Neurogenic bladder sphincter dysfunction (NBSD) can cause severe and irreversible renal damage and bladder-wall destruction years before incontinence becomes an issue. Therefore, the first step in adequate management is to recognize early the bladder at risk for upper- and lower-tract deterioration and to start adequate medical treatment proactively. Clean intermittent catheterization combined with anticholinergics  is the standard therapy for NBSD. Early institution of such treatment can prevent both renal damage and secondary bladder-wall changes, thereby potentially improving long-term outcomes. In children with severe side effects or with insufficient suppression of detrusor overactivity despite maximal dosage of oral oxybutynin, intravesical instillation is an effective alternative. Intravesical instillation eliminates systemic side effects by reducing the first-pass metabolism and, compared with oral oxybutynin, intravesical oxybutynin is a more potent and long-acting detrusor suppressor. There is growing evidence that with early adequate treatment, kidneys are saved and normal bladder growth can be achieved in children so they will no longer need surgical bladder augmentation to achieve safe urinary continence in adolescence and adulthood. Neurogenic bladder sphincter dysfunction (NBSD) can develop as a result of a lesion at any level in the nervous system, including the cerebral cortex, spinal cord, or peripheral nervous system. Neurologic conditions in children leading to neurogenic bladder dysfunction are predominantly congenital neural tube defects . Acquired causes such as spinal cord tumors or trauma or sequelae of transverse myelitis are less frequent. Whereas from an etiologic standpoint neurogenic bladder dysfunction is a heterogeneous group, medical management will be similar irrespective of the underlying cause. The vast majority of knowledge about NBSD management comes from long-term experience with myelomeningocele (MMC), the most common neural tube defect.Following the institution of a general treatment policy with advances in neurosurgical and orthopedic treatments in previous decades, governing the associated NBSD has become crucial for improving quality of life and life expectancy in children with neural tube defects. In MMC patients, disordered innervation of the detrusor musculature and external sphincter adversely affects bladder function, which if untreated not only leads to incontinence but also will cause secondary damage and dysfunction of both the upper and lower urinary tracts. Key elements in optimal NBSD management are early diagnosis (including NBSD typology) and early (presymptomatic) institution of adequate medical treatment. There is indeed growing evidence that management decisions made during infancy, which prevent both renal damage and secondary bladder-wall changes, potentially impact long-term outcomes for renal function and safe urinary continence.After describing the pathophysiology of NBSD and its possible consequences, this paper focuses on diagnosis (including early identification of patients at risk), treatment goals, treatment tools, and practical management of NBSD.The management of NBSD in children has undergone major changes over the years. A first milestone was the introduction of clean intermittent catheterization (CIC) in 1972  and the 2O. Normal voiding pressures for males and females are from 50 to 80 cm H2O and from 40 to 65 cm H2O, respectively . Over a long period of time, hyperreflexia with pressures greater than 40 cm H2O may result in detrusor decompensation (areflexia from myogenic failure) or in detrusor hypertrophy with associated sacculations and subsequent diverticula formation. These pathophysiologic changes affect the elastic and vesicoelastic properties of the bladder and also result in mechanical ureterovesical junction obstruction. Continuous elevation of bladder pressure above 40 cm H2O may occur from a hypertonic detrusor or a hypertrophic small-capacity bladder secondary to outflow obstruction [In patients with NBSD, disordered innervation of the detrusor musculature and external sphincter adversely affects bladder function. In recent years, it has become clear that children with this condition can be categorized into high- and low-risk groups for secondary damage from a neurogenic bladder based on intravesical pressure. When the detrusor (filling) pressure exceeds 40 cm Hl reflux –10. Eventruction . Bladdertruction , 12, 13.The cornerstone of optimal NBSD management is early identification and characterization (typology) and the institution of proactive therapy. Crucial for long-term prognosis of patients with NBSD is the fact that the management must start before consequences of bladder dysfunction become apparent. From the outset, the goals of management are to prevent or minimize secondary damage to the upper urinary tracts and bladder from the primary neurogenic bladder dysfunction and to achieve safe social continence . Thus, lClean intermittent catheterization (CIC) or self-catheterization (CISC) in combination with anticholinergics (oxybutynin) is the standard therapy for children with neurogenic bladder dysfunction with detrusor hyperactivity and/or DSD , 15, 16.At birth, the majority of patients with neurogenic bladder has normal upper urinary tracts. Without proper management, urinary tract infections and elevated bladder pressures with secondary bladder-wall changes may cause upper urinary tract deterioration within 3 years in up to 58% . The spe2O, and DSD [Two different opinions exist in the literature on the use of urodynamic studies in the early evaluation and further follow-up. In one approach, urodynamic assessment has become an integral part of the initial evaluation and subsequent management, as it allows recognition of the different subtypes of NBSD (typology), proactive interventions, evaluation and guidance of therapy, and early detection of neurologic deterioration . Advoca and DSD , 6, 21.  and DSD , 23. ThoAlthough many questions regarding optimal evaluation and management remain unanswered, the consensus on the need of close surveillance, especially in the first years of life, plus the possibility that proactive treatment may be better for the bladder in the very long term, emphasize the need for an integrated approach in which clinical observations, serial imaging, and urodynamics are the basis for early adequate treatment.If properly performed, even with possible shortcomings in newborns and infancy, urodynamic studies allow direct diagnosis of NBSD and recognition of dysfunction subtypes. This functional classification allows adequate treatment for the different types and early proactive treatment for the bladder at risk .It is important for the practitioner to understand the complexities involved in performing urodynamic studies in newborns, infants, and children. Urodynamic assessment can provide reproducible results in newborns and infants, but it requires attention to mechanical factors and filling rates. The younger the child, the higher the risk that mechanical factors (such as bladder-outlet obstruction by the catheter used for the investigation) may produce artificial information (elevated leak pressure or inability to void). It has also been shown that using a bladder infusion rate as close as possible to the natural filling rate is important for correct assessment of detrusor properties . It is pIn children with neurogenic bladder, CIC is the first-choice treatment to empty the bladder adequately  and safely (prior to high-pressure voiding), and it is a valuable tool for achieving continence. The wide variety of used materials and techniques for CIC does not seem to affect efficacy and safety as long as some basic principles are applied: proper education and training, clean and atraumatic application, and achievement of good patient compliance on a long-term basis. For education, training, and further guidance during follow-up, a dedicated continence nurse is invaluable. Patients and caregivers must understand what is wrong with the bladder/sphincter and why CIC is proposed for treatment, and they have to learn how to catheterize properly. CIC has been successfully used by parents even in newborns and infants, becoming a part of their everyday routine . Some auOf the anticholinergic agents available, oxybutynin hydrochloride is most commonly used, and long-term experience supports its safety also in newborns and infants . OxybutyIn children with insufficient response or significant systemic side effects to oral oxybutynin, intravesical instillation of oxybutynin has been shown to be a highly efficacious, reliable, and well-tolerated therapy for children who would otherwise require surgical therapy –43. BecaThe mechanisms underlying the more potent and longer-acting detrusor-suppressive effects of intravesical oxybutyinin, as well as its better tolerability, have been investigated by several groups. It was demonstrated that a reduced first-pass metabolism of oxybutynin after intravesical instillation, resulting in a reduced generation of the N-desethyl metabolite, may explain the clinically relevant reduction of systemic side effects that characterizes intravesical compared with oral oxybutynin therapy . In addiTo date, the vast majority (∼ 90%) of patients can be treated successfully with the gold standard treatment of oxybutynin  and CIC. Other bladder-relaxant drugs include propiverine , trospium , extended-release oxybutynin, and tolterodine . The current experience with compounds other than oxybutynin is still limited in children with neurogenic bladder , 49. BotOptimal management involves first, early diagnosis, including recognition of high-risk subtypes, and second, proactive institution of adequate treatment. Early proactive treatment of high-pressure dyssynergic lower urinary tracts is important in the long term, not only to preserve renal function  but alsoIn clinical practice, four major subtypes can be used to describe NBSD Fig. : sphinctOnce appropriate therapy has been initiated, adequate follow-up is required, with adjustments if needed . Treatment efficacy can be assessed using clinical parameters (including CIC frequency and volume charts), urinalysis, renal and bladder ultrasound, X-ray cystography, and video urodynamics.2O; see [As long-term sequelae of insufficiently treated neurogenic bladders  already have their origin in the first years of life, the frequency of multidisciplinary follow-up visits must be age dependent . Typically, urinalysis and ultrasound are performed at all visits, cystography to investigate unexpected upper urinary tract infections, and urodynamics periodically to verify that under treatment, the catheterized bladder volumes are age appropriate  and stor2O; see ).With early instituted and optimal treatment, the large majority of patients can be adequately controlled without antireflux surgery or surgical bladder augmentation Fig. . AugmentLifelong follow-up with further periodic investigations of upper urinary tract changes, renal function, and bladder status is extremely important. There are two reasons why long-term outcome evaluation in adulthood and life-long patient follow-up are indispensable. First, for the individual patient, therapy is a life-long requisite, and verifying preservation of the patient’s kidneys is only possible by repetitive assessment throughout adolescence and adulthood. Second, in general, detailed long-term follow-up data will show whether a treatment policy driven by long-term goals is sufficiently effective or requires further adaptations. The effectiveness of efforts preserving upper urinary tract function can only be judged by assessing the ultimate outcome once these patients have reached adolescence or adulthood . In popuMedical management with CIC and anticholinergics is effective in preserving renal function and providing safe urinary continence in more than 90% of patients with a neurogenic bladder. Early diagnosis and treatment institution, long before continence becomes an issue at toddler age, can prevent both renal damage and secondary bladder-wall changes, thereby improving long-term outcomes. Compared with oral oxybutynin, intravesical oxybutynin has more potent and longer-acting detrusor suppressive effects with good tolerance and should be used prior to considering surgical therapies. Therapeutic goals should no longer be restricted to prevention of secondary damage to both upper and lower urinary tracts. Instead, our goal should be to achieve normal renal and bladder growth at safe bladder pressure, with appliance-free continence.


Among the most readily available chemical warfare agents, sulfur mustard (SM), also known as mustard gas, has been the most widely used chemical weapon. SM causes debilitating effects that can leave an exposed individual incapacitated for days to months; therefore delayed SM toxicity is of much greater importance than its ability to cause lethality. Although not fully understood, acute toxicity of SM is related to reactive oxygen and nitrogen species, oxidative stress, DNA damage, poly(ADP-ribose) polymerase (PARP) activation and energy depletion within the affected cell. Therefore several antioxidants and PARP inhibitors show beneficial effects against acute SM toxicity. The delayed toxicity of SM however, currently has no clear mechanistic explanation. One third of the 100,000 Iranian casualties are still suffering from the detrimental effects of SM in spite of the extensive treatment. We, therefore, made an attempt whether epigenetic aberrations may contribute to pathogenesis of mustard poisoning. Preliminary evidence reveals that mechlorethamine (a nitrogen mustard derivative) exposure may not only cause oxidative stress, DNA damage, but epigenetic perturbations as well. Epigenetic refers to the study of changes that influence the phenotype without causing alteration of the genotype. It involves changes in the properties of a cell that are inherited but do not involve a change in DNA sequence. It is now known that in addition to mutations, epimutations contribute to a variety of human diseases. Under light of preliminary results, the current hypothesis will focus on epigenetic regulations to clarify mustard toxicity and the use of drugs to correct possible epigenetic defects. Among the available chemical warfare agents, sulfur mustard (SM), also known as mustard gas, has been a widely used chemical weapon. Because of its devastating toxicity, its use during the World War I earned it the sobriquet “king of the battle gasses”. Other compounds such as nitrogen mustard (HN2) were developed during World War II, but found to be unsuitable as a munition ,   to various nuclear proteins. From a physiological view point, PARP-1 activity and poly(ADP-ribosyl)ation reactions are implicated in DNA repair processes, the maintenance of genomic stability, the regulation of gene transcription, and DNA replication. An important function of PARP-1 is to allow DNA repair and cell recovery under conditions associated with a low level of DNA damage. In case of severe DNA injury, overactivation of PARP-1 depletes the cellular stores of NAD+, an essential cofactor in the glycolytic pathway, the tricarboxylic acid cycle, and the mitochondrial electron transport chain. As a result, the loss of NAD+ leads to a marked reduction in the cellular pools of ATP, resulting in cellular dysfunction and cell death via the necrotic pathway . The traditional view that gene and environment interactions control disease susceptibility can now be expanded to include epigenetic reprogramming as a key determinant of origins of human disease , histone acetyl transferases (HATs) and histone deacetylases (HDACs)   in treatment of experimental toxicity may not be beneficial for victims. Data based on the experience in Iranian veterans exposed to the agent during the Iran-Iraq conflict (1983–88) have clearly shown that toxicity of SM is almost incurable even extensive treatments  (3.5 mg/kg subcutaneously) with the same time intervals. Group 2 received MEC only; group 3 received histone deacetylase (HDAC) inhibitor  (1 mg/kg) and group 4 received DNA methyl transferase (DNMT) inhibitor  (0.02 mg/kg), intraperitoneally. MEC injection resulted in severe lung toxicity with strong interstitial and alveolar edema, hemorrhage, emphysematous changes as well as mild inflammatory cell infiltration and septal thickening. In group 3, the HDAC inhibitor significantly reduced interstitial and alveolar edema, hemorrhage and inflammatory cell infiltration. On the other hand, we have observed severe lung damage by using DNMT inhibitor (group 4). In HDAC inhibitor group, the results were close to sham group. In DNMT inhibitor group, however, histology of lungs was worse than MEC group results .These preliminary results revealed that, MEC itself and/or its intracellular metabolites perturb the epigenetic environment of the affected cell in lung tissue. Hypothetically, MEC may cause HDAC induction leading to a variety of gene silencing. Since the animals were healthy and free of disease, inhibiting HDAC by Trichostatine A means that, mustards may activate HDAC which results in silencing a variety of beneficial genes which code, for example, anti-oxidant enzymes and anti-inflammatory proteins. Since decitabine worsen the MEC-induced lung injury, inhibition of DNMT may silence the genes those are physiologically silenced but require methylation to be activated. Although these genes have normally lower activation level or totally inactive, any proper stimulus can cause gene activation. From this manner, it seems logical that, by inhibiting DNMT, we may block gene expression such as anti-oxidant enzymes and anti-inflammatory proteins. If this mechanism is true, inhibiting HDAC may block the silencing of beneficial genes, on the contrary inhibiting of DNMT may result the silencing of the same group genes. Further studies are needed to clarify the involvement of epigenetic perturbations in the pathogenesis of mustard toxicity.It seems that epigenetic modifiers have influence on gene expression in the pathogenesis of mustard-induced lung toxicity. Epigenetic therapy is a new and rapidly developing area in pharmacology. To date, most trials of epigenetic drugs have been conducted to evaluate their effects on cancers, many of which have shown promising results. Epigenetic drugs alone or in combination with conventional drugs may prove to be a significant advance over the conventional drugs used to treat both acute and delayed SM toxicity. Since epigenetic defects are thought to underlie a broad range of diseases, the scope of epigenetic therapy is likely to expand. At present, the targets for epigenetic drugs are DNMTs and HDACs, but since a variety of molecules are involved in epigenetic mechanisms, there are several other targets as well.Collectively, we may speculate that, mustards may cause epigenetic perturbations within the affected cells and reducing mustard-induced lung toxicity requires gene activation rather than gene silencing. This preliminary observation warrants future studies to clarify the epigenetic perturbations in the pathogenesis of delayed-mustard toxicity. A variety of HDAC inhibitors as well as other epigenetic modifiers could give valuable results in experimental studies and may open new avenues for treatment of SM-induced toxicity.


While the deciphering of basic sequence information on a genomic scale is yieldingcomplete genomic sequences in ever-shorter intervals, experimental procedures forelucidating the cellular effects and consequences of the DNA-encoded informationbecome critical for further analyses. In recent years, DNA microarray technologyhas emerged as a prime candidate for the performance of many such functionalassays. Technically, array technology has come a long way since its conception some15 years ago, initially designed as a means for large-scale mapping and sequencing.The basic arrangement, however, could be adapted readily to serve eventually as ananalytical tool in a large variety of applications. On their own or in combinationwith other methods, microarrays open up many new avenues of functional analysis.


The treatment for inborn errors of liver metabolism is based on dietary, drug, and cell therapies (orthotopic liver transplantation). However, significant morbidity and mortality still remain, and alternative strategies are needed. Gene replacement therapy has the potential of providing a definitive cure for patients with these diseases. Significant progress has been made in the pre-clinical arena and achievement of efficacy in different animal models has been reported using multiple gene transfer technologies. This article summarizes the gene transfer strategies being investigated, the pre-clinical data, and the available early clinical results for inborn errors of liver metabolism. Significant advances in the diagnosis and treatment of inborn errors of metabolism have occurred in recent years. Expanded newborn screening using tandem mass spectrometry has led to the ability to identify and treat neonates who have metabolic conditions before symptoms appear . Developex vivo gene therapy [Progress in the direction of clinical application of gene replacement therapy has been scarce so far despite extensive investigations for over 20 years. A general skepticism toward gene therapy was raised by the death of one patient in the ornithine transcarbamylase deficiency (OTCD) clinical trial  and by t therapy . However therapy .in vivo liver-directed gene therapy should be able to transfer genes to a high percentage of hepatocytes with limited toxicity. However, the available vectors have all shown some limitations  were the first vectors used for gene therapy. They can efficiently integrate into the chromatin of target cells. However, they require the target cells to be mitotically active for an efficient transduction. Therefore, induction of liver division or liver regeneration through manipulations such as partial hepatectomy or hapatocyte growth factor treatment have been required for efficient hepatocyte transduction -11. MoreLentivirus vectors (LV) offer similar advantages to the RV, in that they mediate long-term integration of the therapeutic transgene, but unlike RV, they do not require cellular mitosis to gain access to the host genome for integration. They also are thought to share the potential for insertional mutagenesis with subsequent carcinogenesis, although this has not been observed yet in animal models. Following systemic LV delivery, the majority of transduced liver cells are of nonparenchymal origin and therefore, the efficiency of hepatocyte transduction is relatively low.in vivo, first generation of Ad (FGAd) vectors, which are replication-defective but can still express viral genes at low levels, cause acute and chronic toxicity. Helper-dependent adenoviral (HDAd) vectors, which are devoid of all viral genes, offer a better safety profile and can provide long-term transgene expression with negligible chronic toxicity [Adenovirus (Ad) vectors are well suited for liver-directed gene therapy because they can transduce hepatocytes with high efficiency. When tested toxicity . Severaltoxicity . Howevertoxicity . A clinitoxicity . As predtoxicity . Howevertoxicity . Severaltoxicity . Howevertoxicity . This actoxicity -20.in vivo administration. A wide repertoire of different AAV serotypes with different tissue tropisms is now available for several disease applications [AAV vectors are derived from a non-pathogenic human parvovirus that can infect non-dividing cells and remains latent for prolonged periods, predominantly in an episomal state. AAV vectors appear to persist in infected cells and do not trigger a robust innate response following ications . AAV vecications . In the ications . This reications  and inteications , and a wications . A recenications . On the ications .Nonviral vectors offer a number of advantages over viral-based strategies, including minimal toxicity from the vector, long-term transgene expression, lack of a humoral response against the vector, and the consequent ability to repeat dose . A majorExperimental gene therapy has been used to correct several metabolic diseases. We will discuss two diseases (Crigler-Najjar syndrome type I and OTCD) as representative examples to illustrate the potential and the limitations of currently available strategies for liver-directed gene therapy.a) the underlying defect is well characterized at the biochemical and molecular level; (b) the fraction of corrected hepatocytes required for clinical benefit is small, as deduced from hepatocyte transplantation studies [c) the UGT1A1 does not require strict gene regulation for normal activity; (d) an animal model, the Gunn rat, recapitulating the human disease is available; (e) the outcome of the experimental therapies can be easily determined by measuring bilirubin fractions in serum and bile; (f) the UGT1A1 can be produced from skeletal muscle other than liver, its natural production site, and still retain the ability to transform bilirubin into water-soluble derivatives [Crigler-Najjar syndrome is an autosomal recessive condition characterized by non-hemolytic unconjugated hyperbilirubinaemia due to mutations bilirubin-uridinediphosphoglucuronate glucuronosyltransferase (UGT1A1). Patients with Crigler-Najjar syndrome type I (MIM 218800) are refractory to phenobarbital treatment, have life-threatening elevations of bilirubin, and are generally managed with phototherapy throughout childhood and adolescence. Although effective, phototherapy is cumbersome, inconvenient, and its efficacy may diminish with age because of increased skin thickness and decreased surface/mass ratio. Moreover, despite this treatment, patients remain at risk of brain damage when intercurrent infections may increase production of bilirubin above that which can be controlled by the phototherapy . Therefo studies ; (c) theivatives . For theivatives  or in coivatives  have achivatives . Impressivatives . Among divatives . A reducivatives . HoweverUrea cycle disorders typically present in the first few days after birth with poor feeding, vomiting, lethargy, and coma due to hyperammonemia. Despite aggressive pharmacotherapy, patients are at high risk for repeated episodes of hyperammonemia and cumulative neurological morbidity and mortality ,44. GiveGene therapy for liver metabolic diseases as an alternative or adjunctive treatment to cell therapy is a logical target given the problems with the available treatment modalities. Disorders such as Crigler-Najjar syndrome and urea cycle disorders are excellent candidates because of their poor prognosis. However, each of the available vector transfer technologies offers strengths and weaknesses. Integrating vectors such as LV and RV may be associated with long-term risk of genotoxicity and potential life long correction; AAV have a lower risk regarding integration, but are limited by cloning capacity and potential adaptive immune response to viral antigens. HDAd are associated with a dose-related innate immune response but offers efficient transduction without risk of genome integration. None of these obstacles are conceptually immovable and novel strategies need to be investigated to improve the safety profile of these vectors. Based on the significant progress to date, in spite of the expected setbacks of all drug development efforts, gene therapy for liver metabolic disorders may soon become a clinical reality.The author declares that she has no competing interests.


Precancerous cells are often removed by cell death from normal tissues in the early steps of the tumourigenic process, but the molecules responsible for such a fundamental safeguard process remain in part elusive. With the aim to investigate the molecular crosstalk occurring between precancerous and normal cells lgl mutant cells growing in wild-type imaginal wing discs show poor viability and are eliminated by Jun N-terminal Kinase (JNK)-dependent cell death. Furthermore, they express very low levels of dMyc oncoprotein compared with those found in the surrounding normal tissue. Evidence that this is a cause of lgl mutant cells elimination was obtained by increasing dMyc levels in lgl mutant clones: their overgrowth potential was indeed re-established, with mutant cells overwhelming the neighbouring tissue and forming tumourous masses displaying several cancer hallmarks. Moreover, when lgl mutant clones were induced in backgrounds of slow-dividing cells, they upregulated dMyc, lost apical-basal cell polarity and were able to overgrow. Those phenotypes were abolished by reducing dMyc levels in the mutant clones, thereby confirming its key role in lgl-induced tumourigenesis. Furthermore, we show that the eiger-dependent Intrinsic Tumour Suppressor pathway plays only a minor role in eliminating lgl mutant cells in the wing pouch; lgl-/- clonal death in this region is instead driven mainly by dMyc-induced Cell Competition.We observed that lgl tumour suppressor mutant tissue to promote invasive overgrowth in larval and adult epithelial tissues. Moreover, we show that dMyc abundance inside versus outside the mutant clones plays a key role in driving neoplastic overgrowth.Our results provide the first evidence that dMyc oncoprotein is required in  Drosophila, the tumour suppressor gene lethal giant larvae (lgl) functions together with scribble (scrib) and discs large (dlg) to link apical-basal cell polarity regulation to cell proliferation control in epithelial tissues [lgl, loss of cell structure and neoplastic overgrowth indeed occur, despite a low proliferation rate, in larval imaginal epithelia, monolayered diploid organs which give rise to the adult appendages. These epithelia grow as highly disorganised, multistratified masses in which cell differentiation does not occur and the animal dies after a prolonged larval stage [lgl as a tumour suppressor is evolutionarily conserved, since the human orthologue, Hugl-1, can rescue Drosophila lgl mutants, and downregulation of its activity in human cells results in cell polarity and proliferation defects and is associated with cancer [lgl mutant tissues, adult wings from lgl+/- individuals in which lgl-/- clones had been generated at the larval stage by X-rays did not display tumourous growth [lgl mutant cells could be eliminated through a mechanism induced by the surrounding tissue.In  tissues ,2. Lgl,  tissues . Alteratal stage ,2. Furthal stage , thus shh cancer ,6. Despis growth , raisinglgl-/- clones from developing into tumours. First, it has been recently shown that the growth of polarity-deficient scrib or dlg mutant clones is counteracted by the so-called Intrinsic Tumour Suppression (ITS) mechanism, which functions by triggering in the mutant cells both endocytic uptake and endosomal activation of the Eiger protein , which in turn leads to activation of pro-apoptotic JNK signaling [Cell Competition (CC), where slow-dividing cells are killed and replaced by the surrounding faster-growing populations, eventually giving rise to an organ of proper size [Minute (M) mutations in Drosophila [M/+ cells are viable in a homotypic context  though showing a reduced rate of cell proliferation; however, when juxtaposed to wild-type cells, they are eliminated by apoptosis and the wild-type cells overtake the M/+ cells so that the organ eventually reaches normal size. It has been recently speculated that these competitive interactions could have evolved as a mechanism ensuring that viable but unfit, damaged or potentially harmful cells do not accumulate within a growing tissue, and this could be the case in normal development as well as in tumourigenesis [Minute and dMyc-induced CC are assumed to depend on a local difference in ribosome biogenesis or function that affects cell growth and proliferation [lgl mutant cells have both abnormal polarity and a reduced proliferation rate, so both ITS and CC may be involved in their elimination. In Drosophila epithelia, two main pathways are known to trigger apoptosis upon polarity alteration: the JNK signalling and the Hid/dIAP1 pathways [There are two mechanisms described in the literature that may act to prevent ignaling ,9. Howevignaling . ITS canper size . CC was osophila , a groupigenesis ,13. Duriigenesis ,15. Bothferation  and upreferation , among wferation ,19. lgl pathways . JNK sigpathways ,15.lgl mutant cells, we induced lgl-/- clones in diverse backgrounds and tissues. We show that lgl-/- clonal phenotype strictly depends on dMyc oncoprotein levels: when lgl-/- cells have lower levels of dMyc with respect to the surrounding tissue, their clonal growth is restricted by JNK-mediated apoptosis, whereas when lgl-/- cells have high levels of dMyc, mutant clones survive and proliferate to form invasive tumours.In order to identify possible molecules and mechanisms associated with the phenotype of lgl mutant cells during development, we induced clones of two different lgl null mutations in Drosophila wild-type wing discs, larval proliferating epithelia where competitive mechanisms between genetically different cell populations have been extensively characterised [lgl4 [lgl27S3 [lgl-/- clones and their twin lgl+/+ clones were similar in size , ubiquitously expressed in imaginal tissues [lgl-/- cells , lgl mutant clones were smaller than their wild-type twins , as well as smaller than wild-type clones induced in control discs . The wild-type twins of lgl-/- clones  were instead much larger than the wild-type twins from control discs . Since no dominant effects on cellular growth rate have been reported for lgl null mutations, and developmental stages of lgl+/- animals are of the same duration as those of lgl+/+ individuals, even in clonal assays, this result suggests that some non-autonomous mechanisms are at work in lgl-/- clone elimination and that mutant cells are being replaced by the normal surrounding tissue.To test whether competitive interactions were involved in the elimination of d Figure . As expelgl mutant clones with respect to the surrounding lgl+/- tissue  and showed low levels of cell death (not shown). Thus, low dMyc levels in lgl-/- cells seem to affect growth and viability of these cells mainly in the distal region (wing pouch), where the surrounding tissue expresses high levels of dMyc.Since it is known that differences in dMyc abundance among adjacent cells can trigger competitive behaviour ,15, we ne Figure . We therlgl mutant cells could be a cause of their elimination from the epithelium, we took advantage of the MARCM system [UAS-dmyc construct [lgl-/- clones. As can be observed in Figure lgl-/-; UAS-dmyc (dmycover) clones were round in shape and massively overgrown, with the largest clones located in the proximal regions of the disc. A 10-fold increase in clone area was observed with respect to lgl-/- control clones induced through the same genetic system . A gain in cell size has been reported for dmycover cells [lgl-/-; dmycover clone area. Our analysis confirmed that cells in lgl-/-; dmycover clones were larger than in lgl-/- control clones , but this gain in cell size accounts only for a small fraction of clone expansion, indicating that the massive overgrowth of lgl-/-; dmycover clones is due mainly to a substantial increase in cell number.To investigate if the reduced level of dMyc protein in M system  to expreonstruct  in lgl-/er cells , raisinglgl-/-; dmycover clones. However, while small clones showed many active-Caspase 3 positive cells . Furthermore, active-Caspase 3 staining was evident immediately outside the overgrown clones , where the endogenous dMyc levels are very low and competitive interactions between lgl-/- and wild-type cells are relaxed, some lgl-/-; dmycover cells survived and formed clonal progeny that expressed dIAP1 and was therefore able to take advantage of dMyc's role in promoting biosynthesis and proliferation to out-compete surrounding cells  instead grew poorly, did not express dIAP1 protein and underwent untimely cell death , indicating that the differentiation of adult structures was impaired.A staining for the apical marker aPKC indicated that s Figure , arrows,osophila ,31,32. Nlgl-/-; dmycover clones in the wing pouch behave differently from those in the wing hinge/pleura. In Figure UAS-dmyc transgene, clones do not show the high levels of dMyc protein observable in the clone located in the hinge. Since dmyc expression was induced using a heterologous promoter, the fact that dMyc protein is low in the lgl mutant clones in the wing pouch suggests that in this region an lgl-dependent regulation of dmyc at a post-transcriptional level is at work. Moreover, this result suggests that dMyc protein must be stably upregulated in lgl mutant clones in order to trigger overgrowth. This observation is similar to that of many human cancers, where Myc protein is highly and stably overexpressed [dmyc in cooperating with the loss of a tumour suppressor to promote proliferation and to unleash the invasive potential of mutant cells.As discussed above, xpressed . Altogetlgl-/- cells in an lgl+/- background by other growth-promoting molecules, we expressed in lgl-/- clones an activated form of the catalytic subunit of the Phosphoinositide-3 Kinase, dp110CAAX [dp110 is not able to rescue the defective growth of lgl-/- cells. Indeed, UAS-dp110CAAX; lgl-/- clones are comparable in size to lgl-/- clones induced through the same technique ; moreover, no significant impairments in cell polarity were observed . As can be seen in Figure lgl-/-; UAS-dIAP1 clones in the wing pouch still showed active-Caspase 3 signals (arrow). A statistical analysis performed on clones found in the wing pouch indeed demonstrated that they are smaller than their wild-type twins . Since the JNK pathway is activated in lgl mutant clones in the wing pouch  These phenotypes were associated with high dMyc levels, as shown in Figure lgl, scrib and dlg are accompanied by an ectopic expression of activated (oncogenic) Ras or Notch [Since several molecules associated with cell death were found to be deregulated in h Figure , arrow, or Notch ,38,39.lgl-/- clones by using a bskDN transgene [lgl-/- clones, regardless of the region in which they were located (not shown), indicating that JNK signalling-induced cell death is the main pathway by which lgl mutant cells die. As can be seen in Figure UAS-bskDN; lgl-/- clones in the wing pouch (outlined) expressed low levels of dMyc and did not form tumours; statistical analysis performed in this region showed that, despite the fact that UAS-bskDN; lgl-/- clones no longer died, their size was smaller than that of their wild-type twins , demonstrating that even when cell death is blocked UAS-bskDN; lgl-/- cells have a proliferative disadvantage with respect to the wild-type tissue.We then blocked the JNK pathway inside the ransgene  and founUAS-bskDN; lgl-/- clones in the proximal regions (hinge and pleura) showed high dMyc protein levels, lost polarity and overgrew  pathway, involving JNK-dependent apoptosis induced by an endocytic accumulation of the TNF homologue, Eiger (Egr) [scrib and dlg are well-known lgl partners in regulating apical-basal cell polarity and proliferation and show similar neoplastic phenotypes in a homotypic background [lgl-/- clones could be eliminated by a similar mechanism. To investigate this, we first looked for alterations in endocytosis in the lgl mutant clones by using an early-endosome reporter, Rab5, since it was observed by Igaki et al. [scrib mutant clones in the eye disc correlating with pJNK staining. However, in the wing pouch region we did not observe changes in Rab5 levels within lgl-/- clones with respect to the neighbours . Similar effects were seen in lgl mutant clones in discs in which the UAS-egrRNAi construct was expressed under the control of the hedgehog promoter in the whole posterior compartment, thereby also removing Egr protein in the lgl+/- background (not shown). In Figure lgl mutant clone is being basally extruded  in the wing pouch were much smaller than the wild-type twins  . Since sckground , it couli et al.  that Rabe Figure . lgl-/-; of Rab5  to blocklgl-/- cells grew slower than wild-type cells in a clonal context, which is possibly the main reason why they are eliminated from the epithelium. To confirm the hypothesis for an active role of CC in restraining lgl-/- clonal growth, we induced lgl mutant clones in the slow-dividing Minute background, to give them a proliferative advantage. As can be seen in Figure lgl mutant clones in these larvae were able to overgrow  and cells became rounded, indicating that apical-basal polarity was lost, as can be seen in the Z projection where aPKC apical determinant spreads cortically. lgl-/- clones showed high levels of dMyc protein  was observed , suggesting that dmyc is able to induce apoptosis in the surrounding cells also in this tissue. Indeed, lgl-/- clones expressed dMyc protein in early egg chambers . Further, we allowed clones to grow for four additional days in order to obtain stronger phenotypes. As can be seen in Figure lgl-/- cells; clonal phenotype varied from larger areas of multilayered tissue  and no multilayered tissue was seen, demonstrating that also in this epithelium dMyc protein is required for lgl mutant clones to grow as malignant tumours.With the aim of assessing whether the oncogenic cooperation between se cells . We founs Figure , consistr Figure . This cet clones  in adults Figure  as well s Figure , where es Figure . dmyc wae Figure , which se Figure , to clone Figure , arrow. Drosophila, lgl mutant larvae show neoplastic overgrowth of the epithelial tissues, whereas lgl- cells growing in mosaic larvae are usually eliminated by cell death; thus this opposite phenotype results from mechanisms triggered by the confrontation of lgl- and lgl+ cells. In the literature, two main processes have been described to mediate the elimination of unfit/polarity-deficient cells from Drosophila imaginal epithelia: Cell Competition (CC) and Intrinsic Tumour Suppression (ITS) [Deciphering the molecular crosstalk occurring between genetically different cell populations growing within a tissue is relevant to both developmental and cancer biology. In on (ITS) . Both meon (ITS) , while ton (ITS) . There ion (ITS) ,13,46, hlgl mutant clones are eliminated from imaginal wing epithelia . Consistent with the SWH pathway being deregulated, the bona fide Yorkie target, dIAP1 [lgl- clones that overgrew and expressed dMyc  Cell Signaling Technology, Inc., Danvers, MA, USA); mouse anti-dIAP1 ; rabbit anti-Laminin A ; rabbit anti-Scribble ; mouse anti-dMyc (1:5) ; mouse a2) and fluorescence intensity , ImageJ free software from NIH, Bethesda, MD, USA, was used. Fluorescence intensity  was calculated as the average gray value within the selection. The average and the standard deviation alone or the t-Student test P value are given in the text. For the correlation between clone size and active-Caspase 3 staining in Figure http://www.xlstat.com). To measure average cell area in wing disc clones, TOPRO stained nuclei and clone area were scored in confocal series and the relative cell area (in pixels2) was calculated.To measure clone area  is visible. The whole thickness of the disc is shown in which the overgrowth of the mutant clone is clearly observable.Click here for file


We investigated whether lack of perceived neighborhood safety due to crime, or living in high crime neighborhoods was associated with incident mobility disability in elderly populations. We hypothesized that low-income elders and elders at retirement age (65 – 74) would be at greatest risk of mobility disability onset in the face of perceived or measured crime-related safety hazards.We conducted the study in the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE), a longitudinal cohort study of community-dwelling elders aged 65 and older who were residents of New Haven, Connecticut in 1982. Elders were interviewed beginning in 1982 to assess mobility , perceptions of their neighborhood safety due to crime, annual household income, lifestyle characteristics , and the presence of chronic co-morbid conditions. Additionally, we collected baseline data on neighborhood crime events from the New Haven Register newspaper in 1982 to measure local area crime rates at the census tract level.At baseline in 1982, 1,884 elders were without mobility disability. After 8 years of follow-up, perceiving safety hazards was associated with increased risk of mobility disability among elders at retirement age whose incomes were below the federal poverty line . No effect of perceived safety hazards was found among elders at retirement age whose incomes were above the poverty line. No effect of living in neighborhoods with high crime rates (measured by newspaper reports) was found in any sub-group.Perceiving a safety hazard due to neighborhood crime was associated with increased risk of incident mobility disability among impoverished elders near retirement age. Consistent with prior literature, retirement age appears to be a vulnerable period with respect to the effect of neighborhood conditions on elder health. Community violence prevention activities should address perceived safety among vulnerable populations, such as low-income elders at retirement age, to reduce future risks of mobility disability. Preventing the onset of mobility disability among elders is a public health priority in the United States (US) . Generalpsychosocial conditions , lifestyle behaviors , and material resources  [To this end, the growing socioeconomic status (SES) disparity in aging-related disability among elders is of particular concern ,8. Schoeorhoods) ,10-12. Aorhoods) ,13. FindIt is possible that chronic exposure to dangerous neighborhoods may have implications for the onset of mobility disability among low-income elders. Living in dangerous or high-crime neighborhoods is frequently cited as a potential health hazard for low-income elders . An emerTheoretically, chronic exposure to neighborhood crime may contribute to stress, allostatic load, and the onset of co-morbidity. Second, though elders are less frequently victimized by crime than younger adults, crime may expose elders to risk of direct injury leading to mobility disability onset . In addiThus, here we examine effects of neighborhood crime rates and perceived neighborhood safety hazards due to crime in a longitudinal cohort of retirement-aged and older elders free from mobility disability in the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE). We hypothesize that over an eight-year period, elders who live in high-crime neighborhoods and those who perceive their neighborhoods as unsafe due to crime at baseline will have higher risk of an incident mobility disability event than those who do not. Additionally, we hypothesize that these risks will be particularly salient in low-income populations who are at risk for high exposure and have fewer resources for coping with stress.The New Haven EPESE is a longitudinal cohort of 2,812 non-institutionalized elders aged 65 and older in 1982. New Haven is an urban city in Connecticut with a socio-economically diverse population. The EPESE study design and sampling frame have been described elsewhere . BrieflyData were collected annually; face-to-face interviews were conducted at baseline and at three-year intervals, and telephone surveys were conducted in the intervening years. Participants in the present investigation were followed for eight years from baseline in 1982 or until death. Data on deaths were obtained through matching participants with the National Center for Health Statistics National Death Index.Mobility disability, an early marker of elder disablement, was defined as the inability to climb a flight of stairs or walk a half-mile without assistance, based on the work of Guralnik et al . MobilitPerceived neighborhood safety at baseline was measured with the item "how safe from crime would you say your neighborhood is?" This item was also used in the Behavioral Risk Factor Surveillance Survey (BRFSS) . Partici®. The number of UCR crimes per square mile of the census tract reported in the NHR was used to measure neighborhood crime rates (NHR Crimes). Using the PROC RANK procedure in SAS®, neighborhoods were then ranked by the number of NHR Crimes per square mile in the neighborhood (census tract) and divided into "highest-crime neighborhoods" (highest tertile) and lower-crime "comparison neighborhoods" (first and second tertiles). To determine whether our measure of neighborhood crime was at all related to impressions of exposure to crime among neighborhood residents, we calculated the percentage of EPESE participants who perceived neighborhood safety hazards due to crime at baseline within each census tract, and then calculated the ecologic correlation between the NHR Crime rate measure in each census tract, and the percentage of EPESE participants who perceived neighborhood safety hazards due to crime in each census tract.Crime statistics at the neighborhood level were not readily available from public sources in New Haven for the baseline time period in 1982. Thus, the authors collected crime reports meeting Uniform Crime Reports (UCR) category definitions from the city's major newspaper, the New Haven Register (NHR), to derive neighborhood crime rates. Though there is no gold standard for assessing crime rates at the neighborhood level, the definitions of UCR crime categories  are used consistently across government reporting agencies and are considered a valid and reliable index of the types of crime residents view as serious events . To obtaThe participant's baseline annual household income from self-reported wages, salaries, social security, retirement benefits, help from relatives, and rent from property was coded into low , middle , and high  income groups. The federal poverty line in 1980 was approximately $5,000 among those aged 65 and older for a household of two {2007 108/id}. We defined low-SES (impoverished) elders as those below the poverty line. We compared impoverished elders  to middle and highest-income groups .An indicator variable denoted the number of years elders lived in their baseline neighborhoods (≤ 5 years or >5 years). A separate variable indicated whether they moved away from the baseline residence at any point during the study period.Race/ethnicity, sex, and age were assessed by self-report. This analysis was restricted to participants who identified as non-Hispanic black or non-Hispanic white, and excludes 43 New Haven EPESE participants from other or unidentified race/ethnic groups. Age categories were divided into retirement age (ages 65 to 74) and older elders (ages 75 and older).co-morbid conditions at baseline as confounders of the relationship between neighborhood safety (perceptions of safety and crime rates) and mobility disability. Elders were asked to report whether a physician had given a diagnosis of a specific chronic medical condition. A co-morbidity index was then created as the sum of self-reported conditions present at baseline [We measured self-reported baseline ,26. Condbaseline . Obese bcognitive impairment and depressive symptoms as factors that may influence perceptions of neighborhood safety. The 6-item Short-Portable Mental Status Questionnaire (SPMSQ) measured cognitive function [Additionally, we used validated scales to measure function . Inabilifunction ,29.To assess potential mediating effects of neighborhood safety on physical activity, self-reported walking behavior was assessed. Respondents reported subjective walking habits as "often," "sometimes," or "never" during the month prior to the interview.To assess potentially negative coping strategies, we measured smoking behavior and alcohol use. Smoking status was measured by self-report of never, ever, or current smoking through two questions: "Do you smoke cigarettes now?" and "Did you ever smoke cigarettes?" Non-smokers were identified as those who responded that they did now, nor ever smoke cigarettes. Thirty-day alcohol consumption was calculated using self-reported daily intake of cans of beer, ale, glasses of wine, and spirits over the past month. Monthly ounces of alcohol were divided into three categories: (1) none (2) moderate (≤ 70 oz. per month), and (3) heavy consumption (> 70 oz. per month). Prior EPESE findings show that moderate alcohol consumption has protective cardiovascular effects .The analysis excluded participants with mobility disability at baseline, participants with missing data on baseline mobility status, and one participant lost to follow up, for whom the incident mobility disability event could not be identified. Time to incident mobility disability within eight years of follow-up was calculated from annual survey responses between 1982 and 1990. Participants were censored in the year they reported an incident mobility disability event, and stopped contributing person-time to the analysis from that year forward. Elders who died prior to experiencing an incident mobility event were censored as a non-event and stopped contributing person-time to the analysis at the time of death.® to obtain variances estimated with the Taylor Series approximation with replacement (WR) and were weighted with survey design weights to account for the complex EPESE sampling frame. Age-adjusted incidence rates representing the total number of incident cases of mobility disability over eight-years of follow up per 1,000 person-years were calculated in SUDAAN with the PROC RATIO procedure.Descriptive statistics and bivariate associations for continuous and categorical variables at baseline were estimated with the PROC DESCRIPT and PROC CROSSTAB procedures in SAS-callable SUDAAN® version 9.2. The Harvard School of Public Health Institutional Review Board approved this study.Hazard Ratios (HR) with 95% confidence intervals (CI) were computed with proportional hazards models with discrete time intervals in SUDAAN to estimate effects of perceived neighborhood safety hazards or living in the highest-crime neighborhoods at baseline on incident mobility disability in the full cohort, and among subgroups of elders at retirement age (65 to 74 years), older elders at ages 75 and older, as well as among impoverished elders and higher-income groups . Models Baseline cohort characteristics are shown in Table With respect to lifestyle, approximately 19% were current smokers, and 5% were heavy alcohol drinkers . The cohort was physically active, with 54% rating the subjective frequency of their walking behavior as "often" in the past month.The majority of elders were long-time residents in their baseline homes; 77% lived in their baseline homes for more than five years. Thirty-four percent moved from their baseline residences at some point over the eight-year study period. Twenty-seven percent of study participants lived in the highest-crime neighborhoods, and 22% perceived their neighborhoods were unsafe due to crime Table .Figure Table Figure Table Table decreased risk of mobility disability associated with perceived safety hazards was seen among older elders . Taking walks was not statistically significantly associated with reduced mobility disability risk among impoverished retirement-aged elders.However, among retirement-aged elders who were impoverished, perceiving a safety hazard was a statistically significant predictor of mobility disability after adjustment for covariates . Living in the highest-crime neighborhoods did not predict incident mobility disability events in this sub-group. Having multiple co-morbid conditions and having moved from the baseline residence during the study predicted an increased risk of incident mobility disability over the eight-years of follow-up among impoverished retirement-aged elders. However, long-time residential tenure in the baseline residence was associated with a non-statistically significant trend toward an decreased risk of incident mobility disability compared to those who did not perceive safety hazards (HR 0.55 95% CI 0.36 – 0.85). Additionally, elders aged 75 and older with incomes above the poverty line had increased risks of mobility disability if they moved from their baseline residence, or reported never walking for exercise in the past month prior to study entry.In the adjusted model among elders aged 75 and older, those with incomes above the poverty line who perceived their neighborhoods were unsafe due to crime had a No statistically significant effect of perceived safety hazards was found among impoverished elders aged 75 and older. Correlates of mobility risk among impoverished elders aged 75 and older included having multiple co-morbid conditions, being obese, and having a significant cognitive impairment  strong correlations at the ecologic level between our measure of the neighborhood crime rate and the percentage of EPESE residents who believed their neighborhoods were unsafe due to crime, (2) strong associations between an individual's lack of perceived safety and residence in neighborhoods with the highest crime levels, as well as (3) significant cross-sectional associations between an individual's residence in the highest-crime neighborhoods and having multiple co-morbid conditions at baseline. Nonetheless, we found that unlike perceiving safety hazards, living in the highest-crime neighborhoods did not predict incident mobility disability in any group. Finally, we found an inverse association by which older elders above the poverty line appeared to have a Our findings among low-income elders at retirement age (65 to 74) support observations in the literature that neighborhood conditions may have the greatest negative effects on this age group . Robert Our findings contrast with previous studies that have not found strong effects of perceived neighborhood safety or measured crime rates. Two studies measured perceived neighborhood safety as a separate item in relation to mobility disability incidence. Among these, neither the Alameda County Study  nor the African American Health Study (a three-year study of middle-aged adults aged 49–65) found an association between perceived neighborhood safety and incident mobility disability ,18. DireThe finding that perception of safety, rather than crime rates, was related to incident mobility disability in this group generates the hypothesis that dangerous neighborhoods "get into the body" to engender mobility disability through psychosocial or psychological processes. Effects of perceived safety were robust to adjustment for cognitive impairment and depressive symptoms, both of which may increase risks for mobility disability or influence one's appraisal of neighborhood conditions. Strong correlations between living in the highest-crime neighborhoods and perceiving safety hazards among individual study participants suggest that study participants' perceptions were grounded in observable neighborhood conditions related to crime. But at the same time, perceptions more than objective measures appeared to correlate with future mobility disability. Further studies using survey data or biologic data that capture stress-related pathways that may connect perceptions of safety to disablement processes would help us understand the mechanisms underlying these associations.less likely to have ADL disabilities than those who were not victimized by crime [With respect to the older elders in this cohort (75 and older), "inverse" associations between perceptions of safety and mobility disability should not be discounted. Previous research by Lachs et al. among EPESE participants identified an inverse cross-sectional relationship between ADL disability and criminal victimization, by which older adults who were victimized by crime were by crime ,34. Lachby crime . FurtherTaken together, our findings suggest that the effects of neighborhood safety on mobility disability operate through elders' perceptions rather than through direct measures of crime, and that such negative perceptions of safety pose a hazard primarily for retirement-aged elders who are poor. Competing risks of mortality may complicate interpreting findings among the oldest old.Our findings should be interpreted in light of limitations in our data. First, in studying perceived safety, we cannot fully eliminate self-report bias as a contributor to our findings, where those who are developing mobility disability perceive their environments to be less safe due to crime. The prospective study design, limiting the cohort to those mobile at baseline, and adjusting for co-morbid conditions makes reverse causation unlikely as a sole explanation for our findings. Second, due to the difficulty in finding crime statistics for small areas, we obtained our measure of neighborhood crime rates from the city's newspaper. Though journalists work with local law enforcement to find source material, media reports of crime events are known to be biased toward severe and dramatic events, and only a small sample of crimes are reported ,37. HoweAn additional limitation is that we used annual household income to measure of SES, rather than an index of wealth that estimates assets and net worth, which are thought to capture socioeconomic status more completely than income in elderly populations . MoreoveAn additional limitation, in contrast to the existing literature on the effects of neighborhood disadvantage on health outcomes, we measured two facets of disadvantage, perceived neighborhood safety and neighborhood crime, rather than a larger multifaceted index of disadvantage with other observed conditions such as neighborhood walkability. Indices of neighborhood disadvantage may be considered more holistic appraisals of neighborhood conditions, since they assess multiple dimensions known to affect disablement, including social and built environmental characteristics . To be sLast, a potential limitation is that observations of the EPESE cohort were made in the past, from the 1980s to 1990s. Given the small declines in disability prevalence among low-income elders, and persistent SES gradients in risks for disability between this period and the present, the experiences of low-SES elders in this cohort remain quite relevant to understanding contextual factors that contribute to mobility disability risks. We note that during this period, the New Haven EPESE cohort had few participants who were from racial/ethnic backgrounds other than non-Hispanic blacks and whites, and we do not present this data here. Additional cohort studies are needed to determine if our results generalize to other racial and ethnic groups.These important limitations considered, our study has several strengths, including a longitudinal prospective design, a community-based random sample of elders with varied residential exposures, a high response rate (82%), and the use of previously validated measures of mobility disability and safety perception. Moreover, the analysis detected diversity in effects of socioeconomic factors and facets of neighborhood disadvantage in at least two stages of the life course, with evidence for heightened vulnerability at retirement age. Finally, our findings on the effect of a perceived safety hazard on incident mobility disability risk have implications for future public health interventions. For example, community-based interventions might survey low-SES elders at retirement age, and target social capital building, social support, or other appropriate interventions toward elders who feel unsafe in their neighborhoods as strategies to reduce risk for disablement . WhereasWe find that among elders who are impoverished at retirement age, perceiving neighborhood safety hazards increases their risk of incident mobility disability. Additionally, we suggest further investigations of the correlates of perceived safety among the oldest old may help us understand factors that promote healthy aging. Our findings underscore the importance of the psychosocial dimension of neighborhood context as a determinant of healthy aging. Specifically intervening to improve perceptions of neighborhood safety at retirement age may be an important step to reduce the risk of mobility disability among vulnerable elders.The authors declare that they have no competing interests.CRC conceived the analyses, designed and carried out the analyses, prepared the manuscript, and reviewed and approved the final version. IK conceived and contributed to the design of the ecologic data collection, and contributed to the conception of the analysis, and preparation of the manuscript. LR contributed to the design and interpretation of the analysis. KE contributed to conducting the analysis. MEF contributed to the data collection, design and data management of the analysis. LFB contributed to the parent study design and data collection, the conception and design of the present analysis, and preparation of the manuscript. All authors reviewed, edited, and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


The Editor, Current Oncology December 24, 2007In their commentary, Drs. Takahashi and Nishiboriin vivo by inducing the transcription factor forkhead box P3Statins increase the number of regulatory T cells (Tregs) p = 0.009) inverse association between achieved low-density lipoprotein cholesterol levels and cancerIndeed, analysis of large randomized statin trials demonstrate a highly significant (prosper (Prospective Study of Pravastatin in the Elderly at Risk) trialpost hoc analysis of the lipid studytnt (Treating to New Targets) studyThe elderly are relatively immunosuppressed and are more likely to harbour occult cancerscare trialwoscops (West of Scotland Coronary Prevention Study), a 5-year prospective trial of pravastatin in hypercholesterolemic men, revealed an increase in prostate cancer in the men who were randomized to pravastatin therapyAn alarming increase in breast cancer incidence, some of which were recurrences, was seen in women randomized to pravastatin in the Statin therapy has been associated with tumour progression leading to radical cystectomy in patients treated for bladder cancer with bacille Calmette–Guérin immunotherapyStatin trials have typically randomized subjects free of prevalent cancers and have been about 5 years in duration. Long-term follow-up data are limited, particularly for the development of cancer. Statins are now promoted for widespread use in adults of all ages and at high dosesLong-term prospective data are needed on the feasibility of statin therapy in the very elderly, the immuno-suppressed, and those with prevalent cancer. Furthermore, long-term outcome data are needed in young individuals treated with statins for prolonged time periods. Perhaps a constant increase in Tregs over years, even in the young, will weaken host antitumour immune surveillance and increase the risk for various cancers.In conclusion, we feel that there is ample evidence that statins may promote cancer in certain segments of the population. Currently, the indications for statin therapy are based on lipoprotein levels, prevalent cardiovascular disease, other vascular risk factors, and family history


Exercise-induced bronchoconstriction (EIB) is described by transient narrowing of the airways after exercise. It occurs in approximately 10% of the general population, while athletes may show a higher prevalence, especially in cold weather and ice rink athletes. Diagnosis of EIB is often made on the basis of self-reported symptoms without objective lung function tests, however, the presence of EIB can not be accurately determined on the basis of symptoms and may be under-, over-, or misdiagnosed. The goal of this review is to describe other clinical entities that mimic asthma or EIB symptoms and can be confused with EIB. Exercise-induced bronchoconstriction (EIB) is a common entity and is described by the transient narrowing of the airways during or most often after exercise -4. It ocThe diagnosis of EIB is often made on the basis of self-reported symptoms without objective lung function tests. However, the presence of EIB can not be accurately determined on the basis of symptoms ,23,24. RAccurate diagnosis of EIB is essential. EIB is effectively prevented by acute use of b2-agonists, leukotriene receptor antagonists, sodium cromoglycate, and nedocromil sodium and the chronic use of inhaled corticosteroids ,25,26. H1) in response to exercise  for a diagnosis of EIB require a 10% or greater decrease in forced expiratory flow in the first second of exhalation (FEVSymptoms of EIB include dyspnea (sensation of discomfort when breathing), increased effort or work to breathe, chest tightness, shortness of breath, air hunger, wheezing, or cough ,29. HoweThe goal of this review is to describe other clinical entities that mimic asthma or EIB symptoms and can be confused with it. More than one condition may coexist in a given patient.Increased ventilation is a normal physiologic response to exercise. However, the increase in respiratory drive and work may be interpreted as pathologic by subjects who find that it limits their ability to perform to their expectations or results in "normal" discomfort. In a study by Abu-hasan et al, physiologic limitation was the most common reason for exercise-induced dyspnea in pediatric patients who underwent cardiopulmonary exercise testing . It occuDeconditioned subjects have a lower lactate/ventilatory threshold and begin to accumulate lactate and increase minute ventilation with lesser amounts of exercise. Deconditioning is a common etiology for exercise-induced dyspnea . In a stExercise rehabilitation or training can improve aerobic fitness and endurance  and can Exercise-induced dyspnea is very common in obese patients. In one epidemiological study, 80% of obese middle aged subjects reported dyspnea after climbing two flights of stairs . In anotThere are several reasons why obese subjects experience dyspnea during exercise. Obesity is associated with impairment of pulmonary mechanics; in mild obesity, there is a reduced expiratory reserve volume (ERV) which is likely due to the displacement of the diaphragm into the chest cavity by the fat stores within the abdomen. With increasing severity of obesity, there are decreases in total lung capacity (TLC), functional residual capacity (FRC), and maximal voluntary ventilation (MVV)-44. Beca2 max) is decreased when corrected for weight [Aerobic capacity and cardiopulmonary fitness may be decreased in obese patients. Cardiopulmonary fitness, reflected by maximal or peak oxygen consumption , a feared cause of sudden death in athletes, can be associated with exercise-induced dyspnea and progressive heart failure -84. It wCardiac dysrythmias are a rare cause of exercise-induced dyspnea. Atrial fibrillation and other supraventricular tachyarrhythmias are uncommon in elite athletes and similar to that observed in the general population (< 1%) . TachyarVascular anomalies of the thoracic aorta such as a double aortic arch or right aortic arch with persistent ligamentum arteriosum or aberrant left subclavian artery have been associated with dyspnea on exertion ,91. The Pulmonary arteriovenous malformations (AVM) can be associated with exercise-intolerance and arterial hypoxemia. Most pulmonary AVMs are associated with an autosomal dominant disorder, hereditary hemorrhagic telangiectasia (HHT) or Osler-Weber Rendu . The incThe gold-standards for diagnosis of AVMs are pulmonary angiography and chest computed tomography ,102. CheOther pulmonary abnormalities can present with exercise-induced dyspnea. Chest wall or other musculoskeletal abnormalities can impair pulmonary mechanics. In the series of Abu-Hasan et al, 11% of patients had restrictive physiology due to mild scoliosis or pectus abnormality as the cause of their exercise-induced dyspnea . Pectus Tracheobronchomalacia, dynamic collapse of the central airways, may produce airflow limitation during exercise and has been associated with exercise intolerance . The incInterstitial lung disease is associated with exercise-induced dyspnea. Mechanisms for dyspnea and exercise limitation are expiratory flow limitation, hypoxemia and altered pulmonary mechanics -118. DiaThe sequelae of moderate and severe chronic obstructive pulmonary disease (COPD) on exercise-induced dyspnea are well recognized. However, mild COPD can also be associated with increased dyspnea with exertion which reflects abnormal ventilatory mechanics including airway obstruction, increases in end-expiratory lung volumes and deconditioning -122.Dyspnea can be associated with diseases of skeletal muscles (myopathies) . In muscIn summary, reported symptoms and history without objective lung function tests are not adequate to make a definitive diagnosis of EIB. Approximately half of those athletes reporting symptoms of EIB have normal airway function and about half of those who report no symptoms will demonstrate bronchoconstriction after exercise or other indirect challenge ,24,127. The authors declare that they have no competing interests.Both authors have made substantive contributions to drafting and revising the manuscript. Both authors read and approved the final manuscript.


Clinical diagnosis of kidney transplants related illnesses is not a simple task. Several studies were conducted to define diseases and complications after renal transplantation, but there are no comprehensive guidelines about diagnostic tools for their prevention and detection.The Authors of this review looked for the medical literature and pertinent publications in particular to understand the role of Human Polyomavirus BK (BKV) in renal failure and to recognize analytical techniques for BK virus associated nephropathy (BKVAN) detection. Clinical diagnosis of kidney transplants related illnesses is not a simple task. Several studies were conducted to define diseases and complications after renal transplantation, but there are no comprehensive guidelines about diagnostic tools for their prevention and detection.The Authors of this review looked for the medical literature and pertinent publications in particular to understand the role of Human Polyomavirus BK (BKV) in renal failure and to recognize analytical techniques for BK virus associated nephropathy (BKVAN) detection. For reviewing we used Medline and recent pertinent bibliographies.Kidney pathologies in renal transplants are associated with graft function, immunosuppressive drugs and infections . MoreoveThe morbidity and mortality rates associated with renal transplantation and the use of immunosuppressive medications are high. Conventional immunosuppression is based on azathioprine, nevertheless, other immunosuppressive drugs, such as cyclosporine A (CsA), tacrolimus, sirolimus, mycophenolate-mofetil (MMF) and corticosteroids are used ,8. To reViral infections cause several complications in renal transplants that are closely related with the immunosuppressive therapy. On the basis of literature data, viruses implicated in graft failure we could number Varicella zoster, Cytomegalovirus, Influenza A and B, Hepatitis B and C and human Poliomavirus BK and JC -18. In pBKV is ubiquitous in human populations worldwide. BKV infects young children and the seroprevalence is 70%–80% in adults ,21. SeroThe complete genome of BKV contains 5,153 bp and it is functionally divided into three regions: the early, the late, and the transcriptional control region (TCR). The first region codes for the small and large T-antigens (t-Ag and T-Ag), the second region codes for the viral capsid proteins VP1-VP2-VP3 and agno-protein, and the last region (TCR) contains the transcriptional control elements for both "early" and "late" gene expression  Primary BKVAN diagnosis is very difficult since this disease is often misdiagnosed as acute rejection or drug toxicity. Diagnostic tools available include histopathology by means of renal allograft biopsy, detection of BKV DNA on plasma and urine by polymerase-chain-reaction (PCR) and quantitative PCR (QPCR) and presence of "decoy cells" in the urine sediment. Diagnostic confirmation may be obtained using IHC, in situ hybridization (ISH), and/or electron microscopy (EM) in renal biopsy specimens ,41-45.Early identification provides the opportunity for intervention with reduction of the immunosuppression in an effort to control BKV replication and prevent BKVAN. The risk factors predisposing to BKVAN appear to be multiple, with immunosuppressive regimens containing tacrolimus and MMF representing recognized associations ,46. SeveUrine cytology is based on decoy cells recovery. Decoy cells are epithelial cells with enlarged nuclei and large basophilic ground-glass intranuclear viral inclusions, screening for their presence provides a simple and an inexpensive tool for the diagnosis of BKV nephropathy, nevertheless, Papanicolaou-stained urine sediment is not to be considered a specific morphological marker of BKV disease ,49.Electron microscopy is very sensitive for detection of BK virions, but the finding of viral particles is not diagnostic of BKVAN, since the ultrastructural appearance of BK virus is poorly typical. Virions are arranged in paracrystalline arrays of naked, round, electron-dense structures that measure 45 nm in diameter. It is important to emphasize that electron microscopy cannot distinguish BKV from JC virus  Fig. 2)2).The histological diagnosis of BKVAN requires evaluation of a renal biopsy with demonstration and confirmation of the polyomavirus cytopathic changes by IHC and ISH . BKVAN i7 BKV copies per milliliter are associated with BKVAN [For efficient early diagnosis of BKVAN, various molecular approaches are recommended. Quantitative PCR is a non-invasive method clinically useful since it is high sensitive and specific and it supplies quantitative data that allow pharmacological therapy management by clinicians because specific antiviral therapy for BKVAN does not currently exist and the reduction in immunosuppression depend on viral loads in urine and plasma specimens of kidney transplants ,33,36,52th BKVAN ,53. On tth BKVAN . Some Auth BKVAN ,56. Therth BKVAN ,55-58. Nth BKVAN .In conclusion, there are several aspects of BKVAN pathology in kidney transplant patients requiring evaluation; it includes BKV transmissibility within kidneys transplanted, target organ effects, risk factors, time frame of reactivation and the best treatment options. Therefore it is essential to understand and to monitor the delicate balance between viral infection, immune regulation in the transplant population and immunosuppressive therapy in order to minimize viral injury and rejection risk to patients with BKV infection. Measuring of BKV DNA in urine and serum is an useful and non invasive tool for early detection and monitoring, nevertheless a combined approach of molecular techniques must be utilized to identify BK virus-associated nephropathy at an early phase facilitating well timed clinical intervention.


Eccrine porocarcinoma is a rare cutaneous neoplasm that mainly affects elderly people and grows slowly over a long period of time but often experiences an accelerated growth phase. Eccrine porocarcinoma may arise de novo or evolve from a pre-existing benign eccrine poroma. We reported a 86-year-old Japanese woman presenting with two reddish-colored pendulated lesions on a keratotic light brown plaque on the right thigh. Dermoscopic examination of the light-brown plaque demonstrated many whitish globular structures in a light-brown background. At the two reddish-colored pendulated lesions, polymorphous and prominent vessel proliferation was observed together with irregularly shaped whitish negative network. Immunohistochemical study demonstrated a positive CEA staining at ductal structures and atypical clear cells of reddish nodules. A diagnosis of eccrine porocarcinoma arising in a pigmented hidroacanthoma simplex was eventually established, and the dermoscopic features of eccrine porocarcinoma from hidroacanthoma simplex was described for the first time. A 86-year-old Japanese woman presented at Hiratsuka City Hospital with a cutaneous tumor on her right thigh. Examination revealed two reddish-colored pendulated lesions at the peripheries of a keratotic light brown plaque of 27×17 mm , which hHistopathologic examination of the flat pigmented plaque disclosed many well-defined nests within the epidermis . The nesSince the entire tumors were continuous, we made a final diagnosis of eccrine porocarcinoma and eccrine porocarcinoma in situ arising from pre-existing lightly pigmented hidroacanthoma simplex. The patient had been doing well after the operation. However, 8 months later, a right inguinal lymph node metastasis was found. After the inguinal lymph node dissection was performed, lung and para-aortic lymph node metastases were confirmed on the CT. The patient's general condition deteriorated and died 16 months after the surgery.Hidroacanthoma simplex (HAS) is a benign eccrine tumor that is also known as intraepidermal poroma. Eccrine porocarcinoma (EPC) is a rare cutaneous neoplasm that grows slowly over a long period of time but often experiences an accelerated growth phase . EPC mayDermoscopy improves the clinical diagnosis of many pigmented and nonpigmented skin tumors including eccrine poroma. We described additional dermoscopic features for eccrine porocarcinoma and hidroacanthoma simplex. Only a few studies were published about the dermoscopic features of eccrine poroma. Altamura et al. published a case of nonpigmented eccrine poroma of the pubic region that simulated amelanotic melanoma, both clinically and dermoscopically. They described pink to reddish, irregularly shaped and sized structures reminiscent of milky-red areas, red lacunes, and linear irregular vessels . NicolinThe combination of atypical vascular pattern and milky-red globules is especially specific for the diagnosis of eccrine porocarcinoma. The former is also observed in other lesions, such as amelanotic melanoma, actinic keratosis, Bowen's disease, and basal cell carcinoma and squamous cell carcinoma.In this paper, we have shown characteristic dermoscopic features of a lot of whitish globular structures in the light brown back ground. Each whitish round structure would correspond to a nest of cellular proliferation of hidroacanthoma simplex in the epidermis. Since the nests of poroma cells are entirely in the epidemis, hidroacanthoma simplex would only show whitish globular structures without vessels. There are comedo-like, well-circumscribed dark brown structures, which would correspond to keratotic pluggings in the surface. In the two reddish-colored lesions, polymorphous and prominent vessel proliferation is observed together with irregular whitish negative network. Vessels included dotted, linear-irregular, glomerular, and hairpin. Vessels were more conspicuous and irregular in the EPC. The present case is composed of EPC and EPC in situ on the plaque of HAS, and the obvious difference in vessels on dermoscopy could be a helpful clue for an estimation of the grade of malignancy.Although it would be difficult to differentiate amelanotic melanoma from EPC on dermoscopy alone, the peripheral findings suggesting HAS, such as whitish globular structures on the homogeneous brown area, might be helpful for a diagnosis of EPC.In this case, although the three portions of the tumor were continuous, the pathological difference well explained the difference in dermoscopic features. Evaluations of various skin lesions using dermoscopy would be indispensable in the daily dermatology practice.


Cellular membranes are crucial host components utilized by positive-strand RNA viruses for replication of their genomes. Published studies have suggested that the synthesis and distribution of membrane lipids are particularly important for the assembly and function of positive-strand RNA virus replication complexes. However, the impact of specific lipid metabolism pathways in this process have not been well defined, nor have potential changes in lipid expression associated with positive-strand RNA virus replication been examined in detail.Drosophila S2 cells stimulated the transcriptional upregulation of several lipid metabolism genes, and was also associated with increased phosphatidylcholine accumulation with preferential increases in lipid molecules with longer and unsaturated acyl chains. Furthermore, targeted RNA interference-mediated downregulation of candidate glycerophospholipid metabolism genes revealed a functional role of several genes in virus replication. In particular, we found that downregulation of Cct1 or Cct2, which encode essential enzymes for phosphatidylcholine biosynthesis, suppressed FHV RNA replication.In this study we used parallel and complementary global and targeted approaches to examine the impact of lipid metabolism on the replication of the well-studied model alphanodavirus Flock House virus (FHV). We found that FHV RNA replication in cultured These results indicate that glycerophospholipid metabolism, and in particular phosphatidylcholine biosynthesis, plays an important role in FHV RNA replication. Furthermore, they provide a framework in which to further explore the impact of specific steps in lipid metabolism on FHV replication, and potentially identify novel cellular targets for the development of drugs to inhibit positive-strand RNA viruses. The relatively small genome of most positive-strand RNA viruses compels these pathogens to use cellular machinery to complete their replication cycles. The search for these "host factors" utilized by positive-strand RNA viruses is at the forefront of virology research, due in part to the possibility that cellular proteins or processes may represent more stable drug targets or provide broader antiviral activity when disrupted . One divFlock House virus (FHV), a versatile model virus and natural insect pathogen that assembles robust functional RNA replication complexes in yeast -2,5-diphenyltetrazolium bromide (MTT) as previously described .t test assuming equal variances was used and a p value of < 0.05 was considered significant. All results are representative or a composite of at least three independent experiments, where quantitative data represent the mean ± standard errors of the mean.Microarray statistical analyses are described above. For additional statistical analyses a two-tailed KMC, KAS, and DJM conducted all the experiments. DJM wrote the manuscript and coordinated the research efforts. All authors read and approved the final manuscript.Drosophila genes up- or downregulated in response to FHV infectionComplete list of . Drosophila genes that showed significant up- or downregulation after FHV infection are listed in an Excel spreadsheet and include fold change, Flybase ID, gene symbol, gene name, and Gene Ontology  terms curated from the Flybase database http://flybase.org/.Click here for fileDrosophila genes upregulated in response to FHV replicon expressionComplete list of . Drosophila genes that showed significant upregulation after FHV replicon expression are listed in an Excel spreadsheet as described above for Additional File Click here for fileDrosophila genes commonly upregulated after both FHV infection and replicon expressionComplete list of . Drosophila genes that showed significant upregulation after FHV infected and replicon expression are listed in an Excel spreadsheet and include fold change, Flybase ID, CCG number, gene symbol, gene name, Gene Ontology  terms, genetic interaction partners, and yeast and human orthologs, curated from the Flybase database http://flybase.org/.Click here for fileDrosophila S2 cells infected with FHV treated with miltefosine or oleic acidPhospholipid levels in . Levels of individual lysoPC, PC, lysoPE, PE, PG, PI, PS, and PA species as determined by ESI-MS/MS are expressed as the molar percentage of total phospholipids content and listed in an Excel spreadsheet.Click here for file


The antiphospholipid syndrome is an autoimmune disease characterised by recurrent arterial or venous thrombosis, pregnancy morbidity and the persistence of positive antiphospholipid antibodies. Many other clinical manifestations may occur including heart valve disease, livedo reticularis, thrombocytopenia and neurological manifestations such as migraine and seizures. We review a number of other manfestations including stenotic lesions, coronary artery disease and accelerated atherosclerosis, skeletal disorders and the concept of seronegative antiphospholipid syndrome. The antiphospholipid (Hughes) syndrome (APS), first described in 1983, is an autoimmune disease characterised by recurrent arterial or venous thrombosis, pregnancy morbidity and the persistence of positive antiphospholipid antibodies (aPL) , other fVascular occlusions are increasingly being recognized in patients with APS, although the exact etiology remains unclear . We founSince the description of the APS syndrome, a number of cardiac manifestations have been described including cardiac valvular abnormalities (Libman-Sacks endocarditis) ,14. CoroAlthough stroke is the only accepted neurological criterion for the diagnosis of APS, a number of other manifestations are observed in the APS. The spectrum of non- thrombotic cerebral manifestations may range from focal neurological lesions to diffuse global dysfunction. It includes severe headaches, often migranous, hemiplegic migraine, cognitive dysfunction and memory deficits, dysphasia (mixing or inappropriate words), behavioural changes and seizure disorders . ExtrapyAPS may involve multiple organs such as kidney, brain, eye, ear and liver and it may also affect the skeleton. A prospective cohort study  togetherth decade are worth mentioning [Accelerated atheroma has been described as a feature of APS as in other autoimmune inflammatory conditions. APS/aPL are associated with accelerated atherosclerosis  by targentioning . This dantioning ,38.Although APS is by definition a hypercoaguable state, a surprising recent preliminary report by Chaib et al found an increased risk of bleeding complications following renal biopsy in patients with lupus nephritis (LN) and APS/aPL as compared to LN alone . This si"Sero-negative" APS has remained an enigma and the concept is controversial. According to classification criteria for APS, aPL (lupus anticoagulant and anticardiolipin antibodies) and Beta 2 Glycoprotein I (B2GPI) antibodies are essential for the classification of patients with APS. Although aPL and anti-B2GPI are sensitive tests, they are not sensitive enough to pick up all patients with APS. A small group of APS patients remain persistently negative for routine assays of aPL ,44. LiveThe spectrum of APS is not limited to thrombosis or pregnancy morbidity and clinicians should be aware of the broad range of manifestations with multi-system involvement.The authors declare that they have no competing interests.MM has written the manuscript, SRS has conceived and compiled the material and helped to write the manuscript and DPD has supervised the drafting of the manuscript. All authors have read and approved the final manuscript.