were at greater risk of anxiety and depression than those with neither a history of falling nor knee oa .
our findings support the call for continued research on interventions that address self - reported fall and doctor diagnosed knee oa to improve hrqol.26 we can reduce falls by providing effective falls prevention programs for adults in our communities .
the centers for disease control and prevention has reviewed and identified community - based fall prevention interventions with strong scientific evidence of effectiveness.27 research has shown that arthritis conditions , including knee oa , have vast impact on quality of life.28 our study also confirms that having both conditions ( fall and knee oa ) are significantly associated with poorer hrqol compared with persons who had no history of falling or knee oa and persons with either a history of falling or knee oa .
the presence of knee oa has been shown to be a risk factor for falls.29 it makes sense that the presence of knee oa has the greatest impact on fall risk , and functional ability ( eg , gait , ability to rise from a chair ) shows direct associations with fall frequency.30 consistent with our findings , sturnieks et al found an increased risk of falls in adults with knee oa relative to a sample of healthy adults.31 our study has several strengths .
to our knowledge , it is the first to examine hrqol in relation to self - reported falls and doctor - diagnosed knee oa .
our data were obtained from the large publicly available osteoarthritis initiative database and we used well established and validated measurements of hrqol , ie , the sf-12 and the koos - qol subscale . examining the effects of falls on hrqol outcomes is unique and contributes to a broader understanding of falls prevention in older adults.27 the limitations of this study include its cross - sectional design , which prevents comparison of data over time .
further , the self - reported nature of the key variables , ie , self - reported falling and doctor - diagnosed knee oa , and fall data being limited to a 12-month period limits the generalizability of the current findings .
self - reported doctor - diagnosed knee oa was not verified clinically or radiologically , except for cases where the doctor had confirmed the diagnosis , which introduces a degree of bias and makes it impossible to draw a reasonable conclusion .
even with adjusting for confounding between groups , there are still likely to be many unmeasured confounders in this type of analysis .
a better understanding of the relationship between falls , knee oa , and hrqol is necessary to develop effective prevention and treatment programs.32 for example , if future longitudinal research confirms that persons with falls and knee oa have worse hrqol compared with persons who neither had experienced fall nor knee oa and either had experienced fall or knee oa , attention can be devoted to the types of educational and training materials that could assist them in reducing their risk of falling and knee oa .
this particularly important for persons who had both a history of falling and knee oa , some of whom will required information in a bilingual format.33,34
we found that persons who had experienced falls and had knee oa experienced poorer hrqol than those had no history of falling or knee oa and either a history of falling or knee oa
. falls and knee oa were significantly associated with both a lower koos - qol subscale score and a lower pcs score on the sf-12 , even after adjusting for sociodemographic , lifestyle , and clinical factors .
future population - based longitudinal research is necessary in order to examine how hrqol changes over time .
this research is particularly important in underserved groups , such as those who are at high risk of falling and have knee oa . | backgroundthe purpose of this study was to examine the relationship between self - reported falls , doctor - diagnosed knee osteoarthritis ( oa ) , and health - related quality of life ( hrqol ) .
we hypothesized that falls and knee oa would be associated with poor hrqol on both disease - specific and generic measures.methodsthis cross - sectional study used data from the publicly available osteoarthritis initiative data sets .
a total of 4,484 subjects aged 4579 years at baseline were divided into three subpopulations : those who had neither a history of falling nor doctor - diagnosed knee oa ; those who had either a self - reported history of falling or doctor - diagnosed knee oa ; and those who had both a self - reported history of falling and doctor - diagnosed knee oa .
hrqol was assessed using both disease - specific and generic measures .
multiple regression analyses were used to examine the relationship between self - reported falls , doctor - diagnosed knee oa , and hrqol assessed using the knee injury and osteoarthritis outcome score - quality of life ( koos - qol ) subscale and two short form-12 ( sf-12 ) summary scales .
the models were adjusted for participant sociodemographic , lifestyle , and clinical characteristics.resultsfalls and knee oa were significantly associated with lower scores on the koos - qol ( = 34.4 , standard error 2.27 , p0.0001 ) and on the physical component scale of the sf-12 ( = 9.44 , standard error 0.90 , p<0.0001 ) .
no significant relationship was found with the mental component scale score when adjusted for sociodemographic , lifestyle , and clinical characteristics.conclusionwhen compared with those having neither a self - reported history of falling nor doctor - diagnosed knee oa and those with a self - reported history of falling or doctor - diagnosed knee oa , persons with both conditions ( falls and knee oa ) had significantly lower koos - qol and physical component scale scores after adjusting for sociodemographic , lifestyle , and clinical characteristics .
future research should assess potential mediating factors in an effort to improve hrqol in persons with knee oa who are at high risk of falling . |
colorectal cancer ( crc ) is the fourth most commonly diagnosed malignant disease worldwide , with over 1 million new cases and approximately 5,00,000 deaths each year . incidence and deaths from this cancer are generally increasing , most of all in the developed world and urban areas of the developing world .
age adjusted incidence rate ( aar ) per 100,000 person years of colorectal cancer in various population based cancer registries in kolkata in 2005 was 3.1 for males and 3.2 for females .
mucinous adenocarcinoma is a subtype of colorectal adenocarcinoma with more than 50% of the lesion composed of mucin and is characterized by pools of extracellular mucin that contain malignant epithelium as acinar structures , strips of cells , or single cells .
the prognosis of crc patients is mainly dependent on pathological , clinical , and biological factors .
measurement of blood tumor markers is the most widely used and convenient method for the diagnosis of crc .
a total number of 90 patients of crcs were studied for over a period of 30 months from december 2010 to june 2013 in the pathology department in collaboration with the department of general surgery and the department of biochemistry , medical college , kolkata .
the detailed history and relevant clinical / radiological findings were noted in all clinically and/or radiologically suspected cases of crc .
preoperative blood samples were collected from these patients for serum carcinoembryonic antigen ( cea ) and cancer antigen ( ca)-125 level estimation .
the results of serum levels of cea and ca-125 were recorded only for the histopathologically confirmed cases of crc .
periodic acid schiff ( pas ) and alcian blue stains were used as special stains to differentiate neutral and acidic mucin .
the combined alcian blue - pas staining was used to show the presence of both neutral and acidic mucins simultaneously .
in our study the age interval of patients was from 23 to 78 years , the median age being 53 years .
most ( 82.22% ) of the cases occurred in patients above 40 years of age .
there were 52 ( 57.77% ) male patients and 38 ( 42.22 % ) female patients .
seventy - two out of 90 cases ( 80% ) were of adenocarcinoma type [ figure 1 ] . out of 90 cases , 10 ( 11.11% ) were of mucinous type , 4.44% were adenosquamous type , while basaloid and signet ring types were 2.22% each .
( a ) contrast enhanced computed tomography ( cect ) of whole abdomen ( cross - sectional view ) showing colorectal carcinoma .
( c ) well - differentiated adenocarcinoma of colon with invasion of serosa ( hematoxylin and eosin ( h and e ) , 100 ) .
( d ) mucinous adenocarcinoma of colon ( h and e , 100 ) table 1 shows the clinical presentation and the relation with smoking and alcohol consumption .
most ( 40% ) of the carcinomas had a right colonic location followed by rectum with 24.44% of cases
. left colon accounted for 20% of the cases , whereas the rectosigmoid region accounted for 15.55% cases .
fifty - one percent cases presented with tnm stage iii at diagnosis , 26.66% were stage ii , 17.77 % were stage i , and 4.44 % were stage iv tumors .
table 2 shows the relation of tnm stage with preoperative serum cea and ca-125 levels .
table 3 shows the pas and alcian blue staining intensity of the different histopathological variants in our study .
clinical presentation , smoking , and alcohol consumption among the different histopathological ( h / p ) variants of colorectal carcinoma the relation of tnm stage with preoperative serum carcinoembryonic antigen ( cea ) and cancer antigen ( ca)-125 levels pas and alcian blue ( ab ) staining intensity of the different histopathological ( h / p ) variants in the study the combined alcian blue - pas staining was positive for both stains in 68.88 % cases , positive for only one stain in 28.88 % cases , and negative for both stains in 2.22% cases indicating that both neutral and acidic mucins are increased in crc [ figure 2 ] .
( a ) adenocarcinoma colon showing malignant cells with neutral mucins ( periodic acid schiff ( pas ) , 400 ) .
( b ) mucinous carcinoma showing pools of acidic mucin ( alcian blue , 400 ) .
( c ) mucinous carcinoma showing acidic and neutral mucins ( combined alcian blue and pas , 100 ) .
( d ) signet ring cell carcinoma showing neutral mucin ( combined alcian blue and pas , 400 )
sun et al . , performed a retrospective cohort study on 1,422 patients with histologically proven crc in which 55.4% were males and 44.6% were females , the values being close to those in our study . in various studies , mucinous tumors have accounted for roughly 5 - 15% of cases ; while signet - ring cell tumors were rarer , accounting for about 1% of cases . in our study ,
11.11% cases were of mucinous type , the age range being 27 - 42 years and most of these cases occurred in males .
the youngest cases in our study , 23- and 25-year - old male patients , presented with signet - ring cell morphology accounting for 2.22% of total number of cases .
, similarly showed that patients with mucinous tumors were statistically younger than those with nonmucinous tumors , and patients with signet - ring cell tumors were statistically younger than those with either mucinous or nonmucinous tumors .
perea et al . , studied 45 patients with crc aged 45 or younger and found that early onset crc is characterized by advanced stage at diagnosis , right colon location , low - grade of differentiation , mucin production , and presence of polyps .
hereditary forms represented at least 21% of the early onset crc cases . in our study , eight cases had a positive family history accounting for 8.88 % of total cases . among these cases , four had mucinous histology .
all of these cases had a right colon location and presented with higher tnm stage : four were stage iiic tumors and four were stage iv tumors .
mucinous adenocarcinomas and signet ring cell carcinoma tended to occur in patients aged 50 years and were more commonly right - sided than ordinary adenocarcinomas .
chao et al . , found long - term cigarette smoking to be a risk factor of crc in both men and women . in our study ,
though , many epidemiological studies have reported a positive association between alcohol consumption and crc occurrence ; in our study , only 24.44%% of the patients had history of alcohol consumption .
nabi et al . , studied 100 colectomy / hemicolectomy specimens among which , 59 were nonmucinous adenocarcinomas , of which four were in dukes stage a , 51 were in dukes stage b , and four were in dukes stage c. in 30 cases of mucinous carcinomas , 18 were in dukes stage b and 12 were in dukes stage c. all the 11 signet ring cell carcinomas were in dukes stage c. conclusively , it was established that mucin secreting and signet ring cell adenocarcinomas of colon and rectum are high grade tumors and presented at an advanced stage . in our study , most of the mucinous variants and both of the signet ring cell variants presented with stage c at diagnosis .
contrary to findings of the previous studies and our study , a recent study by langner et al .
, showed that mucinous adenocarcinomas and/or adenocarcinomas with mucinous component do not differ from conventional adenocarcinomas with respect to prognosis and histological predictors of outcome .
hence , recording of mucinous differentiation may be used as an indicator of mismatch repair deficiency , but not for prognostic stratification .
ionil et al . , investigated 149 crc patients over a 5-year period . for histochemical investigation , stains such as mucicarmine , pas + alcian blue and high iron diamine + alcian blue .
the predominant cases were those with acidic mucins , especially in pure mucinous adenocarcinomas ( > 90% ) , while those with mixtures of acidic and neutral mucins were present in 62% of the cases .
this study showed the prevalence of sialomucins over sulfomucins ( 68% ) , particularly in pure mucinous adenocarcinomas ( 77% ) .
zakout and ezeldeen studied 100 samples , 50 were colorectal cancer samples ( cases ) and 50 were normal ( controls ) , all were stained with alcian blue method .
it was observed that acid mucin is increased in 30 ( 60% ) of the cases compared to only six ( 12% ) of controls ( p < 0.0001 ) .
however , complete absence of acid mucin was detected among 10 ( 20% ) of cases compared to none among controls .
similarly , in our study the alcian blue staining intensity was strong in 60% cases , weak in 20% cases , and absent in 20% cases indicating that acidic mucins are increased in crc .
thus , secretion of increased amounts of acid mucin in most cases should be considered as a valuable histological finding .
our study indicated that mucin histochemistry was an indirect evidence of carcinoma as we found that both neutral and acidic mucins are increased in crcs .
all the mucinous adenocarcinomas in our study showed strong alcian blue staining intensity , thus highlighting the fact that acidic mucins were predominant in these variants .
four cases among these weakly stained for pas stain , two showed strong pas positivity , while the remaining four were negative .
as our study lacked controls from normal colon mucosa and colon mucosa in benign pathological processes , these changes might not be specific for carcinoma .
however , in comparison to the previous studies , our study also showed that malignancy was associated with an alteration in mucin histochemistry as evidenced by increased amount of neutral mucin secretion which is otherwise present in small amount in normal colon mucosa .
the basaloid variants in our study were negative for both the mucin stains pointing out that this variant is associated with mucin depletion .
the adenosquamous variants showed mucin stain positivity only in the glandular ( adeno ) component , the squamous component not staining for mucins .
fifty - four out of 90 cases ( 82.22% ) in our study had preoperative serum cea levels > 10 ng / ml . recently , gara et al .
, in their study , found preoperative serum cea to be a reliable predictor factor for recurrence in patients with crc .
they claimed that cea might be used in staging system and for therapeutic orientation in patients undergoing curative resection of crc .
the relapse - free survival was significantly higher in patients with cea < 5 ng / ml compared to cea 5 ng / ml .
they observed significant differences in relapse - free survival between patients with cea < 5 ng / ml and those with cea 5 ng / ml among patients classified as dukes stage b and c. however , there was no significant difference in relapse - free survival among those classified as dukes stage d. sun et al . , found that preoperative serum albumin level , cea level and age could affect postoperative outcome of crc patients undergoing surgical treatment
of these factors , preoperative serum cea level is the only significant prognostic factor for patients with stage ii and iii crcs .
they found that high serum cea levels were associated with poor survival in crc patients , and the possible reason might result from increased tumor volume leading to a higher incidence of postoperative metastasis .
0.001 ) had significantly greater cancer - specific survival rates than those with serum cea levels 5 ng / ml . the cases with preoperative serum cea levels
> 10 ng / ml in our study included 54 out of 72 adenocarcinoma variants and all the mucinous variants .
thus , we found that the cases with a higher tnm stage had higher serum cea levels .
by radioimmunoassay the concentration of ca-125 antigen was determined in 26 patients with crcs and it was shown that ca-125 is without clinical value in large bowel cancer . similarly , in our study , we found only 18 cases out of 90 ( 20% ) with raised preoperative serum levels of ca-125 ( > 35 u / ml ) .
most of the cases had normal preoperative serum ca-125 levels , thus highlighting the fact that serum ca-125 is not a good screening tumor marker for crc . among the 18 cases with ca-125
> 35 u / ml , 12 cases presented with tnm stage iii , four cases were tnm stage iv , and two were tnm stage ii tumors . among those 18 cases ,
the others were adenocarcinoma ( six cases ) and signet ring variant ( two cases ) accounting for 33.33 and 11.11% , respectively .
hsu et al . , demonstrated three factors that influence the survival , including more than two organs involved , higher cea level , and different salvage treatment . in our study , there were only four cases presenting with distant metastasis .
in other studies like those by lin et al . , early postoperative cea concentration is an independent prognostic factor for crc and patients with high postoperative cea values should receive aggressive follow - up examinations for early relapse of crc , with special attention paid to recurrence at the liver .
our study established the relation of the mucin stains and tumor markers with the clinicopathological characteristics of crc .
there was increased secretion of mostly acidic mucins and also neutral mucins in crc . also , the majority of mucins present in crc , both acidic as well as neutral , stained intensely with both pas and alcian blue .
most of the cases occurred in males , presented in the right colon with higher stage , corresponding to dukes stage c and tnm stage iii .
all the mucinous variants were strongly alcian blue positive indicating the presence of acidic mucins in abundance .
there were two cases of signet ring cell carcinoma in the study , which presented in young male patients in the rectum with tnm stage iii , these being the most common site and stage of presentation as shown by the previous studies .
mucin histochemistry showed the intracellular mucin of the signet rings to stain intensely with pas indicating their neutral nature . conclusively
, it can be said that the mucin histochemistry still remains one of the valuable methods of mucin evaluation in crcs .
routine use of mucin histochemistry is required , especially in the early malignant lesions where histochemical changes precede morphological changes .
tumour marker study with preoperative serum cea level assessment is an indispensible adjunct to the diagnosis and prognosis of crc , raised levels providing an indirect evidence of advanced disease and the need for proper and immediate therapeutic intervention to decrease the mortality .
however , preoperative serum ca-125 level measurement is not an efficient tool for prognostication in crc and should not be recommended for routine use . | background : colorectal carcinoma ( crc ) is the fourth most commonly diagnosed malignant disease worldwide , with over 1 million new cases and approximately 5,00,000 deaths each year.aims and objectives : this prospective observational study was done to study the clinicopathological characteristics of crc including mucin stains and correlate the preoperative serum carcinoembryonic antigen ( cea ) and cancer antigen ( ca)-125 levels with the prognosis.materials and methods : a total of 90 crcs were included from december 2010 to june 2013 .
detailed history and relevant clinical / radiological findings were noted in all clinically and/or radiologically suspected cases of crc .
preoperative blood samples were collected for serum cea and ca-125 level estimation .
the mucin expression was evaluated with special stains.results:the combined alcian blue - periodic acid schiff ( pas ) staining was positive for both stains in 68.88% cases indicating that both neutral and acidic mucins are increased in crc .
high preoperative serum cea levels were seen in 82.22% cases , whereas preoperative serum ca-125 levels showed an increase in 20% cases .
higher levels of these tumor markers corresponded with higher tnm stage.conclusions:mucin evaluation in crcs remains one of the valuable methods as mucinous variants correlate with worse prognosis .
preoperative serum cea level assessment is an indispensible adjunct to the diagnosis and prognosis of crc .
however , preoperative serum ca-125 level measurement is not an efficient tool for prognostication in crc and should not be recommended for routine use . |
though the majority of us physicians have seen a patient receive poor quality health care due to patient race or ethnicity , responding to these witnessed practices can be challenging.1 many faculty may be uncertain about the link between an observed behavior and clinical outcomes.15 faculty often avoid giving feedback about behaviors or attitudes that suggest a lack of professionalism and this tendency may be heightened when discussing health care disparities , an emotionally charged subject.6,7 emotional reactions , such as shame or anger in teacher and learner , may limit teaching effectiveness . finally , time constraints alone may cause teachers to choose to avoid a perceived pandora s box .
we believe a pedagogical model is needed to facilitate teaching about health care disparities in the clinical setting .
the model should be easily remembered , applicable to teaching in both the inpatient and outpatient settings , and responsive to time - limited environments . while many models have been developed to help clinical educators teach effectively and efficiently , to our knowledge none
have been applied to teaching about health disparities . in this paper , we apply the time - effective strategies for teaching ( test ) model to teaching about health care disparities.8 the test model recommends teachers diagnose the learner s instructional need , then teach rapidly to that need and provide feedback . to demonstrate the application of this model to teaching about health care disparities , we present four clinical scenarios that illustrate common attitudes and behaviors associated with provider - driven health care disparities ( table 1 ) .
we use each of the first three scenarios to illustrate one aspect of the test model : diagnose the learner , teach rapidly , and provide feedback ; the fourth scenario illustrates the integration of the three components of the model . while each of the clinical scenarios offers many teaching opportunities , we select one instructive example .
our goal is to create a framework for teaching about health care disparities that is readily incorporated into clinical teaching rather than to explore root causes of clinician behavior or health care disparities .
table 1illustrative differential diagnosis of learner s need related to the four casessample caseknowledge gapinadequate skillsattitude barriersadverse circumstancescase 1 .
feels skilled using an interpreter in person , but not by telephone ( or vice versa)3 .
misjudges own ability to speak a language other than englishcase 2 . too readily accepts patient refusal of indicated procedure1 .
inability to schedule patients for frequent follow up due to limited outpatient clinic availability and large panel size2 .
lack of knowledge about appropriate treatment of asthma3 . expected pace in ambulatory setting too rapid for learner s abilitycase 4 .
lack of familiarity with strategies to respond to patients with low health literacy including teach - back method2 .
dependence on written material for patient education illustrative differential diagnosis of learner s need related to the four cases
a spanish - speaking woman with limited english proficiency is transferred to your team from the icu following treatment of fulminant hepatic failure due to acetaminophen overdose .
the resident presents a limited history , obtained with the patient s husband as interpreter .
we ll take care of that tomorrow ; we re short on time today.up until this point , you have been impressed with your team .
in this situation , however , they are cutting corners at the expense of patient care . how can you effectively respond ?
a spanish - speaking woman with limited english proficiency is transferred to your team from the icu following treatment of fulminant hepatic failure due to acetaminophen overdose .
the resident presents a limited history , obtained with the patient s husband as interpreter .
we ll take care of that tomorrow ; we re short on time today .
in this situation , however , they are cutting corners at the expense of patient care .
to teach effectively in this setting , one must first identify the learner s needs , then target teaching to those needs.8 identifying the learner s needs is known as diagnosing the learner .
( table 1 provides an illustrative list . ) in addition , adverse circumstances the context of clinical care may challenge learners and contribute to provider - driven health care disparities ; these circumstances provide important teaching opportunities .
addressing the context of care allows learners to understand that processes of care contribute to provider behavior and may lead to inequitable health care . failing to diagnose the learner may cause the teacher to provide information that the learner already knows , while ignoring areas that are needed .
for example , providing factual information to a learner in an attempt to improve her fund of knowledge will be ineffective if the learner already possesses adequate content knowledge , but lacks appropriate skills .
the time - effective strategies for teaching ( test ) model encourages teachers to identify learners needs through probes or brief observation .
questions are used to assess the learner s experience with a particular clinical challenge as well as the ability to assess and manage it .
we recommend the teacher ask a general question such as what would you like to know about this issue ? table 2 contains additional useful questions .
the purpose of this inquiry is not to diagnose all of the learner s needs , but rather to identify at least one area in which the learner would benefit from instruction .
table 2questions a teacher might ask to diagnose the learnerknowledge gapinadequate skillsattitude barriersadverse circumstances1 . tell me about the last time you took care of a patient with this particular problem1 . how often have you had an opportunity to use this particular skill?1 .
how do you feel about taking care of a patient with this particular problem?1 . in what ways
does our office / hospital make caring for a patient with this problem more difficult?2 .
what do you think is going on with this patient ? what led you to that conclusion?2 .
questions a teacher might ask to diagnose the learner alternatively , a two - minute observation of the learner s interaction with the patient can also provide the teacher with valuable information about the learner s needs . irby and wilkerson
recommend the learner and teacher meet beforehand to discuss the portion of the encounter to be observed , that the teacher slip quietly into the room to briefly observe the chosen interaction , leave the room without participating in the encounter , and later meet to discuss the observation.8you say to the team , how do you make the decision about whether to use family members as interpreters?resident : well , if they are at the bedside , we tend to use them to save time .
you say to the team , how do you make the decision about whether to use family members as interpreters ? resident :
well , if they are at the bedside , we tend to use them to save time . based on the resident s description that lack of time
, a common adverse circumstance , motivated the decision to use an ad hoc interpreter , you decide to teach the team about the challenges associated with the use of family members as interpreters.9,10 while waiting for the interpreter to arrive , you review that patients with limited english proficiency often experience more medical errors , and receive lower quality of care.1118 you ask the team to describe the ways that working with ad hoc interpreters could contribute , eliciting or presenting that unlike professional interpreters , ad hoc interpreters have not been trained to perform medical interpretation and are prone to errors in comprehension and translation.19 often relatives or friends of the patient , ad hoc interpreters may be reluctant to discuss personal or sensitive information with the patient ; moreover , the patient may be unwilling to disclose this information through a family member or friend .
finally , relatives who serve as interpreters may experience substantial conflict between their roles as family members and as interpreters.10 you note that clinicians should always inform patients of the availability of professional interpretation and refrain from using family members as interpreters unless both patient and family member wish otherwise.working with the hospital s interpreter , the resident interviews the patient and finds the patient and her husband are relieved to work with a professional interpreter .
the more accurate history now obtained changes the working diagnosis from probable intentional overdose to accidental ingestion .
following the interview you ask the team to identify discrepancies in the histories obtained with the ad hoc and the professional interpreters .
working with the hospital s interpreter , the resident interviews the patient and finds the patient and her husband are relieved to work with a professional interpreter .
the more accurate history now obtained changes the working diagnosis from probable intentional overdose to accidental ingestion . following the interview you ask the team to identify discrepancies in the histories obtained with the ad hoc and the professional interpreters .
a resident presents her patient , a 64-year - old african american man with advanced degenerative joint disease of the knees who has persistent pain despite maximal medical therapy .
she states she has discussed knee replacement surgery with the patient and he does nt want it .
you inquire about the patient s concerns , but the resident repeats , he just said he does nt want it . you probe the learner to diagnose her learning need and find she is unfamiliar with disparities in joint replacement surgery ( a knowledge gap ) and does not know how to elicit a patient s concerns about surgery ( a skill gap ) .
a resident presents her patient , a 64-year - old african american man with advanced degenerative joint disease of the knees who has persistent pain despite maximal medical therapy .
she states she has discussed knee replacement surgery with the patient and he does nt want it .
you inquire about the patient s concerns , but the resident repeats , he just said he does nt want it . you probe the learner to diagnose her learning need and find she is unfamiliar with disparities in joint replacement surgery ( a knowledge gap ) and does not know how to elicit a patient s concerns about surgery ( a skill gap )
effective educators must adapt their teaching strategies to the rhythms of the work environment , selecting when to emphasize a point and when to omit or defer discussion .
while many teaching strategies may be modified for use in time - limited settings , the test model encourages the use of established time - effective teaching strategies .
for example , the one minute preceptor , also known as a five - step microskills model of clinical teaching , is specifically designed to help preceptors care for patients and teach learners both efficiently and effectively.2023 ( see table 3 for options for time - effective strategies for teaching . )
the hallmark of this model is the teaching of general rules to address gaps in knowledge .
the general rule is brief , applicable to the case under discussion , addresses the learner s needs , and highlights key principles that can be translated to the care of other patients.24table 3options for time - effective strategies for teachingdiagnosisknowledge gapinadequate skillsattitude barriersadverse circumstancespotential time - effective teaching strategy1 .
one minute preceptor ( i.e. , diagnose the learner , teach general rules , provide feedback)1 . provide a demonstration , preferably with preview ( before the demonstration ) , commentary ( during the demonstration ) and debriefing ( following the demonstration)1 . identify good work and praise it1 .
activated demonstration ( i.e. , ask the learner to observe the teacher perform a specific task . following the observation ,
introduce abcs of root cause analysis [ antecedents ( what led up to the event ? ) , behavior ( what happened ? ) and consequences ( what happened as a result?)]3 .
encourage reflection ( e.g. , with open ended probe or direct question ) options for time - effective strategies for teaching teaching evidence - based general rules about health care disparities not only provides the learner with fundamental information , but also demonstrates that health care disparities may be approached similarly to other clinical issues and are amenable to discussion and inquiry based on evidence .
for example , one might teach that total knee replacement surgery has been shown to improve function and decrease pain in patients with severe osteoarthritis of the knee ; however , the rate of total knee replacement is 39% lower for black patients with arthritis than for white patients.25 black patients tend to experience more disability and knee pain prior to surgery than whites and may be more likely to believe they will experience a lengthy , painful recovery process.26,27 poor patient - physician communication about patient misconceptions may play an important role in patient refusal of procedures .
bedside rounds are a time - efficient way to teach learners found to have gaps in skills .
this setting enables role - modeling and observation of specific learner behaviors . before heading to the bedside
, the teacher reviews the goals of the session and to ensure active learning , provides a role for each team member.28 the relevant history and examination can be split among team members .
alternatively , one team member can be tasked with interviewing and examining the patient and the others with observing specific behaviors , such as the techniques used to elicit patient concerns .
debriefing the encounter may occur at the bedside with the patient s involvement or privately elsewhere .
an activated demonstration at the bedside is a variation of this technique . in an activated demonstration
, the teacher asks the learner to observe the teacher perform a specific task ( e.g. , watch the way i elicit the patient s concerns about knee replacement surgery and address them explicitly ) .
the learner by asking him to describe and discuss his observations.given the rapid pace of clinic this afternoon , you decide to teach the resident general rules about disparities in joint replacement surgery and the importance of eliciting patient concerns when discussing a procedure . you decide to defer teaching the resident specific skills to elicit patient concerns.attending : patients may decline surgery for many reasons , so it is important to understand each patient s decision . it is helpful to know that rates of joint replacement surgery in the us vary by patient race , ethnicity , gender and geographic location.29,30 as a group , african american patients are less likely to report understanding joint replacement surgery than white patients , and are more likely to believe they will experience a lengthy , painful post - operative course . as a more general rule ,
it is always important to explore the reasons that a given patient refuses a treatment and to understand and address his specific concerns . why do nt you go back and ask the patient what concerns he may have about the surgery and then we can discuss how to address them ? given the rapid pace of clinic this afternoon , you decide to teach the resident general rules about disparities in joint replacement surgery and the importance of eliciting patient concerns when discussing a procedure . you decide to defer teaching the resident specific skills to elicit patient concerns . attending : patients may decline surgery for many reasons , so it is important to understand each patient s decision .
it is helpful to know that rates of joint replacement surgery in the us vary by patient race , ethnicity , gender and geographic location.29,30 as a group , african american patients are less likely to report understanding joint replacement surgery than white patients , and are more likely to believe they will experience a lengthy , painful post - operative course . as a more general rule , it is always important to explore the reasons that a given patient refuses a treatment and to understand and address his specific concerns .
why do nt you go back and ask the patient what concerns he may have about the surgery and then we can discuss how to address them ?
a fourth - year medical student presents his patient , a 44-year - old african american man with frequent asthma exacerbations requiring emergency room care . when you ask why the asthma is not well controlled , the student states dismissively ,
your evaluation reveals a forthcoming patient with no history or physical stigmata of drug use whose asthma is treated with a short - acting beta - agonist alone .
while talking with the patient about the need for inhaled corticosteroids , you find yourself becoming angry with the student and unsure how , or even if , you should discuss his remark with him .
a fourth - year medical student presents his patient , a 44-year - old african american man with frequent asthma exacerbations requiring emergency room care . when you ask why the asthma is not well controlled , the student states dismissively ,
your evaluation reveals a forthcoming patient with no history or physical stigmata of drug use whose asthma is treated with a short - acting beta - agonist alone .
while talking with the patient about the need for inhaled corticosteroids , you find yourself becoming angry with the student and unsure how , or even if , you should discuss his remark with him
. physicians often rely on pattern recognition to simplify decision making in clinical situations , particularly when pressed for time , fatigued or overloaded with information.31,33 while often useful , pattern recognition may involve stereotypes or cognitive shortcuts to obtain , process and recall information about others.33 cognitive shortcuts involving race , ethnicity or gender may contribute to health care disparities and prevent physicians from treating diverse patient populations effectively , particularly when these shortcuts are combined with bias , defined as unjustifiable negative beliefs about others.34 bias is often unconscious and may differ from consciously expressed views.32,3537 in the example above , the student equated inadequate asthma control in an african american patient with the use of inhaled cocaine . though inhaled cocaine can exacerbate asthma , the cognitive shortcut prevented the student from thinking through other etiologies for the patient s poor asthma control .
bias may , or may not , have played a role in the student s remark .
it is often neither possible nor necessarily desirable to attempt to establish the role of bias.38,39 however , the student should be made aware of the shortcoming associated with his cognitive short cut and of the literature that shows physicians often underestimate asthma severity in african americans , and are therefore less likely to prescribe appropriate therapy.40,41 physician behavior may contribute to the longstanding observation that african american patients with asthma are more likely to require visits to the emergency department and hospitalization for their illness than white patients.4246 feedback proves a useful strategy for addressing inappropriate stereotyping or bias .
feedback allows learners to gain insight into their performance so that it may be further modified and refined . it should be a regular and expected component of the education process
feedback should be specific , focused , objective , and offered in a timely manner.28,47,48 the context in which feedback is delivered should be considered carefully as feedback is most likely to be successfully incorporated when delivered in a direct , yet supportive , manner . because situations with the potential to cause health care disparities are emotionally charged for both faculty and learners , teachers may benefit from a brief time out to organize their own thoughts and feelings before providing feedback .
feedback may be used to promote reflection , especially when it is corrective and discordant with the learner s self - perception.49 reflection provides an opportunity for critical thinking and review.50 teachers stimulate reflection by asking learners to share their insights about a particular experience or articulate what they have learned . adding additional probes such as tell me more encourages learners to engage in deeper reflection . through reflection
, learners explore the larger meaning of their actions and experiences , which leads to individual growth.51 reflection can be accomplished in a group setting or individually.attending : what led you to believe the patient s frequent asthma exacerbations were due to drug use?student : i guess he reminded me of so many other patients i ve seen this year with asthma .
while cocaine use can certainly worsen asthma , many other etiologies are more likely in this patient who denies drug use and has no suggestion of drug use by history or physical examination .
there is literature showing that when doctors are busy and under stress , we take cognitive shortcuts .
these shortcuts or stereotypes can be useful , but they can also lead to disparities in care by affecting the way we interpret clinical information . in this case , the stereotype you used was not accurate or helpful and masked the real problem failure to prescribe inhaled corticosteroids for inadequately controlled asthma .
attending : what led you to believe the patient s frequent asthma exacerbations were due to drug use ?
student : i guess he reminded me of so many other patients i ve seen this year with asthma .
a lot of them were using cocaine . attending : ( calmly giving feedback . )
while cocaine use can certainly worsen asthma , many other etiologies are more likely in this patient who denies drug use and has no suggestion of drug use by history or physical examination .
there is literature showing that when doctors are busy and under stress , we take cognitive shortcuts .
these shortcuts or stereotypes can be useful , but they can also lead to disparities in care by affecting the way we interpret clinical information . in this case , the stereotype you used was not accurate or helpful and masked the real problem failure to prescribe inhaled corticosteroids for inadequately controlled asthma .
putting it all together : the test model and health care disparities educationon post - call rounds , your intern presents a 68-year - old white man with hypertension , hypercholesterolemia , and congestive heart failure with exacerbation who has required admission twice this month .
the intern notes that once again , the chf exacerbation is due to non - adherence . as the intern presents the case ,
you have several immediate concerns : determining the cause of the patient s non - adherence , figuring out how to target teaching to the intern , and addressing the intern s frustration.you decide to perform a two - minute observation to simultaneously
you explain to the intern that you would like to watch him assess the patient s use of medication.intern : are you taking the lisinopril every day?patient : is that the blue one or the white one ?
you need to take the lisinopril every day.you suspect the patient has low health literacy and diagnose the learner as unfamiliar with this problem and established skills to address it . outside the room , you teach a general rule.attending : this situation is frustrating , is nt it ?
low health literacy is particularly common in older patients and in those with chronic disease , low socioeconomic status and low educational attainment.52 in fact , two - thirds of adults age 60 and older have inadequate or marginal health literacy.53 patients with low health literacy often fail to understand medication instructions and are at increased risk for hospitalization.54,55 failing to recognize and respond effectively to patients with low health literacy is common and may lead to disparities in health care .
teach - back method is used to assess patients understanding of medication instructions.56,57 have you had a chance to use this skill before?intern : i have heard about the teach - back method , but do not really know what it is.attending : ( initiating an activated demonstration . )
when we return to the room , i would like you to pay attention to how i explain the medications to the patient and ask him to show me teach me how he will use them at home.after the demonstration , the attending seeks to activate the intern by asking questions about his observations.attending : tell me what you observed about the use of the teach - back method.intern : you used simple language to explain the purpose of the medications and how to use them and then you asked the patient to show you how he would take the medication at home .
when he did nt get it quite right , you showed him again and then had him show you another time until he got it right.attending : ( giving feedback . )
you just summarized the teach - back method for patients with low health literacy beautifully .
how do you think the patient perceived us?intern : well , i was pretty exasperated with this patient and i bet he knew it .
i mean , i have spent hours taking care of him and then he goes home and is right back to square one again . after a while
how do you think the patient feels now?intern : i think he feels more like we re on the same team instead of rivals .
your intern presents a 68-year - old white man with hypertension , hypercholesterolemia , and congestive heart failure with exacerbation who has required admission twice this month .
the intern notes that once again , the chf exacerbation is due to non - adherence . as the intern presents the case ,
you have several immediate concerns : determining the cause of the patient s non - adherence , figuring out how to target teaching to the intern , and addressing the intern s frustration .
you explain to the intern that you would like to watch him assess the patient s use of medication .
you suspect the patient has low health literacy and diagnose the learner as unfamiliar with this problem and established skills to address it . outside the room
low health literacy is particularly common in older patients and in those with chronic disease , low socioeconomic status and low educational attainment.52 in fact , two - thirds of adults age 60 and older have inadequate or marginal health literacy.53 patients with low health literacy often fail to understand medication instructions and are at increased risk for hospitalization.54,55 failing to recognize and respond effectively to patients with low health literacy is common and may lead to disparities in health care .
teach - back method is used to assess patients understanding of medication instructions.56,57 have you had a chance to use this skill before ?
intern : i have heard about the teach - back method , but do not really know what it is . attending : ( initiating an activated demonstration . ) when we return to the room , i would like you to pay attention to how i explain the medications to the patient and ask him to show me teach me how he will use them at home .
after the demonstration , the attending seeks to activate the intern by asking questions about his observations . attending : tell me what you observed about the use of the teach - back method .
intern : you used simple language to explain the purpose of the medications and how to use them and then you asked the patient to show you how he would take the medication at home .
when he did nt get it quite right , you showed him again and then had him show you another time until he got it right . attending : ( giving feedback . )
you just summarized the teach - back method for patients with low health literacy beautifully .
intern : well , i was pretty exasperated with this patient and i bet he knew it .
i mean , i have spent hours taking care of him and then he goes home and is right back to square one again . after a while
i feel more optimistic at this point . attending : i m glad to hear that .
intern : i think he feels more like we re on the same team instead of rivals .
in this scenario , the attending selects a two - minute observation , to diagnose the patient and the learner .
the attending teaches a general rule about low health literacy to strengthen the intern s knowledge base and then uses an activated demonstration to improve the intern s skill set .
finally , brief feedback and an invitation to reflect on the patient s perspective allow the intern to give voice to his emotions and recognize that he has entered a partnership with the patient .
in this paper , we adapted an established teaching model , time - effective strategies for teaching , to the teaching of health care disparities at the bedside .
the test model , which recommends teachers diagnose the learner , teach rapidly and provide feedback , offers a straightforward , structured framework for teaching in clinical situations with the potential to result in health care disparities .
evidence - based teaching about health care disparities can and should be readily incorporated into routine clinical care . | clinical teachers often observe interactions that may contribute to health care disparities , yet may hesitate to teach about them .
a pedagogical model could help faculty structure teaching about health care disparities in the clinical setting , but to our knowledge , none have been adapted for this purpose . in this paper , we adapt an established model , time - effective strategies for teaching ( test ) , to the teaching of health care disparities .
we use several case scenarios to illustrate the core components of the model : diagnose the learner , teach rapidly to the learner s need , and provide feedback .
the test model is straightforward , easy to use , and enables the incorporation of teaching about health care disparities into routine clinical teaching . |
musculoskeletal disorders ( msds ) are prevalent among workers in the construction industry which warrants heavy physical work , often necessitating inappropriate working postures for prolonged periods , which significantly increases morbidity and considerably decreases the work ability . the brick manufacturing industry in india , the second largest in the world following china , falls under the above - mentioned category , where the majority of the workforce is part of the unorganized sector , comprising mostly of migrant workers including men , women , and in some cases , even children .
in contrast to other occupational disorders which could be attributed to occupational exposures to toxic substances , msd among brick kiln workers owes its pathophysiology to unorthodox postures opted by these workers , where the joints and muscles are held in unconducive physiological positions for protracted periods of time , in suboptimal working conditions .
the manufacture of bricks begins with mining , preparation , and molding of clay , followed by drying and burning of bricks , after which they are arranged in a prescribed fashion for transport .
prior research in this area has identified that poor working conditions , suboptimal physiological postures that compel frequent bending and twisting , and inadequate rest - breaks are among the risk factors for msd among these workers .
these musculoskeletal disorders take a toll on their lives by affecting their activities of daily living ( adl ) , leading to slow economic growth of their families resulting in poor overall quality of life .
brick kiln workers who comprise a part of the unorganized work sector in rural india are in a disadvantageous position and literature regarding their health problems and needs are largely unavailable .
this study was done with a threefold aim of assessing the prevalence of msd among brick kiln workers in rural tamil nadu , to identify common postures adopted by them during the course of their work , and to measure the intensity of pain among the workers in brick kilns .
this cross - sectional study was conducted among unorganized brick kiln workers in the villages of vellore district in tamil nadu .
mettuedyanpatti , puthur , munjurpet villages in kaniyambadi block of vellore district , where brick making is the prime occupation .
three hundred and ten participants who were involved in brick making for more than 1 year were included for the study after an initial verbal screening , by exhaustive sampling technique .
sample size was calculated using 1 week prevalence of low back pain 20% with 5% absolute precision .
individuals with known systemic diseases involving musculoskeletal system such as rheumatoid arthritis , sjogren 's syndrome , and cervical spondylosis were excluded from the study .
an iinterviewer - administered and structured questionnaire was used which included basic anthropometric and personal data , details of the common postures adopted during work , duration of work , symptoms of musculoskeletal involvement , and the various joints affected .
the questions about musculoskeletal symptoms were adopted from the modified nordic questionnaire . the severity and and intensity of pain
was assessed by the body part discomfort scale ( jacqueline et al . , 1994 ) .
a questionnaire was developed in english and then translated to the vernacular ( tamil ) , which was pilot - tested among a similar population .
data were analyzed using the statistical package of social sciences ( spss version 16.0 ) .
descriptive data are given as mean ( standard deviation [ sd ] ) , or as median ( range ) .
the association of duration of work to the severity was analyzed by univariate and multivariate logistic regression and their 95% confidence intervals ( cis ) were calculated .
for all tests , a two - sided p value of 0.05 or less was considered statistically significant .
this study was approved by the institutional research board of christian medical college , vellore and the confidentiality of the participants during the study and the analytical phase was maintained using unique identifiers .
the brick kiln workers recruited for this study were from the villages of munjurpet ( 61% ) , puttur ( 37% ) , and mettuediampatty ( 2% ) .
the mean age was 37 13.2 years with a range of 18 - 85 years .
majority of the workers 62% ( n = 192 ) had a normal body mass index ( bmi ) , whereas 27% ( n = 85 ) were found to be undernourished with a bmi of < 18 .
most of the women were in the reproductive age group , with only 23% ( 32/139 ) being post - menopausal as shown in table 1 .
demographic profile ( n=310 ) a total of 64% ( 64% ) of the workers had been in the brick manufacturing occupation for more than 10 years .
approximately half of them ( 47.4% ) worked for 6 - 7 days per week , and another 47.4% worked between 3 and 5 days per week as shown in table 2 .
the common postures adopted during majority of the working time were squatting ( 67% ) , stooping ( 19% ) , and standing ( 14% ) .
history of trauma that could have contributed to the msd was elicited in a minority ( 14% ) of the workers .
majority of the study subjects ( 87% ) experienced some kind of pain , with more than half of them ( 51% ) having pain during work .
a total of 65% of them had either moderate or severe form of pain when assessed with the body pain discomfort scale . during last 12 months , 59% ( n = 183 ) of the workers had low back pain and 45% ( n = 139 ) had knee pain .
the sites , frequency , and distribution of chronic pain are shown in table 3 .
adl were affected in 13% of those with low back pain and in 10% of those with knee pain .
workers employed for more than 10 years had a higher incidence of chronic back pain ( 66.55% vs. 45.5% ; p = < 0.05 ) and chronic knee pain ( 56% vs. 24.5% ; p = < 0.05 ) when compared to those employed for less than 10 years and these differences were statistically significant with p < 0.05 and higher odd 's ratio as shown in table 4 .
nature of work ( n=310 ) one year pain - regional distribution days at work in a week and years of service and presence of musculoskeletal pain these workers also had significantly higher odds of suffering from acute ( 1 week ) low back pain [ odds ratio ( or ) : 2.28 ( 95% ci 1.27 - 4.09 ) , p < 0.05 ) ] and acute knee pain [ or : 3.26 ( 95% ci 1.57 - 6.71 ) , p < 0.05 ] .
workers employed for more than 10 years had 3.11 times higher odds of suffering from either moderate or severe form of musculoskeletal pain ( 95% ci 1.78 - 5.66 ; p = < 0.05 ) . approximately , one fourth of them use some form of topical analgesics ( 24.2% ) as self - medication for pain relief , while another quarter of them preferred only rest for pain relief .
nearly , 30% use various forms of oral or injectable analgesics available over pharmacy counters .
those who had severe or moderate form of pain had lower mean score ( 7.57 , sd 2.28 ) in the visual analogue scale on job satisfaction ( p < 0.05 , t statistic 2.476 ) than those with mild pain ( 6.80 , sd 2.22 ) .
as per the economic survey 2007 - 08 out of 440 million workers in india , 93% of the workers are in the unorganized sector .
the contributions made by the unorganized sector to the national income are very substantial as compared with that of the organized sector .
a subcommittee of the national commission for enterprises in the unorganized sector in 2012 estimated that the contribution of unorganized sector to gross domestic product is about 53.9% .
brick kiln industry is one such sector where the workers are prone for a variety of msd due to the stressful work posturing and heavy unregulated work load .
this is further compounded by physical discomforts at the work place and poor access to health care .
workers earn money depending on how many bricks they make and not how many hours they work .
as the workers adopt a constant posture for many hours at a stretch , they are at risk for developing severe musculoskeletal pain which invariably reduces work efficiency and output .
work - related msd includes inflammatory and degenerative processes that may involve the muscles , tendons , cartilages and joints , causing pain and functional impairment .
though our study had male predominance , the high also involved in brick making industry , signifying the way of living in the rural setting . moreover , the unorganized brick kiln industry is a cottage industry in rural areas , where the entire family is involved to sustain their livelihood . in our study ,
as most of these women ( 67% ) were in the reproductive age group and going through physiological events such as menstruation , child birth , they were more vulnerable to pain than men .
a significant proportion of our workers ( 27% , n = 72 ) were malnourished which reflects their poverty and low economic status . as more than 75% ( n = 55 ) of the malnourished workers
experience either moderate or severe form of pain , their productivity at work is likely to be affected .
even though the majority of the workers in our study were employed for more than 10 years , they have no coverage of social security and have to spend out of their meager incomes for all contingencies such as illnesses and children 's education . in their old age they are helpless and none of the provisions under the unorganized workers social security act of 2008 are implemented at their work place .
the act has provisions for life and disability cover , health and maternity benefits , old age protection , and recommends suitable welfare schemes such as provident fund , employment injury benefit , and housing , and so on for unorganized workers .
though regulations on maximum working hours and entitled leave do exist , workers in our study were made to work overtime due to the continuous demand to meet the target number of bricks for the week or month .
handling raw materials with hands in manufacturing industries which involve bent and/or twisted postures are recognized risk factors for back pain .
this is specifically evident in industrially developing countries , where manual materials handling is inherent within industry with manual labour involved in physically demanding tasks is a dominant factor . in the present study ,
the job of the brick makers was described as rather physically demanding , involving frequent twisting and bending of the trunk .
this type of job was also described as highly repetitive and requiring high concentration to arrange alternating brick faces in each row .
therefore , workers must pay constant attention to brick orientation and this may impose more stress and increased mental fatigue .
most participants in this study belonged to families with 3 or 4 members who also involved themselves in various stages of the brick making process .
so it is difficult to comment on which posture is directly related to the musculoskeletal disorders .
however , squatting is the most common posture adopted by the workers at work , since the maximum time is taken for molding the brick followed by mixing the clay .
this requires trunk twisting and bending forward for an extended periods of time . this was evident from our study when pain per body region was measured for the past 12 months and 7 days .
our study revealed that most workers complained of low back pain followed by knee pain .
chung and kee from korea also reported that 78.5% of the workers performing tasks that require trunk twisting experienced low back pain , while 55.6% performing tasks that do not require trunk twisting experienced low back pain .
low back ache was the most common pain among the brick makers in other studies from west bengal , jharkhand , and nigeria .
this is probably due to repeated bending and twisting of the trunk which causes an enormous force generation at the lumbosacral segment of the vertebral column .
neck and upper limb pain were reported in a significant number of brick workers in some studies .
we found only a minority of our workers suffering from neck ( 11.3% , 35/310 ) and upper limb pain , while the knee joint was the second most affected joint .
this could be attributed to the commonly adopted postures in our study population , which is squatting , followed by standing for moulding and clay making .
clay making and moulding work is an important activity , which decides the quality and finish of bricks , which requires hard and long hours of work in similar positions and postures .
these postures can affect soft tissues such as muscles , ligaments , and spinal discs .
squatting exerts great pressure on different body parts such as the leg , knee , thigh , back , spinal cord , and on the shoulder and feet as well .
this posture can lead to contact stress on the popliteal fold ( back of the knees ) and pooling of blood in the feet .
they can also cause fatigue and discomfort , placing the worker at risk of developing a work related msd .
many of the studies conducted in various industries where manual labourers are involved in strenuous work have shown positive correlations between msd and common postures adopted at work . in a study done at a fish processing industry in ghana , where workers were involved in heavy manual handling , trunk flexion and/or twisting , pushing , pulling , and lifting weights from below the ground level , neck and upper limb problems were found to be predominant .
similarly , an indian study among forging workers showed that operators working in an inadequate working environment with awkward postures , have a high risk of development of musculoskeletal disorders .
our study also reveals that most of the workers experience pain during work ( 51% , 158/310 ) , which may cause discomfort , fatigue , and eventually lead to lesser production and earning .
those who experience severe or moderate form ( 64.8% , 201/310 ) of pain also seem to be less satisfied with their work , and this may have psychological impact on the quality of life . a study which examined changes in general health and time with back and neck pain , identified predictors of any such changes .
the study showed that there was a significant decline in general health and significant increase in time with neck pain and back pain .
they concluded the predictors of changes in these outcomes were mainly work - related variables such as job interference with family , work - related psychological demands , job influence , and hours worked .
heuer et al . , found that musculoskeletal complaints among bricklayers decreased with the length of employment .
further investigation revealed this was most likely due to a healthy worker effect where individuals susceptible to musculoskeletal complaints leave the trade , leaving their more resilient colleagues in the workforce .
this is an important phenomenon to be considered while attempting to assess morbidity among the workers in the unorganized sector .
our study is a community - based study with adequate sample size and used validated tools to measure msd .
however , the limitations are the lack of postural analysis and non - assessment of some of the confounders such as domestic activities .
this study shows that awkward postures adopted by brick kiln workers during work are directly related to their msd , which also affect their adl .
prolonged years at service and overwork also have significant impact on the prevalence of msd .
this study recommends detailed research , health education to the workers , implementation and monitoring of laws in unorganized sectors to tackle morbidity related to msds . | background : a variety of musculoskeletal disorders and discomfort are seen among brick kiln workers , where heavy physical work is associated with awkward working postures and manual handling of materials , leading to significant morbidity.materials and methods : this cross - sectional study was conducted in unorganized brick kiln industries in villages of vellore district of tamil nadu and included 310 brick kiln workers .
modified nordic questionnaire was used to survey the prevalence of musculoskeletal disorders and the intensity of pain was assessed by the body pain discomfort scale.results:the mean age of the workers was 37 13.2 years with a range of 18 - 85 years .
62% ( n = 192 ) had normal body mass index , whereas 27% ( n = 85 ) were undernourished .
the commonest posture adopted at work was squatting ( 67% ) followed by standing ( 14% ) .
majority of workers ( 87% , n = 269 ) reported to having symptoms of pain currently of which 51% ( n = 158 ) had pain during work .
chronic low back ache ( lba ) ( 1 year prevalence -59% ) and acute lba ( 1 week prevalence-33% ) were the commonest followed by chronic knee pain .
more than 10 years of work was significantly associated ( p < 0.05 ) with acute lba and acute and chronic knee pain .
severity of the pain was also significantly ( t statistic 2.476 , p < 0.05 ) associated with job dissatisfaction.conclusion:long-term brick kiln workers , who adopt a specific posture for prolonged periods , have severe musculoskeletal pain that interferes with activities of daily living and reduces job satisfaction .
health education on frequent postural change , implementation and monitoring of laws among unorganized industries are recommended to bring down morbidity due to musculoskeletal disorders ( msd ) . |
among the different types of forearm motor activities required in simple day - to - day tasks , two primary types of movements required are closing and opening of hand for grasping and releasing objects of different sizes respectively .
research shows that about 80% of stroke survivors lack in movement control and coordination skill that are vital requirements specifying the grasping abilities of one s upper limb .
here we used the concept of classifying the movement of the affected hand while using the physiological data ( surface electromyogram ( semg ) ) from the healthy hand as template , to develop an individualized rehabilitative platform for stroke patients .
we also deliveredrehabilitation by making our system capable of providing automated fes based on the participant s performance in an exercise task .
based tasks that required the participant to completely open and/or completely close his affected hand and maintain his hand in that configuration for 30 seconds .
if the participant was able to keep his hand open ( for hand extension tasks ) or closed ( for hand flexion tasks ) for the entire 30 seconds , the task was successfully completed .
we designed such vr - based tasks which would give the participants a feeling of navigating through some interconnected events from their daily life .
for example , the tasks were opening a door to enter a room with dim lighting , then closing the door , followed by lighting bulbs in the room , then moving through the room while switching off the lights at the back , to move to a corridor leading to a backyard garden having birds and grow plants by watering the garden .
the complete game had six tasks ( t1 - t6 ) with different environments in the vr world .
after completion of each task , our system delivered audio - visual feedback to the participant regarding his performance in terms of motivational messages ( e.g. ' good job ! ' ) and performance score points ( 0 - 100 ) .
a participant s performance score during t1 ( hand open configuration ) and/or t2 ( hand close configuration ) was less than 90 , our system was designed to give an electrical stimulation to the participant s affected hand preceding each of the subsequent tasks with similar hand configuration ( t3 and t5 for hand
we have used microstim genius , a portable muscle stimulator from technomed electronics comprising of metal electrodes to give surged faradic pulse stimulation for 20 seconds with an intermediate 5 seconds of rest to the motor points controlling the flexor and extensor group of muscles , responsible respectively for hand flexion and extension , of the affected hand of the participants .
one of the most common medical complications after a stroke are falls with a reported incidence of up to 73% in the first year post - stroke.6 fig 2(a ) shows the experimental setup for lower limb rehabilitation exercise platform .
the participants were asked to stand on the bbkept in front of the task computer ( pc ) .
the bb was connected to task computer and measured the participant 's center of pressure ( cop ) data while he performed the tasks shown on the computer monitor .
the task required the participant to shift weight in the instructed direction ( namely north , east , south and west ) , while moving a virtual object in the vr environment to a predefined position and then hold the object in that position for one second .
one s performance in a task was evaluated for each direction and subsequently the cumulative total score was computed for that task .
among the different types of forearm motor activities required in simple day - to - day tasks , two primary types of movements required are closing and opening of hand for grasping and releasing objects of different sizes respectively .
research shows that about 80% of stroke survivors lack in movement control and coordination skill that are vital requirements specifying the grasping abilities of one s upper limb .
here we used the concept of classifying the movement of the affected hand while using the physiological data ( surface electromyogram ( semg ) ) from the healthy hand as template , to develop an individualized rehabilitative platform for stroke patients .
we also deliveredrehabilitation by making our system capable of providing automated fes based on the participant s performance in an exercise task .
based tasks that required the participant to completely open and/or completely close his affected hand and maintain his hand in that configuration for 30 seconds .
if the participant was able to keep his hand open ( for hand extension tasks ) or closed ( for hand flexion tasks ) for the entire 30 seconds , the task was successfully completed .
we designed such vr - based tasks which would give the participants a feeling of navigating through some interconnected events from their daily life .
for example , the tasks were opening a door to enter a room with dim lighting , then closing the door , followed by lighting bulbs in the room , then moving through the room while switching off the lights at the back , to move to a corridor leading to a backyard garden having birds and grow plants by watering the garden .
the complete game had six tasks ( t1 - t6 ) with different environments in the vr world .
after completion of each task , our system delivered audio - visual feedback to the participant regarding his performance in terms of motivational messages ( e.g. ' good job ! ' ) and performance score points ( 0 - 100 ) .
a participant s performance score during t1 ( hand open configuration ) and/or t2 ( hand close configuration ) was less than 90 , our system was designed to give an electrical stimulation to the participant s affected hand preceding each of the subsequent tasks with similar hand configuration ( t3 and t5 for hand
we have used microstim genius , a portable muscle stimulator from technomed electronics comprising of metal electrodes to give surged faradic pulse stimulation for 20 seconds with an intermediate 5 seconds of rest to the motor points controlling the flexor and extensor group of muscles , responsible respectively for hand flexion and extension , of the affected hand of the participants .
one of the most common medical complications after a stroke are falls with a reported incidence of up to 73% in the first year post - stroke.6 fig 2(a ) shows the experimental setup for lower limb rehabilitation exercise platform .
the participants were asked to stand on the bbkept in front of the task computer ( pc ) .
the bb was connected to task computer and measured the participant 's center of pressure ( cop ) data while he performed the tasks shown on the computer monitor .
the task required the participant to shift weight in the instructed direction ( namely north , east , south and west ) , while moving a virtual object in the vr environment to a predefined position and then hold the object in that position for one second .
one s performance in a task was evaluated for each direction and subsequently the cumulative total score was computed for that task .
we designed proof - of - concept usability studies using vr - based platform . as a proof - of - concept for upper limb rehabilitation platform
, we conducted a preliminary usability study with one exposure to two stroke - surviving ( ss ) and six age - matched able bodied ( ab ) participants .
3 shows an improvement in the average performance score points obtained by ss participants for both the hand flexion and extension tasks upon application of electrical stimulation while doing the tasks . on the other hand ,
the ab participants were able to achieve 100 points in nearly all the tasks , as expected , even without stimulation . here
we present our findings on a preliminary usability study where we used audio - visual stimulation for patients with balance disorders .
as mentioned in our prior work on lower limb rehabilitation , designed as a proof - of - concept platform , we conducted a 3 - 4 day usability study on 4 hemiparetic volunteers ( p1-p4 ) , who were attending a rehabilitation program at a local civil hospital .
each participant was exposed to our system for 3 - 4 sessions lasting over 3 - 4 days .
fig 4 shows the task progression of each participant on first day ( dayf ) and last day ( dayl ) . on each day , all the participants started with a vr - based task of difficulty level 1 ( dl1 ) , and then progressed through the vr - based tasks of different difficulty levels increasing from dl1 to dl3 , based on his task performance .
although all the participants were able to reach tasks belonging to dl3 on both dayf and dayl of training , yet for most of them , there was a visible distinction in task progression pattern between the dayf and dayl .
specifically , for participants p1 and p3 , the task progression had lesser switching of tasks belonging to different difficulty levels on the dayl compared to the dayf .
with regard to participant p4 , the pattern of task progression on the dayl was almost similar to that on the dayf with minor improvement in terms of lesser switching of tasks belonging to different difficulty levels . for participant
p2 , the task progression pattern on the dayl was similar to that on the dayf in terms of switching between tasks belonging to different difficulty levels .
however , both p2 and p4 were able to interact with more number of vr - based tasks of dl3 on their dayl compared to the dayf .
as a proof - of - concept for upper limb rehabilitation platform , we conducted a preliminary usability study with one exposure to two stroke - surviving ( ss ) and six age - matched able bodied ( ab ) participants .
3 shows an improvement in the average performance score points obtained by ss participants for both the hand flexion and extension tasks upon application of electrical stimulation while doing the tasks . on the other hand ,
the ab participants were able to achieve 100 points in nearly all the tasks , as expected , even without stimulation .
here we present our findings on a preliminary usability study where we used audio - visual stimulation for patients with balance disorders . as mentioned in our prior work on lower limb rehabilitation , designed as a proof - of - concept platform
, we conducted a 3 - 4 day usability study on 4 hemiparetic volunteers ( p1-p4 ) , who were attending a rehabilitation program at a local civil hospital .
each participant was exposed to our system for 3 - 4 sessions lasting over 3 - 4 days .
fig 4 shows the task progression of each participant on first day ( dayf ) and last day ( dayl ) . on each day , all the participants started with a vr - based task of difficulty level 1 ( dl1 ) , and then progressed through the vr - based tasks of different difficulty levels increasing from dl1 to dl3 , based on his task performance .
although all the participants were able to reach tasks belonging to dl3 on both dayf and dayl of training , yet for most of them , there was a visible distinction in task progression pattern between the dayf and dayl .
specifically , for participants p1 and p3 , the task progression had lesser switching of tasks belonging to different difficulty levels on the dayl compared to the dayf . with regard to participant p4 , the pattern of task progression on the dayl was almost similar to that on the dayf with minor improvement in terms of lesser switching of tasks belonging to different difficulty levels . for participant p2 ,
the task progression pattern on the dayl was similar to that on the dayf in terms of switching between tasks belonging to different difficulty levels .
however , both p2 and p4 were able to interact with more number of vr - based tasks of dl3 on their dayl compared to the dayf .
the systems presented here are built as a proof - of - concept application and not as a full - fledged stroke - rehabilitation platform .
initial results indicate improvement of hand flexion and extension skills of stroke - surviving individuals after the application of fes added to audio - visual stimulation .
also , the results indicate the potential of audio - visual stimulation to bring in improvements in performance in lower limb balance related tasks . while demonstrating proof - of - concept of the technology and trends of improved hand - movement skills and lower limb balance skills with the help of a vr - based task providing audio - visual and electrical stimulation , questions about the practicality , efficacy , and ultimate benefit of the use of these technological tools for demonstrating clinically significant improvements in terms of stroke rehabilitation remain , which will be addressed by empirical investigation in the future .
the ultimate aim is to potentially reduce the burden on the healthcare system of our country and give a new hope to individuals with movement disorders . | neurological disorders often manifest themselves in the form of movement deficit on the part of the patient .
conventional rehabilitation often used to address these deficits , though powerful are often monotonous in nature .
adequate audio - visual stimulation can prove to be motivational . in the research presented here
we indicate the applicability of audio - visual stimulation to rehabilitation exercises to address at least some of the movement deficits for upper and lower limbs . added to the audio - visual stimulation
, we also use functional electrical stimulation ( fes ) . in our presented research
we also show the applicability of fes in conjunction with audio - visual stimulation delivered through vr - based platform for grasping skills of patients with movement disorder . |
our institutional review board approved our retrospective study with a waiver of informed consent . from september 2003 to july 2006 , we enrolled 199 patients who underwent integrated pet / ct and surgical staging and were diagnosed with stage t1 nsclc at ct ( retrospective review and reanalysis of all ct data obtained during this period ) or on pathologic examination . because bronchioloalveolar carcinomas usually do not have nodal or extrathoracic metastases , we excluded patients with that type of tumor ( nodule of pure ground - glass opacity ) . for patients with overt extra - thoracic metastases in which a conventional staging workup was not suggested , ( clinical examination or enhanced thoracic ct covering down to the level of middle portion of the kidneys ) , a pet / ct was performed as a further pretreatment staging workup . at our institution ,
patients with biopsy - proved n2 disease at mediastinoscopy are usually treated by using neoadjuvant concurrent chemo - radiation therapy ( weekly taxane / platinum and 45 gy of radiation therapy over a 5 week period ) and a subsequent surgical resection .
those identified as negative for mediastinal nodal metastases at mediastinoscopy , and subsequently found to have positive mediastinal nodes after surgical resection , were administered adjuvant chemotherapy ( cisplatin - based chemotherapy , three to four cycles of platinum combined with either taxane or vinorelbine ) . in node - negative patients at both a mediastinoscopy and thoracotomy ,
of these 199 patients , 10 were excluded because they did not undergo surgical treatment .
in addition , another five patients were excluded because of death caused by an unrelated disease ( post - operative adult respiratory distress in two , chronic empyema in the lobectomy space and its related pneumonia and sepsis in one , advanced gastric cancer in one , and acute pulmonary thromboembolism in one ) during the follow - up period .
the remaining patients make up the total of 184 patients included in the study ( 124 men and 60 women ; mean age , 59 + 10 years [ standard deviation ] ; range , 32 - 81 years ) ( fig .
details of the imaging methods used have been described in previous reports ( 1 - 3 ) .
patients received an intravenous injection of 370 mbq ( 10 mci ) of fdg and then rested for over 45 minutes before scanning .
scans were acquired using a pet / ct unit ( discovery ls ; ge healthcare , milwaukee , wi ) consisting of a pet scanner ( advance nxi ; ge healthcare , ) and an eight - slice ct scanner ( lightspeed plus ; ge healthcare ) .
a ct was performed from the head to the pelvic floor according to a standard protocol using the following settings : 140 kvp ; 80 ma ; tube rotation time , 0.5 seconds per rotation ; slice pitch , 6 ; and section thickness , 5 mm ( to match the pet section thickness ) .
immediately after an unenhanced ct , an emission pet was performed in the identical transverse field of view .
the pet data sets were reconstructed iteratively using an ordered subset expectation maximization algorithm and by applying the segmented attenuation correction ( two iterations , 28 subsets ) to the ct data .
integrated pet / ct images were evaluated jointly and prospectively by a chest radiologist ( with 18 years of ct interpretation experience and 4 years of pet / ct interpretation ) and a nuclear medicine physician ( with 13 years of experience and 4 years of pet / ct analysis ) . both were unaware of the findings of clinical and pathological evaluations .
primary tumor size was determined by measuring the largest diameter of the primary tumor on transverse lung window ( window width , 1,500 hu ; window level , -700 ) images seen at the ct component of the pet / ct images .
the maximum standardized uptake values ( msuvs ) of primary tumors were measured by placing an region of interest .
nodal stations were assessed visually by allocating mediastinal lymph nodes to nine groups , according to the lymph node map definition for lung cancer staging proposed by mountain and dresler ( 5 ) .
all lymph nodes in the thorax with abnormal fdg uptake ( greater than mediastinal blood pool uptake ) , irrespective of their size , were considered metastatic .
enlarged lymph nodes with their short - axis diameter > 10 mm were designated as benign when they were negative at the pet component of pet / ct images . additionally , lymph nodes even with high fdg uptake , when they showing higher attenuation than mediastinal structures ( great vessels ) or benign calcification ( central , nodular , diffuse , laminated or popcorn - like ) , were regarded as being benign ( 1 - 3 ) . during a mediastinoscopy , one of three surgeons ( 19 , 14 , and 6 years of experience , respectively ) attempted to harvest entire nodes , and the american thoracic society ( ats ) lymph node map areas of 2r , 4r , 2l , 4l , and 7 were routinely sampled . during a thoracotomy , the surgeons sampled all visible and palpable lymph nodes that were accessible in the hilum and mediastinum according to our surgical protocol .
namely , all encountered lymph nodes were removed from the ats lymph node map areas 10r , 9 , 8 , 7 , 4r , 3 and 2r in tumors of the right lung , and from map areas 10l , 9 , 8 , 7 , 6 , 5 and 4l of the left lung . when necessary , especially when imaging results suggested the presence of possible nodal metastasis in nodal stations of group 1 ( highest mediastinal ) or 2l ( when tumor was located in the left lung ) nodes , the nodes were also evaluated during a mediastinoscopy or thoracotomy .
a lung pathologist with 13 years of experience evaluated the nodes as numbered in the surgical field ( surgeons labeled dissected lymph nodes by numbering the nodes according to the lymph node map definition for lung cancer staging ) ( 5 ) .
we subdivided patients into three groups according to pet / ct and pathologic findings for mediastinal lymph node metastasis , i.e. , the pathologically true negative ( p - tn = tn + fp at pet / ct ) , pet / ct fn , and pet / ct tp groups .
a follow - up evaluation was performed every three months for the first two years after operation and six months thereafter .
a chest ct covering the whole thorax and upper abdomen was routinely performed at each follow - up study .
if patients became symptomatic or demonstrated abnormal laboratory findings , appropriate tests ( i.e. , brain mr , spine mr and bone scintigraphy ) were also performed . the median follow - up time following surgery in the 184 patients was 23 months ( range , 10 - 44 months ) .
the statistical analysis was performed using the spss statistical software version 9.0 ( spss inc , chicago , il ) .
the characteristics of the patients in the p - tn , pet / ct fn , and pet / ct tp groups were compared using the fisher 's exact test or the chi - square test .
the differences in nodule size ( < 2 cm versus > 2 cm in diameter ) of primary cancers between n2 and n0/n1 patients were compared by using the chi - square test .
disease - free survival ( dfs ) and overall survival ( os ) times were measured from the date of surgery until the first evidence of disease recurrence or last date of follow - up for patients who remained alive and were free of disease .
dfs and os were determined by using kaplan - meier analysis , and the differences between groups ( p - tn , pet / ct fn , and pet / ct tp ) groups were compared by using the log - rank test . a univariate cox regression analysis was used to determine whether the msuv integer values between three and 10 were predictive of tumor recurrence .
in addition , a univariate analysis was performed to evaluate the relationships between clinical or histologic prognostic factors and the probability of tumor recurrence after surgical resection .
the model was adjusted for the effects of pathologic groups ( p - tn , pet / ct fn , and pet / ct true positive ) , patient age and sex , cell type , tumor size , msuv of the tumor , and the number of nodal stations involved .
next , a multivariate analysis was performed to identify independent prognostic determinants ( cox proportional hazards model ) for both dfs and os .
from september 2003 to july 2006 , we enrolled 199 patients who underwent integrated pet / ct and surgical staging and were diagnosed with stage t1 nsclc at ct ( retrospective review and reanalysis of all ct data obtained during this period ) or on pathologic examination . because bronchioloalveolar carcinomas usually do not have nodal or extrathoracic metastases , we excluded patients with that type of tumor ( nodule of pure ground - glass opacity ) . for patients with overt extra - thoracic metastases in which a conventional staging workup was not suggested , ( clinical examination or enhanced thoracic ct covering down to the level of middle portion of the kidneys ) , a pet / ct was performed as a further pretreatment staging workup . at our institution ,
patients with biopsy - proved n2 disease at mediastinoscopy are usually treated by using neoadjuvant concurrent chemo - radiation therapy ( weekly taxane / platinum and 45 gy of radiation therapy over a 5 week period ) and a subsequent surgical resection .
those identified as negative for mediastinal nodal metastases at mediastinoscopy , and subsequently found to have positive mediastinal nodes after surgical resection , were administered adjuvant chemotherapy ( cisplatin - based chemotherapy , three to four cycles of platinum combined with either taxane or vinorelbine ) . in node - negative patients at both a mediastinoscopy and thoracotomy
, a curative surgical resection was performed without any adjuvant therapy . of these 199 patients ,
in addition , another five patients were excluded because of death caused by an unrelated disease ( post - operative adult respiratory distress in two , chronic empyema in the lobectomy space and its related pneumonia and sepsis in one , advanced gastric cancer in one , and acute pulmonary thromboembolism in one ) during the follow - up period .
the remaining patients make up the total of 184 patients included in the study ( 124 men and 60 women ; mean age , 59 + 10 years [ standard deviation ] ; range , 32 - 81 years ) ( fig .
details of the imaging methods used have been described in previous reports ( 1 - 3 ) .
patients received an intravenous injection of 370 mbq ( 10 mci ) of fdg and then rested for over 45 minutes before scanning .
scans were acquired using a pet / ct unit ( discovery ls ; ge healthcare , milwaukee , wi ) consisting of a pet scanner ( advance nxi ; ge healthcare , ) and an eight - slice ct scanner ( lightspeed plus ; ge healthcare ) .
a ct was performed from the head to the pelvic floor according to a standard protocol using the following settings : 140 kvp ; 80 ma ; tube rotation time , 0.5 seconds per rotation ; slice pitch , 6 ; and section thickness , 5 mm ( to match the pet section thickness ) .
immediately after an unenhanced ct , an emission pet was performed in the identical transverse field of view .
the pet data sets were reconstructed iteratively using an ordered subset expectation maximization algorithm and by applying the segmented attenuation correction ( two iterations , 28 subsets ) to the ct data .
integrated pet / ct images were evaluated jointly and prospectively by a chest radiologist ( with 18 years of ct interpretation experience and 4 years of pet / ct interpretation ) and a nuclear medicine physician ( with 13 years of experience and 4 years of pet / ct analysis ) . both were unaware of the findings of clinical and pathological evaluations .
primary tumor size was determined by measuring the largest diameter of the primary tumor on transverse lung window ( window width , 1,500 hu ; window level , -700 ) images seen at the ct component of the pet / ct images .
the maximum standardized uptake values ( msuvs ) of primary tumors were measured by placing an region of interest .
nodal stations were assessed visually by allocating mediastinal lymph nodes to nine groups , according to the lymph node map definition for lung cancer staging proposed by mountain and dresler ( 5 ) .
all lymph nodes in the thorax with abnormal fdg uptake ( greater than mediastinal blood pool uptake ) , irrespective of their size , were considered metastatic . enlarged lymph nodes with their short - axis diameter >
10 mm were designated as benign when they were negative at the pet component of pet / ct images .
additionally , lymph nodes even with high fdg uptake , when they showing higher attenuation than mediastinal structures ( great vessels ) or benign calcification ( central , nodular , diffuse , laminated or popcorn - like ) , were regarded as being benign ( 1 - 3 ) .
during a mediastinoscopy , one of three surgeons ( 19 , 14 , and 6 years of experience , respectively ) attempted to harvest entire nodes , and the american thoracic society ( ats ) lymph node map areas of 2r , 4r , 2l , 4l , and 7 were routinely sampled . during a thoracotomy , the surgeons sampled all visible and palpable lymph nodes that were accessible in the hilum and mediastinum according to our surgical protocol .
namely , all encountered lymph nodes were removed from the ats lymph node map areas 10r , 9 , 8 , 7 , 4r , 3 and 2r in tumors of the right lung , and from map areas 10l , 9 , 8 , 7 , 6 , 5 and 4l of the left lung . when necessary , especially when imaging results suggested the presence of possible nodal metastasis in nodal stations of group 1 ( highest mediastinal ) or 2l ( when tumor was located in the left lung ) nodes , the nodes were also evaluated during a mediastinoscopy or thoracotomy .
a lung pathologist with 13 years of experience evaluated the nodes as numbered in the surgical field ( surgeons labeled dissected lymph nodes by numbering the nodes according to the lymph node map definition for lung cancer staging ) ( 5 ) .
we subdivided patients into three groups according to pet / ct and pathologic findings for mediastinal lymph node metastasis , i.e. , the pathologically true negative ( p - tn = tn + fp at pet / ct ) , pet / ct fn , and pet / ct tp groups .
a follow - up evaluation was performed every three months for the first two years after operation and six months thereafter .
a chest ct covering the whole thorax and upper abdomen was routinely performed at each follow - up study .
if patients became symptomatic or demonstrated abnormal laboratory findings , appropriate tests ( i.e. , brain mr , spine mr and bone scintigraphy ) were also performed .
the median follow - up time following surgery in the 184 patients was 23 months ( range , 10 - 44 months ) .
the statistical analysis was performed using the spss statistical software version 9.0 ( spss inc , chicago , il ) .
the characteristics of the patients in the p - tn , pet / ct fn , and pet / ct tp groups were compared using the fisher 's exact test or the chi - square test .
the differences in nodule size ( < 2 cm versus > 2 cm in diameter ) of primary cancers between n2 and n0/n1 patients were compared by using the chi - square test .
disease - free survival ( dfs ) and overall survival ( os ) times were measured from the date of surgery until the first evidence of disease recurrence or last date of follow - up for patients who remained alive and were free of disease .
dfs and os were determined by using kaplan - meier analysis , and the differences between groups ( p - tn , pet / ct fn , and pet / ct tp ) groups were compared by using the log - rank test . a univariate cox regression analysis was used to determine whether the msuv integer values between three and 10 were predictive of tumor recurrence .
in addition , a univariate analysis was performed to evaluate the relationships between clinical or histologic prognostic factors and the probability of tumor recurrence after surgical resection .
the model was adjusted for the effects of pathologic groups ( p - tn , pet / ct fn , and pet / ct true positive ) , patient age and sex , cell type , tumor size , msuv of the tumor , and the number of nodal stations involved .
next , a multivariate analysis was performed to identify independent prognostic determinants ( cox proportional hazards model ) for both dfs and os .
a total of 184 patients ( 124 men and 60 women ; mean age , 59 + 10 years [ standard deviation ] ; range , 32 - 81 years ) were included in the study .
the surgical procedures performed included a bilobectomy in three patients , a lobectomy in 179 patients , and a segmentectomy or wedge resection in two patients .
histologically , 132 patients had adenocarcinoma , 40 had squamous cell carcinoma , and 12 had other carcinomas ( large cell neuroendocrine carcinomas in 5 , large cell carcinoma in 4 , sarcomatoid carcinoma in 2 , and pleomorphic carcinoma in 1 ) .
a mediastinoscopy was performed in 19 patients and its sensitivity for detecting n2 disease was found to be 79% ( 15 of 19 patients ) ( fig .
moreover , seven of the 89 patients ( 8% ) with smaller tumors ( < 2.0 cm in diameter ) and 16 of the 95 patients ( 17% ) with tumors > 2.0 cm had n2 nodal metastases ( p = 0.077 ) .
all 23 patients with n2 nodal metastases had a primary tumor with msuvs of > 5 ( mean = 9.9 , ( indicate unit of measure ) range ; 5.1 - 17.5 cm ( indicate unit of measure ) ) .
the remaining 161 patients without nodal metastases had a primary tumor with a mean msuv of 7.06 ( range ; 0.4 - 22.5 ) ( p = 0.003 , mann - whitney test ) .
neoadjuvant therapy was performed in 15 patients in whom a mediastinoscopy revealed a malignant lymph node diagnosis . in these patients , a thoracotomy was followed by the neoadjuvant therapy .
next , postoperative adjuvant therapy was administered in eight patients in whom a thoracotomy pathology revealed a malignant mediastinal node diagnosis ( fig .
the pet / ct had a diagnostic efficacy for the detection of n2 disease of ; sensitivity ( 48% , 11/23 ) , specificity ( 95% , 153/161 ) , accuracy ( 89% , 164/184 ) , and positive and negative predictive values ( 68% , 11/19 ; 93% , 153/165 , respectively ) .
a total of 161 patients were classified in the p - tn group , as opposed to 12 in the pet / ct fn group ( fig .
. the patient characteristics of the p - tn , pet / ct fn , and pet / ct tp groups were based on the various clinicopathologic factors shown in table 1 .
a total of 39 ( 21% ) of the 184 patients in the study experienced tumor recurrence .
the recurrent sites were the lungs in 13 patients , mediastinal lymph nodes in eight , brain in six , lung and mediastinal nodes in four , bone in four , and chest wall , trachea , adrenal gland , and liver in one each .
table 2 shows the recurrence rates in terms of patient characteristics by way of a univariate analysis of the hazard ratios .
only the presence of mediastinal node metastasis and high msuvs were found to be significantly correlated with the presence of tumor recurrence .
an msuv cutoff value of five proved to be the most discriminative criteria of tumor recurrence , based on log - rank probability values .
the number of mediastinal nodal stations involved with metastasis was not found to be a predictor of tumor recurrence ( four of seven patients [ 57% ] , with a single nodal station metastasis experiencing a recurrence and nine [ 56% ] of 16 patients with multiple nodal station metastases experiencing a recurrence ; yielding a hazard ratio of 1.402 , p = 0.577 ) .
both the presence of mediastinal node metastases and an msuv of > 5 were found to be independent predictors of patient survival .
the three - year os rate in the pet / ct fn group ( 43% , 95% confidence interval [ ci ] ; 25.0 to 60.0% ) was similar to that of the tp group ( 49% , 95% ci ; 29.9 to 67.5% ) ( p = 0.863 ) , however both groups had significantly lower os rates than the p - tn group ( 90% , 95% ci ; 86.5 to 93.1 ) ( p
4 ) . moreover , the three - year dfs rate in the pet / ct fn group ( 31% , 95% ci ; 13.6 to 48.0% ) was not statistically different from that of the tp group ( 16% , 95% ci ; 1.7 to 29.5% ) ( p = 0.649 ) ; however , both groups had significantly lower dfs rates than the p - tn group ( 77% , 95% ci ; 72.0 to 81.2% ) ( p < 0.001 ) ( fig
a total of 184 patients ( 124 men and 60 women ; mean age , 59 + 10 years [ standard deviation ] ; range , 32 - 81 years ) were included in the study .
the surgical procedures performed included a bilobectomy in three patients , a lobectomy in 179 patients , and a segmentectomy or wedge resection in two patients .
histologically , 132 patients had adenocarcinoma , 40 had squamous cell carcinoma , and 12 had other carcinomas ( large cell neuroendocrine carcinomas in 5 , large cell carcinoma in 4 , sarcomatoid carcinoma in 2 , and pleomorphic carcinoma in 1 ) .
a mediastinoscopy was performed in 19 patients and its sensitivity for detecting n2 disease was found to be 79% ( 15 of 19 patients ) ( fig .
moreover , seven of the 89 patients ( 8% ) with smaller tumors ( < 2.0 cm in diameter ) and 16 of the 95 patients ( 17% ) with tumors > 2.0 cm had n2 nodal metastases ( p = 0.077 ) .
all 23 patients with n2 nodal metastases had a primary tumor with msuvs of > 5 ( mean = 9.9 , ( indicate unit of measure ) range ; 5.1 - 17.5 cm ( indicate unit of measure ) ) .
the remaining 161 patients without nodal metastases had a primary tumor with a mean msuv of 7.06 ( range ; 0.4 - 22.5 ) ( p = 0.003 , mann - whitney test ) .
neoadjuvant therapy was performed in 15 patients in whom a mediastinoscopy revealed a malignant lymph node diagnosis . in these patients , a thoracotomy was followed by the neoadjuvant therapy .
next , postoperative adjuvant therapy was administered in eight patients in whom a thoracotomy pathology revealed a malignant mediastinal node diagnosis ( fig .
on a per - patient basis , the pet / ct had a diagnostic efficacy for the detection of n2 disease of ; sensitivity ( 48% , 11/23 ) , specificity ( 95% , 153/161 ) , accuracy ( 89% , 164/184 ) , and positive and negative predictive values ( 68% , 11/19 ; 93% , 153/165 , respectively ) .
a total of 161 patients were classified in the p - tn group , as opposed to 12 in the pet / ct fn group ( fig .
the patient characteristics of the p - tn , pet / ct fn , and pet / ct tp groups were based on the various clinicopathologic factors shown in table 1 .
a total of 39 ( 21% ) of the 184 patients in the study experienced tumor recurrence .
the recurrent sites were the lungs in 13 patients , mediastinal lymph nodes in eight , brain in six , lung and mediastinal nodes in four , bone in four , and chest wall , trachea , adrenal gland , and liver in one each .
table 2 shows the recurrence rates in terms of patient characteristics by way of a univariate analysis of the hazard ratios .
only the presence of mediastinal node metastasis and high msuvs were found to be significantly correlated with the presence of tumor recurrence .
an msuv cutoff value of five proved to be the most discriminative criteria of tumor recurrence , based on log - rank probability values .
the number of mediastinal nodal stations involved with metastasis was not found to be a predictor of tumor recurrence ( four of seven patients [ 57% ] , with a single nodal station metastasis experiencing a recurrence and nine [ 56% ] of 16 patients with multiple nodal station metastases experiencing a recurrence ; yielding a hazard ratio of 1.402 , p = 0.577 ) .
both the presence of mediastinal node metastases and an msuv of > 5 were found to be independent predictors of patient survival .
the three - year os rate in the pet / ct fn group ( 43% , 95% confidence interval [ ci ] ; 25.0 to 60.0% ) was similar to that of the tp group ( 49% , 95% ci ; 29.9 to 67.5% ) ( p = 0.863 ) , however both groups had significantly lower os rates than the p - tn group ( 90% , 95% ci ; 86.5 to 93.1 ) ( p < 0.001 ) ( fig .
moreover , the three - year dfs rate in the pet / ct fn group ( 31% , 95% ci ; 13.6 to 48.0% ) was not statistically different from that of the tp group ( 16% , 95% ci ; 1.7 to 29.5% ) ( p = 0.649 ) ; however , both groups had significantly lower dfs rates than the p - tn group ( 77% , 95% ci ; 72.0 to 81.2% ) ( p < 0.001 ) ( fig . 5 ) .
we found that the median os in the pet / ct fn group ( 29 months ) was similar to the median os time determined for the tp group ( 28 months ) ( p = 0.863 ) ; however , both groups had significantly shorter median os times than the p - tn group ( 41 months ) ( p < 0.001 ) .
in addition , the median dfs in the pet / ct fn group ( 16 months ) was lower than the p - tn group ( 35 months ) ( p < 0.001 ) ; however , no significant difference was found between the fn and tp groups ( 12 months ) ( p = 0.649 ) .
therefore , patients diagnosed with pathologic mediastinal nodal metastasis not detected by pet / ct had poorer survival estimates than patients with pathologically negative nodes .
these findings suggest that a more sensitive and accurate measure should be devised to correctly triage patients with stage t1 nsclc in terms of selecting a treatment modality and predicting prognosis . in our patient cohort , patient age , cell type , and primary tumor size had no significant impact on os . by both the univariate and multivariate analyses ,
the presence of pathologic n2 disease and a primary tumor with an msuv > 5.0 were found to be related to the recurrence of the disease .
some disagreement exists concerning the relationship between survival and the msuvs of primary tumors ( 6 - 17 ) , which is probably attributable to the various identifying methods used along with the related factors , such as , disease stages ( wide range of primary tumor sizes ) , tumor staging accuracy , and the fdg uptake measures and analytical methods used . in our study , which addressed stage t1 lung cancers ( < 30 mm in diameter ) with an msuv of > 5.0 , did appear to be significantly predict a poor prognosis by using a multivariate cox proportional hazard analysis .
it has been suggested that patients with a high suv have poorer dfs ( 6 - 10 ) .
previous studies have shown that different msuv cut - off values ranging from 3.3 to 10 are useful for predicting tumor recurrence ( 10 - 13 ) .
the difference in cutoff values between our results and those of previous studies can be explained by differences in cancer stages and nsclc histology . it can be reasonably presumed that patients with an advanced stage of lung cancer have a higher suv and poorer prognosis than those with an early stage form of the disease .
moreover , it has been reported that the relationship between fdg uptake and tumor aggressiveness is significant in adenocarcinoma cases , but not in other histologic types of nsclc ( 14 - 16 ) .
17 ) demonstrated that the fdg uptake values of the primary nsclcs do not provide additional prognostic information beyond tumor size and stage .
further , they reported that msuv is positively correlated with cancer stage and tumor size , but not directly with patient prognosis . when measuring the msuvs of tumors < 28 mm in diameter ( 18 , 19 ) , the effects of limited pet reconstructed resolution and artificially lowered tumor uptake value on the msuvs should be considered . even after measuring partial - volume - corrected tumor msuvs
, they still found no positive relationship between msuv and patient prognosis . in our study
however , cell types ( adenocarcinoma versus non - adenocarcinoma ; squamous versus non - squamous carcinomas ) were not a significant prognosis determinant .
recently , several studies have suggested that tumors < 2 cm have a better prognosis than those of > 2 cm ( 20 - 23 ) . in our study ,
nevertheless , although no statistical significance was not found , tumors of > 2 cm had more mediastinal nodal metastases than those < 2 cm ( p = 0.077 ) .
this lack of statistical significance , despite the presence of a trend toward an effect for size > 2.0 cm , may be due to the small number of our cohort and the small number of node positive patients ( 12% , 23 of 184 patients ) . in our study , the pet / ct diagnostic efficacy for the identification of n2 disease was based on sensitivity ( 48% , 11 of 23 patients ) , specificity ( 95% , 153 of 161 ) , and accuracy ( 89% , 164 of 184 ) .
the low sensitivity of pet / ct for detecting n2 disease in patients with stage t1 lung cancer has already been reported ( 3 , 4 ) , and may be explained by the fact that we only included patients with early stages nsclc ( stage t1 cancer ) and who had undergone a curative surgical resection .
, we excluded patients who had not undergone surgical treatment and those who had died of diseases not related to lung cancer .
this may have distorted the evaluation of the efficacy of pet / ct in terms of its detection of mediastinal nodal metastasis .
second , although we tried to perform a comprehensive review of the clinical and tumor histology - related factors related to prognosis , some potential factors were omitted ( e.g. , performance status , tumor lymphatic or vascular invasion by pathologic examination ) .
finally , the follow - up period was relatively short ( maximum 44 months ) . in conclusion
, the pet / ct was found to have high a specificity and negative predictive values , but low sensitivity for detecting n2 disease in patients with a stage t1 nsclc .
in addition , patients with pet / ct fn n2 disease have survivals that are similar to those of pet / ct tp n2 disease patients , and which are both substantially shorter than those of p - tn patients . keeping in mind our study results ,
we propose the following diagnostic and treatment strategy for stage t1 nsclcs : when pet / ct suggests the presence of mediastinal nodal metastasis , mediastinoscopy should be performed to confirm the presence of n2 disease .
next , treatment plan ( positive results render neoadjuvant chemoradiation therapy with or without following surgery , whereas negative results render curative resection with or without following adjuvant therapy ) should be determined according to the mediastinoscopy results .
when the pet / ct results suggest the absence of mediastinal nodal metastasis , direct curative resection surgery is executed with or without following adjuvant therapy according to the pathologic results of the curative surgery . | objectivewe aimed to compare the prognoses of patients with pathologically true negative ( p - tn ) n2 and pet / ct false negative ( fn ) results in stage t1 non - small cell lung cancer ( nsclc).materials and methodsour institutional review board approved this retrospective study with a waiver of informed consent .
the study included 184 patients ( 124 men and 60 women ; mean age , 59 years ) with stage t1 nsclc who underwent an integrated pet / ct and surgery .
after estimating the efficacy of pet / ct for detecting n2 disease , we determined and compared disease - free survival ( dfs ) rates in three groups ( p - tn [ n = 161 ] , pet / ct fn [ n = 12 ] , and pet / ct true positive [ tp , n = 11 ] ) using the kaplan - meier analysis and log - rank test.resultspathologic n2 disease was observed in 23 ( 12% ) patients .
pet / ct had an n2 disease detection sensitivity of 48% ( 11 of 23 patients ) , a specificity of 95% ( 153 of 161 ) , and an accuracy of 89% ( 164 of 184 ) .
the 3-year dfs rate in the pet / ct fn group ( 31% , 95% confidence interval [ ci ] ; 13.6 - 48.0% ) was similar to that of the tp group ( 16% , 95% ci ; 1.7 - 29.5% ) ( p = 0.649 ) , but both groups had significantly shorter dfs rates than the p - tn group ( 77% , 95% ci ; 72.0 - 81.2% ) ( p < 0.001).conclusionthe pet / ct shows a high specificity , but low sensitivity for detecting n2 disease in stage t1 nsclc .
patients with pet / ct fn n2 disease have survival rates similar to pet / ct tp n2 disease patients , which are both substantially shorter than the survival rate of p - tn patients . |
we present a patient who developed pneumomediastinum after an elective bilateral preperitoneal laparoscopic hernia repair .
as newer approaches to inguinal hernia repair are performed , newer complications of these techniques are being encountered .
laparoscopic approaches to inguinal hernia repair have been described with equivalent short - term recurrence rates as those of open approaches .
although the role of laparoscopic hernia repair has yet to be defined , decreased postoperative patient pain and quicker return to normal activity are potential advantages associated with laparoscopic herniorrhaphy .
many thoracic complications of laparoscopic surgery have been reported including pneumothorax , pneumomediastinum , pneumopericardium , and subcutaneous emphysema .
below , we describe a rarely reported complication of pneumomediastinum after preperitoneal laparoscopic inguinal hernia repair .
although this may be an uncommon complication , surgeons performing laparoscopic herniorrhaphy should recognize it .
a 64-year - old male with no past medical or surgical history presented to our clinic with bilateral inguinal hernia and desired laparoscopic repair . he was taken electively to the operating room for a standard bilateral laparoscopic preperitoneal hernia repair .
intraoperatively , a balloon dissector was used to create a preperitoneal space . with a maximum pressure of 12 mm hg ,
two separate but overlapping 10-cm 15-cm pieces of polypropylene mesh were placed and tacked appropriately .
no obvious tears occurred in the peritoneum nor did any evidence exist of pneumoperitoneum during the procedure .
before all the ports were removed , 0.25% bupivacaine hydrochloride was placed in the preperitoneal space for postoperative analgesia .
no elevation of end - tidal co2 was observed during the procedure . in the recovery room ,
the patient was monitored with continuous pulse oximetry and cardiac monitoring overnight with no desaturation or arrhythmia noted .
his chest pain resolved with 1 dose of intravenous narcotics and he then required only oral analgesics .
in relatively recent years , laparoscopic inguinal hernia repair became popular because of the shorter time needed to return to work and the decreased postoperative pain .
another benefit of laparoscopic inguinal herniorrhaphy is the ability to perform a bilateral repair with the same incisions used for a unilateral repair . also , the surgeon is able to relatively easily diagnose and repair asymptomatic contralateral hernia during unilateral repairs in the hope of avoiding future hernia operations .
although pneumomediastinum has been reported before , the actual incidence is unknown because postoperative chest radiographs are not and should not be routine after any type of hernia repair .
in the situation in which an asymptomatic patient is found to have a pneumomediastinum , deviation from routine postoperative care is not necessary .
pneumomediastinum can occur via air from the esophagus , trachea , bronchi , lung , neck , abdomen , or retroperitoneal space .
the most likely source in our case was the abdomen because a pneumoperitoneum is present on the chest radiograph ( figure 1 ) .
in fact , after paraesophageal hernia repair with or without fundoplication , pneumomediastinum ( secondary to surgical dissection through the esophageal hiatus ) has been considered a normal postoperative finding because it is present in 18% of patients .
the only 2 previous cases of pneumomediastinum after preperitoneal laparoscopic hernia repair required prolonged ventilatory support for the patient .
ramia et al reported an instance of a tear in the peritoneum that was noted and closed .
postoperatively , the patient developed chest pain and oxygen desaturation along with subcutaneous emphysema of the neck .
after 2 hours of ventilatory support , their patient was extubated and discharged 2 days later .
browne et al reported a case in which extensive subcutaneous emphysema involving the scrotum , abdomen , thorax , and neck was observed postoperatively .
although these 2 patients required prolonged mechanical ventilation , this is not always necessary as demonstrated by our own case . in patients without respiratory distress or with no upper airway compromise and who are hemodynamically stable with appropriate oxygen saturations , careful monitoring is all that is necessary for isolated pneumomediastinum .
of course , a chest radiograph is needed to diagnose other associated problems like pneumothorax .
pneumomediastinum is a rare complication of laparoscopic preperitoneal inguinal hernia repair , which potentially prolongs hospital stay and thereby increases total costs .
early diagnosis and appropriate treatment are necessary to avoid serious problems . however , as an isolated finding , pneumomediastinum may only require careful monitoring . | background : as new approaches to herniorrhaphy are popularized , new complications are being encountered .
pneumomediastinum is one such complication.methods:we present a patient who developed pneumomediastinum after an elective bilateral preperitoneal laparoscopic hernia repair.results:the patient was observed and discharged 24 hours later with no permanent sequelae.conclusions:pneumomediastinum is a rare complication of laparoscopic hernia repair . |
. complications due to cholelithiasis and subsequent hospital admissions are responsible for enhanced morbidity and mortality in addition to large expenses and large numbers of hospital beds needed by these patients . for
most surgeons , asymptomatic lithiasis does not require surgical treatment , which is only required in the presence of pain or complications such as cholecystitis , cholangitis , jaundice or pancreatitis.1 however , more severe complications may occur in solid organ transplant patients compared to the normal population.26 the immunosuppression experienced by transplant patients ( including the intensity of immunosuppression and type of immunosuppressant drug used ) is responsible for this increase in complications.78 based on these data , some authors suggest prophylactic cholecystectomy in asymptomatic patients before they undergo transplants , thereby avoiding serious morbidity and increased mortality . the purpose of this paper is to evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants .
we retrospectively reviewed the charts of patients on the waiting list for kidney transplants in our unit .
the analysis was performed until december 2007 and included 342 patients from whom routine complete abdominal ultrasound results could be recovered .
this ultrasound is performed on all patients as part of the initial evaluation before entering the list .
we looked for the presence of gall bladder disease and past history of symptoms of biliary lithiasis , jaundice , pancreatitis or cholecystectomy as well as previous abdominal surgery .
we also collected general data , such as gender , age , body mass index , and number of pregnancies .
when data were not available from patient charts , personal contact by phone was made to obtain missing data .
of these , 12 ( 29% ) had a past history of cholecystectomy due to symptomatic cholelithiasis and 29 ( 71% ) showed current lithiasis . among the 29 patients who had not undergone operations , 5 were symptomatic .
eight patients showed signs of chronic hepatopathy , as shown by enhanced liver echogenicity or portal or hepatic vein size .
twenty - five ( 61% ) out of the 41 above mentioned patients were female .
their mean age was 54 years old ( range 3274 ) , and their mean body mass index was 25.4 .
nineteen women ( 76% ) had previously been pregnant , with an average of 3.6 full - term pregnancies per woman ( average of 4.5 pregnancies when abortions were included ) .
coelho et al.9 studied 1,000 normal adults ( who were randomly selected in shopping centers ) by abdominal ultrasound and found a gallstone prevalence of 9.3% ( 12.9% in women and 5.4% in men ) , with marked age - dependent differences ( 2.4% of people 2029 years of age vs. 27.5% of people over 70 years old ) .
torres et al.10 studied 500 people who had undergone an ultrasound and whose complaints were unrelated to the biliary system and found a gallstone frequency of 18.4% ( 20.8% in women and 16% in men ) .
these data , as well as data from the international literature , point to a high frequency of asymptomatic cholelithiasis , which may remain quiescent for many years .
therefore , many surgeons suggest a follow - up assessment , indicating surgery only in symptomatic or complicated cases.1114 laparoscopic cholecystectomy is considered the gold standard for symptomatic uncomplicated cholelithiasis . after its use became widespread , laparoscopic cholecystectomy was shown to have a remarkably lower rate of morbidity and mortality compared to surgery in patients with complicated cholelithiasis ; thus , many surgeons proposed laparoscopic surgery for asymptomatic patients in good clinical condition.1517 this is the policy in our department .
cholecystectomy in asymptomatic candidates and organ transplant patients is also controversial.1823 kao et al.22 performed an extensive review of the literature on organ transplantation and cholelithiasis .
these authors pointed out an increased prevalence of gallstones in cardiac patients and patients using cyclosporine ( 8% when csa was not used compared to 22% after 2 years of use ) .
the overall prevalence of gallstones in pre - transplant ( heart , lung , pancreas , and kidney ) patients ranged widely , from 6.9% to 43.8% . in patients receiving a pancreas or kidney alone , the frequency was 9.9% .
as the prevalence of gallstones in the general population is estimated to be 1020% , it seems that the prevalence of gallstones in kidney transplant candidates is not different from that of the general population .
however , the aggregate prevalence of new post - transplant ( kidney and pancreas ) gallstones is 12% .
pre - transplant elective cholecystectomy in non - cardiac solid organ candidates leads to no enhanced morbidity or mortality .
however , when performed in the post - transplant period , the risk of cholecystectomy complications rises to an average of 11.8% morbidity and 1.5% mortality ( 0% in one study and 6.3% in another ) , especially when performed during emergencies .
graham et al.2 evaluated 551 patients on a transplant waiting list ( kidney and pancreas ) and found a pre - transplant cholelithiasis prevalence of 10% .
by contrast , 18% of patients who did not undergo pre - transplant surgery presented biliary complications and were submitted to urgent surgery , resulting in 14% morbidity and 7% mortality .
greenstein et al.23 evaluated 211 asymptomatic kidney transplant patients and found a cholelithiasis prevalence of 7.11% ; 87% of these patients had remained asymptomatic for five years .
melvin et al.24 evaluated 662 kidney transplant patients ; 144 ( 21.7% ) had previous or current history of biliary tract symptoms or identified gallstones .
fifty four ( 37% ) , all symptomatic , had undergone cholecystectomy in the post - transplant period : 30 patients ( 55.5% ) laparoscopic , 20 ( 37% ) open cholecystectomy and 2 underwent conversion from laparoscopic to open surgery .
our data showed a 12% prevalence of cholelithiasis , a large percentage of these patients were symptomatic ( 1741.6% ) .
this patient group was at risk for developing post - transplant surgical complications , which may become very serious due to immunosuppression .
the purpose of this paper was not to study post - transplant complications due to cholelithiasis .
these cholecystectomies should be accomplished through laparoscopic methods , which have a very low frequency of morbidity and almost no associated mortality .
a multicenter randomized trial is recommended to establish the best way to deal with chronic renal failure patients with cholelithiasis . | objectivesto evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants.introductionthe prevalence and management of cholelithiasis in renal transplant patients is not well established.methodsa total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied .
patients were evaluated for the presence of cholelithiasis and related symptoms , previous cholecystectomies and other abdominal surgeries , time on dialysis , and general data ( gender , age , number of pregnancies , and body mass index).resultscholelithiasis was found in 41 out of 342 patients ( 12% ) .
twelve of these patients , all symptomatic , had previously undergone cholecystectomies .
five out of 29 patients who had not undergone surgery were symptomatic .
overall , 17 patients ( 41.5% ) were symptomatic .
their mean age was 54 ( range 3274 ) years old ; 61% were female , and their mean body mass index was 25.4 .
nineteen ( 76% ) out of 25 women had previously been pregnant , with an average of 3.6 pregnancies per woman.conclusionsthe frequency of cholelithiasis was similar to that reported in the literature for the general population . however , the high frequency of symptomatic patients points toward an indication of routine pre - transplant cholecystectomy to avoid serious post - transplant complications . |
nodular scleroderma is a rare variant of scleroderma which can occur in connection with systemic sclerosis or morphea .
a biopsy from the lesion can demonstrate the scleroderma pattern , i.e. , keloid pattern or mixed type .
we present a case of systemic sclerosis in a 50-year - old female who developed nodular scleroderma in the absence of deterioration of the scleroderma condition .
although this condition is rare , it has been reported sporadically , and clinicians should be able to recognize this variant in cases of scleroderma presenting with firm nodules or plaques .
a 50-year - old female presented with a 1-year history of systemic sclerosis and interstitial lung disease .
her current medications were prednisolone 5 mg , cyclophosphamide 75 mg , amlodipine 20 mg , sildenafil 50 mg , and aspirin 80 mg daily .
ten months later , she developed multiple asymptomatic papules on the neck , abdominal wall , and back ( fig 1 , fig 2 ) .
the physical examinations demonstrated sclerotic skin changes on the face , trunk , and extremities with sclerodactyly , digital pitting scars , and raynaud 's phenomenon .
there were multiple , nontender , firm skin - colored papules and plaques scattered on the neck , abdominal wall , and back .
the laboratory tests revealed positive antinuclear antibody in a homogenous pattern ( titer 1 : 320 ) and positive anti - scl70 .
the biopsy revealed thick sclerotic collagen fibers in the mid - dermis ( fig 3 ) .
nodular or keloidal scleroderma is a rare variant of scleroderma [ 1 , 2 , 3 , 4 , 5 ] .
the term nodular scleroderma is used when the pathological change resembles scleroderma , and the term keloidal scleroderma
is used when the pathological change shows hyalinization of thick sclerotic collagens similar to keloid [ 1 , 6 , 7 ] . nodular or keloidal scleroderma have been reported in either systemic sclerosis or localized scleroderma , usually 6 months after the presentation of systemic sclerosis [ 1 , 2 , 3 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ] .
however , also the presence of nodular scleroderma before the onset of systemic sclerosis has been reported .
this condition can be found in systemic sclerosis patients either with or without active systemic involvements [ 1 , 2 , 8 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] .
the characteristic clinical presentations were firm nodules or plaques resembling keloid , distributed predominantly on the proximal extremities , i.e. , on the chest , back , and neck .
nodular or keloidal scleroderma usually occur in middle - aged females ( table 1 ) [ 1 , 4 , 8 , 11 , 12 , 13 , 14 , 16 , 17 , 18 ] .
variable histopathologic changes have been reported to include characteristics of keloid or hypertrophic scars , of morphea , or of both morphea and keloid [ 1 , 19 ] .
complex interactions between cytokines , matricellular proteins , and local factors ( minor trauma and vascular insufficiency ) should be determined [ 2 , 19 , 20 ] .
a role of pathogens , including acid - fast bacteria or chronic hcv infection , has been reported [ 11 , 14 , 21 ] .
yamamoto et al . mentioned the role of increasing connective tissue growth factor ( ctgf ) in tissue fibrosis .
nonetheless , an increase in ctgf was identified both in the nodular lesions and in skin with scleroderma .
consequently , the increase in ctgf alone may not be the sole contributor to the pathogenesis of fibrosis in the lesions .
. demonstrated increasing cartilage oligomeric matrix protein ( comp ) , collagen xii , and fibrillin-1 in nodular scleroderma lesions compared to perilesional skin and healthy skin .
comp is induced by tgf- , which is an important cytokine in stimulating fibrosis in scleroderma and is involved in modulating the dermal collagen network as well as in sustaining fibroblast activation .
our case presented with multiple skin - colored papules and plaques , a differential diagnosis that should be considered was localized cutaneous mucinosis , which can be found as a coexisting condition with systemic sclerosis or morphea [ 24 , 25 , 26 , 27 , 28 ] .
however , the diagnosis of localized cutaneous mucinosis should be confirmed by mucin deposition in a skin biopsy .
several treatment modalities are mentioned in the literature , including topical or intralesional steroids , systemic steroids , topical calcipotriene , psoralen photochemotherapy , cyclosporine , d - penicillamine , methotrexate , extracorporeal photochemotherapy , and excision [ 1 , 2 , 4 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 29 , 30 ] .
however , these treatment modalities have shown unsatisfying results . a review of the reports on nodular or keloidal scleroderma in the past 10 years ( table 1 ) revealed that 1 case demonstrated stable nodular scleroderma without any specific treatment . interestingly
, immunosuppressive agents that have previously been received can not prevent the development of nodular or keloidal scleroderma [ 11 , 12 , 13 , 16 ] .
the condition of systemic sclerosis in our case has been stable , and the patient was not concerned about its appearance .
therefore , we decided to closely observe and monitor her for any progression of the lesions . after 4 months ,
although this condition is rare , it has been reported sporadically , and it should be considered in scleroderma patients clinically presenting with firm nodules or plaques .
this research did not receive any specific grant from funding agencies in the public , commercial , or not - for - profit sectors . | backgroundnodular scleroderma is a rare variant of scleroderma which can occur in connection with systemic sclerosis or morphea .
a biopsy from the lesion can demonstrate the scleroderma pattern , i.e. , keloid pattern or mixed type .
treatment is challenging , and several treatments modalities have been reported with unsatisfactory results.main observationswe present a case of systemic sclerosis in a 50-year - old female who developed nodular scleroderma in the absence of deterioration of the scleroderma condition . although no additional treatment was given , the lesions remained stable without progression.conclusionsalthough this condition is rare , it has been reported sporadically , and clinicians should be able to recognize this variant in cases of scleroderma presenting with firm nodules or plaques . |
seven - transmembrane receptors are a family of signaling proteins that bind hormones , autacoids , and neurotransmitters to mediate a myriad of cellular functions .
like all proteins , these exist in collections of tertiary conformations called protein ensembles ; receptors sample these conformations according to changes in the thermal energy in the system .
some of these conformations can be designated as active states , denoting their ability to activate cytosolic signaling mechanisms .
the current model of pharmacological seven - transmembrane receptor agonism describes the selective binding of agonists to these active states to enrich their presence within the ensemble through a process referred to as conformational selection .
thus , through le chatelier s principle , upon agonist binding , the make - up of the ensemble is directed toward the conformations possessing the highest affinity for the agonist and these are stabilized at the expense of other conformations .
the product of this thermodynamic process is a collection of membrane proteins that activate cellular signaling processes and agonism ensues .
early discussions of this mechanism and agonist efficacy in general used the most simple assumptions that the receptor is the minimal unit of control for this process and that a receptor activated by any agonist triggers all cellular signaling processes mediated by that particular receptor type .
first , it was observed that seven - transmembrane receptors pleiotropically interact with a wide range of cytosolic coupling proteins .
second , new technology revealed multiple biochemical behaviors of receptors such as the propensity to be phosphorylated and to interact with multiple g - proteins and -arrestin , internalization , and desensitization .
subsequent studies have indicated that not all agonists uniformly produce activation of these multiple receptor behaviors .
for example , the peptides pacap1 - 27 and pacap1 - 38 activate pacap ( pituitary adenylate cyclase - activating polypeptide type 1 ) receptors to elevate cyclic amp and increase production of ip3 .
however , the relative potency of these agonists for these responses is reversed ; the relative efficacy of pacap1 - 27 for cyclic amp elevation is higher than that of pacap1 - 38 but lower for elevation of ip3 .
this indicates that the receptor is not the minimal unit of control of agonism , it is the agonist - receptor complex that controls the ultimate signaling event ; the data leading to this conclusion also clearly indicate that agonist activation of multiple signaling mechanisms is not uniform but rather is often
this concept has been put into a formal model showing that agonist - selective states can produce biased agonism . in terms of the molecular mechanism of biased agonism ,
two additional factors are relevant to the discussion , namely the nature of the receptor - active state and the interaction of the activated receptor with multiple cytosolic signaling proteins .
the selective activation of cellular pathways with biased agonists is consistent with there being agonist - specific ensembles of receptor conformations mediating these events ; subsequent studies have given independent corroboration of this mechanism through separate lines of experimentation that directly show that ligands can stabilize unique receptor conformations [ 4 - 9 ] .
similarly , molecular dynamics predicts that when proteins such as receptors change conformation , different regions of the receptor change independently ( i.e. , the protein does not form uniform global conformations ) [ 10 - 13 ] . therefore , the fact that signaling proteins interact with different regions of the receptor ( e.g. ) suggests that different conformations would not produce uniform coupling to all signaling proteins ; that is , the unique receptor conformations stabilized by agonists most likely will result in differential ( biased ) activation of cell signaling pathways .
in fact , the activation of a receptor that interacts with multiple signaling components in a cell most likely will never produce equal activation of all pathways ; therefore , from this standpoint , every agonist will have a bias in signaling .
however , a useful point of reference is the natural agonist for the receptor ; this will have a natural signaling bias and can be used as a standard with which other agonists can be compared . within this scale ,
functionally selective agonists are defined as having a signaling bias different from that of the natural agonist .
studies using a wide variety of technologies now indicate that biased agonism is a common phenomenon .
agonists have been shown to differentially activate different g - proteins and -arrestin and have differing susceptibility to phosphorylation , desensitization , and internalization in a wide variety of receptor systems ( for reviews , see [ 17 - 23 ] ) .
in particular , many studies now specifically show how differential activation of g - proteins versus -arrestin results from biased stabilization of receptor conformation . observed most often with synthetic agonist ligands
, bias can also be detected in natural systems such as the chemokine ccr7 receptor .
thus , ccl19 and ccl21 , two natural agonists for the ccr7 chemokine receptor , differ in the type of pathway stimulation they elicit ; although both agonists produce g - protein activation , only ccl19 ( not ccl21 ) causes receptor agonist - dependent phosphorylation and recruitment of -arrestin to terminate the g - protein stimulus .
in addition to g - proteins and -arrestin , seven - transmembrane receptors have been shown to couple to many other signaling proteins such as jak / stats ( janus kinase / signal transducers and activators of transcription ) , src - family tyrosine kinases , g - protein receptor kinases ( grks ) , and pdz domain - containing proteins .
for example , different proteases have been shown to differentially activate protease - activated receptors through stabilization of distinct conformation ( much like biased ligands ) .
the discovery that some ligands can produce activation of some but not all receptor - linked stimulus mechanisms can introduce ambiguity in the classification of drugs .
for instance , the active internalization of receptors by some antagonists indicates that a label of
similarly , while propranolol is a well - known antagonist and inverse agonist of agonist activation of gs - coupled effects of -adrenoceptors , it has also been shown to be an active activator ( agonist ) of extracellular signal - regulated kinase ( erk ) .
biased agonism can be complex and need not necessarily involve excitatory signaling events ; that is , some ligands can be positive agonists for one pathway and antagonists or inverse agonists for another .
pluridimensional ; that is , ligands may have a range of different efficacies to cause a range of receptor behaviors .
the emphasis has clearly shifted from does biased agonism occur? to when it does occur , how can it be harnessed therapeutically? this trend is consistent with the improving technology to detect whole - cell effects through label - free technology ; these data provide cell - specific and detailed information regarding signaling patterns of ligands [ 36 - 40 ] .
thus , while assay technology is making it increasingly possible to detect and characterize agonist bias , focus is shifting to the mechanisms responsible for this effect .
emphasis has also shifted from the cell surface to the cytosol in an effort to understand biased signaling .
for example , detailed studies of biased ligand - induced -arrestin - mediated signaling indicate significant differences in functionally distinct pools of -arrestin accessed through conformational control of receptor sensitivity to phosphorylation by grk isoforms .
bar coding of ligand - bound receptors that lead to further downstream instruction of -arrestin partners within the cell .
moreover , just as receptors adopt different conformations to achieve selective signaling , it has now been shown that -arrestin itself forms different conformations and that these are associated with selective functions within the cell .
the significance of biased signaling is increasingly appreciated as signaling pathways become linked to normal physiology and pathophysiology . for example , the reported erk activation through -arrestin by some antagonists ( i.e. propranolol ) is interesting in light of recent data that suggest that angiotensin receptor - mediated -arrestin stimulation may be beneficial in the treatment of heart failure or , alternatively , may be linked to the progression of heart failure through aldosterone pathways .
biased signaling has been implicated in a unique profile of antagonism and agonism in breast cancer .
specifically , substance - p analogues sp - d and sp - g have been shown to produce biased signaling at vasopressin v1a receptors and receptors for gastrin - releasing peptide to yield a profile of blocked gq - protein - mediated calcium release and concomitant activation of erk .
this is postulated to produce a unique antiproliferative profile of activity . in terms of specific examples in which bias
may be a practical aspect of drug activity , there are interesting divergences in activity for opioid agonists to produce analgesia with reduced propensity to produce desensitization and -opioid receptor internalization [ 46 - 50 ] and intriguing functionally selective dopamine and serotonin agonists for the treatment of psychiatric disorders .
similarly , there are data that suggest that functionally selective thyrotropin agonists may be able to differentiate thyroid growth and thyroid hormone synthesis and orexin receptor functionally selective agonists may differentiate effects on catecholamine release and adrenal steroid production .
the consequences of biased agonism currently are an intense subject of study . while initial work in the field considered acute effects such as desensitization , receptor internalization , and differential activation of g - proteins , more recent studies center on long - term effects of biased signaling such as prolonged signaling through -arrestin activation and effects such as g - protein regulation . in general
, it is not yet clear to what extent these biased stimulations of cellular signaling pathways will yield favorable therapeutic phenotypic agonism .
what is clear is that seven - transmembrane receptors can not be considered on / off switches and synthetic agonists can not be considered surrogates of natural agonists .
stabilization of receptor - active states by different molecules has the potential to traffic receptor stimulus in unique ways to cause complex patterns of cellular activation .
| seven - transmembrane receptors are commonly coupled to multiple signaling pathways in cells .
the simple model describing agonists for these receptors as producing a common active state to induce uniform activation of the pathways linked to the receptor has been shown to be untenable in light of a large body of data that suggest that some agonists produce activation of some but not all available pathways .
these agonists are referred to as
biased in that they select which signaling pathways become activated upon binding to the receptor . the data to support this mechanism as well as ideas on the possible therapeutic application of this effect will be discussed . |
identification is a matter of paramount importance in any crime investigation . even though dna and fingerprints are the time - tested methods , these evidences are not always available at the investigation sites . in such circumstances , it is necessary to apply different and less - known techniques . a new area of investigation in the detection of crime is the use of wrinkles on the lips .
cheiloscopy ( quiloscopy ) is a method of identification of a person based on characteristic arrangement of lines appearing on the red part of lips .
very little has been said or written about the application of lip prints in these days of advanced scientific crime detection . in view of the need of forensic dental services in the different parts of our country
it was found necessary to do research on the use of lip prints for person identification .
it was therefore decided to carry out a pilot study to evaluate the uniqueness of the lip prints and their stability over a period of time .
the authors have introduced the weighted value scoring system for the first time to calculate the lip score for each lip in an intention to settle once and for all the question of the uniqueness of the lip print .
it was felt that such a study would prevent one of the most important forms of evidence from being overlooked .
the studies done so far depended on the manual method for the lip print analysis which has its own demerits .
the information that is lacking in the research of cheiloscopy is an accurate methodology for lip print collection and a standard method for its analysis .
the present study was also aimed to develop an ideal methodology for lip print collection that provides minimal distortion and greater clarity of the image .
the study has been designed to carry out the analysis of the lip prints using computer software program , adobe photoshop 7.0 for the first time .
a pilot study was conducted at the oral medicine , diagnosis , and radiology department of the goa dental college and hospital , bambolim , goa
the study comprised 100 subjects selected from amongst the students of the goa dental college and hospital , bambolim , goa , india , whose ages ranged between 19 to 28 years . subjects with inflammation , ulcers , trauma , congenital developmental defects and malformation , deformity and surgical scars ( e.g. operation for cleft lip ) and other abnormalities of lips were excluded because of their unsuitability for this investigation either because the defect itself was enough for identification or the clinical condition precluded from enrolling the individual in this study .
informed consent of the subjects was taken and they were explained that they would be a part of a research program wherein cosmetics had to be used for recording the lip prints . the object being the human mouth , special attention was paid to the cleanliness and hygiene while recording the lip prints by giving a prophylactic antiseptic mouth rinse followed by cleansing of the upper and lower lips with povidone - iodine cleansing solution .
firstly the boundaries of the lips were marked with a red - colored ( lakme ) lip liner to confine the lipstick application within the marked area .
the tip of the lip liner was later cleansed with a cotton ball dipped in
pure hands , a herbal hand cleanser , prior to using it on the next person .
lipstick was then uniformly applied with the help of a lipstick application brush in a systematic manner to avoid the smudging of the lipstick in the grooves .
once the application of the lipstick to one lip e.g. upper lip , was over , the subject was made to wait for 30 sec for drying of the lipstick .
he or she was told to keep the teeth in occlusion and gently retract the opposing lip when the print of the concerned lip was being taken .
lip print was then obtained using 14-mm wide and 50-mm long scotch tape with gentle pressure on either side .
since the human lips are so mobile that the strength or the direction of the pressure applied and even the minimal movement of the lip can affect the accuracy of the lip print taken , the subject was strictly advised not to change the position and avoid any movement of the lips during the procedure of recording the lip print .
the scotch tape was then stuck onto a plain white a4 size bond paper , with the details like the serial no .
, the name of the subject and the date of recording of the lip print mentioned on the page .
recording of the upper and lower lip prints together was also done using cellophane tape ( width : 50 mm and length : 50 mm ) , to aid in confirming the midline of the upper and the lower lip .
the used lipstick application brush was washed with water and the tips were immersed in diluted 0.5% sodium hypochlorite solution for 30 min and washed with water again prior to reuse .
each time while taking the lipstick with the application brush , a separate chemically sterilized brush was used in order to avoid the cross - contamination of the lipstick .
the lip print was then scanned ( 256 gray shades at a resolution of 300 dpi ) for the digital analysis . using various applications of adobe photoshop 7 software
k. suzuki and y. tsuchihashi 's classification was followed to define the patterns of the grooves .
strict criteria were followed to define type ii , iii and iv pattern . while recording type ii pattern , only those lines that bifurcate , with the bifurcating lines not in the same straight line as the leg of the y were considered whereas lines showing trifurcation and multiple branching appearance were considered as type v. lines that intersect forming an x pattern , without having any superimposition and the length of the arms of x being almost equal from the point of intersection were considered as type iii pattern .
lines showing multiple interconnections and difficult to categorize in type i to iv were directly considered as type v. each type of pattern was given a color code while recording it digitally as pink , blue , green , red , yellow and orange for type i to v respectively .
upper and lower lip print images were categorized into two quadrants each , thus producing a total of four quadrants .
the four quadrants were named as follows : upper right as quadrant i , upper left as quadrant ii , lower left as quadrant iii and lower right as quadrant iv .
thus by noting the classified types of grooves , the individual 's lip print pattern was recorded [ figure 1 ] . lip print image with various color - coded grooves in each quadrant , the first 15 lines appearing from the midline to the periphery were recorded in 15 columns .
each pattern was given an arabic numeral scoring in the following manner and as shown in table 1 .
weighted values were given for the lip lines in the descending order from 15 to 1 with reference to their position from the midline .
the product of the arabic numeral score of the line and the weighted value of the line vis - - vis its position from the midline was given as the lip line score .
more weightage was given for the lines appearing in the center than at the periphery because this is the part of the lip which comes more in contact with any surface , and is the part often recorded without much distortion and smudging . by summing the weighted lip line score values , lip score in each quadrant for an individual subject was calculated . by adding the scores of all the four lip quadrants the lip score for each person
arabic numeral scoring for the individual pattern subject and quadrant - wise display of lip scores including subject and upper lip ( quadrant i , ii , i + ii ) and lower lip ( quadrant iii , iv , iii + iv ) and total lip score for an individual ( lip scores of quadrant i + ii + iii + iv ) was also charted .
the same procedure was repeated after a one - year interval to evaluate the stability of the lip prints .
it was observed that no two lip prints had exactly matching scores in all four quadrants .
there were a number of cases where the lip score in a particular quadrant was the same but their lip scores in other quadrants differed and consequently so did their total lip score [ table 2a - d and table 3 ] . - lip score in quadrants i , ii , iii , iv , i + ii , iii + iv , i + ii + iii + iv subjects with the same lip score quadrant i , ii , iii , iv , i + ii , iii + iv and i + ii + iii + iv . the total lip score i.e. quadrant i + ii + iii + iv was unique for individual lips except for a 70 and a 74 having the score of 2352 and a 77 and a 80 sharing the same score of 2118 [ table 3 ] .
wilcoxon sign rank test was used to check the stability of the lip prints over a period of time .
no statistically significant difference was found in the change of pattern in lip print images collected after 12 months from the same individual , even after exposure of the lips to the seasonal variations and minor or superficial trauma .
the technique followed for collection of the lip prints using lipstick as a recording media and scotch tape as a transferring media provided clear and definable lip print image .
digital method provided better visualization of the image and was convenient for analyzing the lip print pattern .
various type v patterns encountered in the current study included cartwheel appearance , pineapple skin appearance , trifurcations , bridge or
h pattern , horizontal lines ( predominantly found in the centre of the upper lip ) , and multiple branching appearance ( predominantly found at the lateral or peripheral aspect of the lower lip ) .
cheiloscopy ( quiloscopy ) can be defined as a method of identification of a person based on the characteristic arrangement of lines appearing on the red part of lips , or as a science dealing with the lines appearing on the red part of lips .
lip prints can be used with equal reliability in identification as fingerprints since it is claimed that no two individuals have identical lip prints .
apart from identification and evidential use , lip prints may also be used in detection work , being the source of tactical and criminalistic information .
a lip print at the scene of crime can be a basis for conclusions as to the character of the event , the number of the people involved , sexes , cosmetics used , habits , occupational traits , and the pathological changes of lips themselves .
criminals make attempts to conceal their identity and try to destroy the finger skin pattern by self - inflicted wounds , by application of corrosives or by abrading the skin .
these kinds of manipulations are unlikely to be inflicted by the criminals on their lips . hence taking lip prints of all the suspected individuals and comparing them with the items found at the scene of crime
the other investigations become easier once the involvement of a suspect at the scene is confirmed .
the lip crease pattern is on the vermilion border of the lip , which is quite mobile and lip prints may vary in appearance according to the pressure , direction and method used in making the print . if lipstick is used as a recording medium the amount applied may also affect the print .
hence a good method is required for the collection of the lip prints with suitable transferring and recording media .
the authors tried using cellophane tape , paper roller , dabbing of the lips against the paper and scotch tape for recording the lip prints . conventional powder method and photography
the lip prints are on the zone of transition of the lips which are extremely mobile .
smudging of the prints due to excessive or uneven pressure was noticed in subjects with prominent upper and/or lower lip when cellophane tape or paper roller was used to collect upper and lower lip print together . when the subject is asked to press his or her lips against the folded paper ,
there is a possibility of only the central area coming in contact with the paper and in doing so the rest or the relaxed position of the lips is not achieved which invariably leads to distortion of the prints . in conventional powder methods
photographing of the lips was found to be very tricky and subject to errors as the central area of the lips and the angles of the lips are never in the same plane which leads to focusing errors resulting in blurred or partial images of the lips .
this invariably calls for recording the lip prints and then photographing them and then comparing the two photographs .
thus in spite of being a reliable method in other areas of forensics , in the recording of lip print images it adds to the cost but does not enhance the clarity in the same rising proportions . since recording of the lip print becomes the fundamental exercise , the method adopted in the present study could be advantageous .
smaller width of the tape helps in its application along the curvature of the lip without any interference of the opposing lip ( if properly retracted ) and nose .
upper and lower lip print images can be recorded separately with minimal distortion in subjects having either one or both , upper - lower prominent lips or excess curvature of the lips .
the classification that was followed in the present study was suzuki and tsuchihashi 's classification which is generally followed by most of the authors because of its accuracy and simplicity .
strict criteria were followed while considering all the types of patterns to avoid intra - observer bias .
the authors would like to suggest some modifications with respect to the classification to make it more precise and accurate and standardize the readings of the various studies conducted by other workers in the country and elsewhere .
this will help us in comparison of the various parameters in a greater sample size by following a standard classification .
the following modifications are suggested , especially for type i , type ii and type v pattern . according to suzuki and
tsuchihashi 's classification type i is a straight groove that disappears halfway into the lip instead of covering the entire breadth of the lip .
this pattern can be further classified into : type ia - a straight groove appearing from the outer margin of the lip to the inner aspect and type ib - a straight groove appearing from the inner margin of the lip to the outer aspect .
type ii is grooves that fork or bifurcate in their course or a branched groove .
this pattern can be further classified into : type ii a grooves that bifurcate in the outward direction and type ii b grooves that bifurcate in the inward direction .
type v grooves that do not fall into any of the above categories and can not be differentiated morphologically . instead of just giving a generalized term as type v pattern , it is found necessary to sub - classify the type v pattern wherever possible , so as to give a more defined term that will further add to the accuracy of the classification .
the current study has adopted an indirect digital method by scanning the lip print images in adobe photoshop 7 with 256 gray scale , 300 dpi resolution for better visualization of the image and recording each type of the groove patterns with assigned color code as mentioned thus ensuring the recording of each line without missing a single one and also eliminating an error of recording the same groove twice which is most likely to occur with manual recording . the digital method adopted in the present study
has various advantages due to its features like zooming , enhancement , layers and drawing tool .
adobe photoshop is a popular software program , which allows for a multitude of imaging features , functions , enhancements and metric analysis .
the only limitation is the very high resolution of the image ( 300 dpi ) required to avoid pixellation ( fuzziness ) of the magnified picture .
regardless of the method by which an image is captured , once it has been digitized , several computerized enhancements can be performed on the image .
this gives us the chance to salvage an image that is either too dark or too light .
an image in which all of the pixels have been saturated ( too dark ) or where the noise ( useless information ) in the system overwhelms the signal ( useful information ) , can not be saved .
image contrast can also be manipulated by altering the gradient of the gray levels in the image .
manipulating the image contrast can not salvage an image in which the subject contrast is inadequate . with layers
, we can work on one element without disturbing others . to rearrange elements , simply shift the order in the layers palette .
we can lock layers to prevent accidental changes , hide them to get a clear view of the element we are working on , and link layers to move them as a group .
the layers palette also makes it easy to apply instant , editable effects including blending modes , adjustment layers , and layer effects .
resolution - independent vector shapes can be drawn instantly with the line , rectangle , ellipse , polygon , and custom shape tools .
direct digital imaging indicates that the original image is captured in a digital format , i.e. , the image is made up of discrete packets of information called pixels ( picture elements ) . on the other hand
, indirect digital imaging implies that the image is captured in an analog or continuous format and then converted into a digital format .
as with any data conversion , this analog to digital conversion ( adc ) results in the loss and alteration of information . instead of capturing the border that traverses a particular pixel , the pixel value is averaged .
sivapathasundharam b. and prakash p. a. have taken the middle part of the lower lip , ( 10-mm wide ) as a study area , since this fragment is almost always visible in any trace .
the current study has made an attempt to record each and every line of the entire lip starting from the midline to the periphery .
in some subjects , the lip lines were very clear and were easily identified but in some lips only a few lines could be recorded and in others , the lines were not identifiable because of the poor quality of the image . the number of the lines recorded quadrant - wise is shown in detail in table 4 . with the help of digital analysis ,
up to 15 lines were traceable in 66% of quadrant i , 71% of quadrant ii , 52% of quadrant iii and 51% of quadrant iv images .
the reason for some of the images showing very few or non - recordable lines can be attributed to the inherent anatomy of the lips , technical error and processing error .
thin lips , recessive lips , inverted lips , excessive prominence either in the center or lateral portion of the lips , excessive curvature of the lips , fine groove pattern on the lips , all these factors can affect the quality of the lip print image .
the anatomy of the lips varies from person to person . they may be full or thin , wide or narrow , short or long , generally in response to genetic data and the form of the teeth .
the inclination of the teeth may cause the lips to be excessively prominent or recessive . in the edentulous person the lips recede , increasing the prominence of the nose and chin , since the inter - arch distance may be reduced and the nose and chin tend to approximate each other .
with thin , recessive and inverted lips it is difficult to record the lip print using any of the above methods .
excessive prominence in any part of the lips or excessive curvature of the lips leads to pressure areas resulting in distortion of the image . in such cases a compromise has to be made over the lateral areas so as to clearly record the central area with minimal pressure . with fine groove pattern on the lips
, there is all possibility of excess lipstick getting smudged in the grooves resulting in a distorted image .
number of lines recorded in quadrant i , ii , iii and iv excessive application of the lipstick leads to smudging of lipstick in the grooves and thus unclear groove pattern .
lips being highly mobile , minimal variation in the pressure application while recording the lip print using scotch tape or any other method can lead to distortion of the image .
variation in the posture of the lip i.e. contraction or stretching of the lips during the procedure of recording can either lead to overlapping of the grooves or clear area without any groove pattern , thus causing distortion of the image .
mobility of the lips is nature 's creation , and an error caused because of this nature of the lips could not be avoided .
but an effort was made to minimize the technical error and to standardize the technique of recording the lip prints .
for uniform application of the lipstick , a lipstick application brush was used with vertical strokes of the brush starting from the outer to the inner aspect of the lip .
care was taken to evenly apply the pressure while recording the lip prints with scotch tape .
for standardizing the posture of the lips while recording , the subject was advised to keep his / her teeth in occlusion and lips relaxed and strict instructions were given to stabilize this posture during the procedure of recording the lip print .
a set of images were recorded and the image with minimal distortion and clear groove pattern was selected for analysis .
processing errors are the errors expected to occur in indirect or scanned digital method as described above .
the data loss that occurs due to the averaged pixel value in an analog to digital conversion leads to decreased contrast between the creases ( white areas ) and the ridges ( dark areas ) and thus may lead to a decreased contrast or an image with minimal recordable grooves .
no two lip prints were found to have similar characteristics which was in agreement with the previous studies reported .
the combination of the six types of grooves is , theoretically , 6 x 4 , and if they are entered in the dental formula the advisable method is to select the first groove from the median line , and then , focusing on the chief construction of the second group of grooves , to compare the peculiarities and the details with the control . to determine the uniqueness , the current study adopted a scoring method wherein weighted value in descending order from 15 to 1 was given for the lip lines starting from the midline to the periphery .
total lip score for each quadrant i.e. quadrant i , ii , iii , and iv was then calculated along with the score of the individual lips i.e. quadrant i + ii , quadrant iii + iv and the total score of the lip i.e. quadrant i + ii + iii + iv .
it was found that the total lip score i.e. quadrant i + ii + iii + iv was unique for individual lips except for a70 and a74 having the score of 2352 and a77 and a80 sharing the same score of 2118 .
although the total lip score in above cases was matching , they differed in the individual quadrant score viz .
scores of a-70 in quadrant i - 618 , quadrant ii 642 , quadrant i + ii 1260 , quadrant iii 542 , quadrant iv 550 and in quadrant iii + iv 1092 whereas scores of a74 in quadrant i - 702 , quadrant ii 450 , quadrant i + ii 1152 ,
quadrant iii 627 , quadrant iv 573 and in quadrant iii + iv 1200 .
scores of a -77 in quadrant i - 435 , quadrant ii 522 , quadrant i + ii 957 , quadrant iii 684 , quadrant iv 477 and in quadrant iii + iv 1161 whereas scores of a80 in quadrant i - 714 , quadrant ii 645 , quadrant i + ii 1359 ,
quadrant iii 375 , quadrant iv 384 and in quadrant iii + iv 759 .
there were a number of cases where the lip score in a particular quadrant was the same but their lip scores in other quadrants differed and consequently so did their total lip score [ table 2 and table 3 ] .
it was observed that no two lip prints had exactly matching scores in all four quadrants .
the scores were differing either in the individual quadrants i.e. i , ii , iii or iv or in the sum of the two quadrants i + ii or iii + iv or in total lip score i.e. quadrant i + ii + iii + iv .
our method appears to settle once and for all the question of uniqueness of the lip print as it employs whole numbers and thereby is an open - ended method since the last whole number is yet to be written , whole numbers being infinite. thus each individual is assured with his or her own lip identity card number ! injuries to the skin , such as cuts , burns and abrasions , may affect the alignment of ridges and may even result in the destruction of some .
superficial injuries cause only temporary damage ; on healing , the patterns and details of the ridges appear as before .
when , however , the skin is injured causing destruction of the dermal papillae , scars are formed which result in permanent distortion of the ridges . however , the author has not come across any such detailed studies being done on the lips .
histologically the lip can be divided into three parts , outer skin of the lip that consists of keratinized stratified squamous epithelium in which hair follicles , sweat glands and sebaceous glands can be seen , the vermilion border or the red margin of the lip which is very thin keratinized epithelium with no hair follicles or sweat glands and the submucosa of the lip , composed of dense connective tissue containing blood vessels , nerves and mixed seromucous glands .
being an intermediate zone , the lip is composed of the histologic features of the skin as well as the oral mucosa .
healing response depends upon the depth of the wounds even in the case of lips .
but whether the destruction of the dermal papillae leads to scar formation in lips like in the case of skin can not be said with certainty .
also , the depth of injuries leading to scar formation in lips is yet to be investigated .
tsuchihashiy studied lip prints by recording them routinely once a month for three years for comparative study .
the author also studied the samples of the lip prints of the same individual taken at six - monthly intervals .
he has illustrated the serial observations made on the lip print every day ( except sundays and holidays ) for nine weeks which revealed no changes .
parekh b. k. confirmed that the labial wrinkles and grooves of each individual were identical with the ones taken four months earlier . to determine the stability of the lip prints , the current study collected
the lip prints 12 months ( part b ) after the initial collection ( part a ) .
an interval of 12 months was kept to check the effect of any seasonal variation or healing response of the lips to inflammation on the groove pattern if present .
none of the subjects gave history of any deep injuries to the lips , but there was history of cracking or chapping of the lips in the winter .
lip print images of all the subjects were collected after 12 months in a similar manner as in part a. nine subjects dropped out of the study , hence their lip prints could not be recorded .
the author has considered equal number of lines for comparison of part a and part b of the study . using wilcoxon sign rank test , each line in part a
was compared to that of part b for determining any statistically significant changes in the groove pattern that had occurred after 12 months .
the statistical results of comparison showed no significant changes in the first 15 lines in all four quadrants in a study repeated after one year .
further studies are required to be carried out on a larger population to evaluate the uniqueness using the digital method for analyzing the lip prints .
studies in the field of healing pattern and the effect of deep injuries over the groove pattern on the lips are recommended .
the lip crease pattern is on the vermilion border of the lip , which is quite mobile and lip prints may vary in appearance according to the pressure , direction and method used in making the print . if lipstick is used as a recording medium the amount applied may also affect the print .
hence a good method is required for the collection of the lip prints with suitable transferring and recording media .
the authors tried using cellophane tape , paper roller , dabbing of the lips against the paper and scotch tape for recording the lip prints . conventional powder method and photography
the lip prints are on the zone of transition of the lips which are extremely mobile .
smudging of the prints due to excessive or uneven pressure was noticed in subjects with prominent upper and/or lower lip when cellophane tape or paper roller was used to collect upper and lower lip print together . when the subject is asked to press his or her lips against the folded paper ,
there is a possibility of only the central area coming in contact with the paper and in doing so the rest or the relaxed position of the lips is not achieved which invariably leads to distortion of the prints . in conventional powder methods
photographing of the lips was found to be very tricky and subject to errors as the central area of the lips and the angles of the lips are never in the same plane which leads to focusing errors resulting in blurred or partial images of the lips .
this invariably calls for recording the lip prints and then photographing them and then comparing the two photographs .
thus in spite of being a reliable method in other areas of forensics , in the recording of lip print images it adds to the cost but does not enhance the clarity in the same rising proportions . since recording of the lip print becomes the fundamental exercise , the method adopted in the present study could be advantageous .
smaller width of the tape helps in its application along the curvature of the lip without any interference of the opposing lip ( if properly retracted ) and nose .
upper and lower lip print images can be recorded separately with minimal distortion in subjects having either one or both , upper - lower prominent lips or excess curvature of the lips .
the classification that was followed in the present study was suzuki and tsuchihashi 's classification which is generally followed by most of the authors because of its accuracy and simplicity .
strict criteria were followed while considering all the types of patterns to avoid intra - observer bias .
the authors would like to suggest some modifications with respect to the classification to make it more precise and accurate and standardize the readings of the various studies conducted by other workers in the country and elsewhere .
this will help us in comparison of the various parameters in a greater sample size by following a standard classification .
the following modifications are suggested , especially for type i , type ii and type v pattern . according to suzuki and
tsuchihashi 's classification type i is a straight groove that disappears halfway into the lip instead of covering the entire breadth of the lip .
this pattern can be further classified into : type ia - a straight groove appearing from the outer margin of the lip to the inner aspect and type ib - a straight groove appearing from the inner margin of the lip to the outer aspect .
type ii is grooves that fork or bifurcate in their course or a branched groove .
this pattern can be further classified into : type ii a grooves that bifurcate in the outward direction and type ii b grooves that bifurcate in the inward direction .
type v grooves that do not fall into any of the above categories and can not be differentiated morphologically . instead of just giving a generalized term as type v pattern , it is found necessary to sub - classify the type v pattern wherever possible , so as to give a more defined term that will further add to the accuracy of the classification .
various studies have used magnifying lens to record lip prints . the current study has adopted an indirect digital method by scanning the lip print images in adobe photoshop 7 with 256 gray scale , 300 dpi resolution for better visualization of the image and recording each type of the groove patterns with assigned color code as mentioned thus ensuring the recording of each line without missing a single one and also eliminating an error of recording the same groove twice which is most likely to occur with manual recording . the digital method adopted in the present study
has various advantages due to its features like zooming , enhancement , layers and drawing tool .
adobe photoshop is a popular software program , which allows for a multitude of imaging features , functions , enhancements and metric analysis .
the only limitation is the very high resolution of the image ( 300 dpi ) required to avoid pixellation ( fuzziness ) of the magnified picture .
regardless of the method by which an image is captured , once it has been digitized , several computerized enhancements can be performed on the image .
this gives us the chance to salvage an image that is either too dark or too light .
an image in which all of the pixels have been saturated ( too dark ) or where the noise ( useless information ) in the system overwhelms the signal ( useful information ) , can not be saved .
image contrast can also be manipulated by altering the gradient of the gray levels in the image .
manipulating the image contrast can not salvage an image in which the subject contrast is inadequate . with layers , we can work on one element without disturbing others . to rearrange elements , simply shift the order in the layers palette .
we can lock layers to prevent accidental changes , hide them to get a clear view of the element we are working on , and link layers to move them as a group .
the layers palette also makes it easy to apply instant , editable effects including blending modes , adjustment layers , and layer effects .
resolution - independent vector shapes can be drawn instantly with the line , rectangle , ellipse , polygon , and custom shape tools .
direct digital imaging indicates that the original image is captured in a digital format , i.e. , the image is made up of discrete packets of information called pixels ( picture elements ) . on the other hand
, indirect digital imaging implies that the image is captured in an analog or continuous format and then converted into a digital format . as with any data conversion , this analog to digital conversion ( adc ) results in the loss and alteration of information . instead of capturing the border that traverses a particular pixel ,
sivapathasundharam b. and prakash p. a. have taken the middle part of the lower lip , ( 10-mm wide ) as a study area , since this fragment is almost always visible in any trace .
the current study has made an attempt to record each and every line of the entire lip starting from the midline to the periphery . in some subjects ,
the lip lines were very clear and were easily identified but in some lips only a few lines could be recorded and in others , the lines were not identifiable because of the poor quality of the image .
the number of the lines recorded quadrant - wise is shown in detail in table 4 . with
the help of digital analysis , up to 15 lines were traceable in 66% of quadrant i , 71% of quadrant ii , 52% of quadrant iii and 51% of quadrant iv images .
the reason for some of the images showing very few or non - recordable lines can be attributed to the inherent anatomy of the lips , technical error and processing error .
thin lips , recessive lips , inverted lips , excessive prominence either in the center or lateral portion of the lips , excessive curvature of the lips , fine groove pattern on the lips , all these factors can affect the quality of the lip print image .
the anatomy of the lips varies from person to person . they may be full or thin , wide or narrow , short or long , generally in response to genetic data and the form of the teeth .
the inclination of the teeth may cause the lips to be excessively prominent or recessive . in the edentulous person the lips recede , increasing the prominence of the nose and chin , since the inter - arch distance may be reduced and the nose and chin tend to approximate each other . with thin , recessive and inverted lips
excessive prominence in any part of the lips or excessive curvature of the lips leads to pressure areas resulting in distortion of the image .
in such cases a compromise has to be made over the lateral areas so as to clearly record the central area with minimal pressure . with fine groove pattern on the lips
, there is all possibility of excess lipstick getting smudged in the grooves resulting in a distorted image .
number of lines recorded in quadrant i , ii , iii and iv excessive application of the lipstick leads to smudging of lipstick in the grooves and thus unclear groove pattern .
lips being highly mobile , minimal variation in the pressure application while recording the lip print using scotch tape or any other method can lead to distortion of the image .
variation in the posture of the lip i.e. contraction or stretching of the lips during the procedure of recording can either lead to overlapping of the grooves or clear area without any groove pattern , thus causing distortion of the image .
mobility of the lips is nature 's creation , and an error caused because of this nature of the lips could not be avoided .
but an effort was made to minimize the technical error and to standardize the technique of recording the lip prints .
for uniform application of the lipstick , a lipstick application brush was used with vertical strokes of the brush starting from the outer to the inner aspect of the lip .
care was taken to evenly apply the pressure while recording the lip prints with scotch tape . for standardizing the posture of the lips while recording
, the subject was advised to keep his / her teeth in occlusion and lips relaxed and strict instructions were given to stabilize this posture during the procedure of recording the lip print .
a set of images were recorded and the image with minimal distortion and clear groove pattern was selected for analysis .
processing errors are the errors expected to occur in indirect or scanned digital method as described above .
the data loss that occurs due to the averaged pixel value in an analog to digital conversion leads to decreased contrast between the creases ( white areas ) and the ridges ( dark areas ) and thus may lead to a decreased contrast or an image with minimal recordable grooves .
no two lip prints were found to have similar characteristics which was in agreement with the previous studies reported .
the combination of the six types of grooves is , theoretically , 6 x 4 , and if they are entered in the dental formula the advisable method is to select the first groove from the median line , and then , focusing on the chief construction of the second group of grooves , to compare the peculiarities and the details with the control . to determine the uniqueness , the current study adopted a scoring method wherein weighted value in descending order from 15 to 1 was given for the lip lines starting from the midline to the periphery .
total lip score for each quadrant i.e. quadrant i , ii , iii , and iv was then calculated along with the score of the individual lips i.e. quadrant i + ii , quadrant iii + iv and the total score of the lip i.e. quadrant i + ii + iii + iv .
it was found that the total lip score i.e. quadrant i + ii + iii + iv was unique for individual lips except for a70 and a74 having the score of 2352 and a77 and a80 sharing the same score of 2118 .
although the total lip score in above cases was matching , they differed in the individual quadrant score viz .
scores of a-70 in quadrant i - 618 , quadrant ii 642 , quadrant i + ii 1260 , quadrant iii 542 , quadrant iv 550 and in quadrant iii + iv 1092 whereas scores of a74 in quadrant
i - 702 , quadrant ii 450 , quadrant i + ii 1152 , quadrant iii 627 , quadrant iv 573 and in quadrant iii + iv 1200
. scores of a -77 in quadrant i - 435 , quadrant ii 522 , quadrant i + ii 957 , quadrant iii 684 , quadrant iv 477 and in quadrant iii + iv 1161 whereas scores of a80 in quadrant i - 714 , quadrant ii 645 , quadrant i + ii 1359 ,
quadrant iii 375 , quadrant iv 384 and in quadrant iii + iv 759 .
there were a number of cases where the lip score in a particular quadrant was the same but their lip scores in other quadrants differed and consequently so did their total lip score [ table 2 and table 3 ] . it was observed that no two lip prints had exactly matching scores in all four quadrants .
the scores were differing either in the individual quadrants i.e. i , ii , iii or iv or in the sum of the two quadrants i + ii or iii + iv or in total lip score i.e. quadrant i + ii + iii + iv .
our method appears to settle once and for all the question of uniqueness of the lip print as it employs whole numbers and thereby is an open - ended method since the last whole number is yet to be written , whole numbers being infinite. thus each individual is assured with his or her own lip identity card number !
injuries to the skin , such as cuts , burns and abrasions , may affect the alignment of ridges and may even result in the destruction of some .
superficial injuries cause only temporary damage ; on healing , the patterns and details of the ridges appear as before .
when , however , the skin is injured causing destruction of the dermal papillae , scars are formed which result in permanent distortion of the ridges . however , the author has not come across any such detailed studies being done on the lips .
histologically the lip can be divided into three parts , outer skin of the lip that consists of keratinized stratified squamous epithelium in which hair follicles , sweat glands and sebaceous glands can be seen , the vermilion border or the red margin of the lip which is very thin keratinized epithelium with no hair follicles or sweat glands and the submucosa of the lip , composed of dense connective tissue containing blood vessels , nerves and mixed seromucous glands .
being an intermediate zone , the lip is composed of the histologic features of the skin as well as the oral mucosa .
healing response depends upon the depth of the wounds even in the case of lips .
but whether the destruction of the dermal papillae leads to scar formation in lips like in the case of skin can not be said with certainty .
also , the depth of injuries leading to scar formation in lips is yet to be investigated .
tsuchihashiy studied lip prints by recording them routinely once a month for three years for comparative study .
the author also studied the samples of the lip prints of the same individual taken at six - monthly intervals .
he has illustrated the serial observations made on the lip print every day ( except sundays and holidays ) for nine weeks which revealed no changes .
parekh b. k. confirmed that the labial wrinkles and grooves of each individual were identical with the ones taken four months earlier . to determine the stability of the lip prints , the current study collected
the lip prints 12 months ( part b ) after the initial collection ( part a ) .
an interval of 12 months was kept to check the effect of any seasonal variation or healing response of the lips to inflammation on the groove pattern if present .
none of the subjects gave history of any deep injuries to the lips , but there was history of cracking or chapping of the lips in the winter .
lip print images of all the subjects were collected after 12 months in a similar manner as in part a. nine subjects dropped out of the study , hence their lip prints could not be recorded .
the author has considered equal number of lines for comparison of part a and part b of the study .
using wilcoxon sign rank test , each line in part a was compared to that of part b for determining any statistically significant changes in the groove pattern that had occurred after 12 months .
the statistical results of comparison showed no significant changes in the first 15 lines in all four quadrants in a study repeated after one year .
further studies are required to be carried out on a larger population to evaluate the uniqueness using the digital method for analyzing the lip prints .
studies in the field of healing pattern and the effect of deep injuries over the groove pattern on the lips are recommended .
the following conclusions can be drawn from the observations of the current study : lip prints are unique to the individual which can be explained on the basis that no two individuals in the studied group had an exactly matching lip score in all four quadrants .
no statistically significant difference was found in the change of pattern in lip print images collected after 12 months from the same individual , even after exposure of the lips to the seasonal variations and minor or superficial trauma .
thus from the above statements , it can be concluded that lip prints can be used as an evidence or a positive means of person identification just like fingerprints .
the technique followed for collection of the lip prints using lipstick as recording media and scotch tape as transferring media with proper stabilization of the lips while recording can be adopted as a good technique to obtain a definable lip print image .
the digital method of analyzing the lip print images using adobe photoshop 7 software serves as a convenient method that provides better visualization and ease in recording and identification of the lip print pattern .
it also serves as an ideal method of permanently storing the data which will help in keeping an ante- mortem record of an individual .
weighted value scoring system used for the first time to calculate the lip score ( quadrant - wise , lip - wise , and the total score ) , appears to settle once and for all the question of the uniqueness of the lip print as it employs whole numbers and thereby is an open - ended method since the last whole number is yet to be written , whole numbers being infinite. | aim : to evaluate the uniqueness and to define a standard method for the analysis of lip prints.materials and methods : lip prints of 100 students were taken using scotch tape without any distortion .
these prints were then scanned for the digital analysis . using adobe photoshop 7 software
an attempt was made to trace each and every line using suzuki and tsuchihashi 's classification .
weighted value scoring system was used to check for the uniqueness of the lip prints.results:no two lip prints had exactly matching scores in all four quadrants .
no statistically significant difference was found in the change of pattern in lip print images collected after 12 months from the same individual . with digital analysis ,
up to 15 lines were traceable in 66% , 71% , 52% and 51% of quadrant
i , ii , iii and iv respectively.conclusion:lip prints are unique to an individual .
the digital method of analyzing lip print images serves better visualization , ease in identification and recording of the lip print pattern .
weighted value scoring system can be considered as a standard method for determining the uniqueness of the lip prints . |
intraventricular hemorrhage ( ivh ) is a significant cause of preterm morbidity and mortality , with approximately 12,000 infants developing ivh every year in the united states . within the population of very low birth weight ( vlbw ; < 1500 g ) infants , the incidence of ivh has been estimated at 20% .
however , the incidence of ivh among vlbw infants has declined in the past few decades , from 40 - 50% in the early 1980s to approximately 20% in the late 1980s , then remaining relatively stable for the past two decades .
ivh occurs in nearly half of infants born at extremely low birth weight ( 500 - 750 g ) .
infants who survive a severe ivh ( grade iii or iv ) may be at higher risk of significant long - term or permanent neurological injuries / deficits , including cerebral palsy , mental retardation , and post - hemorrhagic hydrocephalus .
previous studies have shown that treatment of pregnant women with steroids prior to delivery is associated with a reduced risk of adverse health outcomes , including ivh
. liggins et al . , conducting the first randomized controlled trial of antenatal betamethasone , showed downward mortality and lower risks of rds in infants of treated mothers compared to controls and the need for respiratory support . in that study , four of the infants of control mothers had ivh , compared to none of the infants of steroid - treated mothers .
although this difference was not statistically significant , this finding raised the possibility that antenatal steroid use might reduce the incidence of ivh . a cochrane review in 2006 consisting of a meta - analysis of randomized trials demonstrated a reduced risk of ivh ( relative risk 0.54 , 95% confidence interval 0.43 to 0.69 ) when treatment with antenatal steroids occurred . as most of the trials included occurred in the 1990 s or early 2000 s when ivh rates were higher , we were interested to see if this positive impact of antenatal steroids would still be present .
furthermore , quality improvement efforts to increase antenatal steroid use , as well as other independent efforts to reduce ivh may have weakened this beneficial link . in the present study
, we aimed to determine the magnitude of the effect of antenatal steroid treatment in the prevention of intraventricular hemorrhage in a modern population - based cohort , and to assess whether there is a difference in effect according to gestational age .
any hospital in california that provides neonatal intensive care is eligible for membership in the california perinatal quality care collaborative ( cpqcc ) .
currently , 132 hospitals are members of the cpqcc , including 100% of all california department of public health children s services ( ccs)-approved intermediate , community , and regional - level nicus in california .
member hospitals submit data on newborn infants who require critical care to the cpqcc data center .
infants in the cpqcc database represent over 90% of vlbw infants treated in california nicus . during the seven - year study period january 1 , 2007 - december 31 , 2013 , 42,904 vlbw births qualified for entry into the cpqcc database , i.e. , a birth weight between 401 - 1500 grams or a gestational age between 22 - 32 weeks . of these
we limited our study cohort to infants who were vlbw who had a gestational age 32 weeks , as this population of neonates is most at risk for ivh .
we limited our analyses to inborn infants as attributing the influence of more than one nicu s care on ivh would not be possible , particularly in the time period immediately surrounding delivery .
infants with missing data on ivh ( n = 5,102 ) or antenatal steroids ( n = 228 ) were excluded .
infants who died prior to having brain imaging performed would be considered as having missing data on ivh .
intraventricular hemorrhage : cpqcc members are instructed to classify intraventricular hemorrhage by neural imaging ( cranial ultrasound , ct scan , or mri ) according to the criteria of papile et al . with the most severe grade of hemorrhage recorded .
the outcome of ivh was recorded as ( 0 ) no ivh , ( 1 ) grade 1 ivh subependymal germinal matrix hemorrhage only ( 2 ) grade 2 ivh
intraventricular blood with ventricular dilation , and ( 4 ) grade 4 ivh intraparenchymal hemorrhage . for this analysis
grades 3 and 4 were combined and defined as an infant having severe ivh and grades 1 to 4 were combined into a category of having any ivh .
yes / no with any maternal receipt of betamethasone , dexamethasone , and hydrocortisone during pregnancy at any time point prior to delivery counting as yes .
other independent variables : birth weight , gestational age , small for gestational age , maternal age , race / ethnicity , prenatal care ( any prenatal care visit vs none ) , multiple gestation , five - minute apgar score , delivery mode , congenital malformations , and hospital level of neonatal care . hospital level of neonatal care was designated by the california children s services ( ccs ) for nicus according to their ability to provide varying levels of care .
community nicus can provide unlimited ventilation , but in general , not major neonatal surgery .
hospitals with licensed nicu beds that do not choose to participate in the ccs program do not receive a ccs level designation and are classified as non - ccs hospitals .
hispanic ethnicity with unknown , missing , or other race was considered to be hispanic race / ethnicity .
infants below the 10th percentile of weight for their gestational age were classified as being small for gestational age while those above the 10th percentile were classified as normal for gestational age .
the outcomes of ivh were compared according to demographic and medical factors noted above . because grades 3 and 4 are more commonly associated with adverse long - term neurological consequences , we examined two main outcomes : 1 ) severe ivh vs. lower grades of ivh / no ivh , and 2 ) any grade of ivh vs. no ivh ( 13 ) .
we conducted univariate analyses to compare infants exposed to antenatal steroids to infants not exposed to antenatal steroids and to compare infants who developed any or severe ivh to infants who did not develop any or severe ivh .
we conducted a similar comparison for the outcome of in - hospital mortality , as death may be a competing outcome for severe ivh . to test for differences amongst groups
, we used the independent t - test for continuous variables and the pearson chi - square test for categorical variables .
tests were two - sided . a p - value of < 0.05 was considered statistically significant .
multivariable logistic regression was used to estimate the odds ratio with 95% confidence intervals as a measure of association between antenatal steroid use and intraventricular hemorrhage in vlbw infants .
we included relevant covariates in our multivariable model to control for the potential confounding effects of maternal sociodemographic factors , obstetric factors , and comorbid conditions .
these covariates were chosen a priori based on a review of the existing literature and included all of the variables listed above in the measures section .
although birth weight and gestational age of the infant are highly correlated with each other ( r = 0.77 ) , we employed both variables as covariates in our statistical models .
we performed likelihood ratio tests to compare the fit of models that included only birth weight as a covariate to the fit of models that included both birth weight and gestational age as covariates .
we found a statistically significant difference between the log likelihoods of the two models , indicating the models with both birth weight and gestational age included as covariates fit the data significantly better .
we tested the goodness - of - fit of our final models with the hosmer - lemeshow test , which indicated that the final model fit the data optimally .
we did not include gestational age as a covariate in the analyses in which we stratified the cohort by gestational age .
we stratified infants by one week gestational age intervals , ranging from 22 weeks to 32 weeks .
there were six infants under 22 weeks gestational age that were included with 22 weeks and combined to form one gestational age group .
all data management and analysis was performed using sas 9.4 for windows ( cary , nc ) .
institutional review board approval was obtained from the stanford school of medicine and the university of california , berkeley .
any hospital in california that provides neonatal intensive care is eligible for membership in the california perinatal quality care collaborative ( cpqcc ) .
currently , 132 hospitals are members of the cpqcc , including 100% of all california department of public health children s services ( ccs)-approved intermediate , community , and regional - level nicus in california .
member hospitals submit data on newborn infants who require critical care to the cpqcc data center .
infants in the cpqcc database represent over 90% of vlbw infants treated in california nicus . during the seven - year study period january 1 , 2007 - december 31 , 2013 , 42,904 vlbw births qualified for entry into the cpqcc database , i.e. , a birth weight between 401 - 1500 grams or a gestational age between 22 - 32 weeks . of these
we limited our study cohort to infants who were vlbw who had a gestational age 32 weeks , as this population of neonates is most at risk for ivh .
we limited our analyses to inborn infants as attributing the influence of more than one nicu s care on ivh would not be possible , particularly in the time period immediately surrounding delivery .
infants with missing data on ivh ( n = 5,102 ) or antenatal steroids ( n = 228 ) were excluded .
infants who died prior to having brain imaging performed would be considered as having missing data on ivh .
intraventricular hemorrhage : cpqcc members are instructed to classify intraventricular hemorrhage by neural imaging ( cranial ultrasound , ct scan , or mri ) according to the criteria of papile et al . with the most severe grade of hemorrhage recorded .
the outcome of ivh was recorded as ( 0 ) no ivh , ( 1 ) grade 1 ivh subependymal germinal matrix hemorrhage only ( 2 ) grade 2 ivh
grades 3 and 4 were combined and defined as an infant having severe ivh and grades 1 to 4 were combined into a category of having any ivh .
yes / no with any maternal receipt of betamethasone , dexamethasone , and hydrocortisone during pregnancy at any time point prior to delivery counting as yes .
other independent variables : birth weight , gestational age , small for gestational age , maternal age , race / ethnicity , prenatal care ( any prenatal care visit vs none ) , multiple gestation , five - minute apgar score , delivery mode , congenital malformations , and hospital level of neonatal care . hospital level of neonatal care was designated by the california children s services ( ccs ) for nicus according to their ability to provide varying levels of care .
community nicus can provide unlimited ventilation , but in general , not major neonatal surgery .
hospitals with licensed nicu beds that do not choose to participate in the ccs program do not receive a ccs level designation and are classified as non - ccs hospitals .
hispanic ethnicity with unknown , missing , or other race was considered to be hispanic race / ethnicity .
infants below the 10th percentile of weight for their gestational age were classified as being small for gestational age while those above the 10th percentile were classified as normal for gestational age .
the outcomes of ivh were compared according to demographic and medical factors noted above . because grades 3 and 4 are more commonly associated with adverse long - term neurological consequences , we examined two main outcomes : 1 ) severe ivh vs. lower grades of ivh / no ivh , and 2 ) any grade of ivh vs. no ivh ( 13 ) .
we conducted univariate analyses to compare infants exposed to antenatal steroids to infants not exposed to antenatal steroids and to compare infants who developed any or severe ivh to infants who did not develop any or severe ivh .
we conducted a similar comparison for the outcome of in - hospital mortality , as death may be a competing outcome for severe ivh . to test for differences amongst groups
, we used the independent t - test for continuous variables and the pearson chi - square test for categorical variables .
tests were two - sided . a p - value of < 0.05 was considered statistically significant .
multivariable logistic regression was used to estimate the odds ratio with 95% confidence intervals as a measure of association between antenatal steroid use and intraventricular hemorrhage in vlbw infants .
we included relevant covariates in our multivariable model to control for the potential confounding effects of maternal sociodemographic factors , obstetric factors , and comorbid conditions .
these covariates were chosen a priori based on a review of the existing literature and included all of the variables listed above in the measures section . although birth weight and gestational age of the infant are highly correlated with each other ( r = 0.77 ) , we employed both variables as covariates in our statistical models .
we performed likelihood ratio tests to compare the fit of models that included only birth weight as a covariate to the fit of models that included both birth weight and gestational age as covariates .
we found a statistically significant difference between the log likelihoods of the two models , indicating the models with both birth weight and gestational age included as covariates fit the data significantly better .
we tested the goodness - of - fit of our final models with the hosmer - lemeshow test , which indicated that the final model fit the data optimally .
we did not include gestational age as a covariate in the analyses in which we stratified the cohort by gestational age .
we stratified infants by one week gestational age intervals , ranging from 22 weeks to 32 weeks .
there were six infants under 22 weeks gestational age that were included with 22 weeks and combined to form one gestational age group .
all data management and analysis was performed using sas 9.4 for windows ( cary , nc ) .
institutional review board approval was obtained from the stanford school of medicine and the university of california , berkeley .
sociodemographic and obstetric characteristics of infants and mothers are presented in table 1 . of the infants in the study cohort ,
most were delivered through cesarean section ( n = 19,464 , 74.9% ) vs vaginal delivery ( n = 6,514 , 25.1% ) .
neonates were primarily cared for at regional ( n = 7,145 , 27.5% ) and community ( n = 16,651 , 64.1% ) nicus rather than intermediate ( n = 856 , 3.3% ) and non - ccs ( n = 1,327 , 5.1% ) nicus .
the mean birth weight in the cohort was 1050.6 grams , and mean gestational age 27.9 weeks .
a large majority of these infants mothers had received prenatal care ( n = 25,119 , 97.0% ) . during the study interval , 87.2% ( n = 22,645 ) of the women in the analytic cohort delivering a vlbw infant received antenatal steroids prior to delivery .
during the seven year study period , the use of antenatal steroids gradually increased each year . in 2007 , the first year of the study period , 84.6% of infants mothers received treatment with antenatal steroids . in 2013 , 89.9% of mothers received antenatal steroids .
of the vlbw infants , 23.7% ( n = 6,165 ) developed any ivh . among infants with any ivh ,
overall , the incidence of any grade of ivh decreased from 25.2% to 22.4% over the seven year study period .
not receiving antenatal steroids was associated with both any ivh and severe ivh ( table 2 ) .
infants with any ivh were more likely to have lower birthweight and younger gestational age .
no prenatal care , singleton gestation ( compared to multiple ) , vaginal delivery , low apgar score , and male sex were associated with any ivh .
similarly , lower birthweight and younger gestational age were associated with higher likelihood of severe ivh ( table 2 ) .
no prenatal care , low apgar score , and male sex were also associated with severe ivh .
the most prominent difference was the higher likelihood of grade 4 ivh in infants whose mothers did not receive antenatal steroids ( 8.9% ) compared to those who did receive steroids ( 3.6% ) .
after adjusting for maternal sociodemographic and medical risk factors in multivariable logistic regression , receiving antenatal steroids was significantly associated with no ivh ( adjusted odds ratio 0.68 , 95% confidence interval 0.62 , 0.75 ) , and with not having severe ivh ( adjusted odds ratio 0.51 , 95% confidence interval 0.45 , 0.58 ) adjusted odds ratios and 95% confidence intervals for the association between receipt of antenatal steroids and any ivh within gestational age subsets are shown in table 3 .
infants in gestational age groups encompassing 20 0/7 weeks to 29 6/7 weeks whose mothers received antenatal steroids had a significantly lower odds of developing any ivh , and groups encompassing 23 0/7 weeks to 29 6/7 weeks had lower odds of developing severe ivh . for infants above 30 weeks gestational age ,
as mortality may be a competing outcome for severe ivh , we examined mortality rates according to receipt of antenatal steroids and found that across all gestational age groups , those infants whose mothers received antenatal steroids had lower risk of in - hospital death .
sociodemographic and obstetric characteristics of infants and mothers are presented in table 1 . of the infants in the study cohort ,
most were delivered through cesarean section ( n = 19,464 , 74.9% ) vs vaginal delivery ( n = 6,514 , 25.1% ) .
neonates were primarily cared for at regional ( n = 7,145 , 27.5% ) and community ( n = 16,651 , 64.1% ) nicus rather than intermediate ( n = 856 , 3.3% ) and non - ccs ( n = 1,327 , 5.1% ) nicus .
the mean birth weight in the cohort was 1050.6 grams , and mean gestational age 27.9 weeks .
a large majority of these infants mothers had received prenatal care ( n = 25,119 , 97.0% ) .
during the study interval , 87.2% ( n = 22,645 ) of the women in the analytic cohort delivering a vlbw infant received antenatal steroids prior to delivery . during the seven year study period ,
the use of antenatal steroids gradually increased each year . in 2007 , the first year of the study period , 84.6% of infants mothers received treatment with antenatal steroids . in 2013 , 89.9% of mothers received antenatal steroids .
of the vlbw infants , 23.7% ( n = 6,165 ) developed any ivh . among infants with any ivh
overall , the incidence of any grade of ivh decreased from 25.2% to 22.4% over the seven year study period .
not receiving antenatal steroids was associated with both any ivh and severe ivh ( table 2 ) . infants with any ivh were more likely to have lower birthweight and younger gestational age .
no prenatal care , singleton gestation ( compared to multiple ) , vaginal delivery , low apgar score , and male sex were associated with any ivh .
similarly , lower birthweight and younger gestational age were associated with higher likelihood of severe ivh ( table 2 ) .
no prenatal care , low apgar score , and male sex were also associated with severe ivh .
the most prominent difference was the higher likelihood of grade 4 ivh in infants whose mothers did not receive antenatal steroids ( 8.9% ) compared to those who did receive steroids ( 3.6% ) .
after adjusting for maternal sociodemographic and medical risk factors in multivariable logistic regression , receiving antenatal steroids was significantly associated with no ivh ( adjusted odds ratio 0.68 , 95% confidence interval 0.62 , 0.75 ) , and with not having severe ivh ( adjusted odds ratio 0.51 , 95% confidence interval 0.45 , 0.58 )
adjusted odds ratios and 95% confidence intervals for the association between receipt of antenatal steroids and any ivh within gestational age subsets are shown in table 3 . infants in gestational age groups encompassing 20 0/7 weeks to 29 6/7 weeks whose mothers received antenatal steroids had a significantly lower odds of developing any ivh , and groups encompassing 23 0/7 weeks to 29 6/7 weeks had lower odds of developing severe ivh . for infants above 30 weeks gestational age ,
as mortality may be a competing outcome for severe ivh , we examined mortality rates according to receipt of antenatal steroids and found that across all gestational age groups , those infants whose mothers received antenatal steroids had lower risk of in - hospital death .
this large population - based study affirms current scientific knowledge showing a significant relationship between receipt of antenatal steroids and decreased risk of ivh .
both in crude assessment and risk adjusted analyses , infants exposed to antenatal steroids were less likely to develop any ivh or severe ivh . adding to prior knowledge however , we found that the association between ans use and ivh is limited to gestational age groups from 22 to 30 weeks .
prior studies have shown that exposure to antenatal steroids was associated with a decrease in the risk of ivh in neonates born between 29 - 34 weeks gestational age when examined as an overall combined cohort . while our stratified analysis showed no significant differences in infants > 30 weeks gestational age , this is likely in part due to the overall lower risk of ivh in this group , which has continued to decrease over time .
shankaran et al . reported an unadjusted odds ratio of 0.39 ( 95% ci : 0.27 , 0.57 ) for the association of a complete course of steroids with the development of grades 3 and 4 ivh in a large cohort of singleton vlbw infants ( i.e. birthweight 501 - 1500 g ) .
wright et al . examined the association between partial , complete , and any course of antenatal steroids and the outcomes of any or severe ivh in 9,949 vlbw infants in 14 nicus with diverse populations and management strategies .
receipt of complete or any antenatal steroid treatment was found to be associated with a statistically significant reduction in the risk of ivh ( any ivh or severe ivh ) . a meta - analysis of placebo - controlled randomized trials by crowley et al .
found that steroid therapy reduces the odds of periventricular hemorrhage , with an odds ratio of 0.38 ( 95% ci : 0.23 , 0.94 ) .
the evidence from these studies led the nih consensus development panel to publish a statement that antenatal steroids reduce mortality and the incidence of ivh in infants born at 29 - 34 weeks of gestation and recommended that mothers at risk for preterm delivery between 24 - 34 weeks gestation be candidates for treatment .
previous data concerning the association between use of antenatal steroids and the incidence of ivh in infants delivered at < 29 weeks gestational age had been conflicting . a systematic review of 21 studies by roberts et al .
reported that antenatal steroids reduce the incidence of ivh in infants born before 28 weeks .
in contrast , a systematic review of nine randomized trials by onland et al . concluded that there was no evidence to support or refute recommending treatment with antenatal steroids to women at risk of preterm birth at < 26 weeks of gestation . since these reviews were published , mori et al .
found that exposure to antenatal steroids was associated with a significant decrease in the risk of ivh and severe ivh incidence in infants born between 24 - 29 weeks of gestational age .
similarly , a retrospective cohort study in australia by wong et al . found a significantly lower incidence of severe ivh in infants of 24 - 28 weeks of gestational age who received a complete course of antenatal steroids .
studies on this question in infants born at 24 weeks of gestational age are scarce . in a study of 117 neonates , abbasi et al . reported that mothers of infants < 24 weeks of gestational age given antenatal steroids had a significantly lower incidence of grade 3 and 4 ivh ( 16.7% versus 36% , p < 0.05 , relative risk = 0.46 ) . however , hayes et al . found that in neonates born at 23 weeks gestation , the occurrence of severe ivh in infants exposed to antenatal steroids was not significantly different compared to the occurrence of ivh in infants not exposed to antenatal steroids ( 23.1% compared with
the odds ratio for the association between antenatal steroids and the outcomes of ivh and severe ivh found by mori et al . in infants
22 - 23 weeks gestational age was also found to be not significant . due to our large sample size
, we were able to detect significant differences even at these youngest gestational age groups .
our study is limited in its observational nature , and therefore causal inference can not be assumed .
although we attempted to account for confounding factors , there may be potential confounding from unobserved variables .
a limitation of our study was lack of detailed information in our dataset on antenatal steroids , including full , partial , or repeated courses , and dosage or timing .
another limitation of our study was a lack of imaging data on 5,102 vlbw infants that were excluded from our analyses due to missing information on whether or not the infant developed ivh .
some infants may have not received a head ultrasound because they were very healthy and were not assessed to have risk .
others may not have had a head ultrasound due to very severe clinical status and subsequent death prior to ability to receive an ultrasound .
however , in either case , we would not expect antenatal steroids to cause bias in either direction .
characteristics of infants with missing data on antenatal steroids or ivh status are presented in table s2 .
these patients tended to have lower birth weight and gestational age , and more likely to have been delivered vaginally .
our study goes further to demonstrate an association between antenatal steroids and decreased ivh in infants of gestational age ranging from 22 - 29 weeks .
currently the nih recommends mothers at risk of preterm birth at 24 - 34 weeks gestational age be treated with antenatal steroids .
our analysis suggest that antenatal steroids could be beneficial in reduction of ivh incidence in infants < 24 weeks gestational age , and mothers at risk for preterm birth at 22 or 23 weeks gestational age may also be good candidates for treatment with antenatal steroids .
| objectiveto determine the association between antenatal steroids administration and intraventricular hemorrhage rates.methodswe used cross - sectional data from the california perinatal quality care collaborative during 2007 - 2013 for infants 32 weeks gestational age . using multivariable logistic regression
, we evaluated the effect of antenatal steroids on intraventricular hemorrhage , stratified by gestational age.resultsin 25,979 very low birth weight infants , antenatal steroid use was associated with a reduction in incidence of any grade of intraventricular hemorrhage ( odds ratio = 0.51 , 95% confidence interval : 0.45 , 0.58 ) and a reduction in incidence of severe intraventricular hemorrhage ( odds ratio = 0.62 , 95% confidence interval : 0.57 , 0.67 ) .
this association was seen across gestational ages ranging from 22 to 29 weeks.conclusionswhile current guidelines recommend coverage for preterm birth at 24 to 34 weeks gestation , our results suggest that treatment with antenatal steroids may be beneficial even before 24 weeks of gestational age . |
patients presenting with recent onset of low back pain and dermatomal sensory loss are often evaluated for common entities including disc herniation , degenerative lateral recess stenosis , nerve sheath tumor , and meningioma .
described herein is a patient presenting with such symptoms who was found to have an extradural soft tissue chondroma in the lumbar spine , which was successfully treated with surgical excision . when found in an intraosseous location ,
if associated with the cortical surface , they are termed periosteal chondromas , and when located at a site distant from the bone , they are referred to as soft tissue chondromas .
true soft tissue chondromas are uncommon , and the identification of this tumor within the spinal canal represents an extreme rarity .
a 46-year - old female presented with a 3-week history of lower back pain with decreased sensation and paresthesias of the left lower extremity .
plain x - ray films of the lumbar spine were noted to be unremarkable with no boney erosion or reactive bone growth visualized [ figure 1 ] .
the magnetic resonance imaging of the lumbar spine with and without contrast demonstrated an extradural soft tissue mass within the spinal canal at the l3 level with extension into the left l3/4 neural foramen [ figure 2 ] .
( a ) anteroposterior and ( b ) lateral x - ray films of the lumbar spine with attention to the l3/4 intervertebral space show no signs of boney erosion or reactive bone growth to suggest invasive tumor axial noncontrast t1 ( a ) and postgadolinium t1 with fat saturation ( b ) magnetic resonance imaging of the lumbar spine show a homogeneously enhancing soft tissue mass within the left l3 lateral recess extending into l3/4 neural foramen the patient initially refused surgery and noted moderate improvement of symptoms following administration of dexamethasone .
as symptoms did not completely resolve , she agreed to proceed with an l3 laminectomy with wide left l3/4 foraminotomy for excision of the lesion .
intraoperative electromyography was utilized for the monitoring of motor potentials during tumor removal . during the operation ,
the thecal sac was noted to have a normal appearance , with moderate amounts of abnormal grey tissue , found both ventrally and dorsally to the ligamentum flavum . at the site of the nerve root axilla ,
excess soft tissue was encountered which was firm in consistency and noted to be compressing the nerve .
while the tissue was resected clear of the dura , transient self - resolving irritation was noted on electromyogram .
postoperatively the patient did well and had exhibited complete resolution of symptoms at 5-month follow - up .
pathologic examination revealed benign cartilaginous tissue organized in a lobulated pattern of loose clusters of chondrocytes surrounded by abundant chondroid stroma .
findings suggestive of aggressive chondrosarcoma such as mitotic figures , double - nucleated chondrocytes , and a significant spindle cell component were notably absent [ figure 3 ] .
hematoxylin and eosin stain at 10 magnification ( a ) shows benign cartilaginous tissue organized in a lobulated pattern . at 40 magnification ( b ) chondrocytes surrounded by abundant chondroid stroma without mitosis
it is rare for these tumors to arise in an extradural location but when such tumors have been encountered they are frequently located within the cranium .
these cranial chondromas typically represent the periosteal variant which is common at the spheno - petrosal , spheno - occipital , or petro - occipital synchondroses .
the soft tissue variant of chondroma such as described above is rare and is thought to arise from cartilaginous cell rests of mesenchymal origin that are thought to be displaced during development .
these ectopic masses are typically asymptomatic and often noted as incidental findings on radiographic evaluation .
this variant of chondroma is a rarity at any location particularly along the central nervous system and exceptionally rare in the lumbar spine .
cho et al . described a case of lumbar extradural chondroma in a patient with ipsilateral lower extremity paresthesias . in their report , cho et al .
cetinkal et al . have reported a single case of extradural chondroma at the l2 level .
this patient presented with femoral numbness and l2 hypesthesia and was treated with complete excision through a partial hemilaminectomy .
it is of note that in this rare case , the intradural compartment was explored , and no gross infiltration of tumor was observed .
recently , ogata et al . described a periosteal chondroma in the lumbar region presenting with lower extremity weakness and radiculopathy .
these periosteal chondromas are distinct in their origination from within the periosteal tissue plane and are frequently nestled partly within the underlying cortical bone .
it is of note that the present case was characterized by localization outside of the periosteal tissues and contained partially by the epidural fat pad .
while the majority of chondromas of the lumbar spine are likely to remain asymptomatic or present merely as a palpable paravertebral mass , many may mimic disc herniation or nerve sheath tumors . for this patient ,
our differential diagnosis upon presentation included nerve sheath tumor , meningioma , or possibly lymphoma . while the majority of vertebral chondromas represent benign tumors , long - term follow - up is recommended for lesions of unusual pathology , such as the presented case as the potential for malignant transformation is unknown .
cells may reside in small nests referred to as isogenous groups and occupy lucent spaces within their myxoid matrix called lacunae .
immunohistochemical staining will typically be positive for s-100 protein , and negative for epithelial markers such as ae1/ae3 and epithelial membrane antigen .
additional research will be helpful in further characterizing the genetic makeup of similar ectopic lesions as this may provide insight into their formation . | the identification of a soft tissue chondroma within the spine represents a rarity and is typically not included within the differential diagnosis for patients with sensory complaints of the leg .
the authors describe 46-year - old female presenting with 3-week history of decreased sensation and paresthesias of the left leg .
magnetic resonance imaging of the lumbar spine demonstrated an l3 extradural soft tissue mass .
she underwent an uncomplicated excision through an l3 laminectomy and exhibited complete resolution of symptoms .
pathologic examination revealed benign cartilaginous tissue ; however , the authors recommend long - term follow - up for such lesions as the potential for malignant transformation is unknown . |
a crucial property of esthetic restorative materials is their long - term stability in the oral environment : although great improvements have been achieved during recent years , color stability is still a problem .
composite resins are susceptible to various degrees of discoloration after prolonged exposure to the oral environment.[24 ] three types of discolorations are generally described : external discoloration due to the accumulation of plaque and surface stains ( extrinsic stain ) , surface or sub - surface color alteration implying superficial degradation or slight penetration and reaction of staining agents within the superficial layer of composite resins ( absorption ) , body , or intrinsic discoloration due to physical
the structure of the composite resin and the characteristics of its particles have a direct impact on susceptibility to extrinsic staining .
moreover , composite resins undergo superficial and microstructural changes resultant from mastication and from finishing and polishing procedures.[68 ] the external and the surface types of discolorations are also closely related to hygiene , dietary , and smoking habits .
every component of composite resins may be involved in sub - surface or intrinsic discolorations .
the affinity of composite resin for stains is modulated by its conversion rate and its chemical characteristics , water sorption rate being particularly important .
an insufficient resin conversion rate will favour the absorption of some colorants and the color stability of composite resins depends on various factors like curing time , curing mode , aging conditions , and composition of the materials .
the intrinsic color of composite resins can also be altered with the passage of time as a result of various influences such as visible and ultra - violet irradiation , thermal changes , and humidity .
the lighter shades of composite resins are likely to be subject to higher color degradation through the effects of environmental exposure to ultraviolet light .
the staining susceptibility of a composite resin may also be attributed to its filler type : nanohybrid absorbs staining substances more easily than microhybrid .
the purpose of this in vitro study was to evaluate the effects on the surface discoloration of eight composite resins , three microhybrid , and five nanohybrid , after staining and bleaching procedures .
there were two working hypothesis : the type of composite does not influence the surface discoloration ; the bleaching process removes staining from the surface of composite resins .
three microhybrid composite resins and five nanohybrid composite resins were evaluated in this study . for each brand ,
twenty disk - shaped specimens of each composite resin were prepared in accordance with the manufacturer 's instructions .
group 3 : microhybrid composite resin gradia direct ( gc corporation , tokyo , japan ) .
specimens were prepared by condensing the material into a silicon mold ( 6,4 mm in diameter and 2 mm in thickness ) , placed on a white opaque paper background covered by a mylar strip ( henry schein ; melville , ny ) .
the mold was filled with the composite resin and a second mylar strip was placed on the top of the filled mold .
a glass slide was pressed against the upper mylar strip to extrude the excess composite resin and to form a flat surface .
the distal end of the light guide was placed against the surface of the matrix strip and positioned concentrically with the cavity in the mold ; the material was then light - cured from the top with the curing light celalux ii ( voco , cuxhaven , germany ) .
one light polymerization mode was used for each material standard : 1000 mw / cm for 40 s. the cordless curing unit was maintained at full charge before use , and irradiance was monitored periodically by using a radiometer ( sds kerr , orange , ca ) .
ind com , cotia , sp , brazil ) with the sequence of 600- , 800- , 1000-grit abrasive paper under water irrigation .
after that the specimens were stored in distilled water for 24 h in complete darkness at 37c as baseline measurement . for each
composite , specimens were subdivided into two subgroups according to storage solutions ( distilled water / subgroup w and tea / subgroup t ) ; every subgroup of 10 samples of composite resin was immersed in staining solution at room temperature over a 14-day test period :
( i)subgroup w ( control ) : 10 specimens immersed in vials containing distilled water at 37c,(ii)subgroup t : 10 specimens immersed in vials containing 500 ml of tea ( twinings , english breakfast , andover , hampshire , uk ) .
subgroup w ( control ) : 10 specimens immersed in vials containing distilled water at 37c , subgroup t : 10 specimens immersed in vials containing 500 ml of tea ( twinings , english breakfast , andover , hampshire , uk ) .
the specimens were dipped for 20 min , once a day ( every 24 h ) for 14 days into the tea to simulate a period of clinical exposure .
solutions were changed daily and put in vials with a cover that prevents evaporation of staining solutions .
every sample was submitted to bleaching procedures with a bleaching agent based on carbamide peroxide at 17% ( perfect bleach , voco , germany ) .
it was painted on the top surface of the specimen according to the manufacturer 's instructions and stored in vials sealed with parafilm ( parafilm m , sigma - aldrich , st .
all bleaching agents were applied at room temperature for 2 h per day for 14 days according to manufacturer 's instruction to simulate the bleaching process . after bleaching the specimens
were rinsed with tap water for 1 min to remove the bleaching agents , blotted dry , and stored in distilled water at 37c . a colorimetric evaluation according to the cie lab system , relative to standard illuminant a against a white background ,
was performed at four experimental periods , after 24 hours immersion in distilled water , at 7 days , at 14 days and after the bleaching process .
color of the specimens was measured with a spectrophotometer ( sp820 ; techkon gmbh , konig - stein , germany ) against a white background . before each measurement session
, the colorimeter was calibrated according to the manufacturer 's recommendations by using the supplied white calibration standard .
all specimens were chromatically measured four times and the average values were calculated ; then , each color parameter for each specimen of the same shade was averaged .
the cie 1976 l a b color system is used for the determination of color differences .
the l value refers to lightness ; the higher is the l value , the higher the lightness ( a value of 100 corresponds to perfect white and that of zero to black ) .
cie l a b values are called the chromaticity coordinates ; a shows red color on positive values and green color on negative values ( + a = red ; a = green ) ; b shows yellow color on positive values and blue color on negative values ( + b = yellow ; b = blue ) . the total color differences ( deab ) were calculated as follows : deab = [ ( dl ) + ( da ) + ( db ) ] = h. a value of deab < 3.3 was considered clinically acceptable .
the color measurements of the experimental specimens ( subgroup t ) were compared with control specimens ( subgroup w ) .
differences in color change by the immersion protocols were calculated and a statistical analysis was performed using statistical software ( stata 7 ; college station , tx , usa ) .
descriptive statistics including the mean , standard deviation , minimum , median , and maximum for each group were calculated .
the distributions were assessed and found to be normal ( kolmogorov smirnov test ) .
a one - way analysis of variance test ( anova ) was applied to determine whether significant differences existed among the groups .
for each composite , specimens were subdivided into two subgroups according to storage solutions ( distilled water / subgroup w and tea / subgroup t ) ; every subgroup of 10 samples of composite resin was immersed in staining solution at room temperature over a 14-day test period :
( i)subgroup w ( control ) : 10 specimens immersed in vials containing distilled water at 37c,(ii)subgroup t : 10 specimens immersed in vials containing 500 ml of tea ( twinings , english breakfast , andover , hampshire , uk ) .
subgroup w ( control ) : 10 specimens immersed in vials containing distilled water at 37c , subgroup t : 10 specimens immersed in vials containing 500 ml of tea ( twinings , english breakfast , andover , hampshire , uk ) .
the specimens were dipped for 20 min , once a day ( every 24 h ) for 14 days into the tea to simulate a period of clinical exposure .
solutions were changed daily and put in vials with a cover that prevents evaporation of staining solutions .
every sample was submitted to bleaching procedures with a bleaching agent based on carbamide peroxide at 17% ( perfect bleach , voco , germany ) .
it was painted on the top surface of the specimen according to the manufacturer 's instructions and stored in vials sealed with parafilm ( parafilm m , sigma - aldrich , st .
all bleaching agents were applied at room temperature for 2 h per day for 14 days according to manufacturer 's instruction to simulate the bleaching process .
after bleaching the specimens were rinsed with tap water for 1 min to remove the bleaching agents , blotted dry , and stored in distilled water at 37c .
a colorimetric evaluation according to the cie lab system , relative to standard illuminant a against a white background , was performed at four experimental periods , after 24 hours immersion in distilled water , at 7 days , at 14 days and after the bleaching process .
color of the specimens was measured with a spectrophotometer ( sp820 ; techkon gmbh , konig - stein , germany ) against a white background . before each measurement session
, the colorimeter was calibrated according to the manufacturer 's recommendations by using the supplied white calibration standard .
all specimens were chromatically measured four times and the average values were calculated ; then , each color parameter for each specimen of the same shade was averaged .
the cie 1976 l a b color system is used for the determination of color differences .
the l value refers to lightness ; the higher is the l value , the higher the lightness ( a value of 100 corresponds to perfect white and that of zero to black ) .
cie l a b values are called the chromaticity coordinates ; a shows red color on positive values and green color on negative values ( + a = red ; a = green ) ; b shows yellow color on positive values and blue color on negative values ( + b = yellow ; b = blue ) .
the total color differences ( deab ) were calculated as follows : deab = [ ( dl ) + ( da ) + ( db ) ] = h. a value of deab < 3.3 was considered clinically acceptable .
the color measurements of the experimental specimens ( subgroup t ) were compared with control specimens ( subgroup w ) .
differences in color change by the immersion protocols were calculated and a statistical analysis was performed using statistical software ( stata 7 ; college station , tx , usa ) .
descriptive statistics including the mean , standard deviation , minimum , median , and maximum for each group were calculated .
the distributions were assessed and found to be normal ( kolmogorov smirnov test ) . a one - way analysis of variance test ( anova )
post hoc tukey 's test showed that test subgroups presented significantly higher h index values ( deab ) than control subgroups for all the three different conditions tested ( p < 0.05 ) . esthetx
hd exhibited significantly higher h values than all other groups tested ( p < 0.05 ) .
no significant differences were found when comparing 7 and 14 days immersion in distilled water ( p > 0.05 ) . on the contrary , when analyzing tea immersion , two materials ( ceramx and grandioso ) showed significantly higher h index values after 14 days immersion than after 7 days ( p < 0.05 ) .
all other materials did not show significant differences between 7 and 14 days of tea immersion ( p < 0.05 ) .
after whitening procedure , materials tested showed significant reduction ( esthetx hd , ceramx , gc kalore , grandioso ) ( p < 0.05 ) or unsignificant differences ( clearfil ap - x , gradia direct , g - aenial , grandio ) ( p > 0.05 ) of h index values than 14 days of tea immersion . all results obtained in function of time are shown in figures 18 .
mean values and standard deviations of color change ( deab ) of specimens esthetx hd : h index values after staining in tea and whitening clearfil ap - x : h index values after staining in tea and whitening gradia direct : h index values after staining in tea and whitening ceramx : h index values after staining in tea and whitening gc kalore : h index values after staining in tea and whitening g - aenial : h index values after staining in tea and whitening grandio : h index values after staining in tea and whitening grandioso : h index values after staining in tea and whitening
this study focused on the problem of surface discoloration of modern composites by investigating their susceptibility to being stained by normal diet and food dyes as well as by assessing reactions to various physical chemical conditions of clinical relevance .
the primary hypothesis that drinks staining of nanohybrid composite resins would not be higher than microhybrid composite resins was accepted .
villalta et al . and lee et al . obtained varying results when comparing in vitro staining of microhybrid and nanohybrid composite resins submitted to various solutions .
villalta et al . assessed that staining susceptibility of a material may be attributed to the type of resin or filler .
the authors demonstrated that nanohybrid composite resins absorb stains such as coffee or red wine more easily than microhybrid composite resins .
obtained analogous results using chlorhexidine and other staining substances , concluding that the smoothest surfaces were not necessarily the most stain resistant , and staining ability was influenced by each composite monomer and filler composition .
in contrast with the results of these authors , in the present study , nanohybrid and microhybrid composite resins reacted in the similar way to the action of tea , with no significant differences after 7 days or 14 days of treatment . surface discoloration was observed in each specimen after 7 days and was significantly higher after 14 days ( ceramx and grandioso ) .
the color differences of the control subgroups after 7 days and after 14 days were not significant ( p > 0.05 ) .
this result can be described to the composite resins susceptibility to chemical erosion of the resin matrix , hydrolytic breakdown of filler particles , and chemical degradation of silane agent , which are responsible processes for discoloration and staining of the composite resin .
therefore , to explain the present results , it is suggested that the greater susceptibility of the composite resin tested to staining by tea may be due to the high temperature employed in the immersion cycle ( 70c ) , which probably heated the surface of the material , thus affecting the staining process . as this process appears to involve the degradation of the organic matrix which facilitates pigmentation ,
the color of stained specimens of four groups ( esthetx hd , ceramx , gc kalore , grandioso ) returned to baseline after bleaching .
the whitening process regarded both the stained specimens , which returned to baseline even after a large discoloration due to staining , both the control subgroups of each product , which partially lost superficial stain .
therefore , the conclusion of the study was that carbamide peroxide was responsible of removing stain from the surface of specimens .
the bleaching mechanism for the teeth is that the active agents ( peroxide solutions ) can flow freely through the enamel and dentin and oxidize the pigments in the teeth .
the results of this study indicated that the surface discoloration of composite resins after bleaching was probably due to superficial cleansing of the specimens , not intrinsic color change .
however , clearfil ap - x , gradia direct , g - aenial , and grandio were not bleached by perfect bleach .
although bleaching agents can partially remove the exterior staining from some composite resins , they will not bleach them , whereas they can effectively bleach teeth .
therefore , after bleaching , the composite resin restoration may not always match the surrounding bleached tooth structure .
in fact , more researches should be conducted in order to confirm the results of this paper .
under conditions and within the limitations of the present in vitro study , it can be concluded that staining procedures used in this study affected the color stability of tested composite resins .
different composite resins ( microhybrid and nanohybrid ) reacted in the same way when exposed in vitro to tea for 7 days and 14 days . after bleaching | background : the purpose of this in vitro study was to evaluate surface discoloration of three microhybrid composite resins ( esthetx hd , clearfil ap - x , gradia direct ) and five nanohybrid composite resins ( ceramx , gc kalore , g - aenial , grandio , grandioso ) , after staining and bleaching procedures.materials and methods : the composite resins were polymerized with a curing light ( celalux ii , voco , cuxhaven , germany ) into 160 silicon molds ( 6,4 mm in diameter and 2 mm in thickness ) to obtain identical specimens .
twenty samples for each composite resin were prepared .
the specimens were polished using an automated polishing machine with the sequence of 600- , 800- , 1000-grit abrasive paper under water irrigation .
the specimens were immersed in tea and distilled water : the specimens were dipped for 20 min , once a day ( every 24 h ) , for 14 days into the drinks .
the specimens were then bleached with carbamide peroxide at 17% ( perfect bleach - voco ) .
the color of specimens was measured with a spectrophotometer according to the cie l*a*b * system after light - polymerization of composite resin specimens , after 7 days , after 14 days , and after bleaching .
the color difference h index ( deab * ) between each measurement was calculated .
statistical analysis was made using analysis of variance ( anova).results : all specimens showed a significant increase in staining with a similar trend and no significant differences between microhybrid and nanohybrid composite resins .
after whitening procedures , materials tested showed both significant and unsignificant differences of the h index.conclusions:microhybrid and nanohybrid composite resins had similar in vitro surface discoloration in tea .
after bleaching , discoloration was removed from some composite resins tested . |
currently , more than 150 000 partial or complete hiv genome sequences are available in the central hiv database at los alamos national laboratory ( 1 ) ; these data are crucial for the development of drugs against aids .
analysis of hiv sequence data is challenging , however , since hiv is among the most genetically variable organisms known and recombinations of different hiv subtypes are very common ( 2 ) .
hiv-1 is divided into three major phylogenetic groups , one of which the m group is responsible for the aids pandemic ( 3,4 ) .
this group is classified into ten subtypes , some of which are further divided into sub - subtypes .
accurate classification of hiv-1 subtypes and recombinants is of crucial importance for epidemiological monitoring and drug development .
therefore , a number of software tools have been developed to classify hiv genome sequences and to identify phylogenetic breakpoints and subtypes in recombinant strains ( 5,6 ) .
we recently developed a hmm - based method to compare nucleic acid sequences to a given multiple alignment a of a sequence family s for which a classification into subclasses is available ( 7 ) .
we called this method jumping profile hidden markov model ( jphmm ) since our approach is a probabilistic generalization of the jumping - alignment ( jali ) algorithm proposed by spang et al .
, a query sequence s is aligned to a multiple alignment a of a sequence family s = { s1 , , sn}but s is not aligned to the alignment a as a whole , but different parts of s can be aligned to different individual sequences si from a. within an alignment of the query s to the sequence family s ,
jumps are allowed between different sequences from s depending on where the strongest degree of similarity is found .
for a jump between two sequences si and sj , a penalty is imposed , similar to the familiar gap penalty used in standard sequence alignment .
this approach is particularly useful if the query sequence s is a result of phylogenetic recombinations such that different parts of s are related to different sequences from the family s. jali has been shown to perform well if an alignment a is to be searched against a sequence database ( 9 ) . in our jphmm approach
, we assume that a partition of the sequences from the family s into subclasses is given .
each subclass is modeled as a profile hidden markov model ( 10 ) . within a subclass ,
the usual transitions between match , insert and delete states are possible , as in standard profile hmm theory but in addition , our model allows transitions between profile hmms corresponding to different subclasses , so a path through our model can switch back and forth between different subclasses .
in ( 7 ) , we found that jphmm is a useful tool to predict phylogenetic breakpoints and subtypes in recombinant hiv and hepatitis c sequences ( 11 ) . for hiv subtyping , we start with a pre - calculated multiple alignment of hiv-1 genome sequences consisting of all major subtypes and sub - subtypes ; these ( sub-)subtypes are modeled as profile hmms in our jphmm approach .
phylogenetic breakpoints and ( sub-)subtypes to which a query sequence s is aligned , reliably indicate the real ( sub-)subtypes in recombinant hiv sequences . to evaluate our tool and to compare its prediction accuracy to competing methods such as simplot ( 12 ) and rdp ( 13 )
, we used a large set of real and simulated data from hiv-1 and hepatitis c. these test runs demonstrated that jphmm is far more accurate than existing tools for phylogenetic breakpoint detection .
details of this program evaluation are described in ( 7 ) . to make jphmm available to the hiv research community
, we set up an easy - to - use www interface at gttingen bioinformatics compute server ( gobics ) : at our server , the user can paste or upload up to 5 full - length hiv-1 genome sequences that is to be searched for phylogenetic breakpoints and subtypes .
our server uses a pre - calculated multiple alignment of 309 hiv sequences from the major hiv ( sub-)subtypes obtained from the hiv database at .
these sequences include nine subtypes a d , f , g , h , j , k , and a persumed recombinant 01_ae .
subtype a has two sub - subtypes , a1 and a2 ; similarly f has two sub - subtypes , f1 and f2 .
b and d could be regarded as sub - subtypes because their relative distance and relation are similar to a1 and a2 , f1 and f2 , respectively .
but we still consider b and d as subtypes , not sub - subtypes because of historical reasons ( 14 ) .
01_ae , though being called recombinant , contains the only information of subtype e. thus we include 01_ae in the alignment . the alignment of these sequences has been carried out using hmmer ( 15 ) and subsequent manual improvement .
a hyperlink to the results of the program run is returned to the user by e - mail .
the result file contains a list of fragments of the input sequence that are assigned to different subtypes and sub - subtypes , including predicted breakpoints between these fragments .
in addition , the output file contains a graphical representation of the predicted recombinant fragments within the hiv-1 genome .
one is based on the original sequence position , and the other is based on hxb2 numbering .
hxb2 ( genbank accession number k03455 ) is the most commonly used reference strain for many different kinds of hiv-1 functional studies .
the hxb2 numbering provided for the output breakpoints is especially useful to facilitate the identification of the precise location of interest in hiv sequences .
it should be mentioned that our tool is sometimes not sensitive to detect hiv-1 subtypes h , j , k , as only few full - length genome sequences of these subtypes are available to train our model . for these subtypes
, we recommend to compare the results of jphmm with those of other hiv-1 subtyping tools , for example , rip ( ) . as shown in ( 7 ) , the overall prediction accuracy of our method is high compared with alternative approaches .
nevertheless , it would be useful for the user to assess the relative reliability of individual predicted breakpoints . in principle , this is possible by using posterior probabilities that can be calculated using the forward and backward algorithms as explained in ( 16 ) .
we are currently implementing these algorithms to estimate the ( local ) reliability of our predictions .
for predicted recombinants , users of our software may want to know putative parental sequences .
our method can not provide this information directly , since jphmm compares input sequences to a model derived from a pre - calculated alignment of representative sequences .
it is possible , however , to search predicted recombinant segments of input sequences against the hiv-1 database to retrieve potential parent sequences .
the output file contains a list of fragments from the input hiv-1 sequences that are assigned to different hiv subtypes , including predicted breakpoints . at the bottom of the file , a graphical representation of the input sequence | detecting recombinations in the genome sequence of human immunodeficiency virus ( hiv-1 ) is crucial for epidemiological studies and for vaccine development .
herein , we present a web server for subtyping and localization of phylogenetic breakpoints in hiv-1 .
our software is based on a jumping profile hidden markov model ( jphmm ) , a probabilistic generalization of the jumping - alignment approach proposed by spang et al .
the input data for our server is a partial or complete genome sequence from hiv-1 ; our tool assigns regions of the input sequence to known subtypes of hiv-1 and predicts phylogenetic breakpoints .
jphmm is available online at . |
a literature search using the title terms metabolic syndrome and diabetes was conducted in pubmed .
we limited the search to articles that were written in english . because the who was the first to release its definition , in 1998 , we started our search for articles published that year and continued through april 2008 .
in addition , we augmented our search with reviews of the reference lists of retrieved articles .
the focus of this article is the prospective association between the metabolic syndrome and incident diabetes in studies that are more or less population based .
therefore , we did not include studies that recruited participants with specific conditions such as cardiovascular disease . to be included in the analyses , articles had to include estimates of rr and cis based on one of the major definitions of the metabolic syndrome ( 27 ) .
articles that presented estimates of rr only in graphical form were not included in the quantitative analyses because of the difficulty in accurately deriving the estimate of rr and its ci . when multiple estimates were available for a particular cohort , only the estimate that most thoroughly adjusted for covariates or that presented estimates for men and women combined was selected .
some studies did not have all criteria required to define the metabolic syndrome according to established criteria , and , consequently , researchers modified definitions of the metabolic syndrome .
two reviews relating metabolic syndrome to risk for vascular events noted similar rr estimates for studies based on use of bmi , waist circumference , or waist - to - hip ratio ( 1,11 ) .
in addition , the who definition technically requires that participants undergo an oral glucose tolerance test ( ogtt ) , have insulin resistance based on a gold - standard technique ( specifically , the hyperinsulinemic - euglycemic clamp ) , and undergo a measurement of microalbuminuria .
therefore , we included studies that did not conduct an ogtt , used a surrogate measure of insulin resistance ( such as fasting concentration of insulin or homeostasis model assessment of insulin resistance [ homa - ir ] ) , and did not measure microalbuminuria .
we abstracted the following data elements : lead author 's name , year of publication , study name and location , sample size , follow - up time , sex composition and age of subjects ( mean , median , or range ) , exclusion criteria , metabolic syndrome definition ( including any changes ) , definition of diabetes , number of incident events , estimate of rr ( odds ratio [ or ] , rr , or hazard ratio ) , 95% ci , and variables used to adjust estimates of rr .
ses for the estimates of rr were estimated from the cis . for each study ,
if no heterogeneity was present ( p of q statistic 0.10 ) , fixed - effects estimates of rr were calculated according to the inverse variance method ( 15 ) .
if heterogeneity was present ( p of q statistic < 0.10 ) , random - effects estimates of rr were calculated using the approach of der simonian and laird ( 14 ) . the influence of single studies on the summary estimates was examined graphically by checking how the elimination of each study affected the resulting summary estimate of rr ( 16 ) .
evidence for publication bias was assessed by examining funnel plots and assessing funnel plot asymmetry ( 17 ) .
for our quantitative analyses , we included articles that are based on 16 cohorts ( supplemental table available in an online appendix at http://dx.doi.org/10.2337/dc08-0423 ) ( 810,12,13,1832 ) .
these 16 cohorts included over 2,604 incident events among 42,419 participants , depending on which of the multiple publications of the same cohort were included in the counts .
three cohorts included only men , whereas the other 13 included both men and women .
two studies were not included because results were presented only in graphical form ( 33 ) or confidence limits were not provided ( 34 ) .
ten cohorts yielded estimates of rr for the association of the metabolic syndrome and incident diabetes defined using the who 1999 definition , and the random - effects summary rr was 5.17 ( 95% ci 3.996.69 ) ( fig .
four cohorts yielded estimates of rr for the egir 1999 definition , and the random - effects summary rr was 4.45 ( 2.418.22 ) .
thirteen cohorts provided an estimate of rr for the ncep 2001 definition , and the random - effects summary rr was 3.53 ( 2.844.39 ) .
six cohorts reported estimates of rr for the national heart , lung , and blood institute / american heart association ( nhlbi / aha ) 2004 definition , and the fixed - effects summary rr was 5.16 ( 4.436.00 ) .
five cohorts reported estimated rrs for the aha / nhlbi 2005 definition , and the random - effects summary rr was 5.12 ( 3.268.05 ) .
nine cohorts produced estimates of rrs for the international diabetes federation ( idf ) 2005 definition , and the random - effects summary rr was 4.42 ( 3.305.92 ) .
funnel plot asymmetry was detected only for the analysis involving the ncep 2001 definition ( egger 's test : p = 0.028 ) .
comparing the summary rrs for the different definitions shown above is to some degree problematic because of differences in study populations and analytic approaches .
thus , a fairer comparison is between results from sets of studies that examined the same definitions and calculated estimated rrs in the same manner .
the random - effects summary rr was 4.40 ( 95% ci 2.876.75 ) for who 1999 and the fixed - effects summary rr was 3.12 ( 2.683.64 ) for ncep 2001 .
three studies compared the who 1999 , ncep 2001 , and idf 2005 definitions ( 23,29,32 ) .
the random - effects summary rr was 5.73 ( 3.0410.79 ) for the who 1999 definition , and the fixed - effects summary rrs were 3.50 ( 2.914.22 ) for the ncep 2001 definition and 3.51 ( 2.834.36 ) for the idf 2005 definition .
the random - effects and fixed - effects summary rrs were 4.10 ( 3.135.39 ) and 3.72 ( 2.974.67 ) , respectively ( 23,27,29,30,32 ) .
five studies compared the aha / nhlbi 2005 and idf 2005 definitions , yielding random - effects summary rrs of 5.12 ( 3.268.05 ) and 5.00 ( 2.848.78 ) , respectively ( 13,2527,30 ) .
four studies of the egir 1999 and idf 2005 definitions produced random - effects summary rrs of 4.45 ( 2.418.22 ) and 4.33 ( 2.348.01 ) , respectively ( 13,26,29,31 ) .
two studies included the ncep 2001 , aha / nhlbi 2005 , and idf 2005 definitions ( 27,29 ) .
summary rrs were 6.16 ( 2.6714.20 ) ( random - effects ) , 4.51 ( 3.226.30 ) ( fixed - effects ) , and 4.15 ( 2.885.96 ) ( fixed - effects ) , respectively .
two studies included the who 1999 , egir 1999 , and ncep 2001 definitions ( 12,29 ) .
the fixed - effects summary rrs were 4.09 ( 3.255.14 ) , 2.78 ( 2.153.58 ) , and 3.13 ( 2.463.99 ) , respectively .
three studies compared the ncep 2001 , nhlbi / aha 2004 , and idf 2005 definitions ( 23,27,32 ) .
the fixed - effects summary rrs were 3.95 ( 3.184.90 ) , 4.44 ( 3.575.52 ) , and 3.77 ( 3.034.70 ) , respectively .
four studies provided results for the who 1999 and idf 2005 definitions ( 23,29,31,32 ) . the random - effects summary rrs were 6.19 ( 3.859.95 ) and 3.95 ( 3.015.19 ) , respectively . finally , three studies produced information about the who 1999 and egir 1999 definitions ( 12,29,31 ) .
the random - effects summary rrs were 4.47 ( 2.797.18 ) and 3.47 ( 1.816.63 ) , respectively .
estimates of sensitivity and specificity were available for ten cohorts ( 10,20,21,25,27,29,3133,35 ) , and estimates of positive and negative predictive values were available for six cohorts ( 25,27,29,31,32,35 ) .
sensitivity ranged from 0.224 to 0.722 , and specificity ranged from 0.613 to 0.939 ( table 1 ) .
positive predictive values ranged from 0.078 to 0.36 and negative predictive values range from 0.90 to 0.983 .
receiver operating characteristic curves were generated for six cohorts with the area under the receiver operating characteristic curve ( aroc ) , ranging from 0.68 to 0.85 ( 10,20,23,26,32,35 ) . for studies comparing existing definitions , differences among the arocs were small and generally nonsignificant ( 20,23,26,35 ) .
several studies examined the risk associated with increasing number of components of the metabolic syndrome ( table 2 ) . in these studies , subjects with zero abnormalities
the estimated rrs for participants in the west of scotland coronary prevention study ( 8) were 7.26 ( 95% ci : 2.2523.40 ) for those with three abnormalities and 24.4 ( 7.5379.60 ) for those with four or more abnormalities . estimated rrs for participants with three abnormalities and four or more abnormalities were 4.56 ( 2.488.78 ) and 10.88 ( 5.7720.50 ) , respectively , in the british regional heart study ( 10 ) . in the framingham offspring study ,
the estimated rr for participants with three or more abnormalities was 23.83 5.8098.01 ) among men and 29.69 ( 9.1096.85 ) among women ( 22 ) .
furthermore , at least two other studies using criteria not based on one of the major definitions also showed substantially elevated estimated rrs associated with three and four or more of abnormalities ( 28,36 ) .
estimates of sensitivity and specificity were available for ten cohorts ( 10,20,21,25,27,29,3133,35 ) , and estimates of positive and negative predictive values were available for six cohorts ( 25,27,29,31,32,35 ) .
sensitivity ranged from 0.224 to 0.722 , and specificity ranged from 0.613 to 0.939 ( table 1 ) .
positive predictive values ranged from 0.078 to 0.36 and negative predictive values range from 0.90 to 0.983 .
receiver operating characteristic curves were generated for six cohorts with the area under the receiver operating characteristic curve ( aroc ) , ranging from 0.68 to 0.85 ( 10,20,23,26,32,35 ) . for studies comparing existing definitions , differences among the arocs were small and generally nonsignificant ( 20,23,26,35 ) .
several studies examined the risk associated with increasing number of components of the metabolic syndrome ( table 2 ) . in these studies , subjects with zero abnormalities formed the reference group .
the estimated rrs for participants in the west of scotland coronary prevention study ( 8) were 7.26 ( 95% ci : 2.2523.40 ) for those with three abnormalities and 24.4 ( 7.5379.60 ) for those with four or more abnormalities . estimated rrs for participants with three abnormalities and four or more abnormalities were 4.56 ( 2.488.78 ) and 10.88 ( 5.7720.50 ) , respectively , in the british regional heart study ( 10 ) . in the framingham offspring study ,
the estimated rr for participants with three or more abnormalities was 23.83 5.8098.01 ) among men and 29.69 ( 9.1096.85 ) among women ( 22 ) .
furthermore , at least two other studies using criteria not based on one of the major definitions also showed substantially elevated estimated rrs associated with three and four or more of abnormalities ( 28,36 ) .
the prospective studies show that the metabolic syndrome , regardless of how it is defined , is a significant predictor of incident diabetes in many different populations , including native americans , u.s .
hispanics , mexicans , turks , iranians , mauritians , chinese , europeans , and those of european descent .
although considerable heterogeneity existed among these studies , the average estimated summary rr of 3.55.2 for incident diabetes with any metabolic syndrome criteria is greater than the association of metabolic syndrome with cardiovascular events ( 1.5 to 2.0 ) ( 1,11 ) .
these data confirm that the metabolic syndrome is significantly more strongly associated with risk for incident diabetes , likely because some of its components ( in particular fasting glucose and waist circumference ) are more strongly associated with diabetes risk .
the heterogeneity among studies emanates from at least two sources : the origins of the study population and the approach in analyzing the study data .
for example , with the ncep 2001 definition , native americans cohorts produced a fixed - effects summary rr of 1.98 ( 95% ci 1.692.32 ) ( 18,19 ) , asian and mauritius cohorts produced a fixed - effects summary rr of 3.53 ( 2.964.20 ) ( 9,12,27,29,32 ) , and north american and european studies produced a random - effects summary rr of 4.13 ( 3.165.40 ) ( 8,10,20,21,23,30 ) .
the variables used to adjust estimated rrs varied considerably among studies , with some adjusting for nothing , others for multiple factors , and others potentially overadjusting with use of , for example , ogtts .
although a variety of diabetes risk prediction models exist , some not requiring any laboratory measures , three direct comparisons of the predictive ability of the metabolic syndrome and a single diabetes risk score , the diabetes risk score , have been conducted ( 21,29,31 ) .
this prediction model includes age , sex , ethnicity , fasting glucose , systolic blood pressure , hdl cholesterol , bmi , and family history of diabetes ( 37 ) .
thus , four components of the metabolic syndrome as per the ncep 2001 definition and subsequent revisions ( with bmi in lieu of waist circumference ) are represented in continuous form in this model .
both in the san antonio heart study and the mexico city diabetes study , the sensitivity of the diabetes risk score was significantly larger than that of metabolic syndrome diagnosis at a given specificity ( 21 ) . in a study conducted in mauritius , cameron et al .
concluded that the diabetes predicting model provided somewhat better prediction than the metabolic syndrome ( 29 ) .
using data of the ausdiab study , cameron et al . reached a similar conclusion ( 31 ) .
furthermore , the concept of risk scores using routinely available or easily collectable data has emerged as an appealing tool for predicting both undiagnosed prevalent diabetes and the risk for future incident diabetes . the finnish diabetes risk score ( findrisc)using categorical variables for age , bmi , waist circumference , history of antihypertensive drugs or high blood glucose , physical activity , and daily consumption of fruit , berries , and vegetables achieved an aroc between 0.85 and 0.87 for 10-year incident diabetes ( 38 ) , exceeding the aroc reported in all the metabolic syndrome studies reporting these data ( table 2 ) .
however , results from the ausdiab study showed that a modified version of findrisc ( score > 10 ) had a worse positive predictive value and specificity at a comparable sensitivity than the metabolic syndrome using the ncep 2001 and idf 2005 definitions ( 31 ) .
similarly , the recent german diabetes risk score ( comprising age , height , waist circumference , history of hypertension , physical activity , smoking , and dietary factors ) has reported an aroc for incident diabetes of between 0.82 and 0.84 ( 39 ) .
of the components of the metabolic syndrome , impaired fasting glucose is generally thought to be the strongest predictor of diabetes ( 8,12,13,22,27,29,31,40 ) .
like that of cameron et al . , most studies reported that concentrations of fasting glucose provided similar or , as in the ausdiab study , better prediction of diabetes than metabolic syndrome diagnosis ( 31 )
. however , lorenzo et al . ( 25 ) showed that the metabolic syndrome provided additional prediction beyond that provided by impaired fasting glucose alone in the san antonio heart study .
little research has been conducted examining the predictive ability of the various combinations of metabolic syndrome components in definitions such as the ncep 2001 , nhlbi / aha 2004 , and aha / nhlbi 2005 .
one possible reason for this is that many studies have not had sufficient incident events of diabetes to evaluate the many combinations .
for example , the ncep 2001 definition and the two subsequent updates yield 16 combinations of three or more cardiometabolic abnormalities . using data from the framingham offspring study , wilson et al .
( 22 ) did examine a number of combinations of the five nhlbi / aha 2004 components and concluded that the rrs of combinations of three abnormalities were not larger than combinations of two factors or , indeed , elevated fasting glucose alone .
another issue that has received little attention is whether the metabolic syndrome represents more than the sum of its parts .
cameron et al . ( 29 ) found that only the who 1999 definition not the ncep 2001 , egir 1999 , or idf 2005 definitions
significantly added to the prediction of incident diabetes in models that included the individual components of the metabolic syndrome .
( 8) concluded that the metabolic syndrome was not a significant predictor of incident diabetes once its components were accounted for .
a number of researchers have examined the effect of changing aspects of the definition of the metabolic syndrome on the predictive ability of the syndrome for diabetes .
lowering waist circumference or glucose thresholds generally increased the prevalence of the metabolic syndrome and the sensitivity but at the expense of specificity ( 8,32,33,35 ) .
some of the most extensive efforts at improving the predictive ability of the metabolic syndrome , starting with the ncep 2001 definition , were conducted by hanley et al .
to some degree , the numerous changes that the authors tested affected the prevalence of the metabolic syndrome , the ors for incident diabetes , and the population - attributable risk .
the lowest arocs of 0.66 were observed for definitions that required fasting plasma glucose or elevated waist circumference as mandatory components .
the highest aroc of 0.72 was observed for a definition that included the insulin sensitivity index as a sixth component .
a couple of investigations also compared the predictive ability of the metabolic syndrome with that of individual components of the metabolic syndrome or ones closely related to it . in the san antonio heart study ,
lorenzo et al . ( 20 ) reported that the aroc for ncep 2001 was similar to that for the 2-h glucose value .
( 23 ) examined the predictive ability of impaired glucose tolerance , quantitative insulin sensitivity check index , insulin sensitivity , the ratio of concentrations of triglycerides to hdl cholesterol , hypertriglyceridemic waist , and concentrations of c - reactive protein compared with ncep 2001 , who 1999 , and idf 2005 definitions of metabolic syndrome .
the prevalence of these conditions ranged from a low of 18.4% for the hypertriglyceridemic waist to a high of 69.6% for a concentration of c - reactive protein 1
a concentration of c - reactive protein 3 mg / l yielded the lowest or for incident diabetes ( 1.83 [ 95% ci : 1.232.74 ] ) , aroc ( 0.60 ) , and population - attributable risk ( 19.4% ) , whereas impaired glucose tolerance yielded the highest or ( 5.42 [ 3.608.17 ] ) , aroc ( 0.72 ) , and population - attributable risk ( 58.47% ) .
our study illustrates that the metabolic syndrome is a fairly strong predictor of incident diabetes in many populations and that it predicts diabetes more strongly than it predicts coronary heart disease events . however , whether the metabolic syndrome was ever intended to be more strongly predictive of diabetes than cardiovascular disease is not entirely clear .
additional comparisons of the metabolic syndrome to simple , readily available non laboratory - based questionnaires are needed because questionnaires appear better placed as initial screening tools to identify high - risk individuals , whose subsequent evaluation would incorporate the results from blood tests . moreover , on the balance of current but limited evidence , it appears that the metabolic syndrome may not add to the prediction of incident diabetes beyond its components , in particular impaired fasting glucose , although more data are needed to confirm this .
the most successful attempts to improve the predictive ability of the metabolic syndrome appear to have revolved around creating more of a continuous scale from its components , emphasizing loss of power from a dichotomous use of data .
current evidence casts substantial doubt on the clinical value of diagnosing the metabolic syndrome to identify those at elevated risk for diabetes .
| objective our objective was to perform a quantitative review of prospective studies examining the association between the metabolic syndrome and incident diabetes.research design and methods using the title terms diabetes and metabolic syndrome in pubmed , we searched for articles published since 1998.resultsbased on the results from 16 cohorts , we performed a meta - analysis of estimates of relative risk ( rr ) and incident diabetes .
the random - effects summary rrs were 5.17 ( 95% ci 3.996.69 ) for the 1999 world health organization definition ( ten cohorts ) ; 4.45 ( 2.418.22 ) for the 1999 european group for the study of insulin resistance definition ( four cohorts ) ; 3.53 ( 2.844.39 ) for the 2001 national cholesterol education program definition ( thirteen cohorts ) ; 5.12 ( 3.268.05 ) for the 2005 american heart association / national heart , lung , and blood institute definition ( five cohorts ) ; and 4.42 ( 3.305.92 ) for the 2005 international diabetes federation definition ( nine cohorts ) .
the fixed - effects summary rr for the 2004 national heart , lung , and blood institute / american heart association definition was 5.16 ( 4.436.00 ) ( six cohorts ) .
higher number of abnormal components was strongly related to incident diabetes . compared with participants without an abnormality , estimates of rr for those with four or more abnormal components ranged from 10.88 to 24.4 .
limited evidence suggests fasting glucose alone may be as good as metabolic syndrome for diabetes prediction.conclusionsthe metabolic syndrome , however defined , has a stronger association with incident diabetes than that previously demonstrated for coronary heart disease .
its clinical value for diabetes prediction remains uncertain . |
patients with heart failure ( hf ) are suggested to have a diabetes mellitus ( dm ) prevalence of 841%,1 which is associated with increased mortality and morbidity.2 , 3 treatment of dm in hf patients is controversial , because many contemporary therapies used for dm treatment , including thiazolidine , are contraindicated in hf.4 , 5 , 6
dipeptidyl peptidase4 ( dpp4 ) inhibitors prolong the action of incretin hormones , including glucagonlike peptide1 and glucosedependent insulinotropic polypeptide , by inhibiting their breakdown . inhibiting dpp4 enzymatic
function in dm animal models seems to suggest that dpp4 inhibition may possibly have a beneficial cardiovascular effect in humans.7 , 8 , 9 many , but not all , studies in experimental animals have found that dpp4 inhibition improves cardiac function and survival following cardiac damage.10 preclinical and clinical studies have investigated the cardiovascular effects of dpp4 inhibitors or glucagonlike peptide1 analogues in hf experimental models or hf patients7 , 11 , 12 and have shown improvements in cardiac function and protection against the development of adverse remodelling .
this suggests that dpp4 inhibitor could have potential as a novel therapeutic strategy in hf patients with dm .
recent major dpp4 inhibitor randomized control trials for dm patients [ saxagliptin assessment of vascular outcomes recorded in patients with diabetes mellitusthrombolysis in myocardial infarction 5313 , 14 and examination of cardiovascular outcomes with alogliptin versus standard of care ( examine)15 , 16 ] have raised the hypothesis that hf may be precipitated with the use of dpp4 inhibitor in dm patients.17 , 18 on the other hand , the trial evaluating cardiovascular outcomes with sitagliptin study has recently revealed that dpp4 inhibitor does not increase hospitalization rate for hf patients.19
furthermore , there is no evidence based on randomized clinical trials that dpp4 inhibitor may improve or worsen mortality in hf patients with dm .
however , in light of the unacceptably high cardiac event rates reported by previous studies on dpp4 inhibitors of dm patients,13 , 14 , 15 , 16 a prospective randomized clinical trial in hf patients with dm using dpp4 inhibitors seems ethically unjustified .
therefore , we aimed to assess the association of dpp4 inhibitor with cardiac and allcause mortality in hf patients with dm based on an observational study using propensity score ( ps ) analyses to reduce selection bias .
this was an observational study analysed by ps methods , which enrolled consecutive symptomatic hf patients with dm , who were hospitalized with decompensated hf and discharged from fukushima medical university between 2009 and 2013 .
the diagnosis of decompensated hf was defined based on the framingham criteria.20 patients with acute coronary syndrome and dialysis were excluded .
diabetes was defined as the recent use of antidiabetic drugs , a fasting blood glucose value of 126 mg / dl and/or a haemoglobin a1c ( hba1c ) value of 6.5% .
patients were divided into two groups based on use of dpp4 inhibitors at hospital discharge : a dpp4 inhibitor group and a nondpp4 inhibitor group .
we compared the clinical features , results from laboratory tests , and echocardiography , which were performed at discharge .
hypertension was defined as the recent use of antihypertensive drugs , systolic blood pressure 140 mmhg , and/or diastolic blood pressure 90 mmhg .
dyslipidemia was defined as the recent use of cholesterollowering drugs , a triglyceride value of 150 mg / dl , a lowdensity lipoprotein cholesterol value of 140 mg / dl , and/or a highdensity lipoprotein cholesterol value of < 40 mg / dl .
the estimated glomerular filtration rate ( gfr ) was measured by the modification of diet in renal disease formula.21 chronic kidney disease was defined as estimated gfr of < 60 ml / min/1.73 cm .
anaemia was defined as haemoglobin of < 12.0 g / dl in female patients and < 13.0 g / dl in male patients.22 the left ventricular ejection fraction ( lvef ) was calculated using the simpson 's method , and recording was performed on ultrasound systems ( acuson sequoia ; siemens medical solutions usa , inc .
the primary endpoint of this study was allcause death , while the secondary endpoint was cardiac death in the present study .
cardiac death was adjudicated by independent experienced several cardiologists including worsening hf , which met the framingham criteria,20 and ventricular fibrillation documented by electrocardiogram or implantable devices .
survival time was calculated from the date of discharge until the date of death or last followup .
if these data were unavailable , status was ascertained by a telephone call to the patient 's referring hospital cardiologist .
reporting of the study conforms to strengthening the reporting of observational studies in epidemiology along with references to strengthening the reporting of observational studies in epidemiology and the broader enhancing the quality and transparency of health research ( equator ) guidelines.23
normally distributed data are presented as mean standard deviation , and nonnormally distributed data ( e.g. bnp ) are presented as log transformed .
categorical variables are expressed as numbers and percentages , and the test was used for their comparisons .
characteristics and data of the two groups were compared using an independent student 's ttest for normally distributed data .
the kaplan meier method was used for presenting the mortality , and the logrank test was used for initial comparisons . to eliminate imbalances in the measurement of baseline characteristics because of selection bias associated with use of dpp4 inhibitors , we used ps .
the ps for treatment with dpp4 was estimated for each patient by logistic regression with the following nine clinically relevant variables associated with introduction of dpp4 inhibitors : age , gender , body mass index , hba1c , estimated gfr , use of 2glucosidase inhibitors , biguanides , sulfonyl urea , and insulin .
the ps is the propensity from 0 to 1 to receive treatment , given a set of known variables , and is used to adjust for potential selection bias , confounding , and differences between treatment groups in observational studies.24 the ps was then used to match patients who received and who did not receive dpp4 therapy , using a 1:1 nearest neighbourmatching algorithm with calliper width = 0.2 of the pooled standard deviation of the logit of the ps ( calliper = 0.03 ) as previously suggested.25 the psmatched datasets were compared using pairwise analysis.26 we assessed the effectiveness of our postmatched model by estimating absolute standardized differences , which were presented as a love plot .
as previously reported , a standardized difference below 10% was considered for adequate balance.27
to further assess the associations of dpp4 inhibitor use on cardiac and allcause mortality , cox proportional hazard models were constructed in the prematched cohort using three different approaches ( unadjusted , adjusted using ps as a covariate , and multivariableadjusted using several confounders ) and constructed in the postmatched cohort to validate the findings of the cox analyses . to prepare for potential confounding in the cox regression analyses , in addition to the previous factors to calculate ps , we considered the following clinical factors , which are known to affect the risk of mortality in hf patients : new york heart association ( nyha ) functional class iii or iv , systolic blood pressure , heart rate , presence of ischaemic aetiology , atrial fibrillation , anaemia , lvef , btype natriuretic peptide ( bnp ) , haemoglobin , use of renin angiotensin aldosterone system ( ras ) inhibitors , and betablockers . among these factors , which independently predicted mortality with a value of p < 0.05
, the following factors were selected in the final adjusted model for predictors of allcause mortality : nyha iii or iv , haemoglobin , log ( bnp ) , presence of betablockers , and ps . the proportional hazards assumption for the model was checked by examining logminuslog transformed kaplan meier estimates of the survival curves for two groups plotted against time to followup period .
in addition , the scaled schoenfeld residuals from the proportional hazards regression model were investigated to assess the proportional hazards assumption . to assess potential heterogeneity of dpp4 inhibitor treatment effect on allcause mortality , we conducted subgroup analyses in the postmatched cohort .
we formally tested for firstorder interactions using multivariable cox proportional hazard models by entering interaction terms between dpp4 inhibitor use and the subgroup variables .
missing values were handled by estimating one logistic regression model for each pattern of missing values .
interactions between dpp4 inhibitors and clinically relevant variables including age , gender , body mass index , duration of dm , nyha class , log ( bnp ) , lvef , presence of ischaemic aetiology , atrial fibrillation , chronic kidney disease , anaemia , use of ras inhibitors , and use of betablockers were estimated by a cox proportional hazards regression model and are shown in a forest plot . a value of p < 0.05 was considered significant for all comparisons .
this was an observational study analysed by ps methods , which enrolled consecutive symptomatic hf patients with dm , who were hospitalized with decompensated hf and discharged from fukushima medical university between 2009 and 2013 .
the diagnosis of decompensated hf was defined based on the framingham criteria.20 patients with acute coronary syndrome and dialysis were excluded .
diabetes was defined as the recent use of antidiabetic drugs , a fasting blood glucose value of 126 mg / dl and/or a haemoglobin a1c ( hba1c ) value of 6.5% .
patients were divided into two groups based on use of dpp4 inhibitors at hospital discharge : a dpp4 inhibitor group and a nondpp4 inhibitor group .
we compared the clinical features , results from laboratory tests , and echocardiography , which were performed at discharge .
hypertension was defined as the recent use of antihypertensive drugs , systolic blood pressure 140 mmhg , and/or diastolic blood pressure 90 mmhg .
dyslipidemia was defined as the recent use of cholesterollowering drugs , a triglyceride value of 150 mg / dl , a lowdensity lipoprotein cholesterol value of 140 mg / dl , and/or a highdensity lipoprotein cholesterol value of < 40 mg / dl .
the estimated glomerular filtration rate ( gfr ) was measured by the modification of diet in renal disease formula.21 chronic kidney disease was defined as estimated gfr of < 60 ml / min/1.73 cm .
anaemia was defined as haemoglobin of < 12.0 g / dl in female patients and < 13.0 g / dl in male patients.22 the left ventricular ejection fraction ( lvef ) was calculated using the simpson 's method , and recording was performed on ultrasound systems ( acuson sequoia ; siemens medical solutions usa , inc .
the primary endpoint of this study was allcause death , while the secondary endpoint was cardiac death in the present study .
cardiac death was adjudicated by independent experienced several cardiologists including worsening hf , which met the framingham criteria,20 and ventricular fibrillation documented by electrocardiogram or implantable devices .
survival time was calculated from the date of discharge until the date of death or last followup .
if these data were unavailable , status was ascertained by a telephone call to the patient 's referring hospital cardiologist .
reporting of the study conforms to strengthening the reporting of observational studies in epidemiology along with references to strengthening the reporting of observational studies in epidemiology and the broader enhancing the quality and transparency of health research ( equator ) guidelines.23
normally distributed data are presented as mean standard deviation , and nonnormally distributed data ( e.g. bnp ) are presented as log transformed .
categorical variables are expressed as numbers and percentages , and the test was used for their comparisons .
characteristics and data of the two groups were compared using an independent student 's ttest for normally distributed data .
the kaplan meier method was used for presenting the mortality , and the logrank test was used for initial comparisons . to eliminate imbalances in the measurement of baseline characteristics because of selection bias associated with use of dpp4 inhibitors
the ps for treatment with dpp4 was estimated for each patient by logistic regression with the following nine clinically relevant variables associated with introduction of dpp4 inhibitors : age , gender , body mass index , hba1c , estimated gfr , use of 2glucosidase inhibitors , biguanides , sulfonyl urea , and insulin .
the ps is the propensity from 0 to 1 to receive treatment , given a set of known variables , and is used to adjust for potential selection bias , confounding , and differences between treatment groups in observational studies.24 the ps was then used to match patients who received and who did not receive dpp4 therapy , using a 1:1 nearest neighbourmatching algorithm with calliper width = 0.2 of the pooled standard deviation of the logit of the ps ( calliper = 0.03 ) as previously suggested.25 the psmatched datasets were compared using pairwise analysis.26 we assessed the effectiveness of our postmatched model by estimating absolute standardized differences , which were presented as a love plot . as previously reported ,
a standardized difference below 10% was considered for adequate balance.27
to further assess the associations of dpp4 inhibitor use on cardiac and allcause mortality , cox proportional hazard models were constructed in the prematched cohort using three different approaches ( unadjusted , adjusted using ps as a covariate , and multivariableadjusted using several confounders ) and constructed in the postmatched cohort to validate the findings of the cox analyses . to prepare for potential confounding in the cox regression analyses , in addition to the previous factors to calculate ps , we considered the following clinical factors , which are known to affect the risk of mortality in hf patients : new york heart association ( nyha ) functional class iii or iv , systolic blood pressure , heart rate , presence of ischaemic aetiology , atrial fibrillation , anaemia , lvef , btype natriuretic peptide ( bnp ) , haemoglobin , use of renin angiotensin aldosterone system ( ras ) inhibitors , and betablockers . among these factors , which independently predicted mortality with a value of p < 0.05
, the following factors were selected in the final adjusted model for predictors of allcause mortality : nyha iii or iv , haemoglobin , log ( bnp ) , presence of betablockers , and ps . the proportional hazards assumption for the model was checked by examining logminuslog transformed kaplan
meier estimates of the survival curves for two groups plotted against time to followup period .
in addition , the scaled schoenfeld residuals from the proportional hazards regression model were investigated to assess the proportional hazards assumption . to assess potential heterogeneity of dpp4 inhibitor treatment effect on allcause mortality , we conducted subgroup analyses in the postmatched cohort .
we formally tested for firstorder interactions using multivariable cox proportional hazard models by entering interaction terms between dpp4 inhibitor use and the subgroup variables .
missing values were handled by estimating one logistic regression model for each pattern of missing values .
interactions between dpp4 inhibitors and clinically relevant variables including age , gender , body mass index , duration of dm , nyha class , log ( bnp ) , lvef , presence of ischaemic aetiology , atrial fibrillation , chronic kidney disease , anaemia , use of ras inhibitors , and use of betablockers were estimated by a cox proportional hazards regression model and are shown in a forest plot .
a value of p < 0.05 was considered significant for all comparisons . analyses were performed using a statistical software package ( spss ver . 21.0
clinical features of the overall and postmatched population are summarized in table
1 . in our hospitalized hf patients who were discharged ( n = 962 ) , 293 ( 30.5% ) had dm and
were divided into two groups based on present use of dpp4 inhibitors ( dpp4 inhibitor group , n = 122 , and nondpp4 inhibitor group , n = 171 ) .
the dpp4 inhibitors used were as follows : sitagliptin ( n = 58 , 47.5% ) , vildagliptin ( n = 44 , 36.0% ) , alogliptin ( n = 10 , 8.2% ) , linagliptin ( n = 6 , 4.9% ) , and teneligliptin ( n = 4 , 3.3% ) .
hba1c was higher , and the prevalence of taking biguanides and sulfonylurea was significantly higher in the dpp4 group than in the nondpp4 group in the prematched cohort .
after ps matching for dpp4 inhibitor use , as shown in figure
1 , the absolute standardized differences were minimized except for insulin use , suggesting substantial bias reduction . in the postmatched cohort ( dpp4 inhibitor group , n = 83 , and nondpp4 inhibitor group , n = 83 ) , use of betablockers tended to be higher , and lvef tended to be lower in the dpp4 group than in the nondpp4 group ( table
1 ) .
comparisons of clinical features bnp , btype natriuretic peptide ; dm , diabetes mellitus ; dpp4 , dipeptidyl peptidase4 ; gfr , glomerular filtration rate ; iqr , interquartile range ; log ; common logarithm ; lvef , left ventricular ejection fraction ; nyha , new york heart association ; ras , renin
gfr , glomerular filtration rate ; hba1c , haemoglobin a1c . in the followup period (
mean 858 days ) , cardiac and allcause mortality was significantly lower in the dpp4 inhibitor group than in the nondpp4 inhibitor group of both the prematched and postmatched cohorts ( p < 0.05 ) , as shown in figures
2 and 3 .
meier analyses for ( a ) cardiac death and ( b ) allcause mortality between the two groups [ dipeptidyl peptidase4 ( dpp)4 group and nondpp4 group ] in pre propensity scorematched cohort . kaplan meier analyses for ( a ) cardiac death and ( b ) allcause mortality between the two groups [ dipeptidyl peptidase4 ( dpp)4 group and nondpp4 group ] in postmatched cohort .
the cox proportional hazard model was used to examine the prognostic value of dpp4 inhibitors as shown in table
2 .
dpp4 inhibitor use was a predictor of cardiac and allcause mortality in the prematched cohort within the crude model , prematched cohort adjusted for ps as covariate model , and postmatched cohort ( p < 0.05 , respectively ) .
cox proportional hazard models of cardiac death and allcause mortality in prematched cohort and postmatched cohort ci , confidence interval ; ps , propensity score .
new york heart association ( over iii ) , haemoglobin , log ( bnp ) , betablocker , and ps .
interactions between dpp4 inhibition therapy and clinically relevant variables were modelled with cox regression and presented in figure
4 as a forest plot for allcause mortality in the matched population .
interaction analyses rendered similar results to subgroup analyses , with the additional benefit of being able to statistically test for differences in associations between dpp4 use and outcomes between subgroups . in figure
4 ,
a forest plot illustrates the association between dpp4 use and allcause mortality in subgroups after adjustment for interactions between prespecified clinically important variables and dpp4 inhibitors .
there was no interaction between dpp4 inhibitor use and other important variables to affect allcause mortality .
bmi , body mass index ; bnp , btype natriuretic peptide ; ckd , chronic kidney disease ; dm , diabetes mellitus ; lvef , left ventricular ejection fraction ; nyha , new york heart association ; ras , renin angiotensin aldosterone system . our findings , both in a matched population based on ps and in an overall population adjustment for ps , were consistent .
importantly , with regard to dpp4 inhibitor use , there was no interaction between other variables associated with allcause mortality .
to the best of our knowledge , the present study is the first to show the association of dpp4 inhibitors and low cardiac and allcause mortality of hospitalized hf patients with dm based on ps analyses .
diabetes mellitus probably impairs cardiac function and causes additional myocardial damage,6 , 28 and an increase of hba1c is associated with prevalence of hf.29 some antidiabetic drugs , such as thiazolidinediones , worsen fluid retention and exacerbate hf,6 , 30 , 31 , 32 whereas sulfonylureas and insulin potentially exacerbate the dysregulation of myocardial metabolism and worsen left ventricular function.33 , 34 , 35 hence , treating hf and dm together is challenging.4 , 5 , 6 , 33 , 34 based on preclinical and early clinical work , dpp4 inhibitors should , in theory , have beneficial effects on left ventricular reverse remodelling36 and renal amelioration36 , 37 resulting in improvement of hf.7 , 8 , 9 , 38 dpp4 stimulates activation of proinflammatory cytokines,39 independent drivers of progression of left ventricular systolic dysfunction , because of their prohypertrophic and profibrotic effect.40 dpp4 inhibition should direct bnp metabolism towards an increase in active bnp rather than biologically inactive bnp precursor fragments.39 there also seems to be interaction between dpp4 inhibitors and ras inhibitors.41
to date , there have only been three random clinical trials regarding associations of dpp4 inhibitors and cardiovascular events in dm patients , and the hospital admission for hf results differs among the three trials .
first , saxagliptin assessment of vascular outcomes recorded in patients with diabetes mellitusthrombolysis in myocardial infarction 53 trial was designed to evaluate longterm cardiovascular efficacy in 16 492 patients with dm ( hba1c of 6.512.0% ) who were at risk of cardiovascular events , including 13% with a previous hf episode.13 , 14 over a median of 2.1 year followup , saxagliptin did not increase or decrease the rate of major adverse cardiovascular events , although the rate of unexpected hospitalization for hf was increased.13 , 14 this increase in risk was the highest among patients with elevated levels of natriuretic peptides , previous hf , or chronic kidney disease.13 the second trial , examine,15 , 16 enrolled 5380 patients with dm ( hba1c 6.511.0% ) and a recent acute coronary syndrome event , including 29% who had previous hf . over a median of 1.5 year followup , alogliptin did not increase or decrease the rate of major adverse cardiovascular events.16 posthoc analyses from the examine trial , with regard to hf ,
recently reported that alogliptin had no effect on hospital admission for hf and that cardiovascular mortality differed by baseline bnp concentration.15 although the rate of cardiovascular mortality was similar in the alogliptin and placebo group in the first to third quartiles of baseline bnp concentration , cardiovascular mortality was significantly lower in the alogliptin group in the highest bnp quartiles.15 these results are concordant with lower mortality in the dpp4 group of our hospitalized hf patients with dm .
the third trial , trial evaluating cardiovascular outcomes with sitagliptin,19 enrolled 14 671 patients with dm ( hba1c 6.58.0% ) and established cardiovascular disease , including 18% with a past history of hf . over a median of 3 year followup , sitagliptin did not increase the risk of major adverse cardiovascular events , hospitalization for hf , or other adverse events.19 the reasons that our results differ from previous studies may relate to the differences in the patients who were enrolled , background therapy including ras inhibitors , and intrinsic pharmacologic differences among dpp4 inhibitors , or it may simply represent the role of chance in previous findings . in addition , there may be a potential class effect among each dpp4 inhibitor.42 most of our study population received sitagliptin or vildagliptin , and these results may positively affect prognosis .
another study , entitled vildagliptin in ventricular dysfunction diabetes trial,43 tested the effects of vildagliptin in 254 patients with dm and hf with systolic dysfunction ( lvef < 40% ) .
the primary endpoint was the change in lvef over 52 weeks , to demonstrate noninferiority compared with placebo .
there was no difference between vildagliptin and placebo in the lvef at 12 months and , interestingly , no excess of hf hospitalization with vildagliptin .
another ongoing trial , the cardiovascular outcome study of linagliptin versus glimepiride in patients with type 2 diabetes , is expected to clarify this issue .
our study has several strengths and differs from previous studies13 , 14 , 15 , 16 , 19 in many ways .
for instance , the present study is the first to show the association of dpp4 inhibitors with lower cardiac and allcause mortality in hospitalized hf patients with dm , including nonischaemic hf , with a relatively long followup period .
our study population included only hospitalized hf patients with dm , many of whom had higher levels of natriuretic peptide , had higher prevalence of chronic kidney disease , and had received higher prevalence of ras inhibitors than previous studies.13 , 14 , 15 , 16 , 19 in addition , diagnosis of hf and causes of death including cardiac and allcause mortality were accurately made by our experienced cardiologists .
first , our study is a nonrandomized and observational study of a single institution , so the number of subjects was relatively small , and there are potential biases and confounders that may be responsible for our findings . although propensity analyses are powerful , they are inherently limited by the number and accuracy of variables evaluated .
importantly , we can not rule out residual confounding from unknown or unmeasured variables , and the effects of differences in backgrounds between the two groups might not be completely adjusted . however , because of the worse outcome for hf patients with dm using dpp4 inhibitors in previous studies,13 , 14 the enforcement of randomized clinical trials to determine the impact of dpp4 on the prognosis of patients with hf and dm is ethically difficult .
second , we have assessed this study using only index hospitalization variables , without consideration for changes in medical parameters and postdischarge treatment .
changes in dpp4 inhibitor use were not considered , and there might be little crossover between the two groups . however , if a crossover bias was present , it would have led to underestimation of the association between dpp4 inhibitor use and survival .
third , a standardized difference between matched groups of less than 10% is generally considered inconsequential .
of all the nine variables assessed , only use of insulin had a standardized difference of > 10% .
hence , further clinical trials for hf patients with dm using dpp4 inhibitors are required , with a larger population .
our study has several strengths and differs from previous studies13 , 14 , 15 , 16 , 19 in many ways .
for instance , the present study is the first to show the association of dpp4 inhibitors with lower cardiac and allcause mortality in hospitalized hf patients with dm , including nonischaemic hf , with a relatively long followup period .
our study population included only hospitalized hf patients with dm , many of whom had higher levels of natriuretic peptide , had higher prevalence of chronic kidney disease , and had received higher prevalence of ras inhibitors than previous studies.13 , 14 , 15 , 16 , 19 in addition , diagnosis of hf and causes of death including cardiac and allcause mortality were accurately made by our experienced cardiologists .
first , our study is a nonrandomized and observational study of a single institution , so the number of subjects was relatively small , and there are potential biases and confounders that may be responsible for our findings . although propensity analyses are powerful , they are inherently limited by the number and accuracy of variables evaluated .
importantly , we can not rule out residual confounding from unknown or unmeasured variables , and the effects of differences in backgrounds between the two groups might not be completely adjusted . however , because of the worse outcome for hf patients with dm using dpp4 inhibitors in previous studies,13 , 14 the enforcement of randomized clinical trials to determine the impact of dpp4 on the prognosis of patients with hf and dm is ethically difficult .
second , we have assessed this study using only index hospitalization variables , without consideration for changes in medical parameters and postdischarge treatment .
changes in dpp4 inhibitor use were not considered , and there might be little crossover between the two groups . however ,
if a crossover bias was present , it would have led to underestimation of the association between dpp4 inhibitor use and survival .
third , a standardized difference between matched groups of less than 10% is generally considered inconsequential .
of all the nine variables assessed , only use of insulin had a standardized difference of > 10% .
hence , further clinical trials for hf patients with dm using dpp4 inhibitors are required , with a larger population .
our findings suggest that use of dpp4 inhibitors may be associated with lower cardiac and allcause mortality than without dpp4 inhibitors in hospitalized hf patients with dm .
25461061 ) from the japan society for the promotion of science and grantsinaid from the japanese ministry of health , labor , and welfare , tokyo , japan . | abstractbackgroundheart failure ( hf ) and diabetes mellitus ( dm ) often coexist .
treatment of dm in hf patients is challenging because some therapies for dm are contraindicated in hf .
although previous experimental studies have reported that dipeptidyl peptidase4 ( dpp4 ) inhibitors improve cardiovascular function , whether dpp4 inhibition improves mortality of hf patients with dm remains unclear .
therefore , we examined the impact of dpp4 inhibition on mortality in hospitalized hf patients using propensity score analyses.methods and resultswe performed observational study analysed by propensity score method with 962 hospitalized hf patients .
of these patients , 293 ( 30.5% ) had dm , and 122 of these dm patients were treated with dpp4 inhibitors .
propensity scores for treatment with dpp4 inhibitors were estimated for each patient by logistic regression with clinically relevant baseline variables .
the propensitymatched 1:1 cohorts were assessed based on propensity scores ( dpp4 inhibitors , n = 83 , and nondpp4 inhibitors , n = 83 ) .
kaplan
meier analysis in the propensity scorematched cohort demonstrated that cardiac and allcause mortality was significantly lower in the dpp4 inhibitor group than in the nondpp4 inhibitor group ( cardiac mortality : 4.8% vs. 18.1% , p = 0.015 ; allcause mortality : 14.5% vs. 41.0% , p = 0.003 , by a logrank test ) . in the multivariable cox
proportional hazard analyses , after adjusting for other potential confounding factors , the use of dpp4 inhibitors was an independent predictor of allcause mortality ( prematched cohort : hazard ratio 0.467 , p = 0.010 ; postmatched cohort : hazard ratio 0.370 , p = 0.003 ) in hf patients with dm.conclusionsour data suggest that dpp4 inhibitors may improve cardiac and allcause mortality in hospitalized hf patients with dm . |
evolution and speciation are believed to be driven in large part by the insertion of transposable elements ( tes ) within eukaryotic genes .
the tes can integrate into a gene with either a forward or reverse pattern according to the transcription directionality of the inserted gene and the transposase gene .
when inserting into the exons of genes , tes may disrupt and cause the loss of function of genes into which they are inserted .
however , the insertion of tes within the intronic sequences of a given gene can also have the effect of altering pre
the as that results from te insertion may cause interference with the normal splicing of the inserted gene s transcribed region , whereas the exonization results in a cryptic splice site of the inserted te to generate a new exon of the inserted gene . any additional variant due to as or exonization may subsequently evolve to form a protein with new functions . moreover
, the operation of natural selection may even serve to enhance the novel splice sites and , in turn , to raise the production level of the new variant if it is advantageous .
alternative splicing is commonly seen in higher eukaryotes , but its role in expanding the functions of the plant proteome is limited .
in contrast , exonization can potentially introduce a portion or portions of a te into the resulting transcripts , thereby altering the reading frames so as to enhance the complexity of proteomes , as was found , for example , in our previous study involving the insertion of a mini ds transposon into the modified tobacco marker gene epsps .
the ac / ds system includes the first tes recognized in the scientific literature , having been identified by barbara mcclintock 60 years ago .
ds transposons of the nonautonomous ( transposase defective ) variety consist of 11 bp terminal inverted repeats as well as approximately 250 bp of both ends ( ie , terminal regions ) of their full form transposon , activator ( ac ) .
there are 3 different types of ds elements , namely , ds , ds1 , and ds2 .
ds1 has 13 bp at the 5 terminal and 26 bp at the 3 terminal in common with ac , whereas the internal region of ds1 is not homologous to ac .
ds1 can be mobilized not only by ac but also by another te , uq , which does not trans - activate ds elements of the ds family .
ds and ds1 are identical for the first 19 bp containing 2 discontinuous but in - framed premature termination codons ( ptcs ; figure 1 ) .
in addition , ds and ds1 are both biased toward providing splice donor and/or acceptor sites located close to their terminal regions .
ds provides only donors ( 1 forward and 4 reverse insertion patterns ) , whereas ds1 provides 3 donors and 2 acceptors associating with 11 possible exonizing patterns ( all in reverse insertion patterns ) .
these different features between ds and ds1 imply possibly independent evolutionary impacts of ds and ds1 induced through exonization . to investigate their roles from an evolutionary perspective
, we have simulated all putative ds - exonized as well as ds1-exonized transcripts in the rice genome .
the exonized transcripts were translated into proteins and characterized as c - terminal variants ( ie , those for which the c - terminus of the reference protein was replaced by the output peptides ) and interior variants ( ie , those for which additional peptides were inserted in the middle of the original transcript even as the same original termination codon was used ) .
we also performed a functional profile analysis based on the prosite database and revealed the possibility of proteome enrichment by ds exonization .
( b ) ds1 and ds sequences yielding splice acceptor ( a ) or donor ( d ) junctions ( arrows ) as well as premature termination codons in exonized transcripts ( bold ) .
the translated products of ds1 are also shown , of which gains / losses of 7 amino acids ( boxes ) yielded using d3/d1 were important to compose functional profiles .
the termini repeat sequences of each transposable element are underlined . note that ds could provide 5 donors , r1 , r2 , r3 , r4 , and f1 , but no acceptor .
the donor , f1 , is used for exonization by the opposite insertion pattern . in this study , we investigated the behavior of ds1 in exonization and compared it with that of ds .
a protocol similar to that used by chien et al , with some modifications ( see materials and methods section ) , was applied to the ds1-exonized protein variants .
we found that the ds1-exonized messages with no more than 59 nucleotides were actively involved in creating diverse functional profiles .
in particular , protein variants exonized from a single ds1 insertion site with 2-amino - acid differences corresponded to 18 different functional profiles .
although ds1 and ds can build functional profiles per intron with similar efficiencies , ds1 exonization produces 459 unique profiles , of which 129 are not produced by ds .
we thus conclude that ds and ds1 are independent but synergistic in their capacity to enrich proteome complexity through exonization .
open reading frame ( orf ) analysis was conducted for all of these exonized transcripts beginning at the original start codon and ending at the first in - frame stop codon .
the transcripts were categorized as type i , type ii , type iii , or type iv transcripts depending on , respectively , whether the in - frame stop codon was located at the conserved region of the original splice junction , at the intron inserted by ds1 , at the ds1 transposon itself , or at any exon occurring after the ds1 insertion .
furthermore , in the event that the orf analysis revealed no in - frame stop codon , the corresponding transcript was categorized as a type v transcript , and the incomplete transcript ( ie , incomplete in that it lacked a stop codon ) was output directly .
in addition , the transcripts were further categorized as belonging to 1 of 2 subtypes : if the termination codon of the transcript was the same as that of the reference transcript ( ie , the transcript without the ds1 insertion ) , it was categorized as an interior transcript ; otherwise , it was categorized as a c - terminal transcript . if a given transcript contained a termination codon that was located more than 55 nucleotides upstream from the last exon / exon junction , it was considered a potential target for the nonsense - mediated decay ( nmd ) pathway and was therefore omitted from isoform prediction .
the proteins of these transcripts not targeted by the nmd pathway were called non - nmd protein variants and were further translated to protein sequences .
the original protein sequences and protein sequences from type iii , iv , and v non - nmd variants were subject to protein profile analysis , in which we scanned the sequences to search for domains ( profiles ) previously reported in the prosite database ( version 20.83 ) .
the prosite database contains a total of 2442 entries that describe the various protein domains , families , and functional sites , in addition to the various amino acid patterns , profiles , and signatures contained within them . instead of using all the entries in prosite , we only scanned for the 1308 patterned ones to consistently identify the newly developed profiles using the same standard .
the functional profiles of each protein variant were compared with the ones of its reference protein . only those variants yielding additional functional profile(s ) were collected .
as described in the text above , the new functional profiles in the protein isoforms were classified into subclasses named with 2 digits from 0 to 4 to indicate the start and the end of the amino acids from which the profiles originated , where 0 to 4 denoted the skipped exon , the flanking intron upstream from ds1 , ds1 itself , the flanking intron downstream from ds1 , and the upcoming exon , respectively ( figure 1a ) .
following the same logic , the profile names shown in the text combined the information of interior ( i ) or c - terminal ( c ) type as well as the ds1 portion used .
for example , a class i22-d1 profile indicates a 22 profile observed in an interior functional variant ( i ) when ds1 provided the first donor ( d1 ) .
further analyses of the resulting protein variants in different types were conducted using r ( version 2.15.1 ) .
functional profile analyses were performed on the previously simulated ds1-exonized non - nmd protein variants in rice according to the patterned - profile database in prosite . from a total of 38 427 898 non - nmd variants , only 14 258 780 ( 4 303 236 interior and 9 955 544 c - terminal ) variants yielding additional functional profile(s ) were collected and termed as functional variants ( table 1 and figure 2 ) . there were 47.33% ( 6 748 622 of 14 258 780 ) , 27.31% ( 3 893 991 of 14 258 780 ) , and 25.36% ( 3 616 167 of 14 258 780 ) of the functional variants using an acceptor ( a ) alone , a donor ( d ) alone , or both a donor and an acceptor ( da ) of ds1 , respectively ( table 1 and figure 2 ) .
most of the interior variants ( 54.59% ) originated from ds1 providing donors only , whereas most of the c - terminal variants ( 55.36% ) originated from ds1 providing acceptors .
number of variants , profiles , and profiles per variant yielded by each donor , acceptor , and donor - acceptor combination .
the proportions of functional variants : ( a ) all variants , ( b ) all variants , ( c ) interior variants , and ( d ) c - terminal variants . a indicates acceptor ; d , donor ; da , donor and acceptor .
the additional functional profiles yielded by the variants were further classified into subclasses named with 2 digits from 0 to 4 to indicate the start and the end of the amino acids from which the profiles originated , where 0 to 4 denoted the skipped exon , the flanking intron upstream from ds1 , ds1 itself , the flanking intron downstream from ds1 , and the upcoming exon , respectively ( figure 1a ) .
for example , a class 02 profile indicates that the functional profile in question was made from amino acids combining the messages ( sequences ) of the skipped exon , flanking upstream intron , and ds1 ; a 22 profile indicates a profile made from the ds1 message alone ; and a 04 profile indicates a functional profile made from combining the messages all the way from the skipped exon to the upcoming exon .
04 profiles were expected to be rare because 95% of the patterned profiles presented in prosite are composed of less than 30 amino acids . indeed ,
04 profiles accounted for only about 0.4% of the total profiles ( supplementary table s1a and s1c ) . following the same logic ,
a class i22-d1 profile is a 22 profile observed in an interior functional variant ( i ) when ds1 provided the first donor ( d1 ) .
supplementary table s1c and s1d presents the numbers of unique profiles in all classes of interior and c - terminal variants , respectively .
for example , exonization caused using donors alone ( d ) can not yield profiles starting / ending with 3 ( the intron downstream from ds1 ) .
about 68% ( 4 975 488 out of 7 368 405 ) of the interior profiles ( ie , additional profiles from interior functional variants ) originated from ds1 providing donors only ( table 1 and figure 3a ) . the classes i11-d1 and i11-d3 yielded the highest number of new profiles ( 870 463 ) composed of 59 unique ones ( supplementary table s1a and figure 3c ) .
the number of d2 interior profiles was generally lower than the numbers of d1 and d3 interior profiles due to fact that the d2 variants share the same reading frame with the stop codon , tag , in the upstream ds1 ( figure 1b ) . for c - terminal protein isoforms , 46.3% of the profiles originated from ds1 providing acceptors only ( table 1 and figure 3b ) . the classes c33-a1 and c33-a2 created the most additional profiles composed of 113 and 120 unique ones , respectively ( supplementary table s1b and sid and figure 3d ) .
a c - terminal isoform was constructed using a reading frame different from that of the reference protein , and therefore , a greater diversity of c - terminal profiles than interior profiles were expected .
in fact , among the 1308 profiles defined in the prosite database , 459 unique profiles were observed in all isoforms in this study , where 334 and 399 unique profiles appeared only in interior variants and only in c - terminal variants , respectively .
the proportions and numbers of functional profiles : ( a ) interior profiles , ( b ) c - terminal profile , ( c ) numbers of interior profile ( in thousands ) , and ( d ) numbers of c - terminal profiles ( in thousands ) . a indicates acceptor ; d , donor ; da , donor and acceptor .
the numbers and types of new functional profiles from d - variants ( meaning the functional variants using a donor alone ) , a - variants ( meaning the functional variants using an acceptor alone ) , and da - variants ( meaning the functional variants using both da ) were very different from each other ( figure 3 ) .
most of functional profiles from a - variants resulted from c - terminal variants , for about 1.96 profiles per variant , but da - variants yielded an average of 4.1 profiles per variant ( table 1 ) .
interestingly , the classes yielding the most additional profiles were not necessarily the classes yielding the most unique profiles .
for example , the profile number of class i12-d1 ( 204 859 ) was 4.3-fold less than that of i11-d1 ( 870 463 ) , but more unique profiles were yielded by i12-d1 ( 111 ) than by i11-d1 ( 69 ) .
this implies the contribution of incorporated ds1 messages , even those consisting of merely 14 bp , for yielding variants with new functions .
33 , 34 , and 44 only using the intron / exon sequences of the affected transcripts are ds1 independent , whereas the other classes are ds1 dependent .
the number of ds1-independent profiles ( 23 618 314 ) was about 1.9-fold higher than the number of ds1-dependent ones ( 12 327 988 ) .
because only a maximum of 59 bp from a ds1 message would be incorporated into the resulting protein isoforms , the major contribution of a te to exonization was expected to be the incorporation of the message of te - inserted intron of the affected transcripts rather than the message itself .
however , the ds1-independent and ds1-dependent profiles were composed of 314 and 398 unique profiles , respectively , with 253 overlapping profiles ( supplementary table 2 ) .
this implies that the exonized ds1 message is important for building functional profiles for selective advantage , either via the ds1 message alone or together with its flanking intron / exon .
there were 1 506 257 ( 20.44% of all the interior profiles ) and 4 302 547 ( 25.58% of all the c - terminal profiles ) class 22 interior and c - terminal profiles , respectively , built using the ds1 message alone .
these abundant class 22 profiles were composed of only 6 unique profiles , ps00004 , ps00005 , ps00006 , ps00007 , ps00008 , and ps00009 ( the underlined profiles were also yielded by ds alone ) .
the remaining 139 unique ds1-dependent profiles were therefore built using the message of ds1 together with its flanking intron / exon , and that number is still 2.3-fold ( = 139/61 ) ( supplementary table 2 ) more than the number of unique ds1-independent profiles . although ds1 may yield 11 exonized transcript isoforms at a single insertion site , the translated protein products might be similar to each other .
for example , isoforms yielded by d2a1 and d3a2 differ from each other by a mere 2 amino acids ( figure 4 ) . this feature seems to underestimate the contribution of ds1 exonization to proteome complexity .
however , these small differences in isoforms from a single insertion site surprisingly contributed various new profiles , which was further illustrated using the two particular examples of ( 1 ) comparing isoforms using either d3 or d1 and ( 2 ) comparing isoforms using one of d1a1 , d2a1 , and d3a2 .
distinct donor / acceptor combinations ( ie , d1a2 , d2a1 , and d3a2 ) resulting in proteins that differ from other proteins by only a few amino acids .
the translated protein isoforms of d3 and d1 at the same insertion site differed by only 7 amino acids ( either as vgngiys or grkrylf according to the reading frames ) because the splice junction of d3 is located 21 bp downstream from that of d1 ( figure 1b ) .
the 7-amino - acid sequences were responsible for 10 more unique profiles in class i12-d3 than in class i12-d1 ( figure 2 ) .
however , the lack of these 7-amino - acid sequences meant that class i14-d3 yielded only 21 unique profiles , less than the 78 yielded by class i14-d1 .
these results indicate that both the presence and absence of a part of the ds1 message would act positively for building unique profiles in exonization events .
table 2 shows the ids of the profiles yielded by gaining or losing 7 amino acids .
the presence or absence of the 7 amino acids caused by alternatives of the d1 or d3 sites of ds1 provided 133 unique profiles , of which 81 and 27 were exclusively yielded by d1 and d3 , respectively .
it is notable that the total number of profiles composing a class may not be equal to the number of unique profiles of that class shown in figures 2 and 3 because messages other than these 7 amino acids can also contribute to creating functional profiles .
similar results were observed when comparing profiles from d1a1 and d3a1 isoforms or those from d1a2 and d3a2 isoforms .
unique functional profiles yielded by gaining or losing 7 amino acids ( either as vgngiys or grkrylf ) , which would be exonized using d1 and d3 donors because the splice junction of d3 is located downstream from d1 by 21 bp .
note that the total number of profiles composing a class may not be equal to the number of unique profiles of that class shown in figures 2 and 3 because messages other than these 7 amino acids can also build functional profiles .
the second example mentioned above consisted of comparing the translated protein isoforms of d1a2 , d2a1 , and d3a2 differing by only 2 to 7 additional amino acids ( figure 4 ) .
table 3 shows the profiles that were built in protein isoforms by 1 or 2 ( but not all ) of the d1a2 , d2a1 , and d3a2 isoforms from a single ds1 insertion site .
for example , 13 , 5 , and 6 profiles were yielded only by d1a2 , d2a1 , and d3a2 , respectively ( bold - faced profiles in table 3 ) .
d1a2 provided the lowest number of ds1 messages , but a specific amino acid sequence , gmktiitfip , from d1a2 exonization exclusively contributed 7 profiles , ps00445 , ps00622 , ps00634 , ps00740 , ps00838 , ps01241 , and ps01359 , which were not observed in d2a1 and d3a2 isoforms ( figure 4 and table 3 ) .
although ps00189 , ps00371 , ps01067 , and ps00041 were present in all the d1a2 , d2a1 , and d3a2 isoforms , they originated from different ds1 insertion sites and , consequently , were built by independent translated ds1 messages .
for example , ps00189 was matched by the translated ds1 messages rdendy ,
naqiitfip , and gmktvgngiy from d1a2 , d2a1 , and d3a2 patterns , respectively , due to its pattern being relatively broadly defined . taken together ,
all the functional profiles shown in tables 2 and 3 contributed about one - third ( 48 of 145 ) of the ds1-dependent exclusive profiles ( supplementary table 2 ) using merely 59 bp .
unique translated ds1 messages for the functional profiles of exonized protein isoforms yielded by joining specific donor and acceptor sites of d1a2 , d2a1 , and d3a2 .
the resulting variants differ from others by only a few amino acids , which build unique profiles by 1 ( bold ) or 2 patterns only .
although ps00189 , ps00371 , ps01067 , and ps00041 present in all three patterns , each profile was built by independent translated ds1 message ( see text ) .
profiles yielded by gaining or losing 7 amino acids ( either as vgngiys or grkrylf ) , which are exonized using d1a2 and d3a2 , were not shown .
new interior profiles due to exonization only using ds1 acceptors accounted for less than 1% of the interior profiles ( figure 3a ) , but new c - terminal profiles using ds1 acceptors accounted for about 46% of the c - terminal profiles ( blue bars in figure 3 ) .
similarly , either gain or loss of the ds1 messages using ds1 acceptors enriches proteome complexity through the creation of unique profiles .
for example , the number of unique profiles in class c33-a2 , 120 , yielded by providing an extra 19 bp was a bit higher than that in c33-a1 , 118 ( figure 3 ) ; however , the number of unique profiles in class c23-a2 , 184 , was less than that in c23-a1 , 193 .
all these results suggest that ds1 messages play a different role than ds messages in building new functional protein isoforms for selective advantage . as shown in figure 1b , the ds and ds1 transposons share a large degree of similarity in their sequences .
however , the behaviors of these 2 tes for exonization involved in splicing events are different : ds provides only donors ( 1 forward and 4 reverse insertion patterns ) , whereas ds1 provides both donors and acceptors .
only 1 splice donor site , d1 for ds1 and r1 for ds , appears in both tes , and the same set of protein isoforms were yielded in both simulations using this particular loci ( figure 1b ) .
however , the new profiles yielded from functional variants using sites other than r1 in ds1 are considered to be ds1-specific profiles . for interior variants ,
an intron may yield up to 75 052 ( average = 96.92 ) new functional profiles via ds1 insertion and subsequent exonization events ( figure 5a ) .
for c - terminal variants , an intron may yield up to 413 354 ( average = 348.84 ) new profiles ( figure 5a ) . the particularly high number of profiles that a given intron could produce in terms of c - terminal variants could result from the peptides generated as a result of a new reading frame being used to replace the reference protein s c - terminus . for the unique profiles
, the interior variants can yield up to 12 unique profiles ( average = 2.91 ) via an intron , whereas the c - terminal can yield up to 18 ( average = 3.78 ) unique profiles ( figure 5c ) .
the distributions of ( a and b ) numbers and ( c and d ) unique numbers of profiles per intron in rice yielded by ds1 and ds exonization , respectively . through a comparison with those profiles obtained with ds exonization in rice ( figure 5b and 5d )
, we found that ds insertion yielded more profiles and unique profiles per intron than ds1 insertion did via exonization .
we reason that the insertion of the specific forward - pattern donor , f1 , provided by ds might possibly cause more distinct variants being exonized ( figure 1b ) ; this forward splice donor is , however , absent in ds1 .
the inflated number of variants by f1 insertion rationally brought on a higher number of ( unique ) profiles per intron , particularly in c - terminal variants .
however , from a total number of 1308 patterned profiles in the prosite database , ds1 and ds built 459 and 365 unique profiles , respectively , with 330 identical ones ( supplementary table 3 ) , meaning that there are only 129 and 35 unique profiles exclusively built by ds1 and ds , respectively .
this implies that although the termini of ds and ds1 are highly conserved , they yield independent sets of exonized protein isoforms and would thus be synergistic in contributing to the evolution of proteome complexity .
functional profile analyses were performed on the previously simulated ds1-exonized non - nmd protein variants in rice according to the patterned - profile database in prosite . from a total of 38 427 898 non - nmd variants , only 14 258 780 ( 4 303 236 interior and 9 955 544 c - terminal ) variants yielding additional functional profile(s ) were collected and termed as functional variants ( table 1 and figure 2 ) . there were 47.33% ( 6 748 622 of 14 258 780 ) , 27.31% ( 3 893 991 of 14 258 780 ) , and 25.36% ( 3 616 167 of 14 258 780 ) of the functional variants using an acceptor ( a ) alone , a donor ( d ) alone , or both a donor and an acceptor ( da ) of ds1 , respectively ( table 1 and figure 2 ) .
most of the interior variants ( 54.59% ) originated from ds1 providing donors only , whereas most of the c - terminal variants ( 55.36% ) originated from ds1 providing acceptors .
number of variants , profiles , and profiles per variant yielded by each donor , acceptor , and donor - acceptor combination .
the proportions of functional variants : ( a ) all variants , ( b ) all variants , ( c ) interior variants , and ( d ) c - terminal variants . a indicates acceptor ; d , donor ; da , donor and acceptor .
the additional functional profiles yielded by the variants were further classified into subclasses named with 2 digits from 0 to 4 to indicate the start and the end of the amino acids from which the profiles originated , where 0 to 4 denoted the skipped exon , the flanking intron upstream from ds1 , ds1 itself , the flanking intron downstream from ds1 , and the upcoming exon , respectively ( figure 1a ) .
for example , a class 02 profile indicates that the functional profile in question was made from amino acids combining the messages ( sequences ) of the skipped exon , flanking upstream intron , and ds1 ; a 22 profile indicates a profile made from the ds1 message alone ; and a 04 profile indicates a functional profile made from combining the messages all the way from the skipped exon to the upcoming exon .
04 profiles were expected to be rare because 95% of the patterned profiles presented in prosite are composed of less than 30 amino acids . indeed ,
04 profiles accounted for only about 0.4% of the total profiles ( supplementary table s1a and s1c ) . following the same logic ,
a class i22-d1 profile is a 22 profile observed in an interior functional variant ( i ) when ds1 provided the first donor ( d1 ) .
supplementary table s1c and s1d presents the numbers of unique profiles in all classes of interior and c - terminal variants , respectively .
for example , exonization caused using donors alone ( d ) can not yield profiles starting / ending with 3 ( the intron downstream from ds1 ) .
about 68% ( 4 975 488 out of 7 368 405 ) of the interior profiles ( ie , additional profiles from interior functional variants ) originated from ds1 providing donors only ( table 1 and figure 3a ) . the classes i11-d1 and i11-d3 yielded the highest number of new profiles ( 870 463 ) composed of 59 unique ones ( supplementary table s1a and figure 3c ) .
the number of d2 interior profiles was generally lower than the numbers of d1 and d3 interior profiles due to fact that the d2 variants share the same reading frame with the stop codon , tag , in the upstream ds1 ( figure 1b ) . for c - terminal protein isoforms , 46.3% of the profiles originated from ds1 providing acceptors only ( table 1 and figure 3b ) . the classes c33-a1 and c33-a2 created the most additional profiles composed of 113 and 120 unique ones , respectively ( supplementary table s1b and sid and figure 3d ) .
a c - terminal isoform was constructed using a reading frame different from that of the reference protein , and therefore , a greater diversity of c - terminal profiles than interior profiles were expected .
in fact , among the 1308 profiles defined in the prosite database , 459 unique profiles were observed in all isoforms in this study , where 334 and 399 unique profiles appeared only in interior variants and only in c - terminal variants , respectively .
the proportions and numbers of functional profiles : ( a ) interior profiles , ( b ) c - terminal profile , ( c ) numbers of interior profile ( in thousands ) , and ( d ) numbers of c - terminal profiles ( in thousands ) . a indicates acceptor ; d , donor ; da , donor and acceptor .
the numbers and types of new functional profiles from d - variants ( meaning the functional variants using a donor alone ) , a - variants ( meaning the functional variants using an acceptor alone ) , and da - variants ( meaning the functional variants using both da ) were very different from each other ( figure 3 ) .
most of functional profiles from a - variants resulted from c - terminal variants , for about 1.96 profiles per variant , but da - variants yielded an average of 4.1 profiles per variant ( table 1 ) .
interestingly , the classes yielding the most additional profiles were not necessarily the classes yielding the most unique profiles .
for example , the profile number of class i12-d1 ( 204 859 ) was 4.3-fold less than that of i11-d1 ( 870 463 ) , but more unique profiles were yielded by i12-d1 ( 111 ) than by i11-d1 ( 69 ) .
this implies the contribution of incorporated ds1 messages , even those consisting of merely 14 bp , for yielding variants with new functions .
the functional profiles from classes 01 , 11 , 33 , 34 , and 44 only using the intron / exon sequences of the affected transcripts are ds1 independent , whereas the other classes are ds1 dependent .
the number of ds1-independent profiles ( 23 618 314 ) was about 1.9-fold higher than the number of ds1-dependent ones ( 12 327 988 ) . because only a maximum of 59 bp from a ds1 message would be incorporated into the resulting protein isoforms , the major contribution of a te to exonization was expected to be the incorporation of the message of te - inserted intron of the affected transcripts rather than the message itself .
however , the ds1-independent and ds1-dependent profiles were composed of 314 and 398 unique profiles , respectively , with 253 overlapping profiles ( supplementary table 2 ) .
this implies that the exonized ds1 message is important for building functional profiles for selective advantage , either via the ds1 message alone or together with its flanking intron / exon .
there were 1 506 257 ( 20.44% of all the interior profiles ) and 4 302 547 ( 25.58% of all the c - terminal profiles ) class 22 interior and c - terminal profiles , respectively , built using the ds1 message alone .
these abundant class 22 profiles were composed of only 6 unique profiles , ps00004 , ps00005 , ps00006 , ps00007 , ps00008 , and ps00009 ( the underlined profiles were also yielded by ds alone ) .
the remaining 139 unique ds1-dependent profiles were therefore built using the message of ds1 together with its flanking intron / exon , and that number is still 2.3-fold ( = 139/61 ) ( supplementary table 2 ) more than the number of unique ds1-independent profiles . although ds1 may yield 11 exonized transcript isoforms at a single insertion site , the translated protein products might be similar to each other .
for example , isoforms yielded by d2a1 and d3a2 differ from each other by a mere 2 amino acids ( figure 4 ) .
however , these small differences in isoforms from a single insertion site surprisingly contributed various new profiles , which was further illustrated using the two particular examples of ( 1 ) comparing isoforms using either d3 or d1 and ( 2 ) comparing isoforms using one of d1a1 , d2a1 , and d3a2 .
distinct donor / acceptor combinations ( ie , d1a2 , d2a1 , and d3a2 ) resulting in proteins that differ from other proteins by only a few amino acids .
the translated protein isoforms of d3 and d1 at the same insertion site differed by only 7 amino acids ( either as vgngiys or grkrylf according to the reading frames ) because the splice junction of d3 is located 21 bp downstream from that of d1 ( figure 1b ) .
the 7-amino - acid sequences were responsible for 10 more unique profiles in class i12-d3 than in class i12-d1 ( figure 2 ) .
however , the lack of these 7-amino - acid sequences meant that class i14-d3 yielded only 21 unique profiles , less than the 78 yielded by class i14-d1 .
these results indicate that both the presence and absence of a part of the ds1 message would act positively for building unique profiles in exonization events .
table 2 shows the ids of the profiles yielded by gaining or losing 7 amino acids .
the presence or absence of the 7 amino acids caused by alternatives of the d1 or d3 sites of ds1 provided 133 unique profiles , of which 81 and 27 were exclusively yielded by d1 and d3 , respectively .
it is notable that the total number of profiles composing a class may not be equal to the number of unique profiles of that class shown in figures 2 and 3 because messages other than these 7 amino acids can also contribute to creating functional profiles .
similar results were observed when comparing profiles from d1a1 and d3a1 isoforms or those from d1a2 and d3a2 isoforms .
unique functional profiles yielded by gaining or losing 7 amino acids ( either as vgngiys or grkrylf ) , which would be exonized using d1 and d3 donors because the splice junction of d3 is located downstream from d1 by 21 bp . note that the total number of profiles composing a class may not be equal to the number of unique profiles of that class shown in figures 2 and 3 because messages other than these 7 amino acids can also build functional profiles .
the second example mentioned above consisted of comparing the translated protein isoforms of d1a2 , d2a1 , and d3a2 differing by only 2 to 7 additional amino acids ( figure 4 ) .
table 3 shows the profiles that were built in protein isoforms by 1 or 2 ( but not all ) of the d1a2 , d2a1 , and d3a2 isoforms from a single ds1 insertion site .
for example , 13 , 5 , and 6 profiles were yielded only by d1a2 , d2a1 , and d3a2 , respectively ( bold - faced profiles in table 3 ) .
d1a2 provided the lowest number of ds1 messages , but a specific amino acid sequence , gmktiitfip , from d1a2 exonization exclusively contributed 7 profiles , ps00445 , ps00622 , ps00634 , ps00740 , ps00838 , ps01241 , and ps01359 , which were not observed in d2a1 and d3a2 isoforms ( figure 4 and table 3 ) .
although ps00189 , ps00371 , ps01067 , and ps00041 were present in all the d1a2 , d2a1 , and d3a2 isoforms , they originated from different ds1 insertion sites and , consequently , were built by independent translated ds1 messages .
for example , ps00189 was matched by the translated ds1 messages rdendy ,
naqiitfip , and gmktvgngiy from d1a2 , d2a1 , and d3a2 patterns , respectively , due to its pattern being relatively broadly defined . taken together ,
all the functional profiles shown in tables 2 and 3 contributed about one - third ( 48 of 145 ) of the ds1-dependent exclusive profiles ( supplementary table 2 ) using merely 59 bp .
unique translated ds1 messages for the functional profiles of exonized protein isoforms yielded by joining specific donor and acceptor sites of d1a2 , d2a1 , and d3a2 .
the resulting variants differ from others by only a few amino acids , which build unique profiles by 1 ( bold ) or 2 patterns only .
although ps00189 , ps00371 , ps01067 , and ps00041 present in all three patterns , each profile was built by independent translated ds1 message ( see text ) .
profiles yielded by gaining or losing 7 amino acids ( either as vgngiys or grkrylf ) , which are exonized using d1a2 and d3a2 , were not shown .
new interior profiles due to exonization only using ds1 acceptors accounted for less than 1% of the interior profiles ( figure 3a ) , but new c - terminal profiles using ds1 acceptors accounted for about 46% of the c - terminal profiles ( blue bars in figure 3 ) . similarly , either gain or loss of the ds1 messages using ds1 acceptors enriches proteome complexity through the creation of unique profiles .
for example , the number of unique profiles in class c33-a2 , 120 , yielded by providing an extra 19 bp was a bit higher than that in c33-a1 , 118 ( figure 3 ) ; however , the number of unique profiles in class c23-a2 , 184 , was less than that in c23-a1 , 193 .
all these results suggest that ds1 messages play a different role than ds messages in building new functional protein isoforms for selective advantage .
as shown in figure 1b , the ds and ds1 transposons share a large degree of similarity in their sequences .
however , the behaviors of these 2 tes for exonization involved in splicing events are different : ds provides only donors ( 1 forward and 4 reverse insertion patterns ) , whereas ds1 provides both donors and acceptors .
only 1 splice donor site , d1 for ds1 and r1 for ds , appears in both tes , and the same set of protein isoforms were yielded in both simulations using this particular loci ( figure 1b ) .
however , the new profiles yielded from functional variants using sites other than r1 in ds1 are considered to be ds1-specific profiles . for interior variants ,
an intron may yield up to 75 052 ( average = 96.92 ) new functional profiles via ds1 insertion and subsequent exonization events ( figure 5a ) . for c - terminal variants , an intron may yield up to 413 354 ( average = 348.84 ) new profiles ( figure 5a ) .
the particularly high number of profiles that a given intron could produce in terms of c - terminal variants could result from the peptides generated as a result of a new reading frame being used to replace the reference protein s c - terminus . for the unique profiles
, the interior variants can yield up to 12 unique profiles ( average = 2.91 ) via an intron , whereas the c - terminal can yield up to 18 ( average = 3.78 ) unique profiles ( figure 5c ) .
the distributions of ( a and b ) numbers and ( c and d ) unique numbers of profiles per intron in rice yielded by ds1 and ds exonization , respectively . through a comparison with those profiles obtained with ds exonization in rice ( figure 5b and 5d )
, we found that ds insertion yielded more profiles and unique profiles per intron than ds1 insertion did via exonization .
we reason that the insertion of the specific forward - pattern donor , f1 , provided by ds might possibly cause more distinct variants being exonized ( figure 1b ) ; this forward splice donor is , however , absent in ds1 .
the inflated number of variants by f1 insertion rationally brought on a higher number of ( unique ) profiles per intron , particularly in c - terminal variants .
however , from a total number of 1308 patterned profiles in the prosite database , ds1 and ds built 459 and 365 unique profiles , respectively , with 330 identical ones ( supplementary table 3 ) , meaning that there are only 129 and 35 unique profiles exclusively built by ds1 and ds , respectively .
this implies that although the termini of ds and ds1 are highly conserved , they yield independent sets of exonized protein isoforms and would thus be synergistic in contributing to the evolution of proteome complexity .
ds and ds1 , which belong to the same te family , share an identical 13 bp at 5-terminal and 26 bp at 3-terminal sequences . for exonization , the small difference in sequences between ds1 and ds may result in different ptcs , donor sites , and incorporated te messages , which could , consequently , build independent sets of protein variants . as demonstrated in this study , this small difference in sequences makes ds1 act unlike ds in exonization .
we have previously reported that ds passively enriches proteome complexity in exonization by mainly adopting the messages of the flanking introns after ds insertion sites . however , by offering acceptors that create new a - variants and da - variants , ds1 is more actively involved in exonization , either through its message alone or together with its flanking intron / exon , allowing the building of various new functional protein variants .
we also demonstrated that , although a few of the 11 possible exonizing patterns from that ds1 inserting into a single site are very similar to each other , even differences of only a few amino acids are enough to result in a wide spectrum of new profiles among these isoforms .
all these features suggest that the evolutionary impacts of ds and ds1 due to exonization are distinct in various respects .
we thus conclude that ds and ds1 exonizations are independent and synergistic in their effects on evolutionary proteome complexity enrichment .
incorporating further molecular analysis , for example , determining the changes in the priority of exonization sites under various stresses , would provide more information about the evolutionary impact of te exonization .
| in exonization events , ds1 may provide donor and/or acceptor sites for splicing after inserting into genes and be incorporated into new transcripts with new exon(s ) . in this study ,
the protein variants of ds1 exonization yielding additional functional profile(s ) were studied .
unlike ds exonization , which creates new profiles mostly by incorporating flanking intron sequences with the ds message , ds1 exonization additionally creates new profiles through the presence or absence of ds1 messages .
the number of unique functional profiles harboring ds1 messages is 1.3-fold more than that of functional profiles without ds1 messages .
the highly similar 11 protein isoforms at a single insertion site also contribute to proteome complexity enrichment by exclusively creating new profiles .
particularly , ds1 exonization produces 459 unique profiles , of which 129 can not be built by ds .
we thus conclude that ds and ds1 are independent but synergistic in their capacity to enrich proteome complexity through exonization . |
acute renal failure is a frequent feature at diagnosis of multiple myeloma ( mm ) .
it is present in 2055% of patients with a newly diagnosed mm , among whom 23% require dialysis .
renal impairment is a poor prognostic factor in patients with mm as it is associated with an increased morbidity and early mortality rates .
however , patients with renal insufficiency are eligible for high - dose chemotherapy and autologous haematopoietic stem cell transplantation ( autohsct ) .
indeed , autohsct - associated morbidity and mortality rates are not increased in these patients compared to those with normal renal function [ 46 ] .
moreover , mm - related renal insufficiency may improve after autohsct even in patients initially requiring dialysis .
renal function recovery usually occurs in the first months following autohsct ( median 1.64 months ) . here
, we report on two unusual cases of late improvement in renal function after autohsct for mm .
a 57-year - old woman with a history of cervix carcinoma and pulmonary tuberculosis was diagnosed with stage iii b lambda light chain mm in january 2003 .
, laboratory tests showed : serum creatinine ( scr ) 673 mol / l , glomerular filtration rate ( gfr ) estimated according to mdrd formula at 6 ml / min/1.73 m , calcaemia 2.28 mmol / l , albuminaemia 33 g / l , haemoglobin 7.9 g / dl and platelets 125 000/mm . on serum immunofixation , a monoclonal lambda light chain ( 4
her renal function did not improve and she was started on haemodialysis , three times weekly .
initial treatment of mm consisted in five courses of vincristine adriamycine dexamethasone ( vad ) chemotherapy with near complete remission ( no plasma paraprotein detected , bjp 0.09
three months after mm diagnosis renal function partially improved allowing the reduction of haemodialysis dose to two sessions per week . on june 2003 , autohsct was performed after high - dose melphalan ( 200 mg / m ) ; complete remission was obtained . in september 2005
second - line chemotherapy with thalidomide ( 100 mg / day ) and dexamethasone ( 40 mg / day 4 daysa month ) was started .
bjp had decreased to 0.07 g / day and no monoclonal component was detectable in the plasma .
following autohsct , renal function slowly and continuously improved ( figure 1 ) . on july 2007 ,
/ l , gfr at 15.86 ml / min/1.73 m ) . as of last follow - up in july 2008 ,
the patient remains independent of dialysis and renal function is still improving ( scr 256 mol/ l , gfr 18 ml / min/1.73 m ) .
evolution over time of serum creatinine ( scr ) ( mol / l ) and glomerular filtration rate ( gfr ) estimated using the simplified mdrd equation ( ml / min/1.73 m ) . haemodialysis was started immediately after multiple myeloma ( mm ) diagnosis .
autologous haematopoietic stem cell transplantation ( autohsct ) was performed in july 2003 after five courses of vincristine adriamycine dexamethasone ( vad ) chemotherapy .
the patient received second - line chemotherapy with thalidomide ( thd ) and dexamethasone ( dxm ) between september 2005 and august 2006 .
a 56-year - old woman with no medical history was admitted in our nephrology department on march 2003 for acute renal failure .
laboratory tests showed scr 576 mol / l ( gfr estimated at 7 ml / min/1.73 m ) , serum calcium 2.43 mmol/ l , haemoglobin 8.4 g / dl and platelets 364 000/mm .
lambda light chains were also detected in the urine ( 0.10 g / day ) .
a renal biopsy showed tubular necrosis , some cast with giant cells ( figure 3 ) and by immunofluorescence linear fixation of anti - lambda and anti - iga antisera along the glomerular basement membrane and tubular basement membrane .
it was finally recognised as the association of a cast nephropathy and a randall syndrome .
the presence of tubular cells necrosis and one intratubular cast surrounded by macrophages and giant cells ( arrow ) .
( b ) immunofluorescence study ( 50 ) . left panel : intratubular casts were positive for anti - iga ( not shown ) and anti - lambda light chain staining ( dashed arrow ) .
right panel : kappa light chain staining was negative along the glomerular and tubular basement membranes and faintly positive in rare tubular casts .
however , no remission was obtained ( plasma paraprotein 10 g / l , bjp 1.6 g / day ) .
second - line chemotherapy with five courses of oral melphalan ( 12 mg / day for 4 days / month ) and dexamethasone was performed and was followed by a near complete remission ( no detectable serum paraprotein , bjp at 0.09 g / day ) .
subsequently , the patient underwent an autohsct after high - dose melphalan ( 140 mg / m ) on january 2004 . at the time of autohsct
, scr had stabilized around 450 mol / l ( gfr at 9 ml / min/1.73 m ) .
six months later , autohsct started to improve gradually ( figure 2 ) . at last follow - up on september 2008 , 66 months after mm diagnosis , the patient was still in complete remission ( no detectable paraprotein in plasma , bjp < 0.10 g / d ) and scr was 240
evolution over time of serum creatinine ( scr ) ( mol / l ) and glomerular filtration rate ( gfr ) estimated using the simplified mdrd equation ( ml / min/1.73 m ) .
autologous haematopoietic stem cell transplantation ( autohsct ) was performed in january 2004 after vincristine adriamycine dexamethesone ( vad ) and melphalan dexamethasone ( m+dxm ) chemotherapy .
a 57-year - old woman with a history of cervix carcinoma and pulmonary tuberculosis was diagnosed with stage iii b lambda light chain mm in january 2003 .
, laboratory tests showed : serum creatinine ( scr ) 673 mol / l , glomerular filtration rate ( gfr ) estimated according to mdrd formula at 6 ml / min/1.73 m , calcaemia 2.28 mmol / l , albuminaemia 33 g / l , haemoglobin 7.9 g / dl and platelets 125 000/mm . on serum immunofixation , a monoclonal lambda light chain ( 4
her renal function did not improve and she was started on haemodialysis , three times weekly .
initial treatment of mm consisted in five courses of vincristine adriamycine dexamethasone ( vad ) chemotherapy with near complete remission ( no plasma paraprotein detected , bjp 0.09
three months after mm diagnosis renal function partially improved allowing the reduction of haemodialysis dose to two sessions per week . on june 2003 , autohsct was performed after high - dose melphalan ( 200 mg / m ) ; complete remission was obtained . in september 2005
second - line chemotherapy with thalidomide ( 100 mg / day ) and dexamethasone ( 40 mg / day 4 daysa month ) was started .
bjp had decreased to 0.07 g / day and no monoclonal component was detectable in the plasma .
following autohsct , renal function slowly and continuously improved ( figure 1 ) . on july 2007 ,
/ l , gfr at 15.86 ml / min/1.73 m ) . as of last follow - up in july 2008 ,
the patient remains independent of dialysis and renal function is still improving ( scr 256 mol/ l , gfr 18 ml / min/1.73 m ) .
evolution over time of serum creatinine ( scr ) ( mol / l ) and glomerular filtration rate ( gfr ) estimated using the simplified mdrd equation ( ml / min/1.73 m ) . haemodialysis was started immediately after multiple myeloma ( mm ) diagnosis .
autologous haematopoietic stem cell transplantation ( autohsct ) was performed in july 2003 after five courses of vincristine adriamycine dexamethasone ( vad ) chemotherapy .
the patient received second - line chemotherapy with thalidomide ( thd ) and dexamethasone ( dxm ) between september 2005 and august 2006 .
a 56-year - old woman with no medical history was admitted in our nephrology department on march 2003 for acute renal failure .
laboratory tests showed scr 576 mol / l ( gfr estimated at 7 ml / min/1.73 m ) , serum calcium 2.43 mmol/ l , haemoglobin 8.4 g / dl and platelets 364 000/mm .
lambda light chains were also detected in the urine ( 0.10 g / day ) .
a renal biopsy showed tubular necrosis , some cast with giant cells ( figure 3 ) and by immunofluorescence linear fixation of anti - lambda and anti - iga antisera along the glomerular basement membrane and tubular basement membrane .
it was finally recognised as the association of a cast nephropathy and a randall syndrome .
the presence of tubular cells necrosis and one intratubular cast surrounded by macrophages and giant cells ( arrow ) .
( b ) immunofluorescence study ( 50 ) . left panel : intratubular casts were positive for anti - iga ( not shown ) and anti - lambda light chain staining ( dashed arrow ) .
right panel : kappa light chain staining was negative along the glomerular and tubular basement membranes and faintly positive in rare tubular casts .
however , no remission was obtained ( plasma paraprotein 10 g / l , bjp 1.6 g / day ) .
second - line chemotherapy with five courses of oral melphalan ( 12 mg / day for 4 days / month ) and dexamethasone was performed and was followed by a near complete remission ( no detectable serum paraprotein , bjp at 0.09 g / day ) .
subsequently , the patient underwent an autohsct after high - dose melphalan ( 140 mg / m ) on january 2004 . at the time of autohsct
, scr had stabilized around 450 mol / l ( gfr at 9 ml / min/1.73 m ) .
six months later , autohsct started to improve gradually ( figure 2 ) . at last follow - up on september 2008 , 66 months after mm diagnosis , the patient was still in complete remission ( no detectable paraprotein in plasma , bjp < 0.10 g / d ) and scr was 240
evolution over time of serum creatinine ( scr ) ( mol / l ) and glomerular filtration rate ( gfr ) estimated using the simplified mdrd equation ( ml / min/1.73 m ) . autologous haematopoietic stem cell transplantation ( autohsct )
was performed in january 2004 after vincristine adriamycine dexamethesone ( vad ) and melphalan dexamethasone ( m+dxm ) chemotherapy .
management of mm - associated renal insufficiency is a crucial issue as renal dysfunction is a poor prognosis factor leading to an increased morbidity and early mortality rate . in contrast
, patients in whom renal function recovers have a survival rate similar to patients without mm - associated renal insufficiency .
renal function recovers in 2073% of patients with mm - associated renal failure and in 3443% of patients who undergo autohsct .
most interestingly , recovery from dialysis - dependent renal failure occurs in up to one - fourth of patients with mm undergoing autohsct .
predictive factors for renal recovery include severity and duration of renal failure , serum calcium level and amount of bjp .
renal function usually improves in the first months following autohsct with a median time to renal recovery ranging from 1.6 to 4 months . to our knowledge ,
the latest renal function recovery reported in the literature occurred 16 months after autohsct for mm .
herein , we report two unusual cases of late and slow improvement in renal function occurring over more than 5 years in two patients who underwent autohsct for mm . both patients presented initially with severe mm - associated acute renal failure and one patient required long - term dialysis . following various mm treatments including autohsct , renal function improved gradually in both patients and chronic haemodialysis
mm - associated renal failure is usually related to acute tubular injury due to myeloma cast nephropathy .
even though the kidney biopsy was only performed in the second patient , the diagnosis of myeloma cast nephropathy associated is highly likely in the first patient .
the improvement of renal function over several years is not typical of acute tubular necrosis recovery .
the latter probably accounts for the initial partial improvement of renal function noted in the first 3 months in both patients .
slow progressive renal function recovery in our patients may be due to the aggressive treatment of mm including autohsct . obtaining
mm complete remission led to the arrest of monoclonal component secretion thus preventing further intra - tubular precipitation of free monoclonal light chains .
however , one can not exclude that autohsct may have contributed to the recovery of renal function through the regeneration of damaged renal tissues .
controversial and contrasted data regarding the impact of haematopoietic stem cells on organ regeneration , including the kidney , have been reported .
several authors have pointed out the lack of specificity of most techniques usually used to detect chimeric cells derived from stem cells in various organs . moreover
however , stem cells may contribute indirectly to tissue regeneration through paracrine mechanisms leading to the recruitment of organ - resident cells .
furthermore , experimental models of acute as well as chronic renal disorder have suggested that mobilization of stem cells may hasten renal function recovery .
no definite conclusions can be drawn regarding the implication of stem cells in renal repair .
however , the slow and significant improvement over several years of renal function in the two patients presented herein raises once again the issue of stem cell in organ regeneration . in all
, clinicians must be aware that slow and progressive improvement in renal function may occur over years in patients with mm - associated renal failure .
these data may suggest the need for an aggressive treatment in mm patients presenting with severe renal dysfunction in the setting of mm . | acute renal failure is a frequent feature in patients with multiple myeloma ( mm ) .
mm - related renal insufficiency may improve after autologous haematopoietic stem cell transplantation ( autohsct ) even in patients initially requiring dialysis .
herein , we report on two unusual cases of late improvement in renal function occurring over more than 5 years after autohsct for mm .
clinicians must be aware that slow and progressive improvement in renal function may occur over years in patients with mm - associated renal failure .
our data underline the need for an aggressive treatment , including autohsct , in mm patients presenting with severe renal dysfunction . |
its causes are varied , but in all cases it is characterized by the appearance of local acute or chronic inflammatory changes occurring in the wall of the trachea .
these changes lead to degradation over time and pathological restructuring of constituent structures and their replacement by fibrous tissue .
they are often combined with the phenomena of general and local tissue hypoxia , which predispose to ischemic necrosis and ulceration of the mucous membrane of the trachea , and the local development of chondrite tracheomalacia .
morphological changes during prolonged mechanical ventilation vary from epithelial damage with the formation of transmural necrosis to erosion of the tracheal wall to form a fistula between the esophagus and the trachea [ 1 , 2 ] . a pathogenetic factor and a trigger mechanism leading to development of the disease
is damage to the wall of the trachea , followed by infection and the development of a purulent - necrotic process the outcome of which is the formation of a scar .
modern respiratory and tracking equipment and development of a variety of pharmacotherapy in an intensive care unit have allowed the patient to be protected from a critical and grave condition for a long time , sometimes up to several weeks or even months .
conducting prolonged mechanical ventilation in some cases creates conditions for the formation of irreversible changes in the tracheal wall and development of tracheal lumen narrowing , in some cases complicated by a tracheo - esophageal fistula [ 46 ] . at present in most cases trauma of the trachea
is iatrogenic in nature and most often occurs during artificial lung ventilation ( alv ) , even more likely during prolonged mechanical ventilation through the endotracheal tube or tracheostomy tube , or as a complication during application of tracheostomy or at the time of intubation [ 710 ] .
the aim of the study was to present the results of the successful one - stage radical surgical treatment of patients with cicatricial granulating tracheal stenosis after tracheostomy complicated by esophageal - tracheal fistula after numerous unsuccessful attempts to correct the narrowing of the trachea and eliminate the fistula by endoscopic and open surgical techniques .
a 24-year - old female patient was diagnosed with scar - granulating tracheal stenosis after tracheostomy complicated by esophageal - tracheal fistula . on august 20 , 2014 as a result of a car accident the patient had severe concomitant injury . in the postoperative period for 22 days the patients underwent mechanical ventilation . after waking up in the early rehabilitation period the patient exhibited stridor . on suspicion of tracheal stenosis
the patient was transferred to the ent clinic , where she underwent tracheoplasty on the t - tube . however , in the postoperative period , the patient began to experience the phenomenon of aspiration while taking liquid food . at the control examination ent doctors revealed that after removing the t - tube on the rear wall of the trachea in the projection of tracheostomy a tracheo - esophageal fistula with a size of 3 to 5 mm was determined .
endoscopists performed installation of a nasogastric tube and laser photocoagulation of the fistula from the trachea side and from the side of the esophagus to cause the growth of granulation tissue which may contribute to the closure of the fistula .
however , the control examination after 2 months by removing the t - tracheal tube despite nasogastric enteral nutrition and performance of laser coagulation showed that the fistula hole was not closed .
the patient was directed to the surgeons for open surgery for closing the tracheo - esophageal fistula . in november 2014
the patient underwent the operation of liquidation of the esophageal - tracheal fistula by cervical access .
the medical records indicated that was separation of the fistula by suturing and ligation , followed by placing a flap of sternocleidomastoid muscle between the esophagus and the trachea in the projection of the eliminated fistula channel .
however , the early postoperative period was marked by the failure of the suture , recurrence of the fistula with an increase in its size and suppuration of postoperative neck wounds .
the patient within 6 months had aspiration respiratory complications of the fistula . in april 2015
complaints of the patient referred to : dyspnea on exertion , the presence of a tracheostomy tube , cough with difficult expectoration , the presence of a nasogastric tube , the inability to eat by mouth , and inability to breathe through the natural airway .
the studies found : defect of the frontal wall of the trachea and the soft tissue on the neck after the earlier projected tracheoplasty , size 15 to 35 mm , pronounced postoperative scars on the neck after suffering several operations of tracheoplasty attempts to eliminate the fistula and postoperative wound festering ( fig .
1 ) , scar - granulation narrowing of the trachea in the projection of tracheostomy and progression of the tracheal stenosis in 20 min after the removal of the t - stent due to lack of skeleton ( frame ) of the trachea and the presence of tracheomalacia ( fig .
2 ) , the presence of a fistula channel between the cervical trachea and esophagus with the size of 6 8 mm ( fig .
the patient underwent preoperative anti - inflammatory therapy , antibiotic therapy , and remedial bronchoscopy . on july 5 , 2014 , the patient underwent the following operation : one - stage extended tracheal resection with end - to - end anastomosis with liquidation of the esophageal - tracheal fistula and elimination of the defect of the anterior wall of the trachea by cervical access .
5.5 cm of the affected part of the upper and middle third of the trachea was resected .
4 ) . the difference between this type of resection carried out in the treatment of isolated cicatricial tracheal stenosis without esophageal - tracheal fistula is that only the cartilaginous part of the tracheal wall is excised and removed and the membranous wall of the trachea is left in the zone of the esophageal - tracheal fistula to create an excess of tissue to perform closure of the fistula ( fig .
also different is the method of forming the tracheal anastomosis : in circular resection of the trachea in patients with cicatricial stenosis we usually apply the technique of anastomosis with the formation of a posterior membranous wall by continuous biosyn 3.0 suture and with interrupted sutures on the side ( angle ) and front wall .
but in formation of the anastomosis in patients with cicatricial stenosis complicated with esophageal - tracheal fistula there is a risk of inconsistency of the esophageal fistula s sutures that can be complicated by fatal failure in the transition to the tracheal anastomosis . in order to create a more solid and sealed back wall of the anastomosis we used the interrupted nodal biosyn 3.0 seams on the back , front and side walls ( figs .
in order to minimize the tension in the area of the anastomosis seam we mobilized the trachea over the projection of the middle and lower third up to the bifurcation of the trachea with pulling in the cranial direction using tight ligatures .
also we used the technique of temporarily fixing the head in position bringing it to the chest wall and suturing the skin of the chin on the chest for 14 days to eliminate the sharp head - up movement during sleep and the load on the anastomosis ( fig .
defect of the frontal wall of the trachea and the soft tissue on the neck after the earlier projected tracheoplasty . pronounced postoperative scars on the neck computed tomography .
defect of anterior wall of trachea , narrowing of the tracheal lumen , fistula computed tomography .
tracheo - esophageal fistula on the back wall of the stoma diastasis between cranial and caudal part after resection of the trachea fistula hole . left tissue of the membranous part of the trachea around the fistula after resection of the cartilaginous part fistula stitched by interrupted absorbable sutures shunt - breathing .
interrupted sutures on the back wall of the anastomosis shunt - breathing removed and orotracheal intubation tube inserted into the lower part of the trachea .
anterior wall of anastomosis completed tracheal anastomosis head temporarily fixed in position at the chest wall the postoperative period was uneventful .
the gastric feeding tube was removed on the 14 day . also after 2 weeks fixing lead sutures on the chin were removed .
the patient was able to lift the head freely , and was breathing through the natural airway , with clear phonation .
the patient underwent routine endoscopic examination at 1 month , 3 months and 5 months after surgery . in the area of
the anastomosis bronchoscopy showed a smooth whitish thin line not protruding beyond the cartilaginous rings of the trachea .
the lumen of the trachea in the zone of the anastomosis was without restriction or distortion .
tracheal resection with simultaneous liquidation of tracheoesophageal fistula with stenosis of the trachea and defect after laryngotracheoplasty is the method of choice which can radically heal the patient at one stage after unsuccessful attempts to liquidate the tracheoesophageal fistula .
the operation belongs to the category of complex reconstructive surgery and requires well - coordinated work of specialists | we present a case of one - stage radical surgical treatment of a 24-year - old female patient with cicatricial granulating tracheal stenosis after tracheostomy complicated by esophageal - tracheal fistula and an extensive defect of the anterior wall of the trachea after numerous unsuccessful attempts to correct the narrowing of the trachea and eliminate the fistula by endoscopic and open surgical techniques .
the patient underwent extended tracheal resection with end - to - end anastomosis with liquidation of the esophageal - tracheal fistula and elimination of the defect of the anterior wall of the trachea by cervical access . |
yttria - stabilized tetragonal zirconia polycrystal ( y - tzp ) ceramic has extensive applications in restorative dentistry due to excellent mechanical properties and biocompatibility .
zirconia computer - aided design and computer - aided manufacturing ( cad / cam ) systems have enabled the fabrication of y - tzp dental ceramic restorations .
use of resin cements between the tooth structure and the restorative material increases retention especially in cases with short crown height .
additionally , application of adhesive bonding improves marginal seal and prevents secondary caries [ 58 ] .
the mtbs is influenced by the choice of cement , surface treatment of zirconia ceramic [ 9,1218 ] , bonding technique [ 1921 ] , water storage and thermocycling [ 2426 ] . among various resin cements ,
panavia f 2.0 has been recommended to achieve the highest mtbs of zirconia ceramic to cement [ 11,2628 ] .
as y - tzp ceramic is white in color , it can affect the optical characteristics of the restoration .
thus , by coloring the y - tzp ceramic , more favorable esthetic results can be obtained .
various techniques have been developed for coloring of zirconia cad / cam systems such as adding metallic pigments to the zirconia powder by the manufacturers , dipping the zirconia framework in color liquids before sintering and using different liner materials after sintering the zirconia framework . in dipping method ,
the milled zirconia ceramic framework is immersed in a color liquid before sintering for a predetermined time by a dental technician .
liquid color shades , marketed by the manufactures , can infiltrate into the zirconia surface structure and color the zirconia .
. showed that liquid color shades affected biaxial flexural strength and surface microhardness of zirconia .
shah et al . found that the flexural strength of zirconia decreased as the concentration of the liquid color shades increased ; however , resistance to low temperature degradation was not affected by the coloring process .
studies on the influence of coloring by dipping on the bond strength of zirconia ceramic to resin cement are lacking in the literature .
therefore , the aim of the current in vitro study was to evaluate the effect of coloring by dipping on the bond strength of zirconia ceramic to resin cement .
the null hypothesis of this study was that the coloring by dipping in different liquid color shades would not affect the mtbs of y - tzp dental ceramic to panavia f 2.0 resin cement .
this in vitro study was conducted on 100 microbar specimens divided into five groups of b2 , c1 , d4 , a3 and control ( not colored ) .
each microbar specimen was then tested to measure the mtbs of zirconia ceramic to resin cement .
this process was done precisely as follows : initially , 25 zirconia blocks measuring 51111 mm were milled from y - tzp dental ceramic blanks ( ice zircon translucent , zirkonzahn , bruneck , italy ) using a cad / cam system ( zirkonzahn cad / cam system 5-tec , zirkonzahn , bruneck , italy ) with cad / cad milling burs ( cad / cam milling bur 1l & 2l , zirkonzahn , bruneck , italy ) .
the blocks of each group were dipped in a liquid color shade including b2 , c1 , d4 and a3 ( color liquid water - based , zirkonzahn , bruneck , italy ) for 10 seconds ( recommended by the manufacturer ) and one group was not colored as the control .
the colored blocks were then dried using a drying lamp ( zirkonlamp 250 , zirkonzahn , bruneck , italy ) for 45 minutes as recommended by the manufacturer .
all the zirconia blocks were then sintered at 1,480c for eight hours in the sintering furnace ( zirkonofen 700 , zirkonzahn , bruneck , italy ) according to the instruction recommended by the manufacturer . in order to prepare composite blocks as bases for the zirconia blocks with similar dimensions ,
an impression was taken of each zirconia block using condensation silicone putty material ( speedex , coltene , altstatten , switzerland ) . a light - polymerized composite resin ( z100 restorative , 3 m espe , st .
paul , mn , usa ) was applied in 2 mm layers to the molds made of impression material and was polymerized by a light - curing unit ( elipar freelight 2 , 3 m espe , st .
paul , mn , usa ) from both sides for 60 seconds with an intensity of 800 mw / cm .
the composite blocks were made as such , polished with 800 grit silicon carbide abrasive papers for 10 minutes and cleaned in an ultrasonic bath ( elmasonic s-30 , dentec , north shore , australia ) containing 98% ethanol for 10 minutes .
afterwards , the surfaces of zirconia blocks were sandblasted with 110 aluminum oxide particles at 0.3 mpa pressure for 15 seconds using a sandblaster ( korostar plus , bego , bremen , germany ) held at a distance of 10 mm and perpendicular to the block surface .
the blocks were rinsed with water for 20 seconds and air dried for five seconds using air spray .
the resin cement ( panavia f 2.0 , kuraray , tokyo , japan ) was prepared as instructed by the manufacturer .
the zirconia blocks were then bonded to the composite blocks using resin cement under a 50 n compressive force in order for the excess cement to leak out .
an oxygen inhibiting gel ( oxyguard ii , kuraray , tokyo , japan ) was applied to the external surface of the cement .
after five minutes , the blocks were light cured from four different directions for 40 seconds with the same light - curing unit , rinsed to remove the gel and stored in distilled water at 37c for 24 hours . to prepare specimens for testing ,
the mold was placed in a low - speed cutting machine ( mecatome , t210a , presi , grenoble , france ) .
the blocks were sectioned with a diamond saw under water cooling . the first section with an approximate thickness of one millimeter
was discarded because the presence of excess cement or lack of cement in this section could confound the results .
two series of sections were vertically cut with a rotational speed of 600 rpm and forward motion speed of 6 mm / min to prepare microbars measuring 1110 mm from each zirconia - cement - composite block .
the microbars were evaluated under a stereomicroscope ( smz 800 , nikon , sendai , japan ) at 25 magnification ( fig .
twenty microbar specimens were prepared for each group ( b2 , c1 , d4 , a3 and control ) .
the microbar specimen under a microscope at 25 magnification the microbar specimens were glued to the jig of the microtensile tester ( microtensile tester , bisco , schaumburg , il ) using cyanoacrylate glue ( loctite , henkel , dusseldorf , germany ) and fixed .
the microbar was positioned parallel to the long axis of the machine to minimize bending stresses .
the fractured surfaces were evaluated under a stereomicroscope at 40 magnification . in case of any fracture in the composite or between the composite and cement ,
the mtbs was calculated using this formula : r = f / a , where f is the failure force in n , a is the interface area in mm and r is the mtbs of zirconia to cement in mpa .
pairwise comparison of groups was carried out using tukey s post hoc test . the fractured microbar specimen after mtbs testing
statistical tests were done using spss 20 ( spss inc . , chicago , il , usa ) .
initially , 25 zirconia blocks measuring 51111 mm were milled from y - tzp dental ceramic blanks ( ice zircon translucent , zirkonzahn , bruneck , italy ) using a cad / cam system ( zirkonzahn cad / cam system 5-tec , zirkonzahn , bruneck , italy ) with cad / cad milling burs ( cad / cam milling bur 1l & 2l , zirkonzahn , bruneck , italy ) .
the blocks of each group were dipped in a liquid color shade including b2 , c1 , d4 and a3 ( color liquid water - based , zirkonzahn , bruneck , italy ) for 10 seconds ( recommended by the manufacturer ) and one group was not colored as the control .
the colored blocks were then dried using a drying lamp ( zirkonlamp 250 , zirkonzahn , bruneck , italy ) for 45 minutes as recommended by the manufacturer .
all the zirconia blocks were then sintered at 1,480c for eight hours in the sintering furnace ( zirkonofen 700 , zirkonzahn , bruneck , italy ) according to the instruction recommended by the manufacturer . in order to prepare composite blocks as bases for the zirconia blocks with similar dimensions
, an impression was taken of each zirconia block using condensation silicone putty material ( speedex , coltene , altstatten , switzerland ) . a light - polymerized composite resin ( z100 restorative , 3 m espe , st .
paul , mn , usa ) was applied in 2 mm layers to the molds made of impression material and was polymerized by a light - curing unit ( elipar freelight 2 , 3 m espe , st .
paul , mn , usa ) from both sides for 60 seconds with an intensity of 800 mw / cm .
the composite blocks were made as such , polished with 800 grit silicon carbide abrasive papers for 10 minutes and cleaned in an ultrasonic bath ( elmasonic s-30 , dentec , north shore , australia ) containing 98% ethanol for 10 minutes .
afterwards , the surfaces of zirconia blocks were sandblasted with 110 aluminum oxide particles at 0.3 mpa pressure for 15 seconds using a sandblaster ( korostar plus , bego , bremen , germany ) held at a distance of 10 mm and perpendicular to the block surface .
the blocks were rinsed with water for 20 seconds and air dried for five seconds using air spray .
the resin cement ( panavia f 2.0 , kuraray , tokyo , japan ) was prepared as instructed by the manufacturer .
the zirconia blocks were then bonded to the composite blocks using resin cement under a 50 n compressive force in order for the excess cement to leak out .
an oxygen inhibiting gel ( oxyguard ii , kuraray , tokyo , japan ) was applied to the external surface of the cement .
after five minutes , the blocks were light cured from four different directions for 40 seconds with the same light - curing unit , rinsed to remove the gel and stored in distilled water at 37c for 24 hours . to prepare specimens for testing ,
the mold was placed in a low - speed cutting machine ( mecatome , t210a , presi , grenoble , france ) .
the blocks were sectioned with a diamond saw under water cooling . the first section with an approximate thickness of one millimeter
was discarded because the presence of excess cement or lack of cement in this section could confound the results .
two series of sections were vertically cut with a rotational speed of 600 rpm and forward motion speed of 6 mm / min to prepare microbars measuring 1110 mm from each zirconia - cement - composite block .
the microbars were evaluated under a stereomicroscope ( smz 800 , nikon , sendai , japan ) at 25 magnification ( fig .
twenty microbar specimens were prepared for each group ( b2 , c1 , d4 , a3 and control ) .
the microbar specimens were glued to the jig of the microtensile tester ( microtensile tester , bisco , schaumburg , il ) using cyanoacrylate glue ( loctite , henkel , dusseldorf , germany ) and fixed .
the microbar was positioned parallel to the long axis of the machine to minimize bending stresses .
the fractured surfaces were evaluated under a stereomicroscope at 40 magnification . in case of any fracture in the composite or between the composite and cement ,
the mtbs was calculated using this formula : r = f / a , where f is the failure force in n , a is the interface area in mm and r is the mtbs of zirconia to cement in mpa .
pairwise comparison of groups was carried out using tukey s post hoc test . the fractured microbar specimen after mtbs testing
statistical tests were done using spss 20 ( spss inc . , chicago , il , usa ) .
the mean and standard deviation of mtbs of microbar specimens in the five groups of b2 , c1 , d4 , a3 and control were 14.77 5.59 mpa , 16.86 5.26 mpa , 39.16 6.52 mpa , 26.61 6.59 mpa , and 23.446.56 mpa , respectively ( fig .
3 ) ( table 1 ) . one - way anova showed statistically significant differences in the mtbs values of the five groups ( p<0.001 ) .
the results of tukey s pairwise comparison revealed statistically significant differences in the mtbs values between b2 and d4 ( p<0.001 ) , b2 and control ( p<0.001 ) , b2 and a3 ( p<0.001 ) , c1 and d4 ( p<0.001 ) , c1 and a3 ( p<0.001 ) , c1 and control ( p<0.009 ) , d4 and a3 ( p<0.001 ) and d4 and control ( p<0.001 ) ; whereas , the differences between b2 and c1 ( p=0.82 ) , and a3 and control ( p=0.48 ) were not statistically significant .
the mean and standard deviation of mtbs for the five groups central dispersion measures for mtbs values of microbar specimens in the five groups of b2 , c1 , d4 , a3 and control
the present study evaluated the mtbs of the prepared microbar specimens in four groups dipped in different liquid color shades and one control group .
a similar pattern of change in the mtbs was not seen after dipping in different liquid color shades . in comparison with the control group ,
b2 and c1 liquid color shades decreased the mtbs ; while a3 liquid color shade did not decrease the mtbs and d4 liquid color shade increased the mtbs . in zirkonzahn zirconia system ,
b2 and c1 liquid color shades had negative effects , d4 liquid color shade had positive effect and a3 liquid color shade had no effect on the mtbs of zirconia to panavia f 2.0 resin cement .
. revealed that biaxial flexural strength and surface microhardness of zirconia discs were influenced by the color liquids and the zirconia colored by d4 liquid color shade had the highest mtbs compared to a3 , b1 , c4 and d2 .
the d4 liquid color shade in contrast to the other tested color liquids did not cause a statistically significant reduction in mtbs . although the current study evaluated the mtbs of colored zirconia to cement , both investigations showed changes in zirconia properties following dipping for coloring . according to the result of a study by hjerppe et al , all the tested color liquids except for the d4 shade had negative effects on the biaxial flexural strength of zirconia .
a similar result was obtained in the current study showing the positive effect of d4 liquid color shade on mtbs of zirconia to cement .
shah et al . performed an in vitro study to investigate the effect of coloring by dipping in cerium acetate , cerium chloride , or bismuth chloride with three different concentrations ( 1 , 5 and 10% ) on the microstructure , color , flexural strength and aging resistance of tetragonal zirconia for dental applications .
the results showed the effects of liquid color shades on zirconia including slight increase in lattice parameters of tetragonal zirconia , increase of grain size and decrease of flexural strength with an increase in concentration of both cerium salts .
however , the liquid color shades did not affect the density or the resistance to low temperature degradation .
a decrease in flexural strength at higher concentrations was attributed to an increase in open porosity .
although our study evaluated the mtbs of colored zirconia to cement and used different liquid color shades compared to the study by shah et al , both investigations showed changes in zirconia properties following coloring by dipping .
evidence suggests that the bonding mechanism of zirconia to resin cement is mainly related to the bond between the metal oxides in y - tzp ceramic and 10-hydroxydecyl dihydrogen phosphate ( mdp ) in a mdp - containing resin cement such as panavia f 2.0 [ 26,27,3335 ] .
vinyl group of mdp reacts with monomers in resin cement when resin is polymerized ; while phosphate group of mdp bonds strongly to metal oxides of y - tzp ceramic .
it seems that some metal oxides at the zirconia surface microstructure play a significant role in the bond .
meanwhile , the bond may be influenced by dipping because liquid color shades infiltrate into the zirconia surface .
therefore , effects of coloring by dipping on the bond strength of zirconia to cement may be explained by two factors : the liquid color shade composition and its effect on zirconia surface microstructure .
the composition of the liquid color shade may impact the bond strength of zirconia to cement in two ways namely by the type of added metal oxides to zirconia structure and tetragonal / monoclinic phase transformation .
the metal oxides added to y - tzp ceramics during the ceramic processing , manufacturing or coloring can influence the zirconia properties .
it has been well confirmed that silica or alumina directly influences grain morphology , microstructure and stability of zirconia .
ceria acts as a sintering aid , increases the grain size and improves aging resistance of y - tzp .
addition of cao , mgo , ceo and y2o3 to pure zirconia allows generating multi - phase materials .
evaluated the biaxial flexural strength , hardness and fatigue life of colored and uncolored zirconia in the lava system .
although the colored zirconia used in their study was prefabricated by the manufacturer , the results showed a difference in oxygen content , which was higher in colored zirconia .
no difference was reported in biaxial flexural strength between colored and uncolored zirconia with the exception of two shades ; while there was a significant difference in hardness among the groups . additionally , the uncolored and colored specimens showed some differences in the grain size and microstructure .
the uncolored samples revealed the spectra as expected for tetragonal and cubic zirconia , while the colored samples were very different .
ardlin determined chemical stability and effect of aging ( 4% acetic acid at 80c for 168 hours ) on flexural strength , surface and crystalline structure of colored and uncolored zirconia in the denzir system and in contrast to pittayachawn et al , he found that the flexural strength of yellow colored zirconia was higher than that of uncolored zirconia .
ardlin suggested that it might be related to the components such as ceo2 , fe2o3 and bi2o3 added during the manufacturing process to obtain different shades .
this difference in results may be caused by the type of oxides added by the different manufacturers to the lava system ( a dental y - tzp ceramic ) used by pittayachawan et al , versus the denzir system ( a dental mg - tzp ceramic ) used by ardlin . in both studies , the effect of coloring by the manufacturer on the flexural strength of zirconia was evaluated ; while the current study evaluated the effect of coloring by dipping on the bond strength .
such controversy in results may be related to the coloring technique and the type of oxides added .
accordingly , in coloring by dipping , where liquid color shades containing metal oxides are utilized before sintering , some metal oxides may infiltrate into zirconia surface microstructure and may be added to or replace the existing ones .
this effect , based on the nature of the oxides , may be positive , negative or neutral .
it may be the reason for positive effect of d4 liquid color shade , negative effect of b2 and c1 liquid color shades and neutral effect of a3 liquid color shade on the mtbs of zirconia to panavia f2.0 in the current study .
the composition of the liquid color shade may be responsible for the weakening effect of a3 , b1 and c4 liquid color shades on the zirconia hardness showed by hjerppe et al , the weakening effect of b2 and c1 liquid color shades and the improving effect of d4 liquid color shade on the mtbs of zirconia to cement ( showed by the current study ) .
the specific effect of liquid color shades on zirconia surface microstructure may be another important factor explaining the effect of coloring on zirconia bond to cement .
the concentration of yttrium , which is the primary stabilizing element of zirconia used in dental restorations , was found to be higher at grain boundaries and surfaces compared with the grain interior .
yttrium also contributes to other dynamic properties such as grain sliding , rearrangement movements and plastic deformation .
there may be a balance between metal oxides and yttria in y - tzp , which protects the tetragonal structure .
infiltration of the metal oxides during dipping may promote or suppress this balance and may create a shift in tetragonal / monoclinic phase transformation .
the zirconia surface structure may be influenced by the dipping time and the concentration of color liquids .
found that prolonging the dipping time from 3 to 60 seconds lowered the zirconia biaxial flexural strength .
dipping time had no effect on zirconia microhardness , but there were some differences among different shades .
the effect of concentration of color liquids on zirconia surface and strength was shown by shah et al .
they demonstrated that solutions with higher concentrations had a greater negative effect on the zirconia strength .
consequently in coloring by dipping , the interaction effect of all the abovementioned factors may influence the surface composition and surface structure of zirconia , which can directly influence the bonding mechanism of zirconia to monomer - based phosphate cements such as panavia f 2.0 .
the current study results can be interpreted from the perspectives of the manufactures , dental clinicians and investigators .
the manufacturers should modify the color liquids with poor performance to prevent their negative effects on the bond strength of zirconia to resin cement .
the clinicians should use the liquid color shades ( b2 and c1 ) with poor performance with caution specially in cases with decreased clinical crown height , decreased bonded surface area , compromised retention of restoration or heavy functional and parafunctional occlusal loads .
the investigators can take advantage of the liquid color shades ( d4 ) with optimal performance to improve the zirconia surface bond .
the results of our study revealed the effects of coloring by dipping on mtbs of zirconia to cement .
another study is recommended using the thermocycling process to better simulate the clinical conditions . using only the zirkonzahn system , specific liquid color shades and 10 seconds of dipping time
therefore , more studies on the mode of failure , elemental composition of y - tzp , dipping time , different shades and different zirconia systems are recommended .
within the limitations of this study , it was concluded that coloring by dipping affected the mtbs of zirconia ceramic to panavia f 2.0 resin cement ; however , a similar pattern of change in the mtbs was not seen among the different liquid color shades . | objectives : studies on the effect of coloring procedures on the bond strength of zirconia to resin cement are lacking in the literature . this study evaluated the effect of dipping of zirconia ceramic in different liquid color shades on the microtensile bond strength ( mtbs ) of zirconia ceramic to resin cement.materials and methods : this in vitro study was conducted on 100 microbar specimens divided into five groups of b2 , c1 , d4 , a3 and control ( not colored ) . to prepare the microbars , 20 white zirconia ceramic blocks , measuring 51111 mm , were dipped in a3 , b2 , c1 or d4 liquid color shades for 10 seconds ( five blocks for each color shade ) and five blocks were not colored as controls .
all the zirconia blocks were sintered in a sintering furnace .
composite blocks of similar dimensions were fabricated and bonded to zirconia ceramic blocks using panavia f 2.0 resin cement .
zirconia - cement - composite blocks were sectioned into microbars measuring 1110 mm .
the mtbs of microbars was measured by a testing machine .
data were analyzed using one - way anova and tukey s test .
all tests were carried out at 0.05 level of significance.results:statistically significant differences were found among the groups in mtbs ( p<0.001 ) .
the d4 group had the highest mtbs value ( 39.16 6.52 mpa).conclusion : dipping affected the mtbs of zirconia ceramic to panavia f 2.0 resin cement ; however , a similar pattern of change was not seen due to the different liquid color shades . |
low - back pain is one of the most common human morbidities worldwide , which is damaging individually , socially and economically .
most of the low - back pains are non - specific though specific ones need more complicated and more expensive treatments .
sciatica or lumbar radiculopathy is one of these specific low - back pains and is explained in iranian traditional medicine textbooks in detail .
massage is one of the therapeutic modalities , advised for sciatica . due to different aspects of sciatica in modern medicine
, massage is not indicated as treatment , but it is advised in iranian traditional medicine . in iran , many patients resort to traditional massage for sciatica and are satisfied .
thus , the effectiveness of one type of iranian traditional massage kermanshahi family and conventional treatment were compared based on three outcomes of pain , disability , and quality of life score .
a total of 50 patients were observed in two groups ( 25 per group ) of case ( massage ) and control ( classic treatment ) in a non - randomized controlled clinical trial .
patients suffering from lumbar radicular pain for 8 weeks or longer , before referring to each center ( neurosurgery or traditional massage clinic ) , were enrolled continuously . in the case group , patients underwent traditional massage sessions whereas in the control group they were prescribed as routine .
three outcomes were observed during three periods of before intervention , 1-month , and 3-month after intervention .
the mean difference of pain severity decrease in both groups was meaningful ( p=0/007 ) .
however , the mean difference of quality of life increase in both groups was not meaningful .
iranian traditional massage may be useful for the treatment of non - acute sciatica , but more studies are required to confirm and clarify the protocols . | background : low - back pain is one of the most common human morbidities worldwide , which is damaging individually , socially and economically .
recent studies have shown that its prevalence is rising .
most of the low - back pains are non - specific though specific ones need more complicated and more expensive treatments .
sciatica or lumbar radiculopathy is one of these specific low - back pains and is explained in iranian traditional medicine textbooks in detail .
massage is one of the therapeutic modalities , advised for sciatica . due to different aspects of sciatica in modern medicine
, massage is not indicated as treatment , but it is advised in iranian traditional medicine . in iran , many patients resort to traditional massage for sciatica and are satisfied .
thus , the effectiveness of one type of iranian traditional massage kermanshahi family and conventional treatment were compared based on three outcomes of pain , disability , and quality of life score.methods:a total of 50 patients were observed in two groups ( 25 per group ) of case ( massage ) and control ( classic treatment ) in a non - randomized controlled clinical trial .
patients suffering from lumbar radicular pain for 8 weeks or longer , before referring to each center ( neurosurgery or traditional massage clinic ) , were enrolled continuously . in the case group , patients underwent traditional massage sessions whereas in the control group they were prescribed as routine .
three outcomes were observed during three periods of before intervention , 1-month , and 3-month after intervention.results:the mean difference of pain severity decrease in both groups was meaningful ( p=0/007 ) .
the mean difference of disability decrease in both groups was meaningful ( p=0/003 ) .
however , the mean difference of quality of life increase in both groups was not meaningful.conclusion:iranian traditional massage may be useful for the treatment of non - acute sciatica , but more studies are required to confirm and clarify the protocols . |
genital self mutilation is a rare and a severe form of self - injurious behavior .
it is usually described in psychotic disorders , mostly in schizophrenia as a result of delusions and hallucinations.[13 ] in most cases , penile mutilation is common .
risk factors of genital self mutilation include commanding hallucination , religious delusions , substance abuse , and social isolation .
genital mutilation has been ascribed to sexual conflicts and offences , body image preoccupation and distortion , expression of internalized aggression and suicidal intent , and a means to get relieved of urinary symptoms .
this phenomenon has been described in schizophrenia , affective psychosis , alcohol intoxication , and personality disorders .
a review of literature suggests that genital self mutilation is usually associated with psychotic illness .
greilsheimer and groves in a group of 52 cases of genital self mutilation found 87% to be psychotic and 13% to be non - psychotic .
the non - psychotic cases included personality disorders , transvestism , and complex religious or cultural beliefs .
a series of 14 patients of self - inflicted genital injuries found 65% to be psychotic and 35% to be non - psychotic .
there have been sporadic cases of non - psychotic genital self mutilation in the literature .
various forms of psychopathology have been postulated in such cases . in the present case , genital self mutilation of scrotum in a 28-year - old male , a case of delirium , due to withdrawal of alcohol ,
a 28-year - old male working as a tractor driver was brought to the emergency surgical ward by his wife with complaints of cutting off at the left side at the base of his scrotum with a kitchen knife .
he started with 200 ml of arrack and slowly increased the amount to 1l over a period of 6 years as he was not getting the desired effect he used to get with 200 ml . on occasions ,
when he did not have the money or opportunity to drink , he used to experience dysphoric state including severe anxiety , palpitations sweating , restlessness , and tremors of hands .
he also did not have any control over the amount of alcohol he is taking and the money he is spending on it once he started to drink .
he also neglected his duties both at work and at home due to this habit , for which he had frequent quarrels with his wife and has also ended up in financial crisis with a big debt . due to above mentioned problems two days before admission , patient decided to stop drinking alcohol and stopped all of a sudden and he has developed abnormal behavior like talking to self , not feeding self , not recognizing family members , and talking irrelevantly . he started to complain that he is hearing voices of male and female when no one around .
on the morning of the day of admission , patient went to the kitchen and cut his scrotum at the base with a knife on left side .
his wife after one hour saw blood stains on floor and on his groins and brought him to casualty .
the mental status examination of the patient showed that the patient is not co - operative , not oriented to time , place , and person , hence cognitive functions could not done .
he was diagnosed as mental and behavioral disorders due to alcohol withdrawal state , complicated with delirium .
the patient was admitted in psychiatry ward , all the investigations done like complete blood picture , liver function tests , blood urea , serum electrolytes , and computed tomography ( ct ) scan brain to rule out any organic cause .
they started on tablet chlordiazepoxide 200 mg in divided doses , tablet thiamine 150 mg both given orally in divided doses to prevent korsakoff 's psychosis and injection lorazepam 2 mg i m on sos basis to prevent any agitation .
the patient became oriented on the 4 day of admission and then stared to complain of pain at injury site for which he was started on non steroidal anti inflammatory drugs .
there were no adverse effects like infection of the injury or cutting of the cord or vas deferens and the wound completely healed in a period of 3 weeks .
for next ten days , we slowly tapered off the chlordiazepoxide and on the 10 day of admission , patient was discharged on tablet disulfiram .
the patient is on regular follow - up now for last 8 months and completely abstinent from alcohol .
some of the unusual features of the present case are as follows :
commonly , amputation of penis and scrotum has been reported but here penis was spared.severe self injuries have been reported mostly in schizophrenia and other psychotic episodes but not in delirium.this case has no apparent sexual or religious connotation.because of his problems at work and home , there may be a sub - clinical depressive episode in the patient and the act was done as a suicidal attempt .
commonly , amputation of penis and scrotum has been reported but here penis was spared .
severe self injuries have been reported mostly in schizophrenia and other psychotic episodes but not in delirium .
this case has no apparent sexual or religious connotation . because of his problems at work and home
, there may be a sub - clinical depressive episode in the patient and the act was done as a suicidal attempt .
psychoanalytically , self - injurious behavior has been linked to castration and explained as a process of failure to resolve oedipal complex , repressed impulses , self punishment , focal suicide , and aggression turned inward model , especially in depression cases .
liebowitz and klein have postulated interpersonal loss preceding self - injurious behavior and linked it to rejection sensitivity .
biologically , serotonergic depletion preceding genital self mutilation has been linked to lack of impulse control and depression .
schweitzer and bhargava et al . claimed a strong moral and delusional component . in the present case ,
this was evident in the present case where he inflicted such a serious injury without seeking help .
as has been communicated by rao and begam , we are in agreement that genital self mutilation , like any self - injurious behavior is not a single clinical entity and can occur in any psychiatric condition with corresponding psychopathology .
it is suggested that there is no difference in the severity of self - inflicted injury between psychotic and non - psychotic group of patients , and sometimes it could be a rational suicidal act .
thus , in this case , genital self mutilation was a psychotic solution to a conflict on the individual plane . in summary
, genital self mutilation may be a pathway out of diverse psychological disorders or behavior and may be influenced by cultural factors . | genital self mutilation is a rare and a severe form of self - injurious behavior usually described in psychotic disorders , with delusions and hallucinations .
it has been ascribed to sexual conflicts , body image distortions , internalized aggression , and suicidal intent .
this phenomenon has been described in schizophrenia , affective psychosis , alcohol intoxication , and personality disorders .
the present case genital self mutilation in a case of alcohol withdrawal state complicated by delirium is reported . |
obesity is a chronic metabolic nutritional disorder that has increased at an alarming rate in the last 20 years . in the us , 68% of the adults ( age 20 years ) and 18% of children ( 219 years ) are either obese or overweight as per the national health and nutrition examination survey [ 2 , 3 ] .
incidence of obesity is associated with many health complications such as hypertension , hyperlipidemia , cardiovascular disease , type 2 diabetes , and a range of lipid abnormalities , the most common being nonalcoholic fatty liver disease ( nafld ) .
nafld is an important health concern due to its high prevalence ( ~20% of adult population ) and its association with insulin resistance and metabolic syndrome .
it is characterized by hepatic lipid accumulation primarily in the form of triglycerides ( tg ) .
some of the potential steps involved in the progression of nafld may involve increased uptake of circulating fatty acids ( fa ) , increased hepatic denovo lipogenesis ( dnl ) , reduced rate of fa oxidation , or reduced fa secretion [ 10 , 11 ] .
when nafld is associated with inflammation and fibrosis , it is termed as nonalcoholic steatohepatitis ( nash ) , a serious condition that could lead to liver cirrhosis , hepatic carcinoma , and liver failure .
the pathogenesis of nafld can be explained by two hit hypothesis suggesting steatosis as the first hit which increases the vulnerability of liver to various second hits like oxidative stress and inflammation leading to nash .
although no specific guidelines exist for treatment of nafld , recommendations are aimed at reducing body weight due to its strong association with obesity and metabolic syndrome . in this
regard , bioactive lipids / fa as functional food may be important in modulating metabolism and body weight . a specific group of polyunsaturated fa collectively known as conjugated linoleic acid ( cla ) have been suggested to have an effect on regulating energy metabolism and is being used commercially as a weight - loss supplement .
however , cla effects are varied depending on the type of cla isomer , the animal 's physiological condition , and the tissue type examined . in this paper , we summarize the recent studies on effect of cla on hepatic lipid metabolism highlighting the potential regulatory mechanisms .
conjugated linoleic acid refers to a group of dienoic derivatives of linoleic acid with conjugated double bonds arranged in different combinations of cis and trans configuration .
currently , 16 naturally occurring cla isomers have been identified with different positional ( 7/9 , 8/10 , 9/11 , 10/12 , and 11/13 ) and geometric ( cis / cis , trans / trans , cis / trans , and trans / cis ) combinations [ 16 , 17 ] .
sources of cla include those naturally present in dairy products and meat from ruminant animals or those contained in industrially hydrogenated vegetable oils and other synthetic products .
the cla originating from the ruminant products predominantly consist of cis-9 , trans-11 cla ( > 80% ) , with a small amounts of trans-10 , cis-12 cla and other isomers . the industrially synthesized cla and other commercial products intended for human consumption
typically consists of equal amounts of cis-9 , trans-11 cla and trans-10 , cis-12 cla and other isomers .
of all the cla isomers , cis-9 , trans-11 cla and trans-10 , cis-12 cla have been the most widely studied due to their biologically active properties .
a great deal of current interest in cla is due to their bioactive properties including anticarcinogenic , antiatherogenic , immunity enhancing , and effects on body composition .
each cla isomer has unique bioactive properties , and hence , the biological effect from a mixture of dietary cla isomers , as is the case in most of the studies , would be the combined effect of their distinct isomers .
cis-9 , trans-11 cla and trans-10 , cis-12 cla have additive effects on cancer and immune cell functions but are antagonistic on insulin sensitivity .
while cis-9 , trans-11 cla improves insulin sensitivity , trans-10 , cis-12 cla causes insulin resistance .
also , trans-10 , cis-12 cla is solely responsible for changes in body composition and reducing adipose mass .
. however , the response appears to vary depending on species , physiological stage , and fat depot [ 22 , 26 ] .
table 1 provides a summary of studies reviewed across species with respect to body weight and adiposity , where the number of experiments showing significant ( p > 0.05 ) increases , decreases , or no change and the mean response to dietary trans-10 , cis-12 cla within those categories are reported .
the range of trans-10 , cis-12 cla addition in these studies varied between 0.1 and 1 percent of the diet .
trans-10 , cis-12 cla reduces body fat to a maximum extent in mice ( 60% to 80% ) [ 27 , 28 ] .
however , modest and inconsistent effects are seen in rats [ 49 , 82 ] , hamsters ( 9% to 58% ) [ 54 , 55 ] , and pigs ( 6% to 25% ) .
similarly , variable responsiveness to cla was observed for epididymal , perirenal , and subcutaneous body fat depots .
inconsistent responses to trans-10 , cis-12 cla have been reported in clinical trials with humans .
some have shown significant effects on body composition [ 63 , 85 ] , while others have not [ 64 , 65 ] . the differences in the responses are attributed to differences in the dose levels , age , and rate of adipose tissue tg turnover [ 14 , 66 , 84 ] . the response to cla isomers
also depends on the physiological state of the animal which is probably due to differences in the preferential uptake of cla by different tissues .
for example , trans-10 , cis-12 cla is preferentially taken up by the mammary tissue during lactation leading to substantial ( ~45% ) decrease in milk lipid synthesis .
liver plays an important role in energy homeostasis , as it converts excessive dietary glucose into fa which is exported as tg .
liver is an important target for cla effects irrespective of the physiological condition . of the different cla isomers , trans-10 ,
cis-12 cla causes increased lipid accumulation leading to hepatic steatosis [ 3032 , 86 ] .
however , the intensity of lipid accumulation varies depending on the level of cla in the diet , duration of feeding , physiological condition , and animal species ( table 1 ) .
the factors leading to hepatic lipid accumulation are multifactorial involving increased fa influx , increased fa synthesis , and altered fa oxidation and tg secretion insufficient to prevent lipid accumulation ( figure 1 ) .
these mechanisms are probably not mutually exclusive and could act in a coordinated manner to hasten the development and progression of fatty liver .
under normal conditions , de novo lipogenesis contributes minimally to the lipid pool in the liver .
the increase in hepatic lipid content due to cla , specifically trans-10 , cis-12 cla , is commonly associated with increased hepatic lipogenesis . in mice
, cla has been repeatedly shown to increase the expression of sterol regulatory element - binding protein-1c ( srebp-1c ) , key transcriptional regulator in hepatic lipogenesis and its downstream genes acetyl coa carboxylase ( acc ) , fatty acid synthase ( fasn ) , and stearoyl coa desaturase-1 ( scd1 ) [ 30 , 34 , 35 ] ( table 2 )
the increase in srebp-1c expression in mice is attributed to hyperinsulinemia ( figure 1 ) .
the decreased expression of lipogenic ( acc1 , acc2 , fasn , and scd1 ) genes in the absence of insulin in mice fed trans-10 , cis-12 cla further supports this argument .
in addition to srebp-1c , insulin induces the expression of peroxisome proliferator - activated receptor- ( ppar- ) , which is in low abundance under normal conditions .
ppar- expression is increased in steatotic liver ( figure 1 ) [ 30 , 92 ] , while its ablation ameliorates the condition in mice .
insulin resistance in response to trans-10 , cis-12 cla could upregulate genes of glucogenic pathway ( e.g. , pepck , g6p ) leading to hyperglycemia ( figure 1 ) . in turn , elevated blood glucose concentrations could upregulate hepatic lipogenesis through carbohydrate response element binding protein ( chrebp ) , a transcriptional regulator modulated by glucose ( figure 1 ) .
the targeted deletion of chrebp in the liver improves the steatotic conditions in ob / ob mice .
however , the role of chrebp in cla - induced hepatic steatosis is not known .
although hyperinsulinemia triggers the hepatic lipogenesis , cla - induced hepatic steatosis in the absence of insulin suggests the involvement of other regulatory mechanisms affecting hepatic lipid accumulation . in mouse experiments , dietary trans-10 ,
cis-12 cla was associated with upregulation of genes associated with fa uptake and tg secretion ( fat / cd36 ; table 2 ) . during hepatic steatosis about 59% of hepatic tg
is derived from free fa released from the adipose tissue and 15% is derived from dietary fat .
fa transporters , ( fatp5 , fat / cd36 , fabp-1 , fabp-4 , and fabp-5 ) regulate the fa uptake by hepatocytes . while the overexpression of these proteins promotes steatosis , functional deletion ameliorates the condition [ 98100 ] .
as cla are natural ligands and activators of ppar- the upregulation of fat / cd36 by trans-10 , cis-12 cla [ 32 , 33 , 102 ] could be through ppar- leading to increased hepatic fa uptake .
in addition to fat / cd36 , we have observed modest increases in the expression of fabp-1 ( 1.39 fold ) and fabp-2 ( 1.7 fold ) in liver of lactating mice fed trans-10 , cis-12 cla ( kadegowda , a. k. g. , erdman , r. a. , and loor , j. j. , unpublished results ) .
besides enhanced fa uptake and lipogenesis , alteration in very low - density lipoprotein ( vldl ) secretion rates could also result in liver fat accumulation . the vldl production and secretion
. however , impaired or insufficient fat export via vldl predisposes animal to hepatic steatosis .
trans-10 , cis-12 cla reduced tg secretion leading to higher lipid accumulation in hepg2 cells due to reduced apolipoprotein b synthesis . conversely , lipoprotein clearance was not affected in mice fed cla [ 31 , 102 ] .
the tg export was increased with higher rate of vldl secretion ; however , it was insufficient to eliminate increased fa flux entering the liver leading to hepatic steatosis .
the fa < c8 to c20 are catabolized through the mitochondrial -oxidation pathway , while fa > c20 are initially catabolized in the peroxisomes to shorter fa which are then shuttled to mitochondria for further oxidation .
previous studies have reported variable responses in hepatic fa oxidation with trans-10 , cis-12 cla .
most of the studies have shown increased fa oxidation [ 27 , 34 , 36 , 56 , 106 ] , while some have reported reduced or unaltered fa oxidation with cla .
carnitine palmitoyltransferase-1 ( cpt1 ) is the rate limiting enzyme for mitochondrial -oxidation pathway , as it regulates the transport of fatty acyl coa into mitochondria .
when measured in mice , cpt1 gene expression was consistently increased by cla ( table 2 ) which might be mediated through transcriptional regulator ppar- as it regulates the key enzymes ( e.g. , cpt1 , cpt2 , and aco ) involved in hepatic fa oxidation . despite increased fa oxidation hepatic steatosis
since studies showing increased fa oxidation were also associated with increased hepatic lipogenesis , it is possible that that the rates of hepatic lipogenesis far exceed the rates of fa oxidation resulting in increased lipid accumulation . along with increased lipogenesis the level of malonyl coa , a product of acc
thus , despite higher expression of fa oxidation genes , it is possible that fa combustion might be depressed in vivo leading to steatosis .
some studies have shown cla induced downregulation of genes related to mitochondrial -oxidation ( cpt1 ) , and oxidation ( cyt p450 and fmo3 ) .
we have also observed decreased expression of cpt1 , acox1 , and fmo3 without any changes in hepatic lipogenic genes of lactating mice fed trans-10 , cis-12 cla ( kadegowda , a. k. g. , erdman , r. a. , and loor , j. j. , unpublished results ) .
the variable responses among different studies can be attributed to the level and type of fat used in the experimental diet along with the physiological conditions of animal used in the experiment .
trans-10 , cis-12 cla - induced hepatic steatosis is characterized by changes in hepatic fa composition [ 29 , 37 , 107111 ] similar to those induced during nafld .
the hepatic fa composition in steatotic liver determines the extent of susceptibility of liver injury .
the steatotic liver fa profile is characterized by substantial reductions in long chain polyunsaturated fa ( lc - pufa ) concentrations ; specifically that of arachidonic acid ( c20:4n-6 ) .
while linoleic ( 18:2n-6 ) and -linolenic acid ( 18:3n-3 ) are unaltered , the concentrations of eicosapentaenoic acid ( epa , c20:5n-3 ) and docosahexaenoic acid ( dha , c22:6n-3 ) are decreased .
the desaturation and elongation of linoleic and -linolenic acid by desaturases ( -desaturase , -desaturase ) and elongases ( elovl-2 , elovl-3 ) are involved in synthesis of lc - pufa .
trans-10 , cis-12 cla inhibits both - and -desaturase in hepg2 cells . a recent tracer study with [ u - c ] linoleic acid showed significant reduction in n-6 pufa synthesis by inhibition of elongation and desaturation in the liver homogenates of neonatal pigs .
a decrease in arachidonic acid synthesis would alter eicosanoid metabolism and potentially reduce the synthesis of prostaglandin e2 ( pge2 ) which is known to have protective effects on liver .
typical nafld is also characterized by increased n-6 : n-3 lc - pufa ratio which favors lipid synthesis over lipid oxidation and secretion leading to hepatic lipid accumulation .
trans-10 , cis-12 cla reduces the n-3 pufa in liver [ 38 , 109 ] in addition to arachidonic acid .
the n-3 pufa downregulate srebp-1c and upregulate ppar- , which regulates lipid oxidation ( cpt1 , acox1 ) and secretion ( apob100 ) .
a decrease in hepatic n-3 pufa would not only reduce lipid oxidation but increase lipogenesis leading to hepatic steatosis . although the trans-10 , cis-12 cla - induced responses in fa oxidation are variable in mice , consistently increased lipogenesis ( table 2 ) suggests a potential role for n-3 pufa . on the contrary , cla feeding increased n-3 pufa content and decreased n-6 pufa in the rats [ 119 , 120 ] which could probably explain the differences in cla effects between the two species .
although the exact mechanism of cla action has not been elucidated , banni et al . has suggested that the metabolites of cla , conjugated dienes ( cd)18:3 , cd20:3 , cd20:4 , could compete with other pufa at the level of formation and metabolism in liver and affect lc - pufa synthesis . in the adipose , there are some similarities between the effects of trans-10 , cis-12 cla and the inhibition of scd1 . for example , reduced adiposity is observed with both dietary trans-10 , cis-12 cla and scd1 inhibition and one could speculate that the effects of trans-10 , cis-12 cla are mediated through scd1 as trans-10 , cis-12 cla decreases scd1 in adipose .
however , a study with scd1 mice showed that the antiobesity effects of trans-10 , cis-12 cla were independent of scd1 gene expression and enzyme activity . unlike adipose ,
the effects of trans-10 , cis-12 cla are varied in liver ( table 2 ) . while trans-10 , cis-12 cla decreased hepatic scd activity in vitro , in vivo studies report increased hepatic scd1 gene expression [ 32 , 95 ] .
in contrast to trans-10 , cis-12 cla effects in mice , scd1 mice showed increased insulin sensitivity , reduced hepatic lipogenic genes , upregulated lipid oxidizing genes , increased hepatic saturated fa and unchanged hepatic n-3 and n-6 pufa .
scd1 mice fed trans-10 , cis-12 cla showed reduced hepatic accumulation compared to wild type confirming that reduced scd1 expression decreases hepatic lipid accumulation .
liver specific scd1 knock out decreased expression of srebp1 and chrebp and their target genes there by reducing hepatic lipogenesis .
in contrast , short - term inhibition of tissue specific hepatic scd increased hepatic tg content and enhanced insulin signaling , but the long - term inhibition decreased hepatic steatosis .
the differences in responses observed in liver specific knockout versus complete scd knockout mice suggests that hepatic lipid metabolism is being affected by lipid metabolism in nonhepatic tissues . as trans-10 ,
cis-12 cla effects in mice are mostly associated with insulin resistance ; increased hepatic scd1 expression is probably due to increased srebp-1c expression .
hepatic steatosis due to trans-10 , cis-12 cla is also seen in the absence of insulin and is associated with reduced expression of scd1 and other lipogenic genes .
these results indicate that the disturbances in hepatic lipid metabolism caused by dietary trans-10 , cis-12 cla are mediated by multiple mechanisms rather than through changes in scd1 alone . the effect of cla on adipose lipid metabolism is well documented .
of all the cla isomers , trans-10 , cis-12 cla is the most potent to induce changes in adipose .
the changes may be caused by reduced lipid content , size , and number of adipocytes .
trans-10 , cis-12 cla reduces lipogenesis by decreasing expression of srebp-1c and ppar- and their downstream genes , acc , fasn , and scd1 , reduces glucose and fa uptake by reducing glut4 and lpl expression , increases fa oxidation by increasing cpt1 and ucp2 expression and reduces adipocyte proliferation and differentiation by reducing ppar-and its downstream genes .
furthermore , cla affects various adipocyte secreted - adipokines ( e.g. , leptin , adiponectin , and resistin ) and cytokines ( e.g. , tnf and il6 ) , which are involved in wide range of physiological activities .
trans-10 , cis-12 cla increases the mrna expression of cytokines , tnf and il6 in adipose tissue .
however , the circulating cytokine levels are reduced in response to trans-10 , cis-12 cla ( table 2 ) . the increased cytokine expression in adipose tissue
is known to reduce the activity of ppar- , and thereby affect its downstream cellular functions .
also , tnf and il6 inhibit the activation of insulin receptor substrate-1 ( irs-1 ) through induction of suppressors of cytokine signaling ( socs3 ) disrupting insulin action .
the expressions of tnf and adiponectin , an adipokine associated with insulin sensitivity , are inversely related .
the adipose tissue depletion would reduce the level of adiponectin and when coupled with increased tnf would lead to severe insulin resistance .
the subsequent pancreatic cell hyperplasia , as a compensatory mechanism to insulin resistance , leads to hyperinsulinemia which promotes lipid accretion in the liver leading to hepatic steatosis . in mice ,
trans-10 , cis-12 cla causes severe lipodystrophy reducing the levels of leptin and adiponectin ( table 2 ) , which leads to hepatic steatosis ( table 1 , figure 1 ) .
re - establishing the levels of leptin or adiponectin either through external supplementation ( in case of leptin ) or induction using rosiglitazone ( rosi ) ( in case of adiponectin ) attenuated hepatic steatotic condition and normalized the insulin levels in cla - fed mice [ 135 , 136 ] .
similar results are seen in studies where prevention of lipodystrophy prevented lipid accumulation in the liver .
serum insulin levels are directly correlated with liver tg , while serum adiponectin levels are inversely related .
however , hepatic steatosis is seen in mice even at low insulin levels , suggesting that different mechanisms could regulate the induction of hepatic steatosis depending on the animal 's physiological condition .
the intensity of hepatic steatosis could be directly related to the relative amounts of adipose tissue .
cla - induced hyperinsulinemia and hepatic steatosis are observed only if there are corresponding decreases in the adipose tissue mass [ 40 , 135 ] .
stout et al . , reported increases in diacylglycerol ( dag ) concentration and membrane associated protein kinase c ( pkc ) during trans-10 , cis-12 cla - induced hepatic steatosis .
increased pkc would affect insulin signaling leading to insulin resistance , hyperinsulinemia , and hyperglycemia .
in addition to its effects on lipid metabolism , trans-10 , cis-12 cla also induces an inflammatory response in adipose tissue [ 131 , 138 ] .
trans-10 , cis-12 cla activates integrated stress response leading to activation of nf - kb pathway , induction of inflammatory cytokines , tnf , il6 , and il8 [ 41 , 138 , 139 ] , and macrophage infiltration .
however , the level of circulating cytokines , tnf and il6 , were decreased in response to trans-10 , cis-12 cla [ 42 , 43 ] .
in contrast to the adipose , the effects of cla on hepatic inflammatory responses are not well defined .
trans-10 , cis-12 cla did not affect expression markers of macrophage infiltration in mice liver such as tnf or f4/80 and cd68 during hepatic steatosis .
however , trans-10 , cis-12 cla increased expression of markers of hepatic inflammation in hamsters without inducing hepatic steatosis .
the authors in attributed this to an increased capacity of the liver for higher fa oxidation leading to inflammation and oxidant stress defense pathway in the hamsters .
several studies have examined either the prevention or amelioration of trans-10 , cis-12 cla - induced hepatic steatosis ( table 3 ) by normalizing serum adipokine levels , altering hepatic pufa composition or both .
external supplementation of recombinant murine leptin ameliorate cla - induced hepatic steatosis and hyperinsulinemia by decreasing hepatic lipogenesis and increasing insulin sensitivity respectively [ 40 , 136 ] . serum adiponectin levels were not restored ( and remained low ) even after leptin supplementation , prompting the authors in to claim that leptin alone could ameliorate cla induced steatosis .
conversely , trans-10 , cis-12 cla - caused hyperinsulinemia associated with lipid steatosis in ob / ob mouse which lack functional leptin suggests the involvement of other factors .
increasing adiponectin levels by supplementation of rosi attenuates liver fat accumulation in ob / ob mouse .
the insulin sensitizing action of leptin and adiponectin normalizes insulin levels which further helps in preventing cla - induced steatosis [ 40 , 141 ] .
dietary fa or oil supplements with higher n-3 and n-6 pufa are able to ameliorate liver steatosis when supplemented along with cla . supplementing arachidonic acid or its precursor -linolenic acid ( 18:3n-6 ) decreased induction of hepatic steatosis and increased liver pge2 levels .
hepatic steatosis is characterized by significant reduction in the levels of arachidonic acid in liver .
arachidonic acid supplementation would not only normalize the level of respective fa but would also increase the levels of hepatic pge2 [ 44 , 140 ] .
both arachidonic acid and pge2 would further reduce hepatic lipogenesis by decreasing fasn and s14 gene expression [ 140 , 144 ] thereby preventing hepatic steatosis .
the importance of n-3 pufa concentrations on hepatic lipid metabolism was explained in the earlier section .
dietary supplements enriched in n-3 pufa along with cla diet increased the content of n-3 and n-6 pufa in liver .
fish oil , a source of pufa has been shown to ameliorate cla - induced steatosis by increasing leptin and adiponectin levels and decreasing plasma insulin .
pinolenic oil , a source of pinolenic acid was able to stabilize insulin levels when fed with cla .
similarly , flaxseed oil , a source of -linolenic acid was able to increase n-3 and n-6 pufa in liver .
supplementing epa and dha prevents lipid accumulation when fed with trans-10 , cis-12 cla [ 45 , 142 ] .
both epa and dha have modest effects in restoring plasma leptin levels , while dha alone can restore plasma adiponectin levels to some extent .
of the 16 naturally occurring cla isomers , trans-10 , cis-12 cla and cis-9 , trans-11 cla have been the most extensively studied with respect to their bioactive properties .
most of the animal studies have used a cla mixture having trans-10 , cis-12 cla and cis-9 , trans-11 cla in 1 : 1 ratio to study the effect of cla on liver metabolism .
while trans-10 , cis-12 cla leads to decreased adipose tissue leading to insulin resistance , hyperinsulinemia , and hepatic steatosis , cis-9 , trans-11 cla shows only modest effects in mice [ 3032 , 86 ] and hamsters [ 56 , 58 ] .
similarly , the effects of cla on scd1 gene and protein expression are isomer specific .
contrary to trans-10 , cis-12 cla , cis-9 , trans-11 cla has no effect on scd1 gene expression either in vitro or in vivo .
for example , cis-9 , trans-11 cla did not alter liver lipid content but reduced 18:1n-9 and 18:1n-7 and increased 18:2n-6 in tg in contrast to trans-10 , cis-12 cla .
in addition , cis-9 , trans-11 cla promotes insulin sensitivity [ 42 , 43 ] by reducing adipose inflammation [ 41 , 132 ] .
furthermore , it enhances hepatic mitochondrial function and protects against oxidative stress by increasing activities of mitochondrial antioxidant enzymes .
the anti - inflammatory role of cis-9 , trans-11 cla is related to the induction of anti - inflammatory heat shock protein ( hsp ) 70 kda and decreased expression of proinflammatory macrophage migration inhibitory factor .
hepatic steatosis induced by trans-10 , cis-12 cla is associated with lipodystrophy in addition to insulin resistance , hyperinsulinemia , and hyperglycemia in mice ( figure 1 ) .
dietary interventions preventing lipodystrophy or normalizing leptin and adiponectin levels prevents or ameliorates hepatic steatosis in mice , suggesting that adipose tissue responsiveness to trans-10 , cis-12 cla could be the main contributing factor . the moderate responsiveness of adipose tissue to trans-10 , cis-12 cla observed in hamsters and rats results in lower ( or absence of ) hepatic tg accumulation when compared with mice ( table 1 ) explains species specific responses .
hepatic steatosis , due to increased lipid accumulation , is multifactorial and is largely attributed to increased rates of lipid synthesis along with lipid uptake , and it far exceeds the rates of fa oxidation and vldl secretion .
in addition , trans-10 , cis-12 cla - induced hepatic steatosis is characterized by reduction of n-6 pufa ( especially c20:4n-6 ) and n-3 pufa ( figure 1 ) .
changes in hepatic fa composition could play an important role in progression of hepatic steatosis , as normalizing the levels of n-6 pufa or n-3 pufa by dietary supplementation prevents or ameliorates hepatic lipid accumulation .
further studies are needed to understand the molecular mechanisms and the interrelationship between trans-10 , cis-12 cla - induced hepatic steatosis and altered hepatic pufa content .
we are still lacking mechanistic details showing relationship between adipokine levels , insulin resistance , and hepatic fa composition in context of hepatic steatosis , and it needs to be addressed in the future experiments . | objective . to summarize the recent studies on effect of conjugated linoleic acid ( cla ) on hepatic steatosis and hepatic and adipose lipid metabolism highlighting the potential regulatory mechanisms .
methods .
sixty - four published experiments were summarized in which trans-10 , cis-12 cla was fed either alone or in combination with other cla isomers to mice , rats , hamsters , and humans were compared .
summary and conclusions .
dietary trans-10 , cis-12 cla induces a severe hepatic steatosis in mice with a more muted response in other species .
regardless of species , when hepatic steatosis was present , a concurrent decrease in body adiposity was observed , suggesting that hepatic lipid accumulation is a result of uptake of mobilized fatty acids ( fa ) from adipose tissue and the liver 's inability to sufficiently increase fa oxidation and export of synthesized triglycerides .
the potential role of liver fa composition , insulin secretion and sensitivity , adipokine , and inflammatory responses are discussed as potential mechanisms behind cla - induced hepatic steatosis . |
patients older than 70 years remain one of the fastest growing populations . in the usa alone
this group increased from 21.1 million in 1990 to over 25 million in 1999 , and is projected to reach nearly 36 million people by the year 2020 . with this in mind , the number of elderly patients presenting with an st - segment elevation ami will continue to increase . despite this , there have been no head - to - head trials of thrombolytic therapy versus pci that are specifically designed for this patient population .
however , there are indications from previous trials that primary pci is likely to be the superior therapy .
elderly patients have a documented increase in bleeding ( including intracranial hemorrhage ) with thrombolytic therapy . in fact , age greater than 65 years has been associated with an odds ratio of 2.2 ( 95% confidence interval 1.4 - 3.5 ) for intracranial hemorrhage as compared with younger patients .
the percentage of women is higher than that of men among elderly patients , and hemorrhagic complications are known to be higher in women ( and even greater if their weight is < 70 kg ) .
also , any previous hemorrhagic stroke , which is more common in elderly patients , is a very strong contraindication to thrombolytic therapy .
elderly patients are likely to have more contraindications to thrombolytic therapy , more comorbid conditions , and more adverse hemodynamic and angiographic predictors of poor outcome than younger patients .
a recent pooled analysis of 3032 patients enroled in primary pci trials revealed that patients older than 75 years were more likely to have a history of hypertension , diabetes mellitus , congestive heart failure , previous coronary revascularization ( pci or bypass surgery ) , peripheral vascular disease , stroke , or chronic obstructive lung disease . at angiography
they had lower left ventricular ejection fraction , higher left ventricular end - diastolic pressure , and more two - vessel or three - vessel coronary disease .
in addition , these patients were significantly more likely to present with an infarction of killip class ii or higher .
many of the early trials of thrombolytic therapy intentionally excluded patients aged 75 years or older because of a perceived increase in bleeding and overall mortality .
later trials began to include these patients , and especially those that compared thrombolytic therapy with primary pci , but the average age in many of these trials remained approximately 60 years . in the global utilization of streptokinase and t - pa for occluded coronary arteries ( gusto)1 trial of four regimens of thrombolytic therapy , the overall mortality rate was 7.0% .
however , the 30-day mortality rates for patients aged 65 - 74 , 74 - 85 and > 85 years were 9.5 , 19.6 and 30.3% , respectively . in an analysis of the gusto iib trial , holmes et al showed that , for each 10-year patient group ( 50 - 59 years , 60 - 69 years , etc ) , outcome was always superior with angioplasty as compared with tissue - type plasminogen activator ( t - pa ) . in the primary angioplasty in
myocardial infarction ( pami)-1 trial , the benefit of percutaneous transluminal coronary angioplasty ( ptca ) over t - pa was marked in patients aged more than 65 years , with a reduction in the 6-month composite endpoint of in - hospital death or reinfarction being reduced from 20 to 8.6% ( p < 0.05 ) .
recently , thiemann et al reported an analysis of 7864 patients ( aged 65 - 86 years ) who were eligible for thrombolytic therapy ( presentation < 12 h from symptom onset , st - segment elevation 1.5 mm [ limb leads ] or 2 mm [ precordial leads ] in two or more contiguous leads ; left bundle branch block was excluded ) .
that study was designed to compare the risks and benefits of intravenous thrombolysis in patients aged 65 - 75 years with those in patients aged 76 - 86 years . of note , over 50% of the patients in each group who met initial electrocardiographic criteria
were excluded for various reasons , with 12% of the younger patients and 17% of the older patients having absolute contraindications to thrombolytic therapy .
intravenous thrombolysis was administered in 3861 out of 5191 ( 74% ) of patients in the 65 - 75 years age group and in 1607 out of 2673 ( 60% ) of the 76 - 86 years age group . at 30 days
there was a survival benefit in the younger patients ( hazard ratio 0.76 , 95% confidence interval 0.61 - 0.95 ) and worsened survival in the older group ( hazard ratio 1.29 , 95% confidence interval 1.06 - 1.58 ) , with mortality rates reduced from 9.8 to 6.8% in the younger group but increased from 15.4 to 18% in the older group ( fig .
thiemann et al speculated that increased rates of intracranial hemorrhage and cardiac rupture in the older patients may explain the lack of benefit of thrombolytic therapy in these persons .
effect of treatment with thrombolytic therapy for st - segment elevation ami by age group .
with regard to prior coronary bypass surgery , several studies have shown that thrombotic occlusion of a saphenous vein graft is the primary mechanism of ami in these patients .
thrombolytic therapy is often ineffective because of poor flow in the graft ( preventing delivery of the thrombolytic agent ) as well as the presence of giant thrombus .
primary pci is successful in up to 90% of these patients because the obstructing thrombus can be mechanically disrupted . as mentioned above ,
systemic thrombolytic therapy has not been shown to provide a survival benefit in these patients . in the gruppo italiano per lo studio
della streptokinasi nell'infarcto miocardico ( gissi)-1 and international study group ( isg ) trials , 17 - 23% of patients presented in killip class ii and 2 - 4% in class iii . at 6-month follow - up in the gissi-1 trial ,
mortality rates were 27% versus 29% for placebo in class ii patients , and 50% versus 53% for placebo in class iii patients ( class iv patients were excluded ) .
it is theorized that poor cardiac pump function results in decreased coronary perfusion , making the thrombolytic agents unable to penetrate the occlusive thrombus .
in a pooled analysis of the pami-1 , zwolle and mayo clinic trials , o'neill et al showed an increasing benefit of primary ptca over t - pa with increasing patient age ( fig .
this is probably due to the fact that primary pci can restore thrombolysis in myocardial infarction ( timi ) grade 3 flow in over 90% of patients , as opposed to 60 - 70% of patients treated with thrombolytic therapy .
data from primary pci trials revealed a mortality rate of approximately 10% in patients older than 75 years , which is lower than that in the thrombolytic trials .
mortality by age group in selected trials of ptca versus thrombolytic therapy . modified from o'neill et al .
emergent catheterization not only defines the status of the infarct - related artery ( patent or not , timi flow grade ) , but is extremely useful for risk stratification .
noninvasive testing can usually be averted and hospital discharge can be accelerated , resulting in significant cost savings . as a result of perceived or real contraindications , fewer than 10% of elderly patients with st - segment elevation
primary pci is not as readily available as thrombolytic therapy in all locations , but there are emerging data that show that primary pci can be performed safely in hospitals without on - site cardiac surgery .
of course , what is most needed is a head - to - head , prospective study of thrombolytic therapy versus primary pci in elderly patients .
the senior pami trial will enrol 530 elderly ami patients , who will be randomized to primary pci or thrombolytic therapy ( t - pa or rpa ) with a primary composite end - point of death or disabling stroke at 30 days .
multiple secondary end - points will be measured at 1 , 6 , and 12 months .
there may also be a role for combination therapy , in which reduced - dose thrombolytic therapy ( with or without a glycoprotein iib / iiia receptor antagonist ) is administered in the field or in the receiving emergency room , with subsequent transfer for pci ( ' facilitated angioplasty ' ) .
as the population increases worldwide , the number of elderly patients who present with an st - segment elevation ami will continue to grow .
there are no head - to - head trials of primary pci versus thrombolytic therapy in elderly patients .
however , data from previous trials that have included elderly patients suggest that primary pci is safer and is probably more effective in such cohorts .
the bleeding risk associated with pci is lower , and pci appears to be more effective in patients with prior coronary artery bypass grafting and those with congestive heart failure , groups that are more common among elderly patients .
primary pci allows those patients who are not eligible for thrombolytic therapy to receive reperfusion therapy , is useful for early risk stratification , and usually obviates the need for noninvasive testing .
early discharge , with resultant lower hospital charges , is also possible in many cases .
access to primary pci is expanding , and continued technical and therapeutic advances will allow for increased distribution and utilization of this therapy among elderly patients .
the ongoing senior pami trial will provide the first randomized , controlled trial evidence of thrombolytic therapy versus pci in elderly patients . | as the population ages the number of elderly patients presenting with acute myocardial infarction ( ami ) will continue to increase .
there has been no head - to - head trial of thrombolytic therapy versus primary percutaneous coronary intervention ( pci ) in this patient cohort , but there is evidence that favors primary pci .
most elderly patients are candidates for primary pci , but many have contraindications to thrombolytic therapy .
hemorrhagic complications are more common in the elderly , and many of these patients present with conditions in which thrombolytic agents have decreased efficacy , such as heart failure or prior bypass surgery .
pci can also obviate the need for further risk stratification in most patients . |
the use of titanium for dental implants and metal ceramic restorations , such as cast
restorations or partial dentures , has increased over the last years because of their
biocompatibility and optimum mechanical properties . however , low bond
strengths between titanium and composite veneering systems have been reported . to overcome this limitation ,
several methods have been
proposed to maximize the bonding of resin composite to titanium .
such methods are based
on macro- and micromechanical retention , chemical bonding , or a combination of both
mechanisms .
the first bonding technique was the silicoater system , introduced in 1984 as a " system
of molecular bond " between resins and metal alloy surfaces . in that system ,
the bonding mechanism consists of a
heat fusion of a microscopic layer of silica to the metal by the so - called silica
coating method , and the composite is bonded to the metal surface with a silane coupling
agent in a process known as pyrolytic silanization .
new bonding systems that combine adhesive resins with chemically active monomers capable
of bonding directly to sandblasted alloy surfaces have also been developed . when these new
adhesive systems are used along with conditioning methods , only sandblasting of the
metal surface
is required for these bonding agents to provide reliable bond strength
between the resin composite and metal surface .
the bonding agents lead to some mechanism of chemical bonding
with different alloys , so the micromechanical retention created by sandblasting
increases considerably .
phosphoric
acid and carboxylic acid functional monomers used in most adhesive opaque resins and
promoters are effective to bond resin composites to base metal alloys . for this reason ,
with the use of an appropriate adhesive metal primer ,
no surface preparations such as
boxes , grooves , or retentive pearls are required on the metal frameworks prior to the
application of light - cured veneering resins .
now , several adhesive primers containing different functional monomers to bond resin to
base metals are commercially available .
however , the effects of these products on the bond strength of
metals to resin have not yet been evaluated .
such an issue deserves more concern when
the bonding between resin composite and titanium surface with metal primers are
subjected to all the stresses created in vivo . in this regard ,
the
combination between water storage and thermal cycling reproduces the in
vivo conditions more accurately , providing evidence of
the long - term effectiveness of metal primers on bond strength of resin composites to
titanium surfaces .
therefore , the purpose of this study was to evaluate whether surface pre - treatment of
commercially pure titanium grade i ( cpti ) with sandblasting associated with three metal
conditioners or with one surface modification system would improve the bond strength of
a light - activated resin composite to the base metal after thermocycling .
the tested
hypotheses were : ( 1 ) metal primers provide similar increase in shear bond strength
( sbs ) ; ( 2 ) and sbs values between resin and metal surfaces treated with metal primers
are not impaired by thermal cycling .
a total of 196 rivet - shaped specimens ( 8.0 x 2.0 mm ) were cast with cpti
( tritan , dentaurum j. p. winkelstroeter kg , pforzheim , germany ) using
electric plasma arc in an inert gas - conditioned casting machine ( edg equipments , so
carlos , sp , brazil ) according to the
manufacturer 's instructions . after casting ,
the disk surfaces were gradually polished
with up to 600-grit silicon - carbide papers under constant cooling water .
the metal
specimens were then washed with isopropyl alcohol for 10 min with ultrasonic
agitation .
the specimens were assigned to 3 groups , and were submitted to 3 surface treatments :
( 1 ) polishing control with 600-grit silicon - carbide paper ( p ) , ( 2 ) sandblasting with
either 50 m al2o3 ( 50sb ) or ( 3 ) 250 m
al2o3 ( 250sb ) .
sandblasting was performed perpendicularly to
the metal surface at a distance of 5 mm and at 0.5 mpa for 15 s ( basic classic ;
renfert gmbh , hilzingen , germany ) .
flowchart of the experimental design after surface preparation was completed , each group ( 56 specimens ) was divided into
four subgroups , according to the metal conditioners and metal surface modification
system applied to the disk surfaces .
in addition , 14 specimens from the 50sb group
and 14 specimens from the 250sb group were left untreated to receive only opaque and
dentin resins ( control groups - od ) .
the following metal conditioners were applied to the metal surfaces : mpp ( metal photo
primer , shofu inc . ,
kyoto , japan ) , op ( cesead ii opaque primer , kuraray co. ltd .
,
osaka , japan ) , s ( siloc bonding system , heraeus - kulzer gmbh , wehrheim , germany ) - a
metal surface modification system , and tl ( targis link , ivoclar vivadent , schaan ,
liechtenstein ) ( figure 3 ) . when the metal
conditioner was presented as a single bottle product , the product was brushed
directly on the alloy surface , according to the manufacturers ' instructions . for the
siloc bonding system , one coat of primer ( siloc pre , heraeus - kulzer gmbh , wehrheim ,
germany )
the
primed specimens were allowed to dry for 2 min and were placed in an activation
chamber ( silicoater md , heraeus - kulzer , wehrheim , germany ) , as recommended by the
manufacturer . at the end of the cycle ,
the specimens were removed from the oven and
were left at room temperature for 4 min .
failure patterns of all experimental groups at t0 ( a ) and t1 ( b ) afterward , one coat of the bonding agent ( siloc bond , heraeus - kulzer , wehrheim ,
germany ) was applied with a single brush and was allowed to dry for 5 min .
two 1-mm
thick layers of an opaque resin ( o ) were applied to the metal surfaces and each layer
was exposed to light for 90 s in a laboratory light - curing unit ( dentacolor xs ,
heraeus - kulzer , wehrheim , germany ) , according to the manufacturers ' recommendation . a
cylindrical stainless steel split mold having an internal hole having 8 mm of
diameter and being
2-mm thick was positioned on the specimen and two 1-mm - thick
layers of dentin composite ( a ) were inserted into the mold .
the mold was removed and
each layer was then exposed to light for 90 s using the same light - curing unit ,
resulting in a total light exposure of 180 s. seven specimens from each experimental group ( n=7 ) were stored in distilled water at
37c for 24 h ( t0 ) , while the other 7 specimens were stored in distilled water at
37c for 24 h followed by 5,000 thermal cycles ( t1 ) , which consisted of water baths
at 4c and 60c with a dwell time of 15 s in each bath ( msct-3 plus ; marcelo nucci -
me ; so carlos , sp , brazil ) .
all specimens were then subjected to an sbs test using a
machine of mechanical test mts 810 ( material test system corporation , minneapolis ,
mn , usa ) at a crosshead speed of 0.5 mm / min until failure occurred .
the sbs values were obtained in kgf and converted into
megapascals ( mpa ) .
fractured surfaces were evaluated with an optical stereomicroscope ( carl zeiss jena
gmbh , jena , germany ) at 40x magnification to determine the failure pattern , which was
classified as follows : cohesive , when the fracture was located within the resin
composite ; adhesive , when the fracture was located between the resin composite and
metal surface ; or mixed , when the fracture was located within the resin composite and
between the resin composite and metal surface .
in addition , a representative specimen
surface of each experimental group was evaluated with a scanning electron microscope
( sem ) operating at 20 kv ( jsm - t33ao , jeol ltd . ,
all representative specimen surfaces were also examined by x - ray
energy - dispersive spectroscopy - eds ( jsm - t33ao , jeol ltd . ,
tokyo , japan ) at 20 kv
and live time of 100 s. levene and shapiro - wilk tests ( statistica 6.0 , statsoft inc . ,
tulsa , ok , usa ) were
applied to evaluate the homogeneity and normality among sbs means
( p>0.05 ) respectively .
the sbs means were submitted to 3-way
anova ( surface treatment , conditioner , and thermocycling ) at a 95% confidence level .
tulsa , ok , usa ) was performed to
compare the differences in sbs means of groups having different conditioners only
within the group with polished surfaces ( p ) .
differences among means were determined
by post - hoc tukey 's test at a pre - set alpha of 5% .
the od group was
not included in the statistical tests because this group was only added to the study
to provide the sbs values when no conditioners are used .
the specimens were assigned to 3 groups , and were submitted to 3 surface treatments :
( 1 ) polishing control with 600-grit silicon - carbide paper ( p ) , ( 2 ) sandblasting with
either 50 m al2o3 ( 50sb ) or ( 3 ) 250 m
al2o3 ( 250sb ) .
sandblasting was performed perpendicularly to
the metal surface at a distance of 5 mm and at 0.5 mpa for 15 s ( basic classic ;
renfert gmbh , hilzingen , germany ) .
flowchart of the experimental design after surface preparation was completed , each group ( 56 specimens ) was divided into
four subgroups , according to the metal conditioners and metal surface modification
system applied to the disk surfaces . in addition , 14 specimens from the 50sb group
and 14 specimens from the 250sb group were left untreated to receive only opaque and
dentin resins ( control groups - od ) .
the following metal conditioners were applied to the metal surfaces : mpp ( metal photo
primer , shofu inc . ,
kyoto , japan ) , op ( cesead ii opaque primer , kuraray co. ltd .
,
osaka , japan ) , s ( siloc bonding system , heraeus - kulzer gmbh , wehrheim , germany ) - a
metal surface modification system , and tl ( targis link , ivoclar vivadent , schaan ,
liechtenstein ) ( figure 3 ) . when the metal
conditioner was presented as a single bottle product , the product was brushed
directly on the alloy surface , according to the manufacturers ' instructions . for the
siloc bonding system , one coat of primer ( siloc pre , heraeus - kulzer gmbh , wehrheim ,
germany )
the
primed specimens were allowed to dry for 2 min and were placed in an activation
chamber ( silicoater md , heraeus - kulzer , wehrheim , germany ) , as recommended by the
manufacturer . at the end of the cycle ,
the specimens were removed from the oven and
were left at room temperature for 4 min .
failure patterns of all experimental groups at t0 ( a ) and t1 ( b ) afterward , one coat of the bonding agent ( siloc bond , heraeus - kulzer , wehrheim ,
germany ) was applied with a single brush and was allowed to dry for 5 min .
two 1-mm
thick layers of an opaque resin ( o ) were applied to the metal surfaces and each layer
was exposed to light for 90 s in a laboratory light - curing unit ( dentacolor xs ,
heraeus - kulzer , wehrheim , germany ) , according to the manufacturers ' recommendation . a
cylindrical stainless steel split mold having an internal hole having 8 mm of
diameter and being
2-mm thick was positioned on the specimen and two 1-mm - thick
layers of dentin composite ( a ) were inserted into the mold .
the mold was removed and
each layer was then exposed to light for 90 s using the same light - curing unit ,
resulting in a total light exposure of 180 s. seven specimens from each experimental group ( n=7 ) were stored in distilled water at
37c for 24 h ( t0 ) , while the other 7 specimens were stored in distilled water at
37c for 24 h followed by 5,000 thermal cycles ( t1 ) , which consisted of water baths
at 4c and 60c with a dwell time of 15 s in each bath ( msct-3 plus ; marcelo nucci -
me ; so carlos , sp , brazil ) .
all specimens were then subjected to an sbs test using a
machine of mechanical test mts 810 ( material test system corporation , minneapolis ,
mn , usa ) at a crosshead speed of 0.5 mm / min until failure occurred .
the sbs values were obtained in kgf and converted into
megapascals ( mpa ) .
fractured surfaces were evaluated with an optical stereomicroscope ( carl zeiss jena
gmbh , jena , germany ) at 40x magnification to determine the failure pattern , which was
classified as follows : cohesive , when the fracture was located within the resin
composite ; adhesive , when the fracture was located between the resin composite and
metal surface ; or mixed , when the fracture was located within the resin composite and
between the resin composite and metal surface . in addition , a representative specimen
surface of each experimental group was evaluated with a scanning electron microscope
( sem ) operating at 20 kv ( jsm - t33ao , jeol ltd .
all representative specimen surfaces were also examined by x - ray
energy - dispersive spectroscopy - eds ( jsm - t33ao , jeol ltd . ,
tokyo , japan ) at 20 kv
and live time of 100 s. levene and shapiro - wilk tests ( statistica 6.0 , statsoft inc . ,
tulsa , ok , usa ) were
applied to evaluate the homogeneity and normality among sbs means
( p>0.05 ) respectively .
the sbs means were submitted to 3-way
anova ( surface treatment , conditioner , and thermocycling ) at a 95% confidence level .
, tulsa , ok , usa ) was performed to
compare the differences in sbs means of groups having different conditioners only
within the group with polished surfaces ( p ) .
differences among means were determined
by post - hoc tukey 's test at a pre - set alpha of 5% .
the od group was
not included in the statistical tests because this group was only added to the study
to provide the sbs values when no conditioners are used .
forty - two thermocycled specimens without any treatment agent showed premature adhesive
failures prior to the mechanical testing and were excluded from the study .
the 3-way
anova detected a significant interaction between " treatment " and " conditioner " factors
as well as between " thermocycling " and " conditioner " ( p<0.05 ) .
within the 50sb group ,
the sbs values of op ( 9.3 mpa ) were only higher than those of mpp
( 6.7 mpa ) ( p<0.05 ) , while no significant difference was noted
between op , s , and tl ( table 1 ) . within the
250sb group ,
op ( 13.2 mpa ) and tl ( 12.4 mpa ) showed significantly higher sbs means than
mpp ( 9.8 mpa ) and s ( 10.2 mpa ) ( p<0.05 ) , while no significant
difference was noted neither between op and tl nor between mpp and s ( table 1 ) .
overall , the sbs means of most 250sb
groups with surface conditioners were higher than those of 50sb
( p<0.05 ) .
the only exception was observed when s was used , as no
significant difference in sbs was noted between 50sb and 250sb groups ( from 6.6 mpa to
9.7 mpa , p>0.05 ) .
shear bond strength ( mpa ) mean values ( standard deviations ) of resin composite to
sandblasted cpti surfaces with metal primers .
means followed by the same capital
letters in a column and lower case on the lines do not differ significantly by the
tukey test ( =0.05 ) no significant difference in sbs means was observed between t0 and t1
( p>0.05 ) . at t0 ,
no significant difference in the sbs values was
observed between tl ( 10.6 mpa ) and op ( 10.4 mpa ) , or between mpp ( 8.4 mpa ) and s ( 9.6
mpa ) ( p>0.05 ) ( table 2 ) .
the
sbs means of op and tl were higher than those of mpp ( p<0.05 ) . at
t1 , op ( 12.1 mpa ) showed higher sbs values than mpp ( 8.1 mpa ) , s ( 9.1 mpa ) , and tl ( 10.2
mpa ) ( p<0.05 ) ( table 2 ) .
one - way anova ( table 2 ) indicated no significant
differences in sbs among groups with conditioners ( p>0.05 ) .
shear bond strength ( mpa ) mean values ( standard deviations ) of resin composite to
sandblasted cpti surfaces with metal primers after 24 h of water storage ( t0 ) or
after thermocycling ( t1 ) .
means followed by the same capital letters in a column
and lower case on the lines do not differ significantly by the tukey test
( =0.05 ) at t0 and t1 ( figure 3 ) , debonded surfaces from
most groups showed 100% adhesive failures located between the metal surface and opaque
resin . at t0 ,
only the op / s250 group exhibited 100% of mixed failures , while op/50sb
( 14% ) , s/250sb ( 28% ) , and tl/250sb ( 28% ) showed small amounts of mixed failures .
a
similar pattern was observed at t1 , but a small increase in mixed failures ( 14% ) was
observed in mpp/250sb and tl/50sb groups in comparison to the failure patterns at t0 . in
contrast to the failure pattern of the s/250sb group at t0 , the s/250sb group at t1
showed a 100% adhesive failure pattern .
the effect of sandblasting on the surface
morphology and composition of specimens from groups p , 50sb , and 250sb can be seen on
sem micrographs and eds spectra ( figures 4 , 5 , and 6 ) .
it
is possible to note the effects of varying sizes of aluminum oxide on surface morphology
( figures 5a and 6a ) , since pressure , time of sandblasting , and distance from the metal
surface were the same in all groups .
eds analysis detected the presence of aluminum and
oxide on the sandblasted cpti surfaces ( figures 5b
and 6b ) .
scanning electron microscopy analysis for cpti before sandblasting scanning electron microscopy analysis for cpti after sandblasting with 50 m
al2o3
scanning electron microscopy analysis for cpti after sandblasting with 250 m
al2o3
the present study evaluated the sbs of a resin composite to cpti after sandblasting with
varying sizes of al2o3 particles associated with three metal
conditioners or with one surface modification .
overall , the association of metal
conditioners and sandblasting increased the sbs in comparison to the values obtained on
polished surfaces .
the effectiveness of the conditioners on sbs to cpti
airborne - particle - abraded surfaces ( 50sb and 250sb ) and either under the influence of 24
h water storage or thermal stress ( t0 and t1 ) was more evident when monomers having
phosphoric acid ( op and tl ) in their composition were used in comparison with those
having the carboxylic derivative ( mpp ) .
these results are in agreement with those from
previous studies that attributed this greater effectiveness to the
presence of a hydrophobic group in their compositions . according to taira , et
al .
( 1995,1998 ) the pure ti surface is covered with a layer of
titanium oxides that guarantees the resin / metal bond by its reaction with the monomers
derived from carboxylic and phosphoric acids . ban ( 2003 )
reported that carboxylic acid ( 4-aet and 4-meta ) and
phosphoric ( mdp ) derivatives interact with the oxide film on the surface of basic
metals , including titanium , via hydrogen bridges , and with the hydroxyl ions
( oh present on the metal surface .
therefore , the first hypothesis ,
stating that the metal primers provide similar increase in sbs , was not validated in the
current study .
we observed a 1.5 times increase in the resin / ti bond strength values in
comparison with the values observed on a noble alloy .
the bond between polymers and metal is not completely justified by these two bonding
mechanisms .
this conclusion is in agreement with our results , when we compared the
polishing group with the 50sb / od and 250sb / od groups .
the effectiveness of op and tl may
be also attributed to chemical affinity of the phosphoric acid group for the aluminum
oxide particles trapped on the metal surface due to sandblasting .
based on the eds analysis , oxygen and aluminum were only detected on the sandblasted
metal surfaces , demonstrating the presence of remaining al2o3
particles , as also observed by ohkubo , et al .
( 2000 ) . however , the influence of aluminum on the bonding
mechanism is not well known .
( 2000 ) described changes in
the surface morphology of gold alloys due to the differences in particle sizes and the
range in pressure during sandblasting .
they also found an increase in the amount of
aluminum on the metal surface and the possible chemical affinity of aluminum for
functional monomers and phosphoric derivatives .
in addition to the micromechanical
retention , kern and thompson ( 1994 )
reported that the remaining aluminum particles on the metal surface play an important
role in the bonding mechanism created by bonding systems with functional monomers . according to the eds analysis
, it was not possible to observe the presence of remaining
compounds from conditioners on the metal surfaces , or even the silicon layer of the s
group . according to kern and thompson ( 1994 ) the pyrolytically deposited silicon results in a layer that
is invisible to sem , while ekstrand
, ruyter and ysaed ( 1988 ) observed that the presence of polymer molecules
on the surfaces of metals can only be detected by infrared spectroscopy .
the effects of
remaining aluminum particles also hels explain the higher amount of mixed failures in
the 250sb group in comparison to those observed in 50sb groups , confirming the greater
retention demonstrated by that group .
thermocycling in a water bath has been used frequently to simulate the intraoral aging
effect on resin composite adhesion . however , these simulations vary considerably and any
evidence of the number of cycles corresponding to those experienced in
vivo was not yet found . in the present study , thermocycling had
no significant effect on conditioners . therefore , the metal primers demonstrated
reliable bonding without a reduction in bond strength after thermocycling .
thus , the
second research hypothesis - establishing that sbs values between resin and metal
surface treated with metal primers is not impaired by thermocycling - was validated .
the results of the present study are in agreement with those observed by zcan and
valandro ( 2012 , 2011 ) that observed higher bond strength of resin
composite to titanium with phosphoric acid derivatives . according to the
authors
, the effectiveness of
the bond strength can also be influenced by the opaque resin layer applied after the
surface treatment and previously the application of aesthetic covering material .
the
effect of opaquers can be attributed to differences in their chemical composition and
form of presentation ( powder / liquid or paste ) that lead to various
consistencies .
zcan and
kumbuloglu(2009 ) concluded
that although thickness did not affect the bond strength between resin composite to
titanium , type of opaquers had a significant effect in the results with higher bond
strength for power - liquid form than paste form in both thin and thick application .
moreover , the authors suggested that the degree of water uptake of the opaquers ,
specifically due the hydrophilic character of the dimethacrylates could influence in
bond strength .
since only one opaque
resin was tested in the present investigation , further studies are needed in order to
evaluate more carefully the influence of this material on the bonding process .
the shear bond strength test was used in this study because shearing forces are the most
predominant during chewing .
for this
reason , this test reproduces more closely what happens to materials in the mouth . on the
other hand ,
it is important to point out that some methods , such as finite analysis and
mathematical analysis of stress , demonstrated that nominal bond strength obtained after
specimen fracture divided by the cross - sectional area may not represent the true stress
generated at the interface .
such a
difference between the stress generated during the test and that created during chewing
may be attributed to other influencing factors , such as specimen geometry , load type ,
moment of load application and cynzel position .
the results of this in vitro study suggest that the use of chemical
bonding systems combined with a mechanical retention improved the bonding between a
resin composite and commercially pure titanium ( cpti ) .
this evidence implies that
clinicians may consider the use of techniques that combine chemical bond and mechanical
retention when reliable bonding is required between a metal surface and resin composite .
thus , clinicians can be more confident when using composite veneering systems coupled to
metals .
according to the results of the current study , it was concluded that an increase in sbs
of resin to cpti may be achieved by associating the mechanical retention provided by
sandblasting with 250 m aluminum oxide particles with the chemical bonding created by
metal conditioners , mainly by those containing functional monomers derived from
phosphoric acid ( cesead ii opaque primer and targis link ) . | objectivethis study evaluated the effect of three metal conditioners on the shear bond
strength ( sbs ) of a prosthetic composite material to cpti grade i having three
surface treatments .
material and methodsone hundred sixty eight rivet - shaped specimens ( 8.0x2.0 mm ) were cast and
subjected to polishing ( p ) or sandblasting with either 50 mm ( 50sb ) or 250 mm
( 250sb ) al2o3 .
the metal conditioners metal photo primer
( mpp ) , cesead ii opaque primer ( op ) , targis link ( tl ) , and one surface
modification system siloc ( s ) , were applied to the specimen surfaces , which were
covered with four 1-mm thick layers of resin composite .
the resin layers were
exposed to curing light for 90 s separately .
seven specimens from each
experimental group were stored in water at 37c for 24 h while the other 7
specimens were subjected to 5,000 thermal cycles consisting of water baths at 4c
and 60c ( n=7 ) .
all specimens were subjected to sbs test ( 0.5 mm / min ) until
failure occurred , and further 28 specimens were analyzed using scanning electron
microscope ( sem ) and x - ray energy - dispersive spectroscopy ( eds ) .
data were
analyzed by 3-way anova followed by post - hoc tukey 's test
( =0.05 ) .
resultson 50sb surfaces , op groups showed higher sbs means than mpp ( p<0.05 ) , while no
significant difference was found among op , s , and tl groups . on 250sb surfaces , op
and tl groups exhibited higher sbs than mpp and s ( p<0.05 ) .
no significant
difference in sbs was found between op and tl groups nor between mpp and s groups .
the use of conditioners on 250sb surfaces resulted in higher sbs means than the
use of the same products on 50sb surfaces ( p<0.05 ) .
conclusionsandblasting associated with the use of metal conditioners improves sbs of resin
composites to cpti . |
combined hepatocellular and cholangiocarcinoma ( chcc - cc ) is an uncommon subtype of primary liver cancer [ 1 , 2 ] .
the disease was first described in 1949 by allen and lisa and has been defined as the intimate intermingling of both a hcc component and cc component ( 2 ) .
allen and lisa described three groups , type a with hcc and cc present at different sites within the same liver , and type b with hcc and cc present at adjacent sites and mingle with continued growth , and type c with hcc and cc are combined in the same tumor .
goodman et al . categorized chcc - cc into three types : ( i ) collision type , ( ii ) transitional type , and ( iii ) fibrolamellar type .
proposed that chcc - cc is a distinct type of primary liver carcinoma , which is morphologically and phenotypically intermediate between hcc and cc and may be derived from hepatic progenitor cells with the bipotential to differentiate into both hepatocytic and cholangiocytic lineages .
because of the rarity of chcc - cc , previously published literature has been based on case series and anecdotal experiences [ 314 ] , with largest case series include thirty cases .
most of these reports were histopathological studies , the demographic features and clinical behavior of this disease remain ill - defined , and the outcomes of these patients are varied in a number of studies .
for example , the reported results of surgical resection from single institution have been inconsistent [ 10 , 1519 ] . in this study , we take advantage of the vast amount of data collected by the seer program to examine the largest series of chcc - cc reported to date .
we examine the incidence , natural history , utilization of cancer - directed surgery ( cds ) as well as prognostic factors that might affect the survival for chcc - cc .
in 1973 , the seer registry program was established to identify all new cancer cases diagnosed within 7 geographic areas . since 1973
, the seer program has expanded several times to improve representative sampling of minority groups as well as to increase the total sampling of cases to allow for greater precision . the original seer 9 registries included atlanta , connecticut , detroit , hawaii , iowa , new mexico , san francisco - oakland , seattle - puget sound , and utah . by 1975 , seer included 9 geographic regions , 5 states ( connecticut , hawaii , iowa , new mexico , and utah ) and 4 metropolitan areas ( san francisco - oakland , seattle - puget sound , detroit , and atlanta ) . in 1992 , four additional registries were added to form the seer 13 registries , which included the seer 9 registries , plus los angeles , san jose - monterey , rural georgia , and the alaska native tumor registry .
more recently , in 2000 , data from greater california , kentucky , louisiana , and new jersey were added to the seer 13 program to form the seer 17 registries .
seer 9 , 13 , and 17 registries cover approximately 9.5% , 13.8% , and 26.2% of the total u.s .
data for this study were obtained from seer*stat public - use data files available from the national cancer institute . for incidence analyses ,
the cases of chcc - cc were extracted from the seer on the basis of anatomic site ( icd - o-2 codes c22.022.1 ) and histological type ( icd - o code 8180 ) for those patients first diagnosed and/or treated between january 1973 and december 2004 .
a total of 42,654 patients with hepatobilliary neoplasms were identified in the seer 17 registries , among them , 380 patients were found with chcc - cc .
cases identified at the time of autopsy or by death certificate only ( 24 cases ) were excluded from survival analyses .
patients ' social demographic characteristics ( i.e. , age , race / ethnicity , and marital status ) and tumor grade and stage at the time of diagnosis , were determined from the seer database . because there is no ajcc ( the american joint committee on cancer ) staging system for chcc - cc ,
this system classifies patients as having local , regional ( extension into adjacent tissues or nodal involvement ) , or distant disease .
the world health organization 's standard grading system was used with four separate categories ( well , moderately well , poorly differentiated , and undifferentiated ) . for analysis purpose , they were grouped into low grade ( well , moderately well differentiated ) and high grade ( poorly differentiated , and undifferentiated ) . in seer database , any treatment that is given to modify , control , remove or destroy primary or metastatic cancer tissue
cds was defined in this study as surgical resection ( hepatectomy ) , transplantation , local regional therapy ( such as radiation frequency ablation , chemoembolazation , and embolization ) , and unknown surgery , based on values for site - specific surgery and surgery of the primary site codes within the database .
since only few patients received local regional therapy , we grouped these patients together with patients underwent unknown surgery together as other surgery . by using linked population files , age - adjusted incidence rates and their 95% confidence intervals ( cis )
were calculated for chcc - cc for all patients , for men and women separately , and for each of the 3 broad categories of race ( whites , blacks , and other ) and in three time periods .
continuous data are reported as mean sd and compared by student 's t - test .
multivariate logistic regression analyses were used to determine the factors associated with receipt of cancer - directed surgery .
survival duration was measured by the kaplan - meier method and compared by the log rank test .
multivariable cox proportional hazards model was used to identify independent predictors of long - term cancer specific death .
seer*stat 6.2.4 ( surveillance research program , national cancer institute ) was used for incidence analyses .
all other statistical calculations were performed by spss 12.0 ( apache software foundation 2000 ) .
between 1973 and 2004 , a total of 380 patients with chcc - cc were identified from 42,654 patients with hepatobilliary neoplasms , which consisted of 0.87% of all patients with hepatobillary cancers .
a constant age - adjusted incidence of 0.03 per 100,000 was observed in these three time periods .
detailed incidence data by time period , gender , and race are included in table 1 .
of the 380 patients with chcc - cc identified in the seer database , there was male predominance with a male - to - female ratio of 1.8 : 1 .
the mean age of patients with chcc - cc was 64 12 years ( median age 65 years , with a range of 19 to 98 years ) .
of the remaining 325 patients , 98 ( 25.8% ) were classified as localized stage ; 97 ( 25.5% ) were classified as regional stage ; and 132 ( 34.2% ) were classified as distant stage .
82 of 125 ( 65.6% ) patients whose histology information available had poorly or undifferentiated histology .
cancer - directed surgery was performed for 79 ( 20% ) patients , among them , 20 patients underwent liver transplantation , 40 patients underwent partial hepatectomy , 5 patients underwent local surgery ( 4 patients received radiofrequency ablation ( rfa ) and 1 patient received percutaneous ethanol injection ( pei ) ) , and the rest of 14 patients underwent unknown surgery .
radiation therapy was performed in a total 22 ( 5.8% ) of patients , in 4 ( 1.1% ) of 22 patients , radiation was used as an adjuvant to surgery ( table 2 ) . in a logistic regression analysis , marital status , tumor stage , and year of diagnosis
the patients who were widowed , patients with advanced stage and those who were diagnosed before 1989 , were less likely receiving cds ( table 3 ) . in a separate analysis restricted to patients with local and regional disease , the above factors remained independent predictors of cds .
a total of 341 of 380 ( 89.7% ) patients died during the followup period . for survival analysis , we excluded the cases that were identified at autopsy or on the basis of death certificates only .
the median overall survival for all cases was 4 months ( 95% ci 35 ) .
cancer - specific survival rates for entire cohort at 1- , 3- , and 5-year were 26.5% , 12.4% , and 9.2% , respectively , ( figure 1(a ) ) .
the 1- , 3- , and 5-year cancer - specific survival rates for patients with local and regional stage tumor were 56.3% , 29.0% , 22.1% , 25.3% ; 9.6% , and 4.8% , respectively , and for patients with distant stage tumor were 6.1% , 1.5% , and 0% , respectively , ( figure 1(b ) ) .
there was a significant difference in survival between patients who underwent cds ( transplantation , resection or other surgery ) versus those did not ( p < .0001 ) ( figure 1(c ) ) .
the outcomes of patients with chcc - cc were significantly improved for patients who were diagnosed in later years ( 19892004 ) compared to those in earlier years ( 19731988 ) ( figure 1(d ) ) .
table 4 presents the result of multivariate survival analyses using cox proportional hazard model . after adjusting for the demographic , clinical , and treatment - related factors , tumor stage , receiving cds , and year of diagnosis
compared to patients with localized disease , patients with regional and distant disease had 1.62 and 2.5 fold increased risk of dying , respectively .
patients who receive cancer directed surgery had significant decrease in the risk of dying than those patients who did not .
( transplantation versus no cds , hr = 0.25 ; hepatectomy versus no cds , hr = 0.26 ; other surgery ( local treatment and unknown surgery ) versus no cds , hr = 0.28 ) .
the reported frequency of combined tumors in series of primary hepatic malignancies varies widely , from 1.04.7% [ 1 , 2 , 11 , 15 ] . in this study ,
chcc - cc accounted for approximately 0.87% of primary liver tumors during study period , which is lower than what was reported in single institution studies .
referral bias may contribute to the observed higher incidence rates in the single institution studies , which usually were from tertiary hospitals and referral centers .
patients with rare histology subtypes are more likely to visit referral centers for second opinion ; pathologists in tertiary centers usually have more opportunity seeing these cases and having expertise to identify these cases , compare with community counterparts . therefore , the incidence rate found in a population - based study , which include wide spectrum of hospitals , are more likely to reflect the true incidence of this rare tumor . similar with previous studies , most of patients with chcc - cc presented with high histological grade tumors and advanced stage disease at the time of presentation ( table 2 ) .
our findings , along with others , supports the notion that chcc - cc represents a distinct , aggressive subtype of liver cancer [ 411 ] .
these findings of subtype - related differences in liver cancer have significant implications : better therapy of liver cancer is more likely to be achieved by investigating each subtype of liver cancer separately rather than grouping them all together . as our understanding of the genetic basis for cancer grows , it is likely that liver cancer will be subdivided into ever finer categories .
the main treatment goal should be complete excision with negative margins and limited impact on liver function . in our cohort
in addition less than half of the patients with localized disease underwent cds ( table 2 ) raises a concern whether cancer - directed surgery was underused in this population .
the findings of disparity of cds utilization in chcc - cc are similar with findings in studies in hcc [ 23 , 24 ] , efforts should be made to reduce these disparities .
the patients diagnosed between 1989 and 2004 were almost three times more likely to receive cds , in comparison to those diagnosed between 1973 and 1988 .
this encouraging trend of increasing utilization cds is in line with the recent advances in radiologic diagnosis [ 25 , 26 ] and a shift towards an earlier stage at diagnosis [ 22 , 27 ] , and advances in liver surgery technique [ 14 , 28 , 29 ] .
although the role of liver transplantation in the management of hcc or cholangiocarcinoma is well defined [ 30 , 31 ] , data about the role of liver transplantation in the management of chcc - cc are lacking .
our study represented the largest series of surgical management of patients with chcc - cc . at present ,
liver transplantation and resection are the only potential curative therapy for chcc - cc , therefore , surgery should be considered in patients when complete resection is possible . because , liver resection carries considerable operative risk ; poor performance status and comorbidities may have precluded some patients from resection . currently , there is no literature available addressing impact local regional treatment options on survival specifically on chcc - cc .
transarterial chemoembolisation ( tace ) and percutaneous treatments such as percutaneous ethanol injection ( pei ) and radiofrequency ablation ( rfa ) are widely used treatments for unresectable hcc and postresection recurrence [ 33 , 34 ] . however , many chcc - ccs are less vascular and much more fibrotic than hcc , and thus are less likely to respond to tace or pei .
our findings suggest rfa is useful in selected patients ; however , the small numbers of the patients underwent this therapy and the short duration of followup , makes any conclusions unreliable , and more research is required to confirm this finding .
consistent with single institution studies , the prognosis of this disease was poor [ 15 , 17 , 18 ] , the median cancer specific survival for the patients with distant disease was 2 months ( range 031 months ) .
we did , however , observe a significant improvement in the outcome of patients with chcc - cc over time ( figure 1(d ) ) .
since there was no effective chemotherapy for liver cancer during the study period , the better outcomes likely reflect the advance in surgical techniques , better perioperative management and supportive care [ 14 , 28 , 29 ] .
our findings should be interpreted within the limitations of the study . although we adjusted for differences in demographic and tumor factors , residual confounding
, the accuracy of staging and pathologic diagnosis within a national registry may vary widely across the institutions .
in addition , seer data did not allow us to examine surgical volume , and patient 's comorbidities , all of which may influence survival in cancer patients .
however , the use of cancer specific survival rather than overall survival in our study has modified the limitation to some degree .
strengths of this study include the populations - based design and the large sample size .
having large sample size is of particular importance for analysis of rare tumors such as chcc - cc , where it is nearly impossible for a single institution to collect enough cases to make meaningful analysis regarding important prognostic factors .
the findings of this study confirmed that cds was associated with statistically significant increase in cancer - specific survival .
further study is warranted to explore and address the potential barriers to the delivery of appropriate care to these patients . | background .
the objective of this study was to examine the epidemiology , natural history , and prognostic factors of combined hepatocellular and cholangiocarcinoma ( chcc - cc ) using population - based registry .
methods .
the surveillance , epidemiology , and end results program database ( 19732004 ) was used to identify cases of chcc - cc .
multivariable logistic regression was used to evaluate factors associated with cancer - directed surgery ( cds ) .
the influence of cds on cancer specific survival was evaluated using kaplan - meier curves and cox proportional hazards modeling .
results .
a total of 380 cases of chcc - cc were identified , which account for approximately 0.87% of primary liver tumors . of all patients ,
69.8% of patients had regional or distant stage ; 65.6% of patients had poorly or undifferentiated histology .
only 44.9% of patients with localized disease , received cds . by logistic regression analysis ,
being widowed , advanced stage , and earlier diagnosis year were associated with lower rate of utilization of cds . in multivariate analysis , tumor stage ,
receipt of cds , and recent year of diagnosis were found to be significant predictors for cancer - specific survival .
conclusions .
patients with localized chcc - cc who are selected for cds were strongly associated with improved survival . however
, many patients with localized tumors did not receive potentially curative cancer - directed surgery .
further study is warranted to address the barriers to the delivery of appropriate care to these patients . |
isoflavonoids and related compounds such as coumestrol have classically been categorized as phytoestrogens because these environmentally derived substances bind to the estrogen receptor ( er ) and increase uterine wet weight in immature rats and mice .
assessment of the binding affinities of isoflavonoids for er and subsequent effects on uterine growth suggest these compounds are less active estrogens than estradiol and therefore may reduce the risk of developing breast or prostate cancer in humans by preventing estradiol binding to er . with the renewed interest in the relationships between environmental estrogens and cancer cause and prevention , we assessed the effects of the phytoestrogen coumestrol on uterotropic response in the immature , ovariectomized rat .
our studies demonstrated that in this animal model , coumestrol is an atypical estrogen that does not stimulate uterine cellular hyperplasia .
although acute ( subcutaneous injection ) or chronic ( multiple injection or orally via drinking water ) administration of coumestrol significantly increased uterine wet and dry weights , the phytoestrogen failed to increase uterine dna content .
the lack of true estrogenic activity was characterized by the inability of this phytoestrogen to cause cytosolic er depletion , nuclear er accumulation , or the stimulation of nuclear type ii sites which characteristically precede estrogenic stimulation of cellular dna synthesis and proliferation .
in fact , subcutaneous or oral coumestrol treatment caused an atypical threefold induction of cytosolic er without corresponding cytosolic depletion and nuclear accumulation of this receptor , and this increased the sensitivity of the uterus to subsequent stimulation by estradiol.(abstract truncated at 250 words)imagesp574-afigure 1.figure 2.figure 3.figure 4.figure 5.figure 6.figure 7.figure 8.figure 9.figure 10 . | |
microarray analysis has been shown to be of crucial importance for the understanding of the genetic etiology of intellectual disability ( i d ) . with this technique
, numerous ( de novo ) copy number variations have been discovered leading to several circumscribed microdeletion syndromes.1,2 especially in patients in whom neuropsychiatric disorders or congenital anomalies are present , in addition to i d , extensive genetic analysis is warranted .
partial deletions of the long arm of chromosome 15 , particularly in the 15q26 region , have been typically associated with somatic anomalies , especially congenital diaphragmatic hernia.3 in addition , i d , epilepsy , and behavioral problems are frequently mentioned.46 with respect to the 15q26.1 subregion , the chromodomain helicase dna binding domain 2 ( chd2 ) gene ( omim : 602119 ) , originally characterized by woodage et al,7 has been repeatedly reported to play a pivotal role in cerebrocortical development.8 both microdeletions encompassing this gene and de novo loss of function mutations lead to a syndrome characterized by i d and epileptic encephalopathy with generalized seizures.9,10 so far , a total of nine patients with i d ( seven females and two males ) has been reported with a genetically proven deletion of the chd2 gene . of these patients ,
eight had a history of severe forms of epilepsy starting from the young age.46,11,12 here , a 15-year - old male with a 15q26.1q26.2 interstitial deletion is described , who was referred to the specialized outpatient department for psychopathology and genetics because of short - lasting psychotic episodes and problematic management of disinhibited behaviors for which over many years symptomatic treatment with antipsychotics ( ie , haloperidol ) was ineffective .
the patient is a 15-year - old male of chinese origin , who was adopted at the age of 18 months in a malnourished condition from an orphanage by his dutch foster parents . shortly after birth , in the people s republic of china
, he underwent the first surgical correction for bilateral cheilognathopalatoschisis followed by several reconstructive surgeries in the netherlands up to the age of 5 years . upon arrival
, he was referred to a pediatrician of a university hospital for evaluation of developmental delay as well as bizarre autistic and disinhibited behaviors . at examination ,
apart from moderate auditory impairment secondary to recurrent upper airway infections , mild motor delay was noticed for which physical therapy was applied .
full laboratory investigation according to the dutch adoption protocol , including screening for metabolic disorders , disclosed no abnormalities .
electroencephalogram ( eeg ) registration revealed focal frontocentral abnormalities that were difficult to interpret because of muscular artifacts . at the age of 2 years , a symptomatic treatment with a low dose of haloperidol was started because of persisting challenging behavior .
subsequently , he was extensively examined by a child neurologist at the age of 5 years .
weight , length , and head circumference were 17.4 kg ( 1 standard deviation [ sd ] ) , 110 cm ( 0 sd ) , and 46 cm ( 2 sd ) , respectively .
his attention was undisturbed , whereas communication was adequate with the use of a hearing aid . since his parents frequently noticed brief moments with a blank staring and unresponsiveness to his surroundings , eeg recording was performed , which showed similar frontal irregularities without , however , specific epileptic configurations .
six months later , due to aggressive , self - injurious , and autistic behaviors , reevaluation by a pediatrician was performed , who advised a more congruent and structured behavioral approach . during subsequent years
, various interventions with antipsychotics for behavioral control were implemented , which , however , frequently induced unwanted side effects such as dyskinesias , akathisia , and facial edema . in this period
, intelligence testing was performed twice with an interval of 3 years showing a total intelligence quotient ( iq ) of 55 and a developmental age of ~3.6 years ( calendar age : 8 years ) . at the age of 12 years , microarray analysis ( agilent 180k oligoarray , amadid 023363 [ agilent technologies , santa clara , ca , usa ] ) demonstrated an 1.8 mb interstitial deletion in 15q26.1q26.2 , encompassing the cdh2 and rgma genes that were considered to be etiologically involved ( karyotype : arr[hg19]15q26.1q26.2(93,408,53295,188,862)x1 ; figure 1 ) . magnetic resonance imaging scan of the brain showed no abnormalities . in the next 18 months , two short - lasting episodes occurred characterized by marked global regression , anxieties , hallucinatory experiences ( visual and auditory ) , as well as disinhibited and aggressive behaviors .
treatment with haloperidol and promethazine in a twice - daily dose of 1.5 and 25 mg , respectively , was prescribed with , however , insufficient efficacy . as a consequence
, the patient was referred to the specialized outpatient facility for psychopathology and genetics for integrative assessment of behavior and psychopathology in the context of the genetic condition .
at examination , a young male adolescent was seen with a status after multiple reconstructive surgical corrections for bilateral cheilognathopalatoschisis .
no dysmorphias were noticed . his behavioral repertoire comprised compulsive elements , hyperactivity , and impulsivity .
detailed heteroanamnestic evaluation revealed that , since the age of 13 years , two short - lasting psychotic episodes had occurred dominated by anxieties , dysphoric mood swings , threatening and disinhibited behaviors , physical aggression , and both visual and auditory hallucinations , accompanied by diminished consciousness as well as restricted interpersonal contact . routine hematological and biochemical laboratory tests were all normal .
for cyp2d6 , however , a * 10/*10 genotype was found that is in accordance with a significantly impaired biotransformation capacity . extensive neuropsychological assessment ( vineland screener,13 visk14 ) showed a developmental age of 2 years with a discrepant profile ( social : 0.8 years ; motor and communication : > 2.6 years ) .
formal intelligence testing could not be fully performed due to major impairments of attention and inhibitory functioning as well as repetitive behaviors .
the latter was objectivated by proxy ratings of attention and executive functioning ( brief,15 bads - dex16 ) .
assessment of psychopathology by means of the psychopathology instrument for mentally retarded adults pointed specifically at chaotic , anxious , and generally inadaptive behaviors ( total score : 32 ; maximum : 56).17 based on the aforementioned information , a preliminary diagnosis of epilepsy - related recurrent brief psychosis was made and it was advised to perform eeg recording .
the latter revealed that some epileptic paroxysms left frontotemporal and sporadic polyspike wave complexes .
for this reason , the antiepileptic compound valproic acid was prescribed , whereas symptomatic treatment for behavioral control with a low dose of haloperidol ( 1.6 mg daily [ gtt ] ; plasma concentration : 1 g / l ) was continued . this antiepileptic intervention ( 600 mg valproic acid ; plasma concentration : 85 mg / l ) resulted in a full remission of psychotic symptoms and a gradual normalization of behavior to the premorbid level that , apart from incidentally occurring odd beliefs , was paralleled by stabilization of mood and marked improvement of social adaptation .
in the moderately intellectually disabled patient presented here , psychotic phenomena appeared to be the result of a previously unrecognized absence epilepsy .
treatment with valproic acid induced a substantial improvement of his behavior while keeping free from further psychotic episodes . as stressed by several authors , epilepsy - related psychoses , both post- and interictal ,
are still a clinical challenge to recognize and treat appropriately.18,19 the 15q26.1 microdeletion , encompassing among others the chd2 gene , is in general associated with febrile seizures starting at early age followed by various epileptic features , myoclonic as well as tonic clonic and absence seizures , and not typically clear dysmorphisms.9,10 in the current patient , absence epilepsy was only present . out of a total of nine published cases ,
this type of epilepsy is mentioned in two , whereas in one , no epilepsy was present ( table 1 ) . as can be inferred , in addition to the published cases , four patients are registered in international databases of whom one ( decipher 304608 ) was not diagnosed with epilepsy .
finally , two patients were detected in large copy - number variation studies , but no clinical information about their phenotype or presence of epilepsy is provided . in eight patients ,
the 15q26.1 deletion also encompassed the rgma gene ( omim : 607362 ) that is assumed to be involved in immune functionality but not regarded to be of clinical significance for i d or epilepsy.20
this case demonstrates the vital importance of detailed anamnesis and careful description of the symptom cognition behavior complex over time , both to ensure early detection of epilepsy - related psychopathology , especially in people with i d , and to avoid diagnostic misinterpretation and inappropriate treatment . | deletions of the 15q26 region encompassing the chromodomain helicase dna binding domain 2 ( chd2 ) gene have been associated with intellectual disability , behavioral problems , and several types of epilepsy . including the cases mentioned in ecaruca ( european cytogeneticists association register of unbalanced chromosome aberrations ) and decipher ( database of genomic variation and phenotype in humans using ensembl resources ) , so far , a total of 13 intellectually disabled patients with a genetically proven deletion of the chd2 gene are described , of whom eleven had a history of severe forms of epilepsy starting from a young age . in this article , a moderately intellectually disabled 15-year - old male with a 15q26.1q26.2 interstitial deletion
is reported , who was referred for analysis of two recent short - lasting psychotic episodes that were nonresponsive to antipsychotic treatment and recurrent disinhibited behaviors since early infancy .
careful interdisciplinary assessment revealed that the psychotic phenomena originated from a previously unrecognized absence epilepsy .
treatment with valproic acid was started which resulted in full remission of psychotic symptoms , and consequently , substantial improvement of behavior .
it was concluded that in case of ( rare ) developmental disorders with genetically proven etiology , a detailed inventory of anamnestic data and description of symptomatology over time may elucidate epilepsy - related psychopathology for which a specific treatment regimen is needed . |
myxomas are the most common benign cardiac tumors , typically originating from the left atrium .
the right atrium is the second most common site where myxomas originate , accounting for 7%12% of cases .
only a few cases of myxomas arising from the right ventricle have been reported . in these cases , myxomas originating from the right ventricle
usually obstruct the right ventricular outflow tract , which may cause pulmonary embolism , syncope , and sudden death . in the present case ,
a myxoma was found to originate from the right ventricular inlet and showed dense adhesion to the anterior and posterior tricuspid leaflets .
a 59-year - old man was admitted to the hospital with a three - month history of chest discomfort .
an initial laboratory work - up , including complete blood count , electrolyte level , and cardiac enzyme level , revealed all results to be within normal ranges .
transthoracic echocardiography revealed a large ovoid - shaped mass in the right ventricle , approximately 4.73.3 cm in size .
the mass was attached to the inlet portion of the right ventricular free wall and to the anterior leaflet of the tricuspid valve ( fig .
however , no tricuspid insufficiency or stenosis was observed , and the right ventricular systolic pressure was 21 mmhg .
the patient was referred to the department of thoracic and cardiovascular surgery for surgical management .
the mass was attached both to the ventricular surface of the tricuspid valve , along the entire posterior leaflet and one third of the anterior leaflet , and to the right ventricular free wall ( fig .
. the mass was removed , and the posterior leaflet and one third of the anterior leaflet were excised as well . an incision was made along the annulus of the tricuspid valve that anchored the remaining anterior leaflet ( fig .
several compression sutures were inserted to reduce the annulus for sliding annuloplasty , and sutures were placed for ring annuloplasty .
the base of the anterior leaflet was attached to the annulus with 5 - 0 prolene sutures and a tricuspid annuloplasty ring was placed ( fig .
intraoperative transesophageal echocardiography revealed no remaining tumor and no evidence of tricuspid regurgitation ( fig .
myxomas arising from the right ventricle are extremely rare , and usually cause symptoms that result from obstructing the right ventricular outflow tract ( rvot ) .
obstruction of the rvot and the main pulmonary trunk may cause complications such as syncope , pulmonary embolism , and sudden death [ 24 ] .
several previous reports have described right ventricular myxomas obstructing the rvot . however , in our case , an extremely large myxoma was located in the inlet portion of the right ventricle , with a dense adhesion to the anterior and posterior leaflets of the tricuspid valve .
it is thought that this dense adhesion to the tricuspid valve and the location of the myxoma in the inlet restricted the mobility of the mass and helped to avoid rvot obstruction .
similarly , hirota et al . described a case of right ventricular myxoma that injured the tricuspid valve , leading to massive tricuspid regurgitation .
unlike atrial myxoma , ventricular myxoma occasionally involves the valvular or sub - valvular apparatus , which makes surgery more complex .
we had three surgical options for managing a myxoma that involved the tricuspid valve : tricuspid valvectomy without prosthetic valve replacement , tricuspid valvuloplasty with partial excision of the tricuspid valve , and tricuspid valvectomy with prosthetic valve replacement .
arbulu and asfaw reported excellent results after using tricuspid valvectomy alone to treat tricuspid endocarditis , although 10%30% of patients subsequently required tricuspid valve replacement .
we decided to perform tricuspid valvuloplasty because the remaining valve leaflet was sufficient for repair and the patient wanted a procedure involving repair of the valve leaflet in order to avoid anticoagulation therapy . in the present case , the entire posterior leaflet and one third of the anterior leaflet
was attached to the mass , and we performed sliding valvuloplasty to excise the mass and surrounding tissue .
two - dimensional echocardiography is useful in the diagnosis of myxoma and in determining the site , size , mobility , and attachment of masses .
the treatment of choice for myxomas is surgical excision and the reported recurrence rate is 1%3% . in conclusion
, this case study reports our surgical experience treating a rare type of right ventricular myxoma . | we report a rare case of an extremely large right ventricular myxoma involving the ventricular side of the tricuspid valve . the tumor was excised along with the entire posterior leaflet and part of the anterior leaflet .
the tricuspid valve was repaired by sliding valvuloplasty combined with ring annuloplasty . |
a 62-year - old woman was hospitalized for the further evaluation of her progressive chest discomfort for 10 days .
the patient had undergone total thyroidectomy 20 years earlier , and she has been managed for hypothyroidism since then .
seven years prior to admission , she was diagnosed with and managed for angina pectoris , but was not evaluated properly .
a month before presentation , she had experienced worsening chest pain with dyspnea on exertion despite medication .
when she was hospitalized , she complained that her chest pain and dyspnea had been aggravated with time .
after dobutamine stress echocardiography , it was determined that the patient should undergo open heart surgery .
, the patient 's general condition and laboratory data were found to be stable except for mild thrombocytopenia .
since postoperative day 4 , she had a fever over 38 and the laboratory data showed signs of disseminated intravascular coagulopathy ( dic ) .
she was treated with broad spectrum antibiotics for sepsis as well as plasma and platelet transfusion for pulmonary hemorrhage , which occurred on postoperative day 6 .
since the thrombocytopenia did not respond to transfusion , intravenous immunoglobulin g was infused and methylprednisolone was administrated intravenously at a dose of 15 mg three times a day . in spite of vigorous treatment ,
the platelet count did not increase , and even worse , it decreased to a lower count .
the lowest platelet count occurred at postoperative day 9 . to identify the reason for the refractory response to platelet transfusion
, a study for antibody to platelet and additional immune workup were performed on postoperative days 9 and 10 .
the findings included hemolytic anemia with thrombocytopenia ( hemoglobin=7.6 g / dl , platelet=15,000/l , schistocytosis(+ ) in a peripheral blood smear ) , negative direct and indirect coombs tests , decreased haptoglobin ( 3 mg / dl ) , normal ranges of an international normalized ratio ( inr 1.13 ) , activated partial thromboplastin time ( 38.2 seconds ) and fibrinogen ( 287 mg / dl ) , slightly elevated d - dimer ( 3.3 g / ml ) , hyperbilirubinemia ( total bilirubin 3.28 mg / dl , direct bilirubin 1.9 mg / dl ) , increased lactate dehydrogenase ( 580 mg / dl ) , normal serum alanine aminotransferase ( 10
iu / l ) , increased blood urea nitrogen ( 51 mg / dl ) , normal creatinine ( 0.8 mg / dl ) , microscopic hematuria ( red blood cell > 30/hpf ) , negative human immunodeficiency virus antibody , and positive hepatitis b surface antibody .
the immune workup results showed decreased complement 3 and 4 levels ( lower - most to 51.5/6.9 mg / dl ; normal range , 90 - 180/10 - 40 mg / dl ) and strong positivity in an autoimmune target test ( autoimmune cytoplasmic antibody level 4 ) .
antiplatelet antibody was negative . since postoperative thrombotic thrombocytopenic purpura ( ttp ) needed to be ruled out at that moment , platelet transfusion was discontinued and the dosage of methylprednisolone was increased to 75 mg / day .
treated with the increased dosage of methylprednisolone , the platelet count steadily increased and maintained within a stable range . the increase in the platelet count and associated dosage of methylprednisolone
since the patient 's general condition was stable without thrombocytopenia , or pulmonary bleeding or bleeding from other sites as of postoperative day 18 , the tapering of the dosage of methylprednisolone was begun and close observation for bleeding or thrombotic events was maintained .
the patient was not given heparin or any other anticoagulation agent until postoperative day 36 due to the above history , but warfarin was given as an anticoagulant since the patient clearly had no risk of bleeding tendency .
the patient was discharged on postoperative day 51 after a long period of not only antibiotics treatment for sepsis due to acinetobacter baumannii but also management and monitoring for ventricular tachycardia .
the patient has not complained since of the symptoms of congestive heart failure and has had a normal platelet count for 28 months of follow - up .
although postoperative ttp is less common than heparin - induced thrombocytopenia , it is associated with high patient morbidity and mortality if the thrombocytopenia persists unresponsive to treatment , especially with thromboembolic events .
the classic pentad of thrombocytopenia , hemolytic anemia , fever , renal dysfunction , and neurologic symptoms is present in only a minority of patients .
ttp after endothelial injury has been recognized for a long time , but postoperative ttp has only recently been appreciated as a distinct clinical syndrome in the surgical field .
the conditions to be identified for differential diagnosis of thrombotic microangiopathies can include ttp , hemolytic uremic syndrome , dic , severe hypertension , preeclampsia , eclampsia , hemolysis - elevated liver enzymes - low platelet count syndrome , systemic lupus erythematosus , drug - induced ttp , and disseminated malignancy . in our patient , the platelet count immediately after surgery was more than 50% of the preoperative count , unlike the phenomenon by cardiopulmonary bypass itself or heparin - induced thrombocytopenia . as our patient had presented signs and symptoms of dic and sepsis since postoperative day 4 , the thrombocytopenia was considered to be one of their signs and treated by routine management for a bleeding episode through platelet transfusion .
however , the decreasing platelet count was aggravated with time and platelet transfusion regardless of the improvement in signs of dic and sepsis .
once we determined that the etiology of the thrombocytopenia was not only sepsis but also postoperative ttp , platelet transfusion , to which our patient was refractory , was discontinued , and the laboratory work - up for differential diagnosis was performed as we described in the case report .
platelet transfusion has been traditionally associated with worse outcomes , although a recent review of platelet transfusion in patients with ttp suggested that the evidence for this might be uncertain . in postoperative ttp
, there might be also an autoimmune - mediated mechanism related to antibodies against a disintegrin and metalloproteinase with a thrombospondin type 1 motif , member 13 ( adamts-13 ) . in our patient
, we did not have a test for the determination of adamts-13 activity or antibodies to adamts-13 , but the patient showed a strong positivity to the autoimmune target test . since the patient had low compliment c3 and c4 levels , we concluded that the thrombocytopenia could not be explained by sepsis alone . because a strong suspicion of postoperative ttp and its early treatment helps the patient 's outcome
plasmapheresis is recognized as a primary treatment for ttp patients [ 3,6 - 8 ] , but we could not perform plasmapheresis because of the persistently positive results of microorganism cultures in our patient 's blood . after 5 days of 75 mg / day treatment with methylprednisolone ,
kessler et al . again emphasized that ttp is a rare but true hematological emergency with fatal consequences , and they recommended that once ttp is considered to be the likely diagnosis , arrangements for emergency plasma exchange should be made and high - dose corticosteroids should be given .
our patient responded to methylprednisolone therapy ; the patient did not need other immunosuppressive therapy such as rituximab or cyclosporine .
the patient underwent a long period of antibiotic treatment for sepsis and monitoring for ventricular tachycardia even after the recovery of a normal platelet count , but the patient did not show the symptoms of neurologic or renal complications when she was discharged from the hospital . in conclusion , we recognized that if the postoperative patient has prolonged thrombocytopenia that has not improved with routine management , postoperative ttp , even though it is a rare disorder , should be considered and ruled out . | although thrombotic thrombocytopenic purpura ( ttp ) is a rare disease , when it develops in a post - cardiac surgery patient , it may have a fatal outcome .
since the frequency of early - onset thrombocytopenia in post - cardiac surgery patients is high , platelet concentrates are commonly transfused during postoperative management . however , when ttp is the likely diagnosis , platelet transfusion is not recommended .
we experienced a postoperative ttp in a cardiac surgery patient and discovered the importance of identifying the etiology of postoperative thrombocytopenia . here , we report the case with a brief review of the literature . |
language can be counted as the first cognitive enhancement , and the invention of writing also dramatically improved our cognitive ability to remember , to learn , and to communicate. today , with the aid of recent phenomenal development of biomedical technology , we are witnessing the emergence of more direct biological cognitive enhancementschemical , physical , or electromagnetic intrusions into our physical brain. brain enhancement has been considered as one of the most important intersections of law and neuroscience .
the idea of directly enhancing the brain with drugs , brain stimulation , or neurosurgery might seem frightening .
but more than frightening , the use of these enhancement technologies raises crucial neuroethical and legal issues .
for example , fairness can be a serious problem , if an effective enhancement technology is very costly and thus , available only to the rich .
also , individuals could be coerced , explicitly or implicitly , to undergo cognitive enhancements for various reasons , such as criminal rehabilitation , medical treatment , or even academic success at school . despite these potential risks , professor hank greely
has argued that safe and effective cognitive enhancement will benefit both individuals and society , and we should require better research on , and better regulation of , cognitive enhancement instead of banning the use of all cognitive enhancements : biomedicine will be creating more and more products and procedures that can be used for cognitive enhancement .
some of them will be used in ways that will , on balance , improve human life and society . at the same time
i am confident , though , that a knee - jerk rejection of all direct brain enhancement will be at least a missed opportunity and at worst an opening for a damaging underground and uncontrolled world of enhancement . in order to maximize the benefits and minimize the harms of these new technologies
, we will need to look at particular enhancements rationally and to adopt , ban or regulate them carefully .
one of the most eye - catching and readily accessible direct brain enhancement technologies is transcranial direct current stimulation ( tdcs ) .
tdcs is a type of non - invasive neuromodulation , which delivers weak direct current ( dc ) ( 12 ma ) to the brain using small saline - soaked electrodes .
this weak current is insufficient to cause neurons to fire , but it can alter the excitability of neurons by shifting their membrane potentials in a de- or hyper polarizing direction ; thus making them more or less likely to fire. anodal dc stimulation is known to increase neuronal excitability , while cathodal stimulation decreases it .
application of electric currents to the human brain for therapeutic purposes is not a new idea . in ancient times
, people placed an electric fish over the scalp to treat headache or epilepsy . later in 18th century , advances in the science of electrophysiology by galvani and volta inspired the use of direct currents for the treatment of mental disorders .
nonetheless , erratic results and the advent of electroconvulsive therapy led to the decrease of interest in dc brain stimulation . however , reappraisal in the last decade has shed new light on the effects of dc stimulation on the human brain .
a number of neurophysiological studies have demonstrated the efficacy of tdcs for the treatment of patients suffering from neuropsychiatric diseases , such as stroke , chronic pain , and depression . moreover
, recent studies have reported that the use of tdcs on specific brain regions can improve cognitive functions , such as attention span , working and long - term memory , language , and mathematical ability of healthy subjects .
for example , de vries and colleagues showed that anodal tdcs over broca 's area a region in the frontal lobe of the hemisphere of the brain improves artificial grammar learning .
numerical learning was enhanced by anodal tdcs of the parietal cortex , and this effect was stable for at least 6 months after training. also , subjects who received anodal tdcs on the right anterior temporal lobe while naming pictures of famous people showed improved retrieval of proper names . in one study funded by the us defense advanced research projects agency , subjects who received anodal tdcs on right inferior frontal and right parietal cortex showed learning and performance improvement in a video game designed to train military personnel to accurately identify obscured and concealed objects in a complex environment .
these interesting experiment results began to draw the media 's attention a new york times article in october 2013 described tdcs devices as
jump starter kits for the mind. also , the number of tdcs articles published per year has been growing rapidly , and currently at least 224 clinical studies on tdcs are going on around the world . on top of the fact that it can be an effective tool for both treatment and cognitive enhancement , tdcs has two other especially appealing features
most of the known side effects of tdcs are minor adverse effects , such as headache , or slight tingling or itching under the electrodes .
at least nine tdcs devices for personal use can be purchased through websites as a complete unit with prices between approximately \documentclass[12pt]{minimal }
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thanks to these special features of tdcs , in recent years , a group of people who built or purchased the tdcs device for home use has appeared .
researchers have expressed concerns about this so - called do - it - yourself ( diy ) use of tdcs .
they have argued that even if there are no serious side effects , potential risks of misusing this device should not be ignored .
for example , lay people who are diy users may not have sufficient knowledge on the structure of brain to place the electrodes accurately , causing unintended effects .
moreover , reversing anodal and cathodal electrodes placement could lead to impairment of the brain by switching areas affected by excitatory and inhibitory stimulation .
it is also possible that tdcs interacts with other treatment that diy users are undergoing , such as psychoactive medication , in detrimental ways .
lastly , using tdcs to enhance some of the cognitive functions may adversely affect other functions of the brain , and potential long - term ( side ) effects of tdcs on the brain have not been fully explored .
the fda 's own description of its regulatory regime for medical devices reads : if a product is labeled , promoted or used in a manner that meets the following definition in section 201(h ) of the federal food , drug , and cosmetic ( fd&c ) act , it will be regulated by the food and drug administration ( fda ) as a medical device and is subject to premarketing and postmarketing regulatory controls .
an instrument , apparatus , implement , machine , contrivance , implant , in vitro reagent , or other similar or related article , including a component part , or accessory which is : ( 1 ) recognized in the official national formulary , or the united states pharmacopoeia , or any supplement to them , ( 2 ) intended for use in the diagnosis of disease or other conditions , or in the cure , mitigation , treatment , or prevention of disease , in man or other animals , or ( 3 ) intended to affect the structure or any function of the body of man or other animals , and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of any of its primary intended purposes .
fda requires all medical products manufacturers to register their facilities , list their devices with fda , and follow general control requirements. medical devices are classified in three categories low ( class i ) , moderate ( class ii ) , and high - risk ( class iii ) devices according to the risks that the devices present .
devices with low risk are considered as exempt from fda 's pre - market review and can be legally marketed upon registration . in terms of moderate- and high - risk devices ,
there are two administrative paths that manufacturers must take to bring the devices to markets .
the first path is pre - market approval ( pma ) , which consists of conducting clinical studies , submitting pre - market approval ( pma ) application and requires evidence providing reasonable assurance that the device is safe and effective. usually novel and high - risk devices are subject to this process , and it is known to be very lengthy and expensive .
the other path involves submitting a 510(k ) notification demonstrating that the devices is substantially equivalent to a device already on the market ( a predicate device) and results in fda clearance .
this path , which tends to be less expensive and time - consuming than pma , is available for moderate - risk medical devices not exempt from pre - market review .
once approved or cleared for marketing , manufacturers must comply with regulation on manufacturing , labeling , surveillance , device tracking , and adverse event reporting. some neurostimulation devices are already classified and regulated as medical devices by fda .
for example , in 2011 , repetitive transcranial magnetic stimulation ( rtms ) , another non - invasive neuromodulation that generates electric currents using electromagnetic coils , was classified as a class ii medical device for treatment of major depressive disorder .
also , cranial electrotherapy stimulation , whose mechanism is similar to tdcs except that it applies alternating current , not dc , to the brain , has been regulated as a medical device ( class iii ) for treatment of insomnia , depression , or anxiety since 1979 .
fda guidance explicitly provides that there is no regulation for the therapeutic tdcs. a few clinics offer tdcs treatment to their patients with various medical conditions , such as depression and chronic pain , but these clinics apply tdcs as off - label use of the iontophoresis device a dc stimulator for introducing ions of soluble salts or other drugs into the body for medical purposes that fda classified as a medical device ( class ii / iii ) in 2004 .
in addition , devices marketed for cognitive enhancement are not covered by any existing legislation in the usa . in their recent article , nick fitz and
peter reiner stated that this regulatory vacuum is understandable given that the myriad applications of tdcs are fairly new. however , since tdcs devices are already on the market and being sold to the public , they argued that now we should begin the discussion on how to develop a regulatory policy for the diy use of tdcs .
for example , foc.us , a fancy tdcs device marketed as a gamer headset to boost attention , completely sold out its first batch of 3000 units less than a month after its release in may 2013 .
fitz and reiner urged all stakeholders regulators , scientists and the diy community to share in crafting policy proposals that ensure public safety while supporting diy innovation. they emphasized the importance of communication between policy makers and diy users to develop the ethos of responsible use based on the idea that people should have access to a diversity of opportunities created by enhancement technologies. responding to fitz and reiner 's call for a policy debate , maslen and colleagues proposed a regime that regulates cognitive enhancement devices such as tdcs by extending the existing legislation for medical devices . in line with the managed technological optimism that fitz and reiner advocate , they suggested the incorporation of a low - risk exemption for any cognitive enhancement devices falling below a given level of risk . in june 2013 , tdcs device kit , inc .
, a tdcs device manufacturer based in california , voluntarily recalled its products after an inspection by california department of public health ( cdph ) .
cdph determined that these products were not manufactured in compliance with good manufacturing practices for medical devices and that the devices lacked adequate labeling for directions for use and warnings against dangerous uses .
this was a meaningful step taken by the government authorities , but it only had power in one state as there is no regulation on tdcs under the current fda regime for medical devices . despite the recent surge of attention to the potential risks and regulations of tdcs , there has been no attempt to systemically study what is really happening in the diy tdcs user community .
discussions of issues related to the diy use of tdcs are mostly based on speculation , which may lead to importantly incorrect understanding of the diy community and its use of tdcs .
this study is the first exploratory research on who diy tdcs users are and what is happening in this community .
specifically , this study aims to answer following four questions on the diy use of tdcs through an online survey , a content analysis of web postings , and interviews with the diy users .
what are the general demographic characteristics of diy users?why and how do they use this device?what are the perceived effects or side effects of this device?what are their concerns , if any , about the diy use of this device ?
what are their concerns , if any , about the diy use of this device ?
in particular , its survey was not of random users but of a set of self - selected diy tdcs users who responded to an invitation to participant the author posted on the two major diy tdcs internet web sites .
also , only a small number of people interviewed , chosen from among those who , based on the websites , appeared to be influential in the diy tdcs user community . the unregulated , unregistered , and otherwise unreachable nature of the community of tdcs users made these the only feasible approaches , but they do undercut , to some extent , the confidence that can be placed in the findings .
nonetheless , even if viewed as only preliminary data , these results provide some basic information on diy tdcs users and their attitudes and practices of diy tdcs which will help us to lay the groundwork for designing sound future policy and official guidelines on tdcs .
section 1 describes the three research methodologies recruited in this study , and the findings on the diy tdcs user community are presented in section 2 . section 3 explores potential legal and regulatory implications of these findings considering possible regulatory options for the diy use of tdcs .
finally , section 4 summarizes the paper 's major findings and briefly discusses future directions for research .
there has been no official report on the size of the diy tdcs user population in the usa , in any other country , or worldwide .
users do not need a prescription , do not need to register their use , and do not even need to purchase tdcs units .
however , two major diy tdcs internet websites , www.reddit.com/r/tdcs and www.diytdcs.com , where diy users usually visit and share information about tdcs are potential resources for exploring diy tdcs users .
the site , www.reddit.com/r/tdcs/ ( hereinafter subreddit tdcs ) , is an open forum for tdcs users and www.diytdcs.com ( hereinafter diytdcs ) is a personal blog by a famous lay expert on diy tdcs .
the research subjects of this study are the registered users or visitors of these two websites ( 1 ) who built or purchased their personal tdcs devices and ( 2 ) who have used them for treatment or as a cognitive enhancer .
the research methodology of this study has three parts : ( 1 ) an online questionnaire survey , ( 2 ) a content analysis of web postings on the diy use of tdcs , and ( 3 ) in - depth interviews .
the survey was composed of a minimum of 21 to a maximum of 29 questions depending on the respondents answers to some questions on basic demographic information of diy users , their aims of practicing diy tdcs , current practices of tdcs ( including types of devices , stimulation protocols , and frequency of use ) , effects and side effects of tdcs , and their concerns about the diy tdcs ( see appendix a for the questionnaire ) .
the survey was posted on subreddit tdcs from december 27 , 2013 to march 10 , 2014 and on diytdcs from december 29 , 2013 to march 10 , 2014 .
the responses of this online survey do not form a random sample , and there is a potential bias because these respondents are self - selected to participate in this survey . however , since this study is the first preliminary attempt to learn about the diy tdcs user community , responses from this convenience sample should provide previously unknown but useful facts about this community .
the second research methodology is a content analysis of web postings on subreddit tdcs . in this well - known and very active online forum ,
diy users ask and answer questions on the diy use of tdcs device , post interesting recent tdcs studies , and share their experiences of positive and adverse effects of tdcs devices .
these web postings are an important source of information to answer some of the research questions .
subreddit tdcs was established in april 2011 ; since then , there has been a significant increase in the number of postings ( fig .
this study took a census of all 825 postings , and the comments to these postings were selectively included in the analysis in cases where the comments showed meaningful discussions on the issues raised in the postings .
number of posting per quarter in www.reddit.com/r/t/dcs ( 20112013 ) . since there is no previously established theory or research study on the diy tdcs user community or subreddit tdcs , the codes were derived from an emergent process . through a preliminary examination of the postings , five major codes to categorize the main theme of each posting
were developed : ( 1 ) building and operation of the tdcs device , ( 2 ) marketed devices , ( 3 ) effects / side effects of the device , ( 4 ) references ( external links ) to research papers , newspaper / magazine articles , or blog posts on tdcs , and ( 5 ) others . when there was more than one theme in a posting , this study coded the posting according to its primary purpose .
for example , if a user began his or her posting with the side effect he or she has experienced , but then later asked about how to improve his or her diy circuit to prevent this side effect , this posting would be classified under the code , building and operation of the tdcs device. in addition to these major codes , two additional emergent codes the commenters reasons for using the tdcs device and their warnings about safety were prepared to describe recurrent topics that answer some of the research questions of this study but do not constitute the main theme of the postings .
for example , diy tdcs users usually mentioned their purpose for using the tdcs device while asking questions about building and operation of the device ( see appendix b for detailed classification of the codes ) .
after survey data analysis and content analysis of web postings were completed , five semistructured interviews were conducted to collect more detailed information on the user experience and users opinions on the official guidelines and potential government regulation of the tdcs device .
first , this study conducted a brief analysis on the user ids and postings at subreddit tdcs to identify
power users who could provide a general overview and informative facts on the diy tdcs user community .
the analysis revealed five users who have made more than 200 postings and comments at subreddit tdcs ( appendix c ) .
four of these five power users participated in the interviews : the moderator of subreddit tdcs , the webmaster of diytdcs , a user who has uploaded popular self - experimentation videos on his youtube channel , and a user who has been using tdcs for treatment of bipolar type ii and other medical conditions .
the interviewees were also asked to give their thoughts on the major findings of the survey and content analysis as an active user or an observer who is familiar with the trend in the community .
second , a physician who has been treating about 350 patients with tdcs for the last seven years was also recruited for the interview to provide a medical perspective on the diy use of tdcs .
the interview with webmaster of diytdcs was conducted through email , and the moderator of subreddit tdcs and the physician was interviewed over skype .
the phone and skype interviews were conducted for about 30 minutes to an hour and audiotaped with the consent of the interviewees .
although the number of samples is very small , given the exploratory nature of this study , these interviews should provide a meaningful preliminary sketch of the diy tdcs community and current uses of tdcs along with the findings of the survey and content analysis of the web postings .
in this section , the results of the survey , content analysis of web postings , and in - depth interviews will be presented and analysed under the four main research topics of this study : general demographic characteristics of diy users ; their reasons for and current uses of tdcs ; effects and side effects of tdcs ; and their concerns about the diy use of tdcs .
there is no official estimate of the size of the diy tdcs user population . as of the end of 2013 , subreddit tdcs had about 2700 subscribers . according to the moderator of the website , there were 4000 individual hits on this forum per month in 2012 .
the number has been gradually increasing , and this forum is now getting 6000 individual hits per month .
although it is very hard to track whether a particular person is really using tdcs , the moderator estimated that
6000 might be the upper bound of the diy tdcs user population and the lower bound might be the number of subscribers to this website , about 3000 , assuming that an active , regular tdcs user will visit the website at least once a month .
one of the power users who has posted self - experiment videos said that 800 people were subscribing his youtube channel , and another famous youtube channel on tdcs has 2700 subscribers .
this power user estimated that the size of the diy tdcs user population is probably a few thousand , but not more than 10,000 .
however , the webmaster of diytdcs , who is also one of the most active participants in subreddit tdcs since the establishment of that forum , questioned this estimate of the size of the diy tdcs community in the media and academic studies : i 'm not sure how large the community is just now .
it seems people pop in for a period and then move on , though there are also committed diy tdcs users who are self - treating daily .
my sense is that tdcs is a fringe interest that wo n't attain popularity unless some sort of yet to be seen benefit emerges .
only half ( 62 ; 51% ) of the respondents reported that they are continuous and regular tdcs users and among these continuous and regular users , 61% of them have been using tdcs less than six months ( appendix d ) .
the majority of the respondents who claimed that they are continuous and regular users began to use tdcs pretty recently .
thus , although , based on evidence of internet uses , the diy tdcs user population seems to have been growing for the last few years , these rough indicators might suggest that the dedicated tdcs user population has been overstated .
there seems to be a small core of dedicated diy tdcs users that enable a sustained presence at the tdcs subreddit .
but apart from that a lot of people come in for a quick look and then wander off. whatever the community 's actual size , the results on the demographic characteristics of the surveyed community are analysed below .
first , the survey respondents are overwhelmingly male114 respondents ( 94% ) are male , 5 respondents ( 4% ) are female .
second , most of the respondents are in their 20s and 30s ( 86 ; 71% ) , but there are a significant number of respondents in their 50s and over ( 15 ; 12% ) ( fig .
the physician who has been treating patients with tdcs reported that there are some elderly patients who want to restore their diminishing cognitive abilities .
he argued that tdcs is an appealing brain stimulation technology not only for young self - experimenters or bio hackers but also for seniors suffering from deterioration of mental functioning . also , it is noteworthy that there are some minors using tdcs ( 7 ; 6% ) .
most of the respondents ( 90 ; 74% ) are from north america the usa and canada , although the rest of them are widely spread around the world . in addition , the majority of the respondents have four - year undergraduate degree or masters degree ( 62 ; 51% ) , though a significant number of respondents only have a high - school degree or below ( 29 ; 24% ) ( appendix e ) .
relatedly , most of the respondents are students ( 25 ; 21% ) or professionals ( 45 ; 37% ) ( appendix f ) .
the reported annual income level of the respondents also seems to fall in line with their occupations the respondents either have reported income of less than \documentclass[12pt]{minimal }
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} { } $ { \$ } $ \end{document}90,000 ( 26 ; 21% ) ( appendix g ) . however , making generalizations on respondents socio - economic status based on these data can be problematic given that the respondents are from all over the world .
this part will delineate and analyse the data on diy users aims of using tdcs device , as well as their current use of tdcs such as types of tdcs devices , stimulation protocols , and frequency of use . according to the survey results
, respondents first learned about tdcs through academic research studies on tdcs ( 43 ; 35.5% ) , tdcs websites ( 43 ; 35.5% ) , and newspaper or magazine articles on tdcs ( 30 ; 25% ) ( appendix h ) .
this indicates that information on tdcs is mainly disseminated and shared through online media and forums , assuming that many of respondents may not have direct access to academic journals , and recent intriguing studies on the various effects of tdcs have been vigorously covered by the media .
3 presents the number and the percentage of subreddit tdcs postings classified under the five codes .
this shows that this website functions as a forum for discussing how to build and use tdcs and sharing new scientific discoveries on the effects of tdcs featured in media and various online forums .
postings at subreddit tdcs . a total of 13 ( 11% ) respondents use tdcs for treatment of medical conditions and 71 ( 59% ) respondents use it for cognitive enhancement .
a total of 29 ( 24% ) respondents reported that they are using tdcs for both cognitive enhancement and treatment .
the most common types of cognitive enhancement purpose for which the respondents use tdcs were attention ( 72 ) , learning ( motor , verbal , or numerical learning , etc . ) ( 68 ) , and working memory ( 67 ) ( fig . 4 ) . types of cognitive enhancement purpose for which respondents use tdcs .
in addition , the most common medical condition for which the respondents use tdcs was depression ( fig .
interviewees of this study also reported that tdcs is very effective for the treatment of depression , especially for treatment - resistant depression . according to the physician who has been treating patients with tdcs , most of his patients came to the clinic because they do not respond to psychoactive medications .
based on his extensive clinical experiences , he claimed that tdcs is significantly beneficial for the treatment - refractory patient suffering from chronic depressionit takes only about five treatments before the effects of tdcs become noticeable. one of the power users who has bipolar type ii disorder also reported that the effect of tdcs is immediate and he can even tell when the machine is shutting off. types of medical condition for which respondents use tdcs .
furthermore , this survey also asked , in cases where the respondents are using tdcs for treatment , whether these respondents are also taking other conventional medications .
this question is intended to assess the risk of diy tdcs , assuming that there could be unknown adverse compounding effects of tdcs and other extant medications .
the pharmacological status of the brain can have meaningful effect on the outcome of tdcs , and the variety of psychoactive agents that home users may employ is legion. in this survey , 18 respondents44% of respondents who are using tdcs for treatment of medical conditions reported that they are currently taking other medications for the same medical conditions .
thus , a significant percentage of respondents who are using tdcs for treatment are exposed to the potential detrimental interactions with other medications .
the survey result showed that among the 121 respondents , 47 ( 39% ) respondents built their own device and 58 ( 48% ) respondents bought out of the box tdcs devices .
some of the respondents ( 11 ; 9% ) reported that they both built and bought their devices .
in terms of home - built tdcs devices , the analysis of subreddit tdcs postings revealed that some open source tdcs circuit designs proposed by diy users had been available at this forum and improved through active discussions among users .
openstim tdcs , by the moderator of subreddit tdcs , and another designed by a user named shawn nock , are the two most well - known open source tdcs circuits .
the moderator of subreddit tdcs initially had wanted to buy one of the devices used at clinics or research labs but the prices of these devices were over his budget . after he found out that building a tdcs device does not require complicated knowledge of electrical engineering
, he decided to design his own circuit , which is affordable ( costs less than \documentclass[12pt]{minimal }
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} { } $ { \$ } $ \end{document}50 ) and , he believes , safe , and to share it with other diy users . later , it has been evolved with the inputs from other users in the community in terms of what kind of features would be useful. in addition to these open source circuits , some users also compiled and posted basic schematics , tools and electrical components needed to build the tdcs device , and online or offline shops that one could get those tools and components , as well as their prices .
thus , at subreddit tdcs , instructions on how to build an easy - to - use tdcs device at a very low cost are easily accessible to anyone who is interested in trying self - experimentation with tdcs . regarding the out of the box tdcs devices , currently about 10 devices are on the market .
the survey result showed that the most prevalent device in this community is the foc.us headset .
6 ) types of out of the box tdcs device that respondents are using . however , both power users and the physician had unfavorable opinions on the foc.us headset , mostly because its placement of electrodes , which is called montage , is fixed .
the physician argued that the montage of foc.us device is different from montages used in any of the clinical studies , and he did not think it has the same effects as the ordinary two electrodes system using iontophoresis devices that researchers have used in finding evidence of effectiveness .
the webmaster of diytdcs also stated that unless some sort of tangible evidence of obvious benefit emerges , foc.us will turn out to be a fad and will most likely fade away. the fact that these commercial devices , such as foc.us , are gaining popularity among the diy users has caused a demographic shift in this diy tdcs community .
the moderator of subreddit tdcs recalled that two years ago when the website was first established people were talking about designing electronics , designing techniques , and designing experiments. however , there is now a population of people who are basically end users and are not programmers , hackers or electronics people. this is also reflected in the recent sharp increase in the number of postings on these commercial devices at subreddit tdcs ( fig .
the moderator argued that this has good and bad sides. it is good in the sense that many of these out of the box products are
quite sophisticated. for example , the foc.us device can deliver custom waveforms , which is difficult with diy devices .
if commercial devices become more popular , they can spur people 's interest in developing tdcs methods that can take advantage of the more advanced functionality .
on the other hand , the moderator said we can not assume that these end users are knowledgeable enough to make informed decisions about their safety in regard to issues like whether a specific type of circuit is safe to use in these devices , and thus ,
three factors determine the safety of a tdcs protocol : dose of current , size of electrodes , and duration of stimulation .
the first two factors determine current density ( current dose divided by electrode size ) , and the total current dosage is then measured by multiplying current density by the duration of stimulation .
researchers have suggested that a stimulation protocol using 2535 cm electrodes with currents of 12 milliamperes ( ma ) for up to 2040 minutes is considered safe .
the survey results showed that most of the respondents are following this safety guideline , though there are some exceptions .
( figs 810 ) for example , 43 respondents are using electrodes smaller than 10 cm .
however , it seems that most of them are foc.us users : the size of electrodes of foc.us headset is about 46 cm , and there are 37 foc.us users among the respondents .
when asked how they try to find out about these three factors that determine the safety of a stimulation protocol , most respondents answered that they find relevant information from academic research studies on tdcs or website postings , such as postings in subreddit tdcs ( appendix i ) .
how often one can safely use tdcs per day or per week for an extended period of time is a question that does not have a clear answer yet .
most of the tdcs studies applied tdcs to the subjects less than five to six times per week for a relatively short term ( ie few weeks ) .
thus , these studies do not provide proper guidelines for people who are using tdcs at home more often for a longer period of time .
a few postings on the frequency of use at subreddit tdcs led to users replying based on their own experiences and acknowledging the absence of proven guidelines by researchers .
a total of 52 out of 56 respondents who are using tdcs regularly reported that they have stimulation sessions fewer than seven times per week ( on average less than once a day ) .
this part presents , the data on the respondents self - reports about the effects and side effects of tdcs . in this exploratory study , it is not feasible to measure and test the actual effects of tdcs , such as to what extent tdcs has affected users cognitive abilities or medical conditions .
the self - reports on the effects of tdcs posted at subreddit tdcs show that diy users themselves are having problems in assessing the effects of tdcs while using it at home .
although the physician who has been treating his patients with tdcs described the effects of tdcs on chronic pain and depression as too good to be true , a power user who used tdcs mainly for cognitive enhancement reported that the effects of tdcs are
extremely subtle. for example , there can be placebo effects and in cases where users take cognitive tests after or while simulating their brain ( ie lumosity , dual n - back game , or cambridge brain challenge ) , learning by repetition can also affect the test results .
in addition , types of side effects which diy users are experiencing and the degree of these side effects will be analysed .
a total of 54 ( 44% ) out of 121 responding users rated the effects of tdcs at four or five on the scale of one ( totally unsuccessful ) to five ( extremely successful ) ( appendix j ) .
the quotes below are two examples of self - reports on the effects of tdcs posted at subreddit tdcs .
the first quote is describing the effects of tdcs on cognitive abilities : a series of memory tests were administered by an electrical engineer who supervised the experiment , initially without tdcs .
these tests demonstrated standard working memory results with a measured span of 58 components retained after a series of 15 terms were listed aloud to remember . with tdcs the data showed very promising results .
apart from the subjective experience of heightened focus and a calmness that can be likened to being in the zone , the results of the memory test indicated a measurable increase in working memory span .
for each subsequent test , all 15 words were remembered in correct order and recalled in correct order after tdcs was administered . [ t]he subjective experience combined with data reflecting very promising cognitive enhancements leads me to conclude tdcs overall effectiveness in increasing my learning potential during and post stimulation .
the second quote describes the perceived effects of tdcs on a medical condition depression : from a subjective perspective , this is awesome .
i actually went out jogging . mostly walking , actually , because there is n't enough electricity in the world to make me not be a fat ass who 's running for the first time since 2010 , but still way out of my usual .
i initially questioned if this was a hypomanic episode or just what the release of 15 years of depression feels like , but i judge it to likely be hypomania . does n't matter , i feel like frankenstein 's monster .
i was dead , if only in my mind , and then with a little bit of lightning , boom .
subjectively perceived effects of tdcs , survey respondents were asked whether they are planning to use tdcs in the future .
a total of 111 out of 121 respondents ( 92% ) replied that they would continue using tdcs in the future .
moreover , 56 ( 46% ) of the respondents rated their willingness to recommend tdcs to family members or friends , who have the same aim(s ) or conditions(s ) as they do , at four or five on the scale of one ( will not recommend ) to five ( strongly recommend ) ( appendix k ) .
a total of 56 out of 121 responding users ( 46% ) reported that they have experienced side effects while using tdcs .
these respondents have experienced headache , discomforting changes such as pain , tingling , itching or burning under the electrodes , fatigue , nervousness , visual perceptual changes , acute mood changes , difficulties in concentrating , nausea , and sleeping disturbance ( appendix l ) .
however , the degree of side effects was not severe the average severity of most types of side effects were rated at about one , on the scale of one ( not severe at all ) to five ( extremely severe ) , except discomforting changes , such as pain , tingling , itching or burning under the electrodes , where the average severity was about 2.3 ( appendix m ) .
power users and the physician reported that the side effects of tdcs are almost negligible , and this result corresponds to previous empirical results showing that there are no severe short - term adverse or side effects . what concerns did diy users have , if any , about the use of tdcs are and what they think about the possibility of government regulation on tdcs or guidelines from government agencies , researchers , or physicians ?
a total of 97 out of 121 survey respondents ( 80% ) reported that they have concerns about the diy use of tdcs .
most of these respondents are worried about long - term potential impairment on the brain and the use of inaccurate position of electrodes ( fig .
the most interesting finding in the analysis of web postings at subreddit tdcs was the users provided safety warnings .
in subreddit tdcs , 100 safety warnings were found in the comments to the postings , and 77 out of these 100 warnings were the comments to the postings on building and operation of tdcs ( table 1 ) .
if you have no idea what a 4 milliamp is , i suggest you stay away from this .
a 9v battery can kill you!remember safety first before you try this.don't up the current , that is the wrong way around.seriously , if you are n't comfortable with your knowledge of currents and what effects different amperages can have on your body , do not attempt this. if you have no idea what a 4 milliamp is , i suggest you stay away from this
remember safety first before you try this. do n't up the current , that is the wrong way around. seriously , if you are n't comfortable with your knowledge of currents and what effects different amperages can have on your body , do not attempt this. sometimes diy users also ask more specific questions on their own diy circuit at subreddit tdcs .
they post pictures or detailed descriptions of their home - built circuit and ask whether it is safe to do self - experiment with the circuit . then
, other users actively correct them if there are issues on the circuit that can cause danger .
the general safety warnings and questions and comments about the safety of a specific diy circuit design show the existence of a self - regulating system within this online forum .
the moderator of subedit tdcs stated that there is a lot of emphasis on individual responsibility a bio hacker 's mentality , but there is also a very much of a culture that values giving people information about dangerous things. the webmaster of diytdcs also acknowledged that there is definitely a self - regulating system in subreddit tdcs : those who do know about electronics easily recognize people who should n't be experimenting with self - built devices. other power users also agreed that there were a certain number of users in the community who have corrected and guided other users not to make dangerous mistakes : we are self - regulating community .
everybody in reddit has to express some type of knowledge as he / she writes a posting and nobody in the community will let up on you understanding the dangers of messing around with electronic current .
the reason that it happens is because i believe at least in the beginning most of the tdcs community on reddit were people who had a background in engineering such as building circuits .
over the course of last three years , i have yet seen anybody post anything that tdcs has done some real damage .
the majority of survey respondents ( 97 out of 121 respondents ) thought that it would be helpful to have an official guideline from government agency or experts ( researchers or physicians ) for the diy use of tdcs .
all of the power user interviewees claimed that the part that most needs guidelines from the government or experts is placement of electrodes .
they reported that getting reliable repeated placement of anodes and cathodes , and what montages should be used to treat or improve which things are the most confusing parts of practicing diy tdcs .
moreover , the power users expressed concern that even though diy users locate the electrodes in the right place according to a specific montage , whether a person is left - handed or right - handed might affect the outcome because left - handed people 's brains may be organized differently from those of right - handed people .
it is also possible that subtle differences in the neuroanatomy of individuals may alter the effects of the device. the physician also warned that the area under the anode that is being stimulated could be changed depending on where you locate the cathodes .
some of the survey respondents also provided more detailed comments on the potential official guidelines or government regulation on tdcs .
official guidelines would only be helpful if they were more than do n't do it .
i think in many cases our society focuses too much on safety rather than encouraging curiosity.i believe that government regulation would be a detriment and stifle any new developments.tdcs has great potential .
i 'd like guidelines to come out that are backed by proper and thorough research into the effects.while i think more information and studies being published from academic and medical sources would be great , i hope that the industry does not undergo any governmental regulation , and remains a practice individuals can perform on themselves and buy the related devices without legal issues.the use of these technologies will evolve and outpace the medically established research merely based on the network effect that the internet creates around anything it touches . we need to create a sort of social network for experimenters to share and teach each other .
if they are smart , they will study and not interfere except to add useful insight from time to time from their own research.about official guidelines i'd welcome any helpful information , but such guidelines , in my experience tend to be over - cautious .
i ca n't imagine any official agency ever advising the public to do what i do .
my own experience has been very satisfactory , but i know that there are a lot of unknowns and that i 'm accepting an unknown measure of risk when i run an electrical current through my cranium .
nobody should do that until they 've researched the matter thoroughly and assessed the risks for themselves .
what i would like is an advisory agency for psychologists and psychiatrists to help them deliver tdcs treatment where it 's appropriate .
i think it can be very beneficial , and not many professionals seem to be aware of it.i have great concerns with some of the equipment people are using to attempt this on their own brains .
i 'm an electrical engineer so when i look at some of the devices people have designed it 's terrifying what these people are hooking up to themselves .
it would be very , very useful for an official guideline to be available since some of these people are using simple voltage dividers with no understanding how current behaves when they apply these things to their heads. official guidelines would only be helpful if they were more than do n't do it .
i think in many cases our society focuses too much on safety rather than encouraging curiosity.
i believe that government regulation would be a detriment and stifle any new developments. tdcs has great potential .
i 'd like guidelines to come out that are backed by proper and thorough research into the effects. while i think more information and studies being published from academic and medical sources would be great , i hope that the industry does not undergo any governmental regulation , and remains a practice individuals can perform on themselves and buy the related devices without legal issues. the use of these technologies will evolve and outpace the medically established research merely based on the network effect that the internet creates around anything it touches .
we need to create a sort of social network for experimenters to share and teach each other .
if they are smart , they will study and not interfere except to add useful insight from time to time from their own research. about official guidelines
i'd welcome any helpful information , but such guidelines , in my experience tend to be over - cautious .
i ca n't imagine any official agency ever advising the public to do what i do .
my own experience has been very satisfactory , but i know that there are a lot of unknowns and that i 'm accepting an unknown measure of risk when i run an electrical current through my cranium .
nobody should do that until they 've researched the matter thoroughly and assessed the risks for themselves .
what i would like is an advisory agency for psychologists and psychiatrists to help them deliver tdcs treatment where it 's appropriate .
i think it can be very beneficial , and not many professionals seem to be aware of it. i have great concerns with some of the equipment people are using to attempt this on their own brains .
i 'm an electrical engineer so when i look at some of the devices people have designed it 's terrifying what these people are hooking up to themselves .
it would be very , very useful for an official guideline to be available since some of these people are using simple voltage dividers with no understanding how current behaves when they apply these things to their heads. these comments suggest that although diy users acknowledge the need for guidelines for the diy tdcs ; many are opposed to and worried about blanket government regulations on tdcs devices , which would prevent them from continuing self - experiments
. these blanket regulations could backfire and draw further attention to diy tdcs , and lead to the opening of uncontrollable underground markets for tdcs . according to the interviewees ,
one of the most serious concerns about government regulations seems to be the potential increase in the cost of practicing tdcs .
the moderator of subreddit tdcs said that the community has a strong preference for devices that are extremely low cost .
it is very difficult to convince people to have a current meter on the home - built device because it costs \documentclass[12pt]{minimal }
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} { } $ { \$ } $ \end{document}5 more. criticizing the current us health care system that discourages physicians from reducing the costs of medical treatments , the physician also argued that other available options , comparable to tdcs , for treatment refractory patients are too expensive .
for example , it costs \documentclass[12pt]{minimal }
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} { } $ { \$ } $ \end{document}30,000 per year for the treatment of chronic depression using rtms , which is a classified medical device by fda , and insurance often does not cover the treatment .
in contrast , his clinic offers a tdcs treatment program at \documentclass[12pt]{minimal }
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} { } $ { \$ } $ \end{document}2500 , which includes four years of at - home supervision , as well as the initial evaluation , training , and a device although it still could be considered expensive for some patients .
in other words , the costs could be the main reason why people with specific treatment refractory medical conditions , such as chronic pain or depression , opt to build or purchase a tdcs device and self - treat them .
these people might view a strict regulatory oversight as a threat to deprive them of the only affordable last resort to keep their medical condition under control . as a last note , below quote from the interview with the moderator of subreddit tdcs suggests an interesting angle for a future regulatory regime regarding tdcs : if the goal of regulating tdcs device is to make sure that when people are getting tdcs device , it is safe and effective , i think labeling and regulating it as a medical device is not practical and that 's because they are so easy to make .
the medical device testing is onerous and expensive and not something that many of the diy users are going to like to go through so , there are always going to be a supply of unregulated devices and you can not stop people from making this device
. it would be better to adopt a wide - spread and easily understandable standard system for tdcs that is based on research on safety of tdcs and have a group to test tdcs devices to make sure that the devices meet the standard you would think twice about buying a car that has one star crash rating , and i would like to see something like that applies to tdcs devices as well .
the findings of this study presented in the last section may provide preliminary empirical indicators to determine whether we need regulations and guidelines for diy tdcs and , if we do , how to design them to ensure a safe and responsible use of tdcs . this section will summarize some of the main findings and explore the tentative regulatory implications of these findings . first ,
unlike the implicit assumption made in media coverage on tdcs , the diy community does not comprise just risk takers with eccentric interests , such as young bio hackers or self - experimenters .
the survey results showed some distinctive characteristics of the respondents clear male dominance and slight skew to ( a ) higher than average education level , ( b ) students and professionals , and ( c ) very low and high income .
also , it should be noted that there was a wide distribution of ages among the respondents , which shows the potential of tdcs as an appealing technology satisfying various aims across generations .
although the survey respondents did not necessarily form a representative sample , this demographic profile of diy tdcs users provides preliminary information on who will be the target subjects of potential regulations or official guidelines on the use of tdcs .
second , according to the findings of the study , diy users interest in tdcs seems transient only half of the survey respondents are continuous and regular users , and the majority of these respondents ( 61% ) began to use tdcs less than six months ago .
one of the interviewees also pointed out that there seem to be only a small number of committed diy users in the community . from this data , it can be inferred that there may be some hype around the estimation on the current size of the diy population .
however , it is also true that findings on the perceived effects of tdcs appear to support more affirmative predictions on the future of the diy use of tdcs .
a total of 54 ( 44% ) survey respondents reported that their use of tdcs was quite successful and satisfactory , and 111 respondents ( 92% ) replied that they would continue using tdcs in the future .
also , 56 respondents ( 46% ) are willing to recommend tdcs to family members or friends , who have the same aim(s ) or condition(s ) as they do .
interviewees expressed conflicting views on the future of the diy use of tdcs . some argued that unless more robust evidence on the effects of tdcs emerges
in contrast , others who strongly believed in the potential of tdcs as treatment and cognitive enhancement predicted substantial increase in the diy tdcs user population .
these somewhat contradictory findings suggest that there are a lot of ambiguities and mistaken assumptions about the use of tdcs . in general
, it can be said that at this stage , diy use of tdcs is not currently widespread , that it does not seem to pose an imminent risk or danger to the public , and that there seems to be only a remote possibility of a dramatic increase of diy use of tdcs in the near future .
nonetheless , more systematic and detailed investigations on the current state and prospect of diy tdcs are required so that regulatory agencies can carefully examine the need for and the appropriate timing of potential regulatory interventions . as discussed above
, there is no regulation on therapeutic use of tdcs and devices intended for cognitive enhancement are not covered by any current regulations in the usa considering possible regulatory options , maslen et al . have expressed concerns about establishing a new separate regulatory regime for cognitive enhancement devices different from the current regime for medical devices .
one of the reasons for their concern is that it is hard to categorically distinguish cognitive enhancement devices from medical devices .
most of the current enhancing technologies , including tdcs , were originally developed for therapeutic purposes , such as treatments for illness or age - related mental deterioration , but the uses of these technologies have been subsequently expanded for enhancements .
in other words , [ t]he very same device may be used both for therapeutic and enhancement purposes , in some cases using similar parameters. the types and levels of risks that are involved with therapeutic and enhancement use of a device also may not be meaningfully different .
in addition , some scholars have argued that there is no philosophical difference between treatment and enhancement[b]oth therapy and enhancement aim to improve a human being 's biology and/or psychology. this study provides preliminary empirical support to the claim that the practical distinction between medical devices and enhancements can be muddy .
the survey results showed the mixed and overlapping use of tdcs13 ( 11% ) respondents use tdcs for treatment of medical conditions , 71 ( 59% ) respondents for cognitive enhancement , and 29 ( 24% ) respondents for both cognitive enhancement and treatment .
this suggests that if a regulatory agency decides to regulate tdcs either as a medical device or as a cognitive enhancement only , it will turn out to be an essentially underinclusive policy .
according to the survey results , diy users claim to conform very well to safety guidelines for the current density ( current dose divided by electrode size ) , and the total current dosage ( current density multiplied by the duration of stimulation ) set by previous clinical studies .
the analysis on the web postings in subreddit tdcs demonstrated that diy users are not only concerned about the safety of their own stimulation protocols but also cared about other users practice of tdcs .
the general safety warnings by the users and the feedback process to verify the safety of individual diy circuit show the existence of an active self - regulating system in this online forum .
according to previous literatures on self - regulation , self - regulation and state regulation can be intertwined and complement each other. the self - regulating system in the diy tdcs community suggests that it may be possible to build a partnership between the diy community and regulatory agencies to oversee the use of tdcs .
in addition , the fact that many users consult website postings to get information on the three main elements ( dose of current , size of electrodes , and duration of stimulation ) of stimulation protocol reflects the users reliance on web postings to self - experiment with tdcs .
thus , incorporating this bottom - up self - regulating system into a top - down state regulatory framework can increase the efficiency of the framework by self - motivating diy users to conform to the regulation and allowing the framework to more flexibly respond to unforeseen circumstances .
fitz and reiner claimed that regulatory approach taken to diy by synthetic biologists ( diy bio ) could be a good example of a potential regulatory option for diy tdcs .
synthetic biology is the design and construction of new biological parts , devices , and systems , and the re - design of existing , natural biological systems for useful purposes. in this case , the national science advisory board for biosecurity chose open communication and education through public events and conferences instead of traditional regulatory practice to develop a culture of responsibility by diy bio practitioners .
fitz and reiner acknowledged that compared to diy bio , the costs of practicing diy tdcs are relatively low or sometimes even negligible , and thus , the risks associated with diy tdcs are greater than those of diy bio . however , they argued that the new regulatory approach for diy bio can be a practical option at least for the interim period until a regulatory agency comes up with a comprehensive regime for tdcs .
the existence of the self - regulating system demonstrated in this study may provide support to fitz and reiner 's argument for the new regulatory approach . with voluntary participation and oversight by diy tdcs users , open communication and education
can be a more viable and effective scheme for developing the culture of safe and responsible use .
however , it is noteworthy that recently , there has been a demographic shift within the diy tdcs user community . the interviews with the power users of subreddit tdcs revealed that when this online forum was first established two years ago , most people in this forum had a background in engineering or did their
homework on the effects and risks of tdcs by researching previous clinical studies on tdcs before their self - experiments .
the self - regulating body was comprised of these people , and they were extremely helpful in giving real advices. however , the recent release of out of the box tdcs devices , such as foc.us , has increased interest in tdcs among the general public , and now there is a growing population of end users who do not know how tdcs circuits work or do not care to thoroughly investigate the effects and risks of tdcs .
the increase in the size of the diy tdcs user community particularly the influx of nave end users may undermine the vitality of the self - regulating system in subreddit tdcs .
if the regulatory agency wants to incorporate the self - regulating system into any future regulatory regime for tdcs , it should take into account the potential impacts of this demographic shift in the community on the self - regulating system .
a total of 97 out of 121 survey respondents ( 80% ) reported that they had concerns about the diy use of tdcs .
these respondents are mostly worried about long - term impairment on the brain and the use of inaccurate placement of electrodes .
also , the same number of respondents answered that it would be helpful to have official guidelines from government agency or experts ( researchers or physicians ) for the diy use of tdcs .
in other words , it can be said that diy users are waiting for the open communication and education by the authorities proposed in fitz and reiner 's article to ensure the safety of their self - experiments with tdcs .
in addition , consistent with the survey results , all of the interviewed power user concurred that the issue where guidelines from the government or experts are most needed is placement of electrodes . as discussed above , locating the electrodes on the scalp to target a specific underlying brain region can be not only confusing but also very risky for lay users .
therefore , in designing a guideline or education program for diy use of tdcs , the regulatory agency or expert groups may want to focus more on how to guide the placement of electrodes rather than other issues such as size of current or size of electrodes , for which there are already relatively clear safety standards .
in contrast to their desire for official guidelines , the survey respondents took a very negative stance toward potential government regulation .
some of the survey respondents answers showed that diy users would practice tdcs regardless of the government regulations , to wit : levying onerous requirements on diy users may drive the work further underground to the benefit of none. the significant financial advantages of diy tdcs compared to other treatments for chronic medical conditions seem to make this scenario more plausible .
this raises a question whether it is legally or practically possible to enforce regulations on tdcs devices .
however , for the fda to intervene and take enforcement actions , there need to be prohibited acts , such as the introduction of adulterated or misbranded drugs or devices into interstate commerce .
building and using a tdcs device only for oneself does not seem to constitute any of the prohibited acts listed in the act .
moreover , even if the fda may legally be able to outlaw the use of home - built tdcs devices through the broad interpretation or amendment of the act , how could it enforce such a ban , considering the ease and low cost of making such devices and the difficulty of detecting them , especially considering the limited resources that the fda has .
in addition , regulations of marketing and sales of out of the box tdcs devices that would make device manufacturers subject to rigorous supervision , would likely lead to cost increases for the manufacturers that could increase the appeal of home - made tdcs devices .
for example , arguing that enhancement devices in european union should be regulated through extending the existing legislations for medical devices , maslen et al .
transparent , detailed , evidence - based information pertaining to the mechanisms , risks and effects that might be construed as benefits of the devices. providing such detailed information is currently not compulsory. this demanding requirement will inflict additional costs on the manufacturers and eventually , the consumers .
however , given the ease of building tdcs devices and the diy community 's strong preference for low - cost devices , increasing the costs of devices may lead to uncontrollable self - manufacturer of the devices , causing users to hide out of reach of the fda .
thus , further investigation is needed to analyse whether , in practice , the fda intervention and supervision can effectively ensure the safety and responsible use of tdcs devices .
direct brain enhancement is not an imaginary story that exists only in the remote future .
it was originally developed for treatment for medical conditions , such as depression , but clinical studies have also reported that it can improve various cognitive abilities among healthy people .
this study is the first empirical attempt to investigate the diy tdcs user community . a questionnaire survey of diy users , interviews with some active power users , and a content analysis of web postings on tdcs showed distinctive demographic characteristics of the diy users , ambiguities and mistaken assumptions around the current state and future prospects of the diy use of tdcs , mixed use of tdcs for both treatment and cognitive enhancement , the existence of an active self - regulating system in the community , and users demands for official guidelines and their concerns about government regulations on tdcs . even with the limitation of a small non - random sample , the findings of this study provide a preliminary but useful empirical illustration of the diy tdcs user community , and increase our current understanding of the practice of diy tdcs
however , more detailed subsequent studies are required to determine the need for and the timing of government interventions and to assess the strength and weakness of regulatory options proposed by researchers . furthermore , although this study just focused on one type of human biological cognitive enhancement
there are numerous other enhancements , such as drugs , biologics , and dietary supplements , which could be used to improve the function of human bodies or brains .
as discussed above , there have been growing discussions on whether and how to regulate these enhancements , including off - label uses of fda - approved drugs and devices for enhancement purposes .
however , empirical understanding on the use of these enhancements is incomplete , as in the case of tdcs . owing to advances in biomedical science and increasing interest in human biological enhancements
thus , for more meaningful and informed discussions of potential regulation , future studies on the actual practices of various human biological enhancements are required to clarify critical issues and factual assumptions regarding the use of these enhancements . | among currently available technologies , transcranial direct current stimulation ( tdcs ) is one of the most promising neuroenhancements because it is relatively effective , safe , and affordable .
recently , lay people have begun to build or purchase the tdcs device to use it at home for treatment or as a cognitive enhancer .
the tdcs device is currently not covered by the existing regulatory framework , but there are still significant potential risks of misusing this device , and its long - term effects on the brain have not been fully explored .
thus , researchers have argued the need for regulations or official guidelines for the personal use of tdcs .
however , until now , no systematic research on the do - it - yourself ( diy ) tdcs user community has been done .
the present study explores the basic demographic characteristics of diy tdcs users as well as why and how they are using this device through a questionnaire survey , in - depth interviews , and a content analysis of web postings on the use of tdcs .
this preliminary but valuable picture of the diy tdcs user community will shed light on future studies and policy analysis to craft sound regulations and official guidelines for the use of tdcs . |
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the top of the tube was fastened shut and the culture was grown overnight ( 0 rpm , 30 c ) .
the bacteria reached a maximum od
600 nm of approximately 0.7 and ph of 6.256.30 before growth ceased .
the cells were pelleted by centrifugation ( 3220 g , 15 min ) and washed twice with mops buffer ( 10 ml ; 20 mm mops , 30 mm na2so4 , ph 7.4 ) before resuspension in mops buffer ( 5 ml ) .
the washed mr1 was stored at 4 c and used as soon as possible ( within 12 h ) for electrochemical experiments .
dm contained the following ingredients ( per litre ) : 1.5 g nh4cl ( melford ) , 0.1 g kcl ( bdh laboratory supplies ) , 0.625 g na2hpo4 ( melford ) , 0.213 g na2so4 , 0.103 g cacl22 h2o ( fisher scientific ) , 0.095 g mgcl2 ( acros organics ) , 1.51 g pipes , 2 ml trace minerals solution and 10 ml vitamin solution .
in addition to this , lactate was added to a concentration of 10 mm .
the ph of dm was approximately 7.4 , and it was sterilised by filter sterilisation ( 0.22 m ) .
the trace minerals solution contained ( per liter ) : 1 g fecl24 h2o , 0.5 g mncl24 h2o , 0.3 g cocl26 h2o , 0.2 g zncl2 , 0.05 g na2moo42 h2o ( acros organics ) , 0.02 g h3bo3 , 0.1 g niso46 h2o , 0.002 g cucl22 h2o ( acros organics ) , 0.006 g na2seo35 h2o and 0.008 g na2wo42 h2o ( acros organics ) .
the vitamin solution contained ( per liter ) : 0.002 g biotin , 0.002 g folic acid , 0.001 g b6 ( pyridoxine ) hcl , 0.005 g b1 ( thiamine ) hcl , 0.005 g b2 ( riboflavin ) , 0.005 g nicotinic acid , 0.005 g pantothenic acid ( santa cruz biotechnology ) , 0.005 g paminobenzoic acid , 0.005 g lipoic acid , 0.2 g choline chloride and 0.001 g b12 ( cobalamin ) crystalline .
templatestripped gold ( tsg ) electrodes were prepared as described previously.24 to form the sams , tsg glass slides were incubated in h2o ( 1 ml ) with 1 mm thiol , that is , either 8mercapto1octanol ( 8oh ) or a 57:43 mixture of 8oh and 8mercaptooctanoic acid ( 8cooh ) .
slides were incubated in the thiol solution at 4 c for at least 16 h. prior to use , the electrodes were washed with isopropanol and dried under a stream of n2 .
in general , for electrochemical experiments , a bespoke , glass , singlechamber electrochemical cell housed in a faraday cage was used with a standard threeelectrode setup . as the working electrode , tsg ( modified with a sam ) or ito
was embedded in a polytetrafluoroethylene ( ptfe ) holder with a rubber oring seal ( exposing an electrode area of 0.24 cm ) .
the working electrode was placed in the electrochemical cell along with a platinumwire counter electrode and a saturated mercury / mercury sulfate ( hg / hg2so4 ) reference electrode ( radiometer analytical , france ) .
all potentials were converted with respect to a standard hydrogen electrode ( she ) , using + 651 mv versus she for the hg / hg2so4 reference electrode .
mops buffer , continuously purged with argon , was used as the basal electrolyte solution for all experiments , unless stated otherwise .
for a typical experiment , washed mr1 was added to the electrochemical cell to od
600 nm=0.45 .
sodium lactate was then added from a 200 mm stock solution to a final concentration of 10 mm ( acting as the sole electron / carbon source for bacterial respiration ) . to promote eet to the working electrode ,
the electrode was poised at + 0.25 v ( vs. she ) . at various time points ,
small variations to this general method are detailed , where relevant , in the results section . in some experiments ,
electrochemical experiments with pyrolytic graphite edge ( pge ) electrodes followed the same experimental method as described for tsg electrodes , but required a different experimental setup .
a bespoke , twochamber , glass electrochemical cell housed in a faraday cage was used with a standard threeelectrode setup . the pge working electrode ( geometrical area ca .
0.24 cm ) was inserted , along with a platinumwire counter electrode , into the main chamber and a saturated mercury / mercury sulfate ( hg / hg2so4 ) reference electrode was inserted into the side chamber .
the two chambers were interconnected with a narrow glass tube , allowing for the diffusion of electrolytes between the two chambers .
electrochemical measurements were obtained by using an autolab electrochemical analyser ( ecochemie , utrecht , netherlands ) equipped with a pgstat 128n potentiostat , scangen and adc750 modules , and fra2 frequency analyser ( ecochemie ) .
cyclic voltammetry measurements were routinely carried out by holding the potential at 0 v for 5 s before cycling between + 0.4 and 0.4 v ( vs. she ) at a scan rate of 10 or 100 mv s. all electrochemical experiments reported here were performed at 20 c .
mr1 with od
600 nm=0.25 was incubated for approximately 22 h in mops buffer ( 2 ml ) with 10 mm sodium lactate on a 8oh:8cooh ( 57:43 ) mixed sammodified tsg electrode , which was poised at + 0.25 v ( vs. she ) .
to separate the cells from the supernatant , the contents of the ec cell were centrifuged at 4500 g and filtered through a 0.22 m polyethersulfone ( pes ) filter .
the filtered supernatant was analysed by using voltammetry with fresh tsg electrodes that were prepared as described above .
s. oneidensis mr1 cultures were grown aerobically in lb ( 30 c , 200 rpm , 16 h ) to an optical density od
600 nm>1 . this culture ( 1 ml )
was used to inoculate lb ( 50 ml ) supplemented with 50 mm lactate and 25 mm fumarate in a 50 ml falcon tube .
the top of the tube was fastened shut and the culture was grown overnight ( 0 rpm , 30 c ) .
the bacteria reached a maximum od
600 nm of approximately 0.7 and ph of 6.256.30 before growth ceased .
the cells were pelleted by centrifugation ( 3220 g , 15 min ) and washed twice with mops buffer ( 10 ml ; 20 mm mops , 30 mm na2so4 , ph 7.4 ) before resuspension in mops buffer ( 5 ml ) .
the washed mr1 was stored at 4 c and used as soon as possible ( within 12 h ) for electrochemical experiments .
dm contained the following ingredients ( per litre ) : 1.5 g nh4cl ( melford ) , 0.1 g kcl ( bdh laboratory supplies ) , 0.625 g na2hpo4 ( melford ) , 0.213 g na2so4 , 0.103 g cacl22 h2o ( fisher scientific ) , 0.095 g mgcl2 ( acros organics ) , 1.51 g pipes , 2 ml trace minerals solution and 10 ml vitamin solution .
in addition to this , lactate was added to a concentration of 10 mm .
the ph of dm was approximately 7.4 , and it was sterilised by filter sterilisation ( 0.22 m ) .
the trace minerals solution contained ( per liter ) : 1 g fecl24 h2o , 0.5 g mncl24 h2o , 0.3 g cocl26 h2o , 0.2 g zncl2 , 0.05 g na2moo42 h2o ( acros organics ) , 0.02 g h3bo3 , 0.1 g niso46 h2o , 0.002 g cucl22 h2o ( acros organics ) , 0.006 g na2seo35 h2o and 0.008 g na2wo42 h2o ( acros organics ) .
the vitamin solution contained ( per liter ) : 0.002 g biotin , 0.002 g folic acid , 0.001 g b6 ( pyridoxine ) hcl , 0.005 g b1 ( thiamine ) hcl , 0.005 g b2 ( riboflavin ) , 0.005 g nicotinic acid , 0.005 g pantothenic acid ( santa cruz biotechnology ) , 0.005 g paminobenzoic acid , 0.005 g lipoic acid , 0.2 g choline chloride and 0.001 g b12 ( cobalamin ) crystalline .
templatestripped gold ( tsg ) electrodes were prepared as described previously.24 to form the sams , tsg glass slides were incubated in h2o ( 1 ml ) with 1 mm thiol , that is , either 8mercapto1octanol ( 8oh ) or a 57:43 mixture of 8oh and 8mercaptooctanoic acid ( 8cooh ) .
slides were incubated in the thiol solution at 4 c for at least 16 h. prior to use , the electrodes were washed with isopropanol and dried under a stream of n2 .
in general , for electrochemical experiments , a bespoke , glass , singlechamber electrochemical cell housed in a faraday cage was used with a standard threeelectrode setup . as the working electrode ,
tsg ( modified with a sam ) or ito was embedded in a polytetrafluoroethylene ( ptfe ) holder with a rubber oring seal ( exposing an electrode area of 0.24 cm ) .
the working electrode was placed in the electrochemical cell along with a platinumwire counter electrode and a saturated mercury / mercury sulfate ( hg / hg2so4 ) reference electrode ( radiometer analytical , france ) .
all potentials were converted with respect to a standard hydrogen electrode ( she ) , using + 651 mv versus she for the hg / hg2so4 reference electrode .
mops buffer , continuously purged with argon , was used as the basal electrolyte solution for all experiments , unless stated otherwise . for a typical experiment ,
sodium lactate was then added from a 200 mm stock solution to a final concentration of 10 mm ( acting as the sole electron / carbon source for bacterial respiration ) . to promote eet to the working electrode ,
the electrode was poised at + 0.25 v ( vs. she ) . at various time points ,
small variations to this general method are detailed , where relevant , in the results section . in some experiments ,
electrochemical experiments with pyrolytic graphite edge ( pge ) electrodes followed the same experimental method as described for tsg electrodes , but required a different experimental setup . a bespoke , twochamber , glass electrochemical cell housed in a faraday cage was used with a standard threeelectrode setup .
0.24 cm ) was inserted , along with a platinumwire counter electrode , into the main chamber and a saturated mercury / mercury sulfate ( hg / hg2so4 ) reference electrode was inserted into the side chamber .
the two chambers were interconnected with a narrow glass tube , allowing for the diffusion of electrolytes between the two chambers .
electrochemical measurements were obtained by using an autolab electrochemical analyser ( ecochemie , utrecht , netherlands ) equipped with a pgstat 128n potentiostat , scangen and adc750 modules , and fra2 frequency analyser ( ecochemie ) .
cyclic voltammetry measurements were routinely carried out by holding the potential at 0 v for 5 s before cycling between + 0.4 and 0.4 v ( vs. she ) at a scan rate of 10 or 100 mv s. all electrochemical experiments reported here were performed at 20 c .
mr1 with od
600 nm=0.25 was incubated for approximately 22 h in mops buffer ( 2 ml ) with 10 mm sodium lactate on a 8oh:8cooh ( 57:43 ) mixed sammodified tsg electrode , which was poised at + 0.25 v ( vs. she ) . to separate the cells from the supernatant
, the contents of the ec cell were centrifuged at 4500 g and filtered through a 0.22 m polyethersulfone ( pes ) filter .
the filtered supernatant was analysed by using voltammetry with fresh tsg electrodes that were prepared as described above .
as a service to our authors and readers , this journal provides supporting information supplied by the authors .
such materials are peer reviewed and may be reorganized for online delivery , but are not copyedited or typeset .
technical support issues arising from supporting information ( other than missing files ) should be addressed to the authors . | abstractexoelectrogenic bacteria can couple their metabolism to extracellular electron acceptors , including macroscopic electrodes , and this has applications in energy production , bioremediation and biosensing .
optimisation of these technologies relies on a detailed molecular understanding of extracellular electrontransfer ( eet ) mechanisms , and shewanella oneidensis mr1 ( mr1 ) has become a model organism for such fundamental studies . here , cyclic voltammetry was used to determine the relationship between the surface chemistry of electrodes ( modified gold , ito and carbon electrodes ) and the eet mechanism .
on ultrasmooth gold electrodes modified with selfassembled monolayers containing carboxylicacidterminated thiols , an eet pathway dominates with an oxidative catalytic onset at 0.1 v versus she .
addition of iron(ii)chloride enhances the catalytic current , whereas the siderophore deferoxamine abolishes this signal , leading us to conclude that this pathway proceeds via an iron mediated electron transfer mechanism .
the same eet pathway is observed at other electrodes , but the onset potential is dependent on the electrolyte composition and electrode surface chemistry .
eet pathways with onset potentials above 0.1 v versus she have previously been ascribed to direct electrontransfer ( det ) mechanisms through the surface exposed decaheme cytochromes ( mtrc / omca ) of mr1 . in light of the results reported here , we propose that the previously identified det mechanism of mr1 needs to be reevaluated . |
stroke involves rapid loss of brain function resulting from a disturbance in the blood
supply to the brain ; it often profoundly affects upper limb stability and movement capacity .
stroke is the third leading cause of death worldwide , and it is the leading cause of severe
disability in patients in the developed world1,2,3 .
, a
person can suffer from paralysis of an arm ; even if some movement control remains , patients
use the affected arm less than the unaffected arm4 ,
5.the paralysis makes arm movements ,
such as reaching , grasping , and manipulating objects , difficult .
generally , patients with
hemiparesis compensate for restricted movement and muscle weakness by primarily using the
non - paretic side . as a result
, the unaffected upper extremity mostly controls the activities
of daily life6 , 7 . as the patient s unaffected hand plays a significant role in everyday life , whether or not
the function of the unaffected hand following stroke is affected is directly related to the
patient s survival and quality of life .
therefore , it is important to determine whether the
function of the unaffected hand is changed in patients with stroke8 . the unaffected side is often considered a reference point , and it is , therefore , assumed
that this side has no deficit .
nevertheless , previous research suggests or tends to show
diminished strength in the unaffected upper extremity ( ue)in stroke survivors compared with
healthy subjects , although two previous studies did not find any differences between the
unaffected ue strength of patients with stroke and the same ue side of healthy subjects9,10,11,12,13 .
however , bi seng et al . compared the
reaction time of healthy subjects and patients with stroke and found that the reaction times
of wrist flexion and extension in the affected sides of patients following stroke were
significantly longer than those in their unaffected sides and those of normal subjects14 .
the main objective of the present study was to compare the sensorimotor performance of the
unaffected ue of subjects with post - stroke hemiparesis with that of a group of age - matched
healthy subjects without ue deficits .
twenty individuals with prior stroke and 20 healthy subjects were included in this study .
the study was approved by the local ethics committee and conformed to the standards set by
the declaration of helsinki . written informed consent was obtained from all patients prior
to data collection .
the inclusion criteria were ( 1 ) age between 45 and 75 years ; ( 2 )
hemiparesis due to ischemic or hemorrhagic stroke 1 month or longer before enrolment .
patients having cognitive impairment , dementia , or an acute brain lesion that caused
consciousness problems were excluded .
ue physical function and symptoms were assessed using the short form of the disabilities of
the arm , shoulder and hand score ( qdash ) , upper extremity functional index ( uefi ) , and
simple shoulder test ( sst ) .
measurement of pain at activity , at rest and at night , was done
using the visual analog scale ( vas ) . a semmes - weinstein monofilament examination ( swme )
gilroy , ca , usa ) was performed
for light touch sensory assessment at four palmar areas .
the qdash outcome measure is a self - report questionnaire designed to measure physical
function and symptoms of the ue during that week the test was done15 .
uefi is a self - report questionnaire that consists of 20
items rated on a 5-point likert scale .
the purpose of the questionnaire is to evaluate ue
functional status in a variety of activities .
total scores ranges from 0 ( lowest functional
status ) to 80 ( highest functional status)16 .
the sst comprises of a series of 12 yes or no questions that
the patient answers about the function of the involved shoulder ( unaffected side of
hemiplegic , and dominant side of healthy subjects ) .
it is important that the patient answer
these questions without assistance : it is the patient s own evaluation of his or her
shoulder function that is required17 .
the
vas is a one - dimensional measure of pain intensity . using a ruler , the score is determined
by measuring the distance ( mm ) on a 10-cm line between the no pain anchor and patient s
mark , providing a range of scores from 0100 .
the swme is a noninvasive , low - cost , examination that provides
rapid results ; it is often used in clinical testing .
the monofilaments are applied
perpendicular to the test site until they bend , for about 1 s. in our study , we started with
the 2.83 mm filament .
if there was no response to the first application , a maximum of 3
attempts was performed , which is the recommended procedure to ensure that 1 of 3 stimuli is
the intended threshold . if the filament was not sensed by the participant , a thicker
filament was used , and if the filament was sensed , a thinner filament was used .
testing points were distributed in 4 areas in the following order : the thenar
area , thumb s palmar surface , third finger s palmar surface , and hypothenar area20,21,22 .
the patients descriptive variables , including age , gender , body mass index , duration of
stroke , and affected side were recorded .
the variables are presented as the mean standard deviation ( x sd ) . the
differences between groups were tested using the mann - whitney u test .
a 95% level of
confidence ( =0.05 , or the margin of error ) was assumed to identify the differences in the
variance analysis .
demographic properties of subjects are shown in table
1table 1.demographic properties of subjectshemiplegic groupx sdcontrol groupx sdage ( years)63.6 13.259.2 7.1height ( cm)166.8 8.9164.2 7.1weight ( kg)76.4 15.277.0 10.5bmi ( kg / m)27.5 4.728.5 3.4duration of the disease ( days)min 30max 2,100_bmi : body mass index .
a statistically significant difference was found in qdash , uefi , and sst
scores between groups ( p<0.001 ) ( table
2table 2.comparing test results of the groupshemiplegic groupx sdcontrol groupx sdqdash41.47 22.92 * 9.89 9.21*uefi39.90 21.93 * 72.50 10.02*sst7.55 2.06 * 9.50 1.10*vas rest1.41 1.98**0.27 0.69**vas night0.66 1.440.77 1.69vas activity1.91 2.811.01 1.55semmes weinstein monofilament test 1st area2.30 0.972.55 0.88semmes weinstein monofilament test 2nd area2.15 1.031.90 0.78semmes weinstein monofilament test 3rd area2.10 0.961.95 0.88semmes weinstein monofilament test 4th area2.10 1.252.40 0.82*p<0.001 , * * p<0.05 .
qdash : short form of the disabilities of the arm , shoulder
and hand score , uefi : upper extremity functional index , sst : simple shoulder test ,
vas : visual analogue scale ) .
pain severity at rest was significantly higher in the hemiparetic group
( p=0.046 ) .
there was no significant difference in the nighttime ( p=0.973 ) and daytime
activity ( p=0.759 ) pain severities between groups ( table 2 ) .
there was no difference in the tactile sensation levels between groups
( p>0.05 ) ( table 2 ) .
qdash : short form of the disabilities of the arm , shoulder
and hand score , uefi : upper extremity functional index , sst : simple shoulder test ,
vas : visual analogue scale
because the unaffected ue of a patient plays an important role in their daily life , if the
unaffected side were in fact affected , the patient s quality of life would decline .
according to our study ,
the unaffected side of patients with hemiparesis , when compared with
healthy people , is different in terms of functionality and pain at rest .
desrosiers et al.11 compared the
sensorimotor performance of the unaffected ue of elderly patients with stroke with that of
healthy elderly people and found significant deficits in the unaffected ue of the
hemiplegic / paretic group in gross manual dexterity , fine manual dexterity , motor
coordination , global performance , and kinesthesia parameters .
zhang et al.23 revealed that the finger - tapping frequency
of the unaffected hand of patients with central nervous system injury was different compared
to those with peripheral nerve injury and dominant hands of healthy individuals .
moreover ,
in children with hemiplegic cerebral palsy , feng et al.24 found that the unaffected side may not be completely unaffected
because in the full - body gait analysis , the energy recovery factor was lower when both the
affected and the unaffected leg trailed than in typically developing children .
the
disability of the ipsilateral limb is often hidden by hemiplegia in the opposite limb and
sensation disorders , neither of which can be measured in a conventional clinical
examination .
moreover , the ipsilateral cerebral hemisphere affects the ipsilateral limb
function . with respect to neuroanatomy ,
80% of nerves on one side of the precentral gyrusin
the cerebral cortex cross over to the other side and control the opposite limb , whereas the
left uncrossing nerves are situated directly in the anterior corticospinal tract to control
the ipsilateral limb . as a result , the ipsilateral cerebral hemisphere has an effect on the
ipsilateral limb function .
in addition , when one side of the cerebral hemisphere is damaged
by stroke , the patients ipsilateral ue and hand function might also be influenced because
of the existence of the uncrossed nerve fibers25 . in patients with hemiparesis ,
furthermore , family members always want to do everything for patients , and their direct help
deprives the patients of the opportunity and desire to participate in daily activities26 .
we found no sensory reduction in the unaffected ipsilateral side in our study subjects .
sherwood noted that there were only few sensory neuron fibers following the ipsilateral
cerebral cortex27 .
no study has
investigated the pain on the unaffected side of patients with stroke . in our study , pain
severity at rest was significantly higher in the hemiparetic group . however , there was no
difference in pain during activity and at night between the groups .
this result supports the
finding that there was no sensory difference between the groups in our study .
the pain at
rest may be the result of decreased function of unaffected side .
the findings of this study reinforce the need , as revealed by other researchers , to not
consider the ipsilateral ue as
kitsos et al.30 conducted a literature review on the sensory - motor
deficits in the ipsilesional ue after stroke and recommended the use of the terms most
affected for the contralesional ue and less affected for the ipsilateral ue .
when people suffer from stroke , they often ignore the movement disability of hemiparalysis
and rehabilitation of the normal ue , and therefore , can not obtain an accurate and
comprehensive assessment and treatment .
however , it is noteworthy that it is erroneous to
equate the patients unaffected side with a healthy person s normal side
. therefore ,
rehabilitation therapists should intensify the functional activities of the normal ue .
the
limitations of this study are small sample size and not including the lower extremities .
further studies are needed to investigate the unaffected ue of patients with hemiparesis ,
with a larger sample size , using various evaluation tests , and to explore the unaffected
lower extremities .
in addition , a more sensitive tool may be required in further studies to
detect the sensory dysfunction in the unaffected side of patients with stroke . | [ purpose ] the aim of this study was to compare the unaffected upper extremity of patients
with hemiparesis with that of healthy subjects in terms of function , pain , and tactile
sense . [ subjects and methods ] upper extremity evaluation parameters of 20 patients with
hemiparesis were compared with an age - matched control group of 20 healthy subjects .
a
shorter version of the disability of arm and shoulder questionnaire , upper extremity
functional index , and simple shoulder test were used to evaluate the upper extremity
functionality .
the visual analog scale was used to measure pain severity at rest , at
night , and during activity .
tactile sensation levels were assessed by semmes - weinstein
monofilaments at four palmar areas .
[ results ] a statistically significant difference was
found in the upper extremity functionality between the groups .
pain severity at rest was
significantly higher in the hemiparetic group .
there was no significant difference in
night and activity pain severities or tactile sensation levels between the groups .
[ conclusion ] according to our results , the unaffected side of patients with hemiparesis
differs in functionality and pain at rest compared with that of healthy persons .
studies
with larger sample size and various evaluation tests are needed to further investigate the
unaffected side of patients with hemiparesis . |
because of the aging population , the number of patients with age - associated joint disorders
has been increasing in japan .
these disorders are a major factor in the reduction of the
activities in the daily lives of the middle - aged .
in particular , the number of patients with
knee osteoarthritis ( oa ) has been rapidly increasing in recent years . for progressive knee
oa , surgical methods such as arthroscopic surgery , osteotomy , or total
knee arthroplasty are commonly used .
early - stage knee oa is treated mainly by oral
administration or topical application of non - steroidal anti - inflammatory drugs ( nsaids ) ,
intra - articular administration of drugs such as hyaluronic acid , physical therapy such as
heat treatment , orthosis therapy such as use of a foot plate or knee orthosis , or exercise
therapy such as muscle strength training1 .
superficial heat treatment is one of the most widely used physical therapies , and moist heat
is considered to be more effective than dry heat , because heat is transferred to deep areas
of the body , which promotes blood circulation2,3,4 and
pain relief5 , 6 .
recent in vitro studies have revealed the influences of heat
treatment on the metabolism of cartilage matrix components such as proteoglycans and
collagen7 , 8 .
we evaluated the effects of local heat treatment and exercise therapy for knee oa on knee
joint symptoms and qualitative clinical changes in cartilage , as well as by magnetic
resonance imaging ( mri ) t2 mapping , which allowed quantitative assessment of articular
cartilage , collagen fiber arrangement , and the water content in the cartilage9 .
irregularity in the collagen fiber
arrangement and an increase in the water content may develop with cartilage degeneration .
is generally prolonged in the early - stage of cartilage degeneration , therefore
we evaluated the changes in t2 as a measure of quantitative changes in cartilage .
this study received ethical approval from juntendo university hospital review board , and
the subjects provided their written informed consent . the subjects were 22 females aged
5069 ( 59.5 5.8 years , mean sd ) years diagnosed as having early - stage knee oa .
the 22
subjects were randomly assigned using computer - generated random numbers to either a local
heat treatment group ( lh group , 11 subjects ) , or an exercise therapy group ( ex group , 11
subjects ) . these study groups were examined in a 12-week intervention experiment .
standing
antero - posterior plain x - ray images were obtained of all patients , and the severity of knee
oa was evaluated according to the kellgren
subjects in the ex group performed 2 sets of straight leg raises , abductor training , and
adductor training ( 20 repetitions per set ) in the morning and evening every day . in the lh group , heat- and steam - generating sheets ( kao corporation , tokyo , japan )
these sheets generate heat and steam by reacting with oxygen in
the air , and can maintain the skin temperature at 40 c for 8 h. the sheets were applied
continuously for 6 h every day , except during sleep .
two sheets were applied to the patella
on the left and right sides ( total heating area using 2 sheets = 96 cm ) , and a
thin flexible supporter was applied to prevent their movement .
1 . schema for the application of heat- and steam - generating sheets on the knee .
schema for the application of heat- and steam - generating sheets on the knee for clinical evaluation , the japanese knee osteoarthritis measure ( jkom)11 and the timed up and go ( tug ) test were
performed .
the tug test measures the time taken by a subject to rise from a chair with arm
rests , walk 3 m , turn , walk back to the chair , and sit down again . following the original
method of mathias et al.12
, measurements
were performed twice at a comfortable walking speed , and the shorter time was used for
analysis . for cartilage imaging ,
mri was
performed on the side with knee pain ( heat application side ) , and the t2 values of before
and after the intervention were compared . for t2 mapping ,
coronal images passing through the center of the weight - bearing area were
obtained using a 3.0 t mri system ( siemens , erlangen ) . for t2
measurement , imaging was
performed using the multi - spin - echo method under the following conditions : tr , 1,800 ms ; te ,
1080 ms ; fov , 150 150 mm ; section thickness , 3.0 mm ; matrix , 384 384 , bandwidth 241
khz . regions of interest involving the full thickness of the cartilage were located in the
medial and lateral condyles of the femur and those of the tibia , and the mean values were
obtained . to standardize the procedure ,
both clinical and mri evaluations were performed at the beginning and the end of the
intervention ( 0 week ( time 0 ) and 12 weeks ) . for statistical analysis ,
differences between
measures taken before and after the intervention were evaluated using the paired t - test in
each group ; p < 0.05 was regarded as significant .
a total of 18 patients ( 9 in the lh group , 9 in the ex group ) participated in the entire
study .
reasons for dropping out of the other subjects in the study were : admission to a
hospital due to another disorder for 1 patient , dizziness during exercise therapy for 1 ,
change of address for 1 , and redness in areas other than the heat- and steam - generating
sheet application area for 1 .
there was no significant difference in age , bmi , or kl - grade
between the lh and ex groups ( table 1table 1 .
baseline characteristics of the subjectsexercise therapy grouplocal heat treatment groupnumber of patients9 10 gender ( male / female)0/90/9age*(years , meansd ) 59.46.058.35.7bmi*(kg / m , meansd)22.03.023.53.2kellgren - laurence gradei : 2 , ii : 6 , iii : 1i : 1 , ii : 8there was no significant difference with regard to age or bmi between the patient
groups .
there was no significant difference with regard to age or bmi between the patient
groups .
* at the time of mr imaging the total jkom score was 16.4 10.5 ( mean sd ) at time 0 and 7.8 4.5 ( mean sd ) at 12
weeks in the lh group , a significant decrease ( p < 0.05 ) . in the ex group ,
the total jkom
score was 13.3 6.8 ( mean sd ) at time 0 and 9.6 9.1 ( mean sd ) at 12 weeks , without
significant difference ( table 2table 2 .
total jkom score of each group at time 0 and 12 weekstime 012 weeksexercise therapy group(points , meansd)13.36.89.69.1local heat treatment group(points , meansd)16.410.67.84.5**p<0.05 ) .
the tug time in the ex group was 9.2 1.4 s ( mean sd ) at time 0 and 7.7 1.2 s ( mean
sd ) at 12 weeks , a significant decrease ( p < 0.05 ) . in the lh group , the tug time was 8.8
2.0 s ( mean sd ) at time 0 and 8.1 1.3 s ( mean sd ) at 12 weeks . although no
significant change was observed in this group , the tug time decreased in 7 of the 9 patients
showing a tendency of improvement ( table
3table 3 . timed up & go test of each group at time 0 and 12 weekstime 012 weeksexercise therapy group(sec , meansd)9.21.47.71.2*local heat treatment group(sec , meansd)8.82.18.11.3*p<0.05 ) .
the t2 value in the lh group was 32.5 2.4 ( mean sd ) at time 0 and 31.4 2.6 ( mean
sd ) at 12 weeks , a significant decrease ( p < 0.05 ) . in the ex group ,
the t2 value was
30.7 3.6 ( mean sd ) at time 0 and 30.4 2.7 ( mean sd ) at 12 weeks , without significant
change ( table 4table 4 .
t2 value of cartilage in each group at time 0 and 12 weekstime 012 weeksexercise therapy group(msec , meansd)30.73.630.42.7local heat treatment group(msec , meansd)32.52.431.42.6**p<0.05 ) .
a previous study using superficial dry heating sheets that use an iron powder to produce an
oxidation reaction , which is also used in the heat- and steam - generating sheets , showed an
increase in the human intracapsular temperature to 3637 c , which was about 4 c higher
than the intracapsular temperature under the control condition without heat treatment13 . in addition , superficial heat treatment
for 10 min using paraffin was reported to increase the intracapsular temperature to at least
37 c14 .
the significant decrease in
the jkom score , i.e. , significant improvement in oa symptoms and activities of daily living
after heat treatment in the present study , may have been partly due to promotion of blood
circulation15 , 16 .
it is known that decreased blood circulation in tissue is
associated with the development of pain17 , 18 .
an association between decreased blood
flow and knee pain has been reported19 , 20 .
long - term local heat treatment using
heat- and steam - generating sheets may have improved blood flow in periarticular tissue ,
resulting in pain relief in the knee in daily life . in addition
, the effects of local heat
treatment include an increase in collagen fiber extensibility21 , analgesic effects due to an increase in the pain threshold22 , and effects on muscle metabolism23 , 24 . in this study
, local heat treatment may have exerted complex effects
on periarticular tissue , and contributed to the improvement in the symptoms of knee oa and
activities of daily living .
an improvement in jkom scores after exercise treatment has
previously been reported25 . in this
study ,
the total jkom score in the ex group was lower at 12 weeks than that at time 0 , but
the change was not significant .
as a relatively small number of subjects participated in
this study , further studies are necessary to determine whether exercise treatment solely
improves the total jkom score . the tug time was significantly shortened in the ex group
this may have been because
exercise , which strengthens walking - associated muscles and widens the range of joint
motions , contributed to improvements in walking abilities in this study . in the lh group ,
the tug time did not significantly change , but in 7 of the 9 patients showed decreased
times , and the improvement rate was similar to that in the ex group . in recent years ,
thermal stimulation alone or in combination with mild exercise has been reported to increase
the muscle mass and strength in humans and rats24 ,
26 , 27 .
on the basis of the jkom and tug test results of the present
study , we consider there is a possibility that exercise therapy used in combination with
local heat treatment further improves exercise function because of improvement in pain
symptoms and muscle reinforcement .
. concerning the effects of heat treatment on articular cartilage , in vitro studies have
revealed that an increase in the cartilage temperature ( 37c ) promotes proteoglycan
production as a cartilage matrix component28 , 29 .
this has not been studied in vivo , but
the effects of heat treatment associated with increased cartilage temperature , and the
effects on cartilage metabolism due to promotion of blood circulation in the surrounding
tissues have been considered30 . in this
study , a significant shortening of the t2 value in the lh group , i.e. , after heat treatment
using heat- and steam - generating sheets , was detected . several possible reasons for this t2
shortening can be considered , including not only the direct effects of heat treatment on
cartilage metabolism , but also a decrease in the water content of cartilage .
water content
changes possibly result from increased weight - bearing resulting from an improved walking
ability , associated with ameliorated knee joint symptoms .
further studies are necessary to
determine whether t2 changes occur in cartilage after heat treatment , and whether such
changes represent improvement in cartilage degeneration . in this study ,
the subjects were patients with early - stage oa primarily exhibiting kl i - ii ,
a good indication for conservative therapy .
therefore , further studies are necessary to
evaluate the clinical effects of heat treatment for patients with advanced knee oa or severe
symptoms .
in addition , for patients with advanced articular cartilage degeneration or
thinning , it is possible that irreversible degeneration is present in the cartilage matrix .
whether heat treatment affects cartilage metabolism even in such patients should be
determined by further evaluation . in conclusion , after treatment with heat- and steam - generating sheets for 12 weeks ,
improvements in clinical symptoms and walking abilities were observed . | [ purpose ] superficial heat treatment is one of the most widely used physical therapies
for osteoarthritis ( oa ) . we clinically evaluated the effects of local heat treatment and
exercise therapy for knee oa , and evaluated the articular cartilage using magnetic
resonance imaging ( mri ) t2 mapping . [
subjects and methods ] eighteen females aged 5069
( 59.5 8.5 years , mean sd ) years diagnosed with early - stage knee oa were randomly
assigned using computer - generated random numbers to either a local heat treatment group
( lh group , 9 subjects ) or an exercise therapy group ( ex group , 9 subjects ) .
these groups
were subjected to a 12-week intervention experiment .
mri t2 mapping was performed for
cartilage imaging and quantitative evaluation . for clinical evaluation ,
the japanese knee
osteoarthritis measure ( jkom ) and the timed up and go ( tug ) test were performed .
both
clinical and mri evaluations were performed at the beginning and end of the intervention
( 0 week ( time 0 ) and 12 weeks ) . [ results ]
the total jkom score had a significantly
decreased in the lh group at 12 weeks .
however , in the ex group the total jkom scores at
time 0 and 12 weeks were not significantly different .
the tug time in the ex group was
significant shorter at 12 weeks , whereas it showed no significant change in the lh group
at 12 weeks , though the tug times of 7 of the 9 patients decreased , exhibiting some
improvement . the t2 value of the lh group was significantly shorter at 12 weeks .
however ,
the t2 value in the ex group showed no significant change at 12 weeks .
[ conclusion ] after
local heat treatment using heat- and steam moisture - generating sheets for 12 weeks , we
observed improvements in clinical symptoms and walking abilities .
moreover , positive
effects on cartilage metabolism were suggested . |
we evaluated the performance of surveillance case definitions for zika virus disease recommended by the cste , who , paho , ecdc , and the singapore moh by using a cohort of 359 adult patients with suspected zika virus disease who came to the institute of infectious diseases and epidemiology , tan tock seng hospital , singapore , the national referral center for zika virus disease during the containment phase of the zika virus outbreak during august 26 september 5 , 2016 .
all adults living or working in the outbreak area who were sick and had symptoms that partially or fully met the moh definition were screened for zika virus disease . at their first visit to the hospital , all patients had their signs and symptoms documented , and blood and urine samples were obtained for detection of zika virus nucleic acids by reverse transcription pcr ( rt - pcr ) ( 15 ) .
parallel testing in the hospital laboratory and at the national public health laboratory ( singapore ) was conducted to maximize sensitivity and negative predictive values to rule out zika virus infection .
a total of 42.0% of the cohort had zika virus infection confirmed in blood ( 4% ) , urine ( 36% ) , or both ( 60% ) samples ( table 1 ) .
most ( 80% ) infected and noninfected patients were tested < 5 days after illness onset ( infected patients , mean 3.6 days ; noninfected patients , mean 4.6 days ) . infected and noninfected patients were similar in age and sex .
infected patients , rash ( 93.3% ) was the most common symptom , followed by fever ( 79.2% ) and myalgia ( 42.3% ) .
headache , arthralgia , and conjunctivitis were reported in < 25% patients with zika virus disease .
for patients not infected with zika virus , fever ( 86.2% ) was the most common symptom , followed by myalgia ( 59.1% ) and rash ( 44.8% ) .
ecdc , european centre for disease prevention and control ; paho , pan american health organization .
definition used in the united states ( interim , february 2016 ; confirmed , june 2016 ) states that clinical criteria for noncongenital zika virus disease are defined as > 1 of the following : acute onset of fever , maculopapular rash , arthralgia , and conjunctivitis .
interim case definition ( february 12 , 2016 ) includes rash or fever and > 1 of the following signs or symptoms : arthralgia or arthritis , or conjunctivitis ( nonpurulent / hyperemic ) .
interim case definition ( april 1 , 2016 ) includes rash with > 2 of the following signs or symptoms : fever , conjunctivitis ( nonpurulent / hyperemic ) , arthralgia , myalgia , or periarticular edema . # interim case definition ( march 17 , 2016 ) includes rash with or without fever and > 1 of the following signs or symptoms : arthralgia , myalgia , or conjunctivitis ( nonpurulent / hyperemic ) . *
* case definition ( august 2016 ) includes fever and rash and > 1 of the following symptoms : headache , myalgia , arthralgia , or nonpurulent conjunctivitis .
the case definition recommended by cste for use in the united states ( us definition ) had a sensitivity of 100% and a specificity of 2% in detecting zika virus in the cohort ( table 2 ) .
the singapore moh case definition had a sensitivity of 54% and a high specificity of 76% , and performed well in diagnosing zika virus disease ( positive likelihood ratio [ lr+ ] 2.2 , 95% ci 1.73.0 ) .
the performances of paho ( lr+ 2.1 , 95% ci 1.52.8 ) and ecdc ( lr+ 2.1 , 95 % ci 1.62.8 ) case definitions were similar .
* ecdc , european centre for disease prevention and control ; lr , likelihood ratio ; moh , ministry of health ; npv , negative predictive value ; paho , pan american health organization ; ppv , positive predictive value ; who , world health organization ; + , positive ; , negative .
despite increasing incidence of zika virus disease and its spread across the americas and asia , there is no internationally adopted common clinical criteria for the surveillance of this disease .
we report a large outbreak cohort of patients with suspected zika virus infection and comprehensive documentation of clinical symptoms and parallel rt - pcr conducted on blood and urine samples for these patients by 2 laboratories .
evaluation of the performance of surveillance case definitions in such a cohort would provide useful findings that would contribute to development of guidance for zika virus disease surveillance .
diagnosis of zika virus disease remains suboptimal because of limited availability of confirmatory testing by rt - pcr during acute illness and cross - reactivity of serologic tests for zika virus with other co - circulating flaviviruses ( 3,4 ) .
thus , a good discriminatory clinical criteria for disease surveillance is crucial for prevention and control of zika virus transmission .
the us case definition would identify all zika virus infections and be useful for prevention of autochthonous transmission by imported cases .
however , because this definition is not specific , considerable resources would be required for confirmatory testing of identified cases .
for zika virus disease surveillance in the absence of commercially available diagnostic laboratory tests , case definitions incorporating rash as a required clinical criteria , such as the paho , ecdc , and singapore moh case definitions , would be useful ( lr+ > 2 ) , although 50% ( range 44%51% ) of cases of zika virus disease could be missed .
however , the small number of children infected with zika virus during the containment phase of the outbreak in singapore had symptoms similar to those for adults ( a. chow et al .
some zika virus infections could have been misclassified as noninfections because rt - pcr could have missed infections late in the illness course or after development of antibodies against zika virus . in conclusion , we evaluated the performance of 5 case definitions for zika virus disease surveillance . in the current effort to halt transmission of this virus worldwide , and with laboratory tests being largely inaccessible , use of surveillance case definitions that include rash as a required clinical criteria would provide a high yield in identifying zika virus disease . | we evaluated performance of 5 case definitions for zika virus disease surveillance in a human cohort during an outbreak in singapore , august 26september 5 , 2016 . because laboratory tests are largely inaccessible , use of case definitions that include rash as a required clinical feature are useful in identifying this disease . |
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