To identify the threshold of reduced sensory perception in Type 2 diabetes mellitus (Type 2 DM) using a range of research grade monofilaments.n = 80); Group 2 (EST) persons with Type 2 DM diagnosed for more than 2 years (n = 91), and Group 3, a Comparison group without Type 2 DM (n = 73), resulted in a total study population, n = 244. Research grade monofilaments  were employed using standardised protocol, at 6 sites on the plantar aspect of both feet. The demographic and anthropometric measures of gender, age, height, weight, body mass index (BMI), blood pressure and duration of Type 2 DM since diagnosis (if applicable) of the participants were analysed.Three groups of participants were recruited into a between subject, cross-sectional study. Group 1(NEW), persons with Type 2 DM diagnosed for less than 2 years (Perception of the research grade monofilaments differed significantly between the 3 groups (p < 0.05). The 6-gram monofilament was found to be the threshold of normal perception, based on 90% of the Comparison group perceiving the 6-gram monofilament at all sites in contrast to 64% of NEW and 48% of EST groups.The 6-gram monofilament was identified as the threshold of normal sensory perception. Inability to perceive the 6-gram monofilament indicates, when using the method described in this study, that diminution of sensory perception is evident. Employing a range of monofilaments, 6, 8 and 10-grams in Type 2 DM foot screening would allow the clinical detection of deteriorating sensory perception and enable implementation of foot protection strategies at an earlier stage than is currently practised. One of the common long-term complications of diabetes is neuropathy  of whicha condition in which patients with diabetes experience symptoms such as pain, burning, hyperaesthesia, or are found to have signs of nerve damage of which they are unaware, principally the anaesthetic and deformed foot.' ['d foot.' It should be noted, however, that a number of persons with diabetes are aware of the signs of developing nerve damage in their feet.Prevalence of DPSN varies widely in studies, depending on the criteria for diagnosis and the sensitivity of its detection . A commuIt has been recorded that 99% of diabetes care is self-care , and it The clinical design of this study was intended to produce results that could be easily interpreted by both clinician and layperson.Whilst acknowledging that assessment of both vibration perception threshold and 10-gram monofilament together provide the most specific and most sensitive method of assessing sensory status in the diabetic foot , for theThe inability to perceive the 10-gram monofilament at non-callused sites on the plantar aspect of the foot indicates that there is a loss of protective sensation which increases the risk of neuropathic foot ulceration ,9,10. OnTherefore for this study a range of research grade monofilaments  applied to specific sites, avoiding overlying callus, were employed in order to identify the threshold for normal perception, thus enabling both clinician and person with diabetes to appreciate diminished sensory perception prior to the 10-gram threshold which indicates loss of sensory perception ,9-11. EaThree groups of participants were recruited; newly-diagnosed (less than 2 years since diagnosis); established (more than 2 years since diagnosis) and a comparison group without Type 2 diabetes mellitus or family history of it. It is recognised that the newly-diagnosed group may well have been developing Type 2 DM for some time prior to official diagnosis as would have been the case for the established group. However the intention was to investigate two separate cohorts of persons with Type 2 DM in order to enable comparison of those with Type 2 DM of longer duration with those of shorter duration as will be seen in the results section.The sites tested by monofilament and number of applications at each site, vary widely in studies as may be seen in Table The six sites selected for testing for this study were the plantar aspect of hallux, first, second, third, fourth and fifth metatarsal heads, avoiding callus  with losInvestigating specific sites in the forefoot with a range of monofilaments in order to ascertain when perception deviates from the expected threshold would allow both preventative therapeutic action and education to be initiated at an earlier stage than is currently the norm. This study was designed to identify the threshold at which it is clinically feasible to detect reduced sensory perception in Type 2 DM. Therefore the experimental hypothesis was: there is a difference between three groups, new and established Type 2 diabetic participants and a comparison group, and their perception of a range of research grade monofilaments applied to six sites on the plantar aspect of the foot.Ethical approval was granted by Torbay Local Research Ethics Committee. Information sheets were provided and written consent obtained from each participant prior to the commencement of the study. Persons with any condition (other than diabetes) associated with peripheral neuropathy or impaired nerve responses, cancer therapy (current or in the past five years), myocardial infarction, angioplasty or bypass graft, rheumatoid arthritis, alcoholism, history of or current ulceration, gross pedal deformity, use of walking aid and pregnancy were excluded from the study.Three groups of participants were recruited for the study by convenience sampling and all were Caucasian except one South Asian. As indicated in Table The demographic and anthropometric measures of gender, age, height, weight, body mass index (BMI), blood pressure and duration of Type 2 DM since diagnosis (if applicable) of the participants were recorded.In order to test sensory perception, research grade monofilaments  2, 4, 6, 8, and 10-gram were employed in accordance with the predetermined protocol. This was informed by a pilot study , and incst, 2nd, 3rd, 4th and 5th MTPJs on each foot were tested, once with each monofilament, but the timing between each test was varied. One investigator conducted all the monofilament testing. Data from both feet of the participants were collected and is available but right foot only data were analysed in detail, as in other studies [In this study, inability to perceive a monofilament at any of the sites on the foot was recorded as loss of perception to that weight of monofilament. The test was clearly explained to the participant, and a monofilament was demonstrated on the inside of the investigator's forearm and then repeated at the same site on the participant. They were asked to say 'yes' every time they perceived the monofilament on their foot. Six sites were marked and tested on each foot; the participant closed their eyes and was therefore unable to see which site was being tested . The tes studies . Data we studies .At completion of data collection all monofilaments were retested by the manufacturer and they were found to deform to their relevant weight.The level of significance selected for the results was 0.05 for hypothesis testing.Data were collected from the 244 participants, see Table 1c than the groups with diabetes (ANOVA with Bonferroni multiple comparisons p < 0.001). Interestingly the BMI, and diastolic blood pressures are significantly greater in the NEW group compared with the EST diabetes group (p = 0.016 and p < 0.001 respectively), suggesting that optimum control of Type 2 DM in the NEW group had not yet been achieved. The Comparison group was significantly younger than the two diabetes groups, p < 0.001 , which was due to the recruitment process.There was a significant difference between the three groups for gender (p = 0.013). The Comparison group were specifically recruited for this study  whereas the other two groups were recruited by convenience sampling. As expected the Comparison group show lower blood pressure (systolic and diastolic), lower body weight, BMI and HbAThe results of the monofilament testing for the three groups at the six sites are presented in Figures Figure It can be seen that with the heavier 4-gram monofilament more participants in all 3 groups perceived it at all 6 sites; 51% of the NEW, 33% of the EST and 81% of the Comparison participants.The numbers of participants in each group able to perceive the 6-gram monofilament at all sites increased again: 64% NEW; 48% EST and 90% Comparison.When the 8-gram monofilament was applied, 75% NEW, 66% EST and 99% of the Comparison group perceived all six sites. And finally, 84% of NEW, 79% of EST and 100% of the Comparison group perceived the 10-gram monofilament at all sites.The summary of monofilament perception at all sites and the Jonckheere-Terpstra test (2 degrees of freedom) results are shown in Table In the context of the results presented above, the null hypothesis was rejected as there were significant differences between the groups (p < 0.05).In this study a series of research grade monofilaments; 2, 4, 6, 8 and 10-gram, were used at six sites on the plantar aspect of the foot to test sensory perception. The study showed that only 52% of the Comparison group could perceive the 2-gram monofilament at all sites, which suggests that its routine use for screening for diminished sensation is not appropriate. The results of the 4-gram monofilament suggest that a clinical sensory threshold was becoming apparent but only 81% of the Comparison group in our study could perceive the 4-gram at all sites and this percentage was considered too low to warrant recognition as the sensory threshold. However, two other studies, a Japanese study  and an AThe results suggest that using a range of monofilaments  provides the ability to detect diminished sensation at an earlier stage than use of the 10-gram monofilament alone. Persons with diabetes frequently do not regard DPSN as a problem unless it causes discomfort, and large discrepancies exist between foot care knowledge, perceived vulnerability and behaviour . It mighThe monofilaments used in this study are estimated, by the manufacturer Bailey Instruments, Manchester, using unpublished archive data on file (1998), to be able to endure approximately 24000 'bounces' before they lose their integrity . Currently, the cost of an individual monofilament manufactured by Bailey Instruments Manchester is £14 plus VAT, therefore setting the cost of a series of monofilaments  of £42 plus VAT against the mean weekly cost of £59 for a non-infected foot ulcer ,29 clearThe results of this study are based on the criteria of testing 6 sites and application of each monofilament once at each of those sites. Other workers have used different criteria; such as testing a different number of sites, from 1 site , 3 sitesMost (90%) healthy persons without Type 2 DM were able to perceive the 6-gram monofilament at the selected sites on the plantar aspect of the foot. It is therefore reasonable to use the 6-gram monofilament as a threshold measure for screening persons with Type 2 DM. Inability to perceive the 6-gram monofilament indicates, when using the method described in this study, that diminution of sensory perception is evident. The 8-gram monofilament should be employed if perception is not apparent at all sites and finally the 10-gram monofilament. This method would allow stepwise progression of education for the person with Type 2 DM at annual review.ANOVA: analysis of variance; DM: diabetes mellitus; DPSN: diabetic peripheral sensory neuropathy; EST: participants diagnosed with Type 2 diabetes for more than 2 years; MTPJ: metatarso-phalangeal joint; NEW: participants diagnosed with Type 2 diabetes for less than 2 years.The authors declare that they have no competing interests.MT conceived and designed the study, undertook all data collection and analysis and wrote the paper. JP supervised the study at all levels from the design stages, interpretation of data through to completion of the paper to which she has given permission for publication. PF has been involved in intellectual discussions with regard to the study throughout, revising the manuscript for important intellectual content and has given approval for the final version to be published. RP has actively participated and supported the conception and design of the study, supervising all the recruitment of the participants actively discussed the interpretation and implications of results and proof read the final paper and given approval for the final version to be published.


The possibility of screening the general population for prostate cancer using serum prostate-specific antigen (PSA) level  as screening test has recently been discussed. A number of studies are on the way, but the published reports have almost exclusively been based on men volunteering for screening. We assessed the feasibility of a screening study based on men identified from a central population registry. A random sample of 600 men in the age groups 55, 60 and 65 years was identified from the Finnish Population Registry as the study population. Half of them were randomised to the intervention group and an invitation to participate was sent to them. The participation rate was 77% (230 out of 300). Twenty-five men had a serum PSA concentration of 4.0 micrograms l-1 or above and were invited for further examination including digital rectal examination, transrectal ultrasound and transrectal Tru-cut biopsies (directed and/or random). Six cases of cancer were detected among the 230 participating men, which corresponds to a detection rate of 2.6% and a positive predictive value of 24%. The number of cases detected is equivalent to the expected number of prostate cancer cases during a 10 year follow-up in this population. The ratio of free to total PSA was also measured and a cut-off level of 0.20 was chosen. Its use as an additional criterion of the screening test would have decreased the prevalence of false-positive screening tests from 8% (19 of 230) to 3% (7 of 230) at a cost of missing one of the six cancers compared with serum total PSA concentration alone. Of the six cancers, five were clinically regarded as localised and locally confined disease was confirmed pathologically in four of them. In conclusion, a population-based study in Finland seems feasible and the properties of the PSA test can be regarded as suitable for a randomised screening study. Thus, all prerequisites for a multicentre study, which is planned, seem to exist.


In neonatology the role of chest physiotherapy is still uncertain because of the controversial outcomes.2, transcutaneous PtcCO2 e PtcO2 were monitored; in order to evaluate the onset of stress or pain following the stimulations, the NIPS score and the PIPP score were recorded; cerebral ultrasound scans were performed on postnatal days 1-3-5-7, and then weekly.The aim of this study was to test the applicability in preterm infants of 'reflex rolling', from the Vojta method, in preterm neonates with lung pathology, with particular attention to the effects on blood gases and oxygen saturation, on the spontaneous breathing, on the onset of stress or pain. The study included 34 preterm newborns with mean gestational age of 30.5 (1.6) weeks - mean (DS) - and birth weight of 1430 (423) g - mean (DS) -, who suffered from hyaline membrane disease, under treatment with nasal CPAP (continuous positive airways pressure), or from pneumonia, under treatment with oxygen-therapy. The neonates underwent phase 1 of 'reflex rolling' according to Vojta method three times daily. Respiratory rate, SatO2 and SatO2 values. No negative effects on PtcCO2 and respiratory rate were observed, NIPS and PIPP stress scores remained unmodified during the treatment; in no patient the intraventricular haemorrhage worsened in time and none of the infants developed periventricular leucomalacia.In this population the first phase of Vojta's 'reflex rolling' caused an increase of PtcOOur experience, using the Vojta method, allows to affirm that this method is safe for preterm neonates, but further investigations are necessary to confirm its positive effects and to evaluate long-term respiratory outcomes. Chest physiotherapy (CPT) has been used to clear secretions, to reduce post-extubation atelectasis, to reduce the use of reintubation, and also to help lung ventilation in newborns with respiratory problems -3. HowevThe forms of CPT more commonly used during the neonatal period are active chest physiotherapy (tapping or vibration delivered on the chest) and non-active techniques , but caution is required also when interpreting the possible positive effects of these chest physiotherapy treatments -8.With regard to the different CPT techniques and the controversial outcomes they yield, we decided to test the applicability in preterm infants of 'reflex rolling', from the Vojta method.The Vojta method is a physical therapy, initially developed in the 1960 s for the treatment of children with or at risk of cerebral palsy. It is a program that employs isometric strengthening techniques through tactile stimulation, to encourage the development of normal movement patterns and therefore to improve respiration. The aim of this study was to evaluate the 'safety' of Vojta reflex stimulations in preterm neonates with lung diseases, investigating particularly the effects on blood gases and on oxygen saturation, the effects on spontaneous breathing and the presence of stress/pain.The Ethical Committee of the Paediatrics Department approved the study protocol, and parents gave their informed consent.The study included preterm newborns with gestational age ranging from 28 to 34 weeks, admitted to the Neonatal Intensive Care Unit of "A.Gemelli" Hospital , from 1 January 2008, to 30 September 2008, who suffered from hyaline membrane disease, under treatment with NCPAP , or from pneumonia, who received oxygen-therapy.nd grade according to Papile's classification, were excluded from the study [Newborns with congenital malformations, asphyxia at time of birth, under treatment with neurotropic drugs, or with intraventricular haemorrhage > 2he study .All newborns breathed spontaneously, and were treated with:2O and maximum FiO2 = 0.40)1. Continuous positive pressure ventilation delivered by nasal cannula  was made.reflex rolling according to Vojta. This manoeuvre does not require the newborn to be moved, but only a slight rotation of the head towards the side from which the stimulus is delivered. The starting position for performing the first phase of reflex rolling is the asymmetric supine position, with the limbs freely lying on the resting surface.The neonates underwent phase 1 of th rib, or between the 5th and the 6th, or between the 6th and the 7th.A digitopressure was exerted on the chest area, where the mammillary line crosses the insertion of the diaphragm, either at the level of the 6Each treatment consisted in delivering four stimuli, two to the left half of the chest (stimulations I and II) and two to the right half of the chest (stimulations III and IV). Each stimulus consisted of a slight pressure, progressively oriented in dorsal, medial and cranial directions, diagonally to the spine. The treatment was repeated three times a day, at time intervals of 0, 2 and 4 hours.The tests performed were the following:2 were monitored by Hewlett-Packard HP monitor ;a. Respiratory rate (RR) and SatO2 e PtcO2 by TINA .b. Transcutaneous monitoring of PtcCOThe tests were performed before the reflex stimulation, at the end of stimulation II, at the end of stimulation IV and at 5, 15, 25 minutes after the whole series of stimulations, during each of the three daily treatments.c. Cerebral ultrasound scan on postnatal days 1-3-5-7, and weekly, using a color Doppler unit. (Hewlett-Packard Doppler 'IMAGE POINT')In order to evaluate the onset of stress or pain following the stimulations, two pain and stress evaluation scales were adopted: the NIPS score  and the PIPP (Premature Infant Pain Profile) Score ,11.The NIPS scores were recorded before the reflex stimulation, at the end of the second stimulation, at the end of the fourth stimulation and at 5, 15, 25 minutes after the stimulation, during all three sessions. The PIPP scores were recorded only once in each session during stimulation.http://www.graphpad.com). A score of p < 0.05 was considered significant.Continuous data are presented as mean ± standard deviation. To compare each parameter at each time point, Repeated Measures One-way ANOVA with Bonferroni's Multiple Comparison Test was performed using GraphPad Prism version 4.00 for Windows  weeks -mean (DS) - and the neonatal weight was 1430 (423) g - mean (DS) -.We studied the effects of the application of 'reflex rolling' during the first week of life and after the first week of life. Therefore, two groups of newborns were observed Table :GROUP 1: 21 newborns with hyaline membrane disease during the first week of life. All newborns were treated with NCPAP.GROUP 2: 13 newborns with a respiratory disease persisting after the first week of life, who were spontaneously breathing and on oxygen-therapy.In any case, the IVH (intraventricular haemorrhage) diagnosis was made during the infant's first day of life; in no patient the intraventricular haemorrhage worsened in time. None of the infants we observed developed periventricular leucomalacia.2 was found to be significantly different across the time points (p < 0.0001); post-hoc analysis according to Bonferroni showed a significant difference (p < 0.05) among the mean values of pO2: before the stimulation and at 5', 15' e 25'; at the end of stimulation II and at 5', 15' e 25'; at the end of stimulation IV and at 15' and 25'. In a similar way, SatO2 was found to be significantly different across the time points (p < 0.001); post-hoc analysis according to Bonferroni showed a significant difference (p < 0.05) among the mean values of SatO2: before the stimulation and at 5'; at the end of stimulation II and at 15' and 25'. No statistically significant difference was found for ptcCO2. No increase in RR was recorded; therefore, it is possible that the improved oxygenation induced by this method may be due to an increased tidal volume. ; post-hoc analysis according to Bonferroni showed a significant difference (p < 0.05) among the mean values of pO2: before the stimulation and at 25'; at the end of stimulation II and at 25'; at the end of stimulation IV and at 25'. SatO2 was found to be significantly different across the time points (p < 0.05); but Bonferroni's multiple comparison test did not show any significant difference among individual evaluations. No statistically significant difference was found for ptcCO2, nor for RR  -mean (SD) - with the first recording; 6.0 (2.0) with the second recording; 6.2 (1.5) with the third recording and in group 2 they were 6.3 (1.6) with the first recording; 6.2 (1.7) with the second recording and 6.4 (1.8) with the third recording.In neonatology, respiratory physiotherapy is still controversial .In treating neonates, the most renowned methods are mechanical techniques such as percussion and vibrations, which represent the so-called active respiratory physiotherapy (ARP), postural drainage, tracheal aspiration, elicitation of the cough reflex, respiratory modifications induced by means of posture.The specialized literature concerning neonates mainly sets its focus on active respiratory physiotherapy and on the specific aspect of preventing post-extubation atelectasis.With regard to the prevention of post-extubation atelectasis, the strong doubts concerning the actual utility of active respiratory physiotherapy seem to be confirmed; in fact, there is no evidence of a clear benefit in terms of a decreased rate of post-extubation lobar collapse -7,12,13.It is not surprising; however, that active respiratory physiotherapy might prove to be an invasive technique for preterm newborns. In fact, it has been stressed that ventilated patients may show irritability, an increased consumption of oxygen, an increased heart rate and arterial blood pressure, a higher rate of gastro-oesophageal reflux and, what represents a high risk for preterm newborns, an increased intracranial pressure ,20.In any case, active respiratory physiotherapy and particularly vibrations and percussion are unsuitable for VLBW neonates, due to their physical features; in fact, in these patients the anatomical and physiological features of the ribcage subdue and cancel the effect of the aforesaid techniques, which nevertheless maintain their effectiveness in childhood and in adult age.Therefore, non-active respiratory physiotherapy  seems to be the only respiratory physiotherapic technique available for VLBW neonates.In 1967 Vàclav Vojta developed and made public the reflex rolling model, defining the chest as a crucial area. By stimulating the chest of a child suffering from athetosis and relapsing episodes of pneumonia and atelectasia unaffected by other active respiratory physiotherapic treatments, Vojta noticed a global reaction, consisting of a rotation of the head with flexion of the lower limbs and rotation of the pelvis, opening of the hands and, what is most important, an increase in depth of costal respiration, with an expansion of the ribcage .The importance of these stimulations, especially if repeated, lies in the fact that the afferences due to induced physiologic muscle activity are imprinted in the central nervous system (CNS) and memorized. The CNS is set in an activated state, and the duration of such activation persists for at least half an hour after the stimulation has ended.2 and SatO2 values, showing a positive action on oxygenation.Our study aimed at evaluating the use of 'reflex rolling' in preterm neonates suffering from respiratory diseases. In the neonates we studied, the first phase of Vojta's 'reflex rolling' caused an increase of PtcO2 were observed, as these values remained constant over the treatment period, and within the normal range. A further confirmation of this technique's safety came from the negative results of the NIPS e PIPP stress scores, which remained substantially unmodified over the treatment.No negative effects on PtcCOThe positive results obtained should be followed by a further investigation concerning the efficacy of the 'reflex rolling' technique in preterm newborns, by means of a randomized controlled study. The positive effects may be confirmed by the evaluation of respiratory functionality tests and by long-term respiratory outcomes.Although the role of CPT in neonates with respiratory diseases remains debated and needs further evaluation, our experience concerning the use of Vojta's method provides a different perspective and takes again into consideration respiratory physiotherapy as a resource for the treatment of neonatal lung diseases. Studies performed on larger series of patients may be able to definitively confirm the effectiveness of Vojta's method as a suitable treatment for neonates, particularly in order to provide a support for all other therapeutic measures based on the use of drugs and ventilation.The authors declare that they have no competing interests.CG: drafted the manuscript, PP: designed and coordinated the study, RC: performed Vojta method on every subject, MGT: acquisition and collection of data, VP: acquisition and collection of data, FC: participated in the design of the study and performed the statistical analysis, CMS: analysis and interpretation of the data, CR: drafted the manuscript and revised it. All authors read and approved the final manuscript.


Candida antarctica lipase B in water and five different organic solvent models was investigated using multiple molecular dynamics simulations to describe the effect of solvents on structure and dynamics. Interactions of the solvents with the protein and the distribution of water molecules at the protein surface were examined.The structure and flexibility of The simulated structure was independent of the solvent, and had a low deviation from the crystal structure. However, the hydrophilic surface of CALB in non-polar solvents decreased by 10% in comparison to water, while the hydrophobic surface is slightly increased by 1%. There is a large influence on the flexibility depending on the dielectric constant of the solvent, with a high flexibility in water and a low flexibility in organic solvents. With decreasing dielectric constant, the number of surface bound water molecules significantly increased and a spanning water network with an increasing size was formed.Candida antarctica lipase B in organic solvents is caused by a spanning water network resulting from less mobile and slowly exchanging water molecules at the protein-surface. The reduced flexibility of Candida antarctica lipase B in organic solvent is not only caused by the interactions between solvent-protein, but mainly by the formation of a spanning water network.The reduced flexibility of  Candida antarctica lipase B (CALB) is an efficient catalyst for hydrolysis in water and esterification in organic solvents [solvents . It is usolvents . CALB besolvents . The binsolvents .It has been shown that many enzymes retain activity in organic solvents  and haveComputer simulations of enzymes in different solvents are a valuable tool to investigate the effect on the structure and dynamics of proteins -23. In mThe aim of this work was to get insight in the structure and flexibility of CALB in water and five different organic solvents using multiple molecular dynamics simulations. CALB was selected in this study, because of its industrial relevance and its stability in different organic solvents. Using explicit solvent models and a low amount of protein-bound water molecules allows to analyze the position of single water molecules, their exchange during the simulation, and the effect of molecular properties of the organic solvents.2 compared to the crystal structure, while in non-polar solvents the total surface is similar to the crystal structure. After simulations in non-polar organic solvents the hydrophilic surface is decreased by about 600 Å2 as compared to simulations in WAT.In the simulations of CALB in water (WAT) Figure  and in tTo evaluate the flexibility of CALB in different solvents, B-factors per residue were calculated from the simulations. In all solvents CALB showed lower flexibility in the core and the active site, and higher flexibility of residues located on the surface. In the WAT, the overall flexibility, as estimated from the sum of all B-factors, is significantly higher than in the organic solvents Table . The oveThe flexibility in different solvents was correlated to logP and the dielectric constant of the solvents. The simulations showed a decrease of CALB flexibility by increasing logP and a decreasing dielectric constant Figure . The sim2 as cutoff. While in WAT there were only 13 ± 2 bound water molecules (averaged over three simulations) with a low B-factor less than 40 Å2 identified, this number increased with increasing logP of the solvent to 26 ± 2 in MET, 31 ± 7 in ISO, 50 ± 17 in CL3, 63 ± 9 in TOL, and 103 ± 6 in CHE out of a total of 286 water molecules included in the organic solvent simulations. However, while the number of less mobile water molecules at the protein surface was similar in the three simulations of the same system, the binding sites of these water-molecules were different. In CHE simulations the 103 less mobile surface water molecules formed a spanning water network covering the whole surface of CALB  and between all conformers (2D-RMSD) and B-factors were analyzed using the PTRAJ of AMBER 7.0 [Multiple molecular dynamics simulations of the protein-solvent systems were performed using the Amber 7 program package  and the MBER 7.0 . The solMBER 7.0  using a MBER 7.0  was mappMBER 7.0 . HydrophMBER 7.0 , respectPT performed the simulations, JP was the principal investigator, conceived the project and guided its development. All authors read and approved the final manuscript.Hydrophobicity of CALB. Surface of CALB colored by hydrophobicity Click here for fileCluster I – Structure. Structure of cluster I in the simulation of CALB in cyclohexane, water molecules are displayed as red and white spheresClick here for fileCluster I – Ligands. Coordination of water molecules in cluster I in the simulation of CALB in cyclohexaneClick here for fileCluster II – Structure. Structure of cluster II in the simulation of CALB in cyclohexane, water molecules are displayed as red and white spheresClick here for fileCluster II – Ligands. Coordination of water molecules in cluster II in the simulation of CALB in cyclohexaneClick here for fileab initio geometry optimizationParameters of solvent models. The parameters of the solvent models cyclohexane, isopentane and toluene parametrized by Click here for fileData of solvent Boxes. Equilibration of solvent boxes by molecular dynamics simulationsClick here for file


Swedish population-based incidence and mortality rates for cancer of the uterine cervix, both in situ and invasive, during the period 1958 to 1981 were determined by means of a dynamic model. This new approach describes without any preconceptions the development of the disease as a sequential process over the stages cancer in situ, invasive cancer before and after diagnosis, and death. The strong disturbance of the steady-state situation that occurred after the introduction of cytological mass screening in the early 1960s permitted the use of a computerized identification technique. The whole natural history of cervical cancer could thus be identified and described consistently, with the mutual compatibility between statistical data, structure, parameters, and the states and flows between the states. The estimated age-specific incidence of cancer in situ increased rapidly to a maximum of 650 per 10(5) woman-years at the age of 30 years, after which it declined, and that of invasive cancer to a maximum of 55 per 10(5) at the age of 43. The natural history of cervical neoplasia did not differ appreciably between eight successive 5-year birth cohorts. The proportion of cases of new cancer in situ that progressed to invasive cancer was 12.2%, with a mean duration of the in situ stage in these cases of 13.3 years. The preclinical phase of the invasive stage (without screening) lasted on average about 4 years.


Saccharomyces cerevisiae to a high ethanol concentration, repetitive cultivation was performed with a stepwise increase in the ethanol concentration in the culture medium.Microorganisms can adapt to perturbations of the surrounding environment to grow. To analyze the adaptation process of the yeast S. cerevisiae was cultivated in medium containing a low ethanol concentration, followed by repetitive cultivations. Then, the strain repeatedly cultivated in the low ethanol concentration was transferred to medium containing a high ethanol concentration and cultivated repeatedly in the same high-ethanol-concentration medium. When subjected to a stepwise increase in ethanol concentration with the repetitive cultivations, the yeast cells adapted to the high ethanol concentration; the specific growth rate of the adapted yeast strain did not decrease during repetitive cultivation in the medium containing the same ethanol concentration, while that of the non-adapted strain decreased during repetitive cultivation. A comparison of the fatty acid composition of the cell membrane showed that the contents in oleic acid (C18:1) in ethanol-adapted and non-adapted strains were similar, but the content of palmitic acid (C16:0) in the ethanol-adapted strains was lower than that in the non-adapted strain in media containing ethanol. Moreover, microscopic observation showed that the mother cells of the adapted yeast were significantly larger than those of the non-adapted strain.First, a laboratory strain of Our results suggest that activity of cell growth defined by specific growth rate of the yeast cells adapted to stepwise increase in ethanol concentration did not decrease during repetitive cultivation in high-ethanol-concentration medium. Moreover, fatty acid content of cell membrane and the size of ethanol-adapted yeast cells were changed during adaptation process. Those might be the typical phenotypes of yeast cells adapted to high ethanol concentration. In addition, the difference in sizes of the mother cell between the non-adapted and ethanol strains suggests that the cell size, cell cycle and adaptation to ethanol are thought to be closely correlated. Saccharomyces cerevisiae has been used for the production of useful chemical compounds as well as alcoholic beverages. In the industrial production of useful target products using yeast cells, cells have faced a variety of the environmental changes, such as an increase in osmotic pressure, the accumulation of ethanol and carbon dioxide and a decrease in the amount of nutrients Cells of microorganisms can adapt to environmental perturbations, such as changes in osmotic pressure and temperature, and depletion of nutrients. The yeast Some researchers have analyzed adaptation phenomena of yeast cells to high ethanol concentration. Lloyd et al. found that yeast previously grown in the presence of 5% ethanol could grow in the medium containing 10% ethanol, whereas yeast inoculated directly into medium containing 10% ethanol failed to grow S. cerevisiae to a high ethanol concentration. For this purpose, a laboratory strain of S. cerevisiae, FY834, was cultured in medium containing a low ethanol concentration, followed by repetitive cultivation. After that, the cells adapted to the low ethanol concentration were inoculated into medium containing a higher ethanol concentration, followed by repetitive cultivation with a stepwise increase in the ethanol concentration. By exposing to a stepwise increase in ethanol concentration in the culture medium, cell growth activity defined by specific growth rate (SGR) of the yeast cells did not decreased during repetitive cultivation in high-ethanol-concentration medium. This indicates that the yeast cells successfully adapted to high ethanol concentration. In addition, analyses of fatty acid composition of the cell membrane and cell morphology of the ethanol-adapted strains were also performed. The results of these analyses suggest that change in fatty acid composition and increased cell size might be the typical phenotypes of ethanol-adapted yeast cells.In this study, we performed a repetitive cultivation with a stepwise increase in ethanol concentration to observe the adaptation process of S. cerevisiae FY834 was directly inoculated into YPD medium containing 2.5, 5, 6.5, 8, 9, or 10% (v/v) ethanol, respectively, and then the cells were incubated at 30°C  in FY834 strain grown in the presence of 10% ethanol was higher than that of the FY834 grown in the medium without ethanol addition  that could not be measured in this study might be changed during adaptation process to high ethanol concentration.The content of oleic acid  that could not be measured in this study and the increase in the size of yeast, to adapt to ethanol stress. These might be the typical phenotypes of ethanol-adapted yeast.In this study, the stepwise adaptation process of From the observation results of the difference in sizes of the mother cell between the non-adapted and ethanol strains, the cell size, cell cycle and adaptation to ethanol are thought to be closely correlated. Enlargement of the mother cell size of the ethanol-adapted strains shown in this study suggests that the critical cell size of the ethanol-adapted strains might be changed to adapt to high ethanol concentration. Moreover, the relationship between the stress response and the cell cycle of yeast has been also suggested S. cerevisiaeS. cerevisiae.In addition, another factors related to the adaptation to high ethanol concentration should be taken into account, such as fatty acids in the cell membrane that could not be observed in this study, lipids content in the cell membrane and ergosterol that is one of the component of cell surface and responsible for ethanol stress tolerance in Saccharomyces cerevisiae FY834 (MATα his3Δ200 ura3-52 leu2Δ1 lys2Δ202 trp1Δ63) 6 cells/ml, because the inoculum size affects the length of the lag time of yeast cell growth as reported by Walker-Caorioglio et al. Repetitive cultivation with a stepwise increase in ethanol concentration was performed as follows. The cultivation of FY834 strain was carried out in YPD medium containing ethanol and then the culture was transferred to fresh medium containing the same ethanol concentration. After that, the culture was transferred to medium containing a higher ethanol concentration, followed by repetitive cultivations. The initial ethanol concentration was set at 2.5% (v/v) and it was changed to 5, 6.5, 8, 9 and 10% step by step. In cases of cultivations with 2.5 and 5% ethanol in the medium, the transfer of the broth at the end of the previous culture to medium containing the same ethanol concentration was performed twice. In cases of the cultivations containing 6.5, 8, 9 and 10% ethanol, the transfer of the culture was performed once. We performed four series of such repetitive cultivations from 2.5% of ethanol concentration to 10%, and the obtained culture series were called A1, A2, A3, and A4, respectively.660) and calculating SGR of all the strains examined using OD660 data at mid-exponential phase. The SGR is defined as increasing rate of cell concentration (OD660) divided by cell concentration, by calculating the slope of the logarithmic plot of OD660 value as described by Blanch and Clark The adaptation of the yeast was evaluated by measuring the optical density of the culture at 660 nm . The extraction of fatty acids and their methyl esterification were carried out as described by Hama et al 660 = about 1) was observed using phase contrast microscope . Microphotographs of yeast cells were taken by a digital camera . For each strain, long and short diameters of mother and daughter cells from 50 cells were measured. For evaluation of the difference in cell sizes between the ethanol-adapted and non-adapted strains, average and standard deviation of long and short diameters of mother and daughter cells, respectively, from 50 cells were calculated.Yeast cells exposed to the stepwise adaptation process were cultivated in YPD medium and the cells at the mid-log phase (OD


Beclin 1 mapped to human chromosome 17q21. It is widely expressed in normal mammary epithelial cells. Although down-regulated expression with mono-allelic deletions of beclin 1 gene was frequently observed in breast tumors, whether there was other regulatory mechanism of beclin 1 was to be investigated. We studied the expression of beclin 1 and explored the possible regulatory mechanisms on its expression in breast tumors.Beclin 1, an important autophagy-related protein in human cells, is involved in cell death and cell survival. beclin 1 was detected by real-time quantitative RT-PCR. Loss of heterozygosity (LOH) was determined by real-time quantitative PCR and microsatellite methods. The protein expression of beclin 1, p53, BRCA1 and BRCA2 was assessed by immunohistochemistry. CpG islands in 5' genomic region of beclin 1 gene were identified using MethylPrimer Program. Sodium bisulfite sequencing was used in examining the methylation status of each CpG island.20 pairs of tumors and adjacent normal tissues from patients with sporadic breast invasive ductal cancer (IDCs) were collected. The mRNA expression of beclin 1 mRNA expression was detected in 70% of the breast tumors, and the protein levels were co-related to the mRNA levels. Expression of beclin 1 mRNA was demonstrated to be much higher in the BRCA1 positive tumors than that in the BRCA1 negative ones. Loss of heterozygosity was detected in more than 45% of the breast tumors, and a dense cluster of CpG islands was found from the 5' end to the intron 2 of the beclin 1 gene. Methylation analysis showed that the promoter and the intron 2 of beclin 1 were aberrantly methylated in the tumors with decreased expression.Decreased beclin 1 in the breast tumors. The findings here shed some new light on the regulatory mechanisms of beclin 1 in breast cancer.These data indicated that LOH and aberrant DNA methylation might be the possible reasons of the decreased expression of  Beclin 1, the mammalian orthologue of the yeast Atg6/Vps30 gene, is the first identified tumor suppressor gene in human to mediate autophagy  with the transcription start site defined as +1, so it is divided into four regions to be cloned. The first region contained part of the beclin 1 promoter from -528 to -65. The second region was located between -83 and 164 from the proximal promoter to part of the first intron. The third region laid between 137 and 400 from a portion of the first intron to part of the second exon. The fourth region was situated between 733 and 977 from a portion of the second intron. We found that certain CpG dinucleotides at the promoter and the intron 2 of the beclin 1 gene are hypermethylated in breast tumors. As dense methylation of the 5' CpG islands was not detected in normal tissues, we speculated that this methylation patterns in tumor cells were aberrant and disease associated. As a whole, the regulation of beclin 1 expression was a little complicated. In some cases, T16 and T20, the decreased expression was due to aberrant DNA methylation; While in T1 and T12, the decrease was from LOH; And in the other cases, T3 and T8, both aberrant DNA methylation and LOH devoted to the decreased expression of beclin 1  with low expression of pression . Recentlpression . Exploribeclin 1 indicated that methylation might be a new mechanism for loss of expression of beclin 1, which has not been shown previously. Sequence analysis revealed that there were four putative consensus Sp1 binding sites at the promoter [beclin 1 affects the binding affinity of transcriptional factor needs to be further determined.Aberrant methylation of 5' CpG islands associated with down-regulated mRNA expression of promoter  and one promoter , and thapromoter -45. Whetbeclin 1 expression is present in breast cancer. Other than deletion in gene copy number, DNA hypermethylation in the promoter and/or intron 2 may be a new mechanism responsible for down-regulation of beclin 1 expression. Since beclin 1 has important functions in apoptosis and autophagy, its epigenetic modification might provide new targets for cancer therapy.In conclusion, our studies confirmed that down-regulation of The authors declare that they have no competing interests.LZD carried out molecular biological studies, participated data collection, analysis and the preparation of the manuscript. CB and JF collected tissue samples and participated in the clinical part of the study and immunohistochemistry. WYQ, XYJ and LXJ supervised the project and overviewed the analysis of the data and the manuscript. All authors have read and approved the present manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/10/98/prepub


Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6–78.1); 12.6 (95% CI: 9.6–15.7); 8.4 (95% CI: 6.5–10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project. Illicit drug overdose remains a leading cause of death and disability in many urban settings worldwide In Vancouver, Canada, the number of fatal overdoses reached unprecedented levels at the end of the 1990s, especially in the Downtown Eastside (DTES) neighbourhood, the site of an open drug market and explosive outbreaks of HIV and hepatitis (HCV) In addition to these public health objectives, the facility aims to reduce the risk of death for clients by providing prompt and appropriate medical attention in the event of an on-site overdose From the initiation of the SIF database on March 1, 2004 until February 6, 2008, there were 766,486 injections in the facility, resulting in 1004 overdose events  in the facility. None resulted in death. The physical manifestations, the substances consumed and the responses taken by staff to these overdose events are shown in From 2004 to 2006, the British Columbia Vital Statistics Agency reported 32, 37 and 38 annual drug-induced deaths in the Downtown Eastside. The median number of drug-induced deaths per annum from 1998 to 2006 was 38.3. The model inputs for the number of fatal overdoses for each year of the study period, as well as all other model inputs, are reported in Model results, including the DTES fatal overdose rate, the estimated ratio of fatal to non-fatal overdoses in the DTES, the estimated number of non-fatal overdoses in the DTES, and the estimated number of on-site deaths averted, expressed as both a count and a proportion of DTES overdose deaths, are presented in Using these inputs, the number of overdose deaths averted in the SIF over the study period was 50.9 (95% CI: 23.6–78.1); 12.6 (9.6–15.7); 8.4 (6.5–10.4) given different estimated rates of non-fatal overdose. The number of averted deaths is equal to between two and 12 per annum over the study period.Using data from North America's first SIF and published estimates of the rate of non-fatal overdose among active IDU, we derived an estimate of the number of fatal overdoses averted by a supervised injecting facility. Following a Monte Carlo simulation and a three-part sensitivity analysis, the estimates of the number of prevented deaths ranged from eight to 51 from March 1, 2004 to July 1, 2008.The estimate of the number of deaths prevented is equal to a substantial proportion of the total burden of overdose mortality in the area during the study period. Despite the pilot facility only hosting, by design, approximately five per cent of the daily injections in the DTES, the estimated number of averted deaths was equal to between 6.1 and 37.0 per cent of the total overdose burden in the area during the study period. It is impossible to declare with certainty if the SIF prevented these fatalities as it is not possible to know if overdoses occurring in the SIF would have occurred elsewhere. However, despite charges to the contrary Our results are similar to those in an evaluation of the medically supervised injection centre (MSIC) in Sydney, Australia Our results differ from those in an unpublished cost-effectiveness report prepared for Canada's federal health minister Obviously, the optimal strategy to evaluate the impact of the SIF on overdose rates would be to randomize participants to use (versus restricted use) of the SIF. This approach has been deemed unethical These findings have immediate policy implications. First, despite initially expressing interest in analyses of Insite's impact on local patterns of overdose Our analysis has several limitations, chiefly the reliance on estimates to inform several model parameters, specifically the number of IDU in the DTES and the incidence of non-fatal overdose in the community. For the former, we relied on two previous capture-recapture studies In conclusion, we observed that non-fatal overdose was a common occurrence at Vancouver's SIF and, using a modelling technique based on evidence-based parameter values, we estimated that the facility prevented between eight and 51deaths over the study period. This is equal to between 37.0 per cent and 6.1 per cent of overdose fatalities in the DTES over the same time or two to 12 averted deaths per annum over the study period. These findings are consistent with analogous evaluations and support the conclusion of the facility's positive impact on public health in Vancouver's Downtown Eastside SIFnfOD) was compiled from the facility's comprehensive on-site surveillance database. This system was the source of data for an earlier analysis of SIF overdose patterns and has already been described in detail In this analysis, we sought to estimate the number of overdose deaths averted by a supervised injection facility using methods described previously For this analysis, we accessed a dataset from the SIF with all pseudonymous identifiers stripped. In order to limit our analysis to on-site overdose events that might conceivably resulted in a death, we restricted our definition of a potentially-fatal overdose event as any that required the provision of naloxone, a 911 call and/or an ambulance.DTESfOD) was calculated using counts of drug-induced deaths in the Downtown Eastside published annually by the British Columbia Vital Statistics Agency DTESnfOD) was estimated from a review of cross-sectional and longitudinal surveys of active IDU in both domestic and international settings The ratio of fatal to non-fatal overdoses in the DTES was estimated using data from various official or peer-reviewed sources. The incidence of fatal overdose  for model outputs. For each year in the study period we performed 10,000 iterations; for the entire study period, we performed 50,000 iterations. We have previously used the Monte Carlo method to model the impact of antiretroviral medication on mortality from HIV infection in the DTES In a subanalyses, we calculated estimates of the number of non-fatal overdoses in the DTES for each year in the study period as well as the entire study period. These estimates are the product of the number of fatal overdoses defined in the model multiplied by the non-fatal to fatal overdose ratio. As above, we performed Monte Carlo simulations using three different non-fatal overdose rates to calculate three point estimates with 95% CI.The evaluation of Vancouver's SIF has been reviewed and approved by the University of British Columbia/Providence Healthcare Research Ethics Board.


The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeirão Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital.The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of São Paulo School of Medicine at Ribeirão Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 . Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined.From 1996 to 2001, the mean age increased from 49 ± 0.9 to 52 ± 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 ± 0.5 to 14.8 ± 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department.The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals. The Unified Health System of Brazil, instituted in 1988, is organized into a network of increasing complexity, with integrated, regionalized hierarchies that ensure that the principles of equity in access to health resources, universality and integration of care are guaranteed for all citizens . HoweverWith the clear expansion of primary care and pre-hospital emergency care, which has occurred with international financial help, the general clinical attendance and emergency care management continue to be centralized in hospitals designed to guarantee first aid to patients presenting acute diseases of all levels of severity, creating excessive demands on hospitals of greater complexity located in large urban centers such as the city of Ribeirão Preto .Ribeirão Preto is a city of 504,923 inhabitants, 72% of them depend on public health care . The priThe Mobile Emergency Attendance System (SAMU), which was instituted in 1996, includes one advanced mobile emergency unit, staffed by doctors and nurses, and 12 basic mobile emergency units, staffed by professionals trained in basic life support. In an attempt to organize the health services in a hierarchical manner and to guarantee the management of patient flow within the emergency care system, the Medical Regulation Office (MRO) was instituted in 2000, in a process which considered the experiences of similar systems in place in North America and Europe -12. The From this perspective, the objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic affections at the EC.The study, conducted after being approved by our Ethics committee, involved 906 patients older than 13 years of age  who presented non-traumatic afflictions and were admitted to the EC in the areas of Internal Medicine, Surgery and Neurology during two different one-month periods: May 1996 (474 patients) and May 2001 (432 patients). The first study period (May 1996) was chosen because it preceded the creation of the SAMU and its MRO. At the time of the second study period (May 2001), the SAMU and MRO had been fully operational for at least one year.The populations studied during the two cited periods were analyzed in terms of general demographic data, origin, presence or absence of other medical affections besides the principal diagnosis (co-morbidities) and in-hospital complications .Data were collected from medical records of patients admitted during the study periods, following a survey performed in the hospital data processing center. The mortality risk for each patient was calculated during the first 24 hours of hospitalization using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was paired with the observed mortality for the two periods of study using the ROC curve analysis, with an area under the curve of 0.801 (95% CI 0.723 to 0.878) and 0.855 (95% CI 0.805 to 0.904), respectively  and Minitab, 13th version  were used. For ROC curve analysis, the SPSS 13.0 for Windows  was used. For multiple logistic regression analysis, the SAS 9.0  was used. The level of statistical significance was set at P < 0.05.Regarding general demographic data Table , overallFrom 1996 to 2001, patient distribution among the three clinical areas studied demonstrated a proportionally higher demand for treatment within the area of internal medicine at the expense of neurology, whereas demand for surgery remained relatively stable. A significant increase in the overall mortality rate was also observed, this was actually due to the increase in mortality rate observed in patients admitted to the area of internal medicine. However, once adjusted by APACHE II mortality risk, using a multivariate logistic regression analysis, with the exception of the overall mortality, there was no differences between the two periods in the three clinical areas studied. In addition, there was an increase in the percentage of patients admitted with co-morbidities, especially within the areas of internal medicine and surgery, and an increase in the percentage of patients with one or more hospital complications during the hospital stay, again, within the areas of internal medicine and surgery . The University of São Paulo School of Medicine at Ribeirão Preto, despite a good deal of resistance on the part of its directors, has increasingly shifted its academic activities, and even its research activities, from the University Hospital to the network of primary and secondary care facilities . The manOn the basis of the data analyzed and the evaluation system adopted, we conclude that the medical regulation of the flow of patients and the control of the dispatch of mobile resources have contributed to the increased severity profile of patients presenting with non-traumatic emergencies to the Internal Medicine Department of the Emergency Care Unit. This process, despite the conflict observed between professionals, managers of the public health system and the academy, gained popular support and induced the internal reorganization of the hospital with an increase in the number of intensive care beds, and promoted the replacement of didactic and medical assistance activities in a non-hospital unit for emergency care, forcing the primary and secondary levels of care to assist in low complexity emergencies, referring only the more complex ones to the tertiary level of care.The author(s) declare that they have no competing interests.SLBL conceived the study and designed the trial, undertook the data collection, participated in the statistical analyses, drafted the manuscript and takes responsibility for the paper as a whole. JSS participated in conceiving the study, supervised the conduct of the trial and data collection and provided statistical advice on study design. SS helped in supervising the conduct of the trial and data collection and in providing statistical advice on study design. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Tactile object discrimination is an essential human skill that relies on functional connectivity between the neural substrates of motor, somatosensory and supramodal areas. From a theoretical point of view, such distributed networks elude categorical analysis because subtraction methods are univariate. Thus, the aim of this study was to identify the neural networks involved in somatosensory object discrimination using a voxel-based principal component analysis (PCA) of event-related functional magnetic resonance images.Seven healthy, right-handed subjects aged between 22 and 44 years were required to discriminate with their dominant hand the length differences between otherwise identical parallelepipeds in a two-alternative forced-choice paradigm. Of the 34 principal components retained for analysis according to the ‘bootstrapped’ Kaiser-Guttman criterion, t-tests applied to the subject-condition expression coefficients showed significant mean differences between the object presentation and inter-stimulus phases in PC 1, 3, 26 and 32. Specifically, PC 1 reflected object exploration or manipulation, PC 3 somatosensory and short-term memory processes. PC 26 evinced the perception that certain parallelepipeds could not be distinguished, while PC 32 emerged in those choices when they could be. Among the cerebral regions evident in the PCs are the left posterior parietal lobe and premotor cortex in PC 1, the left superior parietal lobule (SPL) and the right cuneus in PC 3, the medial frontal and orbitofrontal cortex bilaterally in PC 26, and the right intraparietal sulcus, anterior SPL and dorsolateral prefrontal cortex in PC 32.The analysis provides evidence for the concerted action of large-scale cortico-subcortical networks mediating tactile object discrimination. Parallel to activity in nodes processing object-related impulses we found activity in key cerebral regions responsible for subjective assessment and validation. Tactile exploration, an acquired skill learned early in childhood, constitutes the basis for tactile object recognition and somatosensory discrimination. During action-related somatosensory information processing, the fingers explore with directed motion, adapting exactly to the objects In the following we treat the somatosensory discrimination of solid parallelepipeds, i.e. blocks of pure aluminum identical in all characteristics: volume, weight, surface texture, etc., with the exception of surface area and length. The task was developed and the basic prerequisites for the stimulation paradigm described in detail by Roland and Mortensen The present study analyses functional magnetic resonance imaging (fMRI) data obtained during this stimulation paradigm using principal component analysis (PCA). In comparison to categorical analysis describing activation maxima, the network description is of considerable importance, since brain processes do not take place in single cortical areas but involve functional circuits The rationale of the present exploratory data analysis was to divide the task into phases characterized by their specific sensorimotor and cognitive aspects. Precondition is a subdivision of the task according to its event-related phases of manipulation, exploration, comparison and discrimination of objects, interval and recovery providing the opportunity to perform inferential statistics among the conditions. Only this formal statistical comparison of task conditions identifies PC images suggesting conclusions with respect to the biological relevance of a pattern of interregional covariance (or PC). We hypothesized that: (1) PCA specifically distinguishes differentiated networks subserving somatosensory object discrimination common to the subjects; (2) these networks will be revealed by decomposing the stimulation paradigm into its phases of manipulation, exploration and recovery and (3) these functional circuits accommodate highly differentiated processes including sensory signal processing, focusing of attention, memory encoding and assessment of acquired information.Seven right-handed males between 22 and 44 years of age participated in the study. Handedness was determined using the Edinburgh Handedness Inventory as modified by Salmaso and Longoni 3) and weight (32.5 g) and were made of nonmagnetic, hard aluminum; four different parallelepipeds differing in their oblongness, characterized by the dimensions of the major axes and the square bases, were presented. The difference between the lengths of the major axes of one pair, 3.97 mm, exceeded the discrimination threshold determined in previous studies with a probability of explicit recognition of 95% in normal volunteers; the difference between the lengths of the major axes of the second pair, 0.44 mm, was below the threshold, as indicated by pure guessing in normal volunteers. The square bases of the pairs were indistinguishable The simulation paradigm consisted of a sequential, two-alternative forced-choice requiring the discrimination of parallelepipeds with respect to their oblongness. Consisting of many repetitions, the paradigm demanded a sustained level of directed attention The forced-choice stimulation paradigm comprised four phases: (1) presentation of the first object for tactile exploration, P1; (2) interval between presentations, i.e. holding the extracted information about object 1 in working-memory, R1; (3) presentation of the second object for tactile exploration accompanied by on-line comparison of this object with the memory of the first object and followed by the decision, P2; (4) interval or recovery before the exploration of the next object pair, R2. Each object was placed in the right hand for five seconds (s); the intervals between presentation of the objects in a pair and after presentation of the second object lasted between 12 and 17 s . This prIn a control task, the subjects manipulated spheres of the same volume and weight as the parallelepipeds with their right hand without making a choice; the sequence of active sphere manipulation (Ss) and interval was the same as in the forced-choice paradigm.The subjects lay supine in the scanner with their heads immobilized and eyes closed. Directed via earphones connected to a computer outside the scanner room, an investigator presented and removed the objects promptly on an acoustic signal. The objects were always placed in the same manner on the palm, the long axis parallel to the thenar. The subjects explored the presented object continuously with the fingers of their right hand. While the subjects only manipulated the identical spheres, they were instructed to choose which member of a pair of parallelepipeds was more oblong. The subjects were requested to extend their right thumb as soon as the object was removed if the second object was estimated to be more oblong, or solely to open the hand for the next object if the first was longer or if they could not detect any difference. Each session consisted of the presentations of 34 pairs of parallelepipeds or 68 spheres; four sessions were acquired for each subject, two each of parallelepipeds and spheres. Subjects did not leave the scanner between sessions. The presentation of the parallelepipeds and spheres was done separately in order to ease the demanding task of the attendant, namely the quick and correct presentation of the objects. Furthermore, this procedure allowed reliable comparison of haptic information processing with the reference task of pure manipulation, i.e. sensory-guided motor activity without a cognitive load. The order of presentations (pairs with suprathreshold or subthreshold differences in the long axis) and the order of parallelepipeds within a pair (more or less oblong) were pseudorandomized within and across sessions, implying that the first and second members of pairs were longer an equal number of times. The order of exploration of parallelepipeds and manipulation of spheres was also pseudo-randomized. Subjects were free to choose an exploration strategy but were asked to keep moving their fingers during the entire 5 s of the exploration phase. To permit off-line analysis of the explorations, the sessions were recorded by a video recorder located outside the scanner room viewing the subject close-up through a window.Half an hour prior to scanning, the course of the experiment was explained to the subjects in detail, but they did not practice the task before the acquisitions.2, a slice width of 4 mm and distance between slices of 0.4 mm. Each session consisted of 255 volumes. The first three volumes of each session were disregarded in the analysis. In addition to the functional images, a high-resolution, anatomical T1-weighed image was acquired for each subject, consisting of 128 sagittal slices with a minimal in-plane resolution of 0.9 mm .The acquisitions were performed with a Siemens Vision 1.5 T scanner  using an EPI-GE sequence with a repetition rate (TR) of 5 s, an echo time (TE) of 66 ms and a flip angle of 90°. Covering the whole brain, the image volumes consisted of 30 transaxial slices oriented parallel to the bi-commissural plane with a minimal resolution in plane of 3.125×3.125 mmhttp://www.fil.ion.ucl.ac.uk/spm).Image preprocessing and categorical comparisons used modules of the Statistical Parametric Mapping software  were modeled separately for each subject in a first level analysis, as were the pauses between and following the presentations (R1 and R2), respectively. The four phases of the paradigm were further distinguished in the modeling according to the length differences of the parallelepipeds, i.e. above the threshold (Pa), below the threshold (Pb) or identical (Pid). The presentation of the spheres was also modeled (Ss), but not the pauses in-between. Thus, the procedure yielded 13 regressors, i.e. image volumes related to specific phases of the task, for each of the seven subjects, i.e. P1a, P1b, P1id, R1a, R1b, R1id, P2a, P2b, P2id, R2a, R2b, R2id and Ss. The data sets of each subject for statistical evaluation consisted of 28 repetitions each of P1a, P1b, R1a, R1b, P2a, P2b, R2a, R2b, 12 each of P1id, R1id, P2id, and R2id, and 136 each of Ss. The cerebral coordinates are reported in Talairach space http://www.mrcbu.cam.ac.uk/Imaging/mnispace.html) effected the transformation from MNI space Preprocessing included slice-time correction, realignment, spatial standardization to the standard brain provided by the Montreal Neurology Institute (MNI), and spatial smoothing using a Gaussian filter with an isotropic full width at half maximum (FWHM) of 10×10×10 mmPCA was executed using in-house software of which some modules were adapted from SPM. Extracerebral voxels were excluded from the subject-condition image volumes, using a mask derived from the gray matter component yielded by segmentation of the anatomical image volume into gray matter, white matter and cerebrospinal fluid. Calculation of the residual matrix was the first step. From a matrix whose rows corresponded to the 91 conditions (seven subjects * 13 regressors) and columns to the fifty-five thousand voxels in a single image volume, corresponding to the mask, were subtracted from each element the mean of voxel values of its column and the mean of voxel values of its row and added the grand mean of all voxel values in the original matrix. The result is the residual matrix for which the row, column and grand means vanish. Using the singular value decomposition implemented in Matlab, the residual matrix was then decomposed into 91 components, consisting of an image, an expression coefficient, and an eigenvalue for each component. The procedure differs from that of Alexander and Moeller only in that the data were not transformed logarithmically before computation of the residual matrix To estimate the number of PCs to be retained for analysis, we employed a ‘bootstrapped’ Kaiser-Guttman approach which determines the critical component whose eigenvalue lies closest to the average of all component eigenvalues and retains only those PCs lying within the 95 % confidence limits of the critical component Nine t-tests constituted a minimal set of independent comparisons distinguishing mean contrast patterns among the 13 regressors of the paradigm. This included: i) four comparisons of the phases P1 and P2 with the following recovery for both distinguishable and indistinguishable objects: P1a with R2a, P1b with R2b, P2a with R2a and P2b with R2b –4, ii) cFor the interpretation of the images of PCs selected by the t-tests to reflect significant mean contrasts, only those voxels of relevant components for which the voxel values lie in the first (negative load) or ninety-ninth percentile of voxel values (positive load) were analyzed.To establish a relationship of the PCA to conventional analyses, comparable categorical comparisons of the 13 conditions were formulated as t-tests and evaluated in a mixed-effects model using SPM. The image volumes analyzed were the same as in the principal component analysis. The analyses served as a reference for the PCA, relating the voxels covarying the most to those showing maximum intensity differences. The contrasts of the categorical comparisons were therefore chosen to correspond to the sets of conditions that selected relevant principal components. The comparisons corresponding to the principal components 1 and 3 consisted of unpaired, two-tailed t-tests with the 68 and 33 degrees of freedom, respectively, given by the number of conditions. A threshold p<0.001 corrected for multiple comparisons and a minimum cluster size of 16 voxels provided the significance criteria. The comparisons corresponding to principal components 26 and 32 consisted of paired, two-tailed t-tests with 6 degrees of freedom. To account for the few degrees of freedom the threshold, p<0.01 uncorrected for multiple comparisons and a minimum cluster size of 8 voxels provided the significance criteria. The extent threshold corresponds to the mean cluster size expected of a random t-distribution with the same number of degrees of freedom.We classified finger movements during manipulation and exploration according to Roland and Mortensen into encompassing (very few), rolls (spheres only) and dynamic digital In PC 1 discriminates between the manipulation of spheres Ss or exploration of the second objects (P2) and the following recovery (R2). The difference between exploration of the first objects (P1) and R2 exhibits a trend. In fact, the difference between exploration or manipulation of objects , and R2 was significant at p<0.0001. Both active exploration of the parallelepipeds and manipulation of the spheres yielded significantly higher component expression coefficients than the recovery phases. The regions with positive loads in the left hemisphere included the sensorimotor cortex, SPL, premotor cortex, supplementary motor area (SMA), and anterior cingulate. Adjacent to the SPL, the dorsal part of intraparietal sulcus appeared bilaterally. Regions with negative loads included in the right hemisphere the caudate nucleus and the hippocampus, in the left hemisphere the superior frontal cortex and dorsolateral prefrontal cortex, and bilaterally the fusiform gyrus, and the vermis.PC 3 discriminated between P2 and R2, i.e. exploration, comparison and decision of the second object regardless of its length relative to the first object. The expression coefficients are distinctly higher for P2 than R2. This component differs most strikingly from PC 1 in that it does not distinguish manipulation of spheres from the following intervals. The regions with positive loads include in the left hemisphere the SPL, supramarginal gyrus, lingual gyrus, bilaterally the SMA and the superior temporal gyrus, the right cuneus, the right centro-medial thalamus, and bilaterally the dentate nucleus and the right posterior hemisphere of the cerebellum. Regions with negative loads include in the right hemisphere medial frontal gyrus and motor cortex, bilaterally the premotor cortex, the tectum and reticular formation of the midbrain.PC 26 distinguishes most prominently between the explorations of parallelepipeds for which the length differences are below the detection threshold, P1b and P2b. Furthermore, it discriminates with marginal significance (p<0.009 uncorrected) P1b from R2b. The component expression coefficients are distinctly higher for P1b than for P2b. The regions with positive loads include in the right hemisphere the premotor cortex, SMA and pre-SMA, anterior cingulate, and dorso-medial thalamus, the right posterior lobe of the cerebellum, and bilaterally the medial frontal and prefrontal cortex, the retro-insular cortex, and the left hippocampal gyrus. Regions with negative loads include bilaterally the premotor cortex, the left precuneus and cuneus, the left postero-lateral thalamus and bilaterally the dentate nucleus see also .PC 32 involves the presentation of the second parallelepiped in the case that the difference in lengths of the pair exceeded the discrimination threshold (P2a). The most significant discrimination is that between P2a and R2a; marginally significant (p<0.009 uncorrected) were discriminations between P2a and P2b or Ss. The component expression coefficients are distinctly greater for P2a than for R2a, P2b or Ss, respectively. The regions with positive loads include in the right hemisphere the dorsal part of the intraparietal sulcus, the dorsolateral prefrontal cortex, bilaterally the pre-SMA and SMA, the medial prefrontal cortex, the premotor cortex, the intermediate and posterior cingulate, in the left hemisphere the cuneus, the fusiform gyrus, and vermis. Regions with negative loads include in the left hemisphere the postcentral gyrus, the dorsolateral prefrontal cortex and the temporal operculum, in the right hemisphere the hippocampus, bilaterally the superior frontal gyrus and the temporal pole, and the right pons and the vermis see also .Categorical comparisons corresponding to the differences between the phases and conditions of the paradigm identified as relevant by the PCA were calculated. Shown in Corresponding to PC 1 was the categorical comparison of P1, P2 and Ss with R2, independent of whether the object pairs could be discriminated; i.e. we pooled contrast corresponding to t-test 1–4 and 9 of the Corresponding to PC 3 was the categorical comparison of P2 with R2, regardless of whether the object pairs could be discriminated. The pattern of significant blood flow increases and decreases was similar to that of the categorical comparison of P1, P2 and Ss with R2. Differences in the pattern of blood flow increases occur in the sensorimotor cortex, which involves in this second comparison more of the right hemisphere, including the parietal operculum. The pattern of flow decreases is less extended in this comparison, especially in the lateral occipital gyrus, in the left temporal lobe, and in the left posterior cerebellum. The coefficient of voxel-value correlation, 0.32, indicated moderate correlation between this categorical comparison and PC 3.Corresponding to PC 26 was the categorical comparison discriminating the presentations of pairs which could not be distinguished, P1b and P2b. This comparison showed a circumscribed signal increase during P2b, which was localized in the primary motor and primary somatosensory cortex on the left side. The pattern of significant blood flow changes differed from the categorical comparison of P1, P2 and Ss with R2 in that it did not involve premotor, cingulate or parietal areas. The coefficient of voxel-value correlation between this categorical comparison and PC 26 was negligible.Corresponding to PC 32 was the categorical comparison P2a with P2b. The direct comparison of distinguishable and indistinguishable objects during this phase is of primary interest, as it reflected the explicit somatosensory discrimination, the primary aim of this investigation. The patterns of significant blood flow increases and decreases are markedly different from those of the original categorical comparison of P1, P2 and Ss with R2. Significantly increased blood flow appeared in three compact regions comprising the dorsal part of intraparietal sulcus of the right hemisphere, the ventral premotor cortex of the left and the right vermis. Significant decreases included several areas in the middle and superior temporal gyri, the dorsolateral prefrontal cortex, putamen, and the ventral visual cortex of the left hemisphere, the parahippocampal gyrus, precuneus and posterior cingulate cortex of the right hemisphere, and the lateral occipital gyrus bilaterally. The coefficient of voxel-value correlation, 0.34, between the t-statistical map of the categorical comparison and the component image of PC 32 indicated moderate correlation.In this study we used PCA to identify the neural networks engaged in tactile discrimination of rectangular objects. We applied this method, since tactile object discrimination is a psychologically complex endeavor even if performed under well defined experimental conditions as in this experiment. Before we discuss our findings we would like to emphasize that PCA is a data driven method explaining the variance in the image data. We supplemented this analysis in a second step by inferential testing in which we asked which PC differentiated the experimental conditions across the subjects. This was similar to a categorical comparison of the BOLD signal changes related to the task conditions. In fact, for each contrast we identified a PC. Since the mean contrast in pattern expression was statistically significant for each component identified, it provided independent evidence of the component's functional relevance. Thus, while the categorical comparison of the hemodynamic changes reduced the data to the task specific BOLD signal changes, our PCA approach showed the distributed neural network including brain areas in which BOLD signal changes were not significant according to the categorical comparison. Moreover, image volume correlations between categorical comparison and PC images suggest that changing the threshold for “significant” regional activity would not dramatically alter the apparent dissimilarity between PCA and SPM contrast patterns. Consequently, the interpretation of the observed neural patterns was guided mainly by the task conditions. In addition, the anatomical structures involved in the PCA allowed to tentatively suggest a physiological implication - an approach similarly applied in categorical comparisons as well.We were able to distinguish four PCs corresponding to neural networks implicated in somatosensory discrimination. Showing significant differences among stimulation phases and shape characteristics of the object pairs, they ranked 1st, 3rd, 26th and 32nd among the PCs according to the percentage of variance explained.The formulation of the statistical tests indicates the following interpretations: PC 1 reflects sensory-guided motor activity, PC 3 relates to the perception of shape characteristics and short term memory function, PC 26 to the awareness that the length difference could not be discriminated, and PC 32 to the recognition that the length difference could be discriminated . These pThis PC distinguishes between phases of tactile exploration associated with haptic information processing  or pure manipulation (spheres) and the corresponding pauses. The component therefore represents the concerted, directed and adaptive motion of the fingers which constitutes the basis of both actions.In the principal component image, the sensory and motor cortices contralateral to the exploring hand appear prominently with large positive loads. Only the SPL appears distinctly bilateral in the network, although minimal involvement of the premotor cortex ipsilateral to the exploring hand is indicated. The SPL, the dorsolateral premotor cortex and parts of intraparietal sulcus are essential nodes of a frontoparietal network regulating the manipulation of objects The pattern includes regions of the dorsal medial cortex bilaterally and of the left dorsomedial prefrontal cortex which may mediate self-reflection, i.e. introspection and directed attention in contrast to external perception This PC distinguishes between presentation of the second parallelepipeds and the recovery phase regardless of whether the length difference exceeds or is below the discrimination threshold. The component appears to represent the perception of shape characteristics as well as the involvement of short-term memory required for comparison of the objects and discrimination.Consistent with this hypothesis is the appearance with large positive loads of the posterior parietal lobe contralateral to the exploring hand, including the SPL and the adjacent intraparietal sulcus and supramarginal gyrus. This is in accordance with recent observations This PC distinguishes between presentations of the first and second parallelepiped that could not be discriminated. The occurrence of this PC indicates the particular condition of being confronted with indistinguishable objects, which presumably places special demands on motivational control The PC image is characterized particularly by the marked involvement of the medial prefrontal cortex. Behavioral studies of patients with lesions of this region have indicated its importance for the subjective control of behavior The PC image further indicates participation of the dorsolateral and medial prefrontal cortices suggesting the simultaneous processing of external stimuli produced by the condition. Reciprocal activations of these two regions have been described in the literature according to the content and relationship of internal or external stimuli This PC attains significance in the t-test discriminating between the presentation of the second parallelepiped of a distinguishable pair and the following recovery. It therefore describes the explicit recognition of distinguishable cues which constitutes the basis of somatosensory discrimination, and the decision The basic ability tested by the paradigm, the recognition of the changing stimulus configuration, i.e. kinesthetic impulses in the transition from the first to the second parallelepiped, was recently classified as a specific function of the horizontal segment of the intraparietal sulcus Parallel to activity in nodes processing object-related impulses is activity in key cerebral regions responsible for subjective assessment and validation: multiple medial regions of the cerebral hemispheres including the pre-SMA, the anterior, mid and perigenual cingulate cortices and medial prefrontal cortex Principal component analysis produces without a priori assumptions component images covarying independently and implying the functional connectivity of the constituent regions The component images PC 1, 3 26 and 32 reveal distinctly different aspects of the paradigm, consistent with the finding that decisions of the kind required by the tactile exploration paradigm are a consequence of independent processes The statistical maps of the categorical comparisons, especially those based on rest, reveal only regions that serve the acquisition of sensorimotor information, but not those that are suggested to mediate its valuation, in particular areas like the medial prefrontal cortex, the cingulate and paracingulate cortex as represented in the medial sagittal slices of


Influenza H1N1 or A virus is a new virus serotype capable of human-to-human transmission. This infection causes a flu syndrome similar to that of seasonal influenza, with only one case of conjunctivitis described and no clinical details or microbiological confirmation. Its diagnosis is performed by PCR of pharyngeal smear of the patients affected. We report the first well-documented case in the medical literature of conjunctivitis by H1N1 virus. A 45-year-old woman, five days after diagnosis by pharyngeal smear of influenza H1N1, complained of an acute unilateral conjunctivitis condition of bleeding appearance. Her examination evidenced significant eyelid oedema, severe mixed conjunctival hyperaemia and moderate chemosis, and pseudomembrane formation. A large number of subtarsal follicles and petechiae were seen Figures , and 4.A smear of conjunctival secretion from both eyes and study by PCR of H1N1 virus were performed detecting the presence of H1N1 virus RNA only in the affected eye, being negative in the contralateral. After 15 days of symptomatic treatment with topical NSAIDs and washes associated with topical ganciclovir, the condition subsided.In April 2009, the US CDC identified the organism responsible for the new worldwide influenza pandemic, the influenza A virus H1N1), arising from the gene mutation of segments of two strains of an influenza virus present in swine [N1, arisiThe clinical symptoms caused by this new influenza virus are similar to those of seasonal human influenza, including high fever, cough, sore throat, generalised myalgia, headache, and asthenia, often associated with vomiting and diarrhoea. Only one case of conjunctivitis has been mentioned associated with this syndrome. Nevertheless, no information about its presentation, course, and outcome and no microbiological prove are available . The CDCAlthough multiple complications have been described in association with infection by this virus, to date no microbiologically proven cases of conjunctivitis by H1N1 virus have been published. Viral conjunctivitis in adults is generally caused by an adenovirus, with over 50 serotypes and a high susceptibility to cause epidemics. Its most characteristic clinical signs are those discussed in our case . The preIn the case of our patient, it was shown how the onset of the conjunctival infection, its clinical outcome, its duration of three weeks, and the characteristics of the eye examination would be virtually identical to those of adenoviral conjunctivitis, except for the absence of preauricular node. This should lead us to consider the differential diagnosis of conjunctivitis by the H1N1 virus in patients with consistent influenza conditions, all the more given the worldwide pandemic caused by this virus which now besets us. In our case, the clinical outcome of the infection has been favourable, with no serious complications, and improving since the start of treatment, probably due to both the antiviral effect of topical ganciclovir and the natural course of the disease. She did not need treatment for her systemic infection. However, more cases should be described to evaluate the severity of the conjunctival infection by this new virus and the possible associated consequences.


Age-related cataract is the major cause of blindness in humans throughout the world. The majority of previous studies of cataract in Down's syndrome  have reported that the prevalence of this ocular abnormality is higher for a given age range than in the general population. The objective of the present study was to study the prevalence of cataract in a well-defined population of adults with Down's syndrome.An in-patient population of 68 adults  with Down's syndrome, aged between 28.9 and 83.3 years, underwent ophthalmological examination for the presence of cataracts.Overall, the prevalence of cataract was 16.2%, with no significant difference in the prevalence between males (17.1%) and females (15.2%). In those aged between 45 and 64 years, the prevalence was 16.7%, rising in those aged between 65 and 75 years to 28.6%.SOD1 on chromosome 21. These elevated levels of superoxide dismutase may give rise to increased levels of reactive species, including hydrogen peroxide and hydroxyl radicals, which may increase the risk of cataractogenesis. It is suggested that nutritional supplementation with antioxidants may therefore help reduce the prevalence of cataract in Down's syndrome.Compared with the general population, the prevalence of cataract in Down's syndrome was raised in those aged 45 to 64, but not in those aged 65 to 75 years; the latter might be a function of the relatively small number of patients in this age group. The increased prevalence of cataract found in those in the 45- to 64-year-old age group may be the result of increased levels of the copper- and zinc-containing superoxide dismutase enzyme (CuZnSOD), in turn resulting from the location of the associated five exons of  Age-related cataract is the major cause of blindness in humans throughout the world. In England and the United States the prevalence of cataract in the general population aged 45 to 64 years is between 2 and 8%, rising to between 21 and 39% in the 65 to 75 year age group, and to 65% in those aged 85 years and over [The majority of previous studies of cataract in Down's syndrome have reported that the prevalence of this ocular abnormality is higher for a given age range than in the general population .p = 0.82). The mean age of those with a history of cataract was 55.3 (sd 9.0) years compared with 53.8 (sd 12.4) years for those without such a history; this difference was not significant (p = 0.70). The two groups (those with and those without cataract) were also matched for sex .The total number of adults with Down's syndrome was 68, consisting of 35 males and 33 females, ranging in age from 28.9 to 83.3 years  11.9 years). Eleven individuals were identified as having an ophthalmological diagnosis of cataract, representing a prevalence of 16.2% of the population studied, and there was no significant difference between males (6/35) and females (5/33) , while for those in the age range 65 to 75 years, the prevalence was 28.6% (2/7).Ocular abnormalities are relatively common in individuals with mental retardation, particularly those with Down's syndrome . In the Our finding that the prevalence of cataract in those aged between 65 and 75 years did not differ from the prevalence in the general population may be a function of the relatively small number of cases (seven) in our sample in this age group. It is important to consider the possible cause for the impression of an increased rate of cataract in the 45- to 64-year-old age group. The general consensus is that cataracts are usually the result of free radical damage. There is chronic exposure of the ocular surface to oxidative stress, for example from atmospheric oxygen and exposure to ultraviolet light (in sunlight). However, these factors affect Down's syndrome individuals and non-Down's syndrome individuals alike. The question then becomes: is there any evidence that Down's syndrome individuals have greater exposure to free radicals?in vitro [2•) [Dickinson and Singh have proposed that in Down's syndrome there is increased activity of superoxide dismutase, resulting in overproduction of hydrogen peroxide and hydroxyl free radicals which in turn compromise cellular functioning . Individin vitro ,8. Elevatro [2•) ,7. Down'tro [2•) , high letro [2•) .In light of the increased levels of superoxide dismutase (and therefore increased levels of hydrogen peroxide and other reactive species) associated with Down's syndrome, it seems possible that antioxidant therapy might be helpful in preventing cataractogenesis in this group of individuals. Indeed, Dickinson and Singh have previously suggested that vitamin E, and possibly vitamin C, may be used as a therapy in the treatment of the dementia associated with Down's syndrome, since they may modify the damage caused by excessive hydrogen peroxide production .SOD1 on chromosome 21. These elevated levels of superoxide dismutase may give rise to increased levels of reactive species, including hydrogen peroxide and hydroxyl radicals, which may increase the risk of cataractogenesis. Therefore, nutritional supplementation with vitamin E, and possibly vitamin C, may help reduce the prevalence of cataract in Down's syndrome.Compared with the general population, the prevalence of cataract in Down's syndrome was raised in those aged 45 to 64, but not in those aged 65 to 75 years. The increased prevalence of cataract may be the result of increased levels of CuZnSOD, in turn resulting from the location of the associated five exons of BP and IS conceived of the study, and participated in its design and coordination.BP carried out the statistical analyses.Both authors read and approved the final manuscript.