Worldwide preeclampsia (PE) is the leading cause of maternal death and affects 5 to 8% of pregnant women. PE is characterized by elevated blood pressure and proteinuria. Doppler Ultrasound (US) evaluation has been considered a useful method for prediction of PE; however, there is no complete data about the most frequently altered US parameters in the pathology. The aim of this study was to evaluate the uterine, umbilical, and the middle cerebral arteries using Doppler US parameters  in pregnant women, in order to make a global evaluation of hemodynamic repercussion caused by the established PE.P = 0.021)], and a specificity and predictive positive value of 89.2% and 88.6%, respectively. Other parameters like N presence, RI and PI of umbilical artery, as well as the PI of middle cerebral artery, showed differences between groups .A total of 102 pregnant Mexican women (65 PE women and 37 normotensive women) were recruited in a cases and controls study. Blood velocity waveforms from uterine, umbilical, and middle cerebral arteries, in pregnancies from 24 to 37 weeks of gestation were recorded by trans-abdominal examination with a Toshiba Ultrasound Power Vision 6000 SSA-370A, with a 3.5 MHz convex transducer. Abnormal general Doppler US profile showed a positive association with PE [odds ratio (OR) = 2.93, 95% confidence interval (CI) = 1.2 - 7.3, General Doppler US result, as well as N from uterine vessel, RI from umbilical artery, and PI from umbilical and middle cerebral arteries in their individual form, may be considered as tools to determine hemodynamic repercussion caused by PE. Worldwide pre-eclampsia (PE) is the first cause of maternal mortality, intrauterine growth retardation (IUGR), and fetal prematurity ,2. PE afThe patients were recruited from the high risk consult of the Unidad Medica de Alta Especialidad (UMAE) # 23 of the Instituto Mexicano del Seguro Social (IMSS) in Monterrey, Mexico, between September 2009 and June 2010.Women from 15 to 40 years old, with singleton pregnancy between the 24–37 GW were included and divided in cases and controls groups. The cases group consisted by diagnosed PE women according to the guidelines of the International Society for the Study of Hypertension in Pregnancy . Most ofth percentile standardized for the gestational age were considered abnormal for the uterine and umbilical arteries, and below the 10th percentile for the middle cerebral artery [To determine the Doppler US pattern, only one exam on each patient was carried out at the recruitment time. The Doppler US was performed by trans-abdominal examination with a Toshiba Power Vision 6000 SSA-370A model, with a 3.5 MHz convex transducer. The examination included one uterine artery from the placental side or the mean if there was a symmetrical placenta, the umbilical artery, and one middle cerebral artery (indistinct hemisphere) ,19. Umbil artery ,21. Altet-test and Mann–Whitney Rank Sum test were used for continuous variables; P values were corrected by maternal age using a multiple logistic regression analysis. Sensitivity, specificity, predictive positive (PPV) and negative (NPV) values were calculated according to the Bayes theorem. Statistically, P values < 0.05 were considered significant. Statistical analysis was performed using the SigmaPlot software v11.Chi-square or Fisher’s exact test was used to analyze categorical variables. Unpaired P = 0.019). There were no differences in risk factors such as past personal or familial history of PE, primipaternity and nulliparity, among study groups  and 37 were the control group. 56.9% of the cases were diagnosed with PE before 34 GW (early PE) and the remaining 43.1% had a late onset of disease (34–37 GW). General characteristics of the study population are shown in Table P = 0.047). The N presence was restricted only for the cases group in a proportion of 20% . The medians of RI and PI parameters of the uterine artery showed a close gap between the study groups and therefore they were not associated to PE . The median of umbilical RI and PI were 0.59 and 0.91 for the cases group and 0.51 and 0.78 for the control group, respectively. There was a positive association between individual values of abnormal umbilical RI or PI and PE ; however, considering the general Doppler result for this artery, differences between proportions of abnormal umbilical Doppler US in the study groups were not observed (P = 0.107). An abnormal PI was the only middle cerebral artery parameter associated to PE .Table Figure Table Most of reports related to PE evaluation by Doppler US have been focused on the study of the uterine artery and its parameters -24; therIn our study, maternal age was the only known PE risk factor with differences among groups ,37. DespConsidering the Doppler US findings for motherhood status, from individual parameters evaluated in the uterine artery, N showed to be the most meaningful (but not the most frequent) individual finding, due to the fact that its presence was restricted to the cases group. These results are similar to those reported previously, where the N is considered as a relevant parameter in the uterine artery study ,41. AlthIn the fetal condition, the umbilical artery has been related typically to pregnancy outcome, while the middle cerebral artery has been considered as a fetal circulation marker and a useful non-invasive tool in risk assessment for fetal anemia -45. In oEven though PE prediction was not the aim of this study, the capability of Doppler assessment to classify correctly the study groups was determined using individual parameters and their combinations. In general, individual or combined measurements showed high specificity and PPV, conversely to the low sensitivity and NPV. Our findings reflected a wide gradient in the specificity/sensitivity results with a screening parameter-dependent variation that may explain the conflicting results in the diagnostic accuracy of Doppler flow velocity to predicting PE in the previous reports. On the other hand, these results provide new information about the relevant US indicators for the pathology and it could contribute to generate more descriptive and accurate reports during the PE evaluation using Doppler assessment. In Mexico, there are no reports about the Doppler US features for the three arteries in the PE evaluation; our results provide evidence about the possibilities to select better and specific measurements of each vessel in future early PE Doppler US screenings.General Doppler US result, as well as N from uterine vessel, RI from umbilical artery, and PI from umbilical and middle cerebral arteries in their individual form, may be considered as tools to determine hemodynamic repercussion caused by PE.PE: Preeclampsia; US: Ultrasound; RI: Resistance index; PI: Pulsatility index; N: Notch; SP: Systolic peak; IUGR: Intrauterine growth retardation; GW: Weeks of gestation; PPV: Predictive positive value; NPV: Negative predictive value.The authors declare that they have no competing interests. The authors are responsible for the content and writing of the research paper.MALM, MLMF, drafted the manuscript. MALM, VMG, RCF, RMRG, MAOT, and MLMF, participated in the design of the study and in the coordination of the patients’ recruitment. MALM, VMG, RCF, RMRG, MAOT, IGV, MIMA, and JIBA, participated in data acquisition, data analysis and interpretation, they participated in manuscript review. MLMF conceived of the study, and participated in its design and coordination, and performed the statistical analysis. All authors read and approved the final manuscript.


While severe shortages, inadequate skills and a geographical imbalance of health personnel have been consistently documented over the years as long term critical challenges in the health sector of the United Republic of Tanzania, there is limited evidence on the gender-based distribution of the health workforce and its likely implications. Extant evidence shows that some people may not seek healthcare unless they have access to a provider of their gender. This paper, therefore, assesses the gender-based distribution of the United Republic of Tanzania’s health workforce cadres.This is a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening in the United Republic of Tanzania in 2008. During the survey, 88 health facilities, selected randomly from 8 regions, yielded 815 health workers (HWs) eligible for the current analysis. While Chi-square was used for testing associations in the bivariate analysis, multivariate analysis was conducted using logistic regression to assess the relationship between gender and each of the cadres involved in the analysis.The mean age of the HWs was 39.7, ranging from 15 to 63 years. Overall, 75% of the HWs were women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. Multivariate analysis revealed that the odds ratio (OR) and 95% confidence interval (CI) that a HW was a female  for each cadre was: MCHA/MA, OR = 3.70, 95% CI 2.16-6.33; nurse, OR = 5.61, 95% CI 3.22-9.78; midwife, OR = 2.74, 95% CI 1.44-5.20; CO, OR = 0.08, 95% CI 0.04-0.17 and MD, OR = 0.04, 95% CI 0.02-0.09.The distribution of the United Republic of Tanzania’s health cadres is dramatically gender-skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, adequate representation of women in highly trained cadres is imperative to enhance responses to some gender-specific roles and needs. Some foet al. , the latet al. ,12. Howeet al. ,14, wheret al. . Since pet al. , gender The United Republic of Tanzania’s health workforce is reportedly small, both by international and national standards . In 2006Moreover, previous evaluations have established that the health workforce in the United Republic of Tanzania is inequitably distributed . There aApart from these challenges, most of which are basically distributional, there is a general lack of empirical analysis of the status of the gender-based distribution of the health workforce in the United Republic of Tanzania. The slim evidence available shows a link between gender and geographical imbalance in the distribution of the United Republic of Tanzania’s health workforce. Reportedly, while rural facilities are severely understaffed, they are also less likely to be served by female providers . EvidencWhile gender imbalance in the distribution of the health workforce may be affecting service production, delivery and utilization in the United Republic of Tanzania, there is no evidence available to reveal the status of gender in the distribution of HWs. The gender-based distribution of the health workforce remains barely addressed, and no literature so far clearly documents the situation in the United Republic of Tanzania. Even the few attempts in other countries that have discussed gender in relation to the distribution of the health workforce, lack details as they did not focus solely on gender. As a result, they have simply reported frequencies, without considering such robust techniques of analysis as regressions, where gender skewness could be assessed while other characteristics, such as location, age, education and so on, were controlled for. This paper, thus, has two objectives: (1) to examine the composition of the United Republic of Tanzania’s health workforce cadres by gender and (2) to assess the predictive effect of gender on each of the United Republic of Tanzanian health cadres surveyed, namely, maternal and child health aide or medical attendant (MCHA/MA), nurse, midwife, clinical officer (CO) and medical doctor (MD), using multivariate logistic regression.This is a secondary analysis of data collected in 2008 in a cross-sectional health facility survey in the United Republic of Tanzania. The survey was conducted by the Ifakara Health Institute (IHI), United Republic of Tanzania, in collaboration with Columbia University, USA, as part of the implementation of the Health Systems Strengthening for Equity (HSSE) project. Based on the eight United Republic of Tanzanian zones, one region from each zone was selected randomly through a multi-stage sampling technique which brought up eight regions: Dodoma, Pwani, Mwanza, Tanga, Mbeya, Iringa, Tabora and Mtwara. From each district in these regions, two health facilities  providing emergency obstetric care (EmOC) were selected. This made a total of 88 health facilities from which 825 health workers (HWs) participated in the survey. Of these HWs, 815 (98.8%) with non-missing data on gender and cadre were extracted from the parent database for the current analysis.Selected HWs for the primary study responded to a self-administered provider questionnaire which comprised mostly closed-ended questions and a few open-ended ones. Broadly, the questions pertained to the HWs’ background and employment, pre- or in-service training programs attended, feelings of job satisfaction, and a discrete choice experiment which aimed at understanding factors that affect employment preferences. Following interviewer training, the tool was pre-tested in facilities similar to those actually surveyed to check for relevance and answerability of the survey questions.Original cadres were operationally regrouped by merging those that were closely related because the numbers of respondents for some cadres, such as specialists, were very small. Maternal and child health aide (MCHA), medical attendant (MA) and nursing assistant were joined to form a single category, “MCHA/MA”; registered public health nurse (PHN), enrolled public health nurse (EPHN), registered nurse (RN) and enrolled nurse (EN) were combined into a single category and referred to as “nurse”; registered midwife and enrolled midwife were grouped together as “midwife”; clinical officer (CO) remained unchanged; and assistant medical officer (AMO), medical officer (MO) and specialist were combined and referred to as “medical doctor (MD)”.χ2) and Student’s t-tests for categorical and continuous variables, respectively. Further analyses were performed using multivariate logistic regression to assess the relationship between gender and each of the cadres, controlling for potential confounders. Each of these cadres was assessed as a separate dependent variable with two (binary) categories that classified a HW as either an MD or not an MD, CO or not a CO and so on. As coding of the outcome variable in logistic regression requires, a code of ‘1’ was assigned if a HW belonged to a particular cadre and ‘0’ if not. Therefore, the probability that a HW was an MD for example was expressed in a multivariate logistic regression model as:Gender-specific proportions of the HW in various categories of socio-demographic characteristics were calculated. The degree of association between gender and sociodemographic characteristics was tested using Pearson’s Chi-square . This variable was taken along with other several independent variables including age, educational attainment, region, health facility ownership, and health facility type. Educational attainment was included because of evidence from other countries showing that some women do not prefer courses that take a long time to graduate, resulting in fewer women in specialized professional jobs . FacilitEthical approval to conduct the main survey from which this paper stems was granted by the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR) in the United Republic of Tanzania. Participation in the study was voluntary with all consenting individuals having to sign an informed consent form first. To ensure integrity and confidentiality, the database was anonymous with no information (e.g. names) that could identify the participant. Storage of completed questionnaires and consent forms was carefully managed, and access to the data was restricted to a few experts.Of the 815 HWs analyzed, 75% were women. Their mean age was 39.7 ± 9.0 years, ranging from 15 to 63. The proportions of female staff in different cadres were as follows: MCHA/MA, 86%; nurse, 86%; midwife, 91%; CO, 28%; and MD, 21% , with female HWs being the majority among MCHA/MA, nurses and midwives but the minority among COs and MDs. With respect to the highest level of education attained, 59.6%  were certificate holders; 28.7%  held an ordinary diploma while 11.8%  held at least an advanced diploma. These differences in the highest level of education by gender were statistically significant (P < 0.001).Table P = 0.002). Although the distribution of the female and male HWs by health facility ownership was symmetric (P = 0.995), about 90% of the HWs worked in government facilities. Also, about two-thirds (66.1%) of all HWs worked in hospitals and the rest in health centres with no significant differences by gender (P = 0.125).With regard to the regions where the HWs worked, 13.9%  worked in Dodoma; 14.2%  worked in Iringa, 16.1%  worked in Mbeya; 4.8%  worked in Mtwara. Also, 13.4%  worked in Mwanza, 12.4%  worked in Pwani; 12.5%  worked in Tabora and 12.8%  worked in Tanga. Gender differences across the regions were statistically significant ; 7% less likely to be a midwife ; and 4% more likely to be an MD . In terms of educational attainment, nurses were almost 15 times more likely to be holding an ordinary diploma than a certificate , whereas midwives were 98% and 92% less likely to be holders of an ordinary diploma  and advanced diploma or higher , respectively, than a certificate. COs were about 46 times more likely to hold an ordinary diploma than a certificate .There was also a geographical imbalance in the distribution of some cadres. With Dodoma being a baseline or a reference category, there was a higher likelihood of more MCHA/MAs in Mwanza than Dodoma . The presence of nurses in Tanga was twice as likely as in Dodoma . Also, midwives were about four times more likely in Mtwara than in Dodoma . While the presence of COs in Iringa was 84% less likely compared to Dodoma , it was 3.35 times more likely that they were present in Pwani than in Dodoma . Furthermore, the availability of MDs was 96% less likely in Iringa , 66% less likely in Pwani  and 80% less likely in Tabora  compared to the Dodoma region.With respect to health facility ownership, MCHA/MAs were about three times more likely to be working in private facilities than in government facilities , whereas midwives were 67% less likely to be working in private facilities compared to government facilities . In terms of facility type, MCHA/MAs were 53% less likely to be working in hospitals than health centres. Similarly, COs were 86% less likely to be working in hospitals than health centres. In contrast, midwives and MDs were 2.72  and 3.98  times more likely to be working in hospitals than in health centres, respectively.This paper sought to examine the gender-based distribution of the United Republic of Tanzania’s health workforce cadres. This question has so far received limited attention in previous analyses ,12. Our The gender-based distributional skewness in the United Republic of Tanzanian health workforce cadres persisted and remained highly significant even after controlling for other variables in a multivariate logistic regression model. There is a possibility that care-related jobs, such as nursing and midwifery, attract more women than men in the United Republic of Tanzania. There is also a chance that the services delivered by people from the MCHA/MA, nursing and midwifery cadres tend to be perceived as more suitable for women than men. This, however, needs further elucidation. Previous studies have shown that the dominance of women among nurses is a historical phenomenon  and geneWe observed the presence of more female- than male-holders of certificates, while the proportion of women declined rapidly among those with higher qualifications. Although the higher the qualification the lower was the proportion of both women and men, the data show that the proportion of men outnumbered their female counterparts for diploma, advanced diploma and higher qualifications. This trend somewhat prevailed in terms of the leaving level for basic education, such that the proportion of women with primary education was 1.5 times as high as that for men, whereas the proportion of those holding an ordinary secondary education was similar between women and men. However, the proportion of women with advanced secondary education which is a key entry point into colleges and universities for higher education was five times as small as that of men. Leon and Kolstad  report aMoreover, the demand for more specialized cadres such as MDs may be higher for hospitals than health centres because the former is a higher level of care with more specialized services than the latter. Hospitals also constitute the receiving end of the referral pathway in the health service delivery framework of the United Republic of Tanzania. That is why facility type was a significant explanatory variable of the cadres’ distribution, with hospitals being more likely than health centres to have MDs, for example. Additionally, most hospitals are in urban settings where MDs prefer to work as already noted . Our finGenerally, the gender skewness observed in this study may be linked to gender differences in entering and leaving various academic junctures. In a study on gender differences in performance in science subjects in the United Republic of Tanzania, Mushi  found thWe agree with previous authors that a strong health system requires among other things a strong, adequate and balanced workforce to ensure effective and efficient delivery of quality health services . TherefoAlthough the present paper is limited to HWs in health facilities providing EmOC, the findings and their interpretation respond to the existing gender-related gaps in the health workforce distribution in the United Republic of Tanzania. Factors such as marital status and spouse’s place of work which may also influence one’s choice of career specialization were not available. Future research should examine more cadres at all levels of the United Republic of Tanzanian health care delivery framework.Despite these limitations, this study makes an important contribution to the human resources for health literature by deeply considering the gender dimension in the distribution of the health workforce in the United Republic of Tanzania. Unlike some studies in the field ,16, our The gender-based distribution of the United Republic of Tanzania’s health workforce cadres is significantly skewed, with MCHA/MA, nursing and midwifery cadres being large and female-dominant, whereas CO and MD cadres are slim in absolute numbers and male-dominant. It is important that gender be considered a dimension of crucial importance in human resources planning in the United Republic of Tanzania as this will not only contribute to uplifting the United Republic of Tanzania’s doctor-to-population ratio, but will also respond to possible health service users’ preferences regarding the gender of the service providers. As a result, this may enhance health seeking behaviour and health care utilization.ACSEE: Advanced certificate of secondary education examination; CI: Confidence interval; CO: Clinical officer; EmOC: Emergency obstetric care; HSSE: Health systems strengthening for equity; HWs: Health workers; LMIC: Low- and middle-income countries; MA: Medical attendant; MCHA: Maternal and child health aide; MD: Medical doctor; MoHSW: Ministry of health and social welfare; OR: Odds ratio; SSA: sub-Saharan Africa.All authors declare that they have no competing interests.AE conceptualized the problem, designed the study, participated in field data collection, performed data analysis and drafted the manuscript. AML participated in designing the study, data analysis and critical review of the manuscript. NW participated in drafting the manuscript and critical review of it. GM oversaw the study design as well as critical review of the manuscript. SP and GMM contributed to interpretations and overall review of the manuscript. All authors read and approved the final draft.


We analyzed several angiotensinase activities in the heart left ventricle (VT) of control and captopril-treated SHR, and we search for a relationship between these activities and those determined in the left and right FC. Captopril was administered in drinking water for 4 weeks. Samples from the left VT and from the left and right FC were obtained. Soluble and membrane-bound enzymatic activities were measured fluorometrically using arylamides as substrates. The weight of heart significantly decreased after treatment with captopril, mainly, due to the reduction of the left VT weight. In the VT, no differences for soluble activities were observed between control and treated SHR. In contrast, a generalized significant reduction was observed for membrane-bound activities. The most significant correlations between FC and VT were observed in the right FC of the captopril-treated group. The other correlations, right FC versus VT and left FC versus VT in controls and left FC versus VT in the captopril group, were few and low. These results confirm that the connection between FC and cardiovascular system is asymmetrically organized.The model of  This coegration  and a neegration . Compareegration . There aegration . Similaregration , 7. In aegration . Aspartyegration . Based oegration , it is tn = 10) and captopril-treated (n = 10) groups. Captopril (100 mg/kg p.o.) was administered daily in drinking water (0.5 mL/100 mg body weight) for 4 weeks. The systolic blood pressure (SBP) was monitored by the plethysmographic method throughout the experimental period. At the end of the treatment period, after recording the SBP, each rat was perfused with saline under equithesin anesthesia, and the left and right FC and samples from the left VT were obtained as previously described [t-test was used to compare the data from control and captopril-treated SHRs, and the paired Student's t-test was used for left FC versus right FC comparisons [P values below 0.05 were considered significant. All of the experimental procedures involving animals were performed in accordance with the European Communities Council Directive 86/609/EEC and were approved by the Bioethics Committee of the University of Jaén. Twenty adult male SHRs were divided into control n =  and captescribed . For eacescribed . In addiP < 0.001) [P < 0.05) mainly due to a reduction in the left ventricle weight (P < 0.01)  . The wei < 0.01) . In a prP < 0.05) was observed for all MB AP activities (P < 0.05) after captopril except for AspAP that did not reach statistical significance versus the control group  and positive for AlaAP and CysAP (right FC predominant). The other correlations, right FC versus VT and left FC versus VT in controls and left FC versus VT in the captopril group, were few and low. Surprisingly, the opposite was previously observed between FC and plasma . The plaOur results demonstrated that captopril modified angiotensinase activities in heart and in brain, as previously reported , and tha1 receptor [4 receptor than AT1 receptor in rabbit myocardium where they might exert opposite effects to those of Ang II through the binding of Ang IV [Several components of a local cardiac RAS can result of an uptake from the circulation but a functional intracrine RAS in the heart also exists . Moreovereceptor . In addireceptor . It was f Ang IV .4 receptor, which was proposed to be identical to the insulin-regulated aminopeptidase (IRAP) [4 receptor remains in dispute, and its identification with IRAP is still controversial. Indeed, Ang IV has a very rapid effect on signaling molecules [4, that is, memory facilitation, cerebroprotection, seizure, neurite outgrowth, cerebral blood flow, depression, and Parkinson's and Alzheimer's diseases [The present results of lower MB aminopeptidase activities in ventricle may indicate a local reduction in the metabolism of angiotensin peptides after treatment with captopril. More specifically, the results suggest a lower metabolism/higher availability of Ang II (metabolized to Ang III by GluAP), Ang III (metabolized to Ang IV by AlaAP), and Ang IV  in captopril-treated animals. On the other hand, Ang IV binds specifically to the ATe (IRAP) . Indeed,e (IRAP) , and thee (IRAP) . Cysteine (IRAP) . These eolecules  at pico/olecules . It was diseases .Independently of the discussion on the real nature of the Ang IV binding site, it was proposed that the binding of Ang IV to its receptor results in the inhibition of the receptor's metabolic activity, reducing the catabolism of its substrates and consequently increasing their availability and extending their action . Ang IV These results are in agreement with previous reports indicating that the left ventricular expression of the glucose transporter GLUT4 is regulated by insulin at the transcriptional level  and thatAs previously stated, brain asymmetry is not a static but rather a dynamic phenomenon in which both environmental and endogenous factors act as modulators . In addiIt is particularly interesting that the present results are in contrast with those previously observed in plasma  where, iThere is therefore a clear reciprocal interaction between heart and brain in physiological and pathological conditions , 5 that The asymmetrical organization of the nervous system is the result of evolutionary adaptation , 41. ThiCaptopril asymmetrically modifies angiotensinase activities in frontal cortex and in ventricle and, consequently, affects the functions they are involved in. However, these effects are not independent but according to our results, mutually interdependent. Therefore, but when appropriately characterized and systematized, the present results open new therapeutic consequences in cardiovascular treatment (presumably not only limited to specific drugs) that should be taken into account in the design of protocols for the evaluation of cardiovascular treatments. The present study provides further molecular support for the involvement of the RAS in the brain frontal cortex-heart connection and adds, for the first time, biochemical evidence on the lateralized functioning of that connection. If this connection is asymmetric and the consequences of unilateral brain insults differ depending on the injured side, the necessity of characterizing appropriately the neurovisceral integration of the RAS is relevant and deserves further preclinical work.


Pseudomonas aeruginosa is an important bacterial model due to its metabolic and pathogenic abilities, which allow it to interact and colonize a wide range of hosts, including plants and animals. In this work we compile and analyze the structure and organization of an experimentally supported regulatory network in this bacterium.The regulatory network consists of 690 genes and 1020 regulatory interactions between their products . This complex interplay makes the third largest regulatory network of those reported in bacteria. The entire network is enriched for activating interactions and, peculiarly, self-activation seems to occur more prominent for transcription factors (TFs), which contrasts with other biological networks where self-repression is dominant. The network contains a giant component of 650 genes organized into 11 hierarchies, encompassing important biological processes, such as, biofilms formation, production of exopolysaccharide alginate and several virulence factors, and of the so-called quorum sensing regulons.P. aeruginosa is biased towards pathogenesis and virulence processes, all of which are interconnected. The network shows power-law distribution -input degree -, and we identified the top ten global regulators, six two-element cycles, the longest paths have ten steps, six biological modules and the main motifs containing three and four elements. We think this work can provide insights for the design of further studies to cover the many gaps in knowledge of this important bacterial model, and for the design of systems strategies to combat this bacterium.The study of gene regulation in  Pseudomonas aeruginosa is a metabolically versatile Gram-negative bacterium, able to express a wide variety of virulence factors. These allow P. aeruginosa to grow in soil and marine habitats, as well as on plant and animal tissues. It is also a significant source of bacteraemia in burn victims, urinary-tract infections, hospital-acquired pneumonia and predominant cause of morbidity and mortality in cystic fibrosis patients [P. aeruginosa the most studied bacterial model regarding the control of pathogenic determinants and the third bacterial model more studied with respect to their molecular biology -after Escherichia coli and Bacillus subtilis-. The genome sequence of P. aeruginosa strain PAO1 was reported in 2000 [patients . All the in 2000 .P. aeruginosa. This transcriptional regulatory network (TRN) constitutes the third largest one of any bacteria reported to date. We proceed to analyze the main topological properties of this network and the main functional interactions among their regulatory components. We hope these results will provide insights and guide future studies to increase our knowledge on this important bacterium.It is well know the importance of gene regulation on the organisms' performance as this process defines their metabolic, adaptive and pathogenic capabilities. In this work, we report a collection of known regulatory network interactions connecting transcription factors (TFs), sigma factors (σ), and anti-sigma factors to their target genes in P. aeruginosa, the available published data was searched using a combined strategy: 1) regulatory interactions from dedicated biological databases were extracted [P. aeruginosa PAO1 (the strain on which most of the network reconstruction is based) our network represents roughly 12% of these genes. On the other hand, the regulatory machinery predicted in this bacterium comprises around 500 proteins: 26 sigma factors , the rest corresponding to transcription factors distributed in at least 44 families [With the aim of summarizing all the documented action of the regulatory machinery over the genes encoded in the genome of xtracted -4 and, 2k) of a node (gene) is defined as the number of interactions that it has with other nodes. Here we determined the gene's mean degree as the arithmetic average of all the node-degrees (k) in each network [Additional file P. aeruginosa is connected, on average, with 3 other genes. In directed networks, as in the case of regulatory networks, we can define input (kin) and output degree (kout) as the number of arrows that enter and leave genes respectively, which corresponds to the number of TFs that regulate a certain gene, and the number of genes that a TF is regulating. The degree distribution gives the probability P(k), of finding a node with degree k [A ensures that the P(k) values are normalized towards 1, and γ is a parameter that provides information about the network structure; for networks with γ>3 a lot of the properties for scale-free networks are not present, which are present for 2<γ<3, where there is a hierarchy in the degree of nodes, from the most to less connected ones. However, for γ= 2, the highest degree node influences a large fraction of all nodes [P. aeruginosa, we find A = 0.8856 and, 2<γ<3 for the input degree distribution , P(k ≤K), . Someectivity . The conll nodes . In the n Figure , but witC, is a measure that indicates the probability that two genes with a common neighbor in a graph are also interconnected; that is to say, the clustering coefficient quantifies what so much the local neighborhood of a gene is as member of a group of genes. It is common for networks to exhibit a decreasing value of C(k) with respect to the degree k, such that in small groups or modules of genes the elements are well connected, but as the group increases in size the elements are progressively less connected. The regulatory network of P. aeruginosa shares this general clustering property in . We consider that a connected component is composed by n nodes, and calculate the relative frequency P(n) for every possible n, which give us the distribution of the number of nodes in a connected component  the regulatory mode and connectivity of each component of the transcriptional machinery and, ii) the manner in which endogenous and exogenous information, relevant for transcriptional regulation, enter and pass through the regulatory machinery until conclude on promoters of target genes. All these computes should be associated with the biological functions of the respective genes. In this sense, some interesting findings in the TRN of P. aeruginosa  showed, that activation is by far the dominating regulatory activity in sa Table . For coma Figure , and the E. coli . Positiverevisae ,12.E. coli and B. subtilis, auto-regulation is mostly positive for the TFs of P. aeruginosa , with the exception of developmental processes for biofilm and flagella formation in E. coli where self-activation is enriched [P. aeruginosa (virulence and pathogenic processes), it is premature to conclude whether that distinction should be a property of the whole network, or if, it mainly represents an evolutionary design for the execution of pathogenesis and virulence actions by this bacterium. Using the database of Reciprocal Best Hits (RBH) orthologs genes in bacteria [P. aeruginosa in E. coli, in both organisms with experimental evidence about their mode of self-regulation [Additional file P. aeruginosa conserve this mode of self-regulation in E. coli. For the remaining four positively auto-regulated in P. aeruginosa, one conserved their positive mode of auto-regulation in E. coli and the rest three changes; two are dual and one self-regulate negatively in E. coli. Although this information is scarce, it might be possible that positive auto-regulation in TFs might be effectively selected in P. aeruginosa.The mode in which regulatory genes are auto-regulated is important for network dynamics. It is known that auto-repressions are important controllers to keep homeostatic levels of biological functions, while auto-activation is a condition to reach multiple steady states and differentiation . Operatisa Table . Given t E. coli ,14, and enriched . This obenriched . It is sbacteria , we founP. aeruginosa consists of 11 steps. This is almost the same size than in their E. coli counterpart where the longest paths include 14 steps. The size of paths in P. aeruginosa is interesting if we consider that the TRN is far from complete, therefore it is reasonable to expect that longer paths can be found as the network will be further characterized. The longer regulatory path in P. aeruginosa goes along biological processes that include alginate biosynthesis, iron metabolism and pioverdine synthesis, implying that these processes could be physiologically connected  and one positive , and no cycles with more TF-elements are present in the TRN. The dynamics of positive and negative two-node cycles has been widely studied. They represent important core components for network dynamics acting as robust switches to respond to signals from environmental conditions [Biological systems frequently contain positive or negative feedback loops. Multi-element biological cycles (with two or more components) can also be positive or negative (depending on the product of the signs of the constitutive interactions).The existence of positive cycles is a necessary condition to have multiple steady states or attractors. Negative cycles are important to keep homeostasis, since they maintain the system functioning through periodic orbits. Besides self-regulation, multi-element circuits in a TRN can be defined as self-enclosed paths. Until now, excluding self-regulation, there are only seven cycles with two regulatory factors in a Figure ; six negnditions .P. aeruginosa network are those formed by three and four genes  are: lasR(20), mexT(15), algR(14), ihf(14), rhlR(13), anr(12), ptxR(12). On the other hand, the most regulated genes are (in parenthesis the number of TFs regulating it): rhlI(8), rhlAR(7), algD(7), alg44(6), alg8(6), algA(6), algE(6) algF(6), algG(6), algI(6), algJ(6), algK(6), algL(6), algX(6), hcnA(6), lasR(6), algU(6). It is interesting that the most regulated genes in both E. coli and P. aeruginosa encode for TFs, FhlCD (flagella synthesis) and RhlI (quorum sensing) respectively.Promoter and regulatory regions are zones in transcription units where regulatory information is integrated. This regulatory integration is evidenced by the presence of DNA-binding sites for multiple regulators or promoters for different σ respectively. In the TRN of P. aeruginosa (see Methods section) and the top ten are shown in Table G was introduced here, which indicates if a regulator is more or less global taking into account the regulatory criteria mentioned above. The most influencing regulators in Pseudomonas have a lower qualification than the corresponding seven global TFs in E. coli. This might be due to the limited knowledge of the transcriptional regulation in P. aeruginosa compared to E. coli.The most influencing regulators in a regulatory network are called "global regulators" and are defined by a series of operative properties, including: i) they should regulate a large number of genes; ii) should regulate other sigmas and regulators; iii) should co-regulate together with many TFs and, iv) their target genes should have promoters using more than one kind of σ . All theE. coli network, it might be possible to recover modules with a good approximation to those that are manually defined, on the basis of the knowledge of biological functions of their products [P. aeruginosa , G Nis the number of non-regulatory genes, and SF Nis the number of sigma factors in the whole network. Additionally, TFR and GR, represents the number of TFs and non-regulatory genes regulated by each TF, respectively; SF represents the distinct sigma factors used by the promoters of genes regulated by each TF; and CR represents the number of TFs each TF co-regulates with.Where, 2 /Dwhere D is the distance between two nodes), as reported for E. coli [With the aim of determining biological modules in the TRN we used a shortest path metric criteria among TFs and sigmas  the type of regulatory interactions on the network, strain, experimental evidences and references; sheet 2) the components and length of directed paths in the whole network; sheet 3) the components and length of directed paths in the regulatory sub-network; sheet 4) representative motifs in the entire network with two, three and four genes; sheet 5) components and measures of the whole network and the sub-network; sheet 6) orthologs TFs with auto-regulation identified in Click here for fileThis is a poster version of Figure Click here for file


Objective: to evaluate the therapeutic effect of targeted endostatin-loaded microbubbles, combined with improved, focused, directional ultrasound radiation for inhibition of subcutaneous translocation in situ colon tumor angiogenesis in colon cancer.Methods: 65 BALB/c nude mice with subcutaneous translocation in situ colon tumors were randomly divided into five groups. Group A was the control group, without any treatments. In Group B, the mouse was treated with ultrasonic radiation. In Group C, the mouse was treated with ultrasonic radiation combined with empty SonoVue microbubbles. In Group D, the mouse was treated with ultrasonic radiation combined with empty Targestar-SA microbubbles. In Group E, the mouse was treated with ultrasonic radiation combined with endostatin microbubbles. The tumor size was measured before and 1, 14, and 28 days after irradiation. The peak intensity (PI), regional blood volume (RBV) and regional blood flow (RBF) were recorded using contrast-enhanced ultrasound. The tumor tissue was removed for pathological examination; the tumor necrosis area and microvascular density (MVD) were evaluated by immunohistochemistry.Results: Tumors in Groups C, D and E were significantly smaller than in Groups A and B at 28 days after irradiation, with Group E the smallest. PI, RBF and RBV of Groups C, D, and E were significantly decreased 28 days after radiation with Group E the lowest, and significantly lower than Groups A and B . The tumor tissue necrosis area of Group E was clearly greater while MVD was obviously lower than the other groups  at 28 days after treatment.Conclusion: The targeted endostatin microbubbles, combined with focused, directional ultrasound radiation can damage tumor microvasculature of subcutaneous colon translocation in situ colon cancer, as well as inhibit the tumor angiogenesis. Science magazine in the United States [In 1971, Professor Folkman first proposed the theory that tumor growth depends on new angiogenesis, thus opening a new field of research [d States .3, the tumor cells do not rely directly on blood supply but can obtain enough nutrition from interstitial fluid; therefore, the killing effects of TAI for this part of tumor cells are inadequate [However, the anti-tumor angiogenesis methods that have been found to date nearly all use chemical or biological drugs to attack the specific biological targets of tumor angiogenesis, which not only brings hope for tumor therapy, but also places new challenges on oncologists. First, the responses to anti-tumor angiogenesis therapy vary in different types of tumor, or in different individuals with the same kind of tumor. Owing to the heterogeneity of tumors and the diversity of the angiogenesis-promoting factors released by tumors, it is impossible that any one kind of tumor angiogenesis inhibitor (TAI) can effectively restrain all types of tumors. Secondly, the tumor can release a lot of angiogenesis-promoting factors at the advanced stage but the patients could not tolerate unlimited amounts of drugs to obtain the ideal curative effect. In addition, the TAI can inhibit angiogenesis to prevent further tumor development, but has limited killing effect against the formed tumor. When tumor volume is less than 2 mmadequate . The mecin vitro and focused on the target area within the body, causes the temperature of the target area to increase rapidly to above 65°C, ablating the tumor tissues through its heating effect [Tumor dormancy therapy—with the purpose of suppression, embolization or blocking of tumor angiogenesis—is a mode of cancer therapy newly developed in recent years, following surgery, radiation and chemotherapy. At present, interventional vascular embolization therapy can only embolize arteries of large diameter and is powerless in the collateral circulation. The physical treatments for tumors, including thermal ablation, freezing and electrochemistry etc., can directly kill tumor tissues, but the side-effects are greater. High-intensity focused ultrasound (HIFU) treatment has rapidly progressed in recent years; the ultrasonic energy, radiated Using ultrasound for non-invasive anti-neoplastic therapy has been an aspect of ultrasonic medical research in recent years. Ultrasound-mediated microbubble destruction (UMMD) can effectively prevent tumor angiogenesis and block the tumor microcirculation, but it is difficult to prevent the recurrence of angiogenesis; at the same time, many anti-tumor angiogenesis factors have this ability. Using the existing principle of the empty lipid microbubble, we prepared a new kind of microbubble treatment for anti-tumor angiogenesis by combining the microbubble ultrasound contrast agent (SonoVue) with endostatin. After injection through the peripheral venous system, the microbubbles, combined with the modified, focused ultrasound cavitation equipment, can perform targeted irradiation of the tumor(s) of subcutaneous translocation colon cancer in nude mice, and additionally release endostatins to inhibit tumor angiogenesis, on the basis that UMMD has destroyed and blocked tumor microvasculature.The purpose of this study was to explore a new therapeutic method of combining biological drugs and physical effects to prevent tumor angiogenesis in colon cancer.in situ colon tumor modelling was built by the Nanjing Yuanduan Biological Technology Co. Ltd. , according to the method reported in literature [This study was approved by the Research Ethics Board of The Third People’s Hospital of Hangzhou . Experimental animals were female BALB/c nude mice aged 4–6 weeks, purchased from Yangzhou University medical center. All mice were raised and tested in the specific-pathogens-free barrier system and fed with a special granulated feed after radiation sterilization with Cobalt-60. The transfection of green fluorescent protein-expressing colon cancer HT-29 cells by subcutaneous translocation Sixty-five mice that were successfully modeled were randomly divided into five groups of 13: Group A, the control group, in which the mice were only followed-up, without any treatment; Group B, the simple ultrasonic radiation group, in which the mice were only treated with ultrasonic radiation; Group C, in which the mice were treated with the ultrasonic radiation combined with empty SonoVue microbubbles ; Group D, in which the mice were treated with ultrasonic radiation combined with empty Targestar-SA microbubbles (this type of microbubble can carry drugs but has only been used for study purposes to date) and Group E, in which the mice were treated with the ultrasonic radiation, combined with microbubbles carrying endostatins.The modified focused impulse ultrasonic device is shown in All nude mice models underwent fluorescence radiography examination before the trial (at 41 days after orthotopic transplantation), and images were stored. The tumor size was measured by using Image-Pro-plus v5.1 analysis software , and the tumor area was calculated and recorded according to the fluorescence range, which was drawn along the edge of the fluorescence enhancement envelope curve. After completion of radiography, the configured ketamine compound anesthetic was injected intramuscularly with a 2 μL/g dose for each mouse. After the anesthesic had taken effect, the ultrasonic coupling agent was coated on the tumor surface, and the conventional ultrasonic exam was performed for tumor location. Firstly, in order to determine the best aspect, it was converted to the contrast-tuned imaging model, and the mechanical index was 0.04. Then, the drug-carrying microbubble contrast agent was slowly injected through the postocular veins with a 3.5 μL/g dose at the outer third of the infraorbital margin and pushed in vertically 5 mm or so. Meanwhile, the perfusion of contrast agents within the tumor was synchronously timed and observed in real time.The modified focused ultrasonic broken device was started 10–20 s after the injection of contrast agent and the irradiation was performed on the tumors of Groups B, C, D, and E under real-time ultrasonic monitoring. Its working frequency was 238 kHz; the output voltage of the signal source was 400 mV, and the focus incentive sound pressure was 1.4 MPa. In total, irradiation was performed 10 times, for 10 s on each occasion, with an interval of 10 s between applications. The same irradiation process was repeated on three consecutive days . Mice were withdrawn for feeding after the treatment, underwent the fluorescent radiography examination each week, and all images were stored for analysis. Mice were euthanized at 28 days after irradiation. Tumor tissues were then separated and excised for pathological examination and CD34 immunohistochemical and electron microscope observations.2 and then the tumor growth curve was drawn.Representative fluorescence images were obtained under the fluorescence imaging system. The maximum horizontal (a) and vertical (b) diameters of the transplanted tumors were measured using the Image-Pro-plus v5.1 analysis software . The volumes of tumors were calculated according to the formula v = 0.5 × a × bThe corresponding peak intensity (PI), regional blood volume (RBV), regional blood flow (RBF), and other imaging parameters were calculated and analysed off-line using Parkson Imaging Analysis Software Qontrast v4.0 . The particular area of interest was drawn as far as possible to include the entire tumor on imaging fitting chart.The tumor specimen was completely excised after the mice were euthanized, fixed with 10% neutral formaldehyde, embedded in paraffin, prepared into serial sections of 4 μm thickness after conventional dehydration, and then observed for pathological changes after hematoxylin and eosin staining. CD34 immunohistochemical staining was carried out in accordance with the product manual. Pathological diagnoses were independently evaluated by two pathologists, and immunohistochemical results were then decided after discussion, by using the known positive slices of human angiosarcoma tissue as a positive control and phosphate-buffered saline, instead of primary antibodies, as a negative control.With respect to the necrosis area (NA) of tumor tissue, the tumor necrosis region and normal cell region were observed under low-power microscope (40× magnification). The panorama of slices was scanned and the NA ratio was then calculated using the Image-Pro-plus v5.1 analysis software , according to the formula NA % = region area of death cell/ total area of slice × 100.The counting method for microvascular density (MVD) marked by CD34 was according to the Weidner standard : first it-test was used for the comparison of two sample means before and after treatment. Statistical significance was defined as a P-value less than 0.05.All statistical analyses were performed by using SPSS v17.0 statistical software package . All data were presented as the mean values ± standard deviation. Kolmogorov-Smirnov and Levene tests were used for testing normality and homogeneity of variance. Single-factor analysis of variance (one-way ANOVA) was adopted for comparisons of the means of multiple samples, and Fisher’s least significant difference test was used for the paired comparisons of multiple sample means. Paired P > 0.05) before radiation. The tumor volumes in Groups C, D, and E were significantly lower than those of Groups A and B at 14 and 28 days after irradiation and the tumor volume of Group E was significantly lower than those of Groups A and B at 28 days after irradiation   .Figure P > 0.05). As compared with those before radiation, there were no statistical differences in the parameters of Groups A and B at 1 day after irradiation, , but there were significantly decreased parameters in Groups C, D, and E, . The parameters of Groups A and B significantly increased at 14 and 28 days after irradiation, compared with those before radiation, while those of Groups C, D, and E continued decreasing . Ultrasonic imaging parameters of Group E showed no statistical difference compared with those of Groups C and D at 14 days after irradiation (P > 0.05), but were significantly lower than those of Groups C and D at 28 days after irradiation (P < 0.05).PI, RBV, and RBF ultrasonic imaging characteristics for each group of nude mice, before and after radiation, are shown in P < 0.01): the tumor tissue NA and MVD of Group E were significantly higher and lower, respectively, than those of the other groups , which laid a solid foundation for targeted ultrasonic cavitation drug therapy.Tumor growth depends on angiogenesis. The simple diffusion process cannot guarantee the oxygen and nutrition supply needed for growth when tumor tissue volume is greater than 2 mmll occur . Therefodostatin , and prodostatin . We succUsing ultrasonic energy, non-traumatic treatment for tumors is one of the new ‘hot-spots' in tumor treatment in recent years. The microbubble can produce a significant cavitation effect under ultrasonic radiation , 13. Witin situ colon tumors, and simultaneously performed the focused ultrasound irradiation. As the ultrasonic cavitation damaged and blocked the tumor capillaries, the endostatin was released and the blocking of tumor microcirculation led to time-extended drug retention, so as to bring about a dual anti-tumor effect. It was found from the tumor volume growth curves that tumor sizes in Groups C, D, and E were significantly lower than those of Groups A and B (P < 0.01) at 28 days after radiation, and the tumor volumes in Group E were clearly lower than those of Groups C and D (P < 0.01), which confirmed that the strongest effect for inhibiting tumor growth was obtained from microbubbles carrying drugs, combined with ultrasonic cavitation.It has been confirmed by existing research that intravenous lipid microbubble contrast agent, combined with percutaneous pulsed, focused ultrasound radiation, can effectively disrupt the physical structure of tumor angiogenesis and block tumor microcirculation for more than 24 h in rat tumors . PatholoP < 0.05), while the same characteristics of Groups C, D and E gradually reduced the values of PI, RBV, and RBF after irradiation (P < 0.05). Results illustrated that using ultrasonic radiation alone, without combining microbubble contrast agent, has no obvious effects in damaging the tumor, while the disrupt effect of ultrasound radiation combined with microbubble contrast agent damaged and blocked the tumor vasculature, causing tumor hypoxia and decreasing the tumor blood supply. Mice in Group E were given both endostatin-loaded microbubbles and ultrasonic radiation, which resulted in PI, RBV, and RBF values significantly lower than those of the other groups (P < 0.05) at 28 days after radiation. This is consistent with our previous results [PI, RBV, and RBF are good ultrasonic imaging parameters for reflecting the blood supply and perfusion of a tumor. In this study, the PI, RBV, and RBF of Groups A and B were significantly higher after treatment than before ( results  and suggP < 0.01). Electron microscopy showed that the tumor cell nuclear membrane disappeared in Groups C, D, and E, nuclear chromatin dissolved and clustered in an irregular arrangement, and mitochondria vacuoles and microvascular endothelial cells were injured and bleeding. All these manifested most obviously in Group E, but rarely in Groups A and B, which suggests that ultrasonic cavitation, combined with targeted microbubbles, can enhance the damage to tumor cells tumor microvasculature, but that the effect of targeted drug-loaded microbubbles is much better. The endostatin-loaded microbubbles were better able to target, adhere to, and accumulate within the tumor, and enhance the physical effect of ultrasonic cavitation, directly damaging the tumor microvasculature. Also, as the ultrasonic cavitation damages and blocks the tumor microvasculature, the microbubbles simultaneously release the endostatin, which can effectively inhibit tumor angiogenesis and further enhance curative effects.CD34 is one of the most sensitive endothelial markers, with high specificity and good repeatability, which has been used as a regular indicator for immunohistochemical detection of MVD in colorectal cancer and determination of the tumor angiogenesis . In thisin situ transplantation nude mouse model rather than the subcutaneous colon nude mouse transplantation tumor model, which can better reflect the biological characteristics of colon tumor, and the fluorescence can be observed relatively early, to determine the tumor size, location, and whether transfer occurs. In addition, the tumor is more easily located during the ultrasonic cavitation treatment, and the therapeutic effect is much better. Our research group co-operated with the Wuxi Sea Eagle Electronic Medical System Co. Ltd., , improving the defects and shortcomings of the original ultrasonic cavitation device. The improved cavitation therapy apparatus has a good deep focus on performance and can be operated with conventional ultrasonic positioning, with longer focal length and higher axis pressure, which can be used for the treatment tumors with further improved therapeutic effects. This study has applied for patent . The improvement of metrics and mechanisms of the therapeutic apparatus was just simply introduced within the article, because of involving technology patents.In this study, we adopted the subcutaneous translocation colon cancer fluorescence There are some limitations to this study, such as failure to monitor changes of tumor tissue temperature after cavitation treatment, although the thermal effect was very weak. In addition, the sample size was limited, which was restricted by the shorter observation time of the tumor model. Therefore, further in-depth study is recommended.In conclusion, ultrasonic cavitation combined with drug-loaded microbubbles shows good clinical prospects in the treatment of colorectal cancer.National Natural Science Foundation of China , Zhejiang Provincial Natural Science Foundation of China (No. Y2110782), Public Technology for Applied Research Program Foundation from the Science and Technology Bureau of Zhejiang Province (No. 2013C31002), Key Program Foundation from the Health Bureau of Zhejiang Province (No. 2013ZDA020), and the General Program Foundation from the Hangzhou City Health Bureau (No.2013A27).This work was supported by the following grants: Conflict of interest: none declared


Radiographic descriptions of gout have noted the tendency to hypertrophic bone changes. The aim of this study was to characterize the features of new bone formation (NBF) in gout, and to determine the relationship between NBF and other radiographic features of disease, particularly erosion and tophus.Paired plain radiographs (XR) and computed tomography (CT) scans of 798 individual hand and wrist joints from 20 patients with gout were analyzed. Following a structured review of a separate set of images, films were scored for the presence of the following features of NBF: spur, osteophyte, periosteal NBF, ankylosis and sclerosis. The relationship between NBF and other radiographic features was analyzed.P for all < 0.01. Similarly, on CT, joints with intraosseous tophus were more likely to have NBF; if tophus was present, the OR was 48.4 for spur, 3.3 for osteophyte, 14.5 for periosteal NBF, 35.1 for ankylosis and 39.1 for sclerosis; P for all < 0.001.The most frequent forms of NBF were bone sclerosis and osteophyte. Spur and periosteal NBF were less common, and ankylosis was rare. On both XR and CT, joints with bone erosion were more likely to have NBF; for CT, if erosion was present, the odds ratios (OR) was 45.1 for spur, 3.3 for osteophyte, 16.6 for periosteal NBF, 26.6 for ankylosis and 32.3 for sclerosis, This detailed quantitative analysis has demonstrated that NBF occurs more frequently in joints affected by other features of gout. This work suggests a connection between bone loss, tophus, and formation of new bone during the process of joint remodelling in gout. Classical radiological descriptions of gout highlight a number of characteristic features -4. TheseComputed tomography (CT) provides excellent visualization and characterization of bone morphology, and also allows reliable assessment of tophus detection and size -7. ThrouFollowing a review of patterns and scoring systems of NBF in other arthropathies -12, plaiThe site-by site analysis of NBF was completed using plain radiographs and CT scans of the hands in a further 20 patients with gout. These images were not used in the initial identification and calibration exercises described above. This dataset was selected because the clinical and radiographic features have been characterized in detail previously ,7,14. AlPlain radiographs of the hands were obtained using a Toshiba KXO-50F X-ray machine on single-emulsion film. A standard two view examination  was obtained . A 102 cm focal film distance with the smallest possible focal spot was used. The X-ray was centered between the second and third metacarpophalangeal (MCP) joints, perpendicular to the plane of the film. Plain radiographs were scored for erosion (0-5) and joint space narrowing (JSN) (0-4), according to the Sharp-van der Heijde (S-vdH) rheumatoid arthritis method, modified for gout . This meThe CT scans of the hands were performed on a Philips Brilliance 16-slice scanner , as previously described .The erosion and tophus scoring was undertaken more than three years before the NBF scoring. The scorers of NBF were blinded to the clinical and imaging results . All clinical, laboratory and imaging assessments were approved by the local ethics committee, and patients provided written informed consent.n = 798, two joints were not available due to finger amputation). Each NBF feature was scored as absent or present at each site by both observers. In the case of disagreement, the images were reviewed again and consensus was reached. Pre-consensus agreement for XR scoring was 93% for spur (kappa 0.58), 74% for osteophyte (kappa 0.29), 93% for periosteal NBF (kappa 0.15), 99% for ankylosis (kappa 0.40) and 86% for sclerosis (kappa 0.64). Pre-consensus agreement for CT scoring was 87% for spur (kappa 0.46), 76% for osteophyte (kappa 0.32), 94% for periosteal NBF (kappa 0.15), 99% for ankylosis (kappa 0.33) and 86% for sclerosis (kappa 0.69). In addition, if a spur was present on CT, the spur length was measured in millimetres (mm) as the distance from the point at which cortex changes angle to the tip of spur. In the presence of sclerosis, the relative density was assessed by measuring the Hounsfield units (HU) at the site of sclerosis, and at adjacent cortical and trabecular bone, using the CT workstation software. For spur length the intraclass correlation coefficient was 0.71  0.67 to 0.74) and for sclerosis HU was 0.64 (95% CI 0.60 to 0.68).Plain radiographs and CT scans of the hands were scored for features of NBF by a rheumatologist with experience in gout imaging (ND) and a musculoskeletal radiologist (AM). Plain radiographs and CT scans were scored separately. Plain radiographs were scored first, and the scores for the plain radiographs were not available for review by the scorer at the time of the CT scoring. Sites for NBF scoring were those included in the gout-modified S-vdH method for erosion scoring  and SPPS . Mean with standard deviations (SD) and percentages were used to describe NBF scores. For the site analysis, joints were grouped into the DIP joints, PIP joints (including the IP joint of the thumb), MCP joints, carpal region , and radius/ulna. To account for the different number of joints at each site, data were expressed as the percentage affected/patient. HU at different bone sites and NBF features at the different joint sites were analyzed by repeated measures analysis of variance (ANOVA) with Tukey's multiple comparison The clinical and imaging characteristics of the patients have been reported in detail previously ,7,14. ThP < 0.0001  P < 0.0001. Tophus density, measured in HU, was not associated with features of NBF (data not shown).Site-by-site analysis of the CT scans also showed that joints with bone erosion were more likely to have NBF than those without erosion Table . On CT sP = 0.01) and ankylosis  on CT, but not other features of NBF. Similarly, the number of subcutaneous tophi correlated with the number of joints affected by bone spur  and ankylosis  on CT, but not other features of NBF. Consistent with the site-by-site analysis, the number of joints affected by CT erosion and intraosseous tophus correlated with the number of joints affected by bone spur, sclerosis, ankylosis and periosteal NBF on CT scanning . Serum urate correlated with the number of joints affected by bone spur , with no other differences between other sites. Similarly tophi were more frequently observed in the PIP joints and radius/ulna site compared with the DIP joints . There was no difference between sites for spurs, osteophytes or ankylosis. The radius/ulna site was more frequently affected by sclerosis and periosteal new bone formation compared with other sites . With the exception of tophus at the PIP joints, the percentage of joints affected by periosteal NBF also correlated with the percentage of joints affected by tophus and erosion at each site . At the DIP joints and the PIP joints, there was no correlation between the percentage of joints affected by osteophytes and the percentage of joints affected by erosion or tophus . However, at the other joints sites , there was a modest correlation between percentage of joints affected by osteophytes and the percentage of joints affected by erosion .In the patient level analysis, the percentage of joints affected by spur and sclerosis correlated highly with the percentage of joints affected by tophus and erosion at each group of joints  are more common at the radius/ulna region compared with the distal interphalangeal joints. It is possible this difference may have been due to improved resolution at the larger site, compared with the small DIP joints. However, it is more likely that this represents a real difference. Potential explanations for this observation are that local factors such as biomechanical strain at the distal radioulnar region contribute to formation of MSU crystals, or promotion of tophus formation in the presence of MSU crystals at this site.Patients in this study had longstanding gout with a mean disease duration of almost 20 years and high serum urate levels. Although we did not observe a relationship between disease duration and NBF features in the patient level analysis, the results described in this paper may not necessarily be applied to patients with early disease or with well controlled disease. Similarly, this study only included joints of the hands, and it is possible that NBF changes may occur at different rates in the feet, which are more frequently affected by gout. Analysis of the feet is planned in future studies.A further question that arises from this work is whether CT is preferable to plain radiography to accurately detect features of NBF. CT was able to detect more osteophytes and spurs than plain radiography. However, the inter-reader agreement was similar between XR and CT, with reasonable agreement between the methods for detection of the various features of NBF, suggesting that plain radiographs may be sufficient. The additional cost and radiation exposure from CT further supports plain radiography as the method of choice.The strong relationship between bone loss (erosion) and NBF observed in this cross-sectional study suggests that NBF features such as sclerosis and spur formation may be repair phenomena triggered by joint destruction. At present, it is unclear whether NBF in gout occurs before bone erosion and tophus formation, develops concurrently with bone erosion, or occurs as part of tissue remodelling in response to tophus and erosion. Exploration of the temporal relationship between tophus, NBF and bone erosion now requires detailed longitudinal studies. Ideally these will be multimodality imaging studies which include plain radiography, MRI and dual energy CT, an advanced imaging method that allows visualization of urate deposits . InterveThis detailed quantitative analysis has demonstrated that NBF occurs more frequently in joints affected by other features of gout. This work suggests a connection between bone loss, tophus, and formation of new bone during the process of joint remodelling in gout.ANOVA: analysis of variance; CI: confidence interval; CT: computed tomography; DIP: distal interphalangeal; HU: Hounsfield units; IL: interleukin; IP: interphalangeal; JSN: joint space narrowing; MCP: metacarpophalangeal; NBF: new bone formation; OR: odds ratio; PIP: proximal interphalangeal; SD: standard deviation; S-vdH: Sharp-van der Heijde; TGF: transforming growth factor; TNF: tumour necrosis factor; XR: plain radiography.The authors declare that they have no relevant conflicts of interest.ND (the guarantor) accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish. ND conceived of the study, and contributed to the data acquisition, analysis and interpretation. AD and FM contributed to the design of the study protocol, data acquisition, and interpretation of the data. AM and BC contributed to the data acquisition and interpretation. All authors read and approved the final manuscript.


The relationship between Tei Index (TI) and left ventricular (LV) geometric patterns has not been previously well described. The present study therefore set out to describe the nature of this relationship if any, and to also assess whether a relationship exists between the geometric patterns and LV ejection fraction (LVEF) so as to establish a basis for comparison.The study was carried out in the echocardiography laboratory of Aminu Kano Teaching Hospital (AKTH) in Kano, North-Western Nigeria. The study was cross-sectional in design. Hypertensive subjects referred for echocardiography to AKTH were serially recruited from October 2008 to September 2009. TI was defined as the sum of isovolumic contraction and relaxation times divided by the ejection time, and values of LV TI < 0.40 were considered normal, while higher values were considered abnormal. Four patterns of LV geometry  were determined from the LV mass index and LV relative wall thickness as previously described. Binary logistic regression models and Pearson's Correlation (r) Coefficient were used to analyse the associations between TI or LVEF and a number of variables.A total of 142 subjects were recruited into the study. The prevalence of abnormal TI  in the total population was lower than that of reduced LV ejection fraction (< 50%)  (p = 0.335). There was no association between any LV geometric pattern and abnormal TI. However, there was significant relationship between the geometric patterns and low LVEF (< 50%); tested in a binary logistic regression model. HR was a significant predictor of TI with regression coefficient of -0.218, 95% confidence interval (CI) of -0.005 - < -0.001 and p-value of 0.011. Similarly, HR was the only variable that significantly predicted abnormal TI in a binary logistic regression model with an odds ratio of 1.058 , and also the only variable that correlated with TI significantly .This study has found that LV geometric patterns and LVEF were not associated with TI in hypertensives, but there was strong association between LV geometric patterns and LVEF. TI was found to be dependent on HR. Myocardial Performance Index or Tei Index (TI) was first described by Tei and Colleagues in 1995 as a "simple and reproducible Doppler index of combined systolic and diastolic myocardial performance in patients with primary myocardial systolic dysfunction" ,3. TI isThe study was carried out in the echocardiography laboratory of Aminu Kano Teaching Hospital (AKTH) in Kano, North-Western Nigeria.The Research Ethics Committee of the Hospital reviewed and approved the study protocol, which conformed to the ethical guidelines of the Declaration of Helsinki, on the principles for medical research involving human subjects . The stuAll the recruited subjects were hypertensive in sinus rhythm and on treatment, whether or not blood pressure (BP) was controlled. Subjects with other conditions that could cause LVH or myocardial diseases were excluded, such as ischemic heart disease (IHD), valvular heart disease and cor-pulmonale. IHD was excluded if all of the following were absent: history of angina or IHD, electrocardiographic changes suggestive of myocardial infarction, and regional wall motion abnormalities on echocardiography.Transthoracic echocardiography was performed by the author and Colleagues using Aloka Cardiac Ultrasound System (model SSD 4000 PHD), and the procedures were carried out according to standard guidelines . Left veIn adults, values of LV TI < 0.40 were considered normal, while higher values were considered abnormal, as they were found to correspond to worse pathological states, and to overall cardiac dysfunction .2 for all subjects [The four patterns of LV geometry were classified and defined as: normal geometry  and LVMI); concentric remodelling ; concentric LVH (increased LV RWT and LVMI); and eccentric LVH . RWT was calculated as: RWT = 2/LV end-diastolic dimension . Increassubjects .t-test, Fisher's exact and Chi square (χ2) tests were used for comparison between groups as appropriate. Binary logistic regression models, and Pearson's Correlation (r) Coefficient, were used to analyse the associations between TI or LVEF and a number of variables. A p-value < 0.05 was regarded as significant.Data were analysed with SPSS version 16.0. Means and standard deviations were computed and presented for quantitative variables. Student's A total of 142 subjects were recruited into the study, and the results presented in Tables The result also showed that there was no association between any LV geometric pattern and abnormal TI. There was also no relationship between LVH (eccentric LVH + concentric LVH) and abnormal TI . This result contrasts significantly with the relationship between the geometric patterns and reduced LVEF (< 50%); tested in a binary logistic regression model and shown in Table Subjects with normal and increased TI were on similar antihypertensive drugs, including angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, beta-adrenoceptor blockers, calcium channel blockers and thiazide diuretics. The mean systolic BP for all patients was 155.22 ± 29.83 mmHg, while their mean diastolic BP was 94.74 ± 20.13 mmHg.This study has found that LV geometric patterns as defined by Ganau et al , LVH andWe also found that TI was dependent on HR, which does not agree with some earlier reports that suggested that TI is independent of HR . That TIA cross-sectional study carried out in Osogbo, south-western Nigeria, has just been published . The maiFrom the foregoing therefore, it could be said that there are conflicting reports on the relationship between TI and clinical and echocardiographic variables. To sort out these conflicts, large prospective studies are needed which should also assess the impact of TI on all-cause and cardiovascular mortality.Aside from the estimation of TI, tissue Doppler imaging has several other clinically-applicable roles. These include assessment of ventricular diastolic dysfunction even in the presence of atrial fibrillation, diagnosis of acute myocardial ischemia, ventricular long-axis systolic function, and more recently in assessing mechanical ventricular dyssynchrony -19.The limitations of the present study include those inherent to the TI, such as This study has found that LV geometric patterns, LVH and LVEF were not associated with TI in hypertensives, but there were strong relationships between all LV geometric patterns and LVEF. The lack or existence of a relationship between TI or LVEF respectively, and LV morphology, could possibly be related to whether or not they depend on LV dimensions in their determination. In addition, the study found that TI was dependent on HR, in agreement with some earlier reports. The results of the present study have further clarified the relationship between a measure of ventricular performance (TI) and LV geometric patterns, as well as their relationships with LVEF.The author declares that they have no competing interests.The author (KMK) conceived and carried out the study, analysed data, and wrote and approved the manuscript.


The systolic BP of both groups did not show a significant difference by time or in a group-by-time interaction; however, a significant difference was observed between groups . The diastolic BP did not show any significant difference by time or by a group-by-time interaction; however, a significant difference was observed between groups . In conclusion, the aromatherapy effectively reduced the anxiety levels and increased the sleep quality of PCI patients admitted to the ICU. Aromatherapy may be used as an independent nursing intervention for reducing the anxiety levels and improving the sleep quality of PCI patients.The purpose of this study was to investigate the effects of aromatherapy on the anxiety, sleep, and blood pressure (BP) of percutaneous coronary intervention (PCI) patients in an intensive care unit (ICU). Fifty-six patients with PCI in ICU were evenly allocated to either the aromatherapy or conventional nursing care. Aromatherapy essential oils were blended with lavender, roman chamomile, and neroli with a 6 : 2 : 0.5 ratio. Participants received 10 times treatment before PCI, and the same essential oils were inhaled another 10 times after PCI. Outcome measures patients' state anxiety, sleeping quality, and BP. An aromatherapy group showed significantly low anxiety ( Coronary artery diseases are ischemic heart diseases in which the coronary arteries narrow or close, which decrease the oxygen supply to the cardiac muscle, leading to various clinical symptoms such as angina pectoris, myocardial infarction, congestive heart failure, and sudden death. The prevalence of coronary artery diseases have increased recently as the population ages and as changes in eating habits and lifestyle have led to higher incidences of diabetes, high blood pressure, and hyperlipidaemia in Korea. Cardiovascular diseases ranked as the third leading cause of death and are among causes of circulatory system mortality; cardiac diseases rank second after neurovascular diseases in 2008. The mortality rate of ischemic heart disease in 100,000 people increased from 16.2% in 1998 to 25.7% out of 100,000 as mortality in 2008 .Coronary artery diseases such as myocardial infarction and angina pectoris generally lead to hospitalisation in an intensive care unit (ICU). Most of these patients experience the physical effects of a heart examination as well as an unfamiliar environment, isolation from family, and stress from encountering strangers. Consequently, most patients experience a relatively severe level of psychological anxiety because of the loss of individuality due to the treatment-centric environment and a sense of crisis due to the constantly changing environment . AdditioBecause nursing interventions based on education before coronary angiography have shown to be effective, structured care and education by providing information before the procedure have been implemented in the clinical setting. Aromatherapy, which has a wide range of applications and is easy to deploy, has recently garnered much attention . SpecifiThis study is a nonequivalent control group nonsynchronised quasiexperiment designed to assess the effect of a lavender, roman chamomile, and neroli oil blend aromatherapy on anxiety, sleep, and blood pressure in coronary artery disease patients with ischemic heart diseases after a stent insertion during coronary angiography who were admitted to the ICU. The subjects of this study were patients diagnosed with coronary artery diseases who underwent a stent insertion during coronary angiography and were admitted to the cardiovascular ICU between August 1, 2010, and November 20, 2010, at the Eulji University Hospital in Daejeon, Korea. This study was approved by the Institutional Review Board at Eulji University before data collection (EU 10–14). The specific criteria for subject selection were patients diagnosed with angina pectoris or myocardial infarction who had coronary angiography and were conscious and able to communicate, to understand the purpose of the study, and to give consent. Criteria for exclusion were patients taking antianxiety or sleep medications or who had an aroma-essential-oil contraindication.The subjects were informed of the purpose of the experiment, consent was given, and voluntary participation and withdrawal was also explained. The subjects were given a small gift after participation.G ∗ Power analysis. With a significance level (α) of 0.05, a statistical power (1 − β) of 0.80, and an effect size of 0.74, as calculated from previous studies [The sample size for this study was calculated using  studies , we calcLavandula officinalis), roman chamomile (Chamomile roman), and neroli (Citrus aurantium) at a ratio of 6 : 2 : 0.5 as prescribed by an aromatherapist. Lavender suppresses heart stimulation and lowers blood pressure; therefore, it is useful in the treatment of heart acceleration and high blood pressure. Chamomile has a calming effect and is effective in relieving anxiety and stress, and neroli has a calming effect and is effective in treating insomnia [The experimental treatment was a refrigerated oil blend of lavender  was used to measure the state anxiety periodically. VAS lets the subjects self-ascribe anxiety levels between 0 and 10 on a 10 cm horizontal line, with a higher score indicating a higher level of anxiety.In this study, state and trait anxiety were assessed using the Spielberger's State-Trait Anxiety Inventory-form Korean YZ (STAI-KYZ) . State aBlood pressure (BP) was measured using the Sure V24 patient monitor . The left brachium of the subject was raised to the heart level, the lower end of the cuff was strapped 2 cm anterior to the elbow, and measurements were taken according to the instrumental procedure. The BP was recorded in mmHg units. BP was measured once before PCI and 13 times after the procedure, for a total of 14 measurements.α = .80 in their results [α = .86 and for postprocedure sleep was Cronbach's α = .94.Sleep quality was measured using the Korean translation form  of VSH S results . In thisDemographic characteristics and baseline anxiety, BP, and sleep quality were assessed on the day of admission. Outcome measures including BP, anxiety, and sleep quality were assessed again before and after PCI. BP was measured every hour for 12 hours, for a total of 13 measurements. Outcomes as anxiety, BP, and sleep quality were assessed at 9AM on the day following PCI.χ2-test and the t-test. Anxiety, sleep quality, and BP before and after the treatment in the aromatherapy and control groups were analyzed using the t-test and repeated-measures ANCOVA. The coefficients of reliability of the experimental tools were analysed with the Cronbach's α.The data were analysed with the PASW Statistic 18.0 program. The general characteristics of the subjects were analysed using raw numbers and percentages. The homogeneity tests of the general characteristics of the aromatherapy and control groups were performed using the There were no significant differences between the two groups in gender, age, marital status, level of education, exercise, smoking, alcohol consumption, state and trait anxiety, sleep quality, and BP. The homogeneity test of disease-related characteristics also indicated no significant differences between the two groups in terms of PCI experience, site of insertion, and ICU experience .t = 5.99, P < .001) .After treatment, the anxiety levels were 0.36  in the aromatherapy group and 3.11  in the control group ( < .001) . The chat = −3.65, P = .001) .After the experimental treatment, the aromatherapy group had a sleep score of 52.7 , whereas the control group had a score of 36.2 , showing a significant difference between the two groups ( = .001) . There wF = 4.63, P = .036) and DBP   and diastolic blood pressure (DBP) on the day of admittance were used as the covariates for analysis. There were neither significant differences based on time nor any interaction between time and group; however, there was a significant difference between the groups in both SBP ( Figures .This study was a nonequivalent control group nonsynchronised assessment of the effect of aromatherapy on the anxiety, sleep, and BP of cardiac stent insertion patients admitted to the cardiovascular ICU. The aromatherapy had a positive effect on reducing anxiety, increasing sleep, and stabilising BP in the patients in the cardiovascular ICU after cardiac stent insertion; therefore, it may be used as an independent nursing intervention.The anxiety level of the aromatherapy group was significantly lower than that of the control group. These results are consistent with the anxiety-decreasing effects of aromatherapy in patients before surgery , during After treatment, the aromatherapy group experienced no significant changes in sleep quality, whereas the control group had significantly worse sleep. Assuming that sleep is generally decreased in patients in the ICU and because the aromatherapy group did not have a decrease in sleep, we can conclude that aromatherapy is effective in maintaining sleep despite a stressful situation. This result is consistent with those of previous studies of increased sleep satisfaction among nightshift nurses , haemodiThere were neither a significant difference in BP based on time nor any interaction between time and group; however, there was a significant difference between the groups in both SBP and DBP. Other authors have reported various results, including a decrease in BP  and no eDuring this study, there were no reports of headache or nausea associated with the administration of aromatherapy. Most of the subjects reported that the aromatherapy inhalation had a pleasant odour. They also indicated their satisfaction in being treated in a foreign environment such as an ICU after the procedure.In summary, aromatherapy reduced anxiety, increased sleep, and stabilised the BP of patients undergoing cardiac stent insertion. Among alternative therapies that have recently been introduced, aromatherapy is easy to apply, fast-acting and can be used in independent nursing interventions. More research is necessary for it to become a suitable nursing intervention in practice.