Platanista gangetica (the Ganges and Indus river dolphin), is the sole surviving member of the broader group Platanistoidea, with many fossil relatives that range from Oligocene to Miocene in age. Curiously, the highly threatened Platanista is restricted today to freshwater river systems of South Asia, yet nearly all fossil platanistoids are known globally from marine rocks, suggesting a marine ancestry for this group. In recent years, studies on the phylogenetic relationships in Platanistoidea have reached a general consensus about the membership of different sub-clades and putative extinct groups, although the position of some platanistoid groups  has been contested. Here we describe a new genus and species of fossil platanistoid, Arktocara yakataga, gen. et sp. nov. from the Oligocene of Alaska, USA. The type and only known specimen was collected from the marine Poul Creek Formation, a unit known to include Oligocene strata, exposed in the Yakutat City and Borough of Southeast Alaska. In our phylogenetic analysis of stem and node-based Platanistoidea, Arktocara falls within the node-based sub-clade Allodelphinidae as the sister taxon to Allodelphis pratti. With a geochronologic age between ∼29–24 million years old, Arktocara is among the oldest crown Odontoceti, reinforcing the long-standing view that the diversification for crown lineages must have occurred no later than the early Oligocene.The diversification of crown cetacean lineages  occurred throughout the Oligocene, but it remains an ongoing challenge to resolve the phylogenetic pattern of their origins, especially with respect to stem lineages. One extant monotypic lineage,  Multiple lines of evidence point to the Oligocene epoch as an important period for the origin and early evolutionary history of crown group Cetacea . This inPlatanista gangetica . The inclusion of Squalodontidae and Waipatiidae in Platanistoidea, as suggested by Currently, phylogenetic studies of Platanistoidea have reached a general consensus about the inclusion three groups (two of which are completely extinct): Allodelphinidae, Squalodelphinidae and Platanistidae , it is both the oldest allodelphinid and among the oldest crown Odontoceti known. The results of our phylogenetic analysis continue to support a monophyletic Platanistoidea, along with traditional sub-clades (including a monophyletic Allodelphinidae), which underscores the importance of Oligocene cetaceans in documenting the early diversification of crown Cetacea.Here we describe t Alaska –6. ArktoArktocara yakataga was scanned using Nikon Metrology’s combined 225/450 kV microfocus X-ray and computed tomography (CT) walk-in vault system at Chesapeake Testing in Belcamp, Maryland, USA. Using this vault CT scanner system, we collected CT slices at 0.63 mm, resulting in three-dimensional reconstruction increments of 0.30 mm. We mounted the holotype skull vertically in the vault CT scanner system, with the posterior side down to minimize scanning width. Also, we collected CT scan data for the right periotic (YPM 13408) of Allodelphis prattiArktocara cranium that will be available for viewing and download on the Smithsonian X 3D website (http://3d.si.edu). These 3D files, along with the original DICOM files, are also archived at Zenodo (http://zenodo.org) at the following DOI: 10.5281/zenodo.51363. While the CT data were useful for making 3D models of the holotype, the density of the fossil material prevented the CT scanner from clearly determining internal morphology of the skull, failing to clarify indistinct sutures between skull elements.The holotype of Arktocara yakataga using Notocetus vanbenedeniPhocageneus venustusSqualodon calvertensisWaipatia maerewhenuaZarhachis flagellatorPlatanista gangetica. The stem cetacean taxon Georgiacetus vogtlensis was used as the outgroup. We removed an undescribed specimen (OU 22125), and added 4 allodelphinid taxa (Zarhinocetus errabundus (Goedertius oregonensisAllodelphis pratti and Arktocara yakataga), raising the number of OTUs used in the analysis to 86. We also added codings for four periotic characters (288–291) for Pomatodelphis inaequalisZarhachis flagellator, based on material available at the Smithsonian Institution (see ‘Specimens observed’). We did not add codings for taxa that we could not directly observe, and therefore some platanistoid taxa were excluded from the analysis, including Huaridelphis raimondiiNinjadelphis ujiharaiAllodelphis woodburneiWe tested the phylogenetic placement of rabundus  GoedertiWe performed a cladistic search in TNT*  using all characters as unordered and equally weighted. We then conducted subsequent statistical support analyses by searching for successively longer trees to calculate bremer decay indices and 100 bootstrap replicates. The complete matrix in .txt format, as well as a description of character states  are avaiFollowing http://zoobank.org/”. The LSID for this publication is: urn:lsid:zoobank.org:pub:0194A593-DBE0-47CA-A41F-04A37931BA2F. The electronic edition of this work was published in a journal with an ISSN, and has been archived and is available from the following digital repositories: PubMed Central, and LOCKSS.The electronic edition of this article conforms to the requirements of the amended International Code of Zoological Nomenclature, and hence the new names contained herein are available under that Code from the electronic edition of this article. This published work and the nomenclatural acts it contains have been registered in ZooBank, the online registration system for the ICZN. The ZooBank LSIDs (Life Science Identifiers) can be resolved and the associated information viewed through any standard web browser by appending the LSID to the prefix “Allodelphis pratti (YPM 13408); Allodelphis sp. ; Goedertius oregonensis (LACM 123887); Goedertius sp. ; Notocetus sp. (USNM 206286); Phocageneus venustus ; Phocageneus sp. ; Platanista gangetica (USNM 23456); Pomatodelphis bobengiPomatodelphis sp. (USNM 360054); Squalodon calvertensis ; cast of Waipatia maerewhenua (USNM 508061); Zarhachis flagellator ; Zarhachis sp. ; cast of Zarhinocetus errabundus (USNM 526600); Zarhinocetus errabundus .Definitions. Crown group Platanista refers to the crown clade arising from the last common ancestor of all lineages descending from Platanista, including two subspecies of Platanista gangetica  because these familial level groupings are not the explicit focus of this study, and we defer to future work that can better substantiate their taxonomic scope and better test their monophyly  was discovered and collected in 1951 by United States Geological Survey (USGS) geologist Donald J. Miller (1919–1961), who was mapping what was then the Yakataga District of Alaska (now the Yakutat City and Borough) between 1944 and 1963. Archival notes housed with the specimen at USNM state that Miller found the specimen in the Poul Creek Formation within the then-Yakataga District . Therefore, we delimit the area for the type’s provenance to exposures of the Poul Creek Formation in the Yakutat City and Borough, Alaska, USA, in a grid ranging approximately from 60°22′N, 142°30′W to 60°00′N, 143°22′W , which belongs, based on one equivocal synapomorphy, to the node-based Platanistoidea: width: width of the premaxillae >50% of the width of the rostrum at the antorbital notch (character 51[1]). More convincingly, Arktocara belongs to Platanistoidea based on its affinities to other members of the Allodelphinidae that possess unequivocal synapomorphies of the Platanistoidea (see ‘Discussion’ for further comments on the relationship of Allodelphinidae within the Platanistoidea). We also note that, for the purposes of this diagnosis, we use a broad definition of Waipatiidae that includes Otekaikea spp. ; an occipital shield bearing a distinct sagittal crest (character 118[1]); length of the zygomatic process as percent of the greatest width of the maxillae across the postorbital processes <30% (character 152[1]); lacking a dorsal condyloid fossa (character 119[0]); and lacking any asymmetry in the vertex (character 98[0]).Arktocara also differs from Waipatiidae and Platanistidae in having: frontals posterior to the nasals and between the premaxillae wider than the maximum transverse width across the nasals (character 95[0]); and lacking an anterior transverse ridge and large tympanosquamosal recess, with middle sinus still inferred to be present (character 144[1]). Arktocara further differs from Waipatiidae in having: a lacrimal that wraps around the anterior edge of the supraorbital process of frontal and slightly overlies its anterior end (character 37[0]); maxilla forming the dorsolateral edge of the internal opening of the infraorbital foramen (character 43[0]); ventromedial edge of the internal opening of infraorbital foramen formed by maxilla and palatine (character 44[1]); a nuchal crest weakly convex anteriorly in dorsoposterior view (character 117[1]); a lateral end of the groove for the mandibular branch of the trigeminal nerve wrapping laterally around posterior end of pterygoid sinus fossa and opening primarily anteriorly (character 148[0]); the angle formed by the basioccipital crests in ventral view between 15–40° (character 157[1]); and in lacking a premaxillary crest or posterior maxillary crest adjacent to the nasal (character 72[0]).Arktocara differs from all Platanistidae and Squalodelphinidae in having the anterolateral corner of the maxilla overlying the supraorbital process of frontal being thin and of even thickness to parts posteromedial (character 64[0]). Arktocara also differs from all Platanistidae in having: the apex of the postorbital process of frontal projected posterolaterally and slightly ventrally (character 46[0]); the ratio of the greatest width of the premaxillae to the greatest width of maxillae at the level of postorbital processes between 0.49–0.38 (character 76[1]); a shallow emargination of the posterior edge of zygomatic process by the sternomastoid muscle fossa in lateral view (character 111[1]); the width of the squamosal lateral to the exoccipital in posterior view as a percent of the greatest width of the exoccipitals <15% (character 112[0]); fossae for the preorbital lobe of the pterygoid sinus present in the orbit (character 134[1]); shallow posterior portion of the periotic fossa of the squamosal (character 151[1]); posteroventral-most point on the basioccipital crest forming a closely appressed flange with a narrow crease separating exoccipital dorsally from the rest of crest (character 156[1]); and lacking a pneumatic maxillary crest overhanging medially (character 65[0]). Finally, Arktocara differs from all Squalodelphinidae in having: a narrower width of the premaxillae at the antorbital notches as a percent width of the rostrum at the antorbital notch (50–64%) (character 51[1]).Arktocara differs from all other Allodelphinidae in having: a reduced postglenoid process of the squamosal (character 114[1]); and the posteroventral-most point of the basioccipital crest forming a closely appressed flange separating the exoccipital dorsally from the rest of the crest by a narrow crease (character 156[1]). Arktocara differs from Allodelphis pratti and Goedertius oregonensis in having: both premaxillae extending posterior to the nasals (character 58[1]); and the ratio of the greatest width of the premaxillae to greatest width of the maxillae at the level of the postorbital processes between 0.49–0.38 (character 76[1]).Arktocara also differs from Goedertius oregonensis and Zarhinocetus errabundus in having: the width of the premaxillae between 50–64% of the width of the maxillae a the level of the antorbital notches (character 51[1]); a uniformly thin anterolateral corner of the maxilla overlying the supraorbital process of the frontal (character 64[0]); length of the zygomatic process of the squamosal ≤30% of the width of the maxillae at the postorbital processes (character 152[1]); lacking a rostral basin (character 50[0]), lacking a posterior dorsal infraorbital foramen placed posteromedially near the posterior extremity of the premaxilla (character 60[0]); lacking a dorsal condyloid fossa (character 119[0]) and having a symmetrical cranial vertex (character 98[0]).Arktocara also differs from Allodelphis pratti and Zarhinocetus errabundus in having: two anterior dorsal infraorbital foramina (character 49[1]); and a shallow emargination of the posterior edge of the zygomatic process by the sternomastoid muscle fossa in lateral view (character 111[1]). Arktocara further differs from Goedertius oregonensis having: a fused lacrimal and jugal (character 39[1]); the apex of the postorbital process of the frontal directed posterolaterally and slightly ventrally (character 46[0]); a triangular or anteroposteriorly widened falciform shaped postorbital process of the frontal (character 47[2]); one posterior dorsal infraorbital foramina of the maxilla (character 59[1]); nuchal crest weakly convex anteriorly in dorsoposterior view (character 117[1]); and the posterior edge of the vomer terminating on the basisphenoid (character 154[0]).Arktocara further differs from Zarhinocetus errabundus in having: the transverse width of the nasal >70% the length of the nasal (character 91[2]); a distinct sagittal crest on the occipital shield (character 118[1]); and in lacking an anterior transverse ridge and large tympanosquamosal recess (character 144[1]).Arktocara displays the following apomorphies: a weakly developed antorbital notch (character 10[0]); straight lateral margin of the right premaxilla posterior to premaxillary foramen (character 56[1]); a U-shaped nasal frontal suture (character 94[2]); and a greatly reduced postglenoid process of the squamosal (character 114[1]).Lastly, Etymology. The species epithet ‘yakataga’ derives from the Tlingit name for the point of land along the southeast coast of Alaska between modern day Kayak Island and Ice Bay. This point, currently called Cape Yakataga, is located directly southwest of Watson Peak and represents the southeastern boundary of a floodplain drained by the Bering Glacier. The name Yakataga was first published by Anatomical terminology follows Arktocara yakataga (USNM 214830) consists of an incomplete skull, measuring 23 cm in preserved length. The majority of the rostrum is missing, with an asymmetric transverse break approximately 2–5 cm anterior to the antorbital notch. The skull also lacks both nasals, jugals, tympanoperiotics, and the right occipital condyle  and deep , with a broadly open and deep mesorostral canal . While there is material missing around the antorbital notch, the posterior margin of the right antorbital notch appears to be real, demonstrating it to be weakly developed, forming an L-shape with the lateral margin of the rostrum . Though In ventral view, there is clearly a fossa for the preorbital lobe of the pterygoid sinus , as well as for the hamular lobe of the pterygoid sinus (fossa anterior to the choanae). Also present are an extremely shallow tympanosquamosal recess for the middle sinus, and a middle pterygoid sinus fossa anterior to the periotic fossa . There iBoth of the premaxillae are symmetrical, and overlie either the maxillae or the frontals for their entire preserved length . In lateOn the vertex, the posterior termination of the premaxilla lies on the frontal as an asymmetrical, spatulate lobe, tapering posterolaterally and bordered medially by frontal and the nasal fossa of the frontal, and laterally the maxilla . There iOnly a small portion of rostral maxilla remains, including part of the maxillary flange on the left side, and just over 5 cm of the body of this element on the right side. In anterior view, the maxilla preserved on the rostrum slopes dorsally from the lateral edge to the premaxillary suture . The preIn ventral view, the hard palate of maxilla curves dorsolaterally from the midline to the lateral edge, where it flattens out on the maxillary flange . No alveIn dorsal view, the frontals are mostly covered by the maxillae, with the exception of exposures on the postorbital processes and the vertex . The posThe frontal-maxillary suture is also indistinct along the lateral edge of the vertex, where the maxilla rises dorsomedially to the edge of the vertex’s tabular surface . The sutMost of the medial margin of the antorbital process is composed of the lacrimal. In dorsal view, a narrow margin of the lacrimal emerges from beneath the maxilla as a thin plate along the lateral and anterior edges of the antorbital process . In ventAllodelphis pratti . For further discussion of the lateral lamina of pterygoid as a platanistoid feature, see discussion in “Platanistoid systematics.”Platanistoids bear a bony structure on the ventral side of their skulls: a thin, bony lamina that extends from the ventral surface of the hard palate and runs parallel to the posterior lateral lamina of the pterygoid to finally attach to the alisphenoid medial of the squamosal in the ear region. The holotype of Both of the palatine bones are missing large portions, including the palatine surface, maxillary process, palatal crest, and lateral lamina. However, in ventral view a prominent pterygoid sinus fossa for the hamular lobe is formed by the palatine, anterior to the medial pterygoid lamina and posterior to the palatine groove of the maxilla . These gPlatanista and an undescribed platanistoid USNM 214911  was estimated using the formula created by n weight . It is lic necks . Though Arktocara, or whether it is more broadly observed in other allodelphinids . Also, the missing nasals and palatines suggest that their sutures to adjacent skeletal elements were unfused. We assessed skeletal maturity based on long-established osteological indicators, particularly the fusion of cranial sutures and textural surface of the occipital condyles . Most suArktocara is the sister taxon to Allodelphis, nested within a broader clade of Allodelphinidae, which includes Zarhinocetus and Goedertius. This is the first phylogenetic analysis to include these latter two genera, which were not included in Zarhinocetus and Allodelphis among their allodelphinid sample of Platanistoidea. Our analysis yields robust support for the monophyly of Allodelphinidae, with higher support values  than those recovered for the node-based clade of Platanistoidea  (sensuWaipatia and both species of Otekaikea—Otekaikea species from their definition of Waipatiidae. We recommend defining Waipatiidae more inclusively (both species of Waipatia and Otekaikea).The phylogenetic analysis resulted in 430 most parsimonious trees, all with a score of 1960, consistency index of 0.233 and retention index of 0.631. The strict consensus tree, which was created from the 430 trees, shows a similar topology to the equally weighted analysis of lue <50) . Like Ta0) sensu, yet in Though it is beyond the scope of this study, the incorporation of molecular data into future analyses of odontocete systematics will help to better resolve the relationships among extant cetaceans, and consequently their fossil relatives. See below for further comment on the implications of these results on the systematics of Platanistoidea.Inia, Pontoporia, and Lipotes were more closely related to Delphinoidea than to Platanista  and is slightly overlapped by the pterygoid (though not the maxilla) .Dalpiazina ombonii (Champsodelphis by Longhi (1898), was later reviewed by and given its new genus by  ombonii  . However, in their implied weighting strict consensus, Squalodon was added to Platanistoidea. Allodelphinidae was not included in their analysis. sensu stricto  based on 6 synapomorphies: presence of the posterior dorsal infraorbital foramina of the maxilla (character 59); C-shaped or weakly curved parabullary sulcus (character 169); presence of the articular rim on the periotic (character 186); presence of the anterior spine of the tympanic bulla (character 195); presence of the anterolateral convexity of the tympanic bulla with anterolateral notch (character 196); and presence of the ventral groove (median furrow) of bulla anteriorly (character 212). Arktocara.In contrast to  hectori , both OtGoedertius oregonensis, Ninjadelphis ujiharai, and Zarhinocetus donnamatsonaeIn a broad review of Allodelphinidae, Waipatia maerewhenua + Waipatia hectori + Otekaikea marplesi + Otekaikea huata), Allodelphinidae and a polyphyletic Squalodelphinidae. We note that, for Phocageneus venustus, we followed Waipatia and Otekaikea is consistent with Waipatia, differing from the results in Waipatia maerewhenua and Otekaikea marplesi. Our results are consistent with Squalodelphis fabianii as a basal member of Platanistoidea and an unnamed clade of Notocetus vanbenedeni + Phocageneus venustus as the sister group to Platanistidae. A more detailed coding of Squalodelphinidae in future work, especially one that includes Huaridelphis raimondii, will provide more insight into the relationships among this group.Our phylogenetic analysis herein addresses some of the shortfalls of previous studies by including type genera belonging to all potential platanistoid families that have been presented in recent phylogenetic analyses i.e., . We resoWe diagnose a node-based Platanistoidea by the following synapomorphies: moderately elevated coronoid process (character 33*); premaxillae >65% of width of rostrum at antorbital notches (character 51*); alisphenoidal-squamosal suture coursing along groove for mandibular branch of trigeminal nerve in ventral view (character 147[1]); lateral groove or depression with profile of periotic becoming slightly to markedly sigmoidal in dorsal view (character 166[1]); anteroposterior ridge on dorsal side anterior process and body of periotic (character 167[1]); parabullary sulcus on the periotic weakly to strongly curved and c-shaped ; and ventral surface of the posterior process of the periotic not flat along a straight path perpendicular to its long axis  Of these synapomorphies, the two marked by an asterisk (∗) are equivocal across the group, demonstrating character state reversals or independent origins . Two characters are ambiguous and show independent origins (characters 169 and character 191), but we argue remain useful for characterizing this group.Allodelphis pratti, where there is no distinguishable rim lateral to the posterior process and separated by a sulcus , the anterolateral convexity of the tympanic bulla with anterolateral notch (character 196), and the ventral groove (median furrow) of bulla anteriorly (character 212) are all ambiguous characters, represented by two states each across Platanistoidea. All of the latter traits are present in Allodelphis pratti and Zarhinocetus errabundus, with perhaps the exception of the ventral groove of the anterior surface of the bulla in Allodelphis pratti, which could not be determined from the photos of the referred specimen (UCMP 83791) provided by Only one of the six synapomorphies presented by a sulcus . In ZarhSqualodelphis fabianii and an unnamed sub-clade that includes Notocetus vanbenedeni + Phocageneus venustus + Platanistidae. Allodelphinidae in our study is supported by the following synapomorphies: rostral constriction anterior to the antorbital notch (character 9[1]); premaxillae in dorsal view contacting along midline for approximately half of the entire length of the rostrum and partially fused (character 14[3]); buccal teeth entocingulum absent (character 24[1]); greatest diameter of largest functional tooth <3% of greatest width of maxillae at postorbital processes (character 25[2]); angle of anterior edge of supraorbital process and the median line oriented anteromedially (character 35[1]); dorsolateral edge of internal opening of infraorbital foramen formed by maxilla (character 43[0]); posterolateral sulcus shallow or absent (character 57[1]); lack of premaxillary crest or posterior maxillary crest adjacent to nasals (character 72[0]); temporal fossa roofed over by lateral expansion of the maxillae (character 101[1]); palatines partially covered by pterygoid dividing it into medial and lateral exposures (character 121[1]); lateral lamina of palatine (character 122[1]); lateral end of groove for mandibular branch of trigeminal nerve wrapping laterally around posterior end of pterygoid sinus fossa and opening anteriorly (character 148[0]); lack of anterior bullar facet (character 172[1]); elevated caudal tympanic process of periotic with ventral and posterior edges forming a right angle in medial view (character 178[1]); tubular fundus of internal acoustic meatus (character 182[1]) angle between posterior process of periotic and long axis of pars cochlearis ≤135° from dorsal or ventral view (character 189[1]); and ventral surface of posterior process of periotic convex along a straight path perpendicular to its long axis (character 191[2]). Based on the published descriptions and illustrations provided by Allodelphis woodburnei, Ninjadelphis ujiharai, and Zarhinocetus donnamatsonae) each possess all of the allodelphinid synapomorphies presented by our analysis.Our analysis recovered Allodelphinidae as a well-supported sub-clade within a node-based Platanistoidea, rooted in a polytomy with Waipatia and Otekaikea where the palatine is poorly preserved or missing), and a tympanic bulla with elongated and pointed anterior process, among others. Nevertheless, our diagnosis is consistent with Allodelphis pratti where only one premaxilla is separated from the corresponding nasal by a tiny exposure of maxilla, to further “derived” states in Ninjadelphis and Zarhinocetus where the premaxillae are further retracted anteriorly onto the facial region and away from the nasals. However, it is unclear in the more “primitive” state of Allodelphis whether the lack of contact between the premaxilla and nasal could be a result of diagenetic breakage, or individual variation. Furthermore, speculations on the more “derived states” in taxa such as Ninjadelphis, are based on specimens with incomplete premaxillae. In Goedertius oregonensis, the premaxillae are not separated from the nasals. This condition is likely also true for Arktocara yakataga: although the nasals are missing, the premaxillae directly abut the nasal fossa of the frontal, and therefore would most likely have been in direct contact with the nasals. Further extensive comparative work on allodelphinid taxa  will heAllodelphis pratti, in part due to obstruction by unprepared matrix. However, in Arktocara yakataga, though there is no obvious indication of a postorbital lobe of the pterygoid sinus, the deep and broad fossa surrounding the ventral infraorbital foramen and the sphenopalatine foramen anteromedial of the orbit suggests the presence of a preorbital lobe.Second, Allodelphis pratti was referred to the Platanistidae by Ninjadelphis is the only allodelphinid specimen with an associated scapula, and it is missing the coracoid process. This agreement with Otekaikea huata), the character may still be relevant for diagnosing Platanistoidea . Though the type specimen of Arktocara lacks tympanoperiotics, it is closely allied with Allodelphis pratti, whose periotic shares three more of the platanistoid synapomorphies: presence of lateral groove or depression with the profile of the periotic becoming slightly to markedly sigmoidal in in dorsal view (character 166[1]); anteroposterior ridge developed on anterior process and body of periotic in dorsal view (character 167[1]); and a curved C-shaped parabullary sulcus . Therefore, in the absence of tympanoperiotics associated with new cranial material of Arktocara, we are confident that these elements would share many features with Allodelphis pratti, the sister taxon of Arktocara.Of the 7 supporting synapomorphies for Platanistoidea in our study, none of the unequivocal synapomorphies are preserved and demonstrated on the skull of Arktocara in morphology is Allodelphis pratti , (B) Platanista gangetica (USNM 23456) and (C) USNM 214911, an undescribed platanistoid. This feature (highlighted in red), is a pointed lamina projected anteromedially from the anterior margin of the falciform process (highlighted in blue), posterior to the lateral lamina of the pterygoid and anterior to the posterolateral lamina of the alisphenoid that articulates with the base of the falciform process  USNM 2345 and (C) Click here for additional data file.10.7717/peerj.2321/supp-2Figure S2Goedertius. (A) USNM 335406, (B) USNM 335765, (C) USNM 314421, (D) USNM 13673.Photographs of undescribed platanistoid specimens housed in the Vertebrate Paleontology collections of the National Museum of Natural History, Smithsonian Institution, Washington D.C. All of the skulls are referred in this paper to the allodelphinid genus Click here for additional data file.10.7717/peerj.2321/supp-3Table S1Zarhinocetus errabundus, Goedertius oregonensis, Allodelphis pratti and Arktocara yakataga). Also added were codings for four periotic characters (288–291) for Pomatodelphis inaequalis and Zarhachis flagellator.0, primitive state; 1, 2, 3, derived states; 0/1, a variable between 0 and 1; 1/2 a variable between 1 and 2; 1/3, a variable between 1 and 3; ?, missing character or taxon not coded for this character. Following Click here for additional data file.10.7717/peerj.2321/supp-4Appendix S1Following Click here for additional data file.


The hyperglycemic condition from dysregulated glucose homeostasis has been defined stress hyperglycemia. Following burn trauma it persists in a hypermetabolic flow phase as a response of burn itself and sepsis. Serial Sequential Organ Failure Assesment (SOFA) score is recommended from American Burn Association for evaluation of organ dysfunction/failure.The aim of this study is to test the relation of serial SOFA score evaluation and probability of critical hyperglycemia during burn injury.-rd,7-th,14-th and 21 -st day after burn injury.This is an observational prospective cohort study. Population is composed of adults hospitalized in ICU of the Service of Burns near University Hospital Center, Tirana, Albania for 5 years(2010-2015).Patients are grouped according glucose values on three categories: Patients with Euglycemia ( 80-120 mg/dL), Moderate Hyperglycemia (121-180 mg/dL) and Critical Hyperglycemia (> 180 mg/dL ).Test characteristics and performance as well as AUC are calculated for SOFA score on the 3The prevalence of Critical Hyperglycemia in adult burn patients is 6.9%. Using the value 6 as the cutoff SOFA scoring for dysfunction/ failure, serial SOFA score evaluation and presence of critical Hyperglycemia have a good correlation. On the 14-th day after burn the values of Area Under the Curve, Positive Likelihood Ratios and Positive Predicted Values (PPV) are the better values as complementary information to clinical assessment Figure .Figure 1In patients with clinical sepsis after severe burns the probability for Critical hyperglycemia is higher after the first week  This tells us that 2 of 5 patients with sepsis after the first week of the illness will demonstrate critical hyperglycemia. Hyperglycemia is a sign of sepsis in severely burned adult patients.


Critically ill patients frequently suffer from intensive care unit (ICU) acquired weakness (ICUAW). Evoke muscle contraction by electrical muscle stimulation (EMS) may help to prevent their overall strength diminishing by conserving muscle strength and mass.The aim of the study was to investigate the effects of daily EMS-therapy on muscular strength in ICU patients, compared to a protocol based standard physiotherapy.The interventional randomized controlled trial included critically ill patients at high risk for ICUAW selected by SOFA score ≥ 9 and onset of critical illness in less than 72 hours. Randomization was administered to EMS group  or a physiotherapy group (protocol base physiotherapy). EMS-therapy was applied for 20 minutes 7 days/week to 8 bilateral muscle groups by an experienced physiotherapist. Medical-Research-Council (MRC) score for muscle strength and grip strength measured by hand-dynamometer were recorded on the first day patients were adequately awake and on the day of their ICU discharge. Non-parametric tests were performed. Ethic vote (Charité EA 2/041/10).50 patients, 33 males and 17 females with a median age of 52 (10/90) years and a SOFA score of 13 (10/15) at admission where included in the study. Randomization resulted in 21 to 29 subjects for EMS and controls respectively. Time-points of muscle strength measurements were “first day being awake” at median day 11 (7/19) and discharge form ICU, median day 26 (17/33). Patient characteristics and time-points of recorded parameters were without significant differences between the intervention (EMS) and control group (data not shown). Overall subjects fulfilled criteria for ICUAW on their first day of being awake and significantly improved their MRC score and grip strength until their ICU discharge. Surprisingly we could not show direct group differences between EMS- and control group for MRC score and grip strength. By focusing separately on the course of strength for EMS- and control group we found an increase in MRC score for both groups between the first and second measurement.Grip strength in nonEMS treated patients rose significantly whilst patients receiving EMS couldn't show significant improvements between measurements.Our patients managed to increase their grip- and general strength levels significantly from their first day of being adequately awake until the day of their ICU discharge. Further subgroup analysis however indicates that EMS therapy may not be more beneficial in increasing grip or MRC-measured strength compared to the standard physiotherapy protocol within our study. The missing grip strength improvement of the EMS group between the first day of being awake and ICU discharge may be attributed to greater muscle strength at time of awakening without significant power to show group differences.DFG KFO 192/2 TP3


Respiratory muscle weakness is common in mechanically ventilated patients and impairs liberation from ventilation. Inspiratory muscle training (IMT) might accelerate liberation from mechanical ventilation. We undertook to summarize previously published IMT protocols and the impact of IMT on respiratory muscle function and clinical outcomes.We searched multiple databases using a sensitive search strategy combining MeSH headings and keywords for studies of IMT during MV. Studies were adjudicated for inclusion and data were abstracted independently and in duplicate. Methodological quality was assessed using the GRADE system.n = 5) or after difficult weaning (n = 5); one study implemented IMT within 24 hours of intubation. IMT was associated with greater increases in maximal inspiratory pressure compared with control , I2 = 0%). There were no significant differences in the duration of MV , I2 = 71%) or the rate of successful weaning . The GRADE quality of evidence was low for all these outcomes; risk of bias was high for most studies and summary effects were imprecise and inconsistent. No serious adverse events related to IMT were reported.Eleven studies met the inclusion criteria; of these, six were randomized controlled trials and five were observational studies. A variety of IMT techniques were employed including inspiratory threshold loading (eight studies), biofeedback to increase inspiratory effort (one study), chair-sitting (one study) and diaphragmatic breathing pattern training (one study). Threshold loading was achieved by application of an external device (six studies) or increases in the inspiratory pressure trigger setting (two studies). Most studies implemented IMT in the weaning phase (IMT in mechanically ventilated patients appears safe and well-tolerated and improves respiratory muscle function. IMT was not associated with accelerated liberation from mechanical ventilation. However, because the included studies had important methodological limitations and employed varying methods of IMT, we cannot draw firm conclusions about the effect of IMT on clinical outcomes.


Twenty one fully sequenced and well annotated insect genomes were used to construct genome content matrices for phylogenetic analysis and functional annotation of insect genomes. To examine the role of e-value cutoff in ortholog determination we used scaled e-value cutoffs and a single linkage clustering approach.. The present communication includes (1) a list of the genomes used to construct the genome content phylogenetic matrices, (2) a nexus file with the data matrices used in phylogenetic analysis, (3) a nexus file with the Newick trees generated by phylogenetic analysis, (4) an excel file listing the Core (CORE) genes and Unique (UNI) genes found in five insect groups, and (5) a figure showing a plot of consistency index (CI) versus percent of unannotated genes that are apomorphies in the data set for gene losses and gains and bar plots of gains and losses for four consistency index (CI) cutoffs.


This article gives an overview of recent publications and potential indications of Positron emission tomography/ Magnetic resonance (PET/MR) imaging of prostate cancer. Several original research articles showed that a combination of these functional imaging modalities can improve diagnostic accuracy of MR imaging  or [18F] choline has been examined to a large extent during the past years; however, with partly controversial results. A large meta-analysis defined possible indications of PET/CT examinations of the prostate including initial staging of patients with newly diagnosed prostate cancer and high-risk of nodal extension and suspected recurrent prostate cancer after surgery or radiotherapy indicated by a rising PSA-level. Another indication of a PET/CT scan of the prostate might be a history of negative biopsies in patients with a strong suspicion of prostate cancer to plan a focused re-biopsy in carefully selected cases [PET and PET/CT imaging of prostate cancer with the radiotracers C or [18F18F] choline PET/MR imaging in patients with prostate cancer [11C] and [18F] choline was shown that PET and MR image quality was sufficient and without significant differences in the detection of hyper-metabolic lesions and with excellent correlation of standardized uptake values derived from PET/MRI and PET/CT [18F] choline PET/MRI were reported for detection of prostate cancer relapse after external beam radiotherapy [68Ga] labeled prostate-specific membrane antigen (PSMA) ligand. Recent studies demonstrated the technical feasibility of PET/MR imaging with this new tracer and found a superiority of PET/MRI over PET/CT by using this tracer [68Ga] labeled tracer yielded some difficulties and requires further investigation before routine use  choline PET/MR imaging was performed after PET/CT. The images illustrate the combined findings of anatomical sequences together with diffusion-weighted imaging and PET imaging.Figure legends: Images from a patient with biochemical failure after radical prostatectomy  and fromIn conclusion, the results published so far on PET/MRI of prostate cancer are promising and justify further research in this field. It will be necessary to plan and conduct large prospective studies in order to ascertain the additive value of PET/MRI in comparison to the available diagnostic tools in prostate cancer diagnostics.


Simian foamy virus (SFV) is a retrovirus ubiquitous in non-human primates (NHPs) that can be transmitted to humans, mostly through severe bites. In the past few years, our laboratory identified more than 50 hunters from Central Africa infected with zoonotic SFVs. Analysis of SFV complete sequences obtained from 5 of these individuals had revealed that the env gene was the most variable one. Furthermore, recombinant SFV strains have been recently shown; some of them involved the env gene. This led us to investigate the env gene variability of zoonotic SFV strains, looking especially for possible recombinants. We sequenced the complete or the surface glycoprotein region (SU) of SFV env gene amplified from blood DNA of: 1) a series of 40 individuals from Cameroon or Gabon infected with a gorilla or chimpanzee FV strain; 2) one gorilla and 3 infected chimpanzees living in the same areas than the hunters. All sequences were aligned and analysed by phylogenetic (neighbour-joining and maximum likelihood) and recombinant detection methods . Phylogenetic analyses revealed the existence of two different env variants among both gorilla FV and chimpanzee FV strains. These were present in zoonotic as well as in NHP strains. These variants differ greatly (more than 30% variability) in a 750 bp long region located in the receptor binding domain of the SU; the rest of the gene is very conserved (less than 5% variability among strains from the same species). Within a given variant, protein sequences of the SU are very conserved and stable  which may reflect functional constraint. Recombination analyses highlighted that these variants could have emerged through recombination events.


Radium-223 is an alpha emitter, licensed in 2013 for treatment of symptomatic bone metastases in metastatic castration resistant prostate cancer. The treatment consists of 6 intravenous administrations and ongoing patient management before, during and after treatment. In our institution, this service is led by the nuclear medicine departmentThe ALSYMPCA trial, published in 2013, demonstrated improved overall survival (14.9 vs 11.3 months) and prolonged time to first symptomatic skeletal event (15.6 vs 9 months) for patients administered Radium-223 vs placeboImaging plays a key role in the selection criteria and response assessment for this new therapeutic modality. We present an educational review of the spectrum of multimodality imaging techniques employed for pre-therapeutic assessment and also for therapeutic response assessment• A brief overview of the criteria for treatment with radium-223 will be provided• Examples of CT and MRI scans of patients suitable for treatment, including pre and post therapeutic findings• Isotope bone scans of patients before and following treatment, demonstrating the effect of radium-223 on skeletal lesions.Radium-223 is an emerging innovative treatment for symptomatic bone metastases from castrate resistant prostate cancer and may well be the standard of care in the future. Cancer imagers should be aware of the suitability criteria for treatment, which will help inform discussions when patients are being considered for this treatment. They should also be aware of the multimodality imaging findings on post therapeutic response assessment studies.


Multiple epidemiologic studies have consistently reported association between increased coffee consumption and a lowered risk of Type 2 diabetes mellitus. However, the mechanisms behind this finding have not been fully elucidated.We investigate the effect of coffee (caffeinated and decaffeinated) on glucose effectiveness and insulin sensitivity using the stable isotope minimal model protocol with oral glucose administration in healthy men.Fifteen healthy men underwent 5 arms randomized crossover single-blinding (researchers) clinical trial. They consumed decaffeinated coffee, caffeinated coffee (with and without sugar), and controls – water (with and without sugar) followed 1 hour by an oral glucose tolerance test (75 g of available carbohydrate) with intravenous labeled dosing interpreted by the two compartment minimal model (225 min). One-way ANOVA with Bonferroni adjustment were used to compare the effects of the tested beverages on glucose metabolism parameters.Decaffeinated coffee resulted in 29% and 85% higher insulin sensitivity compared with caffeinated coffee and water, respectively, and the caffeinated coffee showed 15% and 60% higher glucose effectiveness compared with decaffeinated coffee and water, respectively. However, these differences were not significant (p >0.10). In overall analyze (0 – 225 min) there were no significant differences on glucose effectiveness, insulin sensitivity, and glucose and insulin area under the curve between the groups. The beneficial effects of coffee did not seem to act in the short-term (h) on glucose metabolism parameters mainly on insulin sensitivity indices. The benefits of coffee consumption occur in the long-term (yrs.) as has been shown in the reduction of Type 2 Diabetes Mellitus risk in epidemiological studies. The clinical relevance of the present findings is that there is no need to avoid coffee as the drink choice for healthy people.The findings of this study demonstrate that the consumption of caffeinated and decaffeinated coffee with or without sugar has no acute effects on glucose metabolism in healthy men. Further researches, including long-term interventional studies, are needed to fully elucidate the mechanisms behind the coffee effects on reduced risk for Type 2 diabetes mellitus.


The third and fourth authors, Delphine Magis (DM) and Jean Schoenen (JS), should be noted as contributing equally to this work.


The creatinine values in Tables S1 Tablem/z), retention time (sec) and abundance (intensity) of 58 metabolites. The information of sex and age on 50 individuals is indicated on top.Plasma collected from marmoset was analyzed for metabolomics by high-resolution mass spectrometry as described in Methods. The mass spectrometry data includes ion mass Click here for additional data file.


There was an error in the figure legend of Figure 4. Please see the corrected Figure 4 here: The corrected Figure 4 caption reads:Grand-average ERP waveforms for the Grasping Small and the Grasping large conditions. The plots show ERPs time locked to glasses opening.The corrected Figure 3 caption reads:Scalp distribution of ERP differences between Grasping Small and Grasping Large conditions.In the last sentence of the "Electrophysiological recording and data processing" section in Materials and Methods, some of the stimulus appearance sites were listed incorrectly. The corrected sentence is: Based on visual inspection of grand average waveforms and amplitude scalp maps, the following ERP components were statistically analyzed: amplitude and latency of P300, namely the positive peak evoked 200–400 ms following stimulus appearance at parietal sites ; amplitude and latency of N400, namely the negative peak occurring at 300–500 ms after object appearance at frontal , fronto-central , and central  sites; and mean amplitude of the sustained negativity observed in 400–800 and 1200–2000 time windows at frontal , fronto-central , central , and parietal  sites.


Malignancies of biliary tract have been rarely reported in HIV disease.We report 3 cases of biliary tract malignancy associated with HIV infection from Prayas Amrita clinic, an NGO based HIV clinic in Pune, India. Two of the cases were diagnosed with gall bladder malignancies (GBM) and the third one had cholangio carcinoma (CC). All presented with advanced stage of malignancy with metastases and had poor prognosis. All were males with median age at presentation being 47 years (range - 46-48 years) They were diagnosed to have HIV for a median duration of 102 months (range: 69-118 months) . Median nadir CD4 count was 77cells/cmm (range: 71–163 cell/cmm). They were on first line ART for median 63 months (range: 41–72 months). A patient with GBM was Hepatitis B co infected. Prior AIDS related events of anemia, immune thrombocytopenic purpura and tuberculosis were present in the patient with CC and progressive multifocal leukoencephalopathy was in one of the patients with GBM. Being managed in resource limited setting; the absence of other risk factors is corroborative and lacks evidence.These 3 cases of biliary tract malignancies were seen recently in a relatively short span of time. All were men in late forties, infected with HIV for a long time and had no other known risk factors. This could be a pointer towards changing scenario of malignancies among HIV infected patients associated with prolonged survival.


Increasing number of patients with post-herpetic neuralgia (PHN) leads to clinical observation of the fact that it worsening the condition of patients with other chronic pain syndromes such as migraine and tension-type headache (TTH).The aim of this study was assessment of cephalgic pain severity and quality of life (QoL) in patients with primary headaches in comparison with those who additionally suffers of PHN.12 patients with PHN and comorbid migraine and TTH  and 14 patients with migraine and TTH only (4 and 10) as controls were assessed for headache pain severity by visual analog scale (VAS) and QoL by short form (SF-36) screening tools.Patients with PHN had worse results of headache pain intensity and QoL vs patients of control group. Headache pain severity in PHN group was 7-8 vs 5-6 in control group, and QoL scoring was lower in PHN group vs control.PHN as the reason of central sensitization leads to further increase of the other chronic pain syndromes, such as primary headaches, elevate the cephalgic pain and decrease the QoL.No conflict of interest.


Scientific Reports5: Article number: 1448510.1038/srep14485; published online: 09292015; updated: 02022016The original version of this Article contained a typographical error in the Abstract.“Short diffusion distance of few hundreds of nanosecond was also observed in thin films.”now reads:“Short diffusion distance of few hundreds of nanometer was also observed in thin films.”This has now been corrected in the PDF and HTML versions of the Article.


Investigators from Washington University St. Louis studied the impact of electroencephalographic monitoring of neonates with Hypoxic Ischemic Encephalopathy (HIE) and their degree of MRI injury and neurodevelopmental outcomes when increasing seizure burden was present. Investigators from Washington University St. Louis studied the impact of electroencephalographic monitoring of neonates with Hypoxic Ischemic Encephalopathy (HIE) and their degree of MRI injury and neurodevelopmental outcomes when increasing seizure burden was present. Investigators performed a randomized controlled trial to investigate the effect of seizure burden on neurodevelopmental outcomes in infants with recognized electrographic seizures versus infants with clinically recognized seizures. Researchers found 15/35 neonates in the electrographic seizure group (ESG) and 20/34 neonates in the clinical seizure group (CSG) to have seizures. The researchers found that the ESG presented with a lower cumulative seizure burden (SB) than the CSG (p=0.02) likely due to faster identification and subsequent treatment of seizures. The investigators found no difference between ESG and CSG groups regarding developmental outcome due to the power of the study. However, analysis of the cohort as a whole indicated that an increasing SB correlated with worsened outcomes on the Bayley Scales of Infant Development III (p=0.03). The investigators also showed that greater SB in the cohort was associated with a worse MRI injury severity. [COMMENTARY. Neonatal seizures are prevalent in infants with HIE . However


In the fourth paragraph of the Discussion section, reference #37 and #5 are switched. The paragraph should read as follows: "Although this study did not identify any IS6110 positives, previous studies have identified the presence of this locus in New World primates [5]. However, the IS6110 mobile element has been found to be homologous in some related soil mycobacteria [37], and targeting this element with PCR has previously produced false-positives [38]."


Background: Hypospadias is one of the most common congenital abnormalities in the male which is characterized by altered development of urethra, foreskin and ventral surface of the penis. Androgen receptor gene plays a critical role in the development of the male genital system by mediating the androgens effects.Objective: In present study, we looked for new variations in androgen receptor promoter and screened its exon 1 for five single nucleotide polymorphisms (SNP) in healthy and hypospadias Iranian men.Materials and Methods: In our study, at first DNA was extracted from patients (n=100) and controls (n=100) blood samples. Desired fragments of promoter and exon 1 were amplified using polymerase chain reaction. The promoter region was sequenced for the new variation and exone 1 screened for five SNPs  using restriction fragment length polymorphism technique.Results: The results showed a new single nucleotide variation (C→T) at -480 of two patients’ promoter region (2%). None of the mentioned SNPs were detected in patients and controls groups (0%). Conclusion: This finding indicates that new single nucleotide polymorphism in androgen receptor promoter may have role in etiology of hypospadias and development of this anomaly.This article extracted from Ph.D. thesis. (Nasim Borhani) Hypospadias is the most common congenital malformation of the male external genitalia in which the urethral meatus opens on the ventral side of the penis . It affeAR gene is located on chromosome Xq11-12 and consists of eight exons, in which exon 1 encodes the transactivation domain that activates transcription of several different AR-responsive downstream genes , and in addition, AR gene promoter region was scanned for new variations in hypospadias disease in Iranian population.Impaired signaling through the androgen receptor (AR) leads to failure of urethral fold formation and fusion and consequently leads to hypospadias . The AR am genes , 7. The am genes , 9. ThesPatients and controlsThe patients in this analytical association study refered to the Mofid’s children Hospital  between March 2012 to August 2012. The patients should have criteria including diagnosis by urologist and having no sign of other genetic or congenital disease or genital malformations; (the properties distribution of patients in our study are listed in =100) and control group (n=100) were taken using venoject tube containing EDTA (0.5 M). The controls were selected from healthy males in Shahid Beheshti School of Medicine. The control samples should not have any sign of genetic disease, genital malformations or any addiction. Peripheral blood samples of hypospadic patients (nDNA extraction and polymerase chain reaction (PCR)AR transactivation domain were amplified using the primer pair: 5’TCCAGAGCGTGCGCGAA GTG3’ (sense) and 5’CCGACTGCGGCTGT GAAGGT3’ . Genomic DNA was extracted from peripheral blood of patients and controls using the whole blood extraction kit . Nucleotides -756 to -366 of the AR 5’ promoter region (based on Ensemble.org genome browser) were amplified using the primer pair: 5’TCTCCAAA GCCACTAGGCAG3’ (sense) and 5’ACCGAA GAGGAAAGGGCAGCTC3’ (antisense). Nucleotides +604 to +888 of the Restriction fragment length polymorphism (RFLP) analysisFor transactivation domain genotyping, PCR, RFLP and 8% polyacrylamide gel electrophoresis (PAGE) were used. The RFLP reaction condition was detailed and presented in Promoter region sequencingFor AR promoter region sequencing, PCR products were purified using DNA extraction kit  and then scanned for variations using direct sequencing .Ethical considerationsThe informed consent was obtained from all adult participants (control groups) and from the parents or legal guardians of minors (patients). This study had been reviewed and approved by a certified Ethical Committee in Shahid Beheshti University of Medical Sciences.RFLP resultsThe 285 bp PCR product containing five SNP sites was digested using suitable enzymes; SsiI, PstI, CaiI, SfaNI, and BseG1. The two SNPs rs62636528, and rs62636529 produce gain of sites compared to wild type allele, while rs78686797, rs139767835, and rs145326748 supposed to have loss of sites in digestion with the mentioned enzymes . The SsiSequencing resultsAR gene promoter region was scanned for new variations in subjected samples and a new single nucleotide polymorphism (SNP) was detected in two patient samples (2%)  at position -48oC→T (the normal sequence and two sequences curves with a new nucleotide variation are shown in AR gene is a member of the nuclear receptor superfamily that is located on Xq11-12. This receptor plays a critical role in male sexual differentiation by mediating the biological effects of androgens (AR amount or structure may disrupt this patterning (AR for the first time in hypospadic patients and we found a new single nucleotide polymorphism in two patients at -480 using direct sequencing. There have been many reports on AR promoter sequencing. ndrogens . Early det al scanned AR gene promoter and untranslated region in 44 clinical prostate cancer specimens and 36 normal controls; but they did not find any different sequence variations (et al screened promoter region of androgen receptor gene in 240 men with idiopathic infertility and 30 healthy men and this study did not show presence of any deletions or mutations in infertile or healthy men and they suggested that AR gene promoter mutation are not common in men with idiopathic infertility (AR gene promoter region of 100 healthy men suggested that DNA sequence alterations are rare in the human androgen receptor gene promoter (In 2006, Waltering riations . Likewisertility . Furtherpromoter . et al in which mutation screening of genomic DNA of men with hypospadias did not show any point mutation in AR gene exons (et al reported that the majority of patients with hypospadias did not carry androgen receptor gene mutations. In addition Sasagawa et al suggested that alteration of the AR gene is rare in males with isolated hypospadias, cryptorchidism, micropenis, or idiopathic male infertility (et al reported that none of the studied hypospadic patients in their research had AR gene mutations (AR gene mutation is rare in hypospadic patient (Additionally, we did not find any of mentioned single nucleotide polymorphisms in control and patient groups using PCR and RFLP techniques. This finding may declare that these five polymorphisms are not be involved in hypospadias etiology. These data are consistent with the previous report by Muroya ne exons . Also Hiertility . Furtherutations . Likewis patient , 17. et al it was found that a SNP in the AR gene region was associated with susceptibility to severe hypospadias. They concluded that AR rs5919436 polymorphism may act as a new gene marker for increased susceptibility to severe hypospadias in Caucasians (AR gene with the hypospadias; and suggested that expanded CAG repeat length has a role in modifying the risk and development of hypospadias (In addition, In a recent study by Adamovic ucasians . BesidesAR gene expression in the genital system due to decreasing the transcription machinery affinity for binding toward regulatory elements.In addition, in another study on Chilean population, the CAG and GGN polymorphisms in the AR gene has been investigated and showed that in isolated hypospadic boys, there are longer CAG alleles in their AR gene that might be associated with the development of hypospadias . Taken t


One of the most pressing health-related challenges is the worldwide epidemic of type 2 diabetes and associated complications such as nephropathy. Indeed, type 2 diabetic patients account for the majority of individuals with chronic kidney disease requiring renal replacement therapy. This not only suggests inadequacy of current drug therapies but also failure of endogenous protective mechanisms. Stem cells are known to play pivotal roles in repair and regeneration of damaged/dysfunctional tissues. Our initial observations suggested that initiation and progression of type 2 diabetes mellitus is associated with progressive reduction in endothelial progenitor cells in the obese diabetic db/db mice. Thus, the present study was intended to more fully explore the status of components of stem cells in the setting of type 2 diabetic nephropathy and whether the diabetic milieu affects the survivability of these cells.Male 16-week-old obese diabetic db/db mice (and their db/m controls) were used for this study. Accordingly, indices of glycemic status , kidney function  were determined in the context of assessment of components of stem cells in peripheral blood and renal tissue. In addition, we measured apoptotic cell death in components of stem cells.+Ckit+CD31-) mesenchymal stem cells  and endothelial/epithelial progenitor cells  compared to those of db/m controls. Further, kidney cells prepared for experimental groups also showed reductions in components of stem cells. Using annexin V in association with markers of each component of stem cells revealed significant increases in apoptosis for HSC, MSC and EPCs in cells prepared for kidneys of db/db and db/m mice. Collectively, the results suggest that apoptosis of components of stem cells likely contributes to eventual manifestation of renal failure in type 2 diabetes mellitus.The db/db mice showed significant increases in insulin resistance index and hemoglobin A1c in association with marked increase in albuminuria but reduction in creatinine clearance in association with significant increases in apoptotic and necrotic cell death of kidney cells. The peripheral blood cells of db/db mice displayed significant reduction in hematopoietic stem cells (HSC; Sca1The observation of a similar pattern of decline in stem cell components in the peripheral blood and the kidney suggests that monitoring of blood levels of stem cells subsets may be predictive of failure of their renoprotective features. Further, strategies aimed at reducing apoptosis of stem cell components and “empowering” them through genetic modulations could potentially serve as effective strategies to prevent end-stage renal failure in type 2 diabetic patients.


Chronic kidney disease (CKD) caused by renal fibrosis is an important public health concern. It is therefore necessary to understand the molecular pathogenesis of renal fibrosis in order to develop novel therapeutic strategies. KLF4 is the most extensively studied factor among the various members of the Krüppel-like factor (KLF) family of zinc finger-containing transcription factors. Many studies have demonstrated that KLF4 inhibits the activation of myofibroblasts and exerts an inhibitory effect on fibrosis. However, other studies have indicated that KLF4 may promote renal fibrosis. These controversial results suggest that KLF4 may be crucially involved in the development of renal fibrosis, although the underlying mechanism(s) remain unclear. Here, we summarize the recent progress made in understanding the role of KLF4 in renal fibrosis. Together, these findings suggest that KLF4 may participate in the development of renal fibrosis, but that its inhibition of fibrosis is greater than its promotion of the condition, which suggests that KLF4 may serve as a novel therapeutic target for renal fibrosis. Renal fibrosis is characterized by excessive proliferation of fibroblasts and increased deposition of extracellular matrix (ECM), which together lead to extensive scarring (fibrotic tubular and glomerular sclerosis), renal artery stenosis and chronic inflammatory cell infiltration  family consists of 17 zinc finger-containing transcription factors, among which KLF4 is the most extensively studied  is an important participant in a broad spectrum of inflammatory networks that regulate the cytokine activity in renal fibrosis  regulates the expression of VSMC differentiation markers by cooperating with its co-activator, myocardin, or its co-repressor, phosphorylated KLF4 (Wang et al., renal physiological functions and the progression of fibrosis (Chen et al., in vivo models of unilateral ureteral obstruction, a decrease in KLF4 expression was observed (Chen et al., Recently, Chen et al. showed that KLF4 was indeed involved in the regulation of The role of KLF4 in renal fibrosis is complex. For instance, KLF4 can induce the transformation of primary fibroblasts (Rowland et al., Because KLF4 is expressed in kidney cells (Hayashi et al., The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The dynamical fluctuations in the rhythms of biological systems provide valuable information about the underlying functioning of these systems. During the past few decades analysis of cardiac function based on the heart rate variability  has attracted great attention, resulting in more than 17000-publications (PubMed list). However, it is still controversial about the underling mechanisms of HRV. In this study, we performed both linear (time domain and frequency domain) and nonlinear analysis of HRV data acquired from humans and animals to identify the relationship between HRV and heart rate (HR). The HRV data consists of the following groups: (a) human normal sinus rhythm (n = 72); (b) human congestive heart failure (n = 44); (c) rabbit sinoatrial node cells ; (d) conscious rat (n = 11). In both human and animal data at variant pathological conditions, both linear and nonlinear analysis techniques showed an inverse correlation between HRV and HR, supporting the concept that HRV is dependent on HR, and therefore, HRV cannot be used in an ordinary manner to analyse autonomic nerve activity of a heart. Greek Physicians and scientists were the pioneers who measured pulse rate; however, it was not much accurate till the invention of pulse watch in 1707 .The autonomic nervous system (ANS) controls heart rate, hear rate variability (HRV) and breathing. Heart Rate Variability (HRV) analysis is a non-invasive technique used to evaluate the balancing action of sympathetic and parasympathetic branches of the autonomic nervous system , 4,5. OvOver the last 35 years, various linear and non-linear techniques have been developed to extract the valuable information from cardiac interbeat interval time series data, aiming to help clinician for prognostication of illness and assessing malfunctioning of the autonomic nervous system. However, often contradictory results have left clinicians skeptical and there exists no clear consensus about HRV analysis measures . In 1996The main purpose of this study is to identify the relationship of HR with both linear and nonlinear metrics of HRV. The human and animal data sets were analysed under following conditions: (a) human normal sinus rhythm n = 72); (b) human congestive heart failure (n = 44); (c) rabbit sinoatrial node cell (SANC) (n = 67); and (d) conscious rat (n = 11). Both nonlinear and linear methods showed that HRV is primarily dependent on HR. There is an inverse correlation between the HRV and HR: a larger HRV  was correlated with a lower HR, and the vice versa. Such a correlation was observed both in the human data at variant pathological conditions and variant animal species. This study provided support to the concept of a previous study[; (b) humHRV analysis can be done by many ways and a wide range list of techniques explored since 1960 are described in detail by the North American Society of Pacing Electrophysiology and the task force for European Society of Cardiology . This stMeasures included in linear time domain parameters are derived from direct RR interval measurement for standard deviation of all normal to normal RR intervals (SDNN), and from differences of RR interval for root mean square of successive NN interval differences (RMSSD) (RMSSD) . SpecifiIn which ‘I’ is RR intervals, Where ‘I’ is RR intervals and ‘N’ is the total number of RR intervals.The frequency domain measures used in this study included: Very low frequency (VLF), low frequency (LF), high frequency (HF) and total power. VLF is a band of power spectrum range ≥ 0.04 Hz. Normally this measure shows overall activity of numerous slow mechanisms of sympathetic activity. LF is a band of power spectrum ranging between 0.04 and 0.15 Hz. This parameter reflects both sympathetic and parasympathetic function. HF is a band of power spectrum range between 0.15 and 0.4 Hz. Generally this measure reflects parasympathetic function. Total power is a short term estimate of the total power of power spectral density in the range of frequencies between 0 and 0.4 Hz. In this parameter sympathetic activity is a main contributor when its shows overall autonomic activity .m or 30m and m = 2(100–900 data points) will yield statically reproducible and reliable results. He also describe that ApEn can be applied to any system having at least 50 data points. ApEn algorithm counts similar sequences to given sequence of length m, including the sequence itself to avoid natural logarithm of zero within the calculations. As a result, ApEn can sensitive to the size of data. To overcome this, a variant of the ApEn algorithm called Sample entropy (SamEn) [Approximate entropy (ApEn) and sample entropy (SamEn) were used to analyse the nonlinear behaviour of HRV , 13,14.  (SamEn) , which gThe data sets used in the study comprised of both human and animal data and in We used RR-interval time series data of human normal sinus rhythm (n = 72), human congestive heart failure(n = 44), rabbit SANC and conscious rat(n = 11) subjects.In human groups, HRV in terms of SDNN and RMSSD is high in normal sinus rhythm  then in In frequency domain analysis we used Total Power(TP) (high frequency (HF)+low frequency (LF)+very low frequency (VLF)) to analyse RR-interval time series data of human normal sinus rhythm (n = 72),human congestive heart failure(n = 44), rabbit SANC and conscious rat(n = 11). HRV in terms of Total Power in human groups is high in the normal sinus rhythm then conIn nonlinear time series analysis we used Approximate Entropy and Sample Entropy to analyse RR-interval time series data of human normal sinus rhythm (n = 72),human congestive heart failure(n = 44), rabbit SANC and conscious rat(n = 11). In human groups, HRV in terms of Approximate Entropy and Sample Entropy is high in normal sinus rhythm  then conThe baseline cycle length  also varied widely between preparations . In humaIn the Figs Heart rate variability analysis is a non-invasive technique used to assess the cardiac autonomic control under physiological and pathophysiological conditions , 4, 7. TMonfredi et al , used liIn this study, we investigated the relationship of linear (time domain and frequency domain) and nonlinear HRV parameters with heart rate using RR-interval time series data from human and animals. The RR-interval time series comprised of human (72 NSR and 44 CHF subjects) and animal subjects . The research findings indicate that both linear and nonlinear HRV methods showed an inverse correlation between the HRV and HR: a larger HRV  was correlated with a lower HR, and the vice versa. Such a correlation was observed both in the human data at variant pathological conditions and in different animal species. The inverse correlation of nonlinear HRV measures along with linear ones with HR is the salient feature of this study. The outcomes of this study strong the evidence of relationship between HRV with HR and are in line with outcomes of Monfredi and co-authors. It is suggested that in future studies HR should be taken into consideration at which HRV analysis is being performed.


For the first time, complete genome sequences of four lineage III peste des petits ruminants (PPR) viruses  originated from the Middle East and East Africa are reported here. The availability of complete genome sequences from all four lineages (I to IV) of the PPR virus (PPRV) would greatly help in a comprehensive understanding of the molecular evolution and emergence of PPRV. Phylogenetic analysis of the partial F gene (322 nt) (Peste des petits ruminants (PPR) is an important infectious viral disease of domestic and wild small ruminants and endemic in the Middle East, Africa, and Asia  (http://(322 nt)  has defi(322 nt) , 5. AvaiThe complete genomes of four PPRV isolates from the Middle East, Oman 1983  and UnitPhylogenetic analysis of all the available (at GenBank as of August 2014) complete genome sequences of PPR viruses , including the four viruses sequenced in this study , has grouped them into four genetically divergent lineages that are similar to the phylogenetic study using partial F, N, and H genes. Complete genomes of PPRV isolates  sequenced in this study were confirmed to be of lineage III. Therefore, this study demonstrated the co-circulation of lineages III and IV in East Africa . FurtherKJ867543 (Uganda 2012), KJ867540 (Ethiopia 1994), KJ867545 (UAE 1986), and KJ867544 (Oman 1983).The complete genome of the PPRV isolates have been deposited in GenBank under accession no.


In this connexion novel radiopharmaceuticals for the noninvasive molecular imaging of early disease states and monitoring of treatment responses in vivo by means of PET/CT, SPECT/CT and PET/MRI are indispensable prerequisites to further advance and strengthen the unique competence of radiopharmaceutical sciences. In the era of personalised medicine the diagnostic potential of radiopharmaceuticals is directly linked to a subsequent individual therapeutic approach called endoradiotherapy. Depending on the “radioactive lantern” (gamma or particle emitter) used for radiolabelling of the respective tracer molecule, the field of Radiopharmaceutical Chemistry can contribute to the set-up of an “in vivo theranostic” approach especially in tumour patients by offering tailor-made (radio)chemical entities labelled either with a diagnostic or a therapeutic radionuclide.The fields of molecular biology, immunology and genetics have generated many important developments that advance the understanding of the induction and progression of oncological, cardiological and neurological diseases as well as the identification of disease-associated molecules and drugs that specifically target diseased cells during therapy. These insights have triggered the development of targeted radiopharmaceuticals which open up a new dimension of radiopharmaceutical sciences in nuclear medicine. Radiopharmaceuticals, also called radiotracers, are radiolabelled molecules, bearing a “radioactive lantern”, and used as molecular probes to address clinically relevant biological targets such as receptors, enzymes, transport systems and others. Positron emission tomography (PET) and single photon emission computed tomography (SPECT) realised in the in vivo and facilitates to predict and monitor successful therapy strategies. The definition of “molecular probe imaging” is highlighted in detail in this special issue  : “At the heart of all nuclear imaging, radiopharmaceutical science is the design, synthesis and evaluation of compounds containing suitable radionuclides that can be used in vivo to trace (follow) a particular physiological or biochemical phenomena” [Early-stage noninvasive molecular imaging enables to look at the biodistribution of molecular probes al issue  1]. Ind. Indin venomena” .In fact, according to reports of the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) more than 33 million diagnostic nuclear medicine examinations are performed annually worldwide. The annual frequency of diagnostic nuclear medicine examinations and of nuclear medicine treatments in health-care level I countries have thus increased tremendously, from 11 per 1,000 population in 1970–1979 to 19 per 1,000 in 1997–2007 and for therapeutic nuclear medicine procedures from 0.17 per 1,000 population in 1991–1996 to 0.47 per 1,000 in 1997–2007 [(i)reasonable pharmacokinetic behaviour adjusted to the physical half-life of the used radionuclide(ii)ability to penetrate and cross biological membranes and permeability barriers(iii)usage of chemical as well as biological amplification strategies (iv)in vivo stabilityavailability of radiopharmaceuticals with high specific activities and To succeed in the design of targeted high-affinity radiopharmaceuticals that can measure the alteration of a respective biological target several aspects need to be considered:et al. have started a project on targeting the cannabinoid receptor subtype 2 (CB2) with a promising 11C-labelled 2-oxoquinoline derivative [11C]KP23. The CB2 receptor has been shown to be up-regulated in activated microglia and therefore plays an important role in neuroinflammatory and neurodegenerative diseases such as multiple sclerosis, amyotrophic lateral sclerosis and Alzheimer’s disease  could be confirmed, the cellular externalisation of the radioactivity was not improved , PET/CT and PET/MRI , or in a therapeutic radiopharmaceutical (then labelled with 131I) for targeted systemic radionuclide therapy (endoradiotherapy) with identical chemical structure. Similarly to the high efficiency of the combination of radiological diagnostics and radiation therapy, this combined in vivo theranostic approach with targeted radiotracers provide the potential to significantly improve the management of many diseases and the application of individually adapted therapy strategies. One contribution at the current basic research front on Folate Receptor Targeted α-Therapy using Terbium-149 addresses the mentioned in vivo theranostic approach and is described by Müller C et al. who discuss the potential matching pairs of diagnostic and therapeutic folate receptor (FR)-targeted radiotracers bearing different radioisotopes of terbium  and positron emitters  or particle emitters , respectively. This results either in diagnostic radiopharmaceuticals for SPECT/CT  is used for the treatment of different tumours. EGFR can thus be considered as an ideal biological target for combinatorial diagnostic and therapeutic approaches using corresponding radiolabelled cetuximab conjugates. Here Sihver W et al. summarises the hitherto developed radiolabelled cetuximab conjugates for EGFR-targeted diagnosis and therapy (The neurotensin receptor (NTS1) is an attractive biological target for the molecular imaging and endoradiotherapy of NTS-positive tumours owing to the overexpression in a range of malignancies. One contribution shows an example of a ogenesis  8]. Ano. Ano177L therapy  9]..177Lu-la68Ga]Ga-PSMA-HBED-CC was developed at the DKFZ and is the most promising PET tracer for the imaging of prostate cancer to date and clinical trials are currently going to be initiated. Therefore, novel important preclinical data of [68Ga]Ga-PSMA-HBED-CC and relevant aspects of its radiopharmaceutical good manufacturing practice (GMP)-compliant production are presented in this special issue (68Ga) as well as with the beta-minus particle emitters yttrium-90 (90Y) and lutetium-177 (177Lu) which are clinically relevant for systemic radionuclide therapy   has gained highest clinical impact during recent years. The new PET radioligand [al issue  11]. On. On68Ga]therapy)  12]. . 68Ga]GaThe GMP-compliant production and quality control of radiopharmaceuticals have to conform to all aspects of the relevant EU-GMP regulations and radiation protection rules. Specific guidance on current good radiopharmacy practice (cGRPP) for the small-scale preparation of radiopharmaceuticals has been recently published by the EANM radiopharmacy committee . One repet al. provides information about radiolabelling procedures of NPs or polymers intended for PET imaging and their potential use as drug delivery systems  have been designed and used for various purposes, such as magnetic resonance imaging (MRI), computed tomography (CT) and optical imaging (OI) or simply for improved drug delivery. The question is: What is the ideal nanodimensional architecture usable as drug delivery system or for multimodality imaging by means of PET/CT and PET/MRI? In detail the review article of Stockhofe  systems  15]. A . A et alRadiopharmaceutical Chemistry Between Imaging and Endoradiotherapy covers a broad spectrum of representative internationally recognized research and development projects and nicely shows the complexity of the multidisciplinary field radiopharmaceutical sciences located in between nuclear chemistry, radiochemistry, organic chemistry, bioorganic and -inorganic chemistry, labelling chemistry, medicinal chemistry, radiopharmacology and nuclear medicine. The special issue published in Pharmaceuticals intends to reach and attract rather extended readership including students, PhD students and young scientists and talents from medicinal disciplines such as nuclear medicine, radiology and radiation therapy, but especially from natural sciences such as chemistry, pharmacy, biotechnology, technical engineering and physics who are looking for highly innovative translational research conceptions in radiopharmaceutical sciences.In summary this comprehensive special issue


This article also provides supplementary information to the research article, i.e., within-group comparisons between baseline and outcome cortical thickness and subcortical volume measures, between-group tests of performance changes in cognitive benchmark tests (www.cambridgebrainsciences.com [4]), correlation analyses between performance changes in benchmark tests and training-related structural changes, correlation analyses between the time spent training and structural changes, a scatterplot of the relationship between cortical thickness measures derived from the occipital lobe as control region and the chronological order of the MRI sessions to assess potential scanner drift effects and a post-hoc vertex-wise whole brain analysis with FreeSurfer Qdec (https://surfer.nmr.mgh.harvard.edu/fswiki/Qdec [5]).The data and supplementary information provided in this article relate to our research article “Task complexity and location specific changes of cortical thickness in executive and salience networks after working memory training”   Participants could train from home and their progress and compliance was monitored throughout the training time. Eight participants dropped out so the final sample size for both groups was n=20 each . Training-related changes in working memory span and executive functioning as well as in cortical thickness and subcortical volume in regions of interest of cognitive control networks  were assessed. Cortical thickness and subcortical volume indices were derived with the FreeSurfer longitudinal analyses stream 48 healthy participants (19–40 years of age) were pseudo-randomly (with the provision to match groups for age and sex) allocated to an adaptive training or an active control group 2.1post-hoc whole brain vertex-wise analyses in Qdec to test for the effects of group (adaptive training versus active control group) and time of assessment effects (baseline versus outcome) on cortical thickness measures. Cortical thickness indices were derived from the T1-weighted anatomical images smoothed with a kernel of 10. Multiple comparisons were controlled with a False Discovery Rate (FDR) of 5%. There were regions on both hemispheres with significant clusters of group effects across time (see We conducted a time see  but no r


Thymic epithelial tumors (TETs) are comprised of a spectrum of histologically distinct tumors that also exhibit differences at the molecular level . SurgerySomatostatin receptors are expressed in TETs and can be detected by octreotide scan . PalmierHistone deacetylases (HDACs) regulate gene expression through chromosome remodeling. Belinostat is a HDAC inhibitor that has been evaluated in a phase II trial in patients with advanced TETs after failure of platinum-containing chemotherapy . Among 2Thymic epithelial tumors express insulin-like growth factor-1 receptor (IGF-1R), particularly recurrent or advanced tumors and those with aggressive histological subtypes . CixutumMultiple case reports have described responses to the multikinase inhibitors, sorafenib  and suniDespites preclinical data demonstrating overexpression of epidermal growth factor receptor (EGFR)  and KIT Milciclib, an inhibitor of cyclin-dependent kinase 2/cyclin A complex and tropomyosin receptor kinase A (TrkA) is being evaluated in two phase II studies in patients with recurrent B3 thymoma and thymic carcinoma (NCT01011439 and NCT 01301391).A phase II study is evaluating the role of the mammalian target of rapamycin (mTOR) inhibitor, everolimus in patients with TETs previously treated with chemotherapy. (NCT02049047).In conclusion, although the presence of targetable mutations detected by current techniques of molecular profiling is low, whole genome and exome sequencing has the potential to uncover novel biological targets. Although many trials of targeted agents have yielded disappointing results, the unprecedented activity of sunitinib in thymic carcinoma and the disease stabilizing effect of cixutumumab in thymoma provides an impetus to continue to explore the role of novel biological agents in TETs.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.


Pulmonary embolism (PE) is a known cause of morbidity and mortality in oncology patients. Whilst much of the literature focuses on the detection of incidental PE in this cohort of patients (approximately 4%), little is written about the rate of positive CT Pulmonary Angiograms (CTPA) when PE is clinically suspected. We wanted to assess the rate of positive CTPA specifically amongst oncology patients with suspected PE in our teaching hospital.We retrospectively analysed all consecutive CTPAs carried out for clinically suspected PE over a 12 month period in all patients under our oncology services.A total of 230 oncology patients had a CTPA to exclude PE and 40 were positive (17.4%). Of the positive CTPAs, most  showed multiple PEs. The commonest cancer patients to undergo CTPA were lung (38), breast (34) and lymphoma (26) patients, and the highest incidence of positive CTPA were in breast (7/34), ovarian (2/9) and pancreatic (2/5) carcinoma. CTPAs carried out in colorectal carcinoma patients had the lowest probability of being positive (1/15).The published rate of positive CTPA for clinically suspected PE in the general population is 15-20%. Our study shows that despite the widely held view that oncology patients are more prone to pulmonary thromboembolic disease, the incidence of positive CTPA is in fact similar to the general population. Our threshold for imaging oncology patients should therefore be the same as in the general population.


Noninvasive ventilation (NIV) in the management of chronic obstructive pulmonary disease (COPD) patient with acute hypercapnic respiratory failure is considered a first-line therapy. However, higher mortality was shown in patients receiving transition from NIV to invasive mechanical ventilation than in patients receiving invasive mechanical ventilation from the first management. We tried to find parameters associated with early NIV failure in patients presenting to ED with acute exacerbation of COPD.Medical records of 218 patients with acute exacerbation of COPD visiting Asan Medical Center and managed with NIV during their stay in the ED from January 2007 to December 2013 were analyzed.NIV was successful in 191 (87.6%) and 27 (12.4%) failed NIV treatment. Of the variables obtained before NIV treatment, heart rate  and pH  were significant factors associated with early NIV failure. Of the variables obtained after 1 hr of NIV treatment, heart rate  and pH  were still significant.Presence of tachycardia and severe acidosis before NIV treatment, and persistence of tachycardia and severe acidosis after 1hour of NIV treatment predicted early NIV failure.


Aspiration can cause a diverse spectrum of pulmonary disorders some of which can lead to death but can be difficult to diagnose.The medical records and autopsy findings of 57 consecutive patients in whom aspiration was the immediate cause of death at Mayo Clinic  over a 9-yr period, from January 1 2004 to December 31 2012 were analyzed.The median age at death was 72 years  and included 39 (68%) males. The most common symptom before death was dyspnea (63%) and chest radiography revealed bilateral infiltrates in the majority (81%). Most common precipitating factors for aspiration were depressed consciousness (46%) and dysphagia (44%). Aspiration-related syndromes leading to death were aspiration pneumonia in 26 (46%), aspiration pneumonitis in 25 (44%), and large airway obstruction in 6 patients (11%). Aspiration was clinically unsuspected in 19 (33%) patients. Antimicrobial therapy had been empirically administered to most patients (90%) with aspiration pneumonia and aspiration pneumonitis.We conclude aspiration-related deaths occur most commonly in the elderly with identifiable risks and presenting bilateral pulmonary infiltrates. One-third of these aspiration-related pulmonary syndromes were clinically unsuspected at the time of death. Aspiration is defined as inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract Using a computer-assisted search of medical records we identified 57 patients undergoing an autopsy at the Mayo Clinic  over a 9-year period from January 1, 2004 to December 31, 2012 and were identified to have aspiration-related pulmonary disease as the immediate cause of death on postmortem examination. This cohort comprised 1.2% of 4,623 autopsies that included examination of the lungs over this period, Aspiration-related pulmonary syndromes encountered in this cohort included aspiration pneumonia, aspiration pneumonitis and large airway obstruction. Aspiration pneumonia was diagnosed by: 1) clinical and radiologic features of pneumonia  and 2) pathologic findings of aspiration  and acute bronchopneumonia sometimes accompanied by microabscesses and granulomatous inflammation at postmortem examination. Aspiration pneumonitis was diagnosed by: 1) acute onset of respiratory symptoms with new pulmonary infiltrates on chest imaging and 2) pathologic evidence of acute lung injury  combined with the presence of foreign material or foreign body giant cell reaction at postmortem examination. Large airway obstruction was defined as acute respiratory failure related to the presence of large particulate material causing large airway obstruction confirmed on postmortem examination. Patients who died from drowning and amniotic fluid aspiration were excluded. Other forms of aspiration-related pulmonary syndromes including diffuse aspiration bronchiolitis and exogenous lipoid pneumonia were not encountered in this autopsy study. We identified the time of aspiration event based on available medical history as well assessment of clinical course and emergence of new pulmonary infiltrates on chest imaging. The current study was approved by the Mayo Foundation Institutional Review Board .Medical records were examined in detail and the following data were retrieved: age, sex, clinical presentation, risks for aspiration, radiologic findings, events leading up to death, and autopsy findings. We also determined clinician's diagnosis as to the cause of death based on review of all available medical records including clinical notes as well as the clinician diagnoses listed on death certificates. The clinician diagnosis and the type of aspiration-related pulmonary syndrome causing death was assigned based on a review of all available data by consensus of the two authors (XH and JHR).Continuous data are presented as median and range , when appropriate, and frequency, percentages for categorical variables.Of 57 patients with aspiration-related deaths, 39 (68%) were male Table 1.One or more precipitating factors for aspiration were identified in all 57 patients and mainly included depressed consciousness in 26 patients (46%), dysphagia  in 25 patients (44%); 6 patients had two risk factors Table 2.The type of aspiration-related pulmonary syndrome leading to death were classified as aspiration pneumonia in 26 (46%), aspiration pneumonitis in 25 (44%), and large airway obstruction in 6 (11%). All six large airway obstruction cases died within 72 hours of aspiration. Among the 19 aspiration pneumonitis cases in whom the time of aspiration event could be identified retrospectively, 14 (74%) died within 72 hours. In contrast, among 22 cases of aspiration pneumonia in whom the time of initial aspiration event could be identified, only 6 (27%) died within 72 hours.Among 27 patients who suffered aspiration in the hospital were 10 aspiration pneumonia, 14 aspiration pneumonitis and 3 large airway obstruction cases. In the remaining 30 patients with aspiration likely occurring outside of the hospital were 16 aspiration pneumonia, 11 aspiration pneumonitis and 3 large airway obstruction cases.Main symptoms recorded preceding death included dyspnea (63%), decreased consciousness (19%) Table 1.Fifty-three patients (93%) underwent chest radiography, 16 of whom also had undergone chest computed tomography (CT); four patients had no chest imaging available prior to death. Bilateral distribution of parenchymal abnormalities was seen in 44 patients (83%). The predominant radiologic findings were patchy alveolar infiltrates and/or atelectasis in 46 patients (87%); remaining seven patients exhibited mixed patterns of interstitial, consolidative, and ground-glass opacities. These chest imaging findings were relatively nonspecific.During the hospital course, 35 patients underwent invasive mechanical ventilation (non-invasive ventilation in two patients including one with aspiration pneumonia and another with aspiration pneumonitis); 20 patients had aspiration pneumonitis, 14 patients had aspiration pneumonia and, 1 patient had large airway obstruction. Extracorporeal membrane oxygenation was also employed in one patient with aspiration pneumonitis. Bronchoscopy was performed in 16 patients, including one procedure performed at an outside hospital and one patient who underwent the procedure twice. Three of these patients were found to have evidence of aspiration and 12 patients underwent the procedure for clearance of airway secretion; the bronchoscopic inspection was normal in the remaining patient.Staphylococcus aureus , Enterobacter species (two patients), Streptococcus(one patient), Nocardia (one patient), Klebsiella pneumoniae complex coexisting with Enterococcus (one patient), and Candida (one patient with lymphoma). Microbial culture results were available in 14 patients with aspiration pneumonitis , 9 of whom had potential pathogens identified including Staphylococcus aureus , Escherichia coli , Enterobacter species , Klebsiella species (two patients), Citrobacter koseri (one patient) and Streptococcus species (one patient). Antimicrobial therapy had been administered to 23 patients (88%) with aspiration pneumonia and 22 patients (92%) with aspiration pneumonitis, including three in each group treated with antifungal drugs.Microbial culture results were available in 19 patients  with aspiration pneumonia, nine of whom had potential pathogens identified including Aspiration was included among diagnostic possibilities by clinicians at the time of death for 38 patients (67%). Nineteen patients (33%) whose aspiration was clinically unsuspected included nine who died from aspiration pneumonitis, nine with aspiration pneumonia, and one with large airway obstruction Table 3.With the exception of few reported cases, aspiration-related deaths have not been methodically investigated Our data also show that dysphagia related to neurologic disorders comprise the commonest precipitating factor for aspiration-related deaths, followed by depressed consciousness related to sedation. These findings are in agreement with prior studies showing neurologic disorders and sedation to be common precipitating factors for aspiration Dyspnea was the most common symptom recorded for patients in this study and is similar to a prior study describing the presence of this symptom in almost half of 36 aspiration cases confirmed on lung biopsy specimens Aside from large airway obstruction-related death which is very familiar to clinicians According to our data, aspiration pneumonia is the most common type of aspiration-related pulmonary syndrome leading to death. There were more patients with underlying neurological disorders in our study for whom the median age was 72 years old compared to two prior studies Staphylococcus aureus, Enterobacter species rather than anaerobes. This was similar to that previously reported in the literature Our data demonstrated the common isolated pathogens in aspiration pneumonia were Pathogenic bacteria were recovered in a portion of patients with aspiration pneumonitis, a disease entity generally thought to involve aspiration of sterile gastric contents. There are several potential explanations for this finding. Any form of aspiration is likely to include entrance of oral secretions into the lung. Emerging data on human microbiota have demonstrated that multiple species of bacteria can exist in the stomach as well as lungs of healthy individuals Irwin and colleagues Aside from the issue of correctly diagnosing aspiration-related syndromes, our study has some implications on the prevention of aspiration-related deaths. The patients at risk appear to be identifiable such as those with neurologic impairment and dysphagia. Optimal strategies in managing patients identified to be at risk generally require multidisciplinary expertise in maintaining adequate hydration and nutrition while minimizing the risks of aspiration. These options many include tube feeding, oral and bronchial hygiene measures, positioning, antimicrobial and other pharmacologic therapies This study included consecutive patients undergoing autopsy during a nine year period and the diagnostic criteria were based on combined clinical and autopsy findings. We, however, acknowledge that the limitations of this study including the retrospective design which limited the analysis to clinical data available in medical records and autopsy results. There are likely many patients who died from aspiration but did not undergo a postmortem examination and were undiagnosed. There is a selection bias in autopsy studies which tend to enrich for atypical and diagnostically challenging cases. Microbiology data were limited to standard respiratory cultures obtained at postmortem examination and may not have recovered some pathogens such as anaerobic bacteria. Furthermore, aspiration pneumonia and aspiration pneumonitis can sometimes be difficult to distinguish.Aspiration-related deaths most commonly occur in the elderly with identifiable risks and often manifesting bilateral pulmonary infiltrates. In one-third of these patients aspiration as the cause of death was unsuspected by clinicians.