Beyond its role in direct intercellular communication, Cx43 also forms unapposed, non-junctional hemichannels in the plasma membrane of glial cells. These allow the passage of several neuro- and gliotransmitters that may, combined with downstream paracrine signaling, complement direct GJ communication among glial cells and sustain glial-neuronal signaling. Mutations in the GJA1 gene encoding Cx43 have been identified in a rare, mostly autosomal dominant syndrome called oculodentodigital dysplasia (ODDD). ODDD patients display a pleiotropic phenotype reflected by eye, hand, teeth, and foot abnormalities, as well as craniofacial and bone malformations. Remarkably, neurological symptoms such as dysarthria, neurogenic bladder (manifested as urinary incontinence), spasticity or muscle weakness, ataxia, and epilepsy are other prominent features observed in ODDD patients. Over 10 mutations detected in patients diagnosed with neurological disorders are associated with altered functionality of Cx43 GJs/hemichannels, but the link between ODDD-related abnormal channel activities and neurologic phenotype is still elusive. Here, we present an overview on the nature of the mutants conveying structural and functional changes of Cx43 channels and discuss available evidence for aberrant Cx43 GJ and hemichannel function. In a final step, we examine the possibilities of how channel dysfunction may lead to some of the neurological manifestations of ODDD.The coordination of tissue function is mediated by gap junctions (GJs) that enable direct cell–cell transfer of metabolic and electric signals. GJs are formed by connexins of which Cx43 is most widespread in the human body. In the brain, Cx43 GJs are mostly found in astroglia where they coordinate the propagation of Ca GJA1 gene which is located on chromosome 6 (q21-q23.2). ODDD is a rare disease  is a mostly autosomal dominant disease caused by mutations in the GJA1 encodes for one of the most abundant connexin (Cx) proteins, Cx43. Cxs are a family of transmembrane proteins with molecular weights (MW) varying from 26 to 60 kilodaltons (kDa) on which the current nomenclature is based (Cx43 has a MW of ~43 kDa). In vertebrates, Cxs are the building blocks of gap junction (GJ) channels, intercellular channels that connect the cytoplasm of two neighboring cells. A GJ channel consists of two hemichannels (HCs), each composed of six Cx proteins and delivered by each of the coupled cells. Cx43 is ubiquitously present in the human body in a large array of tissues and cells  and clinodactyly  are frequently observed. In the oral region, mandibular overgrowth, cleft lip, and cleft palate may be present. Abnormalities in primary and permanent teeth such as microdontia, partial anodontia, enamel hypoplasia, caries, and early tooth loss are observed in most patients. Brittle nails and hair abnormalities sometimes appear and skin diseases like palmoplantar keratoderma and subclinical wound healing defects are possible as well , cyclic nucleotides, and energy molecules such as ATP  , there is a continuous synthesis and breakdown of the protein, enabling fast adaptation of GJ intercellular communication (GJIC) to the physiological needs of the tissue  of GJIC and paracrine signaling to comply to the specific needs of the tissue. In terms of voltage-dependent channel gating, GJs are influenced mainly by the transjunctional voltage (Vj) which defines the difference in voltage measured between two coupled cells. In contrast, HCs are highly sensitive to Vm: they remain preferentially “silent” at inside negative potentials but are activated upon depolarization by a gating mechanism that resembles gating transitions associated with the docking of extracellular loop domains; therefore this gating is also referred to as loop gating (or slow gating)  disables Cx43 trafficking and most of the Cx43 protein is retained in the intracellular compartment. Overall, the Y17S mutation has similar effects , TM3 (T154A), or TM4 (V216L) all form channels that are present as punctae in the PM, but the coupling capacity of each mutant channel is reduced. All mutants furthermore exert dominant negative effects on WT Cx43 when in a heteromeric or heterotypic conformation , and intramolecular disulphide bridges in and between the ELs stabilize the protein's tertiary structure  and as such, to mediate the closure of GJ channels in response to increasing [CaSeveral ODDD-associated mutations have been identified in the CL domain, most of which are located in the L2 region. Cx43-I130T HCs are transported to the PM and assemble into GJ plaques. Moreover, mutant levels in the PM exceed those of WT Cx43 which might indicate a reduced degree of protein degradation. Despite of this, the mutant exhibits reduced dye and electrical coupling and HC activity is disrupted , result in GJ channels that fail to sustain electrical or dye coupling and have a dominant negative effect on WT or endogenous  Cx43. Interestingly, HC activity, measured by dye uptake and ATP release, is increased in both mutants . Patients may also suffer from hearing loss and decreased visual acuity or blindness; however, the latter two phenotypes are infrequent and only observed in a small fraction of the patients presenting with neurological traits. Magnetic resonance imaging (MRI) and computed tomography (CT) scans of patients' brains revealed abnormalities in both white and gray matter  integrity, modulation of blood supply, maintenance of brain homeostasis, myelination, and neurotransmission. The combined ablation of Cx30 and Cx43, which results in coupling-deficient astrocytes, lowers the threshold for epileptiform events   and that survey solute diffusion in and out the brain . Astrocytic endfeet nearly completely enwrap these capillary endothelial cells, inducing and maintaining barrier properties. Cx43 may contribute to astrocyte maintenance of the endothelial barrier, as mice lacking Cx30 and astroglial Cx43 have a weakened BBB that is more vulnerable to hydrostatic vascular pressure and shear stress but that is otherwise intact in the absence of a pathological insult , astrocyte swelling and proliferation  and arachidonic acid metabolites  supply to those regions where neuronal activity is high by a process termed functional hyperemia or neurovascular coupling that acts at the level of cerebral arterioles and possibly also pericytes  aided by Na+/K+ pump activity and passive uptake with water through aquaporin 4 channels. Altered activity of both K+ channels and Na+ channels in the astrocyte PM are considered pro-epileptic . Stehberg and co-workers have tested the hypothesis of gliotransmitter release via HC opening by making use of an inhibitory peptide (L2 peptide) that specifically targets Cx43 HCs without inhibiting Cx43 GJs  in the basolateral amygdala, blocked the consolidation of fear memory while addition of a cocktail of putative gliotransmitters rescued the L2-mediated inhibition of fear memory consolidation  lie at the basis of Pelizaeus-Merzbacher-like disease (PMLD1), an early onset, progressive dysmyelinating disorder affecting the CNS, and are also known to cause a distinct form of late onset hereditary spastic paraplegia (SPG44). In both cases, Cx47 mutations prevent the formation of functional Cx47/Cx47 and Cx43/Cx47 GJs causing hypomyelinating leukoencephalopathy  as well as in the glial scaffold. Expression of the Cx43-T154A mutant that is able to make adhesions but is unable to form functional GJ channels in the developing cortex did not abolish the migration of new born neurons, but expression of the Cx43-C61S mutant that lacks docking ability (with maintained HC function) did prevent migration of new neurons. These observations suggested that channel activity does not play a role but Cxs are involved as adhesive contact points between the scaffold and the migrating neurones  mutations (reviewed in Laird, ODDD manifests as a pleiotropic disease with patients exhibiting both morphological and functional deficiencies caused by mutations in the widespread 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.


Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that leads to progressive weakness of the respiratory and limb muscles. Consequently, most patients with ALS exhibit progressive hypoventilation, which worsens during sleep. The aim of this study was to evaluate the relationship between nocturnal hypoxia and cognitive dysfunction and to assess the pattern of nocturnal hypoxia in patients with ALS.2<95% for ≥10% of the night) and their clinical characteristics and cognitive function were compared.Twenty-five patients with definite or probable ALS underwent neuropsychologic testing, nocturnal pulse oximetry, and capnography. Patients were grouped according to the presence of nocturnal hypoxia  had poor memory retention (p = 0.039) and retrieval efficiency (p = 0.045). A cluster-of-desaturation pattern was identified in 7 patients (70%) in the Hypoxia Group.These results suggest that nocturnal hypoxia can be related to cognitive dysfunction in ALS. In addition, a considerable number of patients with ALS may be exposed to repeated episodes of deoxygenation–reoxygenation (a cluster-of-desaturation pattern) during sleep, which could be associated with the generation of reactive oxygen species. Further studies are required to define the exact causal relationships between these phenomena, the exact manifestations of nocturnal cluster-of-desaturation patterns, and the effect of clusters of desaturation on ALS progression. Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that involves motor neurons and leads to progressive muscle weakness Some of the frontotemporal dysfunction in ALS may be attributable to nocturnal hypoxia in patients with ALS. A previous study showed that non-invasive positive pressure ventilation treatment partially improved cognitive function in patients with ALS The purpose of this study was to investigate the relationship between nocturnal hypoxia and cognitive dysfunction and to assess pattern of hypoxia in patients with ALS using nocturnal continuous oximetry and capnography.Patients with ALS were recruited from the ALS clinic of Seoul National University Hospital between March 2006 and July 2012. Twenty-five patients  with definite or probable ALS, based on the El Escorial World Federation of Neurology Criteria were included 2SMO, Philips Healthcare, Amsterdam, Netherlands) were used for continuous overnight respiratory monitoring. The gross respiratory pattern, average end tidal carbon dioxide (ETCO2) level, average oxygen saturation (SpO2) level, duration of nocturnal hypercapnia , and duration of nocturnal hypoxia  were measured and analyzed using NovaCARD software . These measurements were chosen because the ETCO2 value obtained using capnography can be used to reliably reflect the partial pressure of CO2 in arterial blood (PaCO2) in patients that do not have dead space in the lungs or are not on a non-invasive ventilator and because SpO2 measured using pulse oximetry primarily reflects the partial pressure of O2 in arterial blood (PaO2) Capnography and pulse oximetry , verbal fluency test, and the Korean version of the mini-mental state examination (K-MMSE) were used to evaluate cognitive function. The Rey-Kim memory test is the first standardized Korean version of the auditory verbal learning test (K-AVLT) and complex figure test (K-CFT), which are widely accepted as useful tools for evaluating memory function worldwide 2<95% for at least 10% of the night t-test. The threshold for statistical significance was set at p<0.05. A computer software package, the Statistical Package for the Social Sciences , was used for statistical analyses.Nocturnal hypoxia was defined as SpO2 , higher mean ETCO2 , and poorer scores for memory retention  and retrieval efficiency . We also found a significant correlation between duration of nocturnal hypoxia and retrieval efficiency  (The respiratory and neuropsychologic characteristics of the patients are summarized in = 0.049) . There wThis study showed that in patients with ALS, nocturnal hypoxia was related to cognitive dysfunction and a pattern of clustered desaturations can frequently be found in patients with ALS who have nocturnal hypoxia.. Frontotemporal dysfunction is a common form of cognitive impairment in patients with ALS To our knowledge, this is the first study to demonstrate a relationship between nocturnal hypoxia and cognitive dysfunction in ALS. Compared to ALS patients without nocturnal hypoxia, the patients with ALS and nocturnal hypoxia had significantly lower scores for memory retention and retrieval efficiency on the Rey-Kim memory test. Also, duration of nocturnal hypoxia showed significant correlation with retrieval efficiencyIn this study, 70% of the patients with ALS and nocturnal hypoxia showed a cluster-of-desaturation pattern. This finding suggests that patients with ALS are exposed to repeated episodes of abrupt deoxygenation and reoxygenation. Abrupt reoxygenation following deoxygenation has been previously shown to generate more reactive oxygen species than a simple episode of deoxygenation Though numerous studies have suggested the possibility that hypoxia might be involved in ALS disease progression, no study has shown an aggravation of the disease course with hypoxia in an animal model of ALS 2 desaturation  have been documented using polysomnography In ALS, episodic desaturations during rapid eye movement sleep or periodic respiratory patterns consisting of mild O2 values, higher mean ETCO2 values, and a longer duration of nocturnal hypercapnia. However, there were no significant differences between the 2 groups for duration of disease, age, total ALSFRSr scores and FVC. Based on these findings, it is likely that the degree of respiratory muscle weakness and disease severity was similar in both groups. Therefore, nocturnal hypoxia may be an independent factor that reflects respiratory function in patients with ALS.The results of this study showed that compared to patients without nocturnal hypoxia, patients with nocturnal hypoxia had significantly lower mean SpOAlthough this study provides important findings, its results must be viewed in light of its limitations. This study was retrospective and included a relatively small sample size, which may have limited the ability to detect significant differences between groups for some tested components. In addition, although a relationship between nocturnal hypoxia and cognitive dysfunction was demonstrated, the causality of this relationship cannot be evaluated using this cross-sectional study design. Additional limitations include that polysomnography was not performed in this study to assess sleep-disordered breathing, which limited the ability to assess the detailed sleep patterns during the cluster-of-desaturation periods. Despite the potential utility of the FAB and MMSE in ALS, the FAB results did not show significant impairment in the Hypoxia Group. However, FAB results may be limited by limb muscle weakness in patients with ALS that could interfere with or even prevent patients from performing some of the tasks included in the FAB. Similarly, the MMSE scores did not differ between the groups, but it is well known that the MMSE might not be a sufficiently sensitive tool for evaluation of frontotemporal dysfunction Despite these potential limitations, this study showed that nocturnal hypoxia in patients with ALS is related to cognitive dysfunction and that nocturnal hypoxia in ALS is primarily characterized by a cluster-of-desaturation pattern that is associated with increased risk of reactive oxygen species generation responses Figure S1The retrieval efficiency in ALS patients correlated significantly with duration of nocturnal hypoxia .(TIF)Click here for additional data file.


Wetlands are valuable ecosystems because they harbor a huge biodiversity and provide key services to societies. When natural or human factors degrade wetlands, ecological restoration is often carried out to recover biodiversity and ecosystem services (ES). Although such restorations are routinely performed, we lack systematic, evidence-based assessments of their effectiveness on the recovery of biodiversity and ES. Here we performed a meta-analysis of 70 experimental studies in order to assess the effectiveness of ecological restoration and identify what factors affect it. We compared selected ecosystem performance variables between degraded and restored wetlands and between restored and natural wetlands using response ratios and random-effects categorical modeling. We assessed how context factors such as ecosystem type, main agent of degradation, restoration action, experimental design, and restoration age influenced post-restoration biodiversity and ES. Biodiversity showed excellent recovery, though the precise recovery depended strongly on the type of organisms involved. Restored wetlands showed 36% higher levels of provisioning, regulating and supporting ES than did degraded wetlands. In fact, wetlands showed levels of provisioning and cultural ES similar to those of natural wetlands; however, their levels of supporting and regulating ES were, respectively, 16% and 22% lower than in natural wetlands. Recovery of biodiversity and of ES were positively correlated, indicating a win-win restoration outcome. The extent to which restoration increased biodiversity and ES in degraded wetlands depended primarily on the main agent of degradation, restoration actions, experimental design, and ecosystem type. In contrast, the choice of specific restoration actions alone explained most differences between restored and natural wetlands. These results highlight the importance of comprehensive, multi-factorial assessment to determine the ecological status of degraded, restored and natural wetlands and thereby evaluate the effectiveness of ecological restorations. Future research on wetland restoration should also seek to identify which restoration actions work best for specific habitats. Wetlands harbor significant biodiversity To compensate for their extensive degradation, wetland restoration has become common practice around the world. Several studies have reported that restoration can recover much of the biodiversity and ES lost due to degradation Recovering biodiversity and recovering ES can be regarded as distinct goals of wetland restoration, with a given restoration focusing on one or the other. However, assessing both types of recovery simultaneously is important for several reasons. Biodiversity and ES of restored ecosystems often do not reach pre-degradation levels or the levels of similar natural ecosystems, and recovery of biodiversity may correlate with recovery of ES To develop an evidence-based approach for planning and assessing wetland restoration, we conducted a meta-analysis of the peer-reviewed literature to address the following four questions: (1) how much biodiversity and (2) how much of ES levels can be recovered through wetland restoration, (3) whether biodiversity and ES recovery correlate, and (4) whether the effectiveness of biodiversity and ES recovery depends on context, including ecosystem type, cause of degradation, restoration action, experimental design, and restoration age. In examining what the literature says on these questions, we hope to inform and improve efforts to restore the biodiversity and ES of degraded wetlands.www.isiwebofknowledge.com), as it provides access to peer-reviewed studies. We searched studies published between 1970 and 2010 using the following string of search terms: (riparian OR river* OR lake OR mangroves OR marsh OR stream OR wetland) AND (restor* OR re-creat* OR rehabilitat* OR forest* OR reforest* OR afforest* OR plant* OR recover*) AND ((ecosystem OR environment) AND (service OR function*)). Preliminary search results were filtered to include only the following ISI-defined subject areas: “agriculture”, “biodiversity and conservation”, “environmental sciences and ecology”, “fisheries”, “forestry”, “marine and freshwater biology”, “plant sciences”, “water resources”, and “zoology”. This resulted in a list of 1,931 references.We systematically searched the research literature to identify quantitative studies of the effects of ecological restoration on biodiversity and ES of non-marine aquatic and semi-aquatic degraded wetlands. We searched the ISI Web of Knowledge database  or active restoration in terms of variables related to biodiversity and/or to the supply of one or more wetland ES Table 1 Comparison of restored wetland with either degraded or natural wetland;Sample size of the reported data and at least a variance estimate of such data.Supporting information S1) satisfied these criteria and were included in our meta-analysis. The number of observations included in each analysis is shown in the corresponding figures.A total of 70 studies . For each study we extracted data on the variables used to measure the impacts of restoration (response variables). Separate databases were built for biodiversity and ES response variables. Whether we used one or the other database, or some combination of columns from both of them, depended on the specific question being addressed. Each measurement of restoration impact was recorded as a separate row in the database, even when the measurements came from the same study. Measurements were also recorded separately when the original study assumed spatially independent conditions within the same study site (e.g. measurements made near the shore vs. made on the open water of the same wetland).We constructed a computer database in which rows were observations and columns were properties of those observations (Supporting information S3).We extracted data on type of wetland and ecosystem, the principal causes of degradation, specific restoration action(s) implemented, experimental design used to assess restoration outcomes, and the time elapsed since completion of the last restoration action (restoration age). All variables except restoration age were nominal and assigned to categories specifically created for our analyses (Supporting information S2).Since our meta-analysis included studies differing considerably in response variables and experimental designs, we assessed the effects of restoration on biodiversity and ES relative to a control using response ratios (RRs) as the effect size metric. As an indicator of the outcome of restoration, we calculated RRs of the restored wetlands relative to reference natural wetlands [ln(Rest/Ref)] and to degraded wetlands [ln(Rest/Deg)] for each measure of the biodiversity and ES extracted from the studies. Most response variables were expected to correlate positively with biodiversity or a particular ES; for example, greater biomass was predicted to mean a higher level of supporting or provisioning ES. However, some response variables were predicted to correlate negatively with biodiversity or ES; for example, a greater concentration of a water or soil contaminant or a greater abundance of non-native species were predicted to reduce, respectively, provisioning ES and biodiversity. In these cases we inverted the sign of the RR (Supporting information S3). RR calculations and statistical analyses were performed using MetaWin v2.1 We performed separate analyses to compare restored and degraded wetlands and to compare restored and natural wetlands All possible measures of biodiversity for which the included studies reported data were used to calculate RRs; these measures included (a) species, gender, taxon or family richness; and (b) indices of species abundance, diversity, similarity, and composition. Using biodiversity measures calculated for different taxonomic levels or by different formulas enabled us to screen for differences in responses to restoration at different levels of ecological complexity Table S2). Therefore we retained all the data in our meta-analysis, similar to Rey Benayas et al.et al.To evaluate possible pseudo-replication effects, we calculated the mean RR for each of the three largest categories: macroinvertebrates, aquatic invertebrates, and vascular plants, using only one randomly selected effect size from each study. These mean RRs were similar to the means obtained when all effect sizes from each study were included, and the bias-corrected 95% bootstrap confidence interval of the reduced dataset overlapped with that of the entire dataset (Table S1). The parallel assessment of these multiple associations allowed us to capture the simultaneous supply of several ES Response variables were related to a wide variety of ES, so multiple RR-ES combinations were included as separate rows in the database  and the continuous fixed factor of restoration age, defined as the decimal logarithm of the number of months between completion of the last restoration action and evaluation. We added a fifth nominal fixed factor with two levels (biodiversity or ES) because we used RRs for both biodiversity and ES recovery in the analysis. Study site was the random-effect factor and RR was the dependent variable.p<0.05) were removed in order of decreasing p value. The selected final model contained main effects but no interactions. All model building and refinement was carried out using Data Desk v6 We also built a second model in which we reduced the degrees of freedom by including only factor categories containing at least 30 observations. Since this reduced the average sample size in each category, we discarded this model in favor of the first. Finally, we applied a backward elimination procedure in which non-significant terms (Supporting information S4). Riverine wetlands were the best-represented ecosystem type (38% of studies), followed by lacustrine wetlands (27%), and finally estuarine (18%) and palustrine wetlands (17%). Nearly all studies (68) were field-based comparisons, including three passive restoration studies (4%). The remaining two studies (3%) involved one field and one greenhouse experiment.The 70 studies analyzed here were distributed across 62 locations in 14 countries .Context variables explained relatively little variance (25.7%) in biodiversity and ES recovery. Nevertheless, the improvement in biodiversity and ES due to restoration varied substantially for different wetland types: salt marshes (+104%), freshwater marshes (+73%), rivers (+100%), lakes (+45%), mangroves (+33%), and streams . Seven of the 10 restoration actions reported by the included studies showed significant effects on biodiversity and ES supply , with habitat creation leading to the greatest benefit (+119%), followed by soil amendment and revegetation (+91%), and passive restoration in third place (+57%). Of all restoration actions examined, exotic species removal was associated with the lowest effect size, which did not achieve statistical significance. Restoration showed significant positive effects on biodiversity and ES recovery for the three types of experimental designs in the included studies: paired experiments (+61%), before-after experiments (+33%) and control-impact experiments .Restoration significantly ameliorated all causes of degradation that we examined, except for the presence of invasive species .Comparison of restored and natural wetlands showed that restoration significantly improved recovery of biodiversity and ES supply Table 2,Our global meta-analysis, including70 studies conducted in 14 countries, shows that wetland restoration increased biodiversity in degraded wetlands, consistent with another global meta-analysis of different ecosystem types Supporting information S1). Indeed a previous meta-analysis of how restoration affects major groups of organisms was restricted to calculating aggregate results for three general categories of vertebrates, macroinvertebrates, and plants Greater diversity by itself is insufficient to ensure high ecosystem functioning et al.et al.Our meta-analysis showed that restoration enhanced ES supply in degraded wetlands. The results also showed that it is more difficult to recover ES supply than to recover biodiversity; an alternative or complementary interpretation is that full recovery of ES supply takes longer than full recovery of biodiversity. Either interpretation is consistent with the meta-analysis by Rey Benayas Restoration did not enhance ES uniformly across all individual ES examined. We observed that restored wetlands provided, on average, 36% higher levels of provisioning, regulating and supporting ES than did degraded wetlands, but similar levels of cultural services. To be sure, we did not expect uniform recovery of all individual ES, given the heterogeneity of ES and wetland types included in the meta-analysis; wetlands types are known to differ in ecological dynamics, recovery rates and extents of recovery Our finding that restoration increased supply of provisioning services more than the supply of other ES may reflect the fact that, among the included studies, the desired outcomes when restoring provisioning services (e.g. abundance of target species) were generally better defined and more homogeneous than were objectives for regulating, supporting, and cultural services. Effect sizes for these last three services showed wide confidence intervals in our study, suggesting higher intra-class heterogeneity than effect sizes for provisioning services Analysis of the ES database, which included abundance data on both non-native plant and animal species, showed that restoration increased regulation of non-native species by reducing their abundance. This result is different than our finding that restoration increased the diversity of such species, though it should be noted that the biodiversity database contained data on non-native plants but not non-native animals. The abundance of non-native species may decrease rapidly during the restoration process because these species are directly eradicated. However, a reduction in abundance, which reduces the supply of ES, does not necessarily indicate a decrease in species diversity, such as when a habitat contains several rare species in low abundance. Thus, assessment of restoration should take into account both abundance and diversity indicators.The relationship between biodiversity and ES supply remains poorly understood The relationship between biodiversity and ES is also important because it has consequences beyond ecosystem restoration. For example, increasing plant diversity has been shown to enhance the provision of goods from plants and the regulation of erosion, invasive species and pathogens Our meta-analysis identified several context factors that significantly affected biodiversity and ES recovery in restored wetlands, including ecosystem type, main cause of degradation, restoration action taken, and experimental design used to assess the restoration. This highlights the need to take context into account when evaluating the effects of wetland restoration. Particularly, examining interaction effects may generate useful insights, but the risk of multiple interactions, including two or even three factors, is too high for the relatively low statistical power of our model.Our results also showed that biodiversity and ES recovery did not depend on restoration age. Nevertheless, they may depend on how long the restoration process took, on how many times a restoration action was repeated and on the conditions of the degraded wetland prior to restoration. Unfortunately most of the studies included in our meta-analysis did not report such data. The type and duration of interventions required in restoration depend heavily on the type and extent of ecosystem damage Our finding that restoration effects depended on ecosystem type is consistent with an earlier meta-analysis showing that wetlands with more hydrologic flow exchange recovered faster than those that did not receive external water flow Our meta-analysis showed that only restoration action determined how close the biodiversity and ES supply of restored wetlands approached those of natural wetlands. This finding implies that unless the correct restoration action is chosen from the beginning, which is often impossible, the restored wetland may not come as close as possible to natural conditions. Applying a combination of restoration actions may therefore improve the likelihood of success.Taken together, the results of our mixed models suggest that comparisons of degraded, restored, and reference conditions should be carried out to guide and evaluate restoration based on multiple indicators of both biodiversity and ES. These indicators should be consistent with the specific restoration goals Comparing degraded, restored and reference conditions to guide restoration may not be feasible in many cases because the irreversibility of much of man-made ecosystem damage makes it difficult to simulate the pre-degradation condition accurately Accurately assessing the impact of restoration on biodiversity and ES supply requires identifying the particular ecosystem attributes in need of restoration. To capture potential differences in the restoration of individual ES, we linked the response variables to ES based on specific measures routinely included in ecological studies Cost plays an important role in restoration planning because it may limit the desired outcomes These elements define a complex scenario for decision makers. Key to guiding decisions will be a systematic account of the relationships between wetland restoration variables and the supply of individual ES, for which the evidence base needs to be expanded. Indeed the low positive correlation between the recovery of biodiversity and ES suggests that reliable modeling of restoration outcomes will require incorporating multiple indicators that capture biodiversity, ES supply, and ecosystem processes. Such indicators should also include performance indicators that describe how much of available ES can be exploited Our meta-analysis strongly supports the idea that ecological restoration increases both biodiversity and ES supply in degraded wetlands, thereby benefiting the human communities that interact with and depend on them. The detailed effects of restoration depend heavily on context factors, emphasizing the need for habitat-specific planning and assessment of restorations Checklist S1(DOC)Click here for additional data file.Supporting information S1Studies used in the meta-analysis.(DOC)Click here for additional data file.Supporting information S2Additional information on database building.(DOC)Click here for additional data file.Supporting information S3Methodological details of the meta-analysis.(DOC)Click here for additional data file.Supporting information S4Overview of studies included in the meta-analysis.(DOC)Click here for additional data file.Figure S1Restoration effects by ecosystem type.(TIFF)Click here for additional data file.Figure S2Restoration effects by main degrading factor.(TIFF)Click here for additional data file.Figure S3Restoration effects by restoration action.(TIFF)Click here for additional data file.Figure S4Restoration effects by experimental design.(TIFF)Click here for additional data file.Figure S5PRISMA 2009 Flow Diagram.(DOC)Click here for additional data file.Table S1Linked databases used in the meta-analysis of biodiversity and ES.(XLS)Click here for additional data file.Table S2Comparison of biodiversity meta-analyses using a reduced or complete database.(DOC)Click here for additional data file.


Reproductive meristems and embryos display dormancy mechanisms in specialized structures named respectively buds and seeds that arrest the growth of perennial plants until environmental conditions are optimal for survival. Dormancy shows common physiological features in buds and seeds. A genotype-specific period of chilling is usually required to release dormancy by molecular mechanisms that are still poorly understood. In order to find common transcriptional pathways associated to dormancy release, we analyzed the chilling-dependent expression in embryos of certain genes that were previously found related to dormancy in flower buds of peach. We propose the presence of short and long-term dormancy events affecting respectively the germination rate and seedling development by independent mechanisms. Short periods of chilling seem to improve germination in an abscisic acid-dependent manner, whereas the positive effect of longer cold treatments on physiological dwarfing coincides with the accumulation of phenylpropanoids in the seed. Prunus persica), almond (Prunus dulcis), and other rosaceous plants may cause, in addition to low germination rates, a shoot development abnormality called physiological dwarfing Perennial plants protect important and delicate tissues as reproductive meristems and embryos in specialized structures respectively designated buds and seeds. Growth of bud and embryo meristems leading respectively to blooming and germination is strictly regulated by dormancy mechanisms, which impose a physiological constraint to this growth until environmental conditions are optimal for long-term survival Arabidopsis thaliana and Solanaceae species have established that ABA is involved in induction and maintenance of dormancy, whereas GAs release dormancy and promote germination VIVIPAROUS 1 (VP1) in maize and ABA-INSENSITIVE 3 (ABI3) in A. thaliana are involved in seed development and dormancy ABA-INSENSITIVE 5 (ABI5) interacts with ABI3 and mediates its effect on the expression of ABA responding genes thought the ABA-response element ABRE Seed dormancy has been observed throughout higher plants with physiological and morphological particularities in different species A. thaliana, have been proposed to regulate bud dormancy processes in peach DAM gene expression correlates with the dormancy state of buds, with higher transcript accumulation during the cold season followed by chilling-dependent down-regulation prior to dormancy release DAM-like and other genes related to dormancy at the expression level Bud dormancy in perennial plants resembles seed dormancy at the hormonal level DAM and other bud dormancy-associated genes, involved in transcriptional regulation, ABA response and metabolism, and desiccation tolerance, during the stratification of seeds in peach. The elucidation of general regulation pathways in both seed and bud structures may contribute to improve our basic knowledge on dormancy mechanisms, and be employed in plant breeding projects that profit from an early prediction of chilling requirements for blooming of new genotypes.In order to find common molecular features between seed and bud dormancy processes, we investigated the expression of in vitro culture experiment was performed in order to characterize the response of peach embryos to different periods of cold stratification. The early variables germination rate, defined as the rate of embryos showing an at least 2-mm long radicle, and shoot emergence were measured after 0, 1, 3, 7 and 9 weeks of chilling treatment. After few days, the germination rate was nearly identical and total in embryos with periods of cold stratification of one week or longer, whereas non-stratified embryos showed a lower rate of about 80%  and cDNA microarray hybridization, led to a set of genes differentially expressed during bud dormancy release in peach  samples . HoweverA. thalianaABA-INSENSITIVE FIVE BINDING PROTEIN (AFP)-like gene showed an early down-regulation in the first chilling week, followed by a slow recovery to reach initial expression values. Most of genes investigated with a higher expression in buds after dormancy release had a negligible expression in embryos, but ppa008548m coding for a putative cinnamoyl-CoA reductase showed detectable expression after 7 and 9 weeks of stratification.We assayed other genes down-regulated during bud dormancy release, related to elements of the ABA and drought stress response in ABA-INSENSITIVE 3 (ABI3)-like transcript (ppa001608m) strongly declined during the first three weeks of chilling, whereas FLOWERING LOCUS T (FT)-like (ppa012320m) had higher expression values in last stratification stages  to less than 10 ng after one week of chilling. The hormone content did not change significantly after longer chilling treatments . No geneDAM1 gene, and four of them had the three elements , C-repeat/dehydration-responsive elements (CRT/DRE), and RY repeats as described in elements . We did A systematic analysis of metabolites was performed in stratified embryos. We found several intermediate metabolites of the phenylpropanoid biosynthesis pathway accumulating in embryos stratified for 7 and 9 weeks. Phenylpropanoids are compounds synthesized from the amino acid phenylalanine that lead to the lignin precursors monolignols through the activity of cinnamoyl CoA reductase and other enzymes. Interestingly ppa008548m gene, coding for a cinnamoyl CoA reductase-like, was also found expressed in 7 and 9 weeks samples after quantitative real-time RT-PCR analysis , which sShort chilling treatments of one and three weeks were sufficient for optimal germination and shoot emergence, respectively. These chilling requirements for radicle and shoot growth were lower than those reported by other physiological studies A. thaliana, associated to the developing vasculature A. thaliana null mutant in one CCR and two CAD genes, leading to a strong reduction in lignin deposition, displayed a severe dwarf phenotype and abnormal leaf morphology Other investigated compounds, as salicylic acid and the phenylpropanoids ferulic, caffeic, coumaric and cinnamic acids, followed a modification pattern opposite to ABA. They accumulated in embryos stratified for seven to nine weeks, coinciding with a lower rate of seedling dwarfing. Overproduction of these compounds could benefit the normal development of seedlings or simply be a biochemical feature of dormancy-released embryos prepared to develop normally, however we have not obtained experimental evidences supporting any of these hypotheses. The phenylpropanoids pathway results in the synthesis of the monolignols p-coumaryl, coniferyl and sinapyl alcohols, which are the main precursors of lignin polymers, through the sequential activity of cinnamoyl CoA reductase (CCR) and cinnamyl alcohol dehydrogenase (CAD) enzymes in silico search of known homologous genes in other species and cis-elements in their promoters pointed to a common effect of ABA and drought signalling on such genes. However ABA could only account for transcript accumulation changes observed during the first week of chilling, due to the stabilization of ABA content after this time. Consequently, later down-regulation of the expression of these genes should be assigned to additional regulatory pathways. Drought and cold share common regulatory mechanisms through the CRT/DRE elements; thus imbibition and chilling of seeds caused by the stratification treatment could exert contradictory effects on the expression of genes showing this element. The intensity and the time response of drought and cold signals could be different and consequently affect differently to gene expression values measured in this work.The quantitative real-time RT-PCR analysis of genes previously related to bud dormancy revealed a parallel pattern of gene expression in buds and embryos. Several genes down-regulated during bud dormancy release after the fulfilment of cultivar-specific chilling requirements were also repressed by cold stratification in embryos. This suggests the presence of common regulatory pathways in dormancy release mechanisms of buds and seeds, although it might also be due to the effect of common environmental factors acting on the expression of certain genes without any regulatory role in dormancy release. The DAM genes are particularly interesting among this set of genes. DAM have been related to bud dormancy maintenance by expression and functional studies in multiple species, and are considered the major known regulators of this process DAM1, DAM5 and DAM6 are also significantly repressed during chilling treatment of the embryo suggests their participation in mechanisms of transcriptional regulation associated to release of seed dormancy by stratification, but additional experimental evidences are required to confirm it. Recently, DAM5 and DAM6 genes have been found modified by long genomic insertions into their first intron in the peach ‘Okinawa’, a low chilling rootstock showing lower DAM5 and DAM6 expression in buds A. thaliana have been recently published. The FLOWERING LOCUS C (FLC) gene coding for a MADS box transcription factor involved in flowering time regulation through the vernalization pathway, also affected the temperature-dependent germination of dormant seeds FLC on seed germination was most likely mediated by FLOWERING LOCUS T (FT), which has also been shown to play a role in meristem growth and possibly dormancy per se DAM genes FT increased its expression after stratification during 7–9 weeks  gene, involved in the ABA-dependent expression of many seed-specific genes in A. thaliana, is expressed in buds during bud set and causes some alterations in bud development when overexpressed and silenced Previous molecular studies relating seed germination and flowering in –9 weeks , which pThe transcriptional similarities between bud and seed dormancy highlighted in this work may also be relevant for plant breeding purposes. The selection of early and late flowering genotypes from a segregating population usually requires the arduous evaluation of large collections of individuals, which could be improved by a previous selection of the desirable trait at the seed level. Previous studies found a positive correlation between the chilling requirements for seed germination and blooming in almond and apple Prunus persica L. Batsch cv ‘Big Top’ was grown in an orchard located at the Instituto Valenciano de Investigaciones Agrarias (IVIA) in Moncada (Spain) under standard agricultural practices. Mature fruits were collected and immediately broken to eliminate the endocarp with special scissors. Seeds were disinfected and flamed with alcohol, and then the coats were removed under sterile conditions. Embryos were cultured in a sterile Woody Plant Medium The Total RNA was isolated from 100 mg of seeds deprived of their coats using the RNeasy Plant Mini Kit , but adding 1% (w:v) polyvinylpyrrolidone (PVP-40) to the extraction buffer before use. From 8 to 10 individuals were pooled for each treatment. We performed two RNA extractions per sample, which were treated independently until cDNA synthesis, constituting two biological replicates. One microgram of total RNA was reverse transcribed with SuperScript III First-Strand Synthesis System for RT-PCR  in a total volume of 20 µl. Two microliter of a 40X diluted first-strand cDNA were used for PCR reactions in a final volume of 20 µl. Quantitative real-time PCR was performed on a StepOnePlus Real-Time PCR System , using Perfecta SYBR Green SuperMix ROX . Primer pairs are listed in –1. The mass spectrometer, a triple quadrupole  was operated in negative ionization electrospray mode using N2 as nebulization and desolvation gas and set at 100 and 800 l h-1, respectively. During measurements, capillary voltage was set at 3.5 kV whereas cone voltage was adjusted for every analyte. The precursor and product ions as well as cone and collision voltages were selected after direct injection of pure commercial standards into the mass spectrometer.Plant hormones and phenolics were analyzed by LC/ESI-MS-MS essentially as described Significant changes of height, level of qualitative dwarfing, metabolite content and gene expression between different stratification treatments or growth times were evaluated by one-way analysis of variance (ANOVA) using the STATGRAPHICS Centurion XVI software . Multiple Range Tests were performed in order to determine which sample means were significantly different from the others, using the Least Significant Difference (LSD) method of Fisher with a confidence level of 95%. Significant differences were labelled with different letters from “a” to “d” in graphic representations.The variables germination rate, percentage of shoot emergence and rate of dwarfing were compared between stratification treatments by confidence intervals in the case of binomial, as proposed by Clopper and Pearson http://www.phytozome.net/cgi-bin/gbrowse/peach/). We selected 1-kb upstream sequence from the transcriptional start site when known, and from the translation start ATG in ppa006974m and ppa008548m genes. The ABRE element was located in these sequences applying a matrix-based procedure The promoter sequence of transcript models was obtained from peach genome database at phytozome Click here for additional data file.


Circulating concentrations of uric acid may be affected by dietary components such as meat, fish and dairy products, but only a few studies have compared uric acid concentrations among individuals who exclude some or all of these foods from their diet. The aim of this study was to investigate differences in serum uric acid concentrations between meat eaters, fish eaters, vegetarians and vegans.A sample of 670 men and 1,023 women  from the European Prospective Investigation into Cancer and Nutrition Oxford cohort were included in this cross-sectional analysis. Diet was assessed using a semi-quantitative food frequency questionnaire and serum concentrations of uric acid were measured. Mean concentrations of uric acid by diet group were calculated after adjusting for age, body mass index, calcium and alcohol intake.In both men and women, serum uric acid concentrations differed significantly by diet group . The differences between diet groups were most pronounced in men; vegans had the highest concentration , followed by meat eaters , fish eaters  and vegetarians . In women, serum uric acid concentrations were slightly higher in vegans  than in meat eaters  and lower in vegetarians  and fish eaters .Individuals consuming a vegan diet had the highest serum concentrations of uric acid compared to meat eaters, fish eaters and vegetarians, especially in men. Vegetarians and individuals who eat fish but not meat had the lowest concentrations of serum uric acid. Uric acid is the end product of purine metabolism, generated from the breakdown of DNA, RNA and ATP High uric acid concentrations can result from low rates of excretion, primarily through the kidneys, and from overproduction of uric acid due to an excess of purine precursors from synthesis, cell turnover and diet The EPIC-Oxford cohort includes 65,429 men and women aged 20 years or older who were recruited from around the United Kingdom between 1993 and 1999. The study was designed to investigate diet, lifestyle and risk of cancer among people with different dietary habits and thus aimed to recruit vegetarians and vegans as well as participants from the general population. A detailed description of the recruitment process has been published elsewhere The present cross-sectional analysis includes men and women who (i) had provided a blood sample at recruitment, (ii) had a known smoking and diet group, (iii) had responded to ≥80% of the relevant questions in the FFQ  and had an energy intake between 3.3 and 16.7 MJ  for men or between 2.1 and 14.7 MJ  for women, (iv) did not have prior cancer (excluding non-melanoma skin cancer) or cardiovascular disease, (v) were not receiving treatment for any long-term illness or condition, (vi) were not pregnant or taking oral contraceptives or hormone therapy for menopause (women only), and (vii) were younger than 90 years at time of blood collection. In order to maximise the heterogeneity of dietary exposure, approximately equal numbers of participants in each of the four diet groups were randomly selected from participants who were stratified by sex and by 10 year age categories. This resulted in 424 meat eaters, 425 fish eaters, 422 vegetarians and 422 vegans being included in this study.At recruitment, participants completed a validated semi-quantitative food frequency questionnaire Participants were categorised into one of four diet groups based on their answers to the questions: “Do you eat any (i) meat, (ii) fish, (iii) dairy products and (iv) eggs?” The derived diet groups were: meat eaters, fish eaters (do not eat meat but do eat fish), vegetarians (do not eat meat or fish) and vegans .In the FFQ, participants were asked to report their average intake of 130 food items over the preceding 12 months in nine categories ranging from “Never or less than once per month” to “6 or more times per day”. The mean daily intakes of food items were estimated by multiplying the frequency of consumption by a specified portion size . Smoking was categorised as “never”, “former”, “current light” (<15 cigarettes/day) and “current heavy” (≥15 cigarettes/day), and age of the participants was recorded at time of blood collection.In the questionnaire, all participants were asked to report their weight and height. Weight and height were also measured in a sub-sample  of the cohort, and self-reported data showed good agreement with the measured data (r>0.9) At recruitment or shortly after, participants attended their local general practice surgeries where a blood sample was taken (participants were not required to fast). Blood was transported overnight to a laboratory in Norfolk by mail at ambient temperature, where samples were centrifuged and serum was aliquoted into 0.5 ml plastic straws. These were heat-sealed at both ends and stored in liquid nitrogen (−196°C) until 2011 and subsequently in electric freezers (−80°C) until analysis. A Beckman Synchron DxC autoanalyser  was used to measure serum uric acid in 2011. Pooled serum samples (n = 196) were included in each run (blinded) and the overall coefficient of variation for uric acid was 0.9%.2 test was used for categorical variables, and for continuous variables one-way ANOVA was used for normally distributed variables and the Kruskal-Wallis test for non-normally distributed variables.All analyses were performed for men and women separately. The distributions of dietary and non-dietary characteristics were compared between the four diet groups; Pearson's χ2).In order to facilitate comparability between results with different levels of adjustment, participants with missing data on BMI were excluded (30 men and 34 women) leaving 408 meat eaters, 405 fish eaters, 404 vegetarians and 412 vegans for further analysis. Partial correlation coefficients between uric acid and dietary and non-dietary characteristics, respectively, were examined adjusting for age  and BMI  and calcium intake (sex-specific fifths) using multiple linear regression.Means and 95% confidence intervals (CI) of uric acid concentration were calculated for each diet group adjusted for age  and alcohol intake (sex-specific fifths) and then further for BMI .Characteristics and intake of food and nutrients for men and women subdivided by diet group are shown in 2)  . In men,In women, the pattern of differences between the diet groups was in general similar to that observed in men. In women however, the meat eaters had the highest intake of fish and the lowest percent energy from dairy protein and sugar; fish eaters had the highest intake of beer but the intakes of milk (among the three diet groups consuming dairy products) and fruit did not differ significantly by diet group .The correlations between dietary and non-dietary variables and uric acid concentrations are shown in The results in The results of this cross-sectional analysis showed that vegans had the highest concentrations of uric acid followed by meat eaters, and that fish eaters and vegetarians had the lowest uric acid concentrations. These differences by diet group were more pronounced in men than in women.The higher uric acid concentrations among vegans might be due to their lack of consumption of dairy products, which are thought to lower uric acid concentrations Soy, other legumes and some vegetables are rich in purines The high purine content of meat might explain the lower concentration of uric acid in vegetarians and fish eaters who both exclude meat from their diet. In accordance with our results, a small (n = 45) study did not find a difference in uric acid concentrations between vegetarians and fish eaters The present study has some limitations. The finding of weak correlations between dietary variables and serum uric acid concentrations might be due to measurement error in the assessment of dietary intake As other studies have reported In conclusion, the results of the present study show that individuals consuming a vegan diet had the highest serum concentrations of uric acid compared to meat eaters, fish eaters and vegetarians, especially among men. Vegetarians and individuals who eat fish but no meat had the lowest serum uric acid concentrations. These findings highlight the importance of distinguishing between vegans and vegetarians in future studies of diet groups and uric acid concentrations. The potential effects on circulating uric acid concentrations of excluding dairy products and of low intake of calcium in the vegan diet deserves further investigation, as does the influence of different types and quantities of purines in the diet.


Soft tissue sarcomas of childhood are a group of heterogeneous tumors thought to be derived from mesenchymal stem cells. Surgical resection is effective only in about 50% of cases and resistance to conventional chemotherapy is often responsible for treatment failure. Therefore, investigations on novel therapeutic targets are of fundamental importance. Deregulation of epigenetic mechanisms underlying chromatin modifications during stem cell differentiation has been suggested to contribute to soft tissue sarcoma pathogenesis. One of the main elements in this scenario is enhancer of zeste homolog 2 (EZH2), a methyltransferase belonging to the Polycomb group proteins. EZH2 catalyzes histone H3 methylation on gene promoters, thus repressing genes that induce stem cell differentiation to maintain an embryonic stem cell signature. EZH2 deregulated expression/function in soft tissue sarcomas has been recently reported. In this review, an overview of the recently reported functions of EZH2 in soft tissue sarcomas is given and the hypothesis that its expression might be involved in soft tissue sarcomagenesis is discussed. Finally, the therapeutic potential of epigenetic therapies modulating EZH2-mediated gene repression is considered. Soft tissue sarcomas (STSs) are a group of heterogeneous malignant neoplasms thought to arise from molecular lesions occurring during the differentiation of mesenchymal stem cells (MSCs) . STSs acEZH2 is one of the Polycomb group (PcG) proteins, which repress expression of developmentally regulated genes that induce tissue differentiation, such as homeotic genes. PcG proteins help maintaining the undifferentiated, multipotent phenotype of the embryonic stem cell compartment -11. In vRMSs are a heterogeneous group of STSs characterized by features of skeletal muscle tissue and thought to be caused by abnormalities occurring during the course of myogenesis ,19. It pSS18 or SYT) gene on chromosome 18 and either synovial sarcoma, X breakpoint 1, 2 or 4  genes on the X chromosome . EW. EWstemnaffected . Notablyaffected . Data frin vitro induces downregulation of EZH2 [in vitro, treatments employing either HDACs or DNA methylation inhibitors have been recently reported to increase in vivo the invasive capabilities of RMS cells through upregulation of the prometastatic gene Ezrin [in vivo mechanism(s) of action of epigenetic drugs. Indeed, the clinical response to azacytidine in terms of prolongation of survival in MDS patients does not appear to be directly correlated with methylation of specific tumor suppressor genes, though methylation status has been shown to correlate with poor survival [Pediatric STSs, especially those metastatic at diagnosis, are highly aggressive tumors for which there is still an unmet medical need of more effective and less toxic therapeutic approaches. The role of the epigenetic regulator EZH2 in maintaining the embryonal cell phenotype of STS, its overexpression in these cancers and its functional interaction with many fusion proteins typical of STS, suggest that EZH2 may represent both a potential marker of undifferentiated precancerous cells and a reasonable candidate therapeutic target in STS. Increasing attention is focusing on epigenetic therapies that have provided promising results in clinical trials for some human tumors -42. The  of EZH2 , as more of EZH2 , gallbla of EZH2  and acut of EZH2 . Consist of EZH2 -53. DZNe of EZH2 ,55. In a of EZH2 . In thisne Ezrin . Major qsurvival . Even ifsurvival .Despite these unresolved questions, epigenetic therapy is a promising approach for targeted anticancer therapies in pediatric STS. Available evidence suggests that targeting the methyltransferase EZH2 may be potentially able to restore physiological patterns of gene expression in pediatric STS. In the future, modulation of EZH2 activity may provide a new line of intervention that could be combined with epigenetic drugs acting on other molecular targets and/or conventional cytotoxic agents to treat these aggressive pediatric tumors.The authors declare that they have no competing interests.RC and RR contributed equally to selection and discussion of the literature and the conception and preparation of the manuscript. FL, AG and LM contributed to the discussion on clinical implications and reviewed the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/9/63/prepub


A 6-year-old girl had undergone multiple operations for an omphalocele but still retains a very large ventral hernia. She presented with an eventrated abdomen with unstable, scarred closure see . A reconWhat defines an omphalocele as giant?What are the different techniques employed to close giant omphaloceles?Is there a benefit to a staged approach compared to a primary closure?What are the risks associated with the use of tissue expanders?-4,6A giant omphalocele is a congenital abdominal wall defect caused by failure of the cephalic, caudal, and lateral folds to fuse at the umbilical ring during the fourth week of gestation.2There are numerous surgical techniques for giant omphalocele closure, which fall into the categories of primary, staged, and delayed closure.,9,12,13Staged techniques of closure require slow reintroduction of the herniated viscera back into the abdominal cavity using: external silo reduction, sequential sac ligation, external skin closure, and vacuum-assisted closure systems. External silo reduction has been attempted with both polypropylene mesh with an intact amniotic sac.6Primary closure of a giant omphalocele is executed through the 2-stage use of tissue expanders: subcutaneously, intra-abdominally, or intramuscularly. Ugarte et alOur experience with intermuscular tissue expanders leads us to agree with the case evidence provided by De Ugarte et al and Adetayo et al that intramuscular tissue expansion is an effective, low risk method of closure in the salvage situation. Tissue expansion has temporary inconvenience to the patient, possibility of infection, and the possibility of loss of domain from postponing the repair.Omphalocele treatment approaches vary due to the varying sizes of defects and associated anomalies. A follow-up survey of giant omphalocele repair case studies published from 1967 to 2009 determined that 42% of surgeons have changed surgical technique.


Gray matter loss in the limbic structures was found in recent onset post traumatic stress disorder (PTSD) patients. In the present study, we measured regional gray matter volume in trauma survivors to verify the hypothesis that stress may cause different regional gray matter loss in trauma survivors with and without recent onset PTSD.High resolution T1-weighted magnetic resonance imaging (MRI) were obtained from coal mine flood disaster survivors with (n = 10) and without (n = 10) recent onset PTSD and 20 no trauma exposed normal controls. The voxel-based morphometry (VBM) method was used to measure the regional gray matter volume in three groups, the correlations of PTSD symptom severities with the gray matter volume in trauma survivors were also analyzed by multiple regression.Compared with normal controls, recent onset PTSD patients had smaller gray matter volume in left dorsal anterior cingulate cortex (ACC), and non PTSD subjects had smaller gray matter volume in the right pulvinar and left pallidum. The gray matter volume of the trauma survivors correlated negatively with CAPS scores in the right frontal lobe, left anterior and middle cingulate cortex, bilateral cuneus cortex, right middle occipital lobe, while in the recent onset PTSD, the gray matter volume correlated negatively with CAPS scores in bilateral superior medial frontal lobe and right ACC.The present study identified gray matter loss in different regions in recent onset PTSD and non PTSD after a single prolonged trauma exposure. The gray matter volume of left dorsal ACC associated with the development of PTSD, while the gray matter volume of right pulvinar and left pallidum associated with the response to the severe stress. The atrophy of the frontal and limbic cortices predicts the symptom severities of the PTSD. Gray matter volume reductions in limbic structures and hippocampus have been found in trauma survivors with recent onset post traumatic stress disorder (PTSD) The stress plays an important role in the onset of PTSD. In previous studies, the population studied consisted of PTSD and trauma exposed non-PTSD subjects A severe coal mine-flood disaster occurred in central China on July 29, 2007, 69 male miners were trapped in a nearly 1400 m underground coal pit, all of them were fortunately rescued after 72 h of the ordeal in the darkness Voxel-based morphometry (VBM) method was used to measure the gray matter volume in coal mine flood disaster survivors with and without recent onset PTSD, compared with a group of age and gender matched no trauma exposed normal controls. Based on the results of previous studies, we hypothesize that gray matter volume may loss in different regions in recent onset PTSD patients and non PTSD subjects relative to normal controls. The severity of PTSD symptoms may correlate with the brain structure in the trauma survivors including the recent onset PTSD and non PTSD.A trauma survivor group (n = 20) and a normal control group (n = 20) were enrolled in the present study. All the trauma survivor group members were from the survivors of a coal mine flood disaster that occurred in July 29, 2007 in the Henan province of China. As a program of psycho-aid organized by the government, the clinical evaluation and diagnosis of the members were carried by a psychiatric team from Xijing Hospital who were trained to expertly use the DSM-IV All MRI scans were performed on a 3.0 T MR scanner  equipped in the Department of Radiology, Xijing Hospital. A high-resolution three dimensional magnetization prepared rapid acquisition gradient echo (MPRAGE) T1-weighted sequence was used to acquire MR images over the whole-brain . Other MR imaging parameters applied in this study were TR = 1900 ms, TE = 2.26 ms, TI = 900 ms, flip angle = 9°, acquisition matrix = 256×256, field of view = 220 mm and 1.00 mm slice thickness with no inter-slice gap.Image analysis was performed on a computer workstation with MATLAB 7.11.01 and SPM8 software  with methods similar to those described previously In the preprocessing step of VBM, DARTEL was used to improve inter-subject registration of structural images. The following processing steps were carried out: (1) the artifacts of raw data for each subject were inspected and image origin was set at the anterior commissure; (2) structural images of the 20 normal subjects were used to make DARTEL templates. (3) Structural images of each subject were applied to unified segmentation and initial import, and the imported data were warped to existing DARTEL templates, and flow fields files were generated; (4) by combining the flow fields and imported data, the Jacobian scaled warped tissue images were generated through Jacobian modulation p<0.05 corrected for multiple comparison using the Family Wise Error (FWE), with a minimum of 50 contiguous voxels required Group differences in demographic and clinical variables were examined with analysis of variance (ANOVA) in SPSS11.0 , considering there is a significant difference in age between PTSD and non-PTSD groups, the gray matter volume, white matter volume and CSF volume were analyzed with analysis of covariance (ANCOVA) with age as covariate. Group comparisons for gray matter volume were performed in SPM8 with ANCOVA, with diagnosis as a fixed factor, education years, age and TIV as covariates. Two sides of contrasts were examined: normal controls>comparison subjects and normal controls<comparison subjects. The statistical significance threshold was set at p<0.05 (corrected at cluster level for multiple comparison), with a minimum of 100 contiguous voxels required.To test the hypotheses about regionally specific covariate effects, in the trauma survivor group, the correlation study between the gray matter volume and the CAPS and SCL90 were performed using multiple regression in the basic model of the SPM8, using CAPS, SCL90 as predict factor, age and TIV were treated as confounding covariates. Two sides of correlations (positive or negative) were examined, and significance level was set to The normal controls and the trauma survivors did not differ in age, but differed in years of education . In the trauma survivors, the PTSD and non PTSD differed in age , but did not differ in years of education. All trauma survivors came from the same community and did not differ significantly in socioeconomic status. As expected, the PTSD patients had higher CAPS scores than the non PTSD subjects , and there was significant difference in SCL90 between the PTSD and non PTSD , there was also significant difference between PTSD and non PTSD in re-experience , avoidance , arousal and intrusion  . The graThe patients with recent onset PTSD had significantly smaller gray matter volume in the left anterior cingulate cortex (ACC) compared with the normal controls , Table 2The non PTSD subjects showed significantly smaller gray matter volume in left pallidum and pulvinar of the right thalamus compared with the normal controls , Table 2No significant difference was identified in gray matter volume between PTSD and non PTSD group.In all trauma survivors including both non PTSD and PTSD, the gray matter volume correlated significantly and negatively with the CAPS scores in the bilateral superior medial frontal lobe, left anterior and middle cingulate cortex, bilateral cuneus cortex, right middle occipital lobe , Table 3In recent onset PTSD patients, the gray matter volume correlated significantly and negatively with the CAPS scores in the bilateral superior medial frontal lobe and right ACC , Table 3There was no significant correlation between SCL90 and gray matter volume in trauma survivors, PTSD group or non PTSD group.There are three major findings in the present study. First, atrophy in the left dorsal ACC of trauma survivors with recent onset PTSD was identified, compared with normal controls. Second, atrophy in left putamen and right pulvinar of trauma survivors without PTSD was identified compared with normal controls. Third, the gray matter volume of trauma survivors correlated negatively and significantly with CAPS scores in bilateral superior medial frontal cortex, anterior and middle cingulate cortex, bilateral cuneus cortex, right occipital cortex. Furthermore, in recent onset PTSD patients, the gray matter volume correlated negatively with the CAPS scores in bilateral superior medial frontal cortex and right ACC. These results implicated that the bilateral frontal lobe and right ACC associate with PTSD symptom severity. For the unique characteristic of the trauma event and homogeneous demographic characteristic of trauma survivors, the present study results implicated that gray matter loss in specific region at 6 months after a single prolonged trauma may associate with PTSD onset and stress response.In the present study, we found a significantly decreased gray matter volume in left dorsal ACC in recent onset PTSD patients compared with normal controls, which indicated that the left dorsal ACC may specifically associate with developing of recent onset PTSD at early stage. This result is partially consistent with previous studies about recent onset PTSD Ventromedial prefrontal cortex (vmPFC) is implicated in fear extinction in animal Different from previous studies The dorsomedial thalamus receives input from the amygdala and is a key structure for visual input into the prefrontal cortex As a protective and adaptive mechanism, the proper function of fear conditioning depends on the integration of content and context information Compared with the normal control group, there is no significant difference in gray matter volume between the PTSD and non PTSD in present study. That is because in previous study The present study also has a number of potential limitations. First, we acknowledge that VBM, though robust for larger samples, is not superior to expert manual segmentation, and the transformations required for VBM may induce artificial volumetric differences (such as mis coregistration) and the VBM method may not detect the gray matter volume change in amygdala and subfield of hippocampus Taken together, in trauma survivors of a unique prolonged trauma event, we found recent onset PTSD and non PTSD had different regions of gray matter loss at 6 months after the trauma, indicated that the gray matter loss in left ACC may associate with the PTSD onset, while gray matter loss in the pulvinar and pallidum may involve in the stress response. The atrophy of frontal-limbic cortex in recent onset PTSD may predicate PTSD symptom severities.


Duchenne muscular dystrophy (DMD) is the most common inherited form of muscular dystrophy, which results in skeletal muscle weakness by age 6. In its later stages DMD leads to dilated cardiomyopathy and heart failure with high level of mortality. At present there are no effective treatments for most of the cardiac pathology in DMD patients.Recently we showed that sildenafil could reverse much of the cardiac dysfunction in the mdx mouse model of DMD. Treatments with sildenafil (in the drinking water) resulted in significant improvements in cardiac function, analyzed by the myocardial performance index (MPI) and Ea/Aa ratios . SimilarIn order to provide a reliable indicator for efficacy of dosing of different PDE5 inhibitors we examined the levels of PDE5 phosphorylation in tissues known to express PDE5, e.g. lung and blood vessels, as a biological indicator of cGMP induced PKG activation in vivo. We found that both tadalafil and sildenafil caused time-dependent equivalent phosphorylation of PDE5 in these tissues. Similar PDE5 phosphorylation patterns were observed in cardiac tissue extracts. Since no PDE5 expression has been detected in adult mouse cardiac myocytes, we consider phospho-PDE5 in the cardiac samples to be from cardiac blood vessels, myofibroblasts and even platelets from residual blood.Differential effects of PDE5 inhibitors on cardiac dysfunctions in MDX mice could point to PDE1C, which can be partially inhibited by sildenafil, but not by tadalafil. PDE1C is the calcium/calmodulin cGMP/cAMP PDE, most highly expressed in mouse cardiac myocytes. However, the functions of PDE1C in myocytes have not been determined.We used specific PDE1 inhibitors  and found that these inhibitors could substantially stimulate cGMP-induced phosphorylation of phospholamban by C-type natriuretic peptide (CNP). Moreover, in cardiac myocytes, isolated from PDE1C KO mice, CNP-induced phosphorylation of phospholamban was substantially higher, and no additional increase of its phosphorylation was detected with PDE1 specific inhibitors.However, we did not detect any induction of phosholamban phosphorylation when sildenafil was applied to mouse cardiac myocytes even at high concentrations; and tadalafil did not have any effects as well. Although the pattern of PDE5 phosphorylation after sildenafil and tadalafil application by oral gavage corresponded to the differences in the pharmacokinetics of these drugs, they produced differential changes in ERK, VASP and GSKb phosphorylation in lung and heart, often in different directions.These data suggest that the sildenafil and tadalafil differential effects could be the result of indirect effects of these drugs on other cell types, subsequently affecting cardiac functions.However, PDE1 specific inhibitors appear to be new potential agents for direct regulation of phospholamban phosphorylation and calcium homeostasis in the heart.


Critical incident audit and feedback are recommended interventions to improve the quality of obstetric care. To evaluate the effect of audit at district level in Thyolo, Malawi, we assessed the incidence of facility-based severe maternal complications  and maternal mortality) during two years of audit and feedback.Between September 2007 and September 2009, we included all cases of maternal mortality and SAMM that occurred in Thyolo District Hospital, the main referral facility in the area, using validated disease-specific criteria. During two- to three-weekly audit sessions, health workers and managers identified substandard care factors. Resulting recommendations were implemented and followed up. Feedback was given during subsequent sessions. A linear regression analysis was performed on facility-based severe maternal complications. During the two-year study period, 386 women were included: 46 died and 340 sustained SAMM, giving a case fatality rate of 11.9%. Forty-five cases out of the 386 inclusions were audited in plenary with hospital staff. There was a reduction of 3.1 women with severe maternal complications per 1000 deliveries in the district health facilities, from 13.5 per 1000 deliveries in the beginning to 10.4 per 1000 deliveries at the end of the study period. The incidence of uterine rupture and major obstetric hemorrhage reduced considerably (from 3.5 to 0.2 and from 5.9 to 2.6 per 1000 facility deliveries respectively).Our findings indicate that audit and feedback have the potential to reduce serious maternal complications including maternal mortality. Complications like major hemorrhage and uterine rupture that require relatively straightforward intrapartum emergency management are easier to reduce than those which require uptake of improved antenatal care (eclampsia) or timely intravenous medication or HIV-treatment (peripartum infections). Despite countless conferences and policy documents, an unacceptably high number of women does not survive childbirth in many low-income countries, particularly in sub-Saharan Africa In order to improve obstetric care and reduce delay, critical incident audit and feedback have been recommended by the World Health Organization (WHO) and other institutions Maternal and perinatal mortality reviews are currently applied in many institutions around the globe Especially in low-resource countries, which carry by far the highest burden of maternal mortality and morbidity, the effects of audit are poorly understood In Thyolo District, Malawi, systematic audit and feedback started being performed in August 2007. Evaluation of one-year audit results showed a reduction in the incidence of uterine rupture at district hospital level by 68%  Therefore, we undertook this study to evaluate changes in incidence of facility-based maternal mortality and SAMM during a two-year period of intensive audit and feedback in the district.The study was performed in full accordance with the guidelines for operational research of the National Research Council and the Health Sciences Research Committee of the Ministry of Health of Malawi and with the Helsinki declaration of 1975, as revised in 1983 This was a facility-based prospective cohort study.st, 2007, to September 1st, 2009, this study was performed in Thyolo District, a predominantly rural area in Southern Malawi, a very low income country in sub-Saharan Africa. The district had a population of 587 455 in 2008 and an HIV-prevalence rate of 21% in 2004 From September 1The publicly-funded Thyolo District Hospital is the largest health facility and most important secondary referral center in the area; 4363 deliveries were conducted in the facility in 2008. During the same year, an additional 11 556 health facility deliveries took place in 28 smaller government, mission and private facilities throughout the district, adding up to a total of 15 919 facility deliveries, almost 55% of the estimated 29 400 deliveries in the district that year (based on a birth rate of 50‰) Due to a very low number of physicians in the district, clinical officers –a cadre of “non-physician clinicians”- perform the bulk of clinical work, including major surgery such as caesarean section We included all cases of maternal mortality and SAMM that occurred in any of the district health facilities into the study which was labeled “4M-study”: maternal mortality and morbidity in Thyolo District. All mortality and morbidity cases were included regardless of additional maternal or gestational factors .th version of the International Classification of Diseases: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes We used the definition of maternal mortality as given in the 10At present, there is no universally accepted case definition of SAMM Therefore, we chose disease-specific criteria and included pregnant and recently delivered women up to 6 weeks postpartum with one or more of the following entities:uterine rupture, defined as the occurrence of clinical symptoms  or intrauterine fetal death that led to laparotomy, at which the diagnosis was confirmed, or laparotomy for uterine rupture after vaginal birth or severe pre-eclampsia, defined as any case of pre-eclampsie with a maternal indication for termination of pregnancy;eclampsia or a hemoglobin level below 6 g/dl measured after vaginal bleeding or an estimated blood loss of more than 1 liter;major obstetric hemorrhage (including hemorrhage from complicated abortions and ectopic pregnancies) defined as a fulfilled need for transfusion of at least two units of 450 milliliters of whole blood  severe obstetric and non-obstetric peripartum infections, defined as all infections for which intravenous antibiotics or intravenous anti-malarials were prescribed or surgical treatment was performed, as well as neoplasms resulting primarily from HIV-infection (e.g. Kaposi's sarcoma and HIV-associated lymphoma);any other complication the clinician considered severe, with the qualification ‘severe’ confirmed by at least two senior clinicians.These criteria were modified for the local setting from similar international studies Patients were identified and included into the study by clinicians and nurses who received assistance from medical students from Leiden University, the Netherlands, during daily ward rounds in the obstetric department and thrice-weekly rounds in the women's medical and surgical wards. Each inclusion was also verified with a senior clinician. Upon discharge or upon confirmation of death of any hospitalized patient, medical records  of each woman were again screened for relevant diagnoses according to SAMM criteria. Staff responsible for including women into the study were unaware of the specific objective to evaluate overall trends in maternal outcome.We postulated that cases seen at the district hospital  comprised the overwhelming majority of SAMM and maternal mortality cases occurring in district health facilities. According to district health protocols, all women with severe maternal complications should be referred to secondary level for appropriate observation and treatment. In order to justify our hypothesis and control for underreporting at primary care level, we searched records of ten smaller primary care centers for cases fitting inclusion criteria at the end of the study period. We were not able to identify any further inclusions from records in these facilities other than cases that had been referred to the district hospital and that had already been included into the study at that level.All relevant data were entered into a Microsoft Excel database and, based on the assumption that audit and feedback would account for a decrease in maternal complications, linear regression analyses were performed with IBM® SPSS® Statistics 17.0 software package with “quarter” as independent variable, and maternal complications, maternal mortality and SAMM per 1000 deliveries per quarter as dependent variables. We also assessed trends for each individual SAMM diagnosis and for the number of HIV-positive women included into the study.Audit sessions were held every two to three weeks, involving members of each cadre of clinical staff, as well as members of the District Health Management Team. External gynecologist-obstetricians were occasionally invited to join for audit. During audit sessions, cases of maternal mortality and SAMM were presented by hospital staff on a rotational basis and discussed by all available health workers and managers, usually between 30 and 45 staff. The hospital team of clinicians and nurses who were taking part in the audit sessions and assessed clinical care remained almost unchanged throughout the two-year study period. Those responsible for supporting departments such as the pharmacy and the transport system joined from time to time. Intention was to evaluate all cases which senior clinicians or audit organizers considered to be of educational value. Occasionally, audits were also held at smaller peripheral health centers.The benchmark against which substandard care was measured were national and district health office protocols, as well as WHO-protocols on all relevant conditions During the two-year study period, 386 women with serious pregnancy-related complications presented to the district hospital: 46 women died and 340 sustained SAMM, giving a case fatality rate of 11.9% (46 out of 386 cases) and a morbidity/mortality-ratio of 7.4.In the 340 women who sustained SAMM (101 (30%) of whom were HIV-positive), 375 SAMM diagnoses were made: 31 (8.3%) of these women had two inclusion diagnoses, and two women had three. These 375 SAMM diagnoses were comprised of: 119 (32%) severe infections or HIV-related complications, 119 (32%) cases of major obstetric hemorrhage, 75 (20%) cases of eclampsia or severe pre-eclampsia, 43 (11%) uterine ruptures, and 19 (5%) other severe maternal complications according to the clinician , Box S1.Of the 119 women with infection-related morbidity (55 (46%) of whom were HIV-positive), 81 had an obstetric infection (36 (44%) HIV-positive), 37 a non-obstetric infection (18 (49%) HIV-positive) and one was diagnosed with HIV-related Kaposi 's sarcoma. Of the 119 cases of major obstetric hemorrhage, eight (7%) were caused by ectopic pregnancies and seven (6%) by complications of abortion.Of the 46 women who died, 23 (50%) died of infection or severe complication of HIV-infection, ten (22%) of major obstetric hemorrhage, five (11%) of uterine rupture and three (7%) of eclampsia. Two died of other causes (sudden cardiac arrest during caesarean section and hepatocellular carcinoma) and in three cases the cause of death remained unclear . Of all Case fatality rates were 16% (23/142) for severe infection (9% for obstetric infection and 26% for non-obstetric infection), 10% for uterine rupture, 8% for major obstetric hemorrhage, 4% for (severe pre-) eclampsia. In HIV-positive women who sustained infection, the case fatality rates were 10% for obstetric infection (4/40) and 33% for non-obstetric infection (9/27).In total, 45 cases were audited in plenary with hospital staff: 24 cases of maternal mortality and 21 cases of SAMM. Practically all hospital clinicians  and nurses had themselves been involved in the management of at least one of the audited cases. In 30 cases (67%) more than half of the auditors assessed care to have been below acceptable standards. A selection of substandard care factors identified at health facility level is shown in The following actions were taken based on these recommendations: (1) formal classroom refresher training on labor graph use, emergency obstetric care and labor monitoring was given twice during the study period with assistance from Médecins Sans Frontières Belgium, Malawi mission, Thyolo project (MSF); a selected group of health workers attended a drill course in advanced life-support in obstetrics (ALSO); ward supervision by senior clinicians was scaled up; (2) updated and appropriate district protocols were posted in each health facility (where unavailable or outdated WHO-protocols were used), presence of these protocols was checked during quarterly supervision rounds with additional logistics and human resources provided by MSF; (3) regular on-job coaching was provided including bedside teachings by medical doctors, quality and attendance of morning handovers was enhanced, follow-up charts for hypertensive disorders were implemented  in the second year of study, from 6.1 per 1000 after audit in the first year and an initial pre-audit incidence of 19.2 per 1000 hospital deliveries To our knowledge this is one of the first studies quantifying improvements in maternal outcome during a prolonged period of systematic audit on a district-wide scale in sub-Saharan Africa A number of possible study limitations merit discussion. First, our study setting is a real-time district health care system rather than a controlled study environment. Therefore, our findings do not allow for the identification of a causal relationship between audit and maternal outcome. However, since audit and feedback were the most significant injection into the quality of obstetric care in the district, the progressive and significant decline in severe maternal complications is likely to be a result of their implementation. Other factors are unlikely to have had significant impact. The socioeconomic and demographic characteristics of the district population were unlikely to have changed much over these two years.Second, it is possible that the eagerness among staff to identify and include cases over time decreased. This is unlikely, however, due to the fact that the health worker responsible for study inclusions rotated on a two- to three-monthly basis. Moreover, these data collection staff were unaware of the objective to perform a trend analysis and were always supervised by the same team of dedicated senior clinicians.Nevertheless, it is important to note that our SAMM and mortality figures are minimum figures. Like in any other operational research study underreporting may have occurred The idea that audit and feedback were the main driver behind the decline in severe maternal complications is enhanced by the finding that the major reductions were found in the incidence figures for major obstetric hemorrhage and uterine rupture. These are the complications on which improved intrapartum care will have the most direct impact. Since audit and feedback focused primarily on improved intrapartum care and health worker performance during obstetric emergencies, it is not surprising that the declines in major hemorrhage and uterine rupture were significant and contrasted with the trends for eclampsia and peripartum infection.Prevention of eclampsia will require increased uptake of appropriate antenatal care. Both an increased uptake and an improved quality of antenatal care are notoriously difficult to achieve. Lack of health worker time, irregular antenatal attendance and faulty blood pressure equipment prohibited significant improvements in antenatal blood pressure monitoring in Thyolo.Since the HIV-prevalence among women with peripartum infections was high , it is likely that the incidence of these infections will reduce as uptake of HIV-treatment increases. In Thyolo, antiretroviral therapy (ART) was scaled up since 2003 with a positive impact on the survival of HIV-positive (pregnant) women as well as on the availability of health workers In conclusion, audit of SAMM can be a useful tool for district health workers and managers, with the capacity to tangibly improve maternal outcome. By addressing health professionals' behavior audit has the capacity to avoid phase-III delay. If health managers and those responsible for transport are part of audit, phase-II delay may also be reduced. And eventually, if improvements in obstetric care are noticed throughout the community, audit may even positively influence care-seeking behavior and lead to a decrease of phase-I delay Box S1Rest group inclusions.(DOCX)Click here for additional data file.