Cardiac MDCT is here to stay. And, it is more than just imaging coronary arteries. Understanding the differences in and the benefits of one CT scanner from another will help you to optimize the capabilities of the scanner, but requires a basic understanding of the MDCT imaging physics.This review provides key information needed to understand the differences in the types of MDCT scanners, from 64 – 320 detectors, flat panels, single and dual source configurations, step and shoot prospective and retrospective gating, and how each factor influences radiation dose, spatial and temporal resolution, and image noise. Computed axial tomography (CAT) scan or CT has developed from imaging 10 mm thick slices of the motionless brain in a period of several minutes, to multidetector CT (MDCT) which continues to advance today to imaging the beating heart in less than 10 seconds, using sub millimeter slice thickness.The future development of MDCT is limited only by imagination and the mechanical limitations of the scanner. Technical invention and innovation has not only advanced well-established imaging indications but has directed medical imaging into new directions. In order to best utilize these technical advances, perhaps direct the manufacturers toward clinically inspired imaging needs and to make the most of current technology the user must be knowledgeable about the mechanics of the various types of CT scanners, the physics of radiation dose and delivery, and the physics of image acquisition. The advances in MDCT scanning have resulted in numerous variations of 64-320 channel MDCT scanners being available on the market and in use throughout the world. In order to best serve an individual patient population and to achieve your imaging goals, interpreting physicians must thoroughly understand the properties and capabilities of the type of scanners in their institution.This article reviews MDCT scanners, from 64 – 320 detectors, single and dual source configurations, flat panel detectors, step and shoot prospective and retrospective gating, and how each factor influences radiation dose, spatial and temporal resolution, and image noise.Increased understanding of current MDCT technology is beneficial to the experienced and new user in that exam quality and patient through-put are increased and radiation dose is optimized and reduced. Further, this greater understanding will serve to inspire continued evolution of new clinical and research applications of cardiac MDCT – myocardial perfusion, myocardial and valve function and even greater spatial and temporal resolution which will have widespread application in the principles of MDCT.Single detector CT scanners were first utilized in the early 1970’s. The images produced were acquired in the axial plane as individual slices 8-13 mm in thickness. The scanner gantry had a single detector which translated around the patient as the patient table moved in the cephalocaudal (z-axis) direction. As early as 1975 there are descriptions of reconstruction techniques using axial CT data to construct coronal and sagittal image planes .In the 1980s 4 channel MDCT appeared in commercial use. Since that era, the addition of more imaging channels, rows or detectors has increased exponentially. Subsequent improvements in the mechanics of the scanners have resulted in faster x-ray gantry rotation, faster z-axis movement of the CT table, thinner collimation and the development of electrocardiographic (ECG) gating. Each of these advances has improved temporal and spatial resolution.The newest commercially available MDCT scanners (seventh generation) offer the greatest degree of spatial and temporal resolution owing to up to 320 detector channels, gantry rotation times of .25 seconds and collimation as narrow as .24 mm. These parameters are important to creation of high definition coronary artery MDCT imaging and are invaluable in imaging of myocardial and valve function, pulmonary vein and aortic anatomy. http://www.gehealthcare.com/usen/ct/index.html; http://www.medical.philips.com/main/products/ct/; http://www.medical.siemens.com; http://www.medical.toshiba.com/Products/CT/).Four major CT manufacturers were asked to provide information about MDCT scanners currently commercially available in the United States; further data were acquired from the manufacturer’s web sites 1).Before discussing the mechanics of each variation in scanner construction, it is important to understand the image parameters necessary to result in high definition ECG-gated cardiac images. The basic anatomy of MDCT scanner components is shown Fig. (2).ECG gating enables acquisition of image data and image reconstruction at precise time points during the R-R interval. Image acquisition can occur throughout the R-R interval (retrospective gating) or at a predefined time point (prospective gating). The R-R interval can theoretically be divided into 100 segments for the purposes of cardiac CT. The first R wave is the zero of 0% time point at end diastole; the next R wave is the 100% time point of the first cardiac cycle and the 0% time point of the next cardiac cycle Fig. (3). When using prospective gating, imaging occurs only during every other heart beat, allowing time for table motion and resetting of timing to the next R wave between images. This type of acquisition is not helical; instead, image data is acquired one slice at a time, while the patient moves incrementally in the z axis. Subsequently the images are stacked into a single sequence of image data which can be post processed in the usual manner to evaluate the coronary arteries and morphology of the heart. Functional data can not be obtained as only a short segment of the cardiac cycle has been imaged; i.e. image data is not acquired during both end systole and end diastole , to 120 mm  and 160 Prospective ECG gating is currently the most radiation dose efficient method for performing coronary artery MDCT. The radiation beam is on only during a very short segment of the R-R interval; with 64 detectors, the radiation dose is decreased to 3-5 mSv.2.To briefly put radiation dose into perspective, it is helpful to review estimates of radiation dose exposure from common diagnostic imaging procedures and background radiation. Table With single detector CT a narrow radiation beam is emitted, with very little slice overlap, exposing one slice of tissue at a time. Therefore, as one 360 degree rotation of the radiation source occurs, one image is produced .As the number of detector rows increases the radiation beam width increases into a broad cone shape from the radiation source to span the detectors. As the cone-shaped beam widens to cover a greater number of detectors, the amount of overlap which occurs during helical image acquisition results in collection of redundant data which contributes to improving spatial resolution and image resolution (noise). The redundancy of data allows one to segment the scan rotation into a partial scan, i.e., using only 180 degrees or ½ of the scan data to create the image. In order to avoid overlap of the radiation beam table speed or gantry rotation speed would have to be markedly slowed, resulting in concomitant decreases in temporal resolution , 9.The rapid growth in cardiac MDCT is both the result of manufacturer progress and the desire of imaging physicians to utilize this technology and to inspire the manufacturer to explore further advanced imaging concepts. Current and potential future options in cardiac MDCT are discussed very briefly in the next section.7A & 7B & 7C). Vascular injury such as aneurysm and dissection may also be detected and have been described in case reports  and other wall abnormalities such as thickening or aneurysm are clearly depicted with MDCT  Fig. .Disease processes that are easily identified include atherosclerotic thickening and calcification of leaflets, vegetations, thrombus and tumor, as well as functional assessment of the valves, recognizing stenosis, incompetence and leaflet malformation such as bicuspid aortic valve  Fig. . The accurate anatomic information can be integrated with angiographic image data to increase confidence of catheter placement and can decrease the time required to perform the ablation procedure. Non-ECG-gated MDCT is almost always adequate when imaging the pulmonary vein anatomy with 64 channel or greater MDCT. This is especially true in patients with arrhythmia, a contraindication for ECG-gating. Although use of ECG-gating could add information regarding the coronary artery anatomy, coronary artery anatomy and superior spatial resolution of ECG-gated scans is not essential [Prior to pulmonary vein ablation procedures MDCT is fundamental in order to provide precise anatomic knowledge of the widely variant anatomy of the venous ostium, branching pattern and the shape and to exclude atrial or atrial appendage thrombi Fig.   and for 13A & 13B).Even in limited anatomical assessment of the heart, segments of the ascending and descending thoracic aorta are included in coronary artery CTA images. Secondary findings such as dilatation of the ascending aorta due to a bicuspid aortic valve, aneurysm or dissection due to atherosclerosis or other vascular disease, pulmonary hypertension or pulmonary embolus are potential diagnoses to recognize. When these secondary diagnoses are seen, a complete thoracic CT is warranted. In the case of aneurysm and dissection, the entire abdomen and pelvis may need to be included in follow-up studies  Fig. (1314A & 14B). Mediastinal and axillary lymph nodes, the trachea, esophagus, pulmonary parenchyma and upper abdominal viscera are also included along with the images of the heart. Each structure can show additional diagnoses or clues to alternative diagnoses [Beyond the cardiac structures, important findings will be included in the imaging field of view. At a minimum, image reconstruction to include the entire chest wall, within the z-axis of the scan should be performed. This said, currently there are limitations on the field of view (FOV) which limit the reconstruction of prospective ECG-gated sequences. Based upon scan type and manufacturer, the reconstruction FOV may be limited to the scanned FOV rather than including the anatomy outside that FOV Fig. (iagnoses , 42.The rapid and continued development of MDCT technology brings an exciting twist to cardiac imaging. Enhancing patient care by improved visualization and understanding of coronary artery anatomy, valve performance and myocardial function and perfusion will continue most efficiently if the end user fully understands the imaging modality and how to get the most out of each manufacturer’s contribution to the field. The ultimate challenge is to use the image data to make accurate diagnoses of cardiac and non-cardiac findings to benefit the patient. A correct and complete diagnostic examination of the coronary arteries, cardiac chambers and valves depends upon consideration of all types of cardiac pathology. One can only see what one looks for: cardiac and noncardiac pathology that is not considered because of a pre-determined expectation of findings, either based upon clinical knowledge or incomplete familiarity with cardiac MDCT will result in a disservice to the patient and will limit future development of the imaging modality. The number of detector channels is not the operative key; it is the relationship of radiologists and cardiologists working together which ultimately will achieve the goal of evaluating the appropriateness of cardiac MDCT and reaching accurate and complete diagnostic interpretation. This collaboration will drive the direction of imaging technology.


There is increasing interest in the development of computational methods to analyze fluorescent microscopy images and enable automated large-scale analysis of the subcellular localization of proteins. Determining the subcellular localization is an integral part of identifying a protein's function, and the application of bioinformatics to this problem provides a valuable tool for the annotation of proteomes. Training and validating algorithms used in image analysis research typically rely on large sets of image data, and would benefit from a large, well-annotated and highly-available database of images and associated metadata.The Yeast Resource Center Public Image Repository (YRC PIR) is a large database of images depicting the subcellular localization and colocalization of proteins. Designed especially for computational biologists who need large numbers of images, the YRC PIR contains 532,182 TIFF images from nearly 85,000 separate experiments and their associated experimental data. All images and associated data are searchable, and the results browsable, through an intuitive web interface. Search results, experiments, individual images or the entire dataset may be downloaded as standards-compliant OME-TIFF data.http://images.yeastrc.org/.The YRC PIR is a powerful resource for researchers to find, view, and download many images and associated metadata depicting the subcellular localization and colocalization of proteins, or classes of proteins, in a standards-compliant format. The YRC PIR is freely available at  Understanding a protein's subcellular localization is critical to understanding a protein's role in the cell. The physical location of a protein limits its possible interaction partners and suggests possible biological functions for the protein . The subProtein-protein interactions may be assessed via fluorescence microscopy by observing the relative subcellular localization of separate proteins simultaneously tagged with different fluorescent proteins. Proteins with strongly overlapping patterns of subcellular localization are said to colocalize; and this colocalization may indicate similar biological function or possible protein-protein interaction. Interactions may be further characterized by exploiting fluorescence energy transfer (FRET) -4, wherede novo prediction of subcellular localization for proteins based on sequence or other criteria.The data from fluorescence microscopy experiments are typically captured using digital imaging systems attached to fluorescence microscopes and stored as images on disk. Developing computational techniques to automate the analysis of these images is an area of active research ,7 with dS. cerevisiae proteins. YPL.db2 [S. cerevisiae proteins. The Saccharomyces cerevisiae Morphological Database (SCMD) [Researchers developing computational algorithms that analyze fluorescence microscopy images typically require large datasets of images for training and validation of their method. Databases of fluorescence microscopy images have been previously developed, which may aid in this research. The Yeast GFP Fusion Localization Database  is a sta YPL.db2  (Yeast Pe (SCMD)  presentsThe YRC PIR is unique among these database because it is primarily an image database and not a protein annotation database. Where localization databases typically focus on annotating proteins in terms of their subcellular localization by providing chosen examples of images depicting that localization, the YRC PIR aims to provide a large number of images and their associated metadata for many proteins across multiple organisms. Although the YRC PIR may be used to find images depicting the subcellular localization of a particular protein, it is well suited to researchers interested in searching for and downloading large sets of images depicting the localization of particular proteins or categories of proteins.http://images.yeastrc.org/.The YRC PIR expands on existing databases by also offering an intuitive interface to a very large (and growing) database of high-quality and well-annotated images that may be downloaded, along with their associated metadata, as user-defined downloads using standards-compliant formats. In addition to standard subcellular localization data, the YRC PIR contains many images from colocalization and FRET experiments. As the YRC PIR expands, it will grow to include images from many organisms and will accept submissions from researchers wishing to disseminate their data to the public. The YRC PIR should be a valuable tool for researchers developing image analysis and pattern recognition techniques, as well as biologists interested in viewing the subcellular localization for specific proteins or examples of certain subcellular localization patterns. The YRC PIR is freely available at http://www.mysql.com/.The YRC PIR was designed to store and disseminate experimental data generated by disparate microscopy data pipelines. Accordingly, a relational database schema Figure  was deveThe database was initially populated with experimental data from two sources: YRC microscopy data and the Yeast GFP Fusion Localization Database.4). The XML was transferred to the YRC PIR database server and processed by a custom-written Java program that read the XML input and saved the data to the relational database schema.These data existed as proprietary-format binary files generated by the Deltavision microscopy system and resided on multiple servers within the YRC microscopy group. A custom-written Java program was run on a computer with access to the YRC microscopy network that processed these data files and extracted image data, image metadata and experimental metadata and saved the data as XML. The image data existed as raw 12-bit grayscale pixel values, and were converted into uncompressed 16-bit grayscale TIFFs via simple multiplication of pixel values by 16  and DAPI  channel images existed as 16-bit grayscale PNG files. The GFP and RFP channel images existed as 48-bit color PNG files, with fluorescence depicted in the green and red channels, respectively. In order to preserve data consistency in the YRC PIR database, all PNG files were converted to 16-bit grayscale TIFF images using the ImageMagick Saccharomyces cerevisiae. The data include protein subcellular localization and colocalization images.The MySQL database and resulting TIFF images were processed and inserted into the YRC PIR relational database schema by a custom-written Java program. These data comprise 14,526 images from 4,842 experiments. The data depict 4,176 proteins, all from A web interface for searching and downloading the data was written in Java and JSP using the Apache Struts web application framework running on the Apache Tomcat servlet container and Apache httpd web servers.All images downloaded via any of the methods for downloading "raw" data from the YRC PIR are formatted as OME-TIFF files. The Open Microscopy Environment (OME) defined OME-TIFF such that it is fully compatible with standard TIFFs and, consequently, software that is able to read and write TIFFs. OME-TIFF files include experimental and image metadata by incorporating OME-XML into oneThe YRC PIR's design is focused on searching, viewing results, refining searches and downloading or viewing pertinent raw data Figure . An exteA web interface was constructed for searching microscopy experiments Figure . From thThe search results consist of a synopsis of the search parameters and a table of microscopy experiments that match the search parameters Figure . Each roThe search may be constrained by most of the values present in these search results by clicking on the value in the table. For example, clicking on the name of a strain from one of the listed experiments will re-search the database with the added constraint of that strain name. Clicking the value for fluorescent tag used , image size and species will also constrain the current search. Hovering the mouse cursor over protein names, GO terms, or whether or not FRET was used in the experiment will produce a "pop up" tool tip that provides a description of that value (such as a description for that GO term) and provides links for adding that constraint to your search or learning more about that protein or GO term by visiting the YRC Public Data Repository (YRC PDR) . The YRCFrom this search results page, the user may refine their search (by clicking "Refine Search"), download all data that matches the current search (by clicking "Save as Bulk Download") or view the images and metadata associated with any experiment (by clicking the "View Experiment" link associated with the desired experiment). The "Save as Bulk Download" option prompts the YRC PIR system to create an archive of all images and metadata that match the current search and then notify the user (at the email address specified) that their data is ready to be downloaded. The organization of this file is described extensively in the User Guide available at the YRC PIR web site.The "View Experiment" link takes the user to a page listing all experimental metadata and all images (and their associated metadata) associated with the experiment Figure . From heBelow the metadata, the images associated with the experiment are shown as thumbnails along with accompanying metadata. By default, the images have their intensity values scaled so that the fluorescence is easier to observe in the web site. This effect may be disabled by clicking "Turn scaling OFF," just above the images. Also by default, a scale bar is present in each image that depicts the physical scale of objects in the image. This may also be disabled by clicking "HIDE scale bars." Very simple image statistics may be displayed by clicking "SHOW image statistics". These statistics include minimum, maximum and mean pixel values in each image, along with a histogram depicting the distribution of pixel values.The displayed thumbnails are in PNG format, and are converted and resized on-the-fly from 16-bit grayscale TIFFs stored in the database. Clicking on a thumbnail will cause a full-size version of the image to appear in a pop up window, also in PNG format. Clicking on the full-size image will trigger a download of a "raw" version of that image. As with all image data that is available for download from the YRC PIR, the "raw" version will be an unmodified  and uncompressed OME-TIFF file.Metadata are displayed for each image in the experiment. These include the name of the tagged protein and the name of the covalently-bound fluorescent protein that are visible in the image. The pattern of fluorescence in these images indicates the location of the tagged protein in the cell, and the strength of the signal is proportional to the amount of tagged protein present. For images of FRET channels, the name of the donor and acceptor proteins and their associated fluorescent proteins are displayed instead. The fluorescent protein bound to the donor protein has been excited and fluorescence from the acceptor protein is visible in the image. In these images, the intensity of this signal is a measure of the potential distance between the two fluorescent proteins and, by extension, between the donor and acceptor proteins. For images taken using differential interference contrast (DIC), whole cells are shown using transmitted light and no data describing the localization of a protein are shown.Additional metadata include the excitation and emission wavelengths of light used to excite and detect fluorescence from the fluorescent proteins in the image. (Except in the case of DIC images where the excitation and emission wavelengths are not meaningful.) The filter channel categorizes images as DIC, FRET or standard color channels. The photosensor is the measured brightness of the lamp. Exposure describes how long the shutter was open. NDFilter describes the level of neutral density filter applied to the image. More descriptions of the metadata are available in the FAQ available at the YRC PIR web site.Further work on the YRC PIR will include analysis tools to be available on the experimental view page, such as creating RGB merged-color images of the different channels in the experiment, the ability to perform FRET analysis and co-localization analysis, and other analysis tools common to fluorescence microscopy studies. Additionally, a web interface will be developed for users in the general community to upload data from their own experiments into the YRC PIR. The YRC PIR will be a platform for data sharing, suitable for collaboration and distributing data associated with microscopy publications.To our knowledge, the YRC PIR is the largest public database of fluorescence microscopy images currently available. To make this large dataset manageable to users, an emphasis was placed on search options and intuitive data view pages that lead to multiple options for downloading raw data. This makes the YRC PIR a valuable tool for computational biologists interested in defining and downloading datasets specific to their research and to cellular and molecular biologists interested in viewing the subcellular localization of particular proteins or viewing examples of subcellular localization patterns.http://images.yeastrc.org/.The YRC PIR is freely available to all at YRC PIR: Yeast Resource Center Public Image Repository; GFP: Green Fluorescent Protein; FRET: Fluorescence Resonance Energy Transfer; DIC: Differential Interference Contrast; RFP: Red Fluorescent Protein; OME: Open Microscopy Environment; GO: Gene Ontology; CFP: Cyan Fluorescent Protein; YFP: Yellow Fluorescent Protein.MR drafted the manuscript and developed the data parsing software, designed and implemented the database, and designed and implemented the web site. TND provided input during all phases of development and participated in drafting and revising the manuscript. All authors have read and approved the manuscript.


Mandatory generic substitution was introduced in Sweden in October 2002 in order to try to curb escalating pharmaceutical expenditure. The aim of this study was to investigate how sales patterns for substitutable and non-substitutable pharmaceuticals have developed since the introduction of mandatory generic substitution; furthermore, to compare sales patterns in different groups of the population, based on patients' age and gender.Five therapeutic groups comprising both substitutable and non-substitutable pharmaceuticals were included. The study period was from January 2000 to June 2005. National sales data were used, covering volumes of dispensed prescription medicines (expressed in defined daily doses per 1000 inhabitants and day) of each pharmacological substance in the therapeutic groups for each age and gender group. Sales patterns for substitutable and non-substitutable pharmaceuticals were compared using a descriptive approach.In most therapeutic groups there has been an increase in the volumes of substitutable pharmaceuticals sold since the introduction of the reform, ranging from one third to three times the initial volume; whereas the volumes of non-substitutable pharmaceuticals have levelled out or declined. There were few gender differences in sales patterns of substitutable and non-substitutable drugs. In three therapeutic groups, sales patterns differed across different age groups, and there was a tendency for volumes of recently introduced non-substitutable pharmaceuticals to be proportionally higher in the youngest age groups.Since the introduction of the reform, there has been a proportionally larger increase in sales of substitutable pharmaceuticals compared with sales of non-substitutable pharmaceuticals. This indicates that the reform might have contributed to larger sales of less expensive pharmaceuticals. Most countries promote the use of generic drugs, and several countries have introduced generic substitution in order to increase the use of generics -6. GenerIn order to increase price competition for medically equivalent products where the patent had expired, Sweden introduced mandatory generic substitution on 1 October 2002 ,11. PresThe aim of the reform was to reduce costs for off-patent pharmaceuticals, through increased price competition, as well as substituting with cheaper equivalents. The introduction of generic substitution was followed by notable reductions in price for several top-selling products, which were highlighted in the media and elsewhere. These price cuts helped to curb the increase of overall pharmaceutical expenditure in Sweden after the introduction of generic substitution . ParalleThe introduction of generic substitution implied considerable changes in the prescribing process for prescribers and patients. The prescribers had to inform the patient that the pharmacy might substitute the prescribed drug with a cheaper equivalent and ensure that reports on performed substitutions sent by the pharmacies were documented in the patient records. The patients faced a new situation when asked to make decisions about substitution themselves; previously the prescribers had dealt with this. Investigating how the sales patterns of prescribed drugs have developed following the reform indicates whether the pattern of prescribing has changed since the reform was introduced. Earlier studies on effects of pharmaceutical reimbursement policies have shown differences between overall effects and effects in subgroups of the population. A previous study reported that although increased cost-sharing was not associated with negative effects on health status, decreased use of essential pharmaceuticals or hospital admissions on an overall level a negative impact on these outcomes was observed for particularly vulnerable groups such as the elderly and the poor -17. InveThe present study aims to investigate how the sales patterns for substitutable and non-substitutable pharmaceuticals have developed since the introduction of mandatory generic substitution in Sweden.More specifically the objectives were:1) to assess how volumes sold of substitutable pharmaceuticals, compared with volumes sold of non-substitutable pharmaceuticals, have changed since the reform was introduced2) to investigate whether sales patterns vary between different groups of the population based on patients' age and genderFive therapeutic groups were selected for case studies. Selection criteria were that the therapeutic groups should encompass both substitutable and non-substitutable pharmaceuticals, be widely used in outpatient care and generate a substantial cost to society. Therapeutic groups used both for short- and long-term treatments were included (long-term treatment > 6 months) with an emphasis on long-term treatment. Pharmaceuticals were classified as substitutable if the patent had expired and one or more equivalent products were available. Table Sales data for the selected therapeutic groups comprising dispensed prescription pharmaceuticals encompassed by the PBS were included in the study. The study period covered pharmaceuticals dispensed between 1 January 2000 and 30 June 2005. Sales data of dispensed prescribed medicines (i.e. regular prescriptions and multidose-dispensed drugs) in outpatient care for the substances in the selected therapeutic groups were collected from the National Corporation of Swedish Pharmacies (Apoteket AB). Monthly sales data were collected that encompassed Sweden in total. Data comprised volumes sold, expressed as defined daily doses (DDD) with information on both substance and product as well as information on age, gender and place of residency of the patients collecting the dispensed drugs. Defined daily doses were constant over the study period. Age was divided into six categories: 0–4, 5–14, 15–44, 45–64, 65–74 and 75-years old. Due to few observations, no separate examinations were undertaken of the two youngest age categories.The volumes of substitutable and non-substitutable substances were combined into two groups  for comparison. Sales of non-substitutable packages, for example when only one company produces a certain package-size or strength, of substitutable substances were removed from the sales of that substance. Defined daily doses per 1000 inhabitants and day (DDD/tid) were calculated both for total volume of the substances, each substance and specifically for each age and gender group. Data on both total volumes of substitutable and non-substitutable pharmaceuticals as well as each substance were presented graphically. The sales patterns of dispensed drugs in the different subsets were compared with a descriptive approach, in order to investigate whether the sales pattern changed when the reform was implemented. The study was approved by the Ethics Committee at Göteborg University.A comparison of the total volumes of substitutable and non-substitutable pharmaceuticals in the three therapeutic groups mainly used for long-term treatment  showed that the volumes of substitutable pharmaceuticals were proportionally higher throughout the period Figure . As showThere was an apparent change in the sales pattern for statins and PPIs during the year of implementation of generic substitution that was not seen in the other groups. The sales patterns for two of the selected groups, ACE-inhibitors and nucleosides and nucleotides, were unaffected by the reform.As shown in Figure The volumes of dispensed prescription pharmaceuticals varied across different age groups in the selected therapeutic groups. In general the levels of DDD/tid increased as age increased, except for nucleosides and nucleotides where the situation was the opposite. The volumes of SSRIs as well as nucleosides and nucleotides were higher among females than males, whereas the volumes of ACE-inhibitors and statins were higher among males than among females.In two groups for long-term use, ACE-inhibitors and statins, there were few differences in how the sales pattern developed for substitutable and non-substitutable drugs between different age and gender groups (data not shown). The sales pattern of substitutable and non-substitutable SSRIs varied between different age and gender groups (data not shown). For females aged 15–44, 45–64 and 65–74 years the volumes of non-substitutable SSRIs more than doubled from the start of the study period until the reform was implemented, and thereafter levelled out. A slight increase was seen for males of corresponding age but not as manifested as for females. Sales of substitutable increased somewhat in these age categories after the introduction of the reform.For nucleosides and nucleotides the volumes of non-substitutable drugs were higher than the volumes of substitutable drugs in younger age groups (data not shown). However, at the end of the study period volumes of substitutable nucleosides and nucleotides were at the same level as non-substitutable nucleosides and nucleotides in the oldest age group. Volumes of both non-substitutable and substitutable nucleosides and nucleotides increased in the three youngest age groups. This was seen for both genders. For both males and females over 75 years of age, volumes of non-substitutable nucleosides and nucleotides remained unchanged, whereas volumes of substitutable nucleosides and nucleotides increased.For PPIs the sales patterns of substitutable and non-substitutable drugs were similar in different age and gender groups (data not shown). However, when volumes of each substance were examined, the sales pattern for esomeprazole varied. Relatively speaking, esomeprazole was more frequent in younger people than in older age groups. There were no differences between the genders.The present study showed a proportionally larger increase in the volumes of dispensed substitutable pharmaceuticals compared with non-substitutable pharmaceuticals, since the introduction of generic substitution. Thus sales of substitutable drugs have increased proportionally more than non-substitutable drugs, which indicates that lowered prices have contributed to an increase in the prescription of substitutable drugs. The changes were more marked in therapeutic groups where the patents expired during the implementation of the reform; however, this should be interpreted with caution, as this study used a descriptive approach. There were no differences between short- and long-term treatments where expiry of patents was close at hand. Differences in sales patterns were more often observed between different age groups than between the genders. Differences in sales patterns were not homogeneous across age and gender and between the selected therapeutic groups. There was a tendency that recently introduced non-substitutable pharmaceuticals were relatively more frequently sold in the youngest age groups.The increased volumes of dispensed substitutable pharmaceuticals in the selected therapeutic groups indicated that prescribers facilitated the implementation of the reform, thus contributing to savings. This is in line with a previous study, reporting that substitution was seldom restricted by the prescriber . The proIn general the most dramatic changes are expected when patents expire, even when there is no substitution policy. However, the magnitude of these changes depends on a number of factors, such as policies that enable dispensing of generic alternatives, the prescribing habits of physicians, and incentives for patients to be cost-conscious. The marked effects seen for statins and PPIs were probably affected by the pronounced price competition for top-selling substances where the patent had expired during implementation of the reform. However, the design of this study does not allow for assessment of possible differences in comparison with a situation where there is no generic substitution. Price differences between originator and generic products were greater in the groups where the patent had expired recently. This seemed to be an important factor influencing sales patterns, as there were no differences between short- and long-term treatments with similar patent expiry times. There were also a larger number of generic alternatives in these groups than in groups where the patent had expired some years ago, which, together with DTC recommendations, might have contributed to the dramatic effects. For therapeutic groups where the patent of the substitutable substances had expired some years before the reform was introduced, ACE-inhibitors and nucleosides and nucleotides, changes in sales patterns related to the introduction of the reform were not as pronounced. However, on substance level there was a delayed increase in sales of non-substitutable substances in both groups. Altogether, these results are in accordance with a previous study which reported that the proportion of performed substitutions was highest in groups where the patent had expired close to the introduction of the reform and price differences were considerable . The potIt was somewhat surprising that the sales pattern of the two top-selling substitutable ACE-inhibitors  was similar to that seen for substitutable and non-substitutable drugs in other groups. Ramipril was similar to a non-substitutable substance since there were few substitutable products and little price competition until 2004, which was reflected by a higher price per dose compared with enalapril, where generic products were available when generic substitution was introduced. Another factor that might have affected sales patterns is the recommendations from the DTCs that varied between the three largest county councils, as well as over time. One recommended the use of ramipril, one recommended enalapril, whereas the third recommended both ramipril and enalapril.All groups except nucleosides and nucleotides were among the five top-selling main drug groups during the study period regarding volume of DDD. Nucleosides and nucleotides were among the most widely sold anti-infective groups for short-term treatment fulfilling inclusion criteria. Three groups: PPIs, statins and SSRIs, were among the five groups that generated the highest expenditures between 2003 and 2005. Expenditure has decreased since the reform was introduced for several groups where the major products became substitutable, e.g. ACE-inhibitors and statins. Although the investigated groups are widely used, it should be noted that the results are not generalisable to all therapeutic groups comprising substitutable and non-substitutable pharmaceuticals. Sales patterns depend on the prevalence and nature of the disease in question, the characteristics of the drugs in the group, and also on when the patent expires and which products become substitutable.A limitation of the study was that sales data comprising dispensed prescription medicines were used to reflect changes in prescribing patterns in this study. Not all prescribed medication is actually purchased by patients, and thus there is a gap between sales and prescribing data ,21. On tSince the introduction of generic substitution, there has been a proportionally larger increase in the volumes of dispensed substitutable drugs compared with the volumes of non-substitutable pharmaceuticals, indicating that the reform has contributed to an increase in sales of less expensive pharmaceuticals. This was especially pronounced for therapeutic groups where one or more major patents expired during the implementation of the reform. However, this study cannot assess whether this differed compared with patent expiry in a setting without generic substitution. This thus indicates that the reduction in prices might have affected the prescription of pharmaceuticals, contributing to increased sales of substitutable products, which in turn implies increased sales of less expensive equivalents.The author(s) declare that they have no competing interests.All authors participated in designing the study and discussed the findings. KA carried out data collection and data management and drafted the manuscript. MP participated in data management and revised the manuscript. PA revised the manuscript. AC took part in data collection and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Health systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa.All primary care sites and specialized birthing centers in a resource constrained sub-district of Cape Metro District, South Africa, were enrolled in a quality improvement (QI) programme. All pregnant women receiving antenatal, intrapartum and postnatal infant care in the sub-district between January 2006 and March 2009 were included in the intervention that had a prototype-innovation phase and a rapid spread phase. System changes were introduced to help frontline healthcare workers to identify and improve performance gaps at each step of the PMTCT pathway. Improvement was facilitated and spread through the use of a Breakthrough Series Collaborative that accelerated learning and the spread of successful changes. Protocol changes and additional resources were introduced by provincial and municipal government. The proportion of HIV-exposed infants testing positive declined from 7.6% to 5%. Key intermediate PMTCT processes improved  compared to baseline.System improvement methods, protocol changes and addition/reallocation of resources contributed to improved PMTCT processes and outcomes in a resource constrained setting. The intervention requires a clear design, leadership buy-in, building local capacity to use systems improvement methods, and a reliable data system. A systems improvement approach offers a much needed approach to rapidly improve under-performing PMTCT implementation programmes at scale in sub-Saharan Africa. More than twenty years into the HIV epidemic, infants in many part of the developing world continue to be infected during pregnancy, birth and infancy at unacceptably high rates. Application of standard anti-retroviral (ARV) protocols in high-income nations has, for the past decade, made maternal to child transmission of HIV a relatively rare event Since 2002, the South African government has provided single-dose Nevirapine (sdNVP) prophylaxis to pregnant women in the public health system and highly active antiretroviral therapy (HAART) was made available from 2004 for pregnant women with low CD4 counts (<200 cell/dl). Dual ARV prophylaxis, Azidothymidine (AZT) and Nevirapine (NVP), was introduced in the Western Cape Province in 2004 with subsequent rollout to the remainder of the country in 2008 Shortly after dual ARV prophylaxis was introduced in the Western Cape, transmission rates of 8.8% were reported, decreasing to less than 5% by 2007 The ethics of undertaking the systems improvement intervention and analysis and dissemination of the findings were evaluated by the Office of Human Research Ethics of the University of North Carolina at Chapel Hill. The Office determined that, given the nature of the intervention and the de-identified characteristics of the data, the study was exempted from further IRB review. Written consent was not obtained from individual patients as this was a population based health systems intervention to improve existing guidelines and protocols, and applied to the patient population without exception or exclusion.The ESD population  includes urban, peri-urban and rural communities. The birth rate is 20/1000 per annum , and antenatal HIV prevalence is 17.4%  The majority of people living in ESD receive their medical care in the public facilities. In 2006, eight of the 15 primary care clinics offered antenatal care and all offered PMTCT infant follow up including PCR testing. Obstetric services are delivered in two birthing units. Although a proportion of women living in ESD receive antenatal care and deliver in adjacent sub-districts, the majority of women access post-natal infant follow up in ESD.PMTCT data was routinely collected in registers at the facilities and collated each month on paper-based forms that were submitted to the sub-district office for entry into electronic collation tables. These tables have built-in validation formulae to flag if numerators exceed denominators. Completeness and consistency of the data is actively monitored.Infant mortality data is compiled from death notifications by the Department of Home Affairs. During the period of the intervention there was a two-year delay before these data became available to the sub-district. Infant mortality data from 2006 were therefore only available for review in 2008. Maternal mortality data were not available for the sub-district during the study period.The health systems intervention was a partnership between the Western Cape Provincial Department of Health and Cape Town Municipality City Health departments and the Institute for Healthcare Improvement (IHI). Working closely with the health departments, IHI provided a systems improvement design and a quality improvement (QI) expert who introduced QI methods to the sub-district facilities, trained managers in QI methods and collaborated closely with senior health department officials on project design and execution.The project was implemented in two phases: a prototype phase in a sub-section of the sub-district (seven primary care clinics and the two birthing units) that formed a self-contained inter-facility PMTCT care and referral system, followed by a spread phase in which the systems improvement approach were disseminated through all 17 PMTCT-linked health facilities in ESD. The health systems intervention had three concurrent components: a quality improvement framework, policy and protocol changes, and targeted resource additions.The improvement project was structured as a “Breakthrough Series (BTS) Collaborative”, a QI model that promotes change simultaneously across large parts of the system Between these learning sessions, clinics formed multidisciplinary improvement teams that applied these QI skills at individual facilities. In addition, project staff provided on-site mentoring in the use of QI methods. The intensity of support decreased over time from fortnightly on-site mentoring in the prototype phase to a more leveraged approach through monthly sub-district meetings in the spread phase as managers became familiar with the methodology.Facility-based improvement activities resulted in the development of local solutions to local problems. These solutions were spread to other sites through extension by the project staff, Department of Health (DOH) managers and through routine monthly meetings and the six-monthly BTS Collaborative Learning Sessions described above.Successful changes developed in the prototype phase were complied into a “Change Package” for testing and adaption by other facilities as the project spread . SuccessIn addition to QI methods, strategic additional resources and policy changes were introduced by the sub-district and province during the study period. The sub-district increased the number of antenatal clinics providing antenatal care through introducing Basic Antenatal Care (BANC) to two additional clinics using existing staff Two major changes to the PMTCT protocol were introduced by the DOH during the study period. The timing of the introduction of AZT prophylaxis during pregnancy was advanced from 32 weeks gestation to 28 weeks gestation, and the age of HIV testing of infants was decreased from 14 weeks to 6 weeks. Both protocol changes were introduced simultaneously with uptake occurring over a period of a few months in the early part of the spread phase of the project (early 2008).From January 2006 to March 2009, facility staff and managers from the different branches of the DOH participated in this project attending a total of six Learning Session workshops in the BTS Collaborative design. Between these workshops, district managers and program coordinators analyzed performance data which was then used to assist frontline staff to test change ideas. Improvement ideas from the “change package” were also actively spread at monthly sub-district staff meetings and by program coordinators during routine clinic visits. Senior managers were kept informed through monthly project reports. A steering committee of district and DOH managers guided the process, sanctioned the spread of changes, and intervened to removed obstacles to improving PMTCT that were identified by the project.All data were obtained from routine monthly sub-district PMTCT data collected at antenatal, labour ward and infant follow up clinics and collated by the Municipal and Provincial DOH. Data measuring the performance of PMTCT processes of care and infant HIV infection rates were tracked over time. We used run chart and Shewhart control chart analysis  to determine the effect of system changes on the processes and outcomes of PMTCT care as changes were made over time before 20 weeks gestation, uptake of AZT prophylaxis, and referral for HAART.Throughout the project, the early steps in the PMTCT pathway were already functioning well. Antenatal attendance (at least one visit) in the Western Cape remained over 97% throughout the study period st ANC visit was decreased by re-allocating a nurse practitioner to the antenatal clinic from within the existing facility staff pool. These changes resulted in a significant improvement in the percentage of pregnant women booking for antenatal care at less than 20 weeks gestation from 18% before the intervention to 33% following the interventions , early antenatal booking was increased through active case finding of pregnancies. All female patients attending the clinic for any reason were screened and tested for pregnancy, and referred for “same day” antenatal care. The backlog of clients waiting for the 1p<0.001, .Further changes were tested to improve the uptake of AZT during the last trimester of pregnancy including: monthly review of AZT uptake indicators by sub-district managers , and implementation of a new protocol to initiate AZT at 28 rather than 34 weeks gestation. These changes resulted in a significant stepwise improvement in baseline AZT uptake from 72% to 89% p<0.001, .As routine monitoring data did not capture maternal CD4 counts, we were not able to assess the proportion of HIV positive pregnant women eligible for HAART at the antenatal clinic. However, we were able to assess access to HAART by the time of delivery by measuring the number of HIV positive women on HAART at the time of delivery. Changes to the HAART referral process resulted in a significant improvement in the proportion of women who had started HAART by the time of delivery from 10% to 25% p<0.001, . The intFrom 2006 to 2008, the proportion of eligible HIV positive women receiving dual ARV prophylaxis in the hospital labour ward improved for both NVP .During the study period, PCR testing of infants on the PMTCT register in ESD improved from 79% to 95% p<0.001, . While Pst immunization visit) rather than 14 weeks.We attribute the improvement in infant HIV testing rates to the introduction of a rapid response system to track infants who had not tested through a monthly PMTCT data review meeting at the sub-district office, and a protocol change in November 2007 to provide HIV PCR testing for infants at 6 weeks (coinciding with the 1Comparing the 12 months before the spread phase of the intervention (from November 2006) with the last 12 months of the intervention (ending March 2009), the HIV positive rate for infants tested with PCR in Eastern subdistrict decreased significantly from 7.6% to 5.0% . We report improvement in the primary outcome (the proportion of positive HIV PCR tests in infants), which dropped by a third to reach the annualized target of 5% in the sub-district for the first time. In addition, improvements in PMTCT processes occurred throughout the continuum of care from early antenatal booking to the postnatal visit at 6–14 weeks. For HIV-infected pregnant women, the ability of the local health system to deliver either AZT or HAART during the third trimester was significantly enhanced as were labour ward practices.The adoption of new PMTCT protocols and strategic addition of resources contributed to these improvements. In addition, for some of the processes that we targeted, the intervention sub-district improved to a greater degree than any other sub-district in the region. Through a time-series analysis, we were able to infer a strong association between the timing and resultant improvements in PMTCT process performance.Several factors contributed to the success of our intervention. The project was conducted in a high performing public health system that already had a culture of reflective data analysis, and was able to effectively introduce protocol changes and add strategic resources. The structure of the routine PMTCT monitoring system facilitated the use of data to drive improvement because it is linked to patient registers that are meaningful to frontline staff. The health system leadership used PMTCT process data feedback to encourage participation in District-wide learning opportunities, and supported the testing of new ideas and the spread of successful interventions. A responsive District leadership deployed additional strategic resources when needed.In addition to these local “host” factors, the Breakthrough Series (BTS) Collaborative learning system used in this project was a central mechanism for engaging front line health care providers in local innovation that led to improvements and facilitated rapid diffusion of successful changes. While there is limited experience using similar learning networks in resource-poor settings As policy changes, improvement methods and resource additions were often deployed simultaneously, one important limitation of our analysis is that attribution of results to any one of these three approaches is difficult. We utilized an annotated time series analysis to correlate the introduction of specific changes with resulting PMTCT process performance shifts in order to help understand which changes resulted in the improvement described above. This analytic method remains one of the best available approaches to understanding the effects of an intervention in “real-life,” uncontrolled trial settings.An important confounder in this study was the protocol change that moved the timing of infant PCR testing forward by eight weeks (from 14 weeks of age to 6 weeks). This change may have biased the outcome towards a lower transmission rate in breast-fed or mixed fed babies who would formerly have been exposed to eight additional weeks of breast milk by the time of PCR testing. Although labour ward data indicate that 94% of women in our cohort elected to exclusively formula feed from delivery, the impact of this change will depend on the prevalence of mixed feeding which we cannot estimate from available data.The likely adoption of more recent WHO guidelines that promote long-term neviripine prophylaxis for breast fed infants is likely to reduce the percentage of HIV positive mothers electing to formula feed The effects of improved PMTCT policies and protocols on reducing perinatal HIV transmission rates have been reported around the world The comprehensive nature of this intervention, involving all facilities with PMTCT activities in the sub-district across the continuum of the PMTCT program, provides a model for how district-level activities can be coordinated to achieve improved results. We conclude that a health systems improvement approach will lead to major improvements in PMTCT processes performance and outcomes in a defined health region given certain conditions: mediation of improvement efforts through regular feedback of reliable performance data, a learning network model that connects all facilities in the area, a design that includes both an innovation (learning) and a spread phase, and close support from leaders who introduce protocol amendments and strategic resources when needed. The intervention described requires a clear design, leadership buy-in, local capacitation in systems improvement methods, and a reliable data system. The successful intervention to decrease HIV transmission clearly benefitted from the resources and leadership provided by the Western Cape Department of Health. Whilst further testing and adaptation of these systems principles to other less well-resourced settings in South Africa and elsewhere are much needed, a systems improvement approach offers a potential way to rapidly improve under-performing PMTCT implementation programmes in sub-Saharan Africa.Figure S1Labour Ward Checklist. Checklist tool that was developed to improve performance of PMTCT care processes in labour ward.(0.05 MB TIF)Click here for additional data file.


Male and female Wistar rats were administered sodium saccharin for life (2 yr) either in the drinking water or diet. The maximum palatable dose of saccharin in the drinking water was found to be 2 g/kg/day and, even then, there was some voluntary restriction of fluid intake in the males. By contrast, double this dose--namely 4 g/kg/day, was palatable in the diet. A control group of rats of both sexes received saccharin-free diet and drinking water. Mild urothelial hyperplasias developed from 85 weeks in rats of both sexes receiving saccharin either in the drinking water or diet; the incidence was statistically significant in both the bladders and kidneys of rats receiving the higher dose of saccharin in the diet, but in the kidneys only of rats receiving the lower dose of saccharin in the drinking water. Telangiectasia of the vasa recta was significant in saccharin-treated rats of both sexes at both doses. A very low incidence of bladder tumours, exclusively in males receiving the higher saccharin dose in the diet was seen from 95 weeks. No consistent relationship between bladder epithelial hyperplasias and crystalluria could be demonstrated, although all 3 bladder tumours were associated with some form of mineralisation. Results suggest a particular susceptibility of males to saccharin treatment. The possibility that saccharin may promote, or enhance, the development of latent tumour cells already present in the experimental population, rather than initiate carcinogenesis per se is considered.


We are reporting a case of right-sided tuberculous otitis media with postaural abscess and multiple submandibular lymphadenopathy which has been reported very infrequently. A high level of suspicion by the treating physician is mandatory to avoid long delay in diagnosis and increased complications in the modern chemotherapy era. Mycobacterium tuberculosis by the bacilli invading the eustachian tube while the infant is being fed or by hematogenous spread to the mastoid process.Tuberculosis is one of the major infectious diseases with predominant involvement of lung and lymph nodes but tuberculosis of the middle ear is uncommon. Primary tuberculosis of the ear has rarely been reported and the disease is usually secondary to infection in the lung, larynx, pharynx, and nose.A 7-year-old boy came to our department with complaints of fever and discharge from right ear of three months duration. He also had multiple right submandibular and right inguinal lymphadenopathy of two months duration. Examination of right ear showed purulent discharge and there was a fluctuant, tender swelling in postauricular area. ENT evaluation showed congested tympanic membrane with multiple perforations and there was whitish granulation tissue in the attic area. He had multiple right submandibular and right inguinal lymphnodes which were matted and nontender. Modified radical mastoidectomy (MRM) had been done in ENT department with open mastoid process to drain the pus .There was history of tuberculosis in the family. The patient's father was on antitubercular therapy. Laboratory investigations showed Hb, 8.2 gm/dl; TLC, 9800 /cmm; and DLC, N38 and L62. There was 18-mm induration in Mantoux test. Skiagram chest did not show any pleural or parenchymal abnormality. Specimens from ear discharge were negative for pyogenic and acid fast bacilli on smear and culture. Fine needle aspiration cytology (FNAC) of the enlarged submandibular lymph node showed well-formed epithelioid granulomas and few Langhan's giant cells in background of lymphocytes and histiocytes, and necrosis suggestive of tuberculous etiology .So, the diagnosis of right-sided tuberculous otitis media with postaural abscess was made and the patient was started on three drug antitubercular therapy . After one month of ATT, patient is clinically improving and gaining weight with regression of all the lymph nodes once again confirming our diagnosis.Tuberculosis of middle ear is known to occur in all age groups, especially in children 50%).0%.5 espeThe route of spread of tuberculosis to middle ear has been argued for many years; the most logical route of entry of organisms being via the pharyngotympanic tube. However, hematogenous spread has also been described.


Objective: The decision about primary or staged reconstruction of all structures in severe hand injuries is controversial. The purpose of this case report is to present a surgical protocol that lead to good functional results and rapid recovery after primary bone grafting with pedicled flap coverage of a complex hand injury. Methods: A case is reported in which 2 iliac crest bone grafts, an extended dorsal metacarpal artery flap and a heterodigital island flap, were performed at primary intervention to reconstruct the index and middle fingers of a 17-year-old patient. Results: Length and sensation of the digits were fully preserved while the destroyed joints were fused and covered with mobile soft tissue. Hereby, a satisfactory pinch grip and hand closure was restored, allowing the patient to return to work after only 2 months. Conclusions: Given proper planning and adequate debridement, primary reconstruction of all injured structures should be considered when dealing with complex hand injuries. Since secondary interventions in reconstructed parts of the hand are the most challenging procedures in hand surgery, every attempt should be made to repair all structures immediately. Large soft-tissue defects of the fingers are a challenge to the reconstructive surgeon, especially when various digits are affected. The concept of early management of severe dorsal finger injuries to preserve functional length of the digits and provide adequate soft-tissue coverage is well established in the hand surgery literature.1A 17-year-old right-handed patient injured his left hand in a planer machine. Inspection of the traumatized hand revealed a severe injury on the dorsum of the index and middle fingers, with substantial soft-tissue defect. The index finger suffered complete destruction of the distal interphalangeal (DIP) joint, with a defect of two thirds of the extensor tendon and half of the nail bed and root. The middle finger suffered destruction of the proximal interphalangeal (PIP) joint and a defect of the ulnar lateral band Fig .Since the fingers' palmar arteries and nerves were fully preserved, amputation was rejected. First, an extended dorsal metacarpal artery (DMCA) flap was raised from the border of the retinaculum extensorum and transposed to the distal defect of the DIP joint of the index finger as described by Pelissier et al.The patient returned to full-duty status 2 months after surgery. At follow-up examination after 6 months, a good functional result was noted Fig  and the Since secondary procedures are considerably hampered by the presence of scar tissue, primary reconstruction should be attempted, whenever possible. Early reconstruction following radical debridement reduces postoperative morbidity, infection rate, the number of procedures, and subsequent hospital stays.The similar skin texture, color, and rapid execution make local flaps the best option in finger or thumb defects, whenever possible. Small free flaps such as from the snuff-box, thenar, first metacarpal artery (“kite” flap), first web space of the foot, dorsal middle phalangeal finger or the venous flaps are more time consuming and technically demanding.Sabapathy et al-18-The use of autogenic or allogenic bone graft in the primary reconstruction of open fractures of the hand or leg has not led to increased infection rates.12Proper planning of the surgery is decisive not only for good workflow among all team members but also for the adequate informed consent of the patient. Complex reconstructions require a thorough evaluation of the extent of the injury, the general condition of the patient, and of course an informed consent unless there is an immediate threat to the patient's life. If the extent of the injury cannot be appreciated before surgery, the procedure should be delayed until the patient can be informed about all options and consequences. The informed consent for reconstruction involving considerable donor site morbidity, such as primary toe transplants or free vascularized toe joint transfer, deserves particular discretion in the emergency setting since medical treatment might be considered as another potential source of damages if the patient seeks legal representation.Only a realistic potential to improve function can justify grafting procedures and flap harvesting at the primary operation while the risks of infection and loss of grafts should be carefully weighed out. In complex reconstructions, the surgeon must not overlook the ultimate goal of useful function. To improve aesthetics of the presented results, a correctional osteotomy of the PIP joint of the middle finger along with the removal of osteosynthesis material and a minor scar correction could be considered during a second intervention. This case illustrates that immediate reconstruction including primary bone grafting can be performed safely as long as radical debridement and adequate soft-tissue coverage of bone are provided. Primary reconstruction allows early postoperative rehabilitation, leading to a good functional outcome and a rapid return to work.


This review focuses on the short and bewildered history of Brazilian scientist Carlos Chagas's discovery and subsequent developments, the anatomopathological features of chronic Chagas cardiomyopathy (CCC), an overview on the controversies surrounding theories concerning its pathogenesis, and studies that support the microvascular hypothesis to further explain the pathological features and clinical course of CCC. It is our belief that knowledge of this particular and remarkable cardiomyopathy will shed light not only on the microvascular involvement of its pathogenesis, but also on the pathogenetic processes of other cardiomyopathies, which will hopefully provide a better understanding of the various changes that may lead to an end-stage heart disease with similar features. This review is written to celebrate the 100th anniversary of the discovery of Chagas disease. Abnormalities of microcirculation have been demonstrated in several different cardiomyopathies Trypanosoma cruzi (T. cruzi) developed a chronic cardiomyopathy similar to that observed in the chronic phase of Chagas disease in humans. Aggregated platelets forming transient occlusive thrombi were found in small epicardial and intramyocardial vessels associated with foci of myocytolytic necrosis and degeneration with an inflammatory mononuclear infiltrate and interstitial fibrosis. Soon afterwards, areas of focal vascular constrictions, microaneurysm formation, and dilatation were demonstrated in mice acutely infected with T. cruziWe suggested that alterations in the microvasculature contributed to the pathogenesis of experimental chronic Chagas cardiomyopathy (CCC) T. cruzi vectors and mode of transmission besides blood transfusion, oral, and congenital T. cruzi infection transmission.This review focuses on the short and bewildered history of Chagas's discovery and subsequent developments, the anatomopathological features of CCC, an overview of the controversies surrounding theories concerning the pathogenesis of CCC, and studies that support the microvascular hypothesis that further explains the pathology and clinical course of CCC. It is our belief that knowledge of this particular and remarkable cardiomyopathy will shed light not only on the microvascular involvement of its pathogenesis, but also on the pathogenetic processes of other cardiomyopathies, which will hopefully provide a better understanding of the various changes that may lead to an end-stage heart disease with similar features. As stressed by Factor Trypanosoma minasense, which he had previously described infesting marmosets, he sent some bugs to Manguinhos to be fed to primates that were free of infection. After some weeks, the same flagellates seen in the hindgut of the bugs were recovered from the bloodstream of the animals, and a new species different from T. minasense or “any other species of the same genus” was recognized. The parasite was first named as Schyzotrypanum cruzi in honor of Oswaldo Cruz, but it was subsequently renamed Trypanosoma cruzi.In 1908, the Brazilian government, when building a railroad from Rio de Janeiro  to Belem (in the north of the Amazon Basin), a task that was never completed, had to halt construction in Minas Gerais, not too far from Rio de Janeiro, because of a severe malaria outbreak involving the railroad workers T. cruzi was published in the first volume of the Maguinhos Institute journal, Memórias do Instituto Oswaldo Cruz, in August 1909 Chagas returned to Lassance looking for the presence of vertebrate hosts of this newly discovered parasite. After several tests in humans and animals, he found a cat with parasites in the bloodstream. A few weeks later, he was asked to investigate the possibility of an acute malarial episode in a two-year-old girl named Berenice living in the same house where the cat was found. He had clinically examined this girl before and now parasites were detected in the blood, suggesting the acute phase of a new disease. Further examinations demonstrated that the flagellates disappeared as the symptoms vanished, thus raising the possibility of a chronic phase of the new disease. On April 15, 1909, Oswaldo Cruz reported Chagas's discovery to the Brazilian National Academy of Medicine. A complete study on the evolutive cycle of the After some time, this important discovery by Chagas resulted in violent arguments and also led to denials, probably because it was beyond the comprehension of many of the physicians and scientists of those days and because his contemporaries envied him. In 1915, the campaign directed against Chagas intensified when Kraus, a German bacteriologist from the Buenos Aires Bacteriology Institute in Argentina, could not find any human cases of Chagas disease in northern Argentina, although a great number of infected bugs were found in hut dwellings. Chagas rejected Kraus's report, but the attacks and doubts against his discovery continued, and he was called “a man who searches in the jungle for diseases which do not exist”. After 1920, Chagas disease was simply forgotten and disappeared from nosology as an infectious disease of public health importance. The rediscovery of Chagas disease was made by Salvador Mazza, an Argentine physician, in 1934, just before Chagas's death, on November 8 of that year. He reported many acute cases found in northern Argentina, exactly where Kraus failed to find any human case of the disease. Like Chagas, Mazza was criticized for “discovering new diseases instead of treating the many already existing ones”. Due to Mazza's research, investigations on once forgotten Chagas disease were reinstated in South America, now recognized just as a cardiopathy. Only two decades later, the now well-known late manifestations of Chagas disease mega-syndromes, usually megaesophagus and megacolon, conjectured by Chagas T. cruzi infection transmission, such as the “Southern Cone Initiative”, explain most of this success By the early 1990s, the World Health Organization (WHO) considered Chagas disease the most serious parasitic disease in Latin America Chagas disease is characterized by three phases: acute, indeterminate or latent, and chronic. The heart is the most severely and frequently involved organ. The cardiac involvement during the acute phase varies from mild (asymptomatic or olygosymptomatic) to severe. The latter may be fatal, occurring in 3%–5% of cases. The indeterminate or latent phase, between the acute and chronic phases, usually of long duration (up to 10–30 years), is characterized by the absence of clinicopathological evidence and is usually accompanied by either a normal electrocardiogram or one with minor disturbances of cardiac rhythm. Approximately 30% of the infected individuals eventually develop late manifestations. The symptomatic disease affects the heart in 94.5% of patients that are considered to have CCC, usually between 15 and 50 years of age. Congestive heart failure is the cause of death in 58% of these patients, whereas cardiac arrhythmias and unexpected death affects 36.5%. The remaining manifests as mega-syndromes of hollow viscera, usually megaesophagus and megacolon.Three stages are seen in CCC. In the initial stage the patient has a few symptoms, usually related to disturbances of rhythm. In the intermediate stage the clinical signs usually correlate with a mildly to moderately enlarged heart. In the final stage, the most significant clinical manifestation includes congestive heart failure, thromboembolic phenomena, severe arrhythmias, and sudden death The main pathological changes reflect the importance of the involvement of the heart in Chagas disease The pathogenesis of chronic chagasic cardiopathy is still not fully understood. Different mechanisms have been proposed.The existence of different clinical forms of the disease was soon identified, which was at first thought to be associated with differences in the parasites implicated. Indeed, even Chagas noticed a peculiar dimorphism, the so-called slender and stout forms of the parasite in the bloodstream, observations later confirmed by many others T. cruzi in the pathogenesis of Chagas disease and set the stage for establishing the notion that genomic variation of T. cruzi might influence the course of the disease.In chronic Chagas disease, parasites are rarely found in tissues examined by routine techniques The autonomic nervous system of patients with Chagas disease has been extensively studied T. cruziThe participation of autoimmune mechanisms in the genesis of the chronic myocarditis of Chagas disease has been postulated Two criticisms are often used against the hypothesis that CCC is an autoimmune disease. The first is that immunosuppressants, which generally relieve symptoms of autoimmune diseases, exacerbate mortality in individuals with Chagas disease, and the second is that therapy directed at the parasite often ameliorates the clinical disease in humans and experimental animals T. cruzi in which the acute myocarditis is directly related to the presence of the parasite.It has been assumed that autoimmunity is triggered after the initial contact with the parasite and that immunological processes continue during the chronic phase of the disease T. cruzi and then challenged with trypomastigotes of the virulent Colombian strain of T. cruzi, isogenic BALB/c mice developed a cardiomyopathy very similar to that observed in the chronic phase of human Chagas disease 2) and platelet activating factor (PAF) by macrophages, which are the predominant inflammatory cells, was proposed to cause transient ischemia and myocytolytic necrosis In mice first immunized with several inoculations with epimastigote forms of the avirulent PF strain of T. cruzi infection on microcirculatory flow in vivo and quantitative measurement of parameters like velocity of red blood cell flow (Vrbc) and vessel diameter were provided. When the cremaster model was examined 20–25 days post-infection in male CD-1 mice infected with the Brazil strain, a significant decrease in Vrbc, reversed by verapamil treatment, was observed in the first- and third-order arterioles and venules. In addition, the marked inflammatory response attenuated was by verapamil treatment. The arterioles of the infected mice exhibited segmental areas of vasospasm and dilatation, possibly the initiating event in microaneurysm formation (A/J mice infected with the Brazil strain and perfused with silicone rubber (Microfil) 15–17 days post-infection revealed numerous areas of focal vascular constriction, microaneurysm formation, dilatation, and proliferation of microvessels , which iormation  [67].T. cruzi showed an increased aggregation of platelets during the early stage, a factor that may contribute to the development of thrombosis. In addition, increased levels of TXA2 were observed. This finding could contribute to the increased intravascular platelet aggregation and focal microvascular spasm 2, but it was most dramatic in amastigotes. These observations suggest that TXA2 could contribute to the pathogenesis of CCC and its clinical manifestations.The exact mechanism of such vascular lesions has not been fully clarified. In addition to spastic phenomena, the observation of platelet thrombi in the coronary microcirculation of infected mice led to an investigation of the possible mechanisms involved. Toward this end, a study using A/J mice and human umbilical vein endothelial cells (HUVECs) infected with the Tulahuen strain of T. cruzi infection. Acutely infected rats developed changes in the endothelial layer characterized by EC swelling and a few points of cytoplasmic discontinuity that appeared as holes exposing the subendothelial collagen that is usually associated with platelet-fibrin aggregates, which might affect the generation of vasoactive substances, and impairs the equilibrium between opposing forces T. cruzi infection of ECs was demonstrated to cause activation of the NF-κB pathway, likely contributing to the induction of cytokine and adhesion molecular expression in the endothelium T. cruzi–infected humans and experimental animals, increased expression of cytokines, iNOS, and adhesion molecules has been reported Early in the course of infection, parasites are evident in the coronary microvascular endothelial cells (ECs) before parasitemia can be detected, suggesting that the coronary endothelium could be an initial, if not primary, target of T. cruzi–derived molecules provoke overexpression of ET-1 Endothelial cells are the major source of endothelin 1 (ET-1), a potent vasoconstrictor, and its role in the pathogenesis of chagasic heart disease has been demonstrated. The infection of CD1 mice with the Brazil strain and C57BL/6 mice with the Tulahuen strain caused an intense vasculitis, high plasma ET-1 levels, and increased expression of mRNAs for the precursor molecule preproET-1, endothelin converting enzyme (ECE), and ET-1 in the myocardium T. cruzi/kg body weight were studied. This study demonstrated that myocarditis characterized by small focal areas of lesion and myocytic necrosis associated with interstitial mononuclear infiltration. Ultrastructurally, degenerative changes were observed in ECs in contact with T lymphocytes, as well as platelet aggregates and fibrin thrombi in the intramyocardial capillaries. These alterations suggested that a possible interaction between ECs and effector immune cells might play an important role in the pathogenesis of the myocellular lesion and of the microangiopathy observed in this model Hearts from dogs sacrificed 18 to 26 days after intraperitoneal inoculation with trypomastigote forms of the 12SF strain of T. cruzi resulted in the alteration of various critical biochemical processes responsible for the maintenance of microvascular perfusion, such as Ca2+ homeostasis and generation of inositol trisphosphate and prostaglandin I2T. cruzi infection of HUVECs results in an alteration of cyclic AMP metabolism, which plays a protective role against the direct and/or indirect lesion caused by the adhesion and aggregation of circulating platelets to ECs Direct infection of human endothelial cells in culture with T. cruzi infection have been extensively studied. The increase of interleukin-1β (IL-1β), IL-6, and colony stimulating factor 1 (CSF-1) in infected ECs may lead to alterations in their function T. cruzi, and by a variety of other cell types, such as ECs T. cruzi. These observations may reflect the growth of the monocyte population in the microvasculature, resulting in the later elaboration of proinflammatory cytokines Cytokines contribute to the pathogenesis of various parasitic infections, and their roles in the pathogenesis of T. cruzi infection of HUVECs with regard to the production of biologically active ET-1 are an increased expression of ET-1 mRNA The consequences of Anatomical studies have shown structural derangement and rarefied microvasculature in the left ventricular myocardium. A histotopographical study comparing the microcirculatory system after injection of an opaque medium into chagasic and control human hearts demonstrated focal decapillarization in chronic Chagas disease due to extraluminal compression, suggesting that this might be the cause of focal myocytolytic necrosis The evaluation of chest pain is a major problem in chagasic patients. Almost all exhibit symptoms that are atypical for classic angina pectoris. Although symptoms suggestive of myocardial ischemia are present, coronary angiographical studies show normal or nearly normal coronary arteries in more than 90% of patients studied Abnormal perfusion in different groups of chagasic patients has been confirmed by various independent investigators using isonitrile-99m-technetium Vasospastic mechanisms have been proposed in the genesis of coronary accidents in patients with CCC Biopsies obtained from chronic chagasic hearts revealed a marked thickening of the basement membrane in most myocytes and capillaries  Significant dilatations of arterioles and capillaries in various ventricular areas of chagasic hearts compared to hearts with dilated cardiomyopathy were described. It was hypothesized that such microcirculatory dilatations could cause inadequate blood flow distribution in the watershed area lying between the two main coronary flow sources , resulting in ischemic and extensive fibrosis within the left ventricle apical and posterior regions The relation of regional sympathetic denervation and myocardial perfusion disturbance to wall motion impairment was described in patients with CCC. Global left ventricular function, segmental wall motion analysis, and myocardial perfusion were evaluated in 58 patients, demonstrating myocardial perfusion defects in the absence of epicardial coronary artery disease. In addition, the extension and severity of perfusion abnormalities parallel the progression of myocardial damage. These results support the notion that perfusion disturbance in CCC may be caused by transient disturbances of coronary blood flow regulation at the microvascular level In CCC there is extensive damage of the myocardium and, consequently, it is not surprising that interstitial fibrosis is one of the most prominent features + or CD8+ T cells and completely abrogated by total T cell depletion + and CD8+ cells may act directly on mesenchymal cells by means of cytokine production that leads to the proliferation of fibroblasts and the synthesis of collagen or indirectly by enhancing the activation of macrophages The pattern of myocardial fibrosis in chronic Chagas heart disease probably reflects the pathogenic mechanisms involved. Diffuse foci of myocardial myonecrosis may be the main etiology factor of the chronic expression in chronic chagasic cardiomyopathy Increasing evidence for abnormalities at the microvascular level has been accumulated from studies both in chagasic patients and experimentally infected animals. The changes suggest that myocardial lesions develop, at least in part, as a consequence of additive and progressive cell necrosis initiated and perpetuated by changes in myocardial microcirculation. Based on these studies, it is possible to speculate that therapy aimed at decreasing the degree of microvascular ischemia could prevent or ameliorate myocardial damage, ventricular dysfunction, and ventricular arrhythmias.T. cruzi, the animals developed acute myocarditis 21 days after infection, characterized by severe focal inflammation, necrosis, and fibrosis. The administration of captopril significantly reduced necrosis and fibrosis in infected mice. Taken together, these results suggest that captopril can reduce myocarditis and fibrosis in T. cruzi infection.Angiotensin-converting enzyme inhibitors (ACEIs) have emerged as the treatment of choice for patients with all degrees of heart failure, ranging from asymptomatic left ventricular dysfunction to severe heart failure. The mechanism of action of captopril, an ACEI, involves suppression of angiotensin II, a potent vasoconstrictor, and increased levels of bradykinin through the inhibition of kininase II, which induces NO release in ECs and stimulates the production of prostacyclin, a vasodilating prostaglandin The effect of enalapril, another ACEI, on ventricular function in patients with CCC has been evaluated. A significant improvement of diastolic function and a trend to improvement of systolic function was seen in the group that received digitalics, diuretics, and enalapril in comparison with the group that received digitalics and diuretics only. This beneficial action of enalapril in diastolic function could be related to decreased venous return and increased arteriolar vasodilatation T. cruzi, developed acute decompensated NYHA class IV heart failure. Both patients were refractory to treatment with ACEI, aldosterone antagonists, and dobutamine. Levosimendan was prescribed, and clinical improvement was observed, with progression to NYHA class II. Levosimendan is a positive inotropic drug with vasodilatory properties with anti-ischemic action through increased coronary flow and reduced preload and afterload. The limitations of this study include lack of studies with a placebo group to ensure that the benefits are a result of the drug and not side effects of other medications Two cases of myocarditis due to acute Chagas disease, resulting from oral intake of sugar cane juice infected with T. cruzi–infected CD1 mice given verapamil immediately after infection showed decreased mortality and attenuated myocardial inflammation and fibrosis T. cruzi infection to prevent ventricular dilatation and myocardial dysfunction Further evidence of the microvascular involvement in CCC pathogenesis has been demonstrated by studies with verapamil, a first generation L-type calcium channel antagonist T. cruzi and treated for the initial 15 days post-infection Phosphoramidon, a potent inhibitor of endothelin-converting enzyme, reduced myocardium inflammation and fibrosis and attenuated right ventricle diameter increase in CD1 mice infected with the Brazil strain of T. cruzi, occurs as a consequence of several physiopathological processes. The very rare finding of parasites in the myocardium in the chronic phase of the disease is out of proportion to the degree of organ compromise and dysfunction. The chronic fibrosing myocarditis development is related to progressive and additive focal cellular necrosis and associated with inflammatory mononuclear infiltrate and reactive and reparative interstitial fibrosis and surrounding myocytes hypertrophy. Based on the evidence presented in the present review, these processes may be initiated and perpetuated by alterations in the myocardial microcirculation. The intrinsic and/or extrinsic cardiac necrosis system abnormalities and immunological mechanisms may contribute, but there has been extensive debate on their significance on the marked cardiac damage.The pathogenesis of chronic chagasic cardiomyopathy, which takes decades to develop after the initial infection with The treatment of the chronic Chagas heart disease has relied on the same conventional treatments for other cardiomyopathies. The studies cited illustrate the potential benefit of therapeutics aimed at the underlying pathophysiological microvascular mechanism of CCC. However, the favorable effect of these changes has not yet been established due to the lack of randomized multicenter clinical trials using different treatments to determine their impact on clinical improvement and survival of chronic chagasic patients. There is an urgent need for developing adequate specific treatment procedures, particularly during the chronic phase of the disease.


Arabidopsis thaliana), poplar (Populus trichocarpa) and rice (Oryza sativa). Presently, no large-scale analysis of TFs has been made from a member of the Solanaceae, one of the most important families of vascular plants. To fill this void, we have analysed tobacco (Nicotiana tabacum) TFs using a dataset of 1,159,022 gene-space sequence reads (GSRs) obtained by methylation filtering of the tobacco genome. An analytical pipeline was developed to isolate TF sequences from the GSR data set. This involved multiple  independent searches with different versions of the TF family-defining domain(s)  followed by assembly into contigs and verification. Our analysis revealed that tobacco contains a minimum of 2,513 TFs representing all of the 64 well-characterised plant TF families. The number of TFs in tobacco is higher than previously reported for Arabidopsis and rice.Regulation of gene expression at the level of transcription is a major control point in many biological processes. Transcription factors (TFs) can activate and/or repress the transcriptional rate of target genes and vascular plant genomes devote approximately 7% of their coding capacity to TFs. Global analysis of TFs has only been performed for three complete higher plant genomes – Arabidopsis (TOBFAC: the database of tobacco transcription factors, is an integrative database that provides a portal to sequence and phylogeny data for the identified TFs, together with a large quantity of other data concerning TFs in tobacco. The database contains an individual page dedicated to each of the 64 TF families. These contain background information, domain architecture via Pfam links, a list of all sequences and an assessment of the minimum number of TFs in this family in tobacco. Downloadable phylogenetic trees of the major families are provided along with detailed information on the bioinformatic pipeline that was used to find all family members. TOBFAC also contains EST data, a list of published tobacco TFs and a list of papers concerning tobacco TFs. The sequences and annotation data are stored in relational tables using a PostgrelSQL relational database management system. The data processing and analysis pipelines used the Perl programming language. The web interface was implemented in JavaScript and Perl CGI running on an Apache web server. The computationally intensive data processing and analysis pipelines were run on an Apple XServe cluster with more than 20 nodes.Solanaceae and helps to fill a current gap in studies of TF families across the plant kingdom. TOBFAC is publicly accessible at .TOBFAC is an expandable knowledgebase of tobacco TFs with data currently available for over 2,513 TFs from 64 gene families. TOBFAC integrates available sequence information, phylogenetic analysis, and EST data with published reports on tobacco TF function. The database provides a major resource for the study of gene expression in tobacco and the  Nicotiana tabacum L.] is a member of the agriculturally important Solanaceae and is one of the most studied higher plant species. This is because of both its economic importance and because it is a convenient plant system for research. Tobacco can be easily transformed and has a relatively short generation time. A system of reduced complexity, the tobacco Bright Yellow-2 (BY-2) cell line, is also available and this cell line is fast growing, responds to a variety of plant hormones and can be stably transformed [Tobacco [nsformed . BY-2 ceThe large genome size of tobacco (approximately 4.5 Gb) makes the goal of sequencing the tobacco genome difficult. Fortunately, there are now a number of methods that can deliver sequence information on the vast majority of genes in a species without the need to sequence and assemble the entire genome. One of these techniques is methylation filtration (MF), which preferentially clones the hypomethylated fraction of the genome, effectively reducing the size of the genome to be sequenced. MF has already been successfully applied in maize, sorghum and cowpea -5. The dThe Tobacco Genome Initiative (TGI) has obtained sequence from an estimated minimum of 90% of tobacco gene space (cultivar Hicks Broadleaf) using MF technology . We haveArabidopsis thaliana), poplar (Populus trichocarpa) and rice (Oryza sativa L.). A number of databases have been constructed that integrate all predicted TFs from these three genomes. These include the Plant Transcription Factors databases [Nicotiana tabacum genome is the result of an interspecific hybridization event between Nicotiana sylvestris and Nicotiana tomentosiformis resulting in an allopolyploid genome with a basic chromosome number of x = 24. Based on a high density microsatellite-based genetic map, there is clear evidence of several large translocation events between the ancestral chromosomes but no evidence of large duplication events. The extent of loss of chromosomal segments is difficult to assess in the absence of diploid maps for the ancestral species. It is therefore difficult to predict the total number of tobacco TFs, but it is likely to be over 3,000. After the databases that cover Arabidopsis, rice and poplar, TOBFAC is currently the most extensive species-specific higher plant TF database. It will be a major resource for the study of gene expression in tobacco and the Solanaceae and will also facilitate studies of TF families across the plant kingdom.Since the publication of the first version of the Arabidopsis genome sequence, finding the complete set of known TFs in plant genomes has become an attainable goal . Howeveratabases ,11, PlnTatabases  and Planatabases . In addiatabases . Howeverth 2006) [A total of 1,159,022 GSRs obtained by methylation filtering were downloaded from the TGI (March 6th 2006) . The GSRbona fide tobacco TFs and each was given a unique identifier. These sequences were uploaded to TOBFAC, where the complete list of tobacco TF sequences is available as one dataset  . Where tIt is estimated that at least 90% of tobacco TF genes have been tagged by the MF technology , but notPhylogenetic and molecular evolutionary analyses were conducted using MEGA version 4 . Phyloge46,546 tobacco EST sequences from the European Sequencing of Tobacco Project  were uplSolanaceae and will also facilitate studies of TF families across the plant kingdom. The current version will be updated regularly to improve the dataset of tobacco TFs. The main page for TOBFAC is the main web interface for all information contained in the database  from 64 gene families together with extensive data on each gene family. TOBFAC integrates these TF sequences with published tobacco TFs, scientific literature on tobacco TFs, phylogenetic trees and EST data. The aim is to make TOBFAC the database of choice for transcription-related projects in tobacco and an important resource for projects in other members of the Solanaceae.Genome-related public databases are invaluable to the scientific community and transcriptional regulation of gene expression is a major control point in many biological processes. Databases that contain information on complete or near-complete complements of TFs are major resource for the plant research community but this does not currently include a member of the The availability of all, or nearly all, members of TF families from several species will facilitate the study of their biological functions, phylogenetic relationships, and the evolution of their DNA-binding domains . The datGene space sequences have been published for maize, sorghum and cowpea ,3,5 and The current version of TOBFAC is based on 1,159,022 GSRs obtained from the TGI website. As additional GSRs, ESTs and BAC sequences become available, we will integrate these new sequences into TOBFAC and update both TF family data and phylogenetic analyses. Microarray-based transcription profiling is currently being performed for tobacco and expression data for TFs will also be included in future versions of TOBFAC.Project name: TOBFAC: The database of tobacco transcription factors..Project home page: Operating system: Platform independent.Programming language: Perl.Other requirements: None.Licence: None required.Any restrictions to use by non-academics: None.PJR designed the project, performed data analysis and assisted in the design of the database. MTB performed data analysis, assisted in the design of the database, and performed the analysis of published papers and genes. TWL participated in the design of the database and database system administration. JFB performed data analysis. XC performed the bioinformatics data analysis and web implementation. MPT served as the principal investigator of the project. All authors have assisted in writing of the manuscript and have read and approved the final submitted version. PJR and MTB are equal first authors.