Members of the small multidrug resistance (SMR) protein family are integral membrane proteins characterized by four α-helical transmembrane strands that confer resistance to a broad range of antiseptics and lipophilic quaternary ammonium compounds (QAC) in bacteria. Due to their short length and broad substrate profile, SMR proteins are suggested to be the progenitors for larger α-helical transporters such as the major facilitator superfamily (MFS) and drug/metabolite transporter (DMT) superfamily. To explore their evolutionary association with larger multidrug transporters, an extensive bioinformatics analysis of SMR sequences (> 300 Bacteria taxa) was performed to expand upon previous evolutionary studies of the SMR protein family and its origins.groEL mutations (SUG), and paired small multidrug resistance (PSMR) using protein alignments and phylogenetic analysis. Examination of SMR subclass distribution within Bacteria and Archaea taxa identified specific Bacterial classes that uniquely encode for particular SMR subclass members. The extent of selective pressure acting upon each SMR subclass was determined by calculating the rate of synonymous to non-synonymous nucleotide substitutions using Syn-SCAN analysis. SUG and SMP subclasses are maintained under moderate selection pressure in comparison to integron and plasmid encoded SMR homologues. Conversely, PSMR sequences are maintained under lower levels of selection pressure, where one of the two PSMR pairs diverges in sequence more rapidly than the other. SMR genomic loci surveys identified potential SMR efflux substrates based on its gene association to putative operons that encode for genes regulating amino acid biogenesis and QAC-like metabolites. SMR subclass protein transmembrane domain alignments to Bacterial/Archaeal transporters (BAT), DMT, and MFS sequences supports SMR participation in multidrug transport evolution by identifying common TM domains.A thorough annotation of unidentified/putative SMR sequences was performed placing sequences into each of the three SMR protein subclass designations, namely small multidrug proteins (SMP), suppressor of Based on this study, PSMR sequences originated recently within both SUG and SMP clades through gene duplication events and it appears that SMR members may be evolving towards specific metabolite transport. Anthropogenic drug overuse combined with the rapid horizontal distribution of multidrug efflux genes encoded on mobile genetic elements has facilitated drug resistance in distant or unrelated microorganisms -3. One sgroEL mutations (SUG), and paired small multidrug resistance (PSMR) subclasses  proteins from Archaea and Firmicutes, ethidium multidrug resistance protein E (EmrE) from Proteobacteria, and plasmid and/or integron encoded Qac proteins such as QacE, QacF and QacH (as reviewed by [Escherichia coli EmrE (Eco-EmrE) serve as the paradigm for all SMR members.The SMR protein family can be subdivided into three subclasses namely, small multidrug proteins (SMP), suppressor of iewed by ,12). Theiewed by ). ProteigroEL mutation phenotypes [qacC' [smr-2 [E. coli SugE (Eco-SugE) and Citrobacter freundii (Cfr-SugE) [SUG subclass members were initially identified based on their ability to suppress enotypes  and thesenotypes ,12). Memenotypes ,15. To denotypes ,17 that s [qacC'  and smr-' [smr-2 . Membersfr-SugE) ,15,20.B. subtilis YvdR/YvdS and YvaD only of the YvaD/YvaE pair [Members of the PSMR subclass are distinct from both SMP or SUG subclasses since they require co-expression of two SMR homologues to confer host resistance to QAC and toxic metabolites ,11,21-25vaE pair  which suEach SMR subclass is thought to have a similar structural architecture based on hydropathy plot analysis and predicts that all SMR homologues adopt four TM strands connected by short loops of varying hydrophilicity ,28. One The short length and limited number of TM strands that comprise the SMR protein family have led to the proposal that they are the evolutionary building blocks of larger α-helical multidrug efflux proteins -31. AlthThe objective of this work is to explore the evolutionary origins of the SMR protein family by examining SMR diversity among Archaeal and Bacterial genomes. The specific goal is to gain insight into the evolutionary constraints exerted upon SMR subclass members to validate the notion that SMR proteins acted or are acting as the evolutionary starting points for larger transporters. We began these studies by surveying SMR sequences within Archaea and Bacteria from diverse taxonomic backgrounds using current genomic and plasmid sequence databases (as of March 2008). This effort identified 685 SMR amino acid sequences which were aligned to putatively classify SMR sequences into the three SMR protein subclasses. The evolutionary relatedness of assigned SMR protein sequences was refined by using phylogenetic analysis and assisted with SMR homologue classification. The degree of amino acid conservation and the selective pressures exerted upon selected taxonomic SMR representatives was determined by their rate of synonymous to non-synonymous nucleotide substitutions. Finally, the genomic loci of SMR homologues were surveyed within the currently sequenced Archaeal and Bacterial genomes to explore their functional association to metabolite transport and their affiliation with transposon and integron mediated inheritance among diverse microorganisms. The results from this bioinformatics exploration support the current models that SMR protein sequences act as genetic building blocks for much larger multidrug efflux proteins based on their diversity and rapid evolution.subtilis and E. coli as seed sequences. In total, 685 putative SMR protein sequences were retrieved from Archaea and Bacteria and a summary of their subclass distribution is presented in Table To understand and explore the extent of SMR subclass distribution and diversity, we surveyed the NCBI sequence database for chromosomally encoded SMR sequences among Archaea and Bacteria using characterised SMR homologues from B. -3). All three Crenarchaeal SMR sequences  served as outgroups for subsequent phylogenetic analysis and will not be discussed further.The results from Archaeal genome surveys identified that SMR sequences are present within Euryarchaeal sub-phylum genomes Table . The lacB. subtilis YvaE (Bsu-YvaE). The presence of Methanomicrobia yvaE homologues could suggest that YvaE potentially represents a PSMR progenitor. This observation is supported upon closer examination of their genomic loci, where all of the Euryarchaeal yvaE homologues lacked the presence of yvaD a poorly conserved SMR that is commonly located in the same putative operon among Bacillus species [Overall, SMR homologues we identified from surveyed Euryarchaeal genomes belonged to SUG, SMP, and the PSMR (only YvaE) subclasses only Table . All Eur species .As expected from the wealth of bacterial genomic sequences available, SMR diversity among bacterial species far outnumbered Archaea Table . SurveysThe SUG subclass prevailed over all other subclasses in Bacteria since SUG homologues were found in nearly every class we examined Table . The preXanthomonas [Vibrio [SMP subclass sequences were identified within the genomes of particular Bacterial classes namely, Cyanobacteria, Chloroflexi, as well as α-, β- and γ-proteobacteria Table . Unlike thomonas  or Vibri [Vibrio -36 that yvaD in Bacilli and Lactobacilli only suggests that yvaD may be a rapidly diverging yvaE gene duplication product within Bacilli and Lactobacilli.PSMR subclass members have the most specific sequence distribution among the sequenced Bacterial genomes we surveyed strongly suggesting they are maintained under selective pressures different from either the SUG or SMP subclasses Table . ParticuTaken together, the unique distribution pattern of SUG, SMP and PSMR subclass members strongly supports SMR diversification that is tailored to particular genera.To explore the evolutionary relationships of SMR protein family members further, we analyzed a taxonomically diverse set of 338 SMR protein sequences. Previous phylogenetic analyses of SMR amino acid sequences using smaller taxonomic data sets ,12,26,37Our phylogenetic analysis demonstrated a division of SMR members into two major clades Figure , namely Since the greatest number of SMR homologues we identified are from Actinobacteria, Bacilli, and various Proteobacteria, it is not surprising that the phylogenetic groupings of SMR homologues within our dendrogram are strongly dominated by these Bacterial classes Figure . PreviouSimilar to the observations made from SMR sequence surveys Table , a trendPSMR subclass homologues grouped in distinct branches to either the SUG or SMP clades Figure . YvaD hoE. coli and B. subtilis, were selected for pairwise comparison to their respective putative homologues from Bacterial and Euryarchaeal class in our survey. Integron and plasmid encoded SMR homologues were included in this analysis to determine the extent of nucleotide changes within chromosomally encoded SMR sequences compared to the rate of divergence from their horizontally transferred counterparts. This comparison also served as a method to gauge differences that arise from the codon bias within the various host genomes.Since SMR subclass distribution is enriched within particular Bacteria, we wanted to compare the frequency of synonymous to non-synonymous changes occurring within SMR sequences at the nucleotide level. Examining the degree of nucleotide changes throughout the whole SMR sequence relative to the rate of change at each codon can identify regions of the protein that are actively evolving. Experimentally examined SMR sequences, specifically SMR homologues from The rate of synonymous to non-synonymous changes (dS/dN) in nucleotide sequences of SMP subclass homologues selected from various Euryarchaeal and Bacterial genera resulted in a mean value of 3.6 Table .Individual dS/dN values from pairwise SMP sequence comparisons indicated that the rate of synonymous and non-synonymous changes range from 1–6 among examined chromosomal SMP sequences Table . These vHalorubrum lacusprofundi sugE (Hla-sugE) sequence relative to the values of Eco-sugE  compared to other PSMR members, reflecting its frequent diverse distribution in the genomes of both Archaea and Bacteria. Although the rate of synonymous to non-synonymous changes among comparisons of Bsu-yvaE to other yvaE homologues are in many cases indeterminable due to pS values exceeding the Jukes-Cantor threshold limits, those that could be calculated resulted in high overall dS/dN values  suggesting that it is maintained under the least amount of selective pressure among all the PSMR members we examined.Members of the PSMR subclass appear to have very different selective constraints placed upon their sequences as reflected by the variable mean dS/dN values for each PSMR homologue in comparison to either SMP or SUG subclasses Table . B. subt to date ,22,25,26dN value .16 compaebrA/ebrB have a slightly lower mean dS/dN value (2.84) than the mean dS/dN values of yvaE, SMP, and SUG homologues , but not when compared to integron encoded Qac homologues   than its counterpart ydgF (0.3–0.6) indicating that only ydgE is actively maintained. This trend is in good agreement with observations made by three dimensional cryo-electron microscopic structural studies of Eco-EmrE protein that support an asymmetrical arrangement of each protein monomer [E. coli has revealed its involvement in spermidine excretion and confirmed that only YdgE (MdtI) was essential for transport activity based on site-directed mutagenesis experiments of each active site Glu14 residue in the pair [ydgF and ydgE homologues to plasmid and integron encoded SMR homologues indicated that only ydgE members were maintained at similarly high levels.YdgE/YdgF homologues demonstrated a much lower mean dS/dN value (1.84) suggesting that these homologues are under far less selective pressure than the SMP or SUG members surveyed  and yvdR/yvdS (2.0), revealed that each pair is maintained under moderately high selective pressures in comparison to all other PSMR members  selective pressures on both pairs. Active maintenance of both homologues in the pair may reflect functional interdependency. More importantly, only ykkC demonstrated high dS/dN values when compared to plasmid/integron encoded SUG homologues suggesting that ykkC has closer association to horizontally transferred SUG counterparts. This contrasts our phylogenetic analysis of these sequences which suggest YkkD has greater evolutionary relationships to plasmid and integron encoded SUG homologues  values were also calculated at each codon position in the SMR nucleotide alignment using Syn-SCAN analysis to determine the selective pressures exerted on each residue of the protein. Sd values were determined from pairwise comparisons of selected members (10–20 species/SMR subclass) and then averaged to generate the mean Sd at each codon. A summary of both analyses are shown in Figures Both SUG and SMP subclasses demonstrated a unique amino acid consensus in addition to the core SMR motif previously reported  Figures and 3A. A striking feature within each panel of Figures Periodic α-helix conservation is also maintained in many PSMR subclass consensus maps but distinctly varies from TM strand to TM strand, where the least TM conservation is observed in the last strand TM4) Figures , and 4.  Figures Amino acid sequence alignments for the PSMR subclass members EbrA and EbrB were difficult to distinguish from each other since they both had similar residue conservation patterns, especially when Actinobacterial EbrA and EbrB homologues were examined. The inability to reliably separate EbrA/EbrB homologues from each other forced an initial comparison of these PSMR members altogether. High amino acid conservation is observed for EbrA/EbrB homologues within the loop and C-terminus regions of the protein Figure . ConservDespite having a distinct amino acid consensus motif from SMP and SUG, YvaE demonstrated a similarly strong periodic amino acid conservation pattern, particularly within predicted loop and turn regions. As expected, YvaD homologues show low overall amino acid conservation throughout the entire protein with the exception of the three to four moderately conserved residues at the ends of the last two TM strands towards the C-terminus. This clearly indicates that YvaD has diverged dramatically from other PSMR members. An important feature of YvaD homologues to consider is loss of the highly conserved residue E14 (according to Eco-EmrE); yet conserved residues within the C-terminal residues are only partially maintained. These infrequently conserved residues are shared with both YvaE and SMP subclass members strongly supporting the idea that YvaD likely originated from YvaE but is maintained under very little selective pressure within the hosts.Examination of mean Sd values at each codon position within all SMR nucleotides demonstrated strong agreement to its corresponding amino acid consensus value within predicted loop and TM regions Figures , and 4. The mean Sd values observed for both SUG and SMP subclass sequences show a similar α-helical periodicity pattern to conserved amino acid residue positions strongly validating the observation that specific TM α-helix faces are highly conserved. However, it should be noted that there are also occasional amino acid positions in each SMR subclass consensus where codons corresponding to loop or TM strand regions have high mean Sd values but very low amino acid consensus value and vice versa. For example, numerous positions in TM4 of the SUG consensus map have high mean Sd values but low values for its conserved amino acid at the same position Figure . ConversA. nicotinovorans plasmid pAO1 encoding NepA and NepB have specifically demonstrated efflux of potentially toxic metabolites such as spermidine and nicotine intermediates, respectively [Experiments implicating SMR protein involvement in toxic metabolite transport suggest broader roles for this family of proteins during host metabolite regulation. Although members of the SMR protein family are known for conferring multidrug resistance to its host organism, very little is known about potential 'natural' substrates. PSMR members Eco-YdgE and Eco-YdgF and ectively ,11. In aectively ,14,48 anAfter completing our SMR genomic loci survey, many trends in SMR genomic arrangement were noted. The first common characteristic identified from these surveys was detection of horizontal gene transfer genes that encoded for integrases, transposons, insertion sequences (IS), plasmid maintenance genes, and bacteriophage replication and coat proteins downstream or upstream from the SMR sequence (within our 10 ORF radius cut-off), strengthening our arguments for horizontal SMR inheritance as shown in the phylogram Table . Mobile The second characteristic we observed upon examining SMR genomic loci was frequency of SMR subclass co-occurrence to various metabolite biosynthetic genes Table . In geneydgE/ydgF and ykkC/ykkD, were shown to frequently overlap (95%–98% surveyed respectively) in all proteobacterial genomic loci we surveyed. This contrasted the PSMR homologues ebrA/ebrB that did not frequently overlap and were often separated by other ORFs within their putative operons. In our survey EbrA/EbrB homologues were also found to correspond to a single gene only within species from Actinobacteria (32%), Clostridia (14%), Cyanophyceae (13%), Chloroflexi (25%) and Planctomycetacia (33%). This observation is similar to the situation we described for yvaE and yvaD pairing suggesting that some isogenic ebrA/ebrB homologues may possess functional activity alone or frequently undergo losses of either pair.The last final characteristic observed from the surveys of genomic loci showed that PSMR homologues had characteristic arrangements in gene pair at the locus. This observation may reflect their potential to act as predecessors of much larger transporters. To clarify this statement, the PSMR gene pairs, It is important to mention again that these surveys in no way prove the functional activities of the various SMR subclasses, but identify potential substrates or activities that could and should be examined experimentally. It also reaffirms that the distribution of particular SMR subclasses are focusing in on specific Archaeal and Bacterial groups, in addition to their shared proximity with other organisms enabling SMR mobile genetic element exchange.et al. 2001 was shown from alignments of SMR TM domains to portions of DME and BAT family proteins in either the N- or C-terminus region of the protein. According to these alignments SMR proteins shared the greatest amount of sequence identity to the C-terminus regions of BAT or DME families [SMR proteins are one of the 14 families that encompass the DMT superfamily  and inclfamilies . Hence, E. coli and B. subtilis homologues) in both heterogeneous (e.g. Eco-EmrE to Eco-SugE) and homogenous (Eco-EmrE to Eco-EmrE) protein combinations to serve as seed sequences for phi-BLAST analyses of genomic databases. These searches identified numerous TM domain regions within SMR fusions that had similarity to various DMT superfamily members in addition to members of MFS  but not E. coli YdgE-YdgF (10%) alignment to DMT superfamily member RarD  and Escherichia coli  [-4 and served as the cut-off value for positive SMR identification. The 685 putative SMR protein sequences were aligned using ClustalW [SMR sequences used for this study were obtained from NCBI genomic blast surveys (tBLASTn and BLASTp) using SMR sequences functionally characterized for transport activity ,22,26,58_416117) . As a reClustalW ,61 and TClustalW  . SMR suSMR proteins alignments to BAT, DMT and MFS transporters were performed using ClustalW and manual alignment using the editing program GeneDoc (v 2.5.010 ). BAT, DemrE codon 3 (W3) to codon 107 (L107). The distribution of point mutations from SMR sequences was examined spanning a 300 bp region which included nucleotides that encoded each of the four predicted transmembrane strands as well as loop/turn regions and truncated poorly conserved codons from the encoded N- and C-termini. For yvdR/yvdS and ebrA/ebrB sequences, poor alignment of three codons within the region encoding the first putative loop1 had to be removed. The rate of synonymous to non-synonymous changes (dS/dN) was determined using the online Syn-SCAN program website [SMR nucleotide sequences used for Syn-SCAN analysis  were sel website -69 and t-3 and each sequence produced highly similar tree arrangements and bootstrap values (data not shown). Therefore, Archaeoglobus fulgidus QacE sequence was selected arbitrarily as the outgroup for the final tree. The results of these analyses are presented in Figure To examine the evolutionary relatedness of the all SMR subclass members assigned from the original 685 SMR protein alignment, a smaller alignment of 338 SMR protein sequences was prepared to adequately represent the taxonomic diversity of sequence origin ; TM: (transmembrane); QAC: (quaternary ammonium compounds).The following abbreviations used in the manuscript are listed here in alphabetical order: BAT: ; DME: (drug metabolite exporter); DMT: (drug metabolite transporter); dS/dN: (rate of synonymous to non-synonymous mutations); MFS: (Major facilitator superfamily); PSMR: ; Sd: (number of synonymous nucleotide substitutions); SMP: ; SMR: ; SUG:  are listed beside their respective nodes above 59%. Plasmid and integron encoded SMR proteins are underlined. SMR sequence accession numbers are indicated adjacent to its genus and species name.Click here for fileSummary of synonymous to non-synonymous nucleotide substitution patterns within PSMR subclass members.Click here for fileAn alignment of 338 SMR protein sequences identified from BLAST surveys of completed Archaeal and Bacterial genomes. The 338 SMR protein sequence alignment was truncated from a larger alignment of 685 SMR sequences that was generated using a manually edited ClustalW alignment. It is important to note that this alignment may contain truncated versions of some SMR sequences.Click here for file


A case of 49-year-old woman with a retroperitoneal undifferentiated foregut cyst attachedto the right adrenal gland is reported. The bronchogenic cyst is a type of foregut cyst witha cartilage component, but in this case the multicystic tumor lacked both cartilage andgland. It is quite rare among retroperitoneal tumors and has not been reported so far tohave malignant potential. The preoperative diagnosis was an adrenal benign incidentaloma, and the patient successfully underwent laparoscopic resection of the cystic tumor togetherwith the right adrenal gland by lateral transabdominal approach. Laparoscopic surgery for a retroperitoneal tumor is problematic, however, since benignancy cannot be predicted. In laparoscopic adrenalectomy for non-functioning adrenal tumor, therefore, a differential diagnosis from retroperitoneal tumor should be given serious consideration.


Aiming to discern the mechanisms by which circulatingglycated albumin alters the glomerular filtration propertiesthat lead to glomerular dysfunction in diabetes, the authorsstudied the distribution and densities of anionic chargesthrough the rat glomerular wall upon intravascular infusionof Amadori products, as well as in various conditions ofincreased glomerular permselectivity. Polylysine-gold wasused as the probe to reveal the anionic charges. The studywas carried on renal tissue sections of bovine serum albumin(BSA)- and glycated BSA–injected, normoglycemicanimals. Results were generated through morphometricalevaluations of the gold labeling. Changes in glomerular anionicdistribution were corroborated on renal tissue sectionsof short- and long-term diabetic rats and of normal newbornrats, situations known for abnormal glomerular filtration.Altered renal function in these conditions was clearlyassociated with changes in glomerular anionic charges. Onthe other hand, the infusion of glycated albumin in the circulationof normal rats, though altering glomerular filtrationproperties, did not modify the distribution and density ofthe polylysine-gold labeling through the glomerular basementmembrane. Thus, anionic charges seem not to be thefactor involved in the early changes of glomerular permeabilityinduced by circulating glycated albumin.


More optimistic perceptions of cardiovascular disease risk are associated with substantively lower rates of cardiovascular death among men. It remains unknown whether this association represents causality (i.e. perception leads to actions/conditions that influence cardiovascular disease occurrence) or residual confounding by unmeasured factors that associate with risk perceptions and with physiological processes that promote cardiovascular disease .To evaluate whether previously unmeasured biological markers of inflammation or endothelial dysregulation confound the observed association between cardiovascular disease risk perceptions and cardiovascular disease outcomes;We conducted a nested case-cohort study among community-dwelling men from Southeastern New England (USA) who were interviewed between 1989 and 1990 as part of the Pawtucket Heart Health Program. We measured C-reactive protein (CRP) and Vascular Endothelial Growth Factor (VEGF) levels from stored sera for a random sample of the parent cohort  and all cases of cardiovascular death observed through 2005 . We evaluated potential confounding using stratified analyses and logistic regression modeling.Optimistic ratings of risk associated with lower odds of dying from cardiovascular causes among men . Neither CRP nor VEGF confounded these findings.The strong cardio-protective association between optimistic ratings of cardiovascular disease risk and lower rates of cardiovascular mortality among men is not confounded by baseline biomarkers of systemic inflammation or endothelial dysfunction. Risk perceptions are plausibly influenced by psychological conditions  that influence inflammatory status and endothelial reactivity. Since biomarkers of systemic inflammation (C-reactive protein) and endothelial dysregulation  also predict CVD events [Considering plausible causal mechanisms D events -16, thesD events .We conducted a case-cohort study nested within a community-based sample of men from southeastern New England (USA). A case-cohort study is an efficient epidemiologic design similar to a case-control study, except that the control group is chosen without regard to the outcome (i.e. a random sample of the base population), thus allowing comparison to multiple "case" groups . This strategy averts the time and financial cost of analyzing frozen sera from a full cohort.All participants completed household interviews between 1990 and 1993. Serum samples were obtained during household interviews and frozen per standard protocol. Death record information was obtained from the National Death Index through December 2005 to identify cases. In depth description of this nested case-cohort study  and the All participants were enrolled during the post-intervention period of the Pawtucket Heart Health Program (PHHP), a controlled community intervention designed to lower prevalence of CVD risk factors . One thoParticipants were asked at the beginning of the household interview, "Compared with persons of your own age and sex, how would you rate your risk of having a heart attack or stroke within the next 5 years?" Participants rated their CVD risk as "high", "average", "low", or "don't know". Endorsing one's risk to be lower than average we refer to as an optimistic rating.We obtained the date of death and underlying cause of death by linking personal identifiers  for each participant to the Center for Disease Control National Death Index (NDI) for the years 1990-2005. Linkage and cause of death were established using NDI-standardized protocols. Cases were those participants whose primary or contributing cause of death was due to cardiovascular disease, as defined by International Classification of Disease (ICD) codes for coronary heart disease or stroke .Using thawed sera, the concentrations of CRP and VEGF were measured using immunoturbidimetric and ELISA assays, respectively. Prior epidemiologic research has verified the validity of these samples and measurement procedures .st degree family history of early-onset coronary heart disease, current use of lipid or blood pressure lowering medications, current aspirin use, physical inactivity, alcohol, and psychotropic medications.We considered the following as potential confounders or effect measure modifiers of the association between comparably optimistic self-rated CVD risk and CVD mortality: CRP, VEGF, age, race/ethnicity, income, education, foreign birth, city, Framingham Risk Score, total/HDL cholesterol ratio, hypertension, smoking status, body mass index, 1We evaluated the frequency and distribution of key study variables. For univariate comparisons shown in Table Since more elaborate adjustment for potential social, biologic and behavioral confounders  for all statistical analyses. Where p-values are reported, we used a statistical significance threshold of 0.05.The institutional research review boards at Memorial Hospital of Rhode Island and the University of Rochester School of Medicine and Dentistry approved this study.i.e. optimistic ratings). Forty-four participants died of cardiovascular causes during the 15-year surveillance period. Higher levels of CRP and VEGF were associated with higher risk of CVD mortality  and CRP  for comparative optimists compared to others were small and statistically insignificant.Thirty one percent of the participants endorsed their risk of having a cardiovascular event in the next five years as lower than average for their age and sex . Adjusting for CRP alone, VEGF alone, or in combination with age, income and Framingham Risk Score did not substantially change these findings [see Table i.e. inflammation and endothelial dysregulation) would confound these provocative observations. We observed that controlling for baseline CRP and VEGF did not weaken the protective association between optimistic ratings of CVD risk and CVD mortality.Following previous findings of an independent association between optimistic perceptions of CVD risk and substantially lower rates of CVD mortality among men, we evaluated whether biomarkers of stress  that will shape our society's understanding of cardiovascular risk.CRP: C-reactive protein; VEGF: vascular endothelial growth factor; ICD: International Classification of Disease; NDI: National Death IndexThe authors declare that they have no competing interests.All authors participated in the interpretation of these findings, contributed substantively to the writing of this manuscript and approved this submission. RG, MR, and CB participated in data collection and initial analyses. WK, LZ, and KH participated in subsequent revised analyses.


The present study set out to evaluate perceptions of risk, psychological morbidity and health behaviours in women with a family history of breast cancer who have attended genetic counselling and determine how these differ from general population risk women. Data were collected from 62 genetic counselees (cases) attending the Royal Marsden and Mayday University Hospital genetic counselling services and 62 matched GP attenders (controls). Levels of general psychological morbidity were found to be similar between cases and controls; however, cases reported significantly higher breast cancer-specific distress despite clinic attendance . Although cases perceived themselves to be more susceptible to breast cancer, many women failed correctly to recall risk figures provided by the clinic; 66% could not accurately recall their own lifetime chance. Clinics appeared to have a positive impact on preventive behaviours and cases tended to engage more regularly in breast self-examination , although few differences were found between groups in terms of health beliefs. We conclude that counselees and GP controls showed considerable similarities on many of the outcome measures, and risk of breast cancer was not predictive of greater psychological morbidity; although cases were more vulnerable to cancer-specific distress. Despite genetic counselling, many cases continued to perceive their risk of breast cancer inaccurately.


Previous investigators have noted that certain ovarian cancer cell lines secrete and respond to transforming growth factor-alpha , suggesting that endogenous activation of the epidermal growth factor (EGF) receptor through autocrine or paracrine mechanisms might contribute to the proliferative response. In order to determine whether autocrine stimulation was partly responsible for the proliferative response in ovarian cancer, we investigated whether the EGF receptor expressed by ovarian cancer cell lines was constitutively activated as assessed by the presence of tyrosine phosphorylation. A specific anti-phosphotyrosine antibody was used in conjunction with an immunoblotting technique in order to detect EGF receptor phosphorylation in ovarian cancer cell lines in the absence and presence of exogenous EGF. The effects of neutralising anti-EGF receptor antibody on the proliferation of ovarian cancer cell lines was also examined. We found no evidence for constitutive tyrosine phosphorylation of the p170 EGF receptor in eight epithelial ovarian cancer cell lines tested, although each line demonstrated inducible phosphorylation in response to exogenous EGF. The absence of constitutive EGF receptor activation was also noted when cells were grown under high density conditions, thus excluding a role for membrane-bound EGF or TGF-alpha in this process. Media conditioned by five ovarian cancer cell lines, as well as malignant ascites obtained from 12 different ovarian cancer patients, were not capable of stimulating EGF receptor phosphorylation. Finally, the proliferation of ovarian cancer cell lines was not significantly inhibited in the presence of neutralising anti-EGF receptor antibody. These data suggest that EGF receptor activation through autocrine pathways is not a major mechanism for the growth of many ovarian cancer cell lines. Other pathways of signal transduction which bypass the requirement for EGF receptor activation may be important in the proliferation for ovarian cancer cells. Such EGF receptor-independent pathways may limit the effectiveness of strategies designed to inhibit ovarian cancer cell growth through disruption of EGF receptor function.


Tubularized incised plate repair is based on an old principle of urethral plate tubularization, also known as the Thiersch-Duplay procedure. Although a good concept, its main drawback was the limitation imposed by the width of the urethral plate. Snodgrass popularized the concept of urethral plate incision with subsequent tubularization and secondary dorsal healing for primary hypospadias repair. This relatively simple yet elegant and effective procedure has gained widespread acceptance, currently being recognized as the surgical technique of choice for distal and other types of hypospadias repair.‐3 In theDecision making in hypospadias repair is no longer determined by meatal location, as in the past, but by severity of penile curvature and appearance of the incised urethral plate. Severe curvature, requiring plate transection or an "unhealthy" incised plate are uncommonly encountered.A treatment Algorithm must consider the following:Differentiation between functionally necessary and aesthetically feasible operative proceduresEstablishing therapeutic objectivesPre-operative hormonal treatmentAge at surgeryPenile curvaturePreservation of the well-vascularised urethral plateRe-do hypospadias repairsUrethral reconstructionUrine drainage and wound dressingAdolescent satisfaction with penis sizeRate of fistula formationThe second thing is the rate of fistulae. Although it is comparable to the literature, they do not favour use of a two-layer coverage and deny that Snodgrass has recommended two-layer neourethra closure to decrease fistula formation in all types of hypospadias defects. Several factors may influence fistula formation, such as surgical technique, delicate tissue handling, patient age, type of hypospadias defect, surgeon's experience, water-proof urethroplasty coverage and concomitant foreskin reconstruction.The meatal stenosis rate varies from 0 to 17%, and Snodgrass has reported meatal stenosis rates below 1%. This has been a controversial topic and considered to be possibly related to the surgical technique. In the present study, meatal stenosis was high (8.8%), with no explanation for this high rate.


The presence or absence of venousinvasion did not influence lymph node metastasis. Laparoscopic surgery involving lymph nodedissection should be indicated for sm1 carcinoma lesions with unfavorable histological factors.In lesions diagnosed as sm2 or sm3 prior to resection, intestinal resection involving lymph nodedissection by laparoscopic surgery should be directly performed without endoscopic resection.We investigated the relationship between histological factors and lymph node metastasis in77 lesions with submucosally invasive colorectal carcinomas to establish useful criteria forlesions in which endoscopic treatment alone results in cure of malignancy. There were positivecorrelations between histological factors, including the level of invasion, the histologic grade,presence or absence of lymphatic invasion, presence or absence of budding, and lymph nodemetastasis  or II (moderately-differentiated), andthe absence of lymphatic invasion and budding, endoscopic treatment alone is sufficient.


Major heart diseases such as ischemia and hypertrophic myocardiopathy are accompanied with significant changes in the passive mechanical properties and active contractility of myocardium. Identification of these changes helps diagnose heart diseases, monitor therapy, and design surgery. A dynamic cardiac elastography (DCE) framework is developed to assess the anisotropic viscoelastic passive properties and active contractility of myocardial tissues, based on the chamber pressure and dynamic displacement measured with cardiac imaging techniques. A dynamic adjoint method is derived to enhance the numerical efficiency and stability of DCE. Model-based simulations are conducted using a numerical left ventricle (LV) phantom with an ischemic region. The passive material parameters of normal and ischemic tissues are identified during LV rapid/reduced filling and artery contraction, and those of active contractility are quantified during isovolumetric contraction and rapid/reduced ejection. It is found that quasistatic simplification in the previous cardiac elastography studies may yield inaccurate material parameters.


Experiments were conducted to determine whether the histological pattern of tumour growth of hormone-responsive MCF-7 human mammary adenocarcinoma varied in different tissues of athymic mice. Tumours in the uterus following intrauterine injection were rapidly proliferating and highly invasive. Tumours injected intracerebrally were also highly invasive. In contrast, s.c. tumours and those which arose in the lung following intrapleural injection, grew as small localized nodules without evidence of aggressive invasion of surrounding tissues. These findings indicate that selective implantation of human tumours in athymic mice can be used to develop different models of tumour growth and aggressiveness.


Borna disease virus, a newly classified nonsegmented negative-strand RNA virus with international distribution, infects a broad range of warm-blooded animals from birds to primates. Infection causes movement and behavioral disturbances reminiscent of some neuropsychiatric syndromes. The virus has not been clearly linked to any human disease; however, an association between infection with the virus and selected neuropsychiatric disorders has been suggested. We reviewed recent advances in Borna disease virus research, focusing on evidence of infection in humans.


DNA fingerprinting has demonstrated predominance of the Beijing genotype among Mycobacterium tuberculosis strains isolated in Southeast Asia. We prospectively examined the occurrence of Beijing genotype strains in tuberculosis patients in Indonesia. Early in treatment, patients infected with Beijing genotype strains more often had fever unrelated to disease severity, toxicity, or drug resistance, indicating that Beijing genotype strains may have specific pathogenic properties.


Metabolite ratios (phosphocreatine (PCr)/beta nucleoside triphosphate (beta NTP), PCr/Pi, beta NTP/Pi) calculated from the NMR spectra were compared with ratios obtained from acid extracts of tumours of similar size. Measurements of creatine and ADP were also made. Three of the tumours showed positive correlations between increasing tumour size and decreasing metabolite ratios measured both by NMR and in extracts, whereas the Walker carcinosarcoma showed no correlation between size and any parameters measured. Phosphorus metabolite ratios, measured in extracts of skin overlying the tumours, indicated a fall in high energy phosphate when there was histological evidence of skin invasion by the tumour. Surface coil 31P-NMR spectra of subcutaneously grown or induced tumours in the rat represent a slowly changing steady state as the tumour increases in size. We conclude that increasing numbers of hypoxic tumour cells, rather than large areas of necrotic tissue, contribute largely to the NMR spectrum.


Twelve mongrel dogs were randomly allocated into two groups using matched paired-design. Catheterswere inserted into the hepatic artery, hepatic vein and the femoral vein, respectively. In the first group,gelfoam supplemented with mitomycin C (MMC) was injected into the hepatic artery, whereas thesecond group received a hepatic arterial injection of MMC solution alone. Simultaneous blood samplingfrom the hepatic and femoral veins at regular intervals was performed. MMC concentrations in plasmawas determined using high performance liquid chromatography (HPLC) and the pharmacokinetics ofMMC were determined.MMC concentrations in hepatic and femoral veins did not differ and no significant difference inpharmacokinetics was found when comparing MMC administration into the hepatic artery with orwithout gelfoam supplementation. Thus, our results revealed that gelfoam could not delay the clearanceof MMC from the liver.


It was demonstrated previously that mice undergoing an inflammatory reaction induced by subcutaneous (SC) implantation of copper rods, produce humoral factors that initially enhance, but subsequently inhibit, diffusion chamber (DC) granulopoiesis. This provided evidence that granulopoiesis is under the control of both humoral stimulators and inhibitors. In order to test the granulopoietic regulatory mechanism in leukaemic mice, we investigated the regulatory role of granulopoietic humoral inhibitors during in vivo granulopoiesis. We noticed that mice suffering from acute myeloid leukaemia (AML) are unable to augment the production of these humoral inhibitory factors when acute inflammation is induced, since no change in DC cell content was observed with or without prior inflammation. Moreover, unlike healthy mice, the serum of leukaemic mice withdrawn during the inhibition phase of acute inflammation did not show any inhibitory activity toward granulocyte—monocyte (GM) colony growth in vitro. Our results also show that increased levels of normal humoral inhibitors do not influence the proliferation and/or differentiation of leukaemic cells implanted in diffusion chamber cultures.


The major histocompatibility complex (MHC) class II is involved both in thymocyte maturationand peptide presentation and might thus play a key role in the pathogenesis of paraneoplasticmyasthenia gravis (MG) in thymomas. To further investigate this issue, we analyzedand scored the expression of epithelial class II expression in 35 thymomas  and correlatedit with the histological tumor subtype, prevalence of MG and thymocyte maturation, whichwas analyzed by flow cytometry and RT-PCR. Our results show that both MHC class IIexpression and thymocyte maturation are highly dependent on the histological tumor subtype.CT / WDTC retain features of the normal outer thymic cortex, namely substantial MHC classII expression together with normal early thymocyte maturation until late phases of positiveselection, but disturbed terminal thymopoiesis. By contrast, MDT and MXT retain features ofthe normal inner cortex and the medulla with low to absent class II expression and highlyabnormal early thymocyte maturation including impaired positive selection, while terminal Tcell maturation in MXT appeared undisturbed. There was no correlation between MHC classII expression and MG status for a given tumor subtype. In conclusion, our results provide evidencefor a different histogenesis of cortical thymomas and well differentiated carcinomas onthe one hand and mixed and medullary thymomas on the other.Decreased expression levels of MHC class II, although of crucial importance for abnormalintratumorous maturation, are not sufficient to explain the emergence of paraneoplastic MG.


The total N-acetyl neuraminic acid (NANA) content of lymphocytes, erythrocytes and plasma obtained from normal and lymphatic leukaemic patients was measured by the Warren thiobarbiturate technique. Lymphocytes from patients with chronic lymphatic leukaemia and lymphoblasts from patients with acute leukaemia had decreased levels.


Miniature spectrometers incorporating array detectors are becoming a viable, low-cost option for field and process deployments. The performance characteristics of one such instrument are reported and compared with those of a conventional benchtop instrument. The parameters investigated were wavelength repeatability, photometric linearity, instrumental noise (photometric precision) and instrumental drift.


Background: Resection of hepatocellular carcinoma is associated with high rates of morbidity and mortality. Since intensive nutritional support can reduce the catabolic response and improve protein synthesis and liver regeneration, we performed a prospective study to investigate whether perioperative nutritional support could improve outcome in patients undergoing hepatectomy for hepatocellular carcinoma.            Methods: We studied 124 patients undergoing resection of hepatocellular carcinoma. Sixty-four patients  were randomly assigned to receive perioperative intravenous nutritional support in addition to their oral diet, and 60 patients  were randomly assigned to a control group. The perioperative nutritional therapy consisted of a solution enriched with 35 percent branched chain amino acids, dextrose, and lipid emulsion (50 percent medium-chain trigylcerides) given intravenously for 14 days perioperatively).            Results: There was a reduction in the overall postoperative morbidity rate in the perioperative-nutrition group as compared with the control group , predominantly because of fewer septic complications . There were also a reduction in the requirement for diuretic agents to control ascites , less weight loss after hepatectomy , and less deterioration of liver function as measured by the change in the rate of clearance of indocyanine green . These benefits were seen predominantly in the patients with underlying cirrhosis who underwent major hepatechtomy. There were five deaths during hospitalization in the perioperativenutrition group, and nine in the control group (P not significant).            Conclusions: Perioperative nutritional support can reduce complications after major hepatectomy for hepatocellular carcinoma associated with cirrhosis.


Two proprietary semi-permanent hair dyes were tested for carcinogenicity in A and DBAf mice by repeated topical applications in aqueous acetone. Mice of both strains developed lymphoid tumours but experimental differences were marked only in DBAf mice. A number of tumours of the ovary and uterus, and some skin papillomas near the penis, occured in dye-treated but not in control DBAf mice. As many hair-dye constituents are known mutagens, adequate carcinogenicity testing of these substances, and epidemiological study of exposed human populations, are needed for evaluating possible health hazard from hair dyeing.


Streptococcus pneumoniae is a major cause of acute otitis media, pneumonia, bacteremia, and meningitis. Because in recent years antibiotic-resistant pneumococcal strains have been emerging throughout the world, vaccination against pneumococcal infections has become more urgent. The capsular polysaccharide vaccine that has been available is neither immunogenic nor protective in young children and other immunocompromised patients. Several pneumococcal proteins have been proposed as candidate vaccines, but no human studies associated with them have been reported. Clinical trials of first-generation pneumococcal conjugate vaccines have shown that covalent coupling of pneumococcal capsular polysaccharides to protein carriers improves the immunogenicity of the polysaccharides. The protective efficacy of the conjugate vaccines against carriage, acute otitis media, and invasive infections is being studied.


In patient tumour samples the activity in vitro of Taxol corresponded fairly well to the known clinical activity and Taxol showed low cross-resistance to standard cytotoxic drugs. However, the Taxol solvent Cremophor EL--ethanol was considerably active alone, whereas paclitaxel formulated in ethanol was less active. Taxol thus seems to contain two components active against patient tumour cells in vitro.


In accordance with the suggested adenoma–carcinoma sequence of the colon, four patients reflected the progressive accumulation of genetic defects in synchronously appearing tumours during carcinogenesis. However, two patients with non-hereditary malignomas presented different genetic instabilities in different but synchronously appearing tumours suggesting non-clonal growth under almost identical conditions of the environment. Thus, sporadically manifesting multiple lesions of the colon were not necessarily driven by similar genetic mechanisms. Premalignant lesions may transform into malignant tumours starting from different types of genetic instability, which indicates independent and simultaneous tumorigenesis within the same organ. © 2000 Cancer Research CampaignThe colorectal adenoma–carcinoma sequence represents a well-known paradigm for the sequential development of cancer driven by the accumulation of genomic defects. Although the colorectal adenoma–carcinoma sequence is well investigated, studies about tumours of different dignity co-existent in the same patient are seldom. In order to address the distribution of genetic alterations in different lesions of the same patient, we coincidently investigated carcinomas, adenomas and aberrant crypt foci in patients with sporadic colon cancer. By utilizing polymerase chain reaction, single-strand conformation polymorphism, heteroduplex-analysis, restriction fragment length polymorphism, protein truncation test and sequencing techniques we looked for mutations and microsatellite instability of APC, H-


Human ovarian carcinoma cells obtained from ascites were tested for susceptibility to lysis by peripheral blood NK cells, alpha-interferon-activated NK cells, and interleukin 2-activated killer cells. Cryopreserved tumour cell preparations were used to allow repeated testing of the same target, and the tumour cells were fractionated using albumin density gradients to determine if fractions containing clonogenic (stem) cells were killed. Four tumour cell donors were studied and each showed a different pattern of susceptibility of unfractionated tumour to lysis by different effector cells. Using fractionated tumour cells, we found that NK and interferon-activated NK cells did not always lyse cells in the clonogenic fractions and that interferon activation could in some cases shift killing away from the clonogenic fractions and towards the peak of proliferating (but not self-renewing) colony forming cells. Interleukin 2-activated killer cells (LAK) however, killed the fractions containing clonogenic cells in all 4 cases. The magnitude of killing seen when fractions of the original tumour were tested were often striking when compared to lysis of the unfractionated cells. Apparent heterogeneity between patients and stem cell susceptibility to effector cells may be important determinants of the efficacy of treatment of patients with biologic response modifiers such as interferon and interleukin 2.


Damage of laryngeal mask airway and other supraglottic airway devices has always been a matter of concern. Although manufacturer recommends maximum 40 uses of LMA (and its congeners) but damage before 40 uses needs to be evaluated. We hereby, describe a novel method of repair of supraglottic devices when damage occurs at mask inflation line or pilot balloon valve assembly. Various supraglottic airway devices like laryngeal mask airway (LMA), Proseal LMA, laryngeal tube etc. are novel innovative devices for upper airway management.Laryngeal mask airway and its variants are most often used in elective surgical procedures, emergency difficult airway management and in fields or camp surgeries. The currently manufactured model is made of silicone rubber and needs special care for its longitivity . The devBiting of airway tube or LMA damage often occurs at cuff portion or airway tube shaft. The junction where airway tube is attached to the cuff may break while inserting laryngeal cuff in oral cavity and this may cause an irreparable loss of the equipment. The mask inflation line or valve assembly of supraglottic airway devices like LMA (and its congeners ) etc. can also damage while handling, washing or cleaning of expensive equipment. We hereby, recommend novel indigenous method of securing various supraglottic airways when damaged at mask inflation line or valve assembly.LMA and its variants contain mainly 4 parts- cuff, connector, airway tube and mask inflation line  to the mask inflation line.The steps of repairing the supraglottic devices (LMA or its congeners) are as follows:1. Expose and clear the damaged part of pilot balloon assembly Fig. 2. Attach mask inflation line  to 'Threeway Stopcock and closed leur access split septum port' assembly by inserting inflation line (teared end) inside End A of Threeway stopcock)Fig. .3. End B of Threeway stopcock is attached to closed leur access split septum port4. Completely repaired LMA assembly is ready  in 1981, it has been successfully used as a ventilatory device in both predicted and unpredicted difficult airway. In certain situations, such as cardiac arrest, there is no time to predict and/or act on the prediction of a difficult airway and supraglottic airway devices act as rescue airway management devices . The othDuring training period of residents, the probability of tearing of mask inflation line of any supraglottic devices is very high and consequently it leads to irrepairable loss of equipment. Further, the mask inflation line may get damaged during extubation phase and this can occur most often in patients with surgeries in psychiatric patients. In situations like cardiac arrest or unanticipated difficult airway if SAD is damaged from inflation line or valve assembly then it may create panic in anaesthesiologist's mind.The present supraglottic equipment repairing technique is a novel indigenous method and can be useful for anaesthesiologists working in developing countries and working in fields/camps. This repairing can also be utilized in cases of patients with trauma and in emergency airway management when LMA or such expansive equipments may damage. This indigenous method can be applicable to expansive equipments like LMA proseal, LMA C-trach, Laryngeal Tube, Laryngeal Tube Suction, ILMA, ETT of ILMA etc. and the cost-effectiveness of equipment can be maintained by this simple, cheap and easier repair technique.


Multiple sclerosis (MS) is a central nervous system disease in which activated            autoreactive T-cells invade the blood brain barrier and initiate an inflammatory            response that leads to myelin destruction and axonal loss. The etiology of MS, as            well as the mechanisms associated with its unexpected onset, the unpredictable            clinical course spanning decades, and the different rates of progression leading            to disability over time, remains an enigma. We have applied gene expression            microarrays technology in peripheral blood mononuclear cells (PBMC) to better            understand MS pathogenesis and better target treatment approaches. A signature            of 535 genes were found to distinguish immunomodulatory treatment effects            between 13 treated and 13 untreated MS patients. In addition, the expression             pattern of 1109 gene transcripts that were previously reported to significantly             differentiate between MS patients and healthy subjects were further analyzed to              study the effect of cytokine-related pathways on disease pathogenesis. When              relative gene expression for 26 MS patients was compared to 18 healthy controls,              30 genes related to various cytokine-associated pathways were identified. These              genes belong to a variety of families such as interleukins, small inducible cytokine              subfamily and tumor necrosis factor ligand and receptor. Further analysis disclosed              seven cytokine-associated genes within the immunomodulatory treatment              signature, and two cytokine-associated genes SCYA4               and FCAR  that were common to both the MS gene              expression signature and the immunomodulatory treatment gene expression              signature. Our results indicate that cytokine-associated genes are involved in various            pathogenic pathways in MS and also related to immunomodulatory treatment effects.


Most lumbar artificial discs are still composed of stainless steel alloys, which prevents adequate postoperative diagnostic imaging of the operated region when using magnetic resonance imaging (MRI). Thus patients with postoperative radicular symptoms or claudication after stainless steel implants often require alternative diagnostic procedures.Possible complications of lumbar total disc replacement (TDR) are reviewed from the available literature and imaging recommendations given with regard to implant type. Two illustrative cases are presented in figures.Access-related complications, infections, implant wear, loosening or fracture, polyethylene inlay dislodgement, facet joint hypertrophy, central stenosis, and ankylosis of the operated segment can be visualised both in titanium and stainless steel implants, but require different imaging modalities due to magnetic artifacts in MRI.Alternative radiographic procedures should be considered when evaluating patients following TDR. Postoperative complications following lumbar TDR including spinal stenosis causing radiculopathy and implant loosening can be visualised by myelography and radionucleotide techniques as an adjunct to plain film radiographs. Even in the presence of massive stainless steel TDR implants lumbar radicular stenosis and implant loosening can be visualised if myelography and radionuclide techniques are applied. Total disc replacement (TDR) is an evolving surgical option for patients with degenerative disc disease ,2. The aIt is widely accepted that lumbar disc arthroplasty is associated with several access- and implant-associated complications. Unfortunately imaging modalities after TDR cannot simply be transferred from fusion patients. In this review the complications following total disc replacement are discussed and guidelines for imaging following lumbar disc arthroplasty are provided.All commercially available lumbar artifical discs are composed of a stainless steel core with titanium surfacing Table . This haMyelography alone and later combined with CT has for many years been the primary diagnostic means in suspected lumbar spinal stenosis. Myelographic findings in central canal stenosis include complete or partial block to the contrast column, appearing as an hour-glass constriction on the AP view. There appears to be poor correlation between clinical symptoms and findings at myelography, with myelography commonly showing more abnormalities than would be expected ,7, althoScintigraphy with 99mTc radionuclide tagged white blood cells can be a helpful means in diagnosing suspicious infections . 99mTc-HPostoperative low-grade-infection or implant loosening can be hard to visualise. As in hip or knee arthroplasty radionuclide scintigraphy has some value with regard to sensitivity, but has lower specificity with regard to loosening or low-grade infection. Gallium 67 scans have a sensitivity and specificity of 89% and 85% .In the last years the increased availability of positron emission tomography (PET) enabled postoperative diagnostics with greater specificity for infection. Gratz et al  found flDespite the biomechanically appealing concept of motion preservation, lumbar disc arthroplasty is associated with access-related and implant-specific complications. Access and implant related complications can be due to technical errors or may be due to abnormal anatomy . ImplantAll commercially available FDA-approved lumbar total disc replacements require an anterior access for the implantation of artificial discs. Lumbar discs can be implanted via a transperitoneal or a retroperitoneal approach, of which the latter is favoured by most surgeons. Complications with regard to these accesses are well known and differ not from those of anterior fusion, even though TDR-implantation requires a wider exposure of the disc, which often requires more traction and pressure of retractors on the surrounding tissue . EspeciaMost access-related complications can be visualised by sonography and abdominal CT with intravenous contrast. In few cases an angiography or an uretherography may be necessary.There is no specific data on the occurrence of infection of artificial discs, but early and mid-term infections may occur as likely as in anterior fusion with 0 and 12% in lumbar instrumented fusion . NeverthPostoperative infections of the spine can optimally be visualised by MR with contrast. A sensitivity and specificity of 93% and 97% makes the MRI superior to all other radiological imaging modalities . If MRI-Daly et al presented a case series of five anterior dislocations of the Charité (Link) or the AcroDisc (DePuy) disc prosthesis causing compression and erosion of vascular structures. In figure Mobile polyethylene cores can dislocate, too, and can cause compression to anterior abdominal or pelvic structures. This is especially true in non-constrained PE inlays (i.e. Charité TDR) Mathew et al  presenteImplant dislocation can easily be diagnosed with plain radiographs figure . This isThe long-term investigation of the first implanted lumbar discs  by Putzier et al  includedImplant fractures are mostly visible on plain radiographs.Since implant wear has for decades been a major issue in hip and knee-arthroplasty it is not surprising that other weight-bearing implants with articulating surfaces – as in lumbar disc prostheses – will have to deal with implant wear and loosening, too. Punt et al  retrieveMetal-metal articulations are known to cause metallosis with chronic inflammation leading to implant loosening . FrançoiDiagnostics of implant loosening range from standard plain radiographs – revealing radiolucencies around the implant – to scintigraphy and PET, showing increased metabolism in the bone-implant interface.The case in figure MR diagnostics are the gold-standard for investigation of spinal canal pathologies. In cases where this is not possible – i.e. stainless steel TDR – other modalities as CT and myelography have to be considered.Bendo et al  found thTo control implant positioning plain radiographs are usually sufficient.Long-term investigations failed to present preservation of motion of the operated segment. Putzier et al  found thTo diagnose fusion either a CT-scan showing ankylosis or dynamic radiographs excluding remaining segmental mobility are required.In osteoporosis or poor bone quality, years after the original implantation, the artificial disc can subside into the endplates, causing secondary implant dislocation and increasing pain. To avoid this complication the choice of the largest possible implant and a placement close to the rim of the endplates is recommended .To visualise implant subsidence plain radiographs are sufficient. If an osteoporotic vertebral endplate fracture is suspected, radionuclide scans may show increased uptake of the fractured vertebra.Postoperative imaging of lumbar total disc replacement requires alternative imaging techniques to conventional MRI-diagnostics. All currently available lumbar artificial discs contain stainless steel alloys, and, therefore, generate major artefacts on MRI. Alternative imaging modalities include plain film radiographs, myelography and radionucleotide imaging. These imaging modalities should be utilised in cases with suspected postoperative complications after lumbar TDR.The appearance of artificial discs on the implant market meant a drawback in postoperative radiological transparency with regard to MR-diagnostics, since all lumbar disc prostheses are still based on stainless steel alloys, thus causing major artefacts. Other imaging modalities are available and are in the first line of choice in cases with suspected postoperative complications after lumbar TDR. Until lumbar titanium artificial discs are available postoperative imaging of the operated segment requires altered radiological strategies.The authors have no competing interests with regard to the publication of this manuscript.YR wrote the manuscript and BS critically revised it. Both authors read and approved the final version of the manuscript


Serum bone alkaline phosphatase (BALP), serum carboxy-terminal propeptide of type I procollagen (PICP) and serum bone gla protein (BGP) as markers of bone formation, serum carboxy-terminal telopeptide of type I collagen (ICTP) as a marker of collagen resorption and fasting molar ratio of urinary calcium to creatinine (CaCr) and serum parathyroid hormone (PTH) were determined in two groups of cancer patients: 48 with advanced or metastatic disease with negative bone scan and 174 with bone metastases categorised as having lytic, mixed or blastic lesions and with more or fewer than or equal to three sites involved. In patients without apparent bone involvement, bone formation markers were rarely elevated. Conversely, serum ICTP was frequently found to be supranormal, showing it to be a non-specific marker for early detection of bone metastases. As expected, values of bone formation markers progressively increased in patients with lytic, mixed and blastic lesions, but ICTP levels did not show any differences according to the types of bone appearances, confirming previous reports of elevated osteoclast activity also in patients with apparent blastic lesions. Serum PTH increased significantly in patients with lytic compared with patients with mixed and blastic appearances, paralleling the bone formation markers, but CaCr showed the opposite pattern. These data are compatible with calcium entrapment in the bone in patients with increased osteoblast activity. This so called 'bone hunger syndrome' is further confirmed by the finding that in the subgroup of blastic appearances CaCr diminished whereas both ICTP and PTH increased according to the extent of tumour load in the bone.


Epidemiologic and pathologic features of prostate cancer have given rise to an interestin focal treatment for carefully selected patients. Prostate cancer remains highlyprevalent, particularly in the U.S. and Europe. As screening programs have become moreaggressive and widespread, a substantial proportion of men diagnosed with localizedprostate cancer have disease characteristics associated with a low risk of progression. Treatments such as radical prostatectomy and radiation therapy can lead to durable recurrence-free survival in most patients, but carry variable risks of bowel, urinary, andsexual side effects. Few men and few urologists are comfortable leaving a potentiallycurable prostate cancer untreated. Focal therapy offers an attractive alternative for thepatient faced with a choice between aggressive local intervention (radiation or surgery)and watchful waiting. Contemporary diagnostic biopsy strategies and imaging tools, andthe development of predictive statistical models (nomograms), have led to improvementsin tumor characterization and risk stratification, making focal therapy a viable treatmentoption for specific men. This article reviews the rationale and indications for focaltherapy and highlights vascular-targeted photodynamic therapy (PDT) as one of manypromising focal therapy techniques.


Accurate amino acid insertion during peptide elongation requires tRNAs loaded by cognate amino acids and that anticodons match codons. However, tRNA misloading does not necessarily cause misinsertions: misinsertion is avoided when anticodons mismatch codons coding for misloaded amino acids.Occasional compensation of misacylation by codon-anticodon mismatch necessarily occurs. Putatively, occasional error compensation may be enhanced beyond the random combination of independent errors in tRNA loading and codon-anticodon interactions: tRNA misacylation might alter potentials for codon-anticodon mismatches, perhaps specifically increasing potentials for mismatching those codons coding for the misacylated non-cognate amino acid. This hypothetical phenomenon is called 'error coordination', in distinction from 'error compensation' that assumes independence between misacylation and mismatch.Eventually, the hypothesis should be tested for each combination of amino acid misacylation and codon-anticodon mismatch, by comparing stabilities or frequencies of mismatched codon-anticodon duplexes formed by tRNAs loaded by their cognate amino acid with stabilities formed by that tRNA when misloaded with the amino acid coded by the mismatched codon. Competitive mismatching experiments between misloaded and correctly loaded tRNAs could also be useful, yet more sophisticated experiments.Detecting error coordination implies estimating error compensation, which also promotes protein synthesis accuracy. Hence even in the absence of evidence for error coordination, experiments would yield very useful insights into misacylation and mismatch processes. In case experiments consider post-transcriptional RNA modifications , results on codon-anticodon mismatches would enable significant improvements and sophistications of secondary structure prediction softwares. Positive results would show that protein translation enhances accuracies of products, not of single steps in the production. Ancient translational machineries putatively optimized error coordination, especially before tRNA editing by tRNA synthetases evolved: few primitive, but functionally versatile tRNA species perhaps executed low accuracy translation. Systems artificially designed/selected for low complexity and high efficiency could make use of this property for anticodons with high levels of error compensation and coordination. The two major groups of tRNA synthetases, class I and II, seem to minimize impacts of misinserted amino acids in protein sequences by tRNAs that were misloaded by these tRNA synthetases ,2. AccurDespite editing, misinsertion sometimes occurs. However, misinsertion is avoided if the misloaded tRNA's anticodon mismatches a codon coding for the misloaded amino acid, a phenomenon potentially meaningful for organisms. If mismatch is unaffected by misacylation, combinatorial probabilities predict their joint occurrence. This phenomenon is called here error compensation. The hypothesis suggested here is that misacylation affects mismatch potentials and hence joint occurrences of misacylations and mismatches do not match combinatorial probabilities, called error coordination. Error compensation is an unavoidable phenomenon whose potential effects are explored elsewhere. Here I focus on error coordination, which is a more readily testable phenomenon because it can be compared to a null hypothesis, that defined by error compensation, hence its detection implies estimating error compensation.The tRNA's acceptor stem and the anticodon are not adjacent. Hence properties of amino acids may have little impact on anticodon potentials for interactions with codons. It is nevertheless plausible that such effects exist, even if subtle. These may be larger when the tRNA molecule has relatively low molecular weight , and/or is relatively small. Sometimes, small tRNA-like molecules might transfer amino acids, as suggested by the observation of aminoacylated RNA corresponding to the mitochondrial light strand replication origin  and hypoAnother amino acid property potentially affecting error coordination is its charge. Charge differences between cognate and misloaded amino acid could affect the tRNA's electro-magnetic properties, including of its anticodon. Codon-anticodon interactions depend on electro-magnetic properties of the interacting atoms . Misacylations altering amino acid charges could affect codon-anticodon interactions: positive charges  might enhance positive partial dipole moments, decrease negative ones; the opposite would occur for negative charges (aspartic and glutamic acids). These effects would alter codon-anticodon duplex stabilities, including for mismatches. Such effects on anticodons are difficult to predict, because tRNA acceptor stems are not adjacent to anticodons. Charge effects on anticodon interactions may be buffered as well as enhanced by particular RNA sequences connecting amino acid and anticodon. Perhaps RNA rich in pyrimidines (which have high dipole moments) functions as conductor of effects of amino acid charge on anticodons. Softwares predicting dipole moments of proteins exist ,18, hencEscherichia coli and Homo sapiens).Other amino acid properties might also affect codon-anticodon interactions. This suggests that experimental observations on effects of misacylations on mismatches should be made for all combinations of misacylations and codon-anticodon mismatches, because effects of swapping one amino acid with another may be unpredictable, as different amino acid properties may be relevant. As noted above, specific tRNA sequences may also influence. If this is the case, models predicting these influences would be particularly important for predicting error coordination, because tRNA sequences frequently vary between species and individuals, and it is unrealistic that experimental data will be produced for more than a few model species , so as to test for associations between that quantity and its assumed effects on protein metabolism and related phenomena at higher organismic levels . Error compensation is a case where a null hypothesis is in itself biologically interesting, similar to the neutral theory of evolution. Error coordination is more adequate in relation to designing classical manipulative experimental tests. It expects that misacylated tRNAs form more stable (or more frequently) mismatched codon-anticodon duplexes with codons coding for the misloaded amino acid than the same tRNA when it is correctly aminoacylated. This can be tested by comparing results from different, independent experiments. Experiments designed to estimate 'competition' between molecules can also be designed. For example, matching and mismatching codons are put in presence of either correctly or incorrectly loaded tRNAs, and duplex stabilities/frequencies of correctly matched and mismatched anticodons are compared (one way competition between codons). Mixing correctly and incorrectly loaded tRNAs with either matching or mismatching codons would estimate one way competition between correctly and incorrectly loaded tRNAs. Two-way competition  could also be considered. Ideally, such experiments should be done for all combinations of codons, anticodons and amino acids.Recent observations suggest that ribosomes select against misacylated tRNAs . Error cPrecisely estimating error coordination would imply producing data that include effects of posttranscriptional tRNA modifications -22, in pError compensation and coordination suggest that accurate translation has probabilistic properties. Design of artificial translational systems might take advantage of error compensation and coordination. Primordial systems at the origins of life perhaps used few versatile, yet accurate tRNAs (or tRNA-like molecules), thanks to high error compensation and coordination. Various editing mechanisms ,26 existThe author declares that he has no competing interests.HS is the sole author of this publication.


The lengthof time the recipient remained euglycemic was used to measurethe ability of the transgenes to protect the graft fromautoimmune destruction. Although the results of these cotransfectionsgave little evidence of a synergistic relationship,they were useful to show that gene combinations can be used to more efficiently protect islet grafts from diabetogenicT cells.Islet transplantation therapy would be applicable to awider range of diabetic patients if donor islet acceptanceand protection were possible without systemic immunosuppressionof the recipient. To this aim, gene transferto isolated donor islets ex vivo is one method that hasshown promise. This study examines the combined effect ofselected immunomodulatory and anti-inflammatory genesknown to extend the functional viability of pancreatic isletgrafts in an autoimmune system. These genes, indoleamine2,3-dioxygenase (IDO), manganese superoxide dismutase(MnSOD), and interleukin (IL)-1 receptor antagonist protein(IRAP), were transferred to isolated NOD donor isletsex vivo then transplanted to NOD


Xenopus thymustumor-derived lymphoid cell lines undergoing apoptosis and also in apoptotic, nontransformedsplenocytes. Cultured Xenopus tumor lymphoid cells induced to undergo, apoptosis by serumdeprivation or treatment with the calcium ionophore, ionomycin, displayed altered morphologytypical of apoptotic cells, as judged by flow cytometric light-scatter characteristics and byfluorescence microscopy of acridine-orange-stained cells. Flow cytometry of permeabilized cellsand fluorescence microscopy of acetone-fixed cytospins revealed that apoptotic Xenopus tumorcells, especially those displaying loss or condensation of DNA, displayed increased expressionof epitopes recognized by a rabbit polyclonal antibody against ASP. Flow cytometry confirmedthat ASP is also expressed in splenocytes induced to apoptose by culture in ionomycin orfollowing concanavalin A stimulation. No increased expression of ASP was seen when lymphoidtumor cells or splenocytes were induced into necrosis by overdose with the antifungal agentamphotericin B. Western blotting with antibody against ASP identified the emergence of severalprotein bands in cell lysates from apoptotic, but not necrotic, Xenopus tumor cells. The new andsimple methodology for identifying apoptotic cells described here is likely to be of value to thosestudying immune system development and associated programmed cell death in Xenopus.A novel apoptosis-specific protein (ASP) has recently been identified in the cytoplasm ofapoptotic mammalian cells. This paper investigates whether ASP is found in


Despite previous advances on miRNA regulation of gene expression, little has been investigated from a genome scale.To gain new insight into miRNA regulation in humans, we used large scale data and carried out a series of studies to compare various features of miRNA target genes to that of non-miRNA target genes. We observed significant differences between miRNA and non-miRNA target genes for a number of characteristics, including higher and broader mRNA expression, faster mRNA decay rate, longer protein half-life, and longer gene structures. Based on these features and by analyzing their relationships we found that miRNA target genes, other than having miRNA repression, were most likely under more complex regulation than non-miRNA target genes, which was evidenced by their higher and broader gene expression but longer gene structures. Our results of higher and broader gene expression but fast mRNA decay rates also provide evidence that miRNA dampening of the output of preexisting transcripts facilitates a more rapid and robust transition to new expression programs. This could be achieved by enhancing mRNA degradation through an additive effect from multiple miRNA targeting.Genome-scale analysis on the nature of miRNA target genes has revealed a general mechanism for miRNA regulation of human gene expression. The results of this study also indicate that miRNA target genes, other than having miRNA repression, are under more complex gene regulation than non-miRNA target genes. These findings provide novel insight into miRNA regulation of human gene expression. Caenorhabditis elegans as post-transcriptional regulators of genes involved in developmental timing ,  were then subjected to the prediction of miRNA binding sites through the RNA22 web server Supplemental Figure 1. Shows the expression differences between non-miRNA and miRNA target genes predicted from TargetScanS and RNA22.Click here for fileSupplemental Figure 2. Shows the expression breadth differences between non-miRNA and miRNA target genes predicted from TargetScanS and RNA22.Click here for fileSupplemental figure 3. Shows the correlation between mRNA expression and decay rate for miRNA target genes predicted from TargetScanS.Click here for fileShows the correlation between mRNA expression and decay rate for miRNA target genes predicted from RNA22.Click here for fileShows the correlation between gene expression and protein stability for miRNA target genes predicted from TargetScanS.Click here for fileShows the correlation between gene expression and protein stability for miRNA target genes predicted from RNA22.Click here for file


Specialized cells found near the dermal-epidermal junction, characterized by numerous membrane-bound granules with dense cores. The cells were named after German anatomy professor Friedrich Sigmund Merkel, who experimented with osmium tetroxide staining and described these cells in 1875. First identified in the skin of a mole, they were later found in human skin. The cells are responsible for the highly malignant skin tumor known as Merkel cell carcinoma. An infectious cause for Merkel cell carcinoma has been proposed.


A middle aged chronic alcoholic presented with deep jaundice, markedly enlarged and tender spleen with leukoerythroblasticblood picture and bone marrow biopsy showing mild fibrosis. He was tested negative for HIV, hepatitis B and C viruses.Besides very high serum bilirubin, alkaline phosphatase was raised four times the normal value. Contrast enhanced CTshowed enlarged spleen and liver with multiple heterogenous lesions in spleen and tiny hypo-dense lesions in liver. Inhospital, he developed haemolytic uraemic syndrome and succumed to his illness. At autopsy spleen weighed 5200 gms andvariegated in appearance due to large areas of necrosis and whitish tumour nodules. Histology revealed morphology of anangiosarcoma. Liver was also infiltrated by the tumour mainly in and around portal tract areas.


To assess regional systolic function and global contractile function in patients with WPW Syndrome.pRS) or range (difference between maximum and minimum peak RS i.e. RangepRS). Spectral Doppler (continuous wave) measurements were acquired through the left ventricular outflow tract to determine Pre Ejection Period (PEP), Left Ventricular Ejection Time (LVET) and measures of left ventricular systolic performance.Eleven cases with manifest Wolff-Parkinson-White (WPW) syndrome in sinus rhythm were compared to 11 age matched controls. 2D strain analysis was performed and peak segmental radial strain (pRS) values obtained from basal ventricular parasternal short-axis images (70 ± 5 frames/sec) using a dedicated software package. Heterogeneity of radial strain pattern in six circumferential basal left ventricular segments was measured in terms of standard deviations of peak RS  and corrected PEP  were significantly longer in WPW patients compared to controls. The PEP/LVET ratio was also significantly greater in WPW cohort  suggesting global systolic dysfunction.LV segmental radial strain was profoundly heterogeneous in WPW cases in contrast to fairly homogenous strain pattern in normal subjects. Wide SDPatients with manifest preexcitation (predominantly those with right-sided pathways) have regional and global contractile dysfunction resulting from aberrant impulse propagation inherent to the preexcited state. Abnormal electrical activation of the accessory pathway results in characteristic electrocardiographic abnormalities and clinical symptoms manifesting as WPW syndrome .  Data oTraditionally, regional left ventricular function has been evaluated using visual wall-motion analysis as well as by other quantitative methods such as integrated backscatter, automatic border detection and tissue Doppler imaging (TDI) -9. HowevIt has recently become evident that chronic right ventricular apical  pacing induced dyssynchrony leads to  deleterious effects on left ventricular systolic function  ,13.  AccTo the best of our knowledge, no data on the prevalence of left ventricular dysfunction in patients with accessory pathway conduction exists in the literature. We sought to characterize regional left ventricular function in patients with manifest WPW syndrome by examining radial myocardial strain patterns. We also attempted to investigate the presence of global dysfunction using systolic time intervals.The study included 11 cases with manifest pre-excitation on surface ECG and an equal number of age-matched controls .  None oAll accessory pathways were localized using the algorithm proposed by Milstein and colleagues  on a staContinuous wave Doppler measurements were acquired through the left ventricular outflow tract. PEP was defined as the time from the beginning of the QRS complex to the onset of ventricular ejection (opening click). LVET was measured from the onset of ventricular ejection (opening click) to the closure of the aortic valve (closure click) . CorrectAll patients and controls were in sinus rhythm and image acquisition was performed in the resting state in the left lateral position. Standard short axis views at the level of mitral valve were obtained from the left ventricle (LV) at a frame rate of 70 ± 5 frames/second during end-expiratory apnea and stored in cine-loop format for subsequent offline analysis . The endocardial border was then traced using the built-in software at end-systole by a 'point-and-click' approach with care taken to adjust tracking of all endocardial segments. Upon defining this endocardial circle, a larger concentric circle was automatically generated outlining the epicardium with a default width of 11 mm and perimeter adjusted manually as needed to track the myocardium. Strain tracings were then generated using a dedicated software package  from a  six segment  LV model . Radial strain values at peak systolic period  were obtained for each individual LV segments using online calipers .pRS): One standard deviation of six  pRS   in each case. Range of pRS (RangepRS): Arithmetic difference between maximum and minimum of six pRS values in each case.For descriptive purpose, following parameters were calculated: Global LV Peak radial strain = Arithmetic mean of pRS of six individual segments for each case as a surrogate marker of overall LV peak systolic radial strain. To measure heterogeneity, following dispersion indices were calculated ): Standard Deviation of pRS . Data are presented as mean ± SD unless stated otherwise. Non-parametric Wilcoxon's signed rank and the Mann-Whitney U test were used to compare the continuous variables in WPW patients and controls. All measurements were done by two independent observers with a minimal degree of variability. Intraclass correlation coefficients (ICC), commonly used as a measure of reliability, with a value of 1 representing a perfect correlation was used to quantify the intraexaminer and interexaminer variation. The ICC was calculated  from mean values according to Portney ,19.  TwoThe study cohort consisted of eleven cases  and age-matched eleven controls . Baseline characteristics of the study population and accessory pathway location are shown in pRS as well as RangepRS) were profoundly greater for WPW cases compared to healthy controls (p<0.001)  . This siAs shown in pRS and RangeSDpRS although the average global LV radial strain was similar to the healthy subjects (mean of pRS)}. Moreover, global systolic contractile function appeared to be depressed as well, as evident from systolic time interval analysis.Our findings suggest that patients with manifest WPW have evidence of regional contractile dysfunction. This is evidenced from a wide dispersion of pRS {higher SDEjection fraction (EF), the most frequently used index to assess global cardiac function is the LV stroke volume expressed as a percentage of the end-diastolic volume. This measure has gained popularity largely because it is widely available, easily obtainable and also because no other alternative optimal measures of myocardial contractility have emerged despite extensive investigation. Nevertheless, accurate EF calculation using the recommended Simpsons biplane method requires precise measurement of LV end-diastolic and end-systolic volumes in multiple views with special attention to avoid foreshortening of the LV cavity. Averaged values from both 4-chamber and 2-chamber views, preferably from 2 or 3 beats are recommended for more reliable estimation of ventricular volumes and EF. However, this technique is predicated on geometric assumptions  and although it is fairly accurate in ventricles with symmetric contractility, it is less reliable in ventricles with overt/subtle regional wall motion abnormalities or geometrically deformed ventricles such as ventricular aneurysms. This limitation of the Simpsons method to reflect regional asymmetry of LV function is the reason why EF was not selected as the preferred metric to assess global systolic function in the present study.Systolic and diastolic 'wall motion' abnormalities have been well described  in patients with WPW Syndrome -3,5,20. In our study, WPW cases exhibited a wide dispersion in pRS values of LV segments during systole suggesting markedly heterogenous strain pattern and contractility. It has to be emphasized that wall motion abnormalities are not necessarily always associated with altered contractility. Toyoda et al studied interventricular septal (IVS) contractile patterns in patients post coronary artery bypass surgery (CABG) and reported that peak tissue Doppler velocities in the IVS were attenuated . HoweverRadial strain data obtained in our patients extends the well-recognized observations of pre-excitation on wall motion and unequivocally demonstrates its detrimental effects on regional left ventricular function.The transmural arrangement of myocardial fibers is not uniform across the wall of the LV. Subendocardial and subepicardial muscle bundles are aligned longitudinally (long axis contraction), with a slight spiral arrangement, and midwall fibers are aligned circumferentially . Although the precise mechanism for abnormal contractile function in the pre-excited state remains speculative, we believe that accessory pathway conduction leads to ventricular depolarization via myocyte-myocyte conduction as opposed to the normal orderly propagation of the impulse via the His-Purkinje system. Depending on the degree of pre-excitation, ventricular insertion site of bypass tract and/or layer of muscle fibers/bundles being recruited, further heterogeneity of depolarization may ensue. As observed with dependent right ventricular apical pacing  it is plSystolic time intervals have been reported as reliable surrogate parameters of left ventricular systolic function. Electromechanical systole comprises the PEP and LVET. LVET is the effective contraction phase during electromechanical systole. Weissler and co-workers -18 have During the cardiac cycle, regional deformation of the myocardium occurs in three major directions: longitudinally, circumferentially and radially, all of which can be quantified using 2-dimensional strain techniques providing real-time automatic assessment of regional cardiac function. This technique analyzes myocardial motion objectively by tracking natural acoustic markers in grey scale ultrasonic images in two dimensions (speckle tracking) and is a validated Doppler-independent method of quantifying regional cardiac deformation ,11,27. TWe found the dispersion indices like standard deviation or range segmental radial strain to be superior estimate of heterogeneity of regional contractility compared to mean radial strain. Interestingly, we also observed hypercontractility in segments diametrically opposite to those with impaired radial strain probably accounting for the lack of difference in mean radial strain values and ejection fraction between groups.Abnormal motion does not always imply contractile dysfunction. With 2D strain imaging, an angle-independent quantification of regional cardiac deformation, relatively independent of wall motion is possible. Our data suggests that the preexcited state is associated with an impairment of regional and global left ventricular contractility. In some respects, the mechanism by which RV apical pacing or left  bundle branch block adversely influence LV contractility in the setting of congestive heart failure appear to be similar to those responsible for impaired contractility in the pre-excited state; both essentially mediated by  electromechanical delay. The extent, progression and reversibility of left ventricular dysfunction in the setting of  chronic  preexcitation  however, is unknown but  certainly merits further study.The number of patients enrolled was limited and they predominantly appeared to have right-sided pathways, even though we enrolled consecutive patients; whether or not patients with left sided pathways have disordered contractility is uncertain. The accuracy of pathway localization using the surface ECG has inherent drawbacks; clearly localization of pathways by electrophysiological studies would be desirable. Speckle Tracking Imaging is very image quality dependent and short axis images cannot eliminate longitudinal motion entirely. We found frame rates in the range of 65 Hz  to be most suitable for speckle-tracking analysis and the algorithm performed poorly with frame-rates of > 100 Hz.We used a modified method for systolic time interval assessment using Doppler-based data but had a control group for comparison; however, direct comparison of normative values with established techniques would have to be done with caution. Controversy exists regarding 'rate' correction for systolic time intervals; it is also not clear whether the prolonged PEP intervals ought to be corrected in the setting of LV conduction blocks. No specific recommendations relating to PEP adjustments in patients with pre-excitation could be found in the literature.Our observations indicate that patients with manifest WPW (predominantly right-sided pathways) have impairment of regional contractility as ascertained by radial strain dispersion parameters, resulting from the abnormal temporal sequence of activation in the pre-excited state.  Differences in surrogate measures of global contractility such as PEP/LVET seem to indicate global LV dysfunction in this cohort of patients. Our findings will need to be validated in a larger group of patients that includes left-sided pathways.


Patients with head and neck cancer were treated with synchronous radiotherapy and chemotherapy . Before treatment, mucositis was absent and low amounts of prostaglandin-like material were extracted from peripheral plasma. As treatment proceeded mucositis occurred, and its degree correlated with the amount of prostaglandin-like material extracted from the plasma. Some patients were given moderate doses of drugs which inhibit prostaglandin synthesis, but mucositis still occurred.