The effectiveness of malaria chemoprophylaxis is limited by the lack of compliance whose determinants are not well known.The compliance with malaria chemoprophylaxis has been estimated and analysed by validated questionnaires administered before and after the short-term missions (about four months) in five tropical African countries of 2,093 French soldiers from 19 military companies involved in a prospective cohort study. "Correct compliance" was defined as "no missed doses" of daily drug intake during the entire mission and was analysed using multiple mixed-effect logistic regression model.The averaged prevalence rate of correct compliance was 46.2%, ranging from 9.6%to 76.6% according to the companies. Incorrect compliance was significantly associated with eveningness (p = 0.028), a medical history of clinical malaria (p < 0.001) and a perceived mosquito attractiveness inferior or superior to the others (p < 0.007). Correct compliance was significantly associated with the systematic use of protective measures against mosquito bites (p < 0.001), the type of military operations  and other individual factors (p < 0.05).The identification of circumstances and profiles of persons at higher risk of lack of compliance would pave the way to specifically targeted strategies aimed to improve compliance with malaria chemoprophylaxis and, therefore, its effectiveness. Non-immune civilians and military personnel traveling in malaria-endemic areas are at risk of getting malaria and may become clinically ill during or after their travel. Approximately 25-30 million travellers from non-tropical regions visit malaria-endemic countries annually, and about 30,000 cases of travel-associated clinical malaria occur each year . In the Plasmodium falciparum to most anti-malarial drugs and the resistance of Anopheles to insecticides may limit the efficacy of these prophylactic measures. Chemoprophylaxis is a key component of malaria prevention because none of the vector protection measures totally avoid mosquito bites during night activities. However, the effectiveness of chemoprophylaxis is limited by lack of compliance with drug intake, even if the regimen is adapted to the chemosusceptibility of P. falciparum [Malaria is an important threat to tourists, soldiers and employees travelling or working in endemic areas, particularly because of the potentially rapid onset of infection and the severity of the disease. Non-immune travellers should be protected from malaria by chemoprophylaxis and prophylactic measures against mosquito bites, including insecticide-impregnated bed nets (IIBN), repellents and insecticide-treated long-sleeved clothes and pants. In malaria-endemic areas, the use of most of these prophylactic measures is mandatory for non-immune soldiers of Western armies or for non-immune employees of most major international groups. The resistance of lciparum ,7.Many clinical malaria cases and outbreaks -11 have It is generally acknowledged that the lack of compliance with medications is unrelated to the lack of symptoms or risk perception. In fact, compliance determinants are not well known, especially for chronic diseases, such as HIV infection ,18, diabThe objective of the present study was to identify the determinants of compliance with malaria chemoprophylaxis among French soldiers on a short-term mission in malaria-endemic areas of tropical Africa.The present study was part of a larger prospective cohort study on the risks of vector-borne diseases among French soldiers carried out between February 2004 and September 2007. The study comprised 19 French military companies  serving a short-term mission (about four months) in five tropical African countries: eight companies in Côte d'Ivoire, four in Gabon, three in Chad, two in Central African Republic and two in Senegal. The soldiers were required to take chemoprophylaxis and apply protective measures against mosquitoes. These companies were selected to represent the various conditions that French soldiers experience in Africa. All members of the companies designated for the mission were eligible for the study and were invited to participate. Soldiers absent from the regiment on the dates of the surveys or who left the company between the survey and the departure or during the mission were excluded from the analysis.The protocol was approved by the ethical committee Marseille II . The informed consent of each participant was obtained at the beginning of the study after a thorough explanation of its purpose.Two self-administered questionnaires containing behavioural items were filled out by each soldier and validated by a member of the research team. The first survey was administered no earlier than 15 days before their departure, and the second was completed no later than 15 days after their return.The dependant variable was the level of compliance with malaria chemoprophylaxis during the mission as assessed retrospectively by the return questionnaire. "Correct" compliance was defined as "No missed doses" of daily drug intake during the entire mission, while "incorrect" compliance was defined as one of the three other possible responses: "Less than one missed dose per month," "One or more missed doses per month, but less than one missed dose per week" or "One or more missed doses per week".Independent variables that were considered potential determinants of compliance were recorded for each soldier either upon departure or return. These variables were related to individual characteristics or to the particular settings of the mission, as described below.i.e. the circadian rhythm of the soldiers: morning people waking up early and being more alert in the first part of the day, evening people being more alert in the late evening hours and preferring to go to bed late.Variables relative to the mission were the dates of departure and return, country and mission type, such asmilitary operation or training. Demographic and behavioural variables were age, gender, rank, usual morningness and eveningness (as determined using the reduced Horne and Östberg morningness-eveningness questionnaire -31), wake.g., birth of a child, illness or death of a relative or friend, or separation or announcement of a divorce). Other variables included the subjective perceived risk level during the mission associated with i) a dangerous situation, ii) the individual likelihood of acquiring clinical malaria, and iii) the severity of disease if malaria were contracted.Other variables pertained to the occurrence of important familial events during the mission . A global score was calculated by combining the frequency of use of each antivectorial measure during each activity with the time spent in each activity. Moreover, a global variable summarizing the use of all anti-vectorial protective measures  was constructed.Independent variables relative to the chemoprophylaxis were the drug itself (either doxycycline or chloroquine-proguanil combination with once-daily dosages), tolerance and usual time schedules of intake.i.e., themain vector-borne diseases experienced by the French Forces). Variables pertaining to medical events that occurred during the mission included clinical malaria, non-malarial fever, diarrhoea, boil, other severe infectious disease , perceived frequency of mosquito bites and perceived personal mosquito attractiveness.The variables incorporating medical antecedents were allergy to insect bites, usual cutaneous response to mosquito bites and medical history of malaria, leishmaniasis or dengue fever . Only participants who completed both questionnaires were considered for statistical analysis. Missing values affected less than 1% of the participants and were replaced using the single imputation method. When a question was not asked to one or more companies, the responses were coded as missing data for those companies.The confidence interval of correct compliance with malaria chemoprophylaxis was estimated by taking into account the clustered design of the study using the svy commands under STATA 9.0. Compliance with chemoprophylaxis was analysed as a dependant variable according to individual and company characteristics using a random effect mixed logistic regression model. The model was designed to take into account the intra-company correlations that could exist due to the sampling design (company effect as random effect). The logistic model was also adjusted using a generalized estimating equations (GEE) approach. Random effect and GEE regression models allow the estimation of company-specific and population-averaged effects, respectively .p-value less than 0.25 [p < 0.05) independent variables and their interactions in the final model. The statistical quality of the final model was assessed by looking at the adequacy between observed and predicted probabilities of correct compliance.First, a descriptive analysis of the independent variables was performed. A bivariate analysis was then conducted by entering each independent variable in a logistic regression model. Variables were retained for the multivariate analysis when their effect had a han 0.25 . A backwOf 2,901 eligible soldiers from 19 companies, 808 were excluded because they did not complete both questionnaires, leaving a sample of 2,093 subjects. The most common reason for not completing the questionnaires was the absence of the subject from the regiment at the time of the survey . Some soldiers who had planned to deploy to Africa and completed the first questionnaire did not travel and were replaced by others who had not completed the survey. Some soldiers returned to France before the rest of their company or were transferred to another regiment and were not present at the time of the second survey. The rate of refusal to participate in the study was lower than 5%.The descriptive characteristics of the companies are summarized in Table Assessment of compliance level with chemoprophylaxis was based on the self-reported occurrences of daily medication doses missed during the mission. "No missed doses" was indicated by 967 out of 2,093 soldiers, or 46.2% "correct" compliance. Between companies, the lowest proportion of correct compliance was 9.6%, and the highest was 76.6%.Among the other three responses corresponding to incorrect compliance, "less than one missed dose per month" was declared by 637 soldiers (30.4%); "one or more missed doses per month but less than one missed dose per week" was declared by 298 soldiers (14.2%); and "one or more missed doses per week" was declared by 191 soldiers (9.1%).The frequency of correct compliance was calculated according tothe following: variables related to the mission, demographics and behavioral characteristics; the occurrence of particular events during the mission and the perception of risks; use of anti-mosquito protective measures; use of malaria chemoprophylaxis; and medical history and occurrence of medical events during the mission. These data are shown in Tables p = 0.0074).The variables retained in the final mixed multivariate logistic regression model are shown in Table There was no significant interaction between independent variables. The company effect was significant in the final model. The OR estimates were similar for both the random effect and GEE regression models.Many studies have been conducted in order to identify factors that influence compliance with medications, most of which focused on treatments to cure, reduce or delay complications and symptoms caused by chronic diseases. Only a few studies have assessed compliance in the context of chemoprophylaxis. Recently, the concept of adherence has supplanted compliance, as adherence implies that the patient agrees with the prescribed recommendations rather than passively obeying them  . HoweverThe systematic use of protective measures against mosquito bites  was associated with correct compliance with chemoprophylaxis. Whereas previous studies showed no association  or even Among life events, only the birth of a child during the mission was associated with correct compliance. This could be explained by an increase in the level of responsibility felt towards the newborn, a greater maturity among those in a position to father a child or internal pressure from the family ,36, any The "morning-type" soldiers, as determined by both the reduced Horne and Östberg morningness-eveningness questionnaire and by sleep/wake hours during the mission, were more likely to have correct compliance. Similarly, "evening-type" soldiers were less compliant with chemoprophylaxis. Eveningness has been associated with certain personality traits and dimensions  -39 and iIt has been shown that travellers who perceived themselves at high risk of becoming ill with malaria after returning home  or traveSimilarly, individuals who perceived themselves to be either more or less potent mosquito attractors than others were more compliant with chemoprophylaxis. This unexpected significant association also persisted after adjusting for the other covariates. Individuals who considered themselves less attractive to mosquitoes could be less compliant because of the perception of a lower risk of contracting malaria. In contrast, those who thought that they attracted mosquitoes more so than others were expected to be more compliant with anti-mosquito measures and could have believed that these anti-vectorial measures were sufficient to protect them. However, no significant interaction was found between the effects of the perceived mosquito attractiveness and compliance with anti-mosquito measures or chemoprophylaxis. Other determinants induced by the military setting such as fatalism or coping with danger by avoidance, denial or vulnerability could explain this unexpected association.A previous medical history of malaria was associated with present lack of compliance. This suggests that having experienced an episode of clinical malaria was not a factor contributing by itself to the adoption of prophylactic behaviours . TherefoThe present study did not show any significant association between compliance and gender or age, although it has previously been shown that women and older travellers were more compliant ,35,45. HMilitary operation-type missions were associated with correct compliance, independent of the country or the army corps. In such conditions, the soldiers were probably more closely supervised by the command, so they were submitted to a higher pressure to comply with the chemoprophylaxis. Indeed, the good health of the soldiers, including the prevention of malaria, was an important concern of the command because of the operational nature of the mission: the global health of the group had to be preserved for a military purpose . CompliaAfter taking all these factors into account, there was still a significant group effect; that is, significant behaviour determinants associated with the companies that were not identified in the present study. Moreover, the rate of compliance was very heterogeneous among companies, meaning probably that individual behaviours were not independent within a company. This unconscious or conscious imitation was not explained by the previous determinants. The lack of isolated soldier limited the possibility of studying the group effect. Compliance with anti-malarial prevention measures appears to be the end result of a complex mixing of the perception of risks and of protective/curative interventions, the acceptance of these measures and their application in spite of discomfort; qualitative approaches could be appropriate for exploring these complexities .®: Medication Event Monitoring System) that records the date and time of bottle cap opening has been conducted to objectively assess the rates of compliance in the first company. This electronic monitoring is considered to be more accurate than questionnaires, diaries or counts of returned untaken tablets for the assessment of compliance [® as the reference), the answers to the questionnaire used in the present study had a 0.69 and 0.75 sensitivity and specificity, respectively, to the assessment of the correct compliance. These quality indexes were close to those previously found by others using only one question [In this study, the compliance was measured based on a self-administered questionnaire. This method could overestimate the rate of correct compliance, as previously shown for anti-viral therapy  or malarmpliance ,50. If cquestion ,51,52. Ta priori determinants likeeveningness, which are associated with compliance. The identification of circumstances and profiles of persons at higher risk of lack of compliance would allow the implementation of specifically targeted strategies of health information, education, and communication, in order to improve compliance with malaria chemoprophylaxis and therefore its effectiveness.The results of the present study are applicable to French soldiers travelling for a short-term mission in intertropical Africa because the companies were representative of the different malaria-endemic areas to which they could be sent. The prevalence of correct compliance with malaria chemoprophylaxis among soldiers was close to those reported elsewhere among civilian travellers ,28,35, aThe authors declare that they have no competing interests.NR performed the statistical analysis and wrote the article. VM participated significantly in the data management. LO, EOP and GT participated significantly in the data management and the conception of the questionnaires. JG participated in the statistical analysis. BP, CTT and AB contributed significantly in the preparation of the study. CR conceived the study, took part in the analysis of the data and the discussion and wrote the article. The final version of the manuscript was seen and approved by all authors.


Little empirical research has examined how cultural factors influence psychosocial factors for heroin drug use. The objectives of the study were to investigate the levels of individualism and collectivism among young adolescents and how cultural differences were associated with the constructs of the Theory of Planned Behavior and other psychosocial factors for heroin drug use.A cross-sectional study was conducted among young adolescents in an HIV and heroin-stricken area in China. The Individualism-Collectivism Interpersonal Assessment Inventory (ICIAI) was used to measure cultural norms and values in the context of three social groups: family members, close friends, and classmates.A total of 220 boys and 241 girls were recruited and participated in an interview. Compared to boys, girls reported higher levels of the three specific-relationship ICIAIs, as well as higher levels of perceived behavioral control for heroin use, perceived peer control, and communication with parent about heroin use, but a lower level of favorable attitude towards heroin use. The levels of descriptive and subjective norms of heroin use were low in both girls and boys. Among boys, family ICIAI was positively associated with perceived behavioral control, and friend ICIAI was positively associated with perceived peer control and communication with parent. Among girls, family ICIAI was positively associated with perceived behavioral control and communication with parents about heroin use, but negatively with favorable attitudes to heroin use; friend ICIAI was positively associated with perceived peer control, and classmate ICIAI was negatively associated with favorable attitudes toward heroin use.This study documents that collectivistic aspects of Chinese culture may influence psychosocial factors for heroin use, although the patterns are varied by gender. Findings provide an empirical basis for the development of culturally competent intervention programs for heroin use intervention and prevention. Culture has been considered an ecological-level variable that may influence mental processes, human behaviors, and health . AlthougThe majority of the theoretical models of behavioral change have been developed and designed for assessing HIV-related risks among people in Western countries. One of the commonly-used models in HIV behavioral intervention is the theory of planned behavior (TPB) . The theIndividualism versus Collectivism (IC) is the most common dimension of culture operationalized at the individual level ,8. IndivMatsumoto and colleagues developed the Individualism-Collectivism Interpersonal Assessment Inventory (ICIAI) to measure IC at the individual level . ICIAI eThere are few studies examining whether the individualistic-oriented intervention theories are sensitive to the collectivistic-oriented culture and how cultural differences influence psychosocial factors for heroin use. We, thus, conducted a cross-sectional study among middle-school students in an HIV- and heroin-stricken area in China. The objectives of the study were to investigate the levels of individualism and collectivism among young adolescents and how cultural differences were associated with the constructs of the theory of planned behavior, communication with parents about heroin use, and perceived peer control for preventive practices. We expected that girls, compared to boys, had higher levels of collectivistic tendencies. This expectation was based on gender-preferences in China. Traditionally, males are socialized to be independent, self-reliant, and emotionally detached, whereas females are expected to be dependent, reliant and emotional . IllicitWe selected "H County" in Guangxi province as the study site. Guangxi is along a drug trafficking route, which originates from the "Golden Triangle", passes through northern provinces of Vietnam and Guangxi and finally into Hong Kong and the rest of the world . GuangxiSince the goal of the study was to investigate how individualism and collectivism influenced psychosocial factors for heroin use, we purposely selected middle schools located in the areas where prevalence of heroin injection use was high. There were 66 middle schools in H County. The following steps were taken to select schools: (1) ranked all rural towns based on the levels of heroin injection prevalence, using local surveillance data; (2) selected the top five towns in the ranking; (3) randomly selected one school from each town if there was more than one school; (4) randomly selected two schools out of five schools for qualitative studies and the remaining three schools for a cross-sectional study. Eligibility of participants included: (1) students in second and third grade  in the three selected middle schools, and (2) students who were able to obtain parental permission and to invite one of their parents or guardians to participate in the study.We first selected classes that had enough students in each of the three schools. If the number of students was not enough because students could not obtain their parental permission or could not invite one of their parents or guardians to participate in the study, students in other classes in the same grade were invited. All students who obtained parental permission and invited one of their parents or guardians participated in the study. The study protocol was approved by the Institutional Review Boards of Virginia Commonwealth University and Guangxi Medical University.Students used a self-administered questionnaire to answer questions in classrooms in each selected middle school. Only one student was permitted to sit at a desk to answer questions on the anonymous questionnaire . One or two trained interviewers presented in the classrooms and answered questions raised by students. All interviewers received training in interviewing techniques, developing rapport, ensuring confidentiality, and answering questions raised by subjects.Measurement items and scales were initially drafted in English and then translated into Chinese by three research members who were fluent in both languages. The Chinese version of measures was then distributed to research team members who reviewed and modified wording to make them appropriate for the Chinese context. Next, the self-administered questionnaire was piloted among students in a second-grade classroom in a middle school . After completion of the questionnaire, we asked students to make comments or suggestions, focusing on understanding and wording of the questions listed in the questionnaire. Some modifications were made based on the results of the pilot.Matsumoto's Individualism-Collectivism Interpersonal Assessment Inventory (ICIAI) was used to measure IC at the individual level . This inStudents were requested to rate how important each of the item as a value to them in a five5-point scale ranging from 1 'not important at all' to 5 'very important'. The score of each of the three relationship-specific ICIAI value scales  were created by averaging the items within each relationship group. Higher scores reflected more collectivism.Measurement scales of the following psychosocial constructs were adopted from reports by Rice et. al. , Orbel SFavorable attitude towards heroin use was measured by a seven-item scale . Response options for these items ranged from 0 (strongly disagree) to 3 (strongly agree). Perceived behavioral control was measured by a ten-item scale . Response choice to each item was from 0 (strongly disagree) to 3 (strongly agree). Descriptive norms refer to students' perceptions of other people's behaviors (heroin use) . Two thirds of the students were in the second grade and 37% in the third grade in the selected middle schools. Most of subjects were members of the Han majority  documented that the within-subject differences in the three relationship-specific ICIAIs were statistically significant among boys  and girls . Both boys and girls exhibited the highest values in the family ICIAI, high values in the friend ICIAI, and lower values in the classmate ICIAI , while girls are expected to be conforming and obedient to parents before marriage, to their husband after marriage, and to their son after the death of their husband. These parental expectations prevail to a greater degree in rural areas as more traditional and conservative cultural patterns are more common there compared to urban areas.As reflected by the different degree of the three relationship-specific ICIAIs, both boys and girls exhibited the highest values toward family members, and reported more collectivistic attitudes regarding close friends compared with classmates. This finding supports Matsumoto and colleagues' argument that if a culture fosters collectivistic tendencies within relationships between the self and in-groups , it is unlikely that those same tendencies would occur to the same degree in relationships with members of out-groups  . ChineseFindings of this study document that the relationship-specific ICIAIs were associated with several constructs of the theory of planned behavior, with variations by gender. Boys and girls who retained stronger collectivistic tendencies towards family members were more likely to perceive abilities to perform positive activities against heroin use. The perception may result from characteristics of collectivistic culture, i.e. collectivistic individuals preserve family values and believe that it is their responsibility, as a family member, to save the family's face and maintain the family's dignity. Avoidance of damage to their family values may motivate and enhance their ability to avoid heroin use. Perceived behavioral control is considered a key construct in the theory of planned behavior and acts as a moderator of the relationships of attitudes and norms with intention . InteresAs expected, perceived peer control for performance of acceptable practices and behaviors was positively associated with friend ICIAI among girls and boys. Triandis  has suggThere are limitations that should be noted in the study. Because the study participants were recruited from HIV and heroin-stricken rural areas in one county, the sample was not representative of all rural areas in China. Future large scale studies need to be done to verify findings from this study. Another limitation is that we could not examine relationships between the three determinants of the intention to use heroin because very few students (1%) reported such intention although heroin use is a serious problem in that area. The low level of intention may be due to the fact, according to available research, that most of Chinese heroin users started using it between the age of 16-24 years old often when they dropped out of middle schools .Taking the findings together, this study suggests how Chinese culture can be integrated with concepts from the theory of planned behavior and other risk and protective factors for drug use that have been developed in western countries. The findings indicate that interventions aimed at preventing heroin-use initiation among adolescents should target both adolescents and their parents. As values towards close friends also play an important role in the theory of planned behavior, interventions that include close peers such as the popular opinion leader intervention approach may be useful ,29. The IC: Individualism versus Collectivism; ICIAI: Individualism-Collectivism Interpersonal Assessment Inventory; IDU: injection drug use; PBC: perceived behavioral control; SD: standard deviation; TPB: the theory of planned behavior.Funding for this study was awarded to Hongjie Liu by NIH-NIDA Grant R03DA019397. The NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. All authors declare that they have no conflicts of interest.HL, ZL and WL designed the study and wrote the protocol. JL and ZZ managed the literature searches and summaries of previous related work. Authors HL and JL undertook the statistical analysis and wrote the manuscript. All authors contributed to and have approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/563/prepub


Despite the small number of ursid species, bear phylogeny has long been a focus of study due to their conservation value, as all bear genera have been classified as endangered at either the species or subspecies level. The Ursidae family represents a typical example of rapid evolutionary radiation. Previous analyses with a single mitochondrial (mt) gene or a small number of mt genes either provide weak support or a large unresolved polytomy for ursids. We revisit the contentious relationships within Ursidae by analyzing complete mt genome sequences and evaluating the performance of both entire mt genomes and constituent mtDNA genes in recovering a phylogeny of extremely recent speciation events.Ursus, the sloth bear is the sister taxon of all the other five ursines. The latter group is divided into the brown bear/polar bear and the two black bears/sun bear assemblages. These findings resolve the previous conflicts between trees using partial mt genes. The ability of different categories of mt protein coding genes to recover the correct phylogeny is concordant with previous analyses for taxa with deep divergence times. This study provides a robust Ursidae phylogenetic framework for future validation by additional independent evidence, and also has significant implications for assisting in the resolution of other similarly difficult phylogenetic investigations.This mitochondrial genome-based phylogeny provides strong evidence that the spectacled bear diverged first, while within the genus Identification of base composition bias and utilization of the combined data of whole mitochondrial genome sequences has allowed recovery of a strongly supported phylogeny that is upheld when using multiple alternative outgroups for the Ursidae, a mammalian family that underwent a rapid radiation since the mid- to late Pliocene. It remains to be seen if the reliability of mt genome analysis will hold up in studies of other difficult phylogenetic issues. Although the whole mitochondrial DNA sequence based phylogeny is robust, it remains in conflict with phylogenetic relationships suggested by analysis of limited nuclear-encoded data, a situation that will require gathering more nuclear DNA sequence information. Ailuropoda (giant panda), Tremarctos (spectacled bear), and Ursus  [Ailuropoda melanoleuca as the most basal offshoot in the bear family, after more than a century of debate since this species' discovery in 1864, was one of the most spectacular events in the history of modern phylogenetics [Ursus [Tremarctos ornatus (the spectacled bear) to the giant panda, and the sister grouping of Ursus arctos (the brown bear) and Ursus maritimus (the polar bear) have been unambiguously accepted. All other relationships within the genus Ursus remained an unresolved polytomy  -3. Despis [Ursus   gene or a small number of mt genes ,10-13. IUrsus by analyzing complete mt genome sequences from all representatives of bears and, for the first time, evaluates the performance of both entire mt genomes and constituent mtDNA genes in recovering a phylogenetic tree within a rapid, recent radiation. The improved reconstruction of ursid relationships utilizing the entire mt genome also permitted a refined dating of evolutionary divergence among these bear species. Our research thus not only generates a strong Ursidae phylogenetic framework for future validation using additional evidence but, most significantly, provides a model system against which to examine the usefulness of mt genomes for resolving difficult phylogenies with rapid species radiation.On the basis of the most comprehensive molecular data set assembled to date for the Ursidae, the present work revisits the contentious relationships within genus The general characteristics of eight bear mt genomes are summarized in Table The combined data set of 12 protein-coding genes  produced a single most-parsimonious tree of 5512 steps without MP weighting Figure . In thisUrsus, while joining the American black bear, the sun bear, and the sloth bear on a common branch (data not shown). However, nodal supports for most relationships in the stem and loop trees are below 50%, with the exception of the earliest branching of the spectacled bear among the in-group and the close association of the brown and polar bears (MP BS = 100%).Both of the combined RNA data sets (rRNAs and tRNAs) demonstrated reduced resolving power for phylogenetic inference compared to protein-coding gene analysis Figure . The aliThe tRNA data set (combined 22 tRNA genes) contained 1518 bp of aligned sites, of which 256 were variable and 100 were parsimony-informative. Parsimony analysis produced a most-parsimonious tree of 341 steps with a different topology from those of protein-coding and rRNA gene analyses. According to this tree, the sloth bear was grouped with the Asiatic black bear, and they are placed as a clade sister to the lineage leading to the American black bear and the sun bear. However, in this tree only the basal position of the spectacled bear, and the close association of the brown bear and the polar bear, were convincingly supported , we performed partitioned Bremer support (PBS) analysis and the result is shown in Figure Ursus began their recent radiation from a common ancestor at 6.34 MYA , and that between the sun bear and the two black bears of 5.673 MYA . The dating for the divergence between the Asian black and American black bear was 5.19 MYA , and that between the brown bear and polar bear 1.32 MYA . Table Results of a likelihood ratio test of the molecular-clock hypothesis for the five data sets, as defined for the phylogenetic analysis, are presented in Table Ursus species, of which only the sister-relationship between the brown bear and polar bear was unanimously favored. The close relatedness of brown bear and polar bear, as well as the paraphyletic association between mtDNA of these two bears has been upheld in previous studies [Among mammalian phylogenies, those characterized by rapid species radiations have long been one of the most plaguing and challenging problems in species tree reconstruction . This is studies -31. MoreUrsus, the sloth bear is the sister taxa of all the other five ursines, and that the latter group is divided into the brown bear/polar bear and the two black bears/sun bear assemblages, upholding and strengthening the hypothesis drawn by our previous analysis of the five fragments of mtDNA [Based on the largest available mt data set from Ursidae, our genome phylogeny provides strong evidence that within genus of mtDNA   and all mt genes  analyses of the eight bear species using available Pinnipedia mt genomes as outgroups  gave an X63726; -13 and rNevertheless, a more in-depth understanding of the Ursidae relationships will definitely benefit from the addition of independent sequence data, considering that the genome phylogeny obtained here is based on a single and haploid linkage unit. The necessity of including other unlinked genes for phylogenetic resolution of the Ursidae is also illustrated by the fact that our recent study on two nuclear genes, transthyretin (TTR) and interphotoreceptor retinoid binding protein (IRBP), has united the sloth bear and the sun bear as sister taxa with high statistical support  Figure  nuA, a rOur genome analyses provide important insights into not only Ursidae phylogeny, but also the phylogenetic utility of different mt genes. Our data add to the well-studied performance of individual mt genes, mostly protein-coding genes, for estimating phylogeny of deep divergence ,36, we aUrsus appear to have occurred in the Late Miocene or Early Pliocene (5–6 MYA), except that in the Early Pleistocene the most closely related bear species, the brown and polar bears diverged. The rather recent origins and rapid succession of these bear lineages are in line with the observation that most short mtDNA sequences used in previous studies lack sufficiently strong phylogenetic signals and provide limited resolving power for recovering a strongly supported Ursidae phylogeny. As is seen in Table Ursidae has one of the most extensive fossil records of extant Carnivora families ,27,35,37iocene 5– MYA, excIdentification of base composition bias and utilization of the combined data of whole mitochondrial genome sequences has allowed recovery of a strongly supported phylogeny that is upheld when using multiple alternative outgroups for the Ursidae, a mammalian family that underwent a rapid radiation since the mid- to late Pliocene.The suggestion of Delisle and Strobeck (2002)  that appUrsus, the polar bear (U. maritimus), the brown bear (U. arctos), and the American black bear (U. americanus), have been determined in previous studies of genome evolution [U. thibetanus), the sloth bear (U. ursinus), the sun bear , the spectacled bear (Tremarctos ornatus) and the giant panda (Ailuropoda melanoleuca) using standard proteinase K, phenol/chloroform extraction [The complete mt sequences of three bear species in genus volution . Thus, ttraction .EF19661–EF19665.Mt genome sequences were initially amplified with sets of universal primers  described in Delisle and Strobeck's original study (2002) . In the The complete mt genome sequences of all extant bear species were aligned with program CLUSTAL X  and veriEach of these data sets was subjected to unweighted maximum parsimony (MP) and maximum likelihood (ML) analyses using PAUP *4.0b8 . For MP To avoid potential tree estimation bias introduced by nucleotide composition ,50 or saUrsus. To examine if the resulting tree topologies were sensitive to outgroup alteration, we also carried out phylogenetic analysis with Pinnipedia, a non-ursine superfamily in Carnivora, for the rooting.The giant panda was used as an outgroup for estimating phylogenetic relationships within genus The molecular clock hypothesis was examined using the likelihood-ratio test  with PUZThe author(s) declares that there are no competing interests.LY and YPZ designed the study. YWL carried out the experiment work. LY performed the analyses. LY, OAR and YPZ prepared the manuscript. All authors read and approved the final manuscript.


Mollicutes. They are obligate intracellular plant pathogens which cause diseases in hundreds of economically important plants including the grapevine (Vitis vinifera). Knowledge of their biology and the mechanisms of their interactions with hosts is largely unknown because they are uncultivable and experimentally inaccessible in their hosts. We detail here the global transcriptional profiling in grapevine responses to phytoplasmas. The gene expression patterns were followed in leaf midribs of grapevine cv. 'Chardonnay' naturally infected with a phytoplasma from the stolbur group 16SrXII-A, which is associated with the grapevine yellows disease 'Bois noir'.Phytoplasmas are bacteria without cell walls from the class We established an on field experimental system in a productive vineyard that allowed application of molecular tools in a plant natural environment. Global transcription profiles of infected samples were compared with the healthy ones using microarray datasets and metabolic pathway analysis software (MapMan). The two-year-long experiment revealed that plant genes involved in primary and secondary metabolic pathways were changed in response to infection and that these changes might support phytoplasma nutrition. A hypothesis that phytoplasmas interact with the plant carbohydrate metabolism was proven and some possibilities how the products of this pathway might be utilized by phytoplasmas are discussed. In addition, several photosynthetic genes were largely down-regulated in infected plants, whereas defense genes from the metabolic pathway leading to formation of flavonoids and some PR proteins were significantly induced. Few other genes involved in defense-signaling were differentially expressed in healthy and infected plants. A set of 17 selected genes from several differentially expressed pathways was additionally analyzed with quantitative real-time PCR and confirmed to be suitable for a reliable classification of infected plants and for the characterization of susceptibility features in the field conditions.This study revealed some fundamental aspects of grapevine interactions with the stolbur 'Bois noir' phytoplasma in particular and some plant interactions with phytoplasmas in general. In addition, the results of the study will likely have an impact on grape improvement by yielding marker genes that can be used in new diagnostic assays for phytoplasmas or by identifying candidate genes that contribute to the improved properties of grape. Mollicutes 13] with y offset . In thisThe Welch two sample t-test was used to determine statistically significant differences between relative expression ratios of infected and healthy samples with a P = 0.05 as the limit for statistical significance., [Samples collected in the field in two subsequent growing seasons were classified into two groups based on the already analyzed qRT-PCR gene expression data of 17 genes with support vector machines algorithm . Gene e, ).MH participated in the design of the study, collected the samples, carried out the microarray and real-time PCR studies and helped to draft the manuscript. PN participated in the real-time PCR studies; AR and AB participated in the statistical analysis; NT participated in the microarray studies; MR, KG and MD elaborate the study, participated in its design and completion; KG helped to draft the manuscript. MD coordinated the study and drafted the manuscript. All authors read and approved the final manuscript.VvvInv2, VvAcyt, VvAgpL, VvHP, VvEtr, VvF3h, VvLox, VvOlp, VvSamt, VvWrky, VvAdh1, VvSuSy, VvCaSy, VvCko, VvGlc1, VvGlc2 and VvGlc3) in the first and second growing season determined by qRT-PCRPlant disease status and differential expression of selected genes (. The data provided represent all tested samples with their phenotypes, a presence of phytopasma and viruses and a differential expression of 17 selected genes.Click here for fileTypical symptoms of grapevine Yellows 'Bois noir' on a 'Chardonnay' grapevine plant in a production vineyard. This panel shows leaf curling and discoloration of leaf veins and laminas and interveinal yellowing with berry withering.Click here for fileList of differentially expressed genes in the first growing season determined by microarray analysis. In a spread sheet A is a list of all differentially expressed genes, and in a spread sheet B is a list of genes that are discussed in the paper.Click here for fileThe average temperature and precipitation in the area of the examined vineyard during growing seasons of 2004 and 2005. The data provided show weather data obtained from a meteorological station positioned around 10 km SE from the vineyard.Click here for fileA schematic view of the vineyard in which the samples were collected. The picture shows the position of all sampled plants and their disease status in the scheme of tested plot.Click here for fileExperimental design of the study. The picture shows the complete workflow including qRT-PCR, microarrays and data analysis.Click here for fileMicroarray experimental design. Summary of microarray experimental design.Click here for fileReal-time PCR design. The protocols of amplicon design for use with SYBRGreen I chemistry are shown for 17 representative genes.Click here for file


The surgical correction of anomalous movement such as upshoot in Duane syndrome is challenging. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall is a new approach used to minimize or eliminate the effects of co-contraction including globe retraction, palpebral fissure narrowing and anomalous vertical movement.We report a case of a 7-year-old boy who underwent this procedure for severe upshoot, globe retraction and exotropia in the left eye due to Duane syndrome. The patient achieved satisfactory ocular alignment following surgery. Upshoot and globe retraction were substantially improved.Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall is a safe and effective procedure for weakening of the anomalous lateral rectus muscle in Exotropic Duane Syndrome. Duane syndrome is an ocular motility disorder characterized by anomalous innervation of the lateral rectus muscle . AbnormaVarious surgical approaches have been described for the treatment of upshoot and downshoot in Duane syndrome including recession of the lateral and medial rectus muscle, Y splitting of the lateral rectus muscle at the insertion, and posterior fixation suture of the horizontal rectus muscles . LateralWe report a case of a patient with unilateral Duane syndrome with exotropia who underwent this procedure for correction of severe upshoot and globe retraction.The parents of a 7-year-old boy noted that he had been unable to move his left eye outward since childhood. He had one strabismus surgery  in the left eye due to exotropia at the age of 3 years. Visual acuity was 20/20 in each eye. A 15° right face turn was found with 30 prism diopters' (PD) left exotropia. Versions revealed an inability to abduct the left eye with moderate limitation in adduction. He had significant upshoot and globe retraction in the right gaze. A left Exotropic Duane Syndrome with severe cocontraction was diagnosed.At the time of surgery, intra-operative forced ductions revealed moderate restriction to adduction. A lateral limbal conjunctival incision was performed and the lateral rectus muscle was isolated on a muscle hook. The insertion of the lateral rectus muscle was in 17 mm posterior to the limbus. Blunt dissection between the lateral rectus and lateral orbital wall was performed and exposed the lateral periosteum 4 to 5 mm posterior to the orbital rim. Single, double-armed, 5-0 nonabsorbable polyester sutures (Ethicon) were placed and locked through the insertional end of the muscle. The lateral rectus muscle was disinserted and reattached to the periosteum with two bites. Intra-operative forced ductions were repeated at the end of surgery and revealed improvement in adduction (free passive adduction of the globe). Follow-up 1 year after surgery showed 6 PD of exotropia in the primary position, and a marked decrease in globe retraction, upshoot and face turn (Figure Exotropic Duane syndrome occurs with or without upshoot and/or downshoots and globe retraction in moderate exodeviations .There are several theories for the anomalous vertical movements in Duane syndrome: compensatory oblique overaction, compensatory overaction of the vertical rectus muscles for defective abductive action , paradoxPosterior fixation sutures on the lateral rectus muscle for the stabilization of the muscle, recession of both medial rectus and lateral rectus, lowering of insertion of the lateral rectus muscle  and Y spIn Exotropic Duane Syndrome, the surgical goal is to correct the deviation and head turn and ameliorate as much of the anomalous eye movement as possible . SurgicaInactivating the muscle may decrease or eliminate the mechanical effects of the aberrant innervations . Sato etThe lateral rectus muscle may be functionally inactivated by disinsertion and reattachment to the orbital periosteum. Britt et al.  reportedThe advantages of this procedure over extirpation and free tenotomy include permanent disinsertion of the muscle from the globe and the ability to reverse the procedure if necessary. Suturing the rectus muscle to the orbital wall also reduces the risk of globe perforation compared with maximal recession. It may be technically difficult to expose the adjacent periosteum .Our patient had recurrent exotropia with severe upshoot and globe retraction. We performed disinsertion of the lateral rectus muscle and reattachment to the orbital wall. It seems that the permanent lateral rectus muscle inactivation could eliminate the anomalous lateral rectus muscle; therefore, the upshoot and globe retraction were substantially decreased.There is a residual abduction force due to periocular connective tissue contracture after longstanding deviation. The other cause is the abducting action of the oblique muscle . TherefoLateral rectus muscle disinsertion and reattachment to the lateral orbital wall in a patient with Exotropic Duane Syndrome is an effective and stable procedure to improve ocular alignment, significant upshoot and severe globe retraction.PD: Prism diopter.The authors declare that they have no competing interests.DA was responsible for the concept and wrote the paper. AJ reviewed and edited the manuscript. Both authors approved the final version.Written informed consent was obtained from the patient's next-of-kin 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.


Several studies have reported associations between respiratory outcomes in children and a range of self-reported, administrative or geographical indicators of traffic pollution. First-time investigation into the frequency of asthmatic symptoms among 7-8 year-old Cypriot children in 1999-2000 showed increased prevalence in the capital Nicosia compared to other areas. Geographical differences on an island the size of Cyprus may reflect environmental and/or lifestyle factors. This study investigates the relationship between self-reported symptoms and residential exposure to motor vehicle emissions among Nicosia schoolchildren.The addresses of children in the metropolitan area of Nicosia who participated in the original survey  were geo-coded and the level of exposure of each child was assessed using distance- and emission-based indicators (i.e. estimated levels of particulate matter and nitrogen oxides emissions due to motor vehicles on main roads around the residence). Odds ratios of wheezing and asthma diagnosis in relation to levels of exposure were estimated in logistic regression models adjusting for person-based factors, co-morbidity and intra-school clustering.We found an increased risk of wheezing at distances less than 50 m from a main road and/or only among those experiencing the highest levels of exposure. The strongest effect estimates were observed when exposure was defined in terms of the cumulative burden at all roads around the residence. Adjusted odds ratios for current wheezing were 2.33  amongst the quartile of participants exposed to the highest levels of PM at all roads 50 m of their residence and 2.14  for NOx, with no effect at intermediate levels of exposure. While the direction of effect was apparent at longer distances, differences were generally not statistically significant.Children experiencing the highest burden of emissions in Nicosia seem to be at a higher risk of reporting asthmatic symptoms. Due to the small number of children residing at close proximity to main roads and lack of evidence of risk at intermediate levels of exposure or longer distances, the observed pattern alone does not explain the generally higher prevalence observed in urban Nicosia compared to other areas. In the last three decades there have been significant increases in the prevalence as well as severity of asthma and other allergic disorders among children worldwide . The IntExposure to traffic pollution may contribute, if not to the development, at least to the exacerbation of asthma as well as a range of other adverse respiratory symptoms. While recently a number of cohort studies indeed suggest a link between early-life exposure and the development of asthma ,7, most The observed higher prevalence of asthmatic symptoms in the capital of Cyprus may be partly due to an increased exposure to traffic pollution. Using information from the original 1999-2000 survey, this study mapped the location of residential addresses (as well as attending schools) of participating children living in the metropolitan Nicosia region  and investigated the relationship between self-reported health status and exposure to motor vehicle emissions at the place of residence assessed using a range of (a) distance-based (i.e. proximity of residence to the nearest main road) as well as (b) emission-based indicators (i.e. estimates of particulate matter and nitrogen oxides due to motor vehicle emissions on roads within a pre-defined distance from the residence).While most evidence on the association between the experience of asthma symptoms in children and exposure to traffic emissions comes from large cities in Europe and North America., similar evidence in the context of smaller cities or other parts of the world has been limited. The aim of this study was to investigate the relationship between asthma symptoms and residential exposure to traffic emissions in Nicosia, a relatively small city in the Eastern Mediterranean region where both geo-climatic conditions and outdoor activity patterns may differ considerably from other much larger European capitals. In addition, the study aimed at elucidating the extent to which any observed pattern of association could explain the overall higher prevalence of asthma recorded in Nicosia compared to the rest of the island.During the original survey between 30 September 1999 and 9 March 2000, the Greek-version of the core ISAAC questionnaire was distributed to all second-grade primary schoolchildren (ages 7-8) at the school setting and was completed at home by consenting parents . The suphttp://www.terra.gr), which in 2006 produced the first (and currently only) digitized vector maps of all Cypriot cities using a series of raster maps  as well as employing 20 ground-teams to geo-reference and inform these maps accordingly with the use of GPS . While the resulting vector maps  incorporated a characterization of roads into major arteries or residential streets, no other traffic-related information was available .Geographical data are not yet routinely available in Cyprus as in the US or many European countries and use of Geographical Information Systems (GIS) in health research is still at its infancy. In fact, we are not aware of any other epidemiological study in Cyprus that has employed GIS. With lack of appropriate maps from public sources, digital maps of the street network were purchased from a private GIS company  [Levels of particulate matter (PM) and nitrogen oxides (NOx) due to motor vehicle emissions along major roads in the city were obtained from the Air Quality Section (Cyprus Ministry of Labor), which in 2001  performed in collaboration with the University of Stuttgart the first systematic emissions inventory on the island from different linear, point and area sources, such as the hotel industry, agricultural activities and petrol stations . For thecations) . Hinderehttp://www.gfk-geomarketing.com).It should be noted that while the street network maps were produced at a more recent point in time than the data collection (and may thus represent changes that occurred since the survey e.g. new roads which appeared since or were re-classified into main roads), only the subset of roads included in the 2001 Emissions Inventory were considered in the analyses more closely representing the point in time when the health questionnaire was administered. Finally, to assist in the effective presentation of maps, additional background maps with administrative information such as municipality boundaries or topographical information such as the UN buffer zone were obtained from the German-based GIS company GfK GeoMarketing  current wheezing (i.e. in the past 12 months), (ii) history of wheezing (i.e. ever having wheezed) and (iii) having ever had an asthma diagnosis. Reported symptoms of hay fever or eczema as well as a family history of atopy (i.e. among siblings or parents) were considered as co-morbidity. In addition to calculating the actual distance of each participant's residence to the nearest main road, a series of traffic exposure indicators were calculated by assigning to each child the estimated levels of PM or NOx emissions at (a) the road nearest to the residence, (b) the road within 150 m of the residence where emission levels were highest, and (c) the cumulative levels of emissions at all roads at a predefined distance of the residence. Rather than restricting the calculation to the nearest or the road with the highest levels, the cumulative measure is the sum of estimates at all road that cross the specified buffer and it does not represent actual total mass within that buffer. Due to their crude nature, these measures were only used as categorical rather than continuous variables in order to classify participants into increasing levels of exposure. As dispersion models indicate that levels of pollutants decrease exponentially to reach a plateau at distances longer than 150 m of a main road , circula2-tests while evidence for trend in proportions across ordered categories was assessed using an extension of the Wilcoxon rank-sum test (nptrend command in STATA). Multivariable logistic regression models were used to assess evidence of increased prevalence of symptoms by exposure indicators after adjusting for person-based risk factors  as well as co-morbidity . In addition to parental history of atopy, we adjusted for personal history of hay fever and eczema in order to assess the possible confounding effect of allergic sensitization  in the association between traffic pollution and asthma symptoms. Studies have shown associations between traffic exposure and allergic sensitization; even though the evidence is less consistent [The unadjusted prevalence of the three outcomes investigated here was calculated in relation to increasing proximity of the residence to the nearest main road  or by levels of exposure (e.g. across quartiles of increasing levels of PM and NOx emissions). Evidence of differences in prevalence was assessed in Pearson χnsistent ,22,23. TFinally, sensitivity analyses assessed the effect of (a) excluding peripheral areas where the level of geographical information as well as the coverage of the emissions inventory was poorer  resided in metropolitan areas and were included in this study. These children attended 48 different schools with an average number of 40 recruited students (inter-quartile range: 29-48). Ranging from no one reporting symptoms in three schools to a maximum of 27% in an inner-city school (IQR: 5-12% across schools), the prevalence of current wheezing averaged to 8.8% in the city of Nicosia. As many as 21.9% of the participants reported having wheezed in the past and 12.9% having been diagnosed with asthma while 29.3% of the participants reported family history of atopy. Along with estimates of all respiratory outcomes, Table The addresses of 1,735 children  were geo-coded successfully. Table Table Furthermore, two degrees of geo-coded accuracy were identified and treated accordingly: (a) cases where the full address was available i.e. both street and house number  and (b) cases where due to inaccurate or incomplete information only the street was identified, in which case the residence was randomly assigned on that street . Figure Figure As expected, the prevalence of symptoms in this age group (as well as asthma diagnosis) was statistically significantly higher in boys. Significant associations were observed between all three outcomes and maternal smoking during pregnancy, which generally persisted after adjusting for the effect of all other participant characteristics in multivariable models; for instance, in the case of asthma diagnosis the adjusted odds ratio was 2.2 . Only small or no associations were observed with other potential risk factors, such as parental smoking and cat ownership while negative associations were observed with regards to the nationality of the child's parents but reasons why this should be a protective factor are unclear. Personal history of hay fever and family history of atopy were by far the strongest predictors of current wheeze with adjusted odds ratios of 4.1  and 2.9  respectively. This was also true in the case of history of wheezing and asthma diagnosis.Those who reported current wheezing N = 156) lived on average at 149.6 metres  of a main road versus 178.7 m  in the case of those who did not report symptoms . At 11.7% , an increased prevalence of current wheezing was observed only among those residing within 50 m of a main road (N = 238), with no evidence of a stepwise association with proximity. At longer distances the prevalence was confined to levels similar to the overall prevalence observed in the city of Nicosia. The figures were 8.7%  among participants whose residence was 50-100 m of a main road, 8.6%  among those within 100-150 m of a main road, 9.0%  among those within 150-300 m against a background prevalence of 9.0%  among participants whose residence was more than 300 m of a main road. Nevertheless, further stratifying participants into those who live within 50 m of main roads with high  of the distribution of non-zero values (i.e. among those within the specified distance from a main road), while when a middle category appears, this represents the 50th percentile. Adjusted odds ratios for current wheezing amongst the quartile of participants who experience the highest levels of PM within a 50 m radius from their residence was 2.33  as compared to those who reside further away (N = 1440) and 2.14  for levels of NOx. Other than slightly larger standard errors, the magnitude of effect remained largely unaffected in multivariable models. Excluding hay fever and eczema from the models does not alter inferences, suggesting that the observed association between traffic pollution and current wheeze is independent of the presence of hay fever or eczema. While we tested for (and found no) evidence of effect modification by allergic status, the study was under-powered to address this issue properly. Associations of a similar magnitude were observed for the other two outcomes - history of wheezing and asthma diagnosis. Perhaps with the exception of history of wheezing which displayed more of a stepwise relationship with exposure, there was no evidence of increased risk among those who experience intermediate levels of exposure. While the direction of effect was also apparent at longer distances, associations were commonly short of statistical significance.Stronger effect estimates were observed in terms of cumulative burden of emissions around the residence. Nevertheless, there was again strong evidence of non-linearity and any association appeared to be mainly driven by a twofold increase in risk concentrated only at the quartile of participants who experience the highest levels of exposure. Table Both the direction and magnitude of effects were largely unaffected after excluding peripheral areas (where the emission inventory was less comprehensive) or restricting the analysis to those children whose addresses were geocoded accurately at house level. Results of the sensitivity analyses with regards to the observed associations between current wheezing and PM or NOx emissions are presented in Figures Finally, gender differences were not statistically significant to allow any inference about effect modification, even though consistent with the literature , the effConsistently increased prevalence of symptoms and asthma diagnosis was observed in those who reside close to main roads and/or experience the highest levels of exposure. Effect estimates were statistically significant when the cumulative burden was considered. Up to 2-fold increases in risk for all symptoms were observed among those experiencing the highest cumulative levels of PM or NOx emissions at roads 50 metres of their residence after adjusting for person-based risk factors and co-morbidity. Nevertheless, there was no evidence of an increased risk at intermediate levels of exposure. While the direction of effect was apparent at longer distances, differences were generally not statistically significant.Since the study is cross-sectional in nature, it can not pinpoint to traffic pollution as a risk factor for the development of wheezing or asthma but only describe the association between the experience of symptoms at different levels of exposure. The participation of children in the original survey was very high and reflected the true prevalence and spatial distribution of the asthmatic population of this age group in the city of Nicosia. Exposure was defined in terms of distance or levels of emissions at the surrounding roads. Despite the limitations of the available data and the crude nature of exposure assessment, the consistency in the direction and pattern of effect estimates across the different definitions of exposure (i.e. proximity or emissions based) is reassuring. While symptoms were self-reported, parents were not obviously aware of the hypothesis investigated here at the time of the original survey. Furthermore, associations were not restricted to current status but were also apparent for asthma diagnosis, generally considered to be a more reliable measure.The lesser degree of geo-coded accuracy of some participants' addresses introduces misclassification in exposure; however, any error should be random  and non-differential (i.e. there is no reason why it should relate to the outcome) and would thus only be expected to underestimate the true effect. Furthermore, there was no evidence of differences in participant characteristics, symptoms or exposure indicators by level of geo-coding accuracy. Furthermore, inferences were largely unaffected when the analyses were repeated to exclude either addresses geo-coded less accurately or peripheral areas.With current lack of area-based socio-economic indicators in Cyprus and with no person-based measures of household income or education available from the original health survey, models did not control for a possible confounding effect of socio-economic factors. Socio-economic gradients in levels of traffic pollution vary greatly across different study areas. For example, while a study in urban areas in Netherlands and Munich found no differences in exposure by parental education as a measure of social class , in sharIncreases in the prevalence of asthma worldwide have occurred over a short period of time to be explained by only genetic changes, suggesting that environmental risk factors may be the underlying cause. A second Cypriot survey, preformed nearly 8 years after the first, has just been completed and analyzed indicating that asthma in this age group is on the rise on the island. A range of lifestyle and environmental factors have been implicated including lack of exposure to infections and microbial products in early life, changes in dietary habits, physical activity, sun exposure and traffic pollution ,28. ExpoA number of studies have investigated residential exposure to traffic pollution using a similar geographical perspective in cities much larger than Nicosia. Using outcomes as diverse as lung function ,32, hospPrevious studies have employed a wide range of exposure indicators, including self-reported traffic density , distancEvidence on the validity of any of the previously used indicators, including emission- or concentrations-based measures, as an estimate of actual personal exposure is still limited ,46. ChilFinally, any cross-sectional measure does not represent past exposures. Generally though, more is known about the experience of symptoms from similar studies with a cross-sectional design than the contribution of long-term exposure. Interestingly, a recent case-control study of 4-14 year-old children used an index of lifelong exposure at home and school addresses since birth and only found an association restricted to the first three years of life . RecentlUsing both proximity as well as distance-weighted estimated levels of motor vehicle emissions on main roads around the residence in a city-wide survey of 7-8-year old children in the capital of Cyprus, this study showed that at least those who reside at close proximity to a main road were more likely to have reported symptoms or having had an asthma diagnosis. The effect appeared to be mainly driven by a twofold increase in risk concentrated among those participants who experience the highest levels of emissions, with no much evidence of risk at intermediate levels of exposure or longer distances. The observed pattern and the small number of children residing at this close proximity to main roads would not explain the overall higher prevalence of symptoms observed in Nicosia, compared to other areas on the island.CI: Confidence Intervals; GIS: Geographical Information Systems; m: metres; IQR: Interquartile range; NOx: Nitrogen Oxides; OR: Odds Ratio; PM: Particulate Matter.The authors declare that they have no competing interests.PY, NN and SP formed the Pediatric Respiratory Research group that designed the original survey. PY and PK conceived and secured funding for the current study. SK had originally designed and performed the emissions inventory and which he kindly provided for the purposes of this study. PY, MZ and NM gathered and compiled the data. NM performed the geographical and statistical analyses and wrote the first draft of this paper. All authors assisted in the interpretation of results and contributed towards the final version. All authors read and approved the final manuscript.


The authors report and discuss the clinical and radiological features of a immunocompetent patient with chronic progressive monoarthritis tuberculosis of the hip without systemic symptoms such as fever, and weight loss presenting as caseating abscess and severe destruction of the hip joint, treated with resection arthroplasty. Mycobacterium tuberculosis that affects joints. It reaches skeleton and joints by hematogenous spread. The clinical presentation includes multiple joint involvement with fever and weight loss, and periarticular abscess formation [Osteoarticular tuberculosis is a chronic inflammatory disease caused by ormation . Howeverormation . FailureWe report and discuss the clinical and radiological features of a patient with chronic progressive monoarthritis tuberculosis of the hip presenting as caseating abscess and severe destruction of the hip joint, treated with resection arthroplasty.M. tuberculosis on cultures and a tuberculin test done at this time was positive (21 mm). Antituberculous therapy  was introduced for 9 months after drainage of the abscess, and resection arthroplasty with osteotomy of the great trochanter. Histological examination of the trochanteric bone revealed an inflammatory reaction with a granuloma with caseous necrosis and giant Langerhans cells with numerous acid-fast bacilli. The clinical course was uneventful. No recurrence was observed after a follow-up of one year.A 58-year-old female white brazilian patient presented with complaints of progressive mechanical pain in the right trochanteric area for 3 years that made it impossible to lean on the right side. Patient was in good general condition and denied systemic symptoms such as fever, weight loss, and loss appetite, and neither had any notion of primary tuberculosis in her past nor any evidence of the disease in her medical history. Routine laboratory tests were within normal limits. HIV-test was negative. Patient was seen multiple times by his primary care physician who prescribed non-steroidal anti-inflammatory drugs. Imaging studies showing severe desctruction of periarticular bony destruction and deformity of the right hip. Magnetic resonance imaging of the hip showing a large periarticular abscess and destruction of the right femour head Figure  and 2. NOsteoarticular tuberculosis has become very rare in western countries, but it is still a common problem in under developing countries . After tTuberculosis of the hip must be in the differential diagnosis of chronic pain of the hip including osteoarthritis, pseudogout, psoriatic arthritis and reumathoid arthritis. In additional to imaging studies, a detailed family and environmental history for pulmonary tuberculosis, history of tuberculosis vaccination, and a tuberculin skin test should be performed.Written informed consent was obtained from the patient for publication of this case report and 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 do not have any competing interests.CR and MA analyzed and interpreted the patient data regarding the diagnosis of tuberculosis and treatment. DF, RS and LG were major contributors in writing the manuscript. All authors read and approved the final manuscript.


The incidence of diabetes is increasing at an alarming rate all over the world. As a consequence, the complications related to diabetes, including those affecting the eye (cataracts and retinopathy), nerve, and kidneys, are also becoming more prevalent. In the eye, diabetes affects both lens and retina resulting in devastating effects on vision. Although significant advances have been made towards understanding their pathophysiology using animal models of diabetes, progress in the area of development of pharmacological means for their prevention and treatment is still very minimal, if any. The pathogenetic mechanisms underlying both of these ocular complications of diabetes are considered multifactorial. The major factors considered to be involved in diabetic cataractogenesis are the hyperglycemia-induced excessive generation of free radicals and consequent oxidative stress as well as aberrations in tissue metabolism. Free radicals have also been implicated in the pathogenesis of diabetic retinopathy (DR). In addition, DR is considered to be associated with aberrations in several other cellular signaling pathways mediated via inflammatory intermediators, pigment epithelium-derived factor, various kinases, and Rho and Ras GTPases. Identification of pathways/molecules that can be targeted for modification by appropriate compounds is highly essential for the development of pharmacological therapy for these highly prevalent blinding diseases. In this special issue intended to present new research on diabetic cataracts and retinopathy, we have invited papers that address these issues.The first four articles in this issue are focused on cataract formation in diabetes. The first one provides an overview of the pathogenesis of diabetic cataracts, clinical studies investigating the association between diabetes and the development of cataract, and current treatment of cataracts in the diabetic population. The anticataractogenic potential of aldose reductase inhibitors and antioxidants has also been discussed. The article by Petrash et al. focuses on the role of aldo-ketoreductases in the eye. The expression profiles of the AKR1B1 and AKRB10 have been characterized in various human ocular tissues and their implications in the pathogenesis of diabetic cataract have been discussed. The next article examines the role of glyoxalase I in the inhibition of methylglyoxal advanced glycation end products-AGEs formation in lenses of transgenic mice overexpressing human glyoxalase I, and the fourth one reviews the pathophysiological characteristics of ocular complications in the Spontaneously Diabetic Torii rat such as the formation of cataracts which can become hypermature. It also suggests the suitability of this model for the study of DR. Subsequent articles in this issue focus on the pathogenesis of DR and examine possible targets for pharmacological intervention. The article by Daniel Ng reviews the genetic aspects of DR, and the next article identifies genes associated with DR among Mexican Americans from Starr County in Texas using genome-wide association study. The seventh paper examines the possibility of treatment with the angiotensin-converting enzyme inhibitor, trandolapril, for regression of DR, and the 8th paper discusses the role of toxic AGEs receptor in the pathogenesis of DR. This is followed by a review implicating Rho/ROCK (Rho Kinase) pathway in DR and suggests the possibility of this pathway being a target for therapeutic intervention. The article by Wu et al. investigates the role of extracellular signal-regulated kinase 5 (ERK5) mediated signaling in modulating glucose-induced expression of VEGF. The final paper in this issue compares NADPH oxidase versus mitochondria-derived reactive oxygen species in glucose-induced apoptosis of pericytes in early DR.This special issue will therefore provide the readers an insight into some of the latest research being pursued to elucidate the mechanisms underlying DR and cataracts. It also presents some interesting targets which could be manipulated pharmacologically for potential clinical use.Kavita R. HegdeKavita R. HegdeRenu A. KowluruRenu A. KowluruSusanne MohrSusanne MohrRam H. NagarajRam H. NagarajJ. Mark PetrashJ. Mark Petrash


We read with interest Heise et al's case report and review of the literature regarding the use of recombinant activated factor VII (rFVIIa) in patients with ventricular assist devices (VAD) . Whilst 'the effect of rFVIIa on plasmatic coagulation derives from its interaction with tissue factor. Thus, the pro-coagulatory effect is predominantly located in regions where tissues or vessels are injured'. This is a simplification of a highly complex and only partially understood process. The authors have based their statement on what we know of endogenous Factor VIIa and Tissue Factor (TF) interaction in physiological conditions, where TF is present as an inactive pool on sub-endothelial cells. Vessel injury exposes this TF to the blood, where it binds and activates FVII. The resulting TF-FVIIa complex catalyzes the conversion of factor X into its active form (Xa), leading to thrombin formation and platelet activation. This creates a surface that supports the binding of coagulation factors and thereby facilitates the full thrombin burst necessary for haemostasis.In their discussion, the authors state that One cannot presume that the pro-coagulatory effect of rFVIIa occurs in the same way in patients undergoing VAD surgery; significant controversy exists surrounding both the source and the role of tissue factor in this setting. The systemic inflammatory response witnessed in patients undergoing major cardiac surgery involving artificial circulatory support has a profound impact on the coagulation system and thus TF expression is highly unlikely to be restricted to the sub-endothelium. Several groups of investigators have reported the presence of physiologically active 'blood-borne TF' in pro-inflammatory conditions, including cardiac surgery -4. What The exact role of TF in rFVIIa's effect also requires further elucidation. The high plasma concentrations of rFVIIa required to induce haemostasis in refractory haemorrhage suggests that TF-dependent activation of the coagulation cascade cannot be the sole mechanism of action. It has been shown that rFVIIa is able to directly activate Factor X on phospholipid vesicles, activated platelets and monocytes, independently of TF -15, alth'the relatively low incidence of thromboembolic events (1–2%) after the use of rFVIIa' in Levi et al's systematic review of the literature [We believe the authors have significantly underestimated both the frequency and seriousness of the risk of thromboembolic (TE) complications in cardiac surgery patients. They refer to terature , but negterature  they 'seIt is difficult to know what the real risk of serious TE adverse events in this cohort of patients is. In a systematic data synthesis of the cardiac surgery literature performed early this year, our group reported a TE adverse event rate in adult patients treated for refractory haemorrhage of 5.3% . This waIt is likely that the level and location of TF expression in patients undergoing VAD surgery is significantly higher and more widespread than in normal subjects, and thus these patients are at risk of spontaneous intra-vascular thrombosis if administered rFVIIa. The level of this risk is currently unquantifiable. We agree wholeheartedly with the authors' conclusion that rFVIIa is a promising therapeutic option when conventional treatments for refractory haemorrhage have been exhausted, and use it in our own clinical practice. However we wish to emphasise that careful risk-benefit analysis must be made before prescribing rFVIIa to any bleeding cardiac patient. Evidence-based recommendations regarding the use of rFVIIa in cardiac surgery are available to the practicing cardiac surgeon or anaesthetist and we refer our colleagues to these guidelines -22.®, the manufacturers of Novoseven, to fund their research in this area. The company has had no input into this letter.OW and TA have both received an unrestricted educational grant from NovoNordiskOW and TA were equally involved in the conceptualization, research, writing and manuscript preparation of this letter. AD was responsible for manuscript revision and important intellectual contact. TA is the guarantor. All authors read and approved the final manuscript.


An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications. The use of the emergency department thoracotomy (EDT) is invaluable in salvaging critically injured patients . PatientThe postoperative infection rate of EDT is not reported in the literature and we have no previous event at Denver Health Medical Center over the past 33 years. We present a 50- year-old male patient with an infected chest wall wound following an emergent anterolateral thoracotomy. Preoperative planning and management of this rare wound complication is reviewed in this report.A 50-year-old alcoholic male with a history of schizophrenia presented in profound shock to the Denver Health Emergency Department with stab wounds to the left thorax. 1.5 liter of blood was aspirated with an emergent pericardiocentesis and the patient underwent resuscitative anterolateral thoracotomy in the ED. The emergency thoracotomy was performed in the standard fashion, with an incision made along the left fifth intercostal space extending across the sternum. After cardiac repair and hemostasis, the incision was closed primarily. At ten days post-operatively, the patient developed a thoracotomy wound infection that cultured positive for methicillin resistant staphylococcus aureus. Despite appropriate antibiotics, the infection necessitated radical debridement of involved bone (lower part of the sternum and rib), cartilage and soft tissue. Vacuum-assisted closure device  was placed after each debridement. The wound after two debridements measured approximately 20 × 8 cm, and extended deep to the pericardium Figure . TherefoWound complications associated with emergency thoracotomy have not been reported in the literature. In light of the almost non-existent infection rate, surgical debridement and the reconstruction of EDT wounds is rarely necessitated. The management of the complicated EDT wound was initiated by adequate surgical debridement and appropriate antibiotic treatment prior to definitive reconstruction. In addition, coverage especially with a muscle flap was planned to overcome the infection and to supplement the healing in such a wound with exposed heart.The pectoralis major, the latissimus dorsi, the rectus abdominis, and omental flap are most frequently employed flaps in the chest and sternal region wound reconstruction ,4. HowevThe superior epigastric artery originates from the internal mammary artery at the level of the seventh rib. Then, it descends between the costal and xiphoid slips of the diaphragm, anterior to the lower fibers of the transversus thoracis and transversus abdominis. Entering the rectus sheath, at first behind the rectus abdominis muscle and then perforating and supplying it, it anastomoses with the deep inferior epigastric branch of the external iliac  Figure .The EDT procedure involved a knife incision along the inferior border of the pectoralis major muscle at the level of fourth or fifth intercostal space running from the border of the sternum to mid-axillary line. In our case, extension across the sternum to the right hemithorax was required for exposure of pleural, anterior, and mediastinal structures. Horizonal transection of the sternum during EDT required ligation of the internal mammary arteries, which lie approximately 1.57 ± 0.30 cm lateral from the right and 1.47 ± 0.30 cm lateral from the left of the sternal edge .Bilateral transection of the internal mammary vessels proximal to the terminal bifurcation during an EDT interrupted the superiorly based blood supply of the both rectus abdominis muscles, precluding the possibility of a superiorly based rectus abdominis flap from either side for wound reconstruction Figure . TherefoIn the event of rare EDT wound complication requiring reconstruction, the integrity and patency of the internal mammary vasculature must be carefully assessed for the potential use of rectus abdominis muscles as a pedicled flap. Nevertheless, the possibility of using the rectus abdominis flap based on the superior epigastric vasculature would be remote in most cases, other flaps such as pectoralis major and latissimus dorsi flaps will not reach to the wound and reconstructive surgery by using free tissue transfer would be required.The authors declare that they have no competing interests.KG: has been involved in drafting the manuscript.KI: assisted the free flap reconstruction surgery.EEM: revised the manuscript critically for important intellectual content.CCB: performed the emergency thoracotomy.RG: performed the free flap reconstruction surgery, contributed significantly to design of the case report and gave final approval of the version to be published.All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.