Reversing anthropogenic impacts on habitat structure is frequently successful through restoration, but the mechanisms linking habitat change, community reassembly and recovery of ecosystem functioning remain unknown. We test for the influence of edge effects and matrix habitat restoration on the reassembly of dung beetle communities and consequent recovery of dung removal rates across tropical forest edges. Using path modelling, we disentangle the relative importance of community-weighted trait means and functional trait dispersion from total biomass effects on rates of dung removal. Community trait composition and biomass of dung beetle communities responded divergently to edge effects and matrix habitat restoration, yielding opposing effects on dung removal. However, functional dispersion—used in this study as a measure of niche complementarity—did not explain a significant amount of variation in dung removal rates across habitat edges. Instead, we demonstrate that the path to functional recovery of these altered ecosystems depends on the trait-mean composition of reassembling communities, over and above purely biomass-dependent processes that would be expected under neutral theory. These results suggest that any ability to manage functional recovery of ecosystems during habitat restoration will demand knowledge of species' roles in ecosystem processes. Significant advances have been made in understanding the cascading effects of global environmental change on biodiversity loss and associated ecosystem functioning Restoration ecology has long sought to identify the mechanisms that determine trajectories of community assembly One effective platform for linking species responses to environmental change with the functional consequences of shifting trait composition has been to employ a response-effect trait framework In this study, we test the trait determinants of dung beetle community responses to experimental habitat restoration in the land-use matrix surrounding heavily degraded montane rainforest edges in Nigeria. Habitat loss, and subsequent degradation of rainforest edges due to cattle encroachment, fire, and altered biotic and abiotic conditions, are amongst the most severe drivers of biodiversity loss and alteration of ecosystem functioning in tropical forests Although terrestrial invertebrates are the second most represented taxa in studies investigating trait-mediated ecosystem processes This study was conducted in Afromontane forest at the Ngel Nyaki Forest Reserve, located on the Mambilla Plateau near the south-eastern border of Nigeria . No specific permissions were required regarding collection of invertebrate specimens in this location and our study did not involve any known endangered or protected species. The forest reserve is an outlying section of the West African montane forest network within the Cameroon Highlands ecoregion As part of the Nigerian Montane Forest Project (NMFP) aimed at protecting Ngel Nyaki Forest Reserve from land clearing, burning and cattle grazing, three fenced exclusion zones were established up to 200 m outside the dense sub-montane forest zone, 3 years prior to the sampling procedure. These regenerating sites could then be compared with degraded edge zones where no restoration in the adjacent matrix had been established . The lenth October to 29th November 2009. To quantify the interactive effects of habitat edges and adjacent matrix restoration on dung beetle community structure and associated ecosystem processes, we sampled dung beetle communities and dung removal rates along three replicate forest-to-matrix edge gradients in both degraded and regenerating sites (n = 6). Although treatment-level replication was low, it is important to note that this is an experimental manipulation of matrix structure which was specifically targeted at a single experimental site where all edges had previously had a common history of edge degradation (just 3 years prior to sampling), and sampling completeness was high Sampling was conducted at Ngel Nyaki Forest Reserve during the late rainy season from 4Degraded edges spanned forest-to-matrix habitats that were fully exposed to anthropogenic threats typical of the area (such as intensive cattle grazing and fires), compared to the regenerating edges where these threats had been entirely excluded for three years . One addca 20 cm above the cup using wooden stakes. From this trap cover, dung bait was suspended with string so that the bottom of the bait was level with the rim of the cup. The bait was contained within muslin mesh which allowed the scent of the bait to easily permeate into the surrounding atmosphere but was fine enough to exclude insects from directly accessing the bait and thus altering its attractiveness. The cup was filled with approximately 200 ml of water and five drops of highly concentrated, odourless, and clear detergent which served to break the surface tension of the water. Pig dung was used as bait because omnivore dung is recognised as the most widely attractive to dung beetles We used pitfall traps baited with 40 g of pig dung placed at each distance across the edge gradient for two consecutive 24 hour periods (pooled 48 hour samples for each edge gradient transect) to ensure adequate sampling of the local community To quantify the impact of edge effects and matrix restoration on dung removal rates we placed experimental dung piles at each of the 101 sampling points and measured the proportion of dung removed in 24 hrs. Dung removal experiments were undertaken 1–2 days prior to baited pitfall trapping of dung beetles at each site, in order to avoid potential trap depletion effects on beetle communities that might otherwise have confounded dung removal rates. It should be noted that there could still have been potential interference of the removal experiment on pitfall trapping, as beetles that had already been attracted to dung placed out in the removal experiment may still have been buried in the soil, either laying eggs, provisioning brood balls, or already satiated. However, there is little reason to expect that this effect would have operated inconsistently across our treatments and is unlikely to have been systematically biased toward particular morphological traits of dung beetles, so we expect any such effect to have had a minor influence on our overall results. At each sampling point  debris such as dead wood or leaves within a 15 cm radius of dung placement was removed down to the topsoil and 40 g of fresh pig dung was placed directly on top of the bare soil. This amount of dung was sufficient to avoid complete removal and allow reliable comparisons among sampling points, but still equal to the amount of bait used in pitfall traps so that dung removal rates could be realistically compared to sampled dung beetle communities. After 24 hours, the remaining dung was collected and, after removing any attached debris, dry mass loss was calculated after taking into account moisture content loss, yielding a rate of dung removed per 24 hrs see .2), multiplied by two for total wing area, which was then used to calculate wing loading as the ratio of body mass to total wing area. To take into account within-species trait variation, we measured multiple individuals within each species for all samples collected. However, for highly-abundant species, we used a randomized subsampling procedure so that at least 20 individuals were measured per sample for each abundant species  or by variation in the abundances of species with differing traits, we used a hierarchical path modelling approach Second, dung removal rates might be dependent on average trait values expressed in a given community. To test this hypothesis, we included all measured traits  within the path model. Because we suspected there could be collinearity among the trait predictors, we checked for correlations among variables while constructing the path model. In most cases, predictors within the GLMMs were sufficiently weakly correlated so that interpretation of the models was considered reliable (|r|<0.7) Third, we hypothesised that there might be a niche complementarity effect whereby community functional trait dispersion determines dung removal efficiency of dung beetle communities. As a measure of functional trait complementarity, we calculated a distance-based metric of trait functional dispersion (FDis) using the “FD” package A total of 4705 dung beetles were captured across all sites, comprising 33 species in 12 genera . Of thesDung removal rates also varied dramatically across habitat edge gradients, ranging from an average of >75% dung removal over a 24-hr period in the forest interior to ∼0% removal in the matrix habitat . MoreoveResults from the multilevel path analysis revealed that dung removal rates were influenced by trait-dependent effects, over and above the positive influence of total beetle biomass on removal rates . First, Second, community-weighted trait composition also responded significantly to both edge effects and matrix restoration, but with variable responses across different traits. For instance, at degraded edge gradients there was a significant increase in mean pronotum width, wing loading and BSI of individual species from the forest into the matrix habitats . HoweverAs expected, variation in the trait-mean composition of species strongly influenced functional trait dispersion, particularly with respect to wing area, body mass, and pronotum width effects, together explaining 76% of variation in functional dispersion across samples. For our study system, however, there were no apparent direct influences of edge effects or matrix restoration on functional trait dispersion after controlling for variation in community-weighted trait composition. There was also no flow-on effect of functional trait dispersion on rates of dung removal, despite the strong association of trait composition with dispersion.Finally, the relative partitioning of trait mean effects, functional trait dispersion, and mass-dependent neutral effects did not capture all the potential proximate factors mediating the effect of anthropogenic disturbance on dung removal rates. There was a significant interaction effect between matrix restoration and edge effects that had a residual direct influence on dung removal rates at matrix restoration sites, although at degraded sites there was no residual direct effect of edge impacts on dung removal rates  . This suWe demonstrate that matrix habitat restoration can have a profound influence on nutrient cycling-related ecosystem functioning at degraded tropical forest edges. For the removal of dung by dung beetles, the path to functional recovery depended not only on the random reassembly processes contributing to total dung beetle biomass , but also on the body sizes (i.e. pronotum widths) of recolonizing individuals. Given the importance of restoring ecosystem functioning in restoration efforts The key to determining the pathways through which matrix restoration drives functional recovery was the application of a response-effect trait framework within a path-modelling context. While this approach has been widely adopted in modelling human impacts on ecosystem processes within degraded systems, it holds untapped promise in a restoration context. From this analysis, we showed that matrix restoration substantially ameliorated the negative impacts of habitat edge effects on dung beetle biomass and community trait composition observed between forest and matrix habitats at the degraded sites. In particular, edge effects on community-weighted trait means of dung beetle pronotum width and wing loading at degraded edges were significantly reduced by the restoration of the adjacent matrix habitat. Given that small-bodied invertebrate species typically have lower physiological tolerance to anthropogenic disturbance In many ways, this rapid rate of recovery is surprising after just three years of experimental matrix regeneration. Many previous studies have suggested there can be long lag-times to faunal community re-assembly following revegetation, particularly for small-bodied species with low dispersal capacity 2 (despite maximum wing area of 1098.53 mm2), the key driver of variation in trait dispersion was the distribution of the few rare beetles with large body mass and relatively large wing area . Interestingly, there was a significant negative effect of community-weighted pronotum width on functional dispersion . We interpret this as species that are smaller than expected based on their body mass making a greater contribution to high trait dispersion.Surprisingly, matrix habitat restoration had no direct influence on community-wide trait dispersion at forest edges, but there were significant indirect effects observed via the mediating effects of community-weighted trait means on functional trait dispersion. In particular, there were highly significant effects of community-weighted mean body mass, pronotum width, and wing area on functional trait dispersion, with all three traits having equivalent standardized effect sizes. Because the vast majority of dung beetles captured (>86%) had a body mass of <10 mg (despite maximum body mass of 1543.07 mg) and wing area of <20 mmBy partitioning community-wide responses into separate trait-mean variables versus overall variability in community-level trait dispersion, our results demonstrate the varying sensitivity of different trait measures to environmental change. Functional trait dispersion was strongly affected by matrix habitat restoration at forest edges, but these effects were only manifested indirectly via the shared influence on multiple components of trait variation. No single trait response variable could explain the observed response in functional trait dispersion in its own right, suggesting the need to quantify multiple traits in order to capture their role in community assembly during restoration. At the same time, though, only very few trait responses were required (three in this case) to explain a relatively high proportion of the variation (76%) in community-wide trait dispersion.Trait determinants of community responses to environmental change also had a significant influence on rates of beetle-mediated dung removal. Although we found no niche complementarity effect on dung removal driven by variation in functional trait dispersion, there was a clear effect of community-weighted mean trait composition on dung removal rates, over and above neutral mass-dependent effects. This was demonstrated by the relatively large standardised effect size of community-weighted mean pronotum width on dung removal (−0.319), which had almost as strong a standardised effect on dung removal as total beetle biomass (0.342), supporting the claim that neutral processes alone may not be able to fully explain functional processes et al. Surprisingly, the mediating effect of community-weighted mean pronotum width on dung removal was negative, suggesting that in samples with a smaller weighted-average body size of dung beetles, the removal rate of dung was proportionately greater per unit mass of beetles. Many previous studies have pointed to the importance of large dung beetles in dung decomposition rates, whereby body size is assumed to be positively correlated with amount of dung sequestered In addition to mass- and trait-dependent effects, we also detected a significant residual interaction effect of our treatment drivers on overall rates of dung removal, with matrix restoration mitigating the low rates of dung removal observed at degraded edges significantly more than could be explained by recovery in dung beetle biomass or trait-dependence in reassembly processes alone. This is almost certainly due to unmeasured variation in environmental parameters along edge gradients, such as substantial reduction in dung desiccation rates at regenerating edges  and facilitation or competition from other dung-associated organisms that are likely to alter removal rates differentially among regenerating and degraded edge gradients. Furthermore, it is possible that other unmeasured traits such as dung removal strategy or diel activity patterns could help to explain some of this residual variation. A better mechanistic understanding of these processes is still needed in order to understand how other contributing factors such as these might help to explain variation in ecosystem functioning following restoration.Overall, this experiment has shown that restoration of the matrix surrounding degraded tropical forest remnants can drive large increases in the biomass of organisms and their associated ecosystem processes, even over very short time periods. Interestingly, the enhancement of dung removal rates through restoration could not be explained solely as a function of increasing biomass of decomposer organisms without recourse to trait-dependence in ecosystem process rates. A notable proportion of variation in dung removal was explained by community-mean body size that in turn resulted in significant effects on dung removal, suggesting that ‘neutral’ measures of community assembly alone cannot explain functional outcomes of habitat restoration. Rather, we found that recovery of a suite of disturbance-sensitive species with low dispersal power and small body size, but high per capita dung removal efficiency (for their size), resulted in higher dung removal rates at habitat edges undergoing adjacent matrix restoration. The observed mediating effects of response and effect traits on dung removal are likely to have far-reaching consequences for heavily-degraded tropical forest remnants, through cascading changes in insect-mediated ecosystem functions such as nutrient cycling rates and secondary seed dispersal that can have strong deterministic impacts on plant communities S1 FigureLayout of edge gradient sampling transects.(DOCX)Click here for additional data file.S2 FigureEdge-gradient sampling design.(DOCX)Click here for additional data file.S3 FigureExample of the left hind wing of an individual male Onthophagus sp. 1.(DOCX)Click here for additional data file.S4 FigureContour plot demonstrating the combined effects of total beetle biomass and community-weighted mean body mass on proportion of dung removed.(DOCX)Click here for additional data file.S1 TableTrait mean values for dung beetle species.(DOCX)Click here for additional data file.S2 TableList of dung beetle species and their occurrences.(DOCX)Click here for additional data file.S3 TableAkaike Information Criterion (AIC) scores obtained from the edge function fitting procedure.(DOCX)Click here for additional data file.S4 TableComplete basis set of independence claims for the selected best-fit path model.(DOCX)Click here for additional data file.S1 AppendixMeasuring rates of dung removal.(DOCX)Click here for additional data file.S2 AppendixMeasurement of dung beetle traits.(DOCX)Click here for additional data file.S3 AppendixContinuous edge response models.(DOCX)Click here for additional data file.S4 AppendixConstructing generalised multilevel path models.(DOCX)Click here for additional data file.


Adult skeletal muscle possesses extraordinary regeneration capacities. After muscle injury or exercise, large numbers of newly formed muscle fibers are generated within a week as a result of expansion and differentiation of a self-renewing pool of muscle stem cells termed muscle satellite cells. Normally, satellite cells are mitotically quiescent and reside beneath the basal lamina of muscle fibers. Upon regeneration, satellite cells are activated, and give rise to daughter myogenic precursor cells. After several rounds of proliferation, these myogenic precursor cells contribute to the formation of new muscle fibers. During cell division, a minor population of myogenic precursor cells returns to quiescent satellite cells as a self-renewal process. Currently, accumulating evidence has revealed the essential roles of satellite cells in muscle regeneration and the regulatory mechanisms, while it still remains to be elucidated how satellite cell self-renewal is molecularly regulated and how satellite cells are important in aging and diseased muscle. The number of satellite cells is decreased due to the changing niche during ageing, resulting in attenuation of muscle regeneration capacity. Additionally, in Duchenne muscular dystrophy (DMD) patients, the loss of satellite cell regenerative capacity and decreased satellite cell number due to continuous needs for satellite cells lead to progressive muscle weakness with chronic degeneration. Thus, it is necessary to replenish muscle satellite cells continuously. This review outlines recent findings regarding satellite cell heterogeneity, asymmetric division and molecular mechanisms in satellite cell self-renewal which is crucial for maintenance of satellite cells as a muscle stem cell pool throughout life. In addition, we discuss roles in the stem cell niche for satellite cell maintenance, as well as related cell therapies for approaching treatment of DMD. Skeletal muscle is the most abundant tissue in the mammalian body accounting for approximately 40% of body weight, and is composed of multinucleated fibers that contract to generate force and movement. In addition, skeletal muscle possesses a remarkable ability to regenerate, and can go through rapid repair following severe damage caused by exercise, toxins or diseases. Muscle satellite cells were discovered by Alexander Mauro in 1961  , indicating the heterogeneity of quiescent satellite cells  mice display reduced significant reduction in satellite cell number, resulting in the failure of muscle growth and neonatal lethality of most Pax7 KO mice  mice display neural tube and cardiac chamber malformations, missing limb muscles which originate from migratory myogenic cells from somites, and die embryonically by day E14  satellite cells demonstrated the equivalent regenerative potency compared to wild-type satellite cells  was significantly increased compared to wild-type myoblasts following intramuscular injection into regenerating mouse muscle  and -206 (miR-206) are up-regulated, while Pax3 is down-regulated by miR-1 and miR-206 via direct binding of these miRNAs to the 3' untranslated region (UTR) of Pax3. This Pax3 down-regulation in activated satellite cells is also mediated by miR-27b  pathway  quiescent satellite cells were YFP(−) cells, indicating that these YFP(−) quiescent satellite cells have never expressed Myf5. Since Myf5 is one of the myogenic regulatory factors and known to regulate embryonic myogenesis, YFP(−) satellite cells may be less committed cells compared to the YFP(+) population. In addition, the transplantation experiments clearly revealed that Pax7(+)YFP(+) cells preferentially underwent myogenic differentiation while Pax7(+)YFP(−) cells were able to extensively contribute to generate satellite “stem cell” in regenerating muscle  lineage using CreMyf5/+/loxP/loxPPax7 mice revealed that the majority of adult satellite cells originate from Myf5-expressing myogenic cells, and that the majority of satellite stem cells are replenished from Myf5-expressing cells /Myf5(−) myogenic progenitor cells also give rise to Pax7-positive satellite cells during development  self-renewing cells   showed delayed muscle regeneration and reduced satellite cell self-renewal  surrounding muscle cells is also known to undergo extensive remodeling during muscle regeneration. Consequently, excessive composition of interstitial ECM promotes the appearance of connective tissue or fibrosis in muscle under certain conditions such as those seen in DMD or aging muscles. Urciuolo and colleagues have recently demonstrated that an ECM protein, collagen VI, is critical as an extracellular niche protein to maintain the satellite cell pool (Urciuolo et al., in vitro. Satellite cells cultured on this substrate have shown higher potency of self-renewal than those cultured on traditional plastic dishes. Additionally, myoblasts cultured on hydrogel could promote the efficacy of cell engraftment and the reconstitution of satellite stem cells in vivo, indicating that substrate elasticity is also an important factor of satellite cell self-renewal (Gilbert et al., As described above, accumulating evidence has elucidated the signaling network for self-renewal in satellite cells while Gilbert and colleagues provide us new insight that the skeletal muscle microenvironment potentially regulates stem cell fate (Gilbert et al., In addition to cell commitment, recent reports indicate that physiological conditions in satellite cells may influence the regulation of self-renewal. Liu and colleagues have proposed that hypoxia does not affect myoblast proliferation but instead promotes satellite cell self-renewal through up-regulating Pax7 (Liu et al., It is widely accepted that satellite cells are essential for postnatal muscle growth and muscle regeneration. Despite high potency of myogenic differentiation in satellite cells, these cells are currently not applicable for cell transplantation therapy against DMD due to severe limitations, such as low cellular survival, incomplete myogenic differentiation, and especially poor satellite cell formation (Tedesco and Cossu, Recently, accumulating evidence has revealed the satellite cell heterogeneity and the molecular mechanisms of cell fate determination, specifically whether satellite cells differentiate into myocytes or self-renew as stem cells. These studies demonstrated that maintenance of the satellite cell pool is intrinsically and extrinsically regulated by many regulators. Novel knowledge about muscle regeneration through satellite cells may provide us new therapeutic approaches for DMD patients. Additionally, there are multiple unexplained muscular diseases, such as sarcopenia or muscle atrophy. In order to discover ideal therapies for muscular diseases, it is essential to explore fundamental molecular mechanisms of muscle satellite cells using new methodological technologies such as sequencing-mediated global gene regulation.Norio Motohashi and Atsushi Asakura wrote the manuscript. Both authors read and approved the final manuscript.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.


Preeclampsia is a unique pregnancy-related disease that affects 5-7% pregnancies worldwide. Placental architecture is modified in PE and eclampsia. Placental morphology and cellular arrangement are important for oxygen delivery from the mother to the fetus. Fetal growth and well-being after 20 weeks of gestation are dependent upon successful placental development. This, in turn, is achieved by an enhanced maternal blood supply to the placenta  and growth/ differentiation of the gas-exchanging placental villi. Conversely, pregnancy with severe placental insufficiency exhibits abnormalities both in uterine artery and in umbilical artery Doppler, and results in adverse perinatal outcome. The evaluation of placental functioning is possible nowadays through ultrasound examinations. Sonographic images associated with placental lesions include cystic areas, heterogeneous appearance of the placental mass, and thick or thin placentas. Sonographic evidence of destructive placental lesions is defined as the evolution of irregular cystic spaces with echogenic borders – the echogenic cystic lesions. Histological examinations of placenta may confirm these antepartum observations. Decidual vasculopathy and accelerated villous maturity are considered indicative of uteroplacental vascular insufficiency. Perivillous fibrin deposition and intervillous fibrin are considered indicative of intervillous coagulation. Detailed sonographic evaluation of the placenta and histopathological confirmation after birth are used to identify lesions associated with preeclampsia, intrauterine growth restriction and adverse short and long-term perinatal outcome, but the presence of cystic images in the placenta is not uniformly associated with adverse perinatal outcome. Combining Doppler studies with placental texture studies may lead to satisfactory results. Abbreviations: PE = preeclampsia; IUGR = intrauterine growth restriction; PI = pulsatility index; RIH = rounded intraplacental haematomas; TV = trophoblastic villi; MRI = magnetic resonance imaging Because of lack of predictive early markers and effective pharmaceutical interventions, PE is a serious obstetric complication leading to increased maternal and fetal morbidity and mortality.Preeclampsia (PE) is a unique pregnancy-related disease that affects 5-7% pregnancies worldwide. It is associated with hypertension and proteinuria. Despite long years of research, the mechanisms underlying the cause and progression of PE remain poorly understood. Risk factors include maternal and paternal family history of PE, nulliparity, ethnicity and existing disorders with several vascular dysfunctions, hypertension or inflammation such as diabetes, chronic hypertension, obesity, kidney disease, systemic lupus erythematosus and antiphospholipid syndrome .Diagnostic procedures during pregnancy complicated with pregnancy-induced hypertension/ preeclampsia include clinical examinations , ultrasound examinations, laboratory testing, fetal well-being assessments. Detailed ultrasound examination of the fetus at 18–20 weeks also includes placenta-related information beyond the fetal measurements and morphology: determination of placental length and thickness, number of cord vessels, cord insertion, and the assessment of placental texture. Uterine artery Doppler evaluation is performed by color and pulsed Doppler mapping. Mean pulsatility index (PI) values > 1.45 or bilateral early diastolic notches are considered abnormal . The ultrasound appearance shows an echodense region inside an echolucent area (or a hypoechogenic image with a hyperechogenic rim), without demonstrable blood flow inside (a recently formed hematoma). Old hematomas within an infarcted area might not be identified by ultrasound, as they tend to appear echolucent; with time, a definitive diagnosis can only be made through histopathologic examinations .A detailed sonographic evaluation of cysts includes an evaluation of shape, size and content as well as the absence/ presence of blood flow around or inside the cyst. Cystic areas are frequently observed in association with preeclampsia, growth restriction or fetal demise. Well-defined rounded cystic areas in the placenta are related to a higher risk of preeclampsia and intrauterine growth restriction. Several authors describe them as “rounded intraplacental haematomas” (RIH) and report that more than 50% of these cystic lesions were associated with placental infarcts reflecting maternal vascular underperfusion. Magnetic resonance imaging is also useful in diagnosing early placental insufficiency. Heparin is proposed as a treatment choice in preeclampsia with placental infarctions  . Insertions of the umbilical cord into the placenta margin or into the fetal membranes (velamentous insertion) rather than into the main placental mass are associated with smaller placentas and smaller infants. Non-marginal, but markedly eccentric cord insertion associates with a weaker chorionic vascular distribution, inefficient transport gradient and a reduced birthweight for a given placental weight   specifically vary in PE. The total numbers of TV are significantly lesser, indicating distal villous hypoplasia . Numerous avascular TV surround the arteriosclerotic stem villi, possibly reflecting failure of vascular organization (villitis). TV syncytiotrophoblasts invariably develop clusters and sprouts to form syncytial knots. Histomorphometric findings indicate that the PE placentas have less villous surface area and smaller diameters, whereas the density of the TV was significantly higher .Several studies propose the use of low molecular-weight heparin and aspirin when placental lesions suggestive of infarcts are observed in the ultrasound scan. The studies suggest that the identification of placental lesions with ultrasound in the absence of fetal growth restriction may be managed by antithrombotic treatment. The association of fetal testing may more correctly identify the appropriate time for fetal birth, avoiding in utero fetal demise [10]. Combining Doppler studies with placental texture studies may lead to satisfactory results. This is important for adequate referral to a tertiary perinatal center, for improved clinical outcome, both for mother and fetus .A detailed sonographic evaluation of the placenta and histopathological confirmation after birth are used to identify lesions associated with preeclampsia, intrauterine growth restriction and adverse short and long-term perinatal outcome, but the presence of cystic images in the placenta is not uniformly associated with adverse perinatal outcome [Pregnancies complicated by PE are reflected in the placenta both macroscopically and microscopically and may be diagnosed early by thorough placental serially ultrasound examinations. Although the placenta adapts well to the hypoxic condition in PE, the compensatory changes that occur are insufficient. These compensatory changes cause placental suboptimal development and placental dysfunction that leads to chronic fetal hypoxemia.


In vivo Cardiac Diffusion Tensor Imaging (cDTI) offers the potential to detect myocardial disarray and describe mean intravoxel myocyte orientation; however to date there is little quantitative cDTI data in the normal heart. In this study, we aim to establish the impact of physical and cardiac characteristics on cDTI parameters in a cohort of healthy volunteers.Myocardial disarray is considered an important histological feature of hypertrophic cardiomyopathy (HCM). In vivoWe recruited 46 healthy volunteers for cDTI at 3T. Three short axis mid-ventricular slices were acquired with multiple breath holds at the systolic pause. Data was post-processed with a platform, developed in-house, to create Fractional anisotropy (FA), Mean diffusivity (MD) and Helical Angle (HA) maps.Two of the original 46 volunteers were excluded due to ECG irregularities. Data was successfully acquired in the remaining 44 volunteers table . FA, MD Our data suggests that the cDTI parameters FA and MD, which describe intravoxel myocyte organisation and average myocardial diffusivity respectively, are independent of physical characteristics in healthy subjects. However, there is an association between age and epicardial HA which may be the result of age related loss in longitudinal function. Future NIHR cardiovascular BRU Royal Brompton Hospital & Imperial College.


Multipotent stem cells have been isolated from multiple sources including, bone marrow, adipose tissue, placenta, umbilical cord and cardiac tissue. It is predicted that large numbers of therapeutically-active cells isolated from these tissue sources will be required to treat patients inflicted with various disorders. Experimental evidence suggests that these various cell types can exhibit distinct characteristics depending upon tissue source and method of expansion: differential expression of cellular markers is sometimes detected, doubling times and expansion limits can differ, and physical differences that influence the ability of cells to adhere to various synthetic surfaces are observed. A novel prototype microcarrier recently developed by Pall promotes rapid attachment and growth of multiple cell types in stirred-tank reactors. Additionally, peptide-coating provides an alternative animal component-free substrate for cell expansion. These desirable attributes manifest in both serum-containing and animal component-free medium formulations.A spherical microcarrier with a chemistry that promotes rapid attachment and superior growth of multiple cell types under a variety of environmental condition has recently been developed. The microcarrier chemistry was optimized through an iterative process using these parameters to guide development. Figure Human bone marrow-derived mesenchymal stem cells expanded on this new microcarrier type reached acceptable cell densities in spinner cultures under a variety of environmental conditions. Harvest efficiencies achieved in small scale cultures were excellent, and cell identity was maintained. Conditions optimized in small-scale spinners were successfully employed in environmentally-controlled bioreactor. Cell harvesting optimization studies at larger scale are currently underway. Results to-date indicate that this novel microcarrier type will provide a superior substrate for large-scale propagation of MSCs under various environmental conditions.In conclusion, two novel animal protein-free microcarrier types that support excellent attachment and growth of human mesenchymal stem cells were generated; optimal surface charge density which promotes rapid cell attachment and subsequent growth was identified; peptide concentrations and coating conditions that support efficient growth of hMSCs were identified; excellent growth of cells was achieved; cell harvest at small scale demonstrated efficient removal of cells with standard enzymatic treatment; cell growth on novel microcarrier types was similar to that achieved with commercially-available collagen-coated microcarriers; environmental conditions were optimized to support excellent growth and harvest efficiencies from two liter bioreactors yielded reached 1 to 2.5 billion cells. Excellent harvest efficiencies from microcarriers were obtained using enzymatic treatment and application of moderate shear force. Harvest efficiencies of 97% with >95% viability were obtained with hMSC. Human mesenchymal stem cells retained the ability to differentiate into adipocytes and osteocytes after growth on novel microcarrier types.


A 30-year-old male, who underwent previous pars plana vitrectomy and silicone oil tamponade due to endogenous endophthalmitis originated from Klebsiella liver abscess, was referred for evisceration. At 2 months after vitrectomy with silicon oil tamponade, conjunctival chemosis and ocular pain were aggravated. Diffuse eyelid swelling and large subconjunctival mass with lipid droplets were noted. On MRI examination, subconjunctival mass and intra- and extraconal orbital mass around superior rectus muscle were observed. Excision of subconjunctival and orbital mass was performed. Histopathologic examination showed multiple silicone oil vacuoles surrounded by foreign body giant cells and fibrosis, which confirmed silicone oil granuloma. In a patient with suspicious melting sclera in diseases such as endophthalmitis, large silicone oil granuloma may be complicated in a rapid fashion after intravitreal silicone oil tamponade due to silicone oil leakage. Silicone oil has been widely used for decades in complex vitreoretinal surgeries. Although it has been known to be inert material, a number of complications such as cataract, glaucoma, and retinal toxicity have been reported . HoweverTo our knowledge, there have been no previous reports of early onset of large granuloma caused by extraocular migration of intravitreal silicone oil. We report subconjunctival and orbital silicone oil granuloma that resulted from the leakage of intravitreal silicone oil in a patient with endogenous endophthalmitis.A 30-year-old male suddenly developed left eyeball pain and visual loss with fever and chilling sensation. He was diagnosed as endogenous Klebsiella endophthalmitis that originated from liver abscess. He underwent pars plana vitrectomy and silicone oil tamponade  in the left eye for severe endogenous endophthalmitis. The infection had been calmed down after the surgery until the eyelid swelling and chemosis were aggravated at 2 months postoperatively. He was referred to oculoplastic clinic for evisceration under the impression of uncontrolled endophthalmitis.On ophthalmologic examination, he had no light perception in the left eye. The intraocular pressure was 14 mmHg in the right eye and 9 mmHg in the left eye. And left upper eyelid showed diffuse swelling and redness with complete ptosis . Large uOrbital magnetic resonance image (MRI) examination showed shrinkage of the eyeball and large subconjunctival and orbital mass. The mass was located in superior part of the orbit between levator muscle and eyeball, surrounding superior rectus muscle. It demonstrated septate cystic form with low signal intensity in T1- and T2-weighted image and heterogenous enhancement in Gd-enhanced image .The authors performed excision of subconjunctival and orbital mass. Large subconjunctival mass was observed under the entire upper bulbar conjunctiva. The conjunctiva was separated from the underlying mass by blunt dissection. Granulomatous mass was removed  and the Histopathology revealed silicone oil globules with inflammatory cellular infiltration. Multiple small and large lipid droplets (silicone oil) surrounded by foreign body giant cells were noted Figures . The fibAt 6 months after the surgery, the patient showed no evidence of recurrence. The patient was comfortable with no pain and showed good cosmesis wearing the prosthesis.Silicone oil is an established tamponade in treating complex vitreoretinal diseases such as retinal detachments, proliferative diabetic retinopathy associated with tractional retinal detachment . It is aIn the present study, silicone oil granuloma developed rapidly within 2 months through the melted sclera in a patient who underwent silicone oil tamponade for endogenous Klebsiella endophthalmitis originated from liver abscess. Endogenous Klebsiella endophthalmitis has generally poor prognosis in which most patients result in either no light perception or evisceration or enucleation . AlthougTo our knowledge, there have been no previous reports of early onset of silicone oil granuloma which was caused by large amount of silicone oil leakage through the melted sclera. Granulomatous inflammation associated with silicone oil leakage can develop rapidly progressing subconjunctival and orbital mass in patients with weakened sclera. In view of this case, surgeon should be prudent to perform silicone oil tamponade in a patient with suspicious melting sclera such as severe or uncontrolled endophthalmitis.


Hyrtios sp. extract induces apoptosis in human colorectal carcinoma RKO cells with different p53 status; Andrographolide induces apoptosis of C6 glioma cells via the ERK-p53-caspase 7-PARP pathway; and osthole induces human colon cancer cell death and inhibits migratory activity.Natural bioactives are generally referred to the compounds exclusive of essential nutrients that have specific biological activity to human. From several decades ago to now, cancer continues to be the leading lethal cause worldwide. Studies have shown that natural phytochemicals derived from certain plants have the capability to prevent carcinogenesis. In this special issue, we collected numerous studies which provide novel evidence to support the opinion. For instance, epigallocatechin gallate inhibits migration of human uveal melanoma cells; marine spongeWe also collected some review articles in this special issue. A paper evaluated the cancer therapeutic potential of cardiac glycosides. A paper proposed vitamin A as the potent anticancer agent on targeting cellular retinol binding proteins. Three other papers addressed the anticancer molecular mechanisms of betulin, Goniothalamin, and Zerumbone. In summary, it is therefore believed that the appropriate application of natural bioactives should be a supplementary and safe way that enhances the efficacy of cancer therapy.Yih-Shou HsiehShun-Fa YangGautam SethiDan-Ning Hu


Endovascular aneurysm repair has revolutionized the therapeutic strategy for abdominal aortic aneurysm. However, hostile proximal aneurysmal neck and tortuosity of access vessels remain challenges in selecting optimal stent-grafts in abdominal aortic aneurysms with difficult anatomy.A 65-year-old woman complained of intermittent abdominal pain for one week. Computed tomography angiogram demonstrated a tortuous infrarenal abdominal aortic aneurysm with a tapered neck and a 136° of infrarenal angulation. Aneurysmal dilatation and severe calcification of bilateral iliac arteries and tortuous aortoiliac access were also showed. Endovascular approach using Endurant stent-graft was attempted at an outside hospital, but failed because of the significant tortuosity of the abdominal aorta and iliac arteries. Since the patient refused to have open aneurysm repair, he was transferred to our hospital for further evaluation and possible EVAR with a different approach. EVAR was performed successfully using Gore Excluder stent-grafts . During the procedure, cannulation of the contralateral limb was unable to be achieved because of the tortuous aortoiliac course. Therefore, a snare was inserted from right radial artery, through the contralateral gate, to grasp the wire from left femoral artery. Two iliac stent-grafts were sequentially deployed with the lower end distal to the opening of the left internal iliac artery. Angiography confirmed complete sealing of the aneurysm with patency of bilateral renal arteries and external iliac arteries. The postoperative courses were uneventful and follow-up computed tomography angiogram at 6 months demonstrated patent bilateral femoral and renal arteries without endoleaks or stent migration.Although endovascular repair of aortic aneurysm with hostile neck and tortuous access is rather challenging, choosing flexible stent-grafts and suitable techniques is able to achieve an encouraging outcome. Endovascular aneurysm repair (EVAR) has revolutionized the therapeutic strategy for abdominal aortic aneurysm (AAA) with low operative mortality and morbidity, short hospital stay, and minimal blood loss compared with open repair ,2. The aA 65-year-old woman presented to an outside hospital with complaining of intermittent left-lower quadrant abdominal pain for one week. Computed tomography angiogram (CTA) demonstrated a severely tortuous descending thoracic aorta and an infrarenal AAA with maximum diameter of 80 mm and hostile neck   during AAA repair has been associated with buttock claudication, impotence, colon ischemia and pelvic necrosis . But witAs far as we know, no data exist on direct comparison of the performance of different stent-graft type in EVAR for AAA, and optimal selection of stent-graft type in hostile neck remains unclear . A retroBeside hostile proximal neck anatomy, challenging artery access conditions such as small-caliber vessels, iliac tortuosity, excessive calcification and occlusive diseases, represent the second most common excluding factor for EVAR . TechnicEVAR in AAA with severely angulated neck and tortuous access is technically challenging. Choosing flexible stent-graft system and various alternative techniques may make the difficult cases feasible, and achieve an encouraging early outcome. Further long-term randomized studies are needed to confirm the safety and durability of EVAR in patients with hostile anatomy.Written informed consent was obtain from the patient for publication of this case report and any accompanying images. A copy of writen consent is available for review by the editor of this journal.


Patched 1 receptor, which senses the Sonic Hedgehog morphogen and limits its mobility in the limb bud. Second, evolutionary changes to the degree of programmed cell death between digits influence their development after their initiation. Similarly, evolutionary modification of leaf margin outgrowths occurs via two broad pathways. First, species-specific transcription factor expression modulates outgrowth patterning dependent on regulated transport of the hormone auxin. Second, species-specific expression of the newly discovered REDUCED COMPLEXITY homeodomain transcription factor influences growth between individual outgrowths after their initiation. These findings demonstrate that in both plants and animals tinkering with either patterning or post-patterning processes can cause morphological change. They also highlight the considerable flexibility of morphological evolution and indicate that it may be possible to derive broad principles that capture how morphogenesis evolved across complex eukaryotes.An open problem in biology is to derive general principles that capture how morphogenesis evolved to generate diverse forms in different organisms. Here we discuss recent work investigating the morphogenetic basis for digit loss in vertebrate limbs and variation in form of marginal outgrowths of angiosperm (flowering plant) leaves. Two pathways underlie digit loss in vertebrate limbs. First, alterations to digit patterning arise through modification of expression of the  A key question in biology is how morphological diversity is generated. Although plants and animals evolved multicellularity independently, within each kingdom conserved gene regulatory networks (hereafter termed networks) control the development of one or more body parts. In this context evolution operates as a “tinkerer,” being strongly influenced by the materials currently at hand as well as prior history . Consequcis elements, leading to their mutation having a lower propensity to generate pleiotropic effects that would compromise development  might be more readily available for evolutionary tinkering . HoweverTwo recent papers have explored the significance of patterning versus post-patterning events on development by studying digit loss in mammals and leaf shape formation in angiosperms and revealed a strong link between altered, species-specific gene expression domains and morphological variation. Both studies suggest considerable versatility in how evolutionary tinkering with developmental processes can ultimately arrive at similar phenotypes.Msx2 , a Shh receptor, is reduced toward the posterior limb bud. Ptch1 acts to restrict the spread of Shh by sequestration, thus reduction in Ptch1 expression leads to an expanded region of Shh activity and more uniform expression of its target genes, presumably causing a shift in limb axis symmetry to the space between digits III and IV  transcription factors are expressed in the meristem to maintain its organ-generating potential (PIN-FORMED 1 (PIN1) efflux transporter, coupled to a self-reinforcing feedback of auxin on PIN1 expression and polarization, likely creates sequential local auxin activity maxima at the flanks of the SAM. This process appears to be self-organizing and the resulting auxin maxima are required for sequential primordium development (CUP-SHAPED COTYLEDON (CUC) genes mark the leaf primordium boundary and allow its separation by repressing growth at the flanks  homeobox gene, of which a loss of function allele simplifies the leaf without causing pleiotropic phenotypes, suggesting a specific requirement for RCO in leaflet formation. RCO evolved in the Brassicaceae family from a gene duplication of LATE MERISTEM IDENTITY 1 (LMI1); originally identified in A. thaliana as a floral regulator (RCO is specifically expressed at the base of leaflets (Figure LMI1 is expressed more distally, in a complementary pattern, along the leaf margins. RCO does not appear to influence PIN1-mediated auxin patterning, but instead functions by repressing cellular growth between individual leaflets in C. hirsuta, a post-patterning process that allows leaflet separation. RCO was lost in A. thaliana during evolution, contributing to its leaf simplification, but re-introducing RCO into A. thaliana drives expression in basal regions of the leaf and increases leaf complexity, partially reversing the consequences of evolution. These results, together with a follow-up study in the sister species Capsella rubella and Capsella grandiflora by RCO is a key regulator of leaf shape and diversity in the Brassicaceae and provide a striking example of organ shape diversification by tinkering with local growth regulation at the flanks of a growing organ primordium (RCO study is that this gene was discovered through performing a forward genetics study in C. hirsuta and could not have been found in A. thaliana, where the gene has been lost, thus highlighting the importance of unbiased studies in diverse taxa for understanding the genetic basis for the evolution of form.Until recently, no genes had been identified that specifically influence leaflet formation without also affecting meristem function or leaf initiation. Such findings suggested that leaflets form through the redeployment of processes that acted earlier in development during leaf initiation . To idenegulator . They fos Figure , while Limordium . AnotherTaken together, these two studies illustrate how evolution can exploit both patterning and post-patterning processes to create morphological diversity in both plants and animals. It will be interesting to explore whether bias might exist for variations of either kind or for particular developmental pathways across different kingdoms. For example, plants and animals have evolved distinct biophysical properties and morphogenetic strategies that pose different constraints for evolution. Whereas animal morphogenesis involves the use of large-scale apoptosis and cell migration, these mechanisms are used to more limited extent  or not aThe 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.


LMNA-related congenital muscular dystrophy and other rare clinical entities). We performed imaging studies on a large cohort of subjects bearing either LMNA or EMD gene mutations; each patient enrolled displayed variable compromise on posterior legs’ muscles, ranging from mild compromise on soleus and medial head of gastrocnemius to overt alterations on soleus, medial head of gastrocnemius[LMNA or EMD gene mutations and lead to hypothesize a common mechanism in the process of damage of skeletal muscles fibers.Laminopathies are a heterogeneous group of disorders related to alterations on genes coding for proteins of the nuclear envelope. Among these clinical entities, there are several diseases affecting mainly the cardiac and skeletal muscles. These disorders include forms with a selective cardiac compromise and muscular dystrophies (autosomal and X-linked forms of Emery-Dreifuss muscular dystrophy, Limb girdle muscular dystrophy 1B, rocnemius. Of note


Though several implementation and quality improvement strategies have been shown to be effective in implementing programs and practices in routine clinical settings ,2, littlThe study tested the effectiveness of the implementation (IF) strategy hypothesizing that, compared to national technical assistance support alone, national support plus IF would improve implementation of PC-MHI. The RE-AIM  Framework guided testing of the IF strategy's effectiveness ,9.Two regions were recruited to receive the IF strategy and two matched regions were recruited for comparison. Regional MH leadership identified primary care (PC) clinics unlikely to implement PC-MHI without assistance. PC clinics in comparison regions were matched to clinics in IF regions. The sample included 14 PC clinics, 174 PC providers and 98,758 PC patients. To evaluate implementation outcomes, administrative data was extracted for two six month periods, 9-15 months and 21-27 months following completion of an implementation plan at IF clinics. Generalized estimating equations were used to control for observations clustered within sites.Reach)  than patients at comparison clinics. PC providers were more likely to refer at least one patient to PC-MHI (Adoption)  than providers at comparison clinics and a greater proportion of PC providers' patients were referred to PC-MHI (Adoption)  at IF clinics. There was no difference between IF and comparison clinics in the likelihood of patients being referred for a first time visit to specialty mental health care (Effectiveness) or the percentage of patients receiving same day access to PC-MHI (Implementation). Similar results occurred during the second six month period (Maintenance).For the first six month period, PC patients at clinics receiving IF were more likely to be seen by PC-MHI providers  can help healthcare system change agents learn how to facilitate implementation of evidence-based programs. For two and a half years, we conducted monthly debriefing interviews with a national expert external facilitator (EF) who was mentoring and coaching two internal regional facilitators (IRFs) in facilitating implementation of a VA policy initiative for Primary Care-Mental Health Integration (PC-MHI) at eight primary care clinics. Interviews focused primarily on the EF's efforts to help the IRFs become experts in IF processes. We also conducted two semi-structured qualitative interviews with each facilitator, midway through and at the end of the intervention.Our qualitative content analysis revealed that although the EF helped IRFs learn general implementation facilitation knowledge and skills, the EF also identified IRFs' individual strengths and weaknesses and tailored mentoring and coaching activities to their characteristics. The EF used a variety of methods to help IRFs learn IF skills, including both active methods  and participatory ones. She also used cognitive supports  and psychosocial supports, as well strategies to promote self-learning. Additionally, the EF tailored the process to sites' implementation needs. Over time, the EF pulled back from IRFs, increasingly turning responsibility for IF activities over to them. IRFs responded differently to this process with one IRF independently "breaking away" and the other being "pushed out of the nest." In addition to helping IRFs learn the skills they needed for facilitating PC-MHI implementation, the EF helped IRFs to identify and modify interpersonal styles that could hinder success of facilitation efforts.This study addresses the critical but understudied area of how implementation scientists can transfer facilitation skills that incorporate evidence-based implementation interventions and strategies to internal change agents to help healthcare organizations implement effective programs.


Vaccinations against infectious diseases are one of the major achievements in medicine in the last century and the most effective method for preventing infections. Concern about safety of vaccinations has been heightened by several reports of possible vaccine-induced autoimmune phenomena following various vaccinations. So far no study was able to show a casual connection between any vaccine and autoimmune syndrome.Few studies were published showing that induction of autoantibodies following various vaccination is possible, but without clinical significance. In few cases antibodies after vaccination were elevated even 6 months after vaccination. Induction of autantibodies, mainly antiphospholipid antibodies, in selected apparently healthy individuals was reported after influenza, hepatitis B and hepatitis A vaccination.Autoimmune manifestations reported have been only temporally related to the respective vaccine. Guillian Barre syndrome was described following vaccination against influenza and few other vacines, multiple sclerosis and arthritis were mainly reported after hepatitis B vaccination. There are some evidence to suggest a connection of reactive arthritis and rubella vaccine. Dermatomyositis was described following hepatitis B, tuberculosis, influenza and tetanus vaccinations. Recently a new syndrome Autoimmune-Autoinflammatory syndrome induced by adjuvants-ASIA has been described.Highlights of lecture:- autoimmune adverse events following vaccinations is possible in selected individuals but the risk of autoimmune disease after vaccination is, comparing to advantages of vaccination, negligible.- induction of autoantibodies in selected individuals after vaccination has no clinical significance.- new generation vaccine, mainly oriented on finding safer and effective adjuvants, are needed. At present few effective adjuvants are considered safe for use in humans.None declared.


Neural systems show a wide variety of complex dynamics on different time scales. Specifically, on the short time scale of neuronal activations (milliseconds to seconds), several theoretical models  demonstIn this study we analyze how this coexistence of transient dynamics and cell assemblies can emerge in one neural circuit. The neural network, we investigate, consists of rate- based neurons with connections adapted by a generic combination of Hebbian plasticity and synaptic scaling . A subse


Philadelphia chromosome positive acute lymphoblastic leukemia is classified as a very high-risk group and it requires an intensive chemotherapy regimen associated with tyrosine-kinase inhibitors and allogeneic hematopoietic stem cell transplant from related or unrelated HLA matched donor. Most times, intensive chemotherapy regimens are associated with prolonged and profound pancytopenia when the risk of invasive fungal infection increases. After Candida and Aspergillus species, Mucormycosis is the third frequent fungal infection in hematology patients and it is associated with a reduced overall survival. When suspected, immediate treatment is needed. We present the case of 24-year-old patient diagnosed with Philadelphia chromosome positive acute lymphoblastic leukemia who developed right rhino-sino-orbital fungal infection with a favorable response to systemic antifungal treatment and noninvasive surgery. Later, patient refused consolidation and allogeneic hematopoietic stem cell transplant from an unrelated HLA matched donor but accepted the first generation tyrosine kinase inhibitor (Imatinib) and maintained a complete hematological and molecular response.Abbreviations: ENT = ear nose throat; BMB = bone marrow biopsy; ALL = acute lymphoblastic leukemia; TKI = tyrosine kinase inhibitor; IFI = invasive fungal infection; BMB = bone marrow biopsy; HE = hematoxylin and eosin; IHC = immunohistochemistry; CD = cluster of differentiation; ob = objective; Tdt = terminal deoxynucleotidyl transferase It represents the most frequent form of acute leukemia in pediatric population. Opposite to paediatric population where complete remission is achieved in 75% of cases, in adult population the results are modest .Mucormycosis is a fungal infection from Mucorales species . The most frequent site of infection is the sinus and associates with brain extension. When Mucormycosis is suspected, urgent treatment should be started and it consists of surgical, antifungal treatment and correction of risk factors  .BCR-ABL1 positivity for p190 transcript.Qualitative and quantitative molecular tests showed In February 2014, induction according to GMALL protocol was started and followed by febrile pancytopenia that required large spectrum antibiotics and antimycotic (Fluconazole).The bone marrow exam performed on day 14 of induction showed hypercellular marrow due to 75-80% blast infiltration. It was considered a treatment failure and the patient received salvage treatment according to GRAAL 2003 protocol and first generation tyrosine-kinase inhibitor (Imatinib), followed by prolonged febrile pancytopenia and grade 4 mucositis for which multiple broad-spectrum antibiotics and antimycotics (Voriconazole) were used.On day 14 of salvage regimen, the patient presented abrupt onset of right side headache followed by chemosis, photophobia and right ptosis.Bacterial screening including pharyngeal swab and palatine swab showed Zygomycetes filamentous fungi.Cerebral MRI showed pan sinusitis, inflammation of eye’s structures and excluded cavernous sinus thrombosis.Right rhino-sinus-orbital Mucormycosis was suspected and liposomal B Amphotericin was started. ENT consult suggested radical surgery but due to the patient’s refusal, right medial maxillectomy with complete resection of right inferior and medium nasal cornet and right anterior-posterior ethmoidectomy with mucocel derange from right retrobulbar recess were performed. Mycological exam of secretion taken during the procedure confirmed Mucormycosis invasive fungal infection.The patient’s status improved after 33 days of liposomal B Amphotericin treatment and palliative surgical intervention.Although complete remission with salvage treatment was achieved, the patient refused consolidation treatment and allogeneic hematopoietic stem cell transplant from unrelated HLA matched donor and accepted Imatinib and Posaconasole treatment.12 months after the Mucormycosis episode, the patient maintained complete hematologic and major molecular remission without any signs of Mucormycosis infection.Table 1).The 5-year survival rate of adult population with ALL is 39%. 25% of this population presents positivity for Philadelphia chromosome and for those patients, the prognosis is reserved. Most patients receive intensive chemotherapy and tyrosine kinase inhibitors (TKI). Imatinib, first generation TKI, improved complete remission rate and increased the number of patients receiving hematopoietic stem cell transplants . In case of suspicion, urgent antifungal and surgical debridement treatment are required. The mortality rate of untreated Mucormycosis infection is of 70- 100%.Table 2) [5].Pagano and al. published a study in which the most affected organs were: lungs (47%), eye and face sinuses (25%), cerebral (19%) and extremely rare, small bowel (necrosis enterocolitis). The most common haematological diseases complicated with IFI are acute myeloid leukemia and acute lymphoblastic leukemia  and surgical removal of necrotic tissues. It has been proved that immediate surgical debridement of necrotic tissues increases the rate of cure but sometimes, this maneuver is difficult in thrombocytopenic patients. For those patients, multidisciplinary strategy is most beneficial  [The case report represents a double challenge: first, to induce the complete remission of progressive ALL and second, to treat Mucormycosis in a pancytopenia patient. The patient maintained complete remission after salvage treatment only with Imatinib and without allogeneic hematopoietic stem cell transplant. For Mucormycosis, the palliative surgical debridement and antifungal treatment (Amphotericin B followed by Posaconazole) were successful in curing IFI without physical mutilation and intact affected organ functions with good quality of life.In this case report, we presented a young patient who was treated unconventionally for Philadelphia positive ALL and Mucormycosis. Due to rapid Amphotericin B treatment and minimum surgical debridement of affected areas, the patient achieved an overall and disease free survival of 12 months with good quality of life. At the time of publication, the patient maintained complete hematological and molecular remission with first generation TKI (Imatinib).Acknowledgment: This work was supported by the grant PN 41-087/ 2007 from the Romanian Ministry of Research and Technology. The authors express the gratitude to European LeukemiaNet for their permanent support.Disclosures: None


Chronic myelogenous leukemia is often treated using tyrosine kinase inhibitors such as dasatinib. Here we describe a rare case of inflammatory myopathy in a patient with chronic myelogenous leukemia treated with the tyrosine kinase inhibitor dasatinib.A 69-year-old Caucasian man with imatinib-resistant chronic myelogenous leukemia achieved complete molecular remission in response to dasatinib therapy. However, from a normal initial serum creatine kinase level, he developed elevated serum creatine kinase levels and gradual-onset progressive muscle weakness after dasatinib therapy was initiated. Our patient was eventually diagnosed with inclusion body myositis. However, we were unable to determine the mechanism underlying the dasatinib-associated muscle weakness. Given the efficacy of dasatinib in the treatment of chronic myelogenous leukemia and our patient’s mild symptoms of inclusion body myositis, he continued to receive dasatinib under close clinical and laboratory observation.Despite the wide use of dasatinib and its documented safety, we report a case of severe muscle injury of unknown etiology. Therefore, patients with chronic myelogenous leukemia receiving dasatinib and perhaps all tyrosine kinase inhibitors should be carefully monitored for signs of muscle injury, especially if this is associated with significant elevations in serum creatine kinase levels. Chronic myelogenous leukemia (CML) accounts for approximately 15–20% of all leukemia cases in adults in the USA . DasatinThe common side effects of dasatinib therapy include recurrent pleural effusions, myelosuppression, and rash. Other treatment-related adverse events include mild to moderate diarrhea, peripheral edema, and headache , 7. ElevA 69-year-old Caucasian man who was diagnosed with chronic phase CML in 1990 demonstrated a reasonable response to initial treatment with interferon and omacetaxine mepesuccinate (homoharringtonine), which was discontinued 14 years later when he began receiving imatinib mesylate (Gleevec) therapy. Our patient became resistant to imatinib one year after its first administration and developed accelerated phase disease; dasatinib was prescribed as second-line treatment. His initial serum CK level was normal. A marked elevation in his serum CK level was noted  and in 7% of those resistant or intolerant to imatinib therapy (minimum follow-up of 36 months) . Other pWe have reported the case of a patient with CML who developed significantly elevated serum CK levels while receiving dasatinib therapy, and who was subsequently diagnosed with IBM. This is what we believe to be the first report of a patient developing muscle weakness while receiving dasatinib, although causality could not be established. Furthermore, the plausible mechanisms underlying dasatinib-induced muscle injury could not be determined. Although dasatinib has been widely used in clinical practice and is safe, based on our experience, severe muscle injury should be investigated. Patients with CML receiving dasatinib or other TKIs should be carefully monitored for symptoms or signs of muscle injury, especially if this is associated with significant elevations in serum CK levels. Further studies are needed to determine the underlying pathophysiology of muscle injury in such patients.Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


A 47-year-old male presented with a subacute inferior myocardial infarction (MI)complicated by inferobasal ventricular septal rupture (VSR) and underwent emergencysurgical repair of VSR with a pericardial patch. In the postoperative period he remainedhypotensive, with low exercise tolerance and a holosystolic murmur was present.Echocardiography showed persistence of VSR with left-right shunt  and reveIn conclusion, this patient presented with an inferior MI complicated by rightventricular infarction, inferobasal VSR and inferior pseudoaneurysm with organizedthrombus inside. Mechanical complications are rare nowadays due to earlyrevascularization. The multimodality imaging approach is essential for their correctdiagnosis.


Lupus nephritis affects 30 to 70% of systemic lupus erythematosus (SLE) patients and its treatment remains insufficiently effective and excessively toxic. Although biomarkers for nephritis are being identified there is still no reliable way of predicting an impending renal flare or determining which patients will respond to therapy. Because human renal tissue cannot be obtained sequentially during remission and relapse, animal models are often used to study progression of lupus nephritis. To elucidate the molecular mechanisms involved in renal inflammation during the progression, remission and relapse of nephritis we performed a transcriptome analysis of renal tissue from two murine lupus models, NZB/WF1 mice that develop proliferative glomerulonephritis and NZM2410 mice that develop glomerulosclerosis with minimal inflammation.Kidneys from NZB/W F1 and NZM2410 mice were harvested at intervals during their disease course or after remission induction with either combination cyclophosphamide/costimulatory blockade or with BAFF inhibition. Genome-wide expression profiles were obtained from microarray analysis of perfused kidneys. Real-time PCR analysis for selected genes was used to validate the microarray data. Comparisons between groups using SAM, and unbiased analysis of the entire dataset using singular value decomposition and self-organizing map were performed.Few changes in the renal molecular profile were detected in pre-nephritic kidneys but a significant shift in gene expression, reflecting inflammatory cell infiltration and complement activation, occurred at proteinuria onset. Subsequent changes in gene expression predominantly affected mitochondrial dysfunction and metabolic stress pathways. Remission induction reversed most, but not all, of the inflammatory changes and progression towards relapse was associated with recurrence of inflammation, mitochondrial dysfunction and metabolic stress signatures. Endothelial cell activation, tissue remodeling and tubular damage were the major pathways associated with loss of renal function.Immune cell infiltration and activation is associated with proteinuria onset and reverses with immunosuppressive therapy but disease progression is associated with renal hypoxia and metabolic stress. Optimal therapy of SLE nephritis may therefore need to target both immune and nonimmune disease mechanisms. In addition, the overlap of a substantial subset of molecular markers with those expressed in human lupus kidneys suggests potential new biomarkers and therapeutic targets.


To review the spectrum of imaging findings of chemotherapy- induced cardiomyopathy in correlation with most common cytotoxic drugs and regimens.Cardio toxic effect of chemotherapy is a well-recognised problem in cancer patients. Cardio toxicity depends on multiple predisposing factors, specific components of the chemotherapy regimen, length of treatment, and dosage.We will present the spectrum of most common cardiotoxic chemotherapy agents and their combinations, specific effects on the myocardium, and imaging features of cardiomyopathies induced by chemotherapy.We will review pathophysiology of chemotherapy induced cardiomyopathy including:• Dose dependent cardiomyopathy• Predisposing conditions –diabetes, presence of coronary artery disease, age.• Potential reversibilityWe will discuss imaging characteristics of chemotherapy induced cardiomyopathy• Imaging modalities • Importance of monitoring cardiac function during and after treatment• Distribution of late Gadolinium enhancement (LGE)• Emerging technologies for early diagnosis of cardiomyopathy in cancer patientsChemotherapy induced cardiomyopathy is a common problem among cancer patients, increasing long term morbidity and mortality and often leading to disability. Patients receiving chemotherapy treatment, particularly cardio toxic agents, should be routinely assessed for cardiac function to diagnose cardiomyopathy during the early phase of treatment and to prevent development of irreversible heart failure.


In medication-overuse headache (MOH) pain modulation is probably dysfunctional at cortical and subcortical level, resulting in disequilibrium between pain inhibition and facilitation. Volumetric grey matter changes have been found in cortical regions, but also in the brainstem , the latSurface-based morphometric analyses should complement volumetric findings, providing more specificity in the metric affected (thickness vs. gyrification). Whereas cortical thickness alterations probably rely on altered trajectories of cortical maturation or neurodegenerative processes, cortical folding (gyrification) abnormalities are thought to reflect early alterations to brain development.In the present study we investigated cortical thickness and gyrification in 29 patients with MOH according to International Headache Society criteria and 29 age- and gender matched controls, using FreeSurfer. Correction for multiple comparisons was performed.In patients with MOH cortical thickness was decreased in the left middle frontal gyrus  compared to controls, whereas local gyrification was increased in the right fusiform gyrus and adjacent temporal regions, as well as in the right occipital pole.Decreased cortical thickness in frontal regions corresponds to decreased grey matter volume in similar regions. Increased local gyrification in the right fusiform gyrus corresponds to increased grey matter volume in the previous volumetric study. Increased gyrification in occipital regions might be related to increased susceptibility for cortical spreading depression.


To investigate the patterns and mechanisms of audiovestibular dysfunction in intracranial hypotension.We had consecutively recruited 16 adult patients with intracranial hypotension at the Dizziness Center of Pusan National University Hospital between November 2011 to November 2013. Spontaneous, gaze-evoked, and positional nystagmus were recorded using 3D video-oculography. Most patients had pure tone audiometry, and bithermal caloric tests.Out of the 16 patients with intracranial hypotension, five (31%) had neuro-otological symptoms along with the orthostatic headache. One of them presented with recurrent spontaneous vertigo and tinnitus mimicking meniere's disease (MD). Oculographic analysis documented abnormal eye movements in 38%, which include spontaneous downbeat nystagmus with variable positional modulation  and positional upbeat nystagmus . During the attack of vertigo in the patient with MD-like symptoms, we observed unidirectional horizontal and torsional nystagmus with normal head impulse test. Bithermal caloric tests were normal in all patients who tested. Audiometry showed unilateral or bilateral sensorineural hearing loss in about half of the patients.Our study demonstrates that intracranial hypotension can induce higher frequency of audiovestibular dysfunction, which may be attributed to both irritation or dysfunction of the peripheral labyrinth or vestibulocochlear nerve, and brainstem or cerebellar dysfunction due to brain sagging.No conflict of interest.


Clinician related factors have been implicated as important reasons for low rates of recruitment to randomised controlled trials (RCTs). Clinicians can experience discomfort with some underlying principles of RCTs and experience difficulties in conveying them positively to potential trial participants. Recruiter training has been suggested to address identified problems but a synthesis of this research is lacking. We therefore systematically reviewed the available evidence on training interventions for RCT recruiters.Studies that evaluated training programmes for trial recruiters were included. Those that provided only general communication training not linked to RCT recruitment were excluded. Data extraction and quality assessment were completed by two reviewers independently.15 studies from 7,337 potentially eligible titles and abstracts were included in the review: three RCTs, three non-randomised controlled studies, six pre-test-post-test studies, two qualitative studies and a post-training questionnaire survey. Most studies were of moderate or weak quality. Training programmes were mostly set within cancer trials, and usually consisted of workshops with a mix of health professionals over one or two consecutive days covering generic and trial specific issues. Recruiter training programmes were well received and there was evidence that some increased recruiters’ self-confidence in communicating key RCT concepts. There was, however, very little evidence that this training increased recruitment rates or patient understanding, satisfaction, or levels of informed consentThere is a need to develop training programmes that can enable recruiters to explain key concepts effectively and evaluate whether they lead to improved recruitment and informed consent in RCTs.


Carcinogenesis is an exceedingly complicated process, which involves multi-level dysregulations, including genomics (majorly caused by somatic mutation and copy number variation), DNA methylomics, and transcriptomics. Therefore, only looking into one molecular level of cancer is not sufficient to uncover the intricate underlying mechanisms. With the abundant resources of public available data in the Cancer Genome Atlas (TCGA) database, an integrative strategy was conducted to systematically analyze the aberrant patterns of colorectal cancer on the basis of DNA copy number, promoter methylation, somatic mutation and gene expression. In this study, paired samples in each genomic level were retrieved to identify differentially expressed genes with corresponding genetic or epigenetic dysregulations. Notably, the result of gene ontology enrichment analysis indicated that the differentially expressed genes with corresponding aberrant promoter methylation or somatic mutation were both functionally concentrated upon developmental process, suggesting the intimate association between development and carcinogenesis. Thus, by means of random walk with restart, 37 significant development-related genes were retrieved from a priori-knowledge based biological network. In five independent microarray datasets, Kaplan–Meier survival and Cox regression analyses both confirmed that the expression of these genes was significantly associated with overall survival of Stage III/IV colorectal cancer patients. Colorectal cancer (CRC) is the third most common cancer in men  and the second in women  worldwide, accounting for roughly 694,000 deaths per yearIt is putatively accredited that carcinogenesis is caused by multi-level dysregulations, including genomics [majorly caused by somatic mutation and copy number variation (CNV)]468101112131617212223262728BRAF could activate MAPK pathway, thus influencing the massive dysregulation of gene activityCNV, aberrant promoter methylation and somatic mutation could all influence gene activation or suppression, thereby influencing the process of carcinogenesis. CNVs may alter gene dosage by changing the number of copies of a gene that is present in the genome303132The multi-level genomic dysregulations during carcinogenesis indicated that while looking into the dysregulation of gene expression in cancer, the aberrant patterns of multi-level events should also be paid considerable attention to shed light on the underlying intricate mechanisms of cancer initiation and deterioration. Therefore, the integrative analysis of cancer genomics, methylomics and transcriptomics is urgently needed to comprehensively dissect cancer etiology and provide clinical guidance.The Cancer Genome Atlas (TCGA) database is an immeasurable source of knowledge launched in 2005, which provides publicly available cancer genomic datasetsIn this study, we first collected genes with significant dysregulations with regard to DNA copy number, DNA promoter methylation, gene expression, and somatic mutation from TCGA paired samples. Differentially expressed genes (DEGs) with consistent aberrant promoter methylation or somatic mutation were found both exhibiting remarkable functional unity in developmental process. Gene to gene regulatory network was constructed by means of merging Human Protein Reference Database (HPRD), and Kyoto Encyclopedia of Genes and Genomes (KEGG) networks. By combining multi-dimensional genomic data of CRC and priori knowledge network, we applied a computational strategy, i.e. random walk with restart, to obtain the genes which were affected considerably by aberrant promoter methylation or somatic mutation. The most of these significant genes were connected in the network, and proven to hold profound prognostic information in late stage (Stage III/IV) patients, which might be helpful for constructing prognosis prediction models and providing novel tools to guide clinical implementations for this deadly disease.A schematic for the study is depicted in https://tcga-data.nci.nih.gov/tcga/). Four levels of paired data  were downloaded, including 32 paired RNA sequencing level 3 data [raw counts and RNASeq by Expectation Maximization (RSEM) normalized read counts], 500 paired DNA copy number level 3 data  and the risk score  generated by these 37 significant genes were significantly associated with patient’s OS. Multivariate Cox analysis indicated the risk score was an independent prognostic factor .Meta-analysis of 37 significant genes and risk score in five Clinicinfo data sets also confirmed the result of survival analysis with both fixed-effect model  and rand53ALK could disrupt the development of central nervous system585960TIAM1, expressed in the base of intestinal crypts, established a fundamental role for Wnt-signaling pathway in the development and maintenance of normal intestinal physiologyTIAM1 and canonical Wnt-signaling pathways could significantly influence intestinal tumor formation and progressionThe booming amount of high-throughput and multi-dimensional genomic data usher us into a new era, when the tremendously complicated molecular mechanism of carcinogenesis were perceived and dissected in a more integrative perspective. In this study, we systematically analyzed CRC genomic data, including CNV, somatic mutation, DNA promoter methylation and gene expression, to discover novel and important molecules and genomic dysregulations in a more comprehensive manner. Paired samples in TCGA database were used to identify differential gene expression and genetic or epigenetic abnormalities, respectively, and collected three groups of candidate genes with differential gene expression pattern and upstream corresponding dysregulations. The result of GO analysis indicated the functions of DEGs with abnormal promoter methylation (Group B) and somatic mutation (Group C) both majorly concentrated on developmental process, of which the outcome is an anatomical structure , or organism over time from an initial condition to a later conditionPTCH1 is a key regulator of development, whose overexpression could drive skin carcinogenesis7172Notch1 signaling pathway, activated during development, are proven to be reactivated in the process of carcinogenesis7472767778It has been more than 150 years since Rudolf Virchow first advocated that neoplasms arise “in accordance with the same law, which regulates development” in 1858. Emerging evidences supported the cellular behavioral similarity between ontogenesis and oncogenesis, for instance, in the process of epithelial-to-mesenchymal transition (EMT)In our study, we adopted a simple and effective computational strategy to randomly walk DPRGs with aberrant promoter methylation or somatic mutation in HPRD and KEGG merged biological network. Random walk with restart was adopted to decipher gene to disease association in priori-knowledge based network, whose performance was proven to be much more superior to other methods, such as neighborhood approaches8081TGFBR1 is a central molecule in TGF-β pathway, whose alteration could strikingly enhance the susceptibility to CRCEP300 may be a feature of gastric and colorectal cancersPRKCA and PRKCB are both member of Protein kinase C (PKC) family, which have a role in cell proliferation, differentiation, angiogenesis, and apoptosisPRKCB inhibition by enzastaurin could lead to mitotic missegregation and preferential cytotoxicity toward colorectal cancer cells with chromosomal instability; loss of PRKCA signaling is a general characteristic of colorectal tumors regardless of other underlying genetic defects, pointing to the importance of this pathwayThe majority of these significant genes were connected to form a relatively compact biological module , implyinSince candidate genes were collected based on aberrant patterns in multi-omic level of TCGA genomic data, we used microarray data sets with OS information from GEO database instead of TCGA to test the prognostic value of these significant genes. Recent expression profiling datasets lack of consistent results between the studies due to different technological platforms and lab protocols8791In summary, with the increasing availability of multidimensional genomic data, we collected genes with high rate of somatic mutation, differential expression, promoter methylation dysregulation and significant CNV, using paired samples in TCGA database. Three groups of DEGs with corresponding genetic or epigenetic abnormalities were obtained; the GO enrichment and overlapping analysis suggested DEGs with aberrant promoter methylation or somatic mutation were both functionally centering on developmental process. Random walk with restart was used to extract significant developmental genes most affected by aberrant promoter methylation and somatic mutation in merged regulatory network. In addition, the significant genes were closely related to OS of late stage patient. It is also very tempting that the identification of the functional regulators of these genes might be profusely beneficial to the discovery of new drug targets for CRC treatment. It is our hope that our preliminary exploration would be helpful for the further study upon cancer etiology and treatment guidance.How to cite this article: An, N. et al. Developmental genes significantly afflicted by aberrant promoter methylation and somatic mutation predict overall survival of late-stage colorectal cancer. Sci. Rep.5, 18616; doi: 10.1038/srep18616 (2015).


In the above article (in vivo. While TEC-based constructs do not have the same ability as scaffold-based constructs to control the internal structures of regenerated tissues, they still have potential utility in certain clinical scenarios.Oxygen delivery is the greatest limiting factor to large-volume tissue engineering. Regenerating post-mastectomy breast tissue requires avascular adipose tissue to be transferred as thin “micro-ribbons” to avoid central necrosis . Similar article , Morrisoin vivo soft tissue regeneration because its function does not depend on tissue microanatomy or organ gross anatomy. However, adipose tissue regeneration with TEC lacks major clinical utility because, with proper technique and recipient site preparation, large-volume autogenous adipose tissue transfers can already safely be performed for reconstruction of breasts and other soft tissue defects (Adipose tissue is an ideal model for  defects . Alterna defects . ReproduMorrison has also contributed to other rodent TEC studies that have successfully regenerated large volumes of functioning pituitary , thymic Whole organ regeneration would require the vascularity associated with TEC and the internal anatomy associated with cell scaffold-based constructs. An intricate combination of TEC and a cell-scaffold based construct might create a solution; however, this concept seems well ahead of our current capabilities given the widely varied results Morrison and colleagues obtained using TEC in humans.Morrison and colleagues should be commended for their novel work. While these findings cannot yet impact clinical practice, they should encourage researchers to continue making strides towards translating tissue engineering breakthroughs to the clinical arena. TEC clearly has great potential for regeneration of human tissues, but before advancing any further, TEC must demonstrate the ability to consistently produce predictable outcomes.The authors have no conflicts of interest to disclose.


Salvinorin A is a potent and selective agonist of kappa opioid receptors in the brain. Recent studies in several animal models have revealed that Salvinorin A has anti-addiction, anti-depression properties and exhibits pronounced neuroprotective effects against hypoxia/ischemia induced brain damage, and have raised interest in potential clinical applications in several acute pathologies involving oxygen deficiency in the brain. This review focuses on the chemical and physical properties of Salvinorin A and their impact on development of a rational formulation to enable its translation from a research compound to a novel therapeutic agent. Salvinorin A (SA) is a psychoactive neoclerodane diterpenoid  isolatedSince the discovery of SA as the only known naturally-occurring, non-nitrogenous kappa opioid receptor (KOR) agonist ,5] rese rese5] rIn this review we discuss the chemical and physical properties of Salvinorin A and their roles in the process of defining a rational translation pathway for formulating the drug substance into a clinically deliverable dosage form for acute medical situations.Physical and chemical properties of SA see  reveal aLacking ionizable functional groups, Salvinorin A cannot form soluble salts. SA has eight hydrogen-bond acceptor sites, all oxygen atoms, and no hydrogen-bond donor groups. It would thus appear likely that its crystal lattice should comprise only weak non-bonded interactions between adjacent molecules and a resultant diminished lattice energy reflected in a low melting point. In factThe chemical stability of Salvinorin A has not been examined in published literature to date. Nonetheless, any clinically relevant formulation will need to circumvent hydrolytic conditions that may affect the ester and lactone moieties essential to the activity of SA at the KOR receptors. For example, hydrolysis of the acetate in SA produces the well-known derivative Salvinorin B which lacks KOR affinity. FurtherIn view of Salvinorin A’s susceptibility to enzymatic degradation as well as being a substrate for P-glycoprotein efflux, the PO route of administration is clearly not viable. Not surprisingly due to the poor aqueous solubility of Salvinorin A, intravenous (IV) formulations described in numerous in vivo studies over the past 15 years have largely employed pharmaceutically unacceptable solvents . IV formulations using moderately high percentages of ethanol and propylene glycol as co-soDespite the poor apparent bioavailability of Salvinorin A when dosed via the oral cavity by recreational drug users, for acutIntranasal administration for direct to brain drug delivery offers several important advantages over other administration routes: rapid onset of therapeutic activity; bypassing the blood brain barrier; avoiding hepatic first pass metabolism. In the Inhalation of Salvinorin A via smoking or vaporization is well known to provide very rapid brain uptake and intense psychotropic effects, 19. InhIn this review we have examined the chemical and physical properties of Salvinorin A, a potential novel drug for neurological diseases, to define viable approaches to developing formulations that can be translated to clinically relevant dosage forms for treatment of acute onset illnesses outside a hospital setting. Salvinorin A exists as a stable stoichiometric hydrate and exhibits very poor solubility in aqueous vehicles. Intravenous administration may be achievable with elevated co-solvent vehicles or nanocrystalline suspensions, although its utility in the absence of medical staff is doubtful. Dosage forms targeting the oral mucosa appear worthy of further investigation: while the bioavailability is low, the ability to readily deliver high doses to the oral cavity (a highly accessible site) may allow maintenance of therapeutic drug levels in the brain. Intranasal drug delivery affords rapid, direct access of the drug to the brain bypassing the hepatic circulation. A multitude of choices for formulation and delivery devices exist, but patient to patient variability to this route of drug delivery remains uncertain particularly for administration by non-medical persons. Preferred among recreational drug users, delivery of Salvinorin A via inhalation offers clear advantages in terms of rapidly reaching therapeutic drug levels in the brain. For the purposes of acute treatment of an unresponsive patient, inhalation delivery may not be suitable.