An important question pertaining to glycoproteins is whether the covalently-bound carbohydrate moieties contribute to its immunogenic activity. Ovomucoid (OM) is, for these kinds of studies, a model compound in view of its relatively high carbohydrate content but the role of the carbohydrate moieties on its immunogenic activity still remains controversial. The aim of this study was to establish the effect of glycosylation on the IgE-binding properties and biological activity of OM.Carbohydrate moieties of OM were removed by enzymatic deglycosylation with PNGase F and the degree of deglycosylation of the protein was evaluated by SDS-PAGE with PAS staining and RP-HPLC. Changes in secondary and tertiary structure of OM due to deglycosylation were evaluated by circular dichroism. Immunoreactivity of native and deglycosylated OM was evaluated by inhibition ELISA and western blot using the sera from ten egg-allergic patients with IgE levels from 37 to more than 100 kU/L. Using PBMCs from egg-allergic patients, the cellular proliferative potency and the capacity to stimulate the secretion of interleukins of native and deglycosylated OM were assessed. Basophil activation by OM, with and without carbohydrates, was assessed using human basophils passively sensitized with serum from children with egg allergy.PNGase F effectively released carbohydrates attached to OM after five days at 37° without apparent structural changes. Immunoassays showed that, in eight out of ten sera of egg-allergic patients, the IgE binding to deglycosylated OM was less effective than to the native protein. The results of immunoblotting showed that six out of ten sera, previously incubated with the deglycosylated protein, kept their IgE binding capacity to the glycosylated protein, supporting the idea that carbohydrates may play a role in antigen recognition. In spite of these results, no influence of glycosylation on T cell activation and proliferation was found.The carbohydrate chains attached to OM play a role in the reactivity against IgE, but their clinical relevance might be low.None declared.


Because of our limited knowledge of the functional role of the thalamostriatal system, this massive network is often ignored in models of the pathophysiology of brain disorders of basal ganglia origin, such as Parkinson’s disease (PD). However, over the past decade, significant advances have led to a deeper understanding of the anatomical, electrophysiological, behavioral and pathological aspects of the thalamostriatal system. The cloning of the vesicular glutamate transporters 1 and 2 (vGluT1 and vGluT2) has provided powerful tools to differentiate thalamostriatal from corticostriatal glutamatergic terminals, allowing us to carry out comparative studies of the synaptology and plasticity of these two systems in normal and pathological conditions. Findings from these studies have led to the recognition of two thalamostriatal systems, based on their differential origin from the caudal intralaminar nuclear group, the center median/parafascicular (CM/Pf) complex, or other thalamic nuclei. The recent use of optogenetic methods supports this model of the organization of the thalamostriatal systems, showing differences in functionality and glutamate receptor localization at thalamostriatal synapses from Pf and other thalamic nuclei. At the functional level, evidence largely gathered from thalamic recordings in awake monkeys strongly suggests that the thalamostriatal system from the CM/Pf is involved in regulating alertness and switching behaviors. Importantly, there is evidence that the caudal intralaminar nuclei and their axonal projections to the striatum partly degenerate in PD and that CM/Pf deep brain stimulation (DBS) may be therapeutically useful in several movement disorders. Although the evolution of the thalamus and striatum pre-dates the expansion of the cerebral cortex Butler, , our knoAlthough the thalamostriatal system originates from most thalamic nuclei, the CM/Pf (or the Pf in rodents) is the main source of thalamostriatal projections in primates and non-primates  the rostral third of Pf which innervates mainly the nucleus accumbens; (2) the caudal two thirds of Pf which project to the caudate nucleus; (3) the dorsolateral extension of Pf (Pfdl) which targets selectively the anterior putamen; (4) the medial two thirds of CM (CMm) which innervates the post-commissural putamen; and (5) the lateral third of CM (CMl) which is the source of inputs the primary motor cortex (M1). Through these projections, the CM/Pf gains access to the entire striatal complex, thereby making the CM/Pf-striatal system a functionally organized network that may broadly affect motor and non-motor basal ganglia functions , the mediodorsal nucleus (MD), the pulvinar, the lateral posterior nucleus, the medial posterior nucleus, midline, anterior and the ventral motor nuclear group are prominent sources of thalamostriatal projections to the caudate nucleus and putamen Royce, . In contThrough the use of trans-synaptic viral tracing studies, Strick and colleagues have suggested that thalamostriatal projections from the VL and other intralaminar thalamic nuclei that receive cerebellar outflow from the dentate nucleus may be the underlying connections through which the cerebellum communicates with the basal ganglia  synapses. In rodents, the principal synaptic target of most non-CM/Pf thalamostriatal projections are dendritic spines of striatal medium spiny neurons (MSNs), a pattern of synaptic connectivity similar to the corticostriatal system   express vGluT1, ~25% contain vGluT2 and ~25% do not display immunoreactivity for either vGluT1 or vGluT2  Gerfen, . These sin vivo and in vitro electrophysiological analyses showing that single direct or indirect pathway neurons respond to both cortical and thalamic stimulation in rodents , the CM receives inputs from motor, premotor and somatosensory cortices Mehler, , while tExperiments to study the role of the projections from the CM/Pf to the striatum date back to the 1970s. These studies described that electrical stimulation of the intralaminar nuclei induces short-latency excitatory post-synaptic potentials (EPSPs) in anesthetized cats and rats , and have long been known as the source(s) of widely distributed “nonspecific” thalamocortical projections, these thalamic nuclei are considered part of the ascending “reticular activating system” that regulates arousal and attention   have been empirically used to treat patients with TS (see below)  which typically peak in preadolescence and decline in the later teenage years. Many TS patients also suffer from psychiatric comorbidities, such as obsessive compulsive disorder, attention-deficit hyperactivity disorder, or depression. Most patients are successfully  treated with neuroleptics and other drugs or with behavioral therapy. However, a few patients continue to experience severe tics in adulthood. These patients are candidates for neurosurgical procedures. Although still under considerable debate, TS may be the result of abnormal GABAergic or dopaminergic transmission in the basal ganglia . Early investigations of the use of stimulation of CM/Pf in movement disorders were carried out in patients that were enrolled in pain treatment studies, but also suffered from movement disorders Andy, . SignifiCM/Pf DBS was found to provide significant anti-parkinsonian benefits in 6-OHDA-treated rats (Jouve et al., Despite significant progress in our understanding of the anatomy, physiology and pathophysiology of the thalamostriatal systems, many unresolved issues remain. The cloning of vGluT1 and vGluT2 has had a significant impact in our understanding of the anatomical and synaptic organization of the thalamostriatal systems, allowing us to further appreciate that the thalamus is a massive source of extrinsic glutamatergic inputs to the striatum that originates either in the CM/Pf nuclear complex, or in the numerous non-CM/Pf thalamic nuclei. Future studies aimed at understanding the physiological role of these multiple thalamostriatal circuits, and their functional interactions with the corticostriatal and nigrostriatal systems, are warranted to decipher the mechanisms by which these extrinsic afferents regulate basal ganglia functions.Because of the complex relationships between the cerebral cortex, thalamus and striatum, the use of traditional stimulation or lesion methods has had a limited impact in our understanding of the physiology and synaptic properties of thalamostriatal connections. However, as presented in this review, optogenetic approaches help overcome some of these technical challenges, setting the stage for a rigorous and detailed characterization of the physiology and pathophysiology of the CM/Pf vs. non-CM/Pf-striatal systems in normal and diseased states.The major breakthroughs that were recently made in characterizing some aspects of the role of the CM/Pf-striatal system in regulating the physiological responses of striatal cholinergic interneurons to attention-related salient sensory stimuli provide a deeper understanding of the mechanisms involved by which the basal ganglia regulate activities such as behavioral switching, attentional set-shifting and reinforcement. Because the CM/Pf-striatal system undergoes massive degeneration in PD, future studies aimed at assessing the effects of this degeneration upon attention and other basal ganglia-related cognitive functions are needed. A better understanding of the respective role played by the thalamostriatal vs. the nigrostriatal dopamine systems in the regulation of cholinergic interneuron activity is another area of great interest for future studies.In light of neuropathology studies of the thalamus in human patients with PD (Halliday, Finally, another area of great interest is the use of DBS of CM/Pf in movement disorders, most particularly in TS. We need to understand better how stimulation of the thalamostriatal system from CM/Pf alleviates tics and psychiatric symptoms of this disease. Furthermore, rigorous blinded trials in a large number of patients still need to be done before this treatment can be recommended for patients with TS.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Many previous studies estimating the relationship between body mass index (BMI) and mortality impose assumptions regarding the functional form for BMI and result in conflicting findings. This study investigated a flexible data driven modelling approach to determine the nonlinear and asymmetric functional form for BMI used to examine the relationship between mortality and obesity. This approach was then compared against other commonly used regression models.This study used data from the National Health Interview Survey, between 1997 and 2000. Respondents were linked to the National Death Index with mortality follow-up through 2005. We estimated 5-year all-cause mortality for adults over age 18 using the logistic regression model adjusting for BMI, age and smoking status. All analyses were stratified by sex. The multivariable fractional polynomials (MFP) procedure was employed to determine the best fitting functional form for BMI and evaluated against the model that includes linear and quadratic terms for BMI and the model that groups BMI into standard weight status categories using a deviance difference test. Estimated BMI-mortality curves across models were then compared graphically.The best fitting adjustment model contained the powers -1 and -2 for BMI. The relationship between 5-year mortality and BMI when estimated using the MFP approach exhibited a J-shaped pattern for women and a U-shaped pattern for men. A deviance difference test showed a statistically significant improvement in model fit compared to other BMI functions. We found important differences between the MFP model and other commonly used models with regard to the shape and nadir of the BMI-mortality curve and mortality estimates.The MFP approach provides a robust alternative to categorization or conventional linear-quadratic models for BMI, which limit the number of curve shapes. The approach is potentially useful in estimating the relationship between the full spectrum of BMI values and other health outcomes, or costs. However, the evidence is mixed as to the exact relationship. While some studies have concluded no relation [Obesity and its impact on health and the healthcare system is one of the most important public health issues Western society faces. Many studies have measured the detrimental effect of obesity on life expectancy by estimating the relationship between mortality and body mass index (BMI) [weight (kg)/heightrelation , an inverelation , the majrelation -10 or a relation -15. One a priori knowledge that the relationship between the two measures is nonlinear. However, Royston, et al. (2006) [The vast majority of studies have employed a non-parametric approach, by treating BMI as a categorical variable. The mortality risk of individuals in different BMI groups is computed relative to a reference BMI category. World Health Organization (WHO) BMI classifications  are typi. (2006)  pointed A number of studies have used other approaches that maintain BMI as a continuous variable. Estimation of the BMI-mortality curve using a continuous measure is problematic because the relationship is nonlinear and the distribution of BMI is right skewed. Schauer et al. (2010)  includedThe purpose of this study was to investigate a flexible approach to modelling the nonlinear and asymmetric relationship between adult mortality and obesity measured using BMI. We implemented the multivariable fractional polynomials (MFP) method ,27 and mThe data used in this study were from the NHIS, publicly available through the Centers for Disease Control and Prevention (CDC). The NHIS is a nationally representative cross-sectional household survey covering the non-institutionalized civilian population in the United States (U.S.) and is conducted annually . HousehoWe investigated the relationship between mortality and obesity through BMI using the logistic regression model, stratified by gender and adjusting for age and smoking history. The logistic model was chosen over the Cox proportional hazards model because the proportional hazards condition did not hold for the BMI fractional polynomial (FP) terms. We used 5-year all-cause mortality as the dependent outcome because of the very low incidence of death annually. To check for robustness, we also estimated all models using 3-year mortality as the outcome, which produced similar results. Analyses were stratified by gender because the biological process by which men and women gain and maintain weight is different . We adjuWe maintained BMI as a continuous variable in our analysis. To account for the nonlinear and asymmetric relationship between BMI and mortality, we first applied the fractional polynomials ,32 methoi πwas the 5-year death probability for individual i, p1 and p2 were the fractional powers for BMI, and q1 was the fractional power for age. The MFP method also scaled and centered variables in model selection process to improve numerical stability and to provide a model intercept that was easier to interpret. A nominal p-value of 0.05 was used to test all hypotheses. To evaluate the validity of the FP model for BMI, we graphically compared three models with the main FP model defined by (1). First, we estimated the model which categorized BMI into 30 narrow bins  while also adjusting for age and smoking status. We then estimated separate FP models after omitting subjects with early death (< 1 year from baseline) and extreme BMI values (> 50).where Interactions between adjustment variables were tested to address the possibility of differences in the BMI-mortality curve across the age distribution, and by smoking history. The multivariable fractional polynomial interaction (MFPI) algorithm  was usedThe BMI associated with minimum mortality was calculated by first estimating the final MFP model (including interaction terms) using logistic regression. To derive the optimal BMI, we set the first derivative of the estimated FP model equal to 0 and solved for BMI. As an example, the optimal BMI for the model with linear and quadratic BMI terms without interactions is We compared the BMI-mortality curves derived using the MFP method with the continuous BMI model containing linear and quadratic BMI terms and the categorical model based on WHO BMI classifications. Models were compared on the basis of model fit, the shape of the BMI-mortality curve, the magnitude and uncertainty in the BMI associated with minimum mortality and mortality estimates. All statistical models were fit using the STATA Statistical Software . The STATA procedure MFP was used to determine the functional forms for age and BMI and the procedure NLCOM was used to calculate estimates and confidence intervals for the BMI associated with minimum mortality.Descriptive statistics for the NHIS sample used in this study are presented in Table p-value < 0.001), the linear-quadratic model  and the categorical model . Similar improvements in model fit were found in the female sample for the FP model relative to the untransformed model , the linear-quadratic model  and the categorical model . The FP model for BMI produced a similar BMI-mortality curve compared to the model categorizing BMI into narrow bins for both genders. Also, the BMI-mortality curves produced by the main FP model and the models omitting early deaths and extreme BMI values were similar in shape  and BMI-age interactions  were both identified as statistically significant in the female sample. The final model was selected using forward selection. After including the age-BMI interactions, the age-smoking history interaction remained significant . Logistic regression results for the FP model, including significant interactions are in Table After finding the best fit for the main model, the age-smoking history  .The other common approach to modelling the nonlinear functional form for BMI is a nonparametric approach incorporating categorical variables defined by WHO BMI classifications. Assessing the risk of a BMI category relative to the normal category is a convenient method to account for the nonlinear form, but assumes mortality is uniform across a BMI category, which is problematic when a category is heterogenous. In particular, the normal category consists of a mix of healthy and sick lean. Studies employing the categorical approach also typically take the mortality risk of obese individuals beyond a given threshold as constant. We addressed this difficulty by allowing the data from across the entire BMI distribution to predict mortality risk at extreme obesity levels, where fewer observations exist. Because our results showed that mortality increased exponentially for extremely obese individuals, categorization can drastically underestimate mortality at the right tail of the BMI distribution. The use of wide BMI categories are also inadequate for the purposes of prediction. Categorizing BMI using finer intervals can alleviate some of these difficulties, but the decision of which categories to add is generally an arbitrary choice. Moreover, the additional categories increase the variance of parameter estimates, particularly in high BMI categories where the sample size is small.Our study also employed methods that differentiate the effect of BMI across gender and age. The identification of distinct FP terms across gender samples point to important differences in the BMI-mortality relationship. Further differences were identified within the female sample through interactions. The finding of significant interactions between age and BMI is not common in literature, but has been identified in a select number of studies ,40. The This study has at least two notable limitations. The logistic regression model with 5-year mortality as the dependent outcome was chosen over the Cox survival model because the assumption of proportional hazards failed to hold. However, the disadvantage of the logistic regression model is that full information regarding the individual's exact time of death was not used. Second, while the primary goal of this study was to compare approaches to modelling the BMI-mortality relation using three important covariables, the complete case approach to addressing missing data and the omission of other potentially important explanatory variables may have introduced biases in parameter estimates.The MFP method identified improvements in model fit compared to other commonly employed models that estimate the BMI-mortality relationship, and is a robust method to determine the functional form for BMI. Using the MFP method, we found that the shape of the BMI-mortality curve was different across gender, but consistent with other previous studies. Specifically, the relation was U-shaped for men and J-shaped for women. We also identified important differences in shape and nadir of the BMI-mortality curve and mortality estimates compared to other commonly used models. Understanding the relation between obesity and BMI is important from a policy perspective, for addressing issues such as determining the efficacy of approaches designed to reduce obesity and in communicating with the public about the importance of obesity as a public health issue. Flexible methods, such as those employed in this study, are central in achieving reliability in measures used relevant analyses and are also potentially useful in estimating the relationship between the full spectrum of BMI values and other health outcomes or costs.The authors declare that they have no competing interests.ESW conceived of the study, participated in its design, performed statistical analyses and drafted the manuscript. BCMW, LPG, RAC and DEA participated in the design of the study and helped to draft the manuscript. DRF and SDS participated in the design of the study, helped to draft the manuscript and acquired funding for the project. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/11/175/prepub


While evidence supports efficacy of acupuncture and/or dry needling in treating musculoskeletal pain, it is unclear which needling method is most effective. This study aims to determine the effects of depth of needle penetration on muscle pain.A total of 22 healthy volunteers performed repeated eccentric contractions to induce muscle soreness in their extensor digital muscle. Subjects were assigned randomly to four groups, namely control group, skin group , muscle group  and non-segmental group . Pressure pain threshold and electrical pain threshold of the skin, fascia and muscle were measured at a point 20 mm distal to the maximum tender point on the second day after the exercise.Pressure pain thresholds of skin group  and muscle group  were significantly higher than the control group, whereas the electrical pain threshold at fascia of muscle group  was a significantly higher than control group; however, there was no significant difference between the control and other groups.The present study shows that acupuncture stimulation of muscle increases the PPT and EPT of fascia. The depth of needle penetration is important for the relief of muscle pain. Recent clinical investigations on the myofascial pain syndrome and fibromyalgia focused on the existence of tender point and/or trigger point, with some literature emphasizing the importance of the tender and/or trigger points as diagnostic points -5. MoreoAh-Shi or 'Oh-Yes' for treatments of myofascial pain syndrome and fibromyalgia. Studies have shown that application of acupuncture at these points improves symptoms in these disorders  and 318.1 ) respectively ; however, no significant difference was found among the four groups in the EPT values of the skin and muscle groups  and skin (P = 0.020) groups immediately after treatment, suggesting that acupuncture stimulation of muscle is effective for DOMS.In the present study, two of the 22 participants recruited originally were asked to take part in the study again because the number of participants was not enough for four groups containing six participants each. A statistically significant difference was found only between the acupuncture stimulation of muscle (P < 0.001) between the affected muscle  and the non-affected muscle  on pressure pain thresholds, suggesting that tender point on the affected muscle may be more effective in treatment of muscle pain than the non-affected muscle.Several studies on the efficacy of acupuncture and/or dry needling treatment for pain conditions ,23,24 inFurthermore, the present study demonstrated a difference among the depths on pressure pain thresholds and electrical pain thresholds. As previous studies found that the applied pressure was transmitted to the muscle tissue through the skin and subcutaneous tissue, and activated muscle nociceptors responsible for pain sensation in the muscle ,29,30, tOur results Figure  and 2shoThe present study shows that acupuncture stimulation of muscle increases the PPT and EPT of fascia. The depth of needle penetration is important for the relief of muscle pain.EMG: electromyogram; PPT: pressure pain threshold; EPT: electrical pain threshold; NS: non-segmental; AU: arbitrary units; DOMS: delayed onset muscle soreness; DNICs: diffuse noxious inhibitory controls; SD: standard deviation.The authors declare that they have no competing interests.KI designed the study, performed the acupuncture treatment and wrote the manuscript. YM and HK designed and performed the statistical design and data analysis. All authors read and approved the final version of the manuscript.


Yearly surveys among the undergraduate students in oral and maxillofacial surgery at Karolinska Institutet have conveyed a wish for increased clinical training, and in particular, in surgical removal of mandibular third molars. Due to lack of resources, this kind of clinical supervision has so far not been possible to implement. One possible solution to this problem might be to introduce simulation into the curriculum. The purpose of this study was to investigate undergraduate students' perception of two different simulation methods for practicing clinical reasoning skills and technical skills in oral and maxillofacial surgery.Forty-seven students participating in the oral and maxillofacial surgery course at Karolinska Institutet during their final year were included. Three different oral surgery patient cases were created in a Virtual Patient (VP) Simulation system (Web-SP) and used for training clinical reasoning. A mandibular third molar surgery simulator with tactile feedback, providing hands on training in the bone removal and tooth sectioning in third molar surgery, was also tested. A seminar was performed using the combination of these two simulators where students' perception of the two different simulation methods was assessed by means of a questionnaire.The response rate was 91.5% (43/47). The students were positive to the VP cases, although they rated their possible improvement of clinical reasoning skills as moderate. The students' perception of improved technical skills after training in the mandibular third molar surgery simulator was rated high. The majority of the students agreed that both simulation techniques should be included in the curriculum and strongly agreed that it was a good idea to use the two simulators in concert. The importance of feedback from the senior experts during simulator training was emphasised.The two tested simulation methods were well accepted and most students agreed that the future curriculum would benefit from permanent inclusion of these exercises, especially when used in combination. The results also stress the importance of teaching technical skills and clinical reasoning in concert. Interactive teaching has been shown to improve students' achievements in oral and maxillofacial undergraduate training . Due to http://www.forsslundsystems.se/ that uses a haptic technology which enables the kinaesthetic and tactile sensation of shape, texture and friction of the operating field. Consequently the surgeon in training may receive real-time knowledge about the surgical procedure based on the modalities vision, hearing and touch [In surgery, the introduction of simulators has provided novel possibilities for a student oriented environment to develop practical skills. However, the success of a certain simulator is dependent on its introduction to a well designed curriculum and that its contribution to learning and advantages over traditional teaching has been well assessed . This innd touch .Mandibular third molar surgery, as any kind of surgery, besides demanding practical skills also requires good clinical reasoning skills to make the correct diagnosis and for treatment planning . The use of virtual patients has been suggested to be an important teaching aid for development of such clinical reasoning . The VirThe undergraduate curriculum in oral and maxillofacial surgery for students in their final (5th) year at the Department of dental medicine, Karolinska Institutet, corresponds to three weeks full time studies. Previously the main part of this course basically contained lectures and observational teaching. Besides problems such as economical cut-down, increased number of students, reduction of teacher resources, this old curriculum faced major problems such as making the students passive. Furthermore the unaltered patient-flow caused uneven learning conditions and was very stressful for the teachers and assisting staff. A new curriculum was developed where the bulk of observational education was replaced by interactive seminars, improving the course .A constant desire, apparent from the yearly student surveys, has been practical training in surgical removal of mandibular third molars. Due to lack of resources, this kind of clinical supervision has so far not been possible to implement. Likewise, the Swedish Dental Association has conducted several studies on the graduated dentists' perception of their dental education. A clear, dominating and recurring apprehension was that the amount of practical training in undergraduate oral and maxillofacial surgery training was insufficient .In an attempt to further improve the curriculum, and partly meet the expectations of the students in terms of increased practical moments, simulator aided teaching has been proposed as a way to improve both clinical reasoning skills as well as practical surgery skills. The purpose of this study was to investigate undergraduate students' perception of two different simulation methods for oral and maxillofacial surgery.All undergraduate students (n = 54), participating in the oral and maxillofacial course during their final year of dental education at the Department of dental medicine, Karolinska Institutet, Stockholm, Sweden, were offered to participate in the study. Forty-seven of these students agreed to be included in the study and signed a written informed consent. Two stations with the Forsslund systems third molar surgery simulator as well as five stations with the Web-SP system was set-up. The teaching staff resources consisted of three persons trained in oral and maxillofacial surgery, one assisted at each oral surgery simulator and the third aided the students working with Web-SP. Two technicians were also available to solve any problem or question of technical nature regarding the oral surgery simulator. An ethical approval was obtained from the local ethics committee at the Karolinska University Hospital, Huddinge, prior to on-set of the study.The aim with Web-SP is to mimic the live patient situation, where medical history and data from physical examination is collected by the student, who subsequently diagnose the patient and suggests therapy. Thus, the student is not passively provided with the necessary data but has to acquire it by asking relevant questions, suggest correct physical examinations and laboratory/imaging tests. The system provides an optional built in feed-back at the end of each exercise . In the Two equal sets of a mandibular third molar surgery simulator prototype of the Oral Surgery Simulator  were used in the study. The simulator provides hands on training of bone removal and tooth sectioning in third molar surgery through a haptic devise. The technology of haptic feed-back systems gives a realistic sensation of drilling concerning anatomy, vibration and resistance of the different tissues i.e.alveolar bone, enamel, dentin and pulpal tissue. The simulated procedure had been created from CT scans of an authentic case of a mesioangulated mandibular third molar. The tactile sensation has been fine-tuned by feed-back from trained oral and maxillofacial surgeons testing the simulator.The seminar lasted for 3 hours and was divided in three parts: an oral introduction, exercises in both the Oral Surgery Simulator and in the Web-SP, respectively, followed by a group discussion.In the oral introduction the students were given a short presentation of the Web-SP system, the Oral Surgery Simulator and the aim of the seminar. Thereafter a white-board aided step-by-step description of the practical steps of surgical mandibular third molar removal was given.In the simulation part of the seminar the students rotated between the two different simulation stations as follows:1. The oral surgery simulator Each student participating in the study was given 15 minutes of hands on training in the Oral Surgery Simulator. During the session a teacher trained in oral and maxillofacial surgery was present introducing the student to the task and giving verbal feed-back. Staff, well familiar with the simulator, were standing by, ready to provide technical assistance if needed.The students also had the opportunity to observe a fellow student work in the simulator.2. Web-SP In the exercise with the Web-SP Virtual patient simulation, the students worked independently in pairs with the cases for approximately 60 minutes, during which a teacher was available to answer possible questions.The seminar ended with a group discussion where the three patient cases in Web-SP were examined and possible questions regarding mandibular third molar removal in general were clarified.After the seminar the students were asked to fill in an anonymous questionnaire consisting of different statements regarding the two different simulation techniques. The students were asked to rank their answers according to a 6-graded scale, where 1 meant "totally disagree" and 6 "agree completely". There were three categories of questions or statements: those of demographic and general issues; regarding Web-SP; and finally regarding the oral surgery simulator (Table Filled out questionnaires were received from 43 participants corresponding to a 91.5% (43/47) response rate. Two of these were not complete, resulting in answers from only 41 individuals for questions 10 to 18. The age of the participants ranged from 23 to 45 with a mean value of 26.2 years. The demographic data showed a gender distribution of 29 females and 12 males. One participant did not state sex affiliation. The range of domestic usage of computers and computer games ranged from "totally disagree"  to "agree completely"  with a mean value of 3.9. Previous experience of computer aided education was moderate with a mean score value of 3.5, where 2 individuals stated "totally disagree" and 1 "agree completely".The students reported that they were positive to Web-SP and that it should be included in the future course (mean 4.9), as well as a desire to have more cases to work with in the future , see Figure The ratings of whether the simulator reproduced a third molar surgery procedure in a realistic way, and if the work in the oral surgery simulator felt realistic, were on average 3.9. The students' perception of improved skills and acquisition of new knowledge after the simulator exercise was scored high to an average value of 4.7 and 4.9, respectively. For details see Figure There was no apparent correlation between the attitude that the simulation methods should be included in the future course and gender, computer experience and accustomedness with computer aided teaching.The results of the present study show that the attitude towards the simulator techniques tested, in terms of agreement that the simulator exercises should be included in the future curriculum, was high. This is in agreement with another report showing that dentistry students preferred e-Learning tools to higher-order learning activities . The accThe aim of the Web-SP activities was to improve students learning in therapeutic decisions, diagnostics and judgement of whether a case should be referred or not. These issues were rated slightly positive, but lower than anticipated (reflected in questions 5 through 7) by the students. One explanation for this rather low figure is probably the limited number of available patient cases since the desire to have more cases to work with was given a high score as well as the suggestion of including this activity in the future curriculum. It also seems that the acceptance of Web-SP was dependent on the feed-back given in the teacher aided discussion. This is supported by a previous study on factors influencing dental students' usage of the Web-SP, where students favoured patient cases with feed-back compared to those lacking feed-back . ObjectiA few individuals (n = 3) criticized Web-SP for requiring extensive clicking when working with the patient cases. This was an unexpected view and should perhaps warrant a more thorough introduction of the Virtual Patient system to the students, since it reflects a misunderstanding of the Web-SP exercise. The purpose is not to click on every possible option in the program but to train/practice to find the relevant questions/laboratory tests/x-ray examination for the individual case as in a true clinical situation.Although the perception of realistic reproduction of mandibular third molar surgery in the oral surgery simulator was rated as just above average, the students still perceived the exercise in the simulator fruitful and developing, which indicates that an oral surgery simulator may play an important role in oral and maxillofacial undergraduate training. The importance of feed-back from senior teachers, during the practice in the simulator, was emphasised by the students in the free comments. This warrants for further studies regarding the optimal nature of the concomitant tutoring while working in the simulator.A key issue in successful surgery is the combination of clinical reasoning skills and technical skills. The combination of the oral surgery simulator and Web-SP gives the students opportunity to practice these skills in concert, which is of outmost importance for training discerning clinicians. It is therefore gratifying that most students agreed that these teaching activities should be used on the same teaching occasion, which indicates a judicious approach to surgery. A future improvement of the teaching session could therefore be, besides increasing the number of patient cases, to have the same cases in Web-SP as in the oral surgery simulator, to further emphasise the coupling of these two skills.The two tested simulation methods were well accepted and most students agreed that the future curriculum would benefit from permanent inclusion of these exercises, especially when used in combination. To fulfil the aims of the seminar, to improve clinical reasoning and technical skills, the students need to be exposed to more virtual patient cases. Furthermore, feedback from teachers during the seminar was considered important. Previous experience of computers and computer aided teaching did not seem to affect students' perception of the simulators.The authors declare that they have no competing interests.BL and AR conceived the study, organized and designed the teaching session and contributed with experience of traditional teaching in oral and maxillofacial surgery undergraduate training. UF contributed which experience of Web-SP and was active in the planning and outline of the study design as well as interpretation of obtained data. RS has provided technical support and experience regarding implementation of Web-SP in undergraduate training. ES has provided with knowledge and experience regarding behavioural science and evaluation of simulators with haptic devices. The manuscript was read and approved by all authors.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/11/82/prepub


Molecular typing of the pneumococcus has played a crucial role in understanding the epidemiology of the organism. However, most of what is known about molecular epidemiology of the pneumococcus pertains to the developed world. The brunt of pneumococcal infections is borne by sub-Saharan African countries, which makes epidemiological monitoring of the pneumococcus essential in this region of the world. This review paper focuses on molecular typing of the pneumococcus and what is known about epidemiology of the organism in sub-Saharan Africa based on the various typing methods. Several molecular typing methods are available for typing the pneumococcus and the major ones include multilocus sequence typing (MLST), multilocus enzyme electrophoresis (MLEE), serotyping and DNA fingerprinting methods such as pulsed field gel electrophoresis (PFGE) and amplified fragment length polymorphism (AFLP). Currently, MLST is the most suitable method for typing the pneumococcus. The pneumococcal population structure in sub-Saharan Africa appears to be quite different from that of the developed world, and pneumococcal serotype 1 related to the ST 618 clone and clones of the ST 217 clonal complex are responsible for outbreaks in sub-Saharan Africa. Streptococcus pneumoniae is part of the normal bacterial flora of the upper respiratory tract, but is also associated with severe invasive diseases, including meningitis, pneumonia, and septicaemia as well as non-invasive diseases such as otitis media . Generally, PCR-based serotyping has been shown to be reliable and accurate, and can often be used directly on clinical specimen. However, a key limitation of current PCR-based typing methods is the inability to distinguish between many serotypes of the same serogroup , Penicillin Binding Protein (PBP) Fingerprinting, BOX-PCR, Restriction Fragment Length Polymorphism (RFLP), and Amplified Fragment Length Polymorphism (AFLP). PFGE, a genotypic method for the evaluation of total chromosomal DNA, had been regarded as the “gold standard” for typing micro-organisms  explores the different electrophoretic mobilities of a large number of cellular enzymes encoded by house-keeping genes  of a strain. So far, over 8000 S. pneumoniae STs from a wide variety of geographical locations have been described in the S. pneumoniae MLST database http://speumoniae.mlst.net/. However, there is little MLST data on African isolates. The major advantage of MLST is that sequence data is unambiguous and the STs of isolates can be compared to those in a central database via the Internet, in contrast to other typing methods which involve comparing DNA fragment sizes on gels. Thus the portability of MLST means it is highly useful in monitoring the population structure of a given pathogen. Due to the sequence conservation in housekeeping genes, sometimes MLST has limited ability to differentiate bacterial strains, which limits its use in the epidemiological investigation of bacteria of a more clonal population structure. For a naturally transformable organism like S. pneumoniae, MLST is a valuable typing tool, as the high rates of recombination result in a high rate of genetic diversification of pneumococcal populations  shares the same principle with MLEE but assigns alleles to housekeeping genes directly by sequencing of those genes, and thus the level of resolution is much better than MLEE Spratt, . For eacOver the years, the various molecular typing schemes of pneumococcus have greatly facilitated our understanding of the molecular epidemiology of the organism. Serotyping data indicates that only a few of the discovered 94 serotypes are responsible for the vast majority of pneumococcal disease, and these serotypes may vary from one geographical region to another . On the other hand, serotypes such as 9V and 14 are associated with a wide variety of clonal types, which may also be seen with some other serotypes (http://spneumoniae.mlst.net/). The Pneumococcal Epidemiology Network (PMEN) provides surveillance on epidemiologically significant clones and currently, 43 such clones are known (http://www.sph.emory.edu/PMEN/index.html).Genotyping of pneumococci has provided further insights into the molecular epidemiology of pneumococcal serotypes. One of such insights is that isolates of certain serotypes such as 1 and 7F are associated with a limited number of clones, and these clones are hardly observed with other serotypes . Twenty-seven different serotypes and 72 different STs were identified, and there was no particular association of clones with specific presentation of invasive pneumococcal disease. For a given serotype, the genotype distribution varied considerably between vaccinated and un-vaccinated children. However, the population structure of serotype 1 obtained from vaccinated and non-vaccinated children were the same and comprised mainly ST 618. In The Gambia, an outbreak of pneumococcal pneumonia and septicaemia caused by serotype 1 occurred between 1997 and 2002  were found to be serotype 1. MLST was carried out on only three of these serotype 1 isolates, and two were found to be ST 618 with the other isolate being a novel ST, and a single locus variant of ST 618. An outbreak of pneumococcal meningitis similar to the outbreak in Burkina Faso also occurred in Ghana during the period of 2002–2003 , whereas in sub-Saharan Africa, the infections seem to be associated with STs 458 and 700 (Adetifa et al., Pneumococcal serotype 1 is also an important cause of invasive disease and epidemics in the developed world (Brueggemann and Spratt, Little is known about molecular epidemiology of the pneumococcus in sub-Saharan Africa though majority of pneumococcal infections occur in this setting. Lack of molecular typing data of the pneumococcus in sub-Saharan Africa is mainly due to lack of facilities as well as technical expertise required for the organism. Thus capacity building in the form of training personnel on the pneumococcus, and also providing adequate research funding constitute a major part of the solution to this problem. Currently, there is an urgent need for molecular epidemiology data on the pneumococcus in sub-Saharan Africa given the expected massive pneumococcal vaccination in the region (PneumoADIP, Few studies have employed molecular methods to investigate the pneumococcus in sub-Saharan Africa. Consequently, little is known about molecular epidemiology of the pneumococcus in sub-Saharan Africa, though majority of pneumococcal infections occur in this region. The pneumococcal population in sub-Saharan Africa appears to be quite divergent from what is known in the developed world, and pneumococcal serotype 1 related to the ST 618 clone and clones of the ST 217 clonal complex are responsible for outbreaks in sub-Saharan Africa. There is an urgent need for molecular epidemiology data on the pneumococcus in sub-Saharan Africa to help monitor evolutionary changes in the pneumococcal population following introduction of pneumococcal vaccines in the sub region.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Objective: The goal of this case report is to characterize injury patterns typical for chainsaw injuries to the face. We describe our approach to the soft tissue and skeletal injury patterns seen in these injuries. Methods: We present a case report of a traumatic chainsaw injury to the face. Results: A literature review of the typical injury patterns seen in chainsaw injuries to the face is discussed. Fractures to the bony orbit are on of the most common findings. Traumatic orbital fractures are often associated with other facial fractures, including those of the maxillary sinus and naso-orbital-ethmoid (NOE) region. There is a reported 47% incidence of lacrimal obstruction after NOE fractures, most caused by bone malposition or damage to the lacrimal sac or duct. Misdiagnosis of this injury pattern can lead to chronic patient morbidity. Conclusion: We present a case of traumatic orbital fracture with subsequent bony intrusion into the orbit, necessitating urgent exploration. The compound soft tissue and skeletal injury in this patient is typical for patients with associated lacrimal injury. Awareness of the injury patterns and treatment algorithms of these cases allows for appropriate assessment and intervention. Although epidemiological data have suggested a lower prevalence of maxillofacial injury compared to other body parts, the incidence of these injuries has increased over recent years.1-Fractures of the orbit are far more common and often involve the orbital floor and/or rim. These fractures can occur internally in isolation or in conjunction with fractures of the orbital rim. Associated subjective diplopia can result from muscle contusion, incarceration, or displacement of the globe 1 cm beyond its normal anatomical position, resulting in diplopia. Traumatic orbital fractures are often associated with other facial fractures, including those of the maxillary sinus and naso-orbital-ethmoid (NOE) region. There is a reported 47% incidence of lacrimal obstruction after NOE fractures, most caused by bone malposition or damage to the lacrimal sac or duct.6The patient is a 41-year-old man who presented to the emergency department with a 12-cm vertically oriented left facial laceration resulting from a chainsaw  Our patient, notably, was found to have a bony foreign body in the orbit with significant displacement of the globe and this prompted emergent exploration and reduction. The pattern of NOE fracture and soft tissue injury also raised a high suspicion of associated lacrimal system damage.,9The nasolacrimal duct originates a few millimeters posterior to the medial canthal tendon and courses from the lacrimal sac inferiorly and posteriorly before becoming enclosed in the bony canal and draining through the valve of Hasner into the inferior meatus of the nose. Loss of patency disrupts the normal tear drainage mechanism and can lead to multiple complications, including visual impairment.10In the case of irreparable injury due to extensive tissue loss, as in the present case, eventual conjunctivodacryocystorhinostomy with the insertion of a Jones tube may be required in order to avoid the long-term sequelae of lacrimal dysfunction, including recurrent dacryocystitis, visual impairment, and impaired quality of life. (A8) Complications, however, often occur following conjunctivodacryocystorhinostomy, requiring tube replacement, repositioning of the tube, and cleaning over an indefinite period of time.Although historically uncommon, maxillofacial injuries from chainsaw have been reported with increasing frequency. Early intervention with operative debridement of devitalized soft tissue and reduction of bony fractures remain the mainstay of treatment. In this case, our patient had a displaced, entrapped globe from bony distortion of the orbit warranting urgent decompression and fracture reduction. With such injuries in the setting of NOE fractures, we believe that clinicians should have a high suspicion for damage to the lacrimal system although the initial management remains controversial.


Foot problems associated with Systemic Sclerosis (SSc)/Scleroderma have been reported to be both common and disabling. There are only limited data describing specifically, the mechanical changes occurring in the foot in SSc. A pilot project conducted in preparation for this trial confirmed the previous reports of foot related impairment and reduced foot function in people with SSc and demonstrated a link to mechanical etiologies. To-date there have been no formal studies of interventions directed at the foot problems experienced by people with Systemic Sclerosis. The primary aim of this trial is to evaluate whether foot pain and foot-related health status in people with Systemic Sclerosis can be improved through the provision of a simple pressure-relieving insole.The proposed trial is a pragmatic, multicenter, randomised controlled clinical trial following a completed pilot study. In four participating centres, 140 consenting patients with SSc and plantar foot pain will be randomised to receive either a commercially available pressure relieving and thermally insulating insole, or a sham insole with no cushioning or thermal properties. The primary end point is a reduction in pain measured using the Foot Function Index Pain subscale, 12 weeks after the start of intervention. Participants will complete the primary outcome measure  prior to randomisation and at 12 weeks post randomisation. Secondary outcomes include participant reported pain and disability as derived from the Manchester Foot Pain and Disability Questionnaire and plantar pressures with and without the insoles in situ.This trial protocol proposes a rigorous and potentially significant evaluation of a simple and readily provided therapeutic approach which, if effective, could be of a great benefit for this group of patients.ISRCTN02824122ISRCTN:  Systemic sclerosis (SSc)/Scleroderma is a connective tissue disease characterised by excessive collagen production resulting in microvascular and macrovascular damage, fibrosis of the skin and internal organs -3. The pFoot problems associated with SSc include: Raynaud's phenomenon, which sometimes can progress to tissue loss/ulceration, subcutaneous calcinosis, skin thickening, callus formation, tendonopathy, foot ulcers, joint space narrowing, bone demineralization, joint subluxation, joint margin erosions and degenerative changes -9. ArthrThere are parallels between some of the foot symptoms seen in SSc and those in people with rheumatoid arthritis (RA). In RA, inflammatory arthropathy leads to joint damage, which in turn causes increased plantar pressures and altered pressure distribution. Plantar pressure has been reported to be higher under metatarsophalangeal (MTP) joints that are eroded and where fibro-fatty padding displacement has occurred, resulting in values exceeding normal limits ,11. PlanAbnormal plantar foot pressures are widely noted as a risk factor for ulceration in people with diabetes and this additive relationship has also been established in diseases closer in nature to SSc, such as RA ,17. The In related diseases, high plantar pressures and prolonged duration of loading are associated with pain during walking ,18. HoweThe presence of both abnormal plantar pressures and plantar foot pain in patients with SSc has been confirmed in a pilot study conducted by the investigating team.A pilot project  investigPatients with SSc reported worse foot pain on a 100 mm visual analogue pain scale (VAPS), SSc mean 36.8 mm (SD = 25.7) compared with a mean of 2.2 mm (SD = 4) in healthy controls. Pressure data demonstrated intense localisation of plantar pressures to discrete areas in close proximity to the MTP joints.The SSc group had markedly higher forefoot pressures across a range of pressure variables when compared with the control group. Peak plantar pressures and pressure time integrals were particularly high over the first MTP joint.To address the possible concern that people with SSc have significant systemic complications that may be considered to overwhelm the impact of relatively minor foot complaints, patients were asked explicitly whether reducing foot pain would improve their quality of life. Thirteen out of fourteen respondents indicated explicitly that they would derive benefit from interventions intended to reduce their foot symptoms.In conclusion, the literature, the pilot study results and the patients themselves indicate that there is a clear need for studies investigating the effect of SSc on plantar pressures and plantar foot pain. Furthermore, if inexpensive and simple interventions known to work in other diseases offer an effective treatment option, then evaluation of these should be a priority for the rheumatology community.To compare foot pain in participants using a commercially available pressure-relieving insole, to those using the sham insole (control), 12 weeks after randomisation.To determine the impact of insoles on patient-reported foot disability and functionTo assess the impact of the insoles on scleroderma health statusTo explore the relationship between pain, and the distribution and magnitude of plantar pressures (Leeds site only)To provide further validation data on the newly developed SSc Quality of Life ScalePressure and pain In Systemic Sclerosis/SCleroderma (PISCES) is a pragmatic, phase III, multicentre, randomised, controlled trial.Recruitment of the 140 participants will occur over 20 months to allow completion of the twelve-week follow-up within the 24-month time frame of the clinical phase of the study. All potentially suitable patients attending the relevant departments' outpatient's clinics will be approached and provided with a verbal explanation of the trial and a copy of the ethically approved patient information sheet. Arrangements will be made prior to the commencement of the trial to stream potentially suitable patients into early trial clinics. Alternatively, patients identified by other means such as waiting lists or upon review of case records, will receive a letter and the ethically approved patient information sheet from their consultant rheumatologist, which will provide comprehensive information and invite them to participate in the study. Those who express an interest to participate will be invited to contact their local research team to make an appointment to discuss the trial further.Informed written consent will be obtained from the patients.Each participant will undergo a pre-trial eligibility screen and baseline assessment prior to randomisation and insole allocation. Randomisation will take place after baseline measures have been recorded to eliminate selection biasThose participants who meet the eligibility criteria will be randomly allocated to receive one of two interventions. The participants will be randomised on a 1:1 basis to receive either the active intervention (simple pressure-relieving insole) or the control (sham insole). Stratified block randomisation will be used to ensure intervention groups are well-balanced for gender and centre.Randomisation will be performed centrally using a 24-h, automated randomisation system based at the Leeds Clinical Trials Research Unit,Participants will wear the insoles for 12 weeks and then return for a 12-week follow-up visit prior to exiting the trial. Mid-trial telephone follow-ups will be performed at 6 weeks post randomisation to identify whether the participant has any problems with tolerability, to establish compliance with the intervention and encourage completion of the patient diary. During the 12-week follow-up visit, participants will be asked to complete the same questionnaires as at baseline, supervised by a member of authorised trial staff blinded to insole allocation, and will be required to return their 12-week diary. Participants unable to attend at precisely 12-weeks will be eligible for follow-up between week 11 and week 14. For those participants who cannot attend during this window, questionnaires will be posted to the participants' home address by the participating site. Following the 12-week assessment visit the participants will exit the trial, and any continuation of care will be followed up by the relevant NHS department at the participating centre, as per local policy. A clinical decision as to the appropriateness of providing the participants with the alternative pair of insoles upon trial exit will be made on an individual basis.In addition, the participants from the Leeds centre will be offered further assessment of bare foot plantar pressures and in-shoe plantar pressures at baseline. Additional written informed consent will be obtained prior to assessment.The trial design is summarized in the trial flow diagram Figure A total of 140 participants with SSc will be recruited from four centres in the UK which specialise in treatment and study of SSc. Sixty participants will be recruited by the Leeds Teaching Hospitals NHS Trust, Leeds; 25 participants from the Salford Royal Hospitals NHS Trust, Manchester; 40 participants from the Royal Free Hampstead NHS Trust, London; and 15 participants from the Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle.Potential participants 18 years of age or over will be screened for enrollment. To be included in the trial, participants must meet the following eligibility criteria:1. Consultant diagnosis of SSc or a positive diagnosis of SSc (ARA/ACR 1980 criteria ) definedMajor criterion:• Proximal diffuse  sclerosis Minor criteria:• Sclerodactyly (only fingers and/or toes),• Digital pitting scars or loss of substance of the digital finger pads (pulp loss), and/or• Bilateral basilar pulmonary fibrosis.(The patient should fulfill the major criterion or two of the three minor criteria unless a consultant diagnosis has been made).2. Patient-reported plantar foot pain.3. Willing and able to comply with the intervention schedule for 12 weeks.4. Able to provide written informed consent to participate in the study.Patients with the following characteristics are considered ineligible for this study:1. Disease overlap syndromes (overlap with Inflammatory Arthritis (IA)/RA)2. History of any lower limb bone or joint orthopaedic surgery within the past 12 months3. Diagnosis of diabetes4. Loss of protective sensation on the plantar surface of the foot5. Current use of prescribed or over-the-counter contoured or made-to-measure insoles/orthoses6. History of any clinically significant disease or major disorder that in the opinion of the treating clinician or Chief Investigator would not be conducive to trial participationDetails of all eligible potential participants will be recorded, along with detailed reporting of inclusion/exclusion to guard against recruitment bias.The active intervention to be tested is a commercially available pressure relieving insole . The insoles are composed of 4 mm thick polyurethane cushioning and a 2 mm Plastazote layer, which provides cushioning and thermal insulation. While a standard insole is being used for consistency, this is a relatively generic product and the insole being evaluated would represent a variety of similar products available on the open market.The sham intervention used in the control arm will consist of a 1 mm thick regenerated leather-board base with a thin (< 1 mm) plastazote cover. The sham intervention will provide a physical insole similar in appearance to the active intervention insole and will look identical once placed in the participants' shoes, but will not offer cushioning or alter the plantar foot pressures. Minimal to none thermal insulating properties are expected, given the thinnest possible plastazote layer achieved in manufacture.The randomised insole (active or sham) will be fitted into the participants' shoes by the attending clinicians. To standardise the delivery of the intervention (i.e. fitting the insoles) all of the practitioners involved in its delivery will undergo a standardised training programme prior to the start of recruitment.Participants will be advised to wear the insoles as much as possible during the day for the next 12 weeks. Participants will be provided with a diary providing clear written information regarding the use of, and care of their insoles, including what to do if they become lost or damaged. To monitor intervention compliance and to identify other confounders (e.g. pain and medication), the participants will also be asked to document compliance with insole use in the diary. The diary will also be used to detail the intake of medication specifically for foot painAlthough the active and sham insoles will look identical when placed in the shoes, it is recognised that protection of blinding may not be possible on all occasions. The following controls will be employed to maintain the blinding of the trial as far as is reasonably practicable:The sham insole (control) will be similar in appearance to the active insole, and will look identical in appearance once placed in the participants' shoes. The key staff at site involved with the trial will remain blinded to the intervention allocation during the study. This will be achieved by having different teams of therapists responsible for randomising participants to those responsible for administering the assessment questionnaires.The majority of outcome measures are patient-reported and should not be influenced by clinician knowledge of the insole allocation. The trial participants will be provided with minimal opportunity to meet and discuss interventions with other participants.The primary outcome measure is a reduction in foot pain as measured by the pain subscale of the Foot Function Index (FFI) . The FFISecondary outcome measures will include participant reported pain and disability as reported via the Manchester Foot Pain and Disability Questionnaire , sclerodObjective gait laboratory data will be obtained at the lead centre in Leeds. Plantar foot pressures will be recorded using the Novel EMED-ST  pressure platform at baseline to obtain high-resolution measures of pressure and force distributions. Pressures at the shoe/insole interface will also be obtained separately, using the Novel Pedar in-shoe system. The following measures will be reported: maximum mean pressure at forefront of the foot  (kPa), maximum mean pressure at heel of the foot (kPa), contact area at forefront of the foot (cm2), contact area at heel of the foot (cm2), gait velocity (metres per second), cadence (steps per minute) and step/stride length (cm).Foot Function Index Pain Subscale, S-HAQ, Manchester Foot Pain and Disability Score and Scleroderma QoL will be completed by participants as part of their baseline and 12 week follow-up assessments.A Foot Pain Map will be completed at baseline to identify the specific area of pain.The modified Rodnan Skin Score (mRSS) will be calculated for each participant as a measure of disease severity at baseline. The mRSS is a validated measure for dermal skin thickness used universally in rheumatology for this purpose ,28. The Participant diaries, instructions on how to complete them and instructions for ongoing use of insoles will be given to the participants prior to them leaving the clinic.Exploratory measures of foot plantar pressures will be carried out at baseline  on consenting participants at the Leeds centre only. The plantar foot pressure measurements are undertaken in two stages:Stage 1: Bare foot plantar pressures (measured by EMED-ST pressure platform (hi-res))Three representative steps, for each foot, are recorded from the participant walking barefoot over the platform using a common 'two-step start' protocol. The EMED platform will allow analysis of a range of pressure, force, area and temporal variables at high resolution (4 sensors/cm2). This will enable a detailed model of the interaction of the participants' foot with the supporting surface to be developed which will inform our characterisation of the baseline effects of the disease. It is not possible however to investigate the effect of the therapy using the platform system, thus requiring a second stage of pressure study.Stage 2: In-shoe plantar pressures measured by the Pedar System .A flexible pressure-measuring insole is inserted into the footwear and the participant undertakes two straight line walks of approximately eight metres, generating approximately 20 representative steps. The trial intervention (active or sham insole) on a separate measure is then added to the footwear, the pressure measuring insole is added over the top, and the process repeated. Randomisation on sequence of measures (with/without insole first) will be employed via a computer generated randomisation.The in-shoe pressure measurements are derived using a capacitance based matrix of 99 sensors per insole which again generate a range of force, pressure, area and temporal variables characterising the loading of the plantar surface of the foot. Measures are derived automatically within software for pre-determined areas of the foot. After collection but with the participant still present, data are evaluated graphically within the software to ensure the integrity of the measures. Once checked the quantitative data is output to a CSV delimited spreadsheet file for subsequent processing.The trial is powered to detect change in the primary outcome, the Foot Function Index pain subscale. The minimal important difference for FFI pain subscale has been reported to be 12 mm . We haveTo detect a difference between groups of 15 mm, with a standard deviation of the response variable = 25.7 ; alpha = 0.05 and power set at 90%, 63 participants per group are needed. To allow for a 10% drop out rate, a total of 140 participants will be randomised.The primary outcome of the change in VAS FFI pain subscale between baseline and 12 weeks will be compared between intervention groups using Analysis of Covariance adjusting for baseline pain score, centre and gender. Model assumptions will be checked and if found to be violated data will be transformed prior to analysis or a non-parametric analysis method will be used. Summary statistics of the foot pain score at baseline and week 12 will be presented for the overall pain component as well as each individual pain question. Similar methods will be used for other study questionnaires.All analyses will be according to intention to treat; no interim analyses are planned due to the short follow-up period and the safe nature of the intervention.The project has been driven from the outset by unmet participant need. First identified as a problem area by participants in the Leeds Connective Tissue Disease Outpatients clinic, the trial was piloted formally with full consultation with people with SSc. While the design of the project has been led methodologically by the CTRU, patient consultation has been undertaken throughout the design phase, and formal patient representation will be undertaken through the trial steering committee.Although the primary outcome is a patient-reported outcome, the two types of insole (active and sham) are as similar as possible in appearance to conceal the allocation from both patient and clinician and to avoid bias and attrition as far as possible. Randomisation will be performed centrally at the CTRU thus ensuring allocation concealment and minimising any imbalance between the two trial arms.The trial evaluates a simple intervention carrying minimal risk to participants. There are no invasive tests and no exposure to ionising radiation or other environmental hazards. To maximise participant protection the protocol includes a rescue provision for participants who are unable to tolerate their allocated intervention, or for whom the intervention causes other physical problems.The 12 weeks follow-up in this trial will allow time for the period of adaptation to the therapy and for the evaluation of its effects. Follow-up in previous studies investigating the effects of orthotic therapy on foot pain varies, but it has been shown that significant decreases in pain can be achieved after 3 months with the therapy . Longer This trial will have immediate and direct health benefits for patients with SSc, extending the knowledge of practitioners to effectively manage foot pain in people with SSc. The trial will establish definitively the burden of foot problems in people with SSc and will determine the effectiveness of a simple and inexpensive insole in reducing plantar pressures and ameliorating symptoms.Ethical and governance approval for this trial has been obtained from the Leeds West Ethics Committee (ref 10/H1307/83) and the Leeds Teaching Hospitals NHS Trust respectively. The trial progress is monitored by an independent Trial Steering Committee.PISCES: Pressure and pain In Systemic Sclerosis/Scleroderma; SSc: Systemic sclerosis; RA: Rheumatoid arthritis; MTP: Metatarsophalangeal; VAPS: Visual analogue pain scale; ARA: American rheumatology association; ACR: American college of rheumatology; NHS: National health service; IA: Inflammatory arthritis; FFI: Foot function index; VAS: Visual analogue scales; S-HAQ: Scleroderma health assessment questionnaire; QoL: Quality of life; mRSS: modified Rodnan Skin Score; CTRU: Clinical trials research unit.The authors declare that they have no competing interests.All authors conceived of the trial and participated in the design. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/11/prepub


Isolations of sylvatic dengue-2 virus from mosquitoes, humans and non-human primates in Senegal show synchronized multi-annual dynamics over the past 50 years. Host demography has been shown to directly affect the period between epidemics in other pathogen systems, therefore, one might expect unsynchronized multi-annual cycles occurring in hosts with dramatically different birth rates and life spans. However, in Senegal, we observe a single synchronized eight-year cycle across all vector species, suggesting synchronized dynamics in all vertebrate hosts. In the current study, we aim to explore two specific hypotheses: 1) primates with different demographics will experience outbreaks of dengue at different periodicities when observed as isolated systems, and that coupling of these subsystems through mosquito biting will act to synchronize incidence; and 2) the eight-year periodicity of isolations observed across multiple primate species is the result of long-term cycling in population immunity in the host populations. To test these hypotheses, we develop a multi-host, multi-vector Susceptible, Infected, Removed (SIR) model to explore the effects of coupling multiple host-vector systems of dengue virus transmission through cross-species biting rates. We find that under small amounts of coupling, incidence in the host species synchronize. Long-period multi-annual dynamics are observed only when prevalence in troughs reaches vanishingly small levels  is approximately eight years, much longer than the one or two year period observed in human endemic settings . In this paper we develop a multi-host, multi-vector differential equation model to test hypotheses that are potentially consistent with these observations. We find that coupling of separate primate-mosquito pairs through mosquito biting induces synchrony that is robust over a wide range of parameters. We also find that the eight year cycle is not robust to the inclusion of a constant introduction of infection, but is to a stochastic rate of introduction, and thus may be due to cycling of immunity among primates with long-period stochastic introductions. An accurate and thorough understanding of the sylvatic cycle of dengue may allow prediction of epidemics and lessen its impact on humans living in surrounding areas. This knowledge is especially important given the potential for these primate species to act as reservoirs for dengue in post-vaccination scenarios. Aedes and other mosquitoes in the forest canopy (the sylvatic cycle) and transmission among humans primarily by Aedes aegypti in rural villages and urban communities (the human cycle) Dengue virus occurs in two distinct transmission cycles: transmission among non-human primates  by Routine surveillance for multiple mosquito-borne viruses has been conducted in southeast Senegal for over 50 years by the Institut Pasteur. Surveillance is performed by capturing mosquitoes via-human landing collection in the gallery forest as well as periodic and opportunistic capture of primates . The datHost population demographics are known to play important roles in the dynamics of many infectious diseases In the current study, we aim to explore two specific hypotheses: 1) primates with different demographics (birth rates) will experience outbreaks of dengue at different periodicities, when observed as isolated systems, and that coupling of these subsystems through mosquito biting will act to synchronize incidence; and 2) the eight-year periodicity of dengue incidence observed across multiple primate species is the result of long-term cycling in population immunity in the host populations. We employ a Susceptible, Infected, Removed (SIR) model to examine the dynamics of dengue transmission in a hypothetical system of coupled non-human primate populations, each with its own mosquito vector. We focus on two features of the dynamics: the period of oscillations in incidence and the correlation of incidence in the multiple host species. To our knowledge, this is the first model of sylvatic dengue and the first to model transmission of dengue among multiple hosts and vectors. This work is exploratory and aimed at characterizing the dynamics of sylvatic dengue in Senegal over a broad range of parameterizations to begin to understand the basic behavior these systems can show and which broad classes of models are consistent with the observed data.Our deterministic SIR model extends a framework presented in Keeling and Rohani (2008) In this paper, we focus briefly on the one-vector  and the primate species experiencing the lower number of bites is off the diagonal . These terms are used for notational convenience as For each primate-mosquito subsystem, we assume that each primate has a vector species that is source of the largest number of bites that could transmit dengue . We organize the biting matrix such that the biting rate of the primate species experiencing the largest number of bites is on the diagonal , the patas monkey (Erythrocebus patas) and the baboon (Papio papio), which have life-spans of 11, 20 years and 40 years, respectively We vary birth rates in both the single and multi-host/vector systems to determine the effect on the periodicity of dengue prevalence. In the multi-host system, we consider a larger primate with a birth rate of 1/60 years and a smaller primate with a birth rate of 1/15 years. Three primate species from which dengue has detected in Senegal are the African green monkey . It is unclear whether there are strong preferences of the vector for particular hosts, or more likely, vectors feed on available hosts without a preference. The latter may still show large disparities in host biting due to spatial separation of vectors and hosts into particular habitat. Our model formulation can represent coupling of two distinct meta-populations of a single species or Aedes feeding on multiple primate species. Here, the off-diagonal biting rates, would represent the rate at which these groups intermix. We explore a broad range of coupling rates.For the multi-host, multi-vector system, we examine two interacting systems  sylvatic strains Ae. aegypti larva from dengue–endemic areas range from 0.259/1000 in Rangoon Ae. aegypti , we find long-period cycles only when the numbers of small primates are higher than the numbers of large primates. In this situation, the value of Even though these long-period regions are found over a fairly large and realistic range of parameters . periods  and 3. W periods , panel CAs presented in the Isolation of sylvatic dengue strains from humans in Senegal demonstrates cross-species dengue transmission from non-human primates to humans This is the first effort that we know of to characterize the dynamics of transmission models of dengue that incorporate multiple hosts and vectors. We found that in our coupled systems the species with the highest birth rate drove the epidemic dynamics in regions where its value of  primate . We founIt is not entirely surprising that when we include a constant introduction of infectious individuals, multi-annual periodicities disappear. Including a constant rate of introduction is analogous to coupling the current primate-mosquito systems with a primate species with low amplitude, annual dengue outbreaks. Similar disruption of long period cycles has been demonstrated in deterministic models when populations with internal transmission are coupled to external infectious populations via mass action or immigration The observed dynamics may reflect a bias in the surveillance techniques used to gather data that happen to undersample smaller outbreaks of dengue or be due to secular changes in collection methods over time. However, these hypotheses are not completely supported by the relative abundance of yellow fever and chikungunya isolates collected over the same time period and harvested from the same mosquitoes, and there is no evidence of significant secular changes in collection methods This study makes qualitative predictions and generates empirically-testable hypotheses about the fundamental role of large and small primates in the sylvatic cycle of dengue virus in Senegal. It makes predictions, robust to large perturbations in parameters, that the coupling of primate-mosquito systems causes synchrony in outbreaks, and demonstrates that long period dynamics may be explained by cycling in immunity with stochastic introductions. An accurate and thorough understanding of the sylvatic cycle of dengue, including the roles of the various primate species in transmission, may allow prediction of epidemics and lessen the impact on humans living in rural and urban areas. Knowledge of the sylvatic cycle is especially important given evidence of recent introductions of sylvatic dengue into human populations and the potential these primate species have as reservoirs for dengue in post-vaccination scenarios. The current study is a step forward in the understanding of the determinants of sylvatic dengue transmission dynamics.Supporting Information S1Supplemental information. Supplemental Information includes: Model equations, analytical derivation of (PDF)Click here for additional data file.


Luprops tristis Fabricius (Coleoptera: Tenebrionidae) following the short spell of summer rains during April, and their extended state of dormancy is a regular event in rubber plantation habitats in south-western India. Strong smelling secretions of the beetle cause blisters on skin of human beings. Such secretions appear defensive because they appear to facilitate their avoidance by other predatory organisms. Defensive glands in the larvae and adults of L. tristis are described, as well as the mode of eversion of the glands. The glands in larvae consist of two pairs of noneversible glands in a conical depression on the 2nd and 3rd sternites, whereas in adults only one pair occurs between 7th and 8th sternal segments. These glands may be a major reason for avoidance of larvae and adults by their natural enemies and their very high numbers in the litter of rubber plantations.Invasion by large populations of the litter-dwelling darkling beetle  Luprops tristis Fabricius 1801 (Coleoptera: Tenebrionidae) , of between 0.5 and 4 million/building immediately after summer rains is a regular event near and within rubber plantation tracts in the western slopes of South-Western Ghats. The continued presence of these nocturnally active beetles inside living areas is a nuisance. Although, these beetles neither sting nor bite, when disturbed by hand-picking them from walls or when they are squashed, they release an irritating, strong-smelling secretion that causes blisters to humans. Observations of L. tristis revealed neither any vertebrate nor invertebrate predators prevalent in rubber litter floor or in the buildings fed on L. tristis . It has been suggested by Sabu et al.  mixture and they were mounted on glass slides in Canada balsam.http://www.labomed.in) with the ventral surface of the insect facing up and keeping the posterior end away from the observer. When pressed, usually both larvae and adults discharged secretions and on pressing with modest pressure, glands were extruded in adults alone. Care was taken to immobilize the hind legs of adults with forceps, to avoid rupturing the gland reservoirs as the release of the oily secretion renders further observations difficult. Line drawings of the adult and larval gland were reconstructed from digital images.Discharge of gland secretions was observed by gently pressing the abdomen of live larvae and adults. The adult or larva was held between the left thumb and index finger, placed on the stage of a stereo zoom microscope , strongly wrinkled conical pouches that open independently; these glands occur parallel to the long axis of the body , 2a. GlaIn the larvae, defensive glands consist of a pair of pouches placed in a conical depression on the second and third sternites . Both paLuprops deviates from the typical Lagriine type. The present study shows that the gland is more of Tenebrio type with a pair of conical reservoirs, opening to a common area of discharge and are devoid of exit ducts.Classifying the adult tenebrionid defensive glands, Tschinkel and Doyen  indicate