The lymphatic system has an important defensive role in the human body. The metastasis of most tumors initially spreads through the surrounding lymphatic tissue and eventually forms lymphatic metastatic tumors; the tumor cells may even transfer to other organs to form other types of tumors. Clinically, lymphatic metastatic tumors develop rapidly. Given the limitations of surgical resection and the low effectiveness of radiotherapy and chemotherapy, the treatment of lymphatic metastatic tumors remains a great challenge. Lymph node metastasis may lead to the further spread of tumors and may be predictive of the endpoint event. Under these circumstances, novel and effective lymphatic targeted drug delivery systems have been explored to improve the specificity of anticancer drugs to tumor cells in lymph nodes. In this review, we summarize the principles of lymphatic targeted drug delivery and discuss recent advances in the development of lymphatic targeted carriers. As a relatively new branch of targeted therapies, lymphatic targeted drug delivery systems are currently eliciting much attention. These systems are used to improve the curative therapeutic effect of chemotherapy drugs and are applied to enhance the mucosal immunity and oral absorption of macromolecular drugs.,According to the Globocan 2012, 65,950 people were diagnosed with Hodgkin’s lymphoma worldwide in 2012, and 25,469 people died of the disease. In the same year, 385,741 people were diagnosed with non-Hodgkin’s lymphoma worldwide and 199,630 people died from the disease. The lymphatic system is the first site of metastasis for most solid tumors, and lesions indicate pathological changes associated with various diseases. However, the unique anatomical properties of the lymphatic system generally make it difficult for medicines to reach the targeted site in the lymphatic tissues, including lymph node metastasesRecent studies have revealed the potential of drug-loaded liposomes, nanoparticles, and micelles, which can deliver a drug into lymphatic tissues, including lymph node metastases, and then release the drug inside these lesions. Consequently, the drug could effectively treat the disease, and its side effects to healthy organs could be reduced as wellth century, the lymphatic system was first described by Gasparo Aselli, who found “milky veins” in the mesentery of “well-fed” dogs. The lymphatic system is a complex network that consists of the lymphatic vessels, lymph nodes, spleen, thymus, Peyer’s patches, and tonsils; this system has an important role in immune surveillance and response,,At the beginning of the 17Other investigations have found that the lymphatic system has a crucial role in the recognition and response of the immune system to disease; most solid cancers initially spread from the primary site via the tumor’s surrounding lymphatic tissue before hematological disseminationGenerally, orally or intravenously administered drugs first enter the blood circulation before they are distributed throughout the body, including the related lesions. Inevitably, this traditional administration route causes drugs to rapidly accumulate in normal organs and tissues, which may cause side effects. Given this dilemma, lymphatic administration possesses obvious advantages. Drugs administered via the lymphatic system could be more easily distributed in the lymphatic system and less in blood circulation, which helps strengthen the therapeutic effects and reduce the systemic toxicityLymphatic targeted therapy for tumor metastasis can be divided into passive and active targeting therapy,Passive targeting refers to the use of the structural features of the lymphatic system for drug transport. For example, orally administrated nanoparticles and chyle particles will be absorbed by Pye’s lymph nodes, whereas subcutaneously injected ones will be absorbed by the lymphatic and lymph nodes. Particles with different sizes can be targeted to different parts of the body. The intravenous administration of emulsion droplets (with sizes ranging from 0.1 to 0.5 μm) is vulnerable to clearance by the macrophages in the reticuloendothelial system (RES) of the liver, spleen, lung, and bone marrow,When monolayer endothelial cells form capillary lymphatic vessels in the process of lymph formation during cancer or inflammation, the basement membranes of lymphatic vessels are incomplete and highly permeable. Moreover, lymphatic drainage channels  may be further expanded to 300-500 nmet al.3) nanoparticles with an average diameter of 58 nm and an average zeta-potential of +28.6 mV. This nanoparticle carried small interfering RNAs (siRNAs) against VEGF-C. Compared with the calcium carbonate nanoparticles containing nonspecific siRNA, nanoparticles with siRNA-targeting VEGF-C showed higher transfection efficiency in the human gastric cancer cell line SGC-7901, which was demonstrated by an ~80% decrease in the concentration of VEGF mRNA and VEGF-C. Animal experimental results showed that the CaCO3 nanoparticle-siRNA-VEGF-C complexes could inhibit lymph angiogenesis, regional lymph node metastasis, and growth of the primary tumor. The tumor lymphatic metastasis rate was 70% in the control group, whereas that in the test group was only approximately 20%.Active targeting is mostly based on ligand-mediated endocytosis. In the process of tumor development, various vascular endothelial growth factors (VEGFs) are secreted by cancer cells; these VEGFs can bind with corresponding receptors on the LECs and induce the growth of tumor lymphatic vessels, thereby promoting tumor metastasis via the lymphatic systemet al.Recently, researchers have found a cyclic peptide, LyP-1The penetration of particles is generally inversely proportional to the size. Smaller particles (<100 nm) find it easier to penetrate the microvasculature of lymphatic metastatic tumors, thereby enhancing the anti-tumor efficiency. Furthermore, drugs can be passively targeted to the lymphoma through the high accumulation of nanometer carriers during lymphatic metastasis. Simultaneously, nanocarrier surfaces can be modified for active targetingIdeal lymphatic targeted nanometer drug delivery systems should meet the following criteria: high uptake by the lymphatic system, release and accumulation of drug during metastasis, and low toxicity to normal tissues. Nano drug delivery carriers that target the lymphatic system in recent literature include liposomes, nanoparticles, macromolecule polymers, polymer micelles (PMs), activated carbons, silicon, and nano-emulsions, among others. In this review, two types of carriers are discussed in detail.A liposome is a type of drug delivery system composed of a lipid bilayer. These structures can be loaded with drugs by entrapping hydrophilic drugs into the aqueous core or entrapping the lipophilic drugs between the phospholipid bilayer. Given its affinity to biological membranes, liposomes naturally have lymphatic targeting properties, as shown by their selected targeting to lymphoid tissue through intraperitoneal, subcutaneous, and intramuscular injections. After coming into contact with tumor cells or being engulfed by these cells, a liposome can release the drug it carries and show a long-term effect. Lymphatic uptake is related to the particle size, composition, and lipid dose of liposome. Based on their natural features, easy modification, well-controlled size, and feasible drug loading, liposomes have been regarded as the most suitable type of nanometer carriers.et al.et al.et al.in vivo and in vitro experiments showed that LMWHA-LPs could be employed as potential lymphatic targeting carriers for diagnosis and treatment.Liposomes have shown unique advantages in lymphatic targeting treatment in recent studies. By manipulating formulation lipids with different fatty acid chain lengths, temperature- or pH-sensitive liposomes can be constructed to permit the controlled release of their contentset al.Further research has revealed that in the process of lymphatic targeting drug delivery, liposomes cannot be completely absorbed by the lymphatic system; a portion of these liposomes is situated in the interstitial injection siteet al.The accumulation of liposomes is caused by mechanical retention or macrophages of liposomes in normal lymph nodes; this process may damage normal lymphatic tissue-et al.In general, the accumulation of liposomes in lymph nodes is a passive process. Liposomes alone cannot discriminate between normal and metastatic lymph nodes. The uptake of liposomes by metastatic lymph nodes is lower than that by normal lymph nodes because of the structural damage in metastatic lymph nodes. This problem has been addressed in recent reports by modifying the drug delivery systems with the cyclic peptide LyP-1Nanoparticles, nanospheres, and nanocapsules are all solid colloid particles made from natural or synthetic polymer materials; these structures have an average particle size of 10-1,000 nm. Nanocapsules are made of polymeric shells with a liquid core, wherein the drug is dissolved. Nanoparticles and nanospheres are both matrix carriers, which are solid spheres or particles, such that the drug is absorbed on its surface, wrapped around it, or dissolved in its core. Currently, nanospheres and nanocapsules are collectively referred to as nanoparticles. Nanoparticles have several advantages, such as their slow drug release, long circulation, good stability, safety, and high efficiency.et al.P<0.05) and very significant (P<0.01) improvement in the lymphatic targeting efficiency of VCR was achieved by VCR-PBCA-NPs and F127-VCR-PBCA-NPs, respectively, compared with the VCR solution.Most nanoparticles are made from natural or synthetic biodegradable polymers. Natural materials include proteins, gelatin, peach gum, chitosan, and HA. Synthetic materials mainly include polyalkyl cyanoacrylate (PBCA), polylactic acid (PLA), poly (lactic-co-glycolic acid) (PLGA), and polymethyl methacrylate (PMMA). To improve the lymphatic targeting efficiency of the anti-cancer agent vincristine sulfate (VCR), Tan et al.in vivo and in vitro. Their results showed that FSHR is a novel therapeutic target for ovarian cancer and the delivery of PTX via FSHP-NP could represent a novel therapeutic approach to ovarian cancer.Active drug targeted delivery systems modified by small molecules like nanoparticles on their surface can increase the binding specificity, thereby ensuring that the specified drug carriers reach the target siteset al.HA is a typical naturally-originating biodegradable material for lymphatic targeted drug delivery. For example, breast cancer cells tend to take in large amounts of HA for the over-expression of P-glycoprotein during their growth. Cai et al.et al.,Active targeting modification is another current research focus together with the search for novel receptors and ligands related to the lymphatic metastasis. During tumor development, a variety of VEGFs are secreted by cancer cells; these ligands bind with corresponding receptors on the LECs, inducing the growth of tumors in lymphatic vessels and promoting tumor metastasis through the lymphatic system. In addition to the successful work of He in vivo. The diameter of polymeric micelles resembles that of natural viruses; their sizes can vary from 10 to 100 nm-,,PMs have been developed since the 1990s and used as drug delivery carriers. PMs spontaneously form into thermodynamically stable systems with core-shell structures in aqueous solution. The inner core formed by PM hydrophobic fragments can load certain insoluble drugs, thereby improving the solubility of these drugs. The hydrophilic shell can protect drugs from outside adsorption or degradation and avoid phagocytosis by RES, such that PMs can prolong drug circulation time et al.in vivo antitumor activity was then studied. Compared with free drugs, the drug-loaded micelles can increase the amount of drugs that reach the cells by changing the membrane fluidity; these micelles can also increase the cellular uptake of drugs by adjusting the genes that control protein expression. In the mouse model for 4T1 breast cancer metastases, both M-DOX and M-VNR inhibited the tumors from lung metastases as well as reduced the systemic and acute toxicity of the free drugs by increasing drug distribution in the lymph nodes.Polyethylene glycol phospholipids (PEG-PE) have been widely studied in recent years because they are approved by the FDA, such that they can be used in the human body as drug delivery carriers. Wang et al.1300-β-(polyethylene glycol-methoxy)2000 (mPEG2000-b-PDLLA1300). A 4T1 mouse breast cancer model was used to compare the therapeutic effectiveness of SPMs and free docetaxel (Duopafei) against breast cancer metastasis. Their results showed that SPMs could provide an enhanced method of docetaxel delivery in breast cancer metastasis, which may be a valid chemotherapeutic strategy for breast cancer patients with resected primary tumors.The small sizes of PMs (10-100 nm) make them suitable for lymphatic delivery, and several studies have examined their role in anti-metastasis therapy. Li A lymphatic targeted drug delivery system with a unique physiological disposition provides an effective tool for the treatment of diseases related to the lymphatic system, such as tumor metastasis, inflammation, and infectious disease. Carriers of colloid particles are viewed as the main methods to realize lymphatic targeted drug delivery. The efficiency of lymphatic targeting may be improved by screening different carriers, formulations, and routes of administration. Taken together, the current lymphatic targeted drug delivery systems have achieved significant advances in various stages, but they still have some limitations. For example, their lymphatic uptake rate is not high and the biocompatibility of some carrier materials is not ideal for the lymphatic system, which may lead to some adverse reactions. Basic research on the mechanism of lymphatic targeting is underway. Several research proposals could be developed to study lymphatic targeted drug delivery systems. Future work can focus on the following aspects: (I) to make the drug delivery system actively target the lesions of interest, active targeting agents for the lymphatic system or metastatic lesions should be given more attention; (II) with respect to the carrier materials, novel materials need to be developed, especially biodegradable materials with active targeting function. In summary, we believe that a lymphatic targeted drug delivery system for tumor metastasis will be a promising approach to treat primary tumors of the lymphatic system and all types of lymphatic metastases.


Pulmonary arterial hypertension is a fatal disease characterized by progressive remodeling of the pulmonary arteries and an increase in pulmonary vascular resistance. Up to 50% of patients with systemic sclerosis have pulmonary arterial hypertension, which significantly affects the prognosis. The endothelin receptor antagonist bosentan is used for the treatment of pulmonary arterial hypertension and shows a great beneficial effect. However, the most frequent side effect of bosentan is liver toxicity, which often requires dose reduction and discontinuation.We report two cases (a 64-year-old Japanese woman and a 69-year old Japanese woman) of systemic sclerosis, both with severe Raynaud’s phenomenon and pulmonary arterial hypertension. Both patients had initially received bosentan monotherapy, which caused liver toxicity as indicated by increased levels of alanine aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase. After dose reduction or discontinuation of bosentan, these liver function abnormalities were normalized and the patients subsequently received retreatment with a combination of bosentan and ursodeoxycholic acid. The results of liver function tests did not show any abnormalities after this combination therapy.These reports suggest the usefulness of ursodeoxycholic acid for preventing liver toxicity caused by bosentan. Thus, the addition of ursodeoxycholic acid to the treatment protocol is expected to be useful when liver toxicity emerges as a side effect of bosentan. Pulmonary arterial hypertension is a debilitating disease characterized by progressive remodeling of the pulmonary arteries with proliferation of fibrous tissue in the vessel walls, leading to death caused by right ventricular failure. Approximately 15 to 50% of patients with systemic sclerosis have pulmonary arterial hypertension, which significantly affects the prognosis . There iThe most frequent severe side effect of bosentan is known to be liver toxicity -8. The pIn the presence of liver toxicity, a dose reduction or discontinuation of bosentan needs to be considered. Although ursodeoxycholic acid can be efficacious against liver injury in clinical practice, there are no published reports of its usefulness in combating bosentan-induced liver toxicity. The incidence of liver toxicity appears to be decreased when ursodeoxycholic acid is simultaneously started with bosentan, but definite evidence of this efficacy has not previously been established.Two of our patients showed liver toxicity after initial bosentan monotherapy but not with the subsequent addition of ursodeoxycholic acid to their treatment protocol. This is the first report that suggests the usefulness of ursodeoxycholic acid combination therapy to prevent liver toxicity caused by bosentan.A 64-year old Japanese woman who presented with edema around her fingers and forearm followed by rapid development of skin sclerosis was diagnosed with systemic sclerosis. She was anti-topoisomerase I (Scl-70) antibody positive and had 35mmHg of estimated right ventricular pressure, as shown by echocardiography in 2006. She was prescribed prednisolone at 7.5mg/day. She was negative for both hepatitis B surface antigen (HBs Ag) and hepatitis C virus antibody (HCV Ab). In 2007, dyspnea at exertion and severe Raynaud’s phenomenon were confirmed. The findings of a chest computed tomography scan showed bilateral pulmonary fibrotic lesion and an elevated KL-6 level of 4360U/mL; she was diagnosed with pulmonary fibrosis. In addition, echocardiography results showed an elevation of her estimated right ventricular pressure to 50mmHg; she was therefore clinically diagnosed with pulmonary arterial hypertension  associated with connective tissue disease-derived pulmonary fibrosis.After bosentan treatment was initiated in May 2008 at 125mg/day, dyspnea at exertion improved and her 6-minute walking distance was increased by 40m from 332m; however, the results of blood tests indicated liver function abnormalities: increased levels of alanine aminotransferase , alkaline phosphatase , and gamma-glutamyltransferase .Bosentan 125mg/day was started from July 2011, and this resulted in the improvement of breathlessness at exertion; however, after 3 weeks the results of her liver function tests revealed abnormal levels: elevation of ALT , ALP , and GGT  occurs, bosentan treatment should be stopped immediately. However, if there is only mild transaminitis , bosentan can be reintroduced after dose reduction or interruption. Abnormal results of liver function tests are, in most cases, normalized after discontinuing bosentan, but we are often reluctant to restart bosentan. Our report suggests that it is, however, worth trying the reintroduction along with ursodeoxycholic acid, at least on the transient mild transaminitis. Pulmonary arterial hypertension still remains an incurable disease with a severe prognosis, and it is therefore important to start treatment with specific and effective drugs. Because bosentan is useful for the treatment of pulmonary arterial hypertension, it is desirable to avoid a dose reduction or discontinuation due to liver intolerance. Although there are alternative drugs  with low liver toxicity approved for pulmonary arterial hypertension , it remaIn summary, the present report suggests that ursodeoxycholic acid has the potential to repress liver toxicity caused by bosentan. Thus, the combined use of oral ursodeoxycholic acid with bosentan is expected to be useful when liver toxicity emerges as a side effect of bosentan monotherapy.Written informed consent was obtained from the patients for publication of this case report and any accompanying images. Copies of the written consents are available for review by the Editor-in-Chief of this journal.ALP: Alkaline phosphatase; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; GGT: Gamma-glutamyltransferase; HBs Ag: Hepatitis B surface antigen; HCV Ab: Hepatitis C virus antibody; WHO: World Health Organization.The authors declare that they have no competing interests.TI supervised and wrote the manuscript. YO, YS, TN, HA, AT, TT, and SN participated in the patients’ therapy and helped to draft the manuscript. All authors read and approved the final manuscript.


Schizophrenia is thought to be a neurodevelopmental disorder with pathophysiological processes beginning in the brain prior to the emergence of clinical symptoms. Recent evidence from neuroimaging studies using techniques such as diffusion tensor imaging has identified white matter abnormalities that are suggestive of disrupted brain myelination and neuronal connectivity. Identifying whether such effects exist in individuals at high risk for developing psychosis may help with prevention and early intervention strategies. In addition, there is preliminary evidence for a role of lipid biology in the onset of psychosis, along with well-established evidence of its role in myelination of white matter tracts. As such, this article synthesises the literature on polyunsaturated fatty acids (PUFAs) in myelination and schizophrenia, hypothesizing that white matter abnormalities may potentially mediate the relationship between PUFAs and schizophrenia.Diffusion tensor imaging studies were identified through a systematic search of existing literature. Studies examined white matter integrity in ultra-high risk (UHR) samples, as assessed using structured diagnostic interviews. Data was extracted and summarised as a narrative review.Twelve studies met inclusion criteria, and findings identified reduced fractional anisotropy and higher diffusivity. Although the exact location of abnormalities remains uncertain, fronto-temporal and fronto-limbic connections, including the superior longitudinal and uncinate fasiculus, cingulum, and corpus callosum appear to be implicated. Because of preliminary evidence suggesting lipid biology may be relevant for the onset of psychosis, a discussion is provided of the role of polyunsaturated fatty acids (PUFAs) in myelination and risk for psychosis.While the function of PUFAs in myelination is well-established, there is growing evidence of reduced PUFA concentration in UHR samples, highlighting the need for research to examine the relationship between PUFA and white matter integrity in high-risk samples and age-matched healthy controls. Such investigations will help to better understand the pathophysiology of the disorder, and potentially assist in the development of novel treatment and early intervention strategies. There is also a substantial body of evidence for lowered cell membrane polyunsaturated fatty acids (PUFA) concentrations in schizophrenia, which compose the myelin sheath surrounding white-matter tracts. Therefore, we end the review with a discussion about the role of PUFAs in myelination and schizophrenia, hypothesizing that white matter abnormalities may potentially mediate the relationship between PUFAs and schizophrenia. We also highlight the need to examine these relationships in further detail among UHR samples to better understand the pathophysiology of the disorder, and potentially assist in the development of novel treatment and early intervention strategies.Schizophrenia is often a chronic disorder, characterised by delusions, hallucinations, blunted affect and cognitive impairment , 2, whicDTI measures the diffusion of water molecules through tissues, and provides a measure of net directionality and magnitude (diffusivity). The net directionality of diffusion, indexed by fractional anisotropy (FA), is the most common index of white matter integrity. Lower FA has been associated with reduced axonal caliber and packing density, myelin pathology, as well as less coherent fibres or crossing fibres within a voxel . Mean diDTI studies have provided extensive evidence for lowered white matter integrity across the brain in schizophrenia, including the uncinate fasiculus and fornix, fronto-occipital fasiculus, arcuate fasiculus, anterior commissure, cingulum bundle and corticospinal tract . Howsystematic review of DTI findings in individuals at UHR for psychosis.Longitudinal research on individuals at UHR for psychosis enables assessment prior to, during and following the onset of illness. These individuals represent a ‘clinical high-risk’ group, who present with sub-threshold or brief psychotic symptoms, may have trait factors such as a genetic risk for the disorder, and exhibit a significant decline in functioning . This prhigh risk, psychosis, diffusion tensor imaging and white matter, to identify studies published in this field to date (July 2015). Inclusion criteria for the review were: i. employed DTI, ii. included subjects at ultra high risk for psychosis, assessed using structured diagnostic interviews  guidelines. An electronic search was conducted in PubMed and Medline, using the key words ate July 15. Incluyndromes ), iii. cPeters and colleagues  conducteWhile the aforementioned studies have identified white matter differences in a range of white matter fasciculi, they did not examine transition to psychosis within UHR samples. As mentioned earlier, while some of these UHR individuals go on to develop full-threshold psychosis, others have resolution of symptoms and some have persistent non-psychotic disorders (i.e. low-level sub-threshold symptoms). Therefore, it is important to look at longitudinal clinical and functional outcomes within UHR populations.N = 7), those who did not transition to psychosis , and healthy controls (N = 10). However, it should be noted that the small sample size in this study may have led to Type II error. In comparison, Karlsgodt et al.’s  found that UHR subjects exhibited a significant reduction in FA over time compared to healthy controls, resulting in significantly lower FA at follow-up. Although the study did not examine transition to psychosis, they did find that positive and negative symptoms declined over time in UHR subjects. A subsequent study by the researchers identified a similar group × time interaction within the thalamic-hippocampal tract [N = 26) exhibited a significant reduction in FA over time in comparison to healthy controls (N = 21). This was driven by a pattern of increased FA in controls over the 12-month follow-up period and reduced FA in UHR subjects, although main effect of time was not significant within either group.Similarly, Mittal and colleagues’  study ofal tract . SpecifiN = 10) compared to controls (N = 10) in the medial frontal lobes bilaterally, approximate to the left anterior thalamic radiation and inferior fronto-occipital fasciculus. Lower FA was also identified in white matter lateral to the right putamen and left superior temporal lobe in UHR-P compared to UHR-N (N = 27) groups. Interestingly, the same group comparison identified higher FA in those who transitioned within the left white matter of the medial temporal lobe. In addition, positive symptoms were negatively correlated with FA in the medial temporal lobe within those who transitioned, and were also negatively correlated with FA in the right superior temporal lobe within the overall UHR group.Only three longitudinal studies have used a whole brain approach to examine FA differences to date. The first of these studies by Bloemen and colleagues  combinedN = 5) exhibited a progressive reduction in FA in left frontal white matter, including the anterior limb of the internal capsule, corpus callosum, superior corona radiata and superior frontal occipital fasciculus in comparison to UHR-N subjects (N = 17). However, neither group exhibited significant within-group change, nor were any significant differences in comparison to controls reported. The only other study to longitudinally examine white matter changes identified significantly lowered FA within the corpus callosum in UHR subjects compared to healthy controls at baseline [N = 4). However, they did identify a significant negative correlation between change in positive symptoms and change in FA within the same region in UHR-N subjects. This effect remained significant after accounting for age, sex and antipsychotic use. The authors argued that preservation of white matter may therefore reduce the risk of developing psychosis, thus acting as a protective neurobiological factor.Carletti et al.  were thebaseline . They weA recent study by Pettersson-Yeo et al.  used macdevelopment of psychotic disorders, although further longitudinal research is needed that examines within-subject change in FA along with progression to psychosis. In addition, the small sample size of many studies to date, along with variations in DTI analytic methods, may be partly responsible for the inconsistencies in findings. Along this line, future meta-analyses may have help clarify the exact location and nature of white matter abnormalities in high-risk samples.Although limited in number, these studies provide some evidence for lower FA and higher MD in UHR subjects who transition to psychosis, relative to UHR individuals who do not transition, and healthy controls  in 9 to 20 year olds. Interestingly, they found that lower blood PUFA concentrations were related to higher FA in the corticospinal tract, anterior thalamic radiation, inferior fronto-occipital fasiculus and cingulum. In addition, lower blood PUFA concentrations were related to lower RD in the same regions, as well as the uncinate, superior and inferior longitudinal fasiculi. The authors argue that active white matter myelination during adolescence may require more vigorous consumption of PUFAs from peripheral membranes, given the continued white matter changes that have been identified during this period [Peters and colleagues  report ts period . Hence wGiven the relationship between PUFAs and myelination, we propose that white matter integrity may mediate the relationship between PUFAs and risk for schizophrenia. There is a substantial body of evidence for lowered blood PUFA concentrations in schizophrenia. These include reductions in blood levels of DHA, AA, NA, docosapentaenoic acid (DPA) and linoleic acid (LA) in patients –49, inclThere is also preliminary DTI research specifically investigating the relationship between PUFA, white matter integrity and schizophrenia. Peters et al.’s  study ofThere are inconsistencies in the literature based on these preliminary studies that need to be addressed. Firstly, the direction of association is not consistent with that identified in healthy adolescents . As mentThere is much to be learnt about the biological underpinnings of the symptoms and deterioration of functioning characteristic of UHR individuals, and the predictive value of these markers for conversion to psychosis. There are strong international research efforts currently aimed at addressing these issues –63, withSpecifically addressing the issue of PUFAs and white matter integrity in UHR is the Myelin Integrity Neuroimaging (MINT) study at Orygen - The National Centre of Excellence in Youth Mental Health, Australia. This is the first study to combine neuroimaging and blood-based assessments with longitudinal clinical assessments, which will allow examination of the interaction between PUFA and white matter prior to the onset of schizophrenia. In addition, the project will examine the role of PUFAs and white matter integrity in disease progression  in UHR patients. It will provide us with new insight into the pathophysiology of psychosis, which will help us better understand the effectiveness of interventions altering cell membrane lipids and potentially provide the basis for development of novel treatments. Together with other cutting-edge research in this area, this study will also ultimately aid in predicting which UHR subjects will actually transition to psychosis, and their likely functional and symptomatic outcomes.AA, arachidonic acid; DHA, docosahexaenoic acid; DPA, docosapentaenoic acid; DTI, diffusion tensor imaging; FA = fractional anisotropy; FADS, fatty-acid desaturase; fMRI, functional magnetic resonance imaging; LA, linoleic acid; MD, mean diffusivity; MRI, magnetic resonance imaging; NA, nervonic acid; PRISMA, preferred reporting items for systematic reviews and meta-analyses; PUFAs, polyunsaturated fatty acids; UHR, ultra-high risk; UHR-N, ultra-high risk negative; UHR-P, ultra-high risk positive; WM, white matter


In addition to this now well-studied regenerative process, the LV niche also generates differentiated astrocytes, playing an important role for glial scar formation after cortical injury. While LV NSCs can be clearly distinguished from their neuroblast and oligodendrocyte progeny via molecular markers, the astrocytic identity of NSCs has complicated their distinction from terminally-differentiated astrocytes in the niche. Our current models of postnatal/adult LV neurogenesis do not take into account local astrogenesis, or the possibility that cellular markers may be similar between non-dividing GFAP+ NSCs and their differentiated astrocyte daughters. Postnatal LV neurogenesis is regulated by NSC-intrinsic mechanisms interacting with extracellular/niche-driven cues. It is generally believed that these local effects are responsible for sustaining neurogenesis, though behavioral paradigms and disease states have suggested possibilities for neural circuit-level modulation. With recent experimental findings that neuronal stimulation can directly evoke responses in LV NSCs, it is possible that this exciting property will add a new dimension to identifying postnatal/adult NSCs. Here, we put forth a notion that neural circuit-level input can be a distinct characteristic defining postnatal/adult NSCs from non-neurogenic astroglia.Throughout development, neural stem cells (NSCs) give rise to differentiated neurons, astrocytes, and oligodendrocytes which together modulate perception, memory, and behavior in the adult nervous system. To understand how NSCs contribute to postnatal/adult brain remodeling and repair after injury, the lateral ventricular (LV) neurogenic niche in the rodent postnatal brain serves as an excellent model system. It is a specialized area containing self-renewing GFAP After elimination of proliferating LV cell types with the antimitotic agent Ara-C, GFAP+ cells remained in the niche, began to divide and could be traced as the precursors of Mash1+ transient amplifying cells (type C cells) and migrating neuroblasts  had the characteristics of NSCs  caused inward currents in B1 cells that were blocked by 5HT antagonists  responses were seen in patch-clamped NSCs following light activation of channelrhodopsin-expressing ChATWhether the proliferation and differentiation of LV NSCs can be directly regulated by neural activity is a source of debate. In one view, NSCs are programmed to undergo mitosis and sustain cell division as a part of their identity, and the controlled environment of the niche is protected from outside signals by astrocytic boundaries (Ma et al., All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Meteorus pulchricornis(Wesmael) (Hymneoptera: Braconidae) progeny in relation to the beet armyworm,Spodoptera exiguaHübner (Lepidoptera: Noctuidae), either singly parasitized or self-superparasitized as second–fifth instar larvae. Selfsuperparasitism caused deleterious effects on the fitness-related traits of parasitoid progeny, as demonstrated by a prolonged egg-to-adult emergence time, a smaller body size, and shorter longevity of the emerging adults, and decreased survival to adult emergence. While the domed fitness function was detected for development time, survival, adult body size, and longevity in relation to host larvae that were singly parasitized, the function was observed only for progeny survival in relation to host larvae that were self-superparasitized. This study suggests that developmental fitness functions with selfsuperparasitism can deviate from those with single parasitism in solitary koinobiont parasitoids.The domed fitness functions are suggested to describe developmental patterns of progeny parasitoids in relation to host age at oviposition in solitary koinobint parasitoids that are engaged in single parasitism, but few studies have investigated the applicability of the functions as related to superparasitism. The present study was designed to compare fitness functions between single parasitism and superparasitism by examining developmental patterns of Among the most important trade-offs faced by organisms is whether to grow larger at the cost of extended development time or to develop more rapidly at the cost of reduced size . To undAs hosts represent a limited discrete resource, superparasitism generally results in reduction in survivorship of larvae and/or size, longevity, and fecundity of emerging adults . HoweveMeteorus pulchricornis(Wesmael) (Hymneoptera: Braconidae) progeny in either singly parasitized or self-superparasitizedSpodoptera exiguaHübner (Lepidoptera: Noctuidae) hosts as second-fifth instar larvae, with the goal of testing whether the domed fitness functions apply to the parasitoid engaged in single as well as selfsuperparasitism.M. pulchricornishas a wide host range of exposed-living lepidopteran larvae . The parasitoid is thelytokous. The host larvae were reared on an artificial diet  before pupation. As the first instar larva was not susceptible to selfsuperparasitism in the exploratory trial (n = 30), it was not used in the experiment. The exploratory trial (n = 50) indicated that females that realized one egg deposition performed a characteristic stinging behavior (flapping wings when withdrawing the ovipositor), which was used to obtain hosts that were either singly parasitized (1 egg) or superparasitized (2 eggs). Host larvae were individually exposed to a parasitoid in a glass vial and continuously observed until they were attacked once (single parasitism) or twice (selfsuperparasitism). The time interval between the first and second stinging was kept within 30 minutes; within this time, symmetrical competition between offspring larvae can be created in this parasitoid  (Longevity of adults was shortened in self-superparasitized hosts as opposed to singly parasitized hosts . Wherea= 0.06) .2= 18.81,P<0.001) and selfsuperparasitism   .M. pulchricornishad deleterious effects on the development of parasitoid progeny, leading to prolonged egg-to-adult emergence time, decreased survival to adult emergence, smaller body size, and shorter longevity of the emerging adults. The results provide data in support of some other studies, which ob served that superparasitism in solitary parasitoids delays the development of the progeny  and selfsuperparasitism  produce large cells, teratocytes, which are released to the host haemocoel when the parasitoid first instar ecloses (Aphidius ervireadily feed on them along with host tissues, and that the larger size of progeny emerging from superparasitized hosts compared with singly parasitized hosts may be a result of increased numbers of teratocytes circulating in the haemolymph of superparasitized hosts. Our study also provides some corroborative evidence for this factor. The body size of progeny initially increased with host instar, but rapidly declined when the host at oviposition was the final instar with single parasitism, whereas it linearly increased with host instar at oviposition with selfsuperparasitism.The domed fitness functions, however, are demonstrated only in parasitoids engaged in single parasitism. There remains a need to know if these functions apply to the parasitoids engaged in superparasitism, in consideration of superparasitism as an adaptive strategy in parasitoids . The reecloses . Among Microplitis rufiventris, where more parasitoid eggs survive to mature larvae when laid in the sixth-instar larva, the suboptimal stage for single parasitism, than the fifth-instar host, which is the optimal stage for single parasitism (Aphaereta.Alternatively, the discrepancy may be explained by the same mechanism for the domed fitness functions in single parasitism.asitism . Furtheasitism .Pexton


Health Information Technology (HIT) is sometimes seen as a silver bullet for human resource, medical and economic challenges facing health systems. The evidence supporting widespread use of HIT is, however, still patchy and inconsistent. In this Perspective piece, we seek to interpret and draw key lessons from a selection of illustrative trials in developed countries with robust health-care settings in respiratory medicine that failed to demonstrate effectiveness, and offer suggestions to maximise the chances of success in subsequent HIT deployments. Particularly low- and middle-income countries, with relatively weak health infrastructures and limited health care, propose considerable room for improvement. Early experiences of studying HIT thus far in high-income country settings suggest that this process should preferably begin with trials of low-cost, well-established technologies in patient groups with a moderate burden of disease while carefully evaluating patient safety. The scientific evidence to support the use of HIT applications on a large scale is, however, still patchy and inconsistent. An analysis of 108 systematic reviews on the impact of electronic health records, computerised physician order entry, computerised decision support systems and ePrescribing technologies revealed that the bold claims of clinical effectiveness sometimes made by policymakers and vendors are seldom supported by sound evidence.4 A subsequent follow-on systematic overview of telehealth interventions came to a similar conclusion.5 Most of these HIT evaluations have been undertaken in high-income country settings, and an increasing body of literature reveals a discrepancy between the anticipated impact and the demonstrated effectiveness of HIT interventions.Futurists, politicians, researchers and health-care insurers are excited about the grand promises of health information technology , with projected annual savings ranging up to $81 billion in the United States from a single HIT intervention alone.In this Perspective piece, we seek to interpret and draw key lessons from a selection of earlier high-quality illustrative large randomised clinical trials in developed countries with robust health-care settings that failed to demonstrate effectiveness, with a view to offering suggestions to maximise the chances of success in subsequent HIT deployments. In particular, there is considerable interest and activity in implementing HIT in many low- and middle-income countries (LMICs) and it is crucial that such implementations draw on lessons from previous attempts in high-income country settings.We searched PubMed for recent trials of HIT interventions for respiratory and allergic disorders, preferably undertaken in primary care contexts. Potentially relevant papers were extracted, referenced articles were obtained and a selection of illustrative trials from all identified papers was made.6 To investigate a possible effect on hospital admissions or emergency visits in patients with several chronic (including respiratory) conditions, an individually randomised controlled trial was performed in the United States, comparing daily telemonitoring  with usual care during 1 year. This well-conducted study among 205 elderly people with multi-morbidity (defined as a Charlson Comorbidity Index7 >2.9) and a high risk for hospitalisation (a score >15 on the Elder risk assessment index)8 did not result in significant benefit of the intervention. No statistically relevant difference was found between the intervention group of patients (63.7%) and the control group (57.3%) in the number of hospitalisations or emergency visits (P=0.35). However, mortality in the intervention group was considerably elevated , which was an ominous and unexpected outcome. The authors speculated that the intensive level of care resulting from automated treatment algorithms may have led to unnecessary and sometimes invasive procedures, causing the excess mortality observed.In 2012 a study on the results of HIT was published, demonstrating not only an inconsistency in anticipated and empirical effectiveness but unexpected adverse results as well.It is deeply worrying when three to fourfold increased mortality risks are seen in the intervention arm. If a trial investigating a novel drug resulted in such outcomes, it would no doubt come under intense regulatory scrutiny and would certainly not be approved for use, or if already in practice may be rapidly withdrawn from the worldwide market to minimise further harm. This particular intervention is at the moment no longer available in its original form.5 These arguments are illustrated by a recent small pilot randomised controlled trial (RCT) in the Netherlands in which telemedicine care, electronic communication through phone calls with patients to serve as an alternative or extension to traditional outpatient visits, was compared with traditional care in stable COPD patients.9 Symptom deterioration measured on the St George’s Respiratory Questionnaire was significantly (P=0.02) higher in the treatment arm (6.1 points) compared with the controls (−2.8 points). In addition, financial and time resource use in both primary and secondary care for COPD over 6 months of follow-up had increased in the treatment arm, with significantly more visits to the pulmonologist and, although not statistically significant, more exacerbations compared with the controls. In the discussion section the authors argued, in line with earlier hypotheses from COPD HIT interventions,11 that telemedicine interventions alone in well-developed (primary) health-care systems intrude on an already optimised strategy of care and might even reduce care quality. Furthermore, the HIT intervention may have resulted in a heightened awareness of their illness, decreasing their natural acceptance and coping capabilities, deteriorating the perceived quality-of-life. In primary care, where care not only focuses on disease parameters but on general well-being in a longitudinal context as well, HIT may not be the Holy Grail for all patients with chronic disease, and could unintentionally even stunt further development of primary care health systems if applied incorrectly.The reasons for unsuccessful HIT interventions are complex and not yet fully understood. Testing of relatively immature technologies, a failure to adequately attend to sociotechnical considerations, the execution of relatively small trials with large postulated clinical effect sizes, and limited headroom for improvement in societies with well-developed health-care infrastructures have been proposed as possible explanations.12 The carefully set-up trial assessed the clinical and cost-effectiveness of mobile phone-supported self-monitoring of 288 poorly controlled asthma patients compared with paper-based monitoring, by monitoring of lung function, self-efficacy and symptoms using electronic questionnaires and providing instantaneous feedback. Over a 6-month follow-up period, no significant differences were found in the two groups regarding asthma control  −0.23–0.19) or self-efficacy . Moreover, the added costs of the mobile phone technology intervention rendered the intervention not cost-effective.12Recent evidence from a large multicentre HIT randomised controlled trial, which attempted to address the earlier identified reasons for unsuccessful implementation, offering the same structured clinical and educational intervention to two groups of participants did not demonstrate better results when the only difference was the use of mobile phone technology in one treatment arm.et al demonstrated that, in settings with substantial room for clinical improvement, technology can help achieve major improvements in outcomes.13With the emergence of reports on ineffective HIT implementations, concerns may arise as to whether HIT is an effective tool in health care at all. In our opinion, this reflects a naïve position, as HIT is an umbrella term that includes within it a very broad array of interventions and because HIT invariably needs to be understood within a wider organisational and sociotechnical framework. Further, as research into HIT progresses, we are developing a more sophisticated appreciation of the contexts in which HIT is likely to be of particular benefit. As technology matures and investigators design trials with respect to realistic and likely effect sizes, the sensitivity to detect smaller effects increases. Moreover, we believe that the room for improvement in both patient health and health infrastructures proposes considerable promise for settings with weak health infrastructures and limited health care. This is illustrated by the fact that in a recent HIT trial on food-related quality-of-life improvement using 24-hour telephone access to specialist clinical advice in children with food-allergy-triggered anaphylaxis, Kelleher 14 we believe that to improve the chances of successful implementations in LMICs it is essential to learn from earlier experiences of HIT interventions in high-income settings and to avoid repeating earlier identified mistakes.LMICs, often with suboptimal local standards of primary care and general poor health with ample headroom for development, are therefore in many ways ideally suited for carefully developed HIT interventions. Both in developed and in developing countries, long-term respiratory conditions increasingly contribute to the burden of disease, making this area of medicine particularly interesting to benefit from future HIT trials. Considering that HIT development and evaluation in developing countries seems to follow the course of development in developed countries,15 and (2) the actual patient group likely to benefit, before implementing often highly complex HIT applications. Often, simple solutions, carefully tailored to local needs, offer the greatest chance for success. Therefore, we propose there is considerable scope to learn from the early experiences in high-income country settings. Key lessons include the following:Importance of not seeing HIT as a silver bulletPreferentially considering low-tech, low-cost interventionsCareful theorising about likely causal pathways and hence patient groups or health-care systems most likely to benefit/least likely to be harmedRecognising the interplay of HIT and sociotechnical considerationsThe need for realistic assessments of likely benefit and hence large sample sizes (patient/years of follow-up) to ensure adequate statistical powerRecognition that HIT may prove ineffective/result in adverse effects and hence the need for independent, rigorous evaluations (preferably using RCT designs and systematic reviews)Accompanying process, qualitative and health economic evaluationsAvoiding premature roll-out of HIT ‘solutions’ until there is a secure evidence base.If we are to maximise the benefits associated with HIT interventions while minimising risks in LMICs, we need to establish (1) the effective components16 We must be able to simultaneously evaluate HIT interventions while they are being designed, developed and deployed.17 Although HIT could be a promising area in health care, we urge future researchers, physicians and patients to treat and research HIT like any other intervention. HIT, at least in primary care, is a possible extension to diagnostic and therapeutic availabilities of health care that needs to be thoroughly researched for effectivity, cost and safety.The studies discussed in this Perspective paper suggest that, in complex disease, personal attention and commitment cannot be simply replaced by automated treatment algorithms. Probably, both patients and health-care providers sometimes overly rely on technology, inadvertently changing their testing and referral behaviour, possibly leading to unwanted effects in both intervention and control groups. Possibly, policymakers, researchers and clinicians take too large strides when it comes down to HIT applications. Similar to the introduction of novel drugs, there is a need to systematically evaluate complex HIT interventions before large-scale roll-out, without hampering innovation.n=271) or to standard care (n=266).18 The cumulative incidence of type 2 diabetes was lower in those who received mobile phone messages than in controls over a mean follow-up time of 20.2 months: 50 (18%) participants in the intervention group developed type 2 diabetes compared with 73 (27%) in the control group . The number needed to treat to prevent one case of type 2 diabetes was 11 (95%CI 6–55). Moreover, a large cluster RCT of simple mobile phone text-message reminders19 showed that Kenyan health workers’ adherence to malaria treatment guidelines could be improved by 23.7% points  immediately after intervention and by 24.5% points  6 months later. Hence, future trials could start in patient groups with low-to-moderate burden of disease, eventually scaling up to implementing interventions in highly complex patient groups with less personal guidance when more robust scientific evidence for effectiveness and safety has been obtained.As a first step for introducing HIT interventions, particularly in LMICs, we propose low-cost, low-tech HIT applications in patient groups with a moderate burden of disease, as sufficient symptoms will be present (offering room for improvement) while safety is not commonly an issue yet (as opposed to severe disease). Crucially, direct personal contact with a dedicated and experienced health-care provider should be provided as backup. Alternatively, one could consider simple yet promising interventions such as mobile phone text-message reminders, depending on highly variable local needs. Recently, several studies from other fields of medicine evaluating HIT in LMICs that comply with the above-mentioned proposed key lessons have demonstrated good clinical results or improvement of health-care systems in primary care. For example, in a large RCT on text-messaging, 537 patients with impaired glucose tolerance from South India were randomly assigned either to the mobile phone messaging intervention with frequent automated starting cues for physical activity, information on diabetes and lifestyle, and motivational texts , and the increased feasibility through innovative research and development by stakeholders, such as the Satellife personal digital assistant (PDA) handheld devices  powered by supplementary on-site solar stations (http://www.satellife.org/), research possibilities in LMICs are expanding. Several ongoing studies from LMICs offer good implementation prospects by offering relatively simple and safe HIT interventions in settings with room for improvement. For example, the Ecompliance programme executed in India, Cambodia, Uganda, the Dominican Republic and Kenya is evaluating whether directly observed treatment regimens for tuberculosis can be improved by recording finger-print scans of patients on a biometric attendance terminal after every dose ingestion, and offer encouragement and coaching to patients found absent from therapy appointments. Initial qualitative results are hopeful; however, future quantitative analysis is needed to assess the clinical benefits and cost-effectiveness of the intervention.20 Another example is the well-designed MIOTIC Study, a multicentre RCT that evaluated long-term efficacy of mobile phone-based internet-of-things HIT in the management of 600 Chinese patients with stable COPD to overcome limited medical resources and increased medical demand. Using mobile phones with Internet connectivity, participants can connect sensors to a cloud platform for instant measurement analysis, self-report symptomatic changes such as stress and schedule medication reminders and get instantaneous personalised advise and educational materials calculated to be tailored to a participant's needs.21 By including COPD patients with a moderate burden of disease, carefully and realistically assessing predicted power and follow-up time requirements, continuously evaluating effectiveness and safety and using a person-focused integral approach of the COPD patient this trial meets a comprehensive list of conditions we believe are required for successfully investigating the effectiveness of an integrated HIT intervention, and because of its design has high potential to be an effective HIT intervention.With increasing global attention on HIT interventions in low-resource settings, such as the calls for innovative health technologies for low-resource settings issued annually by the World Health Organization, specifically on pneumonia and chronic respiratory diseases (It is important that HIT interventions be formally evaluated. The evaluations undertaken in high-income country settings of respiratory conditions offer valuable insights for trials of HIT in LMICs, particularly considering that there is likely to be more headroom available to detect an effect.Experiences of studying HIT thus far in high-income country settings suggest that this process should preferably begin with trials of low-cost, well-established technologies in those patient groups with a moderate burden of disease while carefully evaluating patient safety.


The shoulder is at high risk for injury during overhead sports, in particular inthrowing or hitting activities, such as baseball, tennis, handball, and volleyball.In order to create a scientific basis for the prevention of recurrent injuries inoverhead athletes, four steps need to be undertaken: (1) risk factors for injury andre-injury need to be defined; (2) established risk factors may be used asreturn-to-play criteria, with cut-off values based on normative databases; (3) thesevariables need to be measured using reliable, valid assessment tools and procedures;and (4) preventative training programs need to be designed and implemented into thetraining program of the athlete in order to prevent re-injury. In general, three riskfactors have been defined that may form the basis for recommendations for theprevention of recurrent injury and return to play after injury: glenohumeralinternal-rotation deficit (GIRD); rotator cuff strength, in particular the strengthof the external rotators; and scapular dyskinesis, in particular scapular positionand strength. Injury risk seems toincrease with age5-9. These alterations changebiomechanics and movement strategies during serving and striking, possibly leading tooverload injuries at the shoulder. In particular, glenohumeral internal-rotation deficit(GIRD), rotator cuff strength imbalance, scapular dyskinesis, thoracic spine stiffnessand hyperkyphosis, lumbar core instability, and hip range of motion and strengthdeficits possibly create the "cascade to injury", as defined by Kibler,,Most of the reported shoulder injuries are strains, implicating a process over time,with chronic overload leading to injuryIn order to create a scientific basis for the prevention of recurrent injuries inoverhead athletes, four steps need to be undertaken: (1) risk factors for injury andre-injury need to be defined-,,,,In spite of promising results from prospective studies, no consensus exists regardingintrinsic risk factors for shoulder pain in the overhead athlete. Different requirementson the shoulder and specific throwing activities across the spectrum of overheadathletes might account for these discrepancies. Recently GIRD and rotator cuff strengthdeficit, as well as scapular dyskinesis have been defined as possible risk factors in apopulation of baseball, rugby, and handball players,,,Posterior shoulder stiffness is a common, if not the most common, adaptation seen on thedominant side of overhead athletes of multiple sports disciplinesDuring overhead throwing and serving, the shoulder is highly loaded with an enormouschallenge for the eccentric capacity of the external rotators during the decelerationphase. In specific sports such as tennis, it has been shown that elite players withoutshoulder injury have shoulder rotation muscle strength imbalances that alter the ratiobetween rotator cuff muscles-,,,13,18. Otherstudies discussed scapular position in healthy tennis players, but also with conflictingresults. While Silva et al.There is a body of evidence showing an association between scapular dysfunction andshoulder pain, specifically in the overhead athleteIn summary, glenohumeral range of motion, rotator cuff strength or imbalance, andscapular position and movement are important factors in the assessment of healthy andpreviously injured overhead athletes in order to define risk factors and guide theathlete into the return-to-play stage after injury.In addition to the more local risk factors mentioned above, more functional deficitsmight be risk factors for injury like faulty biomechanics, throwing fatigue etc. Inorder to measure these variables, there is a need for functional testing in athrowing-specific position, for instance endurance tests of the shoulder into a throwingposition, throwing distance, speed and accuracy. However, with the exception of sometests mimicking shoulder function, like the "seated medicine ball throw"According to the decision-based return-to-play model described by Matheson et al.,,With respect to range of motion, loss of internal range of motion is a known riskfactor for chronic shoulder pain,The assessment of the ROM into rotation of the shoulder can be measured with agoniometer or an inclinometer, and in many positions of the body and the shoulder. Acomprehensive reliability studyIn addition, horizontal adduction can be measured in the assessment of posteriorcapsule stiffness,Given the evidenced impact of posterior shoulder tightness on shoulder kinematics,increasing posterior shoulder flexibility is advised when mobility deficits exceedthe limits associated with increased injury risk. Both the cross-body stretch  and the ,,Regarding rotator cuff strength, it is generally recognized that overhead athletesoften exhibit sport-specific adaptations leading to a relative decrease in thestrength of the external rotators, and thus muscular imbalance in the rotator cuff.Isokinetic-In view of the importance of eccentric rotator cuff strength in relation toinjury-free overhead throwing or serving, it is imperative that strength be assessedon a regular base in healthy as well as injured players. Numerous testing protocolshave been described to examine isokineticRecently, a new testing protocol was published, showing that HHD measurements ofeccentric external rotator strength show excellent intra-tester (ICC=0.88) and goodinter-tester (ICC=0.71) reliability, as well as concurrent validity Numerous exercises have been described to strengthen the rotator cuff muscles,including concentric, isometric, eccentric, and plyometric exercises1) Exercises that accentuate the eccentric phase and "avoid" the concentric phase inorder to load the muscles based on their eccentric capacity. 2) Slow exercises for absolute strength, fast exercises for endurance and plyometriccapacity. Endurance and plyometric capacity may be exercised using weight ballsexercises in which the patient is instructed to "catch" the ball , as desc® trainer(3) Exercise highlighting the "stretch-shortening-cycle" of throwing. Specific devicescan be used to train the stretch-shortening cycle, such as XCO trainer.,,,,Evidence supporting cut-off values for prevention of injury or return to play afterinjury with respect to scapular function is scarce. A number of studies used visualobservation as a criterion,,Several studies measured scapular upward inclination in healthy overheadathletes,,,For the scapular muscles proper inter- and intramuscular balance should be assessed.Isokinetic ratio protraction/retraction is shown to be 100% in a healthy population,with slight changes in overhead athletes, in case of throwing athletes in favor ofthe protractors,In the assessment of scapular behavior, besides the clinical observation, severalmeasurements can be performed for scapular position as well as muscle strength. Theuse of a digital inclinometer for the measurement of scapular upward rotation hasbeen shown to exhibit high inter- and intra-rater reliabilityOnce deficits and imbalances in scapular behavior are assessed, an interventionprogram to restore flexibility and muscle performance needs to be installed.Recently, a science-based clinical reasoning algorithm was published guiding theclinician into the different steps and progressionIn summary, with respect to injury prevention as well as return to play after injury,the clinician should evaluate possible risk factors for injury in the shoulder, inparticular GIRD, rotator cuff strength, and scapular performance, using reliableassessment tools. In case abnormal findings are established, the intervention shouldfocus on stretching of the posterior shoulder capsule, strengthening of the posteriorcuff, and restoration of flexibility and muscle balance of the scapular muscles.


The development of renewable biofuels is a global priority, but success will require novel technologies that greatly improve our understanding of microbial systems biology. An approach with great promise in enabling functional characterization of microbes is activity-based protein profiling (ABPP), which employs chemical probes to directly measure enzyme function in discrete enzyme classes in vivo and/or in vitro, thereby facilitating the rapid discovery of new biocatalysts and enabling much improved biofuel production platforms. We review general design strategies in ABPP, and highlight recent advances that are or could be pivotal to biofuels processes including applications of ABPP to cellulosic bioethanol, biodiesel, and phototrophic production of hydrocarbons. We also examine the key challenges and opportunities of ABPP in renewable biofuels research. The integration of ABPP with molecular and systems biology approaches will shed new insight on the catalytic and regulatory mechanisms of functional enzymes and their synergistic effects in the field of biofuels production. The need for sustainable and renewable energy alternatives to replace fossil fuels has become a global issue that requires highly innovative research and development . StrategAn ABPP strategy fills critical knowledge gaps that cannot be determined from genome technologies that only detect and quantify the abundance of macromolecules  –7; namelTo date, several excellent reviews or book chapters have described small-molecule probes designed to profile diverse classes of enzymes and the bio-orthogonal chemistry and ABPP applications in chemical biology research, drug screening, and target proteins related to disease pathology , 11, 12.Emerging as a key technology in the evolution of functional proteomics, the root of ABPP can be traced back to the development of radioisotope and fluorescent probes that were used to track metabolic activities and subcellular disposition of small molecules, respectively. The rapid growth of high resolution and high sensitivity LC–MS-based proteomics brought about the evolution of ABPP, where probe readout enables identification of specific protein targets, their quantification and even subcellular locale. ABPP has also been coupled with fluorescence microscopy and other techniques enabling targeted imaging of subcellular function and localization –15. SincActivity-based protein profiling relies on ABPs that form stable covalent bonds with active proteins in complex proteomes by direct reaction with protein residues or via photoreactive crosslinking. The ABPs consist of three moieties: 1) a reactive group that forms an irreversible covalent bond with a target enzyme or protein. Sulfonate esters, fluorophosphonates, peptide acyloxymethyl ketones, aryl alkynes, iodoacetamides, and cyclitol epoxides are examples of reactive groups that have been successfully incorporated into ABPs; (2) a binding group (“substrate mimic”) that biases the probes toward an enzyme family and may also impart cell permeability, and (3) a reporter tag for rapid and sensitive purification and characterization of labeled enzymes  enables the use of reporter tag-free probes in which probe labeling is performed prior to reporter conjugation , 31. RepThe rapid improvement of biofuel production from renewable lignocellulosic biomass has been made a high priority due to the growing worldwide energy demand and the threat of global warming associated with the combustion of fossil fuels. Biologically derived energy (‘bioenergy’)-relevant enzymatic catalysis plays a critical role in biomass conversion . EnzymatSince 1992, chemical probes designed to target GHs enzymes have been developed, and these probes have achieved a remarkable success in monitoring GHs activities , 36–43. The probes shown in Table Pseudomonas aeruginosa . Th. ThN-ethSynechococcus sp. PCC 7002 cells during light-to-dark transitions and carbon and nitrogen limitation [2), which results in the over-reduction of plastoquinone and NADP+.Later, Ansong, Sadler and co-workers employed IAM-RP and Mal-RP to characterize redox-sensitive protein dynamics in live mitation . The aut2 productions by phototrophs are exciting alternative fuel sources, but both processes are sensitive to and may require specific redox interactions for activation [Collectively, these results provide insight pertaining to the roles protein redox reactions play in reacting to environmental perturbations such as nutrient limitation and diel cycling. A clear understanding of the feedback loops, signaling events, and PTMs used by cells to modify function is essential for gaining a higher resolution of metabolic processes and modulation. Hydrocarbon biosynthesis and Htivation , 69. By In addition to redox-based regulation, ABPP also has potential for providing insights into other forms of post-translational regulation in cyanobacteria and other microorganisms relevant to biofuels production. For example, protein phosphorylation regulates a range of critical functions in cyanobacteria including carbon and nitrogen metabolism, photosynthesis, and stress response but identifying targets of signaling pathways is a major challenge .There is considerable promise for microbial bioenergy conversion. The field of ABPP is poised to yield new insights into the enzymes responsible for biosynthetic and catabolic processes, as well as the regulatory mechanisms cells utilize for partitioning carbon and energy.To more fully realize the benefits of ABPP for bioenergy production, several challenges must be overcome. This includes the selection of important new probe targets, synthesis of novel probes which are capable of targeting and exploring new classes of enzymes and their poorly understood catalytic mechanisms, tight substrate specificity, and/or low expression levels in biofuels development. Simultaneously, the application of ABPP will need to shift from probe labeling studies in well defined axenic microbial cultures, and expanded into characterizing the enzymes dynamics in mixed microbial cultures and complex environmental or engineered microbial communities. The engineering of designer communities would benefit greatly from ABPP strategies. A conceivable approach would include the identification of novel microbes that demonstrate biofuel-relevant processes that could be coupled with photoautotrophic microbes to yield a self-sustaining culture. Additionally, it is likely that considerable realms of functional phylogeny are yet to be identified; ABPP may play an important role in function-enabled mining of microbial communities. Novel enzymes with non-canonical sequences and/or tolerance to extreme conditions may also be identified with high efficiencies for lignocellulose catabolism, lipases, transesterases, and other biofuel-relevant functions. ABPP can also be utilized to establish high-throughput SDS-PAGE based assays for screening and determining ideal culture conditions that induce high enzyme activity levels for biofuel-relevant metabolic processes. Finally, ABPP coupled with fluorescence and electron microscopy, Raman spectroscopy, and other techniques may elicit a much improved understanding of functional protein dynamics at the spatial and interaction scales. This knowledge could be used to create microbial communities for targeted biofuels production, or to understand and mitigate drivers of cyanobacteria or algae pond crashes. Regardless of the biofuel target, ABPP is currently being used to functionally characterize microbes and microbial communities, and future prospects for this application are limitless.Over the past few years, ABPP has boomed in the field of chemical biology through elucidation of target functional proteins in vivo and in vitro. ABPP techniques that integrate transcriptomics, proteomics, fluorescence and electron microscopy, molecular biology , and other disciplines will provide comprehensive characterization of the catalytic and regulatory mechanisms of target enzymes, enzyme complexes, and entire biosynthetic pathways, thereby accelerating systems-level understanding required for efficient and economic biofuel technology development. Where transcriptomic and global proteomic analyses can only be used to infer functional capability in a biological system, ABPP directly measures function. There are exciting opportunities for coupling omic strategies to ABPP, such as linking post-translational modifications  directly to enzyme function. Recent advances in the burgeoning field of intact proteomics may soon enable such comprehensive and high-throughput analyses that assign post-translational modifications to an enzyme’s active state. Additionally, lipidomic and metabolomics analyses may be coupled directly to ABPP data to correlate metabolic output directly to protein functions.Beyond biofuels research and development, ABPP can fill a critical need for new technologies to connect uncharacterized microbial species or guilds to ecosystem processes. While metagenome sequencing has paved the road towards establishing these linkages, critical technical and bioinformatic challenges remain . ABPP ca


Although artemisinin-based combination therapies (ACTs) are widely viewed as safe drugs with a wide therapeutic dose range, concerns about neuroauditory safety of artemisinins arose during their development. A decade ago, reviews of human data suggested a potential neuro-ototoxic effect, but the validity of these findings was questioned. With 5–10 years of programmatic use, emerging artemisinin-tolerant falciparum malaria in southeast Asia, and the first calls to consider an increased dose of artemisinins, we review neuroauditory safety data on ACTs to treat uncomplicated falciparum malaria. Fifteen studies reported a neurological or auditory assessment. The large heterogeneity of neuro-ototoxic end points and assessment methodologies and the descriptive nature of assessments hampered a formal meta-analysis and definitive conclusions, but they highlight the persistent lack of data from young children. This subgroup is potentially most vulnerable to any neuroauditory toxicity because of their development stage, increased malaria susceptibility, and repeated ACT exposure in settings lacking robust safety monitoring. Over the past decade, artemisinin-based combination therapies (ACTs) have been deployed as first- and second-line treatments for uncomplicated malaria across malaria-endemic regions. Since 2001, this deployment has included the delivery of over 500 million treatments of artemether-lumefantrine (AL), making it one of the most widely prescribed drugs worldwide.1Artemisinin derivatives are generally viewed as safe drugs with a very wide therapeutic dose range. However, a number of animal studies conducted before the wide deployment of artemisinins identified their potential ototoxic effects targeting mainly the auditory and vestibular pathways. Damage to specific brainstem nuclei was reported when administering high and parenteral doses of the lipophilic artemisinin molecules arteether and artemether.Given the considerable number of trials in children 6–59 months of age and their wide-scale use in control programs, one might assume that any specific safety concerns would have been previously identified, which is not necessarily the case. Standard phase III trials generally use the drug of interest at the target dose during a single or a low number of exposures, and they are underpowered for safety end points. Furthermore, there are no standardized guidelines to evaluate ACT ototoxicity or neurotoxicity in clinical trials, both of which are more challenging to assess in young children. Without specific encouragement or recommendation of neuroauditory assessments, few research teams voluntarily opt to conduct such assessments. Pharmacovigilance conducted as part of phase IV or post-marketing safety monitoring largely depends on passive detection of adverse events within regular healthcare systems that often lack the capacity to diagnose changes in auditory function.Over the past decades, there has been a considerable increase in the reported prevalence of hearing impairment worldwide. This increase has been attributed to better case finding, ageing populations, an increase in noise-induced hearing loss, excessive use of ototoxic drugs, and untreated otitis media.Techniques, such as otoacoustic emissions (OAEs), electrocochleography, and auditory brainstem responses (ABRs), have been used for detecting and monitoring ototoxicity in infants and non-responsive subjects with success.15In 2004, a study from Mozambique suggested that AL  was associated with hearing impairment in adults being treated for uncomplicated malaria.A search of electronic databases was conducted to identify publications on the treatment of uncomplicated malaria with ACTs that included specific reports on neuroauditory safety outcomes. Exclusion criteria were no inclusion of neuroauditory or neurological safety outcomes, studies on treatment of severe malaria, pre-clinical studies, reviews, case reports, and expert opinions. There was no exclusion regarding participants, interventions, comparisons, overall outcomes, or study design.The search was not limited by language or year, and it was carried out using the databases of EMBASE and PubMed MEDLINE. The latest search was conducted in January of 2013. The search strategy included seven different MeSH medical subject headings (MeSH) term combinations: artemisinin combination therapy and safety, artemisinins and uncomplicated malaria and safety, artemisinins and auditory safety, artemisinins and neurological safety, artemisinins and ototoxicity, artemisinins and neurological assessment, and artemisinins and hearing assessment.Methods currently recommended for auditory measurements in infants and children are described in We included neurological and neuropsychiatric assessments when they were reported. They were either reported as general neurological assessments or specifically described as more targeted, such as fine-finger dexterity, hand coordination, audiovestibular tests (Rinne's and Weber's tests), and/or behavioral–developmental assessments adapted for children . One study reported neuropsychiatric assessments based on questionnaires to caregivers and children over 3.5 years old.Neuro-ototoxic end points varied substantially across studies and among methodologies used.WHO grades of hearing impairment suggest that no impairment is reported at ≤ 25 dB, slight impairment is 26–40 dB, moderate impairment is 41–60 dB, severe impairment is 61–80 dB, and profound impairment, including deafness, is ≥ 81 dB. Hearing threshold levels are taken for the better ear as the mean of the unaided pure tone threshold levels and the frequencies of 0.5, 1, 2, and 4 kHz (decibels). In addition, hearing threshold levels (decibels) defining disabling hearing impairment are established as being > 31 dB in individuals ages < 15 years and > 41 dB in individuals ages ≥ 15 years .There are no standardized end points to assess ototoxicity with ABR, although based on animal studies, the wave III–V latency would most likely be affected by artemisinin toxicity, and any cumulative drug exposure and toxicity effect would be expected to produce a bilateral prolongation of the I–V, I–III, and III–V interpeak latencies (IPLs).There were no specified pre-defined general neurological end points in the reviewed papers, and outcome measures consisted of description of main findings, intensity, frequency, age distribution, onset, and resolution.A structured data collection sheet was developed to extract data from each selected study. Study design, participants, location, auditory method of assessment, neuro-ototoxic end points reported, and main results were appraised. The reported data were appraised separately by two independent assessors (V.R.M. and C.G.M.) and evaluated for the risk of bias in individuals and across studies using The Cochrane Collaboration's tool for assessing risk of bias in randomized and non-randomized studies combined with the Agency for Healthcare Research and Quality (AHRQ) 2012 recommendations .21,2222The heterogeneity of study end points and methods prevented any meaningful meta-analyses.The literature search process is presented in Study characteristics are summarized in Two observational retrospective case-control studies explored the potential ototoxic effect of ACTs after multiple exposures and included children under 5 years old. In children older than 5 years (there were not enough controls under 5 years old to make comparisons), Kissinger and others26N = 150). These individuals were compared with controls without drug exposure. Toovey and Jamieson16Toovey and JamiesonAmong seven single-exposure studies that included auditory assessment before and after treatment, three studies reported neuroauditory abnormalities after artemisinin treatment.Lacking meta-analysis options, we summarize the current available ACT neuroauditory safety data according to the Oxford Center of Evidence Based Medicine (OCEBM) levels of evidence . Grades This review is the first comprehensive and systematic review on specific human neuroauditory safety concerns of ACTs for the treatment of uncomplicated malaria since these concerns were raised a decade ago. Unfortunately, this review reveals a lack of collective effort to obtain the required safety data in a structured way, although ACTs have become some of the most widely used drugs in Africa over the past decade.This review highlights the technical challenges involved in determining this specific safety concern properly, but more importantly, it questions if the scientific community has neglected the opportunity and its responsibility for ongoing targeted assessment of the safety of widely used antimalarials in real-life settings during the post-marketing period. Most of the studies aimed to assess efficacy and general safety of a single exposure. Only 15 studies looked at specific neuroauditory and/or general neurological safety outcomes. The lack of a standardized approach to drug adverse event monitoring hampered the ability to compare data collected in different studies and prevented any meaningful meta-analysis. Systematic assessments for adverse events in efficacy–safety studies generally followed the International Conference of Harmonization Good Clinical Practice guidelines. These assessments, however, did not focus on the existence of system-specific adverse events and could not rule out neuroauditory toxicity of ACTs in humans. The reviewed studies that were looking at multiple and single exposures to ACTs identified some changes in the hearing assessments performed after treatment but collectively failed to accurately and objectively investigate this finding, particularly in children under 5 years of age, most likely for very pragmatic reasons.The investigation of hearing impairment in infants and young children can be particularly challenging, especially when trying to detect subtle and early toxicity in remote settings where trained audiologists and equipment are not available. There is a need to provide objective auditory measurements to predict the pure tone audiogram in young children that cannot report reliable behavioral responses to sound. OAEs and/or ABRs are widely used to detect sensory or conductive hearing loss in this age group . ABR measurements are particularly well-suited in detecting and estimating a magnitude of hearing loss in young children, with click-evoked ABRs providing several advantages: they assist in determining whether auditory neuropathy exists and can be obtained in a relatively brief amount of time.25The variations in study designs and auditory assessment methods used  prevente16Causes of hearing damage are multifactorial, and therefore, potential confounders need to be taken into account. A challenging one in this context is the potential disease-specific damage caused by malaria itself. Hearing loss is a recognized complication of cerebral malaria,39Neuroauditory events could be associated with the use of cumulative high-dose exposure in young children, and more emphasis needs to be given to the potential of dose- and age-dependent adverse events. Drugs are assessed at very narrow dose ranges during the drug development stages, and considerable developmental changes in early childhood affect the pharmacokinetic profile of drugs. With the current recommended weight-based dosing regimens in sub-Saharan Africa, children under 5 years of age could receive oral artemether ranging from 2 to 6 mg/kg per dose and from 8 to 24 mg/kg per course of treatment.The main limitations of this review are the varying quality and descriptive nature of the neuroauditory findings reported by most studies and the lack of robust data from the most vulnerable groups. The risk of bias was unclear or likely for the majority of studies. Of the RCTs, only the study by Abdulla and others43In conclusion, after a decade of use, there remains a lack of high-quality evidence on the neuroauditory safety of ACTs. There is no reported evidence to rule out the occurrence of any ototoxicity in those individuals who have been mentioned over and over again as the most vulnerable subgroup: young children who are treated repeatedly during a potentially vulnerable phase of brain development and may be exposed to some of the highest intake doses. Early evaluation and prevention of hearing impairment in childhood are essential, because hearing impairment can have severe adverse effects on speech, behavior, linguistic understanding, and language acquisition, contributing to global disability and mortality. Early-onset hearing loss detection programs are successful and increasingly implemented in the developing settings.