BRPF1, encoding a chromatin reader, have been associated with a previously unrecognized autosomal dominant syndrome manifesting with intellectual disability (ID), hypotonia, dysmorphic facial features, ptosis, and/or blepharophimosis in 22 individuals.Over 500 epigenetic regulators have been identified throughout the human genome. Of these, approximately 30 chromatin modifiers have been implicated thus far in human disease. Recently, variants in We report a multiply affected nonconsanguineous family of mixed Jewish descent who presented due to ID in three male siblings. Molecular analysis of the family was pursued using whole exome sequencing (WES) and subsequent Sanger sequencing.BRPF1 gene in the affected siblings and their mother. The four affected individuals showed varying degrees of intellectual disability, distinct facial features including downslanted palpebral fissures, ptosis, and/or blepharophimosis. Their clinical characteristics are discussed in the context of previously reported patients with the BRPF1‐related phenotype.Whole exome sequencing analysis brought to the identification of a novel heterozygous truncating mutation  in the BRPF1 in human brain development.The reported family contributes to the current knowledge regarding this unique and newly recognized genetic disorder, and further implicates the role of  By its interaction with several histone acetyltransferases , BRPF1 promotes histone acetylation  was performed using an Agilent v5 SureSelect capture kit and Illumina 2,500 sequencing technology. For each sample, paired end reads (2 × 100 bp) were obtained, processed, and mapped to the genome. We used the BWA‐MEM algorithm (version 0.7.12)  is a 30‐year‐old male, reported to have developmental delay and intellectual disability. As a child he required special schooling and currently finds employment in manual labor. He has never experienced seizures, nor visual or hearing deficits. Upon physical examination, he showed dysmorphic facial features, most notably bilateral ptosis, hypertelorism and downslanted palpebral fissures. Brain imaging was not performed, and previous genetic workup had included molecular studies for Fragile X (30 repeats) and a chromosomal microarray analysis considered to be normal.Interestingly, two additional male siblings, 42 years old (patient III:1) and 25 years old (patient III:9) also share dysmorphic facial features including bilateral ptosis, downslanted palpebral fissures and retrognathia, and both have intellectual disability, with the eldest sibling (III:1) most severely affected. At 42 years of age, he is unemployed and dependent on his parents for daily living. The clinical characteristics of the affected individuals in the family are summarized in Table The family history is also notable for one male sibling (III:6) who had been previously diagnosed with Leber Hereditary Optic Neuropathy due to a m.3460G > A mutation in MT‐ND1, however is otherwise healthy and does not share his brothers' facial features nor intellectual impairment.3.2BRPF1 gene (NM_004634), in the proband and his mother.In order to reach a molecular diagnosis in the family, DNA was extracted from whole blood samples from the proband, his siblings and parents. WES was performed for the proband and his parents (trio WES), and had led to the identification of the previously unreported c.556C>T (p.Q186*) truncating mutation on exon 2 of the Further analysis of the mutation status in family members available for testing, revealed that the mutation fully segregated with the disease in the family Figure , with af4BRPF1 as the causative mutation in the family.The family described herein exhibited a variable phenotype, including intellectual disability of varying severity, accompanied by facial dysmorphic features and especially ptosis, blepharophimosis and dowslanting palpebral fissures. Due to limited medical and developmental history, and nonspecific findings upon physical examination, reaching an accurate clinical diagnosis or pursuing gene‐specific sequencing would have been extremely challenging. Through WES, however, a timely molecular diagnosis was reached, implicating a heterozygous variant in BRPF1‐associated phenotype, the affected individuals showed developmental delay and mild to moderate intellectual disability  shares her sons' bilateral ptosis, and her cognitive status was self‐perceived as normal. This underscores both the variable neurodevelopmental phenotype of BRPF1 haploinsuffficiency, as well as the importance of thorough history taking and accurate phenotyping of probands' family members, as her initial misclassification as unaffected  might have caused a misdiagnosis or misinterpretation of the WES findings.Consistent with the recent description of the BRPF1 and SETD5, with the majority of the phenotype previously considered to be attributed to the latter , manifesting with intellectual disability of variable severity, microcephaly, ptosis, and additional dysmorphic features (Park et al., BRPF1 haploinsufficiency is an underdiagnosed cause of intellectual disability of variable severity, ptosis and/or blepharophimosis and additional nonspecific features, and should be considered in relevant clinical circumstances.To conclude, All authors declare no conflict of interests.


Hepatic glycogen storage diseases (GSDs) are a group of rare genetic disorders in which glycogen cannot be metabolized to glucose in the liver because of enzyme deficiencies along the glycogenolytic pathway. GSDs are well‐recognized diseases that can occur without the full spectrum, and with overlapping in symptoms.We analyzed a cohort of 125 patients with suspected hepatic GSD through a next‐generation sequencing (NGS) gene panel in Ion Torrent platform. New variants were analyzed by pathogenicity prediction tools.n = 53), followed by Ib (n = 23). The most frequent variants were p.Arg83Cys  and p.Gln347*  in G6PC gene, and p.Leu348Valfs  in SLC37A4 gene.Twenty‐seven new variants predicted as pathogenic were found between 63 variants identified. The most frequent GSD was type Ia  for diagnosis. The molecular diagnosis of hepatic GSDs enables the characterization of diseases with similar clinical symptoms, avoiding hepatic biopsy and having faster results. These defects are caused by pathogenic variants that result in enzymatic deficiencies for glycogen breakdown or synthesis, or problems in proteins that regulate glycogen metabolism. The consequence is accumulation of glycogen in tissues, especially in liver , and all patients and guardians provided written informed consent for participation.Were analyzed 125 patients with clinical symptoms of hepatic GSD. Blood samples were collected in EDTA vacuum container. DNA was extracted with Easy‐DNA Purification kit (Thermo Fisher). DNA samples were quantificated in NanoDrop 1000 (Thermo Fisher) and through Qubit dsDNA HS Assay Kit (Thermo Fisher).The gene panel amplicon was designed with Ion Ampliseq Designer software (Thermo Fisher), and included the exons and flanking 40 bp into introns of 11 genes involved in hepatic GSD (Table ® (Varstation) were used to detect and classify variants. To determine the variants causing disease, the following were considered: ACMG guideline , Variant Effect Predictor (Ensembl), Ion Reporter (Thermo Fisher) and VarstationValidations of NGS results were realized by Sanger sequencing in patients and in parents when the sample was available. The unbiased capture and deep coverage of each coding exon and adjacent intronic region of all genes in this panel ensure accuracy of variant detection.3We analyzed 125 patients with clinical suspicion of hepatic GSD. All samples were successfully sequenced. We found 63 different variants in 110 families, and 27 of those were new variants Tables .n = 48, RJ n = 2, MG n = 10, ES n = 3), 50 from the south , eight from the northeast , two from the Midwest  and two from the north (PA n = 2) . In five patients, no variant was identified Appendix . All ideEight families included in this study had multiple affected individuals. For patients 5, 11, and 12 (11 and 12 are sisters), their parents reported consanguinity Appendix . These iSixty‐three alleles were identified, in which 26 are missense variants (41.2%), 16 are nonsense variants (25.3%), six are splice site variants (9.5%), 11 deletions (17.4%), three insertions (4.7%) and one duplication (1.5%) , 23 with GSD Ib (18%), 14 with GSD III (11%), two with GSD VI (1.6%), 16 GSD IXa (12%), six with GSD IXb (4.8%), six with GSD IXc (4.8%), and five were not diagnosed (4%) Appendix .G6PC gene, causing GSD Ia. The other frequent variant, p.Leu348Valfs in SLC37A4 gene, was observed in 10% of alleles causing GSD Ib.The most frequent variants in patients were p.Arg83Cys, observed in 39 alleles (18.5%), and p.Gln347* present in 14 alleles (6.6%), both in Variants not described in the literature were evaluated for protein impact by nine in silico pathogenicity prediction algorithms. All new missense variants were predicted as pathogenic. In the bioinformatics analyses of new splice site variants, all were confirmed to modify the exon–intron structures in different forms importantly, showing sufficient entropy forces to perform the incorrect splicing.4This is one of the largest screening of variants causing the different forms of GSDs in patients, including 125 patients and describing 63 different variants, of which 27 are novel.The GSD Ia and GSD Ib represent 60% of the analyzed patients. In other analyzed cohorts, Vega et al.  reportedG6PC is in the active center of the enzyme G6Pase and presented no detectable activity in transient expression assays  in GSD Ib. This variant was present in 39% of Serbians patients , since GSD type IX had never been described in Brazilian patients.AGL. This gene has the highest number of gaps in coverage of NGS and is one of the biggest genes in panel, with 36 exons. However, the gaps were analyzed by Sanger sequencing and no variant was found. The results obtained from these patients are contradictory, since the variants found in both cases are described for GSD type III; however both patients presented inconsistent clinical findings. One of them has Down syndrome and liver histology similar to GSD III, but no biochemical results are compatible with the disease and the patient does not present any clinical symptoms. The other patient presented hypoglycemia from birth, however, currently associated with hyponatremia and metabolic acidosis. The liver biopsy was inconclusive and not suggestive of GSD. Therefore, it is possible that variants or technical artifacts are eliminating the amplification of the mutated allele or the variants are in regulatory regions, not covered by the panel, but the absence of disease is a possibility  instead of two. Both patients presented variants in In five patients with no identified variants, the clinical suspicions are mild or inconclusive, once they did not have clear clinical indications or laboratory findings supporting the diagnosis of GSD, besides hypoglycemia and/or hepatomegaly. The NGS was a diagnostic exclusion test; therefore, it was an expected result. These patients probably do not have GSD, once hepatomegaly and hypoglycemia are difficult to distinguish from other metabolic storage disorders without more clinical findings. Another possibility is the presence of variants in nontargeted deep intronic and regulatory regions , which does not justify the disease.The patient 120 is possibly a GSD patient because he presented clinical symptoms such as hypoglycemia and ketonuria but no other clinical signs, however only synonymous variants were found in This variety of results reflects the profile of an extremely large country with an interesting and important mix of people from all over the world. The presence of immigrants from the most diverse origins, such as Africans, Asians, and Amerindians justifies the variability of alleles found in a highly mixed population. Genetic analyses indicate that Latin Americans trace their ancestry mainly in the intermixing of Native Americans, Europeans, and Sub‐Saharan Africans. Historically, Latin America has a continuous, differential, and diverse intra‐ and intercontinental migration events, and presents higher prevalence of metabolic diseases (Adhikari, Chacón‐Duque, Mendoza‐Revilla, Fuentes‐Guajardo, & Ruiz‐Linares, Among the advantages of NGS diagnosis, patients undiagnosed by traditional means were investigated and correctly diagnosed in the present study. This method is especially promising for mixed populations with high level of heterogeneity. This method also allows the identification of unexpected diagnoses in the supposed typical phenotypes. Rare genetic diseases can be a diagnostic challenge, sometimes an odyssey. The NGS technologies can provide a fast diagnosis, advantages for treatment management, in reproductive choices, genetic counseling, and fertility services (Schofield et al., This diagnosis is an important advancement for patients with nontypical forms of disease, especially for those who need agile actions, since it evaluates 11 genes at the same time.This was an important step to increase the knowledge about the genetics of the different types of hepatic GSDs in Brazilian patients, since they have a genetically heterogeneous origin, and it is reflected in the variability of types and variants (Vega et al., G6PC in case of GSD Ia or p.Leu348Valfs in SLC37A4 for GSD Ib. Sanger sequencing approach is the most cost‐effective to solve up to 40% of the cases. However, for the cases without prevalent mutations or without suspected type of GSD, NGS is the most effective solution.Differentiated therapeutic management among GSD justifies the population characterization of patients. If NGS analyses are not available or expensive, the molecular diagnosis should be conducted first through the search for the pathogenic variants p.Arg83Cys and p.Gln347* in This study emphasizes that molecular genetic analysis is a reliable and convenient alternative to the assay of enzymatic activity in a fresh liver biopsy specimen for the diagnosis of GSDs. This type of study is an important tool for the estimation of disease progression, since different types of GSDs present variations in their clinical course and treatment, besides serving as a basis for genetic counseling and prenatal diagnosis.The discovery of a significant number of new mutations reinforces the allelic variability of different GSDs and proves that the diagnosis of GSDs in Brazil can be challenging, showing the validity of NGS gene panel use for diagnosis.The authors declare no conflict of interest.  Click here for additional data file.


Antibiotic resistance is one of the most important problems of our era and hence the discovery of new effective therapeutics is urgent. At this point, studying the allosteric communication pathways in the bacterial ribosome and revealing allosteric sites/residues is critical for designing new inhibitors or repurposing readily approved drugs for this enormous machine. To shed light onto molecular details of the allosteric mechanisms, here we construct residue networks of the bacterial ribosomal complex at four different states of translation by using an effective description of the intermolecular interactions. Centrality analysis of these networks highlights the functional roles of structural components and critical residues on the ribosomal complex. High betweenness scores reveal pathways of residues connecting numerous sites on the structure. Interestingly, these pathways assemble highly conserved residues, drug binding sites, and known allosterically linked regions on the same structure. This study proposes a new residue-level model to test how distant sites on the molecular machine may be linked through hub residues that are critically located on the contact topology to inherently form communication pathways. Findings also indicate intersubunit bridges B1b, B3, B5, B7, and B8 as critical targets to design novel antibiotics. The ribosome is the molecular machine that synthesizesproteins in the cell across all kingdoms of life. While thesize of the complex changes from one organism to another,its molecular structure is mainly maintained by twodifferently sized subunits. The small subunit, called 30S inbacteria, accommodates mRNA carrying the genetic codefrom the nucleus to be translated on 30S in the decodingcenter (DC). This small site on the supramolecule is formedof highly conserved residues G530, A1492, and A1493Correct translation of the genetic code to a functionalprotein is a vital process for the cell. Therefore, the 2.5-MDacomplex ensures this by employing highly sophisticatedmechanisms, such as allostery . Manymutational and structural studies have revealed that distantregions of the ribosome complex communicate witheach other by using conformational changes and tertiaryinteractions . For example, DC and PTC areallosterically linked as shown by extensive studies on yeastWhile these experimental studies reveal which sitesare cooperating in an allosteric communication, themechanism of how a perturbation on one site propagatesto another still remains elusive. At this point, proteincontact topology and residue network models offer a key tounderstand these molecular mechanisms by highlightingthe important structural features of the macromolecule, and toidentify allosteric pathways between functional regions ofthe proteinsMotivated by the success of these studies, we recentlyexamined the ribosome structure from this perspectiveand determined potential allosteric communicationpathways between the DC and PTC, and between theribosomal tunnel and PTC .Our analysis based on contact topology successfullypinned numerous known allosteric and drug binding siteson the calculated shortest pathways, which were alteredaccording to translation state during protein synthesis.In this study, we further examine the ribosome complexstructure topology in terms of centrality measuresto reveal hub residues that may be important in theallosteric mechanism of the ribosome. Previously, residuenetwork analysis has been employed to characterizeRNA structure , to studythe conformational space of tRNAEffective translation of the genetic code into afunctional protein is clearly ensured by sophisticatedmechanisms coordinated by key residues, which becometarget points especially for bacteria. A large number ofantibiotics target the ribosomal complex to stop proteinsynthesis in bacteria . However,while bacteria gain resistance to conventional antibiotics,studies focus on revealing intriguing mechanismsemployed by the ribosome and exploring weak points,i.e. key residues, of the bacterial ribosome. Here, differentfrom previous studies on residue networks of the ribosome,(i) four distinct translation states of the intact ribosomalcomplexes for the same organism, Thermus thermophilus ,are investigated; (ii) three centrality measures of variousstructural components are compared; (iii) emphasisis given to the betweenness centrality, which indicatespotential allosteric pathways based on the topology; and(iv) new druggable sites are proposed.Four different ribosomal complex structures of Thermusthermophilus outlining the protein synthesisinvestigated in this study. Three of these crystal structuresare aij = N ij N i .N j 1) belong to the elongation phase, with PDB IDs 2j00-2j01 belong taij of the residues defined as:The ribosome structure is described as a weightedbidirectional graph formed of nodes and edges. Nodesare placed at the alpha-carbon of amino acids and thephosphorus atoms of nucleotides. Neighboring nodes arelinked by edges. The length of edges is calculated based onthe local interaction strength aij=NjNiNjij is the total number of atom–atom contacts of theith and jth residues falling within a cutoff distance of 4.5 Å,where van der Waals and electrostatic interactions occur.This cutoff value is commonly used to determine atom–atom interactions in residue network analyses . TheNij value is weighted by the size of the residues, i.e. Ni andNj, to eliminate any bias due to the size of the residues inthe ribosome complex. Figure Here, Nij , as in the relationshipbetween potential energy and distance for electrostatic andvan der Waals interactions. According to this formulation,strong bias towards covalently bonded interactions issuppressed and edges describing both covalent andlongrange interactions important for the topology are includedin the calculations . Degree centrality is the total numberof edges linked to a node. Closeness centrality CC(l) isdefined as the inverse of the average shortest path lengthdCC(l)=N∑jdij (2)Betweenness of a node l, CB(l), is a useful measure toexplore highly connected nodes indispensable in linkingdistant sites of the network.CB(l)=∑iσjσiσij(l)σij (3)ij is the number of shortest paths between the ithand jth nodes and σij(l) is the number of shortest pathwayslinking i and j, passing through node l. High values of CBpoint to hubs of the graph.Here, σIn this study, centrality measures of all four ribosomestructures are calculated and discussed using the graphtheory approach. As a case study, the ribosome complextopology at the translocation step, i.e. 4juw-4jux, is furtherinvestigated to reveal hub residues of the formed graph,which successfully indicates functionally critical highlyconserved regions.The residue networks are constructed with aninhouse code written in Fortran77 and centrality analysis isperformed using an in-house code in MATLAB with theacademic license of İstanbul Technical University.The measure of degree reflects the number of neighbors ofeach amino acid and nucleotide within a cutoff distanceof 4.5 Å. This distance includes nonbonded interactionsthat can transmit a perturbation on an allosteric siteto the distant functional region by conformationalrearrangements. Similar to a previous study , degrees for residues in allstructures display a normal distribution with a mean of~8.5 ± 2.7 when considering the intact structure of thecomplex Figure . The ribWe also analyzed closeness centrality for the ribosomaltopology. Closeness measures the extent of interactionsof a residue, either directly with others or through fewneighbors. Different translation conformations of theintact complex exhibit distributions with similar meanvalues of ~6 × 10–6 and standard deviation of ~0.7 ×10–6 Figure . ResidueBetweenness values for the ribosome residue networksare calculated for the dataset. By definition, nodes(residues) with high betweenness centrality mediatethe flow of information between distant sites and theirabsence/mutation would disconnect the communicationof these regions . Figure The supramolecule ribosome has evolved in such a waythat its structure determines its function: its uniqueshape is designed to do specific globular motions for itsfunction, such as ratcheting of subunits for translocation,and functional residues are carefully distributed on thestructure to locally ensure its cellular missionCloseness scores of all eight residues are within therange of 6.2–8.3 × 10–6, significantly high when comparedto rRNAs, as was reported before .Betweenness values of all DC residues and A2451,C2452, and U2585 on PTC are at the top 0.05 quantile(>0.013), pinning these critical nucleotides at thecrossroads of all shortest pathways spanning the supramoleculeat all translation states studied here. U2506 and A2602are also at the top 0.05 quantile but in specific translationconformations.Degree centrality analysis of the intact ribosomestructures shows that the number of interactions of aminoacids is higher compared to nucleotides Table . ThisdoIn globular protein structures, residues with highcloseness values usually cluster at the core of the structure,and active site residues of enzymes usually have highdegree and high closeness valuesWhen we focus on the functional sites DC and PTC,we note that degree scores of active site residues vary fordifferent states of the ribosomal complex Figure . ThisobResidue network analysis in this study gives acomprehensive look at the contact topology of theribosome complex at various translation states andhighlights specific regions with high potential to takeroles in allosteric communication between many distantfunctional sites on the molecular machine. Calculationsindicate that a large number of intersubunit bridgesaccommodate highly connected residues supportingthe modularization of the network Figure , where tBridge B1b residues are detected as hub residues in thecalculations for the translocation conformation 4juw-4jux;this dynamic bridge undergoes significant rearrangementsduring the swivel motion of the 30S head to translocatetRNAs . The intersubunit bridgeB2a/d is predicted as a hub region at the prepeptidylstate (2wdk-2wdl), where a high number of atom–atom.contacts are established between A1495 on h44 and C1920on H69. Residues on H69 are particularly known to adoptdifferent conformations during tRNA selection, which iscritical for recruitment of the correct acylated-tRNA tothe complex . Next to thissite, hydrogen-bonding between C783 on helix h24 andC1836 of H68 forms the bridge B2b, which is lost at theprepeptidyl transfer structure .Similarly, our analysis indicates that these residues havehigh betweenness values at the pretranslocation state(2j00-2j01) structure. Still at the B2 region,hydrogenbonding between C1832 of H67 and C899 on h27 aswell as interactions between nucleotides C770-G771 andh27 are important for the stability of the bridge B2c andsubunit association . These criticalinteractions are predicted as hubs for the pretranslocation,prepeptidyl, and termination states.Bridge B3 is fortified by numeroushydrogenbonding interactions, since it is the pivot point duringthe ratcheting motionThe intersubunit bridge B7 is located at the base ofthe L1 stalk interacting with the E-tRNA. Bridge B7a isformed by stacking of A702 on h23 and highly conservedA1848 of H68. Near this site, bridge B7b links h23 andh24 of the small subunit and ribosomal protein L2 ofthe large subunit. Both sites emerge as hub regions inelongation and termination states. As bridges B7a andB7b are next to the E-site, they have high potential torapidly transmit conformational changes on one subunitto the other. In addition, the whole E-tRNA, both in itsclassical and hybrid states, is highlighted to play a role inthe transmission of information. Indeed, studies report theimportance of E-site dynamics in maintaining translationfidelity .The B8 bridge, specifically U340 of helix h14 andribosomal protein Thr96 on L14, also emerges as a hubregion in elongation structures, according to calculations.Disruption at this bridge formed of highly conservedresidues was reported to hold the complex at the decodingstageThese findings agree with our previous study on theprediction of potential allosteric pathways between DC andPTC at different states of translation, crossing intersubunitbridges B2a and B3, as well as P-tRNAs in the ribosomestructures . Besides givinghints about the molecular mechanisms of the ribosomalcomplex for correct protein translation, these resultsalso indicate that intersubunit bridges emerge as criticalregions for allostery that may be considered as drug targets.Supporting this idea, a recent study on yeast  reported the role of intersubunit bridges in providingenergy transfer between two subunits during translationand in helping allosteric communication between distantsites. Moreover, allosteric control of intersubunit bridgesover ribosome dynamics has been long debated, such asfor B1aWhile maintaining stability between subunitsduring large conformational changes for translation,and keeping distant functional sites informed about thetranslation stages, two intersubunit bridges on the longh44 have another critical property in common: beingdrug targets . The antibioticthermorubin targets the intersubunit bridge B2a linkingh44 and H69, and stabilizes nucleotide C1914 in aflipout conformation sterically clashing with A-tRNA. Similarly, neomycin molecules bindto h44 and H69 near B2a and allosterically stabilize anintermediate translocation step by preventing the requiredconformational rearrangements in bacterial B2aBy considering their high potential as hubs linkingfunctional sites at the subunit interface, bridges B1b, B3,B5, B7, and B8 are attractive regions for novel drug designto kill malign bacteria, which rapidly gain resistance toconventional antibiotics.EF-G promotes the movement of tRNAs and mRNA onthe small subunit; however, the exact mechanism of thisaction is still debatedFrom these, three pathways connecting distant functionalsites of 30S and 50S are studied; these are the A-site of thesmall subunit and PTC, docking sites of EF-G on smalland large subunits, and DC and PTC.On the EF-G.70S complex, a string of hub residues isobserved to line up between A532 on helix 18 of 16S, whichis next to DC residue G530 and C2456 on 23S near PTCFigure . These tDC residues A1492 and A1493 do not take part in thisensemble. Interestingly, all these regions and residues havecritical roles in translation. The highly conserved A532 islocated at the A-site on the small subunit and is in directcontact with mRNA, while any disarrangement around the530 loop region effects the fidelity in translationAnother set of hub residues appears to link Arg354of EF-G and U368 on helix 15 of 16S to the intersubunitbridge B8 residues, namely C339 on helix 14 and Asp13 onL14 Figure . PreviouMoreover, flexible SRL residues A2660-G2664 on H95of 23S rRNA appear as hubs symmetrical to U368, bothholding EF-G. The SRL is another important functionalregion neighboring the active center of EFs. Interactionsof the catalytic residue His85 of EF-Tu with nucleotidesG2661 and A2662 on the SRL are critical for GTPaseactivation and hydrolysisFigure In conclusion, the current approach to describeintermolecular interactions and to construct a residuenetwork of the ribosomal complex succeeds indifferentiating residues critical in function or in allostericcommunication, among many others. In addition, itstrongly agrees with a previous study on ribosomalnetworks .The supramolecule ribosome presents an exceptionalresidue network harboring multiple functional siteshighly distant from each other. It astonishingly maintainsan effective communication through residues with highbetweenness scores, which can transmit perturbationsin the form of conformational changes. Moreover, thecurrent findings assemble many distinct observations onallostery employed by the ribosome onto the same map andpropose a new model to test how residues can be linked toeach other to form pathways for allosteric communication.Centrality analysis of the different translational states ofthe ribosomal complex indicates that especially degree andbetweenness scores of the same residues change from oneconformation to another as the contact topology changes.ehTrefore, as this study suggests, interpretation of findingsshould be assured by investigating different conformationsof the protein complex if possible. Finally, intersubunitbridges B1b, B3, B5, B7, and B8 emerge as attractive sitesfor drug design to kill drug-resistant bacteria.This work was supported by the İstanbul TechnicalUniversity Scientific Research Projects Foundation[Project No: 36110].


There is a substantial rise in the incidence of cancer in Saudi Arabia. Life style models and lack of awareness are the prime suspect in this substantial increase. Therefore, the objective of the present study was to assess the relationship between lifestyle and cancer in a population-based Survey in Northern Saudi Arabia.This cross-sectional study was conducted in North Saudi Arabia (Hail Region). Data was collected as a part of a community based cancer's awareness movement that covered an area inhibited with approximately 500,000 individuals.In this study, about 2558/3227 (79.3%) and 641/794 (80.7%) believed that tobacco smoking and smokeless are not a risk of cancer development. In this study large section (87.2%) of the study population believe that exposure to diverse occupational or non-occupational chemicals has no role in cancer development. Furthermore, around 59% of the study subjects in the current study believed that repeated exposure to insecticidal chemicals doesn't influence the risk of cancer.The present study point to the urgent need for awareness educational programs and preventive measures towards may lifestyle factors that can increase or decrease the overall risk of cancer among Saudi population. Regardless of resource limitations a country experiencing, when well-perceived and well-managed, a NCCP supports decrease the cancer burden and improve facilities for cancer patients and their families 2). Regular physical activity, decreases the risk of colorectal cancer and breast cancer. Alcoholic beverage consumption was found to increase the risk of some cancers including; liver, esophagus, pharynx, oral cavity and breast cancer. Foods frequently contaminated with Aflatoxin increases the risk of hepatocellular carcinoma. Salt preserved foods and high salt consumption perhaps upsurge the risk of carcinoma of the stomach. Certain salted fish was found to increase the risk of nasopharyngeal carcinoma. Preserved food particularly red meat possibly increase the risk for colorectal cancer.Increased weight or obesity elevates the risk of several cancers in many organs including; esophagus, colorectum, breast endometrium and kidney. It is necessary to maintain the body mass index within the normal range . Data was collected as a part of a community based cancer's awareness movement that covered an area inhibited with approximately 500,000 individuals. The sample size was calculated using online sample size calculator available at: Applying confidence interval of 60 ± 1.66 and confidence level of 95%, the sample size was 3326.Participants were targeted in different public settings including University of Hail. Each participant was asked to fill a questionnaire about tobacco and alcohol habits and other information regarding their attitudes towards these factors in relation to cancer etiology. Beside the demographical characteristics, the questionnaire also included; Living with smoker, Smokeless tobacco; Chemical usage, Insecticidal exposure, Vegetable and fruit wash before eating, Radiation exposure, Soft or refined food can increase the risk of cancer, Preserved food can increase the risk of cancer, Some food can increase the risk of cancer, Some food can decrease the risk of cancer, Natural food can decrease the risk of cancer, Vegetable and fruit intake decrease cancer risk, Green Tea and other antioxidant decrease cancer risk, Physical activity decrease cancer risk, Increased body weight increases cancer risk, Obesity can increase the risk of cancer.2.1.Statistical analysis was performed by proportion. The Microsoft Excel Office 2007 and the SPSS software (version 16) were used for statistical analysis. The software was used for calculation and production of frequencies and percentages.2.2.Written informed consent was obtained from each respondent, ensuring strict anonymity. The Ethical Committee of the Department of Pathology, College of Medicine at the University of Hail has approved the study.3.This study included 3326 participants, their ages ranging from 15 to 77 years old with a mean age of 25 years. Out of 3253 respondents for gender classification, 1701 (52.3%) were males and 1552 (47.7%) were females.The knowledge about the relationship between cancer risk and factors such as tobacco usage and alcoholic beverages consumption was summarized in With regard to exposure to passive smoking (living with smoker), 1430/3103 (46%) participants were found to believe that exposure to passive smoke is a risk for cancer and the remaining 1673/3103 (54%), were not. Out of 1430 respondents “Yes”, 761/1597 (47.7%) were males and 669/1506 (44.4%) were females. Out of 1673 respondent “No”, 836/1597 (52.3%) were males and 837/1506 (55.6%) were females, as shown in With regard to smokeless tobacco, 1139/1322 (86.2%) participants has pointed out that, smokeless tobacco is a major risk for cancer and only 183/1322 (13.8%) have answered “No”. Out of the 1139 “Yes” respondents, 641/794 (80.7%) were males and 498/528 (94.3%) were females. Out of 183 answered “No”, 153/794 (19.3%) were males and 30/528 (5.7%) were females, as shown in For alcoholic beverages consumption, only 57/3207 (1.8%) have agreed that alcohol consumption may be a risk factor for cancer and the remaining 3150/3207 (98.2%) believed that alcohol beverage consumption is not considered as a cancer risk factor, as indicated in The knowledge on the relationship between cancer, chemical usage, insecticidal, and radiation exposure was summarized in Out of the 3153 respondents, about 1292/3153 (41%) participants believed that comprehensive repeated exposure to insecticidal chemicals is a major cancer risk factor and the remaining 1861/3153 (59%) have reverse believe. Out of the 1861 participants answered “No”, 1210/1663 (72.9%) were males and the remaining 651/1490 (43.7%) were females.Out of the 3207 respondents, about 469/3207 (14.6%) participants believed that comprehensive repeated eating of vegetables and fruits without wash is a major cancer risk factor and the remaining 2738/3207 (85.4%) have reverse believe. Out of the 2738 participants answered “No”, 1341/2738 (49%) were males and the remaining 1397/2738 (51%) were females.Out of the 1750 respondents, about 1514/1750 (86.5%) participants believed that exposure to radiation is a major cancer risk factor and the remaining 236/1750 (13.5%) have reverse believe. Out of the 236 participants answered “No”, 195/1055 (18.5%) were males and the remaining 41/695 (6%) were females, as indicated in The relationship between cancer, and food habits was summarized in When asking the participants whether preserved food can increase the risk of cancer, about 1372 participants have responded. Out 1372 respondents, 1082 (79%)  answered “Yes” and 290 (21%)  answered “No”.When asking the participants whether some food can increase the risk of cancer, about 465 participants have responded. Out 465 respondents, 89 (19%)  answered “Yes” and 376 (81%)  answered “No”.When asking the participants whether some food can decrease the risk of cancer, about 2858 participants have responded. Out 2858 respondents, 1767 (19%)  answered “Yes” and 1091 (81%)  answered “No”.When asking the participants whether natural food can decrease the risk of cancer, about 2581 participants have responded. Out 2581 respondents, 2072 (80%)  answered “Yes” and 509 (20%)  answered “No”.When asking the participants whether vegetable/fruit intake can decrease the risk of cancer, about 2039 participants have responded. Out 2039 respondents, 1738 (80%)  answered “Yes” and 301 (20%)  answered “No”.When asking the participants whether anti-oxidants such as green tea intake can decrease the risk of cancer, about 1834 participants have responded. Out 1834 respondents, 1169 (64%)  answered “Yes” and 301 (36%)  answered “No”, as shown in The relationship between cancer, and body weight and physical activity was summarized in With regard to increased body weight as a factor that can increase the risk of cancer, out of 3172 respondents, 1631 (51%) participants greed “Yes”  that increased body weight can increase the risk of cancer, hence, about 1541 (49%) participants  disagreed “No”.With regard to obesity as a factor that can increase the risk of cancer, out of 1124 respondents, 745 (66%) participants greed “Yes”  that obesity can increase the risk of cancer, hence, about 379 (34%) participants  disagreed “No”.4.Cancer represent a major health problem worldwide. Although the prevalence of cancer is high in developed countries, but there is a tremendous increase of cancer in developing countries. In light of increasing of new cancer cases, there is an uprising need for implementing cancer awareness programs.In the present study we tried to highlight some important cancer issues in order to find out the gaps in this context to make available more information to take effective cancer prevention strategies.2 and a population of 547226 (2010 census) In the current study we screened a large population in a cross sectional survey in Hail region (Northern Saudi Arabia) in order to evaluate the level community awareness and knowledge toward some cancer related life style habits. Hail is a province of Saudi Arabia, located in the north of the country. It has an area of 103,887 kmIn this study, about 79.3% and 80.7% believed that tobacco smoking and smokeless are not a risk of cancer development. These findings have great discrepancies from other studies that reported much lower percentages. In study to evaluate the awareness of oral cancer and perception of tobacco use cessation counseling 97.6% Indian, 96.5% Saudi, 96.5% Yemeni and 98.4% United Arab Emirates respondents recognized the association between oral cancer and cigarette smoking In the present study about 98.2% of the participants disagreed that alcohol consumption is a risk factor for cancer development. Although it was well established that alcohol beverages consumption is a risk for the development of several precancerous and cancerous lesions In this study large section (87.2%) of the study population believe that exposure to diverse occupational or non-occupational chemicals has no role in cancer development. The exposure to diverse types of chemical substances has been linked to a number of cancers. Early-life arsenic exposure, has been linked to lung and bladder cancer Furthermore, around 59% of the study subject in the current study believed that repeated exposure to insecticidal chemicals doesn't influence the risk of cancer. Exposure to insecticidal chemicals such as Organochlorine insecticides has been linked to some cancers, particularly leukemia In the present study about 85.4% of the participants believed that comprehensive repeated eating of vegetables and fruits without wash doesn't increase the risk of cancer. The majority of these vegetables and fruits are contaminated with various chemicals including pesticides insecticides, and herbicides, the risk of which is well established With regard to the exposure to radiation, approximately 86.5% of the participants believed that exposure to radiation is a major cancer risk factor. This is high percentage of awareness toward radiation hazard.When asked the participants whether soft or refined food can increase the risk of cancer, around 74.8% answered yes. Many studies have suggested the relationship between intake of refined and fast food and the risk of cancer When asked the participants whether preserved food can increase the risk of cancer, about 79% of the participants agreed. However, the intake of preserved foods was positively associated with the incidence of epithelial ovarian cancer On we asked the participants whether some food can increase the risk of cancer, only 19% have answered yes. It was suggested that vegetable fiber and total fiber play very important roles in protecting against colorectal cancer On asking the participants whether natural food can decrease the risk of cancer, 80% answered yes. Because of their role as antioxidants, the intake of carotenoids has been found to reduce the risk of head and neck cancer (HNC) On asking the participants whether vegetable/fruit intake can decrease the risk of cancer, about 80% agreed. A higher consumption of vegetable and fruit was found to be associated with a decreased risk of several cancers, such as breast cancer, hepatocellular carcinoma, gastric carcinoma etc When asking the participants whether anti-oxidants such as green tea intake can decrease the risk of cancer, about 64% agreed. An inverse association between green tea intake and lung cancer risk has been observed among never smokers but not among smokers With regard to the physical activity as a factor that can decrease the risk of cancer, about 46% of the study population disagreed. Physical activity is consistently associated with a reduced risk of colorectal cancer in epidemiologic studies. Overall, a stronger relative risk of physical activity on colorectal cancer risk was observed in the higher body mass index group, although the difference was not statistically significant, suggesting an added benefit of physical activity as a cancer prevention strategy in population groups with strong risk factors for colorectal cancer With regard to increased body weight as a factor that can increase the risk of cancer, about 49% of the study population in the present study disagreed. he joint association between energy balance and cancer risk are hypothesized to share the same underlying mechanisms, the amplification of chemical mediators that modulate cancer risk depending on the responsiveness to those hormones to the target tissue of interest. Disentangling the connection between obesity, the insulin-IGF axis, endogenous hormones, inflammatory markers, and their molecular interaction is vital The limitations in the current study include its cross-sectional design. Longitudinal studies in the future might give up insight into developments in the outcomes of existing and future lifestyle related cancer control measures. Another limitation of the present study is that data were obtained via self-report.5.The present study point to the urgent need for awareness educational programs and preventive measures towards may lifestyle factors that can increase or decrease the overall risk of cancer among Saudi population. There is a necessity for in depth cancer prevention related studies and further specific measurements to prove that life style risk factors have influence on cancer burden in Saudi Arabia and in Northern Saudi Arabia in particular.


TNNT2, MYPN, FLNC and TNNI3 have been associated with its familial form.Restrictive cardiomyopathy is a rare cardiac disease, for which several genes including TNNI3 mutation: NM_000363.4:c.586G > C, p.(Asp196His). Her parents were third-degree cousins originating from a small village and although they were found heterozygous for the same variant they displayed no symptoms of the disease. Her older sister who was also found heterozygous was asymptomatic. Her twin sister and her brother who were homozygous for the same variant displayed a restrictive and a hypertrophic phenotype, respectively. Their children are all carriers of the mutation and remain asymptomatic until the age of 21.Here we describe a female proband with a severely manifested restrictive phenotype leading to heart transplantation at the age of 41, who was found homozygous for the novel These observations point to a recessive mode of inheritance reported for the first time for this combination of gene/disease. TNNT2 (MIM*191045) [MYPN (MIM*608517) [FLNC (MIM*102565) [Restrictive cardiomyopathy (RCM) is a rare cardiac disorder that manifests primarily as an abnormality of diastolic filling, which is also reported as a reduced ventricular compliance or increased stiffness, leading to reduced diastolic volume with preserved systolic function . Several*608517)  and FLNC MIM*19105 [MYPN , the latter being the inhibitory subunit of the complex, primarily functioning to prevent actin and myosin from interacting in the absence of Ca2+. Mutations in the troponin complex introduce alterations in Ca2+ affinity and protein-protein interactions, which may ultimately lead to the development of cardiomyopathy.Cardiac troponin serves as a sensor of the intracellular CaTNNI3). In her family all heterozygous carriers were found asymptomatic, while her homozygous sister and brother displayed restrictive and hypertrophic phenotype, respectively, pointing to a recessive mode of inheritance reported for the first time for this combination of gene and disease.We describe here a female patient with a severely manifested phenotype of RCM leading to heart transplantation at the age of 41, attributed to an homozygous mutation in the gene encoding the cTnI . Doppler echocardiography showed restrictive pattern of diastolic transmitral flow , and increased right ventricular systolic pressure (55 mmHg), as well as mild mitral and tricuspid valve regurgitation. At the age of 45, she started complaining for exertional dyspnea. A new cardiac ultrasound confirmed the previously reported findings with similar E/A ratio and even lower DT , although initially asymptomatic, underwent screening exercise stress test and cardiac ultrasound at the age of 43. The stress test, despite LV strain findings on the resting electrocardiogram, was substantially negative for heart ischemia. The cardiac ultrasound revealed normal LV dimensions , systolic function (LVEF 55%) and left atrial enlargement  was admitted to hospital at the age of 42 due to recurrent pre-syncope and exertional dyspnea. His electrocardiogram revealed sinus rhythm with incomplete Right Bundle Branch Block and nonspecific repolarization abnormalities. His echocardiographic study was remarkable for asymmetric hypertrophy of the interventricular septum and papillary muscles, left atrial enlargement (milder than his affected sisters’), mild mitral regurgitation and diastolic dysfunction without restrictive pattern , while LV size and function were normal (Table His parents I1 and I2) along with one of his sisters (II4) remain asymptomatic. The echocardiogram of the proband’s mother (patient I2) presented prominent apical trabeculations, but her electrocardiogram was essentially normal. Similarly all of the children (III1–4) of patients II1 and II3 are asymptomatic. The youngest child (III1) is 5 years old and therefore has not been clinically evaluated yet. The clinical data of children III2 (age 13) and III3 (age 21) are listed in Table  and I2 aTNNI3 gene: NM_000363.4:c.586G > C, p.(Asp196His). The variant  was novel and characterized as likely pathogenic (according to ACMG criteria). It was absent from the population databases of Exome Sequencing Project and Genome Aggregation Database (PM2 criterion) and pathogenicity predictions were all in favor of a damaging effect of this amino acid substitution (PP3 criterion) . The variant affected a highly conserved nucleotide  and a highly conserved amino acid . Additionally, another amino-acid missense variant at this position, p.Asp196Asn, is classified as likely pathogenic using ACMG criteria (PM5 criterion). Surprisingly, the proband was found homozygous for this variant but it was the second child of parents that are third cousins and originate from the same small mountainous village in Peloponnese, Greece  and the Sophia Genetics pipeline. The variant calling files were filtered using VariantStudio Data Analysis Software  and the Sophia Genetics DDM platform and the detected variants were characterized according to the recommendations of the American College of Medical Genetics and Genomics (ACMG) . All benC, p.Asp16His. The2+ activation [2+ hypersensitivity and subsequent impaired relaxation, which is the main manifestation of RCM [The C-terminal of troponin I (amino acids 184–210 in human cardiac TnI) is the most conserved structure of the molecule and interacts with tropomyosin in a calcium-regulated manner, suggesting a functional role. Despite its degree of conservation this region is highly flexible with no stable secondary structure [tivation . In vivon of RCM . In factn of RCM . Addition of RCM , 12 or dn of RCM , 13.TNNI3 variant at homozygous state: NM_000363.4:c.586G > C, p.(Asp196His). A different variant located at the same amino acid position i.e. NM_000363.4:c.586G > A, p.(Asp196Asn) has been repeatedly associated with HCM [TNNI3 mutations have been associated with recessive forms of DCM [Genetic analysis of our proband that presented a severe restrictive cardiomyopathy phenotype leading to heart transplantation at the age of 41, revealed a novel with HCM –16, whilwith HCM . The pars of DCM  and HCM  C, p.Asp6His. A dTNNC1 is a likely novel gene for autosomal recessive restrictive cardiomyopathy. In this family, all heterozygous carriers were asymptomatic pointing to a recessive form of the disease, but it is important to stress out that in families with restrictive cardiomyopathy inherited as dominant trait, penetrance is reduced and age dependent, so the phenotype of generation III may have not reached maturity (Fig. 2+ sensitivity [TNNI3 mutations have been reported in noncompaction cardiomyopathy patients [Restrictive cardiomyopathy is considered to be inherited in an autosomal dominant way, although recently Ploski et al.  have repsitivity . Moreovepatients , a parti


ATM) for Arctic aerosol is established, showing that BC dominates a positive RFATM with a high warming efficiency.Columnar mass concentrations of aerosol components over the Arctic are estimated using microphysical parameters derived from direct sun extinction and sky radiance measurements of Aerosol Robotic Network. Aerosol optical, microphysical, chemical and radiative properties show that Arctic aerosols are dominated by fine mode particles, especially for high aerosol load cases. The average aerosol optical depth (AOD) of the selected Arctic sites in the sampling period is approximately 0.08, with 75% composed of fine mode particles. The fine mode fraction mostly exceeds 0.9 when AOD greater than 0.4. The ammonium sulfate-like component (AS) contributes about 68% of total dry aerosol mass for high-AOD events. The estimated compositions and back trajectories show that the transported aerosol particles from biomass burning events have large amounts of black carbon (BC) and brown carbon, while those from pollution events are characterised by large AS fractions. The instantaneous radiative forcing at the top-of-atmosphere is higher for the more absorbing components, and varies greatly with surface albedo and solar zenith angle. A regression model of columnar composition and radiative forcing within the atmosphere (RF Particles transported from mid-latitude regions in Europe, North America and Asia4 episodically reach the Arctic region5, and significantly influence the radiative energy balance in the Arctic6. For example, carbonaceous particles can absorb solar radiation and heat the atmosphere, resulting in positive radiative forcing. On the other hand, black carbon particles deposited on snow and ice surfaces lead to a decrease in surface albedo and an increase in melting8.Aerosol has important impacts on global climate change and atmospheric environment. However, there is still a lack of understanding of atmospheric aerosol, and as a result, aerosol radiative effect is one of the most significant sources of uncertainty in climate change assessment9). Thus, direct measurements are necessary for better simulations, especially for high aerosol load situations10. The Aerosol Robotic Network11 (AERONET) includes several long-term observation sites in the Arctic region and provides an online archive of the many derived aerosol parameters. Such ground-based remote sensing observations like satellite observations derive column average aerosol properties in ambient conditions12. Previous studies analysed the optical properties of Arctic aerosol using AERONET products15, and some used AERONET data to validate models and satellite retrievals17. However, few studies focused on the chemical composition and microphysical properties, which are essential to the assessment of optical and radiative properties18. Aerosol composition is one of the main sources of uncertainty in estimating the aerosol radiative effect19. Particularly in the Arctic region, light-absorbing aerosol components have significant impacts on the radiative effect because of the high surface albedo of ice and snow surfaces20.Atmospheric models are able to obtain aerosol radiative properties in a global scale, but may have trouble providing accurate simulations, and have noticeable differences from the observations over specific regions  are close to major emission sources; for example, BAR and RES suffer from American biomass burning, SOD and HOR are affected by European pollution, and TIK is disturbed by Russian agricultural combustion. In contrast, some sites located in remote or high Arctic regions  are less impacted by transported particles.We select 8 AERONET sites located within the Arctic Circle, where AERONET level 2.0 optical, microphysical and radiative parameters are available: Barrow  in Alaska, Resolute_Bay  on Cornwallis Island, PEARL  in the Canadian Arctic, Thule  and Ittoqqortoormiit  in Greenland, Hornsund  in Svalbard, Sodankyla  in Finland, and Tiksi  in Russia. Aerosol particles over the Arctic are significantly affected by emissions from mid-latitude regions26 for these 8 sites from the AERONET website . The parameters used in this study are aerosol optical depth (AOD), fine mode fraction (FMF), real and imaginary parts of the complex refractive index (RRI and IRI) at four wavelengths , volume size distribution, spherical fraction and instantaneous radiative forcing at the top-of-atmosphere and bottom-of-atmosphere. The uncertainties of AOD and FMF are 0.0211 and 0.127, respectively. The uncertainties are larger for the microphysical parameters: 0.04 for RRI and 50% for IRI, and 35–100% for each bin of the size distribution depending on the radius28. Note the level 2 refractive index data are only computed when the AOD (at 440 nm) is larger than 0.4 to assure a good enough signal for the inversion. Since the derivation of the aerosol component mass concentrations requires the RRI and IRI, they are also restricted to high aerosol load cases. These cases make up only a small fraction of the total observations and they clearly only represent aerosol properties under severely polluted conditions in the Arctic region. They occur more frequently at sites near major emissions  than at remote sites .We retrieve all the available Version 2 inversion data that pass the level 2 quality assurance criteria25, which is employed for Arctic aerosol considering the ageing process of transported particles from mid-latitude regions. It should be noted that by solely relying on remote sensing measurements, it is difficult to evaluate the physical transformation of aerosol particles over the Arctic  due to the low temperature, so we do not take these complicated situations into account in this study. At last, total residual between the modelled and observed parameters that are weighed by their uncertainties is calculated. Searching for the minimum total residual yields the best composition results based on a look-up table approach. Moreover, the inferred component volume fractions can be transformed into columnar mass concentrations using component densities. More details of the algorithm can be found in our previous study12.Aerosol components are quantitatively estimated from aerosol light absorption, size and particulate shape parameters provided by AERONET products according to the intrinsic relations between microphysical and chemical properties. First, a columnar aerosol composition model that contains black carbon (BC), brown carbon , mineral dust (DU), ammonium sulfate-like (AS), sea salt (SS) and aerosol water uptake (AW) is established, as well as the spectral RRI and IRI, the lognormal size distribution and the spherical fraction of each individual component. Note that the AS component refers to light-scattering and fine-mode aerosol particles, including inorganic salts  and organic species. Then, the microphysical parameters of the aerosol mixture with respect to assumed component volume fractions are calculated based on Maxwell-Garnett internal mixing model24. We employ a method similar to the one introduced in the previous study12 to assess the errors  and at the bottom-of-atmosphere (RFBOA):FTOA and FBOA are the fluxes at the TOA and BOA, the superscript a and c indicate situations with and without aerosol, respectively, and the arrows denote upward or downward flux. Note the downward flux at the TOA is the same either for aerosol absent or aerosol present conditions, and the upward flux at the BOA can be approximated by the downward flux and surface albedo (SA), the RFTOA and RFBOA can be also written as:The instantaneous direct aerosol shortwave radiative forcing is defined in this study as the difference in net fluxes (downward flux minus upward flux) due to aerosol under cloud-free conditions at the top-of-atmosphere  is calculated by RFATM = RFTOA − RFBOA.AERONET radiative forcing products are calculated by broadband fluxes from 0.2 to 4.0 μm, which are computed from aerosol parameters including size distribution, spectral AOD, single scattering albedo and phase function by using the radiative transfer module integrated in the AERONET inversion16. Seasonal AOD patterns for most of the sites in the Arctic, as shown in Fig. 31. The large AOD in spring might be associated with transported particles from boreal forest burning10 and pollution32, given that cyclonic activities in spring create opportunities for long-distance particle transport towards the Arctic in the free troposphere. The small AOD in summer-autumn, in contrast, is attributed to decreasing aerosol transport and increasing wet removal during this period34.The average of all AOD at 500 nm in the sampling period at the Arctic AERONET sites is 0.08 ± 0.08. BAR and TIK have slightly higher AOD (0.10) due to emissions from North America and Russia, respectively. In contrast, the mean AOD at the remote ITT site is only 0.06, which represents the typical Arctic background value35, with an average FMF of 0.75 ± 0.16. Compared to other typical aerosol types36, the FMF of Arctic aerosol is more similar to urban/industrial or biomass burning aerosol rather than the low FMF for natural types . This likely indicates the significant impacts of anthropogenic or combustion sources (which mainly emit fine particles) on Arctic aerosol. The multiyear monthly averages of FMF shown in Fig. 15 and reaches a high level of 0.77 in July (the opposite pattern at the PEA site may be due to the short data duration). From long-term observations , we find that FMF during summer months at the HOR, ITT and THU sites shows generally increasing annual trends with moderate fluctuations, while for other sites or periods, there are barely notable trends.Fine mode aerosol particles dominate total extinction over the Arctic37. The FMF dependency on AOD clearly reveals significant impacts of the transported fine mode particles on Arctic aerosol, especially under high aerosol load conditions. It is also noticed that there are less than 4% of high AOD cases with FMF lower than 0.3, which can be attributed to natural dust or oceanic coarse particles17, as well as the large ice crystals due to ice storms that frequently occur in the Arctic region38.Based on the FMF variations with AOD shown in Fig. 3/μm2), which are mostly from natural sources, is only 1/5 that of fine mode. In addition, the coarse-to-fine mode ratio is even smaller at TIK and RES (approximately 1/10), as the two sites are greatly affected by transported biomass burning particles. Spectral IRI over the Arctic  are comparable to the urban/industrial and biomass burning aerosol39, likely illustrating the major influences of these aerosol types. A previous study argued that the light absorption of Arctic aerosol was mainly due to biomass burning sources4, which agrees well with our observation that the IRI at RES and TIK sites are much larger and the spectral dependency  is more obvious than at other sites.The observed aerosol microphysical parameters at the Arctic sites  and component mass fractions (%) are shown in Fig. 2. Except for the events on May 2, 2006, at HOR and on August 4–6, 2014, at SOD, other TMC values have a good correlation with AOD (the correlation coefficient R is 0.96). Concerning these exceptional cases, we calculate the volume extinction efficiency (the ratio of AOD to volume) of fine mode aerosol using AOD, FMF and volume size distribution. We find these exceptions have small efficiencies . A possible explanation is the high content of the less efficient component .The estimated columnar total mass concentration , except for those at RES and TIK, where the absorbing components can reach a level comparable to that of AS. The average BrC-to-BC mass ratio of the Arctic sites is approximately 2.2, which agrees well with modelling results9. Compared to the fine particles, the mass concentrations of coarse-mode components are much lower41. The average contributions to aerosol mass of DU and SS are only 4% and 7%, respectively, confirming that high-AOD events should be mostly attributed to fine particles transported from mid-latitude regions.The average AS mass concentration is 70 mg/m42 to calculate the light absorption of each component according to the inferred columnar mass. BC, BrC and DU contribute 83%, 15% and 2%, respectively, to the total aerosol absorption, similar to modelling results10. We use the absorption AOD (AAOD) data from AERONET to validate the absorbing component estimates43 given that the light absorption computed from the MAE and the inferred composition is independent of the AAOD. As shown by Fig. 2 = 0.99, slope = 0.95–1.0; see Supplementary Fig. As shown in Fig. 44 (HYSPLIT), forced by GADS (1 degree) and NARR (32 km) meteorology data (depending on data availability), is employed. Aerosol events for different types of sources may have distinct compositions even at the same site. Figure 2 (12% of the dry aerosol mass), and AS is 153 mg/m2 (82%), indicating boreal forest burning in Alaska and Canada32, which can be seen from the back trajectories. In contrast, on May 3, 2009, at the same site, BC and BrC contents are much less (2 mg/m2), while AS still maintains a high level . Combined with the associated back trajectories, the composition likely reflects a typical European pollution transport event, in which fine particles such as inorganic salts are dominant45. Aerosol compositions and back trajectories of the two events at HOR also imply different sources. The high BC and BrC concentrations on May 2–3, 2006, indicate major agricultural combustion sources from eastern Europe46. The one on July 12, 2015, in comparison, is likely caused by pollution from North America, considering the extremely low BC and BrC fraction (1% of dry mass) but very high AS content (91%).To identify the major sources of several typical aerosol events in the Arctic, the NOAA Hybrid Single-Particle Lagrangian Integrated Trajectory43. Specifically, the BrC-to-BC ratio of the event on July 25–26, 2012 reaches ~8, indicating a typical biomass burning aerosol event originating from Russia47. According to the aforementioned events, one notices that the biomass burning particles transported to the Arctic usually contain high BC and BrC contents (approximately 10–40% of dry aerosol mass). However, for Arctic haze or pollution events, the AS mass is extremely high (close to or exceeding 90%), while the light-absorbing components occupy only approximately 1% of the dry aerosol mass.For the two events at RES, the high contents of carbonaceous components and the back trajectories imply primary biomass burning sources from North America. Both of the events at the TIK site also show very high BC and BrC mass fraction (30–40%), which is consistent with other studiesTOA, RFBOA and RFATM of the high aerosol load cases over the Arctic are shown in Fig. TOA is approximately 8.4 W/m2, with remarkable differences among sites (ranging from −41.2 to 98.7 W/m2). The RFTOA generally increase with surface albedo for small to medium albedo values; when albedo >0.5, most RFTOA values are positive, and vice versa48 , the behavior is not obvious , and most RFTOA values are positive when BC exceeds 3 mg/m2 :CMi is the columnar mass concentration of the ith component. The coefficient ai denotes RFATM per unit columnar mass concentration (in W/mg) of individual components, which can be interpreted as the warming (positive) or cooling (negative) efficiency of aerosol components . The model constant c indicates the model bias (c = 9.0). The coefficients are statistically significant according to t-test results . The adjusted determination coefficient over 0.9 and the small standard error of the estimate illustrate that this model is statistically effective.To analyze the relation between component mass concentrations and RFATM. Figure ATM from a previous study (12.9 W/mg)49 . It is worth noting that AS has little impact on RFATM although its contribution to dry mass is dominant, because of its efficiency at the BOA is similar to that at the TOA (−0.3 W/mg).The standardized partial regression coefficients for BC and SS are 0.93 and −0.12, respectively, indicating the relative impacts of these components on RFColumnar aerosol component mass concentrations of high aerosol load cases for 8 Arctic sites are obtained from the microphysical parameters retrieved from the AERONET archive. The uncertainties of the input parameters are propagated to the resulting aerosol composition. The total light absorption calculated from the inferred absorbing components agrees well with observed absorption AOD. The HYSPLIT back trajectory model is employed to identify the major emission sources contributing to the observed high aerosol load events over the Arctic. The estimated aerosol composition, together with aerosol optical, microphysical and radiative properties from AERONET data, show the dominance of fine mode aerosols over the Arctic, especially for high aerosol load cases.The multiyear average AOD at 500 nm for the sampling periods and sites is 0.08 ± 0.08, with an average FMF of 0.75 ± 0.16. In particular, approximately 91% of large AODs  correspond to very high FMFs, implying a significant contribution to total light extinction from fine particles.For high aerosol load cases in the Arctic, columnar aerosol components, including BC, BrC, DU, AS, SS and AW, are estimated from microphysical parameters, including refractive index, size distribution and spherical fraction. The light-scattering and fine-mode component AS dominates aerosol dry mass (approximately 68%). BC and BrC make smaller contributions to aerosol mass, but account for most of the total aerosol light absorption. DU and SS components that are mainly from natural sources have much lower mass concentrations compared to the fine components.According to the HYSPLIT back trajectories of the high aerosol events in the Arctic, events originating from biomass burning usually correspond to high BC and BrC mass fractions (10–40%), but for pollution events, AS fractions are extremely high (approximately 90%), while the fractions of light-absorbing components are small.TOA over the Arctic are probably due to varying BC mass, as well as surface albedo and solar zenith angle. The average RFATM for high aerosol events is 47.3 ± 39.9 W/m2, indicating significant aerosol warming effects on the atmosphere under high-AOD conditions. The composition-RFATM regression model shows that BC contributes most to the RFATM, with a high warming efficiency (12.2 W/mg), while SS has a minor cooling effect.The considerable variations in RFSupplementary information


The self-management of type 2 diabetes mellitus (T2DM), which involves adherence to medical instructions on diet and nutritional advice, physical activity, medication regimen, and weight and stress management, is necessary for the treatment of T2DM.In this study, we investigated the relationship between patients’ perceptions of their disease and their adherence to their medications. And we attempted to determine whether distinct subphenotypes of behavioral change of medication adherence can be discerned based on a patients’ perceptions.A cross-sectional study using a questionnaire was conducted among 157 patients with T2DM from October 2015 to September 2017. Questionnaires were administered to assess the participants’ demographic and clinical characteristics, medication adherence, diabetes knowledge, and perception of being diabetic. Principal component analysis (PCA) and cluster analyses were performed to classify medication adherence patterns in the total cohort. Multiple regression analyses were performed to identify the determinant factors of medication adherence.PCA showed the interpretable medication adherence of patients with diabetes by using component 1  and component 2 (“status of taking medicines”). We identified four groups that show significantly different medication adherence by using cluster analysis on the basis of the two components. Multiple regression analysis showed that body mass index (BMI), family history of diabetes, one factor of patient’s perception (living an orderly life), and diabetes knowledge were found to be significant predictors of medication adherence in patients with T2DM.In patients with T2DM, the patient’s diabetes perception of “living an orderly life” is associated with medication adherence. A poor adherence group may be able to change their adherence to diabetes treatment by developing the perception of “living an orderly life.”The online version of this article (10.1186/s40780-019-0132-8) contains supplementary material, which is available to authorized users. People with chronic conditions must be capable of self-management to protect their own health. Healthcare providers should provide support for patients facing health challenges who need assistance . HoweverSelf-management of type 2 diabetes mellitus (T2DM), which involves adherence to medical instructions on diet and nutrition, physical activity, medication regimen, and weight and stress management, is necessary for treating T2DM –6. AdherAdherence to medical instructions and glycemic control are affected by several factors such as knowledge about diabetes , self-efIllness perception questionnaires for various medical conditions have been developed recently to examine patients’ perceptions about their diseases, symptoms, and causes . KamatanThe primary aim of this study was to investigate the relationship between patients’ perceptions of T2DM and medication adherence. Secondary aims were (1) to categorize a behavioral subphenotypes of medication adherence in T2DM using a custom medication adherence assessment tool, developed by Ueno et al. (2) to report the behavioral profile associated with the behavioral subphenotypes of medication adherence,, and (3) to investigate the relationship between behavioral subphenotypes of medication adherence in T2DM.A cross-sectional study using a questionnaire was conducted from October 2015 to September 2017. This study included adults who were (1) aged over 20 years, (2) diagnosed with T2DM for at least one year, and (3) outpatients of a community pharmacy or a hospital in the Ishikawa Prefecture. The patients were recruited at a community pharmacy (Aozora Pharmacy) or at the Japan Community Healthcare Organization (JCHO) Kanazawa Hospital and Kanazawa University Hospital. After obtaining informed written consent, data was collected using an interview questionnaire that had four domains, namely: (1) demographic and clinical characteristics, (2) medication adherence, (3) illness perceptions about diabetes, and (4) diabetes knowledge.The experimental methods were approved by the Kanazawa University of Medicine Ethics Committee and the JCHO Kanazawa Hospital Ethics Committee. All work was conducted in accordance with the Declaration of Helsinki and ethical principles for clinical research. Written informed consent was obtained from all patients.We collected data on patients’ age, sex, body mass index (BMI), diabetes duration, family history of diabetes, microvascular complications, important comorbidities, and treatment modalities (different types of insulin therapy). Their glycemic control levels (HbA1c), number of medications, number of doses per day, history of microvascular complications, and important comorbidities were obtained from the chart data. The microvascular complication status was defined as the presence of retinopathy, neuropathy, or nephropathy.Ueno et al.  developeThe illness perception questionnaire, developed by Kamatani et al. , was useWe used the revised Michigan Diabetes Knowledge Scale (DKT)  to measuThe significance of the demographic characteristic differences among the study patients was assessed using the Mann–Whitney U test or Fisher’s exact test between two sets of observations, and the Kruskal–Wallis test was performed for three or more variables. The statistical significance of the individual differences was evaluated using Haberman’s residual analysis and the Bonferroni method if the analysis of variance was significant. The relationships between the total medication adherence score and the patient characteristics were analyzed using Spearman’s rho statistic (ρ).Principal component analysis (PCA) and cluster analyses were performed for the total cohort. Medical adherence patterns were extracted with PCA using the correlation matrix. To determine the number of retained components, the proportion of the variance explained by the components was used. In particular, two components were retained because they explained 85% of the medication adherence. For multiple group comparisons of patient perception and patient characteristics between medication adherence groups, we used analysis of variance. For correlations among age, BMI, family history of diabetes, two factors of illness perceptions about diabetes (factor 2: living an orderly life and factor 6: feeling of overindulgence), and diabetes knowledge, Spearman’s correlation coefficient was used. Subsequently, we conducted multiple regression analyses with medication adherence as the dependent variable.p-value < 0.05 considered statistically significant.Data from the questionnaires were analyzed using the Statistical Package for Social Sciences , with a . The two groups were comparable regarding diabetes duration, diabetes knowledge, and patient’s perceptions; however, the mean age and the proportion of the females in the community pharmacy patients were higher than those of the hospital patients. Moreover, more of the hospital patients received insulin treatments than the community pharmacy patients. The mean age for the total sample population was 65.8 years, and the sample population was comprised of 69.2% men. The patients’ median BMI was 24.0. The sex distribution and age of this sample population were different from those of the whole population of the hospital and community pharmacy. The median duration of diabetes in the sample population was 11.0 years. A positive family history of diabetes mellitus was reported by 55.3% of the sample population. Approximately 30% of the sample population reported having complications, including diabetic retinopathy (8.8%), diabetic nephropathy (6.3%), diabetic neuropathy (10.1%), and cardiac problems (11.3%). Insulin therapy was administered to 34% of the patients. The number of doses taken by the patients was 8 per day, and 5 medications were prescribed. The average total score of knowledge about the disease  was 9.8 .A total of 90 and 67 patients with T2DM participated in the hospital and community settings, respectively. The participants’ demographics in each setting are shown in Table 1Table . The corresponding eigenvalues give the information percentages explained by these factors, namely, 52.5 and 23.8% for diabetic patients after the projection of variables and diabetic patients represented by components 1 and 2, respectively)  by dividing the patient cohort into four groups. Table Multiple regression analysis was performed to analyze predictors of medication adherence. BMI, family history of diabetes, one factor of patient’s perception (factor 2: living an orderly life), and diabetes knowledge were found to be significant predictors of medication adherence of patients with T2DM Table .Table 6MThe explanatory variables of interest were BMI, family history of diabetes, patient’s perception, and diabetes knowledge. Table We found that our study T2DM cohort was to categorize to four distinct subphenotypes according to a behavioral subphenotypes of medication adherence in T2DM patients using a validated medication adherence scale and moreover the good adherence group was significantly associated with the patient’s perception of “living an orderly life.”Diabetic patients adherence to their medication schedules more closely if they believe in medication efficacy and perceive their illness as manageable –34. PatiMeasuring patient perception by Kamatani’s method showed that diabetic patients who lived an orderly life had good medication adherence. Better adherence might be related to beliefs in medication efficacy and illness perceptions. Patients’ perceptions change their viewpoint regarding life with T2DM, i.e., whether life goes forward depends on the disease or on their own initiative to live life responsibly. We hypothesized that positive recognition of diabetes and/or understanding of diabetes could be positively associated with the good medication adherence of T2DM patients. Therefore, we suggested devising strategies to promote illness perception that will help patients develop a customized diabetes health plan.As another predictor of medical adherence in T2DM patients, BMI, diabetes knowledge, and family history of diabetes were identified. Tominaga et al. reported that older age was significantly associated with better medication adherence . A high There is a correlation between disease perception and health outcomes because self-management is complex. It involves complicated decision making that depends on the patients’ perception of their illness in terms of whether it is controllable, understandable, curable, or serious –50. We hThis study has several limitations. The responses from the questionnaires were based on self-declaration; therefore, they are prone to potential errors and misunderstanding of the questions. In particular, the results of medication adherence may be subjected to recall bias and social desirability bias, especially when it comes to sensitive questions such as medication adherence. A cross-sectional design with convenience sampling was adopted in this study. There is a difference in the baseline characteristics of patients in the hospital vs. community settings, such as age and gender, considering that patients who have been visiting a pharmacy for a long time might readily agree to participate in this study. This could be a limitation as selection bias might have occurred for participants from the pharmacy.We found that medication adherence in patients with T2DM is presumed by BMI, diabetes knowledge, family history of diabetes, and the diabetic patient’s perception of “living an orderly life.” Patients who have a perception of “living an orderly life” have good medication adherence. It may be beneficial to tailor health risk communications targeting T2DM to match the recipients’ personality characteristics instead of using the “one-size-fits-all” approach. Future prospective studies are required to confirm the therapeutic effects of behavioral interventions for the perception of diabetes.Additional file 1:Table S1. Medication adherence questionnaire. (DOCX 16 kb)Additional file 2:Table S2. Patients’ perceptions of diabetes questionnaire. (DOCX 16 kb)Additional file 3:Table S3. Revised Michigan Diabetes Knowledge Scale (DKT) - True/False Version. (DOCX 15 kb)