Gorham's disease is a rare disorder involving the proliferation of endothelial channels resulting in resorption and disappearance of bone. An unusual case of polyostotic Gorham's disease affecting the scapula, humerus, radius, and ulna in a 39-year-old woman is described. The patient had extensive disease spreading across both the glenohumeral and humeroulnar joints. This is the first report of Gorham's disease spreading across multiple joints in the upper extremity. Massive spontaneous osteolysis of bone was first described by Gorham et al.  in 1954  It is a very rare disorder characterized by abnormal proliferation of thin-walled endothelial-lined channels of vascular or lymphatic origin and an increased number of osteoclasts resulting in progressive resorption of bone . The preTo date, approximately, 200 cases of Gorham's disease have been described in the world literature of which approximately 40 have involved the upper extremity . The greThis paper presents an unusual case of polyostotic Gorham's disease affecting the scapula, humerus, radius, and ulna and, to our knowledge, is the first report of this disease spreading across multiple joints in an adult.A 39-year-old female initially presented to an emergency room 8 years ago complaining of right arm pain after a fall. X-rays taken at that time revealed a destructive lytic process involving the humerus, radius, and ulna with chronic dislocation of the humeroulnar joint . She wasOn physical exam, the skin of the right upper extremity had no cutaneous lesions and there was no sign of infection. Her extremity was diffusely tender and mildly swollen from the shoulder to the wrist. Range of motion of the shoulder, elbow, and wrist was very limited and painful. She had globally decreased motor function and sensation of the hand; however, the vascular examination was normal.Laboratory studies including complete blood count, complete metabolic panel, alkaline phosphatase, C-reactive protein, erythrocyte sedimentation rate, and serum and urine protein electrophoresis were all within normal limits.Plain radiographs of the right upper extremity revealed diffuse osteopenia with extensive radiolucent foci in the intramedullary and subcortical regions of the scapula, humerus, radius, and ulna. She had multiple lytic lesions of the scapula and disappearance of a section of the midshaft of the humerus with tapering of the ends of the bony remnants . Her disAn open bone biopsy of the midshaft of the humerus was performed . HistopaBoth the radiographic and histologic findings were consistent with Gorham's disease, and the patient was started on a course of oral bisphosphonates . She completed external beam radiation of 40 Gray (Gy) in 2 Gy fractions. At her latest followup one year after beginning treatment, she has had substantial improvement of her pain although her radiographs remained unchanged. Surgical intervention was not indicated due to the extensive nature of the disease.Disappearing bone disease or Gorham's disease is a rare disorder characterized by osteolysis with associated proliferation of vascular or lymphatic channels within bone and the surrounding soft tissues . Most caThe etiology of Gorham's disease remains largely unclear. Gorham and Stout attributed the bone resorption to progressive replacement of bone by hemangiomatosis or lymphangiomatosis as a result of hyperemia, changes in local pH, and a traumatic “trigger” which stimulates the production of vascular granulation tissue . Some haThe diagnosis of Gorham's disease is based on clinical and radiologic features of bone loss with histological evidence of angiomatous tumor . PatientOnce a case is clinically suspicious for Gorham's disease, biopsy of the lesion should be undertaken for definitive diagnosis. On gross examination, the cortex of the involved bone appears thinned and the marrow is replaced with fibrous tissue. The cortex may often appear red, suggesting increased vascularity. On microscopic findings, most have reported vascular proliferation (lymphangiomatous/hemangiomatous) involving bone and the surrounding connective tissue. Osteoclastic activity is generally not prominent, and there should be an absence of atypical cells. In some cases, the microscopic appearance is unremarkable , 27. In Because of the rarity of this disease, the ideal treatment remains uncertain. Therapy has generally centered on surgery , 9, 28, In summary, Gorham's disease is a rare entity which can cause extensive destruction of osseous structures and lead to severe disability. There are multiple theories as to the etiology of this disease but none have been definitively proven. The treatment has not yet been fully defined but currently centers around a combination of surgery, radiation, and medical management.


Exposure to deployment, combat, and other traumatic events can induce a spectrum of physical, cognitive, psychological and behavioral effects. This constellation has been termed the “Trauma Spectrum Response” (TSR) and includes depression, anxiety, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), sleep disturbances, substance abuse, cognition, headache, pain, and spirituality. Acupuncture has been shown to effectively treat such symptoms as headache, insomnia, stress, anxiety, depression, and perceived pain. While many literature reviews on acupuncture have been published, their conclusions are often difficult to interpret, inconsistent or contradictory. Thus, in order to comprehensively assess acupuncture’s effectiveness across these symptoms, a rapid evidence assessment of the literature (REAL) was conducted to rigorously and systematically assess the quantity and quality of the existing systematic reviews/meta-analyses to gauge the effectiveness of acupuncture in treating the various components of TSR.We conducted a search of systematic reviews published in the English language in several key databases  from inception to September 2011. Articles were included if they involved needle acupuncture as a treatment for at least one of the TSR components.We present the results of this review of systematic reviews for each of the TSR components and discuss the overall quality of these reports using the Scottish Intercollegiate Guidelines Network (SIGN) 50. Additionally, we present the results on the overall effectiveness of acupuncture and safety rating for each of the TSR components as determined by a group of subject matter experts using a systematic grading methodology.The results of this review of reviews is expected to provide a systematic assessment of the quality of the current body of acupuncture literature for each of the TSR components and identify gap areas that may elicit further research.


The “9th Okazaki Biology Conference: Marine Biology II” held at the National Institute for Basic Biology (NIBB) in Okazaki, Japan and at the Okinawa Institute of Science and Technology (OIST) in Okinawa, Japan (14–19 October 2012) bridged the fields of EvoDevo, symbiosis and coral reef ecology. EvoDevo has come a long way from comparing expression patterns towards functional studies in several of the emerging new model systems. However, there is increasing awareness that the evolution of development of organisms is intimately tied to their environment and, in particular, to the close interactions with other organisms, above all symbionts and parasites. The recent international 9th Okazaki Biology Conference: Marine Biology II brought together researchers from the fields of EvoDevo, symbiosis and coral reef ecology. The meeting was organized around four broad themes: (1) cnidarians and their symbionts as holobionts/metaorganisms, (2) interactions of organisms and meta-organisms with the environment, (3) genomics and gene regulation, and (4) evolution of development in cnidarians and ctenophores. It was organized by Jun Minagawa and Kiyotaka Okada (NIBB), Nori Satoh (OIST), and Thomas Bosch  and sponsored by NIBB, OIST and the Japan Science and Technology Agency (JST). The meeting was highly interdisciplinary and convened a group of broadly trained scientists with expertise spanning marine ecology, photosynthetic biochemistry, evolutionary genomics, developmental biology, microbiology and host-microbe interactions.Hydra, with its complex and diverse prokaryotic microbiota, its intracellular photosynthetic green algal eukaryote and a still-to-be-characterized virome provide an excellent model for in-depth study of a metaorganism, including how these consortia are initiated and regulated. Eugene Rosenberg  advocated for the adoption of a related term, the holobiont, to refer to host organisms and their associated microbiota, and further argued that the hologenome is a key unit of selection in evolution.Much of the meeting centered around the advances in our understanding of the relationships between animals and their associated symbiotic microbiota. Two presentations forwarded a new paradigm of animals with their microbiota as being a critical and fundamental biological unit that has co-evolved over billions of years. Thomas Bosch  discussed how the cnidarian Aiptasia as a model system for the study of symbiosis in corals. He described significant progress in development of genomic resources and predictable spawning of anemones in the lab. However, he also highlighted several remaining challenges, including reliable transfection, gene knockdown and development of cell culture. Virginia Weis  described studies on the regulation of cnidarian-dinoflagellate symbiosis. Evidence suggests that onset and maintenance of symbiosis is driven in part by host innate immune responses, including phagocytosis, the sphingosine rheostat and the TGF-beta pathway and modulation of these responses by colonizing dinoflagellates. François Lallier  described new work in progress on the deep-sea chemoautotrophic mussel Bathymodiolus that harbors both sulfide- and methane-oxidizing bacteria in its gills. His group is engaged in high throughput proteomic and transcriptomic studies aimed at describing host genes important in the symbiosis.Three presentations focused largely on the host side of symbiosis, with two discussing corals and cnidarian-dinoflagellate symbioses Figure  and one Symbiodinium spp., its close phylogenetic placement with apicomplexan parasites, and how it has played a critical role in coral evolution. Sebastian Fraune  discussed the remarkable stability and specificity of host-microbe interactions between Hydra and its associated microbiota. The stability is strongly dependent on host genotype, and recent work on the role of the immunity gene MyD88 has shown that host immune response is critical in shaping the microbial community. In a presentation on chemoautotrophic bacteria-animal symbioses from deep sea hydrothermal vent ecosystems, Tadashi Maruyama  described genomic changes in the chemoautotrophic gamma-proteobacteria in Calyptogena spp. clams, including changes in genome size, increasing AT bias and loss of DNA repair genes.Three talks focused on the microbial components in metaorganisms. Tony Larkum  provided a broad view of eukaryotic photosynthetic microbes and their critical role as endosymbionts in marine animals. He went on to discuss the importance of the dominant symbiont in corals, the dinoflagellate Rhizobium. This system is well understood and may serve as a model for animal symbioses. He described several host factors that participate in the homeostatic maintenance of the balance between host and symbiont biomass. These factors are long-distance root- and shoot-derived signals that serve to regulate root nodule (site of symbionts) number.Masayoshi Kawaguchi  provided an interesting departure from discussions on cnidarians with his presentation on the highly studied symbiosis between leguminous plants and nitrogen-fixing Acropora spp. planula larvae was described by Masayuki Hatta  as being due to detection of induction cues from biofilms composed of a diverse set of bacteria on reef substrata. In addition, he detailed evidence of sensory neurons concentrated at the aboral pole that are responsible for release of neurohormones that drive metamorphosis.Another broad area covered at the conference was environmental biology: how organisms and meta-organisms sense and respond to their environment and to environmental stress, especially related to climate change. Fourteen presenters discussed a broad array of studies in many different systems. Three investigators spoke on circadian rhythms. The timing of coral mass spawning was described by Peter Vize  as including responses entrained to sunlight and moonlight as well as endogenous circadian rhythms. Using transcriptomic approaches, spawning corals were shown to exhibit entrained circadian patterns of gene expression. Similarly, Oren Levy  discussed rhythmic expression patterns of numerous genes in the coral holobiont that are central to coral biology, including calcification and photosynthesis. This raises the important question of which partner(s) in the holobiont is controlling the rhythm. Takao Kondo  provided a detailed understanding of the master pacemaker protein, KaiC, whose phosphorylation state drives circadian oscillations in cyanobacteria. Induction of settlement and metamorphosis in Symbiodinium spp. Peter Ralph  discussed new approaches to quantifying and characterizing photoprotective mechanisms in the light harvesting pigment apparatus in Symbiodinium spp. Photoprotection plays a key role in the ability of symbionts to manage high light and elevated temperature stress and furthermore, it appears to vary between different Symbiodinium types. Similarly, in another presentation on Symbiodinium photosynthesis, Shunichi Takahashi  described differential susceptibility to photoinhibition and photobleaching from thermal stress in differing strains of Symbiodinium. He described his current work aimed at uncovering the mechanisms underlying this differential susceptibility and related mechanisms of thermal acclimation in Symbiodinium that protect against stress and reduce bleaching in the host. Work presented by Jun Minawaga  on the chlorophyte Chlamydomonas reinhardtii, a classic model system for photosynthesis, is revealing a detailed understanding of the dynamic nature of molecular remodeling of the photosynthetic apparatus in response to changes in light. His group has begun to apply this knowledge and expertise to Symbiodinium, where they are beginning to study photosynthetic supercomplexes and how they change under stress.Several researchers discussed the effects of light and temperature on the biology of corals and their photosynthetic dinoflagellate symbionts Symbiodinium diversity among coral hosts. Her work suggests that environmental thresholds in corals are linked to the taxonomic makeup of their Symbiodinium, with highly specific host-symbiont partnerships, such as those in Porites spp., faring better during environmental stress than flexible partnerships, such as those in Acropora spp. Michio Hidaka  described similar results on coral larvae from laboratory studies showing better survival of larvae with vertically transmitted (highly specific) compared to horizontally transmitted (more flexible) symbionts. He also showed evidence that Symbiodinium are a burden on host larvae after a temperature stress. This may explain the high proportion of broadcast spawning species that lack symbionts in the eggs. The dynamics of larval dispersal and settlement of corals in Okinawa after the devastating mass bleaching and mortality event in 1998 was described by Kazuhiko Sakai . He reported that since 1998, the reefs have started to rebound due to both local recruitment (larvae traveling 10s of km) and occasional recruitment from the more distant Kerama Islands that sustained minimal bleaching damage (larvae traveling approximately 100 km).Turning to a set of more ecology-based presentations, Ruth Gates  described new work on patterns of Nematostella vectensis, that commonly occurs in habitats exposed to PAHs and high UV, exhibited transcriptomic patterns of a classic cellular stress response, including up-regulation of SODs, Hsp70 and cytochrome P450s. The most dramatic responses were associated with the high UV exposure, suggesting phototoxicity.Ann Tarrant  gave a presentation on the effects of anthropogenic pollutants, specifically polycyclic aromatic hydrocarbons (PAHs) in combination with high UV radiation, on cnidarian health. The anemone 3 in the presence of high CO2 by tight regulation of pH in both coral cells and within the subcalicoblastic medium where calcification takes place. This new approach gives insight into the origin of sensitivity/tolerance of corals to ocean acidification. David Miller  described an extensive new RNAseq study in which Acropora millepora was exposed to high CO2. Expression levels changed in 20% of host genes after short-term exposure of corals to elevated CO2. Many membrane-associated or secreted carbonic anhydrases showed decreased expression under elevated CO2, but the most dramatic impacts were on expression of genes encoding proteins of the organic matrix, many of which are coral or cnidarian-specific . In a study examining the ecophysiological impacts of OA on corals, Haruko Kurihara  found varying responses to increased CO2 levels in corals collected from different locations on reefs around Okinawa. Overall, however, she found decreased calcification rates with increased CO2 incubation.Three participants described new work on the potentially serious threat posed by ocean acidification (OA) on coral health. OA is hypothesized to compromise the ability of corals to deposit their massive, reef-forming calcium carbonate skeletons, because carbonate chemistry is heavily dependent on pH. Denis Allemand  described physiological studies on coral that show that the animal can continue to deposit CaCOSymbiodinium. A third major topic of the meeting was devoted to genomics and gene regulation of cnidarians. Recently, a team led by Nori Satoh has sequenced the genome of the scleractinian coral Acropora digitifera. Nori Satoh  showed interesting data from the A. digitifera genome that among the fast-evolving genes, genes involved in immunity and apoptosis are overrepresented. One interesting example is the NOD-domain protein, involved in inflammatory reactions and regulation of apoptosis, . Chuya Shinzato  emphasized the comparison with the closely related coral Acropora millepora, one of the most abundant corals on the Great Barrier Reef in Australia. While the A. digitifera genome corroborates the view of a conserved complex gene repertoire shared with bilaterians, a substantial portion of the Acropora genes (about 11%) are shared only with corals. An important component in understanding the interactions between corals and their dinoflagellate symbiont Symbiodinium, is the sequencing of the symbiont genome. The Satoh team is currently sequencing Symbiodinium clade B1 originally isolated from Montastrea faveolata. Eiichii Shoguchi  from the Satoh team reported the current status of the sequence analysis of the 1.5Gbp large genome of this dinoflagellate. One of the remarkable features that may have contributed to the relatively large genome size of this organism is the unusually high number of introns in the nuclear genes, most of which are unidirectionally oriented in the genome. As in other dinoflagellates, the plastid genome is highly fragmented. The fragments form a number of minicircles and show extensive post-transcriptional editing. The genome sequence of a coral and its dinoflagellate symbiont will provide us with many candidate genes involved in the specific interactions and the responses to environmental stresses and immune challenges.Great advances in our understanding of symbiosis and coral bleaching are expected to come from genomic sequences of the coral host and its dinoflagellate symbiont Acropora millepora and Hydra magnipapillata. In both species, DNA methylation is concentrated in gene bodies and associated with ubiquitous gene expression, a common pattern in invertebrates and distinct from vertebrates, where methylation is mostly found in upstream silenced promoters.Another step in the understanding of how corals regulate their development, interact with symbionts and with the environment comes from the analysis of epigenetic regulation. Sylvain Forêt  presented the DNA methylation patterns of two distantly related cnidarians, Nematostella vectensis and Aurelia aurita shown in Figure Pleurobrachia) as well as highly diverged and sophisticated anatomy and gene expression. Thus, ctenophores and other representatives of "basally branching" lineages should not be considered globally more ancestral than others, for instance, insects or vertebrates. A remarkably conserved role for Wnt signaling in early development, in particular in the formation of the primary body axis, involving a positive feedback loop of Wnt signaling, has been reported for the hydrozoan Hydra by Thomas Holstein . In addition, the Holstein group could identify a putative diverged homolog of nodal. Functional work showed that this Nodal-related gene is crucial for the early steps of budding, providing the symmetry break necessary for creating a new axis perpendicular to the main body axis of the polyp. The role of canonical and non-canonical planar cell polarity (PCP) Wnt signaling was also the main topic of the presentation by Evelyn Houliston , whose group has demonstrated that coordinated activation of these two pathways is crucial to establish polarity along the oral-aboral axis during embryonic development in the hydrozoan Clytia hemisphaerica. As in vertebrates, Nematostella and Hydra, Brachyury in Clytia is a conserved downstream target of canonical Wnt signaling; however, unlike in other species (see below), no feedback loop between these genes could be detected. In Clytia maternally localized “determinant” mRNAs not only direct Wnt pathway activation but may also have a conserved role in germ line/stem cell specification.How development in cnidarians is regulated, which processes are conserved and which have diverged or evolved independently was the focus of the EvoDevo section of the meeting  reported on the target genes of a number of genes with a conserved role in mesoderm formation and differentiation in bilaterians, . Technau showed that Brachyury is involved in a conserved feedback loop with Wnt3/beta-Catenin at the blastopore lip. He also presented a comprehensive investigation of the evolutionary origin of all known bilaterian muscle proteins and their analysis in two sponges and two cnidarians, strongly suggesting that cnidarian and bilaterian striated muscles evolved independently on the basis of a core set of ancestral proteins predating the emergence of metazoans.How gene regulatory networks act in cnidarian development might be pivotal for our understanding of how body plans evolved. Joel Smith  is developing high throughput transcriptome data of the first 24 hours of development of the sea anemone Hydra oligactis shows a nerve ring between mouth and tentacles. Shun Hamada  screened this tissue by subtractive hybridization and found synapsin, a synaptic vesicle-associated protein. Synapsin colocalizes to RFamide- but not LWamide-expressing neurons in the hypostome and tentacle region, which may reflect a specific role for these neurons. Of all the known bilaterian neurotransmitters, acetylcholine (Ach) is the best studied system. Ach, PAM-like peptides, as well as numerous Ach receptor subunits are present in cnidarians; however some important members are missing (vAChT) or highly divergent (AchE). The question of whether this transmitter system has a function in cnidarians was addressed by Toshitaka Fujisawa , who investigated the expression of the existing members of the pathway in Hydra. Notably, although the Hydra AchE worked in heterologous patch-clamp systems, none of the members of the cholinergic system appears to be expressed in neurons. Therefore, it seems that the cholinergic neurotransmitter system originated in the bilaterian ancestor.Metamorphosis and settlement of larvae are crucial and discernable steps in the formation of coral reefs. Eldon Ball  reported the dynamic expression of two neurotransmitters, RFamide and LWamide, in two non-overlapping populations of neurons. Both peptides disappear during metamorphosis, indicating a possible turnover of the nervous system. LWamide may be particularly interesting as it has been shown to drive metamorphosis in other cnidarians. The nervous system of hydrozoans was also the focus of interest in two other talks. While the nervous system of cnidarians is commonly described as diffuse and lacking symmetry, Aurelia aurita, up to 20 young medusae (ephyrae) are generated from a single polyp by a process called strobilation . In the scyphozoan Taken together, this exciting meeting showed that previously separated fields, that is, ecology and conservation biology, evolutionary and developmental biology, genetics and cell biology are now emerging as a new synthesis, potentially under the umbrella name of EcoEvoDevo, promoted by Scott Gilbert and David Epel in a recent textbook.The meeting has shown that new attempts are underway to tackle the intimate relationships between organisms, their symbionts and the environment. For many, if not all organisms, symbiosis often not only means a close association of two species but in fact the concept of a holobiont, that is, the close association of many different organisms from several taxonomic levels. These associations are dynamic and crucial for the shape, physiology and life cycle of an animal. They usually build up during early development, dependent on the environment. This shows the need for an integrated effort from developmental evolutionary biology and ecology in order to understand symbiosis and the holobionts. Only recently, through the advent of inexpensive high-throughput sequencing technologies, many of these problems are becoming approachable. Due to the rising data sets from these studies, research communities will require bioinformatic resource centers and servers. It is obvious that cnidarian researchers have stepped forward in this field, but researchers from other fields will surely also follow along these paths.Ach: Acetylcholine; AChE: Acetylcholine esterase; BAC: Bacterial artificial chromosome; CAU: Christian-Albrechts-University Kiel; JST: Japan Science and Technology Agency; NIBB: National Institute for Basic Biology; NOD: Nucleotide binding oligomerization domain; OA: Ocean acidification; OIST: Okinawa Institute of Science and Technology; PAHs: Polycyclic aromatic hydrocarbons; PAM: Peptidyl-glycine alpha-amidating monooxygenase; PCP: Planar cell polarity; RA: Retinoic acid; TGF: Transforming growth factor; vAChT: Vesicular acetylcholine transporter.The authors declare that they have no competing interests.UT and VMW together drafted the manuscript. All mentioned participants of the meeting have approved the manuscript before its publication. Both authors read and approved the final manuscript.


Quinine remains an important anti-malarial drug almost 400 years after its effectiveness was first documented. However, its continued use is challenged by its poor tolerability, poor compliance with complex dosing regimens, and the availability of more efficacious anti-malarial drugs. This article reviews the historical role of quinine, considers its current usage and provides insight into its appropriate future use in the treatment of malaria. In light of recent research findings intravenous artesunate should be the first-line drug for severe malaria, with quinine as an alternative. The role of rectal quinine as pre-referral treatment for severe malaria has not been fully explored, but it remains a promising intervention. In pregnancy, quinine continues to play a critical role in the management of malaria, especially in the first trimester, and it will remain a mainstay of treatment until safer alternatives become available. For uncomplicated malaria, artemisinin-based combination therapy (ACT) offers a better option than quinine though the difficulty of maintaining a steady supply of ACT in resource-limited settings renders the rapid withdrawal of quinine for uncomplicated malaria cases risky. The best approach would be to identify solutions to ACT stock-outs, maintain quinine in case of ACT stock-outs, and evaluate strategies for improving quinine treatment outcomes by combining it with antibiotics. In HIV and TB infected populations, concerns about potential interactions between quinine and antiretroviral and anti-tuberculosis drugs exist, and these will need further research and pharmacovigilance. The discovery of quinine is considered the most serendipitous medical discovery of the 17th century . QuininePlasmodium falciparum to chloroquine was seen in parts of Southeast Asia and South America by the late 1950s, and was widespread in almost all areas with falciparum malaria by the 1980s. With increasing resistance to chloroquine, quinine again played a key role, particularly in the treatment of severe malaria  ha hath cen in Asia . No conv in Asia . These fP. falciparum [Treatment failures with quinine could also be explained by varying pharmacokinetic profiles of the drug. It is known that quinine pharmacokinetic properties and therapeutic responses vary with age, pregnancy, immunity and disease severity . Also, alciparum . Howeverlciparum  and the The quality of quinine used in routine care could play a key role in clinical outcomes. Poor quality drugs remain a problem worldwide and are a serious public health threat. A study in Nigeria evaluating the quality of different anti-malarial drugs found that 37% of 225 anti-malarial drugs did not meet the tolerance limits set by United Sates Pharmacopeia (USP) for the amount of active ingredient, and 46% of these were formulations of quinine . In CongAnother potential explanation for quinine treatment failures may be poor compliance. Quinine's prolonged treatment course and significant tolerability problems may lead to poor compliance, and hence poor therapeutic outcomes ,45,59. IIn the near future, quinine will continue to play a significant role in the management of malaria, particularly in resource limited settings. Following the results of the SEAQUAMAT and AQUAMAT trials, artesunate is now recommended as the treatment of choice for severe malaria patients, with quinine only acting as an alternative when artesunate is not available. The role of rectal quinine as pre-referral treatment for severe malaria has not been fully explored, but this remains a promising intervention given the limited availability of rectal artemisinin preparations in resource limited settings. Quinine continues to play a critical role in the management of malaria in the first trimester of pregnancy, and will remain so until safer alternatives become available. The continued use of quinine in the management of uncomplicated malaria is a concern. Clearly, the seven day duration of therapy and thrice daily administration of quinine present a major challenge to completion of therapy, leading to sub-optimal treatment outcomes. In these situations, ACT is a better option given the simplicity of dosing and shorter treatment duration. However, because of the frequent ACT stock outs, the rapid withdrawal of quinine as a treatment option for uncomplicated malaria cases is risky. The best approach would be, besides improving the supply system, to maintain quinine as a fall-back drug in case of ACT stock-outs.The authors declare that they have no competing interests.AJ, PJR and UD conceived the idea and wrote the first draft of the manuscript. All authors read and approved the final version


Metabolomics coupled with multivariate statistical tools that focus on the comprehensive analysis of small molecules in biofluids is a viable approach to address the challenges of poly-PK. This paper discusses recent advances in the characterization of poly-PK and the metabolism of multicomponent xenobiotic agents, such as compound drugs, dietary supplements, and herbal medicines, using metabolomics strategy. We propose a research framework that integrates the dynamic concentration profile of bioavailable xenobiotic molecules that result from in vivo absorption and hepatic and gut bacterial metabolism, as well as the human metabolic response profile. This framework will address the bottleneck problem in the pharmacological evaluation of multicomponent pharmaceuticals and nutraceuticals, leading to the direct elucidation of the pharmacological and molecular mechanisms of these compounds.Determination of pharmacokinetics (PKs) of multicomponent pharmaceuticals and/or nutraceuticals  is difficult due to the vast number of compounds present in natural products, their various concentrations across a wide range, complexity of their interactions, as well as their complex degradation dynamics  Distl effect , 4. The l effect , 6. As aThe traditional approach to understand the pharmacology of a multi-component agent is to study the effects of single components on single biological reactions, enzymes, genes, and so forth, and gradually assemble the findings into a whole picture. However, assembling the results obtained from such a reductionist approach to achieve a system understanding of a concerted pharmacological intervention has proven impractical . In factin silico for prediction, coupled with in vitro screening and identification, and in vivo validation is deployed for xenobiotic metabolism studies [in vivo xenobiotic metabolite studies require special attention; these compounds are often intermixed against the background of endogenous metabolites in biological samples. Recent advances in liquid, and gas chromatography (LC and GC) and capillary electrophoresis (CE) coupled with mass spectrometry  and nuclear magnetic resonance (NMR) have made it possible to simultaneously detect various small-molecule metabolites [The complicated metabolic fate of chemicals in the human body is primarily determined by the chemical's structure and greatly varies according to dose, routes of exposure, inter- and intraindividual genetic differences, gut microbiota, diet, life style, and environment, as well as other xenobiotics intentionally or unintentionally present. In order to simplify these intricate factors, a knowledge-based engine that sequentially manipulates each factor  studies . However studies , the in abolites . in vivo, as well as identify characteristic metabolic alterations in humans exposed to nutraceuticals [Metabolomics is the study of the metabolome, the complete set of endogenous metabolites in a biological sample. In context of systems biology , 12, meteuticals , 15. Aloeuticals –20. Receeuticals  and condeuticals . in vivo absorption, and hepatic and gut bacterial metabolism, as well as the human metabolic response profile. Metabolomics might assume the new mission to model the variations of both exogenous and endogenous metabolites through a given biological system, which has vital implications in both systems biology and multi-component herbal medicine. The aim of this review is to discuss recent progress in the characterization of poly-PK and metabolism of multi-component xenobiotic agents such as compound drugs, dietary supplements, and herbal medicines using metabolomics. We also propose a research framework that integrates the dynamic concentration profile of bioavailable xenobiotic molecules that result from Metabolomics enables the profiling of a vast number of small-molecule metabolites in an organism or a biological system as a whole, and helps understand how these metabolites respond to a stimulus, highlighting the most relevant potential biomarkers. When the stimulus is a xenobiotic intervention, metabolomics techniques are employed to profile the metabolite pool with and without the xenobiotic and highlight the differential variables to identify the xenobiotic metabolites. A comparison of a typical protocol for xenobiotic intervention studies using LC-MS-based metabolomics and the classical LC-MS-based workflow is illustrated in in vivo metabolites of GSK-X, the structure of which was unknown to the investigators [Such a metabolomics-based protocol was first proposed in 2003 by Plumb and colleagues in an attempt to find the tigators . Shortlytigators . Consequtigators ), (2) vatigators . Two rectigators , 33.in vivo metabolites and leads to further in vitro characterization has been established, which is in stark contrast to the classic, knowledge-based methodology that starts with in vitro identification to in vivo characterization, and is frequently muddled by inconsistent results. Such a methodological shift obviates potential false-negative results that usually result from traditional empirical strategies, and significantly deepens our insight into the in vivo metabolic map of xenobiotics in at least two ways. First, metabolomics captures in vivo xenobiotic metabolites that are otherwise easily overwhelmed by the endogenous background. Examples of such metabolites are those with unexpected skeleton biotransformation or those at extremely trace levels with potential clinical significance and wide usage in the general population. Second, the consideration of genetic and environmental factors affecting the metabolism of xenobiotics in metabolomics studies facilitates the in vivo identification of metabolic pathways and factors affecting them.Compared to the classical methods in xenobiotic intervention studies, metabolomics strategies have clear advantages, firstly, in the capacity of handling a great number of variables—which allows a shift in purpose from targeting xenobiotic metabolites to profiling the complete set of metabolites in biological samples—and secondly, in the unbiased selection of variables that are significantly altered—which facilitates the discrimination of xenobiotic metabolites from endogenous ones. Due to these advantages of metabolomic strategies, a novel, evidence-based methodology that starts with mapping in vivo. It has been proposed that such metabolomics strategies can be used to study any organic molecule in any animal model, provided that the protocol is carefully designed, controlled, and executed [in vivo metabolite map. The detailed information about multiple bioactive metabolites may significantly advance our understanding of various and rare adverse drug reactions in the general population.To date, metabolomics techniques have been employed in metabolism studies of dozens of single xenobiotics with diverse chemical structures , includiexecuted . In our  in vivo due to herbal exposure. However, the unclear metabolic fate of herbal medicines causes significant limitations in understanding the efficacy and toxicity of these substances. Compared to single xenobiotics, of which there are significant advances in terms of metabolic fate, multi-component herbal medicines present a challenge due to their complex nature. Multicomponent drugs and herbal medicines have an extremely complicated and highly variable chemical composition and introduce multiple xenobiotics into the human body. The metabolism of these xenobiotics may provide insights as to why and how they work by revealing changesin vivo xenobiotic metabolism protocols for multi-component drugs and herbal medicines, there are several major obstacles: (1) the difficulty to determine and standardize the chemical composition of multi-component drugs and herbal medicines, (2) the overlap between the chemical composition of herbal medicines with that of daily diets, (3) the extensive microbial-mammalian co-metabolism in the gut of herbal components [in vitro metabolites of aconitine, illustrated in For the development of mponents  that varin vitro and in vivo herbal exposure studies following classic, knowledge-based methodologies have recently been discussed [The strategies and techniques for iscussed , 69. Witiscussed . HoweverNevertheless, two strategies have accomplished noteworthy advances in metabolite mapping of xenobiotics. One of these strategies was developed from the identification of individual metabolites of licorice . In factThe Recent advances in metabolomics encouraged researchers to start exploring the effects of multi-component drugs/herbal medicines using metabolomics strategies. To the best of our knowledge, the first attempt of this kind was the NMR-based metabolomics study on human nutritional intervention of grape/wine extract reported by van Velzen and colleagues in 2008 . This stThe metabolomics-based strategies using LC-MS have clear advantages, as they can handle a great number of variables and large datasets, enable graphic representation of metabolism-related sample classification, and identify drug compounds and significant drug metabolites. In fact, several publications reported the use of metabolomics to capture both drug-derived and drug-induced metabolites  and the P < 0.05). Using multivariate similarity analysis to compare the altered variables to the plant metabolome or the predose human metabonome, 19, 26, and 118 metabolites were categorized as intact tea polyphenols, metabolites of the absorbed polyphenols, and endogenous metabolites altered due to tea intake, respectively. The subsequent dynamic correlation analysis produced, for the first time, a correlation between the herbal metabolic network and endogenous metabolism (We believe that categorization of these metabolites in herbal intervention studies will benefit more from developments in multivariate analyses than in advances in analytical techniques. To this end, we have proposed a multivariate similarity analysis to categorize the altered metabolites as a result of herbal intervention . Recentltabolism .in vivo metabolites, but also the endogenous metabolites altered by herbal interventions. In this regard, the metabolic shells covering the interactions between multiple xenobiotics and human biological system will be shucked in future metabolomics incorporating xenobiotic metabolism.As discussed above, despite great challenges, a strategy based on metabolomics has great potential capabilities to discover not only the components in herbal exposure and their The essence of balances in traditional Chinese medicine and herbal medicines align very closely with the core concepts of systems biology , which ain vivo absorption and the hepatic and gut bacterial metabolism,as well as the human metabolic response profile in Based on the above and guidance from related studies, we propose a research framework to integrate the dynamic concentration profile of bioavailable xenobiotic molecules due to The host-gut microbial metabolic networks for endogenous and exogenous metabolites are highly interactive but with subtle differences in metabolic fates. It is beyond doubt that the superorganism's metabolism has to strike a balance between the uptake of essential nutrients and the elimination of superfluous metabolites to maintain homeostasis, yielding a relatively stable internal environment of endogenous metabolites. The involvement of gut microbiota in endogenous metabolic pathways –104, as Therefore, the superorganism has evolved a highly delicate and interactive host-gut microbiota metabolic network to keep its homeostasis and trigger allostasis. Following our framework, in combination with advances in genomics, transcriptomics, proteomics, and metagenomics, future metabolomics strategies will contribute to our understanding of how the balance emphasized in comprehensive herbal medicine is correlated with the homeostasis and allostasis addressed in systems biology.In conclusion, recent studies suggest that metabolomics coupled with multivariate statistical tools can offer an alternative to address the challenges of the determination of PK of multi-component pharmaceuticals and/or nutraceuticals. We believe that the use of a metabolomics strategy in pharmacological studies has important advantages over conventional approaches for multi-component therapeutics. The integration of metabolomics to study the metabolism of xenobiotics will unravel the complicated variations in multiple metabolites of endogenous and exogenous origin within the host-gut microbial symbiotic network, and tease out the underlying mechanisms of homeostasis and allostasis in terms of systems biology. Progress in this field will definitely help the poly-PK studies of multi-component herbal medicines to assess their efficacy. Acquisition of a complete and dynamic panel of pharmacokinetic parameters for multi-component dosage regimens to achieve desired therapeutic efficacies is essential to minimize toxicity, reduce overdosing and drug complications, keep healthcare costs at a minimum, and ultimately, increase patient compliance and quality of life.


Recently published literature has provided evidence that the unfolded protein response (UPR) is involved in the development of retinal degeneration. The scope of these studies encompassed diabetic retinopathy, retinopathy of prematurity, glaucoma, retinal detachment, light-induced retinal degeneration, age-related macular degeneration, and inherited retinal degeneration. Subsequent studies investigating the role of individual UPR markers in retinal pathogenesis and examining the therapeutic potential of reprogramming the UPR as a method for modulating the rate of retinal degeneration have been initiated. Manipulation of UPR markers has been made possible by the use of knockout mice, pharmacological agents, and viral vector-mediated augmentation of gene expression. Future research will aim at identifying specific inhibitors and/or inducers of UPR regulatory markers as well as expand the list of UPR-related animal models. Additionally, adeno-associated virus-mediated gene delivery is a safe and effective method for modulating gene expression, and thus is a useful research tool for manipulating individual UPR markers in affected retinas and a promising delivery vector for gene therapy in retinal degenerative disorders. Retinal degeneration is progressive deterioration of the retinal cells, eventually culminating in their death. Certain conditions can lead to an imbalance in the retinal microenviroment, which in turn could cause retinal degeneration. These conditions include but are not limited to artery or vein occlusion in diabetic retinopathy, hypoxic retina in retinopathy of prematurity, aging in age-related macular degeneration, expression of mutant proteins in inherited retinal degeneration, traumatic injury leading to retinal detachment, and light sensitivity in the case of light-induced retinal degeneration. Despite recent advances in our understanding of the mechanism of these retinopathies, much work remains to be done to get a clear picture of the molecular pathology of each disease. The understanding of the underlying mechanisms is complicated by the heterogeneity of cases within a particular retinopathy and by the interplay of multiple cellular signaling involved in each disease model.GRP78) or binding immunoglobulin protein (BiP), in addition to Ca2+ binding and protein processing functions, possesses one more key role: master initiator of early UPR signaling. In resting conditions, GRP78 is bound to these mediators. The association of GRP78 with the ER luminal domains of these mediators prevents their activation and maintains the UPR signaling machinery in an inactive state . We. WeRHO (The rapid increase in the study of ER stress in different models of retinal degeneration has improved our understanding of the mechanisms of retinopathy and highlighted the role of the UPR and individual UPR markers in the pathogenesis of retinal degeneration. This suggests that the UPR markers could be potential therapeutic targets, manipulation of which could alter the rate of retinal degeneration and provide for the survival of retinal neuronal cells. Future work should concentrate on the search for pharmacological molecules that selectively inhibit or induce individual UPR markers. Additionally, an expansion of the list of available UPR animal models will facilitate identifying specific roles for every UPR component in the pathogenesis of retinal degeneration. These approaches, in combination with AAV gene delivery, should be useful tools in manipulating individual UPR markers and performing gene therapy for reprogramming the UPR.


In this paper, coronary arterial bypass grafting hemodynamics and anastomosis designs are reviewed. The paper specifically addresses the biomechanical factors for enhancement of the patency of coronary artery bypass grafts (CABGs). Stenosis of distal anastomosis, caused by thrombosis and intimal hyperplasia (IH), is the major cause of failure of CABGs. Strong correlations have been established between the hemodynamics and vessel wall biomechanical factors and the initiation and development of IH and thrombus formation. Accordingly, several investigations have been conducted and numerous anastomotic geometries and devices have been designed to better regulate the blood flow fields and distribution of hemodynamic parameters and biomechanical factors at the distal anastomosis, in order to enhance the patency of CABGs. Enhancement of longevity and patency rate of CABGs can eliminate the need for re-operation and can significantly lower morbidity, and thereby reduces medical costs for patients suffering from coronary stenosis. This invited review focuses on various endeavors made thus far to design a patency-enhancing optimized anastomotic configuration for the distal junction of CABGs. Coronary artery disease (CAD) is the leading cause of death globally, and is expected to account for 14.2% of all deaths by 2030 [Several alternative treatments exist for CAD, including medical therapy, rotablation, endarterectomy, percutaneous coronary intervention (PCI) or balloon angioplasty, stenting, and coronary arterial bypass grafting (CABG). Depending on the severity, number and position of atherosclerotic lesions and the clinical history of the patient, any of the above mentioned treatments may be chosen. For high-risk patients, such as those with left main coronary artery (LMCA) disease, severe three-coronary vessel disease, severe ventricular dysfunction , and diabetes mellitus, CABG is the preferred treatment . In geneCABG is a surgical procedure performed to graft arteries or veins from the patient’s body or synthetic conduits to the occluded coronary arteries in order to bypass the atherosclerotic narrowing and improve the blood supply to the coronary circulation, for nourishing the myocardium. Figure Although CABG is extremely effective for symptomatic relief and prognostic improvement in CAD and is the preferred remedy for high-risk patients, it is not devoid of complications and the long-term benefits are directly related to continuing conduit patency. Approximately 10–15% of vein grafts occlude during the first year after operation ,7. By 10Early graft failure (within 30 days) of bypass grafts is attributable to surgical technical errors and resulting thrombosis, while late graft failures are mainly caused by progression of atherosclerosis and intimal hyperplasia (IH) . VariousAmong the abovementioned factors, hemodynamic parameters (HPs) are believed to be highly important ,18 in thAccordingly, several investigations have been conducted and different anastomotic geometries and devices have been designed to improve the flow fields and HPs distribution at ETS anastomosis, in order to enhance the graft patency. These investigations include studies on the effects of geometrical factors, such as anastomotic angle -27, modiAccordingly, this paper reviews the theories on bypass graft failure and its causative biological and biomechanical factors, followed by various attempts to design an optimal anastomotic configuration for the distal CABG anastomosis. This review illuminates the impact of CABG layout designs towards obtaining higher long-term graft patency rates and the benefit of superior anastomotic designs for the improvement of global ejection fraction of patients with coronary artery disease.The first section of this review covers the studies correlating different biological and biomechanical factors to initiation and progression of atherosclerosis and IH. The majority of the investigations on biological factors are in vivo studies along with complementing in vitro investigations. On the other hand, computational simulations of blood flow along with numerous in vitro and in vivo investigations constitute the studies of the biomechanical factors and hemodynamic parameters, and have provided strong evidence on the influence of these factors on initiation and onset of IH.The second section of this review elaborates on the various attempts to design an optimal anastomotic configuration for CABG. These attempts include adjustments of anastomotic angle and graft-to-host artery ratio, design of different cuffed and patched anastomotic configurations, and design and development of other novel configurations  and synthetic devices.Finally, the current state of the art of CABG anastomotic configurations is discussed and future directions are suggested.According to angiography and histological examinations, common graft failure modes include acute thrombosis, IH, and onset of progressive atherosclerosis ,43,44. TIH, the major cause of graft failure, is the abnormal increase in the number of endothelial cells (ECs) and thickening of the tunica intima of a blood vessel. IH was first described by Carrel and Guthrie , who obsAlthough the pathological mechanisms responsible for the development of IH and atherosclerosis have not been fully elucidated, many theories have been hypothesized, indicating the involvement of both biological and biomechanical factors, some of which are briefly discussed in the following sections.The endothelial cells sense the mechanical forces acting on them through mechanotransducers . The preOlder plaques can develop into a calcified lesion or nodule. The origin or mechanism of the calcification is not precisely known, but it appears to be associated with healed plaque. The artery with a rigid matrix is unable to remodel, causing further cellular proliferation to push the fibrous cap out into the lumen. The rupture of this fibrous cap exposes tissue factors and collagen to the blood, forming a nidus for thrombus formation and consequent restenosis.For more details, see the reviews of hypothesized theories on molecular mechanisms and biological factors involved in the development of IH ,48,51-56During the surgery, endothelium and SMCs of the recipient artery and the autogenous graft are injured in several ways: grasping of the instruments used to harvest the graft; routinely applied high intra-luminal pressure to check for the graft leakage; and sutures for the construction of the anastomoses. In addition, due to implantation of the vein graft in the arterial circulation, the grafted vein is exposed to high pressures and high blood flow causing further damage to the venous endothelium .The injured endothelium is less capable of producing anti-proliferative products , and theFor further details on pathophysiological mechanisms following vascular injury, see references -63.The ability of a blood vessel to expand and contract passively with changes in pressure is an important function of large arteries and veins. Compliance is a measure of the tendency of a hollow organ to resist recoil toward its original dimensions upon removal of a distending or compressing force. In other words, the ability of a vessel to distend and increase volume with increasing transmural (inside minus outside) pressure is the vessel compliance (C), which is defined as:V is change in volume and ∆P is change in transmural pressure. It is usually assumed that an increase in the volume of a blood vessel segment is almost exclusively caused by an increase in its radius since elongation is negligible in-vivo [where ∆ in-vivo . Thus, c in-vivo :Dd is diastolic diameter, Ds is systolic diameter, and PP is the pulse pressure. Veins have a higher compliance than arteries due to their thinner walls. A schematic volume-pressure relationship for an artery and vein is depicted in Figure where It has been shown in vivo that a higher degree of compliance mismatch between the graft and the artery results in a greater amount of suture-line IH formation in ETS anastomoses ,66,67, bAlthough the detailed mechanism for stress-induced IT is not completely understood, it has been shown that endothelial cells respond to stretch stimuli by producing transcription factors which stimulate their replication  and chemCompliance mismatch is not only between the stiffer bypass graft and the artery, but also at the anastomosis itself between the suture and the graft on one side and between the suture and the artery on the other side, forming a para-anastomotic hyper-compliant zone and elevating intramural stresses. Different surgical techniques have been suggested to reduce the level of intramural stresses (elevated by compliance mismatch) and the amount of consequent IH , and also develops on the bed of the host artery across the junction ,67,82,83Arterial floor IT is attributable to altered flow conditions . AlthougSeveral investigations have been conducted to better understand the relationship between blood flow-based stresses acting on the walls and IT in bypass grafts ,19,85-88τw) is the product of dynamic viscosity (μ) and shear rate . Although an ETS anastomosis is basically a bifurcation, it is different from naturally occurring blood vessel bifurcations. The angle between the daughter vessels is effectively obtuse and the flow division between the daughter branches in anastomoses can vary widely which has a significant impact on the hemodynamics . A distaTypically, there is a low-WSS region at the heel, where a vortex forms due to the interaction of the flow from the graft with the relatively slow flow in the occluded proximal artery, whose size changes with the flow phase , usually with a flow separation region just distal to the toe at the inner wall of the coronary artery (causing flow recirculation and low WSS at this area), as shown in Figure Although an ETS anastomosis is essentially a bifurcation, being manmade, surgically created anastomoses can be modified  to yield a flow environment that improves graft longevity . As revichanging the anastomotic angle. It has been shown that tissue remodeling at ETS arterial anastomoses is highly sensitive to graft angle [The first efforts towards attaining an optimal anastomosis have been made by ft angle , and graft angle ,25. A smft angle , (ii) thft angle ,23,26,27The effect of graft caliber  on the hemodynamics of CABGs has also been examined by investigators. It is observed that larger graft-to-host diameter ratios (5:3) have better hemodynamic performance than smaller ones (1:1) [es (1:1) , as theyes (1:1) , and smaes (1:1) ,33. Likees (1:1) .Besides, smaller grafts typically present an increased risk of early graft failure due to thrombosis . SeveralIt has been observed that a small-diameter (<3 mm) saphenous vein graft is associated with a 2.1-fold increased risk of early failure , and sucIn addition, a smaller graft diameter increases the graft resistance against the flow, which can elevate the flow portion through the native  coronary and escalate the competitive flow problem  that eveThe effect of competitive flow  on the graft patency has been extensively investigated, but still is somewhat controversial. Many studies have demonstrated that the patency of bypass grafts on functionally significant lesions is considerably higher than the patency of bypass grafts on non-significant lesions [ lesions -127. The lesions ,128.Although competitive flow (from patent native coronary vessels) is implicated in the failure of internal mammary artery (IMA) grafts, it is not thought to affect the patency of saphenous vein grafts (SVGs) ,124,129.On the other hand, some studies have demonstrated that despite of significant correlation between (low) degree of proximal stenosis of the recipient coronary artery  and occurrence of a string sign , chronic native competitive flow does not significantly affect midterm graft status  and thatThe effects of stenosis severity and distance of grafting on the hemodynamics of distal anastomosis have also been investigated. Computational simulations have shown that in the case of bypass grafting of partially stenosed coronary artery, the flow through partially occluded host artery interacts with the bypass graft flow at the anastomotic junction and that this combined flow can cause adverse hemodynamic effects, particularly when the distance of grafting is short [is short ,133-135.is short . Also, iis short . Thus, iThe influence of out-of-plane graft curvature has been studied by several investigators [tigators . These itigators  and meantigators  in the ntigators . Accorditigators . In vitrtigators ,137. Thitigators .Nevertheless, the graft non-planarity is often constrained by surgical considerations beyond hemodynamics  .design of cuffed and patched anastomotic configurations. Miller et al. [Further efforts have been put to obtain a more favorable anastomosis by r et al.  introducr et al. ,141 and r et al. , other ir et al. , (ii) thr et al. ,139,144,r et al. -147. It r et al. ,148.The Taylor vein patch technique  Figure  has beenLinton patch was introduced as a technique in which the conduit is patched with a venous segment of about 40-50 mm long , as showLei et al. , utiliziThe Tyrrell collar has been developed in attempts to incorporate the advantages of the Miller and Taylor anastomotic designs, by avoiding direct suturing of the graft and artery (which can cause high compliance mismatch in case a synthetic graft is used), and providing a more streamlined shape at the toe  Figure . HoweverLongest and Kleinstreuer  numericaA streamlined anastomotic configuration in which the distal outlet segment (DOS) is aligned with the graft has been developed by Longest et al. . This coO’Brien et al.  have desChua et al.  designedIn an attempt to alter the disturbed hemodynamic on the artery bed in the ETS anastomosis, O’Brien et al.  designedWalsh et al.  have desBased on the advantageous flow characteristics observed within the side-to-side (STS) anastomosis of typical sequential bypass grafts  and higComputational simulations of blood flow through this novel design have shown improvements of HPs, especially at the heel and on the arterial bed of the ETS anastomosis. These improvements in distribution of HPs include an increase in the time-averaged WSS on the artery bed of the ETS anastomosis of the SQA , reduction of the time-averaged WSSG at the heel and bed of the ETS component as well as at the toe and suture line of the STS component of the novel SQA , and reduction of the OSI at the ETS anastomosis of the SQA at the heel region and on the artery wall and bed opposite to the heel . Besides, this design provides a spare route for the blood flow to the coronary artery in order to avoid re-operation in case of re-stenosis in either of the anastomoses. This design can be employed using autologous grafts without the need for any additional training.The search for an ideal distal anastomotic configuration for coronary bypass grafting has led to numerous designs. Optimal anastomosis design must take into account practical issues such as surgical construction. An anastomotic design should be feasible to be implemented by surgeons in a reasonable time.As reviewed, some of the designed anastomotic configurations which are feasible to be constructed during operation using autologous materials  have not shown a remarkable enhancement in patency of bypass grafts. On the other hand, some configurations which have shown considerable improvement in HPs distribution can only be made by synthetic materials due to their complex geometry ; this has consequences of blood-exposed non-intimal surface and high compliance mismatch at the synthetic material-blood vessel interface.Moreover, the anastomotic designs which have improved HPs distribution and are feasible to be surgically constructed by autologous grafts , have not gone through animal trials or clinical investigations yet to demonstrate their in vivo performance and patency rates. Hence, the dilemma of designing an optimal anastomosis, which can bring about considerable improvements in the flow regime, HPs distribution, and graft patency, still remains unsolved.In conclusion, there are a few aspects to be considered in the design of an optimal CABG:Compatibility of the graft with the arterial pressure and the supplied blood flow rate, to ensure a physiologic range of intramural stresses and hemodynamic forces in the graft itself. Arterial grafts, such as left internal mammary artery (LIMA), have demonstrated considerably higher patency rates than the most commonly used saphenous vein grafts [(i) n grafts . Howevern grafts  and theyArterial compliance of the graft, to avoid compliance mismatch with the host artery at the anastomotic junction, to prevent escalation of intramural stresses in the artery and the graft, which can result in IH formation, especially on the suture-line. As discussed in this review, compliance mismatch between the graft and the host artery results in an increase of intramural stresses, which in turn promotes IH. Use of arterial conduits can (to some extent) address this issue too. However, as mentioned above, tissue-engineered grafts might be the future solution to this problem.(ii) Hemodynamic performance driven design of anastomotic configuration of the distal anastomosis, to regulate the hemodynamic parameters and wall shear stress indices, in order to avoid triggering of the pathogenic factors of IH and thrombosis . As reviewed, it is well established that HPs play an important role in the initiation and progression of atherosclerosis and IH. A hemodynamically optimized anastomotic configuration can provide moderate shear stress parameters and smooth blood flow without flow disturbances, to avoid triggering the associated atherogenic phenomena.(iii) Minimal vascular injury, to minimize proliferation of SMCs as a wound healing response. Technological advances may further develop the suggested alternatives to sutures  to a practicable level for routine clinical use. Not only can such products minimize vascular injury, but also they can eliminate the para-anastomotic hyper-compliant zone and the associated elevating intramural stresses which are caused by the stiff sutures.(iv) Patient-specific designs, to tailor the design considerations to each particular patient’s cardiovascular characteristics. Development of clinical imaging  enables a detailed patient-specific description of the actual hemodynamics and structural behavior of living tissues. Coupling of these data with engineering analyses is becoming a standard evaluation that is expected to become part of the clinical practice in diagnosis and surgical planning in advanced medical centers [(v)  centers . This woAVG: Arteriovenous graft; CABG: Coronary arterial bypass grafting; CAD: Coronary artery disease; CFD: Computational fluid dynamic; DAIH: Distal anastomotic intimal hyperplasia; DOS: Distal outlet segment; EC: Endothelial cell; ETE: End-to-end; ETS: End-to-side; HP: Hemodynamic parameter; IH: Intimal Hyperplasia; IMA: Internal mammary artery; IT: Intimal thickening; LAD: Left anterior descending coronary artery; LDL: Low-density lipoprotein; LMCA: Left main coronary artery; OSI: Oscillatory shear index; PCI: Percutaneous coronary intervention; POS: Proximal outlet segment; RCA: Right coronary artery; SMC: Smooth muscle cell; STS: Side-to-side; SVG: Saphenous vein graft; WSS: Wall shear stress; WSSG: Wall shear stress gradient.The authors declare no competing interest with regards to this invited review.FK: collection, organizing, and review of the literature; preparing the manuscript. DNG: manuscript review, modification, editing, and revision. Both authors read and approved the final manuscript.Southern Ozarks Alliance for Rural Development in Willow Springs MO, setting up the Ozark Rural University MO (USA), and advising universities in their Programs development. He is a pioneer in the fields of biomedical engineering, healthcare engineering, and management. He has published over 450 works in the fields of engineering science, biomedical engineering, medical science, and social sciences, as well as 29 books on biomedical engineering, engineering physiology, cardiovascular physics, orthopedic mechanics, medical and life physics, and spinal injury. The inventor of life-saving implant devices has also been the former Chief Academic Officer (Provost) & Registrar of the Parkway College of Health Sciences (Singapore) and Professor in the School of Chemical & Biomedical Engineering of Nanyang Technological University (Singapore).DNG: He is currently involved with National University of Singapore (NUS). He has about 10 years of research experience in Biomedical Engineering, including analytical, experimental, and computational investigations on biofluid and cardiovascular mechanics and design and development of relevant medical devices.FK: He is currently a postdoctoral research fellow at


An important component of the burden of cardiovascular disease in low- and middle-income countries may be attributed to the neglected tropical diseases.There is a growing awareness of the importance of chronic non-communicable diseases (CNCDs) in the world's low- and middle-income countries (LMICs). Beginning in the 1990s, Murray and Lopez predicted a doubling of death rates due to cardiovascular disease in developing countries by 2020 While there is no question that obesity, tobacco, and alcohol represent major underlying conditions responsible for the rise of cardiovascular and other CNCDs in LMICs, they do not provide a complete picture. In March of 2011, Partners in Health and Harvard Medical School sponsored a conference entitled “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion” to examine in more detail some of the neglected causes of CNCDs, particularly those that are unique to the world's poorest people in LMICs. The conference highlighted important risk factors apart from the lifestyle changes linked to CNCDs in high-income countries On a global level, the contribution of infections of poverty to heart disease can be seen in analyzing the Global Burden of Disease estimates from the WHO. According to this data, approximately 8.8% of the disability-adjusted life years (DALYs) of LMICs may be attributable to cardiovascular disease Trypanosoma cruzi, the etiologic agent of Chagas disease (American trypanosomiasis), of whom up to 30% will develop Chagasic cardiomyopathy associated with heart failure, arrhythmias, and mural thrombi causing pulmonary and systemic emboli and sudden death Trypanosoma brucei, with an annual incidence of approximately 17,000, and of infected patients 70% develop the above mentioned electrocardiographic changes Approximately 10 million people are infected with Loa loa and Onchocerca volvulus are among the leading candidate infections linked to this condition Schistosoma mansoni and Schistosoma japonicum, cause chronic hepatosplenic schistosomiasis, an important cause of pulmonary hypertension and cor pulmonale. These pathologies occur in response to parasite egg deposition, hepatosplenic fibrosis, and portal hypertension Schistosoma species, of whom 4%–8% develop hepatosplenic disease, and greater than 270,000 will go on to develop pulmonary artery hypertension S. mansoni schistosomiasis were shown to be synergistic Endomyocardial fibrosis (EMF) causing restrictive cardiomyopathy is most prevalent in tropical and subtropical regions in the world. In endemic areas of sub-Saharan Africa, the prevalence of EMF reaches close to 20% and affects mostly children and young adults Trepomema pallidum (the cause of syphilis), as NTDs Mycobacterium tuberculosis, leads to another cardiac manifestation, tuberculous pericarditis. Among patients with pulmonary tuberculosis, 1% to 2% develop tuberculous pericarditis. The various manifestations can include myopericarditis, pericardial constriction, pericardial effusion, and effusive-constrictive pericarditis M. tuberculosisM. tuberculosis, untreated HIV can still cause pericarditis as well as other forms of cardiovascular disease, including pulmonary hypertension and cardiomyopathy In their first ever report on NTDs in 2010, the WHO classified the endemic treponematoses, including We lack adequate data to determine the true extent of human cardiovascular disease that results from NTDs and other neglected infections of poverty. It also remains unclear how much of the world's ischemic heart disease and cerebrovascular disease, which account for most of the disease burden, may be due to neglected causes. There is an urgent need to understand the contribution of neglected diseases to heart disease in LMICs in order to design appropriate intervention strategies. This has been highlighted by others in the field who also acknowledge the presence of unique risk factors and heart pathologies in LMICs There also remains a dearth of adequate control tools, that is, new drugs or vaccines for the neglected causes of human cardiovascular disease in LMICs. For instance, benznidazole and nifurtimox, the currently available drugs for treating Chagasic cardiomyopathy, require long treatment courses, and exhibit high levels of toxicities Finally, as identified by Commerford and Mayosi, when the etiology and control mechanisms are known, research should include identifying social determinants that prevent disease management. Social determinants such as health systems, attitudes, and perceptions of both patients and physicians and socioeconomic factors should all be explored and recognized as important aspects of cardiovascular disease control and variable between ethnic groups Together, these interventions will address significant neglected causes of cardiovascular disease burden especially prevalent in LMICs. The growing interest in cardiovascular disease in these resource-poor settings is necessary to ensuring the health of the working-age population. Careful analysis reveals the need to look beyond lifestyle risk factors of developed countries and appreciate the nuances of chronic disease in developing countries. In doing so, we will more effectively facilitate the economic advancement of low- and middle-income populations.Table S1List of countries in WHO income-based regions.(DOCX)Click here for additional data file.


The primate visual system has a uniquely high proportion of ipsilateral retinal projections, retinal ganglial cells that do not cross the midline in the optic chiasm. The general assumption is that this developed due to the selective advantage of accurate depth perception through stereopsis. Here, the hypothesis that the need for accurate eye-forelimb coordination substantially influenced the evolution of the primate visual system is presented. Evolutionary processes may change the direction of retinal ganglial cells. Crossing, or non-crossing, in the optic chiasm determines which hemisphere receives visual feedback in reaching tasks. Each hemisphere receives little tactile and proprioceptive information about the ipsilateral hand. The eye-forelimb hypothesis proposes that abundant ipsilateral retinal projections developed in the primate brain to synthesize, in a single hemisphere, visual, tactile, proprioceptive, and motor information about a given hand, and that this improved eye-hand coordination and optimized the size of the brain. If accurate eye-hand coordination was a major factor in the evolution of stereopsis, stereopsis is likely to be highly developed for activity in the area where the hands most often operate.The primate visual system is ideally suited for tasks within arm’s length and in the inferior visual field, where most manual activity takes place. Altering of ocular dominance in reaching tasks, reduced cross-modal cuing effects when arms are crossed, response of neurons in the primary motor cortex to viewed actions of a hand, multimodal neuron response to tactile as well as visual events, and extensive use of multimodal sensory information in reaching maneuvers support the premise that benefits of accurate limb control influenced the evolution of the primate visual system. The eye-forelimb hypothesis implies that evolutionary change toward hemidecussation in the optic chiasm provided parsimonious neural pathways in animals developing frontal vision and visually guided forelimbs, and also suggests a new perspective on vision convergence in prey and predatory animals. It has been suggested that vision originated as a system for the control of distal movements -3. The pIt is commonly suggested that binocular vision and stereopsis in primates was selected for due to the adaptive value of accurate visual control of the hands ,12. HarrVertebrate motor and somato-sensory areas associated with limb movements are largely located in the cerebral hemisphere contralateral to the limb involved Figure . In primThus, the EF hypothesis proposes that the classic contralateral organization for visually mediated directing of limbs has been preserved in primates through evolutionary change in the visual system. If so, it is likely that components of the visual system that are largely involved in guiding the hand are functionally coupled with other sensory modalities and motor neurons involved in hand coordination. This would predict that the visual system is particularly suited for tasks in the space where the hand usually operates, i.e. the ipsilateral visual field, within arm’s length, and in the inferior portion of the visual field, since reaching movements in primates typically begin in the inferior quadrants of the visual field. This review explores inter-hemispheric communication, the location of the hemidecussation line, the achiasmatic syndrome in humans, IRP influence on oculomotor function, hemispheric specialization in eye-hand control, multimodal perception, and frames of reference in hand coordination. Links between the evolution of stereopsis and the evolution of eye-hand coordination are investigated. Implications for the evolution of vision convergence in mammals are also discussed.The primate lifestyle requires frequent relocations in space and coordinated movements of the eyes and hands to interact with objects . Early eRingo et al.  proposedThe achiasmatic syndrome, a rare genetic condition, offers a model of a human vision system without IRP ,35 (FiguThe optokinetic response refers to eye movement in response to movement in the surroundings, which serves to stabilize the visual image on the retina . LateralIn humans, the nasal retina projects to the contralateral hemisphere, while the temporal retina projects ipsilaterally Figure c. The liBinocular cues have since long been considered the most important source of depth information -56. Binoet al. [Keefe et al.  argued aet al. -61. Visuet al. . How areet al.  proposedet al. , and aniet al. . The anaet al. .Neurons in the primate SC are active prior to and during arm movements toward visual targets . NeuronsMultimodal neurons responding to tactile as well as to visual events have been observed also in the putamen  and in tIt has been suggested that humans and animals form cognitive maps of their environment . Such maHumans are able to grip objects whether the objects are heard, seen, or touched. Consequently, information about the location of objects is recoded in a joint-centered frame of reference, despite of the sensory modality involved . The locStudies of the SC , the venThe EF hypothesis implies that the visual system is well equipped to serve the hand in a reaching task. Vision profoundly influences arm movements soon after birth . The preThe concept that binocular vision and abundant IRP result in stereopsis is well established. Studies have used the presence of binocular vision as a verification of stereopsis in, for example, Macropodidae  and tyraIt has been proposed that mammals and birds may use binocular visual fields differently ,142. MarEvidence demonstrates that communication among visual and motor neurons is slower when interhemispheric communication is required -27. MultThe differing proportions of IRP in the non-image-forming visual pathways involved in circadian rhythm and pupillary light responses relative to image-forming pathways  can alsoIt is commonly suggested that binocular vision is especially useful to predators for estimating the distance to prey, while animals preyed upon often have laterally situated eyes, which provides an ability to scan a broad area of the surroundings without moving the head . The lawHeightened depth perception within the working space of the hand has adaptive value in arboreal primates. Arboreal marsupials, as well as fruit bats that use claws on the wing to manipulate fruits -150, posOctopus vulgaris may be another candidate. This species has been reported to combine arm location information with visual input to control complex goal directed movements [The EF hypothesis might be evaluated through comparative analyses of mammalian and non-mammalian associations among IRP, eye convergence, and visual guidance of forelimbs. Ultimately it is DNA that determines whether the axon of a retinal ganglion cell crosses or not -21, and ovements .This review supports the principle that evolutionary modifications in the proportions of IRP in the primate brain contributed to visual guidance of the hands, and emphasizes that stereopsis is largely associated with visual directing of the hand. Accurate movement of primate forelimbs depends on continuous and reciprocal interaction between motor and sensory systems. Goodale proposed that vision originally developed to control movement -3. This OC: Optic chiasm; IRP: Ipsilateral retinal projections; EF hypothesis: Eye-forelimb hypothesis; S2: Secondary somatosensory cortex area; SC: Superior colliculus; M1: Primary motor cortex; PMd: Dorsal aspect of the premotor cortex; PPC: Posterior parietal cortex; PRR: Parietal reach-region; FEF: Frontal eye field; NGM law: Law of Newton-Müller-Gudden.The author declares that there are no competing interests.


Acetylcholine has been implicated in both the pathophysiology and treatment of a number of psychiatric disorders, with most of the data related to its role and therapeutic potential focusing on schizophrenia. However, there is little thought given to the consequences of the documented changes in the cholinergic system and how they may affect the functioning of the brain. This review looks at the cholinergic system and its interactions with the intrinsic neurotransmitters glutamate and gamma-amino butyric acid as well as those with the projection neurotransmitters most implicated in the pathophysiologies of psychiatric disorders; dopamine and serotonin. In addition, with the recent focus on the role of factors normally associated with inflammation in the pathophysiologies of psychiatric disorders, links between the cholinergic system and these factors will also be examined. These interfaces are put into context, primarily for schizophrenia, by looking at the changes in each of these systems in the disorder and exploring, theoretically, whether the changes are interconnected with those seen in the cholinergic system. Thus, this review will provide a comprehensive overview of the connectivity between the cholinergic system and some of the major areas of research into the pathophysiologies of psychiatric disorders, resulting in a critical appraisal of the potential outcomes of a dysregulated central cholinergic system. The central cholinergic system has been implicated in the pathophysiology of schizophrenia  levels. All five receptors are found in the human brain, with discreet distribution patterns, implying different functions  projections from nuclei of the basal forebrain; these include the medial septal nucleus, the nucleus basalis of Meynert, the vertical nucleus of the diagonal band and the horizontal limb of the diagonal band nucleus, which innervate the hippocampus, most cortical regions and some subcortical nuclei, (ii) the pedunculopontine-lateral dorsal tegmental projections from the brainstem to the thalamus, midbrain and other brainstem regions and (iii) interneurons in the striatum (most abundant) and the nucleus accumbens .1−8) receptors  which couple to Gq protein; stimulating inositol phosphate hydrolysis or Group II (mGluR2 and mGluR3) and Group III , both of which couple to Gi/Go protein and decrease levels of cAMP , 2-amino-3-(3-hydroxy-5-methyl-isoxazol-4-yl)propanoic acid (AMPA), and kainate receptors] and metabotropic propyl-1-phosphonic acid (CCP) increased acetylcholine release in the nucleus accumbens, an effect blocked by local perfusions of both CCP and the AMPA receptor antagonist 6,7-Dinitroquinoxaline-2,3-dione (DNQX)  the M1 deficits associated with and (ii) the NMDA receptor hypofunction predicted in schizophrenia. However, animal studies have shown that inhibitory avoidance memory consolidation can be repressed by co-administration of muscarinic and NMDA antagonists to the ventral tegmentum, at doses that were ineffective when used alone  subunits and, because of their similarity to GABAA subunits, is now viewed as a GABAA variant  67 is essential for GABA synthesis and is used as a marker for GABAergic cells. Cortical expression of mRNA for both GAD67 and the GABA transporter, GAT1, are reported to be decreased in tissue from people with schizophrenia  and ventral tegmental area (VTA), forming four major dopaminergic pathways in the mammalian brain, these are the (i) mesolimbic, (ii) mesocortical, (iii) nigrostriatal, and (iv) tuberoinfundibular pathways , which couple to Gi/o proteins and either have no effect on or inhibit cAMP , which couple to G Schetz, . D1and D Schetz, .In both Lewy Body dementia and Alzheimer's disease, where there is a loss of cholinergic neurons, patients have a loss of cognitive function and neuropsychiatric symptoms. Although both groups have similar levels of delusions, anxiety, and depression, patients with mild Lewy Body dementia have more visual and auditory hallucinations than patients with Alzheimer's disease , a serotonergic agonist, caused psychoses which were proposed to have similarities to the positive symptoms of schizophrenia  and inflammatory/immune pathways in the periphery  can determine whether or not a gene can be transcribed. Assuming the RNA is generated, the next step in the process can also be regulated, this time by microRNAs (miRNAs) which have the ability to block the translation of mRNA into proteins. Therefore, these factors also have to be taken into account when considering the interactions between central neurotransmitters, particularly since both epigenetics and miRNAs have been implicated in psychiatric disorders. For example, does the activation of one system affect the prevalence or type of epigenetic markers on the genes that encode components other systems? Will such changes in turn affect the fundamental regulation of expression for that gene? Does transmitter X affect the expression of particular miRNAs? If so, which of the myriad of theoretical interactions ascribed to each miRNA actually occur physiologically and of those, which are relevant to the process under investigation? The involvement of both miRNAs Dwivedi,  and epigAndrew Stuart Gibbons, Madhara Udawela, and Jaclyn Neoreport no competing interests. The following authors have previously received remuneration: Elizabeth Scarrreceived honorarium from Astra-Zeneca and travel support from GlaxoSmithKline (GSK). Brian Deanreceived travel support from GSK, honorarium from Pfizer, Eli Lilly, and Merck Sharp and Dohme (MSD).


Thus, the expression of MGMT, its activity, and its promoter methylation status are associated with the response of GBM to TMZ, confirming that MGMT promotes clinical resistance to TMZ. Previous studies have shown that a variety of drugs such as interferon-β (IFN-β), levetiracetam (LEV), resveratrol, and valproic acid (VAP) increased the sensitivity of TMZ through MGMT-dependent or MGMT-independent mechanisms. In this review, we describe drugs and promising molecules that influence the responsiveness of GBM to TMZ and discuss their putative mechanism of action. In MGMT-positive GBMs, drugs that modulate MGMT activity could enhance the therapeutic activity of TMZ. Thus, administration of these drugs as an adjunct to TMZ chemotherapy may have clinical applications in patients with malignant gliomas to improve the outcome.A combined therapy of the alkylating agent temozolomide (TMZ) and radiotherapy is standard treatment, and it improves the survival of patients with newly diagnosed glioblastoma (GBM). The DNA repair enzyme O Accordingly, increased expression of MGMT is one of the most robust predictors of the TMZ response in malignant glioma cells. The most important mechanism of silencing of the MGMT gene is methylation of its promoter, resulting in the loss of MGMT expression and diminished DNA repair activity. Therefore, the epigenetic silencing of MGMT gene by its promoter methylation has been shown to be a useful predictor of responsiveness of GBM patients to TMZ  is the most common and lethal among all gliomas. The current standard of care includes surgery followed by concomitant radiation and chemotherapy with the oral DNA-alkylating agent with good penetration into the blood-brain barrier, temozolomide (TMZ). OBecause tumor cells that express MGMT are more resistant to TMZ, targeting the MGMT activity can enhance the therapeutic efficiency of TMZ. Recently, a phase III clinical trial examined the effects of dose-dense TMZ as a strategy to deplete MGMT and enhance the outcome in GBM patients . In addition, preclinical studies and clinical trials are investigating whether it is possible to increase the anticancer potency of TMZ by combining it with other pharmacological agents , a low-molecular-weight substrate, can irreversibly inactivate MGMT, by competing with O6-methylguanine. in vitro , which belongs to type I IFNs, was first discovered on the basis of its antiviral activities. Subsequently, it was shown to exhibit pleiotropic biological activities including immunomodulatory activity; antiangiogenic activity; and direct antitumor effects, e.g., growth inhibition and apoptosis  have the ability to inhibit histone deacetylase (HDAC) activity. HDAC inhibitors (HDACi) have transcriptional regulatory activity  and N3 position of adenine (9.2%), whereas O6 methylation of guanine directly removed by MGMT is the least frequent adduct (5%). N7-methylguanine and N3-methyladenine are substrates for the base excision repair (BER) system, which consists of multicatalysis reactions by a wide variety of DNA glycosylases, endonucleases, polymerases, and DNA ligases , which repairs the cytotoxic lesions N^3-methyladenine and NThe GATA transcription factor family consists of six members, which bind to a consensus DNA-binding element. Recently, it was reported that GATA4 is expressed in the embryonic and adult central nervous system, inhibits astrocyte proliferation, and acts as a tumor suppressor in GBM  greatly enhances the effect of TMZ through the imbalance of DNA repair, independent of the MGMT status  polymerase (PARP) is involved in DNA repair. PARP1 particularly has the dual effect. The cytotoxic effect of alkylating agents is enhanced by either its inhibition or hyperactivation. Inhibition of PARP1 accumulates broken DNA in the cells, resulting in cell death Figure . PARP1 i+ biosynthesis also potentiates alkylator-induced cytotoxicity  is a stilbenoid found in the rinds of red grapes and in other fruits. It exhibits antioxidant, anticancer, cardioprotective, and anti-aging effects, among others. Importantly, resveratrol has been identified as a potential cancer chemopreventive agent based on its ability to modulate cancer initiation, promotion, and progression. Resveratrol increases TMZ efficacy and although the influence of resveratrol on MGMT is unknown, the combination of TMZ and resveratrol has a synergistic effect Valproic acid (VPA) is a commonly prescribed AED for the treatment and prevention of seizures in patients with glioma. In addition to its antiseizure properties, VPA inhibits cell proliferation and induces differentiation and apoptosis in cancer cells .Patients with GBM who were treated with VPA appeared to have a better outcome than did those not treated with VPA or treated with other AEDs  from ribonucleotides is an essential step in DNA synthesis and cell replication. Ribonucleotide reductase (RR), the rate-limiting enzyme of this pathway, appears to be a negative predictive factor in patients with cancer  from the Ministry of Education, Culture, Sports, Science, and Technology and from the Japan Society for the Promotion of Science (Mitsutoshi Nakada) and Osaka Cancer Research Foundation (Mitsutoshi Nakada).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.