Identification of drug-induced liver disease (DILI) is difficult, even among hospitalized patients. The aim of this pilot study was to assess the impact of a specific strategy for DILI screening.We prospectively compared the number of acute DILI cases identified in one week of a proactive strategy based on centralized elevated ALT values to those identified with a standard of care strategy for 24-week period based on referral cases to the hepatology unit. In the centralized strategy, a designated study biochemist identified patients with ALT greater than 3 times the upper limit of normal values (ULN) and notified the designated hepatologists, who then went to the patients' wards, analyzed the charts, and if necessary, interviewed the identified patients. During these two periods, patients with possible DILI were included after signing an informed consent in an ongoing European diagnostic study (SAFE-T consortium).During the 24-week period of the standard strategy, 12 (0.04%) patients out of a total of 28,145 were identified as having possible DILI, and 11 of these accepted to be included in the protocol. During the one-week proactive period, 7 patients out of a total of 1407 inpatients (0.498%)  were identified with possible DILI, and 5 were included in the protocol.A simple strategy based on the daily analysis of cases with ALT >3 ULN by designated biochemists and hepatologists identified 12 times more acute cases of drug-induced liver disease than the standard strategy.This pilot cohort is registered on the number AP-HP P110201/1/08-03-2011 and AFSSAPS B110346-70. Adverse drug events occur as a consequence of medication errors or adverse drug reactions (ADR). ADRs rate among the leading causes of death in the Western world Drug-induced liver injury (DILI) due to paracetamol overdose and idiosyncratic drug reactions is the leading cause of acute liver failure and may contribute to as many as 0.3% of all inpatient deaths Approximately 1 in 100 patients develops DILI during hospitalization, but more than 50% of cases have been missed when they occurred in non-hepatology departments http://www.imi.europa.eu) The Safer and Faster Evidence-based Translation (SAFE-T) consortium is a public–private partnership comprising 20 partners from the pharmaceutical industry, small–medium enterprises, academic institutions and clinical units of excellence, with representatives from the European Medicines Agency (EMA) as external observers and advisors. It operates under the framework of the EU Innovative Medicines Initiative Joint Undertaking (IMI-JU)  greater than 3 times the upper limit of normal (ULN) in the presence of a drug and in the absence of other causes We report here on the results of a pilot study describing the proof of concept of a proactive strategy based on a daily centralized analysis of elevated ALT  compared to the usual “passive" strategy based on cases referred to the hepatology unit (standard strategy). The centralized strategy identified 12 times more patients with DILI than the standard strategy.This study was part of the ongoing protocol (Protocol 3 of the Work Package 3) of the SAFE-T consortium, which was in accordance with the Helsinki Declaration and approved by the Pitié Salpêtrière Hospital Ethics Committee. All included patients signed an informed consent. The protocol for this cohort and supporting STROBE checklist are available as supporting information; see The SAFE-T consortium proposes a generic qualification strategy for translational safety biomarkers (TSBM), outlining proposals on how to generate sufficient preclinical and clinical evidence to qualify new TSBM for regulatory decision-making in defined contexts. The experience gained during the course of the SAFE-T project for three organ toxicities will be integrated into improvements for this initial generic approach The “SAFE-T group" of the study included 8 participants. All ALT assay results performed in the two laboratories of the hospital were centralized each day by a senior biochemist (HMK) and a technician (NR). The results of all elevated ALT samples greater than 3×ULN (ALT>3ULN) were sent by intranet to 6 experienced hepatologists . In the 48 hours following the ALT results, one of the hepatologists went to the inpatient wards and analyzed the chart. According to the patient's chart, each case with ALT>3ULN was classified as: hepato-biliary disease , cardiovascular origin (such as septic shock or cardiac arrest), muscle disease , other causes, or possible DILI according to the SAFE-T protocol definition Patients with DILI had liver injury classification based on the first laboratory determination according to the CIOMS  criteria The standard strategy was the routine followed in the hospital. The suspected DILI cases were presented by the non-hepatologist physician to a senior full-time hepatologist; these were then considered for inclusion in the SAFE-T protocol if they met the inclusion criteria, as with the centralized strategy.Biochemical assays were performed with fresh plasma that had been decanted and stored for a maximum of 72 hours at +2 to 8°C under no-light conditions. ALT-activity measurement used the reference method defined by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) with pyridoxal phosphate and was calibrated The ALT ULN was based on a study of 2,200 apparently healthy blood donors whowere negative for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus markers. The study included 1,171 men and 880 women. The thresholds were 26 IU/L in women and 35 IU/L in men. They were determined by the mean +1 SD after exclusion of the 5% extreme values The main endpoint was the prevalence of possible acute cases of DILI identified during the period. The a priori hypothesis was that a centralized strategy would result in a minimum 6-fold increase in the prevalence of identified DILI cases, i.e. from one DILI every two weeks, which was the standard incidence we observed, to three DILI every week. The prevalences were compared using odds ratios and Z-tests, and patient characteristics were compared with the Fisher's exact test and Mann-Whitney test.During the one-week pro-active period, from November 26 to December 2 2011, 1,995 patients had ALT measurements , includiThe characteristics of patients with and without DILI are given in During the 24-week period of the standard strategy , 12 patients out of a total of 36,077 inpatients were identified with possible DILI, i.e. a prevalence of 0.033%; 11 of these accepted inclusion in the SAFE-T protocol.During the one-week centralized period, the prevalence of DILI was 0.498% among inpatients,  which was significantly higher than the prevalence observed during the standard period, 0.043% , with an odds ratio vs. standard of 12.1 .The two periods had the following similar characteristics : number Three (16%) patients had DILI within less than 5 days from drug intake: chemotherapy before a bone marrow transplantation in centralized period; an overdose of acetaminophen due to abdominal pain and a suicidal case, in the standard period. In addition, 11 (58%) patients had history of drug intake more than 5 and less than 90 days.The proportion of patients with full liver analyses, including hepatitis viral markers, auto- antibodies, and abdominal imaging was 12 out of 12 during the standard period, and 6 out of 7 during the centralized period.After the suspicion of DILI, all patients had abdominal imaging (ultrasound or computerized tomography) to eliminate other causes of ALT increase DILI. Despite many of them have had malign diseases none of them had suspected liver images, such as nodules or liver mass.There have been no studies to date that have prospectively compared a real-time strategy to a standard strategy for DILI screening in hospitals. Most studies have been retrospective and used hospital codes The results observed during the standard period had not been underestimated. The prevalence of DILI in 6 months was 12 cases out of 30,023 total hospital admissions (0.04%) and 3.75% (12/3200) of the gastroenterology ward admissions, which were similar to those assessed retrospectively by Carey et al.  The results from the centralized period suggest underreporting of DILI during the standard period, at least in non-hepatology wards. This was already demonstrated by Meier et al., who retrospectively observed 57 DILI cases out of 4,209 inpatients with normal baseline ALT, i.e. DILI incidence of 1.4%. Liver injuries were not mentioned in the diagnoses or in the physicians' discharge letters in about 52–68% of all cases Cases identified during the standard period were more severe than during the pro-active period, with significantly higher ALT levels, more patients who met the Hy's criteria , and more patients who died or were transplanted. This was not a bias and was expected, since the physicians in the non-hepatology ward probably did not call the hepatologist for each case of ALT >3ULN in the absence of jaundice. These results therefore strongly suggest that the centralized method could prevent very severe complications. For instance an increase in ALT just over 3ULN in a chemotherapy patient could lead to an investigation for hepatitis B infection and to an immediate and effective treatment. This was not the case for such a patient during the standard period, who was identified only after the onset of jaundice and was treated too late and finally died from hepatic failure.The present study had limitations due to the short period of evaluation and the commitment of eight persons. The costs and the efficiency of the centralized strategy should be confirmed over a longer period and in different hospitals to prove that the study results are generalizable . We have not evaluated a more specific strategy such as the identification of patients who have increased ALT results on two consecutive occasions. Another limitation is the possibility that treating physicians might have recognized the DILI event and thus stopped the medication or lab tests improved with time (adaption) thereby not requiring a Hepatology consult - thus over emphasizing our findings. However this bias would reduce the overall detection of DILI but not the detection of severe DILI.There is obviously an economic interest for developing such algorithms due to the costs of ADRs in Western countries. The ADR costs in one hospital per bed and per year have been estimated to be approximately €6000 in the USA This pilot study focused on necrosis and did not detect cholestatic injury or micro/macrovesicular steatosis; the design was also not able to identify late-onset drug reactions (e.g. warfarin).The standard of ALT >3ULN is an arbitrary guideline with low accuracy for identification of DILI The implicit assumption in this study was that this real-time strategy would be more helpful than harmful to inpatients, since the offending drug would be discontinued. We recognize that it is difficult to be certain whether stopping the short-term use of life-saving medicines used in hospitals due to a possible DILI will do more good than harm On the other hand the present study shows that more DILI can be identified in real-time than in the standard “wait and see" manner. The subsequent challenge then is assessing the benefit-risk of stopping the drug. Among our identified DILI, we acknowledge that the benefit-risk of stopping amiodarone is controversial In conclusion, a simple strategy based on the daily analysis of cases identified by ALT greater than 3ULN by designated study biochemists and hepatologists identified 12 times more acute drug-induced liver disease than the standard strategy.Checklist S1STROBE checklist for prospective cohort.(DOCX)Click here for additional data file.Protocol S1Protocol of the pilot study.(DOC)Click here for additional data file.Table S1Characteristics of DILI cases.(DOCX)Click here for additional data file.Text S1DILI-GHPS  Group Members.(DOCX)Click here for additional data file.


Intermittent preventive treatment (IPT) has recently been accepted as an important component of the malaria control strategy. Intermittent preventive treatment for children (IPTc) combined with timely treatment of malaria related febrile illness at home to reduce parasite prevalence and malaria morbidity in children aged between six and 60 months in a coastal community in Ghana. This paper reports persistence of reduced parasitaemia two years into the intervention. The baseline and year-one-evaluation findings were published earlier.The main objective in the second year was to demonstrate whether the two interventions would further reduce parasite prevalence and malaria-related febrile illness in the study population.This was an intervention study designed to compare baseline and evaluation findings without a control group. The study combined home-based delivery of intermittent preventive treatment for children (IPTc) aged 6 - 60 months and home treatment of suspected febrile malaria-related illness within 24 hours. All children aged 6 - 60 months received home-based delivery of intermittent preventive treatment using amodiaquine + artesunate, delivered at home by community assistants every four months (6 times in 24 months). Malaria parasite prevalence surveys were conducted before the first and after the third and sixth IPTc to the children. The evaluation surveys were done four months after the third and sixth IPTc was given.Parasite prevalence which reduced from 25% to 3.0% at year-one evaluation had reduced further from 3% to 1% at year-two-evaluation. At baseline, 13.8% of the children were febrile (axilary temperature of ≥37.5°C) compared to 2.2% at year-one-evaluation while 2.1% were febrile at year-two-evaluation.The year-two-evaluation result indicates that IPTc given three times in a year (every four months) combined with timely treatment of febrile malaria illness, is effective to reduce malaria parasite prevalence in children aged 6 to 60 months in the study community. This must give hope to malaria control programme managers in sub-Saharan Africa where the burden of the disease is most debilitating. Malaria is estimated to cause between 300 and 500 million clinical cases with about 700,000 to 1.6 million deaths every year. About 94% of these deaths are believed to occur in sub-Saharan Africa . In 2006Like elsewhere in Africa, malaria control in Ghana relies on early diagnosis and prompt treatment of suspected cases (fevers) and the home is where early recognition and, in most cases, prompt treatment is initiated -8. IPTc Malaria control through prompt and effective treatment remains a challenge, especially in areas where access to early effective treatment is a problem. It is in these areas where IPT, especially IPTc could become an important component of the malaria control strategy, since it has been demonstrated that IPTi given with childhood vaccinations reduced incidence of first episode of malaria and also reduced severe anaemia by more than 50% during the first year of life -13. It wThe Ghana Health Service had aimed at treating 55% of under-five febrile malaria cases within 24 hours of symptom onset by 2007, as opposed to the Abuja target of 60% by 2005, but three clear years after the expiration date of 2007, this target is yet to be achieved. This study was, therefore, designed to assess the potential of a strategy of IPTc delivered at home and timely treatment of febrile illness to reduce parasite prevalence and malaria morbidity in the children-under 5 years as well as contribute to achieving the target of getting 55% of children under five into treatment within 24 hours. The baseline and year-one-evaluation results were published in 2009 . This paThis paper is to further demonstrate the feasibility of controlling febrile malaria illness in the home through combined interventions of intermittent preventive treatment and timely febrile malaria illness management in children aged 6 - 60 months in southern Ghana .The study site was discussed in detail in the earlier publication . In brieThis was an intervention study designed to compare baseline and evaluation findings without a control group.IPTc was delivered every four months beginning in July 2007  and was evaluated in July, four months after the last round of IPTc and just before the fourth round of IPTc [Any child with febrile illness suspected to have malaria by the caretaker was reported to the community assistants who then evaluated and treated those who met the protocol criteria for suspected febrile malaria illness, which was a child with axillary temperature of ≥ 37.5°C; whose caretaker reported suspected febrile malaria together with one or more of the following; headache, hot body, weakness, loss of appetite, among others, with no other overtly observed or reported condition was treated with the full three-day course of artesunate and amodiaquine .During IPTc rounds and prevalence surveys, a simple questionnaire was administered to caretakers to record febrile illnesses in the seven days prior to those events. That is, caretakers whose children received IPTc at any round and those who participated in the prevalence surveys responded to the questions. Questions asked included: Has your child been well in the past seven days, including now? If no, what is/was wrong with him/her? What was done for the child when you found out that he/she was not well? During the prevalence surveys, however, additional questions were asked about bed net usage.This was an implementation research which aimed at enrolling every child aged six to 60 months living in the study area into the study with the consent of their caretakers, mostly parents. However, for the prevalence survey, a sample size of 174 was needed to determine malaria parasite prevalence estimated at 20% in the study population . At the ® photometer  at the field site [A diagnosis of malaria infection was made with light microscopy of thick and thin blood smears. The thick and thin blood smears were stained with 3% Giemsa for 30 minutes. Parasite density was determined by counting the number of asexual parasites per 200 white blood cells, and calculated per μL assuming a white blood cell count of 8,000 cells per μL. Sexual parasite count was done per 1,000 white blood cells. A smear was declared negative if examination of 100 thick-film fields did not reveal the presence of asexual parasites. Quality control was done by allowing a second microscopist to read a random sample of 10% of all slides to confirm the absence or presence of parasites. Haemoglobin concentration was determined from finger pricks using a portable automated HemocueThe Institutional Review Board of the Noguchi Memorial Institute for Medical Research, University of Ghana and the Ethical Review Committee of WHO reviewed and approved the study. Each mother/caretaker was informed of the objectives, methods, anticipated benefits and potential hazards of the study. Caretakers were also informed that they were at liberty to withdraw their children from the study at any time without penalty. They were assured that all information collected during this study would be kept confidential and that in any resulting publication it would not be possible to link the data to individuals in the study .This paper presents the two-year-evaluation of combined IPTc and timely treatment febrile illnesses . Most of the children received IPTc six times in 24 months .Plasmodium falciparum, the dominant species in Ghana. Other clinical and parasitological findings are presented in Table Malaria parasite prevalence at year-one evaluation was 3.0% (10 out of 357), which further dropped significantly to about 1.0% (3 out of 337) at year-two-evaluation, a significant reduction of over 60.0%, p < 0.001, Fisher exact test). This showed a point parasite prevalence reduction of over 90.0% in 24 months . There was a significant relationship between febrile status and parasitaemia at year-one-evaluation  but this was not the case at year-two evaluation. Two out of the three parasite positive cases receive IPTc four times and the remaining one received it twice. All the positive infections were In this study, anaemia was defined as haemoglobin <10 g/dl and trend analysis showed a significant reduction from baseline through to year-two evaluation (p = 0.003). Comparing the baseline level of 27.6% to year-two evaluation level of 15.7% showed about 43.1% reduction in anaemia cases in 24 months  a number of febrile illnesses were reported for the children within seven days prior to data collection Table . A trendIPTc was delivered to children aged 6 to 60 months in the study community six times . There have been marginal increases in the number of children at each subsequent treatment round until the fourth, where it dropped marginally from 433 (IPTc3) to 415 (IPTc4), and then increased to 419 (IPTc5) and 421 (IPTc6). The decrease was largely due to some children attaining the age of more than 60 months and were dropped out of the study. At the time of year-two-evaluation, majority of the children have received all six IPTc doses. A few were lost at various IPTc rounds due mainly to either the movement of these children out of the study community at one point or the other, or the entry points of participants, since enrolment was prospective and any child who attained the age of six month at any given time was enrolled. However, the number of dropouts at each round was too small for any meaningful comparative analysis to be done on them. During each IPTc round, a number of febrile illnesses were reported by caretakers within the past seven days prior to treatment and trend analysis showed significant reductions in reported fever as the number of IPTc rounds increases  and headache (0.021) reported as the IPTc rounds increased but not for chills and rigors, and vomiting Table .There was virtually no serious adverse event reported after drug administrations. However, some caretakers reported that their children were weak for about two to four hours after taking the medicines and these were; five (1.21%) IPTc1, four (0.95%) IPTc2, seven (1.65%) IPTc3, four (0.93%) IPTc4, five (1.13%) IPTc5 and 5 (1.11%) IPTc6. None of these cases warranted any medical intervention. A few caretakers also reported that their children did eat very well after taking the drugs but this could not be independently verified.As this was at year-one evaluation, no caretaker had lost a child in 12 months preceding the year-two evaluation, indicating that, no caretaker had lost a child in the twenty-four months of project implementation, except two infants who died at birth and this was attributed to the absence of a midwife at the clinic at the time of their birth.As expected, over 98% of the caretakers were mothers of the children. Caretakers  reported that they and their families slept under bed nets the previous night. Comparatively, insecticide-treated net usage has increased marginally from 60.0% at year-one evaluation to 63.0% at year-two evaluation. However, compared to baseline (38.5%), there was a significant increase of 63.6% in the use of treated bed net in 24 months.This paper presents the two-year-evaluation of intermittent preventive treatment for children (IPTc) combined with timely treatment at home for malaria control, targeting children aged 6 - 60 months old. The main finding at year-two-evaluation was a further reduction of about 66.6%  in malaria prevalence in the study population compared to about 88.0% reduction reported between baseline and year-one-evaluation  -12,15-18Anaemia in the children, defined as haemoglobin <10g/dl, further improved by 27.4% . Compared to baseline, this was over 65.0% reduction in all cause anaemia prevalence in the study population. This compares well with a recent randomized trial in Tanzania, which showed that IPT given to infants at the time of childhood immunization reduced the incidence of the first episode of malaria and anaemia by more than 50.0% during the first year of life ,12. HoweMalaria-related morbidity in the study population, expressed by the presence of fever and other malaria-related signs and symptoms reported, has reduced as captured either during prevalence surveys or IPTc administration. Timely treatment of febrile malaria cases in the community did not follow any pattern. However, it could be argued that the community assistants who were on hand to deliver effective treatment in a timely fashion have contributed to the marked reduction of parastaemia seen during evaluation surveys. A community randomized trial showed a slightly higher coverage in the community-based delivery arm compared to facility-based arm . This shet al [et al [Findings reported here present a challenge to the existing practice, especially in most sub-Saharan African countries where malaria diagnosis is mostly based on presumption without confirmation. As community interventions or access to treatment increases, this may lead to fewer malaria infections, which may pose the danger of over diagnosis and treatment with expensive drugs for people who do not need them . Controlet al , this mal [et al  also makThe use of IPTc combined with timely home treatment to control malaria was found to reduce malaria prevalence in children aged six to 60 months . AlthougAt this point, it may be recommended to reduce the frequency of treatment from every four months to every six months or providing treatment at the beginning of each peak season (two peak seasons in southern Ghana). Either way, the timing must be related to the major peak season in the study area. At certain point it should be necessary to treat the general population at least once in a year to reduce the circulating parasites in the population such that mosquitoes will have very little or no parasite to transmit. Findings reported in this paper indicates that, with consistent efforts, malaria could be put under control such that it may no longer be a major public health problem, especially in sub-Sahara Africa where it is a threat to millions of people. Also, the study shows that it is possible to train community assistants to deliver IPTc together with home management of malaria on timely basis with very little supervision. However, additional training must be provided to enable community assistance to use RDT in the community so as to move away from presumptive treatment as malaria incidence continues to go down in communities.One major limitation of the study was that rapid diagnostic test (RDT) was not used to confirm the presence of parasite before timely treatment was provided as a result of the ethical consideration not to allow field assistants to take blood from the children. Another weakness of the study is that there was no control group to compare the result so it was not possible to attribute all the reduction in parasite prevalence to the interventions. Also, the contribution of each of the intervention to the reduction of parasite prevalence in the study population was not measured. All these must be taken into consideration when designing s similar study in future.The authors declare that they have no competing interests.CKA was involved in the conception, design and implementation, data analysis and writing of this paper. KAK was involved in the design and writing of this paper. AS-K was involved in the implementation and writing of this paper. MGW was involved in the conception, design and writing of this paper. All the authors have read and approved the final version of the manuscript.


NF-1 gene, a tumor suppressor gene located on chromosome 17q11.2. Hence, it can be considered as a familial cancer predisposition syndrome in which the affected individuals are at increased risk of developing malignancies. Intraoral neurofibromas associated with NF-1 are quite common, but the occurrence of malignant peripheral nerve sheath tumor (MPNST) in the oral cavity is very rare. Oral MPNST can occur either de novo or by malignant transformation of neurofibromas or very rarely can represent a metastatic lesion. Here, we present a case of MPNST involving the maxillary region, in a patient with NF-1. Since MPNST often creates a diagnostic dilemma, histopathologic criteria for the diagnosis of MPNST are also discussed.Neurofibromatosis-1 (NF-1) is a relatively common autosomal dominant disease characterized by multiple cutaneous fibromatoses and café au lait spots. It is associated with the mutation of  Oral neurofibromas are seen in 72% of the NF-1 patients.[The term “neurofibromatosis” refers to a group of genetic disorders that primarily affect the cell growth of neural tissues. Neurofibromatosis-1 (NF-1) is the most common type and accounts for about 90% of all cases. It is one of the frequent genetic diseases with a prevalence of 1 case in 4000 births.[patients. MPNSTs aWe report a case of multiple MPNST in a patient with NF-1, who presented with a swelling on the right maxillary region. Other sites involved include mediastinum, scalp and upper back region and all the lesions developed in a short span of 6 months.A 40-year-old male patient, a known case of NF-1, reported to our hospital with the complaint of a swelling on the right maxillary region in relation to upper back tooth. The swelling, initially noticed 3 weeks back, was small in size, but grew rapidly to reach the present size. He also gave the history of dull aching pain associated with the swelling. His past medical history revealed that multiple cutaneous nodules seen on the entire body Figures  were precafé au lait pigmentation was noticed on the axillary region and on the arms. A large pigmented macule was present on the right side chest [On general examination, the patient was poorly built and nourished. No pallor, icterus, cyanosis, clubbing, pedal edema or lymph node enlargement were noticed. Multiple cutaneous nodules of varying size were seen distributed on the entire body. Multiple de chest .On intraoral examination, an exophytic soft tissue mass measuring around 3 cm × 4 cm × 5 cm was present on the right alveolus in relation to 16 and 17. The lesion presented as a lobulated dumbbell shaped mass extending buccally and palatally. The buccal mass was found to be extending into the buccal vestibule, and the palatal mass involved the entire half of the posterior palate. The swelling was sessile, irregular in shape and normal in color. The surface was smooth with superficial candidal infection in some areas . On palpIntraoral periapical radiograph and orthopantamograph showed severe bone loss in relation to 16 and 17 with periapical radiolucency in relation to 16 .Based on the history and clinical examination, a provisional diagnosis of intraoral neurofibroma was given. Other diagnosis considered included MPNST, other mesenchymal neoplasms and odontogenic neoplasms.Incisional biopsy was done from the palatal aspect of the tumor. Microscopically, the lesion showed alternating fascicles of hypercellular and hypocellular areas arranged in a streaming pattern . The celThe patient was given radiotherapy for the oral lesion and was treated with 3000 cGy in 10 fractions. One month later, the patient developed similar lesions on the scalp and the right side of the upper back region and finally succumbed to death after 2 months.Neurofibromatosis, also known as VonRecklinghausen’s disease, named so after the person who described the disease in 1882, is an autosomal dominant disease of varied clinical manifestation. Two clinically and genetically distinct subtypes were identified and have been designated as NF-1 and NF-2.café au lait spots.[NF-1, otherwise known as the central form, is the most common single gene defect. It is clinically characterized by multiple neurofibromas along the peripheral nerves, optic gliomas, sphenoid wing dysplasias, pigmented iris nodules and hyperpigmented macular skin lesions known as it spots. All thesit spots. The neurThe peripheral nerve sheath tumors are the tumors arising from the nervous tissue outside the brain and the spinal cord. The term “malignant peripheral nerve sheath tumor” refers to all the spindle cell sarcomas arising from the peripheral nerve or neurofibroma or showing nerve sheath differentiation. Previously, various terminologies like neurogenic sarcoma, neurilemmosarcoma, malignant fibrosarcoma and malignant neurilemmoma had been used, but World Health Organization (WHO) has recently adopted the term “malignant peripheral nerve sheath tumor” to denote such tumors. MPNSTs aNF-1 gene, a tumor suppressor gene located on chromosome 17q11.2. This gene encodes a protein known as neurofibromin, which is believed to be important in the control of cell growth through their downregulation of ras gene product. Despite the fact that the precise chromosomal location of NF-1 gene of chromosome 17 is known, neither the primary defect in NF-1 nor the mechanism leading to malignant transformation is understood at the present time. Menon et al., based on their study, had proposed that an MPNST may result from several genetic hits. The first hit, a mutation in one or both copies of NF-1 gene, may lead to the formation of a benign neurofibroma. Additional genetic hits leading to the loss of one or both copies of tumor suppressor gene (p53 gene) on chromosome 17p may be required for the subsequent malignant transformation of a benign tumor.[Association of MPNST with NF-1 is well established. Around 40% of the MPNST cases were found to be associated with neurofibromatosis, though agn tumor.The diagnosis of MPNST is considered to be the most difficult and elusive in the soft tissue disease due to lack of standardized criteria. The clinDiagnosis of MPNST by histopathologic analysis is often complicated by its resemblance to other spindle cell sarcomas like fibrosarcoma, malignant fibrous histiocytoma, leiomyosarcoma and monophasic synovial sarcoma. However, certain histological features which are characteristic of MPNST (summarized in 3MPNSTs are locally invasive lesions, frequently leading to multiple recurrences and eventual metastasic spread. This tumPrognosis of MPNST is poor and survival is found to be influenced by tumor location, size and association with NF-1. The presence of neurofibromatosis negatively affects many of the clinicopathological features of MPNST, and survival has been reported to be worse for patients with neurofibromatosis. In our cNF-I may be considered as a familial cancer predisposition syndrome and the patients with NF-I need to be assessed periodically to rule out any malignant change. Histopathologic appearance of the lesional tissue still remains the mainstay of diagnosing MPNST, and careful and extensive microscopic study of the lesion may often give a conclusive diagnosis.


The Family Smoking Prevention and Tobacco Control Act regulates the sales and marketing of tobacco products in the United States; poor adherence by tobacco retailers may reduce the effectiveness of the Act’s provisions. The objectives of this study were 1) to assess whether and to which provisions retailers were adherent and 2) to examine differences in adherence by county, retailer neighborhood, and retailer characteristics.We conducted multivariate analysis of tobacco retailers’ adherence to 12 point-of-sale provisions of the Tobacco Control Act in 3 North Carolina counties. We conducted observational audits of 324 retailers during 3 months in 2011 to assess adherence. We used logistic regression to assess associations between adherence to provisions and characteristics of each county, retailer neighborhood, and retailer.We found 15.7% of retailers did not adhere to at least 1 provision; 84.3% adhered to all provisions. The provisions most frequently violated were the ban on sales of cigarettes with modified-risk labels  (43 [13.3%] retailers nonadherent) and the ban on self-service for cigarettes and smokeless tobacco (6 [1.9%] retailers nonadherent). We found significant differences in rates of nonadherence by county and type of retailer. Pharmacies and drug stores were more than 3 times as likely as grocery stores to be nonadherent.Most tobacco retailers have implemented regulatory changes without enforcement by the US Food and Drug Administration. Monitoring rates of adherence by store type and locale  may help retailers comply with point-of-sale provisions. In 2009, the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) gave the US Food and Drug Administration (FDA) the power to regulate tobacco products, including the sales and marketing of cigarettes, smokeless tobacco products, and roll-your-own tobacco . The TobTobacco retailers may contribute to disparities in tobacco use by increasing the availability of tobacco products and the number of environmental cues to smoke . The denThese 12 new provisions include bans on certain types of tobacco products , restrictions on advertising and labeling , changes in sales practices , and restrictions on promotions .Only 2 studies have examined the adherence of retailers to the new Tobacco Control Act point-of-sale provisions ,17 or deWe used multivariate logistic regression to analyze data from observational audits of a random sample of 324 tobacco retailers in 3 North Carolina counties . We conducted the audits in September, October, and November 2011, before the introduction of advertising and labeling inspections by the FDA. The University of North Carolina at Chapel Hill (UNC–CH) Public Health–Nursing institutional review board determined that the study did not constitute human subjects research and thus did not require approval.Buncombe County is in Appalachia, Durham County is in the central part of the state in a racially and ethnically diverse urban area in which several universities are located, and New Hanover County is in an urban area on the Atlantic coast . We seleNorth Carolina is one of 12 states that do not license tobacco retailers , and thuWe developed an observational audit protocol that included measures of exterior and interior advertising and marketing similar to measures assessed in other studies –23; we aWe assessed adherence to the 12 point-of-sale provisions of the Tobacco Control Act that had been implemented at the time of the study. We categorized a retailer as adherent if the retailer met all of the following requirements (each corresponding to one of 12 provisions): 1) no sales of flavored cigarettes (excluding menthol); 2) no sales of cigarettes with such labels as “light,” “low tar,” “mild,” “ultra light,” and others ; 3) no self-service for cigarettes or smokeless tobacco; 4) no tobacco vending machines; 5) no sales of loose cigarettes; 6) no sales of smokeless tobacco in less than a full package; 7) no audio or 8) video advertisements that have sound effects, music, or color; 9) no gifts with purchase; 10) no availability of gift catalogs; 11) no sales of branded nontobacco products; and 12) no promotion of tobacco brand–name event sponsorship. We classified retailers that did not adhere to 1 or more provisions as nonadherent. When a retailer sold modified-risk–labeled cigarettes, auditors recorded the brand name of all such cigarettes.We assessed proximity of retailers to schools by using the retailer’s GPS position and county records of public K–12 school parcels. We created a dichotomous measure to code retailers as more than 1,000 feet from or within 1,000 feet of a school parcel boundary.We defined neighborhoods as census tracts . Using aFor the audit phase, we trained 2 or 3 master’s degree–level data collectors per county through a day-long didactic and hands-on session conducted in retailer locations  in a county not selected for the study. As part of a larger study on food, tobacco, and physical activity environments, 2 data collectors visited each retailer, but only one conducted the tobacco audit. We conducted all retailer audits electronically using data collection forms programmed in Pendragon  on an iPod touch . We regularly reviewed data, which were uploaded to a secure central database.2 tests and logistic regression. The regression analyses used robust standard errors, applied with Proc Surveylogistic  to account for the stratified sampling design, and controlled for retailer characteristics, retailer neighborhood characteristics, and county characteristics. We categorized warehouse clubs and supercenters as supermarkets and grocery stores because they were full-service grocery stores . We combined gas and convenience stores and other gas stations into 1 category. We found no news dealers or newsstands. Although we assessed neighborhood characteristics by census tract, almost 30% of census tracts had only 1 retailer; thus, our data were not hierarchical, and our analysis did not need to account for clustering of retailers by census tract. In multivariate analyses, we used the retailer type (supermarkets and grocery stores) and the county (Durham) that had the lowest rates of nonadherence as reference categories. We conducted all analyses using SAS version 9.2. To assess whether retailer and neighborhood characteristics were associated with retailer adherence, we used χOf the 333 retailers in the sample, 51.1% were gas and convenience stores, and 13.5% were convenience stores . We founThe 3 study counties were less rural than the state as a whole, and Durham County was more racially and ethnically diverse than the other 2 counties . RetaileAmong the 3 counties, 15.7% of retailers violated at least 1 point-of-sale provision . Of the No retailer type was significantly more likely to be nonadherent than our reference group, supermarkets or grocery stores (Model 1), even after factoring in retailer neighborhood characteristics (Model 2) . CertainRetailers in Buncombe County were 7.4 times as likely to be nonadherent as retailers in Durham County (Model 3). We found no difference in adherence between Durham County and New Hanover County retailers. After controlling for county characteristics, we found that retailer neighborhood demographics were no longer significantly associated with adherence but that pharmacies and drug stores were 3.4 times as likely as supermarkets or grocery stores to be nonadherent.This study is one of only 3 to examine adherence to Tobacco Control Act point-of-sale provisions 1 or 2 years after the provisions were enacted, and the first to report on all 12 point-of-sale provisions that were in effect in 2011. Our study found that 15.7% of tobacco retailers were nonadherent to point-of-sale provisions, whereas 2 previous studies found nonadherence rates below 10% ,17. Our After controlling for county differences, we did not observe disparities in adherence by retailer neighborhood characteristics such as percentage of families living below federal poverty guidelines, resident educational levels, percentage of black or Hispanic residents, or retailer proximity to a school. Other studies have found differential adherence by neighborhood characteristics to restrictions on access to minors  and on tAfter controlling for an array of neighborhood and county factors, however, we found that pharmacies and drug stores were significantly more likely to be nonadherent than any other retailer type. Tobacco products account for only 1.8% of total pharmacy sales , and 3.2Our study has several strengths. It demonstrated relatively strong adherence to Tobacco Control Act provisions before the FDA implemented formal compliance checks. Thus, this study provides baseline compliance data. We also examined more provisions than were examined in previous studies ,17. Our Our findings indicate that most tobacco retailers have implemented regulatory changes without substantial enforcement by the FDA. However, some patterns remain: high rates of nonadherence to the ban on sales of cigarettes labeled as modified risk, higher likelihood of nonadherence among pharmacies and drug stores than among other retailer types, and the potential for differential adherence by county. Encouragingly, we found little evidence of disparities in adherence to point-of-sale sales and marketing provisions of the Tobacco Control Act in racial/ethnic minority or low-income neighborhoods. As formal mechanisms for compliance checking go into effect, we anticipate that adherence will improve. We recommend monitoring for differential adherence across point-of-sale provisions, retailer types, and locales as a strategy to strengthen the ability and intention of retailers to adhere to Tobacco Control Act regulations.


Cochlear implant (CI) treatment was introduced to the world in the 1980s and has become a routine treatment for congenital or acquired severe-to-profound hearing loss. CI treatment requires access to a highly skilled team of ear, nose and throat specialists, audiologists and speech-language pathologists for evaluation, surgery and rehabilitation. In particular, children treated with CI are in need of long-term post-operative auditory training and other follow-up support.The study is retrospective with updated information on present performance.Since 2001, a total of 11 Greenlandic patients living in Greenland have been treated with CI, 7 children and 4 adults. Of these children, 4 use oral communication only and are full-time CI-users, 2 with full-time use of CI are still in progress with use of oral communication, and 1 has not acquired oral language yet, but has started auditory and speech training. Six children attend mainstream public school while one child is in kindergarten. Of the adults, only 1 has achieved good speech perception with full-time use of CI while 3 do not use the CI.From an epidemiological point of view, approximately 1–3 children below 6 years are in need of a CI every second year in Greenland often due to sequelae from meningitis, which may cause postinfectious deafness. Screening of new-borns for hearing has been started in Greenland establishing the basis for early diagnosis of congenital hearing impairment and subsequent intervention. The logistics and lack of availability of speech therapists in Greenland hampers possibilities for optimal language and speech therapy of CI patients in Greenland. This study aims at describing the results of CI treatment in Greenlanders and the outcome of the CI operations along with the auditory and speech/language outcomes. Finally, we present a suggestion for the future CI treatment and recommendations for an increased effort in the treatment and rehabilitation of implanted patients in Greenland. Persons with a profound hearing impairment, either congenital or acquired or pre- or post-lingual, in the remote Arctic areas are often left alone without much rehabilitation or support from the authorities. In Greenland, there used to be a school for the deaf but it has since been closed down. Since introduction in the 1980s, cochlear implantation (CI) has become a routine treatment option in patients with a severe-to-profound hearing impairment and limited benefit from conventional hearing aids. A CI consists of an electrode array implanted in the cochlea and connected to a receiver placed under the skin. The external microphone and sound processor transmit signals to the internal device providing electrical stimulation to the auditory nerve that is conveyed to the brain and perceived as sound. Thus, it has become possible to restore speech comprehension ability in postlingually deafened patients. Children with a congenital severe-to-profound hearing impairment are, with the use of CI, able to develop speech perception and spoken language skills comparable to normal hearing children when implanted early, preferably before 12 months of age . Also, CThe study is retrospective and covers the period between 2001 and 2011. The medical records have been scrutinised, and the districts where the patients live have been contacted for information on language, school attendance and the use of the CI.The first Greenlandic patient received a CI in 2001. During the 9 years, 7 children aged between 2 and 5 years and 4 adults aged between 42 and 50 years have had CI done. The gender distribution for the children was 3 girls and 4 boys and for the adults, 2 females and 2 males. Of the children, 2 had hearing impairment due to pneumococcal meningitis, 4 had non-specified congenital hearing loss and 1 was congenitally deaf due to genetically verified Connexin 26 related hearing impairment, 35delG mutation (GJB2). Of the adults, 3 were profoundly hearing impaired due to pneumococcal meningitis and 1 was impaired after treatment with aminoglycoside. Six of the 7 children were implanted bilaterally, 2 simultaneous and 4 sequential, while 3 of the 4 adults were implanted unilaterally. Nine patients were implanted with Nucleus CI24RE CA electrodes and 2 adult patients were implanted with split-electrodes due to ossification of the cochlea after pneumococcal meningitis. The 2 patients (aged 49 and 50 years) with cochlear ossification were implanted 4 months and 3.5 years after the meningitis episode, respectively, while the one (46 years-old) without ossification was implanted 5 months after the meningitis episode. The 2 children (aged 27 and 39 months) with hearing loss after pneumococcal meningitis were implanted 1.6 and 2.1 years after the infection, respectively. The median age of identification for the five congenitally hearing impaired children was 1.5 years (range 0.8–3.7) and the median age of implantation was 2.9 years (range 2.1–5.7 years). Four patients live in Nuuk, 3 in Tasiilaq, 1 in Ilulissat, 1 in Sisimiut, 1 in Nanortalik and 1 in Kangaatsiaq. Two patients experienced a post-operative infection and were treated with antibiotics. However, one of these patients needed the CI to be removed and a later reimplantation to control the infection.One patient suffered from post-implantation facial nerve stimulation and needed switch-off of the offending electrodes. Contact to the local districts in Greenland and one of the two speech language therapists in Greenland revealed that 4 children use oral communication mode and are full-time CI-users, 2 are full-time users of CI and are still in progress using oral communication and 1 has not developed spoken language as yet but has started auditory and speech training. One of the children is also psychomotorically retarded. Six children attend mainstream public school while 1 is in mainstream kindergarten. Of the adults, only 1 (deafened after exposure to gentamycin) has developed speech comprehension with full-time use of CI. The other 3 adults who were deafened after meningitis and who have additional alcohol problems do not use the CI and are left with lip-reading.It is expected that between 1 and 3 children are either born deaf or become deaf or attain profound hearing loss mainly after meningitis in Greenland every year. Most deafness in Greenland relates to infections such as meningitis, which is potentially preventable. CI is one of the major breakthroughs in the world of medicine. The technology offers the possibility to establish or re-establish hearing in otherwise totally deaf or profoundly hearing impaired persons. In the case of a severe-to-profound hearing impairment with only limited benefit of conventional hearing aids, CI enables speech comprehension and spoken language communication . Early iThis study demonstrates delayed identification of children with severe or profound congenital hearing impairment typical for a population without a neonatal hearing-screening programme . HoweverCI treatment is difficult to perform optimally in Greenland. CI treatment of severe or profoundly hearing impaired Greenlandic children can be performed successfully. Earlier intervention in both congenital and acquired profound hearing loss is needed. Skype or telemedicine could be a valuable tool in the rehabilitation process. Language barrier and social problems are obstacles. There is a need for systematic auditory and verbal rehabilitation. A yearly control and follow-up by a CI specialised speech-language pathologist is suggested. A program for rehabilitation of all Greenlandic CI patients is urgently needed.


LTBP2 have previously been shown to be the cause of primary congenital glaucoma (PCG) and other disorders that often manifest as secondary glaucoma.To assess for the first time the possible contribution of latent transforming growth factor (TGF)-beta binding protein 2 (LTBP2), an extracellular matrix (ECM) protein that associates with fibrillin-1-containing microfibrils, to the etiology of primary open angle glaucoma (POAG) and pseudoexfoliation (PEX) syndrome. Mutations in LTBP2 were sequenced in the DNA of 42 unrelated patients with POAG and 48 unrelated patients with PEX syndrome. Contribution of candidate variations to disease was assessed by screening in control individuals and use of biochemical, bioinformatics, and evolutionary criteria, and in one case by segregation analysis within the family of a proband with POAG. Microscopy was performed on the skin of a patient with PEX syndrome whose condition developed into PEX glaucoma during the course of the study and on the skin of her son previously identified with PCG who harbored the same LTBP2 mutation.All exons of LTBP2, five found in five patients with POAG and two found in two patients with PEX glaucoma syndrome may contribute to their diseases. One of the mutations was observed in a patient with POAG and in a patient with PEX glaucoma syndrome. Light, fluorescent, and electron microscopy showed that a mutation present in one of the individuals affected with PEX glaucoma syndrome and in her son affected with PCG causes disruptions in the ECM.Among the 30 sequence variations observed in LTBP2 sequence variations can contribute to the etiology of POAG and PEX glaucoma syndrome. It is not expected that in these diseases LTBP2 mutations behave in a strictly Mendelian fashion with complete penetrance. In conjunction with recent findings, the results suggest that anomalies in the ECM are among the factors that can contribute to POAG and PEX glaucoma syndrome. LTBP2 and other related ECM protein coding genes should be screened in larger cohorts with these diseases, which are common disorders and important to the public health.Some  LTBP2 (OMIM 602091), the gene encoding latent transforming growth factor (TGF)-beta binding protein 2, was identified in 2009 as a gene causing primary congenital glaucoma  [LTBP2 mutations can also cause megalocornea [277600) and promote Marfan syndrome  features [LTBP2 to primary open angle glaucoma  and pseudoexfoliation syndrome  is addressed in this study. LTBP2 on chromosome 14 encodes an extracellular matrix (ECM) protein that is a member of a superfamily composed of multiple fibrillin and LTBP proteins [locornea , microsplocornea , and WeiBP2 OMIM 02091, thproteins . LTBP2 iLTBP2 as a PCG causative gene, the authors considered the gene might also cause POAG [CYP1B1 have been observed in patients with POAG, and it was thought that other genes including LTBP2 may also have roles in the etiology of both diseases [LTBP2 often manifest secondary glaucoma.Glaucoma, the second leading cause of blindness, is a heterogeneous group of optic neuropathies that manifest by optic nerve head cupping or degeneration of the optic nerve, resulting in a specific pattern of visual field loss . Increasuse POAG ,2. A POAuse POAG . Cytogenuse POAG ,16. Furtuse POAG . In addidiseases -20. FinaLTBP2 mutations may be associated with this disease was also considered.Pseudoexfoliation (PEX) syndrome is a common disorder that usually affects elderly individuals . It is oLTBP2 in a cohort of 90 patients with POAG or PEX syndrome. To the best of our knowledge, this is the first time LTBP2 has been screened in patients with these disorders. Sequence variations were found in both types of patients, and the properties of the variations support the proposition that LTBP2 may have a role in the etiology of these diseases. Microscopic examination of skin fibroblasts of two patients with LTBP2 mutations showed notable disruption of the ECM. Our results emphasize that the ocular anomalies in some patients with POAG and PEX can be due to disruptions in the ECM.We performed mutation screening of This study was performed in accordance with the Declaration of Helsinki and with approval of the ethics board of the University of Tehran. All participants or their responsible guardians consented to participate after being informed of the nature of the research.MYOC and CYP1B1 as previously described, and only those without disease-associated mutations in these genes were screened for variations in LTBP2 [Forty-two and 48 Iranian individuals with POAG and PEX syndrome, respectively, were recruited from the Ophthalmology Department of Labbafinejad Medical Center  and Hazrat Rassoul Hospital . The patients did not report symptoms of other disorders at the time of recruitment, except one patient 211L) who reported a cardiac anomaly as described below. None of the 90 patients were related. As will be described, one of the patients with PEX syndrome was the mother of a patient with PCG examined in a previous study [11L who rin LTBP2 . After gPEX syndrome diagnosis was based on observation of PEX material on the anterior lens capsule and/or pupillary margin after mydriasis by slit lamp biomicroscopy . SecondaLTBP2 exons and flanking intronic sequences were amplified with PCR, and subsequently sequenced with the Sanger protocol [LTBP2 reference sequences used were NT_026437.12, NM_000428.2, and NP_000419.1. The effects of the variant sequences on splicing were predicted by using NNSPLICE 0.9, Human Splicing Finder V 2.4.1 and GENSCAN. Potential effects of all variations on splicing, including those that affected amino acid changes, were checked. To determine the extent of the conservation of amino acids altered due to nucleotide variations, the amino acid sequences of homologous proteins from other species were aligned using the ClustalW2 software. Variations deemed to contribute to disease status were assessed in control individuals with allele-specific PCR protocols or restriction fragment length polymorphism analysis. The number of control individuals screened differed for the different variations and ranged from 200 to 400 , Santa Cruz Biotechnology, Inc., Santa Cruz, CA) or rabbit polyclonal antibody against human fibrillin-1 . Negative controls were not incubated with primary antibody. The sections were subsequently incubated with fluorescent conjugated secondary antibodies (Santa Cruz Biotechnology). Nuclei in the same sections were counterstained with 4’, 6-diamidino-2-phenylindole . Finally, samples were processed for electron microscopy, and 60 nm sections were visualized with a Zeiss EM900 transmission electron microscope .To assess the effect of an LTBP2 sequence variations were observed in the 90 individuals screened (Appendix 2). Nineteen are previously reported variations, and 11 are novel variations. The allele frequency of 18 of the non-novel variations as reported in the Single Nucleotide Polymorphism Database (dbSNP) ranged from 0.012 to 0.405. The dbSNP data incorporates data derived from the 1000 Genomes Project. Six of the novel variations were observed in controls, created synonymous codons, were not highly conserved during evolution, and/or were intronic variations predicted not to affect splicing. We opted for a conservative approach and considered that these 24 variations did not contribute to disease status; clearly, variations reported in databases and variations observed in controls may predispose individuals to disease, particularly common and late onset diseases such as POAG and PEX syndrome. A previously identified PCG causative mutation and five novel variations were considered reasonable candidates for being variations or risk factors contributing to POAG and/or PEX. All but one were observed in the heterozygous state. Considerations including position of the affected amino acid within the protein, the biochemical nature of the amino acid change, the bioinformatics prediction of the effect of the change, the extent of the evolutionary conservation, and absence in controls were taken into account in making this assessment  or POAG , one can easily consider a plausible cellular and molecular basis for association between LTBP2 and the glaucoma phenotype. LTBP2 is an extracellular matrix microfibril protein, and defects in the ECM of the trabecular meshwork may affect facility of aqueous fluid outflow resulting in increased IOP [LTBP2 mutations for regulating TGF-β signaling may also be relevant to the etiology of glaucoma. Five putative disease-contributing or risk factor mutations in LTBP2 were observed among 42 patients with POAG without CYP1B1 and MYOC mutations. Although the size of the cohort screened was small, the frequency of the observed LTBP2 mutations compares well with that of other known genes causing POAG [ADAMTS10 was recently reported as a POAG causative gene in a canine model of the disease [LTBP2 are implicated in the disease’s etiology. ECM abnormalities have also previously been suggested to affect IOP elevation in glaucoma [Mutations in glaucoma -5. Contrased IOP . This noing POAG ,27. Rele disease . ADAMTS1 disease . Both pr disease . POAG raglaucoma -33.LTBP2 and FBN1 were identified as upregulated genes in anterior segment eye tissues of individuals with PEX [LOXL1 encoding lysyl oxidase-like 1 and PEX syndrome has been reported, although the PEX-associated variants in LOXL1 exhibit low penetrance [LTBP2 mutations in patients with PEX. One mutation affected p.Pro432Leu and was observed in a patient with PEXG. The fact that it was also observed in a patient with glaucoma argues in favor of its pathogenicity. The second mutation caused p.Tyr1792fsX55 and was observed in a patient with PEXG; the same mutation in the homozygous state caused PCG in other family members. It was absent in 400 control individuals over the age of 60 without eye disorders. Penetrance of the p.Tyr1792fsX55-causing mutation regarding PEX is apparently incomplete because the father of the family who harbored the same mutation was diagnosed normal; he is now deceased. Histological analysis showed that the p.Tyr1792fsX55-causing mutation disrupted the ECM and microfibril structures, and that the disruptions were more severe in homozygous carriers of the mutation. Histological analysis in a patient with WMS who harbored a different mutation in LTBP2 also showed disruption of the ECM and microfibril structures. These findings further support the contention that LTBP2 mutations may contribute to various disorders with ocular manifestations by affecting the extracellular matrix.PEX syndrome is a fibrillinopathy that can present with numerous clinical complications . Ocular with PEX . The rolwith PEX . Variablwith PEX . Associanetrance -38. Lysynetrance . Here, wLTBP2. A notable observation is that the mutation affecting p.Pro432Leu was observed in individuals with POAG and PEXG. The data presented here suggest that the penetrance of most observed LTBP2 mutations is incomplete as disease in the patients usually appeared sporadically. This is consistent with the common classification of POAG and PEX syndrome as complex disorders. As both diseases are multifactorial, factors in addition to the LTBP2 sequence variations affected disease status in the individuals harboring the mutation. Phenotypic presentations in individuals of the Roma/Gypsy population who harbored homozygous mutations causing p.Arg299X in LTBP2 were reported to range from PCG with trabecular meshwork dysgenesis to Marfan syndrome-like zonular disease and late onset angle closure glaucoma [LTBP2 mutations are likely to result in a more severe phenotype; homozygous mutations were reported to cause PCG and WMS, which are early onset diseases with more severe clinical manifestations than POAG and PEX syndrome, which are late onset diseases [FBN1 mutations is also evident. As stated, mutations in FBN1 can cause simple ectopia lentis, MFS, WMS as well as other related disorders [LTBP2 and FBN1 may be due to environmental, epigenetic, or stochastic events. More interesting, it is also likely that there are epistatic relationships between genes coding various components of the ECM. An intriguing possibility is that some ECM-related proteins may be able to compensate one another’s functions to different degrees.There is variability in phenotypic consequences of mutations in glaucoma . In anotdiseases ,2. Notabisorders . The mutisorders  and ShprLTBP2 mutations may cause or be risk factors for POAG and PEX. The findings emphasize the importance of the extracellular matrix to biologic functions affected in these disorders. POAG and PEX syndrome are common disorders important to public health issues of most populations. It is of paramount importance that larger patient cohorts with these diseases be screened for mutations in LTBP2 and other related ECM protein coding genes to better quantify their contributions to the diseases.In conclusion, we report that


Histological staining of reactive stroma has been shown to be a predictor of biochemical recurrence in prostate cancer, however, molecular markers of the stromal response to prostate cancer have not yet been fully delineated. The objective of this study was to determine whether or not the stromal biomarkers detected with a thioredoxin-targeted nanodevice could be used to distinguish the stroma associated with benign prostatic hyperplasia from that associated with PCA. In this regard, we recently demonstrated that a thioredoxin-targeted nanodevice selectively binds to reactive stroma in frozen prostate tumor tissue sections. To accomplish this, random frozen prostate tissue sections from each of 35 patients who underwent resection were incubated with the nanodevice and graded for fluorescent intensity. An adjacent section from each case was stained with Hematoxylin & Eosin to confirm the diagnosis. Select cases were stained with Masson's Trichrome or immunohistochemically using antibodies to thioredoxin reductase 1, thioredoxin reductase 2 or peroxiredoxin 1. Our results demonstrate that the graded intensity of nanodevice binding to the stroma associated with PCA was significantly higher (p = 0.0127) than that of benign prostatic hyperplasia using the t-test. Immunohistochemical staining of adjacent sections in representative cases showed that none of the two commonly studied thioredoxin interacting protein partners mirrored the fluorescence pattern seen with the nanodevice. However, thioredoxin reductase 2 protein was clearly shown to be a biomarker of prostate cancer-associated reactive stroma whose presence distinguishes the stroma associated with benign prostatic hyperplasia from that associated with prostate cancer. We conclude that the signal detected by the nanodevice, in contrast to individual targets detected with antibodies used in this study, originates from multiple thioredoxin interacting protein partners that distinguish the M2 neutrophil and macrophage associated inflammatory response in prostate cancer-associated stroma from the CD4+ T-Lymphocyte linked inflammation in benign prostatic hyperplasia. Thioredoxin, a small redox protein, could be involved in the stromal response to this exposure. Thioredoxin expression appears to be a link between oxidative stress and inflammation in that it is a chemoattractant for neutrophils, monocytes and T-cells 2O2 and NO in particular (e.g. thioredoxin reductase 1 (TXNRD1), thioredoxin reductase 2 (TXNRD2) Since taking the measure of the possible up-regulation of the full spectrum of thioredoxin interacting protein partners with immunochemistry using antibodies to known proteins would be both difficult and time consuming, in this report we sought to distinguish between these two forms of inflammation by using nanodevice-borne bacterial thioredoxin ligands Frozen prostate tissue specimens from 35 patients, who underwent surgical resection for prostate cancer at the City of Hope, were obtained as discard tissue under a City of Hope Institutional Review Board (IRB) approved protocol. Written informed consent was obtained from all participants before inclusion in this study. Cases were staged according to the TNM staging of prostate cancer and tumors were graded on the Gleason's scale as standard clinical care prior to release for experimentation. Mouse monoclonal antibodies to thioredoxin reductase 1, TXNRD1 , TXNRD2  and PRDX1 antibody  were obtained from Sigma-Aldrich  or Abcam , respectively. Avidin-biotin-peroxidase complex (ABC), biotinylated horse antimouse immunoglobulins and normal horse serum were purchased from Vector Laboratories, Inc. .Unmodified phosphoramidite monomers, with either standard or mild protecting groups, along with DNA solid supports and other reagents were purchased from Sigma-Proligo  and Applied Biosystems, . TMP-FdU-CE Phosphoramidite for 5-5 fluoro-deoxycytosine insertion was from  as was 5′-Fluorescein-dT Phosphoramidite used to fluorescently label DNA.All other reagents used were of the highest purity available from various commecial sources .Sets of adjacent sections were obtained from each patient specimen. Adjacent frozen sections (5 µm-thick) from resected prostate specimens were stained with Hematoxylin and Eosin (H&E) to determine whether or not prostate cancer was present in the adjacent section set or not. Although each patient in this study showed evidence of prostate cancer as determined by post surgical pathology, seventeen section sets lacked any evidence of prostate cancer, with Benign Prostatic Hyperplasia the only demonstrable pathological feature. Eighteen section sets contained prostate cancer. In those sets the region containing prostate cancer, identified in H&E stained slide, was marked by the pathologist, who was in turn blinded to the fluorescence study. Adjacent sections from selected specimens were stained with Masson's Trichrome to identify reactive stromal regions 3) is a self-assembled molecular device, which targets thioredoxin-binding proteins. It consists of a DNA scaffold, which displays three copies of the thioredoxin redox protein for targeting, and a fluorescein label used for detection in fluorescence microscopy  of PCA or BPH tissue specimens were subjected to immunostaining. Briefly, sections were fixed in cold acetone for 10 minutes to air dry then blocked with Protein Block from DAKO, Inc. Carpinteria, CA. Slides were then incubated with primary antibody at room temperature at the following concentrations and times respectively: Anti-TXNRD2 (2 µg/ml) overnight, Anti-TXNRD1 (0.4 µg/ml) overnight, Anti-Peroxiredoxin 1 (2.5 µg/ml) 30 minutes. Each slide was subsequently washed in DAKO Buffer and incubated in secondary antibody  for 30 minutes at room temp. After washes in DAKO buffer, slides were incubated with the chromogen diaminobenzidine tetrahydrochloride (DAB), counterstained with hematoxylin, and mounted. Adjacent sections were also stained with Hematoxylin and Eosin or Masson's Trichrome by standard techniques.Tiled images photographed at 100× magnification were created from each of three slides: one stained with H&E, one with Trichrome and one immunostained with TXNRD1, TXNRD2, and peroxirdoxin as previously described Differences in binding levels were tested between BPH and PCA using the t-test. We first tested for variance heterogeneity and concluded that the pooled variance test was appropriate. The test for unequal variance was not rejected at 0.05 (p>0.8 with the Brown-Forsythe test).Staining of adjacent serial sections of tissue specimens of PCA or BPH with H&E allowed visualization of many details of cellular components . Each ca3) was found to bind, as indicated by the intensity of fluorescence activity, to the regions of stroma, which were located adjacent to tumor lesions. In 11 of 18 cases of PCA, the intensity of ND-Trx3 binding was scored greater than 1. Regions that exhibited binding activity with the nanodevice (The nanodevice (ND-TrxA sufficient number of unstained consecutive tissue sections were available for immunohistochemical analysis, in five cases where PCA was present in the sections obtained and in five cases where only BPH was present in the sections obtained. These sections were stained with antibodies to TXNRD1, TXNRD2 or PRDX1 to determine if any of them mirrored the fluorescence signal obtained with the nanodevice. The anti TXNDR1 or PRDX1 antibody showed strong reactivity with the tumor cells .In contrast, anti-TXNRD2 antibody exhibited little or no staining of the tumor cells .The strong correlation between fluorescence associated with thioredoxin interacting protein partners in PCA adjacent stroma is quantified by the data given in Although inflammation appears to play a crucial role in both PCA 2O2 to H2O Since thioredoxin expression appears to be a link between ROS and RNS stress due to its ability to act as a chemoattractant for neutrophils, monocytes and T-cells The data presented in As noted in results, the intensity of nanodevice binding to the stroma is weakly associated with a number of patient parameters given in Our data suggests that nanotechnology can be used for the discovery of new biomarkers of reactive stroma in prostate cancer. In addition, the nanodevice has the advantage of binding to a broad range of thioredoxin interacting protein partners, which distinguish PCA associated stroma from that associated with benign tissue regions based on the inflammatory response and may not be seen using antibodies against any specific thioredoxin binding protein expressed in the stroma. Although the subjective qualitative analysis of the nanodevice binding may introduce bias, the data obtained in this study are significant even for the small sample size reported here. Despite this limitation, the statistical analysis of the data, coupled with the detection of the reactive stroma using Masson's Trichrome stain and the expression levels of the thioredoxin reductases support the hypothesis that thioredoxin and its thioredoxin interacting protein partners play an important role in prostate cancer.The data presented here also clearly demonstrated that the thioredoxin-targeted nanodevice can be used in a functional assay to identify reactive stroma in prostate cancer, providing strong support for the hypothesis that an ROS and/or RNS producing inflammatory response is associated with PCA and distinct from BPH. In addition, these results suggest that reactive stroma may be an effective target for prostate cancer therapeutics.


We have previously identified in a study of both self-reported body mass index (BMI) and clinically measured BMI that the sensitivity score in the obese category has declined over a 10-year period. It is known that self-reported weight is significantly lower that measured weight and that self-reported height is significantly higher than measured height. The purpose of this study is to establish if self-reported height bias or weight bias, or both, is responsible for the declining sensitivity in the obese category between self-reported and clinically measured BMI.2), overweight (25–<30 kg/m2) and obese (≥30 kg/m2).We report on self-reported and clinically measured height and weight from three waves of the Surveys of Lifestyle Attitudes and Nutrition (SLÁN) involving a nationally representative sample of Irish adults. Data were available from 66 men and 142 women in 1998, 147 men and 184 women in 2002 and 909 men and 1128 women in 2007. Respondents were classified into BMI categories normal (<25 kg/mSelf-reported height bias has remained stable over time regardless of gender, age or clinical BMI category. Self-reported weight bias increases over time for both genders and in all age groups. The increased weight bias is most notable in the obese category.BMI underestimation is increasing across time. Knowledge that the widening gap between self-reported BMI and measured BMI is attributable to an increased weight bias brings us one step closer to accurately estimating true obesity levels in the population using self-reported data. We have previously identified in a study of both self-report body mass index (BMI) and clinically measured BMI that the underreporting of BMI has significantly increased across time. We also reported a decrease in the sensitivity score in the overweight and obese category over time, more significantly in the obese category (80%→64%→53%) in this 10-year period from 1998 to 2007 A plethora of literature exists on the validity of self-reported weight and height with the general conclusion that overweight and obesity, as determined from body mass index (BMI) categories, are generally underestimated when calculated from self-reported data compared to measured data Two recent studies have examined the bias in self-reported and measured BMI across time in the USA , Canada  and Australia  It is our belief that height bias is constant and that weight bias is increasing. We hypothesise that the decrease in the sensitivity of the obese category over time in our recent study SLÁN 1998 and SLÁN 2002 were approved by the Faculty of Public Health Medicine, Royal College of Physicians of Ireland and SLÁN 2007 was approved by the Research Ethics Committee of the Royal College of Surgeons of Ireland.The Survey of Lifestyle Attitudes and Nutrition (SLÁN) was first conducted in 1998 The data used in this analysis were obtained from physical examination subsamples from three national health and lifestyle surveys in Ireland. In SLÁN 1998 and SLÁN 2002, the self-reported and measured height and weight data were obtained from an out of sample, 10% equivalent of the main postal survey, . This approach was taken for a variety of logistical reasons, including the fact that a) interviewers were not visiting the respondents at home and b) a random subgroup examination at home would be difficult to achieve on a cross-country basis. Research nurses were in attendance for all screening clinics and the examinations were undertaken using the standard European Health Risk Monitoring protocol. In 1998, 16 additional district electoral divisions, 8 on the Western seaboard and 8 on the Eastern seaboard of Ireland were randomly selected for the examination study. The required number of participants was set for each DED location based on its population size, and a target of 1359 participants in total was set. Potential respondents in these selected DEDs received a letter of invitation to attend a designated clinic for examination and to bring with them the completed self-administered questionnaire. In the event 586 were seen, 43.1% of the original targeted number. However, if we assume 10% non availability, as was a minimum established through return to sender in the main surveys, the minimum corrected response rate is 47.9%. If we also assume 40.78% non availability, as was the case in 2002, the response rate would be 72.79%.In 2002 an additional separate sample was randomly selected for the examination component and this was undertaken in 13 district electoral divisions, 7 urban and 6 rural. The reasons for non-response were recorded, in that if the person receiving the letter did not reply by either refusing to participate or agreeing to an appointment, a visit was made to the household and the outcome of that visit was coded. Of 1118 dispatched letters, 411 examinations were achieved. Just 258 (23.01%) refused outright the invitation giving an uncorrected response rate of 30%, but when combined non-contactables  are removed, the response rate was 50.3%. A further comparison of these out of sample respondents with the main surveys indicated no significant difference in key variables such as age, level of secondary educational attainment and smoking status. In all four datasets males were under-represented, significantly so in 1998.SLÁN 2007 consisted of a probabilistic sample in three stages – geographic area, household and ‘next birthday’ participant selection within households. The sample frame was the Geodirectory, a listing of all residential address in Ireland compiled by the postal service. Face-to-face interviews were conducted with adults aged 18 years and over interviewed at home addresses (response rate of 62%). All participants were asked to self-report their weight without clothes and their height without shoes. Examination data were obtained on an approximate 20% subsample, n = 2174. Respondents provided self-reported data at interview before they were asked to agree to have their height and weight measured. Weight and height were measured in light clothing without shoes. Weight was measured to the nearest 0.1 kg using electronic platform scales. Height was measured to the nearest 0.1 cm using height measurement rods. Data were missing, we assume at random, for some measured weight, measured height, self-reported weight and self-reported height variables in each of the SLÁN surveys leading to 208 , 331 (M 147 F 184) and 2037 (M 909 F 1128) complete cases for comparison respectively in 1998, 2002 and 2007.Self-report height (weight) bias was calculated by subtracting the clinically measured height (weight) from the self-reported value height (weight). Graphical views  of the height and weight reporting biases for both males and females, across age subgroups and true BMI subgroup, displayed much evidence of non-Gaussian, asymmetrical long-tailed distributions. The Shapiro test for Gaussian distributed data was applied to the reporting biases and was rejected (p<0.05) in over 60% of these subgroups. To account for this, bootstrap 70%, 90%, 95% and 99% confidence intervals for the mean height and weight biases were calculated for each subgroup and are displayed in Self-reported height bias was calculated and male and female subjects were categorised according to their clinically measured BMI category . The selIt is well known that older adults, particularly females, overestimate their height The 95% confidence intervals for the self-reported weight bias for each clinically measured BMI category are shown in The 95% confidence intervals for the self-reported weight bias for each age group taken individually are shown in As the use of self-reported data to classify obesity continues, the sources of the reporting errors remain unclear. These data from three nationally representative population surveys show that self-reported height bias is stable over time regardless of gender, age or clinically measured BMI category. Self-reported weight bias is continuing to increase regardless of gender or age or knowledge that weight would be measured after self-reporting. These data further show that when classified by clinical BMI measurement, across time, the increase in self-reported weight bias is evidenced only in the obese category for males and the obese and overweight categories for females.A focused search of the BMI literature revealed only one study which focused on height and weight across time Our recent finding, using three population surveys from Ireland with both clinically measured and self-reported BMI A recent 2011 study based their study objectives on the assumption that social norms regarding what constitutes an ideal body weight also affect individuals’ self-reporting decisions when answering anthropometric questions on health questionnaires As in existing literature, we identified that female height reporting bias is not consistent across all age groups and that older women tend to overestimate their height more than younger women The underestimation of weight in the normal category is consistent across time. A recent British study identified a decline in the sensitivity of self-diagnosis of overweight both height and weight. Nevertheless, if we focus on the improvement in BMI categorisations, as outlined by Stommel and Osier, what is calculated is the sensitivity of six BMI categories, underweight <18.5 kg m−2, normal weight 18.5<25 kg m−2, overweight 25<30 kg m−2, obese I 30<35 kg m−2, obese II 35<40 kg m−2 and obese III 40+ kg m−2. The sensitivity of the underweight, normal weight and overweight categories remains the same between the two time points. Improvements in the sensitivity of the obese categories are evident, and this improvement is greatest for those in obese category III, or >40 kg m−2 (54.4%→71.7%). We would argue that these patients are most likely engaged with the health service given their extremely high BMI, and their height and weight are therefore monitored regularly. Consequently, they will know their height and weight and this will result in a smaller self-report BMI bias. This is likely the source of the improvement in BMI categorisation, rather than a population wide improvement in self-reported height and weight. There are some limitations to our own findings, all three are relatively small samples and the two older surveys have modest response rates. Nonetheless we have established that in socio-demographic terms all three surveys are reasonably representative of the main datasets and all three surveys used a clustered random selection strategy countrywide, using standardised measurement protocols.The recent paper by Stommel and Osier The findings in this study question other work that both self-reported height bias and self-reported weight bias contribute equally to BMI underestimation in large population surveys. Our results add significantly to the existing literature. Our findings also give considerable cause for concern – where accuracy is of prime importance, i.e. the obese category, self-reported weight biases are increasing. The magnitude of this increase should be monitored closely in the next round of the SLÁN surveys on a sample size similar to SLÁN 2007.Sixty four percent of Irish adults are measured as overweight or obese While self-reported weight bias is consistent across age group and gender, identifying that this bias is greatest in the obese category and is increasing across time has important implications for future studies. Providing accurate estimates of actual height from self-reported height, and actual weight from self-reported weight should first be undertaken before attempting to estimate actual BMI from self-reported BMI. Accurate monitoring of height and weight are important in the diagnosis, prevention and reduction of overweight and obesity. The implications for future studies are clear, in large population surveys, project investigators should at a minimum obtain clinical measurements from a subsample of participants to monitor underestimation and overestimation trends.The results must be cautiously interpreted, in this analysis. We accept that numbers are small in both 1998 and 2002 sweeps for the out of sample component with a modest response rate, limiting both precision and generalisability, though non systematic factors such as logistics in attendance may be more at play here, rather than outright bias. The respondents are not self-selected, as stated in a recent publication Data collection methods were not identical in the three surveys. SLÁN 1998 and SLÁN 2002 represent out of sample groups while the SLÁN 2007 groups are a subsample of the main survey. We have taken the confirmatory strategy of going back to the original datasets in order to compare the demographic profile of the examined respondents in both SLÁN 1998 and SLÁN 2002 with the main sample for age, sex, education, smoking status and both self-reported and examined body mass index. This shows that these out of sample respondents are reasonably comparable with the respondents in the main datasets. No significant age differences were seen between self-reported and examination data participants at either time-point, or no significant differences in smoking rates. In all four datasets more women than men participated, lowest in the 1998 examination data, with significantly fewer male participants in the examination survey in 1998. Self-reported BMI was significantly higher in examined participants at both time points but that may be explained by self-selection and does not alter the overall premise of the results.While the response rates were 62%, 53% and 62% respectively for the three SLÁN surveys, information on the differences between responders and non-responders is not available for evaluating the potential bias due to non-response.Obesity is a public health and policy problem because of its prevalence, costs and health effects. The findings in this study are significant for shaping future public policy around overweight and obesity awareness. We question other reported work that both an overestimation of self-reported height and an underestimation of self-reported weight contribute equally to an underestimation of BMI. Our findings suggest that self-report weight bias contributes in the main to the increasing underestimation of BMI. Coupled with rising obesity levels