The ChEss project of the Census of Marine Life (2002–2010) helped foster internationally-coordinated studies worldwide focusing on exploration for, and characterization of new deep-sea chemosynthetic ecosystem sites. This work has advanced our understanding of the nature and factors controlling the biogeography and biodiversity of these ecosystems in four geographic locations: the Atlantic Equatorial Belt (AEB), the New Zealand region, the Arctic and Antarctic and the SE Pacific off Chile. In the AEB, major discoveries include hydrothermal seeps on the Costa Rica margin, deepest vents found on the Mid-Cayman Rise and the hottest vents found on the Southern Mid-Atlantic Ridge. It was also shown that the major fracture zones on the MAR do not create barriers for the dispersal but may act as trans-Atlantic conduits for larvae. In New Zealand, investigations of a newly found large cold-seep area suggest that this region may be a new biogeographic province. In the Arctic, the newly discovered sites on the Mohns Ridge (71°N) showed extensive mats of sulfur-oxidisng bacteria, but only one gastropod potentially bears chemosynthetic symbionts, while cold seeps on the Haakon Mossby Mud Volcano (72°N) are dominated by siboglinid worms. In the Antarctic region, the first hydrothermal vents south of the Polar Front were located and biological results indicate that they may represent a new biogeographic province. The recent exploration of the South Pacific region has provided evidence for a sediment hosted hydrothermal source near a methane-rich cold-seep area. Based on our 8 years of investigations of deep-water chemosynthetic ecosystems worldwide, we suggest highest priorities for future research: (i) continued exploration of the deep-ocean ridge-crest; (ii) increased focus on anthropogenic impacts; (iii) concerted effort to coordinate a major investigation of the deep South Pacific Ocean – the largest contiguous habitat for life within Earth's biosphere, but also the world's least investigated deep-ocean basin. These microbiota may be present in free-living form, in the deep water column or at the seafloor as microbial mats, within sediments or even within the fractures of crustal rocks, sub-seabed, or in symbiosis with larger multi-cellular organisms Following the discoveries at the Galapagos vents in 1977, it was recognized that chemosynthetic ecosystems could also be sustained in other chemically reducing seafloor environments, such as at cold seeps along passive and active margins In addition to high concentrations of chemically reduced compounds, equally important to chemosynthetic ecosystems are the steep gradients that arise  and the great propensity for geologic (tectonic and/or volcanic) disturbance that can initiate, perturb or curtail fluid flow from the seafloor. What is commonly observed among fauna colonizing vent- or seep-sites, consequently, is a low diversity of complex multi-cellular organisms despite the high biomass present ChEssBasewww.noc.soton.ac.yj/chess/database/db_home.php. Most of the species described so far belong to the mega- and macrofauna size classes and, although the meiofauna accounts for 20% of the total diversity in vents Since the first discovery of vents in 1977, some 700 hydrothermal vent species previously unknown to science, together with 600 species at cold seeps, have now been described and listed in the ChEss database, At the onset of the ChEss project, and despite the sparse global-scale coverage available then, it was widely accepted that at least 6 separate biogeographic provinces could already be shown to exist for hydrothermal vent fauna Establishing phylogeographic relationships among different chemosynthetic habitats.Seeking evidence for barriers to, or conduits for, gene flow between different chemosynthetic habitats.Investigating the environmental factors that control the diversity and distribution of chemosynthetic fauna.While recognising that the ChEss project would need to be largely exploratory in nature, we established that, within the Census decade, the prioritisation of targets for our internationally-coordinated efforts would need to be very selective and only focus upon those most remote or extensive areas of the deep ocean that no single nation could investigate alone. Consequently, while a number of other target areas remain of great scientific interest, only 4 specific areas were targeted by the ChEss project as a whole: A) the Atlantic Equatorial Belt; B) the chemosynthetic ecosystems close to New Zealand; C) the polar oceans of the Arctic (C1) and Antarctic (C2) and D) the Chile Triple Junction . In the th Century have continued with no drop in rate throughout the first decade of the 21st Century – the Census of Marine Life decade. The exploration conducted in the four ChEss key areas  led to a new map of known vent, seep and whale fall sites  represents ∼25% of the entire history of chemosynthetic ecosystem research and a further 180 species previously unknown to science have been described during this time – i.e. the rapid rates of discovery established during the last quarter of the 20ll sites  and provThe Atlantic Equatorial Belt (AEB) region extends on a longitudinal gradient from the Costa Rica margin in the Pacific Ocean to the continental margin off West Africa, encompassing a very large region around the Equator, from 15°S to 30°N. The key sites include the Costa Rica cold seeps, the Gulf of Mexico cold seeps, the ultra-slow spreading Mid Cayman Rise, the Barbados Accretionary Prism, hydrothermal vents on the Mid-Atlantic Ridge (MAR) north and south of the Equatorial Romanche and Chain Fracture Zones and cold seeps on the continental margin of west Africa (Angola Basin) . The CosOur principal interests in the AEB region concerned studying connectivity among different chemosynthetic ecosystems over different length scales and when confronted with different potential oceanographic and geologic conduits and barriers to gene flow. ChEss scientists addressed questions of how fauna might be related across the breadth of the Atlantic Ocean between cold seep sites on the margin of West Africa and those present in the Americas – along the Atlantic margin, the Barbados Accretionary Prism, the Gulf of Mexico and, in the extreme, along the Pacific margin of Costa Rica which would also have been inter-connected with the Atlantic fauna prior to the closure of the Isthmus of Panama. Would oceanographic flow through the deep transform faults of the Chain and Romanche Fracture Zones Escarpia sp., is known both from the Gulf of Mexico and the California slope Lamellibrachia tubeworms, bathymodiolin mussels, Lepetodrilus limpets, large vesicomyid clams and galatheid crabs. The fauna exhibits both seep and vent affinities, suggesting the potential for hybrid habitats to provide important connections between different reducing systems Kiwa was discovered. As with the vent species Kiwa hirsuta, this new species of Kiwa farms epibiotic bacteria by waving its bacteria-covered arms in methane seep fluid and then scrapes bacteria off its setae and into its mouth The present mid-ocean ridge pathway between the Atlantic and Pacific Oceans runs via the Indian Ocean and Pacific-Antarctic ridge-systems . Prior t−1) was only recognized at the end of the 1990s The presence of hydrothermal activity on ultraslow spreading ridges  and represent significant topographic features (4 km high–935 km ridge offset) that prominently affect both the linearity of the ridge system and large-scale ocean circulation in this region. Van Dover Bathymodiolus heckerae that can reach over 36 cm in length and smaller vesicomyid clams of the species Vesicomya cf venusta) Calyptogena aff. kaikoi is not only present at the Florida Escarpment seeps and the Barbados Accretionary Prism, but is also found at the Logatchev vent site on the MAR near 15°N Bathymodiolus heckerae is found at both North Carolina and Florida Escarpment seeps, while closely related species are also found at MAR vent-sites The AEB area of the ChEss project comprises several cold seep sites at either side of the Atlantic, including the Gulf of Mexico seeps, the Barbados accretionary prism, the Blake ridge diapir and the northwestern Congo, Gabon and Nigeria margins in northwest Africa . The GulOne of the most recent discoveries on the Mid-Atlantic Ridge occurred in October 2010, some 500 km southwest of the Azores. New vents with metre-high chimneys were discovered here hosting marine life typical of that found on other MAR vents . This arin situ images of active cold-seep communities had been obtained, nor had any comprehensive sampling of live cold-seep fauna been undertaken. The fjords of the south-west coast in the South Island are potential target regions for oxygen minimum zones and large organic falls, including sunken wood and kelp. Furthermore, the seas around New Zealand are known as an important whale migration route and whales are particularly abundant in certain areas, providing the likelihood of important seafloor deposits in these locations. Areas provisionally identified as suitable and accessible for whale skeleton investigations included the Kaikoura canyon (east coast South Island) and the Cook Strait canyons (between the North and South islands). Exploring for and investigating deep-water chemosynthetic ecosystems and their fauna in this region would fill a significant gap in our understanding of the global biogeography of chemosynthetically-driven species.The oceans around New Zealand were chosen as a specific site of interest because multiple types of chemosynthetic ecosystems can be expected to exist in reasonably close proximity , present2Pseudosuberites. Although many of these groups are also common in other cold-seep areas, there were significant differences at the species level, with most species being new to science or endemic to New Zealand seeps, suggesting that the New Zealand cold-seep communities could represent a new biogeographic region pers. comm.]. A key objective of the ChEss programme was to address ecological and evolutionary connectivity amongst different chemosynthetic habitats  when located in close proximity to one another. Although sampling and species identification is still preliminary in the New Zealand region, initial results show that 4 species are found in all 4 ecosystem types present, representing a 20% overlap in the fauna described to species level Perhaps the most exciting result from the ChEss project in this region was the discovery of 10 new cold seep sites along the Hikurangi margin, including one extremely large site, the Builder's Pencil site, that covers 135,000 mEvidence for venting at both poles was already well established at the outset of the Census decade st Century has revealed evidence for abundant hydrothermal activity on the Gakkel Ridge in the Arctic Ocean Work conducted during this first decade of the 21Rissoa cf. griegi – which is also known from North Atlantic cold seeps and wood falls. At a similarly northerly chemosynthetic setting, on the Haakon Mossby Mud Volcano near 72°N on the Norwegian margin, colonization of active cold seeps is dominated by siboglinid worms In the Norwegian-Greenland Sea, the Knipovich, Mohns and Kolbeinsey ridges extend from the south of Svalbard to the north of Iceland. The first two of these are ultra-slow spreading ridges, similar to Gakkel while the Kolbeinsey is a slow spreading ridge, more similar to the Mid-Atlantic Ridge that lies immediately to the South of Iceland. These ridge segments are isolated from the Gakkel Ridge by shallow sills connecting to the Arctic Basin, but are even more dramatically isolated from the MAR by Iceland, where the ridge becomes subaereal. Thus, this system offers a further natural laboratory for evolution on an isolated section of ridge. Although evidence for hydrothermal venting on both the Kolbeinsey and Knipovich Ridges pre-dates the start of the ChEss project The Bransfield Strait and East Scotia Ridge are isolated back-arc basins located at the gateway from the Pacific to the Atlantic sector of the Southern Ocean , where eThe most important result of ChEss in the Southern Ocean region was the first direct observation and sampling of vent communities on the East Scotia Ridge south of the Polar Front in 2009 Calyptogena sp., but no living animals nor thiotrophic bacterial mats were observed In addition to the Southern Ocean hydrothermal vent sites recently discovered, a new cold-seep habitat was recently described from the Antarctic. Following the collapse of the Larsen B ice shelf at the southeastern margin of the Antarctic Peninsula in 2002, Domack and colleagues The Chile Triple Junction has represented a particularly important locale for the ChEss project because it is the only place on Earth where an actively spreading ridge is currently being subducted beneath a continental margin Another important aspect of investigating the SE Pacific region off Chile was that every known form of deep-water chemosynthetic ecosystems could be expected to exist in this area: hydrothermal vents, cold seeps, whale falls and oxygen minimum zones. The Peru-Chile margin and subduction zone contains massive methane-hydrate deposits Thioploca) cover the sediments. Isotopic evidence and the occurrence of some symbiont-bearing species indicate that the nutrition of infaunal assemblages in this zone may rely on chemosynthesis At shallower depths, between 200 m and 500 m, the Chile continental margin is intercepted by a well-developed oxygen minimum zone Because of the relative youth of the field of deep-ocean chemosynthetic research, it is perhaps inevitable that the work remaining to be done at the closure of the ChEss project continues to include a strong exploratory element. More than 150 different hydrothermal vent-fields have been identified along that ∼20% of global mid-ocean ridges that has been investigated thus far, at an average spacing approaching ∼100 km between adjacent sites Of course, chemosynthetic fauna do not only colonize high-temperature hydrothermal fields. Typically, the highest concentrations of biomass associated with any hydrothermal field are found hosted in low-temperature diffuse-flow settings and it is now recognized that low-temperature systems like the Lost City hydrothermal field can occur, away from the presence of any high-temperature venting, in a geologic setting that recurs along the slower-spreading ∼30,000 km of the global ridge crest Along ocean margins, cold-seep ecosystems have been located along both active and passive geologic margins  from the South Pacific to the Norwegian Greenland Sea as well as at multiple locations in between . Within While much exploration remains to be done, however, the achievements of the ChEss project have not been without significant reward. During the 8 years of the project we have not only documented some 180 species previously unknown to science (see earlier), but also extended the limits to which “extreme” life can exist with the discovery of both the hottest known vents 407°C,  and the In the global ocean how many symbiotic, chemosynthetic species exist?What are their distributions and how are those distributions controlled?How do fauna from chemosynthetic habitats reproduce, disperse and colonize new sites?What are the evolutionary histories and phylogeographic relationships of species from different chemosynthetic habitats?Long Range Exploration working group held in June 2010 in the UK: (http://www.interridge.org/en/WG/Exploration/workshop2010). At that meeting, a series of targets for future ridge-crest exploration were identified. There, of 24 sections of mid-ocean ridge considered for future exploration, 23 represented areas where either no hydrothermal investigations have yet been undertaken  or where hydrothermal activity is known to exist based on hydrothermal plume studies, but no detailed investigations of the underlying seafloor have yet been undertaken sufficient to provide even a cursory knowledge of what chemosynthetic fauna might be present . Consistent with the relative youth of the field of deep-ocean chemosynthetic ecosystem research and the large gaps in knowledge that persist, the need for continuing exploration remains strong and all 23 of these regions were identified as of potential significance to improving our understanding of what controls the biogeography and biodiversity of chemosynthetic ecosystems worldwide. Within the multi-disciplinary framework of InterRidge, however, these 23 locales were then ranked according to their potential significance to researchers working in 4 further sub-disciplinary criteria to help establish priorities for the next decade of internationally coordinated mid-ocean ridge research (A number of the vent-discoveries achieved during the ChEss project relied heavily upon the advent of the emergent technology - notably deep-ocean autonomous underwater vehicles (AUVs) e.g. . This trresearch . Researcresearch . The othWhat have become increasingly apparent during the lifetime of the ChEss project are the increasing anthropogenic threats, both potential and real, to chemosynthetic ecosystems in the deep sea. Human activities such as deep-water fisheries, mining, hydrocarbon exploitation and littering are moving into deep waters faster than we can begin to understand the abundance, diversity, distribution and functioning of the fauna in unperturbed ecosystems http://www.science.psu.edu/news-and-events/2010-news/Fisher11-2010) demonstrate that anthropogenic impacts resulting from deep-water hydrocarbon extraction need not be restricted to upper ocean and coastal ecosystems With the depletion of land-based and shallow-water resources, the hydrocarbon industry has also begun to conduct oil and gas exploitation from beneath the deep ocean floor. Large subsurface hydrocarbon reservoirs often give rise to cold seeps along ocean margins such as off West Africa and the Gulf of Mexico. Collaborations between the relevant regulatory authorities and ocean scientists have often proceeded well e.g.  and explwww.interridge.org/en/node/5797) and with regulators and emerging industrial interests through the International Seabed Authority. It is to be hoped that concerned scientists will continue to be engaged at the international scale in developing protocols and safeguards that can be adopted as part of an international standard for regulating deepwater mining in the future – especially with the recent demonstration that even “extinct” hydrothermal-vent systems may host endemic chemosynthetic fauna Perhaps the gravest long-term threat to chemosynthetic ecosystems in particular, however, will come from the emerging marine mining industry. The seafloor massive sulfide deposits formed around submarine hydrothermal vents have the potential to be commercially viable for the extraction of important base metals, notably copper, zinc, silver and gold http://www.immsoc.org/IMMS_code.htm). In a parallel development, the OSPAR convention  has also proceeded with the design of their own Code of Conduct for Research on Hydrothermal Vents Design of Marine Protected Areas for Chemosynthetic Ecosystems Potentially Threatened by Human Activities in the Deep SeaThat the scientific community stands ready to meet these challenges and engage constructively with industry is already proved. The adoption of a voluntary code of conduct for responsible research at and near hydrothermal vents www.indeep-project.org) that will train a new generation of researchers equipped to understand better the biodiversity and functioning of deep-sea ecosystems, as well as the connectivity between habitat types. An important goal of INDEEP, as a direct consequence, will be to help meet a pressing need for improved management and conservation of these vulnerable ecosystems. Going forward, it will be critical to (i) evaluate species distributions and differences in community composition and structure in areas that overlap in depth and habitat type; (ii) assess heterogeneous nutrient sources and diverse inputs; and (iii) reveal the genetic relationships among species and populations across diverse deep-ocean habitats. Only then can we expect to understand the formative ecological and evolutionary processes that have shaped current patterns of biodiversity and ecosystem function and serve to sustain deep-sea biodiversity, as well as fisheries-based goods and services in, the face of increasing anthropogenic impacts.For the past ∼30 years, investigations into the diversity, ecology and evolution of different deep-ocean ecosystems  have generally been conducted in relative isolation. Nowhere has this been more apparent than in the Census of Marine Life programme, which established a series of separate field projects to study each environment. Only toward the end of the Census decade did a synthesis of the efforts from those groups come together as the SYNDEEP initiative, which recognised that our future understanding of both (i) the fundamental processes structuring deep-ocean life and (ii) marine management and conservation, are critically dependent upon how well we can integrate our knowledge across these diverse ecosystems and how well we can impart this knowledge to the wider non-scientific community One high-priority area in which we recommend that we should seek to address both long-standing and recently-developed hypotheses is the South Pacific Ocean. This deep-ocean basin represents the largest contiguous ecosystem for life on our planet and contains the full range of known seafloor habitats: vast abyssal plains underlying the huge central oligotrophic gyre, eutrophic hotspots underlying equatorial and Antarctic upwelling zones and active and inactive seamount chains that extend from ocean margins into the ocean interior where they intersect mid-ocean ridges. Furthermore, the South Pacific Ocean also contains the world's most abundant hydrothermal vents, the world's largest seep sites, oxygen minimum zones adjacent to whale and wood falls and networks of canyons.www.coml.org). What is particularly notable in the projection shown, focused on the South Pacific, is that “hot-spot” areas of high biodiversity to the west and east are separated by areas where insufficient data exist to assign an HFI value because insufficient biological observations (50 or more) have yet to be conducted, throughout the entire history of deep-ocean research, within any of the “blank” boxes (pixel size: 5° Latitude×5° Longitude)! In this single ocean basin, all of the habitats present must share a common history and will have interacted, both biologically and geologically, throughout their formative history. What we recommend for a future and concerted effort, therefore, is an internationally coordinated project to investigate the interconnected deep-ocean habitats and ecosystems – from ocean margins to ridge-crests at 2000–3000 m depth, abyssal plains >3000 m deep and ocean trenches that lie more than 10,000 m below sea level – of the South Pacific Ocean: arguably Earth's largest and yet least understood deep-ocean basin. Specifically, we recommend a programme that would seek to address the following key questions:While the South Pacific provides connectivity between established biodiversity and evolutionary hotspots, in a range of habitat types, however, it also includes some of Earth's most poorly studied deep-ocean regions juxtaposed directly against those “hot-spots”. One of the most striking images from the synthesis activities of the Census of Marine Life  is a ploHow do species richness and community diversity vary across diverse habitat types, latitudes, depths and nutrient supply, both locally and regionally in the South Pacific?Do the deep-ocean fauna of the South Pacific reveal patterns of connectivity via gene flow, or patterns of isolation and endemism to their various specific habitat types?Is the vast oligotrophic abyss beneath the South Pacific gyre a biodiversity sink where food limitation exceeds adaptive limits, yielding a region of depauperate biodiversity?Are the South Pacific abyssal, vent, seep and seamount fauna evolutionarily and functionally distinct from each other and from the fauna in other ocean basins?Do the patterns of diversity and connectivity observed in South Pacific ecosystems render them particularly vulnerable to anthropogenic impact and/or variations in patterns of oceanic productivity that are predicted from climate change models?Our vision is that this programme could be implemented over a period of a decade in this single ocean basin, using international coordination to gain access to ships of multiple nationalities and the most sophisticated deep-submergence capabilities worldwide. Such a South Pacific programme would allow us to investigate a broad range of distinct ecosystems and obtain the samples required to characterise the intersection of inter-connected ecosystems and their seafloor habitats, from microbes to meio-, macro- and megafauna, at key abyssal plain, continental margin, vent, seep, whale and seamount sites located across the length and breadth of the South Pacific Ocean . SpecifiWe believe that such a programme would have the potential to change, completely, the way we think about, study and train new scientists to understand diverse deep-ocean ecosystems. The project would provide key information for large-scale understanding of the ecology, biogeography, biodiversity inter-connectivity and evolution of the marine biodiversity of the deep South Pacific and allow direct comparisons with other oceans across comparable latitudes. Such a project would also have a strong exploratory component, providing for exciting new discoveries including, almost certainly, the identification and description of novel species and adaptations previously unknown to science. Although the scope and ambition of the project outlined here, across a largely uninvestigated ocean basin, may speak to some of purely academic “blue skies” research, we anticipate that the knowledge to be gained is also likely to be of critical importance for the development of the applied understanding that will be required for the future management and conservation of living and mineral resources in the deep ocean. Finally, the scale and ambition of the project outlined here would almost certainly lend itself to extensive, multi-media forms of outreach with the potential to expose millions of people to both the exciting expeditions and discoveries throughout the South Pacific and the concept of the common heritage of Earth's deep oceans.In conclusion, the deep ocean has provided some of the most spectacular and paradigm-changing observations and data over the last 40 years. There is no doubt in our minds that the deep sea will continue to challenge scientists to devise ways and means of discovering and analysing its secrets into the future. Just as the discovery of hydrothermal vents could never have been made had scientists restricted their observations to remote sensing of the global mid-ocean ridge crest, it seems inevitable that even more exciting discoveries await as we extend our focus to the deepest seafloor abyssal plains and on, to the very depths of the deep-ocean trenches found at the far end of the plate tectonic cycle, associated with subduction zones.


With the widespread use of carotid artery stenting, previously unknown technical mistakes of this treatment modality are now being encountered. There are multiple strategies for the treatment of in-stent restenosis. With regard to surgical management, endarterectomy and patch plasty are favored. To the best of our knowledge, this report is the first description of a complete stent removal by the eversion technique.We report the case of a 63-year-old Caucasian man with misdeployment of two stents into his stenotic proximal internal carotid artery, resulting in a high-grade mechanical obstruction of the internal carotid artery lumen. With the contralateral internal carotid artery already occluded and associated stenoses of both proximal and distal vertebral arteries, an interdisciplinary therapeutic concept was applied. Bilateral balloon angioplasty and stenting of the proximal and distal stenotic vertebral arteries were carried out to provide sufficient posterior collateral blood flow, followed by successful surgical stentectomy and carotid endarterectomy using the eversion technique. Duplex scanning and neurological assessments were normal over a 12-month follow-up period.Interdisciplinary treatment is a recommended option to protect patients from further impairment. Further evaluation in larger studies is highly recommended. Stroke is the most common cause of disability. Prevention of stroke by carotid endarterectomy (CEA) or carotid artery stenting (CAS) is widely accepted, and they are basically equivalent treatment modalities ,2. The eA 63-year-old Caucasian man initially presented with an asymptomatic 55% stenosis of the right proximal ICA Figure  to anothMagnetic resonance imaging and angiography including diffusion-weighted imaging did not reveal any ischemic lesions of the left hemisphere. Digital subtracted angiography (DSA) of the supra-aortic and intra-cranial vessels confirmed the occlusion of the left ICA and revealed a highly effective mechanical obstruction of the right ICA caused by two stents deployed in an overlapping side-by-side position Figure . FurtherThe first step of the treatment strategy focused on the posterior circulation stenoses in order to improve the potential collateral supply during subsequent stentectomy and CEA. Dual platelet antiaggregation with acetylsalicylic acid and clopidogrel was initiated. Under general anesthesia the stenoses of both vertebral artery origins were treated with short drug-eluting stents (Coroflex), followed by the stent percutaneous transluminal angioplasty of the left and right V4 stenosis using a combination of moderately undersized balloon dilatation and deployment of oversized self-expanding stents (Enterprise).The surgical stent removal from the right ICA combined with CEA completed the treatment. Stentectomy and CEA were carried out under regional anesthesia.As routinely, we operated using ultrasound-guided regional anesthesia  of the cervical plexus using 20 cc of lidocaine 1%  and 50 cc of ropivacaine 0.375% . The dispensation of analgosedation allowed our patient to be awake throughout the operation, while neurological function was monitored by assessing the level of consciousness and our patient's motor function on the left side. At first the proximal ICA was dissected circumferentially beyond the level of the carotid bifurcation after uneventful clamping. The removal of the proximal stent from the common carotid artery was then possible without any neurological deficit, and we decided to proceed with the eversion technique. The simultaneous removal of the two 'hugging' stents together with the atherosclerotic plaque in the proximal ICA was possible. The ICA and common carotid artery (CCA) were reanastomosed using a 6/0 polypropylene suture in a continuous fashion. Intra-operative angiographic assessment was performed to ensure patency and in order to control the distal end of the plaque removal. Our patient made an uneventful recovery with no additional neurological deficit.Histological examination revealed a thickened layer of arterial neointima. Duplex scanning was within normal limits after five days and three months, and was confirmed by DSA after six months Figure . Follow-With experienced staff at dedicated centers, CEA and CAS are considered equally safe and efficient methods for the treatment of proximal carotid artery stenoses. However, carotid artery angiography and stenting requires proper training . In instOur case report deserves some discussion. Whether an asymptomatic mid-grade ICA stenoses with contralateral ICA occlusion should be treated is the subject of an ongoing debate ,8. The dOur subsequent efforts applied generally accepted endovascular and surgical methods, and started with the deployment of a short drug-eluting stent into the proximal vertebral artery stenoses . For treAt present, surgical experience with complications after stenting is limited . In the The strategy of removal of the two 'hugging' stents with prior hemodynamic 'preparation' led to a good clinical outcome for our patient, without any further neurological deficit during follow-up of 12 months.Post-procedural complication management in vascular medicine is a continuous task requiring interdisciplinary co-operation. The increasing numbers of stent procedures will increase the related surgical expertise. Recommendations for re-do procedures required by local complications of carotid stenting are: (1) the earlier the better, (2) biological reconstruction with the eversion technique is beneficial, and (3) institutions which offer the full range of therapeutic options on site are advantageous.Further evaluation in larger studies is highly recommended.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DJ, HvL and TH performed the surgical procedure and drafted the case report. TG and HH performed the endovascular procedure. HM participated in the diagnostic and therapeutic decisions and was responsible for follow-up examinations. TH and HH made major contributions to writing the manuscript. All authors read and approved the final manuscript.


Biological functions of antibiotics are not limited to killing. The most likely function of antibiotics in natural microbial ecosystems is signaling. Does this signaling function of antibiotics also extend to the eukaryotic – in particular mammalian – cells? In this review, the host modulating properties of three classes of antibiotics  will be briefly discussed. Antibiotics can be effective in treatment of a broad spectrum of diseases and pathological conditions other than those of infectious etiology and, in this capacity, may find widespread applications beyond the intended antimicrobial use. This use, however, should not compromise the primary function antibiotics are used for. The biological background for this inter-kingdom signaling is also discussed. We are all familiar with the use of antibiotics for treatment of infectious diseases. But antibiotics do not only kill bacteria, their original role possibly involved signaling functions . These fThere are many examples of antibiotic signaling effects on the host beyond the intended antimicrobial activity. The use of macrolides for treatment of non-infectious diseases has the earliest history among other antibiotics. A considerable amount of information regarding the therapeutic potential of macrolides for non-antimicrobial use has been collected beginning from the late 1980s. Since then, a great number of animal experiments have been performed, many representatives of this class of antibiotics have gone through clinical trials, and a number of drugs in this group have been approved and are currently commonly used in clinical practice for non-antimicrobial purposes.The use of macrolides has been especially successful in the management of various chronic respiratory diseases not only in the role of antimicrobial agents but also due to their anti-inflammatory and pro-kinetic properties. The positive effect of long-term low-dose administration of erythromycin to patients with diffuse panbronchiolitis was demonstrated by Japanese researchers more than two decades ago, thus suggesting other than antimicrobial nature of erythromycin action . From thPseudomonas aeruginosa, which produces biofilms resistant to antibiotic treatment within the airways , the main bacterium associated with the pulmonary disease is  airways . Althougormation . This metrations . In additrations . This prtrations .Mycoplasma pneumoniae and Chlamydophila pneumoniae in asthmatics best identifies the macrolide responsive phenotype because of the antimicrobial and anti-inflammatory properties of macrolides covering the infection and genetic predisposition continuum  remains one of the important causes of morbidity, mortality, and health-care costs worldwide . AlthougNovel effects of macrolides on cardiovascular diseases have been discovered recently. In animal models, clarithromycin has suppressed the development of myocarditis, cardiac rejection, and myocardial ischemia . The posImmunosuppressive activities of macrolides have been known for almost four decades now. The first macrolide with this activity, rapamycin , was discovered by Brazilian researchers during a screening program for antifungal compounds produced by soil bacteria . But itsThe TOR complexes regulate cell growth and metabolism in response to environmental and intracellular cues and are comprised of two distinct multiprotein complexes: TOR complex 1 (TORC1), which is sensitive to rapamycin, and TORC2, which is not . DysreguStreptomyces tsukubaensis and called FK-506 , was initially approved in 1994 for the prophylaxis of liver transplant rejection, and since then the range of its use has expanded dramatically. In fact, it is considered as a cornerstone of modern immunosuppressive therapy and is used to treat allograft rejections that are resistant to other immunosuppressants , the formation of adhesion molecules necessary for neutrophil migration, and the release of superoxide anion by neutrophils . The ketArtemia franciscana , as their name implies, have been selected primarily for their antimicrobial activities, while other activities such as anti-inflammatory went unnoticed for a long time. In a recent non-antimicrobial antibiotic development, a novel macrolide, solithromycin, has displayed the capability to inhibit NF-κB and demonstrated better anti-inflammatory activities hromycin . A bettehromycin . Synthethromycin . On the hromycin , which whromycin .Tetracycline family of antibiotics is one of the best-studied examples of non-antimicrobial effects of antibiotics on the host. Tetracyclines possess multiple and potent biological activities, and minocycline, the best exemplary compound of this class, displays anti-inflammatory, neuroprotective, anti-proteolytic, and anti-apoptotic properties as well as inhibits angiogenesis and metastatic growth . In addi2+ and Zn2+, inhibition of neutrophil migration and degranulation, and suppression of synthesis of oxygen radicals  and other national regulatory agencies in Canada and Europe is the low-dose formulation of doxycycline for the adjunctive treatment of chronic periodontal disease . Other cIn many studies tetracyclines have demonstrated excellent anti-inflammatory activities achieved through the inhibition of chemotaxis, granuloma formation, nitric oxide production, and protease activities . PositivFollowing the first reports on the neuroprotective effects of minocycline in animal models of cerebral ischemic injury , 1999, dPresently, the results of several clinical trials aimed at the estimation of neuroprotective effects of minocycline are available, although with rather discouraging outcomes compared to animal studies. A phase III randomized trial of minocycline in ALS patients actually demonstrated a harmful effect of minocycline . A futilTreatment of a psychiatric illness relies on a combination of psychological and biological approaches. The latter have been for a long time focused on pharmacological interventions targeting mainly the neurotransmitter systems, but there is a growing body of evidence that these conditions are system-wide and include oxidative stress, inflammation, changes in glutamatergic pathways and neurotrophins as well . MinocycMicroglia are glial cells, the only resident immune cells in the CNS that respond to infections and brain injury and are actively involved in brain development and function as well as in neurodegenerative disease . In the Minocycline is known as the only drug capable of inhibiting the activation and proliferation of microglia . In pathc release . The antibiotic is highly efficient against a broad range of pathogenic bacteria, including those resistant to the first- and second-generation tetracyclines . AlthougOne of the most remarkable breakthroughs in the search for the therapy of neurodegenerative diseases has identified β-lactams as a very promising group of drugs. In a large screening effort involving 1,040 FDA-approved drugs and nutritionals, it has been discovered that the only drugs capable of regulating the expression and modulating the activity of the glutamate transporter subtype 1 (GLT-1) are β-lactams . Glutamain vitro is combined with the induction of Nrf2 consistent with the activation of the antioxidant defense system of the cell -like 2, Nrf2, and the spinal muscular atrophy protein SMN . The trethe cell .In various models of brain injury ceftriaxone demonstrates strong neuroprotective effects, mainly via the up-regulation of GLT-1. In an experimental model of focal cerebral ischemia, the administration of ceftriaxone induces ischemic tolerance resulting in a better functional recovery of animals . A dramaThe potent immunomodulatory properties of β-lactam antibiotics, including inflammation control, are not limited to the sole example given above . In a moβ-lactams may be considered as valuable candidates for treatment of alcohol and other drug dependencies due to the capability of normalizing glutamate transmission, which is affected in addiction . To starThe biggest substance abuse problem is associated with excessive ethanol consumption, and β-lactams hold the potential to contribute to this problem as well. The biochemistry of ethanol addiction is more complicated compared to other drug dependencies, but one of its components discussed above, i.e., changes in glutamate transmission, is affected analogous to other drug addictions . PossiblEnhanced glutamatergic transmission is a primary mediator of opiate dependence, and the counteractive effect of ceftriaxone prevents the development of morphine physical dependence in rats . ThroughIn general even the higher doses of ceftriaxone are tolerated well but care should be taken in neonates, especially those with hyperbilirubinemia and those receiving intravenous calcium solutions . There iNeisseria gonorrhoeae  for the majority of pathogens. The irony of the situation is that it has been clear from the beginning that the growth-promoting effects of antibiotics are not due to antimicrobial activities. Since the very early days of the field it has been shown that even if the antibiotic activity of aureomycin in the culture supernatant of otential . Thus Rootential . Other rAnd finally, moving from the applications to the fundamentals, it remains to be discussed whether this multiplicity of antibiotic targets in the human/animal body we have just seen is merely accidental. Our perception of antibiotics as instruments of warfare in microbial communities is mainly influenced by the extrapolation of antibiotic use in clinical and veterinary microbiology, where high concentrations of antibiotics are used to eradicate bacterial infections in humans and animals. Several lines of evidence gathered in recent years suggest that antibiotic concentrations occurring in natural ecosystems are too low to kill the neighbors and, instead, they may play signaling and regulatory roles in microbial communities . The conAre eukaryotes involved in this microbial signaling network? Before the advent of the multicellular organization about 0.5 billion years ago, the single-celled eukaryotes were probably well-incorporated into the then-existing microbial ecosystems, with the corresponding ancient signaling systems, and were also producing signaling substances themselves. They probably retained this capability even after the shift to multicellular organization, as may be exemplified by some of the ancient eukaryotic organisms having survived until the present days such as sponges which produce plethora of biologically active compounds, including antibiotics . FurtherThe importance of this host–microbe communication has been exemplified above by the hygiene hypothesis that explains a dramatic increase in the number of allergies and asthma in more developed countries due to limited exposure to environmental microbiota in the modern world. Another good example of the malfunctioning host–microbiota communication is the periodontal disease that affects 10–15% of adult population globally . AlthougBacillus megaterium ATCC 9885 is used as the indicator organism  where organism . In ordeorganism . MoreoveThe use of antibiotics has been predominantly studied from the antimicrobial activity perspective and focused mostly on infection control and prevention of antibiotic resistance among pathogens. The advent and rapid expansion of non-antimicrobial application of antibiotics may enhance the already existing selective pressure of antibiotics and contribute to the present antibiotic resistance problem. Better understanding of biotic functions of antibiotics may help to design newer antibiotic derivatives with abolished antimicrobial activities and improved biotic functions.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This paper looks at the series solutions of three dimensional boundary layer flow. An Oldroyd-B fluid with variable thermal conductivity is considered. The flow is induced due to stretching of a surface. Analysis has been carried out in the presence of heat generation/absorption. Homotopy analysis is implemented in developing the series solutions to the governing flow and energy equations. Graphs are presented and discussed for various parameters of interest. Comparison of present study with the existing limiting solution is shown and examined. Investigation of non-Newtonian fluids in recent time has received much attention of the researchers for their industrial and engineering applications. In particular these fluids are important in material processing, chemical and nuclear industries, geophysics, bioengineering, oil reservoir engineering, polymer solutions etc. It is well known that all the non-Newtonian fluids on the basis of their behavior in shear cannot be described by a single relationship between the shear stress and shear rate. Therefore many models of non-Newtonian fluids exist. Such models are based either on natural modifications of established microscopic theories or molecular considerations. The complexity of constitutive equations in the non-Newtonian fluids is the main culprit for the lack of analytical solutions in general. Even such complexity also offer interesting challenges to the computer scientists, mathematicians and engineers for the numerical solutions. Amongst the several models of non-Newtonian fluids, the Oldroyd-B is one which can takes into account the relaxation and retardation times effects The boundary layer flow induced by a stretching surface has importance in the aerodynamic extrusion of plastic sheets, crystal growing, continuous casting, glass fiber and paper production, cooling of metallic plate in a bath, the boundary layer along a liquid film in the condensation process and many others. Such consideration in presence of heat transfer has central role in the polymer industry. In such processes, the quality of final product greatly depends upon the cooling rate and kinematics of stretching. Crane All the above mentioned articles deal with the fluids with constant thermal conductivity. However in reality the thermal conductivity changes with the temperature. To our knowledge, no attempt has been made for the three-dimensional boundary layer flow of an Oldroyd-B fluid with variable thermal conductivity. Even such attempt for Maxwell fluid is not available. In this work, the conservation laws of mass, momentum and energy are reduced to nonlinear ordinary differential systems. The outcoming problems are solved by homotopy analysis method (HAM) We consider the steady three-dimensional flow of an incompressible Oldroyd-B fluid. The flow is caused by a stretched surface at The subjected boundary conditions areExpression of variable thermal conductivity isThe following transformations are utilized to facilitate the analysis:The local Nusselt number with heat transfer Initial approximations and auxiliary linear operators for homotopy analysis solutions are selected in the following forms:The associated zeroth order deformation problems can be written asHere the derived series (27)–(29) depend upon the auxiliary parameters hen  see .The effects of Deborah numbers ter  see  Figs. 5ense see  and 6. Tness see .mber see .The three-dimensional flow of an Oldroyd-B fluid over a stretching surface is examined. Analysis with variable thermal conductivity and heat generation/absorption is conducted. The following conclusions can be drawn from the presented analysis.Deborah numbers Effects of Thermal boundary layer thickness and temperature of fluid are enhanced when there is an increase in Numerical values of local Nusselt number are larger for an Oldroyd-B fluid than the viscous fluid.An increase in Results for three-dimensional flow of Maxwell fluid with variable thermal conductivity (which are not available yet) can be recovered by choosing The considered stretched flow of an Oldroyd-B fluid is important because it can be used in production of plastic sheet and extrusion of molten polymer through a slit die in polymer industry. This thermofluid problem involves significant heat transfer between the sheet and surrounding fluid. The extrudate in this mechanism starts to solidify as soon as it exits from the die and then sheet is collected by a wind-up roll upon solidification. Physical properties of the cooling medium, e.g., its thermal conductivity has pivotal role in such process. The success of whole operation closely depends upon the viscoelastic character of fluid above the sheet. The (drag) force required to pull the sheet can be determined by fluid viscosity. The variable thermal conductivity is quite common in polymeric and plastic industries. Electronics engineers rapidly are embracing thermally conductive plastics because they can absorb heat as well as most metals and can be modelled into intricate shapes and act as structural components as well. Especially the new generation of plastics is significant in components where heat build-up can degrade a conventional plastic. No one area gets overheated by spreading the heat load throughout the component. High thermally conductive polymers are useful in processes with dissipation of thermal energy. The knowledge of good thermal conductivity in modern thermal management composites is helpful in retaining typical properties of plastics such as low weight and electrical insulation. High energy generation rates within turbines or electronics require high thermal conductivity materials like copper and aluminium. The low thermal conductance materials such as polystyrene and alumina are useful in building construction or in furnaces for insulation purposes. It is hope that the present work will serve as a stimulus for needed experimental work on this problem.


Cell-surface receptors are the most common target for therapeutic drugs. The design and optimization of next generation synthetic drugs require a detailed understanding of the interaction with their corresponding receptors. Mathematical approximations to study ligand-receptor systems based on reaction kinetics strongly simplify the spatial constraints of the interaction, while full atomistic ligand-receptor models do not allow for a statistical many-particle analysis, due to their high computational requirements. Here we present a generic coarse-grained model for ligand-receptor systems that accounts for the essential spatial characteristics of the interaction, while allowing statistical analysis. The model captures the main features of ligand-receptor kinetics, such as diffusion dependence of affinity and dissociation rates. Our model is used to characterize chimeric compounds, designed to take advantage of the receptor over-expression phenotype of certain diseases to selectively target unhealthy cells. Molecular dynamics simulations of chimeric ligands are used to study how selectivity can be optimized based on receptor abundance, ligand-receptor affinity and length of the linker between both ligand subunits. Overall, this coarse-grained model is a useful approximation in the study of systems with complex ligand-receptor interactions or spatial constraints. The current importance of cell surface receptors as primary targets for drug treatment explains the increasing interest in a mathematical and quantitative description of the process of ligand-receptor interaction. Recently, a new generation of synthetic chimeric ligands has been developed to selectively target unhealthy cells, without harming healthy tissue. To understand these and other types of complex ligand-receptor systems, conventional chemical interaction models often rely on simplifications and assumptions about the spatial characteristics of the system, while full atomistic molecular dynamics simulations are too computationally demanding to perform many particle statistical analysis. In this paper, we describe a novel approach to model the interaction between ligands and receptors based on a coarse grained approximation that includes explicitly both spatial and kinetic details of the interaction, while allowing many-particle simulations and therefore, statistical analysis at biologically relevant time scales. The model is used to study the binding properties of generic chimeric ligands to understand how cell specificity is achieved, its dependence on receptor concentration and the influence of the distance between subunits of the chimera. Overall, this approach proves optimal to study other ligand-receptor systems with complex spatial regulation, such as receptor clustering, multimerization and multivalent asymmetric ligand binding. PLOS Computational Biology Methods article.This is a Extracellular signals, such as morphogens and hormones, bind to specific receptors on the cell surface to activate signaling cascades that ultimately regulate key cell decisions, such as proliferation, migration or apoptosis. In multicellular organisms, dysregulation of this receptor-initiated signaling can lead to uncontrolled cell proliferation and cancer. Nowadays, around 60% of all commercial drugs are designed to target specific receptors on the cell surface. Due to this role in stimulus recognition and upstream regulation of cell signaling, mathematical modeling of ligand-receptor interaction constitutes a major effort in the development and rational design of novel therapeutic strategies. The majority of these models are based on a chemical kinetics description of ligands in a three-dimensional environment that bind to receptors diffusing in a two-dimensional surface Although these assumptions may be valid in simple scenarios, they neglect several important regulatory mechanisms induced by the structural details of the interaction, such as diffusion inhomogeneities or conformational changes after multimerization, or sequential binding In this work we present a coarse-grained approximation to ligand-receptor interactions, which allows for a computationally feasible study of the dynamics of systems with different sets of ligands and receptors at biologically relevant temporal and spatial scales. The model takes into account both spatial and kinetic features of the interaction, while allowing many particle simulations, and statistical analysis. The interaction between ligand and receptor is described by two basic parameters (angular specificity and strength) which can be tuned to fit a broad range of affinities and dissociation rates to model different ligand-receptor pairs. First, we show that the kinetics of ligand binding and unbinding behave as predicted by chemical kinetics theory, in terms of diffusion and receptor abundance. Then we correlate the parameters defining the interaction (angular specificity and strength) with the experimentally relevant affinity and dissociation rate parameters. As a case study, the model is applied to the analysis of the binding properties of generic chimeric ligands, where we show how cell specificity is achieved and how it depends on receptor diffusion and length of the linker between ligand subunits of the chimera.Using a coarse-grained approximation, the ligand-receptor interaction is characterized by the geometry of the reactants and by the chemical nature of their binding. The first feature sets the interaction specificity by inducing a steric contribution that limits the binding region to a specific area of the receptor molecule; the chemical contribution, in turn, sets the strength of the bond.Within this representation, ligands and receptors are simplified as spherical particles of diameters To account for the interaction between ligand and receptor The functions These functions are chosen so that they and their derivatives are continuous at The ligand-receptor interaction potential can be identified as the effective shape of the receptor seen by a ligand molecule . The effThe ligand-receptor interaction is studied using molecular dynamics simulations where ligands of reduced mass Typically, 4 to 32 independent simulations are run for each set of parameters, and the results are averaged to calculate rate constants. Standard deviations due to system fluctuations are represented by error bars. Simulations were performed using in-house code where the model was implemented in a Verlet algorithm , so the shortest linker possible is often implemented experimentally The presented coarse grained model represents a powerful tool to understand general properties of complex ligand-receptor systems with no analytical solutions available, or where analytical approximations remain to be validated. This is the case of systems with many agents involved, multi-interactions between species or situations with special geometries. Some examples could involve receptor dimerization and its influence on binding, multivalent binding and receptor cross-linking. A careful definition of the geometric factor would also allow multiple ligands to bind simultaneously to the same receptor. In addition, the coarse-grained approximation could be implemented as a module for more complex systems including downstream signaling propagation, or even cell membrane dynamics described via generic coarse grained models, opening the possibility to study the effects of membrane fluctuations or membrane inhomogeneties on ligand-receptor dynamics.Figure S1Binding specificity as a function of . Proportional increment in the number of activity complexes at equilibrium versus the total number of A) and low (B) (TIF)Click here for additional data file.Software S1Collection of source code files to compile and run the coarse-grained simulations used in this manuscript can be found in the Software S1 supplementary file.(BZ2)Click here for additional data file.


Oncolytic viruses are a promising approach for cancer therapy. Recent clinical trials proved the safety and anti-tumor activity of several oncolytic viruses in solid tumors. However, very little is known about the potential of the oncolytic viruses to target hematologic malignancies. Careful analysis of the effects of the oncolytic viruses in patients with hematologic malignancies will lead to the development of more specific and effective treatment strategies.We studied the abilities of various vaccinia-based oncolytic virus constructs to target and eliminate leukemic cells derived from patients with several hematologic malignancies. We used vaccinia virus constructs derived from the LIVP strain, LIVP 1.1.1. strain (plaque purified isolate of the nonattenuated LIVP strain), and from the WR strain. The ability of these constructs to infect and amplify in the patients’ leukemic cells and blast cells was studied with fluorescent microscopy, flow cytometry, and plaque assays for viral replication.We found that our oncolytic virus constructs infected and killed the patient-derived leukemic cells. The LIVP 1.1.1.-based construct was the most efficient in infecting the leukemic cells, followed by the WR-based construct and the LIVP-based constructs. Flow cytometry data suggested that some of the infected cells have blast-like characteristics. Importantly, virus infection with the oncolytic vaccinia virus constructs correlated with the disease progression in these patients. In all experiments, the viral amplification and cytotoxicity were significantly higher in the leukemic cells than in the control healthy mononuclear cell subsets.Our findings suggest the potential of our vaccinia-derived oncolytic virus constructs in targeting different hematologic malignancies. These findings are very relevant to the development of optimized clinical grade oncolytic vaccinia viruses for treatment of hematologic malignancies.


Chest pain is a common complaint in primary care, with coronary heart disease (CHD) being the most concerning of many potential causes. Systematic reviews on the sensitivity and specificity of symptoms and signs summarize the evidence about which of them are most useful in making a diagnosis. Previous meta-analyses are dominated by studies of patients referred to specialists. Moreover, as the analysis is typically based on study-level data, the statistical analyses in these reviews are limited while meta-analyses based on individual patient data can provide additional information. Our patient-level meta-analysis has three unique aims. First, we strive to determine the diagnostic accuracy of symptoms and signs for myocardial ischemia in primary care. Second, we investigate associations between study- or patient-level characteristics and measures of diagnostic accuracy. Third, we aim to validate existing clinical prediction rules for diagnosing myocardial ischemia in primary care. This article describes the methods of our study and six prospective studies of primary care patients with chest pain. Later articles will describe the main results.We will conduct a systematic review and IPD meta-analysis of studies evaluating the diagnostic accuracy of symptoms and signs for diagnosing coronary heart disease in primary care. We will perform bivariate analyses to determine the sensitivity, specificity and likelihood ratios of individual symptoms and signs and multivariate analyses to explore the diagnostic value of an optimal combination of all symptoms and signs based on all data of all studies. We will validate existing clinical prediction rules from each of the included studies by calculating measures of diagnostic accuracy separately by study.Our study will face several methodological challenges. First, the number of studies will be limited. Second, the investigators of original studies defined some outcomes and predictors differently. Third, the studies did not collect the same standard clinical data set. Fourth, missing data, varying from partly missing to fully missing, will have to be dealt with.Despite these limitations, we aim to summarize the available evidence regarding the diagnostic accuracy of symptoms and signs for diagnosing CHD in patients presenting with chest pain in primary care.CRD42011001170Centre for Reviews and Dissemination (University of York):  Chest pain is a frequent complaint in many health care settings. In primary care 0.7% to 2.7% of patient encounters are due to chest pain-3. HowevPrimary care physicians (PCP) face several challenges in diagnosing CHD. In primary care, patients with CHD often present in the early stages of their disease, often with uncharacteristic clinical findings that make the separation from other etiologies difficult. PCPs must reliably identify serious cardiac disease while also protecting patients from unnecessary testing and hospital admissions. They must rely on the history, physical findings, and their accumulated knowledge of an individual patient to determine the clinical probability of CHD and decide whether testing, specialist referral or hospital admission is indicated. Tests  lack sensitivity in the early stages of myocardial infarction (MI) and cannot exclude acute ischemia in patients with a high clinical probability. Lastly, the optimal early evaluation of possible CHD uses the patient’s clinical probability in order to decide on the value of further testing and to interpret test results using probabilistic reasoning, a form of thinking that many physicians do not use.The accuracy of medical history and physical examination for CHD has been the subject of previous meta-analyses. Mant et al.. studied the diagnostic value of symptoms and signs for ACS and myocardial infarction (MI) in studies published until 1999. BruyninThe studies included in these reviews have important limitations, especially for application to the primary care setting. Nearly all were conducted in emergency departments of hospitals, or secondary and tertiary care. The respective settings differ with regard to the prevalence and clinical presentation of CHD or other serious conditions. Sox and colleagues showed that varying prevalence of CHD in primary and secondary care resulted in diverging predictive values of a clinical prediction rule. AdditioFurthermore, the authors of these reviews synthesized the results using aggregate data from each study, such as the 2 by 2 tables of diagnostic accuracy. In contrast, meta-analyses using individual patient data (IPD) consider the whole information about each patient that is available in the primary studies. This increases the scope of possible statistical analyses. For example, IPD meta-analysis allows investigation of the relationship between patient-level characteristics like sex and age and the diagnostic accuracy of a test,13. SingIn order to provide PCPs with evidence that applies to their clinical setting, we will perform a systematic review and meta-analysis using individual patient data. We will include only studies conducted in office-based primary care. The aims of this review are:· to determine the diagnostic accuracy of symptoms and signs for myocardial ischemia in primary care patients· to explore possible associations between study- or patient-level characteristics and measures of diagnostic accuracy.· to validate existing prediction rules for diagnosing myocardial ischemia in primary care.The aim of this preliminary report is to describe the methods of our study and the study populations that comprise the meta-analysis.The studies to be included must fulfill the following criteria:We will include studies recruiting unselected adult patients presenting with chest pain in office-based primary care practice. Studies are not eligible if the patients have been recruited in emergency departments of hospitals, by paramedics, or if the patients have been pre-selected by PCPs or other health professionals based on the likelihood of an underlying CHD. If patients of all age groups are included in the original study we will exclude patients aged < 18 years in the analysis.The diagnostic tests under evaluation will include items of history and physical examination like symptoms, signs, age, sex, coronary risk factors. We will not exclude studies or discard individual items because the studies defined the items differently or used different wording of the questions in the standard data set.CHD is the reference condition. We will not exclude studies because of differing case definitions (e.g. ACS vs. stable CHD). Coronary angiography is supposed to be the definite reference standard in diagnosing CHD. However, since the likelihood of CHD in most patients presenting in primary care is low, this reference test is too invasive. Knottnerus and colleagues suggest that follow up of the clinical course during an appropriate period is a good alternative. They refer to this design as delayed-type cross-sectional design. HoweverWe will exclude studies in which the clinical findings were obtained retrospectively from medical records.We will perform a computerized search in MEDLINE , and EMBASE (Excerpta Medica). Terms identifying chest pain will be used along with terms to identify studies conducted in primary care. Search strategies will include subject headings  as well as free-text terms Table. FurtherAt study level we will extract information on methodological characteristics of the studies, such as inclusion criteria, patient recruitment, data collection, and reference standard from publications. Data not retrievable from published reports will be requested from original investigators. Two reviewers, who have not been involved in the conduct of any of the primary studies, will independently assess the internal validity and methodological quality of each study using the quality assessment tool for diagnostic accuracy studies (QUADAS),16. TheyEach study in our final data set will contain data on patient identifier code, patient’s age and gender, PCP identifier code, data on absence or presence of at least one symptom or sign, and results on the final diagnosis. The diagnostic outcome variable will be any manifestation of CHD. As index tests we will consider each item of the medical history or clinical examination. However, we cannot expect that all studies gathered data on the same symptoms and signs or that they used the same wording, definition, operationalization, or coding of the data. Because the original questionnaires or case report forms had been written in different languages, we will translate the variables used in the individual studies into English and will create a synopsis showing the names, definitions and categories of all variables. Using this synopsis we will identify any symptom and sign that was collected in at least two studies and that should therefore be included in the analysis. Based on the studies we have identified so far following variables will be included in the analysis:AgeSexContext of consultationDid the patient require a home visit?Did the PCP know the patient?Was the encounter an emergency/ an urgent visit?Was chest pain the main complaint?Was CP present during consultation?Had the patient experienced CP before?PCPs’/ Patients’ concernDid the GP assumed something serious?Probability of CHD rated by PCPWas the patient anxious?Did the patient think the pain is related to the heart?Pain characteristics - localizationRetrosternal CPPrecordial CPLeft-sided CPRight-sided CPPain characteristics – radiationBand-shaped radiation of painCP radiating to left shoulder/armCP radiating to right shoulder/armCP radiating to neck, jaw, bottom side of faceCP radiating to abdomenPain characteristics intensityIntensity of CPPain characteristics – quality/ word descriptorsStabbing painOppressive painBurning painDull painPain characteristics – duration and courseTime since first occurrence of the painContinuous painDuration of a typical pain episodeFrequency of CPClinical Course of painPain characteristics - classificationTypical anginaUnspecific CPPain depend on/ provoked by / related toCP related to breathingCP related to movementCP related to swallowCP related to ingestionCP related to effort/ exerciseCP related to coughCP related to body positionRelief after administration of NTGRelief after administration of antacidAdditional complaints/associated symptomsFeverCoughDyspneaSweatingPalenessNauseaSigns of a cold/ respiratory infectSputumReduced state of consciousnessPhysical examinationHeart rateBlood pressureArrhythmiaPulmonary auscultationCardiac auscultationPain reproducible by palpationMedical history – coronary risk factors, previous cardiac eventsHistory of dyslipidemia/ hyperlipidemiaHistory of diabetes (diabetes mellitus)Family history of myocardial infarctionHistory of hypertensionSmokingHistory of myocardial infarctionHistory of known CHDNumber of cardiovascular risk factorsPCP primary care physician, CP chest pain, CHD coronary heart disease) to each imputed meta data set:In the ariables. Next, wariables,18. As aij is the outcome variable for patient j in study i , Xk represents the result of the kth index test, βi0 is the study-specific intercept for the ith study, βk is the coefficient for the index test Xk, Iki is the study indicator for the kth index test , P is the number of index tests, ni is the number of patients in study i, and n is the number of studies. Study-specific intercepts will account for heterogeneity across studies and for the fact that the individual studies will contribute data on different sets of index tests. However, model (1) assumes that the effect of a single index test is fixed across studies. A random effects model is possible, but more complex and might be not feasible if the number of studies is small. The multivariate meta-analysis will result in a clinical prediction rule with optimal diagnostic accuracy characteristics. The unique linear combination of selected symptoms and signs with their estimated regression coefficients from the final model defines a “clinical chest pain score”. If the score exceeds a threshold value, the patient is labeled CHD positive; if the score is less than a threshold value, the patient is labeled CHD negative. Such a prediction rule is “personalized” on the one hand and applicable to individuals in a broad community covering several countries or regions and thus exceeding the validity of individual studies on the other hand.where YAll statistical models considered in the multivariate approach will be formulated as logistic regression models, with CHD as response, and the symptoms and signs as explanatory variables. In order to describe the discriminatory power of the study-specific models and the meta model we will calculate the area under the receiver characteristic curve (AUC). In addition, we will calculate the values of sensitivity, specificity and likelihood ratios for different thresholds of the clinical prediction rule.Since the maximum likelihood (ML) estimates of a logistic regression model are not necessarily maximizing the AUC, we will compare the ML results with the alternative approach of Pepe et al.. In thisA secondary objective of the statistical analysis is the external validation of clinical prediction rules (CPR) aimed to support PCPs in diagnosing myocardial ischemia in patients with chest pain. We are aware of several rules developed or validated in a primary care setting and based on items of the medical history and clinical examination.,23-26. TTo date, we have identified six relevant studies, including about 4000 patients and conducted in five different countries,23,27-29interchest) and to provide the data from each study to perform a meta-analysis with individual patient data. An initial meeting took place in January 2010. The coordinating center is the Department of General Practice, University of Marburg, Germany. In a series of video conferences, the whole group has discussed major questions about organizing the data, conducting the analysis, and interpreting the findings. We are inviting investigators of future eligible studies to join this collaboration.The investigators of these six studies have agreed to collaborate as the international working group on chest pain in primary care  have been developed to support physicians in diagnosing myocardial ischemia in patients with chest pains,23-26. WSeveral methodological problems make it difficult to anticipate the results of our study. The individual studies were conducted over a span of almost thirty years during which the criteria for myocardial infarction changed, largely because of troponin assays becoming available. We expect semantic and cultural differences to compromise the comparability of study variables. Further, given the results of previous systematic reviews-7, the lWe hope that the planned systematic review will advance our understanding in the following ways:a) Clinical knowledgeWe aim to report estimates of accuracy for single signs and symptoms and for clusters of signs and symptoms for the diagnosis of myocardial ischemia in unselected patients presenting with chest pain in primary care. In addition, we will investigate the effect of patient characteristics like sex and age on the diagnostic accuracy of signs and symptoms. Furthermore, we will validate clinical prediction rules for the diagnosis of CHD in primary care. Based on these findings we will be able to give recommendations regarding future research including the investigation of diagnostic algorithms based on combinations of findings of the history, physical examination, and technological devices .b) Methodological knowledgeWe will explore possible associations between study-level and patient-level covariates on the one hand, and sensitivity and specificity of medical tests on the other hand. Based on the findings, we aim to provide recommendations regarding the design of future diagnostic studies in primary care and the conduct of diagnostic accuracy reviews based on individual patient data.The authors declare that they have no competing interests.NDB is the principal investigator of the study described in this article. JH coordinates the study. All authors participate in the study design. JH wrote a first draft of manuscript. All other authors commented on this draft and contributed to the final manuscript. All authors read and approved the final manuscript.This study is funded by Federal Ministry of Education and Research (BMBF - grant no. FKZ 01GK0920). The funding source has no involvement in the study.CRD42011001170PROSPERO, Centre for Reviews and Dissemination (University of York): The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/13/81/prepub


Bacillus thuringiensis and Photorhabdus/Xenorhabdus species, are promising alternatives to chemical insecticides, for they are able to efficiently kill insects and are considered to be environmentally sound and harmless to mammals. However, they have the handicap of showing limited environmental persistence or of depending on a nematode vector for insect infection. Intriguingly, certain strains of plant root-colonizing Pseudomonas bacteria display insect pathogenicity and thus could be formulated to extend the present range of bioinsecticides for protection of plants against root-feeding insects. These entomopathogenic pseudomonads belong to a group of plant-beneficial rhizobacteria that have the remarkable ability to suppress soil-borne plant pathogens, promote plant growth, and induce systemic plant defenses. Here we review for the first time the current knowledge about the occurrence and the molecular basis of insecticidal activity in pseudomonads with an emphasis on plant-beneficial and prominent pathogenic species. We discuss how this fascinating Pseudomonas trait may be exploited for novel root-based approaches to insect control in an integrated pest management framework.Insects are an important and probably the most challenging pest to control in agriculture, in particular when they feed on belowground parts of plants. The application of synthetic pesticides is problematic owing to side effects on the environment, concerns for public health and the rapid development of resistance. Entomopathogenic bacteria, notably  With the world population still experiencing continuous growth, an immediate priority of agriculture is to increase crop production to assure food security while becoming more sustainable . One wayAfter decades of intensive pesticide application, it has become evident that there is no silver bullet solution to the control of pests in sustainable agriculture. The integration of many different, complementary approaches of chemical and biological control methods to solve the diverse and challenging problems with pests is the basic idea behind integrated pest management (IPM) programs . Since iBacillus thuringiensis (Bt) is a Gram-positive, spore-forming soil bacterium and the insecticidal organism which is dominating the market for products for microbial control of insects  crops that express variants of the Cry toxins have been developed and successfully commercialized. Planting of GM crops reduced the amount of pesticides applied by 8.9% in the period from 1996 to 2011  and is aDiabrotica virgifera is a significant economic pest insect of maize in the United States and in Europe and acquired the nickname “billion dollar bug,” not without reason  of the Diptera . Some of these bacterial strains are already successfully used as antifungal biocontrol agents in agriculture . The beneficial effects of induced systemic resistance (ISR) triggered by root-colonizing pseudomonads in mono- and dicotyledonous plants against plant pests caused by fungal, oomycete, bacterial and viral pathogens, and also by herbivorous insects are extensively documented  with activity against Pythium, Rhizoctonia, and Fusarium root diseases of vegetables and ornamentals in greenhouses, BlightBan A506 (P. fluorescens) used against fire blight on apple and pear, and Bio-Save 10 LP/11 LP (Pseudomonas syringae) used for the control of post-harvest diseases of fruits and potato . Notably, strains of P. fluorescens were reported to exhibit insecticidal activity toward agricultural pest insects such as aphids  and a phytopathogenic fungus (Rhizoctonia solani) in rice under greenhouse and field conditions  and their analysis revealed astonishing results which opened a new door to future studies on plant-associated pseudomonads. After more than twenty years of research on the biocontrol properties of P. fluorescens group strains it came as a surprise that some of these bacteria do not only harbor numerous genes for the biosynthesis of antifungal metabolites, including DAPG, pyoluteorin, HCN, and pyrrolnitrin (see Table 1), in their genomes, but also possess a gene which codes for a protein that is similar to the potent insect toxin Mcf1 of the entomopathogen P. luminescens  made the Escherichia coli cells expressing it capable of surviving within and killing larvae of the tobacco hornworm Manduca sexta upon injection into the hemocoel. When expressed heterologously in E. coli, Mcf1 was shown to cause hemocytes and midgut epithelial cells to undergo programmed cell death. The disintegration of the midgut caused by Mcf1 was proposed to contribute to the “floppy” phenotype of insects infected with P. luminescens, thereby giving the name to the newly discovered toxin. The pro-apoptotic action of Mcf1 was attributed to the predicted Bcl2-homology 3-like (BH3-like) domain at the N-terminus of the protein. The BH3 domain is a well-studied and important peptide motif of proteins making up part of the pro-apoptotic signal-transduction cascades in animal cells  predicted to encode a type I secretion system and three genes (fitFGH) coding for regulatory proteins. The toxin gene is co-transcribed with the genes encoding the proteins for the putative secretion system, thereby suggesting that the toxin may be transported across the bacterial cell wall via this type I secretion system . The invasion of the insect blood system within a short time period of less than 1 day after oral uptake of the microorganisms strongly suggests that these bacteria should be considered as true insect pathogens.The potential of these plant root-associated pseudomonads as entomopathogenic microorganisms can be demonstrated impressively by feeding Chinese cabbage leaves containing drops of a suspension of GFP-tagged fit cluster and the fact that the regulation of virulence in entomopathogenic bacteria has been addressed only to a limited extent at the molecular level before, it was particularly intriguing to study of the expression of the Fit toxin and its regulation. To this end the Fit toxin gene of P. protegens CHA0 was replaced at its native locus by a gene fusion of fitD to mcherry (coding for a red fluorescent protein), which allowed the direct in situ visualization and quantification of insect toxin production at wild-type level by monitoring and measuring the red fluorescence emitted by single cells with an epifluorescence microscope  the opportunistic human pathogen Pseudomonas aeruginosa, and (iii) the plant pathogen P. syringae (Table 2). As detailed below, studies of the interactions of the three pathogens with insect hosts have significantly advanced our understanding of the molecular mechanisms involved in bacterial invasion of insects, escape from the insect immune response, gut and hemocoel colonization, and insect toxicity. They have also provided first insights into the ecology of vectoring of pseudomonads by insects. Studies on these pathogens can thus provide a valuable source of inspiration for future work on interactions of plant-beneficial pseudomonads with insects.Third, following oral infection several ns group , currentP. entomophila is a bacterium that naturally infects Drosophila and originally was isolated from a fruit fly in Guadeloupe. The species which affiliates with the Pseudomonas putida phylogenetic group  produced by the insect  retain some degree of insect toxicity pointing to the existence of additional virulence factors. The genomic sequence of P. entomophila reveals a number of loci that encode potential candidate virulence factors, e.g., Tc-related toxins, HCN, hemolysins, and lipopeptides  or by feeding the insects with the bacterium (LD50 of about 104 cells per insect). A follow-up study then provided evidence for the passage of small numbers of the P. aeruginosa isolate from the gut into the hemocoel . It is therefore that these bacteria have a high potential as plant protection products. Because they can promote the growth of plants and protect plant roots against several pests simultaneously, Pseudomonas-based formulations may become products of high profit potential (Pseudomonas strains as active ingredient currently exist on the market for biopesticides.As it was illustrated in earlier chapters of this review, natural isolates of otential . While potential , no insePseudomonas-based products were reported to exhibit inconsistency under field conditions and they have raised some concerns of the general public about biosafety because this bacterial genus includes opportunistic human pathogens such as P. aeruginosa. As with every new biopesticide, the expensive and time-consuming registration procedure is a major hurdle for the successful application of a biocontrol agent (P. fluorescens group which are approved in many countries for their use as fungicides in agriculture already went through the evaluation of environmental risks and the registration procedure. The products passed all tests on biosafety and efficacy, and these bacterial strains should therefore be studied for their effects on insects to possibly extend their application range in the future by modifying their formulations.The way to a product based on root-associated pseudomonads for efficient plant protection against insects and phytopathogenic fungi obviously is not free of obstacles. Pseudomonads are known to be challenging microorganisms when it comes to formulation . The surol agent . NeverthPseudomonas strains can also readily be isolated from various insect species. An obvious approach to discover strains with entomopathogenic potential could therefore be the isolation of pseudomonads from the respective target organism. During the selection of strains for a new plant protection product the efficacy of the bacterium as an insecticidal organism, the persistence and competition on plant roots, and the resistance during the formulation process should be considered (P. protegens to launch Fit toxin expression specifically in an insect host while arresting production of the insecticidal factor on roots (Pseudomonas strains, just like the development of products such as Proradix, Cedomon, and Cerall already has demonstrated (Novel nsidered . Moreoveon roots , thus prnstrated .P. fluorescens group are well-adapted to the life on plant roots and show environmental persistence. These microbes are very competitive and aggressive root colonizers (Pseudomonas-based biofungicides, it could be possible to apply entomopathogenic strains of P. protegens and P. chlororaphis as seed coatings for inoculative releases and thereby use these microorganisms in a preventative manner. Because plant-associated pseudomonads are already successfully used as biological fungicides in agriculture, insecticidal products for crop protection with entomopathogenic Pseudomonas bacteria as active ingredient could fit well into integrated systems. They would extend the existing toolbox for IPM and help to optimize the protection of plants against pest insects that feed on roots during at least a part of their life cycle and remain a challenging problem in many agricultural systems. As mentioned before, formulations with plant-beneficial pseudomonads possessing insecticidal activity could potentially be developed to provide products to the farmers that may permit long-term control of root-feeding insects and soil-borne phytopathogens simultaneously in an IPM framework. Future research should investigate the interaction of these pseudomonads with other IPM components. Combinations with other biocontrol agents such as entomopathogenic fungi or nematodes or further IPM tactics could show a synergistic effect on the suppression of plant pests (Microbial control agents are considered environmentally friendly and harmless to mammals, making them ideal components of IPM systems. Commercial insecticides based on entomopathogenic bacteria are mostly applied as inundative releases for short-term pest control when insect populations have already reached a certain threshold . Many stlonizers , and wount pests .Pseudomonas strains. This includes in particular research on Photorhabdus/Xenorhabdus and pathogenic Pseudomonas species, but also studies about less known bacteria capable of killing insects, e.g., the aphid-infecting plant pathogen Dickeya dadantii (Pseudomonas-based products in the field from the beginning.The analysis and comparison of whole genome sequences in order to find candidate genes or gene clusters contributing to the insecticidal activity is a powerful approach to discover novel virulence factors and to extend the knowledge about these bacteria. It is further important to learn from existing data on other entomopathogenic bacteria to get a better understanding of the relevant virulence factors and their regulation, the mechanisms of colonization and invasion, and other functions required for insect pathogenicity of the plant-beneficial dadantii , could bWe think that the current knowledge about the insect pathogenicity of certain root-associated pseudomonads and the powerful tools that are available for further investigations into this exciting feature are promising and a motivation for the development and application of microbial pesticides based on well-selected strains of these bacteria for a better management of root-feeding pest insects in the near future.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.


A decline in breast cancer mortality has been observed in western European Countries since the middle of the 1990s.Different methodological approaches, including case-control studies, incidence-based mortality studies, and trend studies, have been used to assess the effectiveness of mammography screening programmes in reducing breast cancer mortality. However, not all methods succeed in distinguishing the relative contributions of service screening and taking correctly into consideration the potential source of bias that might affect the estimate.Recently, a review of six case-control studies confirmed a breast cancer mortality reduction ranging from 38% to 70% among screened women. This figure is in accordance with the estimate obtained from incidence-based mortality studies if screening compliance is taken into account. We will describe the methodological constraints of mortality trend studies in predicting the impact of screening on mortality and the necessary caution that must be applied when interpreting the results of such studies.In conclusion, when appropriate methodological approaches are used, it is evident that mammographic screening programmes have contributed substantially to the observed decline in breast cancer mortality. Screening mammography is aimed at detecting breast cancer in an early stage in women without breast symptoms. The efficacy of mammography screening programmes has been assessed in eight randomized controlled trials conducted in Sweden, Scotland, New York, and Canada in the 1970s and 1980s . A meta-Now that screening is widespread, non-randomized observational studies will become the main contributors of new information on the impact of breast cancer screening as a public health policy . DiffereThe case-control study is a traditional tool for the evaluation of the effect of screening on BC mortality. This approach has also been used extensively for evaluating the efficacy of cervical and colorectal cancer screening ,14.The case-control study design has been used in several studies because of its efficiency. The rationale of these studies is the comparison of the screening histories in two groups of women, namely: (1) those who have died from breast cancer (cases); and (2) women sampled from the source population from which cases were drawn (controls). The collection of screening histories of a limited number of subjects allows a more accurate and valid evaluation than it could obtain for an entire population.In 2010 a review of recent case-control studies on the effectiveness of population-based BC screening was carried out by Paap and colleagues . AuthorsThe validity of case-control design for evaluating screening programmes has been largely discussed . One of Incidence-based mortality (IBM) studies are those studies including only BC deaths occurring in women with BC diagnosed after their first invitation to screening. The IBM rate is different from the usual mortality rate because the population forms the denominator at diagnosis rather than at death : person The IBM rate in a population invited to screening was compared with the IBM rate expected without screening . A key iUsing this approach, the effect of screening is clearly evidenced and a reduction in BC mortality of around 25% was estimated ,9,27. ThAnalysis of temporal trends in BC mortality rates is a tool frequently used due to the common availability of the data from population statistics and the apparent methodological easiness. Analyses were usually based on the comparison of BC mortality rates before and after the introduction of screening or on the comparison of the annual percentage change in BC mortality in areas with an active screening programme and in unscreened areas -12. We wAnalyses of temporal trends could be misleading due to multiple methodological failures. First, this type of study does not distinguish BC deaths in women who were diagnosed before the start of the screening programme from those diagnosed after the initiation of screening. It appears obvious that screening can only possibly have an effect on women not already diagnosed with BC. The correct way of performing statistical analyses is using the IBM method . Second,Even if the comparison between screened and unscreened groups is set up properly, the interpretation of temporal mortality trend remains a very complex issue. It is well known that mortality rates are a function of both incidence and survival. Any changes of BC incidence rates over time will affect the cause-specific mortality rates in the subsequent years. The second determinant of the mortality rate, cancer survival, can be modified in two different ways: the advance of diagnosis and the improvement in therapy. All these factors  interact with each other to modify the mortality rates over time. The challenge is to assess the relative contribution of each factor to the reduction in BC mortality.Recently, the effectiveness of mammography screening programmes in reducing BC mortality has been questioned on the basis of some observational studies analyzing mortality trends ,11. ThesGiven the methodological constraints of temporal correlation studies in predicting the impact of screening on mortality, the analysis of trends in BC mortality should be interpreted with caution. When specific studies evaluating the exposure to screening at an individual level are performed (including case-control studies and IBM studies), the effect of mammography screening on the reduction of BC mortality is evident and incontrovertible.The authors declare that they have no competing interests.PD and ZM conceived the scheme of the paper. PD wrote the manuscript and ZM revised it. Both authors approved the final manuscript.PD, statistician and master in Epidemiology, works at the Cancer Prevention and Research Institute (ISPO) since 2004 and she has been involved in several studies on breast, cervix, and colorectal cancer screening. ZM, medical doctor, is the director of the Italian National Centre of Screening Monitoring. He is the head of the Unit of Screening Evaluation at ISPO since 2004 and he is co-author of more than 200 peer-reviewed papers.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/10/106/prepub