Without these steps, sex-dimorphic landing mechanics data will play a limited role in identifying the aetiology of ACL injuries in women and men.Anterior cruciate ligament (ACL) injuries continue to present in epidemic-like proportions, carrying significant short- and longer-term debilitative effects. With females suffering these injuries at a higher rate than males, an abundance of research focuses on delineating the sex-specific nature of the underlying injury mechanism. Examinations of sex-dimorphic lower-limb landing mechanics are common since such factors are readily screenable and modifiable. The purpose of this paper was to critically review the published literature that currently exists in this area to gain greater insight into the aetiology of ACL injuries in females and males. Using strict search criteria, 31 articles investigating sex-based differences in explicit knee and/or hip landing biomechanical variables exhibited during vertical landings were selected and subsequently examined. Study outcomes did not support the generally accepted view that significant sex-based differences exist in lower-limb landing mechanics. In fact, a lack of agreement was evident in the literature for the majority of variables examined, with no sex differences evident when consensus was reached. The one exception was that women were typically found to land with greater peak knee abduction angles than males. Considering knee abduction increases ACL loading and prospectively predicts female ACL injury risk, its contribution to sex-specific injury mechanisms and resultant injury rates seems plausible. As for the lack of consensus observed for most variables, it may arise from study-based variations in test populations and landing tasks, in conjunction with the limited ability to accurately measure lower-limb mechanics via standard motion capture methods. Regardless, laboratory-based comparisons of male and female landing mechanics do not appear sufficient to elucidate causes of injury and their potential sex-specificity. Sex-specific  Injuries to the anterior cruciate ligament (ACL) continue to occur at an alarming rate, whilst carrying significant short- and long-term morbidity and an enormous financial burden ,2. IndivAs a step toward more effective injury screening and prevention, the manoeuvres during which most ACL injuries occur have been identified and examined. Most non-contact ACL injuries are reported to arise from a sudden deceleration while either running and changing direction or landing from a jump . Due to The purpose of this review was to (1) synthesise the reported sex-based differences in lower-limb mechanics of landing manoeuvres; and (2) critically discuss the impact of this body of literature on our understanding of the aetiology of noncontact ACL injuries. First, we summarise research targeting sex-based differences in explicit biomechanical variables during high-risk landings, whilst simultaneously providing rationale for targeting these variables. Second, we address methodological heterogeneity and concerns of this body of literature and discuss their role in the results of our synthesis. Third, we recommend future research directions that aim to more effectively determine why some individuals, especially women, may be more susceptible to noncontact ACL injury than others.Whilst a large number of factors have been investigated for sex-specificity pertaining to landing mechanics, the present review focuses on biomechanical variables that have been shown to directly contribute to ACL injury risk Table . These vTo select the research articles that presented original data on sex-based differences in knee and hip mechanics during landing manoeuvres, a literature search was performed. The PubMed database was searched using the following keywords: 1) "sex" OR "gender"; AND (2) "biomechanics"; AND (3) "land*" OR "jump*". Only the articles that met the following criteria, however, were included in the review: (1) healthy, human subjects; (2) comparison of the pre-determined knee and/or hip mechanical variables between sexes, as listed in Table  "sex" ORPotential links between sagittal-plane knee mechanics and ACL injury are highly touted. This is because the ACL is the primary restraint to anterior tibial translation . In factA lack of consistency exists in the literature regarding sex differences in knee flexion angles during landings, whilst knee flexion moment data appear to be similar between sexes. Results from most studies indicate that women land with similar knee flexion angles to men -37,42,44in vivo is challenging, only one study has attempted to do so, finding no sex differences [Findings regarding sex-based differences in anterior tibial translation appear inconclusive. Given that accurately measuring tibial translations ferences . This ouferences , its sucferences . This apferences , for whiferences ,55. By mferences  did acquAs with knee flexion, evidence of sex differences in hip flexion angles is inconclusive, with no apparent differences in hip flexion moments. The majority of studies revealed no significant sex differences in hip flexion angles during vertical landing tasks ,32,34,36Frontal-plane knee biomechanics during landings have been investigated extensively as a potential contributor to ACL injury aetiology. This research has been driven primarily by the role of the ACL in restraining motions and loads in this plane, in combination with recent prospective work linking them to injury ,20. MarkEvidence in the literature supports greater knee abduction angles in females, whilst that for sex-based differences in frontal-plane moments is inconclusive. Most studies  found greater knee abduction angles in females during landings compared to males for at least one variable associated with the ground contact phase  ,37,38,44With regard to frontal-plane hip mechanics, the literature does not provide convincing evidence of sex-dependence Table . Differeexternal rotation [external rotation may have occurred after ligament rupture. In fact, recent cadaveric injury simulations support this tenet, observing internal rotation of the tibia before ligament rupture and external rotation following ligament failure [internal rotation moment in combination with an anterior tibial shear force applied to an extended knee produced the greatest ACL force. In contrast, the addition of a tibial external rotation moment to an anterior tibial shear force reduced ACL force. Most recently, the application of a tibial internal moment was reported to increase ACL strain in comparison to an external moment or to an absence of an axial moment [internal rotation, therefore, appear to play an important role in ACL loading and resultant ACL injury risk.Although transverse-plane mechanics have received less attention in the literature, they have still been theorised to play an important role in the mechanism of ACL injuries. Krosshaug and colleagues used video footage to assess the knee and hip motions of 30 individuals suffering noncontact ACL injuries. They found that in the majority of cases, the knee medially collapsed with combined hip internal rotation, knee abduction, and tibial rotation . Acknowl failure . Whilst  failure , for insl moment . Lower-lThere is limited agreement regarding sex-based differences in transverse-plane knee and hip mechanics during landings Table . AlthougIn spite of strong assertions regarding "known" biomechanical risk factors for ACL injury, there is limited evidence to suggest that sex-based differences in ACL injury rates arise from concomitant differences in such factors. The one exception is peak knee abduction angle, where women were found to typically land with greater abduction than men. For most biomechanical variables of interest, however, no consensus among studies was reached. Further, for knee and hip flexion angles, and hip adduction angle, the majority of the evidence in the literature supports a lack of sex-based differences.When a lack of consistency exists between the results of various studies, investigators have often pointed to methodological discrepancies as the primary cause. The studies investigating sex-based joint mechanical differences within a vertical landing task indeed demonstrate methodological variation in factors such as landing type (single- vs. double-leg landing), height of landing, and population characteristics . These variations, however, do not appear to govern the lack of consensus observed in most of the variables examined herein. As seen in Tables First, all of the studies that reported smaller initial contact knee flexion angles in females compared to males examined double-leg landings; whereas the lone study that revealed greater angles investigated a single-leg landing task. This task-dependency is somewhat counterintuitive seeing that single-leg landings appear to be more difficult to execute . During Second, sex differences in frontal- and transverse-plane knee and hip kinematics may also be task-dependent. Both studies that reported greater hip adduction angles in women than men investigated the mechanics of double-leg landings, as oppose to single-leg landings. The increased sensitivity of out-of-plane knee loading to the female 3D hip posture during landings compared to males is well documented . It coulThird, greater knee and hip internal rotation angles were present in women during a single-leg landing, whereas double-leg landings did not reveal sex differences in transverse-plane knee and hip mechanics. Given the more challenging nature of the single-leg landing, as stated above, it is plausible that women have a decreased ability to counteract transverse-plane moments produced upon landing, thus leading to greater motion in this plane. In fact, Wojtys et al.  have shoLastly, studies reporting greater knee abduction moments in the female group tested adolescent populations, while studies reporting lower female moments or no sex differences tested adults. It is unclear whether an interaction between developmental stage and sex-based knee joint mechanical differences truly exists, or whether it is a coincidence. Only six studies ,14,32,36Some of the discrepancies in results between studies may also stem from anatomical and/or hormonal variations among the participants. None of the studies investigated herein, for example, accounted for potential differences in knee morphology and laxity between participants. Merely two out of the 31 studies controlled for phase of the menstrual cycle during which data collection occurred ,12. ThesThe lack of sex-based differences in knee and hip joint landing biomechanics reported in most studies may be in part due to the means by which joint mechanics are quantified. Typically, joint kinematics are derived from the coordinates (2D or 3D) of retro-reflective markers affixed to the skin that estimate the position of the underlying bones. Whilst skin movement artefact is known to transpire into relatively large errors in the calculation of joint mechanics , howeverIn addition to error caused by skin movement artefact, data processing techniques are also a common source of error in both kinematic and kinetic data. Overzealous filtering of marker trajectory data may remove critical peaks in joint kinematics and resultant kinetic data. This is particularly problematic if the magnitude of such peaks differs between males and females. Furthermore, discrepancies in kinematic model definitions will also be problematic. Although standards do exist in the biomechanics community ,75, a wiin vivo, laboratory-based studies to elucidate the aetiology of noncontact ACL injury appears to be limited.The heterogeneity in the methodologies, the questionable validity of skin marker-based joint mechanics, and potential variations in data processing techniques among studies appears to only partly explain the inconsistencies in reported sex-based joint biomechanical differences. Although some differences appear to be task- or population-dependent, as noted, these trends are generally weak and thus do not seem to explain the lack of consensus in the literature. Also, despite much lower relative error in skin marker-derived joint mechanics in the sagittal plane, evidence of a sex-bias in these examined variables was also inconclusive. Hence, the direct application of the findings of these Although it was our intention to include all original research that compared knee and hip landing mechanics between healthy females and males, our ability to do so successfully was limited in several ways. As discussed, the studies included in our review demonstrated a diverse range of methodologies, which may have masked commonalities regarding true sex-based differences. Also, we did not systematically quantify the studies' quality. Specifically, we did not report on factors such as adopted methodological standards and techniques, degree of subject proficiency in movement tasks examined, and population sample sizes. Consequently, every study was weighted equally within the review regardless of quality, which may have distorted outcomes. Despite these shortcomings, it is our opinion that our review provides an accurate synthesis of the literature pertaining to sex-based differences in knee and hip landing mechanics.in vivo, for example, we are faced with the challenge of distinguishing which factors truly manifest within the mechanism from those that merely demonstrate sex-dependence. Measurement of the in vivo ligament response during such tasks, via implantable gauges similar to those used by Fleming et al. [in vivo joint biomechanical data in isolation may not elucidate sex-specific injury risk, they are vital in driving studies that can do so. Specifically, they afford valid input data  for estimating ACL loading in response to explicit sex-based neuromechanical scenarios. Success of such studies is still dependent on the accuracy with which these biomechanical inputs can be collected. With this in mind, methods geared towards accurate and reliable in vivo joint biomechanical data should be actively pursued.While studies comparing landing mechanics between male and females have provided key baseline information regarding the ACL injury phenomenon, their ability to speak to the aetiology of these injuries may be limited due to the inherent complexity of the injury mechanism. Given that such studies rarely translate findings to the actual ligament load response g et al. ,77 and Cg et al. , may prog et al. , for exag et al. . "Stiff"g et al. . In addig et al. . These sin vivo laboratory setting. Such studies for example, do not adequately replicate the mechanical and neuromuscular control strategies typically utilised within the inherently random field setting where injuries do occur. Myers et al. [In light of that presented above, we contend that greater insight into the role of joint mechanics within sex-specific injury risk may be obtained by extending analyses beyond the s et al.  have sugs et al. -85. Innos et al. , for exaAlthough evidence in the literature supports a multi-planar injury mechanism, most research efforts continue to be aimed at uni-planar injury risk. This is problematic since the ACL injury mechanism is increasingly viewed to arise via a 3D mechanical mechanism . In the in vivo drive these models, these data, however, should not be discounted. In fact, their accuracy is imperative, which fuels the need for the development of superior methods to quantify biomechanics. Unless these critical steps are taken, progress toward elucidating the aetiology of noncontact ACL injuries will be limited.This review revealed that there is limited agreement in the literature as to whether women land differently than their male counterparts. Further, when consensus was reached, a lack of sex differences was reported. The only common difference revealed was that women landed with greater peak knee abduction angles than men. Since knee abduction is known to increase ACL loading, therefore, it is plausible that this variable indeed contributes to observed sex-dimorphic injury rates. Conversely, it may simply demonstrate sex-dependence that is irrelevant to the sex disparity in injury risk. To advance our knowledge of the aetiology of noncontact ACL injuries, as a step toward effective injury screening and prevention, we recommend progressing beyond a sex comparison focus. We recommended adopting a focus that includes additional risk factors and assessments within more realistic and less predictable movement environments. Further utilisation of experimental and modelling techniques that afford quantification of the actual ligament response to realistic joint mechanical inputs also seems imperative. Given that joint biomechanical data measured The authors declare that they have no competing interests.MLB performed the literature search and summary. MLB and SGM drafted and edited the manuscript, as well as read and approved its final version.


Restorative and endodontic procedures have been recently developed in an attempt to preserve the vitality of dental pulp after exposure to external stimuli, such as caries infection or traumatic injury. When damage to dental pulp is reversible, pulp wound healing can proceed, whereas irreversible damage induces pathological changes in dental pulp, eventually requiring its removal. Nonvital teeth lose their defensive abilities and become severely damaged, resulting in extraction. Development of regeneration therapy for the dentin-pulp complex is important to overcome limitations with presently available therapies. Three strategies to regenerate the dentin-pulp complex have been proposed; regeneration of the entire tooth, local regeneration of the dentin-pulp complex from amputated dental pulp, and regeneration of dental pulp from apical dental pulp or periapical tissues. In this paper, we focus on the local regeneration of the dentin-pulp complex by application of exogenous growth factors and scaffolds to amputated dental pulp. Dental pulp is sometimes affected by external stimuli such as caries infection or traumatic injury. Preservation of dental pulp and maintenance of its viability are essential to avoid tooth loss, and dentists carry out restorative procedures with pulp capping to regulate inflammatory responses of dental pulp, or cement lining on a cavity floor to block external stimuli. Reversible damage induces pulp wound healing, and direct pulp capping and pulpotomy with calcium hydroxide are known to be effective to induce pulp wound healing mechanisms. After external stimuli such as cavity preparation, apoptosis of pulp cells including odontoblasts is induced –5, follo When the external damage to dental pulp induces irreversible changes of the pulp, dentists carry out pulpectomy. Generally, a root canal after pulpectomy is tightly filled with biomaterials such as gutta-percha to prevent reinfection by bacteria. However, a tooth without vital dental pulp has lost its defensive ability, which is often followed by the severe damage such as the progression of deep radicular caries or tooth facture, resulting in extraction of the tooth. Furthermore, a treated tooth is often reinfected by bacteria because of its complicated anatomical structure or inadequate treatment by a dentist, resulting in formation of a lesion around the root apex with bone resorption. The success rate of the endodontic retreatment is lower than that of pulpectomy –12. To oIt is well known that growth factors, such as bone morphogenetic proteins (BMPs) and fibroblast growth factors (FGFs), stem cells, and scaffolds, are essential for tissue engineering to regenerate tissues . During in vitro cell aggregate and manipulation method, and that the bioengineered tooth germ generated a structurally correct tooth showing penetration of blood vessels and nerve fibers in vivo transplantation into mouse maxilla, resulting in a successful fully functioning tooth replacement [Regeneration of the entire tooth is accepted as a model of organ replacement and regeneration therapy. Recently, it was reported that tooth germs can be bioengineered using a three-dimensional organ-germ culture method, in which dental epithelial and mesenchymal cells isolated from tooth germs were cultured in three-dimensional scaffolds for the replacement therapy. Scaffolds consisted of synthetic polymers such as poly (lactide-co-glycolide) (PLGA) and bioceramics such as hydroxyapatite, tricalcium phosphate and calcium carbonate hydroxyapatite were examined in the three-dimensional organ-germ culture –21. It wlacement –25. ThesLocal regeneration of the dentin-pulp complex from residual dental pulp has been mainly delivered by researchers who are engaged in clinical practice. Several studies have reported the use of local applications of bioactive molecules such as BMPs and recombinant fusion ameloblastin to exposed pulp –28. Howein vivo sonoporation induced reparative dentinogenesis [ex vivo gene therapy by the transplantation of pulp stem/progenitor cells transfected with some growth factors such as GDF-11/BMP-11 stimulated reparative dentinogenesis [ Induction of appropriate pulp wound healing and formation of new dentin in dentin defects are essential for the local regeneration of the dentin-pulp complex and vital pulp therapies to form new dentin in defects. Several papers demonstrated the local regeneration of dentin-pulp complex in different methods. It was reported that BMP-4 with dentin powder induced dentinogenesis in dentin cavity with pulp exposure . In thisogenesis –32, and ogenesis –36.in vivo biodegradation of gelatin hydrogels that incorporated FGF-2 [ FGF-2 is known to play a role in both physiological and pathological conditions –39. It wed FGF-2 –43  of incompletely developed teeth, and these cells have the ability to differentiate into odontoblast-like cells –48. SCAPco-D, L lactide), polylactic acid, polyglycolic acid, PLGA, polyvinyl alcohol, collagen, hyaluronic acid, hydroxyapatite, tricalcium phosphate, silk fibroin, bioactive glasses, and ceramic materials [It is important to select appropriate scaffolds for successful tissue regeneration. It is well known that essential properties of scaffolds are mechanical properties such as porous three-dimension structure, and mechanical strength, as well as biological properties such as biocompatibility and biodegradation . In receaterials . Of the aterials –60. Recently, we have been focusing on the application of hyaluronic acid for local regeneration of the dentin-pulp complex. Hyaluronic acid is one of the glycosaminoglycans present in the extracellular matrix and plays important roles in maintaining morphologic organization by preserving extracellular spaces, and it has been reported to have excellent potential for tissue engineering –65. The in vivo application of hyaluronic acid gels on the wound healing processes of dental pulp, and the application of gelatin-chondroitin-hyaluronan tri-copolymer scaffold to dental bud cells were reported [ Dental pulp is a type of connective tissue derived from the dental papilla, and contains large amounts of glycosaminoglycans , 72. Prereported , 75.in vitro and in vivo effects of hyaluronic acid sponge and collagen sponge on KN-3 odontoblast-like cell line and amputated dental pulp of rat molars. KN-3 cells, which were established from dental pulp of rat incisors, have odontoblastic properties such as high alkaline phosphatase activity and calcification ability [In vivo results following implantation of both sponges in dentin defect areas above the amputated pulp showed that dental pulp proliferation and invasion of vessels into the hyaluronic acid and collagen sponges were well induced from the amputated dental pulp. These results suggest that hyaluronic acid sponge has an ability to induce and sustain dental pulp tissue regenerated from residual amputated dental pulp. In addition, we found that the inflammatory responses of KN-3 cells and the amputated dental pulp to hyaluronic acid sponge were lower than those against collagen sponge, suggesting that hyaluronic acid sponge has biocompatibility and biodegradation characteristics as well as an appropriate structure to make it suitable as a scaffold for dental pulp regeneration [ To clarify whether hyaluronic acid sponge (molecular weight 800 kDa) is useful as a scaffold for wound healing and regeneration of dental pulp, we compared  ability . We founneration   by extending neurites and exhibit a variety of properties of adrenal medullary chromaffin cells. We applied diluted solutions of 800 kDa hyaluronic acid to NGF-exposed PC12 cells, and noted inhibition of NGF-induced neuronal differentiation of PC12 cells via inhibition of ERK and p38 MAPK activation, caused by the interaction of hyaluronic acid to its receptor, RHAMM . In vivo, our results showed that hyaluronic acid sponge is gradually biodegraded during the regeneration processes, leaving soluble hyaluronic acid in the regenerated dental pulp. Next, we intend to clarify the biological and physiological behaviors of hyaluronic acid throughout the regeneration the of dentin-pulp complex. Our results demonstrated that hyaluronic acid sponge is useful for local regeneration of the dentin-pulp complex, whereas hyaluronic acid gel inhibits the differentiation or neurite outgrowth of neurons. In our strategy, growth factors and scaffolds are exogenously supplied as bioactive materials, while the source of stem cells that are able to differentiate into odontoblast-like cells and pulp cells is dependent on the residual dental pulp. The vitality of the residual dental pulp is a critical point to achieve local regeneration of the dentin-pulp complex. It is generally accepted that the pulp wound healing proceeds well under conditions of low inflammatory responses by the dental pulp. In addition, regulation of dental pulp infection is another critical point regarding the success of such regeneration therapy. The resin bonding system is commonly used as one of materials showing favorable adhesion to enamel and dentin, and composite resin system with antimicrobial ability was reported –81. Thes


Leptospira-specific PCR. Leptospira could not be cultured post mortem from the lungs or kidneys. However, Leptospira-specific PCR was positive in lung, liver or kidneys of three dogs. In summary, a novel pulmonary haemorrhagic syndrome was identified in dogs but the mechanism of the massive pulmonary erythrocyte extravasation remains elusive. The lack of a consistent post mortem identification of Leptospira spp. in dogs with pulmonary haemorrhage raise questions as to whether additional factors besides Leptospira may cause this as yet unrecognized entity in dogs.Severe pulmonary haemorrhage is a rare necropsy finding in dogs but the leptospiral pulmonary haemorrhagic syndrome (LPHS) is a well recognized disease in humans. Here we report a pulmonary haemorrhagic syndrome in dogs that closely resembles the human disease. All 15 dogs had massive, pulmonary haemorrhage affecting all lung lobes while haemorrhage in other organs was minimal. Histologically, pulmonary lesions were characterized by acute, alveolar haemorrhage without identifiable vascular lesions. Seven dogs had mild alveolar wall necrosis with hyaline membranes and minimal intraalveolar fibrin. In addition, eight dogs had acute renal tubular necrosis. Six dogs had a clinical diagnosis of leptospirosis based on renal and hepatic failure, positive microscopic agglutination test (MAT) and/or positive blood/urine  Leptospira-infection has been reported rarely [Severe pulmonary haemorrhage is a rare necropsy finding in dogs and may be caused by pulmonary-renal syndrome, heartworm disease, thrombocytopenia, or coagulopathy, it but has not been reported in natural leptospirosis infection –4. Howevd rarely –8. Leptospira serovars are often associated with the leptospiral pulmonary haemorrhagic syndrome (LPHS), a well-recognized entity in man [Leptospira-specific immunoglobulin subtype M  in the acute stage of the disease [Human infections with pathogenic y in man , 9, 10. y in man –13. Cliny in man . The mic disease . Cultiva disease . The pathogenesis of pulmonary injury in LPHS is poorly understood, but vascular damage due to a leptospiral toxin, immunologic mechanisms, or a disseminated intravascular coagulopathy have been proposed as potential pathologic mechanisms , 16–18. Leptospira-specific PCR of urine or blood supported the tentative diagnosis of an unusual form of leptospirosis in these dogs. Interestingly, leptospirosis is of increasing importance and prevalence in the rural areas of Berlin, where the population of urban wild boars is growing dramatically, and these wild boars have recently been shown to represent a significant reservoir for several Leptospira serovars [Between 2006 and 2010, an increasing number of dogs suspicious for leptospirosis were treated at the Small Animal Clinic of the Freie Universität Berlin. More than two-third of these dogs had clinical and radiological pulmonary manifestation in addition to renal and hepatic insufficiency [serovars .Leptospira sp. may be the etiologic cause of the disease.In this report, we describe the macroscopical and histopathological lesions in 15 of these dogs. Due to the similarities between the canine disease and the human LPHS, we also tested the hypothesis that Leptospira infection developed respiratory distress and a focal or generalized interstitial/alveolar lung pattern on thoracic radiographs [Between 2006 and 2010, 43 dogs suspicious for a Leptospira interrogans-specific rabbit antisera against serogroups Canicola, Icterohaemorrhagiae, Grippotyphosa, and Pomona  were used for detection of leptospiral antigen in fresh-frozen and paraffin-embedded tissue lung and kidney sections using immunofluorescence test or ABC-method. In brief, all four antisera were pooled at equal amounts and diluted 1 : 25 in Tris-buffered saline  and incubated at 4°C overnight after a blocking step with 50% goat serum in TBS (30 min at room temperature). For paraffin sections, goat antirabbit IgG  and for immunofluorescence testing a Dylight 549-conjugated secondary antirabbit antibody  were used as secondary antibodies (60 min at room temperature). Diaminobenzidine tetrahydrochloride (Sigma Aldrich) was used as chromogen and slides were counterstained with haematoxylin . A Levaditi-stain-positive canine kidney was used as positive control, and lung sections of dogs without the pulmonary haemorrhage syndrome were similarly incubated and used as negative controls. No unspecific staining was detected in any tissue examined.Tissue samples of major organ systems, including the respiratory, urogenital, and gastrointestinal tract of all animals were submitted for cultivation in EMJH medium and routine bacteriology . CultureLeptospira DNA, two standard primer pairs were used [L. interrogans serovar Icterohaemorrhagiae (secY gene) und L. kirschneri serovar Grippotyphosa (flaB gene) was used as positive control in all PCR reactions. Furthermore, lung and kidney tissue of three dogs without pulmonary haemorrhage, but other neoplastic diseases, were included as negative controls.Complete DNA was isolated using Nucleospin Tissue Kit  according to the manufacturer instructions. For detection of ere used . These pere used . Each tiNecropsy revealed severe, diffuse, acute pulmonary haemorrhage, and alveolar oedema affecting all lung lobes of all animals . Lungs wHistologically, pulmonary alveoli of all lungs were filled with erythrocytes, mostly without extravascular fibrin Figures  and 3. SSpirochaete-like structures in renal tubular epithelium or lungs.PTAH and PAS stain failed to identify fibrin thrombi in vessels of all calibres and all organs analyzed. Furthermore, Levaditi stain failed to identify Immunohistochemistry on paraffin sections as well as immunofluorescence testing failed to identify leptospiral antigen in lung or kidney of all dogs.Leptospira spp. or other obligatory pathogenic microorganisms under aerobic or anaerobic conditions using EMJH medium and standard diagnostic procedures. By means of PCR, a Leptospira-DNA amplicon targeting the flaB gene (563 bp) was detected in the lungs of dogs Nos. 6 and 10 and in the kidney of dog No. 10 (secY gene (285 bp) was present in lung and kidney of dog No. 8 . Clinically, 6 of the dogs had a diagnosis of acute leptospirosis based on serological and PCR findings. Postmortem PCR detected leptospiral DNA in the lung, kidney, and liver of three dogs. Nevertheless, all other methods, including immunohistochemistry, immunofluorescence test, and Levaditi stain failed to identify leptospiral organisms in all dogs. Furthermore, Postmortem bacterial culturing did not isolate leptospiral organisms from the dogs. One explanation for the failure to cultivate leptospiral organisms even in PCR-positive dogs might be the antibiotic treatment of some of the dogs . The low sensitivity of bacteriological and PCR-based methods to detect leptospiral organisms is well known and a major problem in the diagnosis of leptospirosis in general . PCR is Nevertheless, the failure of postmortem identification of cultivatable leptospiral organisms and the lack of amplifiable leptospiral DNA may also point towards a very low bacterial load in the dogs. Similar to the human disease, pulmonary lesions may, therefore, not be caused by an infection of pulmonary structures, but rather induced by a bacterial toxin or an immunopathologic mechanism induced by bacterial components , 17, 18.Alternatively, the clinical detection of leptospiral DNA in blood and urine and the increase of MAT titters in some dogs could represent an incidental finding of and is unrelated to the aetiology of the pulmonary lesions . SubclinObviously, the difficulties to consistently identify leptospiral organisms raises questions as to whether other factors may be involved in the pathogenesis of the disease. Other bacterial organisms cannot finally be excluded at this point, but failure to detect such organisms with routine bacterial culturing methods decreases the probability of a nonleptospiral bacterial causative agent. Viral infections may be a potential aetiology for the pulmonary haemorrhage, but known viruses such as highly pathogenic influenza H5N1 do not cause similar lesion in dogs or other carnivores –28. ThusThe main necropsy finding and cause of death in all dogs was severe, acute, pulmonary haemorrhage. It is remarkable that the pulmonary vascular system is almost exclusively affected by the disease since disseminated haemorrhage or microthrombi were not observed in the lungs or other organs. Only few animals had petechiation in the mucosa of the urinary bladder or melena. The latter was attributed to swallowing of coughed-up blood, since oesophageal and gastric mucosa was unremarkable. Surprisingly, alveolar wall necrosis or vessel wall disintegration was only detected in 50% of the affected lungs. The location of erythrocyte extravascularisation within the lung, therefore, remains elusive. The striking tropism for the lung and the lack of evidence of a general haemorrhagic diathesis suggest that pulmonary microvessels may represent a highly selective target of the mechanism involved, as hypothesized in human LPHS . GeneralImportantly, the pulmonary lesions were diffusely distributed indicating that whatever cell type or target structure may be linked to the cause of the haemorrhages, it is homogeneously distributed throughout the lungs. A disorder of the primary or secondary hemostasis as the sole cause for pulmonary haemorrhage seems unlikely since extensive haemorrhages were almost exclusively observed in the lungs. For instance, coumarin intoxication was excluded in 3 dogs by toxicological analysis; moreover, coagulation screening tests  performed in several dogs made coumarin intoxication unlikely (data not shown). The role of thrombocytopenia in this disease also remains elusive. Low platelet counts are a common finding in canine leptospirosis but are generally, and in the specific context of leptospiral diseases, not associated with severe pulmonary haemorrhage . The mecThe acute liver lesions seen in some dogs are most likely associated with hypoxia due to respiratory distress, and the same may be true for the renal tubular degeneration. Nevertheless, renal and hepatic lesions may also be caused by leptospiral organisms, although levaditi stain and immunohistochemistry failed to identify leptospiral organisms in affected livers and kidneys.In summary, we describe a new pulmonary haemorrhagic syndrome in dogs with striking clinical and pathological similarities to LPHS in man. However, leptospiral organisms, as the suspected cause, were not consistently identified with any of the diagnostic methods applied. The cause of the emerging pulmonary haemorrhage syndrome in dogs, therefore, remains unclear. Further studies are needed to finally determine whether leptospiral organisms or other causes are associated with the canine pulmonary haemorrhage syndrome.


Compensatory growth (CG) is a period of accelerated growth that occurs following the alleviation of growth-stunting conditions during which an organism can make up for lost growth opportunity and potentially catch up in size with non-stunted cohorts. Fish show a particularly robust capacity for the response and have been the focus of numerous studies that demonstrate their ability to compensate for periods of fasting once food is made available again. CG is characterized by an elevated growth rate resulting from enhanced feed intake, mitogen production, and feed conversion efficiency. Because little is known about the underlying mechanisms that drive the response, this review describes the sequential endocrine adaptations that lead to CG; namely during the precedent catabolic phase (fasting) that taps endogenous energy reserves, and the following hyperanabolic phase (refeeding) when accelerated growth occurs. In order to elicit a CG response, endogenous energy reserves must first be moderately depleted, which alters endocrine profiles that enhance appetite and growth potential. During this catabolic phase, elevated ghrelin and growth hormone (GH) production increase appetite and protein-sparing lipolysis, while insulin-like growth factors (IGFs) are suppressed, primarily due to hepatic GH resistance. During refeeding, temporal hyperphagia provides an influx of energy and metabolic substrates that are then allocated to somatic growth by resumed IGF signaling. Under the right conditions, refeeding results in hyperanabolism and a steepened growth trajectory relative to constantly fed controls. The response wanes as energy reserves are re-accumulated and homeostasis is restored. We ascribe possible roles for select appetite and growth-regulatory hormones in the context of the prerequisite of these catabolic and hyperanabolic phases of the CG response in teleosts, with emphasis on GH, IGFs, cortisol, somatostatin, neuropeptide Y, ghrelin, and leptin. Compensatory growth (CG) is a period of accelerated somatic growth following the alleviation of growth-stunting conditions, that temporarily induces a steeper growth trajectory than that of cohorts not previously exposed to adverse conditions Figure . This phA broad range of teleosts are capable of undergoing CG responses following alleviation of various growth-stunting conditions or their combination, including suboptimal temperature, crowding, or other stressful environments, and feed restriction, the latter reflecting the condition most often studied  suggest that a prerequisite drop in the hepatosomatic index (HSI) to about 1.5 is necessary in order to elicit the response  adipocytes  and is stimulated Acanthopagrus schlegeli; Deng et al., The actions of GH are mediated by GH receptors (GHRs), for which two distinct gene lineages exist in fish and which operate via different signaling pathways  pituitaries   stomach ghrelin mRNA levels increased over 35 days of fasting, then dropped back to basal levels after 10 days of refeeding (Terova et al., in vitro stimulation of GH by ghrelin occurs in somatotrophs derived from both continually fed and fasted fish, but not from refed fish, suggesting the hypophyseal GHSR may be downregulated during CG, which would contribute to the eventual decline in GH seen during refeeding of fasted fish. Taken together, the trends in ghrelin regulation and function observed in fish suggest that catabolically elevated ghrelin simultaneously raises lipolytic plasma GH while priming a hyperphagic response during refeeding. The coincidence of these effects likely contributes significantly to the CG response, and may in part explain why a catabolic phase is needed to precede hyperanabolism.In accord with its orexigenic function, ghrelin levels tend to rise during fasting and decline after feeding in mammals (Ueno et al., Appetite is increased during fasting through the upregulation of central orexigenic neuropeptides (Kalra et al., Central NPY (Peng et al., Hyperanabolism, or the accelerated growth phase that characterizes CG, is the result of hyperphagia and heightened growth axis activity during refeeding, particularly in the rapid rise in IGF-I production that occurs when hepatic sensitivity to GH returns. As discussed in the first half of this review, CG is preceded by a catabolic phase that primes an organism for hyperanabolism. If the endurance of the catabolic state is sufficient, and food is ample when feeding resumes, then a temporal hyperphagic response is elicited and a net positive energy state achieved through the reintroduction of exogenous energy and metabolic substrates. When energy stores are regained, orexigenic signaling declines and hyperphagia subsides. Under these terms, an organism exhibits lipostatic regulation of energy homeostasis (Jobling and Johansen, Phoxinus phoxinus; Russell and Wootton, Salmo salar; Bull and Metcalfe, Lepomis; Hayward et al., Gasterosteus aculeatus; Zhu et al., Hyperphagia is an integral component of CG (Ali et al., Hyperanabolism during refeeding is fueled by an influx of metabolic substrates that are rapidly allocated to somatic growth through heightened mitogenic activity of the growth axis; however, hyperphagia alone may not account for the accelerated growth rate experienced during CG. Gurney et al.  propose,Cyprinus carpio; Fine et al., The mechanism that adjusts energy allocation around assimilation rate is undefined, although the lipolytic and growth promoting functions of GH, along with its regulatory profile under variable metabolic conditions, suggests an influential role in optimizing substrate conversion to skeletal growth. Long-term GH treatment in rainbow trout improved feed conversion by 60% (Kling et al., Compensatory growth ultimately refers to the rapid growth, or hyperanabolic, response that occurs during the feeding of previously fasted animals, and which allows them to recover lost growth opportunity. During positive energy states, circulating GH binds hepatic GHRs to induce production and secretion of IGF-I, the prominent mitogen responsible for somatic growth in vertebrates (Froesch et al., Paralichthys adspersus; Fuentes et al., Consistent with the mitogenic attributes of IGFs, plasma IGF-I (Uchida et al., The CG response to fasting is finite, attenuating once lost energy resources re-accumulate and hyperphagia abates. The lipostatic model of energy homeostasis proposes that adiposity acts as a regulatory mechanism on appetite in order to maintain a threshold of energy deposition Kennedy, . KennedyThe mechanism that represents overall energetic status, endocrine or otherwise, is not well defined in teleosts, in part because different fish partition stored energy in various locations. In mammals, the anorexigenic peptide hormone, leptin, reflects fat deposition. Leptin modulates food consumption and energy expenditure according to endogenous energy availability, and is considered the primary lipostatic hormone (Ahima and Flier, Leptin centrally regulates feeding by stimulating appetite-suppressing neuropeptides and inhibiting appetite-stimulating neuropeptides in mammals (Ahima et al., Studies evaluating leptin responsiveness to metabolic state in teleosts are equivocal. Circulating leptin (Johnson et al., Compensatory growth is a period of accelerated growth following the alleviation of growth-stunting conditions, such as fasting, that potentially allows an organism to make up for lost growth opportunity Figure . The resDuring the precedent catabolic phase Figure B, orexigDuring refeeding Figure C, CG is Compensatory growth is therefore regulated by sequential endocrine responses during distinct metabolic states Table . TeleostThe 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.


Chemotherapeutic agents reduce mortality and can prevent morbidity in a wide range of malignancies. These agents are, however, associated with toxicities of their own, and the treating physician must remain ever vigilant against the risk outgrowing the benefit of therapy. Thus, pre-treatment evaluation and monitoring for toxicity during and following administration is a fundamental tenet of oncologic practice. Among the most insidious and deadly toxicities of anti-tumor agents is cardiac toxicity, which in some cases may be irreversible. Early detection of cardiotoxicity allows the treating oncologist to redirect therapy or dose modify, taking into account the cost of a reduction in therapy against the potential of further injury to the patient. In these instances, the role of the cardiologist is to assist and advise the oncologist by providing diagnostic and prognostic information regarding developing cardiotoxicity. This review discusses noninvasive diagnostic options to identify and characterize cardiotoxicity and their use in prognosis and guiding therapy. We also review established protocols for cardiac safety monitoring in the treatment of malignancy. Over the past decade a bonanza of new chemotherapeutic agents have matured, in many cases rendering cancer a chronic disease rather than a terminal one. As early detection of malignancy leads to a higher likelihood of cure, the treated population may survive to experience secondary toxicities of their cancer therapy, in spite of the initial benefit. Of paramount importance in both morbidity and mortality are the short and long term effects of cancer therapy on cardiac tissue and subsequent effects on cardiac function. Early detection of toxicity during therapy may allow for dose modification, alteration, or abandonment of regimens which may reduce or even eliminate long term complications associated with reduced left ventricular function. Further, there is mounting evidence that early therapeutic interventions with cardioprotective medications such as beta-blockers or angiotensin-renin-aldosterone system altering agents may improve cardiovascular outcomes in the population treated with chemotherapeutic agents , 2. Non-It is important to note that the demographics and exposure history of many oncologic patients is such that the incidence of cardiovascular disease is higher than in other populations. Oncologic patients frequently have one or more risk factors for coronary artery disease . Regarding clinical monitoring for cardiotoxicity in clinical trials of chemotherapeutic agents, the Cardiac Review and Evaluation Committee (CREC) reviewing cardiotoxicity in several trials of trastuzumab in the treatment of breast cancer formulated the following, which has become the de facto standard: cardiomyopathy is characterized by  a decreavia several mechanisms, including a) direct cellular toxicity involving cardiac myocytes, resulting in both systolic and diastolic dysfunction; b) induction of ischemia through vasoactive side effects, thrombogenesis, or vascular toxicities; c) arrhythmia either as a collateral effect to cellular toxicity or due to interference with cellular membrane channels; d) induction of myocardial and/or pericardial inflammation (myopericarditis) with associated direct dysfunction or mechanical sequelae due to a pericardial effusion. Survival can be markedly improved with intervention, both in the form of dose adjustment if cardiotoxicity is recognized early, or with medical therapy to allay the onset of heart failure and perhaps retard its progression. With many of the agents described below, when myocardial dysfunction is present in the chronic phase, it commonly represents permanent myocyte injury, and though the syndrome may be clinically treatable for a time the pathophysiology is most likely irreversible. This belies the importance of early detection of toxicity, in the hopes of preventing disease progression. The nature of the chemotherapeutic agent plays a central role in determining cardiotoxicity. Cardiotoxicity may occur Assessment of potential toxicity begins with physical examination and historical features, including an assessment of functional status. A thorough history and physical examination is paramount. Clinical predictors including age, prior hypertensive, vascular, or other cardiac disease are powerful predictors of subsequent toxicity. Other readily available clinical parameters such as biochemical markers, electrocardiographic studies, and finally noninvasive imaging, provide further diagnostic power in determining the presence, degree, and progression of cardiac toxicity. Intensive monitoring of cardiotoxicity in chemotherapeutic regimens may allow for early detection of cardiac dysfunction, and thereby allow clinical intervention, either by dose adjustment, pharmacologic intervention, regimen modification, or therapy aimed at treating subsequent heart failure as it develops. Further, regimens or agents administered prior to the infusion of anthracycline may induce myocardial dysfunction, which makes the patient more susceptible to a clinically significant decline in cardiac function. The protocol under which the anthracycline was infused also has an impact on the likelihood of subsequent development of cardiotoxicity; bolus protocols tend toward cardiotoxicity more than slow infusion protocols, perhaps unveiling a toxic threshold within the mechanism of anthracycline-induced cardiotoxicity , 5 The aThe nature of the chemotherapeutic agent in use is an important factor in determining the likelihood and natural history of cardiotoxicity, if it develops. Comprehensive discussion of the specific cardiotoxicities of the various chemotherapeutic agents are discussed elsewhere in this series. In summary, the mechanism of cardiotoxicity may result from direct injury to the cardiomyocyte, ischemia either due to native disease or vascular effects of the agents in question , 6-8. Thvia a central vein  across the tricuspid valve and into the right ventricle. There, several small biopsies are taken from various positions on the interventricular septum. Though uncommon, complications can occur and include perforation of the right ventricular free wall with subsequent hemopericardium and possible development of tamponade physiology requiring emergent drainage. Other complications include arrhythmia, injury to the tricuspid valve, fistula formation, bleeding and infection. The nature of cardiotoxicity in the setting of many chemotherapeutic agents often occurs in a patchy fashion, thus multiple (3-5) biopsies are required, and even in this setting the sensitivity of endomyocardial biopsy in diagnosing chemotherapy-induced cardiotoxicity is low. Specificity is, however, quite high and can confirm the diagnosis. Though not a noninvasive procedure, endomycardial biopsy does deserve some mention here. In patients with cardiac toxicity, electron microscopy of endomyocardial biopsy specimens reveal disruption of z-lines, mitochondrial disruption, myofibrillary bundles, myofibrillar lysis and vacuolization within the myocytes . Though Cardiac biomarkers generally refer to proteins released from cardiac myocytes under conditions of both mechanical and severe metabolic stress, up to and including cell death. Myocyte death, or severe metabolic stress, will lead to the release into the blood of intracellular proteins, including AST, ALT, creatine-kinase (CK) and the cardiac isoenzyme of CK (CK-MB), as well as cardiac isoforms of troponins I and T (cTnI and cTnT). While skeletal muscle may encode at least trace amounts of cardiac CK-MB, the exclusive translation of the cardiac troponins within the cardiac myocyte renders them more accurate for the detection of cardiac damage. Cardiac troponin T and I are released from cardiac myocytes under conditions of severe metabolic stress, but more commonly following cell death and eventual lysis. These markers reach the bloodstream where they may then be measured peripherally. Cardiac troponins are established as a sensitive and specific marker of cardiac injury. B-type naturetic peptide is a sensitive biochemical marker of myocardial stretch and strain, and has been validated as a diagnostic tool in identifying congestive heart failure as the source of dyspnea . MechaniElevations of cardiac biomarkers have been closely associated with acute toxicities attributable to chemotherapeutic agents, however evidence is lacking to support long term associations of toxicity as well as the prospective use of cardiac biomarkers in determining a course of therapy. Nonetheless, cardiac biomarkers may play a central role in the early identification of patients at high risk for cardiac toxicity in the setting of chemotherapy . Though During the administration of high-dose chemotherapeutic regimens, elevations in cardiac troponins correlate strongly with the development of cardiac dysfunction in patients treated with high dose chemotherapy  are that the procedure is inexpensive, widely available, and without risk to the patient. ECG is essential in the diagnosis of heart rhythm abnormalities. In addition, reduction in limb lead voltages by >30% may predict cardiotoxicity in patients receiving anthracyclines . HoweverEvaluation and surveillance of cardiac function is recommended before, during, and after administration of chemotherapeutic agents with associated cardiotoxicity. There are not, however, published consensus guidelines on the modality or frequency of cardiac assessment - nor on the most effective parameter or set of parameters to follow in a particular situation. Further, coronary artery disease is prominent among many populations of cancer patients, and non-invasive cardiovascular imaging may be used to assess for significant coronary artery disease in addition to assessing for toxicity. Comparison between imaging of both cardiac structure and of perfusion or perfusion surrogates during both rest and stress conditions is a widely utilized paradigm for assessment of injured or ischemic myocardium.via noninvasive imaging in this context is the left-ventricular ejection fraction (LVEF). Often interpreted as an aggregate of left ventricular systolic function, the ejection fraction represents the fraction of left ventricular blood volume at end diastole that is ejected during systole (often expressed as a percentage). Its assessment relies upon accurate evaluation of the left ventricular chamber volume at these two points in the cardiac cycle. Early data, particularly in patients treated with anthracyclines, demonstrated a fall in LVEF associated with the development of anthracycline associated persistent cardiomyopathy. A minor (≤4%) fall in LVEF early in the course of anthracycline based chemotherapy, below what is considered the standard cumulative toxic dose in adults, has also been demonstrated to predict later sustained fall in EF into the toxic threshold in treated patients [The most common parameter assessed patients . Thus, aAs cardiovascular disease, dominantly ischemic heart disease, remains the most common cause of death in the western world, much of what is known about the non-invasive imaging of cardiac structure, function, and dysfunction is derived from efforts to understand and noninvasively detect myocardial ischemia. As the decoupling of myosin from actin is an energy dependent process, the initial myocyte dysfunction in the ischemic heart induces a decline in diastolic function. This leads to an elevation in filling pressures and activation of stretch receptors within the ventricular  walls, subsequently activating the neuroendocrine axis and leading to a release of natriuretic peptides. Loss of systolic function may occur as ischemia progresses to infarction and myocardial necrosis; autopsy studies have in fact demonstrated patchy areas of myocyte necrosis in such patients. Assessment of other parameters of myocardial motion throughout the cardiac cycle, as well as visualization of myocardial tissue features, may provide clues to subclinical toxicity well before it is reflected by a fall in ejection fraction. The strengths and weaknesses of several methods of assessing left ventricular function are therefore described below. Early studies of doxorubicin cardiotoxicity relied upon radionucleotide ventriculography to risk stratify patients pre-therapy, and to follow patients serially during therapy in hopes of identifying early signs of cardiotoxicity. via equilibrium gated techniques to provide an accurate estimate of left ventricular volumes at end-diastole and end-systole, thus providing a surrogate metric of left ventricular function. A radiolabel (commonly technetium 99m) is attached to red blood cells or serum albumin from a patient blood sample and re-injected. In the multiple-gated acquisition technique (MUGA), the summation of counts from 800-1000 ECG-gated cardiac cycles is performed, producing an average cardiac cycle with good resolution of LV chamber dimensions. These dimensions are acquired in 3 standard projections - anterior, left anterior oblique, and left lateral. Each projection requires roughly 5 minutes of imaging time to acquire. Attempts to compare radionucleotide ventriculography (RVG) to standard 2D and M-mode echocardiography techniques have demonstrated inexact correlation [Radionucleotide ventriculography (RVG) is often performed relation . Serial relation . Unlike relation .99mTechnetium-labelled tracers as well as 201Thallium chloride. This group of myocardial perfusion studies rely on differences in regional myocardial blood flow to identify hemodynamically significant coronary stenosis, as well as uptake of the tracer by metabolically active tissue to assess myocardial viability. Radiation dose estimates with these modalities range from 9.4-12.8 mSv for a 99mTechnetium-sestamibi myocardial perfusion scan to as high as 40.1 mSv for a 201Thallium viability study [Other nuclear medicine modalities may be used to evaluate myocardial perfusion and estimate ischemic burden due to coronary artery disease. These include ty study .To put radiation exposure in context, medical workers and individuals in other occupations which expect repeated exposure to low-dose ionizing radiation typically limit radiation doses to 100 mSv every five years, with a limit of no more than 50 mSv in any given year period. The estimated average annual exposure to ionizing radiation worldwide is 2.4 mSv. Thus, a single study carries perhaps less concern in regard to long-term risk of ill effect, however repeated exposures, for example as part of a surveillance protocol, may be more concerning. The BEIR VII Phase 2 committee estimated an increased lifetime risk of 800 solid malignancies and 100 leukemias per 100,000 persons would result from a single exposure to 100 mSv . The risEchocardiography is the most commonly utilized non-invasive modality for assessing cardiac structure and function. The advantages of echocardiography over other methods of cardiovascular imaging include availability, lesser cost, lack of ionizing radiation and lack of exposure to potentially toxic contrast agents. In addition to accurate assessment of left ventricular function, echocardiography provides information about valvular function, presence of pericardial fluid, pulmonary arterial pressures, left ventricular filling pressures, and intravascular volume status. These additional parameters, while they may or may not be related to chemotherapeutic administration, provide useful clinical information. Like other modalities, body habitus and anatomic variation (such as rib location) affect image quality, and there can be inter-observer differences in study interpretation. Newer techniques, such as 3D echocardiography and tissue Doppler velocity assessments are becoming more widely used and will improve the accuracy and reproducibility of cardiac ultrasound. For example, with 3D echocardiography, volume assessment can be performed without relying on geometric assumptions (which is the case with standard 2D echocardiography) and provides an accurate, quantitative means of assessing left ventricular function. Dobutamine or treadmill stress echocardiography may also have a role in identifying patients with cardiomyopathy, as these studies allow assessment of contractile reserve and response to increased workloads. via the modified Simpson method . This method improves accuracy over M-mode estimates, and reduces inter- and intra-observer variability. These method does suffers from error in estimation of cavity size due to geometric assumptions which may not hold up from patient to patient, under different loading conditions, or when myocardial wall motion abnormalities have developed. Tissue velocity Doppler imaging (DTI) relies upon high-amplitude, low frequency Doppler shifts to measure velocity of various cardiac structures, including the left ventricular endocardium. Tissue velocities at different locations during various phases of the cardiac cycle are measured with this technique, and correlations to outcomes have been found in a number of disease states [endo) at various locations is observed and can be used as a surrogate for left ventricular function. In murine models of anthracycline-induced cardiotoxicity, Vendo allows earlier recognition of LV dysfunction when compared to standard 2D echocardiographic techniques  - as early as 1 day vs 4-5 days, respectively. Further, DTI produces lower rates of inter and intra-observer variability [via a speckle tracking technique were also significantly decreased early in this study [Standard methods of 2D echocardiography can be used to assess left ventricular function. M-mode echocardiography refers to an evaluation of structures along a single dimensional line, followed over time. This mode allows for tremendous temporal resolution, thus allowing for evaluation of motion of various cardiac structures - in particular the left ventricular endocardium. By convention, the LV cavity dimensions are measured at the level of the mitral leaflet tips or papillary muscle using 2D-guided M-mode. From these measurements, the fractional shortening can be calculated as well as an estimate of the fraction of blood volume ejected with each cardiac cycle, the ejection fraction. Using 2D echocardiography, the endocardial border can be traced by the interpreting clinician in two orthogonal planes . From these traced areas, the LV cavity volume may be estimated e states . The veliability . In patiis study . DTI mayis study . 3D echois study . With 3DEchocardiography is a safe imaging modality. The acoustic power of echocardiographic equipment is kept well below levels at which adverse effects of ultrasound energy may be observed. These effects include heating of target and intervening tissues, as well as induction of electrical dysfunction, often observed as frequent premature ventricular contractions (PVCs). Microbubble contrast agents can be administered in patients with difficult echo windows and make it possible to obtain diagnostic quality images in virtually all patients. Of the imaging techniques described here, echocardiography is the least expensive. Overall, echocardiography provides is an excellent method for serially evaluating left ventricular function and provides a significant amount of ancillary information, including valvular assessment, pericardial effusion detection, etc. There are no known long-term sequela from ultrasound evaluation, and the technology is relatively inexpensive and widely available.2010 Cardiac CT Appropriateness Criteria advocate that CCTA is appropriate in any patient with low or intermediate CAD risk with CAD symptoms. It is also appropriate in patients without symptoms but with new-onset or newly diagnosed heart failure with low or intermediate CAD risk [Coronary artery disease (CAD) is pervasive in our society, and is an important consideration in the differential diagnosis of any patient with decreased left ventricular function. CAD is the leading cause of death in the United States for both men and women. Given the high prevalence of CAD, and the fact that patients receiving chemotherapy often have multiple CAD risk factors, it is frequently necessary to exclude ischemia as a cause of cardiomyopathy, even in situations where a temporal correlation exists between onset of the cardiomyopathy and administration of the potentially cardiotoxic agent. Stress imaging studies can help identify potential ischemia; however, interpretation of these studies can be complicated in the setting of decreased left ventricular function. New technology in CT scanning enables direct visualization of coronary arteries and unequivocal determination of presence or absence of coronary artery disease . CoronarCAD risk . In addivia spatial and temporal modulation of the amount of x-ray radiation used during the study have reduced the doses of ionizing radiation in coronary CT substantially [While CCTA enables sensitive detection of coronary artery disease, there are several practical considerations that limit its use in patients with cardiomyopathy. Protocols commonly employed with current generation multi-detector row CT scanners require low heart rates (50-60 bpm) in order to obtain diagnostic images. This frequently requires aggressive pre-study beta blockade. In patients with reduced LVEF and a compensatory tachycardia to maintain cardiac output, beta blockade can be a difficult proposition. Patients with cardiomyopathy and reduced LVEF frequently have co-exiting arrhythmias, such as atrial fibrillation or premature ventricular contractions. Such heart rate irregularity also limits the ability to obtain diagnostic CCTA images. CCTA requires administration of iodinated contrast, which comes with increased risk of contrast nephropathy in patients with decreased renal function. Another consideration is the need for ionizing radiation with coronary CT angiography . Strategies to reduce the radiation dose antially . FinanciCardiac magnetic resonance imaging (CMR) is considered the gold standard for noninvasive estimation of cardiac volumes and assessment of left ventricular function . MultiplMRI has become the de facto standard for measuring cardiac chamber volumes, in particular those of the left ventricle. CMR is particularly useful in visualizing the right sided heart structures, which are often difficult to image using echocardiography and difficult to image with nuclear medicine studies due to overwhelming signal from the much thicker left ventricle. CMR has been validated in women receiving traztuzumab as part of a chemotherapeutic regimen, against both 2D and 3D echocardiography . Those pOne of the tremendous strengths of MRI is the ability to detect even minor myocardial injury with late gadolinium enhancement. Gadolinium contrast agents are typically not protein bound and diffuse freely into the interstitial space where interaction can occur with interstitial structures. This results in compartmentalization and differential washout kinetics. Gadolinium contrast agent remains in fibrosed, or scarred tissues, for a longer period of time than in healthy tissues. Gadolinium shortens T1 relaxation of surrounding tissue and enables identification and characterization of this tissue utilizing a variety of imaging pulse sequences. Late MR imaging (10-20 minutes following gadolinium administration) utilizing an inversion recovery sequence timed to null healthy myocardium produces bright, easily identifiable areas where myocardial scar is present. This late gadolinium enhancement produces different patterns of enhancement in various disease states that affect the myocardium. For example, cardiac MRI is a powerful imaging modality for the non-invasive diagnosis of myocarditis – an entity in which other imaging modalities often fail , 33. CarWithout exception, prognosis in chemotherapy-associated cardiotoxicity is determined by the presence and degree of cardiac dysfunction at presentation. Efficacy of specific therapy for heart failure associated with chemotherapy is not established, nor is the efficacy of prophylactic regimens. Treatment therefore falls to standard heart failure therapies, including beta adrenergic receptor blockade, modification of the renin-angiotensin-aldosterone pathway with angiotensin converting enzyme inhibitors or angiotensin receptor blocking agents, aldosterone antagonists and diuretics as appropriate . Managem3)). Prior to initiation of chemotherapy, baseline cardiovascular health examination should be undertaken, including assessment and management of hypertension, hyperlipidemia, coronary disease and optimization of the patient’s health status for primary prevention of cardiovascular disease. In patients who have known significant cardiovascular disease, such as coronary artery disease associated with left ventricular dysfunction (ischemic cardiomyopathy), valvular heart disease, congenital or other structural heart disease, or arrhythmia, we recommend evaluation by a board certified cardiologist prior to initiation of therapy. When planned chemotherapy is likely to involve an agent associated with significant cardiotoxicity, baseline assessment of left ventricular function and cardiac structure is warranted  should be considered . We would extend this recommendation to all chemotherapeutic agents known to cause long-term cardiac dysfunction. No concrete guideline has been published for many of the chemotherapeutic agents regarding a quantum of change in LV systolic function. For example, a reduction in LVEF to an absolute level <55% or a 10% decline in LVEF indicates deterioration of cardiac function as defined by the CREC . It is rWhen high dose chemotherapy is administered, we recommend evaluation with serial serum troponins immediately following and at 12, 24, 36 and 72h after the end of a each cycle of chemotherapy when feasible . A positive troponin assay (troponin I > 0.08 ng/dL) should trigger a referral to a cardiovascular specialist, as this may serve as a marker for future cardiac dysfunction and consideration should be given to dose reduction, change in regimen, or addition of cardioprotective agents. Follow up one month later with a second troponin assay is also warranted in those patients with early elevations in serum troponin, to further risk stratify those patients at risk for more severe long term LV dysfunction. Of course, after each dose of chemotherapy a clinical assessment is paramount to detect any clinical signs or symptoms resulting from underlying cardiovascular dysfunction. Presence of chest pain not easily attributable to a non-cardiac cause, dyspnea, edema, or other evidence of ischemia or congestive heart failure would trigger immediate re-evaluation by the cardiologist. As patient survival continues to improve in treatment of malignancy, long term toxicity becomes a larger issue. With accumulating evidence behind successful therapy of some cardiac toxicities following chemotherapy, early identification takes on increasing importance. Presently, no evidenced based guidelines exist to guide monitoring for cardiovascular toxicity both during and following the administration of chemotherapeutic agents. It is further important to avoid toxicity secondary to a monitoring strategy, which could itself have long term consequences, either in the form of organ dysfunction or induction of secondary malignancies. In this review we have presented several techniques for detection and monitoring for cardiotoxicity during and following chemotherapuetic administration, and suggest an algorithm to assist the clinician in early detection of cardiac toxicity.


Deep-sea hydrothermal vent chimneys contain a high diversity of microorganisms, yet the metabolic activity and the ecological functions of the microbial communities remain largely unexplored. In this study, a metagenomic approach was applied to characterize the metabolic potential in a Guaymas hydrothermal vent chimney and to conduct comparative genomic analysis among a variety of environments with sequenced metagenomes. Complete clustering of functional gene categories with a comparative metagenomic approach showed that this Guaymas chimney metagenome was clustered most closely with a chimney metagenome from Juan de Fuca. All chimney samples were enriched with genes involved in recombination and repair, chemotaxis and flagellar assembly, highlighting their roles in coping with the fluctuating extreme deep-sea environments. A high proportion of transposases was observed in all the metagenomes from deep-sea chimneys, supporting the previous hypothesis that horizontal gene transfer may be common in the deep-sea vent chimney biosphere. In the Guaymas chimney metagenome, thermophilic sulfate reducing microorganisms including bacteria and archaea were found predominant, and genes coding for the degradation of refractory organic compounds such as cellulose, lipid, pullullan, as well as a few hydrocarbons including toluene, ethylbenzene and o-xylene were identified. Therefore, this oil-immersed chimney supported a thermophilic microbial community capable of oxidizing a range of hydrocarbons that served as electron donors for sulphate reduction under anaerobic conditions. These sediments were formed by precipitation from the highly productive surface waters and terrigenous input , and was collected in Guaymas Basin  by the HUV Alvin (supported by the R/V Atlantis) in November, 2009. The chimney Figure  was keptLow quality sequencing reads were trimmed in Geneious 6.04 (Biomatters Ltd.) with default parameters. Technical replicates  and alkylsuccinate synthase (ass), were retrieved from GenBank  and searched against our Guaymas metagenome.Sequences that were annotated as enzymes in the degradation of cellulose and fatty acids were extracted and subject to manual examination. Annotated KEGG pathways in this metagenome were visualized in MEGAN to demonstrate the metabolic potential in the microbial community. Enzymes involved in the degradation of a few organic chemicals  were collected from the Biocatalysis/Biodegradation Database (BBD) of the University of Minnesota  was conducted in MG-RAST  among metagenomes as following: Guaymas Basin chimney 4558-6 (MG-RAST ID: 4510962.3), Juan de Fuca chimney (MG-RAST ID: 4510965.3)  of sequences potentially originated from sulfate reducing prokaryotes (SRP). Moreover, thermophilic sulfate reducing microorganisms, including bacteria (Thermodesulfobacteriaceae) and archaea (Archaeoglobaceae) were found predominant, highlighting their roles in reducing sulfates and/or sulfites to sulfides during energy metabolism under anaerobic conditions.A total number of 37,372 predicted gene features were utilized to extract taxonomic information by BLASTing against the NCBI NR database. In total, 21,792 (58.3%) and 11,249 (30.1%) hits were assigned to bacteria and archaea , respectively Table . At the Major KEGG function categories were listed Table  and ordebss) and alkylsuccinate synthase (ass), key enzymes in the fumarate addition pathway for the anaerobic oxidation of hydrocarbons  functional gene categories was conducted among different environmental samples Figure . GuaymasAdvances in sequencing technologies have made microbial diversity studies easier and more accurate. However, biases were introduced during sequencing and analyzing of environmental sequences. For instance, biases were generated when multiple reads were produced for a unique DNA fragment in a random manner. Such biases might result in an inaccurate representation of the fragments and lead to misleading conclusions. Therefore, strict quality control of the sequenced reads should be done. In this study, a decent sequencing coverage has been reached Figure  and we aArchaeoglobus, heterotrophic Thermococcales and Thermodesulfobacteriaceae, reflecting the influence of the high temperature on the structure of the microbial community.Estimated from both 16S rRNA sequences as well as taxonomic classifications based on blast hits, the proportion of bacteria in the community was about 60–75%, and 25–30% for archaea. Bacteria were dominated by Proteobacteria, while Euryarchaeota were most abundant among the archaea. So far, sulfate-reducing bacteria and archaea have been isolated in vent chimneys, with either high or low growth temperature (30–90°C) (Burggraf et al., Deep-sea environments have been characterized by the lack of easily biodegradable OM, thus genes related to the degradation of refractory OM have been extensively recovered from the metagenomes of deep oceans (Martin-Cuadrado et al., For the moment, only three metagenomes from hydrothermal vent chimney are available, one from Juan de Fuca (Xie et al., 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.


In sub-Saharan Africa, where two-thirds of all HIV-infected individuals reside, many are now aware of their HIV infection status and millions are receiving antiretroviral therapy. In many countries in the region, new infections are declining and individuals are living longer with treatment to control their HIV infection. The infrastructure behind HIV care and treatment is vital in addressing the HIV pandemic, and similarly could be utilized to address and promote other health issues specific to persons living with HIV.An estimated 2.1 million children are infected with HIV in sub-Saharan Africa, where multiple helminth species are also endemic Helminth infection in HIV-infected children may impact how the host responds to infectious diseases and immunizations, indirectly through the pathway of malnutrition, as well as directly through immunologic mechanisms. Beyond nutritional deficits, helminths also induce immunosuppressive responses, creating an ideal environment for chronic helminth infection, and inhibiting the host's ability to control other diseases such as HIV Helminth infection may also undermine the benefits of childhood immunizations, through malnutrition, and also by diminishing immune responses to vaccines, both at the time of vaccination and at disease exposure. Population-level data show that regional variations in vaccine efficacy correlate with variations in the prevalence of enteric pathogens p = 0.04) more likely to harbor infections with intestinal parasites than vaccine responders p = 0.06) more likely to seroconvert than children who were not dewormed Individual-level evidence also suggests that helminth infection impacts immunologic responses to vaccines. Experimental human and animal studies have shown deworming before immunization increases protective antibody titers, while decreasing immuno-regulatory cytokines The World Health Organization (WHO) recommends annual or bi-annual school-based deworming as a cost-effective strategy to diminish the consequences of chronic helminth infection. Deworming could also be considered part of the nutritional care package for HIV-infected children, to reduce the consequences of malnutrition and anemia in HIV. Incorporating deworming into routine HIV care and treatment is an ideal way to improve the nutritional health of HIV-infected children, and may provide additional benefits. This may be particularly beneficial for children under 5 years of age, who represent 10%–20% of the 2 billion people infected with helminths worldwide Despite WHO recommendations, school-based implementation is not universal and many helminth-infected school-age children go untreated. Children who are sick or otherwise unable to attend school may miss school-based interventions, leading to more illness and absenteeism. Children with HIV may also be less likely to receive other health services. For example, HIV-infected children are less likely to receive complete vaccination series compared to uninfected children Challenges may exist in coupling other health interventions to HIV care, but the potential benefits warrant consideration. Deworming both in schools and HIV clinics is likely justified by the high rates of recurrent infection in children and the low cost of the intervention. Finally, little evidence exists on the impact of deworming in HIV-infected children, highlighting a need for more rigorous studies. These studies should investigate the effects of helminth infection on responses to immunizations, the potential interactions between antihelminthics and HIV treatment, the optimal timing of deworming around both immunizations and ART initiation, and the impact of deworming on incidence of vaccine preventable infections.The benefits of treating and preventing helminth infections in HIV-infected children may go beyond the improved nutritional status and cognitive development observed in all children to also include improved responses to immunizations and control of other infectious diseases. Enhanced control of neglected infectious diseases, such as helminth infections, through existing HIV care and treatment programs, may further reduce childhood morbidity and mortality in this vulnerable population.


Circulating tumor cells (CTCs) are isolated tumor cells disseminated from the site of disease in metastatic and/or primary cancers, including breast cancer, that can be identified and measured in the peripheral blood of patients. As recent technical advances have rendered it easier to reproducibly and repeatedly sample this population of cells with a high degree of accuracy, these cells represent an attractive surrogate marker of the site of disease.Currently, CTCs are being integrated into clinical trial design as a surrogate for phenotypic and genotypic markers in correlation with development of molecularly targeted therapies. As CTCs play a crucial role in tumor dissemination, translational research is implicating CTCs in several biological processes, including epithelial to mesenchymal transition. In this mini-review, we review CTCs in metastatic breast cancer, and discuss their clinical utility for assessing prognosis and monitoring response to therapy. We will also introduce their utility in pharmacodynamic monitoring for rational selection of molecularly targeted therapies and briefly address how they can help elucidate the biology of cancer metastasis. Affecting approximately 200,000 women in the United States alone, breast cancer is now recognized to be a heterogeneous disease comprised of several common different phenotypes . Due to As early as the 1800's when Recaimer first coined the term "metastasis", circulating tumor cells (CTCs) have been postulated to be critical to the process ,6. The dCTCs are now generally defined as nucleated cells lacking CD45 and expressing cytokeratin ,10. SpecAdditionally, more recent data comparing CTCs to both standard imaging for metastatic breast cancer and the newer [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) will be reviewed as well as new data correlating CTC burden as a surrogate for disease burden with the risk of developing thromboembolic disease.The first large, multi-institution, double-blind, prospective clinical trial evaluated the prognostic capability of CTCs in patients with metastatic breast cancer (MBC). One hunSubsequent analysis of the eighty-three newly diagnosed patients undergoing first-line treatment for MBC in the above study confirmed the ability of CTCs to predict response to therapy and global outcome. At first follow-up assessment, median PFS for patients with <5 CTCs was 9.5 months, vs 2.1 months for those with ≥5 CTCs (p = 0.0057). Similarly, those with <5 CTCs had a median OS of 18 months, compared to just 11 months for those with ≥5 CTCs .A similar analysis of the prognostic value of CTCs among newly diagnosed MBC patients prior to beginning first-line salvage therapy was performed in a large, retrospective single-institution study . This stAdditional analysis of CTCs and histologic breast cancer classification and phenotypes in a cohort of 517 MBC patients with either measurable or evaluable disease prior to commencement of new palliative treatment regimens has yielded interesting observations and hypothesis-generating information. Lobular histology and bony  disease burden were associated with higher numbers of CTCs . In thisA summary of clinical trials reviewed that served to validate the predictive and prognostic capability of CTCs can be seen in Table In the prospective, longitudinal, multi-institutional trial described above, that demonstrated the ability of CTCs to predict PFS and OS, a nested retrospective study of 138 of the 177 enrolled patients was performed with the goal of comparing the predictive ability of CTCs assessment to standard imaging . While tOf note, while CTC level does not correlate with radiographic measurable disease burden, CTC burden does correlate with extent of bony disease involvement. Relative to those without bone involvement, patients with multiple sites of disease including bony disease with ≥5 CTC had significantly worse outcome (p = 0.0008). This is in contrast to patients with minimal or no bone involvement, suggesting a potential biologic link between bone metastases and CTCs .In a single institution, retrospective review, Mego and colleagues assessed CTCs level in 290 MBC patients prior to starting a new palliative treatment regimen. The presence of ≥1 CTCs, - the cut-off commonly employed in the adjuvant setting ,26, was This observation indicates a potential role of clotting factors in the peripheral blood in some steps of the metastatic process. In fact, the environment in the bloodstream is highly unfavorable to tumor cells due to physical forces, presence of immune cells and death upon detachment (anoikis), which contributes to metastatic insufficiency . CoagulaElevated CTCs, whether at baseline or at any time throughout the course of MBC are an ominous prognostic indicator. Whether by standard imaging studies and/or PET/CT imaging, elevated CTCs while on treatment, regardless of radiographic assessment, ultimately are predictive of an ineffective therapy. Similarly, low CTCs, especially while on treatment, predict for favorable survival as well as response to therapy. CTCs also reflect tumor biology as well as aspects of the host microenvironment as patients with elevated CTCs have an increased risk of developing thromboembolic disease. Taken as a whole, CTCs, while not directly correlated with volume of disease burden, are a marker of increased morbidity that ultimately impacts mortality.Despite major advances in our understanding of cancer biology, we still lack detailed insight into the mechanisms of tumor establishment and dissemination. CTCs play a crucial role in tumor dissemination in relation to several biological processes, including epithelial to mesenchymal transition  the process whereby epithelial cells lose cell-to-cell adhesion mediated by down-regulation of epithelial associated E-cadherin, and up-regulation of mesenchymal N-cadherin, allowing them to invade the extracellular matrix and migrate to a distant site . The c-DHER-2 amplification by fluorescent in situ hybridization (FISH) has been detected in CTCs, both concordant and discordant with the primary tumor phenotypic analysis. Interestingly, trastuzumab based therapy was administered to 4 of 9 patients with MBC in whom HER-2 positive CTC cells were detected, despite the primary site testing HER-2 negative by standard pathology techniques. Three of those four patients responded - one experiencing a complete response and two experiencing partial responses. This modest sample validates the hypothesis that the most relevant tumor cell population is the one that has proven ability to disseminate through the blood stream and may be the most representative population of metastatic disease . AdditioIn conclusion, CTC assessment has been shown to be a repeatedly, strong and reliable predictor of outcome in metastatic breast cancer. It performs as reliably as imaging studies for assessment of response to therapy, and possibly more so. Although the mechanism is not fully elucidated, CTCs are a unique and heterogeneous cell population with established prognostic and predictive value in MBC particularly in defined subtypes of breast disease, and may related to bone biology in particular. In the era of biologically targeted therapies, molecular characterization of CTCs may hold the key to future pharmacodynamic assessment in drug development of MBC. Currently, most molecularly targeted biologic therapies are developed using the same toxicity assessment as traditional cytotoxic therapies - identifying the maximum tolerated dose. However, in the case of these newer molecularly targeted therapies, the maximum tolerated dose may not necessarily correlate with the most effective dose - i.e. receptor downregulation, protein phosphorylation, etc. The ability to repeatedly sample an accessible tumor population such as CTCs may allow selection of optimal therapies based on confirmed target delivery. Considerable effort is currently being directed at developing additional technologies to be able to reliably characterize the genomic and proteomic information contained within these cells. The full extent of CTCs utility has yet to be explored.The authors declare that they have no competing interests.RFS and MC were involved in drafting and editing the manuscript and MC has additionally given final approval for publishing. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/9/43/prepub