CRC) most likely through the activity of its fermentation product, butyrate. Butyrate functions as a histone deacetylase inhibitor (HDACi) that hyperactivates Wnt signalling and induces apoptosis of CRC cells. However, individuals who consume a high‐fibre diet may still develop CRC; therefore, butyrate resistance may develop over time. Furthermore, CRC cells that are resistant to butyrate are cross‐resistant to clinically relevant therapeutic HDACis, suggesting that the development of butyrate resistance in vivo can result in HDACi‐resistant CRCs. Butyrate/HDACi‐resistant CRC cells differ from their butyrate/HDACi‐sensitive counterparts in the expression of many genes, including the gene encoding vimentin (VIM) that is usually expressed in normal mesenchymal cells and is involved in cancer metastasis. Interestingly, vimentin is overexpressed in butyrate/HDACi‐resistant CRC cells although Wnt signalling is suppressed in such cells and that VIM is a Wnt activity‐targeted gene. The expression of vimentin in colonic neoplastic cells could be correlated with the stage of neoplastic progression. For example, comparative analyses of LT97 microadenoma cells and SW620 colon carcinoma cells revealed that although vimentin is not detectable in LT97 cells, it is highly expressed in SW620 cells. Based upon these observations, we propose that the differential expression of vimentin contributes to the phenotypic differences between butyrate‐resistant and butyrate‐sensitive CRC cells, as well as to the differences between early‐stage and metastatic colorectal neoplastic cells. We discuss the hypothesis that vimentin is a key factor integrating epithelial to mesenchymal transition, colonic neoplastic progression and resistance to HDACis.Dietary fibre protects against colorectal cancer ( Such hyperactivation of Wnt signalling takes place when CRC cells with APC or CTNNB1 mutations are exposed to butyrate; under such conditions, the growth suppressive and apoptotic effects of butyrate are linearly and causatively correlated with the fold up‐regulation of Wnt activity Wnt activity results from increased levels of active beta‐catenin, which associates with DNA‐binding Tcf factors to stimulate transcriptional activity from various genes i.e. beta‐catenin‐dependent) to increased non‐canonical (not dependent upon beta‐catenin) Wnt signalling mediates the butyrate‐resistant HCT‐R cell phenotype However, individuals with a high‐fibre diet may still develop CRC, and such colonic neoplastic development could be attributed to the acquisition of resistance to the chemopreventive action of butyrate. To evaluate the mechanisms leading to butyrate resistance, we have developed a butyrate‐resistant CRC cell line, HCT‐R, which is also cross‐resistant to clinically relevant therapeutic HDACis; HCT‐R cells were derived from butyrate/HDACi‐sensitive HCT‐116 cells However, these findings do not entirely explain the butyrate‐resistant phenotype of HCT‐R cells; thus, additional genes that influence colonic cell physiology likely contribute to the development of butyrate resistance. In support of this possibility, microarray analyses have revealed that vimentin is overexpressed in butyrate‐resistant HCT‐R cells compared to butyrate‐sensitive parental HCT‐116 CRC cells VIM, the gene encoding the intermediate filament protein vimentin involved in cellular structure and integrity, is a Wnt activity‐targeted gene expressed in normal mesenchymal cells. Vimentin influences cell shape and motility in the process of EMT that occurs during metastasis (i) the neoplastic progression in the colon and (ii) the acquisition of a butyrate/HDACi‐resistant phenotype. This question could be addressed by examining in vitro models of the progressive neoplastic phenotypes in the colon. Below we discuss two such cell culture‐based models: LT97 microadenoma cells and SW620 colon carcinoma cells.In vitro studies investigating preventive approaches against CRC have typically used carcinoma cells, instead of cells representative of earlier stages of colonic neoplasia (i.e. adenoma stage). It is likely that the preventive action of butyrate is most effective at the early stage of colonic neoplasia. Thus, studies on the effects of fibre, the dietary source of butyrate, have reported an inverse association of fibre intake with adenoma risk in vitro model of CRC progression to metastasis. SW620 cells were derived from a lymph node metastasis of a primary colon tumour; whereas cells from the primary tumour in the same patient were used to establish the SW480 cell line In contrast to LT97 cells, SW620 cells represent an Based upon the understanding that LT97 and SW620 cells represent the very early and late stages of colonic tumorigenesis, respectively, we have performed comparative microarray analyses of these cells to identify differences in basal and butyrate‐modulated gene expression. The screening studies consisted of a single replicate of a full human genome analysis to identify genes of interest, and selected gene targets were subsequently validated by Western blot analyses p21 promoter activity Vimentin is a potential cancer therapeutic target, since it is overexpressed in a number of cancers, and it is linked to metastatic progression osteocalcin gene promoter; therefore, vimentin represses osteocalcin expression and inhibits osteoblast differentiation Vimentin also associates with the transcription factor ATF4, interfering with that factor's interaction with the Our hypothesis that vimentin is a key factor integrating EMT, neoplastic progression and resistance to HDACis in the colon Fig.  is suppoe.g. HCT‐R cells) and SW620 metastatic CRC cells; whereas vimentin will be overexpressed in butyrate‐sensitive cells . A complimentary experimental approach is that of applying the tumour inhibitor and antiangiogenic agent The hypothesis can be tested by vimentin knockdown and overexpression experiments Fig. . VimentiWe expect that the knockdown of vimentin in butyrate‐resistant, p300‐deficient HCT‐R cells will not only reverse the EMT‐like phenotype, but, considering the association between EMT and butyrate/HDACi resistance, would at least partially reverse this resistance. Exogenous vimentin overexpression in butyrate‐sensitive CRC cells such as HCT‐116 is expected to promote a more EMT‐like phenotype and allow for increased resistance to the effects of butyrate and HDACis. Resistance to HDACi‐induced cell growth inhibition and apoptosis will be evaluated not only for butyrate but also for clinically relevant therapeutic HDACis such as vorinostat and LBH589. Further, the knockdown of vimentin is expected to at least partially reverse the EMT‐like phenotype observed in the p300‐KO HCT‐116 cells, providing support to the hypothesis that increased vimentin expression in these cells mediates the effects of p300 deficiency on cell physiology.The interpretation of the experimental data for the metastatic SW620 cells would be more challenging. Thus, these cells exhibit a degree of EMT phenotype and relatively high levels of vimentin; however, they are still moderately sensitive to the cell growth and apoptotic effects of butyrate compared to nine other CRC cell lines e.g. proliferation, apoptosis, adherent‐independent growth, migration and invasiveness) to ascertain the relative role of these genes in the vimentin‐mediated association between EMT and HDACi resistance. Therefore, full human genome microarray analyses need to be performed on the aforementioned cell lines. Once changes in relevant gene expression are confirmed at the protein level, overexpression and knockdown experiments would be employed to ascertain (i) the vimentin‐targeted genes (the expression of which is directly or indirectly modulated by vimentin) that act downstream of vimentin to influence cell phenotype, and (ii) the genes that are not vimentin‐targeted genes (i.e. genes the expression of which is not modulated by vimentin) that cooperate with vimentin in modulating cell phenotype. One expectation is that, consistent with a role for vimentin in promoting neoplastic progression, vimentin KO SW620 cells would exhibit a gene expression profile more similar to that found in early‐stage LT97 microadenoma cells.A comparison of the gene expression profiles of high‐vimentin butyrate‐sensitive SW620 cells to HCT‐R cells ± vimentin knockdown, and HCT‐116 cells ± vimentin overexpression, as well as to LT97 cells, will identify gene expression that cooperates with vimentin in the proposed vimentin‐mediated association between EMT and butyrate/HDACi resistance. The identified differences in gene expression will be correlated with changes in cell phenotype , to the promoter regions of relevant genes whose expression is altered by vimentin. Column chromatography studies using bound vimentin and relevant cell extracts will be used to identify novel binding partners and activities for vimentin that mediate direct or indirect effects of vimentin on gene expression and cell signalling. Thus, novel functions of vimentin in modulating gene expression in CRC, influencing carcinogenesis, neoplastic progression and butyrate resistance, will be ascertained by in vitro studies will be followed up by in vivo studies. For example, vimentin KO mouse models exist, and vimentin KO mice have been shown to be less sensitive to colitis than their wild‐type counterparts Apc (Apcmin) exhibits vimentin expression in intestinal adenomas min mice is expected to produce hybrid mice that are more sensitive to the tumour‐suppressing effect of butyrate than Apcmin mice min mice are also expected to show greater sensitivity to HDACis and a less pronounced EMT phenotype, compared to cells derived from Apcmin adenomas. We also anticipate that exogenous expression of vimentin in the vimentin KO‐Apcmin cells will (i) reverse any observed increase in the HDACi sensitivity and (ii) promote a more mesenchymal phenotype.The Vimentin, through its effects on cancer cellular morphology and cell signalling/gene expression cascades, likely integrates the process of EMT with the acquisition of resistance to butyrate and other HDACis. The result of such activity would be the establishment of metastases of drug‐resistant CRC cells. Therefore, vimentin might be a relevant target for cancer therapeutic interventions. In this paper, we have discussed supporting evidence for our hypothesis and have outlined the experiments that will address the hypothesis.The authors confirm that there are no conflicts of interest.


Respiratory Syncytial Virus infections are one of the leading causes of severe respiratory diseases that require hospitalization and, in some cases, intensive care. Once resolved, there may be respiratory sequelae of varying severity. The lack of effective treatments for bronchiolitis and the lack of vaccines for RSV accentuate the role of prevention in decreasing the impact of this disease.Prevention of bronchiolitis strongly relies on the adoption of environment and the hygienic behavior measures; an additional prophylactic effect may be offered, in selected cases, by Palivizumab, a humanized monoclonal antibody produced by recombinant DNA technology, able to prevent RSV infection by blocking viral replication.After many years the Italian Society of Neonatology, on the basis of the most recent scientific knowledge, has decided to revise recommendations for the use of palivizumab in the prevention of RSV infection. Respiratory Syncytial Virus infections are one of the leading causes of severe respiratory diseases that require hospitalization and, in some cases, intensive care. Once resolved, there may be respiratory sequelae of varying severity.The respiratory syncytial virus (RSV) was isolated for the first time in 1955 in a monkey. In man, the virus was described in 1957 in two neonates presenting with an airway infection Palivizumab   is a humThe multicenter, randomized, double-blind, controlled clinical study IMpact  licensed in 1998 used palivizumab at the dosage of 15 mg/kg administered via intramuscular injection once a month, during the epidemic season, for a total of 5 administrations . DespiteThe study performed by Robbie et al.  also ass[Level of evidence II – strength of recommendation A]The efficacy and safety profile of palivizumab was proved by a multicenter, randomized, double-blind, controlled clinical trial  .1502 preterm babies of ≤ 35 weeks gestational age (GA) and ≤ 6 months of age at the beginning of the epidemic season, or preterm babies suffering from bronchopulmonary dysplasia (BPD) ≤ 2 years of age at the beginning of the epidemic season and requiring specific medical therapy  in the 6 months preceding the beginning of the epidemic season, were randomized to receive palivizumab by intramuscular injection at the dose of 15 mg/kg once a month for 5 months or placebo.n = 500) compared to subjects who received placebo (n = 1002).The results obtained showed a statistically significant decrease by 55 % (from 10.6 to 4.8 %) in RSV-related hospitalizations in subjects who received palivizumab   recommenSubsequent modifications of the AAP recommendations concerning the use of palivizumab , 15, 31 It must be pointed out that other data available in literature do not agree with this report, citing varying gestational age cut off values as the decisive elements underlying higher and lower risks of hospitalizations in preterm neonates , 34.For this reason, it is difficult to establish a gestational age “threshold” differentiating between a high risk and a lower risk in preterm neonates of less than 32 weeks GA. It is undeniable that risks of RVS-related hospitalization decrease as gestational age increases, but such decrease occurs progressively and not on a step-by-step basis. All this appears to be consistent with the position of the Cochrane Review that, when discussing the efficacy of palivizumab in preventing RSV Hospitalization, generically states “… evidence that palivizumab is effective in reducing incidence of severe lower respiratory tract infection in neonates suffering from CLD or CHD and in preterm babies”, and does not touch upon gestational age subgroups but only uses the generic definition of “preterm” .A pragmatic approach might in any case take into account the coexistence of specific risk factors alongside gestational age alone.A recent paper by Lanari et al.  concerniIt must be also noted that the Italian study states that for the majority of hospitalizations because of RVS infection occurred during the first six months of life .Lacking any clear scientific evidence, neonates of 29–35 weeks GA may receive prophylaxis, limited to the first 6 months of life, in the presence of risk factors for severe RSV infection. The risk factors identified by various studies are: male gender, exposure to maternal smoke and secondhand smoke, treatment with surfactant, living with siblings aged <10 years, attendance at daycare and births occurring close to or during the epidemic season –45. All For infants of gestational age <29 weeks and age ≤12 months at the beginning of the epidemic season: LEVEL OF EVIDENCE II – Strength of recommendation A.For infants of 29–35 weeks gestational age and age ≤6 months at the beginning of the epidemic season, prophylaxis with Palivizumab might be taken into consideration in presence of risk conditions predisposing to severe infections and/or need for hospitalization.[LEVEL OF EVIDENCE IV – Strength of recommendation B]There are no data supporting the use of palivizumab to control hospital epidemics in the Neonatal Intensive Care Unit or in Neonatology wards , 15.2 therapy for at least 28 days after birth, and severity is defined based on the need for respiratory support required at 36 weeks post menstrual age In Italy, approximately 8 neonates out of 1000 suffer from congenital heart disease.In 1982, MacDonald et al. reported for the first time that children with congenital heart disease are at increased risk of severe lower airway respiratory diseases associated with RVS infections .Subsequent studies confirm that these children present an increased risk of hospitalization, with longer hospital stays, admission to the intensive care unit, and frequent need for oxygen therapy and mechanical ventilation for longer periods compared to children without any risk factors –53.Cumulative data from recent published reviews, confirmed an increased mortality rate within patients with significant congenital heart disease (CHD) associated with RSV, even if mortality seems to be in marked decline through years , 55.Moreover, the higher risk of hospital-acquired infection caused by RVS is an unfavorable perioperative prognostic factor in heart diseases with surgical indication.p = 0.003) and a decrease in morbidity and in need of intensity of care. Prophylaxis with palivizumab appeared to be effective also in patients with non-cyanogenic heart disease. No case of adverse effects of prophylaxis on surgical outcome was noted.In 2003 Feltes et al.  publishe[LEVEL OF EVIDENCE IV – Strength of recommendation A]Infants with cyanogenic heart disease prior to the surgical procedure or after a palliative procedure, on indication of the pediatric cardiologist based on the hemodynamic status of the patient. [LEVEL OF EVIDENCE II – Strength of recommendation A]infants with non-cyanogenic heart disease on therapy for congestive heart failure and who are scheduled to undergo surgery; [LEVEL OF EVIDENCE II – Strength of recommendation A]infants with moderate to severe pulmonary hypertension; [LEVEL OF EVIDENCE II – Strength of recommendation A]Infants with surgically repaired congenital heart disease who continue to need therapy for congestive heart failure; [LEVEL OF EVIDENCE II – Strength of recommendation A]infants suffering from congestive cardiomyopathy on treatment with anti-congestive medication; [LEVEL OF EVIDENCE II – Strength of recommendation A]infants on the waiting list for heart transplantation or in the post-transplantation period. Based on the currently available data in literature, it may be considered useful to recommend palivizumab prophylaxis for children with hemodynamically significant congenital heart disease, younger than 12 months at the beginning of the epidemic season, and who meet the following criteria:Palivizumab prophylaxis is not required in patients with non-hemodynamically significant congenital heart disease .The current indications proposed by the Italian Society of Pediatric Cardiology (SIPC) are summarized in the intersociety document .In consideration of a 58 % decrease in mean palivizumab concentrations observed in children who undergo surgical procedures with need for cardiopulmonary bypass graft during prophylaxis, administration of an additional dose of palivizumab after surgery is recommended .Children who underwent heart transplantation during the epidemic season might benefit from palivizumab prophylaxis also during their second year of life , 15.Lung malformations or neuromuscular diseases: in children with neuromuscular diseases or anatomical abnormalities of the lungs with impaired lower airway clearance, pulmonary malformations, tracheoesophageal fistula, severe upper airway dysfunction or tracheostomy, palivizumab prophylaxis might be taken into consideration during the first year of life The conclusions of these recommendations are summarized in Table Italian Society of Neonatology hopes that this document will be useful for all neonatologists and pediatricians involved in the management of infants at risk of RSV infection, and suggests that these recommendations should be revised almost every 3–5 years on the basis of future researches.These recommendations are been compiled for being used in the Italian population and they are based on Italians epidemiological data and on other inter-society documents.


VPT), which can have profound effects on their school achievement and everyday life. However, to date, little is known about the development of the neuroanatomical substrates of memory following VPT birth. Here we focus on episodic and working memory and highlight key recent functional and structural magnetic resonance imaging (MRI) studies that have advanced our understanding of the relationship between alterations seen in the VPT brain and typical neurodevelopment of networks supporting these memory functions. We contrast evidence from the episodic and working memory literatures and suggest that knowledge gained from these functional and neuroanatomical studies may point to specific time windows in which working memory interventions may be most effective.Deficits in memory function have been described in children and adolescents who were born very preterm ( This article highlights how typical brain injuries associated with very preterm birth can interact with the typical development of episodic and working memory networks.By drawing on the lessons of 15 years of neuroimaging studies, suggested targets for cognitive interventions are proposed.  VPTVery pretermIndividuals who were born very preterm  are more likely to exhibit memory deficits compared with term‐born controls, which could impact their school performance and everyday life.After summarizing the organization of episodic and working memory in the typically developing brain, we will examine the structural alterations and injuries that are likely to impact specific memory components in VPT samples. Thirdly, we will describe the mechanisms by which the brains of VPT individuals may attempt to overcome such structural alterations. Lastly, we will contrast the findings from episodic and working memory, and discuss the possible implications these may have for cognitive interventions that aim to ameliorate the cognitive profile of VPT children.n=16) and (primarily) ‘functional’ (n=11) studies, and are shown in Tables Research on the structural and functional memory correlates in VPT samples is presented systematically. Studies were identified using PubMed with the search terms . There were no restrictions on the year the studies took place. Studies in any language were considered. This search was supplemented by hand searching of reference lists of published articles. Studies were included if a group of individuals born preterm (including very or extremely preterm) were compared with a group of controls using quantitative structural MRI, and quantitative structural measures were correlated with memory outcome measures; or, for fMRI studies, if a group of individuals born preterm (including very or extremely preterm) were required to perform an fMRI memory task and activation was compared with a control group. The PubMed search produced 90 articles; 26 of these met the inclusion criteria. One additional article that was found through manually searching the references met the inclusion criteria. The outcomes of these searches were then divided into ‘structural’ n=6 and , and spatial information . The hippocampus is thus in an ideal position to bind object information  with spatial information , to form memories of complete episodes.The hippocampus develops rapidly during the first 2 years of life, and then more gradually until it reaches its peak volume between the ages of 9 years and 11 years.The increased reliance on cortical support for episodic memory occurs in parallel with the maturation of the brain's connectional architecture. The fornix – the main hippocampal connection to other subcortical structures – reaches maturity early, at about 5 years of age.The periventricular location of the hippocampus makes it particularly vulnerable to damage following VPT birth. Reductions in volume in the hippocampus, as well as the interconnected thalamus and posterior cingulate cortex, are already present at term‐equivalent age and are related to the degree of prematurity.As the brain structures centrally implicated in episodic memory do not appear to catch‐up developmentally, even by early adulthood, individuals born VPT may find alternative means of successfully completing tasks requiring episodic memory processing. Various studies have focused on how VPT individuals can bind information to form memories and later recall that information despite structural damage to the core circuit. In an early combined structural/functional MRI study Giménez et al. showed evidence that lateralized structural deficits to the hippocampus in a heterogeneous sample of VPT adolescents can be partially compensated by an increase in functional activation of the contralateral hippocampus.In two recent studies, we analysed the dynamics of how VPT individuals and controls learn memory associations and showed that ‘pure’ memory deficits can be understood in the context of neuroanatomical alterations occurring during learning. Salvan et al. used a task in which participants were required to learn associations between two words across repeated experimental blocks, and were later asked to remember them during a cued recall task.Figure Current working memory capacity depends primarily on a fronto‐parietal system that involves dorsomedial, dorsolateral, and ventrolateral prefrontal cortex, as well as medial and lateral portions of the posterior parietal cortex.The involvement of the hippocampus in working memory is strongly disputed, although it appears that dependence on this structure is seen mainly in childhood,Working memory deficits have been described in childhood following VPT birth (see AndersonIn line with the possible role of striatal structures in the acquisition of working memory abilities in typical development described above, neonatal striatal and thalamic injury is predictive of working memory abilities at age 7 years in VPT children.A summary of structural MRI studies in relation to memory functions in VPT samples is provided in Table Despite considerable neuropsychological evidence of working memory deficits in children born VPT, there have been surprisingly few fMRI studies investigating their functional neuroanatomical underpinnings. Taylor et al. used an fMRI task requiring basic visual working memory processing, and showed evidence of decreased activation in preterm children versus controls in regions belonging to both early and mature working memory systems, namely the right medial temporal and left medial parietal cortices respectively.Figure A summary of functional MRI studies in relation to memory functions in VPT samples is provided in Table To date, studies of memory deficits in VPT samples have focused on episodic and working memory. The available evidence suggests that structural deficits to the hippocampus and connected structures following VPT birth may be long‐lasting, affecting episodic memory abilities from childhood to early adulthood. Functional and structural alterations to hippocampal–cortical networks are also associated with working memory deficits in VPT children. The lack of concluding evidence for an association between hippocampal‐related deficits and working memory function in adolescents or adults born VPT (with the exception of Aanes et al.'s studyAlthough more research is needed, current evidence suggests that working memory may be a more promising target than episodic memory for cognitive training in VPT individuals. Moreover, interventions may be more effective if applied at an age when frontal and parietal cortices are sufficiently developed to be able to undertake such tasks, yet still maturing, so that focused interventions could exploit their residual neuroplastic capacity. Lastly, future research should include the identification of areas outside the typical memory‐specific networks that may be engaged in VPT samples as a result of neural adaptation, to successfully perform specific cognitive tasks.


UK fewer than 15% of familial hypercholesterolemia (FH) cases are diagnosed, representing a major gap in coronary heart disease prevention. We wished to support primary care doctors within the Medway Clinical Commissioning Group (CCG) to implement NICE guidance (CG71) and consider the possibility of FH in adults who have raised total cholesterol concentrations, thereby improving the detection of people with FH.In the Audit+) we developed an FH Audit Tool and implemented a systematic audit of electronic medical records within GP practices, first identifying all patients diagnosed with FH or possible FH and next electronically flagging patients with a recorded total cholesterol of >7.5 mmol L−1 or LDL‐C > 4.9 mmol L−1 (in adults), for further assessment. After a 2‐year period, a nurse‐led clinic was introduced to screen more intensely for new FH index cases. We evaluated if these interventions increased the prevalence of FH closer to the expected prevalence from epidemiological studies.Utilizing clinical decision support software (FH within Medway CCG was 0.13% (1 in 750 persons). After 2 years, the recorded prevalence of diagnosed FH increased by 0.09% to 0.22% (1 in 450 persons). The nurse advisor programme ran for 9 months (October 2013–July 2014) and during this time, the recorded prevalence of patients diagnosed with FH increased to 0.28% (1 in 357 persons) and the prevalence of patients ‘at risk and unscreened’ reduced from 0.58% to 0.14%.The baseline prevalence of FH. This systematic yet simple electronic case‐finding programme with nurse‐led review allowed the identification of new index cases, more than doubling the recorded prevalence of detected disease to 1 in 357 (0.28%). This study shows that primary care has an important role in identifying patients with this condition.Our study shows that two simple interventions increased the detection of  Familial hypercholesterolaemia (FH) is an autosomal co‐dominant lipid disorder that confers an increased risk of premature coronary heart disease (CHD) because of lifelong exposure to high concentrations of low‐density lipoprotein‐cholesterol (LDL‐C) LDLR‐coding sequencing mutation and had LDL‐C > 4.9 mmol L−1According to NICE, the prevalence of heterozygous FH in the UK population is estimated to be 1 in 500, which means that approximately 110 000 people are affected −1 for adults) on repeat measurements, family history, clinical history of premature CHD and tendon xanthomas and corneal arcus on physical examination. In the UK, the ‘Simon Broome Criteria’ are recommended to evaluate patients with raised LDL‐C [FH can be diagnosed using phenotypic criteria and genetic testing. These include very high LDL‐C  are well placed to lead on the identification of new index cases – the majority of LDL‐C measurements are requested within primary care and GPs have access to electronic patient records that lend themselves to simple electronic prompts and audits of patient data. The primary care approach to FH diagnosis can be opportunistic, relying on GPs to consider the diagnosis of FH in patients with elevated LDL‐C, or systematic, using an informatics‐based approach to search electronic patient records and identify people who fulfil the profile of FH for further review , 17.In 2008, NICE issued guidance for FH (CG71) recommending that health care professionals consider the possibility of FH in adults with raised cholesterol, especially in those with a personal or family history of CHD This study was conducted in NHS Medway CCG between October 2011 and July 2014. Medway is a CCG of 56 General Practices serving approximately 290 000 patients. Practice sizes range from 1499 to 19 818 people. In 2011, 37 200 people were aged >65 years and 4400 aged >85 years. The ethnic profile of east Kent shows that the population is predominantly white . Life expectancy in Medway is significantly worse than the average in England. Medway is ranked within the 41% most deprived boroughs nationally in The Index of Deprivation 2010 and includes an area ranked in the most deprived 3% of areas nationally. This study aligned with the overall vision of NHS Medway CCG – ‘from reactive to proactive for a healthier Medway’ – and with the strategic objective of disease prevention – ‘to prevent people becoming ill and to support people to live healthy and well through a systematic approach in primary care that identifies patients at risk’.This study utilized Audit+ software (BMJ), a cross‐platform, primary care data analysis tool that was designed specifically for use within consortia, CCGs and other commissioning organizations. Audit+ enables practices to manage their patient registers as defined in an audit specification, easily identify patients who require attention and set the software to prompt the clinician for intervention opportunities automatically when they consult a patient. Audit+ is used widely across NHS Medway CCG, with around 30 audits currently running. As practices are familiar with performing standard audits, no additional training for GPs was required.The FH Audit Tool was developed in accordance with the Royal College of GPs’ standard criteria for audits and was based on the recommendations of NICE CG71. Specifically, a diagnosis of FH was based on the Simon Broome criteria The nurse‐led clinics conducted in the second part of the study employed the Simon Broome Criteria as well as the DLCN criteria Table . This al−1 in adults or >6.7 mmol L−1 in children <16 years or LDL‐C > 4.9 mmol L−1 in adults or >4.0 mmol L−1 in children) for further assessment. These patients were termed ‘at risk and unscreened’. During the course of the next 2 years, electronic prompts appeared when the patient was in the practice that sought to enhance the GPs’ decision making on FH diagnosis and to help confirm or refute an FH diagnosis.The FH Audit Tool identified and flagged all patients at potential risk of FH according to elevated cholesterol , were referred to other health care professionals for health assessment and lifestyle advice. This pathway is shown in Fig. At the clinic, conducted at a patient's own GP surgery, the nurse explained the purpose of the clinic, provided a Patient Service User Guide and an FH education leaflet and obtained written consent. During the 30‐minute appointment, clinical examination for xanthoma or corneal arcus was conducted, and a family history recorded as specified in Simon Broome and DLCN. Cascade testing was discussed and if a diagnosis of FH was made, patients were provided with cascade letters to pass on to their first‐degree relatives. The role of lifestyle factors was discussed and information and advice were offered, aimed at improving patient concordance to prescribed lipid‐lowering medication and increasing the patient's understanding of their disease. The FH Nurse Advisors role was limited to discussing FH, disease severity and any management issues based on clinical assessment and current NICE guidelines. In the event of a patient not attending the clinic, the patient was flagged to the GP practice for appropriate follow‐up.After clinic completion, the FH Nurse Advisor attended the practice at a later date and worked with the practice to ensure the findings of the FH review were included in the electronic clinical records. Any medical interventions were decided by the GP. The Nurse Advisor made recommendations to the GP based on the clinic review – those patients diagnosed with FH were recommended for referral to secondary care for specialist management; probable or possible FH were recommended for management within primary care, but with secondary care referral if LDL‐C levels were not controlled, if there was previous referral to secondary care of a family member, or if there was a family history of vascular events.The majority of GP practices  in NHS Medway CCG participated in the Audit. Three practices without Audit+‐compatible IT systems were unable to take part and accounted for approximately 8000 patients (at study close in July 2014). Forty‐seven of 53 GP practices (89%) participated in the FH Nurse Advisor Programme. One practice closed during the nurse advisor programme, and the remaining five GP practices that did not participate in the nurse programme each serviced an average 5000 patients. Despite this, no areas of the CCG were excluded, as the areas of participating practices overlapped with non‐participating practices. The Nurse Advisor Programme reviewed the records of 1505 patients. Of 210 patients invited for clinic visits, 109 (52%) attended.The baseline recorded prevalence of FH within Medway CCG was 0.13% (1 in 750 persons). The proportion of patients ‘at risk and unscreened’ was 0.59% Fig. ; Table 4In terms of patient numbers, an additional 99 cases of FH were diagnosed during the 2‐year period. During the 9 months of the nurse advisor programme, an additional 334 cases were diagnosed – 192 with definite FH (DLNCS >8), 83 patients with probable FH (DLCNS 6–8) and 59 with possible FH (DLNCS 3–5). Overall, an additional 433 index patients with FH were identified within NHS Medway CCG  to one in 450 (0.22%) after 2 years. Opportunistic identification of patients with specific computer reminders had little impact on the number of patients identified as at risk and unscreened. The two‐stage process of systematic identification with FH nurse specialist assessment increased the proportion of patients diagnosed with FH to one in 357 0.28%), approaching the Danish and US estimated FH population prevalence of approximately one in 200 %, approa. The proGP participation in this study was high. The FH Audit Tool was incorporated in the majority of GP practices in Medway (95%) and all practices with compatible electronic patient record systems participated. Eighty‐nine per cent of eligible practices took part in the Nurse Advisor Programme with six eligible practices declining to participate, but the audit tool remained in use. The full geographical area of the CCG was covered, with the practice areas of participating practices overlapping with non‐participating practices. The proportion of patients accepting the invitation to the nurse clinic was high (52%). A further strength of the study is the timeframe, with FH prevalence recorded over an almost 3‐year period.An obvious limitation was the completeness of the electronic patient records. The FH nurse sought missing data from the health care professional or patient, but undocumented information may have resulted in missed diagnoses. This is particularly pertinent for family history of CHD, with patients perhaps unaware of the extent of CHD in their family or where such information had not been collected or recorded. This was a pragmatic clinical audit conducted in real‐world practice. As such, there was no retrospective review of patients previously coded as FH, either at baseline or after the introduction of DLNC to confirm the previous Simon Broome FH diagnoses. Coding in primary care is notoriously inaccurate, and therefore, the baseline prevalence reported may not be accurate.Identification of FH via the FH Audit Tool relies on a record of total cholesterol and or LDL‐C values in patients' electronic record. Patients aged 40 years and above are more likely to have lipid values recorded as a consequence of the NHS Health Check programme. Younger patients, in particular children and young adults, are unlikely to have lipid values on record. This points to the importance of identifying new index cases, which can then trigger cascade testing to identify younger family members who may not be identified by an electronic audit. It is unknown what proportion of the Medway population had lipid results available for assessment in this study.NICE guidance recommends genetic testing of all index cases and cascade testing of family members as a cost‐effective method for identifying new cases of FH The purpose of the audit was to increase detection of FH and suggest appropriate management of these patients based on NICE clinical guidance Our study demonstrates that there is an opportunity to increase the diagnosis of FH by exploiting the information contained within GP electronic patient records using automated systems. While each new diagnosis allows appropriate management and treatment of that person, an additional benefit is that each new case acts as a trigger for cascade testing to identify younger family members who may not otherwise be detected and who benefit most from early diagnosis and appropriate treatment. Ultimately improving diagnosis should lead to optimized therapeutic intervention and hence reductions in CHD in this high‐risk patient group. The next step is to enhance the FH Audit Tool to measure the impact of diagnosis on patient management and to provide the FH Audit Tool widely to other interested CCGs.http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that PG has received personal fees from BMJ, outside the submitted work. DN has received honoraria for participation in advisory boards for Genzyme, Roche, Aegerion, Sanofi and Amgen. DN has received sponsorship from MSD to attend an educational meeting. DN has been Newcastle upon Tyne hospital NHS Foundation Trust site investigator for clinical trials sponsored by KaraBio, MSD, Sanofi, Amgen and ISIS. DN is a Trustee and board member of HEART UK – the Cholesterol Charity and Co‐Chairman of the Familial Hypercholesterolemia Guideline implementation group and is a member of Newcastle FATS guideline group on lipid modifying treatment.All authors have completed the Unified Competing Interest form at Contributors: PG conceived and designed the audit design, with additional support from SEH and DN. PG was involved in data cleaning. PG, SEH and DN analysed the data. PG, SEH and DN wrote the first draft of the manuscript, which was then critically reviewed and revised by the other co‐authors. PG, SEH and DN are members of the Medway FH Steering committee. All authors and members of the Steering committee approved the final version of the manuscript for submission. All authors had full access to all of the data  in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.


To determine whether dizziness and falls rates change due to routine cataract surgery and to determine the influence of spectacle type and refractive factors.Self‐reported dizziness and falls were determined in 287 patients  before and after routine cataract surgery for the first , second  and both eyes . Dizziness was determined using the short‐form of the Dizziness Handicap Inventory. Six‐month falls rates were determined using self‐reported retrospective data.2 = 19.14,p < 0.001), but the reduction in the number of patients who fell in the 6‐months post surgery was not significant . Dizziness improved after first eye surgery  and surgery on both eyes , but not after second eye surgery . Multivariate logistic regression analyses found significant links between post‐operative falls and change in spectacle type . Post‐operative dizziness was associated with changes in best eye visual acuity and changes in oblique astigmatic correction.The number of patients with dizziness reduced significantly after cataract surgery  eye cataract surgery and this is linked with improvements in best eye visual acuity, although changes in oblique astigmatic correction increased dizziness. The lack of improvement in falls rate may be associated with switching into multifocal spectacle wear after surgery. Falls are the major cause of death and non‐fatal injuries in the elderly.et al.These studies suggest that providing cataract surgery to older people at risk of falling would lead to reductions in falls rates. However, although two open‐design intervention studies of cataract surgery found significant improvements in falls rates after cataract surgery,Self‐reported dizziness was also included as a principal outcome measure in this study. Dizziness is highly prevalent in the older population,We hypothesised that there are some factors associated with cataract surgery that lead to a relatively greater risk of falling (and increased dizziness) which may in some circumstances offset the reduction in falls risk (and dizziness) due to improvements in visual function. These could include the following:Increased anisometropia after first eye surgery.Adaptation problems to large changes in refractive correction.Switching to multifocal spectacles.Increased confidence leading to greater outdoor activities and increased fall risk.These factors were assessed and multivariate logistic regression analyses were used to determine whether they had a significant independent effect on post‐operative falls rates and self‐reported dizziness.As far as we are aware, this is the first study to attempt to determine why cataract surgery does not improve falls rate as much as expected and the first to evaluate the effect of cataract surgery on dizziness.Participants were recruited for this cohort study from the cataract waiting lists of two hospitals in the UK, Bradford Royal Infirmary and Yorkshire Eye Hospital, between July 1, 2012 and July 31, 2013. All patients 65 years and older who were listed for routine phacoemulsification with a monofocal IOL during this period were sent details about the study (~1240). The study was approved by the East of England NHS Research Ethics Committee and adhered to the tenants of the Declaration of Helsinki. All participants gave written, informed consent to participate in the study and for the research team to access their hospital medical records and contact their optometrist for relevant information regarding their refractive correction.Close to the surgery date participants were sent a list of questions requesting information regarding outdoor activity levels  and type of spectacles worn for walking . Data regarding the participants' age, sex, general health status, the number and type of prescribed medications and their pre‐ and post‐operative habitual refractive correction and habitual visual acuity  were obtained from the participants' medical records. Any missing data were followed up by telephone calls to the participant and/or their optometrist.The most commonly used and accepted questionnaire to quantify the impact of dizziness on everyday life is the Dizziness Handicap Inventory (DHI) yet despite this its structural validity is not established.Given the short waiting times for NHS cataract surgery at the time, patients could only be recruited to the study a relatively short period prior to their surgery . To obtain an assessment of pre‐operative self‐reported falls over a larger period, we retrospectively asked if patients had fallen within the last 6 months. A fall was defined as ‘an unexpected event in which the participants come to rest on the ground, floor, or lower level’.Self‐reported 6‐month falls data were collected in the same way post‐operatively: participants were sent monthly falls diaries for completion for 1–2 months  and after 6 months, they were sent the same questionnaire requesting information regarding the occurrence of falls in the previous 6 months. The response to the 6‐month retrospective falls question was checked against the falls diary information and any inconsistencies were investigated . The data reported are the self‐reported 6‐month falls data.N = 10 k/p, where k is the number of covariates accounted for and p is the likely proportion of positive cases . Data analysis was carried out using STATA, version 13.1. For analysis all Snellen visual acuity (VA) measurements were converted to logMAR. The participant's habitual refractive correction  was converted into power vector format to enable comparison of pre and post‐operative data.0 and J45 were used in the analyses. Changes in refractive correction from second eye surgery were used in the analyses from patients who underwent surgery in both eyes as falls were assessed after second eye surgery for those patients.A target sample size of 280 was calculated using Peduzzi and colleaguesU test for continuous data and the chi‐square test for categorical data.Normality of continuous data was determined using the Kolmogorov‐Smirnov test. Age, dizziness, number of medications, number of chronic conditions and vision data were not normally distributed and therefore they are described in terms of medians and inter‐quartile ranges (IQR). Differences between demographic data for included and excluded participants were analysed using the Mann–Whitney n = 248; outdoor activity at least 1–2 times per week) and those who were inactive . Visual acuity and refractive correction data were assigned to the ‘best’ and ‘worst’ eye (rather than the operated and non‐operated eye) as binocular visual function is typically related to vision in the best eye.p‐value of <0.10 were then entered into the model to produce final models of independent risk factors for both post‐operative self‐reported dizziness and falls.A comparison of the DHIsf score before and after cataract surgery was carried out using the Wilcoxon signed rank test for dependent samples. As the dizziness score data were highly skewed, participants were dichotomised into those who scored 13 on the DHIsf as having no handicap from dizziness, and those who scored <13 on the DHIsf as having some level of handicap from dizziness. Changes in prevalence of dizziness and falls pre and post‐surgery were analysed using McNemar's test. As the activity levels data were skewed, participants were dichotomised into those who were active  or sex  between those included  and those excluded  from the study. Of the 287 patients completing the study , 81 (28%) had routine cataract surgery in the first eye, 109 (38%) in the second eye and 97 (34%) had surgery in both eyes. The latter group were those patients in whom there was <6 months between first and second eye surgery  so that we were unable to collect 6‐month falls data between surgeries. For these participants, a post‐operative falls rate was collected for the 6‐month period after their 2nd eye surgery.Three hundred and sixty‐four patients indicated an interest in participating. Seventy‐seven were excluded from the study and/or analysis with 287 (79%) completing the study. This is similar to the recruitment in the earlier UK cataract surgery studies.p < 0.0001).Median (and IQR) refractive correction and habitual VA data before and after cataract surgery for the operated and non‐operated eye are provided in Table 2 = 0.87, p = 0.35), with 66 of 287 (23%) of the participants reported falling in the 6 months prior to surgery compared to 56 of 283 (20%) that reported falling in the same period after surgery. Levels of activity were similar before (86% active) and after surgery (83% active).The self‐reported 6‐month falls rate remained similar before and after cataract surgery . This was similar for surgery on the first eye or both eyes, but the improvement was not significant for second eye surgery .The median DHIsf score improved significantly following cataract surgery from 12 (IQR: 9–13) to 13 (IQR: 11–13), p = 0.47; sex, p = 0.99) and their inclusion did not substantially affect the influence of the other variables that we did include. Medical factors such as arthritis were weakly associated with post‐operative falls  and post‐operative dizziness was strongly associated with falls , but pre‐operative falls was a much stronger risk factor and acted as a proxy for multifactorial risk factors including age. Post‐operative dizziness was retained in the final model  as it was an important predictor of interest and may be on the causal pathway between vision changes and falls. Changing into multifocals post surgery increased falls risk significantly , change in anisometropia  or post‐operative activity levels. However, the number with large refractive changes in the operated eye were relatively small  and CummingsWe found a substantial falls rate both before and after cataract surgery and identified risk factors relating to spectacle management. The multifactorial logistic model with post‐operative falls as the outcome measure showed associations with pre‐operative falls and changes in spectacle type  was expected and has been suggested by other studies.Self‐reported dizziness was greater in females and patients with multiple medications Table  and thisThe study was limited in several ways. The falls data were self‐reported recall from the previous 6 months and accurate retrospective assessments of falls are difficult due to poor memory recall of older patientsIn summary, this study found that dizziness was reduced by cataract surgery and this was linked with improvements in best eye VA, but increased by changes in oblique astigmatic correction. This needs to be investigated further to determine whether dizziness should be a consideration in the decision of whether to perform cataract surgery. We found no improvement in falls rate with routine cataract surgery. This is probably linked to the relatively good pre‐operative VAs and possibly to too many patients switching to multifocal spectacle wear post‐surgery. This suggests that to maximise the potential for cataract surgery to improve falls rates, patients should be appropriately warned of the potential adaptation problems after surgery, particularly if they had a large change in oblique astigmatism and/or have switched to multifocal wear. In between first and second eye surgeries, multifocal wearers could consider wearing updated multifocals rather than go without spectacles if the intention is to continue multifocal wear post second eye surgery.This work was supported by The Dunhill Medical Trust (grant number SA14/0711).No conflicting relationship exists for any author.


DNA and RNA level. These data sets are being used increasingly to identify the molecular differences that underlie common surgical diseases, and enable them to be stratified for patient benefit.Surgery is entering a new phase with the revolution in genomic technology. Cheap, mass access to next‐generation sequencing is now allowing the analysis of entire human genomes at the This article reviews the recent developments in the molecular biology of colorectal, oesophagogastric and breast cancer.The review specifically covers developments in genetic predisposition, next‐generation sequencing studies, biomarkers for stratification, prognosis and treatment, and other 'omics technologies such as metabolomics and proteomics.There are unique opportunities over the next decade to change the management of surgical disease radically, using these technologies. The directions that this may take are highlighted, including future advances such as the 100 000 Genomes Project. May individualize cancer treatment The field of molecular biology has undergone rapid advancement in the past 5 years, with exciting consequences for the diagnosis, treatment and follow‐up of surgical patients.A series of enabling technologies and projects have expanded the knowledge of how basic molecular biology can assist in the management of surgical disease. The first, and most important, was the Human Genome Project, established in 1990 by the US National Institutes of Health and the UK Sanger CentreThe development of microarray technology and next‐generation sequencing (NGS) within the past 5 years has led to a step‐change in the implementation of genomic technologies; before this, the bulk of genetic research was carried out on DNA microarrays.Figs DNA microarrays are available from a variety of manufacturers  and consist of silicon or glass slides with oligonucleotides complementary to the DNA sequence being studied, which are annealed to their surface. This allows cheap, mass production of microarrays that can be used for large population‐based studies. Typically these microarrays have between 500 000 and 1·5 million genomic markers, usually single‐nucleotide polymorphisms (SNPs). SNPs are single‐nucleotide changes within a gene that lead to protein change and subsequent change in the function of that gene. When scanned with a laser, each individual oligonucleotide fluoresces a specific colour, depending on the bound oligonucleotide fragment Figs .A variety of projects have been undertaken using DNA microarrays, typically taking the form of the genome‐wide association study (GWAS). These are usually case–control studies with cases enriched for the disease of interest. SNPs of interest are identified and taken forward to validation in larger cohorts, giving insights into the disease process being studied. Examples of GWASs include the COGENT  Consortium, and the Wellcome Trust Case Control Consortium 1/2 (WTCCC 1/2) examining colorectal cancer, Crohn's disease, diabetes, ischaemic heart disease, and several other common diseases and pathologies.Fig. The most widely used NGS technology, sequencing by synthesis  allows entire human genomes to be sequenced within 24 h at low cost, with the sub $1000 genome barrier (X‐prize) being achieved earlier this year. Other innovative technologies include single molecular real‐time sequencing , semiconductor sequencing  and nanopore sequencing . Until recently, NGS was limited to small studies on a few samples owing to cost constraints, but because of the rapid fall in price‐per‐sample Fig. , large sTo carry out NGS, an inherently massively parallel technique, several steps are required. All technologies require capture of DNA or RNA into sequencing libraries. Illumina Solexa™ then uses this captured DNA/RNA to generate clusters, which are amplified. Cluster amplification is the process whereby target DNA is immobilized on to spatially separated template sites, allowing sequencing reactions to occur in parallel. Sequencing is then carried out on the clusters present on the glass slide. The slide is portioned into eight channels, enabling independent samples to be run simultaneously. Typically, reads of between 75 and 100 base pairs are possible, and the nucleotide incorporation cycle is repeated until sufficient depth is covered for all targeted regions. Data generated are then aligned with a reference sequence, and variants are called after comparing the sequencing data to a reference. This allows a tumour specimen to be compared with its paired normal tissue sample.A critical difference in analysis of human cancers is the concept of germline and somatic mutations. Germline mutations are the constitutive DNA that the patient is born with, and variation within the germline confers an increased (or decreased) risk of cancer. Somatic mutations occur as a consequence of tumour development, although they may initiate tumour development by occurring spontaneously as a result of external factors such as ionizing radiation or carcinogens.Microarray and sequencing technologies also allow analysis of other types of genetic information, such as DNA methylation (epigenetics), which acts as a switch in the regulation of gene expression. NGS also allows analysis of gene expression by NGS of mRNA (RNA‐seq) and other genetic modifications, such as sequencing of chromatin‐immunoprecipitated DNA (ChIP‐seq). Non‐coding small RNAs that may affect gene function, such as long non‐coding RNA (lncRNA), small interfering RNA (siRNA) and small nucleolar RNA (snoRNA), can also be analysed by NGS.Other technologies are emerging as potential methods for the downstream analysis and stratification of patient samples in surgical disease. Two examples of these technologies are metabolomics and proteomics. Metabolomics uses either nuclear magnetic resonance or mass spectrometry to ascertain the presence of metabolites in surgical specimens. The patterns and relative abundances of the metabolites observed can give clues as to the underlying biological processes at work in the tissues studiedProteomics uses mass spectrometry to understand the structure of proteins. Several methods exist to allow proteins to be studied in the ionized form without fragmentation or damage including matrix‐assisted laser desorption ionization (MALDI)These technologies have allowed advances in understanding of the initiation and progression of multiple surgical diseases, and in adjuvant therapies for surgical disease such as chemotherapy and radiotherapy. They also allow the possibility of population screening of asymptomatic carriers.Table GREM‐associated duplication in hereditary mixed polyposis syndromePOLE and POLD as a cause of hereditary polyposisThe predominant surgically relevant disease types studied in the lower gastrointestinal (GI) tract have been colorectal cancer, Crohn's disease and ulcerative colitis. The COGENT ConsortiumNOD2 gene, which plays an important role in immunity. In total, these loci make up about 20 per cent of the observed inheritability of Crohn's disease.In Crohn's disease, multiple large‐population GWAS studiesComparatively less research has been undertaken in germline susceptibility to ulcerative colitis; several large population GWAS studiesAPC, TP53, SMAD4, PIK3CA and KRAS, but also found novel therapeutic targets in ARID1A, SOX9 and FAM123B. Another studyARID1A are particularly exciting as they present a potential therapeutic targetThe colorectal cancer TCGA projectTable Recent work has examined the role of integration of multiple 'omics data sets to produce classifiers of diseaseA wide variety of biomarkers have been examinedAnother rich field of developing interest in colorectal cancer is sequencing of the microbial genomes that exist within the colon. Experimental murine models seem to indicate that the microbiome within the colon alters the risk of colorectal cancer by modulating inflammationMetabolomic techniques also show promise in acting as screening biomarkers. Mirnezami and co‐workersKRAS, BRAF, NRAS and PIK3CA) conferred resistance to anti‐EGFR mAbs due to hyperactivation of the pathway independent of the EGFRKRAS mutation and those without, finding a clear response and survival benefit for anti‐EGFR mAbs in patients without mutation. A number of other pathway‐specific inhibitors exist for colorectal cancer, including the antivascular endothelial growth factor (VEGF) mAb bevacizumab, MEK inhibitors that target EGF pathway mutated cancers and cancer vaccines. The FOCUS4 trialThe discovery that the epidermal growth factor (EGF) pathway in colorectal cancer was sensitive to inhibition by anti‐EGF receptor (EGFR) monoclonal antibodies (mAbs) led to the rapid development of panitumumab and cetuximab. However, it was found in initial trials that the antibodies seemed to have no clinical effect against colorectal cancer; although a proportion of patients seemed to benefit from therapy, the majority did notA commercially available test exists for prediction of recurrence and benefit for 5‐fluorouracil chemotherapy , based on a multigene panel of RNA expression from formalin‐fixed paraffin‐embedded tissueset al.POLE mutation or those with microsatellite instability, is where the large number of mutations causes a variety of frameshift mutations. These frameshift mutations drive the production of neoantigensAnother intriguing possibility is the use of immune‐based stratification to estimate colorectal cancer prognosis. Lal Research into predisposition to gastro‐oesophageal cancer is complicated by the fact that it can arise in two histologically different epithelial types: squamous cell carcinoma (SCC) and adenocarcinoma. A significant proportion of the risk is likely to comprise lifestyle factors such as smoking, gastro‐oesophageal reflux and diet.FOXF1). It was also found that the predisposition to Barrett's oesophagus was made up of multiple common variants of small effect, rather than a single genetic driver. A further GWAS of oesophageal adenocarcinomaCRTC1, FOXP1, BARX1). In light of these results it is difficult to highlight SNPs that may act as markers for increased disease risk or act as molecular targets for therapy.In adenocarcinoma, a GWAS of the premalignant stage of oesophageal cancerC20orf54, and a cell growth and differentiation gene, PLCE1. Riboflavin deficiency was identified before this study as a risk factorPLCE1 variant was further found to interact specifically with tobacco smoke exposureSeveral GWAS studies have been undertaken, predominantly in Chinese populations at high risk of oesophageal SCCTP53, CDKN2A, SMAD4, ARID1A and PIK3CA. Previously unidentified mutations in SPG20, TLR4, ELMO1 and DOCK2 were also found, and a possible role for the RAC1 pathway  was identified.Both the Broad Institute  and the OCCAMS  Consortium have studied oesophageal adenocarcinoma. The Broad Institute projectTP53 was the dominant mutation seen in adenocarcinoma, in over 80 per cent of samples, but that these mutations were also present in biopsies from never‐dysplastic patients, contrary to what was expected based on the known oncological progression of these lesions. The only stage‐specific mutations seen in high‐grade dysplasia and adenocarcinoma were in TP53 and SMAD4.The OCCAMS ConsortiumTP53, RB1, CDKN2A, PIK3CA, NOTCH1 and NFE2L2, as well as ADAM29 and FAM135B. The genomic landscape of oesophageal SCC was significantly different from that of oesophageal adenocarcinoma, highlighting the different therapeutic strategies that are needed in this disease.Whole‐genome and whole‐exome sequencing of oesophageal SCC has also been performedTP53 mutation as a biomarker of adenocarcinoma, as it has also been identified in biopsies from never‐dysplastic patients, who should not progress to adenocarcinoma. As a precursor to the OCCAMS studyDCK, PAPSS2, SIRT2 and TRIM44 that were independently predictive of survival.Given the above OCCAMS findings, it is difficult to use CDKN2A, vimentin, P14ARF, CDX2, SOCS1/3, SFRP1/2/4/5 and WIF1There have been a number of attempts at developing methylated biomarkers in oesophageal adenocarcinoma, both as screening biomarkers and to identify high‐risk Barrett's oesophagus. The genes studied include Attempts have been made using proteomicsDespite the recent advances in discovery science in gastro‐oesophageal cancer, few therapeutic targets currently exist. A small proportion of cancers overexpress the human EGFR 2 (HER2) proteinFGFR2) have been found in GWAS studies across multiple populationsFGFR2 (frequency 38 per cent of the population) have a relative risk of breast cancer of 0·83 compared with the general populationFGFR2 mutations are of particular interest as they may represent a therapeutic target in breast cancerThe role of inherited variability in breast cancer has been investigated extensively. A very strong signal for variants in the fibroblast growth factor receptor 2 gene , with the mutational burden and spectrum varying in each. The HER2E subtype demonstrated a relatively low mutational frequency, whereas the luminal A subtype demonstrated large numbers of significantly mutated genes, the most frequent mutation being in PIK3CA.A number of NGS projects have examined the mutation spectrum in breast cancer. The most comprehensive of these is from the TCGA projectTP53 mutation. Copy number analysis was also performed, with the previously identified amplifications in HER2 and EGFR being identified, as well as novel amplifications in PIK3CA and FOXA1 and deletions in RB1 and PTEN. A striking finding throughout the study was the detection of genetic heterogeneity both within tumours and between samples, highlighting the diverse nature of this disease.In common with colorectal cancer, methylation array analysis of breast cancer revealed a hypermethylator phenotype, associated with the luminal B expression subtype, and a hypomethylated phenotype associated with a basal expression subtype and comparatively higher frequency of TP53 and PIK3CA mutations were clonally dominant, but also finding a wide variety of mutation spectra, including tumours with few driving mutations and tumours with extremely complex mutational spectra (the hypermutated phenotype). A separate studyCBFB and RUNX1, as well as a gene fusion seen only in triple‐negative breast cancers, the MAGI3–AKT3 fusion transcript. An exome sequencing studyAKT1/2, ARID1B, CASP8 and MAP3K1.Shah and colleagueset al.NGS also has applications in the monitoring of metastatic disease or in recurrence. Dawson CK19) as a surrogate marker of the presence of breast cancer within sentinel lymph nodesOne‐step nucleic acid amplification (OSNA) is an example of the use of genetic technologies to stratify patients. It works by the detection of raised copy number of the cytokeratin 19 gene  and targeted ER modulators (such as tamoxifen) have been used extensively for many years, based on the observation that a proportion of breast cancers are ER‐positive. Identification of the overexpression of HER2 in breast cancer has allowed targeting with both mAbs (trastuzumab) and small‐molecule tyrosine kinase inhibitors such as lapatanib, with appreciable survival benefits.BRCA‐associated double‐strand break repair protein, poly(ADP‐ribose) polymerase (PARP) 1; and the phosphatidylinositol‐3‐kinase (PIK3)–Akt–mammalian target of rapamycin (mTOR) pathway. Immunohistochemistry of IGF‐1 has revealed that it is overexpressed in more than 50 per cent of breast cancers, and a mAb (cixutumumab) that targets these pathways is currently in phase 1 studiesMore recently, several novel pathways have been identified as being dysregulated in breast cancer: the insulin‐like growth factor (IGF) 1 pathway; the BRCA mutant breast cancerBRCA mutations. A small molecular PARP inhibitor, olaparib, has been used to treat germline BRCA mutant breast cancerBRCA mutationsPARP inhibitors were identified from work targeting The union of basic biological research with surgery has allowed the field of translational surgical biology to develop, utilizing modern molecular technologies to stratify surgical disease based on therapeutic and outcome response.A number of possibilities exist for future research. First, whole‐genome studies using NGS technologies of prospectively collected samples will allow identification of biomarkers for response  and treatment . An example of current clinical issues that could be answered using this technology is the response of rectal cancer to radiotherapy. Around 5–10 per cent of patients with advanced rectal cancer given preoperative radiotherapy have a complete responseStratification of premalignant lesions is also an important focus of research. In colorectal, upper GI and breast cancer, few biomarkers exist to predict which premalignant lesions will progress to invasive cancer. Typically less than 1 per cent of patients with Barrett's oesophagus will progress to invasive oesophageal cancer, but no markers reliably predict this. The use of retrospective cohorts of patients with progressive Barrett's oesophagus and NGS analysis might identify genetic markers.The concept of disease classifiers will play an increasingly important role and, as more NGS data sets become available, the granularity of classifiers will improve to the extent whereby a more precise understanding of the biology underlying a tumour will be available. This will be enhanced by the integration of multiplatform  data into these classifiers, and will allow tailoring of therapy to the underlying disease.The availability of NGS data sets for the surgical population will be enhanced by the commissioning of the UK 100 000 Genomes ProjectAlthough the technological advances are numerous, they are not without their own challenges. The recent identification of intratumoral heterogeneity, long hypothesized but only recently identified definitively in renal cell cancerTechnological leaps in molecular biology will enable selection of the right therapy for the right patient at the right time, and further build on the surgical and anaesthetic improvements achieved in the past century to provide maximal benefit for the patient.


B groups vitamins are essential components of cellular metabolism and among them riboflavin is one of the vital vitamins required by bacteria, plants, animals and humans. Here, we focus on the importance of microbial production of riboflavin over chemical synthesis. In addition, genetic abilities for riboflavin biosynthesis by lactic acid bacteria are discussed. Genetically modified strains by employing genetic engineering and chemical analogues have been developed to enhance riboflavin production. The present review attempts to collect the currently available information on riboflavin production by microbes in general, while placing greater emphasis on food grade lactic acid bacteria and human gut commensals. For designing riboflavin‐enriched functional foods, proper selection and exploitation of riboflavin‐producing lactic acid bacteria is essential. Moreover, eliminating the in situ vitamin fortification step will decrease the cost of food production.Consumers are increasingly becoming aware of their health and nutritional requirements, and in this context, vitamins produced  The second and third enzymatic steps (deamination of the pyrimidine ring of structure and the subsequent reduction of the ribosyl side‐chain) are controlled by another bi‐functional enzyme encoded by the first gene of the operon ribG  and regulatory region RFN  is absent from the genome, it is more likely that the riboflavin operon will be incomplete. The sequenced genome of Lactobacillus plantarum strain WCFS1 contains an incomplete rib operon, which is devoid of the entire ribG and part of the ribB genes  of Proteobacteria  and L. plantarum (and 2.13 mg l−1) in MRS medium  in L. lactis  was also studied by the use of riboflavin‐producing L. mucosae KTF .The isolation of spontaneous roseoflavin‐resistant mutants is a reliable method to obtain natural riboflavin‐overproducing strains of various species commonly used in the food industry, and it is also acceptable from a consumer/regulatory point of view as it does not involve deliberate genetic engineering (Jayashree lleagues  stated tet al., de novo synthesize and supply vitamins (LeBlanc et al., et al., et al., et al., in situ riboflavin production by gut commensals. Commercialized probiotic bacteria have been included as active ingredients in products such as yoghurt, cheese, ice cream, chocolates pharmaceutical tablets, infant formulas and dietary supplements (Tamime et al., et al., et al., Bacillus clausii, B. subtilis, Bacillus cereus IP 5832, Lactobacillus rhamnosus ATCC 53103, which were able to produce riboflavin (Salvetti et al., L. acidophilus obtained from curd and cheese samples.Besides traditional applications of LAB, some of the members have been reported to elicit probiotic features (Russo et al., de novo synthesis of riboflavin. LAB also known as power house of dairy industry and imparting health benefits as probiotics are endowed with the ability to synthesize essential biomolecules in particular riboflavin. The carefully selected riboflavin‐producing strains holding probiotic attributes could open the way to be potential candidates for in situ production of riboflavin once these strains get colonized to host intestine (Arena et al., The economic and environmental considerations have led the fermentation‐based method as a model of the environmentally friendly white biotechnology with regard to traditional chemical synthesis of riboflavin (Shi None declared.


To examine whether the adverse effect of obesity on psychological well‐being can be explained by weight discrimination.2. Mediation analyses were used to test the role of perceived weight discrimination in the relationship between obesity and each psychological factor.The study sample included 5056 older (≥50 y) men and women living in England and participating in the English Longitudinal Study of Ageing. Participants reported experiences of weight discrimination in everyday life and completed measures of quality of life , life satisfaction , and depressive symptoms . Height and weight were objectively measured, with obesity defined as BMI ≥30 kg/mObesity, weight discrimination, and psychological well‐being were all significantly inter‐related. Mediation models revealed significant indirect effects of obesity through perceived weight discrimination on quality of life , life satisfaction , and depressive symptoms , with perceived weight discrimination explaining approximately 40% (range: 39.5‐44.1%) of the total association between obesity and psychological well‐being.Perceived weight discrimination explains a substantial proportion of the association between obesity and psychological well‐being in English older adults. Efforts to reduce weight stigma in society could help to reduce the psychological burden of obesity. In addition to the well‐documented physical health risks associated with obesity Weight stigma is often cited as a potential mechanism leading from obesity to poorer psychological well‐being Only one study to our knowledge has tested the mediating effect of weight‐related discrimination, showing a significant reduction in the association between obesity and self‐acceptance after adjusting for perceived weight discrimination n = 5056).Data were from the English Longitudinal Study of Ageing (ELSA); a cohort study of older adults (≥50 y) living in England Weight was measured by nurses to the nearest 0.1 kg using portable electronic scales, and height was measured to the nearest millimeter using a portable stadiometer. Nurses recorded any factors that might have compromised the reliability of the measurements  and these cases were excluded. Underweight was defined as a BMI <18.5, normal weight as BMI 18.5‐25, overweight as BMI 25‐29.9, and obesity as BMI ≥30.In your day‐to‐day life, how often have any of the following things happened to you: (1) you are treated with less respect or courtesy; (2) you receive poorer service than other people in restaurants and stores; (3) people act as if they think you are not clever; (4) you are threatened or harassed; and (5) you receive poorer service or treatment than other people from doctors or hospitals .” Because data were skewed, with most participants reporting never experiencing discrimination, we dichotomized responses to indicate whether or not respondents had ever experienced discrimination . A follow‐up question asked participants to indicate the reason(s) for discrimination from a list including weight, age, gender, race, and physical disability. For the purpose of these analyses, perceived weight discrimination was defined as experiencing discrimination and attributing it to weight.Questions on perceived discrimination were based on items developed and used widely in other longitudinal studies in the USA We included three measures of psychological well‐being in our analyses: quality of life, life satisfaction, and depressive symptoms. Our rationale for including these distinct constructs was to have one broad measure of well‐being, one of positive affect, and one of negative affect.I feel that what happens to me is out of my control”), autonomy , self‐realization , and pleasure . Respondents were asked how often each statement applies to them . Positively worded items were reverse scored so that higher scores indicated higher quality of life. The Cronbach α in the present sample was 0.86.Quality of life was assessed with the CASP‐19 In most ways my life is close to my ideal”). Responses were on a Likert scale from 0 (strongly disagree) to 6 (strongly agree). The Cronbach α was 0.91.Life satisfaction was assessed with the Satisfaction With Life Scale (SWLS) Over the last week have you felt sad”), with binary response options . Positively framed items were reverse scored. The eight‐item version has comparable validity and reliability to the original 20‐item CES‐D Depressive symptoms were assessed with an eight‐item version of the Center for Epidemiologic Studies Depression Scale (CES‐D) z‐scores) were calculated for each scale for ease of comparison across the three scales.For each of these three scales, we computed mean scores for participants with data on at least 75% of items to maximize the number of participants that could be included in the analyses. Standardized scores  across all ELSA participants who took part in wave 5. Wealth has been identified as a particularly appropriate indicator of SES in this age group All analyses were conducted using STATA version 13.1 . Age, sex, and wealth (as a proxy for SES) were entered as covariates for all the analyses because of their known associations with obesity c) of an independent variable (IV) on a dependent variable (DV) consists of a direct effect (path c′) of the IV on the DV and an indirect effect (path a × b) of the IV on the DV via a proposed mediator. Path a represents the effect of the IV on the mediator, and path b is the effect of the mediator on the DV. In these analyses, obesity was the IV, psychological variables were the DVs, and perceived weight discrimination was the mediator. Standardized scores were used for indices of psychological well‐being for ease of comparison across the three psychological variables. We used bootstrapping with 5000 sampling replications to estimate the 95% confidence interval (CI) Mediation analyses were used to test the hypothesis that perceived weight discrimination mediated the relationship between obesity and psychological well‐being Figure . We calcWe performed sensitivity analyses testing for mediation of the association between obesity and psychological well‐being by two other types of perceived discrimination  in order to establish whether effects were—as predicted—specific to weight discrimination or applied to experiences of discrimination in general. Additionally, because previous research has indicated that there may also be causal effects in the other direction [i.e., lower psychological well‐being is associated with greater likelihood of perceiving discrimination P < 0.001) and less wealthy (P < 0.001) than nonobese individuals, and a greater proportion were female . Ethnicity did not differ by obesity status (P = 0.327). Weight discrimination was reported by 4.6% but was strongly related to weight status, with 12.9% of individuals with obesity reporting weight discrimination  and only 0.9% of nonobese individuals .Characteristics of the study sample are shown in Table P < 0.001), lower life satisfaction (P = 0.005), and more depressive symptoms (P < 0.001) than those without obesity . Individuals who reported experiences of weight discrimination also had poorer psychological well‐being in all three domains than those who did not report weight discrimination (P < 0.001)  Table . Associac, path c', and indirect effects in Figure Table We repeated the mediation analyses substituting age discrimination and sex discrimination in turn for weight discrimination to investigate whether mediation was specific to weight discrimination (Supporting Information Table 2). Although perceived discrimination on the basis of age or sex was significantly associated with poorer psychological well‐being, we observed no evidence of mediation of the effect of obesity.We also tested the reverse model Figure  to invesIn this study, we examined associations between obesity, perceived weight discrimination, and three markers of psychological well‐being: quality of life, life satisfaction, and depressive symptoms. Individuals with obesity showed poorer well‐being in all three domains, although effect sizes were modest. They were also substantially more likely to report weight discrimination. We used mediation models with bootstrapping to test the proposition that associations between obesity and well‐being are mediated by weight discrimination and found that approximately 40% of the total effect of obesity on psychological well‐being could be explained by perceptions of weight discrimination.per se, we carried out sensitivity analyses using other types of discrimination. Although age and sex discrimination were commonly reported, and had negative effects on well‐being, they did not explain the lower levels of well‐being among participants with obesity compared to those without obesity. This finding is consistent with a previous study that showed that the relationship between obesity and self‐acceptance was not attenuated when general experiences of discrimination were adjusted for, but became nonsignificant in analyses controlling for appearance‐related discrimination In order to rule out the possibility that any discrimination would have the same effect—i.e., it was nothing to do with weight The fact that perceived weight discrimination explained such a significant proportion of the unique variance in the association between obesity and psychological well‐being emphasizes the need to combat weight stigmatization in society. Public health campaigns designed to tackle obesity may inadvertently stigmatize individuals with obesity, with messages that emphasize volitional control of body weight and minimize the importance of nonvolitional factors that contribute to obesity The occurrence of discrimination is difficult to determine objectively because it relies on interpretation of the intentions of others. As such, discrimination can occur without being perceived by the individual who is discriminated against, and equally, it can be perceived in cases where it did not occur. In the latter situation, a person's psychological state may influence the way they interpret others' behavior and hence whether discrimination is perceived. A study exploring perceptions of race discrimination in minority adolescents in the US showed that those with higher levels of depression or anxiety were more likely to perceive discrimination This study had a number of strengths. It used a large sample drawn from a nationally representative cohort, in which the prevalence of perceived weight discrimination was comparable to previous estimates in the equivalent age group in the US population per se. It is possible that the timing of discriminatory experiences was years prior to when they were reported, which would make mediation effects less plausible as the purported mediator would be temporally prior to the purported IV. The sample comprising older adults may have implications, as high BMI over the life course is a predictor of premature mortality However, there were also limitations. Weight was not measured in the same data collection wave as discrimination, and participants may have changed weight status prior to reporting discrimination. We did not have complete data on weight and it is possible that people most troubled by their weight were more likely to refuse to be weighed. However, although missing cases inevitably pose a source of bias, we think it unlikely that exclusion of ELSA respondents with missing weight data would have resulted in substantial over‐ or under‐estimation of the mediation effect because the discrimination‐well‐being association was the same in that group as in the total included group. Weight discrimination was self‐reported and was therefore subject to recall bias and only reflected participants' own perceptions of discrimination. These results therefore estimate the impact of believing that one has been a target of weight discrimination as opposed to the impact of weight discrimination Future research could extend our findings by investigating the extent to which weight discrimination mediates associations between obesity and other measures of well‐being, such as self‐esteem. It would also be interesting to examine differences in associations between obesity, weight discrimination, and well‐being across demographic subgroups. The greater social pressures on women than men to maintain a slender physique may mean women with obesity are more vulnerable to the adverse psychological effects of weight discrimination, so the mediating effect may be stronger in women than men. Likewise, it is possible that weight discrimination explains a larger proportion of the association between obesity and well‐being in younger populations, where obesity‐associated health problems, which may lead to poorer well‐being among individuals with obesity, have had less time to develop.In summary, our results indicate that a substantial proportion of the association between obesity and psychological well‐being can be explained by perceptions of weight discrimination. Concerted efforts to reduce weight stigma in society could therefore help to alleviate the psychological burden of obesity.Supporting InformationClick here for additional data file.


Hum Brain Mapp 36:1963–1981, 2015. © 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc..We used quantitative, coordinate‐based meta‐analysis to objectively synthesize age‐related commonalities and differences in brain activation patterns reported in 40 functional magnetic resonance imaging (fMRI) studies of reading in children and adults. Twenty fMRI studies with adults (age means: 23–34 years) were matched to 20 studies with children (age means: 7–12 years). The separate meta‐analyses of these two sets showed a pattern of reading‐related brain activation common to children and adults in left ventral occipito‐temporal (OT), inferior frontal, and posterior parietal regions. The direct statistical comparison between the two meta‐analytic maps of children and adults revealed higher convergence in studies with children in left superior temporal and bilateral supplementary motor regions. In contrast, higher convergence in studies with adults was identified in bilateral posterior OT/cerebellar and left dorsal precentral regions. The results are discussed in relation to current neuroanatomical models of reading and tentative functional interpretations of reading‐related activation clusters in children and adults are provided.  Learning to read requires the development of a highly organized brain system capable of integrating orthographic, phonological, and lexico‐semantic features of written words  and with further meta‐analyses of adult reading [Fiez and Petersen, In the domain of language, the function of the SMA was associated with overt articulation (motor execution), whereas the function of the more anterior located pre‐SMA was associated with covert articulatory planning for the production of speech sounds (sequencing motor plans) Price, . In addiAny meta‐analysis is limited by the characteristics of the original studies. In the case of age‐related meta‐analytic comparisons, specific limitations exist with respect to in‐scanner activation tasks and behavioral performance, neuroanatomical maturation, cerebral vasculature, and data acquisition and analysis protocols. In the present meta‐analysis, we attempted to match the child and adult studies as closely as possible. Highest priority was given to matching in‐scanner activation tasks and stimuli, because we assume that this has the biggest impact on reported brain activation, followed by native language, and sample size . In our final set of studies, children compared with adults exhibited lower accuracy (correct responses: 89% vs. 94%) and longer latencies (reaction times: 1600 ms vs. 1113 ms). This reflects the natural situation of higher reading‐related skills in adults. It is plausible to assume that the present meta‐analytic finding of higher convergence in child compared with adult studies in the bilateral SMA  is the consequence of this behavioral performance difference reflecting greater mental effort due to task difficulty in children.It is important to note that a difference identified between two meta‐analytic maps does not mean that activation is higher in one group than in the other. Rather it means that the observed activation is more consistent across studies in one group than in the other. To identify differences in the activation strength the method of choice is a single study that directly compares activation in one group to activation in another group. Thus, single studies and meta‐analyses should complement each other to provide a holistic picture of functional neuroanatomical correlates of reading in children and adults.Despite the limitations, the main strength of our approach is the unbiased and objective quantification of functional neuroanatomical commonalities and differences between child and adult reading. This study is the first direct comparison of reading‐related activation in children and adults within the same meta‐analytic framework. In contrast to narrative reviews, coordinate‐based meta‐analysis provides an unbiased synthesis of original studies and thus has the potential to detect previously overlooked findings. In addition, it results in precise specification of the neuroanatomical location of systematic effects.Using coordinate‐based meta‐analysis, this study provides an objective quantification of functional neuroanatomical commonalities and differences between children and adults during reading. Reading‐related activation common to children and adults was identified in left ventral OT and left IFG regions. Higher convergence in studies with children was found in the left STG and in the bilateral SMA. In contrast, higher convergence in studies with adults was found in bilateral posterior OT and left dorsal PRG regions. The pattern of results in the OT cortex was of specific interest, as it suggests an early engagement of left anterior and middle OT regions (corresponding to the VWFA) in beginning readers, whereas posterior OT regions exhibited specifically reading‐related recruitment only in more experienced readers. Likewise, the left dorsal PRG may serve as an important hub between functional networks relevant for reading primarily in adult readers, whereas the left IFG plays an important role in linguistic and nonlinguistic processes early on in reading acquisition.Supplementary InformationClick here for additional data file.