Postnatal depression (PND) can be experienced by 13% of women who give birth, and such women often exhibit disabling symptoms, which can have a negative effect on the mother and infant relationship, with significant consequences in terms of the child's later capacity for affect regulation. Research has shown that providing support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies. The Mums4Mums study aims to evaluate the impact of telephone peer-support for women experiencing PND.http://guidance.nice.org.uk/CG45). The Mums4Mums telephone support intervention is being delivered by trained peer-supporters over a period of four months. The primary outcome is depressive symptomatology as measured by the Edinburgh Postnatal Depression Scale. Secondary outcomes include mother-child interaction, dyadic adjustment, parenting sense of competence scale, and self-efficacy. Maternal perceptions of the telephone peer-support are being assessed using semi-structured interviews following the completion of the intervention.The study design adopts the MRC framework for the development and evaluation of complex interventions. Health visitors in Warwickshire and Coventry Primary Care Trusts are screening potential participants at the 8-week postnatal check using either the Edinburgh Postnatal Depression Scale (EPDS > = 10) or the three Whooley questions recommended by NICE (The proposed study will develop current innovative work in peer-led support interventions and telecare by applying existing expertise to a new domain (i.e. PND), testing the feasibility of a peer-led telephone intervention for mothers living with PND, and developing the relationship between the lay and clinical communities. The intervention will potentially benefit a significant number of patients and support a future application for a larger study to undertake a full evaluation of the clinical and cost effectiveness of telephone based peer-support for PND.ISRCTN91450073. The study has received a major funding grant from National Institute for Health Research (NIHR) (UK) - Research for Patient Benefit (RfPB) programme (ref: PB-PG-0407-13232).ISRCTN:  Affective disorders following childbirth range from 'maternity blues' to postpartum psychosis, a serious condition requiring hospitalisation . Along tThe aetiology of PND suggests the importance of a multitude of contributing factors such as life stresses, difficult infant behaviour, marital conflict, low maternal self-esteem and lack of social support ,15. ReseA review of non-biological interventions for the treatment of PND identified four evaluations of the effectiveness of peer-support interventions . The fir"the giving of assistance and encouragement by an individual considered equal" [that people who have like experiences can better relate and can consequently offer more authentic empathy and validation". Individuals who have similar lived experiences can often offer practical advice and coping strategies of which health professionals may be unaware, and it is suggested that this non- professional approach is vital in helping people to re-connect with their community [the provision of emotional, appraisal and informational assistance by a created social network member who possesses experiential knowledge of a specific behaviour or stressor and similar characteristics as the target population" [Peer support has been defined as d equal" . Anotherommunity . The mosulation" .the peer principle" , "the helper principle"  and "empowerment" . 'Process' refers to the way in which peer-support is delivered, such that it enables choice, encourages decision-making opportunities, and develops skills through knowledge and education, reciprocity, supportive mutual relationships, developing awareness, and a sense of community [Research to identify the 'critical ingredients' of peer-support has identified three distinct factors: structure (program structure and environment), values (belief systems) and processes  . The strommunity ,26. The ommunity .The current proposal has adapted for use in the UK a telephone-based peer-support intervention shown to be effective in Canada , to piloThe proposal builds on an exploratory study that examined a range of stakeholder's views about the need for, and potential acceptability of, a telephone-based peer-support intervention, their views about the potential impact of the intervention, and how it would fit into current practice. General Practitioners (GPs) (n = 6), health visitors (n = 7) and mothers who had recovered from PND (n = 10) were interviewed and the results indicated that stakeholders perceived a need for a telephone-based peer-support intervention for women currently experiencing PND in the UK. It was suggested that this would represent an additional resource for mothers, and that a telephone-based intervention would be acceptable due to its flexibility and use of non face-to-face contact.The Mums4Mums telephone support intervention was piloted with women currently living with PND (n = 8). The pilot study was conducted to explore key elements of the telephone based peer-support intervention such as training, acceptability, and recruitment. In-depth interviews were again conducted, and the initial findings suggested that the Mums4Mums intervention was acceptable and potentially beneficial in supporting women with PND.The current study aims to test the feasibility of conducting a large-scale randomised controlled trial of a telephone based peer-support intervention to reduce depressive symptomology in women with PND.The objectives of the feasibility study are to:i) ascertain the acceptability of a randomised control trial for women with PND;ii) explore effective methods of recruitment;iii) explore the participants' and health professionals' views about the intervention;iv) ascertain the acceptability of the outcome measures;v) identify a cost-effectiveness measure;vi) provide an estimate of the size of change that might be expected with such an intervention to inform the power calculation for the larger RCT;vii) build a working alliance with health care professionals for the larger clinical trial;viii) make any necessary adaptations to the intervention and develop a full proposal for a main RCT to be submitted to the MRC in 2012.The study design adopts the MRC framework for the development and evaluation of complex interventions . EthicalHealth visitors in Coventry and Warwickshire PCTs identified potential participants to be trained as peer-supporters (n = 18). They were recruited by personal invitation using a specification that set out essential and desirable attributes established from stakeholder consultation, including that they had a) recently experienced PND (i.e. within the last five years) b) fully recovered from depression; c) an empathic and non-judgmental disposition; and d) could commit the time to participate in the training and provide the telephone support. Multiple assessments of mental health and social wellbeing were made and their GPs were required to confirm the suitability of individuals identified for the proposed peer-support role. Eligible peer-supporters were invited to attend a training programme lasting approximately eight hours, to develop their understanding of the role of the peer-supporter and their confidence to deliver the intervention. The training was based on Dennis's training manual , but waswomen >16 years of age at the time of giving birth and who are experiencing depressive symptomatology  at or after the 8-week check, and who are potentially receptive to receiving telephone support.women with a score of 23 or above on the EPDS; women who pose a suicide risk or a risk to their children; women receiving specialist psychiatric care or experiencing any mental illnesses (other than PND) or learning difficulties, or who are not able to speak English, or who are not accessible via the telephone. Participation in the study is only undertaken with the consent of the participant, their health visitor, and their GP.All health visitors within Coventry and Warwickshire Care Trusts (PCTs) are recruiting to the study. Potential participants are screened for eligibility by the health visitors at the 8-week postnatal check using either the Edinburgh Postnatal Depression Scale (EPDS > = 10) or the three Whooley questions recommended by NICE . EligiblIn addition to the recruitment method outlined above, the study information leaflet is available within GP surgeries and Children's Centres within Coventry and Warwickshire allowing participants to self-refer into the study by contacting the research team directly. Participants can also access information about the study using the link at 'Netmums' or via the Warwick University webpage. Eligible patients are also being referred to the study from the 'Improved Access to Psychological Therapies (IAPT) waiting-list.Following referral to the study team, a researcher sends a full information sheet and contact with the mother is arranged two weeks later, to discuss her participation. Once a participant has agreed to take part and provided consent, their details are passed onto the Clinical Trials Unit at the University of Warwick for randomisation. The group allocation information is provided to the researcher who then informs the participant.All participants receive standard care from their GP and health visitor. Women allocated to the intervention group also receive telephone support calls over a period of 4 months from peer-supporters who have been specially trained to deliver the intervention (i.e. the same peer-supporters that delivered the pilot study intervention). Outcome measures tested in the pilot phase are being collected at baseline, 2- and 4-months.A total of 30 participants are being recruited to study. This will enable us to detect an effect size of around 0.6sd using a power of 80% and two-sided significant level of 95%. Analysis of the data will be carried out on an intention-to-treat basis.The primary outcome measure is depressive symptomology, which is being measured using the Edinburgh Postnatal Depression Scale . SecondaIn-depth, semi-structured interviews will be conducted with a random sample of all stakeholders to establish the acceptability and feasibility of the intervention for participants, peer-supporters and health visitors.A prospective economic evaluation is being conducted. The focus is on the additional costs of delivering the training programme for the services involved. The costs of training will be calculated using a record of the resources employed. Unit costs for service delivery will be taken from a national compendium (e.g. costs of training and supervision) and multiplied by the intensity of the service used by each family. A 'Service Use' Questionnaire is being used to collect data on public service utilisation by study participants. Unit costs will be obtained from national databases. Training, delivery and service utilisation costs will be combined to provide an estimate of the total health and social care cost in each arm. The expected incremental cost-effectiveness ratio for peer-support vs. usual care in the prevention of PND cases will be estimated. A within-trial probabilistic sensitivity analysis will be undertaken using non-parametric bootstrap method. The results will be presented as ICERs and cost- effectiveness acceptability curves. Scenario analyses will be used to examine the impact of differential training and resourcing models on the expected cost-effectiveness. The data collected in the trial will be used to inform pre-trial modelling as part of the design process for a future full scale RCT with economic evaluation.Descriptive methods will be used to describe participant characteristics, to compare the 'refusers' with the study participants, and to report levels of participation and drop out. Comparison of intervention and control group outcome data will be provided with regard to the outcome measures described above. The results of the statistical analyses will be used to reach some preliminary conclusions regarding the viability and acceptability of the intervention, the usefulness of the outcome measures being used, and the sample size required in a full trial.Tape-recorded semi-structured interviews will be transcribed verbatim. A thematic framework approach  will be The embedded mixed-methods design of the study will enable the quantitative and qualitative data to be analysed iteratively.A reduction in a woman's depressive symptomatology could potentially produce an improved mother-infant relationship in affected dyads, with significant consequences in terms of the capacity of the infant for affect regulation. This could also impact on the later emotional and behavioural adjustment of the child, especially in the case of disadvantaged boys. Poor emotional and behavioural adjustment in the early years is associated with a range of poor long-term outcomes including delinquency, drug abuse, and a range of mental health and relationship problems, which are very costly for NHS and other services. This form of provision could therefore have an immediate impact on health service use and in the long-term improve a range of public health outcomes about which there is currently considerable concern, and to which postnatal depression undoubtedly makes a significant contribution.The proposed study will develop current innovative work in peer-led support interventions and telecare by applying existing expertise to a new domain (i.e. PND), testing the feasibility of a peer-led telephone intervention for mothers living with PND, and developing the relationship between the lay and clinical communities. The outcome of the proposed study will potentially benefit a significant number of patients and support a future application for a larger study to undertake a full evaluation of the clinical and cost effectiveness of the intervention.PND: Postnatal depression; MRC Framework: Medical Research Council; EPDS: Edinburgh Postnatal Depression Score; NICE: National Institute for Health and Clinical Excellence; DSM IV: Diagnostic and Statistical Manual of Mental Disorders Fourth Edition; APA: American Psychiatric Association; NHS: National Health Service; DoH: Department of Health; PCT: Primary Care Trust; IAPT: Improved Access to Psychological Services; ICERs: Incremental Cost Effectiveness Ratios; RCT: Randomised Control Trial;The authors declare that they have no competing interests.JB and IC undertook the development and setting up of the study and SS took on the role of the researcher in the second stage (pilot study). KMc trained and supervises all the peer-supporters. All authors have read and approved the final version of this manuscript.


High-throughput screens have revealed large-scale protein interaction networks defining most cellular functions. How the proteins were added to the protein interaction network during its growth is a basic and important issue. Network motifs represent the simplest building blocks of cellular machines and are of biological significance.Here we study the evolution of protein interaction networks from the perspective of network motifs. We find that in current protein interaction networks, proteins of the same age class tend to form motifs and such co-origins of motif constituents are affected by their topologies and biological functions. Further, we find that the proteins within motifs whose constituents are of the same age class tend to be densely interconnected, co-evolve and share the same biological functions, and these motifs tend to be within protein complexes.Our findings provide novel evidence for the hypothesis of the additions of clustered interacting nodes and point out network motifs, especially the motifs with the dense topology and specific function may play important roles during this process. Our results suggest functional constraints may be the underlying driving force for such additions of clustered interacting nodes. In the post-genomic era, the study of networks has obtained unprecedented attention and network-based analyses have played fundamental roles in biological research. Indeed, most genes and proteins function through a complex network between them rather than on their own . Recentlet al. for the first time presented the hypothesis that the evolution of PINs has undergone the additions of clustered nodes [In the study of the evolution of PINs, one of the most basic and important problems is to explore how the PIN originated and grew. Many researchers have tried to answer the question by multiple approaches. By the theoretical modeling, several evolutionary models of PINs have been established -10. By ted nodes .Previous studies on the evolution of PINs focus either on the individual protein level ,17-27, iConsidering the advantages of network motifs, in this paper, we explore the evolution of PINs from the perspective of network motifs, and try to provide further evidence for the hypothesis that the evolution of PINs has undergone the additions of clustered interacting proteins. First, we classify proteins based on their original time, and analyze the tendency between proteins of the same/different age classes to form motifs in the PIN. Further we investigate whether co-origins of motif constituents are affected by motif topologies and biological functions. Then we focus on those age-homogeneous motifs whose constituents are of the same age class, and analyze the evolution and functions of their members. Finally we discuss how our findings support the hypothesis of the clustered additions and the underlying driving force of the clustered additions.To understand the evolutionary history of PINs from the network motif perspective, we first analyze the tendency between proteins of the same/different age classes to form motifs in the PIN.We classify proteins based on their original ages. In our work, we use orthologous groups of orthoMCL  to constS. cerevisiae and other fungi . The youngest class contains proteins found only in S. cerevisiae (yeast class).As shown in Figure P -value for each kind of evolutionary motif mode with specific topology to check the statistical significance of its enrichment or depletion in the real PIN (see Methods). Based on the credible yeast PIN of DIP_YEAST_CORE [To study the interconnection tendency between protein nodes of the same/different age classes, based on network motifs, we define "evolutionary motif modes" to characterize particular interconnected patterns of proteins of the same/different age classes Figure . We compAST_CORE , we findWe obtain the similar results on other PIN datasets, such as YEAST_HC , HPRD_HUHere we group ten representative time points into five age classes for yeast based on taxonomy Figure . ActuallProteins of the same age class tend to form motifs, while those of different age classes tend to avoid forming motifs. This finding means that in the PIN, age homogeneity of motif constituents is higher than random expectation. In this part we further analyze whether age homogeneity of motif constituents is different for different classes of motifs with special topology or/and function in the real PIN. For this purpose, we introduce the "age homogeneity rate" and the "age homogeneity ratio". The "age homogeneity rate" is referred to as the fraction of motifs whose constituents are of the same age class among a class of motifs with specific topology or/and function. The "age homogeneity ratio" is defined as the ratio of the age homogeneity rate of the real network to its random expectation, which can measure the extent to which a class of motifs with specific topology or/and function affect co-origins of their constituents.P <10-4 for 3, 4, 5-motifs), while this phenomena is absent in random networks  and age homogeneity ratios: motifs belonging to functional classes of protein fate, protein synthesis, and transcription tend to have high age homogeneity ratios, while those belonging to functional classes of energy, signal transduction and metabolism low co-original constraints.To find out whether the biological functions of the yeast proteins within the motifs affect their age homogeneity, here we only take those motifs whose constituents share at least one common functional category into account, and assign such motifs to the common functional class. First, we find the conclusion that the age homogeneity of motif constituents is higher than random expectation holds for most classes of motifs with specific function Table . FurtherFinally, we also check the joint impact of motif topologies and functions on co-origins of motif constituents  period of time. However such tendencies of clustered additions are affected by topologies and biological functions. Motifs with specific function and dense topology were more likely to be clusteredly added to the PIN Table  and 3.In our work, the recent paralogs in an orthologous group which are likely to retain the similar functions will be traced to the same origin and thus be assigned the same original age, which will result in some age-homogeneous motifs in which some members are ("recent") paralogous to other members. The members of such age-homogeneous motifs may not be thought to be clusteredly added to the network during the (short) period of time when these members originated. Because at the original time of these members, there is only one ancestor of these paralogous members and such age-homogeneous motifs' ultimate formation depends on the later (recent) duplication event. However actually we find the fractions of such motifs with recent paralog pairs among all the age-homogeneous motifs are small, which are only 2.4% for 3-motifs and 2.7% for 4-motifs.P- value of hypergeometric cumulative distribution [Another evidence for the additions of clustered interacting nodes comes from the analyses of yeast protein complexes . We findribution  is less et al. used natural selection to explain the additions of clustered nodes [Qin ed nodes . They thIn the PIN, proteins of the same age class tend to form motifs while those of different age classes tend to avoid forming motifs. The constituents within the motifs with specific function or dense topology tend to be under high co-original constraints. Further the proteins participating in the motifs with members of the same age class tend to be densely interconnected, share the same functions and evolve at similar rates, and these motifs tend to be within protein complexes. These results suggest that the age-homogeneous motifs historically tend to be clusteredly added to the PIN, especially those with dense topology and specific function, providing evidence for the hypothesis of the additions of clustered interacting nodes from the network motif perspective for the first time. Our results also suggest functional constraints may be the underlying driving force for such clustered additions.For yeast, we use two protein-protein interaction datasets. One is from Database of Interacting Proteins (DIP) which catalogs experimentally determined protein interactions from a variety of sources (Version 20080114) . After rIn addition, for testing the robustness of the result of the interconnection tendency between the proteins of the same/different age classes on PINs of other organisms, we also analyze the other two human PINs respectively denoted as HPRD_HUMAN_ALL  and HPRD_HUMAN_HIGH , which are downloaded from Human Protein Reference Database (HPRD) (Release 7) .et al. which contain 199 complexes, 966 proteins [in vivo . For example, in vivo Cdc28p can only interact with a single cyclin at a time, however in MIPS Cdc28p and all its 9 interacting cyclins are organized as a single complex. To correct this, de Lichtenberg et al. annotated 9 complexes instead.We use re-annotated, manually curated MIPS yeast protein complexes provided by de Lichtenberg proteins . Compareproteins , the re-We use the GeneTrace algorithm with default parameters to assess each protein's original age . GeneTra"Network motifs" are recurring, topologically distinct interconnected patterns of nodes in complex networks ,40. BaseP -value to evaluate the statistical significance of enrichment/depletion of each kind of evolutionary motif mode in the real network [P -value is calculated as the fraction of random networks in which its number is not smaller than (upper tail) or not larger than (lower tail) that in real network. The evolutionary motif modes are significantly enriched/depleted in the real network when the upper-tailed/lower-tailed P -value is less than 0.05.If the ages of proteins don't impact the interconnected patterns of proteins of the same/different age classes in the PIN, a random age assignment should give similar interconnected patterns as seen in the real PIN. To analyze the interconnection tendency of proteins of the same/different age classes, we first generate 1000 random networks by randomizing the corresponding relationships between proteins and their ages in real network. Then we use empirical  network ,69. For The molecular functions of yeast proteins are based on Functional Catalogue (FunCat) annotations  from MIPdN ) and the number of synonymous substitutions per synonymous site (dS ). To compute evolutionary rates of S. cerevisiae proteins, we adopt S. paradoxus as reference species which is the most closely related species to S. cerevisiae among all the completely sequenced organisms. Amino acid sequences and corresponding coding sequences (CDS) of proteins of the two species are from Saccharomyces Genome Database (SGD)  [S. cerevisiae-S. paradoxus orthologs are obtained using Inparanoid program [dN /dS s are calculated using PAML program [The evolutionary rate of a protein is defined as the ratio between the number of non-synonymous substitutions per non-synonymous site (ec-2004) . S. cere program . Pairs o program  and dN / program .CDS: coding sequences; CYGD: Comprehensive Yeast Genome Database; DIP: Database of Interacting Proteins; FunCat, Functional Catalogue; HPRD: Human Protein Reference Database; MIPS: Munich Information Center for Protein Sequences; PIN: protein interaction network; SGD: Saccharomyces Genome DatabaseZL designed the study, carried out the study and wrote the manuscript. DL provided guidance and helped write and revise the manuscript. QL, HS, LH and HG participated in the analyses. FH and YZ provided guidance and revised the manuscript. All authors read and approved the manuscript.Supplementary results, methods, tables and figures. supplementary results, methods, tables  and figures Click here for file


Endoscopic ultrasound (EUS) is mainly used for the evaluation and sampling of mediastinal and abdominal lymph nodes, luminal and submucosal lesions of the upper and lower gastrointestinal tract, as well as in the diagnostic approach for pancreatic, biliary and liver disease. However, several non-digestive pathologies may be encountered as well, expanding the diagnostic potential of EUS. In this article, we present nine examples of extra-digestive abnormalities detected by means of EUS, including pathologies of the thyroid gland, mediastinal and abdominal vessels, lungs, kidney and the urinary bladder. The purpose of this article is to review the capabilities of EUS beyond routine evaluation of gastrointestinal organs. Endoscopic ultrasound (EUS) is a well-established imaging modality and plays an important role in the management of gastrointestinal and pancreato-biliary diseases. Since the development of EUS in the 1980s, dramatic changes have occurred and EUS has advanced its role, from an expensive toy for a few experts to an indispensable tool of a modern endoscopy unit.A diagnostic EUS exam is supposed to answer specific questions, such as the presence or absence of biliary stones, the characterization of pancreatic lesions and the sampling of mediastinal or abdominal lymph nodes. However, a complete upper EUS exam should not be focused only on the target organ, but also include a systematic approach and inspection of the mediastinum, celiac axis, pancreas, biliary tract and liver. A meticulous examination may sometimes reveal abnormalities of the adjacent structures. For example, exploration of the mediastinum gives the opportunity to visualize the pulmonary artery and potentially, detect a pulmonary thrombosis. Positioning of the endoscope in the second portion of the duodenum permits the inspection of the right kidney and its vessels and, consequently, may lead to the detection of renal tumour. To further elaborate this concept and show the potential diagnostic implications of EUS, we present in this case series some examples of extra-digestive pathologies encountered during an EUS examination.We conducted a retrospective review of our prospectively maintained image and video database of all EUS procedures performed between January 2011 and July 2013. The selection was restricted to cases with a clinically relevant endoscopic ultrasound observation concerning a non-digestive structure, excluding lesions of the adrenal glands. Among cases with similar findings, the case with the best or most representative images was chosen. A previously published case report from our institution is not included here [All EUS exams were performed under general anaesthesia by four experienced endosonographers and one trainee, using a curvilinear array echoendoscope  and an Aloka Prosound a7 ultrasound processor . Images and videos were stored either to the internal memory of the ultrasound processor or to Telemis PACS storage service  via a Nebula image recorder . This study conforms with the principles outlined in the Declaration of Helsinki and was approved by the ethics review board of our hospital .A 75-year-old woman underwent upper EUS for the investigation of recurrent epigastric pain. EUS revealed multiple biliary stones. In addition, examination of the thyroid gland disclosed numerous thyroid nodules as well as a 17 mm multilocular cyst . PercutaA 57-year-old patient was admitted for fine needle aspiration (FNA) of a pancreatic mass. His previous medical history included a bronchial carcinoma of the right lung. EUS examination through the upper oesophagus disclosed a pleural effusion surrounding an area of tissue-like pattern corresponding to the upper superior lobe of the right lung . The diaA 60-year-old patient with a history of chronic obstructive pulmonary disease was referred for FNA of a para-oesophageal pulmonary nodule of the superior left lobe . EUS dispatient underwent an upper superior lobectomy. Polymerase chain reaction of the resection specimen revealed a Mycobacterium Xenopi infection and the patient was put on a triple antibiotic therapy.A 75-year-old man with previous history of right-sided bronchial carcinoma was referred for the management of an acute non-alcoholic pancreatitis. An EUS exam was performed in order to rule out a biliary origin. Examination of the mediastinum disclosed an intraluminal hypoechoic lesion of the right pulmonary artery, suggesting a thrombosis . CT imagAn 85-year-old patient with mediastinal and abdominal adenopathy was referred for EUS-FNA. Surprisingly, the examination of the mediastinum revealed a mobile thrombus of the pulmonary artery . A subseA 82-year-old woman presented with a non-viral cholestatic hepatitis. EUS exploration of the biliary tract and pancreas was normal. However, inspection of the liver showed dilated hepatic veins and inferior vena cava, with a biphasic waveform as well the presence of ascites. The combination of these findings indicated a right-sided heart failure and the patient was transferred to the cardiology department . This waA 62-year-old patient underwent EUS evaluation of a cystic lesion of the pancreas. Positioning of the endoscope to the second portion of the duodenum permitted the examination of the right kidney. This showed a 6 cm heterogeneous hypoechoic mass . The tumA 81-year-old patient was referred for EUS evaluation of wall thickening of the rectum. Inspection of the urinary bladder disclosed an 11 mm wall thickening . An FNA A 62-year-old patient was admitted for EUS FNA of a 3 cm mediastinal lymph node. A complete upper EUS examination was performed. The endoscope was advanced to the distal duodenum for evaluation of the head of the pancreas. Inspection of the adjacent structures, revealed an infrarenal abdominal aortic aneurysm with a circumferential thrombus . CT scanRalph Waldo Emerson once said, “People only see what they are prepared to see …” This concept is crucial in the field of endoscopy, since endoscopic diagnosis of a particular pathology depends on the recognition of a specific image. A standard upper EUS exam is usually limited to the detection of mediastinal lymph nodes, to the inspection of the celiac axis, of the biliary tree and the liver, as well as of the pancreas. In addition, EUS is time-consuming and, with the increasing burden of examinations, endoscopists may become prone to limit their exam to the target area under investigation and avoid performing a complete examination. However, this attitude may result in failure to detect clinically relevant pathologies.With this case series, we would like to emphasize two main points. First, that an EUS exam should not be limited on a single area but should also include a systematic and detailed examination. Secondly, we would like to draw the attention to the potential role of EUS in the diagnosis of ‘non-digestive’ pathologies. It may sound strange for an endoscopist to diagnose a pulmonary embolism or pneumonia; however, adding this information to an EUS exam report is clinically relevant, contributes to the global management of a clinical case and, finally, indicates a systematic and meticulous exam.A good starting point for the diagnosis of extra-digestive pathologies is the identification of previously known lesions detected by means of other imaging modalities. In addition we suggest the following EUS stations: (i) positioning of the endoscope at the upper oesophagus gives the opportunity to inspect the thyroid gland which has the ultrasound aspect of an ‘ectopic pancreas’; (ii) identification of the pulmonary artery is easy and it could become part of a routine exam of the mediastinal lymph nodes; (iii) positioning of the endoscope close to the gastro-oesophageal junction and clockwise/counterclockwise rotation allows detection of small quantities of pleural fluid as well as of atelectasis; (iv) positioning at the gastric cardia or fundus and clockwise rotation permits the evaluation of the hepatic veins; (v) exploration of the tail of the pancreas gives the opportunity to evaluate the left kidney and adrenal gland, while positioning of the endoscope in the second portion of the duodenum allows inspection of the right kidney, adrenal gland and abdominal aorta. Progressively, endoscopists become familiar with non-digestive abnormalities, however, collaboration with an expert endosonographer or radiologist maybe necessary in order to avoid diagnostic pitfalls.These concepts are further supported by several prior studies, in which, EUS was successfully used in the evaluation and diagnostic management of renal lesions , renal vIn conclusion, with this article we would encourage endoscopic ultrasonographers to extend the horizons of EUS beyond the limits of current practice. Diagnosis of non-digestive pathologies during endoscopic ultrasound requires a methodical and careful approach to EUS examination but can yield important benefits for the patient.


Attempts to maintain or increase vaccination coverage almost all focus on supply side interventions: improving availability and delivery of vaccines. The effectiveness and cost-effectiveness of efforts to increase demand is uncertain.We performed a systematic review of studies that provided quantitative estimates of the impact of demand side interventions on uptake of routine childhood vaccination. We retrieved studies published up to Sept 2008.The initial search retrieved 468 potentially eligible studies, including four systematic reviews and eight original studies of the impact of interventions to increase demand for vaccination. We identified only two randomised controlled trials. Interventions with an impact on vaccination uptake included knowledge translation (KT)  and non-KT initiatives . Most claimed to increase vaccine coverage by 20 to 30%. Estimates of the cost per vaccinated child varied considerably with several in the range of $10-20 per vaccinated child.Most studies reviewed here represented a low level of evidence. Mass media campaigns may be effective, but the impact depends on access to media and may be costly if run at a local level. The persistence of positive effects has not been investigated. The economics of demand side interventions have not been adequately assessed, but available data suggest that some may be very cost-effective. Routine childhood vaccination is an important prevention strategy with largely proven impact. The WHO claimed that, in 2001, childhood vaccination prevented 61% of deaths from measles, 69% of tetanus deaths, 78% of pertussis deaths, 94% of diphtheria deaths and 98% of polio deaths [demand for vaccination and the uptake from the users' perspective. A recent systematic review of 60 studies of evidence on improving routine vaccination programs in developing countries found only three studies that increased demand for vaccination [Despite this impressive potential, childhood vaccination coverage is stagnating or even deteriorating in some areas in South Asia and large parts of Africa . Responscination .In preparation for a cluster randomised trial of knowledge translation (KT) in the Balochistan province in Pakistan , we revia priori protocol. Initial literature scans identified published systematic reviews of the childhood vaccination literature. Two reviewers  scrutinized these to identify relevant studies, and these were included in the review. We then searched for primary studies published since 2004 (the most recent literature update from existing reviews) using MEDLINE, POPLINE, ECONLIT, EMBASE, CINAHL and the Cochrane Library. We did citation searches on relevant articles using SCOPUS up to the end of September 2008. Search terms varied by database (details are available from the authors) and included vaccin*, immuni*, econom*, cost*, benefit* 'developing countries' and the names of countries that are categorised as 'low income' by the World Bank. We did not limit the searches by study type. These searches yielded 71,796 citations between 2004 and 2008.We developed an Combinations of search terms identified a smaller number of potentially relevant titles from each database: MEDLINE (335), EMBASE 106), and CINAHL (27). There was considerable overlap between the retrieval lists for these databases. Two readers  examined all titles and identified 12 articles describing community-based interventions that might increase the demand for childhood vaccination  read the full text copies of reports of these studies.Where interventions described a clear communication strategy we attempted to categorise it as 'knowledge transfer' - a unidirectional process where research is conceptualized and conducted, and the results are then made available to the end-users - or 'knowledge translation', a process that involves active and conscious participation of knowledge translators and knowledge recipients - in this case the parents of children. We confined our literature retrieval to studies that provided quantitative estimates of the impact of 'demand side' interventions. If they used mixed methods, including qualitative techniques, they were included; but we did not extract or evaluate qualitative data. We sought studies with the highest levels of methodological rigour, following an evidence based approach . In the Our search identified seven potentially relevant systematic reviews ,5,11-15 Table Most studies showed improvement and the authors found no difference in effectiveness between 'supply side', 'demand side' and 'mixed' strategies. The economic analyses found estimates of costs per fully vaccinated child ranging from $0.9 with peer training in Indonesia to $245 for children under one year of age in an outreach program in Mauritania. Most estimates fell between $10 and $20 per fully vaccinated child. Channelling (door to door canvassing) and community health workers were both cost effective and both involved some degree of community interaction. The studies provided little information on duration of the improvement of community uptake of vaccinations. The review also highlighted the generally poor methods employed in the evaluation of these key public health interventions.The review by Batt and colleagues  Table 11 came frHaines and colleagues  highlighThe recent review by Ryman  concentra priori protocols nor had two reviewers check the selection and data extraction. No reviewer provided the list of included and excluded studies.The quality of the four systematic reviews included in our review was mixed. All four performed comprehensive literature searches. Three reviews included grey literature. The authors provided reasons and justification for low scores, on several items of AMSTAR ,9. None Only one review provided the characteristics of the included studies. Although the majority of reviewers assessed the scientific quality of the included primary studies, none of the reviewers included these measures of quality in their conclusions and recommendations. The majority of authors did not conduct a meta-analysis, largely because of the limitations of the primary studies in terms of consistent application of methodological and reporting standards. None of the reviewers addressed the potential competing interests of authors of the primary studies Table .st 2004 and Dec 31st2007.In light of the broadly consistent findings of these published reviews, we extracted individual studies from them that reported the use of any information communication strategy to increase community demand for routine childhood vaccination. These reviews were extremely comprehensive in their coverage and covered the period up to the end of 2004. We augmented these with new studies published between January 1From the literature search and scrutiny of the published systematic reviews we identified eight studies ,16-22 thTwo studies considered the effect of mass media on uptake of vaccination. Zimicki and colleagues  describeHutchinson and others  describeAbout one half of the respondents recalled seeing 'Smiling Sun' messages and, in the unadjusted analyses, this exposure was strongly associated with use of health services. Mothers recalling the campaign were more likely than those who did not to report DPT3 vaccination (64% versus 48%) and measles vaccination (79% versus 61%). The authors recognized that better off mothers were more in touch with the media and more likely to access health services. Their multivariate analysis attempted to test "pessimistic assumptions" under which they estimated the campaign increased vaccine coverage by 20% among those who could recall seeing promotional material. Although compatible with a positive impact, the evaluation design precludes firm conclusions about causality. They included detailed costing of the media campaign: the incremental cost effectiveness ratios were $0.30-0.36 per additional child vaccinated, compared with $32-$37 per additional child vaccinated for local publicity campaigns. The latter may be due to the high incremental costs of local promotional activities, including billboards and rallies.Cutts and others  report onot increase the vaccination uptake although they claimed the project met other goals: better access to and utilization of preventive health services. They do not provide costing data.Tulchinsky and his colleagues  tested 'Andersson and colleagues  carried Collateral-free credit to poor women may improve their autonomy and capacity to care for their families. The interactions between thus empowered women could lead, in the logic of these initiatives, to social changes like increased uptake of vaccination. Amin and Li  looked aA second incentive study considered provision of food rather than credit. Loevinsohn and Loevinsohn  describeBrugha and Kevany  used a cOur searches, including published systematic reviews and original studies, retrieved only eight published reports of controlled evaluations of the benefits and costs of interventions designed to increase demand for routine childhood vaccination. All of these studies showed some increases in uptake of vaccination, indicating that improvements of 10 to 20% are readily achievable.The main approaches exemplified by these studies were knowledge transfer and provision of incentives and collateral-free credit. Having reviewed this body of data our main conclusion is that, despite their potential, and some encouraging results, interventions to increase demand for routine childhood vaccination have not been adequately investigated.From a quantitative evidence based perspective, the level of evidence represented in the studies reviewed here is generally low, with a reliance on 'before and after' designs, employing repeated cross sectional surveys or retrieval of routinely collected data. It should be noted that the survey methods employed in some of these studies were of high quality and some authors made adjustments for variables that might act as confounders. However, the lack of concurrent control groups leaves most studies open to the possibility of 'order effects' (such as contemporaneous improvements in service provision) as an explanation for the findings. Attributing cause and effect is therefore difficult. This is disappointing, as the effect sizes seen in some studies were quite substantial. Furthermore, the variety of interventions and the lack of rigorous evaluations precluded any attempt to compare the effectiveness of the different approaches.Thus, despite the crucial importance of the topic, interventions that increase demand for vaccination have received little research attention, in comparison with service enhancement approaches to increase vaccination coverage. Strategies that depend on use of the mass media do not lend themselves to evaluation by controlled trials as one cannot easily randomise exposure. They will not be effective if families are unable to access mass media - for instance in rural and remote areas. There is also the real issue of how long any effects of such campaigns last. To date, follow up times have been brief. We can speculate that the effects of mass media campaigns (on their own) will not last long compared with interventions that use education and reinforcement to engender basic changes in community attitudes to routine childhood vaccination.Of course, the major challenge is to achieve such a sustained change. In our view this probably requires a shift from 'knowledge transfer' to 'knowledge translation', as defined in the Methods section. In this review we found no true example of an intervention that met the definition of 'knowledge translation'. But a realistic middle ground could be the type of village level discussions that we trialled in Pakistan . This waAs illustrated in the studies reviewed here, demand side interventions can involve interventions that do not rely primarily on translation of knowledge. Collateral-free loans to women lead to empowerment and can result in collective actions, which can free up resources and overcome financial and logistical barriers to childhood vaccination. In this review the study by Loevinsohn  found inThe data on cost effectiveness were sparse, but indicated that demand side interventions are sometimes capable of providing incremental cost effectiveness ratios of less than $1 per additional fully vaccinated child. However, these low figures are very context specific as shown by the mass media campaign in Bangladesh ,19 whereThere are a number of important limitations in our work. One weakness of our review is that we did not update the extensive grey literature review undertaken by Batt and others (2004) . This waThe work reported here was very much an update of previous reviews - and therefore depends on the foundational work done by others. Another limitation of our work was the impossibility of doing a meta-analysis, so we are left to present disaggregated results in the form of a narrative.The overriding limitation of the review is the sparseness of the literature on increasing the demand for vaccination; this is of concern given the importance of the topic. To provide sustained effects demand side interventions will have to be integrated with other system-wide approaches and will not work unless procurement and supply are also addressed adequately.In the case of childhood vaccination, demand side interventions have been poorly investigated in developing countries. Even accepting the difficulties of carrying out research in this field, the available studies contribute only low levels of quantitative evidence. Recognising these limitations, the published studies reviewed here reported positive results, some claiming quite large increases in demand for childhood vaccination. However, the limited methodologies precluded any attempt to compare and contrast the effectiveness of different approaches. Mass media campaigns may be effective, but this will depend on access to media and may be costly if run at a local level. The studies reviewed here do not provide information on the duration of positive effects of mass media campaigns. The cost-effectiveness of demand side interventions has not been adequately assessed, but based on limited data some may prove to be very cost-effective.CHW: Community health worker; FVC: Full vaccine coverage; KT: Knowledge Translation.The authors would like to declare two potential 'perceived risks of bias'. 1) Two of the authors  were involved in the Pakistan study, which is reviewed here. This review was conducted to assist with the development of the evidenced-based instruments used in the Pakistan trial. 2) Two of the authors  were involved in the development of AMSTAR and the third author (DH) assisted with the validation process.Funding for this work came from the International Development Research Centre (IDRC) under grant 102172-007. The views expressed are those of the authors and do not necessarily reflect the views of IDRC.BS, DH and NA did the original conceptual development. BS and DH performed the literature search, data and quality assessments. BS, DH, and NA prepared and assisted with the manuscript.A measurement tool to assess systematic reviews (AMSTAR).Click here for file


The health and function of the visual system rely on a collaborative interaction between diverse classes of molecular regulators. One of these classes consists of transcription factors, which are known to bind to DNA and control the transcription activities of their target genes. For a long time, it was thought that the transcription factors were the only regulators of gene expression. More recently, however, a novel class of regulators emerged. This class consists of a large number of small noncoding endogenous RNAs, namely, miRNAs. The miRNAs compose an essential component of posttranscriptional gene regulation, since they ultimately control the fate of gene transcripts. The retina, as a part of the central nervous system, is a well-established model for unraveling the molecular mechanisms underlying neuronal and glial functions. Numerous recent efforts have been made towards identification of miRNAs and their inferred roles in the visual pathway. In this review, we summarize the current state of our knowledge regarding the expression and function of miRNA in the neural retina and we discuss their potential uses as biomarkers for some retinal disorders. The neural retina is an established model for unraveling the molecular mechanisms behind neuronal crosstalk. The initiation of the visual processing arises in the retina and, in accordance with its complex physiology, a broad number of coding genes have been detected and associated with different developmental stages, cellular components, and disorders of the retina. Now, we are beginning to understand the contribution of the noncoding regions of the genome to vision and its disturbances. In fact, only 1.5% of the human genome encodes proteins, so that the majority of DNA is noncoding. A portion of the noncoding DNA gives rise to various noncoding RNA transcripts, and their role is just starting to be unveiled. Among the different noncoding transcripts, microRNAs  are perhaps the best characterized class and possess a deep evolutionary history . MiRNAs MiRNAs constitute an essential component of gene regulation and control well over half of all protein coding genes in humans , 7. A maThe miRNAs are critically involved in many aspects of retinal development, homeostasis, and pathobiology. In this review, we will describe recent advances in knowledge of the role of miRNAs in retinal health and diseases with a primary focus on common retinal pathologies. In addition, we will discuss the postulated roles of circulating miRNAs and their prospective values as biomarkers of retinal degenerative disorders.In recent years, transcriptome analyses have affirmed the existence of considerable abundance of miRNAs expressed in the retina –15. ThisWe now know that there are more than 250 miRNAs that are differentially expressed in developing and mature mouse retina , 14 someTransgenic mice, with the miR-183/96/182 cluster inactivated, displayed gradual synaptic connectivity defects of the photoreceptors resulting in their extreme sensitivity to light and severe retinal degeneration , 36. TheGlaucoma is a multifactorial disease and its cure constitutes a great challenge. Retinal ganglion cell (RGC) death is critical element in the pathophysiology of all forms of glaucoma leading to the irreversible loss of functional capacity of the RGCs and, finally, loss of vision . Since rTaken together, these reports indicate that miRNAs are of importance to the etiology of various retinal pathologies and thus their balanced expression may be important for fine-tuning retinal health. Changes in miRNAs expression may be affiliated with onset and progression of disease and therefore miRNAs profiling might have relevance to early detection of retinal injury and prediction of progression of chronic retinal diseases.It is a great challenge to approach the question whether every cell type in the eye has its own miRNA phenotype (miRNome), since one miRNA can target a plethora of genes that might be expressed in different retinal neurons. However, miRNAs are reported to be differentially expressed in neural retina and therefore their expression patterns could possibly be used as signatures to distinguish retinal cell types . For exaMicroglia cells are essential for the maintenance of the CNS, where they clear debris, derived, for example, from neuronal apoptosis and they can interact with and modify the structure of synapses . The preIt is particularly noteworthy that miRNA transcripts have been identified in almost all body fluids: plasma , 57, serAt present the knowledge about the origin or functions of circulating miRNAs is very limited. It has been shown that altered miRNA expression patterns in the fluids might be the cause or the result of various disease states. Several recent studies are beginning to demonstrate the possibility of making use of circulating miRNAs as biomarkers for detection of biological conditions or severity of disease progression. Recently, blood-derived miRNAs have been established as biomarkers for ischemic heart diseases , multiplHow miRNAs end up in the body fluids is not entirely clear. Studies have suggested passive leakage into the circulating blood stream  as well Despite remarkable findings in other systems, there are no studies at this time reporting on the presence of circulating miRNAs associated with retinal disorders. However, Ragusa and colleagues analyzed the vitreous humor (VH) from patients affected by various ocular diseases . Using TIt would be interesting to explore if some of the miRNAs that significantly changed their expression in response to ischemic insult can be detected in plasma in early stages after the insult. This would suggest that circulating miRNAs are suitable for noninvasive indicators and much needed biomarkers, for early detection of retinal disorders. This is essential because prompt verification might be able to advance clinical management and improve long-term outcomes in visual health.The use of miRNA-based approaches for treatment of retinal pathologies has potential due to the relative accessibility of the retina for gene delivery. Gene therapeutic techniques have already been implemented in treatment of retinal disorders in human , 81. AlsThe miRNAs have great potential in gene therapeutics, since they have the ability to target multiple genes simultaneously and, furthermore, these genes might belong to a single signaling pathway. Therefore, manipulation of miRNAs can affect many components of a pathway as opposed to the gene-specific manipulation achieved by gene delivery or replacement. On the other hand, several coexpressed miRNAs can collectively control a given biological process by regulating shared key molecules of that process. Clear examples of this type of multilevel regulations in retinal disorders are yet to come. However, specific miRNA activity can be inhibited by several available methods, which involve delivery of synthetic miRNA mimics and antagonists (antagomirs). Such strategies have been used to manipulate miRNAs expression in inner retina and to determine if their upregulation and downregulation establish them as reliable drug targets. For example, in a mouse model of oxygen-induced retinopathy treated with an intravitreal injection of miRNA-126 (plasmid pCMV-MIR-126/liposome mixture), there is inhibition of retinal neovascularization induced by ischemia . Also, iMiRNAs may be involved in transferring inflammatory signals between cells and may have prognostic value in diseases in which there are common inflammatory mechanisms. For example, Li and colleagues reported secretion of possibly pathogenic amounts of two miRNAs (miRNA-146a and miRNA-155) from stressed human primary neural cells causing downregulation of an important repressor of the innate immune response, complement factor H (CFH) . Adding α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) mediated transmission in vivo, raising the possibility of involvement of NP in synaptogenesis in normal development of the visual system [Transcription factors (TFs) recognize and bind to transcription factor binding sites (TFBS) located upstream of miR genes and regulate their transcription in a polymerase II dependent manner , 86. Stul system . The neul system  and havel system .We have found evidence of other types of regulatory loops from our IR-injury associated datasets. For example, a single miRNA, miR99a, targeted 3 TFs  and together they regulate the Icam1 gene (adhesion molecule) . They alIn the analyses of our IR associated datasets, we define the regulatory loops as closed loops if they contain a TF and a miRNA in which both target one or more common genes and in the same time the miRNA targets one or more TFs. These closed loops serve as important motifs in gene regulatory networks. In our preliminary results, we have identified 87 closed loops at the 24 h post-IR time point and 140 closed 13 loops at the 7 d post-IR time point.These closed loops were further integrated into larger regulatory subnetworks. Two sub-networks, corresponding to 24 h and 7 d time points after retinal IR-injury, were generated and are shown below . At the According to our preliminary results, it is plausible to propose that different circuits might be executing different functions at different time periods, perhaps in different cell types, after IR-injury. The purpose of our ongoing study is to identify specific “signature-modules,” the manipulation of which, might influence the etiology of ischemic-related diseases. and progression of retinal ischemic-related diseases. Further analyses to experimentally validate some of these regulatory modules and identify the biological significance of their coordinated regulation in healthy and diseased retina are in progress.The future characterization of regulatory networks in various experimental contexts will be essential for better understanding of how regulators coordinately contribute to the diverse dynamic processes occurring in retina in the normal and pathological states.Understanding the cause and consequence of the dynamic changes in mature miRNA levels in diseased and healthy retina requires in-depth knowledge not only of their synthesis but also of how specific miRNAs are destabilized and targeted for elimination.In vivo and in vitro studies have demonstrated that internal loops structures of primary transcripts (pri-miRNA) drive bidirectional processing, which affects the abundance of mature miRNAs in both plants and animals , 107. ThRecent studies have linked the control of miRNAs stability and degradation to two proteins, the atypical poly(A) polymerase PAPD4 and the 5′-to-3′ exonuclease XRN2 , 110. ThIn the context of the retina, PAPD and XRN2 were found to be expressed mainly after neuronal differentiation and do not accumulate in retinal progenitor cells . They haIt would be interesting to investigate how many retinal miRNAs change their expression levels in response to light and if they are involved in fine-tuning the stability-related genes.Despite the recent advances in the field, there is still a need for additional research before the full biological relevance and clinical potential of miRNAs can be realized. Future studies need to provide supporting evidence for the choice of either single or multiple miRNAs whose effect(s) would be sufficiently powerful to treat a particular retinal disorder.There are numerous unresolved issues regarding the identification, functional role, and contribution of miRNAs to retinal diseases and/or disorders. For example, reliable standard methods for miRNA isolation and accurate quantitation are crucial requirement. So far the quantitative characterization of miRNAs relies on RT-PCR and depends on the presence of endogenous unchanging miRNAs and on the amplification efficiency of primers. Discrimination of single nucleotide differences by PCR is not always possible. In addition, PCR-based methods quantify miRNA precursors as well as the mature active miRNA. Although the proportion of pri-miRNA versus mature miRNA in the cell has not yet been extensively evaluated, there are studies suggesting poor correlation between expression of miRNA primary transcripts and mature miRNA . PossiblMicroarray-based analyses allow parallel screening of thousands of miRNAs in one sample and are a powerful tool for selection of differentially expressed miRNAs. However, the concentration of putative miRNA biomarkers in the bloodstream is very low and microarray technology might not be suitable for detection of miRNAs in the circulation. Next-generation sequencing (NGS) based approaches might provide an alternative strategy for identification of more miRNAs associated with variety of chronic retinal diseases. NGS technology does not rely on predesigned primers or probes. Thus Djebali and colleagues used ultra-deep sequencing of RNAs in 15 different cell lines, and they reported that 75% of the cellular genome is transcribed at different periods during the cell's life cycle . This anA major challenge toward using miRNAs as therapeutic agents would be the avoidance of toxicity derived from off-target effects. Therefore, it is clear that the prediction algorithms for identification of miRNA target genes need further development to decrease the rates of false positive targets. The low consensus between major prediction algorithms, such as PicTar, miRanda, and TargetScan, indicates the need of some standardization for the prediction of miRNA targets .The transient transfection of miRNA mimics or inhibitors has been successfully implemented in mouse retina  and humaCirculating miRNAs might be passive by-products of cell death having no biological function, or they could be messengers, activating as yet undiscovered systemic responses. In both of these cases, they could be reliable biomarkers for retinal pathologies in a clinical context. However the mechanisms by which miRNAs are loaded and transported in vesicles or become associated with carrier proteins are not fully elucidated. It is largely unknown how particular miRNAs are “labeled” for export. Additional studies are needed to clarify the ratio between vesicle- and protein-associated circulating miRNAs, for instance, diseased and healthy retina, to provide a basis for more accurate miRNAs extraction and more responsive biomarker assays. A recent report suggested that the mechanism of delivery of miRNAs in the blood might depend on the kind of injury. Using distinct mouse models for liver diseases, where the liver damage is caused by alcohol, drugs, or inflammation, miRNA-122 and miRNA -155 were abundant in the exosome-enriched fraction when the liver damage is caused by alcohol or inflammation, while in drug-induced liver injury model both miRNAs were detected mainly in the protein rich soluble fraction . The autIn addition to the issue of packaging, another area for future exploration is the use of miRNAs as possible messengers for intercellular communications within the retina. If miRNAs can be transferred and utilized by receiver cells, they might offer an elegant way to coordinate the intracellular activities of those cells. For example, Hergenreider and colleagues demonstrated in an in vitro study, that extracellular vesicles shuttle miRNAs from endothelial cells to smooth muscle cells . FurtherIn conclusion, the miRNA represents an exciting area of focus for future discoveries in retinal research. The association of specific miRNAs with particular diseases/disorders of the retina remains a largely unexplored area. Retinal miRNAs in the peripheral circulation may serve as markers of disease stage or monitoring therapeutic response or disease recurrence. In addition to their use as biomarkers, there is a great potential to manipulate miRNAs in the retina to implement cellular health and ultimately improve visual function.


Lack of adherence to antiretroviral medications is one of the key challenges for paediatric HIV care and treatment programmes. There are few hands-on opportunities for healthcare workers to gain awareness of the psychosocial and logistic challenges that caregivers face when administering daily antiretroviral therapy to children. This article describes an educational activity that allows healthcare workers to simulate this caregiver role.Paediatric formulations of several antiretroviral medications were dispensed to a convenience sample of staff at the Baylor College of Medicine-Bristol-Myers Squibb Children's Clinical Center of Excellence in Mbabane, Swaziland. The amounts of the medications remaining were collected and measured one week later. Adherence rates were calculated. Following the exercise, a brief questionnaire was administered to all staff participants.The 27 clinic staff involved in the exercise had varying and low adherence rates over the week during which the exercise was conducted. Leading perceived barriers to adherence included: "family friends don't help me remember/tell me I shouldn't take it" and "forgot". Participants reported that the exercise was useful as it allowed them to better address the challenges faced by paediatric patients and caregivers.Promoting good adherence practices among caregivers of children on antiretrovirals is challenging but essential in the treatment of paediatric HIV. Participants in this exercise achieved poor adherence rates, but identified with many of the barriers commonly reported by caregivers. Simulations such as this have the potential to promote awareness of paediatric ARV adherence issues among healthcare staff and ultimately improve adherence support and patient outcomes. Lack of adherence to antiretroviral (ARV) medications is one of the key challenges for HIV care and treatment programmes -3. WhilePaediatric HIV care and treatment remains a global health priority, but health professionals providing ARVs to children are often unaware of these complexities. There are few training initiatives designed to ensure that healthcare providers understand the psychosocial and logistic challenges of taking ARVs on a daily basis. Such an understanding of common barriers is potentially beneficial to effectively discussing adherence strategies with patients and their caretakers -12. SuchPaediatric formulations of highly active antiretroviral therapy (HAART) medications were dispensed on a voluntary basis to a convenience sample of full-time Swazi and expatriate clinical staff at the Baylor College of Medicine-Bristol-Myers Squibb Children's Clinical Center of Excellence in Mbabane, Swaziland. Most clinical staff working on site participated in the exercise, and all who participated were involved in the direct provision of paediatric HIV care and treatment services. Other clinical and non-clinical staff volunteered to offer adherence support to participants in keeping with the adherence support protocol of the clinic. Liquid stavudine, lamivudine and nevirapine were dispensed as per Swaziland care and treatment guidelines (2006 edition). To avoid waste, medications that were used were combined from the small volumes of leftover liquids turned in by patients.All participating staff attended a group adherence session similar to that offered to caregivers of paediatric clients initiating HAART, including a review of the importance of adherence, the individual ARVs in the regimen and potential adverse effects, the components of successful adherence, and the consequences of poor adherence. Participating staff then read and signed a standard adherence contract and received their assigned three-drug regimen, along with an explanation and dosing calendar from our pharmacists, as per clinic protocol. Participants received liquid formulations of various first-line ARVs as if each was the parent of a young child receiving either an initial ARV regimen or a refill of an ongoing regimen.During the exercise, participants were asked to adhere strictly to the appropriate schedule, carefully draw appropriate doses, and administer the liquid into the sink, and thus no medications were actually consumed. Participants were requested to keep notes about the experience and the challenges faced and to return with any remaining medications seven days later. At that time, each participant's remaining doses were collected and measured and adherence rates were calculated. Staff adherence was calculated based on overall adherence, which assigned an adherence rate equal to the value of the farthest outlier of the three assigned medications, the same method used routinely in the clinic to calculate client adherence rates.Each participant also completed a one-page questionnaire derived from the AIDS Clinical Trials Group Self Report survey, which allowed self-reporting on adherence rates and barriers. Each barrier included was weighted using a numeric scale . Twelve potential barriers were included in the questionnaire , nurses (eight), clinical support staff (eight), a pharmacist and a social worker. More than half (15) were from Swaziland, while the others were from North America (eight), Kenya (two), South Africa (one) and Germany (one). None had participated in an adherence exercise of this type before.Adherence among participants was poor, with only one (4%) of the 27 participating Centre of Excellence staff achieving 95-100% overall adherence during the exercise. Though not possible to make a direct comparison, it is of interest that 46% of paediatric patients aged five years and younger and captured in the clinic's electronic medical record during the month of the exercise achieved 95-100% overall adherence.On a five-level Likert scale ranging from "never" to "all of the time", 11 of the participants reported following his/her specific schedule "all of the time", while 13 reported following it "most of the time". The remaining three reported following the schedule "half" (one) or "some" (two) of the time. The top two reported barriers were being "too busy" and "family and/or friends don't help me remember".The general response of the participants to the exercise was positive. Comments included: "This was an eye-opening exercise", "Very good for us to experience", and "Now I do relate with the challenges faced by our clients."Informed adherence counselling is difficult without a first-hand appreciation of the difficulties inherent in administering regularly scheduled medications. While the clinic staff involved in this exercise understood the importance and complexity of adherence behaviours, few had personally experienced the challenges of daily adherence despite working directly with the end users of these medications on a daily basis.The poor adherence rates among staff participants are likely a reflection of several factors. The primary objective of achieving good adherence among participants was not health related, and as a result, the incentives to achieve good adherence were not as strong as among parents of HIV-positive children. Also, the exercise lasted only a week, and so a single error in dosing has a potentially large effect on the calculated adherence. Moreover, most of the participants were handling paediatric ARVs for the first time.The leading reported barriers among patients are similar to those previously reported. While careful scheduling and adherence support are routinely discussed at length in our pre-ART adherence counselling sessions, other challenges, such as difficulty drawing medicine and spillage, are often not addressed.Good adherence to liquid formulations of ARVs is challenging but essential in the treatment of paediatric HIV. When asked to adopt and simulate a typical paediatric ARV dosing schedule for a week-long exercise, our healthcare workers achieved poor adherence compared with our patient population, but identified with many of the barriers commonly reported by caregivers. With few opportunities to learn first hand what strict adherence to ARVs entails, simulations such as this have the potential to promote awareness of paediatric ARV adherence issues and empower healthcare staff to more effectively counsel caregivers and children taking ARVs, as well as other medications.The authors declare that they have no competing interests.BRP and SJH participated in the adherence exercise, data gathering, and initial manuscript development. JW revised the manuscript, which was finalized by GES. All authors read and approved the final manuscript.


The perineural net (PNN) is responsible for synaptic stabilization of adult brain. It plays an important role in brain signal processing and non-synaptic signal transfer as well . Since iLocal impact changes the correlation length of the fractal lattice: after the restoration, the correlation length becomes short, thus signal processing on the lattice changes significantly. Thus, it can be considered as a good model to study of the extracellular matrix change due to local excitations of strong electromagnetic field.


In suchin vitro  and in v[in vivo , and dis[in vivo  and migh[in vivo  and stor[in vivo . Their a[in vivo .Here we study neuronal avalanches in an open-loop system of cortex and striatum. The striatum is the main input structure of the basal ganglia and plays an important role in motor and cognitive functions. Understanding how the striatum responds to cortical inputs has crucial importance for clarifying the overall functions of the basal ganglia. The projection neurons of the striatum have a high threshold for activation and receive excitatory input from different regions of the cerebral cortex. Although the striatum contains several distinct cell types, 90-95% are GABAergic medium spiny projection neurons (MSNs). These cells are major targets of cortical inputs, the recurrent connection among them mediate weak feedback inhibition and neighboring MSNs are not likely to share cortical inputs . Fast-spPreliminary experiments indicate that activity bursts in the striatum do not follow a power law with characteristic exponent of -1.5. Here we developed an abstract model of the cortico-striatal network that reproduces statistics observed in experimental data. We discuss which kind of connectivity between cortex and striatum, as well as connectivity and strength of inhibition within striatum can lead to results that are in line with experimental data.


Poa alliance, a group comprising about 775 C3 grass species, revealed rapid and parallel diversifications in various parts of the world. Some of these radiations are restricted to isolated areas like the Andes, whereas others are typical of the lowlands of mainly the northern hemisphere. These radiations thus are not restricted to island-like areas and are seemingly actively ongoing. The ages of the diversifying clades are estimated to be 2.5–0.23 million years (Myr). Conservative diversification rates in the Poa alliance amount to 0.89–3.14 species per Myr, thus are in the order of, or even exceeding, other instances of well-known radiations. The grass radiations of the mainly cold-adapted Poa alliance coincide with the Late Tertiary global cooling, which resulted in the retreat of forests and the subsequent formation of cold-adapted grasslands especially in the northern, but also in parts of the southern hemisphere. The cold tolerance, suggested to be one of the ecological key innovations, may have been acquired during the early diversification of the subfamily Pooideae, but became significant millions of years later during the Pliocene/Pleistocene radiation of the Poa alliance.Rapid species diversifications provide fascinating insight into the development of biodiversity in time and space. Most biological radiations studied to date, for example that of cichlid fishes or Andean lupines, are confined to isolated geographical areas like lakes, islands or island-like regions. Using DNA sequence data of the ribosomal internal transcribed spacer (ITS) for many species of the  Dianthus species Lupinus, in the Central and South American genus Costus or in South African ice plants Carex provides another example of rapid diversification in non-island like areas Poa L.) with about 500 species have almost world-wide distribution. Chloroplast and nuclear DNA studies revealed a well-supported clade of Poa and allied genera in the phylogeny of grasses  sequences of nuclear ribosomal DNA representing 217 species of the Poa alliance. ITS is by far the most comprehensively studied molecular sequence marker in this plant group. Chloroplast DNA studies using different markers Plant diversification, i.e. the evolutionary origin of new species, genera and families, proceeds at different speeds. Net diversification of families and genera was estimated as 0.078 to 0.09 per Myr Poa and allied genera, as well as four sequences of outgroup taxa were assembled, representing 217 species. Most sequences were already included in other studies and were collected from GenBank. We added 34 new sequences. These are from insufficiently studied genera or from genera occurring in remote areas .427 nuclear ribosomal ITS1–2 DNA sequences of Poa alliance. Many chloroplast DNA sequences are also available, but they are from different regions of the chloroplast genome and do not enable a dense coverage of taxa. The substitution rates of the ITS vary among groups of the plant kingdom and may be dependent from their life history Poa alliance are unfortunately missing, thus we had to apply a secondary calibration of our data. Absolute ages of the clades were calculated by fixing the split between the outgroup taxa Phalaris and Avena and the ingroup of 20 and 25 Myr, respectively. These dates were taken from a dated chloroplast DNA phylogeny of the Poaceae Poa and its allied genera. The node age of 20 Myr is the split between the subtribe Poinae and the other taxa of the tribe Poeae, the conservative age estimate of 25 Myr is from the split between Poeae and Aveneae The ITS sequences provide the most comprehensive molecular data set for the Divergence time estimates were also performed using the Bayesian uncorrelated relaxed clock method as implemented in BEAST 1.6.1 Poa taxa are missing from the phylogenetic reconstruction. Nevertheless, the numbers derived from this approach were used in the text. The second approach considers the fact that some genera were completely, but others still incompletely sampled for sequence data. The species numbers of the smaller genera, like Milium, Zingeria or Puccinellia are known and based primarily on Watson & Dallwitz Poa an estimation of the clade's species numbers are necessary . Maximum species numbers of the eight Poa clades were estimated under the assumption that the Poa taxa were more or less evenly sampled across the clades. The maximum species number of the clades is estimated using the ratio: Number of molecularly studied species of the clade * 500 total species of Poa/169 molecularly studied species of Poa. Distribution data were obtained from GrassBase Diversification rates were estimated using the method of Magallon & Sanderson Poa and its relatives shows several well-supported clades that are partly restricted to continents, but sometimes more widespread  to mesic habitats (A. pratensis). Temperature is another gradient along which the species are differentiated. There are species confined to lowlands (A. pratensis) or high mountains , of southern areas or arctic environments . In comparison to Phleum, which has similarly condensed panicles, Alopecurus appears not to grow in too dry soils. Arctophila and Dupontia are almost confined to the Arctic. Dupontia is probably of hybrid origin and Arctophila is involved in this origin Limnas may also be involved in the origin of Dupontia as the second parent. The sometimes strongly condensed, spike-like panicles of Dupontia support this suggestion According to the two molecular clock estimates this clade is older than the above-mentioned clades . The divCinna, Arctagrostis) but usually many-flowered. In terms of the ecological differentiation the whole clade shows an astonishing diversity, because species occur in temperate forests of Australia and the northern hemisphere , temperate high mountains habitats , or even in arctic environments (Arctagrostis). The diversification of these plant groups may have started less than 1 My ago.The widespread clade corresponds to the ‘HSAQN clade’ Catabrosella araratica, sometimes considered to be a species of Colpodium) has few-flowered spikelets, whereas the other species of this clade have one-flowered spikelets that are arranged also in an open panicle. All species are perennials. The caryology of Catabrosella araratica is still unknown, the other species are characterized by rather few but large chromosomes. The reduction of chromosome numbers and a subsequent polyploidization was perhaps the key trait for the diversification of this clade Zingeria seem to grow frequently also in disturbed places.The basal species of this clade  or forested areas , some species prefer moist to swampy soils  or dry habitats (P. botryoides). The species are found from the lowlands  to the alpine belts (P. glauca) and from the temperate  to the arctic zones (P. hartzii).Probably also of Late Pleistocene/Early Holocene origin are the species of the P. arctica). According to Tzvelev Poa. This affiliation is not supported in our phylogenetic tree. The other sub-clade, named ‘X-clade’ P. novae-zelandiae is gynomonoecious and a couple of species are dioecious . The species of this group appear to have diversified into a variety of habitats to which they are confined P. matthewsii. Many growth forms are represented in this New Zealand group: almost tussock forming species to slender rhizomatous species. Considering the rather frequent bipolar disjunctive distributions between northern Asia and Australia/New Zealand (e.g. Carex pumila) it seems likely that this group diversified ecologically and morphologically rapidly in New Zealand after its arrival from the North. This ecological diversification seems to be paralleled in the Poa IV clade on the northern hemisphere.This group comprise two weakly supported sub-clades. One sub-clade consists of widely distributed perennial species of the northern hemisphere and comprises additional species, which reach the Arctic . As in other clades, the species are highly differentiated in terms of their ecological and geographical distribution P. keysseri), New Zealand  or the southern Pacific Islands  only a few species occur in south-western Australia . Only P. poiformis and the annual P. fax are widespread and occur more or less throughout the southern margin of Australia. As in other clades of Poa the species are ecologically highly differentiated. Most species grow in rather dry soils, however, P. clelandii grows in moist to wet soils predominantly in lowlands, P. costiana in high mountain moist places. Species of woodlands are rare , most species grow in open conditions. The only species occurring in the drier inland of south-western Australia is P. fordeana, all other Australian species of this group occupy more or less areas close to the coast. Like in the Poa V clade the penalized likelihood estimate of divergence time is about 0.8 Myr older than that of the uncorrelated relaxed clock method. Considering the lowest molecular divergence between the species observed in this study may favour the younger age estimates.This is a species-rich clade of Australia and New Zealand, which was recognized as a recently diverged group . Stipa supposedly split from the remainder of the Pooideae subfamily around the Eocene/Oligocene boundary 3 grass lineages proceeded early and before the onset of the C4 grass evolution, which led to extensive formation of open grasslands. According to the molecular clock results, the Poa alliance was not yet present during this early formation of grasslands  to 0.89–3.14 species per Myr , respectively . ConsidePoa and the allied genera are not evidently associated with the acquisition of morphological key characters. For the environmental “island situation” of South Africa ecophysiological key innovations are considered as important prerequisite of rapid plant speciation Poa alliance Despite the characters that have led to the description of segregate genera, it is notable that the multiple diversifications in Poa and allied genera proceeded only partly in island-like areas. Two clades with different diversification rates are actually confined to the South American Andes, i.e., the rather species-poor Poa VI clade with the highest diversification rate observed in this study and the species-rich Poa VII clade, which represents the former genus Dissanthelium . These time estimates are in the order of Andean Lupinus or Eurasian Dianthus diversifications, which started less than c. 2 Myr ago Poa VII clade proceeded at a slower pace, but had more time available and thus became more species-rich than clade VI , which are restricted to Australia and New Zealand, underwent a slower diversification than the Andean and Northern hemispheric clades. The independent evolution of two lineages in Australia and New Zealand, which arrived probably by long distance dispersal, is paralleled, for example, in the genus RanunculusIn contrast to these diversifications in the Andes or the Mediterranean/Irano-Turanian regions, the Poa show overall similar diversification rates, but have higher nucleotide diversity  and appear to be molecularly faster evolving than Poa  have diversified with low rates. None of these genera is restricted to island-like areas.The genera related with than Poa . Phleum,Poa alliance are important components of grasslands in either the temperate to arctic zones or the high mountain belts of tropical to subtropical zones. Although some lineages date back to the Middle Tertiary, they started to diversify strongly not before the global cooling changed the environmental conditions fundamentally. Cold tolerance, suggested to be one of the ecological key innovations of the subfamily Pooideae Poa alliance.The global diversification of the bluegrasses and related genera provides an example of rapid and parallel speciation in a wide variety of habitats, continents and areas. Some of these features were singly reported also for other plant genera and families, but here we observe them together in a species-rich group of grasses. The members of the Figure S1Complete phylogenetic tree of all ITS sequences used in this study. The colors are as in (PDF)Click here for additional data file.Table S1Taxon names, GenBank accession numbers and sources of the ITS sequences used in this study.(XLS)Click here for additional data file.