High intensity interval training (HIIT) is effective at improving health markers in groups at risk of cardiovascular and metabolic disease. Studio cycling may offer a platform for HIIT in the community, however little is know about how increased adiposity influences thermal control during HIIT and the effect this may have on overweight patients who are new to exercise. The purpose of this pilot study was to investigate the thermal adaptation in response to studio based group HIIT in sedentary overweight adults.-1; BSA 1.97(0.16) m2; 31.8(2.4) %body fat; <1.5 hr.wk-1 of physical activity) otherwise healthy volunteers completed six 30 minute familiarisation sessions followed by 6 weeks of supervised studio cycling 3 times per week. All sessions were completed in a ventilated but non-temperature controlled group fitness studio. Thermal measures were completed in weeks 1, 3 and 6 for all participants. Participants were weighed in minimal clothing before and after exercise, which was corrected for fluid intake to determine sweat loss. During the session, wireless thermistors were attached to the skin for the calculation of mean skin temperature  kg; max respectively with no differences between weeks. Body fat was reduced by 13% following training (pre: 31.8(2.4) %; post 27.5(4.5) % (p < 0.05), but no change for BMI, body surface area or body surface area:mass. There was a significant effect of time (p < 0.0001) and an interaction  on 2 vs 321.1(93.5) mL.m2; p = 0.183) and was correlated to mean Tsk  and body composition .Mean ambient temperature across all weeks was 19.6 ± 1.7 °C. The mean and peak exercise intensity equated to 83(4)% and 9(4) % of HRThe present data suggest that there may be some impairment of thermoregulatory adaptation in response to regular indoor cycle training in overweight and obese individuals. The decline in Care should be taken when overweight or obese individuals begin exercise training, as it is possible that they may experience greater thermoregulatory strain in the initial phases of training before heat acclimation begins to occur. Further work should consider the effect that increasing exercise prescription to overweight and obese populations has on the risk of heat related complications.


To evaluate the perception of an esthetical deformity resultant from arthroscopic long head biceps (LHB) tenotomy according to the degree of experience of the assisting professional.  120 patients submitted to shoulder surgery were photographed and photos were mounted in a PowerPoint presentation. Three shoulder specialist surgeons, three generalist orthopedic surgeons and three graduated residents analyzed the presentation.  On all patients we observed most agreement among the shoulder specialists. When just the patients with LHB tenotomy were analyzed, the specialists agreed moderately, the generalists had small agreement and the residents, a poor one. Analyzing patients with BMI < 30, there was major agreement between the specialists, while the generalists and residents had poor agreement. Analyzing patients with BMI ≥ 30, the generalists had small kappa agreement, while the specialists and residents had no agreement. Level of Evidence III. Case Control Study. The perception of an esthetical deformity regarding a LHB tenotomy did not have significant agreement between different level of professionals, even though the specialists showed similar perception on tenotomy patients. The evaluation of obese patients lowered the agreement on the three groups of professionals.  Godinho et al.Most studies question patients about the perception or not of aesthetic deformity resulting from tenotomy of LHB, these rates vary between 5 and 65%.The objective of this research is to analyze comparatively whether the perception of the aesthetic deformity resulting of tenotomy of LHB varies according to the degree of specialization of the assisting professional.This is a cross-sectional study. A group of 120 patients who underwent arthroscopic surgery on a shoulder in the period from June 12, 2002 and December 3, 2008 was analyzed. The study was approved by the Institutional Ethics Committee.There were not selected to participate in this study patients with atrophy or aesthetic modification of the contralateral upper limb, compromising the comparison between the upper limbs such as the finding of a breach of contralateral LHB; history of fractures and/or surgery in the contralateral upper limb (UL).The mean age of the 120 patients included in the study was 53.9 ± 11.9 years old. Regarding gender, 80 patients were female (66.7%) and 40 patients were male. The dominant side was affected in 93 patients (73.5%).Within this universe of 120 patients, tenotomy of the LHB was performed in 69 patients. The average age of this group was 58.7 ± 10.4 years old. Regarding gender, 50 patients were female (72.5%) and 19 male.The other 51 patients who underwent arthroscopic shoulder surgery without tenotomy of the LHB had a mean age of 47.5 ± 10.9 years. Regarding gender, 30 patients were female (58.8%) and 21 male.All patients underwent measurement of height in centimeters and weight in kilograms in the immediate preoperative period. The values were used to calculate the Body Mass Index (BMI) by the specific equation.Patients were classified according to BMI between different degrees of obesity according to After anesthesia, patients were placed in the lateral position with the upper limb at 30° flexed at 20° and under traction of 5 Kg. Tenotomy of LHB was performed with a Trimmer clamp at its insertion on the upper lip of the glenoid when: 50% or more of the tendon thickness was impaired, instability in the intertubercular groove was diagnosed or a degenerative SLAP was found. The procedure was always performed by the same surgeon.All patients still anesthetized were immobilized in the operating room with a sling. An abduction cushion was used when the injury of the rotator cuff sutured was large or extensive.Patients who underwent tenotomy of LHB were instructed to avoid forced flexion of the elbow, as well as its entire length within the first four weeks after surgery.All 120 patients in the study were evaluated with a median of 16.5 months (IIQ 8 to 23.8) postoperatively. During the evaluation, all patients received the Informed Consent form approved by the Ethics Committee of the institution where the work was performed.Patients were photographed with a digital camera Sony Cybershot W-100 in VGA resolution at a standard distance of 60 cm, with the UL aducted by the trunk, the elbow at 90 degrees and maximum supination. A flash light was used regardless of the room light conditions. The photos showed the arm with the adjacent shoulder and elbow joints. The patient's face was hidden.The photos of the patients were placed in a Microsoft PowerPoint (PowerPoint version 12.1.2-2008 for Mac) presentation with a blue background and size of 8 x 5 cm. Photos of the UL operated were on the left and the photo of the contralateral limb on the right side, for comparison. No description of the patient data or clinical history was revealed. , 2 and 3The Microsoft PowerPoint presentation was submitted for assessment by three professionals specialized in shoulder surgery, three generalist orthopedic professionals and three orthopedics resident doctors from the third year on. The professionals were invited to observe each slide separately for 60 sec at most and score the response grid in case they observed or not any aesthetic deformity that could be the result of a tenotomy of the LHB.The variables studied were age, gender, operated side, dominance, degree of obesity and the correlation between opinions of the medical professionals.t-test for age assessment. The chi-square test was used to evaluate the side, gender, dominance and BMI. Differences with p ≤ 0.05 for a 95% confidence interval were considered significant.Data were analyzed with SPSS  version 12.0 (SPSS Inc. 1989-2003). For statistical analysis, we used: calculation of mean, standard deviation, median, frequency and percentage. We used the Student The Kappa index was used to assess agreement between the observations of different professionals. It is a measure of interobserver agreement and measures the degree of agreement beyond what would be expected solely by chance. This measurement of agreement has as maximum value one, representing total agreement and values close to and below zero, indicating no agreement, or even that the agreement was exactly as expected by chance. A possible Kappa value lower than zero (negative), suggests that the correlation found was less than that expected solely by chance. The study evaluated a total of 120 patients. There was no statistically significant difference between the groups of patients undergoing shoulder arthroscopy with or without tenotomy of the LHB when the following variables were evaluated: mean age (p=0.847), gender (p=0.117), operated side (p=0.042) , dominance (p=0.119) and BMI (p=0.631). The groups were considered similar. When analyzing the overall sample of patients (n=120) we observed a greater agreement among orthopedic surgeons specialists in shoulder surgery (Kappa 0.49 (range 0.38 to 0.59) / p<0.001). The general orthopedists (Kappa 0.29 (range 0.19 to 0.39) / p<0.001) and resident physicians (Kappa 0.23 (range 0.12 to 0.33) / p<0.001) had a small agreement. When we analyzed the sample of patients who underwent tenotomy of the LHB, the experts agreed with each other surgeons moderately (Kappa 0.51 (range 0.38 to 0.65) / p <0.001). However, this correlation does not appear to be statistically different from the general orthopedists, having a small correlation (Kappa 0.30 (range 0.17 to 0.44) / p <0.001). The resident doctors had a poor agreement (Kappa 0.17 (range 0.04 to 0.31) / p=0.013), but statistically it is not very different from the general orthopedists.When we analyzed the sample of patients which did not undergo tenotomy of the LHB, poor agreement was observed among surgeon specialists (Kappa 0.17 (range 0.02 to 0.33) / p=0.032) and small among the general orthopedists (Kappa 0.21 (range 0.05 to 0.36) / p=0.011) and resident physicians (Kappa 0.21 (range 0.05 to 0.37) / p=0.009).2 there was a moderate to substantial agreement among expert surgeons (Kappa 0.54 (range 0.42 to 0.66) / p <0.001), while the general orthopedists (Kappa 0.28 (range 0.16 to 0.40) / p <0.001) and resident physicians (Kappa 0.24 (range 0.12 to 0.36) / p <0.001) remained with poor agreement.  / p=0.005). For experts surgeons (Kappa 0.07 (range -0.15-0.28) / p=0.552) and resident physicians (Kappa 0.12 (range -0.10-0.33) / p=0.292) there wasn't any agreement. , we found a greater agreement among shoulder specialist orthopedic surgeons in perceiving patients with residual deformity from a LHB tenotomy, suggesting that the trained eye contributes to the situation. Among the general orthopedists and medical residents, the correlation was poor.Walch et al.2) we saw an increase in agreement  among experts in shoulder surgery, while the general orthopedists and medical residents remained with poor agreement. This fact has further confirmed that the trained eye is better able to notice the aesthetic deformity.In our study, when we analyzed lean patients (BMI < 30 kg/m2) lowered the level of agreement among the three professional classes, which was low among shoulder surgery specialists and total absent among the general orthopedists and medical residents. It is likely that little agreement among experts has been, in this study, an incidental finding, with no statistically significant difference of the divergence found in other professionals. We agree with Godinho et al.,,,Analysis of obese patients (BMI ≥ 30 kg/mThe perception of the resulting aesthetic deformity resulting from tenotomy of LHB showed no significant correlation between shoulder surgery professional specialists, general orthopedists and medical residents, although the specialists demonstrated a similar perception of deformity in tenotomized patients.2. The evaluation of obese patients with BMI ≥ 30 kg/m2 showed no correlation between the three different groups of professionals.Specialist professionals have shown greater agreement when evaluating patients with BMI < 30 kg/m


Background: Patients with panel reactive antibodies (PRA) have many difficulties to find a crossmatch-negative kidney for transplantation and are at a higher risk of post-transplantation rejection.Objective: To evaluate the effect of simvastatin on PRA and post-transplant outcome of these sensitized patients.th month, PRA was rechecked in all patients. Those patients who underwent transplantation continued to take simvastatin six months after transplantation. Serum creatinine levels were checked at monthly intervals post-operation.Methods: 82 patients with end-stage renal disease (ESRD) with a PRA ≥25% were evaluated. In a one-year follow-up, the patients were treated with simvastatin. These patients were compared with 82 matched controls receiving placebo tablets. At the end of the second and 12Results: The mean±SD PRA level at the end of the second month was 36.63%±31.14% and 45.34%±24.36% in cases and controls, respectively (P=0.012). Seven patients in the case group and 10 in the control group were lost to follow-up. The remaining patients continued to take simvastatin for 12 month.th month was 24.02%±31.04% in cases and 43.15%±26.56% in controls (P=0.001). 25 patients underwent renal transplantation and continued to receive simvastatin 6 months after transplantation. These patients were matched with 25 controls treating with placebo. The mean±SD creatinine level 6 months after kidney transplantation was 2.05±1.14 mg/dL and 3.15±1.09 mg/dL in cases and controls consecutively (P=0.02).The mean±SD PRA level at the end of the 12Conclusion: Simvastatin can be safely used to lower PRA and improve post-transplantation outcomes. In additization -6. This Patients:From 750 patients with end-stage renal disease (ESRD) who were in the waiting list for renal transplantation or referred to our nephrology clinic in Shiraz Transplant Center, 164 patients who met our criteria, were included in this study. Using a simple random method, these patients were randomized to the patient and control groups, each consisted of 82 patients.Inclusion criteria: Patients from both sexes aged from 18 to 75 years old.Patients with ESRD on hemo- or peritoneal dialysis. And,PRAs ≥25%.Exclusion criteria:Pregnant women, patients who need ongoing blood products, patients taking other treatments to decrease PRA, patients listed for multi-organ transplant other than kidney as well as those with liver failure were excluded from the study.Lab tests: Baseline aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were checked for all patients in the case group. Then, all of the 82 patients received 20 mg/day oral simvastatin for two months. Patients in the control group received the same dose of the same shape starch tablets as placebo during these two months. At the end of the second month, PRA was checked for all the patients again. PRA testing was done using the complement dependent cytotoxicity (CDC).th month. In patients who complained of myalgia and muscle weakness, creatine phosphokinase (CPK) was also determined to watch any side effects of simvastatin. The control group were also treated with placebo tablets for 12 months. The complete response to simvastatin was defined as a drop of PRA to <25%. Rejection episodes were proven by kidney biopsy.We continued treatment with simvastatin for 12 months by checking liver enzymes  every two months and PRA at the end of the 12Statistical analysis:Student’s t test for paired data and χ2 test for comparison of categorical data. A P value <0.05 was considered statistically significant.All parameters were expressed as mean±SD and analyzed with SPSS software for Windows version 12.0  using Ethics and consents: The study protocol was carried out in accordance with the Helsinki Declaration revised in 1989. All subjects were informed about the study protocol and written consents were obtained from all participants. Ethics committee of Shiraz University of Medical Sciences approved the study.There were 82 cases and 82 controls. The mean±SD age of patients was 39.3±11.3 years in cases and 37.8±12.1 years in controls (P>0.05). There were 50 (61%) men and 32 (39%) women in case group and 47 (57%) men and 35 (43%) women in control group (P>0.05). Seventy-eight (95%) patients in case group and 78 in control group were on hemodialysis program for a mean±SD duration of 26.56±18.28 months three times a week. Four patients in case group and four in control group were on peritoneal dialysis program for a mean±SD duration of 195±21.48 months. In each group, 32 (39%) patients had history of previous renal transplantation and 11 had history of previous transfusion of blood products. The causes of ESRD are outlined in i.e., PRA<25%). We continued simvastatin treatment up to 12 months. During this period, six patients in the case group and 10 in the control group discontinued the follow-up program; one case deceased  after two months of treatment with simvastatin. The mean±SD drop was 14.22%±19.63% (range: 9.90%–18.53%); in the case group, 28 (34%) patients showed a complete response to the treatment (deceased .th month was 24.02%±31.04% in the case group and 43.15%±26.56% in controls (P=0.001). The mean±SD drop in PRA in cases was 26.57%±26.10% at the end of 12th month . Twenty-five (33%) of 75 patients underwent renal transplantation after a mean±SD period of 6.45±3.56 months since beginning of simvastatin therapy. Eleven patients received their kidneys from living unrelated donors, five from living related and nine from deceased donor in both cases and controls. These 25 patients were matched with 25 renal transplanted controls. From these 25 patients, three were lost to follow-up. Other 22 transplanted patients were followed for six months after transplantation receiving the same dose of simvastatin. The controls received placebo for six months and all of them completed the study. The mean±SD serum creatinine level six months after kidney transplantation was 2.05±1.14 and 3.15±1.09 mg/dL in cases and controls, respectively (P=0.02). The mean creatinine level at the end of the study (1.37±1.61 mg/dL) showed a significant reduction in comparison to the initial values (P=0.001). Two patients presented with graft loss and became dependent on hemodialysis again. Others remained dialysis free with well functioning kidneys. None of the patients presented with liver failure or rhabdomyolysis during the follow-up period. At the first stage of this study, we treated sensitized ESRD patients with simvastatin. Then, we continued simvastatin therapy in those who underwent kidney transplantation. Glomerulonephritis and lupus nephritis comprised a significant proportion of known causes of ESRD in sensitized patients. This study revealed that simvastatinn treatment in cases decreased PRA level significantly compared to the controls treated with placebo. Simvastatin also improved the outcomes after kidney transplantation.et al., reported that the rate of acute rejection was lower in renal transplant patients using simvastatin and pravastatin in comparison with those patients who did not receive these medications [et al., did not observe any useful effects with lovastatin [et al., reported that administration of neither IVIG nor simvastatin alone cannot effectively inhibit preformed HLA-antibodies to allow successful renal transplantation [Interesting results have been reported in clinical trials investigating immunomodulatory role of simvastatin. Truncer, ications . Other sications , 9. Resuications , 5. Despvastatin . Mahmoudantation .This study provided evidence suggesting the role of simvastatin in decreasing PRA level. It also showed that simvastatin may improve the outcome of patients after renal transplantation. Larger sample size and proper duration of follow-up are strength of our study compared to other similar studies conducted on this issue. Considering the presence of many confounding variables including age of patients, causes of ESRD, causes of sensitization, type and duration of dialysis as well as limited number of patients in each categories, there are few controlled trials regarding the role of HMG-CoA reductase inhibitors in the treatment of sensitized patients.Further studies, especially large placebo controlled trials may be more useful and conclusive regarding the use of simvastatin in the treatment of sensitized patients before transplantation along with its usage as a protective medication in acute rejection after renal transplantation.


Background: Several factors influence on the outcome of ischemic stroke. The aim of this study was determination the relationship between stroke mortality and red blood cell parameters.Methods: This cross-sectional study was conducted from 2011 July to June 2012. For all patients with ischemic stroke in middle cerebral artery (MCA) territory, the cell blood count test was performed. We recorded their mortality on the 1st week and the 1st month after ischemic stroke. Data analysis was performed using t-test, χ2, Mann–Whitney U-test, logistic regression and receiver operating characteristic curve in SPSS for Windows 19.0.Results: A total of 98 subjects (45.9% men and 54.1% women) with the mean age of 71.0 ± 13.9 years were assessed, while 67.3% of them were anemic. The prevalence of 1st week mortality among anemic and non-anemic patients was 40.9% and 34.4% (P = 0.534). The prevalence of mortality after 1st week till 1st month was 19.6% and 21.0% respectively (P = 0.636). In univariant analysis, only 1st month mortality had a significant relationship with red blood cell (RBC) count (P = 0.022). However, the result of logistic regression model showed that RBC (P = 0.012) and mean corpuscular volume (MCV) (P = 0.021) remained as predictors of the 1st week and the 1st month mortality (P = 0.011 and P = 0.090 respectively). The best cutoff point of RBC for the prediction of the 1st week mortality with 44.7% specificity and 69.5% sensitivity was estimated 4.07 million/μl and for the 1st month mortality with 46.6% specificity and 72.2% sensitivity was estimated 4.16 million/μl.Conclusion: The RBC count and MCV are independent predictors of ischemic stroke short-term mortality. In addition, the disturbance in oxygenation of the other organ can lead to multiple organ failure and death.During an ischemic stroke, a cascade of cellular and molecular events starts.In this project, we aimed to determine if anemia is associated with stroke mortality? In addition, we were interested to determine the cutoff point of red blood cell (RBC) indices for prediction of stroke mortality.This cross-sectional study carried out in an educational hospital of the Guilan University of Medical Sciences (GUMS), Iran, in 2011-2012 with achievement the confirmation of the ethic committee of GUMS.st week and 1st month mortality by any cause were recorded. Anemia was defined as two standard deviation lower than means of Hb and HCT values for each sex groups. Hence that HCT < 36.0% and Hb < 12.0 g/dl among women and HCT < 41.0% and Hb < 13.5 g/dl among men were considered as anemia.5For omitting the confounding effect of the arterial territory, only middle cerebral artery (MCA) territory infarction was included. The patients who involved by ischemic stroke in this territory participated in the study after fulfilling an informed consent by their legal responsible. The involvement of MCA was ascertained by the brain computed tomography scan. The patients whose medical files were incomplete or MCA involvement were not established were excluded. The treatment was identical for all of them, and no additive expenditure was imposed on patients. The patients’ information and RBC count and its indices including mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), hemoglobin (Hb) and hematocrit (HCT) and their 1The sample volume was determined as 101 patients according to 7 as reference number, with confidence of 99% and the test power of 95%.2 tests, receiver operating characteristic (ROC) curve and multiple logistic regression models in SPSS for Windows 19.0  software were used for analysis of data.Kolmogorov–Smirnov (KS) test, parametric t-test or non-parametric Mann–Whitney U and χFrom 101 patients who participated; 98 patients with a mean age of 71.0 ± 13.9 (25-103) years old (45.9% men and 54.1% women) completed this study.About 67.3% of them were anemic with a mean age of 70.9 ± 15.2 years old with no significant difference with non-anemic ones (17.3 ± 11.0 years) (P = 0.887).st week mortality rates among anemic and non-anemic patients were 40.9% and 34.3% (P = 0.534). The 1st month mortality rates were 60.6% and 56.0% (P = 0.636), that 19.6% of anemic and 21.0% of non-anemic patients were passed away between 1st week and 1st month after stroke.The 1st week or 1st month mortality rate and all studied parameters was not significant (P > 0.050) except between 1st month mortality and RBC count (P = 0.022)  .st week [area under curve (AUC) = 0.604 0.057] and the 1st month (AUC = 0.611 0.059) mortality were close to being significant only for RBC count.The maximum predictive areas for the 1st week mortality predictors and RBC count  and age  as the 1st month mortality predictors.In multivariant analysis, only RBC count  and MCV  remained as the 1st week mortality with 44.7% specificity and 69.5% sensitivity was estimated as 4.07 million/μl  and for the 1st month mortality with 46.6% specificity and 72.2% sensitivity was estimated as 4.16 million/μl . The cutoff point for prediction of the 16In the present study, the prevalence of anemia based on WHO criteria was 67.3% in the present study that is near the maximum reported prevalence among geriatrics in a systematic review of the literature by Beghe et al. (from 2.9% to 61.0% in elderly men and from 3.3% to 41.0% in elderly women).st week was 40.9% and 34.3% among anemic and non-anemic patients respectively. In spite of 6% difference, the result was not statistically significant. After 1 month, 60.6% and 56.0% of anemic and non-anemic patients were dead that 19.6% and 21.0% of them were dead between the 1st week and the 1st month that this difference was not significant also. Whereas, in Tanne et al. study, that was performed in 2001-2002; after 1 month, the mortality rate was 23.9% and 13.2% among anemic and non-anemic patients [OR = 1.90 (95% CI: 1.5-3.43)].7 In another study by Nybo et al., anemia was introduced as a predictive factor of stroke mortality that both of them are in disagreement with our results.8 About the comparison of mortality rate in our study that was higher than the others and also than the population-based study in Iran by Borhani-Haghighi et al.9 and WHO MONICA Project;10 the difference may be due to not only the difference of emergency and hospital care, but also the contribution of all types of arterial territory involvement in their study, not similar to ours which only involved by ischemic stroke in the MCA territory with high mortality rate.The stroke mortality in the 1st week mortality rate has no significant association with all of the RBC indices but the first month mortality was related to RBC count. It can be explained that the 1st week mortality is related to the nature of ischemic stroke and some events such as herniation, whereas the 1st month mortality is related to another factors such as patients’ compensation that may be related to anemia and RBC indices.Although in our study by univariant analysis, the 1st week mortality and RBC and age only account for 1st month mortality. With increasing one unit of RBC count, the 1st week and the 1st month mortalities decrease 3.0 and 2.5 folds respectively. In addition, with increasing one unit of MCV measure, the 1st week mortality decreases 6.0%. In ROC curve, the maximum predictive area for mortality was estimated only for RBC count. The best cutoff point of RBC count for the 1st week mortality was 4.06 million/μl. It seems that its specificity is low (44.7%) and sensitivity is moderate (69.5%). And for the first month mortality was estimated 4.16 million/μl. It seems that its specificity is also low (46.6%), however its sensitivity is high (72.5%). The LR+ and LR− of cut-off point were 2.26 and 0.68 in the 1st week and 1.35 and 0.59 in the 1st month. Although all of them were close to 1, but the measures of 1 month became farther than 1.According to logistic regression analysis, only RBC count and MCV remained as predictors of the 1It seems that we can use RBC count and its cutoff point and eventually MCV measurement as the predictors of short-term mortality of ischemic stroke.


Satellite remote sensing provides globally consistent decadal-scale observations of ambient nitrogen dioxide  concentrations in different regions around the world.We used observations of NONO2 in high-income North America (Canada and the United States) decreased more steeply than in any other region, having declined at a rate of –4.7%/year . PWMNO2 decreased in western Europe at a rate of –2.5%/year . The highest PWMNO2 occurred in high-income Asia Pacific (predominantly Japan and South Korea) in 1996, with a subsequent decrease of –2.1%/year . In contrast, PWMNO2 almost tripled in East Asia  at a rate of 6.7%/year . The satellite-derived estimates of trends in ground-level NO2 were consistent with regional trends inferred from data obtained from ground-station monitoring networks in North America (within 0.7%/year) and Europe (within 0.3%/year). Our rankings of regional average NO2 and long-term trends differed from the satellite-derived estimates of fine particulate matter reported elsewhere, demonstrating the utility of both indicators to describe changing pollutant mixtures.We found that PWM2 provide new information about changing global exposure to ambient air pollution. Our estimates are publicly available at http://fizz.phys.dal.ca/~atmos/martin/?page_id=232.Long-term trends in satellite-derived ambient NO2 concentrations inferred from satellite observations. Environ Health Perspect 124:281–289; http://dx.doi.org/10.1289/ehp.1409567Geddes JA, Martin RV, Boys BL, van Donkelaar A. 2016. Long-term trends worldwide in ambient NO Globally, > 3 million premature deaths were attributed to ambient air quality in 2010 , and air2) is a major constituent of the air pollution mix. Strong associations between NO2 and mortality have been identified in multicity studies around the world .Here, we inferred annual mean ambient ground-level NOSatellite observations. We used NO2 column observations from the Global Ozone Monitoring Experiment (GOME), Scanning Imaging Absorption Spectrometer for Atmospheric Chartography (SCIAMACHY), and GOME-2 satellite instruments. Information on these satellite instruments is available at Earth Online (https://earth.esa.int/). We chose these instruments for their similar observation times , with some temporal overlap owing to the range of viewing angles. Data were obtained from the Tropospheric Emission Monitoring Internet Service [http://www.temis.nl/airpollution/ ]. The NO2 column densities were retrieved from measurements of backscattered sunlight (sunlight . The GOMsunlight .http://dx.doi.org/10.7265/N52R3PMC)].We excluded data contaminated by cloud or snow by rejecting bright pixels (cloud radiance fraction > 0.5) and by filtering data according to the shortest snow-free season . We aggregated the data to 0.1° × 0.1° and linearly interpolated between each interval. We used these data to calculate time series in population-weighted annual mean NO2 (PWMNO2) for the same regions as in the Global Burden of Disease (GBD) Study 2010 .2 worldwide. We have made these data publicly available at http://fizz.phys.dal.ca/~atmos/martin/?page_id=232 (“Surface NO2”). The most notable reductions were observed in North America, western Europe, and Japan. In contrast, ground-level NO2 substantially increased in East Asia and in isolated urban regions of the Middle East, Russia, and India. Trends for specific urban areas around the world are clearly distinguishable. For example, the steep increase isolated in northwestern China is around the city of Ürümqi , where NO2 increased at a rate of 10.1%/year .r = 0.80, n = 223). The correlation was slightly weaker across rural locations  than across nonrural locations . We found that the satellite-derived product for Europe was less strongly correlated with ground-station observations  than that for North America, but in this case, rural locations were highly correlated , and non-rural locations were less so . These correlations are consistent with previous comparisons of satellite-derived NO2 with NO2 data from monitoring networks  and European (n = 305) pixels with continuous ground-station measurements compared with mean ground-station measurements. The linear trends for the satellite estimates across North America of –4.4%/year  and across Europe of –2.2%/year  are consistent with the ground-based measurement trends of –3.7%/year  and –1.9%/year , respectively.2.Population-weighted annual mean NO To our knowledge, this is the first data set that allows estimates to be made of long-term global changes in area-wide ambient NO2 concentrations relevant to outdoor exposure. 2 (PWMNO2). Approximately 1.6 billion people lived in regions where average NO2 significantly decreased (p < 0.01). In contrast, 3.2 billion people lived in regions where average NO2 significantly increased (p < 0.01). The globally averaged PWMNO2 increased by 0.9%/year . The four regions with the highest long-term mean PWMNO2 are high-income Asia Pacific , western Europe, high-income North America (Canada and the United States), and East Asia . All have trends significant at p < 0.01.NO2 time series in these four regions; maps of satellite-derived NO2 concentrations at the beginning and end of the record are also shown. In Canada and the United States  relative to the long-term mean. The steepest decline occurred between 2004 and 2010, when PWMNO2 decreased at a rate of –7.0%/year  relative to the long-term mean. This trend is significantly different from (p < 0.01), and almost three times steeper than, the trend of –2.5%/year  for earlier years between 1996 and 2003. The maps of NO2 concentrations in North America show that the decreases were most notable over urban areas of the eastern United States and California.d States , the satNO2 in western Europe  was weaker than that in North America. The maps show notable decreases over the southern United Kingdom, northern France, Germany, and Benelux  regions.The satellite-derived estimates of PWMn Europe  also decNO2 of all GBD regions was consistently observed for Asia Pacific (South Korea and Japan account for 97% of this population). The region experienced a decrease of 20% from 1996 levels, with a linear trend of –2.1%/year . In contrast, our satellite-derived ground-level estimates indicated that PWMNO2 in East Asia increased 2.7 times over the same period of time, at a rate of 6.7%/year , and now has the highest PWMNO2 of all GBD regions. China accounts for 97% of this population, and the maps in 2 for eastern China in particular.The maps in NO2 was dominated almost entirely by changes in NO2 as opposed to changes in population. If the population is held constant at 1996 levels, the trend in PWM is 6.5%/year , well within the 95% CI of the original slope. Similarly, the slopes for western Europe, North America, and Asia Pacific were within the original 95% CIs when population changes were ignored (data not shown).The GPW population distribution changed remarkably across East Asia from 1996 to 2012. However, the increase in region-wide PWM2.Distribution of population and NO2 as cumulative distribution plots for the same four regions depicted in 2 concentration (highest exposure) decreased by 42% (from 15.7 to 9.0 ppb), and the 50th percentile decreased by 54% (from 3.8 to 1.7 ppb). Concentrations also decreased for less-exposed populations, with the lowest 10th percentile decreasing by approximately 50% (from 1.1 to 0.6 ppb).In North America , the 99t2 concentration both decreased by approximately 30% . In contrast, the lowest 10th percentile only decreased by approximately 10% (from 1.0 to 0.9 ppb).In western Europe , the 99t2 concentration decreased by 16% (from 15.9 to 13.4 ppb) and 12% (4.1 to 3.6 ppb), respectively. The cleanest 10th percentile decreased by 24% (from 0.8 to 0.6 ppb).In Asia Pacific , improve2 concentrations increased for more than 90% of the population in East Asia (2 concentration more than doubled between 1996 and 2012 (from 8.9 to 21.6 ppb). Similarly, the 50th percentile tripled (from 1.0 to 2.9 ppb). The 10th percentile also doubled (from 0.3 to 0.6 ppb), indicating that conditions deteriorated for both the less-exposed and the highly exposed segments of the population.In contrast to the other three regions highlighted, NOast Asia . The 99t2 and PM2.5 distributions.Comparing global ground-level NO Comparing NO2 and PM2.5 offers insight into the air pollution mixture and into the sources that affect exposure. 2.5 trends and long-term mean concentrations from 2 for the same time period (1998–2012).2.5 . In contrast, whereas Asia Pacific ranked highest in terms of NO2 (4.7 ppb), it ranked seventh for PM2.5 (16.8 μg/m3). South Asia experienced the second-highest ambient concentrations of PM2.5 (34.6 μg/m3), yet this region only ranked fifteenth for NO2 (0.5 ppb). Another significant shift in ranking occurred for North America, whose population was exposed to the world’s third-highest ambient concentrations of NO2 (3.5 ppb) but ranked much lower (twelfth) in terms of PM2.5 (9.9 μg/m3).East Asia had the highest long-term population-weighted concentrations of PM2  and PM2.5 . The only other region with statistically significant declines in both was western Europe. Of the remaining seven regions with significant decreasing trends for NO2, none had significant changes in PM2.5: most notably, Asia Pacific. In contrast, PM2.5 increased significantly in eight regions, but only three of these had significant increases in NO2 as well . Southern sub-Saharan Africa is the only region where statistically significant trends were in opposing directions .Uncertainty in the satellite-derived trends. We used the comparison with ground-station observations across North America and Europe to assess the error in our regional satellite-derived trends. The confidence intervals of the satellite-derived trends . Thus, we treated the confidence intervals as a proxy measure of error in the relative trends for which there were no ground-based observations. The steeper slope derived from the comparison of the regional averaged satellite observations with the ground-based measurements . Globally, the correction increased PWMNO2 by 33% (from 1.2 to 1.6 ppb).Sampling losses in the satellite record caused by quality control filtering contributed to systematic error in the annual mean. For 13 of the 21 regions, our correction for incomplete sampling changed the calculated PWMNO2. For example, the trend over North America without the sampling correction was –4.7%/year  versus –4.7%/year  with the correction. Similarly, in western Europe, where the correction was largest, the trend without the correction was –2.4%/year  versus –2.5%/year  with the correction. Globally, the trend without the sampling correction was 1.3%/year  versus 0.9%/year  with the correction (p = 0.04).We tested the sampling correction by comparing the linear regression slopes with and without adjusting for sampling bias. In all cases, the sampling correction had a statistically nonsignificant impact on the regional trends in PWM2 are expected to have less influence on the trend calculation, and estimating trends over large regions reduces random error across space, we caution that errors in annual NO2 over any individual 0.1° × 0.1° pixel will be large. Error in estimating ground-level NO2 from satellite observations (because of errors in the simulated profile and in the retrieved column densities) has been previously estimated as –11% to +36% . The record offers almost complete spatial coverage, not only supplementing gaps in established ground-station observing networks but also providing insight into regions without prior observations.NOtion mix  and conttion mix . Howeverexposure , particu2 concentrations to calculate worldwide trends in population-weighted annual mean NO2 from 1996 to 2012. Decreasing trends were found in North America (–4.7%/year), western Europe (–2.5%/year), and Asia Pacific (–2.1%/year). Increasing trends were found in East Asia (6.7%/year), North Africa/Middle East (2.4%/year), and South Asia (1.3%/year). The trend in global PWMNO2 was increasing (0.9%/year) and statistically significant. Our calculated trends in PWMNO2 were consistent with ground-based measurements in North America and Europe and with previous work describing changes in NO2 tropospheric columns over North America .We used our satellite-derived ground-level NOca e.g.,  and Chinca e.g., , and oveNO2 for East Asia and for the Middle East from 1996 to 2012 reflect rapid development in regions where emissions have been rising but remain uncertain  emission reduction measures to be implemented by mid-2003 and for total anthropogenic emissions in the United States to decrease by 26% between 2004 and 2009 (NO2 that ocurred during this period (40%) compared with the emissions reported by the U.S. EPA and with the decrease in area-weighted mean NO2 , suggests that emission reductions successfully and most efficiently targeted air quality in populated regions. Other factors, including the 2008 economic recession  ranked low for NO2. A driver of these differences lies in the types of combustion that produce NO2 and PM2.5, with biofuel sources in South Asia and intense coal burning in East Asia . Comparing epidemiologic studies of the various regions could yield insight into the health effects of different pollution source types.The regional rankings of population-weighted NOor PM2.5 , suggestast Asia . We also2 concentrations we obtained with the WHO air quality guidelines for NO2 because NO2 exhibits dramatic within-city spatial variation . These regional population-weighted averages are indirectly related to average human exposure. Personal exposure would need to account for additional factors such as individual activity patterns and indoor versus outdoor contributions.We reported trends in population-weighted averages to assess changes in NO2 observations and from higher-resolution modeling of the relationship between ground-level concentrations and the observed column densities. Land use regression could offer additional valuable fine-scale information (http://science.nasa.gov/missions/tempo/), Sentinel-4 (https://sentinel.esa.int/web/sentinel/missions/sentinel-4), and GEMS  PDFClick here for additional data file.


Despite of primary and secondary survey in patients with severe trauma, missed injuries can occur, so some authors consider that the tertiary survey could reduce its incidence.Protocol of tertiary trauma survey was established after literature review, to detect missed injuries in the initial care and as part of the Quality program Unit.Prospective, descriptive, observational study, in patients with severe trauma (Injury Severity Score (ISS) > 15), who were admitted to the Trauma and Emergency ICU of a high complexity hospital from May 2013 to January 2014. The tertiary survey was performed at 24-48 hours of admission patient and it was conducted by an experienced staff and a resident not involved in the initial patient care. We collected demographic variables, initial Glasgow Coma Score (GCS), Injury Severity Score, hemodynamic status on admission, length of stay in ICU, days of Mechanical Ventilation (MV), complications and mortality. Furthermore, we collected missed injuries and their impact on patients outcomes. Quantitative variables were expressed as mean ± standard deviation. For qualitative variables we used percentages. Statistical data were analyzed by SPSS 16.0 considering statistically significant P < 0.05.88 patients were studied, 72.7% male, mean age of 40.63 ± 17.71, average ISS was 22.02 ± 11.74, and GCS ≤ 8 21.8%. The median ICU stay was 2.88 days , with 3.42 ± 3.39 days connected to MV. Overall mortality of 4%. 45 missed injuries were found in 34 patients . There were: extremities and soft tissue injuries (44.4%), head and neck injuries (24.4%) and back injuries (17.8%). 55.6% of them had no impact on patients outcomes, 22.2% required a new complementary test and none of them caused the patient´s death. The presence of a higher ISS, was associated with significantly greater number of missed injuries (p < 0.05).22 new radiological findings in 20 patients were diagnosed: 56.5% were fractures, the majority in costal arches. 72.7% of missed diagnosis had no impact on the patients evolution, 13.6% required a new specialist evaluation and none of them caused the death.These findings match with the published literature about incidence of missed injuries and demonstrate the importance of establishing a tertiary trauma survey for early identification and as a quality indicator. The presence of a higher ISS could be considered a risk factor for these lesions.


Even at NOx concentrations below theacceptable standard, there is association with deaths caused by respiratorydiseases.Exposure to nitrogen oxides (NOx) emitted by burning fossil fuels has been associatedwith respiratory diseases. We aimed to estimate the effects of NOx exposure onmortality owing to respiratory diseases in residents of Taubaté, São Paulo, Brazil,of all ages and both sexes. This time-series ecological study from August 1, 2011 toJuly 31, 2012 used information on deaths caused by respiratory diseases obtained fromthe Health Department of Taubaté. Estimated daily levels of pollutants  were obtained from the Centro de Previsãode Tempo e Estudos Climáticos Coupled Aerosol and Tracer Transport model to theBrazilian developments on the Regional Atmospheric Modeling System. Theseenvironmental variables were used to adjust the multipollutant model for apparenttemperature. To estimate association between hospitalizations owing to asthma and airpollutants, generalized additive Poisson regression models were developed, with lagsas much as 5 days. There were 385 deaths with a daily mean (±SD) of 1.05±1.03 (range:0-5). Exposure to NOx was significantly associated with mortality owing torespiratory diseases: relative risk (RR)=1.035  for lag 2, RR=1.064 (95%CI: 1.017-1.112) lag 3, RR=1.055 (95%CI:1.025-1.085) lag 4, and RR=1.042 (95%CI: 1.010-1.076) lag 5. A 3 µg/m These pollutants act as precursors of secondary airpollutants, such as ozone (O3), nitric acid (HNO3) and others(2), contribute to theformation of acid rain (Nitric oxide (NO), nitrous oxide , NOx,SO2, and CO. The association with PM10 was statisticallysignificant, robust, and independent of other air pollutants. An increase inPM10 equal to 100 µg/m3was associated with an increase inoverall mortality equal to approximately 13%.Saldiva et al.  examined2.5], O3, andNO2 were found to have positive associations with mortality risk in alarge cohort of California adults, using individualized exposure assessments , ranging from 1.4% (95%CI: 5.9-8.7) to 14.2% (95%CI:0.4-28.0).The largest relative risk of death caused by respiratory disease in elderly adults wasfound by Martins et al. . Increme3 in PM10 levels increased hospitaladmissions of elderly adults owing to respiratory illnesses by 3.5%  in Rio de Janeiro  among residents of Taubaté, SP ,between August 1, 2011 to July 31, 2012.The geographical location of Taubaté is between São Paulo and Rio de Janeiro , with a population of approximately 290,000. The city is crossed by thePresidente Dutra highway, the most important road in Brazil, with a high traffic flow ofbuses, cars and heavy trucks. Vehicle numbers in 2012 were estimated at about 180,000cars and motorcycles and 7000 buses and trucks .The Ethics Committee on Human Research of the Universidade de Taubaté (UNITAU) approvedthe study (#068/2012). Data on mortality owing to respiratory diseases were obtainedfrom death certificates stored at the Epidemiological Surveillance Unit, which is linkedwith the Health Department of Taubaté.3, NOx and PM2.5 (µg/m3). This system is an onlinetransport model fully coupled to the CATT-BRAMS atmospheric model and has been designedto study the emission, deposition and transport of gases and aerosol particles usingsatellite data. The system generates daily estimates every 8 hours for differentpollutants that are associated with biomass burning in South America , considering daily means quantified as CO (ppb) andO America . One of  America .Data on temperature and humidity were obtained from the Centro de Previsão de Tempo eEstudos Climáticos website and the apparent temperature, which is a function oftemperature and humidity, was calculated .Models with exposure lags of 0 to 5 days (lag 0 to lag 5) were used to estimate theassociation between exposure to environmental pollutants and deaths associated withrespiratory diseases. It is known that the effects of exposure to pollutants can bedelayed, although there is no consensus about this interval. Therefore, we used thegeneralized additive Poisson regression model for analysis because deaths are discreteevents.The analysis consisted of modeling trends and seasonality in the series using splinefunctions for time; for weekdays and holidays, dummy variables were used. Inclusion andexclusion of terms in the model were evaluated for final fit and model quality. Thecorresponding terms for daily concentrations of pollutants were added to the model,assuming that the association with the dependent variable was linear.The coefficients provided by the model can be translated into risk of death fromrespiratory diseases caused by exposure to pollutants, adjusted for apparenttemperature. These relative risks (RR) with 95% confidence intervals, according to 0-5day lags, were determined.3 in NOx levelswere transformed into percentage decrease in risk of death caused by respiratoryillness, with the respective 95% confidence intervals. A significance level of 5% wasadopted for all analyses.The estimated effects corresponding to a decrease of 3 µg/mDuring the study period, there were 385 deaths owing to respiratory diseases, with 90%of these among elderly adults over 60 years old. The daily mean was 1.05±1.02, rangingfrom 0 to 5 deaths per day, regardless of age and sex.2.5, NOx, O3 and CO did not exceed the standard set by Brazil’sState Decree No. 59113/2013, based on guidelines established by the World HealthOrganization (WHO) establishing new air quality standards through a gradual andprogressive set of targets, such that air pollution is reduced to acceptable levels overtime adjusted for apparent temperature, controlled by weekday and seasonality. This modelprovided the coefficients and SEs  tocalcu2.5 in lags 0 and 1, toO3 in lags 2 and 4, and to NOx in lag 2 up to lag 5. A decrease of 3µg/m3 in NOx concentrations implies a decreased risk of death between11.5% (95%CI: 2.8-21.0) and 17.9% (95%CI: 7.8-28.9), corresponding to lags 2 and 3 sensor.Pollutant concentrations were not directly quantified by environmental agencymeasurements, but estimated by model; estimated data have been used in other studies-25. CO aalidated . In studalidated , PM2.5le2; thus,concentrations of NO2 can accurately reflect NOx concentrations .NOx emitted in the form of NO are rapidly oxidized to generate NOtrations . Among th asthma . Moreove3 and NO2induce permeability of bronchial epithelial cells in primary cultures, with increasedrelease of inflammatory mediators, thereby demonstrating that bronchial epithelial cellsfrom patients with chronic airway diseases, such as asthma and chronic obstructivepulmonary disease, are more susceptible to the deleterious effects of air pollutants  , which ito 5.6%) , the sam2 concentrations of 26 to 67µg/m3, the risk of death caused by respiratory diseases increased by 2.52%(95%CI: 1.44-3.59), with higher risk in older people when concentrations of thispollutant increased 10 µg/m3  for respiratory diseases, RR=1.024 (95%CI:1.015-1.034) for chronic obstructive pulmonary disease, and RR=1.008 (95%CI:1.002-1.014) for pneumonia . This was also the case for particulate matter with a lagof 4 days  after exposure to pollutants (The relationship between exposure to NOllutants .2 and suspended particulate matter, brought about by enforcement ofmeasures to control automobile emissions, contributed to a decrease in the prevalence ofrespiratory diseases (In another study, researchers used data of children collected in different regions ofJapan from 1997 to 2009. They observed that reductions in the concentrations ofNOdiseases .The actual levels of air pollution to which the population is exposed may be alimitation of this study. This is becausewe used modeled data instead of actualobservations. Therefore, deaths may not be directly attributable to exposure toatmospheric pollutants . In contThis time series ecological study also has other limitations, such as a lack ofindividual information on exposure and disease. This study assumes homogeneous exposurethroughout the city and that all individuals were similarly exposed. Anothercharacteristic of this study is that we used records related to hospitalizations ordeaths in the public health system. Thus, results reflect the effects of air pollutantson the portion of the population that uses the Unified Health System network, which isthe majority of the Brazilian population .The analysis performed in this study identified that exposure to NOx may be associatedwith deaths caused by respiratory diseases in a medium-sized city, even with pollutantemissions that are below the established standard. This information may serve as awarning to managers to expand investment in mass transport systems, which indirectlycontribute to the improvement of public health.


Escherichia coli cells in a k-carrageenan matrix, for the detection of oxidative stress challenged by metalloid compounds. The E. coli roGFP2 oxidative stress biosensor shows high sensitivity towards arsenite and selenite, with wide linear range and low detection limit , short response times (0–9 min), high stability and reproducibility. This research is expected to provide a new direction in performing high-throughput environmental toxicity screening with living bacterial cells which is capable of measuring the bioavailability and toxicity of environmental stressors in a friction of a second.Biosensors fabricated with whole-cell bacteria appear to be suitable for detecting bioavailability and toxicity effects of the chemical(s) of concern, but they are usually reported to have drawbacks like long response times (ranging from hours to days), narrow dynamic range and instability during long term storage. Our aim is to fabricate a sensitive whole-cell oxidative stress biosensor which has improved properties that address the mentioned weaknesses. In this paper, we report a novel high-throughput whole-cell biosensor fabricated by immobilizing roGFP2 expressing  Many environmental pollutants can alter the intracellular oxidation status of an organism via oxidative damage which causes biochemical dysfunction and ultimately may lead to cell death. Oxidative stress occurs as a result of an imbalance in cellular redox status, such as a rapid production of reactive oxygen species (ROS) which exceeds the capacity of the antioxidant defense mechanisms of the cells . MetalloAequorea victoria 53 years ago [etc., of cells [Green fluorescent protein (GFP) was first found in ears ago . It is mears ago . Due to ears ago ,10. GFP ears ago ,11. Hazaof cells –14. Exceof cells ,16.GSH) enhance the formation of disulfide bonding between cysteine residues which triggers protonation of the roGFP2 Y66 chromophore, leading to an excitation peak shift [E. coli roGFP2 cells [E. coli roGFP2 cells in buffer suspension. The biosensor was however found to be unstable for long-term storage . We overcame this weakness by immobilizing the bacterial cells in a non-toxic matrix. The aim of this study was to fabricate a sensitive oxidative stress biosensor which is easy to produce, and has high-throughput and with long term stability. In this paper, we report a sensitive oxidative stress biosensor fabricated from roGFP2-expressing E. coli immobilized in k-carrageenan (KC).roGFP2, which possesses two cysteine residues at the positions 147 and 204, has been found to be more suitable with its high intensity of fluorescence and long dynamic range compared with other roGFP variations. The 4-hydroxybenzylidene-imidazolinone chromophore, which is also known as Y66 chromophore, is the chromophore in roGFP2, that emits fluorescence . The chaak shift ,18,19. TP2 cells ,19. The P2 cells  reportedE. coli roGFP2 biosensor to other previous toxicity biosensors, we selected arsenite and selenite as model environmental stressors. Arsenic that is found in the environment occurs from both natural and anthropogenic sources. Naturally occurring arsenic-containing bedrock formations are highly related to well water and ground water pollution episodes in Bangladesh, West Bengal (India) and regions of China [To compare the characteristics of the KC-entrapped of China ,20. Humaof China . In contof China . Due to 2.2.1.Menadione  was obtained from Mitsuwa Chemical Co., Ltd. . Sodium arsenite was a product of Wako Pure Chemicals Industries . Disodium selenite was purchased from Santoku Chemical Industries Co., Ltd. . All other chemicals were of highest purity available. Chemical stocks were prepared by dissolving in Milli-Q water  or analytical grade DMSO.2.2.Escherichia coli strain DH5αTM  transformed with the plasmid pRSET-roGFP2 [The bacterial strain involved in this study was T-roGFP2 . AmpicilT-roGFP2 .2.3.2.3.1.E. coli cells expressing roGFP2 protein (E. coli roGFP2) were cultured, harvested, and suspended in 5 mM HEPES buffer (pH 7.0) containing 171 mM NaCl, and left to settle at 20 °C for 1 h as mentioned in [E. coli roGFP2 in buffer suspension was measured with a spectrofluorophotometer . The emission wavelength was 525 nm. The excitation wavelength was scanned along 350–510 nm with FAST mode. Excitation and emission band widths were set at 3 and 10 nm, respectively. Fluorescence emission of E. coli roGFP2 cells was recorded before and after the addition of menadione at 0.17, 2, 4, 8 and 16 min. E. coli roGFP2 suspension in the cuvette was stirred continuously using a magnetic bar to ensure homogeneity. The ratio of the readings at excitation peaks of 400 and 490 nm was measured as fluorescence ratio (Ex400 nm/Ex490 nm) [ioned in . Fluoresx490 nm) .2.3.2.E. coli roGFP2 oxidative stress biosensor: (i) the concentration of k-carrageenan (KC), the immobilization matrix; and (ii) the cell density of E. coli roGFP2 cells to be immobilized. Step (i) was carried out by immobilizing 50 μL of E. coli roGFP2 cells in buffer suspension (maintained at 35–40 °C) in 50 μL KC, maintained at 40–45 °C, with concentrations of 1.0, 1.2, 1.4, 1.6 and 1.8 (w/v) % respectively. Cell suspension and KC solution were mixed with micropipette tip to ensure even distribution of cells and were solidified in wells of a black flat bottom 96-well microplate . Microplates with immobilized E. coli roGFP2 cells were then sealed with a sheet of parafilm and kept in 4 °C overnight for complete solidification. Step (ii) of optimization was done by fixing the concentration of KC to 1.8 (w/v) % while varying the cell density of E. coli roGFP2. E. coli roGFP2 cells and KC were mixed in 1:1 ratio and immobilized as mentioned above in step (i). Immobilized E. coli roGFP2 oxidative stress biosensors were exposed to 50 μL of test solution. Fluorescence of the oxidative stress biosensor was measured every 1 min for 10 min using fluorescence microplate reader . Emission filter of 528 nm  and excitation filters of 400 nm  and 490 nm  were used as in [Two parameters were optimized for the fabrication of 2.4.E. coli roGFP2 oxidative stress biosensor was exposed to two metalloid compounds: sodium arsenite (NaAsO3) and sodium selenite (Na2SeO3). COI was recorded as mentioned in Section 2.3.2. Both chemicals were prepared with 10−1 dilution each level starting from 100 mg·L−1 to 0.1 μg·L−1. The dose-response relationship and limit of detection (LOD) for both metalloids were determined.The 3.3.1.E. coli roGFP2 cells with the exposure to menadione in liquid suspension was examined. An increment in excitation spectrum peak at 400 nm and a decrement at 490 nm was observed after menadione exposure . Continuous increase in COI was observed reaching a plateau in 16 min of exposure time. The oxidation kinetics of the control was apparently slower. This indicates that E. coli roGFP2 is sensitive in detecting oxidation of cells induced by oxidizing agent, and is suitable to be used in the fabrication of an oxidative stress biosensor.A slow cellular oxidation was observed without menadione exposure . The rat3.2.k-carrageenan (KC) gel matrix was selected because it is comparatively non-toxic to bacterial cells, it forms rigid transparent gel which allows fluorescence detection and its gelling temperature is tolerable by bacterial cells.Optimal conditions of the immobilization matrix and cell density were determined to prepare an immobilized biosensor that is more stable and sensitive than a suspension biosensor. 3.2.1.−1 menadione exposure was obtained at 1.8% (w/v) KC  KC . In 1.0%3.2.2.E. coli roGFP2 oxidative stress biosensor was prepared with different cell densities and challenged with 1 mg·L−1 menadione to determine the optimal density for the biosensor response  resulted in decreased COI.response . COI inc3.3.3.3.1.E. coli cells, as predicted by an immediate increase of COI (−1 or higher concentrations of arsenite. Completion of arsenite-induced cellular oxidation was observed at 3 to 9 min depending on the tested concentrations.Exposure to arsenite induced oxidative stress in e of COI . The incE. coli roGFP2 oxidative stress biosensor to arsenite was examined (−1 to 10 mg·L−1. Limit of detection (LOD) for arsenite-induced oxidative stress was determined as 0.2 μg·L−1 by an extrapolation. No increment in COI was detected for the exposure to 10 ng·L−1 arsenite. These characteristics indicate that the E. coli roGFP2 biosensor is an extremely rapid sensitive sensor to detect oxidative cellular damage caused by arsenite.Dose-dependent response of examined . The bio3.3.2.E. coli cells were oxidized by the selenite exposure  KC can be explained by the stacking of bacterial cells. Weaker KC bonding occurs in KC gel at lower concentrations, which may not stably hold the E. coli roGFP2 cells, allowing cells to accumulate on the bottom of the well. Fluorescence signals could not be recorded accurately when the cells were not distributed evenly in the gel. This explains the results of the biosensor prepared in 1.0% (w/v) gel which gave a lower COI value than the cells suspended in buffer. This was due to increasing interaction of KC polymer chains with increasing concentration [+ cation from the suspension buffer decreases electrostatic repulsion between the sulphate groups resulting in the formation of a double helix domain which contributes to rigid KC matrix on higher concentration [8 cfu·mL−1 appeared to be the optimum cell density. Positive COI values indicated the detection of oxidative stress by the biosensors. This study provides essential information for possible application of the E. coli roGFP2 biosensor in practice. studied  and 3. Kntration . KC doubntration –25. With4.2.E. coli roGFP2 oxidative stress biosensor was studied for a period of 49 days in our previous study [E. coli roGFP2 oxidative stress biosensor, with fluorescence intensity of 442.04 ± 13.94 a.u. in the first 43 days, a small decrease (19%–23%) on the 44–46th day and a drastic 79.36% drop detected on the 47th day. A decrease to 2.8% of the initial readings was observed two days later. We thus concluded that the biosensor was viable for 46 days of storage at 4 °C. The decrease in fluorescence intensity later was caused by cell death, either due to the lack of nutrients or toxicity effects of the bacterial respiratory wastes. Immobilization of cells in KC for the purpose of fabrication of whole-cell biosensor has not been a popular approach. KC is a non-toxic gelation fiber and is industrially available [etc., [E. coli cells. Agarose is rather stiff and brittle compared with KC. Most reported biosensors using entrapment matrixes have short lifetimes, high probability of leakage and lower sensitivity [The stability of the optimized us study . Long teease 19%–% on the vailable . These pvailable . Immobile [etc., ,29. Compsitivity . This st4.3.E. coli roGFP2 oxidative stress is estimated to be related with the formation of OH• radicals via the Haber Weiss reaction in the GSH pathway in the cell [E. coli roGFP2, which thereafter leads to changes of the roGFP2 chromophore's conformation that gives the detected response. The antioxidant system in E. coli roGFP2 is able to stabilize the instability of redox stage in the cell before oxidative stress ocurrs. Therefore, LOD against arsenic is attributed to the capacity of the reduction-oxidation buffering pool in cells. Cellular oxidation of the biosensor dropped with 100 mg·L−1 arsenite exposure due to the cytotoxic effect of arsenite towards the bacterial cells, where E. coli roGFP2 cells might be killed and roGFP2 might be biochemically damaged directly . Both selenium and arsenic are essential elements for trations . Few stuons [2O2 ,34. Selethe cell  and 7. T4.4.E. coli roGFP2 oxidative stress biosensor was compared with previously reported arsenite and selenite detection biosensors. It was to our surprise that only a few whole-cell biosensors were reported to be fabricated for this purpose. To our best knowledge, this study is the first report of an immobilized whole-cell biosensor for detecting metalloids. The metalloid biosensors reported by Arias-Barreiro et al., Fujimoto et al. and Dwivedi et al. were based on free-moving bacterial cells suspended in either buffer or culture medium [The fabricated e medium ,35,36. TE. coli roGFP2 oxidative stress biosensor has a wider linear range as compared with the previously reported arsenite and selenite biosensors. The LODs of the oxidative stress biosensor reported in this study appear to be the lowest among all, except for Arias-Barreiro et al. [E. coli roGFP2 biosensors in the table have short response time. Our biosensor took an additional of 2 min to reach a plateau, because time was needed for the analytes to diffuse through the immobilization matrix. The E. coli roGFP2 oxidative stress biosensor also reported to be stable for long term storage and with high percentage of reproducibility.Our o et al.  that was4.5.The response time of the KC-entrapped biosensor was quick, and comparable to the free-moving cell suspension biosensor in the previous study , despiteThe biosensors detect the degree of oxidative stress burdened on cells. Thus, the biosensor response should reflect the joint action of toxicants within the limits of toxic mode of action through cellular oxidation. With the criteria of quick response, long-term stability, high reproducibility and high sensitivity , our bio5.E. coli roGFP2 oxidative stress biosensor was fabricated for the detection of oxidative stress-inducing chemicals. The biosensor was able to detect cellular oxidation inducing metalloids up to μg·L−1 and ng·L−1 levels with a wide dynamic range. Combined with a multiplate reader, which was able to read the response of the biosensor immobilized in a 96-well plate in as short a time as 10 s, a quick sensing high-throughput sensing array was made possible. This research was able to illustrate future development of a high-throughput, real-time environmental toxicity monitoring system which is time-saving, sensitive and has long term stability.A novel sensitive


SFRP2), GATA binding protein 4/5 (GATA4/5), N-Myc downstream-regulated gene 4 (NDRG4) and vimentin (VIM) promoters were evaluated for their use as markers in the noninvasive detection of CRC. Methylation-specific polymerase chain reaction was performed to analyze promoter CpG methylation of SFRP2, GATA4/5, NDRG4 and VIM in the fecal DNA of 56 patients with CRC and 40 individuals exhibiting normal colonoscopy results. Promoter methylation levels of SFRP2, GATA4/5, NDRG4 and VIM in CRC patients were 57.1% (32/56), 42.9% (24/56), 83.9% (47/56), 28.6% (16/56) and 41.1% (23/56), respectively. Furthermore, the specificity of the genes were 90.0% (4/40), 95.0% (2/40), 82.5% (7/40), 97.5% (4/40) and 85.0% (6/40), respectively. The overall sensitivity of detection for fecal DNA with at least one methylated gene was 96.4% (54/56) in CRC patients. By contrast, only 14 of the 40 normal individuals exhibited methylated DNA in the aforementioned promoter regions. Methylation of the SFRP2, GATA4/5, NDRG4 and VIM promoters in fecal DNA is associated with the presence of colorectal tumors. Therefore, the detection of aberrantly methylated DNA in fecal samples may present a promising, noninvasive screening method for CRC.Aberrantly methylated genes are increasingly being established as biomarkers for the detection of colorectal cancer (CRC). In the present study, the methylation levels of the secreted frizzled-related protein gene 2 ( Colorectal cancer (CRC) is the third most common type of cancer and one of the leading causes of cancer-associated mortality worldwide. Due to the long asymptomatic preclinical phase, the early diagnosis and treatment of CRC is critical for reducing disease-associated morbidity and mortality . The comVIM) gene methylation in fecal DNA from patients with CRC, adenoma and normal individuals, reported a sensitivity of 75% in CRC and 60% in adenoma patients, and a specificity of 86%, respectively , GATA binding protein 4/5 (GATA4/5), N-Myc downstream-regulated gene 4 (NDRG4) and VIM.In the present study, to evaluate the feasibility of fecal DNA methylation as a noninvasive CRC screening method, the methylation status of five gene promoters was investigated in fecal DNA from CRC and normal controls. The genes evaluated were secreted frizzled-related protein gene 2  between July 2011 and May 2012. The mean age of patients in the cancer and control groups was 60.60±12.19 years and 59.80±12.10 years, respectively. The ratio of male to female patients in the cancer group was 21:35, and that of the controls was 24:16. All subjects provided written informed consent for their participation prior to enrollment in this study and ethical approval was obtained from the ethics committee of Ningbo Medical Center, Li Huili Hospital. Stool samples were collected from all normal subjects and 40 CRC patients during the week prior to colonic lavage for colonoscopy or surgery. The remaining 16 CRC stool samples were collected 7–14 days following the initial colonoscopy. Samples were sent to the laboratory within 1 h of defecation and stored at −80°C.DNA was isolated from frozen stool samples (180–220 mg) using the QiaAmp DNA Stool mini-kit , according to the manufacturer’s instructions. The purified DNA was stored at −20°C for use in the experiments.The methylation status of a DNA sequence may be determined using sodium bisulfite, whereby bisulfite converts unmethylated cytosine residues to uracil, leaving the methylated cytosines unchanged . Sodium SFRP2, GATA4/5, NDRG4 and VIM promoters in the bisulfite-modified DNA was investigated using MSP PCR and primer pairs designed to discriminate between methylated and unmethylated alleles. The nucleotide sequences of the primers are shown in The methylation of the TM Robust Hotstart DNA Polymerase (Kapa Biosystems). The thermocycler conditions were as follows: 95°C for 5 min, 10 cycles of 95°C for 30 sec, Tm (−0.8°C) for 30 sec, 72°C for 60 sec, and then 38 cycles of 95°C for 30 sec, Tm (°C) for 30 sec, and 72°C for 60 sec, followed by a final extension step for 10 min at 72°C. PCR products were electrophoresed on a 2.5% agarose gel and visualized under UV light. Each sample was subjected to MSP for all genes, and all MSP assays were performed in triplicate to validate the results. Those who performed the assays were blinded to all clinical information.Each 50 μl PCR mix consisted of 2 μl of bisulfite-modified DNA, 1X KAPA2G buffer , 0.2 mmol/l deoxynucleotide triphosphate mix , 0.5 μmol/l of each primer (1 μl) and 0.5 units of KAPA2G2 tests and Fisher’s exact tests were used. Odds ratios (OR) and the corresponding 95% CIs were used to assess the association between DNA hypermethylation of SFRP2, GATA4/5, NDRG4 and VIM. All statistical tests were performed using SPSS version 11.0 software . All values were two-sided and P<0.05 was considered to indicate a statistically significant difference.The sensitivity and specificity [with 95% confidence interval (CI)] of the fecal DNA assays were calculated. To compare the characteristics of the different groups of patients, χStool samples were collected from 56 patients with CRC , and 40 endoscopically diagnosed healthy controls , MSP was performed on all 96 samples and each sample was subjected to MSP for all genes .SFRP2, GATA4/5, NDRG4 and VIM were found to be methylated at levels of 57.1% , 42.9% , 83.9% , 28.6%  and 41.1% , respectively. The specificity of these genes was found to be 90.0% , 95.0% , 82.5% , 97.5%  and 85.0% , respectively. The overall sensitivity of the detection of fecal DNA exhibiting at least one methylated gene was 96.4%  in CRC patients. By contrast, only 14 of the 40 normal individuals exhibited methylated DNA, with a specificity of 65%   .SFRP2, GATA4, GATA5, NDRG4 and VIM were 12.00 , 14.25 , 24.62 , 15.60  and 3.95 , respectively. With the combined analysis of the five methylation markers, the odds ratio was 50.14 .2 and Fisher’s exact tests were used. The associations between clinicopathological characteristics of the CRC patients and the methylation statuses of SFRP2, GATA4, GATA5, NDRG4 and VIM are shown in To compare the characteristics of the different groups of patients, χet al  in stool samples from individuals with CRC. No association was identified between the presence of methylated fecal DNA and patient gender, age, TNM stage or tumor location. Overall, these results indicated a correlation between early-stage and later-stage CRC, and that this method of detection may have equivalent sensitivity in proximal and distal cancers. Thus, the analysis of fecal DNA methylation may present a useful and noninvasive method of screening for colorectal neoplasia.In the present study, the feasibility of detecting methylated DNA in stool samples was evaluated as a noninvasive screening tool. The evaluation of five methylation markers, SFRP2 gene belongs to a recently established category of tumor suppressor genes, SFRPs, and silencing of SFRPs via promoter methylation causes constitutive activation of the Wnt/β-catenin signaling pathway, which is associated with multiple tumors, including CRC  reported that SFRP2 hypermethylation exhibits a sensitivity of 77–90% with regard to identifying patients with CRC. Huang et al  in CRC detection.te et al  investigIn the present study, the three aforementioned methylated genes were used to investigate the utility of fecal DNA in CRC detection. The results revealed that the specificity and sensitivity of SFRP2 , GATA4  and NDRG4 (97.5 and 28.57%) were lower than those reported in previous studies. These differences may be due to the different methods of detecting methylation, differences in technical personnel and differences in patient populations.VIM gene, a marker of mesenchymal cells, encodes a protein constituent of intermediate filaments and has been demonstrated to be transcriptionally silent in normal colorectal epithelial crypt cells were comparable to those of previous studies.The pt cells . Aberrancialized . Chen etd  for CRC in individual fecal samples. To evaluate the potential of GATA5 as a methylation marker for CRC detection, Hellebrekers et al (GATA5 methylation in CRC (79%) and low levels in normal colorectal mucosa (13%). In the present study, the methylation of GATA5 in fecal DNA for CRC detection exhibited a higher sensitivity (83.9%) than in the study by Hellebrekers et al (79%)  . AlthougIn conclusion, the results of the present study demonstrated the feasibility of using multiple methylation markers as a noninvasive method for detecting early CRC. Further studies are required to refine the panel of potential methylation markers for CRC.


Gaucher disease, an autosomal recessive condition due to deficiency of lysosomal glucocerebrosidase, is a multisystemic disease, with variable age of onset, severity and progression. It is classified into subtypes delineated by the absence (type 1) or presence (type 2 and 3) of primary nervous system involvement.The ethnically diverse, largely immigrant population in South Florida has a spectrum of Gaucher disease phenotypes, creating a challenge for optimization of disease management and an opportunity to explore treatment patterns.Ninety-three records from patients with Gaucher type I in South Florida were retrieved from the International Collaborative Gaucher Group (ICGG) Registry. Individual genotypes were correlated with severity scores and success at achieving published therapeutic goals for haemoglobin concentration, platelet count, spleen volume, liver volume and amelioration of bone pain and bone crises.The majority of patients were diagnosed during the fifth decade of life. Almost two-thirds were homozygous for the N370S mutation, reflecting the large Ashkenazi Jewish population in South Florida. The majority received imiglucerase (62.8%) at various intervals. 24.5% of patients underwent splenectomy before starting enzyme replacement therapy. After a median 12 treatment years, South Florida patients matched or exceeded the ICCG 4 year therapeutic goal achievement for platelet count (85.4% vs. 79.6% success), spleen volume (93.3% vs. 78.0% success), liver volume (93.4% vs. 90.6% success), and bone crises (100% vs. 99% success). Nevertheless, fewer patients with intact spleens had sustained achievement of all 6 therapeutic goals (30.4% versus 41.4%) and only 40% of the splenectomy patients sustained achievement of 5/5 possible goals. 54.7% of the intact spleen patients continued to have bone pain vs. 29.8% in ICCG. Significantly, only 37% of the ICGG patient cohort had bone pain prior to initiation of treatment compared to 73.4% of the South Florida patients (moderate or severe pain in 59.6%).Demographic characteristics are a significant determinant of the differences in response to treatment observed in South Florida Gaucher patients compared to those described in the international population enrolled in the ICGG Gaucher Registry. Individual genotypes and ethnic background are important considerations for optimizing patient care for Gaucher disease. GBA1[Gaucher disease (GD) is an autosomal recessive lysosomal storage disorder that, with the exception of rare patients with saposin C deficiency, is caused by mutations in the glucocerebrosidase gene, GBA1,3 and unGBA1.GBA1 variant alleles that are associated with GD, 6 mutations account for 98% of those found in the Ashkenazi Jewish population in which GD1 is especially prevalent[GBA1 mutation projecting a disease incidence of 1/600 live births[The incidence of GD1is estimated at 1/50,000-75,000 live births in non-Jewish populations in North America, Europe and Australia. Of moree births,11. The e births. Among we births,14. It ie births.Here, we present a demographic and genotypic profile for 93 GD1 patients who live in South Florida and are enrolled in the ICGG Gaucher Registry and correlate genotype with validated severity scores and hematologic, visceral and skeletal therapeutic outcomes.The ICGG Gaucher Registry was launched in 1991 to track the clinical, demographic, genetic, biochemical and therapeutic characteristics of patients with GD throughout the world, irrespective of disease severity, treatment status or treatment choice. GovernaGenotype was obtained for most patients by PCR specific oligonucleotide screening for 5 common mutations prevalent in the Ashkenazi Jewish population . Samples from some patients with unidentified alleles were referred to the ICGG Registry Genotyping Service at the laboratory of H. Ronald Scott, MD, PhD at the University of Washington, Seattle, WA, USA for whole gene sequencing.Patients were categorized based on a validated DS3 disease severity scoring system, performIn 2008, an ICGG Registry benchmark analysis evaluated the attainment of six previously suggested therapeutic goals  in 195 non-splenectomized patients with type I GD after 4 years of imiglucerase treatment. Here, wT test .Demographic analyses used standard descriptive statistics (frequencies and percentages). DS3 scores are summarized using means and standard deviations. ANOVA testing was performed using a 2 tailed 93 individuals  were initially eligible. 57 (61.2%) were women. The mean (SD) age at first assessment was 49.9 years . 75 patients (80.6%) reported Ashkenazi Jewish ethnicity. Five lacked genotype information. There were 4 sibling pairs. Of 84 unrelated patients with genotype data, 52 (61.9%) were homozygous for the N370S allele and 29 (34.5%) carried one N370S allele  were highly variable but generally in the mild to moderate range  indicated a clinically mild phenotype. ERT access was not problematical. One patient with symptomatic bone disease declined ERT and SRT. Until the imiglucerase shortage/interruption beginning in June 2009, virtually all patients who required treatment received imiglucerase. Two patients of unknown genotype who died prior to 1995 received alglucerase 60 U/kg every 2 weeks. They are excluded from the genotype and response analyses . At last evaluation through June 2011, 49 patients were receiving imiglucerase of whom 1 was infused weekly, 33 every two weeks, 2 every three weeks and 13 every four weeks . Fifteen patients (24.5%) had splenectomy prior to treatment initiation.17 patients are deceased of whom 4 had undergone splenectomy. The mean age (SD) at death was 71.9 15.4) years; median age at death (range): 71.5 years (28y-92y); interquartile range: 64.5y-83.8y. The genotypes of deceased patients were 13 - N370S/N370S, 2 N370S/L444P and 1 N370S/V394L. The causes of death are shown in Table .4 years;As shown in Table After a median 12 treatment years, South Florida patients matched or exceeded the ICCG 4 year therapeutic goal achievement for platelet count (85.4% vs. 79.6% success), spleen volume (93.3% vs. 78.0% success), liver volume (93.4% vs. 90.6% success), and bone crises (100% vs. 99% success). Nevertheless, fewer patients with intact spleens had sustained achievement of all 6 therapeutic goals (30.4% versus 41.4%) and only 40% of the splenectomy patients sustained achievement of 5/5 possible goals  continued to have bone pain vs. 29.8% in ICCG. On average, there was no age difference between patients with residual bone pain and those free of pain. Of note, only 37% of the ICGG patient cohort had bone pain prior to initiation of treatment compared to 73.4% of the South Florida patients (moderate or severe pain in 59.6%). Of 28 patients with baseline bone pain scaled as moderate or worse, 20 (71.4%) failed to realize the therapeutic goal for bone pain at their most recent evaluation. Of 35 patients who initially reported either no bone pain or pain no worse than mild, 15 (42.8%) had bone pain at their most recent evaluation. Age at inception of ERT was not significantly associated either with severity of pre-treatment bone pain or with therapeutic goal “failure” due to persistent bone pain. However, of the 61 patients included in the therapeutic goal analysis, only 9 patients were younger than 30 years of age when ERT was begun and only 4 were younger than 18 years. Regardless of age at inception of treatment, severity of pre-treatment bone pain was a key predictor for persistent bone pain. Age at commencement of ERT also did not appear to be a significant determinant of failure to achieve therapeutic goals other than bone pain. Among our patients, poor compliance with treatment schedules was not a contributory factor to poor therapeutic responses.The initial total DS3 bone domain score, although including heavily weighted information about avascular necrosis, lytic lesions, fractures, bone marrow infiltration and bone density, was less likely to predict pain outcomes than the bone pain score itself. There also was no significant association between the baseline DS3 bone domain score and composite attainment of therapeutic goals in either patients with intact spleens or in those with splenectomy Table . LikewisTo our best estimate, the 93 patients included in this report constitute at least 75% of known GD1 patients living in South Florida during a 22 year period. During that time, a 1990 population of 3.5 million in which 57% were non-Hispanic White has grown to 5.5 million with only 41% being non-Hispanic White[Compared to the GD1 patients from the Northeast United States described by Taddei et al., somewha2+1 , we elected to evaluate our patients in terms of achievement of therapeutic goals for hemoglobin concentration, platelet count, spleen and liver enlargement, bone pain and bone crises. These short term goals are not necessarily disease specific over an extended period of observation and they are an incomplete representation of all the elements that are integral to capturing the essence of clinical response to treatment for life long chronic illnesses such as GD1. Nevertheless, regulatory approvals of new therapy for GD1 and most reports of 4–10 year treatment outcomes have relied heavily, and sometimes exclusively on these six parameters,27, and Although assessment of achievement of multiple therapeutic goals is very useful for individualized case management, our results demonstrate the limitations and pitfalls of such applications to studies of patient populations that are not matched in terms of pre-treatment characteristics and potentially confounding concurrent or emerging medical events. Although the percentages of our patients completely at therapeutic goal after a median 12 years of GD1 treatment was less than that reported by ICCG after 4 years of treatment, the clinical circumstances suggested that many “failures” were probably not attributable to “breakthrough” manifestations of GD1. In fact, with the longer duration of treatment, as predicted by the 10 year imiglucerase experience, improveThe clinical outcomes research field is increasingly emphasizing the centrality of patient-reported input and value-based medicine  as a necessary accompaniment to classical efficacy and safety studies with physician-conceived endpoints (evidence-based medicine),30. RareNeal J Weinreb receives honoraria and expense reimbursement for serving on a Board of Advisors of the ICGG Gaucher Registry; travel reimbursements and/or honoraria and/or research support from Genzyme-a Sanofi Company, Shire, Pfizer Corporation, and Actelion Corporation. Olaf A Bodamer is member of the Speaker Bureau for Shire and Genzyme-Sanofi, receives research support from Shire and is on the US Advisory Board for Gaucher Disease for Shire.MO participated in data analysis and helped to draft and to revise the manuscript. DB participated in the study design and data analysis and helped revise the manuscript. OAF helped to review and revise the manuscript. NJW conceived of the study, participated in the study design, data analysis and statistical analysis, and helped to draft and to revise the manuscript. All the authors read and approved the final manuscript.