Mechanical loading is the primary functional determinant of bone mass and architecture, and osteocytes play a key role in translating mechanical signals into (re)modelling responses. Although the precise mechanisms remain unclear, Wnt signalling pathway components, and the anti-osteogenic canonical Wnt inhibitor Sost/sclerostin in particular, play an important role in regulating bone's adaptive response to loading. Increases in loading-engendered strains down-regulate osteocyte sclerostin expression, whereas reduced strains, as in disuse, are associated with increased sclerostin production and bone loss. However, while sclerostin up-regulation appears to be necessary for the loss of bone with disuse, the role of sclerostin in the osteogenic response to loading is more complex. While mice unable to down-regulate sclerostin do not gain bone with loading, Sost knockout mice have an enhanced osteogenic response to loading. The molecular mechanisms by which osteocytes sense and transduce loading-related stimuli into changes in sclerostin expression remain unclear but include several, potentially interlinked, signalling cascades involving periostin/integrin, prostaglandin, estrogen receptor, calcium/NO and Igf signalling. Deciphering the mechanisms by which changes in the mechanical environment regulate sclerostin production may lead to the development of therapeutic strategies that can reverse the skeletal structural deterioration characteristic of disuse and age-related osteoporosis and enhance bones' functional adaptation to loading. By enhancing the osteogenic potential of the context in which individual therapies such as sclerostin antibodies act it may become possible to both prevent and reverse the age-related skeletal structural deterioration characteristic of osteoporosis.  •Loading-related changes in osteocyte sclerostin expression spatially predict subsequent osteogenic responses.•Acute sclerostin down-regulation is not sufficient for maximal osteogenic responses to loading.•Inability to suppress sclerostin precludes bone gain following loading. Lack of sclerostin prevents bone loss in disuse.•Sclerostin influences the osteogenic context in which loading acts as its deletion enhances functional adaptation. Loading levels or distributions which engender strains beyond a habitual minimum effective strain (MES) trigger bone formation resulting in increased bone mass, improved bone architecture and thus re-establishment of habitual levels and distribution of strain Mechanical loading is the primary functional determinant of bone mass and architecture Sost/sclerostin is almost exclusively expressed by osteocytes in the adult skeleton e.g. apoptosing osteocytes around microcracks secrete Rankl via the expression of osteoprotogerin (Opg); mice lacking β-catenin in osteocytes have dramatically reduced bone mass due to reduced Opg levels Osteocytes are embedded in the mineralised matrix and were long thought to have little or no function, but are now known to play a particularly important role in coordinating local bone remodelling responses and have recently described as ‘master-regulators’ Given their location and morphology, with long interlinked dendritic processes forming a functional syncytium extending to the bone surfaces, osteocytes are ideally suited to sense load-associated strains, including shear strains across their membranes as fluid is displaced through their canalicular system. Osteocytes are now considered to be the primary mechanosensors which locally coordinate adaptive (re)modelling responses For many years after this, the mechanisms underlying the coordination of adaptive remodelling responses by osteocytes were largely unknown. Hypothesised mechanisms included direct cell-cell communication 2Sost RNA expression in the mouse tibia. However, protein level analysis of sclerostin expression by immunohistochemistry following tail suspension did not detect changes in the proportion of osteocytes stained positive for sclerostin around the level of the tibia/fibula junction The model presented in Sost despite having opposite effects on bone mass The lack of change in sclerostin expression around the mouse tibia/fibula junction during tail suspension is potentially consistent with the finding that this region appears to be the least affected by disuse, with the most significant bone loss occurring proximal and distal to this region Tg) were generated Sost expression in these mice. Further supporting evidence that sclerostin down-regulation is required for loading-induced bone formation, was the observation that loading induced significantly greater bone formation in wild type than SostTg mice. These independent studies specifically test the roles of sclerostin in bone's adaptation to loading and as such provide strong evidence that both loading-related bone gain and disuse-associated bone loss require changes in sclerostin expression, at least in young mice.Evidence that the spatial correlation between loading-related sclerostin regulation and changes in bone (re)modelling may be causal is provided by loading studies using different genetically modified mouse models. Sclerostin knockout mice do not show bone loss in response to disuse induced by hind limb unloading Sost down-regulation in bones' osteogenic response to loading also comes from studies utilising mice with genetic modifications in mechano-responsive pathways which result in altered Sost regulation following loading. For example, increased basal sclerostin expression, abrogation of sclerostin down-regulation with loading and reduced load-related bone formation is observed in periostin knockout (Postn−/−) mice Sost down-regulation and triggers a diminished osteogenic response to loading compared with wild type controls Evidence supporting the potential importance of 3in vivo studies describing altered basal sclerostin expression and changes in the load-related regulation of sclerostin in genetically modified mice, while informative, provide limited insight into the molecular mechanisms by which osteocytes regulate sclerostin expression. Instead in vitro studies using a variety of model systems have been required to address this. These studies have shown that the basal rate of sclerostin expression is under both transcriptional and broader epigenetic control  enzymes such as Sirt1 and HDAC5 Sost RNA stability is influenced by micro-RNAs such as miR-218 The above  control . Its resSost is down-regulated by PTH Sost regulation by strain have been hindered by the limited availability of cellular models. Primary osteoblasts do not express readily detectable levels of Sost until they form mineralised matrix, which precludes their use for in vitro strain studies. Mouse osteocytic MLO cell lines do not reliably produce readily detectable levels of SostSost after prolonged periods of differentiation Sost. However, rat UMR-106 osteosarcoma cells do respond to strain Sost in a manner akin to them having a constitutively active gene Sost RNA and sclerostin protein in vitro strain by four point bending increases their proliferation Sost over a time course which parallels that seen in rodent bones following in vivo mechanical loading SOST promoter activity is enhanced by Mef2 binding to a distal enhancer element and inhibition of this binding is one of the mechanisms by which Sost down-regulation by strain involves Cox2-initiated PGE2 signalling through an EP4/ERK pathway in vivoSost expression is further demonstrated by the recent report that Cox inhibition with carprofen prevents sclerostin down-regulation in the ulnae of mice subjected to axial loading Sost down-regulation in osteoblastic cells in vivo, produced higher levels of NO when subjected to fluid shear in vitroUsing the Saos-2 model we initially reported that Sost down-regulation by strain in Saos-2 cells, rather ERα inhibition in vitro or global deletion in vivo reduces basal Sost levels Sost levels, but prevents strain-induced Sost down-regulation in Saos-2 cells in vitro models.AR, NO and PGE2 signalling pathways are all influenced by estrogen receptors (ERs), which also interact with canonical Wnt pathway components in mechanically strained osteoblastic cells Sost down-regulation following strain, although ERβ may also act down-stream of PGE2 signalling as PGE2 treatment increases estrogen response element activation in osteoblastic cells VV in the osteoblast lineage prevents Sost down-regulation in the ulnae of mice subjected to axial loading V directly interacts with and facilitates Igf1/Igf1R signalling Sost down-regulation V also facilitates opening of connexin (Cx)43 hemichannels and Cx43 facilitates the release of PGE2, which is involved in the rapid activation of β-catenin in osteoblastic cells subjected to mechanical stimulation in vitroV expression is not required for ERK activation in calvarial osteoblastic cells subjected to fluid shear Both these roles of ERβ are consistent with a down-stream Cox-2/PGE2/ERK pathway mediating in vivo studies have been published that have systematically investigated the roles of different mechano-responsive signalling pathways in sclerostin regulation following loading. The majority of available studies are based on in vitro observations in osteoblastic cell lines subjected to defined mechanical stimuli which cannot fully replicate the effects of in vivo loading on the heterogeneous cell populations residing in and on bone. Currently, only Cox2/prostaglandin signalling has been demonstrated to acutely regulate sclerostin expression in vitro, suggesting a direct effect, and to also facilitate sclerostin down-regulation following loading in vivo. Furthermore, the mechanisms by which unloading results in sclerostin up-regulation have not been investigated and cannot be assumed to be the same as those which result in its down-regulation following increased loading. Nonetheless, putting the available jigsaw pieces together it is possible to propose a linear pathway which links early strain-related signalling events to ultimate down-regulation of Sost expression  as well as resumption of proliferation of cortical long bone derived osteoblastic cells This latter interpretation is consistent with the recent report that Sost knockout mice do not lose bone due to unloading, but still show osteogenic responses to increased loading in vitro is clearly demonstrated by their ability to very rapidly enter into the cell cycle after strain exposure in the absence of sclerostin In vivo, an increase in the number of osteoblasts on the periosteal surface is seen within 24 h following loading in vitro and the increase in the number of periosteal osteoblasts following loading in vivo were impaired. These deficiencies in osteoblast function that occur with age may not only limit bone's adaptive responses to loading but also the beneficial effect of sclerostin neutralising therapies The ability of osteoblasts to sense and respond to strain Sost has recently been independently replicated by Holguin et al. Sost in 5-month-old as well as 12-month-old and 22-month-old mice, although the bone formation response was blunted with age. A possible explanation is that Sost RNA down-regulation is more transient in bones from 22-month-old than 5-month-old mice and others have shown changes in Wnt pathway-related gene transcripts and blunting of β-catenin activity in the old Sost in young mice, only the first bout of loading results in Sost down-regulation in the old. This suggests that old bone cells become refractory to repeated bouts of increased loading. However, we have recently reported that prior and concurrent disuse enhances the osteogenic response to repeated bouts of axial tibial loading in aged mice The finding that osteocytes in tibiae of old mice remain able to sense changes in mechanical loading and acutely respond by down-regulating 6Numerous studies have demonstrated that sclerostin plays a role in the effective working of the mechanisms associated with regulation of bone mass and architecture in relation to mechanical loading (the mechanostat). Sclerostin expression increases following unloading with the consequent inhibition of Wnt signalling and associated bone loss. Down-regulation of sclerostin is permissive for osteogenesis in response to loading, at least in part by relieving inhibition of canonical Wnt signalling. This is consistent with the potently osteogenic responses observed in humans treated with sclerostin-inhibiting antibodies now in advanced stages of clinical development


The glucocorticoid (GC) drugs are one of the most commonly prescribed and effective anti-inflammatory agents used for the treatment of many inflammatory disorders through their ability to attenuate phlogistic responses. The glucocorticoid receptor (GCR) primarily mediates GC actions via activation or repression of gene expression. GCs directly induce the expression of proteins displaying anti-inflammatory activities. However, the likely predominant effect of GCs is the repression of multiple inflammatory genes that invariably are overexpressed during nonresolving chronic inflammation. Although most GC actions are mediated through regulation of transcription, rapid nongenomic actions have also been reported. In addition, GCs modulate inflammatory cell survival, inducing apoptosis in immature thymocytes and eosinophils, while delaying constitutive neutrophil apoptosis. Importantly, GCs promote noninflammatory phagocytosis of apoptotic cell targets, a process important for the successful resolution of inflammation. Here, the effects and mechanisms of action of GC on inflammatory cell apoptosis and phagocytosis will be discussed.


A 90-year-old female presented after sudden collapse with a Glasgow Coma Score of 3, and profound hypotension. Shortly after endotracheal intubation, the patient developed significant hematemesis, and massive transfusion protocol was subsequently instituted. Computed tomography angiogram of the chest revealed active bleeding from an aortoesophageal fistula . During The most common causes of aortoesophageal fistulas are thoracic aortic aneurysm, foreign body ingestion, postoperative complications, and esophageal malignancy. The classic presentation of mid-thoracic chest pain and sentinel arterial hemorrhage followed by exsanguination is known as Chiari’s triad.CPC-EM CapsuleWhat do we already know about this clinical entity?Aortoesophageal fistula is a rare and typically fatal pathology that presents as massive upper gastrointestinal hemorrhage.What is the major impact of the image(s)?This is a rarely seen image, given the degree of extremis and high mortality of patients with aortoesophageal fistula at emergency department presentation.How might this improve emergency medicine practice?Emergency medicine providers must be familiar with the presentation, diagnostics, rapid interruption of diagnostics and treatment of aortoesophageal fistulas.


Dear Editor,We appreciate Drs. Itkonen and Lamberg-Allardt’s interest in our recent article “Dietary Sources of Phosphorus among Adults in the United States: Results from NHANES 2001–2014” [Total bioavailable phosphorus intake is the sum of bioavailable phosphorus from each source. See Equation (1) , below. Note that total phosphorus intake from a specific source is the product of phosphorus content (mg/serving) and intake (servings/day).Identifying important dietary sources of total phosphorus intake is the first step in identifying important dietary sources of bioavailable phosphorus intake. Sources that contribute a small total amount of phosphorus (such as dark cola) necessarily contribute a small amount of bioavailable phosphorus, even if they have high bioavailability. Sources that contribute a large total amount of phosphorus (such as bread) may still contribute a large amount of bioavailable phosphorus with relatively low bioavailability. Our study highlights grain products as an increasingly important source of total dietary phosphorus intake.Drs. Itkonen and Lamberg-Allardt also note the importance of added phosphates to the diet. Many foods, including grain products, contain a combination of different types of phosphorus . Added phosphates are of special interest due to the potential for food manufactures to increase or decrease their use more readily than naturally-occurring phosphates. The Food and Nutrient Database for Dietary Studies (FNDDS) does not currently provide the phosphorus content of foods specifically from added phosphates . In the Research into dietary intake of bioavailable and added phosphorus will benefit from an increased focus on important dietary sources of total phosphorus intake, such as grain products, rather than dietary sources with the highest phosphorus bioavailability.


Although numerous studies have investigated the relationship between saccadic eye movements and spatial attention, one fundamental issue remains controversial. Some studies have suggested that spatial attention facilitates saccades, whereas others have claimed that eye movements are actually inhibited when spatial attention is engaged. However, these discrepancies may be because previous research has neglected to separate and specify the effects of attention for two distinct types of saccades, namely reflexive (stimulus-directed) and voluntary (antisaccades). The present study explored the effects of voluntary spatial attention on both voluntary and reflexive saccades. Results indicate that voluntary spatial attention has different effects on the two types of saccades. Antisaccades were always greatly facilitated following the engagement of spatial attention by symbolic cues (arrows) informing the subject where the upcoming saccade should be directed. Reflexive saccades showed little or no cueing effects and exhibited significant facilitation only when these cues were randomly intermixed with uncued trials. In addition, the present study tested the effects of fixation condition  on attentional modulation. Cueing effects did not vary due to fixation condition. Thus, voluntary spatial attention consistently showed different effects on voluntary and reflexive saccades, and there was no evidence in these studies that voluntary cues inhibit reflexive saccades, even in a gap paradigm.


The importance to develop effective alternatives to known antibiotics due to increased microbial resistance is gaining momentum inrecent years. Therefore, it is of interest to predict, design and computationally model Antimicrobial Peptides (AMPs). AMPs are oligopeptideswith varying size (from 5 to over100 residues) having key role in innate immunity. Thus, the potential exploitation of AMPsas novel therapeutic agents is evident. They act by causing cell death either by disrupting the microbial membrane by inhibitingextracellular polymer synthesis or by altering intra cellular polymer functions. AMPs have broad spectrum activity and act as first lineof defense against all types of microorganisms including viruses, bacteria, parasites, fungi and as well as cancer (uncontrolled celldivision)progression. Large-scale identification and extraction of AMPs is often non-trivial, expensive and time consuming. Hence,there is a need to develop models to predict AMPs as therapeutics. We document recent trends and advancement in the prediction ofAMP. Machine learning is considerably applied in different areas ofbiological knowledge discovery for improved healthcare.Supervised, unsupervised and reinforcement learning are thethree major learning methods. Identification of AMPs using acombination of supervised and unsupervised learning techniquesis available. A set of experimentally annotated positive AMPpeptides collected from the databases is used for supervisedlearning. The negative data of short peptides collected from aspectrum of available non-secretary peptides is often used fortraining. A high performance machine learning model is built toclassify the data into AMPs and non-AMPs with domain featuressuch as amino acid frequencies and composition extracted fromknown data using the most suitable performance measures likeaccuracy, Mathew Correlation Coefficient, ROC etc. SupportVector Machines (SVM), Random Forests (RF) and ArtificialNeural networks have been used profusely for the identificationof AMPs. SVM employs a linear hyper plane in a higherdimensional feature space for separation. Random forestsclassifier combines a forest of decision tree models and builds aconsensus model. Artificial Neural Networks (ANN) usesinterconnected network of neurons.Thomas et al. 2009) , employe009 , empAMP's were also predicted elsewhere  using muDatabases and prediction servers have a key role in the rationaldesign of novel AMPs as reviewed elsewhere . The wor


Recent advances in the development of immunosensors using polymeric nanomaterials and nanoparticles have enabled a wide range of new functions and applications in diagnostic and prognostic research. One fundamental challenge that all immunosensors must overcome is to provide the specificity of target molecular recognition by immobilizing antibodies, antibody fragments, and/or other peptides or oligonucleotide molecules that are capable of antigen recognition on a compact device surface. This review presents progress in the application of immobilization strategies including the classical adsorption process, affinity attachment, random cross-linking and specific covalent linking. The choice of immobilization methods and its impact on biosensor performance in terms of capture molecule loading, orientation, stability and capture efficiency are also discussed in this review. Antibody (Ab) and antibody fragment-based biosensors or immunosensors are compact tools capable of providing sensitive and rapid detection or capture of a range of pathogens or cells of interests for further analysis. The history of biosensors dates back to 1956 when Leland C. Clark described the first biosensor which was developed to detect glucose levels in serum samples using a membrane bound biologically sensitive element [The fundamental basis of all immunosensors is to efficiently create stable linkages between desired capture molecules and the nanomaterial. Abs are the most extensively used antigen binding molecules due to their exquisite specificity and affinity. A vast selection of monoclonal Abs (mAbs) have been developed using hybridoma technology to provide excellent tools to detect, perturb, or enhance key components in biological systems. Recent efforts have been made to shrink Ab-based tools through the dissociation of full size Abs into smaller antigen binding fragments . InitialAbs or immunoglobulins (Igs) are highly soluble serum glycoproteins which can be divided into five main isotypes  based on their heavy chain constant region sequences . PolycloE. coli expression. VHH binders with desired properties can be recombinantly expressed with tag sequences, protein fusion partners, or artificial amino acids through covalent modification [Although full-size Abs generated through immunization have been widely used for immunosensors since the beginning of biosensor development, recently developed recombinant molecules generated in vitro have many advantages over conventional Abs. The advantages of these alternative scaffolds include their compact sizes, excellent thermal and chemical stabilities, as well as low production costs ,15. For fication . Similarfication .Supporting materials of an immunosenor can be selected based on analytic needs . OpticalThe performance of an immnosensor depends upon three key factors: (1) the binding affinity and specificity of antigen binding molecules; (2) the accessibility and proportion of binding sites intact after immobilization; and (3) the density of binding molecules coated on the surface of immunosensor. Different strategies for immobilization may result in different outcomes and efficiencies . ImmobilPhysical adsorption of Abs onto hydrophobic surfaces such as polystyrene offers the simplest attachment. However, the process is uncontrollable in terms of orientation and stability, and often results in denaturation and detachment of protein on surface . ProteinVHHs, also known as nanobodies, are recombinant, antigen-specific, single-domain, variable fragments of camelid heavy chain-only antibodies. Compared to full size IgGs, VHHs can be expressed in high yield in bacterial systems. The small size (~14 kD) provides significant advantages in medical diagnostic and therapeutic applications . HoweverH) and light chains (VL) of Abs connected via a short peptide linker. Shen et al. optimized a 15-mer peptide linker (RGRGRGRGRSRGGGS) to increase the adsorption efficiency on anionic charged biosensor surface [E. coli which can display anti-cancer ScFvs and gold binding peptide on the surface of bacteria at the same time  and highly soluble in aqueous solution. Deyev and others reported that DARPins can bind tightly to gold nanoparticles (GNPs) via adsorption . Aptamers are single-stranded DNA or RNA (ssDNA or ssRNA) oligonucleotides or peptides engineered through repeated in vitro selection or equivalent methods. However, aptamers have distinct limitations, especially for those composed of DNA or RNA. The rapid degradation of aptamers by nucleases in biological media is a serious problem. Such degradation causes instability which is unacceptable for biosensor application. Despite such limitations, many successful attempts have been made to create aptamer-based biosensors in relatively nuclease free systems. One approach employed terminally functionalized thiol group for gold surface binding . Other fThe performance of immunosensors is closely associated to the antigen binding molecules and immobilization approach. While Abs have been increasingly used as detection elements in immunosensors, recent development in antibody derivatives and other alternative binding molecules raise new opportunities and possibilities to create highly stable, efficient, and economically feasible diagnostic device. In this review, a wide range of immobilization strategies are presented for Ab and Ab alternatives and their applications on various nanomaterial surfaces are discussed. Pros and cons of each method are presented. The uniform orientation conferred by site-specific immobilization is essential for small Ab alternatives to retain their binding efficiency.


We report the sequential changes of retinal vessels observed by optical coherence tomography angiography (OCTA) in a case of nonischemic central retinal vein occlusion (CRVO) that converted to ischemic CRVO. An 81-year-old woman visited our Retina Clinic because of visual acuity loss in the left eye. Funduscopic examination showed venous tortuosity and intraretinal hemorrhage in all four quadrants of the fundus. OCT showed macular edema. Fluorescein angiography (FA) and OCTA showed loss of small capillaries. Nonischemic CRVO was diagnosed. Antivascular endothelial growth factor (VEGF) treatment resolved the edema and improved visual acuity. However, during follow-up, capillary dropout was observed on OCTA, which gradually enlarged. Eventually, FA confirmed the conversion to ischemic CRVO. In this case, sequential observations using OCTA showed that nonischemic CRVO did not convert to ischemic CRVO abruptly but occurred stepwise. Additionally, vascular changes began around the veins and blood flow changes were observed more clearly in deep capillary plexus than in superficial capillary plexus. Central retinal vein occlusion (CRVO) is a significant cause of acquired vision loss . CRVO waAn 81-year-old woman was referred to our Retina Clinic because of loss of visual acuity (VA) in the left eye 3 months ago. She had a history of uncontrolled hypertension, hyperlipidemia, and diabetes mellitus. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/30 in the left eye. Funduscopic examination of the left eye showed typical features of nonischemic CRVO, including venous tortuosity and intraretinal hemorrhage in all four quadrants of the fundus. Fluorescein angiography (FA) and OCTA showed loss of small capillaries but nonperfusion areas were not observed, confirming a diagnosis of nonischemic CRVO. Optical coherence tomography (OCT) showed retinal thickening in the fovea with associated inner retinal cysts.  drug aflibercept was initiated. One month later, visual acuity was improved to 20/25 along with gradual normalization of fundus findings associated with CRVO and macular cysts. After one more month OCTA revealed enlargement of the foveal avascular zone and broken foveal capillary ring in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). Color fundus photograph demonstrated cotton wool spots located near the macula ; OCTA reWe performed sequential OCTA observations on a case initially presented with nonischemic CRVO which subsequently converted to ischemic CRVO. OCTA demonstrated capillary dropout occurring preferentially around the vein and these areas gradually enlarged forming avascular lesions. Moreover, OCTA revealed more extensive avascular zones in the DCP than in the SCP. Previous study has also reported that retinal vascular abnormalities in diseases of retinal veins develop more frequently in the DCP than in the SCP . GradualIn conclusion, the present case suggests that conversion to ischemic CRVO starts in the areas around the vein and progresses stepwise rather than abruptly. Moreover, in OCTA study, avascular zones are more readily recognized in the DCP than in the SCP. This is the first report of sequential observations of conversion from nonischemic CRVO to ischemic CRVO using OCTA. Further study of more cases may contribute to elucidation of the mechanism of conversion to ischemic CRVO.


Altered cellular metabolism is considered a hallmark of cancer and is fast becoming an avenue for therapeutic intervention. Mitochondria have recently been viewed as an important cellular compartment that fuels the metabolic demands of cancer cells. Mitochondria are the major source of ATP and metabolites necessary to fulfill the bioenergetics and biosynthetic demands of cancer cells. Furthermore, mitochondria are central to cell death and the main source for generation of reactive oxygen species (ROS). Overall, the growing evidence now suggests that mitochondrial bioenergetics, biogenesis, ROS production, and adaptation to intrinsic oxidative stress are elevated in chronic lymphocytic leukemia (CLL). Hence, recent studies have shown that mitochondrial metabolism could be targeted for cancer therapy. This review focuses the recent advancements in targeting mitochondrial metabolism for the treatment of CLL. A sactivity . CLL cel induce nonclassical cell death that is mitochondrial ROS dependent and facilitated by TCL1 oncogene overexpression [in vitro to therapeutic agents generally used in the treatment of CLL. This also enables a suitable model for mitochondrial targeting in CLL.Increased oxidative stress and altered mitochondrial metabolism in CLL cells are associated with the lymphoid oncogene TCL-1 (T cell leukemia 1). Prinz et al. demonstrated that organometallic nucleosides pression . MCNA inpression . These aDNA crosslinking agents are activated aromatic nitrogen mustards, the ability to crosslink DNA. DNA inter-strand crosslinks are identified as one of principle mechanisms for the cytotoxic effect of many antitumor drugs. These compounds exhibit very powerful crosslinking abilities in the presence of H2O2 and provide a novel strategy for tumor-specific damage. Primary CLL samples were more sensitive (40–80% apoptosis) than non-CLL lymphocytes from healthy donors [ROS inducible y donors . They fuMitochondrial metabolism has only now become of interest in the realm of cancer therapy. CLL is a disease that has many mitochondrial metabolic dependencies. However, the nature of metabolic networks that enable abhorrent cell proliferation, cell-cell communication, evasion of apoptosis, and drug resistance remains poorly understood. The list of therapeutic compounds described in this review implements a strong suggestion that targeting mitochondrial bioenergetics and metabolic alterations may provide a mechanistic explanation for the growth advantage and apoptotic resistance of tumor cells. In CLL patients, standard chemi-immunotherapy and novel targeted agents continue to lead to treatment failures. In order to best target this cancer, a multipronged treatment strategy such as combinations with mitochondrial targeting agents and currently approved treatments may enable a chance at cure for a currently incurable cancer.


Consciousness is often disrupted in epilepsy. This may involve altered responsiveness or changes in awareness of self and subjective experiences. Subcortical arousal systems and paralimbic fronto-parietal association cortices are thought to underpin current concepts of consciousness. The Network Inhibition Hypothesis proposes a common neuroanatomical substrate for impaired consciousness during absence, complex partial and tonic-clonic seizures.Neurostimulation in epilepsy remains in its infancy with vagal nerve stimulation (VNS) as the only firmly established techniqueand a series of other methods under investigation including deep brain stimulation (DBS), intracranial cortical stimulation andrepetitive transcranial magnetic stimulation (rTMS). Many of these systems impact on the neural systems thought to be involvedin consciousness as a continuous duty cycle although some adaptive (seizure triggered) techniques have been developed.Theoretically, fixed duty cycle neurostimulation could have profound effects on responsiveness, awareness of self and subjectiveexperience. Animal studies suggest vagal nerve stimulation positively influences hippocampal long term potentiation. In humans,a chronic effect of increased alertness in VNS implanted subjects and acute effect on memory consolidation have been reportedbut convincing data on either improvements or deterioration in attention and memory is lacking. Thalamic deep brain stimulation(DBS) is perhaps the most interesting neurostimulation technique in the context of consciousness. Neither bilateral anterioror centromedian thalamic nucleus DBS seem to affect cognition. Unilateral globus pallidus internus DBS caused transientwakefulness in an anaesthetised individual.As intracranial neurostimulation, particularly thalamic DBS, becomes more established as a clinical intervention, the effects onconsciousness and cognition with variations in stimulus parameters will need to be studied to understand whether these secondaryeffects of neurostimulation make a significant positive (or adverse) contribution to quality of life.


Since the Korean language has two distinct writing systems, phonogram (Hangul) and ideogram (Hanja: Chinese characters), alexia can present with dissociative disturbances in reading between the two systems. A 74-year-old right-handed man presented with a prominent reading impairment in Hangul with agraphia of both Hangul and Hanja after a left posterior occipital- parietal lesion. He could not recognize single syllable words and nonwords in Hangul, and visual errors were predominant in both Hanja reading and the Korean Boston Naming Test. In addition, he had difficulties in visuoperceptual tests including Judgment of Line Orientation, Hierarchical Navon figures, and complex picture scanning. These findings are consistent with the hypothesis that Hangul reading impairment results from a general visual perceptual deficit. However, this assumption cannot explain why performance on visually complex Hanja was better than performance on visually simple Hanja in our patient. In addition, the patient did not demonstrate higher accuracy on Hanja characters with fewer strokes than on words with more strokes. Thus, we speculate that the left posterior occipital area may be specialized for Hangul letter identification in this patient. This case demonstrates that Hangul-Hanja reading dissociation impairment can occur after occipital-parietal lesions.


Pulmonary vein stenosis is a well-established possible complication following an atrial fibrillation ablation of pulmonary veins. Symptoms of pulmonary vein stenosis range from asymptomatic to severe exertional dyspnea. The number of asymptomatic patients with pulmonary vein stenosis is greater than originally estimated; moreover, only about 22% of severe pulmonary vein stenosis requires intervention. We present a patient with severe postatrial fibrillation (AF) ablation pulmonary vein (PV) stenosis, which was seen on multiple imaging modalities including cardiac computed tomography (CT) angiogram, lung perfusion scan, and pulmonary angiogram. This patient did not have any pulmonary symptoms. Hemodynamic changes within a stenosed pulmonary vein might not reflect the clinical severity of the obstruction if redistribution of pulmonary artery flow occurs. Our patient had an abnormal lung perfusion and ventilation (V/Q) scan, suggesting pulmonary artery blood flow redistribution. The patient ultimately underwent safe repeat atrial fibrillation ablation with successful elimination of arrhythmia. Pulmonary vein stenosis, which occurs in 1% to 3% of cases, is a well-recognized potential complication after radiofrequency (RF) ablation of pulmonary veins. The clinical manifestations of pulmonary vein stenosis vary widely from asymptomatic to severe exertional dyspnea. While these symptoms are primarily affected by the severity and number of affected veins, pulmonary blood flow redistribution is thought to be one of the factors contributing to blunting clinical symptoms after RF ablation of atrial fibrillation (AF) [A 56-year-old male with history of AF, status after ablation, eight years ago at an outside hospital, presented with recurrent AF. Five years after his initial ablation, the patient developed symptomatic palpitations due to atrial fibrillation and he was prescribed flecainide and metoprolol. Despite antiarrhythmic therapy, the patient continued to have symptomatic atrial fibrillation with palpitations but no shortness of breath. The patient was taken for AF ablation. The preablation echocardiogram demonstrated normal ventricular function and pulmonary pressures. The preprocedural computed tomography (CT) scan along with the three-dimensional (3D) reconstruction was done on the procedural table prior to the transeptal puncture but did not pick up the pulmonary vein stenosis. Pulmonary vein potential mapping noted that there was a potential at the ostium of the left superior pulmonary vein. There was also difficulty advancing the catheter into the left superior pulmonary vein due to a possible obstruction. Direct angiography of the left superior pulmonary vein (LSPV) confirmed complete PV stenosis. The procedure was aborted in lieu of further diagnostic work up. A higher resolution cardiac CT angiogram  and leftThe frequency of PV stenosis, a well-established possible complication following an AF ablation of pulmonary veins, has been declining due to the improvement of technique. However, depending on the technique and diagnostic modalities used, PV stenosis occurs as often as 40% of patients who underwent AF ablation . PV stenUltimately, the patient underwent successful repeat atrial fibrillation ablation employing a wide antral circumferential ablation technique with successful resolution of the left superior pulmonary vein. The patient's pacemaker was interrogated six months after ablation and demonstrated successful elimination of atrial fibrillation .We present a patient with severe post-AF ablation PV stenosis without pulmonary symptoms.Our patient's perfusion scan, which demonstrated no perfusion of the affected lung, is suggestive of pulmonary artery blood flow redistribution via pulmonary artery to systemic collaterals. The patient ultimately underwent safe repeat atrial fibrillation ablation with successful elimination of arrhythmia.


Comephorus spp.) represent a highly apomorphic taxon with unique skeletal morphology, soft anatomy, and reproductive ecology. Selection for novel behavior and life history may be evident in genes responsible for organismal energy balance, including those encoding subunits of the electron transport chain. Complete mitochondrial genomes were sequenced for the Big Baikal Oilfish  and Little Baikal Oilfish (Comephorus dybowskii). Mitochondrial genomes encode genes essential for electron transport, and data provided here will complement ongoing investigations of genome-to-phenome maps for teleost respiration and metabolism. Phylogenetic analyses including oilfish mitogenomes and all publicly available cottoid representative sequences are largely concordant with previous studies.Sculpins are predominantly benthic sit-and-wait predators that inhabit marine and freshwaters of the Northern Hemisphere. In striking contrast to riverine relatives, sculpins endemic to Lake Baikal have diversified in both form and function, with multiple taxa having adaptations for pelagic and bathyal niches within the world’s deepest lake. Baikal Oilfishes ( Comephorus baicalensis; Pallas Comephorus dybowskii; Korotneff Comephorus baicalensis is distinguished from C. dybowskii by having greater total length, greater proportional orbit length, shorter proportional pectoral fins, and smaller cephalic pore chambers  was used as a reference sequence. A multiple alignment was conducted with MAFFT version 7 (Katoh and Standley Whole genomic DNA was isolated from fin clips collected from two specimens for each species, and voucher material was retained at the Sandel Laboratory of Aquatic Evolution at UWA. Mitochondrial genomes were generated using traditional Sanger sequencing at the Limnological Institute of the Russian Academy of Sciences and sequencing-by-synthesis on illumina HiSeq at the UAB Heflin Center for Genomic Sciences. Sanger reads were trimmed and aligned with Bioedit 7.0.0 Hall , and HiSCottus mitochondrial genomes (Balakirev et al. MEGA 6 was used to select the optimum nucleotide substitution model and conduct a maximum-likelihood phylogenetic analysis (Tamura et al.


The main goal of this analysis was prioritization of co-expressed genes and miRNAs that are thought to have important influences in the pathogenesis of colon and lung cancers.MicroRNAs (miRNAs) as small and endogenous noncoding RNAs which regulate gene expression by repressing mRNA translation or decreasing stability of mRNAs; they have proven pivotal roles in different types of cancers. Accumulating evidence indicates the role of miRNAs in a wide range of biological processes from oncogenesis and tumor suppressors to contribution to tumor progression. Colon and lung cancers are frequently encountered challenging types of cancers; therefore, exploring trade-off among underlying biological units such as miRNA with mRNAs will probably lead to identification of promising biomarkers involved in these malignancies. Colon cancer and lung cancer expression data were downloaded from Firehose and TCGA databases and varied genes extracted by DCGL software were subjected to build two gene regulatory networks by parmigene R package. Afterwards, a network-driven integrative analysis was performed to explore prognosticates genes, miRNAs and underlying pathways. A total of 192 differentially expressed miRNAs and their target genes within gene regulatory networks were derived by ARACNE algorithm. BTF3, TP53, MYC, CALR, NEM2, miR-29b-3p and miR-145 were identified as bottleneck nodes and enriched via biological gene ontology (GO) terms and pathways chiefly in biosynthesis and signaling pathways by further screening.  Our study uncovered correlated alterations in gene expression that may relate with colon and lung cancers and highlighted the potent common biomarker candidates for the two diseases. The complex molecular interactions underlying cancers warrant identification of biological entities like miRNAs as well as the crosstalk between different cancers. Colon cancer is a fatal malignancy with estimated 1.4 million cases yearly  that canData acquisition and pre-processing In the present article, colon cancer gene expression dataset generated by Illuminaga_RNASeqV2 containing 192 normal and cancer samples and 20532 genes was chosen from Firehose (https://confluence.broadinstitute.org/display/GDAC/Home). For the miRNA expression profiling data, lung cancer Illumina HiSeq included 231 normal and cancer samples and 1045 genes were retrieved from TCGA (https://www.synapse.org/#!Synapse:syn300013/wiki/27406). The expression values of miRNAs and mRNAs were subjected to expression Based filter and variance Based filter functions implemented in DCGL v2.0 R package  to filteIn silico analysis and networking Predicted gene-miRNA interactions were collected from miRWalk 2.0 server  based on miRBase database. Regarding the mRNAs, only the miRNAs target genes were retrieved by miRWalk from colon cancer transcripts. Afterwards, two independent gene regulatory networks were built using unique miRNAs and their target genes using arcana function with eps=0.05 implemented in parmigene R package . Next, gGene Ontology analysis and visualization To find the significantly over-represented biological GO terms and functions of gene products within regulatory network mRNAs, functional classification was performed using BINGO Cytoscape plugin  running In order to study the functional roles of miRNA and their targets in biological pathways, pathway analysis was performed using PANTHER  and mirPath v.3 (http://snf-515788.vm.okeanos.grnet.gr/), respectively. Building miRNA-mRNA interaction networksThe 192 most variable miRNAs and target transcripts extracted from lung and colon cancer data were subjected to build two independent interaction networks by ARACNE algorithm implemented in parmigene software (setting epsilon to 0.05). Information-theoretic approaches like ARACNE  have beeAs shown in Exploring miRNA–TF–mRNA network The 192 miRNA variable transcripts of lung cancer data targeted 13711 validated genes based on miRWalk server. We then intersected between these 13711 targets and the most variable mRNAs in colon cancer data extracted from DCGL R package. As the parmigene method demands orthogonal matrices for inferring co-expression network, we then processed further with two matrices of miRNAs and mRNAs both including 192 samples and genes. Degree distribution and following motif discovery  and receThe crossroads among the screened miRNAs, genes and TFs was illustrated in GO and pathway functional enrichment analysisAs shown in By representing the molecular interactions underlying biological processes, network biology paves the path to drug discovery, better understanding of diseases mechanism and cancer therapeutics -37. miRNWe aimed to explore biomarkers underlying both colon and lung cancers ;therefore, in the frame of network mining methods and topology feature analysis, a small number of putative genes, miRNAs and transcription factors were explored whose interplays are probably related to colon and lung cancers. An expected outcome of such a work would possibly identify crosstalk of miRNAs and genes in tumorigenesis in different tissues and more evidence for cancer diagnosis and treatment. In the present study, NGS data was chosen over microarray because: I) this technique provides more sensitive detection of transcripts, which is likely to be the reason for the ability of NGS data to detect low expressed genes while microarrays fail to differentiate between very low expressed and non-expressed genes ; II) accHowever, this analysis is challenged by some limitations. Firstly, despite well-demonstrated roles of miRNAs in regulating multiples target genes involved in different oncogenic pathways in cancers, we should be cautious about the fact that each miRNA could potentially target hundreds of genes. Therefore, we need a deeper understanding of miRNA biology and undeniable role of experimental practices to improve fidelity of bioinformatics results. Next, evidently from ontology analysis, target genes could barely provide a clear biological finding; therefore, research works addressing validating miRNA sites within mRNAs will decrease the ambiguity in defining regulatory interactions among miRNAs-targets. Furthermore, we inferred information-theoretic based undirected networks while connectivity between nodes does not mean the causal relationships; we then should be cautious about dynamic nature of cancers via strict analysis of statics networks. Additionally, it is essential to remove overestimated regulation dependencies by employing more sophisticated gene regulatory inference algorithms. Finally, network analysis at transcriptome level could be more intensified through merging studies with protein networks to draw more practical conclusions.It is concluded that utilizing dual information of miRNAs and mRNAs in cancers trade-off can help to discover important findings to identify underlying mechanisms and enlighten more molecular underpinnings of different cancers. We observed that the identified miRNAs-mRNA covered a wide range of known functions, mainly signaling pathways and biosynthesis implicated in colon and lung cancers.To summarize, conserved miRNAs and TFs like miR-195, miR-145, BTF3, Myc and TP53 with their targets could be considered as hallmark genes for future diagnosis and therapeutic researches where their rules could be confirmed by experiments.Utilizing dual information of miRNAs and mRNAs in cancers trade-off can help to discover important findings to identify underlying mechanisms and enlighten more molecular underpinnings of different cancers. We observed that the identified miRNAs-mRNA covered a wide range of known functions, mainly signaling pathways and biosynthesis implicated in colon and lung cancers.To summarize, conserved miRNAs and TFs like miR-195, miR-145, BTF3, Myc and TP53 with their targets could be considered as hallmark genes for future diagnosis and therapeutic researches where their rules could be confirmed by experiments.


Human learning and memory evaluation in real-life situations remains difficult due to uncontrolled variables. Buenos Aires waiters, who memorize all the orders without written support, were evaluated in situ. Waiters received either eight different orders and customers remained seated in their original locations (OL), or changed locations (CL). Match between orders, subjects and location was decreased only in CL. Waiters’ feature/location strategy links client with position at the table and beverage later. The hypothesis we raise is that memory-schemas link working memory to long-term memory networks through rapid encoding, making the information resistant to interference and enabling its fast retrieval if necessary cues are present.


Lower extremity trauma during earthquakes accounts for the largest burden of geophysical disaster-related injuries. Insufficient pain management is common in disaster settings, and regional anesthesia (RA) has the potential to reduce pain in injured patients beyond current standards. To date, no prospective research has evaluated the use of RA in a disaster setting. This cross-sectional study assesses knowledge translation and skill acquisition outcomes for lower extremity RA performed with and without ultrasound guidance among a cohort of Médecins Sans Frontières (MSF) volunteers who will function as proceduralists in a planned randomized controlled trial evaluating the efficacy of RA for pain management in an earthquake setting.Background:Generalist humanitarian healthcare responders, including both physicians and nurses, were trained in ultrasound guided femoral nerve block (USGFNB) and landmark guided fascia iliaca compartment block (LGFICB) techniques using didactic sessions and interactive simulations during a one-day focused course. Outcome measures evaluated interval knowledge attainment and technical proficiency in performing the RA procedures. Knowledge attainment was assessed via pre- and post-test evaluations and procedural proficiency was evaluated through monitored simulations, with performance of critical actions graded by two independent observers.Methods:Twelve humanitarian response providers were enrolled and completed the trainings and assessments. Knowledge scores significantly increased from a mean pre-test score of 79% to post-test score of 88% (p<0.001). In practical evaluation of the LGFICB, participants correctly performed a median of 15.0 (Interquartile Range (IQR) 14.0-16.0) out of 16 critical actions. For the USGFNB, the median score was also 15.0 (IQR 14.0-16.0) out of 16 critical actions. Inter-rater reliability for completion of critical actions was excellent, with inter-rater agreement of 83.3% and 91.7% for the LGFICB and USGFNB evaluations, respectively.Results:Prior to conducting a trial of RA in a disaster setting, providers need to gain understanding and skills necessary to perform the interventions. This evaluation demonstrated attainment of high knowledge and technical skill scores in both physicians and nurses after a brief training in regional anesthesia techniques. This study demonstrates the feasibility of rapidly training generalist humanitarian responders to provide both LGFICB and USGFNB during humanitarian emergencies.Discussion: Among geophysical disasters, earthquakes result in high mortality rates and account for the largest burden of injuries,,,,,,,,Prior studies have demonstrated that regional anesthesia (RA) is a rapid and safe method for reducing pain caused by lower extremity trauma, and as such may have a role in improving pain management during the acute response phase of a major earthquake,,,,,The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study is randomized controlled trial (RCT) that will be carried out in the immediate aftermath of a major earthquake to determine whether RA provided by generalist humanitarian medical responders, either with or without ultrasound-guidance, can improve pain treatment for lower limb injuries, above current standards of careEthicsThe RAPID study has received ethical approval from the Médecins Sans Frontières Ethical Review Board (Reference number: 1524) and has been preregistered at ClinicalTrials.gov (number: NCT02698228)Study Design Setting and PopulationThis cross-sectional study was designed to evaluate the efficacy of a focused training in regional anesthesia for lower extremity injuries provided to MSF volunteers who will serve as research proceduralists in a future RCT of RA for pain management in earthquake victimsThe study population was comprised of physician and nurse responders who had previously been deployed to humanitarian emergencies and were members of the MSF-USA association. Participants were made aware of the RAPID study and training prior to the meeting via digital correspondence with study investigators and were solicited to volunteer for participation.Participant Training and AssessmentTraining activities were designed to provide understanding of RA principles and competence in performing landmark guided fascia iliaca compartment blocks (LGFICB) and ultrasound-guided femoral nerve blocks (USGFNB). Study throughput is outlined in Following the initial assessment, participants took part in a three-hour interactive didactic session lead by study investigators using a semi-structured discussion platform that allowed for open-form content exchange between all participants. The educational information focused on RA principles and specific methodologies in performing LGFICB and USGFNBAfter completion of training activities, each participant was assessed through two observed simulation exams for performance of the LGFICB and the USGFNB. In each exam, participants were asked to perform the RA techniques using standard clinical equipment and a femoral regional anesthesia ultrasound model . During the simulation exams, two independent reviewers assessed each participant’s technical competency using a preformed critical actions checklist with an objective scoring system. Assessed parameters evaluated appropriate positioning; identification of anatomic and ultrasonographic landmarks; use of sterile technique; provision of local superficial anesthetic; needle delivery; anesthetic injection; and proper procedural monitoring for possible adverse events.A post-training, fifteen question multiple-choice exam was performed to assess interval knowledge attainment. In the post-training assessment, participants were crossed-over to complete the alternative exam to the one they took at baseline .Data Collection Outcome MeasuresBaseline data on participants was collected using a structured questionnaire. Information on demographics, healthcare training, humanitarian response activities, ultrasound and RA experience was gathered. Knowledge assessment exams were scored with a single best answer for each question and participants were assigned a percent correct for both the pre-test and post-test. During observed simulation exams for the RA techniques, each rater provided a critical action completion score ranging from zero to sixteen based on eight assessment parameters. Accrued data was de-identified and entered into a password-protected database that was accessible only by study personnel.The primary outcome measures were the change in knowledge attainment based on mean pre- and post-test scores on the standardized exams and demonstration of technical competency in performing the LGFICB and USGFNB RA techniques. Technical competency was assessed based on adequate performance of critical actions during simulation assessments. Secondary outcome measures included the inter-rater reliability for the standardized critical action checklist and separate subgroup analyses of physician and nurses.Statistical AnalysisStatistical analyses were performed using STATA 13.0 . Characteristics of the cohort were evaluated using descriptive methods. Categorical variables were explored using frequencies with percentages, and continuous variables were analyzed using medians with corresponding interquartile ranges (IQR) or means with associated 95% confidence intervals (95% CI). Given the small sample size knowledge attainment data was analyzed using Shapiro-Wilks tests and frequency distributions to evaluate for normality. The results were found to satisfy criteria for normality and as such, one sample paired t-tests were used for the primary outcome of change in mean knowledge scores. A p value less than 0.05 was considered significant in primary outcome assessments.,Median scores with IQR for each rater were calculated for the LGFICB and USGFNB simulation assessments. Inter-rater reliability (IRR) was evaluated across all critical assessment variables based on rater agreement derived using Cohen’s kappa calculation. Kappa values were interpreted according to previously utilized criteria with agreement classified as greater than 0.80 as representing excellent IRRTwelve MSF association members were enrolled and all participants completed the full study training and assessment procedures. The median age of the cohort was 41 years and the majority of participants were female. Half of participants reported their primary healthcare training as nurse and half as physician. The median years of healthcare practice and humanitarian response experience were eleven and five years respectively. Half of the cohort had prior experience with ultrasound use, though only a minority reported previous clinical application of RA techniques  .The primary study outcomes are summarized in This study assessed knowledge translation and skill acquisition outcomes for simulated lower extremity RA performed both with and without ultrasound guidance among a small cohort of MSF volunteers who will function as proceduralists in a planned randomized controlled trial that will assess the efficacy of RA for pain management in the acute phase of a major earthquake,,,,,,,,,In the acute response phase to a natural disaster, where resources are often constrained, oligoanalgesia is common,,,Standardized assessment and training in research procedures is important in reducing error and deriving valid trial results,,,Although prior studies have assessed the performance of femoral never blockades after brief trainings in emergency department settings among physician and nurse trainees this study is the first to evaluate formal training of generalist humanitarian response providers in RA methodsThis work must be interpreted in the context of certain limitations. The presented results illustrate short-term acquisition of knowledge and skills among the MSF volunteers trained, but do not allow for assessment of application in actual disaster situations, nor for evaluation of skill retention over time. It is likely that similar to most technical skill sets, the study proceduralists will require refresher training prior to execution of the RAPID study, which has been built into the trial design. Although the population of humanitarian responders was drawn from a large pool of MSF volunteer personnel, the cohort was relatively small and not randomly selected, and as such the generalizability of these outcomes to the greater population of disaster healthcare personnel is not certain. During completion of the RAPID study this will be partially addressed, as there will be further onsite training for locally recruited healthcare providers, who will also serve as proceduralists during the later study phases. These later phase providers will be trained and assessed onsite using the same methods as described in this report.Prior to conducting a trial of RA in a disaster setting, providers need to gain the knowledge and skills necessary to perform the interventions. This study demonstrated high knowledge and technical skills scores with excellent inter-rater agreement between independent evaluators, illustrating the success of the focused training for generalist humanitarian response providers in the selected RA techniques. This work, in conjunction with the planned RAPID study, will contribute to the development of an enhanced evidence base to guide future care and improve health outcomes among high-risk patients injured in the settings of humanitarian emergencies.The data used for this analysis can be accessed via: https://figshare.com/s/1825267cbf21863b6cf4.All authors declare that they have no competing interests to disclose.Adam R. Aluisio, MD, MScWarren Alpert School of Medicine, Brown University, Department of Emergency Medicine55 Claverick Street, Room 274Providence, Rhode Island 02912, USAEmail: adam.aluisio@gmail.comCRED: Centre for Research on the Epidemiology of DisastersFICB: Fascia iliaca compartment blockFNB: Femoral nerve blockIQR: Interquartile RangeIRR: Inter-rater reliabilityLG: Landmark guidedLGFICB: Landmark guided fascia iliaca compartment blockLMIC: low- and middle-income countriesMoH: Ministry of HealthMSF: Médecins Sans FrontièresRA: Regional anesthesiaRCT: Randomized Controlled TrialSAE: Serious Adverse EventsSD: Standard DeviationUS: UltrasoundUSG: Ultrasound guidedUSGFNB: Ultrasound guided femoral nerve blockWHO: World Health Organization


The circadian clock underpins most physiological conditions and provides a temporal dimension to our understanding of body and tissue homeostasis. Disruptions of circadian rhythms have been associated with many diseases, including metabolic disorders and cancer. Recent literature highlights a role for the circadian clock to regulate innate and adaptive immune functions that may prime the host response to infectious organisms. Viruses are obligate parasites that rely on host cell synthesis machinery for their own replication, survival and dissemination. Here, we review key findings on how circadian rhythms impact viral infection and how viruses modulate molecular clocks to facilitate their own replication. This emerging area of viral-clock biology research provides a fertile ground for discovering novel anti-viral targets and optimizing immune-based therapies. Circadian rhythms are autonomous, self-sustaining, 24-h oscillations that synchronise physiological processes, such as sleep–wake cycles, hormone release, cell regeneration, fluctuations in body temperature and metabolism, to external environmental cues. These rhythmic processes are controlled by the circadian timekeeping system that consists of a central circadian clock located in the suprachiasmatic nucleus (SCN) that links to a network of peripheral clocks located in every tissue Fig. . The mamBMAL1 is a key component of the circadian clock ; mice deMany aspects of the innate and adaptive immune systems are under circadian control , 10. To Inflammatory lung diseases frequently show time-of-day variation in their severity, and a recent study from Gibbs and colleagues  showed t. To assess the functional consequences of this observation, the authors immunised mice with ovalbumin and TLR9 ligand (CpG ODNs) adjuvant at various times of day. Vaccination at the time of increased TLR9 expression (ZT19) resulted in a greater immune response to ovalbumin, and this phenotype was lost in PER2 deficient mice. These observations are consistent with emerging evidence showing a role for the circadian clock to regulate host defences against bacterial pathogens [In addition to regulating host immunity to viral infections, the efficacy of viral vaccination has been reported to be under circadian control in rodents and humans. Silver et al. reported that expression of pattern recognition receptor Toll-like receptor 9 (TLR9) that recognises bacterial and viral DNA is circadian regulated . To asseathogens  and suggPhillips et al. showed that patients immunised in the morning developed greater antibody responses to both hepatitis A and influenza vaccines . More reThe liver is one of the most circadian-regulated organs with 20% of genes showing circadian patterns of expression . Benegiabmal1-/- mice. Importantly, both studies confirmed an anti-viral role for BMAL1 using in vitro viral replication models that lack systemic circadian cues or host defenses, supporting a model where BMAL1 regulates cellular factors that are essential for viral replication. A comprehensive proteomic analysis of wild type and bmal1-/- primary cells revealed an enrichment of proteins involved in protein biosynthesis, endoplasmic reticulum function and intracellular vesicle trafficking [Bmal1 shows seasonal variation in human blood samples with the lowest levels observed during the winter months [Two recent studies report increased replication of herpes, influenza , respirafficking ; all patr months  coincidir months .Herpes simplex virus (HSV) is a DNA virus whose gene expression is limited by histone deacetylation. CLOCK can function as a histone acetyltransferase, and Kalamkovi et al. reported that HSV hijacks this clock repressor to facilitate transcription of viral genes, where depletion or silencing CLOCK reduced viral protein expression , 31. TheGlucocorticoids (GCs) regulate carbohydrate, lipid and protein metabolism and are widely used as anti-inflammatory agents. GCs are secreted from the adrenal gland in a rhythmic circadian fashion, and their peak expression coincides with the onset of the active phase, suggesting a role in synchronizing signals between the SCN and peripheral tissues. GCs regulate gene transcription by activating the glucocorticoid receptor that binds GC response elements (GRE) in target gene promoters . Of noteWhile individual molecular circadian components have been reported to modulate viral infection, melatonin, a potent regulator of the circadian rhythm secreted by the pineal gland  exhibitsA growing awareness of ‘circadian disruption’-associated pathologies, such as a high risk of cancer in shift workers, highlights the potential for this pathway to be deregulated in viral-associated cancers –44. Yang+ T-lymphocytes between the morning and evening coinciding with changes in the circadian pattern of serum cortisol levels [Human Immunodeficiency Virus (HIV) infection has been associated with the disruption of circadian-regulated physiological processes, including a blunting of systolic blood pressure decline from day to night . Malone l levels . To undel levels . Furtherl levels , 54.Studies with Simian Immunodeficiency Virus (SIV) reported perturbation of several circadian parameters of body temperature and activity parameters, where the amplitude of temperature and locomotor activity was significantly reduced . The autOther viral infections have been reported to influence circadian rhythms. Coxsackievirus A16 (CVA16) is one of the major causes of hand, foot and mouth disease, and transcriptomic analysis of infected human embryonic kidney cells identified differentially expressed miRNA target genes involved in circadian rhythm pathways, providing some insights into CAV16 induced pathogenesis . Human TAedes aegypti mosquito acts as a carrier for many viral infections such as dengue fever and Zika virus. Lima-Camara et al. reported that dengue virus infection increased the amplitude of rhythmic locomotor activity in the mosquito and speculated this would increase the vector’s capacity to transmit virus [Culicoides biting midges that are vectors for African horse sickness and Bluetongue virus [A. aegypti, circadian regulators may provide new therapeutic targets [Circadian rhythms are likely to impact viral transmission especially if one considers zoonoses where multiple species can act as viral reservoirs Fig. . For patit virus . This ciue virus . Conside targets .Given the interplay between virus and the host circadian mechanism, host susceptibility to infection or disease is not only dependent on the infectivity of the viral inoculum, transmission route and length of exposure, but on the time of day when the pathogen is encountered. Understanding how viruses interact with host circadian rhythms has the potential to influence the treatment and clinical management of viral infections. In terms of circadian modulating therapies for treating or preventing viral infections, this could involve both pharmacotherapy and chronotherapy. Thus, it is possible that the efficacy of current anti-viral therapies could be improved by altering the time of drug administration. Recent advances in T cell engineering therapies show promising results using T cell receptor (TCR) or chimeric antigen receptor engineered T cells targeted against human viral antigens –67. InteHow do viruses engage with the molecular clockwork and modulate timekeeping? The discovery that the transcriptional clock mechanism is universal and exists in essentially every cell of the body highlights the potential of these TFs to regulate host susceptibility to viral infection directly via binding viral DNA genomes or indirectly via controlling host gene expression Fig. . The rep


These data show that cigarette smoke exposure decreases in vivo MSC and HSC number and also increases pro-proliferative gene expression by cigarette smoke-exposed MSCs, which may stimulate HSPC expansion. These results of this investigation are clinically relevant to both bone marrow donors with a history of smoking and bone marrow transplant (BMT) recipients with a history of smoking.Effects of tobacco smoke on hematologic derangements have received little attention. This study employed a mouse model of cigarette smoke exposure to explore the effects on bone marrow niche function. While lung cancer is the most widely studied consequence of tobacco smoke exposure, other malignancies, including leukemia, are associated with tobacco smoke exposure. Animals received cigarette smoke exposure for 6 h/day, 5 days/week for 9 months. Results reveal that the hematopoietic stem and progenitor cell (HSPC) pool size is reduced by cigarette smoke exposure. We next examined the effect of cigarette smoke exposure on one supporting cell type of the niche, the mesenchymal stromal cells (MSCs). Smoke exposure decreased the number of MSCs. Transplantation of naïve HSPCs into irradiated mice with cigarette smoke exposure yielded fewer numbers of engrafted HSPCs. This result suggests that smoke-exposed mice possess dysfunctional niches, resulting in abnormal hematopoiesis. Co-culture experiments using MSCs isolated from control or cigarette smoke-exposed mice with naïve HSPCs  While pulmonary disorders are the most obvious manifestation of cigarette smoke-induced disease, there is a growing appreciation that smoking and chronic lung disease are associated with significant systemic consequences and comorbidities. Distal organ and tissue injury, linked to systemic inflammation and oxidative stress, commonly result in skeletal myopathy, cardiovascular disease, osteoporosis, depression and metabolic derangement.Stem and progenitor cells play a pivotal role in tissue maintenance and repair in response to injury, and it has been proposed that resident and/or hematopoietic progenitor cell perturbations may be pathogenic in smoking-related emphysema . Further+ cytotoxic T cell lymphocytosis and neutrophilia. BrdU labeling studies show decreased transit time through the post-mitotic pool of the bone marrow, consistent with chronic stimulation of hematopoiesis .,33.18,33These data support our hypothesis that hematologic changes in cigarette smokers are caused by damage to niche cells, specifically MSCs and their progeny. We have shown that smoke exposure decreased HSPC pool size and concomitantly deceased MSC number. The decreased number of MSCs corresponded to a decrease in naïve HSPC engraftment after bone marrow transplantation in smoke-exposed animals. In spite of this decrease in engraftment and number of HSPCs and MSCs, smoke exposure also altered MSC gene expression of pro-proliferative signaling proteins. Our data thus suggest that smoke exposure leads to dysregulation of hematopoiesis through disruption of MSC signaling pathways in addition to decreasing MSC number. This may serve as one mechanism by which smoke exposure promotes greater peripheral leukocyte production in cigarette smokers. These data also offer potential targets of therapeutic intervention with regards to both bone marrow donor and transplant recipient with a history of cigarette smoke exposure.


Aortic valve replacement is the second most common cardiothoracic procedure in the UK. With an ageing population, there are an increasing number of patients with prosthetic valves that require follow-up. Imaging of prosthetic valves is challenging with conventional echocardiographic techniques making early detection of valve dysfunction or complications difficult. CT has recently emerged as a complementary approach offering excellent spatial resolution and the ability to identify a range of aortic valve replacement complications including structural valve dysfunction, thrombus development, pannus formation and prosthetic valve infective endocarditis. This review discusses each and how CT might be incorporated into a multimodal cardiovascular imaging pathway for the assessment of aortic valve replacements and in guiding clinical management. The utility of cardiac CT for the assessment of possible aortic valve replacement dysfunction has risen rapidly over the past 10 years following a similar, albeit delayed, trajectory to CT coronary imaging. It can be used to assess mechanical and bioprosthetic valves inserted surgically as well valves inserted using transcutaneous aortic valve implantation (TAVI). Clinicians familiar with both cardiac CT and valvular heart disease have identified a number of specific situations where CT can help in the assessment of possible aortic valve replacement dysfunction by providing complementary diagnostic information to transthoracic echocardiography, transoesophageal echocardiography and cardiac MR. These include the identification of pannus formation, thrombus, premature bioprosthetic leaflet degeneration, assessment of bileaflet mechanical valve leaflet motion and aortic root abscess formation. While the role of cardiac CT is relatively new in this setting, its use is steadily expanding across the world, with many experienced centres now using it routinely. This article evaluates the evidence in support of cardiac CT imaging for the detection of possible aortic valve replacement dysfunction and aims to prompt clinicians to consider it in specific clinical scenarios.Selecting the appropriate prosthetic heart valve has traditionally been a difficult decision for many patients undergoing surgical aortic valve replacement. However, recent advances in bioprosthetic valve design, coupled with an ageing population, have witnessed increasing use of these valves in preference to metallic valves. With the recent addition of TAVI, the number of patients with functioning bioprostheses is only set to expand further. Surveillance of bioprosthesis function, looking for evidence of valve degeneration, forms an integral part of the long-term management of patients with these valves and a substantial healthcare burden.Structural valve dysfunction can have catastrophic consequences, yet its underlying pathophysiology remains incompletely understood. The term structural valve dysfunction encompasses intrinsic functional changes to the valve leaflets including retraction or tearing, progressive stenosis and disruption of the annular housing or sewing ring. The principal pathological driver behind this degeneration and eventual failure appears to be leaflet calcification. This most commonly results in valvular regurgitation due to tearing of the leaflets but may also cause increasing valve stiffness, restenosis and peripheral embolism.The mechanisms driving prosthetic valve calcification are incompletely understood with several different processes having been implicated.While large-scale clinical trials are currently lacking, the requirement for improved assessment of bioprosthetic valve calcification was recently illustrated in the case of severe bioprosthetic valve obstruction in a 13-year-old girl who died suddenly just 23 months after implantation of a bovine pericardial aortic bioprosthesis.et alOne of the major advantages biological prosthetic heart valves have over mechanical alternatives is the lack of a requirement for long-term anticoagulant use. During bioprosthesis endothelialisation, in the first 3 months after implantation, thrombus formation can occur in 0.8–4.0% of cases.et alLeetmaa In light of the asymptomatic presentation of cusp thrombosis that occurs in spite of dual-antiplatelet therapy, important questions have been raised regarding the clinical relevance of hypoattenuated thickening and whether CT may more appropriately stratify antithrombotic therapy following transcatheter valve implantation. Importantly, the clinical significance of HALT has not been validated beyond these observational studies and the recent publication of low 30-day stroke rates following TAVI suggests that the presence of this finding does not always translate into significant thromboembolic events.Imaging of mechanical prosthetic valves has traditionally been performed using transthoracic echocardiography, transoesophageal echocardiography and fluoroscopy.Acquired mechanical prosthetic valve obstruction (PVO) is an uncommon but serious and potentially fatal complication of valve replacement.30Cardiac CT in suspected acquired mechanical PVO enables evaluation of leaflet opening and closing angles, dynamic leaflet motion and the composition of perivalvular masses valve helping to differentiate between valve thrombosis and pannus formation.33Prosthetic valve infective endocarditis carries a very high in-hospital mortality rate of 20–40%.37While the temporal resolution of echocardiography often means that highly mobile vegetations are better visualised on echocardiography, large prosthetic valve vegetations can be readily seen on CT as microlobulated, hypoattenuating lesions attached to the leaflets or sewing ring.35et alIn 2014, Ghersin 2.40Multiple factors can affect image quality when assessing mechanical aortic valve prostheses using CT, in particular the presence of cardiac arrhythmia and older prosthetic valve types.Based on current practice in experienced valve centres, we suggest that CT should be performed as an anatomical assessment following transthoracic echocardiography in patients with suspected prosthetic aortic valve dysfunction  and 5. TThe diagnosis and management of aortic valve replacement dysfunction remains a significant clinical challenge. Cardiac CT provides complementary assessments of these valves allowing detection of structural dysfunction, leaflet calcification, thickening, thrombus and pannus formation. This can help to stratify downstream management and clinical decision-making as part of multimodality imaging approach.


In utero exposure to infections is associated with adverse neurocognitive outcomes in the offspring. Elevated maternal prenatal serum inflammatory markers, such as C-reactive protein (CRP), have been associated with increased risks of neurodevelopmental disorders, including schizophrenia, later in life. The objective of this study is to investigate the associations between elevated serum concentrations of CRP in early gestation, prospectively assayed in maternal sera, and adolescent psychotic experiences and academic performance. We hypothesised that elevated maternal CRP is associated with adolescent psychotic experiences and poorer academic performance.Using data from the Northern Finland Birth Cohort 1986 (NFBC1986), a prospective birth cohort including data since before birth, we examined the association between maternal CRP levels in early gestation  and adolescent psychotic experiences  and poorer academic performance , controlling for sex and maternal education level using multivariable regression analysis. Prior to analyses we determined there was sufficient power to detect small associations (OR>1.68) for these variables.After controlling for sex and maternal education, those in the highest tertile of prenatal maternal CRP had increased odds of auditory hallucinations (on the PROD-screen) at age 16 years , and poorer school academic performance .Maternal prenatal immune activation is associated with neurodevelopmental outcomes in adolescent offspring. This work extends previous findings regarding prenatal/childhood immune activation and clinical psychiatric diagnoses in adult offspring.


Salmonella enterica subsp. enterica serovar Poona strain ATCC BAA-1673. We employed in silico bioinformatics tools to subtract the strain-specific paralogous and host-specific homologous sequences from the bacterial proteome. The sorted proteome was further refined to identify the essential genes in the pathogenic bacterium using the database of essential genes (DEG). We carried out metabolic pathway and subcellular location analysis of the essential proteins of the pathogen to elucidate the involvement of these proteins in important cellular processes. We found 52 unique essential proteins in the target proteome that could be utilized as novel targets to design newer drugs. Further, we investigated these proteins in the DrugBank databases and 11 of the unique essential proteins showed druggability according to the FDA approved drug bank databases with diverse broad-spectrum property. Molecular docking analyses of the novel druggable targets with the drugs were carried out by AutoDock Vina option based on scoring functions. The results showed promising candidates for novel drugs against Salmonella infections. The emergence of novel pathogenic strains with increased antibacterial resistance patterns poses a significant threat to the management of infectious diseases. In this study, we aimed at utilizing the subtractive genomic approach to identify novel drug targets against Salmonella enterica subsp. enterica serovar Poona str. ATCC BAA-1673 using the subtractive genomics approach.Recent progress in the field of computational biology and bioinformatics has generated various in silico analysis and drug designing approaches, eliminating the time and cost involved in the trial and error experimentations that go into drug development . These mSalmonella enterica subsp. enterica serovar Poona str. ATCC BAA-1673 is a potent food-borne pathogen in humans  N-acetyl-glucosamine-deacetylase and 3-deoxy-manno-octulosonate cytidylyltransferase (CMP-KDO synthetase) are associated with lipopolysaccharide biosynthesis pathway. Phosphate regulon response regulator OmpR, nitrogen regulation sensor histidine kinase GlnL, and response regulator CheB are associated with two-component system pathway. LPS is composed of a conserved core oligosaccharide, lipid A, linked to a variable O-antigen in the cell membrane of the Gram-negative bacteria, thus providing outer membrane stability [ Salmonella Poona have developed pathways that attribute resistance to CAMP [The proteins in tability . Drug th to CAMP , 20. Met to CAMP , 18. ThuThe current study was further reinforced by performing comparative docking studies of the novel druggable proteins with the ligands. Binding affinities from docking were compared between our target proteins and intended targets from other species against the corresponding drug. The shortlisted potential drug targets showed a pattern of similar binding characteristics, similar residues involved in the active site, and lower free energy –7. Thus, Salmonella Poona system. Among these, 11 proteins were already highly identical with the FDA approved drug targets. 6 proteins were proposed as novel drug targets to combat against Salmonella Poona which showed moderate similarity (65–30%) with the targets of FDA approved drugs that were used against other organisms. Furthermore, docking studies were used to predict the binding of existing FDA approved drugs to the novel targets within the proteome of the pathogen and also with the drug-specific FDA approved database target to compare the binding pattern between them.The vast array of information regarding the proteomes and genomes of various prokaryotic organisms and knowledge obtained from the human genome project can be manipulated to accelerate drug designing and gain further knowledge of pharmacogenomics in the treatment of bacterial infections. Subtractive genomics can aid in the identification of proteins targeted by existing FDA approved targets. A total of 52 potential targets were found within the


Dear SirAlimentary tract duplications are epithelial-lined cystic or tubular structures attached to bowel wall and supplied by mesenteric vessels. Association between intestinal malrotation and duplication cyst, especially of jejunal location is rarely mentioned in literature[1-5]. We are reporting a rare coexistence of isolated jejunal duplication cyst and malrotation in a neonate with intestinal obstruction.A 15-day-old male neonate was brought to emergency for multiple episodes of bilious vomiting. The baby was born full-term by spontaneous vaginal delivery at home and antenatal ultrasonography(USG) was not done. At presentation, he was 2500 gm, moderately dehydrated, pulse 160/min and respiratory rate was 46/min. Resuscitation was started immediately and the nasogastric tube inserted. Abdomen was soft, non-tender and a mobile mass was palpable in left upper abdomen. Plain X-ray abdomen showed distended stomach and duodenum. Rest of the abdomen was gasless, but there was presence of rectal gas in pelvis . USG revealed a well defined thick walled cystic lesion in left mid abdomen measuring 42х37mm suggestive of duplication cyst . Doppler imaging showed "Whirlpool sign" in epigastric region with superior mesenteric vein (SMV) curving from right to left of superior mesenteric artery (SMA) suggesting midgut malrotation . At surgery, a non-communicating jejunal duplication cyst, intimately adherent to jejunal wall and compressing the intestinal lumen was found . Malrotation was also present which was corrected. Duplication cyst was excised along with a portion of adjoining jejunum. End-to-end jejunal anastomosis was done. Postoperative period was uneventful. Combination of enteric duplication and intestinal malrotation is a rare entity and may present as an acute surgical emergency [1-5]. Gastric and duodenal distension on plain X-ray of abdomen is suggestive of duodenal obstruction. The presence of rectal gas in addition to dilated stomach and duodenum will commonly point towards partial duodenal obstruction. This can occur in malrotation due to compression of distal duodenum by Ladd's bands [3]. Similarly our preoperative suspicion was malrotation on plain X-ray abdomen. Color Doppler imaging showing Whirlpool flow pattern of SMV around SMA is suggestive of midgut malrotation. Ultrasonography is very reliable in diagnosing duplication cysts.It will show an inner hyperechoic rim of mucosa-submucosa and an outer hypoechoic rim of muscular layer [2]. Duplication cysts are thick walled because it is composed of smooth muscle and mucosa as opposed to other types of cysts such as mesenteric and omental cysts. Our preoperative diagnosis coincided with operative findings.Surgical removal of duplication cyst preserving normal bowel is possible in some cases, but is extremely difficult [1]. Resection of duplication with the native bowel is the usual procedure due to common blood supply . This case represents a rare coexistence of two congenital malformations of GIT. Ultrasonography is very helpful in detecting both duplication cyst and malrotation.Source of Support: NilConflict of Interest: None


Neurodegenerative disorders, such as Alzheimer’s disease (AD), are associated with characteristic patterns of neuropathological spread in the brain. Disease progression is usually accompanied by regional atrophy that can be detected noninvasively using structural magnetic resonance imaging (MRI). A wealth of data has demonstrated the value of quantitative measurements of regional atrophy in AD, suggesting that volumetric MRI (vMRI) may be a useful clinical tool. vMRI provides biological evidence of neurodegenerative disease in patients with cognitive impairment. However, several hurdles impede implementation of vMRI in clinical practice. These include a lack of standardized MRI acquisition protocols, spatial distortions in MRI data, labor-intensive vMRI methods susceptible to interoperator variability, a lack of normative ranges for volume measures, and difficulty integrating vMRI in clinical workflow. Advances in vMRI have resulted from multi-institutional studies of brain imaging, such as the Alzheimer’s Disease Neuroimaging Initiative (ADNI), and help address these challenges. New, fully-automated measures of brain structure volumes coupled with large, multi-center studies using standardized MRI protocols now allow the development of age-adjusted normative ranges for vMRI. Such advances are critical for providing physicians a framework for assessing the pattern and degree of regional atrophy in a patient's brain and applying vMRI in clinical practice.


Impairments in self-assessment are commonly found in people with schizophrenia and impairments in introspective accuracy (IA) predict impaired functional outcome. previous studies have suggested mis-estimation of cognitive and functional skills predict impairment in everyday functioning at least as much as ability scores. In this study, we examined self-assessment of social cognitive ability and related these self-assessments to assessments of social cognition from informants, to performance on tests of social cognitive ability, and to everyday outcomes. The difference between self-reported social cognitive abilities and informant ratings was our measure of IA.People with schizophrenia (n=135) performed 8 tests of social cognitive abilities. They also rated their social cognitive abilities on the Observable Social Cognition Rating Scale (OSCARs). High contact informants also rated social cognitive ability and everyday outcomes, while unaware of the patients’ other scores. Social competence was also measured with a performance-based assessment and clinical ratings of negative symptoms were also performed.Patient reports of their social cognitive abilities were uncorrelated with performance on social cognitive tests and with three of the four domains of everyday functional outcomes. IA, in specific overestimation of performance compared to informant ratings, predicted impaired everyday functioning across all four functional domains. IA scores predicted functional outcomes even when the influences of social cognitive performance, social competence, and negative symptoms were considered in regression models. Thus, self-assessment of social cognition had a relatively specific impact social outcomes.Mis-estimation of social cognitive ability was a more important predictor of social and nonsocial outcomes in schizophrenia than performance on social cognitive tests. These results suggest that consideration of IA is critical when attempting to assess causes of everyday disability and when implementing interventions aimed at disability reduction.


Until now, no consensus is reached for the standardized assessment and quantification of extent and severity of myocardial ischemia and necrosis by cardiac magnetic resonance imaging (CMR). However, there is a good evidence base suggesting that these parameters might ameliorate established risk prediction models and thus might lead to an improved management of patients with stable coronary artery disease (CAD). Objective of this study therefore is to elaborate an easy-to-use algorithm for the quantification of ischemia and necrosis and to validate the obtained data in a large cohort of CAD patients.Patients with known or suspected CAD referred for adenosine-perfusion CMR were consecutively and prospectively enrolled. Examinations were conducted on a 1.5 Tesla whole-body scanner  using a 5-element phased array surface receiver coil. All patients underwent standard first-pass perfusion imaging  under adenosine infusion for the detection of myocardial ischemia and late gadolinium enhancement (LGE) imaging  for the assessment of myocardial necrosis. Based on these sequences, ischemia and necrosis were quantified using a novel algorithm.Primary endpoint was defined as combination of cardiac death, non-fatal myocardial infarction and stroke. Several risk prediction models containing clinical and CMR parameters were built and analyzed with regard to correct risk stratification and endpoint prediction.The study cohort consisted of 845 patients. Median follow-up was 3.66  years. During this time, 61 primary endpoints occurred. Cutoff values for myocardial ischemia and LGE could be defined . A risk prediction model containing this information proved to be superior in comparison to models based on conventional CMR features .Myocardial ischemia and necrosis above the defined cutoff values are strongly associated with major clinical endpoints. Quantification of these parameters provides additive information and leads to improved risk stratification.


Cognitive impairments are a core feature in schizophrenia patients and are also observed in first-degree relatives of the schizophrenia patients. However, substantial variability in the impairments exists within and among schizophrenia patients, first-degree relatives and healthy controls. A cluster-analytic approach can group individuals based on profiles of traits and create more homogeneous groupings than predefined categories.Here, we investigated differences in the Brief Assessment of Cognition in Schizophrenia (BACS) neuropsychological battery  among 81 schizophrenia patients, 20 unaffected first-degree relatives and 25 healthy controls. To identify three homogeneous and meaningful cognitive groups regardless of categorical diagnoses , cognitive clustering was performed using a k-means clustering analysis approach, and differences in the BACS subscales  among the cognitive cluster groups were investigated. Finally, the effects of diagnosis and cognition on brain volumes were examined.As expected, there were significant differences in the five BACS subscales among the diagnostic groups . The cluster-analytic approach generated three meaningful subgroups: (i) neuropsychologically normal , (ii) intermediate impaired  and (iii) widespread impaired . The cognitive subgroups were mainly affected by the clinical diagnosis , and significant differences in all BACS subscales among clusters were found . The effects of the diagnosis (SCZ<FR<HC) and cognitive clusters (Clusters 3<2<1) on brain volumes overlapped in the frontal, temporal and limbic regions. Frontal and temporal volumes were mainly affected by the diagnosis, whereas the anterior cingulate cortex volumes were affected by the additive effects of diagnosis and cognition .We investigated the cognitive heterogeneity and cognitive continuum among schizophrenia patients, first-degree relatives and healthy controls. The cognitive clustering approach without using clinical diagnoses successfully produced more homogeneous cognitive clusters: a neuropsychologically normal, an intermediately impaired and a globally impaired cognitive cluster. Clinical diagnoses  were not evenly distributed into the three clusters; i.e., these clusters were mainly affected by clinical diagnoses. Both diagnoses and cognitive clusters were associated with decreased anterior cingulate cortex volumes. Our findings demonstrate a cognitive continuum among schizophrenia patients, first-degree relatives and healthy controls and support the hypothesis that cognitive impairments and the related anterior cingulate cortex volumes would be useful intermediate phenotypes in the pathophysiology of schizophrenia.