Distress after prostate cancer treatment is a substantial burden for up to one-third of men diagnosed. Physical and emotional symptoms and health service use can intensify, yet men are reticent to accept support. To provide accessible support that can be cost effectively integrated into care pathways, we developed a unique, Web-based, self-guided, cognitive-behavior program incorporating filmed and interactive peer support.To assess feasibility of the intervention among men experiencing distress after prostate cancer treatment. Demand, acceptability, change in distress and self-efficacy, and challenges for implementation in clinical practice were measured.A pre-post, within-participant comparison, mixed-methods research design was followed. Phase I and II were conducted in primary care psychological service and secondary care cancer service, respectively. Men received clinician-generated postal invitations: phase I, 432 men diagnosed <5 years; phase II, 606 men diagnosed <3.5 years. Consent was Web-based. Men with mild and moderate distress were enrolled. Web-based assessment included demographic, disease, treatment characteristics; distress ; depression ; anxiety ; self-efficacy (Self-Efficacy for Symptom Control Inventory); satisfaction . Uptake and adherence were assessed with reference to the persuasive systems design model. Telephone interviews explored participant experience ; interviews with health care professionals (n=3) explored implementation issues.P=.03, r=−.55; phase II, P=.001, r=−.59. Self-efficacy improved for coping P=.02, r=−.41. Service assessment confirmed ease of assimilation into clinical practice and clarified health care practitioner roles.A total of 135 men consented ; from 96 eligible men screened for distress, 32% (30/96) entered the intervention . Twenty-four completed the Web-based program and assessments . Adherence for phase I and II was module completion rate 63%  versus 92% ; rate of completing cognitive behavior therapy exercises 77%  versus 88% . Chat room activity occurred among 63% (5/8) and 75% (12/16) of men, respectively. In phase I, 75% (6/8) of men viewed all the films; in phase II, the total number of unique views weekly was 16, 11, 11, and 10, respectively. The phase II mood diary was completed by 100% (16/16) of men. Satisfaction was high for the program and films. Limited efficacy testing indicated improvement in distress baseline to post intervention: phase I, The Web-based program is acceptable and innovative in clinical practice. It was endorsed by patients and has potential to positively impact the experience of men with distress after prostate cancer treatment. It can potentially be delivered in a stepped model of psychological support in primary or secondary care. Feasibility evidence is compelling, supporting further evaluative research to determine clinical and cost effectiveness. In developed regions of the world, men are more likely to be diagnosed with prostate cancer than any other cancer, and those diagnosed are more likely to develop distress or serious psychological problems than healthy men ,2. Over The numbers of men with prostate cancer living with and beyond diagnosis are predicted to grow. There are over 1.1 million new prostate cancer cases globally per year, accounting for some 15% of all cancer diagnoses in men . Incidenneeding help [Providing early psychological support is vital to ensure men experiencing distress after prostate cancer treatment do not fall into a cycle of negative thinking and avoidance behaviors, which can escalate symptoms and lead to the need for more intensive, prolonged support ,6. Howeving help . To suppThe effectiveness of cognitive behavior therapy (CBT) is well documented; it can offer an acceptable, brief intervention within mental health services for people experiencing emotional difficulties as a consequence of comorbid problem(s) ,22. Moreworried prostate cancer patients than to a clinically distressed prostate cancer population requiring a therapeutic service.Web-based CBT for cancer patients, and prostate cancer in particular, is a less-developed area compared with other chronic physical conditions -31. For In this study, we describe the development and feasibility of delivering a Web-based intervention in clinical practice for men with mild and moderate distress after treatment for prostate cancer. The program offers self-guided CBT augmented with filmed peer support and low-level chat room facilitation to encourage self-management; it aims to offer men the ability to monitor their condition and to affect the cognitive, behavioral, and emotional responses necessary to maintain an acceptable level of psychological well-being ,34,35. TWe conducted 2 phases of feasibility research. Phase I assessed the program prototype in a low-intensity, primary care psychological service within which it was developed. Data from that phase informed further development, and phase II tested a slightly revised version in a secondary care cancer service.The studies were approved by the UK NHS National Research Ethics Service, phase I reference 13/SC/0065; phase II reference 15/SC/0690.In accordance with the Medical Research Council framework for developing and evaluating complex interventions , we usedIdentification, eligibility, and screening are outlined in The program concept was developed from our previous research in urinary symptom self-management after prostate cancer treatment . In respThe Web-based program, Getting Down to Coping, was produced in conjunction with a low-intensity psychological service that accepted general physician and self-referrals. The service was part of England’s National Health Service, Improving Access to Psychological Therapies (IAPT) program, which offered low- or high-intensity therapy, or referral to specialist mental health services . ParticuThe research team, in collaboration with a software engineer, senior mental health practitioners, urologist, psychosexual therapist, specialist nurse, and 3 user representatives, codeveloped the initial program prototype based on the manualized short course of CBT delivered by the service. The course was then tailored to reflect prostate cancer-related examples and concerns and supplemented with links to medical, physical, emotional, social, and financial prostate cancer information. The program website was styled with graphics and language to appeal to a male audience and to reduce connotations of mental health.A fundamental component of the program was peer support, but providing this over the internet is complex. Active engagement with others through posting messages can mediate positive outcomes, but not all men are prepared to do this, and evidence shows that passively viewing messages is not associated with the same beneficial outcomes ,44. To sThe program contained 4 weekly, consecutive CBT modules with an introduction at the beginning of Module 1 see . It was The IAPT service used the Patient Health Questionnaire-9 (PHQ-9)  and the The prototype was developed with hard-coded software, which limited functionality. For phase II, the program was redeveloped within a content management system to enable integration into clinical practice and facilitate further research.There were 3 chat room facilitators, each responsible for 1 cohort of men and all were trained by a subteam of researchers, clinicians, and user representatives. Training covered Web-based facilitation, prostate cancer issues, and/or CBT theory. In phase I, 2 low-intensity psychological practitioners from the collaborating service carried out facilitation. Each practitioner allotted 2, predesignated 2-h slots per week to facilitate the chat forum for their cohort. They also visited the website intermittently during office hours to assess risk. During these slots, the practitioners did not continue with their usual clinical caseload. In phase II, a specialist cancer nurse delivered facilitation and accessed and interacted with the program on an ad hoc basis during the time it was available to participants.Uptake was assessed as the proportion of men who took up the initial invitation, visited the website, and gave their consent.Demographic, disease, and treatment characteristics were collected in both phases from eligible participants before distress screening. Comorbidity was assessed separately at baseline in phase I and post intervention in phase II.Distress screening took place at baseline 2 weeks before the intervention; the remaining baseline assessments were completed 1 week before the intervention. Participants who entered the intervention were followed-up and assessed through the website in the week after intervention completion.Attrition was assessed by the number of men offered the intervention who dropped out before, during, or after the program and the proportion of core users who continued to use the program .deception, coercion or inducement [task to communicate meaningful content, (2) support given to a dialogue between the program and the participant to help participants move toward their goal, (3) support provided through social features of the program to enhance participant motivation, and (4) credibility support that makes the system trustworthy and believable [task support and social support  recruitment, (2) program, (3) chat room, and (4) films. In-depth telephone interviews were conducted by the study researcher with 10 phase II participants to understand personal experiences and contexts. Interviews were audio recorded, transcribed, and analyzed using framework analysis .r=.8) and high validity (≥80%) [Screening for distress was measured by the General Health Questionnaire-28 (GHQ-28) . Performy (≥80%) . Mild anThe PHQ-9  and GAD-In phase II, the Self-Efficacy for Symptom Control Inventory (SESCI) was administered at baseline and post intervention to assess participant self-belief to cope and manage prostate cancer-related symptoms. The SESCI contains 3 subscales: self-efficacy for physical function, self-efficacy for coping or tolerating symptoms, and self-efficacy for symptom management. Participants indicate how confident they feel on scales for each domain from 0 (not confident) to 100 (very confident). The measure is a modified version of a self-efficacy scale used in chronic pain and lung cancer symptoms ,57. For Time spent by the facilitators in the program was assessed by log-in data. Issues related to delivery and integration in practice were explored after the intervention: in phase I, the study researcher conducted face-to-face interviews with the 2 facilitators; in phase II, a telephone interview was conducted with the facilitator. Issues relating to delivery and integration into current practice were explored. Interviews were audio recorded, transcribed, and analyzed with framework analysis .We assessed participant demographic, disease, treatment and satisfaction profiles, and uptake and adherence descriptively. We used descriptive statistics  and box plots to examine the distribution of distress measured by the GHQ-28 and self-efficacy. The samples were not powered to detect significance in the outcome measures, nevertheless we present nonparametric data in relation to distress and self-efficacy to aid understanding of the potential effect of the program within these samples and provide data on which to base a power calculation for a larger study of efficacy. Statistical testing was performed on the 2 samples of core users, which for feasibility testing in this design provides a more useful measure of overall outcome .A total of 14.1% (61/432) of invited men consented to the take part in phase I, and 12.2% (74/606) of invited men consented to take part in phase II .In phase I, 47 eligible men were screened, of whom 32% (15/47) were experiencing distress: 21% (10/47) indicated mild and moderate distress and were offered the intervention and 11% (5/47) indicated suicidal thoughts and were referred for clinical assessment.In phase II, 49 eligible men were screened, of whom 43% (21/49) were experiencing distress, 41% (20/49) indicated mild and moderate distress and were offered the intervention, and 1 indicated a suicide risk and was referred for clinical assessment.In phase I, 10 participants were offered and started the intervention, and 2 withdrew in the first module (1 felt the program was not appropriate for his needs and 1 gave no reason). A total of 80% (8/10 across 2 cohorts) remained in the program for the 4 weeks and completed all assessments .In phase II, 20 participants were offered the intervention, 1 did not start (no reason given), and 3 withdrew during the first module (1 declined because he had been recently bereaved and 2 gave no reason). A total of 80% (16/20 in 1 cohort) remained in the program for the 4 weeks and completed all assessments .Baseline demographic, disease, and treatment characteristics for core users are reported in least deprived areas of the region. All were of white ethnicity, living with a partner, and reported co-existing health conditions.In phase I, the median age was 68 years; typically, men were retired or working part-time, educated up to the age of 16 or 18 years without any higher education, and living in most and least deprived areas. All except one reported co-existing health conditions.In phase II, the median age was 62 years; men were typically living with a partner, retired, or working full-time; a fifth were on long-term sick leave. All were of white ethnicity, polarized between The majority of men in both phases had been diagnosed under 2 years; locally confined disease at diagnosis was reported by less than half in phase I and by nearly 3 quarters in phase II. The majority in both phases recalled a PSA at diagnosis >10.Most men in both phases were undergoing active treatment at the time of the intervention, either hormone treatment or hormone plus external beam radiotherapy.All those who had completed treatment had done so within 1-2 years. In phase I, men had received hormone and or external beam radiotherapy; in phase II, there was a broad range of treatment experience, including prostatectomy. A minority in each phase had experience of active surveillance; 1 man in phase II was undergoing active surveillance.On the basis of page views, 50% (4/8) of men in phase I reached the end of all the modules. In phase II, 88% (14/16) of men reached the end of all the modules. This equates to overall module adherence rates of 63%  and 92%,  respectively.On the basis of a possible 21 CBT entries, there was an adherence rate of 77%  in phase I, and 88%  in phase II. The mood diary in phase II was completed by 100% (16/16) of men.A total of 6 out of 8 men (75%) in phase I viewed all 4 peer support films, 1 (1/8) man watched 2 films, and 1 (1/8) man watched 3 films, equating to an adherence rate of 91% (mean 3.6 SD 0.7). Data available for the 4 weeks of phase II, indicated a total of 16, 11, 11 and 10 unique weekly views, respectively.In phase I, 63% (5/8) of men posted in the chat room: median posts n=2 (range 1-6). In phase II, 75% (12/16) men posted: median posts n=5 (range 1-24).In phase I, median time logged in was 5 h 35 min (range 2 h 38 min to 11 h 31 min). In phase II, median time logged-in-and-active was 4 h 5 min (range 1 h 8 min to 8 h 33 min).Getting There was shorter than the preceding modules, which was disappointing; (2) questions about suicide (at screening and assessment) were alarming for some; and (3) the need to enhance identification with the men in the films by providing details of what treatments they had received. In phase I, the chat room was poorly endorsed: it had been difficult to locate, there had been little activity and opportunity to chat, and the facilitation was not perceived as supportive. These issues were addressed in phase II and satisfaction improved: access and ease of use was enhanced, notifications of chat room activity were provided, and facilitator interaction was increased.Questionnaire responses indicated that the Web-based recruitment and consent process was understood, appropriate in language and style, swift to respond, and easy to access . Responsthings to do in the final module.Phase II interviews helped clarify the questionnaire responses. . In phase II, we also calculated change in domain scores. From baseline to post intervention, there was a positive change in somatic domain symptoms  and anxiety domain symptoms . Scores for social dysfunction domain symptoms were z=−1.531, P=.13, r=−.27 and for severe depression domain symptoms scores were z=−1.283, P=.20, r=−.23  of participants overall registered scores on the PHQ-9 and GAD-7 that were above the clinical threshold for depression and anxiety and defined them as cases requiring clinical intervention in accordance with IAPT protocols. Of these 4, 3 scored over the threshold for depression on the PHQ-9, and 3 scored over the threshold for anxiety on the GAD-7 see .P=.02, r=−.412). Change was not indicated in managing symptoms (P=.11) or in performing daily activities (P=.08).At baseline, men were most confident in performing daily activities , less-confident coping/tolerating symptoms , and least confident managing their symptoms  started the program. This exceeds reported rates in comparable cancer and prostate cancer Web-based studies for distress where enrolment after screening, which excluded distress, was between 31% and 41% ,59. Our Initial uptake to our invitation of 12-14% among an unscreened sample, however, was low. Comparison with other Web-based, distress-related prostate cancer studies is problematic as they do not report the base numbers from which their screened samples were drawn ,33. Yet risky. Our recruitment materials were intended to reduce perceptions of mental health and stigmatizing signals, but the research focus and length could have been burdensome for some. Information that is focused on the health problem rather than the trial process, and that is also brief and relatively simple, has been associated with enhanced recruitment rates [Uptake may be enhanced if the nature and benefits of psychological support are conveyed so that accepting it is perceived as less nt rates -66. To int rates . The oppnt rates . The waynt rates .the self, which increased feelings of physical, social, and emotional control. This is consistent with the notion that support programs need to reflect masculine ideals to involve men and optimize benefit [Usage of the program and satisfaction of participants indicated that it is appropriate and acceptable to its core users. The adherence rates we achieved, from 63% to 100% across task and social support elements, illustrated that commitment was relatively high. In review of Web-based mental health programs, and in a trial among men with prostate cancer, rates of between 50% and 70% have been reported ,60. Men’ benefit .We found a larger proportion of men with mild and moderate distress in the second phase of our research , and also higher adherence rates in this second phase. There was some previous experience of psychological support in phase II, and adherence would have been enhanced by improvements to the program between phases. However, the higher distress levels and adherence could also be evidence of a greater level of commitment to the program in men of lower socio-economic status who characterized the phase II sample. These men experience poorer access to support and higher-than-average psychological need, indicating that regional differences will be an important consideration in further research and clinical implementation ,72,73.We found improvement in distress with a medium-large effect size in each phase. Particular improvements were in the somatic and anxiety domains of the GHQ-28. The nature and definition of distress is complex in a cancer population ,75, and We also found an improvement in confidence to cope with prostate cancer symptoms but not for confidence to perform daily activities or to manage symptoms. This can be expected; performing daily activities was at a high level at baseline, leaving little room for improvement, whereas physical symptoms related to the longer-term effects of prostate cancer treatment can often be intractable . OngoingImplementing the Getting Down to Coping Program has potential within both primary and secondary care settings. The intervention is a self-guided program, but some facilitation is optimal for risk monitoring and would be expected by a psychological service. However, the facilitation required calls for neither advanced psychotherapeutic skills nor high-level nursing skills, only the ability to perform the core skills necessary to motivate self-management and to monitor risk. In both settings, our facilitators were not practiced in communicating within Web-based support programs, and had no previous experience of supporting self-management. Our training contained elements of both, but all the facilitators still had difficulty performing the role; greater emphasis in training on facilitating self-management via Web-based interaction is required. Notwithstanding this, facilitation may be delivered in either setting by a lower band, health support role.Although we were not able to assess cost-effectiveness in these studies, the time spent facilitating in each service suggests that the flexible model of intervention interaction may have the greatest potential: it did not disrupt the facilitators’ standard caseload and, for the sample we had (n=16), amounted to 1 h per participant per 4-week program. This would be inversely related to the number of men in each program.There are limitations to these studies. The sample sizes were small and were not powered to detect change, and participants were not randomized. Generalization of our findings must therefore be cautious. Where we found change we do not know what variables are responsible; natural recovery could play a role and so could extraneous events. Nevertheless, with feasibility testing in 2 clinical settings, we have developed our knowledge of both the intervention and research required to move to the next trial stage. The consistency across our 2 samples on a number of measures, and the effects found, indicate that larger scale, evaluative research is justifiable. Our further research will include a longer follow-up period to provide an indication of maintenance of change, as well as full cost-effectiveness analysis. Furthermore, we will analyze covariance in respect of facilitator and group effects.social and task design elements, which we posited were the most important features in our intervention for effecting behavior change. Measuring intended use is reflective of assessing compliance in face-to-face therapy and has been proposed as the most realistic reference standard for adherence in Web-based interventions [log-in time in phase I gave little indication of what interaction took place. In phase II, we measured time logged-in-and-active, which gave a clearer indication for adherence purposes, but we still had to make assumptions, that is, how long a log-in was deemed to contain active time. Such assumptions are often not reported in studies. More extensive application of the theoretical underpinnings of how design and system components can influence behavior change is called for [A strength of our studies was that we incorporated the theoretical model of PSD , which cventions ,60. Anallled for .To integrate psychological services for cancer patients in the existing care pathways, interventions that fit with health provider parameters of care provision are required . WithoutThe program has the potential to fit within a stepped model of care by providing psychological support for men who are mild or moderately distressed and who fall within the clinical parameters for low-intensity support. Addressing these men’s needs will prevent escalation of symptoms and the need for higher-intensity therapy. Potentially, this would lead to service cost savings in terms of reduced physical and mental health service use.In a stepped model of therapeutic care, the program requires low-level facilitation for monitoring risk, which raises cost implications versus a completely automated system. However, within the clinical services we researched, risk surveillance was a mandatory requirement, and the true cost comparison would be versus a therapist-led, face-to-face, or telephone approach. The numbers of men who can be supported with the Web-based program at any one time is subject to economies of scale, and cost advantage can increase exponentially with the volume of patients taking part. Furthermore, facilitation need not be carried out by advanced practitioners, which contributes to delivery cost advantage. Assigning staff to the facilitator role who possess appropriate competencies, as well as ensuring their involvement with and commitment to the innovation, will be crucial to its success .Clinical effectiveness, and cost-effectiveness in terms of clinical delivery and health service utilization, need to be tested in an evaluative research design. Future research should be underpinned by exploratory enquiry to establish the most relevant and engaging ways to communicate study and intervention characteristics for this prostate cancer population. In future, we hope to develop the Web-based program for men with other cancers.


Renal cell carcinoma metastasizing to rectum is very rare, and the unusual metastatic sites should be paid attention to during the follow-up of renal cell carcinoma.We describe a case of a 65-year-old male who was diagnosed with metastatic renal cell carcinoma to rectum 10 years after the right radical nephrectomy. Histopathology and immunohistochemical examinations contribute to making differential diagnosis between rectal metastasis of renal cell carcinoma and primary rectal clear cell carcinoma. Positron emission tomography-computed tomography with fluorodeoxyglucose shows hypermetabolic activity in upper rectum and other sites of metastasis at the same time.Possibility of unusual metastatic sites of renal cell carcinoma such as rectum indeed exists, which should not be ignored in the surveillance after resection of the primary tumor. The frequent sites of metastasis are successively the lungs, lymph nodes, bones, liver, adrenal glands, and brain, while it is extremely rare for RCC to metastasize to rectum. Here, we present a case of metastatic RCC to the rectum, bilateral lungs, right ilium, and pulmonary hilar lymph nodes, after initial radical nephrectomy.Renal cell carcinoma (RCC) is the most common type of renal tumor, accounting for about 2% to 3% of adult malignancy.2A 65-year-old male underwent a right radical nephrectomy 10 years ago, and the postoperative pathologic examination revealed renal clear cell carcinoma (RCCC). After operation, he received a course of chemotherapy. From then on, he did not accept any treatment or follow-up examinations related to RCC. In 2008, 2 years after nephrectomy, he received a rectal polyp resection by colonoscopy, and the pathologic examination revealed primary rectal benign polyps. Since then, he received an electronic colonoscopy every 1 to 2 years until the year 2016, when a protruded lesion was found in his rectum.The electronic colonoscope examination showed a hyperemic mass covered with sphacelus, approximately 1.2 cm × 1.5 cm size, which was protruded from rectal mucosa  examination was performed, which showed an abnormal increased radioactive uptake in the upper rectum, 1.6 cm × 2.8 cm × 1.8 cm size, with an average standardized uptake value (SUV) of 5.0 and SUVmax of 10.0, indicating possibility of malignancy Figs.  and 4. I3 The other patient with metastatic RCC to rectum directly received surgery, without any endoscopic or sonographic images.We reported a rare case of metastatic RCC to rectum, furthermore showing the characterization of FDG-PET/CT images of metastatic RCC in rectum for the first time. The definite diagnosis was based on the medical history of RCCC, hypermetabolic activity in FDG-PET/CT images, result of colonoscope, and histopathologic examination with immunohistochemical staining. However, the patient has not experienced symptoms associated with rectal lesions, for instance of hematochezia or changes in bowel habits. There were only 2 cases of metastatic RCC to rectum previously being published. One patient with hematochezia was found to have a submucosal mass with ulcerated area in rectum by colonoscopy and ultrasound, after receiving a left nephrectomy for RCC.–11 These rare metastatic sites were usually accompanied by multiple metastasis in the whole body, and the period from the initial diagnosis of RCC to metastasis may range from several years to more than 10 years.The exact mechanism of metastasis of RCC is still unclear, but the blood supply and thin tissue of rectum may be not appropriate for the development of RCC, compared with common metastatic sites such as lungs. We assume that maybe the high malignancy and strong invasive ability of tumor lead to metastasis to rectum, because the presence of such a rare metastatic site of RCC usually indicates relatively poorer prognosis. Other unusual metastatic sites of RCC include colon, intestine, stomach, pancreas, gallbladder, prostate, thyroid gland, and skeletal muscle. it is necessary to make a differential diagnosis between metastatic RCC to rectum and primary rectal clear cell carcinoma. Identification of source of the tumor could influence the establishment of therapeutic strategy. The 2 types of tumors both contain plentiful clear cells, which are typically round or polygonal with abundant clear cytoplasm, while the characterization of histopathology is different. Cells of RCC mainly form nests or aciniform structure in various shapes containing a network of delicate vascular sinusoids interspersed between nests or acini of tumor cells, rarely developing authentic glandular tube. In contrast, cells of primary rectal clear cell carcinoma mostly arrange in glandular tube structure similar with traditional adenoma, partially forming cribriform architecture or solid nest-like structure as well.Although the primary clear cell carcinoma in rectum is rare,In addition, the difference in immunohistochemical markers may contribute to differential diagnosis between the 2 types of tumors. RCCC mainly shows positive staining for RCCA, CD10, PAX-8, PAX-2, Vimentin, and AE1/AE3. On the contrary, CK20 and CDX-2 are negative markers for diagnosis of RCC, which were both positively expressed in carcinoma originating from colorectum. This patient has a clinical history of the previous diagnosis of renal cell cancer. Moreover, immunohistochemical examination revealed positive expression of AE1/AE3, PAX-8, and Vimentin, together with negativity for CDX-2. On the basis of above, we could confirm that the mass in upper rectum of the patient was metastasis from RCC. Therefore, FDG-PET/CT is an optional valuable examination for appropriate case in order to increase the concern about metastatic disease and to influence further evaluation and management, because it could efficiently detect small lesions and identify malignant cases.In this report, FDG-PET/CT images of metastatic RCC in rectum showed hypermetabolic activity in upper rectum with an average SUV of 5.0 and SUVmax of 10.0, which was a relatively high level. Higher SUV usually indicates higher malignancy of tumors, stronger invasiveness of tumor cells, and worse prognosis of patients. Better yet, metastasis of other sites such as bilateral lungs and right ilium could be discovered at the same time, contributing to systematically evaluating the patient's condition and prognosis. FDG-PET/CT is a very effective method to find some distant and infrequent sites of metastasis in surveillance on RCC, due to its good specificity and sensitivity. It could supply anatomical details such as CT as well as functional information of small sized tumors indiscoverable on CT, through a single procedure of body scanning.4Regular examinations and strict follow-up after nephrectomy are necessary for patients with diagnosis of RCC. Rectum and other unusual metastatic sites of RCC should not be ignored in surveillance on RCC. In addition, FDG-PET/CT contributes to discovering rare metastasis of RCC and other multiple metastatic sites of whole body at the same time.Ethical review is not necessary, because this is a case report. And the patient is informed consent.


Then, the “mcAb-toxin-pcAb” sandwich model was built to actualize the quantitative detection of abrin on the surface of the screen-printed electrode. The linear detection range was 0.5–1000 ng/mL; the regression equation was Y = 89.251lgX + 104.978 ; and the limit of detection (LOD) was 0.1 ng/mL. The sensing system showed high sensitivity, excellent specificity and good anti-interference ability, and could be used for the analysis of trace abrin in various environmental samples with good recovery and reproducibility. Compared with the traditional electrochemiluminescence sensing device, its miniaturization and portability gives it potential to satisfy the requirement of in situ detection.For the convenience of fast measurement in the outdoor environment, a portable electrochemiluminescence biosensor with the screen-printed electrode as the reaction center was developed, which possesses the characteristics of high sensitivity, small scale, simplified operation and so on, and has been used for in situ detection of abrin. First, combining with magnetic separation technique, the “biotin-avidin” method was used to immobilize the polyclonal antibody (pcAb) on the magnetic microspheres surface as the capture probe. Secondly, the Ru(bpy) Abrus precatorius is a highly toxic ribosome inactivating protein. It has similar characteristics to ricin, which has been used as a terrorist threat, but more toxic .n = 7, p < 0.0001), the LOD at the signal-to-noise ratio of 3 was 0.1 ng/mL. Compared with the piezoelectric immunoassay established by Mu [The established portable ECL sensor was used to test the magnetic microspheres complex binding with different concentrations of abrin standard substance and obtain the corresponding ECL intensity values. The integrated ECL spectra for the abrin detection at different concentrations is illustrated in ed by Mu , sensitied by Mu ,26 was sIn the quantitative detection range, 11 parallel determinations were performed on the concentration of 1 ng/mL, and the ECL intensity was 173 ± 17 with the RSD of 9.9%. In addition, the other six groups within the range were repeated four times, and the corresponding RSD values were, respectively, 16.5%, 8.3%, 10.2%, 4.7%, 3.6%, and 15.8%. The overall deviation was slight, and this portable sensor exhibited good reproducibility.With 0.01 M PBS as the blank control, the ECL responses of 1 mg/L bovine serum albumin (BSA), ricin and human IgG were measured, and the response values were all at baseline . It is wThe practical value of the sensor can be assessed by testing the spiked samples. Milk, honey and soil samples (organic substance content > 5% or fat content > 30%) containing 100 ng/mL abrin were detected, respectively, and the measured values were calculated by regression equation . The recThe SPE has several typical characteristics of simple preparation, low cost, miniaturized and good electrochemical performance. Taking SPE as the reaction center, the authors built a portable ECL sensing platform, possessing some outstanding features such as simplified operation, miniaturization and portability. In this experiment, based on the portable sensor and magnetic separation immunoassay technique, a specific sandwich model was built and a successful detection of abrin was finally achieved. The LOD was 0.1 ng/mL and the quantitative range was 0.5–1000 ng/mL. The portable sensor exhibited high sensitivity, good reproducibility and excellent specificity, achieving a fine result better than the conventional ECL sensor. Subsequently, based on the feature that SPE is easy for surface treatment, nanophase materials can be used to modify SPE to improve the electrochemical performance and ECL reaction efficiency, thus greatly improving detection sensitivity. Then, the portable ECL sensor would have greater potential for application in the fields of physiological and pathological examination, environmental pollution monitoring and biological terrorism prevention.


Squamous cell carcinomas (SCCs) are the most prevalent malignant tumours within the head and neck. Evidence exists that distinct genes are differentially regulated in SCCs of the oral cavity compared to other head and neck regions. Given this background, the aim of this study was to investigate whether such tumour site-specific gene expression can also be observed in different localizations within the oral cavity.2, interdependency and Kaplan-Meier analysis.Using tissue microarrays (TMAs), we investigated 76 SCCs of the floor of the mouth, 49 SCCs of the tongue and 68 SCCs of other anatomic regions within the oral cavity. The expression of 17 genes involved in cell cycle and growth control , cell adhesion , and apoptosis/stress response genes  were investigated by means of immunohistochemistry. The data were subjected to chip <0.05) in SCCs of the floor of the mouth compared to SCCs of the tongue and other locations within the oral cavity. The increased XIAP expression was further associated with significantly decreased overall survival in all cases of SCCs of the oral cavity (p <0.05). Expression levels of p53, CA IX, beta-catenin, Hif-1-alpha, and c-kit were also observed to be inversely related between SCCs of the floor of the mouth and those of the tongue respectively, although these differences did not reach statistical significance. Overall and event-free survival did not differ in patients with T1/T2/N0 SCCs according to tumour localization.Our study suggests a remote difference in the site-specific gene expression patterns of oral cancer. X-linked inhibitor of apoptosis (XIAP) showed a significantly higher expression (In summary, the protein expression patterns of SCCs of the oral cavity suggest the existence of a molecular and morphological spectrum of SCCs in the oral cavity. In particular the expression pattern of XIAP indicates distinct gene expression patterns between carcinomas of the floor of the mouth and oral tongue cancer. Further studies are needed to identify possible tumour site-specific factors that influence patient prognosis and management. Malignant oral neoplasms are a heterogeneous category of cancer, which are dominated by squamous cell carcinomas (SCCs) . The incSeveral studies have reported specific metastatic pathways according to tumour localization and different responses to radiation therapy depending on the anatomical site –6. BelbiThe tested samples were procured by the Institute of Pathology, University of Muenster, Germany. A total of 193 formalin-fixed, paraffin-embedded archival cancer tissue samples of oral SCCs were tested. Details on the clinical procedures and pathological methods of the tumour series are provided in previous publications . As showA total of 193 cancer tissues samples were examined for the expression of p16, p21, p27, p53, cyclin D1, EGFR, c-kit, bcl-6, alpha-, beta-, and gamma-catenin, Hif-1-alpha, Glut 1, CA IX, caspase, hsp70, and XIAP.To ensure identical conditions for the investigation of all tumour specimens, we used tissue microarrays (TMAs) and immunohistochemistry. As described in earlier publications, all TMAs were constructed under a standard protocol .For the preparation of the TMA, each donor block was used to supply the new acceptor block with two punch biopsies measuring 0.6 mm in diameter. The samples where taken at the tumour margin to ensure consideration of the tumour front in histopathological analysis. Therefore, a special TMA construction tool was used according to the guidelines of Beecher Instruments, New Jersey, USA .The immunohistochemistry was carried out on 4-μm-thick sections. The source of the antibodies, clones, dilutions and the antigen retrieval are shown in Table The thresholds for most markers have been described previously , 10, 13.2 analysis and Kaplan-Meier analysis. A statistical test on differences between the slope of the regression lines was performed , Fig. p <0.05), as shown in Fig. The second test set Fig.  showed mAs demonstrated in Fig. Table Table In summary, the opposing trends of the regression curves for SCCs of the floor of the mouth and of the tongue indicate a slightly different regulatory role of XIAP as a tumour marker.However, overall and event-free survival did not differ in patients with T1/T2/N0 SCCs according to tumour localization Fig. .Fig. 4KaSCCs of the oral cavity account for more than 90% of all malignant neoplasms in this anatomic region. Apart from Asian, countries where buccal oral SCCs rank first on the list of anatomical sites, in Western countries, the oral tongue is most frequently affected (40–50%) followed by the floor of the mouth , 20. TheBelbin at al. detected altered gene expression levels at different anatomic sites in the head and neck by examining the whole RNA sequence of 45 head and neck SCCs compared to samples of a healthy control group. Out of the wide range of genes identified, Belbin et al. extracted TGF β, IL 1, and matrix metalloproteinases as typical of oral SCCs, PCK, IL 8, and FGFR 1 as characteristic genes of oropharyngeal SCCs, and IL 6, p53, and PRLR as representative of hypopharyngeal and laryngeal SCCs, suggesting distinctive hallmarks for each anatomical subsite in head and neck SCCs . In 2011Our own results as well as those described above support our theory that tumour development in the head and neck area can be evaluated as a single interlocked path affected by exposure to carcinogenic substances. However, the individual tumour growth patterns and hence the highly variable therapy responses observed may be influenced by other factors.Based on these observations, we evaluated whether SCCs of different anatomic localizations within the oral cavity might also differ with respect to their molecular background. The molecular biology of malignant tumours often determines the clinical behaviour and long-term outcome. With our first approach, we were able to show that the overall and event-free survival did not differ in patients with T1/T2/N0 SCCs according to tumour localization Fig. .n = 193) as well as the statistical methods applied spares the idea of non-significant punch biopsies [Using the TMA technique and a set of 17 different antibodies, we were able to show that different anatomic localizations within the oral cavity seem to be associated with slightly different molecular expression patterns. TMA is a profound method to evaluate immunohistochemical patterns in large numbers of tumour samples , 16. Evebiopsies . In partbiopsies . The supbiopsies , 26. HenSimilar findings and tendencies could be observed for the expression levels of p53, CA IX, beta-catenin, Hif-1-alpha, and c-kit in both localizations.Hypoxia inducible factor (HIF) is a heterodimer protein consisting of a three-part alpha subunit and a single beta subunit. In hypoxemia, induced cell stress, Hif-1-alpha functions as a transcription factor. As oxygen levels decrease, the alpha subunit accumulates with the beta subunit, transfers to the nucleus, and activates the hypoxia-responsive element that operates as a transcription factor. The upregulation of Glut 1, VEGFR, CA IX, erythropoietin, heat shock proteins, and other cell growth factors affect protein expression and activation. This cascade is involved in the differentiation of embryonic stem cells, bones, blood vessels, and organs as well as in tumour cells with underlining similarities in growth habits, leading to fast tumour progression –33. Agai2 analysis only showed statistical significance for the differential expression of XIAP.The other markers also showed globally differing regulation patterns but with lower impact. The interdependency analysis, which is a statistical tool used to reveal small differences in regulatory pathways, indicated that there are different underlying molecular mechanisms in SCCs of the floor of the mouth and the tongue. The regression curves showed an almost antagonistic protein expression profile between floor of the mouth cancer and oral tongue cancer. However, it has to be stated that the chiUsing interdependency analysis in invasive breast cancer the existence of a number of independent, parallel progression pathways was identified . TherefoIn summary, we analysed 193 SCCs with a focus on 17 different protein expression patterns in relation to the anatomical location within the oral cavity using a sophisticated biomathematical algorithm. Our results point towards a wide molecular spectrum of SCCs in the oral cavity. Even though the carcinomas showed a large range of protein expression, only minimal site-specific protein mechanisms could be detected that could potentially reflect the different clinical behaviours of SSCs within the oral cavity. For T1/T2/N0 tumours no significant difference in tumour site-specific survival could be seen. Further studies are needed to define possible tumour site-specific factors with relevance for patient prognosis and management.


Previous studies have demonstrated the influence of changes in the age at which women give birth, and of developments in prenatal screening and diagnosis on the number of pregnancies diagnosed and terminated with chromosomal anomalies. However, we are unaware of any population studies examining pregnancy terminations after diagnosis of chromosomal anomalies that has included all aneuploidies and the influence of maternal factors. The aims of this study were to examine the association between results of prenatal tests and pregnancy termination, and the proportion of foetuses with and without chromosomal anomalies referred for invasive diagnostic tests over time. Diagnostic information of 26,261 prenatal invasive tests from all genetic service laboratories in Scotland from 2000 to 2011 was linked to Scottish Morbidity Records to obtain details on pregnancy outcome. Binary logistic regression was carried out to test the associations of year and type of diagnosis with pregnancy termination, while controlling for maternal age, neighbourhood deprivation and parity. There were 24,155 (92.0%) with no chromosomal anomalies, 1,483 (5.6%) aneuploidy diagnoses, and 623 (2.4%) diagnoses of anomaly that was not aneuploidy (including translocations and single chromosome deletions). In comparison with negative test results, pregnancies diagnosed with trisomy were most likely to be terminated  followed by other aneuploid anomalies . During the study period, fewer pregnancies that were diagnosed with aneuploidy were terminated, including trisomy diagnoses . Older women were less likely to terminate , and parity was also an independent predictor of termination. In keeping with previous findings, while the number of invasive diagnostic tests declined, the proportion of abnormal results increased from 6.09% to 10.88%. Systematic advances in prenatal screening have improved detection rates for aneuploidy. This has been accompanied by a reduction in the rate of termination for aneuploidy. This may reflect societal changes with acceptance of greater diversity, but this is speculation, and further research would be needed to test this. The age at which women give birth has increased progressively in many high income countries, such that in Scotland, the proportion of mothers giving birth at age 35 or over has increased from 14.9% in 2000 to 19.7% in 2011 , 9.Recent systematic reviews of factors, which may influence the decision to terminate or continue the pregnancy, have reported inconsistent results. With respect to maternal age, studies have reported increased likelihood of termination for Down syndrome in both younger and older women, as well as no association with age , 11. SimWith respect to parity, an association has been demonstrated between parity and the decision to terminate for Down syndrome  but the Whilst the evidence in relation to maternal characteristics and past obstetric history is inconclusive, the actual diagnosis has been found to be more clearly related to the decision to terminate. Trisomy, including Down syndrome, is associated with higher termination rates than sex chromosome abnormalities , 16–18. In spite of increasing maternal age and increasing detection rates of chromosomal anomalies, termination rates have been reported as remaining stable over the last decade in both single centre and population studies , 8, 14. The study cohort comprised all pregnancies during which genetic testing had been undertaken from January 2000 to December 2011 inclusive, in four NHS regional genetic services , covering the total population in Scotland. A service was also provided in Inverness until 2010 when Aberdeen took over its cases. Chorionic villus sampling or amniocentesis  was used to collect foetal cells for prenatal diagnosis via karyotyping, fluorescence in situ hybridization (FISH), or quantitative fluorescence polymerase chain reaction (QF-PCR). Reasons for referral to genetic counselling services included advanced maternal age, an abnormal ultrasound scan, a high-risk biochemistry result, family history of chromosomal abnormalities and maternal anxiety about having an abnormal pregnancy. Ultrasound scans and biochemistry tests are part of the pregnancy screening that is offered to all pregnant women in Scotland.The screening programmes offered in Scotland were standardised from 2001 to a second trimester blood sample test for Down syndrome and neural tube defects using two serum markers  to a firData were provided by all the genetic service laboratories in Scotland. These included the month and year of investigation, diagnostic test results, and pregnancy outcome if known. Year of investigation was categorised into: 2000–2003, 2004–2007 and 2008–2011. Diagnoses were grouped into three main categories: aneuploidy, other anomaly, and normal. Aneuploidy comprised Down syndrome, Edwards syndrome, Patau syndrome, Turner syndrome, Klinefelter syndrome, triple X, 47 XYY, triploidy and tetraploidy. In the secondary analyses, the aneuploid karyotypes were further categorised into two sub-groups: trisomy 21, 18, or 13  and other aneuploid anomalies . The ‘other anomaly’ category consisted of all other abnormal results, including balanced and unbalanced  translocations, and single chromosome deletions, inversions and variants.The data from the genetic service laboratories were linked, at an individual level, using the Community Health Index  to two Scotland-wide health administrative databases routinely collected and centrally collated as part of the Scottish Morbidity Record (SMR). SMR01 collects data on all acute hospital admissions and day cases including disease codes and the SMR02 maternity records collect data on all discharges from obstetric units in Scotland, including details of live births and stillbirths, and maternal age, marital status, parity, and the Scottish Index of Multiple Deprivation (SIMD) .Permission to access, link and analyse these data was granted by the Privacy Advisory Committee (PAC) to the National Health Service (NHS) National Services Scotland (NSS) and the Registrar General. Written informed consent was not obtained from participants for their clinical records to be used in this study, but patient records were anonymized and de-identified prior to analysis.SIMD is an area-based measure of socioeconomic deprivation derived for postcode of residence (mean population 800) using Census data on 7 domains: employment, income, health, education, access to services, crime, and housing . The indSMR02 records provide pregnancy outcome as livebirth and stillbirth (i.e. baby born dead after 24 weeks gestation), and distinguish between therapeutic abortion, spontaneous, incomplete and missed abortion (i.e. baby dies before 24 weeks gestation), trophoblastic disease, and other and unspecified abortion. SMR01 records contain ICD-10 disease codes and were used to identify any therapeutic abortions (O04) and spontaneous, incomplete and missed abortions (O02-03) in women without an SMR02 record. Other abortions, unspecified abortions, trophoblastic disease and other abnormal products of conception were grouped as ‘other outcomes’. The remaining outcomes were then categorised into pregnancies ending in therapeutic abortion, and those that did not. The latter included livebirths, stillbirths, and spontaneous, incomplete and missed abortions.Multiple pregnancies were identified and excluded. Cross tabulations and Pearson’s chi-squared tests were employed to compare the characteristics of the prenatal diagnostic groups. Binary logistic regression was undertaken to determine whether year and diagnosis were associated with termination of pregnancy and whether any associations were independent of maternal age, parity and SIMD. Interactions of year with maternal age, parity and SIMD were also examined. Results are presented as unadjusted and adjusted odds ratios with 95% confidence intervals (CI). All analyses were carried out in SPSS 22.Data were available on 26,594 prenatal diagnostic tests. Following exclusion of 281 multiple pregnancies and 52 where the diagnostic result was not recorded, the study sample comprised 26,261 pregnancies. The distribution across the genetic laboratories reflected the sizes of their catchment populations: Glasgow 43.4%; Edinburgh 26.9%; Aberdeen 14.0%; Tayside 12.0%; and Highland 3.6%. The most common reason for referral to the genetic services was a high risk screening result: high risk biochemistry 57.8%; and an abnormal scan (11.6%). Other reasons included: advanced maternal age 20.1%; family history of chromosomal abnormalities 6.6%; maternal anxiety 2.8%; and in-vitro fertilization 1.1%. Overall, 24,155 (92.0%) tests revealed no detectable chromosomal anomaly, 1,483 (5.6%) aneuploidy, and 623 (2.4%) another anomaly . Aneuploidy included 851 (57.4%) with Down syndrome, 302 (20.4%) Edwards syndrome, 93 (6.3%) Patau syndrome, 122 (8.2%) Turner syndrome, 25 (1.7%) Klinefelter syndrome, 17 (1.1%) triple X, 8 (0.5%) 47XYY, and 65 (4.4%) triploidy or tetraploidy. The characteristics of patients differed significantly according to the prenatal diagnosis . The proWhen the univariate model was re-run including only pregnancies in which trisomy was diagnosed, termination rates fell significantly over time: 2004–2007  and 2008–2011  in comparison to 2000–2003 . Adjustment for maternal age, SIMD and parity did not alter the results: 2004–2007  and 2008–2001  in comparison to 2000–2003 . There were no statistically significant interactions.2 (2) = 13283.00, p < .001). After adjustment for year of testing, maternal age, SIMD quintile and parity, diagnosis remained a significant predictor of termination. In comparison with normal chromosomal test results, termination was significantly most likely following a diagnosis of trisomy 21, 18, or 13  and other aneuploidy anomalies . Older women were less likely to terminate their pregnancy . Parity was a significant independent predictor of termination (The percentage of pregnancies that were terminated varied significantly by diagnosis: 85.2% for trisomy, 65.4% for other aneuploid anomalies and 1.9% for normal karyotypes (χmination Between 2000 and 2011, the total number of invasive diagnostic tests carried out each year decreased from 2,447 to 1,655. However, the number of diagnoses made each year of aneuploidy and other anomalies has increased gradually from 149 to 180 see , resultiOverall, the likelihood of a diagnosis of aneuploidy resulting in a decision to terminate the pregnancy has fallen over time. However, the use of termination varies greatly within the aneuploidy group. A diagnosis of trisomy is more likely to result in termination, perhaps due to the more serious health implications. It is likely that the temporal trend we observed predates our study period, as our trisomy pregnancy termination rate of 85% compares with a previous Scottish report in the 1990s of 97.3% for Down syndrome, 85.9% for trisomy 18, and 90.0% for trisomy 13 . Our resPrevious research provided the contrary findings that termination rates were stable over time for aneuploid diagnoses in Australia, England and Wales, and in the USA , 8, 14. We found that older women were markedly less likely to terminate, and also found that parity was an independent predictor of termination, whereas neighbourhood deprivation was not.Religion is likely to play a role in decisions around pregnancy termination , 26. HowA number of studies have found a relationship between earlier gestation at diagnosis and greater likelihood to terminate the pregnancy , 15. DruIn keeping with previous reports, pregnancies diagnosed with trisomy remained more likely to be terminated than pregnancies diagnosed with other aneuploid anomalies , 16–18. This is the first non-selective, population based study in Scotland examining pregnancy terminations after prenatal diagnosis of chromosomal anomalies. It took account of potential confounders such age, SIMD and parity. It was not subject to selection bias, as the study was based on routine data sources from all genetic service laboratories in Scotland. We had access to both SMR-02 maternity records and SMR-01 hospital admissions to ascertain pregnancy outcome, thereby improving completeness. The outcome could not be determined for only 7.3% of the pregnancies. This is likely to be because of admission to a hospital outside of Scotland or the NHS.In order to protect anonymity, the current study could not report data on individual diagnostic groups, as the groups were too small. There was a large amount of missing data for marital status which was therefore not controlled for in the analyses. Marital status however is closely related to age and SIMD, which were both included. In addition, we did not have access to information on religion. Years were collapsed into groups of three to avoid having too many predictors and reduced power, especially for analyses that excluded normal karyotypes. Therefore, detailed information regarding year to year changes over time may have been lost.In Scotland, termination rates for trisomy are higher than for other aneuploidy, but rates for both have fallen over time. This may be linked to societal changes in accepting greater diversity, but further research would be needed to test this. Older women were less likely to terminate. In keeping with previous findings, screening procedures are now better at identifying those pregnancies in which the diagnosis will be positive therefore fewer pregnancies with normal karyotypes are undergoing prenatal invasive diagnostic tests, which have a risk of procedure related miscarriage. Recent developments in non-invasive prenatal testing may improve this further.


Between November 8, 2016, and September 30, 2017, more than 1,150 cases of HPAI H5Nx clade 2.3.4.4b in wild birds and 107 outbreaks in birds kept in captivity  were reported in Germany. This HPAI epidemic is the most severe recorded in Germany so far. The viruses were apparently introduced by migratory birds, sparking an epidemic among wild birds across Germany with occasional incursions into poultry holdings, zoos and animal parks, which were usually rapidly detected and controlled by stamping out. HPAI viruses  were found in dead wild birds of at least 53 species. The affected wild birds were water birds  and scavenging birds . In a number of cases, substantial gaps in farm biosecurity may have eased virus entry into the holdings. In a second wave of the epidemic starting from February 2017, there was epidemiological and molecular evidence for virus transmission of the infections between commercial turkey holdings in an area of high poultry density, which caused approximately 25% of the total number of outbreaks in poultry. Biosecurity measures in poultry holdings should be adapted. This includes,  Orthomyxoviridae with a segmented single-stranded RNA genome. These viruses occur in two pathogenicity variants (low/highly pathogenic) and a multitude of different subtypes. Wild water birds (Anseriformes) as well as gulls, terns, and wader birds (Charadriiformes) are regarded as the natural reservoir for all low pathogenic avian influenza viruses (LPAIVs), i.e., viruses of the subtypes H1–H16 and N1–N9. While LPAIV of the subtypes H5 and H7 may cause almost no or only mild disease in domestic poultry, these subtypes have the capacity to evolve spontaneously into highly pathogenic forms [highly pathogenic avian influenza viruses (HPAIVs)]. The underlying mutational steps seem to be associated with adaptation to domestic poultry after transmission of the low pathogenic progenitors from wild birds   can be transmitted to humans and may cause fatal disease. Due to the segmented genome of influenza A viruses, new viruses can evolve, when simultaneous infections of a single host with different influenza A viruses allow mixing (reassortment) of the genome segments. Therefore, there is a permanent risk for the generation of novel influenza viruses with pandemic potential if different zoonotic influenza A virus strains cocirculate .In 1996, a HPAIV of subtype H5N1 originating from geese  in southern China caused outbreaks in chickens and disease in 18 humans with six fatalities. This virus evolved steadily during the following two decades into various phylogenetic clades, subtypes, and genotypes within the so-called gs/GD lineage. A combination of blanket vaccination of poultry against HPAI H5, trading at live bird markets and the traditional way of keeping waterfowl, for example, in rice fields, in contact to wild or feral water birds is a perfect source for the genesis, emergence, and evolution of new HPAIVs in large parts of Asia, especially in South East Asia. Migratory water birds mixing with poultry may contribute to the development of new viruses by reassortment and eventually give rise to intra- and intercontinental spread. Many of the gs/GD H5-descendants caused serious outbreaks of fowl plague in poultry in South East Asia and some were detected in Europe as well: in 2005/2006 (H5N1 clade 2.2), in 2010 (H5N1 clade 2.3.2.1c), and in 2014 (H5N8 clade 2.3.4.4a). This led to a massive increase of HPAI outbreaks worldwide since 1996  and no hIn September 2016, the FAO released a risk alert about the potential westward spread of a novel HPAIV H5N8 of clade 2.3.4.4b, which was detected through surveillance of wild migratory birds in the Tyva Republic, Russian Federation, in June 2016 . Only onHere, we provide a brief account of the course of the HPAI epidemic that took place in wild and kept birds in Germany in 2016–2017.Records of cases of HPAIV infections in wild birds and HPAI outbreaks in kept birds in Germany, i.e., commercial and backyard poultry holdings as well as zoos, were obtained from the German National Animal Disease Data Base . In brieRecords on HPAI cases in wild birds in Germany were retrieved from the “Wildvogelmonitoring-Datenbank”, the National Avian Influenza Data Base run by the Friedrich-Loeffler-Institut . Data onData on outbreaks in poultry and cases in wild birds in Europe were obtained from the European Animal Disease Notification SystemEpidemiological outbreak investigations were conducted in affected poultry holdings and zoos according to Council Directive 2005/94/EC as previously described . In brieAythya fuligula) at Lake Constance in Baden-Württemberg, in the southwest of Germany. One day later, on November 8, 2016, HPAIV H5N8 was identified in wild birds (mostly tufted ducks) at Lake Constance as well as in tufted ducks found dead at Lake Plön in Schleswig-Holstein, northern Germany. Simultaneously, an increased number of wild water birds and sea gulls were found dead at the eastern coast of Schleswig-Holstein, around Lake Constance in Switzerland, Austria, and Germany (Bavaria and Baden-Württemberg) as well as at the Baltic Sea Coast in Mecklenburg-Western Pomerania, northeastern Germany  were reported in Germany Figures . The vasGenerally, the temporal course of the epidemic in wild birds was characterized by at least two waves, with maxima in mid-November 2016 and mid-February 2017, respectively Figure . A few dvia direct contact to infected wild birds  or via indirect contact . No evidence for the transmission of HPAIVs through trade of live animals, feed, or products of animal origin was detected in the course of the epidemiological outbreak investigations.A total of 68 commercial poultry holdings were affected by the epidemic, including 52 turkey, 5 laying hen, 9 duck, and 2 geese holdings Figure . MoreoveThe majority of outbreaks in large commercial poultry holdings were apparently caused by single incursion events, often affecting only one out of several stables of the respective holding. In a number of cases, substantial gaps in farm biosecurity may have eased virus entry. This refers to outdoor storage of bedding material, lack of personal hygiene when entering the stables , regrouping of poultry flocks (mainly turkeys) during fattening, attraction of wild water birds close to the stables either by ponds or by storing silage on the premise as supply for a biogas plant. Only in the late phase of the epidemic, there was epidemiological and molecular evidence for direct farm-to-farm transmission affecting mainly turkey holdings in the area with the highest poultry densitiy, which caused approximately 25% of the total number of outbreaks  were estimated as in excess of 17 million Euros.Continuous cocirculation of HPAIVs and LPAIVs in poultry with frequent spill-over transmissions into migratory wild birds has been observed in several parts of Asia over more than two decades. Chances to eradicate these viruses at their source in poultry in Asia are estimated to be low. Similarly, in Egypt and West-Africa HPAIV H5N1 2.3.2.1c and HPAIV H5N8 2.3.4.4b are continuously circulating. Therefore, the poultry industry, risk managers and poultry associations must anticipate future incursions and improve their preparations for prevention and control. Fortunately, the recent HPAIV H5N8 clade 2.3.4.4a and b had no zoonotic potential, but this is prone to change as new viruses within this clade (2.3.4.4c and d) that may lead to fatal infections in mammals have already evolved in Asia . MoreoveHistorically, HPAI outbreaks were usually geographically limited and mainly restricted to poultry, i.e., the viruses causing the outbreaks did not circulate in wild birds. This situation has fundamentally changed since the expansion of Gs/GD HPAIVs H5 to other continents, including Europe, which has led to a panzootic . AlthougAdequate farm biosecurity is essential to decrease the risk of introduction and spread in poultry farms, which is particularly relevant in areas with high poultry density, particularly during epidemics. In high-risk periods and locations, losses should be compensated according to the level of biosecurity established and enforced on the affected holdings.The most important lesson learned during the epidemic was the finding of substantial gaps in farm biosecurity and the impact of HPAI in an area of high poultry density, i.e., substantial farm-to-farm spread.In general, protection of domestic poultry holdings from infection with HPAIV H5N8 has highest priority. Emphasis is put on the creation of a physical and functional barrier between wild bird habitats and domestic poultry holdings. Among other biosafety measures, mandatory indoor housing of poultry or the use of protected shelters (fenced and covered with fabric) minimize the risk of direct and indirect contact with infected wild birds. In particular, indirect introduction routes, e.g., through feed contaminated by wild birds, contaminated water, litter, and objects  must be interrupted and adequate disinfection measures applied. Revision, optimization and strict implementation of biosafety measures are of utmost importance.The HPAI H5N8 epidemic has taught the German veterinary authorities some limitations, but also the use of possible exceptions from culling as laid down in the national legislation, e.g., minimizing culling of birds kept in zoos. Based on the experience made, the national legislation is currently under revision. Furthermore, the German legislation on biosafety in poultry holdings has been amended. Not only commercial poultry farms but also small holders must now follow rules and principles that aim at reducing the risk of introduction of HPAIV into poultry farms. An online tool for an assessment of the quality of farm biosecurity by the farmers themselves is under development.AG, CS, and FC designed the study and analyzed the data. AG and FC drafted the manuscript. CS-L, KD, TH-B, CP, JG, KD, CG, TH, ES, AP, DH, MB, and TM collected or analyzed data and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The best way to select individuals for lipid-lowering treatment in thepopulation is controversial.In healthy individuals in primary prevention:to assess the relationship between cardiovascular riskcategorized according to the V Brazilian Guideline onDyslipidemia and the risk calculated by the pooled cohortequations (PCE);to compare the proportion of individuals eligible for statins,according to different criteria.In individuals aged 40-75 years consecutively submitted to routine healthassessment at one single center, four criteria of eligibility for statinwere defined: BR-1, BR-2 , USA-1 and USA-2.The final sample consisted of 13,947 individuals . Most individuals at intermediate or high risk based on the V BrazilianGuideline had a low risk calculated by the PCE, and more than 70% of thosewho were considered at high risk had this categorization because of thepresence of aggravating factors. Among women, 24%, 17%, 4% and 2% wereeligible for statin use according to the BR-1, BR-2, USA-1 and USA-2criteria, respectively (p < 0.01). The respective figures for men were75%, 58%, 31% and 17% (p < 0.01). Eighty-five percent of women and 60% ofmen who were eligible for statin based on the BR-1 criterion would not becandidates for statin based on the USA-1 criterion.As compared to the North American Guideline, the V Brazilian Guidelineconsiders a substantially higher proportion of the population as eligiblefor statin use in primary prevention. This results from discrepanciesbetween the risk stratified by the Brazilian Guideline and that calculatedby the PCE, particularly because of the risk reclassification based onaggravating factors. Data were prospectively collected. The study protocolcomprises complete clinical history and physical examination performed by aclinician, treadmill exercise test and blood tests , aspreviously detailed.Individuals with the following characteristics were excluded: age < 40 yearsor > 75 years; self-reported antecedents or detection of significant clinicalor subclinical cardiovascular atherosclerotic disease, abdominal aortic aneurysmor diabetes mellitus; LDL-c ≥ 190 mg/dL; and current use oflipid-lowering drugs. In addition, individuals with parameters outside therecommended range for using the cardiovascular risk equations  were excluded, as were those whose missing dataprevented risk calculation.10 That score calculates the riskof death from coronary artery disease, myocardial infarction, angina, ischemicor hemorrhagic stroke, transient ischemic attack, peripheral vascular disease orheart failure in 10 years.10As recommended by the V Brazilian Guideline, the Framingham generalcardiovascular risk score was calculated by using the proper equation withcontinuous variables and categorical variables .2The following aggravating risk factors were considered: hs-CRP > 2 mg/L and< 10 mg/L in the absence of inflammatory conditions (not related toatherosclerosis); family history of premature coronary artery disease ; metabolic syndrome ; and subclinical atherosclerosis (detected on ultrasoundof the carotid arteries or computed tomography of the coronaryarteries).2 Theassessment of subclinical atherosclerosis is not part of the routine protocol atour service, so its request was up to the clinician in charge or to thepatient’s attending physician.In addition, the presence or absence of aggravating risk factors, capable ofre-stratifying cardiovascular risk, based on the V Brazilian Guidelinerecommendations, was assessed.2Individuals with a Framingham general cardiovascular risk score < 5% wereconsidered at low or intermediate risk, depending on the absence or presence ofa family history of premature coronary artery disease, respectively. Women witha general risk score between 5% and 10%, as well as men with a general riskscore between 5% and 20%, were classified as at an intermediate or high risk,depending on the absence or presence of aggravating factors, respectively. Womenand men with global risk scores > 10% and > 20%, respectively, werestratified as at high risk.8 The PCE used a more modernstatistical modeling that allows greater flexibility in accommodating theclinical variables used for risk prediction, which are the same described abovefor the Framingham general risk score, in addition to ethnicity.8 Differently from the generalrisk score, the PCE calculate the risk of major cardiovascular events, such asdeath from coronary artery disease, non-fatal myocardial infarction and fatal ornon-fatal stroke, in 10 years.8The cardiovascular risk was also calculated by use of the PCE, as recommended bythe North American Guideline.Based on the V Brazilian Guideline, two criteria of eligibility for statin usewere arbitrarily considered: LDL-c above the goal advocated by the V BrazilianGuideline (BR-1 criterion) or LDL-c at least 30 mg/dL above that goal (BR-2criterion).2 Individuals atlow cardiovascular risk, according to the V Brazilian Guideline, to whom theguideline recommends an individualized LDL-c goal, were not considered eligiblefor statin use according to the BR-1 and BR-2 criteria.The following LDL-c goals are recommended by the V Brazilian Guideline: < 100mg/dL for individuals at intermediate risk and < 70 mg/dL for those at highrisk.3According to the North American Guideline, statin should be considered forindividuals aged between 40 and 75 years, not diagnosed with clinicalatherosclerotic cardiovascular disease or diabetes mellitus, with LDL-c between70 mg/dL and 189 mg/dL, and cardiovascular risk by using PCE ≥ 7.5% in 10years. Those with risk between 5.0% and < 7.5% can also be considered forstatin use.Thus, this study considered two criteria of eligibility for statin use based onthe North American Guideline: cardiovascular risk by using the PCE ≥ 5.0%(USA-1 criterion) or ≥ 7.5% (USA-2 criterion).Knowing in advance that the data bank used in this study is mainly composed ofmale individuals and does not represent the general Brazilian population, thecardiovascular risk stratification was planned to be evaluated separately forwomen and men. Likewise, statin eligibility was analyzed in subgroups defined bysex, age group and cardiovascular risk categories.t test was used to comparebaseline characteristics between men and women, while analysis of variance(ANOVA) was used to compare the cardiovascular risk obtained from the PCE amongthe low, intermediate and high risk categories. Considering the large samplesize and the central limit theorem, according to which the distribution of thesample means always tends to normality, we assumed that all variables had anormal distribution and could be analyzed by use of parametric tests.Categorical variables were expressed as percentages, and the chi-square test wasused for comparisons. Continuous variables were expressed as means and standarddeviations; non-paired Student The analyses were performed with Microsoft Office Excel tools and Statastatistical program, 13.0 version. A p value < 0.05 was consideredstatistically significant.The study was approved by the Ethics Committee in Research of the Albert EinsteinIsraeli Hospital (CAAE 54537916.2.0000.0071). Considering that this is aretrospective study using a data bank and involving a large number ofindividuals, many of whom seen several years before this study began, thewritten informed consent could not be used and the Ethics Committee approved itswaiver.Of the final sample of 13,947 individuals, 9,901 (71%) were male. A significant percentage of individuals was re-stratified into a higher-riskcategory because of the presence of an aggravating factor. Of the 577 women atintermediate risk based on the V Brazilian Guideline, 332 (58%) had a Framinghamgeneral risk score < 5% and family history of premature coronary arterydisease. However, that situation occurred in only 187 (5%) of the 3,775 menstratified as at intermediate risk.In addition, of the 500 women at high risk according to the V BrazilianGuideline, 366 (73%) had a Framingham general risk score between 5% and 10%, andwere re-stratified due to the presence of an aggravating factor. Of the 4,046men at high risk, 3,221 (80%) had a Framingham general risk score between 5% and20% and an aggravating factor. Metabolic syndrome was the major singleaggravating factor responsible for re-stratification into high risk, for bothsexes .Among women, the means ± standard deviations of cardiovascular risksaccording to the PCE were as follows: 0.8 ± 0.6% in the low-riskcategory; 1.8 ± 1.6% in the intermediate-risk category; and 4.3±3.4% in the high-risk category (p < 0.01). Among men, the respective valueswere 1.2 ± 0.4%, 4.1 ± 2.4% and 6.9 ± 5.4% (p <0.01).Statin eligibility was significantly higher according to the BR-1 and BR-2criteria, as compared to the USA-1 and USA-2 criteria, for both women and men.According to the BR-1, BR-2, USA-1 and USA-2 criteria, 975 (24%), 705 (17%), 156(4%) and 63 (2%) women, respectively, would be eligible for statin use (p <0.01). The respective numbers for men were 7,381 (75%), 5,704 (58%), 3,050 (31%)and 1,696 .A higher proportion of women eligible for statins according to the V BrazilianGuideline criteria as compared to those of the North American Guideline wasobserved in all age groups analyzed, and in those both at intermediate and highrisks, according to the V Brazilian Guideline  and 5. TIn men, the higher rate of statin eligibility according to the Brazilian criteriawas also observed in those at intermediate risk and at high risk  and agedThe BR-1 and USA-1 criteria were used to assess agreement and disagreementregarding statin eligibility based on the Brazilian and North Americanguidelines.Among women, there was agreement between the criteria to not indicate statin in76% of the population, while both criteria considered statin in only 4% of thecases.Among men, there was agreement between the criteria in 54% of the cases: in 24%statin would not be considered by any criterion, while 30% of the individualswould be candidates for statin according to both criteria.Eighty-five percent of women and 60% of men who were eligible for statin based onthe BR-1 criterion would not be candidates for statin based on the USA-1criterion . HoweverAnalyzing the subgroups defined by age group, the disagreement rate between theBR-1 and USA-1 criteria increases with age in women, but decreases in men . While fAmong individuals classified as at intermediate risk and, to a lower extent, athigh risk according to the V Brazilian Guideline, the disagreement rate betweenthe BR-1 and USA-1 criteria was high, with an expressive number of cases ofstatin eligibility by the BR-1 criterion, but not by the USA-1 criterion, mainlyamong women .In the present study, we observed a large discrepancy in statin eligibility betweenthe V Brazilian Guideline and the 2013 ACC/AHA Cholesterol Guideline, the number ofcandidates for statin being significantly higher following the recommendations ofthe Brazilian Guideline.12Among individuals stratified as at intermediate or high risk, according to the VBrazilian Guideline, the number of those eligible for statin based on the BrazilianGuideline, but not on the North American Guideline, is high mainly among women. Thisis directly related to the fact that most individuals considered at intermediate orhigh risk by the V Brazilian Guideline has a low risk calculated with the PCE. Forthose classified as at high risk according to the Brazilian Guideline, for example,the mean risk in 10 years calculated with the PCE was < 5% for women and < 7%for men, while North American guidelines consider individuals at high risk thosewith risk ≥ 15% or ≥ 20% in 10 years.That discrepancy between the risk stratifications recommended by the V BrazilianGuideline and the North American Guideline is associated with the finding that mostindividuals classified as at high risk by the V Brazilian Guideline has a Framinghamgeneral risk score at intermediate levels, being re-stratified due to the presenceof an aggravating factor, mainly metabolic syndrome and hs-CRP elevated levels.The magnitude of risk reclassification observed in this study might be overestimatedas compared to that of clinical practice. The hs-CRP measurement was performed aspart of this study protocol and was available in 96% of the participants, aproportion certainly higher than that in the real world. In addition, hs-CRP wasmeasured only once. Among individuals reclassified due to hs-CRP elevation, theremight be cases in which that elevation would not repeat, if a second measurement wasperformed, and cases in which the hs-CRP increase occurred due to incipient orsubclinical inflammatory conditions, not diagnosed or not reported by the attendingphysician.2 as compared tothe previous one,13 which made itmore “aggressive”: a reduction in the LDL-c goals, a reduction in the thresholds tocategorize intermediate and high risks (mainly in women), and the adoption of theFramingham general risk score in the place of the risk score for “hard” coronaryoutcomes. The Canadian guideline, for example, which also recommends riskstratification based on the same general cardiovascular risk score, althoughmodified (the risk is doubled in the presence of family history of prematurecardiovascular disease), uses higher cutoff points than those of the V BrazilianGuideline to separate the risk categories: low-risk individuals are those with score< 10%, intermediate-risk individuals are those with score ≥ 10% and <20%, and high-risk individuals are those with score ≥ 20% in 10 years, withno distinction between men and women.6The highest rate of statin eligibility according to the Brazilian Guideline ascompared to the North American Guideline can also be related to changes in the VBrazilian Guideline13 in participants of the ELSA-Brasil Study.14 The North American recommendationshave also shown higher statin eligibility as compared to the Europeanguidelines,16 but not to the Canadianguideline.17Our results differ from those of a recent publication that reports a higher number ofcandidates for statin according to the North American Guideline, as compared to theIV Brazilian Guideline on Dyslipidemia,16 In addition, that finding might be related to thepossibility that PCE overestimate the cardiovascular risk in the subgroups of higherrisk, such as the elderly, which has been reported in some cohorts.19The only subgroup analyzed in this study that showed a high agreement between theBrazilian and North American criteria was that of men aged 60-75 years, whoseproportion of statin eligibility was very elevated, regardless of the criterionused. Other analyses have also detected a high rate of statin eligibility for theelderly, when applying the North American Guideline.20 That benefit,however, would be provided at the expense of higher costs, higher incidence ofstatin-related side effects, and especially a greater number needed to treat (NNT)to prevent one cardiovascular event, which foster discussions on medicalovertreatment.21Cost-effectiveness analyses might help to better define the advantages of followingone or the other guideline.More individuals on statins would mean a lower mean LDL-c level and greatercardiovascular benefit for the population, because of the unquestionablerelationship between those two factors, even in populations at lower cardiovascularrisk.3This study was based on theoretical considerations that might not reflectprecisely the real world. For example, this study considered non-eligible forstatin those stratified as at low cardiovascular risk, according to the VBrazilian Guideline, but part of those individuals could receive a drugprescription in clinical practice. Conversely the present study did not includethe North American Guideline recommendation to consider statin use forindividuals with a low calculated cardiovascular risk, but with some conditionsknown to increase the risk, such as LDL-c ≥ 160 mg/dL, family history ofpremature atherosclerotic cardiovascular disease, hs-CRP elevation, andsignificant coronary calcification on computed tomography.For healthy individuals in primary prevention, management of blood cholesterol basedon the V Brazilian Guideline on Dyslipidemias or the 2013 ACC/AHA CholesterolGuideline can vary substantially. Among those classified as at intermediate or highrisk according to the V Brazilian Guideline, there is a high proportion ofindividuals eligible for statin according to the Brazilian Guideline criteria, butnot according to the North American Guideline criteria. This finding is associatedwith the fact that most individuals at intermediate or high risk according to theBrazilian Guideline have a low risk calculated by the PCE, in addition to the factthat most individuals classified as at high risk owe that to the presence of anaggravating factor.Our results can allow a critical reflection on the current guidelines and continuousimprovement of the recommendations. In addition, they can help attending physicianswith clinical judgement and therapeutic decision making.


Mya arenaria is a bivalve mollusk of commercial and economic importance, currently impacted by ocean warming, acidification, and invasive species. In order to inform studies on the growth of M. arenaria, we selected and inbred a population of soft-shell clams for a fast-growth phenotype. This population displayed significantly faster growth (p < 0.0001), as measured by 35.4% greater shell size. To assess the biological basis of this growth heterosis, we characterized the complete transcriptomes of six individuals and identified differentially expressed genes by RNAseq. Pathways differentially expressed included structural gene pathways. Also differentially expressed was the nucleotide-binding oligomerization domain 2 (NOD2) receptor pathway that contributes to determination of growth, immunity, apoptosis, and proliferation. NOD2 pathway members that were upregulated included a subset of isoforms of RIPK2 (mean 3.3-fold increase in expression), ERK/MAPK14 (3.8-fold), JNK/MAPK8 (4.1-fold), and NFκB (4.08-fold). These transcriptomes will be useful resources for both the aquaculture community and researchers with an interest in mollusks and growth heterosis. Mya arenaria, is an infaunal, benthic marine bivalve that inhabits soft-sediments in the intertidal and shallow subtidal zone and ranges in the northwest Atlantic from North Carolina to Labrador )EF2), are all represented in the most significantly differentially expressed genes. This is consistent with other studies on growth heterosis that emphasize the importance of protein synthesis genes and protein processing [About a quarter of the characterized differentially expressed genes were metabolic genes. For example, two isoforms of fatty acid synthase, ATPase and elongation factor 2 . Lack of representation in the database of annotated mollusks prevented us from identifying over half of the transcripts. RPS3A served as a stable gene in the qPCR analysis and chose BIRC2 as a differentially expressed gene to analyze. Between individuals, both FG and WT, the RPS showed low variability with a single melt peak and a single band by DNA analyzer. RPS3A produces a ribosomal protein that is a component of the small ribosomal subunit. It is a member of the S3AE family of ribosomal proteins and is located in the cytoplasm. In the realm of FG phenotype, RPS3A is an interesting gene. On one hand, it has appeared in screens for genes highly associated with growth heterosis [ RPS3A has also been used in screens of FG cells, especially cancer, as a housekeeping gene, as seen in a meta-analysis by Popovici et al. [We determined thateterosis  but RPS3i et al. . BIRC2 gene seen in both the RNAseq screen and the qPCR was of particular interest because the gene product BIRC2 lies at a crossroads between growth, cancer, and immunity. The sevenfold increase in BIRC-2 expression assayed by qPCR was consistent with the differential expression seen in the RNAseq, but the fold-difference was smaller, a result that has been seen in other RNAseq/qPCR comparisons [ BIRC-2 knockout has been reported to have no phenotype [The upregulation of theparisons  and in pparisons . The BIRhenotype , 52, so  BIRC-2, will inform analysis of growth regulation in these ecologically and economically important species. Since these genes lie at the crossroads of immunity, growth, and cancer, there are a range of biomedical implications. In addition, elucidation of growth in bivalves can have implications for conservation and policy for M. arenaria.Our sequence database contributions and annotation will serve to improve the bivalve representation in GenBank . Our results show that suites of genes involved in structural remodeling, signaling, and apoptosis correlate with a fast-growth phenotype. Functional analysis of some of these genes, such asSupplemental material includes: RNAseq quality control data, PCR conditions and data, and a plot of global transcriptional changes seen in our RNAseq.