No objective technique exists to distinguish necrotic from viable tissue, risking over-excision in burns and loss of wound healing potential. Using delayed fluorescence imaging of indocyanine green (ICG), a method called second window ICG (SWIG), we have shown that high dose ICG persists in burn wounds in both animals and patients 24 hours after infusion. The necrotic avidity of ICG is proposed as the underlying mechanism, although inflammation also likely has a role. The objective of this study is to examine the hypothesis at both the tissue and cellular levels.To examine the localization of ICG in burn tissue, 4-mm biopsies taken from burn patients who underwent SWIG were embedded and sequentially sectioned for H&E (tissue architecture) and LDH (tissue viability) and ICG fluorescence imaging. To examine whether ICG preferentially binds to necrotic cells, primary skin cells (fibroblasts or keratinocytes) were subjected to thermal injury at 65ºC for 0 (untreated), 2.5 or 5 minutes. The cells were subsequently incubated with ICG at concentrations ranging from 0.5 to 5 μg/mL at 37ºC for 30 minutes. A necrosis and apoptosis detection kit with Yo-Pro™-1 and propidium iodide (PI) was used to differentiate live, apoptotic and necrotic cell populations in flow cytometry. The ICG florescence intensity of each cell population was measured with flow cytometry.The fluorescence microscopic imaging revealed that ICG intensity was most intense in the superficial severely thermally-injured tissue and gradually decreased with depth. This zone of high ICG intensity was co-localized with high cellularity (shown in H&E) consisting of a mixture of nonviable skin cells (shown in LDH) and inflammatory infiltrates. Using flow cytometry, the optimal concentration of ICG with the highest ICG florescence median intensity (FMI) and the best separation of live, apoptotic and necrotic cell populations was 2.5 μg/mL, which was used for subsequent flow cytometry experiments. For both fibroblasts and keratinocytes, the ICG FMI was significantly higher in the necrotic cell population than that of either the live or apoptotic cell population, suggesting higher affinity of ICG to necrotic cells. The ICG FMI of necrotic cells with longer heat exposure (5 minutes) was significantly higher than that of necrotic cells with shorter heat exposure (2.5 minutes), suggesting that the binding sites for ICG increase with the degree of thermal injury.This study demonstrates the necrotic avidity of ICG in burned skin tissue and two primary skin cell types. Further studies are needed to study the ICG binding characteristics with inflammatory cell populations and single cell suspensions dissociated from human burn tissue.This, along with our pilot study of SWIG in patients, supports the feasibility of SWIG in guiding surgical decision-making in burn excision by defining thresholds of fluorescence intensity values.


PLOS Biology demonstrates that combined therapy targeting enhancer of zeste homolog 2 (EZH2) and histone deacetylases (HDACs) may sensitize CRPC to both epigenetic and standard therapies.Development of resistance in castration-resistant prostate cancer (CRPC) involves epigenetic pathways. A new study in  Development of resistance in castration-resistant prostate cancer (CRPC) involves epigenetic pathways involving EZH2 and HDACs. This Primer explores a PLOS Biology study showing that combined epigenetic therapy targeting these enzymes can activate cellular stress pathways, which may sensitize CRPC to both epigenetic and standard therapies. Despite advances in diagnosis and treatment, prostate cancer remains the second-leading cause of cancer-related death in men and a significant health concern. This is attributable to its high incidence (an estimated 1 in 8 men are diagnosed with prostate cancer), late stage of diagnosis and development of treatment resistance. Prostate cancer develops in the prostate gland mainly due to dysregulated androgen signaling through the androgen receptor. Androgen receptor has a critical role in regulating the growth and differentiation of prostate cells and is frequently overexpressed or mutated in prostate cancer cells. Suppression of androgen receptor signaling by androgen deprivation therapy (ADT), which involves blocking the production or activity of androgens, has been a major treatment approach for prostate cancer. However, the effectiveness of ADT is limited, and prostate cancer cells can eventually develop resistance to this therapy by finding alternative ways to activate the androgen receptor signaling pathway, leading to development of castration-resistant prostate cancer (CRPC). CRPC consequently is an advanced stage of prostate cancer with limited treatment options. Understanding the biological mechanisms involved in maintenance of CRPC and ways to directly target the resistance mechanisms are therefore critical.Development of the CRPC state involves epigenetic reprogramming in response to persistent androgen receptor targeting, wherein the epigenetic enzyme enhancer of zeste homolog 2 (EZH2) has a critical role. EZH2 is a histone methyltransferase that complexes with polycomb repressive complex 2 (PRC2) components to catalyze the trimethylation of histone H3 lysine 27 (H3K27me3), which is associated with gene repression . EZH2 ovIn addition to EZH2, another key epigenetic enzyme important in CRPC is the class of histone deacetylases (HDACs). HDACs are enzymes that remove acetyl groups from histone proteins in chromatin, which can lead to a tighter packing of DNA and a reduction in gene expression . HDACs aPLOS Biology, Schade and colleagues found that targeting the epigenetic functions of both EZH2 and HDACs together had a synergistic effect in killing CRPC cells, independent of androgen receptor activity [ATF3, which resulted in an acute cytotoxic effect both in vivo and in in vitro models of aggressive CRPCs. Schade and colleagues hypothesized that genes suppressed by EZH2 are incompletely derepressed upon inhibiting EZH2 alone because of sustained presence of deacetylated histones at the target gene regulatory elements  by performing expression analysis to identify up-regulated genes and pathways, ChIP-seq, and siRNA knock-down screens. reatment . ATF3 ha results  show thaFinally, combination epigenetic therapies have been a focus of research for various cancer types . While E


Streptococcus infections (iGAS) among children in the United States. Colorado and Minnesota observed an increase in the number of cases in the Fall 2022. Similarly, the Pennsylvania Department of Health issued a health alert that was then lifted in February 2023. Preliminary CDC data showed that iGAS infections were higher in some areas of the country compared to pre-pandemic levels. Lehigh Valley Reilly Children’s Hospital is a community teaching hospital in Allentown, Pennsylvania. A rise in the number of children admitted with GAS infections was noted in the same period compared to previous years. The aim of our study was to determine the clinical characteristics of patients admitted with iGAS and non-iGAS infections during fall and winter 2022-2023.In December 2022 the CDC issued an alert about possible increase of invasive group A st 2022 through March 31st 2023 and diagnosed with GAS infection plus those admitted with the same diagnosis between 2018 and 2022.Retrospective chart review of patients 18 years and younger admitted to Reilly Children’s Hospital between September 1There were 19 children admitted to the hospital with GAS infection: 6 (32%) with iGAS and 13 (68 %) with non-iGAS infections. The iGAS infections included bacteremia without source (2), myositis (1), pneumonia (2), and vascular infection (1). Non-iGAS infections included retropharyngeal abscess (3), peritonsillar abscess (2), parotid abscess (1), submandibular abscess (1), lymphadenitis (2), mastoiditis (1), cellulitis (1), pharyngitis (1), and erythema nodosum (1). Six children required intensive care and two were transferred to higher level care. Median age was 2.2 year for iGAS infections and 4.8 years for non-iGAS. All but one patient had no underlying medical conditions. There were no patient deaths. In 2018 there were zero cases of iGAS infection; in 2019: two cases; 2020: two cases; 2021: zero cases. There were no admissions between May 2020 and April 2022 for either iGAS or non-iGAS.The number of children admitted for iGAS and non-iGAS infections in the fall and winter of 2022-2023 surpassed the preceding 4 years combined. This is reflective of what was happening in some other areas of the country as a result of reduced exposure and lack of immunity due to pandemic restrictions.All Authors: No reported disclosures


Staphylococcus aureus (MSSA) bacteremia and/or abscess following sacroiliac (SI) joint injections for pain at an outpatient surgery center. Two recovered after treatment and one expired 9 days after the injection. CDPH-HAI and the LHD conducted an investigation.In February 2023, a local health department (LHD) notified the California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program of 3 patients hospitalized for methicillin-susceptible LHD and CDPH infection preventionist staff went on site to evaluate infection control (IC) practices. Whole genome sequencing (WGS) was performed on all available MSSA isolates at the CDPH Microbial Diseases Laboratory.Initial investigation revealed single-dose vials of one product had been used for multiple patients; this practice was discontinued. WGS found the 3 patient isolates were identical (0 single nucleotide polymorphism (SNP) difference). The same healthcare personnel (HCP) team had performed the procedures for all 3 infected patients. A site visit identified gaps in IC and injection safety practices. One HCP who provided care to all 3 patients had visible skin lesions on their hands, wore bracelets, and was unaware of a facility policy to report if they were unable to perform adequate hand hygiene. MSSA screening cultures were collected from 3 involved HCP and were positive in only the HCP with skin lesions. WGS showed that the HCP MSSA isolates were highly related to the patient isolates (0-2 SNP difference). We advised the facility to develop an IC program tailored to the procedures performed, including adverse event surveillance, adherence monitoring of hand hygiene and environmental services practices, and attention to injection safety. The MSSA colonized HCP was referred for treatment of their skin condition and decolonization and was restricted from patient care until their skin condition improved.Phylogenetic tree for MSSAA combination of injection safety and hand hygiene lapses led to MSSA transmission from an HCP to 3 patients. This cluster underscored the importance of IC programs in outpatient clinics and the risk of transmission of infectious agents from HCP to patients with gaps in IC practices. It also highlighted the contribution of WGS in investigating HAI outbreaks.All Authors: No reported disclosures


Frontiers in Physiology focused on emerging research on nuclear receptors and cardiovascular function in health and disease. Unlike cell membrane G-protein-coupled receptors that elicit biological responses through second messenger signaling, nuclear receptors are a large family of transcription factors that primarily bind to genomic DNA and regulate the expression of target genes, although non-genomic actions of nuclear receptors have also been identified . These studies demonstrate that 2ME2 downregulates AT1 receptor expression in the kidney cortex and liver without impacting angiotensin II binding affinity . The blood pressure-lowering effect of 2ME2 is independent of sex in Wistar rats infused with angiotensin II. In addition, prolonged 2ME2 treatment decreases heart rate and body weight in male SHRs. Collectively, this study demonstrated that 2ME2 plays a critical role in regulating the renin–angiotensin system and resting heart rate through the downregulation of angiotensinogen and AT1 receptor . Sundin et al. determined that turbulent kinetic energy of blood flow in the healthy human thoracic aorta increases with dobutamine stress and is strongly related to cardiac output. Quantification by magnetic resonance imaging (MRI) was performed to determine 4D flow-based hemodynamic parameters and turbulent kinetic energy and evaluate dobutamine stress on thoracic aortas. Findings of this study demonstrate that turbulent kinetic energy with cardiac stress could serve as a risk assessment for aortic disease development . Future studies that focus on the therapeutic potential of 2ME2 to treat hypertension and MRI-based 4D turbulent kinetic measurement to assess cardiovascular disease progression are required.Two original research articles provide novel findings on the regulation of angiotensin type 1 (AT1) receptors by the estrogen metabolite, 2-methoxyestradiol (2ME2), and quantification of turbulent flow and aortic disease development. Imig focused on PPAR and FXR dual modulating drugs for the treatment of metabolic diseases, organ fibrosis, and hypertension. Evidence from clinical studies and animal hypertension models demonstrated that PPAR and FXR agonism can lower blood pressure and decrease end-organ damage in metabolic diseases and hypertension. This review article details the emerging dual modulating drugs that combine PPAR and FXR agonism with soluble epoxide hydrolase (sEH) inhibition or Takeda G-protein receptor 5 (TGR5) agonism (Imig). In preclinical studies, these novel drugs demonstrate reduced side effects in addition to anti-hypertensive, anti-fibrotic, and anti-inflammatory actions. Ertuglu et al. focused on PPARγ regulation in salt-sensitive hypertension and insulin resistance. This review highlights the ability of PPARγ agonists to increase insulin sensitivity and ameliorate salt sensitivity. These findings on the role for PPARγ in pathogenesis of insulin sensitivity and salt sensitivity were coupled with newly found effects on the immune system and vascular function . These review articles provide a framework for future studies to explore nuclear receptor-based drugs in treating metabolic and cardiovascular diseases.Two review articles in this Research Topic focused on PPAR and farnesoid X receptor (FXR) therapeutics for hypertension and PPARγ regulation in salt-sensitive hypertension and insulin resistance. Nuclear Receptors in Hemodynamics and Blood Pressure Control presents two original articles and two review articles that highlight emerging findings in the field that could lead to enhanced cardiovascular risk detection, therapeutics for hypertension including salt-sensitive hypertension, and development of dual modulating drugs for metabolic and cardiovascular diseases. Continued understanding of the contribution of nuclear receptors to controlling organ blood flow and blood pressure is needed for the development of effective therapies to combat hypertension and other cardiovascular diseases.The Research Topic


The advent of enhanced conjugate pneumococcal vaccines for adults has created a need to assess the burden of pneumococcal disease in different populations to support recommendations for vaccination. We assessed the epidemiology of invasive pneumococcal disease (IPD) in adults with underlying lung disease in Ontario, Canada.Streptococcus pneumoniae; annual audits ensure completeness. Isolates are serotyped at the National Microbiology Laboratory. Population data are from Statistics Canada, with estimates of prevalence of underlying conditions from ICES.Ontario introduced PCV7 and PCV13 for children in 2007 and 2010, and PCV13 for immunocompromised adults over 50 years in 2014. TIBDN performs population (pop’n)-based surveillance for IPD in a pop’n of ∼4.5 million. Microbiology laboratories serving area residents report sterile site isolates of From 2014-2022, 2769 episodes of IPD occurred in adults; detailed clinical data are available for 2366 (85%), and serotyped isolates for 88%. Of these, 573 (24%) had no chronic underlying illness (undill); 1155 (49%) had an undill not affecting the lungs, 165 (7%) had asthma only, 409 (17%) had COPD (with/without asthma or other lung disease (OLD), 64 (2.7%) had OLD alone (most commonly ILD or bronchiectasis). Among those with asthma, 87 (53%) had another undill predisposing to IPD; compared to 290 (71%) of those with COPD and 45 (70%) of those with OLD. Persons with asthma were younger (median age 56y) than those with no or other undill (64y and 61y), and those with COPD or OLD (70 and 71y). Persons with lung disease were more likely to present with bacteremic pneumonia and less likely to have primary bacteremia or meningitis that those without or with other chrill. ICU admission and case fatality rates are in Table 1. The distribution of serotypes causing disease by conjugate vaccine types did not differ among those with lung disease and others . The incidence of disease in persons with asthma and COPD by age group is shown in Figure 2.The epidemiology of IPD differs somewhat in persons with lung disease compared to others, but conditions other than lung disease have a greater impact on incidence and outcome of IPD in adults. Enhanced PCVs likely provide cost-effective protection for 50-64 year olds with asthma/COPD.All Authors: No reported disclosures


Correction: Research Involvement and Engagement (2022) 8:8 10.1186/s40900-022-00337-xSearch strategy and study selection. The revised Appendix 3: Prisma flow chart and the Search strategy and study selection section is indicated hereafter and the changes in the given section have been highlighted in bold typeface.Following publication of the original article [1], the authors reported errors in Appendix 3: Prisma flow chart and would like to correct the number of studies under the heading The incorrect Search strategy and study selection section reads:248 papers were excluded leaving a total of 23 studies from the published literature search.After full-text screening, a further The correct Search strategy and study selection section should read:249 papers were excluded leaving a total of 23 studies from the published literature search.After full-text screening, a further Appendix 3: Prisma flow chart should read:Appendix 3: Prisma flow chartAll the changes requested are implemented in this correction and the original article [ article  has been


Schizophrenia is a chronic psychiatric illness with symptoms in positive, negative and cognitive domain.The interplay of dietary folic acid intake with common genetic variants that influence folate metabolism, has potential implications for Schizophrenia pathogenesis and treatment.Therefore, it’s deficiency has been identified as a risk factor for Schizophrenia through epidemiologic, biochemical and gene association studies.1-To assess the efficacy of folic acid supplementation on severity of symptoms and overall functional status of patients2-To assess the correlation of serum folate levels with symptom severity and overall functional status of patientsexperimental Group A which received 5mg folic/day along with anti psychotic drugs and control Group B which received only anti psychotic drugs) and followed up for 3 months. Blood sample for measuring serum folate level was obtained from the experimental group at the beginning and at the end of the study period. Scales applied were Positive and Negative Syndrome Scale(PANSS) for symptom severity and Global Assessment of Functioning scale(GAF) for overall functional status.A randomized control trial study was carried out in the inpatient department of a psychiatric tertiary care centre on 40 participants who were between the ages of 18 – 55 years,met diagnostic criteria for Schizophrenia (ICD 10) and had at least 2 years of illness duration while those with a co-morbid psychiatric illness, medical illness and substance abuse were excluded. The participants were then randomly allocated into two groups (table 1) and also in GAF scores between both the groups after 3 months(table 2). At the end of the study period,a strong negative correlation(r= -0.9) was found between serum folate level and total PANSS score in the experimental group (figure 1) while the correlation between GAF score and serum folate level was strongly positive (r= 0.8) (figure 2).A significant difference  was observed in PANSS scores at the end of the study between experimental group and control group( Image:Image 2:Our study is among the few to use a randomized controlled study design for assessing the effect of folic acid supplementation on severity of symptoms and global functioning in Schizophrenia,strongly suggesting the use of folic acid as an adjuvant treatment for Schizophrenia.None Declared


Serial point of care ultrasound (POCUS) exams are essential to assess acute pericardial effusions which can rapidly evolve into cardiac tamponade. A typical presentation includes dyspnea, tachycardia, and chest pain. Importantly, serial cardiac exams in such high-risk patients can detect other concurrent pathologies. We present an unusual case of a patient who initially presented with an acute circumferential pericardial effusion and upon serial POCUS exams developed an unexpected Takotsubo cardiomyopathy in the setting of cardiac tamponade.  A 63-year-old woman with a past medical history of Human Immunodeficiency Virus, asthma, and previously treated Hodgkin’s lymphoma presented to the emergency department with 3 weeks of worsening shortness of breath. On initial assessment in the emergency department, the patient was hemodynamically unstable with a heart rate of 140 beats per minute (bpm) and a blood pressure of 88/68 mm Hg. Bedside point of care ultrasound (POCUS) was performed and demonstrated a moderate circumferential pericardial effusion with normal left ventricular function and a collapsible inferior vena-cava (IVC). Intravenous fluids were initiated with resolution of the patient’s hemodynamic instability (Video S1). A computer tomography (CT) of the chest was also obtained in the emergency department which showed extensive mediastinal lymphadenopathy with right middle lobe consolidation. The patient was admitted for evaluation of the pericardial effusion and CT findings. Forty-eight hours after admission, the patient reported persistent midsternal chest pain and shortness of breath with a blood pressure of 110/60 mm Hg, heart rate of 127 bpm, and an oxygen saturation of 100% on 2-liters nasal cannula. Repeat troponin I was elevated at 1.02ng/ml (ref - <0.03 ng/ml). POCUS was performed which revealed mid-to apical left ventricular (LV) akinesis and an interval reduction of LV function along with right atrial systolic collapse, right ventricular diastolic collapse and a plethoric IVC (Video S2). Limited transthoracic echocardiogram done by the echocardiography lab shortly after confirmed the findings. These findings were concerning for Takotsubo/stress induced cardiomyopathy in the setting of tamponade physiology. The patient underwent a pericardiocentesis with removal of 240 mL of fluid with improvement of tachycardia and dyspnea. Formal echocardiography 48 hours after the procedure showed minimal residual effusion with improvement of LV function, which returned to normal within a week (Video S3). Cytology of the pericardial fluid showed inflammatory and mesothelial cells with no evidence of malignant cells. However, subsequent lymph node biopsy revealed recurrence of Hodgkin lymphoma to which her pericardial effusion was attributed. Cardiac tamponade is a pericardial syndrome characterized by impairment of diastolic filling of the ventricles causing reduction of cardiac output. The classically advanced signs of tamponade described as hypotension, distension of jugular veins, and diminished heart sounds (Becks Triad) are present in a minority of patients. The most common initial presenting symptoms are dyspnea and tachycardia, which may be present in the absence of hypotension Echocardiographic evaluation of tamponade includes: i) Quantity and quality of pericardial fluid ii) Systolic right atrial collapse iii) Diastolic right ventricular size and variability with the respiratory cycle iv) Interventricular septal shift of the left ventricle during inspiration v) Collapsibility of IVC Diastolic right ventricular collapse is specific for tamponade while IVC plethora is highly sensitive. Systolic right atrial collapse is often the earliest sign of tamponade. Comprehensive or advanced critical care echocardiography can be used to detect exaggerated respiratory cycle changes in mitral and tricuspid valve in-flow velocities as a surrogate for pulsus paradoxus In this patient the initial POCUS exam revealed a moderate sized pericardial effusion with a fully collapsible IVC making tamponade physiology less likely. When the patient developed new onset chest pain and shortness of breath this raised the concern for worsening tamponade. A repeat ultrasound revealed an unexpected finding of stress induced cardiomyopathy which can potentially be attributable to progressive tamponade development. Potentially the tamponade was further exacerbated by left ventricular dysfunction.In dog models right atrial and ventricular collapse occurred with significantly smaller volumes of pericardial fluid in the setting of induced left ventricular dysfunction Takotsubo-associated myocardial dysfunction is irrespective of vascular territories, and commonly presents as transient mid to apical akinesia, hypokinesia, or dyskinesia in the absence of obstructive coronary disease. Other findings include circumferential apical dilatation , basal hyperkinesia and a severely reduced left ventricular function This case highlights the importance of serial cardiac POCUS examinations in the evaluation of pericardial effusion. Additionally, it highlights the importance of recognizing an acute concurrent cardiac pathology that can quickly lead to a vicious cycle of cardiac dysfunction leading to decompensation. The authors confirm that consent to publish this case was obtained from the patient.All authors of this manuscript have no conflicts of interest. The authors listed have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript. Video S1 Video S2 Video S3


Since the development of optical coherence tomography (OCT), technological improvements have made this diagnostic imaging tool adaptable to clinical settings . OCT proA 2018 Cochrane review, “Optical Coherence Tomography for Diagnosing Skin Cancer in Adults,” provides an in-depth review of the accuracy of OCT for detecting skin abnormalities. Data from five test accuracy studies were obtained, permitting comparison of the index test to a reference standard. The diagnostic accuracy of OCT was assessed for melanoma (n=2) and keratinocyte carcinomas (n=3). There were insufficient data to determine the diagnostic accuracy of OCT for melanoma or cutaneous squamous cell carcinoma. In a sample of 346 lesions (n=2 studies), the sensitivity and specificity of OCT for detecting basal cell carcinoma (BCC) was potentially superior versus visual assessment and dermoscopic exam—however, given a limited sample size and the high prior probability of BCC, results must be interpreted cautiously. Applied to a hypothetical population (n=1000 people), OCT had better outcomes than visual and dermoscopic exams, correctly identifying 53 more BCC lesions while reducing the incidence of false positives and unnecessary excisions by 87 [The high sensitivity and specificity of OCT for BCC diagnosis are noted in subsequent reviews and expert consensus ,4. An inThe insufficient number of studies available for inclusion, study heterogeneity, and restricted study populations limit the conclusions that may be drawn regarding the diagnostic utility of OCT . Include


In recent years, there has been an increase in the number of candidates for bariatric surgery and a decrease in psychiatric contraindications.We aim to make an descriptive evaluation of unfavorable feedback concerning mental health of the candidates for bariatric surgery of the Local Health Unit of Matosinhos .Descriptive analysis of unfavorable feedback of mental health of candidates for surgical treatment of obesity.From March 2017 to August 2022, the Mental Health Service of the Local Health Unit of Matosinhos issued 347 pre-surgical feedback. In 63 cases the initial opinion issued was unfavorable: 11 cases due to a psychiatric contraindication (not meeting conditions for intervention) and 52 cases had a conditional opinion . Regarding contraindications, these were due to alcohol use disorder (n=3), binge eating (n=3), intellectual development disorder (n=2), purgative behavior (n=1), psychotic disorder (n=1) and mood disturbance (n=1). In terms of conditional opinions, the issues mencioned were lack of motivation for surgery (n=22), psychopathology (n=20), doubts about informed consent (n=8) and need for multidisciplinary discussion/coordination (n= 7).There was an increase in eligibility of candidates for surgical treatment as most of the initial unfavorable opinions were conditional. This could be explained by the decline of complications associated with bariatric surgery, but also because psychiatric disorders are now being viewed as treatable. Notably people with eating disorders are now fit for surgery after a medical or psychotherapeutic intervention.None Declared


The pathogenesis of Psoriatic Arthritis (PsA) remains poorly understood. The underlying chronic inflammatory immune response is thought to be triggered by unknown environmental factors potentially arising from a defective immune function.To determine whether an impaired acute inflammatory response by Dendritic Cells (DCs) might compromise the clearance of bacteria and predispose to chronic inflammation in PsA.Mycobacterium tuberculosis, Mycobacterium avium paratuberculosis and a range of other bacteria and TLR ligands was determined. Phenotypical differences involved in cellular responses against (myco)bacteria were determined by qPCR and flow cytometry.The cytokine production by DCs from 13 healthy controls, 11 Rheumatoid Arthritis, 13 PsA and 8 psoriasis patients from The Netherlands and from 6 Scottish healthy controls and 6 PsA patients towards The secretion of the proinflammatory cytokines TNFα and IL-6 by PsA DCs was impaired upon in vitro challenge with mycobacteria and TLR2 ligands compared to DCs from healthy controls and RA patients. DCs from psoriasis patients did not demonstrate such a dampened reaction towards mycobacteria. This impairment demonstrated by PsA DCs was associated with elevated serum CRP levels. The expression of TLR2 and other receptors known to mediate mycobacterial recognition was unaltered. The intracellular TLR(2) inhibitors SOCS3 and A20 were more highly expressed in DCs from PsA patients. PsA DCs further demonstrated up regulated levels of the autophagy-related genes ATG16L1, NOX2 and LL37; molecules implicated in the immune response against intracellular bacteria.Our findings indicate that DCs from PsA patients have a disordered immune response towards some species of (myco)bacteria. This might predicate to impaired immune responses to, and in turn impaired clearance of, these bacteria, setting the stage for the chronic inflammation of joints, entheses, skin and the gut found in PsA.


Mycobacterium avium complex (MAC) clinical isolates with varying catalase activity recovered from the blood of HIV patients in terms of invasiveness and intracellular multiplicity in host cells. The catalase activity in MAC isolates was also analysed in context to CD4 counts and clinical presentation of mycobacterial disease in HIV patients.The mycobacterial catalase-peroxidases protect it from the reactive oxidative metabolites and allow its survival within the host phagocytes. We compared the virulence of Catalase activity of KatG protein of 51 mycobacterial isolates from HIV patients was determined. MAC isolate with maximum catalase activity (KatG-max) was compared to isolate having minimum activity (KatG-min) for adherence, intracellular replication and katG mRNA expression by ZN staining, colony forming units (CFU) enumeration and RT-PCR respectively in A549 and HT29 cell lines.rd day of infection (doi) [p<0.001], whereas, it was comparable at 1st doi. CFU enumeration results correlated well with the levels of katGm RNA expression.Catalase activity of mycobacterial isolates was found to be inversely related to CD4 counts and unrelated to the clinical presentation of mycobacterial disease in HIV patients. The intracellular replication of KatG-max isolate was found to be 2 fold higher than KatG-min at 3The MAC isolates having maximum catalase activity and increased katGm RNA expression was favoured for its survival and replication in the host cells. High levels of catalase activity in isolates from HIV patients with low CD4 counts suggest an important role of KatG in the establishment and progression of disseminated MAC disease.


Conservation planning and the design of marine protected areas (MPAs) requires spatially explicit information on the distribution of ecological features. Most species of marine mammals range over large areas and across multiple planning regions. The spatial distributions of marine mammals are difficult to predict using habitat modelling at ecological scales because of insufficient understanding of their habitat needs, however, relevant information may be available from surveys conducted to inform mandatory stock assessments.Dugong dugong) abundance to create spatially-explicit models of dugong distribution and relative density at the scale of the coastal waters of northeast Australia . We interpolated the corrected data at the scale of 2 km * 2 km planning units using geostatistics. Planning units were classified as low, medium, high and very high dugong density on the basis of the relative density of dugongs estimated from the models and a frequency analysis. Torres Strait was identified as the most significant dugong habitat in northeast Australia and the most globally significant habitat known for any member of the Order Sirenia. The models are used by local, State and Federal agencies to inform management decisions related to the Indigenous harvest of dugongs, gill-net fisheries and Australia's National Representative System of Marine Protected Areas.We use a 20-year time series of systematic aerial surveys of dugong (In this paper we demonstrate that spatially-explicit population models add value to data collected for stock assessments, provide a robust alternative to predictive habitat distribution models, and inform species conservation at multiple scales. Ecological scales can vary from 10 s of km2 for isolated, sedentary species with small geographic ranges , to 100,000 s of km2 for migratory species . The scales of planning regions and ecological features are rarely congruent The data that inform conservation planning and the design of marine protected areas (MPAs) are primarily spatially explicit 2Marine mammals are some of the most highly dispersed species with geographic ranges up to 300,000,000 kmDugong dugon) occur in the shallow, protected coastal waters of some 40 countries and territories in the tropical and subtropical Indo-West Pacific. As the only herbivorous mammal that is strictly marine, dugongs are often used as a flagship species because of their high biodiversity and cultural values. Although dugongs are seagrass community specialists, their habitat needs are not yet sufficiently understood to predict their distribution at broad spatial scales using habitat modelling Dugongs (2) would require information on the distribution of: (1) seagrass habitat community composition; and (2) the various factors that influence the choice of seagrass species or habitats by dugongs. This information is currently unavailable for most of the habitats exploited by dugongs in northern Australia.Dugongs are of high cultural and nutritional value to Indigenous Australians and northern Australia is internationally recognised as supporting the most globally significant remaining dugong populations 2; almost half of their range in northern Australian waters from Moreton Bay in Queensland, the southern extremity of the dugong's range on the east coast (27°50′21″S), through the Gulf of Carpentaria (12°13′8″S) (2). These models have informed dugong conservation initiatives within the Great Barrier Reef World Heritage Area because they effectively delineate the spatial distribution of dugongs at the required scale Systematic aerial surveys have been used to monitor the abundance and distribution of dugong populations in northeast Australia  since th°13′8″S) . The sur°13′8″S)  to develThis paper updates and extends the spatially-explicit model of dugong distribution and relative density in the Great Barrier Reef region Marsh's group undertook systematic aerial surveys of northeast Australia in seven survey regions  approximUsing the technique of Grech and Marsh (2007) Most aerial surveys were conducted in late spring or early summer when weather and sea states provide optimum survey conditions . In highsensu Marsh and Sinclair (1989) 2) making them inappropriate to use in the spatially-explicit models which we developed at the scale of 2 km * 2 km planning units. Thus the models were based on relative rather than absolute population estimates, nonetheless, relative densities among regions should be approximately comparable All the aerial surveys estimated absolute dugong abundance by correcting sightings for perception bias  and availability bias  We corrected the spatial data from the aerial surveys for differences in sampling intensity and area sampled between surveys using equations described in Grech and Marsh (2007) As independent data on dugong abundance at the scale of northeast Australia do not exist, we used a re-substitution approach to validate the individual spatially-explicit population models International Union for Conservation of Nature and Natural Resources Red ListWe estimated dugong distribution and relative density at a planning unit of 2 km * 2 km because this scale: (1) corresponds with the scale of the aerial survey data allowing the model to account for: (a) slight changes in altitude of the aircraft (which affects transect width at the surface); and, (b) the blind area under the aircraft; and, (2) is recommended under Criterion B of the 2; medium density 0.0015<0.25 dugongs/km2; high density areas 0.25≤0.5 dugongs/km2; and very high density areas >0.5 dugongs/km2. We included planning units with 0 dugongs/km2 to ensure that the spatial layers extended across the entire survey region , Hervey Bay (0.43 dugongs/km2), Moreton Bay (0.19 dugongs/km2) and the northern Great Barrier Reef region (0.16 dugongs/km2). The planning units with the highest relative densities were in Moreton Bay (9.0 dugongs/km2), Torres Strait (6.49 dugongs/km2), the northern Great Barrier Reef region (6.03 dugongs/km2) and Hervey Bay (4.56 dugongs/km2). The southern Great Barrier Reef region and coastal waters of the Gulf of Carpentaria had the lowest mean (<0.07 dugongs/km2) and maximum density estimates (<1.92 dugongs/km2).The average relative dugong density in the ongs/km2 . Density2; Planning units of very high and high relative dugong density in Moreton Bay and Hervey Bay were adjacent to the mainland coast and islands . In the 2; high: 12,432 km2, medium: 63,024 km2 and low: 61,800 km2  because: (1) specialised areas of high conservation value such as calving or mating areas and migratory corridors have not been identified; and (2) density estimates are regarded as robust surrogates of habitat utilization The spatially-explicit models suggest that the broad-scale patterns of dugong distribution in coastal regions of northeast Australia are determined by the physical characteristics of their seagrass habitats: exposure to wind and wave activity, tidal ranges and seabed current stress The broad-scale patterns of dugong distribution predicted by our model can assist in the identification of important dugong habitats in data-poor areas of the Indo-Pacific. It is likely that dugongs exhibit habitat preferences similar to those in northeast Australia throughout their range , coastal waters, bays and estuaries with low wave exposure Australia aims to realise its international commitments as a signatory to the Convention on Biological Diversity through the significant expansion of its existing Marine Protected Area network throughout Australia's Exclusive Economic Zone by 2012. The central component of Australia's Oceans Policy  is the development of Marine Bioregional Plans and a National Representative System of Marine Protected Areas in Commonwealth  waters. Australia's Commonwealth , State and Northern Territory governments are working together to implement this initiative. The models of dugong distribution and relative density currently inform Australia's Oceans Policy and species conservation initiatives of local and State (Queensland and Northern Territory) governments across multiple scales. In the following section, we provide specific examples of the application of the models at local, regional and national scales to demonstrate the merits of using survey data collected for stock assessment in species conservation and the design of MPAs.2). Primarily, the models assist with the development of management decisions related to the harvest of dugongs  at the scale of Torres Strait .One of the major outcomes of our modelling exercise was the improved understanding of the relative importance of the seven survey regions to dugong conservation in northeast Australia. Torres Strait has the greatest number of very high dugong density planning units when compared to the other survey regions of northeast Australia ; Table 3Hervey Bay also has a large proportion of very high and high dugong density planning units relative to its size ; Table 3Dugongs are listed as vulnerable to extinction under schedule 3 of the Queensland Nature Conservation (Wildlife) Regulation of 1994 and were one of several explicit reasons for the World Heritage listing of the Great Barrier Reef region The Australian Government is using the models of dugong distribution and relative abundance at the scale of northeast Australia  to assisMany government agencies have developed comprehensive and dedicated monitoring programmes to estimate the size and trends of marine mammal populations for stock assessment . For example, the US Marine Mammal Protection Act of 1972 and subsequent amendments mandates the use of the Potential Biological Removal technique to estimate the maximum number of animals that may be removed from a stock Figure S1Spatially-explicit population models of dugong distribution and relative density in Moreton Bay and Hervey Bay.(TIF)Click here for additional data file.Figure S2Spatially-explicit population models of dugong distribution and relative density in the southern Great Barrier Reef.(TIF)Click here for additional data file.Figure S3Spatially-explicit population models of dugong distribution and relative density in the northern Great Barrier Reef and Torres Strait.(TIF)Click here for additional data file.Figure S4Spatially-explicit population models of dugong distribution and relative density in the Gulf of Carpentaria.(TIF)Click here for additional data file.


This study aims to quantify the acute exercise response to early passive and active activities in order to inform exercise prescription when designing rehabilitation programmes for the critically ill. Critical care survival is often associated with a poor functional outcome , with reThis study is a prospective randomised controlled trial with a repeated-measures crossover design. Eligible participants, requiring mechanical ventilation for 4 or more days, completed two exercise activities routinely used in early critical care rehabilitation, a passive chair transfer (PCT) and active sitting on the edge of the bed (SOEOB). The oxygen consumption and cardiovascular parameters were measured to quantify and compare the exercise response between the two activities.Data are presented as the median (interquartile range). Data for five patients have been collected, aged 68 years (23), with an ITU stay of 15 days (10.5) and duration of mechanical ventilation 8 days (12), at the point of intervention. Exercise response results are reported (Table Intensive care patients with prolonged mechanical ventilation demonstrate a higher rate of oxygen consumption when actively sitting on the edge of the bed, compared with a passive chair transfer. This may have important consequences for early mobilisation of the critically ill.


Ossification of the Posterior Longitudinal Ligament (OPLL) is a condition caused by new bone developing in the posterior longitudinal ligament within the spinal canal. OPLL is a common cause of myelopathy in East Asian countries. Here, we report a case with OPLL in thoracic and lumbar spine in Kermanshah, West of Iran. A 40 years old man gradually developed lower extremities paresis with defecation or voiding difficulties. Radiographic evaluation by computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the mass of ossification at the posterior aspect of the T2-T4 and T12-L1 of vertebral body with spinal cord compression. Although OPLL is a common cause of myelopathy in the East Asian countries, it should be included in differential diagnosis of myelopathy in other regions.Ossification of the posterior longitudinal ligament (OPLL), Spinal canal, Myelopathy


Sox genes encode for a group of transcription factors that share the presence of an HMG-type (high mobility group) box. This is a 79 amino acid motif that encodes their DNA binding domain. They were identified soon after the discovery of the mammalian testis-determining gene Sry, which also possesses an HMG box, and obtained their name from Sry (“Sox” Sry-related box genes). The members of the Sox family are highly conserved among vertebrates and so far 26 different genes have been identified  and SoxB2 (Sox14 and 21) subgroups, code for a group of highly related transcription factors expressed mainly in the developing and adult Central Nervous System (CNS) in mammals , either self-renew or exit the cell cycle and differentiate. NEPs make cell fate decisions controlled by extrinsic and/or intrinsic determinants . Neuronal fates are determined around the final cell cycle of NEPs during which neural differentiation factors regulate the cell cycle either directly or indirectly. Only recently, SoxB genes have been implicated in the regulation of cell cycle. Studies in the mouse developing cortex showed that Sox1 acts to maintain the undifferentiated state of NEPs via a mechanism involving suppression of Prox1–mediated cell cycle exit and neurogenesis (Elkouris et al., The transcription factors Sox1-3 have been proposed to block neuronal commitment and thus prevent differentiation (Bylund et al., Sox2 null embryos die soon after implantation, masking a potential role for Sox2 in the CNS (Avilion et al., + cortical radial identity and plasticity (Remboutsika et al., Sox2 has found itself in the position of the most celebrated of the Sox proteins due to its role in epiblast formation (Avilion et al., This review is dedicated to the memory of Prof. Larysa Pevny.


Trisomy 21 affects virtually every organ system and results in the complex clinical presentation of Down syndrome (DS). Patterns of differences are now being recognized as patients’ age and these patterns bring about new opportunities for disease prevention and treatment. Low bone mineral density (BMD) has been reported in many studies of males and females with DS yet the specific effects of trisomy 21 on the skeleton remain poorly defined. Therefore we determined the bone phenotype and measured bone turnover markers in the murine DS model Ts65Dn. Male Ts65Dn DS mice are infertile and display a profound low bone mass phenotype that deteriorates with age. The low bone mass was correlated with significantly decreased osteoblast and osteoclast development, decreased bone biochemical markers, a diminished bone formation rate and reduced mechanical strength. The low bone mass observed in 3 month old Ts65Dn mice was significantly increased after 4 weeks of intermittent PTH treatment. These studies provide novel insight into the cause of the profound bone fragility in DS and identify PTH as a potential anabolic agent in the adult low bone mass DS population. Although Down syndrome (DS) was initially described in 1866 Several investigators, including ourselves have reported that adults (and children) with DS have lower bone mass, expressed as BMD, especially in the lumbar spine, compared with their peers without mental retardation or with mental retardation but without DS The Ts65Dn mouse is one of several mouse models of DS that has been developed to investigate the pathology of DS phenotypes 16)65Dn (Ts65Dn) mouse model of DS at both 3 and 24 months of age To investigate bone health in DS, we determined the skeletal phenotype of the Ts at both 3 months and 24 months of age . There w2)); bone area fraction ; cortical thickness (mm); anteroposterior and mediolateral diameters (mm). Sub-region analysis of the mid-shaft of the femur revealed that trisomy significantly decreased cortical thickness in both 3-month old  were used.Mice were treated with daily i.p. injections of 30 or 80 ug/kg PTH(1–34), or vehicle control, for 28 days. PTH increased whole-body BMD in both 3 month old WT and Ts65Dn mice as determined by DXA . In WT mIntermittent PTH treatment caused an approximately equivalent increase in BV/TV in both WT and Ts65Dn mice . PTH incThe observed increase in trabecular bone mass and volume was mediated by a PTH-stimulated increase in mineral apposition rate and bone formation . Osteoblex vivo bone marrow cultures, the differentiation capacity of osteoblasts and osteoclasts were impaired in Ts65Dn mice, demonstrating the cell intrinsic nature of the bone phenotype, and confirming both mesenchymal and hematopoetic lineages as targets of trisomy 21. Interestingly, and as reported by others The present study demonstrated that Ts65Dn DS mice have lower trabecular bone volume and trabecular number and higher trabecular separation in the proximal tibia and distal femur as well as decreased cortical thickness and strength compared with WT littermates. The low bone mass phenotype is consistent with the human DS population that also displays a low BMD due to decreased bone turnover Ts65Dn mice at 3-months and 24-months of age have significant decreases in trabecular and cortical bone. The BV/TV and trabecular number are significantly decreased at both ages. With the decreased number of trabeculae, there was a subsequent significant increase in trabecular spacing. Interestingly, trabecular thickness was not significantly affected, suggesting that the fundamental mechanism controlling the development of trabeculae is intact in trisomic Ts65Dn mice, but the rate at which they are generated is decreased. These results extend those of Blazek Other DS mouse models have been developed and their bone phenotype investigated The low bone mass phenotype of Ts65Dn male mice like people with DS is profound and is the result of decreased bone turnover. The decreased bone turnover is unexpected, given the hypogonadism and infertility associated with the disorder in humans ex vivo bone marrow cultures and in the histomorphometric analysis of tibias from 3-month old Ts65Dn mice. In ex vivo cultures, both osteoblast and osteoclast differentiation was significantly decreased in Ts65Dn compared with control. In vivo, osteoblast number per bone surface, osteoclast number per bone surface and bone formation rate were all significantly decreased. These observations suggest an intrinsic defect in both the mesenchymal and the hematopoetic cell lineages. While the defect in megakaryocyotopoiesis in DS has been well studied in humans and is recapitulated in the Ts65Dn mouse The defect in both osteoblast and osteoclast differentiation in Ts65Dn mice was observed in both th decade of life and are presenting in increasing numbers with low bone mass and fracture Histological evaluation of the bone marrow confirmed the megakaryocyte hyperplasia as has been reported in Ts65Dn mice and in DS patients Collectively, these observations provide evidence that the low bone mass observed in humans with DS and Ts65Dn mice is due to a cellular defect in both the hematopoietic and mesenchymal lineages, such that aneuploidy’s effects on the available pool of precursor cells decreases their capacity for normal differentiation and function. Thus, fewer cells differentiating into functional osteoblasts and osteoclasts results in the accrual of lower bone mass, which is a mechanism fundamentally distinct from the high bone turnover observed in hypogonadal women and men, where increased numbers and activity of cells leads to low bone mass.In support of this idea, the Ts65Dn mice demonstrate a lifelong deficit in bone turnover, such that normal peak adult bone mass is never achieved. It is important to note that the serum bone turnover markers of control animals revealed the expected age-dependent increases in both formation and resorption markers, whereas markers in Ts65Dn mice do not increase with age and are consistently lower compared with control throughout the life of the mice. If this temporal difference in bone turnover is recapitulated in humans with DS, it would indicate that low bone turnover is sustained in DS resulting in lower bone accrual and is an area that we are actively investigating. Perhaps most importantly, our studies provide the first data to demonstrate the efficacy of a bone anabolic agent in the treatment of low bone mass in DS and call into question the routine use of bisphosphonates (which decrease bone turnover) in this patient population.Intermittent PTH therapy increases bone formation by stimulating osteoblast numbers at sites of bone remodeling, where old bone is replaced with new by the concerted efforts of both osteoclasts and osteoblasts Thus, these data provide a clearer understanding of the cellular mechanisms leading to the low bone mass in DS, suggest a new direction for treatment and provide a relevant animal model for continued studies of the skeleton in DS. Given the elevated fracture risk and rate in DS patients our data provide the rationale to consider bone anabolic therapies in DS patients with low bone mass.ad libitum and a 12-hr light:dark cycle. Only male mice were evaluated due to the decreased fertility of Ts65Dn male mice and the necessity of Ts65Dn female mice for colony maintenance. Animals were purchased at 6 weeks and aged as required. Some mice were aged and maintained at UAMS for up to 24 months.All animal handling and experimentation was performed in accordance with approved University of Arkansas for Medical Sciences (UAMS) institutional guidelines and protocols and approved by the UAMS Institutional Animal Care and Use Committee (IACUC). Ts65Dn male mice and wild type euploid littermate controls were purchased from the Jackson Laboratory . Upon arrival they were housed individually with food and water available For bone phenotyping, animals were sacrificed at 3 months and 24 months and long bones and spines harvested. Some three month old animals were injected with calcein  (administered 8 days prior to sacrifice) and alizarin red S (Sigma) or alizarin red complexone (Sigma) (administered 2 days prior to sacrifice), for subsequent determination of dynamic parameters of bone histomorphometry with an inter-label distance of 6 days as described In Ts65Dn and WT mice, serum was extracted from blood drawn at sacrifice and serum procollagen-1 N-terminal peptide (P1NP) and tartrate resistant acid phosphatase (TRAP) measured. P1NP was measured using a commercially available enzyme immunoassay (EIA) (Immunodiagnostic Systems) and TRAP using a TRAP-5b solid phase immunofixed enzyme activity assay (Immunodiagnostic Systems) according to the manufacturer’s protocol.All MicroCT analyses were consistent with current guidelines for the assessment of bone microstructure in rodents using micro-computed tomography The MicroCT slices were segmented into bone and marrow regions by applying a visually chosen, fixed threshold for all samples after smoothing the image with a three-dimensional Gaussian low-pass filter  to remove noise, and a fixed threshold . Femoral cortical geometry was assessed in a 1-mm-long region centered at the femoral midshaft. The outer contour of the bone was found automatically using the built-in manufacturer’s contouring tool. Total area was calculated by counting all voxels within the contour, bone area by counting all voxels that were segmented as bone, and marrow area was calculated as total area - bone area. This calculation was performed on all 25 slices (1 slice = ∼12.5 µm), using the average for the final calculation. The outer and inner perimeter of the cortical midshaft was determined by a three-dimensional triangulation of the bone surface (BS) of the 25 slices, and cortical thickness and other cortical parameters were determined as described After MicroCT analysis, the same tibia and femora, fixed in 10% neutral-buffered formalin, were decalcified in 5% formic acid with agitation until deemed clear by the ammonium oxalate endpoint test Specimens for plastic embedding and cancellous bone histomorphometry were harvested at sacrifice and the muscle dissected away before fixation in Mallonig’s fixative as we have described previously Mechanical testing was performed to determine bone strength of frozen Ts65Dn intact femora (3 month and 24 month), using standard three-point bending as we have described 6 cells per well in α-minimal essential medium (α-MEM), supplemented with 15% fetal calf serum, and 10−8 M 1,25-dihydroxyvitamin D3 2D3 in quadruplicate wells per treatment. Cells were fed every 3 days with half-volumes of medium, until day 14, when cells were fixed and stained with tartrate resistant acid phosphatase (TRAP) to facilitate determination of the number of TRAP-positive multinucleated (3 or more nuclei) cells formed per well.Bone marrow cells were harvested from femurs for osteoclastogenic culture as previously described 5 cells/cm2 on six-well tissue culture plates (Becton Dickinson Labware) osteoblast medium (α-MEM +15%FBS containing 10 mM BGP and 50 µM ascorbic acid). The total number of mesenchymal progenitors recruited into the osteoblastic lineage was measured by alkaline phosphatase-positive staining for colony forming unit-fibroblast (CFU-F) at day 10. Replicate cultures were fed every 3 days with half-volumes of medium, until day 28, when cells were fixed and minerals stained with Alizarin Red to facilitate determination of the number of bone nodules representing CFU-osteoblastic (CFU-OB) formed per well For osteoblastogenesis, bone marrow cells were harvested from femurs and seeded in triplicate at 2.5×10All data were analyzed by either Student’s t-test or one way ANOVA with post-hoc analyses by Bonferroni post-hoc test as appropriate. Parametric data are presented at mean ± SEM. Differences with P values <0.05 were considered statistically significant and are reported as such. The SigmaStat (SPSS Science) software package was used for all statistical analysis.Figure S1Age-related bone phenotype in Ts65Dn mice. (A) Micro CT reconstructions of proximal tibia and femur from 3-month (left column) and 24-month (right column) old WT (top) and Ts65Dn (bottom) mice. Low bone volume and cortical thinning is evident. (B). Paraffin-embedded decalcified histological sections of proximal tibia from 3-month (left column) and 24-month (right column) old WT (top) and Ts65Dn (bottom) mice stained with H&E. The expected age-related decrease in trabecular bone is observed in both WT (top) and Ts65Dn (bottom), however, the expected increase in marrow fat is observed in WT (top) but not Ts65Dn (bottom). In contrast, Ts65Dn mice reveal the reported elevation in marrow megakaryocyte number (TIF)Click here for additional data file.Figure S2Decreased cortical bone parameters of 24-month old Ts65Dn mice. Determination of femoral midshaft cortical parameters from Micro CT reconstructions of mid shaft femur shows significant decreases compared to WT in (A) cortical cross sectional area, (B) total cross sectional area, (C) periosteal perimeter, (D) Peak load (load tolerated at the breaking point adjusted for bone size), (E) Stiffness (deformation tolerated before breaking). Open bars WT; solid bars Ts65Dn. *, p<0.05 vs. WT control.(TIF)Click here for additional data file.


The G-protein coupled parathyroid hormone 2 receptor (PTH2R) is concentrated in endocrine and limbic regions in the forebrain. Its endogenous ligand, tuberoinfundibular peptide of 39 residues (TIP39), is synthesized in only two brain regions, within the posterior thalamus and the lateral pons. TIP39-expressing neurons have a widespread projection pattern, which matches the PTH2R distribution in the brain. Neuroendocrine centers including the preoptic area, the periventricular, paraventricular, and arcuate nuclei contain the highest density of PTH2R-positive networks. The administration of TIP39 and an antagonist of the PTH2R as well as the investigation of mice that lack functional TIP39 and PTH2R revealed the involvement of the PTH2R in a variety of neural and neuroendocrine functions. TIP39 acting via the PTH2R modulates several aspects of the stress response. It evokes corticosterone release by activating corticotropin-releasing hormone-containing neurons in the hypothalamic paraventricular nucleus. Block of TIP39 signaling elevates the anxiety state of animals and their fear response, and increases stress-induced analgesia. TIP39 has also been suggested to affect the release of additional pituitary hormones including arginine-vasopressin and growth hormone. A role of the TIP39-PTH2R system in thermoregulation was also identified. TIP39 may play a role in maintaining body temperature in a cold environment via descending excitatory pathways from the preoptic area. Anatomical and functional studies also implicated the TIP39-PTH2R system in nociceptive information processing. Finally, TIP39 induced in postpartum dams may play a role in the release of prolactin during lactation. Potential mechanisms leading to the activation of TIP39 neurons and how they influence the neuroendocrine system are also described. The unique TIP39-PTH2R neuromodulator system provides the possibility for developing drugs with a novel mechanism of action to control neuroendocrine disorders. It was discovered based on its sequence similarity to other proteins belonging to this receptor family  animals administered a PTH2R antagonist as discussed below.in situ hybridization histochemistry  and dopamine neurons in the arcuate nucleus , hotplate tests were performed before and after an inescapable foot shock, used as the stressful stimulus  or saline) while no differences were observed between groups in the number of closed arm entries or total arm entries, suggesting an anxiolytic-like effect of TIP39  neurons, whose activity is suppressed during lactation. In addition, the TIP39-PTH2R neuromodulator system might also play a role in conveying the effect of suckling on other systems adapted in the postpartum period. PTH2Rs in the preoptic area, the lateral septum, and the periaqueductal gray could be involved in the control of maternal behaviors Dobolyi, . EmotionThere is limited information available showing that TIP39 neurons are activated in stress situations. At present, only the effects of an h-long high intensity noise stress have been reported. Medial paralemniscal and posterior intralaminar TIP39 neurons demonstrate Fos induction together with CRH neurons in response to noise stress, suggesting that TIP39 neurons could be involved in the transmission of acoustic stress derived information to CRH neurons in the PVN (Palkovits et al., c-fos in some PVG neurons (Kiyohara et al., c-fos expression in the PVG significantly outlasts the cold exposure (Miyata et al., Cold exposure but not warm ambient temperature induced The PVG is a site of stimulation-induced analgesia (Rhodes and Liebeskind, via the facilitation of copulatory behavior by current injection into the area (Shimura and Shimokochi, Fos expression following ejaculation (Wang et al., The TIP39-PTH2R neuromodulator system is present in several brain areas that are activated in males following mating (Sachs and Meisel, c-fos expression in the PIL but not in the PVG in response to reunion with their litter (Cservenak et al., Another reproductive influence reaching TIP39 neurons in the PIL was reported in mother rats. Dams deprived of their pups for a day demonstrated 2+ levels (Goold et al., via presynaptic excitation of their afferents (Dimitrov et al., in situ hybridization histochemistry (Figure via potentiation of excitatory inputs to inhibitory interneurons acting on the AVP and dopaminergic neurons, respectively.There are no indications at present that TIP39 would have any action apart from activating the PTH2R. The PTH2R elevates cAMP and in some cells also increases Cay Figure . In othey Figure . Thus, tThe TIP39-PTH2R neuromodulator system may play an important role in the regulation of several different aspects of neuroendocrine functions. TIP39 neurons in the PVG may be stimulated by stress inputs compromising the homeostasis of the animal while TIP39 neurons in the PIL may be stimulated by various reproductive events Figure . AdditioThe 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.


Drosophila are remarkably conserved. As IIS pathway governs growth and development, metabolism, reproduction, stress response, and longevity; temporal, spatial, and nutrient regulation of dilps encoding Drosophila insulin-like peptides (DILPs) provides potential mechanisms in modulating IIS. Of eight DILPs (DILP1–8) identified, recent studies have furthered our understanding of physiological roles of DILP2, DILP3, DILP5, and DILP6 in metabolism, aging, and responses to dietary restriction (DR), which will be the focus of this review. While the DILP producing IPCs of the brain secrete DILP2, 3, and 5, fat body produces DILP6. Identification of factors that influence dilp expression and DILP secretion has provided insight into the intricate regulatory mechanisms underlying transcriptional regulation of those genes and the activity of each peptide. Studies involving loss-of-function dilp mutations have defined the roles of DILP2 and DILP6 in carbohydrate and lipid metabolism, respectively. While DILP3 has been implicated to modulate lipid metabolism, a metabolic role for DILP5 is yet to be determined. Loss of dilp2 or adult fat body specific expression of dilp6 has been shown to extend lifespan, establishing their roles in longevity regulation. The exact role of DILP3 in aging awaits further clarification. While DILP5 has been shown associated with DR-mediated lifespan extension, contradictory evidence that precludes a direct involvement of DILP5 in DR exists. This review highlights recent findings on the importance of conserved DILPs in metabolic homeostasis, DR, and aging, providing strong evidence for the use of DILPs in modeling metabolic disorders such as diabetes and hyperinsulinemia in the fly that could further our understanding of the underlying processes and identify therapeutic strategies to treat them.The neuroendocrine architecture and insulin/insulin-like signaling (IIS) events in  Drosophila, eight insulin-like peptides (DILPs) and one insulin receptor (DInR) are found. DILPs 1–8 have been identified mostly through their sequence homology to the mammalian insulin and the typical B-C-A domain structure as observed in mammalian insulin  in the brain has provided a physiological link between those two major tissues governing nutrient sensing, metabolism, and aging  pathway governs growth and development, metabolism, reproduction, stress response, and longevity. In Drosophila insulin-like peptide genes (dilp1–7) with diverse temporal and spatial specific expression patterns  and several neurons in the brain  constructs in their fat body similar to the levels observed in dSir2 RNAi flies , short neuropeptide F (sNPF) modulates metabolism and lifespan revealed an up-regulation of dilp1 and dilp2 mRNA as the result of sNPF overexpression accompanied by increased IIS in the periphery , a member of Drosophila E3 ubiquitin ligases and adaptor proteins, negatively regulates the expression of brain dilps. Neuronal and IPC-specific knockdown of dcbl results in up-regulation of dilps 2, 3, 5 whereas the Epidermal growth factor receptor (EGFR) signaling pathway mediates this regulatory effect of dCbl only on dilps 2 and 3. Thus, a likelihood of other mediators for dilp5 is speculated  play a prominent role in regulating insulin secretion in β-pancreatic cells  signaling -producing corpora cardiaca (CC) cells are neurosecretory cells that function to regulate metabolic processes in the fly (Rulifson et al., dilp2 overexpression strongly supported the notion that loss of DILP2 was responsible for the phenotypes (Rulifson et al., The first set of compelling evidence demonstrating the functional extent of DILPs in controlling growth, development, and glucose homeostasis was generated by the destruction of IPCs. Ablation of IPCs during the early larval stage results in severe developmental delay with a reduction of both cell numbers and body size accompanied by an increased level of circulating sugars suggesting a diabetic-related phenotype (Rulifson et al., daf-2, a gene encoding the insulin receptor homolog in C. elegans nearly doubled the lifespan of the organism (Kenyon et al., Drosophila homolog of the insulin receptor substrate CHICO similarly render cell non-autonomous effects in lifespan extension as the result of reduced IIS (Clancy et al., The role of IIS pathway in aging was first discovered when mutations of dilps and DILP2 possesses the highest homology to the mammalian insulin with a 35% identity in protein sequence (Brogiolo et al., dilp2 is associated with lifespan extension under several conditions. First, activation of dFOXO in the pericerebral fat body extends lifespan with an accompanied reduction in dilp2, but not in dilp3 or dilp5 mRNA levels (Hwangbo et al., dilp2 is associated with the extension of lifespan observed in those flies (Wang et al., dilp2 transcript levels, again indicating that the reduction of dilp2 expression was closely associated with extended longevity under those genetic conditions (Bauer et al., dilp2 expression and increased lifespan, direct modulation of dilp2 levels was needed to assess the causal relationship between dilp2 expression and lifespan control. To this end, surprisingly, while causing a severe reduction of dilp2 transcripts, targeted knockdown of dilp2 in IPCs did not result in any lifespan extension (Broughton et al., dilp3 and dilp5 expression was observed in those flies raising the possibility that a compensatory mechanism exists to modulate overall dilp expression in the IPCs. However, this compensatory increase in dilp3 and dilp5 expression could not completely account for the lack of lifespan extension in dilp2 knockdown flies as a similar increase of dilp3 and dilp5 transcripts was observed in long-lived dilp2 null mutant flies and increased dilp5 expression levels in long-lived dilp2–3 mutants (Gronke et al., dilp2 knockdown elicits additional genetic alterations neutralizing the effect on lifespan associated with reduced dilp2 transcripts. The extended lifespan measured in dilp2 null mutants, however, confirms a major role of DILP2 in longevity control. The absence of any change in lifespan in flies with a dilp3 deletion is intriguing as both dilp2 and dilp5 transcript levels are lowered in those flies (Gronke et al., dilp transcript levels and lifespan effects in dilp2, dilp2–3, and dilp3 null mutants requires further clarification with measurements of DILP peptide levels as possible compensatory mechanisms to modulate IIS and lifespan regulation. An involvement of DILP3 in longevity control is worth further investigation, however as dilp3 transcript levels appeared to be specifically reduced in long-lived flies with increased mitochondrial uncoupling in adult IPCs (Fridell et al., dilp5 null mutant appeared to have no effect on lifespan under standard diet (Gronke et al., dilp5 levels are moderated in DR-mediated lifespan extension (Min et al., dilp6 loss-of-function mutation neither had any effect on adult Drosophila survival nor on any compensatory increase in the expression of other dilps (Gronke et al., dilp6 in the adult abdominal fat body significantly extends lifespan in females in a diet-dependent manner and negatively affects expression of dilp2 and dilp5, whereas a modest effect in survival is observed when dilp6 is expressed in the pericerebral fat body. This study also shed light on the fact that the longevity effect of dFOXO when overexpressed in the pericerebral fat body requires dilp6 (Bai et al., dilp mutants has confirmed lifespan extension as the result of dilp2 deficiency suggesting a major role of DILP2 in modulating IIS. On the other hand, targeted expression of dilp6 in the adult fat body results in profound longevity and metabolic consequences that underlies its role in lifespan regulation.A significant amount of interest has been bestowed upon DILP2 as its transcript is most abundantly expressed among all dilp mutants have paved the way. IPC ablated flies exhibit high levels of trehalose, lipid and glycogen stores, accompanied by increased stress resistance (Broughton et al., dilp2 loss-of-function mutant with no change in lipid or glycogen levels (Gronke et al., dilp 1–4 loss of function mutants were starvation resistant recapitulating the role for dilp2 in starvation resistance (Gronke et al., dilp2 null mutants nor dilp 2–3, 5 deletion mutants, created by homologous recombination, were resistant to starvation (Gronke et al., dilp2 null mutants. A putative role for DILP2 in response to oxidative stress was discovered in the context of JNK signaling upon oxidative stress where dilp2 expression is repressed in IPCs (Wang et al., dilp2 RNAi hypomorphs (Broughton et al., dilp2 loss-of-function mutants (Gronke et al., dilp6 over expression in the abdominal fat body exhibit metabolic phenotypes reminiscent of those seen as a consequence of reduced IIS (Bai et al., dilp6 loss-of-function mutants only had high stored lipid levels revealing its specific role in lipid storage (Gronke et al., To aid a better understanding of the significance of DILP2 and DILP6, physiological alterations that accompanied lifespan extension in respective dilp3 or dilp5 single mutants were neither resistant to starvation or oxidative stress nor was there any change in their trehalose, glycogen, or lipid levels (Gronke et al., dilp3 overexpressors play a role in regulating triglyceride levels (Varghese et al., Unlike DILP2 and DILP6, an involvement of DILP3 and DILP5 in any physiological feature that plays a part in lifespan regulation has not been identified. Drosophila. While the exact molecular mechanisms behind DR-mediated lifespan extension are yet to be completely elucidated, several molecular pathways have emerged as important players involved in DR responses (Narasimhan et al., C. elegans, depending upon the methods of DR, lifespan extension associated with DR is largely independent of IIS (Kaeberlein et al., Drosophila (Clancy et al., chico mutants did not respond to optimal DR for additional lifespan extension indicating an overlap between IIS and DR (Clancy et al., dFOXO mutants remained sensitive to DR thus suggesting that DR acts independently of IIS (Min et al., Drosophila in order to reconcile discrepant findings as well as pinpoint a role of IIS in DR (Tatar, Through dilution of nutrient content, DR is a robust intervention that has been shown to extend lifespan in R Tatar, .Drosophila are shown to extend lifespan with changes in dilp5 mRNA levels but not dilp2 or dilp3 levels (Min et al., dilp5 mRNA and DILP5 protein levels are down-regulated in wild type flies under a yeast DR diet where only yeast is diluted while keeping carbohydrate levels constant (Broughton et al., There is emerging evidence on the role of IPCs in lifespan extension through DR, as those neurosecretory cells appear to respond to nutrient changes (Broughton et al., dilp5 knocked down by a UAS-dilp3RNAi construct that repressed expression of dilps 2, 3, and 5 and blocked the nutrient-dependent expression of dilp5, exhibited a normal response to DR under a yeast DR regime implying that DR-mediated lifespan extension works independently of DILP5 (Min et al., dilp6 in the fat body lowers dilp2 and dilp5 expression as well as the respective hemolymph peptide levels, the lifespan of dilp6 overexpressors was similar to the controls under a yeast restricted diet corroborating with the evidence that DR works independently of dilp5 and DILP5 (Bai et al., Flies with dilp5 null mutant flies that displayed a normal DR response also exhibited a compensatory up-regulation of dilp2 mRNA when raised on food with high yeast concentration while dilp3 mRNA levels were up-regulated in these flies raised on food with relatively low yeast concentration (Gronke et al., dilp5 loss-of-function flies raised on yeast DR diet. Supporting evidence for the involvement of DILPs in DR, if not a direct role, was presented when dilp 2–3, 5 deletion mutant flies (Gronke et al., per se but whose activity has shown to modulate DR response when over-expressed (Giannakou et al., dilp5 is modulated under DR, this change in expression could simply be a response associated with dietary alterations but does not trigger the longevity effect of DR. Further clarification is required to definitively assign a physiological role of DILP5, if any, in DR response.However, Drosophila homolog of IGF-binding protein, Imp-L2 is shown to bind to DILP2 (Honegger et al., dilps have confirmed that loss of dilp2 and over-expression of dilp6 is sufficient to extend lifespan (Gronke et al., Drosophila as a model to study cross talk between the nutrient sensing fat body and the neurosecretory IPCs has shed significant insight into a systemic control of DILP activities as the result of communication between those two tissues tightly associated with metabolism. The studies highlighted in this review have underscored the importance of measuring DILP levels in order to substantiate and validate their functional significance. Specifically, measuring circulating DILPs in the hemolymph should provide most relevant assessment on secreted DILP levels and their systemic effects (Bai et al., DILPs are involved in a myriad of physiological processes ranging from growth (Brogiolo et al., dilps 1–5 mimics phenotypes seen in type 1 diabetes (Rulifson et al., dilp levels in modeling type 2 diabetes (Musselman et al., dilps in Drosophila, metabolic disorders such as diabetes, hyperinsulinemia, or those affecting glucose homeostasis can be modeled in this genetic organism. These approaches will likely further characterize the molecular mechanisms behind these disorders, discover drug targets, and screen potential therapeutic modes to treat these disorders. Apart from disease models, emerging research has revealed an involvement of DILPs in stem cell biology including stem cell proliferation (LaFever and Drummond-Barbosa, dilp8 in tumor eye discs that responds to signals from peripheral tissues to mediate their growth and development has further strengthened Drosophila as a model for investigating mechanisms underlying inter-organ communication and demonstrated a role for DILP8 in cancer biology (Garelli et al., Drosophila through diverse mechanisms that are being unraveled.Ablation of IPCs or deletion of The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study evaluated the potential of the NAVIGATOR (Applied Physiology) haemodynamic monitor to improve consistency of cardiovascular assessments amongst ICU members with different levels of expertise and experience.n = 20) post cardiac surgery were monitored by NAVIGATOR to display heart efficiency (Eh), mean systemic filling pressure (Pms) and vascular resistance (SVR) against targets for mean arterial pressure and cardiac output set by the clinical team. Four categories of staffparticipated: nine consultants (C), eight senior registrars (SR), nine registrars (R) and 11 nurses (N)  and were asked to score Eh, Pms, and SVR ranging (discrete steps of one) from -5  to 0  to 5  first without (BLIND) and then given (OPEN) access to the NAVIGATOR display. Recommendations for therapeutic interventions were noted. Agreement , disagreement (median and interquartile range of steps) and therapeutic agreement  were recorded and analysed for statistical difference BLIND versus OPEN .Patients (Eh was commonly overestimated, Pms commonly underestimated with no clear trend for SVR. Agreement amongst all categories of staff increased and disagreement score decreased for Eh, Pms and SVR Table  comparinThe assessment of heart function, intravascular filling and resistance state in postoperative cardiac patients was made significantly more consistent amongst different ICU staff members using the NAVIGATOR haemodynamic monitor. Such enhanced consistency could potentially make the haemodynamic management more effective with improved clinical outcomes.


Early diagnosis of macrophage activations syndrome (MAS) in systemic juvenile idiopathic arthritis (sJIA) may be challenging because it may mimic the clinical features of the underlying disease or be confused with an infectious complication. However, the diagnostic value of the guidelines for hemophagocytic lymphohistiocytosis (HLH) (1) or sJIA-associated MAS (2) has seldom been examined.To investigate the sensitivity and specificity of diagnostic guidelines for HLH and sJIA-associated MAS in patients with sJIA who developed MAS.The study sample included 155 children with sJIA who had MAS (diagnosed and treated as such by the attending physician) and 2 control groups with potentially “confusable” conditions, including active sJIA without MAS (n=303) and a systemic febrile infection requiring hospitalization (n=191). Diagnostic guidelines for HLH and sJIA-associated MAS were applied to all MAS and control patients. Because no patient had NK-cell activity and soluble CD25 determination available and bone marrow aspirate was performed in only a few patients, these 3 criteria were excluded from HLH guidelines. HLH criteria were, therefore, met when at least 4 of the 5 remaining variables were present. sJIA-associated MAS criteria were met when at least 2 laboratory criteria or at least 1 laboratory criterion and 1 clinical criterion were present. Sensitivity and specificity of guidelines in discriminating patients with MAS from control patients were assessed.The table shows the comparison of sensitivity and specificity of diagnostic guidelines.The diagnostic guidelines for sJIA-associated MAS revealed strong sensitivity and specificity, whereas HLH guidelines were highly specific, but lacked sensitivity. Sensitivity of HLH was mostly hampered by the excessive stringent threshold for cytopenia and hypofibrinogenemia, and the infrequent occurrence of splenomegaly in patients with MAS.


Ischemic brain injury due to stroke and/or cardiac arrest is a major health issue in modern society requiring urgent development of new effective therapies. The use of appropriate animal models is essential to study the mechanisms of ischemia-induced injury and neuroprotection. The goal of our study was to establish a reliable and reproducible model of brain ischemia in pigs  for further research.in vivo SDF videomicroscopy) and histological structure (light microscopy) of brain tissue in healthy control animals and after 3 hours of brain ischemia (three different models).Eighteen pigs (18 to 22 kg) were anesthetized and randomly assigned to the one of the following groups: 1 - control, 2 - unilateral carotid occlusion, 3 - bilateral carotid occlusion, 4 - bilateral carotid occlusion + hypotension (MAP 40 to 50 mmHg). In order to investigate the effects and mechanisms of cerebral ischemia, we assessed the mitochondrial respiration (high-resolution respirometry), microcirculation . Mitochondrial respiration rates after addition of atractyloside and cytochrome c were the same in all experimental groups, suggesting that intactness of mitochondrial outer membrane was not affected by cerebral ischemia. Microcirculatory and histological alterations also demonstrated increasing derangement and reversible structural changes after bilateral carotid occlusion and vascular occlusion combined with systemic hypotension.LEAK respiration  was not affected by ischemia in any model. The OXPHOS capacity with pyruvate + malate as substrates decreased by 20% and 79% compared to the control level after bilateral carotid artery occlusion and bilateral carotid occlusion + hypotension, respectively, resulting in the decrease of RCI (ADP/PM) by 14% and 73%. The OXPHOS capacity with succinate as substrate remained constant after unilateral carotid artery occlusion but decreased by 53% after bilateral carotid artery occlusion and hypotension compared to the control level .


Objectives. To evaluate the feasibility of implementing a statewide children with special health care needs (CSHCN) program evaluation, case management, and surveillance system using a standardized instrument and protocol that operationalized the United States Health and Human Services CSHCN National Performance Measures. Methods. Public health nurses in local public health agencies in Washington State jointly developed and implemented the standardized system. The instrument was the Omaha System. Descriptive statistics were used for the analysis of standardized data. Results. From the sample of CSHCN visit reports (n = 127), 314 problems and 853 interventions were documented. The most common problem identified was growth and development followed by health care supervision, communication with community resources, caretaking/parenting, income, neglect, and abuse. The most common intervention category was surveillance (60%), followed by case management (24%) and teaching, guidance, and counseling (16%). On average, there were 2.7 interventions per problem and 6.7 interventions per visit. Conclusions. This study demonstrates the feasibility of an approach for statewide CSHCN program evaluation, case management, and surveillance system. Knowledge, behavior, and status ratings suggest that there are critical unmet needs in the Washington State CSHCN population for six major problems. Children with special health care needs (CSHCN) are at increased risk for poor health outcomes . The CSHThe Maternal Child Health Bureau (MCHB) defines CSHCN as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” . The MCH Identifying health care problems experienced by CSHCN and their families provides information about the larger service system, while a successful system of services results in high levels of child and family health and well-being . Partner Programs that address the unique needs of CSCHN have long been a component of the public health system . Public The adoption of electronic health records and public health information systems varies across jurisdictions in the United States . Many loThe objective of this study was to evaluate the feasibility of implementing a state-wide case management, surveillance, and program evaluation system for CSHCN program using a standardized Omaha System protocol and visit report. This paper reports preliminary data from the first four months after the implementation of the standardized data collection protocol.The University of Minnesota Institutional Review Board and State of Washington Institutional Review Board approvals were obtained for this study. All local public health agencies in Washington State were invited to a statewide training on the data collection system (September 2010) and to participate in the data collection starting November 2010. The data collection period for this study ended in February 2011. Visit reports were submitted to State of Washington Department of Health CSHCN officials for program evaluations by 25 of the 35 local agencies during this time period. The Department of Health entered the deidentified data into a spreadsheet and provided the spreadsheet to the research team for analysis . The Omaha System  was seleThe Problem Classification Scheme is used to identify and classify health-related issues and includes 42 problems. Problems are uniquely identified by distinctive definitions and signs and symptoms (s/sx). The Intervention Scheme is used for addressing the problems which are described using the four-level Intervention Scheme. The four terms of the Intervention scheme are: problem from the Problem Classification Scheme, category (action term), target (defined term that further specifies the intervention), and care description  [The Problem Rating Scale for Outcomes is used to measure client knowledge, behavior, and status (KBS) related to each client problem. KBS ratings are documented using a Likert-type ordinal scale from 1 (lowest) to 5 (highest). The knowledge scale measures what the client understands and knows. The behavior scale measures the appropriateness of client actions. The status scale describes the level of severity of client sign and symptoms . The defThe State of Washington Department of Health together with PHNs serving CSHCN sought to develop a uniform CSHCN evaluation protocol including the development of practice standards and assessment guidelines. The purpose of their project was to generate data for overall quality improvement and outcomes reporting. They created the evaluation protocol in response to three important trends: 1) the need to respond to federal maternal-child health national performance measures, (2) the fact that many of the public health agencies had the electronic capacity to collect standardized data, and (3) many of the agencies were using the Omaha System for other maternal-child health programs . Title V the needn = 127). The client demographics were excluded from analysis because of Washington State data deidentification protocols. The only known characteristics of the sample were that the CSHCN who received PHN visits qualified for services through the HHS Title V CSHCN definitions and criteria. There were CSHCN visit reports , 314 problems and 853 interventions were documented. The most common problem identified was growth and development followed by health care supervision, communication with community resources, caretaking/parenting, income, neglect, and abuse. The most common intervention category was surveillance (60%), followed by case management (24%) and teaching, guidance, and counseling (16%). On average, there were 2.7 interventions per problem and 6.7 interventions per visit. The mean KBS ratings for each problem are reported in  From the visit reports (n = 80), the most common s/sx were abnormal results of developmental screening tests (40%), inadequate achievement/maintenance of developmental tasks (40%), age-inappropriate behavior (30%), and abnormal weight/height/head circumference in relation to growth/age standards (23%).  For the growth and development problem (n = 57), the most common s/sx were inability to coordinate multiple appointments/treatment plans (23%), inadequate source of health care (21%), inadequate treatment plan (21%) fails to obtain routine/preventative health care (18%), inconsistent source of health care (11%), fails to return as requested by health care provider (9%), and fails to seek care for symptoms requiring evaluation/treatment (7%).  For the health care supervision problem (n = 57), the most common s/sx were unfamiliar with options/procedures for obtaining services (58%), language, cultural, educational, transportation barriers (38%), difficulty understanding roles/regulations of service providers (36%), inability to communicate concerns to provider (24%), dissatisfaction with services (20%), limited access to care/services/goods (14%), and inability to use/have inadequate communication devices/equipment (2%).  For the communication with community resources problem (n = 48), the most common s/sx were difficulty providing physical care/safety (33%), difficulty providing cognitive learning experiences and activities (33%), difficulty providing preventative and therapeutic health care (31%), expectations incongruent with the stage of growth and development (19%), difficulty providing emotional nurturance (17%), dissatisfaction/difficulty with responsibilities (15%), difficulty interpreting or responding to verbal/nonverbal communication (15%), and neglectful or abusive (4.2%).  For the Caretaking/parenting problem (n = 45) were low/no income (78%), ability to buy only necessities (33%), uninsured medical expenses (18%), difficulty buying necessities (18%), and difficulty with money management (11%).  The most common s/sx of the income problem (n = 18), the most common s/sx were cluttered living space (44%), structural barriers (11%), homelessness (11%), structurally unsound (6%), inadequate heating/cooling (6%), steep, unsafe stairs, (6%) inadequate/obstructed exits and entries (6%), presence of lead based paints (6%), and unsafe equipment/wiring (6%).  For the residence problem (n = 12), the most common s/sx were of the signs and symptoms documented in the neglect problem included inadequate/delayed medical care (25%), included lacks necessary supervision (17%), while lacks adequate physical care (8%), lacks emotional support (8%).For the neglect problem . The use of the CSHCN visit reports will generate large data sets that will enable further evaluation of the effectiveness of PHN interventions for these problems. Previous studies have described intervention tailoring and effectiveness for high risk families –21. Furt The use of the Omaha System enabled the aggregation of standardized CSHCN data for program evaluation. Assessments and intervention data from 25 of 35 local health jurisdictions were included in this study. The 127 visit reports were submitted to the Department of Health on the paper visit report forms. Data from electronic documentation of CSHCN assessments and interventions were not included in this study but will be available in the future. The interoperability of electronic systems continues to be a challenge. It is essential for state and local health jurisdictions, software vendors, and policy makers to work together to achieve the goals of standardized, interoperable systems to support uniform data collection for program evaluation and research.The results of this study will be used by the Washington State CSHCN program to focus nursing activities on the problems most likely to be encountered by PHNs serving the CSHCN population. Additionally, these results will be used to further refine the program evaluation process.National, state, and local officials have a responsibility to develop, support, and maintain CSHCN programs , 22. Pub With all research using large observational data sets, limitations of the data include observer bias and fidelity to documentation procedures. While the sample of 127 clients from 25 local health jurisdictions demonstrates the feasibility of the approach, bias toward submitting forms for clients with the greatest need may exist. This limitation is supported by the PHN interpretation of the findings reported in Section 5.0. Therefore, alternative explanations for the findings must be considered. In this study, many of the local health jurisdictions started to use the Omaha System for the CSHCN at the beginning of the data collection period. Documentation quality was supported by peer training and the use of KBS rating guide supplements. However, no evaluation of documentation quality was included in the program evaluation protocols. Further research is needed to create quality assurance measures that can be implemented as an integral part of program evaluation.This study demonstrates the feasibility of a structured approach to case management, surveillance, and program evaluation for CSHCN using a standardized terminology. The use of the Omaha System facilitated uniform data collection of client assessments and services across 25 of 35 local health jurisdictions in the first four months of the evaluation. Preliminary findings suggest that critical needs existed among CSHCN in Washington State. In the future, larger data sets will be used to evaluate the quality of PHN services, inform public policy, and improve the health CSHCN and their families.


A number of studies have outlined mechanisms by which mycoplasma infection may promote allergic lung inflammation. In addition, there is increasing evidence from human studies suggesting that mycoplasma infection contribute to asthma exacerbations, and severity with the change of cytokines. The present study evaluated the change of serum levels of eosinophil count, eosinophil cationic protein, and interleukin-5 in atopic children with Mycoplasma pneumonia infection.We recruited 145 children including 45 atopic children with mycoplasma pneumonia (Group 1), 39 non-atopic children with mycoplasma pneumonia (Group 2), 35 children with viral pneumonia (group 3), 26 non-atopic children with viral pneumonia with mycoplasma infection (Group 4). The change of total eosinophil count, serum levels of interleukin (IL)-5, eosinophil cationic protein were measured at admission and at recovery for each group by using commercial ELISA.The serum level of IL-5 at admission was increased at recovery in group 1 . However, Buserum eosinophil cationic protein concentrations were increased at clinical recovery compared to the mean serum concentration at admission .Mycoplasma infection may be associated with the mechanism by which the Mycoplasma pneumoniae contribute to the development of airway hypersensitivity.The outcomes of the present study implied changes of eosinophil and its mediators during