Over the last decades the cellular immune inflammation markers neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic immune-inflammation index (SII = NLR × platelets) have emerged in clinical context as markers of disease-related inflammation and are now widely appreciated due to their integrative character. Transferring these clinically established inflammation markers into exercise physiology seems highly beneficial, especially due to the low temporal, financial and infrastructural resources needed for assessment and calculation. Therefore, the aim of this review is to summarize evidence on the value of the integrative inflammation markers NLR, PLR and SII for depiction of exercise-induced inflammation and highlight potential applications in exercise settings. Despite sparse evidence, multiple investigations revealed responsiveness of the markers to acute and chronic exercise, thereby opening promising avenues in the field of exercise physiology. In performance settings, they might help to infer information for exercise programming by reflecting exercise strain and recovery status or periods of overtraining and increased infection risk. In health settings, application involves the depiction of anti-inflammatory effects of chronic exercise in patients exhibiting chronic inflammation. Further research should, therefore, focus on establishing reference values for these integrative markers in athletes at rest, assess the kinetics and reliability in response to different exercise modalities and implement the markers into clinical exercise trials to depict anti-inflammatory effects of chronic exercise in different patient collectives. Acute inflammation is a physiological response of the human body to local tissue damage, aiming at restoring tissue integrity and tissue homeostasis in both physiological context such as exercise Chazaud  and pathwhen and how the next exercise session can be carried out  or interleukin-6 (IL-6) find their way into exercise physiology. These inflammation markers are usually assessed as objective correlates of inflammatory processes to give an insight into the individual inflammatory state, thereby allowing predictions as to When considering blood-derived inflammation markers, it is important to keep in mind that they mostly originate from clinical settings. Inflammatory processes, patient characteristics and (patho) physiology can differ considerably compared to exercise settings, thereby potentially changing the way of interpretation. Nonetheless, inflammation markers are of great benefit in exercise settings since they allow an objective and physiology-based insight into the individual inflammatory state. Beside basic research approaches investigating the physiology behind acute and chronic exercise-induced alterations of immune homeostasis in different populations, further application includes performance and health settings. In performance settings, inflammation markers are frequently used to measure exercise strain and recovery processes, as indicated by altered values in response to acute exercise. Return to baseline of these markers is interpreted as restoration of homeostasis, suggesting completion of the recovery process. Reflecting individual recovery kinetics, inflammation markers are, therefore, assessed to improve exercise programming by adjusting exercise characteristics  to the individual recovery state. However, prior correlation of the respective inflammation markers with performance measures is crucial to ensure validity. Apart of post-exercise deviations, altered baseline concentrations of several biomarkers have additionally been suspected to depict periods of overtraining or increased susceptibility to infection Gleeson . In healvolitional expulsion of CK in metabolically stressed cells to avoid cell death  one of these markers was first applied in exercise context as early as 1965 , but show different post-exercise kinetics. The response of neutrophils is marked by a persistent neutrophilia, while lymphocyte counts decrease within 10–15 min after exercise cessation (lymphocytopenia) (Shek et al. Although total leukocyte count is a useful measure to depict general inflammation, it fails to consider the distinct kinetics of different leukocyte subsets. Tackling this problem, the integrative cellular immune inflammation markers NLR, PLR and SII have emerged in clinical context during the past decades. Considering multiple immune cell populations, they provide a multifactorial insight into inflammatory processes. Although no conclusions can be drawn on the kinetics of lymphocyte subsets such as T- and B-cells, these markers are increasingly implemented as inflammatory and prognostic markers in various clinical conditions such as neoplastic (Howard et al. As a calculated ratio of leukocyte subsets the NLR was first proposed as an inflammatory marker after observing that cancer patients exhibit sustained neutrophilia accompanied by lymphocytopenia Zahorec . Since tA second cellular immune inflammation marker is the PLR. In contrast to NLR, this marker is not only based on leukocyte subsets, but takes platelet counts into consideration. Beside the well-known role of platelets in primary haemostasis, they also exhibit various pro-inflammatory properties, underlining their value as inflammation marker (Zarbock et al. Only recently, Hu et al.  introducTo enable frequent utilization of the integrative markers in clinical context, several authors have determined age- and gender-stratified reference values for NLR, PLR and SII in healthy individuals at rest (see Table To date, evidence regarding the potential value of NLR, PLR and SII as cellular immune inflammation markers for the depiction of exercise-induced inflammation is limited. However, due to the low temporal, financial and infrastructural resources needed for assessment and calculation, application in exercise settings seems highly feasible and easy to implement. Including these markers in both performance- and health-related exercise settings might enable an integrative depiction of exercise-induced inflammation, as reflected by cellular alterations within the bloodstream. In competitive sport these markers might facilitate depiction of exercise strain and recovery processes or help identify periods of increased infection risk or overtraining, thereby improving exercise programming. In health settings, they might indicate anti-inflammatory effects of chronic exercise, especially in patients exhibiting chronic inflammation.physiological training interventions induced a decrease in both healthy (Makras et al. Given these potential applications, the few studies that have investigated NLR, PLR and SII in the context of exercise showed promising results. In response to acute exercise 9 of 11 studies revealed an increase of NLR (see Table Compared to NLR, far less evidence is available on the PLR in the context of exercise. Of the five studies investigating the impact of acute exercise on the PLR, three showed increased values post-exercise, indicating an inflammatory response (see Table For SII even less evidence is available in the context of exercise. However, three of the four studies conducted so far showed an increased SII after acute exercise, thereby indicating a potentially promising role as inflammation marker in exercise settings (see Table Considering blood-derived inflammation markers, caution is warranted what conclusions can be drawn from them, since this can differ depending on their physiological origin. Therefore, it is important to stress that NLR, PLR and SII are inflammation markers based on cellular alterations within the bloodstream. In contrast to muscle-derived damage markers such as CK, they allow no assessment of the occurrence of tissue damage or the associated repair processes. Instead, they should be seen as markers of general inflammation in both performance and health-related exercise settings. However, to enable regular assessment, resting values for athletes and kinetics of different exercise modalities have to be established. While already described by several authors in the general population (Fest et al. After establishing baseline values, alterations of these values could be utilized for exercise programming. Regarding the reliability of these markers, a recent study by Reichel et al.  assessedThis review introduced the clinically established cellular immune inflammation markers NLR, PLR and SII in the context of exercise physiology. In response to acute exercise the presented markers might prove beneficial to depict exercise strain and recovery processes in competitive sport. In chronic exercise interventions, they might additionally depict periods of overtraining and increased infection risk in athletes or indicate amelioration of baseline inflammation in patients with chronic inflammation. So far, comparatively few studies have assessed the cellular immune inflammation markers in the context of exercise. Further research should, therefore, focus on establishing reference values for athletes at rest and investigate the kinetics and reliability of the markers in response to different exercise modalities. Since the inflammatory response can differ considerably depending on the applied exercise stimulus and the investigated population, it is crucial to consider these characteristics when assessing inflammation.


DNA repair and metabolic pathways are vital to maintain cellular homeostasis in normal human cells. Both of these pathways, however, undergo extensive changes during tumorigenesis, including modifications that promote rapid growth, genetic heterogeneity, and survival. While these two areas of research have remained relatively distinct, there is growing evidence that the pathways are interdependent and intrinsically linked. Therapeutic interventions that target metabolism or DNA repair systems have entered clinical practice in recent years, highlighting the potential of targeting these pathways in cancer. Further exploration of the links between metabolic and DNA repair pathways may open new therapeutic avenues in the future. Here, we discuss the dependence of DNA repair processes upon cellular metabolism; including the production of nucleotides required for repair, the necessity of metabolic pathways for the chromatin remodeling required for DNA repair, and the ways in which metabolism itself can induce and prevent DNA damage. We will also discuss the roles of metabolic proteins in DNA repair and, conversely, how DNA repair proteins can impact upon cell metabolism. Finally, we will discuss how further research may open therapeutic avenues in the treatment of cancer. DNA repair and metabolic pathways are vital to maintain cellular homeostasis. Under normal cellular conditions, DNA repair proteins can maintain genomic stability following exposure to exogenous and endogenous genotoxic insults. When growing in normal physiological conditions, cells predominately rely on the TCA cycle to generate ATP and other essential precursors for cellular processes. However, it has been well established that tumor cells are more likely to generate energy via glycolysis and hyperactivate their DNA damage response pathways, both of which promote the uncontrolled proliferative, survival and cellular growth pathways . It was High glucose intake is a characteristic shared amongst most solid tumors, and this phenomenon was first described in 1920 by Otto Warburg . This obIn the early studies of Warburg’s effect, it was thought that cancer cells experience mitochondrial dysfunction via the “irreversible injuring of respiration,” as cancer cells downregulate oxidative phosphorylation during the tricarboxylic acid cycle  . However18F-deoxyglucose-positron emission tomography (FDG-PET) based imaging, where a radioactive fluorine-labeled glucose analog it utilized to diagnose and stage tumor progression  proteins can lead to defects in the HDR of DNA DSBs, sensitizing tumor cells to PARP inhibitors and radiotherapy that induce lesions that require HDR for repair . ConversIn the process of MMR, proteins recognize mismatched bases in DNA which arise from processes such as replication. MMR proteins identify, excise and replace these mismatched bases with the correct pairing base. Mutations in the MMR genes Mlh1 and Msh2 are associated with the human colon cancer-prone syndrome, Lynch Syndrome [also known as hereditary non-polyposis colorectal cancer (HNPCC)], but MMR genes are also frequently mutated in other cancers. Tumors with mutated Mlh1 and Msh2 in colon tumors were historically targeted with methotrexate, which leads to the accumulation of oxidative damage. However, due to the high number of somatic mutations found in MMR-deficient tumors, which can contribute to stimulation of the immune system, immunotherapy is showing potential to become the preferred therapy for tumors with defects in MMR .The nucleotide excision repair pathway recognizes damaged nucleotides including pyrimidine dimers, intrastrand crosslinks, and bulky adducts. Alkylating agents, such as platinum compounds like cisplatin are commonly used to treat many types of cancers and induce intrastrand crosslinks within the DNA, activating the NER pathway. Expression of the NER proteins, including ERCC1 are correlated with sensitivity to platinum agents in multiple tumor types due to an inability to resolve DNA crosslinks .Therefore, although alterations in DNA repair pathways contribute to the development of tumors, and can lead to resistance to tumor therapies, they also hold huge potential as the next generation targets for the treatment of many cancer types. Due to the metabolic reprogramming in tumor cells, it is likely that targeting cellular metabolism may also be advantageous. The current literature supporting a link between metabolic reprogramming and the DNA damage response pathways will be further explored below.de novo synthesis pathways to produce purine and pyrimidine rings to sustain rapid DNA metabolism . The non-oxidative arms of the PPP produce ribose-5-phosphatase, which is then further metabolized for the production of nucleotides . The PPPCells lacking G6PD are more sensitive to oxidative damage and therefore have increased sensitivity to ionizing radiation (IR), which in addition to inducing DNA strand breaks, also causes oxidative damage . G6PD isThe wild type tumor suppressor protein, p53, has also been shown to downregulate the PPP via directly reducing G6PD activity . HoweverActivating mutations of FMS-like tyrosine kinase 3 (FLT3) have been shown to drive the initiation and progression of acute myeloid leukemia (AML). As such, inhibition of FLT3 was suggested to be a promising treatment for AML; however, targeting FLT3 as a monotherapy did not achieve long term remission . In contAtaxia telangiectasia mutated and DNA-dependent kinases (DNA-PK) are key proteins that recognize DNA damage and initiate DNA damage repair signaling . Upon acBesides its primary function in the recognition of DNA damage, ATM functions as a metabolic stress sensor, identifying reductions in the energy levels of tumor cells, subsequently promoting increased PPP activity, which can lead to increased cancer cell survival and resistance to conventional therapies . AdditioDNA-dependent kinases is best known for recognizing DSBs and initiating DNA repair responses by activation of the NHEJ pathway. DNA-PK is an abundant, cytoplasmatic protein that migrates to the nucleus after DNA damage . There iCell starvation leads to the phosphorylation of AMPKα (Thr172) and acetyl-CoA carboxylase (ACC). However, the inhibition of DNA-PKcs inhibits AMPK phosphorylation, thereby disrupting the sensing of glucose metabolism by AMPK. In addition, it was shown that DNA-PKcs directly interacts with the energy monitoring regulatory subunit of AMPK . This fiAutophagy is the process by which damaged proteins or organelles are degraded by the lysosome, this provides a mechanism to recycle cellular components providing macromolecular precursors and energy for cellular metabolism. Autophagy is generally classified into five defined steps: initiation, vesicle nucleation, vesicle elongation, vesicle fusion and cargo degradation. The regulation of autophagy by metabolic proteins and vice versa have been well charactered but there is also mounting evidence that DNA repair is also regulated by autophagy [reviewed in The Phosphoglycerate mutase 1 (PGAM1) is a key glycolytic enzyme that coordinates different metabolic process including glycolysis, PPP, and serine biosynthesis in cancer cells. As a result of its dynamic role in metabolic coordination, PGAM1 is overexpressed in several cancer types, including gliomas, oral carcinomas and pancreatic cancers . For exaUnder normal cellular conditions FH localizes mainly in the cellular cytosol and mitochondria . A study2O2, migrates to the nucleus  is highly expressed in cancer cells and a master regulator of tumor metabolic reprogramming . Under n nucleus . The mig nucleus . It was  nucleus . As part nucleus . This AT nucleus .ATP-citrate lyase is a nuclear-cytoplasmic enzyme that utilizes acetyl-CoA to generate citrate, and plays a crucial role in conserving the global histone acetylation in mammalian cells . ACLY dede novo nucleotide synthesis (Glutamine synthetase (GS) is an enzyme that catalyzes the conversion of glutamate and ammonia into glutamine. Transcriptome analyses revealed that GS is responsible for the metabolic reprogramming that occurs in tumor cells, as GS activity was shown to enhance DNA repair via ynthesis . FurtherRadiotherapy remains a key anti-cancer therapy, with over 50% of patients undergoing radiation treatment as a monotherapy or in combination with other therapies . HoweverIn ovarian cancer, three glycolytic enzymes, HK2, PFK, and PKM2, have been suggested to be promising targets due to their positive correlation with chemo- and radio-resistance via anti-apoptotic and cell survival mechanisms . There aHexokinase 2 (HK2) is a key glycolytic enzyme that catalyzes the first essential step of glucose metabolism. Like many other glycolytic proteins, HK2 is highly expressed in several tumor types . SimilarThe glucose transporter GLUT1 is involved with the early steps of glucose uptake and metabolism. GLUT1 is overexpressed in many types of cancers and has been evaluated as a potential target for anti-cancer drugs . DepletiL-lactate is produced by glycolysis and is found to be expressed in high quantities in malignant tumors. High lactate levels have also been associated with resistance to clinical chemotherapeutics in numerous cancer subtypes. Recently, studies have shown that lactate can inhibit the activity of histone deacetylases (HDACs), which leads to changes in chromatin structure and transcription , 2017. HGenomic instability and metabolic reprogramming are central components in cancer development and evolution. These changes in chromatin structure, DNA repair enzyme expression and mutation allow the cancer cells to develop genetic heterogeneity, which in turn can promote evolution and metastasis. The metabolic changes allow cancer cells to increase growth rates, adapt to the rapidly changing external environment and to reduce the reliance on oxygen. It has become increasingly apparent that these two processes do not exist in isolation, but instead are mutually dependent. This raises the notion that the cell must adapt more globally to small changes in metabolism. While the DNA damage signaling kinases regulate the metabolic state of the cell, the opposite is also true. This generates a regulatory loop that ensures that changes in one pathway have compensatory changes in the other pathways. It must be considered that this link, and the peer reviewed studies supporting the link, have predominantly occurred in cancer cell lines and studies. It is likely these studies sit at the extreme of changes that have occurred in genomic instability and metabolism, as these cells have adapted to a metabolic and genetic state that gives them a growth and survival advantage. Understanding how these processes function under normal physiological cell conditions and indeed how they may drive the process of aging and other age-related diseases needs to be further addressed. During the aging process, the DNA repair capacity of cells declines and also undergo metabolic changes induced by cellular and endocrine changes. Understanding, how these changes in metabolism and DNA repair capacity under the normal process of aging may shed further light on why cancers form in the first place. In cancer, further studies may also identify new therapeutic targets that can target both metabolism and DNA repair concurrently.TS made the figures. All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.KO and DR are founders of CARP Pharmaceuticals. EB, DR, and KO are founders of Carpe Vitae Pharmaceuticals. EB, KO, and DR are inventors on patent applications filed by Queensland University of Technology. The remaining 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.


Using tools to acutely manipulate astrocytes, such as optogenetics or chemogenetics, studies reviewed here have demonstrated a causal role for astrocytes in sleep, memory, sensorimotor behaviors, feeding, fear, anxiety, and cognitive processes like attention and behavioral flexibility. Current tools and future directions for astrocyte-specific manipulation, including methods for probing astrocyte heterogeneity, are discussed. Understanding the contribution of astrocytes to neuronal circuit activity and organismal behavior will be critical toward understanding how nervous system function gives rise to behavior.Astrocytes are non-neuronal cells that regulate synapses, neuronal circuits, and behavior. Astrocytes ensheath neuronal synapses to form the tripartite synapse where astrocytes influence synapse formation, function, and plasticity. Beyond the synapse, recent research has revealed that astrocyte influences on the nervous system extend to the modulation of neuronal circuitry and behavior. Here we review recent findings on the active role of astrocytes in behavioral modulation with a focus on  A major goal in neuroscience is to understand how neuronal circuitry maps onto specific physiological functions and behaviors. Neural circuits are recognized as the basis of nervous system function, therefore neuroscience research has largely focused on neurons from the level of the synapse to brain-wide circuits . Yet, thin vivo studies, of astrocyte influence on behavior in rodents. In vitro studies remain critical for elucidation of molecular and cellular mechanisms, but in vivo experiments are necessary for understanding the role of astrocytes in whole organismal behavior. Likewise, in vivo experiments can address the effects of sensory input and behavioral state on astrocytes themselves . Next, chemosensitive hindbrain astrocytes were shown to modulate respiration in rats    that altIn vivo two-photon calcium imaging allowed researchers to correlate astrocyte calcium activity with features of sleep. For example, astrocyte calcium activity increases with sleep need in D. melanogaster  sleep neural oscillations are fast and desynchronized while neuronal activity in non-REM (NREM) sleep is synchronized with high-amplitude, low-frequency oscillations also referred to as slow wave sleep . Channelnogaster . Additionogaster . While tnogaster .Itpr2  knockout mice, which have attenuated astrocyte calcium signaling throughout the brain (3 5′-phosphatase (IPP) in astrocytes  . In hippAstrocytes respond to sensory and motor activity through elevations in intracellular calcium signaling. For example, astrocyte calcium signaling increases in response to the stimulation of whiskers, in a frequency-dependent manner , noting In the cerebellum, large networks of radial astrocytes called Bergmann glia display increased calcium activity at the onset of locomotion . ChannelItpr2 knockout mice with blunted astrocyte calcium signaling indicating astrocyte regulation of sensory-evoked neuronal activity. Likewise, astrocyte Gq activation by hM3Dq DREADD reduced sensory-evoked neuronal gamma activity . It is important to note that both studies used the GFAP promoter to target DREADD expression to hypothalamic astrocytes which also targets tanycytes lining the third ventricle, that are also implicated in feeding and energy homeostasis . An addiin vivo studies may employ simultaneous monitoring of neuronal and astrocyte calcium signaling during feeding behavior, alongside astrocyte manipulations, to further resolve the role of astrocytes in feeding in a region-specific manner.While the differing roles of ARC versus all MBH astrocytes in feeding and their effects on AgRP neurons remain to be further elucidated, recent research corroborates a role for ARC astrocytes in facilitation of AgRP neuron excitement . AgRP neBoth the hippocampus and the amygdala are important for fear and anxiety . As discUnderstanding of neuronal regulation of cognitive functions like learning, memory, attention, and decision-making has greatly advanced in the last two decades  yet the Behavioral flexibility is critical to achieving a goal as it allows an organism to pivot to an alternative strategy or to stop the current behavior and preserve energy after repeated failures. In zebrafish, radial astrocytes modulate these adaptative behavioral responses. With increasing failed attempts at swimming, noradrenergic neurons signal to astrocytes which accumulate this “failure signal” as increasing intracellular calcium. Astrocytes then activate GABA neurons that drive cessation of swimming . In miceIn the striatum, different astrocyte populations differentially regulate goal-directed behavior. Habitual behavior can become detrimental when the reward or goal has changed. Chemogenetic activation of dorsomedial striatum astrocyte Gq signaling promotes flexible goal-directed behavior in an operant paradigm in which control mice without astrocyte activation continued to demonstrate habitual behavior . AstrocyB agonism, increases excitatory synapse number, MSN firing rate, and hyperactivity behavior in the open field assay. Further, attention is disrupted in both a modified open field assay and novel object recognition test (Striatal astrocytes are also implicated in attention. Chemogenetic activation of astrocyte Gi-GPCR pathways, mimicking endogenous GABAion test . These sion test . The aution test . Striataion test .Lastly, astrocytes are implicated in reward and addiction behavior. Studies have employed astrocyte Gq-GPCR activation to query the role of astrocytes in ethanol intake. Activation of PFC astrocytes increased ethanol consumption in ethanol-naïve male mice whereas reduction of astrocyte calcium via CalEx expression reduced ethanol drinking indicating a bidirectional regulation of ethanol-consumption by PFC astrocytes . In the Itpr2 knockout mice or in the presence of G protein signaling blockade. Chemogenetic Gq-GPCR activation of NAc astrocytes depresses local excitatory neuronal transmission, via adenosine A1 receptor signaling. Further, Itpr2 knockout mice and mice lacking dopamine D1 receptors in astrocytes showed reduced amphetamine-induced locomotor activity (NAc Gq-GPCR activation in male rats also reduced cue-induced reinstatement of cocaine seeking but did not affect initial cocaine self-administration indicating a potential role for astrocytes in relapse behavior . Generalactivity  indicatiIn this review we have discussed the role of astrocytes in regulation of behavior. Acute manipulation of astrocytes with chemogenetic and optogenetic tools allow for the probing of causal relationships between astrocyte activity and animal behavior. This is in contrast to earlier gene knockout, or even inducible knockout studies, that relied on the manipulation of astrocytes over a timescale that might allow for compensatory mechanisms to affect circuitry, neuronal networks, and downstream behavior. Indeed, the ability of astrocytes to regulate synapses extends to larger circuitry and behavioral outputs. Future studies of neural circuits and behavior must therefore consider astrocyte contributions and may even incorporate astrocytes into their circuit diagrams or computational models. While not discussed here, it will also be important to consider the impact of other brain cells such as microglia , oligodein vivo, there is a growing list of neurochemical sensors that may provide insight (Toward further understanding how astrocyte gliotransmission affects local circuitry and behavior  insight . Many st insight  and the  insight  thereforThe currently used Aldh1l1 , GFAP L, and GfaMany of the tools discussed here target astrocyte GPCRs ultimately leading to increased calcium signaling . Key queNeuroscience research in mice has regularly focused on male subjects with one analysis finding only 20% of studies used both male and female mice while around 25% did not state the sex of subjects . CorticaResearch reviewed here demonstrates the importance of astrocytes in the regulation of homeostatic functions and diverse behavioral processes. Astrocytes can influence local neuronal circuitry through release of secreted factors or gliotransmitters leading to changes in synaptic structure and altered neuronal excitability. Through these capacities, astrocytes are able to shape behavior via changes in neuronal activity . In turnBoth authors conceptualized and wrote this review together. Both authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Triple negative breast cancer (TNBC) is a malignant breast cancer subtype that is prone to progression, with high associated metastasis and five-year mortality rates and an overall poor prognosis. Chemotherapy is usually administered to treat TNBC without additional targeted therapies. Novel nanomaterials have a variety of excellent physical and chemical properties and biological functions (including targeting specificity), and contrast agents and drug delivery vectors based on nanotechnology are progressing towards a more accurate and targeted direction. This review discusses the mechanisms of action and prospects for the use of nanotechnology in the treatment of TNBC, thus providing potential new strategies for the diagnosis and treatment of TNBC. Therapies for metastatic disease include targeted therapy , chemotherapy, radiotherapy, immunotherapy , and novel material-based therapies –9. The dWomen comprise 49.5 percent of the global population, and are disproportionately represented among elderly people over age 60. In fact, due to population growth and aging, the global cancer burden for women has been increasing in all countries regardless of income level. Breast cancer is the most common malignancy among women worldwide, with one study estimating that approximately 160,000 patients with advanced breast cancer were diagnosed in the United States as of 2017 .Due to the influence of multi-modal factors, such as genetic susceptibility, lifestyle, and other environmental factors, breast cancer incidence and mortality show extreme variance across countries and demographics . For exaERBB2), the activation of hormone receptors (estrogen receptors and progesterone receptors), and BRCA mutations  as well as systemic therapies. Molecular subtypes have a profound influence on the therapeutic strategies selected for breast cancer. Specifically, systemic therapies have been developed primarily on the basis of molecular characteristics, including targeted chemotherapy, endocrine therapy for hormone receptor-positive diseases, anti-HER2 therapy for HER2-positive diseases, polymerase inhibitors for dalities .In addition to surgical topical treatment, patients with hormone-receptor-positive cancer need endocrine therapy. A few of these patients also receive chemotherapy. Patients with ERBB2-positive cancer are treated with ERBB2-targeted antibodies or small molecule inhibitors combined with chemotherapy. Patients with triple-negative cancer typically receive only chemotherapy or radiation. Whether breast cancer patients receive radiotherapy is determined according to their specific indications. More and more patients are choosing to undergo systemic treatments, including targeted preoperative chemotherapy  following preoperative puncture examination . Breast Advances in nanotechnology over the past two decades offer potential new strategies for treating various diseases –32. NanoNanooncology is a branch of nanomedicine. Cancer diagnosis and treatment based on nanotechnology has received wide attention on a worldwide scale in the past decades –40. For In terms of treatment, nanotechnology has unique physicochemical properties, including a high surface volume ratio. In recent years, drug delivery systems based on nanomaterials, including micelles, nanoemulsions and liposomes, have been widely used. Nanomaterials can bind and load bioactive molecules, including DNA, RNA, drugs, and proteins. These bioactive molecules can easily cross many biological barriers and can easily be transported to the target. Therefore, nanomaterials are widely used in the loading and delivery of drugs for treating various cancers so as to improve the efficacy of chemotherapy combined with radiotherapy and photodynamic cancer therapy , 45–47. Additionally, the cancer microenvironment plays a critical role in determining cancer survival and reducing mortality. Microenvironmental factors, such as cancer hypoxia or hyperglycemia and inflammation, are also directly associated with the survival and expansion of cancer cells. Interventions aimed at changing the microenvironment of cancer cells can induce cancer cell death and form the basis for new anticancer therapies .TNBC is an important and recalcitrant breast cancer subtype. The treatment of patients with TNBC remains an immense clinical challenge, characterized by aggressive progression, high metastasis rates, and poor overall prognoses . BecauseMoreover, chemotherapy resistance caused by P-glycoprotein overexpression, DNA damage repair, topoisomerase II mutations, low solubility and bioavailability of chemotherapy drugs, and the immune escape of cancer cells limits the therapeutic effects of drugs on TNBC. Chemotherapy resistance results in a recurrence rate of 50% and a mortality rate of 37% for TNBC , 56. InvTherefore, in order to avoid non-specific targeting and chemotherapy side effects among TNBC patients, the need to open up new molecular targets and treatments is much more urgent than for other types of breast cancer. Nanotechnology-based drug delivery systems are auspicious tools that can selectively target tumors and eliminate the cytotoxicity of drugs to other organs .via nanomaterials combined with other therapies  to produce therapeutic synergistic effects will be the key to the application of nanomaterials within TNBC.Nanodrug delivery systems mostly rely on enhanced permeation and retention effects for targeting drug delivery . In gene® P123 and F127 copolymer nanoparticles (HA-TQ-NPS) as selective drug carriers to deliver anticancer phytochemical TQ to TNBC cells. HA-TQ-NPS meaningfully promotes apoptosis, anti-metastasis, and anti-angiogenesis in TNBC cells via upregulation of microRNA-361 with no associated toxicity to normal cells  is ineffective in the treatment of TNBC due to the lack of effective therapeutic targets. In order to solve this problem, Cheng et al., used gold nanocage (AuNC) as a photothermal conversion agent combined with anti-heat shock protein monoclonal antibody (cmHSP) as a target ligand in order to prepare a microwave triggered heat shock protein (HSP)-tar gold nanosystem (CMHSP-AUNC). Microwave irradiation can effectively activate HSP70 overexpression in TNBC, thus meaningfully improving the targeting ability, accumulation in cancer area, and anti-cancer efficacy of CMHSP-AUNC . Xu et aal cells .The immune microenvironment affects the occurrence and development of breast cancer according to the principles of immune monitoring and immune editing. In the early stages of tumorigenesis, the immune microenvironment plays an anti-cancer role mainly through the cytokine environment . In contrast, once the cancer becomes aggressive, the cellular composition of the microenvironment, including fibroblasts and the cytokine content associated with cancer, facilitates cancer promotion and is invaded by breast cancer cells .via inhibiting negative immune regulation. Immunotherapy has achieved some success thus far, thereby providing a new therapeutic strategy for TNBC treatment. Current immunotherapies include immune checkpoint blockers, cytotoxic T lymphocyte (CTL) exchange activation, adaptive cell transfer therapy (ACT), and TME regulation. Nanotechnology presents a novel immunomodulatory strategy that can be implemented as a personalized immunotherapy modality for TNBC  are already implemented to help improve antigen expression pathways by delivering epigenetic regulators and immune-stimulating cytokines . For exareatment . AlthougCancer vaccines are comprised of cancer cells and/or cancer antigens and lead to an effective anti-cancer host immune response. Cancer vaccines include DNA vaccines, Ab vaccines against idiotypic types and cancer-associated pathogens, and dendritic cell vaccines , 71. In Triple negative breast cancer is a difficult and often intractable disease because of its high heterogeneity and low associated survival rates. Currently, the available treatment methods for patients diagnosed with TNBC are limited, especially with respect to refractory TNBC. Novel nanotechnology modalities represent auspicious strategies for efficient and accurate diagnoses and targeted therapies for TNBC due to their tailored physical and chemical properties and biological functions. Our work guides and informs future research directions and will ultimately contribute to informing medical guidelines.All authors contributed to the design of the study and writing of the manuscript. KH and HC undertook the research, YW and ZN wrote the main manuscript text and prepared figures. YW revised the article critically for important intellectual content and final approval of the version to be submitted. All authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Follow-up care after transient ischaemic attack (TIA) and minor stroke has been found to be sub-optimal, with individuals often feeling abandoned. We aimed to explore factors influencing holistic follow-up care after TIA and minor stroke.Qualitative semi-structured interviews with 24 healthcare providers (HCPs): 5 stroke doctors, 4 nurses, 9 allied health professionals and 6 general practitioners. Participants were recruited from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Interview transcripts were deductively coded using the Theoretical Domains Framework and themes were generated from coded data.There was no clear pathway for supporting people with TIA or minor stroke after rapid specialist review in hospital; consequently, these patients had limited access to HCPs from all settings . There was lack of understanding of potential needs post-TIA/minor stroke, in particular residual problems such as anxiety/fatigue (‘Knowledge’). Identification and management of needs was largely influenced by HCPs’ perceived role, professional training  and time constraints . Follow-up was often passive – with onerous on patients to seek support – and predominantly focused on acute medical management .Follow-up care post-TIA/minor stroke is currently sub-optimal. Through identifying factors which influence follow-up, we can inform guidelines and practical strategies to improve holistic healthcare.The online version contains supplementary material available at 10.1186/s12913-022-07607-0. Transient ischaemic attack (TIA) and minor stroke are important risk factors for major stroke. Over 46,000 people experience a first TIA or minor stroke per year and half a million people live with TIA and/or minor stroke in the United Kingdom .National guidelines promote rapid diagnosis and long-term management that focuses on stroke prevention –4. HowevSeveral studies have explored TIA and minor stroke patients’ perspectives of initial treatment and follow-up , 14, 16;Qualitative, theory-guided, semi-structured interviews. A qualitative approach was selected as this study focuses on exploring attitudes and perceptions of HCPs. Semi-structured interviews were preferred to focus groups because it allowed the researcher to obtain richer and deeper data.Changing clinical practice requires an understanding of the influences on behaviour; therefore, our study was underpinned by the Theoretical Domains Framework (TDF) . This thParticipants were HCPs who work with TIA or minor stroke patients, including: secondary care doctors, nurses or AHPs; primary care general practitioners [GPs]; and community care AHPs and nurses. Convenience and snowball sampling were used initially; however, sampling became increasingly purposeful to achieve variation in clinical role  and setting . Secondary care doctors, nurses and AHPs were recruited from three TIA clinics in the West Midlands (England). Community HCPs were recruited from Birmingham Community Healthcare Trust. GPs were recruited from two general practices in the West Midlands and through snowballing. A pragmatic approach to site selection was used whereby research invitations were sent to potential sites and those that responded first were selected. Recruitment rates (percentage of HCPs interviewed of those invited to participate) were: 86% (12/16) for secondary care, 60% (6/10) for community care and 43% (6/14) for GPs.One-to-one, semi-structured interviews were conducted by telephone or face-to-face (at the University of Birmingham or participants’ workplace). All interviews were conducted by GT, a female, non-medical researcher trained in qualitative research methods. All participants were interviewed once. The interviewer did not have a relationship with any of the participants.Topic guides were informed by existing literature and consultation with the research team and patient partners, and refined through piloting with patient partners. Topic guides covered: follow-up pathways and communication between healthcare settings, and current practice to identify and address needs. Participants also completed a short demographic questionnaire. Fieldnotes were taken during and after each interview to add contextual information, and reflect on how the interview was conducted. Adjustments were made if necessary during the following interviews, thereby improving reflexivity and trustworthiness of the data.Digital audio recorded interviews were transcribed verbatim by a professional transcription service. Interviews were conducted between March and November 2018, until the research team judged that the sample and data had sufficient depth and breadth to address the research questions.n = 2). GT and RA are both experienced qualitative researchers. Responses coded in different domains were discussed by GT and RA to establish a consensus; all differences in coding were resolved. Themes were iteratively generated from coded data. Initial data coding and generation of themes was concurrent with the interviews and data collection stopped when no new themes were identified. Themes were identified initially by GT, reviewed by RA, and developed and refined by discussion between GT and RA. The wider research team and our patient partners met on a regular basis to discuss and further refine the themes.Computer Aided Qualitative Data Analysis Software (CAQDAS) QSR NVivo 12 supported the sorting, coding and organisation of transcribed data. A key advantage of using CAQDAS software is that it facilitates and enhances researcher reflexivity . TranscrEthical approval was given by the Warwickshire North West - Greater Manchester East Research Ethics Committee . Participants’ years of experience ranged from 3 to 37 , characteristics are summarised in Table Eleven TDF domains were identified as relevant: Environmental context and resources; Social influences; Knowledge; Intentions; Memory, attention and decision processes; Social/professional role and identity; Beliefs about capabilities; Beliefs about Consequences; Reinforcement; Skills; and Goals Tables  and 4.TaPathways and access to follow-up care . For example, one hospital had a nurse-led follow-up clinic, but consultants within that hospital differed in whether they referred their patients there or not (Intentions); whereas, another hospital had no follow-up . The eligibility criteria to access early supported discharge varied across regions; minor stroke patients “rarely” received early supported discharge and TIA patients were not eligible . In primary care, there was a spectrum of active vs passive approaches to follow-up with some general practices actively contacting patients and others relying on patients to contact them (Intentions). GPs often relied on annual long-term condition reviews as follow-up for these patients .Communication between healthcare settings was restricted. It was usually one way and comprised electronic or paper discharge letters which varied in the speed they were sent, the content, and how the recipient HCP engaged with the letter . Some GPs described frustration with the lack of access to results of imaging/ investigations and difficulty in contacting stroke consultants for specialist advice .HCPs’ perceived role in follow-up care  and knowledge of potential patients’ needs (Knowledge) influenced their approach to identifying needs. Consultants mostly considered the purpose of their follow-up clinics to be related to the acute management of TIA/ minor stroke, in particular interpreting and actioning imaging and investigations . For GPs, follow-up was predominantly focused on stroke prevention medication and risk factor management, such as blood pressure control . GPs and consultants were usually passive and relied on patients to raise issues themselves . In contrast, nurses and AHPs took an active approach to identifying needs . In general, nurses and AHPs had a more holistic understanding of potential needs and were confident in their ability to identify needs (Knowledge/ Beliefs about capabilities).Overall, there was a lack of knowledge and understanding of sequelae post-TIA/ minor stroke, particularly amongst consultants and GPs who often viewed TIA/ minor stroke as transient events (Knowledge). Knowledge of residual impairments post-TIA/ minor stroke was gained through experience of following-up these patients (Knowledge) or, less commonly, through personal experience with family members .Checklists, usually developed in-house, were commonly used by nurses and AHPs and considered useful prompts . However, checklists were less commonly used by experienced nurses and AHPs who referred to using “instinct” to identify needs, gained through professional experience working in the field (Skill). In primary care, a long-term conditions template is used by nurses at annual reviews. However, the content was medically focused and influenced by a performance-based incentive: the Quality and Outcomes Framework (QOF) (Reinforcement).AHPs varied considerably in their use of screening tools, if at all . When used, screening tools informed decision making, such as psychology referral . In one early supported discharge team, the Barthel index was mandated by the local service commissioners (Reinforcement); however, this tool was not considered useful by AHPs (Beliefs about consequences). Screening tools were rarely used by GPs and consultants. Barriers to use of screening tools included lack of knowledge of available tools (Knowledge), lack of training to used and interpret tools (Skills) and lack of time .Culture and language were sometimes barriers to identifying needs . There was a perception that patients do not want to raise non-medical or minor issues with doctors, but are more willing to discuss these problems with nurses and AHPs . It was perceived that some patients withheld information due to embarrassment, not wanting to admit to problems for fear of consequences, such as driving restrictions .Family members facilitated identification of needs, in particular, women raised issues on behalf of their male partners . On occasion, family members acted as translators . However, in some instances, presence of family could be a barrier if patients were embarrassed to discuss problems in front of them .There was disparity between consultants and GPs regarding perceived responsibility for prescribing stroke prevention medication . Some consultants considered this to be part of their role , but varied in tailored versus protocolised approaches to prescribing (Intentions). In contrast, other consultants were less confident prescribers and relied on GPs (Beliefs about capabilities/ Intentions). Some GPs perceived preventative medicine as a strength of general practice and believed prescribing medication was their role, particularly in the context of comorbidities and polypharmacy . However, other GPs felt they lacked specialist stroke knowledge and relied on stroke consultants . This influenced whether GPs actively saw patients and reviewed their medication or simply issued repeat prescriptions based on secondary care recommendations (Intentions).Although HCPs recognised the importance of lifestyle change for stroke prevention (Beliefs about consequences), this was rarely addressed in a meaningful way or actively supported (Intentions). Time constraints were a key barrier ; however, behaviours were also influenced by lifestyle change not being considered a key goal of their follow-up  and lack of knowledge of support services and resources to support lifestyle change (Knowledge). As a substitute, HCPs used information leaflets and consultants made recommendations to GPs through discharge letters .Consultants rarely addressed residual problems, such as fatigue, psychological and cognitive problems, due to lack of knowledge of potential problems and lack of confidence in how to address these problems (Knowledge/ Beliefs about capabilities). Although most GPs lacked understanding of residual problems related to TIA and minor stroke, they were aware of holistic consequences from long-term conditions in general (Knowledge); however, restricted time  and prioritisation of stroke prevention – partly influenced by performance based financial incentives (QOF) – were commonly cited as reasons for not addressing these issues .AHPs and nurses considered addressing holistic needs part their role and were confident in their ability to address residual needs . Often AHPs and nurses had the skills to actively addressed residual needs, such fatigue management, and tailored their approach to patients’ demographic traits and personal circumstances (Skill/ Memory attention and decision processes). Many AHPs and nurses also believed in the value of a “supportive chat” which involved active listening, acknowledging patients’ needs and reassurance (Beliefs about consequences) and recognised the importance of lay language (Skill).Consultants usually provided information on diagnosis and stroke risk (Intentions); however, this was not comprehensive and there was belief that it is difficult for patients to retain information provided at the acute stage (Beliefs about consequences). Most GPs did not routinely provide education due to time constraints and an assumption that this had been done in secondary care . Most nurses and AHPs actively provided education and considered this part of their role . They often used stroke charity websites to supplement verbal information .Support services were mentioned as potential sources of support, both formal healthcare services, such as smoking cessation and talking therapy, and local community groups . However, barriers to accessing services were reported, including a lack of services, long wait times to access services, lengthy or complicated referral processes, transport issues, and geographical boundaries .Another important barrier was lack of knowledge of services, particularly as they changed rapidly (Knowledge). In-house directories were sometimes used in primary and community care; however, directories were often outdated unless someone was delegated to regularly update them . In early supported discharge teams, knowledge of support services was facilitated by multidisciplinary team working, building relationships in the community and experience of working in the area (Knowledge). AHPs also proactively searched for services to meet specific patient needs . In primary care, GPs having access to social prescribers or community champions facilitated identification of support services .Patient factors were sometimes barriers to addressing needs, including patients refusing referral to support services, denial, low education, IT illiteracy and comorbidities . Family members were often facilitators and supported patients to find or access services, access the internet or computers, relaying or repeating information .There is no clear pathway for supporting people with TIA or minor stroke after rapid specialist review in hospital. Consequently, these patients have limited access to HCPs from all settings. HCPs’ approaches to identifying and addressing needs are predominantly influenced by their professional training, perceived role and purpose of their clinic, knowledge of potential needs, and time constraints. In general, consultants and GPs are medically focused; whereas, nurses and AHPs are more holistic in their approach to follow-up care. However, TIA/ minor stroke patients are unlikely to receive follow-up from nurses and AHPs.This is the first study to explore perceived influences on HCPs’ behaviours related to follow-up care post-TIA/minor stroke, specifically identification and management of patients’ needs. In stroke research, HCPs’ perceived roles and beliefs about consequences have been found to influence rehabilitation assessment and referral practices on Australian acute stroke units . SimilarLack of adequate follow-up is reflected in studies exploring perspectives of follow up from people with TIA and minor stroke, which found these individuals feel abandoned post-discharge ; frustraResearch has shown that structured stroke care at the post-acute stage is essential to improve secondary prevention post-stroke –30. HoweIdentification and management of needs post-TIA/minor stroke is currently sub-optimal. Through identifying TDF domains relevant these behaviours, our findings provide an understanding of what needs to change to improve follow-up post-TIA/minor stroke and potential intervention targets. Future research should use this knowledge to inform intervention development. The Behaviour Change Wheel , a frameA strength of our study is that we drew upon a wide range of HCPs experiences across different healthcare settings and disciplines. These different perspectives enriched our understanding of the diverse range factors influencing follow-up care across different settings. Through use of TDF, we used behavioural theory to identify influences on behaviour (i.e. identifying and addressing needs post-TIA/ minor stroke), which are potentially amenable to change and could be targeted to improve care. An advantage of TDF is that it links to the Behaviour Change Wheel which provides a methodology for progressing to developing behaviour change intervention . HoweverFollowing rapid discharge from hospital, people with TIA or minor stroke have limited access to follow-up care and care they do receive is inadequate. Through identifying factors which influence follow-up care of these patients, we can inform guidelines and practical strategies to improve holistic healthcare post-TIA and minor stroke.Additional file 1: eTable 1. Theoretical Domains Framework (TDF) version 2. eTable 2. Characteristics of healthcare provider participants.


Untreated human immunodeficiency virus (HIV) infection in humans is typically characterised by persistent high virus load, failure of the immune response to clear the virus, and fatal disease outcome. Natural hosts of closely related simian immunodeficiency viruses (SIVs)—e.g., sooty mangabeys ,2—mainta+ T cells, which constitute the primary target cell type of the virus and which are key players in adaptive immunity. Immune functions slowly decline, eventually giving rise to opportunistic infections that ultimately result in death in nearly all untreated cases. These processes were first thought to be driven by the loss of infected CD4+ T cells, killed directly by the cytopathic effect of the virus. However, accumulating evidence  indicat T cells , and the T cells ) after t T cells . We here T cells , which d T cells  and the  T cells , respect T cells , while i T cells , where t T cells , and ret T cells . Alterna T cells . Both meMost germline retroviral integrations are probably purged from the genome during evolution. However, the thymus- and/or bone marrow–specific expression of those SIV antigens that are responsible for chronic hyperactivation would be beneficial for the host, and would therefore be conserved by natural selection. Considering that neonatal HIV infection by vertical transmission does not result in immune tolerance and inhibition of immune hyperactivation in humans, efficient tolerance induction probably requires the expression of a specific subset of viral antigens under appropriate conditions. Finally, efficient tolerance induction by host genomic elements depends on low variability of the targeted viral antigens. In the SIV hosts with long coevolutionary history, we therefore predict the thymic- and/or bone marrow–specific expression of conserved SIV-derived gene fragments. Importantly, immune responses against viral epitopes not involved in the induction of chronic immune hyperactivation are likely to be beneficial for the hosts and are therefore expected to be retained. Indeed, naturally infected sooty mangabeys do display humoral and cellular responses against SIVsm ,18, althThe integration hypothesis emphasises the role of host adaptation in host–SIV coevolution. Reducing indirect harm to the host is the mutual interest of the host and the virus, because it extends the lifespan of the host without limiting the replication of the virus. However, viral evolution towards decreasing virulence is probably limited by within-host competition: the lifespan of the host is expected to be determined by the most aggressive variant in the host . Furtherhttp://hiv-web.lanl.gov/content/hiv-db/mainpage.html]) and SIVsm sequences (accession number M31325) of all viral proteins as queries, we performed translated similarity searches with tBLASTn against all sequences of primate origin in the complete “nonredundant” and expressed sequence tags databases of the National Center for Biotechnology Information Entrez Nucleotide database [At present, our hypothesis remains an intriguing possibility that requires experimental testing. It is not known if nonspecific mechanisms contribute to HIV-induced hyperactivation, which would limit the efficiency of antigen-specific tolerance induction. Whole-genome sequencing of the natural hosts of SIVs should demonstrate the presence of SIV-related sequences. In addition to actively expressed sequences involved in tolerance induction, silenced, nonexpressed gene fragments may also persist in the genome. Using predicted ancestral HIV-1 subtype B sequences (obtained from the Los Alamos database [database . We founSeveral years ago, Norley et al.  proposedThe integration hypothesis proposes an evolutionary pathway to benign SIV infections that is technically plausible given the ability of retroviruses to insert their genetic material into the germline of the host, and that would not have been opposed by evolutionary barriers since it serves the mutual benefit of viruses and hosts. Whether this path was indeed taken by evolution must still be verified by experimental tests that can be performed by current technology. Whereas we have plenty of examples of viruses stealing host genes for their benefit, this would be a rare example of hosts utilising viral genes in the course of coevolution.


Previous studies have evaluated the individual effects of acute myocardial infarction (AMI) and diabetes mellitus on health-related quality of life outcomes (QOL). Due to the rising incidence of these comorbid conditions, it is important to examine the synergistic impact of diabetes mellitus and AMI on QOL.In this study, we assessed using several previously validated questionnaires the QOL and functional status of 96 diabetic patients and 491 non-diabetic patients admitted to Quebec hospital sites with AMI between 1997 and 1998. We also conducted multivariate analyses to ascertain whether diabetes mellitus was an independent determinant of SF-36 physical functioning (PCS) and mental health (MCS) component score QOL outcomes after AMI.Both patient groups had similar baseline clinical characteristics, but diabetic patients had slightly higher rates of cardiac risk factors compared to non-diabetics. Overall, QOL measures were similar between both patient groups at baseline, but diabetic patients reported poorer functional status than non-diabetic patients. Over the study period, there were significant differences between the QOL and functional status of diabetic and non-diabetic populations. By one year, diabetic patients reported poorer QOL outcomes than non-diabetic patients. However, diabetic patients showed greater improvements in their functional status, but were less likely to return to work compared to non-diabetic patients. In contrast with these findings, our multivariate analyses showed that diabetes mellitus was not an independent determinant of QOL and functional status.Our study findings suggest that diabetes mellitus is not an independent determinant of QOL after AMI. Several clinical studies have shown that acute myocardial infarction (AMI) causes a decline in the social, physical and psychological functionality of affected patients -12. ThesThe purpose of this paper is to measure and compare QOL outcomes for diabetic and non-diabetic patients who have sustained a Q-wave or non Q-wave AMI. Specifically, this paper aims to address 1) whether diabetes mellitus influences the QOL of post-AMI patients and 2) which QOL dimensions are most or least affected by the diagnosis of diabetes mellitus.1C.From January 1997 to November 1998, 587 Quebec patients with a confirmed Q wave or non-Q wave AMI were enrolled in a 1-year prospective cohort study of QOL after AMI, as detailed previously [We measured changes in patient QOL by means of questionnaires completed by the patients at baseline admission, at 30 days, at 6 months, and at 1 year following AMI. We relied on previously validated questionnaires to assess the patients' overall health perception, namely the SF-36 health survey , a visuaFirst, we conducted a univariate analysis to compare the raw outcomes for diabetic versus non-diabetic patients. For SF36 scores, differences of 5 points were considered clinically significant. P-values of <0.05 were considered statistically significant. A multivariate linear regression model was then created to obtain adjusted comparisons of the QOL scores for physical and mental health, and to isolate any demographic, clinical, and psychosocial baseline characteristics that influenced patient QOL 1 year after AMI. Variables that were included in the multivariate model were: baseline score, diabetes, sex, age, education, congestive heart failure, previous coronary artery bypass surgery (CABG), previous percutaneous transluminal coronary angioplasty (PTCA), ventricular fibrillation, recurrent ischemia, previous angina, and hypercholesterolemia. An optimal model was estimated using backward and forward model selection algorithms that have been previously described .Of the 587 enrolled patients, we identified 96 16%) diabetic patients and 491 (84%) non-diabetic patients. In general, the diabetic and non-diabetic patients had similar demographic and clinical characteristics at baseline, but there were some clinically significant differences between the groups  and the mental health composite score (MCS) at 1 year showed that, after adjustment for baseline prognostic factors, a diagnosis of diabetes mellitus was not associated with poorer QOL after AMI . However, both groups showed declines in their levels of optimism from baseline to 1 year .For employment status at baseline and at 1 year, fewer diabetic patients were engaged in full or part-time employment (14% versus 36% non-diabetics at 1 year). Multivariate analysis indicated that, when all prognostic factors included in the SF-36 models were considered, the number of diabetics who were employed was similar to the number of employed non-diabetics.The results of our linear regression models suggest that there is no clinical or statistical significant difference between the QOL of diabetic and non-diabetic patients after AMI. Although the diabetic patients reported lower QOL results than non-diabetics 1-year after AMI, our regression models for physical functioning and mental health composite scores showed that these differences could be attributed to the diabetics' poorer QOL characteristics at baseline. Furthermore, the differences between QOL scores for the two patient groups were also confounded by the increased age, higher proportion of women and lower levels of education of the diabetic patient population.In general, our diabetic patients had more severe disease than the non-diabetic patients at baseline. At baseline, the diabetic patients had more cardiac risk factors Table  and moreIn our study, diabetic patients received fewer invasive procedures than non-diabetic patients did following an AMI event Table . These rAlthough it was not assessed in this study, the diabetic patients' slower rate of return to work may have been associated with differences in their baseline demographic and clinical characteristics. For example, in the older diabetic population, it is possible that more of the patient had already reached or were close to the normal age of retirement when their AMI occurred, which would have influenced their decision to return to work. As discussed earlier, the diabetic patients also tended to have more severe coronary artery disease characteristics and associated morbidity than the non-diabetic patients Tables  and 2. TThere were several limitations to this study. First, the size of the diabetic patient group was not very large because the patients were not recruited based on their diabetic status, when the original study was designed. As a result, our sample sizes are more representative of prevalence of diabetes mellitus among patients with ischemic heart disease. Our sample size was further limited as there were more diabetic patients than non-diabetic patients who were lost to follow-up over the study period .Other limitations to this study were the various demographic differences between the two patient groups at baseline. These differences were accounted for as much as possible in our linear regression model, but it is possible that we did not include other all the contributory variables in our model.Our study findings suggest that a diagnosis of diabetes mellitus is not an independent determinant of QOL after AMI. Similar to the non-diabetic patients, the diabetic patients showed correlations between their QOL and their baseline scores, age, sex, and level of education.All authors have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. They have been involved in drafting the article or revising it critically for important intellectual content and they have given final approval of the version to be published. Both authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content. They have read and approved the final manuscript.


Because angiogenesis is necessary for the growth and metastasis of solid tumours, and vegf is believed to have a pivotal role in that process, sunitinib treatment may have broad-spectrum clinical utility. In the present article, we discuss the biologic and clinical rationales that have recently led the Investigational New Drug Program of the National Cancer Institute of Canada Clinical Trials Group to initiate four phase ii trials testing this agent in the following four different tumour types: relapsed diffuse large cell lymphoma, malignant pleural mesothelioma, locally advanced or metastatic cervical cancer and recurrent epithelial ovarian, fallopian tube, or primary peritoneal carcinoma.Sunitinib (SU11248) is an orally bioavailable inhibitor that affects the receptor tyrosine kinases involved in tumour proliferation and angiogenesis, including vascular endothelial growth factor ( Numerous agents are currently under development. One class of anti-angiogenic agents includes the multi-targeted receptor tyrosine kinase inhibitors. Agents within this class often inhibit more than one of the receptors that initiate the intracellular signalling that culminates in an angiogenic phenotype. Sunitinib is one such agent. In the present article, we discuss the biologic and clinical rationales that have recently led the Investigational New Drug (vegf) has been associated clinically with disease prognosis in many different types of malignancies. This expression is increased by diverse stimuli, including proto-oncogene activation and hypoxia, with the hypoxic state frequently arising in solid tumours because of inadequate perfusion. In addition to its angiogenic role, vegf also profoundly increases the permeability of the vasculature, thereby potentially contributing to tumour progression, because a leaky tumour endothelium enhances nutrient and catabolite exchange and lowers barriers to tumour cell migration and extravasation during metastasis.Expression by tumours of vascular endothelial growth factor  signalling in tumour angiogenesis. Recent preclinical evidence suggests that inhibition of pdgfr signalling augments the antitumour and anti-angiogenic effects of vegfr inhibitors pdgfr signalling is implicated in the autocrine growth of tumour cells and in the recruitment and regulation of tumour fibroblasts.Two high-affinity receptors for vegf receptors 1, 2, 3, and pdgfra and pdgfrb. The demonstrated activity of sunitinib in gastrointestinal stromal tumours (gist)aml)rcc) Sunitinib SU11248) it is an orally bioavailable inhibitor that affects the receptor tyrosine kinases involved in tumour proliferation and angiogenesis, including 48 it is pdgf- and vegf-driven angiogenesis and, as a consequence, to limit solid tumour growth. Because angiogenesis is necessary for the growth and metastasis of solid tumours, and vegf is believed to have a pivotal role in that process, sunitinib treatment may have broad-spectrum clinical utility pdgfr, and Ret.With chronic oral dosing, sunitinib is expected to inhibit i testing of sunitinib has demonstrated single-agent activity in patients with rcc, gist, non-gist sarcomas, non-small cell lung cancer, colorectal cancer, neuroendocrine tumours, melanoma, prostate cancer, and thyroid cancer. Phase i testing in patients with aml has been completed. Phase ii and iii testing have included single-agent trials in metastatic rcc, imatinib-resistant gist, metastatic breast cancer, non-small cell lung cancer, and carcinoid and islet cell neuroendocrine tumours. Results of some of these trials have led to approval of sunitinib for specific indications by the U.S. Food and Drug Administration. The most promising results have included a report of phase ii testing in patients with metastatic rcc: among 63 patients, 25 (40%) achieved a partial response (pr) as determined by the Response Evaluation Criteria in Solid Tumors (recist), and an additional 17 (27%) had stable disease (sd) for ≥ 3 months. In a multinational, randomized, double-blind, placebo-controlled phase iii trial that included more than 300 patients with imatinib-resistant gist, results of an interim analysis demonstrated a median time-to-progression of 27.3 weeks in the sunitinib arm as compared with 6.4 weeks in the placebo group (p < 0.001) ind Program of the ncic ctg has initiated separate phase ii trials testing sunitinib in patients with progressive diffuse large B cell lymphoma, malignant pleural mesothelioma, locally advanced or metastatic carcinoma of the cervix, and recurrent carcinoma of the ovary .Phase chop) remains the standard of care for most patients with aggressive-histology lymphoma chop-r) has improved survival in the primary treatment of diffuse large B cell lymphoma (dlbcl) Anthracycline-based chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone , with a relationship between vegf and vegfr expression suggesting a possible autocrine pathway in some patients ii combination studies of bevacizumab with chop and chop-r and a phase iii study comparing chop-r with or without bevacizumab for newly diagnosed patients with dlbcl is in its initial stages.Preclinical and clinical data that are now available support the important role of tumour angiogenic growth factors and angiogenesis in the pathogenesis and prognosis of lymphoma ncic ctg centres demonstrated a response rate of 37% and a sd rate of 20% in 32 heavily pretreated patients with relapsed and refractory aggressive non-Hodgkin lymphoma using anti-angiogenic “metronomic” oral chemotherapy (cyclophosphamide 50 mg daily) and high-dose celecoxib 800 mg daily. One third of these patients had disease progression after autologous transplantation cecs) and circulating endothelial cell progenitors (ceps) declined in patients responding to treatment. In the bevacizumab study referenced earlier cecs and plasma vegf declined during therapy, but no relationship to response was described.Furthermore, independent research undertaken at some vegf- and vegfr-targeted agents in dlbcl. Evaluation of cecs and ceps would be logical correlative questions to be included in such testing.These data provide a rationale for studying other Malignant pleural mesothelioma is an unusual malignancy. Approximately 400 new cases are diagnosed annually in Canada vegf ligands vegf ligands, mesothelioma tumours and cell lines have also been shown to express the receptors for vegf ligands vegf in an autocrine and paracrine manner. Additionally, an autocrine growth stimulatory effect of pdgf via pdgfr may play a role in the disease pathogenesis and in the metastatic potential. Because angiogenesis is felt to be important in the pathogenesis of mesothelioma, there is a good rationale for the use of anti-angiogenesis agents in this cancer.Recent reports in the literature have suggested a link between angiogenesis and prognosis in malignant mesothelioma. Mesothelioma tumours and cell lines have been found to express Carcinoma of the cervix is the second most common malignancy in women after breast cancer. With the introduction of Papanicolaou smear screening programs, the incidence and mortality have decreased, but approximately 200,000 women worldwide still die from their disease each year iii studies, standard approaches for many patients include potentially curative treatment using primary radiotherapy and concurrent platinum-based chemotherapy. Long-term survival is approximately 85% for patients with T1 disease, 70% for those with T2 disease, and 40% for those with T3 disease Based on the results of several phase A number of chemotherapeutic agents have shown activity in advanced and metastatic cervical cancer, including cisplatin vegf in adenocarcinomas of the cervix suggests that vegf is involved in tumour angiogenesis in this histologic subtype vegf and vegf-c in patients with squamous cell carcinomas of the cervix correlated with poor outcome Overexpression of Ovarian cancer is the leading cause of gynecologic cancer deaths in North America. In 2005, an estimated 22,000 and 2400 women were diagnosed with this disease in the United States and Canada respectively; at least 70% would be expected to die of their disease pfi), which is the time from completion of initial platinum-based therapy to first evidence of recurrence pfi of at least 6 months have a higher likelihood of response to second therapies and superior survival Standard initial treatment includes debulking surgery followed by combination chemotherapy that includes a platinum drug and a taxane vegf and tissue microvessel density, have been correlated with the presence of metastasis and survival in ovarian cancer vegf signalling pathway appears to contribute to growth and progression in 80% or more of all ovarian cancers pdgf and its receptor pathway have also been implicated in disease progression vegf monoclonal antibody bevacizumab when used either as a single agent in recurrent disease or in combination with low-dose metronomic chemotherapy Indicators of enhanced angiogenesis, such as circulating levels of rcc, gist, and other cancer types, the ncic ctg, in conjunction with the Cancer Therapy Evaluation Program of the U.S. National Cancer Institute, has initiated four trials testing this agent in the management of relapsed dlbcl (ind.182); malignant pleural mesothelioma (ind.183); squamous cell, adenosquamous, or adenocarcinoma of the cervix (ind.184); and advanced or metastatic epithelial ovarian, fallopian tube carcinoma, or primary peritoneal carcinoma (ind.185). All are non-randomized, non-blinded, multicentre phase ii trials. Key objectives and inclusion and exclusion criteria shared by all four trials are summarized in the next few subsections, and Based on the strong biologic rationale linking angiogenesis with disease progression, and with the promising results of sunitinib in treating Among the common objectives are these:Assess the efficacy and toxicity of sunitinib.Document response rates, objective progression rates, and response durations.Assess dynamic biomarkers of angiogenesis in select studies and centres.recist , and the modified recist criteria for mesothelioma The primary endpoint of each study is to determine the overall response defined by International Workshop Criteria (for lymphoma) or The most frequent adverse events seen following sunitinib treatment are constitutional (fatigue or asthenia), gastrointestinal , and hematologic . Hand–foot syndrome and skin discoloration are also seen lvef) that are primarily reversible upon drug reduction or discontinuation. Infrequently (1.5%), grade 3 reductions in lvef have been seen in some trials, and symptomatic systolic dysfunction has been documented in 1% of patients. Because patients who presented with cardiac events within 12 months before sunitinib administration were excluded from clinical trials, whether patients with these concomitant conditions may be at higher risk of developing drug-related left ventricular dysfunction is unknown. Patients should be carefully monitored for signs of cardiac dysfunction, and baseline and periodic evaluations of lvef should be performed in patients with risk factors for cardiac disease such as prior anthracycline use or mediastinal radiation (product monograph). Sunitinib has been shown to prolong the QT interval in a dose-dependent manner, which may lead to an increased risk for ventricular arrhythmias such as torsade de pointes. Torsade de pointes has been observed in <0.1% of sunitinib-exposed patients. Sunitinib should be used with caution in patients with a history of arrhythmias, QT prolongation, pre-existing cardiac disease (product monograph). Hypertension is a common side effect of this class of angiogenesis inhibitors, and therefore strict guidelines for blood pressure monitoring and recommendations for antihypertensive medications and dose reductions by grade are indicated in the each of the four ind protocols. Each protocol also includes dose attenuation schedules if pre-specified toxicity criteria are observed.Sunitinib may induce asymptomatic mild declines in left ventricular ejection fraction  and circulating endothelial cell progenitors (ceps) as biomarkers of angiogenesis, because the development of biomarkers that describe the angiogenic profile of a tumour type and might predict for response to anti-angiogenic agents carries great potential cecs and ceps s have been found to be increased in lymphoma ceps (measured by four-colour flow cytometry) can serve as biomarkers for angiogenic responsiveness to vegfr2 blocking antibody or a thrombospondin mimetic peptide in several mouse strains cecs and their cep subset cecs and ceps will be included for selected patients in ind.182 testing of sunitinib in patients with dlbcl to assess whether these biomarkers are predictive of response.There is a strong rationale for evaluating circulating endothelial cells (rcc and in patients with gist who are resistant to imatinib. Given that neoangiogenesis is virtually ubiquitous in cancer and contributes to disease pathogenesis and propagation, it is logical to test sunitinib in the four cancers described earlier. If activity is demonstrated, future directions would include developing appropriate sunitinib-based combination regimens with chemotherapy or other targeted therapies for these malignancies. Insights gained from serial cec and cep measurements may help to identify patients likely to respond and may validate the anti-angiogenic mechanism of action of sunitinib.Sunitinib is an orally bioavailable inhibitor affecting receptor tyrosine kinases involved in tumour proliferation and angiogenesis. It has important antitumour activity in patients with metastatic


DNA microarrays provide the ability to interrogate multiple genes in a single experiment and have revolutionized genomic research. However, the microarray technology suffers from various forms of biases and relatively low reproducibility. A particular source of false data has been described, in which non-random placement of gene probes on the microarray surface is associated with spurious correlations between genes.In order to assess the prevalence of this effect and better understand its origins, we applied an autocorrelation analysis of the relationship between chromosomal position and expression level to a database of over 2000 individual yeast microarray experiments. We show that at least 60% of these experiments exhibit spurious chromosomal position-dependent gene correlations, which nonetheless appear in a stochastic manner within each experimental dataset. Using computer simulations, we show that large spatial biases caused in the microarray hybridization step and independently of printing procedures can exclusively account for the observed spurious correlations, in contrast to previous suggestions. Our data suggest that such biases may generate more than 15% false data per experiment. Importantly, spatial biases are expected to occur regardless of microarray design and over a wide range of microarray platforms, organisms and experimental procedures.Spatial biases comprise a major source of noise in microarray studies; revision of routine experimental practices and normalizations to account for these biases may significantly and comprehensively improve the quality of new as well as existing DNA microarray data. With the availability of complete genome sequences, the ability to probe multiple genes in a single experiment using DNA microarrays provides an unprecedented tool for genomic research. Accordingly, tens of thousands of microarray experiments have been conducted to monitor changes in gene expression, identify genome-wide protein binding sites, characterize genetic variability and more. Overall, the microarray technology is of ever-increasing usefulness for multiple sorts of biological inquiries.in-situ oligonucleotide synthesis, or by spotting gene-specific nucleic acid fragments organized in source plates. In the latter case, robotic printers containing several print-tips are used, which partition the microarray into discrete subarray blocks representing the different tips. Subsequently, one or two labeled nucleic acid samples are hybridized to the microarray under optimally calibrated conditions and the slide is then scanned to quantify probe-specific intensity calls. The raw data obtained is usually subjected to several steps of quality control and normalization in order to remove possible biases originating in any of above steps ..in-situ The reliability of microarray results has been questioned due to inconsistencies in the reported data and in conclusions reached within and between different studies -13. Othein-situ printed microarrays, which nonetheless exhibit spurious chromosomal-position-dependent correlations. This indicates that additional or different sources of bias are responsible for spurious correlations observed in gene expression studies.Here, we investigated a specific technical effect previously reported to influence microarray data. In certain microarrays, gene probes are printed on the microarray surface according to their chromosomal position or a simple transformation thereof. When coupled to spatial biases, i.e. uneven intensity measurements across the microarray surface, such non-random probe placement designs give rise to spurious correlations between genes at particular relative positions in the genome -23. ThisIn order to assess the extent of the effect causing spurious correlations in yeast microarray studies, we applied an autocorrelation analysis on a database of over 2000 individual microarray experiments. Remarkably, we find that spurious periodicities dominate yeast microarray datasets. Moreover, we demonstrate that they result from large and continuous spatial biases on the microarray surface, which are generated at the microarray hybridization step. The extent of such spatial biases, which are probably ubiquitous in microarray studies, has not been previously appreciated. We also show that autocorrelation can be used for the identification of aneuploidies in the strains used for expression studies, and that in certain cases, conclusions regarding segmental genetic changes can also arise spuriously.Spurious correlations between adjacent and periodically spaced genes were previously identified by gene-gene correlations across experimental datasets encompassing multiple microarrays -23. ThisWe tested the utility of the autocorrelation analysis on two cell cycle experiments ,27 reporTo directly demonstrate that the different periodicities represent microarray designs rather than a true biological signal, we hybridized a single RNA sample, taken from cells traversing the cell cycle, to two microarrays of different design. Indeed, the two hybridization experiments yielded different periodicities, of 24 and 48 genes respectively. Furthermore, comparison of the autocorrelation patterns with the average gene probe distance on the microarrays as a function of the genes' distance on the chromosome revealed that the different autocorrelation periodicities could be attributed entirely to the different microarray designs Figure . Thus, tWe next took advantage of the fact that autocorrelation analysis is applied to individual experiments in order to analyze in a more discrete manner three cell cycle datasets (as described above), as well as two additional datasets obtained with yet different microarray platforms. In each dataset, most experiments exhibited periodic autocorrelation, albeit with different magnitudes Figure . Moreove-16. We consider this percentage a lower bound for the fraction of experiments suffering from periodic autocorrelations. Only one source of microarrays, those produced by Rosetta Inpharmatics, did not display such periodicities, presumably due to a random probe placement design . Numerous periodic autocorrelation patterns were observed in these experiments Figure . We quann Figure . None oferiments .To identify the technical source underlying the spurious autocorrelations we observed, we simulated different forms of biases introduced onto random gene expression data in the UHN yeast microarray design. We first considered biases in separate subarray blocks, which simulates print-tip-dependent biases. Such biases have previously been suggested to underlie the spurious chromosomal-position-dependent correlations , and theTo determine the significance of the spatial biases in actual studies and the degree to which they may affect the data obtained, we considered a continuum of sizes and intensity magnitudes of horizontally-shaped biases in the UHN microarray design. As can be seen in Figure In order to determine the relative contribution of foreground and background signals to spatial biases, we visually inspected several representative microarrays. As can be seen in Figure The argument that large, print-tip independent spatial biases are the cause of spurious periodicities is also consistent with the stochastic, rather than systematic nature of the appearance of periodicities Figure . It is aThe occurrence of large spatial biases in microarray experiments from both yeast and other organisms was previously reported ,28-30). -30. 28-3The above conclusions emphasize the need to apply a spatial bias correction step when analyzing microarray data. We tested several methods for spatial bias correction and found that virtually any method, including print-tip normalization and corrections of spatial gradients, effectively eliminate all periodic autocorrelation signals (data not shown). However, none of these capture the actual nature of the spatial trends and can introduce additional biases and edge effects. Instead, a method termed MANOR  has previously been presented , which aIn addition to periodic autocorrelations, we observed many experiments with long tracts of continuously high autocorrelation Figure  lane 1, Several of the long autocorrelation tracts we observed in our expression data assembly may represent additional cases of aneuploidies in the strains used for generating the data. However, others occur in experiments in which the control and experiment samples were taken from genetically-identical culture samples. We suspected that the autocorrelation patterns observed in these cases may be the result of another ramification of the effect of specific spatial biases coupled to microarray design. Indeed, we found that narrow and long spatial biases in the SMD microarray design can cause such an aneuploidy-like signal, which is nonetheless spurious in origin Figure . Thus, sIn this study we have demonstrated the utility of autocorrelation analysis for the efficient identification and filtering of spurious chromosomal-position-dependent correlations. In particular, we provide compelling evidence for the prevalence of large spatial biases in microarray studies, to an extent unappreciated thus far. Our conclusions are based on data simulations, the stochastic nature of spurious autocorrelation patterns, and the existence of spurious correlations in spotted as well as Affymetrix microarray experiments. Although we have identified spatial biases by their manifestation in the form of periodic autocorrelation, which in itself depends on microarray design, their frequency of occurrence should be constant over many microarray platforms irrespective of design. Our simulations suggest that spatial biases are commonly associated with signal changes of a factor of two or more over large portions of the data, which represents a significant extent of bias and a potent source of false data. Spatial biases can accordingly explain the many cases of poor or suboptimal reproducibility in microarray studies. We suggest that normalization methods that correct for spatial biases, such as MANOR , should Saccharomyces cerevisiae cells grown in YPD media were arrested in late G2 by addition of 10 μg/ml Nocodazole (Sigma) for 1.5 hours and subsequently released into the cell cycle. Sample preparation, microarray hybridization and data extraction were performed as previously described [S. cerevisiae 16K array version 1.1, which consist of 70-mer oligonucleotide probes unique for each yeast gene. The raw data and log2-transformed ratio data ordered by genomic position, for each of the microarray designs, can be found at our website, at [BY4743 diploid escribed . The datsite, at .All public data analyzed is background-subtracted intensity or ratio calls without any spatial bias normalization.et al., 1998 [Saccharomyces cerevisiae Array y744, and the cdc15 temperature-sensitive mutant arrest and release experiments from Cho et al., 1998 [Yeast cell cycle expression data corresponds to the α-factor arrest and release experiment from Spellman l., 1998 , hybridil., 1998 , hybridiWe analyzed a total of 2438 separate microarray experiments from the following sources: 1) A previously described yeast gene expression database  experiments from the SMD database gave a unique autocorrelation signature and were analyzed separately. An additional 340 experiments from three studies performed on microarrays designed by Rosetta Inpharmatics [Experiments performed with deletion strains harboring verified aneuploidies , as wellarmatics ,41,42 shSaccharomyces Genome Database  was used for autocorrelation analyses. Genes were ordered according to their genomic position, taken from the se . Pearso-16 .In order to evaluate the significance of periodic patterns in the autocorrelations, we performed an autocorrelation analysis on the autocorrelation data itself. Any periodic signals are significantly enhanced by this procedure, while having only a marginal effect on non-periodic signals. We chose a significance criterion of second-iteration autocorrelation r values of >0.05, and demanded that at least 20 data points out of the first 200 pass this criterion in order for an experiment to be regarded as containing significant periodicities. These figures were chosen since they yielded zero false positives in the control dataset Figure  and, by 1 and C2 represent the center coordinates (set at the center of the microarray surface), F is a circularity factor (set at 1 for horizontally-shaped circular biases and for generating Figure Random expression data was generated by permutating measurements from a given experiment. Either individual subarray blocks, or circular spatial shapes, were given a ten-fold higher value in one channel. Circular shapes were defined as complying to the formula: AK conceived of the study, designed the study, performed the experiments and the computational analyses and drafted the manuscript. IT participated in the computational analyses and helped to draft the manuscript. NB designed the study and helped to draft the manuscript. All authors read and approved the final manuscript.