Hepatitis E virus (HEV) is a common etiology of acute viral hepatitis worldwide. Recombinant HEV vaccines have been developed, but only one is commercially available and licensed in China since 2011. Epidemiological studies have identified genotype 3 as the major cause of chronic infection in immunocompromised individuals. Ribavirin has been shown to be effective as a monotherapy to induce HEV clearance in chronic patients who have undergone solid organ transplant (SOT) under immunosuppressive therapy. Efforts and improvements in prevention and control have been made to reduce the instances of acute and chronic hepatitis E in endemic and nonendemic countries. However, this review shows that further studies are required to demonstrate the importance of preventive vaccination and treatment worldwide, with emphasis on hepatitis E infection in the public health system. After the development of serological tests for the detection of hepatitis A and hepatitis B viruses in the 1980s, a large waterborne outbreak which occurred in 1955-1956 in New Delhi, India, was investigated and classified as enteric non-A, non-B hepatitis . To bothYears later, in 1983, HEV was first identified by electron microscopy when they replicated the infection with a pool of human feces in one volunteer who had previously contacted with hepatitis A virus. It was also the first time to detect genotype 1 , 5.Other cases occurred in Costa Rica in 1975 , 6. In 1HEV genome was first cloned in the early 1990s, and genotypes 3 and 4 were identified in 1995 and 2003, respectively , 7. Othe Orthohepevirus with four species (A–D) and Piscihepevirus with one species (A) [ Orthohepevirus A species include almost all mammalian HEV variants; it is divided into seven genotypes, of which at least five of them are of interest in human public health. First, genotypes 1 and 2 (HEV-1 and HEV-2) infect only humans and are responsible for sporadic cases and large waterborne outbreaks in endemic areas. Furthermore, genotypes 3 and 4 (HEV-3 and HEV-4) are able to infect humans and animals and are enzootic in pigs, which are considered the main reservoir of HEV in the environment [Hepatitis E virus (HEV) is a small, nonenveloped virus 27–34 nm) with icosahedral symmetry in the Hepeviridae Family. HEV is divided into two genera:cies (A) , 12, 13. nm with ironment , 10. Untironment .Orthohepevirus B species include viruses, which infect birds, while Orthohepevirus C include viruses that infect rat and ferret. Viruses isolates were detected in bats, and they were grouped into Orthohepevirus D species. Piscihepevirus genus is formed by only one species, Piscihepevirus A, and comprises all the isolates identified in trout fish [out fish .Nevertheless, there is one serotype of hepatitis E circulating worldwide , 16, 17.HEV contains a 7.2 kb single-stranded, positive-sense RNA genome that consists of three overlapping open reading frames (ORF) with distinct functions: ORF1, ORF2, and ORF3. ORF1 encodes a nonstructural polyprotein (with 1690 amino acids (aa)), which consists of proteins required for RNA replication such as methyltransferase, papain-like cysteine protease, RNA helicase, and RNA-dependent RNA polymerase. ORF2 is the most important structural protein for targeting HEV vaccine development since it encodes the capsid protein, which carries neutralizing epitopes inducing antibody production in the host and reservoirs. ORF3 has 123 aa, overlaps with ORF2, and encodes a small multifunctional protein involved in viral particle secretion , 17.Complete particles of HEV are vulnerable to boiling or frying and they become inactivated after 5 minutes at temperatures above 90°C. To completely inactivate HEV in the food, an internal temperature of 71°C for 20 min is necessary . HEV is Hepatitis E is mainly transmitted by a fecal-oral route through contaminated water ingestion and the consumption of undercooked pork or wild boar . HoweverThe diagnosis of HEV infection is not easy considering the short period of HEV viremia, which is not always concomitant with the onset of symptoms. Serum samples are used to perform molecular detection of RNA and specific-antibodies against capsid (ORF2) as the main tool for HEV diagnosis. Two serological markers can be used to investigate the presence of past or recent HEV infection. The first is anti-HEV IgM, which indicates the acute phase, and the second is anti-HEV IgG, which indicates current infection when observed together with anti-HEV IgM detection or past contact when it is detected alone , 22, 23.According to the World Health Organization (WHO), HEV infection is one of the most common causes of acute hepatitis and has a large distribution worldwide . It is eHEV genotypes 1 and 2 are highly endemic in tropical and subtropical areas where hepatitis E occurs as outbreaks and sporadic cases transmitted by a fecal-oral route through contaminated water caused by genotypes 1 or 2 . OutbreaOutbreaks of HEV-1 and HEV-2 have been documented in areas with limited access to water and inadequate sanitary conditions, generally in resource-limited countries  Figure . The WHOOutbreaks of HEV-1 and 2 reach thousands of people, and up to 15% of the infected population present signals and symptoms , 40. OveBesides fecal-oral transmission, vertical , 46 and Regions with adequate sanitary conditions and well-controlled water supplies are considered low endemic areas for hepatitis E, such as Europe, East Asia (including China), and the Americas . In thesAdditionally HEV  can be iatrogenically transmitted between humans through infected blood and blood products . TransfuThe prevalence rates of anti-HEV in Europe could be explained by pork consumption, as in France and Germany, where the seroprevalence is 17% and 35%, respectively. In France, anti-HEV IgG prevalence was also high in an investigation of blood banks (52%), which reinforces the findings about the prevalence of hepatitis E in Europe. Recent studies detected genotypes 1, 3, and 4 in Europe , 60–63. In the Americas, the seroprevalence of anti-HEV IgG ranges from 3 to 31%, which can be explained by the sporadic HEV cases reported in the area , 64, 65.Conventionally, symptomatic HEV-3 and HEV-4 infection results in self-limited acute hepatitis in humans. However, in recent years, the occurrence of chronic hepatitis by infection, especially with genotype 3, has been described in immunosuppressed patients, especially posttransplant patients –73. The Acute or chronic HEV infection caused by genotypes 1–4 may also cause extrahepatic manifestations that include neurological disorders, kidney injury, acute pancreatitis, and hematological abnormalities. Particularly for HEV infection, physicians need to have attention to neurological manifestations such as Guillain-Barré syndrome, brachial neuritis, and meningoencephalitis, which are a risk, despite rare occurrence in viral hepatitis .The need for hepatitis E vaccine is related to its worldwide distribution. The WHO estimates that 44,000 deaths were caused by HEV in 2015, representing 3.3% of the mortality due to viral hepatitis . Normall in vitro cell culture replication [It is not feasible to develop live attenuated or inactivated vaccines for hepatitis E virus bylication –85. Passlication . Thus, slication –85.The only vaccine that is commercially available is the HEV 239 vaccine , which has been registered in China since 2011. However, it has not yet been approved in other countries , 88. ThiThe HEV 239 vaccine is protective against hepatitis in animal models based on Rhesus monkeys immunized and challenged with infectious virus strains (genotypes 1 and 4) , 85. Theμg of the purified antigen plus aluminum hydroxide as adjuvant. The vaccine's efficacy is greater than 90% for 1 year after one dose and for 4.5 years after three doses [The vaccination schedule in China with HEV 239 vaccine involves three doses administered intramuscularly at months 0, 1, and 6. In 2010, Zhu and colleagues performed a phase 3 trial in healthy adults (>16 years old) in China using the HEV 239 vaccine, which contained 30 ee doses –96. AddiConsidering that only China has experience with vaccination against hepatitis E, and HEV infection has remained a health problem, the cost-effectiveness of the HEV vaccine has been debated. The Hecolin HEV 239 vaccine from Xiamen Innovax Biotech costs around USD 17.60–41.70 per dose , 88, whiNevertheless, further studies are necessary to establish or improve HEV immunization worldwide in humans and animals . Furthermore, health surveillance will be very important for monitoring the prevalence and incidence of HEV before and after immunization. In addition to these efforts, developing countries still need sanitary and environmental improvements. For more clarification, Treatment for hepatitis E infection can be justified by the chronic and persistent infections commonly caused by genotype 3 and involved with immunosuppressive or immunocompromised conditions , 98–101.Recently, a large follow-up study related the effect of ribavirin as a monotherapy for SOT recipients with prolonged HEV viremia. Kamar and colleagues observed HEV clearance in 95% of patients on ribavirin monotherapy with a median dose of 600 mg/day for 3–6 months. The only side effect in this study was anemia, which required reduction of the ribavirin dose in 29% of the patients, as well as the use of erythropoietin (54%) and blood transfusion (12%) , 98. Peg in vitro. Thus, they have been suggested as potential drugs to control HEV infection [ in vitro, such as sofosbuvir, calcineurin inhibitors, and mTOR inhibitors, which may help in virus clearance and show promise for future treatments [HEV replication is inhibited by the inactivation RNA polymerase function using antiviral drugs such as zinc salt and nucleoside analogue 2′-C-methylcytidine (2CMC) in human cell linesnfection , 103. Wheatments , 17, 103There is few information about treatments against acute hepatitis E infection, for which ribavirin is recommended to treat immunocompetent and immunocompromised individuals , 99, 102Several studies have been performed to investigate HEV infection and reduce the numbers of hepatitis cases caused by this etiology. Considerable improvements in vaccination and treatment have been achieved, but there have been limitations that bound the success of HEV elimination. This is particularly true in developing countries, where HEV remains an important health problem. In this review, we have presented an update on the cost-effectiveness vaccination to spread the program worldwide. Together with information about treatment of immunocompromised and immunocompetent individuals, approaches were suggested to help continue the surveillance and optimize future research in this area.


Deserts are the main sources of emitted dust, and are highly responsive to wind erosion. Low content of soil moisture and lack of vegetation cover lead to fine particle’s release. One of the semi-arid bare lands in Iran, located in the South-West of Iran in Khoozestan province, was selected to investigate Sand and Dust storm potential.This paper focused on the metrological parameters of the sampling site, their changes and the relationship between these changes and dust storm occurrence, estimation of Reconaissance Drought Index, the Atterberg limits of soil samples and their relation with soil erosion ability, the chemical composition, size distribution of soil and airborne dust samples, and estimation of vertical mass flux by COMSALT through considering the effect of saffman force and interparticle cohesion forces during warm period (April–September) in 2010. The chemical compositions are measured with X-ray fluorescence, Atomic absorption spectrophotometer and X-ray diffraction. The particle size distribution analysis was conducted by using Laser particle size and sieve techniques.st in the studied period showed an extremely dry condition. Using the results of particle size distribution and soil consistency, the weak structure of soil was represented. X-ray diffraction analyses of soil and dust samples showed that soil mineralogy was dominated mainly by Quartz and calcite. X-ray fluorescence analyses of samples indicated that the most important major oxide compositions of the soil and airborne dust samples were SiO2, Al2O3, CaO, MgO, Na2O, and Fe2O3, demonstrating similar percentages for soil and dust samples. Estimation of Enrichment Factors for all studied trace elements in soil samples showed Br, Cl, Mo, S, Zn, and Hg with EF values higher than 10.There was a strong negative correlation between dust storm occurrence and annual and seasonal rainfall and relative humidity. Positive strong correlation between annual and seasonal maximum temperature and dust storm frequency was seen. Estimation of RDIThe findings, showed the possible correlation between the degree of anthropogenic soil pollutants, and the remains of Iraq-Iran war. The results expressed sand and dust storm emission potential in this area, was illustrated with measured vertical mass fluxes by COMSALT. Reference elements are usually Si, Al or Fe, but it is not a universal accepted rule. In this study, Si was considered as the reference element . The valose to 1 . EFs for’s crust .∗ is the friction velocity or wind shear velocity, z is the vertical distance from the surface, and d) [∗ by the amount of the kinetic energy impacting on the soil surface and saltation flux  mm, when wind velocity exceeds 14 Km/h and last as long as wind velocity persist. When the wind exceeds a critical speed, sand grains start to move forward along with the ground surface. For higher wind velocities, sand grains in sand storm are moved by saltation process . Since tis model . The effis model . Saltatiis model . Consideodel [d) . However10−2 m−1  and Q isThe annual and seasonal changes of meteorological parameters over the last 60 years were studied. Also, the correlation coefficients between the annual and seasonal dust storm occurrence and precipitation, maximum temperature, relative humidity and wind speed were calculated. Data taken from Abadan and Khoramshahr metrological station , which is the nearest station to the Shalamcheh, records the climatic elements within Shalamcheh and dust storm frequencies (times of the dust storm occurrence) for the years 1951–2014. Also, the variations of meteorological parameters during warm period (April to September) and cold period (October to March) for the last 60 years were studied [The dust storm occurrence of about 25 years period (1990–2014) were studied. The observations indicated a considerable increase in dust storm frequencies in the studied area. The average number of dust storms in 2008, 2009 and 2010 is higher compared with the mean trend line , maximum temperature (°C) and relative humidity (%) of about 60 year’s period were studied. The results show a remarkable decrease in the annual rainfall. It reached to 36.8 mm in 2010. Considering the changes in precipitation during the cold season, a substantial reduction was revealed in the last 60 years Fig. . Also, rWind rose plots are frequently used to show the distribution of wind speeds and their varying directions in the study area, based on their metrological observations. As it can be seen in Fig. The results show for Standardized RDI, during the years of 1995, 2001, and 2007, there was Moderately Dry Condition. Also, during the years of 1998, 2002, 2008, 2009, and 2011, there was Severe Dry Condition. While the Extreme Dry Condition was seen during the years of 2000, 2003, and 2010  as a qualitative manner classified soil samples as medium plasticity. Similarly, according to the plasticity chart classified they are classified inorganic clay, and medium compressibility .2O while BaO is not detected in dust samples too.The soil and dust samples were detected for major oxides and minerals by using XRD and XRF techniques, respectively. The recognized frequent minerals in soil and dust samples are; Quartz, Chlorite, Dolomite, Kaolinite, Mica, Montmorillonite, Illite, Calcite, Gypsum and Halite. Furthermore, mean major oxides content of soil and dust samples are demonstrated in Table The EF calculation of soil samples show that Br, Cl, Mo, S, Zn and Hg had average EF higher than 10, were considered to originate mainly from anthropogenic origins. Also, the EFs for trace and major elements of dust samples indicated that EFs of trace elements Br, Mo, S, Zn and Hg higher than 10, showing their anthropogenic sources Table .Table 5AThe study area is about 38 Km × 38 Km and is located in the South-West of Iran in Khoozestan province. By considering prevail average wind speed in last 60 years u = 18.72 Km/h) with dominate percent of 36%, and according to the capabilities of numerical model COMSALT, horizontal and vertical particle mass fluxes are measured for Shalamcheh in various situations. The initial soil and wind parameters are set for a case study according to the physical properties of soil samples and local metrological parameters  as evidenced by the relatively low OM (0.060%) showed the soil volunteer to wind erosion in this area, which was supported by the similar study reporting an increase in erosion capacity with low OM , 33. On 2. More specifically, mean major elements of soil indicate a predominant SiO2 mass component (29.2%) with significant CaO (17.8%) and MgO (6.3%) contributions; a little percent of Al2O3 (4.9%), Na2O (1.82%), K2O (1.12%) and total iron as Fe2O3 (4.19%), as well as the trace amounts (<1%) of V2O5, TiO2, P2O5, Cr2O3, NiO,Co3O4, MnO, SrO, Rb2O, CuO, ZrO2 and Y2O3. Compared with various mean shale analyses [2O3, SiO2, K2O, Na2O and Fe2O3. It is also significantly enriched in MgO and CaO. Emphasizing the dust minerology over Khoramshahr city, can be seen that the airborne dust mainly consists of Quartz, which is dominant component for all dust samples (with average amount of 31.9%). Na2O and MgO are the second main mineralogical constituents of dust samples over the studied area with mean mass percentage of 20.9 and 17.7%, while CaO contributes 10.1% and Al2O3, 6.1%. On the other hand, the soil samples exhibit a lower average percentage for SiO2 and higher percentage for Fe2O3, CaO, TiO2 and MnO in comparison with the airborne dust. The distance between the source area and where the dust is deposited can also influence the mineralogical and chemical composition of dust and particle size distribution [The mineralogical composition can indicate regional geology and wind- transported dust, deposited in local soils . Accordianalyses , the Sharibution . The knoribution . TherefoIn airborne dust samples, Br, Mo, S, Zn and Hg had EF values higher than 10, derived from non- crustal origins. Also, the calculated EFs values for major and trace elements detected in soil samples show Br, Cl, Mo, S, Zn and Hg are of anthropogenic origins in this area Table . One of Saltation and sandblasting are the major processes causing particles entrainments and dust producing from soils. To be a major origin of dust, a soil should consist of enough both sand particles to start the saltation mechanism and fine particles such as clays and silts could be transported over long-range distance and local factors such as: the particle size distribution of soils, climate (wind speed and soil moisture content) and surface roughness are controlling the dust emission capacity of soil . The salst estimation as a drought index. The vertical estimated mass fluxes in different conditions, using COMSALT model showed an important role of cohesion forces in inhibition of saltation. The results of models were confirmed by soil consistency tests due to its weak structure, which was expected. The chemistry and mineralogy compositions of the airborne dust samples taken in Khoramshahr city were almost the same and quiet similar to the soil samples collected at several locations downwind. According to the contamination assessments of dust and soil samples, some of these trace elements had EF values higher than 10, suggesting their anthropogenic sources because of the human activities. One of the major non-crustal sources of these trace elements could be the remains of the Iraq-Iran war. Regarding the high vulnerability of this area, wind rose plots and the direction of the dominant blown winds, it is reasonable to conclude that carrying this harmful and contaminated soil by wind can affect the areas, which are far from this region including agriculture lands, would endanger human health. Due to the spread of this crisis to the rest of the world even European countries, it is necessary to identify hotspots, measure their wind erosion capacity and take the effective and functional stabilizing methods of highly erodible regions immediately.For the first time, the estimated vertical dust fluxes through the COMSALT, soil consistency and variation in regional metrological parameters show the susceptibility of this area  to wind erosion. The results indicated the changes in metrological parameters in Shalamcheh located in South –West of Iran. There is an obvious increase in annual mean average Maximum and remarkable reduction in the amount of annual rainfall and the average mean relative humidity content. The strong correlation was seen between changes in metrological parameters and sand and dust storm occurrence in the studied area during the last decades. An extreme dry condition was shown by RDI


Two very effective antihypertensive medications with well-established and significant cardiovascular outcome studies have been combined and used for the first time in early combination therapy in the TALENT study. Results from this multicentre, prospective, randomised, doubleblind trial were announced at the 2010 European Society of Hypertension (ESH) congress held in June in Oslo, Norway, and highlighted the rapid, safe and effective blood pressure-lowering action of this combination.1The TALENT  enrolled 405 patients with office systolic blood pressure at a baseline of ≥ 135 mmHg and with a high cardiovascular risk because of diabetes, the metabolic syndrome, and echocardiographic/ECG evidence of left ventricular hypertrophy or microalbuminuria. Patients could be admitted to the trial if other antihypertensive medication  could be safely withdrawn.Patients were randomised to initial administration of telmisartan (80 mg/day) plus nifedipine GITS (20 mg/d), telmisartan alone, or nifedipine GITS alone in a 2:1:1 ratio. Treatment was continued for 24 weeks, shifting the monotherapy groups to combination therapy after eight weeks .Office and ambulatory blood pressure was measured after two, eight, 16 and 24 weeks and after eight, 16, and 24 weeks, respectively. Up-titration occurred when needed but not to blood pressure levels below 120 mmHg.Initiating treatment with the combination therapy resulted in earlier blood pressure control. This was maintained throughout the study period both with regard to office and ambulatory blood pressure control, which was reduced by 14.2/3 mmHg and 10/4.7 mmHg, respectively.Both combination and monotherapy substantially lowered systolic and diastolic blood pressure. The 24-hour data showed that the effect was consistent throughout the 24-hour period. Of importance is that longer-term control was similar, irrespective of the initial monotherapy treatment strategy followed or whether the combination was initiated first.In terms of the evidence-based reduction of cardiovascular outcomes, telmisartan in the ONTARGET


Glaucoma is one of the leading causes of irreversible visual loss, which has been estimated to affect 3.5% of those over 40 years old and projected to affect a total of 112 million people by 2040. Such a dramatic increase in affected patients demonstrates the need for continual improvement in the way we diagnose and treat this condition. Annexin A5 is a 36 kDa protein that is ubiquitously expressed in humans and is studied as an indicator of apoptosis in several fields. This molecule has a high calcium-dependent affinity for phosphatidylserine, a cell membrane phospholipid externalized to the outer cell membrane in early apoptosis. The DARC  project uses fluorescently-labelled annexin A5 to assess glaucomatous degeneration, the inherent process of which is the apoptosis of retinal ganglion cells. Furthermore, this project has conducted investigation of the retinal apoptosis in the neurodegenerative conditions of the eye and brain. In this present study, we summarized the use of annexin A5 as a marker of apoptosis in the eye. We also relayed the progress of the DARC project, developing real-time imaging of retinal ganglion cell apoptosis in vivo from the experimental models of disease and identifying mechanisms underlying neurodegeneration and its treatments, which has been applied to the first human clinical trials. DARC has potential as a biomarker in neurodegeneration, especially in the research of novel treatments, and could be a useful tool for the diagnosis and monitoring of glaucoma. Glaucoma is a progressive, neurodegenerative disease of the optic nerve, which is characterized by retinal ganglion cell (RGC) apoptosis ,3,4,5,6.The most common subtype of glaucoma is primary open-angle glaucoma (POAG) . SeveralThe current gold-standard investigation for diagnosis and monitoring is Standard Automated Perimetry (SAP), which assesses the patient’s peripheral field of vision ,30. SAP Glaucoma imaging is currently dominated by optical coherence tomography (OCT) technology, which provides non-invasive cross-sectional imaging of the retina and automated segmentation of the retinal nerve fiber layer and ganglion cell complex. Single baseline images hold moderate value in predicting future glaucoma progression due to the heterogeneity of normal anatomical variants ,34. MoniOptimal glaucoma management involves early and accurate diagnosis . This enApoptosis, or programmed cell death, is a process that was first described by Kerr et al. in 1972, which plays a central role in the normal development and regulation of multi-cellular organisms . AlteratUnder normal conditions, the distribution of phosphatidylserine is maintained in an asymmetric state by a family of ATP-dependent proteins called flippases , which p−9 M [Due to the large number of processes in which apoptosis dysregulation has been implicated, it is perhaps not surprising that many groups have sought to develop tools to monitor the extent of apoptosis both in vitro and in vivo. Annexin A5 is an endogenous 36 kDa protein ubiquitously expressed in humans that electrostatically binds to phosphatidylserine (and phosphatidylethanolamine to a lesser extent) in a calcium-dependent manner, with an affinity in the order of 10−9 M . Althoug−9 M  and memb−9 M , the pro−9 M  and anti−9 M . Further−9 M .By exploiting the phosphatidylserine-binding property of annexin A5, fluorescently conjugated annexin A5 (fluorescein-annexin A5) was first proposed as an early stage marker of in vitro apoptosis using flow cytometry by Vermes et al. in 1995 . Today, 18F, 124I or 99mTc [The first use of annexin in patients was with radiolabels, such as or 99mTc ,67,68. Tor 99mTc . Dual raor 99mTc ,71, tumoor 99mTc , prostheor 99mTc  and stroor 99mTc  . More ror 99mTc . Furtheror 99mTc  and crosor 99mTc  have alsor 99mTc , stroke or 99mTc  and prosor 99mTc .In contrast to most human tissues, the eye  is optically transparent. This permits the use of techniques, such as confocal scanning laser ophthalmoscopy (cSLO) and optical coherence tomography (OCT) . UnfortuThe DARC technique enables better visualization at a single cell resolution due to the presence of the fluorescent tag acting as a “contrast agent”. Two fluorescently-labelled annexin A5 molecules have been trialed thus far in DARC studies, including Alexa Fluor 488-labeled annexin A5 and a fluorescently-labelled variant of human annexin A5, RhAnnexin V128  to the superior colliculi of rats. This was combined with histological staining using 4,6-diamidino-2-phenylindole (DAPI) to assess the nuclei, Cy5-labeled anti-caspase-3 to confirm apoptosis and fluorescent-labeled annexin A5 to represent the DARC spots in vivo [Histological evidence supporting DARC spots as apoptosing RGCs has been demonstrated using the dual-labelling of annexin 5 and caspase-3 positive RGCs. This was accomplished using the retrograde labelling of RGCs by an injection of DiAsp (4-(4-(didecylamino)styryl)- in vivo .Since the DARC technique was established in 2004 , variousN-methyl-d-aspartate (NMDA) receptors with specific antagonists, such as memantine, was reported to be effective in reducing RGC death in experimental glaucoma [Glutamate excitotoxicity has been implicated in the death of RGCs in glaucoma ,24,103. glaucoma ,105,106 glaucoma ). DARC hglaucoma . All thrglaucoma .Another pathological process investigated with DARC is the deposition of amyloid-β (Aβ) plaques, which are characteristic of Alzheimer’s disease. Aβ deposition is also implicated in the development of RGC apoptosis in glaucoma ,109,110.The pathological process behind Parkinson’s disease (PD) has also been studied using DARC, the hallmark of which is the death of dopaminergic cells in the substantia nigra . Visual Mitochondrial dysfunction and oxidative stress are known mediators of RGC death in glaucoma ,122. CoeCell-based therapies are becoming an increasingly recognized strategy with the potential to treat retinal neurodegenerative disease ,125. UnfThe DARC technique has also been trialed in humans using intravenous injections of ANX776. Intravenous administration of the agents used to augment imaging is already a well-established routine in ophthalmology, which is commonly used in medical retinal clinics in the form of fundus fluorescein and ICG angiography . Phase In = 15, p = 0.0033, 2-way ANOVA) in the glaucomatous cohort of patients when compared to the normal subjects across all the doses. In particular, at the 0.4 mg dose, the mean DARC count was 25 in the glaucomatous group compared with 10 in the healthy controls . Other factors that were significantly associated with the DARC count were thin central corneal thickness  and high cup-to-disc ratio in glaucoma patients . Post-hoc analysis showed that the DARC count was significantly increased in glaucoma patients with an increasing rate of progression in any parameter  when compared to healthy controls , although this was not significantly different from stable glaucoma patients.The retinal imaging in the study used confocal scanning laser ophthalmoscopy (cSLO) and fluorescent settings for ICG angiography (diode laser with 786-nm excitation and photodetector with 800-nm barrier filter). Images were captured from a 30-degree field of view, which corresponded to an average width of 8.87 ± 0.28 mm of retina. The imaging was performed at baseline and following injections of 0.1 mg, 0.2 mg, 0.4 mg and 0.5 mg of ANX776 in four groups of four patients, two healthy and two glaucomatous. Imaging was captured at 15, 30, 60, 120, 240 and 360 min timepoints post-injection . One patmax = 5.0–7.0 min), dose-dependent maximum serum concentrations (5.5–40.9 ng/mL) and half-life  and no accumulation .With regards to safety, no patients withdrew from the study and no serious adverse events were recorded. Six mild adverse events were recorded in all 16 participants, including issues related to intravenous cannulation, headache, influenza, dizziness and metatarsal inflammation. These adverse events were deemed unlikely to be related to the ANX776 injection. The majority of the remaining complaints were symptoms that patients had previously suffered from, except one patient, who was diagnosed with metatarsal inflammation 3 weeks following the injection. The pharmacokinetics in all 16 participants were examined by serial blood tests at 5, 15, 30, 60, 120 and 300 min using 0.1, 0.2, 0.4 and 0.5 mg doses, which demonstrated fast absorption  is the commonest endpoint of choice to prove the efficacy of the majority of treatments for glaucoma. This is due to its ease of acquisition and fast response to therapy. However, the progression of disease can occur with adequately treated IOP and glaucoma can occur when IOP is within normal limits . Given tThe other gold standard in glaucoma is visual field testing, but this is associated with prolonged clinical trials, which can be very expensive in assessing new treatments, despite the introduction of new algorithms for rates of progression. Using frequent repetition and computer-aided analysis of visual field tests, recent studies have shown the ability of visual field testing to reveal significant rates of progression within a two-year period . Visual In clinical practice, the decision as to how low an individual patient’s IOP should be to avoid progression (target IOP) is difficult to predict. Clinical measurements can vary significantly according to the time of day  and therWith ageing populations and lengthening life expectancy in many countries, the number of glaucoma patients is rapidly increasing. From an estimated 64.3 million people  in 2013, it is estimated that glaucoma sufferers worldwide could reach 111.8 million by 2040 , creatinFurther work to be done with DARC will involve both continual sophistication of the technique and its applications in humans. The technique itself has the potential to be improved in terms of sensitivity and cell-type differentiation in addition to possibly exploring alternative routes of fluorescent marker administration. New applications in humans will involve increasing patient numbers, diversifying disease pathologies under examination and testing the effects of existing and novel treatments on the levels of retinal cell apoptosis.


Pneumo Rischio eHealth project, which consists of an app, a website, and social networking activity, is aimed at increasing public awareness of invasive pneumococcal disease (IPD). The launch of this project was prompted by the inadequate awareness of IPD among both laypeople and health care workers, the heavy socioeconomic burden of IPD, and the far from optimal vaccination coverage in Italy, despite the availability of safe and effective vaccines.The recently launched Pneumo Rischio usage before and after a promotional campaign, to characterize its end users, and to assess its user-rated quality.The objectives of our study were to analyze trends in Pneumo Rischio, we established a 4-month marketing campaign to promote the project. This intervention used various approaches and channels, including both traditional and digital marketing strategies. To highlight usage trends, we used different techniques of time series analysis and modeling, including a modified Mann-Kendall test, change-point detection, and segmented negative binomial regression of interrupted time series. Users were characterized in terms of demographics and IPD risk categories. Customer-rated quality was evaluated by means of a standardized tool in a sample of app users.At 7 months after launching P ≤.01) increasing trend in both app and website users, while change-point detection analysis showed that the first significant change corresponded to the start of the promotional campaign. Regression analysis showed a significant immediate effect of the intervention, with a mean increase in daily numbers of users of 1562% (95% CI 456%-4870%) for the app and 620% (95% CI 176%-1777%) for the website. Similarly, the postintervention daily trend in the number of users was positive, with a relative increase of 0.9% (95% CI 0.0%-1.8%) for the app and 1.4% (95% CI 0.7%-2.1%) for the website. Demographics differed between app and website users and Facebook fans. A total of 69.15%  of users could be defined as being at risk of IPD, while 4729 users expressed intentions to ask their doctor for further information on IPD. The mean app quality score assigned by end users was approximately 79.5% (397/500).Over 1 year, the app was accessed by 9295 users and the website was accessed by 143,993 users, while the project’s Facebook page had 1216 fans. The promotional intervention was highly effective in increasing the daily number of users. In particular, the Mann-Kendall trend test revealed a significant (Pneumo Rischio was accessed by a considerable number of users, who ranked it as a high-quality project. In order to reach their target populations, however, such projects should be promoted.Despite its specific topic,  Streptococcus pneumoniae, also known as pneumococcus, is an important human pathogen. It can cause both noninvasive  and invasive pneumococcal disease (IPD), which is described as the presence of pneumococcus in normally sterile body fluids. IPD has a variety of clinical presentations, the most common being meningitis, bacteremia, and bacteremic pneumonia [Neisseria meningitidis accounted for 163 (13%) and those caused by Haemophilus influenzae accounted for 105 (9%) [neumonia ,2. It haneumonia  that app105 (9%) . The risVaccination is the only public health measure able to drastically reduce the incidence of IPD ,8 and isPneumo Rischio [We have previously shown  that, de Rischio . Impleme Rischio -13 and t Rischio , despitePneumo Rischio was launched on February 26, 2015 in the three main app stores available in Italy, namely Google Play  [Pneumo Rischio have been reported elsewhere [Pneumo Rischio product page, subcategory app page) [Pneumo Rischio app, website, and Facebook page.CA, USA) , iTunes CA, USA) , and MicCA, USA)  stores. lsewhere . Brieflylsewhere  to ensurlsewhere . MoreovePneumo Rischio, which proved to be a user-friendly product, we tried to make it evidence based by involving IPD experts in drafting content and features of the project and by carrying out a comprehensive literature review [To be effective, an app concerning health and health care should not only be technically efficient but also (1) be evidence based , (2) sate review . Howevere review . ContinuPneumo Rischio project, our goals were (1) to describe and analyze the trend in usage and its determinants, (2) to characterize users and their representativeness, and (3) to evaluate users’ ratings of the quality of the app.In the light of the above considerations, we aimed to provide some potentially useful insights into assessing an app/eHealth project from different points of view. Specifically, with regard to the Pneumo Rischio Facebook page to periodically post stylistically coherent messages concerning IPD risk factors. Most posts could be classified as designed questions [Pneumo Rischio increase if…?”). Moreover, we posted banners on some popular thematic and informational portals.In the first 7 months after the project was launched, we had no defined marketing strategy for its promotion; we only occasionally presented it at conferences, and we made some Web press releases. From the fourth week of September 2015, we established a more intense 4-month marketing campaign (henceforth referred to as the intervention). This used various approaches and channels, including both traditional and digital marketing strategies. The traditional approach consisted of presenting the app and the first results of its use at meetings, congresses ,26, and uestions   number of app and website users. We considered app and website users separately, since they have different characteristics and usage patterns [We used Google Analytics data, which are rigorously anonymous and presented in aggregated form, to record the number of users, number of sessions, users’ demographic characteristics, and the risk (related to IPD) profiles of patterns .Pneumo Rischio users over time. We then performed change-point detection analysis to locate points at which the statistical properties (both mean and variance) of the time series changed [We exploited different techniques of time series analysis to highlight the usage trend. The modified Mann-Kendall test  for seri changed . For thiWe subsequently carried out segmented negative binomial regression analysis (to account for overdispersion) of interrupted time series in order to quantify immediate and time-related changes in the counts of users after the launch of the intervention. Specifically, the equation was formulated as follows:t= β0+ β1×timet+ β2×interventiont+ β3×time postinterventiont+ εt,Ut is the mean number of app or website users on day t; time is the day from the Pneumo Rischio launch; intervention is a binary variable indicating time t before (0) or after (1) the start of the intervention; postintervention is the number of days after the start of the intervention on day t, expressed as 0 before the intervention and (time-detected change point) after the intervention; β0 is the baseline level of users at time 0; β1 is the day-by-day change in the mean number of users before the intervention; β2 is the level change in the mean number of users immediately after the intervention; β3 is the trend change in the day-by-day mean number of users after the intervention in comparison with the preintervention period; and ε is the error term [where Uror term . Since rPneumo Rischio Facebook product page; we collected these anonymous and aggregated data from Facebook Insights. We also investigated how different types of Facebook posts—ie, “Photos” (posts containing photos), “SharedVideo” (posts containing videos), “Notes” (posts with HTML capability and no word limit), and “Links” (posts with links to other sites)—can affect the engagement of visitors with the Pneumo Rischio Facebook page. Posts were also dichotomized by type into personalized  and neutral posts . Since the distribution of people’s engagement with Facebook posts was highly skewed, we applied the nonparametric Mann-Whitney U test and computed the effect size as Cohen rc= z /√ n [Subsequently, we described usage of the = z /√ n .Pneumo Rischio users (app and website users and Facebook fans) in terms of sex, age, and IPD risk categories; that is, low , medium , and high (immunocompromised people of any age) [Pneumo Rischio users were asked  whether they intended to ask their GP for further information on IPD and its prevention. The second proxy measure of project effectiveness was the number of emails with detailed IPD risk profiles sent. This proxy measure is based on the assumption that a user sends a personal health-related record to his or her GP.Next, we characterized any age) . These dThe quality of the app was assessed by means of the Mobile Application Rating Scale (MARS) , the ItaSince the MARS was originally intended to be used by trained professionals, a simplified training-free version of the scale was also created in order to obtain app-user quality ratings . The twoPneumo Rischio project.Subsequently, we assessed the customer-determined quality of the app. For this purpose, we enrolled participants during conferences and courses  and lectures (students in various graduate and postgraduate courses). Enrolled participants were instructed to navigate in all app components and functions for at least 10 minutes, to examine the description/definition of the app quality provided for each subscale, and then to fill in an anonymous paper-and-pencil survey form. Before evaluating the app, participants were not aware of the Participation in this nonbiomedical, noninterventional study was voluntary, and anonymity was guaranteed. Ethical approval for this study was not required, since it focused only on the quality evaluation of an existing service, which is freely available in the public domain, with no potential risks for participants. We collected no personal or sensitive data.t test, and calculated the Pearson r correlation coefficient between the score and the age of raters. The effect size for the t test was quantified by means of Cohen d. Finally, we constructed multivariable linear models (chosen by minimizing the corrected Akaike information criterion) with heteroskedasticity consistent standard errors to predict the MARS total and subscale scores.We express approximately normally distributed summary scores as means with standard deviations, and we summarized single Likert scale items as medians with interquartile ranges (IQRs). Average MARS summary scores exceeding 3.0 points (60%) were regarded as satisfactory . We compAll statistical analyses and modeling procedures were performed in R environment .On February 25, 2016, exactly 1 year after being launched, the app had been downloaded 9295 times and 10,090 sessions were run (1.09 sessions/user). On average, a session lasted 04:01 minutes. The website had been visited by 143,993 users, who ran 150,790 sessions (1.05 sessions/user), with a mean number of 2.13 pages per session. Website sessions lasted approximately four times less (01:02 minutes) than an average app session.z=3.33, P<.001) and website  users. Change-point detection analysis revealed 5 significant changes in the daily time series of both app and website use. The first point corresponded to the start of the intervention (fourth week of September 2015). Analogously, segmented regression analysis confirmed the effectiveness of the intervention (P<.001) immediately after the start of the intervention: we estimated an increase in daily numbers users of 1562% (95% CI 456%-4870%) for the app and 620% (95% CI 176%-1777%) for the website. Moreover, the postintervention day-by-day trend in the number of users was also positive and statistically significant for the website, with a 1.4% (95% CI 0.7%-2.1%) increase, but not for the app, with only a 0.9% (95% CI 0.0%-1.8%) increase.The modified Mann-Kendall trend test showed a statistically significant increasing trend in both app  and website users . Since the start of the intervention, 30 posts had been published; most of these were of the Notes (n=16) and Photos (n=12) types, while there was only 1 SharedVideo and 1 Link. We excluded the SharedVideo and Link types of posts from the analysis, owing to their singularity. We categorized 9 posts as personalized, and the remaining 19 as neutral. Photo posts engaged a significantly (P<.001) higher median number of users than Notes (1075 vs 376), and the effect size was large (rc=0.74). By contrast, the higher number of users with personalized (median 631) rather than neutral (median 540) posts was not statistically significant (P=.76).On February 25, 2016, the Demographic profiles differed between app users, website visitors, and Facebook fans . In termPneumo Rischio Facebook fans were older than Pneumo Rischio users, the most representative age class being 45-54 years, followed by the 55-64 and 35-44 age classes. It is encouraging that approximately 12% (145/1216) of the Facebook fans were aged ≥65 years.Conversely, a higher number of men visited the website. The most numerous age class of both app and website users was that of adults aged 25-34 years. Approximately 70%  of users may be defined as being at risk of IPD. The distribution of risk categories was similar between app and website users . A totalA total of 171 participants filled in the MARS user version. The mean age of participants was 34.3 (SD 12.7) years; females were more numerous . A total of 117 (68.4%) respondents were health care professionals. The mean MARS total score was 3.97 (SD 0.45), corresponding to 79.5%.The mean scores on all MARS subscales exceeded the prespecified threshold of 60%, ranging from 62.8% for the subjective quality subscale to 84.4% for the functionality subscale. With regard to single items, most (15/20) had median scores of 4.0 points, while the median scores were 3.0 points for 4 items and 5.0 points for 1 item .t169=0.67, P=.50) between-sex difference emerged in the MARS total scores . There was a weak positive  correlation between the score and the age of participants. Non-health care professionals scored significantly  higher than health care professionals , and the effect size was large . P<.001) predictor of the MARS total score: on average, health care professionals attributed 0.78 (15.6%) fewer points than those outside the health care sector. Moreover, there was a significant (P=.01) interaction between age and profession: with increasing age, health care workers awarded higher scores, while no age-related pattern emerged among non-health care professionals. The model explained 15.5% of variance; its residuals were normally distributed (Shapiro-Wilk test: P=.94) but heteroskedastic (Breusch-Pagan test: P=.02), justifying the use of robust standard errors. The 5 subscale-specific models , dai success  to be inPneumo Rischio was clearly divided into two stages, a fact undoubtedly attributable to the promotional campaign. Thus, promotional activities were essential to disseminate information on the project. Indeed, without this intervention, the daily number of Pneumo Rischio app users would probably not have changed, or may even have decreased, while implementation of the marketing strategy increased app downloads exponentially. Moreover, the creation of a sister website and social media activity may be valuable ways of increasing population exposure.We noted that the 1-year life cycle of Our promotional campaign may be regarded as a natural experiment with an interrupted time series design. This quasi-experimental approach is very robust in quantifying the longitudinal effects of an intervention . The resPneumo Rischio website had 15.5 times more visitors than the number of app downloads, an average session was much shorter. This finding supports the results obtained by Hearn et al [We observed that the usage parameters of the app and website differed substantially. Indeed, while the rn et al , who sugrn et al . A higheThe Photo type of Facebook posts had a significantly higher number of engaged users. This confirms previous findings that these types of posts enhance user interaction and user engagement, and may be seen as a useful metric for social media marketing . By contPneumo Rischio was cited and criticized by an antivaccination Facebook group, “Autism and Vaccines,” which as of September 2016 had more than 8600 fans. Specifically, their post questioned “the eulogized scientific method” and urged people “not to fall into the trap of confusing pneumococcus with meningococcus”—presumably a reference to the causative agent of meningitis. This post is typical of the antivaccination movement; skewing science is a frequent claim of antivaccine activists in the era of Web 2.0 [tranello), which has a clear negative connotation. Although this post had no negative impact on the image of Pneumo Rischio or its daily downloads (no negative reviews or decrease in the number of users were registered around that week), this type of risk is difficult to detect and manage.It should, however, be borne in mind that, although social networking helped to promote the app, it may also engender some risks. For instance, about 2 months after its launch,  Web 2.0 . MoreovePneumo Rischio users were not fully representative of Italian adult Web users [As expected, in terms of age and sex, eb users . Indeed,A noteworthy result regards the distribution of IPD risk categories: about two-thirds of users could be defined as being at risk of IPD. While, to the best of our knowledge, there are no Italian data on IPD risk distribution, a large German study  found a The observed patterns of the distributions of app users in terms of sex, age, and IPD risk categories are consistent with the results from an Italian survey on eHealth use . Indeed,Pneumo Rischio website with those of VaccinarSì [VaccinarSì project have recently been published [Pneumo Rischio and VaccinarSì websites had a similar share of male and female users, a pattern that reflects the national use of the Internet by both sexes, in which males are slightly prevalent. This phenomenon, which still persists even in developed societies, is known as the digital gender divide [Pneumo Rischio were older than those of VaccinarSì. Another similarity between the two websites regards the mean duration of sessions and the number of pages viewed [While users of the app, website, and Facebook page were not fully representative of Italian Internet users in terms of age and sex, it is largely unknown who downloads vaccination- or disease-specific apps and surfs the Web for immunization-related purposes. To better understand issues concerning the representativeness of our data, it is worth comparing usage patterns of the ccinarSì , which iublished . The Pner divide . Age-clas viewed .Pneumo Rischio users declared their intention to request further information on IPD from their physician, and about 2000 sent an email (probably to their GPs) with their detailed IPD risk profile. In the modern digital age, doctor–patient relationships change continuously and become more participatory when a better-informed patient is more closely involved in the decision-making process [It is encouraging that about 5000  process . In a la process . The rolTo date (as of September 2016), to the best of our knowledge, our investigation is the largest study to have used the MARS in the community setting. Users rated the app as highly functional; that is, highly performing, easy to use and to navigate, and informative . These 2 MARS subscales exceeded 80%. Indeed, throughout the process of app development , the appPneumo Rischio would therefore be useful to many GPs, too.Health care professionals attributed lower MARS scores to all subscales and app-specific items. The adjusted regression models to predict both MARS total and subscale scores confirmed this finding. It is, therefore, plausible that health care professionals have higher expectations of a health-related app. These lower scores are not surprising, since the app target was the general adult population . HoweverPneumo Rischio effectiveness would be the proportion of users who really asked their GP for information on IPD and its prevention, or even were vaccinated against pneumococcus after (and because of) using the project. However, obtaining such data is computationally, economically, and ethically challenging. Second, despite the fact that the professional and user versions of MARS are very similar, only the professional Italian version of MARS has been validated. Considering that the two original English versions of MARS differ only slightly , we supposed that the psychometric properties of the professional Italian version of MARS [In interpreting our results we noted three main limitations. First, we were compelled to use proxy measures of project effectiveness, namely intentions to ask GPs for further information on IPD and number of emails with detailed IPD risk profiles sent. In our opinion, these two indicators approximated project effectiveness better than the number of app downloads, website visits, or Facebook fans. An optimal indicator of  of MARS  would bePneumo Rischio may be deemed a successful project, as it attracted more than 150,000 users in a 1-year period. Moreover, it was also professionally recognized in an eHealth contest. We therefore hope that our project will contribute to the fight against invasive bacterial diseases.Despite its highly specific topic and somewhat niche nature, However, in order to reach their potential end users, such projects should be popularized. Indeed, the process of development of a health-related app should be continuous, and not end with the public release of the app. In our opinion, there is a need to develop a multidimensional framework for assessing health-related apps; this should at least include (1) an evidence base, (2) objective and subjective quality, (3) usefulness, (4) usage indicators, and, if applicable, (5) an outcome assessment.


To evaluate the incidence of postoperative infection and fracture nonunion as well as the risk factors for postoperative infection in human immunodeficiency virus (HIV) positive patients.From May 2013 to March 2016, the HIV positive fracture patients treated surgically in orthopaedics department of our hospital were analyzed retrospectively, and fifty HIV negative fracture patients during the same period were selected as control. The clinical data of included patients were reviewed. The incidence of postoperative infection and fracture nonunion were compared between the two groups, and the risk factors for postoperative infection in HIV positive patients were evaluated.The incidence of poor wound healing and incision infection in HIV positive group was higher than that in HIV negative group, but there were no significant differences between the two groups (p>0.05). Multivariable regression analysis demonstrated that HIV clinical category (p<0.05), CD4+T-lymphocyte category (p<0.01) and open fracture (p<0.05) were independent risk factors for postoperative wound infections, but age, gender, operation time, incision type, emergency operation, albumin and lymphocyte count were not (p>0.05). There was no significant difference in the rate of nonunion between the two groups (p>0.05).The incision can be healed, and fracture can be united normally in most of HIV positive patients with fracture, and postoperative wound infections were significantly associated with HIV clinical category, CD4+T-lymphocyte category and open fracture. Acquired immune deficiency syndrome (AIDS), arising from human immunodeficiency virus (HIV) infection, is one of the largest pandemics of the modern age.1Many clinical studies have been published to report the clinical outcomes of orthopaedic surgeries in HIV-positive patients. Some authors suggest that HIV-positive patients have higher rates of wound infection and nonunion than HIV negative patients after internal fixation.Moreover, in terms of the risk factors correlated with postoperative infection in HIV positive patients, Abalo suggested that they were associated with HIV clinical category B, CD4+ T-lymphocyte category of ≥2, and contaminated wounds.Therefore, we retrospectively reviewed the HIV positive patients with fractures treated surgically in our hospital from May 2013 to March 2016. The purpose of our study was to evaluate: (1) the incidence of postoperative infection and fracture nonunion, and (2) the risk factors for postoperative infection in HIV positive patients, to help surgeons make better treatment strategies for these patients.From May 2013 to March 2016, sixty-nine fracture patients with HIV positivity who had been treated surgically in orthopaedics department of our hospital were analyzed retrospectively. The clinical data including age, gender, date of admission, operation time, albumin, hemoglobin, lymphocyte count, operation time, incision type, CD4+T-lymphocyte count, HIV clinical category, postoperative comorbidities, emergency operation or not, wound class, fracture type, surgery type, surgical wound infections, follow-up and outcomes were reviewed.The inclusion criteria were: 1) patients with proven HIV positive who underwent operation for fracture internal fixation; (2) integrated clinical records; (3) at least 15 months of follow-up. The HIV status of patients was confirmed by enzyme-linked immunosorbant assay for HIV antibody and by western blot. patientsAt the same time, fifty HIV negative patients with fracture during the same period were selected as control, whose age, gender, fracture site, surgery type are similar as those in HIV positive group. The study was approved by the institutional review board of our hospital. All patients provided informed written consents at the beginning of the study.To evaluate the immune system status of HIV positive patients, CD4+ T cell count was measured and classified into three levels, < 200/μL, 200-499/μL, and ≥ 500/μL. A CD4+ T cell count of < 200/uL indicates a high risk of opportunistic infection.6P value < 0.05 was regarded as statistical significance.The statistical analysis was carried out using SPSS 21.0 . The continuous variables were presented as mean ± SD and compared by Analysis of variance. The categorical variables were compared by chi-squared test. Multivariate regression analysis was used to identify independent risk factors associated with postoperative infection. A In this study, fifteen patients were excluded because of failing to meet the inclusion criteria, and finally fifty-four patients were included in HIV positive group. Of the 54 patients, 42 (77.8%) were males and 12 (22.2%) were females, and the mean age was 39.6 years, ranging from 23 to 72 years. In the control group of 50 HIV negative patients, 36 (72%) were males and 14 (28%) were females, and the mean age was 41.5 years, ranging from 20 to 69 years. All the patients were treated surgically with internal fixation. The baseline characteristics of two groups are shown in In 54 HIV positive patients, incision had healed normally in forty-one cases, and poor healing was found in 13 patients, including incision redness and swelling in four cases, wound discharge in two cases, fat liquefaction in one case, wound dehiscence in two cases and incision infection in four cases, the incidence of poor incision healing and infection was 24.1% and 7.4% respectively. In HIV negative group, incision was healed normally in 42 cases and poor healing was found in 8 cases, including incision redness and swelling in two cases, wound discharge in two cases, incision hematoma in one case, wound dehiscence in one case and incision infection in two cases, the incidence of poor incision healing and infection was 16% and 4% respectively. The incidence of poor healing and incision infection in HIV positive group was higher than that in HIV negative group, but there were no significant differences between two groups (p>0.05). All the infections resolved after debridement, dressing change and antibiotic treatment, and no infections developed chronic osteomyelitis.The 54 HIV positive patients were divided into normal and poor incision healing subgroups. The comparison of age, albumin, hemoglobin, lymphocyte count, operation time, incision type, CD4+T-lymphocyte category, HIV clinical category, open fracture and emergency operation between two subgroups is listed in Postoperatively, in HIV positive group, three fractures including one tibia and two humerus fractures failed to unite, which underwent revision surgery resulting in a final union. The nonunion rate in HIV positive group was 5.6%. In the control group, one humerus fracture failed to unite, the rate of nonunion was 2%. There was no significant difference in the rate of nonunion between the two groups (p>0.05).In this study, we focused on the evaluation of the incidence of postoperative infection and fracture nonunion as well as the risk factors for postoperative infection in fracture patients with HIV positivity, to clarify the controversial viewpoints, help surgeons better understand the issues.We found the incidence of incision infection in HIV positive group was higher, but there was no significant difference between the two groups, demonstrating that HIV positivity does not significantly increase the incidence of postoperative infection. The result is consistent with Li’ study.In addition, we found that in the HIV positive group the value of albumin, hemoglobin, lymphocyte count in patients with poor incision healing was lower than those with normal incision healing, indicating that nutrition support plays an important role in the normal healing of patients.  Many stuSome scholars studied the risk factors related to postoperative wound infection in HIV positive patients13In terms of fracture union, some studies suggested that HIV infection and its treatment have been linked with an altered bone mineral density and cytokine environment as well as increased avascular necrosis, which results in increased risks of fracture nonunion.First, the current study was a retrospective instead of a prospective one, although a randomized controlled trial is difficult to carry out in this regard, a prospective study may be better in explaining the current issues. Second, the sample size of this study was small, and some significant results can’t be achieved, which may affect the readers to understand correctly some controversial viewpoints in this field. While, despite limitations, we can conclude from this study that the incisions can be healed, and fracture can be united normally in most of HIV positive patients with fracture, and postoperative wound infections were significantly associated with HIV clinical category, CD4+T-lymphocyte category and open fracture.GYX, JZ conceived, designed & editing of manuscript. JS did statistical analysis.GYX, YZL, JZ did data collection, manuscript writing and performed review and final approval of manuscript.


Sirtuins are a class of histone deacetylases (HDACs) that have been shown to regulate a range of pathophysiological processes such as cellular aging, inflammation, metabolism, and cell proliferation. There are seven mammalian Sirtuins (SIRT1-7) that play important roles in stress response, aging, and neurodegenerative diseases. However, the location and function of Sirtuins in neurons are not well defined. This study assessed the retinal expression of Sirtuins in mice, rats, and humans and measured the expression of Sirtuins in aged and injured retinas. Expression of all 7 Sirtuins was confirmed by Western blot and Real-Time PCR analysis in all three species. SIRT1 is highly expressed in mouse, rat, and human retinas, whereas SIRT2-7 expression was relatively lower in human retinas. Immunofluorescence was also used to examine the expression and localization of Sirtuins in rat retinal neurons. Importantly, we demonstrate a marked reduction of SIRT1 expression in aged retinal neurons as well as retinas injured by acute ischemia-reperfusion. On the other hand, none of the other Sirtuins exhibit any significant age-related changes in expression except for SIRT5, which was significantly higher in the retinas of adults compared to both young and aged rats. Our work presents the first composite analysis of Sirtuins in the retinal neurons of mice, rats, and humans, and suggests that increasing the expression and activity of SIRT1 may be beneficial for the treatment of glaucoma and other age-related eye dysfunction. The Sirtuins (SIRT) are an NAD+ dependent class III HDACs that share extensive homology with the yeast HDAC Silent Information Regulator 2 (Sir2) . SIRT/SiThe Sirtuins are involved in cell and tissue metabolism, making the study of Sirtuin expression in the retina important given that the retina is one of highest energy-consuming tissues in the body . SIRT1 hSirtuins are expressed throughout the brain , ears, muscle, liver, kidney, vasculature, skin, lungs, and other locations in the body . SIRT1 iC57BL/6 male mice, 6–8 weeks of age; and Sprague-Dawley (SD) male rats, 2–3 months of age were obtained from Center of Laboratory Animal Science of Nanchang University. For aging study, the rats were used in the following age groups: young (2 months of age), adult (12 months of age), and old (20 months of age), which are roughly equivalent to human aged 20, 40, and 80 year old, respectively . All proSix pairs of adult donor eyes (age range 30–50 years) were obtained from Red Cross Society of China Jiangxi Branch. All experiments involving human samples were approved by the Ethics Committee of Affiliated Eye Hospital of Nanchang University. All volunteer signed informed consent documents in written form in accordance with the principles of the Declaration of Helsinki. To obtain fresh eye tissues for RNA/protein and staining, we restricted the globes in the present study to those received less than 48 h postmortem. The previous medical and ocular histories of all donors were assessed to exclude donors with any eye disease. The retinas were processed as described below.Sprague-Dawley rats, 2–3 months of age were used. Under anesthesia , transient, unilateral, retinal ischemia was produced in rat eyes. Briefly, the anterior chambers of both eyes were cannulated and the IOP in one eye was elevated above systolic blood pressure (∼110 mm Hg) for 60 min and the contralateral eye was cannulated and maintained at normal IOP . Rats weTable 1) were synthesized by TINGEN Biotech, Beijing, China. Real-time PCR was performed using the RealMasterMix (SYBR Green) kit  with the following conditions: denature, 95°C, 20 s; annealing, 58°C, 20 s; and extension, 68°C, 30 s. All samples were tested in triplicate PCR reactions and the mean of the reactions was used for calculating the expression levels. All the data were collected from the linear range of each amplification. Expression levels were normalized to the average of tubulin mRNA levels from the same samples.Total RNA was extracted from each mouse, rat, and human retina using TRIZOL (Invitrogen) according to the manufacturer’s instructions. The concentration of isolated RNA was quantitated spectrophotometrically. Two hundred nanograms of total RNA from each sample was reverse transcribed into cDNA using the Quantscript RT Kit . Specific primers for each gene (Table 2) followed by incubation with peroxidase-conjugated secondary antibodies . Finally, proteins on membranes were detected with enhanced chemiluminescence western blotting detection reagents (EMD Millipore).Retinal tissues were dissected from the retinal pigment epithelium and choroids and lysed in the RIPA buffer containing PMSF . The lysates were centrifuged, and supernatants were collected and subjected to western blot analysis. Protein concentrations were measured using the Bradford assay (Beyotime Institute of Biotechnology) according to the manufacturer’s instructions. Sample proteins (30 μg) were separated by 7.5–15% SDS-polyacrylamide gels and transferred to nitrocellulose membranes. The blots were blocked in 5% non-fat dry milk in Tris-buffered saline/Tween-20 and incubated with the appropriate primary antibodies  at a sub-boiling temperature for 10 min followed by cooling 30 min. Then the tissue sections were incubated with specific primary antibodies (Table 2) diluted in 5% bovine serum albumin (BSA) in PBS for overnight at 4°C. The sections incubated with PBS without primary antibody were used as negative controls. After several wash steps, the tissue sections were incubated with the secondary antibody, Alexa Fluor 594 donkey anti-rabbit IgG (H+L) for 1 h at room temperature. The sections were counterstained with DAPI  and coverslipped. The staining was repeated three or more times for each antibody and the results were consistent.For immunohistochemical analysis, the animals were deeply anesthetized with chloral hydrate and then perfusion fixed through the left cardiac ventricle with ice-cold 4% paraformaldehyde (PFA) in 0.1 M phosphate saline buffer . After perfusion, eyes were enucleated and the anterior segments were removed. The posterior segments were fixed by immersion in 4% paraformaldehyde in 0.1 M phosphate buffer saline for 2 h. After washing in PBS, the tissues were transferred to 70% ethanol overnight, then dehydrated and embedded in paraffin. The 5-μm-thick paraffin tissue sections were dewaxed and then rehydrated. Endogenous peroxidase activity was blocked by placing the sections in 3% Ht-test or Chi square test as appropriate. P < 0.05 was considered significant.All quantified data represented an average of at least three samples. SPSS 16.0 and Graph Pad Prism 5.0 software (Image J) were used for statistical analysis. All data are expressed as mean ± SD. Significance was established by paired Figure 1). The Sirtuins’ mRNA levels were different in each species. The mRNA level of SIRT1 was the highest in rat and human retinas, while SIRT2 was the highest in mouse retina. The mRNA level of SIRT7 was the lowest in rat and human retinas. SIRT3 mRNA was lowest in mouse retina. The mRNA levels of SIRT5, SIRT7, SIRT4, SIRT1, and SIRT6 were found in descending order in the mouse retina. Our results show that SIRT2, SIRT5, and SIRT7 were expressed primarily in mouse retina. Differences in the mRNA levels of SIRT2, SIRT3, and SIRT5 were not obvious in rat retina, while SIRT1, SIRT4, and SIRT6 were expressed at higher levels. The mRNA level of SIRT2 was almost as low as SIRT7 in human retina, while the mRNA levels of SIRT3, SIRT6, SIRT5, and SIRT4 descended in that order. We also discovered that SIRT1, SIRT3, and SIRT6 were primarily expressed in mouse retina . Importantly, we confirmed that all seven Sirtuins were expressed in the retinas of all three species, and the high level of Sirtuin mRNA expression in the retina is consistent with the retina being one of the highest energy-consuming tissues in the body . Sirt3 protein was detected in mouse retina, and was observed at a low level in rat retina . Expression of Sirt4 and Sirt5 in human retina was not obvious whereas their expression was more visible in mouse retina than in rat . Sirt6 and Sirt7 were expressed in mouse, rat, and human retina, and were lowest in human retina . Our results demonstrate that the protein levels of the Sirtuins in mouse retinas descend in the following order: SIRT3, SIRT1, SIRT5, SIRT4, SIRT7, SIRT2, and SIRT6 . The protein levels of the Sirtuins in rat retinas descend in the following order: SIRT4, SIRT1, SIRT2, SIRT5, SIRT7, SIRT6, and SIRT3. Finally, the protein levels of the Sirtuins in human retinas descend in the following order: SIRT3, SIRT4, SIRT1, SIRT2, SIRT7, SIRT5, and SIRT6 . Remarkably, we found the protein levels of the Sirtuins, including that of SIRT1 and SIRT3, but especially SIRT5 and SIRT6, in human retina did not correspond to their respective mRNA levels .The protein expression levels of Sirt1 and Sirt2 were highest in the retina of rats, while their levels were lowest in human retina . SIRT1 expressed in the GCL layer, inner nuclear layer, outer nuclear layer and retinal pigment epithelium. SIRT2 mainly expressed in the GCL layer, outer plexiform layer and retinal pigment epithelium. Meanwhile, SIRT3 mainly expressed in the inner plexiform layer, outer plexiform layer and retinal pigment epithelium, but was less expressed in the GCL layer. SIRT4 mainly expressed in the GCL layer and inner nuclear layer in the form of threadiness. SIRT5, SIRT6 and SIRT7 mainly expressed in the GCL layer, inner plexiform layer and retinal pigment epithelium. From the overall analysis, all Sirtuins except SIRT3 were expressed in the GCL layer, while all Sirtuins except Sirt4 were expressed in the retinal pigment epithelium.Since all Sirtuins were expressed in rat retina, we selected normal adult rat retina for immunofluorescence detection. We observed that SIRT1, SIRT 6, SIRT7 were localized in the nucleus, SIRT2 was predominantly in the cytoplasm, SIRT3, SIRT4, SIRT5 were localized in the mitochondria . SIRT1 protein levels also decreased in the retinas following acute retinal ischemic injury . On the other hand, SIRT3-5  were all expressed at the highest level in adults but were not significantly lower in old rats , while the expression levels of SIRT2, SIRT6, and SIRT7 did not significantly change with age .Prior studies have suggested that SIRT1 is involved in retinal neuron degeneration during aging  and retiTo date, the significance of Sirtuin expression in the retina is unknown. To establish a basis for studying the pleiotropic functions of the Sirtuins in the retina, we analyzed the expression pattern and location of the Sirtuins (SIRT1-7) in the aging retinas of different species at the mRNA and protein level. Our results demonstrated that all members of the Sirtuin family are detected in the retinal neurons of mouse, rat, and human, which is in agreement with previous observations that, in the mice retina, certain cells express SIRT1 . MoreoveIn the present study, we demonstrated that certain Sirtuins are abundantly expressed in the retinas of mouse, rat, and human, and there are some similarities in the expression patterns of Sirtuins among different species. However, there is also considerable variability in the localization and distribution between Sirtuin family members. We found that the mRNA and protein content of SIRT1, which is the earliest discovered and most studied member of the Sirtuin family, is abundant in mouse, rat and human retinas. In previous studies, SIRT1  and SIRTInterestingly, SIRT3 protein was not only detected in mouse, rat, and human retinas, but was highly expressed in human retinas with different antibodies. Overexpression of SIRT3 increases mitochondrial respiration and reduces reactive oxygen species (ROS) production, which may explain its high expression in human retina in order to protect the organ from oxidative stress-induced injury . NotableIn the retinas of mice, rats, and humans, SIRT1 can be observed in the GCL, INL, ONL and RPE, whereas other studies have reported that SIRT1 is only expressed in the GCL, INL, and RPE of rat retinas  or in thWe found that SIRT3 is mainly in the GCL, IPL, OPL, and RPE of rat retinas. Previous reports have demonstrated that SIRT3 is present in the mitochondrial matrix and can regulate mitochondrial function . FurtherS-nitrosocysteine, and therefore PTMs could also be responsible for the two SIRT1 bands seen in young adults. It is interesting to speculate why the lower SIRT1 band is only present in young rat retinas, which also have the highest overall SIRT1 protein levels, as it may represent a more active form of SIRT1 that provides additional protection to the developing retinal neurons.Previous studies have shown that SIRT1 plays a crucial role in age-related retinal degeneration . Its actInterestingly, although SIRT1 decreased with age while SIRT2, SIRT6, and SIRT7 did not change significantly during aging in the rat retina, the mitochondrial Sirtuins  were expressed maximally in adult retinas. This might be due to an increased demand for the antioxidant activities of the mitochondrial Sirtuins during adulthood in the retina, perhaps because of an enhanced reliance on mitochondrial oxidative phosphorylation at this life stage. The subsequent drop in expression of the mitochondrial Sirtuins in old rat retinas could also be partly responsible for age-related retinal dysfunction, and future studies should look to increase their expression in old rat retinas along with SIRT1 to determine which will have the most beneficial effects for delaying retinal neuronal functional decline.To date, calorie restriction (CR) is the most well-known and accepted effective means to extend the lifespan without genetic or pharmacological intervention. The expression of all Sirtuins except SIRT4 increase as an effect of CR . SIRT6 hOur study has provided foundational knowledge about Sirtuins in the retinal neurons of humans, mice, and rats, which will be helpful for future investigations on retinal metabolism and Sirtuin regulation. The present study also provides information on specific Sirtuin family members that may be targeted pharmacologically to combat diseases of retinal neurons. Future studies on Sirtuins should examine their precise protective roles in retinal neurodegeneration and the mechanisms by which they mediate such protection to inform development of treatments for age-related retinal decline.The study was conceived and designed by XZ and HL. Data collection and analyses were conducted by HL, MZ, KJ, JZ, WD, SF, TS, and XZ. The paper was written and revised by HL and XZ.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 reviewer SK and handling Editor declared their shared affiliation.


The detailed investigations of many such enzymes from pathogenic and non-pathogenic bacteria afford the opportunity to design both novel therapeutic agents, as well as biomimetic processes, for example, for CO2 capture. Investigation of bacterial CA inhibitors and activators may be relevant for finding antibiotics with a new mechanism of action.Bacteria encode carbonic anhydrases  belonging to three different genetic families, the α-, β-, and γ-classes. By equilibrating CO The actsertions  .β-CAs, such as those from Escherichia coli, Haemophilus influenzae, Mycobacterium tuberculosis, Salmonella enterica, and Vibrio cholerae [Vibrio cholerae (VchCAβ) was determined in its closed active site form at pH values <8.3  from d so far  46]. Th. ThMethad so far  [46]. Ind so far . In factd so far  [46].2 hydration reaction in the absence of the catalyst has an effective first-order rate constant of 0.15 s−1, while the reverse reaction shows a rate constant of 50 s−1 [2 hydration and the HCO3− dehydration are connected to very fast processes, such as those related to transport/secretory processes. The main metabolic role of CAs is to catalyze the carbon dioxide hydration at a very high rate, with a pseudo first order kinetic constant (kcat) ranging from 104 to 106 s−1 [cat = 1.40 × 106 s−1), belonging to the α-class and abundantly present in the human erythrocytes [2 into carbonic acid, while when the blood reaches the lungs, dehydrates the HCO3− to CO2 for it exhalation. In 2012, a new α-CA was identified, and was shown to be a highly and catalytically effective catalyst for the CO2 hydration reaction  exist ,48 and t1–24 and AAZ-HCT are either simple aromatic/heterocyclic sulfonamides widely used as building blocks for obtaining new families of such pharmacological agents, or they are clinically used agents, among which acetazolamide (AAZ), methazolamide (MZA), ethoxzolamide (EZA), and dichlorophenamide (DCP) are the classical, systemically acting antiglaucoma CAIs. Dorzolamide (DZA) and brinzolamide (BRZ) are topically acting antiglaucoma agents; benzolamide (BZA) is an orphan drug belonging to this class of pharmacological agents. Moreover, the zonisamide (ZNS), sulthiame (SLT), and the sulfamic acid ester topiramate (TPM) are widely used antiepileptic drugs. Sulpiride (SLP) and indisulam (IND) were also shown by our group to belong to this class of pharmacological agents, together with the COX2 selective inhibitors celecoxib (CLX) and valdecoxib (VLX). Saccharin (SAC) and the diuretic hydrochlorothiazide (HCT) are also known to act as CAIs. Sulfonamides, such as the clinically used derivatives acetazolamide, methazolamide, ethoxzolamide, dichlorophenamide, dorzolamide, and brinzolamide, bind in a tetrahedral geometry to the Zn(II) ion in the deprotonated state, with the nitrogen atom of the sulfonamide moiety coordinated to Zn(II) and an extended network of hydrogen bonds, involving amino acid residues of the enzyme, also participating in the anchoring of the inhibitor molecule to the metal ion [Derivatives etal ion ,47,48,67etal ion ,47,51,52Anions, such as inorganic metal-complexing anions or more complicated species such as carboxylates, are also known to bind to CAs ,48. ThesFrancisella tularensis, Burkholderia pseudomallei, Vibrio cholerae, Streptococcus mutans, Porphyromonas gingivalis, Legionella pneumophila, Clostridium perfringens, and Mycobacterium turberculosis, etc. [In the last ten years, numerous results concerning the inhibition profile of the three bacterial CA classes  have been reported using anions and sulfonamides. Most of these studies were carried out on bacterial CAs from pathogenic bacteria, such as is, etc. ,68,69,70is, etc. ,72,73,74is, etc. . The inhis, etc. ,62,76. Gis, etc. ,25,76,772 to the CA active site but mediate the rate-determining step of the catalysis hurrying the transfer of protons from the active site to the environment. The final result is an overall increase of the catalytic turnover. Thus, the CA activators enhance the kcat of the enzyme, with no effect on KM [25–43  has also been explored [cat by one order of magnitude compared to those without activators.An interesting feature of the CA superfamily is that they can bind within the middle-exit part of the active site molecules known as “activators” (CAA). They are biogenic amines , amino acids, oligopeptides, or small proteins  identified in their genome. Prokaryotes appeared on the Earth 3.5–3.8 billion years ago, while eukaryotes were dated to 1.8 billion years ago . During α-CAs known to date is the presence of an N-terminal signal peptide, which suggests a periplasmic or extracellular location , VchCA (from Vibrio cholerae), NgonCA (from Neisseria gonorrhoeae), and SsalCA , present a pre-sequence of 18 or more amino acid residues at the N-terminal part, which resulted in a secretory signal peptide [α-CAs [A common feature of all bacterial location . From thorganism ,77. In functions ,77. Not SignalP/ . We note peptide ,77. Intre [α-CAs ,77. Ralstonia eutropha (Gram-negative bacterium found in soil and water) and Escherichia coli (a facultative Gram-negative bacterium), it has been demonstrated in vivo that the bacterial growth at an ambient CO2 concentration is dependent on CA activity [2 and bicarbonate are both produced and consumed by bacterial metabolism. Since CO2 is rapidly lost from the bacterial cells by passive diffusion, their rate is maintained individually in balance by the CA activity. In fact, the reversible spontaneous CO2 hydratase reaction is insufficient to restore the amount of dissolved inorganic carbon. More interesting is the in vivo evidence concerning the involvement of CAs for the growth of pathogenic bacteria. For example, CAs encoded by the genome of Helicobacter pylori, a Gram-negative, microaerophilic bacterium colonizing the human stomach, are essential for the acid acclimatization of the pathogen within the stomach and thus, for bacterial survival in the host [Vibrio cholera (Gram-negative bacterium responsible of cholera), its CAs are involved in the production of sodium bicarbonate, which induces cholera toxin expression [V. cholera uses the CAs as a system to colonize the host [Brucella suis, a non-motile Gram-negative coccobacillus, and the Mycobacterium tuberculosis, an obligate pathogenic bacterium responsible for tuberculosis, are needed for the growth of functional CAs [In the past ten years, the understanding of the function of the bacterial CAs has increased significantly ,77. We sactivity ,94. In fthe host ,16,95,96pression ,99,100. the host ,14,101. onal CAs ,103,104.Escherichia coli cultures, in order to produce a usable biocatalyst for CO2 capture, has been described [3O4 nanoparticles (MNP) by using the carbodiimide activation reaction [3O4 [Escherichia coli for lowering the costs of the purification of the biocatalyst and immobilization has been proposed [Escherichia coli cells have been engineered using the well-described INP (Ice Nucleation Protein) technique [Pseudomonas syringae INP domain (INPN), and the SspCA gene encoding for the thermostable α-CA, SspCA, has been prepared. During protein overexpression, the signal peptide makes possible the translocation of the neo-synthetized protein through the cytoplasmic membrane, while the INPN domain is necessary for guiding and anchoring the protein to the bacterial outer membrane. The results demonstrated that the anchored SspCA was efficiently overexpressed and active on the bacterial surface of E. coli [3O4 nanoparticles (MNP) clearly has important advantages. It is a one-step procedure for overexpressing and immobilizing the enzyme simultaneously on the outer membrane, and it drastically reduces the costs needed for enzyme purification, enzyme immobilization, and the support necessary for biocatalyst immobilization [E. coli could be considered as a good method for approaching the biomimetic capture of CO2 and other biotechnological applications in which a highly effective, thermostable catalyst is needed.Recently, the heterologous expression of the recombinant thermostable SspCA by the high-density fermentation of escribed . The enzreaction . This apion [3O4 . The maiproposed . To accoechnique . Briefly E. coli . Moreove E. coli . This aplization . In addiHelicobacter pylori, the alkaline one in the gut for Vibrio cholerae, etc.), CAs probably participate in biosynthetic processes in which bicarbonate or CO2 are substrates, as in the case of other organisms for which these roles are demonstrated. The inhibition and activation of bacterial CAs may be exploited either from pharmacological or environmental viewpoints. On the one hand, the inhibitors of such enzymes may lead to antibiotics with a new mechanism of action, devoid of the drug resistance problems encountered with the various classes of clinically used agents. Moreover, catalytically highly efficient, thermally stable bacterial CAs may have interesting applications for biomimetic CO2 capture in the context of global warming due to the accumulation of this gas in the atmosphere as a consequence of anthropic activities. Furthermore, Ca activators of such enzymes may represent an even more attractive option for mitigating global warming.Bacterial CAs were rather poorly investigated until recently. However, in the last years the cloning, purification, and characterization of many representatives, belonging to all three genetic families present in Bacteria, has led to crucial advances in the field. The role of CAs in many pathogenic as well as non-pathogenic bacteria is thus beginning to be better understood. Apart from pH regulation and adaptation to various niches in which bacteria live (e.g., the highly acidic environment in the stomach, in the case of