Several mass strandings of sperm whales occurred in the North Sea during January and February 2016. Twelve animals were necropsied and sampled around 48 h after their discovery on German coasts of Schleswig Holstein. The present study aims to explore the morphological variation of the primary sensory organ of sperm whales, the left and right auditory system, using high-resolution computerised tomography imaging. We performed a quantitative analysis of size and shape of cochleae using landmark-based geometric morphometrics to reveal inter-individual anatomical variations. A hierarchical cluster analysis based on thirty-one external morphometric characters classified these 12 individuals in two stranding clusters. A relative amount of shape variation could be attributable to geographical differences among stranding locations and clusters. Our geometric data allowed the discrimination of distinct bachelor schools among sperm whales that stranded on German coasts. We argue that the cochleae are individually shaped, varying greatly in dimensions and that the intra-specific variation observed in the morphology of the cochleae may partially reflect their affiliation to their bachelor school. There are increasing concerns about the impact of noise on cetaceans and describing the auditory periphery of odontocetes is a key conservation issue to further assess the effect of noise pollution. Physeter macrocephalus), the largest toothed whales (Odontoceti), are highly pelagic animals and are normally found in deep oceanic waters. In some cases, however, individuals mistakenly wind up in the shallow, nutrient-poor North Sea during their migrations from the North Atlantic feeding grounds around the Norwegian shelf edge southwards to their breeding grounds around the Azores23Sperm whales  and biological factors 5678910th centuryDuring January and February 2016, several mass strandings of sperm whales occurred in the North Sea where thirty dead animals were observed along European coasts, amongst which sixteen beached on German coasts. The very shallow North Sea with a local coastline characterised by an intricate system of sand banks, mudflats, sandy islands and estuaries may have become a death trap because it is totally unsuitable for these deep-diving oceanic animals. Many theories have attempted to explain that seldom to rare phenomenon of sperm whale mass strandings, which probably result from complex interactions of physical  and baleen whales (Mysticeti) has been illustrated in many studies161718192021222320Orcinus orca), although the body size of sperm whales equals that of mysticetes20The tympanic-periotic (T-P) bone complex of sperm whales shows several particularities shared among cetaceans. It is modestly dimensioned with a mass comparable to that of the killer whale  and size  for all studied planes, but no directional asymmetry was detected between the left and the right ears for shape  and size .The morphological assessment of sperm whale ear structures was consistent with descriptions of other members of toothed whales212 = 0.238) for the frontal view . A phenetic covariance matrix was calculated by UPGMA and we tested for the existence of phenetic signals in centroid size and shape. We found significant phenetic signal for both centroid size  and shape , indicating that our stranding clustering partially determines the intra-specific variation observed in the morphology of the cochleae in frontal view  is constrained by the length and height of their cochlear capsule. Comparisons on frontal CS indicated differences in size among stranding clusters  in grey tal view . Variabltal view . Cochleatal view . This retal view . Vector tal view . Individ2 = 0.268) for the sagittal view . No phenetic signal for both centroid size  and shape  were observed in sagittal view . Individuals from stranding clusters differed on cochlear width and sagittal centroid size  in blacktal view . Variabltal view . Cochleatal view . This notal view . IndividSize and shape of cochleae in transverse view (separates head from tail) was mainly driven by width and height. No significant differences could be identified among stranding clusters for transverse centroid size (p > 0.05) and no allometric variation was detected . The firPhyseter macrocephalus.Cetacean T-P bone complexes present extreme compactness, density and mineral content, which are functionally supposed to increase the efficiency of ultrasound conduction and to facilitate the bilateral discrimination of sound direction underwater1617181920212223242633Inia geofferensis and Delphinus capensis and additionally performed vibrational analyses suggest that the resonant frequency modes of left and right ears were identical in functional significance for these speciesOne potential factor of variance might be variation related to symmetry. Indeed, skulls of odontocetes are typified by directional asymmetry, particularly in elements associated with the airways and it is assumed that this asymmetry is related to biosonar productionDelphinus delphis), and reached their full mineralization within the first 6 monthsTursiops truncatus) and La Plata dolphins (Pontoporia blainvillei)33Mesoplodon speciesBalaenoptera physalus)The observed inter-individual differences in size and shape of sperm whale cochleae might also be related to differences in size among individuals. The sperm whales that stranded in the North Sea during January and February 2016 were young males sized between 10 and 12 m and aged around 10 to 15 years. However, variation related to age and size would presume that postnatal growth of cochlear structures occurs. No association could be detected between shape and size variation of sperm whale cochleae and variables like age, length and weight, which are closely related to growth, development, and life history of the whales. Based on the collected data to date, postnatal growth of cochlear structures is unlikelyGonatus fabricii) that occurs in the northern Atlantic Ocean from Canada to the Barents Sea, indicating that the animal was foraging in northern waters before it beached. We hypothesize that this animal was the first of a larger group of eight sperm whales that entered into the North Sea mid-January. The other stranding cluster is composed of four animals that stranded on 12/01 on Helgoland and on 03/02 in Büsum.A third possibility is that the observed variations are related to the structure of bachelor schools as the morphology of cochleae varied among stranding locations and clusters of sperm whales. Except during breeding seasons, male and female sperm whales are geographically distant. Males leave their cohort between an age of 4 to 21 years and live either solitary or form loose bachelor groups with other males of similar age and sizeSotalia guianensis) were found in a recent study between the coasts of northern and south-eastern Brazil, which are consistent with population genetic structureS. guianensis, our analysis of landmark-based geometric morphometrics suggests that the sperm whales that stranded on German coasts came from distinct groups. Apparently, the cochleae are individually shaped, varying greatly in dimensions and the intra-specific variation observed in the morphology of the cochleae may partially reflect their affiliation to their bachelor school. These regional differences have to be considered in future examinations of samples; these observations could be confirmed by other techniques of morphology, phenology, behavioural ecology, diet and ultimately genetic structure of bachelor schools.The shape variations were more pronounced in the frontal and sagittal view than in the transverse one. Size and shape of cochleae in transverse view were mainly driven by width and height and the disposable space inside of the cavities below the brain case where the ears are located possibly limit the variation and expansion of the height of the ears. This might explain the fact that no variation could be revealed in the transverse view. Geographical differences in the middle ear of Guiana dolphins The functional consequences of inter-individual variation of cochlear structure are difficult to define. Size and shape are important components of functional morphology of the T-P bone complex because these factors determine their vibrational parameters25The landmark-based geometric morphometrics was revealed to be an efficient tool to identify inter-individual variations of the tympanic-periotic bone complex of sperm whales. Some shape variation is associated to allometry but a relative amount of shape variation could be attributable to geographical differences and social groups. Our geometric data suggest that the sperm whales that stranded on German coasts came from distinct bachelor schools. Apparently, the cochleae are individually shaped, varying greatly in dimensions and that the intra-specific variation observed in the morphology of the cochleae may partially reflect their affiliation to their bachelor school. Future research might analyse the functional consequences of morphological variation of cochlear structures. There are increasing concerns about the impact of noise on cetaceans and describing the auditory periphery of odontocetes is a key conservation issue to further assess the effect of acoustic pollution.Several mass strandings of sperm whales occurred in the North Sea during January and February 2016. During this period, thirty dead animals were observed along European coasts among them sixteen beached on German coasts . Twelve 3.18)Thirty-one external morphometric characters were measured on the twelve specimens of stranded sperm whales . Age detDuring the necropsies sperm whale ears were approached from the ventral side after removal of the lower jaws. The ears sit in cavities below the brain case, located either side of the occipital condyles and behind a large squamosal shield. The ears consist of two dense joined bones about the size of a tightly closed fist. We removed the soft tissue surrounding the ear bones with a knife to find the tympanic-periotic (T-P) bone complex. In sperm whales there is an osseous connection between the ears and the skull, so that the ears had to be cut or levered out of the skull. After removal, the ears were fixed immediately in 10% buffered formalin.To conduct a comparative analysis of sperm whale ear morphology, we used computerised tomography (CT). Amongst other advantages, CT is a non-invasive technique and allows the information, obtained in a series of slices, to be further rendered in 3D. CT scans of the T-P bone complex of both ears from twelve sperm whales were performed using a BrightSpeed, GE Medical Systems . The tympanic-periotic bone complexes were examined for perimortem fractures: such fractures might occur when whales have been exposed to a loud acoustic source that was matched to the resonant frequency of the bulla33®. This mode shows three orthogonal planes, the original data set and the major two perpendiculars to it. All the view ports are equal and behave similarly. The lines on each window show the location of the other two orthogonal planes and permit to align perfectly cochleae in the three anatomical planes: dorsal, sagittal and transverse i.e. landmarks (LMs). The data acquisition software TPSDig51i.e. frontal, sagittal and transverse views) and thus created separate data files. The LMs were selected in the cochlear spiral to be representative of the spiral shape and its potential variations in different individuals. Nine, seven and seven LMs for cochleae in frontal, sagittal and transverse view were used, respectively. We quantified shape and size variation of cochlea using landmark-based geometric morphometric methods4647For each cochlea view, landmark configurations were optimally aligned using a generalized Procrustes superimposition46We checked directional asymmetry of the left and the right sperm whale ear to investigate the degree to which directional asymmetry might contribute to directional cues in odontocete sound reception. To do so, shape variation was decomposed into variation among individuals and variation among sides. These components were statistically evaluated using Procrustes ANOVA using the function ‘ bilat.symmetry’ of the R-package geomorphWe tested the null hypothesis that cochlea shape is unrelated to cochlea size (CS). A Procrustes ANOVA with permutation procedures was performed to assess statistical hypotheses describing patterns of shape covariation with size for a set of Procrustes-aligned coordinates using the function ‘ procD.allometry’ of the R-package geomorphTo explore differentiation in cochlea shape across sperm whale groups, we performed a principal components analysis on shape variables to explore inter-individual variation. Deformation grids were used to illustrate shape variation along the principal component axes  and 6b.The relative amount of shape and size variation was evaluated, as well as the shape variation associated with variation in centroid size. We quantified the relative amount of shape variation attributable to stranding location and stranding cluster as a factor in a linear model and estimated the probability of this variation, via distributions generated from resampling permutations. This was performed using a Procrustes ANOVA which is implemented in the ‘ procD.lm’ function of the geomorph R-package54The extent to which our classification of individuals based on overall similarity in external morphology  is translated into variations of shape and sizes of the bony component was also evaluated. We used the previously computed phenetic covariance matrix and tested for the existence of phenetic signals in centroid size and shape using the function ‘physignal’ of the R-package geomorphFinally, the shape differences between the cochleae of sperm whales from the two stranding clusters could be visualised graphically, by obtaining the average landmark coordinates for each group and the overall mean, and plotting the differences as vector displacements  and 6d.All the analyses were performed in R 3.1.1How to cite this article: Schnitzler, J. G. et al. Size and shape variations of the bony components of sperm whale cochleae. Sci. Rep.7, 46734; doi: 10.1038/srep46734 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Before circulating insulin can interact with membrane bound insulin receptors and trigger downstream signalling it must first cross the endothelium of the blood vessels in the target tissue. This transfer across the endothelium from the blood is recognised as a rate limiting step in insulin action in muscle and fat in humans , but theThe sinusoids, or blood vessels of the liver are lined by specialized endothelial cells that are very thin and perforated with transcellular holes or pores that traverse the entire cell from apical to basolateral membranes. These pores, known as fenestrations, have no diaph-ragm and are patent passages through the cell. The fenestrations provide efficient ultrafiltration of small material from the blood into the liver . CoupledIn the current work, the hepatic and systemic dis-position of insulin was explored in young and old animals and insulin resistance was confirmed to be present in the older animals. Critically, using multiple indicator techniques insulin transfer across the liver endothelium was shown to be significantly impaired. The 20 % reduction in insulin's volume of distribution in the liver was consistent with limited transfer across the sinusoidal endothelium and retention of insulin in the sinusoid. In concordance with these changes, there were very high circulating insulin levels indicative of both increased secretion (measured by circulating C-peptide levels) and impaired clearance. Despite normal glucose tolerance tests in the older animals, insulin resistance, as determined by the product of insulin and glucose  was present. Of key importance, insulin and glucose uptake into muscle and fat was shown to be unchanged with age, suggesting age related insulin resistance was most likely being driven by impaired hepatic uptake and clearance. To explore insulin signalling in insulin treated livers phospho-proteomic and PCR studies were used, revealing significant impairment of insulin signalling pathways with no changes in gene expression- this is all highly consistent with the selective impact of age-related defenestration on hepatic insulin sensitivity.A key strength of the study is the recognition of the multifactorial nature of aging and use of the acute model of defenestration, poloxamer 407 (P-407) [This work suggests that defenestration and pseudo-capillarization of the liver sinusoidal endothelium seen in aging prevents the access of insulin to the insulin receptor on the hepatocyte membrane through impaired transfer across the endothelium. This results in hyper-insulinemia, impaired hepatic insulin signalling and insulin resistance. Further the work demonstrates, the liver endothelium does not provide a barrier for the uptake of insulin under normal conditions. In summary, patent fenestrations are required for hepatic insulin uptake, clearance, and signalling and loss of fenestra-tions is a probable causative mechanism for insulin resistance and diabetes seen with aging. This work provides evidence that maintaining the integrity of the liver sinusoidal endothelium into old age may prevent age-related insulin resistance and excitingly, introduces a novel therapeutic target.


The use of fat grafting as a reconstructive surgical option is becoming much more common. Adipose-derived stem cells found in fat grafts are believed to facilitate wound healing via differentiation into fibroblasts and keratinocytes and the release of pro-healing growth factors. Several small studies have shown a positive effect of fat grafting in healing of wounds of a variety of aetiologies. When fat is combined with autologous platelet-rich plasma (PRP), there may be enhanced healing effects. This may be due to the pro-angiogenic and anti-inflammatory effects of PRP. We aim to synthesise the current evidence on combination fat grafting and PRP for wound healing to establish the efficacy of this technique.We will conduct a comprehensive literature search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (up to July 2017) to identify studies on fat grafting and PRP for wound healing. All primary studies and systematic reviews of these studies will be included, except case reports and case series with fewer than three patients, to evaluate the outcome of fat grafting and PRP on wound healing either on its own or when compared to other studies. Primary outcome measures are expected to be the proportion of total wounds healed at 12 weeks and the average wound healing time . Expected secondary outcome measures are the proportion of wounds achieving 50% wound healing, the type of wound benefitting most from fat grafting, economic evaluation, health-related quality of life, and adverse events. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology.This review will provide robust evidence of the efficacy of fat grafting and PRP for wound healing. This is an emerging technique, and this review is expected to guide clinical practice and ongoing research aimed at improving wound care.CRD42016049881PROSPERO The online version of this article (doi:10.1186/s13643-017-0505-8) contains supplementary material, which is available to authorized users. Wound management places a significant burden on healthcare, costing the NHS in the UK billions of pounds per annum . TraditiFat grafting has become increasing popular in contouring procedures over the last few decades ; howeverPlatelet-rich plasma (PRP) is an autologous blood-derived product enriched in platelets, growth factors, chemokines, and cytokines. It is a reservoir of essential growth factors, including platelet-derived growth factor, vascular endothelial growth factor, transforming growth factor-beta 1, and insulin-like growth factor which facilitate repair and healing. Platelet-derived biologic mediators have two primary effects on wound healing: recruiting and activating cells that affect wound healing and regulation of angiogenesis , 13. PlaWhen fat and PRP are used in combination, there may be increased survival of the fat graft which may in turn increase the healing properties of the adipose-derived stem cells. This is believed to be due to the pro-angiogenic effects of PRP which allows early vascularisation of the fat therefore reversing the early ischaemic phase of the graft . AnotherAn extensive search will be undertaken in the MEDLINE (Ovid SP), EMBASE (OvidSP), Cochrane Central Register of Controlled Trials (CENTRAL), Science Citation Index, and Google Scholar databases to identify systematic reviews and primary studies on combination fat and PRP for wound healing. This review will provide robust evidence of the efficacy of fat grafting and PRP for wound healing. This is an emerging technique, and this review is expected to guide clinical practice and ongoing research aimed at improving wound care.This systematic review aims to summarise the best available evidence for the technique of combination fat grafting and PRP in an effort to aid in establishing the efficacy of this technique. This will be achieved by evaluating the use of the technique in the clinical setting by measuring the proportion of wounds healed and the mean wound healing time .This protocol has been registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42016049881) and will be reported adhering to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement . The PRI([fat graft] OR [fat transfer] OR [adipose graft] OR [adipose stem cell] OR [adipose derived stem cell] OR [adipose tissue transplantation]) AND [wound healing] AND ([platelet-rich-plasma] OR [PRP])We will conduct searches of the MEDLINE (Ovid SP), EMBASE (OvidSP), (CENTRAL), Science Citation Index and Google Scholar databases from 1946 up to July 2017 to identify studies of relevance to this review. Publicly available trial registers  will be searched for all trials. The reference list of all articles included will be crosschecked for further articles of relevance. The search strategy will use a combination of text word and Medical Subject Headings (MeSH) terms relating to the use of epidermal graft in treating wounds. There will be no restriction by study design or outcomes as the research questions are broad. No date or publication restriction will be applied. The initial search will be conducted in English; if full articles not written in English are identified and deemed to meet the criteria for inclusion in the study, they will be translated into English. A sample search strategy for MEDLINE (OvidSP) is shown, and a similar strategy will be adapted for use in other databases.All human studies related to fat grafting and PRP for treating wounds will be included.All primary studies (excluding case reports or case series with fewer than three patients) or systematic reviews of these studies, which evaluate the outcome of fat grafting and PRP for wound healing, will be included.The participants are all patients (child and adult) with wounds of any size or aetiology treated by a combination of fat grafting and PRP.Studies performed in any clinical setting will be included.Any technique of autologous fat harvesting which is then combined with autologous PRP will be included. Traditional techniques of fat harvesting include the Coleman technique using cannula and syringe with or without centrifuging, and the suction assisted liposuction technique. Both techniques may or may not include infiltration of tumescent solution into the donor site. Autologous PRP is harvested by obtaining a peripheral blood sample and centrifuging this using a variety of different commercially available platelet purifying devices to produce PRP. The two substances are mixed together and infiltrated directly into and around the wound bed. The amount injected varies between studies. There is no evidence on a more efficacious standardised fat and PRP technique. Information regarding the harvesting methods for both fat and PRP, the volume of each substance harvested, the volume applied, and the dressing used after grafting will be documented.Studies comparing combination fat grafting and PRP to any other wound management option will be included in this review.The primary outcome measures will be the proportion of wounds with complete healing at 12 weeks and the mean wound healing time . Secondary outcome measures will be the type of wound benefitting most from fat grafting, economic evaluation, health-related quality of life, and adverse events. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology dependent on sufficient data sets .The exclusion criteria will be case series of less than three cases; studies describing the use of fat grafting and PRP in cases not involving wound healing, studies not reporting time or proportion for 100% wound healing, studies in animal models, and studies describing only the harvest technique without treatment outcome.Study selection will be conducted in a two-stage process. The titles and abstracts will initially be screened by two reviewers, using pre-specified screening criteria, for potential eligibility after excluding duplicate records. Next, studies identified as relevant will undergo full-text review by both reviewers. Any discrepancies between the reviewers will be resolved by discussion or by referral to a third reviewer. Any relevant non-English language articles will be translated where necessary. The search results, including abstracts, full-text articles, and record of the reviewer’ s decisions, including reasons for exclusion, will be recorded in Endnote X7 .Study characteristics Patient demographics Wound characteristics Characteristics of the intervention and control group Outcomes Length of follow-upCost of fat grafting and PRP combination plus dressings and follow-upHealth-related quality of life and patient-reported outcome measures in patients managed with fat and PRPComplications or adverse events occurring within the study durationStatistical analysis model usedThe data from all full-text articles accepted for the final analysis will be independently retrieved by two authors using a standardised data extraction form. Any disagreements and differences will be resolved by discussion or referral to a third reviewer. Primary study authors will be contacted if further information is needed or some data are missing. The following data will be extracted:Included studies will be critically appraised for methodological quality and risk of bias by two review authors independently. Discrepancies will be resolved through consensus or referral to a third reviewer if necessary. The included studies are expected to all be observational studies, with no RCTs. Should there be any RCTs, they will be assessed according to the Cochrane Collaboration Risk of Bias Assessment Tool . The obsI2 statistic. The thresholds for interpretation of I2 will be in accordance with the definitions presented in the Cochrane Handbook for Systematic Reviews of Interventions [The main outcome measure of the included studies will be the pooled estimate of the proportions of wounds healed at 12 weeks and the mean wound healing time with corresponding 95% confidence intervals. Meta-analysis will be performed should a sufficient number of studies with consistent characteristics be found in terms of study design and outcome reporting. We will explore the sources of potential clinical and methodological heterogeneity based on the study design, population, intervention, and comparator characteristics and outcomes. Statistical heterogeneity will be assessed using the chi-square test and quantified with the ventions . NarratiData synthesis will be performed using Review Manager 5.3 provided by The Cochrane Collaboration . Should This review aims to determine the efficacy of a combination treatment of fat grafting and platelet-rich plasma for wound healing. This will be done by evaluating the overall proportion of wounds completely healed with this technique and the mean wound healing time. Although there is some evidence that when used in isolation these techniques improve wound healing, the efficacy of them used in combination is currently unclear. It is important to evaluate these two emerging autologous treatments for their regenerative potential in order to guide clinical practice and future research. To our knowledge, this is the first systematic review to evaluate the efficacy of this technique for wound healing.We expect the sensitivity of our search to be limited by the lack of MeSH terms for platelet-rich plasma and a combination of fat grafting and PRP. We have included a wide range of text word combinations to overcome this. We also expect the small number of studies to limit the potential for meta-analysis of studies although we will continue to proceed with a narrative review in this instance.


Exosomes are nanovesicles having a maximum size of 150 nm and is a newly emerging focus in various fields of research. Its role in cargo trafficking along with its differential expression is associated with the disrupted homeostasis and provides an opportunity to defend against different diseases like cancer. Furthermore, exosomes are rich in cargos, which contain proteins and nucleic acids that directly reflect the metabolic state of the cells from which it originates. This review summarizes recent studies on tumor-derived exosomes with an overview about biogenesis, their functions and potential of using as diagnostic and prognostic markers. We also discussed the current challenges and microfluidic-based detection approaches that might improve the detection of exosomes in different settings. More intricate studies of the molecular mechanisms in angiogenesis, pre-metastatic niche formation, and metastasis can give more promising insights and novel strategies in oncotherapeutics. Exosomes are extracellular vesicles, which are functionally pleiotropic in nature. These nanoparticles have a size of 50–140 nm and carry specific cargos in it. They act as a transporting system for various biomolecules including DNA, RNA, proteins, and lipids. These are bilipid-layered vesicles that can carry their cargos on the plasma membrane and also in its cytoplasmic core Figure .Exosomes are found to be present in almost all kinds of body fluids such as blood, plasma, cerebrospinal fluid, bile, breast milk, etc. In normal homeostatic state, a basal level of exosomal release will aid in the elimination of cellular debris and also for cell-to-cell communication purposes. An increase in exosomal quantity and altered cargo expression can be considered as a potent biomarker for alteration of normal physiological states , 3, 4.Exosomes are surrounded by a lipid bilayer with a small fraction of cytosol and devoid of any kind of cellular organelles. Exosomes can be synthesized by means of two major pathways, and the process is highly regulated by multiple signal transduction cascades. Its release from the cell follows the normal exocytosis mechanism characterized with the vesicular docking and fusion with the aid of SNARE complexes Figure . Mode ofEndosomal sorting complex required for transport (ESCRT)-dependent pathway relays on a complex of various proteins as well as certain carbohydrate molecules for the successful biogenesis of exosomes through MVB formation. ESCRT consists of five distinct protein complexes, namely, ESCRT 0, I, II, and III, AAA ATPase, and Vps4. This process is initiated within the endosomal system. Molecular characterization of dendritic cell (DC) exosomes suggested its endosomal origin by indicating the presence of hsc73, an endosomal chaperone . In addiIn vitro experiments conducted in Hrs-depleted cells revealed the significance of this particular protein in MVB formation. TSG101 and VPS4b (vacuolar protein sorting factor) are the two major ESCRT downstream proteins which were not found in Hrs-depleted DC exosomes and were enriched in control DCs  trafficking. A comparative study of endosomal sorting of EGF with PLP revealed the decreased sorting of EGF with RNA interference in the expression of ESCRT and its associated proteins, which was just opposite in the case of PLP sorting. Study suggests the presence of certain microdomains in endosomal membrane that is rich in sphingolipids from which ceramide is formed whose cone-shaped structure is responsible for membrane curvature, which finally results in PLP sorting and vesicular abscission into the endosomes . Five RaKajimoto et al. suggested the role of an inhibitory G-protein-coupled sphingosine-1-phosphate receptor in cargo sorting and exosome release. Constant supply of sphingosine-1-phosphate with the cytosolic localization of sphingosine kinase 2 enzyme to the receptor can cause continuous activation of the receptor and leads to cargo sorting and budding of intra-endosomal vesicles . The funExosomes are bioactive vesicles that carry different molecular cargos. Proteins are one of the dominant contributors among them. Cells release exosomes in normal physiological conditions, which are mainly for cell-to-cell communication. Ligand molecules that are packaged in exosomes can be targeted to the adjacent cells, where they can interact with specific receptors . Exosoma+ breast cancer cell lines was also reported  is a predominant cytoplasmic protein that has a role in vesicular biogenesis. DC exosomal membrane is rich in tetraspanin proteins including CD9, 63, 81, and 82, which are responsible for their immunological functions . Along wreported . 27-OHC er cells . A detaivia gap junctions or extracellular coulee. It can cause bystander effect, which make the cells as cancerous or can lead to its autophagy. Most of the studies are focusing on the increased release and bystander integration of these vesicles in response to radiation which is specifically named as radiation-induced bystander effect (RIBE)  –40.In esophageal squamous cell carcinoma, specific miRNAs have shown an increased expression with tumorigenesis and its aggressiveness. Exosomal miR-17, miR-19a, miR-21, miR-126, and miR-149 expression exhibited a positive correlation with the progression of metastatic sporadic melanoma by targeting around 40 genes . ExosomeOncogenic proteins enclosed in exosomes can lead to spreading of tumor to the adjacent tissues. Recently, a novel protein, myoferlin is reported to be present in pancreatic and breast cancer cells, described as a common protein in cancer cell releasing exosomes. The study unravels the importance of myoferlin in cancer progression and metastases with increased exosomal biogenesis and packaging of nucleic acid cargo to adjacent cells . The oncTumor microenvironment consists of cellular and acellular factors contributed by the tumor and its surroundings. Its main composition includes extracellular matrix (ECM), cancer-associated fibroblasts (CAFs), inflammatory immune cells and tumor-associated vasculature. CAFs play a major role in the maintenance of tumor microenvironment with the release of different proteins to the extracellular sites that are involved in various signal transduction pathways and their regulations. Almost all these factors are released with the aid of exosomes . InflammFc receptor-mediated recognition of exosomes by macrophages promotes tumor growth and metastasis. These vesicles with functional proteins induce the immune system with the activation of macrophages, accomplished with the cytoskeleton rearrangements of the cell . ConditiOn the other hand, immune suppression is a major trait of tumor microenvironment. Cancer cells show different strategies to inhibit the immune system action for the clearance of tumor deposition. Recent studies revealed that exosomes are potent players in this process. Hypoxic tumor-derived microvesicles can block NK cells, well known for tumor surveillance. These vesicles are loaded with miR-23a which is absent in vesicles from normoxic cancer cells. This emphasizes hypoxia as a prominent characteristic for an immunocompromised tumor microenvironment . HypoxicIn vitro studies of tube formation in normoxic and hypoxic human umbilical vein endothelial cells (HUVECs) that were incubated with exosomes released from human leukemic cells have suggested differential cargo expressions in hypoxic vesicles and its role in angiogenesis  will induce angiogenesis with the incorporation of vesicular cargos such as tetraspanin 8 and CD106 and 49d, which can activate vascular endothelial growth factors (VEGFs). VEGFs can cause EC proliferation, migration, sprouting, and maturation of EC progenitors . Exosomeogenesis . Beyond ogenesis . Role ofogenesis . Tetraspogenesis . Expressogenesis .Metastasis is the process of detachment and successful invasion of cancerous cells from the primary site of tumor to the secondary one mainly through blood flow. It is mainly characterized by different steps including metabolic reprogramming of cells, loss of cell connections with increased action of matrix metalloproteases, and diapedesis of cancerous cells and its integration to specific target sites. Metastasis is the process that makes the disease more dreadful with its recurrence . The proCancer is one of the major diseases which show a high rate of resistance toward various therapeutic strategies. Recent studies suggest exosomes as major players in increased survival rate of cancerous cells after chemotherapy. Drug-resistant breast cancer cells transfer the resistive power to the adjacent sensitive cells through exosomes. Horizontal transfer of specific cargos with the aid of these biological nanovesicles alters specific gene expression patterns in recipient cells . SeveralRabinowits et al. reported that in lung adenocarcinoma, circulating total miRNAs can be used as a screening tool because they observed a significant difference between patients and healthy controls . Severalg followed by sucrose gradient centrifugation as a purification step. Inconsistent results of this practice further lead to the development of different exosome isolation kits  . StudiesMore sophisticated techniques and methodologies for isolating cancer exosomes.The nature of the cargo in the exosomes majorly depends on the origin of the cells from where the exosomes get released. Therefore, how the cargo is packed in exosomes needs to be fully elucidated. It is important because cancer cells are known for their heterogeneity and nature of cargo from each cancer cell will be different. This will further help us in designing strategies for early diagnosis and monitoring response to treatment using exosomes.The role of exosomes in diagnostics and therapeutics is mostly confirmed using cancer cell lines and animal models. A large-scale, randomized clinical trials must be conducted in different types of cancers for further validation and establishing the use of exosomes as point of care diagnostics.Identification of exosomes based biomarkers in response to conventional cancer therapies to study the treatment response.The potential use of exosomes as delivery vector needs more critical evaluation. How tractability can be improved? Whether multiple drugs can be packaged in exosomes? As we are in the era of personalized medicine, whether we can make personalized approach for delivering therapeutically relevant exosomes?Till date, there is a dearth of well-defined guidelines for manufacturing, storage and administration of therapeutically relevant exosomes. There is an urgent need to develop guidelines with respect to safety and quality of exosomes and GMP standards to be followed.Exosomes are considered as heterogeneous entities, and the complexity of exosomes is still not thoroughly understood. We propose following areas which require an urgent attention to understand the complexity of exosomes.These studies on the composition and biogenesis of exosomes provide us with detailed insight into the role of cancer-derived exosomes in tumor growth, drug resistance, metastasis, and angiogenesis. The exosomes are rich in different types of cargo and reflect the state of tumor cells from which it is derived and can be explored as minimally invasive biomarkers for early detection, diagnosis and prognosis of different type of cancers.All authors listed have made substantial and intellectual contribution in the preparation of the manuscript and final version was approved for publication.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.


Medicaid is the largest primary health insurance for low-income populations in the United States, and it provides comprehensive benefits to cover treatment and services costs for chronic diseases, including diabetes. The standardized per capita spending on diabetes by Medicare beneficiaries enrolled in the fee-for-service program in Hawaii increased from 2012 to 2015. We examined the difference in odds of diabetes between Medicaid and non-Medicaid populations in major racial/ethnic groups in Hawaii.We used data from 2013 through 2015 from the Hawaii Behavioral Risk Factor Surveillance System in this cross-sectional study to compare the difference in risk for self-reported diabetes between Medicaid  and non-Medicaid  beneficiaries. We used multivariate logistic regression models that could accommodate the complex sampling design to examine the difference in odds of diabetes between the 2 populations.P = .02). After adjusting for confounding variables, the odds of diabetes in the Medicaid population was still significantly higher than those in the non-Medicaid population . Adjusted analysis stratified by race/ethnicity showed that non-Hispanic Asian  and NH/OPI  Medicaid beneficiaries had significantly higher odds of diabetes than their non-Medicaid counterparts.In Hawaii, the Medicaid population was younger, was less educated, had more health impairments, and was more likely to be obese and Native Hawaiian/Other Pacific Islander (NH/OPI) than the non-Medicaid population. The unadjusted prevalence of diabetes in the Medicaid population in Hawaii was higher than that for the non-Medicaid population (10.3% vs 8.9%, The odds of diabetes was significantly higher among the Hawaii Medicaid population than among the non-Medicaid population. Diabetes prevention programs should address the challenges and barriers that the Medicaid population faces. Our findings can be used to promote culturally competent diabetes education programs. Diabetes is a complex disease that affects nearly 400 million people worldwide and in 2014 was the seventh leading cause of death in the United States ,4. In 20Low-income populations have a disproportionately high prevalence of diabetes . MedicaiThe annual Behavioral Risk Factor Surveillance System (BRFSS) conducted in Hawaii traditionally does not distinguish between Medicaid and non-Medicaid populations . In the A review of the literature indicated that little research had investigated the association between Medicaid status and risk of diabetes in the Hawaii adult population. We examined the difference in odds of diabetes between Medicaid and non-Medicaid populations in major racial/ethnic groups in Hawaii.BRFSS survey data from 2013 through 2015 were obtained from the Hawaii Department of Health through a data use agreement. The BRFSS is a cross-sectional telephone survey of noninstitutionalized civilians in the United States aged 18 years or older . FundingA multistage cluster design was used in the BRFSS to produce a nationally representative sample. Each respondent had a corresponding final weight based on the respondent’s probability of being selected into the BRFSS sample and a poststratification factor to ensure consistency of the age and racial/ethnic distribution between the BRFSS and US census data. For combined BRFSS 2013–2015 data, the final weight was calculated as the average of the final weight in each year’s data. Requested BRFSS data included core sections and state modules on prediabetes, diabetes, and cardiovascular health. The core sections included in the data analysis were health status, number of healthy days and health-related quality of life, health care access, sleep status, hypertension awareness, cholesterol awareness, chronic health conditions, alcohol consumption, fruit and vegetable consumption, exercise, immunization status, and demographic information. A participant with diabetes was defined by a yes response to the question “(Ever told) you have diabetes?” Survey respondents with gestational diabetes were excluded from the study population.2 tests were used to assess the bivariate association between demographic characteristics and Medicaid status. Bivariate and multivariate logistic regression analyses were used to examine the association between Medicaid status and risk for diabetes, controlling for the independent effects of sex, body mass index (BMI), age, race/ethnicity, marital status, checkup within past year, exercise, immunization status, and alcohol consumption. Stratified analyses using multivariate logistic regression models were conducted for Medicaid and non-Medicaid groups separately to examine the group differences in diabetes risks. Stratified analyses were also conducted for racial/ethnic groups . The effects of other independent variables on risk of diabetes were compared between the Medicaid and non-Medicaid groups and among the 3 non-Hispanic racial groups. The Hosmer and Lemeshow purposeful model selection method was used to select the confounding variables used in the multivariate logistic regression models  self-identified as a Medicaid beneficiary. After adjusting the complex sampling design weight, the proportion of Medicaid population was 8.8% during the 3-year period. Most demographic and health characteristics were significantly different between the Medicaid and non-Medicaid populations . The MedP = .02). The adjusted odds of diabetes among the Medicaid population was significantly higher than the odds among the non-Medicaid population   . The adjAlthough men had slightly higher odds of diabetes than did women in the overall sample, the difference between sexes was not significant in either the Medicaid group or non-Medicaid group . High BMThe adjusted odds of diabetes was not significantly different between the Medicaid population and non-Medicaid population among non-Hispanic whites  . HoweverA checkup within the past year was associated with elevated odds of diabetes among both whites  and Asians ; however, this association was not significant among NH/OPIs . Physical activity was a protective factor for diabetes among whites  and Asians  but was not significant among NH/OPIs . More alcohol consumption in the past 30 days was significantly associated with reduced odds of diabetes among both whites  and Asians  but was not significant among NH/OPIs .Few studies have examined the difference in health behavior risk factors between the Medicaid and non-Medicaid populations in Hawaii, and we found no research on adults with Medicaid in relation to diabetes. A study on children and adolescents with type 1 or type 2 diabetes that included participants from Hawaii found that worse health-related quality of life was associated with a primary insurance source of Medicaid or other government-funded insurance .Our study was the first to compare the adult Medicaid and adult non-Medicaid populations in Hawaii on demographic characteristics and association with diabetes after the Medicaid question was added. Although studies on the association between low SES and diabetes have been conducted using various SES indicators such as income, occupation, or educational level, Medicaid status is a more comprehensive indicator for those with low SES and insured in the Hawaii population ,20. The Stratified analysis by Medicaid status demonstrated different risk factors associated with elevated risk of diabetes. Having received an influenza vaccination in the past 12 months was significantly associated with diabetes in the non-Medicaid population; this finding is a correlation and does not imply causation or an increased odds of diabetes. It may indicate a marker of increased interaction with the medical system and thus increased opportunity for diabetes detection and diagnosis. It is current standard of practice and recommended by the American Diabetes Association (ADA) that people with diabetes receive the influenza vaccine annually.Our study showed that racial/ethnic minority populations in Hawaii had significantly higher diabetes risk. The risk remained elevated for Asian and NH/OPI Medicaid beneficiaries compared with their non-Medicaid counterparts. This finding was consistent with data showing that NH/OPIs have significant disparities in health risks and outcomes and suggests that outreach efforts should be conducted for Asian and NH/OPI Medicaid beneficiaries .A limitation of this study was that BRFSS data are self-reported; therefore, only people who self-reported that they have been told they have diabetes were included, and those who were undiagnosed were not included. Thus, detection bias could affect the associations between risk factors and diabetes. BRFSS survey data are also limited by the survey questions. For example, the BRFSS asked only whether the participant had any exercise in the past 30 days and did not ask about frequency or intensity of the exercise. Moderate physical activity is inversely associated with diabetes . The ADAMedicaid beneficiaries in Hawaii were younger and had different health associations in terms of diabetes risk compared with non-Medicaid beneficiaries. These findings have implications for the health care system and for prevention and screening measures. Preventive strategies should be culturally competent and tailored to the risk factors of the Medicaid population. For example, Hula, a cultural dance program implemented in Hawaii, improved hypertension management in NH/OPIs, and could also be used to reduce BMI . The PILOur study design may be generalized to other states interested in assessing the association between Medicaid status and diabetes or other chronic disease risk among racial/ethnic groups. However, it is important for stakeholders such as FQHCs and public health practitioners to be cognizant of the differences between the Medicaid and non-Medicaid populations and among various racial/ethnic groups in the design and implementation of effective diabetes preventive strategies that meet the unique needs stemming from patients’ Medicaid status, racial/ethnic backgrounds, and cultural heritages. Policy makers should be aware of the link between Medicaid status and increased risk for almost all chronic diseases and the burden of cost in the Medicaid population for management of diabetes or other chronic diseases. Programs with policy support for value-based care specific to reducing the burden of chronic diseases in the Medicaid population are in great need. Finally, inclusion of the Medicaid status question in the BRFSS may benefit other states that seek to study chronic disease risk factors in the Medicaid population.


Triticeae demonstrates that a genetic bottleneck may have led to its decreased diversity during domestication and the subsequent cultivation. It has also highlighted the fact that the wild relatives of wheat may offer an unexploited genetic resource for the regulatory region of these genes. Significant research efforts have been made in the public sector and by international agencies, using wild crosses to exploit the available genetic variation, and as a result synthetic hexaploids are now being utilized by a number of breeding companies. However, a newly emerging tool of genome editing provides significantly improved efficiency in exploiting the natural variation in HMW-GS genes and incorporating this into elite cultivars and breeding lines. Recent advancement in the understanding of the regulation of these genes underlines the needs for an overview of the regulatory elements for genome editing purposes.Wheat has been cultivated for 10000 years and ever since the origin of hexaploid wheat it has been exempt from natural selection. Instead, it was under the constant selective pressure of human agriculture from harvest to sowing during every year, producing a vast array of varieties. Wheat has been adopted globally, accumulating variation for genes involved in yield traits, environmental adaptation and resistance. However, one small but important part of the wheat genome has hardly changed: the regulatory regions of both the x- and y-type high molecular weight glutenin subunit (HMW-GS) genes, which are alone responsible for approximately 12% of the grain protein content. The phylogeny of the HMW-GS regulatory regions of the  Triticum turgidum subsp. dicoccum and a wild goat grass (Aegilops tauschii). In one possible scenario its progenitors were as follows: Triticum urartu – A genome, Aegilops speltoides – B genome and Aegilops tauschii – D genome.Hexaploid wheat only exists in a cultivated form, and it is derived from a cross between the cultivated The progenitors of wheat acquired many morphological and physiological improvements, such as loss of seed shattering, increased yield, decreased chemical, and morphological defenses, loss of seed dormancy, uniformity in germination and growth phenology, and erect growth in order to facilitate increased plant density in crop fields. These are collectively referred to as a ‘domestication syndrome’ , 2014. Fgenetic bottleneck, may restrict the possibilities of the breeder. Indeed, haplotype analysis of high molecular weight glutenin subunit (HMW GS) genes in bread wheat reported less genetic diversity than their wild counterparts, which is mainly due to the genetic bottleneck caused by human selection processes  is reported to be responsible for a major domestication syndrome, and a polymorphism analysis showed that the reduction of diversity was the most severe in the 5′-UTR (untranslated region) (Regulatory regions are one of the major contributors to forming novel traits. Genome wide association studies highlighted the importance of non-coding genomic regions in phenotypic variation in plants . Accordi region) . They co region) . This ge region) .Glu-1 locus on the chromosome 1 of the three homoeologous genomes of hexaploid wheat. Due to a duplication event, each locus contains two paralogous glutenin genes named as x- and y-type subunits  including the proximal basal promoter region  genes raises many questions: (i) What genetic variability is available in the wild species? (ii) How and when were the paralogs (x and y type) separated? (iii) Which gene was the original copy and how has the evolution of the regulatory regions changed during the duplication? (iv) What are the signs of functional shift that are usually characteristic of duplicated genes?The high similarity between the regulatory region of the homeologous HMW GS . The tree has two main branches separating the x- and y-type promoter paralogs. The branches are marked with different colors. The figure also presents a condensed view of the regulatory sequences marking only the binding sites (BS) of transcription factors (TF). These binding sites are known for their involvement in the regulation of HMW GS genes. The x-type promoters carry the unique CEREAL box motif and MYB BS at their basal promoter regions. The y-type promoters are missing these features but carry a NAC binding site at their CRM4 region that was lost in the x-type promoters. The condensed promoter view offers a graphical representation of the changes in the promoters. Many motifs disappear by the growing distance from the middle to form the typical x- and y-type promoter profiles at the outer parts of the tree. The sequences at the middle part of the tree  contain features of both x- and y-type promoters therefore we refer to them as hybrid type promoters.A phylogenetic study was used to compare 139 regulatory sequences (or promoters) of HMW GS from nearly 40 species of the packing or trafficking. This is in concert with the view that after duplication the expression patterns and/or the function of genes are shifted apart . In the case of the A, B, and R genomes the x-type promoters had lower divergence values, while in the case of the S and D genomes it was the y-type promoters. The reasons for these biased differences in diversity are unknown. The tetraploid species (AB) were longer exposed to the selective pressure of mankind . Many studies have reported the importance of TFs and their polymorphisms as a contributor to improved quality. The haplotype analysis of storage protein activator (SPA) genes has presented evidence for such correlations . Geneticnatural selection had a preference for this type of promoter. Since GRNs are conserved across species  may promote an early transition from grain filling to maturation stage  wheat may have finely tuned regulatory mechanisms controlling the expression of HMW GS genes that produces high yield in optimal conditions. In contrast, the regulatory regions of HMW GS of the wild relative seem to be better adapted to environmental changes. With regard to the increasing amount of evidence suggesting the role of TF in yield  and withHowever, a precisely targeted gene replacement of the regulatory regions of HMW GS via genome editing currently faces many challenges. One is due to the high homology between the paralogs and homeologs. To overcome this, the precise sequence data of the targeted region and its homeologs and paralogs of the chosen wheat genotype must be known and guide RNA(s) should be designed accordingly. Other challenges may be the low efficiency of HDR mediated gene replacement and the low frequency of successful transgenic events in plants as recently reviewed by SM conceived the original idea and suggested the proposed view. SM, LT, and AJ wrote the manuscript.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.


Recent studies have reported a significant decrease in wound problems and hospital stay in obese patients undergoing renal transplantation by robotic-assisted minimally invasive techniques with no difference in graft function.Due to the lack of cost-benefit studies on the use of robotic-assisted renal transplantation versus open surgical procedure, the primary aim of our study is to develop a Markov model to analyze the cost-benefit of robotic surgery versus open traditional surgery in obese patients in need of a renal transplant.Electronic searches will be conducted to identify studies comparing open renal transplantation versus robotic-assisted renal transplantation. Costs associated with the two surgical techniques will incorporate the expenses of the resources used for the operations. A decision analysis model will be developed to simulate a randomized controlled trial comparing three interventional arms: (1) continuation of renal replacement therapy for patients who are considered non-suitable candidates for renal transplantation due to obesity, (2) transplant recipients undergoing open transplant surgery, and (3) transplant patients undergoing robotic-assisted renal transplantation. TreeAge Pro 2017 R1 TreeAge Software, Williamstown, MA, USA) will be used to create a Markov model and microsimulation will be used to compare costs and benefits for the two competing surgical interventions.The model will simulate a randomized controlled trial of adult obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state of the model will be patients' death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death and perform sensitivity analysis around patients' age at the time of randomization to determine if age is a critical variable for cost-benefit analysis or cost-effectiveness analysis comparing renal replacement therapy, robotic-assisted surgery or open renal transplant surgery. After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values.After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. Kidney transplantation (KT) is the best treatment strategy for patients with end-stage renal disease (ESRD). KT allows patients to return to a normal lifestyle with relatively few side effects from modern immunosuppression medications . SeveralThe insufficient degree of freedom provided by non-articulating laparoscopic instruments and the two-dimensional view of conventional laparoscopic cameras have represented significant barriers preventing the widespread use of minimally invasive techniques for renal transplantation. However, most of those obstacles have been overcome by the introduction of robotic technologies such as the da Vinci surgical system (DVSS) . Robotic surgery allows intracorporal maneuvers that mirror the natural dexterity of surgeons’ hands with the additional advantages of eliminating the natural hand tremor -7. OtherDue to the lack of cost-benefit studies on the use of robotic-assisted renal transplantation versus open surgical procedure, we aim to develop a mathematical model designed to analyze the cost-benefit of robotic surgery versus open surgery for the treatment of obese patients undergoing renal transplantation. Our primary aim is to assess the cost-benefit ratio for the health care payer’s perspective. The selection of obese recipients for this study is based on the current evidence indicating that, for this group of patients, robotic assisted renal transplantation is associated with a significant lower risk of wound complications, and therefore, lower costs for wound care and other expensive interventions such as repair of incisional hernias or use of open negative pressure wound dressings.2 -15.The number of patients affected by renal insufficiency and obesity is growing, especially in North America where obesity has reached epidemic proportions . Recent Wound infections, incisional hematomas, and seromas are predisposing factors for incisional hernias that, most of the times, will require surgical repair to prevent intestinal incarceration or strangulation, causing abdominal or back pain due to the disruption of balance between the anterior abdominal wall muscles and the paraspinal posterior musculature.In theory, all wound complications are preventable. Yet, they still represent a significant clinical and economic burden to the health care system -20. WounThe higher incidence of wound complications in obese patients is multifactorial. Obese patients have a higher prevalence of diabetes that is a predisposing factor for delayed wound healing and to bacterial infections -25. In aP=.004). There were no patient or graft losses within the first six months after transplantation and the two groups had comparable graft function with similar serum creatinine levels (1.5 mg/dL for robotic recipients versus 1.6 mg/dL for open surgery recipients) [P=.98), number of hospital days during the first 6 months after transplantation , mean number of readmissions , percentage of reoperations during the first six months after surgery , hospital costs for transplantation  and total hospital costs over six months  [2 and who underwent robotic assisted renal transplant developed an incisional hernia that required surgical repair.During the period between June 2009 to December 2011, a prospective cohort of 39 obese patients underwent robotic kidney transplantation at the University of Illinois Hospital and Health Sciences System . This coipients) . The aut; P=.04) . OberholIn recent years, there has been a trend to move health services towards value-based organizations and to improve the cost-effectiveness of interventions by reducing costs and increasing the value of care -34. PortCost-benefit analysis (CBA) in health care focuses on the analysis of the use of resources relative to expected medical benefits . CBA plaWith assistance of a librarian, electronic searches will be conducted to identify published studies on comparisons between open renal transplantation versus robotic assisted renal transplantation. Highly sensitive search strategies will include appropriate subject headings and text word terms, interventions under consideration, and specific study designs. No language restriction will be used but searches will be restricted from year 2000 onwards, reflecting the time of introduction of robotic assisted surgery. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index, and Cochrane Central Register of Controlled Trials will be searched for primary studies, while the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and the Health Technology Assessment database will be searched for reports of evidence syntheses. Reference lists of all included studies will be scanned to identify additional potentially relevant reports. Conference abstracts from meetings of the European, American, and British Urological Associations will be searched. Ongoing studies will be identified through searching Current Controlled Trials, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry and the National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results. Websites of manufacturers, professional organizations, regulatory bodies, and the Health Technology Assessment will be checked to identify unpublished reports.Two reviewers will independently screen titles and abstracts of all potentially relevant manuscripts. Full-text copies will be obtained whenever possible. Necessary variables found in the literature will be used to populate the mathematical model. Central tendency values and their variances will be used to create distributions used in the model. Probabilistic sensitivity analysis will be performed to assess the critical variables that influence the results of the model. For variables for which values are still unknown, we will elicit expert opinions to create plausible distributions. Alternatively, we will extract values reported in scientific publications that did not include transplant recipients but that used comparable surgical techniques or interventions. For example, variables associated with the costs of using robots in renal transplantation are unavailable. However, there are several observational studies and systematic reviews that analyzed the costs of robotic-assisted prostatectomies or partial nephrectomies that can be used for our model ,39. SimiIn this part of the study, transplant surgeons, robotic surgeons, and transplant nephrologists will create a list all the possible costs that might be associated with open and robotic assisted renal transplant surgery. After reaching a state of saturation where no further costs are identified, investigators and a representative sample of individuals who require renal replacement therapy will list all the potential benefits for the two competing surgical interventions. Costs and benefits of the two interventions will be captured for the perioperative period. Since the costs of immunosuppression medications and follow-up appointments occurring after renal transplantation are similar for both groups of patients, these costs will not be included in our final analysis. On the other hand, due to the expected differences in the incidence of wound complications leading to incisional hernias between robotic versus open renal transplantation, the added costs for the care of the repair of incisional hernias will be included and added to the operative costs of transplant surgery. We will assume that the costs for the care of wound complications and repair of incisional hernias between the two groups of patients will be the equivalent.Costs associated with the two surgical techniques will incorporate the expenses of the resources used for the operations . Training cost for surgeons will not be included as it depends on many variables including the overall level of experience of the surgeons, the number of hours spent for training on the robotic platform by the surgeons, and the maintenance costs for the training robotic system. Also, we will not include the costs to train operative nurses and technicians, anesthesia, and other health care providers working in the operating room to reach adequate proficiency in robotic assisted surgery. Similarly, because the preoperative workup is comparable for both groups, these costs will not be considered in our analysis.Monetary values associated to the benefits of each surgical technique will be obtained from studies already published in peer-reviewed scientific journals. We will include the costs of obese patients who might remain on renal replacement therapy since some transplant programs will not consider them candidates for renal transplantation unless their BMI is lower than 40. To obtain pertinent costs, a systematic search of the scientific literature will be performed with the assistance of one of the librarians at the University of Pittsburgh or University of Pittsburgh Medical Center. When unavailable, monetary values will be obtained using unpublished data from the University of Pittsburgh Medical Center or from suitable hospital accounting services. Additionally, there will be intangible, or soft, benefits associated to overall patients’ satisfaction, different levels and duration of perioperative discomfort, cosmetic results, time to full recovery, potential publicity, and marketing value associated with robotic surgery for either the hospital or the surgical team. To address how these intangible benefits should be measured and whether they should be included in the computerized model, all the members of our research team and a representative sample of patients requiring renal replacement therapy will be invited to a Delphi session to stimulate ideas and solutions based on sound clinical and methodological decisions. The Delphi Technique is a method used to estimate the likelihood and outcome of future events or to estimate probabilities or values that are unknown or not measurable ,42. A grA decision analysis model will be developed to simulate a randomized controlled trial comparing three interventional arms: A) continuation of renal replacement therapy for patients who are considered non-suitable candidates for renal transplantation due to obesity; B) transplant recipients undergoing open transplant surgery; and C) transplant patients undergoing robotic-assisted renal transplantation. TreeAge Pro 2017 R1  will be used to create a Markov model and microsimulation will be used to compare costs and benefits for the two competing surgical interventions .The model will simulate a randomized controlled trial of adult (age ≥ 18) obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state  of the model will be patients’ death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death and perform sensitivity analysis around patients’ age at the time of randomization to determine if age is a critical variable for CBA or CEA comparing renal replacement therapy, robotic-assisted surgery, or open renal transplant surgery.Obesity will be defined as patients’ BMI higher than 30 according to the World Health Organization classification ,44. For After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. The rationale of sensitivity analysis in decision analysis is summarized in Primary aimsTesting the robustness of an optimal solution.Identifying critical values, thresholds or break-even values where the optimal strategy changes.Identifying sensitive or important variables.Investigating sub-optimal solutions.Developing flexible recommendations which depend on circumstances.Comparing the values of simple and complex decision strategies.Assessing the “riskiness” of a strategy or scenario.CommunicationMaking recommendations more credible, understandable, compelling or persuasive.Allowing decision makers to select assumptions.Conveying lack of commitment to any single strategy.Increased Understanding or Quantification of the SystemEstimating relationships between input and output variables.Understanding relationships between input and output variables.Developing hypotheses for testingModel DevelopmentTesting the model for validity or accuracy.Searching for errors in the model.Simplifying the model.Calibrating the model.Coping with poor or missing data.Prioritizing acquisition of informationThe model will simulate a randomized controlled trial of adult obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state of the model will be patients’ death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death, and perform sensitivity analysis around patients’ age at the time of randomization to determine if age is a critical variable for CBA or CEA comparing renal replacement therapy, robotic-assisted surgery, or open renal transplant surgery. After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. In the discussion, we will summarize the results of our study and put them in the contest of the current knowledge on the value of robotic-assisted minimally invasive renal transplantation. We expect that, for some groups of patients, robotic surgery will be the most cost-effective treatment. The strength and limitations of our study will be presented and we will assess if our study could lead to the development of future research projects.After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values.Sharing of data generated by our study is an essential part of our proposal. We would wish to make our results available to the community of scientists interested in robotic surgery, minimally invasive surgery, and transplantation to avoid unintentional duplication of research. We would welcome collaboration with other researchers within the University of Pittsburgh and from other institutions interested in CBA and CEA of new technologies in surgery. From this project, we expect that approximately two presentations will be delivered at national or international meetings. In addition, it is our explicit intention that the results of our study will be made readily accessible to the scientific community after the final analysis of the data generated by our mathematical model through publications in peer-reviewed journals.


The interactions between the processes of urbanization and international migration in less developed and transition countries have important repercussions for socioeconomic development, but are not well understood. Based on the retrospective data from the Albanian Living Standards Measurement Survey 2008, we first assess the geography of migration in terms of the rural–urban continuum, the urban hierarchy and the outside world since 1990. We then investigate the spatio-temporal diffusion of rural-to-urban and international movements using survival models. Results reveal an immediate onset of large-scale rural exodus, despite the post-communist crisis. Internal migrants mainly moved to the capital, bypassing secondary cities, and were predominantly female. Initially, international migrants were primarily men who tended to originate from the main urban agglomerations. The diffusion of opportunities to emigrate down the urban hierarchy and across the sexes then redirected the rural exodus abroad, despite domestic economic development. This evolution in population mobility is related to the gendered patterns and interlinkages of the two flows, as well as to rising inequalities within the urban hierarchy. Urbanization driven by rural-to-urban migration sustains socioeconomic development in less developed and transition countries through agglomeration economies and improved access to public services  located in the Western Balkans on the margin of Western Europe. The mainly rural society was completely isolated from the outside world under one of the most restrictive communist regimes between 1944 and 1990. The demographic and economic situation was similar to that observed in developing countries. The onset of the fertility transition was late, leading to an average annual population growth of over 2 % during the communist era. After a period of rapid heavy industrialization and major progress in public health and education in the 1950s to 1970s, the economy fell back into crisis in the 1980s. However, the government denied its people the right to emigrate and restrained rural-to-urban migration. In 1989, two-thirds of the 3.2 million inhabitants still lived in rural and mountainous areas  was marked by a financial crisis related to the collapse of illegal pyramidal banking schemes.  Large segments of the society lost all their savings, and the situation escalated into renewed social upheavals. Internal migration intensified and international migration diffused into the interior of the country, as well as among women. This was sustained by the attractive force provided by the regularization of Albanians without documents in Italy and Greece (Azzari and Carletto The third period (2002–2011) was characterized by political stabilization, strong economic growth (leading to a GDP per capita of 4087 dollars) and declining levels of rural poverty . This would be confirmed by a stronger selection of male migrants compared with females among wealthier and better educated subgroups, as pioneer migrants face higher costs, and a higher level of skills raises their probability of finding a job in the upper levels of the urban hierarchy. These hypotheses are informed by the moral primacy of patriarchy in an Albanian context of social upheaval and dangerous illegal border crossing. Similar gendered patterns of migration have also been found in other patriarchal settings . This provides retrospective information on socioeconomic conditions and on migration within and from Albania for a sample of 3600 households, comprising 14,875 residents, which is representative at the national, regional, and urban–rural levels. Households were randomly selected according to a stratified, two-stage clustered design; the non-response rate was 2 % (more information is provided by INSTAT).We reconstructed municipality-specific and international residence trajectories for the population aged 15–64 in 1990–2007 , using the following information. Besides place of residence at survey date, the interviewed household members stated the number of months spent abroad each year since 1990, and the years and places of departure of their last three internal movements. For the household-head’s children living permanently in another place within Albania or abroad , the respondent parent proxied the year and the destination of parental-home leaving, as well as of the subsequent domestic move and of the last three trips abroad. Information on the former members’ internal movements prior to parental-home leaving was not provided. We thus assumed that they did not move independently within Albania until that date, and imputed the internal migration history of the head-of-household for the period of cohabitation. The data may underestimate emigration, as entire families who left Albania before the survey date are not observed.We linked these residence trajectories to a multidimensional typology of municipalities, which was elaborated based on geo-referenced data from the Albanian Population and Housing Census 2001  between each pair of the urban hierarchy’s levels and the outside world. We considered all movements of the 1990–2007 synthetic cohort aged 15–64, constituted by the 16,057 current and former household members; place of residence was allowed to vary over time.The first internal move across the urban hierarchy and the first international departure since 1990 were then analyzed using discrete-time survival models to account for the time-varying nature of the covariates Allison . In accoIn order to measure household-level determinants  consistently over time, individuals were characterized by the status of their parental household, for which there is information covering the whole period. We therefore restricted the model’s sample to household heads’ children  and considered only the synthetic cohort aged 15–39, in order to avoid sampling-related underrepresentation of older children in the early 1990s . This sample selection did not affect the robustness of the  results: the conclusions from models including older children and adults interviewed in neo-local households were qualitatively the same (not shown).Individuals were observed annually starting in 1990 or the year they reached age 15. Exposure ends with the occurrence of the event modeled (first out- and first emigration), truncation at age 40 or in 2007. The sample for the international migration model comprised 4293 men and 3559 women , with place of residence within Albania allowed to vary over time . The average of 97 men for 100 women is significantly below the biological norm , indicating high emigration, which in the 1990s predominantly involved men. Relative municipality-specific stocks of out-migrants among these redistributed populations were estimated as well. As the LSMS 2008 did not observe people’s family building process, which is expected to influence women’s mobility in particular, additional descriptive statistics were computed from other sources.Following Plane et al. , Fig. 1 All net flows are to the benefit of the upper levels in the urban hierarchy. The majority of the underlying population exchanges are unidirectional, especially the internal flows. This confirms a rural exodus. The geography of departure highlights a role for population pressure and economic deprivation as push factors in lower levels of the urban hierarchy  located on the borders with the European Union, move into the nearby centers and, particularly, abroad. The secondary city centers’ net flow to foreign countries is also larger than Tirana. The population in the suburbs of the capital essentially moves into the city-center and abroad. Tirana migrants almost exclusively leave the country.These patterns of population redistribution explain the divergent demographic trends across the urban hierarchy and clarify the processes that underlie the country’s fast urbanization. While internal and international migration depletes the rural population, the only urban agglomeration that experiences a net gain from population mobility is Tirana, where net in-migration is larger than net emigration. Regional and, particularly, secondary cities are affected by demographic losses due to large-scale emigration, and by being bypassed by movers from lower order settlements. Moreover, Tirana appears less attractive than foreign locations, as almost two-thirds of the total rural exodus (from the plain and the mountains) is directed abroad. Cities are also important sources of emigration, accounting for almost half of the total net international flow.Although emigration clearly out-weighs immigration at all levels of the urban hierarchy, international exchanges were less unidirectional when compared to internal mobility. Many emigrants moved back and forth on several occasions before resettling abroad . Women’s likelihood of leaving manifests an unexpected center-periphery gradient, with higher levels in rural areas, particularly in the mountains. Surprisingly, out-migration was high from the beginning of the 1990s and declined after 2001 for both sexes (M2). There is also no spatial diffusion of migration over time, as period-interacted effects of the urban hierarchy are not statistically significant (not shown).Male out-migrants are positively selected according to educational attainment, whereas no significant differences are observed among women. This is in line with the predominantly economic motivations stated by internal male migrants in the Demographic and Health Survey 2008/2009; by contrast, a majority of women mention family reasons . The period-interacted effects are therefore not shown for women. Male out-migrants were wealthier than non-migrants in the early 1990s and in the 2000s, whereas during the financial crisis in the late 1990s, the likelihood of migration was the highest among the poorest strata.Domestic family migration capital increased the male and female likelihood of out-migration (M2). Differences by period were only observed for men : the effect was inversed in the intermediate crisis period. Thus, a family step-wise migration pattern is confirmed, although the financial crisis may have motivated men with relatives living in cities to stay in the countryside, in an attempt to secure a multi-site livelihood. Moreover, a higher rate of domestic migration from the community also boosts individual out-migration among both sexes, with a significantly stronger effect among men.Likelihood of out-migration was increased among men having made a higher number of international trips previously, but this is true only for the 1990s. This decreasing incidence of J-shaped residence trajectories over time may be related to a negative selection of returnees, in the context of the opportunities to regularize residence status abroad. The effect of individual emigration experiences could not be tested among women because of the low numbers of returnees.The control in the model of these spatio-temporal variations in networks totally accounts for the higher likelihood of out-migration observed for women in mountainous areas, and strongly reduces it for men (compare M2/M3 with M1). Thus, chain migrations lifted the barriers to mobility constituted by remoteness, as revealed in migrants’ narratives Caro .Unlike in the case of out-migration, the annual rate of first post-1989 emigration is significantly higher for household heads’ sons when compared to daughters . It is lowest in Tirana and regional cities. Women’s urban gradient is similar, with the exceptions of the significantly lower likelihoods in mountainous and suburban areas. Patriarchal culture has great authority in both of these areas, as out-migrants leaving the mountains have mainly moved to suburban destinations INSTAT , b.The likelihood of emigration increased sharply in the 1990s and did not significantly change in the 2000s among women (M3). Although the likelihood among men has declined recently at the national level, the trend differs across the urban hierarchy. Figure In 1990–1995, the highest probabilities of male emigration are found in suburbs, Tirana city, and secondary cities. Regional cities and the mountains rank the lowest. Yet this center-periphery gradient is not statistically significant, which may be related to the smaller sample when compared to later periods. Early emigration is also likely to be underestimated in central places, where the subsequent (unobserved) relocation of entire households abroad was more affordable. Emigration from Tirana stabilized during the financial crisis and declined to the lowest levels observed throughout the country in 2002–07, confirming the capital’s increasing economic attractiveness over time. By contrast, the probabilities of leaving other cities increased strongly during the crisis and then declined in regional but not significantly in secondary city centers, where since 1996 the level of urban emigration has remained the highest of all. Suburban areas and the rural plain experienced the sharpest increase in emigration in 1996–2001, which was followed by a plateauing at Albania’s highest levels thereafter. The probabilities of leaving the mountains, by contrast, increased more slowly but continuously through 2002–2007 to similarly high levels. Thus male emigration diffused down the urban hierarchy, with persistently high levels in secondary cities, suburbs, and the countryside.Conversely, the lower probabilities of female emigration (not shown) rose to a similar extent during the financial crisis throughout Albania, and stabilized or continued to increase in the 2000s. Emigration also remained significantly lower in the mountains when compared with the rural plain and secondary cities.Male and female international migrants are selected among the median educational and wealth strata of society M2). While the upper strata may have more domestic employment opportunities, the poorest probably cannot afford to emigrate—as has also been found in Mexico VanWey . Yet poo. While tAmong women, by contrast, the increased socioeconomic selection of emigrants when compared to out-migrants . Thus the high endowment of international networks explains much of the urban emigration. Specialization in out-migration in the mountainous areas, by contrast, accounts for their lower participation in international movements.There is increasing recognition that both internal and international movements should be considered as part of better monitoring of trends in developing countries’ population mobility UNDP . In ordeThe results highlight the usefulness of the transitional perspective for understanding the onset and the geographic patterns of migration. Internal mobility clearly was a rural exodus. The onset of emigration in the main urban agglomerations and its diffusion down the urban hierarchy as the process intensified suggest a role for international connections. The selection of migrants among the upper social strata reflected the importance of financial capacities. However, the early trends in Albanian out-migration, its persistent focus toward the capital, and the recent evolution in the internal and international flows challenge the transition hypothesis. The onset of rural exodus throughout the country in 1990 can be explained by the end of totalitarian control of the population. Yet this cannot account for the large scale of rural-to-urban migration despite the crises, nor for its subsequent decline alongside unabated emigration in a favorable economic context in the 2000s. This diffusion of mobility was mediated by three factors revealed by our results, which are backed up by qualitative studies.First, rural exodus was often a means for international migration, and vice versa. The locational advantages and the early development of international migrant networks in cities attracted men from rural areas to engage in step-wise movements toward foreign countries. Permanent resettlement of families in urban areas also rested on J-shaped residence trajectories which aimed to accumulate savings abroad Caro . Thus, uSecond, we found clear gendered patterns of mobility, which are in line with migrants’ narratives about the role of patriarchal culture in structuring the settlement process , people from peripheral areas chose the capital and, increasingly, foreign destinations as the focus of rural exodus. Migrants either bypassed secondary cities on the route abroad, or transited through them and thereby inflated the important share of urban emigration. Future research may investigate the reasons for these persistent step-wise movements, despite the diffusion of international networks throughout the country. Although our data do not cover the period since the 2008 financial crisis, we expect an intensification of the recent patterns observed, not least because of the renewed rise in youth unemployment. The increasing number of mainly male returnees may add to the pool of potential emigrants, as recent flows shift toward new destinations which are less affected by the crisis INSTAT , b.To conclude, the hypothesis of a mobility transition fails to predict the trends in rural-to-urban and international migration in Albania because of its theoretical and empirical basis. The short-term effect of discontinuous trends in development on migrant destination choice cannot be accounted for within the modernization paradigm that underlies the transitional perspective. The crisis-driven substitution of international for internal migration has long-term implications for the course of the mobility transition, through social processes that perpetuate international flows. Subsequent economic growth may therefore not redirect migrants toward domestic cities, especially when the destination and sending countries are spatially close to each other Skeldon . ProlongThis has implications for policies dealing with population distribution and development. As a majority of the Albanian rural exodus was diverted to foreign countries, the recent catch up in urbanization has been driven to a larger extent by rural depopulation, rather than by urban in-migration. Urban primacy was exacerbated by emigration from secondary cities and by rural migrants who bypassed them while heading abroad. Although this constituted a security valve during periods of economic crisis, it is now relocating abroad the potential work force of a rapidly aging population. This has disrupted social life, depleted professional services, and hampered development initiatives as well as cultural conservation in secondary cities. To curb international departures and exploit demographic potential for development within the country, the widening inequalities across the urban hierarchy should be addressed.