Portopulmonary hypertension is a relatively common pathologic condition in patients with end-stage liver disease. Traditionally, severe pulmonary hypertension is regarded as a contraindication to liver transplantation (LT) due to a high perioperative mortality rate. Recently, extracorporeal membrane oxygenation (ECMO) has been utilized for intraoperative management of LT. As venoarterial (VA) ECMO may benefit certain high-risk LT patients by reducing the ventricular workload by the equivalent of the programmed flow rate, its usage requires multidisciplinary planning with considerations of the associated complications. We highlighted two cases at our single-center institution as examples of high-risk pulmonary hypertension patients undergoing LT on planned VA ECMO. These patients both survived the intraoperative period; however, they had drastically different postoperative outcomes, generating discussions on the importance of judicious patient selection. Since ECMO has removed the barrier of intraoperative survivability, the patient selection process may need to put weight on the patient’s potential for postoperative recovery and rehabilitation. Considerations on LT recipients undergoing preemptive ECMO need to expand from the ability of the patients to withstand the demands of the surgery during the immediate perioperative period to the long-term postoperative recovery course.  PPH is defined as a mean pulmonary artery pressure (mPAP) greater than 25 mmHg and pulmonary capillary wedge pressure (PCWP) less than 15 mmHg in the setting of portal hypertension [included . LT patiincluded . TraditiThe time of donor graft reperfusion is often considered the most challenging stage of the LT surgery since it is associated with significant hemodynamic instability and electrolyte abnormalities due to the release of inflammatory mediators, vasoactive substances, potassium, and hydrogen ions from the ischemic donor graft into the systemic circulation. During the reperfusion stage, the heart is under enormous stress with added risks for cardiac arrhythmias, profound hypotension, direct myocardial depression, and acute pulmonary artery hypertension . ExtracoAs VA ECMO reduces the ventricular workload by the equivalent of the programmed flow rate, it can provide significant support for the high-risk LT population during the intraoperative period. Over the past several decades, ECMO has been used to treat acute pulmonary and cardiac dysfunction both during and after LT . PreemptA 49-year-old female with ESLD secondary to cryptogenic cirrhosis and PPH presented to our institution in January 2022 for LT. The patient’s PPH was diagnosed via serial TTEs during her hospital course and by right heart cath as part of a routine pretransplant workup. She was diagnosed with ESLD when in 2021 a new mass was discovered to be hepatocellular carcinoma. Soon after, she began developing ascites and jaundice and was referred to our institution for a liver transplant workup. She initially presented with a model for end-stage liver disease (MELD) score of 19 and a pretransplant transthoracic echocardiogram (TTE) revealed a mildly enlarged right ventricle (RV) with normal systolic function, an estimated right ventricular systolic pressure (RVSP) of 39 mmHg, a mild to moderate intrapulmonary shunt, a small patent foramen ovale, and a left ventricular ejection fraction of 73% refer to . The patWhen a suitable donor organ was available at the end of January, the patient was brought to the operating room. After the induction of general anesthesia and the placements of a transesophageal echocardiogram (TEE) and a pulmonary artery catheter (PAC), the pulmonary artery pressure (PAP) of 89/34 mmHg and mPAP of 57 were discovered. While the patient remained hemodynamically stable, her oxygen saturation ranged from 85 to 92 percent. The PAP was significantly higher than previously shown on preoperative TTE. The risk of intraoperative mortality was deemed too high, and the transplant was aborted. The patient was subsequently transported to the intensive care unit (ICU) where she was started on sildenafil, extubated, transferred to the floor, and discharged home.Two weeks later, in mid-February, the patient presented to the emergency department for worsening dyspnea. A repeat TTE showed worsening pulmonary hypertension with an estimated RVSP of 85 mmHg, a mPAP of 56 mmHg, moderate tricuspid regurgitation, and a moderately enlarged right ventricular chamber size with borderline contractile dysfunction. Due to the severity of symptoms and lack of curative options, multidisciplinary discussions concluded the plan for the patient to proceed with LT on preemptive VA ECMO support at the end of February. Twenty-four hours prior to the LT, the patient was placed on VA ECMO with a 23 French right internal jugular venous cannula, a distal cannula tip advanced to the infra-hepatic inferior vena cava (IVC), and a 21 French right axillary arterial cannula. ECMO support was initiated, achieving 2.5 L/min of flow. The patient’s PAP significantly improved from systolic in 70 mmHg to approximately 50 mmHg. The day following ECMO cannulation, a liver became available, and the patient returned to the operating room for transplantation. The intraoperative anesthetic plan included general anesthesia and peripheral VA ECMO. Radial and brachial arterial lines, a central venous line with PAC, and a hemodialysis catheter were placed. Physicians from Transplant Anesthesiology, Cardiac Anesthesiology, Transplant Surgery, and Cardiothoracic Surgery teams were present throughout the procedure. TEE was used to monitor cardiac function and guide ECMO flows throughout the procedure. VA ECMO flows were maintained at a minimum of 1.5 L/min to minimize clotting and serial activated clotting times (ACT) were monitored every 30 min and maintained between 170 to 220 s. No anticoagulation was required throughout the case due to the patient’s baseline coagulopathy. The patient was kept on a low-dose norepinephrine infusion (less than 0.05 mcg/kg/min) and 0.04 units/min of vasopressin infusion throughout the procedure. Intraoperative TEE on VA ECMO revealed a severely enlarged right ventricle, borderline reduced right ventricular systolic function, patent foramen ovale, mild tricuspid regurgitation, and normal left ventricular ejection fraction. Immediately following reperfusion, PAP significantly increased from a systolic of 40 mmHg to 78 mmHg, with TEE showing severe right ventricular systolic dysfunction and impending RV collapse refer to . VA ECMOA 58-year-old male with ESLD secondary to cryptogenic cirrhosis, status post-Ross (pulmonary autograft) procedure, and prosthetic pulmonic valve placement presented to our institution in February 2022 with an estimated right ventricular systolic pressure (RVSP) of 61 mmHg and associated chamber dilatation. He was diagnosed with cirrhosis around 2015–2016 when he was found to have low platelets during routine labs. The patient’s PPH was diagnosed via serial TTEs during his hospital course and by right heart cath as part of a routine pretransplant workup. The patient was initially evaluated for LT several years prior, but his case was postponed due to pulmonary valve stenosis necessitating transcatheter pulmonary valve implantation. At the end of February, he was admitted for decompensated cirrhosis with his pre-transplant hospitalization course complicated by acute hypoxic respiratory failure and gastrointestinal bleeding, requiring transjugular intrahepatic portosystemic shunt revision. Pre-transplant TTE showed a pulmonary valve prosthetic gradient of 19 mmHg, an estimated RVSP of 61 mmHg, a mild–moderately enlarged right ventricular chamber size with preserved systolic function, and a normal left ventricular ejection fraction. A multidisciplinary committee met prior to LT to discuss the specific intraoperative risks associated with the patient’s comorbidities. Due to the high risk for right ventricular collapse, the plan of preemptive VA ECMO for intraoperative support was formulated.When a liver became available in late March of 2022, the intraoperative anesthetic management and invasive monitors included general anesthesia, peripheral VA ECMO, bilateral radial arterial lines, venous access central line with a PAC, and a rapid infusion catheter to allow intraoperative continuous renal replacement therapy (CRRT). Physicians from Transplant Anesthesiology, Cardiac Anesthesiology, Transplant Surgery, and Cardiothoracic Surgery teams were present throughout the procedure. After the incision, 2000 units of intravenous heparin was administered in anticipation of ECMO cannulation to prevent thrombotic complications. A 19 French arterial cannula was placed into the right common femoral artery, a 23 French venous cannula was placed into the left common femoral vein, and a 6 French distal perfusion cannula was placed by cardiac surgery. ECMO support was initiated and maintained with flows ranging from 1.9 to 2.4 L/min. Serial ACT measurements were drawn every 30 min to an hour with the therapeutic goal of 170 to 200 s. Appropriate ACT measurements were maintained throughout the procedure. Intraoperative TEE on VA ECMO showed a moderate–severely enlarged right ventricle with normal systolic function, a moderate tricuspid valve regurgitation, a moderate–severe pulmonary valve stenosis with a peak gradient of 37 mmHg, and a preserved left ventricular ejection function. At reperfusion, acute right-sided chamber dilatation and dysfunction with concomitant atrial septal bowing, right ventricular distention, and biphasic ventricular septal flattening on TEE showed right ventricular volume and pressure overload with reduced left ventricular filling. Intravenous calcium chloride (500 mg) as inotropic support was given with ECMO flows maintained at 2 L/min. Right ventricular function improved, and the patient remained hemodynamically stable through reperfusion with only a low dose norepinephrine infusion at 0.03 mcg/kg/min running for support. Right ventricular function returned to baseline 5 min post reperfusion. The patient remained hemodynamically stable throughout the procedure. The ECMO support was subsequently discontinued, and the patient was decannulated prior to abdominal closure. Post VA ECMO decannulation TEE exam showed moderate right ventricular chamber dilation with normal systolic function. No complications were noted with caval anastomosis or increased hemorrhage. The patient was transferred to the ICU postoperatively hemodynamically stable without the need for ECMO, inotropic, or vasopressor support. The day after the LT, mechanical ventilation and CRRT were both discontinued while the patient continued to have no need for vasopressors and inotropes for hemodynamic support. The major postoperative complications due to the ECMO cannulas were narrowing at the venous piggyback anastomosis. This was corrected by balloon angioplasty. The rest of his postoperative course was unremarkable with no other significant complications and good graft function. He was discharged to outpatient rehab at the end of April 2022 after 24 days of hospitalization. This patient was seen one year post transplant in the outpatient setting by the medical transplant team. Both patient and graft are doing well as evidenced by labs and ultrasound.These two cases at our single-center institution present the successful intraoperative management of LT with a high risk of right ventricular failure due to severe pulmonary hypertension or equivalent. Although both patients survived the immediate perioperative period with minimal resuscitation by utilizing VA ECMO support through the LT surgery, principally during the reperfusion stage, their long-term postoperative outcomes greatly differed, highlighting the importance of appropriate patient selection for this strategy. The first patient was a poor surgical candidate due to her poor preoperative functional capacity, frail condition, severe pulmonary hypertension, and right ventricular systolic dysfunction. With her inability to complete basic activities of daily living, her functional capacity was estimated to be one metabolic equivalent. While her PPH was presumed reversible, the patient was debilitation and unable to make a meaningful recovery postoperatively. The patient in the second case presented a more favorable postoperative rehabilitation potential due to his adequate preoperative functional capacity of approximately four metabolic equivalents with a normal right ventricular systolic function. In the second case, ECMO was used to address the immediate perioperative cardiopulmonary risk.PPH is a common, but serious, sequelae of ESLD with high mortality implications for LT. Without right ventricular unloading and support via intraoperative ECMO, this patient population would be unlikely to survive LT . VA ECMOWhile some complications are associated with the usage of ECMO , LT patiThe preemptive use of ECMO for high-risk pulmonary hypertension patients for liver transplantation has been supported in the literature. A Duke case report presents a successful liver transplantation on a high-risk pulmonary hypertension patient with preemptive initiation of VA-ECMO after previously aborted attempts . A high-ECMO is a feasible option in high-risk patients. Multidisciplinary planning and careful consideration of associated complications with ECMO during LT is paramount. This case report presents the unique employment of VA ECMO as preemptive support during the intraoperative period. The two different postoperative outcomes demonstrate the importance of judicious candidate selection with a new focus on the patient’s long-term survivability and rehabilitation potential in addition to the immediate intraoperative survivability.


Ca2+ acts as a secondary messenger, connecting various environmental stimuli to different biological processes, especially during stress rejoindering in plants. Even though many studies involving Ca2+ signalling in plants have been published, there have been no studies on the roles of Ca2+ signalling in herbicide stress response. Hence, this mini-review will highlight the possible sensing and molecular communication via Ca2+ signals in weeds under herbicide stress. It will also discuss some critical points regarding integrating the sensing mechanisms of multiple stress conditions and subsequent molecular communication. These signalling responses must be addressed in the future, enabling researchers to discover new herbicidal targets.The continuous use of herbicides for controlling weeds has led to the evolution of resistance to all major herbicidal modes of action globally. Every year, new cases of herbicide resistance are reported. Resistance is still in progress in many species, which must be stopped before it becomes a worldwide concern. Several herbicides are known to cause stressful conditions that resemble plant abiotic stresses. Variation in intracellular calcium (Ca Thereafter, the [Ca2+]cyt couples the extracellular stimuli to their distinctive intracellular responses and synchronize a wide range of endogenous processes. Besides increasing the concentration of the [Ca2+]cyt, sometimes these special Ca2+-binding proteins directly interact with other targets and allow them to execute their respective response  signal transduction pathway and regulates the homeostasis of cellular Na+ and K+  and Ca‐dependent protein kinase 6 (CDPK6) in Arabidopsis were found to regulate the metabolism of plant cells positively and confer cold tolerance  tends to accumulate in plants as a response to stress like high temperatures and has been extensively used as a physiological indicator to assess the intensity of stress felt by plants  and glutathione-S-transferases (GSTs). Hence, the development of herbicide resistance in grass weeds can be considered almost similar to other abiotic stresses such as temperature and drought. Weedy plants have developed several exciting mechanisms to adapt against herbicide stress. Although numerous mechanisms have been discovered, several such mechanisms, especially different signalling events, are yet to be discovered.The most basic molecular mechanisms of herbicide resistance include target-site resistance (TSR) and non-target-site resistance (NTSR). Among the TSR, genetic mutations and gene overexpression are the most prevalent mechanisms. NTSR mechanisms include enhanced metabolism, reduced absorption and translocation etc. . NTSR me2+ signalling events amend the expression patterns of several essential genes (mainly NTSR genes) in response to several biotic and abiotic stresses , glutamate receptor-like channels (GLRs), Cyclic nucleotide-gated channels (CNGCs), mechanosensitive-like channels (MSLs) and the reduced hyperosmolality-induced [Ca2+]cyt increase (OSCAs) channels. Within the plant cells, these channels are maintained precisely in an extremely synergistic manner  decodes and relays the signals for further processing . These Ca2+ binding proteins can be classified into sensor relay proteins and sensor responder proteins. The sensor responder proteins include calcium-dependent protein kinases (CDPKs), which mainly bind to these Ca2+ ions and induce conformational changes  and CBL-interacting protein kinases (CIPKs). These kinases and their specific Ca2+ binding proteins form a complex cellular network in various cellular processes  to respond and adapt to recurring stresses , the area of alternative splicing has remained unexplored in weedy plants , in general, generates multiple mRNA isoforms from the same pre-mRNA and is alleged to contribute to increasing transcriptomic and proteomic diversity . The puty plants . Althougy plants . We hypostresses . So, it proteins . For exaproteins . Moreoveproteins . As a re52+ signalling in alleviating herbicide stress. Since changes in the intracellular and cytosolic Ca2+ concentration are stimulus-specific, Jaffe posited three critical criteria to ensure that a particular Ca2+ signal pattern is associated with a particular stress response. These criteria include: (a) inhibition of the levels of Ca2+ must also impede the physiological response; (b) an artificial increase in the Ca2+ levels must provoke the physiological response, even in the absence of the stimulus; and (c) an increase in the cytosolic Ca2+ concentration must either precede or accompany the response  and Selective Plane Illumination Microscopy (SPIM). Even though FRET has been used in Arabidopsis, to our knowledge, these techniques have not been used to understand calcium signalling in any weedy plants. In addition to these Ca2+ dyes, protein-based Ca2+ indicators (such as aequorin–based and GFP–based indicators) are also used to measure Ca2+ in living plant cells  is emitted, which can be detected with a luminometer. Bioluminescent probes paired with Ca2+-sensitive aequorin can be used in the weeds for real-time measurement of the Ca2+ signal patterns linked with herbicide stress. In addition to the aequorin-based Ca2+ sensors, since their discovery in 1997, the GFP-based Ca2+ indicators have also gained the interest of plant biotechnologists  will be very useful in identifying the candidate Ca2+ transducing proteins, channels, exchangers and pumps involved in weed-herbicide interactions and other abiotic stress responses in weeds. Weeds have developed resistance against all the major herbicidal modes of action. Hence, further genetic engineering of these stress-specific Ca2+-signalling regulators might enable the herbicide industries to discover novel targets and use them for herbicide discovery. Research on weed molecular communication during herbicide stress  is still in its infancy. This area of research should be an exciting area for future research in terms of novel and applied science.Despite extensive research on the mechanisms of herbicides in recent years, the mechanisms of herbicides and the herbicide stress signalling network have not been investigated and discovered. Much progress has been made in understanding several Ca drought . Similar drought . Hence,  drought . Several drought . In thisThe original contributions presented in the study are included in the article/MS and AR conceived the idea. MS, KH, RB and PK drafted the manuscript. MS and RAC designed and created the figure. AR and JS edited the manuscript MKS revised the manuscript. All authors contributed to the article and approved the submitted version.


The landscape of advanced prostate cancer treatment has evolved tremendously in past decades. The treatment paradigm has shifted from androgen deprivation therapy (ADT) alone to doublet combinations comprising ADT with docetaxel or an androgen receptor inhibitor, and now triplet therapy involving all 3 classes of agents. Robust clinical data has demonstrated survival benefits with this strategy of upfront treatment intensification. Subgroup analysis has alluded to the importance of tailoring treatment according to metastatic disease burden. However, defining the volume of disease is becoming increasingly controversial due to the advent of next generation molecular imaging. Several trials testing established agents in the castrate-resistant setting are now underway in metastatic hormone sensitive prostate cancer patients. As the treatment milieu is enriched earlier in the disease trajectory, future studies should elucidate biomarkers to further define specific patient populations who will benefit most from treatment intensification and/or de-escalation, with what agents and for what duration. The landscape of advanced prostate cancer treatment has evolved tremendously in the past two decades . SeveralAndrogen deprivation therapy (ADT) has been the backbone of metastatic prostate cancer treatment since the androgen sensitivity of prostate cancer was established more than eight decades ago. Since the discovery of the Gonadotropin-releasing hormone (GnRH) signalling pathway in 1971 , luteiniThe concept of intensifying treatment by combining a luteinizing hormone-releasing hormone (LHRH) agonist with another agent was explored as early as the 1990s by two phase III studies conducted by The European Organization for Research and Treatment of Cancer (EORTC), albeit with conflicting results . The EORP = 0.0018), and was shown to be more pronounced for the subgroup of patients with high-volume disease, defined as the presence of visceral metastases or ≥ 4 bone lesions with ≥ 1 beyond the vertebral bodies and pelvis  compared to patients with low-volume disease where an overall survival benefit could not be confirmed  ), although median time to PSA progression was significantly improved in the RT arm (HR: 0.78 [0.63–0.97]) . The STABeyond advancements in systemic therapy, metastases-directed therapy is another strategy that is beginning to refine the management of mHSPC. The concept hinges on the understanding of metastasis as a disease spectrum rather than a binary state of all-or-nothing. This dogma was challenged as early as the 1990s with the recognition of a low-volume metastatic state otherwise known as oligometastasis. With the burgeoning use of PSMA PET/CT, the opportunity to improve outcomes by consolidation of low volume disease is now ever more appealing. Two recent phase 2 RCTs provided early insights into the benefits of MDT in oligometastatic prostate cancer.P = 0.002). The STOMP trial [P = 0.11). Other prospective trials investigating MDT in the oligorecurrent disease setting include the POPSTAR trial [The ORIOLE study  comparedMP trial  randomisAR trial , assessiAR trial , which ep < 0.01) and ADT-free survival  as compared to active surveillance with low rates of grade 3 or higher toxicity [Pooled data suggest metastasis-directed therapy improves both biochemical-free  has now become the standard of care , 31, 32.Most novel agents discussed hitherto were evaluated initially in the metastatic castrate-resistant prostate cancer (mCRPC) setting. With the emphasis on utilising therapies earlier in the prostate cancer treatment paradigm to intensify upfront treatment, several other novel agents currently approved for use in the mCRPC space are also under evaluation in the mHSPC setting , 34.177Lu-PSMA, which has recently been FDA approved for use in mCRPC, is currently being studied in patients with locally advanced and mHSPC. The UpFrontPSMA trial is a randomised phase II study comparing the combination of 177Lu-PSMA-617 with upfront docetaxel chemotherapy to docetaxel alone in patients with de novo high volume mHSPC [177Lu-PSMA will hopefully lead to higher disease eradication and, therefore, prolong the time to developing castration resistance. Recruitment is currently ongoing. Similarly, the PSMAddition trial randomises patients with mHSPC to receive standard treatment with ADT and an ARI, either with or without 177Lu-PSMA-617 [177Lu-PSMA cohorts, the use of 177Lu-PSMA may eventually be integrated into standard upfront treatment for mHSPC.me mHSPC . The ratPSMA-617 . DependiSimilarly, following the publication of the PROfound study results demonstrating a survival benefit with the PARP inhibitor olaparib in BRCA-mutated mCRPC, the FDA approved its use in mCRPC after progression on an ARI . The NatThe PI3K-Akt-mTOR pathway has been implicated in prostate cancer development and progression and is deregulated in up to 50% of prostate cancers. Most commonly, this is driven by PTEN loss of function. Prostate cancers with PTEN loss are more sensitive to AKT inhibition, and therefore, PTEN loss can be used as a predictive factor for response to such therapy. The IPATential150 trial evaluated the addition of the AKT inhibitor ipatasertib with abiraterone compared to abiraterone alone . This stThe androgen receptor (AR) plays a crucial role in regulating the cell cycle and, therefore, prostate cancer progression towards castration resistance. In particular, it increases cyclin D1, which activates CDK4 and CDK6, allowing the cell to progress from the G1 to S phase. CDK4/6 inhibitors have been used in advanced prostate cancer to disrupt such AR signalling pathways and prevent cell proliferation. The CYCLONE-2 trial (NCT03706365) is currently evaluating whether abemaciclib plus abiraterone is superior to abiraterone alone in mCRPC. A similar trial  is currently underway in the mHSPC setting. Other novel hormonal agents such as orteronel, a nonsteroidal 17,20-lyase inhibitor (an enzyme necessary for androgen synthesis), are also being evaluated in the mHSPC setting (NCT01809691).Checkpoint inhibitors have demonstrated limited clinical benefit when used alone in advanced prostate cancer , 42. ProSeveral emerging biomarkers are under evaluation in mHSPC to aid in risk-stratification of patients, thereby providing a framework to guide initial treatment selection and when to intensify or de-intensify treatment. In addition, such biomarkers can monitor treatment response and predict and detect resistance. In the era of precision medicine, they can also be used to personalise treatment and administer targeted therapies. These biomarkers can be predictive or prognostic and are derived from molecular imaging, tissue or blood samples.Biomarkers that can be assessed at the initial diagnosis of mHSPC can provide prognostic information about OS, which may assist with patient discussions and choice of therapy. Elevated markers of bone formation  and bone-specific alkaline phosphatase (BAP)), as well as bone resorption markers (N-telopeptide (NTx) and pyridinoline (PYD)), have previously been associated with poor OS outcomes in mCRPC . More reAnother surrogate for biological tumour aggressiveness, in addition to patient factors such as having de novo or high-volume metastatic disease, is the presence and number of circulating tumour cells (CTCs). CTCs can be measured peripherally through a ‘liquid biopsy’ and can assist with predicting response to treatment and guiding whether initial treatment should be intensified. Two prospective studies analysed patients with mHSPC who had samples taken for CTC analysis before starting ADT ± additional systemic therapy. CTC expression at baseline is more likely in patients with high-volume disease (as per CHAARTED criteria ) and is Comprehensive genomic profiling of each patient with mHSPC through liquid biopsy may also play a key role in risk stratification and longitudinal disease monitoring. Circulating tumour DNA (ctDNA) has been extensively studied in mCRPC, however, research is limited in hormone-sensitive disease. Peripheral ctDNA samples have been correlated with baseline and on-treatment biopsies, and in fact represent broader and more complex subclonal populations that genomic analysis of an individual metastatic tissue sample . In a laConversely, an SPOP mutation, which occurs in about 5% of mHSPC patients, is predictive of a favourable response to AR targeted therapies and improved survival outcomes . The preAberrations in the DNA damage repair (DDR) pathway are common in prostate cancer. They are associated with a higher histological grade and a higher chance of developing de novo metastatic disease . In the 177Lu-PSMA earlier in the treatment paradigm, including in the mHSPC setting [177Lu-PSMA becomes is integrated into the initial standard treatment for mHSPC, next generation PET imaging will become essential in guiding care.Several imaging biomarkers are already in use in the mCRPC setting. An SUVmean ≥ 10 on PSMA PET is predictive of a favourable response to PSMA-radionuclide based therapy . Convers setting . If thesThe evolution of metastatic prostate cancer management in the past decade has been rapid and fast-paced with the approval of several novel agents supported by landmark phase 3 studies, as well as the paradigm shift towards upfront treatment intensification earlier in the disease trajectory. Patients are currently faced with a barrage of treatment options which looks set only to expand in the coming years with newer class agents being added to the current chemohormonal milieu as well as the emerging field of MDT. The development and discovery of biomarkers will undoubtedly help further refine and personalise the metastatic prostate cancer patient’s treatment journey, hopefully with the continued lengthening of meaningful survival years too.


Caroline Free and colleagues systematically review controlled trials of mobile technologyinterventions to improve health care delivery processes and show that currentinterventions give only modest benefits and that high-quality trials measuring clinicaloutcomes are needed. Mobile health interventions could have beneficial effects on health care deliveryprocesses. We aimed to conduct a systematic review of controlled trials of mobiletechnology interventions to improve health care delivery processes.We searched for all controlled trials of mobile technology based health interventionsusing MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHSHTA (Jan 1990–Sept 2010). Two authors independently extracted data on allocationconcealment, allocation sequence, blinding, completeness of follow-up, and measures ofeffect. We calculated effect estimates and we used random effects meta-analysis to givepooled estimates.I2 = 6%). The pooled effects on the number of cancelledappointments was not significantly increased RR 1.08 (95% CI 0.89–1.30). There was nodifference in attendance using SMS reminders versus other reminders . To address the limitation of the older search, we alsoreviewed more recent literature.We identified 42 trials. None of the trials had low risk of bias. Seven trials ofhealth care provider support reported 25 outcomes regarding appropriate diseasemanagement, of which 11 showed statistically significant benefits. One trial reported astatistically significant improvement in nurse/surgeon communication using mobilephones. Two trials reported statistically significant reductions in correct diagnosesusing mobile technology photos compared to gold standard. The pooled effect onappointment attendance using text message (short message service or SMS) remindersversus no reminder was increased, with a relative risk (RR) of 1.06 , photographs, and data at the touch of a button. These advances have ledto the development of mobile-health —the use of mobile computing andcommunication technologies in health care and public health. mHealth has manyapplications. It can be used to facilitate data collection and to encourage health-careconsumers to adopt healthy lifestyles or to self-manage chronic conditions. It can alsobe used to improve health-care service delivery processes by targeting health-careproviders or communication between these providers and their patients. So, for example,mobile technologies can be used to provide clinical management support in settings wherethere are no specialist clinicians, and they can be used to send patients test resultsand timely reminders of appointments.Many experts believe that mHealth interventions could greatly improve health-caredelivery processes, particularly in resource-poor settings. The results of severalcontrolled trials (studies that compare the outcomes of people who do or do not receivean intervention) of mHealth interventions designed to improve health-care deliveryprocesses have been published. However, these data have not been comprehensivelyreviewed, and the effectiveness of this type of mHealth intervention has not beenquantified. Here, the researchers rectify this situation by undertaking a systematicreview and meta-analysis of controlled trials of mobile technology-based interventionsdesigned to improve health-care service delivery processes. A systematic review is astudy that uses predefined criteria to identify all the research on a given topic; ameta-analysis is a statistical approach that is used to pool the results of severalindependent studies.The researchers identified 42 controlled trials that investigated mobiletechnology-based interventions designed to improve health-care service deliveryprocesses. None of the trials were of high quality—many had methodological problemslikely to affect the accuracy of their findings—and nearly all were undertaken inhigh-income countries. Thirty-two of the trials tested interventions directed athealth-care providers. Of these trials, seven investigated interventions providinghealth-care provider education, 18 investigated interventions supporting clinicaldiagnosis and treatment, and seven investigated interventions to facilitatecommunication between health-care providers. Several of the trials reported that thetested intervention led to statistically significant improvements (improvements unlikelyto have happened by chance) in outcomes related to disease management. However, twotrials that used mobile phones to transmit photos to off-site clinicians for diagnosisreported significant reductions in correct diagnoses compared to diagnosis by an on-sitespecialist. Ten of the 42 trials investigated interventions targeting communicationbetween health-care providers and patients. Eight of these trials investigated SMS-basedappointment reminders. Meta-analyses of the results of these trials indicated that usingSMS appointment reminders significantly but modestly increased patient attendancecompared to no reminders. However, SMS reminders were no more effective than postal orphone call reminders, and texting reminders to patients who persistently missedappointments did not significantly change the number of cancelled appointments.These findings indicate that some mHealth interventions designed to improve health-careservice delivery processes are modestly effective, but they also highlight the need formore trials of these interventions. Specifically, these findings show that although someinterventions designed to provide support for health-care providers modestly improvedsome aspects of clinical diagnosis and management, other interventions had deleteriouseffects—most notably, the use of mobile technology–based photos for diagnosis. In termsof mHealth interventions targeting communication between health-care providers andpatients, the finding that SMS appointment reminders have modest benefits suggests thatimplementation of this intervention should be considered, at least in high-incomesettings. However, the researchers stress that more trials are needed to robustlyestablish the ability of mobile technology-based interventions to improve health-caredelivery processes. These trials need to be of high quality, they should be undertakenin resource-limited settings as well as in high-income countries, and, ideally, theyshould consider interventions that combine mHealth and conventional approaches.http://dx.doi.org/10.1371/journal.pmed.1001363.Please access these Web sites via the online version of this summary at PLOS MedicineResearch Articleby Free et al. investigates the effectiveness of mHealthtechnology-based health behavior change and disease management interventions forhealth-care consumersA related mHealth Wikipedia has a page on mHealth:New horizons for health through mobile technologies is a global surveyof mHealth prepared by the World Health Organization’s Global Observatory foreHealth mHealthin Low-Resource Settings website, which is maintained by theNetherlands Royal Tropical Institute, provides information on the current use,potential, and limitations of mHealth in low-resource settingsThe resources and information about mHealthThe US National Institutes of Health Fogarty International Center provides links to Mobile health, the use of mobile computing and communication technologies in health careand public health, is a rapidly expanding area within e-health. There is considerableenthusiasm for mobile-health interventions and it has been argued that there is hugepotential for mobile-health interventions to have beneficial effects on health and healthservice delivery processes, especially in resource-poor settings Mobile technologies include mobile phones; personal digital assistants (PDA) and PDA phones; Smartphones ; enterprise digital assistants(EDA); portable media players ; handheldvideo-game consoles , Nintendo DS); and handheld andultra-portable computers such as tablet PCs .These devices have a range of functions from mobile cellular communication using textmessages (SMS), photos and video (MMS), telephone, and World Wide Web access, to multimediaplayback and software application support. Technological advances and improved computerprocessing power mean that single mobile devices such as smart phones and PDA phones areincreasingly capable of high level performance in many or all of these functions.Mobile health interventions designed to improve health care service delivery processes havebeen used to provide support and services to health care providers  or target communication between health careservices and consumers (such as appointment reminders and test result notification).The features of mobile technologies that may make them particularly appropriate forimproving health care service delivery processes relate to their popularity, their mobility,and their technological capabilities. The popularity of mobile technologies has led to highand increasing ownership of mobile technologies, which means interventions can be deliveredto large numbers of people. In 2009, more than two-thirds of the world's population owned amobile phone and 4.2 trillion text messages were sent The mobility and popularity of mobile technologies means that many people carry theirmobile phone with them wherever they go. This allows temporal synchronisation of theintervention delivery and allows the intervention to claim people's attention when it ismost relevant. For example, health care consumers can be sent appointment reminders thatarrive the day before and/or morning of their appointment. Real-time (synchronous)communication also allows interventions to be accessed or delivered within the relevantcontext, i.e., the intervention can be delivered and accessed at any time and wherever it isneeded. For example. at the time health care providers see a patient, they can access amanagement support system providing information and protocols for management decisions towhomever requires them. This application could be particularly relevant for providingclinical management support in settings where there is no senior or specialist health careprovider support or where there is no such support at night or at weekends. As mobiletechnologies can be transported wherever one goes, interventions are convenient and easy toaccess.The technological capabilities of mobile technologies are continuing to advance at a highpace. Current technological capabilities allow low cost interventions. There are potentialeconomies of scale as it is technically easy to deliver interventions to large populations. The technologicalfeatures that have been used for health interventions include text messages (SMS), softwareapplications, and multiple media  interventions. The technology allowsinterventions to be personalised and interactive.In this rapidly changing field, existing systematic reviews of mobile-health interventions to improve health care service processes require updating A current overview of the evidence for all mobile technology interventions evaluated incontrolled trials to improve health care processes is lacking.This systematic review aimed to quantify the effectiveness of mobile technology basedinterventions delivered to health care providers or to support health care services, on anyhealth or health care service outcome.We adhered to our published plan of investigation as outlined in the study protocol Participants were men and women of any age. We included all controlled trials using anymobile technology interventions , Nintendo DS]; and handheld and ultra-portable computers such astablet PCs  and Smartbooks) to improve or promote health or health serviceuse or quality. Trials were included regardless of publication status or language.We only included studies in which the mobile electronic device is the stated interventionunder evaluation, i.e., we excluded studies evaluating mixed mobile electronic device andnon-mobile electronic device interventions such as an intervention involving face-to-faceeducational sessions with a software application educational intervention compared to acontrol group receiving paper-based information only. We excluded general videos, unlessauthors stated they were specifically designed to be viewed on mobile technologies. Internetinterventions that were not specifically designed for mobile technologies were outside thescope of this review.The interventions in trials meeting the inclusion criteria and aiming to improve healthcare delivery process are reported herein. Other trials identified are reported elsewhereThe trials with interventions aiming to improve health care delivery processes were thencategorised into two groups: those directed to health care providers or those involvingcommunication between health care services and health care consumers . Interventions for health care providers were thensubcategorized according to their purpose: education, diagnosis and management, andcommunication between health care providers. Interventions involving health care servicecommunication to consumers were subcategorized according to their purpose: appointmentreminders and test result notification. Primary outcomes were defined as any objectivemeasure of health, health service delivery, or use. Secondary outcomes were defined asself-reported outcomes related to health behaviours, disease management, health servicedelivery or use, and cognitive outcomes. Outcomes reported for any length of follow-up wereincluded.We searched the following electronic bibliographic databases MEDLINE, EMBASE, PsycINFO,Global Health, The Cochrane Library , NHS HealthTechnology Assessment Database, and Web of Science  from 1990 to Sept 2010 and the reference lists of included trials. The list ofsubheadings (MeSH) and textwords used in the search strategy can be found in Two reviewers independently scanned the electronic records to identify potentially eligibletrials.Two reviewers independently extracted data on number of randomised participants,intervention, intervention components, sequence generation, allocation concealment, blindingof outcome assessors, completeness of follow-up, evidence of selective outcome reporting,and any other potential sources of bias on measures of effect using a standardised dataextraction form. The authors were not blinded to authorship, journal of publication, or thetrial results. All discrepancies were agreed upon by discussion with a third reviewer. Riskof bias was assessed according to the criteria outlined by the International CochraneCollaboration 2 test and the I2 statistic. We assessed evidenceof publication bias using Funnel plots.All analyses were conducted in STATA v 11. We calculated risk ratios and standard meandifferences. We used random effects meta-analysis to give pooled estimates. We examinedheterogeneity visually by examining the forest plots and statistically using both theχThe combined search strategies identified 26,221 electronic records; these were screenedfor eligibility, and the full texts of 334 potentially eligible reports were obtained forfurther assessment . Out ofThe 32 trials included 5,323 participants. Samples ranged from 14 to 1,874participants. There were 15 randomised controlled trials with parallel groups, sixrandomised cross over trials, three cluster randomised controlled trials, and eightnon-randomised controlled trials. Seven were trials of health care provider educationThe ten trials recruited 4,473 participants with sample sizes ranging from 31 to 1,859participants. Seven were randomised controlled trials with parallel groups and threewere non-randomised parallel group trials. Of the ten trials of health services support,eight were trials of short messaging service -based appointmentreminders The interventions are described according to the authors' descriptions in For the medical education interventions, six used application software delivered viapersonal digital assistants For interventions supporting clinical diagnosis and management, 14 trials usedcustomised application software . Four trials used photographs and video capabilities usingmobile phones.For interventions using mobile technologies to communicate between health careproviders for clinical/patient management, three trials All the interventions used SMS messages delivered by mobile phone. One appointmentreminder trial also used voice messages. Details of the control groups are provided inThe trials reported between one and 15 outcomes. Nineteen of the 28 trials providedsufficient data to calculate effect estimates.For primary outcomes, there were no objective measures of health or health servicedelivery reported.In terms of secondary outcomes, for medical education interventions, one trial reportedtwo outcomes regarding documentation of health care problems The trials reported between one and three outcomes. Nine of the ten trials providedsufficient data to calculate effect estimates.For primary outcomes, eight trials reported appointment attendance as an outcome In terms of secondary outcomes, for patient notification of test results, outcomes werethe following: time to diagnosis (1 outcome), time from first contact to treatment (1)and time from test to treatment (1), and anxiety scores (2) study quality is reported in The assessment of study quality is reported in The assessment of None of the trials were at low risk of bias for all quality criteria. There was noevidence of publication bias on visual and statistical examination of funnel plots.We report the effect estimates for primary outcomes and a summary of the effect estimatesfor secondary outcomes .The pooled effect for trials evaluating the effect of attendance reminder using textmessage against reminders that used other modes, such as postal reminder and phonecalls, showed no significant change . Two trials I2 = 0%)  . Another2 = 0%) ; both sh2 = 0%) .Secondary outcomes were as follows: One trial We identified 42 controlled trials that investigated mobile technology-basedinterventions designed to improve health care service delivery processes. None of thetrials were of high quality and nearly all were undertaken in high-income countries.Thirty-two of the trials tested interventions directed at health care providers. Of thesetrials, seven investigated interventions providing health care provider education, 18investigated interventions supporting clinical diagnosis and treatment, and seveninvestigated interventions to facilitate communication between health care providers. Noneof the trials reported any objective clinical outcome, and the reported results for healthcare provider support interventions are mixed. There may be modest benefits in outcomesregarding correct clinical diagnosis and management delivered via application software,but there were mixed results for medical process outcomes regarding the time taken andcompleteness of or errors in reports or warning scores. For educational interventions forhealth care providers, there was no clear evidence of benefit. For interventions aiming toenhance communication between health care providers, one trial showed benefits in usingthe telephone functions of a mobile phone to enhance verbal communication between surgeonsand nurses. Two trials showed reductions in the quality of clinical assessment usingmobile technology based photos when compared to a gold standard and one trial reported areduction in quality of ECG print outs delivered via mobile phones.For the category of communication between health services and consumers, SMS remindershave modest benefits in increasing clinic attendance and appear similar in their effectsto other forms of reminder. There is no evidence that SMS reminders influence appointmentcancellations, but the 95% CIs for the pooled effect were wide. One trial To our knowledge, this is the first comprehensive systematic review of trials of allmobile technology interventions delivered to health care providers and for health servicessupport to improve health or health services. The review expands and updates the findingsof earlier systematic reviews that focussed on specific devices, and/or specificfunctions, and/or specific health topics Our systematic review was broad in its scope. We only pooled outcomes where theintervention function , trial aim, and outcomes used in trials werethe same. Here, findings in relation to clinical diagnosis and management and educationalinterventions are summarised, the individual trial results are reported in It was beyond the scope of our review to review internet or video-based interventions notspecifically designed for mobile technologies. We also excluded interventions combiningmobile technologies with other interventions such as face-to-face counselling, whichshould be subject to a separate systematic review. Thirteen trials (31%) did not providesufficient data to calculate effect estimates and authors did not respond to requests fordata, which could have resulted in bias in the systematic review findings. Factorsinfluencing heterogeneity of effect estimates include low trial quality, in particularinadequate allocation concealment At the request of the editors we re-ran our search on 1 November 2012 to any identifyother trials eligible for this review published since our last search, and we identifiedeight trials. One high quality trial demonstrated that text message reminders increasedKenyan health workers' adherence to malaria treatment guidelines with improvements inartemether-lumefantrine management of 23.7 percentage points (95% CI 7.6–40.0) andimmediate intervention of 24.5 percentage points (95% CI 8.1–41.0) and 6 mo Trials of heath care provider support show some promising results for clinicalmanagement, appropriate testing, referral, screening, diagnosis, treatment, and triage.However, trials included in our review were subject to high or unclear risk of bias. Inparticular, only one of the 17 trials clearly reported that allocation was concealed andwhere there is no allocation concealment, the reported results may be an over-estimate ofeffects. To date no trials have reported effects of mobile technology-based clinicaldiagnosis and management support on objective health outcomes. Most of the trialssupporting health care providers in clinical diagnosis and management employed PDA devicesand customised application software functions. While PDA devices are no longer widelyused, customised application software functions are now deliverable on smart phones ortablets. Mobile technology-based interventions may not be suitable for some clinicalprocesses.The data available for making clinical diagnoses or calculating early warning scores maybe reduced and the time taken for medical processes may be increased. There was no clearevidence of benefit of mobile technology-based educational interventions for health careprofessionals. For interventions using mobile technologies to communicate visual data,there were increases in time to diagnosis or ECG transmission or diagnostic errors. Twotrials using photos taken by mobile phone reduced diagnostic accuracy of fractures, skinecchymoses, and potential to perform re-implantation when compared to a gold standard.However, the use of such technologies may be more relevant for settings where the goldstandard is not available. Furthermore, the quality of photos on mobile phones hasimproved since these studies were completed.Mobile technology-based diagnosis and management support may be most relevant to healthcare providers in developing countries where mobile phones potentially allow clinicalsupport and evidence-based guidance to be delivered to health care professionals workingremotely and in circumstances where senior health care professional support or otherinfrastructure is lacking SMS messages are modestly effective as appointment reminders. Their effects appearsimilar to other forms of reminder. Health care providers should consider implementing SMSappointment reminders because the cost of missed appointments in health services is high,the cost of providing SMS appointment reminders is low, and SMS reminders are cheaper thanother forms of reminder .High quality trials should be conducted to establish the effects of clinical diagnosisand management support (such as protocols/decision support systems) on clinical outcomesusing customised application software functions on mobile phones. The effects of suchsupport on the management of different diseases and on objective disease outcomes shouldbe evaluated. It is imperative that future trials of clinical decision support, guidance,and protocol delivered via mobile technologies take place in low- and middle-incomecountries. Many of the interventions evaluated to date are single component interventionsof low intensity. The effects of higher intensity multi-component mobile technologyinterventions should be evaluated. Authors must describe the components of futureinterventions in detail so that mechanisms of action and the impact of differentcomponents on outcome can be explored.Trials should evaluate the effects of the use of photographic or video functions tosupport health care providers compared to standard care (where gold standard options arenot available). As the technological capabilities of mobile phones improve, such as inphotographic quality, further trials of the effects of using photos taken on mobiletechnologies on diagnostic accuracy may be a warranted. Further research should evaluatethe effects and cost-effectiveness of mobile technologies to increase the speed ofcommunication between clinicians and patients, such as test results.Interventions combining elements delivered by mobile technology with other treatmentssuch as clinics based counselling combined with text messages should be systematicallyreviewed.The reported effects of health care provider support interventions are mixed. Trialsreport modest benefits for clinical diagnosis and management support outcomes. Forinterventions for health services, SMS reminders have modest benefits on attendance.Service providers should consider implementing SMS appointment reminders. One high qualitytrial published since our literature search was completed shows benefits in adherence tomalaria treatment guidelines Checklist S1PRISMA checklist.(DOC)Click here for additional data file.Table S1Excluded studies.(DOCX)Click here for additional data file.Text S1Search strategy.(DOCX)Click here for additional data file.Text S2Systematic review protocol.(PDF)Click here for additional data file.


As indicated by their name, morphogens were first identified for their role in the formation of tissues early in development. Secreted from a source, they spread through the tissue to form gradients by which they affect the differentiation of precursor cells in a concentration-dependent manner. In this context, the antagonistic roles of the morphogens of the Wnt family and Sonic hedgehog (Shh) in the specification of cell types along the dorso-ventral axis of the neural tube have been studied in detail. However, more recently, morphogens have been demonstrated to act well beyond the early stages of nervous system development, as additional roles of morphogen gradients in vertebrate neural circuit formation have been identified. Both Wnt and Shh affect neural circuit formation at several stages by their influence on neurite extension, axon pathfinding and synapse formation. In this review, we will summarize the mechanisms of morphogen function during axon guidance in the vertebrate nervous system. Morphogens, defined as secreted molecules that act in a concentration gradient to affect the differentiation of precursor cells, are also involved in the establishment of neural connections. Both Sonic hedgehog (Shh) and Wnts play important roles in different cellular events during neural development  and Boc (Brother of Cdon) were tested for their ability to bind Shh and mediate its attractive axon guidance effects  is shaped by the graded expression (anteriorlow to posteriorhigh) of the Wnt antagonist, Secreted frizzled-related protein (Sfrp)  Figure .Sfrp1 and Sfrp2  of Sfrps in the floorplate was induced by the corresponding gradient of Shh. Interestingly, these Sfrps did not act directly as guidance cues, but rather indirectly by preventing Wnts from binding to their Fz receptors and thus by shaping a Wnt activity gradient. Together, these findings identified a close link between the two guidance cues for post-crossing commissural axons in chicken: Shh not only repels post-crossing commissural axons directly , and its homolog cxcl12b.To confirm this result, Stacher Hörndli and Chien  applied cxcl12a mutants exhibited highly penetrant intraretinal RGC pathfinding errors, which resembled the phenotypes observed in Shh pathway mutants. Ectopic expression of Cxcl12a and additional transplantation experiments revealed that Cxcl12a was a direct chemoattractant for RGC axons. Additionally, the Shh and chemokine pathways interacted genetically to mediate RGC axon guidance inside the eye. Taken together, this study provided evidence that in zebrafish, Shh does not directly guide RGC axons toward the optic disc. Rather, Shh is required earlier in development to correctly pattern the eye and induce the expression of chemokines. In turn, Cxcl12a acts as an attractant for RGC axons inside the eye  and anteroposterior (A-P) axes, but also in the mediolateral (M-L) axis during guidance of serotonergic RST axons. These gradients of repulsive Shh would not only direct axons posteriorly down the spinal cord, but would also restrict the RST axons to the ventral and ventrolateral funiculus  descend ipsilaterally and project to the caudal-most regions of the spinal cord, forming the raphe-spinal tract (RST). Along their trajectory, these serotonergic axons are specifically restricted to the ventral and ventrolateral funiculus. In contrast to what was observed in the posterior spinal cord in chick  caused RST axons to loop back and deflect to the brainstem, suggesting that increased Shh-Smo repulsion pushed the descending axons away from the cervical spinal cord. Taken together, these findings showed that Shh guides serotonergic RST axons multidirectionally. Shh not only directs the posterior growth of these axons in the longitudinal axis, but is also required to position the descending tracts in their appropriate mediolateral position in the ventral spinal cord. In addition to identifying a new Shh-responsive population of axons, this study revealed a novel, efficient mechanism of axon guidance along several axes: simultaneous, multidirectional guidance by a single molecule.g et al.  examinedhigh to posteriorlow expression gradient of Wnt1 and Wnt5a at cervical and thoracic levels of the mouse spinal cord  are a functionally diverse population, which is reflected by a structural heterogeneity in their axonal projections. In mammals, mDN axons project rostrally toward the forebrain, where they expand both dorsoventrally and mediolaterally. The axons from the medially located ventral tegmental area (VTA) project along a ventromedial course and primarily target more medial target tissues in the forebrain, while the more lateral axons originating from the substantia nigra (SN) project dorsolaterally and target lateral forebrain regions. Several classical guidance cues have been implicated in mDN pathfinding, including Netrins  in which Smo is specifically and completely inactivated in the central nervous system by E11.5. In these embryos, the patterning and specification of the embryonic midbrain (including mDNs) and their forebrain targets are unaltered, since canonical Shh signaling is no longer required for these processes after E10  of the midbrain during the time that mDN axons traverse rostrally (E12.5-E15.5 in mouse). As in other regions along the neural tube, Shh forms a ventral to dorsal gradient within this area  to be identified and analyzed.Shh signaling could occur via at least two pathways: (1) Boc/Smo could elicit a canonical Shh signal in the nucleus via Gli-dependent transcriptional changes, or (2) Shh could act locally at the growth cone through an alternative, transcription-independent pathway. In order to distinguish between these possibilities, Yam et al.  used an Dissociated commissural axons responded very swiftly to a gradient of Shh in this assay. The addition of transcriptional inhibitors had no effect, supporting the idea that the chemoattractive turning response to Shh occurred independently of transcription. Accordingly, the expression of Gli3R, a dominant repressor of Gli-mediated transcription  in the growth cone, in a Smo- and Boc-dependent manner  were attracted up a Shh gradient  of post-crossing commissural axons, an effect that was dependent on PKA activity. Results from the converse gain-of-function experiments were consistent with the idea that 14-3-3 proteins can regulate a cell-intrinsic, temporal change in turning responses to Shh , an important scaffolding protein that can link cell adhesion and growth factor signaling to the actin cytoskeleton . Indeed, the expression of DN-PKCα or ILK-DM resulted in misprojection of RGC axons into the ipsilateral optic tract and contralateral optic nerve at the optic chiasm, consistent with a disruption in Shh-mediated signaling at the chiasm. Interestingly, neither DN-PKCα nor ILK-DM affected the projection of RGC axons within the retina toward the optic disc . This finding was consistent with PKCα and ILK specifically mediating the negative guidance effects of high concentrations of Shh on RGC axons. ILK-DM was less effective than DN-PKCα in inhibiting Shh-induced repulsive effects. This observation suggests that ILK is not the sole effector of PKCα signaling. The identification of other cytoplasmic targets is open to future research.Finally, Guo et al.  assessedhigh/cGMPlow, and cAMPlow/cGMPhigh favoring repulsion. Since Shh can reduce the activity of protein kinase A (PKA), it can therefore influence cyclic nucleotide levels, thus modulating the responsiveness of axons to guidance cues.In addition to acting directly as an axon guidance cue, Shh may also influence growth cone responsiveness via local intracellular mechanisms. One cytoplasmic, non-canonical target of Shh signaling is the cyclic nucleotides, which can modulate signaling responses to axon guidance cues   pathway and the PCP pathway. In the canonical Wnt pathway, stimulation of Dvl leads to inactivation of GSK3β, preventing it from phosphorylating β-catenin. Unphosphorylated β-catenin is no longer degraded by the proteasome and is able to enter the nucleus, where it interacts with the Tcf/Lef transcription factors to activate the transcription of target genes   and the Celsr3 knockout mouse exhibit strong impairments of the directionality of post-crossing axons , but many of the signaling components that elicit these distinct signaling outputs are unknown, especially for the Wnts. How are biphasic effects of Wnts and Shh possible, such that the same axon can respond differently in a concentration-dependent manner?Future studies will reveal whether additional cross-talk between these pathways occurs at the level of cell surface receptors, signaling modulators or intracellular signaling components. Wnt and Shh signaling may also be influenced by post-translational modifications or the contributions of non-receptor binding molecules such as heparan sulfate proteoglycans. And finally, it is also unclear whether and how morphogens interact with more “classical” axon guidance cues, such as IgSF CAMs (immunoglobulin superfamily cell adhesion molecules), Semaphorins, Netrins, or Eph/Ephrins.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The search for new ligands with potent biological activities, particularly as potential novel therapeutic agents, utilizing computational and synthetical approaches, is a key goal of life science research and drug development. Herein, we present the in silico, in vitro and in vivo profiles of new molecular scaffolds as novel KOP receptor ligands.The κ opioid (KOP) receptor belongs to the family of seven transmembrane G protein-coupled receptors (GPCRs) and it plays a significant role in a broad range of physiological functions. Stimulation of the KOP receptor results in analgesic actions, and KOP agonists appear to have some advantages over the μ opioid (MOP) receptor agonists. Inhibiting KOP receptors is proposed to be useful for treating addiction and stress-related conditions, such as depression and anxiety. The pharmacology of currently available KOP antagonists shows a delay in onset of action and an extremely long duration of action in vitro opioid receptor binding and [35S]GTPγS functional assays. Antinociceptive properties were assessed in mice using the writhing test.LigandScout and Catalyst softwares were used to generate and validate a merged feature ligand-based 3D pharmacophore model for KOP receptors. Biological activities were evaluated in Rhazya stricta binds with high selectivity to the KOP receptor and shows antagonist activity. A comprehensive SAR analysis on several analogues was pursued and primary chemical features responsible for KOP activity have been identified. Combining synthetical and pharmacological methodologies, two phenolic molecules were identified as novel highly selective ligands interacting with KOP receptors, and displaying full agonist or partial agonist properties, respectively. Dose-dependent and nor-BNI-sensitive antinociceptive effects were produced by the KOP agonist after subcutaneous administration to mice, exhibiting a potency comparable to that of U-50,488.The integrated computational screening strategy has led to the discovery of sewarine as KOP receptor ligand. This phenolic alkaloid from the plant This study uncovers new classes of ligands interacting with KOP receptors and sharpens the understanding of ligand-receptor interactions, thus increasing the chance of developing useful clinical agents among KOP ligands.


Efficacious strategies for the primary prevention of coronary heart disease (CHD) are underused, and, when used, have low adherence. Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice.We conducted a randomized trial of a CHD prevention intervention (including a computerized decision aid and automated tailored adherence messages) at one university general internal medicine practice. After obtaining informed consent and collecting baseline data, we randomized patients (men and women age 40-79 with no prior history of cardiovascular disease) to either the intervention or usual care. We then saw them for two additional study visits over 3 months. For intervention participants, we administered the decision aid at the primary study visit (1 week after baseline visit) and then mailed 3 tailored adherence reminders at 2, 4, and 6 weeks. We assessed our outcomes  and self-reported adherence) between groups at 3 month follow-up. Data collection occurred from June 2007 through December 2009. All study procedures were IRB approved.We randomized 160 eligible patients  and followed 96% to study conclusion. Mean predicted CHD risk at baseline was 11.3%. The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points (95% CI 8% to 42%), with the biggest effect for aspirin. It also changed predicted CHD risk by -1.1% (95% CI -0.16% to -2%), with a larger effect in a pre-specified subgroup of high risk patients.A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk.NCT00494052ClinicalTrials.gov:  Efficacious strategies for the primary prevention of coronary heart disease (CHD)  reduce the relative risk of CHD events by 20-50% each -4. HowevMultiple systematic evidence reviews -15 and aGiven limited resources for counseling in clinical practice , alternaThis paper reports on the effects of an intervention designed to promote initiation and adherence to efficacious strategies for the primary prevention of CHD. The intervention includes both a decision aid and a series of automated tailored adherence reminders.To test the feasibility of delivering the intervention in clinical practice and the effect of the intervention on important efficacy outcomes, the research team conducted a randomized trial at one university general internal medicine practice between June 2007 and December 2009. After collecting baseline data, study staff randomized participants to either the intervention or usual care, and then saw them for two additional study visits over 3 months.  engage their patients in decisions about CHD prevention and 2) use readily available resources to support adherence. Prior to the education session, physicians gave written informed consent.Patients were eligible to participate if they were presenting for routine care with an enrolled physician; were between the ages of 40-79 years; had no prior history of cardiovascular disease, diabetes mellitus, or other serious medical condition that limited their life expectancy to less than 5 years; and were at moderate (6-10%) or high risk (> 10%) of CHD over 10 years based on a Framingham risk equation . PatientTo recruit patients, study staff identified all age eligible patients returning for visits with enrolled physicians. After reviewing patients' charts, staff mailed recruitment letters to potentially eligible patients and made 3 attempts to call patients who did not "opt-out" of further contact by returning an opt-out postcard. When they reached patients by phone, staff reassessed eligibility and arranged a visit for interested patients.Patients presented for their initial study visit at least one week prior to a regularly scheduled clinic visit with an enrolled physician. During this visit, patients provided written informed consent; filled out a baseline survey about their demographics, medication use, and plans and self-efficacy for risk reduction; and had their CHD risk factors assessed. Study staff used baseline risk factor assessments to recalculate baseline predicted CHD risk and assure study eligibility.Following enrollment, patients were randomized by study staff who accessed an online randomized schedule. Staff told patients only that they were participating in a study about "prevention of heart disease." Physicians were not blinded and saw patients in both the intervention and control group.The patient-directed intervention consisted of two components: a computerized decision aid to promote initiation of effective CHD prevention strategies, and a series of automated mailed tailored messages to promote adherence. Intervention components were based on the Integrative Theory, Protection Motivation Theory, and Self-Determination Theory as previously described . FurtherThe web-based decision aid, called Heart to Heart, had five main functions: it 1) calculated patients' overall risk of CHD events in the next 10 years using a continuous Framingham equation ; 2) educThe tailored messaging system helped patients circumvent self-identified barriers and gain the necessary resources and skills for adherence. This automated messaging system included a library of 76 unique messages, which could be combined in over a million combinations in response to a few brief survey questions. The basic logic of this tailoring is shown in Figure The primary study visit occurred in conjunction with a previously scheduled visit with a participant's usual physician. Participants randomized to the intervention group presented 45 minutes early to their clinic visit to view the decision aid and received a list of their risk factors to get them started. They then self-entered their risk factors and navigated the decision aid on their own using a computer stationed in a private room in the clinic. They had access to research staff at all times for questions about navigation. After viewing the decision aid, participants proceeded to their clinic visit. Participants randomized to the control group did not receive a decision aid and proceeded directly to their clinic visit. Following the clinic visit, a research assistant administered surveys to both intervention and control patients to assess their plans for CHD risk reduction. She then mailed tailored adherence messages to participants in the intervention group approximately 2 weeks, 4 weeks, and 6 weeks after their initial study visit.Approximately 3 months after the initial study visit, all participants presented for a final study visit and final measures.Investigators measured the feasibility of intervention delivery by measuring the total time participants spent with the decision aid, whether or not participants required assistance with the decision aid, and the time spent by the research assistant preparing and mailing tailored messages.Investigators measured predicted global CHD risk , and CHD death over 10 years) using a well-validated Framingham risk equation , that coThe research team measured intent to start any effective risk reducing strategy after the primary study visit by asking participants whether or not they planned to initiate aspirin or smoking cessation or initiate or increase blood pressure or cholesterol medication.any new or escalated risk reduction strategy and by self-reported adherence to each individual strategy separately. To verify self-reported adherence, the team then examined changes in CHD biomarkers  among those who self-reported adherence.Adherence was assessed at 3 months both by self-reported adherence to Study staff measured CHD risk factors at baseline and follow-up study visits using well-defined protocols. They measured blood pressure using a non-invasive oscillometric automatic monitor (Omron HEM-907) after the patient had been seated for at least 5 minutes. They averaged three measurements taken at one minute intervals, and defined hypertension as a systolic measurement > 140 mm Hg . They meSample size was not based on hypothesis testing, but instead on a reasonable estimation of the sample size necessary to 1) assess the feasibility of the intervention, and 2) determine the effect sizes for the main effects of the intervention.All data analysis was performed using SAS  software. To examine the effects of the intervention on primary and secondary efficacy outcomes, including predicted CHD risk, intent to start therapy, self-reported adherence to therapy, and changes in risk factors, investigators used mixed effects models. The study team used a logistic link function for binary outcome variables. They used linear mixed effects models for the continuous outcome variables. Each model included the intervention, education as fixed effects and physicians as random effects. Models on CHD risk factors additionally included baseline measures of the pertinent CHD risk factors as fixed effects. As a check on self-reported adherence, analyses examined the effect of self-reported adherence on CHD risk factors among those who self-reported adherence to blood pressure and cholesterol medication.To test intent for CHD risk reduction and self-reported adherence as mediators of the intervention's effect on predicted CHD risk, the team used generalized linear mixed effects models and the Baron and Kenny 4-step approach to mediation analysis .The study sample included 24 eligible physician participants who had patients enrolled in the study and 160 patient participants who agreed to participate and were randomized (see Table Intervention participants spent an average of 12 minutes (range: 1-45 minutes) with the decision aid and were able to navigate it with minimal assistance. Tailored message mailings took research assistants less than 5 minutes per participant.At follow-up, participants in the intervention group had a statistically significant lower mean 10-year predicted CHD risk than participants in the control group . In a pre-specified high risk subgroup, the effect was larger, but not statistically significant due to the smaller sample . Increases in overall intent primarily resulted from increases in intent to take aspirin  and cholesterol medication among those with abnormal cholesterol .Patients in the intervention group also had higher self-reported adherence to the chosen risk reducing therapies promoted by the intervention  and total cholesterol  in individuals self-reporting adherence to blood pressure and cholesterol medications respectively.In mediation analysis, adding intentions for CHD risk reduction to the model testing the relationship between the intervention and predicted CHD risk reduced the difference in predicted CHD risk by 0.18 absolute percentage points, while adding self-reported adherence to the model reduced the difference in predicted CHD risk by 0.22 absolute percentage points.At 3-month follow-up, a computerized intervention designed to promote CHD prevention medication use and adherence increased self-reported adherence by 25 percentage points and reduced 10-year predicted global CHD risk by 1.1 percentage points, with a larger effect seen in a pre-specified high risk sub-group. The effect on predicted CHD risk was mediated, in part, by intent to reduce CHD risk and by self-reported adherence.These findings are similar to those reported in previous studies of more resource-intensive interventions for CHD prevention. For instance, multiple systematic reviews have shown 10-25 absolute percentage point increases in adherence, with the largest effects in studies using multiple telephone or in-person counseling sessions . FurtherAlso noteworthy about this study are the reported effects of the intervention on aspirin adherence. Given the risk based recommendations for aspirin therapy  and indiWhat is somewhat surprising about this study is the apparent lack of effect of our intervention on cholesterol-lowering medication adherence. Not only are cholesterol guidelines risk-based, but a recent systematic review  found coTo better understand the effects of our intervention, investigators performed mediation analyses. These analyses suggest that both intent to reduce CHD risk and self-reported adherence to medications partially mediate reductions in 10-year predicted CHD risk. The proportional effects, however, are small (~20%), raising questions about other potential mediators such as diet and physical activity.Interpretation of these findings should proceed with acknowledgement of the following limitations. First, this was a relatively small study not designed to look at subgroup effects. Subgroup analyses are small and underpowered, and should be used only for hypothesis generation. Second, physicians saw patients in both the intervention and control groups, which may have resulted in contamination between study groups. This may have reduced the effects of our intervention. Third, the effect of the intervention was diluted by the presence of participants (10%) who had no options for CHD risk reduction. Fourth, investigators measured adherence primarily by self-report . Based on studies comparing objective and subjective measures of adherence , it is lLimitations aside, the results of this study preliminarily suggest that an adherence intervention employing a computerized decision aid and automated adherence messages can increase patients' adherence and reduce CHD risk. This result should be confirmed in larger and broader populations with longer term follow-up. Additionally, future studies should consider additional implementation issues, such as cost, cost-effectiveness, and alternate mechanisms of delivery .The authors declare that they have no competing interests.SS conceived of the study and its design, participated in data analysis, and wrote the manuscript. LD participated in acquisition of data, data analysis, and manuscript drafting. MP, TK, RS, and BR participated in study design and reviewed the manuscript critically for intellectual content. SB participated in study design and data analysis. JC participated in data analysis. ZG participated in study design and performed data analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/331/prepubCoaching Portion of the Heart to Heart Decision Aid.Click here for fileContent of Tailored Adherence Messages.Click here for file