Probiotic encapsulation technology (PET) has the potential to protect microorgansisms and to deliver them into the gut. Because of the promising preclinical and clinical results, probiotics have been incorporated into a range of products. However, there are still many challenges to overcome with respect to the microencapsulation process and the conditions prevailing in the gut. This paper reviews the methodological approach of probiotics encapsulation including biomaterials selection, choice of appropriate technology,  PETprobiotic encapsulation technologyMmannuronic acidGguluronic acidFDAfood and drug administrationFAOfood and agricultural organizationWHOworld health organizationCAPcellulose acetate phthalateASMamerican society of microbiologySDS-PAGEsodium dodecyl sulphate polyacrylamide gel electrophoresisFTIR-ATRfourier transformer infra red-attenuated total reflectanceSEMscanning electron microscopeTEMtransmission electron microscopeProbiotic survival in products is affected by a range of factors including pH, post-acidification during products fermentation, hydrogen peroxide production and storage temperatures . ProvidiProbiotic encapsulation technology (PET) is an exciting field of biopharmacy that has emerged and developed rapidly in the past decade. Based on this technology, a wide range of microorganisms have been immobilized within semipermeable and biocompatible materials that modulate the delivery of cells. The terms immobilization, entrapment and encapsulation have been used interchangeably in most reported literature . While eThe best application of PET in biopharmacy is the controlled and continuous delivery of cells in the gut. The potential benefit of this therapeutic strategy is to maintain greater cell viability despite the acidity into the stomach. In their viable state, probiotics may exert a health benefice on the host ,5. One rSelecting the encapsulation technology is very important. Whereas probiotics are living cells, the conditions for implementation of this technology are designed to maintain cell viability, and solvents involved in the encapsulation technology must be non-toxic. Furthermore, assess the release conditions of encapsulated probiotics in a gastrointestinal tract model is an essential approach, which would give an idea of the cells’ behavior.in vitro release studies of encapsulated probiotics, and highlights the challenges to be overcome in this area.This paper reviews the methodological approach of probiotics encapsulation including biomaterials selection, choice of appropriate technology, The concept of biomaterials usually results in various definitions. A definition often accepted in the field of biology and medicine is “any natural material or not, which is in direct contact with a living structure and is intended to act with biological systems” . The bioAfter microencapsulation, the protective device-based biomaterial is intended to be in contact with the digestive tract of the host. For all these reasons, much of the general criteria developed for choosing biomaterials can be applied. Issues involved when selecting biomaterials for probiotics encapsulation are: (a) physicochemical properties  toxicology assay; (c) manufacturing and sterilization processes.Biomaterials are inorganic or organic macromolecules, consisting of repeated chain of monomers linked by covalent bonds. Their chemical structure and the conformation of the monomer chains give them specific functionality such as ability to form gels . The mosL-guluronic (G) and acid β-D-mannuronic (M) linked by β (1–4) glycosidic bonds in vitro The challenge of equipment refers to beads or capsules sizes, which are crucial and should be carefully controlled. Small capsules or beads under controlled conditions will not affect the texture of food products . Most ofin vitro studies, through simulation of simple and reproducible gastrointestinal tract models. At this level, the lack of standard protocol in the conduct of these tests remains a concern. Efforts should be made in this direction by the scientific community. A model of gastro-intestinal tract has been recently published by Gbassi et al. [Another challenge will be to determine the physicochemical characteristics of encapsulation materials to predict their mechanisms of disintegration or dissolution under varying conditions of pH and salinity and their interactions with probiotic cells or other components present in the digestive tract. PET will be of importance in delivering viable strains of probiotic to consumers in the near future. Evidence of this delivering must firstly be provided by the results of i et al. . This moin vivo studies will confirm the delivering of probiotics in the gut, but also provide evidence of their health benefits. Legislation in the United State of America allows probiotics under dietary supplement health [Clinical data resulting from t health . In Eurot health . ProbiotThe final challenge is to minimize the costs of PET. According to , the dev


Carex lasiocarpa in riparian wetlands in Sanjiang Plain to the environmental gradient of water depth was analyzed by using the Gaussian Model based on the biomass and average height data, and the ecological water-depth amplitude of Carex lasiocarpa was derived. The results indicated that the optimum ecological water-depth amplitude of Carex lasiocarpa based on biomass was , while the optimum ecological water-depth amplitude of Carex lasiocarpa based on average height was . The intersection of the ecological water-depth amplitudes based on biomass and height confirmed that the optimum ecological water-depth amplitude of Carex lasiocarpa was  and the optimist growing water-depth of Carex lasiocarpa was 21.4 cm. The TWINSPAN, a polythetic and divisive classification tool, was used to classify the wetland ecological series into 6 associations. Result of TWINSPAN matrix classification reflected an obvious environmental gradient in these associations: water-depth gradient. The relation of biodiversity of Carex lasiocarpa community and water depth was determined by calculating the diversity index of each association.The response of  Carex lasiocarpa wetland is the main wetland type in the mire wetlands in Sanjiang Plain, Northeast China , while the optimum ecological amplitude of Carex lasiocarpa to water depth based on average height was . The optimum ecological amplitude of Carex lasiocarpa to water depth was  and the optimist growing point of Carex lasiocarpa to water depth was 21.4 cm.The results indicated that the optimum ecological amplitude of Carex lasiocarpa maintains high cover across most water-depth gradients but requires high variation at the wettest conditions. Water depth for plant species in the freshwater marsh showed the order as Carex pseudocuraica > Carex lasiocarpa > Glyceria spiculosa > Calamagrostis angustifolia.TWINSPAN classification matrix results reflected an obvious environmental gradient for wetland plant species: water-depth gradient. Carex lasiocarpa community was significantly correlated with water depth. With the increase or decrease of water depth, the densityof Carex lasiocarpa decreased, and the evenness index and diversity index of Carex lasiocarpa communities were low. In moderate water depth condition, the density of Carex lasiocarpa was the highest.The growth of


Treatment of locally advanced head and neck cancer remains a challenge because of the head and neck complex anatomy and the tumor invasion to the adjacent organs and/or metastases to the cervical nodes. Postoperative irradiation or concurrent chemoradiation may lead to damage of radiosensitive structures such as the salivary glands, mandible, cochlea, larynx, and pharyngeal muscles. Xerostomia, osteoradionecrosis, deafness, hoarseness of the voice, dysphagia, and aspiration remain serious complications of head and neck irradiation and impair patient quality of life. Intensity-modulated and image-guided radiotherapy by virtue of steep dose gradient and daily imaging may allow for decreased radiation of the organs at risk for complication while preserving loco-regional control. Treatment of locally advanced head and neck cancer remains a challenge because of the high rate of loco-regional failures and the potential for serious complications following treatment. The tumor frequently invades adjacent organs and/or regional neck nodes. Standard of care has been either postoperative irradiation or concurrent chemoradiation . RegardlSignificant reduction of spinal cord dose may be achieved with IGRT compared to IMRT by a reduced PTV margin . HoweverPositron-emission tomography (PET) scan or PET-computed tomography (PET-CT) allows accurate delineation of the tumor and cervical lymph nodes that can be incorporated into the planning CT. PET-CT is superior to CT for tumor imaging because of its ability to detect the tumor metabolic activity in addition to its anatomic location. In a study of 102 unresectable head and neck cancer, PET-CT significantly changed the staging and management of these patients compared to CT alone . Twelve Although PET-CT is the diagnostic imaging of choice for head and neck cancer IGRT, magnetic resonance imaging (MRI) also plays a critical role when there is suspicion of nerves infiltration, base of skull or parapharyngeal space invasion by the tumor given its better soft tissue discrimination compared to CT. For patients with nasopharyngeal cancer, MRI is complementary to PET-CT because of the tumor location with high risks for intracranial invasion through the skull base foramen and parapharyngeal extension , 10. In Xerostomia remains one of the most common complications of head and neck cancer Irradiation and may severely affect the QOL of patients. Xerostomia results from apoptosis of the acinar glands secondary to radiation and its severity is proportional to the radiation dose to the parotid glands .Compared to the three-dimensional conformal radiotherapy technique (3D-CRT), IMRT may significantly reduce radiation dose to the parotid glands because of the steep dose gradient. Mean dose to the parotids is usually kept around 26 Gy to allow recovery of the saliva following head and neck irradiation. However, if only one parotid gland can be spared from radiation, current recommendation is to keep mean parotid dose at 20 Gy or lower . A recenHearing loss commonly occurred following concurrent head and neck chemoradiation. A significant proportion of head and neck patients had baseline hearing deficit prior to radiation related to their age. Cisplatin can cause hearing loss which is dose-dependent and may exacerbate the elderly patients hearing deficits. When cisplatin is combined with radiotherapy, the hearing loss may worsen because of the radiosensitization effects of cisplatin on the normal cochlea cells. The threshold for hearing deficit ranges from 10 to 13 Gy when radiotherapy is combined with chemotherapy and affects mainly the high frequency range  . HoweverOsteoradionecrosis remains one of the most feared complications of head and neck cancer irradiation because of its effect on patient QOL. In severe cases of osteoradionecrosis unresponsive to conservative management, resection of the damaged bone may result in severe alteration of speech, chewing, and swallowing. The risk of radionecrosis is related to the volume of normal bone radiated to high radiation dose. Damage of the microvasculature irrigating the mandible may lead to decreased blood flow, poor wound healing, and ultimately necrosis. Mandibular radionecrosis usually occurs when the mandible dose exceeds 66 Gy . The preLaryngeal edema and resulting dysphonia commonly occur following head and neck cancer radiation when the laryngeal dose exceeds 43.5 Gy . The dysAspiration is a life-threatening complication of a head and cancer irradiation because of the risk of pneumonia and sepsis. Aspiration commonly occurs following head and neck cancer irradiation because of damage to the pharyngeal constrictor muscles. Aspiration risk is proportional to radiation dose to the pharyngeal muscles. Even though there are still controversies about which pharyngeal muscles are critical for the development of aspiration, 32% of the patients developed aspiration when the dose to the inferior pharyngeal muscles exceeds 52 Gy . Thus, pPreliminary clinical experiences of IGRT for head and neck cancers have been very encouraging. Excellent loco-regional control and survival have been achieved for various anatomic head and neck cancer sites. In a study of 19 patients with locally advanced oral cavity cancer who received postoperative irradiation with IGRT, the 2-year survival and loco-regional control were 94 and 92%, respectively . In anotImage-guided radiotherapy for head and neck cancer is a promising technique of radiation because of the potential for normal organ sparing without compromise of target coverage. Preliminary clinical results suggest that the dosimetric advantages of IGRT may be translated into excellent loco-regional control for patients with head and neck cancer. Further prospective studies with a large number of patients should be performed to verify this hypothesis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study analyzes the temporal variability/stability of the spatial distributions of key exploited species in the Gulf of Lions (Northwestern Mediterranean Sea). To do so, we analyzed data from the MEDITS bottom-trawl scientific surveys from 1994 to 2010 at 66 fixed stations and selected 12 key exploited species. We proposed a geostatistical approach to handle zero-inflated and non-stationary distributions and to test for the temporal stability of the spatial structures. Empirical Orthogonal Functions and other descriptors were then applied to investigate the temporal persistence and the characteristics of the spatial patterns. The spatial structure of the distribution  of the 12 key species studied remained highly stable over the time period sampled. The spatial distributions of all species obtained through kriging also appeared to be stable over time, while each species displayed a specific spatial distribution. Furthermore, adults were generally more densely concentrated than juveniles and occupied areas included in the distribution of juveniles. Despite the strong persistence of spatial distributions, we also observed that the area occupied by each species was correlated to its abundance: the more abundant the species, the larger the occupation area. Such a result tends to support MacCall's basin theory, according to which density-dependence responses would drive the expansion of those 12 key species in the Gulf of Lions. Further analyses showed that these species never saturated their habitats, suggesting that they are below their carrying capacity; an assumption in agreement with the overexploitation of several of these species. Finally, the stability of their spatial distributions over time and their potential ability to diffuse outside their main habitats give support to Marine Protected Areas as a potential pertinent management tool. The Mediterranean Sea is a marine biodiversity hotspot Beside traditional management measures  and other indicators were then applied to investigate the temporal persistence and characteristics of the spatial patterns.Data was collected within the “International Bottom Trawl Survey in the Mediterranean Sea” (MEDITS) project Merluccius merluccius), angler (Lophius piscatorius) and black-bellied angler (Lophius budegassa), Atlantic horse mackerel (Trachurus trachurus), Mediterranean horse mackerel (Trachurus mediterraneus), grey gurnard (Eutrigla gurnardus), red gurnard (Aspitrigla cuculus), Norway lobster (Nephrops norvegicus), red mullet (Mullus barbatus), horned octopus (Eledone cirrhosa), small-spotted catshark (Scyliorhinus canicula), elegant cuttlefish (Sepia elegans) and three squid species belonging to the Teuthoidea Order . Because of identification problems for juvenile anglers and squids, we had to put the two angler species into one group and do the same for the three squid species. We decided to include these 5 species because they are important targets for fisheries. Finally, we retained 12 species-like categories .Since the onset of the MEDITS survey, 300 different species have been identified in the Gulf of Lions, but many are low in abundance or even rare http://cg.ensmp.fr/rgeos).Our goal was to describe the spatial distributions of the selected key species in the Gulf of Lions and to evaluate their temporal variability. In order to analyze the whole 204 distributions sampled (17 years and 12 species), we chose a spatial statistical method that is valid for all the species. Firstly, we analyzed the spatial structures of the annual observations of the 12 selected key species. Indeed, many animals have a tendency to aggregate, for social reasons or because they depend on the same external factors, which are also spatially structured . The spatial structure is thus the value of the spatial autocorrelation at different lags . This led us to use geostatistics, a common technique to analyze the spatial patterns from in-situ data Empirical variograms from the raw data of the 12 key species did not lead to satisfactory results. The variograms were either flat or highly variable from one class of distance to another. It appears that some underlying stationary assumptions were violated due to two reasons: the presence of large areas with zero values and a proportional effect.Z = log(Y+c), where c is a positive constant and log is the natural logarithm. We set c to the smallest observable density to generate the smallest impact on the form of the variogram:i,j is the trawled surface at station i and of year j. The results and interpretations are done on the logarithm scale, and the term ‘log-density’ refers to the variable Z as described above.The histograms of species densities were highly skewed (coefficients of variations ranging from 0.7 to 7.1), characterized by large proportions of zero (or low) values and by very low proportions of extremely large values. Skewness of distributions is symptomatic of a proportional effect For some species, this transformation did not totally resolve the issue of stationarity because of the presence of many locations with zero values. The large proportion of zero values does not contradict the stationarity assumption, unless they are concentrated in the same area, which was the case in this study. Zero values in the observations may appear in two contexts: (i) the species was actually absent at the sampled site, thus a zero value will be always sampled in the neighborhood, or (ii) the trawl did not catch the individuals because of their scarcity, mobility and aggregative behavior, so it will appear in areas with small densities values. The stationarity assumption is violated only in the former case, thus the sub-areas should be removed from the analysis, but in practice there is no objective criterion to distinguish the underlying process. Thus we only excluded sub-areas where no individual has been caught during the 17 years (1994–2010). To get homogeneous areas, we only considered contiguous sites with zero values according to the bathymetry. To do this, we removed all the sites of depths smaller than 70 m, 310 m and 350 m, for the Norway lobster, the cuttlefish and the red mullet, respectively (we kept the full area for the other 9 key species).For comparison purposes, the analysis was also performed on presence/absence data. Binomial presence/absence data is relevant in the case of many zero values and it also avoids a proportional effect. Maps produced with such variables are spatial predictions of the probability of the presence of at least one individual. Furthermore, it enabled us to calculate presence/absence areas, which are an interesting indicator of spatial distribution (see below).We calculated the empirical variogram on the transformed variable Z to investigate the spatial structure  of each species for each year. The distance lag was set to 9 km, which corresponds to the minimum distance including at least 5 sites. The empirical variogram is associated with a sampling variance, which quantifies the uncertainty to assess the underlying true variogram, owing to the limited number of available samples (62 on average). For this reason, we examined if the annual empirical variograms of a given species were significantly different from year-to-year, in comparison with the sampling variance associated with the mean variogram. To do so, we first estimated the mean variogram of each species, by averaging the 17 annual empirical variograms at each distance lag. Then, the mean empirical variogram of each species was modeled using curves with known properties, as is common practice We also produced distribution maps of juvenile and adult stages over the 17 years. A year-to-year analysis was not possible because the densities of adults for many species were too low. Even so, such an analysis could be not done for squids, anglers, cuttlefish and red gurnard because: (i) squids and anglers included two to three species (see above) that display different length-at-maturity, (ii) the length and the maturity stages were not estimated for cuttlefishes and (iii) adult abundance was too low over the whole time period for red gurnard. For the nine remaining species, we kriged the means of the log-densities Z (or presence P) at each station over the 17 years. Juveniles and adults were discriminated using the length at 50% of maturity (L50) from Sardà The Empirical Orthogonal Functions (EOF) method was first applied to quantify the temporal stability of the spatial patterns in a more objective manner than simple visual inspection, as it is usual T) was estimated from the kriged data Several indices have been used to characterize the spatial distributions. Centre of gravity and inertia are two simple indices able to detect spatial shifts Annual empirical variograms on log-density values depicted clear spatial structures . For allFor nine retained species we mapped the average log-density of adult and juvenile stages over the survey period. EOFs were applied on the annual maps of each species to assess the temporal persistence of the spatial patterns . The percentage of variance explained by the first axis of the EOF was in general high (71% on average), but varied among species, i.e. from 39% (for squid) to 88%  of 12 key benthic/demersal species in the Gulf of Lions to evaluate the temporal stability/variability of the spatial patterns. We produced annual maps of log-densities for each key species by kriging bottom trawl survey data collected annually from 1994 to 2010, while the spatial structures were taken into account using variograms. Geostatistics One of the objectives of this study was to test the stability/variability of the spatial structures over time. To do so, we developed an original approach based on geostatistical non-conditional simulations of spatial Gaussian processes defined by the mean variograms obtained during the data-analysis phase. By calculating empirical variograms at the 66 sampling sites, we simulated the uncertainty inherent to stochastic models that comes from the fact that we used an incomplete census of the study area. It is interesting to note that the Box-Cox transformation of the data insured a consistency of the entire simulation exercise. Simulations are theoretically founded for Gaussian processes, which are the only situations where the knowledge of a variogram amounts to the full characterization of the model. The log-transformed densities were reasonably Gaussian, so that comparing the variograms obtained from log-transformed data and the variograms obtained by  simulations was relevant. The results clearly showed that the variograms were all included in the 95% confidence intervals (except for squids in 2000), revealing stable spatial autocorrelation patterns for each species. The presence of spatial structure had already been detected in other regions, for Norway lobster Illex coindetii, which tends to support such a hypothesis. Temporal stability of the spatial distributions is not so surprising for some species like the Norway lobster, due to its burrowing behavior and its dependence to particular sediments Annual maps of species' log-densities were produced by kriging, using annual observations and the mean variogram. The mean variograms were clearly more robust because they were based on the whole dataset. Furthermore, their forms were smoother and the models fitted better. Note that the stability of the annual variograms is an indication of the stability of spatial structures but does not necessarily imply the stability of the spatial distributions. For instance, if the spatial structure is due to interactions among individuals, the population may move across the area through time , while keeping the same spatial structure. This was not the case here as the annual maps displayed similar patterns from year-to-year for all the species. EOF enabled us to detect for each species their most persistent patterns over time, which were different between species. As contributions from each year to the first EOF were relatively equal, part of the variance explained by the first EOF axis confirmed the persistence of the spatial distribution through the 17 years. The percentages of variance due to the first axis were globally high, about 71% on average and even more for the grey gurnard, Norway lobster and hake. Only the squids exhibited a relatively low percentage of variance (38%), possibly because this group includes three different species that may have dissimilar spatial distributions, implying additional variability. A recent study in the Tyrrhenian Sea versus those of juveniles remain poorly documented and need further investigations. From a fisheries-management viewpoint, the protection of nurseries could be insufficient if the adult populations are distributed elsewhere The limit of the MEDITS sampling gear, which is more efficient for fishing on the shelf than at the upper slope where adults of several species are often concentrated, explains the relatively poor number of adults observed in some years for many species. This made a spatio-temporal analysis on only the adults intractable. Therefore, we produced average log-density maps in the 1994–2010 period, which was meaningful because of the temporal stability of annual spatial distributions. Adults were generally more concentrated than juveniles and occupied sub-areas within those of the juveniles. For instance, hake juveniles were homogeneously distributed in depths of 100 m to 200 m, whereas adults were more concentrated in depths of around 200 m. This is consistent with previous studies that describe an ontogenetic migration from the nurseries, located generally in shallow waters, to the end of the shelf, where spawning occurs The MEDITS survey is shown to be a suitable material for the study of the spatio-temporal patterns of marine species. Since 1994, it has been carried out in a standard manner . As we have already stressed, MEDITS bottom-trawls cannot, however, access the deepest areas of the continental slope because of the marine canyons. The biggest hake caught by Spanish longliners in this area are therefore not accessible to the MEDITS trawl survey. Furthermore, the survey occurs only once a year, for the month of June, so that year-to-year variations in abundance might partially reflect seasonal variations. While the MEDITS trawl survey obviously includes some limitations due to a restrictive sampling period, the high stability of the spatial distributions of all the species indicates that this survey is, nonetheless, able to capture the bulk of the spatial dynamics of these species. Another limitation in the ecological interpretation of our results was due to the identification uncertainty of some species, which forced us to mix several species of angler and squid. As these species are neither distinguished in the exploitation context, our results could, however, be of interest from a management viewpoint.We also conducted the same analysis by transforming the densities into presence/absence data. This approach does not require data to be log-normally distributed and the binary transformation also removed the proportional effect. Simulation analysis was done by generating a binary field using the relation between a Gaussian and an indicator variogram Despite the strong persistence of the spatial distributions, we also detected a link between the expansion/contraction of the presence areas of these 12 key species and their log-abundance: the more abundant the species, the larger the presence area. The linear relationship was positive and significant for all the species, except for hake, Atlantic horse mackerel and gray gurnard, for which it was only positive. However, these species occupied almost all the study area, whatever their level of abundance. Therefore, our results tend to support MacCall's basin theory, which states that the presence area is positively correlated to the abundance. Geographical expansion at high levels of abundance were already observed among pelagic and demersal fish, such as haddock Finally, our results give support to MPA as a pertinent management tool for exploited bentho-demersal species in the Gulf of Lions. Despite the high mobility of most of the species, their spatial distributions appear to be surprisingly stable over time. This was already empirically recognized for hake. Its relative resistance to overexploitation is supposed to be due to the persistence of large spawners at the end of the continental shelf and at the upper side of the slope, which are less accessible to fisheries Figure S1Annual maps of anglers. Kriged annual maps of both anglers (Lophius budegassa and Lophius piscatorius) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S2Annual maps of Atlantic horse mackerel. Kriged annual maps of Atlantic horse mackerel (Trachurus trachurus) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S3Annual maps of Mediterranean horse mackerel. Kriged annual maps of Mediterranean horse mackerel (Trachurus mediterraneus) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S4Annual maps of grey gurnard. Kriged annual maps of grey gurnard (Eutrigla gurnardus) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S5Annual maps of Norway lobster. Kriged annual maps of Norway lobster (Nephrops norvegicus) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S6Annual maps of red mullet. Kriged annual maps of red mullet (Mullus barbatus) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S7Annual maps of horned octopus. Kriged annual maps of horned octopus (Eledone cirrhosa) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S8Annual maps of small-spotted catshark. Kriged annual maps of small-spotted catshark (Scyliorhinus canicula) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S9Annual maps of cuttlefish. Kriged annual maps of cuttlefish (Sepia Elegans) log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S10Annual maps of squids. Kriged annual maps of squids  log-density (Z) from 1994 to 2010.(PNG)Click here for additional data file.Figure S11Average distributions of juveniles versus adults. Average maps (1994–2010) of the log-density (Z) of juveniles and adults of Trachurus trachurus, Trachurus Mediterraneus, Eutrigla gurnardus, Nephrops norvegicus, Mullus barbatus and Eledone cirrhosa.(PNG)Click here for additional data file.Figure S12Correlation circles from the EOF analysis. The correlation circle depicts the contribution of each descriptor (i.e. the years) to the two first axes of the Empirical Orthogonal Functions (EOF). Higher the contribution of a given descriptor to the first EOF axis, longer the arrow. Here, all the descriptors have positive and high contributions to the first axis, which insured that the percentage of variance explained by this EOF is an indicator of the stability of the spatial distributions through time.(PDF)Click here for additional data file.Figure S13Gravity centers and inertia. For each key species, gravity centers (crosses) and inertia axes of annual log-density maps, from 1994 to 2010.(TIF)Click here for additional data file.


Appropriate supervision, along with availability of an effective system for monitoring and evaluation, is a crucial requirement to guarantee sufficient coverage and quality of malaria vector control procedures. This study evaluated the efficacy of self-assessment practice as a possible innovative method towards achieving high coverage and excellent quality of larviciding operation in Iran.The research was conducted on the randomly selected rural health centre of Kanmbel Soliman with 10 staff and 30 villages, in three main steps: (i) assessment of effectiveness of larviciding operations in the study areas before intervention through external assessment by a research team; (ii) self-assessment of larviciding operations (intervention) by staff every quarter for three rounds; and, (iii) determining the effectiveness of applying self-assessment of larviciding operations in the study areas. Two toolkits were used for self-assessment and external evaluation. The impact of self-assessment of larviciding operations was measured by two indicators: percentage of missed breeding habitats and cleaned breeding habitats among randomly selected breeding sites. Moreover, the correlation coefficients were measured between self-assessment measures and scores from external evaluation. The correlation coefficient and Mann Whitney test were used to analyse data.Following the utilization of self-assessment, the percentage of missed breeding habitats decreased significantly from 14.23% to 1.91% (P <0.001). Additionally, the percentage of cleaned breeding habitats among randomly selected breeding sites increased from 66.89% to 95.28% (P <0.001). The external evaluation also showed significant effects of self-assessment in performance of vector control; the maximum effect of intervention were seen in an action plan for monitoring and evaluation of larviciding operations at field level, geographical reconnaissance for the registration of breeding habitats and worker skills related to larviciding.Before intervention, the results of self-assessment practice were compatible with external evaluation in 76.3% of 139 reviewed reports of self-assessment. After intervention, the findings of self-assessment and external evaluation were similar in the vast majority of reviewed reports (95%).The self-assessment tool seems to be valid and reliable in improving effectiveness of larviciding operations. Furthermore, the result of self-assessment is more compatible with external evaluation results if it would be applied frequently. Therefore, it can be used as an alternative assessment technique in the evaluation of larviciding operations in addition to traditional assessment methods. Plasmodium falciparum and the remaining were Plasmodium vivax[Malaria is the world's most important tropical parasitic disease with about 655,000 deaths each year and a further 216 million new cases of malaria diagnosed annually . Additioium vivax. The souium vivax.To achieve the malaria elimination goal in Iran, the Center for Disease Control and Prevention has focused its efforts on the World Health Organization’s (WHO) recommended strategies -10, inclAnopheles mosquitoes [Anopheles species with exophilic and exophagic behaviour [Generally these methods have been effective in the control of squitoes -17. Howeehaviour . The firehaviour  which maehaviour . Accordiehaviour . Accordiehaviour  and therehaviour .High coverage and high quality implementation are very important elements in vector control measurements . Strict Some epidemiological studies have shown that self-assessment as a method of monitoring and evaluation is an effective evaluation tool for improvement of organizational/personal performance ,17,25. TSelection criteria for study areas included having a long period of malaria transmission, the prominent role of larviciding in vector control measures, easy access to the field, and willingness of health authorities to use the self-assessment method in larviciding operations. Chabahar was selected as the target district for the present study. Chabahar is located in the south of Sistan and Baluchistan province (south-east Iran) and it is one of the most malarious areas in the country with a more than nine-month transmission season (February to May and July to November).Anopheles stephensi and Anopheles culicifacies have been reported as the main vectors in the study areas [Among all eight eligible rural health centres (RHC) in Chabahar, Kanmbel Soliman was selected randomly as the study region. Kanmbel Soliman is located in the north of Chabahar district. The 30 villages covered by Kanmbel Soliman RHC have a total population of 5,887 and 1,124 households . Anopheldy areas .The study is an action research with a before-and-after approach. It is a triangulation study, combining qualitative study, focus group discussions (FGDs), and quantitative studies; the second part of the study is a quasi-experimental study.Data were gathered by well-qualified data collectors. Validated questionnaires were used to gather expert opinion in order to design the required toolkits. Data regarding effectiveness of larviciding operations and effects of intervention were also collected  by direct interviews with related personnel, the review of official documents and field observation.The study was carried out following three main steps: (i) assessment of the effectiveness of larviciding operations in the study areas before intervention as baseline; (ii) design and establishment of a system for self-assessment of larviciding operations (intervention); and, (iii) determination of the effectiveness of applying self-assessment of larviciding operations in the study areas after intervention.As a primary phase to facilitate and standardize study procedures two toolkits were developed to determine the effectiveness of larviciding operations (DELT) and for the self-assessment of larviciding operation (SALT). The method for development of the toolkits was as follows:After investigating similar studies in the other parts of the world ,27-30 anMeetings and teleconferences were held between 30 experts and academic staff from international, national, provincial and district levels. After which a final draft of the toolkits was designed using the valuable comments obtained from the above-mentioned specialists in the field of management, monitoring and evaluation of vector-borne diseases. The toolkits and questionnaires were pre-tested in the field and the final versions were developed for this survey.Using DELT, the effectiveness of larviciding operations before intervention were measured during field visits to 30 villages in Kanmbel Soliman's RHC by the research team acting as external evaluators. Two indicators: “percentage of missed breeding habitats” and “percentage of cleaned breeding habitats among randomly selected breeding sites” were measured as impact indicators of larviciding operations as baseline. The first indicator generally shows the coverage and the second indicator denotes the quality of larviciding operation. Same indicators were measured for determining effectiveness of applying self-assessment of larviciding operation after intervention. In addition, some pertinent processes and output indicators were measured to obtain a clear picture of larviciding operations.Each village in the study area was searched for open water bodies to determine the percentage of missed breeding habitats . To locate potential breeding sites, the search was led by malaria experts with a good knowledge of the area. All possible breeding places within houses and other buildings, as well as open spaces within a range of 1.6 km  of human habitation in all 30 target villages, were carefully investigated.During the external evaluation process all detected breeding habitats were checked by the larviciding operator that they had been registered on the relevant registration sheet and the number of missed breeding habitats  was determined. the calculation of missed breeding habitats was divided by the total number of detected breeding sites.To measure this indicator in villages covered by the study, on average 25% of the total breeding habitats of each village was randomly selected  and screened for larvae and pupae using a dipper. The assessment was conducted during the transmission season when breeding places were expected to be covered by routine larviciding operations. The number of cleaned breeding habitats was divided by the total number of randomly selected breeding sites to calculate this indicator.Bacillus thuringiensis (Bioflash™ granule 10%) was used as the larviciding agent. Based on the product quality control protocol, breeding habitats where no Anopheles pupae were recorded by dipping were considered as a cleared site.The presence of larvae and their density was determined by dipping. From every randomly selected, potential breeding site, up to 10 dips were taken using a standard white 350 ml dipper. A slow-release formulation of A system for self-assessment of the operation was designed using lessons learned from other countries and the points of view of local experts and health authorities regarding standard larviciding operations. The system included a toolkit (SALT) and relevant procedures.The research team briefed target groups who were involved in larviciding operations in the study areas regarding the system for self-assessment of larviciding operations and the method of using SALT. Their role and responsibilities, and procedures for the establishment of self-assessment of larviciding operations, were identified by the main investigators. The system had been established in collaboration with local authorities and staff. The researchers advised and supervised local authorities to facilitate implementation of the system. No direct intervention in the procedure of conducting self-assessment of larviciding operations was made by the research team in order to avoid the possibility of any bias in the results.Using SALT toolkit, self-assessment by the involved staff in larviciding operations was carried out on a quarterly basis. Staff were asked to use the results of their self-assessment to determine areas in need of enhancement and to take necessary action towards the improvement of larviciding operations. Study subjects recorded the results of their self-assessment on the designed forms.The effectiveness of applying self-assessment of larviciding operations (after intervention) was measured through field visits to the 30 villages of Kanmbel Soliman's RHC by determining two impact indicators of larviciding operations including “percentage of missed breeding habitats” and “percentage of cleaned breeding habitats among randomly selected breeding sites”. This step was carried out by the research team acting as external evaluators, without giving prior notice to the staff involved in the intervention, exactly one week after the third round of self-assessment. . The method of measuring the indicators was exactly the same as that used in the preceding stage. It was evident that randomly selected breeding habitats for determining cleaned breeding sites were not the same as at the “before” stage. In addition, as in the previous stage (before intervention) the process and output indicators of larviciding operations were measured by the research team to find how larviciding operations worked compared to the previous stage (before intervention) which was considered as the baseline. Therefore, the quantity and quality of changes in the various areas of larviciding operations following the intervention were determined.To measure validity of the received data from the self-assessment process, the recorded self-assessment reports by staff in the first round, including process and output indicators, were collected by the research team and compared with the results of the first round of the external assessment. In addition, the results of the third round of self-assessment were compared with the results of external assessment that was conducted after intervention. Noting the short period (one week) between the third round of self-assessment and external assessment after intervention, the results were not affected by the time lag between the two evaluations.All indices’ scores were transformed to a scale of 100 and correlation coefficient and Mann Whitney test were used to analyse the data.Assessing the effectiveness of larviciding operations in the study areas before intervention was conducted from September to October 2010. The system for self-assessment of larviciding operations was established from October 2010 to September 2011. Assessment effectiveness of larviciding operations in the study areas (after intervention) was conducted from September to October 2011.This study was approved by the Research Ethics Committee of Zahedan University Medical Sciences, Iran. The aims of the project were discussed with all district health authorities and their written or verbal informed consent to cooperate was received. The names of staff pertinent to assessment were kept strictly confidential and were not used in the presentation of the results.Table Based on external assessment, there was a significant increase in all areas of larviciding operations after intervention compared to before. To have a better understanding, all indices’ scores were transformed to a scale of 100 Table . These fCorrelation between total score difference of larviciding operations based on external evaluation before and after intervention and differences of impact of larviciding operations before and after intervention are shown in Table The findings show an acceptable validity of data from self-assessment practice particularly after intervention when larviciding operators had carried out three rounds of self-assessment. Before intervention, the results of self-assessment practice were compatible with external evaluation in 76.3% of 139 reviewed reports of self-assessment. The remainder were mostly (25.0%) overestimated and a few were underestimated (2.87%). After intervention, the consistency in results between self-assessment and external evaluation increased considerably, such that the findings of both methods were similar in a vast majority of reviewed reports (95%). Although, it is expected that larviciding operators may rate their skills better than the reality with a “positive-self” bias. However, the presence of external evaluation in the present study reduced the possibility of this type of bias.There is sufficient evidence that self-assessment is a reliable assessment technique in both producing consistent evaluation results across tasks and items as well as contributing to higher individual/organizational achievement and improved performance -35. ThisNo study had examined the efficacy of self-assessment in malaria subjects. However, the utilization of self-assessment has been investigated in other topics, including driving ,32, nursThe present study supports the findings of these previous studies, claiming that self-assessment provides valid and reliable measures. For example, in the current study the self-assessment measures were significantly correlated with scores of external evaluation and indicated that self-assessment is reliable. Thus, it proves that the self-assessment tool provides valid and reliable measures of larviciding operators’ proficiency. It is suggested that self-assessment is a valuable assessment technique in the evaluation of larviciding operations, particularly when finding gaps and resolving detected defects is the main aim of monitoring and evaluation.A limited number of sample sizes were a restriction to the present study. However, the study included external evaluation along with self-assessment, which allowed the authors to discover the percentage of discrepancy between the two methods. Therefore, it is believed that this study provides valuable findings to be used in malaria vector control.In conclusion, self-assessment is a valid and reliable tool for assessing larviciding operations and that can play a positive role in enhancement of larviciding operations resulting in positive effects on impact of operation. It prompts operators to not only be acquainted with and correct possible shortcomings, but also to establish consolidated plans for improvement in coverage and quality of larviciding operations. The assessment may additionally help them to understand the concerns of others, including local and national health authorities. One of the most important lessons learned from this study is the fact that the results of self –assessment is more reliable and valid when this tool would be repeated and applied constantly as a routing practice. Finally, future research in this field should focus on establishing self-assessment practice in other vector-borne diseases.The authors declare that they have no competing interests.The overall implementation of this study including survey design, designing toolkits and questionnaires, data management and analysis, report writing and manuscript preparation were joint efforts by the authors of this paper. All authors have made extensive contribution to the review and finalization of the manuscript.


Phantom limb pain is very common after limb amputation and is often difficult to treat. The motor cortex stimulation is a valid treatment for deafferentation pain that does not respond to conventional pain treatment, with relief for 50% to 70% of patients. This treatment is invasive as it uses implanted epidural electrodes. Cortical stimulation can be performed noninvasively by repetitive transcranial magnetic stimulation (rTMS). The stimulation of the hemisphere that isn't involved in phantom limb (unaffected hemisphere), remains unexplored. We report a case of phantom limb pain treated with 1 Hz rTMS stimulation over motor cortex in unaffected hemisphere. This stimulation produces a relevant clinical improvement of phantom limb pain; however, further studies are necessary to determine the efficacy of the method and the stimulation parameters. Phantom limb pain (PLP) is very common after limb amputation and has a reported incidence of up to 87% of amputees . This tyμV in peak-to-peak amplitude with 10 consecutive stimulations, when the coil was placed over the optimal position to activate the abductor pollicis brevis muscle in right hand based on electromyographic recording [A 36-yr-old, right-handed man, who had had a motorbike accident ten years ago, had total surgical amputation of the left arm. At the time of his arrival to our institute, he had perception of phantom limb and was experiencing severe phantom limb pain. This perception and pain have existed immediately after the amputation. The perception of phantom limb was always in the same position near the chest with the hand partially closed near the shoulder. The patient experienced pain like paresthesia, dysaesthesia and burning sensation especially in phantom thumb, index and medium, and in the total phantom limb too. The pain was present every day, always in wakefulness but not in sleep. Such pain persisted during the day and sometime became very intense for some seconds. In the past, the patient tried antiepileptic drugs, tricyclic and SSRI antidepressant, anti-inflammatory-analgesics, and opioids in order to relieve the pain. At the time of his arrival to our institute, he was having the best therapy that gave a partial relief to the pain. The therapy consisted in methadone 30 mg/day and pregabalin 300 mg/day. Neurological examination showed miosis and light ptosis in left eye, like Bernard-Horner syndrome which has existed immediately after the amputation. The examination also showed tactile hypoesthesia in the surgical scar, while the tactile stimulation of the area near the scar increased the pain in the phantom limb. The tactile stimulation of the left side of the face increased the pain in the phantom limb too. Chest MRI and CT with contrast excluded a peripheral component of pain due to a concomitant lesion of the inferior brachial plexus. The patient gave the written informed consent. At the baseline, at the end of every week, for three weeks during treatment and at the end of every week for three weeks after treatment, the following tests were administered: Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating scale for Anxiety (HAM-A), Mania Rating Scale (MRS), CORSI TEST, Phonemic Verbal Fluency, and Visual Analogue Scale (VAS) for pain-0 (no pain) and 10 . The percentage of pain level modification was calculated from the VAS score by the following equation (post.rTMS – pre.rTMS pain scores) × 100/(pre.rTMS pain scores). ecording . During ecording . A full Although the study has a strong limitation due to the absence of placebo (sham) control, it nevertheless shows that the method of stimulation in nonphantom limb hemisphere with 1 Hz stimulation ameliorates the phantom limb pain with longlasting antalgic effects. The effects of rTMS on pain are similar to effects obtained by Passard et al. . PassardThe low frequency rTMS has showed antidepressant effects , 18, butInstead, the low frequency rTMS is known to reduce the excitability of the stimulated motor cortex. This can increase the excitability of the controlateral motor cortex via transcallosal pathways, and so it can have analgesic effects in a way similar to the epidural motor cortex stimulation and to the high frequency rTMS of motor cortex. In fact chronic motor cortex stimulation using implanted electrodes is an effective treatment of drug-resistant pain , but itsThe physiopathology of the phantom limb pain is still an open field between various hypotheses. The two major research streams on the painful phantom limb are focused on the pivotal influence of the periphery and of the spinal cord, while the other is focused on the fundamental role of suprasegmental structures and of the cortex. These two research streams seem to be more complementary than in opposition . However 1 Hz stimulation over motor cortex in unaffected hemisphere ameliorates phantom limb pain with longlasting antalgic effects. New experiments with this approach are necessary to confirm the therapeutic results and to improve them with better parameters of stimulation.


Breast cancer subgross morphological parameters  provide significant prognostic information and guide therapeutic decisions. Modern multimodality radiological imaging can determine these parameters with increasing accuracy in most patients. Large-format histopathology preserves the spatial relationship of the tumor components and their relationship to the resection margins and has clear advantages over traditional routine pathology techniques. We report a series of 1000 consecutive breast cancer cases worked up with large-format histology with detailed radiological-pathological correlation. We confirmed that breast carcinomas often exhibit complex subgross morphology in both early and advanced stages. Half of the cases were extensive tumors and occupied a tissue space ≥40 mm in its largest dimension. Because both in situ and invasive tumor components may exhibit unifocal, multifocal, and diffuse lesion distribution, 17 different breast cancer growth patterns can be observed. Combining in situ and invasive tumor components, most cases fall into three aggregate growth patterns: unifocal (36%), multifocal (35%), and diffuse (28%). Large-format histology categories of tumor size and disease extent were concordant with radiological measurements in approximately 80% of the cases. Noncalcified, low-grade in situ foci, and invasive tumor foci <5 mm were the most frequent causes of discrepant findings. Breast cancer is a heterogeneous group of diseases which deviate from each other in natural history, morphology, molecular phenotype, clinical and radiological manifestations, and prognosis. Prognostic parameters are essential for predicting the outcome and response to therapy in individual cases. The long list of more or less powerful prognostic parameters that includes patient age, mode of detection, tumor size, histologic grade, lymph node status, and presence or absence of distant metastases was recently widened with molecular tumor phenotypes assessed with either genetic tests or immunohistochemistry. Since the number of therapeutic options is rather limited, the parameters for which assessment is routinely required for therapeutic decisions are also few. Whereas hormone receptor status, HER-2 status, and proliferative activity are the major determinants of oncological therapy, proper characterization of the subgross morphology of breast carcinoma is essential for planning appropriate surgery and radiation therapy –4. The pFor correct subgross characterization of a case, the following parameters should be assessed: tumor size (defined as the largest diameter of the largest invasive focus), lesion distribution , disease extent , intratumoral or intertumoral heterogeneity, and the position of the tumor within the breast . These pAn applied histopathology method substantially influences the success rates of documenting and assessing this subgross morphological parameters and correlating them to radiological findings. The traditional small block sampling method is based on taking 1-2 cm sized samples from breast specimens, often under the control of only the pathologist's naked eye and sometimes using radiological guidance. This way, the specimen is fragmented and the interrelationship of the different tumor components, which are not represented in the same block, is destroyed. Taking large numbers of small blocks, sequential numbering of the blocks, and marking the sample placement on a macrophotograph of the specimen or in the specimen radiograph represent attempts to compensate for the obvious limitations of the sampling method. At the same time, these attempts are proof that such compensation is necessary. Large-format histopathology is based on embedding and processing contiguous tissue slices representing the entire cross section of a segmentectomy specimen, preserving the interrelationships of the components of the tumor, and documenting them together in one plane. This advantage makes this method the best approach in correctly assessing the subgross morphological parameters, which also facilitates the detailed radiological-pathological correlation , 6, 8–10Defined as the tumor volume containing all the actual malignant structures within the breast, the extent of disease is the most important subgross parameter influencing the feasibility of breast-conserving surgery in an actual case . This isin vivo orientation of the specimen by inking it at its margins [In everyday routine, the pathologist should begin the analysis of a case by recapitulating the radiological findings, including the radiological disease extent. The next step should be comparing the uncut specimen with the whole specimen radiograph and keeping the  margins . Breast cancer is a lobar disease most often involving parts of a single sick lobe , 19. TheThe space the malignant structures occupy in the breast rarely shows the regular shape of a geometric body; it is almost always irregular. This means that the borders of this space are different at different levels of the specimen and in different projections. Consequently, the area representing the cross section of this tissue space in the tissue slices of the specimen also varies. For correct visualization of the real disease extent, the slice with the largest disease area should be chosen (based on the specimen radiograph and macroscopy), embedded, and processed; but additional levels should also be embedded because some components of the disease may not be visible on imaging and macroscopy . The microscopic analysis should begin with determining the disease extent. Approaching from the periphery of the section, the pathologist should mark the most peripheral malignant structures (in situ or invasive) and repeat the process from all directions. The result will be a marked area representing a cross section through the diseased tissue. Summarizing the findings in adjacent tissue slices and/or tissue slices taken at different levels of the specimen is often necessary. Correlating the radiological and histological findings is essential . The reaIn a consecutive series of 1000 newly diagnosed breast cancers in our material , 495 cases were extensive and occupied a tissue volume of ≥40 mm in the greatest dimension and 505 were nonextensive occupying smaller tissue volumes. Purely in situ carcinomas together with microinvasive  tumors comprised 14% (144/1000) of the series, and half of the cases were extensive  and half were nonextensive . Early invasive carcinomas (1–14 mm) comprised 35% (349/1000) of the series; 42% (146/349) were extensive, and 58% (203/349) were nonextensive. In more advanced cancers , 55% (273/500) of the cases were extensive .After the extent of the disease is characterized as described in On the preoperative tumor board, the pathologist should register the radiological lesion distribution and plan the dissection of the specimen on the basis of this information. Radiologically unifocal lesions are usually properly represented in one or two large-format histology sections, provided that one of these contains the tumor at its largest cross-section . In radiOur previously published system is the only one that takes into account both the invasive and in situ components of the tumor and defines their distribution both individually and in combination . In addiMultifocality is often described in the literature as the presence of satellite tumors around and in the vicinity of a dominant mass . AlthougThe cases in our series of 1000 breast carcinomas showed the following combined lesion distribution: unifocal in 36% (366/1000), multifocal in 35% (347/1000), and diffuse in 28% (280/1000), as shown in Testing the prognostic significance of the lesion distribution defined above has resulted in clear separation of the unifocal, multifocal, and diffuse tumors with regards to the invasive component, the in situ component, and the combined distribution. Patients with multifocal or diffuse invasive carcinomas have a more than double risk of lymph node metastasis compared with unifocal tumors , 33, 34,By stereomicroscopic examination of large-format thick histological sections, Foschini at al. demonstrated that the distance between the individual foci of some low-grade in situ carcinomas is more than 20 mm indicating the possibility that these foci are located within different lobes . AlthougTumor size is defined as the largest diameter of the largest invasive tumor focus  and reprDetermining tumor size is a complex task. The pathologist should register the radiologically measured tumor size on the preoperative tumor board. Breast cancers are often irregular in shape, such that the largest diameter of their nongeometric body varies in different projections. During the dissection, the pathologist should attempt to slice the specimen so that the cross section with the largest diameter of the tumor can be visualized see  and to dRadiological methods, especially modern ultrasound and magnetic resonance imaging, provide an accurate measure of the size of the tumor in several projections. The main shortcoming of these otherwise very accurate measurement methods is that they do not always distinguish in situ and invasive parts of the same tumor; because of this, the histologically verified tumor size may deviate from the radiological one. Obvious additional discrepancies between the radiological and histological tumor size may be the result of preoperative neoadjuvant therapy, but can also be caused by an erroneous choice of the embedded slice during the dissection or result from a failure in the radiological-pathological correlation.There is no international consensus about measuring tumor size; for example, as a size restricted to measuring the tumor body or including the invasive extensions (spiculations). Because the spiculations may be long but are usually thin, they contain invasive cancer representing only a minor part of the tumor burden. Including such extensions when measuring tumor size may lead to an overestimate of the tumor burden. The aim of the tumor size measurement should be to categorize the case as early (<15 mm in size) or more advanced, rather than to expect a millimetric concordance of radiological and histopathological findings. Radiological-pathological correlation is essential for diagnosing breast carcinoma and in assessing the subgross morphological prognostic parameters listed above. A pathologist who is not familiar with the radiological findings when processing a preoperative biopsy or an operative specimen is more likely to make mistakes. Testing the concordance between the radiological and histological findings is not a matter of just comparing the values provided by these methods. Deviating data may result from technical/natural factors. The breast is hanging during the magnetic resonance imaging examination and the antero-posterior axis of the breast becomes transiently longer than when the patient is in an upright position. During mammography, the breast is compressed to a certain level, and the cranio-caudal axis becomes shorter. The breast tissue is much softer than the tumor itself and is easily deformed when placed on the firm surface of a transport plate or the bottom of a formalin-filled dish. Formalin fixation will cause shrinkage of the specimen, but deformation of the specimen during fixation in a dish of inadequate size may cause much more obvious discrepancies. The most common cause of discrepancies is, however, failure in the radiological-pathological correlation. Modern multimodality breast radiology is very accurate in determining the subgross morphological prognostic parameters . It usesMost breast carcinomas exhibit both in situ and invasive components. Although up to 70% of invasive tumors have only an unifocal invasive component, most breast carcinomas have a complex morphology when the distribution of the in situ and invasive components are combined. This complexity is evident both at early and more advanced stages of the disease. Half of breast cancer cases are extensive and occupy a tissue volume measuring ≥40 mm in the greatest dimension. Tumor size, disease extent, and lesion distribution are essential parameters for planning appropriate therapy and also have very significant prognostic power. Proper assessment of these parameters requires additional effort from the pathologists, including a detailed and systematic radiological-pathological correlation in every case of breast cancer. The method of large-format histopathology is a prerequisite for such correlations.


Continuous assessment of hepatitis A virus (HAV) seroepidemiology is a useful tool to control the risk of infection.This study aimed to evaluate the changing patterns of anti-HAV seroprevalence in a population,which isgenerally considered to be anarea ofhigh endemicity.Overall, the results of 3349 sera collected during the period 2005-2008 from patients attending the University Hospital of Cagliari, Italy were studied; their mean age was 52.7 years, (s + 16.22). Patients with liver disease were excluded from the study. Age specific seroprevalence results were compared with those observed in similar previous studies carried out in the same area.The overall prevalence of anti-HAV was 74.6% with consistently lower values in subjects younger than 40 years  particularly in those under 30 years of age . A significant declining trend in age specific seroprevalence has been foundin people under 30 years;61% in 1988, 33% in 1995 and 8.9% in 2005-2008.Our findings show that a significant decline inherd immunity has occurred in the last 20 years as a consequence of lower HAV circulation due to improvementsin socio-economical and hygienic conditions. Adolescents and young adults are becoming increasingly susceptible to HAV infections, as recent outbreaks of acute HAV hepatitis have occurred. Persistent environmental monitoring and the implementation of prevention measures must be considered in order to contain the risk related to this epidemiological shift. Hepatitis A is generally an acute, self-limiting liver infection transmitted through the faecal-oral route by a picornavirus, the Hepatitis A Virus (HAV), which causes 10 million infections worldwide each year. The cliThe aim of the present study was to assess the anti-HAV seroprevalence rates in a sample of population in Southern Sardinia, a major island of Italy, to compare the pattern of immunity with those reported by studies carried out in the same area during the last 20 years, to compare our findings to seroprevalence data from Italy and to determine the most appropriate preventive measures to control and manage the risk of HAV infection.The results of anti-HAV tests were retrospectively collected from 3349 patients attending the University Hospital of Cagliari, Italy. All subjects affected by or suspected of hepatic disease were excluded from the study in order to avoid possible selection bias resulting in limitations in statistical inference. For the purposesof thisstudy, results were collected anonymously and only the age and gender of subjects and sample date were recorded.The samples were tested for anti-HAV IgG by a commercially available MicroparticleEnzyme Immunoassay .All specimens were tested for anti-HAV-IgG: 135 of them (4%) had equivocal analytical results and were excluded; they were equally distributed in the age classes. Overall, age-specific and gender seroprevalence rates were computed. In order to compare results with previous prevalence rates, data from studies carried out in 1988 , 1995 1 were conThe statistical analysis was performed using a SPSS version 10 program. In order to assess differences in the seroprevalence rates a chi-squared test was used, a significant difference was consideredwhen P < 0.05. A95% confidence interval (CI) and the Poisson confidence interval, were used when the number of observations was lower than ten.After the exclusion of the subjects with equivocal analytical results 3214 subjects  were included in the study; their distribution according to age and gender is reported in Overall our data shows a declining trend of herd immunity with regard to HAV infections in the population of South Sardinia during the last 20 years.This dramatic decline was most relevant in young adults and was a result of decreased exposure to HAV during the first years of life. This was probably due to the improvementsin socio-economic and sanitary conditions which have occurred in this area during the past decades and it confirms the changing pattern of immunity, shifting Sardinia from a high to a low HAV endemicity area. Nonetheless, the lower rate of immunity in young adults suggests the persistence of a relevant HAV related risk, due to the marked decline of herd immunity. Our study shows a higher immunity rate compared with seroprevalence values reported in 1999-2000 possibly as the result of an increase in the circulation of HAV in the exposed population from 2000 to 2008.This is also confirmed by reports from thelocal health service regarding outbreaks which occurred in Sardinia in the last few years as a result of raw shellfish consumption, with 94% (31/33) of the cases occuring in young-adults (< 40 years). Several studies have shown thateating raw seafood is the main risk factor for acquiring an HAV infection in Southern Italy 11] and  and 11] This different seroprevalence picture suggests the need to adopt tailored preventive strategies based on specific risk assessments. In order to reduce the risk of HAV infections in an epidemiological picture characterized by high rates of susceptible subjects among adolescents and young adults, vaccination of household contacts of sporadic cases and vaccination of individuals at higher risk of infection or at risk of complications of HAV hepatitis,in particular those individuals affected by underlying liver disease, represents the main preventive measure. In Italy the current National Vaccination Plan 2005-2008  recommenHowever, in Sardinia, the very low herd immunity picture suggests the need to implement educational campaigns for subjects at higher risk and about dietary habits (to eat only cooked shellfish) as well as the implementation of controls by the local health services regardingsanitation when harvesting shellfish and outlets, in order to avoid this source of infection. Moreover, despite improvementsin hygiene conditions, dietary habits and higher standards of agriculture and manufacturing, the HAV risk associated with importing food from countries with lower standards of environmental hygiene and higher levels of HAV, endemicityremains high. In a global economy fruits and vegetables imported from developing countries can pose a serious risk of an HAV outbreak in a population with no herd immunity, thus allowing the spread of HAV infections from endemic to nonendemic areas .Our study has some strengths and limitations. The main limitation is whether or not the study population is representative of the Southern Sardinia population. In this regard, a possible limitation to our study sample could be that we did not include subpopulations with a high prevalence of HAV infection . Likewise, travellers, drug users, people of low socio-economic status and people with health problems may have been overly represented, since a significant rate of serum samples were taken from individuals who received care in hospital or for specific screening. Despite these limitations, the anti-HAV distribution that we observed probably reflects the overall picture of prevalence in the different age groups of Southern Sardinia. In this scenario, seroprevalence studies can provide the most accurate picture of the circulation of HAV in a given population and represent the most appropriate tool for risk assessment. It is in fact suggested that routine surveillance of HAV infection, based solely on the reporting of symptomatic cases who seek medical care, could underestimate the risk .


In the present case, we describe the abrupt transformation of intra-pulmonary vein activity from rapid firing to dissociated ectopic activity during sinus rhythm, as an easily identifiable, though rare to encounter, sign which documents the achievement of bidirectional block. A 47-year old patient underwent a catheter ablation procedure due to recurrent, symptomatic, drug-resistant episodes of atrial fibrillation. The ablation strategy included pulmonary vein (PV) isolation by deployment of circumferential lesions surrounding the PVs with an irrigated ablation catheter  and the use of a three-dimensional electroanatomical mapping system (CARTO-3). A circular mapping catheter  was placed within each of the PVs to guide ablation based on the recorded PV potentials.During the procedure, the right superior PV was highly arrhythmogenic with frequent firing. After a 20-minute waiting period following initial isolation of all PVs, we controlled each vein for potential resumption of electrical connection with the left atrium. The figure  presentsIn the right part of the recording the rapid intra-PV firing ceases abruptly and a dissociated slow ectopic intra-PV activity is recorded. The measured intervals between atrial activation and PV spikes, as shown in the figure, are not constant, supporting the presence of dissociated PV ectopy and entrance block. Adenosine was not administered due to coexistent contraindication.It should be noted that apart from the dissociated PV rhythm, the circular catheter also records residual potentials. These electrograms are far-field with an origin from the superior vena cava based on the following: (a) they are recorded by the catheter bipoles situated at the superior and anterior part of the vein which is adjacent to the superior vena cava and (b) the timing of the recorded potentials is less than 30 msec from the onset of the P wave, which is a highly sensitive and specific marker to recognize far-field potentials of SVC origin recorded in the right superior PV.In the present case, we describe the abrupt transformation of intra-PV activity from rapid firing to dissociated ectopic activity during sinus rhythm, as an easily identifiable, though rare to encounter, sign which documents the achievement of bidirectional block.Based on the recently issued expert consensus statement on catheter and surgical ablation of atrial fibrillation, electrical isolation of PVs is the primary goal for most ablation procedures. The concThe most stringent endpoint of PV isolation is the demonstration of bidirectional conduction block, meaning the interruption of conduction from the LA to PV (entrance block) as well as in the opposite direction from PV to LA (exit block). From a pathophysiological perspective, it is more important to document conduction block from the PV to LA (exit block) since this is the direction of impulse conduction when a rapidly firing PV focus triggers AF paroxysms. However, as stated in the expert consensus statement, only 10% of the task force members rely on the documentation of exit block as an endpoint of the ablation procedure, while 75% use only entrance block as a primary endpoint of PV isolation.[Entrance block is verified by elimination of PV potentials or by recording dissociated PV rhythm (isolated ectopy or slow regular rhythm). Dissociated PV potentials represent intra-PV electric discharges which are independent from left atrial electric activity (parasystole-like).Exit block can be demonstrated with or without the use of pacing maneuvers. The concept of electrophysiologic maneuvers is to pace within the PV at a rate faster than the sinus rate and to demonstrate the inability of the captured intra-PV impulses to propagate to the left atrium. The limitation of this maneuver is the difficulty to achieve reliable local PV capture. Therefore, pacing at high output is needed frequently, which though may result in inadvertent far-field capture of neighboring anatomic structures and thus to an erroneous diagnosis of persistent PV to LA connection. Exit bloThe verification of conduction block at a certain direction should not be considered synonymous to bidirectional block. The term "unidirectional block" has been used to describe the persistence of PV-LA conduction (absence of exit block) despite the proof of LA-to-PV conduction (entrance) block or vice versa. However, the reported occurrence rates of unidirectional block vary in the literature from 0.6% to 42%, reflecting differences in implemented ablation strategy , methodological issues and use of differential pacing maneuvers.-5In conclusion, the achievement of bidirectional block is the sine-qua-non during PV isolation. The presented sign verifies spontaneously bidirectional block and the electrical disconnection of pulmonary veins.


Neuropsychiatric disorders are one of the main challenges of human medicine with epilepsy as one of the most common and serious disorders of the brain. Temporal lobe epilepsy represents the most common type of epilepsies and is often accompanied by marked neuronal degeneration. One main factor that causes neural loss is the excitotoxicity of glutamate, which is copiously released during seizures and hypoxia accompanying seizures. There is evidence that endogenous opioids, namely dynorphin (Dyn), act as modulators of neuronal excitability. It was also shown that the deletion of proDyn in mice and low expression in humans is associated with increased epilepsy vulnerability. Dyn targets opioid receptors and in particular the κ opioid receptor (KOP). The KOP receptors in the hippocampal formation are located in very strategically points for the control of the glutamate release and most important they are not altered under epileptic conditions. Interestingly, proDyn expression is reduced after an initial increase in most epilepsy models and activation of KOP receptors may be neuroprotective. Still, the functional background of these neuroprotective effects is not fully understood. The aim of this study was to investigate the influence of KOP agonists and antagonists on EEG patterns of epileptic mice.Kainic acid  was injected unilaterally into the dorsal hippocampus, causing acute and delayed behavioral and EEG effects. Four-channel EEG traces were recorded from ipsi-and controlateral hippocampi and motorcortices applying depth and surface electrodes, respectively. The KOP-specific agonist U-50,488H and antagonist GNTI were dissolved in saline (adjusted to pH 7.4) and applied i.p. or intracisternally, respectively.Sharp waves and paroxysmal discharges in the ipsilateral hippocampus were recorded about 2 weeks after KA injection. Paroxysmal discharges were accompanied by behavioral arrest and stereotypic behaviour like head nodding. Application of KOP agonists at different doses  markedly reduced paroxysmal discharges. In contrast, the KOP antagonist (3 nmol) prolonged the duration of such discharges. These data represent observations from preliminary experiments.Data collected so far confirm the anticonvulsant action of KOP agonists in the subchronical phase of epilepsy, suggesting that neuroprotective effects are indeed due to reduced seizure activity.


Little is known about the long-term impact of the killing of a parent in childhood or adolescence during war on distress and disability in young adulthood. This study assessed current prevalence rates of mental disorders and levels of dysfunction among young adults who had lost their father due to war-related violence in childhood or adolescence.179 bereaved young adults and 175 non-bereaved young adults were interviewed a decade after experiencing the war in Kosovo. Prevalence rates of Major Depressive Episode (MDE), anxiety, and substance use disorders, and current suicide risk were assessed using the Mini–International Neuropsychiatric Interview. The syndrome of Prolonged Grief Disorder (PGD) was assessed with the Prolonged Grief Disorder Interview (PG-13). Somatic symptoms were measured with the Patient Health Questionnaire. General health distress was assessed with the General Health Questionnaire.Bereaved participants were significantly more likely to suffer from either MDE or any anxiety disorder than non-bereaved participants (58.7% vs. 40%). Among bereaved participants, 39.7% met criteria for Post-Traumatic Stress Disorder, 34.6% for PGD, and 22.3% for MDE. Bereaved participants with PGD were more likely to suffer from MDE, any anxiety disorder, or current suicide risk than bereaved participants without PGD. Furthermore, these participants reported significantly greater physical distress than bereaved participants without PGD.War-related loss during middle childhood and adolescence presents significant risk for adverse mental health and dysfunction in young adulthood in addition to exposure to other war-related traumatic events. Furthermore, the syndrome of PGD can help to identify those with the greatest degree of distress and dysfunction. Recent and ongoing wars and open conflicts have affected millions of civilians around the globe and about half of the survivors have been estimated to be under the age of 18 years In general, the death of a parent is regarded as one of the most stressful life events children and adolescents can experience In an effort to identify the most vulnerable bereaved individuals, clinical researchers have refined and tested diagnostic criteria for the syndrome of prolonged, or complicated, grief However, current findings on bereavement possess at least two limitations. First, most research on grief has been conducted among older bereaved individuals Based on bereavement research in general as well as on preliminary findings on the effect of war-related bereavement among adults All interviews were conducted face-to-face between fall 2008 and summer 2009 (i.e. a decade after the war). The survey was conducted in cooperation with a psychosocial center for children and adolescents in the town of Gllogovc that enabled potential counseling for study participants in case they would feel distressed by the interview and seek professional counseling. Thus, the survey was conducted in the municipality of Gllogovc and three neighboring municipalities: Kline, Skenderaj, and Vushtrri. The three neighboring municipalities were randomly selected out of seven municipalities bordering Gllogovc. The total population of these four municipalities constitutes about 15% of the Kosovar population of about two million people. All participants were Kosovar Albanians as no other ethnicities live in the municipality of Gllogovc. The interviews were conducted face-to-face by five female psychologists who were experienced in conducting clinical interviews for a prior project Prior research with bereaved survivors of war in Kosovo had indicated that signed consent often leads to confusion among this population due to the fact that during the repression period people were forced by the police to sign declarations about false accusations Potential participants needed to report exposure to at least one potential war-related traumatic event and no mental impairment due to an organic cause. In line with our objective to include participants who had lost the father during childhood or adolescence due to war-related violence, potential participants had to report a minimum age of six years and a maximum age of 18 years during the war. This criterion was chosen to make sure that participants had been old enough to remember the war (minimum age of six years) and yet still be living with their parents as the war had started (maximum age of 18 years). Potential participants were contacted directly at home without prior notification as telephone and postal communication services in Kosovo do not function effectively in the countryside. Furthermore, people in Kosovo have the habit of visiting each other without advance notice. Prior surveys also have contacted potential participants directly at home Bereaved participants had to report exposure to at least one potential war-related traumatic event and the loss of their father due to war-related violence. Lists of all families who had lost relatives during the war in the municipalities of Gllogovc, Kline, Skenderaj, and Vushtrri were provided by communal authorities. In each municipality, we approached 65 bereaved families. Out of 260 contacted participants, 67 did not meet the specified age criterion. Of 193 potential participants, 13 declined to participate in the study, indicating not wanting to talk about the war again or not having time for the interview. This resulted in a participation rate of 93.3% (180/193). Missing values resulted in the exclusion of one participant and leading to a total of 179 bereaved participants. Missing data were a minor problem in the study as a function of the interview format used to collect data.Non-bereaved participants were contacted in exactly the same localities as bereaved participants. Potential participants had to report at least one potential war-related traumatic event and no loss of first-degree family members neither during nor after the war. We defined as first-degree relatives parents, siblings, and children. A random walk approach that has been reported in prior research with war survivors in the Balkans Socio-demographic characteristics of the samples were assessed using a brief structured questionnaire that has been used in prior research in Kosovo MDE, anxiety disorders, suicide risk, and substance use disorders were assessed with the MINI International Neuropsychiatric Interview Prolonged Grief Disorder (PGD) was assessed with the structured Prolonged Grief Disorder Interview, the PG-13 Somatic symptoms for the last four weeks were measured with the Patient Health Questionnaire (PHQ-15) General health distress for the last four weeks was assessed with the 12-item version of the General Health Questionnaire (GHQ-12) 2χ tests and t-tests were used depending on whether the variable was continuous, ordinal or categorical. Multivariate logistic regression analyses were used to examine associations between socio-demographic and war-related variables and mental disorders that significantly differed between bereaved and non-bereaved participants . All variables were entered simultaneously in these analyses. Multicollinearity among potential predictor variables was assessed using the variance inflation factor (VIF) statistic from the equivalent linear regression model.Analyses were conducted using SPSS V17. Prevalence rates of mental disorders were calculated as percentages of participants with a positive diagnosis at the time of the interview. Bivariate differences in socio-demographic characteristics, traumatic experiences, and prevalence of mental disorders between groups were evaluated using the Incremental validity of the three most prevalent disorders  on dysfunction among bereaved participants was analyzed with hierarchical regression analysis. Here, number of war-related traumatic events and socio-demographic variables were entered at step one. PTSD and MDE status were entered at step two and PGD status was entered at step three.Socio-demographic and loss-related characteristics of the samples are reported in Among bereaved participants, nearly one third reported the killing of more than one first-degree relative during the war. Additionally, two participants reported death of first-degree relatives (brother) after the war.Exposure to retrospectively reported war-related characteristics is shown in Pre- and post-war potentially traumatic events were reported only by a small proportion of participants and there were no significant differences between the samples.Observed prevalence rates of mental disorders and suicide risk of bereaved and non-bereaved participants are shown in Multivariate logistic regression analyses examined associations between socio-demographic and war-related variables and mental disorders that significantly differed between bereaved and non-bereaved participants see . The assBereaved participants reported significantly higher scores of general health distress as measured with the GHQ . However, bereaved participants did not report higher scores of somatic complaints as measured with the PHQ than non-bereaved participants .The prevalence rate of PGD among bereaved war survivors was 34.6%. Criteria for comorbid diagnoses of PTSD, MDE and PGD were met by 8.9% of all bereaved participants and 59.8% of them met criteria for any of these three disorders. Prevalence rates of mental disorders and suicide risk among bereaved participants with versus without PGD are reported in Bereaved survivors of war with PGD also reported significantly higher scores of somatic complaints  and general health distress  than those without PGD.Three separate hierarchical regression models examined the predictive value of the three most prevalent disorders, PTSD, MDE, and PGD, on severity of suicide risk, general health distress, and somatic complaints. At step one, the number of war-related traumatic events, home displacement during war, gender, age, and years of schooling were entered. At step two, PTSD and MDE status were entered, whereas PGD status was entered at step three. Results are reported in This study provides evidence that war-related loss of the father during childhood or adolescence uniquely contributes to distress and disability into adulthood over and above the experience of other war-related trauma. Results demonstrate that war survivors whose fathers had been killed during the war were significantly more likely to suffer from MDE, PTSD, and Panic Disorder as compared to non-bereaved war survivors. Accordingly, the majority of bereaved war survivors met criteria for either MDE or an anxiety disorder a full decade after the war. Additionally, one third of the bereaved participants met criteria for PGD while reporting that these symptoms caused persistent dysfunction in social, occupational, or other important areas of functioning. Among bereaved participants, the presence of PGD was associated with a higher prevalence rate of MDE or an anxiety disorder. Finally, survivors of war with PGD were significantly more likely to report current suicide risk than bereaved participants without PGD and to also report higher scores of somatic complaints and general health distress.Given the lack of research on long-term effects of bereavement in childhood or adolescence as well as the lack of bereavement-related findings outside North America and Western Europe, the current study provides novel information on long-term sequelae of the violent death of the father during childhood or adolescence. The results are strengthened by the fact that both groups of participants were survivors of war and were recruited in exactly the same localities. Additional strengths of the study are that the interviewers were well trained with a relevant professional background and were familiar with the studied locations. Nevertheless, the study has a few limitations. Participants were recruited in only four municipalities and this might reduce the generalization of findings to other areas of war-related bereavement. Further, due to the cross-sectional format of the study, only point prevalence rates of the disorders were assessed and no definite conclusions on causal associations between the measured variables can be made. The reporting of traumatic experiences might have been influenced by recall bias with people with more current symptoms reporting more traumatic experiences The results are consistent with other studies suggesting that war-related experiences can be associated with long-term psychiatric sequelae The fact that no participant reported any substance abuse disorder might appear surprising as research in other countries shows that people with a history of traumatic experiences report high rates of substance abuse disorders Apart from higher prevalence rates of mental disorders, bereaved participants reported significantly lower education and a significantly higher unemployment rate. Lower education might be a consequence of the killing of the father. It might be a direct consequence of the absence of the father and the resultant need to take care of the family, which would leave less time and energy for pursuing education. It might also be a result of emotional difficulties related to the violent loss of the father in conjunction with other war-related experiences. Additionally, loosing the father often meant loosing the main, and mostly the only, breadwinner in the family. Finally, it is also likely to be a consequence of the absence of a father figure to support the child in pursuing education. Unemployment, on the other hand, might partly be due to a lower education. It is also likely that the higher unemployment rate among the bereaved group was associated with higher scores of adverse mental health The syndrome of PGD proved to be a good indicator of vulnerable bereaved individuals. As compared to bereaved individuals without PGD, those with PGD reported significantly higher prevalence rates of either MDE or any anxiety disorder, suicide risk, and higher scores of somatic complaints as well as general health distress. Additionally, PGD was uniquely associated with higher suicide risk, general health distress, and somatic complaints after controlling for war-related traumatic events, socio-demographic variable, and MDE and PTSD. These data are consistent with the literature on PGD In general, our findings demonstrate that the killing of the father during childhood and adolescence and the experience of other war-related events are associated with adverse health complaints and dysfunction during young adulthood. More importantly, while taking into account socio-demographic and war-related characteristics, the results yielded that war-related killing of the father can exacerbate the effects of other war-related traumatic experiences. The outcomes of the study highlight the need for long-term policies to meet the special mental health needs of bereaved war survivors.