Hypertension developing during pregnancy may be caused by a variety of different pathophysiological mechanisms. The occurrence of proteinuric hypertension during the second half of pregnancy identifies a group of women whose hypertensive disorder is most likely to be caused by the pregnancy itself and for whom the risk of complications, including maternal mortality, is highest. Physicians identifying patients with hypertension in pregnancy need to discriminate between pre-eclampsia and other forms of hypertensive disease. Pre-eclamptic disease requires obstetric intervention before it will resolve and it must be managed in a multidisciplinary environment. The principles of diagnosis and management of these different entities are outlined in this review. Hypertension during pregnancy is widespread, representing the most common medical complication of pregnancy and affecting 6–8% of gestations in the United States of America. Two hospital-based studies in sub-Saharan Africa have put the prevalence of this disorder at 11.5 and 26.5% of all deliveries, respectively.Hypertension during pregnancy is not only common but also associated with a risk of morbidity and mortality.3Pre-eclampsia is uniquely manifest during pregnancy and is associated with a pathophysiological phenotype that encompasses placental disease, growth restriction of the foetus and the development of severe but reversible hypertension during pregnancy.9In this review we discuss the different types of hypertension during pregnancy, and the physician evaluation, including physical examination and laboratory investigations of the hypertensive pregnant patient.Pre-eclampsia affects one in 30 primigravid women and one in 60 women in their second or subsequent pregnancies.12Obstetric risk factors include an increasing risk of developing pre-eclampsia related to multiple and even higher-order multiple pregnancies. A large placenta, such as those seen in women with trophoblastic disease or various kinds of foetal aneuploidy, are also associated with an increased risk of developing pre-eclampsia. Other risk factors that have been identified as leading to an increased probability of pre-eclampsia developing during pregnancy include antiphospholipid antibody syndrome, chronic hypertension, chronic renal disease, a maternal age over 40 years, nulliparity, incidence of pre-eclampsia in a previous pregnancy and pre-gestational diabetes.The highest incidence of pre-eclampsia is among women having their first baby, whereas the greater prevalence of the disease is in multiparous pregnant women. The disease is described as a condition of primigravidity but it is also, to some extent, associated with primipaternity.10Pre-eclampsia is a syndrome characterised by the development of hypertension and proteinuria in the latter part of pregnancy, which then remits after delivery.Hypertension is defined in different ways but the most widely accepted definition is the sustained elevation of diastolic blood pressure above 90 mmHg over a period of four hours. Proteinuria is similarly defined in different ways but dipstick proteinuria of 1+ or more merits further investigation. The 24-hour urinary excretion of protein greater than 300 mg is regarded as being pathological.Pre-eclampsia may present in an asymptomatic form. It may also develop acutely or progress to a phase of illness in which multi-organ disease becomes evident.16Characteristically, the delivery of the baby signals the onset of disease resolution, although the mother may continue to exhibit worsening disease for up to 24 hours after delivery. The hypertension associated with pre-eclampsia may take up to six weeks to resolve completely, even if the risk of fulminant disease abates within 24 hours of parturition.Pre-eclampsia is a disease of defective placentation.The evolution of the clinical phenotype follows these pathophysiological events in the placental bed. The precise mechanisms are not fully elucidated but some combination of systemic immune activation in response to an increasing maternal circulatory burden of trophoblastic tissue released from the ischaemic placenta combines with components of oxidative stress and an imbalance in the production of angiogenic and anti-angiogenic factors to give rise to changes in systemic vascular endothelial function.18The volume-overloaded circulation of normal pregnancy is offset by endothelial-dependent vasodilatation to such an extent that normal pregnancy is characterised by falling blood pressure, despite the volume overload.25Specific organs show patterns of ischaemic change, and haemorrhage with or without oedema. These include the brain, kidneys, placenta and liver.28The cardiovascular and pulmonary changes seen are those of pulmonary oedema in severe cases, usually without other overt signs of heart failure.30There are two major causes of death among women with pre-eclampsia, cerebrovascular haemorrhage and pulmonary oedema, and each account for roughly half the number of deaths.Cerebrovascular haemorrhage is related to severe hypertension.Pulmonary oedema may develop for different reasons. The iatrogenic administration of excessive amounts of intravenous fluids may lead to an absolute increase in preload, resulting directly in interstitial pulmonary oedema.23The loss of protein in the urine may lower the colloid osmotic pressure and contribute to development of the generalised oedema so characteristic of pre-eclampsia, with similar effects on the lungs. Changes in capillary permeability and the lymphatic drainage of the lungs all modulate the risk of pulmonary oedema in women with variable changes in vascular resistance and ventricular function. Consequently, the precise mechanism of pulmonary oedema cannot be simply attributed to heart failure in this condition.Pre-eclampsia is not a condition that can be managed adequately outside a hospital environment.4 The definitive management of pre-eclampsia is delivery.4 Once manifest, the condition tends to worsen and it is unusual for delivery to be delayed by more than 10 to 14 days once the patient develops symptoms or signs of the condition. Because the foetus is at risk of impaired growth and likely to deliver prematurely, management needs to take place in an obstetric unit with access to the best available level of paediatric care. Any improvement in neonatal outcome can only be secured by minimising the risks of prematurity. This is accomplished by delaying delivery for as long as the mother’s condition can be considered to be satisfactory.35The development of symptoms, an uncontrollable spike in blood pressure or the evolution of defined organ dysfunction signal the onset of life-threatening disease, requiring that the focus of treatment shift from the neonatal outcome to protecting the interests of the mother. Delivery at this point is inevitable and the neonate will need to be cared for in the best available circumstances. The second means of improving perinatal outcome revolve around the use of corticosteroids, given to the mother. These accelerate the maturation of the foetal lungs and lessen the likelihood of neonatal intraventricular haemorrhage in the newborn.The prevention of eclampsia is ensured by the use of magnesium sulphate, given as a continuous infusion or as intermittent intramuscular doses.Women who are fitting should have their seizures aborted with intravenous benzodiazepines. Women who continue to fit despite treatment or those who are unable to protect their airway because of a low Glasgow coma scale need intubation and mechanical ventilation until the pregnancy is over and the mother’s condition shows signs of improvement.39Proper management of severe hypertension is always a priority. Drugs used to lower the blood pressure are a variety of agents, including direct-acting vasodilators , calcium channel blockers (nifedipine), alpha-and beta-blockers , and combined arterial and venous vasodilators (nitroglycerine). Potent vasodilators such as sodium nitroprusside or diazoxide should not be used because they are associated with a risk of precipitous decline in blood pressure.Eclampsia requires attention to seizure control as outlined above. Recurrent seizures may only be controllable by continuous infusion of propofol or diazepam; this usually requires intubation and ventilation for up to 24 hours after delivery has been effected. The co-morbidity associated with seizures needs individual management (see below); specific screening and treatment of aspiration pneumonia is important. Any focal neurological signs merit neuro-radiological investigation to exclude haemorrhage and infarction. The differential diagnosis of seizure activity also merits consideration and may extend to other possible diagnoses, including metabolic causes for seizure activity, thrombotic thrombocytopaenic purpura, systemic lupus erythematosis, cerebral venous thrombosis, malaria and amniotic fluid embolus.40Renal failure may be manifest on the basis of diminished preload together with peripheral, including renal, vasospasm. Acute renal injury may also cause oliguria and azotaemia. This is the consequence of ischaemia (due to pre-eclampsia or pre-eclampsia complicated by hypovolaemia caused by abruptio placentae) and haemoglobinuria. The principles of management are those of cautious intravascular volume expansion  and vasodilatation.Liver injury is associated with the HELLP syndrome. This condition needs to be distinguished from other causes of micro-angiopathic haemolytic anaemia as well as other causes of liver failure. The differential diagnosis therefore includes thrombotic thrombocytopenic purpura, acute fatty liver of pregnancy, auto-immune disease, malaria and sepsis. The hallmark of the HELLP syndrome is that it reverses after delivery, with the nadir of thrombocytopaenia occurring on the third day postpartum.43 The management is obstetric, meaning delivery. Patients who do not exhibit the characteristic resolution of the thrombocytopaenia merit investigation for other causes of micro-angiopathic haemolytic anaemia. The only lethal complication of the HELLP syndrome is the development of a large subcapsular liver haematoma, which ruptures, causing massive intraperitoneal haemorrhage.Pulmonary oedema is the most difficult complication of severe pre-eclampsia in which to make a specific diagnosis.Delivery of the pre-eclamptic pregnant woman will trigger reversal of the underlying disease. Generalised oedema begins to dissipate as the capillary leak reverses and the pregnancy preload is excreted. Commonly, 48 to 72 hours after delivery, the left ventricular preload may start to increase as the oedema resolves.One of the most important aspects of managing the postpartum pre-eclamptic is that of counselling. Pre-eclampsia has been shown to be a marker of long-term risk. Specifically, there is an association between hyperinsulinaemia, dyslipidaemia and the risk of pre-eclampsia. These underlying metabolic disorders are also risk factors for early onset vascular disease (both coronary artery and cerebrovascular disease).Chronic hypertension during pregnancy may be divided into two groups: uncomplicated chronic hypertension and chronic hypertension with superimposed pre-eclampsia. The latter group requires management according to the principles outlined above, whereas the former requires out-patient care, often with an altered approach to therapeutic intervention. Chronic hypertension is defined as blood pressure of 140/90 mmHg or more on two occasions before 20 weeks of gestation or persisting beyond 12 weeks after deliveryThe risk of developing superimposed pre-eclampsia is estimated to be between 10 and 25%.The second strategy used to reduce the occurrence of pre-eclampsia is based on the prophylactic administration of large doses of oral calcium. Meta-analysis of the studies conducted to date indicate that calcium administered in doses of up to one gram three times a day may significantly reduce the occurrence of pre-eclampsia and may also reduce the development of severe hypertension.Interventions that are not of benefit in preventing pre-eclampsia include bedrest, the use of anti-oxidant vitamins and antihypertensive therapy itself.Given the imperfect prophylactic measures aimed at preventing pre-eclampsia, care of pregnant women with chronic hypertension requires appropriate precautions to ensure that the development of superimposed disease is detected early in its development because of the attendant risks of foetal and maternal morbidity and mortality. Knowing who will develop superimposed pre-eclampsia before it becomes clinically manifest would be useful information.a priori renal disease with secondary hypertension .The clinical phenotype of pre-eclampsia arises from changes at the level of the foetoplacental unit and any early signs of intra-uterine growth restriction or abnormal uterine artery Doppler velocimetry may precede the onset of the clinical disease.This distinction may not be easily made on a clinical basis and where a diagnosis of pre-eclampsia enters the differential diagnosis, the patient deserves in-patient care and management for presumptive pre-eclampsia until an alternative diagnosis can be made. The natural history of pre-eclampsia sometimes facilitates the distinction between pre-eclampsia and renal disease as a cause for proteinuria because pre-eclampsia tends to worsen as the pregnancy continues, whereas the chronically hypertensive patient has an indolent condition that changes little with the passage of time.The recent interest in biomarkers may provide an alternative way of diagnosing which hypertensive conditions have a placental origin. Angiogenic and anti-angiogenic factors [placental growth factor and the soluble receptor for vascular endothelial growth factor (sFlt)] have been shown to be good predictors of placental disease and may provide a ready means of discriminating between various types of hypertensive disease in pregnancy, specifically identifying those most at risk of adverse outcome.53Uncomplicated chronic hypertension does not usually affect the pregnancy outcome to any significant degree. The drugs used to treat hypertension outside pregnancy may need to be revised and alternatives introduced in order to protect the foetus.Physiological changes during pregnancy have an impact on chronically hypertensive women as well. Specifically, they will vasodilate during the second trimester, leading to a fall in blood pressure and a reduction in the requirement for treatment at this point in the pregnancy. As the volume expansion during pregnancy continues and peaks at about 32 weeks’ gestation, the need for treatment may increase again. The goals of treatment also may need to be revised during pregnancy.Outside pregnancy, the aim of treatment is prevention of end-organ damage to the heart, vasculature and kidneys. The use of diuretics with ACE inhibitors is common and the goal of therapy is normotensive blood pressure. This strategy does not apply during pregnancy because the drugs may harm the foetus, and placental perfusion (in theory) may be adversely affected by antihypertensive drugs that diminish perfusion pressure.Diuretics, although used to treat cardiac conditions during pregnancy, are generally held to be contra-indicated in the management of chronic hypertension during pregnancy because pregnancy relies upon volume expansion to secure an accelerated rate of delivery of oxygenated blood to the peripheral tissues, including the placental bed. ACE inhibitors are also contra-indicated because they may interfere with the physiological regulation of uterine blood flow through local uterine mechanisms. More seriously, they are associated with neonatal renal failure in children of women treated with them during pregnancy. Of the other categories of antihypertensive drugs, beta-blockers are also relatively contra-indicated, being considered to be an independent risk factor for the development of intra-uterine growth restriction.54Antihypertensive therapy during pregnancy in chronically hypertensive women is usually secured through the use of alphamethyldopa or calcium channel blockers. The aim of treatment is to reduce the occurrence of severe hypertension to safer levels of blood pressure. Practically, the threshold for introducing treatment is a sustained increase in blood pressure to above 160/110 mmHg to levels below this without seeking to reduce the pressure to normotensive levels.The complications of chronic hypertension during pregnancy may extend to various forms of cardiac decompensation, depending on the severity of the condition. Hence, hypertensive cardiomyopathy is rarely seen in relatively young women with chronic hypertension, although it may develop and can give rise to maternal mortality.Obstetric intervention is not commonly required in chronically hypertensive women. However, some mild degree of foetal growth restriction may be present and the risk of superimposed pre-eclampsia cannot be excluded with absolute certainty. Consequently, induction of labour is usually recommended for women who do not labour spontaneously before 40 weeks’ gestation.Pregnancy may render overt hypertension that is not yet clinically manifest outside of pregnancy. Women who have a strong familial history of hypertension, whose genetic predisposition will manifest as essential hypertension in later life, may become hypertensive during pregnancy. The mechanism is thought to be related to subnormal pregnancy vasodilatation in vessels, with a hereditary defect in vasoregulation. In this circumstance, the increased intravascular volume of pregnancy cannot be accommodated by adequate vasodilatation, with a rise in blood pressure developing in the late second to third trimester of pregnancy.56This condition should be managed according to the same principles as those outlined for women with chronic hypertension. The outcome of the pregnancy is usually unaffected and the only consideration might be the need for induction of labour in women not yet delivered by 40 weeks’ gestation.Hypertension does not always indicate disease. Pregnancy is characterised by massive plasma volume expansion, and the cardiovascular adaptation needed to accommodate this increased intravascular volume is that of equally massive peripheral vasodilatation. The net consequence of this is a fall in blood pressure during the second trimester, with increasing levels of blood pressure closer to term. The entire adaptation is mediated by the placenta, and the adequacy of the pregnant physiological change depends on the amount of biochemically active trophoblast in the uterus. Hence women with multiple pregnancies or those who have singleton pregnancies with a large placenta will have a greater degree of volume expansion than those with a smaller placental mass. The consequences of this may be a supraphysiological increase in plasma volume that exceeds the degree of compensatory vasodilatation close to term. These individuals have normal pregnancies in every respect, with normally grown babies and no other signs of pre-eclampsia. This is not a condition requiring treatment or intervention and should be recognised as a variant of normal.3The difficulty of managing these patients lies in being certain that the distinction can be safely made between physiological hypertension and pre-eclampsia. For this reason, many of these women would be allowed to continue to term but induction of labour would be justified at 40 weeks’ gestationDetermining whether high blood pressure identified during pregnancy is due to pre-eclampsia or chronic hypertension is sometimes a challenge to the physician, especially if there are no recorded blood pressures available from the first half of the gestation. Clinical characteristics obtained through a good history, physical examination and some laboratory investigations may be used to help clarify the diagnosis.The time of detection of hypertension is very important. Hypertension occurring before 20 weeks’ gestation is almost always due to chronic hypertension, while new-onset hypertension after 20 weeks’ gestation should lead to a suspicion of gestational hypertension. Worsening hypertension after 20 weeks of gestation should lead to careful evaluation for the manifestations of pre-eclampsia.Patients with pre-eclampsia may describe new-onset headache that is frontal, throbbing or similar to migraine headache. They may also have visual disturbances, including scintillations and scotoma, which has been linked to cerebral vasospasm. Gastrointestinal complaints, such as epigastric pain, may be moderate to severe in intensity and due to hepatic swelling and inflammation, with stretch of the liver capsule. Rapidly increasing or non-dependant oedema may be a symptom of developing pre-eclampsia. In addition, rapid weight gain as a result of oedema due to capillary leak, as well as renal sodium and fluid retention could be a pointer to pre-eclampsia. New-onset seizures in pregnancy suggest pre-eclampsia–eclampsia, but primary neurological disorders must always be excluded.Pre-eclampsia is a multi-systemic disease with various physical signs. Oedema can be seen in non-dependent areas such as the face and hands, apart from the dependent areas. Maternal systolic blood pressure above 160 mmHg or diastolic blood pressure above 110 mmHg can occur and denote severe disease.In measuring the blood pressure, women should be made to sit quietly for five to 10 minutes before each blood pressure measurement, and blood pressure should be measured in lateral recumbency with the cuff at the level of the heart. Korotokoff sounds I and V should be used to define the systolic and diastolic blood pressure, respectively. In about 5% of pregnant women, an exaggerated gap exists between the fourth and fifth Korotokoff sounds with the fifth sound approaching zero. In this type of case, the fourth sound may more closely approximate the true diastolic blood pressure.Signs of secondary hypertension such as buffalo hump, wide purple abdominal striae suggesting glucocorticoid excess, systolic bruit heard over the abdomen or in the flanks suggesting renal artery stenosis, and radio-femoral delay or diminished pulses in the lower versus upper extremities suggesting aortic co-arctation should be looked for. The presence of a fourth heart sound on auscultation is not a normal finding in pregnancy and may suggest left ventricular hypertrophy from chronic hypertension. Carotid bruits may also reflect atherosclerotic disease due to longstanding hypertension. In addition, retinal changes of chronic hypertension may be noted. Retinal vasospasm and retinal oedema, which may manifest as severely impaired vision, generally reflects pre-eclampsia.In pre-eclampsia right upper-quadrant abdominal tenderness stemming from hepatic swelling and capsular stretch may be seen. Although brisk or hyperactive reflexes are common during pregnancy, clonus is a sign of neuromuscular irritability that usually reflects severe pre-eclampsia.Laboratory investigations to evaluate chronic hypertension include testing for target-organ damage, and to exclude secondary causes of hypertension and co-morbid factors. For chronic hypertension in the first trimester, it is very useful to obtain a full blood count, electrolyte, urea and creatinine levels, liver enzyme concentrations and testing for proteinuria. These serve as baseline values to be referred to later in the pregnancy if there is a concern regarding superimposed pre-eclampsia.Serum lipids usually increase during pregnancy and therefore measurement should be deferred until the postpartum period. Also, the increase in endogenous corticosteroids levels during normal pregnancy makes it difficult to evaluate for secondary hypertension due to adrenal corticosteroid excess.Useful blood tests when evaluating eclampsia and pre-eclampsia include urinalysis, a full blood count, serum electrolyte levels, urea and creatinine 24-hour urinary protein excretion, and serum uric acid, liver enzyme and bilirubin levels.The long-term implications of having a pregnancy complicated by pre-eclampsia or hypertension have been highlighted above. It is important that pregnant women with hypertensive disease be given every opportunity to attend appropriate follow-up care in order to prevent long-term premature morbidity and mortality.


The intestinal microbiota plays a critical role in the development of the immune system. Recent investigations have highlighted the potential of helminth therapy for treating a range of inflammatory disorders, including celiac disease (CeD); however, the mechanisms by which helminths modulate the immune response of the human host and ameliorate CeD pathology are unknown. In this study, we investigated the potential role of alterations in the human gut microbiota in helminth-mediated suppression of an inflammatory disease. We assessed the qualitative and quantitative changes in the microbiota of human volunteers with CeD prior to and following infection with human hookworms, and following challenge with escalating doses of dietary gluten. Experimental hookworm infection of the trial subjects resulted in maintenance of the composition of the intestinal flora, even after a moderate gluten challenge. Notably, we observed a significant increase in microbial species richness over the course of the trial, which could represent a potential mechanism by which hookworms can regulate gluten-induced inflammation and maintain intestinal immune homeostasis. Bifidobacterium spp. and Staphylococcus spp. and reductions in Bacteroides spp.1112The human gut is inhabited by ~1000 species of bacteria (i.e. the gut microbiota) that play essential roles in human health, including nutrient metabolism, protection against pathogens and regulation of both innate and adaptive immune responses12568One of the hypotheses as to why allergic and autoimmune diseases of the gastrointestinal tract, such as food allergy and CeD, are increasing is the change in relative exposure to commensal and pathogenic organisms as a consequence of urbanization and improved sanitation in the developed world151617181920212324Necator americanus, improved gluten tolerance in CeD subjectsN. americanus infections were associated with suppression of pro-inflammatory cytokines and increase of both the frequency of immune-regulatory cells and cytokines in the gut following gluten challenges1922N. americanus exert on the composition of the gut microbiota and the relative abundance of different microbial speciesN. americanus, as well as following the administration of escalating doses of gluten.We have recently demonstrated that experimental infection with the human hookworm, Ruminococcus dominated the fecal microbiota of the Control subjects  (Ruminococcus (data not shown). Together, these data demonstrated that the microbiota of the healthy Trial subjects pre-hookworm and pre-gluten challenge was distinct from individuals with active CeD.Each of the eight Trial subjects had been on a strict GFD for at least 5 years prior to trial commencement, and recorded sub-clinical Marsh scores prior to entering the trial = 0.16) . Compari = 0.16) , associaN. americanus, as evidenced by positive detection of hookworm eggs in the feces from weeks 8 to 52 post-infectionWe next aimed to assess whether the nature of the commensal makeup was altered in the Trial subjects following experimental hookworm infection and subsequent escalating gluten challenges. All eight subjects were successfully infected with Consistent with the results of our previous studyN. americanus enabled individuals with CeD to tolerate escalating challenges with dietary gluten. The biological, immunological and molecular mechanisms underlying this outcome are yet to be fully determined; however, we hypothesized that an expansion of regulatory T cells, together with reductions in pro-inflammatory effector T cells in the duodenum, may have been responsible for the restoration of the intestinal homeostasis and, consequently, for the improved gluten tolerance1922In our recent studyTrichuris and/or hookworms and/or Ascaris sp.) when compared with helminth-free, uninfected subjects from the same areas3031243031We had hypothesized that experimental hookworm infection, combined with exposure to escalating doses of gluten, would result in significant quantitative and qualitative fluctuations of the gut microbiota populations of the volunteers. However, we detected no significant differences in the overall community structure, Shannon diversity or relative abundance of individual bacterial species over the course of our study, in accordance with the findings of our previous investigation in which a 8-week, acute hookworm infection alone did not result in significant alterations of the fecal microbiotaLachnospira (a Firmicutes) was more abundant in the Trial subjects ; Clostridia and Ruminococcus (both within the phylum Firmicutes) dominated the fecal microbiota of the Control subjects. A shift in the Bacteroidetes to Firmicutes ratio in association with active CeD has already been documented in a previous study examining the effects of sustained GFD on the composition of the duodenal microbiota of adult CeD volunteers6Ruminococcus , in the Control subjects is in disagreement with previous findings reporting Methylobacterium (class Alphaproteobacteria) and Mycobacterium (Actinobacteria) as the prevalent genera of bacteria in the gut microbiota of adults with active CeDet al.et al.Three fecal samples from volunteers with active CeD (Control) were included in our study and compared with the pre-trial (T0) samples from the Trial subjects. Quantitative differences in the abundance of the main phyla were observed between the two groups; in particular, the Firmicutes dominated the microbiota of the Control subjects with active CeD , whereas the Bacteroidetes were more abundant in the healthy Trial subjects. Despite this overall trend, the genus In conclusion, the present study has revealed a potential beneficial consequence of hookworm infection in the context of an autoimmune disease, i.e. supporting the maintenance and diversity of commensal flora. Whether hookworm-mediated changes in the microbiota are causal for the improved gluten tolerance and reduced inflammation in CeD is unknown, but could be examined in greater detail in an animal model of the disease. It also remains possible that hookworm-induced immunoregulation is mediated by additional mechanisms, in particular the direct actions of parasite excretory/secretory proteins on immune cellsThis study was approved and carried out in strict accordance and compliance with the National Statement on Ethical Conduct in Research Involving Humans guidelines of the National Health and Medical Research Council of Australia (NHMRC). The Prince Charles Hospital  and James Cook University Human Research Ethics Committees approved the study. Written informed consent was obtained from all subjects enrolled in the study. This study was registered as a clinical trial at ClinicalTrials.gov as NCT00671138N. americanusEight otherwise healthy volunteers with HLA-DQ2 + or HLA-DQ8 + CeD on a strict GFD (>5 years)  were infected percutaneously with 20 infective third stage larvae of TM DNA isolation kit , according to the manufacturer’s instructions. The V1-V3 hypervariable region of the 16S gene was PCR amplified using universal primers described previouslyGenomic DNA was extracted directly from each sample using the PowerSoilhttp://greengenes.secondgenome.com/; cut-off: 97% sequence similarity) using the UCLUST software; then, sequences were assigned to taxonomy using the Ribosomal Database Project (RDP) Classifier with the confidence level set at 0.8. Statistical analyses and data mining were conducted using the Calypso software . Shannon diversity and rarefied richness (rarefy function in vegan Bioconductor package) were compared by paired t-test and rarefaction curves. Differences in abundance of individual OTUs were assessed by paired t-test on square root transformed relative abundance values and Wilcoxon test  software suitexon test , and p-vHow to cite this article: Giacomin, P. et al. Experimental hookworm infection and escalating gluten challenges are associated with increased microbial richness in celiac subjects. Sci. Rep.5, 13797; doi: 10.1038/srep13797 (2015).


Dear Editor,Alleviation of back pain and/or any disability due to pain in patients with lumbar disc disease undoubtedly gives a sense of relief and well being. The use of noninvasive or minimally invasive interventional procedures for this condition is basically aimed at limiting pain and disability. A number of such minimally invasive percutaneous techniques for the treatment of lumbar disc disease have been developed over the years, with the common tenet being the ability to act directly on the disc content without violating the spinal channel or increasing subsequent risk of scarring.Electrosurgical technology has been developed for use in the spine and possesses few, if any of the drawbacks of the other percutaneous disc decompression techniques. These are usually plasma-mediated radiofrequency-based excision and allow precise etching of tissue. When used for tissue ablation (excision) in the disc, these procedures excise target material without gross thermal or structural damage to adjacent tissue .We have studied patients using the nucleoplasty procedure developed by Arthro Care Corporation , which is performed using a plasma-mediated radiofrequency-based device. This procedure uses radiofrequency to excite the electrolytes in a conductive medium, such as saline solution, to create precisely focused plasma. The energized particles in the plasma have sufficient energy to break molecular bonds, excising or dissolving soft tissue at relatively low temperatures -4. In ouTwo main mechanisms are reported as possibly being the basis of the effect of percutaneous disc decompression. Mechanical decompression of the nucleus pulpous with partial emptying of the disc space with consequent pressure lowering inside the disc space is considered as a mechanical explanation of the procedure . The othFarzanegan et al.  in a stu


Motivation: The field of structural bioinformatics and computational biophysics has undergone a revolution in the last 10 years. Developments that are captured annually through the 3DSIG meeting, upon which this article reflects.Results: An increase in the accessible data, computational resources and methodology has resulted in an increase in the size and resolution of studied systems and the complexity of the questions amenable to research. Concomitantly, the parameterization and efficiency of the methods have markedly improved along with their cross-validation with other computational and experimental results.Conclusion: The field exhibits an ever-increasing integration with biochemistry, biophysics and other disciplines. In this article, we discuss recent achievements along with current challenges within the field.Contact:Rafael.Najmanovich@USherbrooke.ca Structural bioinformatics, originally known as structural computational biology, predates other forms of bioinformatics. It can be argued that the seminal 1953 article by Watson and Crick  is in faStructural bioinformatics or structural computational biology, broadly defined, is a field at the intersection between computer science, physics, chemistry and molecular biology. Historically, the term ‘structural bioinformatics’ describes data-driven statistical, knowledge-based research of representative non-redundant ensembles of structures to understand the statistical behavior of the system under investigation. Alternatively, ‘computational biophysics’ describes a hypothesis-driven physics-based treatment of biological molecular systems. The ergodic hypothesis guarantees that conclusions from the two types of approaches converge over large non-redundant samples or long simulations . CurrentBiologically, structural bioinformatics aims to understand the factors that influence and determine the function of biological macromolecules, the interplay between evolution, kinetics and thermodynamics, the determinants of specificity and selectivity in molecular interactions, the dynamic aspects of macromolecular structures and their effect on function and stability and, finally, the ability to use all these for engineering, design and biotechnology. In fact, a complete understanding of biological processes must inescapably pass through an understanding of the factors influencing such processes at the atomic and sometimes even subatomic levels. In this article, we discuss some of the most notable achievements in structural bioinformatics over the past 10 years and discuss existing challenges in the field. Without a doubt, the topics and the specific articles mentioned here are biased by the opinion of the authors.Some of the numerous achievements in the field in the last 10 years include the following .Fig. 1.The human genome sequencing revolution marks the availability of sequence data at scale. The realization that sequence alone is not enough to understand/predict function led to the establishment of large structural genomics initiatives where the structure of proteins with low sequence similarity to proteins with known structures were targeted to increase the coverage of fold space and permit more accurate fold recognition, threading and homology modeling . In the Folding@home (The increased availability of computer power has enabled applications that were beyond imagining just a few years ago. Dedicated hardware [e.g. ANTON  [e.g. Foing@home ] vastly The CASP critical assessment of protein structure prediction began a new era in the field providing an objective double blind test for structure prediction methods . This alCorrelated mutation data have enabled the generation of pairwise amino acid contact maps from sequence data . Such coAlso known as systems pharmacology, the integration of the vast amounts of ‘omics’ data with accessible structural methods such as the detection of binding site similarities .Docking simulations (Although considerable progress has been made, advances are still needed in the following areas .Most proteins are large and multi-domain and take part in complex assemblies requiring fine-tuned recognition  and the The accurate modeling of large conformational changes due to ligand binding, allosteric effects, post-translational modifications or as the result of protein–protein interactions is essential. Techniques such as molecular dynamics  and elasThe prediction of RNA structures is still in its infancy . With siAlthough protein structure is resilient to mutation (Beyond the detection of cross-reactivity targets to a given drug and the impact on the complete system, a full understanding of specificity and selectivity at the molecular level requires studying all macromolecules that are sharing the crowded  cellularProtein engineering of single proteins  are stilIs fold space discrete or continuous? If discreet, why are some folds so much more common than others? Have we identified nearly all possible folds? How do new folds appear? All these questions have been partially addressed but definitive answers still remain illusive.The biggest challenge in structural bioinformatics remains unsolved. That is, the ability to consistently predict the structure of a protein based solely on its amino acid sequence. The Levinthal paradox inspires us to continue. Thus, although conformational space is so immense as to be intractable, proteins do fold, leading to a variety of advances based on different ways of addressing the paradox (Data, methods and publications must be open , NAMD (Y3DSIG is a special interest group within the International Society for Computational Biology. 3DSIG holds an annual meeting preceding the annual ISMB meeting. The insights shared in this article come as a synthesis of the trends observed at 3DSIG since its inception 10 years ago.


To describe the rationale and design of the Northern Finland Birth Cohort (NFBC) Eye Study.The NFBC Eye Study is a randomised prospective cohort study. The original NFBC study population consists of 12058 subjects born in the region of Lapland and the Province of Oulu. A postal questionnaire covering extensively the medical and socioeconomical background was sent to the 10300 subjects of the NFBC alive and residing in Finland. For the NFBC eye study the subjects were randomised to the screening group (50%) and the control group (50%). The screening protocol includes the following tests: automated and manifest refraction, best corrected visual acuity, central corneal thickness, intraocular pressure, Humphrey 24–2 perimetry, stereoscopic optic nerve head (ONH) and retinal nerve fibre layer (RNFL) photography and imaging with Scanning Laser Ophthalmoscopy (HRT), Scanning Laser Polarimetry (GDx) and Optical Coherence Tomography (OCT).Two ophthalmologists evaluate the ONH and RNFL photographs and the visual fields independently. All suspected glaucoma cases are re-evaluated by two independent glaucoma experts. HRT, GDx and OCT findings are assessed separately. In the future, both groups (100%) will be examined. The effectiveness and the cost-effectiveness of glaucoma screening will be calculated. The response rate of the questionnaire was 67% (n = 6855) and 871 randomised subjects had undergone the eye screening protocol by the end of April 2013.The trial is designed to address the following questions: what is the best combination of diagnostic tests for detecting glaucoma in an unscreened population, what are the benefits and disadvantages of the screening to the individual and the society and is glaucoma screening both effective and cost-effective. The prevalence, incidence and risk factors of glaucoma and other eye diseases will be evaluated, as well as their impact on quality of life. Open angle glaucoma (OAG) is a major cause of avoidable blindness worldwide. Due to its insidious nature and irreversible consequences, OAG is considered to fulfil the criteria for population screening. However, there are no randomised controlled trials that demonstrate the effectiveness of screening for preventing blindness from OAG -3.OAG is the most common type of glaucoma with a prevalence of 1.5-2% in the Caucasian population aged over 50. The worldwide number of OAG patients is estimated to be 61 million and approximately 6.7 million of them are bilaterally blind due to glaucoma . The onsTo date there is no systematic glaucoma screening in any country and most glaucoma cases are diagnosed by chance. Epidemiological studies have shown that at least half of the glaucoma patients are still undiagnosed ,9. An orThe NFBC main study was set out to explore the long-term morbidity, disease markers, spectrum of symptoms and psychosocial wellbeing throughout the life span. This unselected, geographically defined population sample consists of individuals born in 1966. The NFBC Eye Study includes three separate entities: the diagnostics of glaucoma, the effect of screening on glaucoma incidence and the cost-effectiveness of screening for glaucoma and other eye diseases. The analysis for the diagnostics is based on both cross-sectional and cohort designs whereas the analysis for the cost-effectiveness is based on randomised controlled design. Hence, the trial seeks to address the following questions: (i) what is the best combination of diagnostic tests for detecting glaucoma in an unscreened population, (ii) what are the benefits and disadvantages of the eye screening to the individual and the society and (iii) is glaucoma screening both effective and cost-effective. Other eye diseases as well as related factors, e.g. retinal perfusion parameters, diabetic retinopathy, early changes related to macular degeneration, presbyopia and vision associated quality of life, are also assessed. Also the relationship between birth weight and growth patterns during early life to eye diseases is evaluated. The purpose of the NFBC Eye Study is to evaluate the diagnostic methods and cost-effectiveness of glaucoma screening as well as other ocular morbidity in middle-aged Caucasian population.th gestational week. The course of the delivery and neonatal outcome has been confirmed from the patient records. The original data has been supplemented by the information collected with postal questionnaires and clinical examinations carried out at the age of 1, 14 and 31 years. In the previous NFBC analysis during 1997–1998 the response rate to the questionnaire was 75% [The original cohort consists of 12058 subjects born in the region of Lapland and the Province of Oulu (96% of the deliveries in these regions). The cohort is comprised of males and females in approximately equal proportions .Out of the original cohort, 460 subjects have died and 961 have moved abroad. 10300 subjects with an address in Finland were included in the randomisation. The participants were stratified into three categories based on gender, age and postcode. The subjects were divided into four age categories according to their month of birth: January-March, April-June, July-September and October-December. They were divided into 13 postcode categories roughly following the regional centres of the national mail agency Itella. All in all, there were 104 (2 × 4 × 13) strata for randomisation. Randomisation was performed using Resampling Stats software . The epidemiologist responsible for the randomisation was blinded to all other information than the factors used for stratification.The subjects randomised to the eye screening group (50%) undergo the examinations presented in Table By the end of April 2013 the response rate of the questionnaire was 67% (n = 6855) and 871 randomised subjects had undergone the eye screening protocol. The enrolment for the clinical examination is still in progress. Informed consent has been obtained from all subjects attending examinations.i . Static white-on-white perimetry (white test points on a white background) limited to the 24 degree central area is considered to be the current standard for detecting glaucomatous visual field defects [The visual field examination is performed using the 24–2 Swedish Interactive Threshold Algorithm (SITA) of the Humphrey Field analyser II- defects ,10,13. NColor and grayscale digital fundus images are obtained with a Canon CF-60DSi Digital Mydriatic Fundus Camera with attached Canon EOS-1Ds MK III SLR Digital Camera . The pupils are dilated for imaging. The images are processed with Adobe Photoshop CS  and Neacapture software . Stereoscopic ONH photography still represents the standard for detecting glaucomatous damage and progression of the optic disc . The sepThe evaluation of optic nerve head topography is carried out using the Heidelberg Retina Tomograph . The HRT explores the ONH and the adjacent retinal nerve fibre layer at stepwise progressing depths. The stack of captured images is used to form a three-dimensional topography image. The stereometric optic nerve head parameters , the Moorfield’s regression analysis (MRA) and Glaucoma probability score (GPS) are calculated from the topography image -19. The Scanning laser polarimetry is carried out with the GDxPRO with Enhanced Corneal Compensation . The RNFL polarizes light making the reflected beam proceed in two focus planes (“birefringence”). The thickness of the RNFL is related to the alteration of the polarized light. The enhanced corneal compensation mode is used to improve signal-to-noise ratio and the quality of the image. It has been shown to improve diagnostic accuracy for glaucomatous damage . The RNFCirrus HD-OCT 4000  is used to obtain spectral domain optical coherence tomography (OCT) images. Anterior Segment HD Images (5 Line Raster) are obtained from the central cornea and limbus to evaluate central corneal thickness and the angle opening distances of the anterior chamber angle. The standard Macular Cube 512 × 128 protocol is used to evaluate macular thickness parameters and the Optic Disc Cube 200 × 200 protocol to assess the peripapillary ONH parameters. The ONH parameters acquired with Cirrus HD-OCT have been shown to be able to discriminate between normal and glaucomatous eyes .In this study, the definition of glaucomatous damage is based on the examinations of the ONH, RNFL and VF and Finnish Evidence Based Guideline '2 out of 3 rule’. When at least two out of three of the examinations are found to be abnormal, glaucoma is likely . IOP is Two ophthalmologists (EK and KS) evaluate the ONH and RNFL photographs and visual fields independently. All suspected glaucoma cases  found by EK or KS or both are re-evaluated by two independent glaucoma experts (ML and PH) to confirm the diagnosis. A third glaucoma expert (ATu) will re-evaluate the findings in case of disagreement between the two glaucoma experts. If glaucomatous damage is identified by the imaging instruments  in subjects not considered glaucoma suspects by the ophthalmologists, they are re-evaluated by the glaucoma experts. A random sample of subjects with normal findings is also re-evaluated by the experts for quality control  will be examined with a similar screening protocol described here. The incidence of glaucoma and other eye diseases in both groups will be evaluated and the effectiveness and cost-effectiveness of glaucoma screening for preventing blindness can be assessed. So far, there has not been compatible evidence for calculating the cost-utility of glaucoma screening . A EuropThe authors declare that they have no competing interests.VS participated in the design of the study, data analysis and writing the manuscript. EK participated in data analysis and writing the manuscript. KS, PH and ML participated in data analysis, the evaluation of glaucomatous damage and revising the manuscript. JK performed the randomisation and participated in the design of the study and writing the manuscript. ATa participated in the design of the study and revising the manuscript. ATu participated in the design of the study, data analysis and writing the manuscript. All authors have approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/13/51/prepub


Substance use disorders are highly prevalent in community correctional populations, yet these settings frequently are ill-equipped to identify and refer offenders to community-based treatment services. In particular, community corrections staff are often opposed to the use of medication in addiction treatment because of inadequate knowledge, resources, and organizational structures to facilitate client linkages to evidence-based services.Each of the NIDA-funded Research Centers recruited 2 criminal justice agencies to participate in the study. Eligibility rules required study sites that were focused on community corrections , had few or no formal relationships with treatment providers for referring clients to medication-assisted treatment, and had no state or local policies prohibiting such relationships. Sites under the oversight of the same parent agency were eligible only if they were in geographically distinct catchment areas, and could be assigned to different study arms without cross-contamination at any level. The 18 clusters consisted of community corrections officers and their offender caseloads nested within agencies, each of which was partnered with at least one community-based substance abuse treatment program. Randomization was blocked by Research Center, within which one cluster was randomly assigned to a training-only condition (comparison) and the other to training followed by a strategic organizational linkage process (intervention). Line staff received a scientifically-grounded, systematically-delivered training session that addresses gaps in existing knowledge, perceptions, and information about medication-assisted treatment (MAT) and local availability of MAT services. Key decision-makers subsequently were asked to collaborate in a strategic planning process to enhance formal and informal linkages between criminal justice agencies and local MAT providers. It was hypothesized that the two implementation intervention components together would be more likely than staff training alone to improve the process of referring opioid- and alcohol-dependent adults under community supervision to appropriate addiction pharmacotherapy. Outcomes were measured at the client , line staff (attitudes), and organizational (linkage) levels.Through closer collaboration among criminal justice agencies and treatment providers, improved linkages to effective substance abuse treatment should yield significant clinical, public health and public safety benefits.NCT01344122.Clinical Trials gov registration number  By facilitating linkages to effective substance abuse treatment through closer collaboration among criminal justice and addiction treatment agencies, significant benefits to public health and public safety are likely to be achieved.The Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) multisite cooperative is engaged in research on implementing and sustaining evidence-based drug abuse treatment services for persons with substance use disorders involved with the criminal justice system. As such, the CJ-DATS studies seek to determine the effectiveness of one or more Approximately 4.9 million adults in the U.S. were under parole or probation at year end 2010. Glaze  It has bWhile offenders’ lack of insurance coverage for MAT and the prohibitive out-of-pocket cost of these medications are commonly cited as implementation barriers, a planning survey of potential CJ-DATS study sites  protocol addressed interagency collaboration through staff training and coordinated strategic planning. The project did not seek to implement the delivery of addiction pharmacotherapy within community correctional agencies; rather, this study tested the implementation of an organizational linkage intervention (OLI) to increase offenders’ access to already-available evidence-based treatment services in the communities in which they reside. Because the intervention was designed to affect the behavior of community corrections agencies  and staff , a cluster randomized design was used.The consolidated framework for implementation research (CFIR) guided the MATICCE study design.  were not the focus of this study because the treatment programs involved in this project had already adopted MAT.For the criminal justice agencies in this protocol, challenges to linking clients with MAT were nested in the external environment in which these agencies operate. These barriers included a lack of formal relationships with MAT-enabled treatment programs, and limited incentive to negotiate such relationships. Improvement of interagency collaboration and formalization of interorganizational ties were the primary goals of the MATICCE implementation intervention.Relationships between criminal justice agencies and local substance abuse treatment providers may be in part constrained by the characteristics of those agencies – e.g., by an organizational culture that is resistant to collaboration, a low degree of readiness to change current practice, and/or a lack of information systems to support the monitoring of client exchanges between organizations. In this domain, the MATICCE study protocol introduced a strategic planning process to assist probation and parole staff in identifying and overcoming organizational barriers to linking clients with MAT.Effectively linking clients with MAT is a task ultimately carried out not by organizations but by individual community correctional staff working in these settings. Staff knowledge and perceptions must be addressed in order to promote acceptance of MAT and its potential role in promoting both public health and public safety. Similarly, information about local MAT resources is needed to permit staff to initiate treatment linkages and to follow up on the progress of individual clients. The MATICCE study protocol included a Knowledge, Perception and Information (KPI) training intervention targeting this implementation domain.the KPI training + organizational linkage implementation (OLI) strategy increased service coordination and formalization of interorganizational relationships (Aim 1);the KPI training + OLI was superior to the KPI training alone in promoting client referral to MAT in the community (Aim 2);the KPI training had desired impacts on staff knowledge, perceptions and information about resources relative to baseline (Aim 3); andthe extent to which the interorganizational linkages were sustained beyond the active intervention period. This domain also includes measurement of the degree to which the implementation intervention was executed as intended .Finally, the implementation process itself must be specified and measured. The MATICCE study protocol used a multi-method design  that allowed for the examination of whether:Each of 9 CJ-DATS Research Centers partnered with 2 community corrections agencies (probation or parole offices) in distinct geographic catchment areas. Agencies could be under state, federal, or county authority. Agencies within the same parent organization were eligible for inclusion only if they could be randomized in such a way that the participation of one agency in the intervention would not impact the agency assigned to the control group. As part of the MATICCE protocol, the community corrections agencies identified at least one local community-based treatment provider that currently offers medication-assisted treatment, and to/from which the agency would benefit from improving its client flow. If no MAT providers were known to the probation/parole agency, the Research Center staff assisted in identifying and recruiting the participation of a suitable treatment provider organization. Depending on the catchment area and client flow, involvement of multiple treatment provider agencies could be logical and beneficial. Each study site or cluster thus included the community corrections-treatment agency dyad in a given catchment area, the community correctional officers (line staff), and their clients (offenders). MATICCE was tested in 18 study sites located in Arizona, Connecticut, Delaware, Illinois, Kentucky, Maryland, Missouri, New Mexico, Pennsylvania, Puerto Rico, and Rhode Island.Block randomization occurred by Research Center such that each Research Center contributed one experimental and one control site (cluster) to the study. The requirement for even distribution of sites across Research Centers was a function of the CJ-DATS structure and NIDA grant award requirements. Given the distribution of Research Centers, this effectively meant that there is no more than one experimental site in any single state.Phase 1 was an initial pre-intervention pilot phase in which the researchers assessed each site and developed, where necessary, any site-specific data collection procedures or methods. For example, sites may have jad somewhat different procedures for storing client records and administrative data; during this initial phase, Research Center staff examined those records and developed a plan for accessing and abstracting each of the protocol’s required data elements. Study investigators reviewed each site’s procedures to ensure consistency of measurement across sites. Phase 1 ended with the collection of baseline survey, interview, and records data from all study sites.The MATICCE study protocol had 4 phases  about the definition, evidence base, and local availability of MAT for persons with opioid and/or alcohol dependence. The content of the KPI training was developed by the MATICCE workgroup and the Pacific Coast Addiction Technology Transfer Center (ATTC), one of a network of federally-funded training centers that serve as regional information resources on substance abuse treatment. The KPI curriculum drew from a variety of existing resources previously developed by NIDA and by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (CSAT), grounded in the results of peer-reviewed clinical research. Topics included common myths about MAT and scientific evidence to refute them; a basic overview of brain functioning in relation to drug addiction and MAT; descriptions of the FDA-approved addiction pharmacotherapies and their clinical indications; and advantages that MAT might have for those under criminal justice supervision. The protocol workgroup played an important role in helping shape the presentation to anticipate the needs and interests of a criminal justice audience.Finally, each Research Center developed an informational pamphlet listing community-based treatment programs in the local catchment area that provdie one or more FDA-approved pharmacotherapies for the treatment of opioid or alcohol dependence. These pamphlets included the name and address of each program, telephone number or other contact information, and a summary of services offered. To reinforce the training content, the pamphlets also included a brief description of each FDA-approved medication and the conditions for which each is indicated.The KPI training content and its delivery were standardized across all study sites. All probation/parole officers and supervisors in the participating office were invited to attend; research centers had the option to invite staff from other agencies  as interest warrants. Attendees were consented immediately prior to the training session. Each session began with an introduction by a corrections departmental official stating the facility’s goal of increasing the number of clients who have access to medication assisted treatment. Experienced trainers delivered the KPI curriculum using lecture, question-and-answer, and group discussion methods.Phase 3 began random assignment of criminal justice agencies, blocked by Research Center, to either the experimental (KPI + linkage intervention) or control (KPI-only) group. As each Research Center completed Phase 2, a neutral member of the MATICCE study team assigned clusters to conditions via a coin toss. Research Centers worked with the experimental group sites to identify members for a Pharmacotherapy Exchange Council (PEC), including key decision makers from both the corrections agency and treatment program; line staff from both settings; and other relevant parties depending on local policies and networks. Across study sites, the average PEC roster included 10 members on average [range 6 to 16]. The research team also worked with the study site to identify and recruit a “Connections Coordinator;” that is, a designated person with the skills and networks to facilitate implementation of the plans developed by the group, without serving as the group leader. The PECs were co-led by members representing CJ and treatment agencies.The organizational linkage intervention fundamentally sought to bridge the “trust gap” that exists between the public health orientation of treatment agencies and the public safety orientation of community corrections agencies. The disconnect between advocacy for the individual in treatment settings and individual accountability in correctional settings sets up a duality of mission that often results in a lack of open communication or even antagonism in the day-to-day workings of organizations that on the surface work together. The PEC took these differences as the starting point for organizational change by focusing on communication. The ability to establish, improve and maintain linkages among community corrections agencies and treatment providers fundamentally depends on building relationships between individuals. The PEC worked to formalize these relationships by establishing objectives, procedures, information sharing protocols, target outcomes, and measures of success that were shaped by both organizations. The PEC engaged in a group strategic planning process to maximize the integration of relationships between community corrections and treatment services, with the ultimate goal of facilitating offenders’ movement between the two systems.Using a step-by-step manual developed by the MATICCE study workgroup, the researchers trained the PEC members in a strategic planning process that acknowledged the adaptive complexity of the system and mobilized the natural organizing ability and creativity of staff and stakeholders  to keep the group on task and to encourage adherence to the overall project timeline. The researchers did not actively facilitate the strategic planning activity other than to guide the PEC back to the steps in the written framework as needed. Investigators from each Research Center met with one another via teleconference bi-weekly to review the project’s overall progress, monitor timelines, and troubleshoot problems as they arose to ensure integrity of the study protocol.Phase 4 represented the PEC’s final task, which was to develop a sustainability plan to guide the participants’ ongoing interactions after the strategic planning period ends. Ideally, sites had jointly adapted local policies and procedures to institutionalize the implemented changes. With a sustainability plan in place, the research team convened the PEC for a final wrap-up meeting, and then formally disengaged from the group. The MATICCE research project period included a 6-month sustainment phase following the active intervention period. After the 6 months elapsed, the researchers returned to the intervention sites to measure sustainment of organizational linkages and client referral patterns.Data collection activities were designed to address each of the study’s specific aims. Table Baseline Survey of Organization Characteristics (BSOC) collected from community corrections and treatment managers and line staff measure several important dimensions of organizational structure and climate that may influence implementation outcomes. The BSOC was derived from validated subscales of the Organizational Readiness for Change survey  further assessed changes in referral to MAT. The record abstraction activity reviewed client records for the preceding 6 months and documented the total number of (a) active probationers/parolees in the facility, (b) records with indications of alcohol or opiate involvement, (c) records with indications that the client had been referred for assessment or treatment, and (d) records with indications that the client had received assessment or treatment. While both the self-report and the chart records were imperfect sources for verifying the absolute numbers of client referrals and receipt of treatment, significant changes over time from either or both sources in the intervention group relative to the control group sites would indicate that the intervention had the intended downstream effects on client flow (Aim 2).Change in the flow of clients from community corrections settings to local treatment programs was measured by counts of client referrals in two ways  had not started, were partially completed, or were fully completed. These measures assessed adherence to the intervention protocol across sites, measured the time required to complete each step, and related adherence and time-to-completion with site variation in intervention outcomes. Monthly surveys of the PEC membership measured the development of a working alliance between the connections coordinator and the PEC. These surveys provided information about how well the group members worked together and whether this facilitated or impeded completion of the component tasks in the linkage intervention as well as the study’s focal outcomes. Finally, staff satisfaction with the organizational linkage intervention was measured by surveying the probation and parole officers in each participating study site at 6 months into the linkage intervention and at the end of the implementation phase. These surveys assessed the positive and negative impacts of the intervention on staff, including items such as whether the linkage intervention increased their workload and/or increased their ability to link clients with needed treatment services.To the implementation intervention across study sites and over time was captured by three measures. A sustainability survey, which measured the extent to which the organizational linkage intervention and its components were accepted by agency staff, were integrated into ongoing procedures, and continued to inform agency practice.The MATICCE study protocol included a 6-month sustainment period to allow the researchers to assess whether any gains in interorganizational linkages and client referrals were sustained beyond the active intervention period. Sustainment was measured using three sources of data. First, the study sites continued to provide Monthly Survey of Treatment Referrals (MSOTR) data on the number of clients referred from the probation/parole agency to the treatment agency, and the number received by the treatment agency from community corrections. Second, the research team again reviewed agency records for documentation of the number of offenders screened, identified, and referred to treatment. Finally, a key informant at each community corrections agency completed a brief In the community corrections agencies and PEC members allowed for a more in-depth understanding of Aims 1 and 3. These semi-structured interviews produced data that speak not only to the acceptability of MAT within the organizational culture, but also to the participants’ process and experience with the organizational linkage intervention. It is possible that the KPI training and the organizational linkage interventions increased either knowledge of MAT or interorganizational coordination, without actually producing marked changes in client referrals as reflected in agency records. In such instances the qualitative interviews help to elucidate the organizational change process that occurred, as well as help to identify any remaining cultural, structural, or organizational barriers (including stigma about drug abuse treatment) that may have persisted. The qualitative interview guides complemented and supplemented the information obtained from the various surveys, thereby providing critical information necessary for triangulating survey and records data for the participating sites at baseline and follow-up time points. Finally, the exploratory nature of the semi-structured interviews created an opportunity to identify and examine unforeseen barriers and facilitators to enhancing treatment services linkages at the participating sites.Randomization occurred at the site level, with the Research Center as a blocking factor. Thus, MATICCE was a multisite cluster randomized trial , and outcomes were measured at the individual PO level (level 1). The calculated Minimum Detectable Effect Size (MDES) ranges for 3-level MSCRTs reflect that, under the best case scenario of smaller Intra-Class Correlations (ICC) and larger variances explained by blocking and covariates, there was at least 80% power to detect a true population effect as small as 0.37 for hypotheses associated with the study’s specific aims.A 3-level HLM model was applied to determine the sustainability of the intervention effect for the KPI + OLI group. This model focused on the within-group difference across study phases (repeated measures). Instead of treating time as a continuous variable, which is more common in repeated measure multi-level modeling, two dummy variables representing Phase II, the immediate post-KPI period versus Phase III, the end of the OLI period, and the end of Phase III versus the 6-month follow-up, were created and incorporated as level one covariates. Calculation of the MDES for the 3-level repeated measures HLM model was based on the sample size formula from Teersenstra et al.  were employed to address the need for accurate and accessible information. Extensive organizational- and staff-level data collection allowed examination for comparability across the study sites and understanding of the target populations to which the findings apply. The protocol addressed issues of interest to implementation science ; health services research ; and practical concerns of criminal justice partner agencies .Success in this intervention would address the need to expand access to effective drug treatment services for offenders under community supervision, and may provide a roadmap for facilitating coordination among agencies whose core missions  are often viewed as incompatible and even adversarial. Likewise, if the combined KPI+OLI intervention shows intended effects relative to the training-only condition, it may provide important evidence for community-based agencies about the limits of staff training as the default approach to implementation of evidence-based practices and system change. Finally, it is hoped that the findings of this study will have practical utility as community corrections agencies seek more efficient and effective ways to manage growing client caseloads in the face of increasingly constrained resources.MATICCE Workgroup Authors include : Sami Abdel-Salam (University of Delaware), Carmen Albizu-Garcia (University of Puerto Rico), Lori J. Ducharme , Jamieson Duval (University of Kentucky), Juliane Fenster (University of Connecticut), Peter D. Friedmann , Linda Frisman (University of Connecticut), Michael Gordon (Friends Research Institute), Elizabeth Hall (UCLA), Timothy Kinlock (Friends Research Institute), Kevin Knight (Texas Christian University), Shannon Gwin Mitchell (Friends Research Institute), Jennifer Pankow (Texas Christian University), Dan O’Connell (University of Delaware), Lynda A. Stein (University of Rhode Island), Terry Urbine (Arizona State University), and Wayne Welsh (Temple University).


Biogeographers seek to understand the influences of global climate shifts and geologic changes to the landscape on the ecology and evolution of organisms. Across both longer and shorter timeframes, the western North American landscape has experienced dynamic transformations related to various geologic processes and climatic oscillations, including events as recently as the Last Glacial Maximum  that have impacted the evolution of the North American biota. Redside shiner is a cyprinid species that is widely distributed throughout western North America. The species’ native range includes several well-documented Pleistocene refugia. Here we use mitochondrial DNA sequence data to assess phylogeography, and to test two biogeographic hypotheses regarding post-glacial colonization by redside shiner: 1) Redside shiner entered the Bonneville Basin at the time of the Bonneville Flood , and 2) redside shiner colonized British Columbia post-glacially from a single refugium in the Upper Columbia River drainage.Genetic diversification in redside shiner began in the mid to late Pleistocene, but was not associated with LGM. Different clades of redside shiner were distributed in multiple glacial age refugia, and each clade retains a signature of population expansion, with clades having secondary contact in some areas.Divergence times between redside shiner populations in the Bonneville Basin and the Upper Snake/Columbia River drainage precedes the Bonneville Flood, thus it is unlikely that redside shiner invaded the Bonneville Basin during this flooding event. All but one British Columbia population of redside shiner are associated with the Upper Columbia River drainage with the lone exception being a population near the coast, suggesting that the province as a whole was colonized from multiple refugia, but the inland British Columbia redside shiner populations are affiliated with a refugium in the Upper Columbia River drainage. A major goal of biogeography is to investigate the influences of geological and climatic changes on the divergence and distribution of populations, species, and higher taxa. A reasonable expectation in biogeographic studies is that episodes of geographic isolation, and consequently, opportunities for divergence should be favored on topographically complex landscapes ,2. The cClimatic oscillations during the Pleistocene have played a significant role in the evolution of the western North American biota by forcing organisms through a series of range contractions and expansions, range shifts, or localized extinctions as glacial ice sheets expanded and retracted . In nortIn addition to ice sheets, glacial-age lakes associated with the ice sheets altered the landscape of western North American in ways that may have affected gene flow. Perhaps the best studied of these is Lake Missoula, a glacial lake that formed in western Montana when the Clark Fork River was dammed by a lobe of the Cordilleran Ice Sheet . CatastrThe increased precipitation and decreased evaporation associated with glacial maxima resulted in the formation of pluvial lakes in many of the valleys of the Basin and Range province during the Pleistocene. Pluvial Lake Bonneville in the Bonneville Basin experienced lake high-stands coincident with glacial melt waters . The higRichardsonius balteatus (Richardson), occurs in many areas heavily influenced by Pleistocene climatic oscillations, either by glaciation directly, or by glacial and pluvial lakes. The species’ native range spans the Bonneville Basin and the Snake-Columbia River basins west of the Rocky Mountains, ranging from southern Utah to northern British Columbia, and westward to the Pacific Coast of Oregon, Washington and British Columbia , during the Pliocene  as references for aligning and editing cyt b sequences. There were no gaps in the final cyt b alignment, but there were in the final CR alignment. Individuals carried between three and five insertion/deletion sequences (each one bp long) in their non-coding CR sequences, but these were straightforward to align. Because both CR and cyt b are in the mitochondrial genome, and are thus inherited as a unit, we concatenated the sequences prior to performing phylogenetic analyses.We aligned sequences using the automatic assembly function in Sequencher v. 4.8 (Gene Codes Corp.) then inspected the aligned sequences by eye and made corrections manually. We used amino acid sequence and a To get a broad assessment of redside shiner phylogeography, we generated phylogenies using maximum likelihood (ML) and Bayesian inference. We selected the appropriate model of sequence evolution to be used in the phylogenetic analyses using jModeltest , and we R. balteatus, we created a haplotype network using the software program TCS v.1.21  .The authors declare that they have no financial or non-financial competing interests.DDH, DKS, and BRR designed the study. DDH obtained field samples and generated DNA sequence data. DDH and BTS performed the data analyses. All authors contributed to the writing of the manuscript. All authors read and approved the final manuscript.


Dislocation of the hip is a critical injury that results from high-energy trauma. This paper describes a case of posterior dislocation of the right hip in a 35-year-old woman with associated ipsilateral femoral head fracture. Initial treatment included reduction of the right hip through posterior approach and fixation of the femoral head fracture with three absorbable screws. After 15-month follow-up, a full range of motion has been achieved and there are no signs of avascular necrosis, hip instability, or limping. The authors describe their method of surgery. Traumatic hip dislocation is an infrequent and important injury that results from high-energy trauma. Associated injuries are common and they will influence the final outcome. These include fractures of the femoral head, neck or shaft fractures, acetabular fractures, pelvic fractures, knee injuries, ankle and foot injuries, or a combination of these. The vast majority of hip dislocations occur from motor vehicle accidents , 2. type I: fracture below the fovea not involving weight-bearing surface of the head, type II: fracture above the fovea involving weight-bearing surface of the head, type III: type I or II fracture with associated femoral neck fracture, type IV: type I or II fracture with associated acetabulum fracture.Hip dislocation is categorized into anterior and posterior dislocation. Posterior dislocation is much more common than anterior dislocation (90% postdislocation). Two original classification schemes have been described for posterior dislocation . EpsteinA hip dislocation or fracture dislocation is an orthopedic emergency. Time of presentation and more importantly reduction of the hip dislocation are essential in treating this injury and minimizing long-term complications, such as avascular necrosis of the femoral head and late osteoarthritis of the hip. The authors present a case of traumatic posterior hip dislocation with associated femoral head fracture (Pipkin type 2).In February 2012, a 35-year-old female suffered from a high-velocity accident. She had been unable to weight bear since the injury. The patient was transferred to the nearest hospital by EMS. On admission, the injury was closed and there were no accompanying injuries. Popliteal and ankle pulses were palpable on the right foot and neurosensory examination was normal. Her blood pressure and pulse rate were within normal limits. No other injuries or skin lesions except bruising were noted on physical examination. Direct radiographs revealed posterior dislocation of right hip. This kind of injury often occurs when the knee hits the dashboard in a collision. This force drives the thigh backwards, which drives the ball head of the femur out of the hip socket. Closed reduction was performed under general anesthesia and she was discharged from the hospital. Four days later, the patient presented to our hospital with a complaint of limitation of motion in the right hip. Her general condition was stable. Further radiographs  and magnHip dislocation is a rare injury, requiring a massive force to occur. The incidence of long-term complications such as avascular necrosis (AVN) following dislocation of the hip varies from 6% to more than 40%. The rate of AVN may be affected by the time the femoral head remains dislocated. Occasionally, congruent reduction may not be achieved because of small cartilaginous or osseous fragments that remain in the joint space. In a traditional manner, immediate closed reduction is the treatment of choice based on Thompson and Epstein's classification. In cases of unsuccessful closed reduction, with fragments trapped in the joint after reduction, or associated fractures of the femur, open reduction is required . DreinhoWe chose to combine the posterior approach in order to allow access to the hip and fixation of the ipsilateral femoral fracture with three absorbable screws. Our surgical protocol of fixation of the femoral head fractures using the posterior approach was applied because the posterior hip joints structures were already damaged by trauma. This allowed us to use this route for accessing the femoral head and acetabulum without any additional surgical trauma (iatrogenic). Due to that, we observed and manipulated the femoral head more easily . Delayed


Synchronous multiple malignancies of the larynx are rare. We present a case here of synchronous primary laryngeal squamous cell carcinoma (SCC) and malignant fibrous histiocytoma (MFH) in a patient with hoarseness though with no history of exposure to radiation. Clinical, intraoperative, and histopathological findings in this patient are discussed.Wide laser excision of the left supraglottic lesion and laser cordectomy of the right true vocal cord were performed.The patient presented with a recurrence of the ΜFH alone (with no recurrence of the SCC) two months after the first operation and was managed with an extended second look laser cordectomy. The patient is under regular follow-up and remained disease-free nine months from diagnosis.Our results show that early-stage simultaneous tumours of the larynx and particularly MFH and SCC can be treated efficiently with endoscopic laryngeal surgery alone. Close follow-up is of paramount importance because of the aggressive nature of MFH. The first case of multiple primary tumours was reported in 1889 by Billroth . We repoA 69-year-old man with a history of smoking and alcohol consumption was referred to otolaryngology complaining of hoarseness for almost one year. Full head and neck examination was performed including flexible laryngoscopy revealing a mass emanating from the left supraglottic part of larynx without erosion or haemorrhage and a lesion of the true right vocal cold presenting as leukoplakia . BilaterThe prominent neoplastic population consisted mainly of plump spindle cells arranged in short fascicles in a storiform pattern. A portion of these cells were arranged in a diffuse growth pattern. In these areas, the neoplastic cells had hyperchromatic, irregular nuclei with prominent one or more nucleoli. Giant, bizarre, or multinucleated cells were commonly along with typical and atypical mitotic figures. Aggregates composed predominantly of lymphocytes and plasma cells and strands of collagen were seen in the stroma. The immunophenotype  and the The second neoplastic population consisted of epithelial component and corresponded to a moderately differentiated SCC. The neoplastic cells were arranged in solid masses or cords and had eosinophilic or clear cytoplasm and big irregular nuclei with prominent nucleoli. Intercellular bridges were present. The immunophenotype of this population was typical to that of any SCC . The celA wide laser cordectomy of the left supraglottic mass and the right vocal cord with CO2 laser were performed. The results of the right true vocal cord biopsy were compatible with moderately differentiated SCC. During follow-up period, two months after the operation a very small granulomatous-type exophytic mass was found just above the anterior commissure . An exteSCC represents over 95% of all laryngeal malignant tumours. MFH is a non-epithelial tumour of mesenchymal origin that is composed of a variety of cell types, such as fibroblasts, atypical giant cells, and histiocyte-like cells. MFH is usually localised in the limbs, the abdomen, and the retroperitoneum. Almost 3–10% of all MFH are localised in the head and neck region. The most frequent localisations are sinonasal cavities (30%), craniofacial bones (15%), and larynx (10–15%) . MFH repThe first case of laryngeal MFH was described in 1972. Laryngeal MFH is more prevalent in men than in women with a ratio of 3:1, and it usually appears in adults of average age of 43 with a wide age range . HoweverThe immunohistochemical analysis in this case was crucial for the final diagnosis. In the case of the spindle/pleomorphic population the absence of any immunoreactivity for high molecular weight cytokeratin 34βΕ12  and cytokeratin 5/6, along with the at least focal positivity for markers of mesenchymal differentiation  excluded the diagnosis of a SCC. On the other hand, the absence of specific myogenic, vascular or neuromatous differentiation  lead to the diagnosis of PUS/MFH.Focal or weak immunoreactivity for mesenchymal markers such as vimentin , 9, SMA In 1889, the first case of multiple primary tumours was reported. Primary multiple malignant tumours of the larynx are extremely rare. On reviewing the literature we only found seven cases, and to our knowledge our case is the second report of synchronous laryngeal SCC and MFH . The supIn conclusion synchronous multiple malignancies of the larynx are uncommon. We report here a case of a laryngeal SCC, moderately differentiated, with simultaneous primary MFH which was confirmed with histopathological and immunohistochemical examination. Our results show that early-stage of simultaneous tumours in the larynx and in particular the MFH and SCC can be removed via laser laryngeal conservation surgery. Close follow-up is mandatory in order to detect early recurrences or a distal metastasis, considering the fact that MFH is an aggressive tumour.


Following last year's computational vaccinology workshop in Shanghai, China, the third ISV Pre-conference Computational Vaccinology Workshop (ICoVax 2013) was held in Barcelona, Spain. ICoVax 2013 provided an international platform for the attendees to showcase their research and discuss problems and solutions in the development and application of computational vaccinology and vaccine informatics tools. The first of the three full-length papers presented at ICoVax discussed the discovery of viral "camouflage" through cross-conservation of T-cell epitopes using a tool called JanusMatrix. This important paper reports that viruses may camouflage their presence in the human body by incorporating sequences in their proteins that are highly cross-conserved at the T-cell receptor surface with human genome proteins, a discovery that has wide ranging implications for the development of vaccines against viruses that use the camouflage method. The other papers described a database for storing experimentally verified data on DNA vaccines and compared therapeutic targets of western drugs to Chinese herbal medicines for cardiovascular diseases. The short poster presentations covered various uses of informatics tools for processing the DNA and microRNA of pathogens to improve vaccine coverage, efficacy and development. A live (on-line) demonstration of the vaccine design toolkit, iVax, presented by Frances Terry of EpiVax, illustrated how computational vaccinology could be used in the design of next generation vaccines. As a multidisciplinary field of research, computational vaccinology integrates computer science, mathematics, statistics, molecular biology, genomics, immunology and vaccinology. The capabilities of data processing and computational algorithms have dramatically increased in parallel with the number of genomes available for analysis. By leveraging the power of these data resources and algorithms, vaccine researchers are better positioned to design the next generation of vaccines, to study the fundamental immune responses that are relevant to vaccines, and to innovate in the field of vaccinology.BMC Bioinformatics.One means of advancing the field is to organize conferences where information on computational vaccinology approaches can be exchanged. The goal of the ISV Pre-conference Computational Vaccinology (ICoVax) workshops is to create an annual international forum for researchers to report, summarize, and discuss the most recent developments and ideas in the emerging areas of computational vaccinology and vaccine informatics. The most recent workshop took place immediately before the seventh Vaccine & ISV Annual Global Congress in Sitges, Spain on October 26, 2013. The first two ICoVax workshops took place in Seattle, USA and Shanghai, China in 2011 and 2012, respectively [BMC Bioinformatics. These papers covered the use of informatics to reveal viral camouflage patterns by analyzing the cross-conservation of T-cell epitopes among different species [The three full-length original research papers accepted for the workshop were invited for extension and included in a special issue in the journal  species , describ species , and com species . A briefThe paper titled "Integrated assessment of predicted MHC binding and cross-conservation with self reveals patterns of viral camouflage" by He et al. introduces a new method for understanding T cell cross-reactivity between human-like and foreign protein sequences and how it can reveal patterns of camouflage in specific pathogens . This mehttp://www.violinet.org/dnavaxdb) that stores over 400 manually annotated DNA vaccines for over 90 infectious and non-infectious diseases [The paper titled "DNAVaxDB: the first web-based DNA vaccine database and its data analysis" by Racz et al. introduces a new web-based DNA vaccine database DNAVaxDB . The method analyzes western and Chinese herbal treatments for cardiovascular diseases, assessing the biochemical properties, regulated pathways and disease network. The findings show that Chinese herbal medicines tend to affect multiple signaling pathways and target the immune system, signal transduction and apoptosis associated pathways where as western drugs affected only a select few pathways and targeted upstream proteins regulating vascular smooth muscle contraction. The study also finds that the biochemical characteristics of Chinese herbal medicines may make them valuable sources for multi-target drug compounds or vaccine adjuvants.Out of the eight poster abstracts accepted for the ICoVax 2013, seven abstracts were presented in short oral format and had associated posters exhibited at the workshop.Five epitope-based abstract submissions were accepted in the workshop. The abstract "iVAX web-based vaccine design"  presenteTwo gene- or MicroRNA-focused vaccine research posters were presented. The poster "A Pan-Genome Approach for Vaccine Design Against Johne's Disease in Dairy Herds"  showed hFinally, the software demonstration of iVAX, the vaccine design and analysis tool used in several of presented papers, gave attendees the opportunity to see informatics-driven vaccine design in nearly real time. In addition to the related research that was presented, this demonstration presented the power and utility of immunoinformatics in the rapid development of next-generation vaccines .The authors were organizing committee members of ICoVax2013. Anne S. De Groot and Yongqun He served as co-chairs. ADG is the founder and majority shareholder at EpiVax, Inc., a privately owned vaccine design company located in Providence, Rhode Island, USA which developed and own the rights to the iVAX platform. ADG is also a faculty member at the University of Rhode Island Institute for Immunology and Informatics. This author acknowledges that there is a potential conflict of interest related to her relationship with EpiVax and attests that the work contained in this research report is free of any bias that might be associated with the commercial goals of the company. All other authors declare they have no other conflict of interest.ADG and YH were the lead editors for the workshop supplement. PDG contributed to the workshop organization, attended the workshop, recorded the proceedings and co-wrote the editorial. YH managed the Easychair paper and abstract submission system and organized the reviewing process. ADG chaired the workshop.