Candida and Aspergillus and the emergence of less common genera including Fusarium and Zygomycetes. Despite availability of new antifungal agents these opportunistic infections have high mortality. Rapid and reliable species identification is essential for antifungal treatment, but detection of the increasing diversity of fungal pathogens by conventional phenotypic methods remains difficult and time-consuming, and the results may sometimes be inconclusive, especially for unusual species. New diagnostic techniques  could improve this scenario, although further studies are necessary to confirm their usefulness in clinical practice.Recent advances in the management of patients with haematological malignancies and transplant recipients have paralleled an increase in the incidence of fungal diseases due to pathogenic genera such as  Despite the development of new techniques and new antifungal agents, diagnosis of invasive fungal infection (IFI), which still relies upon a combination of clinical observation and laboratory investigation, remains a challenge especially for immunocompromised patients with haematological disease.4albicans Candida , Aspergillus terreus, Scedosporium species, and Zygomycetes, many of which are intrinsically resistant to the available antifungal agents.6The exact identification of the infecting organism is became essential in light of the increased use of prophylactic schedules that predispose the patient not just to fungal infection, but also to the selection of fungal species such as non-Aspergillus cannot be cultured from a significant proportion of sputum or bronchoalveolar lavage samples from patients with invasive aspergillosis (IA).7Laboratory diagnosis of IFI remains based on conventional approaches, such as the direct microscopically detection of the etiologic agent in clinical specimen and the isolation and identification of the pathogen in culture, and non-culture based methods involving detection of a serologic response to the pathogen or other marker of its presence such as fungal antigens or metabolites.Candida species, including C. albicans, C. tropicalis, C. glabrata, and C. parapsilosis. Most yeasts isolated from clinical samples can be identified using one of the numerous commercial identification systems, such as API 20C AUX, VITEK 2, and RapID Yeast Plus.Although a variety of culture media and incubation conditions may be required for recovery of fungal agents, chromogenic primary isolation media  can be employed for the presumptive identification of the most medically important Histoplasma capsulatum), an alternative and useful approach to the detection and identification of fungi in clinical specimens involves a broad-range polymerase chain reaction (PCR) followed by nucleic acid sequencing, after which the nucleic acid sequence is compared with known sequence database and identification is based on DNA homology.Unlike pathogenic yeasts, filamentous fungi can be identified only by visualization of macroscopic  or microscopic (spore-bearing structures) morphologic characteristics, following to sub-cultivation of a mould isolate to encourage sporulation,Aspergillus and Fusarium. Recently, the MALDI-TOF technology provided a fast and accurate identification of common and unusual species of Aspergillus when tested on 124 clinical and 16 environmental isolates.Fusarium species, a recent case report supported the usefulness of MALDI-TOF analysis in diagnosing an infection due to Fusarium proliferatum, which is a very infrequent pathogen within this genus.13By contrast, matrix-assisted laser-desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) is becoming a reliable method for identification of microorganisms. The remarkable reproducibility of the methodology is based on the measurement of constantly expressed and highly abundant proteins such as ribosomal molecules.To facilitate early diagnosis of IFI, important advances have been made in the development of laboratory markers , which have led to the potential for newer paradigms regarding prevention and early treatment of IFIs.24Aspergillus, Candida, and Fusarium, a spectrum of pathogens that encompasses the majority of those emerging in neutropenic patients with either prolonged neutropenia or chemotherapy-induced mucositis, with some notable exceptions such as Zygomycetes, a rare but emerging cause of invasive mycosis.fumigatus Aspergillus species, whereas BG was shown to have a higher sensitivity in detecting IA and other mould infections.30In contrast to GM, BG is a cell wall constituent of several fungi, including Candida infection when compared with blood cultures.32Non-culture based methods for diagnosis of candidiasis are of limited value because the levels of circulating antigens are low and the transient nature of the antigenaemia requires sensitive assays and frequent sampling of at-risk patients.Aspergillus and Candida species, using different specimens types , even though pan-fungal PCR amplification technology may be able to detect a broad range of fungal targets.Aspergillus PCR tests for diagnosis of IA,Aspergillus PCR, only a few Candida PCR methods have received major clinical evaluation.Candida.39A range of polymerase chain reaction (PCR)-based methods have been developed with the prospect of give highly specific, highly sensitive, and rapid means for fungal detection and identification.Molecular detection methods, combined with additional microbiological and clinical information, has the potential not only to accurately and rapidly identify fungal pathogens, but also to indicate whether the pathogen is likely to respond to conventional antifungal treatment.


The purpose of this review is to describe how the function and connections of the paraventricular thalamic nucleus (Pa) may play a role in the regulation of stress and negative emotional behavior. Located in the dorsal midline thalamus, the Pa is heavily innervated by serotonin, norepinephrine, dopamine (DA), corticotropin-releasing hormone, and orexins (ORX), and is the only thalamic nucleus connected to the group of structures comprising the amygdala, bed nucleus of the stria terminalis (BNST), nucleus accumbens (NAcc), and infralimbic/subgenual anterior cingulate cortex (sgACC). These neurotransmitter systems and structures are involved in regulating motivation and mood, and display abnormal functioning in several psychiatric disorders including anxiety, substance use, and major depressive disorders (MDD). Furthermore, rodent studies show that the Pa is consistently and potently activated following a variety of stressors and has a unique role in regulating responses to chronic stressors. These observations provide a compelling rationale for investigating the Pa in the link between stress and negative emotional behavior, and for including the Pa in the neural pathways of stress-related psychiatric disorders. Stressful life events can facilitate and exacerbate anxiety disorders (ADs), substance use disorder (SUD), and major depressive disorder , norepinephrine, corticotropin-releasing hormone (CRH), orexins (ORX), and the endogenous opioids in rat, monkey, and human studies , dorsomedial and ventromedial hypothalamic nuclei, lateral septum, the BNST, CeA and basomedial amygdala, anterior olfactory nucleus, olfactory tubercle, NAcc, infralimbic, piriform, and perirhinal cortices, ventral subiculum, and endopiriform nucleus  and activation of the Pa with functional magnetic resonance imaging (fMRI). For example, as described below, high levels of receptor binding specifically in the Pa in postmortem human brains  suggest that radioligand binding for that particular receptor in the medial thalamus detected with PET  is likely in the Pa. We describe below the only human neuroimaging studies to our knowledge that have identified the Pa. Given the strong connections of the Pa to structures often showing abnormal neural activity in AD, SUD, and MDD , and its role in regulating stress, the Pa may be considered a key component of the neural pathways involved in these disorders Figure .125I]epidepride D2/3-binding sites  in the thalamus as shown by in situ autoradiography  receptor binding were found in the midline thalamic nuclei, with low to absent binding in the mediodorsal thalamus  coordinates) in healthy individuals (Bingel et al., Although the spatial resolution used in most fMRI studies does not allow for the identification of the Pa beyond what can be called the “medial” thalamus, a few studies are worth mentioning. Following eight days of repeated experimental pain, peak levels of The Pa is positioned to influence limbic structures controlling motivation and mood. The Pa is sensitive to environmental stressors and cues for drugs of abuse and may mediate stress-induced changes in mood and behavior through the amygdala, BNST, NAcc, and sgACC. The Pa also plays an important role in the regulation of chronic stress through ORX inputs, although several neurotransmitter systems are likely involved. These observations bring the Pa into focus as a critical component in a pathway by which stressors, particularly chronic stressors, can influence motivation and mood, potentially promoting stress-related psychiatric disorders. Further investigation of the Pa in this role in animal models and in humans is warranted.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.


It has been estimated that 20% of pregnant women suffer from depression and it is well-documented that maternal depression can have long-lasting effects on the child. Currently, common treatment for maternal depression has been the selective serotonin reuptake inhibitor medications (SSRIs) which are used by 2–3% of pregnant women in the Nordic countries and by up to 10% of pregnant women in the United States. Antidepressants cross the placenta and are transferred to the fetus, thus, the question arises as to whether children of women taking antidepressants are at risk for altered neurodevelopmental outcomes and, if so, whether the risks are due to SSRI medication exposure or to the underlying maternal depression. This review considers the effects of maternal depression and SSRI exposure on offspring development in both clinical and preclinical populations. As it is impossible in humans to study the effects of SSRIs without taking into account the possible underlying effects of maternal depression , animal models are of great value. For example, rodents can be used to determine the effects of maternal depression and/or perinatal SSRI exposure on offspring outcomes. Unraveling the joint (or separate) effects of maternal depression and SSRI exposure will provide more insights into the risks or benefits of SSRI exposure during gestation and will help women make informed decisions about using SSRIs during pregnancy. The number of women using selective serotonin reuptake inhibitors (SSRIs) during pregnancy is increasing, although knowledge on long-term neurodevelopmental effects to the child is lacking. This review summarizes clinical and preclinical findings of how SSRI exposure during pregnancy affects child outcomes. Many clinical findings parallel aspects of the preclinical data, such as decreased gestational length, birth weight, pain responses, and social behavior, increased spontaneous abortion/mortality rate, risk of cardiac anomalies, anxiety, depression, and rapid eye movement (REM) sleep, and affected 5-HT metabolism, motor development, and hypothalamic-pituitary-adrenal (HPA) stress reactivity. However, antenatal depression also has been associated with long-term neurodevelopmental outcomes. This review therefore starts by describing effects on the offspring exposed to antenatal depression and will then focus on outcomes of SSRI exposure during pregnancy.Women are at an increased risk of becoming depressed during pregnancy and in the postpartum period, especially when they have pre-existing psychiatric illnesses. In fact, depressive symptoms may occur more frequently during pregnancy than in the postpartum period  side-effects, and therapeutic safety , 5-hydroxyindoleacetic acid  and homovanillic acid  concentrations in the umbilical vein  admission and neonatal seizures. Several studies report an increased risk of neonatal seizures, longer hospital stays, and NICU admissions after SSRI use during pregnancy  the pulmonary vasculature fails to relax after birth, which results in hypoxemia. The occurrence of PPHN is ~0.2% in live-born infants and it is associated with substantial infant mortality and morbidity. Several studies have shown an increased risk for PPHM in SSRI-exposed infants. Exposure during the first trimester . Oberlander et al.  used thiin utero). These data indicate that SSRI-exposure may alter the developmental time course of language perception.Although some studies exist, the long-term neurodevelopmental outcomes of prenatal SSRI exposure have not been extensively studied. With regards to language development, Nulman et al. ; Nulman However, there are several studies which describe an effect of prenatal SSRI exposure on neurobehavioral outcomes. Oberlander et al.  studied Apart from its role in neurodevelopment, 5-HT is implicated in the development and function of the HPA axis  plays a critical role in moderating environmental influences and developmental risks  SS-allele carriers and lower 5-min Apgar score and risk for neuromotor symptoms; (2) LS-allele carriers and low birth weight; and (3) LL-allele carriers and respiratory distress and tachypnea  mice that were exposed to hypoxia for several weeks, the number and wall thickness of pulmonary vessels decreased compared with controls  there is a 3-fold increase in right ventricle pressure compared to wild-type mice  has been reported to cause a transient delay in motor development in rats on PND10 and PND12; decreased horizontal activity in an open arena on PND8, but increased retention time on a rotating rod on PND22 and PND49  increased REM-sleep duration and decreased REM latency in mouse offspring  fluoxetine exposure  exposed to citalopram a neophobic response to an auditory stimulus, as well as reduced exploration to a novel object, were found  rodents mimic the long-term behavioral outcomes of early SSRI exposure. 5-HTT−/− rodents display reduced pain, exploratory behavior, social behavior, and increased anxiety-like and depression-like behavior , the dose of the medication and the gestational age of the infant. In preclinical studies, discrepancies between findings may be due to the timing of SSRI exposure , the duration of exposure, the dose administered and the SSRI used, as well as rodent strain.Both genetic and environmental factors contribute to the well-being of a child. In humans, it is impossible to study the effects of SSRI exposure without taking the underlying depression into account. In animals, it is possible to disentangle the effects of maternal depression from the effects of maternal SSRI exposure. Moreover, the timing of maternal adversity and SSRI exposure (duration and dosing) can be studied during the prenatal or postnatal period or during both periods. The additional advantages of using animal models are that one can readily examine long-term neurodevelopmental outcomes, specific roles of maternal care, and neural plasticity. Unfortunately, most preclinical research to date has studied the effects of SSRIs in healthy animals. In order to make preclinical findings translational, it is important to study the effects of SSRIs in a model of maternal depression or adversity, as the actions of developmental exposure to SSRIs can significantly vary with exposure to maternal adversity. Finally, preclinical studies reveal sexually dimorphic responses which likely apply to humans as well. It is, therefore, important to take the sex of the offspring into account.It remains to be determined whether maternal SSRI use is more beneficial or has adverse effects beyond the underlying depression. Much more research is needed to understand the risks and benefits of perinatal exposure to SSRIs on the developing child. Future research should focus on the effects of maternal depression alone, and compare it to offspring exposed to SSRIs, and offspring exposed to SSRIs combined with maternal adversity. Unraveling the different underlying mechanisms  in these three different groups will provide the answer for the risks and benefits of SSRI use during pregnancy.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.


In primates, the meaningful use of facial signals and eye contact is a prerequisite for normal social behavior. Just by looking at the face of another monkey, an individual can determine its age, sex, dominance status, health, etc. Facial expressions are useful to determine the emotional state and possible intentions of others. Eye contact facilitates affiliative behaviors such as facial mimicry in the context of mother-infant interactions, but also conveys threats and dominance status in adult-adult interactions. The neural circuitry that underlies these behaviors is largely unknown. One goal of our research is to determine the role of the primate amygdala in basic aspects of social communication that involve looking at the eyes of other individuals. To achieve this goal we developed an experimental paradigm that elicits reliably and reproducibly several aspects of social behavior including eye contact, facial mimicry, and gaze following . Additio


Mitochondrial carriers are integral proteins of the inner membrane that allow for the exchange of metabolites, nucleotides, and cofactors between the cytosol and the mitochondria and thus, enact a variety of energetic adjustments ,2.de novo lipogenesis, these activities would theoretically place CIC at a nodal point in the regulation of metabolic pathways and mitochondrial activity in cancer.The mitochondrial citrate carrier, SLC25A1 or CIC, catalyses the efflux of citrate from the mitochondrial matrix in exchange for cytosolic malate. Mitochondrial citrate is necessary for the Krebs cycle and oxidative phosphorylation (OXOPHOS), while cytosolic citrate provides the only carbon source for fatty acids and sterol biosynthesis. In addition, cytoplasmic citrate is an allosteric inhibitor of enzymes involved in glucose catabolism, particularly of phosphofructokinase (PFK), while at the same time providing a source for the production of NAD+ , which can be used to support glycolysis. Because tumor cells display enhanced glycolytic capacity and enhanced rates of Oncotarget, Avantaggiati and colleagues [de novo lipid synthesis as expected, CIC inhibition also resulted in destabilization of the mitochondrial membrane potential, enhanced ROS (reactive oxygen species) production and increased production of L-lactate, indicative of a re-wiring of metabolism towards glycolysis.In this issue of lleagues  provide via autophagy. In support of these data, blocking of autophagy rescues the anti-proliferative effects due to CIC loss both in tumor cells and in the model organism Zebrafish.The major implications of their findings is that a key component of CIC's ability to support proliferation of tumor cells might be in fact be the preservation of mitochondrial pathways of energy production while limiting the glycolytic addiction of tumor cells, essentially suppressing the Warburg effect, a metabolic trait that is proposed to promote malignancy. In addition, the authors provide compelling new evidence that CIC inhibition results in mitochondrial depletion and degradation These studies describe a previously unknown role for CIC in regulating mitochondrial homeostasis and autophagy/mitophagy and are important and provocative for several reasons.The Warburg theory proposes that the mitochondria of cancer cells are unable to provide energy via oxidative phosphorylation, and therefore rely upon glycolysis for energy production . This viHowever, numerous lines of evidence fully support the existence of a much more complex interplay between the metabolism of glucose and mitochondrial activity, which is dependent upon the region of the tumor, -whether hypoxic or non-hypoxic- as well as the tumor microenvironment. For example, recent studies have provided for a model whereby hypoxic cancer cells convert glucose to lactate leading to its extracellular accumulation, where aerobic non-hypoxic cancer cells up-take it via monocarboxylate transporter 1 (MCT1) and utilize it for oxidative phosphorylation .In the newly proposed “Two-Compartment Tumor Metabolism” model and the “Reverse Warburg Effect”, ROS produced by the tumor cells, activates autophagy and leads to mitochondrial dysfunction and glycolysis in cancer associated fibroblasts, which in turn results in the production of recycled nutrients, including L-lactate and ketone bodies, that drive the anabolic growth of tumors -9. This Thus, in this model of metabolic-coupling, the oxidative capacity of the tumor mitochondria and the concomitant bypassing of autophagy both act in concert to support cancer growth. Therefore, it is not unlikely that CIC is also involved in the positive-feedback and crosstalk provided by the stroma.It will be important to determine whether CIC impinges upon other tumor-promoting metabolic branches, particularly the catabolism of glutamine.


Laboratory mice and rats failed to display any of the common coordinated actions of these indices after typical emetic stimulation  compared to musk shrews. Overall the results suggest that the inability to vomit is a general property of Rodentia and that an absent brainstem neurological component is the most likely cause. The implications of these findings for the utility of rodents as models in the area of emesis research are discussed.The vomiting (emetic) reflex is documented in numerous mammalian species, including primates and carnivores, yet laboratory rats and mice appear to lack this response. It is unclear whether these rodents do not vomit because of anatomical constraints  or lack of key neural circuits. Moreover, it is unknown whether laboratory rodents are representative of Rodentia with regards to this reflex. Here we conducted behavioral testing of members of all three major groups of Rodentia; mouse-related , Ctenohystrica , and squirrel-related (mountain beaver) species. Prototypical emetic agents, apomorphine (sc), veratrine (sc), and copper sulfate (ig), failed to produce either retching or vomiting in these species . These rodents also had anatomical constraints, which could limit the efficiency of vomiting should it be attempted, including reduced muscularity of the diaphragm and stomach geometry that is not well structured for moving contents towards the esophagus compared to species that can vomit . Lastly, an  The presence of the vomiting (emetic) reflex is widespread among mammals. Members of several major lineages, including carnivores , veratrine , and copper sulfate , which are thought to produce emesis by acting on the area postrema in situ brainstem preparation of rats, mice, and musk shrews The current study focused on directly addressing these questions by conducting emetic testing and making anatomical measurements in species from the three major lineages of Rodentia: 1) Mouse-related , 2) Ctenohystrica , and 3) Squirrel-related (mountain beaver) species  [18],  but there was no statistical difference between the three species . In contrast, there was a statistically significant change in phrenic nerve bursting across species after naloxone , and musk shrews displayed an increase in bursting  compared to mice  and rats .After RTX injection, shrews showed the first indication/sign of an emetic-like event at a median of 67 s, based on the movement of the esophagus, and at 78 s based on the movement of the mouth. Corresponding latencies were 224 s and 122 s for mice and 90 s and 60 s for rats. Representative recordings of the mouth, esophagus, and phrenic nerve responses are shown in in situ preparation of the musk shrew that are consistent with emetic-like episodes Electrical stimulation of the vagal afferents, from 5 to 20 V, produced consistently large coordinated responses in mouth, esophagus, and shoulder movements in musk shrews but not rats or mice , top. Moin situ brainstem testing of laboratory rats and mice indicated that these animals do not have the diagnostic signs of the coordinated components of an emetic-like episode seen in the musk shrew, i.e., multiple closely spaced longitudinal esophageal contractions and phrenic nerve bursting activity (fictive emesis) with an associated mouth opening None of the rodents tested in free moving behavioral assays showed either retching or vomiting after injection of drugs known to induce emesis in the dose range and observation time used in multiple species known to be capable of emesis 2 receptor agonists The selected rodent species did not retch or vomit after administration of the prototypical emetic agents apomorphine (sc), veratrine (sc), or copper sulfate (ig). There is little doubt that these three emetic agents produce both retching and vomiting within 15 min in emetic species. Apomorphine  produces emesis in ferrets, dogs, mink, and least shrews with a latency of 2 to 10 min e.g., . VeratriIt appears that individually none of the anatomical features that were measured explains the lack of emesis. In contrast, some of these anatomical metrics might indicate that it would be difficult for rodents to efficiently vomit. For example, rodents have reduced diaphragmatic muscle to assist in abdominal pressure changes in situ brainstem approach. With this methodology we were able to make sensitive measures of the force of the esophagus and mouth movements, shoulder displacement, and phrenic nerve bursting activity; all of these features are critical components of emetic responses in vitro study of the mouse and musk shrew esophagi 1 receptors in the emetic circuitry is strongly supported across several emetic models, including musk shrews, ferrets, cats, and dogs in vivo physiology experiments using musk shrews, ferrets, cats, and dogs Free moving behavioral testing cannot address the possibility that rodents have more subtle emetic responses, perhaps existing as a degenerate reflex. This is the power of the Although rodents have peripheral musculature and gastrointestinal physiology (e.g., absence of functional motilin The current study is limited in scope to those rodents that were included. Rodents tested in the current report are a small selection of the approximately 1800 species of rodents in situ brainstem physiology preparation to collect sensitive measures of mouth, esophagus, and shoulder movements, and phrenic nerve bursting activity. These findings indicate the need for CNS neurophysiological studies to directly compare rodents and emetic species following activation of possible nausea-related pathways and the absence or presence of the critical motor output pathways of the emetic reflex. Understanding the lack of emesis in rodents has implications for the suitability of typical laboratory species, such as rats and mice, for the study of nausea and vomiting (Chap. 8 in In summary, the current study shows that the inability to vomit is likely a general phenotype of rodent species. The current report represents the first detailed experimental study of the lack of emesis in diverse rodents. The strengths of this study include the combined use of free moving behavioral testing, detailed anatomical measures, and use of an


The goal of this paper is to review the current state of the art in mathematical and computational modeling of blast-induced TBI, identify research gaps, and recommend future developments. A brief overview of blast wave physics, injury biomechanics, and the neurobiology of brain injury is used as a foundation for a more detailed discussion of multiscale mathematical models of primary biomechanics and secondary injury and repair mechanisms. The paper also presents a discussion of model development strategies, experimental approaches to generate benchmark data for model validation, and potential applications of the model for prevention and protection against blast wave TBI.Blast-induced traumatic brain injury (TBI) has become a signature wound of recent military activities and is the leading cause of death and long-term disability among U.S. soldiers. The current limited understanding of brain injury mechanisms impedes the development of protection, diagnostic, and treatment strategies. We believe mathematical models of blast wave brain injury biomechanics and neurobiology, complemented with  In the current conflicts in Iraq and Afghanistan improvised explosive devices (IEDs) are frequently used weapons of adversary combatants and terrorists against U.S. troops and civilians  has performed substantial research on blast trauma to the body, primarily to address injuries seen in previous conflicts, and to improve personal protective equipment (PPE)  and negative (tension) stress waves as well as shear stress waves. In tissues, the steep gradient pressure waves are absorbed by viscoelastic damping and tissue plastic deformation , resulting in mechanical injury. When the pressure wave crosses material interfaces with different densities, large perturbations in stress and deformation take place. A wave impacting a denser material compresses it and when it emerges from denser to lighter material it creates tensile deformations. Therefore in the human body, organs and tissues of different densities are accelerated at different relative rates, resulting in displacement, stretching, and shearing forces  due to the shock wave, secondary blast insult due to blast-propelled debris fragments causing blunt or penetrating ballistic trauma, and tertiary blast insults due to human body translocation by blast loads and the resulting impact on rigid objects. Quaternary blast insults refer to all other types of injury including burns, environmental wound contamination, etc. Detailed discussion of the injury mechanisms and pathophysiology of trauma for these insult types, particularly lung injury, have been described in military medicine publications and reports  the skull deformation creating a stress wave within the brain, (2) translation/rotation of the head causing compression/shear waves within the brain as well as brain rotation within the skull, 3) the pressure wave directly entering the brain via various foramina , and (4) an elastic wave propagating along blood vessels from a compressed thorax , the geometric/material asymmetries of the skull/brain and non-uniform blast loading will also generate shear waves in the brain. These shear waves are orders of magnitude slower (~10 m/s), persist longer and can be more damaging then compression waves. The human brain has several deep sulci filled with CSF separating various gyri, probably to facilitate larger access area for the perfusing blood vessels. We believe that they may also have an evolutionary biomechanical protective role. As it was mentioned above, the shear waves in brain can be more injurious than compression waves. A fluid filled sulcus between two gyri is a perfect transmitter of a compression wave but it is a very poor transmitter of shear waves. Therefore, sulci may play a protective role in the brain gray matter located close to the surface of gyri during the shear  motion.2 and CO2 which would act as nuclei spots for cavitation.Large, rapidly changing tensions in the brain and in CSF may also cause short living cavitation spots. A collapsing cavitation gas bubble can cause extensive damage to the surrounding tissue. However, the possibility of blast wave induced cavitation in the brain remains controversial. Cavitation has been experimentally observed in laboratory experiments with idealized human head surrogates  loaded with high speed impactors  so the relative motion will be slow and it may take a long time for the brain to contact the cranium. This has been experimentally observed in a physical surrogate model of an idealized head , contusion, and acute subdural hematoma  waves traversing the brain just after the blast impact and after any mechanical impulse to the head, all lasting tens to hundreds of milliseconds. Accordingly the secondary brain injury and repair involves a time evolving myriad of biophysical, neuro-biological, physiological, and potentially cognitive mechanisms, caused by the primary injury, and lasting for hours and, sometimes for life.As the brain is connected to the rest of the body through large blood vessels and the spinal canal, there is a strong possibility of the blast energy to enter the brain in the form of elastic waves propagating along the vessels to the brain  are particularly vulnerable to damage caused by high stain rate loads typically observed in the blast brain injury. These macro and micro interfaces may include the blood brain barrier (BBB), choroid plexus, brain-CSF interface, neuronal/axonal membranes, nodes of Ranvier, dendritic spines, synaptic clefts, transmembrane structures, and others. These interfaces may be particularly susceptible to mechanical damage if their resonant properties are matched to frequencies of the primary wave. In severe TBI, the primary mechanical damage, e.g., skull fractures or hematomas can be visibly detectable on CT or MRI images. In concussions and mTBI, the primary damage, such as diffuse neuroaxonal injury . Any additional energy requirements needed for structural repair of the injury will have to be facilitated by accelerated supply and utilization of Glc and oxygen to produce ATP. This hypermetabolic state may cause local cerebral ischemia, hypoxia, neuroexcitation, and failure of axonal and neuronal conduction. Because the intra-arterioral and capillary blood pressures are much larger than the intracranial pressure (ICP), any mechanical damage to the BBB may cause efflux of water and small molecules (some of them neurotoxic) from the luminal to the interstitial space causing brain swelling, mechanical deformation of the brain tissue and increase of ICP. These in turn may compress the venous and CSF volumes reducing the cerebral blood flow (CBF) rate and causing ischemia. Altered metabolic states may result in further cellular/mitochondrial damage due to oxidative stress, while penetrating blood borne molecules such as cytokines may initiate inflammatory responses  exchange of ionic, molecular, and fluid constituents occurs between the intracellular and extracellular neuronal and microvascular structures. This exchange generates cytotoxic and ionic swelling (edema) of astrocytes and neurons at the expense of the extracellular space, causing reduction in the diffusive transport of vital metabolites and neurotransmitters. The limited intrinsic energy reserves of the CNS require continuous supply of glucose (Glc) and oxygen for a normal function, most notably for neurotransmission (predominantly for glutamate (Glu) uptake) and for neuronal ionic repolarization  precisely packed in the CNS at an incredibly high density (estimates range from ~ 2 × 108 to 4 × 109 in rat’s brains) , finite element method (FEM) structures, biomechanics, and computational neurophysiology and neurobiology. A coupling between primary injury models  and the secondary mechanism models (neurobiology) is also required. Development of complex and computationally expensive high-fidelity 3D models for a human and an animal  should be accompanied with the development of “reduced” (compact) but computationally fast models using approximate anatomic/geometric representation, yet affording advanced models of neurobiology. The model development effort should be paralleled with model-guided experiments on neural cells and brain tissue cultures, animal models, physical surrogates, and to some extent on humans to generate benchmark quality data for model validation and scaling.in vitro and in vivo experimental data. There are however, several mathematical models of neurophysiology and neurobiology which could be used as a starting point for the development of a comprehensive model of the secondary mechanisms  models  needed for the development and validation of mathematical models of secondary brain injury and repair mechanisms. We envision that the next generation of in vivo and in vitro micro-biomechanics models will be able to elucidate neuroaxonal injury mechanisms and will help establish brain region and insult specific injury criteria.Finite element method biomechanics models may also be used to simulate brain tissue/cell damage at the micro-scale. Mathematical models of mechanical damage to neuroaxonal structures may be able to describe damage to cell membranes, cytoskeleton, ion channels, synaptic clefts, dendrites, and axons. These in turn, could provide inputs for the secondary injury and repair models, simulating electrophysiology and ion homeostasis, alterations in metabolism, neuroexcitation, cytotoxic edema, oxidative stress, apoptosis, and other injury and repair mechanisms. In the last few years, the first FEM biomechanics simulations of very simplified axonal structures have been reported . The micromechanical model could be coupled to cellular electrophysiology and neurobiology models to simulate various secondary events such as solute, electrolytes and water shifts, cellular depolarization, local cytotoxic edema, initial hypermetabolism needed for repolarization, loss of action potential signals due to damage to ion channels, and current leaks, loss of synaptic transmission due to spillover of neurotransmitters outside of the synaptic cleft, synaptic plasticity , and other mechanisms. The results of such a model may be able to show that the exacerbated secondary mechanisms, not just the initial mechanical injury, may be responsible for the long-term neurocognitive effects. This in turn could identify targets for neuro-interventions and optimal treatment strategies. The development and validation of such models will require detailed spatiotemporal experimental data from Mathematical modeling of coupled micro-biomechanics and electrophysiology of neuronal injury has not been reported yet, but has been identified as an important recommendation , or cells/tissues have been placed inside or in front of a shock tube  heads. Several teams have used the HYBRID III head/neck phantoms as well as custom human head phantoms to evaluate its mechanical responses to shock tube loads  for culture maintenance. Nevertheless, at this time the in vitro models are probably the best platform to develop and validate mathematical models of secondary brain injury. To the best of our knowledge, with the exception of the primary biomechanics of the in vitro tissue, limited work has been documented on mathematical models of in vitro neurotrauma . FEM models of primary biomechanics, validated on head phantoms and animal models, could provide a better understanding of how the blast load is transmitted to the brain, where the blast energy is deposited and how to design the protective armor to minimize the blast energy transmission to the brain. Predicted macroscopic tissue strains, strain rates and stresses may provide “initial conditions” for modeling microscopic tissue damage that could be correlated with injury thresholds from High resolution computational models of a human and rat head/neck and articulated whole body models for blast wave and biomechanics simulations, specifically improved morphological resolution of brain structures such as CSF, sulci, gray/white matter, and vascular systemAnatomic geometry and morphology of selected brain tissue structures such as cortical gray matter, dendritic/synaptic structures, and axonal network in corpus callosum, to support multiscale models of tissue micro-damagein vitro cell/tissue cultures and human head physical phantoms to provide data for validation of blast biomechanics modelsBenchmark quality, reproducible experimental models replicating blast injury mechanisms in animals, in Constitutive material models of high strain rate brain tissues for macro- and micro-biomechanics analysis of tissue damage and cavitationImproved numerical methods for modeling FSI events , cavitation, presence of vascular structures and enable long-time simulationsCalibrated reduced order models for fast simulations of coupled primary injury biomechanics, cerebral hemodynamics, tissue perfusion, secondary injury, and repair mechanisms and structural and functional deficitsin vitro to animals to humansModel based scaling of the injury and repair dynamics from Model-guided development of load- and tissue-specific brain injury criteria and thresholds and their effects on the neurological outcomeEffective use of brain injury models to support diagnostics , prescribed resting period and return to duty, development of drug targets, exploration of novel protection and treatment methods , and injury specific optimal pharmacology  and treatment Support development of novel head  protective armor.The views expressed in this paper are those of the authors and may not necessarily be endorsed by the U.S. Army or U.S. Department of Defense.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.


Intervertebral disc degeneration (IVD) is a frequent pathological condition. Conservative management often fails, and patients with IVD degeneration may require surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. The aim of biological strategies is to prevent and manage IVD degeneration, improve the function, the anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells, and inhibit matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of mesenchymal stem cells and gene therapy for the prevention and treatment of IVD degeneration. The normal intervertebral disc (IVD) has a rich extracellular matrix (ECM), and three parts are anatomically distinguished: the central gelatinous nucleus pulposus (NP), which contains chondrocyte-like cells surrounded by a more fibrous annulus fibrosus (AF) containing fibroblast-like cells along with cartilaginous endplates (EP) connecting the adjacent vertebral bodies –6.The IVD matrix consists of a well-organized framework of macromolecules which are able to attract and retain water . The strFunctionally, the collagen provides shape and tensile strength, while proteoglycans confer tissue viscoelasticity, stiffness, and resistance to compression, through their interaction with water.A proper balance between matrix synthesis/apposition and degradation is responsible for the maintenance of the integrity of the IVD and hence the mechanical behaviour of the IVD itself. This is related to the activity of cytokines, growth factors, enzymes, and enzyme inhibitors that act in a paracrine or/and autocrine way –11.With aging, morphological and molecular changes in the IVD can induce progressive degeneration and pathologic alteration of this particular tissue . The morA variety of growth factors have anabolic function in IVD cell metabolism, resulting in accumulation and synthesis of matrix, while the opposite effect has been observed for cytokines, since they inhibit the synthesis of IVD matrix and promote the catabolic breakdown of its components , 17.Although inflammatory mediators have been detected in IVD degeneration conditions, the actual pathologic role of these mediators is either unknown or not well defined. Nitric oxide (NO), interleukin-6 (IL-6), prostaglandin E2 (PGE2), TNF-alpha, fibronectin, and matrix metalloproteinases (MMPs) are few of the many identified mediators , 18, 19.IL-6, NO, and PGE2 seem to exert an inhibitory effect on proteoglycan synthesis. These factors are activated by interleukin-1 (IL-1), which also plays a role in the direct degradation of the proteoglycan matrix. This direct breakdown process by IL-1 occurs through a family of enzymatic mediators known as MMPs. In the cascade of inflammatory mediators, IL-1 likely plays a major role, although the nature of such role has not been defined yet.To find new efficient treatment options, further investigations are required to identify the mediators that promote IVD degradation or matrix accumulation with the aim of targeting the homeostatic state of IVD-matrix metabolism by modulating the factors involved in synthesis and degradation towards the most favourable state to ensure their metabolic balance. Only recently, considerable attention has been placed on the use of stem cells as a clinically applicable therapeutic option for IVD degeneration. in vitro and in vivo experiences currently available.The aim of this paper was to report the state of the art on the treatment of IVD degeneration (IVD-d), with mesenchymal stem cells (MSCs) based on the An active regulation and balance between anabolism and catabolism of the IVD cells is responsible for the maintenance of the physiological homeostasis in IVD tissue.This mechanism is guaranteed through a complex and accurate coordination of the effect of a number of substances and molecules, including growth factors, enzymes, enzyme inhibitors, and cytokines, that act in a paracrine or/and autocrine way.IVD degeneration commonly begins during the second decade of life, and it progresses towards severe conditions with ageing .The lack of an adequate nutrient supply , along wIVD herniation, radiculopathy, myelopathy, spinal stenosis, instability, and low back pain represent the common medical conditions usually associated with symptomatic IVD-d, and they represent the most common among the conditions managed by spine surgeons, in addition to being the leading cause of disability in people younger than 45 years of age.Various therapeutic strategies have been proposed for IVD-d in the last decade, with the most frequently used ones consisting of surgical interventions characterized by discectomy with vertebral fusion or, as an alternative, conservative management of IVD-d . Neither of such approaches deals with the loss of IVD tissue, and therefore new biological strategies appear challenging.Researchers and clinicians have focused their attention on tissue engineering and regenerative medicine to identify long-term tissue repairing options offering the possibility to restore IVD tissues .Attention has been posed on stem cells as a potential source of cells to repopulate and regenerate the IVD. There is a large number of potential sources of MSCs, including adipose tissue, bone marrow, and other tissues , 23 as eIn terms of IVD regeneration, many studies have shown that IVD-d can be treated or repaired with the injection of MSCs, multipotent cells able to differentiate into tissues of mesenchymal origin including bone, cartilage, fat, muscle, and fibrous tissues depending on the biological environment. These cells can be obtained from multiple adult tissues, including bone marrow, trabecular bone, articular cartilage, muscle, and adipose tissue, which represent a variant of the adult stem cell.Several authors have speculated that MSCs can also differentiate into the chondrocyte-like cells present in the NP, but, since the phenotype of NP cells has not been clearly characterized yet, confirmation of the differentiation from MSCs to NP cells has not been achieved , 25, 26,While a variety of cell sources in the field of stem cell research have been proposed for clinical application , autologBased on the high incidence of symptomatic IVD-d caused by disc herniation, radiculopathy, myelopathy, spinal stenosis, instability, and low back pain, there is a great interest around the use of MSCs to repair degenerated IVD tissues. Since the IVD phenotype of NP cells has not been clearly defined yet, there is still a lack of knowledge about differentiation from MSCs to NP cells, complicated by the fact that AF, NP, and EPs components are differently composed of cartilage or bone and matrix. in vitro experiments have demonstrated that the application of growth factors and specific culture conditions can guide MSCs to differentiate into particular cell phenotypes [Nevertheless, enotypes .in vitro study conducted with MSCs cultured in the presence of TGF-b, it was observed that the MSCs were able to express a phenotype similar to NP cells with the production of type II collagen and aggrecan [in vitro cultures, and subsequently the combination of hypoxia and TGF-b1 exposure proved to advance differentiation of the MSCs into an NP-like phenotype. On the basis of this experience, researchers suggested that the hypoxic environment of the IVD could promote differentiation of the MSCs towards an NP-like phenotype in vivo [In an aggrecan . Moreove in vivo , 32.in vivo may be applied without any need to differentiate the MSCs before implantation [The effect of cocultures of MSCs with AF and NP cells obtained from human degenerative IVDs in 3-dimensional pellet cultures has also been investigated. The coculture determined an increased proliferation in both the MSC-AF and MSC-NP cultures, but a higher proteoglycan production was found only in the MSC-AF coculture. Based on the interaction between AF cells and MSCs, a direct implantation of the MSCs antation . In their research in the IVD implantation of MSCs, Sakai et al. –36 initiTo repair the matrix of degenerative NP tissue, transplanted cells must produce large quantities of collagen, proteoglycans , and other matrix proteins . GeneralMoreover, in coculture of NP cells and ASCs combined in micromasses, separated by a permeable membrane to allow the diffusion of soluble factors, an upregulation of the aggrecan and collagen II expression was detected . Therefoin vitro both in terms of 3D cell organization and matrix production [Coculture of human NP and ASCs improves the quality of the tissue reconstructed oduction . Conversoduction . However, adipose tissue might be considered as an adequate source of stem cells for clinical use, based both on the ease of the procedure to retrieve adipose tissue and the cell quantities that can be obtained. In fact, on one hand, the collection of adipose tissue occurs through a minimally invasive procedure allowing for this to be straightforwardly performed in outpatient clinics, and, on the other hand, it allows for yields of adherent ASCs to reach up to 25,000/g of tissue. Therefore, although somewhat new in the stem cell research area, ASCs have gained intensive attention as a cell source in bone and cartilage repair  and the The results of cocultured rabbit ASCs with NP tissues through a specifically designed device showed that ASCs responded to soluble mediators from NP tissues . In expein vitro and in vivo study. In the in vitro portion of the study, in which bone-marrow-derived stem cells (BSCs) and IVD cells were cocultured, the results showed an improvement of ECM production, while the in vivo study persistence of BSC for at least 24 weeks after implantation in rabbit IVD was shown [Recently, confirmation of the feasibility of a stem cell therapy for IVD repair has been obtained by a parallel as shown .The future of treatment options for IVD degeneration should deal with evidences regarding the use of MSCs in animal studies. The possibility of allogeneic MSC transplantation has also been suggested and should be considered , based oIt is theorized that the use of autograft MSCs may have the same genetic predisposition for degeneration as the native NP cells, while it should be possible to escape this genetic predisposition by using an allograft cell population. The use of allograft MSCs may in fact allow for the selection and maintenance of a cell population that is less likely to undergo degeneration. Also, in comparison to collection and culture of MSCs for each individual patient, allograft cells could be maintained for “off the shelf use” with a higher convenience and reduced costs .in vivo animal experiments conducted with the implant of MSCs into the IVD have highlighted promising results in terms of long-term viability of the implanted cells and differentiation into a phenotype similar to the native NP cells with the production of type II collagen and aggrecan [Several aggrecan .Crevensten et al.  were theSubsequently, allograft MSCs were also transplanted into the New Zealand white rabbit: the cells survived, proliferated, and differentiated into native NP cells like phenotype. After grafting, the animals were followed for 6 months, and no immune reactions occurred towards these allograft cells. In the IVDs treated with MSCs, type II collagen production along with an increased proteoglycan concentration was detected .The effectiveness of MSC transplantation has also been confirmed in large animal models (chondrodystrophoid breed canine with nucleotomy) closer to humans. In fact, in a canine model of IVD degeneration, MSC transplantation determined a positive outcome on preservation of immune privilege, possibly by differentiation of the transplanted MSCs into FasL expressing cells . These din vivo viability of allograft NP tissue, the “immunologically privileged” environment of the avascular IVD space may also allow for long-term viability of allograft stem cells [Other researchers have also investigated the use of allogenic MSCs for IVD regeneration, despite the concerns for immunologic rejection of the allograft tissue. Similarly to previous experiences showing em cells , 60.The ability of allogenic MSCs to escape alloantigenic immune recognition and determine an immunomodulatory effect has been noted also in other studies , 62. TheAn immunomodulatory effect of MSCs on the local environment by producing anti-inflammatory cytokines such as TGF-b and IL-10 has also been reported , 63. In  in vivo can survive, proliferate, and differentiate into cells expressing the phenotype of NP cells with suppression of inflammatory genes [Several studies have now confirmed the effectiveness of MSC transplantation, demonstrating that MSCs transplanted into degenerating IVDsry genes .There are a large number of different types of stem cells and a variety of possible sources of MSCs including bone marrow, adipose tissue, and other tissues that have received significant attention as potential sources of cells to repopulate and regenerate the IVD.Bone marrow aspiration, which has been used by spinal surgeons in fusion procedures, is an excellent source of MSCs . When boRecently, other stem cells such as synovial MSCs have been studied as a potential source of cells to be used for IVD-d. In an induced IVD-d model in rabbits, allogenic synovial MSCs have been transplanted and evaluated up to 24 weeks postoperatively with imaging analyses such as magnetic resonance imaging, radiographs, and histological analysis. T2-weighted MR imaging revealed a higher signal intensity of the NP in the MSC group. Radiographs showed that the height of IVD in the MSC group remained higher compared to that in the degeneration group. Immunohistochemical analyses showed a higher expression of type II collagen around NP cells in the MSC group compared to that of the normal group. These results brought to the conclusion that synovial MSCs injected into the NP space promote synthesis of the remaining NP cells to type II collagen as well as inhibition of degrading enzymes and inflammatory cytokines expression, resulting in the structure of the intervertebral IVD being maintained .Several authors have recently reported their successful results using different types of stem cells, but there is still a lack of published evidence regarding adipose-derived stem cells (ASCs) implantation for IVD degeneration management, and, only recently, experiments with ASC have confirmed this type of stem cells as another potential cell source for IVD repair and regeneration. In fact, in a goat ABC chondroitinase degeneration model , ASC canDespite the promising results deriving from animal studies, there is still a lack of studies performed in humans. To our knowledge, the only trial conducted in humans, a nonrandomized, noncontrolled study evaluating autologous hematopoietic stem cells transplanted into IVD for the treatment of low back pain in 10 patients, did not report any significant improvement of the patients' condition . Therefore, further research and randomized controlled studies are required for a better definition of the effectiveness of the administration of ASC, rather than BSC or other types of stem cells for the management of IVD degeneration.


Etiological treatment of peri-implantitis aims to reduce the bacterial load within the peri-implant pocket and decontaminate the implant surface in order to promote osseointegration. The aim of this literature review was to evaluate the efficacy of different methods of implant surface decontamination. A search was conducted using the PubMed (Medline) database, which identified 36 articles including in vivo and in vitro studies, and reviews of different decontamination systems . There is sufficient consensus that, for the treatment of peri-implant infections, the mechanical removal of biofilm from the implant surface should be supplemented by chemical decontamination with surgical access. However, more long-term research is needed to confirm this and to establish treatment protocols responding to different implant characterics. Key words:Peri-implantitis, treatment, decontamination, implant surface, laser. Treatments using dental implants to replace missing teeth are effective and predictable and show good long-term success rates ,2. HowevPeri-implantitis has been defined as an inflammatory lesion of the tissues surrounding the implant subjected to functional loading, with a loss of supporting bone.When affectation is limited to the mucosa and does not involve bone loss, it is known as mucositis .Aggregatibacter Actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia y Treponema denticola)  .According to Teughels et al. , in addiLongitudinal prospective studies of peri-implant disease are needed to identify the real risk factors for peri-implant disease, but to date few have been published. A systematic review of research published before January 2008  identifiThe objective of the present review was to evaluate the information available in the literature as to the efficacy of different mechanisms for decontaminating implant surfaces in the treatment of peri-implantitis.peri-implantitis and sub-terms prevention and control and treatment. The search was then refined using a combination of the terms: peri-implantitis and decontamination; implant surface decontamination; peri-implantitis and treatment; laser decontamination of implant surface.An Internet search was made using the PubMed (Medline) database. Clinical studies, meta-analyses, clinical guides and reviews published during the last ten years were included. The search strategy used the MeSH browser and the search term Of the 135 articles identified in the search only 36 fulfilled the quality criteria as recommended in recent literature ,9. StudiAll literature reviewed analyzed the diverse methods of implant surface decontamination which were classified as two main groups: chemical and physical. The latter was sub-divided into mechanical decontamination techiques and laser decontamination techniques. Photodynamic therapy, a technique covered by various authors, falls into either category as it combines light-sensitive chemical agents with lasers used to promote their cytotoxicity. The relevant features of each method are as follows.-Physical Decontamination Methods.Mechanical The mechanical removal of biofilm from the implant surface is considered a priority for the etiological treatment of peri-implantitis. Its objective is the elimination of toxins from the implant surface in order to produce a surface compatible with health, to promote re-osseointegration. The main difficulty lies in the implant’s surface roughness, which facilitates bacterial adhesion and colonization. One of the techniques proposed for dealing with this is implantoplasty, that is, the mechanical elimination of surface roughness together with the implant thread. This technique allows to optimize the maintenance and facilitates the oral hygiene to the patient when implant threads are exposed. There are few studies that show the clinical and radiological long-term outcomes of implantoplasty. Romeo et al. ,11 showeSandblasting systems using different abrasive particles have been used for the surgical treatment of peri-implantitis in animals and humans, without producing adverse effects. The use of this technique on smooth or roughened surfaces makes them less susceptible to bacterial adhesion, possibly because of the modification of the surface texture and because of the presence of abrasive deposits , but it In peri-implantitis treatment, mechanical debridement of granulation tissue with teflon curettes and abrasive sodium carbonate air-powder, performing full thickness flap elevation, produces clinical  and microbiological improvements after three months ,15.A review realized in 2004 concluded that bicarbonate air-powder abrasion systems and physiological saline obtain the best results for eliminating endotoxins and detritus from all surfaces .-Decontamination Using Laser Laser decontamination is based on its thermal effect, which denatures proteins and causes cellular necrosis.The use of Er:YAG laser has been widely studied in recent years and has been shown to be effective for biofilm removal, having bactericidal effects that do not damage implant surfaces . Its useKreisler et al. , using sIn agreement with these findings, a literature review showed that the application of CO2 and diode lasers with different wave lengths were effective for eliminating bacteria without producing alterations to the surfaces treated. Nor were significant rises in temperature detected in the implant body .Photodynamic Therapy (PDT)Photodynamic therapy is a technique that uses a photosensitizing substance that fixes itself to the bacteria of the biofilm, and when irradiated with laser, cytotoxic singlet oxygen is produced which is able to destroy the bacterial cells. The use of PDT and lasers has generated much interest because of its potential for decontamination of implant surfaces in peri-implantitis treatment. A recent review of in vitro studies, which aimed to analyze the effect of laser on titanium surfaces, has shown that it is possible to carry out photosensitization which is lethal to bacteria but does not damage the implant surface . PDT app-Chemical Decontamination and Antibiotic Therapy in vitro studies on different types of implant surface.Chemical decontamination involves the localized use of anti-microbial solutions such as topical chlorhexidine, tetracycline or minocycline, citric acid, hydrogen peroxide or 35% phosphoric acid gel, in combination with mechanical debridement for elimi-nating hard and soft deposits . CompariReviews made by various authors conclude that 40% citric acid with pH 1 for 30-60 seconds has proved the most effective agent for the reduction of bacterial growth on HA surfaces, although clinical application at a more acidic pH could affect the peri-implant tissues and if the time of application is prolonged this can affect the union between the HA and the implant body. Chlorhexidine has been seen to be ineffective on HA surfaces. Machined titanium decontaminates more effectively than other surface types, with topical applications of tetracycline as the antibiotic of choice ,25,26. Hin vitro and in humans are needed to determine its efficacy for decontaminating implant surfaces  and metronidazole (400 mg) for seven days, together with 0.20% chlorhexidine mouthwash, twice daily for four weeks  in combination with cetylpyridinium chloride (CPC), compared with a placebo. The study group showed greater suppression of anaerobic bacteria than the placebo group in the short term. However, the results were not clinically significant and the microbiological effects in the long term remain unknown . Accordie others , althouge others ,25,26.Recent studies have shown the usefulness of lasers for decontaminating titanium implants. The most frequently used are Er:YAG, CO2 and diode due to their haemostatic properties, the selective elimination of calculus and bactericidal effects, which achieve complete or almost complete elimination of bacteria from titanium surfaces, providing they are used within the appropriate parameters for each surface type . GaAlAs Aggregatibacter Actinomycetemcomitans, P gingivalis and P intermedia on different implant surfaces, reduce bleeding on probing and inflammation, but more long-term clinical studies are needed to confirm its effectiveness . An application of toluidine blue with soft laser irradiation has been shown to significantly reduce the presence of tiveness ,25.The real influence of decontamination techniques on the implant surface remains unknown as there have been few studies made using human subjects. However, the scant information available does suggest that smooth implant surfaces are less affected by peri-implantitis than roughened ones . Animal There are few clinical studies in existence that evaluate the etiological treatment of peri-implantitis in isolation. Most combine this with regenerative techniques of the bone defect caused by the disease, a factor that might obscure the true outcomes of decontamination treatments. Nevertheless, there would appear to be sufficient consensus that, for the treatment of peri-implant infections, the removal of the biofilm from the implant surface should be supplemented by chemical decontamination by means of surgical access. Due to the great heterogeneity of studies, which have used empirical combinations of different decontamination methods, and the variablility of the implant surfaces treated, it is impossible to establish a single protocol for implant decontamination for peri-implatitis treatment. Further long-term clinical studies are needed to confirm the results of the present review and to establish treatment protocols in direct relation to each implant and surface type to be treated.


Simulation is a modern educational tool that has recently gained in the field of medical education. The use of simulation continues to expand, and studies evaluating the effectiveness of simulation-based medical education are ongoing. The history of medical education and adult educational theory are reviewed, and the details of effective simulation techniques are described. Finally, outcomes of simulation-based medical education are summarized. Over the past century, medical education in North America has been delivered based on the principles described and implemented by Abraham Flexner in 1910. He recommended that medical school education consist of two years of basic science education and two years dedicated to clinical experienceLike the aviation industry, medicine is perceived as a technologically innovative and high-stakes profession. Technological advances require healthcare providers to develop new psychomotor and visual-spatial skill setsDr. Gaba, a pioneer of simulation in medical education, defined simulation as an instructional process that substitutes real patient encounters with artificial models, live actors, or virtual reality patientsLearners in medical education at all levels are typically adult learners. Adult learners characteristically want to know why they are learning, prefer to problem-solve, have diverse backgrounds, possess knowledge assumptions based on prior experiences, and demand an educational process that is active and immediately applicableDebriefing is the process in which instructors and learners reexamine the clinical scenario through reflective discussion. Critical Incident Stress Debriefing (CISD) was developed by Mitchell with the intent of helping health care workers better manage the stress and emotional tension of critical medical events by reviewing facts, events and reactions with a facilitator Debriefing consists of three phases: recollection of scenario events and participant actions, exploration of the feelings and emotions experienced, and analysis and application to real-life situationsThe simulation experience stimulates critical thinking, decision-making and clinical judgment. It provides the adult learner with active, experiential learning and enables participants to practice rare or emergent medical conditions in a safe, non-threatening environment. Learners can make mistakes without fear of injuring an actual patient ; animal models; human cadavers; interactive video-based simulation   as well as the desired level to be achieved. In the cognitive domain, knowledge and comprehension do not require simulation. On the other hand, application and analysis can be easily taught, observed and debriefed after a simulated experience. The use of simulation for the planning of a new procedure is an example of simulation being used at the level of synthesis and perhaps even evaluation. Simulation has been used for the development of the affective domain of learning. Training of team, leadership, and organizing behaviors can be successfully done with the use of simulation. The utility of simulation for teaching different visual-spacial skills and for practicing procedures are well-documented in the literature. However, teaching with simulation requires a careful evaluation of whether or not the learner has achieved complex overt response -a level of psychomotor skills that they will transfer from the simulation laboratory into clinical practice.The types of simulators available and the most effective type for teaching the particular objectivesSimulation has been proposed as an educational modality that improves safety in High Reliability Organizations and has been extensively utilized in the aviation industry. In medicine, simulation has been used for routine training for emergencies, developing teamwork, establishing an environment for discussing errors without punishment, evaluating and testing new procedures for safety, assessing competence, testing usability of devices, investigating human performance, and providing skills training for novices outside of the clinical environmentWhen assessing the value of an educational experience, one needs to consider Miller's four levels of clinical competence assessment n. An individual moves from knowledge through integrated knowledge, competence and finally to performance; Miller called these four stages 'Knows, Knows How, Shows How, and DoesSelf-efficacy, which reflects one's beliefs about the ability to perform actions (Knows and Knows How). Crisis resource management courses have demonstrated effectiveness on self-efficacy for emergency medicine residentsCompetence, which demonstrates one's ability to perform a task in the simulated environment (Miller's Shows). Procedural simulators and high-fidelity simulations have been shown to increase trainee competence in emergency airway managementOperational performance, which measures how competent care in a simulated environment translates into clinical care (Miller's Does). Numerous studies investigating the effect of simulation training on laparoscopic skills of residents demonstrate the transfer of skills from the simulation laboratory into the clinical environmentPatient outcome, which analyzes the positive effects of learning for patient care. The impact of simulation education on actual patient safety is of paramount importance. In recent years, evidence has accumulated that supports the beneficial effects of SBMETwo questions related to patient outcomes have been explored in the literature. The first evaluates whether education with simulation improves knowledge, skills and attitudes and thus translates into a better patient outcome. The second question explores the persistence of the educational effects.Several systematic reviews and meta-analyses have examined these issues. Cook and coauthors evaluated the outcomes of technology-enhanced simulation training for health professions in comparison to no interventionRoss and coauthors reviewed studies of simulation-based education in anesthesia-related journalsP < 0.001).Another quantitative meta-analysis by McGaghie and coauthors reviewed simulation-related publications over two decades (1990-2010)Besides the effect SBME can have on patient management skills, an important aspect of SBME resides in interdisciplinary team training. By analyzing existing teamwork patterns and communication principles, inefficient practices can be uncovered and corrected. Frequently, the cause of adverse events can be related to institutional policies and their implementation. Simulation team training can be utilized to identify system-level, specialty-specific practices, policies or procedures that could adversely affect patient careSkills acquisition longevity is another important aspect of any educational effort. Do the learners maintain their skills levels or do they deteriorate rapidly following the educational experience? Several recent studies have shown positive effects in terms of long-term effects. Wayne and coauthors have shown that ACLS skills acquired by internal medicine residents in the simulation laboratory persist for up to 14 months post-trainingSimulation-based education has been in use for several decades and its usage is likely to continue expanding. Evolving public expectations about the safety of medicine  as well as decreasing resident patient contact hours are some of the factors involved in an increased need for SBME. Simulation training is a proven training modality in other high-risk industries, and it should be increasingly utilized in the high-stakes field of medicine. Studies support its positive effects on learner knowledge, skills and behaviors, and patient outcomes by translating skills from the simulated environment to the clinical environment.


Epidemiological, clinical, physiological, cellular, and molecular evidence suggests that the origins of obesity and metabolic dysfunction can be traced back to intrauterine life and supports an important role for maternal nutrition prior to and during gestation in fetal programming. The elucidation of underlying mechanisms is an area of interest and intense investigation. In this perspectives paper we propose that in addition to maternal nutrition-related processes it may be important to concurrently consider the potential role of intrauterine stress and stress biology. We frame our arguments in the larger context of an evolutionary-developmental perspective that supports roles for both nutrition and stress as key environmental conditions driving natural selection and developmental plasticity. We suggest that intrauterine stress exposure may interact with the nutritional milieu, and that stress biology may represent an underlying mechanism mediating the effects of diverse intrauterine perturbations, including but not limited to maternal nutritional insults (undernutrition and overnutrition), on brain and peripheral targets of programming of body composition, energy balance homeostasis, and metabolic function. We discuss putative maternal-placental-fetal endocrine and immune/inflammatory candidate mechanisms that may underlie the long-term effects of intrauterine stress. We conclude with a commentary of the implications for future research and clinical practice. A growing body of empirical evidence suggests that the origins of obesity and metabolic dysfunction can be traced back to the intrauterine period of life, at which time the developing fetus is acted upon by and responds to suboptimal conditions during critical periods of cellular proliferation, differentiation, and maturation by producing structural and functional changes in cells, tissues and organ systems. These changes, in turn, may have long-term consequences to increase the individual's risk for developing a range of complex common disorders including, but not limited to, obesity and metabolic dysfunction . A larg For these reasons, we highlight and review below the effects of stress and stress biology on fetal programming of body composition, obesity, and metabolic function. We review empirical evidence for interactive effects between stress and nutrition, describe findings from some of our own recent studies on prenatal stress and stress biology, and discuss putative maternal-placental-fetal endocrine and immune/inflammatory candidate mechanisms that may underlie and mediate short- and long-term effects of prenatal stress on the developing human embryo and fetus, with a specific focus on body composition, metabolic function, and obesity risk. We conclude with a commentary of the implications for research and clinical practice.The origins of health and disease susceptibility for many of the complex, common disorders that confer the major, global burden of disease in developed societies as well as other societies in rapid transition can be traced back to the intrauterine period of life. Development is a plastic process, wherein a range of different phenotypes can be expressed from a given genotype (contained within the fertilized zygote). The unfolding of all developmental processes across the multicontoured landscape from genotype to phenotype is context-dependent, wherein the developing embryo/fetus responds to, or is acted upon by, conditions in the internal or external environment during sensitive periods of cellular proliferation, differentiation and maturation, resulting in structural and functional changes in cells, tissues, and organ systems. These changes may, in turn, either independently or through interactions with subsequent developmental processes and environments, have short- and/or long-term consequences for health and disease susceptibility. These concepts have variously been referred to as the fetal or developmental origins of health and disease risk , 6.The rationale for considering a role for stress and stress biology in fetal programming of child and adult obesity and metabolic dysfunction derives, in part, from concepts in evolutionary biology and developmental plasticity. From conception onwards the mother and her developing fetus both play an obligatory, active role in all aspects of development. Based on the consideration that key environmental conditions that have shaped evolutionary selection and developmental plasticity include not only variation in energy substrate availability  but also challenges that have the potential to impact the structural or functional integrity and survival of the organism , it is likely and plausible that prenatal stress represents an important aspect of the intrauterine environment that would be expected to influence many, if not all, developmental outcomes . Moreovein utero stress as a contributor to subsequent risk of obesity and metabolic dysfunction derives from the effort to elucidate and better understand the underlying reason(s) for the well-documented, persistent and large socioeconomic and racial/ethnic disparities in the population distribution of these outcomes in the US and other developed nations. Many of the factors that disproportionally affect socially disadvantaged individuals, such as medical care, diet/nutrition, and health-related behaviors, have been shown to play only a limited role in accounting for these disparities [ Another compelling rationale for considering a role for parities –12. The parities , 13. A large body of the literature supports the notion that conditions in the early postnatal period of life  can induce changes in the metabolic, endocrine, cardiovascular, and behavioral phenotypes, and these effects could be independent of prenatal exposures or could moderate or mediate the effects of prenatal adversity. Several of these findings are derived from animal (rodent) models, in which maturational status over the first two weeks of postnatal life is approximately equivalent to that of the human during the third trimester of gestation. A comprehensive summary of the effects of early postnatal life stress is beyond the scope of the current paper, but we refer to reader to excellent recent reviews on this topic , 15.Obesity and metabolic dysfunction are complex, multifactorial outcomes. At the individual level, the major risk categories include sociodemographic, nutritional, historical, biophysical, obstetric, behavioral, psychosocial, genetic, and other environmental factors. Studies of the effects of stress and stress-related processes on these outcomes generally treat other risk factors as potential confounding variables and attempt to account (adjust) for their putative effects by either study design (subject selection criteria) or statistical adjustment. However, emerging concepts of causation for complex common disorders, including but not limited to obesity and metabolic dysfunction, suggest it is not only possible, but in fact probable, that causation does not reside in any single factor or in the additive effects of numerous factors, but lies at the interface between multiple risk factors (interaction or multiplicative ). We con As discussed briefly in the preceding section, the two fundamental processes that are believed to shape evolutionary selection and developmental plasticity are variation in energy substrate availability (nutrition) and challenges that have the potential to impact the structural or functional integrity and survival of the organism (stress). Maternal nutrition, assessed by indicators of body size such as body mass index (BMI), nutritional intake or serum measures of nutritional biomarkers, is a well-established risk factor for childhood and adult obesity and metabolic dysfunction. Growing evidence supports the concept of a bidirectional interaction between nutrition and stress, such that the effects of nutrition on health may vary as a function of stress, or that the effects of stress on health may vary as a function of nutritional status. For example, several experimental studies in animals have demonstrated that nutritional manipulations, particularly in the preconception or early pregnancy period, may produce their effects on maternal and fetal outcomes via alterations in stress biology . Con We note that only a small number of studies have examined the relationship between maternal stress and diet or nutritional state in pregnancy. A study by Hurley et al.  found th Findings from a recent study on maternal high-fat diet during pregnancy suggest that the effects on offspring hypertension in adult life are mediated through an exacerbated sympathetic tone that arises very early in life . We note Despite the plausibility of stress-nutrition interaction effects in the context of pregnancy, we are not aware of any human studies to date that have examined these interactive effects during pregnancy on offspring body composition and metabolic function.The fetal programming hypothesis has led to the search for underlying mechanisms by which disparate intrauterine insults exert a multitude of effects on different physiological systems in the developing offspring. A question of particular interest relates to whether these biological mechanisms are exposure and/or outcome-specific, or whether there may be some common mechanisms that mediate the effects of various exposures on a range of disparate outcomes. We suggest that stress-related maternal-placental-fetal endocrine and immune processes in gestation constitute an attractive underlying common candidate mechanism because they are responsive to many classes of intrauterine perturbations and they act on multiple targets of fetal programming , 40. UnlStress biology refers to the set of biological adaptations in response to challenges or demands that threaten or are perceived to have the potential to threaten the stability of the internal milieu of the organism. The nervous, endocrine, immune, and vascular systems play a major role in adaptations to stress. There are no direct neural, vascular, or other connections between the mother and her developing fetus—all communication between the maternal and fetal compartments is mediated via the placenta, an organ of fetal origin. Based on the physiology of stress, parturition and the evidence linking maternal stress to earlier delivery, we have previously proposed a biobehavioral framework of stress and adverse birth outcomes , that maPregnancy produces major alterations in neuroendocrine and immune function, including changes in hormone and cytokine levels and control mechanisms (feedback loops), that are crucial in providing a favorable environment within the uterus and fetal compartment for growth, differentiation and maturation, and conveying signals when the fetus is ready for extrauterine life. Starting very early in gestation the placenta, the first fetal organ to develop and function, produces hormones, neuropeptides, growth factors, and cytokines, and appears to function in a manner resembling that of compressed hypothalamic-pituitary-target systems .β-hydroxysteroid dehydrogenase enzyme system (see [Glucocorticoid physiology (cortisol in humans) has received extensive and well-placed consideration as a critical endocrine mediator of fetal programming, with an emphasis on not only hormone production but also hormone action mediated by tissue-specific glucocorticoid receptor expression, sensitivity and affinity, and by maternal-fetal transfer mediated by the activity of the placental 11tem , trophoblast expression of key immunomodulatory molecules, and a progressive switch from a THytokines .α, IL-1β, and IL-6, can activate components of the MPF neuroendocrine system [Although distinct neuroendocrine, immune/inflammatory, and vascular pathways have been described, growing evidence suggests that these and other physiological systems involved in pregnancy are highly interrelated, and that they extensively regulate and counterregulate one another. The potential complexity of the interrelationships among these physiologic systems is seen when considering the role of infection in the etiology of adverse fetal developmental and birth outcomes. For example, inflammatory cytokines that are produced in response to infection, such as TNF-e system –54. Conve system –57. Cente system . Impairee system . Thus, tSubstantial evidence in nonpregnant humans and animals demonstrates that stress exposure produces activation of the neuroendocrine system  and exaggerated inflammatory responses , 61; howα, with lower circulating levels of the anti-inflammatory cytokine IL-10 and ex vivo endotoxin (LPS)-stimulated levels of IL-1b and IL-6 [in vivo antigen challenge (influenza virus vaccination) in pregnant women reported an association between depressive symptoms and sensitization of the inflammatory cytokine responses [Studies by other groups have reported that elevated psychosocial stress in pregnant women is associated with higher circulating levels of inflammatory markers like C-reactive protein (CRP) and the proinflammatory cytokines IL-1b, IL-6, and TNF-and IL-6 , 66. Anoin vitro and in vivo evidence indicates that maternal-placental-fetal endocrine and immune processes during pregnancy respond to a variety of other maternal and intrauterine perturbations, including biological effectors of stress [ In addition to psychosocial stress, substantial f stress –72, obstf stress –70, gestf stress , 74, inff stress –78, reduf stress , 80, andf stress , 81, 82.JAMA editorial [Based on these findings, it is apparent that measures of maternal-fetal endocrine and immune/inflammatory stress markers capture physiological responses to a wide range of intrauterine perturbations including, but not limited to prenatal stress. In accordance with our suggestion that stress-related maternal-placental-fetal endocrine and immune processes in gestation constitute an attractive candidate mechanism for fetal programming, a recent ditorial  on an arditorial , specula1/TH2 cytokines), (iv) cognitive function , and (v) cellular aging (as indexed by leukocyte telomere length). Because subtle physiological differences in disease susceptibility are often not detected in basal state, we employed appropriate challenge tests to quantify the function of these systems under stimulated conditions .The majority of human epidemiologic studies of the fetal programming hypothesis have operationalized unfavorable intrauterine environments using indicators of adverse birth outcomes such as low birth weight. We and others have argued that the long-term effects on child or adult disease-related phenotypes of interest may not necessarily be mediated by adverse birth outcomes. For example, several experimental studies in animals suggest that maternal exposure to psychosocial stress during gestation can independently exert long-term effects on several central and peripheral systems in the offspring, and that titration of the prenatal stress exposure dose can produce significant long-term effects without necessarily altering the birth phenotype –89. Howe Our results . Obesity  is recognized as one of the most serious health problems in the US and other societies. At the individual level, obesity results when energy intake exceeds energy expenditure. However, the relationship between excess energy intake and adiposity is not linear and monotonic; there is wide variation among children or adults at identical levels of excess energy intake in their propensity to gain weight and accrue fat mass. This variation across individuals defines susceptibility for developing obesity/adiposity. Once an individual becomes obese, it is difficult to lose weight, and even more difficult to sustain weight loss, because of the remarkable efficiency of energy balance homeostasis mechanisms –103. ForIt is well established that the primary targets of programming of body composition, metabolic function, and obesity risk are the neural networks that regulate energy balance  and peripheral organs and tissues involved in fat synthesis/breakdown, storage and metabolic function . In this section, we consider and review findings that pertain to the potential role of prenatal stress biology in programming these major targets of interest see . Stress-related endocrine and immune processes in human pregnancy are associated with not only fetal development and birth outcomes but also with later disease risk. For example, we have reported that placental CRH concentrations in human pregnancy significantly predict the rate of fetal growth and size at birth , which, The central role of ventromedial hypothalamic (VMN) circuits in regulating feeding and energy balance is well established. VMH neurons contain receptors for and receive afferent signals related to fat stores (leptin), nutrient metabolism (insulin), hunger (ghrelin), and satiety (peptide YY), and they integrate peripheral signals of effectors of food intake and energy expenditure so as to prevent substantial variations in the level of energy balance . Also inIn vitro studies could show that the differentiation of human adipocyte precursor cells in the presence of insulin is stimulated by cortisol in a dose-dependent manner and occur at physiological concentrations [in vitro exposure of isolated human adipocytes to insulin and corticosteroids synergistically induces peroxisome proliferator-activated receptor (PPAR-γ) mRNA expression [Obesity is impacted by increases in fat cell number, size, or both. Fetal adipose tissue development is regulated by the complex interaction of maternal, endocrine, and paracrine influences that initiate specific changes in angiogenesis, adipogenesis, and metabolism . Adipogetrations , 120. Fupression .in utero “restricted” individual is born into a postnatal environment in which nutrient supply is no longer constrained, a period of “catchup” fat deposition ensues, mainly in the visceral adipose depot [ CRH seems to be an important regulator of adipocyte function, and CRH receptors are expressed in both white and brown adipocytes . The rolse depot . These ise depot  and, conse depot .α and the glucocorticoid receptors in the liver in offspring after birth, thereby altering their metabolic phenotype [The liver controls the production and fate of metabolic fuels through the action of hepatic enzymes. Phosphoenolpyruvate carboxykinase (PEPCK), a key enzyme in hepatic gluconeogenesis, is under potent glucocorticoid regulation. In animals, prenatal exposure to dexamethasone produces an increased expression of hepatic glucocorticoid receptors as well as increased levels and activity of PEPCK , therebyhenotype , 132. Inhenotype ). For exhenotype , 134. The ascertainment of genetic contributors to body composition, obesity, and metabolic dysfunction is an area of active and intense investigation. Although weight and body composition are highly heritable, known genes account for only a modest proportion of their variance –137. GenThe search for mechanisms by which environmental conditions during development can produce long-term changes in the structure and function of cells, tissues, and organ systems has led to the identification and study of epigenetic processes in the context of fetal programming of health and disease risk. A detailed review of epigenetics is beyond the scope of the current paper, and we have elaborated on this issue elsewhere , 140. Th We suggest that the incorporation of the genetics and epigenetics of stress and stress biology in the context of fetal programming of body composition, obesity, and metabolic function is likely to yield additional important information that supplements and complements investigations of nutrition-mediated genetic and epigenetic processes underlying fetal programming. As discussed above, many of the effects of maternal nutrition on the developing embryo and fetus may be mediated, in part, by stress hormones such as CRH and cortisol. Diet in prenatal or early postnatal life has been shown to alter the methylation status of several genes implicated in stress and stress physiology, including genes encoding the glucocorticoid receptor and proopiomelanocortin . Convers With respect to the issue of the contribution of stress and stress biology it is very likely that genetic and epigenetic variations will be determined to play an important role in moderating the association between intrauterine stress and obesity and metabolic dysfunction risk via maternal-fetal gene-gene and gene-environment interactions at multiple levels, originating with the likelihood of encountering stressful life circumstances, and culminating in modifying the effects of stress-related biological processes on relevant target tissues. For example, women who are carriers of certain genotypes  may be more likely to place themselves in stressful life circumstances –154. The To date, only a small number of studies have systematically addressed the issue of a genetic predisposition for susceptibility to psychosocial stress and related psychobiological states. For example, we and others have described that certain polymorphisms in the promotor region of the gene encoding the glucocorticoid receptor are associated with changes in the regulation of the HPA axis at different levels including basal level, feedback regulation, and response following a psychosocial stressor (summarized in ). Becaus Genetic and epigenetic mechanisms have been proposed to explain the observed racial/ethnic disparities in obesity and metabolic diseases, particularly with respect to the hypothesized contribution of prenatal stress. These observed racial/ethnic disparities are commonly assumed to reflect the burden of adverse societal conditions associated with minority racial/ethnic status in the US. Prenatal stress is a plausible mediator of the effects of race/ethnicity via one or both of two possibilities: greater cumulative exposure to stress and greater vulnerability to the effects of stress . The characterization of racial/ethnic differences in DNA sequence or epigenetic variation in genes associated with the stress response will prove particularly informative in this regard. For instance, we and others have previously reported significant racial/ethnic differences in stress-related hormonal states in human pregnancy , 158. ThBy incorporating the developmental programming approach into the traditional paradigm of causation of complex common health disorders, the focus shifts to placing a far greater emphasis on the health and well being of young women of reproductive age prior to conception and across gestation, in order to more effectively address health and disease risk-related issues in their offspring from infancy and childhood through adolescence and into adult life. A multilevel approach is required that includes molecular and cellular studies, the use of appropriate animal models, and well-designed human studies. In the context of human research, opportunities are limited for experimental manipulations of prenatal stress and the intrauterine environment, and for access to many of the target tissues of interest, particularly in fetal life. Hence, for future research purposes, the value of prospective, longitudinal, follow-up studies, ideally starting before conception, and extending through pregnancy and birth into childhood and beyond, is emphasized. For these studies, deployment of state-of-the art methods, including the assessment of metabolomic and gene expression profiles to precisely characterize maternal nutritional biomarkers and their interactive effects with stress biology during pregnancy, 3D/4D fetal ultrasonography for quantification of fetal growth (biometry), regional blood flow , hepatic and renal volume , 161, gr Regarding clinical implications, it is apparent that current approaches to the prevention and management of obesity and associated metabolic disorders have yielded only very limited success. Once an individual becomes obese, it is difficult to lose weight, and even more difficult to sustain weight loss –103; sysBased on the conceptual framework and empirical findings presented here, we suggest that in addition to maternal nutrition it is important to also consider the potential role of intrauterine stress and stress biology in arriving at a better understanding of developmental programming of health and disease susceptibility. Moreover, we submit that stress-related maternal-placental-fetal endocrine and immune processes in human gestation represent a potentially attractive underlying candidate mechanism for elucidating the common biological basis (pathway) for mediating not only the long-term effects of prenatal stress but also those of a host of other intrauterine perturbations including maternal over- and under-nutrition that have been implicated in this area.