The primary aim of this study was to examine the self-reported, routine clinical practice behaviors of Australian optometrists with respect to advice regarding smoking, diet and nutritional supplementation. The study also sought to assess the potential influence of practitioner age, gender, practice location , therapeutic-endorsement status and personal nutritional supplementation habits upon management practices in these areas.A survey was electronically distributed to Australian optometrists . Respondents anonymously provided information about their personal demographics and lifestyle behaviors  and routine patient management practices with respect to advice across three domains: smoking, diet and nutritional supplementation. Multivariate logistic regression analyses were performed to assess for potential effects of the listed factors on practitioner behavior.A total of 283 completed surveys were received (completed survey response rate: 6.7%). Fewer than half of respondents indicated routinely asking their patients about smoking status. Younger practitioners were significantly (p < 0.05) less likely to enquire about patients’ smoking behaviors, but this did not extend to counseling for smoking cessation. Almost two-thirds of respondents indicated routinely counseling patients about diet. About half of practitioners specified routinely asking their patients about nutritional supplement intake; this form of questioning was significantly more likely if the respondent was female (p < 0.05). Practitioners who recommended nutritional supplements most commonly did so for age-related macular degeneration (91.2%) and dry eye disease (63.9%). The primary source of evidence used to guide practitioners’ nutrition-related patient management was reported to be peer-reviewed publications.These findings demonstrate that there are no clear predictors of practitioner behavior across the three domains. Overall, this study suggests that there is scope for Australian optometrists to improve their routine engagement by questioning patients, as well as providing evidence-based clinical advice, about smoking status, diet and nutritional supplement behaviors, being key modifiable lifestyle risk factors with long-term implications for eye health. Cigarette smoking, diet and nutritional supplementation are major modifiable lifestyle factors that can strongly influence the long-term risk of sight-threatening ocular pathology. Smoking has been causally linked to degenerative eye conditions including cataract,2 and agIn addition to smoking, nutrition represents another important potential avenue for modifying a patient’s longer-term risk of eye disease.,8 ObservAs the major providers of primary eye care, optometrists are ideally positioned, as part of the health care team, to provide patient counseling with regard to these modifiable risk factors for eye disease.–18 In reThe primary aim of this study was to examine the self-reported, routine clinical practice behaviors of Australian optometrists with respect to smoking, diet and nutritional supplementation. The potential influence(s) of practitioners’ age, gender, practice location, therapeutic-endorsement status and personal habits for nutritional supplementation were also examined.A link to a web-based survey was distributed via email to the membership list of Optometry Australia  in November 2013. OA membership is currently held by approximately 93 percent of registered Australian optometrists . The survey was designed to assess both the self-reported personal smoking and nutrition-related attitudes and behaviors of optometrists (these findings have been recently reported ) and theSurveyMonkey online software was used to host the survey, which comprised of 45 questions; the survey is provided as supplementary material . The surpractitioner demographics and lifestyle behaviors: age, gender, practice location , therapeutic endorsement status, smoking status, frequency of nutritional supplement intake over the past year;patient management: (i) smoking: routine smoking questioning (forced-choice: yes/no response), advice about smoking behaviors (forced-choice: yes/no response) and the rationale for not making recommendations with regard to smoking cessation (open-ended text box), (ii) diet and nutritional supplementation: routine questioning of patients with regard to diet and nutritional supplement intake (forced-choice: yes/no response) and practitioner-driven recommendations regarding nutritional supplements (open-ended text box), and (iii) information and evidence base: sources used by respondents to guide patient care in relation to nutritional supplementation  on patients, non-peer reviewed journal articles, peer-reviewed journal article, meta-analyses of clinical trials and other, with an open-ended text box).The survey was pilot-tested by two health practitioners (a pharmacist and an optometrist), who were not involved in the creation of the survey, to assess the clarity of the questions and the length of time required to complete the survey.http://www.wordle.net).Statistical analyses were performed using GraphPad Prism  and the Statistical Package for the Social Sciences . Graphical plots were created using GraphPad Prism. Descriptive statistics were used to analyze practitioner demographics and lifestyle behaviors, patient management  and the sources of information and evidence used by practitioners to guide clinical decision-making. Univariate and multivariate logistic regression analyses were performed to assess for potential effects of practitioner age, gender, practice location , therapeutic endorsement status and personal nutritional supplement intake on patient management. Chi-squared tests were used to compare data consisting of proportions of respondents; an alpha of 0.05 was adopted for statistical significance. Free text responses were used to generate ‘word clouds’, consisting of an image composed of words in which the relative size of the word indicates the frequency in the source text (Survey responses were received from 379 optometrists (response rate: 8.9%) over two weeks beginning 4 November 2013. Data from surveys completed in their entirety  were used for analyses. The mean (± SEM) taken by these respondents to complete the survey was 11.8 (± 0.50) minutes.Respondents varied in age and optometric practice experience ; 42.4% oThe gender split of respondents was: females  and males . Responses were received from optometrists practicing in all Australian states and territories. Based upon postcode, most respondents practiced in a major city (71.0%), with the remainder (29.0%) in regional locations , outer-regional (7.6%) or remote (0.4%) locations as defined by the Australian Standard Geographical Classification—Remoteness Area system, 2010 ). Sixty-In relation to practitioners’ own lifestyle behaviors, only one-percent (n = 3) indicated being ‘current’ smokers, herein defined as a person who smokes more than one cigarette per day, 1 cigar per week or chews 30 grams of chewing tobacco for a month, for at least the past year. Almost one in seven  practitioners indicated having a prior smoking history. Three-quarters of practitioners responded positively to having taken nutritional supplementation over the past year; there was no significant difference in nutritional supplement consumption between genders (p > 0.05). More detailed analyses of the practitioner demographics and personal nutrition-related attitudes and behaviors derived from this survey, which are distinct from the scope of the present paper, are available in a recent publication.Overall less than half of respondents (47.4%) indicated routinely asking their patients whether they smoke(d). No significant association was observed for any of gender , practice location  or therapeutic- versus non-therapeutically-endorsed optometrists (p > 0.05) and these variables were not included in the multivariate analysis .A significant inverse association was found between practitioner age and the likelihood of routinely asking patients about their smoking behaviors Tables  and 3. YOf the respondents who indicated questioning their patients about smoking status, most (80.2%) responded positively to providing recommendations about smoking behavior and this association was highly significant (p < 0.001). Multivariate analyses showed no significant difference in approach between male versus female practitioners (p > 0.05), those practicing in urban versus regional areas (p > 0.05) or therapeutic- versus non-therapeutically-endorsed optometrists (p > 0.05). Unlike the findings relating to smoking questioning, no significant association was found between practitioner age and the likelihood of providing counseling with regard to smoking cessation .Respondents who indicated that they did not routinely make recommendations to patients with regard to smoking behavior were invited to comment on the reason(s) for this in a free-text commentary box. Less than two-thirds of optometrists  indicated routinely counseling their patients with regard to diet. No significant association was found between providing advice regarding diet and practitioner gender (p > 0.05), practice location (p > 0.05) or ocular therapeutic endorsement status (p > 0.05). Although univariate regression analysis suggested older practitioners and those personally taking nutritional supplements over the past 12 months were more likely to provide dietary recommendations to patients, this was not confirmed by multivariate analysis .Slightly more than half of respondents  specified routinely asking their patients if they were taking nutritional supplements. As shown in Respondents were also asked whether they routinely suggest to their patients to use nutritional supplements and to specify the medical conditions underlying these recommendations. Positive recommendations for nutritional supplements were made by 80.2% (n = 227) of practitioners. Unlike the association between gender and asking about supplement use, there was no significant association between a practitioner’s gender and whether they provided advice about nutritional supplementation use to their patients . A negatThe three most common conditions that these practitioners reported to promote nutritional supplementation for were age-related macular degeneration , dry eye disease (63.9%) and eyelid twitching (3.5%); other responses are detailed in Respondents indicated using a range of different resources to guide their clinical decision-making in relation to recommending nutritional supplements to their patients . OverallThis study has analyzed the self-reported clinical management practices of Australian optometrists with respect to smoking, diet and nutritional supplementation. This is the first study to have assessed such practices in optometrists within the southern hemisphere. No previous studies have specifically examined the potential influence of practitioner-derived factors  on patient care in these areas. Furthermore, we examined optometrists’ self-reported behaviors regarding the sources of information and evidence that they use to guide clinical decision marking.A major finding of this study is that fewer than half of respondents indicated routinely enquiring about their patients’ smoking status. Tobacco smoking has significant adverse effects upon eye health; in partiWe acknowledge the limitation of smoking questioning with respect to smoking deception, involving patients failing to self-report as smokers, and the potential misclassification of smoking status. However,Notably, younger optometrists were significantly less likely to ask about a patient’s smoking status but were more likely to provide advice on the use of dietary supplements. A recent European study found age-dependent differences in the knowledge of medical physicians relating to pharmacotherapy for tobacco cessation; physicians aged 50 years or over demonstrated higher knowledge scores than younger doctors.. It is pIn the present study the two most frequent justifications given by respondents for not providing patient counseling to quit smoking were a perception that this form of medical care was primarily the responsibility of the general medical practitioner (GP) and/or a lack of sufficient consultation time to administer such advice. Inadequate training to prepare eye care providers to deliver smoking cessation assistance to patients has been reported as a major barrier to initiating smoking-related counseling. For GPs,in vivo and therefore must derive from dietary sources. Foods rich in these carotenoids include kale, spinach, peas, pumpkin and eggs. The xanthophyll carotenoids have been implicated in a number of essential physiological functions in the retina, including anti-oxidant protection and the filtration of short-wavelength light.[In addition to smoking, nutrition is another potentially modifiable lifestyle factor that can alter a patient’s long-term risk of developing sight-threatening eye disease.,8 A wealth light. Omega-3 th light. DHA and th light. Such bioth light.–12 were th light. and AREDth light.) evaluatth light.Such interactions between nutrition and eye health are clearly relevant to the delivery of primary eye care by optometrists. Specifically, optometrists are well positioned to initiate conversations about their patients’ dietary habits and to advise with regard to whether certain foods and/or nutritional supplements could be beneficial, or otherwise, to ocular health. As a starting point, this could be in the form of simple advice that is supported by the epidemiological evidence, such as that promoted the Macular Disease Foundation Australia, to encourage a healthy well-balanced diet that incorporates the consumption of dark green leafy vegetables daily and oily fish two to three times per week. More advanced, nutrition-focused healthcare could then be achieved through appropriate co-management with GPs and other health professionals, such as dieticians, to achieve desirable lifestyle changes.In the present survey, it was found that almost 40 percent of respondents would not routinely counsel patients about their diet. While it could be suggested that this is due, at least in part, to a relatively weak understanding of the importance of nutrition for eye health, another potential contributory factor is that dietary assessment is perceived as complex and beyond the scope of routine practice for optometrists. There are currently no simple quantitative clinical tools available to eye care providers to assess the key aspects of diet that may be important for eye health. Addressing this issue, along with providing associated education programs, may enable such discussions about diet and nutrition to be implemented more readily into optometric practice.The two eye conditions that practitioners most frequently recommended nutritional supplements for were AMD (91.2%) and dry eye disease (63.9%). The current survey did not seek to assess participants’ knowledge of the possible benefit of nutritional supplementation relative to disease severity, as was undertaken in relation to AMD in a UK demographic. However,Regarding the information and evidence used by respondents to guide their clinical decision-making for recommending nutritional supplements to patients, the most common response was peer-reviewed journal articles (88.5%). These findings contrast to a recent survey, conducted by our research group on the optometric management of dry eye disease, which reported that less than one quarter of respondents identified using peer-reviewed resources to guide their clinical management. The currWe acknowledge some limitations to the present study. With a survey response rate of 8.9% there is the potential for the findings to be influenced by selection bias. In particular, a tendency for individuals who are more engaged with the topic being more likely to provide their response. Our finding that just under half of respondents would routinely enquire about smoking status and nutrition may be an overestimation when applied to the wider Australian optometric population. Indeed, significantly lower rates of smoking questioning have been reported in studies from other demographics.,22 AlthoThe proportion of respondents who reported holding therapeutic endorsement (64%) was somewhat higher than in the general population of Australian optometrists, at 37%. NonethelNevertheless, the population sample accurately reflects both the age and gender distribution of the Australian optometric workforce and is nThe present study provides a valuable insight into the current self-reported practice behaviors of Australian optometrists, as related to smoking and nutrition. The findings suggest that many practitioners do not routinely ask their patients about smoking status, nor do they provide counseling with regard to smoking cessation; younger optometrists (20 to 29 years of age) were less likely to enquire about smoking behaviors than older practitioners. Overall, optometrists tended to provide patient advice in relation to diet and nutritional supplementation slightly more regularly than for smoking. Almost two-thirds of respondents indicated routinely counseling patients about their diet; practitioners who consumed nutritional supplements themselves were no more likely to discuss the use of dietary supplements with their patients. These findings highlight scope to improve patient-related guidance in relation to smoking, diet and nutritional supplementation in Australian optometric practice.S1 FileHard copy of the survey that was electronically distributed to participants.(PDF)Click here for additional data file.


Paraneoplastic syndromes are serious immune caused diseases of the peripheral and/or central nervous system associated with malignant neoplasm. Symptoms develop when antibodies against antigens expressed by tumor cells cross-react with neuronal proteins. Antineuronal antibodies are usually examined in patient’s sera while examination of the cerebrospinal fluid (CSF) often fails. Furthermore, the few previous reports describing CSF data summarized different antineuronal antibodies and/or regarded patients with different neurological symptoms as one group.We retrospectively evaluated data of 18 patients with paraneoplastic syndromes due to anti-Hu antibodies. The study aimed to differentiate patients with peripheral neuropathy and encephalitis by cerebrospinal fluid (CSF) parameters including anti-Hu antibody titers.Our results confirm previous observations that serum titers of anti-Hu antibodies and standard CSF values do not differ between patients with neuropathy and encephalitis. However, analysis of CSF anti-Hu titers and calculating the intrathecal synthesis helped to discriminate between both groups.In conclusion, our results indicate that patients even with one defined antineuronal antibody need to be regarded separately depending on the involved location of the nervous system. We recommend incorporation of anti-Hu analyses in the CSF and calculating the intrathecal synthesis in patients with anti-Hu syndrome. Paraneoplastic neurological syndromes (PNS) are rare neurological disorders associated with malignant neoplasm . The patCSF analysis is crucial in the diagnosis of nervous system infections and inflammatory driven autoimmune diseases. CSF results such as cell count, glucose, total protein, and oligoclonal bands were previously reported in few series of patients with anti-Hu associated paraneoplastic syndromes . Anti-HuThe retrospectively evaluated data originate from 25 patients collected for routine diagnosis in the Hannover Medical School in the time from 1996 to 2015. Only patients who fulfilled the diagnostic criteria of a paraneoplastic syndrome and were tested positive for anti-Hu antibodies in serum by two independent analytical techniques were included in the study. CSF was obtained in all of these patients. The investigation was approved by the local ethics committee of the Hannover Medical School.CSF and serum were analysed by routine methods . CSF leuAnti-Hu antibodies were detected by indirect immunohistochemistry using commercially available cerebellum primate slides (INOVA Diagnostics) and immunoblots with recombinant antigens  according to the instructions of the manufacturers. Anti-Hu antibody titration was performed by indirect immunohistochemistry using cerebellum primate slides with increasing dilutions. The starting dilution was 1:100 for serum and 1:1 for CSF. To obtain an intrathecal synthesis of anti-Hu antibodies the same approach was used to calculate an antibody index (AI) in CNS inflammatory/infectious diseases . Anti-HuP value <0.05 was considered as statistically significant.Fisher’s exact test was performed to assess the association between dichotomous variables. For comparison of two independent groups, the two-tailed unpaired two-sided Mann–Whitney test was performed. For each comparison, a A total of 25 patients with neurological symptoms confirmative with a paraneoplastic syndrome were tested positive for anti-Hu antibodies in serum by using the immunoblot technique. Eighteen patients showed a clear intense band while in seven patients only a borderline or moderate intense band was found. By using immunohistochemistry none of the latter seven patients showed an anti-neuronal staining in the cerebellar tissue, and thus, these patients were considered negative for anti-Hu antibodies. The weak positive immunoblot band was rather the result of a non-specific cross-reaction. In three of these patients concurrent autoimmunological diseases were known . Another patient presented with acute lymphatic leukemia.The remaining 18 patients with intense blot results presented a clear anti-neuronal staining in the cerebellar tissue. The typical staining for anti-Hu antibodies showed a nuclear staining of neurons in the granular, purkinje, and molecular cell layer  involvement Table . DuratioAt first presentation in our clinic, all eight patients reported sensory abnormalities in terms of numbness and tingle paresthesia. Involvement of both hands and feet was found in five patients. In two patients, symptoms were initially restricted to either hands or feet but extended to all extremities in the course of the disease. One patient reported sensory deficits of both feet only which remained localized in the lower extremities. At first examination weakness of extremities was not found, but during the disease course, four patients developed distal arm and leg palsy. Signs of sensory ataxia were found in six patients at first presentation but all patients developed relevant gait disturbance in the course of disease.Electrophysiological examinations revealed axonal damage in all patients, while four patients showed signs of an additional demyelinating damage. In all patients sensory nerves were affected. Four patients showed an additional damage of motor nerves.In seven patients involvement of the rhombencephalon defined as either cerebellar or brainstem symptoms was found Table . The durFour patients suffered from cerebellar and brainstem symptoms including cerebellar ataxia, scanning dysarthria, dysphagia, hemiparesis, oculomotor disturbance , saccadic eye movement, and/or nystagmus. In three patients brainstem symptoms without cerebellar involvement were found including oculomotor disturbance , hemiparesis, and hemihypesthesia. One patient with brainstem symptoms reported numbness on the left side of the face, on the left arm and leg. In this patient, MRI showed a cervical lesion indicating an additional myelitis.Only one patient presented with symptoms of isolated CNS involvement. The other six patients reported numbness and tingle paresthesia of hands and feet as first symptoms. In these patients a concomitant peripheral neuropathy was found. In the disease course these patients developed an additional distal palsy of hands and feet.Limbic encephalitis was diagnosed in three patients Table . The durThree patients showed a slightly elevated CSF cell count between 7 and 28 cells/μl, while in five patients normal cell counts were found  indicating intrathecal IgG synthesis. One of these patients showed a combination of oligoclonal bands restricted to the CSF and identical oligoclonal IgG bands in CSF and serum (type 3). Identical oligoclonal IgG bands in CSF and serum were found in three patients with peripheral neuropathy. Intrathecal synthesis of immunoglobulins of either IgM, or IgG, or IgA occurred in only two patients. Intrathecal synthesis of IgM as calculated by the method of Reiber-Felgenhauer was found in one patient and IgG synthesis in another one patient. Both patients presented oligoclonal bands restricted to the CSF.Five patients with encephalitis showed a slightly elevated cell count between 7 and 11 cells/μl, while in the other five patients normal cell counts were found Table , Fig. 2.Oligoclonal bands restricted to the CSF were found in all ten patients (100 %) indicating intrathecal IgG synthesis. Three of these patients showed a combination of oligoclonal bands restricted to the CSF and identical oligoclonal IgG bands in CSF and serum (type 3). Intrathecal synthesis of immunoglobulins of either IgM, or IgG, or IgA occurred in five patients. One of these patients presented with a combined three-class reaction of intrathecal synthesis of IgG, IgM, and IgA. One patient showed a two-class reaction of intrathecal synthesis of IgG and IgA. The remaining three patients showed an isolated IgG synthesis.Serum anti-Hu titers were available from all 18 patients and were similar in patients with peripheral neuropathy (between 1:1600 and 1:12.800) and patients with CNS involvement  was calculated with the aim to indicate an intrathecal synthesis of anti-Hu antibodies. Intrathecal synthesis of anti-Hu antibodies was found in all eight patients with encephalitis Fig. . In contCranial MRI confirmed the diagnosis of limbic encephalitis in one patient showing T2 weighted lesions in both temporal lobes. In one patient with rhombencephalitis MRI depicted a T2 weighted lesion in the spinal cord. In the other two patients with limbic encephalitis and all seven patients with brainstem encephalitis MRI did not reveal radiological sings of inflammation in the brain. In these patients, only signs of brain atrophy and unspecific vascular lesions unrelated to a paraneoplastic disease were found. Cerebral metastases and leptomeningeal enhancement as a sign of neoplastic meningitis were neither detected in patients with rhombencephalitis nor limbic encephalitis.In 16 patients (89 %) with anti-Hu syndrome a malignant tumor was either known or diagnosed consecutively  and one patient with breast cancer (liver). In the other patients no metastases were found.In this retrospective study, we analyzed characteristics of clinical and immunological features in patients with paraneoplastic syndromes associated with anti-Hu antibodies. Our results show crucial differences in CSF results depending on whether the peripheral or central nervous system is affected. We found that intrathecal synthesis of anti-Hu antibodies discriminates between patients with isolated peripheral neuropathy and patients with encephalitis.It is widely accepted that CSF analysis is essential in the diagnosis of paraneoplastic syndromes . HoweverIt is known that serum titers of anti-Hu antibodies do not correlate with disease progression. In our work, we confirm these previous observations as we found similar serum titers in patients with peripheral and central nervous system involvement. In contrast, all patients with encephalitis displayed an intrathecal synthesis of anti-Hu antibodies, while patients with peripheral neuropathy did not. We hypothesize that these results indicate different disease progression in isolated peripheral neuropathy and encephalitis. It is well known that anti-Hu antibodies react with nuclei of both peripheral and central nervous system neurons . In our Neuropathological brain studies of patients with anti-Hu encephalitis revealed severe loss of neurons in combination with inflammatory infiltrates with predominantly T lymphocytes . These iOur data show that patients with paraneoplastic syndromes due to anti-Hu antibodies need to be regarded separately depending on the involvement of the peripheral or central nervous system. CSF analysis with determination of intrathecal synthesis of anti-Hu antibodies presents an important tool to discriminate these patients. However, with respect to the limited group size a larger multicenter study is needed to confirm our results.CNS, central nervous system; CSF, cerebrospinal fluid; MRI, magnetic resonance imaging; NSCLC, non-small cell lung cancer; OCB, CSF-specific oligoclonal bands; PNS, paraneoplastic neurological syndromes; QAlb, CSF-serum albumin quotients; SCLC, small cell lung cancer


In carotid artery stenting (CAS) procedures, distal embolism, periprocedural stent thrombosis, and 30-day stroke due to the plaque fragmentation and protrusion caused by stent implantation and balloon dilation are frequent complications. In this technical case report, a case is presented of extracranial carotid artery stenosis treated with a covered stent and subsequent implantation of a bare stent. In addition, the possibility is discussed that this new technique prevents the distal microembolic complications, periprocedural stent thrombosis, and 30-day stroke of extracranial CAS. In carotid artery stenting (CAS) procedures, distal embolism due to the plaque fragmentation caused by stent implantation and balloon dilation is the most frequent complication. Periprocedural stent thrombosis, 30-day stroke, and late in-stent stenosis are also possible complications causing serious neurologic problems. During stent implantation and/or balloon dilation before and after stenting, disruption of plaque and distal migration of the plaque particles may cause symptomatic or asymptomatic ischemic events seen on diffusion-weighted magnetic resonance imaging (MRI) even though protection devices are used. Many physicians may encounter plaque particles filling the filter and causing symptomatic cerebral embolism in some CAS cases, especially with ulcerated, fibrofatty plaque and severe stenosis , 2. AddiA 59-year-old male patient suffering from transient ischemic attack (TIA) occurring two times in one year was admitted to our clinic for evaluation for CAS. The last TIA had occurred one week before admission. Doppler ultrasonography (US) and MR angiography (MRA) were performed and fibrofatty, eccentric, short plaque was seen causing stenosis over more than 70% of the proximal part of the left internal carotid artery (ICA). He had been on medicine for hypertension for about 10 years and had been smoking half a pack a day for about 40 years. Daily, 300 mg of acetylsalicylic acid  and 75 mg of clopidogrel  were prescribed and the CAS was planned. Before the procedure, Aspirin and Plavix sensitivity were tested with VerifyNow . The patient was sensitive to Aspirin but resistant to Plavix. Ticlopidine (250 mg)  was ordered two times a day and the procedure was performed two days later. Before the procedure, a diffusion-weighted MRI was performed to detect any new ischemic lesion caused by the CAS procedure. Diagnostic angiograms obtained under local anesthesia showed 75% stenosis consistent with the Doppler US and MRA . HeparinIn CAS, patients are still under high complication rates due to plaque disruption causing distal embolism and plaque protrusion resulting in periprocedural thrombosis, 30-day stroke, and late in-stent stenosis, in spite of the operator experiences and evolving technology that have decreased CAS complications. Current stent designs may trap larger fragments, but they may not efficiently prevent microemboli because gaps between the stent struts are too large. Furthermore, the introduction of proximal and distal protection devices has lowered the rate of periprocedural ischemic complications , 6. EspeStroke seen from 24 hours to 30 days after the procedure is also a major complication in addition to periprocedural stroke . This sun = 3) was seen in 8 patients that had been treated with covered stents for carotid artery stenosis, while no restenosis was seen in their bare stent group [The major causes of late in-stent stenosis seen in CAS cases are the neointimal proliferation caused by self-expending stents, small postprocedural stent dimensions due to inefficient balloon dilation, and plaque protrusion inside the stent . Plaque nt group . The caunt group . In thisAnother advantage of the covered stent is its usability without any distal protection devices in tortuous ICAs, in which a distal protection filter is impossible to place , 6.In conclusion, some suitable cases of carotid artery stenosis have been treated in our clinic by coating the plaque with a covered stent  before implantation of the bare stent. With this technique, the cerebral embolism due to plaque fragmentation and the 30-day stroke and stent thrombosis due to plaque protrusion can be reduced, but the high rate of restenosis in cases treated with covered stents may be still a problem.


However, more specific therapeutic targets to limit axonal damage in MS need investigation and may include such integral axonal proteins such as the collapsin response mediator protein-2 (CRMP-2), a molecule which upon post-translational modification may propagate axonal degeneration in MS. In this review, we discuss the current clinical determinants of axonal damage in MS and consider the cellular and molecular mechanisms that may initiate these neurodegenerative changes. In particular we highlight the therapeutic candidates that may formulate novel therapeutic strategies to limit axonal degeneration and EDSS during progressive MS.Axonal degeneration is a major determinant of permanent neurological impairment during multiple sclerosis (MS). Due to the variable course of clinical disease and the heterogeneity of MS lesions, the mechanisms governing axonal degeneration may differ between disease stages. While the etiology of MS remains elusive, there now exist potential prognostic biomarkers that can predict the conversion to clinically definite MS. Specialized imaging techniques identifying axonal injury and drop-out are becoming established in clinical practice as a predictive measure of MS progression, such as optical coherence tomography (OCT) or diffusion tensor imaging (DTI). However, these imaging techniques are still being debated as predictive biomarkers since controversy surrounds their lesion-specific association with expanded disability status scale (EDSS). A more promising diagnostic measure of axonal degeneration has been argued for the detection of reduced N-acetyl aspartate (NAA) and Creatine ratios via magnetic resonance spectroscopic (MRS) imaging, but again fail with its specificity for predicting actual axonal degeneration. Greater accuracy of predictive biomarkers is therefore warranted and may include CSF neurofilament light chain (NF-L) and neurofilament heavy chain (NF-H) levels, for progressive MS. Furthermore, defining the molecular mechanisms that occur during the neurodegenerative changes in the various subgroups of MS may in fact prove vital for the future development of efficacious neuroprotective therapies. The clinical translation of a combined Na Destructive, inflammatory demyelinating multiple sclerosis (MS) lesions can occur throughout the central nervous system (CNS) with preferential anatomical patterns forming. Clinical symptoms in an MS patient may manifest as a range of neurological deficits, including paresthesia, dysesthesia, weakness, or visual disturbances such as blurring or greying of vision and black spots in the visual field . There have been several risk factors postulated for the development of MS, namely genetic, inadequate exposure to Vitamin D, smoking, Epstein Barr virus infection early in life and geographical in relation to latitude gradient . In apprTherefore, MS is considered a heterogeneous condition where disease features may vary from one patient to another. Despite the different histopathologically characterized lesions of MS, they share common hallmarks that include areas of focal demyelination with inflammatory infiltrating immune cells, along with axonal injury. Contrary to the original focus of research on the autoimmune mechanisms that are operative in MS, there is now clear evidence that axonal damage/loss is the major determinant of profound neurological deficit in MS sufferers. In light of the variable course of the disease and different prognostic outcomes we discuss the possibility that in some subgroups of MS, molecular mechanisms may initiate axonal degeneration as a primary event, preceding inflammatory destruction of myelin, leading to variable capacity for repair and thus variable patient presentation.This review focuses primarily on why MS may progress to permanent disability. The discussion covers clinical, pathological, cellular and molecular mechanisms, which govern axonal pathology in progressive MS, the etiology of permanent neurological disability. The recent advances in biomarkers and possible molecular mechanisms driving axonal dysfunction through ion channel and axonal transport defects will be highlighted with an emphasis on therapeutic targeting in an attempt to halt axonal pathology and hence progression of the disease.Currently there is no clinical, laboratory, imaging or pathological sign of MS that is pathognomonic for the disease. At present, the diagnosis of MS is based on the two McDonald criteria . The firDefining axonal damage during MS, a prediction of progression, has proven somewhat problematic since conventional magnetic resonance imaging (MRI) does not provide clinicians with an accurate interpretation of the underlying pathology. Despite numerous biomarkers of axonal damage being recently reported to be superior in their diagnostic and eventual prognostic capacities for MS progression, limitations still exist for their utility in isolation.Further revision of the McDonald criteria in 2010 has led to a more simplified version of MS diagnosis which now include those patients that present with CIS, either as monofocal or multifocal demyelinating lesions, with involvement of the optic nerve, brainstem and cerebellum, spinal cord and cerebral deep white matter tracts . Such slCurrent MRI technologies are elucidating the substantial involvement of axonal degeneration with increasing disability parameters , previouin vivo has been established through optical coherence tomography (OCT), which measures the thickness of the RNFL [Another non-conventional MRI approach utilized to study axonal degeneration is the magnetization transfer ratio, which has been demonstrated to show strong correlations with the degree of myelin content, therefore serving as an indicator of axonal degeneration . Recentlthe RNFL . It has the RNFL . Given tthe RNFL  have focthe RNFL . A very the RNFL . Such tethe RNFL ,27. Thisthe RNFL ) and broA means by which the degree of axonal degeneration may be studied involves the use of magnetic resonance spectroscopic (MRS) imaging. MRS allows for the detection of changes in metabolites such as N-acetyl aspartate (NAA), a marker of axonal integrity . Reducedper se. In fact measurements obtained from the corpus callosum of patients with CDMS, via the sensitive diffusion fractional anisotropy, could demonstrate reduced size which correlated with patient EDSS but no such correlation could be seen with reduced NAA levels relative to tissue water [However, the MRS signal obtained for NAA may not necessarily correlate with tissue atrophy and axonal damage ue water . Furtherue water . Despiteue water . It is aue water ,44. A fuue water . Therefoue water , its patHowever, these imaging techniques have also been used to study cortical adaptive functions in patients with RRMS, SPMS and PPMS ,48. In tAs axonal degeneration can directly correlate with disease progression, a reliable prognostic biomarker for MS must target the detection of clear, reproducible axonal changes. Even though demyelination is a pathognomic feature of MS, a recent study has identified patients that exhibit a normal baseline MRI but present clinically with optic neuritis, have eventually manifested CDMS . DemyeliDetecting the presence of neuron-specific proteins in the CSF can be a powerful diagnostic/prognostic tool during MS, only if these proteins are shown to be directly correlative to the pathological sequelae of progression, beyond a causal association. Although lumbar puncture is considered as a safe method of obtaining CSF samples, its invasive nature, with requisite continuous sampling, is a limitation for the development of potential prognostic biomarkers of its incorporation in any clinical research study . Despitein situ. For instance, elevated levels of NF-L have been detected in CSF samples from individuals presenting with CIS which have subsequently progressed to CDMS [As neurofilament is an integral protein that forms the axonal cytoskeleton, detection of neurofilament and its breakdown peptides within the CSF or serum can predict definitive axonal damage  to CDMS . More sp to CDMS . These e to CDMS ,60. Circ to CDMS ,62, expe to CDMS ,62.The other major isoform, neurofilament heavy chain (NF-H), has also been found to be elevated in the CSF of all clinical MS types compared with normal healthy controls . In part+ channel blocker, lamotrigine (based on serum lamotrigine adherence) [It has recently been demonstrated that the immunotherapeutic, natalizumab, was shown to limit the rise in NF-L CSF levels during relapsing MS -66. In aherence) . The serherence)  which fuin vivo imaging techniques applied in MOG35–55-EAE-induced mice revealed functional defects in intra-axonal mitochondria occurring even before prominent demyelination. This suggests that axonal mitochondria may be undergoing substantial damage prior to demyelination, indicating that an energy imbalance in axons may be the driver of the axo-glial degenerative phase. Recently, comprehensive reviews have covered the experiments that outline the unique mitochondrial deficits along with the generation of reactive oxygen species (ROS) and reactive nitrogen species (RNS) during the disease course of EAE leading to compromised axonal integrity [Following demyelination, the substantial energy demands placed upon axons, increase the stationary size of mitochondria and the speed of their transport along axonal microtubules . Recent ntegrity ,70 and scox genes, which encode for functional mitochondrial complex I and III activity [Of particular importance to cortical atrophy attributed to MS pathology, whole-genome microarray analysis performed on post-mortem motor cortex tissue obtained from individuals who had exhibited SPMS, have demonstrated the down-regulation of neuronal-specific mitochondrial and activity . In accoactivity . On the activity , collectactivity . This isactivity  when comactivity . What thactivity .35–55-induced EAE could reduce disease severity. Furthermore, immunohistochemical analysis revealed that a higher axonal density in lumbo-sacral spinal cords could be demonstrated only in the trichostatin A treated group [2+-dependent export of class I HDAC1 to the neuronal cytosol. This caused binding of HDAC1 with α-tubulin and kinesin motor proteins (KIF2A and KIF5), which were only detected in demyelinated areas, leading to an impairment of mitochondrial transport in neurons [Dysregulation of mitochondrial transport can also severely impact the energy balance in axons, which may drive axonal degeneration. One scenario by which axonal degeneration may be initiated through mitochondrial dysfunction can be derived from the alterations exhibited in the histone deacetylases (HDACs). For the past decade, many groups have reported that HDAC inhibition was neuroprotective in MS . It wased group . The moled group  who sugg neurons . The sam neurons . As HDAC neurons , the mol139–151-induced EAE within the SJL/J mouse model [35–55-induced EAE mice demonstrated neuroprotection with reduced inflammation and demyelination. Increase in brain-derived growth factor (BDNF) was seen in SIRT1 overexpressed neurons, which may indicate that SIRT1 overexpression can restore BDNF function, subsequently facilitating axonal protection [Sirtuins (SIRT), class III family members of HDAC, have been raised as one of the candidate molecules that may serve as a therapeutic target to treat axonal degeneration in MS. Intravitreal administration of SIRT1 activator, SRT647 and SRT501, was shown to ameliorate retinal ganglion cell loss in PLPse model . The samse model . Furtherse model . Overexpotection . Althougnestin-Cre/loxP-sirt1 transgenic model, can improve remyelination upon lysolecithin-induced experimental demyelination as well as during MOG35–55-induced EAE [A plausible reason to investigate other neural lineages may be as a result of the recent study by Rafalski et al.,  which imuced EAE . As plasuced EAE . Therefo+ channels along denuded axons [+ channels in MS lesions [+ channels in demyelinated axons may produce an increase in axonal membrane potential oscillations [2+, culminating in axonal degeneration [+ within the axon due to the failed Na+ channels and persistent currents [+-Ca2+ exchanger, which normally facilitates Na+ influx, instead functions in reverse mode to offset the rising levels of Na+ within the axon. However, the elevation of intracellular Ca2+ levels, a consequence of the failure in the ion exchanger, leads to the activation of a common pathway precipitating axonal degeneration [The clinical use of sodium channel blockers to treat specific MS symptoms such as carbamazepine  has fuelled interest in the mechanism by which persistent sodium influx can induce axonal injury during the symptomatic phase of MS. It has been posited that periods of remission from MS symptoms, may in-part, be related to a restoration of action potential conduction by Naed axons . Despite lesions . Increasllations , therebyneration . ROS andneration . This encurrents . In respneration  . Not sud the UK .+ and Ca2+ and can contribute to the excessive accumulation of intracellular ions. Both genetic knockout and pharmacological blockade of this ion channel was shown to be neuroprotective in EAE-induced mouse spinal cord tissue [+ and Ca2+ were the targets of amiloride treatment.Another ion-channel blocking strategy set out to target Acid-sensing ion channel-1 (ASIC1), which is permeable to Nad tissue . As thisd tissue , these sd tissue . This ap+ channel blockers during EAE significantly reduce clinical EAE scores, however, upon withdrawal of these drugs, marked increase in clinical severity were observed which were associated with a burst of inflammatory infiltrates within the CNS [+ channels immune cells, thereby exerting its neuroprotective effects via immunomodulation and not directly upon CNS axons as hypothesized. Furthermore, the Phase II clinical trial for lamotrigine (Na+ channel blocker), on secondary progressive MS patients showed exacerbation in motor function abnormalities, which were reverted upon a reduction in the lamotrigine dose [+ channel blocker (CFM6104) specifically targeted the early lesion (inflammatory penumbra) during EAE challenge in Biozzi ABH mice possibly through changes in p-glycoprotein [35-55 EAE model a direct immunosuppressive role for the non-specific Na+ channel blocker Phenytoin highlighted caution for its use in Clinical Trials as the specific cellular target remains clearly unresolved [Although ion channel blockade holds substantial promise to limit axonal damage in MS, studies have reported significant worsening of disease upon withdrawal of specific ion channel blockers, a potentially fatal contraindication ,98. For  the CNS . This maine dose  demonstroprotein , which woprotein . This nooprotein . The autoprotein . Althougoprotein . Furtherresolved . Therefo35–55-induced EAE within a cohort of thy1-YFP reporter mice revealed that significant reductions in inhibitory neurons along with pre-synaptic puncta observed within demyelinating grey matter throughout the hippocampus may be the reason for the reduced spatial learning exhibited by these mice [Retrograde neurodegeneration in demyelinating grey matter lesions within the corpus callosum and hippocampus during neuroinflammation has recently been shown in a marmoset model of EAE as indicated by increased immunostaining of βAPP and decreased neuronal size and number . Furtherese mice . These aese mice . Moreoveese mice . A profoese mice . Decreasese mice . In addiese mice . These rConcerning the mechanisms of cortical demyelination in MS, the literature provides several likely hypotheses. Bruce Trapp’s group support the contention that alteration in glutamate uptake from hippocampal demyelination can cause neuronal energy imbalance thereby potentiating neurodegeneration . A wholeThere exists evidence to suggest that the initiation of an autoimmune response can occur via the recognition of the glycoprotein autoantigen, contactin 2, on/near the endothelial cells of the grey matter by autoantibodies, type 1 helper T cells (Th1) and type 17 helper T cells (Th17) . It is tIt is known that failure in axonal transport is one of the main causes of Wallerian degeneration . Axonal CRMPs are a family of neuronal phosphoproteins  which reIn terms of a pathogenic role attributed to the phosphorylated forms of CRMP-2, there is a clear link with the neurodegenerative processes of Alzheimer’s disease (Aβ-mediated phosphorylated CRMP-2) ,134. RecCalpain-mediated cleavage of integral myelin proteins, including myelin basic protein, has been proposed as a prominent pathological mechanism leading to profound demyelination during EAE disease onset and progression . Indeed,2+-influx and the release of intracellular Ca2+ stores are plausible mechanisms by which axonal degeneration is potentiated during CNS injury and disease [Calpains are members of the highly conserved calcium-dependent proteases capable of cleaving a vast array of cellular proteins . Calpain disease , the ref+ and subsequently Ca2+ influx. The sustained activation of calpain can lead to axonal degeneration, a hallmark of the pathophysiology of EAE [v1.6-positive axons  in spinal cords of MOG35–55-induced EAE mice [Two major isoforms of calpains exist namely, calpain-I  activated at micromolar concentrations, and calpain-II  activated at up to millimolar concentrations . In EAE,y of EAE . Preservy of EAE . This iny of EAE . Hassen y of EAE , have reEAE mice . These din vitro, and calpain-mediated cleavage of CRMP-2  through the dysregulation of axonal transport machinery which may include abnormal modifications to the microtubule-associated proteins such as CRMP-2, thereby culminating in catastrophic damage of the axonal cytoskeleton. As current immunomodulatory therapies are limited in their ability to reduce relapses and in many ways ineffective during SPMS or PPMS, future therapies must be designed to halt the progression of clinical severity. From pre-clinical and clinical data, it is becoming evident that axonal injury is directly related to clinical progression. Therefore, ameliorating axonal damage during MS can limit the severity of disease to enhance the quality of life for MS sufferers. However, the mechanisms of potential therapy targeting axonal degeneration must be clearly defined with the potential effects upon non-neuronal cells, documented to ensure disease stage specificity without contraindications for MS patients.Permanent neurological deficits in MS are governed by CNS axonal degeneration of major fiber tracts but the molecular mechanisms, which contribute to this damage, are poorly understood. The major contributors to axonal damage and loss may include: (1) axoplasm energy depletion caused by mitochondrial injury elicited through a hypoxic environment of sustained ROS and RNS, generated through activated microglia; (2) increased expression of Na


The Hedgehog pathway is a pivotal morphogenic driver during embryonic development and a key regulator of adult stem cell self-renewal. The discovery of resident multipotent vascular stem cells and adventitial progenitors within the vessel wall has transformed our understanding of the origin of medial and neointimal vascular smooth muscle cells (SMCs) during vessel repair in response to injury, lesion formation, and overall disease progression. This review highlights the importance of components of the Hh and Notch signalling pathways within the medial and adventitial regions of adult vessels, their recapitulation following vascular injury and disease progression, and their putative role in the maintenance and differentiation of resident vascular stem cells to vascular lineages from discrete niches within the vessel wall. Hedgehog signalling is a critical component of the transcriptional machinery that drives early vascular development , ischemiThe Notch pathway embodies a cell-cell signaling system that primarily governs cell-fate choices, and more in particular controls the balance between commitment to differentiate and repression of differentiation while permitting, or even promoting, proliferation of the undifferentiated cells (reviewed ). Notch Resident stem cell niches are generally regulated in specialized microenvironments by complex interacting signalling networks that provide cues for self-renewal, differentiation, migration, and retention. It has been known for some time that the Hh pathway is a crucial component for maintenance of stem cell niches where it is associated with the promotion of stem cell self-renewal , 16. in vitro and phenotypic changes during vascular remodelling in vivo [Vascular SMC biology has been at the forefront of cardiovascular disease research for the last 50 years. The classic concept of dedifferentiation and “phenotypic modulation” of vSMCs was first developed to explain vSMC proliferation and growth in vivo , 18. How in vivo .In this paper, we review the current status of Hh signalling and its interaction with Notch and propose how recapitulation of Hh and Notch signalling components within the vasculature may act to coordinate SMC accumulation through the regulation of resident vascular stem self-renewal and differentiation to SMC and contribute to vascular disease by promoting vascular remodelling. Hh gene family encode 45 KDa precursor proteins, which undergo autoproteolysis to produce a 20 KDa N-terminal fragment (Hh-N) that is covalently bound to a cholesterol molecule at its C-terminus and a 25 KDa C-terminal fragment (Hh-C) that is later degraded by the ER-associated degradation pathway  and its role as a key mediator of numerous cellular and developmental processes have greatly enhanced our collective understanding of numerous developmental pathways . The Hh  Figures . Hh-N ha Figures . These lHh ligand secretion is accomplished via two distinct and synergistic cholesterol-dependent binding events, mediated by two proteins that are essential for vertebrate Hh signaling: the membrane protein Dispatched (Disp) and a member of the Scube family of secreted proteins. Cholesterol modification is sufficient for a heterologous protein to interact with Scube and to be secreted in a Scube-dependent manner. Disp and Scube recognize different structural aspects of cholesterol similarly to how Niemann-Pick disease proteins 1 and 2 interact with cholesterol, suggesting a hand-off mechanism for transferring Hh from Disp to Scube. Thus, Disp and Scube cooperate to dramatically enhance the secretion and solubility of the cholesterol-modified Hh ligand .The Hedgehog (Hh) signalling pathway relies on the primary cilium to regulate tissue patterning and homeostasis where ciliary localization and trafficking of Hh components lead to pathway activation and regulation. Recent studies reveal specific roles of discrete ciliary regulators, components, and structures in controlling the movement and signaling of Hh components. Active Hh signalling is associated with increased levels of Hh components along the primary cilium or in a ciliary subdomain , 26. On  Ptch1−/− is embryonically lethal in mice. In the absence of Hh, Ptch catalytically represses the seven-transmembrane protein Smoothened (Smo) [Downstream signalling of the hedgehog pathway is stimulated when Hh binds to the integral-membrane protein Patched (Ptch). There are two distinct homologs of the Ptch gene  in vertebrates that are differentially expressed during development.ed (Smo) . The exaed (Smo) . The subed (Smo) . Gli1 aned (Smo) . In the ed (Smo)   .A number of other signal pathways are also regulated by the Hh-ligands. These include those involving Rac1, Protein kinase C, and MAP kinase, which respond to Hh signalling in a Smo-dependent manner –37. SomeAnalysis of Shh and Ihh expression during different time-windows of mouse embryogenesis has demonstrated the importance of Hh signalling in the development of the mouse vasculature (reviewed ). Hh tar sonic you (Syu), the gene that encodes the zebrafish homolog of Shh, have determined that Hh signalling mediates the arterial-venous determination by regulating the Notch pathway via VEGF  had been implicated in atherosclerotic lesions and neointimal formation for some time . Originabilities , 71, 77  In vivo studies confirmed their ability to contribute to vessel morphogenesis in mice, a process that was enhanced by the application of VEGF, FGF-2, and TGF-β1 [Other multipotent stem cells that reside within vasculogenic zones of the adventitial and medial layers of the vessel wall have also been reported , 78, 79 d TGF-β1 . in vitro, demonstrating their multipotency  may contribute in part to vascular remodelling and disease progression . These cr, Sox17 . Additioin vitro .− negative medial MVSC-derived SMCs [ in vitro and in vivo have also been presented [ Cre-LoxP transgenic mice to the neointimal layer using confocal microscopy, as many as 60% of cell population in some vascular sections are MYH11− negative following vascular injury [− negative MVSC-derived SMCs are present in the vessel wall raises the further possibility that most SMCs in culture are also derived from a resident medial stem cell population during the culture process underscoring the potential importance of this medial MVSC population to vascular biology in general [The majority of medial differentiated SMCs within the uninjured vessel wall are positive for MYH11 , 88, 89.ved SMCs  in additved SMCs , 93. Corresented  versus iresented , 93 systresented  and humaresented  are mult general –97. in vitro and neointimal SMCs within vascular lesions in vivo awaits a more rigorous use of a conditionally regulated SMC lineage tracing systems using the MYH11 gene in addition to other specific genes for differentiated SMC, such as SM22α and smoothelin B [+ and Sca1+ cells are significantly increased following vascular injury [β as an injury-activated messenger essential for the mobilization and recruitment of MSCs to participate in tissue repair/remodelling, a role for resident Nestin+ and Sca1+ cells cannot be ruled out.Consistent with the niche function of both adventitial and medial vasculogenic zones, APCs and medial MVSCs have been reported in rodents , 63, 67 thelin B . In addir injury . While t in vitro [β/Smad3 stimulates stem cell/developmental gene expression and SMC dedifferentiation in vitro [Finally, there is also increasing evidence that supports the plasticity of differentiated SMCs, and it is highly likely that SMCs may also dedifferentiate or transdifferentiate in response to specific environmental cues to a more plastic stem-like state. Such plasticity of dedifferentiated SMCs may be the ultimate driver for various vascular pathologies. Indeed, murine SMCs are capable of transdifferentiation to macrophage-like cells following cholesterol treatment , in addiin vitro –104. Morin vitro . Finallyin vitro  further β1, and Hh [It is therefore likely that a delicate balance exists between stem cell differentiation and self-renewal to drive vessel regeneration, resulting in ordered layers of functional differentiated SMCs and residual stem cells responsible for renewal and repair. Such a scenario has been documented for prostate cancer (reviewed ). In add, and Hh , 109.The clear importance of Hedgehog (Hh)/Notch signalling axis in vascular development  suggests in vitro [ in vivo in uninjured vessels is the adventitia [+ progenitor stem cells in normal vessels only to reappear within the media and intima following vascular injury [+ population at the adventitial boundary and/or transition of resident stem cells within the medial layers of the blood vessel wall. Indeed, Sca1+ cells in late embryonic and early postnatal mice require Shh signalling for their self-renewal since a restricted domain of Shh signalling has been localized to the arterial adventitial APC niche within the artery wall [+ progenitors also notably contribute to neointima formation in vein grafts from atherosclerosis-prone apolipoprotein E-knockout mice [Several groups have demonstrated that Hh signalling components promote changes in SMCs phenotype and growthin vitro , 56, 57,r injury  is instrery wall . Sca1+ pout mice  and cellout mice , 113. Moout mice . Shh is out mice . in vivo attenuated medial intimal hyperplasia concomitant with a reduction in adventitial volume [+ progenitor cells and/or differentiation of stem cells to SMC thereby decreasing the number of medial and intimal SMCs present within the lesion. Hh signalling is known to promote the growth of human pulmonary SMCs following hypoxic injury [The functional importance of activation of Hh positive cells in the pathogenesis of vascular proliferative disease is further validated following specific knockdown of the Hh signalling pathway within the vessel wall following perivascular delivery of Ptch1 siRNA . Althougl volume , it is nc injury . Importac injury .+ also differentiates to SMC by adopting an elongated, mesenchymal cell shape and expressing SMA, SM22α, calponin1, and SM-MHC [+ transition to SMC in vitro [ in vivo using a neutralising antibody (5E1) strategy resulted in decreased plasma cholesterol levels but increases atherosclerosis due to enhanced lipid uptake by macrophages [The different patterns of Notch receptor expression in vascular tissue suggest that Notch receptors may also have distinct roles in SMC function . Howeverd SM-MHC . Howeverd SM-MHC . Intrigud SM-MHC . Moreovein vitro . Finallyrophages .β1-) induced expression of the Notch ligand Jagged 1 is known to act on MSCs and promote vSMC marker expression [+ cells from various tissues and plays a significant role in their self-renewal [+ adventitial vasculogenic zone in vivo [γ-secretase Notch signalling inhibitors, DAPT and L-685,458, respectively, implicating a Hh-Notch role in MSC-like cell transition to SMC .Transforming growth factor-beta 1- (TGF-pression . While N-renewal , Notch1  in vivo , 116. Inn to SMC . Considery models, a direcrt MVSCs  have pre+ precursor appears to represent an immediate vascular precursor predisposed to a SMC fate in the presence of Notch activation, regardless of the embryonic tissue from which the cells originated [While a direct role for Notch in the regulation of medial MVSCs has not yet been fully investigated, a putative role is strongly implicated as activation of Notch signalling in MVSCs directs their differentiation into mature SMCs when cocultured with OP9-Delta1 Notch ligand presenting feeder cells . This isiginated .The colocalisation of Hh responsive cells within the adventitial regions of normal vessels, in conjunction with the recapitulation of Hh and Notch components within the medial layer concomitant with the appearance of stem cell derived SMCs following injury, raises the likelihood that a Hh-Notch responsive resident stem cell population is responsible for the generation of neointimal SMCs to support vascular remodelling and neointimal formation during disease progression. Interestingly, previous GWAS studies have reported 13 loci with risk allele frequencies associated with an increase in the risk of cardiovascular disease, one of which is associated with Hh signalling . Notably


Legumes play a vital role in ensuring global nutritional food security and improving soil quality through nitrogen fixation. Accelerated higher genetic gains is required to meet the demand of ever increasing global population. In recent years, speedy developments have been witnessed in legume genomics due to advancements in next-generation sequencing (NGS) and high-throughput genotyping technologies. Reference genome sequences for many legume crops have been reported in the last 5 years. The availability of the draft genome sequences and re-sequencing of elite genotypes for several important legume crops have made it possible to identify structural variations at large scale. Availability of large-scale genomic resources and low-cost and high-throughput genotyping technologies are enhancing the efficiency and resolution of genetic mapping and marker-trait association studies. Most importantly, deployment of molecular breeding approaches has resulted in development of improved lines in some legume crops such as chickpea and groundnut. In order to support genomics-driven crop improvement at a fast pace, the deployment of breeder-friendly genomics and decision support tools seems appear to be critical in breeding programs in developing countries. This review provides an overview of emerging genomics and informatics tools/approaches that will be the key driving force for accelerating genomics-assisted breeding and ultimately ensuring nutritional and food security in developing countries. Arachis hypogaea) and soybean (Glycine max) play important role in the production of cooking oil and other confectionaries preparations to the consumers. The unique ability to fix atmospheric nitrogen by the legume crops play a crucial role in sustaining the farming system by making available the residual nitrogen to the non-legume crops. Legumes also serve as an excellent source of high quality and nutritious feed to livestock leading to ∼20% increase in animal productivity , winged bean , cowpea , groundnut (24–34%), mung bean (Vigna radiata), pea , moth bean (Vigna aconitifolia), urd bean , lentil , grass pea , chickpea , horse gram (Macrotyloma uniflorum), pigeonpea , and rice bean  and genotyping technologies need to be used for precise marker-trait association, gene discovery, functional marker development, and their deployment in routine breeding programs. The detailed information on the availability of genetic and genomic resources in important legumes has been extensively reviewed in many articles  are currently available. As a result, the sequence-based genotyping (SbG) methods are becoming popular and method of choice for understanding the genetics of complex traits both in plants and animals. So far the SbG technologies have been deployed extensively in genetic mapping, purity testing, establishing marker-trait associations, marker-assisted selection (MAS), and genomic selection (GS) for crop improvement see . These tTM which is based on restriction digestion of DNA using methylation sensitive restriction enzyme that reduces the complexity of two or more genetically diverse samples are prepared by AFLP. High conversion rate to genotyping assays makes it more attractive for medium to large scale genotyping particularly for SNPs in low or single copy genome sequences. While Amplicon based targeted sequencing is amenable for addressing questions in population genetics and systematics that rely on sequence specific genes of known function or diversity levels . HoweverOryza sativa; 50 K SNPs; Zea mays; 616 K SNPs; In recent years, exome sequencing technique is gaining importance as this enables discovery of many low-frequency and rare coding variants that need to be examined systematically for association with complex traits in both plants and animals . VariousArabidopsis  was the first plant species for which genome sequencing was completed  by International Chickpea Genome Sequencing Consortium (ICGSC). Around 153 Gb sequence data were generated using Illumina sequencing technology of which 87.65 Gb of high-quality sequence data were assembled into 544.73 Mb of genomic sequence scaffolds representing 74% of chickpea genome  and B-genome  together represent the tetraploid genome of cultivated groundnut (Arachis hypogaea). In this context, a total of 216 Gb WGS data at 154.4X coverage for accession V14167 while 168.8 Gb data at 120.6X coverage for accession K30076 were generated  successfully sequenced the genomes of diploid groundnut progenitors. The progenitors representing A-genome (enerated . In addiCajanus accessions from reference set were re-sequenced using WGRS approach and were used to identify 13.8 million sequence variations (SNPs and InDels) with average of 41.1 variations per Kb , backcross inbred lines (BILs), near isogenic lines (NILs), advanced intercrossed lines (AILs), or double haploid populations in crop plants. On the other hand, germplasm sets were used for association mapping. All the above mentioned mapping populations had a major disadvantage that only few traits can be mapped. Realizing the long time spent in developing these populations, the recent trend has shifted in development and deployment of multi-parent mapping populations. These populations include nested association mapping (NAM) and multi-parent advanced generation inter-cross (MAGIC) populations . Gene discovery activities in the past were limited by the extent of availability of genomic data in a crop but with NGS technology there is a need to redesign the way to understand the genetics of traits of interest. These populations have advantages of both bi-parental (high power of QTL detection) and association mapping  approaches need to be used. Marker-assisted backcrossing (MABC) for improvement of single or multiple traits (gene pyramiding) is the most successful GAB approach which has helped in the development of several improved varieties and lines in many crops. However in order to deploy GAB, the identification of genomic regions either through linkage mapping or association mapping is mandatory for the traits of interest. There are three trait mapping approaches using forward genetics namely (1) linkage mapping/quantitative trait locus (QTL) mapping, (2) association mapping/linkage disequilibrium (LD) mapping, and (3) joint linkage-association mapping (JLAM). Majority of the linkage mapping studies used either Fulations  , NAM population is being developed. In this regard 10 different F1 combinations were generated by crossing Asha variety (ICPL 87119) with 10 different elite pigeonpea lines. As a result a total of 10 NAM-F2:3 populations were developed. These developed populations are currently being genotyped through GBS based approach and phenotyped for the target traits for identification of marker-trait associations. Similarly, in the case of groundnut, two NAM populations, i.e., one each for Spanish type (ICGV 91114 and 22 testers) and Virginia type (ICGS 76 and 21 testers) are being developed at ICRISAT.The NAM populations are currently being developed at ICRISAT see . In the The MAGIC population is generated from multiple parents (4–8) of diverse origins including alien backgrounds possessing desired features to bring multiple favorable alleles in multiple combinations in the population. This population allows both coarse and fine mapping and the complex architecture of many traits which are associated with crop yield and quality can be deduced using epistatic interactions . MAGIC pThe MAGIC populations are currently being developed at ICRISAT see . In the 1s) followed by funnel based mating design (14 four-way and 7 eight-way F1s) was utilized for the development of MAGIC lines. Currently, 7 eight-way F1s are being selfed in the controlled conditions for the development of high resolution MAGIC lines. In the case of groundnut, three MAGIC populations are under development targeting different trait combinations. The first MAGIC population  targets different traits such as fresh seed dormancy, oil content, seed mass, kernel Fe and Zn content, aflatoxin tolerance, stem rot tolerance, and PBND tolerance. The second MAGIC population targets the different components of aspergillus resistance and aflatoxin contamination while the third one targets different component traits of drought tolerance. The genotypes for aflatoxin resistance include 55-437, ICG 51, ICGV 12014, U4-7-5, VRR245, ICGV 88145, ICGV 89104, and ICGV 97278 while for drought tolerance include ICGV 02022, ICG 7190, ICGV 97183, ICG 3053, ICG 14482, ICG 11515, TAG 24, and ICGV 02266.In pigeonpea, MAGIC population is also being developed to enhance the genetic base and to identify the marker trait associations. A total of eight diverse founder parents  were selected for the development of MAGIC population. Half di-allele crossing approach . The brief description of the specific approaches and current status in different legumes are given below.Advances in NGS technologies and a steeper drop down in the cost of sequencing provides a significant opportunity for trait mapping at sequence level and selection of plants at nucleotide levels. Traditional approaches of trait mapping were time-consuming and costly in comparison to NGS-based approaches. Recently, a large number of sequencing-based approaches have been proposed and used for trait mapping, which can be mainly classified in two groups (i) trait mapping through sequencing of complete populations and (ii) trait mapping through sequencing of pooled samples  associated with RKN resistance in soybean  and chickpea using SkimGBS. GWAS based gene enrichment analysis of skim sequenced data of RIL population in chickpea was useful to split the earlier identified “QTL-hotspot” in two sub-regions viz. “QTL-hotspot_a” and “QTL-hotspot_b” of 139.22 and 153.36 Kb sizes, respectively (Hordeum vulgare) and wheat ,” the strength of RNA-seq approach was combined with BSA and new genetic mapping approach to identify candidate genes for the target trait. This strategy has been successfully applied for the identification of of maize . Similarin wheat . This apFigure 1). Whole genome bisulfite sequencing (WGBS) and chromatin immuno precipitation-sequencing (Chip-Seq) are the two important approaches for mapping epigenetic factors. In case of WGBS, the NGS based technologies enable us to find genome-wide 5-methylcytocine, in rapid and precise manner. Methylation of DNA cytosine plays a significant role in many cellular processes, including expression of the gene. DNA methylations have been playing an important role in the understanding of the molecular mechanism of heterosis. NGS-based WGBS approach has been found promising for understanding the molecular mechanism of heterosis in Arabidopsis, rice, and maize  . Transcriptome sequencing is a better alternative approach to genome sequencing for targeted expressed gene sequencing. Furthermore, global gene expression analysis provides insights into gene function and molecular basis of various cellular components and transcriptional programs. Therefore, in legumes, to begin with, efforts have been focused on the development of cDNA libraries, generation of expressed sequence tags (EST), gene expression analysis, and the in silico mining of functional information from EST data sets even before genome sequences became available. The transcriptome sequencing has been applied for various other functional genomics approaches such as gene expression profiling, genome annotation and discovery of non-coding RNA, etc.  with an average contig length of 459 bp . In a diTranscriptome assemblies generated using different sequencing technologies or in combination of two or more sequencing technologies provide valuable transcriptomic resources such as functional markers  for use in crop breeding programs. For example, a total of 1,682 and 4,099 SNPs were identified in soybean  and commFigure 1). The above developments will ensure higher integration of ‘omics’ information with crop breeding leading to evolution from GAB to omics-assisted breeding (OAB) in coming years.Advances in ‘omics’ technologies provide opportunities through which new datasets can be produced for crop plants. This is particularly important in crop research to identify candidate genes and pathways involved in important agronomic traits, especially through the integration of genomics and functional ‘omics’ data together with genetic and phenotypic information  , identification of posttranslational modifications (PTMs) and interaction networks through protein–protein interactions PPI; . TranslaAdvances in mass spectrometry (MS) applications in terms of speed, accuracy, sensitivity, and software tools have been instrumental for high-throughput protein quantification. Quantitative proteomics platforms have emerged due to advances in MS technologies for high-throughput protein quantifications and involve gel-based or gel-free, ‘shot-gun’ and ‘label-based’ (isotopic/isobaric) or ‘label-free’ approaches . Gel-basProteomics studies in legumes have been carried out mainly in the model systems, Medicago and Lotus  or soybeIn crop legumes, differential expression analyses and comparative proteomics approaches have provided insight to stress responses. Some examples include dehydration in chickpea , early pMetabolomics approaches involve the identification and quantification of low molecular weight metabolites in an organism, at a particular developmental stage in a specific organ/tissue/cell and have been successfully implemented to investigate the molecular phenotypes of plants in response to abiotic stress . High-thThe two main metabolomics profiling strategies using MS and nuclear magnetic resonance (NMR) have been described in the literature. A wider coverage of the great number of metabolites in plants has been obtained through the combination of several analytical techniques that usually consist of a separation techniques coupled to MS –TOF–MS for metabolic profiling . A couplThe integration of metabolomics with transcriptomics datasets, high-throughput phenotyping and bioinformatics platforms, for profiling of large and genetically diverse populations, will enable the identification of novel metabolic QTLs and enhance the identification of candidate genes for trait of interest. Also metabolomics used as an additional tool with genomics-assisted selection strategies for crop-improvement, reduces the times spent for the discovery of new traits and allelic variations .3 has been developed to help breeders to manage their day-to-day activities through all phases of their breeding programs. The BMS Workbench is useful from straightforward phenotyping to complex genotyping. It provides all the tools needed to conduct modern breeding in one comprehensive package including, project planning, germplasm management, germplasm evaluation, molecular analysis, data analysis, and breeding decision support . Identification of marker-trait associations through detailed analysis of genotypic and phenotypic data and finally applying markers in molecular breeding programs depends on a sequential use of a number of decision support tools . In this support .2, RIL, NIL, BIL, DH and germplasm sets). There are three GAB approaches namely MABC, marker-assisted recurrent selection (MARS), and GS which are currently been deployed for developing improved lines .The conventional breeding approaches led to development of large number of improved cultivars over the time for legumes. However, these improved cultivars lags far behind in attempting to match the ever increasing human population and thus putting more pressure on the ongoing breeding programs across the world. Further, the limiting natural resources in terms of land and water in addition to climate change and uncertain rains have further made the ongoing breeding programs on the high pressure. Nevertheless, last decade has witnessed a speedy development in the area of NGS and high-throughput genotyping technologies. These developments led to development of trait-linked markers for several traits using first generation of markers  and mapping populations (FQTL-hotspot” harboring several QTLs controlling several drought tolerance related root traits in the elite chickpea variety JG 11 (drought tolerant variety; The MABC has been the most preferred and result oriented molecular breeding approach for improving existing popular genotypes for one or two traits and pyramiding of few genes/QTLs. This approach has become very popular and widely accepted among breeders for these reasons; optimum time utilization and resources, opportunity to perform selection at early growth stages for multiple genes/loci, ability to break linkage between desirable and non-desirable traits, and most importantly no phenotyping requirement except for final trait confirmation. In the case of chickpea, MABC has been successfully used for introgressing a “3 lines and phenotyping data on F5 lines, superior lines were selected using OptiMAS ver. 1.0 (Another molecular breeding approach termed MARS promises improve to accumulate superior alleles for quantitative traits such as drought resistance, yield, etc., which are controlled by several QTLs, each with a small effect on the phenotype and the ideal genotype cannot be attained through MABC . In suchver. 1.0 . Althoug1s have been developed through hybridization using 55 restorer lines and 10 CMS lines for phenotyping at multiple locations. Based on the genotypic datasets of parental lines and phenotypic datasets of test cross F1s, the GS models will be defined for use in GS breeding to develop improved parental lines and new hybrids in pigeonpea.Another emerging molecular breeding approach called GS holds great promise in achieving higher genetic gains in lesser time for complex traits. Unlike MABC and MARS, the GS approach does not require population development and identification of linked markers prior to its deployment and has potential to enhance genetic gains for even complex traits such as yield under drought stress. This approach deploys evenly distributed genetic markers across the genome to predict GEBV using multiple methods with varying degrees of complexity, computational efficiency, and predictive accuracy . For achThe demand-supply gap for the legumes is perpetually increasing widening day-by-day which will lead to a huge shortfall in the supply to the ever increasing global population in coming years. The only option is to maximize the efforts toward developing improved high yielding cultivars possessing resistance/tolerance to the major stresses especially in context of climate change. The cost-effective sequencing technologies have introduced a new era in genomics and breeding by pinpointing the genes responsible for distinct phenotypes leading to selection of plants based on genotyping information. The knowledge generated through all the “omics” studies need to be integrated in breeding so that breeders can move toward “knowledge-based breeding” from “chance breeding.” In recent years, several emerging genomic technologies have been developed to foster trait mapping, gene discovery, and trait improvement programs in several crop plants. Some of these technologies have been already deployed in the three legume crops as discussed in this review. In addition, important information generated through transcriptomics, proteomics, metabolomics, and epigenomics have greatly benefitted the scientific community in developing better understanding of the traits and crops leading to development of effective strategy for achieving higher genetic gains in less time. It is obvious that the current and the upcoming technologies will further assist legume improvement programs in a more cost-effective, user-friendly, and less time consuming manner.MP planned the MS content, coordinated with other coauthors, contributed in drafting special sections, brought flow between different sections, and finalizing the manuscript. MR, VS, AbiR, HK, MT, AC, and AbhR contributed specific sections of this manuscript. MP, MR, and VS worked on this MS in several rounds to bring in proper shape. RV was involved in planning the content and finalizing the manuscript.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.


Diabetic foot complications are a significant source ofmorbidity and mortality. Patients who undergo recurrentadmissions for the same diabetic foot problems represent adifficult subgroup to treat. From July 2007 to June 2008,there were 38 such patients who were admitted recurrently.Eighteen patients (47%) were re-admitted because ofprevious refusal of surgical treatment. Eighteen patients(47%) received treatment as necessary but were still readmittedfor recurrent infection at the same wound site.Assessment of patients’ compliance to outpatient treatmentwas found to be generally lacking. As a significantproportion were re-admitted because of previous refusal ofsurgery, a trained counselor may be suitable in counsellingpatients for debridement or amputation surgery.Diabetic foot, complications, ulcer, abscess, amputation Diabetes-related foot complications are a major health careproblem with significant socioeconomic burdenThe primary aim of treatment of diabetic foot problems islimb preservation. The risk of lower limb amputation indiabetic patients has been estimated at 8 to 12.3 times therisk in non-diabetic patientsIn our clinical experience, a significant number of patientsare admitted repeatedly for treatment of diabetes-related foot complications, and not infrequently it is for treatment of apersistent problem which has previously already receivedappropriate medical care. We asked ourselves: what was themanagement of these patients in their index admissions andwhat were the factors that led to their re-admission?Anecdotally practitioners are well aware of reasonsincluding non-compliance to treatment or refusal oftreatment that would lead to re-admissions, but the currentEnglish literature is lacking in the description of thiscategory of patients. To gain preliminary insight into ourquestions, we conducted a retrospective review of patientswith diabetic foot problems who were admitted to ourinstitution for treatment and subsequently re-admitted for thesame foot conditions. We concentrated on patients who representedwith the same foot conditions in order to reviewour treatment outcomes and elucidate the potential factorsthat might result in failure of treatment.This is a descriptive study done via a retrospective review ofpatients admitted to a public hospital over a period of oneyear (from July 2007 till June 2008). Approval from theInstitutional Review Board was obtained prior to thecommencement of the study. In our institution, diabeticpatients with foot complications are routinely admitted to theDepartment of Orthopaedic Surgery. From our department,we will then refer to the vascular surgeon if there is evidenceof significant peripheral vascular disease which requiressurgical or procedural treatment. A list of patients wasobtained from the Medical Information ManagementDepartment satisfying the following criteria: admissions tothe Department of Orthopaedic Surgery during the studyperiod; a re-admission to the same department within 30days from the date of discharge; a diabetic-foot related 2009ICD-9-CM  code in the first and subsequent admissions. TheICD codes were chosen to represent diagnoses includingdiabetes mellitus, ulceration, cellulitis, abscess, gangreneand osteomyelitis. We also included ICD codes where therewas a possibility of diabetic foot pathology (Table I) in orderto overcome the possible problem of under-reporting ofdiabetic foot problems.From the list of patients generated using the ICD codes, caserecords were screened through to assess the reasons for theprimary and subsequent admissions. Only patients admittedfor treatment of diabetic foot problems were included.Furthermore, patients were included in the review only ifthey were re-admitted for treatment of the same diabetic footproblem as the primary admission. The following specificinformation was then extracted from the case records using astandardized data collection form: Number of re-admissionepisodes, reasons for each re-admission episode, patients’demographic data, documentation of clinical examination ofthe diabetic foot problem, relevant investigation resultsincluding inflammatory markers ,radiographic findings and wound swab cultures,documentation of patients’ understanding of condition andcompliance to treatment, assessments by the relevantauxiliary health services Seventy-six patients with 179 re-admission episodes wereidentified using the selected ICD codes . We founThe distribution of the 57 re-admission episodes according tothe number of re-admissions and the foot condition leading tore-admissions is shown in Eighteen patients (47.4%) had refused surgical or vascularinterventional treatment in their primary admissions. Of these,nine patients (23.7%) refused surgical debridement oramputation surgery, and seven patients (18.4%) whounderwent initial surgical debridement or ray amputationslater refused further debridements or more proximalamputations when their wounds remained infected or were nothealing well. In addition, two patients (5.3%) refused lowerlimb angioplasties for critical vessel stenosis of more than75% on arterial duplex scan. The conditions of these 18patients comprised of abscesses ,infected ulcers  and wet gangrene . All 18 patients’ case records had adocumented discussion of the risks and benefits of theproposed intervention, including possible outcomes if thecondition was not treated as recommended. Loss of limband/or life was consistently documented in the records.However, the exact reasons for refusal were often notspecifically identified.When re-admitted, 10 out of these 18 patients (55.6%)subsequently agreed to surgical treatment including one whoagreed to lower limb angioplasty. Seven patients (38.9%) stillrefused surgical treatment. One patient (5.6%) with chronicosteomyelitis of the toe was eventually treated conservativelywith suppressive antibiotics. The seven patients who stillrefused surgical treatment consisted of five patients who wereadvised for below knee amputation, one for above kneeamputation and one for big toe ray amputation. Two of thepatients who refused major limb amputation eventually diedduring their period of re-admission, and one subsequently dieda month later at home.Eighteen other patients (47.4%) underwent treatment inaccordance with medical treatment plan during their primaryadmissions. This included commencement of appropriateintravenous antibiotics and surgical debridements oramputations as required. Upon re-admission, sixteen patients were deemed to haverequired surgical treatment and two were continued onconservative treatment . The HbAThe findings of this study suggest that a significantproportion of our local patients with diabetic foot-relatedcomplications refuse surgical treatment even when advisedto by doctors. Many of them subsequently agreed to surgerywhen their conditions failed to improve with conservativetreatment leading to re-admission. Inevitably, re-admissionepisodes are associated with emotional and financial strainson the patient; they also represent potentially preventablesources of expenditure to the health care system. A smallergroup of patients still refused any surgery despite beingadmitted to hospital again. Our anecdotal experience is thatmany patients are firmly opposed to the loss of a limb evenif it is medically required and life-saving. Due to thereligious beliefs of the Muslims, most of the patients would want to be buried whole, and thus they usually refuseamputation. Also, the common sentiment amongst patients isthat losing a limb makes one a ‘cripple’, and they wouldrather lose their lives than a limb. The key to this problem iscorrecting the patient’s misconceptions about losing a limband the eventual functional status. However, doctors on busymorning ward rounds often do not adequately help patientsovercome the emotional hurdle to accepting an amputation.We postulate that a trained counselor with expertise andexperience in amputation counselling will reduce the rate ofrefusal of surgery. That said, doctors are not absolved of ourresponsibility in obtaining a complete assessment of suchpatients, including patients’ compliance to outpatienttreatment and their understanding of their own diseaseconditions.Eighteen patients 47.4%) in our review underwent medicaltreatment as deemed necessary in their primary admissionsbut were still re-admitted for recurrence or progression ofinfection affecting the same wound or in the areassurrounding the wound. These 18 patients had poorglycaemic control as a group with an average HbA1c readingof 10.0%. Poor glycemic control is known to constitute asignificant risk factor towards susceptibility to infection.4% in ouThe weaknesses of this descriptive study include theretrospective nature and the lack of complete documentationin many of the patients’ case records. That said, it can betaken as a learning point for ourselves to improve on clinicalassessement and documentation. Secondly, being aretrospective descriptive study, there is no opportunity toobserve the effects of intervention, for example by having atrained counselor spend time with a patient to counsel inaccepting an amputation.Our study found that a significant proportion of our localpatients presenting with diabetic foot complications refusesurgical treatment, leading to re-admission episodes. Thesere-admission episodes pose a significant socioeconomicburden both on the patients and on the health care system. Onthe other hand, almost half of the patients in our review werere-admitted for recurrent infection of the same foot problemdespite receiving adequate treatment in their primaryadmissions. Compliance to outpatient medications andwound dressings should be an integral part of assessment ofthese patients. It is helpful to perform prospective studieswhere a cohort of diabetic foot patients are monitoredbeyond their initial hospitalizations to track the success orfailure (thereby leading to re-admissions) of their treatment.In addition, there is a need for a thorough and detailed multidisciplinaryassessment of the patient presenting withdiabetic foot complications. This builds upon therecommendations from previous studies noting that therewas significant room for improvement in the assessment ofthe diabetic foot patient8-9. Lastly, we feel that the availabilityof a trained nurse counselor to engage and counsel patientsin amputation surgery may help in preventing unnecessarydelays in patients receiving definitive surgical treatment.