To assess the impact of intracranial pressure monitoring on the short-termoutcomes of traumatic brain injury patients. Retrospective observational study including 299 consecutive patients admitted dueto traumatic brain injury from January 2011 through July 2012 at a Level 1 traumacenter in São Paulo, Brazil. Patients were categorized in two groupsaccording to the measurement of intracranial pressure . We applied apropensity-matched analysis to adjust for possible confounders . Global mortality at 14 days (16%) was equal to that observed in high-incomecountries in the CRASH Study and was better than expected based on the CRASHcalculator score (20.6%), with a standardized mortality ratio of 0.77. A total of28 patients received intracranial pressure monitoring , of whom 26 were paired in a 1:1 fashion with patients from thenon-measured intracranial pressure group. There was no improvement in the measuredintracranial pressure group compared to the non-measured intracranial pressuregroup regarding hospital mortality, 14-day mortality, or combined hospital andchronic care facility mortality. Survival up to 14 days was also similar betweengroups. Patients receiving intracranial pressure monitoring tend to have more severetraumatic brain injuries. However, after adjusting for multiple confounders usingpropensity scoring, no benefits in terms of survival were observed amongintracranial pressure-monitored patients and those managed with a systematicclinical protocol. The worldwide incidence of TBI isincreasing, especially in developing countries where the use of motor transportation isalso increasing. Despiteimprovements in trauma systems and critical care, mortality rates of approximately 40%have been reported in a review of unselected observational studies. In addition to death, disability inyoung, productive people leads to large direct and indirect costs to society.Traumatic brain injury (TBI) is a medical and social problem worldwide, with anestimated 10 million cases leading to hospitalization or death each year. The insertion of an intracranial cathetercarries risks of hemorrhage and infection, and the benefits of such monitoring inpatients with TBI have been questioned in recent years.The Brain Trauma Foundation recommends monitoring intracranial pressure (ICP) in allpatients with survivable severe traumatic brain injuries and abnormalities observed on acomputed tomography (CT) scan obtained at the time of admission as well as in selectedpatients  with a normal CT scan. However, there werecaveats in the pre-hospital care in the Chesnut´s study, such as a low proportion ofpatients admitted to the hospital by ambulance; therefore, the impact of an aggressivestrategy of ICP monitoring may have been mitigated.Chesnut et al. recently conduct a clinical trial to determine the potential benefits ofmonitoring ICP. They found no benefit of directly measuring ICP compared to patientsmanaged with a rigorous and aggressive clinical protocol to control intracranialpressure.We sought to compare two groups of TBI management  in a contextoutside of a clinical trial in a trauma population in a middle-income country.Hospital dasClínicas of the Faculdade de Medicina of theUniversidade de São Paulo .Informed consent was waived due to the strict observational nature of the study.This retrospective observational study included 299 consecutive patients admitted due totraumatic brain injury from January 2011 through July 2012 at a Level 1 trauma center inSão Paulo, Brazil. Patients were categorized in two groups according to the measuring ofICP (measured ICP and non-measured ICP groups). All data were collected during ICUadmission using a standardized database system. Demographic and clinical data werecollected during intensive care unit (ICU) admission, and patients were followed-upuntil hospital discharge. Discharge to a chronic care facility was also noted. Thisstudy was approved by the Research Ethics Committee of the Head CT were evaluated independently by two investigators (CBF and EB) and classifiedaccording to the components of the Crash prognostic score system. Disagreements betweenthe two investigators were resolved by a third investigator (LCM). The followingcharacteristics of the head CT were evaluated: presence of midline shift, presence ofsubarachnoid hemorrhage, presence of non-evacuated hematoma, presence of petechia, andobliteration of the third ventricle. We also observed whether the patient had a majorextracranial injury; the first available Glasgow coma scale score ; and pupil reaction to light .®, Helmbrechts, Germany). Intraparenchymal probes werecalibrated in the operating room. When an external ventricular drainage system wasplaced, it was zeroed at the tragus level . Cerebral perfusion pressure was calculated as ICPminus mean arterial blood pressure.An intracranial pressure catheter was inserted at admission at the discretion of theattending neurosurgeon. When the patient had already been admitted to the ICU, theindication was discussed with the intensivist. Of the patients in the study, 28 receivedICP monitoring (measured ICP group), with 11 of those receiving an external ventriculardrainage system and the other 17 receiving an intraparenchymal device(Raumedic2 - PaCO2 - between35 and 38mmHg). If an external ventricular drainage system was in place, it was leftopen with a starting drainage pressure of 20mmHg. Second-tier therapies includedinduced hypothermia ; barbiturates ; and, in selected cases, mild hyperventilation (targetPaCO2 between 28 and 30mmHg). A decompressive craniectomy was used as alast resource in selected cases. Therapies were weaned from the most recently addedto the initial therapies according to the reduction in ICP levels.Patients in the measured ICP group had therapy targeted to maintain ICP ≤20mmHg and cerebral perfusion pressure between 60 and 70mmHg. ICP control wasinitially attempted through the use of continuous sedative agents (propofol andfentanyl), 30º head positioning; hyperosmolar therapy (0.5mL/kg bolus of NaCl 20% andNaCl 3% as maintenance aimed at a serum sodium level between 145 and 150mEq/L); andnormocapnia . A head CT was repeated within24 hours post-trauma and then every 48 hours or if there was a new critical event.TCD was performed on a daily basis and acted as an adjuvant tool to orient thetherapy. All patients were managed with continuous hypertonic saline infusion . Second-tier therapies wereadded on a case-by-case analysis only if the head CT showed no improvement during theinitial 48 hours after ICU admission. Sedatives and hypertonic saline infusions werewithheld when the head CT showed an open third ventricle.Corticosteroids were not used in TBI patients, as supported by major recommendations.Prophylactic anticonvulsants  were used asrecommend. Glycemic control was achieved through intravenous insulin adjusted bypoint-of-care measurements targeting a blood glucose level between 150 and200mg/dL.Hospital Auxiliar de Suzano, Suzano, Brazil) andshares the same electronic database.Our primary endpoint was hospital mortality. As a secondary endpoint, we evaluated14-day mortality, discharge to chronic care facility, and combined mortality. The latter analyses were possiblebecause the chronic care facility that receives patients from our hospital is linkedto our institution  or Fisher´s exact test. Weexpected that patients who received ICP monitoring would differ from patients who didnot receive ICP monitoring in several ways. Therefore, to adjust for confounders, weused a propensity-matched analysis that would adjust for possible confounders. Thepropensity score (PS) resembled the given probability of a patient receiving aspecific therapy. We defined a priori that the PS would be adjusted for all variablescontained in the Crash Score prognostic algorithm, namely age; gender; GCS; pupilreaction to light; major extracranial injury; and head CT features, includingpresence of non-evacuated hematoma, midline shift, subarachnoid hemorrhage, andobliteration of third ventricle. The PS was obtained using logistic regression withICP measurement as the outcome. Matching was performed using a 1:1 basis (one patientwho received ICP monitoring for one who did not) using a caliper of 0.05. The 14-daysurvival rate for matched patients was also assessed by a Kaplan-Meier plot with alog rank test.Continuous variables were tested for normality using the Kolmogorov-Smirnov test.Parametric continuous variables were compared between groups using Student'sAll analyses were conducted using R project with matching and survival packages.The -day mortality rate of the total sample was 16%, which was very similar to what wasexpected based on the CRASH score (20.6%) for high-income countries, with a standardizedmortality ratio of 0.77. Of 299 patients included in the analysis, only 28 (9.3%)received ICP monitoring during their ICU stay. Characteristics of the whole populationand comparisons between patients with and without ICP monitoring are shown in Propensity score matching pairing was possible for 26 of the 28 patients in the measuredICP group. The results comparing propensity-matched patients in the measured ICP andnon-measured ICP groups are shown in This study showed no clear evidence that ICP monitoring offers any short-term survivaladvantages in TBI patients. In a propensity score analysis adjusted for major short-termconfounders, mortality, survival up to 14 days and frequency of discharge to chroniccare facilities were not different between groups. Global mortality in 14 days (16%) wasequal to that observed in high-income countries in the CRASH Study and was better thanexpected based on the CRASH calculator. Evidencein favor of strict intracranial pressure control gained importance during the followingyears, and it is currently recommended by international guidelines.,5,9 While direct pressure monitoring is thegold standard for ICP measurement and clinical management, its use is associated withrisks, such as bleeding and infection, that may overcome the benefits of ICP control.Data comparing management strategies with and without ICP monitoring has yieldedconflicting results.-13 Chesnut et al. performed a randomizedcontrolled trial assessing the role of ICP measurement in 324 TBI patients and concludedthat ICP monitoring offered no advantages in terms of both short- and long-termmortality. Nevertheless, majorconcerns regarding pre-hospital care may have mitigated the potential benefit of ICPmeasurement. Therefore, the role of ICP monitoring in scenarios where pre-hospital careis structured and performed by trained personnel may be different.,15 All patients included in our analysis were transported to thehospital by helicopter or ground ambulance by trained personnel.The association between intracranial hypertension and poorer outcomes in TBI patientshas been known since 1951.,17 Despite its use being widely accepted,some reports suggest that close to 20% of neurosurgeons have a high level of confidencethat ICP monitoring improves prognosis in TBI patients. It could be suggested that our results could be relatedto the lack of experience of the ICU personnel in dealing with neurotrauma patients;however, our expected short-term mortality was proven to be similar to that ofhigh-income countries when using the CRASH model. Our results are aligned with not onlythe most recent randomized controlled trial but also a recent meta-analysis on thissubject. It should behighlighted that from the six studies that favored ICP monitoring included in thisrecent meta-analysis, five were conducted in developed countries.ICP monitor use is highly variable. The retrospective nature of the study leads to its inherentweaknesses, such as reporting bias; however, most of the data collection was performedusing a computerized databank. Moreover, this single-center study was limited to bias inlocal care. Beyond that, other relevant outcomes of TBI, such as quality of life andlong-term mortality, were not assessed. Therefore, our conclusions should be interpretedwith caution, considering the specific features of the center where this study tookplace.There are several limitations in the present study. We could not account for allpossible confounders in this analysis, such as other markers of illness severity. We donot have data regarding pre-hospital care, the specific number of interventions eachpatient received for ICP control, and the results from monitoring devices . Despite the moderate size of oursample, few patients received ICP monitoring. Nevertheless, we were able to adequatelypair most (26 out of 28) patients in the monitored ICP group with non-monitored ICPgroup patients using a propensity score analysis, which may produce results that aresimilar to those of randomized controlled trials.In a cohort of traumatic brain injury patients, intracranial pressure monitoring wasmainly used for patients with more severe traumatic brain injuries. After adjusting formultiple confounders using propensity score matching, no differences in terms ofsurvival were observed among intracranial pressure-monitored patients compared to thosemanaged with a systematic clinical protocol.


With emerging cases of adrenal suppression being reported in pediatric patients, finding appropriate steroid sparing agents is of clinical importance. Tiotropium bromide (TB), a long-acting anticholinergic, has recently been investigated in adults as a steroid-sparing agent in asthma step-up therapy. We report the first case of tiotropium bromide (TB) used as a step-up steroid sparing agent in an adolescent with adrenal suppression secondary to inhaled mometasone furoate (MF).A sixteen-year-old female with asthma and allergic rhinitis treated MF/formoterol fumarate 800/ 20 mcg per day in addition to intranasal MF presented with increasing fatigue, weight loss, nausea and striae. Extensive initial hospital investigations were normal. An AM cortisol was reported < 50 nmol/L (170-540). She was started on hydrocortisone therapy and changed to ciclesonide 400 mcg, as well as montelukast and formoterol. Her energy and weight improved after initiation of replacement hydrocortisone therapy. Despite using sublingual grass immunotherapy, during grass pollen season the patient's asthma control worsened. Rather than increase the dose of inhaled corticosteroids, 18 mcg of daily TB was added for a therapeutic trial. The patient experienced symptomatic improvement with less nocturnal cough, normal exercise tolerance and 4% improvement in FEV1.There is a limited repertoire of steroid sparing agents available for use in the pediatric asthma population. While adrenal suppression due to inhaled corticosteroids is considered relatively uncommon, and prior MF-induced adrenal suppression has only been reported by the authors, finding suitable alternatives to inhaled corticosteroids is paramount in this population. Physicians may consider a trial of TB in an attempt to decrease the dose of inhaled corticosteroids in their pediatric patients to avoid adrenal suppression.Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Recent advances that incorporate combination chemotherapy and the anti-CD20-targeted agent rituximab (Rituxan) have improved the clinical outcome of patients diagnosed with diffuse large B-cell lymphoma (DLBCL), but only 60% of all DLBCL patients are potentially cured and achieve sustained progression-free survival (PFS). PFS after salvage therapies including autologous stem cell transplantation drops to 30% leading to a disease relapse and a poor prognosis.18F-labeled-fluorodeoxyglucose (18F-FDG) PET can differentiate viable tumor from posttreatment necrotic tissue or fibrosis making it the imaging modality-of-choice upon completion of chemotherapy.2 Although there has been an increasing trend to perform interim PET/CT (interim PET) after 2–4 cycles of induction chemotherapy to monitor response and tailor consolidation therapy, the optimal interpretation method for interim PET analyses remains uncertain.3 Importantly, there is an unmet for a quantitative, standardized and reproducible method for this purpose.4Positron emission tomography (PET) integrated with computerized tomography (CT) combines anatomical delineation and metabolic activity of tumor tissue counts as the main tool to determine the therapeutic response of DLBCL patients. max), partially meet these criteria, studies have not defined a uniformly applicable SUVmax reduction cutoff that accurately predicts PFS or clinical outcome.6 SUVmax represents a single-pixel value, which reflects maximum intensity of 18F-fluorodeoxyglucose (FDG) activity in the tumor and ignores the extent of metabolic abnormality and changes in the distribution of a tracer within a lesion. SUVmax reflects increased anaerobic metabolism and higher glucose consumption. This region of tumors is located in the hypoxic tumor core with irregular angiogenesis, which result in more leaky and less effective vasculature that may cause less effective medication delivery.7 Thus, using SUVmax reduction to assess chemotherapy effectiveness may miss the more dynamic area of the tumor and those with improved drug delivery. Although complete disappearance of SUVmax may indicate complete response, SUVmax, in fact, may not be the best index to determine the early tumor response to a given treatment. Therefore, alternative metabolic parameters that integrate both tumor volume and intensity of uptake may provide more precise clinical information. We hypothesized that a method that maximized the detection of all metabolically active regions within the tumor mass, defined as the metabolic tumor volume (MTV), could serve as a better predictor of clinical outcome than semiquantitative methods, that is, SUVmax measurement. Here, we compared the ability of MTV measurement by gradient- or threshold-based methods with semiquantitative SUVmax measurement on interim PET analyses to predict the PFS of DLBCL patients after initial therapy.Although semiquantitative methods, such as determination of the maximum standard uptake value .8 Gradient-based methods are designed to allow a better estimation of intensity by reconstructing images that are denoised and deblurred with an edge-preserving filter and iterative deconvolution algorithm.9 Differences in uptake and metabolism at tumor periphery, where a sharp drop in FDG uptake is seen, are considered to be the edge of the metabolically active tumor volume. Gradient-based methods appear to be more accurate compared with source-to-background ratio methods for segmenting FDG-PET images.10 SUVmax and MTV were determined from the initial and interim PET images using PET Edge software .To evaluate the contribution of metabolic activity within the tumor periphery in assessing clinical outcomes, two different methods—fixed threshold- and gradient-based—were used to measure MTV. Fixed threshold-based measures tumor volume using software that includes all detectable areas with P=0.37). Compared with the threshold-based method, the gradient-based method resulted in a statistically significant greater MTV in pretreatment, as well as interim PET images. However, no significant difference was noted between the reduction in MTV determined by the threshold-based (ΔMTVT) or gradient-based (ΔMTVG) methods . However, the reduction in SUVmax (ΔSUVmax) was smaller when measured by ΔMTVT and ΔMTVG .Median follow-up period for patients in the study was 37 months. R-CHOP  and R-DA-EPOCH  were the first line of therapy in 74% and 26% of patients, respectively. On interim PET/CT, 69% of patients achieved complete response with the remaining patients showing partial response based on visual assessment. Dichotomous visual interpretation of interim PET did not correlate with PFS   were then stratified into two groups based on an ΔMTV cutoff value > or <52%. From a total of 115 patients who achieved a ΔSUVmax >72% on interim PET/CT imaging, 77 (67%) had a ΔMTV >52%. Importantly, patients who achieved a ΔMTV >52% had a statistically significantly greater PFS compared with patients who achieved a ΔMTV <52% .As no difference was found between the two methods to determine ΔMTV and as the threshold-based method was more versatile, this method was used to correlate interim PET values with PFS. To identify an optimal threshold cutoff that could predict PFS more accurately, receiver operating characteristic (ROC) curve analysis was used. The area under the ROC curve (AUC) provides a measure of the accuracy of a diagnostic test and ranges from 0.5 (random guessing) to 1.0 (perfect test). 0.0324) . All patmax on interim PET with PFS. MTV measurement using a gradient-based method rendered assessment of a greater tumor volume compared with the threshold-based method. The two methods reveal a similar percent reduction in MTV and appear equivalent with respect to interim PET results. However, MTV measurement by either method after initial treatment was a better predictor of PFS compared with SUVmax reduction. Further analysis also revealed the underlying importance of MTV reduction on interim PET to predict PFS for patients who had also achieved a significant reduction in SUVmax  more accurately predicted PFS as it incorporates the metabolic contribution of the tumor periphery. Commonly, peripheral tumor is not adequately assessed, although it is metabolically active.In this study, a retrospective study was performed to correlate the reduction in MTV and SUVn SUVmax . Althoug13 Such results may be because of the high degree of interobserver variability inherent in visual assessment methods. The ΔSUVmax cutoff values estimated by ROC analysis used here to distinguish good and bad responders were similar to those values previously reported in independent cohorts after either two or four cycles of induction treatment.14 Thus, these thresholds appear to be robust and reproducible regardless of patient age and International Prognostic Index in DLBCL patients. Our study highlights the importance of MTV assessment combined with semiquantitative measurements on interim PET to better predict the clinical outcome of DLBCL patients. Metabolic activity of peripheral tumor should be incorporated into response-adaptive strategies and prospective trials that evaluate the response to current and novel therapeutic regimens to treat DLBCL patients.Although prior reports highlight the prognostic value of imaging PET based on visual assessment, other studies, including ours, have not demonstrated a statistically significant difference for positive or negative.


Although compulsive sexual behaviour (CSB) has been conceptualized as a “behavioural” addiction and common or overlapping neural circuits may govern the processing of natural and drug rewards, little is known regarding the responses to sexually explicit materials in individuals with and without CSB. Here, the processing of cues of varying sexual content was assessed in individuals with and without CSB, focusing on neural regions identified in prior studies of drug-cue reactivity. 19 CSB subjects and 19 healthy volunteers were assessed using functional MRI comparing sexually explicit videos with non-sexual exciting videos. Ratings of sexual desire and liking were obtained. Relative to healthy volunteers, CSB subjects had greater desire but similar liking scores in response to the sexually explicit videos. Exposure to sexually explicit cues in CSB compared to non-CSB subjects was associated with activation of the dorsal anterior cingulate, ventral striatum and amygdala. Functional connectivity of the dorsal anterior cingulate-ventral striatum-amygdala network was associated with subjective sexual desire (but not liking) to a greater degree in CSB relative to non-CSB subjects. The dissociation between desire or wanting and liking is consistent with theories of incentive motivation underlying CSB as in drug addictions. Neural differences in the processing of sexual-cue reactivity were identified in CSB subjects in regions previously implicated in drug-cue reactivity studies. The greater engagement of corticostriatal limbic circuitry in CSB following exposure to sexual cues suggests neural mechanisms underlying CSB and potential biological targets for interventions. Excessive or problematic engagement in sex, which has been termed compulsive sexual behaviour (CSB), hypersexuality disorder or sexual addiction, is a relatively common clinical entity that may carry significant mental and physical health consequences How best to conceptualize CSB has been debated, with rationales proposed for considering the condition as an impulse-control disorder or a non-substance or “behavioural” addiction Cue reactivity relates importantly to clinically relevant aspects of substance-use disorders. For example, heightened cue reactivity is associated with relapse Different models have been proposed to explain addictive behaviours, with one model positing that in addictions, “wanting” becomes dissociated from “liking” as one becomes addicted Multiple studies have previously focused on sexual cues in healthy volunteers identifying regions including the hypothalamus, thalamus, amygdala, anterior cingulate cortex, anterior insula, inferior frontal cortex, fusiform gyrus, precentral gyrus, parietal cortex and middle occipital cortex Neurophysiological studies focusing on CSB in the general population rather than healthy volunteers are comparatively more limited. A diffusion MRI study focusing on a small group of non-paraphilic CSB subjects (N = 8) compared to healthy volunteers (N = 8) showed lower mean diffusivity in superior frontal regions Here we assessed cue reactivity comparing sexually explicit video cues with non-sexual exciting stimuli (such as videos of sporting activities) and assessed scores of sexual desire or wanting and liking in subjects with and without CSB. We hypothesized that individuals with CSB as compared to those without would show greater desire (wanting) but not liking (similar across groups) in response to sexually explicit but not to non-sexually exciting cues. Although a range of regions have been implicated in response to sexual cues in healthy volunteers, as we were studying patients with CSB, we hypothesized that there would be greater activation to sexually explicit as compared to non-sexual exciting cues in regions implicated in drug cue reactivity studies including the ventral striatum, dACC and amygdala. We further hypothesized that these regional activations would be functionally linked across groups but more strongly in individuals with CSB as compared to those without, and that sexual desire (wanting) would be more strongly linked to activity within these regions in individuals with CSB as compared to those without. Given developmental changes in motivational systems underlying risky behaviours CSB subjects were recruited via Internet-based advertisements and from referrals from therapists. Healthy volunteers were recruited from community-based advertisements in the East Anglia area. For the CSB group, screening was conducted using the Internet Sex Screening Test (ISST) By design and given the nature of the cues, all CSB subjects and healthy volunteers were male and heterosexual. Male healthy volunteers were age-matched (+/−5 years of age) with CSB subjects. An additional 25 age-matched male heterosexual healthy volunteers underwent the video ratings outside of the scanner to ensure adequacy of the subjective responses to the videos as assessed by subjective responses. Exclusionary criteria included being under 18 years of age, having a history of substance-use disorders, being a current regular user of illicit substances (including cannabis), and having a serious psychiatric disorder, including current moderate-severe major depression (Beck Depression Inventory >20) or obsessive-compulsive disorder, or history of bipolar disorder or schizophrenia  Subjects completed the UPPS-P Impulsive Behaviour Scale Subject characteristics are reported in Table S1 in Written informed consent was obtained, and the study was approved by the University of Cambridge Research Ethics Committee. Subjects were paid for their participation.Subject characteristics and questionnaire scores were compared using independent t-tests or Chi-square tests. Multivariate analyses were used for the ASES scores. For the ratings of sexual desire or liking, mixed-measures ANOVA were used to compare the explicit versus erotic ratings with group  as a between-subjects measure, video type (explicit or erotic cues), and subjective rating (desire or liking) as within-subjects measures.In the imaging task, subjects viewed video clips presented in a counter-balanced fashion from one of 5 conditions: explicit sexual, erotic, non-sexual exciting, money and neutral. The videos were shown for 9 seconds, followed by a question if the video was indoors or outdoors. Subjects responded using a 2-button key-pad with their second and third digits of their right hand to ensure they were paying attention. The question occurred during a jittered inter-trial interval of 2000 to 4000 milliseconds. Explicit videos showed consensual sexual interactions between a man and a woman obtained from videos downloaded from the Internet with licenses obtained where necessary. Examples of erotic videos included a dressed woman dancing erotically or a scene of a woman brushing her thigh. Non-sexual exciting videos displayed sporting videos similar in nature to highly arousing images from the International Affective Picture System such as skiing, sky-diving, rock-climbing, or motorcycle-riding. Money videos showed images of coins or paper money being paid, falling or scattered. Neutral videos showed scenes of landscapes. The conditions were randomized with eight trials per condition shown for a total of 40 video clips. Five different videos per condition were shown for a total of 25 different video clips.In the video-rating task outside of the scanner, subjects watched the same videos and completed a continuous rating scale for sexual desire and liking. Subjects were asked the following questions on 2 separate slides: ‘How much did this increase your sexual desire?’ and ‘How much did you like this video?’ and indicated an answer using a mouse along a line anchored from ‘Very little’ to ‘Very much’. An additional 25 male healthy volunteers were tested on the video-rating task. Subjects were asked if they have previously viewed the videos prior to the study. All tasks were coded using E-Prime 2.0 software.a priori hypothesized regions of interest were conducted if the contrast of condition (e.g. explicit – exciting) identified regions significant at the whole-brain FWE P<0.05 level. Age and depression scores were used as covariates. Variables including subjective measures of sexual desire and liking responses to the video cues, scores on the Young Internet Addiction Test, and days abstinent were included in models as covariates of interest. The covariate of age was also investigated, controlling for depression and subjective desire, across groups and using explicit masking.The acquisition parameters of the fMRI study are described in a priori hypotheses, we combined the ROIs using a small-volume-correction (SVC) with Family-Wise-Error correction at p<0.05 considered significant. Given findings linking subjective ratings of desire to dorsal anterior cingulate activation, psychophysiological interaction analysis was conducted with dorsal cingulate as the seed region  contrasting explicit – exciting videos. Given the potential involvement of mesolimbic and mesocortical circuitry, activity in the substantia nigra was also assessed on an exploratory level. The ventral striatal anatomical region of interest (ROI), previously used in other studies The ventral striatum, amygdala and dorsal cingulate were hypothesized regions of interest. For these three regions with strong Nineteen heterosexual men with CSB (age 25.61 (SD 4.77) years) and 19 age-matched (age 23.17 (SD 5.38) years) heterosexual male healthy volunteers without CSB were studied ; CSB: 13.89 (SD 2.22) in years) relative to the age of onset for Internet use in general (HV: 12.94 (SD 2.65); CSB: 12.00 (SD 2.45) in years)  = 4.13, p = 0.048). CSB subjects had greater Internet use relative to healthy volunteers  although the linear regression was not significantly different between groups . There were also no differences in the video-rating scores for desire and liking for each condition between the scanned healthy volunteers and an additional 25 healthy volunteers suggesting the subjective ratings to the videos were representative (p's>0.05). All subjects reported they had not previously seen the videos prior to the study.Subjective ratings of desire and liking of videos were dissociated in which there was a group-by-rating-type-by-video-type interaction  = 4.794, p = 0.037): desire ratings to explicit videos were greater in CSB compared to healthy volunteers  but not to erotic cues , whereas liking ratings to erotic cues were greater in CSB compared to healthy volunteers  but not to explicit cues . The desire and liking scores to explicit cues were significantly correlated  but not the a priori hypothesized regions.No between-group main-effect brain activation differences survived whole-brain correction. The contrast of explicit – exciting videos across subject groups identified activation of the ventral striatum, dACC and amygdala at the whole-brain-corrected FWE p<0.05 level . The conWe next examined between-group differences in the explicit – exciting contrast which had shown a significant effect across groups in our hypothesized regions. CSB subjects demonstrated greater activity in the right ventral striatum , dACC  and right amygdala  . Given aTo examine the relationship between neural response to cues and ratings of desire and liking, we conducted covariate analyses involving brain responses to the explicit cues. In both groups, ratings of subjective sexual desire were positively correlated with dACC activity , with no differences between groups . There wOn an exploratory level, neural activity was investigated as a function of age. Age across all subjects was negatively correlated with activity in the right ventral striatum  and dACC . Greater activity as a function of age was observed in the CSB group as compared to healthy volunteers in bilateral ventral striatum  .Given the association between ratings of subjective sexual desire dACC activity, a psychophysiological interaction analysis using the dACC as a seed was conducted comparing explicit – exciting cues. Across both groups, there was increased functional connectivity of the dACC with the right ventral striatum  and right amygdala . There were no between-group differences in functional connectivity. When subjective desire scores were assessed as a covariate, there was a positive correlation between desire scores and greater functional connectivity in CSB subjects between the dACC and right ventral striatum  and right amygdala   and, on In this study of sexually explicit, erotic and non-sexual cues, individuals with CSB and those without showed similarities and differences with respect to patterns of neural responsivity and relationships between subjective and neural responses. Sexual desire or wanting of the explicit sexual cues was linked to a dACC-ventral striatal-amygdala functional network evident across both groups and more strongly activated and linked to sexual desire in the CSB group. Sexual desire or subjective measures of wanting appeared dissociated from liking, in line with incentive-salience theories of addiction Compared to healthy volunteers, CSB subjects had greater subjective sexual desire or wanting to explicit cues and had greater liking scores to erotic cues, thus demonstrating a dissociation between wanting and liking. CSB subjects also had greater impairments of sexual arousal and erectile difficulties in intimate relationships but not with sexually explicit materials highlighting that the enhanced desire scores were specific to the explicit cues and not generalized heightened sexual desire. In CSB subjects as compared to healthy volunteers, higher scores of sexual desire to explicit cues were associated with greater dACC activity and enhanced functional connectivity between the dACC, ventral striatum and amgydala (as described below), suggesting a network involved in the processing of subjective wanting related to sexual cues. A previous study of compulsive hypersexuality related to dopamine agonists in Parkinson's disease, which can include behaviours such as compulsive use of sexually explicit materials, demonstrated greater neural activity to sexual picture cues that correlated with enhanced sexual desire Drug-cue-reactivity and craving studies of nicotine, cocaine and alcohol implicate networks including the ventral striatum, dACC and amygdala In the current study in response to sexually explicit cues, sexual desire was associated with greater dACC activity, and greater dACC-ventral striatal-amygdala functional network activity was related to enhanced desire to a greater extent in the CSB subjects than in the healthy volunteer subjects. CSB subjects also demonstrated greater substantia nigra activity compared to healthy volunteers, thus possibly linking the findings to dopaminergic activity. In humans and non-human primates, the dACC is an important target of dopaminergic projections from the substantia nigra and ventral tegmental area Our findings suggest dACC activity reflects the role of sexual desire, which may have similarities to a study on the P300 in CSB subjects correlating with desire The current findings suggest age-related influences on the processing of sexual cues. Maturation of fronto-cortical grey matter involved in executive control persists in adolescence into the mid-20 s In keeping with the literature on brain activity in healthy volunteers to explicit sexual stimuli activated regions, we show a similar network including the occipito-temporal and parietal cortices, insula, cingulate and orbitofrontal and inferior frontal cortices, pre-central gyrus, caudate, ventral striatum, pallidum, amygdala, substantia nigra and hypothalamus a priori hypotheses based on available meta-analytic data from cue reactivity studies, we felt a region of interest analysis family wise error corrected for multiple comparisons, an approach commonly used in imaging studies The current study has multiple limitations. First, the study involved only heterosexual male subjects, and future studies should examine individuals of various sexual orientations and females, particularly as girls with mental health concerns may exhibit high rates of CSB The current and extant findings suggest that a common network exists for sexual-cue reactivity and drug-cue reactivity in groups with CSB and drug addictions, respectively. These findings suggest overlaps in networks underlying disorders of pathological consumption of drugs and natural rewards. While this study may suggest overlaps with substance-use disorders, further clinical studies are required to determine whether CSB should be categorized as an impulse-control disorder, within an obsessive-compulsive spectrum or as a behavioural addiction. Large multi-centre epidemiological studies with long-term follow-up are required to assess the frequency of CSB and its long-term outcomes. Epidemiological studies on the relationship between CSB and disorders of impulsivity, compulsivity and addictions are required. Similarly, more extensive comparisons on neurocognitive and neurophysiological profiles across disorders would be helpful in further understanding the physiology and neural networks underlying these disorders. We emphasize also that these findings are relevant particularly to the subgroup of individuals who develop difficulties with compulsive use of online sexually explicit materials and likely do not reflect on the wider population who use such materials in non-harmful manners. The findings indicate an influence of age on enhanced limbic reactivity to sexual rewards, particularly in the CSB group. Given the recent increases in Internet use, including among young individuals, and the ready access to online sexually explicit materials, future studies focusing on identifying risk factors for individuals (particularly youth) at risk for developing CSB are warranted.File S1Supporting information.(DOCX)Click here for additional data file.


Transgenerational epigenetic inheritance may be considered when developmental programming is transmitted across generations that were not exposed to the initial environment which triggered the change. So far, inter- and transgenerational programming has been mainly described for cardiovascular and metabolic disease risk. In this review, we discuss available evidence that epigenetic inheritance also occurs in respiratory diseases, using asthma and chronic obstructive pulmonary disease (COPD) as examples. While multiple epidemiological as well as animal studies demonstrate effects of ‘toxic’ intrauterine exposure on various asthma-related phenotypes in the offspring, only few studies link epigenetic marks to the observed phenotypes. As epigenetic marks may distinguish individuals most at risk of later disease at early age, it will enable early intervention strategies to reduce such risks. To achieve this goal further, well designed experimental and human studies are needed.Evidence is now emerging that early life environment can have lifelong effects on metabolic, cardiovascular, and pulmonary function in offspring, a concept also known as fetal or developmental programming. In mammals, developmental programming is thought to occur mainly via epigenetic mechanisms, which include DNA methylation, histone modifications, and expression of non-coding RNAs. The effects of developmental programming can be induced by the intrauterine environment, leading to  Asthma and chronic obstructive pulmonary disease (COPD) are chronic lung diseases, both thought to result from a complex interplay of genetic factors and environmental exposures. These gene-environment interactions, in general, are now known to be mediated by epigenetic mechanisms such as histone modifications , DNA metIn this review, we describe evidence from epidemiological and experimental studies for asthma and COPD which suggest that epigenetic inheritance does occur. However, epigenetic marks can only be retained and transmitted from one generation to the next when reprogramming of the germ line fails to remove epigenetic signatures that are required during development. The effects of developmental programming can be induced by the intrauterine environment  which not only affect the fetus (F1) but also the germ line of the fetus (F2), leading to so-called intergenerational epigenetic effects. When developmental programming is transmitted across generations beyond F3, it is considered to be transgenerational and can not be explained by direct environmental exposure anymore. Only a few studies provide evidence for transgenerational epigenetic inheritance, which was mainly transmitted down the paternal line .Asthma is a common chronic inflammatory disorder of the airways, of which the prevalence has increased dramatically during the last two to three decades. Asthma is characterized by recurring episodes of airflow obstruction, intermittent chest symptoms such as wheezing, coughing, and shortness of breath, as well as bronchial hyperresponsiveness (BHR) ,16. In tper se unable to explain the escalating incidence of chronic inflammatory disorders during the past decades. Over time, it became evident that DNA variation can be associated with modified responses to environmental challenges [et al. [Genetic sequence variations are associated with risk for asthma -23 but aallenges . Howeverallenges . Interes [et al. , who shoNonetheless, it remains an open question why environmental exposures interact with gene variations and thereby possibly bear potential to modify disease risks during critical developmental windows only. As outlined in the introduction, it has been hypothesized that environmental influences during vulnerable developmental periods may lead to lasting changes of the epigenome resulting in altered functionality of the lung and/or the immune system. So far, the majority of human studies have looked at associations of epigenetic modifications - for technical reasons mainly DNA methylation - with respiratory disease.versus healthy controls. While nine genes  were hypermethylated and common to all asthma phenotypes, single in silico constructed networks were characteristic for the different asthma phenotypes [For example, genome-wide DNA methylation was analyzed in isolated peripheral monocytes from adult patients with eosinophilic, paucigranulocytic, or neutrophilic asthma enotypes .2 correlated positively with ADBR2 methylation, indicating the latter may directly or indirectly modify the effect of NO2 on asthma severity. This observation was recently challenged by Gaffin et al. [In addition, using candidate gene approaches, a number of genes related to asthma and involved in oxidative stress, immunity, and lipid metabolism were investigated. In an analysis of 12 genes implicated in oxidative stress pathways, higher methylation of protocadherin-20 (PCDH-20) was observed in sputa from adult smokers with asthma compared to non-asthmatic subjects with a similar smoking history and without COPD . Methylan et al.  who repoet al. emphasized the importance of addressing epigenetic changes in relevant target tissues [In this line, differential methylation of FOXP3 and IFNγ promoter regions was demonstrated in isolated peripheral regulatory and effector T cells from 21 monozygotic twin pairs discordant for asthma (age range 9 to 76 years). Higher methylation of both genes was associated with reduced mRNA and protein levels and was further associated with reduced suppressor function and T cell proliferation. Interestingly, FOXP3 levels were lowest in asthmatic twins who were additionally exposed to passive smoking. Moreover, increased methylation of FOXP3 was confirmed in purified bronchoalveolar lavage fluid (BALF) Tregs obtained from a subset of twins . This in tissues  while DN tissues .In peripheral B cells, the promoter region of prostaglandin D2 (PGD2) - an arachidonic acid-derived metabolite supporting Th2 cell differentiation and eosinophilia - was found to be hypomethylated from children with physician-diagnosed asthma compared to healthy controls . Of noteStudies on epigenetics in asthma may have been hampered, as over the years, different clinical subgroups have been described. Hierarchical cluster analysis has demonstrated that there are at least five phenotypes which segregate according to age of onset, atopy, pulmonary function, requirement for medications, and a number of other factors . HoweverCOPD is a life-threatening lung disease, mainly caused by cigarette smoking although other inhaled noxious particles and gases may contribute . This leAdditionally, an epigenome-wide analysis in peripheral blood cells demonstrated a large number of differentially methylated genes, including the aryl hydrocarbon receptor repressor (AHRR) , which wet al. reported reduced peripheral blood DNA-methylation which was only partially reversible after smoking cessation [Although the examples above illustrate that epigenetic changes occur in asthma and COPD, they bear the risk of reverse causation as epigenetic modifications are inducible and may represent a response to the pathology rather than being its root. Therefore, temporal changes of epigenetic marks as well as the timing of exposure and outcome need to be investigated during the life course. Temporal persistence of epigenetic DNA modifications were observed in adults after extended periods of smoking cessation in adults, which may explain the prolonged health risks after cigarette smoking. Thus, differential methylation of F2RL3 and GPR15 was shown to be significantly associated not only with current smoking but also with time since quitting smoking, in a dose-response relationship . Similaressation . In addiessation .With regard to asthma, genome-wide DNA methylation of CpG sites was recently assessed in peripheral blood leukocytes from 245 female participants of the Isle of Wight cohort at the age of 18 years . In a sumaternal smoking during pregnancy is one of the most important risk factors for impaired lung function development and asthma risk [Numerous prenatal exposures such as maternal asthma or atopy, maternal nutrition or obesity during pregnancy, maternal gestational stress, and pollutants have been brought into context with respiratory disease. Among these, hma risk -53. Sinchma risk , prenataMaternal smoking has been linked with genome-wide higher methylation of peripheral blood. In 92 adult women from a birth cohort dating back to 1959  methylation of repetitive elements , which are markers of global methylation in the identical blood samples, showed an inverse association between prenatal smoke exposure and Sat2 methylation . In addiet al. observed lower DNA methylation levels of the short interspersed nucleotide element AluYb8 in buccal cells from 348 prenatally exposed kindergarten and elementary school children [S-transferase (GST) M1 null, while methylation was higher in those with GSTM1. Thus, variants in detoxification genes may modulate the effects of prenatal exposure via differential epigenetic marks.Breton children . Hypomet.In candidate gene approaches, significant, albeit small differences in methylation of Neuropeptide S Receptor 1 (NPSR1) were observed in whole blood samples from adults with severe asthma and children with physician-diagnosed allergic asthma of a Swedish Birth cohort (BAMSE). In children, the NPSR1 methylation status was influenced by prenatal smoke exposure . Prenataet al. analyzed the interaction of six CpG sites in the IL-13 promoter with two functional gene variants of IL-13 in 245 female participants at the age of 18 years. The authors demonstrated a) an interaction of one functional IL-13 gene variant, rs20541, and maternal smoking during pregnancy with DNA methylation at one CpG site and b) that the interaction of this CpG site with another functional SNP affected airflow limitation and airway reactivity [Within the Isle of Wight birth cohort, Patil (CYP1A1) gene and hypermethylation of most investigated CpG sites of the aryl hydrocarbon receptor repressor gene (AHRR) were demonstrated in 1,062 prenatally smoke-exposed children of the Norwegian Mother and Child Cohort Study (MoBa) [In an epigenome-wide association study (EWAS), lower cord blood DNA methylation of cytochrome P450 aryl-hydrocarbon-hydroxylase y (MoBa) . Thus, py (MoBa) . Furthery (MoBa) .Another recent large EWAS identified and partly newly confirmed 185 CpG sites with altered methylation among FRMD4A, ATP9A, GALNT2, and MEG3, in whole blood of infants of smokers within 889 newborns from the Norway Facial Clefts Study.lung and the corresponding placental tissue samples of which 41 were smoke exposed, using the Illumina HumanMethylation450 BeadChip array. Analyses of DNA methylation was conducted to evaluate the variation associated with nicotine exposure. The most significant differentially methylated CpG sites in the fetal lung analysis mapped to the PKP3, ANKRD33B, CNTD2, and DPP10 genes. In the placental methylome, however, the most significant CpG sites mapped to the GTF2H2C and GTF2H2D genes and 101 unique CpG sites were concordant between lung and placental tissue analyses. Gene Set Enrichment Analysis demonstrated enrichment of specific disorders, such as asthma and immune disorders, suggesting a role for DNA methylation variation in the fetal origins of chronic diseases [These genes are implicated in processes related to nicotine dependence, smoking cessation, and placental and embryonic development . In addidiseases .exposure to airborne pollutants has been suggested as risk factor for asthma. High prenatal exposure to polycyclic aromatic hydrocarbons (PAH) has been reported to be associated with higher methylation of an enzyme involved in fatty acid metabolism termed acyl-CoA synthetase long-chain family member 3 (ACSL3) in cord blood DNA and matched fetal placental tissues [Besides maternal smoking, prenatal  tissues . The rel tissues . Higher  tissues .farming environment has further been associated with decreased risk for asthma and allergies. The CD14 promoter region was differently methylated in placentae from women living on a farm compared to non-farming women [Intrauterine exposure to a ng women .In a birth cohort, cord blood Treg cell counts were increased with maternal farming exposures during pregnancy and associated with higher FOXP3 expression . FOXP3 hStudies based on historical records of a small population in North Sweden  reported that the mortality rate of men is linked to food supply of the father’s father in mid-childhood, while the mortality rate of women was exclusively related to food supply of their father’s mother . Data fret al. reported in 2005 that a grandchild’s asthma risk is increased if the grandmother smoked cigarettes during her pregnancy, even if the mother did not smoke [To date, there is very limited evidence for an exclusive establishment of risk for respiratory disease via the mother. Li ot smoke . So far,ot smoke . Interesot smoke . This hoAnimal models facilitate to investigate epigenetic inheritance across generations. So far, a number of prenatal exposure scenarios including maternal exposure to allergens , tobaccoet al. reported that in utero exposure to environmental tobacco smoke (ETS) did not alter the respiratory structure or function in offspring at the age of 10 weeks [Aspergillus (A.) fumigatus instillation as compared to non-exposed controls. BHR, but not allergic sensitization, was mediated by increased expression of M1, M2, and M3 muscarinic receptors and the phosphodiesterase-4D5 isozyme as shown in inhibitor experiments [Up to date, several intergenerational animal models exist which address fetal exposure to maternal passive smoking . A study10 weeks . Howevereriments .A. fumigatus challenges. In contrast, goblet cell metaplasia and the expression of mucus-related genes were downregulated. The authors propose that prenatal ETS may alter the ability of mucociliary clearance [Upregulation of Th2 cytokines and molecules along the Th2 pathway was further confirmed in another set of experiments with prolonged postnatal ETS exposure followed by repeated intratracheal learance . In anotlearance .active smoking, similar to the human situation, active smoking during second and third trimester of pregnancy negatively affected birth weight and lung volume in murine offspring [et al. showed, in animals prenatally exposed to active maternal smoke exposure, BHR development following postnatal exposure to a single intratracheal injection of A. fumigatus extract in early adulthood. Interestingly, the increased BHR was not associated with more leukocyte migration or mucus production in the lung but was causally related to lower lung cyclic adenosine monophosphate levels, modulated by increased phosphodiesterase-4 enzymatic activity in the lung [was related to airway inflammation or mucus production in a different (ETS) model for maternal smoke exposure, investigated by the same research group [In an animal model for ffspring . In addithe lung . Howeverch group .et al. [In children, Haley et al.  investiget al. . Disruptet al. demonstrated that active smoking from 3 weeks prior to conception until birth resulted in lower expression of encoding forkhead box a2 (FOXA2), frizzled receptor 7 (FZD-7), epidermal growth factor (EGF), β-catenin (CTNNB1), fibronectin (FN1), and platelet-derived growth factor receptor alpha (PDGFRą) in neonatal offspring [adult non-smoking F1 progeny from these smoking mothers, increased deposition of collagen III and smooth muscle layer thickening around the airways was found [adult mice that were not exposed to cigarette smoke after birth, it suggests that persistent smoke-induced epigenetic changes occurred in embryonic lungs during pregnancy.Data from our own lab also indicate an effect of maternal smoking on gene transcription and lung development. Blacquiére ffspring . These gffspring . In addias found . These cmaternal sensitization and/or asthma phenotype in the offspring [et al. demonstrated in 2011 that adoptive transfer of dendritic cells (DCs) from allergen-naive neonates from asthmatic mothers into 3-day-old mice from non-asthmatic mothers conferred increased allergen responsiveness resulting in heightened BHR and allergic inflammation. While the phenotype of ‘asthma-susceptible’ DCs was largely unaltered, DCs showed enhanced allergen-presentation activity in vitro and a global increase in DNA methylation. The ‘asthma-transferring’ ability seemed to be restricted to DCs, as other investigated immune cell types did not show this ability [Numerous studies investigated the effect of ffspring ,105-107.ffspring . Fedulov ability . In a mo ability . Pyroseqtransgenerational transmission of asthma risk beyond the F1 generation was demonstrated by Hollingsworth et al. who were the first to describe the effect of dietary methyl donors on the risk for allergic airway disease via epigenetic mechanisms [A. fumigates, in early vs late pregnancy, resulted in lower IgE in grand-offspring who were re-exposed in young adulthood [A. fumigatus exposure, whereas IFNγ was hypomethylated independent of the timing of exposure. The results from the epigenetic studies do not accord very well with the data on airway eosinophilia. However, the work demonstrates again that maternal exposures can affect the second generation and that the effects may depend from the timing of exposure during pregnancy.Evidence for chanisms . In thisdulthood . BALF eotransgenerational transmission of the asthma phenotype to F3 offspring was shown in a rat model of perinatal nicotine exposure [Truly exposure . The F3 in vivo, analysis of around 1,000 CpG islands (CGIs) within ovulated eggs showed that 15% are methylated [A major barrier to transgenerational inheritance is developmental reprogramming. During this process, DNA methylation, histone variants and their modifications, as well as small RNAs are all reset. This is required to remove epigenetic signatures acquired during development or imposed by the environment. It enables the zygote to acquire the totipotent state needed for the differentiation into all cell types. In mice, there are at least two rounds of genome-wide DNA methylation reprogramming. The first occurs just after fertilization, in the zygote and early cleavage stages, to erase gametic (sperm and oocyte) epigenomic marks. The next major reprogramming process occurs in the cells that will form the germ line of the developing embryo to achieve an epigenetic state distinct from somatic cells. In each reprogramming window, a specific set of mechanisms regulates erasure and re-establishment of DNA methylation ,14. Stilthylated . The levthylated . These wParental imprinting, also known as genomic imprinting, is the process by which genes are expressed on only one of the two parental inherited chromosomes (either from the mother or father). During gamete formation, following germ line reprogramming where the paternal and maternal somatic programs are erased, parent-specific imprints are laid down in the germ line by epigenetic mechanisms ,113. ImpDuring mammalian spermatogenesis, chromatin in differentiating germ cells is extensively remodeled, with the majority of nucleosomes being removed and ultimately exchanged by highly basic proteins named protamines. The remaining nucleosomes, unlike protamines that are exclusively re-replaced by maternal nucleosomes in the zygotes, may potentially direct certain processes of development and are thus a potential source for epigenetic inheritance through the paternal germ line . TherefoNon-protein coding RNAs (ncRNAs) are RNA sequences that regulate transcriptional and/or translational processes. Of the species of ncRNAs, the four best-characterized forms are microRNAs (miRNAs), small interfering RNAs (siRNAs), Piwi-interacting RNAs (piRNAs), and long non-coding RNAs (long ncRNAs) . miRNAs Human spermatozoa are known to contain a large range of RNA molecules, including over 100 miRNAs ,123,124.Also in oocytes (mouse), different classes of ncRNAs have been described .Although a number of human studies have reported an association of prenatal smoke exposures with epigenetic changes in relation to asthma and COPD, there is very few human data available regarding the effect of grandparental exposures on disease risk in grandchildren and even less with information on epigenetic events. In addition, all available epidemiological studies address intergenerational rather than true transgenerational propagation of risk for respiratory disease. Although the few data from experimental animal models show evidence for transgenerational inheritance, also for early nutritional environmental exposures, further investigations in these models are clearly needed to unravel the underlying mechanisms. Moreover, large, well-characterized cohort studies would be needed to explore whether transgenerational inheritance indeed also occurs in humans. It will be important to investigate epigenetic signatures over time in birth cohorts and, where possible, across generations and to validate them in independent cohorts. Other important knowledge gaps that need to be addressed in the future are the need to understand the functional consequences of differentially methylated genes: even though some studies can associate subtle changes with phenotype, these may still represent an epiphenomenon. On the other hand, small changes could be important when multiple genes along a given pathway are affected. Also, epigenetic regulation is likely to differ in men and women, but this gender-specific difference has received little attention so far. In this respect, animal models can facilitate inter- and transgenerational research and may allow preclinical testing of interventions preventing deviation of epigenetic signatures to interrupt propagation of disease risks.


TMstent-graft system has been shown to be safe and effective in high-risksurgical patients with complex suprarenal and/or infrarenal abdominal aorticaneurysm anatomy. The wireformed M-shaped stent architecture and proximalsprings with anchoring pins theoretically permit optimal sealing in shorterand more angulated proximal aneurysm necks even under off-label conditions.Nonetheless, extremely difficult anatomical situations and inherent graftsystem-related limitations must be anticipated. Herein, we describe ourtechniques to overcome the capture of the tip sleeve within the suprarenalbare-stent anchoring pins, other endograft segments, and native vessels.Endovascular aortic aneurysm repair with the Endurant Previous randomised trials have confirmed the short and mid-term benefits ofendovascular abdominal aortic aneurysm repair versus open repair.The success of these new stent-graft devices results from better adaptation andimproved performances in challenging anatomies and better trackability of deliverysystems.TM  stent-graft device.TM tip sleeve within the suprarenal bare-stentanchoring pins or within other endograft and native vessel segments, in order toavoid emergency conversion to open repair and the potential for adverseoutcomes.A recent report highlighted the application of troubleshooting techniques to overcome‘pitfalls’ in some of the steps of EVAR with the EndurantThis stent-graft is a new fourth-generation device comprising a high-densitymultifilament polyester graft material of low porosity, externally supported by anelectropolished nitinol stent structure and loaded in a low-profile hydrophiliccoating delivery system. The seals of the European Union (EU) as well as Food andDrug Administration (FDA) approval for this device were received in July 2008 andDecember 2010, respectively.TM stent-graft is designed to enhance performance in AAApatients with straightforward (friendly) or challenging (hostile) anatomies. Itshigh flexibility and conformability enables the device to adapt to straight as wellas severely tortuous proximal aortic necks and challenging iliac artery anatomies.These stent-grafts have a sinusoidal M-shaped architecture with a small amplitudeproviding optimal sealing in short and angulated proximal aneurysm necks.Furthermore, the M-shaped proximal stent at the upper pole of the endograft bodyfacilitates enhanced wall apposition, minimising the risk of in-folding andproviding another 5 mm of sealing zone.The EndurantTM stent-graft relies on proximal active fixation,incorporating a suprarenal bare stent ring with anchoring pins of increasedflexibility, compared to earlier generation stentgrafts. Initially covered by thetip sleeve, the suprarenal stent with anchoring pins provides controlled release andsecure fixation. The radiopaque markers at the proximal and distal edges of thestentgraft as well as the flow divider and contralateral gate markers ensureaccurate positioning of the device. Apart from a more flexible main body, the limbstent and optimal stent spacing offer more distal longitudinal flexibility and aredesigned to prevent kinking and provide refined adaptation to tortuous iliacarteries.The EndurantFinally, the graft delivery system is reduced by approximately 3 French (Fr) sizesfrom the smallest prior endograft delivery system. It is available in outerdiameters from 18- to 20-Fr for the main body and from 14- to 16-Fr for theextensions. Bifurcated main body proximal diameters include sizes of 23, 25, 28, 32and 36 mm; limb diameters include sizes of 10, 13, 16, 20, 24 and 28 mm. Thediameter of the stent-graft is oversized by approximately 20% in relation to theouter aortic diameter at the proximal fixation zone and about 10% in the distallanding zones .TM system has resulted in an improvedversion. Endurant® II provides three additional advanced design features: (1) a35% extended hydrophilic coating allows the 28-mm-diameter bifurcated component tofit inside an 18-Fr outer diameter catheter ; (2) availability of two new contralateral limb lengths (156 and 199 mm)enables more configuration options and requires fewer total components; and (3)improved radiopacity of the distal end of the bifurcated component’s contralateralgate increases visibility. The Endurant® II device received FDA approval in June2012.Recently, renovation of the EndurantTM stent-graft is deployed and the delivery system advancedproximally as far as 3 cm apart from the suprarenal stent [see manufactureinstructions for use (IFU) for system details]. The next step is very crucial andfailure to withdraw the delivery system until the spindle is retracted into thefabric portion of the stent-graft results in trapping of a suprarenal crown withinthe tapered tip sleeve.This scenario assumes that the main body of the bifurcated component of theEndurantTM stent-graftsystem may be followed accurtely, in some cases, especially severe angulated necks(≥ 60°), the markedly flexible delivery system will follow the aortic configurationand stack within the hooks of the suprarenal stent. To avoid the need for openconversion, three simple techniques to successfully remove the delivery system ofthis endograft are described:Even though the steps described in the IFU for the EndurantTM, Ontract, ArcherTM or Lunderquist)inside the delivery system, and then rotationally withdraw the deliverysystem. Removing the wire allows the graft to follow the natural aorticanatomy. Under straightforward circumstances, the device may bend along thebody–ipsilateral endograft, possibly avoiding stacking at the level of theanchoring pins.• The first action is to completely remove the stiff or superstiff guide wire the molding balloon at the pins’ level prior to downwardremoval of the delivery system • When compelling anatomical conditions exist, another option is to place alarge introducer sheath (e.g. Cook 16- or 24-Fr), through the alreadycatheterised docking limb, advancing above the suprarenal stent beforedelivery system withdrawal. This manoeuvre leads to aorto-iliac axis‘technical remodelling’ with further proximal neck straightening, acondition that may help to alter the path that the system follows whenrotated downwards for removal. The proximal neck might also be straightenedafter placing a super-stiff or extra-stiff guide wire from the left brachialartery and through the endograft to exit from the contralateral femoralside.• The last option replaces the guide wire with a snare device that isintroduced through a 7-, 12- or 14-Fr sheath via the left brachial arteryaccess, and captures the spindle while simultaneously retracting thedelivery system with slow rotational movements In this situation the delivery system moved slightly upwards. The troubleshootingtechnique includes first deployment of the contralateral limb in the standardfashion, followed by insertion of a moulding balloon , which is inflated in the same manner as required to push the deliverysystem to the ipsilateral endograft wall, when the latter is retracted slowly Two moulding balloons  are required in thissituation. They are inserted through a 14-Fr Cook introducer sheath from thecontralateral site after the contralateral limb is completely liberated and dilated.One moulding balloon is positioned above the flow divider and the second one at thebody-to-contalateral limb overlapping area. They are simultaneously dilated and keptin a constant position, thus stabilising the endograft while the delivery system iswithdrawn from the ipsilateral limb The same concept may be applied with a larger balloon coming from above through theleft brachial artery. In this case the balloons are inflated and retracted inopposite directions. This bidirectional balloon retraction allows more powerfuldownward movement of the delivery system.The only way to avoid open conversion in this scenario is to perform a balloonangioplasty of the external iliac artery. Catheterise the delivery system, insert asecond 180-cm (0.035-inch) hydrophilic wire between the delivery system and thearterial wall, and place it into the aneurysm sac TM trapped delivery systems should prove especially usefulfor procedures involving adverse proximal aortic necks and iliac anatomies. It isimportant to remember that hostile infrarenal aortic aneurysm anatomy such as a veryshort, severely angulated or dilated proximal neck still remains a major cause ofearly failure of EVAR and jeopardises long-term efficacy.Improvements in the endovascular stent-graft design, device delivery and deploymentcharacteristics have all resulted in increased use of EVAR for not onlystraightforward cases but for those with more complex and challenging aneurysmanatomies. The tips and tricks presented in this report regardingEndurantIntroduction of new endograft devices into the vascular realm will most likely expandthe indications for procedures once considered not feasible in the past. Anatomicalmorphology and measurements of the aneurysm will be crucial to device selection, anddevice choice critical to the successful positioning and adaptation of thestent-graft to the aneurysm environment for its exclusion from the circulation.TM stent-graft is part of a next-generation system that wasdesigned with the clear intention of expanding the applicability of EVAR for AAA.Initial clinical experience has demonstrated that it can be used in challenginganatomies and can be delivered and deployed safely, even in highly angulated (> 60°)and short (< 15 mm) proximal necks.TM device remains to be demonstrated, intra-operativeperformance of this endograft in hostile aneurysm morphology adds valuableinformation to other recently reported clinical short- and mid-term results.12The Endurantshort < 1 mm proxiulated > 0°and shshort < 1 mm proxiTechnical manoeuvres may occasionally be required in difficult anatomies in order toavoid severe complications. Although not confirmed in all Endurant clinicalstudies,In a recent study, comparing the performance of the newly released Edurant II®endograft in patients with friendly and hostile infrarenal aortic anatomy eligiblefor EVAR, the necessity of troubleshooting techniques was significantly higher inthe hostile group.10Its easy, accurate and controlled deployment, coupled with its unique highflexibility and conformability contributes to its successful use, even in severelyangulated proximal necks and/or iliac arteries. Friendly and hostile groups hadequal performance regarding all primary outcome measures, suggesting that expandedEVAR indications can be applied with this stent-graft.TM delivery system becomes trapped inthe suprarenal stent anchoring pins or other graft segments. While this report iswritten specifically for the EndurantTM device system, lessons gleanedare applicable to similar endograft systems.The tips and tricks presented in this report should prevent or reduce conversion toan open procedure when the Endurant


Decades of research have demonstrated that rapid alterations in protein abundance are required for synaptic plasticity, a cellular correlate for learning and memory. Control of protein abundance, known as proteostasis, is achieved across a complex neuronal morphology that includes a tortuous axon as well as an extensive dendritic arbor supporting thousands of individual synaptic compartments. To regulate the spatiotemporal synthesis of proteins, neurons must efficiently coordinate the transport and metabolism of mRNAs. Among multiple levels of regulation, transacting RNA binding proteins (RBPs) control proteostasis by binding to mRNAs and mediating their transport and translation in response to synaptic activity. In addition to synthesis, protein degradation must be carefully balanced for optimal proteostasis, as deviations resulting in excess or insufficient abundance of key synaptic factors produce pathologies. As such, mutations in components of the proteasomal or translational machinery, including RBPs, have been linked to the pathogenesis of neurological disorders such as Fragile X Syndrome (FXS), Fragile X Tremor Ataxia Syndrome (FXTAS), and Autism Spectrum Disorders (ASD). In this review, we summarize recent scientific findings, highlight ongoing questions, and link basic molecular mechanisms to the pathogenesis of common neuropsychiatric disorders. The majority of cytoplasmic mRNAs in neurons are associated with RBPs and other accessory proteins as part of large macromolecular complexes termed ribonucleoprotein (RNP) granules . Granuleα, beta actin, MAP2, ARC, and BDNF [α isoforms with shortened 3′UTRs lacking DTEs are not dendritically targeted, suggesting that alternative splicing of cis-elements can regulate mRNA localization [The control of RNA distribution is a fundamental mechanism underlying localized expression of proteins . This isand BDNF –24. BDNFlization , 25. Onelization . Intereslization . We havelization . WhetherDiverse mRNA targeting mechanisms have been identified in neurons. Retained introns in cytoplasmic mRNAs represent an additional and surprising class of cis-acting dendritic targeting elements that are regulated by the spliceosome. Cytoplasmic intron-sequence retaining transcripts (CIRTs) contain intronic elements that are sufficient to target these mRNAs to dendrites –30. The Many of the over 2550 mRNAs present in dendrites , 40 lackInput specificity requires the localized expression of proteins following mRNA transport. Dendritic translation in neurons was first evidenced by the presence of ribosomes , 49 and RBPs like FMRP and ZBP1 mediate translational repression and release cargos locally in response to particular stimulus-driven posttranslational modifications. For example, locally active Src kinase phosphorylates ZBP1 upon arrival at the synapse, which reduces its affinity for beta-actin mRNA and liberates it for subsequent translation . Other RProtein translation and degradation both contribute to proteostasis and are essential for proper synaptic function. Aberrant protein levels at synapses are thought to be pathogenic primarily by affecting the expression and/or maintenance of synaptic transmission and plasticity. Several ASD susceptibility genes encode for proteins that regulate translation, or proteasomal degradation (outlined below). These genes are also involved in the induction and expression of mGluR-mediated long-term depression (mGluR-LTD), a type of synaptic plasticity that requires protein synthesis –65. DefiIn addition to FXS and ASD, RBP dysfunction may also play a role in other disorders including schizophrenia and amyotrophic lateral sclerosis. The protein disrupted in schizophrenia-1 (DISC-1)  was receConsistent with links between unbalanced protein levels and disease, several neuropsychiatric disorders have been associated with mutations in components of the ubiquitin proteasome system (UPS) –86 incluIn the case of FXS, studies demonstrate that FMRP is rapidly degraded by the proteasome during the induction of synaptic plasticity , 107. ThFragile X Tremor Ataxia Syndrome (FXTAS) is a neurodegenerative disorder characterized by adult-onset ataxia and cognitive decline. In FXTAS, a pathogenic premutation trinucleotide repeat expansion (50–200 repeats) in the 5′UTR of the FMR1 gene (FMRP) does not result in transcriptional repression but rather causes a toxic gain-of-function through the formation of intranuclear inclusions containing the FMR1 mRNA and sequestered RBPs . Recent We have recently shown that Sam68 is critically involved in coordinating mRNA translation and degradation via the proteasome during the induction of synaptic plasticity. Sam68 is likely necessary to promote the rapid translation of several plasticity-related proteins in response to mGluR activation. In Sam68 KO animals, the balance of proteostasis is abnormal and tipped towards degradation. Interestingly, Sam68 KO mice display impaired mGluR-LTD that can be rescued by blocking the proteasome . In our  postsynaptic sites. However, many forms of synaptic plasticity are presynaptically expressed in vertebrate and invertebrate preparations and may require protein synthesis [In accordance with current scientific research, the bulk of this review has focused on the mechanisms by which RBPs regulateynthesis –116. Oveynthesis . During ynthesis , 118–121ynthesis . In matuynthesis . It has ynthesis , 125 andynthesis . This maα) is typically an order of magnitude less than the number of synapses. This discrepancy poses the simple mechanistic problem that there are not nearly enough mRNAs to supply proteins on a one to one basis with synapses as required. This problem may be circumvented by a high translational efficiency of synaptic mRNAs, with each mRNA being translated many times to produce an adequate number of proteins. Newly synthesized proteins would then traffic towards the appropriate synapse and thus few mRNAs could supply proteins to an entire dendritic branch, rather than a single dendritic spine or synapse. To our knowledge, direct measurements of mRNA translational efficiency at synapses have been prohibitively difficult to obtain. Exciting new developments in fluorescent tagging, including spaghetti monster fluorescent proteins [The breadth of the dendritic transcriptome supports an important role for local translation in long-term plasticity . Howeverproteins  and SunTproteins , may sooAdditionally, electron microscopy studies in adult hippocampus reveal that there are far fewer dendritic polysomes  than synapses –131. Perα mRNA and protein demonstrate branch specificity in response to mTOR activity [As we propose in the previous paragraphs, the discovery of motile dendritic RNPs suggests that the local area served by a single mRNA may well be a dendritic branch rather than a single spine. Recent work suggests CaMKIIactivity . If the activity , 138, thactivity , 140. In5 actin molecules per spine (each stereocilia contains ~100–700 actin filaments on average and 370 actin molecules per micron of actin filament). Considering ribosomal processing speeds (6–9 amino acids/sec) [ newly made as opposed to being recycled from large synaptic pools or transported from the cell body. Temporally regulated irreversible posttranslational modifications may functionally distinguish beta-actin molecules. Indeed, newly synthesized beta-actin localizes at the leading edge of filament formation, perhaps through fast arginylation at the N-terminus [To our knowledge, accurate numbers of actin molecules at neuronal dendritic spines have not been calculated and likely vary substantially based on conditions. However, an estimate based on studies of stereocilia of the inner ear , which aids/sec)  and the terminus , which hterminus , 145. Interminus . Thus, tterminus , may pro promoted by Sam68 leads to impaired mGluR-LTD and loss of FMRP repression leads to enhanced mGluR-LTD [Several mRNAs contain nonoverlapping binding sites for diverse RBPs, suggesting complex and multifactorial regulation of mRNA metabolism. Beta-actin mRNA itself contains nonoverlapping binding sites for ZBP1 , Sam68 , and FMRGluR-LTD , Sam68 aTo achieve proteostasis, neurons must spatially coordinate multiple cellular processes across thousands of synapses. In the cellular milieu, mRNAs are always packaged into ribonucleoprotein (RNP) granules, which coordinate the transport and translation of their cargo mRNAs. Disease causing mutations in mRNAs or RBPs may lead to disruption of mRNA packaging into granules and alter subsequent transport and translation. These pathological mechanisms underscore the importance of mRNA being in the right place at the right time, as well as the importance of mRNA as a structural platform to coordinate interactions between RBPs and associated proteins. However, many unanswered questions remain, including a lack of sufficient mRNA particles for synapses, the contribution of local translation to existing pools of protein, and the interactions and complex regulation of multiple RBPs per single mRNA. There are numerous limitations in studying mRNA trafficking and translation in neurons, such as the lack of an assay to determine the exact localization and timing of synthesized proteins . Moreov


Fas ligand  is a type-II membrane protein within the tumor necrosis factor (TNF) superfamily of death receptors Although FasL is expressed by many cell types, it is primarily recognized as associated with activated T lymphocytes and natural killer (NK) cells. FasL-dependent apoptosis plays important roles in tissue remodeling and the deletion of potentially autoreactive thymocytes to maintain immune tolerance during development, and it also contributes to tumor cell clearance by effector NK cells gldFasL mice, which contain a single residue mutation (F275L) within FasL that prevents binding to the Fas receptor lprFas mice, which lack a functional Fas receptor and thus cannot be activated by FasL In response to many bacterial pathogens, the host responds by triggering FasL-dependent cell death as an inflammatory innate immune response Pseudomonas aeruginosa, FasL has been identified as a central regulator of innate defenses and inflammation. The presence of P. aeruginosa in the lungs leads to FasL-dependent apoptosis of host cells; the experimental use of gldFasL mice with an intranasal P. aeruginosa infection model shows increased disease severity with more rapid sepsis as compared to wild-type controls gldFasL mice determined that the protection conferred by FasL-dependent apoptosis was due to FasL interactions among lung epithelial cells during infection Helicobacter pylori: infection leads to Fas-dependent apoptosis of gastric epithelial cells gldFasL mice produce lower levels of interferon gamma (IFNγ) from splenocytes and have enhanced disease severity compared to wild-type mice During pneumonias caused by infection with Chlamydia pneumoniae as a normal host defense mechanism. To evade killing of infected macrophages and to enhance pathogenesis, C. pneumoniae blocks cytochrome C release by the cell, thus inhibiting apoptosis via the intrinsic pathway Legionella pneumophila and AvrA of Salmonella Typhimurium suppress apoptosis by inhibiting Bcl2 family proteins and by blocking c-Jun N-terminal kinase (JNK) signaling, respectively Yersinia pestis, the causative agent of the disease plague, prevents Fas induction by cleaving and inactivating FasL on the surface of effector cells, while enteropathogenic Escherichia coli (EPEC), a cause of gastrointestinal infections, post-translationally modifies FADD within target cells to arrest Fas-induced apoptosis  form of plague and is required for bacterial outgrowth in the lungs We recently reported that gldFasL mice reduces caspase-3 activation in recruited immune cells, including neutrophils, and allows for the enhanced outgrowth of Y. pestis Δpla bacteria in the lungs. As a consequence of FasL cleavage by Pla, immune cell recruitment and inflammatory cytokine production are altered, while local tissue damage accumulates, resulting in increased pulmonary edema. In the absence of Pla, however, increased caspase-3/7 activation is observed in multiple cell types recruited to inflammatory lesions within the lungs, demonstrating a direct role for Pla in preventing host cell apoptosis during pneumonic plague. Specific inhibition of caspase-3/7 with the peptide inhibitor DEVD recapitulates the loss of FasL by enhancing bacterial outgrowth and reducing cytokine secretion, indicating that the cleavage of FasL by Pla overcomes these caspase-3/7-dependent host defenses. This work describes a previously unknown mechanism by which Y. pestis controls host cell death pathways and the activation of Fas signaling through the proteolytic degradation of FasL.Our study showed that the Pla protease alters pulmonary apoptosis by directly cleaving both soluble and membrane-bound FasL to block the activation of Fas Yersinia species via the Yop-Ysc type III secretion system (T3SS) is well established. The conserved Yersinia T3SS effector protein YopJ  has been shown to enhance apoptosis in vitro under artificial secretion conditions Y. pseudotuberculosis, however, Y. pestis acquired mutations within YopJ that reduce the efficiency of its translocation, which results in decreased caspase activation and diminished apoptotic activity Yersiniae that lack Pla and have a more cytotoxic variant of YopJ, the virulence of Y. pestis is enhanced by coordinate efforts to reduce apoptosis via the direct inactivation of FasL by Pla and the concomitant suppression of YopJ function, particularly in the lungs.While a role for Pla in altering caspase activation was not previously known, the manipulation of host cell apoptosis by pathogenic Y. pestis has evolved away from a gastrointestinal lifestyle towards one that favors extraintestinal environments. Therefore, a shift in virulence strategy to prevent apoptosis during the later stages of disease may reflect an adaptation to the host response of the organs and tissues that the plague bacillus now infects. In the lungs, it is possible that cells injected and reprogrammed by the Yersinia T3SS may be recognized by the host and thus targeted for clearance via caspase-3/7-dependent mechanisms, with associated activation of the innate immune response. Indeed, injection of the T3SS effector YopK is known to stimulate apoptosis of pulmonary macrophages, and the inhibition of Fas-FasL signaling by Pla may therefore act to limit the recognition and clearance of these cells, resulting in an altered cytokine response in the lungs.Over the past 1,500–20,000 years, Yersinia species, enteric bacterial pathogens have also been shown to manipulate apoptotic signaling to successfully colonize the gut As with pathogenic It is becoming clear that the manipulation of cell death is a major strategy by which bacterial pathogens enhance virulence, although the specific mechanisms through which this occurs appear to be different from species to species. Some pathogens actively promote host apoptosis, while others inhibit Fas-FasL signaling. Understanding the in vivo effects of FasL on the virulence of a pathogen is made even more complex since different microbes stimulate varying levels of cell death (and by different pathways) and are likely to produce factors that both induce and abrogate apoptosis, with fine-tuning of cell death pathways for maximal virulence.Y. pestis and NleB of EPEC disable Fas-FasL signaling to promote virulence, the administration of proapoptotic compounds, exogenous FasL protein, or agonistic antibodies that trimerize Fas may serve as possible therapeutics Y. pestis or NleB of EPEC may also confer more targeted protection.Despite our limited mechanistic understanding of cell death manipulation by pathogens, therapeutics that prevent bacterial virulence factors from modulating apoptotic cell death may have broad implications. Since both Pla of Streptococcus pneumoniae colonization is reduced, and mouse survival is enhanced, demonstrating the viability of increased apoptosis to bolster host defenses Preliminary studies have been conducted using the related apoptotic ligand TRAIL. When exogenous TRAIL is administered during pneumococcal pneumonia, apoptosis levels are restored,


The melanoma-specific graded prognostic assessment (msGPA) assigns patients with brain metastases from malignant melanoma to 1 of 4 prognostic groups. It was largely derived using clinical data from patients treated in the era that preceded the development of newer therapies such as BRAF, MEK and immune checkpoint inhibitors. Therefore, its current relevance to patients diagnosed with brain metastases from malignant melanoma is unclear. This study is an external validation of the msGPA in two temporally distinct British populations.n=231) and Cohort II  using Kaplan–Meier methods and Harrell's c-index of concordance. Cox regression was used to explore additional factors that may have prognostic relevance.Performance of the msGPA was assessed in Cohort I (1997–2008, The msGPA does not perform well as a prognostic score outside of the derivation cohort, with suboptimal statistical calibration and discrimination, particularly in those patients with an intermediate prognosis. Extra-cerebral metastases, leptomeningeal disease, age and potential use of novel targeted agents after brain metastases are diagnosed, should be incorporated into future prognostic models.An improved prognostic score is required to underpin high-quality randomised controlled trials in an area with a wide disparity in clinical care. Metastatic melanoma causes brain metastases in 30–60% of patients with stage IV disease . TreatmeMore recently, the graded prognostic assessment (GPA) . It may However, these scoring systems must be considered in the context of the changing landscape of melanoma treatment, resulting from the emergence of novel targeted agents. Inhibitors of BRAF kinase , MEK , and immune checkpoints (CTLA4 (ipilimumab) and PD-1  have all emerged as active agents in melanoma and may have intra-cerebral activity in some patients .Data extracted from electronic patient records included basic demographics (age and sex), date of diagnosis of brain metastases, number of brain metastases and KPS at the time of diagnosis of brain metastases. The presence or absence of leptomeningeal disease and the number of sites of extra-cerebral metastases were also recorded. Data on the number and type of treatments received for brain metastases were collected including neurosurgery, stereotactic radiotherapy and WBRT. Routine BRAF testing began at our institution in March 2010. Therefore, where available, BRAF mutation status was recorded. Details of treatment with novel targeted agents, started after the diagnosis of brain metastasis, were collected. Intra-cerebral radiological response according to RECIST criteria on the first scan to assess response to the novel agents was recorded. For patients receiving ipilimumab, later scans were checked for a possible delayed response. Finally, date of death or last clinical review was recorded.The msGPA was calculated as described previously  for all The Sperduto study does not report details of model coefficients, hazard ratios, indices of discrimination or a baseline survival function for the derivation cohort . KM survvs BRAF mutant tumours. Patients with BRAF mutant tumours were split into those treated or not treated with a BRAF inhibitor after diagnosis of brain metastases. The log-rank test was used to formally compare survival between patients with BRAF wild-type tumours and patients with BRAF mutant tumours irrespective of subsequent treatment. The log-rank test was also used to compare survival of patients with BRAF mutant tumours who did or did not receive a BRAF inhibitor after diagnosis of brain metastases. Univariate and multivariate Cox regression analysis was used to assess the impact of novel targeted agents on survival, alongside previously identified prognostic factors .To assess the impact of BRAF status and treatment with BRAF inhibitors on survival in Cohort II, KM survival curves were constructed for patients with BRAF wild-type Overall 231 patients in Cohort I and 162 patients in Cohort II were eligible for this analysis following exclusion of 21 patients due to missing KPS (17 patients) or number of brain metastases (15 patients). Baseline characteristics of the two cohorts are shown in The KM curves shown in et al did not provide a c-index for their derivation cohort for comparison (Harrell's c-index of concordance was 0.65 (95% CI 0.61–0.69) in Cohort I and 0.67 (95% CI 0.63–0.72) in Cohort II. A probability of concordance between observed and predicted outcomes of <0.7 indicates modest discrimination at best . SperdutMedian survival times for Cohorts 1 and 2 are shown in vs those with a BRAF mutation, divided into those who did or did not receive a BRAF inhibitor after diagnosis of brain metastases, is shown in vs BRAF wild-type (log-rank test P=0.79). The KM curves, which are unadjusted for other prognostic factors, suggest that patients receiving a BRAF inhibitor after diagnosis of brain metastases had better survival outcomes than patients with BRAF mutant tumours who did not receive this treatment (log-rank test P=0.029).BRAF mutation status was available for 71 patients in Cohort II—42 patients had a BRAF mutation, whereas tumours of 29 patients were BRAF wild-type. BRAF status was untested in 90 patients and unknown in 1 patient. The majority of untested patients were diagnosed with brain metastases between 2008 and 2010, when routine BRAF testing was not available at our institution. Survival of patients with BRAF wild-type tumours Treatment with novel agents following diagnosis of brain metastases included vemurafenib (21 patients), ipilimumab (23 patients) or trametinib (1 patient). No patients received PD-1 antibodies. Intra-cerebral responses to the novel agents on the first radiological assessment of response are shown in P=0.07). On multivariate analysis all five factors remained statistically significant predictors of survival (P=0.06).Factors shown to predict survival on univariate analysis of patients in Cohort II included KPS, number of brain metastases, number of sites of extra-cerebral metastases, age and treatment with novel agents. Presence of leptomeningeal disease was of borderline significance  with a BRAF mutation did not receive a BRAF inhibitor after diagnosis of brain metastases, usually because it had been given prior to development of radiologically visible brain metastases. Patients with BRAF mutant tumours who did not receive a BRAF inhibitor after the diagnosis of brain metastasis had a significantly worse prognosis than those who did receive such treatment. This finding is intriguing and certainly warrants further analysis in prospective studies of BRAF inhibition in the context of intra-cerebral disease.No significant differences in survival were seen between patients with wild-type Exposure to novel agents predicted for improved survival in the multivariate analysis, which accounted for KPS, number of brain metastases, leptomeningeal disease and extra-cerebral metastases. The intra-cerebral radiological responses seen suggest that such novel agents may exert their effects both inside and outside of the brain. A possible interpretation of these data is that patients with a future opportunity for targeted agents and newly diagnosed brain metastases might be particularly appropriate for more aggressive treatment of intra-cerebral disease. However, despite considerable progress in predicting which patients will respond to novel agents  and the basic score for brain metastases (BSBM). The SIR includes age, KPS, systemic metastases, number of brain lesions and volume of lesions treated  and the effect of treatment options based on their presence or absence. Other prognostic factors previously shown to be important in this disease and excluded from the msGPA, including LDH (


The breast endures vast changes during reproductive phases of a woman's life . Each phase uniquely shapes cancer susceptibility, formation, and progression. Although pregnancy at a young age decreases lifetime breast cancer risk, the first five years following pregnancy at any age are associated with increased breast cancer risk regardless of the woman's age, and with even greater risk with increasing age at the woman's first pregnancy . IncreasMouse models of ppBC that specifically compare mammary tumors from nulliparous (virgin) mice to those from age-matched parous (single pregnancy) mice confirm that post-partum involution increases metastasis by up to 10-fold , 3. The Under physiological conditions, dying cells are rapidly removed from the breast to prevent secondary necrosis of the dying cell, wherein intracellular antigens released from the necrotic cell might trigger inflammation, tissue damage, or autoimmunity . To ensuWe recently found that efferocytosis was a key driver of malignant progression in ppBCs, responsible for exaggerated M2-like polarization of tumor-infiltrating macrophages and production of IL-4, TGFβ, and IL-10 . GeneticThese observations highlight tumor cell death as a double-edged sword in the tumor microenvironment: although the chemotherapies, targeted therapies and radiation provide the benefit of widespread tumor cell death and tumor shrinkage, widespread efferocytosis in response to tumor cell death may enhance tumor wound healing, thus limiting the effectiveness of the targeted agent. In some cases, efferocytosis may even promote tumor metastasis. These issues require careful consideration and experimental testing, as the role of efferocytosis in modulating the stromal response to therapeutically-induced tumor cell death is not fully understood. These recent findings support future endeavors to examine efferocytosis/MerTK targeting in combination with current treatment strategies to block unhealthy ‘tumor healing’ and improve tumor response to treatment.