During early pregnancy, the placenta develops to meet the metabolic demands of the foetus. The objective of this analysis was to examine the effect of malaria parasitaemia prior to 20 weeks’ gestation on subsequent changes in uterine and umbilical artery blood flow and intrauterine growth restriction.Data were analysed from 548 antenatal visits after 20 weeks’ gestation of 128 women, which included foetal biometric measures and interrogation of uterine and umbilical artery blood flow. Linear mixed effect models estimated the effect of early pregnancy malaria parasitaemia on uterine and umbilical artery resistance indices. Log-binomial models with generalized estimating equations estimated the effect of early pregnancy malaria parasitaemia on the risk of intrauterine growth restriction.There were differential effects of early pregnancy malaria parasitaemia on uterine artery resistance by nutritional status, with decreased uterine artery resistance among nourished women with early pregnancy malaria and increased uterine artery resistance among undernourished women with early pregnancy malaria. Among primigravidae, early pregnancy malaria parasitaemia decreased umbilical artery resistance in the late third trimester, likely reflecting adaptive villous angiogenesis. In fully adjusted models, primigravidae with early pregnancy malaria parasitaemia had 3.6 times the risk of subsequent intrauterine growth restriction  compared to the referent group of multigravidae with no early pregnancy malaria parasitaemia.intrauterine growth restriction. The findings support the initiation of malaria parasitaemia prevention and control efforts earlier in pregnancy.Early pregnancy malaria parasitaemia affects uterine and umbilical artery blood flow, possibly due to alterations in placentation and angiogenesis, respectively. Among primigravidae, early pregnancy malaria parasitaemia increases the risk of  In malaria endemic areas, the World Health Organization recommends prevention and control strategies for malaria parasitaemia in pregnancy, including case management of malaria parasitaemia and anaemia; insecticide-treated nets (ITNs); and, at least two doses of intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine after the awareness of foetal movement  , but were more likely to have a low level of education and to be undernourished (data not shown). There were 6 probable recrudescent malaria episodes which occurred within 14 days of a previous infection, despite receiving treatment. Recrudescent malaria episodes were excluded from all analyses. There was no association between being a recrudescent case and parasite density as reflected by qPCR Ct-value (data not shown). Participants in the analytical sample were enrolled at a median of 18 weeks’ gestation  and were followed up for a median of 19 weeks . Study participants had a median of seven follow-up visits , with five ultrasound scans  from enrolment to delivery.Plasmodium species from dried blood spot samples and Plasmodium positive samples were speciated as previously described [Baseline data were collected in an interview ; medical examination ; ultrasound examination ; and laboratory testing  as previously described . At montscribed .Colour pulsed-wave Doppler ultrasound was used to interrogate the flow velocity waveforms in the left and right uterine arteries and the umbilical artery using standard techniques. The external iliac artery and uterine artery located medial to it were identified using colour flow settings. Flow velocity waveforms were obtained from the uterine artery near the iliac vessel prior to division of the uterine artery into branches. For left and right uterine artery analyses, Doppler indices were measured from the Doppler signal, with qualitative assessment of early diastolic notching. For the umbilical artery, the flow velocity waveform was obtained from the free flowing portion of the umbilical cord and Doppler indices and presence of absent or reversed end-diastolic flow were recorded. All ultrasound measurements were taken by a single, trained obstetrician-gynaecologist (VL) on the GE Logiqbook Ultrasound System .Plasmodium falciparum malaria parasitaemia ≤20 weeks’ gestation. Quantitative PCR of peripheral dried blood spots rather than blood microscopy was used due to the higher detection threshold of microscopy and the potential for poor microscopy sensitivity and specificity [The exposure variable, “early pregnancy malaria parasitaemia”, was a binary, time-independent measure representing whether a woman was ever qPCR positive for peripheral ificity .Outcome variables for placental blood flow included the continuous, time-dependent mean of the left and right uterine artery resistance index (RI); and, the umbilical artery RI after 20 weeks’ gestation. The RI is defined as (peak systolic velocity – end diastolic velocity)/peak systolic velocity. The resistance index was selected as the outcome for several reasons: RI values are constrained between 0 and 1; demonstrate the least variance of the Doppler indices under identical hemodynamic conditions; are frequently used in clinical settings; and, have a truncated normal distribution, making the RI amenable to parametric statistical analyses .th percentile of sonographically estimated foetal weight for gestational age in completed weeks, using Hadlock’s algorithm to estimate foetal weight [IUGR after 20 weeks’ gestation was also examined. IUGR was a binary, time-dependent outcome. At each visit, women were classified as having an IUGR episode if, at that visit, their foetus was <10 weight  and the  weight . The Joh weight  was not The continuous time metric, gestational age in weeks, was back-calculated from the first ultrasound using Hadlock’s algorithm . Ultrasovs. multigravidity), female foetal sex , and baseline maternal mid-upper arm circumference (MUAC) ≤24.3 cm   were examined. MUAC is a proxy for pre-pregnancy weight [Based on previous literature of the association between malaria parasitaemia during pregnancy and foetal growth, the potential modifying effects of primigravidity ( weight . PotentiFor linear mixed effect (LME) models, mean differences were reported and population average growth curves were plotted to describe the unadjusted and adjusted effect of early pregnancy malaria parasitaemia on uterine artery RI and umbilical artery RI. To describe the effect of early pregnancy malaria parasitaemia on IUGR, unadjusted and adjusted risk ratios (RRs) and 95% CIs were modelled using log-binomial regression generalized estimating equation (GEE) regression models with an exchangeable working correlation matrix. LME and GEE regression models are appropriate for longitudinal analyses as they account for the correlation between repeated measures in an individual ,22.a priori cut-off of p < 0.10). The addition of additional random effects was tested using -2LL tests with a mixed chi-square distribution (a priori cut-off of p < 0.05). In the final uterine artery RI and umbilical artery RI models random intercepts and slopes were included for each woman. For log-binomial GEE models, a crude model fitted for the early pregnancy malaria parasitaemia exposure variable was utilized. Next, simple log-binomial models with early pregnancy malaria parasitaemia, a theorized effect measure modifier, and their product interaction term were constructed. If the product interaction term was significant using the Wald test (a priori cut-off of 0.10), it was considered an effect measure modifier and was included in the multivariable model. For multivariable modelling, a fully adjusted log-binomial model was initially modelled, including the early pregnancy malaria parasitaemia exposure, the significant product interaction terms and potential confounders of the association between malaria parasitaemia and IUGR. A backward elimination approach was used to assess effect measure modification. In LME models, -2LL tests were used to assess the contribution of the product interaction terms to the model using a maximum likelihood approach; in GEE models, Wald tests were used (a priori cut-offs of p < 0.10). Potential modifiers that did not modify the association between malaria parasitaemia and the outcome were assessed as potential confounders. Covariates were considered confounders if the change in the co-efficient of the main exposure was greater than 10%, within strata of modifiers. Restricted maximum likelihood was used for final LME model estimates, as is common practice [For multivariable modelling of the effect of early pregnancy malaria parasitaemia on uterine artery RI and umbilical artery RI, a fully adjusted LME model with a random intercept was initially modelled. Linearity between gestational age and the outcome variables was considered by examining polynomial transformations of gestational age using −2 log-likelihood (−2LL) tests for nested models using maximum likelihood estimation  . Of the study participants, 27% of women were primigravidae and 22% of women had a low baseline MUAC. More than half of women (55%) were pregnant with a female foetus. Women with and without early pregnancy malaria parasitaemia had approximately balanced gravidity, foetal sex, SES and low baseline MUAC. There was a non-significant trend towards greater risk of early pregnancy malaria parasitaemia among younger women and women with less education.Individual trajectories of the continuous outcomes, uterine artery RI and umbilical artery RI, were plotted in order to examine intra- and inter-individual variability over gestational age in weeks Figure . There iThere was no crude effect of early pregnancy malaria parasitaemia on uterine artery RI  Figure , Panel AThere was no crude effect of early pregnancy malaria parasitaemia on umbilical artery RI Figure , Panel Ath percentile sonographically estimated foetal weight to capture truly IUGR foetuses than a single episode.In the unadjusted model, early pregnancy malaria parasitaemia was associated with 1.8 times the risk of subsequent IUGR during pregnancy  . VL conducted all Doppler ultrasound measurements and interpreted the Doppler data. SHL designed and implemented the study while at the Department of Epidemiology, University of North Carolina – Chapel Hill and contributed to manuscript revision while at GlaxoSmithKline. AHH assisted with statistical analyses and helped prepare the Methods section of the manuscript. AKT supervised field activities, oversaw quality control at the University of Kinshasa and interpreted the data. JMT, SJR and SRM made substantial contributions to the interpretation of results and manuscript revision. All authors read and approved the final manuscript.


The second conceptual advance is the huge expansion in our understanding of the homeostatic-physiological roles, as well as the pathophysiological involvement, of the immune system in diverse types of diseases. In this context, two decades ago, the finding that tumour necrosis factor-α (TNF-α) is overexpressed in adipose tissue of obese mice provided the first clear link between obesity and chronic inflammation [The concept proposing a major role for interorgan crosstalk as a link between dysmetabolism and inflammation largely builds on two major conceptual advances that developed mainly in the last two decades. The first one is the recognition that endocrine-type crosstalk exists between virtually all organs and tissues, extending way beyond very specific, “classical” endocrine glands. This has relied on various lines of experimental approaches, including “omics” types of data, revealing that a large fraction of the expressed genome of many tissues encodes known and predicted secreted proteins. Complementarily, tissue-specific genetic manipulations provided ammation . Almost ammation . More reammation , 4. The ammation . The metammation . In addiThis special issue aims to highlight selected topics projecting on advances in our current understanding of the players involved in interorgan communication in obesity-associated metabolic diseases. In their review, S. Raschke and J. Eckel present an update on bioactive proteins secreted by adipose tissue and skeletal muscles , revealing their peculiar interplay, which represents a yin/yang-type balance: adipokines, upregulated in the obese state, tend to contribute to establish a chronic inflammatory environment that promotes pathological processes such as atherosclerosis and insulin resistance, whereas myokines seem to largely counteract these effects of adipokines, likely reflecting their essential regulatory role in muscle metabolism during contraction. Yet, as more than half of the described myokines are also secreted by adipocytes, the authors suggest to term these cytokines “adipo-myokines,” whose beneficial or adverse effects are strictly dependent on their local concentration and kinetics. A confirmation of this general principle can be found in the review by T. Romacho and colleagues describing the cellular effects of the recently identified adipokine Visfatin/Nampt. Within the adipose tissue, Visfatin/Nampt is not only synthesized and released by adipocytes but also by inflammatory cells, like activated macrophages. Very recently, Visfatin/Nampt expression has been reported in cardiomyocytes, hepatocytes, and myoblasts, thus suggesting its potential role in an even more intricate interorgan metabolic crosstalk. The authors summarize convincing evidence for its deleterious effects on the cardiovascular system, including monocyte/macrophage activation, vascular inflammation, and remodeling. At the same time, the authors quote several papers on beneficial actions of Visfatin/Nampt in ischemia-related clinical conditions.In their research article, R. Schlich and colleagues investigate the role of vascular endothelial growth factor (VEGF). This well-known growth factor is also released from visceral adipose tissue in obesity and from perivascular adipose tissue of patients with type 2 diabetes and may constitute yet another interorgan mediator, in this instance, linking adipose tissue inflammation to abnormal vascular smooth muscle cells (VSMC) proliferation. Using a model of VSMC proliferation induced by adipocyte-conditioned medium (CM), the authors clearly show that this effect was mainly mediated by VEGF. Moreover, they demonstrate that CM also induced the release of VEGF by VSMC, which in turn could stimulate proliferation via “second-level” autocrine/paracrine communication.in vivo model of diet-induced obesity, which mimics a typical unhealthy western diet with both high fat and high sucrose intakes, A. Fisette and colleagues demonstrate the paradoxical effects of acute administration of ASP. Particularly, they show that ASP supplementation improved glucose clearance through a short-term insulin sensitizing process in spite of its proinflammatory properties, as demonstrated by increased serum and tissue levels of IL-6 and TNF-α. This may represent a growing current notion expanding our view of the links between inflammation and metabolic regulation [Another immune system (complement-related) mediator, adipose-derived factor with potential autocrine/paracrine and endocrine functions is the acylation stimulating protein (ASP). Using an gulation .δ, which positively correlated with increased muscular levels of the myokine FGF-21, a mediator with expanding roles in metabolic and energy regulation [E. Benetti and colleagues focus their attention on the deleterious effects of high sugar intake. They demonstrated that mice chronically fed a sugar-enriched diet develop dyslipidemia and hyperinsulinemia. These metabolic effects were associated with increased infiltration of inflammatory cells into skeletal muscle. Most notably, dyslipidemia and hyperinsulinemia could be prevented by oral administration of a selective agonist of the nuclear receptor peroxisome proliferator activated receptor-gulation . κB activation. The role of diet components/additives in affecting subclinical inflammation and insulin resistance is further investigated by S. Bhattacharyya and colleagues. They provide novel insights into the mechanisms of carrageenan-induced inflammation. Interestingly, mice lacking Bcl10, a key molecule in the activation of the inflammatory cascade in epithelial and immune cells, were partly protected from carrageenan-induced inflammation, and such effect was related to an inhibition of both canonical and noncanonical pathways of NF-A potential intestinal participation in the pathogenesis of insulin resistance is more widely addressed in the review by B. M. Carvalho and colleagues, showing how gut microbiota modulation promoted by a bacterial diversity shift mediated by overnutrition increases intestinal permeability, culminating in inflammation and insulin resistance. Herein, activation of inflammatory pathways by gut-derived bacteria products and metabolites is discussed, with particular reference to the key role of the inflammasome multiprotein complex. This recently identified novel player of the intercellular crosstalk linking chronic inflammation to metabolic disease pathogenesis is also the main topic of the review article by B. Benetti et al.β-cell dysfunction has been investigated in two different research articles. L. Quintana-Lopez and colleagues demonstrate in cultured islet β-cells that nitric oxide (NO) is an important mediator of the antiproliferative effect induced by proinflammatory cytokines, such as IL-1β, IFN-γ, and TNF-α. In keeping with these in vitro data, the same authors report that early treatment of biobred rats (inbred laboratory rats spontaneously developing autoimmune type 1 diabetes) with the NO synthase inhibitor L-NMMA improved β-cell proliferation compared to untreated animals. In addition, A. Puddu and colleagues demonstrate that the detrimental effects evoked by exposing the hamster pancreatic β-cell line HIT-T15 to a pool of advanced glycation end products are prevented by cell treatment with the incretin hormone glucagon-like peptide-1 (GLP-1), which was shown here to restore selective pathways regulating proinsulin production. The role of selective inflammatory mediators in pancreatic α and IL-6 as crucial inflammatory mediators connecting these different diseases.Two additional articles discuss the molecular mechanisms underlying the positive association between obesity-associated insulin resistance and cardiac hypertrophy or destructive periodontal disease. Specifically, M. Asrih and colleagues report evidence on the dual role of the cytosolic signaling proteins mitogen-activated protein kinases in inducing synthesis of both specific mediators of cardiac hypertrophy (such as the gap junction protein connexin 43 and the cardiotrophin-1) and glucose transporters  in cardiomyocytes, thus suggesting selective intracellular mechanisms of cardiac adverse remodeling associated with insulin resistance. R. Khosravi and colleagues offer in their overview potential explanations for the higher risk of destructive periodontal disease in obesity and insulin resistance; that is, they provide evidence for TNF-β-cell function can be confirmed by evidence, demonstrating that common monogenic pancreatic β-cell defects lead to early onset of diabetes even in the absence of obesity-related insulin resistance.Finally, R. Murphy and colleagues propose an intriguing approach to better elucidate the firm cause-effect relationships between obesity and insulin resistance development. In fact, although obesity is often reported to confer the highest risk for the development of metabolic diseases, the key events in this process are difficult to disentangle from compensatory effects and epiphenomena. The authors of this review support the suggestion that a deep investigation on key monogenic disorders may significantly contribute to unravel the pathogenic links between the defined molecular defect and the related exaggerated metabolic disorders, without the confounding effects of all the other components. For instance, they show how the key role of components of pancreatic Overall, we hope that readers will find the articles in this issue not only interesting but also instructive. They might even serve as a source of inspiration for future investigations aiming to further elucidate the intricate inflammatory mechanisms operational in the pathogenesis, and potentially also the resolution, of obesity-associated insulin resistance and type 2 diabetes. Such lines of research may raise hope for discovering new strategies to battle one of the key drivers of human morbidity in modern sedentary times.Massimo CollinoMassimo CollinoAssaf RudichAssaf RudichDaniel KonradDaniel Konrad


Introduction: Heterotopic mesenteric ossification is an extremely rare condition, which often follows trauma and is frequently symptomatic. To date, there are no reports in the literature of abdominal compartment syndrome occurring after surgical resection of mesenteric calcification. The present report documents an unusual case of compartment syndrome complicating resection of extensive mesenteric calcification despite abdominal closure with the components-separation technique. Method: A 48-year-old man undergoing components-separation technique for posttraumatic laparostomy hernia repair  was found to have extensive heterotopic mesenteric calcification, which needed resection. Results: Resection of the mesenteric calcification was complicated by intraoperative hemorrhage and unplanned small bowel resection. Later the patient developed secondary hemorrhage leading to an abdominal compartment syndrome, which was successfully treated by decompression, hemostasis, and Permacol-assisted laparotomy wound closure. The patient remains symptom-free more than 2 years after surgery. Discussion: The case herein reported gives an account of the rare occurrence of abdominal compartment syndrome following resection of posttraumatic ectopic mesenteric ossifications. It is highly unusual in that it occurred because of “secondary hemorrhage” and despite abdominal closure with the components-separation technique, which had been undertaken precisely to prevent compartment syndrome with direct closure. It therefore highlights the need for continued clinical vigilance in complex posttraumatic cases. Myositis Ossificans Progressiva.Paraosteoarthroplasty. Although Hansen was the first to describe peritoneal ossification in 1983,heterotopic mesenteric Ossification (HMO) was coined by Wilson et al in 1999 after concluding that 5 of their postabdominal surgical cases, with small bowel obstruction associated with heterotopic bone formation in the mesentery, clinically and pathologically resembled Myositis Ossificans as previously described by Ackerman.4,Heterotopic ossification was originally described in 1692 by Guy Patin, who noted the condition in children and termed it Intra-abdominal ossification is a rare entity with an otherwise poorly understood etiology and pathophysiology. Reported cases in literature often describe patients presenting with significant obstructive abdominal symptoms on a background of previous abdominal insult, with the process more likely to occur thereafter.7We herein report how one case of HMO, in an otherwise symptomless patient requiring complex surgical intervention, was complicated further by postoperative abdominal compartment syndrome (ACS) due to secondary hemorrhage.plastic surgery service. Prior to referral, he had undergone numerous exploratory laparotomies, washouts, and applications of vacuum-assisted closure (VAC) dressings. This period was further punctuated with an emergency decompression for ACS, pleural effusions, and a prolonged period of endotracheal intubation for treatment of respiratory failure.A 48-year-old man was admitted to hospital in mainland Europe with multiple traumatic injuries following a severe road traffic accident on the Christmas Day of 2009. He presented with a Glasgow Coma Scale of 4 to 6 with associated bilateral pneumothoraces; multiple rib fractures; left humeral, right femoral, and right patella fractures; and bilateral fractures of the L4 transverse processes and nasal bones. After initial hemodynamic stabilization, he underwent emergency cecostomy and loop ileostomy procedures for peritonitis secondary to “spontaneous” sigmoid colon perforation. The patient was subsequently transferred to the United Kingdom, where he spent 2 months on the intensive care unit (ICU) before being referred to the The patient was referred to the plastic surgeons for closure of his large “iatrogenic” abdominal hernia but the size of the defect and level of exposed herniating bowel precluded direct closure, necessitating the application of a split-thickness skin graft with VAC dressing.Six months later  or nonneoplastic origin.Interestingly, despite the increased relative risk posed and the mesenteric location of our patient's calcifications, he did not present with any obstructive signs or symptoms. The pathological findings from his excised specimens were however more in keeping with reported cases. Microscopy showed dense collections of lamellar bone, with some resembling the cortices of long bone and others resembling the medulla. These collections showed no active inflammation and were primarily within the vessels of excised fibroadipose tissue but also surrounded one normal lymph node. There were no features of malignancy in the report.Abdominal compartment syndrome is often a fatal, multiorgan, end-stage process, resulting from poorly compensated intra-abdominal hypertension. The latter occurs when increased capillary permeability in critically ill patients with systemic inflammatory response syndrome (SIRS) leads to the sequestration of fluid into the cavity. Our patient notably survived 2 episodes of hemorrhage-induced ACS, pre and post components-separation surgery, and has been symptom-free for more than 2 years.We concluded the innocuous appearance on radiological imaging, the significant challenge experienced during laparotomy, and the serious peri- and postoperative complications make HMO a rare but potentially fatal entity that warrants surgical intervention. Surgeons must therefore consider HMO and its complications as a differential when managing complex multitrauma patients with “suspicious” radiographic densities.


Nucella lapillus generally has thicker shells at sites sheltered from wave action, where crabs are abundant and pose a high risk of predation, than at exposed sites where crabs are rare. We studied two populations showing the opposite trend. We reciprocally transplanted snails between field sites and measured shell length, width and lip thickness of those recaptured 12 months later. Snails transplanted to the sheltered site grew larger than sheltered-site residents, which in turn grew larger than transplants to the exposed site. Relative shell-lip thickness was greater in residents at the exposed site than at the sheltered site. Transplants from shelter to exposure developed relatively thicker shells than their controls and relatively thinner shells from exposure to shelter. Progeny of the two populations were reared for 12 months in a common garden experiment presenting effluent from crabs feeding on broken conspecifics as the treatment and fresh sea-water as the control. The crab-effluent treatment decreased foraging activity, concomitantly reducing cumulative somatic growth and reproductive output. Juveniles receiving crab-effluent grew slower in shell length while developing relatively thicker shell lips than controls, the level of response being similar between lineages. F2 progeny of the exposed-site lineage showed similar trends to the F1s; sheltered-site F2s were too few for statistical analysis. At sexual maturity, shell-lip thickness was greater in snails receiving crab-effluent than in controls, indicating plasticity, but was also greater in the exposed-site than in the sheltered-site lineage, indicating heritable variation, probably in degree of sexual thickening of the shell lip. Results corroborate hypotheses that ‘defensive’ shell thickening is a passive consequence of starvation and that heritable and plastic control of defensive shell morphology act synergistically. Shell thickening of juveniles was similar between lineages, contrary to hypotheses predicting differential strengths of plasticity in populations from low- or high-risk habitats.The intertidal snail  It is widely reported that certain rocky shore gastropods develop thicker-walled shells at sites sheltered from wave action, where crabs are often abundant and pose a high risk of predation, than at exposed sites where crabs tend to be scarce e.g. . Shell-wNucella lapillus (L.) that contravene the general trend by having thicker shells at a site exposed to heavy wave action and free of crabs than at a more sheltered site infested with crabs. In contrast to shell thickness, shell shape in the two populations follows the normal trend for N. lapillus in which shells at exposed sites have relatively shorter spires and larger, wider apertures than shells at sheltered sites.Accordingly, we combined a reciprocal transplant experiment in the field with common garden experiments deploying laboratory-hatched progeny to examine plastic and heritable components of variation in shell morphology in two populations of The reciprocal transplant and common garden experiments were designed to examine the roles of inheritance and plasticity on adaptive shell morphology and to yield samples for studying associated gene expression. Because of the large volume of data, effects of reciprocal transplantation and common garden conditions lacking wave action or crab-effluent on shell shape are presented elsewhere N. lapillus were obtained from two sites in North Wales, U.K.  had grown to a shell length of 8–12 mm (August 2008), they were colour-coded with a waterproof pen according to lineage (exposed or sheltered).Source populations of Procedural details are given in Pascoal et al. −1with permanent aeration supplied from air-diffusion stones. Ambient temperature fluctuated seasonally between 8–16°C. Twenty-five F1s of sheltered site ancestry and 90 of exposed site ancestry were allocated per tank . After allowing snails to acclimatize for 1 wk, two tanks were left unchanged as controls and two were supplied with water-borne olfactory cues assumed to be perceived by N. lapillus as risk of crab predation Carcinus maenas, carapace width 8–12 cm, collected from the Menai Strait, were placed in the 25-litre cistern supplying the treatment-tanks and fed cracked adult N. lapillus. Crabs that died were replaced within 48 h. Tanks were spatially transposed at monthly intervals to avoid incidental position effects. Barnacles attached to stones were renewed as needed to maintain an unlimited supply of food for the N. lapillus in each tank.A ‘control garden’ and a ‘treatment garden’, each with two replicates, were established in four 25-litre aquaria. The control garden presented an artificial environment lacking most natural characteristics including the effects of wave exposure typical of the exposed field site and of crab predation characterizing the sheltered field site. The treatment garden presented an olfactory cue signaling risk of crab predation. Seawater was supplied via two constant-head cisterns at a rate of 3 ml sAt 6 months and again at 12 months from the beginning of the experiment, snails were photographed and their shell-lip thickness measured as above. Shell length and width were measured using tpsDig and MODICOS software, as above.At 12 months, tissue and shell mass were measured (±0.0001 g) after breaking the shell, extracting the tissue and drying for 24 h at 80°C. This procedure could be applied only to snails of exposed-site ancestry, as destructive sampling for a parallel study had depleted the sheltered-site lineage.1 generation fortuitously laid eggs in all tanks. Hatchlings (F2s) were grown for 10 months, then genetically assigned to exposed- or sheltered-site ancestry  and comparison of adjusted means was based on models lacking the interaction term.Mean shell-lip thickness, shell mass and tissue mass were adjusted to appropriate covariates by ANCOVA of log10-transformed data.Shape of the shell and of the external and internal rims of the aperture was quantified by using tpsRelwto generate relative warps. After confirming their independence of centroid size, scores on the first three relative warps were subjected to MANOVA (SPSS 11.3). To aid interpretation of relative warp analysis, width adjusted to length was compared among treatments by ANCOVA of logNo specific permits were required for the described field studies, which took place on shores with public right-of-way and did not involve endangered or protected species. The location is not privately-owned or protected in any way.Statistical comparison of mean log(shell-lip thickness) adjusted to the geometric mean of shell length and width, hereafter referred to as shell size, between transplants and controls within lineages was invalidated by disparate covariate values ; other cUnadjusted mean log(shell-lip thickness) was similar between controls and transplants within each lineage .Within 12h of exposure to crab-effluent, snails tended to crawl up the sides of the tanks and were less frequently seen than controls among stones bearing the food supply of barnacles. Snails receiving crab-effluent produced fewer egg capsules than controls , but there was no difference in the size of egg capsules produced  or in the number of eggs per capsule .1 generation) mean shell length was ranked higher in controls than in snails receiving crab-effluent . At 12 months from the beginning of the experiment, mean shell length was not significantly different among categories , whereas in the F2 generation (exposed-site only) mean shell length was greater for control than for treatment snails .At 6 months from the beginning of the experiment  adjusted to log(tissue mass) was greater in snails exposed to crab-effluent than in controls, but within those categories there was no difference between generations , Table 11 snails , Table 1At 6 months from the beginning of the experiment, log(shell-lip thickness) adjusted to shell size was greater in snails receiving crab-effluent than in controls, but within those categories there was no difference between lineages , Table 2Shape of the shell Mean scores on RW3 differed between treatment and control snails of exposed-site ancestry, all other comparisons being statistically non-significant . Although the marked increase in shell mass per unit tissue mass of snails experiencing crab-effluent is consistent with proposals that increased shell thickness is an actively induced defensive response to risk of crab predation Nucella lamellosa.Relative shell-lip thickness of juveniles at 6 months was markedly greater in snails receiving crab-effluent than in controls. Such an early ontogenetic response will be especially effective in promote fitness because vulnerability to crab predation falls most heavily upon juveniles whose shells have not yet reached a size-refuge from predation At 12 months, the difference in relative shell-lip thickness between snails receiving crab-effluent and controls had become much greater in the exposed-site than in the sheltered-site lineage. Experimentally induced changes in shell shape were subtle and statistically significant only for exposed-site snails. Snails exposed to crab-effluent had slightly wider shells than controls, with narrower aperture internal rims. Narrowing of the internal rim of the aperture, with little change in the external rim, reflects thickening of the rim itself. Thickening in response to crab-effluent, however, may be confounded with thickening due to sexual maturation In conclusion, our common garden experiment corroborates previous studies demonstrating a negative influence of crab-effluent on prey foraging activity, tissue growth and shell growth, and a corresponding positive influence on shell thickness. Our results are consistent with, but do not critically test, the hypothesis that shell thickening is a secondary consequence of starvation rather than a direct response to predation risk. Further support of the starvation hypothesis, however, may be adduced from the slower growth and development of thicker shells by snails transplanted from the sheltered to the exposed field-site where feeding opportunities are more frequently constrained by weather than at the sheltered site.Littorina saxatilisNucella lamellosaN. lapillus, at least during the vulnerable juvenile phase. Induction of defensive phenotype might be expected to be stronger in populations from habitats where risk of predation is high when integrated over time, but which varies unpredictably in the shorter term N. lapillus from a sheltered than from an exposed site, situated within 14 km of our sites. Development of secondary sexual characters such thickening of the shell rim further complicates interpretation. Moreover, even congeners may show contrasted morphological changes. Whereas N. lapillus develops a narrower aperture correlated with an elongated spire N. lamellosa develops greater globosity in response to crab-effluent Whereas greater plasticity has been reported in


Spinal infections remain a challenge for clinicians because of their variable presentation and complicated course. Common management approaches include conservative administration of antibiotics or aggressive surgical debridement. The purpose of this study was to evaluate the efficacy of percutaneous endoscopic debridement with dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis.From January 2005 to July 2010, a total of 32 patients undergoing PEDI were retrospectively enrolled in this study. The surgical indications of the enrolled patients included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serologic testing, and imaging studies to determine whether continued antibiotics treatment or surgical intervention was required.Causative bacteria were identified in 28 (87.5%) of 32 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from infected tissue biopsy cultures were prescribed to patients. Twenty-seven (84.4%) patients reported satisfactory relief of their back pain after PEDI. Twenty-six (81.3%) patients recovered uneventfully after PEDI and sequential antibiotic therapy. No surgery-related major complications were found, except 3 patients with transient paresthesia in the affected lumbar segment.PEDI was successful in obtaining a bacteriologic diagnosis, relieving the patient’s symptoms, and assisting in the eradication of lumbar infectious spondylitis. This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery. Spinal infections continue to be a considerable diagnostic and therapeutic challenge to clinicians because of their subtle presentation in the early stages. Medical imaging technology, laboratory tests, and a high degree of suspicion can help spinal surgeons make a correct diagnosis in a timely fashion to avoid severely debilitating complications-4. IdentPercutaneous endoscopic discectomy (PED) was first employed for treating uncomplicated herniated discs in the early 1980s. Some stThis study was approved by the Institutional Review Board of E-DA Hospital, a 1200-bed tertiary referral center (IRB number: EMPR-101-027). Thirty-two patients with infectious spondylitis underwent PEDI procedures between January 2005 and July 2010 at our institute. There were 9 women and 23 men with an average age of 57.4 years . The patients’ medical records, including outpatient and emergency room notes, admission notes, inpatient progress and nursing notes, discharge summaries, procedure notes, surgical reports, radiology reports, pathology reports, and microbiology laboratory results were reviewed. The microbiology reports comprised microscopy and culture findings and any specific pathogens identified by either method. All of the patients presented with intractable back pain requiring narcotic pain control and bed rest. Infectious spondylitis was diagnosed on the basis of clinical examinations, including elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values, and radiographic and magnetic resonance imaging (MRI) findings.The surgical indications of the 32 patients undergoing PEDI included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. The infectious spondylitis of all patients who underwent PEDI in this study did not respond to conservative administration of empirical antibiotics and was not so severe to absolutely need aggressive surgical debridement. Patients who sustained severe infection resulting in severe structural deformity or significant neurological deficit were excluded in this study and they were advised to receive open surgery for their severe infectious spondylitis.-1. A guide wire was introduced through the spinal needle into the central disc space, and the spinal needle was then withdrawn. After creating a small stab-wound incision (about 1 cm), a dilator and a cannulated sleeve were guided over the wire and progressed sequentially into the disc center. Additional IV bolus dose of propofol 0.5 mg · kg-1 were administered if the patients complained pain during the procedures. Fluoroscopy was repeated in 2 orthogonal planes to verify the correct position of the endoscope tip. The tissue dilator was then removed, and the cutting tool was inserted. The cutting tool, a cylindrical sleeve with a serrated edge at its distal end, was used to harvest a core of the biopsy specimen. Discectomy forceps were then inserted through the cannulated sleeve to extract additional tissue from the infected disc. Percutaneous debridement was conducted piecemeal by manipulating the biopsy forceps, flexible rongeurs, and shaver into different positions to withdraw as much tissue as possible under fluoroscopic monitoring and endoscopic view  of 32 infected tissue biopsy cultures. Of these 28 patients, 2 patients had 2 different pathogens cultured. Seventeen patients were infected with staphylococcus aureus, 8 with the oxacillin resistant strain and 9 with the oxacillin sensitive strain. Three patients had haemophilus influenzae infection, 2 had streptococci viridans, 2 had pseudomonas aeruginosa, and the other 6 had prevotella species, mycobacterium tuberculosis, enterococcus faecalis, escherichia coli, klebsiella pneumoniae, and candida albicans infection, respectively. Systemic antibiotics and anti-tuberculous or anti-fungal chemotherapy were administered according to sensitivity studies for identified pathogens. There were no pathogens isolated from the other 4 patients (12.5%). Two of them had good outcomes after PEDI, but the other 2 had persistent back pain. Short-term broad-spectrum antibiotics were administrated after PEDI in these patients. Three of the 4 patients recovered uneventfully after treatment with broad-spectrum antibiotics. The other one underwent surgical intervention for intractable back pain and was proved to have staphylococcus aureus infection by open surgical biopsy.Overall, 6 of 32 patients underwent anterior debridement and autograft interbody fusion with iliac crest because of persistent severe back pain, failure to identify the pathogens, or progressive infection. In addition to 2 patients with single-level infection, 1 with paraspinal abscess and the other 3 with multilevel infections were included. Three patients with multilevel infections who had uncontrolled infection and mechanical instability underwent anterior debridement and autograft interbody fusion, followed by supplemental posterior fixation. Extensive osteolytic destruction of the vertebral body with spinal instability or kyphotic deformity was observed in these 6 patients. Twenty-six (81.3%) patients responded to PEDI and were successfully treated with at least a 6-week course of parenteral antibiotics therapy or full-course antimicrobial chemotherapy Figures . The chaConservative therapy with sensitive antibiotics and bracing is adequate for most patients with infectious spondylitis. A delay in diagnosis and treatment is common in all forms of spinal infection because of their early indolent course-4. RezaiSeveral minimally invasive methods have been used to treat infectious spondylitis. Computed tomography-guided percutaneous catheter drainage has been approved as an efficient and safe procedure in the management of early-stage spondylodiscitis. Haaker The minimal invasiveness and simplicity of PED have led the authors to apply it as a modality for treating patients with infectious spondylitis. Direct endoscopic observation makes possible the direct collection of sufficient amounts of samples from the infected region for microbiological examination. Eradication and debridement of the infected and necrotic tissue from a disc and even an epidural space can be achieved under endoscopic monitoring. During the irrigation procedure, the disc debris and turbid abscess can be washed out by dilute betadine solution through the suction sheath. Moreover, postoperative negative-pressure Hemovac drainage in larger-diameter can continuously suck out the pathogens from the infected area. A combination of effective debridement with dilute betadine solution irrigation and full-course specific antimicrobial therapy resulted in favorable outcomes in current study.Povidone-iodine is a widely used antiseptic and disinfectant agent. It can eradicate most pathogens, including oxacillin resistant staphylococcus aureus, and no bacterial resistance has been reported-18. In aTwenty-six patients with infectious spondylitis were successfully treated with PEDI in this series. This minimally invasive technique produces less morbidity than open surgery and provides effective relief to the patient’s back pain by reducing the intradiscal pressure and preserving adequate stability. These patients could ambulate with brace protection as early as possible after PEDI. Patients who sustained epidural or paraspinal abscesses could also be treated by this method and avoid having to undergo open anterior or posterior decompression surgery. A connection generally exists between these abscesses and the infected disc, which is the actual origin of spinal infection. After aggressive debridement of the infected disc and neighboring vertebral endplates, a cavity was created and even the sticky abscesses could be washed out by pressurized irrigation with betadine solution. With postoperative negative-pressure Hemovac suction, the pathogens in the infected tissue can be removed continually.Six patients eventually underwent open surgery for poorly controlled infections and considerable mechanical back pain caused by progressive destruction. Three of 4 patients with multilevel infections who experience medical therapy failure received open anterior debridement and autograft interbody fusion with supplemental posterior fixation. Only 1 elderly patient with 2-level infections responded to PEDI. However, this patient still complained of mild back soreness with progressive kyphotic deformity. Therefore, the effectiveness of this procedure for extensive destruction of vertebral bodies and multilevel infections may be limited, from the viewpoint of either surgical technique or clinical prognosis.This study has several limitations. First, we examined only 32 cases. Second, the retrospective nature of this study does not allow including patients undergoing different treatment methods for comparison, as well as lacks randomization because of ethical and legal considerations. The feasibility and benefits of PEDI for infectious spondylitis need to be rigorously evaluated in a large patient population with prospectively controlled comparison groups. Third, the enrolled patients had different kinds of spinal infections, such as early-stage infection or advanced infection, single-level infectious spondylodiscitis or multilevel infections, and spinal infection with or without epidural or paraspinal abscess. Thus, careful classification of patients through meticulous clinical examination and comprehensive image studies can further evaluate the efficacy and indications of this procedure in different stages and severities of spinal infection.On the basis of the findings obtained from this study, we propose that PEDI is an effective alternative to extensive open surgery for the treatment of single-level infectious spondylodiscitis or even complicated infection with epidural or paraspinal abscesses. It is successful in obtaining a bacteriologic diagnosis, relieving the patient’s symptoms, and assisting in the eradication of lumbar infectious spondylitis. Extensive anterior or posterior surgery is not always necessary in these cases. Additionally, the clinical course can be repeatedly evaluated and the treatment strategy can be modified accordingly after the PEDI procedure.CRP: C-reactive protein; ESR: Elevated erythrocyte sedimentation rate; MRI: Magnetic resonance imaging; PED: Percutaneous endoscopic discectomy; PEDI: Percutaneous endoscopic debridement with dilute betadine solution irrigation.The authors declare that they have no competing interests.SCY wrote the original manuscript, helped in the data analysis, and contributed to the interpretation and presentation of the data. TSF was responsible for the analysis and the interpretation of the data and contributed to all parts of the work of this study. HSC co-coordinated the study design, carried out the literature search, data analysis and drafting of the manuscript. YHK and SWY were responsible for the data acquisition, helped in the analysis and the interpretation of the data. YKT provided expert clinic advice in the field, design and structure and critically revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/15/105/prepub


Adaptation to stress signals in the tumor microenvironment is a crucial step towards carcinogenic phenotype. The adaptive alterations attained by cells to withstand different types of insults are collectively referred to as the stress phenotypes of cancers. In this manuscript we explore the interrelation of different stress phenotypes in multiple cancer types and ask if these phenotypes could be used to explain prognostic differences among tumor samples.a priori phenotypic information about samples, SLEA calculates an enrichment score per sample per gene set using z-test. This score is used to determine the relative importance of the corresponding pathway or module in different patient groups.We propose a new approach based on enrichment analysis at the level of samples  in expression profiling datasets. Without using Our analysis shows that tumors significantly upregulating genes related to chromosome instability strongly correlate with worse prognosis in breast cancer. Moreover, in multiple tumor types, these tumors upregulate a senescence-bypass transcriptional program and exhibit similar stress phenotypes.Using SLEA we are able to find relationships between stress phenotype pathways across multiple cancer types. Moreover we show that SLEA enables the identification of gene sets in correlation with clinical characteristics such as survival, as well as the identification of biological pathways/processes that underlie the pathology of different cancer subgroups. In breast cancer, enrichment with the CIN signature is strongly related to bad prognosis even among samples with wild-type p53, indicating that indeed the predictive power of this signature is independent of p53 mutation  . As seen sample) ), the CINext we performed EA with all Gene Ontology biological process terms in order to identify the biological properties characterizing CIN-positive tumors. These tumors significantly downregulate genes related to processes such as 'cell communication' and 'wound healing'   [de novo synthesis of sterols, isoprenoids, and fatty acids [HIF1A [HIF1A along with its target vascular endothelial growth factor /Akt pathway and its downstream mammalian target of rapamycin (mTOR) signaling: 'genes deregulated in PI3K-hyper-activated, hormone resistant cells'  (modulesSC1-ko') . Figure ty acids . We usedty acids , to checty acids ). mTORC1s [HIF1A . In agreIn order to determine if we can see similar patterns in other types of cancers, we performed the same EAs in tumor datasets comprising different types of cancer : brain, lung, ovary, bladder and colon. In all the datasets the enrichment of the CIN signature divided the samples into two . There EA is an effective way to analyze the statistically significant gene sets obtained using high-throughput functional genomics data. In this work, we propose an alternative approach for the analysis of tumor genomics data to detect clinically relevant patient subgroups. Instead of finding genes differentially expressed between two groups, we identify differentially enriched modules by performing sample-level EA (SLEA). Our method does not require information related to phenotypic classification of samples and can directly take gene sets as input. Moreover, by comparing enrichment results with available clinical information, SLEA enables the understanding of pathways/processes that underlie the clinical phenotypes such as survival. We applied our methodology to test the prognostic power of a gene signature related to chromosomal instability and to study the prevalence of stress phenotypes in different patient subgroups defined by the expression of this gene signature. The tumors significantly upregulating this signature were strongly correlated with worse prognosis in the three breast cancer datasets studied, but not in other tumor types. In all cancer types, however, the tumors with positive enrichment for this gene signature displayed a transcriptional program pointing to evasion of the senescence barrier and particular stress phenotypes, indicating strong interdependencies between these different pathways and therapeutic vulnerabilities for the tumor.CIN: chromosomal instability; GEO: Gene Expression Omnibus; mTOR: mammalian target of rapamycin; PI3K: Phosphoinositide 3-kinase; SLEA: sample-level enrichment analysis.The authors declare that they have no competing interests.GG and NL designed the study, interpreted the data and drafted the manuscript. GG performed all statistical and other data analysis. All authors have read and approved the manuscript for publication.Supplementary figures. Supplementary figure 1: result of overlap analysis of the modules used. Heat map of the Jaccard indices for overlap analysis among modules used in this study. Pink cells indicate high overlap (Jaccard index ≥ 0.6) while light blue shows no overlap. Supplementary figure 2: comparison of z-score mean and z-score median. Scatter plot of z-scores obtained using mean and median as the test statistic in EA of the Ivshina et al. [et al. [et al. [a et al.  dataset  [et al. ), TCGA-O [et al. ) and GSE [et al. ). Each pClick here for file


Prostate cancer is the most common cancer among men in the United States. For decades, the cornerstone of medical treatment for advanced prostate cancer has been hormonal therapy, intended to lower testosterone levels, known as Androgen Deprivation Therapy (ADT). The development of hormone-resistant prostate cancer (now termed castration-resistant prostate cancer:CRPC) remains the key roadblock in successful long-term management of prostate cancer. New advancements in medical therapy for prostate cancer have added to the hormonal therapy armamentarium. These new therapeutic agents not only provide a survival benefit but also show potential for reversing hormonal resistance in metastatic CRPC, and thus redefining hormonally sensitive disease. Prostate cancer is the 2nd most frequently diagnosed cancer and the 6th leading cause of death among males worldwide . In 2011Practical Observations on the Treatment of Diseases of the Prostate Gland [Hormonal therapy has long been an integral part of prostate cancer treatment. In 1811, Scottish surgeon John Hunter (1728–1793) observed the relationship between prostate growth and testicular function for the first time in his textbook te Gland . Louis Ate Gland . In 1941te Gland .Similar to breast cancer, prostate cancer is a hormonally driven solid malignancy. Androgens are the key driver of growth for both the normal prostate and prostate cancer cells. Vital in the definition of castrate-resistant disease is the recognition of the potential sources of androgen and approaches aimed at the reduction of their levels. While we have historically focused on the testicular production of androgens, other sites of production include the adrenal glands and the more recently appreciated source of intratumoral androgen production. Normally 90–95% of circulating testosterone is produced by the Leydig cells of the testes. Another 5–10% of systemic testosterone is synthesized by the adrenal glands . While pGiven the multiple sources and associated biosynthesis pathways of androgen productions, hormonal therapy in prostate cancer is achieved through multiple mechanisms with several different classes of agents .Though in limited use today, estrogen was initially used to systematically treat prostate cancer decades ago. Beyond an agent simply to induce a reduction in testosterone levels, Serrate et al. reported in 2009 that diethylstilbestrol (DES) is a reasonable option for salvage therapy for CRPC in patients previously treated with docetaxel chemotherapy, suggesting a direct anticancer effect and larger “hormone sensitive” treatment window . MedicalCommon side effects of hormonal therapy in prostate cancer treatment include hot flashes, weight gain, gynecomastia, and osteoporosis . EstrogeHormonal therapy can produce dramatic clinical responses when initially used to treat advanced prostate cancer. Unfortunately, prostate cancer patients become resistant to androgen deprivation after about 2-3 years on average with progressive disease, despite castrate levels of testosterone , 23. It Historically, a serum testosterone level of <50 ng/dL (<1.74 nmol/L) has been used as the benchmark to assess the efficiency of hormonal therapy, as comparable to the level of suppression achieved with surgical castration . Subsequα-hydroxylase and C17,20-lyase) [α-hydroxylase and C17,20-lyase) inhibitor analogous to abiraterone acetate but also an androgen receptor modulator [The CYP17 enzyme is a member of the cytochrome P450 family of enzymes that mediates the biosynthesis of dehydroepiandrosterone and androstenedione, both precursors of testosterone. Previously, nonselective inhibitors of CYP17 such as ketoconazole have been used in prostate cancer treatment . In cont0-lyase)  and demo0-lyase) , 32. Sim0-lyase) . Clinica0-lyase) . TOK-0010-lyase) . Uniquelodulator . These nP < 0.0001). Circulating serum testosterone levels are reduced to levels of 1-2 ng/dL with abiraterone acetate—much lower than the previous standard of 50 ng/dL used to define CRPC. In this trial, abiraterone plus prednisone also showed significant improvement in time to PSA progression , radiographic progression-free survival (PFS) , and PSA response rate  when compared to prednisone alone. The immediate side effects of abiraterone were manageable and primarily related to elevated mineralocorticoid levels, including hypertension, fluid retention, and hypokalemia [In a landmark phase III clinical trial from 2011, de Bono et al. reported that abiraterone acetate plus prednisone compared to prednisone alone yielded an improved median overall survival from 10.4 to 14.8 months in patients with metastatic hormonal-resistant prostate cancer after docetaxel chemotherapy (okalemia .While androgen receptor signaling remains an important pathway of growth in CRPC, the currently available antiandrogens have not been able to completely block androgen receptor signaling . In anotGnRH plays a key role in the androgen axis. GnRH agonists have been used to achieve medical castration in prostate cancer for decades. Unlike the original GnRH receptor agonists, the recently approved degarelix acts as a direct GnRH antagonist, suppressing LH release without the iniital androgen flare and potential exacerbation of symptoms noted with GnRH receptor agonists . GnRH anThe phase III, landmark findings of the abiraterone acetate study by de Bono et al. have drawn into question our traditional definition of CRPC. Previously, phase I/II clinical trials of the CYP17 inhibitor abiraterone acetate demonstrated clinical activity in CRPC , 32. ThiIt is exciting to envision a future with additional clinical gains from the earlier use of potent CYP17 enzyme inhibitors in the course of disease treatment or with combination therapy of abiraterone acetate and other newer agents such as MDV3100. As a general principle, selective pressures from cancer therapy typically yield resistant strains of disease with progressively more aggressive features. Currently, we do not have a good understanding of the phenotypes of advanced prostate cancer that may emerge after early treatment with much more potent hormonal therapies such as MDV3100 and abiraterone acetate. Many unanswered questions remain about the prostate cancer phenotype that will emerge after early use of CYP17 inhibition in terms of robustness, virulence, speed of disease progression, and the responsiveness to cytotoxic chemotherapy.Since John Hunter first described the link between the testis and the prostate over 200 years ago, hormonal therapy remains one of the mainstays of advanced prostate cancer treatment. After initial response, metastatic prostate cancer typically becomes resistant to standard androgen deprivation therapy. Improved survival in this setting has been demonstrated in recent clinical trials involving new agents such as the CYP17 inhibitor abiraterone acetate and the antiandrogen MDV3100, showing that CRPC remains hormonally driven even after treatment with docetaxel chemotherapy, challenging our traditional definition of hormone-sensitive disease. Even though the survival benefit is incremental in the phase III study of very advanced CRPC patients, a threshold has clearly been crossed in defining and treating advanced prostate cancer.With so many new agents for advanced prostate cancer, individual patient characteristics may become very important in the selection and monitoring of therapy. The advantages of Degarelix over previous GnRH agonists may be incremental for most CRPC patients, but the quicker fall in testosterone may be very important to those with critical metastatic or painful lesions such as spinal metastases or near-total urinary obstruction. Likewise, the combination of “complete” androgen deprivation with abiraterone along with the required safety medication of low-dose glucocorticoid may induce more bone disease via worsening osteoporosis. Men with preexisting bone mineral density loss in this setting may require careful monitoring of the bone mineral density and the use of early bisphosphonates. In this same light, the side effect profile of a potent antiandrogen, which will not lower circulating androgen levels by itself, may become an important consideration if monotherapy with such agents becomes accepted. Furthermore, much like breast cancer is classified and treated based on hormonal receptor characterization today, we believe that advanced prostate cancer may one day also be treated based on molecular assessment. As more is known about the molecular characterization of advanced prostate cancer, it will be imperative to develop more personalized hormonal therapy for individual patients. Taken together, one of the major challenges moving forward will be the personalized application of these new agents in those with advanced CRPC, now that we have many more hormonal agents at our disposal with different side effects and mechanisms of action.


Helicobacter pylori infection is a leading cause of ulcers and gastric cancer. We show that expression of the H. pylori virulence factor CagA in a model Drosophila melanogaster epithelium induces morphological disruptions including ectopic furrowing. We find that CagA alters the distribution and increases the levels of activated myosin regulatory light chain (MLC), a key regulator of epithelial integrity. Reducing MLC activity suppresses CagA-induced disruptions. A CagA mutant lacking EPIYA motifs (CagAEPISA) induces less epithelial disruption and is not targeted to apical foci like wild-type CagA. In a cell culture model in which CagAEPISA and CagA have equivalent subcellular localization, CagAEPISA is equally potent in activating MLC. Therefore, in our transgenic system, CagA is targeted by EPIYA motifs to a specific apical region of the epithelium where it efficiently activates MLC to disrupt epithelial integrity. Helicobacter pylori is a Gram-negative bacterium that is estimated to infect over half the world's population CagA has been shown to alter the cytoskeleton of cultured cells. For example, in a cultured epithelial monolayer, individual CagA-expressing cells elongate, lose polarity, and migrate away from the monolayer, a process resembling an epithelial to mesenchymal transition D. melanogaster eye epithelium, MLC-mediated apical actin constriction drives formation of a dynamic signaling center in the developing eye imaginal disc called the morphogenetic furrow (MF) D. melanogaster expressing a constitutively active mutant form of MLC (MLC E20E21) has been generated in which the key phosphorylation sites, Ser20 and Thr21, were replaced with phosphomimetic glutamates A key effector of RhoA in cell retraction is myosin light chain (MLC), a component of the hexameric motor protein, non-muscle myosin 2 (NMM2) D. melanogaster CagA transgenic model D. melanogaster, making it an attractive model for assessing potential interactions with CagA. Because of the availability of a large collection of Gal4 lines, it possible to express our UAS:CagA transgene with exquisite spatial and temporal resolution at all stages of development. Furthermore, transgenic expression of CagA with this system has the advantage of being highly reliable and reproducible, unlike cell culture-based studies where CagA transfection is often toxic to cells and transfection rates are low. A complementary transgenic system for exploring CagA function has been developed in mouse To gain mechanistic understanding of CagA’s activity in complex tissues, our group developed a In this study, we uncovered a role for CagA in activating MLC. Using the Gal4-UAS system, we expressed CagA in the developing larval eye epithelium, a well-characterized model for epithelium formation, and found that CagA induced rapid epithelial disruption. We showed that reducing the levels of active MLC decreased the severity of epithelial disruption induced by CagA. In addition, we demonstrated that CagA causes increased phosphorylation and mispatterning of MLC. From these results, we conclude that MLC activation is a key target of CagA-induced epithelial disruption. Furthermore, we showed that the EPIYA motifs of CagA are necessary for proper apical targeting in the polarized retinal epithelial cells, and loss of these motifs renders CagA less potent in inducing morphological disruption in the epithelium. We showed that wild-type CagA and a CagA mutant lacking the EPIYA motifs are equally potent in inducing MLC redistribution in a cell type in which their subcellular localization patterns are equivalent, leading us to conclude that targeting of CagA to the apical domain is critical for efficient activation of MLC and subsequent epithelial disruption in the larval eye epithelium.Previous work in our lab showed that expression of CagA using the eye specific Gal4 line, GMR-Gal4, caused an adult “rough” eye phenotype Because GMR-Gal4 drives expression initially in third instar larvae, we assessed morphological disruption at this stage. The eye imaginal disc is a pseudostratified epithelial monolayer comprised of undifferentiated cells that become photoreceptors whose nuclei are positioned apically, and support cells whose nuclei are positioned basal to the photoreceptors . An invaTo assess epithelial disruption, we examined F-actin expression and the position of photoreceptor nuclei in control and CagA-expressing eye epithelia. Control larval eye epithelia expressing only GMR-Gal4 display spatially separated ommatidia with actin foci at the apical cortex of each ommatidium . In contIn contrast to the normal organization of discrete actin foci at the apical ommatidial cortex in control epithelia , the spaTo further characterize the apicobasal mispositioning elicited by CagA expression, we analyzed expression of the pleckstrin homology domain of Phospholipase C tagged with GFP (PH-GFP) driven with the GMR-Gal4 driver, which we fortuitously discovered to be an excellent marker for the deep support cells. In the apical regions of control eye epithelia, ElaV-expressing cells were observed in a patterned array . PH-GFP D. melanogaster eye epithelium is highly dependent on proper MLC regulation Patterning of the complex epithelial architecture of the D. melanogaster MLC when it is phosphorylated at both threonine-20 and serine-21. We refer to this form of MLC as MLCpp. In control eye epithelium, MLCpp is expressed strongly in arrays perpendicular and anterior to the MF, but weakly, in small foci posterior to it, suggesting that MLCpp is rapidly depleted in cells immediately posterior to the MF ) in which one of the two phosphorylation sites on MLC is mutated, rendering it unphosphorylateable at this site sqhA21 mutants, no discernible actin mispatterning defect or ElaV mispositioning was observed , which we refer to as RhoCA, displayed ectopic furrows highly similar to those induced by CagA expression  flies expressing CagA displayed enhanced disruption when compared to eye epithelia expressing only CagA , S2 cells acquire a flattened morphology that is amenable to high-resolution imaging , and found that CagA induced similar redistribution of MLC-GFP as seen in cells expressing activated Rho or RhoGEF2. The induction of a central ring of MLC-GFP expression in the S2 cell model provided us with a straightforward read-out of CagA’s ability to activate MLC. To compare MLC-GFP expression across different treatments, we classified cells into 3 phenotypic categories. Cells displaying MLC-GFP throughout the cell were labeled as “diffuse.” “Intermediate” cells displayed MLC-GFP expression predominantly around the periphery of the cell and in intimate association with the underlying substrate. “Central ring” cells displayed MLC-GFP expression in a tight ring around the nucleus or immediately adjacent to it. Control cells predominantly displayed the intermediate phenotype, however, a minority of cells displayed largely diffuse cytoplasmic staining . In CagATo determine if CagA indeed requireed Rho and Rok to redistribute MLC, we used RNA interference (RNAi) to knock down expression of Rho and Rok, as well as a chemical inhibitor of Rok, Y-27632, to determine if CagA was able to redistribute MLC-GFP even in cells depleted of Rho and Rok activity. Rho RNAi on its own caused MLC to become highly diffuse throughout the cell . When CaEPISA) is capable of inducing morphological disruption. CagA phosphorylation occurs within EPIYA motifs, and these repeated motifs have been shown to mediate diverse biological processes, particularly SHP-2-mediated cell elongation EPISA is able to cause disruption of the larval eye epithelium. Previously, we showed that CagAEPISA does not cause “roughness” in adult eyes . In larvae raised at 25 degrees C, we observed that CagAEPISA caused ectopic furrowing, but did so only in 32% of cases , which is targeted to the membrane via an engineered myristoylation site DN) containing an inactivating mutation in the phosphatase domain that is predicted to create a dominant negative form of the protein (CswDN)DN did not cause morphological disruption at larval stages, but did cause a mild rough eye phenotype in adults (not shown). When co-expressed with CagA, we found that this phosphatase-dead Csw mutant did not reduce the degree of epithelial disruption caused by CagA expression  binding motif within CagA has been shown to direct CagA to the membrane or cells . Howevermatidium . TherefoEPISA had similar subcellular localization in a simpler context, S2 cells. In examining the expression patterns of CagAEPISA and CagA, we found that both are expressed throughout the cortex and cytoplasm  of CagAEPISA transfected S2 cells displayed the central ring phenotype versus 87% (n = 24) of CagA transfected S2 cells. Therefore, we argue that subcellular localization of CagA, which varies as a function of CagA sequence and cellular context, is a critical factor in determining the potency of CagA’s activation of MLC.The complexity of the larval eye epithelium made it difficult to predict CagA localization. We asked whether CagA and CagAytoplasm . CagAEPIrphology , a patteed cells . In factD. melanogaster model to elucidate a role for H. pylori CagA in activating MLC and inducing epithelial disruption. CagA caused a characteristic disruption of the eye epithelium that corresponded to elevated MLC phosphorylation levels and was suppressed by co-expression of an inactivating MLC mutation. In S2 cells, CagA activated MLC in a Rho and Rok dependent manner. We asked whether CagA’s ability to influence MLC activity is dependent on the phosphorylation of the EPIYA domains of CagA and found that CagAEPISA has impaired capacity to disrupt epithelia. We showed that the reduced potency of the CagAEPISA mutant could not be explained by a role for SHP-2/Csw in the morphological disruption. Instead, we argue that this impairment is due to CagAEPISA’s failure to concentrate in the apical domain of the larval eye epithelia, because in culture cells in which subcellular localization patterns of CagAEPISA and CagA are the same, CagAEPISA and CagA are equally potent in activating MLC.In this study, we used a transgenic D. melanogaster model we used in this study, unlike in cultured cells, we were able to directly test functional interactions between CagA and the Rho/MLC pathway. In this intact epithelial tissue, we find that the Rho/MLC pathway is the critical mediator of cytoskeletal disruption, whereas SHP-2 activation caused no epithelial disruption in larval stages, and SHP-2 inactivation failed to rescue CagA-induced epithelial disruption. Therefore, by examining CagA function within an intact epithelium, our study reveals Rho/MLC as a critical host effector of CagA-induced epithelial disruption.Based on work in cultured cells, SHP-2 is thought to be a primary mediator of cytoskeletal disruption induced by CagA H. pylori activates MLC in host cells. However, the connection between CagA and MLC remains controversial. In one report, it was shown that blocking MLC activity with blebbistatin exacerbates CagA-induced cell elongation H. pylori infection leads to activation of MLC H. pylori infection, such as IL-1R and urease, to cause maximal MLC activation.Recent studies have suggested that EPISA, because CagAEPISA only has the PS binding domain. However, this is not what we observed. PH-GFP and CagAEPISA have different patterns of localization suggesting that there are other factors that determine whether CagA is directed to the membrane besides the EPIYA motifs and the PS-binding motif. Other domains within CagA that have not yet been characterized may be critical for membrane localization. Additionally, interactions between CagA domains and host proteins specific to different cell types may be critical for determining localization. This point is reinforced by our observation that CagA localizes differently in the follicular epithelium of the ovary versus the larval eye epithelium. We speculate that the reason for this difference is that the mechanisms that position junctional proteins within the follicular epithelium are distinct from those acting in the larval eye epithelium The results of this study demonstrate a correlation between CagA localization and potency of epithelial disruption. However, the mechanisms that target CagA intracellularly are not fully understood. We show that the EPIYA motifs are critical for targeting CagA to the apical foci of epithelial cells in the retina. Previously, it was shown that EPIYA motifs are critical for membrane localization in cultured human gastric cells D. melanogaster larval eye is a highly specialized epithelium and is in many ways unlike CagA’s normal milieu, the human stomach, we found the D. melanogaster larval eye to be highly responsive to CagA. What likely contributes to CagA’s effectiveness in disrupting our model epithelium is the dynamic nature of apical MLC within it. Networks of apical MLC are a feature of most epithelia, and upregulation of apical MLC has been shown to be clinically significant. For example, increased levels of apical MLC and MLCK in enterocytes of the human intestine correlate with the severity of Intestinal Bowel Disease (IBD) H. pylori influences MLC activity within the human gastric epithelium.Although the H. pylori infection and chronic MLC activation by transgenic MLCK expression lead to broad immune activation through enhanced paracellular flux and heightened pro-inflammatory cytokine expression H. pylori infected patients do not develop peptic ulcers or cancer H. pylori, these additional insults include activation of the oncogene SHP-2, impairment of the polarity protein, Par-1, and activation of the epidermal growth factor (EGF) signaling Both src90 and UAS-cswD545A (provided by Lizabeth Perkins): UAS-Cdc42.V12 , UAS-Rac1.N17 (Bloomington Stock #6292), UAS-Rac1.V12 (Bloomington Stock #6291), UAS-RokCAT (Bloomington Stock #6669), UAS-RhoGEF2 (Bloomington Stock #9386), UAS-MLCK-CT , UAS-DiaCA (Bloomington Stock #27616), UAS-Ssh (Bloomington Stock #9114), sqhA21 . Stocks were provided by the Bloomington Stock Center unless otherwise noted above. Flies were raised at 25 degrees (unless otherwise noted) using standard techniques.The following fly lines were used: GMR-Gal4, UAS-CagA , UAS-RhoV14 , UAS-RhoN19 (Bloomington Stock #7327), UAS-cswD. melanogaster anti-Elav , mouse anti-HA , D. melanogaster ppMLC . Tissues were fixed in 4% Paraformaldehyde (30 minutes for eye discs and S2 cells (except for ppMLC staining which was 27 minutes), 20 minutes for egg chambers), blocked in PBSBT for 1 hr, and overnight primary antibodiy incubation at 4 degrees overnight was following by secondary antibody incubation overnight. Phalloidin 488  was added to the secondary antibody incubation.Phalloidin and antibody staining of eye imaginal discs, egg chambers and S2 cells was carried out by standard techniques and with the following antibodies: Images were collected with a Nikon confocal microscope. The 3D reconstruction in EPISA (provided by H.Higashi) were cloned into pMT vector using standard cloning procedures. After 24 hours of incubation with the transfection complex, CagA expression was induced with copper sulfate (1 mM) for 24 hours. For experiments involving combined transfection and RNAi treatment, transfection was performed 48 hours after addition of RNAi and cells were fixed at 72 hours of RNAi treatment. Y-27632 was purchased from Calbiochem and used at 100 uM.Drosophila S2 cell maintenance was performed as described previously. MLC-GFP cells were obtained from the Drosophila Genomics Resource Center. RNAi was performed according to published methods using previously reported sequences for template generation


Culex pipiens, an epidemiologically important vector of a wide array of pathogens. Using both isogenic laboratory strains and field-caught mosquitoes, we investigate the impact of two main insecticide resistance mechanisms (metabolic detoxification and target site modification) on the relative transcription of several genes involved in the immune response to pathogens, at both their constitutive and inducible levels. Our results show a discrepancy between the isogenic laboratory lines and field-collected mosquitoes: While in the isogenic strains, insecticide-resistant mosquitoes show a drastic increase in immune gene expression, no such effect appears in the field. We speculate on the different mechanisms that may underlie this discrepancy and discuss the risks of making inferences on the pleiotropic effects of insecticide-resistant genes by using laboratory-selected insecticide-resistant lines.Because of their role as vectors of diseases, the evolution of insecticide resistance in mosquitoes has been intensively investigated. Insecticide resistance is associated to a wide range of pleiotropic effects on several key life-history traits of mosquitoes such as longevity and behavior. However, despite its potential implications in pathogen transmission, the effects of insecticide resistance on mosquito immunity have received little, if any, attention. Here, we investigate the impact of insecticide resistance in  However, it has been recently suggested that insecticide resistance may also have an impact on the quality of these mosquitoes  and induced  the overproduction of detoxifying enzymes that sequester and/or degrade the insecticide before it reaches the nervous system (metabolic resistance) and (ii) mutations in the insecticide neural targets that render them less sensitive to the insecticide's active ingredient  have resulted in the evolution of two types of insecticide resistance (carboxylesterase overproduction and acetylcholinesterase modification). In this region, there is an insecticide-treated area (a 20-km band close to the sea), a nontreated area (further north), and an intermediate area where metabolic and target-site-resistant mosquitoes coexist with susceptible ones , the nitric oxide synthase (NOS), and transferrin. Antimicrobial peptides (AMPs) are an essential component of the defense machinery of mosquitoes against bacteria  Does insecticide resistance alter the level of expression of these immune-related genes? (ii) Does this effect depend on the insecticide resistance mechanism involved (esterase overproduction versus acetylcholinesterase modification)? (iii) Is this effect consistent at both their constitutive and inducible expression levels? and (iv) Do laboratory-reared and field-collected mosquitoes give similar answers to these questions? We discuss the potential implications of our results for disease transmission.Cx. pipiens mosquitoes sharing the same SLAB genetic background but differing by the alleles at the insecticide resistance loci were used in the experiments. Details of these strains are given in ad libitum source of 10% sugar solution for the emerged adults. One week after emergence, 90 females from each insecticide-resistant strain were haphazardly chosen from the different emergence cages and randomly assigned to one of three experimental treatments .Three different isogenic strains of Cx. pipiens egg rafts were collected in October 2010 from a population where insecticide susceptible , esterase-resistant , and acetylcholinesterase-resistant mosquitoes  coexist in sympatry (More than 50 sympatry . One wee2 pad. Mosquitoes were either: (i) uninjected, to measure constitutive gene expression levels in the absence of any immune stimulation, (ii) injected with the LPS immune elicitor , to measure inducible gene expression levels, or (iii) injected with physiological saline (Drosophila Ringer) as a trauma control. Injections of 69 nL of liquid per mosquito were performed intrathoracically by using a Nanoinjector (Drummond) equipped with a sterile, finely drawn glass capillary needle. Mosquitoes were then individualized into numbered dry 30-ml drosophila plastic tubes covered with a mesh and kept under our standard insectary conditions. Food was provided in the form of a cotton pad soaked in a 10% glucose solution placed on top of each tube. To match the induction peak of most of the immune genes investigated (Cx. pipiens were killed 24 h after injection using a CO2 pad. Mosquitoes were placed into an eppendorf containing 1 mL of Trizol reagent (Invitrogen Corp.) and immediately frozen at −80°C. Wild caught females were first decapitated before freezing in Trizol and mosquito heads were separately frozen to identify their insecticide resistance status . Injection of LPS was preferred to the injection of live bacteria as an immune challenge because it allows controlling for the eventual differences that could exist in bacterial growth between the strains.The injection protocol was identical for the isogenic lines and field-caught mosquitoes. Adult females were briefly anesthetized using a COstigated , femalesEster and ace-1 loci was performed on mosquito head homogenates using an RFLP analysis as described in Ester0, ace-1R) present in our initial pool of 360 wild mosquitoes was too low to achieve a satisfying number of replicates for the three injection treatments, only fully susceptible  and metabolic resistant  females were retained in for the qPCR analysis.Genotyping at the cecropin A, cecropin B, gambicin, defensin, transferrin, and NOS) and the esterase-2 gene by quantitative PCR (qPCR). Briefly, total RNA was extracted from whole mosquitoes (n = 270 isogenic and 153 field-caught mosquitoes) using Trizol Reagent following the manufacturer's protocol (Invitrogen). RNA integrity was electrophoretically verified by ethidium bromide staining before quantification using a NanoDrop spectrophotometer (NanoDrop Thermo Fisher Scientific). Oligo-dT primed cDNAs were produced from 1 μg of total RNA using M-MLV reverse transcriptase according to manufacturer's protocols and reagents (Invitrogen). The qPCR assays were performed with LightCycler480 (Roche) in 384-well qPCR plates. The qPCR reaction consisted in a 1 × Light-Cycler 480 master mix, 0.5 μm of each primer, and 1 μL of cDNA (1/8 dilution) to obtain a final volume of 5 μL. The primer sequences used for the qPCR reactions are given in Cx. pipiens sequences  gene as a reference. This method relies on the assumption that the amplification efficiencies of the target genes and the reference genes are approximately equal  under different dilutions of the template (1/1 to 1/32). For most target genes, ΔCT values were not significantly affected by dilutions, which indicate that the amplification efficiencies are indeed similar. After testing four different couples of primers, the cecropin A gene failed to meet these efficiency criteria and was thus discarded from the study . To ensure that mean gene expression, mosquito treatment, and mosquito insecticide resistance status would not be confounded with the microplate effect, we designed the qPCR plates according to two criteria: (i) the same individuals were simultaneously assayed for the expression of several genes on the same plate and (ii) qPCR plates included all combinations of insecticide-resistant categories and treatments for each gene.We set out to investigate the relative expression of six immune-related genes . Target gene expression  fitting plate identity as a random explanatory variable, and mosquito strain (isogenic mosquitoes) or genotype (field-collected mosquitoes), experimental treatment, and their interaction as fixed explanatory variables. Maximal models were simplified by sequentially eliminating nonsignificant terms and interactions to establish a minimal model , using mosquito treatment, mosquito genotype, and their interaction as fixed explanatory variables .Analyses were conducted using the R statistical package  mosquito injection . Defensin expression, however, was stimulated by the injection itself and not by the LPS immune elicitor . The results for the NOS also showed a significant treatment effect on gene expression , although this seemed to stem from a reduction in NOS expression in Ringer-injected females , transferrin and gambicin transcriptional activation appeared to be specific to the injection of LPS . Mosquito injection had, however, no discernible effect on the cecropin B , defensin , transferrin , and NOS  but not of cecropin B , except for transferrin .In the laboratory isogenic mosquito lines, insecticide resistance was found to have a very significant effect on the relative expression of cecropin B , defensin , transferrin , and NOS . The only exception was the gambicin, where Ester4 metabolic-resistant females had significantly higher expression levels after the LPS induction than insecticide susceptible mosquitoes .In sharp contrast to what happens in the isogenic laboratory lines, in field-caught mosquitoes insecticide resistance had no effect on the relative expression of most of the immune-related genes investigated: esterase-2 gene was higher in mosquitoes carrying the metabolic insecticide-resistant (Ester4) allele than in mosquitoes carrying the wild-type susceptible (Ester0) one , independently of the experimental treatment applied  are significantly higher in esterase-resistant (SA4B4) females than in susceptible (SLAB) ones. In addition, using microarray analyses, Vontas et al. found the defensin and cecropin genes to be constitutively expressed at a higher level in laboratory-maintained insecticide-resistant strains of Anopheles gambiae compared with their insecticide susceptible counterparts  have shown that the activities of two key enzymes involved in the terparts , and thetephensi . These Aablished , which resterase-2 transcripts in the isogenic lines  mosquitoes. We do not have a clear mechanistic explanation for how a single point mutation in the acetylcholinesterase gene could bring about this change. Target site resistance mutates key components of the vector's neural network and is thus mostly expected to have an effect on mosquito behavior  and the SLAB genetic background  LPS insult  and sympatric field-caught-mosquitoes from a population where insecticide-resistant and susceptible mosquitoes coexist. Our results lead us to make two distinct conclusions. The first one is that, under the specific conditions used in our experiments, insecticide resistance does not have any immune expression costs in field-caught mosquitoes. This result contrasts with previous studies that have shown that insecticide resistance in stigated , and whi but see  and that but see . For man


Symptomatic cardiac involvement is seen in less than 5% of all cases of sarcoidosis. Although clinically apparent cardiac sarcoidosis is an uncommon entity, ventricular tachyarrhythmias as the first presenting symptom are very rare.We discuss the case of a 41-year-old Asian woman who presented to our hospital with intermittent palpitation and on evaluation was diagnosed to have systemic sarcoidosis with cardiac involvement. She was started on multiple antiarrhythmic drugs and corticosteroids without any satisfactory response.Our case report indicates that sarcoidosis can manifest as ventricular tachycardia without any detectable systemic findings. This makes sarcoidosis an important diagnostic consideration in patients with ventricular tachycardia of unknown origin given the high mortality associated with ventricular tachyarrhythmias. Sarcoidosis is a multisystem granulomatous disorder of unknown etiology that mainly affects the lungs, skin, eyes, and lymphoreticular system, with cardiac involvement being a rare entity. A recent review of sarcoidosis placed cardiac involvement at 2%; it is one of the least common manifestations . HoweverAlthough the disease can manifest itself with comparatively benign signs and symptoms, cardiac involvement can prove to be fatal . The earA 41-year-old Indian woman presented with a history of intermittent palpitations of 10 days’ duration to our hospital. She denied any history of fever, cough, chest pain, dyspnea or syncope or relevant past history of these. She had a past history of pulmonary tuberculosis in 1992 with 6 months of antitubercular treatment. She denied any past history of hypertension, coronary artery disease, diabetes mellitus, thyroid or connective tissue diseases. On examination she was afebrile with a regular pulse of 142 beats/minute, and a blood pressure of 120/70mmHg. She had brownish, waxy papules in the skin of her bilateral lower limbs above her medial malleolus but the rest of the general physical examination did not reveal any abnormal findings. Her systemic examination was within normal limits. She was transferred from our emergency department to the cardiac coronary unit and a synchronized electrical cardioversion successfully terminated her VT.On investigation, her hemogram, blood biochemistry, liver, renal function and thyroid function were within normal limits. Her angiotensin-converting enzyme level was 147μL . Her serum calcium was normal. Her immunological markers were negative with normal erythrocyte sedimentation rate and C-reactive protein. A contrast-enhanced computed tomography (CT) chest scan showed findings suggestive of stage-III sarcoidosis -CT scan was performed. The study showed evidence of active disease involving her bilateral lungs, mediastinal, right supraclavicular, peripancreatic and retrocrural lymph nodes with focal lesions in segments VII and VIII of her liver  of 48% with hypokinesia of the mid-basal interventricular septum (IVS). Cardiac magnetic resonance imaging (MRI) with gadolinium contrast showed evidence of late enhancement in both the apical and anteroseptal left ventricular regions suspicious for fibrosis Figure . To furtOn the basis of the above clinical and investigational findings, diagnosis of systemic sarcoidosis with cardiac involvement was made. She satisfied the Japanese Ministry of Health and Welfare guidelines for diagnosis of cardiac sarcoidosis (see section Guidelines for the diagnosis of cardiac sarcoidosis) . She wasCardiac sarcoidosis is confirmed when endomyocardial biopsy specimens demonstrate non-caseating epithelioid cell granulomas with histological or clinical diagnosis of extracardiac sarcoidosis.If endomyocardial biopsy specimens do not demonstrate non-caseating epithelioid granulomas, then extracardiac sarcoidosis is diagnosed histologically or clinically when the following combination of major or minor diagnostic criteria are satisfied:1. Two or more of the four major criteria are satisfied2. One in four of the major criteria and two or more of the five minor criteria are satisfied1. Advanced atrioventricular block2. Basal thinning of the interventricular septum3. Positive gallium-67 uptake in the heart4. Depressed ejection fraction of the left ventricle (<50%)1. Abnormal electrocardiogram findings: ventricular arrhythmias , complete right bundle branch block, axis deviation or abnormal Q wave2. Abnormal echocardiography: regional abnormal wall motion or morphological abnormality 3. Nuclear medicine: perfusion defect detected by thallium-201 or technetium-99m myocardial scintigraphy4. Gadolinium-enhanced contrast magnetic resonance imaging: delayed enhancement of myocardium5. Endomyocardial biopsy: interstitial fibrosis or monocyte infiltration of moderate gradeSarcoidosis is a multisystem granulomatous disease, which predominantly affects 20- to 30-year olds of both sexes. Most patients present with pulmonary involvement. In addition to the lungs, other affected organs are, in decreasing order of frequency, skin, liver, gastrointestinal tract, eyes and nervous system . CardiacThe course of sarcoidosis can be indolent; however, acute complications in cardiac sarcoidosis can lead to sudden cardiac death ,10. Non-Ante mortem diagnosis of cardiac sarcoidosis is difficult because of its wide-ranging clinical manifestations and the limitations of available diagnostic tests. Guidelines for the diagnosis of cardiac sarcoidosis have been published by the Japanese Ministry of Health and Welfare although they have not been validated (see section Guidelines for the diagnosis of cardiac sarcoidosis) ,12. AlthSarcoidosis that involves the heart warrants prompt treatment with corticosteroids with or without other immunosuppressive agents . A recenVentricular arrhythmias are common in cardiac sarcoidosis but are often refractory to antiarrhythmic drugs including amiodarone. Most authorities recommend placement of an electronic pacemaker for complete heart block and an automatic implantable cardioverter-defibrillator for ventricular fibrillation or tachycardia and markedly reduced left ventricular EF . CardiacCardiac involvement should be ruled out in any patients with systemic sarcoidosis. A negative endomyocardial biopsy should not be taken as evidence of the absence of cardiac sarcoidosis, particularly if suspicion is strong. Advances in cardiac imaging seem to be improving the diagnosis and, when highly suggestive, should prompt a search for a positive tissue biopsy in a visualized abnormal area of the myocardium or from a non-cardiac site. Steroid therapy seems to be beneficial when used relatively early in the course of the disease. Due to the risk of arrhythmia in this disease, a strong consideration for prophylactic implantation of an AICD should be considered, particularly in the presence of ventricular arrhythmias or reduced EF.Written informed consent was obtained from the patient’s relative for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no conflicting interests.ME received the patient, collected data and wrote the paper. SS, RP, RN and NN were responsible for the patient, performed all the cardiac procedures, managed the patient and critically revised the manuscript. LS carried out the histopathological examination of tissue biopsies. All authors read and approved the final manuscript.