Agouti-related protein encodes a neuropeptide that stimulates food intake. Agrp expression in the brain is restricted to neurons in the arcuate nucleus of the hypothalamus and is elevated by states of negative energy balance. The molecular mechanisms underlying Agrp regulation, however, remain poorly defined. Using a combination of transgenic and comparative sequence analysis, we have previously identified a 760 bp conserved region upstream of Agrp which contains STAT binding elements that participate in Agrp transcriptional regulation. In this study, we attempt to improve the specificity for detecting conserved elements in this region by comparing genomic sequences from 10 mammalian species. Our analysis reveals a symmetrical organization of conserved sequences upstream of Agrp, which cluster into two inverted repeat elements. Conserved sequences within these elements suggest a role for homeodomain proteins in the regulation of Agrp and provide additional targets for functional evaluation. Agrp expression is restricted to a discrete population of neurons that sense the levels of peripheral energy stores, and is dramatically elevated by deficits in energy balance.AGRP is an orexigenic, hypothalamic peptide whose role in energy homeostasis has been conserved during vertebrate evolution. In a wide range of species, including mammals Agrp mRNA levels Agrp regulation, where STAT3 represses and FoxO1 stimulates Agrp transcription. However, conserved STAT binding sites in the Agrp promoter region do not function as simple repressor elements and, paradoxically, are required for fasting induced stimulation of Agrp transcription AGRP neurons directly receive information about energy stores from leptin, an adipocyte-derived hormone that circulates at levels proportional to fat mass. Diminished levels of circulating leptin correspond to increased Agrp expression. For example, AGRP neurons directly mediate the orexigenic effects of glucocorticoids Agrp mRNA levels Agrp expression Support for this also stems from the observation that peripheral energy signals other than leptin regulate Agrp expression in transgenic mice and that contain regions of high sequence conservation between mouse and human, including a 760 bp region located immediately upstream of AgrpCross-species comparative sequence analysis has facilitated the detection of functional elements that participate in transcriptional regulation Agrp expression in vertebrates suggests that sequence comparisons of disparate vertebrate species provide an appropriate evolutionary scope for identifying Agrp regulatory elements. However, Agrp genomic sequences from distantly related vertebrate species have diverged to the extent that regional conservation is no longer detectable using traditional alignment methodologies Agrp genomic region from ten mammalian species, representing several different orders and all three subclasses of mammalia. Our analysis reveals a symmetrical organization of conserved sequences upstream of Agrp, which cluster into two inverted repeat elements (IREs). The proximity of the elements to Agrp and the nearly perfect evolutionary conservation of their specific constituent sequences in all ten mammalian species and in chickens suggest a role in Agrp regulation. In addition, the resolution of the conserved elements provided by this approach allows general predictions concerning putative trans-regulatory factors.The inclusion of sequences from multiple, divergent species sharing a commonly derived phenotype improves the resolution of comparative sequence analysis. The conserved nature of Agrp locus for chimpanzee (Pan troglodytes), human (Homo sapiens), dog (Canis familiaris), mouse (Mus musculus), and rat (Rattus norvegicus) was obtained from publicly available genome assemblies  on the UCSC genome browser (http://genome.ucsc.edu). Genomic sequence for other species, including chicken , cat (Felis catus), cow (Bos taurus), tenrec (Echinops telfairi), platypus (Ornithorhynchus anatinus), and opossum (Monodelphis domestica), was obtained from the trace sequence archives at NCBI (http://www.ncbi.nlm.nih.gov) and assembled using SeqMan . Our assembly of chicken genomic sequence at the Agrp locus differed from the publicly available genome assembly (Chicken v1.0), since additional trace sequence was available. Notably, the chicken sequence corresponding to the STAT site and inverted repeat element is not present in the public assembly. Our assembly of the chicken Agrp locus is provided as supplementary material  Agrp regulatory sequences has been previously interrogated using mouse transgenic models Approximately 1.8 kb of genomic sequence from the Agrp exons, the STAT sites, and the IREs, we modified the concept of an RS score, such that the score for constraint represents the sum of constrained alignment columns in these regions while ignoring unconstrained alignment columns. In this way, the constraint score reflects the level of sequence conservation within a particular region without penalizing unconstrained positions  surrounding Agrp, each one flanking a conserved STAT binding element Agrp underwent a duplication that occurred prior to mammalian radiation, and portions of the duplicated region have been subjected to purifying selection such that specific sequences (those corresponding to the STAT elements and IREs) are maintained in two closely related copies.As shown in Agrp locus, we aligned 1.8 kb of Agrp genomic sequence from 10 mammalian species – human, chimpanzee, mouse, rat, cow, dog, cat, tenrec, opossum, and platypus - with multi-lagan. We then used GERP Agrp locus and compares the position of constrained sequences with annotated elements. Based on this approach, the level of evolutionary constraint for sequences overlapping the IREs and the STAT binding sites are extremely high relative to other genomic regions Agrp coding sequences in this alignment of species  transcription factors, which are generally involved in the regulation of development and cell fate but also function post-developmentally to modulate cell type specific gene expression. While HD transcription factors represent a large family of proteins with over 100 members, most display restricted expression patterns that are predictive of function. Several HD transcription factors are regionally expressed in the hypothalamus.PomcOrexinGonadotropin Releasing Hormone (GnRH) GnRH has been extensively studied, due in part to an immortalized cell line which has retained important characteristics of endogenous GnRH neurons. Multiple HD transcription factors cooperatively bind to the sequences upstream of GnRH, regulating not only cell type specific expression but also dynamic, physiologic responses by serving as scaffolds for additional cofactors Agrp regulation proposed by Kitamura and colleagues to integrate observations regarding input from other signals and the organization of conserved sequences identified in this analysis.HD transcription factors have been previously implicated in the regulation of neuropeptide gene expression, and conserved HD binding sites have been identified in the regulatory regions of other hypothalamic neuropeptide genes, including Agrp defined by mouse/human sequence conservation, the IREs and STAT binding sites comprise the majority of non-coding sequence conserved among mammals. Only two other non-coding sequences, which are both ∼15 bp in length, meet the threshold for constraint set by GERP  FoxO1 is capable of recognizing non-canonical FoxO1 binding sites in some species, (2) FoxO1 regulates Agrp expression only in a subset of mammalian species, (3) or FoxO1 associates with Agrp upstream regions through a mechanism that does not involve a direct interaction with the putative FoxO1 binding sites. Notably, direct interactions between forkhead and HD transcription factors have been previously described and implicated as a general mechanism for post-developmental regulation of gene expression In contrast to the STAT binding sites, the putative FoxO1 binding sites identified by Kitamura and colleagues, which are located between to the IREs and STAT binding sites, are not well-conserved Click here for additional data file.Text S2A FASTA file containing the mammalian sequences used for GERP analysis.(0.02 MB TXT)Click here for additional data file.


Despite its popularity and rapid advancements in the field, many obstacles for cancer therapy PG still need to be overcome. By borrowing scientific systems from other disciplines such as cancer diagnosis, and therapeutic information from the diversity of tumor origins, categories and stages, cancer therapy PG may hopefully be improved. Furthermore, to quickly acquire genetic and pathologic information and seek therapeutic interventions, possible breakthroughs may come from beyond – changing the cancer therapeutic landscapes. The next generations of PG protocols and hospital routines for searching deadly cancer pathogenic pathways versus drug-targeting predictions are of great clinical significance for the future. Yet, progress of cancer therapy PG is entering into a bottleneck stage owing to simple model of relevant techniques and routines. Promoting or even innovating present PG modular is very necessary. This perspective highlights this issue by introducing new initiatives and ideas. Cancer is a common disease that claims the lives of about 7–10 million people annually across the world. As a result, cancer remains a great medical challenge worldwide . Many efDespite the popularity of cancer therapy PG, human genetic information used for forecasting disease risk, therapeutic agent options, drug characteristics (doses/toxicities and responses to cancer) in individual humans have not been perfected yet. The similarities and differences of PG between cancer therapy and other disease therapies are important for future scientific investigations and therapeutic improvements. Possible future perfections are proposed herein.Drug ADME studies by polymorphism analysis of individual metabolic enzymes and approximately 300 human metabolic enzyme genes and molecules have been subjected to PG investigations and clinical applications . TechnicThe paramount task of greatest therapeutic significance is to find the biologic relationships between disease progression (tumor genetic mutations/invasive/remote metastasis) and therapeutic outcomes (relevant anticancer drugs selections and applications). Ninety percent of cancer deaths are caused by neoplasm metastasis  and cancNeoplasm metastasis treatment is different from primary tumor treatment ,12–16. AOne of the thorniest problems in clinical cancer trials is the occurrence of multidrug resistance (MDR) in tumor cells or tissues. Soon after cancer chemotherapy, a series of drug transporter or DNA repair molecules, such as ATP-binding cassette transporters (ABC transporters), p-glycoprotein , MDR-related proteins (MRPs) and so on, work together to dramatically offset therapeutic efficacies and decide the nature of drug resistances and therapeutic failure in individual cancer patients. Thus, detecting polymorphisms of these genes and relevant biological molecules helps to predict the occurrence of drug resistance in tested cancer patients .Predictions of drug responses against cancers and toxicity to the human body are indispensable parts of cancer therapy. The polymorphisms or epigenetic information of drug-targeted genes, tumor environmental molecules, drug metabolic enzymes, tumor suppressive genes, metastatic-related or cancer stem cell-related molecules can impact on the chemotherapeutic outcomes for cancer patients . Proper Anticancer PG and PG for other disease therapies generally share the same analytical routines and technical supporting systems (mostly single nucleotide polymorphisms [SNPs]) of drug-related or DME genes – the same as for other disease therapies. Since the DME genes for anticancer drugs are biologically identical in human bodies and regarded as parallel systems, no difference has been applied between anticancer therapy and other disease therapies in general hospital protocols and routines. Despite the homogeneity of human metabolic enzymes, etiologic and pathogenic processes between cancer and other diseases are diversified greatly. For example, the etiologies of most diseases initiate in a fixed string of genes and molecules – pathogens commonly come from outside infections. Moreover, drug targets for most disease categories are fixed and can be repeated again and again. Cancer drug responsiveness prediction is, nonetheless, different because cancer comprises different diseases with pathogenesis of unlimited growth and metastasis. The great diversity and unresolved mechanisms of action for cancer progression and proliferative or metastatic inhibitions make current cancer therapy PG at its initial stages. Much effort must be created and verified for cancer therapy PG improvements that can save the life of a great numbers.Anticancer drugs, especially cytotoxic anticancer drugs, are highly toxic. Most cytotoxic anticancer drugs are even carcinogenic and can cause secondary tumors after administrations of higher than tolerated drug dosages. Approximately 1–10% of normal humans are deficient in one or several wild-type human metabolizing enzymes from one or several genetic polymorphisms. These patients cannot transform anticancer prodrugs into active metabolites (low-active drug components and responses) or reduce active metabolite clearance rates that lead to higher active metabolite concentrations in human plasma and toxicity. Increasing active anticancer drug or metabolite concentrations in patients’ plasma or normal tissues means significantly harmful impacts on cancer patient treatments, or even the cost of a patient's life ,8–10 Fi. Yet incDifferent from other types of diseases, cancer is caused by a wide diversity of oncogenic mutations and environmental matrix and factors (such as vasculature activators like EGF or VEGF etc.) that support the transformations of normal cells into malignant ones . More seTumor growth and metastasis are determined by different cancer genes or hallmarks. Neoplasm metastasis is caused by the interactions of cancer cells and human environments . TheoretAfter the advent of cancer therapy PG, we have never attempted any new initiatives outside the boundary of the PG norm and technical routines that are different from widely practiced PG protocol in cancer therapy PG. If we stay on this course and in these mindsets, we might never have the opportunity to overcome the drawbacks and pitfalls of current cancer therapy and make a difference to now. Creative ideas and novel PG techniques for improving in cancer therapy are welcomed.Human cancer is a unique type of disease that in which a great diversity backgrounds of gene mutations and malfunctioning biomolecular profiling are found. According to general PG mindsets and routines, beside ADME-related metabolizing enzymes (≈300), at least the same amount of oncogenic genes can be mutated. From our past experience, at least 5–10 oncogenic genes or biomolecules will normally be found in tumor tissues among advanced cancer patients. Since a huge amount of human genes are related to cancer growth, metastasis, drug toxicities/responses, an indispensable topic is to design a high efficient strategy that can solve this technical difficulty. Brand-new strategies relevant to human gene and therapeutic prediction, even outside of current available polymorphisms information, might help us realize our dreams of making a difference to PG systems. However, this interesting topic seems unlikely to be solved by conventional PG routines in utilities.Since cancer is a complicated disease, conventional cancer therapy needs more than one anticancer drug. As a result, anticancer drug therapy PG is different from other PG diseases. These differences for complex therapeutic recipes call for new ideas and PG routines. Obviously, the next generations of anticancer therapy PG systems must be capable of predicting complicated clinical circumstances and situations in clinical cancer trials. How can this goal be realized? It needs to build the technical capability of translating biological modular into therapeutic optimizing paradigms. Technical innovations and computational data analytical systems can guide us into new clinical horizon and predict complex formulae of cancer treatment recipes.Apart from genetics of metabolic enzymes, anticancer drug targeting genes and oncogenic- or metastatic-related genes are other parts of personalized cancer therapy ,27–36. ADespite great monetary support and quick technical improvements, cancers remain to be an unresolved enigma and of therapeutic significance. Development of drug resistance, drug-induced severe side effects, cancer stem cells and tumor metastasis contribute to the majority of therapeutic failures in clinical cancer trials. Due to the poor drug specificity of many cytotoxic drugs, normal tissues are also damaged by such cancer treatments. As a result, the highest tolerated drug dosages cannot kill all tumor populations of large tumor volumes. Induction of drug resistance after conventional trials, cancer stem cells (mystery characteristics of tumors) and neoplasm metastasis and so on are the real culprits for therapeutic failures. Those PG systems designed to analyze genetic status of tumor or human tissues should be omnipotent for predicting both toxicity and efficacy of drugs in individual cancer patients. The present anticancer therapy PG systems are proving too little and too incapable for advanced cancer patients.Since oncogenic- or metastatic-related genes or molecules are too diversified and disconnected, it is hard to find optimal drugs utilizing present PG systems and routines. Apart from PG systems, other personalized cancer therapy strategies such as drug sensitivity testing (DST)  or canceThe overall theme of PG is the right drug for the right patient, by analyzing human genetics variations that play roles on predicting drug toxicities or responses. However, current PG systems are more suitable for fixed small ranges of pathological processes and change slightly after its advent. New knowledge coming from clinical case reports, doctors’ experience or hypothesis-driven systematic studies ought to provide a useful foundation for updating PG systems, especially cancer therapeutic PG systems and routines. After accumulating enough clinical data and large-scale human genome drafting, computation and validating, framing different genetic markers and pathogenic-related therapeutic efficacies are followed. Finally, we need to transform our knowledge and understanding from empirical into successful clinical paradigms . PossiblSince genetic variations between individuals and disease progressions are not negligible, relationships between individual genes and drug therapeutic outcome are the priority. Much supportive information on this issue can easily come from other cancer biological or therapeutic advancements. Also, technical innovations can be implemented after absorptions of new fruits of scientific discoveries. However, basic rules behind the scenes are not understood yet.An approximately 1–5% difference between different races or ethnic groups is present worldwide. Presently, PG studies are heavily reliant upon European descendants (Caucasian) ,39. ThesDetermining the toxicities, activities and blood concentrations of anticancer drugs by PG plays an important role in clinical cancer trials. In spite of these utilizations, PG is not very useful for choosing the most suitable anticancer drugs from the large anticancer drug arsenal (≈84 anticancer agents or drugs licensed in the USA)  and 178 Two cancer therapy PG systems (drug-oriented PG and pathogenesis-oriented PG) have been categorized  & 4. OptMoreover, potential new PG systems need an ingenious design via integration of two systems and scientific investigations supporting improvement of PG routines.Presently, cancer therapy PG, however, is only superior for drug dosages or toxicity determinations by SNPs of drug ADME profiling.An imbalance between the rapid development of genotyping technology and the slow pace of genetic testing marketing is generally met. The great degree of uncertainty in interpreting drug responses to tumor progressions, stem cells or metastasis PG has not been the breakthrough in cancer therapy worldwide. Despite a lot of successful stories, presently cancer therapy PG does not develop into compulsory routines, even in developed countries. A shortage of large sample-sized retrospective or clinical cohort studies has been reported . MoreoveGWAS are always the priority for PG technical updating. Owing to the invention of next-generation sequencing (NGS) techniques, human genome sequencing can be a joint effort between biomedical students and mathematical or physics students or scholars in the future. For these undertakings, mathematics or physics students and scholars will prove to be more adept than biomedical students in the postgenomic study age. Since the tremendous speed-up  and low budget  of genotyping human genomes by NGS  comparedBioinformatics (omics technology) are more advantageous for quantifying specific gene or biological molecular changes than those used by current PG systems. At first, we need to detect the clinical data of both PG and bioinformatics. Then, ingeniously designing a new generation of PG techniques or systems that can provide genetic information of both quantity and quality, even omnipotent systems, are possible routes to renew PG techniques for cancer therapy predictions. Cooperating merits from NGS and GWAS or other new techniques may improve cancer therapy PG or even change the landscape of personalized cancer therapies worldwide. Then, improvements of predicting therapeutic efficacies, toxicity and outcomes may be realized by integrating growing bodies of diagnostic or pathological profile information.Anticancer drug responses in tumor tissues and human bodies, especially those of cytotoxic anticancer drugs, are often multigenetic and multifactorial ,45. PresNo central dogma or paradigms of cancer therapy PG are capable of being universally utilized. Borrowing ideas and lessons from other scientific disciplines, hypothesis-driven data collections and workable computations for revealing the relationship of cancers diversity and a variety of therapeutic options are important resources for inventions of new generations of PG systems. In future, cancer therapy PG might transform from a number of genetic testing modalities into omnipotent, science-guarded and high-throughput predictive systems. The summary table outlines the roadmap and avenues of future directions of cancer therapy PG past and in future.Briefly, PG in clinics might no longer be considered a hobby in the future. Increasing occurrences of mandatory PG trials might be required in most advanced countries, or even become indispensable worldwide.Since we speculate that key breakthroughs of anticancer PG may not come from simply increasing the sample-size of clinical PG data, it relies on injections of insights and breakthrough of other disciplines, biological/medical discoveries or developments of new generations of anticancer drugs  and rulePresent cancer therapy PG systems are imperfect for large populations of cancer deaths . Possible future cancer therapy PG advancements may come from ideas and outcomes of other researchers instead of keeping up present mindsets and hospital routines.Techniques and strategies for prediction of both toxicity and efficacy in individual cancer patients.Pharmacogenetics (PG) study, especially drug absorption, distribution, metabolism and excretion molecules, such as metabolic enzyme genes and dose-optimizing.Description of established PG protocols and routines, comparisons between cancer therapy and other disease therapies.Outlook of different categories of PG techniques, such as drug-targets and disease-based genetic systems.Discover and predict the relationship between cancer pathology and treatments by PG practice in individual cancer patients.Find ways of pinpointing the diversity of pathologic origin and different therapy of primary, stem or metastatic cells or tissues in each cancer patient and be able to maximize the efficacy of drugs or therapy.Lacking established relations between therapeutic outcomes and PG applications.Limitations and shortcomings of conventional PG techniques and systems.The importance of neoplasm metastasis, multidrug resistance and cancer stem cells in cancer therapeutic outcome improvements.Comparisons of therapeutic efficacies between primary tumors and metastatic nodules.Create some original, innovative systems or biomedical software for integrating diversified and combinative pathological, pharmacological and clinical information into utility paradigms.Invest more money into developments of effective antimetastatic drugs or cancer stem cell inhibitors.Construct usable anticancer drug combinative PG systems.Promote genome-wide association studies, especially among different ethnic groups, races and/or tumor types and stages.


Fusobacterium nucleatum and Porphyromonas gingivalis were highly increased within tissues, comprising 15–40% of the total bacteria. Furthermore, biofilm formation within the tissue was observed by Alcian Blue staining and atomic force microscopy, where degradation of fibers was prominent. Taken together, bacteria formed complex biofilm communities within gingival tissues that may serve as a reservoir for persistent infection. This novel finding may instigate new research into therapeutic strategies to treat periodontitis.Periodontitis is caused by dysbiosis of subgingival plaque that results in increased bacterial invasion into gingival tissues. Although shifts in subgingival microbiota from healthy to periodontitis have been well characterized, the characteristics of bacterial communities located within gingival tissues have not been studied. To characterize microbiota within the tissues of periodontal lesions in comparison with plaque microbiota, gingival tissues and subgingival plaque were obtained from the same tooth of patients with periodontitis (n = 7). A pyrosequencing analysis of the 16S rRNA gene revealed that species richness and diversity were not significantly different between the two communities. However, inter-subject variation in intra-tissue communities was smaller than that in plaque communities. Intra-tissue communities were characterized by decreased Firmicutes and increased Fusobacteria, compared with the plaque communities. Particularly,


Apis mellifera) implicated in elevated colony mortality rates worldwide and facilitated through vector transmission by the ectoparasitic mite Varroa destructor. Clinical, symptomatic DWV infections are almost exclusively associated with high virus titres during pupal development, usually acquired through feeding by Varroa mites when reproducing on bee pupae. Control of the mite population, generally through acaricide treatment, is essential for breaking the DWV epidemic and minimizing colony losses. In this study, we evaluated the effectiveness of remedial mite control on clearing DWV from a colony. DWV titres in adult bees and pupae were monitored at 2 week intervals through summer and autumn in acaricide-treated and untreated colonies. The DWV titres in Apistan treated colonies was reduced 1000-fold relative to untreated colonies, which coincided with both the removal of mites and also a turnover of the bee population in the colony. This adult bee population turnover is probably more critical than previously realized for effective clearing of DWV infections. After this initial reduction, subclinical DWV titres persisted and even increased again gradually during autumn, demonstrating that alternative non-Varroa transmission routes can maintain the DWV titres at significant subclinical levels even after mite removal. The implications of these results for practical recommendations to mitigate deleterious subclinical DWV infections and improving honeybee health management are discussed.Deformed wing virus (DWV) is a lethal virus of honeybees ( Apis mellifera). At highly elevated titres, it causes wing deformities in developing pupae, resulting in flightless adults that die shortly after emerging , , . I. IVarroacaricide . However removed .Varroa mite removal treatment to evaluate the time necessary to clear a DWV infection from a honeybee colony after mites are removed. Such information would be valuable for improving honeybee health management and colony survival by optimizing the duration and the timing of acaricide treatments.The aim of this study was to quantify the DWV infection dynamics during and following a ™  according to manufacturer recommendations while the other colony received no mite-control treatment. Apistan™ is a potent synthetic pyrethroid acaricide with up to 98–100% efficacy against Varroa mite infestation , , . T. TVarroatic bees .7 virus particles/bee are usually sufficient for successful oral infection of larvae or adult bees . D. D7 viruult bees . As brooult bees , 42]. S. S7 viruult bees .Varroa control treatments are administered too late in the season, the overwintering bees will have already been reared under Varroa-infested conditions and may be too ill-affected by virus infections to survive the winter, even if the mite treatment itself was effective at removing the mites.Honeybee colony death most often occurs during the winter months in temporal climates during the sensitive overwintering phase of the annual colony cycle . The lonVarroa treatment regime is probably more critical than previously realized. Highly infected adult bees must be replaced with a new generation of adults reared in a Varroa–free environment, so that new and progressively healthier bees will nurse and feed the larvae of the long-lived overwintering bees. By conducting our study over the summer months it was possible to observe the influence of the bee population dynamics in addition to mite removal on DWV infections. A previous study using Apistan treatment in the late summer showed high DWV titres in adult bees (> 1010 copies / bee) and pupae (> 109 copies / bee) over the entire 6-week study , [, [Varroae spring , causingS1 FileVarroa mite removal and a bee population turnover.Persistence of subclinical deformed wing virus infections in honeybees following (XLSX)Click here for additional data file.S1 TablePrimer sequences and performance indicators, including the melting temperature of PCR products, for the RT-qPCR assays for DWV and internal reference gene RP-49.(PDF)Click here for additional data file.


Normal, youthful arteries generally maintain constant radius/wall thickness ratios, with the relationship being described by the Laplace Law. Whether this relationship is maintained during aging is unclear. This study first examines the Laplace relationships in postmortem coronary arteries using a novel method to correct measurements for postmortem artifacts, uses data from the literature to provide preliminary validation, and then describes histology associated with low circumferential stress. Measurements of radius and wall thickness, taken at sites free from atheromas, were used with national population estimates of age-, gender-, and race-specific blood pressure data to calculate average circumferential stress within demographic groups. The estimated circumferential stress at ages 55-74 years was about half that at ages 18-24 years because of a disproportionate increase of wall thickness relative to artery radius at older ages, violating the expected relationships described by the Laplace Law. Arteries with low circumferential stress (estimated at sites distant from atherosclerosis) had more necrotic atheromas than arteries with high stress. At sites with low stress and intimal thickening, smooth muscle cells (SMCs) were spread apart, thereby diminishing their density within both the intima and media. Thus, older arteries displayed both low circumferential stress and abundant matrix of low cellularity microscopically. Such changes might alter SMC-matrix interactions.


Extracorporeal membrane oxygenation (ECMO) is a therapeutic option used increasingly in the treatment of severe acute respiratory distress syndrome (ARDS). Choosing an adequate cannula type and insertion site can be a challenge. The insertion of a bi-caval dual lumen  catheter in the superior vena cava instead of two venous single-lumen catheters facilitates mobilisation and physiotherapy of patients, and hence is being used more and more .A middle-aged patient was admitted to our hospital after severe multiple trauma. Before admission to our hospital, damage control surgery including bilateral diaphragmatic repair and ileotransversostomy was performed.The postoperative course was complicated by disseminated intravascular coagulation (DIC). Six days after the accident, the patient could be stabilized to be eligible for transportation to the hospital by an air rescue service. The patient was transferred directly to the Surgical ICU under controlled mechanical ventilation.Within the first 24 h after admission, the respiratory function deteriorated to ARDS. Advanced respiratory support, including veno-venous ECMO, was applied to sustain gas exchange in the hope it could improve survival. Because of the underlying complex abdominal trauma we tried to insert a bi-caval dual lumen catheter into the right jugular vein. Due to surgical reconstruction of the bilateral diaphragmatic rupture and consecutive anatomical changes, several attempts to place either the guide wire or the catheter tip into the inferior vena cava (IVC) under transthoracic and transoesophageal echocardiography visual guidance failed; both guide wire and dual lumen catheter could not bypass the right ventricle to the IVC..Therefore, we decided to insert two single lumen catheters into the right jugular and femoral vein, whereupon ECMO treatment could be performed without further technical problems. In a post-hoc reconstruction of the thoracic computed tomography (CT) scan we discovered an altered path of IVC transition into the right atrium following surgical repair of the bilateral diaphragmatic rupture Fig. .Fig. 1PIn patients with right-sided diaphragmatic rupture and surgical reconstruction we recommend a three-dimensional reconstruction based on three-dimensional echocardiography or CT of the venous inflow to the right atrium before attempting to insert a bi-caval dual lumen catheter . Notwith


The immune system has evolved pairs of activating and inhibitory receptors that modulate the magnitude of immune responses, enabling the maintenance of immune homeostasis. Inhibitory signaling dampens the immune response, which prevents inflammatory damage to the host. It has now become increasingly clear that viruses have evolved means of exploiting the inhibitory signaling pathways of the immune system in order to blunt the responses that would otherwise abrogate infection. Recent evidence demonstrates how viruses exploit inhibitory receptors both for host cell entry and to down-regulate antiviral responses for enhanced viral pathogenesis. Both acute and chronic viral infections also induce expression of intermediates of inhibitory signaling for improved odds of survival within the intracellular environment. This review highlights and synthesizes from recent findings how medically important viruses exploit the inhibitory pathways that maintain immune homeostasis for successful human infection.The rapid initiation and timely termination of the immune response are coordinated by paired receptors expressed on immune cells. Paired receptors consisting of activating and inhibitory receptors recognize self and non-self ligands. They are essential for maintaining self-tolerance, mounting an immune response during infection, and modulating the intensity of the response to prevent autoimmunity and inflammatory damage to bystander cells . ActivatAlthough activating and inhibitory signals are integrated for immune homeostasis, they might not contribute proportionately to signaling output due to dominant inhibitory signaling, as exemplified by natural killer (NK) cell responses . NK cellThe complexity of signal integration is further underscored by how signaling outcome is tuned by viral manipulation of inhibitory signaling. Coevolution of viruses and their hosts has resulted in viruses acquiring strategies for attenuating immune responses to favor viral replication and disease in humans. Viruses are known to utilize inhibitory receptors for host cell entry, which also initiate inhibitory signaling to down-regulate antiviral responses for enhanced viral replication. The recent use of quantitative temporal viromics, which profiles proteomic changes in viral and host cell proteins over time, has demonstrated how viruses also dramatically alter the expression of cell surface proteins to counter the host cell’s defenses . FinallyThe viral life cycle starts with host cell entry, which involves direct fusion with cell membrane or ligating an appropriate receptor to trigger endocytosis, pinocytosis, or macropinocytosis. Use of inhibitory receptors during host cell entry could thus simultaneously initiate inhibitory signaling to dampen the immune response for enhanced viral replication .CD300a is an inhibitory receptor that belongs to the CD300 family of transmembrane receptors. It binds cell surface phosphatidylserine and phosphatidylethanolamine (PE), which are exposed following increased levels of intracellular calcium during human immunodeficiency virus type 1 (HIV-1) and hepatitis C virus (HCV) infection . InteracDENV is also known to ligate leukocyte immunoglobulin-like receptor B1 (LILRB1) , an inhi+ T cells, and binding of HIV-1 to DCIR promotes infection of DCs and CD4+ T cells .,42.+ T cnfection . T cell feration ,45.+ T cells, rapidly inducing a transcriptional state synonymous with T cell exhaustion   or respihaustion . AntigenA substantial body of work has now refined our mechanistic understanding of how various medically important viruses manipulate inhibitory signaling for survival within the host cell. Given that members of a virus family share many conserved structural and non-structural proteins, it is plausible that viral strategies to manipulate inhibitory signaling could be relevant to a broader range of viruses than those discussed here. Understanding how viruses exploit inhibitory signaling could lead to rationally designed interventions that interrupt these critical virus–host interactions. The potential of an anti-PD-L1 antibody in reducing viral reservoirs in HIV-1 patients was recently evaluated in a clinical trial (NCT02028403). We anticipate that a combination of therapies targeting critical steps of the viral life cycle and boosting different arms of the immune response could provide recourse for both acute and persistent viral infections.


The discovery of RNA interference (RNAi) has been a major scientificbreakthrough. This RNA-guided RNA interference system plays a crucial role in awide range of regulatory and defense mechanisms in eukaryotes. The key enzyme ofthe RNAi system is Argonaute (Ago), an endo-ribonuclease that uses a small RNAguide molecule to specifically target a complementary RNA transcript. Twofunctional classes of eukaryotic Ago have been described: catalytically activeAgo that cleaves RNA targets complementary to its guide, and inactive Ago thatuses its guide to bind target RNA to down-regulate translation efficiency. Arecent comparative genomics study has revealed that Argonaute-like proteins arealso encoded by prokaryotic genomes. Interestingly, there is a lot of variationamong these prokaryotic Argonaute (pAgo) proteins with respect to domainarchitecture: some resemble the eukaryotic Ago (long pAgo) containing a completeor disrupted catalytic site, while others are truncated versions (short pAgo)that generally contain an incomplete catalytic site. Prokaryotic Agos with anincomplete catalytic site often co-occur with (predicted) nucleases. Based onthis diversity, and on the fact that homologs of other RNAi-related proteincomponents (such as Dicer nucleases) have never been identified in prokaryotes,it has been predicted that variations on the eukaryotic RNAi theme may occur inprokaryotes. TtAgo fromThermus thermophilus and RsAgo fromRhodobacter sphaeroides. Like eukaryotic Argonautes, bothTtAgo and RsAgo are long pAgos that areco-purified with oligonucleotide guides , themajority of which are complementary to plasmids. Together with the observation thatTtAgo  target DNA,this has led to the conclusion that both pAgos play a role in host defense .However, apart from these similarities there are important functional differencesbetween the two bacterial Argonaute proteins. The guides acquired byRsAgo are mRNA-derived RNA oligonucleotides that target the templatestrand of plasmid genes. As RsAgo lacks a catalytic site, it mostlikely requires a partner nuclease for target cleavage. In contrast,TtAgo acquires DNA guides that allow targeting of AT-rich sequences ofdouble-stranded plasmid DNA. Whereas the functional nuclease site ofTtAgo catalyzes nicking of a single targeted DNA strand, twoTtAgos loaded with overlapping complementary guides can generatedouble-stranded DNA breaks. Recent studies by us and the working group of Alexei Aravin have described molecularanalyses of two distinct bacterial Argonautes, These studies have revealed interesting variations on the eukaryotic RNAi theme. Severalbasic features of these two variant pAgos remain elusive, concerning mechanistic detailsof both guide acquisition and target interference. Moreover, apart from the twocharacterized prokaryotic Argonautes, many more pAgo variants exist, that may differ infunctionality with respect to (i) guide preference (RNA/DNA), (ii) target specificity(RNA/DNA), and (iii) catalytic mechanism (nuclease activity). Apart from providinginsights in the evolution of the prokaryotic Ago variants and their eukaryoticcounterparts, future research will aim at revealing the molecular basis for the distinctfunctionality of these different pAgo variants. Moreover, gained insights will result inan interesting set of novel nucleases that may allow for dedicated geneticengineering.


Coral reefs are among the most biodiverse and productive ecosystems on Earth, and provide critical ecosystem services such as protein provisioning, coastal protection, and tourism revenue. Despite these benefits, coral reefs have been declining precipitously across the globe due to human impacts and climate change. Recent efforts to combat these declines are increasingly turning to restoration to help reseed corals and speed-up recovery processes. Coastal restoration theory and practice has historically favored transplanting designs that reduce potentially harmful negative species interactions, such as competition between transplants. However, recent research in salt marsh ecosystems has shown that shifting this theory to strategically incorporate positive interactions significantly enhances restoration yield with little additional cost or investment. Although some coral restoration efforts plant corals in protected areas in order to benefit from the facilitative effects of herbivores that reduce competitive macroalgae, little systematic effort has been made in coral restoration to identify the entire suite of positive interactions that could promote population enhancement efforts. Here, we highlight key positive species interactions that managers and restoration practitioners should utilize to facilitate the restoration of corals, including (i) trophic facilitation, (ii) mutualisms, (iii) long-distance facilitation, (iv) positive density-dependence, (v) positive legacy effects, and (vi) synergisms between biodiversity and ecosystem function. As live coral cover continues to decline and resources are limited to restore coral populations, innovative solutions that increase efficiency of restoration efforts will be critical to conserving and maintaining healthy coral reef ecosystems and the human communities that rely on them. Coral reefs are one of the most biodiverse and productive ecosystems on Earth, and provide critical services to at least 500 million people throughout the world . In addiFor many decades, the paradigm in coastal restoration has been to minimize negative interactions  between transplant neighbors . This paWith increased consideration of facilitation in ecological theory , recent Trophic facilitation occurs when one species is positively impacted through the feeding activities of another species. One example includes trophic cascades where predators, by suppressing densities of primary consumers, can increase densities of basal prey species such as plants  has been studied for decades. Results of comparative and experimental studies have shown that herbivorous fish and urchins are critical for the success of corals, and this positive interaction is general across almost all regions where corals occur . BecauseDrupella snails in the Western Indian Ocean , which provide substantial nutrition to corals and enhance skeletal deposition  is one of the most well-known reciprocal positive interactions that can encourage healthy coral reef functioning. While coral reefs provide habitat, CCA is critical for cementing and stabilizing reef structure and facilitating settlement of coral larvae . Reef-dwseastars . Similarseastars , predatiseastars , and verseastars . Many fiseastars .Despite these many examples of mutualisms that support coral success, few studies to date have examined or experimented with incorporating species-specific mutualisms into restoration. One recent study that seeded a reef with sponges prior to transplanting corals found significant increases in rubble consolidation that in turn enhanced coral survivorship in that environment . SimilarPositive interactions can also occur between species that are not in contact but separated by distances of tens or thousands of meters . Long-diDecades of research has shown that the health, productivity, and biodiversity of coral reefs is directly related to their proximity to tropical seagrass meadows and mangrove forests. For example, both habitats facilitate corals by reducing stressors such as sedimentation or nutrient pollution from coastal development and runoff that may smother corals or enhance algal overgrowth . SeagrasDiadema) that live within the interstitial matrices of larger corals  found increasing density significantly reduced coral growth within the first three months of transplantation, likely due to competition for space (Montipora digitata in high density (spaced 10-cm apart) and low density (spaced 20-cm apart) plots over 15 months. These studies suggest that studies examining the effects of density on coral transplants may have varied results depending on spacing between colonies. For endangered Caribbean acroporid corals, recent experimental research shows a unimodal relationship may exist, with positive density effects occurring at moderate levels  but negative density effects occurring at higher densities  and planting configuration of staghorn coral Acropora ensities . Howeverxcrement  While most of these studies examine colony-specific metrics, such as growth and survivorship of individual corals, the effects of density are likely affected by environmental stressors and temporal scales. Although ecological theory  suggests that positive density dependency may emerge under high stress conditions in coral reefs, no studies to date have examined how the impacts of density vary across a stress gradient. For instance, because of the tendency of branching corals to fuse, higher density plots may enhance structural resistance to wave energy such as intense storms , due to a history of restoration methods that take advantage of their high growth rates and ease of propagation through fragmentation (Orbicella spp.). In addition, Caribbean branching corals can be more susceptible to natural enemies such as predators and disease  relative to conspecifics, however this facilitation stopped when nutrient enrichment was introduced to plots. Diverse coral species facilitated A. cervicornis growth and survivorship by reducing the number of coral predators  that attacked plots of A. cervicornis  or in areas where stress is not an issue but recruitment limitation is impeding natural recovery . For newHarnessing naturally-occurring positive interactions in restoration designs has recently been suggested  and demo (1)Identifying specific trophic linkages or food webs that promote coral health and transplanting corals in areas with where these food webs are robust and protected. (2)Identifying mutualisms between corals and other reef- or coral-associated organisms that promote coral health and enhancing or protecting these mutualistic partners. (3)Locating sites for coral restoration close to healthy and well-functioning seagrass and mangrove habitats and protecting these habitats from extractive or destructive uses. (4)Identifying species-specific density effects for corals of restoration interest to take advantage of transplant densities that facilitate coral growth or survivorship. (5)Exploring the legacy of former reef-builders or occupiers, such as coral skeletons left behind, for use in coral transplantation. (6)Determining ways in which increased coral diversity facilitates the success of coral transplants as well as the long-term success of the restored coral reef community to environmental fluctuations and disturbances .


Drosophila imaginal disc cells exhibit preferred cell division orientations according to location within the disc. These orientations are altered if cell death occurs within the epithelium, such as is caused by cell competition or by genotypes affecting cell survival. Both normal cell division orientations, and their orientations after cell death, depend on the Fat-Dachsous pathway of planar cell polarity (PCP). The hypothesis that cell death initiates a planar polarity signal was investigated. When clones homozygous for the pineapple eye (pie) mutation were made to initiate cell death, neither Dachsous nor Fat was required in pie cells for the re-orientation of nearby cells, indicating a distinct signal for this PCP pathway. Dpp and Wg were also not needed for pie clones to re-orient cell division. Cell shapes were evaluated in wild type and mosaic wing discs to assess mechanical consequences of cell loss. Although proximal wing disc cells and cells close to the dorso-ventral boundary were elongated in their preferred cell division axes in wild type discs, cell shapes in much of the wing pouch were symmetrical on average and did not predict their preferred division axis. Cells in pie mutant clones were slightly larger than their normal counterparts, consistent with mechanical stretching following cell loss, but no bias in cell shape was detected in the surrounding cells. These findings indicate that an unidentified signal influences PCP-dependent cell division orientation in imaginal discs. Oriented cell division influences how animal tissues grow, especially in tissues where cells are not very motile–4. It isDrosophila is altered in the vicinity of apoptotic cells. The. The53].pie homozygous clones to those of pie heterozygous or wild type cells at comparable locations  pathway of tumor suppressors, 60–63. s mutants. Cell dict growth. Recent ct growth, 68. Thi


Direct comparisons revealed that EOs showed greater response to cannabis cues in the dorsal striatum than LOs . Within-group analyses revealed that EOs showed greater neural response to cannabis cues in the dorsal striatum, whereas LOs exhibited greater neural response to cannabis cues in the ventral striatum. Although cross-sectional, these findings are consistent with recent addiction theories suggesting a progressive shift from ventral to dorsal striatal control over drug-seeking behavior and highlight the importance of age of onset of cannabis use on the brain and cognition.Addiction theories posit that addiction is the result of a progressive transition from voluntary to habitual, compulsive drug use—changes that have been linked, in animals, to a shift from ventral to dorsal striatal control over drug-seeking behavior. Thus, we hypothesized that early-onset (EOs) cannabis users versus late-onset (LOs) cannabis users might exhibit, respectively, greater dorsal versus ventral striatal response to drug cues. We used functional magnetic resonance imaging and an event-related blood oxygen level-dependent backward-masking task to evaluate striatal responses to backward-masked cannabis cues  in EOs (<16 years old,  These transitions include a shift from ventral to dorsal striatal control over behaviors  that contribute to habitual and progressively compulsive drug seeking.10–12 The majority of the research supporting this theory has been conducted in animal models; however, recent human studies on age of onset of cannabis use may provide additional support for such brain changes and impairments in prefrontal inhibitory control. Specifically, early (before age 16) onset of cannabis use (EO) has been associated with structural connectivity differences of the orbitofrontal cortex (OFC),13 decreased white matter integrity in fibers connecting the right and left dorsolateral prefrontal cortex,14 and increased functional connectivity between the OFC and prefrontal and motor regions.15 Furthermore, research indicates that EO cannabis users (EOs) perform worse than late-onset (age 16 or later) cannabis users (LOs) across a variety of neurocognitive domains, including measures of sustained attention, impulse control, and executive functioning.17 Together, these findings suggest that EO of cannabis use may contribute to morphological alterations in prefrontal brain regions that are associated with cognitive control deficits observed in EOs.Although cannabis use may lead to alterations in the brain and cognition, these changes occur over time. Indeed, addiction theories posit that substance use disorders are the result of “a series of transitions from initial voluntary drug use to habitual, and ultimately compulsive drug use”19 and investigated the associations between striatal activity and cannabis craving. Based on the research described above, we expected that EOs would show neural response to backward-masked cannabis cues  in the dorsal striatum, whereas LOs would show neural response to cannabis cues in the ventral striatum. Because research suggests that heightened motivational/emotional states  lead to heightened sensitivity to associated cues,20 we also hypothesized that cannabis craving would correlate with these cannabis cue-related activations and that different association patterns would emerge in EOs and LOs.While morphological and cognitive changes have been well characterized in EOs, it remains unknown whether age of cannabis use onset is differentially associated with ventral or dorsal striatal activity or control over cannabis use. Thus, the current study explored potential differences in striatal activity during cannabis cue exposure  among EOs and LOs who report similar patterns of cannabis use. We compared striatal responses to cannabis cues presented during a functional magnetic resonance imaging (fMRI) backward-masked cannabis cue paradigm19 Participants were 41 treatment-seeking individuals who met the DSM-IV21 criteria for cannabis dependence. Participants were medically stable, educated, and had no concomitant serious comorbid psychiatric or substance use disorders (except nicotine dependence). See All study procedures adhered to the Declaration of Helsinki and were approved by the University of Pennsylvania Institutional Review Board. Details of the recruitment process and selection criteria were reported previously.As part of a larger study, participants completed baseline questionnaires, interviews, and an MRI session. Participants were asked to abstain from alcohol and illicit substances for the 24 h before the MRI session and completed a urine drug screen and alcohol breathalyzer. All participants were positive for cannabis use and negative for other substance use.22 and the Addiction Severity Index23 measured lifetime alcohol and substance use and age of onset of cannabis use. Based on the existing literature and that age 16 is when significant brain changes typically occur,24 participants were grouped as EO (<16 years old) or LO (≥16 years old). Lifetime cannabis exposure was quantified using gram years.25 The Marijuana Craving Questionnaire-Short Form (MCQ-SF)26 measured self-reported baseline cannabis craving using a scale covering behavioral experiences associated with aversive and appetitive aspects of drug motivation. The magnitude of cannabis craving was assessed before the neuroimaging session and was determined by summing items of the MCQ-SF.Cannabis, alcohol, and other drug use during the preceding 30 days was assessed with the Timeline Follow-Back interview,19 Briefly, imaging data were analyzed using statistical parametric mapping . Imaging analyses were focused on regions of interest (ROIs) in the dorsal and ventral striatum. The ROIs were created using the Harvard–Oxford probabilistic anatomical atlas provided with the FMRIB Software Library.27 To control for type 1 error, neural activity within the ROI mask of each voxel was considered significant at a nominal alpha level of p<0.01 and a cluster extent of 50 contiguous resampled voxels as determined via Monte Carlo simulations using 3dClustSim Analysis of Functional NeuroImages software28 (http://afni.nimh.nih.gov/).A detailed description of the backward-masking cannabis cue paradigm, imaging parameters, and analyses are provided in previous publications.2 =4.37, p=0.04); however, small sample size prevented the exploration of potential sex differences in the current analyses.As noted in p<0.01, k>50 voxels). Analyses among EOs revealed greater response to backward-masked cannabis cues in the dorsal striatum, whereas LOs showed greater response to backward-masked cannabis cues in the ventral striatum . There were no significant correlations among LOs.Correlation analyses between cannabis craving scores and As hypothesized, preliminary analyses revealed that EOs and LOs showed different patterns of neural response to backward-masked cannabis cues, with EOs showing greater response within the dorsal striatum compared to LOs. When examining groups separately, EOs exhibited neural response to backward-masked cannabis cues in the dorsal striatum, yet LOs exhibited neural response in the ventral striatum. It is important to note that the EO and LO groups reported similar patterns of recent cannabis use, and as such, findings are not due to differences in recent cannabis use. Furthermore, groups did not show significant differences in lifetime cannabis use, suggesting that striatal activation findings in EOs and LOs were specific to age of onset of cannabis use and not due to history of daily use or duration of use. Correlation analyses revealed that dorsal striatal activations in EOs correlated with cannabis craving. Although cross-sectional, these preliminary findings are the first of their kind and suggest that differential striatal activation between EOs and LOs may reflect cannabis-induced alterations in neuroplasticity during early adolescent maturation that strengthened reward-related associations in EOs and possibly accelerated the shift from voluntary occasional use to habitual compulsive use.13–15 provide evidence that EOs also exhibit striatal brain changes that may underlie habitual, compulsive cannabis use, whereas LOs exhibit a pattern of neural activity in the ventral striatum that is characteristic of voluntary cannabis use, which may be regulated by prefrontal control processes. Although compulsivity and impulsivity were not assessed in the current study, future research in a larger sample could explore these hypotheses more fully.Our findings, in conjunction with previous research demonstrating altered prefrontal structure and function,Limitations should be considered when interpreting the findings. First, sample size is moderate; thus, future studies should include a larger sample with greater diversity to validate these findings and ensure generalizability. Furthermore, we did not assess or control for the influence of menstrual cycle phase/gonadal hormones, cannabis withdrawal symptoms, or motivations for treatment, and as such, it remains unclear as to whether these factors influenced findings. Finally, this study used a cross-sectional design, so it is not possible to know whether EOs exhibited ventral striatal activation earlier in their addiction. Longitudinal studies will be helpful in parsing the effects of these factors on cannabis cue reactivity.In summary, EOs and LOs exhibited differential patterns of striatal response to backward-masked cannabis cues, with EOs demonstrating dorsal striatal response and LOs showing a ventral striatal response. This differential pattern of striatal response parallels recent hypotheses of drug addiction, through which a series of transitions from initial voluntary use to habitual, compulsive use involve transitions from ventral to dorsal striatal control. Although additional research is warranted, our findings are the first neuroimaging findings among cannabis users to demonstrate differential striatal responding to cannabis cues in EOs and LOs.


The redox balance modulation is also highly dependent on the level of physical activity. For example, both high-intensity exercise and inactivity, representing the two ends of the physical activity spectrum, are known to promote oxidative stress. Numerous to-date studies indicate that hypoxia and exercise can exert additive influence upon redox balance alterations. However, recent evidence suggests that moderate physical activity can attenuate altitude/hypoxia-induced oxidative stress during long-term hypoxic exposure. The purpose of this review is to summarize recent findings on hypoxia-related oxidative stress modulation by different activity levels during prolonged hypoxic exposures and examine the potential mechanisms underlying the observed redox balance changes. The paper also explores the applicability of moderate activity as a strategy for attenuating hypoxia-related oxidative stress. Moreover, the potential of such moderate intensity activities used to counteract inactivity-related oxidative stress, often encountered in pathological, elderly and obese populations is also discussed. Finally, future research directions for investigating interactive effects of altitude/hypoxia and exercise on oxidative stress are proposed.Increased oxidative stress, defined as an imbalance between prooxidants and antioxidants, resulting in molecular damage and disruption of redox signaling, is associated with numerous pathophysiological processes and known to exacerbate chronic diseases. Prolonged systemic hypoxia, induced either by exposure to terrestrial altitude or a reduction in ambient O Reactive oxygen species (ROS) and reactive nitrogen species (RNS) are constantly produced within the living cells  , exercise likely drives more oxidative stress than systemic hypoxia per se. This hypothesis is congruent with the findings of Sinha et al. ]. The following section recaps the up-to-date studies scrutinizing the influence of activity during prolonged hypoxic/altitude exposures.Besides increasing oxidative stress, acute hypoxic exercise may also, at least transiently, alter antioxidant capacity  performed upon acute exposure and following 13-day of acclimation did not increase oxidative stress. It is also important to note that the employed oral antioxidant supplementation was inefficient in reducing hypoxia-induced oxidative stress. Very informative data on the effects of chronic exercise training during prolonged hypoxic exposures on oxidative stress and antioxidant status have also been derived from investigations related to altitude training in (mostly) endurance athletes. The vast majority of these studies were performed using the Live-High Train-Low altitude training modality (LHTL) first introduced by Levine and Stray-Gundersen  performed twice daily throughout the 10-day hypoxic confinement period was shown to improve antioxidant capacity and thereby blunt hypoxia-related oxidative stress in untrained individuals , mostly underlined by augmented antioxidant capacity. On the other hand, performing exercise of higher-intensities seems to additively increase hypoxia-induced oxidative stress. This might compromise adaptations to hypoxic training in athletes and also prove detrimental for individuals who exhibit chronically elevated systemic oxidative stress levels. These observations need to be taken into account while providing expert-advice on altitude/hypoxic training, as well as guidelines for high altitude sojourns in vulnerable populations. Given that the exact mechanisms of the interactive effects of hypoxia and physical activity on redox balance are not entirely clear, future well-controlled investigations should scrutinize different dose-response effects of both in healthy as well as patient populations.TD, GM, and VP: Drafted the manuscript, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript submitted.This study was supported by the Institut Universitaire de France.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.


COPD is a common inflammatory disease of the airways, alveoli and microvasculature that is under-diagnosed in smokers at risk for the disease. The majority of COPD patients have mild airway obstruction. Symptomatic smokers with mild COPD are at higher risk for earlier mortality and poorer perceived quality of life than non-smokers. Moreover, dyspnoea and activity restriction are common among smokers with minor spirometric abnormalities. Tobacco-related inflammatory injury of the lungs manifests as heterogeneous physiological impairment with highly variable clinical expression. Thus, simple spirometry provides only a crude assessment of disease pathophysiology, especially in the early stages of the disease.1, plethysmographic lung volumes and resting inspiratory capacity being within the normal range.Several studies have shown consistent physiological abnormalities on oscillometry, together with abnormal configuration of the mid-volume maximal expiratory flow-volume loop and increased pulmonary gas trapping, which collectively point to the presence of extensive small airway dysfunction despite FEVE/VCO2 nadir) is common in mild COPD and mainly reflects high physiological dead space  and thus a preponderance of lung units with high ventilation-perfusion ratios. This presentation explores the clinical consequences of this heterogeneous physiological impairment in smokers with unremarkable spirometry.Recent exercise studies in symptomatic smokers with or without mild COPD have highlighted that exercise limitation is common and is multifactorial but that respiratory factors such as increased dynamic mechanical constraints are contributory. Lung microvascular inflammation, disruption of the alveolar-capillary interface and reduced pulmonary perfusion are increasingly identified in smokers with minor spirometric abnormalities. In this context reduced ventilatory efficiency during exercise (high V


Tumour microenvironment (TME) is a key determinant of tumour growth and metastasis. TME could be very different for each type and location of tumour and TME may change constantly during tumour growth. Multiple counterparts in surrounding microenvironment including mesenchymal-, hematopoietic-originated cells as well as non-cellular components affect TME. Thus, therapeutics that can disrupt the tumour-favouring microenvironment should be further explored for cancer therapy. Previous efforts in unravelling the dysregulated mechanisms of TME components has identified numerous protein tyrosine kinases, while its corresponding inhibitors have demonstrated potent modulatory effect on TME. Recent works have demonstrated that beyond the direct action on cancer cells, tyrosine kinase inhibitors (TKIs) have been implicated in inactivation or normalization of dysregulated TME components leading to cancer regression. Either through re-sensitizing the tumour cells or reversing the immunological tolerance microenvironment, the emergence of these TME modulatory mechanism of TKIs supports the combinatory use of TKIs with current chemotherapy or immunotherapy for cancer therapy. Therefore, an appropriate understanding on TME modulation by TKIs may offer another mode of action of TKIs for cancer treatment. This review highlights mode of kinase activation or paracrine ligand production from TME components and summarises the findings on the potential use of various TKIs on regulating TME components. At last, the combination use of current TKIs with immunotherapy in the perspectives of efficacy and safety are discussed. Protein phosphorylation, one of the most prevalent post-translational modification of protein, is tightly regulated by specific protein kinase that transfer phosphate group to the amino acid residue . To our The binding of ligand such as growth factors or cytokines to the extracellular domains of RTKs initiate the signalling cascade by changing its structure and kinase activation. Whereas the non-RTKs which lack of extracellular domains mainly serves as the downstream effector of RTKs . UnderstKinase inhibition in tumour cells by tyrosine kinase inhibitors offers promising clinical benefit to cancer patients, especially, who have tumour with mutated kinases . NonetheEndothelial cells are known to play pivotal role in tumour neovascularization. The role of TKIs in endothelial cells has been identified either through direct action on endothelial cells or through mediating the communication between endothelial cells and tumour cells. Earlier studies observed the PKI 166, epidermal growth factor receptor (EGFR) inhibitor attenuated EGFR activation in tumour associated endothelial cells and caused cell apoptosis. The action is deemed to be EGFR-specific as it was not observed on EGFR-negative mice . SubsequGiven that several target receptors act as endothelial cell regulators, multi-targeted tyrosine kinase inhibitors are also being evaluated for better therapeutic outcome. The dual tyrosine kinase inhibitor AEE788 is utilized to inhibit EGFR and VEGFR binding on endothelial cells and resulted in apoptosis in both tumour and endothelial cells . The intCancer associated stromal cell, comprised of approximately 40% of total tumour volume , plays aFibroblast/stromal cells highly expressed PDGF receptors; production of PDGF ligands by cancerous cells triggered the up-regulation of fibroblast growth factors (FGF) by fibroblast which favours of tumour angiogenesis and proliferation. Notably, bone marrow stromal cells highly express PDGFRβ, while minimally detected in cancer cells. Therefore, there are emerging strategies targeting PDGFR or FGF on fibroblast in regressing tumour cell growth. For instances, inhibition of PDGFR by imatinib declined the secretion of FGF-2 and FGF-7 by cancer associated fibroblast resulted in reduced tumour progression ; combinaThe acquired resistance of tumour cells towards TKI has been frequently reported , 54. TheApart from endothelial cells and fibroblast, mesenchymal stem cells are also able to secrete EGF and express EGF receptor. Suppressing EGF receptor using AG1478 therefore suppressed mesenchymal stem cells mediated mammosphere formation . YoshidaEarly findings postulated that the osteoblast, bone marrow precursor cells in bone marrow microenvironment tend to produce substances for instance HGF which further promotes cancer cell proliferation and migratory activities. Intervention of NK4, HGF inhibitor or imatinib mesylate declined the cancer cells functions in the presence of osteoblast , 73. As The immunosuppressive environment, which primarily composed of myeloid-derived suppressor cells (MDSCs), regulatory T lymphocytes (Treg) and tumour associated macrophages, promoted escape of tumour cells from immune surveillance . AccumulMyeloid-derived suppressor cells MDSCs, the bone marrow derived heterogenous suppressor cells, has been shown to positively correlate to cancer progression. In advanced stage of cancer patients, tumour may induce expansion of MDSCs and in turn resulted in suppressive action of innate and adaptive immune response by high populations of MDSCs in tumour microenvironment . SunitinIn addition to VEGFR/c-KIT as therapeutic target of MDSCs, the use of AZD4547, the FGFR inhibitor has also been proposed as a target of MDSCs action. AZD4547 reduced breast cancer proliferation and migration through declining the MDSCs population while enhancing T populations . ConsistAccumulating studies have related the cross-talk between MDSCs and regulatory T subset, generally, MDSCs recruited and supported the activation of T regulatory populations . Thus, iDasatinib, a multikinase inhibitor, reduced T cellular proliferation, its associated cytokine production and cellular response , 103. ThOn the other hand, many small molecules inhibitors may acquire resistance upon disease progression whereby single treatment may not sufficient in altering the immunosuppressive tumour microenvironment. The VEGFR inhibitor, axitinib has been shown to increase CD4 (+) and CD8 (+) T population, while progressive patients showed increase regulatory T subset and PD-1 expression following axinitib treatment . LikewisMuch of the past and current efforts in eliminating the tumour associated macrophages (TAMs) have focussed on blocking TAMs survival or recruitment, inhibiting TAMs function and re-polarizing the TAMs phenotype that favour tumour regression. Typically, the c-fms kinase, or known as CSF1 receptor is a ligand-activated kinase that modulate monocytes and macrophage survival and proliferation . The potTherefore, apart from macrophage depletion, therapeutic strategies in re-programming TAMs immunosuppressive phenotype towards anti-tumour profile by TKIs intervention have also emerged as potent TAMs-targeted cancer therapy. For instances, sorafenib treatment stimulated IL12, IL18 and IL6 production in TAMs after LPS priming, which further supported natural killer cells function . Tie2 reAccumulating studies postulate the BTK was activated/phosphorylated upon Toll like receptors (TLR) stimulation , and actRecruitment of mast cells to tumour microenvironment has been shown to promote pancreatic cancer cell survival and inhibition of mast cell degranulation led to cancer cell death. Intervention of PCI-32765, the BTK inhibitor, declined mast cells degranulation and cancer cell growth . The samExtracellular matrix ECM components including fibronectin, laminin and collagen have been shown to determine the fate of cancer cells whether to remain dormant or proliferative . It was It has been proposed in various types of human cancers that immunotherapeutic regimen could offer favourable outcome, though large-scale randomized, placebo-controlled trials shall be carried out prior to its application. Given the accumulating reports on acquired resistance of TKIs, the use of TKIs alone as first-line treatment seems challenging in spite of its better prognosis. TKIs treatment often gain rapid but not durable tumour response, which result in early improvement of survival curve of cancer patients without clear beneficial effect on the overall survival. The effect of TKIs could be strategically complemented by immunotherapy, which induces a low percentage but highly durable tumour response . This noFurthermore, safety of the combination use is still contradicting and unclear. Some studies have reported the increased risk of adverse reaction after combination therapy, including higher incidence of grade 3/4 liver enzyme elevation (40–70%) and high incidence of interstitial lung disease (38%) . A lot oThe development of acquired resistance remain as the major clinical challenge to TKIs treatment, despite TKIs are still the first line therapeutic regimen for many malignancies. For instances, non-small cell lung cancer patients who initially well responded to EGFR inhibitors, erlotinib or gefitinib had host adaptive response and tumor growth within 6–12 months , 157. MaAlso, it is believed that cancer cells develop an immunosuppressive microenvironment for evasion from immune surveillance upon TKIs intervention. Although the detailed mechanisms of acquired immune evasion is not yet understood, previous studies suggested that the inducible expression of immune checkpoints PD-1/PD-L1 may be involved. Notably, the elevated expression of PD-L1 was observed in EGFR-resistant tumor biopsy compared to pre-treated tumor samples. This suggests the activation of immune checkpoint may hinder the treatment efficacy of TKIs to cancer patients . FurtherWith recognition of the actions of TKIs on TME, our previous studies have also suggested the beneficial role of complementing TKIs with immune-modulatory therapy. Complementary treatment using PHY906, a composite herbal formula that had potential to increase the therapeutic index of cancer treatments in multiple clinical trials, was recently identified to modulate TME in sorafenib-treated hepatocellular carcinoma (HCC). This immune-modulatory effect of PHY906 improved the anti-tumour TME signature and thereby enhanced the efficacy of sorafenib . An actiIn past decade, tyrosine kinase inhibitors targeting at tumour cells represent a promising therapeutic agent for cancer patients; yet, the use of TKIs in modulating tumour microenvironment is still in its infancy. The recent advances we summarized here emphasize the potential use of TKIs for re-educating or normalizing the dysregulated tumour microenvironment for cancer treatment. An understanding of the modulatory effect of TKIs on tumour microenvironment could expedite the maximal use of TKIs on cancer therapy as well as re-positions the existing TKIs as combination cancer treatment. Furthermore, phosphorylated status of target protein could also be determined by protein phosphatase, which belongs to another group of protein involved in microenvironment status of tumour cells, is worthy for further exploration. Much more efforts, either pre-clinically or clinically, is therefore anticipated in order to maximize the efficacy and safety for patients.


Macropinocytosis has long been known as a primary method for cellular intake of fluid-phase and membrane-bound bulk cargo. This review seeks to re-examine the latest studies to emphasize how cancers exploit macropinocytosis to further their tumorigenesis, including details in how macropinocytosis can be adapted to serve diverse functions. Furthermore, this review will also cover the latest endeavors in targeting macropinocytosis as an avenue for novel therapeutics. Macropinocytosis is an endocytic pathway that leads to internalization of large patches of plasma membrane along with extracellular fluid through irregularly formed vesicles called macropinosomes. When compared to endosomes originating from coated vesicles, macropinosomes are significantly larger by a factor of up to a thousand-fold  and pancreatic cancer cells. When macropinocytosis is upregulated in GBM cells by a quinine-derivative chemical, Vacquinol-1, massive membrane ruffling and macropinocytosis lead to cell death through excessive vacuolization and deformations in the plasma membrane  family receptors, where exosomes shed by cancer cells can internalize into distant cancer cells in a paracrine fashion through binding with RTKs  via macropinocytosis in an H-Ras dependent manner to evade TNF-related apoptosis-inducing ligands (TRAILs) and subsequent apoptosis  of one particular PIP5K, Iγi2, leads to decreased oncogenic growth of breast cancer cells (Thapa et al., Another therapeutic venture includes disrupting cancer cell metabolic activity through inhibition of macropinocytosis (Zeitouni et al., Lastly, other therapeutic ventures have shown that hyper-stimulating macropinocytosis in cancer cells can lead to non-apoptotic cell death known as methuosis (Li et al., As cancer cells frequently employ macropinocytosis to aid in receptor regulation and internalize essential metabolites, extensive efforts have been underway in utilizing macropinocytosis to deliver cytotoxic therapeutics specifically into cancer cells. Some anti-cancer agents innately undergo macropinocytosis, such as AS1411, which internalizes into various cancer cells through cell-surface nucleolin-dependent mechanisms that activate macropinocytosis only in malignant cells (Reyes-Reyes et al., Potent cancer therapeutics that exhibit excessive, systemic toxicities or unstable pharmacokinetics from hydrophobic profiles are excellent candidates for conjugation to yield chemical conjugates or nanoparticles. The resultant conjugates or nanoparticles can be engineered to yield greater specificity and enhanced pharmacokinetics. In many other examples, synthetic conjugates comprising any combination of small chemicals, lipids, proteins, genetic components, and chemical scaffolds can be developed to form nanoparticles that can then be internalized into target cells via macropinocytosis. Nanoparticles, which vary widely in composition, size, chemical charge, and shape, all contribute to distinct, cellular specificities and in endocytic mechanisms (Kettler et al., Another intriguing therapeutic front includes conjugating cytotoxic payloads onto albumin primarily for enhancing drug pharmacokinetics and because albumin has long been observed to accumulate within solid tumors through macropinocytosis Kratz, . An examAnother component commonly used for conjugation is the poly-arginine peptide. As poly-arginine peptides induce macropinocytosis and cancer cells generally have increased macropinocytosis, efforts have been underway in conjugating poly-arginine peptides with cytotoxic compounds. These conjugates can be employed to deliver a variety of materials into cells, including cytotoxic reagents against cancer cells (Biswas et al., in vitro, with therapeutic proteins either electroporated into exosomes or intracellularly incorporated through targeted overexpression of genes in the cell cultures (Munson and Shukla, As cancers routinely internalize exosomes, a logical maneuver includes formulating therapeutics that mimic exosomes. Exosomes can be derived from same-host cells to avoid inducing immune responses (Hall et al., Mycobacterium smegmatis (Baltierra-Uribe et al., Salmonella (Francis et al., Plasmodium sporozoites, or malaria, also infiltrate into host hepatocytes by inducing macropinocytosis through the EphA2 receptor (Kaushansky et al., If cancers commonly exploit macropinocytosis for efficient endocytosis of scarce nutrients and proteins, it is not surprising that various pathogens also infiltrate into host cells through this pathway. Pathogens such as viruses and bacteria commonly enter human cells by activating macropinocytosis through receptor-dependent means. Several examples include human cytolomegavirus (Hetzenecker et al., Macropinocytosis appears to play vital roles across a variety of neurodegenerative diseases as well, and this has been comprehensively reviewed (Zeineddine and Yerbury, Cancer cells, in addition to pathogens and neurodegenerative diseases, all exploit macropinocytosis for its efficiency in endocytosis. In particular, cancer cells seem to possess increased macropinocytic activity to fulfill diverse functions that include metastasis, metabolism, and signal transduction Figure . For thiKH wrote the manuscript, SB edited the manuscript, BL selected the review topic and edited the 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.


Eurosurveillance invites authors to submit papers in the categories, Research articles, Surveillance and Outbreak reports, Reviews and Perspectives for a special issue on advanced diagnostics to inform public health policy.Recent advances in laboratory technology, including the application of qualitative and quantitative molecular diagnostics, proteomics (e.g. MALDI-TOF MS) and genomics, particularly whole genome microbial sequencing (WGS) and metagenomics are transforming the field of clinical and public health microbiology. The use of advanced methods enables unprecedented capability and capacity for rapid and comprehensive pathogen detection, quantitation and characterisation, when applied to clinical and environmental samples. Advanced diagnostics may therefore impact public health policy during specific incidents or on a wider scale.Topics of interest may include, but are not limited to:• Focused reviews portraying pathogen- or disease-specific use of advanced diagnostics in public health microbiology or practical aspects of integrating new diagnostics in public health;• Advanced laboratory tools for generating data that inform risk assessment and risk management;• Possible role of rapid diagnostic testing in public health and cross-border health security;• Moving to culture-independent public health microbiology;• Policy and Regulatory aspects of harnessing new technologies for public health.eurosurveillance@ecdc.europa.eu.The submission deadline is 15 April 2018. If you would like to submit a paper or ask for more information, please see our instructions for authors regarding article formats or contact the editorial team at


Cerebrovascular disease (CVD) is often present in old age and may be associatedwith microstructural pathology of white matter (WM) and cognitive dysfunction.The current review investigated the relationship between CVD, cognitive statusand WM integrity as assessed by diffusion tensor imaging (DTI).DTI studies were searched on ISI and Pubmed databases from 2002 to 2012.Studies evidenced DTI changes in WM as associated with vascular disease andprovide increasing support for DTI as a valuable method for early detectionof CVD.DTI parameters can serve as important biomarkers in monitoring vasculardisease progression and treatment response and may represent a surrogatemarker of WM tract integrity. Depending on thesite, intensity, and severity, CVD may either cause or contribute to furthercognitive decline.2 Earlier reportsdescribe CVD pathology as a consequence of blood perfusion deficits generated byhypoxia, hypoperfusion and hemorrhage which in turn result in neuronal injury,necrosis, apoptosis and ischaemic penumbra.2 The presence and severity of CVD hinge on non-modifiablerisk factors such as ageing, gender and genetics but also on several other variablessuch as smoking, systemic arterial hypertension, diet and metabolic diseases.Structural studies have identified subcortical hyperintensities as macroscopic whitematter (WM) changes which have been cited by several reports as associated with CVD,mood disorders, executive dysfunction and higher conversion to dementia. Morerecently, the underlying pathology associated with normal-appearing WM as well asits clinical significance has become the main focus of investigation.3Cerebrovascular disease (CVD) occurs in one third of the populationin vivo.6 One of themost useful of these techniques is diffusion tensor imaging (DTI), which issensitized to the motion of water molecules as they interact within tissues, thusreflecting characteristics of their immediate structural surroundings.8 Earlier DTI studies used a region-of-interest (ROI) analysisapproach, with brain areas being delineated manually or with semi-automatedmethods.11 However the ROI approach has a number ofdrawbacks, such as difficulty precisely replicating and delineating anatomicalregions as well as the use of pre-selected brain areas rather than consideringdiffusion changes in the whole brain.12 To improve the objectivity and interpretability of DTI studies,Tract-Based Spatial Statistics (TBSS) was developed to enable DTI scans to becompared across subjects more robustly.13 TBSS is based on voxel-wise analysis, which approaches thewhole brain without any a priori selection of regions. Anotheradvantage of TBSS is that it minimizes the problem of misalignment.14 To date, the vast majority ofstudies have concentrated on the role of FA in cognitive disorders.17 However, a rangeof factors influence FA decreases, including myelination, axon density, axondiameter and intra-voxel coherence of fiber orientation.19Therefore, there is an increasing awareness of the limitations of single FAmeasurements, and of the need to investigate how other DTI indices  change over the course of bothvascular and neurodegenerative diseases.15In recent years, novel methods of neuroimaging have enabled WM microstructureintegrity to be investigated 2 the influence ofmilder vascular risk factors such as controlled hypertension, or high normal bloodpressure is largely unknown.2Another promising topic of DTI investigation is the common pathological routesbetween CVD and Alzheimer's Dementia (AD), especially the landscape involvingneurodegenerative and vascular changes. Cerebral atherosclerosis is associated witha higher risk of AD while cardiovascular risk factors are associated withclinically-diagnosed AD and vascular dementia (VaD).20 Thesimilarities in association between cardiovascular risk factors and dementiadiagnosed as AD or VaD underline the relevance of CVD for aging-related cognitivedecline in general and the flaws in simplistic diagnostic categories.20 Although vascular and degenerationprocesses often overlap, relatively few studies have focused on the interactionbetween these two pathologies. Conversely, no serum or plasma biomarker has beenestablished as a reliable biomarker of CVD compared to other types of dementia andnon-demented individuals.20There is an open field of investigation on DTI and CVD. To date, the majority ofstudies conducted have investigated only WM abnormalities in relation toneurodegeneration predominantly among AD patients but the pathological processes ofWM associated with vascular disease are not yet fully understood. In contrast to thedamaging effects of CVD and untreated hypertension on diffusion-based parameters ofWM,This review investigated the main results of DTI studies in patients with CVD. Weaimed to discuss these results and the integration of diffusion findings withstructural data and WM microscopic pathology and progression of cognitive impairmentin relation to vascular disease.A systematic review of DTI studies on CVD was performed by searching data from ISIand Pubmed web databases from the first DTI studies in 2002 (January) to 2012 (May).The search strategy included key words aimed at investigating a broader spectrum ofprimary vascular disorders affecting subcortical areas, particularly white-matterlesions: DTI, vascular dementia, subcortical disease, white-matter, neuroimaging,dementia, MCI, blood vessels.All abstracts were independently read by six authors and those studies which complied with the inclusion criteria were selected forfurther reading. A manual search was also performed to retrieve articles related tothis subject found among the references of the selected studies. The articles whichsatisfied all the following criteria were included for further reading and analysis.For inclusion, articles had to:[1] have at least one DTI parameter, such as FA;21[2] be cohort, cross-sectional, or case-control studies with at least onecriterion for vascular dementia  and mild cognitive impairment, vascular type as developed by theNINDS research group;4 and[3] provide data on cognitively impaired patients ≥60 years ofage, with or without clinical diagnosis of dementia;[4] include a comprehensive neuropsychological assessment.The Pubmed electronic search retrieved 156 articles. Only 12 remained eligible forfurther analysis. 22 The classical viewin which vascular disease was related to WM hyperintensity (WMH) burden has beenprogressively substituted by new insights on the pathological development of brainvascular disease and its dynamic interaction with neurodegeneration. DTI paperssupport previous evidence from genetics and biomarkers25 showingthat vascular disease plays an important role in the development and clinical courseof AD.26 The ensuing topics coveraspects of the pathology and clinical features of the studies.The majority of studies evidenced diffusion changes in WM as associated with vasculardisease and supported DTI as a valuable method for the early diagnosis ofCVD.The pathological basis of vascular changes. There is growing evidencefrom DTI studies demonstrating that macroscopic and microscopic changes in WM resultfrom distinct pathological processes which have been described by some authors as WMlesion formation and WM atrophy.27Both processes result from a complex combination of independent factors such as age,hypertension, metabolic and degeneration, but there is no established modelexplaining these underlying changes.2826 whereas temporal and occipital lobes weredescribed by another study.29 In athird study, periventricular areas were described as more susceptible to ischemicinjury.30The territorial pattern of progression of WM changes has been discussed in somepapers with equivocal findings. Parietal WM and the centrum semiovale were reportedas the regions most associated with the vascular pathology27 Additionally,one study showed that atrophy of the corpus callosum was significantly associatedwith changes in diffusion in deep WM hyperintensities. According to Schimidt etal.,31 such findings canfurther etiologic understanding of age-related WM damage because they argue againsta diffuse pathological process as the origin of WMH.Among the WM tracts most susceptible to damage due to atrophy of WM were thosecomponents of the limbic system (which comprise the anatomic substrate ofAlzheimer's disease) such as the fornix, the cingulum tracts and in the region ofthe hippocampus.Correlation of WM changes with clinical variables. Diabetes andhypertension32 have beencited as the most important clinical variables associated with CVD. Hypertension hasbeen associated with reduction in WM volume35 and increase in WMH burden.38 In a recentinvestigation,39 theeffects of Mean Blood Pressure were present both in subjects with mildcardiovascular risk and those with established hypertension. Hence, significanteffects of cognitive decline were present even in individuals outside thehypertensive range.39 Takentogether, these findings support that systemic vascular function is an importantvariable to be considered in the investigation of cognitive changes also in thecontext of patients without known vascular disease or overt brain vascularchanges.Use of overlapping DTI indices in the differential diagnosis between vasculardisease and neurodegeneration. Contrasting with earlier reports, recentevidence in vascular disease has attempted to investigate WM pathology through thecombination of FA and non FA indices15 thus following a general tendency seen in otherstudies, e.g. those with Alzheimer individuals.40 The overlap between axial and radial diffusionincreases was associated with atrophy of WM in different regions , while acuteaxonal injury results in a decrease in diffusion parallel to the fibers .27 Theseincreases suggest decreased packing within a voxel.43 An alternative explanation is that apparentincreases in axial diffusion may stem from a loss in fiber coherence among regionswith fiber crossing.44 Early reports characterize thevascular pathology of subcortical areas by extensive occlusion of arterioles andmicro-atherosclerosis. One study28showed statistically significant FA and MD differences in areas of WMH burden andthose with apparent normal WM. FA-MD and MD-DR overlaps may thus reflectdemyelination and axonal loss within the fibers and early vascular disease. However,as the interpretation of multiple indices is not clearly established, furtherstudies should comprehensively analyze the application of DTI indices to theunderstanding of complex interactions between vascular disease and degeneration. regions  and coulCorrelation between DTI and neuropsychological testing. One outpatientstudy20 analyzed theassociation of brain structural parameters and cognitive tasks and found a greatercoefficient of correlation with diffusion indices than with WM volume or WM burdenrated by the Fazekas scale.20 In alarge multicenter study conducted by the LADIS multicenter group,31 which included 340 patients withvarying degree of macroscopic WMH (leukoaraiosis), the correlation of microscopicchanges in normal-appearing brain tissue was more strongly related to executive andmemory impairment than WM volume and WMH burden. A similar conclusion was found bythe Rotterdam study (28 Findings from these three studies31 evidence agreater variability of WM microscopic pathology and support non-FA indices assensitive biomarkers for assessing the integrity of WM independently of otherstructural measurements such as atrophy of white and gray matter or WM burden.Future studies should evaluate the usefulness of multiple diffusion parameters asbiomarkers of cognitive decline in research and their applicability in monitoringresponses to therapeutic interventions and treatment success.am study  in whicham study .28 Findi39 DTI parameterscan serve as important biomarkers in monitoring vascular disease progression andtreatment response and may represent a surrogate marker of WM tract integrity.Therefore, the studies discussed in the current review encourage the use of multiplediffusion indices as important tools for the diagnosis of microscopic changes in WMassociated with early-onset vascular disease.This summary of findings demonstrates that loss of integrity in normal-appearing WMpoints to an independent process of WMH burden and may reflect a constellation ofpathophysiological interactions, including ageing, neurodegenerative mechanisms andalso vascular disease. Current evidence highlights the increasing importance ofvascular health as a major component of general neural aging as demonstrated byprevious studies.