The existing cluster kernel methods based on neighborhoods and profiles and the Markov clustering algorithms are currently the most popular methods for protein family recognition. The deviation from random walks with inflation or dependency on hard threshold in similarity measure in those methods requires an enhancement for homology detection among multi-domain proteins. We propose to combine spectral clustering with neighborhood kernels in Markov similarity for enhancing sensitivity in detecting homology independent of “recent” paralogs. The spectral clustering approach with new combined local alignment kernels more effectively exploits the unsupervised protein sequences globally reducing inter-cluster walks. When combined with the corrections based on modified symmetry based proximity norm deemphasizing outliers, the technique proposed in this article outperforms other state-of-the-art cluster kernels among all twelve implemented kernels. The comparison with the state-of-the-art string and mismatch kernels also show the superior performance scores provided by the proposed kernels. Similar performance improvement also is found over an existing large dataset. Therefore the proposed spectral clustering framework over combined local alignment kernels with modified symmetry based correction achieves superior performance for unsupervised remote homolog detection even in multi-domain and promiscuous domain proteins from Genolevures database families with better biological relevance. Source code available upon request. Contact:  The remote homology detection from available protein sequences is one fundamental problem in comparative genomics. With higher sequence similarity, several panoply of methods can detect homologs accurately. However detecting remote homologs with subtle sequence similarity still remains a challenging problem.In general, there are three categories of methods to solve this problem – simple approaches based on sequence similarity like BLAST or Smith-Waterman Recently, the discriminative kernel methods with SVMs like mismatch string kernels To compute the sequence distances, some groups utilized Connected Component Analysis(CCA) The semi-supervised protein clustering achieved efficiency earlier, introducing the neighborhood vector over profiles in cluster kernels by Symmetry is an inherent feature to enhance recognition and reconstruction of shapes and objects. It reflects to be powerful for recognizing homolog protein clusters in kernel space. In In this work, at first we develop new valid Mercer kernels based on similarities explicitly in local alignment methods like BLAST and PSI-BLAST. We present two positive semi-definitive local-alignment kernels based on the singular-value decompositions of respectively MCL similarity scoring and position-specific scoring matrices (profiles). The Markov cluster similarity kernel further with the neighborhood feature vectors is enhanced. Furthermore incorporating the mismatches with profiles the diagonal dominance issue problem is reduced. This enables more accurate detection of remote homologs boosted by similarity deemphasizing multi-domain proteins. To reduce promiscuous domain problems, we further incorporate the spectral clustering approach over kernel matrices to alleviate inter-cluster edges implicitly selecting the leading eigenvectors from ‘global’ distances without using any hard-threshold. Finally, we introduce the modified-symmetry based correction over the homolog distributions in Hilbert space. This reduces number of singletons (represented as outliers) and classifies multi-domain proteins into more biologically-significant clusters with closest nearest-neighbor homologs from different domains. Contradicting with earlier discriminative approaches, this approach detects remote homology among unlabelled multi-domain proteins without any prior annotation. Local-alignment kernels or Markov similarities are combined cascadingly with neighborhoods in spectral clustering, which are further enhanced by modified-symmetry based correction.We experiment all our kernel frameworks over the multi-domain proteins from Genolevures Yeast database In this section, we briefly describe existing state-of-the-art cluster kernel methods for remote homolog proteins detection and the modified symmetry based distance measure for clustering.In semisupervised learning, To project the selection of closely related neighbor sequences through evolution from PSI-BLAST profiles in mismatch kernel, Among the different distance measures for clustering like Euclidean, Pearson correlation or Spearman distance, none can detect symmetrical overlapping clusters. Su and Chou Candida glabrata, Eremothecium gossipii, Kluyveromyces Lactis, Yarrowlo lipotytica, Zygosaccharomyces rouxii, Saccharomyces kluyveri, Kluyveromyces thermotolerans, Debaryomyces hansenii, Saccharomyces cerevisiae) The Genolevures database explores nine complete genomes .However utilizing the HSP (high-scoring segment pair) score of BLASTP results directly resembles the functionality of mismatch string kernel II). A related protein structure kernel, based on MAMMOTH score To explore the statistically significant alignments produced by BLASTP with the position-specific score matrix (http://micans.org/mcl/) The Markov Cluster algorithm(MCL – III).We incorporate the neighborhood probabilistic representation of each input sequence over the above explained MCL similarity scores, following earlier neighborhood mismatch kernel IV).To construct the kernel based on profile information, we generate a variant kernel with MCL similarity and PSI-BLAST profile-based scores. Following the profile mismatch kernel based on spectrum kernel V, VII) and similarly the combined IV, VI). Therefore our combined local alignment kernels , which are the tensor products The position specific scoring kernels are based on the singular value decompositions and therefore, are Mercer's kernels. Again the neighborhood similarity kernel and mismatch profile kernel are also proved to be Mercer kernels. We define the kernels combining For unsupervised classification, we apply the spectral clustering method directly to the combined local alignment cluster kernel matrices without using a transductive setting like in This algorithm also constructs the Markov transition matrix as used in Markov Clustering algorithm (MCL) The modified-symmetry based distance measure Furthermore to prove the non-negative definiteness in spectral kernel with modified symmetry, for arbitrary Therefore the spectral kernel matrix with modified symmetry norms is itself positive semidefinitive in nature. Alternatively, let IX, XI) and combined PSI-BLAST kernel with OMCL NM and OMCL MP kernels as respectively kernels .Accordingly, we correct the combined spectral kernel results with modified symmetry with reallocating proteins to a cluster with its optimal modified symmetry distance norm less than the pre-defined threshold In this section the framework for the experiments and comparative results of all local alignment kernels and combined spectral kernels after modified symmetry based correction are described. The comparative study of the clustering solutions of the existing string Several frameworks have been implemented for demonstatating the performance of twelve different kernels proposed in this article. The I), PSI-BLAST kernel(II), OrthoMCL Neighborhood Mismatch III) and OrthoMCL Mismatch Profile IV) to classify the multi-domain protein families of our dataset with mean ROC and mean ROC50 scores. These results show that IV) performs best over all other methods indicating the influence of profiles in homolog detection. All the modified local alignment kernels outperforms simple score based kernels in this experiment. As an illustration, the distribution of ROC50 scores for all local alignment-based kernels is shown in III), IV) kernels retrieve approximately two times more ROC50 scores than the two simple score based BLASTP(I) and PSI-BLAST(II) kernels for similar number of families.VI) and VIII) kernels provide respectively ROC values V) and VIsI) kernels. VIII) outperforms all other methods with the highest ROC50 score of I) and PSI-BLAST (II) kernels cannot successfully perform in the absence of sufficient positive training data for a huge unlabelled protein database VI) and VIII) kernels combined with the proposed II) consistently show superior performance while significantly outperforms other combined kernels.In order to investigate the performance of our spectral kernels over simple alignment kernels, we combine all modified local alignment kernels using normal product. Combining X, XII).In the unsupervised setting of homolog detection, the simple score based kernels do not show very strong performance in comparison with the combined modified spectral alignment kernels. Incorporation of the modified symmetry based cluster correction imporves the performance further see  for unlaIX, X, XI, XII). These results show that X, XII), consistently outperform other combined kernels with higher ROC50 values.VI, VIII). The points fall approximately near evenly above and below the diagonal, indicating similar performance of both methods. However there exists more points on upper triangle of the VIII). I) and its improvement after combination with the XI). For most of the families, the XI) provides higher ROC50 scores than simple I). All the experiments demonstrate the utility of combined spectral kernel approaches with modified symmetry corrections in the remote homolog detection.We have presented and experimentally evaluated twelve spectral kernels for remote homology detection that classify protein sequences in comparison with the explicit evaluation of modified symmetry based proximity norm. These kernels measures sequence similarity on the unlabelled data. For this unsupervised protein family classification approach, we focus on our spectral clustering approaches with combined local alignment score-based valid kernels. This approach performs competitively with state-of-the-art neighborhood I), PSI-BLAST (II) and newly experimented OrthoMCL scores for kernel formations . After combined with neighborhood similarity and mismatch profile features , our proposed Mercer kernels provide significant solutions after introducing modified symmetry based updating  in spectral clustering results.Weston et al in I, II) proves to be a valid kernel for homology detection. Second, as discussed earlier in coperation of previously detected OrthoMCL scores to reduce the “recent” paralog effects in BLASTP/PSI-BLAST results gains significance. The neighborhood similarity and the mismatch profile kernel over OrthoMCL scores  also proves to be significant in comparison with earlier cluster kernels, reducing the diagonal dominance issue with arbitrary lower magnitude distribution of diagonal values. Third, we do not need to diagonalize the matrix of all labelled and unlabelled data as in Four major observations can be made by analysing different experiments presented in this article. First, the direct use of local-alignment based BLASTP and PSI-BLAST scores to create a kernel matrix with singular value decomposition  and XII) kernels respectively provide Dunn's index values of VII) and VIII) kernels in We evaluate the clustering solutions for all kernels objectively by measuring five validity measures Dunn, Davies-Bouldin, Kruskal, Rand and Jaccard indices as defined in III) and IV) kernels over those values I) and II) kernels, shows the significance of the Markov cluster similarity scoring kernels considering neighborhood similarity and mismatch profile respectively. The Rand index III), V) and VI) kernels respectively with increasing values of VI), X), VIII) and XII) kernels respectively further show the significance of modified symmetry based corrections over the clustering solutions provided by the combined local alignment spectral kernels. This shows superiority of the combined kernels even over local alignment kernels proving The increasing values of We evaluate the clustering solutions of our proposed kernels comparatively with those of the already-existing linear The homologous protein family detection tool within Hemiascomycete yeast complete genomes are appreciated in genomics to detect the conservation of function. Therefore, we propose a computational approach for computing local alignment based Mercer kernels utilizing Markov similarity to reduce “recent” paralog effects. Introducing profile mismatching and neighborhood feature vectors in combined Mercer kernels for spectral clustering, effectively escalates remote homolgy detection from unlabeled protein sequences database. We experiment the corrections by the modified symmetry based proximity norm producing improved clusters with reduced outliers/singletons and selecting more biologically significant domains for multi-domain proteins. Our position specific scoring kernel combined with the modified symmetry based corrections, achieves state-of-the-art prediction performance in the context of unsupervised homology detection. When combined with Markov cluster similarity kernels in well-known neighborhood feature space and considering neighborhood mismatch based on profiles, this approach performs superiorly over other cluster kernels. Therefore to detect the homologs among multi-domain proteins, our spectral clustering approach with combined local alignment kernels results in clusters having better more biological significance. We suggest that this is achieved due to the incorporation of the modified symmetry based corrections in kernel space.Table S1List of 23 multidomain family names used from Genolevures database.(TXT)Click here for additional data file.Table S2PSI-BLAST kernel matrix.(TXT)Click here for additional data file.Table S3OrthoMCL Neighborhood Mismatchkernel matrix.(TXT)Click here for additional data file.Table S4OrthoMCL Mismatch Profilekernel matrix.(TXT)Click here for additional data file.Table S5Combined+kernel matrix.(TXT)Click here for additional data file.Table S6Combined+kernel matrix.(TXT)Click here for additional data file.Table S7Combined+kernel matrix.(TXT)Click here for additional data file.Table S8Combined+kernel matrix.(TXT)Click here for additional data file.Table S9ROC50 scores obtained over all families.(PDF)Click here for additional data file.Table S10ROC scores obtained over all families.(PDF)Click here for additional data file.Table S11ROC50 scores obtained after modified symmetry based correction over all families.(CSV)Click here for additional data file.Table S12ROC scores obtained after modified symmetry based correction over all families.(CSV)Click here for additional data file.


Hypertension (HTN) is a major worldwide cause of stroke, heart failure, myocardial infarction, and chronic kidney disease. Human genetics offers the potential to identify novel physiologic mechanisms that underlie blood pressure (BP). BP is a heritable trait but until recently genetic factors that influence BP at the population have been difficult to identify.NPPA-NPPB locus to identify genetic variants that influence atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) [NPR3 encoding the natriuretic peptide clearance receptor [NPR3 SNP has recently been reported to be associated with taller stature in humans [We used a candidate gene association study of common variants across the de (BNP) . The minde (BNP) . Recentlreceptor . The minn humans , consistn humans  or apparn humans  in NPR3.The ANP-BNP/pGC/cGMP axis is important in the regulation of BP in humans. Further ongoing GWAS studies have identified additional novel loci. Human genetics can offer an entrée into the physiologic determinants of blood pressure at the population level and point to therapeutic opportunities to reduce the morbidity and mortality due to HTN.


A 40-year-old gentleman came to surgical OPD with chief complaint of crampy abdominal pain since last 12 days. He had complaint of occasional vomiting. Physical examination was not contributory. On per rectal examination, finger was stained with blood. His past surgical and medical history was not significant. His vitals were normal. After routine investigations, Barium enema was advised and it showed the findings revealed in What is the diagnosis?Which are the common lead points for Colocolic intussusceptions?How to differentiate between non-lead point and lead point intussusception?Enumerate the signs of intussusception on USG?Barium enema revealed typical claw sign in left lumber region suggestive of colocolic intussusceptions.Colocolic intussusception in the adults is almost always due to pre-existing disease like carcinoma or polyp.Abdominal CT scan with contrast helps in differentiating non-lead point and lead point intussusception.Transverse section revealed ‘Doughnut sign and longitudinal section showed Bull’s eye and pseudo kidney sign.3


Apis mellifera, are able to distinguish mixtures where both odors arrive at the same time (synchronous mixtures) from those where odor onsets are staggered (asynchronous mixtures). Surprisingly, this ability persists down to an onset delay of only 6 ms.Insects have a remarkable ability to identify and track odor sources in multi-odor backgrounds. Recent behavioral experiments show that this ability relies on detecting millisecond stimulus asynchronies between odors that originate from different sources . HoneybeOn this poster we explore this surprising ability in a model of the honeybee antennal lobe. We hypothesize that a winner-take-all inhibitory network (see Figure We present a detailed data-driven model of the bee antennal lobe that reproduces a large data set of experimentally observed odor responses  and demo


Tubercular spinal epidural abscess (SEA) is is a devastating infectious disease. Its presence without associated osseous involvement may be considered an extremely rare scenario. We present a rare case of tubercular SEA complicated by paraplegia in an immune-competent 58-year-old male patient. MRI shows a multisegmental posterior collection of epidural fluid extending from C7 to L2 vertebral level and displaces the ventrally located thecal sac, without any evidence of vertebral involvement. The patient made an uneventful recovery following surgical decompression and antitubercular chemotherapy. The diagnosis was confirmed by histopathological demonstration of Mycobacterium tuberculosis in drained pus. Such presentation of tubercular SEA has not been reported previously in the English language based medical literature to the best of our knowledge.


Demand for critical care services is increasing yet a comprehensive understanding of how critical care nurses - the largest group of ICU direct care providers - impact outcomes remains unclear. The purpose of this study was to determine how critical care nurse education  and ICU work environment influenced 30-day mortality of mechanically ventilated older adults.A multi-state cross-sectional nurse survey was linked to hospital administrative data and Medicare claims (2006 to 2008). The final sample included 55,159 mechanically ventilated older adults in 303 hospitals. Logistic regression modeling was employed to jointly assess the relationship of critical care nurse education, work environment and staffing on 30-day mortality while adjusting for hospital and patient characteristics and accounting for clustering.A 10% increase in the proportion of ICU nurses with a bachelor's degree or higher was associated with 2% lower odds of death while controlling for patient and hospital characteristics. Patients cared for in better work environments experienced 11% lower odds of risk-adjusted death than those cared for in poorer ICU work environments.Patients cared for in hospitals with a greater proportion of bachelor's prepared ICU nurses and in better ICU work environments experienced significantly lower odds of death. As the demand for critical care services increases, attention to the education level of ICU nurses and ICU work environment may be warranted to optimize currently available resources and potentially yield better outcomes.


A winch-capable helicopter emergency medical service (HEMS) offers several advantages over standard rescue operations. Little is known about the benefit of physician winching in addition to a highly trained paramedic. We analysed the mission profiles and interventions performed during rescues involving the winching of a physician in the Greater Sydney Area HEMS (GSA-HEMS).All winch missions involving a physician from August 2009 to January 2012 were identified from the prospectively completed GSA-HEMS electronic database. A structured case-sheet review for a predetermined list of demographic data and physician-only interventions (POI) was conducted.2 scores were more likely to receive a POI when compared with those with normal RTSc2 (P = 0.03). The performance of POI had no effect on median scene times . See Tables We identified 130 missions involving the winching of a physician, of which 120 case sheets were available for analysis. The majority of patients were traumatically injured (90%) and male (85%) with a median age of 37 years. Seven patients were pronounced life extinct on the scene. A total of 63 POI were performed on 48 patients. Administration of advanced analgesia was the most common POI making up 68.3% of interventions. Patients with abnormal RTScOur high POI rate of 40% coupled with long rescue times and the occasional severe injuries supports the argument for winching doctors. Not doing so would deny a significant proportion of patients time-critical interventions, advanced analgesia and procedural sedation.


In this brief report, we share our observations on a splitted Dexamethasone implant (Ozurdex) which we discovered a week after the injection. It is likely that implant splitting neither changes the efficacy of the implant nor creates a mishap for the patient. Dexamethasone implant (Ozurdex) is approved for eyes with posterior uveitis and macular edema associated with retinal vein occlusions , 2. Very A 68-year-old man received a Dexamethasone implant (Ozurdex) for macular edema due to nonischemic type central retinal vein occlusion at our institution Figures . The imp The implant is preloaded into a specially designed single use applicator that promotes easy and controlled drug delivery. Thereby, the slow release provides long-term effectivity and less steroid-related side effects. First, Rishi et al.  reported Implant splitting may not be a rare occurence but Ozurdex splitting most possibly do not change the effectivity of the implant or create a mishap for the patient.


Transgenic tumor models provide the closest animal approximation of human cancer development and progression, and a challenging treatment model. The orthotopic location of these tumors presents challenges in testing radiation therapies because conventional radiation models using patient linear accelerators or untargeted units with selective shielding are difficult or impractical in transgenic tumor models. We have tested CT-guided radiation therapy using a Small Animal Radiation Research Platform to treat transgenic MMTV-PyMT mammary tumors. Image guiding permits close targeting of tumors with no measurable toxicities at single tumor doses tested up to 20Gy. We demonstrate that tumor treatment results in a dose-dependent control of mammary tumors. Histology illustrates destruction of invasive carcinoma in the mammary gland with remaining tissue features of premalignant disease due to ongoing transgene-driven tumorigenic progression in other mammary cells. We demonstrate progressive expansion of CD11b+Gr1+ myeloid cells detectable in the blood of mice that correlates with tumor progression, and that focal treatment of mammary tumors with radiation therapy reverses this myeloid expansion without affecting systemic T cell numbers. The result is an improved systemic myeloid cell: T cell ratio in treated mice, which has been associated with improved immune function in many animal models of cancer. This platform provides an approach to study hypofractionated radiation therapy in authentic animal models of tumor progression without causing systemic lymphopenia and permits experiments investigating the interaction between radiation therapy and endogenous immune responses in transgenic and orthotopic tumor models.


Adult T-cell leukemia/lymphoma (ATLL) is highly chemotherapy resistant. The combination of AZT and interferon (IFN) is a first line treatment option for the leukemic forms of ATLL. We and others have demonstrated AZT/IFN can effectively suppress ATLL long-term; however, these drugs fail to eradicate malignant ATLL clones. At our institution we have recently established a clinical trial for ATLL using AZT/IFN in combination with the inexpensive histone deacelytase (HDAC) inhibitor valproic acid (VPA) during the maintenance treatment phase. Histone acetylation can result in HTLV-I promoter activation and viral transcription. We hypothesized that HDAC inhibitors would re-activate latent HTLV-I in ATLL cells harboring intact provirus and help eliminate residual disease after cytoreductive treatment. We have exciting preliminary data which suggest we can achieve this. So far, we have enrolled 13 subjects with acute-type ATLL in our study. We observed a serial decrease in clonal ATLL disease followed by molecular clearance by multiplex PCR in one subject after VPA treatment. We had not seen such effect previously in long-term responders treated with AZT/IFN alone. Using fresh ATLL cells from this subject we augmented HTLV-I expression and induced cell death ex vivo after treatment with the newer HDAC inhibitor vorinostat. We are currently testing other newly available HDAC inhibitors in our pre-clinical models. The dual anti-neoplastic and viral inducing roles of HDAC inhibitors can be exploited in the treatment of ATLL. This exciting approach may help advance the cure for this disease. We will present our interim clinical trial results at the conference.


A novel approach to increase erythropoietin (EPO) using oxygen has been reported in healthy volunteers. The purpose of this study is to investigate whether the EPO increase is sufficient to induce erythropoiesis.We compared exposure to daily versus every other day oxygen administration on haemoglobin variation during a 12-day period. Each subject underwent the two protocols at a 6-week interval period to achieve the same baseline values.P < 0.001). These data provide demonstration of an enhanced production of erythrocytes.See Figure The normobaric oxygen paradox seems effective to increase haemoglobin in non-anaemic healthy volunteers assuming there is a sufficient time interval between the two oxygen applications. This could permit interesting clinical applications in perioperative medicine as an adjunct therapy to EPO for blood predonation.


Pseudomonas aeruginosa is a human opportunistic pathogen. It can cause infection of immunocompromised people or people suffering from cystic fibrosis, which is often fatal. Bacterial colonization of human tissues is mediated by interaction of bacterial surface proteins – lectins – with cellular surface carbohydrates. PA-IIL is Pseudomonas aeruginosa tetrameric lectin, which contains two calcium ions in each binding site and recognizes fucosylated oligosaccharides [Bacterium charides . SaturatTwo different approaches for identification of promising compounds were employed. Subset of drug-like molecules was docked into the PA-IIL binding site by Autodock Vina  and Dock


Drosophila sensory neurons, we focused on a subset that were targets of the transcription factor Fd3f, which regulates functional specialization of mechanosensory cilia. Bioinformatic enrichment for known ciliary domains as well as orthologous protein-protein interaction network modelling provided a list of putative ciliary genes for further functional characterization. One such candidate, CG31320, has been initially characterized in Drosophila. Little is known about this gene, except the encoded protein contains HEAT repeats – belonging to an armadillo-like fold family associated with intracellular transport. In situ analysis confirms that CG31320 mRNA is highly expressed in the ciliated chordotonal neurons. RNAi-mediated knock-down resulted in abnormal chordotonal ciliary morphology and locomotory defects, consistent with impaired mechanosensory cilium function. Currently, we are studying whether the ortholog Heatr2 is also required for mammalian cilia. Protein localization studies suggest that Heatr2 plays a role in trafficking to primary cilia. RNAi knock-down and protein interaction studies using mammalian cells are underway to functionally dissect Heatr2 roles; results will be presented. We are generating a Heatr2 conditional mouse mutant to investigate its function in different types of cilia and sperm flagella. We present a multisystem experimental pipeline for functional characterization of novel genes expressed in cilia as well as putative ciliopathy candidates.The structural and functional roles of many of the 800-1000 proteins that make up the microtubule core and specialized membranes of cilia and flagella are poorly understood. Following from our recent expression study to identify putative ciliary candidates in


Compressed sensing with PCA based coil compression is a promising way to obtain high quality radial perfusion images without incurring the high computation cost and memory requirements associated with large multi-coil arraysImaging with large coil arrays is desirable for rapid imaging and high signal to noise ratio. Compressed sensing (CS) is a promising way to accelerate myocardial perfusion imaging . HoweverDynamic cardiac perfusion data at rest and stress were acquired using a 32-channel cardiac coil on a Siemens 3T scanner using a 2D radial turboFLASH sequence . The acqCS reconstruction using temporal and spatial total variation constraints (STCR)  was perfFigure 1 shows 32-channel images and the five compressed coil images. Five compressed coil images are sufficient for accurate reconstruction, as seen in Figure 2 which compares CS reconstructions on the original and compressed channel data. With coil sensitivity weighting, streaks  are reduced for original and compressed channel images. Images and time curves from compressed coils match well with those from all 32 coils. Reconstruction time for four slices and 250 time frames using compressed channels took ~26 min and was ~6 times longer for the 32-channel data.Compressed sensing with coil compression is a promising and efficient way to obtain high quality cardiac perfusion images using large coil arrays.Ben B. and Iris M. Margolis Foundation.


Long-term use of mechanical ventilators may lead to ventilator-induced diaphragmatic dysfunction (VIDD) and increase the duration of weaning from MV . It was Two juvenile pigs were anesthetized with propofol (150 to 250 μg/kg/minute) and ventilated (VENT) with an assist control mode MV (Nellcor Puritan Bennett 840). Using fluoroscopy, a novel multipolar neurostimulation catheter  was threaded into the left internal jugular vein and advanced to the junction of right atrium and the superior vena cava using a modified Seldinger technique. The successful capture of the right and left phrenic nerves was confirmed by fluoroscopic visualization. Peak airway pressures (PAWP) and blood gases were determined after 10 minutes MV (MV), MV and stimulation applied together (MV+STIM) and stimulation only (STIM).2 and PO2 confirmed that adequate ventilation and oxygenation can be provided by the system, while PAWP could be reduced  was noted while peak airway pressures were reduced. During STIM there was no discernible paradoxical movement of the diaphragm. In addition, PCOed Table .It was possible to capture and stimulate both phrenic nerves using a minimally invasive approach to support respiration and sustain blood gases at physiological levels. This development could help wean MV-dependent ICU patients earlier. Further long-term studies are needed to assess the full potential of this novel system.


Large or giant intracranial aneurysms can simulate brain tumors clinically and radiologically by virtue of their progressive mass effect. Unlike aneurysms from alternative locations, those arising from the distal posterior inferior cerebellar artery (PICA) are uncommon. We report a patient who experienced progressive hemiparesis with magnetic resonance imaging findings suggestive of an infratentorial ependymoma. Intraoperatively, a thrombosed large aneurysm of the distal PICA was unexpectedly encountered. The aneurysm was clipped and the patient did not develop any permanent neurological deficit. This case illustrates the radiological nuances of large aneurysms and infratentorial ependymomas. Three-dimensional contrast-enhanced magnetic resonance angiography can be falsely negative and the importance of the “target” sign is emphasized. One should be cognizant of this possible diagnosis for patients with midline fourth ventricular lesions in order to reduce surgical risk. Aneurysms arising from the posterior inferior cerebellar artery (PICA) are uncommon and constitute 0.5 to 3.0% of all intracranial aneurysms . While mA 79-year-old woman, with a history of hypertension, presented with dizziness and progressive left side weakness for two months. There was neither headache nor symptoms to suggest raised intracranial pressure. She found it increasingly difficult to walk and required assistance.Physical examination revealed left hemiparesis of medical research council (MRC) power grade 4/5. Deep tendon reflexes were equivocal and muscle tone was normal. Cranial nerve palsy, cerebellar signs, and papilloedema were not detected.Computed tomography revealed a midline hyperdense posterior fossa lesion that displaced the fourth ventricle and compressed the pontine-medullary junction of the brainstem . There wA suboccipital craniotomy was performed and the telovelar approach was planned for tumor excision. Exploration of the cerebellomedullary fissure revealed a fibrous encapsulated 3 cm extra-axial lesion that indented the floor of the fourth ventricle. Upon microsurgical dissection, it transpired that the lesion was a saccular aneurysm arising from the telovelotonsillar segment of the left PICA with no perforator incorporation . ClippinThe posterior inferior cerebellar artery has five segments: 1) the anterior medullary segment; 2) the lateral medullary segment; (3) the telovelomedullary segment containing the caudal loop ending at the cerebellar tonsils; (4) the telovelotonsillar segment from the medial aspect of the tonsils to the roof of the fourth ventricle containing its cranial loop; and (5) the cortical segment that supplies the cerebellar vermis and hemispheres . Accordi the late the anteDistal PICA aneurysms are uncommon and their pathogenesis is a matter of debate –3. WhileOur patient demonstrates how a large partially thrombosed distal PICA aneurysm can mimic an infratentorial ependymoma both clinically and radiologically. Most large distal PICA aneurysms rarely rupture and seldom cause thromboembolic events due to the rich anastomotic arterial supply of the inferior cerebellum. Their presentation is similar to posterior fossa neoplasms inducing chronic brainstem or cerebellar compression . DeficitRadiologically infratentorial ependymomas can share common characteristics with partially thrombosed distal PICA aneurysms. Both are predominantly midline lesions located near the fourth ventricle. They can appear iso- or hypointense on T1W imaging and elicit heterogeneous contrast enhancement with significant perilesional vasogenic edema. Almost half of all ependymomas demonstrate T1- and T2-weighted signal heterogeneity due to areas of necrosis, cystic change, repeated hemorrhage, or calcifications . LamellaThe most significant radiological feature for this patient was the presence of the “target” sign. Best demonstrated on gadolinium contrast T1W imaging, it represents enhancement of the aneurysm wall as well as within the cavity of a partially thrombosed aneurysm . This isClipping is an effective means of treating distal PICA aneurysms, as they are often superficial and surgically easily accessible. Most patients have good functional outcomes as described in several operative series , 18, 19.The clinician must be aware of the limitations of 3D MRA in identifying thrombosed aneurysms. We recommend meticulous multiplanar evaluation of contrast T1-weighted MRI for the “target” sign in older patients with midline fourth ventricular mass lesions. Catheter angiography is recommended in suspected cases and if they remain undetectable one should be cognizant of this possible diagnosis when surgically treating such lesions.


Taenia solium antibody was positive at high titers. A T2 sagittal magnetic resonance image of the brain showed numerous circumscribed lesions with visible scolices and involving adjacent soft tissues (T. solium. Disseminated cysticercosis has the potential to cause severe clinical manifestations.2Human cysticercosis is an important cause of seizures in the developing world. A small subset of patients acquires heavy infections with large numbers of lesions disseminated throughout the brain and skeletal muscle. tissues . Cystice


Local field potential in-vivo recordings often show oscillations with frequencies ranging from < 1 Hz to 100 Hz. The underlying mechanism could change across frequency bands but likely involves network interactions such as recurrent synaptic excitation-inhibition loops. Particularly fast rhythmic activity in the beta and gamma range is thought to be caused by synaptic inhibition . In addiHere we investigate how the dynamics of such neuronal adaptation currents contribute to synaptically generated spike rate oscillations and resonance properties in recurrent networks of excitatory and inhibitory neurons. Based on a network of sparsely delay-coupled adapting spiking model neurons we take a mean-field approach using the Fokker-Planck equation to analyze oscillatory network activity. In the limit of slow adaptation timescales we obtain population spike rates and membrane potential distributions . To alloFor constant external input we find that fast oscillations stabilize if recurrent inhibition is slower than excitation. The oscillation frequency increases with increasing inhibitory synaptic efficacy and decreasing inhibitory delay. Neuronal adaptation facilitates such network-based oscillations for fast synaptic inhibition and leads to decreased frequencies (see Figure


Migraine is a condition which consumes maximum revenue of a family, state & nation & still the suffering goes on. In the world millions are suffering from Migraine .. & having pain killer medicine & suffering from their side effect like kidney failure etc Migraine sufferers may have depression deep down... but psychiatry being a stigma - very few sufferer goes for consultation to psychiatrist. History of migraine needs a long time to listen & the ability to listen ,.... which normally a psychiatrist does not have time to listen the painful past & long details without getting revenue - or fee or financially paid for - so depression goes unnoticed. Depression assessment scale -although available - but very few psychiatrist has a team work in India & most of the countries.1. To see that by treating depression & adding specific group of dietary supplements - is there any effect on frequency severity & relapse? 2. Frequency of pain killer - can it be reduced & patient be saved from kidney failure?1. Used exclusion criteria ..... where no other cause of migraine found...all investigation within norm. 2. After assessment treated with antidepressant & CBT & specific group of dietary supplememt. In follow up video of their statement regarding frequeny was noted & use of pain killer was recorded.1. 50 patients dropped out of the study. 2. 450 completed the study. 3. 90% of patients reported a 90% reduction in the use of pain killer. 4. 100% reported that CBT helped them. 5. 10% of patients reported a mixed picture of attacks but reported reduced severity.Migraine patient may have depression underlying which if addressed can be a useful method to reduce severity of migrane attacks. If stigma of mental health or depression can be reduced - will benefit migraine patient. Nti depressant therapy coupled with CBT & specific group of dietary supplement plays an important role in treatment of migraine .


Medulloblastoma with extensive nodularity is a rare subtype of the most common malignant childhood brain tumor and has been associated with more favorable prognosis. The authors report the case of a 10-month-old girl with a posterior fossa tumor of excessive nodularity with decreased diffusivity on diffusion-weighted magnetic resonance imaging sequences and robust grape-like postgadolinium contrast enhancing features. The unique neuroradiographic features were confirmed by histopathology and a diagnosis of medulloblastoma with extensive nodularity was made. This case highlights the importance of recognizing this unique medulloblastoma subtype preoperatively, as the more favorable outcome may preclude less aggressive medical management. Primary childhood central nervous system brain tumors occur at an incidence of 5.0 cases per 100,000/person-years in the United States according to data from the Central Brain Tumor Registry –6. NeuroA 10-month-old full term female presented to our hospital following a 4–6 month history of delayed motor milestones and enlarging head circumference. She had an external ventricular drain placed at an outside hospital prior to arriving at our institution. Her neurological examination revealed mild limited upgaze and moderate axial hypotonia without obvious dysmetria. Magnetic resonance imaging (MRI) examination of the brain revealed a very large posterior fossa tumor with decreased diffusivity on diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences Figures . On T2-w2 of residual tumor postmaximum surgical resection. The newly stratified molecular classification of medulloblastoma has revealed distinct subsets of children who have better prognosis in spite of their young age. Among these children are those with either nodular desmoplastic or extensive nodularity. The distinguishing feature at the histologic level is those patients with extensive nodularity have an expanded lobular architecture of the classic reticular free zones that are enlarged with neuropil. Previously termed “cerebellar neuroblastoma” medulloblastoma with extensive nodularity belongs to a molecular subgroup driven by sonic hedgehog pathways. The neuroradiographic features of this medulloblastoma with what we describe as “excessive” nodularity are important to recognize as these children may be cured with chemotherapy alone and spared from the neurocognitive consequences of radiation therapy. While a similar finding of medulloblastoma with “extreme” nodularity has been reported [The five-year overall survival of children with average risk medulloblastoma who are treated with a combination of craniospinal radiation and chemotherapy approaches 90%. Currently average risk is defined as age greater than 3 years at diagnosis, negative CSF or leptomeningeal spread, and less than 1.5 cmreported , we feel


This paper describes a rare finding of an inguinal ovary in an adult woman who presented with pelvic pain. Inguinal ovary may occur if the gubernaculum fails to attach to the uterus or if the canal of Nuck remains open during fetal development.The online version of this article (doi:10.1186/2193-1801-2-545) contains supplementary material, which is available to authorized users. Ovary within the inguinal canal is occasionally seen in infants, but is rare in adult women. This paper describes a woman with an inguinal ovary who presented with pelvic pain. We review the literature and discuss its embryological background.A 33 year-old-woman presented with pelvic pain on a background of longstanding left sided iliac fossa pain, which was exaggerated by constipation and movement. Past medical history included depression, scarred left kidney from recurrent urinary tract infections and surgery for urethral diverticulum. Obstetric history included two vaginal deliveries following subfertility treatment. Ultrasound scan demonstrated an unremarkable retroverted uterus and normal renal tract. The right ovary appeared normal however left ovary was not identified. Diagnostic laparoscopy revealed the left ovary herniating through the left internal inguinal ring Figure a-b. The A literature search revealed twelve case reports in adults. The majority presented with a palpable groin mass and they were diagnosed at time of surgery for suspected bowel hernia Additional file 2: Figure S2: Laparoscopic image of left ovary following its removal from the inguinal canal and mesh repair of the hernia. (JPEG 329 KB)Authors’ original file for figure 1Below are the links to the authors’ original submitted files for images.


Thalidomide is a drug, which has its own place in the history of medicine and has been used in various types of cancers and other chronic inflammatory disorders (erythema nodosum leprosum) but its mode of action as an immunomodulatory drug in acute infections  is not clear. Thus, the present study was designed to investigate its effect on pulmonary innate immune response during acute lung infection in BALB/c mice.Lung innate immune response plays an important role in the clearance of pathogens  from lungs. However, profound activation of innate immune cells  can lead to development of acute lung inflammation or injury observed during pneumonia, acute respiratory distress syndrome (ARDS), or sepsis by producing various proinflammatory cytokines  and molecules . Acute lung inflammation was induced by intranasal instillation of Klebsiella pneumoniae B5055 into mice without any anesthesia and treated with thalidomide (30 mg/kg/day/p.o.) or normal saline orally using a treatment schedule shown to modulate proinflammatory innate immune response. Various proinflammatory  as well as anti-inflammatory  cytokines were estimated by ELISA. Pulmonary macrophage-mediated phagocytosis and bactericidal assays were performed. Alveolar macrophages were evaluated in terms of macrophage spreading ability assay. H2O2 production by macrophages was assessed according to the method based on the process of horseradish peroxidase-dependent oxidation of phenol red assay. Neutrophil infiltration to the lungs was determined by histopathological analysis.Animals were divided into four groups  were found to be decreased significantly in the thalidomide-treated group but the levels of IL-10 were found to be significantly elevated.Thalidomide treatment modulated proinflammatory function of alveolar macrophages by significantly decreasing their phagocytic potential in terms of phagocytic uptake and intracellular killing, spreading and HThalidomide proved a promising immunomodulatory agent with a potential to modulate aggravated innate immune response observed during acute lung inflammation associated with pneumonia or sepsis caused by Gram-negative bacterial infection.


Cell structure depends on both matrix strain and stiffness, but their interactive effects are poorly understood. We investigated the interactive roles of matrix properties and stretching patterns on cell structure by uniaxially stretching U2OS cells expressing GFP-actin on silicone rubber sheets supporting either a surface-adsorbed coating or thick hydrogel of type-I collagen. Cells and their actin stress fibers oriented perpendicular to the direction of cyclic stretch on collagen-coated sheets, but oriented parallel to the stretch direction on collagen gels. There was significant alignment parallel to the direction of a steady increase in stretch for cells on collagen gels, while cells on collagen-coated sheets did not align in any direction. The extent of alignment was dependent on both strain rate and duration. Stretch-induced alignment on collagen gels was blocked by the myosin light-chain kinase inhibitor ML7, but not by the Rho-kinase inhibitor Y27632. We propose that active orientation of the actin cytoskeleton perpendicular and parallel to direction of stretch on stiff and soft substrates, respectively, are responses that tend to maintain intracellular tension at an optimal level. Further, our results indicate that cells can align along directions of matrix stress without collagen fibril alignment, indicating that matrix stress can directly regulate cell morphology. Cyclic stretching causes the alignment of several cell types perpendicular to the direction of stretch Experiments involving cells cultured on soft hydrogels have demonstrated that substrate stiffness strongly regulates many cell processes, including cell–cell adhesion Since the stiffness of silicone rubber  were cultured in DMEM (Gibco) supplemented with 10% fetal bovine serum (Gibco), 2 mM L-glutamine (HyClone), 1 mM sodium pyruvate (HyClone) and 1 mM (HyClone) penicillin/streptomycin in a humidified 5%CO2) by incubating 100 µl of 0.3 mg/ml rat tail collagen type-I (BD Biosciences) in the well and allowing the solution to evaporate. The collagen solution (3 mg/ml) was then added to form a gel within the collagen-coated well as described previously Silicone rubber stretch chambers  were modified to form a circular well (15 mm diameter) by adhering a silicone rubber sheet onto the chambers . The chaCells were cultured on the top surface of the collagen gels and subjected to cyclic stretch by stretching the chambers with two linear motors  as described previously E1) and lateral directions (E2) were computed from the E11 and E22 components of the Lagrangian strain tensor The strain fields produced by the device were determined by tracking the displacement of markers on the collagen gel and silicone rubber surfaces. Strains on the bottom surface of the silicone rubber sheeting were measured by marking membranes at several points with a permanent marker and imaging before and after stretch using nominal stretch values ranging from 2.5 to 12.5%. To quantify the strains on the collagen gel surface, red fluorescent beads  were mixed into the gel prior to polymerization to serve as fiducial markers. Triads of markers in a focus plane in various locations on the surface were selected to compute the symmetric Lagrangian strain tensor at each location. The finite strains in the longitudinal  as described previously The shape of each cell was determined from the background signal of the Alexa 488-phalloidin stained cells. Each cell was fit to an equivalent ellipse using NIH ImageJ software 2-independent media (Hyclone). The stretch device was mounted under the objective of the confocal microscope and subjected to a 10% step change in stretch with images of GFP-actin captured at 10 min intervals.One hour before starting the experiment, the media in stretch chamber was changed to Hyclone L-15 COSignificant differences in order parameters between groups were identified using ANOVA followed by Student-Newman–Keuls posthoc multiple comparisons testing.Two-dimensional strains measured on the surfaces of 500 µm-thick collagen gels and the supporting silicone rubber membranes were very similar . Strains2) rather than the thick gel. In each case, the cells were subjected to 3 h of 10% cyclic uniaxial stretch at 1 Hz. Consistent with our previous findings using non-confluent and confluent U2OS and bovine aortic endothelial cells on fibronectin-coated silicone rubber We evaluated the effects of stretch on SF organization in non-confluent U2OS cells adhered onto the top of collagen gels. For comparison, experiments were also performed where the cells were adhered on the supporting silicone rubber membranes, but coated with a low concentration of collagen , a transient hold , and subsequent release of the stretch . In eachConsistent with previous findings with NIH 3T3 fibroblasts on soft polyacrylamide gels To observe the dynamic process of SF alignment in cells stretched on collagen gels, we collected time-lapse videos of GFP-labeled actin in U2OS cells. Our results demonstrate that stretch-induced cell and SF alignment are highly dependent on the mechanical properties of the collagen matrix upon which cells are cultured. Cyclic stretch promoted alignment parallel to the direction of stretch cf.  in cellsWe previously reported a theoretical model predicting that SFs reorient perpendicular to the direction of cyclic stretch on matrix-coated silicone rubber to avoid excessive levels of tension acting on actomyosin binding sites The dependence of alignment on cyclic stretch frequency is consistent with previous measurements using U2OS cells and endothelial cells on fibronectin-adsorbed silicone rubber Our results provide evidence that two mechanisms contribute to stretch-induced alignment on soft collagen gels. Prestretched collagen gels are expected to have anisotropic mechanical properties, with greater stiffness in the direction of stretch. The alignment of the cells and SFs along the direction of greater stiffness cf.  is consiIt is interesting to speculate on why the stretch stimulus is only effective on soft collagen gels, but not on collagen-coated sheets cf. . PreviouCells in stretched 3-D collagen matrices are often elongated in parallel with the predominant alignment of collagen fibrils Extracellular matrix geometry and topography at the nanoscale can impact cellular function A recent study by Pang et al. Our results indicate that stretch-induced SF alignment on soft collagen gels is dependent on MLCK, but not Rho-kinase. Rho-kinase and MLCK regulate central and peripheral SF populations, respectively Our findings shed new light on experimental and theoretical observations by other groups on cells stretched on soft 2D and 3D substrates Recent studies by Quinlan et al. In summary, our results clearly demonstrate that cells respond to applied strains in a manner dependent on substrate rigidity. Recent experiments employing high-resolution traction force microscopy on polyacrylamide substrates indicate that focal adhesions individually sample the substrate rigidity and that FAK/phosphopaxillin/vinculin signaling defines the rigidity range over which cells migrate toward regions of higher rigidity Figure S1Silicone rubber chamber with collagen gel before (A) and after stretch (B).(TIF)Click here for additional data file.Figure S2Influence of substrate stiffness on cell elongation during stretch. Representative images of U2OS cells before and after a 10% step stretch depicting cell elongation and change in cell length in the direction of stretching for cells cultured on collagen gels (A) and collagen coated silicone rubber sheets (B) (n = 3).(TIF)Click here for additional data file.Table S1Influence of substrate stiffness on cell strains during stretch.(DOCX)Click here for additional data file.Video S1Live Cell Microscopy. Time-lapse video depicting data in (AVI)Click here for additional data file.


Chronic liver diseases are characterized by inflammatory and fibrotic liver injuries that often result in liver cirrhosis with its associated complications such as portal hypertension and hepatocellular carcinoma. Liver biopsy still represents the reference standard for fibrosis staging, although transient elastography is increasingly used for non-invasive monitoring of fibrosis progression. However, this method is not generally available and is associated with technical limitations emphasizing the need for serological biomarkers staging of liver fibrosis. The enhanced liver fibrosis (ELF) score was shown to accurately predict significant liver fibrosis in different liver diseases, although extracellular matrix components detected by this score may not only mirror the extent of liver fibrosis but also inflammatory processes.In this prospective biopsy-controlled study we evaluated the utility of the ELF score in comparison to transient elastography to predict different stages of fibrosis in 102 patients with chronic liver diseases.Both techniques revealed similar area under receiver operating characteristic curve values for prediction of advanced fibrosis stages. Compared to transient elastography, the ELF score showed a broader overlap between low and moderate fibrosis stages and a stronger correlation with inflammatory liver injury.Both the ELF score as well as transient elastography allowed for high quality fibrosis staging. However, the ELF score was less discriminative in low and moderate fibrosis stages and appeared more strongly influenced by inflammatory liver injury. This should be considered when making clinical interpretations on the basis of ELF score values. Liver fibrosis is the consequence of a variety of chronic liver diseases and can result in liver cirrhosis. Early detection of fibrosis progression and development of cirrhosis are crucial for management of patients with chronic liver diseases since advanced fibrosis is associated with clinical complications and formation of hepatocellular carcinoma. Although liver biopsy remains the reference standard for evaluating liver fibrosis, it is limited by sampling errors and risk of complications The liver volume explored by transient elastography is estimated to be 100 times larger compared to liver biopsy and might thus be more representative of the entire organ Extracellular matrix components may not only mirror the extent of liver fibrosis but are also involved in inflammatory processes. For instance, direct immunological impact of HA by regulating inflammatory cell recruitment and release of inflammatory cytokines has been described In the present study we have evaluated the performance of the ELF test against transient elastography for non-invasive assessment of fibrosis in a prospective biopsy-controlled manner. In this context we have analyzed the influence of possible confounders, such as liver inflammation or steatosis, on fibrosis detection by ELF score and transient elastography.16 In addition to the ELF score alanine and aspartate aminotransferase  levels were determined. At the time of blood withdrawal, all patients obtained liver biopsy and liver stiffness measurement using the Fibroscan . The fibrosis stage (F1–F6) was determined according to Ishak et al.We investigated sera from 102 patients  with chronic liver diseases . Serum samples were analyzed for markers of the ELF score, including tissue inhibitor of matrix metalloproteinase 1 (TIMP-1), hyaluronic acid (HA), and amino-terminal propeptide of type III collagen (PIIINP). The proprietary assays developed for the ELF test by Siemens Healthcare Diagnostics Inc.  were used and analyses were performed on an Immuno-1 auto-analyser . Results were entered into the established algorithm and expressed as score as described.Statistical analyses were performed by using Graphpad Prism 5.0 and SPSS 19.0 software and confirmed by a professional statistician. Data are presented as box plot and whiskers analysis as well as mean ± standard error of the mean (SEM). The results obtained with the different serum markers or liver stiffness measurements were compared using the Mann-Whitney’s U test. Regression analyses were performed to calculate the Spearman rank correlation coefficient. Receiver operating characteristics (ROC) analysis was calculated. A P value <0.05 was considered significant. A multivariate logistic regression analysis was performed in order to adjust for variables found to be associated with fibrosis.The ELF test was compared with transient elastography for detection of different fibrosis stages in patients with chronic liver diseases (n = 102). Transient elastography allowed a better discrimination between low  6.9±0.4 kPa) and moderate  and between moderate and high fibrosis stages  or progressed fibrosis/cirrhosis (≥F5) with the best compromise sensitivity/specificity. To this end, we performed a ROC plot analysis including all patients (n = 102) with different fibrosis stages. The cut-off value of transient elastography of 8.5 kPa correctly predicted fibrosis stages of ≥F2 with a sensitivity of 86% and a specificity of 73%  95%: 0.85–0.98; To analyze a potential influence of liver inflammation on ELF score and transient elastography, we performed regression analyses comparing ALT or AST levels with ELF score and transient elastography. Both methods of fibrosis detection significantly correlated with AST and ALT levels Figure 3Chronic liver diseases represent a substantial public health problem with a worldwide mortality of around 800.000 deaths per year Ideally, non-invasive markers of liver fibrosis should be liver-specific and easy to perform with high diagnostic performance (compromise sensitivity/specificity) for accurate fibrosis staging. Among the most studied non-invasive detection methods of liver fibrosis is transient elastography. A prospective study in patients with chronic liver diseases demonstrated that measurement of liver stiffness by transient elastography is a reliable method to predict moderate or severe fibrosis stages, but shows less accuracay to differentiate between lower fibrosis stages according to METAVIR Compared to transient elastography, the ELF score revealed a lower significance (p<0.05) for discrimination between low and moderate fibrosis stages and showed a broad overlapping range for those stages. Nevertheless, AUC values for prediction of relevant fibrosis (≥F2) are high for both non-invasive methods with similar sensitivity and specificity. Both transient elastopgraphy and ELF score showed also a comparable high diagnostic accuracy to predict progressed fibrosis/cirrhosis (≥F5). The cut off-value of transient elastography for prediction of progressed fibrosis evaluated in this study was nearly the same (17.5 kPa) compared to that (17.6 kPa) of a previous study A recent study showed lower diagnostic performance for transient elastography in detection of liver cirrhosis compared to lower fibrosis stages There is also increasing evidence that liver stiffness is influenced by acute exacerbation of liver disease with ALT flares resulting in overestimation, e.g. up to three fold increase, of liver stiffness values It has been reported that liver stiffness values are higher in subjects with enhanced BMI or metabolic syndrome Our present large biopsy-controlled prospective study showed that the ELF score reveals similar diagnostic accuracy to predict relevant (≥F2) or advanced (≥F5) stages of fibrosis compared with transient elastography. However, the cut-off values of the ELF score to predict relevant stages of fibrosis are close to the cut-off value for detection of progressed fibrosis whereas the respective cut-off values for transient elastography showed a higher difference. The ELF score appears less discriminative in lower fibrosis stages compared to transient elastography. Furthermore, the ELF score showed a higher correlation with inflammatory liver injury compared to transient elastography. These observations should be considered when making clinical interpretations or decisions on the base of ELF score values.


Trauma and sepsis can cause acute lung injury (ALI) and Acute Respiratory Distress Syndrome (ARDS) in part by triggering neutrophil (PMN)-mediated increases in endothelial cell (EC) permeability. We had shown that mitochondrial (mt) damage-associated molecular patterns (DAMPs) appear in the blood after injury or shock and activate human PMN. So we now hypothesized that mitochondrial DAMPs (MTD) like mitochondrial DNA (mtDNA) and peptides might play a role in increased EC permeability during systemic inflammation and proceeded to evaluate the underlying mechanisms. MtDNA induced changes in EC permeability occurred in two phases: a brief, PMN-independent ‘spike’ in permeability was followed by a prolonged PMN-dependent increase in permeability. Fragmented mitochondria (MTD) caused PMN-independent increase in EC permeability that were abolished with protease treatment. Exposure to mtDNA caused PMN-EC adherence by activating expression of adherence molecule expression in both cell types. Cellular activation was manifested as an increase in PMN calcium flux and EC MAPK phosphorylation. Permeability and PMN adherence were attenuated by endosomal TLR inhibitors. EC lacked formyl peptide receptors but were nonetheless activated by mt-proteins, showing that non-formylated mt-protein DAMPs can activate EC. Mitochondrial DAMPs can be released into the circulation by many processes that cause cell injury and lead to pathologic endothelial permeability. We show here that mitochondria contain multiple DAMP motifs that can act on EC and/or PMN via multiple pathways. This can enhance PMN adherence to EC, activate PMN-EC interactions and subsequently increase systemic endothelial permeability. Mitochondrial DAMPs may be important therapeutic targets in conditions where inflammation pathologically increases endothelial permeability. We also set out to determine whether these effects occur via MTD interactions with EC, PMN or both. To study these processes under the most realistic and relevant possible conditions, we created studies that centered on the changes in endothelial monolayer permeability occurring ‘in real-time’ when human EC were exposed to fragmented whole human mitochondria (MTD) or to purified mtDNA in the presence or absence of human PMN. We then focused on the molecular biologic and cell signaling events that led to the alterations in EC permeability seen in the translational models we had created.Cellular damage due to mechanical trauma, hemorrhage and sepsis can release mitochondrial (mt) damage motifs like mtDNA and formyl peptides. We previously showed that these molecules can trigger inflammation and organ injury  of Beth Israel Deaconess Medical Center, Boston, MA USA. Written consent was obtained from blood donors. The tissue samples obtained for isolation of human mitochondria were portions of surgical pathology specimens that were not needed for diagnostic purposes. All samples were de-identified.Human tissues such as the margins of liver resections, portions of spleens removed due to injury and bone marrow reamed from the femur during fracture fixations were obtained from operations performed at Beth Israel Deaconess Medical Center (BIDMC). Whole mitochondria (mt) were prepared using a mitochondrial isolation kit from Thermo Fisher Scientific . For certain experiments, mitochondrial debris (MTD) fractions were prepared by sonicating whole mitochondria (prepared from human liver) five times for 30 s as previously described 2+]i response in Fura 2-loaded human PMN equal to that induced by 1 nM fMLP 2+ response, does not guarantee identical changes in permeability. This approach is by necessity very different from using commercial agents that are purified and fully characterized, but also reflects real biologic variability.Activity of MTD samples was standardized using a bio-assay based upon the ability of MTD to elicit a i) was monitored with a Basic InCyt Im2 calcium imaging system . 20–30 cells were typically selected for each experiment. The ratio of fluorescence at 340/380 nm was used to indicate [Ca2+]i.EC calcium mobilization was determined using a fluorescent calcium imaging system where cells are attached to glass coverslips. Cells were loaded with Fura-2 2 using a Zeiss LSM 510 Meta Live Cell Inverted Confocal System.To visualize localization of mtDNA in HPAEC, human mtDNA was labeled with Alexa 488 using the Ulysis Nucleic Acid Labeling Kit  following the manufacturer’s protocol MTD applied to EA cells showed marked effects in endothelial permeability in the absence of PMN. As shown in MtDNA (25 and 50 µg/mL) was prepared from mitochondria isolated from human liver and applied to EA cells with and without human PMN present. We note an immediate, dose-dependent rise in monolayer permeability both in the presence and absence of PMN  with or without PMN were also evaluated. As seen in DNA-sensing TLRs are endosomal in location. We therefore next sought to show that mtDNA applied to EC externally was taken up into endosomes. To do this, we applied mtDNA prepared from human liver and freshly labeled with Alexa 488 to HPAEC along with FM4-64, a marker that localizes to endosomes. We then examined live cells under confocal microscopy. As shown in . Protease activity was terminated by heat (75°C/20 min) prior to treating EC. As shown in In addition to mtDNA, mitochondria contain proteins that EC might sense as alarmins. These could be formylated proteins synthesized in the mitochondria that act on formyl peptide receptors (FPR) like those on PMN, or they could be non-formylated proteins sensed via other mechanisms. We examined the permeability of EC exposed to MTD pre-treated with a protease cocktail or media only 2+]i). We therefore applied MTD to EA cells or HPAEC to evaluate calcium mobilization  the [Ca2+]i increases were very limited.Agonists like thrombin and histamine increase EC permeability in part by increasing cytosolic calcium concentrations ([Ca2+]i transients in response to fMLP despite responding briskly to thrombin stimulation. This suggests the absence of formyl peptide receptors (FPRs)  had no direct effect on EC permeability. Moreover, application of fMLP to EC in addition to MTD or mtDNA had no additional effect on the permeability changes seen (C&D). Thus exposure to mtDNA increases expression of selectins and integrins in both PMN and EC and causes them to adhere to each other.Next, we examined whether enhanced PMN-EC adherence might contribute to the increased permeability observed when PMN and EC were exposed to mitochondrial alarmins. EA cells were treated with mtDNA  for 6 hrs and calcein-loaded PMN were applied to the EA cell monolayers for the last 60 min. Exposure to mtDNA significantly increased PMN adherence to EA cells  and related organ failure syndromes (like ALI/ARDS) are often thought of as reflecting the effects of inflammatory cytokine release on PMN-EC interactions. But cytokine release is the delayed, indirect response to injury seen after intermediate events transduce physical stimuli into immune ‘Danger’ signals. Similarly, release of known endothelial activators like thrombin is strictly limited to sites of wounding. We hypothesized that MTD released from sites of injury might participate in the acute activation PMN-EC interactions that underlie the increased systemic endothelial permeability typical of SIRS and ALI. In this context, we focused our studies on the effects of mitochondrial DAMPs (MTD) on EC activation and permeability in the presence and absence of PMN. Although the concentrations of these molecules under clinical conditions are difficult to ascertain, we have tried to maintain translational relevance by examining the effects of biologic mixtures of mitochondrial DAMPs removed directly from fresh human cells and used at concentrations that produce similar modest activations of PMN i) are a common mechanism of immune cell activation. We found mtDNA-treated PMN to have an increased Ca2+ influx response to TG  to enhance barrier integrity intracellular S1P synthesis activates store-operated Ca2+ channels. Increases in [Ca2+]i due to SOCE in PMN or EC could then activate pathways leading to increased vascular permeability. Studies by our lab and others have suggested that S1P acts as a second messenger and has an important non-receptor mediated role in the regulation of [Ca2+]i mobilization and cell permeability 2+ store depletion by other signaling agents Such further investigations will involve direct evaluation of intracellular S1P levels as we have shown previously 2+ flux responses may be an important source of the diversity in endothelial responses seen in different vascular beds.The increase in Sphk1 induced by mtDNA treatment (Finally, we show here for the first time that endothelial cell expression of HMGB1 is up-regulated in inflammatory environments and that sterile mitochondrial motifs can activate HMGB1 expression. Although HMGB1 has been thought to act as a late cytokine mediator of sepsis that activates cells via innate immune receptors The ability of DAMPs derived from mitochondria to initiate changes in endothelial permeability has not been previously studied. The events described here are actually responses to a spectrum of molecular species that can act on both EC and PMN. The current work establishes that release of molecular motifs from the mitochondria of disrupted, dead or dying cells may be a critical event in determining early systemic endothelial response to injury. Subsequent studies will be aimed at determining the dominant active agonists and the pathways by which they act.


The choice of footwear and custom modification of footwear in fast bowling in cricket lacks biomechanical and clinical evidence. This demonstrates that despite professional advice being available, elite fast bowlers continue to wear shoes that may not be appropriate for them. The aim of this study was to investigate the biomechanical effects of three cricket shoes commonly used by fast bowlers and whether footwear modification could play a role in injury.Four male cricket fast bowlers were included in the study. A 20 camera VICON Mx system was used to collect three-dimensional kinematic data. A four segment marker set was used to track and model the lower limb. Four force platforms  were positioned at both back and front foot strike to capture kinetic data. Participants’ perceptions of footwear were measured using a VAS. Freidman two-way ANOVA with post hoc pairwise comparison was used to analyse the differences between shoes. Linear regression analysis was used to correlate predictive outcome measures.P = 0.038) and a significant decrease in front knee joint external rotation moment (P = 0.022) relative to the custom modified shoe (ASICS 490TR). Exploratory regression analysis identified that front foot peak lateral shear force was significantly correlated  to sagittal plane knee joint angle at initial contact. Sagittal plane knee joint angle at initial contact was also significantly correlated  to front foot loading rate.The custom modified cross-trainer (ASICS 490tr) demonstrated the highest participant perception footwear score (mean 9/10 VAS). The conventional cricket shoes (ASICS 170no) demonstrated a significant reduction in front foot lateral shear force (The findings of this research demonstrate that custom modified cricket shoes increase lateral shear force and knee external rotation moment at the front leg. However, the relationship between these findings and injury remain unquantified. Further research must identify the role of footwear in the mechanism of lower limb injury in fast bowlers and what characteristics of footwear correlate to improved footwear VAS scores in regards to comfort, support and performance.


A variety of complications related to endovascular procedures are being reported. We present an annoying complication implying complete migration of stent-graft of subclavian artery into the aortic lumen.A 61 years old man with abdominal endovascular aortic stent-graft inserted previously, had a saccular aneurysm of descending aorta distal to left subclavian artery and a small dissection flap with saccular aneurysm originating from left subclavian artery. Since the patient refused to have any surgical procedure for left subclavian artery revascularisation, thoracic aortic-stenting for descending aorta just below subclavian origin and a second stent-graft for left subclavian artery just above the orifice was planned. Coverage of left subclavian artery was not preferred aiming to avoid possible cerebrovascular events. During intervention, stent-graft to be inserted inside subclavian artery migrated totally into aortic arch in a perpendicular fashion.Bilateral femoral and left brachial artery accesses were done. A 16x41mm stent-graft was inserted inside left subclavian artery. While insertion with balloon dilatation, stent-graft migrated distally with the balloon forming a partial prolapse into aortic arch. We tried several endovascular maneuvers including inserting a second graft into subclavian artery to stabilize the first one or trying to press this graft with the one inserted into descending aorta, but unfortunately the stent totally migrated into aorta. We catheterized migrated stent with balloon catheter and were able to move the graft with inflated balloon fixing it. Stent-graft and inflated balloon were pulled slowly back together to proximal part of left arm of the previously inserted abdominal aortic stent-graft and stabilized it carefully. Control DSA showed settled graft without any stenosis.We present a bothering complication and an endovascular solution we performed without complication.


Isometric exercise is a powerful stimulator of the cardiovascular system. Therefore, exercise can be used to unmask subtle cardiovascular changes that are not evident at rest. MRI is a proven method for comprehensive cardiovascular assessment in the resting state. Unfortunately, lack of fast imaging sequences and an appropriate exercise test has prohibited the use of isometric exercise in MRI.We aimed to devise an isometric exercise test for use in MRI in order to comprehensively assess the hemodynamic response to exercise using fast-imaging MRI.A sustained isometric biceps exercise test was devised for the MRI scanner. Ten healthy male volunteers (24 to 44 years) underwent three minutes of sustained isometric exercise using a weight load adjusted to 35% of maximum biceps strength. The hemodynamic response was elucidated during rest, exercise  and recovery . At each time point we obtained 1) aortic flow - spiral prospectively-gated breath-hold phase contrast CMR, 2) LV volumes - real-time radial k-t sensitivity encoding free-breathing CMR and 3) oscillometric upper arm blood pressure. Using this data vascular resistance and compliance was calculated.All participants completed the isometric exercise test. All data sets were complete. Sustained isometric exercise in the MRI scanner produced a marked hemodynamic response Table . Both vaIsometric biceps exercise testing is highly feasible using a MRI safe methodology, which allows exercise in the supine position within the scanner. The test evokes a hemodynamic response that corresponds to isometric exercise conducted outside the MRI scanner. The hemodynamic response can be comprehensively and safely assessed at any point of time during isometric exercise using this exercise methodology together with fast-imaging MRI.


We report a rare complication after successful Evita Open Plus® implantation with cardiopulmonary bypass and circulatory arrest complete for total aortic aneurysm treatment.A 71 year old male with aortic aneurysm was referred for consideration of surgery. The patient comes to the emergency department to present an acute left chest pain. He was a history of duodenal ulcer and arterial hypertension. Rx thorax demonstrated mediastinal widening compatible with giant aortic aneurysm. The echocardiogram (TTE) confirmed normal sized cardiac cavities and ascending aortic aneurysm. Aortography presented severe dilatation of ascending thoracic aorta with moderated aortic regurgitation. CT Angiography established supra-aortic ascending aneurysm with maximum dimension of 53 mm, 65 mm arch aneurysm and descending 106 mm in the transverse plane.Upper medial resternotomy, cardiopulmonary bypass and circulatory arrest complete with moderated hypothermia were performed as well as ascending aorta and arch replacement with reimplantation of the supra-aortic trunks by hybrid prosthetic Evita Open Plus® 33.The patient evolution was favourable. In the control TTE was observed on the left ventricular apex two interconnected cavities support with left ventricular pseudoaneurysm, confirmed by CT angiogram. The patient required a new intervention, performing exclusion of the pseudoaneurysm in the left ventricular (LV) apex with a Teflon patch. After surgery remains stable and was discharged without complications.The total aortic replacement  using hybrid routines are reserved for patients with complex pathology. Iatrogenic LV pseudoaneurysms postoperative may uncommon. In some cases is related to the increase in consistency (due to hypothermia during circulatory arrest complete) of the cannula vent of the LV during extracorporeal circulation.


Celiac artery compression syndrome is a rare disorder characterized by episodic abdominal pain and weight loss. It is the result of external compression of celiac artery by the median arcuate ligament. We present a case of celiac artery compression syndrome in a 57-year-old male with severe postprandial abdominal pain and 30-pound weight loss. The patient eventually responded well to surgical division of the median arcuate ligament by laparoscopy. Celiac artery compression syndrome also known as median arcuate ligament syndrome is a rare cause of abdominal pain and weight loss. It is caused by compression of the celiac artery by the median arcuate ligament. We report a case of a 57-year-old male who presented to us with this rare diagnostic challenge. Various imaging techniques such as duplex ultrasound, magnetic resonance angiography, computerized tomography angiogram, and visceral angiography can be used to diagnose this condition. Surgical decompression of the celiac artery by division of the median arcuate ligament has been shown to be very effective.A 57-year-old male with past history significant for hepatitis C and chronic abdominal pain with 50 admissions in various hospitals over the last 2 years presented with worsening epigastric and left upper quadrant pain as well as a 30-pound weight loss over one year . The pai9/L, and white blood cells 6.8 × 109/L. Liver function tests were elevated  likely secondary to Darvocet use, which returned to baseline during his hospital course. Antismooth muscle antibody (ASMA), antinuclear antibodies (ANA) and intrinsic factor blocking antibody were within normal limits. Computed axial tomography (CAT) scan of the abdomen was normal and showed no signs of cirrhosis. Stool hemoccult was positive. Capsule endoscopy was done which showed delayed gastric emptying. Visceral angiogram was done which showed no signs of vasculitis but near complete stenosis of celiac axis secondary to median arcuate ligament compression and retrograde filling of celiac artery , magnetic resonance angiogram (MRA), and computerized tomography angiogram (CTA). However, CT angiogram remains the gold standard. Findings include retrograde filing of celiac artery via gastroduodenal branch of the superior mesenteric artery and poststenotic dilatation.Various treatment modalities have been tried to decompress the celiac artery. Surgical division of the fibers of the median arcuate ligament either by conventional open surgery  or by laparoscopic approach is usually adequate in most patients . RecentlCeliac artery compression syndrome is a rare condition that may present a real diagnostic challenge for the clinician. We presented an unusual case of a 57-year-old male, with the median arcuate ligament compressing on the superior mesenteric artery, thereby causing postprandial abdominal pain and weight loss. Our patient was successfully treated by laparoscopic division of the median arcuate ligament. At least three-fourths of the patients have a good long-term prognosis following the surgical division of the median arcuate ligament .


Biologic agents may cause auto-antibody formation and drug induced lupus but no paediatric guidelines exist regarding monitoring of auto-antibodies. The UK Royal College of Nursing Guidance advises checking ANA and anti-dsDNA before starting biologic treatment and repeating anti-dsDNA if concerned.The Alder Hey protocol tested an autoantibody profile Table , 2 3-6 mTo analyse frequency of antibody positivity in rheumatology patients on biologics in order to estimate costs and to devise a rational protocol for test frequency.A retrospective audit of a 2 year period, August 2008 to July 2010. All patients on biologics were included with data on auto-antibodies collated using the hospital computer system.111 children were receiving biologic therapy and 2511 auto-antibodies were tested at a cost of over £26,000.With the exception of ANA antibody, all other antibody tests were usually negative. Those that were positive tended to be non specific  and/or were negative on subsequent testing. The results did not alter patient care yet costs are significant. This audit would suggest that antibody tests are checked too frequently at Alder Hey Hospital. A new protocol in development is likely to recommend testing auto-antibodies annually in the absence of clinical signs / symptoms of lupus.


High sensitive troponin T (hsTnT) is a highly specific marker of myocardial injury and one of the keystones in the diagnosis of acute coronary syndrome. Although hsTnT is thought to be released by myocardial cell damage, recent studies reported elevated levels after exercise testing and endurance sports. The exact mechanism of this phenomenon is discussed controversially. CMR stress testing is widely used for detection of myocardial ischemia. The kinetic of troponin release after CMR stress testing has not been studied previously.To assess the impact of adenosine and dobutamine CMR stress testing on hsTnT.21 Patients underwent CMR stress testing  for evaluation of coronary artery disease using dobutamine wall motion (13 patients) or adenosine perfusion imaging (8 patients). Standard protocols included dobutamine infusion  to reach a target heart rate [(220-age)*0.85] or adenosine infusion (0.14 mg/kg/min). Blood samples were taken immediately before and 12-24 hours after CMR.At baseline, hsTnT levels of all patients were below the detection limit of 0.010 ng/ml. After dobutamine stress, hsTnT levels raised in 7 patients (54%), of which 3 had evidence of myocardial ischemia in wall motion analysis. 4 patients with an increase in hsTnT did not show ischemia in CMR. Elevation of hsTnT was not detected in any patient after adenosine stress. A significant positive correlation between hsTnT levels and increase in systolic blood pressure after dobutamine stress was observed . Myocardial ischemia  was not associated with the release of hsTnT.HsTnT release seems to be a common phenomenon using different stress testing modalities associated with increased blood pressures. This is supported by previous reports of hsTnT elevation related to increased blood pressure like physical stress testing, whereas adenosine does not alter blood pressure. Therefore, mechanisms different from cardiomyocyte necrosis might contribute to hsTnT release.


In early development stages of biologicals there is often more than one molecule against a specific target. A careful candidate evaluation is crucial to choose an optimal lead variant for further development. Complex biologicals are typically produced in CHO cells and host cells as well as the process are known to influence important molecule features such as glycan patterns or activity. To streamline the generation of stable producer cell lines we have established an Flp-based RMCE system in our CHO-DG44 platform. RMCE application allows for multi-parallel production of candidate material in the host cell and process background used for the pharmaceutical cell lines. Therefore, the molecular features of this material are expected to match with material that will be derived from a future producer cell line.A replaceable gfp gene cassette was established at random chromosomal integration sites in CHO-DG44 cells. This clone pool was subjected to a primary RMCE with a secreted and complex glycosylated alpha1-antitrypsine (A1AT) reporter. Resulting cells were screened for A1AT producers that have undergone a successful cassette exchange. This strategy allows for selection of a RMCE host cell line that combines transgene expression from highly active genomic loci with superior processing and secretion capabilities.The selected RMCE host cell line is susceptible for cassette exchange with any desired target gene and candidate protein. Successful cassette exchange is enforced by promoter trap and a well defined selection system Figure . For RMCRMCE application results in cell populations showing comparable expression levels of the newly introduced genes as exemplified for individual RMCEs with a gfp reporter and different selection formats Figure . Also, aRMCE was applied to a monoclonal antibody and single cell clones have been generated from the RMCE derived population. Those clones were analyzed together with the original population in fed batch culture using ProBioGen's chemical defined platform medium and process Figure . The RMCIn a second study two variants of a soluble receptor-Fc fusion protein were analyzed for manufacturability. Over a number of individual RMCEs variant #1 was expressed at a ~2-fold higher rate. In a fed batch process the difference was maintained yielding in final titers of 1.2 g/L for variant #1 Figure . The 2-3At minimal effort RMCE application allows for streamlined generation of stable cell lines and production of POC material Figure . ApplyinA robust protocol provides for efficient and reproducible RMCE application for antibodies and single chain proteins.At minimal effort RMCE application enables fast and multi-parallel evaluation of complex biological drug candidates.RMCE application allows for streamlined production of candidate material in the background of ProBioGen's CHO-DG44 platform.


AIRE, characterized by autoimmune endocrinopathies and mucocutaneous candidiasis. It is accompanied by serum auto-antibodies whose generation has been mainly related to autoreactive T cells escape from tolerance mechanisms. Recent data suggest a T cell independent mechanism implicated in altered peripheral B cell selection and its possible contribution to the pathogenesis of autoimmune disease. Despite these observations, B cell subsets phenotype in these patients is still poorly characterized.Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a rare autosomal recessive syndrome due to mutations in To perform a detailed analysis of B and T cell subsets in a cohort of APECED patients in order to better understand whether an intrinsic alteration in B cell compartment is present. We also evaluated B lymphocytes related cytokines  in patients’ sera compared to age matched control.Flow cytometric analysis of B cell subsets was performed in 12 patients with APECED coming from Sardinia, Italy, compared to age-matched healthy donors. The following B cell subsets were analysed: transitional, naïve, IgM and switched memory and plasmacells; T cell subsets: Treg, CD4 and CD8 T cell subsets  ELISA assay was performed for cytokines determination in sera.Analysis show an altered distribution of the immature peripheral B cells compartment in APECED patients and an increased level of BAFF in patients’ sera. The T cell compartment is skewed towards effector memory T cells.Increasing the knowledge on B cells in APECED patients improves the comprehension of autoimmunity pathogenesis in immunodeficiency and may allow the exploration of the possible clinical efficacy of B cell targeted therapy.