The mechanism of hearing loss (HL) in Paget's disease of bone was investigated. The present study was a systematic, prospective, controlled set of clinical investigations to test the hypothesis that there is a general underlying mechanism of HL in Paget's disease of bone and to gain additional insights into the auditory and otologic dynamics of this disease. Specific questions were 1) whether the mechanism is cochlear or retrocochlear and 2) whether the bone mineral density of the cochlear capsule is related to hearing levels.Several double-blinded, cross-sectional, prospective, correlational studies were conducted in a population of elderly human subjects with skull involvement with Paget's disease versus a control population of elderly subjects free of Paget's disease. Demographic and clinical data were recorded. Longitudinal observations were made in subjects under treatment.Subjects were recruited from a Paget's disease clinic. Pure-tone auditory thresholds, word recognition, and auditory brainstem responses (ABRs) were recorded. The dimensions of the internal auditory canals were measured using computed tomographic (CT) images and digital image analysis. The precision, accuracy, and temporal stability of methods to measure the bone mineral density of the cochlear capsule and an adjacent area of nonotic capsule bone were validated and applied. Correlations were sought between hearing levels and cochlear capsule bone mineral density.P < .001. The regressions were consistent throughout the ranges of hearing level. There were no significant correlations between cochlear capsule mean density and hearing level in the volunteer subjects.ABRs were recorded in 64 ears with radiographically confirmed Paget's disease involving the skull. Responses were absent in eight ears, all of which had elevated high pure-tone thresholds. ABRs were interpreted as normal in 56 ears; none were abnormal. The mid-length diameter and minimum diameter of the internal auditory canal of 68 temporal bones from subjects with Paget's disease were found to have no statistically significant relationship to hearing thresholds. The Pearson product-moment correlation coefficients (age- and sex-adjusted) in the group with Paget's disease involving the temporal bone were −0.63 for left ears and −0.73 for right ears for high-frequency air conduction pure-tone thresholds  versus cochlear capsule density. Correlation coefficients (age- and sex-adjusted) between cochlear capsule density and air-bone gap (mean at 0.5 and 1 kHz) for the affected group were −0.67 for left ears and −0.63 for right ears. All correlations between hearing thresholds and cochlear capsule density in pagetic subjects were significant at The evidence supports the existence of a general, underlying, cochlear mechanism of pagetic HL that is closely related to loss of bone mineral density in the cochlear capsule. This mechanism accounts well for both the high-frequency sensorineural HL and the air-bone gap. Early identification, radiographic diagnosis of temporal bone involvement, and vigorous treatment with third-generation bisphosponates are important to limit the development and progression of pagetic HL. Its etiology is unknown. There is evidence of the involvement of a paramyxovirus Hearing loss (HL) is a prominent feature of Paget's disease of bone when the skull is involved. Because of the lack of an animal model for Paget's disease of bone, studies of the mechanisms of HL are limited to postmortem studies and in vivo clinical investigations. Before 1990, efforts to understand the mechanism of HL in many otologic disorders, including Paget's disease of bone, were limited to descriptive histopathologic studies, usually of a small numbers of cases as they became available for study. The histopathologic findings in human temporal bones with Paget's disease have now been described in more than 50 cases, including some with audiometric data. 12In a differing analysis, Khetarpal and Schuknecht The present study was a systematic, prospective, controlled set of investigations to test the hypothesis that there is a general underlying mechanism of HL in Paget's disease of bone and to gain additional insights into the auditory and otologic dynamics of this disease. A group of elderly subjects with Paget's disease involving the skull and a control group of elderly subjects without Paget's disease were recruited for several investigations.Auditory brainstem responses (ABRs) were recorded to search for evidence of retrocochlear disease. The presence of normal ABRs would be taken as evidence of normal retrocochlear function and a cochlear site of lesion. Dimensional measurements were made of the internal auditory canal using digital image analysis from computed tomographic (CT) images. Correlations were sought between internal auditory canal dimensions and hearing levels (both high-frequency air-conduction thresholds and the low-frequency air-bone gap) to determine whether narrowing of the internal auditory canal or compression of the auditory nerve would account for hearing levels in subjects with Paget's disease of the skull.Precise, accurate, stable techniques of quantitative CT (QCT) have been used to measure the mineral density of human bone in vivo. For this study, a QCT method was developed and validated to measure the bone mineral density of small volumes of bone in the skull, specifically the cochlear capsule. Subjects with Paget's disease involving the temporal bone were scanned. Correlations were sought between density values versus hearing levels. If statistically significant correlations were found, the hypothesis would be supported.All subjects in this study gave informed consent according to procedures of the institutional review board (Human Rights Committee) and the principles of the Declaration of Helsinki. Forty-two subjects with Paget's disease of the skull were evaluated during the term of the study. The diagnosis of Paget's disease was established using standard clinical criteria, including medical history, physical examination, laboratory tests, and radiologic studies by an endocrinologist subspecializing in bone and mineral diseases. The diagnosis was confirmed by clinical evaluation of CT scans by a neuroradiologist. The duration of disease, severity of disease, and degree of cochlear involvement varied widely.A priori exclusion criteria included systemic bone disease, prior middle ear surgery, and known extraneous causes of HL . Subjects with diabetes, mild hypothyroidism corrected by hormone replacement, or with histories of noise exposure were not excluded.Thirty-seven subjects with Paget's disease involving the skull were recruited for studies of ABRs and dimensional studies of the internal auditory canal. Subjects ranged in age from 40 to 87 years. The mean age was 68 years. There were 23 female and 14 male subjects. Nine (24%) of these subjects were black and 28 (76%) were white.Thirty-three subjects (66 ears) were available for studies of ABRs. Of these, two left ears were excluded from analysis because of prior middle ear surgery, leaving 31 left ears and 33 right ears, or 64 total ears with ABR data for analysis.Thirty-seven subjects were available for CT scanning for dimensional measurements. The processing of CT images included a data reduction step that resulted in inadvertent omission of the medial portion of the internal auditory canal from the image data set of one right and two left ears . Dimensional measurements could not be made from these incomplete data sets, leaving 36 right and 35 left ears  for analysis of dimensions in pagetic versus normal subjects.Thirty-five patients with Paget's disease involving the skull were available for both studies of the bone mineral density of the cochlear capsule (QCT) and hearing levels. There were 21 female and 14 male subjects with Paget's disease involving the skull. Eight (23%) of these subjects were black and 27 (77%) were white. The 35 patients ranged in age from 40 to 87 years. The mean age was 68 years. Data from three ears from three subjects were excluded from the analysis, two ears for a history of ear surgery and another because of chronic mastoiditis. Data from the remaining 67 ears (33 left and 34 right ears) were analyzed.A control group of 22 volunteer subjects over age 50 was recruited from among the spouses of pagetic subjects and others. Two volunteers were excluded, one each for Ménière's disease and otosclerosis, leaving a total group of 20 subjects. There were 10 men and 10 women in the control group. One woman was of black descent. The remaining 19 control subjects were white. The mean age was 59 years.Volunteers had no clinical history of Paget's disease and underwent determination of serum alkaline phosphatase to exclude Paget's disease. A neuroradiologist unaware of the clinical diagnosis reviewed each set of QCT images to confirm the presence of Paget's disease in each pagetic subject and its absence in the volunteers. Other exclusion criteria for volunteers were the same as for the pagetic subjects.Pure-tone behavioral audiometric thresholds for air and bone conduction were determined at 2.5 dB increments. Because of reports that a high-frequency sensorineural HL and a low-frequency air-bone gap are characteristic in Paget's disease, 5), filtered (100–3000 Hz), and averaged .The ABR was recorded with a commercially available clinical evoked potentials system . Electrodes were applied with a conductant paste to the vertex (noninverting input Cz), left and right mastoids , and at the midfrontal location (ground Fpz). Simultaneous ipsilateral and contralateral recordings were conducted to optimize the identification of component wave V. The bioelectric activity was differentially amplified  as were the amplitudes of waves I, III, and V. The wave V/wave I amplitude ratio was calculated.There is no universally accepted method of interpretation of ABRs. In this study, ABRs were interpreted as though they were diagnostic tests for retrocochlear disease . It was reasoned that abnormal ABRs could be taken as evidence of abnormal auditory nerve function  as the site of the auditory lesion. ABR findings were compared with normative data established for interpretation for retrocochlear disease. These data consisted of latency and amplitude values from 32 clinic subjects with normal hearing. ABRs were considered normal if values were within 2.5 SD of the normal hearing group. 15If latency or amplitude values were not within 2.5 SD of the values of the normal hearing group, another level of analysis was applied. No specific “correction factor” in milliseconds of latency per dB of high frequency HL was used; however, the degree of HL in the higher frequencies and the steepness of the audiometric slope in these frequencies was assessed. In the presence of a high-frequency cochlear HL, the portion of the cochlea that gives rise to the transduction events that will result in the ABR is understood to be the domain that normally codes for middle- and low-frequency sounds. The traveling wave takes a finite amount of time (approximately 1.2–1.5 ms) to reach the middle- to low-frequency portion of the cochlear duct, producing a latency shift, which is reflected in the ABR in subjects with high-frequency sensory HL. Thus, measured latencies that exceeded the reference values by the time expected based on the degree of high-frequency HL were interpreted as normal (for the degree and configuration of the HL) and consistent with intact auditory nerve function. 15Measurement of the dimensions of the internal auditory canal was accomplished with digital image processing. In step 1, a perpendicular pair of planar CT images  was selected from the three-dimensional data set using digital image analysis software developed for this purpose. In step 2, the length, the mid-length diameter, and the minimum diameter of the internal auditory canal in the axial and coronal planes of each temporal bone were measured. To simplify data analysis, the two sets of data  for length and mid-length diameter were averaged. The smaller of the two minimum diameters  was taken to identify all cases where auditory nerve compression might occur. Left and right ears were analyzed separately.The precision of the dimensional measurements was tested in two ways. Step 2 was repeated for each pair of axial and coronal images in eight temporal bones at least 24 hours after the initial set of measurements (24 pairs of observations). Steps 1 and 2 were also repeated in eight temporal bones each (24 pairs of observations). During each second set of measurements, the operator was unaware of  the first result. For the length and mid-length diameter, the average coefficients of variation were less than 3% for the first test of precision described above and less than 5% for the second test. The measurement of the minimum diameter was somewhat less precise, with a coefficient of variation of 5% for the first test and 11% for the second. 15Much of the present study depended on the development and validation of the radiologic method of measuring bone mineral density of the cochlear capsule using a particular type of QCT. 173). The amount of radiation exposure was similar to that of conventional CT.The method of measuring bone mineral density of the cochlear capsule used in this study was a modification of a technique originally used to measure the regional bone mineral density in human vertebral bodies in vivo. 2 focal spot. The head holder incorporated a solid bone-mineral calibration phantom marketed by Image Analysis . This device had a graded series of five density standards consisting of hydroxyapatite embedded in a plastic resin  were consistent with the results of other laboratories. 18To assess measurement accuracy, four cochlea-shaped plastic density standards were inserted into the temporal bones of a skull phantom. Measurements were confirmed to be linear through the range of densities encountered in Paget's disease. Measurements of the mineral density of normal cortical bone  was performed to account for the two measures of hearing that were tested.Regression methods were used to examine the relationship between hearing thresholds and mean bone mineral density of the cochlear capsule. Linear regression relationships and Pearson product-moment correlations were computed to assess the simple associations. Analysis of covariance was used to compute partial correlation coefficients, adjusted for the covariates of age and sex. A Bonferroni adjustment to the Eight ears in five subjects had no recordable auditory evoked responses caused by low hearing levels. ABRs from the remaining ears were normal, indicating that there was no electrophysiologic evidence of impairment of auditory nerve transmission.Results are summarized in There were no significant correlations between hearing level and the minimum diameter in either the pagetic or the volunteer subjects. There were significant correlations between mid-length diameter and high-tone average, but these were weak and were significant only in left ears . In one P < .001). The regressions were consistent throughout the ranges of cochlear capsule density  after adjustment for age and mean bone density of the cochlear capsule. 16The robustness of the correlations was explored by examining the effect of risk factors for HL. The effect of risk factors, including noise exposure (by history) and diabetes mellitus, was examined by comparing selected pagetic subjects without risk factors (n = 22) to those with risk factors (n = 13). There were no significant differences between the two groups in correlations of either the high pure-tone threshold level or the air-bone gap. There was no apparent relationship between sex and high-frequency pure-tone thresholds; however, men may have had a smaller air-bone gap by 3.8 dB for left ears or 3.7 dB for right ears  were minimized but not completely eliminated.A strong and statistically significant relationship was demonstrated between the bone mineral density of the cochlear capsule and both the high-frequency pure-tone air-conduction thresholds and the air-bone gap in subjects with Paget's disease of the skull. There does not appear to be an inflection in the regression line or suggestion of a threshold phenomenon in this relationship. This consistency of the regression throughout its range suggests that the effect of Paget's disease on hearing is a continuous, graded process.The bone of the normal cochlear capsule is lamellar bone with few haversian canals and vascular elements and thus consists of dense, compact bone tissue. The findings in the studies reported here strongly support the hypothesis that there is a general underlying mechanism of HL in Paget's disease of bone. The finding of normal ABRs supports the cochlea as the site of the pagetic lesion rather than the auditory nerve. The lack of evidence for nerve compression further supports the cochlear hypothesis and demonstrates that there is very little distortion of consequence in the shape of the temporal bone, except perhaps in rare, extreme cases. The demonstrated relationship between cochlear capsule mean density and hearing levels also supports the cochlear hypothesis and the hypothesis of a general underlying mechanism. This relationship also suggests that alteration of bone mineral density may be close to the mechanism of HL.These correlational findings are not necessarily in direct conflict with the findings of earlier histologic studies of pagetic temporal bones. The possibility of additional mechanisms, particularly in advanced cases, is not excluded.Audiometric data, particularly data involving the determination of bone-conduction thresholds, are subject to considerable variability, especially in elderly subjects. The subjects in this study were older than the general population. Consequently, it must be acknowledged that the strength of the correlations is remarkable. The positive finding of correlations between cochlear capsule mineral density versus hearing levels supports the validity of the negative finding of no significant correlations between dimensional measurements of the internal auditory canal and hearing levels.The idea that an air-bone gap can exist without a conductive HL in the manner usually understood may be difficult to accept. Khetarpal and Schuknecht Pagetic bone has been observed to change shape. Gradual bowing of the weight-bearing long bones is common when they are involved. HL in Paget's disease does not seem to be related to changes in the shape of the skull or inner ear. Platybasia, a flattening and widening of the skull base, occurs only in the most advanced cases of pagetic involvement of the skull, whereas HL occurs with almost any degree of involvement of the temporal bone. The dimensional analysis of pagetic temporal bones in this study did not show changes in the internal auditory canal. Also, we did not observe qualitative changes in the shape of the cochlea.Treatment with the newer bisphonsponates provides rapid arrest of the pagetic process and long-term control. Histologic studies show that the pagetic process involves the entire cochlear capsule in essentially all cases observed. This finding suggests that the entire capsule is involved early. A reasonable inference from the cross-sectional data of the study is that bone mineral density is gradually lost as the disease progresses. It may be suspected that continuous remodeling of pagetic otic capsule bone results in progressive sensorineural HL, predominantly in the higher frequencies. One is tempted to speculate that perhaps Paget's disease reveals the normal auditory function of otic capsule bone. This bone normally does not undergo remodeling. When it does undergo remodeling in Paget's disease, a gradual decline occurs in auditory function.Sensory transduction in the cochlea is a process of interaction between mechanical (acoustic) and electrical events. It appears that conformational change in membrane-bound ion channels may be induced by mechanical deformation. The flow of ions across hair cells is dependent on the maintenance of the “silent” current. This study demonstrates the importance of studying a disease process in a systematic, prospective manner. It also demonstrates the difficulties of doing so. Progress requires the combination of a large group of subjects, advanced investigative techniques that are validated, and a multidisciplinary approach. Bone disorders that affect hearing, such as otosclerosis, are among the most common otologic disorders. Progress in understanding disorders of bone that affect hearing is hampered by a general lack of knowledge of the biology of calcified tissue, by the lack of more detailed knowledge about the unique features of otic capsule bone, and the lack of a suitable animal model. It is likely that each disease process  will prove to involve different mechanisms of HL. Despite the difficulties, the effort is worthwhile. Not only can more be learned about the causes, prevention, and treatment of HL, but we also may gain insight into normal auditory function.The findings in this study support a new view of the mechanism of HL in Paget's disease of bone and a new approach to clinical management of skull involvement:There is a general underlying mechanism of HL in Paget's disease.The mechanism of HL is cochlear.The loss of bone mineral density in the cochlear capsule is a marker of disease effect and is close to the mechanism of both the sensory HL and the air-bone gap.The strong correlation between the bone mineral density of the cochlear capsule and air-bone gap supports the suggestion that the air-bone gap in Paget's disease is not caused by pathology of the ossicular chain but by alteration of the acoustical mechanics of the ear. This alteration may include facilitation of bone conduction of sound.Treatment that normalizes biochemical markers of active disease does not result in clinically significant improvement in hearing levels.The pagetic process and associated HL are established well before signs appear in the facial skeleton. Consequently, it is not appropriate to withhold treatment until such signs appear.HL caused by Paget's disease of bone is gradually progressive but potentially preventable with early diagnosis and vigorous treatment. Third-generation bisphosponates are highly effective in controlling the pagetic process.Pagetic HL should be suspected in any middle-aged or elderly person, especially if hearing levels progress more rapidly than would be suspected in presbycusis or if a low-frequency air-bone gap is present.


Ethnobotanical studies are crucial in South-Eastern Europe for fostering local development and also for investigating the dynamics of Traditional Environmental Knowledge (TEK) related to plants in one of the most crucial European hotspots for biocultural diversity. The current medico-ethnobotanical survey was conducted in rural alpine communities in Kosovo. The aims of the study were twofold: 1) to document the state of TEK of medicinal plants in these communities; 2) to compare these findings with that of similar field studies previously conducted among local populations inhabiting the Montenegrin and Albanian side of the same Alpine range.Field research was conducted in 36 villages on the Kosovar side of the Albanian Alps. Snowball sampling techniques were used to recruit 91 elderly informants (≥ 50 years-old) for participation in semi-structured interviews and structured surveys regarding the use of the local flora for medicinal and food purposes. Standard ethnobotanical methods were employed and prior informed consent was obtained for all study participants.arduus nutans L., Echinops bannaticus Rochel ex Schrad., and Orlaya grandiflora Hoffm. may merit phytochemical and phytopharmacological investigations.The uses of 98 plants species belonging to 39 families were recorded; the most quoted botanical families were Rosaceae, Asteraceae, and Lamiaceae. Mainly decoctions and infusions were quoted as folk medicinal preparations and the most common uses referred to gastrointestinal and respiratory disorders, as well as illnesses of the uro-genital system. Among the most uncommon medicinal taxa quoted by the informants, CComparison of the data with other ethnobotanical field studies recently conducted on the Albanian and Montenegrin sides of the same Alps has shown a remarkable link between the medical ethnobotany of Montenegrin and Kosovar side of the Albanian Alps. Moreover, folk uses of the most quoted wild medicinal taxa recorded in Kosovo often include those recorded both in Albania and in Montenegro, thus suggesting a hybrid character of the Kosovar local plant knowledge. This may be also explained with the fact that Montenegro and Kosovo, despite their differences in the ethnic composition, have shared a common history during the last Century. Ethnobotanical studies in South-Eastern Europe are seen as a crucial initial step for local rural development based on eco-tourism, small-scale trade of local medicinal plants, high-quality local foods, eco-museums, and community-based bio-conservation strategies .However, this region is also considered very special for conducting studies having a human ecological focus, since it represents a unique hotspot of biological and cultural diversity in Europe, thus allowing cross-cultural comparisons of traditional environmental knowledge (TEK) concerning medicinal plants. In very recent years, the Western Balkans have been the focus of a remarkable number of ethnobotanical studies -9, mainl2, which is geo-politically divided among the sovereign states of Albania, Kosovo, and Montenegro.In this study, we investigated the Kosovo side of the Albanian Alps , which extends within a triangle among the Dinaric Mountains in the North-West, the Sharri (Šar) Mountains in the South-East and the Rhodope Mountains in the East and North-East. This covers a very pristine, and sometimes, remote area of ca. 3,500 km2 of these mountains belong to the Kosovo territory. The Albanian Alps system consists of 24 groups of mountains with 152 peaks higher than 2,000 m a.s.l. , with a large number of gorges, canyons, valleys, which make them among the most inaccessible [About 1,000 kmcessible , but alscessible .Due to the rich levels of biodiversity characteristic to this region, three national parks were established in the past in the Albanian Alps: one in Montenegro  and two others in Albania . A fourth national park in the area has been proposed to be located in Kosovo. Furthermore, Kosovo, Albania, and Montenegro are planning to join these parks and to create the cross-border Balkan Peace Park .In general, Kosovo is characterised by a continental climate and in higher altitudes it is influenced by Alpine features ; for thiCarpinetum orientalis scardicu), hop hornbeam mixed and with oriental hornbeam forest , thermophilous oak forests community , chestnut forests (Castanetum sativae), beech forests (Fagetum montanum), and pine forests  [These unique features are reflected in the high plant biodiversity, which includes 1,609 taxa and ca. 150 vegetation units . The mostypicum) ,24.People have withstood the extreme conditions of these areas for centuries - including very harsh winters. Until very recent decades, limitations in infrastructure and communication forced local residents to be self-sufficient in the provision of their healthcare. As a result, their primary pharmacopoeia consisted of local medicinal plants.While recent studies on the Albanian and Montenegrin sides of the Albanian Alps have reported findings on TEK of wild medicinal and food plants ,12,13,15The aims of this study were twofold: 1) to document the ethnobotanical knowledge related to the use of local medicinal plants in the Albanian Alps region of Kosovo; and 2) to compare the recorded data with the ethnobotanical studies recently conducted in the Albanian and Montenegrin sides of the same Albanian Alps. This was done with the overarching goal in mind of elucidating the role played by cultural/ethnic components in shaping use patterns of wild medicinal plants.Ethnobotanical field research was conducted in 36 villages belonging to the municipalities of Pejë and Deçan, located close to the Koprivnik and Strellc mountains, and which represent the central group of the Albanian Alps located in the western part of Kosovo Figure .The settlements and villages investigated are relatively small in terms of inhabitants (≤ 500 inhabitants per village). The native residents are ethnic Albanians, who speak Gheg varieties of the Albanian language. The exact population is currently unknown, as no population census has been conducted in Kosovo since 1981. Most recently, the area populations have been negatively affected by migration due to displacement and harsh economic conditions caused by the last Kosovo War (1998-1999).Field studies were conducted from May to October 2010. TEK was recorded using semi-structured interviews and a questionnaire . In partData were collected from 91 informants  older than 50 years (50 to 79 years old). The respondents were mainly engaged in agricultural activities and typically inherited their ethnobotanical knowledge from their direct ancestors  via oral traditions. Study participants were selected using the snowball sampling method [Prior informed consent was obtained conducting interviews and researchers adhered to the ethical guidelines of the International Society of Ethnobiology . During Flora Europaea [Taxonomic identification was done using relevant standard botanical literature of the area -31. PlanEuropaea , while pEuropaea . VoucherDespite the fact that it is always problematic to compare ethnobotanical data recorded from studies conducted using different field methods and at different times, we have attempted to compare the wild medicinal plant uses recorded in Albanian Alps in Kosovo with those recorded in previously conducted ethnobotanical studies on the Albanian and Montenegrin sides of the same alpine range -14. The The results of the field survey are presented in Table Achillea millefolium L., Cornus mas L., Hypericum perforatum L., Juglans regia L., Juniperus communis L., Malus sylvestris Mill., Plantago major L., Sambucus nigra L. were cited more then 30% of the informants. From 98 species presented in Table We found that 98 species (belonging to 39 families) are employed in the traditional medicine of the area. These includes three fern species, three gymnosperms and 92 angiosperms (84 dicotyledonous and 8 monocotyledons); 74 taxa are wild. Of these species, The predominantly quoted botanical families were Rosaceae (12%), Asteraceae (10%), and Lamiaceae (5%). These same three "top" families were found to be also predominant among the wild medicinal taxa used in the folk medicine of the Alps in Montenegro, Albania, and in the Gollak region in Kosovo ,11-14.The most frequently quoted manner of preparation of medicinal plants was represented by decoctions (51%) and infusions (26%). The most frequently cited medicinal uses referred to gastrointestinal (26%), respiratory (19%) troubles, and illnesses affecting the urogenital system (12%). The first two categories were also the most frequently quoted in the ethnobotanical studies conducted on the Montenegrin and Albanian sides -14.Upon analysis of the bio-pharmacological literature on the quoted medicinal species available on PubMed, we found that it could be worthwhile to further investigate the following reports:Carduus nutans L. in the treatment of eczema . In 2000 a Turkish research group pointed out the hepatoprotective effects of extracts from this plant [1. The internal use of cold water macerates of the inflorescences of is plant ;Echinops bannaticus Rochel ex Schrad. for kidney stones ; and2. The internal use of decoction of the roots of Orlaya grandiflora Hoffm. for its laxative effects .3. The internal use of decoctions of aerial parts of Table Figure The link between the medical ethnobotany of the Montenegrin and Kosovar sides of the Alps - despite the different ethnicity/language of the local populations - appears stronger than the link between the ethnobotany of these two locations and the ethnobotany Albania.This apparent paradox could be explained in a number of ways:Hypericum perforatum used as an anti-depressive) were recorded.1. Different sampling techniques may have been adopted during the field survey in the three locations or the socio-economic background of the interviewees could have been different. For example, on the Albanian side of the Alps, the previous ethnobotanical studies selected local informants from very remote areas, which remained quite isolated during Communist times and with very limited access to urban environments and culture. It could be especially worthwhile to further assess the influence of the popular phytotherapeutical literature on folk medicine in Montenegro and Kosovo, since during the Yugoslavian time this kind of popularised knowledge was said to be "en-vogue". For example, this is very evident in the Montenegrin data, where a number of possible "modern" uses of local medicinal plants . This may have "homogenised" eventual pre-existing differences in plant perceptions/uses between the Albanian and Slav communities. Moreover, a few South-Slav communities  cou4. The Montenegrin study included self-declaring Serbian and Bosniak communities. However, a large part of the Bosniak community living in the Gusinje area is represented also by "bosniakised" Albanians, whose Catholic tribes settled on this side of the Albanian Alps and converted to Islam a couple of centuries ago . This coDespite the commonalities found on the quoted medicinal plants, Table From Table Medicinal plants still play a crucial role in the sphere of human health in the Albanian Alps, not only in the Montenegrin and Albanian territory, but also on the Kosovar side. Oftentimes, these mountainous communities have limited or non-existent access to Western biomedical modalities, and are instead self-reliant on their TEK. The local flora is thus incredibly important to provide the first health care within the households of the Albanian Alps.Moreover, the biodiversity richness and unique bio-cultural heritage of the local people here is something to be highly valued. Steps towards this end are evident in the formation of protected parks for biodiversity conservation - but further efforts in conservation of the human TEK diversity and cultural heritage are necessary as well. TEK-dependent activities such as sustainable gathering of wild medicinal taxa, their small-scale trade, and production of local high quality plant-based foods and dairy products can all contribute to the growing eco-tourism initiatives. Thus, TEK is a critical component to success in the future economic development and biocultural conservation efforts of the region.The authors declare that they have no competing interests.BM and AH conceived the study, and participated in its design and coordination. AH and HA carried out the field study; EH and FK verified the identification of the plant taxa; AH, AP, and CLQ performed the data analysis and drafted the discussion. CLQ edited the manuscript. All authors read and approved the final manuscript.


There is significant interest in the restoration of the double-bundle anatomy of the native ACL when performing ACL reconstruction. Possible techniques include those utilizing two separate grafts with independent tunnels and those that attempt to mimic this anatomy with a single graft and fewer tunnels. Many of the latter techniques require specific instrumentation and are technically challenging. We demonstrate that the double-bundle anatomy of the native ACL can theoretically be mimicked by a single-bundle reconstruction.We performed single bundle ACL reconstruction with a bone-patellar tendon-bone (BTB) graft in two cadaveric knees. Both grafts were placed to mimic the native ACL footprints – one reconstruction was performed with rectangular bone blocks and oval tunnels and one was performed utilizing a standard BTB graft and round tunnels. Qualitative assessment of graft behavior was made as the knees were taken through a range of motion.The ACL graft was able to qualitatively mimic the behavior of the native ACL in both knees provided the bone blocks were correctly orientated.ACL reconstruction with a single BTB graft can qualitatively mimic the behavior of the two bundles of the native ACL. The key to ensuring this behavior was noted to be appropriate orientation of the graft in the tunnels. Quantitative biomechanical investigations are necessary to evaluate the impact of graft orientation on function. Improvements in understanding of the anatomy and function of the native anterior cruciate ligament (ACL) have lead to increasing interest in reconstructing both bundles of the ACL -6. DiffeDouble-bundle reconstruction techniques are not without drawbacks. Many described techniques require the surgeon to prepare three or four different tunnels, requiring the surgeon to place tunnels very precisely -11. The While a technique that mimics double bundle anatomy with a single bone-patellar tendon-bone graft has been previously described, this method requires creation of rectangular tunnels, requiring significant surgical expertise and specific instrumentation ,24. We dTwo fresh cadaveric knees were used for this feasibility study, including the knee of an 82 year-old female (knee A) and a 78 year-old male (knee B). Neither knee had undergone prior surgery and both were noted to have normal ACL’s. Some mild degenerative changes of the patellofemoral joint were present in knee A, while the other knee was free of osteoarthritis. To obtain an optimal visualization of the native ACL, the femur, tibia and fibula were cut above and below the knee though their respective diaphyses. Surrounding soft tissues were then removed, leaving only the menisci and cruciate and collateral ligaments.The medial half of the distal femur was removed with a sagittal saw cut along with the medial collateral ligament, posterior cruciate ligament, and medial meniscus. The anteromedial (AM) and posterolateral (PL) bundles of the ACL were identified and separated. For improved visualization, the AM bundle was colored in red and the PL bundle in blue. This preparation allowed a clear medial view of the native ACL and its two bundles during full range of motion. Following photographic documentation of the native ligament and the orientation of the two bundles in flexion and extension, the bundles were resected and their femoral and tibial attachment sites were marked with the respective color of each bundle.Before the knee was dissected as detailed above, a bone-patellar tendon-bone graft was harvested from the central aspect of the patellar tendon. For knee A, the bone blocks were rectangular in shape Figure a. From tIn knee A, two parallel 6 mm tunnels were drilled in both the femur and tibia based on the marked native attachment sites of the ACL. Due to the proximity of the two tunnels to each other, they merged and resulted in oval tunnels on the femur and tibia centered over the native ACL attachment sites Figure . The preIn knee B, conventional 10 mm bone tunnels were drilled in the center of the ACL footprints on the femur and tibia and the graft was then placed into the tunnel. The graft was oriented similarly to that in knee A, with the red part oriented toward the anteromedial portion of the footprint on the femur and tibia and the blue part oriented toward the posterolateral bundle footprints. Fixation was achieved by a press fit technique, preventing rotation of the bone blocks in the tunnels.The orientation of the grafts in both knees were photographically documented as the knees were brought through a range of motion from the extended to flexed position. Photographs of the graft position in the fully extended and fully flexed positions were then compared to identify qualitative differences between the native and reconstructed knees.The femoral insertion of the AM bundle was proximal to the PL insertion on the femur. On the tibia, the AM inserted anterior to the PL bundle. In full extension, the bundles were nearly parallel Figure A. FollowIn knee A as in the native ACL, the two bundles were observed to be parallel in extension Figure C. At 120The main finding of this cadaver feasibility study was that a single bundle patellar tendon graft can mimic the anatomy of the two ACL bundles, provided that it is oriented such that the fibers leaving the anteromedial portion of the ACL tibial footprint and enter the femur near the native femoral origin site of the AM bundle. It was demonstrated that such behavior could be produced not only through the use of oval tunnels, but also through the use of conventional round tunnels.There are several theoretical advantages to reconstructing the ACL with one graft. First the necessity to use four bone tunnels and four independent fixation devices is avoided, reducing cost and potentially operative time. Second, significant bone loss can occur due to tunnel enlargement following double bundle ACL reconstruction, particularly if tunnel convergence occurs . RevisioThe concept of mimicking the double bundle anatomy of the native ACL using one graft placed through a single tibial and femoral tunnel is not new. Several authors have described fixation techniques that allow soft tissue grafts to be used in this manner ,28. Shinin vivo was thus not assessed. Further, the removal of soft tissue from the single specimen precluded the performance of any useful mechanical testing of the reconstructed knee to determine the effect of graft orientation on stability.This cadaveric feasibility study has several weaknesses. First, the focus of the study is to demonstrate qualitatively the behavior of the ACL graft. No attempts were made to quantitatively assess behavior by assessing tension in the different parts of the graft. In addition, the reconstruction was performed in an open manner without utilizing standard arthroscopic instrumentation. The feasibility of performing such a reconstruction A single bundle patellar tendon ACL reconstruction can mimic qualitatively the behavior of the two bundles of the native ACL if the graft is correctly positioned relative to the ACL footprint on the femur and tibia. Quantitative biomechanical investigations are necessary to evaluate the impact of graft orientation on function.ACL: Anterior cruciate ligament; BTB: Bone-Tendon-Bone (patellar tendon autograft); AM: anteromedial; PL: posterolateral.The authors declare that they have no competing interests.MJ & RAM wrote the manuscript. MJ, RAM and VV performed the study. GD & PN edited and proofread the manuscript. All authors have read and approved the final manuscript.


Spiking models of small areas of the neocortex have so far mainly been studied under the assumption that neurons are sparsely and randomly connected. The absence of structure allows for the use of powerful mean-field approximation techniques, whereby statistical properties of spike trains such as the average firing rate and the interspike interval coefficient of variation are described in terms of their distributions across neurons ,2. Such Connectivity in cortex is not purely random: published data on synaptic connectivity suggests a model of cortical connectivity in which excitatory neurons make long-range patchy projections while inhibitory neurons only target their close neighbours . How doeWe examine the dynamics of linear networks with patchy connectivity structures. With long-range patchy inhibition, about 25% of the eigenvalues of the connectivity matrix have strictly positive real parts. Since real parts must be smaller than one for stability, the overall magnitude of the connections, and therefore also the amount of transient amplification, need to be constrained. The presence of eigenvalues with real parts close to one also predicts dynamical slowing with a small number of modes  completely dominating the dynamics and limiting the representational power. If inhibition is kept local, as it seems to be in nature, the connectivity matrix has the nice property that all its eigenvalues have negative real parts. The network can thus be arbitrarily rescaled and yet remain stable. Strong amplification can coexist with fast network dynamics that yields a rich repertoire of transient spatial states.Extensive simulations of the noise-driven linear networks confirm the theoretical insights. Importantly, we also ran large-scale simulations of conductance-based spiking neurons with sparse connectivity spatially organized as mentioned above. Despite the strong deviation from linearity, the network activity matches the linear predictions remarkably well, in terms of both speed and amplification of the Schur modes. We conclude that the activity in spatially organised networks is highly structured and can be described on the level of two-dimensional activity patterns. Local inhibition, but not long-range inhibition, enables rapid state switching on the time scale of a few milliseconds.


Alternative splicing of premessenger RNAs is a key step in the gene expression process, which allows the synthesis of different products from the same gene and contributes to increase the complexity of the proteome coded by a limited number of genes. Specialized high-throughput technologies  aiming at analyzing alternative splicing in normal or pathological situations have allowed to make a promising step forward in basic and translational molecular oncology by identifying a variety of cancer-associated splicing variants. However, modification of alternative splicing is among the myriad of alterations present in cancer cells and whether splicing alteration is a cause or a consequence of cancer remains to be elucidated.The main focus of this special issue is to highlight some of the mechanisms involved in splicing alteration in cancer and to present new evidence demonstrating the involvement of alternative splicing alterations in different steps and aspects of cancer initiation and progression.To highlight the applications of large-scale approaches in the search for relevant cancer-associated splicing events, S. Germann and colleagues give an overview of the studies that have been carried out so far using such strategies. This has allowed to identify sets of functionally related genes whose expression is altered at the splicing level in cancer cells and to characterize some of the factors which control specific splicing programs that are deregulated in tumors.The other reviews give a series of specific examples of cancer-associated splicing variants. S. Druillennec and colleagues address how alternative splicing modifies the physiological and pathological functions of a variety of protein kinases. Taking several examples of membrane-associated or cytosolic kinases, they explain more particularly how the oncogenic properties of this important class of factors between specific splicing isoforms.More specifically, K. Holzmann and colleagues summarize the various splicing alterations that affect, in different tumor types, the transcripts encoding the fibroblast growth factor receptors (FGFR) 1–3, at the level of their IgIII loop. Splicing-induced variations in this domain, which occur naturally during embryonic development and are regulated in a tissue-specific manner, directly affect the interactions between the receptors and their ligands and have profound consequences on their activity. In cancer cells, alterations in FGFR2 splicing are involved in the epithelial-mesenchymal transition, an important step in the formation of metastases.In their paper, Hilmi and colleagues focus on the alternative splicing of vascular endothelial growth factor (VEGF), which produces isoforms with opposite functions in the control of angiogenesis, a process involved in the progression and metastasis of several cancers. They discuss the emerging possibility of targeting angiogenesis more accurately by modulating the splicing of VEGF transcripts through the factors that control it.TP53, TP63, and TP73 genes. Evidence shows that the aberrant expression of some of these isoforms in cancer cells contributes to tumor progression and may explain in some cases the resistance of tumors to therapeutic treatments.J. Wei and colleagues review our current knowledge of the functional diversity of protein isoforms that compose the p53 family, encoded by the Altogether those review articles illustrate how cancer cells may divert the natural properties of tissue-specific or developmentally regulated splicing variants to alter cellular functions and lead to a malignant phenotype or to a propagation of the tumor. This also underlines the need for a better understanding of the molecular mechanisms that control such splicing alterations.Didier AuboeufDidier AuboeufMaria Carmo-FonsecaMaria Carmo-FonsecaJuan ValcarcelJuan ValcarcelGiuseppe BiamontiGiuseppe Biamonti


To review the current evidence on therapeutic agents for burns pruritus and use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) classification to propose therapeutic protocols for adult and paediatric patients. All published interventions for burns pruritus were analysed by a multidisciplinary panel of burns specialists following the GRADE classification to rate individual agents. Following the collation of results and panel discussion, consensus protocols are presented. Twenty-three studies appraising therapeutic agents in the burns literature were identified. The majority of these studies (16 out of 23) are of an observational nature, making an evidence-based approach to defining optimal therapy not feasible. Our multidisciplinary approach employing the GRADE classification recommends the use of antihistamines (cetirizine and cimetidine) and gabapentin as the first-line pharmacological agents for both adult and paediatric patients. Ondansetron and loratadine are the second-line medications in our protocols. We additionally recommend a variety of non-pharmacological adjuncts for the perusal of clinicians in order to maximise symptomatic relief in patients troubled with postburn itch. Most studies in the subject area lack sufficient statistical power to dictate a ‘gold standard’ treatment agent for burns itch. We encourage clinicians to employ the GRADE system in order to delineate the most appropriate therapeutic approach for burns pruritus until further research elucidates the most efficacious interventions. This widely adopted classification empowers burns clinicians to tailor therapeutic regimens according to current evidence, patient values, risks and resource considerations in different medical environments. Pruritus is a common and distressing symptom affecting the majority of burns patients’ rehabilitation. Recent work has confirmed the lack of a unified approach in assessing and managing the symptom in UK burns units. One of tPruritic stimuli are transmitted by a subpopulation of C-fibres extending from the skin to the dorsal root ganglion of the spinal cord. Subsequently, impulses are conveyed onto higher central nervous system centres to reach the cortical areas, including the somatosensory, motor, prefrontal cortical and cingulated gyral areas.–8 The twA small number of protocols for burns pruritus have been published in the literature. One uses oral antihistamines and topical emollients as first line, followed by the recruitment of a clinical psychologist and a variety of third-line agents, including capcaisin, transcutaneous electrical nerve stimulation (TENS), massage and silicone sheets.The hierarchy of this therapeutic algorithm is largely based on the risk of adverse effects, which increase from the first to the last step of the protocol. One of tSince the 1970s, a growing number of organisations have used various different systems to grade the quality of evidence and stratify the strength of recommendations in medical practice.The most popular techniques described in the literature are the Delphi method, the nominal group technique and a combination of these two approaches. The DelpThe GRADE working group began as an informal collaboration of individuals with an interest in tackling the shortcomings of previous grading systems. The principles governing the system allow for more consistent judgements and communication by using two discrete categories of recommendations; strong and weak. Key factors determining the strength of recommendation are:The balance between desirable and undesirable consequences of a particular and alternative management strategies.The quality of evidence, with randomized controlled trial results carrying more weight than observational studies.Patient values and preferences variability.Cost/resource allocation. This is variable over time and geographical location.It is evident that quality of evidence is only one of the factors implicated in the decision about whether a particular intervention will be recommended strongly or weakly by members of the panel. A strong recommendation reflects the consensus judgement that the desirable effects of an intervention outweigh the undesirable effects . A weak recommendation implies that the desirable effects will outweigh the undesirable effects but the panel is not confident about the tradeoffs, either because key evidence is of low quality or because the benefits and drawbacks are closely balanced. The apprThe Surviving Sepsis Campaign employed a GRADE approach to classify the quality of evidence regarding managing severe sepsis and septic shock, recruiting 50 experts from more than 10 countries.Since 2006, the British Medical Journal has requested in its “instructions to authors” that authors should preferably use the GRADE system for appraising evidence when submitting a clinical guidelines article. Additionally, the World Health Organization and the Cochrane Collaboration are among the 25 organisations that have adopted this classification. The advaClear separation of quality of evidence and recommendation.Explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings and acknowledgement of patient values and preferences.A transparent process of moving from evidence to recommendations.Disadvantages of the GRADE classification include a degree of arbitrariness in the discrete categorisation of quality of evidence and recommendation strength with both being a continuum.We adopted the following methodology to appraise the literature and derive our multidisciplinary protocolsIdentification of the evidence. Our assigned librarian conducted a comprehensive literature search using the Cochrane Database of systematic reviews, MEDLINE and Embase between 1966 and the present time. We also collected data from internet journal sources and abstracts from relevant conferences in an attempt to be exhaustive in our search.We categorised papers on burns pruritus in terms of levels of evidence using the NHS Centre for Reviews and Dissemination (CRD) as shown below.Level 1: Experimental studies .Level 2: Quasi-experimental studies .Level 3: Controlled observational studies.3a: Cohort studies.3b: Case–control studies.Level 4: Observational studies without control groups.Level 5: Expert opinion based on pathophysiology, bench research or consensus.Formation of the multidisciplinary panel. The first author and panel coordinator (IG), who has an active ongoing interest in the pathophysiology and treatment of burns pruritus, invited the following experts to appraise the studies individually using the GRADE system:MC is a senior occupational therapist with 27 years of experience in acute and reconstructive burns care.CU is a senior physiotherapist with 8 years of experience in burns scar management.PMR is an anaesthesiology consultant with 10 years service in a regional burns centre and has an ongoing interest in the management of burns pain and itch.SJG is a consultant in burns surgery with 10 years of experience in acute burns care provision and rehabilitation.Presentation of evidence. Three separate tables were compiled summarising the salient points of relevant papers identified for adult, paediatric and mixed(adult and paediatric) patients Tables , 2, 3. TGrading the strength of recommendation. All members of the panel were presented with the data for all eligible studies and were given scoring sheets, which comprised of four choices of scores for each agent as shown below.Score+1: strong recommendation in favour of an intervention.Score+2: weak recommendation in favour of an intervention.Score-2: weak recommendation against an intervention.Score-1: strong recommendation against an intervention.Each panel member assigned a particular grade to each study using the GRADE system and was encouraged to review the final individual scoring before submission to the panel coordinator. Subsequently the median score for each intervention was calculated to stratify the strength of the panel’s recommendation for individual agents . The preliminary results were distributed to all panel members for final comments and adjustments before an agreement for the final version of the protocols was reached [Figures Analysis of the available literature in the subject of postburn itch reveals that the overwhelming majority of studies (16 out of 23) are of an observational design, which corresponds to CRD levels 3 and 4. Any attempt to rely on an evidence-based approach to derive therapeutic protocols is severely hindered by the lack of high-quality studies. The employment of the GRADE classification has the potential to dictate the best available agents for therapy by using four different parameters, with quality of evidence being one of these. We present the principles underlying our consensus treatment templates for adult and paediatric patients.Pruritus is one of the many distressing symptoms that burns patients will experience during their rehabilitation. Successful assessment and treatment needs to be viewed in the context of a holistic multidisciplinary approach.We advocate the early involvement of all members of the burns team, including surgeons, anaesthesiologists, physiotherapists, occupational therapists, nurses and psychologists. Each member of the team has a unique role to play in identifying and managing nociceptive symptoms and multidisciplinary meetings are crucial in coordinating therapeutic strategies for individual patients.Quantification of symptom severity is paramount in planning optimal therapeutic interventions and defining the clinical response. Recent work has confirmed that higher itch scores before treatment predict the need to recruit a combination of agents to achieve satisfactory relief from pruritic symptoms. There isThe use of topical emollients and cooling agents to the pruritic wounds/scars is a widespread practice in burns units. There are no studies to support the use of these agents. Nevertheless, they form an integral part of skin care routine, and the globally positive clinical experience allows their inclusion in our protocols.P < 0.001).Gabapentin forms the first-line, centrally acting agent in both the adult and the paediatric protocols. A comparative study of two stepwise protocols in inpatient burns victims has revealed that gabapentin monotherapy is four-times more effective than chlorpheniramine monotherapy .[Additionally, gabapentin in combination with two antihistamines  rendered a statistically significant higher proportion of patients itch-free than the following combination of three antihistamines – chlorpheniramine, hydroxyzine and cyproheptadine (χ= 0.001).Gabapentin has also been shown to have an opioidsparing effect on acutely burnt patients. This appOndansetron forms the second-line, centrally acting agent in our adult protocol. No interventions focusing on the central nervous system pathway have been tested on paediatric patients, a fact that is reflected by the lack of a second-line, centrally acting agent in our paediatric protocol.Our protocols recommend the combination of cetirizine and cimetidine as the first-line choice of antihistamines for both adult and paediatric patients. The combination achieves comprehensive blockade of histaminic receptors employing a second-generation H1 partial agonist (cetirizine) and an H2 receptor antagonist (cimetidine).H1 receptor antagonists are divided into first-generation antihistamines, which bind to muscarinic, alphaadrenergic and serotonergic as well as histaminic receptors, and second-generation antihistamines, which have minimal activity at the nonhistaminic receptors. The latter generation has a more favourable side-effect profile  and a longer duration of action, necessitating less-frequent administration.Loratadine is another second-generation antihistamine that forms a second-line medication in our paediatric protocol.The use of TENS in adult patients is recommended as a first-line non-pharmacological intervention in our protocol. Second-line adjuncts include laser and pressure garment therapy in both adults and children and massage therapy in adult patients. Non-pharmacological adjuncts have a low level of uptake among UK burn units. We belieStudies in the subject have concluded that a single agent is most likely to be insufficient in eradicating postburn itch. Hence, a combination of interventions is needed to achieve satisfactory relief in the majority of patients.38 We advOur protocols categorise therapeutic options according to the GRADE strength of recommendation (first vs. second line) and nature of intervention . The choice between peripherally and centrally acting agents needs careful consideration and calls upon consideration of the likely pathophysiological mechanisms underlying the postburn itch.The pathophysiology of pruritus has been widely believed to be of peripheral origin, with histamine being the chief mediator for the generation of stimuli acting on primary neuronal afferents. There isRecent evidence suggests the existence of two subtypes of pruritus:Acute pruritus affecting the majority of patients and possibly relating to a period from wound closure to the early remodelling phase of healing, andChronic pruritus affecting a subgroup of patients with deeper burns and early posttraumatic stress disorder (PTSD) symptoms.The same work has identified an interesting pattern of risk factors at various times of rehabilitation. At 3 months, pruritic complaints were predicted by female sex, TBSA, number of surgical procedures undergone by the patient and PTSD symptoms as measured at 2 weeks postburn. At 12 months, female sex, number of surgical procedures and PTSD symptoms were significant predictors, whereas at 24 months, only the latter two variables persisted as predictors for postburn pruritus.This study provides an excellent platform towards identifying patients most likely to develop chronic pruritus and allows clinicians to tailor regimens using the most appropriate agents. In the current state of knowledge, we advocate the early employment of centrally acting agents in combination with peripherally acting agents in all patients, especially in those at a high risk of chronic pruritus development.We have conducted a detailed review of all the available evidence on therapeutic interventions for postburn itch to date. It is apparent that most studies are of not sufficient statistical power to allow the recommendation of certain agents for the treatment of burns pruritus. We additionally present our approach to derive a treatment template for adult and paediatric patients using the GRADE classification, which is a widely accepted system to make recommendations in clinical practice. Validation of treatment protocols in the subject area is of paramount importance, but is currently hindered by the lack of research to define the ‘gold standard’ for treatment. We recommend the judicious use of a combination of peripherally and centrally acting pharmacological agents as well as the use of nonpharmacological interventions for the treatment of postburn itch.


Treatment switching in clinical trials dilutes estimates of treatment effect which is problematic in decision making, especially in an economic context. In one example 75% of patients crossover from the randomised treatment which emphasises the need to address such bias. We consider methodologies that compensate for this bias.The methods assessed are; intention to treat (ITT), per-protocol (PP), adjusted Cox model , causal Survival data having an underlying Weibull distribution was simulated and designed such that probability of switching for patient subgroups could be varied within treatment-arms. Other subgroup characteristics could be controlled and 24 scenarios with varied levels of bias were analysed. A review of submissions to the National Institute of Clinical Excellence was performed and used to inform the scenario parameters.The RPSFT and IPE methods returned the lowest biases, <8%, in all scenarios. The estimates of the parametric randomisation based method were often far less variable than other methods but were subject to erratic behaviour with extreme biases observed. The other methods performed poorly in general, with biases of up to 50% not uncommon. In particular the IPTW method over-compensates in most scenarios.Under these conditions the results clearly identified the RPSFT and IPE methods as most consistent and accurate, with the latter the more consistent of the two. None of the other methods returned consistent results, and as such cannot be recommended.Further avenues of investigation include exploring the effect of other underlying survival distributions, extending from univariate models to adjust for other covariates, and extending from situations where just control-arm patients switch to scenarios with multidirectional cross-over.


To determine the prevalence of clinically relevant unrequested extra-cardiac imaging findings on cardiac Computed Tomography (CT) and explanatory factors thereof.A systematic review of studies drawn from online electronic databases followed by meta-analysis with meta-regression was performed. The prevalence of clinically relevant unrequested findings and potentially explanatory variables were extracted .Nineteen radiological studies comprising 12922 patients met the inclusion criteria. The pooled prevalence of clinically relevant unrequested findings was 13% . The large differences in prevalence observed were not explained by the predefined  variables.Clinically relevant extra-cardiac findings are common in patients undergoing routine cardiac CT, and their prevalence differs substantially between studies. These differences may be due to unreported factors such as different definitions of clinical relevance and differences between populations. We present suggestions for basic reporting which may improve the interpretability and comparability of future research. Improvements in the quality of cardiac Computed Tomography (CT) are driving its increasingly widespread use in an expanding patient-group Whilst they apply to all diagnostic imaging modalities, unrequested findings are particularly germane to cardiac CT due to the density of organ systems in the chest and the practice of exclusively evaluating the cardiac/coronary structures. Furthermore, typical patients referred for cardiac CT may also be relatively prone to co-morbidities, due to the confluence of wide-ranging (cardiovascular) risk factors, such a smoking, hypertension, diabetes and obstructive pulmonary disease Concerns over the growth of healthcare consumption and radiation exposure are driving calls for the efficient use CT This uncertainty poses a challenge to radiologists and referring physicians alike, with responses ranging from calculated disregard to evaluation of all imaging data available and aggressive follow-up of unrequested findings Here we review those publications examining the prevalence of incidental findings amongst patients referred for routine cardiac CT scans and assess the effect of candidate explanatory factors abstracted from these articles through a systematic search, review and meta-analysis with meta-regression.A systematic review method was employed to ensure comprehensive coverage of the available evidence. The Meta-analysis of observational studies (MOOSE) checklist The titles and abstracts from the different databases resulting from this search were combined and duplicates were manually filtered. The remaining articles were then subjected to the selection procedure further outlined in The ‘STrengthening the Reporting of OBservational studies in Epidemiology’ (STROBE) Briefly, we deemed the items concerning the setting, the sources/eligibility criteria of participants, and the description of study participant characteristics and the reporting of results to be the most germane and these were further specified to our research question. The resulting specified items, alongside the original STROBE items from which they were derived,  were scoData on study parameters and the prevalence of unrequested findings were extracted from the included papers by two authors independently, with consensus sought in cases of disagreement. The primary outcome of interest was clinically relevant unrequested findings, defined as those unrequested findings which required short-term follow-up, either with further diagnostic procedures or therapeutic interventions.2 and Tau2 statistics 2 was found to be higher than 25% 2 statistic reflects. Funnel plots were generated and visually inspected for approximate symmetry to assess the risk of publication bias.All statistical analyses were carried out using the R statistical program For the meta-regression, mixed effects regression using unrestricted maximum likelihood estimator method was employed to estimate the effects of potentially explanatory variables that could be abstracted from the articles. The reported mean age, proportion of smokers, years since publication and use of full Field Of View  were considered as potentially explanatory for differences in the levels of clinically relevant unrequested findings reported. Where an explanatory variable was not reported, we imputed it using simple median imputation (only relevant for the proportion of smokers).The majority of the nineteen papers reviewed routine cardiac CT’s were conducted in convenience samples of patients with suspected Coronary Artery Disease (CAD) to determine the prevalence and significance of any unrequested findings. Three studies only retrospectively reviewed the radiology reports Several studies also drew a direct comparison between the unrequested findings detectable on full thoracic FOV and smaller, cardiac FOV. Kim et al. All studies distinguished between clinically relevant unrequested extra-cardiac findings and clinically irrelevant findings by classifying the former as those that require further action or follow-up and the latter as those that do not (non-relevant). Some also opted for a multimodal classification into mild, moderate and severe, with the latter two requiring some form of clinical action This classification did not seem systematically pre-specified in any of the papers and was typically described pragmatically and briefly in the methods as based upon the attendant need for further follow-up or action according to the insights of the evaluating radiologists and cardiologists  relevant unrequested findings actually led to therapeutic or diagnostic consequences, chiefly through chart-review. Machaalany et al 2 statistic of 98%. This suggests excess inter-study variability and correspondingly random effects were employed to generate pooled estimates. We found that the random-effects pooled prevalence estimates differed substantially from the fixed effects estimates, in keeping with the degree of heterogeneity suggested by the I2 . We found that 14 articles mentioned cursory study patient characteristics but that these were usually limited to age and gender, with parameters such as smoking status missing in 8/19(42%) studies  was not explained by likely study and population characteristics, such as smoking and age. Similarly, imaging technique (i.e. FOV) did not explain the heterogeneity between studies. More detailed imaging and population characteristics that could have explained the heterogeneity were not systematically reported, as shown by the results of the STROBE quality check, with a only a third of articles fully describing the referral population source and reporting their risk profiles.Differences in definition and classification of the endpoint, i.e. clinically relevant unrequested findings, is probably the largest contributor to the high level of heterogeneity. In each article the clinical relevance of the unrequested findings were defined based upon prevailing local insights and the expert opinion of the evaluating radiologists rather than any systematic evidence of prognostic significance, making it very difficult to begin to assess the nature of the criteria.Consensus on the definition and classification of relevant unrequested findings is impossible in the absence of evidence concerning the prognostic and diagnostic value of such findings. Evidence supporting the wider prognostic value of (types of) unrequested findings might support more systematic reporting and acting-upon unrequested findings observed on cardiac CT and other scan-types by demonstrating their value and raising awareness. It is plausible that further research could also differentiate between findings with higher value and those with little or none. Such evidence would improve studies in this field, which until now have treated unrequested findings as large undifferentiated groups and assigned significance according to individual author’s insights.The growing acceptance of more and earlier cardiovascular CT screening We found large discrepancies between the prevalence of clinically relevant (i.e. requiring follow-up) findings and the number of findings that actually led to therapeutic or diagnostic interventions We acknowledge that our study suffers from several limitations, including language limited to English, Dutch and German. Furthermore by choosing to limit our analysis to only cardiac CT, the prevalence’s we found may not be representative of the prevalence of unrequested findings in other anatomical regions or using other modalities. We examined the effects of study parameters on the prevalence of clinically relevant unrequested findings using the aggregate level data reported in the included studies and did not pursue the individual patient data . The latter approach is likely to have been more sensitive to subtle variations between the populations In the absence of a standard definition of clinically relevant unrequested and to facilitate comparison between studies, we recommend that future studies transparently report the nature of the unrequested findings detail their absolute numbers and prevalence, the impact on patient care and outcome (if applicable), and the demographic and clinical characteristics of the source population. This is in lieu of reporting detailed criteria for clinical relevance, which may be impossible to pre-specify at this stage. In addition to adhering to the STROBE checklist, we suggest authors further specify the exact referral sources of patients included and report the prevalence of relevant risk factors, as specified in We found a high prevalence of clinically relevant unrequested findings among published studies. The large range of prevalence’s could not be satisfactorily explained in this analysis. Further research to assess the true prognostic value of individual (sets of) unrequested findings that incorporates follow-up to measure associated patient outcomes would be desirable to inform an evidence-based response to the high prevalence of potentially clinically relevant unrequested information on thoracic CT scans.Supplement S1MOOSE reporting checklist and location of items in article.(DOC)Click here for additional data file.


The effects of systemic disease on the lower extremity of high-risk patient groups, namely Diabetes and Rheumatic disease is well recognised and established within the Podiatrist’s scope of practice. However, it appears limited information is known within in the Podiatry profession about patients with Chronic Kidney Disease (CKD) and the onset of lower extremity complications. The main objective of the study was to systematically review the prevalence of lower extremity Peripheral Arterial Disease (PAD) and Peripheral Neuropathy (PN) in CKD and provide recommendations on the development of clinical guidelines.The role of the Podiatrist is to identify the factors which may place the individual’s lower extremity ‘at-risk’. In many cases, these factors do not present in isolation and often co-exist to further increase the risk of the limb. The presence of lower extremity PAD and PN in the development of foot ulceration has been extensively studied in systemically high-risk groups. However, very little evidence appears to be available to support the effects of co-existing risk factors on the lower extremity of individuals with CKD.A systematic review was performed in accordance with the methodology employed within in the Scottish Intercollegiate Guideline Network (SIGN) guideline development process.The findings confirmed an increased prevalence of PAD and PN within the CKD population. Prevalence rates of PAD ranged from 19-25.5% and PN from 44-74%. Indeed, placing this patient group at risk for further complications, which in turn increases the risks of lower extremity ulceration and possible amputation.This systematic review has highlighted that the independent presence of PAD and PN in CKD can have profound effects on the viability of the lower extremity. However guidelines, treatment strategies and screening programmes are currently minimal to support this high-risk patient group.National frameworks such as SIGN and NICE have recognised the benefits of foot screening programmes to be invaluable in preventing foot related complications within other high-risk groups, such as Diabetes, however this has not included the CKD population. This systematic review would recommend all patients presenting with CKD should be screened for lower extremity vascular and neurological impairment. Furthermore, National guidelines should be developed to highlight the profound effect these risk factors can have on the lower extremity in CKD and encourage the Health Care Professional to undertake simple non-invasive tests to detect and prevent the development of these potentially serious complications.


We and other workers have shown that accessory enzymes, such as β-glucosidase, xylanase, and cellulase cofactors, such as GH61, can considerably enhance the hydrolysis effectiveness of cellulase cocktails when added to pretreated lignocellulosic substrates. It is generally acknowledged that, among the several factors that hamper our current ability to attain efficient lignocellulosic biomass conversion yields at low enzyme loadings, a major problem lies in our incomplete understanding of the cooperative action of the different enzymes acting on pretreated lignocellulosic substrates.The reported work assessed the interaction between cellulase and xylanase enzymes and their potential to improve the hydrolysis efficiency of various pretreated lignocellulosic substrates when added at low protein loadings. When xylanases were added to the minimum amount of cellulase enzymes required to achieve 70% cellulose hydrolysis of steam pretreated corn stover (SPCS), or used to partially replace the equivalent cellulase dose, both approaches resulted in enhanced enzymatic hydrolysis. However, the xylanase supplementation approach increased the total protein loading required to achieve significant improvements in hydrolysis (an additive effect), whereas the partial replacement of cellulases with xylanase resulted in similar improvements in hydrolysis without increasing enzyme loading (a synergistic effect). The enhancement resulting from xylanase-aided synergism was higher when enzymes were added simultaneously at the beginning of hydrolysis. This co-hydrolysis of the xylan also influenced the gross fiber characteristics  resulting in increased accessibility of the cellulose to the cellulase enzymes. These apparent increases in accessibility enhanced the steam pretreated corn stover digestibility, resulting in three times faster cellulose and xylan hydrolysis, a seven-fold decrease in cellulase loading and a significant increase in the hydrolysis performance of the optimized enzyme mixture. When a similar xylanase-aided enhancement strategy was assessed on other pretreated lignocellulosic substrates, equivalent increases in hydrolysis efficiency were also observed.It was apparent that the 'blocking effect' of xylan was one of the major mechanisms that limited the accessibility of the cellulase enzymes to the cellulose. However, the synergistic interaction of the xylanase and cellulase enzymes was also shown to significantly improve cellulose accessibility through increasing fiber swelling and fiber porosity and also plays a major role in enhancing enzyme accessibility. A crucial step in the bioconversion of lignocellulosic feedstocks to biofuels is to cost-effectively maximize the saccharification of the cellulose and hemicellulose components to fermentable sugars. One of the challenges is the still too high enzyme costs involved in the saccharification of the cellulosic component ,2 and, tThe hemicellulose-degrading enzyme activities detected in most of the commercially available cellulase preparations are too low, or are insufficiently active enough, to achieve significant conversion of the residual hemicellulose ,12. TherHemicellulose, which is generally found in higher concentrations on the outer surface of cellulose fibers but is also diffused into the interfibrillar space through fiber pores ,16, has It has been suggested that xylan forms a sheath on each cellulose microfibril and that it is also 'zipped into' the cellulose microfibrils during crystallization, shortly after cellulose synthesis ,21. ThusThe synergistic action among the multiple forms of hemicellulose-degrading enzymes  and also among the cellulose-degrading enzymes (such as exoglucanases and endoglucanases) has been studied extensively ,24-26. AIn the work reported here, the possible additive or synergistic interaction of xylanase with cellulases was determined during the hydrolysis of steam pretreated corn stover (SPCS) at the minimum enzyme loading required to achieve substantial (greater than 70%) cellulose hydrolysis. Initially, two strategies were evaluated; xylanase supplementation of the minimum cellulase dose required for effective cellulose hydrolysis, and replacement of a portion of the minimum cellulase dose with xylanase while keeping the total protein loading constant. The degree of synergism (DS) was calculated and compared at various xylanase:cellulase ratios. To further investigate the xylanase-cellulase interaction mechanisms, hydrolysis experiments were also carried out by adding the enzymes (cellulases and xylanase) separately, simultaneously and sequentially. The changes in the gross fiber characteristics of SPCS were also monitored over the course of hydrolysis with or without xylanase addition. Finally, the beneficial hydrolysis-boosting effect of xylanase was further evaluated on a range of lignocellulosic substrates. In all of the hydrolysis experiments, controls containing BSA and additional cellulolytic enzymes at equivalent protein loadings to the xylanase were carried out in an attempt to evaluate whether xylanolytic activity offers any advantage over simply increasing the protein dose or the overall cellulase activity.Initially, the protein concentrations and specific activities of the three commercial glycoside hydrolase preparations used in this study were determined and compared Table . As expeIn order to assess the influence of xylanase addition during the enzymatic hydrolysis of the SPCS substrate, the hydrolysis experiments were carried out over a range of increasing dosage of cellulase activity (Celluclast) in the absence and presence of fixed amounts of xylanase activity (Multifect Xylanase) Figure .In the absence of xylanase, cellulose and xylan hydrolysis increased with increasing cellulase loading and reached a plateau at a cellulase protein loading of 35 mg/g cellulose Figure . At thisInterestingly, the addition of xylanase (60 mg/g cellulose) alone, in the absence of cellulases, resulted in only 60% of the xylan being hydrolyzed and further increases in xylanase loading did not improve the hydrolysis of the xylan (data not shown). However, the addition of low amounts of cellulases (5 mg/g cellulose) significantly increased xylan hydrolysis Figure .It appears that the supplementation of cellulases with xylanase not only substantially increased the rate of hydrolysis of both the cellulose and xylan, it also increased the extent of hydrolysis. For example, the maximum degree of cellulose and xylan hydrolysis in the absence of xylanase supplementation were about 75% and 93%, respectively, at a cellulase loading of 95 mg/g cellulose, whereas cellulose and xylan hydrolysis were about 80% and 100%, respectively, when xylanase was added (60 mg/g cellulose), even at relatively low cellulase loadings of 5 mg/g cellulose. This increase suggested that the residual xylan present in the pretreated SPCS substrate played an important role in limiting the ease of cellulose hydrolysis.Although it was clear that xylanase supplementation improved both cellulose and xylan hydrolysis at various levels of cellulase loading Figure , it appeIt was apparent that supplementing the cellulases with varying amounts of xylanase increased both the cellulose and xylan hydrolysis Table . HoweverMost of the previous work in this area has reported an increase in substrate digestibility upon xylanase supplementation, without further explanation of the likely mechanism behind the cooperative interaction between both types of enzymes. To try to further clarify the mechanisms behind the observed synergistic cooperation between the cellulases and xylanase, various time course hydrolysis profiles were followed using simultaneous, separate, and sequential addition of cellulases and xylanase Figure .It was apparent that, regardless of the enzymes addition strategy used, much of the xylan was solubilized during the first three hours of hydrolysis Figure . The simIt was apparent that the addition of xylanase alone (30 mg/g cellulose) resulted in limited (5%) cellulose hydrolysis Figure . HoweverWhen both types of enzymes were added simultaneously (simultaneous hydrolysis), the enzymatic digestibility of SPCS was substantially increased Figure . For exaHemicellulose is known to contribute to fiber strength and its solubilization is known to influence pulp fiber properties. One method that has been successfully used by the pulp and paper sector to evaluate changes at the fiber level is the use of a fiber quality analyzer (FQA). By using this equipment we hoped to determine any changes in the fiber dimensions and fiber size distribution of the unhydrolyzed and residual SPCS after simultaneous and separate hydrolysis with cellulase and xylanase addition over 24 hours Figure  and 3B.When compared to the unhydrolyzed SPCS control, xylanase addition alone did not result in any changes in the fiber length distribution Figure . In contWe next measured changes in the fiber width of the residual SPCS after hydrolysis, as this value can provide a general indication of the degree of fiber swelling Figure . As was To see if we could quantify any increases in accessibility of the SPCS fibers to the enzymes, we used the Simons' stain method, which has previously been shown to provide a good estimation of cellulose accessibility . An incrTo determine if the xylanase-boosting effect observed during hydrolysis of SPCS could also be observed with other biomass substrates, steam pretreated sweet sorghum bagasse (SPSB) and steam pretreated lodgepole pine (SPLP) were hydrolyzed with similar combinations of cellulases and xylanase as were carried out with the SPCS substrate Figure . The SPSEffective enzymatic hydrolysis of the cellulose and hemicellulose present in pretreated lignocellulosic substrates to fermentable sugars has been shown by many workers to require a combination of various glycoside hydrolases whose combined action is believed to be more efficient than the sum of the actions of the individual enzymes. This is the basis of the so called 'synergistic enzyme interaction' effect. Many studies have looked at the synergistic interactions among the major cellulase components and different explanations have been given for their interactions on model cellulosic substrate. Hypotheses include the creation of new hydrolysis sites, removal of physical obstacles , presencThe major beneficial effect of xylanase supplementation to cellulase enzymes mixtures has frequently been suggested to be a result of increasing cellulose accessibility to the cellulase enzymes due to the removal of the xylan coating on the outer surface of the pretreated pulp fibers ,12. Howeet al. [et al. [In the work described here, our initial approach was to define the minimum amount of cellulase enzymes required for effective hydrolysis and to assess the type and extent of the interaction between xylanase and cellulase enzymes in an attempted to improve hydrolysis efficiency of pretreated lignocellulose at low protein loadings. It was apparent that the type of interaction between xylanase and cellulase enzymes is dependent on the total enzyme loading and enzymes ratio, as has been observed previously ,35. A stet al.  and Berl [et al.  also fouet al. [There are several possible explanations for the strong synergistic interaction observed between cellulases and xylanase. As mentioned earlier, xylanase have been suggested to remove the xylan coat on the surface of pulp fiber, improving cellulose accessibility to cellulase enzymes ,8,12. Inet al.  found thet al. ,37. The et al. , and thiet al. . Previouet al. . TherefoXylanases have also been shown to result in the solubilization of lignin fractions from pretreated lignocellulosic biomass by breaking down the lignin-carbohydrate complex and consequently improving substrate digestibility ,22. It iSince it has been predicted that a diverse range of plant biomass will be needed to satisfy the projected demands for advanced biofuels , the hydIn summary, it appears that the observed xylanase-boosting effect during hydrolysis of pretreated lignocellulosic biomass is a result of both increased cellulose accessibility to cellulase enzymes as a result of xylan removal from pulp fibers, and the synergistic interaction of the xylanase and cellulase enzymes increasing cellulose accessibility through increasing fiber swelling and fiber porosity.It was apparent that the overall protein loading required to achieve fast, nearly complete hydrolysis of a model cellulosic substrate (SPCS) could be significantly reduced by making use of the synergistic interaction that occurs between cellulases and xylanase. It is likely that the added xylanase enhanced overall hydrolysis by solubilizing xylan, which impedes access to the cellulose. The 'xylanase-boosting' effect was observed on a range of pretreated lignocellulosic materials, regardless of their xylan content. So called accessory enzymes such as xylanase might offer considerable potential to increase the overall performance of cellulase enzyme mixtures, while reducing the protein loading required to achieve effective hydrolysis of pretreated lignocellulosic substrates.Corn stover, sweet sorghum bagasse and lodgepole pine were steam pretreated according to previously described procedures ,43. The Trichoderma reesei, β-glucosidase  from Aspergillus niger, and xylanase  from a genetically modified strain of T. reesei were used. The protein content and enzyme specific activities of the enzyme preparations are summarized in Table p-nitrophenyl-β-D-cellobioside, p-nitrophenyl-β-D-xylopyranoside, and p-nitrophenyl-β-D-glucopyranoside as substrates, respectively, as described previously [Cellulases , from eviously . Proteineviously .®, Yang-Chung, Seoul, Korea) at 50°C in accordance with previously described methods [The hydrolysis experiments were carried out at 2% (w/v) solids loading in sodium acetate buffer . The reaction mixtures (1 mL) were mechanically shaken in an orbital shaker incubator  as described elsewhere . The hydThe following equation was used to calculate the degree of synergism between cellulase enzymes and xylanase during SPCS hydrolysis:mixture is the cellulose hydrolysis achieved with cellulases and xylanase added together, and ∑GCindividual is the sum of cellulose hydrolysis achieved with the individual enzymes.where GCTo assess changes in fiber characteristics during hydrolysis, a FQA  was used to monitor fiber length and width according to the procedure described previously . The setThe changes in available surface area were determined using a modified version of the Simons' staining technique previously used to evaluate cellulose accessibility to cellulase enzymes ,50. The BSA: bovine serum albumin; CMCase: carboxymethyl cellulase; DB: blue dye; DO: orange dye; DS: degree of synergism; FQA: fiber quality analyzer; HPLC: high performance liquid chromatography; SPCS: steam pretreated corn stover; SPLP: steam pretreated lodgepole pine; SPSB: steam pretreated sweet sorghum bagasse.The authors declare that they have no competing interests.All authors contributed jointly to all aspects of the work reported in the manuscript. JH carried out much of the laboratory work, contributed to planning, interpretation of results and drafting of the paper. VA contributed to the planning, interpretation and drafting. JS contributed to the planning, interpretation and writing of the manuscript. All authors read and approved the final manuscript.


Leber Congenital Amaurosis (LCA) is one of the most common forms of congenital blindness in young children. It is the most severe retinal dystrophy, characterized by strong visual impairment or blindness within the first months after birth. Despite its genetic heterogeneity, the clinical phenotype is highly overlapping, pointing towards a common disease mechanism. To gain insights into the mechanism, we compared the interactomes of wild type and LCA causing mutants of lebercilin by quantitative mass spectrometry using SILAC followed by MaxQuant based analysis. This revealed that the link of lebercilin to the IFT complex is disrupted due to LCA-associated mutations. The interaction of the IFT proteins with lebercilin was confirmed by GST pull-down from retina, the loss of IFT proteins from the complex of mutants by western blot. While the disruption of the lebercilin-IFT interaction does not lead to disturbed ciliogenesis in both, hTERT-RPE1 cell and in the generated lebercilin knockout mice, the light dependent translocation of arrestin and transducing is clearly impaired, as well as the transport of opsins to the outer segments of photoreceptors. As a consequence this results in improper outer segment formation and finally photoreceptor degeneration. These data suggest that the interaction of lebercilin with the IFT complexes is important for ciliary transport in photoreceptors and thereby for formation and/or maintenance of outer segments. Further, our findings demonstrate that the disruption of ciliary transport to the outer segment is a cause for LCA.http://www.eye.uni-tuebingen.de/medical-proteome-center


Children with asthma and their parents usually can not cope with this disease leading to poor control. A constructed supporting program can improve treatment outcomes.We conducted an open-label randomized controlled trial to investigate the impact of support intervention to the outcome of parents of asthmatic children. The constructed supporting program includes scheduled one-by-one and group asthma knowledge education, treatment adherence reinforcement, family support course, and telephone follow-up. The differences of parental knowledge of asthma, medication adherence, hospital re-admission, and health care resource usage between two groups were compared.The study enrolled 130 parents of asthmatic children who were randomized into 2 groups in the Pediatric Allergic Clinic of the Chang Gung Memorial Hospital. The experimental group (65 parents) who received support program and training course in addition to the regular care provided to the control group. There was less emergency room visits in experimental group . The understanding of the disease was much improved in parents of experimental group . Furthermore, parents acquired a more positive attitude to asthma and had better adherence The control group without supporting program presented with irregular follow-up and poor compliance of medication usage.This study emphasizes that a support program in children with asthma must be an important part of treatment and it can reduce unpredicted heath care resource usage. used to educate parents in how to provide the best treatment plan for their children. It may play a significant role in reducing asthma progression and morbidity of late stage asthmatic children.