Genetic information is faithfully copied by DNA replication through many rounds of cell division. In mammals, DNA is replicated in Mb-sized chromosomal units called “replication domains.” While genome-wide maps in multiple cell types and disease states have uncovered both dynamic and static properties of replication domains, we are still in the process of understanding the mechanisms that give rise to these properties. A better understanding of the molecular basis of replication domain regulation will bring new insights into chromosome structure and function. In mammals, many potential replication origins are distributed throughout the genome. Replication forks from selectively activated origins proceed at approximately 1–2 Kb/min, which enables mammalian genomes to be replicated in an 8–10 h S phase. If each mammalian chromosome consisted of only a single replication origin like the bacterial genome, it would take nearly a month to complete duplication of the entire chromosome. Early pioneering work that directly visualized DNA replication on DNA fibers revealed the multi-replicon structure of the mammalian genome  Figure A. TemporOver the last decade, several methods have been developed to map replication domain structure at the genome-wide level in various human and mouse cell types. David Gilbert and colleagues devised a method in which BrdU-labeled replicating DNA is immunoprecipiated from FACS-sorted early and late S phase cells and the quantitative ratio between them (early vs. late) at each chromosomal segment is determined genome-wide using microarrays or next-generation sequencing (NGS) technologies ,20 FiguC. The reIn mammals, many potential origins are distributed throughout the genome. Genome-wide short nascent strand mapping in embryonic stem (ES) cell populations revealed that origin density is 25–40 origins/Mb . HoweverDespite stochastic activation, origins are often grouped in specific regions, contributing to preferred initiation zones within individual CTRs B. The poSeveral factors such as chromatin structure and specific DNA sequences that form G-quadruplexes are thought to regulate origin firing ,31,32. IIgh locus (~3 Mb) of non-B cells [Igh locus resulted in poor firing efficiency. Currently the mechanism behind this phenomenon remains largely unclear, except that the insertion of an active transcription unit that brings about several euchromatic histone modifications is not sufficient to induce origin firing in the Igh TTR. The extent to which findings from the Igh TTR can be applied to others is also unclear. These observations, however, do not necessarily require that a single replication fork moves unidirectionally across several hundred Kb from early to late domains  have shown that spatial separation of differentially labeled foci in the nucleus requires an approximately 60 min chase period that is species independent ,45,46,47What is the cause of this discrepancy? It is possible that the 60 min interval only reflects the time required to resolve newly replicated regions in the nucleus at the level of conventional light microscopy, and does not reflect activation of neighboring replication units in most cases. Recent studies using super-resolution light microscopy provided us a totally different view of replication foci that are greater in number and smaller in size. Although super-resolution light microscopy has not yet been applied to pulse-chase-pulse experiments, it is likely that the 60 min rule will be revised by the application of this new technology ,49,50,51DNA fiber experiments provide some clues to resolve this discrepancy. Clustered initiation sites spaced at ~150 Kb are often observed at chromosomal regions replicated at the onset of S phase . In thesChromatin conformation capture methods such as Hi-C quantify long-range chromatin interactions and are used to analyze the 3D chromatin organization not only at the level of local interactions between promoters and enhancers but also at the level of higher-order chromatin folding . PrincipCell cycle dependent establishment of chromatin interactions coincides with the establishment of replication timing at the TDP ,55,56, sAn important but unanswered question is whether replication domain reorganization precedes or follows A/B compartment switching during cell differentiation. Analysis of replication domain organization and chromatin interactions at multiple intermediate differentiation stages would provide a definitive answer as to which is the upstream event.Igf2 imprinted region, coordination of asynchronous replication  generally occurs over several hundred Kb. However, in a small population (~10%) of cells, this coordination is not observed [Existing methodologies to analyze replication domain structure provide either a single-cell resolution view at a handful of chromosomal regions or a genome-wide average view of thousands of cells. The extent of cell-to-cell variability in replication domain organization is thus largely unknown. As different types of chromatin are assembled in different stages of S phase , fluctuaobserved . This maulation ~% of cellobserved ,64. Convobserved .It is increasingly recognized that during ontogenesis, developmental gene expression programs are often established on the basis of Mb-sized, multi-genic chromosome units ,67. Rece


The recent surge in commercially available wearable technology has allowed real-time self-monitoring of behavior  and physiology . However, there is limited neuroimaging work  to identify how people’s brains respond to receiving this personalized health feedback and how this impacts subsequent behavior.Identify regions of the brain activated and examine associations between activation and behavior.This was a pilot study to assess physical activity, sedentary time, and glucose levels over 14 days in 33 adults (aged 30 to 60 years). Extracted accelerometry, inclinometry, and interstitial glucose data informed the construction of personalized feedback messages . These messages were subsequently presented visually to participants during fMRI. Participant physical activity levels and sedentary time were assessed again for 8 days following exposure to this personalized feedback.P<.001). Reductions in mean sedentary time  were observed. Activation in the subgyral area had a moderate correlation with minutes of moderate-to-vigorous physical activity .Independent tests identified significant activations within the prefrontal cortex in response to glucose feedback compared with behavioral feedback (Presenting personalized glucose feedback resulted in significantly more brain activation when compared with behavior. Participants reduced time spent sedentary at follow-up. Research on deploying behavioral and physiological feedback warrants further investigation. Physical inactivity, insufficient levels of physical activity, is attributable to 9% of premature mortality and 7% of type 2 diabetes cases . In addiOver the last decade, wearable activity monitors have grown in popularity in consumer markets to help users physically track their movement behaviors  ,7. Over Neuroimaging techniques are useful to recognize and identify the intricate relationships between cognitions, brain functions, and behavior . There hfMRI can improve our understanding of how cognitive processes vary between those who do change their behavior following exposure to a stimulus and those who do not subsequently change . The mPFA total of 33 participants  were recruited from a university in the United Kingdom via advertisement posters and email. Participants were aged 30 to 60 years, had no mobility-related musculoskeletal problems, had no confirmed diagnosis of diabetes, were willing and able to comply with the study protocol, met standard fMRI safety criteria , and were right-handed. All participants completed a physical activity readiness questionnaire  prior toEach participant’s consent was obtained according to the Declaration of Helsinki, and all experimental procedures were approved by the Loughborough University Ethics Advisory Committee (R15-P142).Data were collected between June and September 2016. The study design is presented in 2). Glucose and hemoglobin A1c (HbA1c) were analyzed using a Cholestech LDX system and Afinion AS100 Analyzer (both Alere Inc), respectively. Participants arrived fasted for ≥8 hours prior to the collection of a capillary blood sample.Weight and body fat percentage were measured using the MC 780 MA scale (Tanita) following the removal of shoes and socks. Body mass index was calculated as weight (kg) divided by height (m) squared (weight/heightAn ActiGraph wGT3x-BT accelerometer (ActiGraph LLC) was worn on a waistband (on the right anterior axillary line) to objectively measure physical activity. Participants were asked to wear the validated device  during wA Lumo (Lumo Bodytech Inc) posture sensor was worn on a waistband  in contact with the skin to measure sedentary behavior  during baseline and follow-up. Devices were calibrated to the wearer. Participants were asked to wear the device only during waking hours, remove it for any water-based activities , and place the device on charge overnight each day. The Lumo has been found to produce valid measurements of sedentary behavior compared with the ActivPAL (PAL Technologies Ltd), with a mean error of 9.5% . Data frThe Freestyle Libre flash glucose monitor (Abbott Laboratories) measures interstitial glucose levels via a minimally invasive 5 mm flexible filament inserted into the posterior upper arm. The sensor works based on the glucose-oxidase process by measuring an electrical current proportional to the concentration of glucose. Tegaderm transparent film dressing  was applied on top of the sensor to maintain its position. Participants were informed not to remove the sensor and to scan at least once every 7 hours (a conservative decision as the manufacturer states 8 hours to avoid data loss). As a result, participants were able to see their real-time glucose levels during baseline wear. An indication of how many times participants viewed this information (level of exposure) was identified by the number of time they scanned. Missing data were obtained because of a fault (sensor lasted <14 days) or the participant failed to scan at least once every 8 hours. The Freestyle Libre has been previously validated against venous sampling with an overall mean absolute relative difference of 11.4% with consistent accuracy throughout the 14 days . GlucoseTwenty personalized feedback messages were created for the purposes of this study and covered 4 topics: MVPA, light physical activity, sedentary behavior, and glucose levels  using a 32-channel head coil at the National Centre for Sport and Exercise Medicine, Loughborough University, United Kingdom. Structural images (T1-weighted) were acquired using a fast spoiled gradient echo (FSPGR) Bravo sequence . One functional scan lasting 16 minutes (480 volumes) was acquired during the task . Stimulus presentation and synchronization to scanner acquisition were performed using Presentation version 18.1 .PFWE. At the first level for each participant, contrasts were computed using a series of univariate analyses of covariance (ANCOVAs), averaging activity across the topics compared with baseline: (1) MVPA>baseline, (2) light physical activity>baseline, (3) sedentary>baseline, (4) glucose>baseline, and (5) behavior>baseline. Additional contrasts were computed using a series of univariate ANCOVAs, averaging activity between the different blocks of stimuli  and reverse contrasts also computed .Functional data were preprocessed and analyzed using statistical parametric mapping . All data reported are from scans that exhibited ≤3 mm in translational movement. Data were processed using a standard statistical parametric mapping approach, which consisted of scan realignment, coregistration, segmentation, normalization, and smoothing. Data were spatially aligned to the first functional image using 4th degree B-spline interpolation. Scans were then coregistered . Functional images were normalized into the Montreal Neurological Institute (MNI) standard stereotactic space with parameters applied to all functional images. A final smoothing step with a Gaussian Kernel with full width half maximum of 8 mm was applied to improve signal-to-noise ratio. The onsets and durations of each of the conditions of interest were modeled according to the block design described in the protocol. For each participant, brain activation was estimated using a general linear model (GLM) and included movement parameters  and a session constant as regressors. All regressors were convolved with SPM12’s canonical difference of the hemodynamic response function. Data were high-pass filtered with a cut off of 128 seconds to remove low-frequency noise and slow drifts in the signal. Family-wise error (FWE) correction was used to correct for multiple comparisons at  P<.001 and P<.05 for the baseline contrasts and intergroup contrasts, respectively (cluster threshold of k=0 voxels). Between-group analyses were conducted to compare gender differences and differences between those least (<150 minutes of MVPA per week) and most (≥150 minutes of MVPA per week) active. Using independent samples t test analysis, brain regions were labeled according to the MNI anatomic labeling tool implemented in the Wake Forest University Pickatlas (WFU Pickatlas)  minutes vs 554.5 [SD 18.1] minutes, P=.001, respectively). Despite a lack of change at the whole sample level for time spent in light physical activity, MVPA, and step count, 9 (32%), 17 (61%), and 16 (57%) participants, respectively, positively increased the amount of steps, light physical activity, and MVPA at follow-up . Males accumulated significantly more vigorous physical activity compared with females at baseline and follow-up  and also significantly more minutes of MVPA (P=.033) at follow-up. No significant associations were observed between number of scans and changes in behavior via accelerometry or inclinometry .The behavioral characteristics obtained via accelerometry and inclinometry are presented in r=0.392, P=.043). No significant associations were observed for the inclinometry data.To investigate the relationship between brain activation and subsequent behavior, parameter estimates were calculated for the patterns of neural activation. Of these, only glucose feedback was positively associated with subsequent minutes of MVPA  in time spent sedentary from baseline to follow-up. Previous findings support this finding, having observed a 39.6 minute per day reduction in time spent sedentary . HoweverIn regard to the relationship of activation and subsequent behavior during the follow-up period, findings identified a positive partial correlation with minutes of MVPA. Previous studies have investigated behavior change subsequent to fMRI and have demonstrated positive associations between neural response  and smoking cessation ,54. For Positioned at the intersection of a number of evolving interest areas, this interdisciplinary study offers a number of strengths. One strength was presenting the personalized feedback pertaining to both movement behaviors and physiology to participants. These components were objectively measured during baseline and follow-up using novel self-monitoring technologies, obtaining data to directly inform the feedback. In addition, the information that was presented in the fMRI tasks were designed based on feedback commonly presented via wearable devices or smartphone apps, reflecting what could be received in real-time in a real-world setting. Objective quantification of behavior at follow-up permitted the assessment of behavior following exposure and associations between neural activation and behavior.Limitations of our study include the situation that participants viewed their glucose levels during baseline wear, an unavoidable situation given intentions to minimize data loss. This protocol confirms that participants had prior exposure to the glucose-related feedback subsequently presented during fMRI. However, to help try and account for this, analysis included the number of scans as a covariate because we thought the number of scans suggested the frequency with which participants viewed their glucose levels . In addition, a lack of behavior change could be attributable to the sample that we recruited  and as such they could be profiled as a highly motivated audience who may not have viewed their behavior as in need of improvement. Furthermore, our unpowered sample size was another limitation, as we are unable to offer definitive interpretation of the findings. In addition, because of the number of people as active and inactive, we were unable to make any comparisons between groups of participants . Finally, the pattern of neural activity observed and related psychological processes should be interpreted with caution due to the nature of reverse inference . Future This multidisciplinary study highlighted that fMRI can be used to assess the neural response to personalized health feedback. In particular, greater activation in the prefrontal cortex during exposure to glucose compared with behavioral feedback was observed. A reduction in time spent sedentary and a negative association between the parameter estimates and subsequent minutes of MVPA were observed. Future research deploying behavioral feedback in parallel with physiological feedback to encourage positive behavior change is warranted.


In utero alcohol exposure is emerging as a major risk factor for lifelong aberrant neuroimmune function. Fetal alcohol spectrum disorder encompasses a range of behavioral and physiological sequelae that may occur throughout life and includes cognitive developmental disabilities as well as disease susceptibility related to aberrant immune and neuroimmune actions. Emerging data from clinical studies and findings from animal models support that very low to moderate levels of fetal alcohol exposure may reprogram the developing central nervous system leading to altered neuroimmune and neuroglial signaling during adulthood. In this review, we will focus on the consequences of low to moderate prenatal alcohol exposure (PAE) on neuroimmune interactions during early life and at different stages of adulthood. Data discussed here will include recent studies suggesting that while abnormal immune function is generally minimal under basal conditions, following pathogenic stimuli or trauma, significant alterations in the neuroimmune axis occur. Evidence from published reports will be discussed with a focus on observations that PAE may bias later-life peripheral immune responses toward a proinflammatory phenotype. The propensity for proinflammatory responses to challenges in adulthood may ultimately shape neuron–glial-immune processes suspected to underlie various neuropathological outcomes including chronic pain and cognitive impairment. In discrete regions/countries, the percentage of women who consume alcohol while pregnant is much more (~46%)  and behavioral  sequelae representing a continuum referred to as fetal alcohol spectrum disorder (FASD). Despite nearly 40 years of clinical studies and research in animal models demonstrating e (~46%) .While the most profound and most widely known consequences of prenatal alcohol exposure (PAE) encompass clearly identifiable neurobehavioral outcomes, more recent reports are uncovering PAE’s far more subtle and insidious lifelong effects on neuroimmune function. Studies examining altered neuroimmune responses as a consequence of PAE are shedding light on potential underlying molecular mechanisms associated with PAE-induced neurological dysfunction –6. In stBirth anomalies resulting from PAE were first described as FAS in 1973 by Jones and colleagues , 14. SinAlthough immune dysfunction is not considered diagnostic of FASD, multiple clinical reports and case studies indicate that children with FASD frequently face secondary medical disabilities related to immune dysregulation . For example, FAS children have high rates of upper respiratory infection and recurrent serious otitis media (middle ear inflammation). Additionally, children diagnosed with FAS and neonates prenatally exposed to alcohol experience a high incidence of infection and immune-related pathologies, such as urinary tract infection, meningitis and the chronic autoimmune neuromuscular disease, myasthenia gravis . FurtherA surprisingly limited number of human studies address the causal effect of moderate drinking  during pregnancy and later outcomes of these children . Of the A number of published reports have modeled the impact of moderate PAE on the developing and adult CNS in animals , 30–32. While collective evidence from many animal studies suggest that moderate or low-alcohol exposure can persistently alter multiple neurotransmitter and neuromodulatory systems , few stuImmune reactions within the CNS are initially and predominantly mediated by glial cells, often with engagement of infiltrating innate/adaptive immune cells from the periphery . While gWhile the animal model for moderate PAE is the primary focus of this review, most of our knowledge of neuroimmune responses following alcohol exposure has come from experiments that model binge-drinking where sporadic and high levels of developmental alcohol exposure occurs. In consideration of these animal models, the data reveal that alcohol exposure during early postnatal development in rodents  results in microglial and neuronal loss, microglial, and astrocyte activation , 45 and moderate prenatal and postnatal alcohol exposure. In this model, pre-pregnant female breeder mice received 10% ethanol (v/v) in their drinking water for 2 months before mating resulting in an average peak blood alcohol concentration (BAC) of 125 ± 20 mg/dl. After 2 months, these pre-pregnant females were placed with male breeders, and following pregnancy, dams continued to receive 10% ethanol solution throughout gestation and lactation, with weaning occurring at postnatal day (PND) 25  25 . Tissues(PND) 25 . In this(PND) 25 , suggestHowever, as alluded to above, interesting sex differences were observed in these neuroinflammatory effects, with increased levels of MCP-1 and MIP-1α only detected at PND 20 in male pups without an increase at PND 0, suggesting the basal postnatal expression of these chemokines is influenced by as yet unrecognized postnatal gender-specific factors, with cytokine expression patterns programmed during prenatal development. In support of this possibility, increases in female-derived CCL2 and MIP-1α protein levels were observed significantly sooner (PND 0) but, plummeted by the third week of postnatal development (PND 20) compared with levels observed in males. Additional sex differences in cytokine levels, as no changes in IL-1β levels were measured in male pups with pre- and postnatal alcohol exposure. Overall, these sex differences were associated with increased neuroinflammation in female pups in this particular model of pre- and postnatal alcohol exposure .In a third model of PAE, pregnant dams were administered alcohol  only during gestational days 10–16, with dam’s peak BACs reaching 70 mg/dl . This stIntriguingly, these seminal reports on the impact of PAE on neuroimmune function revealed distinctly different observations of neuroimmune responses between males and females. Specifically, Terasaki and Schwarz  reported+ cells collected from spinal cord was measured. Increased expression of these adhesion molecules may reflect altered/impaired regulation and/or hypersensitivity to immune stimuli by immune cells and/or microglia  in adulthood. In support of this possibility, a growing body of evidence, as discussed in the following sections highlights the potential long-term impact of moderate PAE in shaping CNS responses to subsequent challenges.As noted above, greater levels of alcohol exposure during early postnatal development in rodents  results in microglial and astrocyte activation and microglial loss , 45. Howin utero. The PAE offspring were maintained until adulthood and underwent discrete cortical damage via a stab injury. Data show increased vascular cell adhesion molecule-1 (VCAM-1) and cluster of differentiation 68 (CD68) on both microglia and macrophages in PAE animals, indicating brain endothelial cell activation in addition to microglia and/or macrophage activation. Interestingly, glial fibrillary acidic protein (GFAP), a marker of astrocyte activation, and proinflammatory TNF production were diminished in PAE rats compared with the experimental controls in this brain region 4 days following injury. However, re-exposure to alcohol several days before and after the stab wound surgery further augmented CD68 and VCAM-1 expression in adult brains of PAE animals , with classic activation markers returning to basal levels. However, these previously stimulated glia may develop an increased propensity for enhanced responses following subsequent immune stimulation , 53. Tha animals . These dThe hippocampus and cortex are critical brain regions for learning and recognition memory. These brain regions are also vulnerable to glial and immune activation . In the In a more recent study, PAE rats were further exposed to an acute binge-like dose of alcohol in adulthood . This stMultiple studies now suggest that even low levels of PAE may pathologically prime CNS glial cells and disrupt their supportive role in neuronal function, not only during development, but also throughout adulthood. PAE may generate CNS susceptibility to injury through the actions of aberrant immune responses that ultimately act to exacerbate challenges in the CNS rather than sequester damage and enhance healing. Therefore, we hypothesize that the risk and severity of chronic neurological disorders is enhanced as a consequence of PAE. In recent years, our laboratory has examined the development of adult-onset chronic neuropathic pain in an animal model of moderate PAE to better elucidate the spinal cellular and molecular neuroimmune adaptations PAE induces.An intriguing behavioral manifestation in children diagnosed with developmental disabilities including FASD is abnormal sensory function such as tactile hypersensitivity –63. In sAs noted, a large body of evidence demonstrates that the neuro-glial-immune interface may underlie aberrant adult CNS function as a consequence of PAE. This background pointed to the hypothesis that PAE may exacerbate allodynia through elevated spinal glial actions. Therefore, a well-characterized rat model of low/moderate PAE  was utilA brief overview of chronic pathological pain will provide the appropriate context supporting the rationale for studies that explored spinal glial mechanisms underlying enhanced pain in PAE offspring. Chronic pathological pain often results from peripheral nerve damage, infection, or a combination of both trauma and inflammation. While chronic pathological pain involves hyperexcitability (sensitization) of pain projection neurons in the spinal cord or brainstem, critical roles of glial cells in the spinal cord, and satellite glial cells of the dorsal root ganglia (DRG) have been established , 66. Fol+ (leukocyte function-associated antigen) and β1-intergin+ and MHC2+ population of microglia and leukocytes in the lumbar spinal cord  responses are identical to non-PAE controls . This stsingle suture, robust allodynia was observed in PAE adults while touch sensitivity in control animals remained entirely unaltered  that was initiated in late adulthood (1-year-old rats). However, when CCI is reduced to a minor injury with only a naltered . Surprisnal cord , 83. Conr injury .While exact mechanisms underlying the long-term impacts of moderate PAE on the CNS and the neuroimmune system are currently under investigation, a summary of several putative mechanisms based on available supporting evidence is discussed below. Additionally, Figure in utero environmental signals such as alcohol exposure. Epigenetic modification can potentially create long-term reprogramming of gene expression where the initial insult to the fetus is long gone, as observed with FASD.The term “epigenetic” refers to stable, but potentially reversible alterations of genetic information that result in changes in gene expression, but do not involve changes in the DNA sequence itself . This includes DNA modifications and its regulatory factors such as chromatin structure and actions of non-coding RNAs (ncRNAs) . NotablyEmerging clinical evidence of epigenetic modification due to PAE provides a possible mechanism for the enduring effects of PAE . For exaFew studies exist that link long-lasting alterations in miRNA expression in the brain due to moderate PAE , 89. Howin vitro and in vivo studies support that alcohol-mediated neuroinflammation involves downstream signaling following TLR and NLR activation , rendering glia and peripheral immune cells highly responsive to further immune activation with consequent augmentation of CNS proinflammatory responses.Like other peripheral immune cells, innate immune cells in the CNS express receptors that recognize pathogen-associated molecular patterns such as TLRs and NOD-like receptors (inflammasome NLRs). Data from tivation , 94. Chrtivation . In addipathways . Furtherpathways . Moreovepathways . Therefopathways . Similarpathways . To dateAnother possible mechanism by which moderate PAE may enhance neuroinflammation is via modification of BBB function, resulting in increased permeability. A fundamental component of the BBB is the neurovascular unit, which is made up of neurovascular endothelium, basal lamina, pericytes, and astrocytic end-feet. During inflammation, activated glial cells release factors that further activate each cellular component of the neurovascular unit. The BBB is also responsive to circulating peripheral cytokines and oxidative stress, which alert glial cells residing in the CNS of either pathogen invasion or tissue damage . TherefoA strong and dynamic interplay exists between the CNS and the peripheral immune system . SpecifiClinically, fetal alcohol effects on peripheral immune competence have been suspected for a long time and multiple experimental studies support the possibility that PAE leads to long-term adverse effects on peripheral immune function , 104. Dy+), seem to be partially activated during young adulthood with moderate PAE, as indicated by increased MHC2 and adhesion molecule expression along with increased cytokine (CCL2) production following ex vivo stimulation of splenic leukocytes , an astrocyte-specific glutamate transporter, is dysregulated under neuroinflammatory conditions . AlteratTo summarize, it is evident that PAE poses long-term consequences for neuroimmune function by reprogramming immune activity in the CNS and in the periphery. Therefore, moderate PAE may be a risk factor for various neurological diseases that involve immune-neuroimmune interactions. Though multiple studies report altered neuroimmune responses due to moderate PAE, most of these studies restricted their examination to a microglial role in producing inflammatory cytokines in the CNS. However, endothelial cells and astrocytes also produce and express receptors for many of the same cytokines and have been shown to be important in CNS-immune responses. Currently, a limited amount data exist identifying cell-specific contributions of PAE-related neuroinflammation. A better understanding of immune cell and astrocyte-specific roles may delineate PAE-related mechanisms underlying chronic CNS disease throughout the life span.moderate PAE on the immune and neuroimmune systems have drawn significant attention. This area demands more extensive research given the fact that a significant percentage of the human population diagnosed with FASD does not readily display overt early-life indicators of PAE. Yet, these individuals remain vulnerable to impaired CNS function during childhood and likely throughout adulthood. Our current knowledge is based on, a significant amount of research on PAE and neuroimmune interactions driven by previous findings from heavy alcohol exposure . Therefore, extensive research using animal models, as well as careful dissection of existing data from high versus low PAE-induced effects on the developing and adult neuroimmune system will significantly enrich the field. Such work will aid in the identification of key neuroimmune factors underlying FASD, with the possible development of appropriate interventions that could significantly improve the quality of life for these individuals.While vast majority of initial research in FASD has been conducted to explore the mechanisms of alcohol-induced neurotoxicity due to binge or high exposure of alcohol, in recent years, diverse effects of SN and EM prepared the manuscript and figures, provided substantial contribution to the intellectual content of the manuscript and figures.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Metabolic alterations are common in patients suffering from psychosis. The rise in glycemic lipids may be related to and observed increased in the prevalence of hepatic steatosis measured by the Fatty Liver Index. However, we have recently reported a probable protective effect of cannabis smoking on weight gain and related metabolic alterations in a sample of patients drug-naïve suffering from a first episode of psychosis. We aimed to explore the effect of cannabis smoking on hepatic steatosis in a sample of first-episode non-affective psychosis patients.Anthropometric measurements, glycemic and lipid parameters, and liver steatosis index (FLI), were obtained at baseline and after 3 years of having initiated treatment. Patients were divided into two groups depending on self-reported cannabis use (cannabis users and non-users).Cannabis users presented at baseline lower FLI  than non-users. These differences were also observed after 3 years of treatment .Our results support the hypothesis that cannabis has a protective effect against hepatic steatosis. However, before being transferred to clinical practice, this study should be replicated, using larger samples.


Tumor metabolism is a thrilling discipline that focuses on mechanisms used by cancer cells to earn crucial building blocks and energy to preserve growth and overcome resistance to various treatment modalities. At the same time, therapies directed specifically against aberrant signalling pathways driven by protein tyrosine kinases (TKs) involved in proliferation, metastasis and growth count for several years to promising anti-cancer approaches. In this respect, small molecule inhibitors are the most widely used clinically relevant means for targeted therapy, with a rising number of approvals for TKs inhibitors. In this review, we discuss recent observations related to TKs-associated metabolism and to metabolic feedback that is initialized as cellular response to particular TK-targeted therapies. These observations provide collective evidence that therapeutic responses are primarily linked to such pathways as regulation of lipid and amino acid metabolism, TCA cycle and glycolysis, advocating therefore the development of further effective targeted therapies against a broader spectrum of TKs to treat patients whose tumors display deregulated signalling driven by these proteins. The switch from normal tissue to malignancy is a result of oncogenes-driven biochemical processes aimed at sustaining an accelerated rate of proliferation and growth . Otto WaIn recent years, in addition to investigating the role of cell metabolism in tumor cell development, particular attention has been devoted to metabolic changes occurring as a response to targeted treatments –7. In viProtein kinases constitute an immense enzyme family that emerges as a strikingly valuable set of targets in therapy of various tumors considering their high sensitivity to specific kinase inhibitors, which are often relatively well tolerated by normal cells. Development of TKIs created a therapeutic window for selective diminishing of malignancies with constitutively active kinase. The majority of these compounds share a common mechanism of action – they competitively inhibit adenosine triphosphate (ATP) at the catalytic binding site of the targeted protein . As aforAs metabolic reprogramming towards aerobic glycolysis has been suggested as one of the hallmarks of cancer, considerable research efforts focused for over a decade on enzymes and metabolites of the glycolytic pathway following antineoplastic treatments. Glucose metabolism, a paramount energetic resource for the cell, is a very complex process regulated in neoplastic cells by different oncogenes on multiple levels, ranging from transcription to post-translation modifications . In thatOncogene-conducted activation of glycolytic pathway takes frequently place through hypoxia-inducible factor 1α (HIF-1α) , 19. TheEGFR, a broadly studied RTK system, is overexpressed, deregulated and mutated in a large number of malignancies. Specifically, EGFR protein overexpression was detected in tumors of breast, brain, cervix, ovary, colon, head and neck and lung , 26, cre18F–FDG radioassay, a reduction of consumption of glucose and hexokinase activity following erlotinib treatment in patient-derived glioblastoma (GBM) neurosphere tumor cells (GBM39) that express EGFR glutamate, in contrast to imatinib-resistant cell lines, suggesting a decrease in the activity of glycolysis together with TCA cycle fluoro-2-deoxy-D-glucose-positron emission tomography) analysis with MRI  deoxyglucose uptake was increased in axitinib-treated cells after 24 and 48 h [Differently from what was reported previously using other TKIs, Hudson and colleagues treated mouse pancreatic ductal adenocarcinoma (PDAC) cell lines from pancreatic cancer mouse model (Krasand 48 h . It has and 48 h . These rand 48 h .ENO2), and the platelet phosphofructokinase (PFKP), three genes directly associated with glycolysis, hence suggesting a metabolic shift towards glucose metabolism [Sorafenib (Nexavar®), a multikinase inhibitor targeting BRAF, PDGFR and VEGFR, enhanced in the hepatocholangiocarcinoma cell line LCSC-2 the expression of GLUT3, Enolase 2 , significantly increased enzymatic activity of PKM2 in human myeloid leukemia cell line KG1, breast cancer cell line MDA-MB-134 and a lung cancer cell line NCI-H1299, all three of them overexpressing FGFR1 . Additio2, spawning NADH and FADH2, whose electrons are used in electron transport chain (ETC) to generate ATP for chemical and physical work within the cell [TCA cycle is commonly presented in a simple viewpoint of a cyclic mitochondrial pathway continually oxidizing acetyl-CoA to COthe cell . Mitochothe cell  and furtthe cell , 65. Domthe cell . These m50 value of 2.5 μmol/L) was accompanied by a higher energy state ), being possibly a result of an activation of the TCA cycle together with dysregulation of glucose metabolism [In the already mentioned study focusing on imatinib-treated BCR-ABL-positive cells, the increase of mitochondrial glucose metabolism following treatment by high imatinib concentration , and the combination of these two drugs using a NMR-based metabolomic approach, the group of Ji-Xiang Zhang reported that key metabolites are significantly altered in everolimus-treated cells . AspartaComparable to the aforementioned, metabolic profiling of gefitinib-sensitive myeloma cancer cells LP-1 revealed upregulation of threonine, histidine, proline, asparagine and tyrosine following EGFR inhibition by gefitinib . RelatedTo fulfil biosynthetic demands associated with proliferation, tumors increase the import of nutrients including amino acids for their survival. Studies discussed in this section suggest that many amino acids are consistently decreased following the treatment with TKs inhibitors. Since most of these reports have been primarily focused on changes in glucose and mitochondrial metabolism, we are only starting to unravel the extent to which amino acids contribute to tumors’ pathology and if fluctuations in their levels that occur upon administration of TKIs could be plausibly considered as markers of therapy efficacy, or are rather merely passengers of events that take place upon inhibition of the respective oncogenic kinases.Although phospholipids, fatty acids and cholesterol represent extensive energetic storage and important building blocks for plasma membrane, impact on lipid metabolism in cancer cells received less attention than changes in glucose or amino acid metabolism. At the same time it has been well established that cancerous tissues are defined also by an increased rate of lipid synthesis . TranscrTaken together, although our current expertise regarding alterations in lipid metabolism upon distribution of distinct TKIs is rather limited, the aforementioned results strongly suggest that TK inhibition often leads to a decrease in levels of fatty acid metabolites such as phosphocholine. Given the central role that lipids are playing in tumor development and tumor progression, further investigations regarding potential clinical relevance of TKI-related modulations in lipid metabolism are needed.The introduction of TKIs to the armamentarium for the modulation of growth factor signaling has revolutionized treatment outcome of many cancer patients. Nevertheless, acquisition of drug resistance and reported side effects strongly limit their clinical use. Importantly, molecular mechanisms responsible for these complex processes induced by TKIs are not sufficiently understood yet. Metabolomics, either as a unique approach or in use in combination with other omics technologies, is a highly effective approach not only for biomarker discovery but has also the potential to unravel molecular processes that underlie mechanisms of action of various compounds including TKIs.Nowadays it is relatively well established that TKIs such as imatinib, erlotinib or gefitinib impose metabolic changes on glycolysis profile of cancer cells expressing their respective targets. Indeed, recent studies show that these compounds decrease glucose uptake, potentially affecting major players of glucose metabolism such as transporters and rate limiting enyzmes, and by still unknown mechanisms contribute to side effects such as reactivation effort of mitochondrial respiration. On the contrary, metabolic effects of TKIs on amino acid and lipid metabolism are much less clear and cannot be generalized yet.In summary, although the current knowledge on TKIs impact on cellular metabolism is continuously expanding, the detailed molecular mechanisms underlying many of the observations described within this review remain largely unknown and further biological investigations are warranted to understand the metabolic on- and off-target effects related to TKIs treatment.


Posttransplant lymphoproliferative disease is a serious complication following stem cell and solid organ transplantation. Early recognition of the disease is important in facilitating timely therapy and improving long-term outcomes. We report a renal transplant recipient presenting with an extracranial frontoparietal soft tissue mass that was subsequently diagnosed as a B-cell lymphoma. The patient was treated successfully with immunosuppression reduction, anti-CD20 monoclonal antibody therapy, and cytotoxic chemotherapy. Our case highlights the importance of recognizing soft tissue masses in the head and neck as a potential clinical manifestation of PTLD in solid organ transplant recipients. Posttransplant lymphoproliferative disease (PTLD) is a serious immunosuppressive-related complication of patients following solid organ or stem cell transplantation with a reported incidence between 1 and 25%  and mortA 24-year-old man with end-stage renal disease secondary to hypertension underwent a cadaveric renal transplant (donor Epstein-Barr virus (EBV) IgG positive, recipient EBV IgG negative) with basiliximab induction and maintenance immunosuppression consisting of tacrolimus, mycophenolate mofetil, and prednisone. Nine months after the transplant, he presented to the clinic complaining of a forehead mass that had been present for four weeks. He ascribed the development of this mass to mild head trauma sustained previously when he fell out of bed. He denied neurological or constitutional symptoms. His physical examination was notable for a golf-ball-sized mass in the left frontoparietal region that was firm in consistency, nonmobile, with no overlying skin abnormality. There were no neurological abnormalities, hepatosplenomegaly, or peripheral lymphadenopathy. Further imaging of the mass was ordered with an MRI of the brain which showed focal cranial bone marrow infiltration and a left frontoparietal 6 × 2 × 9 cm dominant extracranial soft tissue lesion  with thiCerebrospinal fluid studies were negative for malignant cells. Further staging imaging with a contrast-enhanced CT of the chest, abdomen, and pelvis showed necrotic retroperitoneal lymphadenopathy. A serum EBV viral load performed was elevated at 75,000 copies/ml. A final diagnosis of Epstein-Barr virus (EBV) positive B-cell lymphoma was made. Mycophenolate mofetil was stopped. The patient was considered to be at high risk for central nervous system disease and received a single dose of prophylactic intrathecal cytarabine. He underwent his first cycle of R-CHOP  as an inpatient and was monitored closely for treatment toxicities. Aside from a chemotherapy-related neutrophil nadir of 800 neutrophils/microliter which recovered quickly with growth factor support (granulocyte-colony stimulating factor), he suffered no adverse treatment-related events. By the end of his first cycle of R-CHOP, the forehead mass had decreased mildly in size and his serum EBV viral load had declined to 20,400 copies/ml. He went on to complete a further 6 cycles of R-CHOP  and achieved remission 6 months later. Transplant immunosuppression was maintained with tacrolimus and prednisone both during and following his chemotherapy, and renal allograft function remained normal with no acute rejection events.The necessary use of long-term immunosuppression following solid organ transplantation (SOT) is associated with a number of infectious and noninfectious complications, including PTLD. PTLD represents a spectrum of clinical disorders due to lymphoid hyperproliferation (most often B-cell in origin), ranging from a benign hyperplasia to an aggressive malignant lymphoma . In apprThe mainstay of treatment for PTLD is the reduction of immunosuppression which has led to variable response rates of between 6 and 48% –21. Not The use of antiviral drug therapy for preventing or treating PTLD remains controversial. Lytic EBV replication can be inhibited in vitro by the guanine nucleoside analogs acyclovir and ganciclovir , 27. HowAn alternative and promising therapy is the use of adoptive transfer of EBV-specific cytotoxic T-lymphocytes, which has been successful in a number of studies for the treatment and prevention of PTLD in allogeneic stem cell transplant recipients and to a lesser degree in solid organ transplant recipients –35. Haqu5 and 106 copies/ml were used to guide not only reduction of immunosuppression (stopping mycophenolate mofetil and reducing cyclosporin dose) but also administration of single-dose rituximab (375 mg/m2) in 299 adult heart transplant recipients [As a strong association between EBV and PTLD exists, detection of the EBV genome  has been proposed as a potential screening strategy to guide therapeutic interventions to prevent the development of PTLD . Lee et cipients . Followicipients  and the cipients . Togethecipients , 45.In summary, PTLD is a rare but serious complication of solid organ transplantation. Awareness of the potential clinical manifestations of this disease is important in making an early diagnosis. Our case highlights the importance of considering PTLD in the differential diagnosis of a transplant recipient presenting with a soft tissue extracranial mass.


The twin pandemics of obesity and Type 2 diabetes (T2D) are a global challenge for health care systems. Changes in the environment, behavior, diet, and lifestyle during the last decades are considered the major causes. A Western diet, which is rich in saturated fat and simple sugars, may lead to changes in gut microbial composition and physiology, which have recently been linked to the development of metabolic diseases.We will discuss evidence that demonstrates the influence of the small and large intestinal microbiota on weight regulation and the development of insulin resistance, based on literature search.Altered large intestinal microbial composition may promote obesity by increasing energy harvest through specialized gut microbes. In both large and small intestine, microbial alterations may increase gut permeability that facilitates the translocation of whole bacteria or endotoxic bacterial components into metabolic active tissues. Moreover, changed microbial communities may affect the production of satiety-inducing signals. Finally, bacterial metabolic products, such as short chain fatty acids (SCFAs) and their relative ratios, may be causal in disturbed immune and metabolic signaling, notably in the small intestine where the surface is large. The function of these organs  may be disturbed by the induction of low-grade inflammation, contributing to insulin resistance.Interventions aimed to restoring gut microbial homeostasis, such as ingestion of specific fibers or therapeutic microbes, are promising strategies to reduce insulin resistance and the related metabolic abnormalities in obesity, metabolic syndrome, and type 2 diabetes. This article is part of a special issue on microbiota. •The small and large intestinal microbiota influence weight regulation and glucose homeostasis.•A Western diet, which is rich in saturated fat and simple sugars, may lead to changes in the gut microbial physiology.•Changes in the gut physiology and microbial composition are involved in the development of metabolic diseases.•Ingestion of pre- or probiotics and fecal microbiota transplantation may stop this deleterious process. The main bacterial phyla, a high-level taxonomic rank, of the intestinal microbiota are Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria, and Verrucomicrobia Akkermansia muciniphila, is also mainly located here The microbial composition and diversity differ along the intestine This difference is due mainly to higher oxygen concentrations and the presence of antimicrobial compounds in the proximal intestine As indicated above, gut microbiota serves important functions in human physiology. Microbiota residing in the large intestinal facilitate fermentation of dietary fibers, which increases the energy harvest by the host from the diet and is an important factor contributing to the growth and maintenance of the gut microbiota. In addition, gut microbiota produces the short-chain fatty acids (SCFAs), such as acetate, propionate, and butyrate, as well the gases carbon dioxide, hydrogen, and methane The gut microbiota not only metabolizes nutrients but also is involved in the breakdown of several xenobiotics such as drugs, dietary compounds (which are non-digestible for the host), and environmental toxins Faecalibacterium prausnitzii via the induction of junction proteins and reduction of pro-inflammatory cytokines or A. muciniphila by endocannabinoid production Although the intestinal microbiota carries out these important functions for the host physiology, it nevertheless poses a threat when breaching the intestinal wall Bifidobacterium brevis reduce the production of inflammatory cytokines and thus dampen B cell response Bacteroides fragilisClostridium spp. stimulate the production of the anti-inflammatory interleukin (IL)-10 by regulatory T cells (Treg) Intestinal immune cells, especially dendritic cells, sample antigens or whole bacteria from the lumen and carry them  to the mesenteric lymph nodes. Thereby, they induce a protective secretory IgA (sIgA) response, which coats bacteria in the intestinal lumen for immune exclusion (excretion) or controlled uptake to further train the immune system. Similarly, gut epithelial cells release microRNAs (miRNA), which can regulates bacterial gene expression and growth Finally, the gut microbiota dampens the growth of potential pathogenic bacteria through several mechanisms: 1) inhibition of pathogenic growth via bacteriocins and SCFAs 2Diet is a major factor driving the composition and metabolism of the gut microbiota Similarly, commonly used emulsifiers (detergent-like molecules) have been shown to induce low-grade inflammation, obesity, and metabolic syndrome in mice. The compounds changed the gut microbial composition and increased their pro-inflammatory potential. Transfer of emulsifier-treated microbiota into GF mice reproduced this phenotype, suggesting a role of these compounds in these conditions Antibiotics have a major influence not only on their targets (bacteria) A stable microbiota develops from the age of 2–3 years Akkermansia and the number of mucin-producing goblet cells in mice. Oral administration of Akkermansia muciniphila to HFD-treated mice without metformin enhanced glucose tolerance and attenuated adipose tissue inflammation by inducing a Treg dependent response Escherichia coli and the SCFAs production was enhanced E. coli) play in this context.Similar to the dietary intake, several drugs influence the gut microbiota 3An interesting observation that was made in GF mice is that they are resistant to diet-induced obesity (DIO). This coincides with lower levels of pro-inflammatory markers (TNF-α) and improved insulin sensitivity as compared to wild-type mice that are on a HFD de novo lipogenesis. This leads to an increase in body weight in conventional mice. To date, GF mice do not produce SCFAs in the gut due to the lack of fermenting microbes Based on comparison of GF mice and conventional mice, several evolutionary advantages with respect to food intake and immune maturation have been proposed for the presence of gut microbiota. First, the gut microbiota is essential for processing (non-digestible) dietary polysaccharides to monosaccharides, which can be absorbed by the host or further fermented to SCFAs by the microbiota. Subsequently, SCFAs are delivered via the portal vein system to the liver, where they serve as substrates for hepatic gluconeogenesis and Lactobacillus paracasei exhibited reduced body fat accompanied with increased circulating levels of Angptl4. This suggests that a specific population of the microbiota can induce the expression of Angptl4. Lack of Angpt4 in mice led to higher weight compared to their wild-type counterparts without any difference in food intake, energy expenditure, or locomotive activity. Therefore, they favor energy (lipid) storage rather than utilization. Further, the lipid content in the stools of Angpt4−/− was decreased, and the luminal pancreatic lipase activity was elevated. Interestingly, recombinant Angptl4 administration resulted in decreased pancreatic lipase activity. Therefore, Angptl4 is able not only to inhibit systemic LPL activity (lipid storage), but also to inhibit luminal LPL (lipid digestion and uptake) Secondly, the gut microbiota not only enhances energy uptake from the gut but also helps to store calories in adipose tissue. For example, the gut microbiota inhibits the expression of Angiopoietin-like 4 (Angptl4) in enterocytes. Angptl4 is a potent inhibitor of lipoprotein lipase (LPL). LPL is the enzyme responsible for the hydrolysis of triglycerides (TG), enabling the uptake of fatty acids in tissues for use of energy or storage. GF mice have higher levels of Angptl4 and therefore less LPL activity leading to reduced fat storage in adipocytes Human data also suggest a link between Angptl4 and obesity. Plasma levels of Angptl4 were higher in twins with a low body mass index (BMI) as compared to obese counterparts, suggesting an important role of Angptl4 in obesity AMPK is another player in nutrient metabolism that is influenced by microbiota. AMPK is an important sensor, which senses low energy content in cells . To resolve the lack of energy, AMPK induces energy producing processes (fatty acid oxidation) and food intake via the hypothalamus AMPK is regulated not only via Angptl4 but also by SCFAs produced by the microbiota. Interestingly, GF mice show increased skeletal muscle and liver AMPK activity compared to conventional mice, favoring energy utilization. A lower energy harvest from the diet due to the lack of fermenting microbes may explain the higher activity of the energy sensing AMPK 2-producing Prevotellaceae (Bacteroidetes) as well as H2-utilizing Methanobacteriales (Archaea) was enriched in obese subjects. The authors postulate that H2 transfer between bacterial and archaeal species is an important mechanism for increasing energy uptake in obese subjects. After gastric-bypass surgery, Firmicutes and H2-producing bacteria were lower than in obese subjects, accompanied by an increase in Proteobacteria The gut microbiome  of obese subjects also exhibited more genes responsible for carbohydrate fermentation compared to lean microbiomes, which is in line with the higher SCFA concentration in obese subjects In summary, in mouse models of obesity and in obese individuals, an increased potential to extract energy from the diet was observed, amongst others through the production of SCFAs. Controversially, treatment with SCFAs in animal models led to an improved glucose homeostasis and weight loss possibly through AMPK-mediated pathways. Therefore, the role of SCFAs in obesity requires further studies.4Recent findings point to the involvement of the microbiota in appetite and satiety signals. The gut expresses several proteins, which are involved in the regulation of food intake, for example peptide YY (PYY), which is expressed in enteroendocrine cells (L-cells). Loss of SCFAs production from microbes in GF mice led to a reduced activation of the SCFA receptor G protein coupled receptor (Gpr) 41 and, subsequently, a decrease in PYY expression. Therefore, GF mice show higher energy intake, but a lower weight gain, due to a higher intestinal transit time and lower hepatic lipogenesis in vitroin vitro and in vivo as well as an impaired glucose tolerance The incretin glucagon-like peptide 1 (GLP-1) is another satiety inducing protein, which is secreted by the intestine. Ingestion of prebiotics increased the synthesis of GLP-1 and PYY in plasma of rodents and humans and was accompanied by reduced hunger rates BifidobacteriaBifidobacterium spp.) have a higher expression of tight junction/barrier proteins and lower levels of plasma LPS, resulting in improved intestinal permeability. Additionally, the GLP-2 expression in the intestine was enhanced Bifidobacterium animalis. Prebiotics increased portal GLP-1 levels, whereas probiotics increased GLP-2. However, both compounds improved metabolic parameters  GLP-2 exerts a similar function as GLP-1. Both gut hormones result from post-translational processing of pro-glucagon in intestinal L-cells. GLP-2 is associated with intestinal proliferation and an improvement of the gut permeability Glucose-dependent insulinotropic polypeptide (GIP) is the fourth important gut hormone, which is modulated via the gut microbiota. It is expressed in intestinal K-cells and is an important modulator of energy homeostasis and glucose metabolism. Similar to PYY and GLP, its expression was induced by SCFAs, possibly mediated by Gpr43 and Gpr41 Lactobacillus acidpophilus modulated the expression of cannabinoid receptors in intestinal cells in rats Recent findings also suggest the involvement of the gut microbiota in the regulation of the endocannabinoid (eCB) system 5In their seminal paper, Cani et al. F. prausnitzii showed a decreased abundance, whereas several common infectious and LPS-producing bacteria were enriched, explaining, to some extent, the impaired barrier function and high LPS level in diabetic subjects A. muciniphila has been noted in obese subjects A metagenome-wide association study (MGWAS) showed that there are similar microbial aberrations in (pre) diabetic subjects Tlr4−/− mice have lower expression of pro-inflammatory markers such as TNF-α and IL-6 and are protected from insulin resistance, emphasizing that inflammation may affect metabolism Increased LPS levels in plasma are associated with a low-grade inflammation Increased plasma LPS levels of diabetic and obese subjects are negatively correlated with muscle insulin sensitivity. LPS treatment of a human muscle cell line increased the expression of pro-inflammatory markers monocyte chemotactic protein 1 (MCP-1) and IL-6 and reduced insulin stimulating factors such as insulin receptor substrate 1 (IRS-1), protein kinase B (Akt), and Akt substrate of 160 kDa (AS160). Inhibition of Tlr4 suppressed this inflammatory response and resolved the insulin resistance B. animalis, which improved the overall inflammatory and metabolic status of the animal. These findings demonstrate that bacterial translocation occurs before the onset of metabolic diseases and is an integral part of the development of these conditions Bacterial components such as LPS, but also live bacteria are able to translocate from the intestinal lumen to other tissue sites. For example, a HFD in mice led to translocation of viable intestinal bacteria to adipose tissue where they induce inflammation. This process occurred before the onset of diabetes. Mice lacking the PRRs nucleotide-binding oligomerization domain-containing protein 1 (Nod1) or Tlr4 were protected from the bacterial translocation. The bacterial translocation could be reversed with probiotic treatment of in vitro and in vivo were able to internalize LPS-coated latex particles E. coli was co-localized with dendritic cells (DC) in the intestinal lamina propria of DIO mice. After phagocytosis, the DCs disseminated into mesenteric lymph nodes (MLN) and mesenteric adipose tissue (MAT) inducing an inflammatory response similar to LPS Enterobacter cloacae (B29) was highly abundant in the gut of a morbidly obese subject (35%) with metabolic syndrome features. Upon extensive weight loss E. cloacae was not detectable anymore E. cloacae, an increased abundance of Bifidobacterium is associated with a healthy gut microbiota. Obese Bifidobacterium, which was associated with higher inflammatory markers as well as disturbed glucose homeostasis and lipid metabolism.Several mechanisms have been proposed to explain bacterial translocation. The internalization of bacteria by enterocytes with an intact barrier function resembles phagocytosis and is Tlr4 dependent. Interestingly, the bacteria remain viable in the phagosome In summary, a connection between the microbiota and the glucose tolerance has been postulated . However6Bifidobacterium spp. and F. prausnitzii, which are Gram-positive bacteria that are associated with anti-inflammatory properties Lactobacillus acidophilus and Bifidobacterium lactis for 6 weeks decreased fasting blood glucose and hemoglobin A1c (HbA1c) in diabetic subjects. Further, it improved antioxidant status L. acidophilus for 4 weeks led to improved insulin sensitivity, but did not alter inflammatory parameters Lactobacillus plantarum) enhanced the intestinal barrier by increasing the expression of ZO-1 and occludin in tight-junction structures Several treatment strategies targeting the gut microbiota have been tested. Probiotics may help to restore microbiota function. As mentioned before, patients with diabetes show lower levels of Clostridium difficile infection with antibiotic resistance and repetitive treatment failure. Infusion of healthy donor feces into infected patients led to an improvement of C. difficile associated diarrhea after the first infusion in 81% of the patients. After treatment, patients showed increased fecal bacterial diversity and increased levels of Clostridium clusters IV and XIVa, which are associated with the mucosa health via the production of the SCFA butyrate Fecal microbiota transplantation (FMT) is another approach to ameliorate the disturbed gut microbiota composition. The first successful findings were made in patients with recurrent The transfer of fecal microbiota from lean donors to obese subjects was similarly successful. Recipients of a lean-type microbiota showed an improvement in insulin sensitivity and higher abundance of butyrate-producing species six weeks after transplantation F. prausnitzii negatively correlated with inflammatory parameters, strengthening the association of this species as an anti-inflammatory commensal bacterium Bariatric surgery (weight loss surgery) is another, more drastic approach to improve metabolic function in (morbid) obesity. Roux-en-Y gastric bypass (RYGB) is the most common weight loss surgery and is performed to decrease the stomach volume, which leads to reduced food intake. Interestingly, improvement in glucose metabolism is independent of weight loss, suggesting other mechanisms may be involved 7The (gut) microbiota is an organ within an organ (the intestine) that is involved in inflammatory as well as metabolic pathways in the host. Disruption of the gut microbiome may disturb the homeostasis of the microbial ecosystem to an alternative stable state associated with pathophysiological traits in microbiota and host Many other questions remain to be answered. Most work done in the gut microbiota field is done in animals, questioning causality in humans. Further, many contradictory results need to be clarified in future research. However, due to the vast progress in culture-independent methods such as sequencing, it can be expected that our knowledge will rapidly increase and reveal the potential of the (gut) microbiota. We are just beginning to understand how microorganisms influence our health and behavior. Various innovative therapeutic options are in the developing phase with promising outcomes.


To compare long GnRH agonist with GnRH antagonist protocol in poor responders.Medical charts of 531 poor responder women undergoing in-vitro fertilization (IVF) cycle at Zeynep Kamil Maternity and Children’s Hospital, IVF Center were retrospectively analysed. Those who received at least 300 IU/daily gonadotropin and had ≤3 oocytes retrieved were enrolled in the study. Poor responders were categorized into two groups as those who received long GnRH agonist or GnRH antagonist regimen.Treatment duration and total gonadotropin dosage were significantly higher in women undergoing the long GnRH agonist regimen compared with the GnRH antagonist regimen (p<0.001 for both). Although the number of total and mature oocytes retrieved was similar between the groups, good quality embryos were found to be higher in the GnRH antagonist regimen. The day of embryo transfer and number of transferred embryos were similar in the groups. No statistically significant differences were detected in pregnancy (10.5% vs 14.1%), clinical pregnancy (7.7% vs 10.6%) and early pregnancy loss rates (27.2% vs 35%) between the groups.GnRH antagonist regimen may be preferable to long GnRH regimen as it could decrease the cost and treatment duration in poor responders. Poor ovarian response (POR) is one of the most challenging situations in assisted reproductive technology (ART), with disappointing overall in-vitro fertilization (IVF) success rates.. In comparison to normal responders, these patients have impaired fertilization rates, lower embryo quality and decreased pregnancy rates. Various treatment modalities have been proposed in an effort to improve ovarian response and IVF outcome. These include different regimens for pituitary suppression, the use of high doses of gonadotrophins, the use of gonadotropins with luteinizing hormone activity as well as adjuvant therapies. The introduction of GnRH agonists (GnRHa) in assisted reproduction has increased the success rate of IVF treatment by reducing the incidence of a premature LH surge. However, gonadotropin releasing hormone antagonists (GnRH-ant) have some advantages in mechanisms of actions over GnRHa. Unlike GnRHa, GnRH-ant act by the mechanism of competitive binding on GnRH receptors in pituitary and rapid action for pituitary suppression makes them rational to use in poor responders undergoing IVF. However, most of these treatment regimens failed to increase the success rate of assisted reproduction in poor responders. The lack of uniform definition of POR is another confusing factor in previously reported studies, which makes it difficult to compare different regimens in these women. In an effort to make a universal definition of POR, a consensus was reached on the minimal criteria needed to define this issue by ESHRE working group in Bologna. According to Bologna consensus, at least two of the following three features must be present:POR to ovarian stimulation usually indicates a reduction in follicular response, resulting in high cancellation rates or a reduced number of retrieved oocytes in women undergoing IVF1. Advanced maternal age (≥40 years) or any other risk factor for POR;2. A previous POR ;3. An abnormal ovarian reserve test . Additionally, two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ovarian reserve test. Thus, the definition of POR by ESHRE group makes future meta-analysis more reliable and also prospective randomized trials more homogeneous.The aim of this retrospective cohort study was to compare IVF outcome of poor responders undergoing the long GnRHa versus GnRH antagonist regimen.This study was conducted as a retrospective cohort analysis of poor responder women who underwent IVF treatment with the long GnRHa or GnRH-ant protocol at Zeynep Kamil Maternity and Children’s Hospital IVF center between January 2008 to April 2014. The medical charts of women who had ≤3 oocytes retrieved were reviewed and their demographic characteristics and IVF data were recorded. Mild stimulation cycles, the cycles obtained >3 oocytes and cycles stimulated with <300 IU/day gonadotropins were excluded from the study. The local Ethics Committee approved the study.In the long GnRHa regimen, pituitary down-regulation with either a subcutaneous injection of triptorelin 0.1 mg daily  or leuprolide acetate 10 IU daily  was commenced in the midluteal phase of the menstrual cycle and continued until the second day of menstrual cycle. This was followed by an ultrasound confirmation of down-regulation by endometrium thickness and measurement of estradiol. When down-regulation was achieved, ovarian stimulation was commenced with gonadotropin injections  at a dose of 300-450 IU/day and continued with a half of applied dose of triptorelin (0.05 mg/daily) or leuprolide acetate (5 IU/daily) until the administration of hCG injection. In the GnRH-ant regimen, gonadotropin injections at a dose of 300-450 IU/day were commenced on day 2 or 3 of the cycle. Antagonists  were added to stimulation protocol when the leading follicle achieved ≥13 mm in diameter. In both groups, the hCG injection  was administered aiming at least one follicle reaching ≥17 mm in diameter to trigger final oocyte maturation. The luteal phase support in both groups was provided with the daily administration of 600 mg of progesterone intravaginally  or 90 mg of progesterone gel intravaginally  until clinical pregnancy was achieved.Pregnancy was defined as a positive β-hCG measurement 12 days following embryo transfer. Clinical pregnancy was diagnosed when fetal heart motion was observed during sonographic examination. Early pregnancy loss rate was defined as pregnancy losses that occurred in the time interval between a positive hCG test and the appearance of fetal heart beats. Good-quality embryos were defined as embryos with a normal cleavage rate and 10% fragmentation.Statistical analyses were performed using the SPSS 17.0 program  and R statistical software. Continuous variables were presented as mean ± standard deviation (SD) and categorical variables were defined as percentages (%). Continuous variables were compared with the Student’s t-test, while chi-squared or Fisher’s exact tests were used for comparison of categorical variables. P value <0.05 represents significance.A total of 531 women who reached the oocyte-pick up procedure were recruited in this study. Of these women, 311 underwent with the long GnRHa regimen and 220 underwent with the GnRH-ant regimen. Demographic and clinical data of patients are presented in In the present study, the number of total and mature oocytes retrieved, and fertilized oocytes were similar in the long GnRHa and the GnRH-ant regimens. Although there was not a difference in pregnancy rate, the rate of good quality embryos was found to be higher in GnRH-ant group than long GnRHa group.,7. In a RCT by Cheung et al.,8, they couldn’t find any difference regarding duration of stimulation, consumption of gonadotrophins in long GnRHa and GnRH-ant regimens. However, other studies are in line with our findings,9,10. Morever, a recent meta-analysis comparing the long GnRHa versus GnRH-ant regimens in poor responders revealed that the duration of stimulation and gonadotropin dosage were significantly lower in GnRH agonist regimens,11. However, the difference in these parameters could not be observed when micro-dose flare up protocol compared with the GnRH-ant protocol. Taken together, competitive binding of GnRH-ant to pituitary GnRH receptors shortens the stimulation cycle and reducing the dose of gonadotropin. Downregulation by the long GnRHa protocol significantly increases the gonadotropin dosage required and prolongs the stimulation period.This study demonstrated a higher gonadotropin consumption and longer duration of stimulation with the long GnRHa regimen compared to the GnRH-ant regimen. Previous randomized controlled trials (RCT) comparing the efficacy of these regimens showed conflicting results owing to definition of poor response,8,11,12. However, other studies demonstrated higher number of total oocyte retrieved in GnRHa regimen than GnRH-ant regimen,13,14. Although the number of total oocytes retrieved was lower in the GnRH-ant protocol than the GnRHa protocol in these studies, number of mature oocytes retrieved was found to be similar. The rate of good quality embryos was higher in GnRH-ant than the long agonist regimen in our study. In contrast to our findings, Prapas et al. reported that mean embryo quality was significantly higher in the agonist group,13. Although the rate of good quality embryos was higher in GnRH-ant group we found slightly lower clinical pregnancy rate (non-significant) in these women. This finding may be related to ill effect of GnRH-ant on endometrial receptivity. Rackow et al demonstrated that the use of GnRH-ant in comparison to GnRH-a in IVF cycles may be associated with impaired endometrial receptivity. Moreover, a recent study comparing GnRHa and GnRH-ant regimens with the transfer of one high-quality embryo revealed that the GnRH-a group showed significantly higher pregnancy rate. We are of the opinion that the reason for slightly lower clinical pregnancy rates in GnRH-ant IVF cycles in spite of higher quality embryos may be due to the decreased receptivity of the endometrium.Our findings showed that there was no significant difference on the number of mature oocytes retrieved between the GnRH-ant and the long GnRH-a protocols, which was similar to the results of previous studies,18,19,20. Additionally, no difference could be detected in early pregnancy loss rate between the groups in this study. Although early pregnancy loss rate was not compared between agonist and antagonist regimen in previous studies one retrospective study reported no significant difference in early pregnancy loss rate between poor and normo-responder women undergoing IVF,21.In our study, both groups presented a similar mean number of transferred embryos, and comparable pregnancy rate per transfer. Many randomized controlled trial (RCT) studies showed the similar resultsIn conclusion, although there was no difference in pregnancy rates between the groups, lower gonadotropin consumption and shorter duration of ovarian stimulation in GnRH-ant cycles compared with the GnRHa cycles seem to decrease the cost and to make GnRH-ant more patient-friendly regimen for poor responders.


Although physical activity has been shown to contribute to long-term disease control and health in breast cancer survivors, a majority of breast cancer survivors do not meet physical activity guidelines. Past research has focused on promoting physical activity components for short-term breast cancer survivor benefits, but insufficient attention has been devoted to long-term outcomes and sustained exercise adherence. We are assessing a health coach intervention (iMOVE) that uses mobile technology to increase and sustain physical activity maintenance in initially inactive breast cancer survivors.This pilot randomized controlled trial (RCT) is an initial step in evaluating the iMOVE intervention and will inform development of a full-scale pragmatic RCT.We will enroll 107 physically inactive breast cancer survivors and randomly assign them to intervention or control groups at the University Health Network, a tertiary cancer care center in Toronto, Canada. Participants will be women (age 18 to 74 years) stratified by age (55 years and older/younger than 55 years) and adjuvant hormone therapy (AHT) exposure (AHT vs no AHT) following breast cancer treatment with no metastases or recurrence who report less than 60 minutes of preplanned physical activity per week. Both intervention and control groups receive the 12-week physical activity program with weekly group sessions and an individualized, progressive, home-based exercise program. The intervention group will additionally receive (1) 10 telephone-based health coaching sessions, (2) smartphone with data plan, if needed, (3) supportive health tracking software , and (4) a wearable step-counting device linked to a smartphone program.We will be assessing recruitment rates; acceptability reflected in selective, semistructured interviews; and enrollment, retention, and adherence quantitative intervention markers as pilot outcome measures. The primary clinical outcome will be directly measured peak oxygen consumption. Secondary clinical outcomes include health-related quality of life and anthropometric measures. All outcome measures are administered at baseline, after exercise program (month 3), and 6 months after program (month 9).This pilot RCT will inform full-scale RCT planning. We will assess pilot procedures and interventions and collect preliminary effect estimates.ClinicalTrials.gov NCT02620735; https://clinicaltrials.gov/ct2/show/NCT02620735  Breast cancer, the most frequently diagnosed female cancer, accounts for approximately 25% of new Canadian cancer diagnoses . With imDespite these improvements, breast cancer treatments can result in the long-term effects of chronic pain, fatigue, neuropathy, functional limitations, sleep disturbance, sexual dysfunction, infertility, cognitive impairment, cardiorespiratory dysfunctions, and generally reduced well-being -14. BreaPhysical activity can improve cancer outcomes and quality of life while reducing adverse effects and risks. Moderate-to-vigorous physical activity (MVPA) during or after breast cancer treatment is specifically associated with reductions in cancer-specific and all-cause mortality ,24. As rThe American College of Sports Medicine (ACSM), the American Cancer Society, and Worldwide Cancer Research  recommend 150 minutes per week of moderate intensity physical activity for cancer survivors -37. WhilNonetheless, the impact of a cancer diagnosis often stimulates patients to reconsider lifestyle modification ,46,50-52MVPA benefits following breast cancer diagnosis are only maintained for as long as exercise behaviors continue -72. TherDespite varying reports of barriers, the long-term maintenance of and adherence to MVPA protocols in cancer survivors has not been adequately studied -84. For Not surprisingly, the health behavior change methods guiding counseling in long-term MVPA maintenance have been inadequately tested in breast cancer survivors. Patient-centered interventions affecting multiple factors  ,89 have Implementation of theory-based behavior change models for breast cancer survivors aimed at longitudinally maintained MVPA must account for treatment-related sequelae, including adaptations that distract from or discourage health behaviors . Accordingly, healthy physical activity promotion requires a cognitive component that emphasizes protective MVPA effects  and a cognitive-behavioral component that assists incremental physical activity increases. Exercise prescriptions identify protective goals while carefully incremented training programs assist breast cancer survivors with immediate experiences of improved fitness, well-being, and achievement.Counseling strategies for improving MVPA can benefit from Internet linkage, smartphone use, and wearable technologies. As of 2012, high proportions of Canadian households access broadband Internet, with mobile services adopted by nearly 80% . ConcomiIn support of health behavior change, Internet linkage can provide timely reminders, assessments, behavior-tracking, and “just in time” reinforcement . SupportDespite the accumulating evidence of improved health outcomes with mobile technologies in diabetes, asthma, cardiovascular disease ,103,108,Aim 1: To evaluate recruitment, retention, and adherence with a goal of recruiting more than 40% of eligible, contacted patients, retaining more than 75% of participants until the 6-month assessment, and seeing more than 70% of intervention components completed.Aim 2: To evaluate acceptability feedback for intervention modification in the anticipated full-scale RCT.Aim 3: To determine pilot estimates of intervention efficacy on fitness (primary outcome) and patient-reported, anthropometric, physical, and psychosocial outcomes (secondary outcomes).This pilot RCT will enroll physically inactive breast cancer survivors stratified by age (55 years and older/younger than 55 years) and adjuvant hormone therapy (AHT) exposure (AHT or no AHT). Recruitment will be undertaken through the Princess Margaret Cancer Centre (PMCC), and interventions will occur at the Electronic Living Laboratory for Interdisciplinary Cancer Survivorship Research (ELLICSR), the Cancer Survivorship and Wellness Centre located at the Toronto General Hospital. Both institutions are members of the University Health Network in Toronto, Ontario, and research ethics board approval was obtained from the University Health Network (13-6157-DE). The trial is registered at ClinicalTrials.gov [NCT02620735].Adult (aged 18 to 75 years) female breast cancer survivors deemed disease-free after primary cancer treatment are eligible. See After identification from weekly generated clinic lists and chart reviews, patients will be approached by a member of their clinical team, and interested patients will meet with a research assistant for additional study explanation and eligibility screening. Participants will also be recruited by advertisement flyers located in hospital common areas. Eligibility will be ascertained in person when possible, with written consent obtained in person prior to randomization. After participants complete baseline questionnaires and initial physiological assessments, stratification-related data  will be emailed to a biostatistician in the Department of Biostatistics at PMCC who will perform randomization and then send a study identification with intervention or control group allocation.Inclusion criteria:Less than 2 years of completion of adjuvant therapy with the exception of hormone therapy for stage 0 to IIIASelf-report of fewer than 60 minutes of weekly preplanned physical activityPhysician clearance for moderate-to-vigorous physical activityEnglish proficiencyAbility to attend exercise training sessions and study assessments at prescribed intervals for 9 monthsExclusion criteria:Plans to join a weight loss or exercise program within 9 monthsCurrent pregnancy or planned pregnancy within 9 monthsPlanned surgery during study durationUnwillingness to be randomizedParticipants in the intervention and control groups will receive individualized exercise programming progressing toward the ACSM guidelines of 150 minutes per week of moderate intensity aerobic exercise, 2 to 3 days of resistance training, and routine flexibility training.In the first 12 weeks, intervention and control participants have 1 supervised, facility-based group exercise class plus instruction for 2 additional unsupervised, home-based exercise sessions. Facility-based sessions will be offered at a variety of times and days weekly to accommodate schedules and increase accessibility. From weeks 13 to 26, participants will complete 3 to 5 home-based exercise sessions per week and no facility-based sessions. Each exercise program is individualized based on the initial fitness assessment, physical limitations, and exercise preferences. The exercise prescriptions are developed and monitored by a certified exercise physiologist (CEP) and a registered kinesiologist (RKin) with volume progression over the intervention course see . FacilitIntervention group participants are additionally provided with a technology-enabled health coach intervention (iMOVE) with 3 components: one-on-one telephone-based counseling, supportive health tracking smartphone software , and use of Fitbit and associated software . The iMOVE intervention is intended to enhance sustained behavior change  by integrating several active ingredients outlined in the cancer-survivor behavior change literature ,114 and Theoretical constructs focus on promoting motivation and establishing exercise self-efficacy, exercise social support, and positive exercise-related feelings during the acute intervention (12 weeks) that are sustainable during the postexercise program period (6 months). The telephone-based health coaching component of iMOVE includes 10 30-minute telephone calls with a trained health coach, scheduled at weeks 1, 2, 3, 4, 5, 6, 8, and 12 (during the exercise program) and at weeks 20 and 28 (postexercise program booster sessions). Health coaches with a counseling background in MI and CBT are trained and supervised by a registered clinical psychologist and a Motivational Interviewing Network of Trainers–certified trainer. The training of health coaches involves instructions on breast cancer and related survivorship issues and continual exposure to the multitheoretical approach. Training proceeds weekly from the trial start to end based on case review and participant responses to the approaches implemented. Each health coach call to participants focuses on the assessment and enhancement of motivation, promotion of self-efficacy, and collaborative problem solving. Telephone-based counseling provides several advantages over face-to-face, notably the potential to reach multiregional populations, as telephone access is widely available  and requIn the scheduled telephone-based sessions, participants will interact with the Connected Wellness software  by smartphone or Internet-linked computer. This software, previously found effective with participants diagnosed with type 2 diabetes -123, hasUse of the Fitbit Flex provides further assistance to participants in adhering to recommended physical activity routines and tracking physical activity, notably providing real-time feedback . Additional connectivity in the Health Coach program allows the participant and health coach to jointly explore daily physical activity experiences. Fitbit Flex vibrates when preset goals  are reached and records the steps taken, combining them with user data to calculate distance walked, calories burned, and the duration and intensity of activity. Fitbit Flex also measures sleep quality by tracking periods of restlessness  and the estimated sleep duration. The user can monitor their own activity on the Health Coach platform and create summaries and periodic analyses.As is common with behavioral interventions, a handbook specifies sessional objectives and provides clinical tools for health coaches to use each session. The health coach creates a session-by-session agenda based on patient goals, monitored activity, and motivations as collected with the software during intervals between sessions and at each session. MI and CBT are the core health behavior change theories employed. MI is a collaborative counseling method that elicits and strengthens motivation for change by addressing and resolving ambivalence . MI has While there are multiple theoretical models integrated within our intervention, these models are consolidated in the focus on addressing and resolving motivational ambivalence and identification and modification of the cognitive distortions that maintain motivational ambivalence and prevent adoption of appropriate health behaviors.Multifactor focus:Intrinsic motivationsPerceived costs-benefitsIdentification of barriersAbilities to changeExercise self-efficacyExercise social supportPositive exercise-related feelingsApplication of evidence-based theory:Transtheoretical modelSocial cognitive theoryMotivational interviewingCognitive behavioral therapyRelapse prevention theoryTheory of planned behaviorSuccessful physical activity promotion features:Self-directed physical activity with more than 4 sessions of counseling guidanceFollow-up behavioral promptsUnique tailoring to breast cancer survivors:Program pacing per treatment sequelae Cognitive emphasis on protective physical activity effects Cognitive behavioral emphasis on paced, regulated physical activity increasesFlexible exercise prescription for protective goals and incremental increases that optimize fitness and well-beingTechnological assistance:Rapidly increasing role for mobile technology in health managementEnabling patient-provider contacts during critical periodsUser-friendly wearable technologies These measures reflect appropriateness and effectiveness of design features:Recruitment rate: based on Consolidated Standards of Reporting Trials criteria  via a scRetention rate over the trial duration: the percentage of participants who complete the interventions and each data point; with reasons for drop out documented.Capture of outcomes: recording of the proportion of participants at each time assessment point with complete or missing data.Treatment implementation and fidelity: implementation of telephone sessions for the intervention group will be assessed by use documentation of the health coaching techniques and tools and identified barriers. Data from the health coaching software is stored on secure server and used to measure and analyze self-report and health coach activity.Acceptability: telephone interviews will be conducted with a randomly selected subsample (n=25) of intervention participants following intervention completion. The goals are to explore participant perspectives of intervention feasibility and acceptability and to gain an understanding of experiences among those successful and unsuccessful at physical activity maintenance over differing time periods . An interpretive descriptive qualitative methodology will be used , and a rMeasures for fitness (primary), self-report (secondary), and anthropometric and physical outcomes (exploratory outcomes) are repeated at baseline, T1 , and T2 .Cardiorespiratory fitness will be assessed by a graded exercise test using the modified Bruce protocol . DirectlWe will gather preliminary data on a number of exploratory variables which have been identified as important to understanding the potential impact of the intervention on patient-relevant and clinically-relevant outcomes. They are being collected to examine whether they are feasible to collect in a larger trial and whether they are responsive (sensitive to change) to the intervention ,146.Godin-Shepherd Leisure-Time Exercise Questionnaire: a brief validated 3-item questionnaire that asks respondents to report on typical weekly exercise habits Functional Assessment of Cancer Therapy—Breast: generic quality of life measured with 44 self-report items Spielberger's State-Trait Anxiety Inventory—State : a widelCenter for Epidemiological Studies—Depression Scale short form: a 10-item self-report measure of depressionFunctional Assessment of Cancer Therapy—Fatigue subscale : a 13-itBreast Cancer Prevention Trial Symptoms Scale: a 42-item scale to assess side effects associated with the treatment of breast cancerFear of Recurrence Questionnaire: assesses anxiety about breast cancer recurrence Physical Activity Group Environment Questionnaire : assesseBrief Pain Inventory : a widelMultiple Intervention Satisfaction Survey: an investigator-generated instrument that facilitates intervention participants in rank-ordering discrete intervention components with respect to how helpful they are in achieving outcomes during study participation. Additional items facilitate participant suggestions for deleting intervention components deemed (by participants) as of negligible benefit.Body composition is assessed via body mass index, waist circumference, and body fat percentageWaist circumference is measured according to the World Health Organization protocol (midpoint between lowest rib and iliac crest)Body fat percentage is measured using bioelectrical impedance analysis Grip strength is measured using a Jamar dynamometer according to the Canadian Society for Exercise Physiology 2004 protocolRecruitment and retention rates will be assessed  with estg and associated confidence intervals [Variability of the main and interaction effects will be examined in the primary clinical outcome (cardiovascular fitness) and each secondary outcome using separate repeated measures analysis of covariance models with Bonferroni corrections applied to the models. Hedges’ ntervals  will be ntervals . MissingWe previously conducted a simulation for a range of sample sizes and different SD values for precision of the treatment effect estimate. The precision of the estimate is represented by the inverse of the margin of error. Type I error was set at α=0.05 and power at 80%. From our simulation result, a sample size of 35 to 40 was at the elbow point of the curves, indicating the precision of estimates did not proportionally increase with a larger sample size. Therefore, our projected sample size is 80 participants (40 per arm) . With anInterpretation of the effect size and mean difference scores and calculation of the sample size for a larger RCT (fitness outcome) will be based on a minimally important clinical difference (MCD) of 3.5 mL/kg/minute (peak volume of oxygen) between the 2 experimental groups at the 6-month T2 assessment ,160. We While current data suggest an important role for physical activity in disease control and the long-term health of cancer survivors, most breast cancer survivors are inactive. This discrepancy must be addressed with physical activity promotion that supports long-term exercise adherence. To date, research has focused on specific physical activity components linked to clinical benefits, but insufficient attention has been paid to factors influencing long-term physical activity maintenance. The current project employs a behavioral support intervention that assists breast cancer survivors in adopting physical activity and maintaining physical activity adherence. While multiple RCTs demonstrate effectiveness in physical activity participation during trial conduct, decreases in physical activity after trial conclusion are an important concern. It is not yet known the degree to which smartphone-enabled health coaching combined with wearable fitness technology can contribute to the lifestyle changes required for breast cancer survivors to maintain healthy physical activity over the longer term.Our commitment to the devised intervention  accepts the design limitation of being unable to identify which intervention components provide key contributions to significant effects; future studies may be needed to tease out what worked best in further streamlining the intervention. However, we have mitigated limitations by logging all phone counseling calls undertaken  and additionally itemizing and quantifying all use of the health tracking software, Connected Wellness . Furthermore, we track all Fitbit use, including use patterns per time period . Additionally, use of the Multiple Intervention Satisfaction Survey facilitates each participant in subjectively ranking the intervention components on importance and suggesting deletions of components that have not been significantly helpful. These efforts will enable us to learn about the prioritization of intervention components from each subject’s perspective. Another limitation entails not knowing which allocations of staff time (to the intervention) represent a cost savings when compared to other physical activity promotion approaches. Therefore, we will carefully assess staff time, preparing for ascertaining this cost dimension in the future.This pilot will document the implementation of the methods and intervention, preliminary outcomes, and acceptability of the interventions by qualitative interview. It will assess effect size in primary and multiple secondary outcomes with corresponding confidence intervals for more definitive sample size calculations. Although pilot results will provide a foundation for full-scale RCT planning, we anticipate challenges for which we currently have only partial or potential solutions. For example, we will only have suggestive data for assessing specific intervention components and for selecting the optimal subset for full RCT testing. Furthermore, as a pilot study, we are still refining the ultimate sample size of the planned full-scale RCT. Additionally, while control subjects receive an approximation of current standard care for exercise promotion (at ELLICSR), we cannot fully account for the attentional differences in intervention and control conditions. Nonetheless, this pilot is a distinct step forward in addressing a gap in the promotion of longer term exercise adherence for breast cancer survivors.